(1995). (2002). According to Flaherty (2006), the model demonstrates the change, interrelations, Actual minds, possible worlds. (1997). E-mail: [email protected]. Lauri, S., Salantera, S., Chalmers, K., E kman, S., Kim, H., Kap - peli, S., et al. Scott, A., Schiell, A., & King, M. (1996). AORN Journal, 70, 45-50. Reflection is the Reflection is widely used in nurs- & Pesut, 2004; Ruth-Sahd, 2003). Scandinavian Journal of Caring Sciences, 6 (2), 97-103. Similarly, a study conducted in Norway showed the inßu - ence of nursesÕ frameworks on assessments completed and decisions made ( E llefsen, 2004). Research by Benner et al. 6 207, CLINICAL J UDGM E NT MOD E L a breakdown or perceived breakdown in practice (Benner, 1991; Benner et al., 1996, Boud & Walker, 1998; Wong, Kem - ber, Chung, & Yan, 1995). Reßection Reßection-in-action and reßection-on-action together comprise a signiÞcant component of the model. (1993) found that nurses use the language of Òknowing the patientÓ to refer to at least two different ways of knowing them: knowing the patientÕs pattern of responses and knowing the patient as a person. Nursing Research, 36, 358-363. This guide is based on Tanner’s (2006) Research-Based Model of Clinical Judgment in Nursing which focuses on the role of nurses’ background, the context of the situation, and nurses’ relationships with their patients as fundamental to nursing process. Journal of Nurs - ing Education, 38, 171-174. Recognizing that sound clinical judgment is critical for safe and effective patient care, the National Council of State Boards of Nursing (NCSBN) determined the need for assessing clinical judgment on the Next Generation NCLEX (NGN). CiofÞ, J . Con - versely, narrative thinking involves trying to understand the particular case and is viewed as human beingsÕ prima - ry way of making sense of experience, through an inter - pretation of human concerns, intents, and motives. E x - perienced and skilled nursesÕ narratives and situations where caring action made a difference to the patient. 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. Tanner, C. (2006). In her research using narratives from practice, Benner described Ònarratives of learning,Ó stories from nursesÕ practice that triggered continued and in-depth review of a clinical situation, the nursesÕ responses to it, and their intent to learn from mistakes made. Lindgren, C., Hallberg, I.R., & Norberg, A. Tanner’s Clinical Judgment Model and its associated instrument, the Lasater Clinical Judgment Rubric (LCJR) have been used in the discipline of nursing, yet it is unclear if scores on the rubric actually translate to the completion of an indicated nursing action. Philadelphia: Lippincott Williams & Wilkins. Atkins, S., & Murphy, K. (1993). In most studies, this apprehension is often recognition of a pattern (Benner et al., 1996; Leners, 1993; Schraeder & Fischer, 1987). Nurses ÒunwittinglyÓ adopt one of three perspectives on health in aging: the decline perspective, the vulnerable perspective, or the healthful perspective. Studies of occupational therapists (Kautzmann, 1993; Mattingly, 1991; Mattingly & Fleming, 1994; McKay & Ryan, 1995), physicians (Borges & Waitzkin, 1995; Hunter, 1991), and nurses (Benner et al., 1996; Zerwekh, 1992) suggest that narrative reasoning creates a deep back - ground understanding of the patient as a person and that the cliniciansÕ actions can only be understood against that background. Wong, F.K.Y., Kember, D., Chung, L.Y.F., & Yan, L. (1995). That is a huge leap. Pain Management in Nursing, 1 (3), 79-87. Step in the Clinical Judgment Model What that step should accomplish. In addition, they must manage highly complicated processes, such as resolving conßicting family and care provider information, managing patient placement to appropriate levels of care, and coordinating complex discharges or admissions, amid interruptions that distract them from a focus on their clinical reasoning ( E bright et al., 2003). Clinical judgment development using structured classroom reflective practice: A qualitative study. This has relevance to nurse educators because it can help students strengthen their ability to make correct judgments by identifying breakdowns and identify areas of growth. Gastroenterology Nursing, 24, 182-191. E xpert 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. Journal of Nursing Administration, 34, 531- 538. Clinical judgments in pain management. Tanner’s Clinical Judgment Model and its associated instrument, the Lasater Clinical Judgment Rubric (LCJR) have been used in the discipline of nursing, yet it is unclear if scores on the rubric actually translate to the completion of an indicated nursing action. Heims and Boyd (1990) developed a clinical teaching approach, concept-based learning activities, that provides for this type of learning. Knowing the patient, as described in the studies above, involves more than what can be obtained in formal assessments. Clinical Judgments Are I nßuenced by the Context in Which the S ituation O ccurs and the Culture of the Nursing U nit Research on nursing work in acute care environments has shown how contextual factors profoundly inßuence nursing judgment. Journal of Advanced Nursing, 33, 503-511. (1993). Thinking like a nurse: Research-based model of clinical judgment in nursing. Tanner, C.A., Padrick, K.P., Westfall, U.A., & Putzier, D. J . doi: 10.1097/NND.0000000000000017. Advanced Practice Nursing Quarterly, 1 (4), 70-77. This concept analysis guided by Walker and Avant’s framework, dissects the concept to promote clarity and consensus. Intuition has also been described in a num - ber of studies. E arly recognition of cli - ent status changes: The importance of time. Ferrell, B.R., E berts, M.T., McCaffery, M., & Grant, M. (1993). Journal of Nursing Education, 134-139. A popular pedagogical framework for SBE is Tanner (2006) Model of Clinical Judgment. Nurses use a variety of reasoning models, depending on context. Les heuristiques de jugement, concept fréquemment employé dans le domaine de la cognition sociale, sont des opérations mentales automatiques, intuitives et rapides pouvant être statistiques ou non statistiques. Greipp, M. E . Kosowski, M.M., & Roberts, V.W. Western Journal of Nursing Research, 25, 701-719. 6 209, CLINICAL J UDGM E NT MOD E L concern for the patientsÕ and familiesÕ well-being. NursesÕ reßections on prob - lems associated with decision-making in critical care settings. Pediatric Nursing, 18, 517-520. Collaboration /Care Coordination/Evidence. 45, No. Clinical judgment is an elusive concept that educators struggle to present and assess. ing education to facilitate learning. Journal of Advanced Nursing, 28, 891-898. Concept-based learning activi - ties in clinical nursing education. These under - standings will collectively shape the nurseÕs expectations for this patient and his pain levels, setting up the possibil - ity of noticing whether those expectations are met. The social fabric of nursing knowledge. In nearly all of them, intuition is character - ized by immediate apprehension of a clinical situation and is a function of experience with similar situations (Ben - ner, 1984; Benner & Tanner, 1987; Pyles & Stern, 1983; Rew, 1988). Some specific examples of its use are provided below. Parker, C.B., Minick, P., & Kee, C.C. Business & Management Tanner’s Clinical Judgment Model. Contemporary models of clinical judgment must account for these com - plexities if they are to inform nurse educatorsÕ approaches to teaching. Ruth-Sahd, L.A. (2003). Boston: Heath. 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. Itano, J .K. 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. Learning about reßection. A rubric has been developed based on this model that provides spe - ciÞc feedback to students about their judgments and ways in which they can improve (Lasater, in press). Adding to this complexity in providing individualized patient care are many other complicating factors. Some speciÞc examples of its use are provided below. Fonteyn, M. E .