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 instruction.

DefiNiTioN of TeRMs

In the nursing literature, the terms “clinical judg-
ment,” “problem solving,” “decision making,” and “critical
thinking” tend to be used interchangeably. In this article,
I will use the term “clinical judgment” to mean an inter-
pretation or conclusion about a patient’s needs, concerns,
or health problems, and/or the decision to take action (or
not), use or modify standard approaches, or improvise new
ones as deemed appropriate by the patient’s response.
“Clinical reasoning” is the term I will use to refer to the
processes by which nurses and other clinicians make their
judgments, and includes both the deliberate process of

Dr. Tanner is A.B. Youmans-Spaulding Distinguished Professor, Ore-
gon & Health Science University, School of Nursing, Portland, Oregon.

Address correspondence to Christine A. Tanner, PhD, RN, A.B.
Youmans-Spaulding Distinguished Professor, Oregon & Health Sci-
ence University, School of Nursing, 3455 SW U.S. Veterans Hospital
Road, Portland, OR 97239; e-mail: [email protected]

204 Journal of Nursing Education

TANNeR

generating alternatives, weighing them against the evi-
dence, and choosing the most appropriate, and those pat-
terns that might be characterized as engaged, practical
reasoning (e.g., recognition of a pattern, an intuitive clini-
cal grasp, a response without evident forethought).

Clinical judgment is tremendously complex. It is re-
quired in clinical situations that are, by definition, under-
determined, ambiguous, and often fraught with value con-
flicts among individuals with competing interests. Good
clinical judgment requires a flexible and nuanced ability
to recognize salient aspects of an undefined clinical situa-
tion, interpret their meanings, and respond appropriately.
Good clinical judgments in nursing require an under-
standing of not only the pathophysiological and diagnostic
aspects of a patient’s clinical presentation and disease, but
also the illness experience for both the patient and fam-
ily and their physical, social, and emotional strengths and
coping resources.

Adding to this complexity in providing individualized
patient care are many other complicating factors. On a
typical acute care unit, nurses often are responsible for
five or more patients and must make judgments about
priorities among competing patient and family needs
(ebright, Patterson, Chalko, & Render, 2003). In addition,
they must manage highly complicated processes, such as
resolving conflicting 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 (ebright et al., 2003). Contemporary
models of clinical judgment must account for these com-
plexities if they are to inform nurse educators’ approaches
to teaching.

ReseARCh oN CLiNiCAL JuDgMeNT

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

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CLINICAL jUDGMeNT MODeL

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).

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Nurses use a Variety of Reasoning Patterns Alone
or in Combination

The pattern evoked depends on nurses’ initial grasp
of the situation, the demands of the situation, and the
goals of the practice. Research has shown at least three
interrelated patterns of reasoning used by experienced
nurses in their decision making: analytic processes (e.g.,
hypothetico-deductive processes inherent in diagnostic
reasoning), intuition, and narrative thinking. Within each
of these broad classes are several distinct patterns, which
are evoked in particular situations and may be used alone
or in combination with other patterns. Rarely will clini-
cians use only one pattern in any particular interaction
with a client.

Analytic Processes. Analytic processes are those clini-
cians use to break down a situation into its elements. Its
primary characteristics are the generation of alternatives
and the systematic and rational weighing of those alterna-
tives against the clinical data or the likelihood of achiev-
ing outcomes. Analytic processes typically are used when:

l One lacks essential knowledge, for example, begin-
ning nurses, who might perform a comprehensive assess-
ment and then sit down with the textbook and compare
the assessment data to all of the individual signs and
symptoms described in the book.

l There is a mismatch between what is expected and
what actually happens.

l One is consciously attending to a decision because
multiple options are available. For example, when there
are multiple possible diagnoses or multiple appropriate
interventions from which to choose, a rational analytic
process will be applied, in which the evidence in favor of
each diagnosis or the pros and cons of each intervention
are weighed against one another.
Diagnostic reasoning is one analytic approach that has
been extensively studied (Crow, Chase, & Lamond, 1995;
Crow & Spicer, 1995; Gordon, Murphy, Candee, & Hil-
tunen, 1994; Itano, 1989; Lindgren, Hallberg, & Norberg,
1992; McFadden & Gunnett, 1992; O’Neill, 1994a, 1994b,
1995; Tanner et al., 1987; Westfall, Tanner, Putzier, & Pa-
drick, 1986; Timpka & Arborelius, 1990).

