ArticleLiterature Review

Intuition: a critical review of the research and rhetoric

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Abstract

This paper will explore the concept of intuition in nursing from an acute care and community nursing perspective. It will consider definitions of intuition and examine the research which can inform our understanding of this important component of decision making. In the current health service climate, which demands measurable research-based evidence, the involvement of intuition as an element of judgement is often denigrated. The result is that many nurses are being forced to be covert in their use of this crucial aspect of judgement and focus solely on the conscious elements of decision-making. However, research evidence would suggest that intuition occurs in response to knowledge, is a trigger for action and/or reflection and thus has a direct bearing on analytical processes in patient/client care. The authors therefore argue that the essential nature of intuition cannot be ignored in the practice, management, education and research of nursing.

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... The goal of this paper is not so much to review the extensive literature dealing with intuition and expertise in nursing (for pointers to this literature, see Field, 2004; King & Appleton, 1997) as to discuss two theories of expert intuition critically. We start by briefly considering the role of intuition in nursing practice. ...
... The role of intuition in nursing has been the topic of considerable debate, with some authors (such as English, 1993) considering that this concept should be subjected to critical scrutiny at best and rejected at worst, while others (such as Darbyshire, 1994; Effken, 2001; King & Appleton, 1997) considering it central to our understanding of nursing expertise. In particular, the work of Patricia Benner and her colleagues (Benner, 1984; Benner et al., 1992; Benner, Tanner, & Chesla, 1996) has done much to convince the field of nursing of the importance of intuition. ...
... Several authors have noted that emotions are part and parcel of intuitions (Benner, 1984; De Groot, 1965, 1992; King & Appleton, 1997). The original version of TempT does not include mechanisms accounting for emotions, but Chassy and Gobet (2005) have recently proposed biological mechanisms showing how emotions can be linked to memory in general and, in particular, how they modulate the use of chunks and templates. ...
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Several authors have highlighted the role of intuition in expertise. In particular, a large amount of data has been collected about intuition in expert nursing, and intuition plays an important role in the influential theory of nursing expertise developed by Benner [1984. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Menlo Park, CA]. We discuss this theory, and highlight both data that support it and data that challenge it. Based on this assessment, we propose a new theory of nursing expertise and intuition, which emphasizes how perception and conscious problem solving are intimately related. In the discussion, we propose that this theory opens new avenues of enquiry for research into nursing expertise.
... Multiple sources of information were used by health visitors in formulating their understanding of parent-child relationships (Appleton 1994a). These include use of known risk factors (Appleton et al. 2004), knowledge of local norms, direct observations of behaviour, reflection on the relationship between the parent and health visitor, as well as more intuitive reactions (Appleton 1994a; King et al. 1997; Paavilainen & Tarkka 2003). In many cases understanding difficulties in parent-child relationships involved piecing together a jigsaw over a considerable period. ...
... Health visitors use a range of techniques to make complex judgements about relationships between children and their parents. As well as checklists and guidelines (Appleton et al. 2004), HVs utilise their 'intuitive' responses (King et al. 1997; Paavilainen & Tarkka 2003) and other types of 'professional judgement' (Appleton et al. 2004). While this approach may be sensitive, there are potential dangers in uncritical use of such 'internal models,' particularly in terms of culturally sensitive practice. ...
Article
Health visitors (HVs), also known as public health nurses, in the UK provide a universal community-based service to preschool children and their parents. Since they have ongoing supportive contact with almost all mothers and young children they have opportunities to identify problems in the parent-infant relationship: for example during developmental screening, home visits and immunisation clinics. Research into the role of screening for problems in the parent-child relationship in early childhood is sparse and little is known about how such problems are currently identified in the community. To explore the approaches taken by health visitors (HVs) to identifying problems in the parent-child relationship. Focus group study. Glasgow, Scotland. Participants: 24 health visitors sampled purposively. Multiple sources of information were used by health visitors in assessing parent-child relationships. These include use of known risk factors, knowledge of local norms, direct observations of behaviour, reflection on the relationship between the parent and health visitor, as well as more intuitive reactions. In many cases understanding difficulties in parent-child relationships involved piecing together a jigsaw over a considerable time span. Continuity of relationships appeared to be crucial in this task. Home visits were described as the most informative setting in which to develop an understanding of the parent-child relationship. Participants reported a lack of formal training in the assessment of parent-child relationships and were keen to obtain more training. Health visitors use complex strategies to integrate information about parent-child relationships. These strategies are acquired in a variety of ways, but receive little emphasis during basic professional training.
