Running head: CLINICAL NURSING JUDGEMENT

Clinical Nursing Judgement:

A Commentary on Autonomy

Alexis Hertz

Youngstown State University

 2
CLINICAL NURSING JUDGEMENT

Clinical Nursing Judgement: A Commentary on Autonomy

Clinical nursing judgement is a crucial component to the outcome of patient care as well

as the professionalism of nursing. Much like the scientific method, clinical judgement combines

intellect, experience, observation, analysis, and logical deduction skills to ultimately improve

patient outcomes quickly, precisely, accurately, and efficiently. According to Papathanasiou et al.

(2014), critical thinking is an essential process for the safe, efficient, and skillful nursing

practice. Nursing, in a sense, is much like a puzzle. The nurse must look at the pieces, gather and

associate information, and put them together to gain insight on the picture as a whole. Using

clinical judgement allows the nurse to identify, associate and interpret the signs or symptoms of a

given condition, and once all the components are pieced together, an action and decision must be

made to deliver safe and appropriate care. Some of these skills are acquired only through

experience and effective communication throughout the healthcare providers. New graduate

nurses may lack the time and experience, which in return may inhibit clinical nursing judgement.

Once self-actualization is achieved in ones nursing career, autonomy in their practice will

continue to grow along with their clinical nursing judgement abilities.

Clinical nursing judgement is a skill built upon experience. Nurses move through

developmental stages beginning as a novice then continuing to move through the stages of

beginner, to competent, proficient, and finally expert practitioner (Phaneuf, 2008). Most

advanced beginner nurses follow unit protocol and procedures to make clinical nursing

judgements (Benner, Hughes, & Sutphen, 2008). When presented with a multifaceted and

complex case, novice nurses had a hard time making clinical judgement that they deemed safe

and competent for the situation. Therefore, the advance beginner relies on the communication
 3
CLINICAL NURSING JUDGEMENT
and collaboration with other experienced or expert nurses to gain insight on a situational matter.

This is one of the first steps to recognizing what it means to be able to make clinical judgement

from deductive reasoning, observation, communication, and a previous body of knowledge. As

stated by Benner et al. (2008):

Competent nurses continuously questioned what they saw and heard, feeling an

obligation to know more about clinical situations. In doing do, they moved from only

using care plans and following the physicians orders to analyzing and interpreting

patient situations. Beyond that, the proficient nurse acknowledged the changing

relevance of clinical situations requiring action beyond what was planned or anticipated.

Nurses not only have to make clinical judgements frequently, they must also be accurate. The

conclusions made by the nurse influences decisions of subsequent patient care. Clinical

judgement in nursing leads to the identification and logical interpretation of symptoms as well as

the planning of care to alleviate or prevent complications. Coming to the correct and appropriate

conclusion is half of the battle, this process relies on the nurses preceding pool of knowledge

and experience.

Student nurses may feel like they are deficient the skills of clinical nursing judgement

because of the lack of actual nursing experience with decision making. Educators try and

alleviate this shortfall by providing students with the opportunity to become involved with a

preceptorship, onsite clinical experience, and offsite simulations. Simulations provide students

with the opportunity to practice critical thinking skills along with clinical judgement within a

safe and controlled environment under the supervision of an instructor. Simulation provides an

alternative way of learning and practicing clinical nursing judgement, the nurse is presented with

a situation that facilitates the student nurse to use signs and symptoms observed to make clinical
 4
CLINICAL NURSING JUDGEMENT
judgements. The simulation usually includes a concerned family member which adds to the

realism of the scenario. A group of student nurses work together to gather information and

interpret data while simultaneously comforting family members. The student nurses collaborate

and brainstorm ideas to correct the situation at hand and provide optimum patient care based on

clinical judgement. Another advantage to simulation is the feedback provided by the instructor at

the end of the scenario. Through this experience, student nurses have a better understanding of

critical thinking and clinical judgement skills.

