The social context of critical care clinical judgment.

Background: Clinical judgment in critical care is supported by a rich social network of care providers. The purpose of this study was to describe the social context in which the process of critical care clinical judgment occurs from the nurse's perspective.

Methods: An ethnographic study was conducted that included interviews with 10 nurses and participant observation in an open heart surgery unit with 59 nurses and two surgical teams during a 2-year period.

Results: Nurses and physicians were organized in hierarchies of nurse manager, resource nurse, charge nurse, and staff nurse or attending surgeon, fellow, chief resident, and resident. These parallel hierarchies allowed for checks on judgment both within and across professional lines. Rituals, such as nursing report, physician rounds, and flow sheet use, provided a context for a critique on judgment processes. Communication of judgment was frequently a casual, open conversation. At other times, differences in perspective could result in conflict. Communication between nurses and physicians has been associated with better patient outcomes. Critical care unit directors and managers can use an analysis of communication patterns to develop supports to clinical judgment.