... In the expert judgment technique, an expert considers many sources of information and uses an intuitive model that combines many relevant factors to produce a forecast. Many authors have used this method in fields such as software development (Boehm 1981, Fenton 1991, Heemstra 1992), clinical care (King and Appleton 1997), real estate (Xu 1998), and economic and financial forecasting (OECD). The Delphi approach aims to build a compromise or a consensus among a group of experts (Linstone and Turoff 1975). ...
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NBC-Universal (NBCU), a subsidiary of the General Electric Company (GE), implemented a novel demand prediction and analysis system to support its annual upfront market. The upfront market is a brief period in late May when the television networks sell a majority of their on-air advertising inventory. The system uses an innovative combination of the Delphi method and the Grass Roots forecasting methodology to estimate demand for television commercial time. We embedded this forecasting methodology within a workflow system that automates the demand estimates gathering process and seamlessly integrates into NBCU's existing sales systems. Since 2004, over 200 sales and finance personnel at NBCU have been using the system to support sales decisions during the upfront market when NBCU signs advertising deals worth over $4.5 billion. The system enables NBCU to sell and analyze pricing scenarios across all of NBCU's television properties with ease and sophistication, while predicting demand with a high accuracy. NBCU's sales leaders credit the system with having given them a unique competitive advantage.
... Intuition has been cited as an integral part of nursing clinical practices (Benner and Tanner, 1987). It helps to develop creativity and often it is not directly communicable in language it is a hunch, gut feeling (Effken, 2001; King and Appleton, 1997). The use of a variety of knowledge is necessary when using the two-phase framework. ...
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This article provides a comprehensive review of how a two-phase framework can promote and engage nurses in the concepts of critical thinking. Nurse education is required to integrate critical thinking in their teaching strategies, as it is widely recognised as an important part of student nurses becoming analytical qualified practitioners. The two-phase framework can be incorporated in the classroom using enquiry-based scenarios or used to investigate situations that arise from practice, for reflection, analysis, theorising or to explore issues. This paper proposes a two-phase framework for incorporation in the classroom and practice to promote critical thinking. Phase 1 attempts to make it easier for nurses to organise and expound often complex and abstract ideas that arise when using critical thinking, identify more than one solution to the problem by using a variety of cues to facilitate action. Phase 2 encourages nurses to be accountable and responsible, to justify a decision, be creative and innovative in implementing change.
... In contrast, the role of intuition in diagnostic reasoning has been extensively investigated in nursing, and results show that intuition is an integral part of nurses’ decision making and is assumed to be based in expert knowledge.10–14 Recent research into the role of intuition in general practice found that many GPs experience so-called gut feelings in their diagnostic reasoning about patients.15 ...
