Nursing Skills: Clinical Judgment and Population Health

Clinical Judgment in Nursing Practice

  • Nurses must маке accurate and appropriate clinical decisions or judgments.
  • A clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as the observed outcome of critical thinking and decision making (NCSBN, 2019).
  • Clinical decision-making separates professional nurses from technicians or other assistive personnel.

Clinical Judgment Model

  • Models help to explain concepts.
  • Critical thinking in nursing is complex.
  • A model explains the many variables involved in making decisions and clinical judgments about patients.

Clinical Judgment Model Components

  • Patient Needs
  • Nursing Process:
    • Assessment
    • Analysis/Diagnosis
    • Planning
    • Implementation
    • Evaluation
  • Critical Thinking
    • Clinical Decisions
    • Critical Thinking Competence
      • Knowledge Base:
        • Basic and nursing science
        • Nursing and healthcare theory
        • Patient data
      • Experience:
        • Personal
        • Clinical practice
        • Skill competence
      • Environment
        • Time pressure
        • Setting
        • Task complexity
        • Interruptions
      • Critical Thinking Attitudes
      • Standards
        • Intellectual
        • Professional

The Nursing Process ("ADPIE")

  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

The 6 Functions of Clinical Judgment

  1. Recognize cues: What matters most?
  2. Analyze cues: What does it mean?
  3. Prioritize hypotheses: Where do I start?
  4. Generate solutions: What can I do?
  5. Take action: What will I do?
  6. Evaluate outcomes: Did it help?

NCSBN Clinical Judgment Model

Layers of the NCSBN Model

  • Layer 0: Client Needs
  • Layer 1: Clinical Judgment (Not Satisfied/Satisfied)
  • Layer 2: Clinical Decisions (Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take Actions, Evaluate Outcomes)
  • Layer 3: Environmental Factor Examples & Individual Factor Examples
    • Environmental: Observation, Time Pressure, Task Complexity, Resources
    • Individual: Medical Records, Knowledge, Skills, Specialty, Cultural Considerations, Candidate Characteristics, Prior Experience, Level of Experience
  • Layer 4: Nursing Process (Assessment, Analysis, Planning, Implementation, Evaluation)

Clinical Judgment Cognitive Skills

  1. Recognize Cues: What matters most?
  2. Analyze Cues: What could it mean?
  3. Prioritize Hypotheses: Where do I start?
  4. Generate Solutions: What can I do?
  5. Take Action: What will I do?
  6. Evaluate Outcomes: Did it help?

Assessment/Recognize Cues: Subjective Data

  • Symptoms described by the patient (e.g., pain, fatigue, nausea, “I feel sad”).
  • Patient/significant other (SO)/caregiver direct quotes.
  • Significant data that pertains to the specific patient problem being addressed.

Assessment/Analyze Cues: Objective Data

  • Signs (e.g., fever, height, weight, diagnostic tests, labs).
  • Relevant physical assessment findings.
  • Pertinent lab data: WBC 11.8, glucose 75mg/dl.
  • Pertinent diagnostic tests results: MRI indicates torn ligament….
  • Medications ordered for that problem: morphine for severe pain, acetaminophen for fever.
  • Related vital signs (VS): BP 80/40, RR 30.

Helpful Hint

  • If you observe something and someone else can observe the same thing, it is OBJECTIVE (example: redness, vomiting).
  • If you can’t physically observe the data, it's based on patient statements, it is SUBJECTIVE (pain, nausea).

Nursing Diagnosis/Problem Statement/Prioritize Hypothesis

  • A nurse’s clinical judgment about an individual’s response to actual or potential health problems and life processes.
  • Clinical Judgment – the process by which the nurse decides on data to be collected about a client, makes an interpretation of the data, arrives at a nursing diagnosis, and identifies appropriate nursing actions; this involves problem-solving, decision-making, and critical thinking.

Diagnostic Statements (PES Format)

  • Diagnostic statements can be one-part, two-part, or three-part using the PES format.
    • Three-part statement: ACTUAL problem
    • Two-part statement: potential problem

Three-Part Statement

  • Problem - Etiology - Symptoms
  • [Problem/Diagnostic Label] 'related to' (rt) [Etiology] "as evidenced by (a.e.b.) [Symptoms]
  • Examples:
    • Impaired Physical Mobility related to decreased muscle control as evidenced by the inability to control lower extremities.
    • Acute Pain related to tissue ischemia as evidenced by a statement of "my chest is so painful," pain scale of 8/10.

