Clinical Judgement – An Essential Tool In The Nursing .
Clinical Judgement – An Essential Tool in the Nursing ProfessionBy Margot Phaneuf, R.N., Ph.D.December 17, 2008Nurses must deal with a broad range of issues related to the condition of each patient,including complications and improvements, as well as annotations to clinical records andcommunications with physicians. As such, the nurse’sjudgement is at the heart of care delivery. Judgement guides Clinical judgement is theaction and decisions, not only of the nurse, but also of conclusion or enlightenedphysicians and other care providers. It is therefore essential opinion at which a nursefor the nurse to have observational and reasoning skills in arrives following aprocess of observation,order to make sound, reliable clinical judgements.reflexion and analysis ofobservable or availableDefinitioninformation or data.It is difficult to come up with a unanimous definition forclinical judgement, a concept which is critical to the nursing profession as a result of itsoutcomes. Many authors have come up with thoughtful definitions. Nonetheless, the topic iscomplex, so humility and simplicity are required to grasp this concept.Le Grand Robert, a Frenchdictionary,definesjudgement as having anClinical Judgement Processidea, a clear opinionClinicalfollowing a period ofJudgementreflexion whereas the termclinical indicates that it isrelated to the patient. 1 A ObservationReasoningCritical Thinkingdifficult task for nurses ismakingaclinicaljudgement. It requires bothintellectualandprofessional maturity. InKnowledge,experienceparticular, it requires theability to pay attention, toreason and to summarize inorder to achieve logicaldeduction. Clinical judgement is complex because the nurse is required to have prior trainingin order to develop further understanding of the subject. It depends on her ability to observe,to identify relevant information, to identify the relationships among given elements and to1Marjory Gordon. Diagnostic infirmier : méthodes et applications (Paris: Medsi, 1996) 16-17.1
reason. Clinical judgement in itself encompasses a cycle of sensory activities which beginswith perceptions and which is followed by cognitive functions associated with the intellectualprocessing of information through the mental operations of reasoning and judgement.Beyond observation, clinical judgement allows the nurse to associate pieces of information, toreview them, to establish relationships with known facts, and to analyze and interpret the dataat hand from both a critical and rational perspective. Using clinical judgement allows thenurse to identify, associate and interpret the signs or symptoms of a given condition.Christy, could you pleasetell me how toarrive at a clinical judgement.First, you have to payattention to the patient’scondition or what he isexperiencing. Then you gatherthe information regarding theproblem, use your reasoningabilities to interpret the factsand apply critical thinking toconfirm or exclude certainhypotheses. Finally, youresort to logical deduction toidentify the problem.Thought process to make a clinical judgementFor example, in the presence of a senior whose lips and skin are dry, who eats few proteins,who is bedridden and who moves little, a nurse will recognize that the individual is at risk ofdeveloping bedsore. The nurse will subsequently implement the required preventivemeasures.If each piece of information is considered and assessed individually, the nurse will fail toreach this conclusion.The elements must be observed, identified and grouped togetherlogically. Their combined effects must be considered as a whole and in a manner which isrelevant. This perspective is what allows the nurse to make decisions and to deliver adaptedcare.Clinical judgement as a tool for professionalsA professional is an individual who has specific knowledge of a subject which allows him tobe accountable and to manage serious human matters. The professional must be able tounderstand the problems at hand. He must have a clear understanding of their elements andeffects in order to come up with appropriate solutions. The professional must possess a blend2
of sensory and intellectual abilities to make clinical judgement. She needs to understand themechanisms and the significance of the case at hand.Lipman says that professionalism and clinical judgement are closely related and practicallysynonymous. 2 It is almost impossible to imagine a health care professional practicing withoutbeing capable of exercising this kind of judgement. Such an individual would quickly bedeemed incompetent and unfit for working with patients and dealing with their problems. Asfor all health care professionals, clinical judgement is also essential in nursing.Clinical judgement is not limited to identifying a problem; it also involves seeking a broadrange of possibilities. According to Clémence and Martine Dallaire, clinical judgement“enables the individual to recognize the aspects of a given situation, to foresee possibleinterventions to stabilize the condition of a patient, to articulate the nursing perspective for allsituations which require care delivery, to determine which areas leave room realistically forpersonal improvement and development, and to make elaborate qualitative distinctions incritical areas of the profession.” 