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Read the article “Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing” by Christine Tanner, which is linked below:Link to articleIn at least three pages, answer the following questions:What do you feel are the greatest influences on clinical judgment? Is it experience, knowledge, or a combination of those things?In your opinion, what part does intuition play in clinical judgment? How do you think you’ll be able to develop nursing intuition?Additional sources are not required but if they are used, please cite them in APA format.
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Thinking Like a Nurse: A Research-Based
Model of Clinical Judgment in Nursing
Christine A. Tanner, PhD, RN
Abstract
ment in nursing has become synonymous with the widely
adopted nursing process model of practice. In this model,
clinical judgment is viewed as a problem-solving activity,
beginning with assessment and nursing diagnosis, proceeding with planning and implementing nursing interventions directed toward the resolution of the diagnosed
problems, and culminating in the evaluation of the effectiveness of the interventions. While this model may be
useful in teaching beginning nursing students one type
of systematic problem solving, studies have shown that
it fails to adequately describe the processes of nursing
judgment used by either beginning or experienced nurses
(Fonteyn, 1991; Tanner, 1998). In addition, because this
model fails to account for the complexity of clinical judgment and the many factors that influence it, complete reliance on this single model to guide instruction may do a
significant disservice to nursing students. The purposes of
this article are to broadly review the growing body of research on clinical judgment in nursing, summarizing the
conclusions that can be drawn from this literature, and
to present an alternative model of clinical judgment that
captures much of the published descriptive research and
that may be a useful framework for instruction.
linical judgment is viewed as an essential skill
for virtually every health professional. Florence
Nightingale (1860/1992) firmly established that
observations and their interpretation were the hallmarks
of trained nursing practice. In recent years, clinical judg-
Definition of Terms
This article reviews the growing body of research on
clinical judgment in nursing and presents an alternative
model of clinical judgment based on these studies. Based
on a review of nearly 200 studies, five conclusions can
be drawn: (1) Clinical judgments are more influenced by
what nurses bring to the situation than the objective data
about the situation at hand; (2) Sound clinical judgment
rests to some degree on knowing the patient and his or
her typical pattern of responses, as well as an engagement
with the patient and his or her concerns; (3) Clinical judgments are influenced by the context in which the situation
occurs and the culture of the nursing care unit; (4) Nurses
use a variety of reasoning patterns alone or in combination; and (5) Reflection on practice is often triggered by a
breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. A model based on these general conclusions
emphasizes the role of nurses’ background, the context of
the situation, and nurses’ relationship with their patients
as central to what nurses notice and how they interpret
findings, respond, and reflect on their response.
C
Dr. Tanner is A.B. Youmans-Spaulding Distinguished Professor, Oregon & Health Science University, School of Nursing, Portland, Oregon.
Address correspondence to Christine A. Tanner, PhD, RN, A.B.
Youmans-Spaulding Distinguished Professor, Oregon & Health Science University, School of Nursing, 3455 SW U.S. Veterans Hospital
Road, Portland, OR 97239; e-mail: tannerc@ohsu.edu.
204
In the nursing literature, the terms “clinical judgment,” “problem solving,” “decision making,” and “critical
thinking” tend to be used interchangeably. In this article,
I will use the term “clinical judgment” to mean an interpretation or conclusion about a patient’s needs, concerns,
or health problems, and/or the decision to take action (or
not), use or modify standard approaches, or improvise new
ones as deemed appropriate by the patient’s response.
“Clinical reasoning” is the term I will use to refer to the
processes by which nurses and other clinicians make their
judgments, and includes both the deliberate process of
Journal of Nursing Education
tanner
generating alternatives, weighing them against the evidence, and choosing the most appropriate, and those patterns that might be characterized as engaged, practical
reasoning (e.g., recognition of a pattern, an intuitive clinical grasp, a response without evident forethought).
Clinical judgment is tremendously complex. It is required in clinical situations that are, by definition, underdetermined, ambiguous, and often fraught with value conflicts among individuals with competing interests. Good
clinical judgment requires a flexible and nuanced ability
to recognize salient aspects of an undefined clinical situation, interpret their meanings, and respond appropriately.
Good clinical judgments in nursing require an understanding of not only the pathophysiological and diagnostic
aspects of a patient’s clinical presentation and disease, but
also the illness experience for both the patient and family and their physical, social, and emotional strengths and
coping resources.
