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clinical judgement def

Clinical judgment, sometimes called nursing judgment, is an iterative process that uses nursing knowledge to observe and access clinical situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions to deliver safe patient care

scope of clinical judgement

• leads to positive patient or staff outcomes.

failure to rescue

is the inability of nurses or other interprofessional health team members to save a patient’s life in a timely manner when a health care issue or medical complication occurs. Patients often have beginning or subtle signs and symptoms 1 to 3 days before cardiopulmonary arrest or multiple organ failure. FTR occurs when those signs and symptoms are not noticed (failure to recognize) or accurately interpreted, and therefore action to improve the patient’s condition is not implemented (failure to escalate).

six cognitive (thinking) skills or pro cesses of clinical judgment (CJ)

• Recognize Cues: Assessment • Analyze Cues and Prioritize Hypotheses: Analysis • Generate Solutions and Take Actions: Planning and Imple mentation • Evaluate Outcomes: Evaluation

why is clinical judgement needed

clinical judgment is needed to improve patient safety and pre vent failure to rescue. Increased patient acuity and complexity demand that nurses know how to quickly recognize changes in a patient’s condition and implement interventions to help pre vent negative clinical outcomes.

early warning scoring system [EWSS])

An EWSS is a guide for the health care team to quickly determine a patient’s condition on the basis of a physiologic scoring matrix.

The most commonly used type of EWS is the modified early warning system (MEWS).

This guide is a screening and scoring tool for medical-surgical nursing assessment to determine a patient’s condition based primarily on the patient’s level of consciousness and respiratory rate. A sustained increase in a patient’s respiratory rate is the first sign of clinical decline! Declines in either of these assessments often occur about 6 to 8 hours before a cardiac or respiratory arrest. Most MEWS tools also include measurements of systolic blood pressure, temperature, heart rate, oxygen saturation, and hourly urinary output

• • Behavioral and social determinants of health:

What “health” means to each person within the context of their culture, and what actions they are willing or able to take to achieve or maintain it.

Evolving approaches to population health management:

Evidence-based methods to reduce health inequities and improve the health of the human population within groups, defined areas, nations, and worldwide using methods of data collection and analysis that allow health care to be proac tive rather reactive. A focus on attaining, maintaining, and regaining health, as well as on best practices for improved outcomes, such as those outlined in Healthy People 2030.

policy and health care reform

The view that health care is a right rather than a privilege and that individuals should be active participants in their own health choices and actions.

• • Available and emerging technologies:

Use of new technologies to assess specific health risks and implement treatment plans based on personal factors rather than on a “one-size-fits-all” traditional approach to prevention and care.

interprofessional practice in the form of teamwork and collaboration, an emphasis on patient-centered care

The involvement, coordination, and respect of all members of the health care team to provide competent, precise, and personalized care to meet the needs of individual patients.

shift toward systems thinking

The recognition that health maintenance and health care activities and interventions do not occur in isolation and that a systems approach to prevention and care is more likely to have positive health outcomes than actions taken by a single provider.

critical thiking

“involves the skill of using logic and reasoning to iden tify the strengths and weaknesses of alternative health care solu tions, conclusions, or approaches to clinical or practice problems”

\- Without critical thinking, safety lapses and errors occur that can lead to harm or death

Quality and Safety Education of Nurses (QSEN)-fundamental elements of critical thinking can be found here

1. Patient-centered care—recognizing that patients, with their own autonomy, are at the center of all decision making

2. Safety—designing all nursing care with the focus on safety at the forefront of planning and execution of care, both at the individual and the systems level of care

3. Evidence-based practice—using the best evidence in con junction with clinical experience and patient preference to deliver safe care

4. Informatics—making use of the most up-to-date technology to support decision making, delivery, and documentation of care

5. Teamwork and collaboration—functioning well within the interprofessional team; recognizing that shared decision making contributes to safety and quality

6. Quality improvement—using data to make informed deci sions to continually improve health care outcomes

clinical reasoning

is a process by which nurses make informed and responsible clinical decisions and address problems faced by their patients or clients; it involves wise, professional, and patient-centered actions (Higgs et al., 2018; Higgs, 2016).

• It takes place through a process known as ADPIE— Assessing, (Nursing) Diagnosis, Planning, Implementing, and Evaluating or AAPIE—Assessing, Analyzing, Planning, Implementing, and Evaluating.

example of clinical reasoning

For example, let’s assume that a nurse is caring for a patient who was admitted to a medical-surgical unit because of ongoing dizziness. The patient requests to use the bathroom. When the nurse helps the patient to a sitting position and then to a standing position, the patient reports feeling light-headed and is noted to seem unstable when standing. The nurse has assessed the situation by noticing cues: dizziness and instability are noted on changing positions. At this point, the nurse begins to think through what this could mean and hypothesizes causes associated with these assessment data. The nurse recalls that low blood glucose can cause dizziness and possible instability but then considers that the patient’s symptoms began on changing position. This leads the nurse to think about the pathophysiology associated with orthostatic hypotension. In this process, the nurse has analyzed the data collected to hypothesize the possible underlying cause. In determining that this is the most likely cause of the patient’s condition, the nurse then plans for management of this concern. Instead of ambulating an unsteady patient, the nurse helps the patient to a urinal or bed pan. Once the patient is safe, the nurse dialogues with the health care provider about obtaining an order for a bedside commode. The nurse implements the change via nursing actions by ensuring that the patient is identified as a fall risk. The nurse confirms that a fall risk bracelet is in place, educates other members of the interprofessional team about the patient’s status, and monitors responses to make sure that these interventions are being con sistently put in place. Finally, the nurse evaluates, or reflects on the actions taken to determine whether the fall risk precautions are working after being put in place. If needed, the nurse can revisit the AAPIE process to make necessary, patient-centered alterations in the plan of care

