Concepts For Clinical Judgment Discussion

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.

Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing Christine A. Tanner, PhD, RN Abstract 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:

Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand;

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;

Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit;

Nurses use a variety of reasoning patterns alone or in combination; and

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.

Clinical 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 judgment 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 too broadly reviewing 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. 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 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: 204

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. In 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, 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 June 2006, Vol. 45, No. 6 205 clinical judgment model nurse is able to respond intuitively, based on an immediate clinical grasp and just “knowing what to do” (Cioffi, 2000)