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Recent reforms in the South African health care and educational system were founded in the ideal that the country would produce independent, critical thinkers. Nurses need to cope with diversity in a more creative way, defining their role in a complex, uncertain, rapidly changing health care environment. Learning facilitators are held accountable for finding adequate learning experiences to prepare nursing students for such practice demands so that newly qualified nurses do meet expectations for entry level clinical judgement ability. Quality clinical judgement is therefore imperative as an identified characteristic of newly qualified professional nurses. There is a scarceness of information on the concept of clinical judgement especially within the South African nursing environment. Relevant information in this regard can assist in clarifying the meaning, which will facilitate a common understanding of the concept within the clinical nursing environment. This in turn can lead to the formulation of a teaching-learning strategy to facilitate clinical judgement in undergraduate nursing students, which would be of benefit in the nursing care environment. The objective of this study was addressed in three phases. The first phase of this research analysed the concept of clinical judgement through various data sources and a review of literature to clarify the meaning and facilitate a common understanding through identification of the characteristics and to develop a connotative (theoretical) definition of the concept. The second phase of the research investigated professional nurses‟ understanding of the meaning of clinical judgement, as well as the factors that influence the development of clinical judgement within the nursing environment. During the third phase a conceptual framework for an enabling teaching-learning environment was constructed from a modern day constructivist approach to facilitate clinical judgement. The section included a description and diagrammatic presentation of the framework. The conceptual framework formed the scientific basis from which a teaching-learning strategy for the creation of an enabling teaching-learning environment to facilitate clinical judgement in undergraduate nursing students within the South African nursing environment was synthesised. A qualitative design was used for the study. During the first phase (manuscript 1) an explorative, descriptive qualitative design was used to discover the complexity and meaning of the phenomenon. Multiple data sources and search engines were consulted for the time frame 1982-2013. An extensive concept analysis resulted in a theoretical definition of the concept „clinical judgement‟, a complex cognitive skill to evaluate patient treatment alternatives within the clinical nursing environment. The second phase (manuscript 2) is qualitative in nature and explored professional nurses‟ understanding of clinical judgement, as well as the factors influencing the development of clinical judgement in undergraduate nursing students. The findings emphasised clinical judgement as skill within the nursing environment. This assisted in the development of teaching-learning strategy for the creation of an enabling teaching-learning environment to facilitate clinical judgement in undergraduate nursing students within the South African Nursing environment as the third phase (manuscript 3). Such an environment should impact positively to promotion of autonomous and accountable nursing care. / PhD (Nursing), North-West University, Potchefstroom Campus, 2015

Recent reforms in the South African health care and educational system were founded in the ideal that the country would produce independent, critical thinkers. Nurses need to cope with diversity in a more creative way, defining their role in a complex, uncertain, rapidly changing health care environment. Learning facilitators are held accountable for finding adequate learning experiences to prepare nursing students for such practice demands so that newly qualified nurses do meet expectations for entry level clinical judgement ability. Quality clinical judgement is therefore imperative as an identified characteristic of newly qualified professional nurses. There is a scarceness of information on the concept of clinical judgement especially within the South African nursing environment. Relevant information in this regard can assist in clarifying the meaning, which will facilitate a common understanding of the concept within the clinical nursing environment. This in turn can lead to the formulation of a teaching-learning strategy to facilitate clinical judgement in undergraduate nursing students, which would be of benefit in the nursing care environment. The objective of this study was addressed in three phases. The first phase of this research analysed the concept of clinical judgement through various data sources and a review of literature to clarify the meaning and facilitate a common understanding through identification of the characteristics and to develop a connotative (theoretical) definition of the concept. The second phase of the research investigated professional nurses‟ understanding of the meaning of clinical judgement, as well as the factors that influence the development of clinical judgement within the nursing environment. During the third phase a conceptual framework for an enabling teaching-learning environment was constructed from a modern day constructivist approach to facilitate clinical judgement. The section included a description and diagrammatic presentation of the framework. The conceptual framework formed the scientific basis from which a teaching-learning strategy for the creation of an enabling teaching-learning environment to facilitate clinical judgement in undergraduate nursing students within the South African nursing environment was synthesised. A qualitative design was used for the study. During the first phase (manuscript 1) an explorative, descriptive qualitative design was used to discover the complexity and meaning of the phenomenon. Multiple data sources and search engines were consulted for the time frame 1982-2013. An extensive concept analysis resulted in a theoretical definition of the concept „clinical judgement‟, a complex cognitive skill to evaluate patient treatment alternatives within the clinical nursing environment. The second phase (manuscript 2) is qualitative in nature and explored professional nurses‟ understanding of clinical judgement, as well as the factors influencing the development of clinical judgement in undergraduate nursing students. The findings emphasised clinical judgement as skill within the nursing environment. This assisted in the development of teaching-learning strategy for the creation of an enabling teaching-learning environment to facilitate clinical judgement in undergraduate nursing students within the South African Nursing environment as the third phase (manuscript 3). Such an environment should impact positively to promotion of autonomous and accountable nursing care. / PhD (Nursing), North-West University, Potchefstroom Campus, 2015

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.

