Journal of Nursing Education

Major Article 

From a Medical Problem to a Health Experience: How Nursing Students Think in Clinical Situations

Louise Boyer, PhD, RN; Jacques Tardif, PhD; Hélène Lefebvre, PhD, RN

Abstract

Background:

Nursing clinical judgment (NCJ) is a core competency that must be developed in nursing education. The objective of this study is to explore the development of NCJ among undergraduate nursing students, according to teachers and preceptors.

Method:

The collaborative group, composed of three educators, three nurse preceptors, and one researcher, analyzed six situations in which students in the program were assessed for NCJ.

Results:

Key learnings and development indicators were identified for each of the three levels of NCJ development. Reasoning process, type of relationships with patients and their families, perception of the nursing role, and reflection are parameters of NCJ that exert a mutual influence and evolve from one level to the next.

Conclusion:

Knowing this evolution can help educators to plan the curriculum, select effective teaching methods, and provide feedback that will support NCJ development. For students, these developmental markers support self-evaluation with a view to self-regulation. [J Nurs Educ. 2015;54(11):625–632.]

Abstract

Background:

Nursing clinical judgment (NCJ) is a core competency that must be developed in nursing education. The objective of this study is to explore the development of NCJ among undergraduate nursing students, according to teachers and preceptors.

Method:

The collaborative group, composed of three educators, three nurse preceptors, and one researcher, analyzed six situations in which students in the program were assessed for NCJ.

Results:

Key learnings and development indicators were identified for each of the three levels of NCJ development. Reasoning process, type of relationships with patients and their families, perception of the nursing role, and reflection are parameters of NCJ that exert a mutual influence and evolve from one level to the next.

Conclusion:

Knowing this evolution can help educators to plan the curriculum, select effective teaching methods, and provide feedback that will support NCJ development. For students, these developmental markers support self-evaluation with a view to self-regulation. [J Nurs Educ. 2015;54(11):625–632.]

Nursing clinical judgment (NCJ) is a core competency of the nursing profession and its value should be recognized as much in practice as in teaching and research. Patient safety is at stake (Clarke & Aiken, 2003; Thompson, Aitken, Doran, & Dowding, 2013). It is imperative that those involved in nursing education provide guidance and foster optimal development of clinical judgment in their students. Several nursing researchers have studied NCJ (Harbison, 2006; Tanner, 2006; Wilber, 2014) or clinical reasoning (Fonteyn & Ritter, 2008; Levett-Jones et al., 2010; O’Neil, Dluhy, & Chin, 2005; Simmons, Lanuza, Fonteyn, Hicks, & Holm, 2003) for many years. However, few studies have explored the development of clinical judgment among nursing students (Lasater, 2011). One qualitative exploratory study (Boyer, 2013) conducted in a Canadian university has recently shed new light on this topic.

Development of Nursing Clinical Judgment Among Nursing Students

Tanner (2006) defined clinical judgment as the interpretation of a patient’s health-related needs, concerns, or problems, as well as the decisions regarding interventions to address these. Tanner (2006) developed a research-based model of clinical judgment in nursing. Based on Tanner’s model, Lasater (2007), in an exploratory scientific study, created a rubric with four performance levels to assess the clinical judgment of nursing students in clinical simulations. Lasater (2007, 2011) explained that the tool can also serve as a guide because it describes the development process. Lasater’s (2007) rubric has been used in other studies that have evaluated teaching strategies aimed at fostering the learning of NCJ (Bussard, 2013; Gubrud-Howe, 2008; Mann, 2010) or at assessing NCJ in clinical simulations (Hur et al., 2012; Strickland, 2013). However, to the current authors’ knowledge, no other scientific study has described the development of clinical judgment in undergraduate nursing students.

A recent collaborative study (Boyer, 2013) has contributed to the corpus of knowledge on the development of clinical judgment in undergraduate nursing students. Its objectives were to (a) develop a cognitive model of the learning involved in developing NCJ during undergraduate education and (b) identify indicators for each of the three levels of development of this competency. NCJ is considered to be a competency in which development begins with initial education and continues throughout professional practice. According to Tardif (2006), a cognitive model of learning is “a modelling, constructed using valid scientific data, that builds on key learnings to describe the stages of development for the competency in question, from the level of novice to that of expert” (p. 83; authors’ translation). The key learnings, which are mutually exclusive at each stage of development, are qualitative in nature and signal a cognitive reorganization that involves integrating and combining several types of resources (e.g., knowledge, procedures, attitudes). The criteria for evaluating competencies, called development indicators, operationalize the key learnings (Tardif, 2006).

