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Nursing Judgment

A Concept Analysis

de Tantillo, Lila MS, BSN, RN; De Santis, Joseph P. PhD, ARNP, ACRN, FAAN

doi: 10.1097/ANS.0000000000000245
Original Articles
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Charged with making decisions to protect and enhance patient well-being, a nurse relies on nursing judgment to render effective patient care. Nursing judgment is the culmination of education, experience, and insight that allows nurses to execute the best action possible on behalf of patients. This concept analysis uses the Walker and Avant method to demonstrate the role of nursing judgment in assessments and interventions, delegation of tasks, and prioritization of care. Nurses, other health care collaborators, and recipients of health care should be aware of the role played by nursing judgment to improve patient care and the health care system.

School of Nursing and Health Studies, University of Miami, Coral Gables, Florida.

Correspondence: Lila de Tantillo, MS, BSN, RN, School of Nursing and Health Studies, University of Miami, 5030 Brunson Dr, Coral Gables, FL 33146 (l.detantillo@umiami.edu).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

WHEN an individual in need of health care seeks out medical attention, decisions are made by the health care team and treatment is administered, in many cases by a nurse. How care is delivered relies heavily on the nurse and, specifically, on the quality of nursing judgment. The purpose of this concept analysis is to analyze the concept of nursing judgment so that nurses, other health care workers, and patients can better grasp the unique role of the nurse in rendering care.

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DEFINITION OF NURSING JUDGMENT

As health care continues to transform, nursing care demands are also changing. Nurses are using new technologies, taking on additional duties, and assuming intensified responsibilities while managing increasingly complex patients.1 In addition, nursing care is being delivered in a constantly widening number of institutional sites outside the traditional acute care setting.2 Most importantly, nurses must be prepared to provide care that upholds the human rights and inherent dignity of each member of the diverse patient population.3 As a consequence, nursing judgment has become more vital than ever.

The American Nurses Association has emphasized the centrality of nursing judgment in its Code of Ethics,4 which cautions nurses regarding accountability for individual judgments. The onus is on the nurse to execute quality nursing judgment at all times even when the responsibility has interdisciplinary implications. For example, imprudent or incorrect orders from a physician require that the nurse use nursing judgment to ensure that care provided to clients is appropriate. And while the Code of Ethics relates the impact of this perspective on nurses' liability, it is clear the perspective is founded on the core ethical principles of nursing.

It should be emphasized that nursing judgment is relevant to all settings where the nurse is required to make decisions regarding patient care. While about 60% of registered nurses (RNs) work in hospitals,5 this exploration of nursing judgment also applies to nurses who work in non–acute care settings such as long-term facilities, schools, home health, hospice care, and other locations. Nursing judgment also may be required outside the primary place of employment (eg, as a bystander to a motor vehicle accident).6

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Statements of Significance

What is known or assumed to be true about this topic:

Registered nurses assume a unique role in delivering patient care. As health care continues to transform, nurses are frequently assuming increased roles and responsibilities. As a result, the quality of health care is often connected to the quality of nursing judgment. For this reason, conducting a concept analysis of nursing judgment, including its antecedents, attributes, and consequences, will provide insights that may benefit patient care and improve the overall health system.

What this article adds:

This concept analysis found that nursing knowledge, nursing experience, and nursing intuition are antecedents necessary for a nurse to render quality nursing judgment. Furthermore, such judgment is evidenced by nursing characteristics of critical thinking, discernment, correct prioritization of patient needs, and self-awareness of limitations. Nursing judgment enables a nurse to render effective patient care and is linked with quality measures that indicate improved outcomes. In years to come, nursing schools can play crucial roles fostering judgment of future nursing professionals and nurses can collaborate with health care facilities to promote quality nursing judgment.

Nursing judgment may not be equally applicable to nurses in different settings. In the past, some nurses were instructed to document “Drainage appears red” rather than being permitted to use nursing judgment to assert that the red drainage was blood.7(p104) One study surveying nurses from 7 countries found that nurses in the United States reported considerable more “autonomy” and “control of practice environment” than those of any of the other countries being evaluated, which were Cyprus, Finland, Greece, Portugal, Sweden, and Turkey.8 Educational requirements for nurses—and the education received—vary widely across the globe, from 2 to 5 years.9

The influence of nurses in the health care setting in some parts of the world may also be limited by the influence of patriarchal societies upon a predominantly female profession.10 As a result, the role of the nurse may be only to distribute medication or follow medical orders rather than to use nursing judgment to provide patient care. This concept analysis may have limited applicability to nurses serving in such conditions.