In my educational career as a student nurse I have both witnessed and performed clinical

nursing judgement. As I wrap up my education, clinical nursing judgement has become a more

prevalent entity in my practice as a nurse. With my time at my preceptorship in the SICU at St.

Elizabeths Belmont campus, I have learned what it means to make clinical nursing judgements

in several different situations because of the large variety of patients that present in the SICU.

According to Thompson, Aitken, Doran, & Dowding (2013), acute care nurses face a decision or

judgement task every 10min, while critical care nurses make clinical judgment as frequently

as every 30seconds. I believe this statement is accurate in describing the fast-paced skills

required in any ICU setting. In one instance in the SICU, a patient had suffered an epidural

hematoma due to a fall on aspirin. I received report from the day time nurse and he reported that

he had given her fentanyl as ordered by the physician for pain and that she was alert and oriented

x4, follows commands, and responds appropriately. After receiving report, I continue with my

assessment and I could not arouse the patient. I used a sternal rub and called the patients name

and asked her to squeeze my hand. The patient withdrew from pain; however, she did not follow

commands or open her eyes to my voice. The patient was not on any type of sedation and this

observation was startling to me. I continued with a neurological exam because I reviewed in the
 5
CLINICAL NURSING JUDGEMENT
chart from a previous CAT scan that she had suffered a midline shift of the brain after the fall.

Her pupils were round, equal, and reactive to light, but she was unable to follow my commands.

I immediately sought the guidance of my preceptor and he explained to me that her change in

mental status could be due to continued herniation in the brain or because of the fentanyl she

received. We reviewed in the chart that the fentanyl was given at 0900; however, we were

assessing her at 1600 which seemed to be a very long time for the patient to be experiencing

continued sedation effects from the fentanyl. We then proceeded to examine her lab work, but

nothing seemed to stick out. I made the clinical judgement to ask the physician to examine the

patient and made a recommendation to send her back to CAT scan to identify and changes to the

hematoma. The physician agreed and we then proceeded to CAT scan. I had to use clinical

nursing judgement to decide whether the altered mental status was due to the fentanyl and

alterations in her drug metabolism, or if her head injury had worsened. I was lucky enough to

have a physician on site and by the bedside to assess the patient, but nurses are the patient

advocate. Nurses must recognize a situation and make clinical nursing judgement based on

rational and deduction.

Clinical nursing judgement is an acquired skill through time, practice, expertise, and

confidence. Nursing is a complex profession that requires integrity and accountability in their

autonomy as a practitioner. Nursing not is not just a nice paycheck, one must be absolutely

dedicated to the craft and patient, while maintaining the satisfaction of improving patient

conditions. A quote from Papathanasiou et al. (2014) encompasses and concludes this study on

clinical nursing judgement: Nursing students in order to learn and apply critical thinking should

develop independence of thought, fairness, perspicacity in personal and social level, humility,

spiritual courage, integrity, perseverance, self-confidence, interest for research and curiosity.
 6
CLINICAL NURSING JUDGEMENT

References

Benner P, Hughes RG, Sutphen M. (2008). Clinical Reasoning, Decisionmaking, and action:

thinking critically and clinically. Hughes RG, editor. Patient Safety and Quality: An

Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare

Research and Quality (US); Chapter 6. https://www.ncbi.nlm.nih.gov/books/NBK2643/

Papathanasiou, I. V., Kleisiaris, C. F., Fradelos, E. C., Kakou, K., & Kourkouta, L. (2014).

Critical thinking: The development of an essential skill for nursing students. Acta

Informatica Medica, 22(4), 283286. http://doi.org/10.5455/aim.2014.22.283-286

Phaneuf, M. (2008). Clinical judgement An essential tool in the nursing profession. 4.

http://www.infiressources.ca/fer/Depotdocument_anglais/Clinical_Judgement%E2%80%

93An_Essential_Tool_in_the_Nursing_Profession.pdf

Thompson, C., Aitken, L., Doran, D., Dowding, D. (2013) An agenda for clinical decision

making and judgement in nursing research and education. Internal Journal of Nursing

Studies. 50(01), 1720-1726.