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General practitioners (GPs) are often faced with complicated, vague problems in situations of uncertainty that they have to solve at short notice. In such situations, gut feelings seem to play a substantial role in their diagnostic process. Qualitative research distinguished a sense of alarm and a sense of reassurance. However, not every GP trusted their gut feelings, since a scientific explanation is lacking. This paper explains how gut feelings arise and function in GPs' diagnostic reasoning. The paper reviews literature from medical, psychological and neuroscientific perspectives. Gut feelings in general practice are based on the interaction between patient information and a GP's knowledge and experience. This is visualized in a knowledge-based model of GPs' diagnostic reasoning emphasizing that this complex task combines analytical and non-analytical cognitive processes. The model integrates the two well-known diagnostic reasoning tracks of medical decision-making and medical problem-solving, and adds gut feelings as a third track. Analytical and non-analytical diagnostic reasoning interacts continuously, and GPs use elements of all three tracks, depending on the task and the situation. In this dual process theory, gut feelings emerge as a consequence of non-analytical processing of the available information and knowledge, either reassuring GPs or alerting them that something is wrong and action is required. The role of affect as a heuristic within the physician's knowledge network explains how gut feelings may help GPs to navigate in a mostly efficient way in the often complex and uncertain diagnostic situations of general practice. Emotion research and neuroscientific data support the unmistakable role of affect in the process of making decisions and explain the bodily sensation of gut feelings.The implications for health care practice and medical education are discussed.
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This is a qualitative study in a descriptive exploratory approach with the purpose to characterize the intuitive knowledge in nursing care. The qualitative data were generated through semi-structured interviews with 87 nursing professionals. The analysis of the data was done using QSR Vivo and interpreted through a framework based on studies of the North-American nursing literature. Intuition emerged as a feeling, as a type of knowledge, and as both. Further analysis showed three defining attributes: 1) knowledge of a fact or the truth, as a whole; 2) immediate possession of knowledge; 3) knowledge independent from linear reasoning process, as well as three types of intuition: cognitive inference, gestalt intuition, and precognitive function. The result of this study shows a parallel with the others found in North-American nursing literature.
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E-technology is increasingly used in oncology to obtain self-reported symptom assessment information from patients, although its potential to provide a clinical monitoring tool in palliative care is relatively unexplored in the UK. This study aimed to evaluate the support provided to lung cancer patients post palliative radiotherapy using a computerized assessment tool and to determine the clinical acceptability of the tool in a palliative care setting. However, of the 17 clinicians identified as managing patients who met the initial eligibility criteria for the study, only one clinician gave approval for their patient to be contacted regarding participation, therefore the benefits of this novel technology could not be assessed. Thirteen key clinicians from the centres involved in the study were subsequently interviewed. They acknowledged potential benefits of incorporating computerized patient assessment from both a patient and practice perspective, but emphasized the importance of clinical intuition over standardized assessment. Although clinicians were positive about palliative care patients participating in research, they felt that this population of patients were normally too old, with too rapidly deteriorating a condition to participate in a study using e-technology. In order to encourage acceptance of e-technology within palliative care, emphasis is needed on actively promoting the contribution of technologies with the potential to improve patient outcomes and the patient experience.
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Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. The high-performance expectation of nurses is dependent upon the nurses’ continual learning, professional accountability, independent and interdependent decisionmaking, and creative problem-solving abilities.
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There is limited theory or knowledge regarding dietitians' practice philosophies and how these philosophies are generated and incorporated into their professional practices. For the purposes of this study, a conceptual framework will explain and define the 'philosophies' as three different types of knowledge; episteme, techne, and phronesis. This study aimed to develop an explanatory theory of how dietitians in private practice source, utilise, and integrate practice philosophies. A grounded theory qualitative methodology was used to inform the sampling strategy, data collection, and analytical processes. Semi-structured interviews with dietitians in private practice were undertaken and data were collected and analysed concurrently. The results show that dietitians form collaborative relationships with their clients, in order to nurture change over time. They use intrinsic and intertwined forms of episteme, techne, and phronesis, which allow them to respond both practically and sensitively to their clients' needs. The learning and integration of these forms of knowledge are situated in their own practice experience. Dietitians adapt through experience, feedback, and reflection. This study highlights that private practice offers a unique context in which dietitians deal with complex issues, by utilising and adapting their philosophies.
