Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing Christine A. Tanner, PhD, RN A B S TRACT 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, Þve conclusions can be drawn: (1) Clinical judgments are more inßuenced 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 judg - ments are inßuenced 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 combina - tion; and (5) Reßection on practice is often triggered by a breakdown in clinical judgment and is critical for the de - velopment of clinical knowledge and improvement in clini - cal reasoning. A model based on these general conclusions emphasizes the role of nursesÕ background, the context of the situation, and nursesÕ relationship with their patients as central to what nurses notice and how they interpret Þndings, respond, and reßect on their response. C linical judgment is viewed as an essential skill for virtually every health professional. Florence Nightingale (1860/1992) Þrmly established that observations and their interpretation were the hallmarks of trained nursing practice. In recent years, clinical judg - 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 inßuence it, complete reli - ance on this single model to guide instruction may do a signiÞcant 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. DEFI N I T IO N OF TE RM S In the nursing literature, the terms Òclinical judg - ment,Ó Òproblem solving,Ó Òdecision making,Ó and Òcritical thinkingÓ tend to be used interchangeably. In this article, I will use the term Òclinical judgmentÓ to mean an inter - pretation or conclusion about a patientÕs 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 patientÕs response. ÒClinical reasoningÓ 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, 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. 204 Journal of Nursing Education

TANN E R 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 deÞnition, under - determined, ambiguous, and often fraught with value con - ßicts among individuals with competing interests. Good clinical judgment requires a ßexible and nuanced ability to recognize salient aspects of an undeÞned 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 patientÕs 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 Þve or more patients and must make judgments about priorities among competing patient and family needs ( E bright, Patterson, Chalko, & Render, 2003). In addition, they must manage highly complicated processes, such as resolving conßicting 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 ( E bright et al., 2003). Contemporary models of clinical judgment must account for these com - plexities if they are to inform nurse educatorsÕ approaches to teaching. RESE ARC H O N C L I N I CAL JU D G M E NT 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 Òclinical judgmentÓ and Òclinical decision making,Ó limited to E nglish language research and nursing jour - nals. Since 1998, an additional 71 studies on these topics have been published in the nursing literature. These stud - ies are largely descriptive and seek to address questions such as: 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 inter - vene? What is the role of knowledge and experience in these processes? What factors affect clinical reasoning patterns? The description of processes in these studies is strongly re - lated 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 infor - mal statisticians (Brannon & Carson, 2003; OÕNeill, 1994a, 1994b, 1995). Studies using information processing theory fo - cus on the cognitive processes of problem solving or diagnos - tic reasoning, accounting for limitations in human memory (Grobe, Drew, & Fonteyn, 1991; Simmons, Lanuza, Fonteyn, Hicks, & Holm, 2003). Studies drawing on phenomenologi - cal 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 tradi - tional theoretical perspectives, but rather seeks to describe nursesÕ clinical judgments in relation to particular clinical issues, such as diagnosis and intervention in elder abuse (Phillips & Rempusheski, 1985), assessment and manage - ment of pain (Abu-Saad & Hamers, 1997; Ferrell, E berts, McCaffery, & Grant, 1993; Lander, 1990; McCaffery, Fer - rell, & 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 Òverbal protocols for analy - sisÓ (Corcoran, 1986; Redden & Wotton, 2001; Simmons et al., 2003; Tanner, Padrick, Westfall, & Putzier, 1987) or re - spond to the vignette with probability estimates (McDon - ald et al, 2003; OÕNeill, 1994a). More recently, research has attempted to capture clinical judgment in actual prac - tice through interpretation of narrative accounts (Ben - ner et al., 1996, 1998; Kosowski & Roberts, 2003; Parker, Minick, & Kee, 1999; Ritter, 2003; White, 2003), observa - tions of and interviews with nurses in practice (McCarthy, 2003b), focused Òhuman performance interviewsÓ ( E bright et al., 2003; E