Clinical Nursing Judgement in New Graduate Registered Nurse

Kortney Squibbs

Nursing Department, Youngstown State University

4852 Senior Capstone

Dr. Ballone and Mrs. Thomas

15 March 2021
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Abstract

“Clinical decision making, clinical reasoning, and clinical judgement are all terms used to

describe the complex cognitive work of nurses in patient-care settings” (Hensel, Billings, 2019.

p. 128). Research has also shown that new graduates demonstrate only 23% of beginning-level

competencies (Hensel, Billings, 2019 p. 128). Clinical judgment is something that is gained

through experience. It is important to note that Hensel and Billing also stated “that up to 65% of

adverse patient events could have been prevented if nurses had engaged in better decision

makings, yet only one-fifth of employers think their new nurse hires have satisfactory decision-

making skills (Hensel, Billings, 2019. p. 128). This just solidifies that nursing judgment occurs

over time. Clinical nursing judgment allows experienced nurses to make quick and educated

decisions about patients and interventions that best suit the situation. Development of nursing

judgment occurs over time and I will explain how mine has developed in the past months.

There is one specific example of clinical nursing judgement I have learned over the past

month. It occurred in my Critical Care Clinical. I had a patient who was diagnosed with Acute

Respiratory Failure. I am going to refer to her as EM. EM was a 76-year-old female who was

diagnosed with Covid-19 in the previous admission and was intubated. She was discharged to a

long-term care facility on oxygen. A week later she started have shortness of breath and was

brought to the Emergency Room for increased confusion. Her oxygen was only at 86% on 8

Liters of high flow oxygen. They decided to intubate and transferred patient to the ICU. After

being admitted my patient’s oxygen status was at 95%.

On the day of care, EM oxygen saturation was at 85% after a chest x-ray was performed.

Her vent settings were 100% Fi02 and a PEEP of 7. EM total breaths were 42 per minute. I asked

my instructor to come help me to see what I can possibly do for her. We then started discussing
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possible reasons for the tachypnea and low saturations. We discussed how some patients can

show pain when increased respirations and agitation. Since EM also had Covid-19 she was at

high risk for Acute Respiratory Distress Syndrome. My instructor reminded me to think back to

classes. She mentioned to me that my patient with high Fi02 but oxygen saturation still low was

refractory hypoxemia. I remember learning that those patients need an increased PEEP to expand

the Alveoli for more gas exchange to occur. Once we talked through the possible interventions

the doctor came into the room. After long consideration the doctor increased her sedation and

added a Fentanyl drip. He also asked respiratory to increase PEEP to 12. After all these

interventions occurred my patient became stable and relaxed. My instructor talked to me after

this situation and we both decided that this moment has helped me work through and critically

think through a situation. My hope is to learn how to do this quicker and more efficiently.

This small moment reminded me how I have to think about how each individual thing

can affect my patient, especially when my patient is unable to talk to me. This specific situation

has helped me develop my critical thinking skills. Now if I see my patient struggling to breath in

the ICU, I know what possible interventions I can take to improve my patient’s status. Hensel

and Billings also wrote how simulations can help increase critical judgment (Hensel, Billings,

2020. p. 129). Joyce Victor also supported simulations and how it helped develop critical

thinking. Victor’s study showed that students scored higher when they participated in

simulations, compared to those who did not. (Victor, 2017. p. 734). I believe my situation was a

prime example how critical thinking is developed when immediate feedback is given on a

situation.

A third study I looked at discussed a nurse residency program and how it develops and

changes the clinical judgment and clinical decision making. In this study, new grads wrote in
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journals about how the residency program went as time progressed. There are a few journal

entries that stick out to me in this study. One new grad wrote:

“The observation that stuck out the most for me that day was when we had a patient go

into cardiac arrest, and unfortunately didn’t make it. I had to perform chest compressions,

which I’ve done a few times in the past, but this time I was so nervous, I couldn’t even

remember how to interlock my hands. The attending physician commented on my

performance, which wasn’t that bad, and she was nice enough to give me some tips on

how to improve my compressions.” (Wright, Scardaville, 2020. p. 4)

This specific journal entry focused on the importance of something such as CPR. Many of us put

it to the side until it is needed. The fact that the attending helped the new grad to fix mistakes

tells me that they would also help educate the new grad about other things. This includes giving

the new grad people to help fall back on to work out some critical judgement calls. I know that

one thing I have learned in my preceptorship is that we have to be willing to ask for help,

because everyone there was a new grad once.

Clinical Nursing Judgement is something that develops over time and with experience. It

is important to note that as said earlier most new graduates do not have satisfactory decision-

making skills. After researching into critical nursing judgement, I will take the next two months

leading up to graduation to hone into my critical thinking skills. I will use my clinical

experiences and instructors to help work on my critical thinking.

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References

Hensel, D., & Billings, D. (2019). Strategies to Teach the National Council of State Boards of

Nursing Clinical Judgement Model. Nurse Educator. 45(3), 128-132.

Doi:10.1097/NNE.0000000000000773

Victor, J. (2017). Improving Clinical Nursing Judgment in Prelicensure Students. Journal of

Nursing Education. 58 (12), 733-736. Doi:10.39228/01484834-20171120-05

Wright, J., & Scardaville D. (2020). A nursing residency program: A window into clinical

judgement and clinical decision making. 58 (102931), 1-7. Doi:

10.1016/k.nepr.2020.102931.