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E DUCATIONAL I N N O VAT I O N S

Guide for Reflection Using the Clinical Judgment Model


Ann Nielsen, MN, RN; Susan Stragnell, MS, RN; and Priscilla Jester, MN, RN

ABSTRACT ical experiences (Johns, 1995; Kuiper ing of the situation. Reflection is the
Reflection is widely used in nurs- & Pesut, 2004; Ruth-Sahd, 2003). The integration of the two.
ing education to facilitate learning. idea for this project arose from con- Various authors have suggested
Student writing and thinking, how- cern about the quality of student de- that reflective writing promotes
ever, is not always of the quality scriptions of learning in a senior-level knowledge transfer (i.e., application
faculty expect or desire. This project precepted clinical practicum. Because of previous knowledge to current
originated from concern about the the faculty was not with the students situations), knowledge transforma-
quality of student descriptions of consistently in the clinical setting, tion (i.e., consideration of how cur-
clinical experiences in a senior-level unstructured reflective writing was rent experiences can be used in fu-
precepted clinical practicum. Provid- used to enhance communication. ture actions), critical thinking about
ing students with more structure and However, faculty noted wide variation and analysis of a given situation, and
guidance for consideration of clinical between students’ writing in terms of metacognition (i.e., understanding of
experiences, as well as thoughtful identification of significant aspects learning) (Di Vito-Thomas, 2005; Kui-
faculty feedback, can potentially en- of a given situation, critical think- per & Pesut, 2004; Schön, 1987). In
hance thinking and move students to- ing about the situation, description of addition, it allows students to explore
ward increased nursing competence. emotional aspects of the situation, as emotional aspects of a given situation
In this learning activity, a structured well as what was learned by the stu- (Bilinski, 2002; Bransford, Brown, &
guide was used to facilitate reflection. dent. Some students listed events and Cocking, 2000; Fink, 2003; Kuiper,
The accompanying rubric was used skills, whereas others described their 2004; Pierson, 1998; Wong, Kember,
to evaluate and communicate about thoughts and decision making with Chung, & Yan, 1995).
progress in the development of stu- great eloquence. The Guide for Re- Writing can be used to develop un-
dent thinking and clinical judgment. flection described in this article was derstanding and promotes “dialogue
developed to provide students with a with self,” which enhances higher-
structure that would help them make level thinking (Schmidt, 2004). To
eflection involves thoughtful more in-depth descriptions of clinical become critically reflective, one must

R consideration of an experi-
ence (Kuiper & Pesut, 2004).
In nursing education, reflection is
experiences and their thinking about
those situations.
challenge the established and habitual
patterns of expectations and question
the validity of assumed meanings. The
thought to promote learning from clin- reflective process begins when one re-
Background and Literature turns to the experience, recalls what
Received: February 4, 2006 Review has occurred, and replays the experi-
Accepted: April 12, 2006 Reflection ence. This is accomplished through
Ms. Nielsen and Ms. Jester are Instruc- Reflection helps move thought four key elements: relating new data
tors, Oregon Health & Science University, from an existing situation to emerging to that which is already known, seek-
School of Nursing, and Ms. Stragnell is In- situations and connect initial under- ing relationships among data, deter-
structor, University of Portland, School of standing with deeper understanding mining the authenticity of ideas and
Nursing, Portland, Oregon. Ms. Jester is also (Perry, 2000). In a review of the use of feelings, and making knowledge one’s
Community Health Nurse, Multnomah Coun- reflection in nursing, Pierson (1998) own (Wong et al., 1995).
ty Health Department, Portland, Oregon. discussed different kinds of thinking. Reflection is not an intuitive pro-
Address correspondence to Ann Nielsen, Calculative thinking is deliberate and cess but rather one that requires de-
MN, RN, Instructor, Oregon Health & Sci- involves managing a given situation velopment (Perry, 2000). Both struc-
ence University, School of Nursing, 3455 SW and applying knowledge to problem ture, in the form of cue questions, and
U.S. Veterans Hospital Road, Portland, OR solving. Contemplative thinking is guidance, in the form of faculty chal-
97239; e-mail: nielsena@ohsu.edu. spontaneous and explores the mean- lenging and supporting thinking, are

