Providing patients with consistent, quality, and compassionate care is an important aspect of nursing. In their everyday work, nurses must rely on clinical judgment models to make critical decisions regarding a patient’s needs and interventions. Based heavily on critical thinking and observational skills, clinical judgment in nursing is essential to providing patients with the personalized level of care they deserve.
Whether you’re already working in the nursing field or are in school to become a nurse, understanding the importance of clinical judgment in nursing and how it can be used to deliver quality, patient-centered care is a must.
What Is Clinical Judgment in Nursing?
Before we dive any deeper into the importance of clinical judgment in nursing, as well as some clinical judgment and nursing care plan examples based on clinical judgment, let’s begin with a basic definition of what this term entails.
Definition and Importance
Specifically, clinical judgment in nursing refers to a model that empowers nurses to quickly and effectively assess a patient’s needs, cues, and other factors surrounding a patient’s care to determine evidence-based interventions with the patient’s best interests in mind.
All nurses will need to use clinical judgment in their everyday work, as it is an important aspect of on-the-job autonomy and being able to adapt to changing circumstances. In order to follow clinical judgment models, nurses need to have sharp analytical and critical thinking skills. This allows them to constantly be on the lookout for changes in a patient’s vital signs, symptoms, and other cues that may require them to take action.
The Evolution from Nursing Care Plans to Clinical Judgment Models
It’s also important to understand the differences between nursing care plans and clinical judgment models, particularly when it comes to scope and versatility.
What is a nursing care plan? Specifically, a nursing care plan is a document that provides nursing teams with critical information about a patient’s specific needs, diagnosis, condition, and goals. The overall purpose of a nursing care plan is to ensure that every member of the nursing team stays up-to-date on a patient’s needs, treatments, goals, and any other relevant information needed to provide consistent and quality care.
Compared to a nursing plan, clinical judgment models rely more heavily on critical thinking and the ability for nurses to weigh options for treatment/intervention based on context. In this sense, clinical judgment models are broader in their scope and require constant assessment and adjustment based on a patient’s changing needs.
A common framework for clinical judgment and decision-making in nursing is the Clinical Judgment Measurement Model, which was developed by researchers at the National Council of State Boards of Nursing (NCSBN).
The Role of Clinical Judgment in Patient-Centered Care
At the end of the day, a personalized approach to patient care is the goal, and clinical judgment models are the tools that nurses use to achieve that goal. In many ways, clinical judgment in nursing allows nursing professionals to deliver patient-centered care because this model is centered around nurses planning and implementing interventions based on changing patient needs and the unique circumstances of the patient.
Using clinical judgment and exercising professional autonomy in nursing allows these professionals to truly tailor care plans based on a patient’s specific needs while keeping the lines of communication open if patients have additional concerns or symptoms that need to be addressed. From there, the adaptive nature of clinical judgment makes it possible for nurses to collaborate with care teams and make changes to plans as needed.
Steps to Applying Clinical Judgment in Nursing Practice
So, what exactly does clinical judgment look like in everyday nursing practice? In general, there are five steps nurses follow when carrying out a clinical judgment model in their everyday work. Below, the steps of the NCSBN’s clinical judgment measurement model are laid out in detail.
Step 1: Patient Assessment and Data Collection
During the initial assessment phase, nurses should take the time to get to know their patients as much as possible. This can be done in a number of ways that involve collecting both subjective and objective data.
More specifically, nurses may use patient assessments and a check of vital signs to gather information that may be relevant to a patient’s condition. Likewise, nurses may use patient interviews and general observation to collect the information they need before moving onto the next step of the process.
Step 2: Recognizing and Analyzing Cues
Following the initial assessment phase, nurses must use their observational skills and attention to detail as a means of further observing patients and making note of other cues that may not have presented during the assessment. This may include noticing trends in a patient’s data (such as an increasingly high blood pressure reading) that could be relevant to their condition.
In other words, this phase of clinical judgment involves taking in contextual information in addition to hard data collected during the assessment phase to work towards more patient-centered interventions.
Step 3: Prioritizing Hypotheses and Nursing Actions
With all the information gathered from the first two steps, now is the time for nurses to determine which of the patient’s needs require the most urgent action. Often times, patients may present with more than one complaint — but it is the job of care teams to determine which problems should be prioritized based on any number of factors, including potential risks and complications.
