Mutual Intacting: Keeping the patient-practitioner relationship and patient treatment intact

Naomi Elliott, MSc., BNS, RGN, RNT, PhD Candidate

Abstract

The aim of this grounded theory study was to discover the main
concerns of clinical practitioners when making clinical
judgments in the community care context and to explain the
processes they used to resolve practice problems. Interview
data from twenty-one advanced practitioners working in
various mental healthcare and accident and emergency settings
in Ireland was collected. In this paper, the process of clinical
judgment is conceptualised as ‘Mutual Intacting’. It proposes
that clinical judgment comprises three stages: situated
patterning, intacting therapeutic relationship
, and intacting
therapy
. ‘Mutual Intacting’ explains how clinical practitioners
make clinical judgments through a process of adapting
treatment so that the patient-practitioner relationship is
maintained and treatment is delivered in a way that takes
account of the patient’s circumstances.

Background

The importance of understanding how clinical judgments
are made is highlighted by the professional and policy
literature about advanced practice in nursing (National
Council, 2004; Royal College of Nursing, undated). The ability
to make clinical judgments is an essential skill required for all
areas of professional practice; however, it is the level of clinical
judgment which involves initiating and delivering therapeutic
interventions that differentiates advanced practitioners from
other grades in nursing. From an international perspective,
developments in nurse prescribing have resulted in a growing
number of nurses who are responsible for prescribing
medication and for making clinical judgments affecting direct
patient care (International Council of Nurses, 2001). These
developments place clinical judgment firmly on the research
agenda with questions concerning the relevance of the
knowledge base that currently informs clinical practice.

Current explanations of clinical judgment in nursing tend
to be extrapolated from the knowledge gained from the
hypothetico-deductive approach (Elstein, 1978) and the related
information processing theory (Simon, 1978; Newell & Simon,
1972), and Benner’s (1984) work on intuition. According to the
hypothetico-deductive approach, practitioners work through a
process of cue acquisition in order to generate potential
hypotheses then further cue and data collection to confirm or
negate each hypothesis so that eventually a single outcome or
diagnosis is reached. The main contribution of this approach is
that it provides a systematic analytical process for clinical
practitioners when making a diagnosis. Assumptions within
the hypothetico-deductive approach are based on normative
cues; that is, the association of clusters of cues with a
particular diagnosis is based on knowledge derived from
generalisations. This excludes a small, but nevertheless,
important part of the patient population. Patients who present
with atypical symptoms when compared to the general
population or patients who present with an individual set of
symptoms unique to them are effectively outside of the ‘norms’
and this limits the usefulness of the hypothetico-deductive
approach in clinical practice. Another limitation, noted by
Buckingham and Adams (2000a), is that the majority of
research studies focus on biomedical signs and symptoms and
on how clinical practitioners process these cues. In contrast,
there is a paucity of research considering the role of
psychosocial factors as cues in clinical judgment. This is an
important gap, particularly in view of the evidence on patient
behaviour in chronic illness which demonstrates that
significant cues may be unrelated to the illness or,
alternatively, patients may have learnt to minimise or view
persistent symptoms as being ‘normal’ (Paterson et al., 2001).

An alternative explanation of clinical judgment, intuition,
is said to involve the rapid and unconscious processing of data
(Cader et al., 2005; Buckingham & Adams, 2000b, Hammond,
2000). Contrary to the view that intuition does not involve
analysis, intuition entails the use of heuristics or ‘mental rules
of thumb’, which are short cuts to making clinical judgments
(Hallett et al., 2000; Cioffi, 1997). Whilst Tversky and
Kahneman (1982) describe three different types of heuristics;
namely, representativeness, availability and anchoring and
adjustment, a common cognitive activity throughout all
heuristics involves pattern recognition. Pattern recognition is
essential to intuition and clinical practitioners, through
experience, learn how to recognise and act on appropriate
patterns (Easen & Wilcockson, 1996). Opinions regarding the
contribution of intuition to clinical judgment in nursing are
divided. Some consider intuition important to nursing practice
(McCutcheon & Pincombe, 2001; Cioffi, 1997); others point to a
commonly cited criticism of intuition that links errors in
human judgment with heuristics and bias (Thompson, 2002).
This criticism, however, is now being challenged as further
research in cognitive psychology regarding the use of heuristics
demonstrates that simple rules, which yield quick decisions,
can be highly accurate (Ayton, 2005).

