Beyond protocol versus judgment: A qualitative study of nurses' prioritization and integration strategies.

Background: The tension between protocol adherence and clinical judgment is a central challenge in nursing practice. While protocols ensure standardization and safety, their rigid application can hinder clinical reasoning, patient-centered care, and professional autonomy. Although this tension is well-documented, research on how nurses achieve balance between these competing demands is lacking. Objective: to examine how nurses experience and cope with the competing demands of strictly adhering to protocols versus exercising clinical judgment. Specifically, to identify the modes of response, guiding criteria, behavioral coping strategies, and the consequences of each approach. Design: A qualitative descriptive design was employed. Method: In-depth interviews were conducted with 20 nurses purposively sampled from five internal medicine departments. Interviews focused on concrete clinical situations and were analyzed using inductive thematic analysis until data saturation was achieved. Results: Analysis identified three empirically recurring response patterns: prioritizing protocols, prioritizing clinical judgment, and integrating both approaches. Nurses who prioritized protocols often felt strained and reported negative emotions such as frustration and helplessness. Those relying on clinical judgment described emotional tolls like self-doubt, social sanctions and fear of consequences. In contrast, nurses who integrated both approaches experienced a mix of positive and negative emotions and reported enhanced patient care and personal growth. Key integrative coping strategies included anticipation, institutional navigation, coalition building, and reflective processing. Conclusions: The findings provide practice-near, descriptive insights into how nurses navigate the persistent tension between protocol adherence and clinical judgment. Theoretically, the findings contribute to a deeper understanding of how paradoxes are navigated in healthcare. Practically, the study underscores the need for healthcare organizations to cultivate integrative thinking, emotional and coping flexibility through supportive leadership, psychological safety, and reflective practices for fostering more adaptive, resilient, and patient-centered care systems.