Clinical judgment a known and forgotten nursing concept: review

INTRODUCTION

Nursing is one of the largest professions around the globe. As in the year, 2020 was completely dedicated to different types of nursing practitioners, once again the nursing personnel proved to be the strongest block of the medical team. Still, the work and the free skill set of this community are rarely on the public’s mind. Some people tend to relate nursing with the provision of care to the sick and other physical tasks. Others imagine that nursing means being a doctor’s helper or giving out pills. Although these are part of the nursing profession, nursing also involves attending patients, clinical judgment, and making decisions. Growing up as Head, Hand, and Heart is the reason why nursing is also said to be holistic in its approach.

NEED FOR THE CLINICAL JUDGMENT IN NURSING

The distinction between an experienced or expert nurse and an amateur nurse lies in clinical judgment. Today’s clinical environment, patients’ conditions, and situations are way more complex than ever. Nursing now demands higher cognitive skills and higher critical thinking abilities and it is triggered by the various challenging situations in the clinical environment. Observation and its interpretation in correlation with patient cues lead to clinical judgment and it needs to be based on a sound body of knowledge. Critical, innovative thinking and clinical judgment are considered to be essential skills for trained nursing practice.^1-3

Long standing gap have always existed in knowledge & practices and has contradiction and controversy. The gap is not only observed among nurses, it is deficient among nursing students as well, and study conducted among 105 undergraduate nursing students revealed that the knowledge about ECG was low. Nurse educators are producing nurses that are proficient and excellent on paper and less proficient in clinical practice and the reason identified was, that clinical practice is way different from the ideal situations or circumstances taught in theory.^4-8

The ability to use clinical judgment is seen as a fundamental competency for all nurses and separates professionals from those doing strictly technical duties. “Learning to think like a nurse" is how educators describe their students' development of clinical judgment. Clinical judgment is the process through which nurses learn to comprehend the challenges, problems, or worries of their patients or customers, pay attention to the most important details, and act with care and involvement.^1,9,10

Clinical judgment, which involves critical thinking and decision-making abilities to offer safe and effective patient care, is a basic idea in nursing practice.¹¹ This article aims to explore the significance of clinical judgment in nursing, its historical roots, the challenges it faces in contemporary healthcare, and strategies to revitalize its importance.

THE ESSENCE OF CLINICAL JUDGMENT

Nursing has a rich history that dates back to the early days of Florence Nightingale and the Crimean War Even in the era of Florence Nightingale critical thinking and clinical judgment were made when she observed that the sickest patient needed more attention and observation and hence should be kept near the nursing station.¹⁰

During these times, nurses relied heavily on their observational skills, intuition, and clinical judgment to care for wounded soldiers. The concept of clinical judgment was deeply embedded in the nursing profession as nurses had limited access to medical technology and relied solely on their abilities to assess patients and make informed decisions.^10-12

The defining attributes of sound clinical judgment: are making a holistic assessment, critical thinking, clinical reasoning, practical wisdom, intuition, and reflection Tanner suggested a model of clinical judgement which involves the following stages:

Noticing

When a student or a nurse enters a patient unit has formal education or training, her personal beliefs and experiences. Noticing involves recognizing patient cues and clinical environment observations and making holistic assessments. For example, a nurse approaches a terminally ill client and tries to interact without noticing that the client looks anxious. This may lead to sullen behavior from the patient. If the nurse notices the clinical environment cue, then the nurse would approach the patient with the intention to develop eye-to-eye contact first and then notice the chance to interact further suggesting the therapeutic measures as nurse.

Interpreting

The nurse makes interpretations of the cues noticed in the form of physical data (like temperature – 104 degrees Fahrenheit) or psychological cues like an anxious face or facial grimace. In this phase, analytical thinking and intuition play an important role. For example, on entering the patient's unit nurse feels silence then her intuition usually is something wrong. Over period and with experience nurses develop intuitive feelings and thinking with similar experiences.

Responding

It is choosing or taking action based on interpretation. Reasoning plays a role in this phase. Choosing from multiple solutions selecting one solution is responding. Prioritizing is another domain taken care of in this phase. The client might have many needs to be addressed, in this phase nurse notices and interprets all of them but choosing to meet which one first is prioritizing and working to meet it is responding.