Method

The methodological choices for the current study were guided by the collaborative approach (Desgagné, 2001). One of the researchers (L.B.) formed and animated a collaborative group that included three nurse educators and three nurse preceptors who were involved in the evaluation of students’ NCJ. The decision to mix academic and clinical educators was made to ensure that the cognitive learning model would be constructed from solid qualitative data stemming from different perspectives (data triangulation). Also, a model built with those who conduct evaluations could be integrated into nursing education (National Research Council, 2001). Data collection was inspired from the group analysis method of Van Campenhoudt, Chaumont, and Franssen (2005). That method consists of 12 steps that are organized into three phases: the narrative, the interpretation of the narrative, and the analysis. It consists of bringing together actors from different settings to discuss a common theme and, by so doing, to deepen their reflexivity in intersubjectivity. A total of six analysis sessions were held over a period of 3 months. Each session lasted 3 hours. During each of these, one nurse educator or preceptor from the collaborative group presented a narrative in which he or she evaluated students’ NCJ. These six narratives were used to represent first-year, second-year, and third-year students’ NCJ.

Data were analyzed by the researcher, using thematic analysis (Paillé & Mucchielli, 2010) and conceptual maps (Daley, 2004). Conceptual maps of undergraduate nursing students’ NCJ were constructed, with each of three maps representing a different year in the program. From each map, the researcher extracted different salient elements relating to students’ NCJ. These elements were then presented to an external researcher for data audit. After the data audit, these elements were transformed into key learnings and developmental indicators, building a first version of the cognitive model of learning (CML). This first version of the CML was presented to the collaborative group to integrate their comments. The final version of the CML was then validated by academic experts who had developed CMLs in previous studies. The experts were asked to comment about the progression of learnings from one level to the next and about the clarity of the statements. Discursive notes were kept by the researcher throughout the study in a research diary and regular discussions occurred with experienced researchers. These activities enabled the researcher to bring to light the influence of the collaborative process on data analysis, which contributes to confirmability and credibility of the study (Lincoln & Guba, 1985). Member checking, triangulation of data, and investigators also help to establish the study’s credibility (Lincoln & Guba, 1985).

Ethics certificates were obtained from the relevant authorities. All participants signed a consent form after having it explained to them by the researcher. The confidentiality of personal information was safeguarded both during and after the study.

Results

The cognitive learning model of NCJ development in undergraduate nursing education consists of three levels. For each level, key learnings and development indicators have been identified. The first level consists of six key learnings and 12 development indicators. Designated as “intervening step by step,” the first level is situated near the end of the first year of the undergraduate nursing program. Students who have attained this first level of NCJ follow a reasoning process that is procedural, and they want to identify interventions rapidly to help patients with their health problems. The second level, “investigating to understand,” is situated near the end of the second year of the program and consists of seven key learnings and 10 development indicators. Students who have reached the second level of NCJ development are interested in patients and their families and are conscious of the various elements to be explored in considering a health-related situation. The third level of development, “responding to the whole person,” is situated near the end of the third year and consists of seven key learnings and 15 development indicators. Students who have attained this level take into account the comprehensive health experiences of patients and their families to provide personalized care. Tables 13 present the key learnings and development indicators for the three levels of NCJ development. A clinical situation included in Table 3 demonstrates the differences in NCJ among first-year, second-year, and third-year nursing students.

