Nurses' Clinical Judgment Development: A Qualitative Research in Iran

Acknowledging: A classic grounded theory explaining how nurses' employ clinical judgement when complying with early warning system protocols

BACKGROUND

Recognition and response to clinical deterioration of hospitalised patients is a worldwide health priority area. In response to this concern, international bodies have implemented early warning systems to help clinicians keep people safe and prevent patient deterioration. Registered nurses hold a significant role in managing care provision and utilise early warning system tools to support their clinical judgement when making decisions about patient care.

OBJECTIVE

To generate a theory explaining how registered nurses employ their clinical judgement when complying with an early warning system protocol.

DESIGN

Classic grounded theory.

PARTICIPANTS

Participants included twenty registered nurses working with early warning systems who are currently employed in a state health care system within Australia. Data were collected via interviews generated from a grand tour question in line with classic grounded theory.

METHODS

Classic grounded theory methodology and methods were used. This approach facilitated the identification of the participants main concern and supported the generation of a theory explaining how the participants resolved this issue.

RESULTS

Analysis of data, including associated field notes and memos, identified participants often experienced unease when complying with an early warning system protocol and employing clinical judgement. The mental discomfort participants voiced in the interviews described internal conflicts that are reflective of the term 'cognitive dissonance'. How the participants sought to resolve their cognitive dissonance, revealed participants' main concern as: Compliance with early warning systems is sometimes incongruent with nurses' use of clinical judgement. The outcome of this study is a grounded theory that explains how nurses resolve this concern through 'Acknowledging'. Nurses acknowledge the efficacy of early warning systems, whilst valuing their clinical judgement and the importance of patient safety, through the subcategories of Acting and Pausing.

CONCLUSION

The Theory of Acknowledging explains how nurses overcome their main concern when employing clinical judgement and complying with early warning systems, whilst acknowledging the importance of ensuring patient safety. Reconciling the dissonance caused by trusting their clinical judgement and remaining compliant with early warning systems, enables nurse-led assessment of the patient, promoting patient safety. Tweetable abstract The theory of Acknowledging - How nurses employ clinical judgement when complying with early warning systems @Jusconnor25.

The use and usefulness of the Peninsula Health Falls Risk Assessment Tool (PHFRAT) process in residential aged care: a mixed methods study across 25 aged care facilities

BACKGROUND

Falls remain a persistent problem in residential aged care (RAC) facilities. Fall screening and assessment tools such as the Peninsula Health Falls Risk Assessment Tool (PHFRAT) are widely used to inform falls risk and guide fall prevention interventions. However, it is unclear how it is used in practice and whether clinicians believe it supports resident care. This study aimed to measure the extent of use of PHFRAT to understand clinicians' perceptions of its value and usefulness.

METHODS

This mixed method study involved an analysis of PHFRAT assessment from 25 RAC facilities in New South Wales, Australia, and interviews with seven RAC staff about how PHFRAT information is used in practice. In the quantitative component, descriptive statistics were applied to PHFRAT data to summarise how RAC staff use the PHFRAT including the completeness and content of the three parts. In the qualitative component, thematic analysis techniques were applied to interview data.

RESULTS

The sample included 215 RAC residents with 703 PHFRATs, of which 617 documented fall prevention interventions. Among these 617 PHFRATs, 593 (96.1%) included strategies related to staff assistance and 283 (45.9%) recorded strategies related to device provision. While nearly all residents (96.74%) received at least one PHFRAT assessment over the study period, many PHFRAT assessments were incomplete (part 1: 11.5% of information missing; part 2: 10.8%; part 3: 17.1%). There were few variations in fall interventions prescribed to individual residents by their fall risk level. Interviews with RAC staff indicated that PHFRAT assessments are the responsibility of registered nurses with limited input from other staff or residents. While the structured process was viewed positively in guiding risk assessment and intervention assessment, a lack of input from others prevented strategies from being tailored to residents' specific needs and preferences. A shortage of resources, lack of communication, and limited staff education were identified as the main barriers to PHFRAT guideline implementation.

CONCLUSION

The PHFRAT provides a useful structure for clinicians to assess falls risk factors and plan falls prevention strategies. In the future, increased multidisciplinary input into fall prevention strategy development may improve the comprehensiveness of fall prevention plans.

