International Journal of Nursing Practice 2009; 15: 376–388

RESEARCH PAPER

Nursing prioritization of the patient need for

care: A tacit knowledge embedded in the clinical
decision-making literature ijn_1778 376..388

Sarah Lake MN(Distinction) RN

PhD Candidate, Graduate School of Nursing Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand

Cheryle Moss PhD RN

Associate Professor, Graduate School of Nursing Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand

Jan Duke PhD RN RM

Professor and Head of School, Graduate School of Nursing Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand

Accepted for publication April 2009

Lake S, Moss C, Duke J. International Journal of Nursing Practice 2009; 15: 376–388
Nursing prioritization of the patient need for care: A tacit knowledge embedded in the clinical
decision-making literature

Every day in clinical settings, nurses practise in complex and dynamic situations. Nurses work to achieve emergent order
in these situations through nursing prioritization of the patient need for care. As direct research on nursing prioritization
had not been reported, a study, using critical realism as method, was designed to discern the profession’s embedded
understanding from within the clinical decision-making literature. The research synthesizes a tacit knowledge on nursing
prioritization of the patient need for care from key international literature (from 1966 to 2003). Nursing prioritization was
discerned in both education and practice literatures; interrelationships between these and theoretical approaches were also
identified. Nursing prioritization of the patient need for care was revealed both as a non-sequential decision-making
process throughout unfolding patient situations and as an advanced skill of nursing practice. Increasing confidence with this
skill is the hallmark of developing expertise.
Key words: clinical decision-making, clinical judgement, experiential learning, literature review, nursing assessment.

Correspondence: Sarah Lake, Graduate School of Nursing, Midwifery
and Health, Victoria University of Wellington, PO Box 600, Welling-
ton, 6140, New Zealand. Email: sarah.lake@nmdhb.govt.nz
Cheryle Moss is currently: Associate Professor, Graduate School of
Nursing Midwifery and Health, Victoria University of Wellington,
Wellington, New Zealand.
Jan Duke is currently: Deputy Registrar, Zealand Social Workers’
Registration Board, Wellington, New Zealand.
INTRODUCTION
Every day in clinical practice, nurses work in complex,
dynamic and uncertain situations. In the hospital setting,
throughout the 24 h daily cycle of shift work, mediated by
handover of patient status and progress, nurses attend to
patient needs for care relevant to the course of the pa-
tient’s hospital stay. Each nurse will look after several
patients for the duration of the shift so that there might be

