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Scholarly Capstone Paper

Emily Schrecengost

Youngstown State University

4852 Capstone

Dr. Ballone

February 2017
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Scholarly Paper

Critical thinking is a crucial element of nursing. Clinical judgment is the way nurses

incorporate critical thinking into their work. Clinical judgment directs the nurse to make

decisions and actions while ensuring health care quality and safety. These decisions are based on

the nurses observations, reflections, and analysis of information related to each patient. Clinical

nursing judgment is a complex concept that requires one to incorporate critical thinking,

reasoning, and opinions into their knowledge and experience to be competent in their work.

According to Loucine Huckabay (2009), a professor and director of nursing at California

State University, the nursing process enables nursing students and the practicing nurse to think

systemically and process pertinent information about the patient (p. 72). It gives the nurse the

ability to obtain valid data, create a nursing diagnosis regarding the obtained data, and devise a

plan of care. After that, the nurse will implement, evaluate, and revise the care. Huckabay claims

that critical thinking and accurate reasoning is required in each step of the nursing process (p.

72). Richard Paul and Linda Elders handbook (as cited in Huckabay, 2009) states the following:

Whenever we think, we think for a purpose with a point of view based on assumptions

leading to implications and consequences. We use data, facts, and experiences to make

inferences and judgments based on concepts and theories in attempting to answer a

question or solve a problem. (p. 73)

This quote defines clinical judgment very well. In any healthcare organization, nurses are

important decision makers (Thompson, Aitken, Doran, Dowding, 2013). As a nurse, every

thought that runs through your mind is imperative. We must think with a purpose at all times in

order to efficiently care for our patients properly. Our interpretations are some of the most
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substantial because we are the staff member that sees the patient the most. It is our duty to be

observant and knowledgeable at all times to make appropriate clinical judgment. Utilizing the

nursing process helps assist with critical thinking. The importance of clinical nursing judgment is

astounding. It could be the deciding factor between life and death of a patient.

I vividly remember a time during my clinical at Northside Hospital when I was

commended for my clinical judgment. I had just arrived to the hospital and was going into the

patients room to introduce myself and do an initial assessment. She was admitted for intractable

vomiting. When I entered, the patient was sleeping. I attempted to wake her up by quietly saying

her name. When I lightly shook her, she still didnt awaken. She was snoring, so I thought she

must just be a heavy sleeper. I was able to get her vital signs while she was sleeping, and they

were all within normal range.

After obtaining vital signs, I had a gut feeling that a problem existed. After a few more

minutes of shaking her and speaking loudly, she still did not wake up. I decided to alert my

clinical instructor, Mrs. Nalbach, of the situation. Unfortunately, she was off the floor with

another student. I quickly found the patients nurse and explained the situation to her. The nurse

and I went back into our patients room and she rechecked the vital signs. Again, everything was

within normal ranges. She brushed it off and said the patient is probably just exhausted and

sleeping heavily. Although I still felt uncomfortable, I believed the nurse and continued to do my

head to toe assessment on the patient. I thought to myself, Im just a nursing student, shes been

a nurse for a long time. She must know better than me. Shes also seen this patient all day

whereas I have no previous encounters with her.

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Once I finished my assessment, I attempted to wake her up again. Still, she did not

respond to me. Although I didnt know this patients normal actions, I knew something wasnt

right. I decided to get another opinion and finally found Mrs. Nalbach, who came to assess the

patient as well. She agreed that something didnt seem right. We decided to call the physician,

who promptly arrived to the room to assess the patient. The physician and residents attempted to

get an arterial blood gas (ABG) while also applying painful stimuli to the patient. The patient did

not react to the multiple ABG attempts, fingernail pressure, loud yelling, or aggressive shaking.

When one of the residents performed a sternal rub on the patient, she finally woke up.

When the patients ABG results showed no abnormalities, the doctors decided to do a

CAT scan on the patients brain. This test revealed that the patient had a brain tumor that was

likely causing her vomiting that brought her to the hospital initially as well as these intermittent

comatose states. The nurse and Mrs. Nalbach both came up to me afterwards and told me I did a

wonderful job at being observant and promptly reacting to a situation. My instructor also said

that if it werent for me, this situation could have been discounted and the CAT scan revealing

her brain tumor could have never occurred. It was this clinical experience that taught me to trust

my clinical judgment. Because of my actions, a patient was not overlooked.

The article Nursing Judgment: Educating Nurses to Make Decisions in Practice by

Mary Schoeelser et al. (2012), declares that instinctual, critical, or narrative processes are used to

develop an action when there is a potential issue. You cannot begin the process of clinical

judgment until you notice a problem is present. Once you declare there is a problem, this is

when ones knowledge is comes into place. Having background knowledge as well as knowing

the context of the situation allows one to notice any abnormal occurrences. In my clinical

experience mentioned earlier, I immediately noticed a problem. Even though I knew very little
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about this specific patient, I was aware that it is abnormal for a patient to be unresponsive to

shaking and yelling. Although the nurse told me not to worry, my knowledge and my instinct still

told me to take action.

A question commonly asked is if clinical judgment can be taught. Can education improve

a nurses ability to make critical decisions? In Thompson and Stapleys systemic review (2011),

it was found that educational interventions work, but not consistently. Only in some situations

did the interventions provide positive results. Thompson and Stapley also stated that it is difficult

to measure the effectiveness of instructive interventions regarding critical thinking because of the

vast number of possible interventions possible. Educators use a wide variety of teaching methods

as well.

Schoessler et al. (2012) suggest that clinical judgment can be taught. In this article, it

declares that simulation activities allow students to strengthen their critical thinking skills by

walking them through a situation step-by-step and helping them explore their thinking process.

The use of debriefing allows the student to receive feedback from the faculty about their actions.

Per Schoessler et al., nurse educators have the responsibility for creating the learning pathways

to ensure that nursing judgment is a key program outcome (p. 422).

In closing, clinical nursing judgment is a multifaceted term. It is the way nurses interpret

certain findings and make appropriate actions regarding a patients care. Whether or not

education improves clinical judgment, critical thinking and problem solving are extremely

important in nursing.
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References
Huckabay, L. M. (2009). Clinical Reasoned Judgment and the Nursing Process. Nursing
Forum, 44(2): 72-78. doi:10.1111/j.1744-6198.2009.00130.x

Schoessler, M., Brady, M., Engelmann, L., Larson, J., Perkins, I., & Shultz, C. (2012). Nursing
Judgment: Educating Nurses to Make Decisions in Practice. Nursing Education
Perspectives (National League for Nursing), 33(6): 422.

Thompson, C., Aitken, L., Doran, D., & Dowding, D. (2013). An Agenda for Clinical Decision
Making and Judgement in Nursing Research and Education. International Journal of
Nursing Studies, 50(12): 1720-1726. doi:10.1016/j.ijnurstu.2013.05.003

Thompson, C., & Stapley, S. (2011). Do Educational Interventions Improve Nurses Clinical
Decision Making and Judgement? A Systematic Review. International Journal of
Nursing Studies, 48(7): 881-893. doi:10.1016/j.ijnurstu.2010.12.005