bright, Urden, Patterson, & Chalko, 2004), chart audit (Higuchi & Donald, 2002), self-report of deci - sion-making processes (Lauri et al., 2001), or some com - bination 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 I nßuenced by What the Nurse Brings to the S ituation than the O bjective Data About the S ituation at H and 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 scientiÞc ab - stractions are Þlled 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, Peden- McAlpine & 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 J UDGM E NT MOD E L nurse is able to respond intuitively, based on an immedi - ate clinical grasp and just Òknowing what to doÓ (CiofÞ, 2000). However, the beginning nurse must reason things through analytically; he or she must learn how to recog - nize a situation in which a particular aspect of theoretical knowledge applies and begin to develop a practical knowl - edge that allows reÞnement, extensions, and adjustment of textbook knowledge. The profound inßuence of nursesÕ knowledge and philosophical or value perspectives was demonstrated in a study by McCarthy (2003b). She showed that the wide variation in nursesÕ ability to identify acute confusion in hospitalized older adults could be attributed to differenc - es in nursesÕ philosophical perspectives on aging. Nurses ÒunwittinglyÓ adopt one of three perspectives on health in aging: the decline perspective, the vulnerable perspective, or the healthful perspective. These perspectives inßuence the decisions the nurses made and the care they provided. Similarly, a study conducted in Norway showed the inßu - ence of nursesÕ frameworks on assessments completed and decisions made ( E llefsen, 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 inßuence 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 ÒgoodsÓ that show up across exemplars in nurs - ing, for example, the intention to humanize and personal - ize care, the ethic for disclosure to patients and families, the importance of comfort in the face of extreme suffering or impending deathÑall of which set up what will be no - ticed in a particular clinical situation and shape nursesÕ particular responses. Therefore, undertreatment of pain might be understood as a moral issue, where action is determined more by cli - niciansÕ attitudes toward pain, value for providing com - fort, and institutional and political impediments to moral agency than by a good understanding of the patientÕs ex - perience of pain (Greipp, 1992). For example, a study by McCaffery et al. (2000) showed that nursesÕ personal opin - ions about a patient, rather than recorded assessments, inßuence their decisions about pain treatment. In addi - tion, Slomka et al. (2000) showed that cliniciansÕ values inßuenced their use of clinical practice guidelines for ad - ministration of sedation. S ound Clinical Judgment Rests to S ome Degree on Knowing the Patient and H is or H er Typical Pattern of Responses, as well as E ngagement with the Patient and H is or H er Concerns Central to nursesÕ clinical judgment is what they de - scribe in their daily discourse as Òknowing the patient.Ó In several studies ( J enks, 1993; J enny & Logan, 1992; MacLeod, 1993; Minick, 1995; Peden-McAlpine & Clark, 2002; Tanner, Benner, Chesla, & Gordon, 1993), investiga - tors have described nursesÕ taken-for-granted understand - 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 typi - cally 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 Òknowing the patientÓ to refer to at least two different ways of knowing them: knowing the patientÕs 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 patientÕs typical patterns of responses, certain aspects of the situation stand out as salient, while others recede in importance. Second, quali - tative distinctions, in which the current picture is com - pared to this patientÕs typical picture, are made possible by knowing the patient. Third, knowing the patient allows for individualizing responses and interventions. Clinical Judgments Are I nßuenced by the Context in Which the S ituation O ccurs and the Culture of the Nursing U nit Research on nursing work in acute care environments has shown how contextual factors profoundly inßuence nursing judgment. E bright et al. (2003) found that nurs - ing judgments made during actual work are driven by more than textbook knowledge; they are inßuenced by knowledge of the unit and routine workßow, as well as by speciÞc patient details that help nurses prioritize tasks. Benner, Tanner, and Chesla (1997) described the social embeddedness of nursing knowledge, derived from obser - vations of nursing practice and interpretation of narra - tive accounts, drawn from multiple units and hospitals. BennerÕs and E brightÕs work provides evidence for the signiÞcance 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 con - Þrms the enormous inßuence 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 pa - tients is socially embedded, independent of patient char - acteristics, and as much a function of the pervasive norms and attitudes of particular nursing units (Grieff & E lliot, 1994; J ohnson & Webb, 1995; Lauri et al., 2001; McCar - thy, 2003a; McDonald et al., 2003). 206 Journal of Nursing Education

