NUR 634 Module 2 Theory Application Paper Example

Thinking Like a Nurse in Week Three: Applying Tanner's Clinical Judgment Model to a First Medical-Surgical Course

[Student Name]

Southern New Hampshire University

NUR 634: Facilitating Learning and Teaching Innovation in Nursing Education

Module Two Theory Application Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Thinking Like a Nurse in Week Three: Applying Tanner's Clinical Judgment Model to a First Medical-Surgical Course

Nursing programs often say they teach clinical judgment, but their course calendars show something else: a sequence of body systems, each covered by lecture and tested by multiple-choice questions about facts. Clinical judgment is expected to appear on its own in clinical placements. Tanner's model offers a way to teach it deliberately. This paper explains the model, connects it to the framework used by the licensure examination and applies both to one week of a first medical-surgical course. It argues that each phase of clinical judgment can be taught and assessed on purpose, even in the third week of a novice's first clinical course, if class time and clinical time are designed around the phases rather than around content alone.

Tanner's Model

Tanner developed her model from a review of research on how nurses make clinical judgments. It describes four phases. Noticing is the nurse's initial read of what is happening, colored by what she expected to find, what she knows of this patient and the setting around her. Interpreting is developing an understanding of the situation sufficient to respond, using analytic, intuitive or narrative reasoning. Responding is settling on what to do. Reflecting includes reflection-in-action, the nurse's reading of the patient's response while care is under way, and reflection-on-action, learning from the experience afterward. Tanner emphasized that the nurse's own background, values, and relationship with the patient shape noticing more than the objective data alone, and that reflection is what turns experience into clinical knowledge (Tanner, 2006).

Connecting to the NCSBN Model

The Next Generation NCLEX added a second framework that programs now have to reckon with: the licensing board's clinical judgment measurement model. It splits judgment into six steps, starting when the nurse picks out the cues that matter, then making sense of them, ranking the likeliest explanations, weighing possible actions, acting and finally checking whether the action worked. Dickison and colleagues showed how this model can be integrated with existing educational frameworks, including Tanner's, noting that the NCSBN model's layers break Tanner's broader phases into steps that can be measured by examination items (Dickison et al., 2019). In practice, noticing corresponds to recognizing cues, interpreting spans analyzing cues and prioritizing hypotheses, responding spans generating solutions and taking action and reflecting corresponds to evaluating outcomes. Using both models lets faculty teach with Tanner's language, which students find intuitive, while preparing students for items built on the NCSBN steps.

The Course and the Week

The composite first medical-surgical course at Riverbend Community College enrolls 64 associate degree students in their second semester. Week three covers fluid and electrolyte balance and introduces heart failure. Currently, students attend a three-hour lecture, complete a quiz and spend one clinical day on a medical unit, where they care for one patient and write a care plan. Faculty report that students list signs of fluid overload from memory but rarely connect them to their own patient's daily weight or lung sounds, which is to say they know content but do not yet notice.

Redesigning the Class Session

The class session will be built around an unfolding case of Mr. R., a 70-year-old admitted with heart failure. Students first watch a 20-minute video on fluid balance before class. In class, the case unfolds in four segments, each aligned with a phase. For noticing, students receive a shift report and bedside data, including a weight up 2 kg in three days, crackles at both bases and new ankle edema, and must list what stands out and why, which also practices recognizing cues. For interpreting, small groups decide what the pattern means and rank possible explanations, practicing analysis and prioritization of hypotheses. For responding, groups choose nursing actions and the information they would give the provider. For reflecting, the case continues with the patient's response to diuresis, and students write two sentences on what they would do differently. Faculty circulate and ask the question Tanner's model suggests at each step: what are you seeing, and what do you think it means? Groups that jump straight to interventions are asked to go back and state what they noticed first, because skipping from data to action without interpretation is exactly the habit the session is meant to change. The session ends with each student writing one cue from Mr. R.'s case that he or she would have missed a week earlier.

Redesigning the Clinical Day

On the clinical day, the written care plan will be replaced by a structured clinical judgment reflection. Each student identifies, for his or her own patient, one thing noticed during the shift that mattered, how it was interpreted, what was done and what the patient's response showed. The post-conference is organized in the same four steps, and students share examples with the group. This moves reflection-on-action, which Tanner argues builds clinical knowledge, from an afterthought into the core of the clinical day.

Assessing Clinical Judgment

Assessment will use the Lasater clinical judgment rubric, which Lasater developed from observation of students in simulation and built directly on Tanner's four phases. It describes 11 dimensions across noticing, interpreting, responding and reflecting, each rated at one of four levels from beginning to exemplary (Lasater, 2007). Faculty will use it formatively during the week three clinical day to give each student written feedback on one dimension from each phase. Because the rubric uses the model's language, students can see where their judgment is strong and where to focus, and faculty feedback becomes more specific than comments such as good job or needs work.

Limitations

Applying the model in week three has limits. Novices notice less than experienced nurses by definition, and the redesign cannot give them experience they do not have. Faculty will need preparation to facilitate unfolding cases and to rate students consistently with the rubric. And a single week cannot show whether clinical judgment improves; that requires evaluation across the course, which later milestones will address.

Conclusion

Tanner's model gives faculty a vocabulary for teaching clinical judgment on purpose. Mapped onto the NCSBN model, it also connects classroom and clinical learning to how students will be tested. In week three of Riverbend's first medical-surgical course, an unfolding heart failure case, a structured reflection and the Lasater rubric turn the phases of clinical judgment into activities students practice and receive feedback on, rather than qualities they are hoped to develop.

References

Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing clinical judgment model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72-78. https://doi.org/10.3928/01484834-20190122-03

Lasater, K. (2007). Clinical judgment development: Using simulation to create an assessment rubric. Journal of Nursing Education, 46(11), 496-503. https://doi.org/10.3928/01484834-20071101-04

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. https://doi.org/10.3928/01484834-20060601-04