The implementation of Tanner's Clinical Judgment Model and the Indonesian version of the Lasater Clinical Judgment Rubric in the clinical setting

A critical component for nurses to provide safe and quality care with strong patient outcomes is clinical judgment. This study aimed to identify the difference in the clinical judgment score in newly graduated nurses by implementing Tanner's Clinical Judgment Model. This study followed an experimental design with a pretest-posttest and involved thirty-two newly graduated nurses from three private hospitals in Indonesia. The intervention group had a scheduled post-conference with their preceptors using Tanner's Clinical Judgment Model's guidelines with high-level, open-ended questions for two consecutive weeks. Independent samples t-test was used to compare pre-and post-test scores utilizing the valid and reliable Indonesia version of the Lasater Clinical Judgment Rubric. There was no significant difference between the pre-test results of the intervention and control groups, with a significance value of 0.647. The results indicated a significant difference in the mean clinical judgment scores between the intervention and control groups after two weeks of intervention, where the intervention group's scores were higher than the control group's with a significance value of <0.001 with a mean difference of 6.75 and CI of 95 % (4.18-9.31). Tanner's Clinical Judgment Model showed a significant impact in increasing clinical judgment scores. The Indonesia version of the Lasater Clinical Judgment Rubric is a valuable tool for assessing and evaluating the development of clinical judgment and provides detailed targeted areas needing improvement. Preceptors and nursing leaders in the clinical setting should continue to use this model and tools to assist newly graduated nurses in developing clinical judgment skills during their transition period.

Clinical judgement in nursing - An evolutionary concept analysis

AIMS

The aim of this concept analysis was to develop a contemporary operational definition of Clinical Judgement in nursing.

DESIGN

Concept analysis.

METHODS

Rodgers' evolutionary method of concept analysis. Throughout the study, the authors followed the SRQR checklist.

RESULTS

This concept analysis guided the development of an operational definition of clinical judgement, within the context of nursing, articulated as Clinical judgement is a reflective and reasoning process that draws upon all available data, is informed by an extensive knowledge base and results in the formation of a clinical conclusion.

CONCLUSION

The purpose of this concept analysis was to propose a detailed definition of clinical judgement in nursing, that reflected its theoretical base within today's contemporary healthcare system. Using Rodgers' evolutionary method of concept analysis, surrogate terms, attributes, antecedents and consequences were identified, and a contemporary definition was developed. No patient or public contribution was required to design or undertake this research.

Clinical judgment skills among junior-level nursing students enrolled in adult health nursing courses: Errors and risk level classification

As the acuity of patients increases, so does the requirement for nurses who are capable of making proper clinical judgment for safe and quality patients' care. Assessment of students' clinical judgment at different stages of their nursing program is thus required. This descriptive cross-sectional study assessed the clinical judgment of 55 junior nursing students using a questionnaire that required participants to rate the severity and perceived risk and identify factors leading to errors described in four vignettes. Participants' perceptions of the impact of the errors described in the four vignettes differed. However, satisfactory agreement on error risk was evident (the highest rating ranged from 36% to 53.6%). Lack of clinical knowledge and experience and excessive workload were the most commonly identified contributory factors. Many of the junior nursing students in the study showed capability for critical analysis and classifications of error, risks, and associated factors. Based on current study results on error classification, associated risk and potential contributors the overall agreement of the students was moderate. Therefore, there is a need to increase efforts to impart higher clinical judgment skills to students enrolled in nursing education, for which regular longitudinal assessment is required.

Construção e validação de um cenário de simulação sobre sepse: estudo metodológico

RESUMO Objetivo Construir, validar e testar um cenário de simulação clínica de alta fidelidade para o manejo da sepse. Método Estudo metodológico desenvolvido em três fases: construção do cenário de simulação utilizando o framework Modelo de Simulação de Ensino em Enfermagem e os protocolos instituídos pelo Instituto Latino Americano de Sepse; validação do conteúdo por nove juízes; e o teste do cenário por dois enfermeiros de uma instituição hospitalar. A análise dos dados se deu pelo Índice de Validade de Conteúdo, considerando-se adequado um valor > 0,90 entre os juízes. Resultados O cenário de simulação mostrou-se apropriado, obtendo valor geral > 0,90. No entanto, foram feitos alguns ajustes no cenário e no teste no que tange à clareza da redação, às funcionalidades e à pertinência de protocolos, conforme sugestão dos juízes. Conclusão Espera-se que o cenário de simulação validado seja um instrumento facilitador para docentes e profissionais de núcleos de educação permanente/continuada de instituições de ensino e saúde.

