Putting the pieces together: Clinical judgment from the perspective of registered nurse anaesthetists and anaesthesiologists at tracheal extubations after general anaesthesia.

BACKGROUND: Extubation of patients undergoing general anaesthesia is a shared concern among registered nurse anaesthetists and anaesthesiologists. Although it has been described as complex and unpredictable, knowledge of this critical moment remains limited. Clinical judgment is consistently applied when making crucial decisions regarding patient care. This study aimed to investigate how RNAs and ANs expressed clinical judgment during extubation through noticing, interpreting, responding, and reflecting. METHODS: A qualitative reflexive thematic analysis was conducted, using interviews with registered nurse anaesthetists and anaesthesiologists from university and regional hospitals in Sweden. Triangulation was used to explore the perspectives of registered nurse anaesthetists (n = 20) and anaesthesiologists (n = 17) at extubations. Two datasets, one from focus group interviews with registered nurse anaesthetists and one from individual interviews with anaesthesiologists, were used to triangulate data. RESULTS: Extubation was described as a dynamic process of clinical judgment, where anaesthesia professionals continuously integrated clinical cues, experience, and situational awareness to ensure patient safety. Multisensory patient-related and situational cues were attended to and integrated to form an initial understanding of the patient's condition. These cues were interpreted through prior experience and pattern recognition, while responses were shaped by context and often guided by embodied intuition. Reflection both in action and on action supported ongoing adjustment and the development of clinical judgment over time. CONCLUSIONS: During extubation, registered nurse anaesthetists and anaesthesiologists exercised clinical judgment by putting the pieces together, continuously integrating clinical cues, experience, and situational awareness. This process involved multisensory noticing, experience-based interpretation, context-dependent responding often guided by embodied intuition, and ongoing reflection to ensure patient safety. These findings highlight the importance of supporting clinical judgment through experience-based learning, reflective practice, and work environments that enable focused attention during extubation.