Both approaches, hypothetico-deduction and intuition,
provide some insight into the cognitive aspects of clinical
judgment; however, they fail to consider other aspects including
what is the clinical practitioners’ main concern and what
strategies are used to resolve practice problems. Given that
advanced practitioners are often making clinical judgments in
situations where patients are actively involved in their own
care, this is an important gap in understanding the process of
clinical judgment. Having broadly identified the research area
from the literature, the problem, however, did not emerge until
the researcher entered the clinical practice area and began the
inductive process of grounded theory inquiry.

The Research Method

The aim of this study was to generate a substantive theory
that explains how advanced practitioners make clinical
judgments effecting direct patient care in community care
settings. Grounded theory (Glaser, 1998; Glaser & Strauss,
1967) was selected as it provides for the systematic and
inductive generation of theory from data and consequently,
offers a viable means of developing theory that is relevant to
everyday clinical practice. From an advanced practice
perspective, the development of practice-based theory is
important, so that practitioners can have access to useful and
dependable knowledge. This has led practitioners and
researchers to develop numerous middle-range theories that
are considered highly relevant for specific aspects of clinical
practice (Brown, 2005).

Advanced practitioners working in community care
settings in Ireland were invited to take part in the study. For
the purpose of this study, an advanced practitioner was defined
as an autonomous practitioner with nursing qualifications who
was responsible for initiating and providing therapeutic
interventions and for managing a patient caseload. Each
participant was provided with information about the research
and gave written consent prior to the interview. Theoretical
sampling was used later in the research process to develop the
key categories that were emerging from the initial data
analysis. Theoretical sampling led to data collection in
contrasting clinical judgment contexts: new and established
patients; long-term mental health and acute accident and
emergency (A&E). Comparative data were used throughout the
process of data analysis. Importantly, it provided a means of
exploring how clinical practitioners adapted their decisionmaking
in these different clinical situations. At a point when
theoretical saturation had been reached, a total of twenty-one
clinical practitioners had been interviewed. The sample
consisted of fifteen practitioners from mental healthcare and
six from A&E. Fifteen were female and four were male. As part
of negotiating access to clinical practitioners working in six
healthcare organisations, institutional consent was obtained
and, where required, from the appropriate research ethics
committee.

Data collection took place directly in the clinical
practitioner’s clinical area immediately following patient
treatment. Interviews were based on the clinical judgments
made for actual patient care. An important grounded theory
maxim is that researchers enter the research field with open
questions to allow the participant’s own story to unfold without
the direction of pre-conceived questions. Therefore, the guiding
questions used throughout the interviews focused on eliciting
what were the clinical practitioners’ main concerns and how
they addressed or resolved such concerns when making clinical
decisions. These open questions proved useful in facilitating
clinical practitioners to tell their story. The use of such open
interview questions also enabled multi-layered storytelling
whereby during the same interview clinical practitioners could
revisit key issues/concerns and tell another ‘mini-story’ which
provided yet further detailed information about their main
concerns.

Once the first interview was completed the process of data
analysis began. The systematic analysis started with open
coding, whereby the interview transcript was analysed line-byline.
Glaser’s (1998) key questions, namely, ‘what category does
this incident indicate?’ and ‘what property of what category
does this incident indicate?’ were asked constantly during the
process of data analysis. The emergence of categories from the
open coding and constant comparative analysis was the trigger
for starting selective coding. Interview transcripts were
analysed again; this time using the newly developed codes to
test if they patterned out. The purpose of selective coding was
to delimit coding to those categories relevant to the emerging
conceptual framework (Glaser & Holton, 2004). Importantly,
selective coding also provided verification that the emergent
theory fitted the practice of clinical practitioners in the
substantive area. Of the early substantive codes that emerged
during the initial data analysis some (for example, ‘Levelling’)
endured and became visible throughout subsequent data
collection and analysis. Other early codes (for example, ‘See-
Saw Debating’) were not substantiated during further data
collection and analysis and were ultimately superseded by
other codes. Memoing was used throughout data analysis to
put down on paper any thoughts and ideas that came up. These
memos became the powerhouse of the research process in the
sense that they mapped out what was happening and provided
the impetus and direction for subsequent data collection.
Theoretical sampling was used to collect further data from
specific areas; in this case, contrasting new with established
patients and chronic with acute patient care situations.