Intuition. Intuition has also been described in a num-
ber of studies. 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). In most studies, this apprehension is often
recognition of a pattern (Benner et al., 1996; Leners, 1993;
Schraeder & Fischer, 1987).

Narrative Thinking. Some evidence also exists that
there is a narrative component to clinical reasoning.
Twenty years ago, jerome Bruner (1986), a psychologist
noted for his studies of cognitive development, argued
that humans think in two fundamentally different ways.
He labeled the first type of thinking paradigmatic (i.e.,
thinking through propositional argument) and the second,
narrative (i.e., thinking through telling and interpreting
stories). The difference between these two types of think-

ing involves how human beings make sense of and explain
what they see.

Paradigmatic thinking involves making sense of some-
thing by seeing it as an instance of a general type. Con-
versely, narrative thinking involves trying to understand
the particular case and is viewed as human beings’ prima-
ry way of making sense of experience, through an inter-
pretation of human concerns, intents, and motives. Nar-
rative is rooted in the particular. Robert Coles (1989) and
medical anthropologist Arthur Kleinman (1988) have also
drawn attention to the narrative component, the storied
aspects of the illness experience, suggesting that only by
understanding the meaning people attribute to the illness,
their ways of coping, and their sense of future possibility
can sensitive and appropriate care be provided (Barkwell,
1991). 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 clinicians’ actions can only be understood against that
background. Studies also suggest that narrative is an im-
portant tool of reflection, that having and telling stories of
one’s experience as clinicians helps turn experience into
practical knowledge and understanding (Astrom, Norberg,
Hallberg, & jansson, 1993; Benner et al., 1996).

Other reasoning patterns have been described in the lit-
erature under a variety of names. For example, Benner et
al. (1998) explored the use of modus-operandi thinking, or
detective work. Brannon and Carson (2003) described the
use of several heuristics, as did Simmons et al. (2003). It
is clear from the research to date, no single reasoning pat-
tern, such as nursing process, works for all situations and
all nurses, regardless of level of experience. The reason-
ing pattern elicited in any particular situation is largely
dependent on nurses’ initial clinical grasp, which in turn,
is influenced by their background, the context for decision
making, and their relationship with the patient.

Reflection on Practice is often Triggered by
Breakdown in Clinical Judgment and is Critical
for the Development of Clinical Knowledge and
improvement in Clinical Reasoning

Dewey first introduced the idea of reflection and its im-
portance to critical thinking in 1933, defining it as “the
turning over of a subject in the mind and giving it serious
and consecutive consideration” (p. 3). Recent interest in re-
flective practice in nursing was fueled, in part, by Schön’s
(1983) studies of professional practice and his challenges
of the “technical-rationality model” of knowledge in prac-
tice disciplines. The past 2 decades have produced a large
body of nursing literature on reflection, and two recent
reviews provide an excellent synthesis of this literature
(Kuiper & Pesut, 2004; Ruth-Sahd, 2003).

Literature linking reflection and clinical judgment is
somewhat more sparse. However, some evidence exists
that there is typically a trigger event for a reflection, often

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CLINICAL jUDGMeNT MODeL

a breakdown or perceived breakdown in practice (Benner,
1991; Benner et al., 1996, Boud & Walker, 1998; Wong, Kem-
ber, Chung, & Yan, 1995). In her research using narratives
from practice, Benner described “narratives of learning,”
stories from nurses’ practice that triggered continued and
in-depth review of a clinical situation, the nurses’ responses
to it, and their intent to learn from mistakes made.

Studies have also demonstrated that engaging in reflec-
tion enhances learning from experience (Atkins & Mur-
phy, 1993), helps students expand and develop their clini-
cal knowledge (Brown & Gillis, 1999; Glaze, 2001, Hyrkas,
Tarkka, & Paunonen-Ilmonen, 2001; Paget, 2001), and im-
proves judgment in complex situations (Smith, 1998), as
well as clinical reasoning (Murphy, 2004).

