Indiana University-Purdue University Indianapolis (IUPUI) / Clinical judgment provides the basis for nurses’ actions and is essential for the provision of safe nursing care. Tanner’s Clinical Judgment Model and its associated instrument, the Lasater Clinical Judgment Rubric (LCJR) have been used in the discipline of nursing, yet it is unclear if scores on the rubric actually translate to the completion of an indicated nursing action. This is important because clinical judgment involves identifying and responding to patient situations through nursing action, and then evaluation of such actions. The purpose of this observational study was to explore the relationship between clinical judgment, as measured by the LCJR, and the completion of an indicated nursing action, as measured by a nursing action form. The clinical judgment and completion of an indicated nursing action was measured in 92 participant students at a Midwestern university school of nursing who were enrolled in an adult medical/surgical nursing course that included simulation and debriefing during which scoring occurred. This study explored whether clinical judgment, as measured by the LCJR, was related to the completion of an indicated nursing action. In addition, this study evaluated whether Responding, as measured by the LCJR was related to the completion of an indicated nursing action. The data revealed that a very weak relationship was present between clinical judgment, as measured by the LCJR, and the completion of an indicated nursing action; however, these findings were not statistically significant. The data also revealed that a very weak relationship was present between the dimension Responding, and the completion of an indicated nursing action; however, these findings were also not statistically significant. This study expands upon previous clinical judgment research in nursing and identifies a need for additional methods of evaluating clinical judgment in baccalaureate nursing students including action appraisal so that deficiencies are established and targeted for improvement.

Seclusion is an intervention used in mental health settings, with nurses playing a key role in decisions related to secluding a patient. The purpose of this interpretive description study was to explore the place of ethics in mental health nurses’ clinical judgements on seclusion use. Data collection involved interviews of nine registered psychiatric nurses and eight registered nurses. Nurses described their experiences with seclusion and identified factors that impacted their decision to seclude. Ethical tensions related to seclusion use were outlined. Two themes were identified. The complexity of promoting safety and preventing harm illustrates nurses’ sometimes competing responsibilities to keep people safe, understanding of power differentials and patient vulnerability, and recognition of the various types of harms that can arise with seclusion. The importance of knowing for ethical action with seclusion use highlights the role of knowing oneself, the patient, other team members, and the unit in judgments to seclude.

Seclusion is an intervention used in mental health settings, with nurses playing a key role in decisions related to secluding a patient. The purpose of this interpretive description study was to explore the place of ethics in mental health nurses’ clinical judgements on seclusion use. Data collection involved interviews of nine registered psychiatric nurses and eight registered nurses. Nurses described their experiences with seclusion and identified factors that impacted their decision to seclude. Ethical tensions related to seclusion use were outlined. Two themes were identified. The complexity of promoting safety and preventing harm illustrates nurses’ sometimes competing responsibilities to keep people safe, understanding of power differentials and patient vulnerability, and recognition of the various types of harms that can arise with seclusion. The importance of knowing for ethical action with seclusion use highlights the role of knowing oneself, the patient, other team members, and the unit in judgments to seclude.

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Research investigating clinical versus actuarial prediction and judgment has consistently demonstrated the superiority of actuarial (statistical) methods. Little research to date has directly compared clinical and actuarial predictions in the context of patient-focused psychotherapy outcomes. The most relevant study on this issue was completed with an adult population and results indicated that the actuarial method was significantly more accurate at predicting client treatment failure compared to clinician’s predictions. This study examined clinical versus actuarial prediction of client deterioration in a sample of children and adolescents receiving treatment in a managed care and community mental health setting. Predictions of treatment failure made by the actuarial method were found to be significantly more accurate than predictions of treatment failure made by clinicians. More specifically, participating clinicians did not make a single prediction of treatment failure. These findings add further evidence to support the use of actuarial methods in enhancing clinical decision-making in community-based mental health services for children and adolescents.