TANN E R Nurses U se a Variety of Reasoning Patterns Alone or in Combination The pattern evoked depends on nursesÕ 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 clini - cians use only one pattern in any particular interaction with a client. Analytic Processes. Analytic processes are those clini - cians 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 alterna - tives against the clinical data or the likelihood of achiev - ing outcomes. Analytic processes typically are used when: One lacks essential knowledge, for example, begin - ning nurses, who might perform a comprehensive assess - ment and then sit down with the textbook and compare the assessment data to all of the individual signs and symptoms described in the book. There is a mismatch between what is expected and what actually happens. 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, & Hil - tunen, 1994; Itano, 1989; Lindgren, Hallberg, & Norberg, 1992; McFadden & Gunnett, 1992; OÕNeill, 1994a, 1994b, 1995; Tanner et al., 1987; Westfall, Tanner, Putzier, & Pa - drick, 1986; Timpka & Arborelius, 1990). Intuition. Intuition has also been described in a num - ber of studies. In nearly all of them, intuition is character - ized by immediate apprehension of a clinical situation and is a function of experience with similar situations (Ben - ner, 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, J erome Bruner (1986), a psychologist noted for his studies of cognitive development, argued that humans think in two fundamentally different ways. He labeled the Þrst 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 think - ing involves how human beings make sense of and explain what they see. Paradigmatic thinking involves making sense of some - thing by seeing it as an instance of a general type. Con - versely, narrative thinking involves trying to understand the particular case and is viewed as human beingsÕ prima - ry way of making sense of experience, through an inter - pretation of human concerns, intents, and motives. Nar - rative 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 meaning people attribute to the illness, their ways of coping, and their sense of future possibility can sensitive and appropriate care be provided (Barkwell, 1991). Studies of occupational therapists (Kautzmann, 1993; Mattingly, 1991; Mattingly & Fleming, 1994; McKay & Ryan, 1995), physicians (Borges & Waitzkin, 1995; Hunter, 1991), and nurses (Benner et al., 1996; Zerwekh, 1992) suggest that narrative reasoning creates a deep back - ground understanding of the patient as a person and that the cliniciansÕ actions can only be understood against that background. Studies also suggest that narrative is an im - portant tool of reßection, that having and telling stories of oneÕs experience as clinicians helps turn experience into practical knowledge and understanding (Astrom, Norberg, Hallberg, & J ansson, 1993; Benner et al., 1996). Other reasoning patterns have been described in the lit - erature under a variety of names. For example, Benner et al. (1998) explored the use of modus-operandi thinking, or detective work. Brannon and Carson (2003) described the use of several heuristics, as did Simmons et al. (2003). It is clear from the research to date, no single reasoning pat - tern, such as nursing process, works for all situations and all nurses, regardless of level of experience. The reason - ing pattern elicited in any particular situation is largely dependent on nursesÕ initial clinical grasp, which in turn, is inßuenced by their background, the context for decision making, and their relationship with the patient. Reßection on Practice I s O ften Triggered by Breakdown in Clinical Judgment and I s Critical for the Development of Clinical Knowledge and I mprovement in Clinical Reasoning Dewey Þrst introduced the idea of reßection and its im - portance to critical thinking in 1933, deÞning it as Òthe turning over of a subject in the mind and giving it serious and consecutive considerationÓ (p. 3). Recent interest in re - ßective practice in nursing was fueled, in part, by SchnÕs (1983) studies of professional practice and his challenges of the Òtechnical-rationality modelÓ of knowledge in prac - tice disciplines. The past 2 decades have produced a large body of nursing literature on reßection, and two recent reviews provide an excellent synthesis of this literature (Kuiper & Pesut, 2004; Ruth-Sahd, 2003). Literature linking reßection and clinical judgment is somewhat more sparse. However, some evidence exists that there is typically a trigger event for a reßection, often June 2006, Vol. 45, No. 6 207