Step 4: Planning and Implementing Evidence-Based Interventions
During the next phase of the process, nurses choose evidence-based nursing interventions for a patient based on the goals chosen and other important factors, such as the patient’s overall condition. This portion of the plan is especially important because it will lay out, in detail, the specific care the nursing team should provide to the patient.
In implementing interventions, nursing teams must decide how the plan will be put into action. Often, this is done in collaboration with the rest of the nursing team to ensure that everybody is on the same page. Involving the patient in the process whenever possible is also encouraged here.
Step 5: Evaluating Outcomes and Adjusting Care
After an intervention has been implemented, nurses have an important and ongoing responsibility to evaluate the overall success of the chosen interventions. From there, nurses can make changes as needed to continue working towards goals while keeping nursing teams on the same page.
Clinical Judgment in Action
To better understand what clinical judgment looks like on the nursing floor, it can be helpful to look at some examples of nurses using clinical judgment in a number of different contexts. This includes examples of using clinical judgment to treat patients with chronic conditions, acute conditions, and even ongoing mental health conditions.
Applying Clinical Judgment to Chronic Conditions
When a patient is suffering from a chronic condition, they are dealing with a persistent health issue that can have a significant impact on their everyday lives. When clinical judgment skills are used by nurses treating patients with chronic conditions, care teams can set realistic goals for improvement while tailoring interventions to a patient’s specific needs and responding to changes as they arise.
Consider, for example, a patient suffering from a chronic condition like diabetes. In assessing a patient with diabetes, nurses may make note of relevant data (such as blood pressure, weight/BMI, and blood glucose levels) as well as symptoms provided by the patient. From there, nurses may consider potential interventions and goals for the patient, which may include administering medication and changing the patient’s diet.
Goals and outcomes for these types of interventions may include keeping blood glucose levels within a certain range, educating the patient on how to live a healthier lifestyle, and avoiding certain complications that are common in diabetes patients. Throughout the process, nursing teams must take into account not just hard data from the patient, but other cues before implementing evidence-based interventions.
Clinical Judgment for Acute Patient Care
With acute conditions, which occur suddenly and typically last for only a short period of time, nurses must be focused on providing the best care to the patient while the condition is at its worst.
When a patient has undergone surgery, for example, the nurses caring for a patient after the surgery will need to use their clinical judgment to provide the highest standard of post-surgical care. This may include assessing the patient’s level of pain, monitoring vital signs, and keeping a close eye on the surgical site for signs of infection.
Interventions to promote a swift recovery and minimize patient discomfort may include administering pain medication, providing proper wound care, and getting patients up and moving as soon as possible. In this type of scenario, strong clinical judgment can help patients recover from their procedures and reduce the risk of complications.
Clinical Judgment in Mental Health Nursing
Just as in dealing with chronic and acute cases, nurses must also be prepared to care for patients suffering from mental health disorders. One common example of a mental health disorder that nurses may encounter in patients is anxiety disorder.
Patients experiencing anxiety symptoms may experience generalized anxiety, panic, social anxiety, or any number of phobias. Nurses must carefully assess patients for physical signs of anxiety, including restlessness, elevated heart rate, tremors, and hyperventilation. Interviewing patients can also be helpful in assessing anxiety symptoms and their severity.
Evidence-based interventions for anxiety patients may vary greatly but may include medications to manage symptoms, comfort measures, and even referrals to a therapist or mental health professional. With compassionate care and a thorough care plan in place, patients suffering from mental health challenges can receive the quality care they deserve.
Learn More in an RN to BSN Online Program
Reviewing diverse nursing care plan examples can help nursing students and professionals understand best practices across various healthcare scenarios. As a nurse, you’ll be expected to work with and refer to nursing plans daily to provide the highest standard of care while staying on top of changes in your patients, so it’s critical to know the ins and outs of these vital documents.
Looking to take your nursing career to the next level? It may be time to pursue your Bachelor of Science in Nursing (BSN) from Nevada State University. Our RN to BSN online program is designed for nursing professionals who already have their RN licenses or those who have plans to obtain their licenses within seven weeks of starting the program. With both indirect and direct practice experiences and a focus on both critical thinking and leadership, this program can help you prepare for the demands of an evolving nursing field.
Get in touch to request more information about our RN to BSN online program, or get started with your online application for admission today!