Research Method: It is assumed that practices and clinical judgment of nurses are largely influenced by applicable national healthcare systems and differences in roles of nurses. The scope of literature search in this research was limited to domestic literature available through Google Scholar and the web version of Igaku Chuo Zasshi (ICHUSHI). For the primary screening, articles containing keywords of "clinical judgment " and "visiting nursing" were retrieved from among those available as of the end of June 2017 and then narrowed down based on acceptance criteria. The authors read abstracts of the articles and selected subject articles. For the secondary screening, the authors read carefully the entire articles selected based on their abstracts and further narrowed down the subject articles. Then overview of the shortlisted articles was prepared. Finally, descriptions about clinical judgment were extracted by contexts and analyzed qualitatively and inductively.
Results:
- Researches on Clinical Judgment in Visiting Nursing Settings
First, 19 articles were retrieved by a keyword search with "clinical judgment" and "visiting nursing." Then a keyword search was conducted again with "visiting nursing" and "judgment" and 201 articles were retrieved. Of the retrieved articles, 12 articles that satisfied all the acceptance criteria were subjected to the review.
The subject articles were all qualitative researches except one questionnaire survey research. Among the 12 articles, only one presented a clear definition of "clinical judgment," and assessment in nursing processes and ad-hoc clinical judgment at patient' home were mixed in items of judgment by visiting nurses. Matters discussed in the articles highly varied, including specific judgments based on changes in elderly care receivers' conditions (e.g. possibility of bathing), components of visiting nurses' judgments, and analysis of judgment patterns.
- Specific Clinical Judgments in Visiting Nursing Settings
Specific clinical judgments were stated in six of the subject articles. Through analysis of the specific judgments, a process of visiting nurses' clinical judgment was revealed: (1) clinical nurses have "presuppositions" that guide them in what to observe in visiting nursing practices based on their theoretical and practical knowledge and experiences; (2) "inference (IF)" arises, in which nurses conduct integrated assessment through actual observation during visiting, evaluate more than one possible option, and create meaning of their practices; (3) nurses then make "decisions" on subsequent nursing practices; (4) they "implement" their decisions; and finally, nurses acquire further practical knowledge from "reflection" by capturing reactions of patients receiving care and attempt to deploy it in subsequent nursing processes.
For "presuppositions," practical knowledge specific to visiting nursing obtained through their own experiences were extracted in 13 categories, including "awareness of roles and calling as a visiting nurse," "limitation of visiting nursing," "flexible and impromptu coordination with other professionals," "comprehension of patient's family situation," "focus on relationship between patient and their family," and "comprehensive observation of physical conditions and lifestyle."
For "inference (IF)," categories of "considering," "inferring," and "nurse's own awareness" were extracted along with 22 sub-categories. The category of "considering" was composed of nine sub-categories: "consideration and respect of patient's will," "consideration of patient's lifestyle," "consideration of abilities of family care providers," "consideration of physical condition of family care providers," "consideration of conditions and judgment criteria," and "thinking about appropriate ways to ensure balance with other services."
The category of "inferring" included eight sub-categories including: patient-oriented sub-categories such as "inferring the patient's current condition by comparing with his/her ordinary condition," "inferring future changes in patient's condition," and "inferring effects of cares provided," and inference to project multiple possible options and possible future conditions from integrated patient data including "inferring livelihood of family care providers," "inferring characters and lifestyle of family care providers," and ""inferring impact of environment."
Sub-categories of "nurse's own awareness" were "recognizing calling and roles of a visiting nurse," "expressing visiting nurse's value set and judgment overtly," "recognizing visiting nurse's own difficult situation," and "feeling uncomfortable with doctor's or superior's judgment."
Nurses' choices regarding "inference (IF)" suggested a process of eventually selecting what is valuable to patients and their family, "making decision" on nursing practices, and "implementing" the decision.
No category was extracted regarding "reflection."
Discussion:
From the analysis of specific judgment situations, the process of clinical judgment composed of "presuppositions," "inference (IF)," "decision making," "implementation," and "reflection" was identified. Particularly, the finding of "inference (IF)" is significant.
For "presuppositions," visiting nurses instantaneously observe, recognize, and obtain necessary information from patient situations based on their experiences and practical knowledge. Due to the characteristics of visiting nursing settings, nurses observed patient's living environment and family, captured their individualities, and integrated observations, which are tactics specific to visiting nursing practices unlike nursing in hospitals.
For the sub-category of "nurse's own awareness" in the "inference (IF)" category, it was suggested that visiting nurses deliberate on more than one option (IF) from their own value set and experiences in inferring patient's situation, and make decisions through interaction with patients. This was the distinct characteristic of clinical judgment revealed by this research. The new finding is an important point in clinical judgment. In visiting nurses, there are visiting nurse's acts of "considering" in respect of patient and family wills and lifestyles and "inferring" based on possible options (IFs), which lead to their clinical judgment. This suggests that the thinking process of integrating various observations and establishing multiple options and projections is critical in instantaneously assessing patient's physical and mental state and their social resources (physical, human, and economic resources) and providing care appropriate for patient needs based thereon.
No category was extracted regarding "reflection." However, reflection of nursing practices and further study on reflection of nurses should be conducted in the future. Further, sharing experience-based knowledge (knowledge assets) of expert nurses will help inexperienced nurses compensate for their lack of experience-based knowledge, which cannot be obtained through their own reflection. It can also be opportunities for expert nurses to obtain new ideas through sharing. Thus, sharing of experience-based knowledge should play a significant role in securing care quality, and reflection is an important means of improving clinical judgment quality.
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