Academic journal article Scholarly Inquiry for Nursing Practice

An Interpretive Study Describing the Clinical Judgment of Nurse Practitioners

Academic journal article Scholarly Inquiry for Nursing Practice

An Interpretive Study Describing the Clinical Judgment of Nurse Practitioners

Article excerpt

Devaluation of nursing practice by both practicing nurses and nurse educators is giving way to keen interest in clinical scholarship. A naturalistic study was conducted to provide a contextual account of the actual practice of experienced nurse practitioners. Data collection procedures consisted of clinical situation interviews with nurse practitioner pairs, participant observation of patient visits to nurse practitioners in four hospital-based ambulatory settings, individual interviews with nurse practitioners, and administration of a brief demographic questionnaire.

The 199 clinical situations that constituted the resulting text were analyzed using phenomenological and existential perspectives. The clinical judgment of experienced nurse practitioners is described through interpretive analysis of the text according to the dictates of hermeneutical phenomenology. This methodology provides a way of describing and communicating the knowledge that develops among experienced practitioners and their patients. Text interpretation also produced an adaptation of Benner's (1984a) domains and competencies specifically for nurse practitioner practice, which may be useful as a conceptual framework for nurse practitioner practice, education, and research.

How does one describe the clinical practice of experienced nurse practitioners? This is no simple task. Over time, clinical practice tends to be characterized more by discretionary judgment than by rigid rule following and strict adherence to stated criteria (Dreyfus & Dreyfus, 1985). A description of the practice of experienced clinicians must employ a method that encompasses the qualitative aspects of clinical judgment.

The study reported here needs to be considered in the framework of practical "knowing how" and theoretical "knowing that" (Kuhn, 1970; Polanyi, 1958). According to this view, clinical knowledge develops as both practical and theoretical knowledge are applied, refined, and extended in practice situations (Benner, 1983). Thus, clinical knowledge encompasses both practical and theoretical knowledge.

The more global practical knowledge of experienced clinicians is uniquely human. It cannot be formalized and programmed into a computer.

All of knowledge is not necessarily explicit. We have embodied ways of knowing that show up in our skills, our perceptions, our sensory knowledge, our ways of organizing the perceptual field. These bodily perceptual skills, instead of being primitive and lower on the hierarchy, are essential to expert human problem-solving which relies on recognition of the whole. (Benner, 1985)

It is the kind of knowledge that computers do not have (Dreyfus, 1979). It requires a living person, actively involved in a situation. It is not amenable to formalization. This distinction between human and computer capabilities sheds light on the theory/practice gap so widely referred to in practice disciplines. Theoretical knowledge can be acquired in a decontextual fashion through reading, observing, or discussing, while the development of practical knowledge requires actual experience in a situation since it is contextual and transactional. Clinical nursing requires both types of knowledge.

Clinical wisdom is the kind of global integration of a body of knowledge that develops when theoretical concepts and practical know-how are refined through experience in actual (as distinct from simulated) situations. Clinical judgment is the essence of practical wisdom. It is the least specifiable, yet most crucial, aspect of clinical knowledge.

Numerous attempts have been made to identify and describe judgment processes through simulation and process tracing. Still more numerous attempts to prescribe clinical judgments have been carried out using the decision-theory perspective. (For reviews of this extensive research literature, see Berner, 1984; Elstein & Bordage, 1979; McGuire, 1985; Tanner, 1983; Tanner, 1987. …

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