Reflection

Tanner suggested two categories, reflection in action and reflection on action. Reflection in action involves the response of the client to the intervention done by the nurse. Reflection on action means the process of examining the event from experience (retrospectively) and it becomes a habit when interventions are made based on experience. For example, when one feels anxious before an exam for the first time, the client will adopt some method to overcome the anxiety (reflection in action), but in case the same anxiety-triggering event occurs repeatedly then the method to overcome the anxiety becomes a habit (reflection on action) The model's four stages, noticing, interpreting, responding, and reflecting describe the key elements of clinical judgment in challenging patient care scenarios that entail shifts in status and a lack of clarity on the best course of action.^10-13

Throughout the history of nursing, clinical judgment has been at the core of nursing practice, guiding nurses in their daily interactions with patients. However, with the emergence of advanced technologies and evidence-based practice, there has been a growing concern that clinical judgment is being overshadowed and, in some cases, even forgotten.¹³

CHALLENGES TO CLINICAL JUDGMENT IN CONTEMPORARY HEALTHCARE

Nurses must exercise clinical judgment when caring for patients. This entails integrating cognitive functions such as decision-making, problem-solving, and critical thinking. Nurses can evaluate patient data, identify any issues, and choose the best course of action by applying their expertise, experience, and intuition. Nurses can deliver individualized treatment while taking cultural, social, and psychological issues into account thanks to this extremely complicated talent that is developed over time.^2,3

Technological advancements and overreliance

The practice of nursing has been greatly impacted by the quick development of medical technology. Technology can improve patient care, but it can also hinder the growth of clinical judgment abilities. A disengagement from the patient and a loss of focus on the human element of treatment could result from an over-reliance on computers and data-driven methods.^13,14

Time constraints and workload pressures

Nurses frequently deal with time limits and significant workloads in the hectic and demanding healthcare industry. These demands may make it more difficult for them to accurately evaluate and consider the situations of their patients, which could result in mistakes or lost chances for early intervention.^15,16

Emphasis on evidence-based practice

The foundation of contemporary healthcare is now evidence-based practice. The sole focus on evidence-based standards may restrict the flexibility needed for individualized patient care, even if they are crucial for delivering high-quality treatment. It might unintentionally inhibit nurses' ability to use clinical judgment and creativity when coming up with patient-centered strategies.^16,17

STATEGIES FOR REVITALIZING CLINICAL JUDGMENT IN NURSING

Promoting reflective practice

Promoting reflective practice among nurses can improve their ability to make clinical decisions. Nurses can evaluate their experiences critically, examine their choices, and pinpoint areas for development through reflective practice.^18-20

Integration of simulation and case studies

Morton defines simulation as "an attempt to reproduce some or nearly all of the key elements of a clinical situation so that the scenario may be more easily understood and managed when it occurs for real in clinical practice." Incorporating simulation into nursing courses is an effective way to provide students with safe, realistic opportunities to enhance clinical nursing judgment.

Case studies and simulation-based learning provide a secure setting for nurses to hone their clinical judgment. By bridging the gap between theory and experience, these techniques enable nurses to hone and assess their decision-making abilities.^19-23

Interprofessional education and collaboration

Working together with other medical specialists can help nurses see the world from a wider angle and encourage a patient-centered attitude. Enhancing clinical judgment requires efficient communication and teamwork, both of which are fostered by interprofessional education.^23,24

Continuous professional development

In order to keep nurses abreast of the most recent research and improve their clinical judgment abilities, it is imperative that lifelong learning be promoted through ongoing professional development. Continuous education guarantees that nurses maintain their competence and self-assurance when making decisions.^24-26

