Tanner's Clinical Judgment Model Research Articles

Acute Care Nurses' Partnership With Patients to Recognise and Respond to Changes in Patients' Clinical States: AQualitative Study.

To explore and describe acute care nurses' partnership with patients to recognise and respond to changes in patients' clinical states. Acute care nurses' decisions to partner with patients to recognise deterioration in clinical states and to respond by activating a rapid response system improves patient outcomes. Acutely unwell patients can also experience clinical changes that include improvement and deterioration that does not trigger rapid response system activation over the course of hospitalisation from illness and treatment. How acute care nurses partner with patients in response to improvement and deterioration not triggering a rapid response system is not well-understood. An exploratory, descriptive study underpinned by Tanner's Clinical Judgement Model. Using purposive and quota sampling, 20 nurses with direct patient care responsibilities on one medical and one surgical ward in a large Australian hospital were recruited. Nonparticipant observations followed by semistructured interviews were conducted between January and May of 2021. Nurse-patient interactions were observed for 4 h, and verbally described and recorded. Semistructured interviews were recorded and explored nurses' reasoning behind decisions observed. Reflexive thematic analysis was used to analyse the data. Three themes were identified from the data: nurses checking in for changes; nurses forming judgements; and nurses partnering with patients to respond. Acute care nurses promoted subjective assessment based on patients' safety risks. Patients' participation in response to changes was prioritised based on acute care nurses' judgement of safety. Patients receive significant safety benefits when acute care nurses partner with patients in response to their experience of improvement and deterioration during acute illness. Further research should evaluate the sensitivity of subjective cues in patient assessment. Partnership with patients in assessment and management of improvement and deterioration improves the quality and safety of patient care. Assessment frameworks should equally prioritise the use of objective and subjective cues. Nursing education should promote the safety benefits of patient partnerships in responding to patient changes. Equator checklist COREQ. Data collected included description of patients' interactions with study participants.

Conceptualising personhood in nursing care for people with altered consciousness, cognition and behaviours: A discussion paper.

The aim of this discussion paper is to explore factors and contexts that influence how nurses might conceptualise and assign personhood for people with altered consciousness, cognition and behaviours. While a biomedical framing is founded upon a dichotomy between the body and self, such that the body can be subjected to a medical and objectifying gaze, relational theories of self, multiculturalism and technological advances for life-sustaining interventions present new dilemmas which necessitate discussion about what constitutes personhood. The concept of personhood is dynamic and evolving: where historical constructs of rationality, agency, autonomy and a conscious mind once formed the basis for personhood, these ideas have been challenged to encompass embodied, relational, social and cultural paradigms of selfhood. Themes in this discussion include: the right to personhood, mind-body dualism versus the embodied self; personhood as consciousness, rationality and narratives of self; social relational contexts of personhood and cultural contexts of personhood. Patricia Benner's and Christine Tanner's clinical judgement model is then applied to consider the implications for nursing care that seeks to reflexively incorporate personhood. Nurse clinicians are able to move between conceptions of personhood and act to support the body, as well as presumed autonomy and relational, social and cultural personhood. In doing so, they use analytical, intuitive and narrative reasoning which prioritises autonomous constructions of self. They also incorporate relational and social contexts of the person receiving care within the possibilities of technological advances and constraints of contextual resources.

Effects of simulation with problem-based learning (S-PBL) on nursing students’ clinical reasoning ability: based on Tanner’s clinical judgment model

BackgroundClinical reasoning ability, a complex cognitive and metacognitive process, is a crucial core competency required in nursing practice. Therefore, undergraduate nursing students should be provided with nursing education to strengthen their clinical reasoning ability based on real-life nursing scenarios.MethodsThis study was conducted using a quasi-experimental single-group pretest–posttest design. Three sessions (lasting three hours each) of Simulation with Problem-Based Learning (S-PBL) using high-risk obstetrics-gynecology scenarios were provided to 71 third-year nursing students of a university. The sessions were conducted from September to December 2022, and they aimed to strengthen their clinical reasoning ability. For data collection, an online survey was conducted using Rubric for Clinical Reasoning and learning satisfaction evaluation tool. Data were analyzed using descriptive statistics and repeated measures analysis of variance in SPSS.ResultsThe mean score of clinical reasoning ability significantly increased from 29.42 (standard deviation: 4.62) out of 40 points in the pre-test to 32.28 (4.36), 33.44 (5.35), and 33.80 (5.91) after the first, second, and third S-PBL sessions, respectively (F = 61.668, p < .001). The learning satisfaction score was as high as 107.04 (12.66) out of 120 points.ConclusionThis S-PBL program is an effective nursing education strategy to strengthen nursing students’ clinical reasoning ability. Future studies must examine learner variables and standardize the S-PBL design and operation process by comparison to a traditional teaching approach and a higher range of clincal reasoning ability.