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The aim of this systematic review was to illuminate intuition in clinical nursing. Frequently described as a defining characteristic of professional expertise, intuition is gaining acceptance as a legitimate form of knowledge in clinical nursing. A total of 352 abstracts were read and eight quantitative studies included. A thematic analysis was performed to one main theme, two themes, and four sub-themes emerged. The main theme was: Sensing an unconscious and conscious state of mind, and the two themes were: A sudden emotional awareness and reflection, and arousal of conscious thought processes. The first theme included two sub-themes: Sensing spiritual connections with patients and experiencing physical sensations; worrying and reassuring feelings. The second theme comprised two sub-themes: Willingness to act on personal, interpersonal, and clinical experiences; the influence of maturity and social support in clinical decision-making. An implication for clinical nursing was the need to develop sensitivity as a key to understanding the patient’s illness. In conclusion, leadership and management could facilitate discussions about intuition as a legitimate method of processing information and making decisions about patient care.
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Purpose: The purpose of this article is to conceptually examine intuition; identify the importance of intuition in nursing education, clinical practice, and patient care; encourage acceptance of the use of intuition; and add to the body of nursing knowledge. Background: Nurses often report using intuition when making clinical decisions. Intuition is a rapid, unconscious process based in global knowledge that views the patient holistically while synthesizing information to improve patient outcomes. However, with the advent of evidence-based practice (EBP), the use of intuition has become undervalued in nursing. Review methods: Walker and Avant's framework was used to analyze intuition. A literature search from 1987 to 2014 was conducted using the following keywords: intuition, intuition and nursing, clinical decision making, clinical decision making and intuition, patient outcomes, EBP, and analytical thinking. Results: The use of intuition is reported by nurses, but is not legitimized within the nursing profession. Defining attributes of intuition are an unconscious, holistic knowledge gathered without using an analytical process and knowledge derived through synthesis, not analysis. Consequences include verification of intuition through an analytical process and translating that knowledge into a course of action. Conclusion: This article supports the use of intuition in nursing by offering clarity to the concept, adds to the nursing knowledge base, encourages a holistic view of the patient during clinical decision making, and encourages nurse educators to promote the use of intuition.
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Current midwifery practice is regulated by the Nursing and Midwifery Council (NMC), whose primary role is to safeguard the public through setting standards for education and practice and regulating fitness to practise, conduct and performance through rules and codes (NMC, 2012; 2015a). Practice is informed by evidence-based guidelines developed and implemented by the National Institute for Health and Care Excellence based on hierarchies of evidence, with meta-analyses and systematic reviews being identified as the 'gold standard'. This positivist epistemological approach as developed by Auguste Comte (1798-1857), with scientific evidence at the top of a knowledge hierarchy, fails to acknowledge the 'art of midwifery', where a constructivist paradigm of experiential, intuitive and tacit knowledge is used by reflective practitioners to provide high-quality care. As midwifery pre-registration education is now degree-level, is the essence of midwifery practice being 'with woman' providing holistic care under threat, as the drive for a systematic and analytical approach to decision-making gathers momentum?.
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This article addresses clinical intuition from the standpoint of interpersonal neurobiology, the study of how brains, minds, and bodies are shaped through relationship. First, clinical intuition is placed in a developmental framework consistent with nonlinear science. Then, the operation of intuition is described in terms of implicit processes, which operate automatically in bottom-up fashion, as guided by the right brain, under the radar of conscious awareness. A case example of intuition in action demonstrates the holistic potential of a single image to illuminate the nature of a problem plus point the way toward resolution. This article ends with a cautionary note about the limitations of clinical intuition.
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Traditionally in nursing intuition has been linked to experience, typifying the expert practitioner. In the current health service climate, which demands measurable evidence based care, the involvement of intuition as an element of judgment is often denigrated. However, research evidence would suggest that intuition occurs in response to knowledge and is an important component of clinical decision making. The authors therefore argue that the essential nature of intuition cannot be ignored in the practice, management, education and research of nursing. Intuitive practice evolves from the merger of knowledge, skill and practice and, therefore, encompasses the broadest of knowledge bases. It can be a useful tool contributing to best evidence in nursing practice. Some of the benefits derived from intuition in practice is enhanced clinical judgment, effective decision making and crisis aversion. Denying the value of intuition devalues an important part of experience-based nursing practice.
