Abstract

Clinical judgment and decision-making are essential competencies in nursing, emerging as expanding learning areas of nursing education. Aiming to characterize the types of clinical judgment and decision-making adopted by nursing students in clinical education, we designed a qualitative, exploratory and descriptive study, with data collection obtained through documental analysis of nursing student’s reflective journals, in clinical education settings. Data analysis was performed according to Bardin using the webQDA software. Thirty-four students participated in the study, while attending the Clinical Learning Curricular Unit: Caring for Clients with Increased Vulnerability and Families in Transition, producing a total of 40 reflective journals. Of the 248 identified registration units, we highlight the evaluation decision-making with 45 registration units and the intervention decision-making, with 55 registration units. It is concluded that student´s reflections in the context of clinical teaching, are mainly about the assessment of the care situation and the decision-making related to the action. This study is intended to guide the learning of these competencies in nursing education.

Key words:
Students, Nursing; Clinical training; Decision making; Qualitative study; Education, Nursing

Introduction

The increase in the clients’ acute conditions, the reduction in the hospital length of stay and the constant advances in technology require nurses to make decisions, from an evidence-based perspective of practice, about the care to be provided. Clinical decision-making skills portray a complex mental process in which data are collected, interpreted and evaluated to select the most appropriate action, supported by scientific evidence¹1 Clemett VJ, Raleigh M. The validity and reliability of clinical judgement and decision-making skills assessment in nursing: a systematic literature review. Nurse Educ Today 2021; 102:104885.^,22 Hensel D, Billings DM. Strategies to teach the National Council of State Boards of nursing clinical judgment model. Nurse Educ 2020; 45(3):128-132.. Clinical judgment, as a global assessment of the care situation, is understood as the observed result of decision-making²2 Hensel D, Billings DM. Strategies to teach the National Council of State Boards of nursing clinical judgment model. Nurse Educ 2020; 45(3):128-132.. Clinical judgment and decision-making competencies are recognized internationally as being crucial³3 Baxter PE, Boblin S. Decision making by baccalaureate nursing students in the clinical setting. J Nurs Educ 2008; 47(8):345-350.^,44 Marques MFM. Decision making from the perspective of nursing students. Rev Bras Enferm 2019; 72(4):1102-1108. for nursing practice and reflect an expected standard of university graduates in Portugal¹1 Clemett VJ, Raleigh M. The validity and reliability of clinical judgement and decision-making skills assessment in nursing: a systematic literature review. Nurse Educ Today 2021; 102:104885.^,55 Cantante APDSR, Fernandes HIVM, Teixeira MJ, Frota MA, Rolim KMC, Albuquerque FHS. Cien Saude Colet 2020; 25(1):261-272.. Thus, nursing education has been responsible for developing the capacity of nurses to make good clinical judgment and make appropriate clinical decisions⁶6 Farcic N, Barac I, Lovric R, Pacaric S, Gvozdanovic Z, Ilakovac V. The influence of self-concept on clinical decision-making in nurses and nursing students: a cross-sectional study. Int J Environ Res Public Health 2020; 17(9):3059.. The initial nursing training aims to allow the students to acquire specific knowledge and skills so they can make clinical judgments and make effective decisions in clinical practice²2 Hensel D, Billings DM. Strategies to teach the National Council of State Boards of nursing clinical judgment model. Nurse Educ 2020; 45(3):128-132.^,77 Ciftci B, Gok S, Aksoy M, Avsar G. The effect of internships on clinical decision making and professional values of nursing students. Int J Caring Sci 2020; 13(2):1230-1239.^,88 Tesoro MG, Simmons AM, Barros ALBL, Lopes CT, Guandalini LS, Cruz EDA, Maurício AB. Effects of clinical reasoning prompts on nursing students' clinical judgment for a patient experiencing respiratory distress. Int J Nurs Knowl 2021; 32(1):37-43..

At Escola Superior de Enfermagem de Lisboa (ESEL), the Study Program (called Curso de Licenciatura em Enfermagem [CLE]) predicts a four-year course to attain a degree in Nursing: the first two years comprising theoretical and theoretical-practical teaching and the remaining two years of Clinical Teaching (CT). Considering that judgment and decision-making are more influenced by the nurses’ background than objective data about the care situation⁹9 Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ 2006; 45(6):204-211., ESEL has developed educational strategies to enable the student to acquire these competencies. The Study Plan includes a curricular unit (CU) called Decision-Making Process in Nursing (PTDE, Processo de Tomada de Decisão em Enfermagem), which focuses on the development of clinical judgment and decision-making, among others, and the CTs whose learning outcomes comprise the training of the student for clinical judgment and decision-making in a real-life context¹⁰10 Portugal. Despacho nº 6687/2017, de 22 de julho de 2017. Alteração ao plano de estudos do curso de licenciatura em Enfermagem da Escola Superior de Enfermagem de Lisboa. Diário da República 2017; 22 de julho..

