Professional support as a facilitator to the development of Iranian nurses' clinical judgment: A content analysis.

BACKGROUND: Nurses' clinical judgment development is essential for the professional nursing practice. The aim of this study was to explore the facilitators to the development of Iranian nurses' clinical judgment.
MATERIALS AND METHODS: A qualitative design using conventional content analysis method was employed in the study. A purposive sample of 24 participants was recruited from three hospitals located at Sanandaj, Iran. Study data were collected in 2013 by using semi-structured individual interviews. A content analysis approach was used to analyze the study data and MAXQDA was used for coding and categorizing the data.
RESULTS: The main theme of the study was "professional support as a facilitator to the development of nurse's clinical judgment." The sub-themes of this main theme included "provision of direct support to nurses" and "provision of clinical judgment resources." The first sub-theme consisted of different types of managerial, clinical, educational, and social supports. The two categories of the second sub-theme included the provision of necessary clinical evidence and the provision of medical equipments.
CONCLUSION: The study findings highlighted the importance of providing nurses with adequate professional support for facilitating the development of their clinical judgment.

INTRODUCTION

Developing nurses’ clinical judgment is a key characteristic of professional nursing practice.[12] One of the most important factors contributing to nurses’ ability to reflect on practice is the use of reflection-related theories[3] such as Tanner's clinical judgment model (2006). According to Tanner, nurses consider context and background and communicate with patients to collect critical information concerning the patient and the environment. Then, they use reasoning and intuition to reflect-in-action and reflect-on-action and interpret the gathered information. In reflection-in-action, nurses make clinical judgments based on patients’ responses to the immediate situation.[4] On the other hand, in reflection-on-practice, nurses use their own knowledge and experience for the purpose of making clinical judgment. However, the availability of a supportive context[4] and adequate professional support for nurses[567] are the basic requirements for the successful application of clinical judgment development theories.

There is a vast literature on the factors contributing to the development of nurses’ clinical judgment. Broom et al. conducted a qualitative study on 25 Australian oncology consultants and nurses and found that the use of clinical evidence facilitated the maintenance of professional autonomy and helped nurses make accurate clinical judgments.[7] Storm-Versloot et al. also found that adherence to postoperative body temperature measurement guideline significantly improved nurses’ clinical judgment.[8] Broom et al.[7] and Stenner and Courtenay[9] reported that providing nurses with clinical evidence and guidelines is a kind of clinical and educational support that helps improve nurses’ clinical judgment.

Another factor contributing to the development of nurses’ clinical judgment is having access to organizational and social support. According to Trybou et al., organizational support can significantly improve nurses’ professional performance.[10] Kalicińska et al. found that social support provided by supervisors and nurse managers decreased hospice nurses’ and midwives’ professional burnout, increased their professional interest, and helped them maintain their professional autonomy.[11] Alstveit et al. also reported social and professional supports as predictors of midwives’ and female nurses’ personal achievement and professional success.[12] Thompson and Stapley reported that nurse preceptors’ and mentors’ educational support plays an important role in improving nurses’ clinical judgment.[13] Finally, according to Stenner and Courtenay, intra- and inter-professional supports provided by peers, physicians, and other healthcare professionals improves nurses’ confidence in their ability to provide care in a professional environment.[9]

In Iran, there is a lack of powerful supportive working condition for nurses.[14151617] Mardani et al. conducted a qualitative study on a group of Iranian nurses and found that lack of peer support was a clinical challenge to them. Nurses participating in their study emphasized a great need for creating a nonjudgmental supportive working environment for nursing staffs.[15] Adib-Hajbaghery and Aminoroayaei-Yamini found that professional support – including occupational, financial, spiritual, and legal supports – for nurses facilitated the process of clinical decision-making. On the other hand, they reported that lack of a supportive environment had resulted in unfair prejudices about nurses, decreased their self-confidence, and increased their passivity.[16] Consequently, Iranian nurses face different professional challenges which weaken their perceived support.[17] Nonetheless, previous studies conducted in Iran mainly dealt with the concepts related to clinical judgment and professional support. Accordingly, facilitators to the development of Iranian nurses’ clinical judgment have still remained unknown.

