Chris Tanner The Nursing Process, Really

March 9, 2025 -- Every nursing student has drummed into them the so-called nursing process. This is this cycle: assess/diagnose, plan, implement, evaluate (did it work?), repeat as needed. Is this an effective strategy?

In her ground-breaking 2006 paper, Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing, Chris Tanner (of whom I've written before) writes in the Journal of Nursing Education,

[This is] one type of systematic problem solving [but] ...it fails to adequately describe the processes of nursing judgment... this model fails to account for the complexity of clinical judgment and the many factors that influence it, complete reliance on this single model to guide instruction may do a significant disservice to nursing students.

The diagram at left depicts Tanner's more realistic model:

  • A perceptual grasp of the situation at hand, termed noticing.
  • Developing a sufficient understanding of the situation to respond, termed interpreting.
  • Deciding on a course of action, termed responding.
  • Attending to patients' responses to the nursing action while acting, termed reflecting.
  • Reviewing the outcomes of the action, focusing on the appropriateness of all of the preceding aspects (i.e., what was noticed, how it was interpreted, and how the nurse responded).

Nurses must "think like a nurse." What does that mean? From her extensive literature review (120 articles) with keywords "clinical judgment" and "clinical decision making," and of course her own experience at the bedside, Tanner concludes that in reality, nurses' judments and decisions are reached through processes that are considerably more nuanced than the tired assess/plan/implement/evaluate model:

  • Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand;
  • 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;
  • Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit;
  • Nurses use a variety of reasoning patterns alone or in combination; and
  • Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning.

Paraphrasing all this -- dumbing it way down -- I would say her more accurate description of the nursing process is:

  • When I've seen this before, I did X and it worked;
  • My patient wants/doesn't want X;
  • In this unit/hospital we do it this way;
  • Other nurses might do this differently; let me consider their approaches; and
  • We learn from our mistakes.

After all, what is the goal of nursing education? Good nurses! And good nursing requires good thinking. To teach that, we must first understand it. Tanner is getting us there.