The CT is a privileged time to learn these competencies¹¹11 Alarcão I, Rua M. Interdisciplinaridade, estágios clínicos e desenvolvimento de competências. Texto Context - Enferm 2005; 14(3):373-382.

12 Lam CK, Schubert CF, Herron EK. Evidence-based practice competence in nursing students preparing to transition to practice. Worldviews Evid Based Nurs 2020; 17(6):418-426.^-1313 Visiers-Jiménez L, Suikkala A, Salminen L, Leino-Kilpi H, Löyttyniemi E, Henriques MA, Jiménez-Herrera M, Nemcová, J, Pedrotti D, Rua M, Tommasini C, Zeleníkova R, Kajander-Unkuri S. Clinical learning environment and graduating nursing students' competence: a multi-country cross-sectional study. Nurs Health Sci 2021; 23(2):398-410.. Clinical teaching involves a process of construction of professional knowledge, set in a certain context, in which the student has the theoretical knowledge as references in relation to the experience of skilled professionals who guide them¹¹11 Alarcão I, Rua M. Interdisciplinaridade, estágios clínicos e desenvolvimento de competências. Texto Context - Enferm 2005; 14(3):373-382. and the reflection on their experiences in practical clinical situations¹²12 Lam CK, Schubert CF, Herron EK. Evidence-based practice competence in nursing students preparing to transition to practice. Worldviews Evid Based Nurs 2020; 17(6):418-426.. In this context, nursing students must be taught and practice how to make accurate and safe clinical judgments, as well as to make decisions about the care situation in which they are involved⁸8 Tesoro MG, Simmons AM, Barros ALBL, Lopes CT, Guandalini LS, Cruz EDA, Maurício AB. Effects of clinical reasoning prompts on nursing students' clinical judgment for a patient experiencing respiratory distress. Int J Nurs Knowl 2021; 32(1):37-43..

Providing students with structures in which they can reason and reflect on this reasoning, clinical judgments and decision-making can promote the identification and correction of cognitive errors to maintain client safety⁸8 Tesoro MG, Simmons AM, Barros ALBL, Lopes CT, Guandalini LS, Cruz EDA, Maurício AB. Effects of clinical reasoning prompts on nursing students' clinical judgment for a patient experiencing respiratory distress. Int J Nurs Knowl 2021; 32(1):37-43.. Aiming to maximize this reflective learning¹⁴14 Bayoumy HMM, Albeladi GA. Clinical judgment skills among junior-level nursing students enrolled in adult health nursing courses: errors and risk level classification. Nurse Educ Pract 2020; 48:102888., one of the pedagogical methods used is the creation of the reflective journal. It is a written document that allows the student to acquire competencies in nursing, experiential learning and learning about themselves, enhancing their learning skills through reflection¹⁵15 González-García M, Lana A, Zurrón-Madera P, Valcárcel-Álvarez Y, Fernández-Feito A. Nursing students' experiences of clinical practices in emergency and intensive care units. Int J Environ Res Public Health 2020; 17(16):5686.. When faced with complex situations, reflection allows the student to differentiate between several factors that influence it and make a clinical judgement, a decision or draw up an action plan¹⁶16 Bulman C, Schutz S. Reflective practice in nursing. Oxford: John Wiley & Sons; 2013..

When providing care, given the uniqueness of the situation, the nursing student must learn the appropriate time to act, in order to know how to decide on the current care situation. This judgment and decision-making constitute competencies that are developed throughout the initial nursing training and continue during the professional training process. The focus on this thematic represents a significant area in international research¹1 Clemett VJ, Raleigh M. The validity and reliability of clinical judgement and decision-making skills assessment in nursing: a systematic literature review. Nurse Educ Today 2021; 102:104885.^,66 Farcic N, Barac I, Lovric R, Pacaric S, Gvozdanovic Z, Ilakovac V. The influence of self-concept on clinical decision-making in nurses and nursing students: a cross-sectional study. Int J Environ Res Public Health 2020; 17(9):3059.^,1414 Bayoumy HMM, Albeladi GA. Clinical judgment skills among junior-level nursing students enrolled in adult health nursing courses: errors and risk level classification. Nurse Educ Pract 2020; 48:102888.^,1717 Bektas I, Bektas M, Ayar D, Kudubes AA, Sal S, Ok YS, Celik I. The predict of metacognitive awareness of nursing students on self-confidence and anxiety in clinical decision-making. Perspect Psychiatr Care 2021; 57(2):747-752.

