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What is Clinical Nursing Judgment?

What is Clinical Nursing Judgment?

Daelyn A. Lazor

Department of Nursing, Youngstown State University

NURS 4852: Senior Capstone

Dr. Kim Ballone, DNP, APRN-CNP and Mrs. Wendy Thomas, MSN, RN, CNS, FNP

March 2, 2020
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What is Clinical Nursing Judgment?

What is Clinical Nursing Judgment

Over the past three years, clinical nursing judgment has been looked at and reiterated

multiple times in lecture, clinical and nurse practicums. In order for a nurse to be the best he or

she can be and provide the best quality and safe care to their patients, one must master the

skillfulness of using clinical nursing judgment. How one learns and is proficient in nursing

judgment comes from past experiences, education and ones learning style. Every day nurses,

whether in the hospital, home care, outpatient facilities or wherever they work must make

numerous decisions pertaining to clinical practice daily in order to make the best decisions for

their patients and to ensure the best outcomes. At the same time, they have to balance multiple

tasks and make important decisions, while still providing the best quality care to their patients.

So now what is Clinical Nursing Judgment? According to NCLEX Next Generation

clinical nursing judgment is defined as “the observed outcome of critical thinking and decision

making. It is an interactive process that uses nursing knowledge to observe and assess presented

situations, identify a prioritized client concern and generate the best possible evidence-based

solution in order to delivery safe client care” (2019). Wendy Manetti described clinical

judgment from a theoretical point of view. She stated that

“a sound clinical judgment is a cognitive process in which the nurse forms a holistic

assessment of a patient situation. Critical thinking, clinical reasoning, practical wisdom,

and intuition are used in the decision-making process that ensues. Through careful

deliberation, the nurse chooses among alternative actions in light of anticipated outcomes

in the best interest of the patient. The nurse reflects on and monitors the patient’s
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What is Clinical Nursing Judgment?

responses and modifies actions accordingly. Afterward, further reflection empowers the

nurse with the improved judgment for future situations”(Manetti, 2018, p. 106-107).

When I think about my definition of clinical nursing judgment, I think it is the ability to make

the best decisions and solve problems that will result in the best outcomes based on your

patient’s needs, wants, health status and what is in their best interest.

Now that we see some of the professional definitions of clinical judgment, why is it so

important to incorporate it in your daily nursing practice? Having good sound clinical nursing

judgment is the most important skill a nurse can have in their profession and is the foundation of

quality care nursing (Manetti, 2018, p 102). Reason being, if the nurse does not have good

nursing judgement then they are unable to make the best plan of care for their patients. For

example, a patient weighs 300lbs and is 1 day postoperative for lower back surgery. During the

plan of care process, the nurse goes in to do the shift assessment and to obtain shift vital signs.

The nurse notices that the patient’s blood pressure is 80/50 and heart rate 121. As a result, the

nurse has concerns and proceeds to turn the patient to check out the patient’s incision. Upon

turning the patient, the nurse sees the patient is hemorrhaging from their back incision. Without

the knowledge of what the vital signs should indicate, the patient could have bled out. As a

nurse, you must maintain sound medical judgement decisions about patient care; while still being

open to new ideas or changes in the plan of care that has been created for your patient. There are

many factors that affect clinical nursing judgement such as education, experience, emotions,

knowledge, time, distractions, how hard the task is, professional autonomy and the ability to

think critically. There was a study done by Mary Cazzell and Mindi Anderson that looked at the

impact critical thinking had on clinical judgment during a stimulation with Senior Nursing
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What is Clinical Nursing Judgment?

students. In this study, they examined the student’s ability to administer medication to a

hypertensive pediatric patient in a simulation and their ability to critically think while performing

fifteen tasks. During this study, they were trying to determine if a nursing student was able to

critically think how to perform the numerous tasks while maintaining competent enough to know

how to administer the patients to give medications. Results showed that the students were

focusing on the details of the medication administration rather than the big picture of the patient.

Further, they also showed that the participants could have critical thinking and do majority of

those tasks, but they may not have clinical judgment (2016, p.86-89). In conclusion just because

one has critical thinking does not mean they have clinical judgment and therefore clinical

judgment takes more effort and focus than just being able to think critically.