In this study, the emergent categories were derived
directly from the rich descriptions provided by the clinical
practitioners and through the systematic analysis of data. One
of the main categories, ‘intacting therapeutic relationship’, was
developed as it became clear from the clinical practitioners’
accounts that keeping the patient-practitioner relationship
intact was an important part of the clinical judgment process.
Comparative analysis of different incidents revealed that
avoiding break-upable moments was a strategy that clinical
practitioner used to increase the likelihood of maintaining a
therapeutic relationship. Comparative analysis of new versus
established patients demonstrated that there was a
relationship between avoiding break-upable moments and the
stage of the patient-clinical practitioner relationship. With new
patients, the clinical practitioner is more likely to avoid
anything that jeopardises the relationship whereas she is more
likely to take the risk of using interventions that challenge
patients once she is sure that a clinical patient-practitioner
relationship has been established.

The Emergent Theory

From data analysis of 33 in-depth interviews that explored
practitioners’ experiences and concerns in various clinical
judgments, ‘Mutual Intacting’ emerged as a basic social
process. It explains how clinical practitioners make clinical
judgments through a process of adapting treatment so that the
patient-practitioner relationship is maintained and treatment
is delivered in a way that takes account of the patients’
circumstances. The theory of ‘Mutual Intacting’ (see Figure 1)
consists of three stages: ‘situated patterning’, ‘intacting
therapeutic relationship’, and ‘intacting therapy’. ‘Situated
patterning’ describes how clinical practitioners use such
strategies as selectively looking for evidence in order to identify
patterns, gauging levels of priorities, situating clinical
judgment in the context of the patient’s circumstances and the
clinical practitioner’s professional and core value systems as
part of patient assessment. ‘Intacting therapeutic relationship’
describes how clinical practitioners build up and then maintain
their relationship with patients by getting alongside patients,
building up the patient-practitioner relationship whilst
maintaining professional boundaries, avoiding situations that
interfere with the relationship and moderating patient
treatment so that a therapeutic relationship is built-up and
then maintained throughout the course of patient treatment.
Finally, ‘intacting therapy’ describes how clinical practitioners
use strategies such as providing information, guiding patients
towards reaching therapeutic goals, working around problems
that could interfere with treatment and avoiding situations
that could block progress so that patient treatment is
maintained and ultimately completed.

Why ‘Mutual Intacting’? How did this emerge as the core
concept? As data collection and analysis progressed, it became
clear that the clinical practitioners’ main concerns were
twofold: firstly, to maintain the patient treatment and,
secondly, to maintain the therapeutic relationship. For
example, the strategies that clinical practitioners used in order
to get alongside patients to avoid break-upable moments during
nurse-patient encounters and to de-limit boundaries indicated
that they actively worked at developing and then maintaining
the patient-practitioner relationship; that is, keeping it intact.
‘Intacting’ best summarised the complex strategies used in
keeping the therapeutic relationship together, uninterrupted
and undamaged. Itcaptured the essence of what had emerged
from the data. Furthermore, the dynamic relationship between
‘intacting therapeutic relationship’ and ‘intacting therapy’ was
evident from the ways in which clinical practitioners described
moderating patient treatment in order to keep the therapeutic
relationship intact and conversely, from the ways they
described needing to establish the therapeutic relationship
before starting patient treatment. The relationship between the
two concepts, ‘intacting therapeutic relationship’ and ‘intacting
therapy’, was based on their inter-dependence insofar as
clinical practitioners actively and simultaneously worked at
keeping both intact. ‘Mutual Intacting’ encapsulates this key
process and conveys the sense of joint dependence, interconnectedness,
interaction and reciprocity which emerged from
the data.