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EDUCATIONAL INNOVATIONS

necessary for novices to learn mean- and the family. Interpretation follows knowledge base has been acquired in
ingful reflection (Johns, 1995). Other noticing and is characterized by ana- traditional lecture format, the guide
strategies that promote transfer and lytic reasoning, narrative thinking, helps students describe how that
transformation of knowledge in re- intuition, and pattern recognition. knowledge was applied and integrat-
flective writing include identifying a This leads to responding (action), ed into the new situation and identify
clear purpose for the written reflec- which may include gathering more sources of information within the clin-
tion, making explicit the expectations data to aid interpretation of the situ- ical setting needed to enhance their
of the student, and providing probing ation or simply taking an appropriate understanding of the current clinical
questions (Bilinski, 2002; Schmidt, (or inappropriate) action. Evalua- situation. Students are guided to con-
2004). Identifying the nursing in- tion of the outcomes then follows and sider how the background knowledge
terventions used and reviewing why leads to appraisal of clinical learning was applied to patient assessment,
they either worked or did not work and reflection (Tanner, 2006). how all information gathered was in-
enhances student understanding of This model describes the complex- terpreted, and how they themselves
the learning that has occurred (Schön, ity of thought involved in expert nurs- responded to the clinical situation.
1987). Using the same prompts for ing. In our experience, use of the Clin- Finally, the guide promotes in-depth
each writing experience may promote ical Judgment Model to guide student reflection on the learning experience.
cognitive reasoning in future clinical reflection and faculty questioning When students respond to questions
situations (Kuiper, 2004). often results in deeper, more mean- about learning that occurred, meta-
Reflective writing provides anoth- ingful reflections on learning and fos- cognition is enhanced. When they re-
er means of communication between tering of movement toward greater spond to prompts about their feelings
students and faculty. When faculty competence in nursing care. about the situation, they connect with
response is included in the process, the human dimension of the situation,
a dialogue is created that encourages as well as the caring involved (Brans-
student exploration of more subtle The Learning Activity ford et al., 2000; Fink, 2003).
aspects and the deeper meaning of a Design After students complete the writ-
given situation (Bilinski, 2002). The Active learning is recognized as a ing, the faculty promptly respond to
enhanced faculty insight into stu- strategy that promotes understanding the students, guided by the evalua-
dent experiences can be used to guide of complex subject matter, as well as tion rubric. By asking questions that
student support (Landeen, Byrne, & transfer of learning to new situations invite students to think in new ways
Brown, 1995). Limitations of reflec- (Bransford et al., 2000). Fink (2003) about the situation, faculty help stu-
tive writing include vague objectives suggested three strategies for imple- dents move to the next level of perfor-
or expectations; use of formal grad- mentation of active learning: creating mance (Bilinski, 2002). Students have
ing, which can increase the power rich experiences that are tied to the the opportunity to either continue the
differential between faculty and stu- real world, finding new ways to intro- dialogue about this situation or move
dents; and decreased trust within the duce students to ideas, and promot- on to incorporate the feedback into
teacher-student relationship (Bilin- ing in-depth reflection about learn- the next patient encounter. Faculty
ski, 2002; Pierson, 1998). ing. The proposed learning activity is can encourage continued dialogue if
based on active learning in the real salient points require further explora-
Clinical Judgment Model world—in other words, the students’ tion. This social interaction provides
Tanner’s (2006) Clinical Judgment own clinical nursing experiences. The support for clinical progress (Benner,
Model offers a sensible way to un- Guide for Reflection Using Tanner’s Tanner, & Chesla, 1996, 1997).
derstand the ongoing influences and Clinical Judgment Model (Table) is
processes that result in nursing judg- used to structure student thinking Evaluation: Student Learning and
ments and actions and, ultimately, in about learning experiences in clinical Faculty Feedback
providing optimal nursing care. The situations. The Lasater (2007) Clini- If reflective writing has value as
model depicts constant change, inter- cal Judgment Rubric (see pp. 496-503 a process of personal transforma-
relations, and feedback loops, begin- of this issue) has been adapted for tion—a medium in which students
ning with the understanding that the faculty use in evaluation of student make essential links among theory,
nurse’s background and the context thinking and learning and in provid- research, and clinical practice—then
of the situation will influence every- ing feedback that helps students move the question of evaluation arises.
thing else. What gets noticed depends to new levels of competence. Fink (2003) delineated four essen-
on the many factors that comprise the The Guide for Reflection directs tial elements of effective feedback: it
background component of the model students to consider what knowledge should occur frequently, be given im-
(e.g., previous experience, theoreti- is brought to the experience, as well mediately, be discriminative, and be
cal and practical knowledge, culture as what new knowledge they need to lovingly delivered. Journal writing
of the unit, values, ethics, biases), the acquire to manage the situation, and can place students in a vulnerable po-
expectations of the current situation, to consider how to access that knowl- sition in which they may fear reveal-
and the relationship with the patient edge. Although some of students’ ing their true thoughts and feelings