Specifically, this concept analysis focuses on the nursing judgment of the registered professional nurse or “RN.” The designation “registered professional nurse” requires a professional license in the United States. According to the American Nurses Association, a registered professional nurse is equipped not only to administer medications but also to use intellectual capacities to perform physical assessments and provide education, to interpret information, and to intervene in patient care.11 Almost half of RNs currently working in the United States have a bachelor's degree; all are expected to have a minimum of 2 years of higher education.11,12

This level of preparation can be differentiated from that of a licensed practical nurse/licensed vocational nurse (LPN/LVN).13 By virtue of licensure, an LPN/LVN works under the direction of the RN and may not be able to perform certain nursing skills.14,15 Because the scope of LPN/LVN practice is far narrower and therefore substantially different, this analysis may not be applicable to the role of the LPN/LVN.

Also beyond the examination of this concept analysis is the role of advanced practice registered nurses (APRNs). Because APRNs receive additional specialized education beyond the bachelor's degree, comparisons between the registered professional nurse and the APRN cannot be made.16

RNs therefore assume a unique role in patient care: constantly in contact with patients, assessing and intervening on a continuous basis. Each of these nursing actions, no matter how minute, is the result of nursing judgment. The core of nursing is not the specialized technology found in hospitals but the unique ability of nurses to make decisions on behalf of the patient's well-being.17 Nursing decisions arise from the implementation of nursing judgment. As a result, the nurse's use of judgment has an impact on patient outcomes.18

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METHODS

This analysis is based on the method developed by Walker and Avant19 for clarifying the meaning of a given concept. This modified approach to concept analysis involves 6 steps: (1) selection of a concept; (2) determine aims/purpose of analysis; (3) identify concept uses; (4) determine attributes; (5) identify antecedents and consequences; and (6) determine empirical referents. This approach was modified to eliminate the development of cases to illustrate the concept's attributes, antecedents, and consequences, as the authors believe illustration of these cases can be exemplified using existing literature. The concept of nursing analysis is examined in detail so that the importance of nursing judgment in relation to the health care system may be better understood.

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SELECTION OF THE CONCEPT

The concept of nursing judgment was selected as the focus of a concept analysis because of the concept's applicability to all practicing nurses. Today's nurses are required to manage changing technology, expanding nursing roles, and care of patients with high-acuity nursing care needs in a competent and collaborative manner.1 The management of patient care requires the nurse to use judgment in the assessment, diagnosis, planning, implementation, and evaluative phases of nursing care.11 Finally and arguably most important, nursing judgment has an impact on patient outcomes.18 Because nursing judgment directly influences patient outcomes, the concept of nursing judgment is an essential concept for nurses to understand and implement. One method that has been used to develop an understanding of concepts is a concept analysis.19

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AIMS OF THE CONCEPT ANALYSIS

The second step in concept analysis is to identify the aims.19 The principal aim of this concept analysis is to clarify the meaning of the concept of nursing judgment. At this point, nursing judgment is a relatively abstract concept. Clarification of the concept of nursing judgment is necessary to develop a clearer understanding of the concept and to explore how the concept can be useful in nursing practice, research, policy, and education.

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USES OF NURSING JUDGMENT

Nursing judgment is a crucial aspect of adhering to the standard of care practices at hospitals and other health care facilities and has the potential to play a vital role in optimizing structures at clinical settings, nursing administration, and nursing education.

