Clinical judgement
In this chapter so far you have been learning about the foun-
dations (personal attributes, knowledge and experience) that
underpin the processes (problem solving, critical thinking,
creative thinking and intuitive thinking) of clinical reason-
ing, as illustrated in Figure 14-1. The culmination of clinical
reasoning is clinical judgement and decision making, as this
is what determines the actions taken and the processes of
care. (See Figure U3-1 for how clinical judgement fits
within the model of thoughtful practice.)
Clinical judgement is a term frequently linked to, and used
interchangeably with, problem solving, critical thinking and
decision making (Duchscher, 1999). Clinical judgement is
the next step in the clinical reasoning trajectory that trans-
lates into nursing and midwifery action.
Clinical judgement
has been described as ‘an interpretation or conclusion about
a patient’s needs, concerns or health problems, and/or the
decision to take action (or not), use or modify standard
approaches, or improvise new ones as deemed appropriate by
the patient’s response’ (Tanner, 2006, p. 204). Many situa-
tions in nursing and midwifery care require the clinician to
analyse the situation and come to some decisions related to
the actions to be taken. However, not all clinical situations
are clear cut, and in many circumstances a range of possible
solutions to an identified problem is available to the clinician
(Oermann, Truesdell & Ziolkowski, 2000). Clinical judge-
ment is therefore often referred to as a process of elimination.
Unit III Thoughtful practice and the process of care
262
This situation is demonstrated when you undertake an
assessment (Levett-Jones et al., 2010). You must identify
cues or signals in the data collected, and organise the data
into meaningful clusters. In an assessment, cues can range
from simple observational data such as height and weight to
more complicated data such as pathology reports. Through a
process of pattern-matching, your previous learning gives
meaning to the current data. The more experienced you are,
the more developed the patterns with which the new data
can be matched. You must then decide what actions should
be taken, using clinical judgement. For instance, when a
nurse decides to alert a doctor to a potential problem that
may be developing, the nurse is described as having good
clinical judgement. When a nurse does not respond appro-
priately to an abnormal observation, the nurse is said to have
poor clinical judgement. Clinical judgement does not
always lead to the correct clinical decision, as it is depend-
ent on the accuracy of the data collected, the experience of
the clinician and the confidence of the decision maker
(Cioffi, 2002). Failure to rescue is an example of poor clin-
ical judgement (Levett-Jones et al., 2010).
Clinical judgement can also be based on what is
not
observed. When a situation does not match the expected
pattern, this can alert the clinician to a health problem. For
instance, when a labouring woman experiences pain that does
not fit the usual patterns of a normal uncomplicated delivery,
the midwife is alerted to investigate further. This demon-
strates good clinical judgement. When all the data have been
Much has been written about decision making in acute
care contexts, but many of the conditions that exist
in this setting do not apply in a rural context. Hence,
decision-making processes are different. Here nurses
are often the first to assess and interpret the cues from
the patient’s clinical presentation.
Related research
Seright, T.J. (2011). Clinical decision-making of rural
novice nurses.
Rural and Remote Health
, 11, 1726.
Available online via
This study involved a small group of novice registered
nurses in rural hospitals. These early-career nurses were
often working with limited support, while managing an
ever-changing clinical environment and acuity of
patients. Decision making usually involves ill-structured
problems set in situations where patient safety is a
concern. To study decision making, a grounded theory
approach was used that evolved from face-to-face inter-
views with 12 nurses and observations of nine of them
during their work day. The participants were interviewed
a second time so they could review their transcripts, the
emerging themes and categories. From an axial coding
process, ‘sociocentric rationalising’ emerged as the
central phenomenon and referred to the sense of belong-
ing and agency that impacted on the decision making
in this group of nurses. Despite access to a number
of resources at their disposal (including policy books,
decision trees, standing orders, textbooks and, in some
cases, Internet resources), the nurses in this study indi-
cated collaboration with colleagues was a major means
of facilitating their decision making.
Relevance to practice
The need for mentorship, facilitation and orientation is
just as acute in rural settings as in urban settings. Deci-
sion making should be guided by more experienced
nurses who are willing to encourage novice nurses to
reflect upon their clinical decisions. In a rural setting,
this is especially important because novice nurses are
required early in their career to make significant deci-
sions that may have to be done independently with
little support.
Clinical decision making in the rural context
R E S E A R C H I N P R A C T I C E