Figure 1: The Theory of Mutual Intacting (please see PDF version for figure)

Situated Patterning

As part of the process of patient assessment, clinical
practitioners are highly aware of the importance of reaching a
diagnosis and of having a comprehensive understanding of the
patient’s problem. ‘Situated patterning’ is essential not only in
deciding which clinical intervention to use at the start, but also
in evaluating the effectiveness and on-going use of treatment.
Practitioners are aware of the importance of making sense of
the patients’ problems before deciding which treatment is
needed, and they work at achieving this by taking pieces of
information during patient assessment and constructing them
into patterns that they can recognise. Clinical experience is
essential insofar as repeated exposure to similar types of
problems or patient presentations enables practitioners to build
up their own reference library of patterns; this forms the basis
of their assessment of the patient’s problem and diagnosis.
Furthermore, practitioners also build up a reference library of
treatments of which they have first-hand experience and have
found to be effective in the past. Practitioners link the choice of
treatment to ones that previously have worked and are
considered to be ‘tried and tested’. ‘Situated patterning’ not
only involves matching patients with past experience of similar
patients but also in putting the clinical judgment in context so
that treatments can be moderated to suit the patient’s specific
needs. In order to complete ‘situated patterning’, practitioners
use a range of different strategies including ‘selective
evidencing’, ‘levelling’ and ‘touchstoning’.

Selective Evidencing

As part of the process of looking for patterns, practitioners
search for evidence and use strategies such as looking for telltales,
selective questioning and back-upping to collect the key
information that is needed for making a clinical judgment.
Selective evidencing is an important part of clinical judgment;
however, practitioners use it differently depending on whether
they are dealing with new or established patients. For new
patients, practitioners use selective evidencing to develop
recognisable patterns that support a diagnosis whereas for
established patients, they focus more on establishing whether
the treatment is effective.

During patient sessions, one of the key strategies is
looking for tell-tales, whereby practitioners filter the dialogue
and observe the patient’s behaviour looking for indicators as to
the nature of the problem or for positive/negative indicators as
to how they are responding to treatment. In many situations,
these tell-tales are subtle and practitioners are constantly alert
to detecting indicators that are relevant to the patient’s
problem. As one practitioner explains:

It may be the way they said it. It may be the amount of
emphasis they put on. It may be the fact that he
actually diverted from it in the first place. But there is
usually something that alerts me… it’s like you are able
to separate the chaff from the wheat and you are able to
go down the particular route that you are looking for.

Importantly, if there are any gaps in the information needed by
the practitioners they use selective questioning to fill in these
gaps. Selective questioning is used to: rule-out various factors;
ascertain more fully the circumstances surrounding the
problem; address specific concerns about the patient’s situation,
particularly about safety issues; and, assess how patients are
responding to treatment. If sensitive issues such as domestic
violence /abuse or sexual issues are involved or if the patientpractitioner
relationship is not established, practitioners avoid
direct questioning, which may have the effect of closing down
the lines of communication and, consequently, be counter
productive to obtaining necessary information. Instead,
practitioners tend to wait until the patient-practitioner
relationship is more established and then carefully collect the
information needed to complete ‘situated patterning’.
Therefore, there is a link between selective evidencing,
patterning, and maintaining the patient-practitioner
relationship; namely, the practitioners work at completing the
pattern whilst also keeping the patient relationship intact.

Practitioners also use back-upping particularly in
situations where there is a high degree of uncertainty or risk
associated with the clinical judgment. Common sources of backupping
include healthcare colleagues or tests such as X-rays,
blood tests or psychological tests. In situations where the
patient is not considered a reliable source of information, the
patient’s family or friends are a useful means of validating the
patient’s history. There are limitations to using family and
friends as back-ups; namely, that the patient’s confidentiality is
maintained and some patients may not agree to having them
present during history taking and assessment.