Key Learnings for Each of the Three Levels of Development of Nursing Clinical Judgment in Undergraduate Nursing Education

Table 1:

Key Learnings for Each of the Three Levels of Development of Nursing Clinical Judgment in Undergraduate Nursing Education

Development Indicators for Each of the Three Levels of Development of Nursing Clinical Judgment in Undergraduate Nursing Education

Table 2:

Development Indicators for Each of the Three Levels of Development of Nursing Clinical Judgment in Undergraduate Nursing Education

Examples of the Three Levels of Development of Nursing Clinical Judgment Among Nursing Students

Table 3:

Examples of the Three Levels of Development of Nursing Clinical Judgment Among Nursing Students

Discussion

The key learnings and development indicators are developmental markers indicating progress in relation to NCJ parameters. Figure 1 illustrates these parameters and how they are related. The parameters are inherent to the reasoning process associated with the perception of the clinical situation, the type of relationship with the patient and the patient’s family, the perception of the nursing role, and reflection. The reasoning process is structured around three broad activities: data collection, data analysis, and identification of interventions. Students’ perceptions of the nursing role become more complex over the three stages of development and influence the reasoning processes, as well as the other NCJ parameters. The types of relationships that students establish with patients and families also evolve, as do their perceptions of the nursing role and their reflection on their NCJ. In addition, all of the NCJ parameters influence each other (Figure 1).

Parameters of nursing clinical judgment in undergraduate nursing education. Reflexion = reflection.

Figure 1.

Parameters of nursing clinical judgment in undergraduate nursing education. Reflexion = reflection.

The progression of learnings related to NCJ entails certain changes in these parameters that form an integral part of undergraduate nursing students’ NCJ development.

The Reasoning Process Associated With the Perception of the Clinical Situation

In the first level of NCJ development, the reasoning process is conducted in a procedural manner, one step after the other. Students view the clinical situation as a current health problem affecting the patient. In most situations, this problem is associated with a pathology—hence, the data collection oriented toward the physiopathological dimension. This is what the first student, Mary (Table 3), did with her patient, Mrs. Smith (Note. All names are pseudonyms). From this starting point, it is primarily objective data that are collected, rather than subjective data. Lasater (2007) pointed out that nursing students who are at the first level of performance (i.e., who are just beginning their education program) confine themselves only to objective data. Along the same lines, Levett-Jones et al. (2010) observed that novice nurses focus only on symptoms presented by the patient without paying attention to the context of the clinical situation.

The analysis is conducted after data collection and consists of sorting through the data to identify the patient’s needs. Not much attention is given in the analysis to the context of the situation, as the data collected have mainly to do with physiological symptoms. In sorting the data and identifying needs, students rely on declarative knowledge because, thus far, they have integrated few resources (e.g., knowledge, procedures, attitudes). Lasater (2007) and Ashley and Stamp (2014) also noted that beginning students require outside support to understand the significance of the data.

After analyzing the data and identifying patient needs, students select interventions based on the suggestions they find in scientific references—especially books—as in the example of Mary, the first-year nursing student. The selected interventions address one or more needs related to a pathology affecting the patient, but they are not prioritized. According to Benner, Sutphen, Leonard, and Day (2010), nursing students beginning their education program put all tasks, demands, and concerns requiring action on an equal footing.

In the second level of NCJ development, students realize that a clinical situation involves other equally important dimensions besides the physiopathological one, such as the psychological, sociological, and ethical dimensions. Students then move from investigating not simply a health problem but rather a health situation. It is crucial for the data collection to become more comprehensive and targeted, because applying their NCJ to partial data can result in errors (Levett-Jones et al., 2010; Thompson et al., 2013). The data regarding different dimensions of the clinical situation include both objective and subjective data, such that the students can now take into account the specific situation of the patient and family. In addition, the data collection becomes targeted, aimed at finding the most important and relevant data on these different dimensions. The interaction created between analysis and data collection is helpful in identifying what data have the greatest priority and relevance. The solicitation of subjective data from patients and their families, as described in the “accomplished” level of Lasater’s rubric (2007), is similar to the act of taking into account the specifics of the patient–family situation in the second level of the NCJ development model.