The aim of the thesis was to develop and evaluate a Computerised Decision Support System (CDSS) for use in pre-hospital care.The thesis was guided by a theoretical framework for developing and evaluating a complex intervention. The four studies used different designs and methods. The first study was a systematic review of randomised controlled trials. The second and the last studies had experimental and quasi-experimental designs, where the CDSS was evaluated in a simulation setting and in a clinical setting. The third study included in the thesis had a qualitative case study design.The main findings from the studies in the thesis were that there is a weak evidence base for the use of CDSS in pre-hospital care. No studies have previously evaluated the effect of CDSS in pre-hospital care. Due to the context, pre-hospital care is dependent on protocol-based care to be able to deliver safe, high-quality care. The physical format of the current paper based guidelines and protocols are the main obstacle to their use. There is a request for guidelines and protocols in an electronic format among both clinicians and leaders of the ambulance organisations. The use of CDSS in the pre-hospital setting has a positive effect on compliance with pre-hospital guidelines. The largest effect is in the primary survey and in the anamnesis of the patient. The CDSS also increases the amount of information collected in the basic pre-hospital assessment process. The evaluated CDSS had a limited effect on on-the-scene time.The developed and evaluated CDSS has the ability to increase pre-hospital patient safety by reducing the risks of cognitive bias. Standardising the assessment process, enabling explicit decision support in the form of checklists, assessment rules, differential diagnosis lists and rule out worst-case scenario strategies, reduces the risk of premature closure in the assessment of the pre-hospital patient. / För avläggande av doktorsexamen i Kvalitetsförbättring och ledarskap inom hälsa och välfärd som med tillstånd av Nämnden för utbildning och forskarutbildning vid Högskolan i Jönköping framläggs till offentlig granskning torsdagen den 5 juni 2014 kl.13.00 i sal M 204, Högskolan i Borås.

<p>Klinisk blick är en term som frekvent återkommer under sjuksköterskeutbildningen och i klinisk verksamhet. Den återfinns ofta i samband med klinisk bedömning och som</p><p>en övergripande beskrivning av en patient. Endast antydda betydelser har framkommit och då tätt knutna till andra termer och processer. Syftet med studien var att</p><p>undersöka komponenterna intuition och tyst kunskap som delar i sjuksköterskans kliniska blick. Studien genomfördes som en litteraturstudie där 17 vetenskapliga artiklar granskades. Resultatet visar att intuition och tyst kunskap är huvudkomponenter i sjuksköterskans kliniska blick. Intuition verkar som en länk mellan kognitiva, affektiva och perceptuella processer. Tyst kunskap sammanbinder intuition och teoretisk kunskap. Intuition och tyst kunskap utvecklas över tid och baseras på personlighet, erfarenhet och teoretisk kunskap. Förslag till vidare forskning är att försöka utveckla</p><p>och specificera termen och förstå de bakomliggande processerna bättre med syftet att utbilda och stödja sjuksköterskan i hennes professionella utveckling.</p>

Klinisk blick är en term som frekvent återkommer under sjuksköterskeutbildningen och i klinisk verksamhet. Den återfinns ofta i samband med klinisk bedömning och som en övergripande beskrivning av en patient. Endast antydda betydelser har framkommit och då tätt knutna till andra termer och processer. Syftet med studien var att undersöka komponenterna intuition och tyst kunskap som delar i sjuksköterskans kliniska blick. Studien genomfördes som en litteraturstudie där 17 vetenskapliga artiklar granskades. Resultatet visar att intuition och tyst kunskap är huvudkomponenter i sjuksköterskans kliniska blick. Intuition verkar som en länk mellan kognitiva, affektiva och perceptuella processer. Tyst kunskap sammanbinder intuition och teoretisk kunskap. Intuition och tyst kunskap utvecklas över tid och baseras på personlighet, erfarenhet och teoretisk kunskap. Förslag till vidare forskning är att försöka utveckla och specificera termen och förstå de bakomliggande processerna bättre med syftet att utbilda och stödja sjuksköterskan i hennes professionella utveckling.