What is Nursing Judgment and how do I get it?
Written by Joana Z
Nursing judgment is a vague term. I’ve heard it used to describe times when nurses bring a situation to a doctor’s attention and thereby avert a crisis. Sometimes it’s not executing an order because we know it will cause more harm than good. Is it a gut feeling or book smarts? What is this power and how do I get it?!?
For me, it’s simply this: the difference between being task-oriented and an independent thinker. An easy example, you receive a patient who has metoprolol scheduled. Her heart rate is 52bpm. There are no parameters. Do you give the med because technically there is no order to hold it? Or do you use your knowledge of beta blockers to question this action and clarify with the MD before giving the med?
Sometimes it’s just simple textbook knowledge and sometimes it’s experience in certain situations. For example, the way a sepsis patient looks before they circle the drain. Perhaps, he hasn’t quite met the criteria for an RRT, but you’ve been there all day and have watched his vitals decline... he says he’s tired but that’s not quite it.
Experience is like a wound. You can help it along with dressings and ointments galore, but nothing can substitute for time. I know, “no sh*t Sherlock... I’m reading this blog to expedite that process.” I hear you, i hear you!! I have to say it though. There’s no way around it so swallow that patience pill and take it day by day. You will get there. But what are these metaphorical “dressings and ointments” to help the process along? I know it’s not my cutest analogy, but forgive me. I’m a nurse and we all have a weird sense of humor. It’s a job requirement.
So here are my real-world learning tips to help build nursing judgment. These are truly things I do, not just generic “be positive!” statements. Although do be positive- this is a tough job and you worked hard to get here!
- Take note of trends. Not every patient is the same, that’s true. But let’s look at an easy example: you notice dialysis patients tend to have “hold BP meds on day of dialysis” orders and your new admission does not. She is going to have hemodialysis today for hyperkalemia. Sometimes med orders are simply put in faster than other orders are. Maybe nephrology hasn’t come around yet but the primary MD put in orders first. It may be worth waiting a little while or just asking! Dialysis tends to lower the BP and giving anti-hypertensives can impair or even cut a dialysis session short if the patient’s BP cannot tolerate it. This is a bad outcome over a simple delay in order inputting.
- Be okay with a little embarrassment. I tend to remember things better when i was wrong. I asked a “dumb question” (in reality, there’s no such thing but you get my point), I got an irritated response from a doc, or perhaps another nurse picked up on something very quickly that I didn’t. Frankly, it’s that sense of embarrassment that makes the info stick in your brain. Just like you remember the answers to questions you got wrong on a test. I’m sure there’s a more technical reason, but as humans, we don’t like to make the same mistake twice so we remember things so much better when we were wrong before. So, get over your pride and take the experience as a good thing- you learned a lesson you will likely never forget again.
- Read the notes. As if you have an abundance of time (I know), read the progress notes, consults, and of course H&P. For the most part, the doctors will outline their thought process on there: “XX med for XX condition secondary to XX disease process.” Sometimes i even see comments such as “will order XX to check for XX” (ie. a CXR to check for consolidation) and then they never actually put the order in. They might thank you for the reminder! Then you have also learned that chest x-rays are useful for seeing consolidations. Win-win!
- Butt in. When i see a doctor (or speech therapist, PT/OT, etc) go into a room, i try to listen in. You can do something seemingly productive, like filing vital signs, if you don’t want to be awkward. Since they often have to explain things to nonmedical patients, it’s a great learning opportunity for you too! You might learn something new or even just how to explain a concept a little better next time for another patient.
- Get a certification. I am not arguing that being certified makes someone a better nurse. Just very simply: it keeps you learning-motivated. After nursing school, the last thing we want to do is keep studying. Ughhhhh. Take some time but not too much. Most certs require a certain amount of experience anyways. So don’t stress yourself being on a new unit and studying after work. When you start to feel comfortable on your unit (perhaps a year), look into a cert and get re-motivated. The longer you wait, the more you realize you can “get by” without a cert. And while that’s totally true, it just gets harder to want to get back to hitting the books.
- Rejoice and reinforce! The first day you get that sense of nursing judgment, yay!!! It’s natural to be doubtful though. Maybe it’s a weird order. The MD ordered a liter bolus for your very fluid overloaded heart failure patient. It seems the order was meant for your sepsis patient. Run it by your coworkers. Reinforcement builds confidence! If you’re wrong, oh well! A good doc will explain to you their thought process and you can cache it into your knowledge bank. If you’re right, you may have averted a negative patient outcome!! Is there really a loss in either scenario?
So yes, nursing judgment comes from experience. That wasn’t rocket science, I know. It comes with exposure and you have to find ways to make the most of it. I almost think of it like parenthood. New parents are always scared. There is fear in not knowing what to do and messing up. But eventually a parent starts to know which cries means wet diaper versus hunger or when their baby isn’t acting like themself. You wouldn’t call them a bad parent for not knowing these things on the very first day, they just need the experience! Perhaps my analogy game isn’t on point today, but hopefully you get the idea!Those things that were hard in school will get easier in the real world. The repetition and reinforcement will make lab values, pharmacology and protocols stick. Those are building blocks to understanding a disease process, treatments, and eventually more complex concepts. Nursing judgment builds simultaneously with each of those steps. It might start with a small catch, like getting a hold parameter for metoprolol, but it grows from there. Be okay with a swing and a miss- you will have learned something! Every question you ask benefits the patient. You got this nurse!!