Running Head: Clinical Nursing Judgment

Clinical Nursing Judgment

Natalie Noday

Youngstown State University

Clinical Nursing Judgment 2

Abstract

The purpose of this paper is to define clinical nursing judgment and describe how those entering

the profession will develop the skills needed in the clinical setting by thinking critically and

making patient benefit decisions. This paper will also go into great detail explaining how clinical

judgment applies to the interdisciplinary health care team as a whole, and how nurses can

develop knowledge implementing these skills in the professional setting. A brief overview of

techniques that are utilized to increase growth of clinical judgment in nursing will be analyzed,

along with personal experiences and reflections as a student nurse entering the field.

Keywords: clinical nursing judgment, critical thinking, decision making, patient safety
Clinical Nursing Judgment 3

The Concept and Importance of Nurse Judgment

Nurses are significant decision makers in any well- developed, successful health care

system and serve as advocates to those they are caring for. Along with evidence based research,

clinical judgment in the nursing profession is defined as, “An interpretation or conclusion about

a patient’s needs, concerns or health problems, and the judgment to take action (or not), use or

modify standard approaches, and improvise new ones as deemed appropriate by the patient’s

response” (Thompson, C. 2013). To become competent in clinical judgment, it is the Registered

Nurse’s responsibility to be constantly aware of the patient’s stability and engage in

interdisciplinary communication within the health care team to relay any pertinent data and

information that protects the patient’s safety and well- being. Throughout my preceptorship, I

have had multiple opportunities to complete hourly assessments on patients when their stability

was declining and required immediate intervention.

Through these experiences, I have learned that due to the complexity of patient care

situations, nurses need to develop the ability to respond and act quickly and appropriately in any

given scenario. Nurses must be flexible with managing their time and judgment skills due to

multiple patient work loads, frequent interruptions, information and privacy requirements

(HIPPA), changing levels of care, and complex admission and discharge criteria. For example, I

completed a full adult admission to the unit during precepting last week, and the physician had

put an order in for Tramadol. With my clinical judgment skills, I had reviewed the patient’s

allergy history in the admission, and caught while my nurse was giving medications that the

patient was allergic to Toradol, which can cause adverse reactions to the patient. I made a call to

the MD and he was very gracious in accepting his error and thanked me for catching it. This was

a moment I really realized how important clinical judgment is in the clinical setting.
Clinical Nursing Judgment 4

Efficient clinical judgment helps to bridge the gap between bedside care and physician

orders to prioritize and provide valid and accurate decisions regarding these circumstances. I

have learned through making calls to several doctors that assessment of making these sometimes,

tough decisions, is based off of what can be used almost interchangeably with clinical judgment-

and that is the principle of critical thinking. “Both critical thinking and clinical nursing judgment

involves active questioning with assumptions, dialog, interaction, and continual reflection, and

self- evaluation” (Thompson, 2013). These two go hand and hand and are equally needed to

accomplish patient- centered goals and promotion of health. According to The International

Journal of Nursing Studies, “Critical thinking is purposeful conceptual thinking that includes the

processes of interpretation, evidence based analysis, contextualization, self- correction, and

regulation” (Thompson, 2013). Applying critical thinking to direct patient care situations means

utilizing these fundamental problem- solving and critical thinking skills of nursing, such as:

assessment, diagnosis, intervention, and the evaluation of outcome effectiveness. It is ultimately

the thought, problem- solving, and decision making process that creates nursing judgment and

makes it a core component of being a great nurse.

Obtaining Nurse Judgment

Within this section, three techniques will be analyzed on different ways that show how to

effectively teach and generate clinical nurse judgment among nursing students throughout their

education. Reflection, debriefing, and concept mapping will be reviewed in relation with

obtaining clinical nursing judgment. A study completed at Duke University examines the

relationship between reflection and debriefing with junior and senior undergraduate nursing

students by having them participate in three simulations. The students were then interviewed on

how they perceived the effects of the simulations helped with the development of clinical
Clinical Nursing Judgment 5

judgment skills. The study was conducted around the Reflective Debriefing After a Patient

Deterioration Simulation (REsPoND) method, which is based on the idea that reflection on

simulation can improve nursing students’ clinical judgment. “Reflection is framed as the

hallmark of debriefing, which sets it apart from the more one- sided evaluative feedback on a

student’s performance” (Coram, 2016). As a senior nursing student, I can relate to this statement

because in each of my clinical rotations throughout the program, we had pre- conferences and

post- conferences where debriefing occurred. Debriefing helped me to better understand my

mistakes and make changes to my actions as a future nurse. It was also beneficial to debrief with

a group of peers, while an experienced leader in the field guided the topics and conversations

allowing so much learning and opportunity for growth throughout the conferences. We would

seek out rationales for each and every intervention and prioritize those interventions based on the

patient’s specific diagnoses and outcomes.

