Page 95 - Encyclopedia of Nursing Research

62 n CLInICAL JUDGMEnT

interview and observe nurses with varying Table 1
degrees of clinical expertise. In the inter- Four Phases of the Tanner CJM
C view process, nurses were asked to describe
outstanding clinical situations from their CJM Aspect Description
practice. Benner found that a holistic grasp noticing Perceiving the situation based
of clinical situations is a necessary precur- on clinical knowledge, clinical
experience, and knowing the patient
sor to expert clinical judgment (Benner, Interpreting Developing a deep understanding of
1984). Subsequent research supports these the situation
findings and discriminates between differ- Responding Intervening based on clinical
ences in clinical judgment among clinicians reasoning
with varying levels of experience (Corcoran, Reflecting Reading the patient response to
1986). In a 6-year interpretive study of nurs- interventions and making
adjustments to care based on that
ing practice, Benner et al. (1996) identified response; ongoing deliberation of
five interrelated aspects of clinical judg- practice to secure lessons learned
ment: (1) disposition toward what is good From Tanner, 2006.
and right, (2) extensive practical knowledge,
(3) emotional responses to the context of a
clinical situation, (4) intuition, and (5) role of Using the CJM as a conceptual frame-
narrative in understanding a patient’s story, work, Lasater (2007) developed the Clinical
meanings, intents and concerns. The authors Judgment Rubric to provide a means to
suggested that these aspects play a signifi- describe and quantify levels of performance
cant role in clinical judgment and deserve in clinical judgment. neilson further devel-
equal consideration along with the aspects oped this work though development of the
arising from the “rationalistic” perspective CJM study guide that uses the phases of
of clinical judgment. Tanner’s model to assist students in appli-
on the basis of a critical review of liter- cation of the model to assigned patients in
ature published through 2004, Tanner (2006) clinical practice (nielsen, Stragnell, & Jester,
proposed an alternative model of clinical 2007). Together, the Clinical Judgment Rubric
judgment. The Tanner Clinical Judgment and the study guide provide an evaluation
Model (CJM) represents the complexity of framework to assist faculty and preceptors
the construct including its interrelation with in recognizing and evaluating clinical judg-
the nurses’ background, the situational con- ment skills in more novice nurses. In addi-
text, and the degree to which knowing the tion, these tools provide guiding principles
patient influences interpretation of findings, and a standardized language for offering
response, and reflection on that response feedback to students as they work to develop
(Tanner, 2006). The CJM proposes a nonlinear clinical judgment skills.
process that characterizes the clinical judg- Although early research on clinical judg-
ment skills used by expert nurses. However, ment identified two divergent but legitimate
the model supports the diagnosis of break- perspectives of rationalistic and phenome-
down in clinical judgment with novice nurses nological approaches, the more recent work
by faculty members and preceptors. The CJM (Lasater, 2007; neilson 2007; Tanner, 2006)
also supports self-diagnosis of lapses in clin- indicates signs of convergence. The challenge
ical judgment by more experienced nurses for future research is continued integration
through self-reflection on practice. The CJM of these perspectives to apply what is known
includes four distinct yet iterative phases: (1) and to study the impact of integrated models
noticing, (2) interpreting, (3) responding, and on clinical reasoning and patient outcomes.
(4) reflecting. A description of each phase is Tanner’s CJM provides a framework that
included in Table 1. holds promise not only for supporting the