Levelling

‘Situated patterning’ also involves levelling whereby
practitioners calculate what treatment priorities, risk of
consequences and level of organisational support. Importantly,
as part of the initial assessment, practitioners gauge the
patient’s comprehension level because it is perceived to be
linked to the patient’s ability to understand and follow
healthcare advice. It is for this reason that practitioners note
the patient’s ability to understand language, the patient’s age,
gender, occupation and level of education so that they can
moderate the vocabulary or indeed the information given to
patients.

Touchstoning

Finally, ‘situated patterning’ involves touchstoning
whereby practitioners refer to the guiding principles
underpinning their actions. For example, practitioners
sometimes refer to theoretical principles they have learned
about in their professional training courses that are considered
relevant to the particular patient problem. In situations where
the healthcare institution has clinical guidelines developed
specifically for the practitioner’s scope of practice, they ensure
that clinical judgments meet these guidelines. As this
practitioner explains:

…our approach to patients would be quite similar you
know, again I think it is because it is a safe and well
outcome for the patient but, the guidelines have to be
there for safe practice, but you can adapt them…not
going outside of our scope of practice either.

Although clinical guidelines are used as part of everyday
clinical judgment, they are not used as a rigid framework
perceived as restricting clinical judgment but rather as a set of
flexible guidelines that can be adapted to the specific situation.
In touchstoning, practitioners also refer to ethical principles
drawn from their professional code of practice especially in
relation to protecting the patient, doing no harm and
maintaining confidentiality. This includes recognising the
importance of the patient’s right to choice in deciding whether
or not to accept treatment. The degree to which touchstoning
occurs varies across the different clinical situations. In most
situations, the level of touchstoning is low insofar as
practitioners just briefly refer to the guiding principles and are
aware that they set the parameters for their scope of clinical
practice. In contrast, the level of touchstoning becomes high in
situations where a difficult conflict needs to be resolved.

Intacting – Therapeutic Relationship

For clinical practitioners, ‘intacting- therapeutic
relationship’ is considered critical to effective treatment insofar
as the quality of clinical diagnosis or assessment is conditional
on the patient’s willingness to provide the necessary
information for ‘situated patterning’. The therapeutic
relationship needs to be established before treatment can begin
and furthermore, the patient’s willingness to follow the
practitioner’s treatment advice or to continue with treatment is
conditional on the therapeutic relationship. Clinical
practitioners, therefore, are highly aware of the importance of
firstly establishing and then maintaining therapeutic
relationships with their patients.

Getting alongside

‘Intacting-therapeutic relationship’ involves getting
alongside whereby practitioners work at engaging their
patients. In situations where practitioners work in busy clinics
with a lot of different people around, they actively work at
creating an atmosphere where patients can feel that they are
getting individual attention. In order to build up a one-to-one
relationship, practitioners organise to see their patients in a
quiet area or private room away from interruptions.
Practitioners also use other strategies such as positioning the
patient alongside them as opposed to sitting behind a table,
avoiding using an interrogation or interview approach and
mimicking a friendly, homely situation in which the patient can
feel at ease.

Avoiding break-upable moments

Keeping the therapeutic relationship intact involves
avoiding break-upable moments, which includes avoiding
anything that can interfere with the patient’s level of trust in
the practitioner or which distresses/angers patients so that
they want to end treatment before it is completed. Practitioners
continuously monitor patients for indicators that the
relationship is deteriorating.

De-limiting boundaries

Although the practitioners’ main concern is to maintain a
therapeutic relationship, it can also involve the use of delimiting
boundaries. Particularly with first appointments,
practitioners avoid situations that cause embarrassment and
instead work at helping patients feel at ease. Although
strategies are used to get alongside and to befriend the patient,
boundaries are also laid down to limit the level of friendship.
Practitioners are aware of the importance of being friendly and
supportive to patients; however, they are equally aware of the
need to maintain a balance between being friendly and
maintaining a professional boundary.

