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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 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:

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 inter- vene?

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 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; O’Neill, 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 nurses’ 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, eberts, 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 “verbal protocols for analy- sis” (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; O’Neill, 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 “human performance interviews” (ebright et al., 2003; ebright, 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 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 ab- stractions 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, 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




nurse is able to respond intuitively, based on an immedi- ate clinical grasp and just “knowing what to do” (Cioffi, 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 refinement, extensions, and adjustment of textbook knowledge.

The profound influence of nurses’ knowledge and philosophical or value perspectives was demonstrated in a study by McCarthy (2003b). She showed that the wide variation in nurses’ ability to identify acute confusion in hospitalized older adults could be attributed to differenc- es in nurses’ philosophical perspectives on aging. Nurses “unwittingly” adopt one of three perspectives on health in aging: the decline perspective, the vulnerable perspective, or the healthful perspective. These perspectives influence the decisions the nurses made and the care they provided. Similarly, a study conducted in Norway showed the influ- ence of nurses’ frameworks on assessments completed and decisions made (ellefsen, 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 influence 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 “goods” 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 death—all of which set up what will be no- ticed in a particular clinical situation and shape nurses’ particular responses.

Therefore, undertreatment of pain might be understood as a moral issue, where action is determined more by cli- nicians’ attitudes toward pain, value for providing com- fort, and institutional and political impediments to moral agency than by a good understanding of the patient’s ex- perience of pain (Greipp, 1992). For example, a study by McCaffery et al. (2000) showed that nurses’ personal opin- ions about a patient, rather than recorded assessments, influence their decisions about pain treatment. In addi- tion, Slomka et al. (2000) showed that clinicians’ values influenced their use of clinical practice guidelines for ad- ministration of sedation.

sound Clinical Judgment Rests to some Degree on Knowing the Patient and his or her Typical Pattern of Responses, as well as engagement with the Patient and his or her Concerns

Central to nurses’ clinical judgment is what they de- scribe in their daily discourse as “knowing the patient.” In several studies (jenks, 1993; jenny & Logan, 1992; MacLeod, 1993; Minick, 1995; Peden-McAlpine & Clark, 2002; Tanner, Benner, Chesla, & Gordon, 1993), investiga- tors have described nurses’ 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 “knowing the patient” to refer to at least two different ways of knowing them: knowing the patient’s 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 patient’s 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 patient’s typical picture, are made possible by knowing the patient. Third, knowing the patient allows for individualizing responses and interventions.

Clinical Judgments Are influenced by the Context in Which the situation occurs and the Culture of the Nursing unit

Research on nursing work in acute care environments has shown how contextual factors profoundly influence nursing judgment. ebright et al. (2003) found that nurs- ing judgments made during actual work are driven by more than textbook knowledge; they are influenced by knowledge of the unit and routine workflow, as well as by specific 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. Benner’s and ebright’s work provides evidence for the significance 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- firms the enormous influence 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 & elliot, 1994; johnson & Webb, 1995; Lauri et al., 2001; McCar- thy, 2003a; McDonald et al., 2003).


Journal of Nursing Education

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