Clinical Judgement In Nursing
Whats is Clinical Judgement
Clinical judgment has been defined as the process by which nurses come to understand problems, issues, or concerns of patients, attend to salient information, and respond in concerned and involved ways.
Clinical judgment occurs within a framework of clinical, legal, ethical, and regulatory standards and is closely aligned with phenomena such as critical thinking, decision making, problem solving and the nursing process (Benner, Tanner, & Chesla, 1996).
Clinical Judgment Expertise
Expert clinical judgment is held in high regard by nurses as it is generally viewed as essential for provision of safe, effective nursing care and the promotion of desired outcomes.
Nursing research has been conducted on the processes of clinical judgment with the intent of better understanding how nurses identify relevant information from the vast amounts of information available and then how information is used to make inferences about patient status and appropriate interventions.
The complexity of the clinical judgment process has brought about collaboration of nurse researchers with multi-disciplinary experts from a broad array of scientific backgrounds including cognitive psychology, informatics, phenomenology, and statistics.
The body of research on clinical judgment generated by interdisciplinary collaboration has been categorized into two absurd theoretical classifications: the "rationalistic" and the "phenomenological" perspectives.
In this context, the term "rationalistic" describes scientific inquiry into the deliberate, conscious, and analytical aspects of clinical judgment (Benner et al., 1996).
Examples include research on the role of information processing, diagnostic reasoning (Tanner, Padrick, Westfall, & Putzier, 1987) and decision analysis (Schwartz, Gorrie, Kassirer, & Essig, 1973) in the clinical judgment process.
The term "phenomenological" refers to research on
the skill-acquisition component of clinical judgment as advanced by Benner et
al. in the Novice to Expert Model (Benner & Tanner, 1987; Benner et al.,
1996).
Clinical Judgment And Diagnostic Reasoning
Information processing theory and diagnostic reasoning are based on the work of Newell and Simon (1972b) and Elastin (Elstein, Shulman, & Sprafka, 1978) and collectively describe problem-solving behavior and the effect of memory and the environment on problem solving.
These theories hold that human information processing capacity is restricted by short term memory and effective problem-solving ability is dependent on adoption of strategies to overcome human limitations.
Information processing theory and diagnostic reasoning have been widely applied to the study of clinical judgment and the use of information in the clinical judgment process.
Published research suggested that nurses and physicians use a similar process for clinical judgment which involves information gathering, Carly hypothesis generation and then additional information gathering to confirm or rule out a suspected diagnosis or clinical problem.
According to the "rationalistic theories," early hypothesis generation "chunks" data and is an effective strategy for conserving short-term memory (Corcoran, 1986; Elstein et al., 1978; Tanner et al., 1987).
While knowledge generated from work completed in the fields of information
processing and diagnostic reasoning has been descriptive in nature, decision
analysis is a prescriptive approach to decision making and involves the process
of weighing questions and employing mathematical models (generally made
possible through expert systems) to determine the course of action most likely
to produce desired outcomes.
Clinical Judgment Informational Process And Verbal Responses
Corcoran (1986) used an information-processing approach and verbal-protocol technique to compare care planning strategies used by hospice nurses.
She found that unlike novice nurses, the overall approach of expert nurses differed by case complexity with a systematic approach employed for less complex cases and an exploratory approach for cases of greater complexity.
In addition, expert
nurses generated more alternative actions during the treatment planning
process, were better able to evaluate alternative actions, and developed better
care plans than did novices.
Tanner et al. (1987) used verbal responses to videotape vignettes to describe and compare the cognitive strategies of diagnostic reasoning used by nursing students and practicing nurses.
They found that practicing nurses were more likely to employ a systematic approach and to be more accurate in diagnosis than the students.
Henry (1991) examined the effect of patient acuity on
clinical decision making of experienced and inexperienced critical care nurses
using computerized simulations. Findings suggest that inexperienced nurses
collected more data and had poorer patient outcomes than experienced nurses.
Salantera, Eriksson, Junnola, Salaminian, and Lauri (2003) employed simulated case descriptions and the think-aloud method to compare and describe the process of information gathering and clinical judgment by nurses and physicians working with cancer patients.
The authors found that while nurses. and physicians
identify similar problems, they employ divergent approaches to information
gathering and clinical judgment.
Clinical Judgment Characteristics And Objectives
Unlike the objective, detached approach to the study of clinical judgment characteristics of the rationalistic perspective, the phenomenological perspective holds that intuition is a legitimate and essential aspect of clinical judgment and is the feature that distinguishes expert human judgment from that of expert systems (Benner & Tanner, 1987).
Benner's work is based on the skill acquisition model advanced by Dreyfus. According to this model, there are six key aspects of intuitive judgment: pattern recognition, similarity recognition, commonsense understanding, skilled know-how, sense of salience, and deliberative rationality (Benner & Tanner).
Much of the
research related to Benner's work and the Novice to Expert Model relates to the
relationships that exist between nursing knowledge, clinical expertise and
intuition.
Expert Model In Clinical judgment
The Novice to Expert Model is based on Benner's early work where a phenomenological approach was used to interview and observe nurses with varying degrees of clinical expertise.
In the interview process, nurses were asked to describe outstanding clinical situations from their practice. Benner found that a holistic grasp of clinical situations is a necessary precursor to expert clinical judgment (Benner, 1984).
Subsequent research has supported these findings and has teased out differences in clinical judgment between clinicians with varying levels of experience (Corcoran, 1986).
In a six-year interpretive study of nursing practice, Benner et al. (1996) identified five interrelated aspects of clinical judgment:
(1) disposition towards what is good and right
(2) extensive practical knowledge
(3) emotional responses to the context of a clinical situation
(4) insight
(5) the role of narrative in understanding a patient's story, meanings, intents and concerns.
The authors suggested that
these aspects play a significant role in clinical judgment and deserve equal
consideration along with the aspects arising from the "rationalistic"
perspective of clinical judgment.
Research On Clinical Judgment
Research on clinical judgment identified two divergent but legitimate perspectives. The challenge for future research is to integrate these perspectives to study the impact of integrated models on clinical reasoning and patient outcomes, Synthesis holds promise for promoting evidence-base practice (EBP).
Rationalistic models can be employed in the form of guideline-based tools to bring the best evidence to patient care. Phenomenological models hold potential for bringing effectiveness to EBP by providing a holistic evaluation of patient systems.
A holistic perspective would serve as a guide to clinicians in the
care of individuals through identification and application of evidence which is
most relevant at the local level and for individual patients.
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