Learning Objectives
By the end of this section, you will be able to:
- Explain the application of the nursing process
- Explain clinical judgment in nursing practice
- Explain the integration of clinical judgment within the nursing process
Applying the nursing process to a multitude of different people, patients, settings, conditions, and experiences requires the ability to discover and analyze subjective and objective data, think about those findings critically, and proceed to action when required. Nurses assess patients to discover and analyze their subjective and objective data. Analysis of the data leads the nurse to the diagnosis of the patient's problem(s). The diagnosis leads to the identification of the patient outcomes. The nurse begins to develop a plan of care based on prioritizing the identified problem(s) and associated outcomes. The nurse next implements actions to treat the problem(s), prevent complications of the problem(s), and improve the patient’s condition.
Nursing Process
The nursing process (Figure 27.2) is what nurses do. The nurse evaluates the patient’s condition to determine if the nursing actions brought about the expected patient outcomes. The five steps of the process—assessment, diagnosis, planning/outcomes, implementation, and evaluation (ADPIE)—are performed by nurses in all areas of gynecologic and obstetric nursing practice.
Assessment
Nursing assessment includes gathering data provided by the patient, the patient’s medical record, the patient's physical assessment, and other sociocultural considerations. In gynecologic and obstetric nursing practice, all the information in the patient’s prenatal record provides many subjective and objective sources of assessment data. (See Chapter 11 Prenatal Care.)
Assessment also involves analyzing the patient data within the context of the patient’s current situation (Benner et al., 2009). This analysis leads the nurse to discover the essential data relevant to patient care decisions. The nurse acknowledges the expected data, focuses on unexpected data, and finds patterns in the data. An example is when the nurse notices that over the past three prenatal visits, the patient’s blood pressure measurements have gradually risen above normal values. The blood pressure pattern is recognized as a trend and is not routine or expected during pregnancy.
Diagnosis
Analysis of the patient data provides direction for the nurse to diagnose or determine the patient’s current or potential problem(s). The nurse also considers the patient’s situation. Using the assessment data example, the nurse sees that the current problem is gestational hypertension and the potential problem is preeclampsia. If a similar trend in blood pressure values were to occur in a patient who was not pregnant, the nurse would determine the problem to be essential hypertension.
The nurse also prioritizes the patient’s diagnosed problems. If the same patient arrived in the labor and delivery suite and informed the nurse that the baby was coming, the patient’s imminent delivery would take priority over the patient’s preeclampsia. The context of the patient’s situation has changed. Prioritization of diagnoses is the foundation of the patient’s plan of care.
Outcomes/Planning
The nurse identifies the outcomes and goals for each diagnosis that will enhance the patient’s condition. For the patient with preeclampsia who is about to deliver, the planned outcomes are controlled blood pressure and seizure prevention. To achieve these outcomes, the nurse plans for possible complications, such as seizure and postpartum hemorrhage. Everyone involved in the patient’s care is aware of the planned actions to achieve the outcomes.
Implementation
The nurse implements a series of interventions that align with the assessment, diagnosis, and plan for the individualized plan of care. These actions are based on the planned patient outcomes: control blood pressure and prevent seizure, ultimately aiming for prevention of the complication of preeclampsia and the desired outcome of a vaginal delivery. Nursing interventions are also prioritized to enhance patient safety and effectiveness (Magley et al., 2024).
Evaluation
Once the nursing interventions have been implemented, the nurse evaluates the patient’s current status and determines if the actions were effective and if the patient outcomes have been achieved. This evaluation may result in a modified diagnosis, plan, or implementation. The nursing process continues to circle from assessment through outcomes (American Nurses Association, 2021). Documentation of all steps in the nursing process is essential.
What Is Clinical Judgment in Nursing Practice?
The process nurses use in cognitive decision-making while providing patient care is called clinical judgment (Tanner, 2006). Nurses use clinical judgment to organize and prioritize nursing knowledge and skills into nursing actions based on the clinical situation. The clinical judgment process used in nursing practice is multifaceted and is learned. As the nurse evolves from novice to expert, cue recognition and analysis become instinctual (Benner, 1984). Effective solutions for patient care situations are formed and implemented quickly. Developing sound (appropriate) clinical judgment is the foundation of safe and competent nursing practice. The new graduate nurse will be expected to demonstrate novice achievement of sound clinical judgment when taking the National Council Licensure Examination, NCLEX-RN.
