RUNNING HEAD: Clinical Nursing Judgment 1

Clinical Nursing Judgment

Abstract

Clinical nursing judgment is a complex and critical aspect of nursing. There is

common research shown that more experienced nurses act with more of an intuition

while making their assessments and judgment as compared to new graduate nurses.

Different research proposes models and plans in order to help improve the nursing

judgment and ways that nurses will quickly pick up on cues to find what is causing

deterioration in patients. One of the major key factors is to act in a timely manner and

implement the needed intervention in order to improve patient outcomes who have

suffered an adverse complication.

Clinical nursing judgment or clinical reasoning is a very important component of

nursing that should hold more importance than other aspects. Clinical judgment often

deals with nurses being able do assess, determine what the issue, generate alternatives,

weigh the options and choose the most appropriate action to take next (Tanner, 2006).

While being on the cusp of graduation and being a nurse on our own, it is a very

important topic that needs addressed with all nurses, including new graduates.

Nursing judgment is a complex issue with multiple components, one that I think

takes high priority is in situations where there is a patient in an acute care setting. Often,

patients who are in an intensive care environment have the potential to make changes in

their status, very quickly. Typically there are warning signs that will alert someone that

an adverse incident is going to occur, but, if the nurse or other hospital staff does not pick

up that sign right away, it could be extremely detrimental. ‘Failure to Rescue’ is defined

as mortality of patients who experienced a hospital acquired complication directly related

to the quality of care and nursing judgment made by the nursing staff (Levitt-Jones,

2009) They have identified three main reasons for poor outcomes during adverse

complications: failure to properly diagnose, failure to institute appropriate treatment, and

inappropriate management of complications (Levitt-Jones, 2009).

It has been found that nurses with experience tend to have and intuitive way of

thinking when it comes to clinical judgment and is almost automatic when providing

care. In order to teach new nurses, Levitt-Jones explains a clinical reasoning model,

which emphasizes the different aspects including: The right cues, the right patient, the

right time, the right action and the right reason (Levitt-Jones, 2009). When discussing the

right cues, it is any physiological or psychosocial need of the patient. According to

Levitt-Jones, “making judgment or decisions based on incomplete information is the

leading cause of mistakes.” It is found that it is more difficult for students to pick up on

cues because not only do they need to recall information, but also, it needs to be applied

and tied into one patient. Levitt-Jones uses the example providing that the patient

presents with oliguria, hypotension and tachycardia – not only does the student nurse

need to identify those three aspects, but they also need to tie together that the patient may

be presenting with hypovolemic shock. There are also instances when incomplete

assessments are done, and a sign, symptom or cue is attributed to something unrelated for

lack of assessment.

When discussing the right patient, they are referring to the nursing student

prioritizing the right patient over another, dependent upon their acuity. Tanner believes

that it is crucial for students to identify the patient who is at greater risk (Tanner, 2006).

As for the right time in critical judgment, it is imperative that nurses can identify a

warning sign in a timey manner and intervene appropriately. Failure to rescue is not only

occurring when assessments are not made, but when they are made and interventions are

started too late. The right action is what the nurse does after making a judgment or

assessment. For students, Levitt-Jones attributes lack of confidence as a downfall. She

believes that even if students are unsure, going to a senior staff member or asking for

help could be appropriate action, but the student needs to be confident enough in their

decision-making and assessment. Lastly, the right reason is deemed if the action taken is

ethical, legal and professional. If students do not understand the 5 steps in decision

making with clinical judgment, there is a vast increase in the amount of poor outcomes

when a patient succumbs to an adverse complication.

In the application to my own nursing judgment, one experience I can recall dealt

with an intubated and sedated patient. Although it may not be an extreme case or an issue

that was life threatening, it did have regard to the patient care and comfort. Upon

assessing the patient, he was showing agitation, while grabbing at the bed and constantly

trying to move, although he was in two-point restraints. As he was on a continuous

propofol drip, to reduce the anxiety and discomfort, it would have been easy to just

increase the amount of propofol he was receiving. After taking more time to assess the

patient, I had realized that the moving and agitation was due to pain, and he needed pain

medication rather than increased sedation. After giving more of the ordered PRN pain

medication, after checking back in with him, he seemed much more comfortable and the

agitation and discomfort stopped without changing the rate or level of sedation. Even

though this is a minor judgment call in comparison to others, while being in an intensive

care unit for my clinical and preceptorship, this occurs more often than not, where nurses

will be quick to increase the sedation rather than find the underlying cause of agitation.

With the common ground of all research, nurses gain clinical judgment with their

knowledge and experience. Novice nurses still may find this difficult whereas

experienced nurses rely more so on their intuition. Clinical reasoning may be the viewed

as the hallmark of being the expert nurse and an essential component of competent

nursing shown in experienced nurses (Banning, 2007). As all nurses have to begin

somewhere, experience only comes with time. As there are many factors that affect the

complex issue of nursing judgment, I believe it all begins with a basis of a good

assessment of the patient and understanding the patients overall needs, making it more
RUNNING HEAD: Clinical Nursing Judgment 6

clear when the patient is giving cues into a deteriorating state. If all novice nurses follow

the five rights of clinical reasoning, there is a better chance for a positive outcome.
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References

Banning, M. (2007, June 7). Clinical reasoning and Its application to nursing: Concepts
and research studies. Retrieved March 18, 2018, from
http://libportal.medilam.ac.ir/documents/10129/36460/Clinical reasoning and its
application to nursing Concepts and research studies.pdf

Levitt-Jones, T., Hoffman, K., Dempsey, J., Noble, D., & Norton, C. A. (2009, October
30). The 'five rights' of clinical reasoning: An educational model to enhance
nursing students' ability to identify and manage clinically 'at risk' patients.
Retrieved March 18, 2018, from

Tanner, C. A., PhD, RN. (2006, July). Thinking like a nurse: A research-based model of
clinical judgment in nursing. Retrieved March 18, 2018.