The implementation of Tanner's Clinical Judgment Model and the Indonesian version of the Lasater Clinical Judgment Rubric in the clinical setting

A critical component for nurses to provide safe and quality care with strong patient outcomes is clinical judgment. This study aimed to identify the difference in the clinical judgment score in newly graduated nurses by implementing Tanner's Clinical Judgment Model. This study followed an experimental design with a pretest-posttest and involved thirty-two newly graduated nurses from three private hospitals in Indonesia. The intervention group had a scheduled post-conference with their preceptors using Tanner's Clinical Judgment Model's guidelines with high-level, open-ended questions for two consecutive weeks. Independent samples t-test was used to compare pre-and post-test scores utilizing the valid and reliable Indonesia version of the Lasater Clinical Judgment Rubric. There was no significant difference between the pre-test results of the intervention and control groups, with a significance value of 0.647. The results indicated a significant difference in the mean clinical judgment scores between the intervention and control groups after two weeks of intervention, where the intervention group's scores were higher than the control group's with a significance value of <0.001 with a mean difference of 6.75 and CI of 95 % (4.18–9.31). Tanner's Clinical Judgment Model showed a significant impact in increasing clinical judgment scores. The Indonesia version of the Lasater Clinical Judgment Rubric is a valuable tool for assessing and evaluating the development of clinical judgment and provides detailed targeted areas needing improvement. Preceptors and nursing leaders in the clinical setting should continue to use this model and tools to assist newly graduated nurses in developing clinical judgment skills during their transition period.

Preparing for the Next Generation NCLEX Using a Virtual Simulation.

Virtual clinical simulation is a digital innovation that augments clinical reasoning and clinical judgment, narrowing the theory-practice gap, preparing new graduates for the Next Generation NCLEX (National Council Licensure Examination), and mitigating the demand for clinical placement and clinical faculty. The purpose of this article is to describe an educational innovation employing a virtual clinical simulation using the tenets of Tanner's Clinical Judgment Model and a National League for Nursing Advancing Care Excellence for Seniors unfolding case. A virtual clinical simulation successfully served to replace direct care clinical for 86 undergraduate nursing students enrolled in a foundation nursing course, augmenting the students' ability to transfer and apply theoretical knowledge to clinical practice. This virtual clinical simulation served as a viable platform for teaching clinical reasoning and clinical judgment, mitigating the education-practice gap for new graduate registered nurses. [J Nurs Educ. 2024;63(7):485-489.].

Revising Reflection Assignments to Align With Clinical Judgment Measurement Model Language: Maximizing Critical Thinking, Feedback, and Measurement in Simulation.

Student reflection stimulates self-awareness, deep learning, insight into patient care challenges, and professional role development. As such, reflection assignments are an ideal target for revision using language associated with the steps of the clinical judgment measurement model (CJMM) to maximize critical thinking. Tanner's clinical judgment model aligns with the CJMM and underpins the curriculum in many nursing programs. Faculty used the model to update a simulation reflection assignment template, incorporating CJMM language and facilitating improved measurement of clinical judgment. Substantially improved student responses resulted during an initial quality improvement pilot study.

Frontline Nurses' clinical judgment in recognizing, understanding, and responding to patient deterioration: A qualitative study

BackgroundEarly warning systems and rapid response teams have been widely implemented in hospitals worldwide to facilitate early recognition and response to patient deterioration. Unfortunately, evidence suggests that these interventions have made little impact on unexpected cardiac or respiratory arrest, hospital mortality, unplanned admission to intensive care units, or hospital length of stay. These programs depend on nurses recognizing at risk patients and initiating a timely response. Although physiologic abnormalities commonly precede serious adverse events, nurses often fail to recognize or respond effectively. Clinical judgment is a critical component in the effective response to deterioration, yet little is known about factors that influence nurses' clinical judgment in these situations. Noticing, interpreting, and responding are aspects of clinical judgment and are essential to preventing further patient deterioration and serious adverse events. ObjectiveTo describe medical-surgical nurses' perceptions of factors that influenced their clinical judgment in situations of patient deterioration. DesignA qualitative descriptive design using individual, semi-structured interviews. Tanner's Clinical Judgment Model served as the framework for interview questions and data analysis. ParticipantsA purposive sample of 20 medical-surgical registered nurses were recruited from 10 adult medical-surgical units at an academic medical center hospital in the United States. MethodsTelephone interviews occurred between March and July 2018. A directed approach to content analysis was used to code the transcribed data and identify themes. ResultsEight themes related to each aspect of clinical judgment emerged from the analysis: Knowing the patient, Experience matters, Lots of small points where the system can fail, Making sense of the data, Something doesn't go together, Caught in the middle, Culture of teamwork, and Increased nursing workload. An overarching theme was Nurses' keen sense of responsibility. Findings revealed that factors within the nurse, the patient, and the work environment influence each component of noticing, interpreting, and initiating an effective response to deteriorating patients. ConclusionsFindings have implications for health care systems regarding interventions to support timely recognition and response to deterioration. Nurses' clinical judgment and factors that influence each aspect (noticing, interpreting, and responding) should be a key consideration in organizational efforts to improve the overall response to patient deterioration. Research is needed to enhance understanding of the contextual factors that impact nurses' clinical judgment to inform interventions to support timely recognition and response.