3In a press release accompanying the November/December edition of the Journal, the Ordredes infirmières et infirmiers du Québec (O.I.I.Q.) is stated the need undertake skills andprofessional judgement assessments in the professional examinations (ECOS). It is mentionedthat “Clinical judgement is required in care delivery. Judgement makes it possible tosimultaneously apply knowledge, skills and attitudes to solve clinical problems in a specificcontext." The release also stated that passing such an exam would constitute “a good indicatorof the clinical judgement expected of newly trained nurses.” 4 Therefore, it can be said that theO.I.I.Q. has a regard for clinical judgement.Variances in abilities to reach a sound clinical judgementThe speed and ability of nurses to make a sound clinical judgement is affected by theirexperience. Newly trained nurses may find this process long and difficult whereas theexperienced nurse may be faster and rely on her intuition. 5 6A concept that is difficult to put into practiceThe concept of clinical judgement is difficult to put into practice. Perhaps this partly explainswhy nurses experience difficulty mastering this essential skill. Another obstacle is the lack ofimportance granted to clinical judgement in certain forms of training as well as in certaindepartments in which technological and administrative skills are emphasized. The intellectualelements are thus often superseded by the more technical aspects of the profession.That being said, cognitive functions are highly needed to develop essential skills andknowledge in nursing. These types of knowledge are: 1. empirical - stemming from dataperceived by the senses; 2. conceptual – arising from associating these observations; 3.2Lipman, M. À l’école de la pensée : enseigner une pensée holistique (Bruxelles: De Boeck, 2006) 276.Freely translated from Clémence Dallaire et Martine Dallaire. Le savoir infirmier au cœur de la discipline et dela profession (Montréal:Gaëtan Morin, 2008) 279.4. O.I.I.Q. "Évaluer connaissances et jugement clinique" Le Journal, 6 (2), November/December 2008.5Patricia Benner. De novice à expert : excellence en soins infirmiers (Paris: InterEditions, 2005).6. Claire-Andrée Leclerc. "Sur le chemin de potdocuments/Sur le chemin de l expertise.pdf . Accessed January 5, 2008.33
rational - developed by applying thought to data; and 4. decision-making – used to makeresponsible decisions. 7 8The Evolution of the Nurse from Novice to ExpertClinical Judgement Requires: Theoreticalknowledgeandof theproblem at hand; Stage 1: novice. Little or limited knowledgeexperience;adheres to principles Clinical experience;and rules; rigid or limited interventions. Clinical judgement is analytical and Rigourous observational abilities;requires effort. A fairly good ability to reason on the event being observed; Stage 2: beginner. Posessescertain levelof knowledgeand toexperiencewhich Thea developmentof criticalthinking abiltiesweigh the pros the cons aspectsof an ideaofor asolution;allows her to recgonize theandrelevantsituation. Clinical judgement is Theserequirementsallowthe nurseto recognizethe signsanalytical and guided by principlesinaregisterofleadswhichis greaterthan thator symptoms of certain problems or conditions and toof the novice.identify certain leads or hypotheses in order to make ajudgement. two to three years of experience. ClinicalStage 3: competent. Nurse possesses Acceptingthe responsibilityfor planninga clinical judgementit leadsjudgement is faster, interventionsareeffective andis madeasina longto a decision;term perspective. Nurse on Sufficient self-confidence and the ability to dare;of unforeseen events. Registerof leadsis evengreater. Abidingby qualityof carestandards and ethical guidelines.AdaptedfromKataoka-Yahiro& SaylorA critical events.Stage 4: proficient. Able modelto modifyheractionstoface (1994).unanticipatedfor nursing judgement. Journal of Nursing Education,Knowledge can be transferredand applied in new circumstances. The overall33(8), 351-356.judgement process is faster and requires less effort. Identifies priorities logically.Stage 5: expert. After 5 years of experience. Less analytical in approach; greaterability to summarize; greater intuition; faster and more self-confident injudgement. Capable of transferring knowledge while sticking to what is essential.Nurse is less constrained by cofied nursing rules and regulations. Is creative insolving problems, in facing emergencies and in dealing with complex situationsSource: Benner,1995 ( pp. 23-35).Nursing is not limited to taking immediate action. The human component of the professionrequires nurses to acquire fundamental knowledge and to be able to reflect, to make decisions,to foresee required interventions according to the needs and challenges faced by the patient, toengage in long-term planning, and to prevent potential complications. Sensory andobservational skills as well as the intellectual skills of reflection, reasoning and criticalthinking allow the nurse to