The focus of this study is the decision-making process of thirty Registered Nurses from three distinct cohorts practising in the field of medical/surgical nursing. The successful study of clinical practice of nurses has been reported for the past two or more decades and much of the discussion pertaining to clinical practice has focused on the decision-making skills of expert nurses (Benner, 1984); (Benner & Tanner, 1987); (MacLeod, 1996). The process, which governs clinical reasoning and decision-making, involves making clinical judgments concerning patients' health status. How nurses make these judgments is not exactly known although clinical knowledge, critical reflection, past experience and intuition all play a role in making such judgments.
The aim of this research was to understand the process of clinical reasoning and decision-making and the impact that longitudinal experience has on the decision-making of RNs by investigating the clinical practice of novice, competent and expert nurses. Through an ethnographic interpretive paradigmatic approach to the study of clinical practice of registered nurses with differing levels of expertise and experience in medical and surgical nursing, this was realised. The natural setting for the study participants was the hospitals' wards in which they were situated either by choice because they had chosen to work there or else had been assigned to work. Within this environment, hospitals symbolised the socio-cultural institutions and the hospital wards signified a subculture, while nursing is the professional culture that was under study and in this culture nurses represent the study participants.
The level of everyday ward activity had a bearing on the functioning of nurses who worked there and this was the environment that provided the backdrop for the 'natural setting' in this study. By being present in this environment, the researcher's purpose was to attempt to make sense of and interpret the occurrences and experiences of these nurses who participated in the study and at the same time to discover the meanings that they attached to these nursing phenomena. The nature of the social phenomena under consideration in this study involved the clinical reasoning and decision-making processes that underpin the clinical practice of the study participants. The focal point of the research described here, centres on the creation of a conceptual model of nursing knowledge and medical knowledge in patient centred (collaborative) decision-making.
The evocative nature of the medical/surgical RNs' stories reported herein articulate how these nurses engaged in day-to-day clinical practice and those events that helped to shape their practice. Through this study, we are better able to understand the everyday clinical practice of novice, competent and expert RNs in medical and surgical practice, which has gone unreported. The study of clinical practice of nurses is better understood by being present in the ward environment, when moment-by-moment situations unfold because such situations cannot be re-enacted. Human behaviour and attitudes are best studied through observation in the naturalistic setting, particularly from the perspective of studying one's own culture and that of others.
The significance and importance of this research is that it demystifies the decision-making process of RNs and acknowledges that such decisions do not take place in vacuo. Rather, this process (with medical decision-making) is symbiotic. The findings from the decision-making process of novice and competent nurses demonstrated the impact that longitudinal experience has on this process especially when such experiences were accompanied by learning. It was evident that the single most important factor was the trajectory of experience, which provided the context for learning to take place. Such experiences were highly valued by the research participants. In this research nursing knowledge was found to pre-empt medical knowledge during life threatening events and once the event passed and the patient's condition was stabilized, the expert nurses returned to dealing with everyday situations inherent in medical and surgical clinical practice.
The findings of this research are threefold. Firstly, it was found that the novice nurses who participated in this study were cognizant of the cultural-ecological orientation of their practice and inherent in their practice was a highly developed perceptual awareness of the individual needs of patients and their families, which resulted in a close bond with their patients. This is an unusual finding given that many of these nurses had recently entered the workforce as RNs.
The second finding is associated with the practice of competent RNs who participated in this study and two of the competent RNs in particular revealed situational understanding, similar to that which was observed in expert practice. Their qualitative analysis of the patient's problem enabled them to read and interpret the situation accurately, which prevented the patient's demise. Although they did not possess vast experience in solving such critical problems they had gained specialized knowledge and expertise in specific areas, and similar to experts this enabled them to solve critical problems.
The third finding concerns the practice of expert RNs and when a critical event was looming during the patient recovery phase the expert nurses were found to pre-empt medical diagnosis and intervention. Their tacit knowledge enabled these expert nurses to detect the salient changes in the patient's condition, because they had come to know the trajectory of recovery through their involvement with many previous cases. In such instances nursing knowledge was found to pre-empt medical knowledge and once the life-threatening event had passed and the patient's condition was stabilized expert nurses returned to everyday situations inherent in their practice. These were atypical events that attest to the performance of expert RNs in medical and surgical nursing and their expertness is signified in the words of Tofias (1989, cited by Jasper, 1994) when he proffered "expertise creates the possibility that allows an otherwise improbable outcome to evolve".
This research has added original findings to the literature in the clinical practice of medical and surgical nurses and in particular by making visible the cultural-ecological orientation of novice nurses, expertly performing competent RNs in averting life-threatening situations and the skills in clinical reasoning and decision-making of expert nurses in influencing medical diagnosis and intervention during looming critical events.