18 Marino MA, Andrews K, Ward J. Clinical decision making at the bedside. Nurs Clin North Am 2020; 55(1):29-37.

19 Phillips BC, Morin K, Valiga TMT. Clinical decision making in undergraduate nursing students: A mixed methods multisite study. Nurse Educ Today 2021; 97:104676.^-2020 Thompson C, Stapley S. Do educational interventions improve nurses' clinical decision making and judgement? A systematic review. Int J Nurs Stud 2011; 48(7):881-893., albeit with little impact at the national level⁴4 Marques MFM. Decision making from the perspective of nursing students. Rev Bras Enferm 2019; 72(4):1102-1108.^,2121 Marques MFM, David CLAHP, Santos MAFD, Neves SCDS, Pinheiro MJF, Leal MTS. Perceptions of senior nursing students regarding clinical decision-making. Rev Bras Enferm 2021; 4(1):e20200921.^,2222 Marques FM, Pinheiro MJ, Alves PV. Estudante de enfermagem em ensino clínico: estudo qualitativo da tipologia de decisão. New Trends in Qualitative Research 2021; 8:121-129.. This is why the UC PTDE pedagogical team has reflected on the mobilized contents and the pedagogical strategies used to make the learning process of clinical judgment and decision-making an effective one throughout the initial nursing training.

The CT in the final year of the course covers several complex healthcare environments to provide learning opportunities and prepare the student for the professional context¹²12 Lam CK, Schubert CF, Herron EK. Evidence-based practice competence in nursing students preparing to transition to practice. Worldviews Evid Based Nurs 2020; 17(6):418-426.^,1515 González-García M, Lana A, Zurrón-Madera P, Valcárcel-Álvarez Y, Fernández-Feito A. Nursing students' experiences of clinical practices in emergency and intensive care units. Int J Environ Res Public Health 2020; 17(16):5686., in which they will soon take part. Hence, this study was carried out aiming at characterizing the types of clinical judgment and decision-making of nursing students attending the 4^th year of clinical education in order to outline pedagogical strategies to facilitate their competence development. The following research question guided the research: “What is the typology of clinical judgment and decision-making that nursing students attending the 4^th year of the CLE used in the learning activities developed in the context of clinical teaching?”.

Methods

The present research constitutes a qualitative, exploratory and descriptive study, which includes a comprehensive knowledge format, highlighting interpretation as a key feature in the investigation. The recommended protocol for qualitative research SRQR (Standards for Reporting Qualitative Research) was used ²³23 O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med 2014; 89(9):1245-1251..

The qualitative research plays an important role in ensuring a subjective perspective of the stories narrated by different social actors²⁴24 Gonçalves JP, Marques CG, Gonçalves SP. Manual de investigação qualitativa - conceção, análise e aplicações. Lisboa: Pactor; 2021., widely used in health professions, and specifically in nursing¹⁵15 González-García M, Lana A, Zurrón-Madera P, Valcárcel-Álvarez Y, Fernández-Feito A. Nursing students' experiences of clinical practices in emergency and intensive care units. Int J Environ Res Public Health 2020; 17(16):5686.^,2525 Squires A, Dorsen C. Qualitative research in nursing and health professions regulation. J Nurs Regul 2018; 9(3):15-26.. In an attempt to characterize the typology of the nursing student’s decision-making, data collection was carried out through the documental analysis of reflective journals prepared by senior-year nursing students in clinical education. The present study was supported by an investigation carried out in 2010, with participants in a similar clinical context and using the same theoretical framework of analysis⁴4 Marques MFM. Decision making from the perspective of nursing students. Rev Bras Enferm 2019; 72(4):1102-1108., so that similarities and differences in the findings could be identified²⁵25 Squires A, Dorsen C. Qualitative research in nursing and health professions regulation. J Nurs Regul 2018; 9(3):15-26.. The team of researchers consisted of three faculty professors from the PTDE CU.

The study participants comprised 4^th-year students of CLE attending the clinical CU ‘Caring for Clients with Increased Vulnerability and Families in Transition (ECCCVAFT)’, in the academic year of 2020-2021, taking place between January 4^th and April 23^rd, 2021 This clinical teaching CU encompasses three different learning contexts: mental health and psychiatry; other vulnerabilities; and elderly in the community. The reflective journal was one of the documents to be prepared by students in this clinical teaching CU, in different contexts²⁶26 Escola Superior de Enfermagem de Lisboa (ESEL). Guia orientador da unidade curricular ensino clínico: Cuidar de clientes com vulnerabilidade acrescida e famílias em transição. Lisboa: ESEL; 2020.. The reflective journals were collected between January 18^th and March 13^th, 2021, through the blackboard platform, validating the authenticity of this type of documental information²⁷27 Burgess RC. A pesquisa de terreno: uma introdução. Oeiras: Celta Editora; 2001..