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Clinical judgment

Clinical judgment involves the manner in which the nurse makes decisions in the clinical setting to enhance the well-being of the patient. One author defined clinical judgment as an integration of knowledge and bodily skill and cited the 5 elements as crucial to the process as follows: a factual base, understanding, comparison, priorities, and a review of standards.18 Research with newly hired nurses indicates that they should be evaluated and, if necessary, receive further education regarding the ability to execute their judgment to improve the quality of nursing care.20

While these institutional applications of nursing judgment have a broad impact on patient care, frequently it is the reflexive decisions of an individual nurse with a given patient that matter most. These duties may be interrelated and dependent upon one another; for example, a nurse relies on judgment of the assessment as to whether to proceed with one action or initiate another. Thus, in addition to executing orders as directed, the nurse must remain vigilant for abnormal signs and symptoms, which would then prompt an additional decision-making process, including possibly to wait and watch, a judgment in its own right.21

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Administrative judgment

In addition to provision of direct clinical care, nursing judgment may be used by members of nursing administration who oversee other nurses. For example, supervisors may use judgment to determine what skills are needed in certain departments, such as the intensive care unit.22 Nursing judgment is also used by charge nurses to evaluate the expertise of available nurses and to make nursing assignments according to the complexity of patient care needs.23

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Education

Nursing judgment is also used to develop uniform requirements for nursing students. Nursing schools are increasingly likely to incorporate patient care scenarios that require application of nursing judgment into the curriculum, in some cases even preregistration programs.24 Nursing students are regularly asked to respond to various case studies and to engage in simulation exercises to begin developing the skills and knowledge base that will be used as nursing judgment after graduation.25

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Applications

Failure of the nurse to implement nursing judgment in any component of provision of care could compromise a patient's safety, either by performing an incorrect action or by neglecting to perform a needed one. Nursing judgment therefore requires for the nurse to be not only ever vigilant but also continuously ready to intervene upon a nearly endless list of contingencies.25 As it is not possible for every possible scenario to have been taught in nursing education programs, nursing judgment will help the nurse make the best nursing decision under the circumstances.

This principle in defense of nursing judgment was solidified in an important judicial case. In a lawsuit against a hospital, the plaintiff argued that the nurse violated the doctor's orders by not implementing restraints as ordered, whereupon the patient experienced a fall. However, in its ruling the court determined that, despite the unfortunate outcome, the decision not to apply the restraints was within the scope of a nurse's discretion. As the authors examining the case summarized, “The court did not attempt to substitute ‘hindsight’ for the judgment of the nurse ‘on the spot.’”26(p44) In other words, nursing judgment allows that in many cases, there is a range of acceptable responses to a patient care situation.

This individual decision-making is a key component of the critical thinking model for nursing judgment that was established by Kataoka-Yahiro and Saylor.27 From this perspective, critical thinking in the nursing realm should not be confined to problem solving, scientific methodology, or the nursing process. Instead, applying critical thinking to nursing judgment consists of thinking reflectively about the problem to decide upon the best course of action. In a patient care scenario, it is possible for there to be more than 1 action that demonstrates a nurse's use of nursing judgment.

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ATTRIBUTES OF NURSING JUDGMENT

According to Walker and Avant,19 it is necessary to examine key characteristics, or attributes, of a concept to understand how to differentiate one concept from another. To exercise nursing judgment, it is essential for a nurse to be equipped with not only nursing knowledge, which may be abstract or formal knowledge, but must also clinical and caring knowledge.28 Nursing knowledge requires the ability of a nurse to retain and integrate information and entails the intersection of a variety of disciplines (eg, anatomy, chemistry, psychology) that provide the scientific basis for care provided in a clinical setting. However, for this learning to be transformed into nursing judgment, the nurse must be able to identify relevant information and apply it toward the nursing decision-making process.28 The attributes of nursing judgment identified in this concept analysis include critical thinking, prioritization, recognition of limits, and discernment.

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Critical thinking

It is important to note that critical thinking represents one aspect of nursing judgment but not its entirety. The critical thinking element of nursing judgment consists of clinical and diagnostic skills such as the interpretation of vital signs, laboratory values, and other assessment findings. A nurse may then utilize this information as one component to determine the most appropriate course of action in a given situation, which requires nursing judgment.29

Some researchers have examined how the critical thinking aspect of the decision-making process—and as a result, nursing judgment—differs in new versus experienced nurses.28,29 In this context, experience is defined as time spent in actual nursing situations, with one study defining some nurses with more than 5 years of experience as experts.28 Nursing judgment is needed to determine which conditions require intervention and, specifically, what that action should be. Tanner29 asserts that a beginning nurse would need to identify situations based on theoretical knowledge while gradually acquiring a base of practical experience from which the nurse can broaden the scope of textbook learning. This style of decision making may also be used in certain other nursing contexts, such as when a patient outcome does not match the expectation, or when multiple options are available for the nurse. Other analytical techniques such as concept mapping can be used to foster nursing judgment to address issues such as reducing medication errors and helping improve unit performance measures.30

