Background Recognition and response to clinical deterioration of hospitalised patients is a worldwide health priority area. In response to this concern, international bodies have implemented early warning systems to help clinicians keep people safe and prevent patient deterioration. Registered nurses hold a significant role in managing care provision and utilise early warning system tools to support their clinical judgement when making decisions about patient care.

Objective To generate a theory explaining how registered nurses employ their clinical judgement when complying with an early warning system protocol.

Design Classic grounded theory.

Participants Participants included twenty registered nurses working with early warning systems who are currently employed in a state health care system within Australia. Data were collected via interviews generated from a grand tour question in line with classic grounded theory.

Methods Classic grounded theory methodology and methods were used. This approach facilitated the identification of the participants main concern and supported the generation of a theory explaining how the participants resolved this issue.

Results Analysis of data, including associated field notes and memos, identified participants often experienced unease when complying with an early warning system protocol and employing clinical judgement. The mental discomfort participants voiced in the interviews described internal conflicts that are reflective of the term ‘cognitive dissonance’. How the participants sought to resolve their cognitive dissonance, revealed participants' main concern as: Compliance with early warning systems is sometimes incongruent with nurses' use of clinical judgement. The outcome of this study is a grounded theory that explains how nurses resolve this concern through ‘Acknowledging’. Nurses acknowledge the efficacy of early warning systems, whilst valuing their clinical judgement and the importance of patient safety, through the subcategories of Acting and Pausing.

Conclusion The Theory of Acknowledging explains how nurses overcome their main concern when employing clinical judgement and complying with early warning systems, whilst acknowledging the importance of ensuring patient safety. Reconciling the dissonance caused by trusting their clinical judgement and remaining compliant with early warning systems, enables nurse-led assessment of the patient, promoting patient safety.