Considered as one of the three steps of the clinical reasoning process in the first level, analysis becomes the core focus of the reasoning process in the second level. Analysis is conducted in interaction with data collection, with feedback loops between the two activities. The example of Anna (Table 3) refers to these interactions between data collection and analysis when she asks questions of Mrs. Smith and her daughter to complete her assessment. Some contextual elements, such as taking into account the different dimensions of the health situation, the specifics of the patient–family circumstances, and the patient’s prior health experiences, influence the analysis and make it more contextualized than as in level one. The analysis is also further enriched by evidence and the student’s knowledge. The aim of the analysis is to identify one or more aspects of the health situation that should be given priority. For students in the second level of NCJ development, using nursing research to enhance analysis is a first step toward evidence-based practice. Levett-Jones et al. (2010) pointed out that there are several elements to be considered in any clinical situation and that this calls for skills in synthesizing and an ability to apply different kinds of knowledge, including an understanding of what constitutes evidence-based practice. Integrating evidence into nursing practice involves, for nurses as much as for students, thinking critically about the validity and reliability of studies to select the most relevant studies (Alfaro-Lefevre, 2013).

Interventions at the second level are the product of interaction between data collection and analysis of several aspects of the health situation, with priority given to one or two. First, the student must perform an assessment and discern the nature of the situation (Benner, Sutphen, Leonard, & Day, 2010), so that the interventions selected will address the most important physiopathological, psychological, social, or ethical needs identified and will be well suited to the patient and family. Anna, the second-year student, identified the psychological aspect as being the most important in Mrs. Smith’s situation and organized her interventions accordingly. The impacts of these interventions on the patient and family must also be considered. However, as noted by Lasater (2007), students at this level confine themselves to the planned interventions.

In the third level of NCJ development, the reasoning process is considered to be dynamic, as the three activities—data collection, analysis, and interventions—are continually influencing each other. The perception of the clinical situation as being a health situation, with different aspects requiring investigation, evolves, in level three, toward a more integrated view of the clinical situation, or “the big picture,” as it is called by Benner et al. (2010, p. 49). The clinical situation is no longer broken down into different components but is viewed comprehensively as a health experience that the patient and family are undergoing. To arrive at a global view of the health experience, the interaction between analysis and data collection leads to the formulation of hypotheses about the experience. These hypotheses are verified with the people concerned (i.e., the patient and his or her family) but also with the help of other data sources to supplement the data collection. The data collection process is continuous, fueled by the implementation of interventions and by their outcomes.

In the third level of development, the analysis is contextualized by accounting for the views of patients and their families, as well as their living environments. The analysis also becomes more complex because of (a) the many possible links among the data collected in the effort to take into account all of the data collected; (b) the need to adapt to new and important information; and (c) the use of a variety of resources to enhance the analysis. Adding to this complexity is the fact that the analysis interacts with the data collection and the interventions. The analysis leads to a prioritization of needs, in collaboration with the patient and family. In the vignette, Kim (Table 3), who is near the end of her undergraduate nursing program, explores with Mrs. Smith and her family their views about the patient’s return to home, and together they reach a decision. In level three of NCJ development, analysis also includes identifying needs with respect to follow-up, as well as prevention and health promotion. This description of analysis as it relates to the third level of NCJ development is part of the final profile for this competency upon completion of the bachelor’s program in nursing. It is similar to one of the main goals of nursing education program identified by Benner et al. (2010). Those authors stressed the need for students to learn to contextualize their assessment of a clinical situation by taking into account the patient’s experience, cultural references, environment, previous experiences of care, and family relationships. Contextualizing the assessment of the clinical situation requires a global view of the situation that can be used to set care priorities (Benner et al., 2010). A certain degree of flexibility is observed in interventions at the third level of NCJ development. Interventions are personalized based on the prioritized needs identified with the patient and family, while also accounting for the time available and the care environment. Other professional resources could also be requested to address these needs. In interaction with data collection and analysis, interventions are also adjusted as new, and important data are gleaned. It is essential that the student keep abreast of any changes occurring in a clinical situation, as these modify action priorities (Benner et al., 2010).

In summary, the manner in which the reasoning process is conducted in the first level of NCJ development resembles an analytical process and, more specifically, a hypothetico-deductive process. This type of process is predominant among students (Lasater, 2007) and novice nurses (Tanner, 2006; Thompson et al., 2013). Although more dynamic than in level one, because of the interaction between data collection and analysis, the reasoning process in the second developmental level nevertheless remains essentially analytical. However, in the third level of NCJ development, the consideration of the views of the patient and family on their health experience is more akin to a narrative reasoning process (Tanner, 2006). Nursing students who reach the third level are still using an analytical process, but in combination with a narrative process.

