Although every nursing specialty has its challenges, correctional nursing involves complex situations that can appear simple, but aren’t. There are many unknown factors in sizing up a situation. Correctional nurses are most often the first healthcare staff to review the patient complaint/situation. Thus, during patient triage, the nurse must make a fairly autonomous judgment on what needs to be done and who needs to be involved.

Here are five reasons clinical judgment is especially important for correctional nurses:

1. Incarcerated persons are legally entitled to a clinical judgment whenever attention to a health concern is requested.
2. Nurses most often are the first health care provider to see a detainee or inmate for any health concern. The nurse’s clinical judgment will determine if the person needs an evaluation by another health care provider, and if so, when that evaluation should occur.
3. Ineffective clinical judgment may adversely affect the patient at the time of evaluation, and potentially in the future. It may affect other nursing staff and providers’ judgments and actions as they continue to care for the patient. It can also affect the relationship with custody staff.
4. Correctional nurses must make judgments in a wide array of situations from minor discomforts to life-threatening emergencies.
5. And, they must do it while navigating the correctional environment with safety, location, and resource challenges.

How Clinical Judgments are made

Understanding how clinical decisions are made can help correctional nurses to improve their clinical judgment. Much work in the area of clinical decision-making has taken place in the medical profession, but can be applied to nursing.

Experts suggest that clinical decision-making is an interplay of two types of thinking. On the one hand, it is a reflexive and intuitive process based on pattern recognition.  On the other hand, decision-making involves a deliberative analytical process based on reasoning through the diagnostic data. Let’s take a closer look at each of these thinking processes.

The reflexive, intuitive process is called System I Thinking; sometimes termed non-analytic thinking. This thinking relies heavily on the practitioner’s experience and inductive logic. Here, the practitioner recognizes a group of presenting features as a pattern that suggests the diagnosis. This is a holistic process that can involve conscious or unconscious thinking. Mental shortcuts, or heuristics, help in the pattern recognition, making System I Thinking a faster, more automated, and emotionally driven process.

System II thinking, on the other hand, is deliberate and rule-based analytic thinking. This thinking involves greater cognitive effort and more mental resources. Here the practitioner rationally tests out a hypothesis using a logical and deliberative process through extensive data gathering and sorting. Novice clinicians with little experience must rely on this method more heavily while developing capacity for System I Thinking.

Experienced nurses tend to use System I (intuitive) Thinking when they recognize the patient presentation and use System II (rule-based) Thinking when no pattern is recognized. The difficulty lies in those presentations that have some – but not all — elements of a recognizable pattern. For example, nurses may be overconfident in their pattern recognition skills or their understanding of a particular patient and settle on a working diagnosis early, without seeking corroborating evidence. This can happen in a correctional setting where patients who have been found to feign medical conditions to seek secondary gain subsequently present with legitimate symptoms that are disregarded in future encounters.

Hypothesis testing is a primary way that nurse experts move between System I (intuitive) and System II (rule-based) Thinking to arrive at a clinical determination. Here the clinician considers possible scenarios to explain the presentation, usually starting with a worst-case scenario, and the uses patient questioning and physical assessment to rule out various options. Moving through this process, the expert nurse intuitively recalibrates the probability of various alternatives. An experienced and knowledgeable nurse can perform this quickly, while a novice must be more slow and methodical, relying heavily on System II analytical thinking.

Unfortunately, personal and system issues can negatively affect the clinical judgment process. Fatigue, emotional state, and past experience with a patient can negatively impact even well-developed decision-making skills. External factors such as environmental chaos or team communication issues can also dramatically affect these two internal processes. Correctional nurses need to be aware of these internal and external factors in those situations when sound clinical judgement is imperative.

This Clinical Judgment post is based upon The Correctional Nurse Educator class entitled Clinical Judgment for the Correctional Nurse.