Intacting Therapy

An important feature of clinical judgment is the strategies
that practitioners use to maintain treatment and keep it
progressing towards the stated goal. ‘Intacting therapy’
explains that practitioners are also concerned about
maintaining treatment and achieving the treatment objectives.
Whilst treatment is considered important, practitioners do not
carry it out if it risks jeopardising the patient-practitioner
relationship. It is for this reason that practitioners moderate
treatment. Under conditions where treatments are carried out
over a prolonged period of time, it is moderated for the purpose
of bringing patients back for further treatment sessions. If
patients do not attend their appointments, they cannot be
treated and consequently this can delay recovery. Under
conditions in which treatments are completed in once-off
sessions, practitioners moderate treatment for the purpose of
using treatments that are acceptable to patients. This increases
the likelihood that patients will follow the healthcare advice
and make the best possible recovery. The extent to which
practitioners can moderate treatment, however, is limited and
they work within the boundaries of accepted practice. ‘Intacting
therapy’ involves a variety of different strategies; namely,
protective steering, enablers, avoiding blockers and
workarounds that help maintain treatment and keep it
progressing towards a completion.

Protective steering

Protective steering is one strategy used by practitioners in
guiding patients towards reaching their therapeutic goals and
shielding them from setbacks during the process of making a
recovery. It involves leading patients rather than telling them
to do something. Practitioners provide information in the form
of verbal advice or written leaflets that support patients in
making the ‘right’ decisions. In some situations, specific advice
sheets have been developed and are used in combination with
verbal advice for the reason that it increases the likelihood that
patients would understand and follow the advice.

In situations in which a patient’s ability to understand
information is considered limited, practitioners avoid giving
complex information and use alternative strategies whereby
patients can have their information needs met. Therefore,
decisions regarding what information to give the patient are
based on the practitioner’s judgment of whether it is helpful to
patients. For some practitioners, protective steering not only
concerns what information is given but how it is communicated.
Different styles of communication are used for the purpose of
emphasising important elements. Whilst practitioners actively
guide patients in taking a particular line of action, on the other
hand, they are aware of the importance of not forcing advice on
patients. Protective steering also involves supporting patients
as they navigate their way through a complex or unfamiliar
healthcare system. The main reason for this aspect of
protective steering is to facilitate the smooth movement of the
patient through the healthcare system so that patients get
what they need to facilitate recovery yet do not become overly
dependent on the services.

Workarounds

‘Intacting therapy’ is also characterised by workarounds
whereby practitioners work at resolving actual problems that
interfere with treatment. Problems can be classified into three
main types; namely, problems relating to patient
characteristics, ineffective treatment, and organisational
arrangements. For problems relating to patient characteristics
such as the patient’s intellectual level or ability to cope with
illness/ treatment, practitioners moderate and adapt
treatments to suit the patient’s individual circumstances. For
problems relating to a mismatch between the individual
patient needs and the facilities available within the
organisation, practitioners work within the system so that
patients can continue with treatment. An important prerequisite
to workarounds, therefore, is the practitioners’
knowledge of the healthcare system insofar as knowing what
treatments are available and how to access them. As this
practitioner explains:

knowing what is available…you are in the system for a
while, so you know. I have been there for about 12
years, so I know the wards well. I know all that, so to
actually leave this job is kind of very difficult starting
another job cause you are in the system…knowing the
ground level running some of these programmes helps.

This kind of knowledge results from years of working in the
service during which time practitioners have direct experience
of what treatments are effective and for which type of patient
problems. In contrast, practitioners are more cautious about
using services they have not used before. Consequently, the
degree to which practitioners use workaround is dependent not
only on their knowledge of what services are available but also
on whether they have first-hand knowledge of their
effectiveness.

Enablers and avoiding blockers

In addition to protective steering, practitioners use a
combination of enablers and avoiding blockers to maintain
patient treatment. As one practitioner explains:

…you work on it in different ways, you find what we
call an in-road, and it does feel sometimes that you are
going up these roads and you are getting somewhere
and it’s a cul-de-sac. There is a block. You have to come
back down and try again, some other route in and
usually you find it.

Many of the techniques, for example keeping a diary, are
specific to a particular type of treatment. Nevertheless, they
serve the function of keeping patients actively involved with
their treatment until the next appointment. Practitioners use
avoiding blockers for the reason that it prevents disruptions to
therapy. Avoiding blockers could be considered as a parallel to
the practitioner’s use of avoiding break-upable moments in
maintaining the therapeutic relationship. Avoiding blockers
involves avoiding any treatments that are considered counterproductive
to patient progress.

