Running head: CLINICAL NURSING JUDGEMENT 1

Clinical Nursing Judgement in Nursing School

Katelyn Dustman

Youngstown State University

CLINICAL NURSING JUDGEMENT 2

Abstract

Clinical Nursing Judgement is a very crucial tool for all nurses to have. It affects how nurses care

for their patients and influences every decision they make. A lot of times nurses do not even

realize when they are using nursing judgement because it has become second nature. The focus

of this paper is describing how nurses develop clinical judgement and how it is used.
CLINICAL NURSING JUDGEMENT 3

Clinical Nursing Judgement in Nursing School

What is Clinical nursing judgement? There is no exact definition of clinical nursing

judgement. Joyce Wright and Debra Scardaville’s definition states, “clinical reasoning as a

thoughtful comprehensive process, and clinical judgement as an interpretation or conclusion

based on the clinical reasoning” (2021, p. 2). According to the National Council of State Boards

of Nursing (NCSBN):

Clinical Judgement is defined as the observed outcome of critical thinking and decision

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

presenting situations, identify a prioritized client concern and generate the best possible

evidence-based solutions in order to deliver safe client care. (NCSBN, 2019, p. 1)

One of the major focuses in nursing school is developing clinical nursing judgement. Developing

this skill is natural for some but others have to work very hard on it. The main way that clinical

nursing judgement is taught in nursing school is through the nursing process. What is the nursing

process? The nursing process is the steps nurses should use when making decisions. It starts with

assessment. Assessment is one of the most crucial tools nurses have. A nurse assesses their

patient status in order to find any discrepancies from the patient’s baseline. Any discrepancies

that are found then need to be treated, leading into the next step in the nursing process. The next

step is nursing diagnosis. Developing an appropriate nursing diagnosis is important because it

influences what interventions will be done. Nursing diagnosis are not the same as medical

diagnosis however. Think of the medical diagnosis as the “umbrella” diagnosis and the nursing

diagnoses are all covered underneath that one medical diagnosis. For example, a patient with the

medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD) could have the following

nursing diagnosis related to the condition: Impaired Gas Exchange, Activity Intolerance, Anxiety,
CLINICAL NURSING JUDGEMENT 4

etc. After a nursing diagnosis has been formulated the next step is Planning/Outcomes. This is

where the nurse uses evidence based practice to develop appropriate goals and interventions to

treat the nursing diagnosis. The final step of the nursing process is Evaluation. In this step the

nurse determines whether the goal/outcome was met, partially met, or not met. While this

process sound very formal and rigid, a lot of times nurses complete this process without even

thinking about it.

A great personal example of this happened during a precepting shift I had recently. Our

patient had 3+ pitting edema in her lower extremities and 3+ non-pitting edema in her upper

extremities (Assessment). The patient’s medical diagnosis was Right-sided Heart Failure. A

common nursing diagnosis for Right-sided Heart Failure is excess fluid volume (Diagnosis). We

knew that we needed to pull the fluid off the patient but diuretics alone were not working. So we

went to the resident and asked to have a one-time dose of Albumin ordered. Ashley Barlow, et.al.

described albumin as a protein made in the liver that is responsible for maintaining pressures in

the intravascular space (2020, p. 24). One of the ways albumin maintains pressure is through its

ability to pull fluid from the extravascular space into the intravascular space. So while in this

case we were not using albumin to maintain pressures, rather we used it to pull the extravascular

fluid that was causing severe edema into the vasculature so it could then be excreted with the

help of the diuretic. So our goal was to decrease the patient’s edema by using albumin

(Planning/Outcome). After we received the order and administered the albumin we reassessed

the patient’s edema every two hours. Within the first two hours we were able to see a decrease in

the edema and an increase in the urinary output, making our outcome met (Evaluation). While

we were going through this process though we did not think of it as formally going through the
CLINICAL NURSING JUDGEMENT 5

nursing process, instead it was a matter of this is what’s wrong with the patient, what can I do to

help correct it.

Another way that clinical nursing judgement is used is during prioritization of care. This

is something that a lot of new nurses struggle with. Mary Ann Jessee discusses this struggle:

Increasingly complex patient situations and high patient-to-nurse staffing ratios hinder

new graduate nurses' successful management of patient care, contributing to avoidable

patient decline and death. This phenomenon is often attributed to the persistent deficit in

clinical reasoning and judgment of new graduate and novice nurses. (2019, p. 302)

With this trend in deficiency she goes on to state, “Therefore, it is imperative that educators

focus on improving strategies to ensure students are prepared” (Jessee, M., 2019, p. 302). Some

strategies that can be taught to assist in prioritization are the ABCs (Airway, Breathing, and

Circulation), Maslow’s hierarchy of needs, and time sensitive tasks. Not only do these strategies

help prioritize care for an individual patient but it also helps to prioritize which patient(s) to see

first. The ABCs are the most important technique to utilize because if someone is having a

problem with any of these three things, they will be unstable and therefore be the highest priority.

Maslow’s hierarchy of needs indicates that physical and basic needs have to be met before

someone can begin to meet psychological needs. For example, a patient with anorexia nervosa

has to meet their nutritional needs before they can begin to work on their body image and self-

esteem needs. Finally the nurse needs to look a time sensitive tasks. This strategy is common

sense that whatever task needs to be completed the soonest, gets the nurses attention first. For

example a patient has medication due at 0800, labs due at 0430, and a blood glucose check due at

0700. The nurse would obviously do the labs first then the blood glucose check and lastly
CLINICAL NURSING JUDGEMENT 6

administer the medication. Without successful prioritization a nurse cannot appropriately care for

their patients and will often times feel overwhelmed and burn out quickly.

Clinical nursing judgement is used throughout all of a nurse’s care they deliver to their

patients. It is the foundation of our decision making and prioritization. It contributes to why

nurses have been named the number one most trusted profession for nineteen year in a row.
CLINICAL NURSING JUDGEMENT 7

References

Barlow, A., Barlow, B., Tang, N., Shah, B. M., King, A. E. (2020). Intravenous Fluid

Management in Critically Ill Adults: A Review. Critical Care Nurse. Pages 17-27

Jessee, M. (2019). Teaching Prioritization: “Who, What, & Why”. Journal of Nursing Education.

Pages 302-305.

NCSBN. (2019). Clinical Judgement Measurement Model. Retrieved from

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

Wright, J., Scardaville, D. (2021). A nursing residency program: A window into clinical

judgement and clinical decision making. Nurse Education in Practice. Pages 1-7