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Clinical Nursing Skills

1.1 Principles of Nursing Practice

Clinical Nursing Skills1.1 Principles of Nursing Practice

Learning Objectives

By the end of this section, you will be able to:

  • Define the goals of nursing practice
  • Describe the primary ethical principles of nursing practice
  • Identify how principles of clinical judgment are incorporated into nursing practice

As an aspiring nurse, it is important to understand the fundamental principles, goals, and ethics that guide the nursing profession. This section provides a comprehensive overview of the goals of nursing practice, the primary ethical principles that underpin nursing care, and the way principles of clinical judgment are incorporated into your daily practice to inform and guide your nursing care.

Nursing Definition and Goals

The most recent definition of nursing, according to the American Nurses Association (ANA) (2021), states “nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.”

The goals of nursing have evolved over time in response to changes in society, healthcare systems, and the understanding of healthcare needs. Historically, nursing was primarily focused on providing basic care, such as nutrition and comfort, during times of illness or injury. As health care advanced, nursing goals expanded to encompass a broader scope of practice. Florence Nightingale (Figure 1.2) is considered to be the founder of holistic nursing care, which emphasizes the healing of the whole person, including mind, body, and soul (American Holistic Nurses Association, 2023).

Florence Nightingale.
Figure 1.2 Florence Nightingale (1820–1910) is considered the founder of holistic nursing. (credit: “Three Quarter length portrait of Florence Nightingale” by Unknown/Wikimedia Commons, Public Domain)

The twentieth century saw significant progress in nursing education, research, professionalization, and technology. Nurses became actively involved in health promotion, disease prevention, and patient advocacy.

In recent decades, the goals of nursing have further evolved to emphasize evidence-based practice, patient-centered care, and interdisciplinary collaboration. Nurses now play critical roles in care coordination, healthcare leadership, and policy development. They actively engage in health promotion, disease management, and support for individuals and communities. Nurses are the coordinators of care for patients and communities, and nursing goals continue to change and develop as society progresses.

Role of the Nurse

The role of the professional nurse is multifaceted and dynamic. Nurses provide direct patient care, educate individuals and families, act as advocates, coordinate care, and provide leadership and change within the healthcare system. They play a crucial role in promoting health, delivering holistic care, and improving patient outcomes.

Health Promotion

The nurse’s role in health promotion is centered around empowering individuals, families, and communities to take control of their well-being and make positive choices (Burke, 2023a). Nurses provide education, guidance, and support to promote healthy lifestyles, prevent illness, and enhance overall wellness. They assess individuals’ health needs, identify risk factors, and develop personalized plans to promote optimal health. Nurses also collaborate with other healthcare professionals and community organizations to create strategies for health promotion, such as conducting health screenings, offering counseling services, and advocating for policies that support healthy environments. By fostering a culture of health, nurses play a vital role in empowering individuals to make informed decisions, adopt healthy behaviors, and achieve their highest level of well-being.

Illness Prevention

The nurse’s role in illness prevention is to identify potential health risks, educate patients and communities about preventive measures, and implement interventions to reduce the occurrence and impact of diseases (Burke, 2023a). Nurses assess a patient’s health status, gather information about their medical history and lifestyle factors, and identify risk factors that could lead to illness. They then provide education on disease prevention strategies such as immunizations, screenings, and other healthy behaviors. Nurses collaborate with individuals, families, and communities to develop personalized prevention plans and support them in making informed choices that promote their well-being. By actively engaging in illness prevention, nurses contribute to reducing the incidence of preventable diseases and improving overall population health.

Restoring Health

The nurse’s role in restoring health is to provide care and support to patients experiencing illness or injury (Burke, 2023a). Nurses play a vital part in facilitating the healing process and helping patients regain optimal health and well-being. They bring together their clinical expertise, critical thinking skills, and therapeutic communication to address the physical, emotional, and social needs of patients. Nurses administer treatments, monitor vital signs, manage medications, and perform various interventions to promote recovery. They collaborate with the interdisciplinary healthcare team and educate patients on self-care strategies, rehabilitation exercises, and lifestyle modifications. The nurse’s role in restoring health involves creating a healing environment, providing compassionate care, and empowering patients to actively participate in their recovery journey.