© 2009 Blackwell Publishing Asia Pty Ltd doi:10.1111/j.1440-172X.2009.01778.x

Nursing prioritization of patient care
new, unfinished, competing and/or conflicting patient
needs for care occurring simultaneously. With increasing
patient acuity, decreasing length of hospital stay, family
involvement in care and nursing shortages, the situation
can readily become chaotic.
Effective nursing prioritization of the patient need for
care is the key to nurses ‘getting it right’ in such situa-
tions. Prioritization implies choice of imperatives among
options, also inferring an ability to recognize these
options. Choice and/or determination of relativity are
specific aspects of decision-making, whereas imperatives
are influenced by the values of the decision-maker and the
context in which the decision is made. In daily nursing
practice, nursing prioritization is the decision by a nurse as
to which nurse–patient interaction to address first
among many potentially competing requirements and
options.
Better understanding of this aspect of the clinical
decision-making process would enable development and
improvement of nursing practice. However, a prelimi-
nary search of the Cumulative Index of Nursing and Allied
Health (CINAHL)1 using the search terms ‘nurs* AND
priorit*’ showed that nursing prioritization is not a spe-
cifically researched subject, although it is something that
nurses, as well as other health professionals, discuss as
part of health-care delivery. Some nurses see that priori-
tization is something that nurses do,2,3 and that it is
relevant to nursing practice.4–6 Prioritization of patient
care might be taught as part of undergraduate nursing
education,2,7–9 and be used by nurses to describe and plan
nursing interventions.7,10–12 When nurses triage the
patient need for care, clinically specific information is
sought.13,14 It was apparent within the limited selection of
papers retrieved through this search strategy that although
this vital aspect of nurse decision-making has not been
specifically identified or researched, there is an embedded
understanding in nursing about nursing prioritization of
the patient need for care and this is integral to nurse
decision-making.
To discern the profession’s tacit knowledge of this
embedded understanding, a study was designed to
explore the nursing literature and answer the question:
What is the process of nursing prioritization of the patient
need for care as inferred, described and/or discussed in
the nursing literature?
The study by Lake15 discerned five main themes of
embedded understanding related to nursing prioritization
of the patient need for care, and these are summarized in
377
this paper. Discussion of the relevance of these findings
draws together an inclusive view of the various conceptual
approaches to the study of clinical decision-making. A
relationship for nursing prioritization of the patient
need for care to nurse clinical decision-making is
proposed.
METHOD
Critical realism, comprising a realist ontology and a rela-
tivist epistemology, provided a coherent framework with
which to structure the study.16–18 The approach is based on
a retroductive research strategy, where model building,
analogy and metaphor are used to postulate mechanisms
that account for observed phenomena.18 Littlejohn sum-
marizes the ontological approach of critical realism as a
world encompassing three layers of reality: empirical,
actual and real.17 The empirical layer comprises what is
experienced and forms the intransitive aspect of the
approach. The actual layer where things happen but are
not experienced forms the transitive aspect. The real
layer, where generative mechanisms exist, forms the
transcendental aspect of the approach.17 Blaikie states
that:
transitive objects are the concepts, theories and models that
are developed to understand and explain some aspects of
reality and intransitive objects are the real entities that make
up the natural and social worlds’.16
For the purposes of the research question, written
descriptions of clinical decision-making, including
content and context, were determined as the empirical
(intransitive) aspect of the approach, theoretical and con-
ceptual discussions within the literature were determined
as the actual (transitive) aspect of the approach, whereas
nursing prioritization was determined to be the generative
mechanism of clinical decision-making, the real (transcen-
dental) aspect of the approach.
The CINAHL1 thesaurus terms associated with the
process of clinical decision-making were reviewed in con-
junction with summaries of related research topics in the
Encyclopaedia of Nursing Research (ENR).19 The rela-
tionships between the terms and topics were mapped (see
Fig. 1). The map was built from the two main research
arenas (identified by the ENR) of nursing practice and
nursing education, through the levels of cognition
relating to decision-making from the CINAHL thesaurus
tree.
© 2009 Blackwell Publishing Asia Pty Ltd
378
Figure 1. Mapping of the terminology. NIC, Nursing Interventions Classification; NOC, Nursing Outcomes Classification; NANDA, North
American Nursing Diagnosis Association; NMDS, National Minimum Data Set; ICNP, International Classification of Nursing Practice.
The search strategy then used CINAHL terms, chosen
according to their relevance (see Table 1) within the
mapping, in a series of combinations to search the data-
base (see Table 2), identifying 738 citations. Elimination
of duplicates, review of abstracts and application of the
exclusion criteria (see Appendix I) refined selection to
343 citations in the English language. Inclusion criteria
were, based on abstract and/or initial read, that the
papers discussed or were likely to provide insight into the
process of clinical decision-making.
Antecedent literature and material from other sources
(e.g. a sample of nursing texts), which has shaped the
embedded understandings of the discipline, were also
retrieved. Altogether this process identified approxi-
mately 600 books, theses and papers, covering a time span
of almost 40 years, from 1966 to 2003. Through further
refinement during the process of the research, the final
dataset comprised 461 items.15 Not all can be acknowl-
edged specifically in this paper; however, without these
contributions, which enable discussion, scholarly debate
and development of the knowledge base of the nursing
profession, the study would not have been possible.
© 2009 Blackwell Publishing Asia Pty Ltd
S Lake et al.
RESULTS
Thematic analysis discerned five main areas of embedded
understanding within the selection. In the first two areas,
relating to the two main arenas of nursing research,19 the
fundamental understanding of the discipline around
nursing prioritization in clinical decision-making was
examined in relation to how this is taught and then how
this is practised. The third area reviewed the influence of
practice context (both setting and scope) on the relativity
of both the options and the imperatives that nurses priori-
tize, whereas the fourth area, relating to the content of
nurse decisions, drew inferences about nursing prioritiza-
tion from the patient needs for care that nurses pay atten-
tion to and/or see as important for in-depth study, and
also from studies discussing the way nurses manage the
complexity of daily clinical decision-making. These first
four areas relate to the intransitive aspect of critical
realism. The fifth area drew through the language of both
scholarship and practice and also conceptualizations used
in the previous areas and relates to the transitive aspect of
critical realism. Salient features such as research interests,
Nursing prioritization of patient care 379

Table 1 Findings from the nursing terminology according to their relevance to the question for research