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EDUCATIONAL INNOVATIONS

TABLE
Guide for Reflection Using Tanner’s (2006) Clinical Judgment Model
Instructions
This Guide for Reflection is intended to help you think about a given clinical situation you have encountered during the past week
and your nursing response to that situation. The situation can be a specific physiological patient problem, such as an elevation in
temperature, respiratory difficulty, or electrolyte imbalance. You may choose to describe a situation involving a patient’s family. The
situation can be a description of your role in interdisciplinary problem solving. The reflection situation may describe an ethical issue you
encountered in practice. Use the guide for reflection as a way to help you tell the story of the situation you encountered.
The guide provides you with a way of thinking about care that supports the development of your clinical judgment. Although there are
many ways of organizing your thinking about patient care and professional nursing practice, Tanner’s (2006) Clinical Judgment Model
provides the framework for the questions in this study guide. Your professional development is further supported with feedback from
faculty. Feedback about your reflections will be provided using the Lasater (2007) Clinical Judgment Rubric.

Introduction
Describe a nursing situation you encountered this week. (See the instructions above.)
Background
• Describe your relationship to the patient at the time you noticed the situation (e.g., previous contact with patient and/or family, the
quality of your relationship).
• Consider experiences you have had that helped you provide nursing care in this situation. Describe your formal knowledge (e.g.,
physiology, psychology, communication skills), previous nursing experience with a similar problem, and/or personal experiences that
helped guide you as you worked with the patient.
• Describe your beliefs about your role as the nurse in working on the situation.
• Describe any emotions you had about the situation.
Noticing
• What did you notice about the situation initially?
• Describe what you noticed as you spent more time with the patient and/or family.
Interpreting
• Describe what you thought about the situation (e.g., its cause, potential resolutions, patterns you noticed).
• Describe any similar situations you have encountered in practice before. Describe any similarities and differences you observed when
compared with the current situation.
• What other information (e.g., assessment data, evidence) did you decide you needed as you considered the situation? How did you
obtain this information? What help with problem solving did you get from your preceptor?
Your conclusion: What did your observations and data interpretation lead you to believe? How did they support your response to the
situation? Include pertinent pathophysiology and/or psychopathology.
Responding
• After considering the situation, what was your goal for the patient, family, and/or staff? What was your nursing response, or what
interventions did you do? List all actions that you took.
• Describe stresses you experienced as you responded to the patient or others involved in the situation.
Reflection-in-Action
• What happened? How did the patient, family, and/or staff respond? What did you do next?
Reflection-on-Action and Clinical Learning
• Describe three ways your nursing care skills expanded during this experience.
• Name three things you might do differently if you encounter this kind of situation again.
• What additional knowledge, information, and skills do you need when encountering this kind of situation or a similar situation in the
future?
• Describe any changes in your values or feelings as a result of this experience.

to faculty. Faculty cannot engage in students unless the power differen- evaluation of the process of writing
mutually reflective relationships with tial is removed (Pierson, 1998). Any to learn should focus on the progress

