Running Head: SCHOLARLY CAPSTONE PAPER 1

Scholarly Capstone Paper:

Clinical Nursing Judgment

William Erskine

Youngstown State University

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Clinical decision making and judgment is a vital component of the nursing profession at

the core. The skill of clinical decision making is becoming more important than ever as

technology advances and the healthcare environment continues to grow in complexity,

demanding higher cognitive skills from nurses. It is a common thought that entry level nurses do

not meet the expectations for the entry level clinical judgment, requiring further educational

experiences to prepare for such actions. Clinical judgment is something that is thought to

progress with time and experience along with the development of critical thinking skills. One

barrier for graduate nurses may be the amount of focus it takes to look at the individual tasks and

orders at hand rather than developing autonomy and decision making skills on their own accord.

One of the largest barriers identified to the development of Clinical Judgment is the lack of

accompaniment, described as the conscious, purposeful guidance and support of students in the

clinical environment to empower them (Graan, Williams, & Koen 2016).

One may question the importance of Clinical Judgment, or ask why is the exploration of

this topic so important?. According to Thompson, Aitken, Doran, & Dowding (2013),

Worldwide, 19 million nurses (WHO,2011) will exercise their clinical judgment before making

choices with, for, and on behalf of patients. These patients trust nurses to make decisions that do

more good than harm (p. 1721). The number of nurses making decisions daily is staggering

alone, however, the estimations of frequency are even more difficult to believe. Acute care

nurses are thought to make a decision or judgment action every ten minutes, while critical care

nurses are thought to make similar judgment actions or decisions every thirty seconds

(Thompson et al., 2013). These numbers point directly at the reason for necessity of continuing

research into the development of clinical judgment as well as the barriers to the development of
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such in new graduate nurses. Although it is thought these nurses do not have the experience or

base skills necessary in Clinical Judgment upon working, they are, however, still required to

make those judgment calls every ten minutes as soon as they begin as a staff nurse. Thompson et

al. (2013) stated the following:

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 (Doran et al., 2006). 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. (p. 1721)

If the variations above are not addressed, one may argue it is logical to assume as the

number of potential intervention/decisions are increasingly available to nurses increases, the

variability in such decisions/interventions will also increase. Understanding why these variations

occur are a key component in improving practice and Clinical Judgment decision making in

nurses. Two of the main causes of variations identified by Thompson et al. (2013) are the lack of

adaptive reasoning, or the ability to apply previous clinical/theory based knowledge and apply it

to a new, slightly different situation, as well as lacking in the ability to identify critical

information to making a clinical judgment (i.e. not knowing what you dont know). (p. 1722)

Nursing theory facilitates the development of nursing knowledge and provides principals to

support nursing practice (Matney, Avant, & Staggers 2015). Making advancements in these

areas through continuing education and placing focus in theory on application of the knowledge

in the clinical setting (even when circumstances are not ideal) may prove important to the

development of clinical judgment skills in nurses around the world.

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In my short nursing career, I have gotten to see the application of clinical judgment first

hand a number of times. This has become more prevalent as I have completed my final year of

nursing school and spent a semester on the ICU at Trumbull Memorial Hospital and precepting

on the CMIC at St. Elisabeths, downtown Youngstown. When I think of the term Clinical

Judgment as it applies to nursing and my specific practice there is one specific situation that

comes to mind. I was caring for a patient in the ICU who was in the hospital for an AKI which

was suspected to be resulting from uncontrolled diabetes. The patient also had other kidney

complications that ultimately led to the placement of renal stents. I was caring for the patient the

second day after placement. One of the primary goals was fluid management, specifically

flushing the patients kidneys by running Normal Saline at 150 Ml/hr. The morning of care I had

spent time looking through my patients chart and noted they had a cardiac history including

CHF. This was slightly concerning knowing we were loading fluids on board quite quickly. In

report the patient was said to be tolerating therapy well with stable vital signs and no assessment

data indicative of complications. Upon my entry into the room and beginning of assessment, I

felt strongly that this was not the case. The patients SPO2 began dropping slowly and was

around 90-91% while on a NC 4L (no O2 at home). The more concerning portion of the

assessment arose when I noticed bilateral crackles through the upper and lower lobes, much

more severe in the lower lobes. I also noted JVD in the patient. I called for the cover nurse to

have a look at the patient and ask for her opinion. She stated she was busy in another room and

was not going to call the physician because the patient needed the kidneys to be flushed. At this

point in time, I had to make a clinical decision. I, along with my instructor, called for the

nephrologist who was already on his way to the unit to make rounds. I informed him of my
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findings and suggested stopping or slowing the fluids. The physician agreed, ordering to slow the

IV to KVO and consult cardiology so they could work conjunctly to focus on all aspects of care.

On the ICU, these types of decisions and fast actions are required daily by the nurses. At times,

the ability to contact an attending may not be an option and decisions must be made by a charge

nurse or with residents on the unit. This small situation is one which exemplifies the importance

of Clinical Judgment development in nurses in all fields of care.

Clinical judgment is a very in depth topic that can be analyzed from several different

angles. Whether assessing the causes for deficit in clinical judgment or the solutions to better

nurses ability to make such judgment, the general consensus seems to be that there is still plenty

of room for progress in our scope of care. This topic will continue to grow in importance as the

responsibility of all health care workers, specifically nurses, grows with time and technology.

Moving forward with my career it is an area I feel must be made a focal point in my continuing

education as I look to not only better myself in clinical judgment abilities, but to also better

others ability to develop these skills as well.

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References

Graan, A. C., Williams, M. J., Koen, M. P., (2016). Professional nurses

understanding of clinical judgment: A contextual inquiry. Health SA

Gesondheid, 21(01), 280-286.

Matney, S., Avant, K., Staggers, N., (October 30, 2015). "Toward an

Understanding of Wisdom in Nursing" OJIN: The Online Journal of Issues in

Nursing Vol. 21 No. 2.

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

clinical decision making and judgment in nursing research and

education. Internal Journal of Nursing Studies, 50(01), 1720-1726.