Art-rw-5

Thinking Like a Nurse: A Research-Based
Model of Clinical Judgment in Nursing
Christine A. Tanner, PhD, RN

ABsTRACT
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, five conclusions can
be drawn: (1) Clinical judgments are more influenced 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 influenced 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) Reflection 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 nurses’ background, the context of
the situation, and nurses’ relationship with their patients
as central to what nurses notice and how they interpret
findings, respond, and reflect on their response.

C
linical judgment is viewed as an essential skill
for virtually every health professional. Florence
Nightingale (1860/1992) firmly 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 influence it, complete reli-
ance on this single model to guide instruction may do a
significant 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 instru