This article reviews the growing body of research on clinical judgment in nursing and presents an alternative model of clinical judgment based on these studies. Based on a review of nearly 200 studies, five conclusions can be drawn: (1) Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand; (2) Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns; (3) Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit; (4) Nurses use a variety of reasoning patterns alone or in combination; and (5) Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. A model based on these general conclusions emphasizes the role of nurses' background, the context of the situation, and nurses' relationship with their patients as central to what nurses notice and how they interpret findings, respond, and reflect on their response.

Thinking like a nurse: a research-based model of clinical judgment in nursing.

This study examines the effect of online reviews on new product sales for consumer electronics and video games. Analyses of panel data of 332 new products from Amazon.com over nine months reveal that the valence of reviews and the volume of page views have a stronger effect on search products, whereas the volume of reviews is more important for experience products. The results also show that the volume of reviews has a significant effect on new product sales in the early period and such effect decreases over time. Moreover, the percentage of negative reviews has a greater effect than that of positive reviews, confirming the negativity bias. Thus, marketers need to consider the distinctive influences of various aspects of online reviews when launching new products and devising e-marketing strategies.

The Effect of Online Consumer Reviews on New Product Sales

Background Effective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skills While a number of strategies have been implemented and tested to promote these skills, educators have not been able consistently to predict their development Self-regulated learning theory suggests that this development requires concurrent attention to both the cognitive and metacognitive dimensions of reasoning in nursing care contexts

Aims  This paper reports on a study to explore the impact of self-regulated learning theory on reflective practice in nursing, and to advance the idea that both cognitive and metacognitive skills support the development of clinical reasoning skills

Methods  Integrative review of published literature in social science, educational psychology, nursing education, and professional education using the Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resource Information Center (ERIC), and American Psychological Association (PsychInfo) Databases The search included all English language articles with the key words clinical reasoning, cognition, critical thinking, metacognition, reflection, reflective practice, self-regulation and thinking

Findings  Reflective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skill acquisition This skill acquisition is best accomplished through teaching–learning attention to self-regulation learning theory A critical analysis of the literature in the areas of critical thinking and reflective practice are described as a background for contemporary work with self-regulated learning theory It is apparent that single-minded attention to critical thinking, without attention to the influence of metacognition or reflection, is but one perspective on clinical reasoning development Likewise, single-minded attention to metacognition or reflection, without attention to the influence of critical thinking, is another perspective on clinical reasoning development While strategies to facilitate critical thinking and reflective practice have been used in isolation from each other, there is evidence to suggest that they are inextricably linked and come together with the use of self-regulated learning prompts

Conclusions  Students and practising nurses are able to improve their cognitive and metacognitive skills in clinical contexts by using self-regulated learning strategies The self-regulated learning model in nursing is offered to support teaching and learning of reflective clinical reasoning in nursing practice contexts

Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self‐regulated learning theory

Aims and objectives.  The aim of this paper was to review the current literature clinical decision-making models and the educational application of models to clinical practice. This was achieved by exploring the function and related research of the three available models of clinical decision making: information-processing model, the intuitive-humanist model and the clinical decision-making model.

Background.  Clinical decision making is a unique process that involves the interplay between knowledge of pre-existing pathological conditions, explicit patient information, nursing care and experiential learning. Historically, two models of clinical decision making are recognized from the literature; the information-processing model and the intuitive-humanist model. The usefulness and application of both models has been examined in relation the provision of nursing care and care related outcomes. More recently a third model of clinical decision making has been proposed. This new multidimensional model contains elements of the information-processing model but also examines patient specific elements that are necessary for cue and pattern recognition.

Design.  Literature review.

Methods.  Evaluation of the literature generated from MEDLINE, CINAHL, OVID, PUBMED and EBESCO systems and the Internet from 1980 to November 2005.

Results.  The characteristics of the three models of decision making were identified and the related research discussed.

Conclusions.  Three approaches to clinical decision making were identified, each having its own attributes and uses. The most recent addition to the clinical decision making is a theoretical, multidimensional model which was developed through an evaluation of current literature and the assessment of a limited number of research studies that focused on the clinical decision-making skills of inexperienced nurses in pseudoclinical settings. The components of this model and the relative merits to clinical practice are discussed.

Relevance to clinical practice.  It is proposed that clinical decision making improves as the nurse gains experience of nursing patients within a specific speciality and with experience, nurses gain a sense of saliency in relation to decision making. Experienced nurses may use all three forms of clinical decision making both independently and concurrently to solve nursing-related problems. It is suggested that O'Neill's clinical decision-making model could be tested by educators and experienced nurses to assess the efficacy of this hybrid approach to decision making.