exercise genuine clinical judgement.Adequate trainingThe development of sound clinicaljudgement is an essential part of training. Itrequires that close attention be paid tooffering adequate training based onjudicious patient observation and themeticulous analysis of relevant data. Thenext stage involves the detailed analysis ofthe elements observed. Relationshipsconcerning the subject are established byEssential Knowledge in NursingKnowledge: Empirical: stems from data perceived bythe senses ; Conceptual: arises by associating thisdata; Rational: developed by applying thoughtto data; Decision-making: used to makeresponsible decisions.7L.E. Palkiewicz "Développement de la pensée et de l'action responsable dans une perspective d'acquisition decompétences au collégial." AQPC, Actes du 10e colloque annuel (1990).8. Kataoka-Yahiro & Saylor. “A Critical Model for Nursing Judgement.” Journal of Nursing Education, 33(8):351-356.4
combining theoretical and practical knowledge acquired through experience. Critical thinkingallows the nurse to determine whether the reasoning is valid. She must then weigh itsadvantages and disadvantages. This allows the nurse to give herself a logical interpretation ofevents, to make appropriate decisions and to assess their relevance. When this process iscoupled with experience, the nurse is able to easily and rapidly use her clinical judgement tomake the decisions required by the circumstances.Certain theoretical concepts of clinical judgement must be covered during training.Outcomes of Clinical Judgement in Nursingand in MedicineMedical Judgement leads to: The identification of adisease; The development of anappropriate treatment; A cure for symptoms; The prevention ofcomplications; The prevention of relapses; Limiting the, side-effects orcomplications of a disease. Clinical Judgement in Nursingleads to:The identification and logicalinterpretration of symptoms;The planning of care to alleviateor prevent complications orrelapses;The nurse is doing what thepatient would do for himself if hehad the required strength orknowledge;Helping the patient satisy hisphysical, psychological andspiritual needs at the same time;Assisting the patient in passingaway with dignity, if necessary.5
Simulation and learning exercises should complete the training. The student should analyze aproblem within its bio-psychosocial and spiritual sphere before making a clinical judgement.The lesson is completed during internships with live patients and in real-life situations. Thisrequires that an experienced nurse accompany the student to determine the relevance of herclinical judgement.The need to avoid confusionClinical judgement is an essential tool which allows nurses to exercise their role in the healthcare environment in a professional manner. The term clinical judgement needs to be clarifiedin order to avoid confusion. 9Clinical judgement is much more than mere observation. It is also much more than theassessment findings required by the nursing therapeutic plan.There are many ways to interpret the term assessment findings. In French, évaluer, as definedby the Grand Robert, is to “place a value on something or someone or to judgeapproximately." This is not quite the clinical judgement context with its accompanyingsensory and conceptual stages. The term assessment findings is not mentioned as an elementof clinical judgement. As the documents which explain the mechanisms of the therapeuticnursing plan do not refer to any model, theory or author, we are forced to make a lexicalinterpretation. As the first section of the nursing therapeutic plan requires the nurse to writedown her assessment findings, it is important to make a distinction between this concept andclinical judgement. 10A necessary distinctionIt is important to note that the nursing therapeuticplan form in its simplicity cannot reflect theoverall thought process of the nurse and itsintricacies. The therapeutic nursing plan isintended to leave a legal footprint of theintervention made by care providers. It is a stepforward in the profession. This requirementmakes the leadership role of the nurse officialwithin the basic team administering care. It allowsher to delegate certain tasks to the nursingassistants and to the beneficiary attendants.Furthermore, this legal recognition enhances therole of the nurse and guarantees that herinterventions will be filed and stored instead ofbeing eliminated. ticss of a ProfessionSome characteristics of a professioninclude: A complex and organizedactivity; A long-term trainingprogram focusing on thedelivery of exclusiveknowledge; Offering an essential serviceto society; A certain level of autonomyto take action; An order which governs itsmembers.Source: Adapted from O.Goulet (1999) 1351509O.I.I.Q. À la découverte du PTI. Form available n/index.html. Accessed on Jan. 5, 2009.10Phaneuf, margot. Bill 90 and the therapeutic nursing plan. Infirressources :http://www.infiressources.ca/fer/Depotdocument anglais/Bill 90 and the therapeutic nursing plan.pdf11Phaneuf, Margot (2008). Changes in our profession: an upgrading or downgrading of our cripto.asp?resultat 7102286
