Early recognition of patient problems: a hermeneutic journey into understanding expert thinking in nursing

The purpose of this study was to explicate the unconscious activity of early recognition of patient problems to better understand the thinking of expert critical care nurses. Multiple interviews were done with 15 peer-nominated expert critical care nurses. These nurses met specific inclusion criteria for expertise and the interviews were conducted over 9 months. Narrative accounts of critical incidents where early recognition of patient problems occurred were audiotaped and transcribed. The transcribed interviews were shared with the participants after each interview to stimulate reflection on their practice. Reflection on practice enriched subsequent interviews. A text comprising interview data was compiled and an interpretive approach based on the philosophy of human action developed by the author was used to interpret the activity of thinking behind the nurses' actions in the text. Interpretation of action revealed three common subplots or characteristics embedded in the nurses' thinking. The subplots included different types of information used in thinking, a mode of understanding situational meaning, and a temporal component of thinking in practice. The findings demonstrate an integrated model of situational understanding and informed action, thinking-in-action, similar to Aristotle's notion of practical wisdom.