Despite the wealth of studies on professional support and clinical judgment, there is still a wide knowledge gap regarding factors that facilitate the development of nurses’ clinical judgment. A large number of the studies conducted are quantitative ones which address only specific aspects of facilitators to clinical judgment development. We conducted this qualitative study to reduce this knowledge gap. The aim of this study was to explore the facilitators to the development of Iranian nurses’ clinical judgment.

MATERIALS AND METHODS

The purpose of this study was to describe the facilitators of the Iranian nurses’ clinical judgment development. With regard to the aim of this research, a qualitative research design with a conventional content analysis approach was used, which offers instruments for examining the experiences and results in the acquisition of valuable and in-depth data from the participants.[1819] Content analysis is a systematic coding and categorizing approach that can be used to explore large amount of textual information in order to ascertain the trends and patterns of words used, their frequency, their relationships, and the structures and discourses of communication.[20] In conventional content analysis, the coding categories are derived directly from the text data[20] and this allows researchers to understand social reality in a subjective but scientific manner.[20] The present study was conducted in 2012–2013.

We recruited a purposive sample of 14 staff nurses, 2 nurse managers, 2 nurse educators, 2 physicians, 2 fourth-year students, and 2 hospitalized patients and their family members. The study participants were selected from different hospital wards including medical-surgical, intensive care, emergency, psychiatric, dialysis, and post-delivery units and the operating rooms affiliated to three teaching hospitals located in Sanandaj, Iran. The first participant recruited to the study was a practicing nurse. The remaining 23 participants were selected based on the developing concepts and categories.

The study was approved by the ethics committee of Tarbiat Modares University, Tehran, Iran. We informed the study participants about the aim of the study and ensured them that both participation in and withdrawal from the study were voluntary. We also guaranteed the confidentiality of their personal information. Finally, we obtained a written informed consent from each participant immediately before starting data collection.

Data collection was performed by the semi-structured individual interview method. Initially, we conducted a literature review to develop a primary interview guide. Then, we revised the interview guide based on the comments provided by a panel of experts consisting of nursing faculties. Thereafter, we pilot-tested the interview guide by conducting two pilot interviews.

Accordingly, the final version of the interview guide was prepared for the main interviews. The interview guide consisted of both general and specific questions [Table 1]. Probing questions were also used to obtain in-depth information regarding participants’ experiences. Interviews were arranged according to the participants’ preferences and lasted for 30–60 min. Five participants were interviewed twice. Accordingly, we performed 29 interviews in total. All the interviews were recorded by using a digital sound recorder. Data collection was continued until reaching data saturation. Data saturation is a state in which all the developed concepts and categories are fully developed and no new information is obtained from the data.[2122]

Table 1

The interview guide

Study data were analyzed by using the conventional content analysis method.[2324] Interviews and field notes constituted the units of analysis. Immediately after each interview, we transcribed the interview content verbatim by using the Microsoft Office Word software. Each transcript was then read and reviewed many times to obtain a general understanding of the content. Accordingly, we identified, condensed, and coded the meaning units. We constantly compared and abstracted the generated codes and concepts and categorized them according to their similarities and differences. Sub-categories and categories were also compared constantly and categorized to constitute the sub-themes and main theme of the study. We used MAXQDA 10 for managing the study data.

Different forms of trustworthiness have been considered. We employed the constant comparison, active listening, prolonged engagement with data, immersion in data, as well as data source and investigator triangulation techniques for enhancing the credibility of the study findings. To ensure the dependability of the findings, we documented and kept a record of our analytic activities for the purpose of audit trailing. The confirmability of the study findings was assured by using peer-checking and member-checking techniques. We also strived to recruit a sample with maximum variation to improve the transferability of the study findings.