Two-Part Statement

  • [Risk Diagnosis/ Diagnostic Label] 'as evidenced by' (AEB) [Etiology]
  • Examples:
    • Risk for Falls as evidenced by improper use of crutches.
    • Risk for Injury as evidenced by altered clotting factors.

Problem/Nursing Diagnosis

  • North American Nursing Diagnosis Association (NANDA).
  • Stated in terms of approved NANDA diagnoses.
  • Use your Potter & Perry text or Ackley and Ludwig (nursing care plan book)/Evolve resources.

Outcomes/Goals – Generate Solutions

  • MUST BE realistic.
  • MUST BE specific, measurable.
  • MUST HAVE a specific timeframe.
  • Person, family, or caregiver-centered: Facilitate them to be involved in his/her own care.
  • Ex: the person will verbalize 3 low-carb snacks by the end of today’s diabetic education class…
  • Include criteria/meaning.
  • Example: How?--with a cane.
  • Often use action verbs – verbalize, identify, demonstrate, ambulate, eat, drink, sleep, etc.

SMART Outcomes/Goals

  • Specific: State what you'll do, use action words.
  • Measurable: Provide a way to evaluate, use metrics or data targets.
  • Achievable: Within your scope, possible to accomplish, attainable.
  • Relevant: Makes sense within your job function, improves the business in some way.
  • Time-bound: State when you'll get it done, be specific on date or timeframe.

Short-Term Outcomes/Goals

  • A person-centered outcome that is often a stepping stone to reaching a long-term goal.
  • Often 7 days or less.
  • By end of shift.

Long-Term Outcomes/Goals

  • An objective that is expected to be achieved over a relatively long time period, usually weeks or months.
  • Often more than 7 days.
  • Example: Within three months, the person will …
  • Timeframe varies.

Implementation/Take Action

  • (what will you do to meet the Outcome/Goal?)
  • The most specific actions required to prevent, resolve, or minimize a health problem.
  • Evidence-based practice (EBP) - use actions that have been proven by research to be effective.
    • Braden Scale for skin assessment has been validated.
    • Fall risk tool that has been validated.
    • Pain scales.
  • Support with a rationale.
  • Document with reference in APA format (in text citation and reference page).

Evaluation/Evaluate Outcomes

  • Evaluate Achievement of Outcome/Goal, NOT effectiveness of your intervention.
  • Was the outcome achieved, not achieved, or partially achieved.
  • If not, why not and REVISE.

Nursing Care Plan

  • Includes sections for:
    • Patient Initials
    • Age
    • Gender
    • Medical Diagnosis and Definition (with APA citation)
    • Date of Care
    • Subjective assessment/data leading to identified nursing diagnosis.
      • Clinical Judgment Model (CJM): Recognize Cues (What matters most?)
    • Objective assessment/data to support identified problem/nursing diagnosis and type # of problem/nursing diagnosis.
      • Clinical Judgment Model (CJM): Analyze Cues (What does it mean?)
    • Problem statement/NANDA nursing diagnosis plus "related to" (r/t- etiology) and "as evidenced by" (AEB- defining characteristics; not needed with Risk for diagnosis)
      • CJM: Interpreting/Analysis/ Prioritize Hypothesis (Where do I start?)
    • Expected Outcomes/Goals SMART short-term goal (STG) and long-term goal (LTG)
      • CJM: Interpreting/Planning/ Generate Solutions (What can I do?)
    • Nursing Interventions (Nurse-driven, physician-ordered, or collaborative assessment and teaching may be included; FIVE interventions)
      • CJM: Implementation/ Take Action (What will I do? Support why you are doing this.)
    • Rationale (Supporting scientific reason for the intervention - provide APA in-text citations)
      • CJM: Interpreting Outcomes Evaluation
    • Evaluation (Expected outcome achieved, partially achieved, or not achieved; suggest revisions of goals or interventions if outcome not achieved)
      • CJM: Reflecting (Did it help?)

Rutgers Undergraduate Curriculum

  • Shifts focus from acute individual care to a broader framework centered on health promotion and disease prevention within populations.
  • Emphasizes population health and equips nurses to provide care beyond the individual level.
  • Students are exposed to social determinants of health, develop and implement health education strategies for prevention, conduct community assessments, and gain insights into transitional care from hospital to the community.

What is Population Health?

  • Population: Collection of people who share one or more personal or environmental characteristics.
    • Used interchangeably with the term aggregate.
  • Population Health: Core of public health – emphasizes health protection, health promotion, and disease prevention of a population.
    • The health outcomes of a group of individuals, including the distribution of such outcomes within the group.
    • Patterns of health determinants, and policies and interventions that link these two.