Effect of Manikin and Virtual Simulation on Clinical Judgment

Evidence suggests competency in clinical judgment may be lacking in new graduate nurses. Graduates from accelerated baccalaureate nursing (ABSN) programs have even less time to develop clinical judgment competency. Various simulation modalities, including high-fidelity manikin and virtual reality, have been used to develop clinical judgment in prelicensure students. However, the outcomes of these simulation modalities on clinical judgment in ABSN students is not well understood. An integrative literature review was conducted using five databases with primary research that examined the effect of manikin or virtual simulation on clinical judgment in BSN students. Fourteen studies were included in this review. The findings were organized using Tanner's Clinical Judgment Model. Findings from this review were mixed, with a lack of evidence comparing the two modalities. Future research should include comparison studies aimed at examining the effects of these modalities with ABSN students. [J Nurs Educ. 2022;61(12):693-699.].

A National Report on Clinical Judgment Model Use in Prelicensure Nursing Curricula.

This study examined US prelicensure nursing program use of clinical judgment models and teaching strategies to promote students' clinical judgment. Growing interest in teaching clinical judgment associated with upcoming changes in NCLEX-RN testing warrants exploration of how models and teaching strategies are currently used. A cross-sectional survey with multiple-choice and open-ended response items was used to examine programs' use of clinical judgment educational models. Of 234 participants (9 percent response rate), 27 percent reported using a model; 51 percent intended and 20 percent did not intend to start using a model. Tanner's clinical judgment model was the most used, followed by the clinical reasoning cycle. Models were used to inform design of teaching/learning strategies and facilitate clinical teaching and evaluation. Clinical judgment model use may increase as programs prepare for changes in NCLEX-RN. Research is needed to understand how model use contributes to measurable differences in clinical judgment skill.

Effectiveness of neonatal emergency nursing education through simulation training: Flipped learning based on Tanner's Clinical Judgement Model.

AimTo examine the effects of neonatal simulation‐based practice by applying flipped learning based on Tanner's clinical judgement model to pre‐simulation briefing for nursing students.DesignA quasi‐experimental non‐equivalent control group pre‐ and postintervention design.MethodsUsing Tanner's clinical judgment model, flipped learning was developed and applied to the pre‐simulation briefing curriculum prior to the neonatal nursing simulation exercise. Flipped learning was compared with a general pre‐simulation briefing with 65 South Korean students. From September 7, 2019, to October 25, 2019.ResultsThe experimental group's critical thinking, self‐confidence and clinical judgement ability increased, but knowledge, satisfaction and anxiety did not differ from that of the control group. Pre‐simulation briefing design focuses on improving students’ environmental comfort and reducing anxiety rather than developing complex reasoning skills and clinical judgement abilities. Applying flipped learning based on Tanner's clinical judgement model to pre‐simulation briefing increased critical thinking, self‐confidence and clinical judgement ability.

A survey of accuracy of nurses' clinical judgement of cutaneous graft-versus-host disease in Japan.

AimWe examined accuracy of nurses’ clinical judgement of graft‐versus‐host‐disease (GVHD) symptoms and related factors using Common Terminology Criteria for Adverse Events (CTCAE) for patients who developed chronic cutaneous GVHD after haematopoietic stem cell transplants.DesignCross‐sectional design using nationwide survey.MethodsA questionnaire survey based on Tanner's clinical judgement model to assess patients with chronic cutaneous GVHD using CTCAE was used. Free‐text descriptions and statistical analyses of relationship between correct responses and demographic data were performed.ResultsThe rate of correct responses for main symptoms of skin GVHD was < 50%; there was no statistical significance between correct responses and demographic data, knowledge about GVHD and collaborative practice with physicians. The accuracy of cutaneous GVHD clinical judgements was not directly related to nurses’ background. Educational opportunities that reinforce nurses’ abilities to reflect on knowledge and experiences to interpret patient symptoms are essential for improving accuracy of clinical judgement.

