CH 2 Clinical Judgment and Critical Thinking Study Guide

Learning Outcomes

• Give one definition and one example of clinical judgment.

• List and describe at least one clinical judgment model.

• List the four types of nursing knowledge.

• Discuss the relationship between critical thinking and clinical judgment.

• Discuss the relationship between clinical reasoning and clinical judgment.

• Explain ways in which nurses use clinical judgment.

• Name and describe the main concepts of the full-spectrum nursing model.

• Explain how nursing knowledge, clinical reasoning, critical thinking, nursing process, and clinical judgment work together in full-spectrum nursing.

Case Study: Explore Your Nursing Role

• Nurse Participant: Jan, who graduated from nursing school $8$ months ago and has worked on the medical-surgical unit for $3$ months. She completed orientation $6$ weeks ago and works the $1900-0700$ shift.

• Client Case: Mr. Anderson:

  • Demographics: $72$-year-old male.

  • Procedure: Colon resection performed several hours earlier.

  • Companion: Accompanied by his wife, Lilly.

  • Admission Data at $2045$ (from PACU):

    • Recovery was uneventful.

    • Vital signs stable (VSS) at $2025$: Blood Pressure (BP) $158/82$, Pulse (P) $78$, Respirations (R) $14$, Temperature (T) $98.9$.

    • Oxygen saturation: $99\%$ on room air.

    • Intake and Output: IV fluid (IVF) intake $500\,mL$; urinary output via Foley catheter $200\,mL$ (clean and yellow).

    • Physical Condition: Abdominal dressing clean, dry, and intact; nasogastric tube patent with $100\,mL$ of gastric drainage.

• Jan's Documentation at $2100$:

  • VS: BP $160/84$, P $82$, R $16$, T $99.1$.

  • Physical: Dressing unchanged; patient is drowsy but oriented; skin warm and dry.

  • Pain level: $2/10$.

  • Treatment: IVF infusing at $125\,mL/hr$.

  • History: Non-insulin-dependent diabetes (type $2$), high blood pressure, and early-stage Alzheimer's disease.

• Jan's Documentation at $2200$:

  • VS: BP $150/78$, P $90$, R $20$, T $99.5$.

  • Pain level: $4/10$ (patient refuses medication).

  • Status: Drowsy/sleepy; wife reports he has been sleeping since admission.

• Jan's Documentation at $2400$:

  • Status: Lethargic; confused (states he is on his boat fishing).

  • VS: BP $138/68$, P $102$, R $24$, T $100$.

  • Indicators: Skin cool and moist; abdominal dressing dry/intact.

  • Outcome: Surgeon notified; prescribes pain medication and hourly VS, attributing confusion to "sundowning."

• Intervention by Lisa (Charge Nurse):

  • Lisa has been a nurse for $10$ years. She immediately conducts an assessment and notifies the hospitalist.

  • Result: Mr. Anderson is transferred to the intensive care unit (ICU) with a diagnosis of shock from abdominal bleeding.

Defining Clinical Judgment

• NCSBN ($2019$) Definition: Clinical judgment integrates critical thinking and decision making. Nurses apply knowledge to observe/access situations, identify prioritized concerns, and generate evidence-based solutions for safe care.

• Tanner ($2006$) Definition: Interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones based on patient response.

• Benner, Tanner, and Chelsa ($2009$) Definition: The ways in which nurses come to understand the problems/concerns of clients, attend to salient information, and respond in involved ways.

• Core Requirements of Clinical Judgment:

  • Assess/recognize evidence of problems.

  • Interpret problems.

  • Prioritize response.

  • Take action.

  • Evaluate outcomes and modify actions.

  • Consider context: Environmental (staffing, resources) and Individual (skill level, knowledge).

Kinds of Nursing Knowledge

• Theoretical Knowledge: Knowing "why." Includes facts, principles, and evidence-based theories from nursing and related fields (physiology, psychology). Includes research findings and understanding pathophysiology or treatments.

• Practical Knowledge: Knowing "what to do and how to do it." Involves processes (nursing process, decision process) and procedures (giving an injection).

• Self-Knowledge: Self-understanding. Awareness of one's own beliefs, values, and cultural/religious biases. Gained through personal reflection.

• Ethical Knowledge: Knowledge of obligation and right versus wrong. Consists of information about moral principles and processes for moral decision-making.

Tanner Model of Clinical Judgment ($2006$)

• Noticing: Forming an impression of the situation based on expectations, past experiences, and theoretical knowledge (e.g., looking for specific symptoms of pneumonia in an older adult).

• Interpreting: The reasoning process to make sense of the situation.

  • Analytical Reasoning: Used by new nurses; relies on textbook information and data to select diagnoses/interventions.

  • Intuitive Reasoning: Used by experienced nurses; an intuitive grasp based on in-depth knowledge.

  • Narrative Reasoning: Understanding the client's illness experience and vision for the future to create client-centered plans.

• Responding: The course of action taken by the nurse.

• Reflecting:

  • Reflection-in-action: Evaluating results during implementation to decide if a course change is needed.

  • Reflection-on-action: Self-evaluation after the event to refocus future actions and grow professionally.

Lasater Clinical Judgment Rubric (LCJR)

• Identifies $11$ dimensions based on Tanner's four aspects.

