Youmans-Spaulding Distinguished Professor,
Youmans-Spaulding Distinguished Professor,
Dr.Tanner is A.B.Youmans-Spaulding Distinguished Professor, Ore- gon & Health Science University, School of Nursing, Portland, Oregon.
Address correspondence to Christine A. Tanner, PhD, RN, A.B. Youmans-Spaulding Distinguished Professor, Oregon & Health Sci- ence University, School of Nursing, 3455 SW U.S. Veterans Hospital Road, Portland, OR 97239; e-mail: tannerc@ohsu.edu.
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, pro- ceeding with planning and implementing nursing inter- ventions directed toward the resolution of the diagnosed problems, and culminating in the evaluation of the effec- tiveness 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 judg- ment and the many factors that influence it, complete reli- ance 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 re- search 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.
DefiNiTioN of TeRMs
In the nursing literature, the terms “clinical judg- ment,” “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 inter- pretation 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
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generating alternatives, weighing them against the evi- dence, and choosing the most appropriate, and those pat- terns that might be characterized as engaged, practical reasoning (e.g., recognition of a pattern, an intuitive clini- cal grasp, a response without evident forethought).
Clinical judgment is tremendously complex. It is re- quired in clinical situations that are, by definition, under- determined, ambiguous, and often fraught with value con- flicts among individuals with competing interests. Good clinical judgment requires a flexible and nuanced ability to recognize salient aspects of an undefined clinical situa- tion, interpret their meanings, and respond appropriately. Good clinical judgments in nursing require an under- standing 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 fam- ily 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 com- plexities if they are to inform nurse educators’ approaches to teaching.
ReseARCh oN CLiNiCAL JuDgMeNT