The use of clinical judgment does not just apply to small everyday hospital decisions, but

also to the more life effecting ones such as withdrawing life sustaining therapy, giving narcotics

for pain, addiction signs and symptoms and so on. There was a study that looked at nurse’s

judgment and decision making on using a withdrawal sedation score to help decide whether or

not the children showed signs of withdrawal and what the nurse would do about it. The results of

the study showed that the nurses still struggled with determining whether to wean the children

off the sedation or continue their sedation even though they had the assessment score. The

decision was a difficult one because they had to use their knowledge of the withdrawal

symptoms, the patient’s response, as well as moral views in order to make the best clinical

judgment for their patients (Craske, Carter, Jarman and Tume, 2017). Having a sound clinical

nursing judgment is not an easy thing. There are so many items that go into forming this skill and

it takes years of experience, knowledge and patient care in order to achieve sound nursing

judgment. Today, concerns exist that new nurses do not possess sound and consistent clinical
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What is Clinical Nursing Judgment?

judgment skills needed to perform. Therefore, we need educators to teach and reinforce the need

for applied nursing judgment skills even in nursing school clinicals, so that nursing students can

strive to possess this skill early on in their profession.

Thinking about a time when clinical nursing judgment came into play in my life was last

summer, when I was in my Student Nurse Externship at Bon Scour Mercy Health- St. Elizabeth

Hospital. I had a patient who was 65 years old with a history of Gastrointestinal Ulcers and

Diabetes Mellitus- Type 2. The patient had a Hemoglobin of 8.1 grams/deciliter and as a result of

the low Hemoglobin level the Doctor wanted to give the patient 1 unit of Packed Red Blood

Cells. My patient blood type was A- and they ordered O- blood. They did the type and cross

match, went through all the checks of the blood bag labels, orders and patient wrist band. We

hung the blood with 0.9% Normal Saline Solution, blood transfusion tubing, good IV site and

everything was going well. We started the infusion slowly and watched the patient closely for the

first fifteen minutes to ensure that they did not have a reaction. All of the patients vital signs

were stable and in normal range. Approximately twenty minutes into the transfusion, I went into

the room to check on the patient, they appeared to look a little flushed and further they indicated

their back hurt. These displayed symptoms did not feel right to me, so I took the Dinomap

already in the room and took the patients temperature, blood pressure, heart rate and respirations.

The results were as follows: 130 heart rate, temperature 101 degrees Fahrenheit, blood pressure

78/53 and respirations were 24. I quickly yelled to the other nurse on the other side of the curtain

that I think she was having a reaction and the nurse came running over and said yes, she was and

she shut off the Alaris pump. Without my knowledge of what signs and symptoms of an allergic

reaction to blood were, this patient could have had some serious complications and even possible

death.
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What is Clinical Nursing Judgment?

In conclusion, Clinical Nursing Judgment is one of the most important skills a nurse must

have. Every day we make decisions for our patients, ourselves, the community and the

organization. As a result, if we do not have the sound judgment to make the best decisions then

the care we provide to our patients will suffer. The ability and skill to make nursing judgments

needs to be introduced earlier in nursing schools and we need to give the students more ability to

help make those decisions not just in class, but throughout their clinical rotations.
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What is Clinical Nursing Judgment?

References

Cazzell, M., Anderson, M. (2016). The impact of Critical Thinking on Critical Judgment during

Stimulation with Senior Nursing Students. Nursing Education Perspectives (National

League for Nursing).  37(2). 83-90. DOI: 10.5480/15-1553.

Craske, J., Carter, B., Jarma, I.H., & Tume, L.N. (2017). Nursing Judgment and Decision-

making using Sedation Withdrawal Score (SWS) in children. Journal of Advanced

Nursing, 73 (10). 2327-2338. Doi: 10.111/jan.13305

National Council State Board of Nursing (NCSBN). (2019, Winter). The clinical judgement

model. Next Generation NCLEX News. Retrieved from

https://www.ncsbn.org/NGN_Winter19.pdf

Manetti, Wendy. (2019). Sound Clinical Judgment in nursing: A concept Analysis. Nursing

Forum.  54(1). 102-110. DOI: 10.1111/nuf.12303.