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To begin with, development of clinical judgment among nursing graduates has been an issue of concern in the nursing practice. In this connection, there has been a great challenge for graduate nurses while applying decision making. As such, graduate nurses are those fresh from school without much experience regarding what happens in reality. In spite of the enormous changes in nursing practice and the need for nurses with advanced competencies in practice, nursing education has been incapacitated to respond to the need. Research has pointed out that new nurses enter practice feeling inadequate in regard to how prepared they are. Equally, in many areas employers have ranked the preparation for new nurses as inadequate. 

In particular, it has been argued that graduates are under-prepared to respond to emergency situations, supervise care provided by others, manage medication administration for multiple patients, communicate with physicians regarding patient conditions and perform intricate psychomotor skills. It is important at this point to point out that a recent national survey indicated that employers ranked critical thinking, or clinical decision making, as the most important skill set needed when it comes to the new graduates (Benner, Tanner, & Chesla , 2009).

Literature provides that nurse education and practice are two aspects whereby there has been a big gap that needs to be filled. Therefore, in order to fill this gap, undergraduate nursing education should fully equip nursing students to enter the practice with a full orientation to learning from practice. As a matter of fact, while educating students to learn clinical skills, they must also learn how to be with and as well to be able to take care of patients. This means, students should be couched in sound clinical reasoning as informed in their own notion of good in practice.

This should be done with the best available evidence and by a deep understanding of the very concerns of the patient (Benner, Tanner & Chesla, 2009, p.370). Following this point, there has been a suggestion to help graduate group to identify clinical issues that are deemed to be under-attended in basic educational programs and as such require further exploration and adjustment. From this point of view, it is clear from the literature that there is need for development of clinical judgment among nursing graduates.

The question of how do nursing graduates develop clinical judgment skills, has been of great concern especially with the changes that have been taking place in the current nursing practice. Needless to say, there are several factors that influence critical thinking. As such, they involve thinking style, age, culture, life experiences, self confidence, education or knowledge level and health. On the other hand, time to do work can influence critical thinking. At the same time, organizational culture, peers, management, staff and environment can as well influence decision making or clinical judgment. Among the many aspects that affect nursing clinical judgment, education has been labeled as a factor. In this sense, nursing graduates develop clinical judgment skills owing to the kind of education that has been given to them.

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According to Dorothy (2005), aggregate results for competency assessment of new registered nurses using a performance based development system indicated that most new graduates do not meet expectations for entry-level clinical judgment level. In regard to this point, it was found out that new nurse graduates do not think like nurses. As such, findings pointed out that only 35 percent of the new registered graduates in spite of educational preparation and credentials, meet entry expectations for clinical judgment. As a matter of fact, many of them find it difficult to translate knowledge and theory into practice. In line with this, clinical judgment can be defined as the nurse's cognitive processes and strategies commonly used by nurses to identify and diagnose actual and potential patient problems. This is done with the sole aim of making clinical decisions to assist in problem resolution in order to achieve positive patient outcomes.

From a general point of view, clinical judgment happens to be a complex task directed towards the identification and management of patients' health needs that requires a knowledgeable practitioner along with reliable information and supportive environment.  According to the provision of literature, there has been a great distinction between how nurses reason in practice and how they first learn to reason as an academic endeavor. In this context, Higgs (2008) asserts that previous studies that were carried out in regard to nurse's clinical judgment, revealed that with experience, nurses develop a method of reasoning that provides them with an innate grasp of the whole clinical situation without following the learnt process using step by step analytic approach (p.236).

In connection to this point, it was suggested that with the ongoing problem of new graduates being inefficient in terms of clinical judgment, inclusion of activities that would foster students' skills in intuitive judgment in the curricula would work towards solving the problem faced by new graduates. According to research, nursing process which is offered by the nurse education focuses on individual patient problems and associated interventions separately. This way may translate to a less efficient way of reasoning and as such it may not reflect the realities of the actual nursing practice. This may occur in a situation whereby one patient's problem may be associated with another. As a matter of fact, nursing and clinical judgment is developed by means of a practice whilst nursing education provides one approach of many approaches nurses use in problem solving (Higgs, 2008, p.236).

It has been pointed out that, first work experience of new nurses is overwhelming. Outstandingly, there is an alarming 60 percent turnover rate for newly graduated nurses in the first job. Therefore, research has suggested that school to work transition programs lasting at least a year should be put in place. In essence, new graduates have limited or no experience if it may be said in the management of highly complex situations. This is given to the reason that the demands of work practice exceed their capability to respond. Benner, Tanner & Chesla (2009) points to the need for school-to-work transition programs since there has been a prevalence of error and practice breakdowns realized among new nurse graduates. In today's acute care setting, nurses anticipate numerous interruptions during the process of solving patient's problems. This may hinder a new graduate effective performance.