Therefore, this helped to improve critical thinking skills and expand my clinical judgment

knowledge. Clinical instructors from the univerisity agree that, “Educational debriefing differs

from feedback or assessment, because it requires a two-way communication process between

educators and students to help the students understand specific situations and develop strategies

to implement in the future” (Coram, 2016). The findings of the study after reviewing the

student’s observations, concluded that the most active element in the simulations was conducted

through a systemic approach to assessment. The interviews highlighted the importance of

considering students’ expectations of a clinical situation through teaching strategies, such as,

debriefing and reflection aimed at clinical judgment development. This proves that reviewing

initial observations and actions will allow students to analyze their plan of care.
Clinical Nursing Judgment 6

The next research study was conducted by Kaddoura, M. to reveal that concept mapping

promotes critical thinking and supplemental learning among nursing students. The five phase

nursing process of assessment, diagnosis, planning, implementing, and evaluation helps students

develop a better grasp for appropriate plans of care. In this study, nursing students were required

to complete concept mapping on patients they provided direct care for and then evaluated their

experiences utilizing a Clinical Judgment Self- Evaluation Rubric (CSJR). The CSJR was then

reviewed by both the students and instructors to see how the technique contributed to the

students’ clinical judgment skills. A descriptive data analysis was also performed once the course

was completed. The study supports that the theory defining, measuring, and improving clinical

judgment through teaching techniques, such as concept maps; emphasizes critical reasoning and

decision making.

“Eighty-six participants evaluated their noticing as “excellent” on the rubric and

indicated that concept mapping helped them to gather both subjective and objective data”

(Kaddoura, 2016). It was also reported by the students that the concept mapping helped to put

emphasis on the most important information and data collection, while collaborating effective

interventions. “Another sixteen percent rated their noticing as “good” on the rubric, stating that

concept mapping helped them actively seek information about clinical situations” (Kaddoura,

2016). These findings suggest that concept mapping promotes self- directed learning and the

development of clinical judgment. “Through concept mapping and the emphasis on critical

reasoning, students can prioritize and organize problem severity, identify priority interventions,

and implement care for each individual patient” (Kaddoura, 2016). In our intensive care rotation,

we completed a concept map on a critically ill patient and from that experience, I can relate to

these studies as if I was one of the nursing students. I feel this was a very effective technique in
Clinical Nursing Judgment 7

gaining a better understanding of prioritizing a patient’s plan of care and my ability to make

accurate clinical judgments.

Conclusion

In conclusion, clinical judgment will come into play with every action taken as a nurse,

and in order to make good judgment even better, it is essential to have constant awareness.

Researching the patient’s history, chronic illnesses, allergies, treatments, education, and finding

the root of the issue will provide a backbone of knowledge when caring for that patient. Nursing

judgment is so critical, therefore, developing clinical reasoning skills is the foundation for

making accurate clinical decisions and providing overall safe patient care. This process is

ongoing and can be complex due to the ever rapid changing situations. As a nurse, it is crucial to

possess self- awareness and characteristics that reflect a strong moral compass regarding patient

advocacy.
Clinical Nursing Judgment 8

References

Cheng, B., Kaddoura, M., Shea- Foisy, K., & VanDyke, O. (2016). Impact of Concept Mapping

on the Development of Clinical Judgment Skills in Nursing Students. Teaching and

Learning in Nursing. 11, 101-108.

Coram, C. (2016, September). Expert Role Modeling Effect on Novice Nursing Students’

Clinical Judgment. Clinical Simulation in Nursing. 12, 384-392.

Thompson, C. Aitken, L., Doran, D., & Dowding, D. (2013). An Agenda for Clinical Decision

Making and Judgment in Nursing. Research and Education. International Journal of

Nursing Studies, 50(12), 1720-1726.