how to improve critical thinking as a nurse

Tanner’s Clinical Judgment Model: Enhancing Critical Thinking Skills in Nursing

Nov 12, 2024 | RN to BSN

To deliver the most holistic and compassionate care possible, nursing experts must value the crucial role that clinical judgment plays in modern nursing practice. Going far beyond simple symptom recognition, clinical judgment involves drawing on a comprehensive framework that combines observations and information to aid in decision-making related to patient care.

Understanding Tanner’s Clinical Judgment Model

In the words of the nursing education resource  SimpleNursing , clinical judgment can help decide “the best course of action for optimal patient outcomes” through a “thorough assessment of a patient’s condition and the application of evidence-based knowledge and critical thinking.”

To fully understand the numerous ways that clinical judgment can enhance critical thinking skills in nursing, it is useful to examine clinical judgment through the lens of Tanner’s Clinical Judgment Model. Often abbreviated as “TCJM” or simply “Tanner’s Model,” Tanner’s Clinical Judgment Model is a conceptual framework that guides nurses through the information gathering, assessment, and analysis processes that lead to effective decision-making.

Christine Tanner, PhD, RN, first published her four-phase model in 2006, identifying “noticing,” “interpreting,” “responding,” and “reflecting” as essential to nursing success. Since then, Tanner’s Model of clinical judgment in nursing has been a core component of college nursing programs in the United States and around the world.

The Four Domains of Tanner’s Model

Tanner’s Model breaks down into the following four components:

Noticing  – A nurse must stay attentive in the clinical setting to collect information that is relevant to a patient’s condition and need. This includes noticing subtle nonverbal cues such as body language and significant changes in appearance and/or behavior.
Interpreting  – A nurse must mentally synthesize, critically evaluate, and strategically analyze all collected patient information to form meaningful interpretations that impact patient health. This might mean recognizing problems that must be addressed, developing theories about patient conditions, or establishing valuable connections between various symptoms and cues.
Responding  – A nurse must be able to act appropriately in light of information gathered in the “noticing” phase and analyzed in the “interpreting” phase. Effective response to these phases requires weighing the risks and benefits of various clinical actions while prioritizing evidence-based interventions that meet specific patient needs.
Reflecting  – A nurse must engage in thorough self-assessment and address areas of improvement through continuous learning. Through reflection, nurses can critically analyze healthcare decisions while considering alternative decisions that may have improved patient outcomes. This stage of Tanner’s Model is key when it comes to closing gaps and knowledge and driving professional growth.

Though the four domains of Tanner’s Model of clinical judgment can be viewed as sequential steps, nurses should be prepared to shift into any of them as necessary. For example, as nurses respond to meet patient needs with a specific course of action, they should concurrently strive to notice cues or patterns that indicate changes in health condition.

The Role of Context and Experience in   Clinical Judgment

SimpleNursing  praises Tanner’s Model for stressing “the importance of intuition and the integration of experiential and contextual cues in decision-making.” To further the delivery of safe and effective patient care, nurses must take context and experience into consideration.

Any and all factors surrounding patients, their condition, and the clinical situation in which they find themselves can suggest viable interventions and, in turn, elevate the quality of care. While emphasizing context in their clinical judgment, nurses should draw upon their unique background knowledge and previous professional experiences. They can improve performance today by making relevant connections that are informed by what they learned in the past.

Tanner’s Model and the Nursing Process

Although it is far from the only conceptual framework or step-by-step guide in the realm of nursing, Tanner’s Model tends to integrate seamlessly with other nursing process models like the well-known and widely implemented ADPIE model. The North American Nursing Diagnosis Association introduced the ADPIE model in the early 1970s to optimize the interpretation of patient data and enhance customized patient care.

Comprising “assessment,” “diagnosis,” “planning,” “implementation,” and “evaluation,” ADPIE provides a systematic way to approach the delivery of targeted and personalized care. By progressing through each of its component parts with strategic deliberation, nurses can improve patient outcomes in a variety of ways.

Fortunately, ADPIE dovetails with Tanner’s Model quite neatly, allowing a nurse to adhere to both frameworks simultaneously. The nursing education technology organization Elsevier  provides a one-to-one comparison of ADPIE and Tanner’s Model — which equates the “assessment” component of ADPIE with the “noticing” component of Tanner’s Model. Elsevier equates both “diagnosis” and “analysis” with “interpreting,” along with both “planning” and “implementation” with “responding.” Additionally, it draws a direct parallel between ADPIE’s “evaluation” component and Tanner’s Model’s “reflecting” component.

How Tanner’s Model Enhances Critical Thinking in Nursing

Paying careful attention to each of the four domains in Tanner’s Model, nurses can significantly improve their critical thinking skills. As they learn to approach each stage in the care process with systematic and strategic attention to detail, their ability to think critically will naturally develop and become stronger.