because of the need of simplification, obliges us to consider our action in a narrower andsimpler view. It brings us once more to the level of interpretation. The nursing therapeuticplan is an important professional document. The nurse needs to consider its advantages andseek ways to overcome difficulties encountered in order to abide by the recognized principlesand values of the nursing profession in a fair and just manner.What should this term be compared with?Faced with a new context, it is customary to seek to compare elements and points of referenceto enhance our understanding. If the assessment findings do not necessarily constitute aclinical judgement, to what exactly are they similar? This question is difficult to answer.Many of the terms suggested for use resemble raw data and lack sustained intellectualprocessing. Other terms take on a different form. For example, “redness on the left heel” isjust a piece of datum provided in the interactive training document of the OIIQ. 12Other elements registered in the therapeutic nursing plan resemble a clinical judgement asexpressed in the nursing diagnosis. For example, “chronic pain related to mobilisation" is alsomentioned in the O.I.I.Q. document. What needs to be considered or favoured?Raw data alone do not reveal on their own the causes or details of a problem. Only after all ofthe information available is gathered, analyzed and subjected to reasoning and criticalthinking can a clinical judgement be made and responsible nursing directives developed. Inorder to get a better grasp of clinical judgement, it would be worth getting a grasp of theunderlying logic of the nursing therapeutic plan.A significant differenceWhere we are the furthest from the clinical judgement is in the standard therapeutic planwhere The reason for the hospitalization, housing, ambulatory or home follow-up is listed asthe minimal information requirement of the nursing therapeutic plan. As such, thisrequirement becomes either the priority or the problem for the patient. In the exampleprovided by the O.I.I.Q., the hip prosthesis or any other medical diagnosis becomes thepriority. And so, the human who wears it is overshadowed by the device or the disease. 13This minimal information requirement presented in the O.I.I.Q.video is surprising. 14 Over the past few decades, many thinkersfrom Quebec and elsewhere in the world have striven to make adistinction between the nursing and medical professions in orderto give nurses relative conceptual autonomy. There is also a greatneed for educators to make a logical justification. Over the pastfew generations, they have been striving to get students to graspthe difference between the two professions. 15Clinical judgement isan essential path toacquiring thereflective ability andknowledge tounderstand thecondition and needsof the patient.12O.I.I.Q. "À la découverte du PTI." Form available n/index.html. Accessed on Jan. 5, 2009.13Olive Goulet. "L’Autonomie professionnelle et la pratique infirmière." Soins infirmiers et société(Boucherville: Gaëtan Morin Éditeur, 1999) 135-150.14O.I.I.Q. "À la découverte du PTI." ex.html. Accessed Jan.5, 2009.15Clémence Dallaire et Martine Dallaire. Le savoir infirmier au cœur de la discipline et de laprofession (Montréal: Gaëtan Morin, 2008) 279.7
An unfortunate omissionIt would be a shame for clinical judgement to be put into question by the mere fact that it isnot required in the nursing therapeutic plan. No profession can avoid evolving. The nursingprofession is in line with this modern-day trend. It is still unknown what course the professionwill take. Hopefully, clinical judgement will remain relevant for training future nursesregardless of the trends which will eventually emerge in the profession. In their book, Lesavoir infirmier au cœur de la discipline et de la profession (nursing know-how at the heartof the discipline and profession), Clémence and Martine Dallaire state that clinical judgementis a condition “to provide nursing care inspired by knowledge available." 16 17Are there any deeper rrépercussion ?A loss of clinical judgement
outcomes. Many authors have come up with thoughtful definitions. Nonetheless, the topic is complex, so humility and simplicity are required to grasp this concept. Clinical judgement is the conclusion or enlightened opinion at which a nurse arrives following a process of observation, reflexion and analysis of observable or available
2 Sticky judgement and the role of rhetoric Victoria McGeer and Philip Pettti 99780521764988c02.indd 48780521764988c02.indd 48 33/24/2009 2:50:53 PM/24/2009 2:50:53 PM. Sticky judgement and the role of rhetoric 49 providing reason and judgement with an indispensable resource. As unreason may be cunning, in the title of Dunn’s book, so reason .
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Review the 2019 NCLEX Test Plan. Embrace the NCSBN's Next Generation plan for nursing education. Discuss environmental and internal factors that influence clinical judgement. Identify teaching strategies reflective of increasing students' clinical judgement. Evaluate ways your nursing program can improve students' NCLEX outcomes.
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