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Prioritization

Complicating matters is that the nurse must also prioritize care by recognizing available options and choosing among nursing interventions, thereby determining which patient or patient need to address first.31 While executing this component of nursing judgment, a nurse must be especially cognizant of the scope of the patient care situation and individual limitations. Although a nurse is legally confined to render care within the Nurse Practice Act of each state, nursing judgment would dictate this nurse further restrict care provided to that within the scope of given knowledge and skill and to seek consultation from a more experienced nurse or a different health care professional when necessary. Deferring nursing judgment to another nurse with appropriate expertise, or concluding certain circumstances call for another type of judgment (eg, medical decision-making), can also represent a proper execution of nursing judgment.

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Discernment

The culminating attribute of nursing judgment is discernment. When faced with either a routine task or a patient in crisis, a nurse can review the qualities of a situation and apply this attribute of judgment to make a decision. As described in one study focusing on newly graduated nurses, this requires a process that merges inner knowledge with external information to render judgment.32 In other words, there is no precise formula that will automatically produce optimum nursing judgment. Rather, the burden is on the nurse to weigh potential alternatives to select the most appropriate course.29

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ANTECEDENTS OF NURSING JUDGMENT

According to the Walker and Avant19 method, a concept must be considered in the context of its antecedents or the events that must occur prior to the occurrence of the concept in question. Antecedents of nursing judgment identified from this concept analysis include knowledge, experience, and intuition.

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Knowledge

One analysis found knowledge to be a recurring component in the ability of nurses to execute critical thinking, a key component of nursing decision making.33 In the years preceding a patient care encounter, a nurse has received considerable education. However, it is crucial that a nurse be aware not only of the textbook aspects of nursing but also of the human ones. Uniting the corporeal and sociodynamic aspects of nursing education will be necessary for a nurse to implement nursing judgment.

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Experience

Another essential precursor to nursing judgment is experience. In a difficult circumstance, a nurse may find it helpful to use previous experiences similar in nature to compare or contrast with the current patient care encounter.18 Clearly, nurses who have had the benefit of years of practice have an advantage in this case; one must have adequate nursing experience with which to evaluate the current circumstance.

However, the concept of experience is not merely accumulation of patient encounters over the years. A nurse must have a mind-set open to continuous attainment of learning from patient care scenarios. Without such an attitude, a nurse with more clinical experience will not necessarily become an “experienced” one. According to this perspective, even clinicians of long-standing duration should spend time considering evidence-based guidelines, consulting relevant literature, and analyzing possible consequences of potential actions in preparation to execute nursing judgment.28

At the same time, a newer nurse will be better prepared to take advantage of learning experiences if receiving guidance and explanation from experienced nurses, opportunities for increased responsibilities, and acceptance from nursing colleagues.34 While there is no precise formula for teaching nursing judgment, nurses in all stages of their careers can continue to acquire knowledge and develop a readiness to implement nursing judgment by obtaining additional formal education, exchanging clinical feedback, and participating in evidence-based training.35

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Intuition

Another antecedent to nursing judgment is the role of intuition or the role of the nurse as recognizing a pattern in the patient response.29,36 Intuition represents an intersection of knowledge and expertise that usually requires previous experience with the patient.36 A nurse may demonstrate judgment by incorporating intuition as a component of the nursing process.

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CONSEQUENCES OF NURSING JUDGMENT

The Walker and Avant19 method of concept analysis denotes that consequences, or effects, associated with a given concept be examined. Ultimately, it is the responsibility of the nurse to use nursing judgment for the sake of patient well-being. Thus, teaching new nurses to employ nursing judgment has potential to achieve better communication within the health care setting, enhance patient comfort, avoid errors, and contribute to a system of quality health care.37

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Communication

In the clinical setting, numerous barriers can impair effective communication between a patient and the nurse. A consequence of nursing judgment occurs when the nurse is able to demonstrate application of clinical knowledge for specific patients and use this ability to address patient concerns.29 Sometimes, these nurse-patient interactions are not easy, yet a crucial duty of the nurse is to use judgment to critically engage the patient about health decisions.38 In this way, nursing judgment can inform a nurse of what needs to be communicated to a patient, in what manner to initiate the discussion, and how to help address patient needs by listening in response.