Facilitating Coping with Altered Function

One of the nurse’s roles is to care for patients and help them and their families adapt to temporary and permanent life changes (Burke, 2023b). Examples include changes in the patients’ physical and mental functioning, both short and long term. Illness or injury can seriously affect almost every aspect of a patient’s life, and every patient will handle their altered functioning in a different way. The altered functioning might be something short term, such as a patient who had a hip replacement who must now use a walker to ambulate safely for a few weeks. Or, it may be long term or chronic, such as a patient who has had a limb amputated.

The patient’s ability to institute, maintain, and regain psychological homeostasis when this homeostasis is disrupted for one reason or another is called coping strategy. There are many ways in which a nurse can assess how a patient is coping with their altered functioning, including the following:

  • Assessing the patient’s support systems and available resources.
  • Assessing the patient’s ability to adapt to temporary/permanent role changes.
  • Assessing the patient’s reaction to a diagnosis of acute or chronic mental illness (e.g., rationalization, hopefulness, or anger).
  • Assessing the patient’s coping skills for navigating life changes and provide support when needed.
  • Identifying situations that may necessitate role changes for a patient (e.g., spouse with chronic illness or death of parent).
  • Providing support to the patient with unexpected altered body image (e.g., trauma-related limb amputation).
  • Evaluating the constructive use of defense mechanisms by a patient.
  • Evaluating whether the patient has successfully adapted to situational role changes (e.g., accept dependency on others).

A coping strategy is an action, a series of actions, or thought processes used in meeting a stressful or unpleasant situation or in modifying one’s reaction to such a situation. Coping strategies are classified as adaptive or maladaptive. An adaptive coping strategy includes problem-focused coping and emotion-focused coping. The problem-focused coping strategy typically focuses on seeking treatment such as counseling or cognitive behavioral therapy. The emotion-focused coping strategy includes mindfulness, meditation, and yoga; using humor and jokes; seeking spiritual or religious pursuits; engaging in physical activity or breathing exercises; and seeking social support. A maladaptive coping response includes avoidance of the stressful condition, withdrawal from a stressful environment, disengagement from stressful relationships, and misuse of drugs and/or alcohol (Amnie, 2018).

Nurses can educate individuals and their family members about adaptive, emotion-focused coping strategies and make referrals to interdisciplinary team members for problem-focused coping and treatment options for individuals experiencing maladaptive coping responses to stress. Some of these positive strategies include

  • positive reframing with techniques such as the appropriate use of humor;
  • positive self-talk;
  • utilizing the help of social supports;
  • utilizing community resources that are appropriate to the patient’s needs;
  • learning and using new and more effective coping skills, problem solving skills, and decision-making skills;
  • the use of relaxation and stress management techniques, such as meditation, yoga, or journaling; and
  • readjusting and setting expectations of self that are achievable and realistic as based on the patient’s current state or status.

Ethical Principles of Nursing

The ANA’s ethical principles serve as a crucial foundation for nursing practice, guiding nurses in ethical decision-making and ensuring the provision of high-quality, patient-centered care (Burke, 2023c). An ethical principle is a general guide, basic truth, or assumption that can be used with clinical judgment to determine a course of action. These seven principles provide a framework that upholds the values and ethical standards of the nursing profession.

  • Accountability involves taking responsibility for one’s own actions and accepting all consequences, both personal and professional, that can result from these actions.
  • Autonomy is respecting the right of patients to make their own decisions and participate in their care. Nurses support patients in making informed choices while considering their values, beliefs, and capacity to understand.
  • Beneficence is acting in the best interest of patients and promoting their well-being. Nurses strive to provide interventions and care that maximize positive outcomes and minimize harm.
  • Fidelity is demonstrating faithfulness, loyalty, and commitment to patients. Nurses establish trusting relationships, maintain confidentiality, and uphold professional standards to ensure the trust and confidence of patients and the public.
  • Justice is maintaining fairness and equity in health care. Nurses advocate for equal access to healthcare services, fair allocation of resources, and equitable treatment of all patients, regardless of their background or circumstances.
  • Nonmaleficence is avoiding harm and preventing or minimizing potential risks to patients. Nurses uphold the principle of “do no harm” by carefully assessing and managing potential risks, and taking necessary precautions to protect patients.
  • Veracity is honesty and truthfulness in communication. Nurses are transparent and provide accurate information to patients, respecting their right to be fully informed about their health condition, treatment options, and potential outcomes.