CLINICAL J UDGM E NT MOD E L a breakdown or perceived breakdown in practice (Benner, 1991; Benner et al., 1996, Boud & Walker, 1998; Wong, Kem - ber, Chung, & Yan, 1995). In her research using narratives from practice, Benner described Ònarratives of learning,Ó stories from nursesÕ practice that triggered continued and in-depth review of a clinical situation, the nursesÕ responses to it, and their intent to learn from mistakes made. Studies have also demonstrated that engaging in reßec - tion enhances learning from experience (Atkins & Mur - phy, 1993), helps students expand and develop their clini - cal knowledge (Brown & Gillis, 1999; Glaze, 2001, Hyrkas, Tarkka, & Paunonen-Ilmonen, 2001; Paget, 2001), and im - proves judgment in complex situations (Smith, 1998), as well as clinical reasoning (Murphy, 2004). A RESE ARC H-B A SE D MO D E L OF C L I N I CAL JU D G M E NT The model of clinical judgment proposed in this article is a synthesis of the robust body of literature on clinical judgment, accounting for the major conclusions derived from that literature. It is relevant for the type of clini - cal situations that may be rapidly changing and require reasoning in transitions and continuous reappraisal and response as the situation unfolds. While the model de - scribes the clinical judgment of experienced nurses, it also provides guidance for faculty members to help students diagnose breakdowns, identify areas for needed growth, and consider learning experiences that focus attention on those areas. The overall process includes four aspects ( F igure ): A perceptual grasp of the situation at hand, termed Ònoticing.Ó Developing a sufÞcient understanding of the situa - tion to respond, termed Òinterpreting.Ó Deciding on a course of action deemed appropri - ate for the situation, which may include Òno immediate action,Ó termed Òrespond - ing.Ó Attending to patientsÕ responses to the nursing action while in the process of acting, termed Òreßect - ing.Ó Reviewing the out - comes of the action, focus - ing on the appropriate - ness of all of the preceding aspects (i.e., what was noticed, how it was inter - preted, and how the nurse responded). Noticing In this model, noticing is not a necessary out - growth of the Þrst step of the nursing process: assessment. Instead, it is a func - tion of nursesÕ expectations of the situation, whether or not they are made explicit. These expectations stem from nursesÕ knowledge of the particular patient and his or her patterns of responses; their clinical or practical knowledge of similar patients, drawn from experience; and their text - book knowledge. For example, a nurse caring for a post - operative patient whom she has cared for over time will know the patientÕs typical pain levels and responses. Nurs - es experienced in postoperative care will also know the typical pain response for this population of patients and will understand the physiological and pathophysiological mechanisms for pain in surgeries like this. These under - standings will collectively shape the nurseÕs expectations for this patient and his pain levels, setting up the possibil - ity of noticing whether those expectations are met. Other factors will also inßuence nursesÕ noticing of a change in the clinical situation that demands attention, including nursesÕ vision of excellent practice, their val - ues related to the particular patient situation, the cul - ture on the unit and typical patterns of care on that unit, and the complexity of the work environment. The factors that shape nursesÕ noticing, and, hence, initial grasp, are shown on the left side of the F igure. I nterpreting and Responding NursesÕ noticing and initial grasp of the clinical situa - tion trigger one or more reasoning patterns, all of which support nursesÕ interpreting the meaning of the data and determining an appropriate course of action. For exam - ple, when a nurse is unable to immediately make sense of what he or she has noticed, a hypothetico-deductive rea - soning pattern might be triggered, through which inter - pretive or diagnostic hypotheses are generated. Additional Figure. Clinical Judgment Model. 208 Journal of Nursing Education