In a Journal of Nursing Education article,  Christine Tanner (creator of Tanner’s Model) writes, “Research on nursing work in acute care environments has shown how contextual factors profoundly influence nursing judgment.” She cites studies that confirm “nursing 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.”

Noticing: Cultivating Observational Skills

While focused on the “noticing” domain, nurses should pay close attention to patient cues, both obvious and elusive. To detect more subtle patient cues that are often unintentional, keen observational skills are required. After all, nurses who want to form the most accurate patient assessments must gather all the relevant information possible, and non-explicit cues can provide a wealth of relevant information.

A peer-reviewed study in  Mental Health in Family Medicine  determined that patient cues “can point towards ideas, worries or expectations the patient has not shared before” and that “exploring the patient’s ‘cues’ is helpful; it can serve as a ‘tool’ to clarify the agenda of the patient.” However, the study also recognized that healthcare providers “appear to have great difficulty in detecting and responding to more indirect forms of communication such as cues.”

Interpreting: Analyzing and Making Sense of Data

The textbook  Nursing Fundamentals  considers the detection of cues to be a fundamental building block of interpretation: “Cues are data that fall outside of expected findings that give the nurse a hint or indication of a patient’s potential problem or condition,” it states. “The nurse organizes these cues into patterns and creates a generalization.”

The chapter uses a hypothetical example to illustrate the power of inductive interpretation to help nurses formulate hypotheses that can improve patient outcomes. If a nurse notices that the site of a surgical incision is warm, red, and sore, she can recognize these cues as signs of infection. By presenting the hypothesis that the incision has become infected, she can precipitate a course of antibiotic treatment that could save a patient’s life.

Responding: Taking Action Based on   Clinical Judgment

Any hypothesis based on careful interpretation can suggest a clear course of action. The third component of Tanner’s Model, “responding,” demands solid clinical judgment. After all, the wrong treatment approach can exacerbate a medical problem rather than solve it.

To maintain sound clinical judgment when considering potential responses to interpreted data, begin by considering all valid or relevant intervention options. After evoking this option set, you can start to rank and prioritize each intervention based on factors that range from effectiveness to availability.

A poor nursing response can make the difference between life and death. Therefore, all proposed responses must be based on firm evidence.

Reflecting: Learning From Experience

While the first three domains of Tanner’s Model can substantially improve outcomes for the patient at hand, its benefits would generally end there without the fourth and final domain of “reflecting.” Reflection encourages nurses to learn from their experiences and continuously improve their clinical judgment skills.

Nurses should pay close attention to their own thoughts and feelings as well as feedback from patients, supervisors, and colleagues to evaluate their actions alongside the actions of others. This honest reflection is a great way to identify areas for improvement and adjust nursing approaches for optimal results.

Applying Tanner’s Model in Nursing Practice

The relative simplicity of Tanner’s Model makes it incredibly versatile and adaptable. In fact, nurses can apply it across the full spectrum of healthcare settings and patient care scenarios. Acute care and community health present just a couple of such clinical situations.

Using Tanner’s Model in Acute Care Settings

Nurses in hospitals, urgent care centers, and other emergency response settings can use Tanner’s Model to make rapid yet accurate clinical judgments in dynamic and often high-pressure environments. A wealth of independent research attests to the effectiveness of Tanner’s Model when employed by acute care nurses.

For example, a 2023 study in  Applied Nursing Research  examined the results of Tanner’s Model use among 32 recent nursing graduates who were working professionally at three different private hospitals. The study concluded, “The implementation of Tanner’s Clinical Judgment Model in the clinical setting resulted in a significant increase in the clinical judgment scores of newly graduated nurses.”

Applying Tanner’s Model in Community Health Nursing

Community health nurses can apply Tanner’s Model to assess the needs of individuals and families in their homes and communities, develop tailored care plans, and evaluate the effectiveness of various intervention approaches. Nurses should:

Strive to notice community health trends.
Interpret their findings by identifying relationships and patterns.
Respond with appropriate community health interventions.
Reflect on their relative success or failure based on solid community health metrics.

Ample evidence demonstrates the effectiveness of Tanner’s Model in the community health sector. In her Journal of Nursing Education article “ Clinical Judgment Development ,” Kathie Lasater, EdD, RN, examined the use of clinical judgment frameworks like Tanner’s Model in a wide range of clinical contexts. Lasater ultimately concluded that these frameworks have profound relevance in the field of community health.

Learn About Tanner’s Model as Part of a Comprehensive Nursing Program

Tanner’s Model of clinical judgment is just one among many helpful nursing frameworks and step-by-step guides that nursing students can examine. Looking to enroll in a quality college nursing program? At Nevada State University, our online RN to BSN  degree program is designed for working nursing professionals who want to earn their bachelor’s in nursing. Our comprehensive curriculum helps students enhance their clinical, analytical, and management skills in healthcare settings. Request more information or apply for this fully online program today.