Fitting Things Together: A Grounded Theory Study of Clinical Judgment in Nursing

Safe and appropriate patient care hinges on the nurse\u27s skill in assessment and interpretation of data to support accurate clinical judgments; however, a review of nursing literature reveals the lack of an empirically derived theory of clinical judgment or methods to teach the skill. Progress has been limited because of the difficulties inherent in measuring cognitive work in complex practice environments, as well as the tendency of nursing authors and researchers to substitute a wide variety of terms for clinical judgment. Knowledge development in any discipline is hampered when terms are not clearly defined and the distinction between related concepts is blurred. The purpose of this study was to develop a substantive theory of clinical judgment in nursing to overcome the limitations of existing research. Classical ground theory was used to discover the process hospital based registered nurses with two to three years of clinical experience use to make clinical judgments as they provide care to patients in the course of a work shift. Semi-structured interviews were conducted with 15 nurses employed on a variety of inpatient nursing units in three Magnet® status teaching hospitals in the Midwestern United States. Data were analyzed using the constant comparison method. A substantive theory of clinical judgment emerged from the data, with the core category Fitting Things Together integrating additional categories that represent stages in the model, including Knowing, Anticipating, Prioritizing, Observing, Thinking, Catching Things, Figuring Out What\u27s Going On, and Determining What Needs to be Done. The theory that emerged in the study explains how each stage of the model contributes to knowing the patient and how each situation that requires clinical judgment provides an opportunity for learning at work. The substantive theory of the clinical judgment process that emerged from this study will facilitate research and measurement of clinical judgment in nursing practice and education and the design of strategies to teach the skill at various levels of clinical expertise