RESULTS

The main theme of the study was “professional support as a facilitator to the development of nurses’ clinical judgment.” The two sub-themes of the main theme included “provision of direct support to nurses” and “provision of clinical judgment resources.” These sub-themes and the related categories and sub-categories are shown in Table 2 and are explained below.

Table 2

Main theme and the related sub-themes, categories, sub-categories, and coding samples

Providing direct support to nurses

The sub-theme “providing direct support to nurses” consisted of four main categories including “managerial support,” “clinical support,” “educational support,” and “social support.” The availability of these types of support facilitated the development of nurses’ clinical judgment.

Hospital managers facilitated the development of nurses’ clinical judgment by providing them with opportunities to engage in clinical judgment activities. A matron stated,

“We have developed the independent nursing interventions guideline to help nurses engage in clinical judgment activities.”

Nurse managers also provided nurses with educational and research-related supports to enhance their self-confidence in making accurate clinical judgments. A matron said,

“My educational support for nurses enhanced their clinical judgment skills.”

Moreover, hospital administrators and senior managers also supported nurses to facilitate the process of clinical judgment and help them maintain their professional autonomy in making judgments. A senior nurse manager mentioned,

“In the Iranian Nursing Organization, we are striving to attract legal support for nurses to empower them in making independent clinical judgments.”

Clinical support that was related to the support provided by mentors, peers, colleagues, physicians, and other healthcare professionals also helped in enhancing nurses’ self-confidence and motivation for participating in clinical judgment activities. A practicing nurse said,

“When physicians and supervisors support and encourage us, we have stronger motivation for making accurate judgments.”

Educational support was related to the development and implementation of effective educational interventions aiming at enhancing nurses’ clinical judgment. Nurse managers, supervisors, and staff nurses supported each other and facilitated the process of independent clinical judgment through making effective educational interventions and conducting continuing education programs. An educational supervisor mentioned,

“We supported nurses in conducting self-learning and continuing education programs in the area of clinical judgment.”

Nurse educators also supported nurses during their clinical education. A clinical instructor said,

“We are striving to develop joint clinical education programs involving both medical and nursing students.”

Mutual cooperation of clinical instructors and staff nurses also facilitated the process of clinical judgment. A staff nurse mentioned,

“To develop nurses’ clinical judgment, clinical instructors and practicing nurses share their knowledge and expertise with each other.”

Social support refers to the cooperation of patients, their families, and other healthcare consumers with nurses in the process of making clinical judgment. When patients and their families recognized and respected nurses as independent healthcare professionals, nurses felt having considerable confidence in their own ability for making independent clinical judgment. A mother of a child patient stated,

“I believed in the diagnosis established by the nurse and told the doctor that nurse's explanations exactly fit my problem. The doctor respected nurse's points of view. That nurse usually made accurate judgments.”

Provision of clinical judgment resources

The second sub-theme of the study was “provision of clinical judgment resources.” This was a broad sub-theme consisting of two categories including “provision of necessary clinical evidence” and “provision of medical equipments.” Clinical evidence and medical equipments were the vital resources for making accurate clinical judgments.

Provision of necessary clinical evidence that included easy access to clinical guidelines, research papers, textbooks, clinical and laboratory findings, and experts’ opinions facilitated the development of nurses’ clinical judgment. Nurses believed that having clear evidence for making accurate clinical judgments provides them with strong legal and scientific support. A practicing nurse said,

“We asked our head nurse to provide us with internet services to be able to search for necessary clinical evidence.”

Easy access to clinical evidence helped nurses integrate and use their clinical judgment skills according to the immediate situation. The integration of clinical evidence with other clinical judgment resources such as knowledge, experience, and reasoning helped nurses interpret the gathered data and make accurate judgments. A nurse manager stated,

“We are currently trying to provide nurses with updated guidelines. Such guidelines can guide nurses’ clinical judgment practice.”

Easy access to clinical evidence also facilitated nurses’ engagement in clinical judgment activities. A head nurse said,

“I tried to equip the ward library with evidence such as books, research papers, and guidelines so that nurses could refer to them while caring for patients and participating in in-hospital educational programs.”