TANN E R assessment is performed to help rule out hypotheses until the nurse reaches an interpretation that supports most of the data collected and suggests an appropriate response. In other situations, a nurse may immediately recognize a pattern, interpret and respond intuitively and tacitly, conÞrming his or her pattern recognition by evaluating the patientÕs response to the intervention. In this model, the acts of assessing and intervening both support clini - cal reasoning (e.g., assessment data helps guide diag - nostic reasoning) and are the result of clinical reasoning. The elements of interpreting and responding to a clinical situation are presented in the middle and right side of the F igure. Reßection Reßection-in-action and reßection-on-action together comprise a signiÞcant component of the model. Reßection- in-action refers to nursesÕ ability to ÒreadÓ the patientÑhow he or she is responding to the nursing interventionÑand adjust the interventions based on that assessment. Much of this reßection-in-action is tacit and not obvious, unless there is a breakdown in which the expected outcomes of nursesÕ responses are not achieved. Reßection-on-action and subsequent clinical learning completes the cycle; showing what nurses gain from their experience contributes to their ongoing clinical knowledge development and their capacity for clinical judgment in future situations. As in any situation of uncertainty re - quiring judgment, there will be judgment calls that are insightful and astute and those that result in horrendous errors. E ach situation is an opportunity for clinical learn - ing, given a supportive context and nurses who have de - veloped the habit and skill of reßection-on-practice. To engage in reßection requires a sense of responsibility, connecting oneÕs actions with outcomes. Reßection also re - quires knowledge outcomes: knowing what occurred as a result of nursing actions. ED U CAT IO NAL IMPL I CAT IO N S OF T HE MO D E L This model provides language to describe how nurses think when they are engaged in complex, underdeter - mined clinical situations that require judgment. It also identiÞes areas in which there may be breakdowns where educators can provide feedback and coaching to help stu - dents develop insight into their own clinical thinking. The model also points to areas where speciÞc clinical learning activities might help promote skill in clinical judgment. Some speciÞc examples of its use are provided below. Faculty in the simulation center at my university have used the Clinical J udgment Model as a guide for debrief - ing after simulation activities. Students readily under - stand the language. During the debrieÞng, they are able to recognize failures to notice and factors in the situation that may have contributed to that failure (e.g., lack of clin - ical knowledge related to a particular course of recovery, lack of knowledge about a drug side effect, too many inter - ruptions during the simulation that caused them to lose focus on clinical reasoning). The recognition of reasoning patterns (e.g., hypothetico-deductive patterns) helps stu - dents identify where they may have reached premature conclusions without sufÞcient data or where they may have leaned toward a favored hypothesis. Feedback can also be provided to students in debrieÞng after either real or simulated clinical experiences. A rubric has been developed based on this model that provides spe - ciÞc feedback to students about their judgments and ways in which they can improve (Lasater, in press). There is substantial evidence that guidance in reßec - tion helps students develop the habit and skill of reßection and improves their clinical reasoning, provided that such guidance occurs in a climate of colleagueship and support (Kuiper & Pesut, 2004; Ruth-Sahd, 2003). Faculty have used the Clinical J udgment Model as a guide for reßec - tion on clinical practice and report that its use improves studentsÕ reßective abilities (Nielsen, Stragnell, & J ester, in press). SpeciÞc clinical learning activities can also be devel - oped to help students gain clinical knowledge related to a speciÞc patient population. Students need help recog - nizing the practical manifestations of textbook signs and symptoms, seeing and recognizing qualitative changes in particular patient conditions, and learning qualitative distinctions among a range of possible manifestations, common meanings, and experiences. Opportunities to see many patients from a particular group, with the skilled guidance of a clinical coach, could also be provided. Heims and Boyd (1990) developed a clinical teaching approach, concept-based learning activities, that provides for this type of learning. CO NCL USIO N S Thinking like a nurse, as described by this model, is a form of engaged moral reasoning. E xpert nurses enter the care of particular patients with a fundamental sense of what is good and right and a vision for what makes ex - quisite care. E ducational practices must, therefore, help students engage with patients and act on a responsible vision for excellent care of those patients and with a deep Educational practices must help students engage with patients and act on a responsible vision for excellent care of those patients and with a deep concern for the patientsÕ and familiesÕ well-being. June 2006, Vol. 45, No. 6 209