Using a clinical judgement model to understand the impact of validated pain assessment tools for burn clinicians and adult patients in the ICU: A multi-methods study

BackgroundIntensive care (ICU) patients’ burn pain is difficult to assess, communicate and address, risking chronic pain syndromes and psychological morbidity. AimsTo understand how the introduction of validated pain tools (Critical Care Pain Observation Tool [CPOT], Numerical Rating Scale [NRS], Pain Assessment in Advanced Dementia [PAINAD]) affected clinical judgement processes, analgesia/sedation administration and the experience of burn-injured patients. MethodsConsecutive chart review compared type and amount of analgesia/sedation administered, ventilation time and length of ICU/hospital stay between consecutive burn patients pre- and 6-months post-intervention (n=70). Analysis of 36 qualitative interviews with ICU clinicians (n=12) and burn-injured adults (n=12) pre- and post-intervention was guided by Tanner's (2006) Clinical Judgement Model. ResultsOverall, there was a significant increase in morphine (P=0.04) and propofol (P=0.04) use and a trend towards increased paracetamol (P=0.06) use post-intervention. There was a trend towards greater Midazolam use for TBSA<20% (P=0.06), and significantly increased propofol use for TBSA≥20% (P=0.03). Ventilation time and ICU/hospital length of stay were unchanged.Qualitative analysis revealed complex clinical judgement dependent on the context of the patient's situation, unit culture, background beliefs of clinicians and in knowing the patient. Whilst the CPOT and NRS enhanced analytic reasoning and pain advocacy, the PAINAD appeared redundant. ConclusionsEffective pain assessment, management and advocacy are assisted by evidence-based assessment practices.

Social Mission

Those who are hired to teach nursing students in the clinical setting often learn on the job and may lack a complete understanding of the teaching process. Knowledgeable clinical instruction is critical in facilitating student learning experiences, just as knowledgeable nursing care is crucial for providing safe patient care.Dr. Christine Tanner's clinical judgment model (CJM) illustrates the way practicing nurses develop clinical judgment. Many similarities exist with the way practicing nurses and novice clinical teachers learn to apply judgment in practice. An adaptation of Tanner's CJM (2006) was revealed as a useful framework in supporting the growth of clinical teaching judgment with novice clinical teachers.

Teaching Clinical Reasoning Piece by Piece: A Clinical Reasoning Concept-Based Learning Method

Recent discourse generates a more thorough understanding of what clinical reasoning entails. Although numerous strategies prioritize clinical reasoning development, teaching and evaluating the thinking involved in clinical reasoning remains a struggle for nurse educators, particularly regarding clinical education. In response, the author developed a concept-based clinical reasoning teaching method with weekly themes, lessons, and learning activities adapted from Tanner's clinical judgment model and Lasater's Clinical Judgment Rubric. The method offers an organized, consistent approach to teaching and learning clinical reasoning, with multiple opportunities for student reflection, instructor guidance, and discussing clinical reasoning concepts. Clinical education became transformed for both the nurse educator and nursing students as clinical reasoning became a visible part of students' budding nursing practice. Nurse faculty must ensure future nurses are prepared to think-inaction. The clinical reasoning teaching method offers one potential solution. [J Nurs Educ. 2018;57(12):727-735.].

Learning to Think Like a Clinical Teacher

Those who are hired to teach nursing students in the clinical setting often learn on the job and may lack a complete understanding of the teaching process. Knowledgeable clinical instruction is critical in facilitating student learning experiences, just as knowledgeable nursing care is crucial for providing safe patient care.Dr. Christine Tanner's clinical judgment model (CJM) illustrates the way practicing nurses develop clinical judgment. Many similarities exist with the way practicing nurses and novice clinical teachers learn to apply judgment in practice. An adaptation of Tanner's CJM (2006) was revealed as a useful framework in supporting the growth of clinical teaching judgment with novice clinical teachers.

Instructional Storytelling: Application of the Clinical Judgment Model in Nursing.