Most relevant Used as the basis of the Source

literature search strategy

Clinical judgement CINAHL/ENR

Clinical decision-making CINAHL/ENR
Diagnostic reasoning CINAHL
Critical thinking CINAHL
Problem solving CINAHL
Intuition CINAHL
Relevant Included in the search strategy
Nursing assessment CINAHL/ENR
Nursing process CINAHL/ENR
Prioritization (and/or priority setting) Key word
Triage Key word
Staff nursing and/or staff nurses Key word
Less relevant Included where referred to in abstracts of literature selected through the search
Judgement CINAHL
Decision-making CINAHL
Thinking CINAHL
Cognition CINAHL
Perception CINAHL
Language processing CINAHL
Not included But could appear in the abstracts and discussions
Decision-making, ethical CINAHL
Decision-making, family CINAHL
Decision-making, patient CINAHL
Decision-making, computer aided CINAHL
Decision-making IOWA (NOC) CINAHL
Decision-making support, IOWA (NIC) CINAHL
Nursing diagnosis CINAHL/ENR
Nursing intervention ENR
Patient assessment ENR
Nursing practice models ENR
Formal languages (e.g. NIC or NOC etc.) ENR

CINAHL, Cumulative Index of Nursing and Allied Health; ENR, Encyclopaedia of Nursing Research; Iowa NIC, Iowa Nursing Interven-
tions Classification; Iowa NOC, Iowa Nursing Outcomes Classification.

antecedent literature, use of language, areas of practice
and theoretical perspectives were also identified.
Throughout the research, a database of the selected litera-
ture was maintained, recording these identifiers and the-
matic indicators and also tracking the incidence of nursing
prioritization of the patient need for care as to whether
this was discussed, mentioned or discerned within each
item.
The findings within the selected literature on each
area of embedded understanding relating to nursing pri-
oritization of the patient need for care are summarized in
the following sections.
Learning about nursing prioritization
Embedded understanding of setting priorities for the goals
of patient care is a tenet of initial nursing education, but

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380 S Lake et al.

Table 2 Structure of the final search strategy

Terminology Code

1. Diagnostic reasoning and (clinical decision-making or clinical judgement) DR + (CDM/CJ)

2. Critical thinking and (clinical decision-making or clinical judgement) CT + (CDM/CJ)
3. Problem solving and (clinical decision-making or clinical judgement) PS + (CDM/CJ)
4. Intuition and (clinical decision-making or clinical judgement) In + (CDM/CJ)
5. Nursing assessment and (clinical decision-making or clinical judgement) NA + (CDM/CJ)
6. Nursing process and (clinical decision-making or clinical judgement) NP + (CDM/CJ)
7. Setting priorities and (clinical decision-making or clinical judgement) SP + (CDM/CJ)
8. Prioritization and (clinical decision-making or clinical judgement) Pn + (CDM/CJ)
9. Triage and (clinical decision-making or clinical judgement) TR + (CDM/CJ)
10. Staff nursing and (clinical decision-making or clinical judgement) SN + (CDM/CJ)
11. Pattern recognition and (clinical decision-making or clinical judgement) PR + (CDM/CJ)

‘Wild Cards’ were used to ensure citations using either the American and English spelling of Judgment and Prioritization were retrieved.
Truncated terms Staff Nurs* and Set* Priorit* or Priorit* Set* were used for Staff Nurse(s) or Nursing and Setting Priorities or Priority
Setting, respectively.

nursing prioritization of the patient need for care is Such tacit knowledge is embodied in the nurse.45 A
not presented as a formal concept in many texts.20–24 nurse’s perceptive grasp of a patient situation, in combi-
Teaching25–27 and learning2,28–30 about nursing prioritiza- nation with the necessary remedial nursing action, is
tion are two different aspects of such education. Nursing nursing prioritization of the patient need for care in
prioritization becomes a key learning issue at the point of action.
student transition to practice situations,31,32 distinct from
but interrelated with time management skills,2,33 and is
Nursing prioritization in specialized
identified in this way in discussion of student/preceptor
practice and practice settings
relationships.9,29,32,34
Differences in the relative values of clinical criteria
according to practice setting imply reframing of nursing
Nursing prioritization in practice
prioritization to meet the aims of the patient need for care
It was evident from the selected literature that learning the
in each setting. The patient need for care might relate to
skill of nursing prioritization of the patient need for care
life-threatening situations in the critical care setting,52–61
takes place in practice. Novice nurses might be over-
through access to acute services,37,62–69 to facilitation
whelmed by the amount of information,35 and nurses new
of individuals’ continued independence in the
to an area of practice might also be less able to differentiate
community,70–74 or providing support for patients’ choices
relevant domain-specific information.36,37 Comparative
at the end of life.75,76
studies of novice/expert use of information showed similar
Across all settings, in daily nursing practice, the three
findings.38–42 Increasing familiarity with what is required
main contextual influences on nurse decision-making
enables the nurse to gain confidence in making appropriate
and therefore also nursing prioritization of the patient
choices for action, developing competence and moving
need for care are time as a resource,3,77–79 resource
beyond the need to work with explicit rules to proficient
constraints5,80–82 and multidisciplinary interaction.55,83–86
nursing practice. With the development of this skill to an
advanced level comes expertise,43,44 and the innate intui-
tive ability to directly grasp45–48 or anticipate49–51 a patient The content of clinical decision-making
situation and develop an effective response. Benner et al. relating to nursing prioritization
specifically relate this development to the nurse’s ability to The things that nurses regard as important: the concerns
prioritize within his/her skill level.44 of nursing, are apparent in the studies, and can be