clinical judgement

is “the observed outcome of critical thinking and decision making. It is an iterative process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care”

Clinical Judgment Measurement Model (CJMM)

built as an information-processing framework, was developed in response to the understanding that clinical decision making does not happen in an isolated “bubble.” Context surrounding situations influences clinical judgment. Factors such as time constraints, risks, and available resources always affect choices that a nurse makes when determining how to formulate and implement a plan of care

• The CJMM “represents a fundamental shift from the current dichotomous measurement models in which something is either right or wrong” (Dickison et al., 2019, p. 12), allowing for evaluation of comprehensive clinical judgment based on layers of collected information and surrounding context.

Clincial judgement under the CJMM

Under this model, clinical judgment can be viewed and evaluated according to four levels of information. Each time the nurse encounters a patient, assessment begins. Whether the setting is in a hospital, in a health care provider’s office, or in the community, the nurse begins receiving and analyzing cues based on objective and subjective assessment. Nursing analysis is heavily based on formal classroom education coupled with what has been learned in personal clinical experiences. This information becomes the foundation on which the nurse will form hypotheses, prioritize decision making, formulate solutions, and then implement nursing interventions based on the designed plan of care. Evaluation of outcomes can confirm or change the plan of care at any point within the sequence.

• The most important part of the CJMM is that another layer—the context of the situation—considers and supports clinical judgment. The factors within this layer, such as envi ronment, time pressure, availability or content of electronic health records, resources, and individual nursing knowledge, have a direct impact on clinical judgment.

CJMM: 6 step process to help guide decision making leading to clinical judgement

1. Recognize Cues. Cues are elements of assessment and data that provide important information. What data are relevant(directly related to patient outcomes or the priority of care) versus irrelevant (unrelated to patient outcomes or priority of care)? What assessment information is the most import ant and immediate concern to the nurse? Identify the relevant information first to help determine what is most important.

2. Analyze Cues. Consider the cues in the context of the patient history and presentation. How do the cues (assessment data) connect to the patient’s condition or history? Think about priority collaborative problems that support and contradict the information presented in this situation.

3. Prioritize Hypotheses. Consider all possibilities and deter mine their urgency and risk for the patient. What will happen? Which possible outcomes present the greatest concern?

4. Generate Solutions. Use the hypothesis to develop expected outcomes. What interventions will lead to the expected out comes? What interventions should be avoided or are potentially harmful? Determine the desired outcomes first to help decide which interventions are appropriate.

5. Take Actions. Use nursing interventions to address the highest priorities of care and indicate how these will be performed. Consider additional assessment, health teaching, documen tation, requested health care provider orders or prescriptions, nursing skills, interprofessional collaboration, and so on.

6. Evaluate Outcomes. Consider patient outcomes in relation to expected outcomes. What signs indicate an improvement, decline, or unchanged patient condition?

the nursing process includes

(1) assessment, which corresponds to recognizing and analyzing cues;

(2) analysis or diagnosis, which corresponds to

prioritization of hypotheses;

(3) planning, which corresponds to generating solutions;

(4) interventions, which correspond to taking action; and (

5) evaluation, which corresponds to evaluating outcomes.

model and theories (breif)

NCSBN Clinical Judgment Measurement Model- recognize cues, analyze cues, prioritize hypotheses, generate solutions, take actions, evaluate outcomes

nursing process (aapie)- assessment, analysis, planning, implementation, evaluation

tanner moder- noticing ,interpreting, responding, reflecting

inpatient care

An inpatient stay involves admission to a health care facility such as a hospital or a skilled nursing agency (U.S. Centers for Medicare and Medicaid Services, n.d.a). This stay may be for observational or monitoring purposes or to actively care for an injury, illness, or other health condition. The largest portion of U.S. national health care spending continues to be directed toward hospitals (Nunn et al., 2020), despite efforts to shift care to wellness and health promotion and community-based care

community health care- 2 branches

community-oriented primary care (COPC) and community-based care. COPC exists in some countries outside of the United States and incorporates the model of primary care delivery with a population-based approach. Although financial barriers are well understood in the United States, other key barriers to implementation of care for communities include discrimination based on personal characteristics, the need to correct workforce shortages, and understanding and amelioration of social determinants of health

managed care or health maintenance organizations

• intention is to reduce health costs

medical home

• a medical home is a model of philosophy of primary care that encompasses the functions and attributes of comprehensive care, patient-centeredness, coordinated care, accessible services, and quality and safety

It is not an actual physical place; rather, it is a care model that exists to decrease frag mentation of care for patients with ongoing health needs. The patient-centered medical home (PCMH) consists of an interprofessional health care team that continually commu nicates with the patient and family members to ensure that comprehensive care is delivered. Assessment of the medi cal home is based on The Joint Commission’s Primary Care Medical Home Certification Program standards

long term care

involves numerous services that include medical and nonmedical care (personal care) over a period of time to indivisuals who cant perform basic ADLs.

