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Why a clinical judgment model
The National Council of State Boards of Nursing (NCSBN) developed the Clinical Judgment Measurement Model (NCJMM) to measure clinical judgment and decision making on the NCLEX, drawing on research with more than 100 nursing experts and data from more than 200,000 candidates (NCSBN, n.d.). Its third layer names six cognitive steps that can be measured: recognize cues, analyze cues, prioritize hypotheses, generate solutions, take actions and evaluate outcomes. Dickison et al. (2019) found that the model aligns with the information-processing and intuitive-humanistic models used to teach clinical judgment.
Case
The patient is illustrative. Mrs. K., 66, is on day 2 after a total knee replacement. At 1000 she says she suddenly feels short of breath and has a sharp pain on the right side of her chest when she breathes in. Her heart rate is 112, respiratory rate 26, blood pressure 132/84, temperature 37.2 °C and oxygen saturation 89% on room air. She is anxious and says, "Something's wrong."
The six steps
| Step | Applied to Mrs. K. |
|---|---|
| Recognize cues | Sudden shortness of breath, pleuritic chest pain, tachycardia, tachypnea and low oxygen saturation after major orthopedic surgery |
| Analyze cues | The cues cluster around a problem with oxygenation. Recent surgery and reduced mobility raise the risk of a blood clot |
| Prioritize hypotheses | Pulmonary embolism is the most urgent possibility; atelectasis and anxiety are less dangerous explanations that don't account for every cue |
| Generate solutions | Improve oxygenation, get the provider or rapid response team to the bedside, and prepare for ordered diagnostic tests |
| Take actions | Stay with Mrs. K., raise the head of the bed, start oxygen as ordered or per protocol, call for help using SBAR and keep her on bed rest until she is evaluated |
| Evaluate outcomes | Recheck oxygen saturation, respiratory rate, heart rate and pain within minutes; if she doesn't improve, escalate again |
Prioritizing across the shift
The same reasoning decides priorities across a whole assignment. A sudden change in a patient's breathing outranks scheduled care for stable patients, so the nurse hands routine tasks to colleagues while staying with Mrs. K. The model makes that reasoning visible: each action can be traced back to the cues that justified it.
References
Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical Judgment Model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72–78. https://doi.org/10.3928/01484834-20190122-03
National Council of State Boards of Nursing. (n.d.). Clinical judgment measurement model. Retrieved October 19, 2026, from https://www.nclex.com/clinical-judgment-measurement-model.page