Nursing education programs are important as it regards how they are structured and the reason for their inclusion. A good nursing education program should be as such one that is able to provide the students with the right knowledge and skills. As a matter of fact, these programs should enable the student to efficiently and effectively apply what he or she has learnt in class into a real clinical setting whereby clinical judgment is required in order to provide a solution. Nursing graduates have in actual sense been provided with an opportunity to develop clinical judgment skills even before they graduate.

However, there have been challenges for new graduates once they enter in the field of practice. As it has been highlighted earlier on, nursing education has provided room for nursing students to develop clinical judgment of which it is deemed to have been ineffective. Actually, this has translated to errors and practice breakdown mostly associated with the new graduates. It is important at this point to note that nursing education program is not complete without clinical teaching.

 Clinical teaching or rather education is the opportunity in nursing education programs which is responsible for equipping students with the required judgmental skills required in practice. In a clinical setting, the teacher is responsible for guiding, supporting, stimulating, and facilitating learning. He or she does this by means of designing appropriate activities in appropriate settings and thus he or she allows the student to experience learning. According to Gaberson, Gaberson & Oermann (2010), the appropriate role of a clinical teacher in a clinical setting is competent guidance.

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More to this point, it is argued that clinical education should actually reflect the nature of professional practice. In this context, nursing as a professional discipline should be differentiated from academic disciplines by the practice component thereof. In a more practical point of view, clinical practice requires critical thinking and problem solving abilities. They incorporate the specialized psychomotor and technological skills along with a professional value system.

Accordingly, practice in clinical settings brings about an exposure of students to realities of professional settings which in reality they are not conveyed in the textbook or a simulation. In line with this, clinical teaching activities should give room for the students to encounter the real practice problem so that when they graduate issues of error and practice breakdown are not even mentioned. For this reason, Gaberson, Gaberson & Oermann (2010), states that clinical teaching is more important than classroom teaching. This is given to the reason that clinical learning activities provide real-life experiences and opportunities for transfer of knowledge to practical situations. Unfortunately, there are some learners who perform well in the classroom but in clinical setting they cannot successfully apply the knowledge.

Despite the fact that clinical teaching has been in place for development of judgmental skills by nursing students, the problem of incompetence among new graduates still persists with an overwhelmingly large percentage. Attributed to the failure of new graduates is the fact that nursing student in the clinical setting has been treated as a nurse rather than a learner. Unquestionably, in preparation for professional practice, the clinical setting is the place where the student comes in direct contact with the patient for the purpose of testing theories and learning skills.

 Historically, clinical learning activities have continued to be confused with patient caring and as a result, these activities centre on patient care. If this is done, a student comes out as a nurse having not learnt. This is why in this case the student is termed as a nursing student rather than student nurse. On the other hand, clinical teaching for students should be allocated substantial time which the student can be able to effectively utilize while learning and thus evaluation may take place later. However, this is not the case as research suggests. Research suggests that many nursing students perceive clinical teacher as an evaluator and thus their learning is incapacitated. Subsequently, many nursing clinical teachers spent much time of evaluation as compared to teaching activities (Gaberson, Gaberson & Oermann, 2010).

At the same time, nursing faculty members as indicated by research, put expectations on the members to perform skills with aptness the first time of their attempt. As a consequence, they continually keep detailed records of student's failures and shortcomings.  This should not be the case and therefore faculty members should expect students to make mistakes, correct them and by thus doing, they acquire skills. This is due to the reason that skill acquisition is a complex process involving making mistakes, learning how to correct them and as well learning how to prevent such mistakes.

In line with this, clinical teaching along with learning should be focused on the essential knowledge, skills and attitudes that a nursing student should acquire for competence. Learning how to practice nursing involves high level cognitive abilities. Such abilities involve problem solving, critical thinking, decision making, and clinical reasoning. Having learnt in class setting, a nursing student may only use the nursing process learnt as the only way to solve problems. Needless to say, problems encountered in a clinical setting are related to patients and their health needs along which other problems that arise as a result of the clinical problems.