CLINICAL J UDGM E NT MOD E L concern for the patientsÕ and familiesÕ well-being. Clinical reasoning must arise from this engaged, concerned stance, always in relation to a particular patient and situation and informed by generalized knowledge and rational pro - cesses, but never as an objective, detached exercise with the patientÕs concerns as a sidebar. If we, as nurse educa - tors, help our students understand and develop as moral agents, advance their clinical knowledge through expert guidance and coaching, and become habitual in reßection- on-practice, they will have learned to think like a nurse. REFE R E NC ES Abu-Saad, H.H., & Hamers, J .P. (1997). Decision making and paediatric pain: A review. Journal of Advanced Nursing, 26, 946-952. Astrom, G., Norberg, A., Hallberg, I.R., & J ansson, L. (1993). E x - perienced and skilled nursesÕ narratives and situations where caring action made a difference to the patient. Scholarly In - quiry for Nursing Practice, 7, 183-193. Atkins, S., & Murphy, K. (1993). Reßection: A review of the litera - ture. Journal of Advanced Nursing, 18, 1188-1192. Barkwell, D.P. (1991). Ascribed meaning: A critical factor in cop - ing and pain attenuation in patients with cancer-related pain. Journal of Palliative Care, 7 (3), 5-14. Benner, P. (1983). Uncovering the knowledge embedded in clinical practice. Image, 15 (2), 36-41. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Benner, P. (1991). The role of experience, narrative, and commu - nity in skilled ethical comportment. Advances in Nursing Sci - ence, 14 (2), 1-21. Benner, P. (2004). Using the Dreyfus Model of skill acquisition to describe and interpret skills acquisition and clinical judg - ment in nursing practice and education. Bulletin of Science, 24, 188-199. Benner, P., Stannard, D., & Hooper, P.L. (1995). A Òthinking-in- actionÓ approach to teaching clinical judgment: A classroom innovation for acute care advanced practice nurses. Advanced Practice Nursing Quarterly, 1 (4), 70-77. Benner, P., & Tanner, C. (1987). Clinical judgment: How expert nurses use intuition. American Journal of Nursing, 87 (1), 23- 31. Benner, P., Tanner, C., & Chesla, C. (1996). Expertise in nurs - ing practice: Caring, clinical judgment and ethics. New York: Springer. Benner, P., Tanner, C.A., & Chesla, C.A. (1997). The social fabric of nursing knowledge. American Journal of Nursing, 97 (7), 16BBB-16DDD. Borges, S., & Waitzkin, H. (1995). WomenÕs narratives in primary care medical encounters. Women and Health, 23 (1), 29-56. Boud, D., & Walker, D. (1998). Promoting reßection in profession - al courses: The challenge of context. Studies in Higher Educa - tion, 23, 191-214. Brannon, L.A., & Carson, K.L. (2003). The representativeness heuristic: Inßuence on nursesÕ decision making. Applied Nurs - ing Research, 16, 201-204. Brown, S.C., & Gillis, M.A. (1999). Using reßective thinking to develop personal professional philosophies. Journal of Nurs - ing Education, 38, 171-174. Bruner, J . (1986). Actual minds, possible worlds. Cambridge, MA: Harvard University Press. Bucknall, T., & Thomas, S. (1997). NursesÕ reßections on prob - lems associated with decision-making in critical care settings. Journal of Advanced Nursing, 25, 229-237. CiofÞ, J . (2000). Recognition of patients who require emergency assistance: A descriptive study. Heart & Lung, 29, 262-268. Coles, R. (1989). The call of stories. Boston: Houghton-Mifßin. Corcoran, S. (1986). Planning by expert and novice nurses in cases of varying complexity. Research in Nursing and Health, 9, 155-162. Crow, R., Chase, J ., & Lamond, D. (1995). The cognitive compo - nent of nursing assessment: An analysis. Journal of Advanced Nursing, 22, 206-212. Crow, R., & Spicer, J . (1995). Categorisation of the patientÕs medi - cal condition: An analysis of nursing judgment. International Journal of Nursing Studies, 32, 413-422. Dewey, J . (1933). How we think: A restatement of the relation of reßective thinking to the education process. Boston: Heath. E bright, P.R., Patterson, E .S., Chalko, B.A., & Render, M.L. (2003). Understanding the complexity of registered nurse work in acute care settings. Journal of Nursing Administra - tion, 33, 630-638. E bright, P.R., Urden, L., Patterson, E ., & Chalko, B. (2004). Themes surrounding novice nurse near-miss and adverse- event situations. Journal of Nursing Administration, 34, 531- 538. E llefsen, B. (2004). Frames and perspectives in clinical nursing practice: A study of Norwegian nurses in acute care settings. Research and Theory for Nursing Practice, 18 (1), 95-109. Ferrell, B.R., E berts, M.T., McCaffery, M., & Grant, M. (1993). Clinical decision making and pain. Cancer Nursing, 14, 289- 297. Fonteyn, M. E . (1991). Implications of clinical reasoning studies for critical care nursing. Focus on Critical Care, 18, 322-327. Glaze, J . E . (2001). Reßection as a transforming process: Student advanced nurse practitionersÕ experiences of developing reßec - tive skills as part of an MSc programme. Journal of Advanced Nursing, 34, 