Adding to this complexity in providing individualized
patient care are many other complicating factors. On a
typical acute care unit, nurses often are responsible for
five or more patients and must make judgments about
priorities among competing patient and family needs
(Ebright, Patterson, Chalko, & Render, 2003). In addition,
they must manage highly complicated processes, such as
resolving conflicting family and care provider information,
managing patient placement to appropriate levels of care,
and coordinating complex discharges or admissions, amid
interruptions that distract them from a focus on their
clinical reasoning (Ebright et al., 2003). Contemporary
models of clinical judgment must account for these complexities if they are to inform nurse educators’ approaches
to teaching.
Research on Clinical Judgment
The literature review completed for this article updates
a prior review (Tanner, 1998), which covered 120 articles
retrieved through a CINAHL database search using the
terms “clinical judgment” and “clinical decision making,”
limited to English language research and nursing journals. Since 1998, an additional 71 studies on these topics
have been published in the nursing literature. These studies are largely descriptive and seek to address questions
such as:
l What are the processes (or reasoning patterns) used
by nurses as they assess patients, selectively attend to
clinical data, interpret these data, and respond or intervene?
l What is the role of knowledge and experience in
these processes?
l What factors affect clinical reasoning patterns?
The description of processes in these studies is strongly related to the theoretical perspective driving the research. For
example, studies using statistical decision theory describe
the use of heuristics, or rules of thumb, in decision making,
demonstrating that human judges are typically poor informal statisticians (Brannon & Carson, 2003; O’Neill, 1994a,
June 2006, Vol. 45, No. 6
1994b, 1995). Studies using information processing theory focus on the cognitive processes of problem solving or diagnostic reasoning, accounting for limitations in human memory
(Grobe, Drew, & Fonteyn, 1991; Simmons, Lanuza, Fonteyn,
Hicks, & Holm, 2003). Studies drawing on phenomenological theory describe judgment as an situated, particularistic,
and integrative activity (Benner, Stannard, & Hooper, 1995;
Benner, Tanner, & Chesla, 1996; Kosowski & Roberts, 2003;
Ritter, 2003; White, 2003).
Another body of literature that examines the processes
of clinical judgment is not derived from one of these traditional theoretical perspectives, but rather seeks to describe
nurses’ clinical judgments in relation to particular clinical
issues, such as diagnosis and intervention in elder abuse
(Phillips & Rempusheski, 1985), assessment and management of pain (Abu-Saad & Hamers, 1997; Ferrell, Eberts,
McCaffery, & Grant, 1993; Lander, 1990; McCaffery, Ferrell, & Pasero, 2000), and recognition and interpretation
of confusion in older adults (McCarthy, 2003b).
In addition to differences in theoretical perspectives
and study foci, there are also wide variations in research
methods. Much of the early work relied on written case
scenarios, presented to participants with the requirement
that they work through the clinical problem, thinking
aloud in the process, producing “verbal protocols for analysis” (Corcoran, 1986; Redden & Wotton, 2001; Simmons et
al., 2003; Tanner, Padrick, Westfall, & Putzier, 1987) or respond to the vignette with probability estimates (McDonald et al, 2003; O’Neill, 1994a). More recently, research
has attempted to capture clinical judgment in actual practice through interpretation of narrative accounts (Benner et al., 1996, 1998; Kosowski & Roberts, 2003; Parker,
Minick, & Kee, 1999; Ritter, 2003; White, 2003), observations of and interviews with nurses in practice (McCarthy,
2003b), focused “human performance interviews” (Ebright
et al., 2003; Ebright, Urden, Patterson, & Chalko, 2004),
chart audit (Higuchi & Donald, 2002), self-report of decision-making processes (Lauri et al., 2001), or some combination of these. Despite the variations in theoretical
perspectives, study foci, research methods, and resulting
descriptions, some general conclusions can be drawn from
this growing body of literature.
Clinical Judgments Are More Influenced by
What the Nurse Brings to the Situation than the
Objective Data About the Situation at Hand
Clinical judgments require various types of knowledge:
that which is abstract, generalizable, and applicable in
many situations and is derived from science and theory;
that which grows with experience where scientific abstractions are filled out in practice, is often tacit, and aids
instant recognition of clinical states; and that which is
highly localized and individualized, drawn from knowing
the individual patient and shared human understanding
(Benner, 1983, 1984, 2004; Benner et al., 1996, PedenMcAlpine & Clark, 2002).