Why Population Health

  • Renewed interest in public health and in population-focused health care in the United States
  • Patient Protection and Affordable Care Act
  • National Prevention, Health Promotion, and Public Health Council
  • Prevention and Public Health Fund
  • Improvements in prevention (Task force on Preventive Services)
  • Population-focused approach
  • Emphasis on prevention!!
  • Upstream Thinking

Public Health Practice

  • Foundation for healthy populations in US
  • Solid history of preventive improvements
    • Sanitation
    • Immunizations to prevent infectious diseases
    • Public health initiatives
  • Institute of Medicine (IOM) Report 2013
    • Emphasis on funding public health services
    • Emphasis on population-based prevention – up to 70% of early deaths in the US can be prevented through population-focused public health approaches
  • Medical treatments AFTER illness is diagnosed can only prevent approximately 10% of early deaths.

Focus of Public Health

  • Vision:
    • Healthy people in healthy communities
  • Mission:
    • Promote physical and mental health
    • Prevent disease, injury, and disability
  • "what we, as a society, do collectively to assure the conditions in which people can be healthy"

Public Health Core Functions

  • Assessment
  • Policy Development
  • Assurance

10 Essential Public Health Services (Revised, 2020)

  • Assessment:
    • Assess and monitor population health
    • Investigate, diagnose, and address health hazards and root causes
  • Policy Development:
    • Communicate effectively to inform and educate
    • Strengthen, support, and mobilize communities and partnerships
    • Create, champion, and implement policies, plans, and laws
  • Assurance:
    • Utilize legal and regulatory actions
    • Build a diverse and skilled workforce
    • Improve and innovate through evaluation, research, and quality improvement
    • Build and maintain a strong organizational infrastructure for public health
    • Enable equitable access

Population-Focused Practice vs. Individual-Focused Practice

  • Population-focused practice
    • Diagnoses, interventions, and treatments are carried out for a population or subpopulation.
    • Levels of prevention (primary, secondary, tertiary).
    • Population-level decision making is different; concerned with more than one subpopulation.
  • Individual-focused practice
    • Diagnoses, interventions, and treatments are carried out at the individual client level.

Foundation of Preventative Services

  • Public health nursing aims to focus more on:
    • Community, population-based promotion, and prevention.
    • "the greater the effectiveness of services in the lower tiers, the greater is the capability of higher tiers to contribute efficiently to health improvement."

What is Healthy People?

  • Surgeon General’s Report on Health Promotion and Disease Prevention.
  • First published in 1979 – goals set for 1990.
  • 10-year increments of time.
  • Framework for prioritizing national healthcare goals.
  • Focus is on HEALTH PROMOTION and DISEASE PREVENTION (NOT just treatment of illness).
  • Currently, we refer to Healthy People 2030.

Healthy People 2030: Overarching Goals

  • Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury, and premature death.
  • Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all.
  • Create social, physical, and economic environments that promote attaining full potential for health and well-being for all.
  • Promote healthy development, healthy behaviors, and well-being across all life stages.
  • Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all.

Leading Health Indicators - Examples

  • Persons who use the oral healthcare system (infant to adult).
  • Persons who are vaccinated annually against influenza (infant to adult).
  • Persons who have medical insurance (infant to adult).
  • Use of tobacco products – vapes, cigarettes (child to adult).
  • Household food insecurity (infant to adult).
  • Obesity (child to adult).
  • Exposure to unhealthy air (infant to adult).
  • Meeting minimum guidelines for aerobic activity (adult).

Overall Health and Well-Being Measures

  • Broad, global outcome measures intended to assess the Healthy People 2030 vision
  • Life Expectancy at Birth
  • Free of activity limitation
  • Free of disability
  • In good or better health
  • Summary Mortality and Health
  • Free of activity limitation
  • Free of disability
  • In good or better health

Health Behaviors Related to Health Promotion

  • Health Communication
  • Physical Activity
  • Nutrition and Healthy Eating
  • Sleep
  • Vaccination
  • Tobacco Use
  • Drug and Alcohol Use
  • Injury Prevention
  • Violence Prevention
  • Emergency Preparedness

Invest in Your Community

  • The conceptual framework underlying current thinking about the factors related to health (the what);
  • Defining the target population living in a specific community/area (the where);
  • The many sectors which need to collaborate in problem identification, planning, priority setting, implementation, and evaluation (the who);
  • And the four major action areas.