Internal and external variables such as the nurse's personal experience, knowledge, creative thinking ability, education, self concept, as meshed with the nurses' working environment, and situational stressors all can work to enhance or inhibit effective clinical decision making for a nurse. (O'Reilly, 1993) Clinical decision-making is defined as the ability to sift and synthesize information, make decisions, and appropriately implement those decisions within a clinical setting. Practicing nurses must effectively identify and solve the problems of patient diagnosis and treatment by using such a model. One means of doing so, paradoxically, is to identify the barriers to decision making so they can be overcome by the use of more effective decision-making tools. The nursing process itself involves the need for quality decision-making at every sage of assessment, diagnosis, planning, implementation, and evaluation of patient needs and demands. ("Nursing process,' 2006, Wikipedia) Thus, both processes are interrelated; as to be a good nurse a nurse must be a good decision-maker.

Describe Patricia Benner's stages of clinical judgment

A competent nurse might, by sight, be able to evaluate if the patient's pain was nausea, as in heartburn, or if the clutching pain seemed to affect the patient's breathing or numb the patient's limbs as might be typical of an oncoming heart attack. A proficient nurse might be able to assess the immediate severity of the condition-even if the pain was heart-related, she or he might be able to offer a finer-tuned diagnosis and plan. For example, if the patent's angina was life threatening and required immediate care, or if the pain could be taken care of through a nitroglycerin tablet, for example, and patient rest, before a doctor was called for to evaluate the patient's physical health and provide advice regarding future heart care.

An advanced beginner nurse, less shaken by the emotion of patient, but proceeding by rote and by the knowledge given to her by professional mentors during her minimal previous clinical experience, might go down a checklist of evaluating the patient's pain, such as where is the pain localized, when the pain began, then asking the patient to describe and rate the pain, and based upon such an assessment, diagnosis the cause and severity of the case before seeing assistance in planning and implementing a treatment plan either for a cardiac condition or for heartburn.

Nursing processes are thus always in a dialogue between the nurse's own personal competence (internal factors) and the external stressors of the environment. For example, take a highly contentious situation in the ER when a patient may come in, late at night, complaining of chest paints, agitated, and certain that he or she is suffering a heart attack. A novice nurse, in her process of assessment, diagnosis, planning, implementation, and evaluation might merely register the patient's emotional distress and immediately call for a doctor specializing in cardiac care, accepting the patient's own assessm

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