Bakgrund: Kliniskt omdöme kan beskrivas som förmågan att på ett insiktsfullt sätt identifiera och agera på en förändring eller ett behov relaterat till patientens hälsotillstånd. Kliniskt omdöme kommer till sin spets i komplexa situationer som exempelvis när en patient plötsligt försämras. Det har skett en akademisering av sjuksköterskeutbildningen som gett sjuksköterskor en stadigare teoretisk grund men det kliniska omdömet behöver utvecklas efter examen. Syfte: Syftet var att beskriva faktorer som påverkar utvecklingen av nyexaminerade sjuksköterskans (NS) kliniska omdöme. Metod: Metoden som användes var litteraturöversikt, baserad på tio vetenskapliga artiklar varav åtta kvalitativ metod och två mixad metod. Artiklarna hämtades ur databaserna CINAHL Complete och PubMed. Resultat: Faktorer som påverkar utvecklingen av NS kliniska omdöme sammanfattas under tre huvudteman: Förvärvandet av kliniska förmågor, Ansvarsfull kommunikation och Integrerat stöd. NS behöver utveckla förmågan att identifiera relevanta förändringar, tolka dem i relation till en helhetsbild av patienten, prioritera åtgärder samt kommunicera med kollegor. Utvecklande av kliniskt omdöme underlättas i ett positivt arbetsklimat med stöd av erfarna sjuksköterskor (ES). Vårderfarenheter ger teoretiska kunskaper en ny mening, vilket också bidrar till utvecklandet av kliniskt omdöme. Diskussion: Resultatet diskuterades med utgångspunkt i Benners teori för hur sjuksköterskans kliniska omdöme utvecklas från novisens till expertens. NS är inte mogen att hantera komplexa kliniska situationer och organisationen måste utformas för att ge NS det stöd som behövs för att utveckla det kliniska omdömet. Tillgången till ES, reflektion och ett rimligt arbetstempo är viktiga stöttande faktorer, men sällan en självklarhet i vården. / Background: Clinical judgement can be described as the ability to wisely identify and act upon changes in - or needs of a patient’s - health status. Clinical judgement is most applicable to complex situations such as caring for deteriorating patients. As nursing was included in higher education nurses have acquired a more solid theoretical knowledge base, however their clinical judgement needs to be further developed post graduation. Aim: The aim of was to describe factors influencing the development of newly graduated nurse’s (NN) clinical judgment. Method: The method consists of a literature review based upon ten scientific articles, of which eight were qualitative and two followed a mixed method. The articles were retrieved from CINAHL Complete and PubMed databases. Results: Contributing factors to the development of NN clinical judgment were grouped into three main themes: Development of clinical abilities, Responsible communication and Integrated support. NN needs to develop the ability to recognise relevant changes, relate them to a holistic assessment of the patient and to communicate findings. The development of clinical judgment is supported by a positive work climate and by access to experienced nurses. Caring for patients adds a new dimension to theoretical knowledge and contributes to the development of clinical judgment. Discussion: The results were discussed using Benner´s theory of how the clinical judgement of nurses develops from novice to expert. NN is not able to safely handle complex clinical situations without the support of experienced staff. It is also essential for the development of clinical judgment that NN is given a reasonable workload and opportunities for reflection. However, there may often be a lack of these supporting factors in nursing organisations today.

This study explores the use of early warning scores (EWS) in deteriorating patients. These are widely used tools to measure vital signs and highlight abnormal physiology in acutely unwell patients. Measurements of the process in the management of the deteriorating patient includes time to first assessment of such patients. The level of clinician involved in the subsequent management is also investigated to determine whether escalation of care was appropriate. This work is a retrospective case note analysis of the recognition and management of deteriorating patients prior to critical care admission. Research Questions 1. What violations in the optimum process are associated with sub-optimal recognition and management of deteriorating patients and delayed critical care admission in patients triggering early warning scores in acute care wards? 2. Are there independent variables which can predict the delay in the recognition and management of deteriorating patients and subsequent critical care admission? Methods The literature was reviewed to determine the optimum process of recognition and management of deteriorating patients in acute care wards. A data collection tool was then specifically designed and locally validated to extract objective data from the case records. A sample of 157 patients admitted to critical care from acute wards over a 6 month period were included in the study. The case records were then retrospectively reviewed and information was extracted using the data collection tool. Results The accuracy and frequency of early warning scores were measured and findings demonstrated that 59% of Early Warning Scores (EWS) were miscalculated. The most frequent of those miscalculated were the intermediate scores (4 or 5) (error rate - 52%) followed by the higher scores (6 or more) (error rate - 32%). The least frequently miscalculated were the lower scores (0 -3) (error rate 15%). Descriptive data from the sample such as age, ward, diagnosis, time of hospital admission, time and day of transfer / EWS triggering were included. From the total case records reviewed, 110 patients had abnormal Early Warning Scores (4 or more) and were included in the inferential data analysis. The independent variables related to the processes objectively measurable in the recognition and management of deteriorating patients were included. After descriptive analysis the independent variables were cross-tabulated with the dependent variable using Pearson chi-square. The dependent variable was identified from the literature. This was whether time from triggering an abnormal EWS to critical care admission was delayed more than 6 hours. The subsequent predictor variables were then entered in to a binary logistic regression model for statistical analysis using SPSS version 21 software. Binominal Logistic Regression Analysis identified three significant variables predicting delay of the recognition and management of deteriorating patients. • Frequency of EWS measurement not increased appropriately • Length of stay prior to critical care admission 12-36 hours • If no consultant review during 6 hours of abnormal EWS Implications for Future Practice This study highlights areas of risk in the detection of patients’ clinical deterioration in acute wards. These findings should guide quality improvement to prevent unnecessary morbidity and mortality. As a key area of patient risk included the lack of frequency and accuracy of EWS measurements, staff education is required to ensure staff are given the appropriate knowledge to understand the use of the tool. Regular review of the frequency of measurement is also required as this was statistically significant in the delay to critical care admission. The high risk time from admission of 12-36 hours needs further investigation. This study also highlights the need for senior decision makers to be involved in the care of deteriorating patients to improve outcomes.