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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 “narratives of learning,” stories from nurses’ practice that triggered continued and in-depth review of a clinical situation, the nurses’ responses to it, and their intent to learn from mistakes made.

Studies have also demonstrated that engaging in reflec- 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 ReseARCh-BAseD MoDeL of CLiNiCAL JuDgMeNT

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 (figure):

l A perceptual grasp of the situation at hand, termed “noticing.”

l Developing a sufficient understanding of the situa- tion to respond, termed “interpreting.”

l Deciding on a course of action deemed appropri- ate for the situation, which may include “no immediate action,” termed “respond- ing.”

l Attending to patients’ responses to the nursing action while in the process of acting, termed “reflect- ing.”

l 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 first step

of the nursing process: assessment. Instead, it is a func- tion of nurses’ expectations of the situation, whether or not they are made explicit. These expectations stem from nurses’ 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 patient’s 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 nurse’s expectations for this patient and his pain levels, setting up the possibil- ity of noticing whether those expectations are met.

Other factors will also influence nurses’ noticing of a change in the clinical situation that demands attention, including nurses’ 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 nurses’ noticing, and, hence, initial grasp, are shown on the left side of the figure.

interpreting and Responding

Nurses’ noticing and initial grasp of the clinical situa- tion trigger one or more reasoning patterns, all of which support nurses’ 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

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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, confirming his or her pattern recognition by evaluating the patient’s 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 figure.

Reflection

Reflection-in-action and reflection-on-action together comprise a significant component of the model. Reflection- in-action refers to nurses’ ability to “read” the patient—how he or she is responding to the nursing intervention—and adjust the interventions based on that assessment. Much of this reflection-in-action is tacit and not obvious, unless there is a breakdown in which the expected outcomes of nurses’ responses are not achieved.

Reflection-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. each situation is an opportunity for clinical learn- ing, given a supportive context and nurses who have de- veloped the habit and skill of reflection-on-practice. To engage in reflection requires a sense of responsibility, connecting one’s actions with outcomes. Reflection also re- quires knowledge outcomes: knowing what occurred as a result of nursing actions.

eDuCATioNAL iMPLiCATioNs of The MoDeL

This model provides language to describe how nurses think when they are engaged in complex, underdeter- mined clinical situations that require judgment. It also identifies 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 specific clinical learning activities might help promote skill in clinical judgment. Some specific examples of its use are provided below.

Faculty in the simulation center at my university have used the Clinical judgment Model as a guide for debrief- ing after simulation activities. Students readily under- stand the language. During the debriefing, 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 sufficient data or where they may have leaned toward a favored hypothesis.

Feedback can also be provided to students in debriefing after either real or simulated clinical experiences. A rubric has been developed based on this model that provides spe- cific feedback to students about their judgments and ways in which they can improve (Lasater, in press).

There is substantial evidence that guidance in reflec- tion helps students develop the habit and skill of reflection and improves their clinical reasoning, provided that such

TANNeR

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 patients’ and families’ well-being.

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guidance occurs in a climate of colleagueship and support (Kuiper & Pesut, 2004; Ruth-Sahd, 2003). Faculty have used the Clinical judgment Model as a guide for reflec- tion on clinical practice and report that its use improves students’ reflective abilities (Nielsen, Stragnell, & jester, in press).

Specific clinical learning activities can also be devel- oped to help students gain clinical knowledge related to a specific 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.

CoNCLusioNs

Thinking like a nurse, as described by this model, is a form of engaged moral reasoning. expert 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. educational practices must, therefore, help students engage with patients and act on a responsible vision for excellent care of those patients and with a deep

CLINICAL jUDGMeNT MODeL

concern for the patients’ and families’ 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 patient’s 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 reflection- on-practice, they will have learned to think like a nurse.

RefeReNCes

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., & jansson, L. (1993). ex- perienced and skilled nurses’ 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). Reflection: 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.

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