Clinical teaching and learning is designed to bring about the ability to solve clinical problems. Problems in a clinical setting range from simple to complex ones. As an end result, such problems require new methods of reasoning and problem-solving strategies. As a remedy, students should be exposed to realistic clinical problems of increasing complexity rather that narrowing it to patient care. Clinical reasoning and critical thinking being integral to the ability to practice professional nursing, most employers of new graduates expect a demonstration of these.

It is essential at this point review literature that has tried to answer the question of how do nursing graduates perceive decision-making in clinical practice. As a start off point, professional nursing practice calls for nurses to be able to make decisions about the patient care problems. Such decisions are deemed to bring about possible solutions and the best approaches to be employed in such cases. It involves gathering, analyzing, weighing, and valuation of information in order to choose the best course of action among many alternatives. This requires rationality in order to measure the associated benefits of the decision along with the consequences thereof. Nonetheless, the new graduates have limited skills when faced with the situations whereby decisions have to be made. From this perspective, clinical education should involve learners with opportunities that require them to make such decisions (Gaberson, Gaberson & Oermann, 2010).

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New nursing graduates have been associated with limited experience and as a result decision making to them as it is related to patient care and solving of the related problems becomes a challenge. However, there is much attached to their perception than it is with the experience. According to Gillespie& Peterson (2009), new nursing graduates when faced by complex or unfamiliar clinical situations, they frequently respond to such situations by drawing on theoretical knowledge and psychomotor skills. They are in particular required to enact decision making that addresses the complex and multidimensional nature of the situation, but they rarely apply this factor.

Equally important, novice or new graduates lack confidence in a clinical setting situation and thus they heavily rely on the experienced nurses and as such avoid situations of making decisions. Generally, new graduates tend to view decision making as responding to patient complaints and following protocols or documented care plans. Interestingly enough, as they make decisions, their focus leans towards doing rather than on thinking and reflecting. In reality, new graduates do not often recognize or rather appreciate the relevance of deviations from the textbook picture of clinical situation (Gillespie& Peterson, 2009, p.1).

Owing to the reason of more reliance on textbook abstract principles, new graduates have an abstract perception of decision making and this is the factor that makes most of them to miss the point. Subsequently, they end up experiencing dissatisfaction with their roles. How nursing graduates perceive decision-making in clinical practice is born out of reliance on abstract principles and theory learnt in class. From this point of view, nursing graduates perception towards decision making far deviates from the reality of the definition given to decision making in a clinical set up. Definition given to decision making as it should be applied by nursing graduates is; gathering, analyzing, weighing, and valuation of information in order to choose the best course of action among many alternatives (Gaberson, Gaberson & Oermann, 2010). This is where it becomes a difficult task for a nursing graduate to effectively make decisions.

In conjunction with nursing graduate perception of decision making as a challenge to their competence in work, there is the issue of the factors influencing nursing graduates' clinical decision-making process in the acute care setting. When the term acute care setting is used in this context, it brings the meaning of a setting where patients receive short-term medical treatment for acute illnesses or injury. Additionally, it is a setting where one may be put in order to recover from surgery. In such a setting, medical and nursing personnel are given to the responsibility of administering the critical care which is needed for the patient to be restored to health. In this connection, there are several factors that can influence nursing graduates' clinical decision-making process. As such, the issue of the environment comes in the context since the situation presents the graduate with acute illnesses which requires critical thinking and making of tough decisions.

In regard to the requirements of acute care nursing practice, Daniels (2004) points out that the nurse should possess as well as integrate all nursing knowledge, make rapid decisions and constantly advocate for the client (p.410). Apart from this, acute care nursing requires critical thinking an attribute that is a must for an acute care nurse to possess.  Just as it has been highlighted earlier in the text, acute care nursing requires critical thinking skills possessed by the nurse. In this combination, quick decisions need to be made in order to help the patients to get restored to health. This is the reason why in most acute care setting expert nurses are required. This automatically disqualifies the graduate nurses whose experiences are limited and at the same time their expertise being not yet tested. Following this point, the critical thinking skills of an acute care nurse need to be proficient of which it has earlier on been noted that graduate nurses have an abstract perception of decision making as they are unable to think beyond the provisions of the textbook.

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There are several factors that can influence the decision making process of a graduate nurse other than the faults with the clinical education provided. As such, they include the factors that affect the ability to critically think and come up with quick decisions. Such factors involve personal and workplace variables. How one thinks has great influence on how he or she can think critically. This effect comes in trying to answer the question of whether a nurse is analytical, methodical or intuitive in the approach.

