Clinical Judgement

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Clinical judgment is

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aninterpretation or conclusion about a patient’s needs, concerns, or healthproblems, and/or the decision to take action (or not), use or modify standardapproaches, or improvise new ones as deemed appropriate by the patient’sresponse.

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conceptof clinical judgment

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ingeneral refers to interpretations and inferences that

influence actions inclinical practice.

asan inference or interpretation made in a caregiving setting, a processresulting in such an inference or interpretation, or the capacity for makinginferences or interpretations about patient care.

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clinicalreasoning and critical thinking are used

interchangeably

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Clinical reasoning is the thinkingprocess by which a nurse reaches a clinical judgment, “an iteractiveprocess of noticing, interpreting, and responding—reasoning in transition witha fine attunement to the patient and how the patient responds to the nurse'sactions.” - the ability to perceive therelevance of scientific

evidence and its fit with the specific patientsituation.

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Standards-BasedApproach

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Decisionmaking from this perspective involves selection from options of mutuallyexclusive possibilities, implying that there is one right decision, involvesuse of algorithms, decision trees, and patient care guidelines

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Interpretivistapproaches originate from the belief that life experiences are culturallybound, that individuals

interpret these experiences on the basis of their

encounters within a given culture, and that one

circumscribed approach is oftennot appropriate for a large number of patients.

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Reasoning in interpretivistapproaches may involve “rule of thumb” methods and be intuitive. It involves

understood knowledge, isoften inductive in nature, and is referred to as engaged,practical reasoning.

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Evidence-BasedPractice and Clinical Judgment

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applying the best availableresearch results (evidence) when making decisions about health care. Healthcare professionals who perform evidence-based practice use research evidencealong with clinical expertise and patient preferences.”

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Holistic view of the patient situation:

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Clinicaljudgment requires aholistic view. Making

excellent clinical judgments requires a willingness to

consider all factors involved in patient care, including

certaincharacteristics of the nurse, and is much more

than simply a combination of theindividual aspects.

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Process orientation

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Clinicaljudgment is circular, interactive, and moves fluidly between and among all ofthe aspects of the process.

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Reasoning andinterpretation:

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Clinicaljudgment involves reasoning and interpretation. Asdescribed previously, reasoning is the process that leads to clinicaljudgments. At least three types of reasoning are used: analytic, intuitive, andnarrative.

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CLINICAL JUDGEMENT NIS NOT A LINEAR

PROCESS

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Noticing:

ljudgment is not a linear process

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Isinfluenced by the background of the nurse and the nurse’s relationship with thepatient, as well as the context of care. The nurse notices various things suchas clinical assessment findings, laboratory work, data, patient demeanor, andfamily situation and looks for patterns that are consistent with his or herprevious experiences and uses that information to guide care.

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Interpreting:

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Isthe process of assembling all the information to make sense of it. The nursedraws on a variety of reasoning patterns to interpret the meaning of what hasbeen

noticed.

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Reflecting:

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Includestwo types—reflection-in-action,which occurs while care is being delivered, and reflection-on-action,which is the consideration of a situation after patient care has occurred.

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Reflection-in-actionrefers to

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the nurse's understanding of patient responses to nursing actionswhile care is occurring. Inobservations and interactions with the patient, the nurse determines patientstatus and adjusts care accordingly. It is the thinking that happens in “realtime” during patient care.

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Reflection-on-action

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is consideration of the situation after the patient care occurs. Inreflection-on-action, the nurse contemplates a situation and considers what wassuccessful and what was unsuccessful. Reflection-on-action is critical fordevelopment of knowledge and improvement in reasoning.

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INTERRELATED CONCEPTS

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ClinicalSkills

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Decisions about urinary orintravenous catheter placement, such as

determination regarding size & typeof urinary or intravenous catheter or whether placement is needed.

Decisions about timing & extentof bathing and personal care.

Assessment of a wound Exemplar. Assessmentof a wound&

determining next steps. Selection of an appropriatedressing

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Urgent/EmergentSituations

subtle signs of sepsis Exemplar

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• Detection of subtlesigns of sepsis

• Early treatment of patienthemorrhage

• Starting oxygen to respond todecreased saturation levels

• Early recognition of anaphylaxis

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Communication:

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• Content and depth of patientteaching at discharge, pre- and postoperatively

• Advocacy for patient at carecoordination conferences

• Communicationwith distraught or fearful patient or family

Communication with patient orfamily Exemplar

• Defusing potentiallyconfrontational interactions

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MedicationManagement

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MedicationManagement

• Selection of dose when a range isordered

• PRN decisions - Holding a medication Exemplar

• Holdinga medication

• Early recognition of adversereaction or side effect from

medication

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Managementof Care and Nursing Leadership

Delegation Exemplar

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• Delegation toancillary nursing personnel

• Prioritization of care amongpatients

• Calling a physician

• Referral to another healthprofessional (e.g., wound care specialist, dietitian)

• Decisions about patientassignments