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Patient comfort

Improving communication between nur-ses and patients will also increase patient level of comfort. A nurse using nursing judgment at its highest level will be attuned to patient concerns such as pain, need for toileting, and improper positioning. Research has shown that nurses who have worked closely with certain patients become better able to consider the patient's perspective when rendering direct patient care.39 In addition, helping student nurses develop nursing judgment as part of the nurse's skill set will support the nurse to become more proficient in conducting routine nursing tasks (such as injections and insertion of Foley catheters).40

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Patient outcomes

A nurse who employs nursing judgment in the nurse decision-making process has the distinct potential to improve patient outcomes, such as reducing morbidity and mortality. Effective decisions impact clinical practice because these decisions are more likely to result in favorable patient outcomes.39 Applying nursing judgment can reduce errors, hospital-acquired-infections, falls, and other “never” events, but nursing judgment can also be used on a routine basis to promote patient well-being. From this perspective, problem solving can be used to determine patient needs and develop and implement a plan of care to improve outcomes.41 An emphasis on nursing judgment will then improve the benchmarks of patient care and institutional quality by improving nursing care.42

As the largest segment of the health care workforce in the United States, nurses are responsible for rendering the majority of health care to patients.42 Nursing actions that incorporate an underlying decision-making process based on nursing judgment can serve to help improve the patient outcomes and benefit the health care system.28

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EMPIRICAL REFERENTS OF NURSING JUDGMENT

When employing the Walker and Avant19 method, empirical referents are used to better understand the concept in question. Empirical referents are the measurable occurrences that help demonstrate the impact of the concept in an objective fashion. Ultimately, the purpose of nursing judgment is not for the nurse; it is for the patient and, on a greater scale, the effective functioning of the wider health care system. While providing nurses resources necessary to act on individual nursing judgment improves outcomes for patients, it is the responsibility of nurses to uphold the autonomy allowed by nursing judgment by structuring care appropriately and communicating accordingly.35

A method of empirically measuring nursing judgment currently does not exist related to the complex and abstract nature of this concept. However, Magnet hospitals, which empower nurses in key leadership roles, exemplify one widely recognized method to identify health care facilities that uphold the value of nursing judgment.35 In this sense, whether a hospital has received Magnet status designation can be interpreted as an outward indicator of its commitment to the principles of nursing judgment. On a national level, a number of governmental and accreditation organizations regularly inspect health care facilities, enforcing quality assurance measures and evaluating nursing care. These include The Joint Commission, the Agency for Health Care Administration, the state and local Departments of Health, and the Centers for Medicare & Medicaid Services (CMS). The CMS provides a particularly relevant measure of health care quality, resulting from its decision in recent years to reduce reimbursements to hospitals for services rendered because of inadequate nursing care, such as hospital-acquired pressure ulcers.42 Another CMS quality measure directly impacted by nursing care is the rate of catheter-associated urinary tract infections.43 Members of the public may seek out and consider these data as a proxy for the quality of nursing judgment in a facility.

Another indirect way nursing judgment can be evaluated is by patient satisfaction. As research has demonstrated that patient satisfaction is tied to quality and improved outcomes, hospitals and other health care facilities have grown increasingly reliant on postdischarge surveys.44 While some discrepancy may arise between a patient's perceptions and the quality of the nursing judgment, these assessments provide a valuable tool to determine the impact of nursing judgment on client outcomes. If patients consistently report unmitigated pain or unsafe or unhygienic conditions, this may reflect serious lapses in the nursing judgment at a facility.

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DISCUSSION

The purpose of this concept analysis of nursing judgment has been to explore and develop the concept of nursing judgment using available literature. Attributes, antecedents, and consequences of nursing judgment were located by reviewing previous research and writing on the concept. In addition, several proxy measures of nursing judgment were identified. The results of this concept analysis provide implications for practice, education, policy, conceptual/theory development, and further research.

