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Applying Nursing Clinical Judgment and Critical Thinking

Joshua Picket

Nursing Department, Youngstown State University

NURS 4852 Senior Capstone

Professor Wendy Thomas

March 23rd, 2020

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Clinical judgement is a concept that is practiced daily in the career of nurses. According

to the American Association of Colleges of Nursing, clinical judgement is defined as “the

outcomes of critical thinking in nursing practice… this includes evaluation of all assessment

data, generation of every possible course of action, anticipation of potential outcomes for each,

prioritization of actions, while remaining flexible and open to alternatives” (Manetti, 2019, p.

104). Clinical judgement is a tremendous attribute that practicing nurses must possess to provide

safe, quality care to their patients. Nurses possessing sound clinical judgment have evidence-

based knowledge, can quickly identify the important information in a given situation, prioritize

patient needs and nursing responses, while continually assessing and evaluating outcomes,

revising approaches to manage problems as necessary (Manetti, 2019, p. 108). Sound clinical

judgement is a quality that is attained through practice within the clinical nursing setting, it is not

something that can be learned by reading a book. For this reason, nursing programs must

graduate students who are “prepared to care for diverse, complex patients in health care

environments that are incorporating new knowledge, technologies, and processes at an increasing

rate” (Candela & McPherson, 2019, p. 583). The best way to prepare these students is to give

them as much exposure possible to the clinical setting, via local hospitals, clinics, offices, etc…

The importance of clinical nursing judgement is something that cannot be overlooked.

This attribute is seen to many as the most important quality of a nurse in the field. This quality is

not only judged by managers and potential employers, but by the patients as well. Commonly,

the degree of clinical judgment a nurse possesses correlates with the experience that they have

had in the clinical setting. This great experience and judgement allow these nurses to provide

safe, exemplary care to their patients. However, a potential problem is that of newly graduated

nurses having little experience in the clinical setting working in places of higher acuity. “If nurse
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graduates do not have the ability to think critically, or have poor clinical reasoning skills, they

often fail to detect impending patient deterioration, including failure to synthesize and act on

clinical information resulting in a failure-to-rescue which effects quality care and patient safety”

(Van Graan & Williams, 2017, p. 276). Both failing to act on clinical information and failing to

rescue are scenarios that a nurse of any level may encounter if they do not have the appropriate

clinical judgement to allow them to identify crucial information in an uncommon situation. The

most important skill for a novice nurse to attain while trying to reach this high level of clinical

judgement is a thorough assessment. This thorough assessment allows for early recognition of

both small and large changes in the patient’s condition that can then be handled in a safe, timely

manner. Without early recognition, some of these minor complications can grow to life

threatening problems for the patient. When trying to identify these issues, it begins with proper

recognition, then gathering information from all sources and knowing what additional

information to seek. A concept analysis done by Wendy Manetti, PhD, RN, CRNP, regarding

clinical judgement found the following results:

“Nurses with 16 or more years of experience, self‐assessed significantly higher than less

experienced nurses in problem recognition, clinical decision making, prioritizing, clinical

implementation, and reflection. The researchers found nurses with less than 1 year of experience,

self‐assessed lower than nurses with 6 to 10 years of experience in problem recognition. Fenske

et al, also found novice nurses struggled to identify critical data and the needed actions caring for

patients. This supports the notion that nurses gain knowledge, self‐confidence, and sound clinical

judgment as a result of practice experience” (Manetti, 2019, p. 106).

While these novice nurses may feel overwhelmed in their new practice setting, it is

extremely important for them to seek guidance from experienced nurses on the unit when unsure
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of decisions regarding patient care. Without guidance, these novice nurses may make devastating

mistakes that could lead to critical situations in their patients, or even death. All nurses must be

able to recognize pertinent information regarding their patients and take appropriate action to

allow for the safe, quality of care that these patients deserve.

In my own life, I have practiced this clinical nursing judgment mainly within my

precepting experience where I am taking on the workload of an experienced RN. Within my time

precepting in the Intensive Care Unit, I have come across various scenarios where clinical

judgement is a large factor in my patient’s safety and care. A time in particular would be when

receiving report at shift change, the nurse did not mention any significant labs. While looking

through labs, imaging, and other reports I had noticed the results of the 5 AM CMP showing that

the patient’s blood sugar was in the 50’s. I knew this was an abnormally low result for her by

comparing her previously drawn labs and I knew that her glucose level would likely still be

decreasing due to her being NPO for multiple days and lack of any fluids running through her

IV. At the time I noticed it was about 7:30 AM, immediately following report, so I entered the

room to assess the patient for any signs of hypoglycemia, where she did present with multiple

symptoms, and performed a stat POC Glucose test which resulted in the low 30’s. After getting

this result, the nurse and I immediately contacted the physician for orders that would prevent the

patient from deteriorating any further. We received an order for Dextrose IV, which we then

administered and then assessed and rechecked the patient’s glucose about 30 minutes and one

hour later. Our assessment found the patients hypoglycemic symptoms had relieved and her

glucose was back within normal range. My ability to recognize this critical value and act on it

appropriately allowed me to help alleviate the discomfort my patient was experiencing while also

possibly preventing a critical issue from arising in her care.

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References

Manetti, W. (2019). Sound clinical judgment in nursing: A concept analysis. Nurs Forum,
54, 102-110. https://doi.org/10.1111/nuf.12303

McPherson, S & Candela, L. (2019). A Delphi Study to Understand Clinical Nursing Faculty

Preparation and Support Needs. Journal of Nursing Education, 58(10), 583-
590. DOI:10.3928/01484834-20190923-05
Van Graan, A. C., & Williams, M. J. S. (2017). A conceptual framework to facilitate clinical
judgement in nursing: A methodological perspective. Health SA Gesondheid, 22, 275–
290. https://doi.org/10.1016/j.hsag.2017.01.004