The Nature of the Relationship With the Patient and Family

Over the course of the three levels of NCJ development, the nature of the relationship between the nursing student and the patient and family is transformed. In the first level, the relationship is centered on the patient and involves communication aimed at eliciting information from the patient about the health problem. The focus is on active listening in a relationship that is more social than professional. From this standpoint, according to Levett-Jones et al. (2010), the patient is seen primarily as a data source. In the second level, a professional relationship is created. In contrast to level one, the relationship now also includes the patient’s family. The student considers the patient and family as a unit in themselves, with a specific character. When exercising NCJ, the student takes this specific character into account. The student engages in a professional relationship with the patient and family by taking on the nursing role. In level three of NCJ development, the student actively solicits the views of the patient and family on their health experience, and this information then influences the student’s NCJ. The student fosters a collaborative relationship by involving the patient and family in identifying needs and setting priorities and personalizes the care to meet those needs. It is this understanding of the patient’s perceptions that makes it possible to personalize the interventions (Tanner, 2006).

Underlying the transition from a social relationship in the first level of development to one of collaboration with the patient and family in level three is a progressive recognition of the patient as a person. This person has a family, and together they have their own perceptions of the health experience they are undergoing. The patient is no longer the object of care and instead becomes a human being in the eyes of the student, who, to help the patient, needs to understand the patient’s concerns (Benner et al., 2010). Levett-Jones et al. (2010) emphasized the influence that this recognition of the person’s uniqueness has on decision making. According to Tanner (2006), knowledge of the patient and his or her reactions is one of the defining features of solid clinical judgment.

The Perception of the Nursing Role

While developing NCJ over the course of their program, students gradually take on the nursing role. They develop a conception of the nursing discipline that influences the way they embody this role. In the first level of NCJ development, students enter into their professional role in care provision. They become particularly conscious of the professional responsibilities inherent in this role, including that of ensuring patient safety. This consideration for patient safety primarily takes the form of asking for assistance as needed and seeking advice from a resource person on the safety of a planned intervention. Levett-Jones et al. (2010) agreed with this view of the safety of care provided by nursing students. They explained that students require communication skills and a certain amount of self-confidence to let the care team know when they need help. In this first stage of NCJ development, the student role takes precedence over the nursing role.

In the second level of development, students experiment with the nursing role. This experimentation occurs in their interactions with patients and families, as well as with health professionals, with whom they discuss clinical situations. In these professional interactions, students detach themselves from their role as students and take on the role of nurse, which they are exploring. This concrete exploration of different aspects of the nursing role enables students to integrate a comprehensive vision of that role. This integration of a comprehensive vision of the nursing role is expressed in the third level of NCJ development. It influences students’ interactions with patients and families, their perception and consideration of different aspects of clinical situations, and their identification and prioritization of needs, including needs related to follow-up, prevention, and health promotion.

The accumulation of key learnings about the nursing role over the course of the three NCJ development levels provides the foundation for the progressive construction of professional identity. Along these lines, Benner et al. (2010) noted that students act like nurses as they begin their education program and gradually become nurses over time. This nursing role influence was incorporated into the guide developed by Nielsen, Stragnell, and Jester (2007) to help students reflect on their NCJ.

Reflection

Between the first level of development and the third, students’ reflection on their own NCJ evolves. In level one, their metacognitive strategies are centered on the learning itself. At the start of the education program, students find it difficult to evaluate their performance with regard to their NCJ (Ashley & Stamp, 2014; Lasater, 2007). However, students engage in a process of continuous learning of NCJ by demonstrating a self-critical approach to evaluating their own performance and a willingness to receive feedback and by taking steps to optimize their learning. In the second level, students’ metacognition is focused on their NCJ. They begin a reflexive practice on NCJ as they demonstrate autonomy and self-confidence about their capacity for reflection. They reflect on their own reasoning process and on the care provided, with a view to self-regulation. In this way, nursing students learn from their experience, acquire more knowledge, and improve their clinical judgment and reasoning (Tanner, 2006). In level three, students push their reflection even further and are able to discuss their NCJ with various health professionals, which involves being able to explain and defend it. Thus, students’ metacognitive strategies are broadened from one level to the next, reinforcing their reflexive practice on their NCJ. Several nursing researchers (Alfaro-Lefevre, 2013; Fonteyn & Ritter, 2008; Lasater, 2007; Levett-Jones et al., 2010; Nielsen et al., 2007; Tanner, 2006) have highlighted the importance of reflection in strengthening NCJ. The progressive expansion of reflexive practice over the course of the three levels of NCJ development influences the development of students’ reasoning processes, their appropriation of the nursing role, and the transformation of their relationships with patients and families.