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EDUCATIONAL INNOVATIONS

Brain, mind, experience, and school


of student growth, not on the product dent level, and course competencies (Expanded ed.). Washington, DC: Na-
(Bilinski, 2002). The imperative that or objectives. For example, students tional Academy Press.
trust and sharing between faculty may be asked to or may choose to Di Vito-Thomas, P. (2005). Nursing stu-
and students be maintained in the reflect on a physiological problem, a dent stories on learning how to think
like a nurse. Nurse Educator, 30, 133-
written dialogue suggests that fac- problem related to health care access,
136.
ulty guidance be provided in the form a family support situation, or a com- Fink, D. (2003). Creating significant nurs-
of feedback and guided questioning to munication problem among staff. In ing experiences. San Francisco: Jossey-
help students find ways to improve preparation for the learning activity, Bass.
but that the writing not be graded students are given a brief orientation Johns, C. (1995). Framing learning through
reflection within Carper’s fundamental
(Fink, 2003; Pierson, 1998; Ruth- to the Clinical Judgment Model (Tan- ways of knowing in nursing. Journal of
Sahd, 2003). However, the content ner, 2006), the guide, and the evalua- Advanced Nursing, 22, 226-234.
can be used as evidence of students’ tion rubric (Lasater, 2007). The focus Kuiper, R. (2004). Nursing reflections from
completion of course objectives and of this assignment—development of journaling during a perioperative in-
ternship. AORN Journal, 79, 195-218.
competencies. In review of student thinking, analysis, and reflection—is
Kuiper, R.A., & Pesut, D.J. (2004). Pro-
writing, faculty will be able to guide emphasized. Consistent use of the moting cognitive and metacognitive
students to points of learning within guide throughout a course provides reflective reasoning skills in nursing
the journal that may be applied to students with repetitive practice us- practice: Self-regulated learning the-
specific course requirements. ing a specific process to consider pa- ory. Journal of Advanced Nursing, 45,
381-391.
In this learning activity, faculty tient care and clinical judgments. Landeen, J., Byrne, C., & Brown, B. (1995).
feedback is guided by the Lasater Exploring the lived experiences of psy-
(2007) Clinical Judgment Rubric. The chiatric nursing students through
rubric is based on Tanner’s (2006) Conclusion self-reflective journals. Journal of Ad-
vanced Nursing, 21, 878-885.
Clinical Judgment Model and con- The guide for reflection is a struc-
Lasater, K. (2007). Clinical judgment de-
tains the components of effective tured approach to promotion of stu- velopment: Using simulation to create
noticing, interpreting, responding, dent reflective writing using questions an assessment rubric. Journal of Nurs-
and evaluating. The rubric describes based on Tanner’s (2006) Clinical ing Education, 46, 496-503.
specific criteria that represent the Judgment Model. The questions en- Perry, M. (2000). Reflections on intuition
and expertise. Journal of Clinical
progression of clinical thinking and courage critical thinking, knowledge Nursing, 9, 137-145.
judgment from beginning to exempla- transfer, transformation, metacogni- Pierson, W. (1998). Reflection and nursing
ry. Use of the rubric helps faculty de- tion, and exploration of the emotional education. Journal of Advanced Nurs-
termine the level of student thought aspects of situations encountered in ing, 27, 165-170.
Ruth-Sahd, L.A. (2003). Reflective prac-
and self-described performance. It clinical experiences. Use of the guide
tice: A critical analysis of data-based
also guides faculty to ask the higher- gives faculty a window into student studies and implications for nursing
level questions that address analysis, experiences and student thinking education. Journal of Nursing Educa-
synthesis, and evaluation and help about nursing care. Lasater’s (2007) tion, 42, 488-497.
students progress in maturation of Clinical Judgment Rubric guides fac- Schmidt, L. (2004). Evaluating the writ-
ing-to-learn strategy with undergradu-
clinical thinking (Sellappah, Hussey, ulty evaluation of and communication ate nursing students. Journal of Nurs-
Blackmore, & McMurray, 1998). In about student progress toward com- ing Education, 43, 466-473.
addition, the rubric provides lan- petence. Faculty feedback provides Schön, D.A. (1987). Educating the reflec-
guage to communicate about student students with formative evaluation tive practitioner: Toward a new design
for teaching and learning in the profes-
performance. Over time, faculty can on thinking about their experiences
sions. San Francisco: Jossey-Bass.
observe progress in the development and support for future learning. Sellappah, S., Hussey, T., Blackmore, A., &
of student thinking. McMurray, A. (1998). The use of ques-
tioning strategies by clinical teachers.
Use of the Guide References Journal of Advanced Nursing, 28, 142-
Benner, P., Tanner, C., & Chesla, C. (1997). 148.
The guide can be used in a variety of Tanner, C.A. (2006). Thinking like a nurse:
clinical courses and settings with stu- The social fabric of nursing knowledge.
American Journal of Nursing, 97(7), A research-based model of clinical judg-
dents at different academic levels. It 16BBB-16DDD. ment in nursing. Journal of Nursing
is potentially useful especially in situ- Benner, P., Tanner, C.A., & Chesla, C.A. Education, 45, 204-211.
(1996). Expertise in nursing practice: Wong, F., Kember, D., Chung, L., & Yan,
ations when faculty are not observing
Caring, clinical judgment, and ethics. L. (1995). Assessing the level of stu-
students directly on a consistent ba- dent reflection from reflective journals.
New York: Springer.
sis. Faculty may select specific kinds Bilinski, H. (2002). The mentored journal. Journal of Advanced Nursing, 22, 48-
of situations or topics that students Nurse Educator, 27, 37-41. 57.
are to write about during the term, Bransford, J.D., Brown, A.L., & Cocking,
depending on the clinical setting, stu- R.R. (Eds.). (2000). How people learn:

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