For the experienced nurse encountering a familiar
situation, the needed knowledge is readily solicited; the
205
clinical judgment model
nurse is able to respond intuitively, based on an immediate clinical grasp and just “knowing what to do” (Cioffi,
2000). However, the beginning nurse must reason things
through analytically; he or she must learn how to recognize a situation in which a particular aspect of theoretical
knowledge applies and begin to develop a practical knowledge that allows refinement, extensions, and adjustment
of textbook knowledge.
The profound influence of nurses’ knowledge and
philosophical or value perspectives was demonstrated in
a study by McCarthy (2003b). She showed that the wide
variation in nurses’ ability to identify acute confusion in
hospitalized older adults could be attributed to differences in nurses’ philosophical perspectives on aging. Nurses
“unwittingly” adopt one of three perspectives on health in
aging: the decline perspective, the vulnerable perspective,
or the healthful perspective. These perspectives influence
the decisions the nurses made and the care they provided.
Similarly, a study conducted in Norway showed the influence of nurses’ frameworks on assessments completed and
decisions made (Ellefsen, 2004).
Research by Benner et al. (1996) showed that nurses
come to clinical situations with a fundamental disposition
toward what is good and right. Often, these values remain
unspoken, and perhaps unrecognized, but nevertheless
profoundly influence what they attend to in a particular
situation, the options they consider in taking action, and
ultimately, what they decide. Benner et al. (1996) found
common “goods” that show up across exemplars in nursing, for example, the intention to humanize and personalize care, the ethic for disclosure to patients and families,
the importance of comfort in the face of extreme suffering
or impending death—all of which set up what will be noticed in a particular clinical situation and shape nurses’
particular responses.
Therefore, undertreatment of pain might be understood
as a moral issue, where action is determined more by clinicians’ attitudes toward pain, value for providing comfort, and institutional and political impediments to moral
agency than by a good understanding of the patient’s experience of pain (Greipp, 1992). For example, a study by
McCaffery et al. (2000) showed that nurses’ personal opinions about a patient, rather than recorded assessments,
influence their decisions about pain treatment. In addition, Slomka et al. (2000) showed that clinicians’ values
influenced their use of clinical practice guidelines for administration of sedation.
Sound Clinical Judgment Rests to Some Degree
on Knowing the Patient and His or Her Typical
Pattern of Responses, as well as Engagement with
the Patient and His or Her Concerns
Central to nurses’ clinical judgment is what they describe in their daily discourse as “knowing the patient.”
In several studies (Jenks, 1993; Jenny & Logan, 1992;
MacLeod, 1993; Minick, 1995; Peden-McAlpine & Clark,
2002; Tanner, Benner, Chesla, & Gordon, 1993), investigators have described nurses’ taken-for-granted understand206
ing of their patients, which derives from working with
them, hearing accounts of their experiences with illness,
watching them, and coming to understand how they typically respond. This type of knowing is often tacit, that is,
nurses do not make it explicit, in formal language, and in
fact, may be unable to do so.
Tanner et al. (1993) found that nurses use the language
of “knowing the patient” to refer to at least two different
ways of knowing them: knowing the patient’s pattern of
responses and knowing the patient as a person. Knowing
the patient, as described in the studies above, involves
more than what can be obtained in formal assessments.
First, when nurses know a patient’s typical patterns of
responses, certain aspects of the situation stand out as
salient, while others recede in importance. Second, qualitative distinctions, in which the current picture is compared to this patient’s typical picture, are made possible
by knowing the patient. Third, knowing the patient allows
for individualizing responses and interventions.
Clinical Judgments Are Influenced by the Context
in Which the Situation Occurs and the Culture of
the Nursing Unit
Research on nursing work in acute care environments
has shown how contextual factors profoundly influence
nursing judgment. Ebright et al. (2003) found that nursing judgments made during actual work are driven by
more than textbook knowledge; they are influenced by
knowledge of the unit and routine workflow, as well as by
specific patient details that help nurses prioritize tasks.
Benner, Tanner, and Chesla (1997) described the social
embeddedness of nursing knowledge, derived from observations of nursing practice and interpretation of narrative accounts, drawn from multiple units and hospitals.
