Clinical Nursing Judgment

Tori McCormick

Youngstown State University

April 2, 2018
 Nurses have many duties some of which include performing assessments,

charting, administering medications, transferring patients, inserting catheters and

nasogastric tubes, delegating tasks appropriately and much more. All of the duties that

are assigned to the nurse are to complete the nursing process. In order to complete the

nursing process correctly and to the best of abilities a nurse must use clinical nursing

judgment. This means that the nurse forms an educated opinion after observation and

reflection and analysis of patient information. This opinion or judgment acts as a tool in

order to provide the safest care possible. The clinical judgment process occurs in the

order of observation, reasoning, and critical thinking. Ganesan Karthikeyan and Prem

Pais support this theory in their article Clinical Judgment and Evidence – Based

Medicine: Time Reconciliation by explaining that clinical judgment can be considered the

total of all cognitive processes involved in clinical decision-making. In order to truly

understand the job of a nurse we must agree that clinical judgment plays a huge factor in

standard of care.

Psychiatric nursing is a beast of it’s own to say the least. Learning the dos and

don’ts of therapeutic communication is the foundation of this type of nursing along with

risk assessment. Risk of harm to oneself and others is of top priority. In order to fully

grasp what clinical judgment is a study will prove the importance and overall method

relating to psychiatric nursing. In the article Understanding Clinicians’ Use of Cues

When Assessing the Future Risk of Violence: A Clinical Judgment Analysis in the

Psychiatric Setting by Barbara Brown and Tim Rakow a study was conducted relating

cues from clients contributing to nursing judgments. In this study cues representing

recent behaviors are given more weight than cues relating to past events or to fixed
features of the individual. This correlates to all aspects of nursing. Although both

observations play a role in forming clinical judgments the patient’s symptoms now are

more viable and take weight than history. In this study some of that categories included

behavioral problems at school, severity of violence pre-admission, frequency of hospital

violence, and psychotherapy. Basically what this study is saying is that diving deeper and

gathering more information such as what is in these categories can assist nurses in

making educated clinical judgments along with the ongoing nursing assessments and

therapeutic groups and communication.

After understanding the basis of what clinical nursing judgment is, the importance

of using this tool is clearly seen. These judgments play a major role in the decision

making of not only nurses but physicians and patients as well. Stated by Laurence B

McCullough in the article Critical Appraisal of Clinical Judgment: An Essential

Dimension of Clinical Ethics “Responsible clinical judgment is essential to the formation

and implementation of ethically justified healthcare policy. Clinical judgment,

increasingly, functions in synergy or contention with organizational culture and health

policy, making them essential to responsible clinical judgment.” From the beginning of

nursing school it is taught to be culturally competent. To see each patient the same

without considering age, race, gender, religion or even what insurance is being used.

Looking at the observations and facts alone results in responsible clinical judgment that is

essential to good nursing care. Every person working in the medical field whether it be

nurses, doctors, respiratory therapists or even dieticians use clinical judgment. Someone

who has been working as a nurse for thirty plus years will typically have better clinical

judgment than a novice nurse because they have seen the situation before and know what
to do. This does not mean the novice nurse has bad clinical judgment it just means they

have to use more critical thinking to come up with a solution to a problem they have

never seen before. As explained by Sayra Crstancho, Lorelei Lingard etc. in the article

Putting the Puzzle Together: the Role of Problem Definition in Complex Clinical

Judgment, it is not at the individual level but at the situation and system level that we are

able to define problems when experts make clinical judgments during complex situations.

Clinical judgment is used with every patient everyday in every aspect of nursing

whether it be pediatrics, labor and delivery, critical care, emergency, psychiatric and so

on. One skill that I personally take an extreme amount of pride in is; knowing

medications inside and out. Throughout the nursing program I have been working as a

pharmacy technician and have been exposed to medicine what it is used for and what

combinations you can use together. I was privileged enough to do my preceptorship in

the St. Elizabeth Youngstown emergency room. One thing I know from being a

technician is that ondansetron (Zofran) has a major cardiac adverse reaction. It is

dispensed all the time for nausea and vomiting but what many people do not know is that

it can prolong a QT interval. Having my critical care class last semester I learned how to

read EKGs. I was able to recognize that after a baseline 12 lead EKG my patient had a

prolonged QT interval. This patient came in for extreme chest pain and by using good

clinical judgment before we gave her the morphine ordered and sent her down to CT scan

we had to get a urine sample because she could not urinate. Because the pain was so

excruciating the patient could not urinate. We had to insert a straight catheter in order to

get the sample. Once the results came back she was not pregnant we were able to

administer the morphine and mark her ready for scan. One of the major side effects of
morphine is nausea. The doctor had ordered ondansetron with the morphine to take care

of that. Using good clinical nursing judgment I refused to administer the medicine

knowing about her condition of always having a prolonged QT interval and requested the

doctor give her something else for nausea. He was very nice and thankful about the

situation saying it was good we caught it before we administered the medicine. The order

was discontinued and changed to phenergan. Knowing medications what they are used

for and their side effects plays a major role in clinical nursing judgment. Clinical nursing

judgment is an aspect of nursing that is never going away. It is knowing what patient to

treat first, what patients you can transfer safely, what medications interact with each

other, whether or not a psychiatric patient has a high risk of suicidal or homicidal

behaviors it is the sum of all that a nurse learns. Clinical judgment is using the basic skills

along with critical thinking to keep patients safe and provide the best care possible.

Although we may not have a lot as novice nurses with each chapter we cover, class we

pass and patient we see our clinical judgment is expanding.

 References

Brown, B., & Rakow, T. (2016). Understanding Clinicians' Use of Cues When Assessing
the Future Risk of Violence: A Clinical Judgement Analysis in the Psychiatric
Setting. Clinical Psychology & Psychotherapy, 23(2), 125-141.

Cristancho, S., Lingard, L., Forbes, T., Ott, M., & Novick, R. (2017). Putting the puzzle
together: the role of 'problem definition' in complex clinical judgement. Medical
Education, 51(2), 207-214. doi:10.1111/medu.13210

Denig, P., Wahlström, R., De Saintonge, M., & Haaijer-Ruskamp, F. (2002). The value
of clinical judgement analysis for improving the quality of doctors' prescribing
decisions. Medical Education, 36(8), 770-780.

McCullough, L. B. (2013). Critical Appraisal of Clinical Judgment: An Essential

Dimension of Clinical Ethics. Journal Of Medicine & Philosophy, 38(1), 1-5.