Although clinical reasoning is both broad and complex, the term “clinical reasoning” is contested and multiple definitions have been mooted within different contexts. In its simplest form, clinical reasoning is regarded as a “decision-making” process. Other definitions outline it in terms of a complex cognitive process, posited within multiple contextual factors. Traditionally, clinical reasoning models have been based upon cognitive theories. More recently, interpretive theories have been applied. Despite extensive research over the past four decades, no consensus on how clinical reasoning actually occurs has been achieved. Accurate clinical reasoning is vital to patient safety. Its importance as an essential clinical competence for healthcare professionals is well established. Indeed, it is the crux of a clinician’s work. Frequently, Foundation doctors are the first to review acutely unwell patients. During out-of-hours shifts senior help can be scant and Foundation doctors may have to rely on their own initial clinical reasoning to manage acutely unwell patients. This PhD explores clinical reasoning development in the transition phase between final year medical student and Foundation doctor (5MB-FY1 transition) in relation to acutely unwell patients. It follows a cohort of final year medical students from a single UK university on their clinical reasoning journeys as they transition into Foundation doctors, focusing on the role of the simulated healthcare setting and the workplace. The principle research question for this PhD was how does clinical reasoning develop across the transition phase between final year of medical school and Foundation year one? Within this overarching research question, the following sub-questions were posed: What do participants understand by the term clinical reasoning? What types of clinical reasoning experiences do participants narrate? How do participants clinically reason for acutely unwell patients? Which factors do participants perceive as being facilitating and hindering to their clinical reasoning? How do participants’ clinical reasoning processes develop across the 5MB-FY1 transition phase? This PhD uses multiple methodologies derived from interpretive approaches in innovative ways to tap into clinical reasoning processes and its development across four data collection points: T1: group and individual interviews; T2: Ward Simulation Exercise observations and stimulated recall interviews; T3: workplace observations and stimulated recall interviews; T4: final interviews. Data were collected from T1/T2 and T3/T4 during the final year of medical school and Foundation year one respectively. Primary thematic analyses were carried out cross-sectionally and longitudinally in terms of what participants said and how they said it. Secondary narrative analyses were undertaken of participants’ Personal Incident Narratives. By taking an interpretive approach, the complexities of clinical reasoning processes, both in terms of internal cognition and external socio-cultural influences were illuminated, drawing upon clinical reasoning, complexity and situated learning theories. The key findings of this PhD were that participants conceptualised clinical reasoning as a “decision-making” and “thinking” process, leading to a clinical judgement for patient care; participants narratives aided understanding of clinical reasoning process and factors which facilitated and hindered them; participants used experiential knowledge and protocols to clinically reason for diagnosis, investigation, management and prioritisation; participants retained flexibility and contextual variability in the processes of making their clinical judgements; multiple factors facilitated and hindered the equilibrium of clinical judgement processes; and clinical reasoning development is dependent upon a complex interplay of individual, interpersonal and systemic factors which are deeply embedded in social-cultural theory. This study has multiple strengths and original features such the high participant retention rate throughout the longitudinal study, the exploration of the 5MB-FY1 transition, contemporaneous observations of clinical interactions with patients, the exploration of the out-of-hour setting contemporaneously and the multiple methods of data collection used in innovative ways. This PhD develops the published literature further in these domains. However, its challenges were predominantly ethical, such as lack of patient capacity to consent in the workplace.