The selection criterion for the students was to be attending the CCVAFT CU. As exclusion criteria: not having prepared a reflective journal in the context and having written a reflective journal without reporting on clinical judgment and decision-making in nursing. A total of 39 students agreed to participate in the study. Of the 35 students who created a reflective journal, two students were excluded because their reflective journals did not answer the research question. The predominant gender was female (90.9%) and age ranged from 21 to 33 years, with a mean of 22.24 years. The sample corresponds to 12.2% of students enrolled²⁷27 Burgess RC. A pesquisa de terreno: uma introdução. Oeiras: Celta Editora; 2001. in the CCVAFT CT. The sample aimed to meet the sufficiency criterion, through the inclusion and reflection of the variability of the three contexts of clinical teaching and of the learning experiences, as well as the theoretical saturation through student representativeness in the different contexts.

Reflective journals created in professional practice situations constituted a narrative source of investigation, due to the fact that they comprise an important documentation on nursing learning¹⁵15 González-García M, Lana A, Zurrón-Madera P, Valcárcel-Álvarez Y, Fernández-Feito A. Nursing students' experiences of clinical practices in emergency and intensive care units. Int J Environ Res Public Health 2020; 17(16):5686.^,2828 Bashan B, Holsblat R. Reflective journals as a research tool: the case of student teachers' development of teamwork. Cogent Education 2017; 4(1):1374234.. These were carried out by the students according to the requests of specific guiding documents²⁶26 Escola Superior de Enfermagem de Lisboa (ESEL). Guia orientador da unidade curricular ensino clínico: Cuidar de clientes com vulnerabilidade acrescida e famílias em transição. Lisboa: ESEL; 2020., a reflection on an experienced situation of care that was relevant to their learning, therefore without suffering any influence from the team of researchers²⁹29 Bogdan R, Biklen S. Investigação qualitativa em educação. Porto: Porto Editora; 2013.. The reflective journals presented a structured reflection according to the six stages of Gibbs cycle: description of the situation; experienced feelings; assessment of positive and negative aspects; analysis of the actions taken; conclusion about what could have been done differently; and planning of a future action in response to the reflection process, according to the guiding document provided by the coordination teams of ECCCVAFT CU²⁶26 Escola Superior de Enfermagem de Lisboa (ESEL). Guia orientador da unidade curricular ensino clínico: Cuidar de clientes com vulnerabilidade acrescida e famílias em transição. Lisboa: ESEL; 2020.. The assessment of the teacher in charge of clinical teaching was not included so as not to bias the student’s narrative in the first person about their experiences²⁴24 Gonçalves JP, Marques CG, Gonçalves SP. Manual de investigação qualitativa - conceção, análise e aplicações. Lisboa: Pactor; 2021..

The ‘discreet’ information from these personal documents²⁴24 Gonçalves JP, Marques CG, Gonçalves SP. Manual de investigação qualitativa - conceção, análise e aplicações. Lisboa: Pactor; 2021. gave voice to the thoughts and feelings of nursing students about situations of clinical judgment and decision-making experienced in the context of care²⁵25 Squires A, Dorsen C. Qualitative research in nursing and health professions regulation. J Nurs Regul 2018; 9(3):15-26.. The analysis content comprised the perspectives of students in the care process and not about the care itself ²⁹29 Bogdan R, Biklen S. Investigação qualitativa em educação. Porto: Porto Editora; 2013..

Data analysis was carried out through content analysis, using a thematic approach, and followed three stages, according to Bardin³⁰30 Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2016.. In the first, the corpus was constructed, that is, the selection of the analysis documents taking into account the representativeness, exhaustiveness, homogeneity and relevance of the reflective journals in relation to the study object³⁰30 Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2016.. Thus, the corpus of the analysis comprised 40 reflective journals produced by the 33 students participating in the study. Then, the text was separated into thematic units, with previous categories, which expressed the underlying idea in each one of them, and the coding was carried out based on Record Units (RU). Finally, the categorization and measurement of frequencies was carried out, focusing on the type of RU, which was performed using the WebQdA software³¹31 Costa AP, Amado J. Análise de conteúdo suportada por software. Aveiro: Ludomedia; 2018.. Although the qualitative analysis program is a facilitating strategy, it requires human codification³²32 Fornari LF, Fonseca R. Critical-emancipatory workshop analysis through qualitative analysis software. The Qualitative Report 2020; 25(13):90-103.. For this reason, the analysis was independently carried out by two investigators and later a new triangulation was performed by the third member of the investigation team³³33 Denzin N, Lincoln YS. The Sage handbook of qualitative research. Thousand Oaks: Sage; 2018.. Aiming to guarantee the rigor of the study, the methodological procedures were permanently monitored throughout the study and self-correction strategies were used, such as the redefinition of the inclusion and exclusion criteria, by the researchers³⁴34 Corbin J, Strauss A. Basics of qualitative research. Thousand Oaks: Sage; 2015.^,3535 Morse MJ, Michael B, Maria M, Karin O, Jude S. Verification strategies for establishing reliability and validity in qualitative research. Int J Qual Methods 2002; 1(2):13-22..

