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Clinical Nursing Judgement

Kaitlynn Porterfield

Department of Nursing, Youngstown State University

NURS 4852: Senior Capstone Seminar

Kimberly A. Ballone

January 11, 2023

Clinical Nursing Judgement

 Clinical judgement is the result of critical thinking, reasoning, and intuition. Clinical

nursing judgement is used by nurses in providing quality healthcare to patients whilst avoiding

adverse events and patient harm. The ability to provide safe, high-quality care can depend on a

person’s ability to think, reason, and judge. Critical thinking is thinking in which

you question, analyze, interpret, evaluate; and make a judgement about what you hear, read, say,

or write. Identifying a problem, determining the best solution, and choosing the most effective

method are all parts of the critical thinking process. After executing the plan, critical thinkers

reflect on the situation to figure out if it was effective or if it could have been done better. One

way to implement critical thinking is by applying the nursing process. The nursing process

includes assessment, diagnosis, outcomes/planning, implementation, and evaluation. Another

way to implement critical thinking is by using the Tanner's Clinical Judgment Model which

includes noticing, interpreting, responding, and reflecting. The nursing process and Tanner’s

Clinical Judgement Model both improve clinical judgement decisions. Reflecting on clinical

judgement decisions further improves judgement.

There are many ways nurses use clinical judgement. Nurses often make triage decisions

in the emergency department. With an overflow of patients and limited staff, they must evaluate

which patients should be treated first. They must use nursing judgement to analyze the

consequences of delaying treatment for each patient. Nurses use critical thinking in their

everyday routines no matter their specialty. When faced with decisions that could mean life or

death, the ability to analyze a situation and come to the best possible solution is crucial.

The nursing journals “Nursing Judgment: The Key to Pain Assessment in Critically Ill

Children” and “A critical review: a combined conceptual framework of severity of illness and
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clinical judgement for analysing diagnostic judgements in critical illness” both discuss the

importance of clinical nursing judgement with critically ill patients. To have early prevention and

reduced morbidity and mortality critical care needs to be provided to patients at risk of critical

illness as well as the critically ill. As a nurse you want to promote health and prevent illness.

When someone is critically ill the main goal is to decrease deterioration and improve patient

outcomes. The concurrent assessment of severity of illness and the correction of life-threatening

abnormal physiological indicators to minimise further deterioration constitute the two

overarching principles guiding the immediate management of critical illness (Coulter Smith et al.

2014). Catching subtle patient changes and using nursing judgement for deciding what needs

immediately implemented can drastically decrease deterioration in critically ill patients.

Nursing judgement is crucial in all situations. The main components of a pain assessment

consist of self-report, behavioral cues, and physiologic indicators of pain. When verbal and

behavioral cues are limited nursing judgement is a critical key component of the pain

assessment. Judgements are based on comprehensive data gathered in the overall baseline

assessment and honed through keen observation of subtle changes in response to physiologic and

environmental stimuli (Foster 2001). Physiologic changes occur in response to pain. Due to the

reliance on physiological changes alone, assessing a chemically paralyzed patient is possibly the

most challenging. Assessment of physiological changes consists of monitoring a compilation of

things like vital signs, MAP, oxygenation saturation, pallor, and much more. Assessment of

neurologically impaired patients also presents challenges due to the alteration of pain perception,

pain response, the language used to express pain, and the understanding of pain. Using clinical

nursing judgement and a checklist of behaviors including stiff, spastic, tense, and rigid, a nurse
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can identify pain in nonverbal individuals with mental retardation and in neurologically impaired

individuals.

Nursing judgement should always be utilized when caring for and assessing patients.

During my experience as a STNA, student nurse, and nurse extern I have had the opportunity to

see an abundance of different situations where nurses used nursing judgement. For instance,

during my preceptorship a patient was admitted to the ICU with labored breathing. The nurse

used her nursing judgement to call the doctor for intubation due to the patients current condition.

I have witnessed nurses use nursing judgement to question orders provided by doctors and

residents. Nurses use nursing judgement to titrate medications including pain medications,

sedatives, and vasopressors. There are so many ways nurses use clinical nursing judgement. I

have fortunately experienced using good nursing judgement while working as a student nurse.

While reviewing a patients chart I noticed the patient was receiving a medication that was listed

as an allergy. I notified the nurse I was working under, and we notified the doctor. Another

situation where I personally used nursing judgement is while caring for a patient with accessory

muscle use breathing. I noticed the patient was not properly sedated. I notified the nurse that the

patient was working extra hard to breathe, and the sedatives were not decreasing the workload as

indicated. After assessing the patient, their vital signs, and pain, we titrated the sedative to

increase sedation and decrease workload for the patient to properly heal.

Overall, nursing judgement is a major component of caring for patients. There are good

judgement calls and judgement errors. Judgement errors occur more often with lack of nursing

experience. Ways to increase individual nursing knowledge to improve nursing judgement is to

ask an experienced nurse for opinions, continuing education, and reflecting on previous nursing

judgement calls. Optimal nursing judgement creates optimal patient care.

References

Benner, P. (2008, April 1). Clinical Reasoning, Decisionmaking, and Action: Thinking Critically

and Clinically. Patient Safety and Quality - NCBI Bookshelf. Retrieved March 11, 2023,

from https://www.ncbi.nlm.nih.gov/books/NBK2643/

Center for Teaching, Learning & Mentoring. (2022, October 5). Developing clinical judgment

skills in nursing students. Instructional Resources KnowledgeBase. Retrieved March 11,

2023, from https://kb.wisc.edu/instructional-resources/page.php?id=121687

Coulter Smith, M. A., Smith, P., & Crow, R. (2014). A critical review: a combined conceptual

framework of severity of illness and clinical judgement for analysing diagnostic

judgements in critical illness. Journal of Clinical Nursing (John Wiley & Sons,

Inc.), 23(5–6), 784–798. Retrieved March 11, 2023, from

https://doi-org.eps.cc.ysu.edu/10.1111/jocn.12463

Foster, R. L. (2001). Nursing Judgment: The Key to Pain Assessment in Critically Ill

Children. Journal of the Society of Pediatric Nurses, 6(2), 90. Retrieved March 11, 2023,

from https://doi-org.eps.cc.ysu.edu/10.1111/j.1744-6155.2001.tb00127.x