Many entry-level nurses are not prepared to handle medical emergencies. Although responsible for managing the care of individuals with complex medical conditions, many of these nurses compromise the safety of patients due to a lack of experience and an inability to apply clinical judgment. The purpose of this study was to explore the perceptions of registered nurses about their transition from entry-level to advanced beginner. Bandura's social cognitive theory, along with Colaizzi's descriptive method of data analysis, provided a basis for this phenomenological study. Research questions focused on challenges that entry-level nurses have experienced with problem-solving and complex patient care that requires advanced critical thinking and the application of clinical judgment. Criterion sampling facilitated recruitment of advanced-beginner RNs, with data collected through semistructured, one-on-one interviews. Data analysis occurred in a series of steps, including extracting and developing meanings from interview transcripts, clustering meanings into description lists, and eliminating outliers. Data analysis revealed 12 major themes aligned with behavior, clinical environment, and personal/cognitive factors. Among the findings were that nurses often felt unsupported, unable to manage conflict, unprepared, unseasoned, inefficient, and unable to lead others effectively. This study was necessary because its findings may provide insights leaders in health services can use to develop strategies to better prepare entry-level nurses to care for individuals with complex medical conditions. Among the implications for positive social change are developing a better tool for the training and advancement of entry-level nurses, consequently improving patient safety and reducing health care costs.

No / Multi-disciplinary team members predict each patient’s rehabilitation potential to maximise best use of resources. A lack of underpinning theory about rehabilitation potential makes it difficult to apply this concept in clinical practice. This study theorises about rehabilitation potential drawing on everyday decision-making by Health Care Professionals (HCPs) working in stroke rehabilitation services. Methods: A clinical scenario, checked for face validity, was used in two focus groups to explore meaning and practice around rehabilitation potential. Participants were 12 HCPs working across the stroke pathway. Groups were co-facilitated, audio-recorded and fully transcribed. Analysis paid attention to data grounded in first-hand experience, convergence within and across groups and constructed a conceptual overview of HCPs’ judgements about rehabilitation potential. Results: Rehabilitation potential is predicted by observations of “carry-over” and functional gain and managed differently across recovery trajectories. HCPs’ responses to rehabilitation potential judgements include prioritising workload, working around the system and balancing optimism and realism. Impacts for patients are streaming of rehabilitation intensity, rationing access to rehabilitation and a shifting emphasis between management and active rehabilitation. For staff, the emotional burden of judging rehabilitation potential is significant. Current service organisation restricts opportunities for feedback on the accuracy of previous judgements. Conclusion: Patients should have the opportunity to demonstrate rehabilitation potential by participation in therapy. As therapy resources are limited and responses to therapy may be context-dependent, early decisions about a lack of potential should not limit longer-term opportunities for rehabilitation. Services should develop strategies to enhance the quality of judgements through feedback to HCPs of longer-term patient outcomes.Implications for Rehabilitation Rehabilitation potential is judged at the level of individual patients (rather than population-based predictive models of rehabilitation outcome), draws on different sources of often experiential knowledge, and may be less than reliable. Decisions about rehabilitation potential may have far reaching consequences for individual patients, including the withdrawal of active rehabilitation in hospital or in the community and eventual care placement. A better understanding of what people mean by rehabilitation potential by all team members, and by patients and carers, may improve the quality of joint decision making and communication.