Provision of medical equipments included the modern medical equipments needed for clinical judgment (such as monitoring devices and diagnostic tools), which facilitated the process of judgment making. A practicing nurse mentioned,

“Equipping the emergency ward with hi-tech monitoring devices improved our ability to establish accurate nursing diagnoses. Consequently, we were able to cooperate with physicians in making joint clinical judgments.”

DISCUSSION

The aim of this study was to explore the facilitators to the development of Iranian nurses’ clinical judgment. The study findings demonstrated that professional support had a pivotal role in developing nurses’ clinical judgment. The types of professional support differed according to the immediate situation and context. Benner (cited in Rodríguez-Maribona, 2010)[25] reported that experienced nurses need to base their practice on patient's condition and the immediate situation. Rodríguez-Maribona[25] reported that facilitating factors affect nurses’ response to the ever-changing condition of patients and environment.

Our findings revealed that managerial support helped facilitate the development of nurses’ clinical judgment.[25] Karanikola et al. found that improvement of nursing management as well as physicians’ support for nurses greatly contributed to nurses’ clinical judgment and professional autonomy.[26] According to Gray-Stanley et al. and Hutchinson and Janiszewski Goodin,[27] hospital managers can help nurses develop their clinical judgment by providing them with a safe and supportive working environment.

The study findings also revealed that clinical support provided by mentors, peers, colleagues, physicians, and other healthcare professionals enhanced nurses’ self-confidence and motivation for participating in clinical judgment activities. Gillespie and Peterson found that experienced nurses’ and mentors’ support improved novice nurses’ self-confidence and clinical decision-making ability.[28] We also found that educational support – through making effective educational interventions and conducting continuing education programs – helped facilitate the development of nurses’ clinical judgment. Boese et al. reported that when supported strongly by mentors and experienced healthcare professionals, educational interventions such as simulation can improve nurses’ ability in making accurate clinical judgments.[29] Boyd (2008) also found that supporting learners educationally by using the Kolb's theory of reflective practice significantly improved dental students’ reflective judgment.[30] Foster et al. reported that continuing education programs can improve nurses’ ability in making accurate clinical judgments. Consequently, health and education authorities need to provide nursing students and practicing nurses with educational guidelines, as well as conduct a close clinical supervision to help them improve their own clinical judgment.[31]

We found that the provision of necessary clinical evidence was an important source of support for developing nurses’ clinical judgment. Simpson and Courtney found that providing nursing students with evidence necessary for evidence-based practice improved their reasoning, critical thinking, and clinical judgment-making abilities.[32] Wøien and Bjørk also found that nurses who referred to clinical guidelines made clinical judgments that were more accurate.[33] We also found that nurses used different types of evidence according to patients’ condition and the immediate situation. Ease of access to the necessary evidence was a determining factor in deciding what types of evidence should be used. For example, if there were no clinical guidelines for guiding nurses’ practice, they were compelled to refer to physicians’ opinions. Vugt et al. reported that clinical and radiographic findings were among the evidence that the nurses used for diagnosing pneumonia and making clinical judgments.[34] Dadgaran et al. also found that nurses used information acquired from the internet for expanding their knowledge and promoting their professional clinical practice.[35]

Another source of support for developing nurses’ clinical judgment was the availability and accessibility of modern medical equipments. Burritt and Steckel noted that creating a safe clinical environment and providing necessary equipments help facilitate nurses’ professional development.[1]

The study findings suggest that professional support – consisting of managerial, clinical, educational, social, and evidence-related supports – provided for nurses facilitates the development of their clinical judgment. Given the diversity of the facilitators, nurse managers need to develop and implement comprehensive strategies for developing nurses’ ability in making accurate and independent clinical judgments. Moreover, nurses need to be informed about different types of support that facilitate the development of their clinical judgment. This study provided primary evidence concerning the facilitators to the development of Iranian nurses’ clinical judgment. Further studies are needed for producing ample conclusive evidence.