Abstract

Nursing practice often occurs within increasingly complex, unpredictable and resource-variable environments demanding adaptive, creative and context sensitive responses. While evidence-based protocols and standardized guidelines guide much of the nursing care of the present day, the frontline nurses frequently in improvised actions that aim at maintaining their safety, continuity and therapeutic effectiveness. Despite its prevalence, improvision in nursing is under-theorized and little conceptualized in formal knowledge systems in nursing. This literature-based paper proposes the formation of a Nursing Improvision Theory that recognizes improvision as a legitimate and structured dimension of nursing practice rather than informal work-around behavior, that is ethically grounded. Drawing from the literature on adaptive expertise, clinical judgment, complexity science, resilience, innovation in care delivery, and practice theory, the paper draws on conceptual foundations for theorizing nursing improvision. The article presents a review on eight subtopics: conceptual understanding of improvision as applied to clinical practice, historical development of adaptive nursing practice, improvision and clinical judgment, complexity and uncertainty of care environments, constraints of resource and creativity in action, ethical boundaries for improvised care, organizational and educational factors, and statements of outcomes for improvised nursing interventions. The theoretical structure posited identifies core constructs and relational propositions and implications for practice. The theory establishes nursing improvisation as a professional, ethical, competent, adaptive, patient-centered process. Developing this theory adds to the science of nursing by legitimizing adaptive action, training, enhancing safety frameworks, and informing resources policy in resource variable health systems.

Keywords: nursing improvision, adaptive practice, clinical judgment, complexity, nursing theory, innovation in care,

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