Ascertaining patient condition : a grounded theory study of diagnostic practice in nursing

___________________________________________________________________ Ascertaining Patient Condition: A Grounded Theory Study of Diagnostic Practice in Nursing by LEE Kok Long Joseph Doctor of Philosophy in Social Sciences In the past decade, much research has been conducted on the practice nurses engage in diagnosing the clinical condition of patients. Many of the studies suggest that diagnostic practices of nurses in simulation settings follow a hypothetical deductive model that similar to the clinical decision-making or diagnostic reasoning process. A second line of inquiry claims that experience used in conjunction with intuition form the major core of diagnostic practice in nursing. However, these studies either assume nurses are reasoned in a primarily rationalist fashion or offer no conclusive explanations of the details on how intuition directs diagnostic practices. In particular, the distinctive processes when nurses engage in diagnosing the clinical condition of patients in acute clinical environments still remain largely undefined, under documented and essentially invisible. Within the tenets of grounded theory, a research study was therefore conducted to generate a substantive theory to provide comprehensive explanations of the following question: “What exactly is going on when nurses diagnose patients’ clinical conditions in acute clinical environments? ” Underpinned by the constant comparative method, data were derived from twenty-eight theoretically sampled in-depth informal interviews of nurses who were working in acute medical or surgical settings of a regional hospital during a twenty-month period. With the use of coding and memoing, a three-stage social-psychological process identified as ascertaining patient condition emerged. It conceptualized diagnostic practice in nursing as a series of purposeful actions where by nurses, through interacting with patients and the environment, articulated their professional skills, knowledge, experiences and perceptions to find out the clinical condition of patients. Stage one was the stage of attending the patient, where nurses started approaching and interacting with the patient. Stage two, the stage of perceiving the situation, began when nurses solicited information from all possible sources to augment their understanding of the patient. The last stage, unfolding the picture, was the stage at which nurses transformed data into facts, and articulated these facts into a sensible pattern that reflected the clinical condition of patients. Each of these stages was a theoretically complete unit comprising of unique strategic behaviors. The stages were interdependent; each was a consequence of the former and pre-requisite for the next. Each stage was equally necessary to insure adequate and thorough ascertaining. Besides, these stages also emerged to be context dependent and closely associated with a number of psycho-socio-structural variables, which, in turn, either facilitated or hampered the process of ascertaining patient condition. This study generates a practice theory, which uncovers that diagnostic practice in acute clinical settings goes beyond the analytic rational model and intuitive reasoning. It is a dynamic integration of cognitive, psychosocial and interpersonal behaviors where by nurses, through interacting with patients and the environment, articulated their professional skills, knowledge, experiences and perceptions to diagnose their patient’s clinical condition. It is through ascertaining patient condition that nurses develop solid platforms to ground their interventions to protect patients from vulnerability to harm and to support recovery. The findings of this study, in the long run, shed light to inform the pedagogical and clinical practices of the nursing profession in Hong Kong. I declare that this thesis《 Ascertaining Patient Condition: A Grounded Theory Study of Diagnostic Practice in Nursing 》is the product of my own research and has not been published in any other publications. ________________________ LEE Kok Long Joseph September 2002 CERTIFICATE OF APPROVAL OF THESIS ASCERTAINING PATIENT CONDITION: A GROUNDED THEORY STUDY OF DIAGNOSTIC PRACTICE IN NURSING by LEE Kok Long Joseph Doctor of Philosophy Panel of Examiners: ____________________________ (Chairman) Dr. Peter BAEHR ____________________________ (External Member) Prof. Ann MACKENZIE ____________________________ (Internal Member) Prof. Alfred C.M. CHAN ____________________________ (Internal Member) Dr. William K.M. LEE Chief Supervisor: Prof. Alfred C.M. Chan Co-supervisor: Prof. David Phillips Approved for the Senate: _______________________________________________ Prof. Mee-Kau NYAW Chairman, Research and Postgraduate Studies Committee 26 October 2002