NU702 Unit 8 Clinical Judgment Analysis Example

"She Said She Understood": A Unit 8 Clinical Judgment Analysis of Deciding a Patient Is Ready to Go Home on Insulin

[Student Name]

Purdue University Global

NU702: Translating Evidence into Nursing Practice

Unit 8 Clinical Judgment Analysis

[Instructor Name]

[Date]

The hospital, patient, nurse and events are composite and illustrative; the models and sources cited are real.

The Situation

Mrs. Pruett, 78, was admitted with cellulitis and found to have uncontrolled type 2 diabetes. She started insulin glargine in the evening and insulin aspart with meals. On the morning of discharge, her nurse, an experienced clinician with five patients, three of them leaving that day, reviewed the pen with her and played the education video. Mrs. Pruett nodded and said she understood. The nurse checked "diabetes education complete" and the patient left at noon. On Sunday evening her neighbor found her drowsy, with a glucose of 41. She had taken a mealtime dose and then skipped supper because she was tired.

Two Models of Clinical Judgment

Tanner (2006) built her model from studies of how experienced nurses actually think: they notice something, make sense of it, act and then learn from what happened, and what they notice depends on what they already know about the patient and the pressures of the unit. The NCSBN Clinical Judgment Measurement Model divides the same thinking into six steps, which serve as the headings below, and adds the individual and environmental influences acting on each step (Dickison et al., 2019). This analysis uses the NCSBN steps because they make it easier to see exactly where the Friday decision went wrong.

Recognize Cues

The relevant cues were available. Mrs. Pruett wore thick glasses and squinted at the dose window. Her hands shook slightly when she held a cup. She lived alone; her son worked out of town during the week. She had mentioned that she often skipped supper when tired. None of these appeared in the nurse's discharge note. The cue the nurse recognized was the patient's statement that she understood.

The most visible cue was a nod, and it was the least informative one.

Analyze Cues

Analysis means connecting cues to what they could mean. Poor vision could lead to a dialing error. A tremor could make priming and injection unreliable. Living alone meant no one would notice early signs of a low. Skipping meals after a mealtime dose is a recognized trigger for hypoglycemia; reduced food intake was among the most common precipitants identified in national surveillance of insulin-related emergency visits (Geller et al., 2014). Taken together, the cues pointed to high risk. Because the cues were not recognized, this step did not happen.

Prioritize Hypotheses

The nurse's working hypothesis was that the patient was ready because she had been taught. A competing hypothesis, that she could not yet manage two kinds of insulin safely alone, was never formed. Under time pressure, nurses tend to anchor on the first plausible explanation, especially when it allows the task to be completed.

Generate Solutions and Take Action

Had the second hypothesis been considered, several solutions were available: asking Mrs. Pruett to dial and inject a dose while the nurse watched; simplifying the regimen with the prescriber, perhaps to basal insulin alone at first; involving her son by phone or video; arranging a home health nursing visit; and teaching what to do if she skipped a meal after a mealtime dose. The action taken was to complete the checklist.

Evaluate Outcomes

The model's final step asks whether the action achieved the expected result. In this case, evaluation came two days later in the emergency department. The unit had no mechanism, such as a follow-up call, to evaluate the decision before harm occurred.

Factors Outside the Nurse

The NCSBN model emphasizes that environmental factors shape judgment. Here they included a heavy discharge assignment, a late-morning teaching window, a checklist that asked whether teaching occurred rather than whether the patient could perform the task, and a prescriber order for a two-insulin regimen written without information about the patient's vision or living situation. The judgment was poor, but the system made a poor judgment likely.

Supports for Better Judgment

The planned DNP project addresses several of these factors, and the analysis suggests two additions.

First, the return demonstration converts the nod into an observable cue. A patient who cannot read the dose window or prime the pen will show it.

Second, a short cue prompt in the discharge navigator for patients on new insulin will ask four questions: Can the patient read the dose window? Can she prime and inject without help? Who will be with her in the first week? Does she eat regular meals? A "no" to any prompts the nurse to consider the alternative hypothesis and its solutions, including discussing a simpler regimen with the prescriber.

Third, moving supervised self-injection to the second day of insulin gives the nurse several chances to notice cues before discharge day.

Fourth, the 72-hour call creates the evaluation step the unit lacked.

Conclusion

The nurse's judgment that Mrs. Pruett was ready rested on her statement of understanding, the least reliable cue available. The NCSBN model shows that cues were not recognized, competing hypotheses were not formed and outcomes were not evaluated, all under conditions that favored a quick decision. Making cues observable, prompting alternative hypotheses and adding a follow-up call are system supports that make good judgment the easier path.

References

Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical Judgment Model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72-78. https://doi.org/10.3928/01484834-20190122-03

Geller, A. I., Shehab, N., Lovegrove, M. C., Kegler, S. R., Weidenbach, K. N., Ryan, G. J., & Budnitz, D. S. (2014). National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Internal Medicine, 174(5), 678-686. https://doi.org/10.1001/jamainternmed.2014.136

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. https://doi.org/10.3928/01484834-20060601-04