CONCLUSION

Clinical judgment is a process that is readily stimulated, acquired, and exposed to a variety of settings. Virtual simulations are a convenient way to teach clinical judgment. In nursing practice, clinical judgment is still a fundamental and timeless idea. Even if evidence-based practice and technology have revolutionized healthcare, nursing's human component cannot be overlooked. To deliver safe, efficient, and patient-centered care, nurses must constantly work to hone their clinical judgment abilities. Nurses may regain their position as knowledgeable medical professionals and champions for their patients' welfare by reviving this core idea.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Benner P, Tanner CA, Chesla CA, editors. Expertise in nursing practice: Caring, clinical judgment, and ethics. Springer Publishing Company. 2009.
2. 2. Coles C. Developing professional judgment. J Continuing Edu Health Profess. 2002;22(1):3-10.
3. 3. Pesut DJ. Education: clinical judgment: foreground/background. J Prof Nurs: Official J Am Assoc Coll of Nurs. 2001;17(5):215-9.
4. 4. Jang KS, Hwang SY, Park SJ, Kim YM, Kim MJ. Effects of a Web-based teaching method on undergraduate nursing students’ learning of electrocardiography. J Nurs Educ. 2005;44(1):35–9.
5. 5. Ko Y, Issenberg SB, Roh YS. Effects of peer learning on nursing students’ learning outcomes in electrocardiogram education. Nurse Educ Today. 2022;108(2):105182.
6. 6. Bendall E. 30th anniversary commentary on Bendall E. (1976). Learning for reality. J Adv Nurs. 2006;53(1):34.
7. 7. Bendall E. Learning for reality. 1975. J Adv Nurs. 2006;53(1):14–7.
8. 8. Glick M. Clinical judgment: a requirement for professional identity. J Am Dental Assoc. 2011;142(12):1333-4.
9. 9. Hoeve YT, Jansen G, Roodbol P. The nursing profession: Public image, self‐concept and professional identity. A discussion paper. J Adv Nurs. 2014;70(2):295-309.
10. 10. Tanner CA. Clinical judgment and evidence-based practice: Toward pedagogies of integration. J Nurs Edu. 2008;47(8):335-6.
11. 11. Jerak-Zuiderent S. Certain uncertainties: modes of patient safety in healthcare. Social Studies of Science. 2012;42(5):732-52.
12. 12. Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ. 2006;45(6):204–11.
13. 13. Gerdeman JL, Lux K, Jacko J. Using concept mapping to build clinical judgment skills. Nurse Education in Practice. 2013;13(1):11-7.
14. 14. Pongmarutai T. Application of a judgment model toward measurement of clinical judgment in senior nursing students. Las Vegas: University of Nevada. 2010
15. 15. Falzer PR. Valuing structured professional judgment: Predictive validity, decision‐making, and the clinical‐actuarial conflict. Behav Sci law. 2013;31(1):40-54.
16. 16. Légaré F, Stacey D, Gagnon S, Dunn S, Pluye P, Frosch D, et al. Validating a conceptual model for an inter‐professional approach to shared decision making: a mixed methods study. J Eval Clin Prac. 2011;17(4):554-64.
17. 17. Yaghoubi M, Javadi M, Rakhsh F, Bahadori M. A study of determining factors affecting the performance of nurses based on the achieve model in selected hospital of Isfahan (Iran). J Edu Heal Prom. 2013;2(1):49.
18. 18. Glynn DM. Clinical judgment development using structured classroom reflective practice: A qualitative study. J Nurs Edu. 2012;51(3):134-9.
19. 19. Morton PG. Academic education. Creating a laboratory that simulates the critical care environment. Critical Care Nur. 1996;16(6):76-81.
20. 20. Traynor M, Boland M, Buus N. Professional autonomy in 21st century healthcare: Nurses’ accounts of clinical decision-making. Social science & medicine. 2010;71(8):1506-12.
21. 21. Thompson C, Yang H, Crouch S. Clinical simulation fidelity and nurses’ identification of critical event risk: A signal detection analysis. J Adv Nurs. 2012;68(11):2477-85.
22. 22. Kantar L, Alexander R. Integration of clinical judgment in the nursing curriculum: Challenges and perspectives. J Nurs Edu. 2012;51(8):444-53.
23. 23. Fero LJ, O’Donnell JM, Zullo TG, Dabbs AD, Kitutu J, Samosky JT, et al. Critical thinking skills in nursing students: Comparison of simulation‐based performance with metrics. J Adv Nurs. 2010;66(10):2182-93.
24. 24. Thompson C, Aitken L, Doran D, Dowding D. An agenda for clinical decision making and judgement in nursing research and education. Inter J Nurs Stud. 2013;50(12):1720-6.
25. 25. Davis AH, Kimble LP. Human patient simulation evaluation rubrics for nursing education: Measuring the essentials of baccalaureate education for professional nursing practice. J Nurs Edu. 2011;50(11):605-11.
26. 26. Marc W, McKnight P. Department of curriculum and teaching and the graduate faculty of the university of Kansas in partial fulfilment of the requirements for the degree of doctor of philosophy. Available at: http://kuscholarworks. Accessed on 21 August 2024.