Running head: CLINICAL NURSING JUDGEMENT: FOREVER CHANGING

Clinical nursing judgement: Forever changing

Kenneth Jones

Youngstown State University

March 20, 2018

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Clinical nursing judgement: Forever changing

What is clinical Nursing Judgement? It is an educational process that is forever evolving

due to evidence based practices. Obviously, clinical judgement started all the way back to

Florence Nightingale when she started doing clinical research to have better outcomes of patient

care. “In recent years, clinical judgement in nursing has become synonymous with the nursing

process model of practice viewed as a problem-solving activity. The nursing process has

dominated nursing education since the 1960’s as theorists tried to link their theories with the

clinical judgement process and to link nursing theory with clinical practice” (van Graan,

Williams, & Koen, 2016, p. 3). Many people believe that clinical judgement involves two

different aspects, the first being the forever changing evidence based decision making along with

the experienced humanistic approach to nursing. Unfortunately, many new nurses do not have

the experience or education to have the humanistic approach because they lack the experience to

make judgement on past experience. “As nurses work in ever-changing health care

environments, either the positivist model or the intuitive model is adequate to describe the

dynamic processes nurses use in clinical decision making. Therefore, it was suggested that the

cognitive processes used in decision making were neither completely analytical nor completely

intuitive (Krishnan, 2018, p. 73). So, when discussing clinical judgement, I suppose it changes

with each graduating class and each school. Each person takes the same licensure exam and only

has to have a minimal score to show that they are safe to practice in a clinical environment. The

rest of that knowledge has to come from knowledge gained through practice and learned clinical

judgement. From all the literature I have read, it doesn’t seem like there is one definition that

would fit everyone. “With 19 million nurses worldwide, the potential for introducing

unnecessary harms into health systems through less than optimal judgments and decisions is
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clear” (Thompson & Aitken, 2014, p. 1721). With all this being said, clinical nursing judgement

is different for every nurse.

The importance of clinical judgement is crucial to our changing healthcare. Our population

is aging and our insurance companies are dictating care. Decades ago, having a baby or a simple

procedure would end in a week-long stay in the hospital. Today, many of the same surgeries or

even giving birth have either a limited stay or result in an outpatient procedure. Now many of the

patients in the hospital are there for more critical reasons which make nursing judgement even

more important. “Estimates vary but nurses make lots of decisions: acute care nurses facing a

decision or judgement “task” every 10 min, critical care nurses every 30 sec and family or public

health nurses making up to 10 judgements for each contact” (Thompson & Aitken, 2014, p. 1721).

This is a lot for nurses to handle and a reason why so many nurses can’t handle the pressure and

“get out”. Because every nurse has a similar base of knowledge but a different amount of time in

their position, the outcomes of clinical judgement can be very different. Therefore, resulting in

different patient outcomes that may be good or bad. “Variation becomes a problem however when

we do know which interventions are clinically effective and/or valued by patients. Significant

variations exist in the decisions that nurses’ make when intervening to improve functional

impairment, pain, nausea, dyspnea, fatigue, and pressure ulcers. A number of studies have

highlighted that when given the same information, and undertaking the same decisions, nurses will

make consistently different judgments and decisions (Thompson & Aitken, 2014, p. 1721), Given

all this information, it becomes increasingly aware why clinical judgement is so important. Patient

outcomes. Are you going to make the right decision and do something such as call the physician

or rapid response team or are you going to stand by and wait? Are you going to suction the patient

when needed and provide excellent mouth care to prevent nosocomial pneumonia? If not willing
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to follow protocol and make sound judgement, chances are the patient will have a poor outcome

and the insurance company isn’t going to pay for their treatment. Nursing judgement is what

makes the healthcare circle complete. Without it, or lack of it, the patient won’t get well, the

insurance companies won’t pay, the doctors can be sued, the families will grieve and the patients

will suffer the consequences.

As for my own development of nursing judgement, I am going to reflect on what my

preceptor Dana Marcum had to say to me. On my last day of clinical, I had a patient with

hyponatremia. After my assessment and looking at labs, it was time for breakfast. I took her tray

to her, and as I do with all patients, I looked at her orders for food. She was ordered a low sodium

diet. It is not a big deal but I questioned that and Dana did not understand either. A quick call to

the physician changed the diet to regular. It is not a big deal but as Dana said, she watched me use

critical thinking with many of my patients, I wasn’t always right but I was still thinking and trying

to make the best decision for my patients. She asked me if I had any idea of why I was good at

critical thinking? I replied no, unless it was the humanities class I took on critical thinking. Her

reply was your age. She stated that because of life experience and knowing there is a consequence

for actions, that I had better natural critical thinking skills than most younger students. This was

probably the first time that I felt my age gave me an advantage. I was very lucky to work with a

nurse that had been in ICU for almost 27 years. I really watched and listened. I was amazed at

the questions she asked about care that really made me think. With critical thinking being so much

of a practiced skill along with a learned skill, it makes me wonder about the other students. I was

not only lucky to have a great preceptor, but also great clinical instructors and nurses. I have

always determined that a learning experience is what you make of it. If you are done with patient

care, are you actively seeking to help and learn with someone else. I know my first couple days
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of my preceptorship, I was helping everyone. From turning all the patients every two hours to

cleaning up the patient with C-dif. After I proved that I was there to learn and work, everyone on

the floor made sure I had the opportunity to help or learn something from their patient. They

actually asked me to apply there to work because they thought I would be great. I still struggle

with the thought of so many clinical rotations where students were more concerned with

completing their paperwork before they left, got on cell phones to text, or study for a test. I

personally think they were cheating themselves from learning how to make clinical judgements. I

am thankful that this is not something I will have to look back on and question.
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References

Krishnan, P. (2018, January 31). A Philosophical Analysis of Clinical Decision Making in

Nursing. Journal of Nursing Education, 57(2), 73-78.

http://dx.doi.org/10.3928/01484834-20180123-23

Thompson, C., & Aitken, L. (2014, May, 4). An agenda for clinical decision making and

judgement in nursing research and education. International Journal of Nursing Studies,

50, 1720-1726. http://dx.doi.org/10.1016/j.ijnurstu.2013.05.003

van Graan, A. C., Williams, M. J., & Koen, M. P. (2016, December). Professional nurses'

understanding of clinical judgement: A contextual inquiry. Health SA Gesondheid, 21,

280-293. http://dx.doi.org/10.1016/j.hsag.2016.04.001