• Care received in the long-term setting is highly individualized and well coordi nated to help provide partial or total care for a period of time, sometimes indefinitely. Common examples of long-term care services include rehabilitation care and dementia care.

Types of Long-Term Care Services (Offered in the United States)

• Private medical practices • Nursing care • Rehabilitation care • Mental health • Dementia care • Social support • Respite care • End-of-life care

systems thinking

encourages encourages the nurse to look beyond this individual action for additional or enhanced methods to promote safety and increase quality improvement.

• The goal of systems thinking is to encourage the nurse to develop an awareness of the interrelationships that exist between indi vidual care and the overall context of health care safety and quality improvement.

Influencers on clinical judgment within a system of care. (C

determinants of health

emerging technology

population health

health policy

complexity of care

interproffessional practice

evidence based practice

The Essentials Core Competencies of Systems-Based Practice

Systems-Based Practice:

Applies knowledge of systems to work effectively across the continuum of care

• Articulates organizational mission, vision, values, and philosophy • Understands relationships between macrosystems, mesosystems, and microsystems

• Understands differences between health care delivery environments

• Recognizes that internal and external factors affect care coordination and transition management

Optimizes system effectiveness through application of innovation and evidence-based practice

• Approaches decision making from a systematic perspective

• Uses performance metrics to compare and monitor outcomes

• Participates in system efficacy evaluations

• Recognizes system processes and structures that perpetuate racism and discrimination within health care Incorporates consideration of cost-effectiveness of care • Understands financial and payment model associated with cost of care

• Recognizes the impact that health disparities; social determinants of health; policy; regulatory requirements; economics; and system struc tures, leadership, and workforce have on outcomes of care • Correlates cost and payment models to delivery, access, and quality of care • Incorporates an understanding of efficiency, value, and cost in the provision of care

clinical cues

a) Objective findings (signs)

b) Subjective findings (symptoms) that indicate

client deterioration and improvement’

Recognize Cues

 What data is most relevant or important in the

clinical scenario?

 What information is of immediate concern or

requires immediate follow-up?

Consider different sources of information

- signs and symptoms (manifestations)

- laboratory values

-medications

-client statements

-medical history and physical exam

(can include both subjective [what the patient says]

and objective data [what the nurse measures from the

patient])

analyzie cues

 Organize and connect the recognized cues to the

client’s clinical presentation. [What could it mean?]

(NCSBN, 2023)

 Organizes and links the cues to the client’s

presenting situation

 Makes sense of the cues; identify patterns in the

clues and clusters related clues together

 Which cues are causes for concern, which are not a

concern?

Prioritize Hypotheses

 Evaluate and prioritize hypotheses

(urgency, likelihood, risk, difficulty, time

constraints, etc.).

[Where do I start?] (NCSBN, 2023)

hypothesis

s

‘suppositions, assumptions, or likely conclusions

that are made based on presenting client data.

In practice, the nurse recognizes relevant

clinical cues in a client situation that need

timely follow up and interprets those

assessment data to determine one or more

hypotheses (actual or potential client

conditions).

Prioritize Hypotheses

 Hypotheses are prioritized based on

• Likelihood of occurrence

• Urgency

• Risk for complications

 Which client condition or health problem is the most

important to address or manage in a given clinical

situation?

Generate Solutions

 Identify expected outcomes and use hypotheses to

define a set of interventions for the expected

outcomes. [What can I do?] (NCSBN, 2023)

Generate Solutions

 Determine what solutions (goals) are desired or

expected for the client

 Solutions (goals) can be client condition focused or

intervention focused

 Should be SMART: specific, measurable, achievable,

agreed upon, realistic, and time bound

 Ex. Client will…

Take Actions

 Implement the solution(s) that address the highest

priority. [What will I do?] (NCSBN, 2023)

 Actions: ‘Nursing interventions or assessments that

are implemented to assist the client in improving

health and attaining desired clinical outcomes’

(Ignatavicius & Andersen, 2025, p. 149)

 Generate a list of possible actions (nursing

interventions) to manage or resolve the client’s

priority health problem or concern.

 What are the priority actions or interventions that

should be taken to achieve the solution (goal)?

evaluate outcomes

 Compare observed outcomes to expected outcomes.

[Did it help?] (NCSBN, 2023)

 Clinical outcomes: ‘…measurable changes in signs

and symptoms, health, ability to function, quality of

life, or survival’ (Ignatavicius & Andersen, 2025, p.

186)

 What cues indicate that the client solution (goal) has

been met?

 What signs or symptoms indicate the client’s

condition has improved?

 Based on evaluation of outcomes – plan of care can

be continued or modified