This study investigates the phenomenon of clinical decision making, deriving a grounded substantive theory to explain how home health care nurses make patient care decisions. Despite the continuing shift of health care from acute care settings to the patient's home, little is known about home health care nurses' clinical decision making processes and the factors influencing them.

The study employs a field research design using grounded theory based on symbolic interactionism. Data collection at two Visiting Nurse Associations includes participant observation and open-ended interviews of 21 nurses, and document analysis of patients' records and home care nursing practice policies. The study uses the constant comparative technique for data analysis and incorporates measures to enhance its credibility, transferability, dependability, and confirmability.

Managing patient care emerged as the basic social process that explains home health care nurses' clinical decision making. This process has three components. First, it embodies the problem solving process with the phases of problem finding and problem management. Problem finding consists of the cognitive processes and decisions of cue searching and inferring patient problems, while problem management consists of planning, intervening, and evaluating. Second, to manage patient care, home care nurses use three styles based on their approach to gathering and evaluating information--"skimming," "surveying," and "sleuthing." Third, interacting clinical and non-clinical factors influence patient care management: the nurse's education and experience, the patient's health-related attributes, the nurse-patient interaction, and the organizational, legal, and economic factors. With these three components, the emergent theory of managing patient care integrates elements of three cognitive theories--information processing, cognitive continuum, and skills acquisition--thus bridging the traditionally dichotomous rational and phenomenological perspectives underpinning clinical decision making.

The emergent theory raises issues critical to the teaching and improvement of clinical decision making among practicing and future home care nurses, in the context of the potential ethical dilemmas implied by the sometimes conflicting factors that influence patient care management. It serves as the springboard for extending the study to other clinical specialties, building a body of substantive theories that would lead to a formal theory of clinical decision making in nursing.