/pdf/a-review-of-clinical-decision-making-models-and-current-3t43ef7qsy.pdf

A review of clinical decision making: models and current research

The clocks that time us. Physiology of the circadian timing system

This study described and compared the cognitive strategies of diagnostic reasoning used by junior nursing students (n = 15), senior nursing students (n = 13), and practicing nurses (n = 15). Verbal responses to three videotaped vignettes provided the data. Findings suggested that diagnostic reasoning processes of both nurses and nursing students can be described by a general model developed from studies of physicians. Subjects activated diagnostic hypotheses early in the encounter and used systematic information gathering to rule in and rule out hypotheses. With increased levels of knowledge and experience, there was a trend toward more systematic data acquisition and greater accuracy in diagnosis. The number of hypotheses activated, the earliness with which they were activated, and their diagnostic accuracy were task-specific components of the process, but selection of data-acquisition strategies appeared to be more generalizable across cases.

Diagnostic reasoning strategies of nurses and nursing students.

The purpose of this study was to describe selected temporal systemic responses to different enteral feeding schedules using an animal model, as one prerequisite for determining optimal delivery times for human enteral feedings. The effect of feeding schedules and time of day were examined relative to body weight and plasma glucose, insulin, glucagon, and corticosterone levels. Adult male Sprague-Dawley rats (N = 80) were used in a 4 x 4 randomized block design. Rats started the feeding schedules on Day 11 post-gastrostomy tube placement. The following feeding schedules, often used by humans, were tested: 24-hour enteral; 24-hour oral; 12-hour (rest time) enteral; and 12-hour (rest time) oral. Plasma was collected on Day 20. Despite very different feeding schedules, there were no statistical differences in weight gain, or plasma glucose and glucagon levels. Levels of insulin and corticosterone were significantly influenced by time of day and/or feeding group. Temporal pattern disruption was greatest in the rest-time fed enteral group. Both route and timing of enteral delivery modified metabolic hormone patterns.

Systemic responses to different enteral feeding schedules in rats.

These multiple measures of health were positive and encouraging. It was possible to integrate nursing actions into protocols for this long-term study. It is the author's belief that by strengthening the humane care and handling of animals the study results can more accurately reflect the discipline of nursing. Through such efforts, discipline-specific findings could be strengthened when an animal model is used, particularly in long-term or survival nursing research.

Animals, care, and nursing research.

Nurses frequently make decisions about when treatments and actions are performed. The nursing concern driving this review is the timing of nursing activities to optimize desired and minimize untoward effects. A nursing conceptual framework is proposed that highlights individual and environmental factors, as they relate to rhythmic responses; as well as places within the framework for nursing actions based on customary and usual temporal patterns.

Nursing chronotherapeutics: a conceptual framework.

Even with all the nutritional research conducted to date, it is not clear which enteral nutrition delivery and composition options are most physiologically sound. Glucocorticoid temporal patterns are reported to be shifted or disrupted with restricted feeding schedules, but because of intermittent sampling, temporal patterns have not been completely depicted. The purpose of this study was to characterize corticosterone temporal patterns while systematically varying selected enteral feeding options in a well-established nutritional animal model. A 2 x 2 x 2 x 2 randomized block experimental design was used in which enteral feeding schedules, delivery methods, kilocalorie levels (kcal), and fiber contents were systematically varied in rats (n = 80), and plasma corticosterone was measured by 125I radioimmunoassay. Blood samples were drawn hourly over 24 h. With cosinor analysis, 24-h and 12-h corticosterone rhythmic components were tested in each feeding group. Five of 16 feeding groups had a significant (p 0.05 < 0.10); 7 of these groups were on 24-h feeding schedules. When rhythmic components were detectable, groups receiving high-fiber formula displayed more uniform rhythm characteristics than did no-fiber groups. Only 1 group had a significant 12-h rhythmic component, and 1 showed a trend. Both were on 12-h, high-fiber restricted kcal feedings. In this small animal sample, no one enteral feeding option guaranteed a 24-h corticosterone pattern. The option coming closest was formula delivered on a 24-h schedule. This temporal pattern is one aspect to consider in enteral nutrition. The underlying mechanisms have yet to be elucidated.

How enteral feeding options influence corticosterone patterns in rats.

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