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Nursing prioritization of patient care
discerned through the choice of subject, the emphasis
within the subject and the language used to highlight as-
pects of the subject. For instance, the most discussed sub-
ject, studies of nursing management of patient pain,87–93
crossed the physical boundaries of different practice set-
tings, representing a primary focus of nursing concern.
Discussions on the complexity of clinical
decisions52,88,91,94–97 acknowledge not only the amount of
clinical detail involved,88,91 but also that one or more
outcomes are possible,97 and/or that not all relevant
information might be available.95 Guidelines and proto-
cols are accepted as being useful to navigate such
complexity,98–101 but expert opinion is seen to be more
effective if available.98,102 Trading off93,94,103 or weighing
and balancing76,104 are considered options when discussing
nurses’ responses to patient need. The process of nursing
prioritization of the patient need for care involves discre-
tionary judgement55,57,76,92,98,105,106 incorporating ongoing
assessment (implying reprioritization as required) of
unfolding patient situation(s) in all settings.
dela-Cruz describes three different styles of nursing
assessment within home health nursing as ‘surveying’,
‘skimming’ and ‘sleuthing’, indicating ways that nurses
focus on what is important for patient care.107 Although
nursing prioritization in critical situations is more fre-
quently discussed in the literature, it is evident that nurses
prioritize the patient need for care within a plethora of
less acute patient needs as an integral component of daily
clinical decision-making.
Discerning nursing prioritization from
the language used to describe and
discuss clinical decision-making
Within the selected literature, there are many different
approaches to discussing and understanding clinical
Table 3 Incidence of nursing prioritization of the patient need for care according to research interest
Research interest Discussed Mentioned
Practice 15 38
Education 8 20
Both 4 2
Theory/concept 4 6
Discussion 1 2
Other 2 2
Total 34 70
381
decision-making in nursing. A range of language and
terms are used, but definitions might be study-specific and
do not necessarily relate to a specific theoretical approach.
For instance, the information-processing term
‘cues’,55,60,74,89,92 implying recognition of a significant
concern, has a common usage, but is not necessarily used
in conjunction with a rationalistic approach to the study of
clinical decision-making.
There is also a common understanding that pattern
recognition52,86,108–111 is a key component of the nursing
assessment required to make a decision. However, refine-
ments of understanding about pattern can also be
described as heuristics,49,112,113 rules of thumb,114,115
maxims116 and/or sense of salience.43 Inferences that
nurses select significant information can be drawn from
the usage of such terms. The variety of terms and inter-
changeability of usages suggest that no single approach is
able to reflect the wider understanding within the profes-
sion, or be identified as the preferred way to describe
nurse clinical decision-making.
Although studies of nursing practice and nursing
education predominated in the selection, research
interests also included conceptual and theoretical
discussions. Nursing prioritization of the patient need
for care could be referred to as a discussion point
within the study, could be mentioned in passing, or
could be inferred from the study content and/or
context of nurse descriptions of clinical decision-making.
In that the concept ‘priority setting’ creates the pre-
practice understanding of nursing prioritization, refer-
ence to this has been included in the ‘mentioned’
grouping unless accompanied by discussion. The inci-
dence of nursing prioritization according to the
identified arenas of research interest is shown in
Table 3.
Implied Not mentioned Total
102 38 193
24 28 80
13 5 24
31 57 98
19 36 58
3 1 8
192 165 461
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382 S Lake et al.