Theoretical Foundation of Clinical Judgment in Nursing Care
Patricia Benner (1984) is credited with developing the novice-to-expert model of nursing practice. Benner’s research demonstrated how nurses start out as novices in professional practice. Novice nursing actions are rule driven. Advanced beginners become aware of how nursing actions are situation driven. Expert nurses can apply clinical judgment within each patient’s situation. Benner’s research described how clinical judgment evolved with experience and is summarized in Table 27.1.
| Stage | Characteristics |
|---|---|
| 1: Novice | Has no practical experience in the patient care situation Follows the rules and is inflexible |
| 2: Advanced Beginner | Has minimal clinical experience Is task oriented with difficulty in establishing priorities, building nursing skills |
| 3: Competent | Has 2–3 years of experience as a nurse Is organized, self-directed, confident in their skill level Begins to see situations holistically and can anticipate the next steps in care Performs slowly but can cope with situational context by consciously organizing a plan of care |
| 4: Proficient | Has 3–5 years of experience as a nurse Understands the patient's situation Can draw from past experiences and make decisions with ease |
| 5: Expert | Relies on intuition to integrate needed changes when providing patient care |
Christine Tanner (2006) created a Clinical Judgment Model in the world of nursing. Tanner’s research delineated the structure of how nurses think when using clinical judgment. Nurses first notice things when caring for patients. Nurses next interpret what the noticed things mean. Based on their analysis of the noticed things, nurses develop a prioritized plan of action. The nurse then implements the prioritized plan of action. After responding, the nurse evaluates the patient outcomes of the nursing actions and reflects on the effectiveness of the actions. Tanner’s research on clinical judgment described the thinking process linked to the steps of the nursing process and is summarized in Table 27.2.
| Step | Characteristics |
|---|---|
| Noticing | Awareness of the patient’s subjective and objective data, situation, and environment |
| Interpreting | Analyzing the subjective and objective data, situation, and environment for relevance, normality, and completeness |
| Responding | Implementation of nursing actions based on the patient data, situation, and environment |
| Reflecting | Evaluating the effectiveness of the nursing actions and reflecting on what actions were omitted or need to be modified |
Kathie Lasater (2007) is credited with the development of the clinical judgment competency assessment rubric for clinical nursing practice. Lasater based her rubric on Tanner’s Clinical Judgment Model and added a numerical value for clinical instructors and preceptors to assess the current level of nursing students’ and new graduates’ clinical judgment. The four levels in Lasater’s rubric are similar to the novice, advanced beginner, competent, proficient, and expert levels of Benner (Benner, 1984). Lasater’s assessment levels are beginning, developing, accomplished, and exemplary (Lasater, 2007).
What Part Does Clinical Judgment Play within the Nursing Process?
Clinical judgment is the multifaceted thinking required while carrying out the steps of the nursing process when providing safe and effective nursing care. Nurses use clinical judgment during every step of the nursing process. The interaction between these concepts is shown in Figure 27.3. The Clinical Judgment Measurement Model (CJMM) is the framework for measuring both clinical judgment and decision making in assessment. Both clinical judgment and decision making are important factors in the education of nurses. Current evidence-based research has shown the need for a CJMM to bring all aspects of high-level reasoning and actions together (National Council of State Boards of Nursing, 2019).
Assessment requires the nurse to gather, review, and analyze the subjective and objective data of patients. Assessment, or noticing, includes observation, auscultation, palpation, questioning, review of the patient’s medical record, and exploration of the patient’s situation and sociocultural considerations. All the assessed data are analyzed (or interpreted) for relevance and accuracy. Interpretation of the data also clusters data into normal versus abnormal, expected versus unexpected, and stable or unstable. Analysis and interpretation are cognitive processes and are not observed.
The data's analysis and interpretation provide the foundation for identifying the patient’s problems (diagnoses) and developing the plan of care based on the desired outcomes. Nurses use their knowledge of and experience with similar situations when prioritizing the problems. The prioritization aspect of diagnosing and outcome planning is also a cognitive process.
Implementation (or responding) refers to the nursing actions the nurse performs. Actions are prioritized and carried out based (again) on the nurse's knowledge and previous experience. The nurse has determined the priority of each required action in the same cognitive process of clinical judgment.
When evaluating (or reflecting) on the effectiveness of the nursing actions (responses), the nurse determines if the patient outcomes were met or not met (another cognitive activity) and if the patient’s status has improved, remained the same, or worsened. The nurse also reflects on what actions were effective, what additional actions need to be implemented, and what data were overlooked, beginning the nursing process and steps of clinical judgment all over again.