Discussion

When compared to existing clinical judgment theory, there
are several notable differences in how clinical judgment is
explained in ‘Mutual Intacting’. One difference is found
between the approach used by clinical practitioners,
conceptualised here as ‘situated patterning’, and that described
by heuristics. In heuristics, the clinical practitioner’s reasoning
is said to involve a process of associating current patient
presentation with prior experiences of similar situations (Cioffi,
2000; 1997). Likewise, clinical practitioners in this study
actively looked for patterns which not only matched the patient
with previous experience of similar patients but also identified
a ‘fit’ within the patient’s own usual behaviour or usual state of
health. An important difference in ‘situated patterning’,
however, is that the process also includes the application of
rule-based systems either in the form of verification by external
sources, application of theoretical principles of treatment or
ethical principles concerning patient rights to choice and selfdetermination.
Previous clinical judgment research in nursing
has tended to juxtapose the two forms of reasoning as either
information processing (Corcoran-Perry et al., 1999; Lajoie et
al., 1998; Fowler, 1997; Narayan & Corcoran-Perry, 1997;
Greenwood & King, 1995; Grobe et al., 1991; Corcoran, 1986) or
intuition (Cioffi, 2000; 1997; Benner 1984,). By contrast,
‘situated patterning’ suggests that in everyday clinical practice,
practitioners use a mixture of different forms of reasoning.

Another difference is found between ‘situated patterning’
and that described by the hypothetico-deductive approach. In
the hypothetico-deductive approach, assessment is dominated
by the identification of signs and symptoms as cues, and
matching these against pre-set, normatively defined cues;
together, these processes comprise a diagnosis. By contrast, in
‘situated patterning’ the emphasis is on assessing a wider
range of cues that takes into account the patient’s subjective
experience of illness, including the ability to cope with illness
or treatment. Thus, patient assessment and diagnosis involves
understanding the patient’s problem, is not limited to finding a
diagnostic label but instead positions the problem within the
patient context. Previous research supports the finding that
nurses take into account the context in which a patient’s
problem exists (Rydon, 2005; Clark, 2004; Haworth & Dluhy,
2001; Offredy, 1998). Similarly, the way that clinical
practitioners in this study ‘knew’ the patient in terms of family
circumstances, social/ work life, previous experiences of
treatment, issues causing concern/ anxiety, lifestyle habits and
preferences, suggests that clinical practitioners are able to
interpret the problem differently for each patient. Although the
type of presenting problems differ across mental health and
A&E areas, clinical practitioners take into account the
particular set of conditions surrounding the problem, so that
each problem is situated within the patient context.

A key feature of ‘Mutual Intacting’ is that it identifies the
main concerns of clinical practitioners when making clinical
judgments and the strategies used to resolve these concerns.
Data suggests that the clinical practitioners’ concerns are
twofold; firstly, in maintaining treatment by ensuring the
delivery of care to the patient, thereby facilitating patient
recovery and, secondly, in maintaining a therapeutic
relationship with patients. The main strategy used by clinical
practitioners to resolve these concerns involves moderating the
treatment to take account of the patient’s needs. Clinical
practitioners continuously adjust treatment and make subtle
adaptations so that treatment is presented in a form that is
acceptable to patients. Importantly, ‘Mutual Intacting’
highlights the dynamic relationship between maintaining
treatment and maintaining a patient-practitioner relationship.

Other research on clinical judgment reports that nurse
practitioners often negotiate treatment plans with patients.
This may be a compromise initially, leading to compliance at a
later stage (Offredy, 1998). Similarly, the strategies of
protective steering, workaround, enablers and avoiding
blockers identified in this study suggest that clinical
practitioners actively reason throughout assessment and
treatment to work out the ‘best’ way forward for the individual
patient. In the context of midwifery, Levy (1999) conceptualised
the processes by which midwives facilitate informed choices for
pregnant women as Protective Steering. Levy’s study, which
portrayed midwives as ‘walking a tightrope’ between meeting
the wishes of pregnant women and acknowledging their own
concerns about ensuring a safe delivery, is now considered
dated and a product of a medically dominated maternity service
(Maimbolwa, 2006; Mander, 2006). In this study, protective
steering refers to a process of information giving in the context
of navigating a way through the healthcare services and of
enabling the patient to recover from chronic mental health
problems or acute minor injuries. It is, however, one strategy
that fits within a more complex explanation of clinical
judgment.