Principles of Clinical Judgment

The purpose of nursing clinical judgment measurement model (CJMM)s is to provide a structured framework that guides nurses in developing and applying their clinical judgment skills and knowledge. These models aim to enhance nurses’ critical thinking abilities, improve their decision-making processes, and promote consistent and evidence-based nursing practice.

Clinical judgment models provide nurses with a systematic approach to collecting and analyzing patient data, identifying patterns and trends, and making informed clinical decisions. These models typically involve a series of steps that nurses can follow to ensure a comprehensive and logical thought process. By utilizing clinical judgment models, nurses can enhance their ability to recognize and interpret complex patient situations, anticipate potential problems, and implement appropriate interventions. These models also facilitate effective communication and collaboration with other healthcare professionals, as they provide a shared language and structure for discussing patient care.

Moreover, nursing clinical judgment models help bridge the gap between theoretical knowledge and practical application. They encourage nurses to integrate evidence-based practice, clinical expertise, and patient preferences in their decision-making, resulting in improved patient outcomes and a higher quality of care.

Clinical Judgment Measurement Model

National Council of State Boards of Nursing (NCSBN) and the Six Steps of the Clinical Judgment Measurement Model (NCJMM)

The Clinical Judgment Measurement Model (NCJMM) was developed by the National Council of State Boards of Nursing (NCSBN) to provide a standardized framework for assessing and enhancing clinical judgment skills in nursing practice. It addresses the need for a structured approach to evaluate nurses’ decision-making abilities and promote safe and effective patient care. By guiding the measurement and development of clinical judgment, the NCJMM contributes to improved nursing education, research, and practice, ultimately leading to better patient outcomes.

The six steps of the NCJMM consist of the following:

  1. Cue recognition: Identifying relevant cues or information from the patient’s situation and healthcare environment.
  2. Pattern recognition: Recognizing patterns or relationships among the cues to form a meaningful understanding of the situation.
  3. Problem representation: Clearly defining and articulating the nature and significance of the identified problem or clinical situation.
  4. Hypothesis generation: Generating possible hypotheses or alternative explanations to explain the problem and guide further assessment and intervention.
  5. Hypothesis evaluation: Evaluating the hypotheses through a systematic analysis of the available evidence and data, considering their validity and applicability.
  6. Final judgment: Making a clinical judgment or decision based on the evaluation of hypotheses and selecting the most appropriate course of action for the patient’s care.

These steps provide a structured framework for nurses to navigate the complex process of clinical judgment and decision-making in their practice (NCLEX, 2023).

There are many traditional models of clinical judgment. One of the best known is Tanner’s clinical judgement model (Mann, 2018), which includes four major components: noticing, interpreting, responding, and reflecting (Figure 1.3). This model provides a framework for assessing and evaluating the clinical judgment skills of both novice and experienced nurses. Its purpose is to focus on capturing the essential elements of clinical judgment that nurses should possess in order to make sound decisions in complex patient-care situations in order to provide valuable feedback.

Diagram showing Tanner’s Model of Clinical Judgment: Noticing, Interpreting, Responding, Reflecting.
Figure 1.3 Tanner’s clinical judgment model focuses on the basic skills a nurse needs for sound clinical judgment. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)


The noticing component of Tanner’s clinical judgment model is a critical aspect of the clinical reasoning process in nursing (Mann, 2018). It involves the nurse’s ability to gather and attend to relevant cues or information from the patient’s situation and the healthcare environment. Noticing is more than simply observing; it requires an active and deliberate focus on key details that are significant to the patient’s health status.

During the noticing phase, nurses gather data through observation, assessment, and interaction with the patient, family, and physical environment. They rely on their clinical knowledge and experience to recognize patterns, identify deviations from normalcy, and notice any potential problems or changes in the patient’s condition. This can include physical signs, symptoms, nonverbal communication, patient statements, and changes in vital signs. Effective noticing requires keen observation skills, active listening, and an awareness of the context in which care is being provided. For example, a nurse may have a patient with pneumonia who is calmly sitting in bed and states that they “feel fine” when asked. However, their oxygen saturation is only 89 percent on room air, and when the nurse auscultates the patient’s lungs, they hear crackles. Even though the patient stated that they felt fine, the nurse noticed other abnormal signs, including vital signs and physical signs, that needed addressing.