This study is part of an investigation on the learning of decision-making in the care process, in a clinical context, and was approved by the Research Ethics Committee of ESEL. The clinical teaching management team as well as the teaching staff were informed, so they could feel involved and involve the students. The students were recruited by sending a request through the blackboard platform, requesting access to their reflective journals for the purposes of this investigation. The request included an explanation of the study to be carried out, ensuring confidentiality, anonymity and guaranteeing the absence of coercion and harmful consequences. The students who agreed to participate in the study sent their informed consent by email. Throughout the entire investigation process, the students’ names were removed from the reflective journals and identified by an “E” (student) plus a number following the order in which the informed consents were received. That was complemented with the characterization of the gender using the letters F (Female) and M (Male).

Results

The analysis of the typology of clinical judgment and decision-making that students narrated in their journals was supported by the categorization developed by Thompson et al.²⁰20 Thompson C, Stapley S. Do educational interventions improve nurses' clinical decision making and judgement? A systematic review. Int J Nurs Stud 2011; 48(7):881-893. (Chart 1). The authors describe four types of clinical judgment (cause/diagnosis, descriptive, evaluative and predictive) and six types of decision-making (intervention; targeting; timing; communication; management; and understanding), which were used in the analysis of the reflective journals.

Based on the performed analysis, of the 248 registration units identified, the clinical judgment typology achieved 106. With greater representativeness, the evaluative judgment showed 45 registration units, followed very closely by the descriptive judgment with 43 registration units. The cause/diagnosis judgment reached 15 registration units, and finally the predictive judgment had one registration unit (Table 1).

The evaluative judgment subcategory seems to be represented by the judgment on the change in the client’s status, which the students report:

Regarding the descriptive judgment subcategory, the students suggest a judgment about the condition of the person receiving their care, supported by the observed data: M.R. was sitting on the bathroom floor, crying and mutilating her forearms with the cap of her water bottle (E4F). The lady had a neat and tidy appearance, with no apparent physical injuries (E18F).

The findings on the Predictive Judgment suggest the student’s judgment about a likely situation in relation to the client they were caring for:

Regarding the decision-making typology, with a total of 142 registration units, the intervention decision showed the highest frequency, with 55 registration units, followed by the understanding decision, with 39 registration units, the communication decision, with 33 registration units, the management decision, with 11 registration units, and finally, timing and targeting decision, with three and one registration units, respectively (Table 2).

In the intervention decision-making subcategory, the students seem to describe how they decide to intervene by identifying the risk for them and for the client:

Decision-making also seems to emerge as an intervention option according to the results they hope to achieve: I approached C. and just touched their shoulder, I did not say anything (E1F).

Regarding the understanding decision subcategory, the students’ narratives suggest an interpretation of the care process that leads them to decide:

Regarding the communication decision subcategory, in the selection of information to be transmitted to clients and their families and healthcare team, the students seem to facilitate the cooperation and interaction between them:

In the management decision subcategory, the continuity of care seems to underlie the definition of their transfer and the articulation between the health teams:

The care transfer process also suggests being present among nursing students, as a way to ensure its continuity: I asked a nursing student who was also there to discreetly keep an eye on M.R (E4F).

The results of the timing decision subcategory suggest a decision based on the selection of the best time to intervene:

The targeting decision seems to imply a nursing intervention centered on the person receiving care:

Discussion

Nursing is intended to have a role in solving people’s problems, in different contexts, ranging from the community to the hospital. For this purpose, nurses must be capable of making decisions about the care to be provided based on data interpretation and selection of the best course of action⁹9 Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ 2006; 45(6):204-211.. In this sense, nursing students must learn to make clinical judgments and make decisions independently and autonomously⁸8 Tesoro MG, Simmons AM, Barros ALBL, Lopes CT, Guandalini LS, Cruz EDA, Maurício AB. Effects of clinical reasoning prompts on nursing students' clinical judgment for a patient experiencing respiratory distress. Int J Nurs Knowl 2021; 32(1):37-43., in which situation the clinical teaching is assumed as a dialogic reflection on what they see and what they feel, in a methodology of learning to be a nurse by doing it⁷7 Ciftci B, Gok S, Aksoy M, Avsar G. The effect of internships on clinical decision making and professional values of nursing students. Int J Caring Sci 2020; 13(2):1230-1239.^,1111 Alarcão I, Rua M. Interdisciplinaridade, estágios clínicos e desenvolvimento de competências. Texto Context - Enferm 2005; 14(3):373-382.. In ECCCVAFT CT, nursing students seem to perform more evaluative and descriptive clinical judgments and make more decisions related to acting, the understanding of the care situation and communication with the client.