In fact, all of the parameters of NCJ influence each other and advance together in terms of learning. These advances in learning support the emergence of students’ autonomy in deploying this competency. The presence of mutual influences among the NCJ development parameters supports the necessity of acquiring all the key learnings associated with a development level to complete that level. Figure 2 summarizes the three stages of NCJ development in undergraduate nurse education.

Development of nursing clinical judgment (NCJ) in undergraduate nursing education. Reflexion = reflection.

Figure 2.

Development of nursing clinical judgment (NCJ) in undergraduate nursing education. Reflexion = reflection.

Future Research Needs

Adding different perspectives (e.g., from nursing students, nurse educators, and nurses practicing in clinical settings) could enrich the CML of nursing clinical judgment. More studies could also be undertaken to follow the CML’s implementation in undergraduate nursing programs.

Conclusion

This study contributes to the limited corpus of knowledge on the development of NCJ in undergraduate nursing students. A better understanding of NCJ’s development in undergraduate students and tools to evaluate this competency can support nursing curricula that aim to educate students with sound clinical judgment (Kantar & Alexander, 2012). The study results provide a key reference for nurse educators with respect to NCJ development in undergraduate nursing education programs. The learning sequence described in the cognitive learning model for NCJ development could guide the selection of learning situations that fit with the development level and the use of teaching strategies that are suited to the intended learnings. The development indicators, which express the key learnings in practice, serve, among other things, as evaluation criteria for determining whether the NCJ development levels have been completed. Nurse educators and nurse preceptors can use this information to give students feedback on the progression of their clinical judgment and what indicators they need to work on to continue this progression. For students, development indicators are reference points for understanding the intermediate goals of the education program, as well as the self-evaluation and self-regulation that will prepare them for a reflexive and responsible professional practice.

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Key Learnings for Each of the Three Levels of Development of Nursing Clinical Judgment in Undergraduate Nursing Education

Level 1: Intervening Step by StepLevel 2: Investigating to UnderstandLevel 3: Responding to the Whole Person
Follows a procedural reasoning process focused on a health problemApplies a reasoning process that is focused on analyzing the health situationIntegrates the combined influences of data collection, analysis, and interventions in a dynamic reasoning process focused on the health experience
Communicates with the patient to gather data about the current health problemTakes into account the specifics of the patient–family situationTakes into account the views of the patient and family
Applies declarative knowledge to analyze and respond to the health problemBegins relying on evidence in his or her reasoning processTakes into account the living environment of the patient and family
Considers the patient’s safetyEvaluates the ethical and biopsychosocial dimensions of the health situationConsiders the care environment
Is involved in a continuous process of learning nursing clinical judgmentConsiders the impacts of his or her interventions on the patient and familyFormulates hypotheses regarding the patient–family health experience
Begins to assume the professional role of nurse in providing care to patientsBegins a reflexive practice on his or her nursing clinical judgmentExercises nursing clinical judgment in relation to the patient–family and health professionals
Tries out the role of nurse in relation to the patient–family and health professionalsIntegrates a comprehensive vision of the nursing role.

Development Indicators for Each of the Three Levels of Development of Nursing Clinical Judgment in Undergraduate Nursing Education