A ReseARCh-BAseD MoDeL
of CLiNiCAL JuDgMeNT

The model of clinical judgment proposed in this article
is a synthesis of the robust body of literature on clinical
judgment, accounting for the major conclusions derived
from that literature. It is relevant for the type of clini-
cal situations that may be rapidly changing and require
reasoning in transitions and continuous reappraisal and
response as the situation unfolds. 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.

The overall process includes four aspects (figure):
l A perceptual grasp of the situation at hand, termed

“noticing.”
l Developing a sufficient understanding of the situa-

tion to respond, termed “interpreting.”

l Deciding on a course
of action deemed appropri-
ate for the situation, which
may include “no immediate
action,” termed “respond-
ing.”

l Attending to patients’
responses to the nursing
action while in the process
of acting, termed “reflect-
ing.”

l Reviewing the out-
comes of the action, focus-
ing on the appropriate-
ness of all of the preceding
aspects (i.e., what was
noticed, how it was inter-
preted, and how the nurse
responded).

Noticing
In this model, noticing

is not a necessary out-
growth of the first step

of the nursing process: assessment. Instead, it is a func-
tion of nurses’ expectations of the situation, whether or
not they are made explicit. These expectations stem from
nurses’ knowledge of the particular patient and his or her
patterns of responses; their clinical or practical knowledge
of similar patients, drawn from experience; and their text-
book knowledge. For example, a nurse caring for a post-
operative patient whom she has cared for over time will
know the patient’s typical pain levels and responses. Nurs-
es experienced in postoperative care will also know the
typical pain response for this population of patients and
will understand the physiological and pathophysiological
mechanisms for pain in surgeries like this. These under-
standings will collectively shape the nurse’s expectations
for this patient and his pain levels, setting up the possibil-
ity of noticing whether those expectations are met.

Other factors will also influence nurses’ noticing of a
change in the clinical situation that demands attention,
including nurses’ vision of excellent practice, their val-
ues related to the particular patient situation, the cul-
ture on the unit and typical patterns of care on that unit,
and the complexity of the work environment. The factors
that shape nurses’ noticing, and, hence, initial grasp, are
shown on the left side of the figure.

interpreting and Responding
Nurses’ noticing and initial grasp of the clinical situa-

tion trigger one or more reasoning patterns, all of which
support nurses’ interpreting the meaning of the data and
determining an appropriate course of action. For exam-
ple, when a nurse is unable to immediately make sense of
what he or she has noticed, a hypothetico-deductive rea-
soning pattern might be triggered, through which inter-
pretive or diagnostic hypotheses are generated. Additional

Figure. Clinical Judgment Model.

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assessment is performed to help rule out hypotheses until
the nurse reaches an interpretation that supports most of
the data collected and suggests an appropriate response.
In other situations, a nurse may immediately recognize
a pattern, interpret and respond intuitively and tacitly,
confirming his or her pattern recognition by evaluating
the patient’s response to the intervention. In this model,
the acts of assessing and intervening both support clini-
cal reasoning (e.g., assessment data helps guide diag-
nostic reasoning) and are the result of clinical reasoning.
The elements of interpreting and responding to a clinical
situation are presented in the middle and right side of the
figure.

Reflection
Reflection-in-action and reflection-on-action together

comprise a significant component of the model. Reflection-
in-action refers to nurses’ ability to “read” the patient—how
he or she is responding to the nursing intervention—and
adjust the interventions based on that assessment. Much
of this reflection-in-action is tacit and not obvious, unless
there is a breakdown in which the expected outcomes of
nurses’ responses are not achieved.

Reflection-on-action and subsequent clinical learning
completes the cycle; showing what nurses gain from their
experience contributes to their ongoing clinical knowledge
development and their capacity for clinical judgment in
future situations. 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. each situation is an opportunity for clinical learn-
ing, given a supportive context and nurses who have de-
veloped the habit and skill of reflection-on-practice. To
engage in reflection requires a sense of responsibility,
connecting one’s actions with outcomes. Reflection also re-
quires knowledge outcomes: knowing what occurred as a
result of nursing …