In the Evaluative Judgment, students seem to favor situations in which there are changes in the client’s condition, which require mobilization of knowledge and previous experiences, and also the existing research, because that is how they see the need to intervene and the type of decision³⁶36 Thompson C, Aitken L, Doran D, Dowding D. An agenda for clinical decision making and judgement in nursing research and education. Int J Nurs Stud 2013; 50(12):1720-1726..

For this reason, the descriptive judgment may not be so relevant, because the student wants to reflect on their decision-making in the sense of providing specific nursing care and they might not have experienced it yet²⁰20 Thompson C, Stapley S. Do educational interventions improve nurses' clinical decision making and judgement? A systematic review. Int J Nurs Stud 2011; 48(7):881-893.^,3737 Lasater K. Clinical judgment development: using simulation to create an assessment rubric. J Nurs Educ 2007; 46(11):496-503..

As for the cause/diagnosis judgment, students seem to interpret the data obtained in order to make a statement that corresponds to a client’s problem²⁰20 Thompson C, Stapley S. Do educational interventions improve nurses' clinical decision making and judgement? A systematic review. Int J Nurs Stud 2011; 48(7):881-893..

Regarding the predictive judgment, the student seems to make a prediction of an imminent result that corresponds to a judgment on new data obtained²⁰20 Thompson C, Stapley S. Do educational interventions improve nurses' clinical decision making and judgement? A systematic review. Int J Nurs Stud 2011; 48(7):881-893.. This fact requires an acceptable proficiency of care situations due to its complexity³⁸38 Fedko AS, Dreifuerst K. Examining the relationship between clinical judgment and nursing actions in prelicensure students. Nurse Educ 2017; 42(1):47-50., which is why it would have been less significant for the student.

In the students’ narratives, the intervention decision emerged with greater prominence where the student conceives hypotheses in view of the different options for solving the problem and selects those appropriate to the situation and context²¹21 Marques MFM, David CLAHP, Santos MAFD, Neves SCDS, Pinheiro MJF, Leal MTS. Perceptions of senior nursing students regarding clinical decision-making. Rev Bras Enferm 2021; 4(1):e20200921.^,2222 Marques FM, Pinheiro MJ, Alves PV. Estudante de enfermagem em ensino clínico: estudo qualitativo da tipologia de decisão. New Trends in Qualitative Research 2021; 8:121-129.. Decision-making seems to depend on the situation they have to face, in seeking to meet the individual needs of clients¹⁹19 Phillips BC, Morin K, Valiga TMT. Clinical decision making in undergraduate nursing students: A mixed methods multisite study. Nurse Educ Today 2021; 97:104676.^,2020 Thompson C, Stapley S. Do educational interventions improve nurses' clinical decision making and judgement? A systematic review. Int J Nurs Stud 2011; 48(7):881-893.. Compared to the study by Marques⁴4 Marques MFM. Decision making from the perspective of nursing students. Rev Bras Enferm 2019; 72(4):1102-1108., the decision to intervene came in third place as reported by the students.

The understanding decision also remarkably emerges in the way the students made decisions. The reflection process that subsidizes nursing education, both regarding the theoretical and practical components, seems to have allowed students to analyze their reasoning process during client care and, at the same time, make them aware of this reflective process⁷7 Ciftci B, Gok S, Aksoy M, Avsar G. The effect of internships on clinical decision making and professional values of nursing students. Int J Caring Sci 2020; 13(2):1230-1239.. In analogy to the study that supports it⁴4 Marques MFM. Decision making from the perspective of nursing students. Rev Bras Enferm 2019; 72(4):1102-1108., metacognition was maintained as a crucial element in decision-making, contributing to the understanding of the care process¹⁷17 Bektas I, Bektas M, Ayar D, Kudubes AA, Sal S, Ok YS, Celik I. The predict of metacognitive awareness of nursing students on self-confidence and anxiety in clinical decision-making. Perspect Psychiatr Care 2021; 57(2):747-752.. The reasoning methods involved in the critical analysis and interpretation of data seem to have contributed to the ‘reading’ of the client, the events and the established relationships⁹9 Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ 2006; 45(6):204-211..