Typically, most graduate nurse are young in age while theoretically as one gets older, the better he or she is in thinking and thus it depends on ones willingness to change and learn. The factor of age and thinking analytically may limit decision making process of an acute care nurse who is a graduate nurse. Life experiences play a great role in influencing decision making process of a graduate nurse. Thus, if it happens that the graduate nurse was not previously exposed to an acute care setting, he or she may have difficulties while making decisions. At the same time, a lack of self confidence from the side of the graduate nurse may hinder the process of decision making fearing to make mistakes. Likewise, it becomes more difficult to concentrate if one is uncomfortable, exhausted or stressed to make a decision in the acute care setting where emergency is required in all faculties (Jackson, Ignatavicius, & Case, 2006).  

On the other hand, Jackson, Ignatavicius & Case (2006) points out that the state of the acute workplace may influence ones process of making decisions. This involves the time to do work and the organizational culture as it can allow or hinder a graduate nurse from thinking flexibly. Depending on the people who surround a graduate nurse, he or she can make good or bad decisions. This is because if one is surrounded by individuals who think critically he will be influenced to apply critical thinking and come up with an apt decision.

Another factor that can influence a graduate's process of making decision is the management which may allow or disallow the ability to make decisions. The staff equally has influence on the decision making process of the graduate nurse. If it happens that they are supporting to learning experience and open to questions and new ideas, they can help a graduate nurse to make decisions with proficiency in the acute care setting. In addition to this point,  the environment state of acute care setting may influence decision making process of the graduate nurse in the sense that if there are too many distraction and disruptions the graduate nurse may not think critically. Another point to note is that it is so hard a task to think in an over-stimulating setting (Jackson, Ignatavicius & Case, 2006). 

According to Nehring& Lashley (2009), by 2003, there was already a remarkable shortage in nursing sector. This was attributed to one factor among others that acute care setting needed experienced nurses who became hard to find with excessive applications of the recent-graduate nurses. As a result of this, there was no otherwise than to employ graduate nurses in the acute care setting. In order to meet their limitations a program was designed known as Nurse Residency Program.

The program would implement and evaluate an innovative residency program with both clinical and theoretical components designed to assist graduate nurses in their transition from novice to competent practice in medical/surgical specialties. Additionally, the program was aimed at expanding and strengthening critical care specialty practice using innovative educational experiences for recent graduates and registered nurses with experience. This case reveals the limited critical care specialty practice by graduate nurses while making decisions in an acute care setting (p.168).

Having provided the information as it regards the question of how nursing graduates develop clinical judgment skills, it is important to put it that it is a complex process. It is actually developed by means of clinical education. Clinical education as it has been highlighted earlier in the text is a clinical based teaching whereby nursing student are brought to a point of applying theory to practice. Regardless of its inclusion in the nursing education program, graduate nurse decision making in clinical judgment is highly challenged. Development of clinical judgment among nursing graduates has been challenged by the kind of clinical education administered. Notably, clinical teachers have taken nursing students as student nurses thus limiting their process of learning. Similarly, clinical education has been made a matter of teachers evaluating students instead of helping them to learn. At the same time, classroom education has been overemphasized than clinical teaching. Along with this, students only engage in clinical learning which patient care is centered. As such, students have limited opportunities to make decisions and thus applying decision making becomes a hard task.

Perception of decision-making in clinical practice among graduates has been a biased one. New graduates tend to view decision making as responding to patient complaints and following protocols or documented care plans. Interestingly enough, as they make decisions, their focus leans towards doing rather than on thinking and reflecting. In reality, new graduates do not often recognize or rather appreciate the relevance of deviations from the textbook picture of clinical situation. On the other hand, factors influencing nursing graduates' clinical decision-making process in the acute care setting are those factors that influence critical thinking since acute care nursing requires critical thinking as a mandatory since it is involved with quick decisions and critical care. It is also involved with emergency scenarios which need critical thinking for apt decision making. As such, factors that influence the decision making process of graduate nurses involve the personal and workplace variables. Such variables involve thinking style, age, culture, life experiences, self-confidence, education level and health. Likewise, workplace variables involve time of work, organizational culture, peers, management, staff and environment of the work.

In summation, challenges for nursing graduates in applying decision making are associated with nursing education program. As such, clinical education provides graduates with the basic skills that enable them to develop critical thinking skills and decision making skills. In actual sense, the clinical education gives room for the nursing student to apply theory in practice. Nevertheless, the nursing clinical education has not been offering this experience. This is what has caused the many challenges to graduate nurses. At the same time, clinical education has treated the nursing student as a student nurse a factor that has limited the skills of the graduate nurse.

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