Nursing judgment is essential for providing quality patient care, and nursing knowledge, nursing experience, and nursing intuition are the antecedents that must occur for a nurse to be able to render quality nursing judgment.28,29 Such judgment is evidenced by nursing characteristics of critical thinking, discernment, correct prioritization of patient needs, and self-awareness of limitations.31,32 This sequence is demonstrated in the Figure. For the patient, fostering nursing judgment in the clinical setting may serve to improve health care quality outcomes via specific measures such as pressure ulcer incidence, failure to rescue, and length of stay.45 In the wider sense, the public benefits from quality nursing judgment via empirical proxy measures such as enhanced safety, a reduction in errors, and system-wide quality standards.46

Figure

Figure

Practicing nurses should be reminded of the importance of nursing judgment on the safety of hospitalized patients. When a nurse fails or neglects to implement judgment, the results are disturbing: one study examined 21 cases from 9 State Boards of Nursing and found that 8 cases involved “clinical judgment.”47 Other categories of complaints, such as medication errors, may also be considered lapses of nursing judgment. In addition, it should be considered that nursing judgment can be affected by environmental factors such as patient load and patient level of acuity.48,49 For this reason, it is imperative that nurses be able to implement their nursing judgment effectively.

The concept of nursing judgment can be used to guide future educational programs for nursing students. Researchers have shown improved outcomes with nursing care delivered by RNs with bachelor's degrees as opposed to associate degrees.48 Specifically, patients are less likely to die when cared for by BSN prepared nurses than ASN prepared nurses, and research indicates that the effect of education is enhanced in positive work environments with adequate staffing ratios.48 In addition, qualities such as communication and patient advocacy are linked with higher levels of education.49 These associations indicate the importance of providing nursing students additional opportunities to develop nursing judgment by exposing students to further didactic coursework on nursing theory, research, and practice. This didactic coursework should be supplemented with clinical experiences or simulated-learning experiences, challenging students to use nursing judgment to apply their learning in a clinical setting.

Policy makers can leverage the importance of nursing judgment by safeguarding the ability of a nurse to implement this skill in practice. Policy makers at the hospital/health care facility level must take a strong stance to preserve the capacity of a nurse to execute nursing judgment by committing to organizational structures that support sound nursing judgment. These include appropriate staffing structures, limits on interruptions during medical dosage calculations or administration, and restrictions on excessive or continuous working hours. While the nuances of nursing judgment may vary among nursing specialties, the concept is applicable to improving safety and quality of care by nurses at all delivery settings, including schools, clinics, and long-term care facilities.42

For nurses to execute judgment at an optimum level, it is critical to provide an improved work environment.50 Policy makers at the state and federal levels must continue to lobby to ensure that nurses are permitted to execute nursing judgment and that resources at the state and federal levels are available to support nurses and impact on the health of patients that results from nursing judgment. One way to do so is to include nurses in decision making at both hospitals and government agencies that manage patient well-being.1 Providing nurses with opportunities to serve as leaders, not only in health care settings but also alongside other health care professionals, will enable the principles of nursing judgment to be applied on a broader scale throughout the health care system.

More conceptual and theoretical works need to be conducted on the concept of nursing judgment. At this point, nursing judgment remains abstract and unmeasurable without the use of proxy measures. Abstract concepts are not useful clinically. To make nursing judgment less abstract and more applicable clinically, empirical work in the form of qualitative research studies must be conducted to help identify the components of nursing judgment that might be measured and eventually used to improve patient outcomes that result from nursing judgment.50

Once such work has been completed to make nursing judgment less abstract, opportunities for future nursing research will necessitate testing conceptual and theoretical models involving nursing judgment. As a consequence, the interrelationships among nursing judgment, patient outcomes, and patient safety will be able to be studied.

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CONCLUSION

The public's focus on health care and health care reform is an opportunity for the nursing profession to explain how nursing judgment contributes to the care and safety of patients requiring nursing care. Defining, teaching, and implementing nursing judgment entail a granular process that merits further research. It is important to continue conceptual, theoretical, and empirical works on the concept of nursing judgment so that the nursing profession, other professional disciplines, and the public can realize and appreciate the contribution that nursing makes on the health of patients and families.

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Keywords:

concept analysis; decision making; judgment; nursing; patient care; patient outcomes

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