Another key feature of Mutual Intacting is the way in
which it conceptualises clinical judgment as a social encounter.
In contrast to the traditional approaches of hypotheticodeduction
or intuition that view clinical judgment as cognitive
reasoning by the individual, Mutual Intacting highlights the
patient-practitioner interaction as an integral part of clinical
judgment. In the mental health literature, it is well established
that a therapeutic relationship between clinical practitioner
and patient is of central importance to mental healthcare
(Clark, 2004; McGuire et al., 2001). In this study, clinical
practitioners in mental health contexts used a number of
strategies to develop and maintain a therapeutic relationship
for the reason that bringing patients back was essential to
continuing treatment. An unexpected finding, given that
clinical practitioners in A&E see patients on a once-off basis,
was the extent to which ‘intacting-therapeutic relationship’ was
also used in the acute care setting. The reasons for developing a
therapeutic relationship by A&E clinical practitioners differed
from those in mental health contexts. In A&E, establishing a
relationship with patients was fundamental to patient consent
for procedures such as physical examination, suturing of
wounds, immobilising fractures and application of Plaster of
Paris. Furthermore, establishing a therapeutic relationship
was important, firstly, for the purposes of diagnosis in that it
influenced the patient’s willingness to disclose relevant
information and, secondly, in terms of compliance in that it
influenced the patient’s level of trust and willingness to accept
the healthcare advice.

Empirical support from other studies identifies the links
between the patient-practitioner relationship and treatment.
For example, partnership and involvement in clinical judgment
are identified as key determinants of patient satisfaction and
acceptance of healthcare advice (Winefield et al., 1995). Taylor
(2006) also identifies knowing the patient and gaining their
trust as key factors for the reason that it enables nurses to ‘get’
patients to work with them. For Morse (1991), it is critical that
both the nurse and the patient are involved in negotiating
healthcare. If either is unwilling to be committed to resolving
the healthcare problem, then a unilateral relationship will
develop where one side tries to manipulate the other, including
patient withdrawal from the health service. The patientpractitioner
relationship, therefore, is inextricably linked to the
effectiveness of patient treatment.

Limitations

Although clinical practitioners from all areas of healthcare
practice who met the inclusion criteria could have participated,
only those working in mental healthcare and A&E were
involved in this study. It is recognised that other concepts may
have emerged if the study had been extended to include other
areas of clinical practice. Further research to determine if the
emergent theory holds in other areas of clinical practice and in
other areas of professional practice is necessary.

Conclusion

The theory of ‘Mutual Intacting’ provides an expanded
understanding of clinical judgment that challenges traditional
approaches of reasoning; namely, hypothetico-deduction and
intuition, to consider issues relating to the patient context and
the integration of association and rule-based forms of
reasoning. Importantly, ‘Mutual Intacting’ conceptualises
clinical judgment as a social encounter in which the
establishment and maintenance of a patient-practitioner
relationship is central. It sensitises advanced practitioners to
consider clinical judgment as a social interaction and how these
issues influence the process of clinical judgment in community
care contexts. ‘Mutual Intacting’ is an emergent concept and is
one perspective that is premised on the clinical practitioners’
understanding of clinical judgment. As a conceptual
explanation of clinical judgment, however, ‘Mutual Intacting’ is
limited to the context from which it is derived. Further
theoretical development is needed so that the concept is
modified through a process of further theoretical sampling
drawing from other areas of clinical practice within nursing
and indeed, from other healthcare professions.

Author

Naomi Elliott, MSc., BNS, RGN, RNT, PhD student.
Director for Academic & Professional Affairs for Nursing
School of Nursing & Midwifery
Trinity College Dublin
24 D’Olier Street
Dublin 2, Ireland
E-mail: Naomi.Elliott@tcd.ie

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