The interpreting data component of Tanner’s clinical judgment model is a critical step in the clinical reasoning process. After gathering relevant cues and data from the patient’s situation, the nurse must make sense of the information to develop a meaningful understanding of the patient’s health status (Mann, 2018).

During the interpretation phase, nurses analyze and synthesize the collected data from the noticing phase, connecting the dots to identify patterns, relationships, and potential implications for the patient’s condition. This process involves comparing the collected information with their knowledge base and clinical expertise.

Interpreting data requires critical thinking skills, including the ability to differentiate between significant and insignificant information, identify potential cause-and-effect relationships, and consider the contextual factors influencing the patient’s health. Nurses must consider the patient’s unique circumstances, such as their medical history, personal preferences, and cultural background, when interpreting the data. Effective interpretation of the data collected allows nurses to develop hypotheses or possible explanations regarding the patient’s health status and the underlying factors contributing to their condition. It enables the nurse to formulate educated guesses about the possible diagnoses, problems, or areas of concern that need further exploration or intervention.


The responding component of Tanner’s clinical judgment measurement model (CJMM) involves the nurse’s ability to develop and implement appropriate actions or interventions based on the interpretation of the collected data and the identified patient needs (Mann, 2018). During the responding phase, nurses utilize their clinical knowledge, expertise, and evidence-based practice to generate a range of possible actions or interventions to address the patient’s health condition. They prioritize the interventions based on the urgency and significance of the identified problems or needs.

Responding also involves effective communication and collaboration with the healthcare team and the patient. Nurses engage in therapeutic interactions with patients, providing education, support, and guidance to help them understand and participate in their care. Nurses must advocate for the patient’s preferences, rights, and autonomy, ensuring that the interventions are tailored to the patient’s unique circumstances.

Nurses implement the planned interventions with attention to safety, quality, and ethical considerations. Interventions can range widely from clinical care, to mental and spiritual support, to assistance navigating the healthcare system. In this phase, nurses administer medications, perform treatments, provide emotional support, facilitate patient education, and coordinate care services. The nurse’s response should be aligned with evidence-based practice, reflecting the best available research and clinical guidelines.

Throughout the responding phase, nurses continually assess the patient’s response to the interventions and make necessary adjustments or modifications to the plan of care. They monitor the patient’s condition, evaluate the effectiveness of the interventions, and document the outcomes and any changes in the patient’s health status. The responding component then proceeds to the reflection stage, although nurses continuously observe and gather new cues to refine and adapt their responses throughout the care process.


The reflecting component of Tanner’s clinical judgement model involves the nurse’s ability to engage in self-assessment, introspection, and critical reflection on their own thinking, actions, and decision-making throughout the patient care experience (Mann, 2018). During the reflecting phase, nurses pause and examine their own thoughts, assumptions, biases, and feelings that may influence their clinical judgment. They reflect on their performance, seeking to understand their strengths and areas for improvement. This introspective process allows nurses to develop a deeper understanding of their own clinical reasoning abilities and to refine their practice.

Reflecting also involves considering the outcomes of the interventions and evaluating their effectiveness in achieving the desired patient outcomes. Nurses examine the impact of their decisions and actions on the patient’s well-being, and they are able to critically analyze any discrepancies between the expected and actual outcomes. They reflect on interdisciplinary collaboration, communication, and teamwork within the healthcare team, identifying areas for improvement in future situations.

Through reflective practice, nurses continually learn and grow as professionals. They may actively seek feedback from colleagues, patients, and other members of the healthcare team to gain different perspectives and improve their clinical judgment skills. Reflecting also allows nurses to identify patterns or trends in their clinical decision-making, leading to enhanced future performance and more refined clinical judgment. By engaging in critical reflection, nurses enhance their self-awareness, improve their clinical reasoning abilities, and promote professional growth. It fosters a culture of continuous improvement, ensuring that nurses are continually learning from their experiences to provide the best possible care for their patients.


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