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CHAPTER 2 Clinical Judgment
judgment are noticing, interpreting, responding, and reflecting (Tanner, 2006). Noticing entails forming an impression of the client situation based on the nurse’s expectations, knowledge of the client, past experiences with similar clients, theoretical or textbook knowledge, and work environment (e.g., unit culture, patterns of care). For example, a nurse caring for an elderly client with pneumonia will look for certain signs and symptoms based on information learned from text- books, past experiences with both elderly adults and cli- ents with pneumonia, unit guidelines on the care of clients with respiratory illnesses, and knowledge of the client. Interpreting is the reasoning processes nurses use to make sense of the initial clinical situation. ■ Analytical reasoning would be used by a new nurse who probably relies heavily on information from text- books and limited client encounters. The nurse would develop several diagnoses and use the assessment data to select the most favorable one. Interventions are selected based on their likelihood of producing the desired outcome. ■ Intuitive reasoning is used by experienced nurses and is based on their in-depth knowledge to intuitively grasp the situation and know how to respond. ■ Narrative reasoning helps the nurse to use the infor- mation obtained to understand the meaning of the cli- ent’s illness experience, coping abilities, and vision of the future to develop person-centered plans of care. Responding is the course of action taken by the nurse. Reflection is a powerful tool that involves examin- ing the actions implemented for validation or modifica- tion, and it can foster personal and professional growth. Reflection-in-action is used during the implementation process to evaluate results and determine whether a dif- ferent course of action is needed. Reflection-on-action involves a self-evaluation process to learn and refocus actions in future situations. Reflection is essential for the development and expansion of intellectual and professional growth. Knowledge Check 2-2 ■ Define reflection . ■ Why is reflection an important process for nurses? ■ What are the two types of reflection? Think Like a Nurse 2-2: Clinical Judgment in Action ■ Reflect on Tanner’s clinical judgment model. How do errors or weaknesses in the noticing phase affect client outcomes? ■ Jan asked herself,“Lisa (the charge nurse) has been a nurse for 10 years—how did she know something was wrong?” How would you answer this question? Lasater Clinical Judgment Rubric (LCJR) The LCJR identifies 11 dimensions that are used to mea- sure each of the four aspects of Tanner’s clinical judg- ment model (Table 2-1).
Table 2-1 ➤ Model of Clinical Judgment With Corresponding Dimensions
ASPECTS OF CLINICAL JUDGMENT (TANNER, 2006) Noticing— understanding the situation or scenario
MEASUREMENT DIMENSIONS (LASATER, 2007) Focused observation—a perceptual understanding of the situation Recognizing deviations from expectations Information seeking
Prioritization of data
Interpreting—based on the use of evidence to form understanding
Making sense of data
Responding—selecting the best course of action
Manner of response— expectation of a calm,
rational, purposeful, confident response Concise, clear, comprehensive communication Well planned, executed, safe; appropriate actions (skillful)
Reflection—focusing on the outcomes
Reflection-in-action and reflection-on-action
Sources: Data from Tanner (2006) and Lasater (2007).
The LCRJ measures and categorizes the progressive development of clinical judgment in each dimension as beginning, developing, accomplished, and exemplary. The rubric assigns a ranking of 1 to 4 to each of the 11 dimensions as the student performs the simulation-based scenario or actual clinical experience. Participants’ devel- opment of clinical nursing judgment is scored as begin- ning (1 to 11), developing (12 to 22), accomplished (23 to 33), and exemplary (34 to 44; Lasater, 2007). Think Like a Nurse 2-3: Clinical Judgment in Action Using the LCJR, how would you categorize Jan’s level of clinical nursing judgment? National Council of State Boards of Nursing (NCSBN) Clinical Judgment Measurement (CJM) Model Why Is the CJM Model Important? (Fig. 2-1) Research revealed that many new graduate nurses enter the work setting with a “preparation-to-practice” gap (Kavanagh & Szweda, 2017). Most new nurses
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