Clinical Nursing Judgement

Sarah Newman

Youngstown State University

NURS 4852

Dr. Ballone

02/28/2018
 Clinical judgement is a topic that should be discussed thoroughly during pre-licensure

education. Nursing students are expected to develop clinical judgement skills by graduation.

When looking at clinical nursing judgement, Tanner (2006) defined it best as “The term ‘clinical

judgment’ means an interpretation or conclusion about a patient’s needs, concerns, or health

problems, and/or the decision to take action (or not), use or modify standard approaches, or

improvise new ones as deemed appropriate by the patient’s response” (p. 204).

Tanner reviewed nearly 200 studies on this topic and concluded that there are five major

aspects that summarize clinical nursing judgement. First, “Clinical judgments are more

influenced by what nurses bring to the situation than the objective data about the situation at

hand” (Tanner, 2006 p.204). Clinical nursing judgement, therefore, is not just the concepts

learned, but also about listening to that “internal voice” and blending the two in action. Second,

“Sound clinical judgment rests to some degree on knowing the patient and his or her typical

pattern of responses, as well as an engagement with the patient and his or her concerns” (Tanner,

2006 p. 204). This affirms the connection between a nurse and patient and reminds us that the

“patient in room 9” is an individual with needs. Third, “Clinical judgments are influenced by the

context in which the situation occurs and the culture of the nursing care unit” (Tanner, 2006 p.

204). In other words, no one patient on a unit will respond in the same way as the others. Nurses

must flex to individual situations. Fourth, “Nurses use a variety of reasoning patterns alone or in

combination” (Tanner, 2006 p. 204). Each mind interprets situations uniquely. Frequently, a new

point of view can strengthen an individuals’ clinical judgement. Fifth, “Reflection on practice is

often triggered by a breakdown in clinical judgment and is critical for the development of

clinical knowledge and improvement in clinical reasoning” (Tanner, 2006 p. 204). Good nurses
sometimes make mistakes. Great nurses learn to turn their mistakes into improved future

outcomes.

According to Tanner, 2006 “Clinical judgments require various types of knowledge

which is abstract, generalizable, and applicable in many situations and is derived from science

and theory; which grows with experience where scientific abstractions are filled out in practice

and that which is highly localized and individualized, drawn from knowing the individual patient

and shared human understanding” (p. 206). Experienced nurses develop these traits through

practice. New graduates “must learn how to recognize a situation in which a particular aspect of

theoretical knowledge applies and begin to develop a practical knowledge that allows

refinement, extensions, and adjustment of textbook knowledge” (Tanner, 2006 p. 206).

In 2017, Joyce Victor, PhD, RN-BC, CHSE-A devoted her time to improving nursing

judgement in pre-licensure students. Victor, 2017 used Kolb’s model of experiential learning

(1984), Tanner’s model of clinical judgment in nursing (2006), and independent samples to

examine differences in clinical nursing judgement development scores. Looking at the difference

between students who completed the nursing program before the introduction of an Experimental

Learning Theory (ELT) based simulation and those who completed the program after the

adoption of the ELT for all Scenario Based Learning (SBL) activities she determined “SBL

experiences should be designed to progressively challenge students so they can develop

knowledge, skills, clinical reasoning, and clinical nursing judgment” (Victor, 2017 p. 733). The

study concluded that there was an increase in clinical nursing judgement in those students whose

baccalaureate program SBL activities used an ELT design. Victor then went a step further and

examined not only simulation participation, but also clinical participation on a pre-licensure

student’s nursing judgement. The Creighton Simulation Evaluation Instrument (C-SEI) was used
to evaluate performance in the simulation setting and the CCEI was used to evaluate

performance in the clinical environment. These instruments measure performance in 4

categories: assessment, communication, critical thinking, and technical skills (Victor, 2017 p.

237). Raters would observe student behaviors during an SBL activity and rate clinical nursing

judgment development behaviors on a scale of 1 (beginning) to 4 (exemplary) (Victor, 2017 p.

237) and concluded “Results of this study support the use of SBL as an interactive strategy in

prelicensure nursing education to develop clinical nursing judgment” (p. 238). There was also a

correlation between how students responded in simulation and their performance in the clinical

setting. While nursing students often do not take simulation seriously, these results emphasize

how important simulation can be to the development of a new nurse’s clinical judgement.

My clinical nursing judgement has improved as a result of classroom simulations.

Comparing my first simulation experience to my most recent, I see how much I have developed.

Fear influenced my first simulation and the inclination to take lead was not present. During my

last simulation, I experienced no fear, finding myself easily working with my teammates. I was

calm, able to work through each situation, and readily able to utilize the concepts learned even

though I also made mistakes. One in particular, is a mistake that I will never forget. In this

simulation we had a patient code. We all rushed to react and not one of us stopped to notice that

this particular patient was a DNR, not realizing until mid-chest compressions when the

“physician” pointed this out to us. This mistake has stuck with me and I am grateful for having

had the opportunity to make this mistake in a lab. Because of this, one of the first things I do

when entering a patient room is to check wrist bands and ensure that they match the chart. This

may be an example of the mild side of nursing clinical judgement, but safety is never a wrong

side to error on.

References:

Tanner, C. (2006). Thinking like a nurse: a research-based model of clinical judgment in nursing.

Journal of Nursing Education, 45(6), 204-211

Victor, J. (2017). Improving clinical nursing judgment in prelicensure students. Journal of

Nursing Education, 56(12), 733-736.

Victor, Joyce PhD, RN-BC, CHSE-A; Ruppert, Wanda MS, RN; Ballasy, Sara MS, RN

(2017). Examining the Relationships between Clinical Judgment, Simulation

Performance, and Clinical Performance. Nurse Educator, 42(5):236-239