the terms “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.