Distinctively, the communication decision still emerged when confronted with the other types of decision-making by the students. The decision on what to communicate and which communication strategies to use with the client and family in an attempt to involve them in the decision process³3 Baxter PE, Boblin S. Decision making by baccalaureate nursing students in the clinical setting. J Nurs Educ 2008; 47(8):345-350. seems to be present in the students’ discourse. The underlying knowledge that guides communication⁸8 Tesoro MG, Simmons AM, Barros ALBL, Lopes CT, Guandalini LS, Cruz EDA, Maurício AB. Effects of clinical reasoning prompts on nursing students' clinical judgment for a patient experiencing respiratory distress. Int J Nurs Knowl 2021; 32(1):37-43., as well as the development of communication skills with the nursing team, leads the student to confidently communicate³3 Baxter PE, Boblin S. Decision making by baccalaureate nursing students in the clinical setting. J Nurs Educ 2008; 47(8):345-350.^,1515 González-García M, Lana A, Zurrón-Madera P, Valcárcel-Álvarez Y, Fernández-Feito A. Nursing students' experiences of clinical practices in emergency and intensive care units. Int J Environ Res Public Health 2020; 17(16):5686. with other professionals in an attempt to involve them in the decision-making process. Regarding the results presented by Marques⁴4 Marques MFM. Decision making from the perspective of nursing students. Rev Bras Enferm 2019; 72(4):1102-1108., the selection of what to communicate to the client and their family and to the nursing team was the most frequently reported decision. Currently, the challenge that the pandemic has brought us regarding the level of interpersonal relationships in the context of care, with the use of personal protective equipment and the maintenance of social distancing, may have implications will this have on the way students interact with the clients and their families³⁹39 Soccol K, Santos N, Marchiori M. Estágio curricular supervisionado no contexto da COVID-19 e o desenvolvimento profissional de estudantes de enfermagem. Enferm Foco 2020; 11(2. esp):148-151..

The management decision, with less representation than the previous ones, is associated with the process of organization and management of care by the nursing students. Its decision process suggests the use of resources, such as their peers and other health professionals, in the articulation of care³3 Baxter PE, Boblin S. Decision making by baccalaureate nursing students in the clinical setting. J Nurs Educ 2008; 47(8):345-350.^,2020 Thompson C, Stapley S. Do educational interventions improve nurses' clinical decision making and judgement? A systematic review. Int J Nurs Stud 2011; 48(7):881-893.. One of the aspects to be highlighted was the lack of references in this category in the previous study⁴4 Marques MFM. Decision making from the perspective of nursing students. Rev Bras Enferm 2019; 72(4):1102-1108.. Did the PTDE CU allow students to feel more confident in the way they made decisions¹⁹19 Phillips BC, Morin K, Valiga TMT. Clinical decision making in undergraduate nursing students: A mixed methods multisite study. Nurse Educ Today 2021; 97:104676., making them feel prepared to decide on the organization and articulation of care to ensure its continuity?

The students scarcely referred to the timing decision, that is, the selection of the best time to intervene²⁰20 Thompson C, Stapley S. Do educational interventions improve nurses' clinical decision making and judgement? A systematic review. Int J Nurs Stud 2011; 48(7):881-893.. In the adequacy and prioritization of care, students suggest demonstrating clinical reasoning that allows effective decision-making according to the understanding of the clinical situation¹⁷17 Bektas I, Bektas M, Ayar D, Kudubes AA, Sal S, Ok YS, Celik I. The predict of metacognitive awareness of nursing students on self-confidence and anxiety in clinical decision-making. Perspect Psychiatr Care 2021; 57(2):747-752.. This reference showed a similar result to that of the previous study⁴4 Marques MFM. Decision making from the perspective of nursing students. Rev Bras Enferm 2019; 72(4):1102-1108., being second to last in the developed analysis. Are the students adequately prepared during their training for this type of decision¹⁹19 Phillips BC, Morin K, Valiga TMT. Clinical decision making in undergraduate nursing students: A mixed methods multisite study. Nurse Educ Today 2021; 97:104676.^,4040 Klenke-Borgmann L, Cantrell MA, Mariani B. Clinical judgment in nursing students after observation of in-class simulations. Clin Simul Nurs 2021; 51:19-27.?

The lower relevance among the types of decisions that the students made was the targeting decision. The student seems to decide on the intervention to be carried out in search of the greatest benefit for the client²⁰20 Thompson C, Stapley S. Do educational interventions improve nurses' clinical decision making and judgement? A systematic review. Int J Nurs Stud 2011; 48(7):881-893., implying knowledge of the client, either by the way they often react to care situations, or as a person⁹9 Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ 2006; 45(6):204-211.. Also in the study by Marques⁴4 Marques MFM. Decision making from the perspective of nursing students. Rev Bras Enferm 2019; 72(4):1102-1108., deciding which client would benefit the most from the nursing intervention came last. Students learn to focus on the care to be provided according to the clinical context they experience⁷7 Ciftci B, Gok S, Aksoy M, Avsar G. The effect of internships on clinical decision making and professional values of nursing students. Int J Caring Sci 2020; 13(2):1230-1239.. Considering the adverse situations that the pandemic brought to health institutions, how were the students able to make decisions based on the individual needs of their clients¹⁹19 Phillips BC, Morin K, Valiga TMT. Clinical decision making in undergraduate nursing students: A mixed methods multisite study. Nurse Educ Today 2021; 97:104676.?