Level 1: Intervening Step by StepLevel 2: Investigating to UnderstandLevel 3: Responding to the Whole Person
Carries out the steps of the reasoning process (data collection, analysis, interventions) sequentiallyCollects the relevant and most important data on ethical and biopsychological dimensionsIntegrates the interaction among the different stages of the reasoning process
Collects data primarily on the physiopathological dimensions of the health problemSupplements data collection interactively with analysisExplores the perceptions of the patient– family about their health experience
Assesses the current health problemConsiders the prior health experiences of the patient–family in his or her analysisVerifies his or her hypotheses with the patient–family and other data sources
Listens to the patientEnters into a professional relationship with the patient–familyEnters into a collaborative relationship with the patient–family
Uses declarative knowledge to gather data to identify the patient’s needsUses evidence and his or her own knowledge to deepen the analysisComprehensively analyzes the different relevant and high-priority data collected
Chooses interventions suggested by the theoretical literature in relation to the identified needsIdentifies one or more high-priority dimensions of the health situationDeepens his or her analysis using a variety of resources
Checks with a resource person regarding the safety of his or her interventions with the patientAdapts his or her interventions to patient– familyAdapts his or her analysis and interventions to new high-priority data
Shows initiative in optimizing his or her learningDiscusses clinical situations with different health professionalsCollaborates with the patient–family in setting priorities
Is open to receiving feedbackDemonstrates self-confidence and autonomy with respect to his or her capacity for reflectionIdentifies professional resources that could assist in addressing patient–family need(s)
Demonstrates self-criticism in his or her self-evaluationReviews and reflects on his or her reasoning process and on the care providedIdentifies health promotion and prevention needs
Requests assistance at appropriate timesAdapts his or her interventions to the needs of the patient–family, the care environment, and the time available
Is conscious of the professional responsibilities inherent in the nursing roleConsiders patient–family needs and living environment when evaluating and planning follow up
Explains his or her views to the patient–family
Demonstrates self-assurance when providing care
Discusses his or her clinical judgment with health professionals

Examples of the Three Levels of Development of Nursing Clinical Judgment Among Nursing Students

Example

Mrs. Smith, 82 years old, has been hospitalized for several days for left lower lobe pneumonia. Students (Mary, Anna, Kim) from 3 different years of the nursing undergraduate program are in training in the unit where this patient is located. All three, in turn, will provide care for Mrs. Smith under their preceptor’s supervision.

Mary is a student at the end of her first year of studies. She is somewhat intimidated by patients but finally resolves to enter Mrs. Smith’s room. She takes her vital signs, performs pulmonary auscultation, and verifies with the patient whether she is presenting signs and symptoms that are typical of pneumonia. After consulting the literature on pneumonia, Mary sorts through the data she has collected and then chooses some nursing interventions. Now she wants to validate these with her preceptor before going back into Mrs. Smith’s room.

Anna is at the end of her second year of studies. She went to Mrs. Smith’s room this morning to assess her health status. Upon entering the room, she saw that the patient’s daughter was at her bedside, so Anna spoke with them both. On the basis of the information given to her by Mrs. Smith and her daughter, Anna asked questions to complete her data collection. She made sure to collect the most important and relevant data on the patient’s physical status and also on her psychological status. She also took the opportunity to investigate the patient’s living environment and her family and social network. She noted that the patient is very anxious about being dependent on others to be able to get around. Anna is therefore planning some interventions to help improve Mrs. Smith’s autonomy, which she communicates to her preceptor.

Kim will soon complete her bachelor’s degree in nursing. She has only a few days left to her clinical placement. Her patient, Mrs. Smith, is expected to return home in 3 days. Kim has explored with Mrs. Smith and her family their views about her return to home. She has also shared with them her assessment of the situation. After these discussions, the patient and her family decide to seek help from community-based resources to organize a safe return to her home, rather than a stay in a rehabilitation facility. Kim has explained to the care team and to her preceptor the reasons for this choice and why she agrees with it.

Authors

Dr. Boyer is Assistant Professor, and Dr. Lefebvre is Tenured Professor, Faculty of Nursing, University of Montreal, Montreal; and Dr. Tardif is Tenured Professor, Faculty of Education, University of Sherbrooke, Sherbrooke, Quebec, Canada.

Dr. Boyer received grants from the Quebec Ministry of Education, Recreation and Sports, and from Équipe FUTUR (FRQ-SC).

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the participants who made this study possible.

Address correspondence to Louise Boyer, PhD, RN, Assistant Professor, Faculty of Nursing, University of Montreal, C.P. 6128, succ. Centre-Ville, Montreal, Quebec H3C 3J7, Canada; e-mail: louise.boyer@umontreal.ca.

Received: December 04, 2014
Accepted: July 08, 2015

 

10.3928/01484834-20151016-03

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