This article reviews the growing body of research on clinical judgment in nursing and presents an alternative model of clinical judgment based on these studies. Based on a review of nearly 200 studies, five conclusions can be drawn: (1) Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand; (2) Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns; (3) Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit; (4) Nurses use a variety of reasoning patterns alone or in combination; and (5) Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. A model based on these general conclusions emphasizes the role of nurses' background, the context of the situation, and nurses' relationship with their patients as central to what nurses notice and how they interpret findings, respond, and reflect on their response.

Thinking like a nurse: a research-based model of clinical judgment in nursing.

Clinical judgment is a skill every nurse needs, but nurse educators sometimes struggle with how to present it to students and assess it. This article describes an exploratory study that originated and pilot tested a rubric in the simulation laboratory to describe the development of clinical judgment, based on Tanner's Clinical Judgment Model.

Clinical judgment development: using simulation to create an assessment rubric.

The main research question addressed in this two-phase descriptive study was 'What are the values underlying nurses' professional identity as expressed through what is meaningful in nurses' work? The first phase was a survey of 767 randomly selected nurses with one, five, and 10 years of experience in nursing, and in the second phase data on work-meaning were obtained from a convenience sample of six nurses by in-depth interviews eliciting nurses' stories about providing care to patients. Content analysis of survey-data revealed that the nurses held both other-oriented and self-oriented values, i.e. moral and work values. Human dignity and altruism were the most prominent moral values, whereas the most significant work-values were intellectual and personal stimulation. The interview-data, analysed by means of hermeneutic and narrative analysis, revealed a greater diversity in value-expressions compared to the survey-data. Altruism, the moral orientation of care, was the overall philosophy, and human dignity appeared as a core value. The nine additional values appeared to be linked to human dignity either by arising from it and/or being aimed at preserving this basic value.

Professional identity: values embedded in meaningful nursing practice

BackgroundMental disorders create high individual and societal costs and burden, partly because help-seeking is often delayed or completely avoided. Stigma related to mental disorders or mental health services is regarded as a main reason for insufficient help-seeking.AimsTo estimate the impact of four stigma types (help-seeking attitudes and personal, self and perceived public stigma) on active help-seeking in the general population.MethodA systematic review of three electronic databases was followed by random effect meta-analyses according to the stigma types.ResultsTwenty-seven studies fulfilled eligibility criteria. Participants' own negative attitudes towards mental health help-seeking (OR = 0.80, 95% CI 0.73-0.88) and their stigmatising attitudes towards people with a mental illness (OR = 0.82, 95% CI 0.69-0.98) were associated with less active help-seeking. Self-stigma showed insignificant association (OR = 0.88, 95% CI 0.76-1.03), whereas perceived public stigma was not associated.ConclusionsPersonal attitudes towards mental illness or help-seeking are associated with active help-seeking for mental problems. Campaigns promoting help-seeking by means of fighting mental illness-related stigma should target these personal attitudes rather than broad public opinions.

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Association between mental health-related stigma and active help-seeking: systematic review and meta-analysis.

Nurse educators are finding it increasingly more challenging to prepare undergraduate students for the ever-changing and more acute clinical environment. As an answer to this dilemma, the human patient simulator can provide students with the opportunity to enhance knowledge, to facilitate skill acquisition, to decrease anxiety, and to promote clinical judgment in a safe environment. These experiences assist the novice nursing student to progress to the advanced beginner stage of practice. This article describes how faculty used the human patient simulator in creating a case scenario that enhanced critical thinking in senior nursing students.

Use of the human patient simulator to teach clinical judgment skills in a baccalaureate nursing program.

PURPOSE. The purpose of this paper is to examine the concept of nurse-to-nurse lateral violence (LV). SOURCE. Published literature-LV among nurses is significant and results in social, psychological, and physical consequences, negative patient and nursing outcomes, and damaged relationships. An extensive review of literature through Health Source, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest health, and Medical Complete was used to determine agreement and disagreement across disciplines and emerging trends. CONCLUSION. This concept analysis demonstrates that nurse-to-nurse LV is nurse-to-nurse aggression with overtly or covertly directing dissatisfaction toward another. Origins include role issues, oppression, strict hierarchy, disenfranchising work practices, low self-esteem, powerlessness perception, anger, and circuits of power. The result of this analysis provides guidance for further conceptual and empirical research as well as for clinical practice. Organizations must learn how to eliminate antecedents and provide nurses with skills and techniques to eradicate LV to improve the nursing work environment, patient care outcomes, and nurse retention. Language: en

Concept Analysis: Nurse-to-Nurse Lateral Violence

This study investigated how fourth-year nursing students learned clinical decision making Seventeen fourth-year nursing students between ages 21 and 37, who were completing their last semester of a baccalaureate nursing program, were interviewed A research team using a modified seven-step process developed by Diekelmann and Allen analyzed the data Five themes or essential components associated with learning clinical decision making were identified, including gaining confidence in their skills, building relationships with staff, connecting with patients, gaining comfort in self as a nurse, and understanding the clinical picture

Clinical Decision Making Among Fourth-Year Nursing Students: An Interpretive Study

The purpose of this study was to explore the differences in how advanced beginners, competent, and expert nurses prioritize and reprioritize patient care. This qualitative study had a purposive sample of 23 nurses on cardiac/ telemetry units at five hospitals. Four themes emerged from the data: cognitive strategies, communication, integration of roles, and response to the work environment. As the nurses progressed in expertise, they were better able to organize, more effectively deal with interruptions, anticipate patient needs, integrate varied nursing roles into their work, and communicate effectively. The significance of this study is the identification of factors that affect the nurse's ability to work productively in today's care environment. It increases understanding of the graduate nurses' perception and response to the complexity and work of nursing. An understanding of these factors provides the basis for further research to understand and promote transition of nurses from advanced beginner to expert.

Responses to work complexity: the novice to expert effect.

AIM. This paper is a report on the concept of role confusion as it applies to nurse case management.

BACKGROUND.  Nurse case managers (NCMs) play an important role in the delivery of quality health care. There has been considerable discussion and debate as to the exact role of the NCM. Research has not produced a conceptual model for the NCM. A clear and concise definition of the role of the NCM is not available from published literature.

METHODS.  This analysis was conducted using the Walker and Avant method. Literature searches were conducted using Cumulative Index of Nursing and Allied Health, ProQuest, PsychInfo, PubMed, Academic Search Premier, and ERIC. Time line covered the period of 1980–2010.

FINDINGS.  Based on the analysis, role confusion occurs when there is no clear set of expectations for the NCM. Organizations have created positions that often are not patient centered and underutilize the nursing aspect. Nursing literature does not report significant investigation of the phenomena of role confusion in nurse case management.

CONCLUSION.  There needs to be a conceptual model for the role of the NCM. A skill set designated exclusively to nurses who practice case management would emphasize the patient–nurse relationship and provide clarity of the role and function of NCMs.

Ann H. White

Papers

Concept Analysis: Nurse-to-Nurse Lateral Violence

Clinical Decision Making Among Fourth-Year Nursing Students: An Interpretive Study

Responses to work complexity: the novice to expert effect.

Concept analysis: case management role confusion.

Role socialization of graduating student nurses: Impact of a nursing practicum on professional role conception