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Clinical Nursing Judgement

Joni Neal

Youngstown State University

NURS 4852 Senior Capstone

March 13, 2017

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The concept of clinical nursing judgement is not necessarily understood by the general

nursing public. A study by van Graan, Williams, and Koen found that nurses often confuse

clinical judgement with good nursing care (284). Although clinical nursing judgement is

intertwined with good nursing care, it is more complex than that. Clinical nursing judgement

has been recognised as a vital skill that enables nurses to determine the appropriate nursing

interventions when planning patient care (van Graan, 281). It is inherent in the processes of

assessment, diagnosis, implementation, and evaluation (van Graan, 281). And those processes

are inherent to the practice of nursing.

Dowding et. al believe that there are three requirements to teaching clinical nursing

judgement: that students develop knowledge or domain expertise in their field of practice, that

they possess the thinking skills to use that knowledge effectively, and that they have an

understanding of what constitutes good decision making practice (Dowding, 349). These three

requirements make up clinical nursing judgement: using knowledge and domain expertise with

critical thinking skills to make appropriate decisions dictating nursing care. Some also believe

that it also includes a nurses intuition and I would have to agree. Sometimes a nurse can just

tell when something is up in his or her gut.

Clinical nursing judgement is extremely important because it saves lives. Nurses are the

front line in patient care. They are there providing the hands on care to patients every day and

are the first people to notice even subtle changes in patient condition and can act to maintain

patient safety and wellbeing. Because of this importance, nurses need to think critically,

self-critique, synthesize information, link concepts and become self-directed, reflective, lifelong

learners (van Graan, 282).

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It is also important to recognize that judgement and decision-making skills develop and

change with experience and expertise (Dowding, 358). This can lead to confidence in nursing

care, but overconfidence in judgements such as critical event risk assessment may result in

delayed or inappropriate interventions (Yang, 2). Yang, Thompson, and Bland did a study on

the the effect of clinical experience, judgement task difficulty, and time pressure on nurses

confidence calibration in a high fidelity clinical simulation. They found that simply being

clinically experienced did not help a nurses performance in a high fidelity situation, just

increased the chance that the nurse would be overconfident. Time pressure had an effect too;

time pressure increased confidence in easy cases and decreased confidence in difficult cases.

Yang et al. concluded that their findings highlight the need for nurses to recognise the

uncertainty associated with clinical judgements they face if their clinical judgements are to be

the best possible (Yang, 8). Nurses should trust themselves but should not become so

comfortable in their skills that they miss little things that they once might have caught.

I believe that I have had many experiences where I used clinical nursing judgement, in

clinical but also working as a nurse aide on the medical surgical floor. I worked the midnight

shift and the nurses were often understaffed so I was the one who was doing hourly rounding

and sometimes I was able to use nursing judgement. In one instance in particular I had a

disoriented patient who by 4:00am had no urine output for my shift. Using my knowledge that

usually a person should have about 30 ml/hr output, I knew that something might be up. I

assessed their abdomen and noticed what I thought to be a distended bladder. I checked the

chart and no output had been charted on this patient for the entire day. This could have been a

charting error or could have been that the patient had no output.
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I bladder scanned the patient for 999 ml, which is the highest the scanner will report. I

then reported all this information to my nurse, who then called the doctor and got an order for

a straight cath. The patient was not able to communicate any discomfort and I may have

helped the patient avoid a very serious issue by being vigilant and using my knowledge and

judgement to take action for the patient.

Another instance where I believe that I used clinical nursing judgement is when I kept an

elderly mentally disabled patient from having a very long and uncomfortable night. The patient

was complaining of having an upset stomach and had been vomiting off and on for a couple of

hours. From what I can recall, there was no correlation to the patients presenting problems or

diagnosis and vomiting. I mentioned it to the nurse that was caring for the patient and she

shrugged it off as an emotional disturbance. I however had saw something strange in the

patients allergies. The patient was allergic to legumes. Not an individual legume; the entire

legume family. I made an educated guess that an allergy like that probably predisposed the

patient to being exposed to allergens regularly.

I investigated and it appeared as though the patient had recently eaten two hospital

vanilla ice creams. A brief scan of the ingredients label and a google search revealed that the

ice cream contained guar gum, a member of the legume family. The patient had unknowingly

eaten an allergen. I alerted the nurse who contacted the physician and was able to give the

patient Maalox and relieve the patients symptoms.

Clinical nursing judgement is an important aspect of nursing care that synthesizes

everything a nurse learns in the nurses education and the nurses overall experiences with

critical thinking and decision making. It is at the root of everything nurses do and its
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understanding is important to its teaching and the goal of forever bettering oneself in the

nursing practice.
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References

Dowding, D., Gurbutt, R., Murphy, M., Lascelles, M., Pearman, A., & Summers, B. (2012).

Conceptualising decision making in nursing education. Journal of Research in Nursing,

17(4), 348-360. doi:10.1177/1744987112449963

van Graan, A. C., Williams, M. J., & Koen, M. P. (2016). Professional nurses' understanding of

clinical judgement: A contextual inquiry. Health SA Gesondheid, 21, 280-293.

doi:10.1016/J.HSAG.2016.04.001

Yang, H., Thompson, C., & Bland, M. (2012). The effect of clinical experience, judgment task

difficulty and time pressure on nurses confidence calibration in a high fidelity clinical

simulation. BMC Medical Informatics and Decision Making, 12(1), 113.

doi:10.1186/1472-6947-12-113