• Scoring Rankings:

  • $1 = \text{Beginning}$

  • $2 = \text{Developing}$

  • $3 = \text{Accomplished}$

  • $4 = \text{Exemplary}$

• Score Ranges:

  • Beginning: $11$

  • Developing: $12-22$

  • Accomplished: $23-33$

  • Exemplary: $34-44$

NCSBN Clinical Judgment Measurement Model (CJM)

• Layer 0: Clinical Decisions made by the nurse to address client needs.

• Layer 1: Outcome (Clinical Judgment).

• Layer 2: Forming, refining, prioritizing, and evaluating hypotheses.

• Layer 3: The step-by-step process of clinical judgment:

  • Recognize Cues.

  • Analyze Cues.

  • Prioritize Hypotheses.

  • Generate Solutions.

  • Take Actions.

  • Evaluate Outcomes.

• Layer 4: Contextual Factors:

  • Individual Factors: Knowledge base, skill level, and prior experiences.

  • Environmental Factors: Physical environment, time pressure, resources, task complexity, and cultural considerations.

Clinical Reasoning

• Definition: The process of synthesizing knowledge and information from numerous sources and incorporating experience to develop a plan of care for a particular client.

• Purpose: Application of knowledge to generate and evaluate alternatives based on evidence.

• Tools for Development: Algorithms, reflective journaling, thinking aloud, simulation, and case studies.

Critical Thinking

• Definition (Victor-Chmil, $2013$): A cognitive process that uses intellectual standards based on evidence and science to approach a problem.

• Definition (Papp et al., $2014$): Ability to apply higher-order cognitive skills (conceptualization, analysis, evaluation) and a disposition to be deliberate about thinking.

• Critical Thinking Skills:

  • Objectively gathering information.

  • Recognizing the need for more information.

  • Evaluating credibility/usefulness of sources.

  • Recognizing gaps in own knowledge.

  • Recognizing differences/similarities.

  • Listening carefully; reading thoughtfully.

  • Separating relevant from irrelevant data.

  • Organizing information in meaningful ways.

  • Making inferences (tentative conclusions).

  • Integrating new info with prior knowledge.

  • Visualizing potential solutions.

  • Exploring consequences of actions.

• Critical Thinking Attitudes:

  • Intellectual Autonomy: Checking things for oneself; not believing everything told.

  • Intellectual Curiosity: Asking "What if?" or "How does this work?"

  • Intellectual Humility: Asking for help and reevaluating conclusions.

  • Intellectual Empathy: Trying to see a situation through eyes of others.

  • Intellectual Courage: Fairly examining own and others' beliefs even if uncomfortable.

  • Intellectual Perseverance: Not settling for quick, obvious answers.

  • Fair-mindedness: Making impartial judgments despite biases.

  • Confidence in Reasoning: Relying on inductive and deductive processes.

Why Nurses Need Critical Thinking

• Complex Situations (Comorbidities): Example: A healthy $9$-year-old with a fracture vs. an older adult with a fracture plus recovery from a stroke.

• Unique Clients: Clients vary by illness, age, and culture. Nurses must modify protocols for individuals (e.g., fluid intake for a normal client vs. a client in renal failure).

• Personal Beliefs and Roles: Ethnicity, cultural background, and family roles (e.g., single mother needing early discharge) impact responses to health problems.

• Applied Discipline: Nursing requires analysis of cues, not just memorizing facts.

• Fast-Paced Environment: Conditions change minute to minute; nurses must respond under stress.

• Scientific Changes: Continuous updates to knowledge and skills are required.

The Critical Thinking Model (The Star Model)

• Contextual Awareness: Deciding what to observe; awareness of the total situation (values, culture, interpersonal).

• Inquiry: Based on credible sources and standards of good reasoning.

• Considering Alternatives: Exploring and imagining multiple possible explanations or actions.

• Analyzing Assumptions: Recognizing and examining underlying beliefs shaping choices.

• Reflecting Skeptically and Deciding: Questioning and analyzing the rationale for decisions.

Caring in Nursing

• Definition: Personal concern for people, events, and things that allows for connection and compassionate response.

• Components of Caring (Swanson, $1990$):

  • Knowing: Striving to understand an event's meaning in the client's life (e.g., illness, new baby).

  • Being With: Emotionally present (e.g., eye contact, active listening).

  • Doing For: Doing what the client would do for themselves (e.g., bathing, feeding).

  • Enabling: Supporting the client through coping and changes (e.g., hospitalization, new colostomy).

  • Maintaining Belief: Having faith in the client's ability to get through the change (e.g., cardiac rehabilitation).

The Full-Spectrum Nursing Model

• Core Concepts: Thinking, Doing, Caring, and Client Situation.

• How it Works:

  • Thinking: Critical thinking, theoretical knowledge, and clinical reasoning.

  • Doing: Practical knowledge and the nursing process (skills/procedures).

  • Caring: Self-knowledge and ethical knowledge; motivates the thinking and doing.

  • Client Situation: Physical, psychosocial data, context, and environment.

• Ultimate Purpose: To achieve good outcomes for the client and practice safe, effective care.

• Full-Spectrum Example (Oral Temperature):

  • Thinking: Recognizing an ice water glass on the table as a cue that could lower a reading (theoretical knowledge).

  • Doing: Asking the client when they last drank and returning later to retake the measurement (practical/nursing process).

  • Caring: Being patient and obligated to get an accurate reading rather than guessing (ethical/self-knowledge).