Table 4 Incidence of nursing prioritization according to theoreti- Table 5 Key influences in the nursing clinical decision-making
cal perspective literature

Perspective N of papers Discerned % Study N of

Citation
Interpretive† 55 55 100
Nursing practice 32 30 94 From novice to expert (Benner, 1984/2000)118 182
Triage 17 14 82 Clinical judgement: how expert nurses use intuition 107
Alternative model 14 10 71 (Benner and Tanner, 1987)43
Information processing† 66 46 70 Diagnostic reasoning strategies of nurses and nursing 83
Clinician as statistician† 30 19 63 students (Tanner et al., 1986)119
Combination 37 22 59 Tanner’s work on clinical judgement in research and 72
Comparison 18 10 56 education (Tanner, 1986, 1987, 1989, 1993)120–123
Problem solving† 76 40 53 Either or both of Corcoran’s research studies from 69
General discussion 116 50 43 1986 (Corcoran 1986, 1986)38,88
Total 461 296 64 Skilled clinical knowledge: The value of perceptual 52
awareness (Benner and Wrubel, 1982)45
†
The four acknowledged perspectives Tanner identified.117

Tanner identifies: in Table 5. Although not retrieved through the primary

four major theoretical perspectives (that) have informed most
of the research on clinical judgment in nursing
as: the clinician as an informal statistician, the clinician as
an imperfect information processing system, the clinician
as a fully situated interpreter of meaning and the clinician
as a scientific problem solver and critical thinker.117 The
fourth perspective, deriving from the nursing process, has
perhaps the widest implicit acknowledgment in the back-
ground understanding of nursing.
Although almost 50% of the selected literature could
be aligned to one of the four main perspectives, several
alternative approaches to the study of nurse clinical
decision-making were identified, particularly in more
recent work. Studies also used a combination of perspec-
tives, or drew comparisons. A further number discussed
decision-making in nursing practice without identifying a
theoretical perspective, and a number discussed decision-
making in more general terms. Table 4 shows the various
theoretical perspectives of the studies and the numbers in
each group where prioritization of the patient need for
care was discerned. This is compared as a percentage to
the total in each group.
Frequently cited sources were recorded for 350
studies, identifying key reference points for the selected
literature. The five primary nursing resources are shown
search strategy (where the search criteria related to the
process of clinical decision-making), it is evident that
Benner’s118 work has overwhelming resonance within the
field, no matter which approach is used to study nurse
clinical decision-making.15 Nursing prioritization is effec-
tively defined by Benner as ‘the advanced clinical skill of
judging the relative importance of different aspects of the
situation’.118
It is apparent that although the embedded understand-
ing of nursing prioritization of the patient need for care is
discernible throughout the literature, it is more readily
perceptible in discussions within the interpretive perspec-
tive, or where nursing practice is described in plain lan-
guage, rather than in studies framed in structured
approaches and/or in the conceptual discussions within
the literature.
DISCUSSION
Nursing prioritization of the patient need for care is a
critical aspect of nursing practice, but was found to be not
directly researched or reported in the selected literature.
In order to ensure that the study findings are current, the
search strategy was repeated in early 2008. Further
studies of clinical decision-making in practice,124–128 in
education,129,130 theoretical studies,131–133 texts presenting
new approaches to the complexities of clinical decision-
making in practice,134,135 and also the development of