639-647. Gordon, M., Murphy, C.P., Candee, D., & Hiltunen, E . (1994). Clinical judgment: An integrated model. Advances in Nursing Science, 16 (4), 55-70. Greipp, M. E . (1992). Undermedication for pain: An ethical model. Advances in Nursing Science, 15 (1), 44-53. Grieff, C.L., & E lliot, R. (1994). E mergency nursesÕ moral evalua - tion of patients. Journal of Emergency Nursing, 20, 275-279. Grobe, S. J ., Drew, J .A., & Fonteyn, M. E . (1991). A descriptive analysis of experienced nursesÕ clinical reasoning during a planning task. Research in Nursing & Health, 14, 305-314. Heims, M.L., & Boyd, S.T. (1990). Concept-based learning activi - ties in clinical nursing education. Journal of Nursing Educa - tion, 29, 249-254. Higuchi, K.A.S., & Donald, J .G. (2002). Thinking processes used by nurses in clinical decision making. Journal of Nursing Ed - ucation, 41, 145-153. Hunter, K.M. (1991). DoctorsÕ stories: The narrative structure of medical knowledge. Princeton, N J : Princeton University Press. Hyrkas, K., Tarkka, M.T., & Paunonen-Ilmonen, M. (2001). Teacher candidatesÕ reßective teaching and learning in a hos - pital settingÑChanging the pattern of practical training: A challenge to growing into teacherhood. Journal of Advanced Nursing, 33, 503-511. Itano, J .K. (1989). A comparison of the clinical judgment process of experienced registered nurses and student nurses. Journal of Nursing Education, 28, 120-126. J enks, J .M. (1993). The pattern of personal knowing in nurse de - cision making. Journal of Nursing Education, 32, 399-405. J enny, J . J ., & Logan, J . (1992). Knowing the patient: One aspect of clinical knowledge. Image, 24, 254-258. J ohnson, M., & Webb, C. (1995). Rediscovering unpopular pa - tients: The concept of social judgment. Journal of Advanced Nursing, 21, 466-475. Kautzmann, L.N. (1993). Linking patient and family stories to caregiversÕ use of clinical reasoning. American Journal of Oc - cupational Therapy, 47, 169-173. King, L., & Clark, J .M. (2002). Intuition and the development of expertise in surgical ward and intensive care nurses. Journal of Advanced Nursing, 37, 322-329. 210 Journal of Nursing Education

TANN E R Kleinman, A. (1988). The illness narratives: Suffering, healing and the human condition. New York: Basic Books. Kosowski, M.M., & Roberts, V.W. (2003). When protocols are not enough: Intuitive decision making by novice nurse practitio - ners. Journal of Holistic Nursing, 21 (1), 52-72. Kuiper, R.A., & Pesut, D. J . (2004). Promoting cognitive and metacog - nitive reßective reasoning skills in nursing practice: Self-regulat - ed learning theory. Journal of Advanced Nursing, 45, 381-391. Lander, J . (1990). Clinical judgments in pain management. Pain, 42 (1), 15-22. Lasater, K. (in press). High-Þdelity simulation and the develop - ment of clinical judgment: StudentsÕ experiences. Journal of Nursing Education. Lauri, S., Salantera, S., Chalmers, K., E kman, S., Kim, H., Kap - peli, S., et al. (2001). An exploratory study of clinical decision- making in Þve countries. Journal of Nursing Scholarship, 33 (1), 83-90. Leners, D.W. (1993). Nursing intuition: The deep connection. In D.A. Gaut ( E d.), A global agenda for sharing (pp. 223-240). New York: National League for Nursing. Lindgren, C., Hallberg, I.R., & Norberg, A. (1992). Diagnostic rea - soning in the care of a vocally disruptive severely demented pa - tient. Scandinavian Journal of Caring Sciences, 6 (2), 97-103. MacLeod, M. (1993). On knowing the patient: E xperiences of nurses undertaking care. In A. Radley ( E d.), Worlds of illness: Biographical and cultural perspectives on health and disease (pp. 38-56). London: Routledge. Mattingly, C. (1991). The narrative nature of clinical reasoning. American Journal of Occupational Therapy, 45, 998-1005. Mattingly, C., & Fleming, M.H. (1994). Clinical reasoning: Forms of inquiry in a therapeutic practice. Philadelphia: Davis. McCaffery, M., Ferrell, B.R., & Pasero, C. (2000). Nurses personal opinions about patientsÕ pain and their effect on recorded as - sessments and titration of opioid doses. Pain Management in Nursing, 1 (3), 79-87. McCarthy, M.C. (2003a). Detecting acute confusion in older adults: Comparing clinical reasoning of nurses working in acute, long- term and community health care environments. Research in Nursing and Health, 26, 203-212. McCarthy, M.C. (2003b). Situated clinical reasoning: Distinguish - ing acute confusion from dementia in hospitalized older adults. Research in Nursing and Health, 26, 90-101. McDonald, D.D., Frakes, M., Apostolidis, B., Armstrong, B., Gold - blatt, S., & Bernardo, D. (2003). E ffect of a psychiatric diagno - sis on nursing care for nonpsychiatric problems. Research in Nursing and Health, 26, 225-232. McFadden, E .A., & Gunnett, A. E . (1992). A study of diagnostic reasoning in pediatric nurses. Pediatric Nursing, 18, 517-520. McKay, E .A., & Ryan, S. (1995). Clinical reasoning through story telling: E xamining a studentÕs case story on a Þeldwork place - ment. British Journal of Occupational Therapy, 58, 234-238. Minick, P. (1995). The power of human caring: E arly recognition of patient problems. Scholarly Inquiry for Nursing Practice, 9, 303-317. Murphy, J .I. (2004). Using focused reßection and articulation to promote clinical reasoning: An evidence-based teaching strat - egy. Nursing Education Perspectives, 25, 226-231. Nielsen, A., Stragnell, S., & J ester, P. (in press). Guide for reßec - tion using the clinical judgment model. Journal of Nursing Education. Nightingale, F. (1992). Notes on nursing: What it is, what it is not (Commemorative ed.). Philadelphia: Lippincott Williams & Wilkins. (Original work published 1860) OÕNeill, E .S. (1994a). Home health nursesÕ use of base rate infor - mation in diagnostic reasoning. Advances in Nursing Science, 17 (2), 77-85. OÕNeill, E .S. (1994b). The inßuence of experience on community health nursesÕ use of the similarity heuristic in diagnostic rea - soning. Scholarly Inquiry for Nursing Practice, 8, 259-270. OÕNeill, E .S. (1995). Heuristics reasoning in diagnostic judgment. Journal of Professional Nursing, 11, 239-245. Paget, T. (2001). Reßective practice and clinical outcomes. Prac - titionersÕ views on how reßective practice has inßuenced their clinical practice. Journal of Clinical Nursing, 10, 204-214. Parker, C.B., Minick, P., & Kee, C.C. (1999). Clinical decision- making processes in perioperative nursing. AORN Journal, 70, 45-50. Peden-McAlpine, C., & Clark, N. (2002). E arly recognition of cli - ent status changes: The importance of time. Dimensions of Critical Care Nursing, 21, 144-151. Phillips, L., & Rempusheski, V. (1985). A decision making model for diagnosing and intervening in elder abuse and neglect. Nursing Research, 34, 134-139. Pyles, S.H., & Stern, P.N. (1983). Discovery of nursing gestalt in critical care nursing: The importance of the Gray Gorilla Syn - drome. Image, 15, 51-57. Redden, M., & Wotton, K. (2001). Clinical decision making by nurses when faced with third-space ßuid shift: How do they fare? Gastroenterology Nursing, 24, 182-191. Rew, L. (1988). Intuition in decision making. Image, 20, 150-154. Ritter, B. J . (2003). An analysis of expert nurse practitionersÕ diag - nostic reasoning. Journal of the American Academy of Nurse Practitioners, 15, 137-141. Ruth-Sahd, L.A. (2003). Reßective practice: A critical analysis of data-based studies and implications for nursing education. Journal of Nursing Education, 42, 488-497. Schn, D.A. (1983). The reßective practitioner: How professionals think in action. New York: Basic Books. Schraeder, B.D., & Fischer, D.K. (1987). Using intuitive knowl - edge in the neonatal intensive care nursery. Holistic Nursing Practice, 1 (3), 45-51. Scott, A., Schiell, A., & King, M. (1996). Is general practitioner de - cision making associated with patient socio-economic status. Social Science and Medicine, 42 (1), 35-46. Simmons, B., Lanuza, D., Fonteyn, M., Hicks, F., & Holm, K. (2003). Clinical reasoning in experienced nurses. Western Journal of Nursing Research, 25, 701-719. Slomka, J ., Hoffman-Hogg, L., Mion, L.C., Bair, N., Bobek, M.B., & Arroliga, A.C. (2000). Inßuence of cliniciansÕ values and per - ceptions on use of clinical practice guidelines for sedation and neuromuscular blockade in patents receiving mechanical ven - tilation. American Journal of Critical Care, 9, 412-418. Smith, A. (1998). Learning about reßection. Journal of Advanced Nursing, 28, 891-898. Tanner, C.A. (1998). State of the science: Clinical judgment and evidence-based practice: Conclusions and controversies. Com - municating Nursing Research, 31, 14-26. Tanner, C.A., Benner, P., Chesla, C., & Gordon, D.R. (1993). The phenomenology of knowing the patient. Image, 25, 273-280. Tanner, C.A., Padrick, K.P., Westfall, U.A., & Putzier, D. J . (1987). Diagnostic reasoning strategies of nurses and nursing stu - dents. Nursing Research, 36, 358-363. Timpka, T., & Arborelius, E . (1990). The primary-care nurseÕs di - lemmas: A study of knowledge use and need during telephone consultations. Journal of Advanced Nursing, 15, 1457-1465. Westfall, U. E ., Tanner, C.A., Putzier, D. J ., & Padrick, K.P. (1986). Activating clinical inferences. A component of diagnostic rea - soning in nursing. Research in Nursing and Health, 9, 269- 277. White, A.H. (2003). Clinical decision making among fourth-year nursing students: An interpretive study. Journal of Nursing Education, 42, 113-120. Wong, F.K.Y., Kember, D., Chung, L.Y.F., & Yan, L. (1995). As - sessing the level of student reßection from reßective journals. Journal of Advanced Nursing, 22, 48-57. Zerwekh, J .V. (1992). The practice of empowerment and coercion by expert public health nurses. Image, 24, 101-105. June 2006, Vol. 45, No. 6 211