The process of learning about decision-making in CT is regulated through two essential elements: the clinical learning environment⁷7 Ciftci B, Gok S, Aksoy M, Avsar G. The effect of internships on clinical decision making and professional values of nursing students. Int J Caring Sci 2020; 13(2):1230-1239.^,99 Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ 2006; 45(6):204-211.^,1212 Lam CK, Schubert CF, Herron EK. Evidence-based practice competence in nursing students preparing to transition to practice. Worldviews Evid Based Nurs 2020; 17(6):418-426.^,1313 Visiers-Jiménez L, Suikkala A, Salminen L, Leino-Kilpi H, Löyttyniemi E, Henriques MA, Jiménez-Herrera M, Nemcová, J, Pedrotti D, Rua M, Tommasini C, Zeleníkova R, Kajander-Unkuri S. Clinical learning environment and graduating nursing students' competence: a multi-country cross-sectional study. Nurs Health Sci 2021; 23(2):398-410.^,1818 Marino MA, Andrews K, Ward J. Clinical decision making at the bedside. Nurs Clin North Am 2020; 55(1):29-37. and clinical supervision¹¹11 Alarcão I, Rua M. Interdisciplinaridade, estágios clínicos e desenvolvimento de competências. Texto Context - Enferm 2005; 14(3):373-382.^,1919 Phillips BC, Morin K, Valiga TMT. Clinical decision making in undergraduate nursing students: A mixed methods multisite study. Nurse Educ Today 2021; 97:104676.^,3939 Soccol K, Santos N, Marchiori M. Estágio curricular supervisionado no contexto da COVID-19 e o desenvolvimento profissional de estudantes de enfermagem. Enferm Foco 2020; 11(2. esp):148-151.^,4141 Rodríguez-García MC, Gutiérrez-Puertas L, Granados-Gámez G, Aguilera-Manrique G, Márquez-Hernández VV. The connection of the clinical learning environment and supervision of nursing students with student satisfaction and future intention to work in clinical placement hospitals. J Clin Nurs 2021; 30(7-8):986-994.. It is important to analyze the changes that the pandemic situation has caused in terms of health and nursing education, specifically, due to the reduction in CT time, changes in clinical supervision and changes in contexts, among others. What consequences will these factors have on the development of student decision-making competencies? These should be investigated. On the other hand, the experience of single experiences in CT by the students provides them with the development of decision-making and their own empowerment³⁹39 Soccol K, Santos N, Marchiori M. Estágio curricular supervisionado no contexto da COVID-19 e o desenvolvimento profissional de estudantes de enfermagem. Enferm Foco 2020; 11(2. esp):148-151..

Final considerations

Clinical judgment and decision-making in clinical teaching that emerge from the students’ reports suggest the appreciation of evaluative and descriptive judgment, as well as the decision to act, followed by the understanding of the care situation and communication with the client. The cause/diagnosis and predictive judgments show a lower impact, as well as the management decision-making to ensure continuity of care, timing in choosing the best time to act and targeting, that is, the selection of the intervention that shows the greatest benefit to the client. Learning clinical judgment and decision-making induces the nursing student to acquire and develop global knowledge and competencies, reinforcing judgment and decision-making skills in clinical practice, contributing to the practice of excellence.

The qualitative methodology through the interpretation, comparison and synthesis of the ‘reading’ of the narratives that the reflective journals represented, allowed a characterization of the clinical judgment and decision-making of the nursing student. This methodological approach allowed an interpretation of the types of judgment and decision, due to the description, explanation and understanding as a non-mathematical process of interpretation.

As a consequence in terms of training, the characterization of the several types of clinical judgment and decision-making of the nursing student allows the teaching team at PTDE CU to reflect and assess the contents and pedagogical methodologies aiming to enhance the development of all types of clinical judgment and decision-making of students in their academic path. We intend to disseminate the results obtained in this investigation to the academic community in order to promote other pedagogical strategies that promote the development of clinical judgment and decision-making by students.

At the research level, this study characterized the type of clinical judgment and decision-making of nursing students participating in CT. However, and taking into account the methodology used, these results cannot be extrapolated. This study could be supported by the triangulation of data collection techniques, such as interviews or focus groups. Another limitation is that the development of the reflective journals does not intend to portray this investigation; however, the depth of the documents allowed us to constitute a corpus whose analysis answers the research question and the objective of the study. Simultaneously, the results and limitations of this investigation open up other areas of study on the clinical judgment and decision-making of nursing students.

Acknowledgements

We would like to thank the students who provided the reflective journals that allowed this study to be carried out.

References

Publication Dates

History