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Nursing prioritization of patient care
theoretical models136,137 were evident but nursing priori-
tization is still not specifically addressed. This study’s por-
trayal of a tacit knowledge of this in the published clinical
decision-making literature remains unprecedented.
A key limitation is that literature from the USA pre-
dominated in the selection, but, although study of the topic
is less developed in other countries, a series of studies led
by Lauri and Salantera drew comparisons between clinical
decision-making models of nurses across nationalities and
health-care settings, and provided a sense of an interna-
tional perspective.59,111,138,139 Further work in countries
such as England140,141 and Canada94,103 also contributed.
Attention in the study was limited to the literature
described earlier, other aspects of decision-making such as
how nurses work with the nurse–patient relationship
incorporating patients’ preferences, abilities and indi-
vidual responses to the situation were not explored. These
might offer a wider view of the practice of nurse clinical
decision-making in relation to nursing prioritization.
Within these limitations, nursing prioritization of the
patient need for care has been clearly identified both as a
process and as an advanced skill of nursing practice.
Within the limitations of the selected literature, it is
apparent that nursing knowledge on clinical decision-
making has matured over time and that nursing prioriti-
zation of the patient need for care is discernible
internationally in a diversity of research approaches.
This study makes several new contributions to nursing
knowledge. The understanding of the tacit knowledge of
clinical decision-making in nursing that has been devel-
oped in this research is unprecedented in the literature.
The retroductive research strategy of critical realism has
not previously been used as a research method to review
literature, but has shown the complexity and intricacy of
nurse decision-making that is known in the embedded
understanding within nursing, but which has not previ-
ously been made explicit in this way.
This study has also revealed the tacit understanding of
nursing around experiential learning of nursing prioritiza-
tion of the patient need for care. Increasing confidence
with this skill is the hallmark of developing expertise, and
it is best learnt from experience and understanding of
practice situations. It is only recently that the profession
has explicitly developed experiential learning pro-
grammes to specifically address such central issues
that have ‘typically (been) excluded from standard
approaches’.142 Further development in this area would
seem to be warranted.
383
A further contribution is that the wider view of the
study of clinical decision-making in nursing drawn
together in this research has not been presented in this
way before. Within the selected literature, it is apparent
that nurses problem solve, process extensive ranges of
information, work with probability and heuristic repre-
sentations of previous experience, and also practise with
possibilities as situated interpreters of meaning. Other
approaches to this study are also now being developed. No
one approach is able to fully represent the complexity that
is nurse decision-making, although this is most readily
realized through the interpretive paradigm in the plain
language of everyday nursing. The body of work within
the discipline is such that a unifying framework would
support the development of further knowledge in and
international understanding of the field. Tanner’s synthe-
sis of the literature pulling together key features of
research in this area, creating a ‘thinking like a nurse’
model of clinical judgement, goes a considerable way
towards meeting this need.136 Text books now also
present a more inclusive approach.134,135
This research has further highlighted that there is a lack
of formal recognition and study of the concept of nursing
prioritization of the patient need for care. Yet, nurses do
manage to prioritize the patient need for care effectively
in daily nursing practice where determining what to do
first and meeting the need is the key skill in complex
practice situations. An inclusive collaborative approach to
further development of knowledge and understanding in
this area is recommended.
In conclusion, the tacit knowledge discerned within the
selected literature indicates that nurses use discretionary
judgement and ongoing assessment to prioritize the
patient need for care throughout the many aspects of
individual patient situations as they unfold. Increasing
confidence with this skill is the hallmark of developing
expertise, which is best learnt through experiential learn-
ing. Varied frames of reference within different practice
settings create specific imperatives on this dynamic and
non-sequential process.
Effective nursing prioritization, as an advanced skill of
nursing practice reliant on discretionary judgement and
ongoing assessment to manage complex and uncertain
situations, is the basis of getting it right in these
situations. Further study is critical to the future of
nursing practice so that nursing prioritization is not left
as a tacit knowledge in the clinical decision-making
literature.
© 2009 Blackwell Publishing Asia Pty Ltd
384
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APPENDIX I
Citation exclusion criteria (based on review of abstract).

1. Papers discussing setting priorities for research.

2. Papers discussing health-care delivery (e.g. structure/models of care, care plan writing, equipment selection, policy,
evidence-based nursing; or diseases of risk to nurses such as hepatitis C).
3. Papers with an informatics focus (e.g. use of computer programs for nursing, development of nursing diagnosis).
4. The majority of papers presenting opinion or with no abstract (e.g. personal journeys, commentary on prescriptive authority, or
news items—as being too far removed from clinical practice).
5. Papers focusing on interpersonal relationships in practice (e.g. discourse focus, patient experience).
6. Citations of legislation and government or state-based clinical practice guidelines (e.g. Montana state law).
7. Citations for allied health professions (e.g. physiotherapy, occupational therapy, chiropractic, audiology, dietetics, social work).
8. Papers from medical journals were only included if the abstract discussed cognitive strategies. These were selected more to
provide some background conceptual material relevant to clinical practice as nursing discussions on this were limited.
9. Papers from areas of less acute health care (e.g. domestic violence, ethics, rehabilitation/stroke nursing, community/home health
care, health promotion, school health) were generally excluded as the researcher’s experience is in the acute-care setting. Papers
from some areas of more acute health care (e.g. mental health, midwifery, paediatrics) were selected more stringently as the
researcher is less familiar with these practice settings. In both cases, papers were included if the abstract addressed the specifics of
clinical decision-making or clinical judgement.
10. Papers on performance in nursing education (e.g. measurement of performance, faculty practice, assessment of staff needs).

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