Clinical judgment in nursing: Judgment processes in psychiatric mental health nursing.

Abstract

This study addressed the issue of judgment in nursing pertaining to the use of clinical cues cited by nurses as relevant in the process of deriving nursing diagnosis. Using an exploratory, qualitative approach, subjects were asked to retrace their mental processes when they formulated a judgment regarding the health status of a patient recently interviewed for intake assessment purposes. Psychiatric mental health nurses practicing in three types of facilities (i.e., psychiatric emergency services, a comprehensive psychiatric hospital, and a psychiatric unit of a community hospital) reported the signs, symptoms, and other information that they used in coming to their judgments. Fifteen nurses with varied educational preparation and experience in psychiatric mental health nursing provided 36 in-depth interviews. Comparative content analysis was used to determine the underlying structure and the cue use strategies in the subject reports. All subjects assessed categories labelled as "universals" in psychiatric mental health nursing assessment: suicidality, drug and alcohol use, signs and symptoms of depression, and patient functional abilities. The cue reporting process was characterized by the subjects listing cues and coming to judgments based on those cues. Also identified as characteristic of this process was a deviation from the subject's line of questioning to pursue another topic on the basis of patient response. These "pivotal cues" triggered a context-based exploration of significant areas of patient behavior or experience. Experience, personal feelings of the nurse, intuitive thinking were all reported to influence the judgments reached. More striking in effect on the judgment process, however, were "system factors". Specifically, judgments were highly context-dependent, as the setting in which the subject practiced heavily influenced what information was sought from the patient. The hypotheses derived from this study suggest that the judgment process used by subjects is characterized by inductive thinking, and that presenting patient behavior and practice setting are strong determinants of the conclusions reached by subjects. Likewise, it is hypothesized that a systematic categorization system can be validated by practicing nurses, and that it can be used as the basis for the specification of outcome criteria for psychiatric mental health nursing practice. (Abstract shortened with permission of author.)