An exploration of factors influencing inpatient nurses’ care behaviour in an acute hospital setting

Objective

To examine factors influencing caring behaviour of nurses in Singapore.

Design

Descriptive correlational study using Care Behaviour Inventory (CBI-24) questionnaire to assess nurses’ perceptions of their caring behaviours.

Setting

Acute tertiary hospital in Singapore.

Participants

A convenience sample of 167 full time registered nurses working in subsidized wards, with more than 1 year of experience in current practising ward were recruited.

Main outcome measure(s)

Nurses’ perception of their caring behaviours.

Results

Data analysis yielded a mean CBI score of 123.11 out of 144, indicating that nurses had a positive perception of their caring behaviours. Among the 4 CBI subscales, Respectfulness and Connectedness components of CBI were ranked the lowest with a mean score of 4.2 and 4.9, respectively. This indicated that although nurses generally performed adequate caring during patient care, they appeared to be lacking in the expressive aspect of caring. Significant differences (P < 0.05) were found among subgroups of nationality, ethnicity, religion and education level. Nurses’ perception of their caring behaviours was positively correlated to their age and total working experience. Linear regression showed that age, religion, education level positively influenced nurses’ perception of their caring behaviours.

Conclusion

Findings from this study raise awareness to the caring behaviours that nurses were lacking in and also offer valuable insights to the potential factors influencing nurses’ caring behaviours. This information serves as a foundational knowledge to guide the development of interventions aimed to promote patient-centred care and improve quality of future nursing care.

Exploring nurses' experience about facilitating factors in medication administration based on clinical judgment of nurses: A content analysis

Background

Clinical judgment of nurses to conduct medication orders is based on patient assessment, medication knowledge, observation, and interpretation of the data collected. This process is influenced by many factors.

Objective

This study aims to explore nurses’ experience about facilitating factors in medication administration based on clinical judgment of nurses.

Methods

This qualitative study was part of an approved project research of the Iranian National Institute of Health Research, which was conducted in Kurdistan University of Medical Sciences in 2015. Based on purposive sampling of 18 participants, 26 open and semistructured interviews were conducted. Based on conventional content analysis method and using MAXQDA2010, coding and categorizing the data were applied. During the analysis, data collection continued until saturation.

Results

Analysis of the data led to the emergence of five themes, including the implementation of evidence-based medication orders, situational-based medication orders, medication orders in critical condition, educational interventions in medication orders, and supporting the nurses as facilitator of the implementation of medicinal orders based on clinical judgment of nurses.

Conclusion

In response to constraints such as the routines, clinical crisis and lack of evidence in medicinal orders, nurses used following ways to fix these barriers and facilitators. Combining evidence such as clinical guidelines, physician’s views based on patients, and clinical conditions proved the best facilitator. It is recommended that, using these results, a perfect background for the proper administration of medication orders by nurses should be provided.

Factors Influencing Nursing Students' Clinical Judgment: A Qualitative Directed Content Analysis in an Iranian Context

INTRODUCTION

Clinical judgment is necessary for clinical decision making and enhancing it in nursing students improves health care quality. Since clinical judgment is an interactive phenomenon and dependent on context and culture, it can be affected by many different factors.

AIM

To understand the experiences of Iranian nursing students and teachers about the factors influencing nursing students' clinical judgment.

MATERIALS AND METHODS

A qualitative study was conducted using a directed content analysis approach. In this study, purposive sampling and semi-structured interviews were applied with seven nursing students, six faculty member teachers and four clinical instructors from Guilan University of Medical Sciences, Gilan, Iran.

RESULTS

The factors influencing nursing students' clinical judgment consisted of five main categories including thoughtful behaviour, professional ethics, use of evidence based care, the context of learning environment and individual and professional features of clinical teachers.

CONCLUSION

Relying on the results of this research, teachers can create an appropriate educational condition and a safe psychological atmosphere, use instructional strategies strengthening deep thought processes, applying professional ethics and scientific evidence and principles to establish clinical judgment in nursing students.