Little is known about the teaching and learning implications of instructional storytelling (IST) in nursing education or its potential connection to nursing theory. The literature establishes storytelling as a powerful teaching-learning method in the educational, business, humanities, and health sectors, but little exploration exists that is specific to nursing. An example of a story demonstrating application of the domains of Tanner's clinical judgment model links storytelling with learning outcomes appropriate for the novice nursing student. Application of Tanner's clinical judgment model offers consistency of learning experience while preserving the creativity inherent in IST. Further research into student learning outcomes achievement using IST is warranted as a step toward establishing best practices with IST in nursing education. [J Nurs Educ. 2017;56(5):305-308.].

Simulation-Based Learning: Improving Knowledge and Clinical Judgment Within the NICU

BackgroundNeonatal critical care knowledge is beyond that required for nursing licensure. Knowledge gaps among neonatal intensive care unit (NICU) nurses for pulmonary, cardiovascular, and neurology areas were addressed using simulation in an effort to strengthen knowledge, improve clinical judgment, and affect patient outcomes. MethodsThe Tanner Model of Clinical Judgment (2006) was used as the conceptual framework. The quasi-experimental pre–post test design included n = 130. Participants received three sessions of simulated scenarios and structured debriefing. ResultsOverall differences in knowledge scores were noted: p = .0167 (Year 1) and p = .0021 (Year 2). Trended patterns demonstrated improvement over time for clinical judgment (Year 2) for both self- and evaluator ratings using the Lasater Clinical Judgment Rubric (2007). Clinical outcome trends of decreased ventilator days, increased utilization of alternative oxygen delivery methods, and stable intraventicular hemorrhage rate were realized. ConclusionsSimulation-based learning can be effective in advancing knowledge and clinical judgment for NICU nurses as evidenced in pre–post assessment scores/ratings. Clinical outcomes have been favorably impacted in areas influenced by nursing knowledge and clinical judgment.

Clinical Judgment Scripts as a Strategy to Foster Clinical Judgments.

Clinical judgment encompasses how nurses use their knowledge of the patient to generate, assess, and prioritize patient care alternatives. Previous research has identified debriefing as critical to developing clinical judgment. Best practice for debriefing has yet to be identified. The purpose of this research was to investigate whether a standard debriefing script, based on Tanner's clinical judgment model, could foster clinical judgment. Participants were senior nursing students in their final semester of study. Data were gathered and analyzed from three sources: independent raters observing students in simulation, participating students, and the students' clinical instructors. Students identified the script as an effective debriefing tool, and significant improvements were observed in clinical judgment scores from all data sources. The standardized debriefing script helped students focus on the learning process, resulting in student improvement in all areas of clinical judgment: noticing, interpreting, responding, and reflecting. [J Nurs Educ. 2016;55(12):691-695.].

Self-Reflection of Video-Recorded High-Fidelity Simulations and Development of Clinical Judgment.

Nurse educators are increasingly using high-fidelity simulators to improve prelicensure nursing students' ability to develop clinical judgment. Traditionally, oral debriefing sessions have immediately followed the simulation scenarios as a method for students to connect theory to practice and therefore develop clinical judgment. Recently, video recording of the simulation scenarios is being incorporated. This qualitative, interpretive description study was conducted to identify whether self-reflection on video-recorded high-fidelity simulation (HFS) scenarios helped prelicensure nursing students to develop clinical judgment. Tanner's clinical judgment model was the framework for this study. Four themes emerged from this study: Confidence, Communication, Decision Making, and Change in Clinical Practice. This study indicated that self-reflection of video-recorded HFS scenarios is beneficial for prelicensure nursing students to develop clinical judgment. [J Nurs Educ. 2016;55(9):522-527.].

Pursuing Improvement in Clinical Reasoning: Development of the Clinical Coaching Interactions Inventory.

Clinical coaching has been identified as a signature pedagogy in nursing education. Recent findings indicate that clinical coaching interactions in the clinical learning environment fail to engage students in the higher order thinking skills believed to promote clinical reasoning. The Clinical Coaching Interactions Inventory (CCII) was based on evidence of supervisor questioning techniques, the Tanner clinical judgment model, Bloom's Taxonomy, and simulation evaluation tools. Content validity was established with expert assessment, student testing for clarity, and calculation of scale-content validity index/average (S-CVI/Ave). Reliability was established with Kuder-Richardson Formula 20 (KR-20). CVI (S-CVI/Ave) was .91, and KR-20 was .70. The CCII identified differences in clinical coaching behaviors in university faculty supervisors and staff nurse preceptor supervisors. The CCII advances the measurement of clinical coaching interactions from qualitative to quantitative. Ultimately, results from use of this inventory may facilitate the design of prelicensure clinical coaching strategies that promote the improvement of students' clinical reasoning skill. [J Nurs Educ. 2016;55(9):495-504.].