Benner’s and Ebright’s work provides evidence for the
significance of the social groups style, habits and culture
in shaping what situations require nursing judgment,
what knowledge is valued, and what perceptual skills are
taught.
A number of studies clearly demonstrate the effects
of the political and social context on nursing judgment.
Interdisciplinary relationships, notably status inequities
and power differentials between nurses and physicians,
contribute to nursing judgments in the degree to which
the nurse both pursues understanding a problem and is
able to intervene effectively (Benner et al., 1996; Bucknall
& Thomas, 1997). The literature on pain management confirms the enormous influence of these factors in adequate
pain control (Abu-Saad & Hamers, 1997).
Studies have indicated that decisions to test and treat
are associated with patient factors, such as socioeconomic
status (Scott, Schiell, & King, 1996). However, others have
suggested that social judgment or moral evaluation of patients is socially embedded, independent of patient characteristics, and as much a function of the pervasive norms
and attitudes of particular nursing units (Grieff & Elliot,
1994; Johnson & Webb, 1995; Lauri et al., 2001; McCarthy, 2003a; McDonald et al., 2003).
Journal of Nursing Education
tanner
Nurses Use a Variety of Reasoning Patterns Alone
or in Combination
The pattern evoked depends on nurses’ initial grasp
of the situation, the demands of the situation, and the
goals of the practice. Research has shown at least three
interrelated patterns of reasoning used by experienced
nurses in their decision making: analytic processes (e.g.,
hypothetico-deductive processes inherent in diagnostic
reasoning), intuition, and narrative thinking. Within each
of these broad classes are several distinct patterns, which
are evoked in particular situations and may be used alone
or in combination with other patterns. Rarely will clinicians use only one pattern in any particular interaction
with a client.
Analytic Processes. Analytic processes are those clinicians use to break down a situation into its elements. Its
primary characteristics are the generation of alternatives
and the systematic and rational weighing of those alternatives against the clinical data or the likelihood of achieving outcomes. Analytic processes typically are used when:
l One lacks essential knowledge, for example, beginning nurses, who might perform a comprehensive assessment and then sit down with the textbook and compare
the assessment data to all of the individual signs and
symptoms described in the book.
l There is a mismatch between what is expected and
what actually happens.
l One is consciously attending to a decision because
multiple options are available. For example, when there
are multiple possible diagnoses or multiple appropriate
interventions from which to choose, a rational analytic
process will be applied, in which the evidence in favor of
each diagnosis or the pros and cons of each intervention
are weighed against one another.
Diagnostic reasoning is one analytic approach that has
been extensively studied (Crow, Chase, & Lamond, 1995;
Crow & Spicer, 1995; Gordon, Murphy, Candee, & Hiltunen, 1994; Itano, 1989; Lindgren, Hallberg, & Norberg,
1992; McFadden & Gunnett, 1992; O’Neill, 1994a, 1994b,
1995; Tanner et al., 1987; Westfall, Tanner, Putzier, & Padrick, 1986; Timpka & Arborelius, 1990).
Intuition. Intuition has also been described in a number of studies. In nearly all of them, intuition is characterized by immediate apprehension of a clinical situation and
is a function of experience with similar situations (Benner, 1984; Benner & Tanner, 1987; Pyles & Stern, 1983;
Rew, 1988). In most studies, this apprehension is often
recognition of a pattern (Benner et al., 1996; Leners, 1993;
Schraeder & Fischer, 1987).
Narrative Thinking. Some evidence also exists that
there is a narrative component to clinical reasoning.
Twenty years ago, Jerome Bruner (1986), a psychologist
noted for his studies of cognitive development, argued
that humans think in two fundamentally different ways.
He labeled the first type of thinking paradigmatic (i.e.,
thinking through propositional argument) and the second,
narrative (i.e., thinking through telling and interpreting
stories). The difference between these two types of thinkJune 2006, Vol. 45, No. 6
ing involves how human beings make sense of and explain
what they see.
Paradigmatic thinking involves making sense of something by seeing it as an instance of a general type. Conversely, narrative thinking involves trying to understand
the particular case and is viewed as human beings’ primary way of making sense of experience, through an interpretation of human concerns, intents, and motives. Narrative is rooted in the particular. Robert Coles (1989) and
medical anthropologist Arthur Kleinman (1988) have also
drawn attention to the narrative component, the storied
aspects of the illness experience, suggesting that only by
understanding the …
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