För att kunna ge vård av säker och god kvalitet krävs att sjuksköterskor har kunskap inom många områden, eftersom de har ansvar för såväl bedömning, planering och genomförande, som utvärdering och dokumentation av omvårdnadsarbetet. Ett av flera ansvarsområden för sjuksköterskor i deras dagliga arbete är beslutsfattande om insättning och skötsel av perifera venkatetrar (PVK). En PVK är en tunn plastkateter som sätts in i ett blodkärl via en kanyl. PVK används vid intravenös behandling med till exempel antibiotika och andra läkemedel, blodkomponenter eller näringslösningar. En stor andel av alla patienter inom hälsooch sjukvård kommer någon gång i kontakt med en PVK och riskerar då också att utsättas för komplikationer. En vanlig komplikation i samband med PVK är tromboflebit. Tromboflebit förekommer i olika svårighetsgrader och innebär att inflammation har uppstått i blodkärlet i kombination med samtidig blodpropp. Symtom som kan uppstå är rodnad, svullnad, smärta, hårdhet i kärlet och varig infektion. Det finns kliniska riktlinjer om PVK framtagna både på nationell och på lokal nivå som fungerar som ett stöd i beslutsfattandet. Tidigare forskning har visat att kliniskt verksamma ibland inte följer riktlinjer. Anledningar till att inte riktlinjer följs kan till exempel vara att de kliniskt verksamma inte håller med om det som rekommenderas, inte känner till rekommendationerna, inte har tid eller möjlighet att påverka de beslut som fattas eller att det finns individuella faktorer att ta hänsyn till för den enskilda patienten. 52 Frågan kan ställas om sjuksköterskor använder sig av kliniska riktlinjer i sitt dagliga arbete eller om det är andra faktorer och aspekter som har betydelse och påverkar beslutsfattandet. Denna licentiatavhandling syftade till att beskriva sjuksköterskors kliniska beslutsfattande genom att fokusera på deras följsamhet till riktlinjer och beslutsresonemang om PVK. Två studier har genomförts inom ramen för denna licentiatavhandling. Studie I undersökte i vilken utsträckning sjuksköterskor följer nationella och lokala riktlinjer om PVK. PVKns placering och storlek, tiden som PVKn varit placerad i blodkärlet, dokumentation vid PVKns förband samt om det fanns tecken på tromboflebit vid PVKn var variabler som undersöktes i relation till de rekommendationer som fanns. Utifrån två protokoll samlades strukturerad data in och analyserades. Totalt 343 PVK ingick i analysen. I studie II undersöktes de tecken och påverkande faktorer som har betydelse när sjuksköterskor fattar beslut om skötsel av PVK. I studien observerades 43 sjuksköterskor i sitt dagliga arbete. Sjuksköterskorna intervjuades också dels om PVK-besluten som de fattade under observationerna, dels om deras beslutsfattande om PVK-skötsel i allmänhet. Studie I visade att sjuksköterskor delvis följer riktlinjer. Det fanns skillnader mellan de vårdavdelningar som hade nationella riktlinjer och de som hade lokala riktlinjer, i hur de olika avdelningarna valde placering, storlek och dokumenterade vid PVKns förband. PVKn hade suttit längre tid än rekommenderat i varierande utsträckning. Andelen tromboflebiter var låg (7.0%) och tromboflebiterna var milda. Det tyder på att sjuksköterskor är noga med att ta bort PVK vid tecken på komplikationer. Studie II visade att sjuksköterskor i sitt kliniska resonemang om PVK-skötsel tar hänsyn till den individuella patientsituationen, sjuksköterskans arbetssituation och erfarenhet av PVK-skötsel. Det framkom även att sjuksköterskor balanserar mellan att undvika eller minimera obehag och smärta för patienten och samtidigt förebygga komplikationer från PVKn. Resultaten från denna licentiatavhandling kan få betydelse för undervisning av sjuksköterskestudenter och även när kliniska riktlinjer ska införas på vårdavdelningar. / Every working shift nurses make several decisions, including decisions about management of peripheral venous catheters (PVC). Peripheral catheterisation is a common procedure, which affects numerous patients in health care today. PVC are for example used for intravenous infusions with antibiotics, nutrients and blood components. Having PVC in situ may lead to complications such as thrombophlebitis. Clinical guidelines have been developed within the area to assist nurses in their decision-making, but clinical guidelines are not always adhered to. There are several reasons why clinicians do not always adhere to clinical guidelines, although such adherence may lead to fewer complications. Choices for decisions regarding PVC management have been investigated in previous studies, but not in a naturalistic setting. The overall aim of this licentiate thesis was to describe nurses’ clinical decision-making through focusing on their adherence to clinical guidelines and their clinical reasoning concerning decisions of PVC. Two studies have been conducted and data were collected during a six-month period, from December 2004 to June 2005. Study I investigated nurses’ adherence to national and local PVC guidelines by focusing on time in situ, site, size and documentation at the dressing. The thrombophlebitis frequency associated with PVC in situ was also investigated. Structured observations through two protocols were carried out and data about 343 PVC were analysed. Study II investigated nurses’ clinical reasoning regarding PVC management and cues and factors of importance in the decision10 making process were analysed. Nurses were observed in their daily work with focus on PVC management. They were interviewed both about the PVC decisions made in the observed situations and about factors influencing their reasoning regarding PVC management in general. The observations facilitated the interviews. Transcribed interview texts were analysed with content analysis. The results in study I showed that thrombophlebitis frequency was 7.0% and the nurses seemed to replace or remove PVC before any severe complications arose in accordance with clinical guidelines. Nurses partly adhered to national and local guidelines concerning site, size, documentation at the dressing and time in situ. Differences in guideline adherence were observed for wards with local or national guidelines, as well as for wards with different specialities. The results indicate that local guidelines may have an impact on guideline adherence but these results need further exploration. Analysis of interview texts in study II resulted in a category system with three main categories describing cues and factors of importance in the nurses’ clinical reasoning about PVC: the individual patient situation, the nurse’s work situation, and experience of PVC management. An overall theme was also revealed in the interview texts and the nurses balance in their clinical reasoning between avoiding or minimizing discomfort and pain for the patient and preventing complications from the PVC. The results from this licentiate thesis have implications for the education of nurses as well as during implementation of clinical guidelines. / <p>Note: The papers are not included in the fulltext online.</p><p>Paper I in thesis as accepted manuscript, paper II as manuscript.</p><p></p>

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