Patient preferences in nursing decision-making. A theory about fine-tuning knowledge in acute care.
Ria den Hertog – Voortman

The general objective of this grounded theory study was to develop a substantive theory of how good nurses in acute care tune in to patient preferences in nursing decision making, and what knowledge they deploy in doing so. In Evidence-Based Practice (EBP) literature, the focus is mostly on the evidence from scientific research to the detriment of patient preferences. The operationalization of patient preferences in EBP is dependent on the espoused scientific tradition of the researcher. Because the answer is not found in the literature, an empirical study was conducted to describe how good nurses address norms, values and patients’ preferences in the daily nursing decision-making. The respondents (n=27) emphasized in the interviews the importance of a good nurse-patient relationship as a prerequisite to discover the patient preferences and taking account into them in the nursing decision making. They establish instant connection in creating a ‘click’, use ‘antennae’ or probes and communicate openly by asking ‘empathic’ questions. Based on the acquired knowledge they form, often unconsciously, a broad frame of reference and use it in nursing decision-making. Additionally, seven 'good' nurses have been observed during their shifts in a nursing ward to discover what can be seen regarding attuning to patient preferences and the use of tools in daily nursing practice. One of the respondents summarized their working attitude as ‘Teach me the best way to take care for you in this situation’.
The discovered part of professional knowledge about taking account into patient preferences to providing adequate, individualized care is termed as 'fine-tuning knowledge'. The three dimensions of this knowledge in nursing practice have been compiled to a ‘theory on fine-tuning knowledge', i.e. a model of knowing-why, knowing-how and knowing-what. The theory is compared with other theories of practical knowledge and it is ascertained that in Benner's theory of adaptive knowledge in nursing the knowing-why is missing. Other authors show that the fine-tuning knowledge is been found in the reflective practice, moreover, in the practical wisdom of professionals. The literature shows a renewed interest in the concept of practical wisdom or phronesis to fill the void left by the sole interest in propositional knowledge in training and practice. Further research is recommended to specify the concept of fine-tuning knowledge as practical knowledge in nursing, and its connection with practical wisdom to increase the understanding of how patient preferences can be included in nursing decision making to provide good nursing care.