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Background Diagnostic intuition is a rapid, non-analytic, unconscious mode of reasoning. A small body of evidence points to the ubiquity of intuition, and its usefulness in generating diagnostic hypotheses and ascertaining severity of illness. Little is known about how experienced physicians understand this phenomenon, and how they work with it in clinical practice. Methods Descriptions of how experienced physicians perceive their use of diagnostic intuition in clinical practice were elicited through interviews conducted with 30 physicians in emergency, internal and family medicine. Each participant was asked to share stories of diagnostic intuition, including times when intuition was both correct and incorrect. Multiple coders conducted descriptive analysis to analyze the salient aspects of these stories. Results Physicians provided descriptions of what diagnostic intuition is, when it occurs and what type of activity it prompts. From stories of correct intuition, a typology of four different types of intuition was identified: Sick/Not Sick, Something Not Right, Frame-shifting and Abduction. Most physician accounts of diagnostic intuition linked this phenomenon to non-analytic reasoning and emphasized the importance of experience in developing a trustworthy sense of intuition that can be used to effectively engage analytic reasoning to evaluate clinical evidence. Conclusions The participants recounted myriad stories of diagnostic intuition that alerted them to unusual diagnoses, previous diagnostic error or deleterious trajectories. While this qualitative study can offer no conclusions about the representativeness of these stories, it suggests that physicians perceive clinical intuition as beneficial for correcting and advancing diagnoses of both common and rare conditions.
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Reflection within the healthcare professions is suggested to empower nursing care and promote ethical practice. It certainly has the potential. However, working in a healthcare culture favouring empirical evidence over all other forms of knowledge identifies reflective practice as being soft and unquantifiable. This paper explores this tension by reflecting on a series of clinical experiences taken from a reflective journal, opening up the possibilities of their meaning when introduced to the work of the philosopher Martin Heidegger and neuroscientist Vilayanur Ramachandran. Both paradigms offer contrasting yet epistemological resources to potentiate reflective experiences and concepts of the self, Being and authenticity in order to understand clinical practice.
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Risk assessment is an example of professional decision-making pared to its stark essentials. Political pressures towards accountability and the need for defensible decisions encourage a ‘tick-box’ approach to risk assessment, but this can create unrealistic expectations of certainty. In practice, as technological approaches produce ever more complex formal tools for assessing risk, their effectiveness remains dubious while our human decision-making apparatus is marginalized. This article examines whether we should respect our ability to apprehend complex multi-stranded narrative realities intuitively, with the hope that such intuitions might contribute to professional decision-making. This idea is explored with reference to a case study.
Article
SYNOPSIS Clinical intuition is controversial, not least because of a confusion of definition. Excluding mysticism, three categories of intuition are identified; the spurious, the inferential and the holistic. Intuition is located in the understanding that the patient is much more than the disease. To question our assumptions about how the evidence-base informs our decisions, rehabilitates intuition and recovers reason from rationalisation.
Article
Classifying clinical decision making: a unifying approach This is the first of two linked papers exploring decision making in nursing which integrate research evidence from different clinical and academic disciplines. Currently there are many decision-making theories, each with their own distinctive concepts and terminology, and there is a tendency for separate disciplines to view their own decision-making processes as unique. Identifying good nursing decisions and where improvements can be made is therefore problematic, and this can undermine clinical and organizational effectiveness, as well as nurses’ professional status. Within the unifying framework of psychological classification, the overall aim of the two papers is to clarify and compare terms, concepts and processes identified in a diversity of decision-making theories, and to demonstrate their underlying similarities. It is argued that the range of explanations used across disciplines can usefully be re-conceptualized as classification behaviour. This paper explores problems arising from multiple theories of decision making being applied to separate clinical disciplines. Attention is given to detrimental effects on nursing practice within the context of multidisciplinary health-care organizations and the changing role of nurses. The different theories are outlined and difficulties in applying them to nursing decisions highlighted. An alternative approach based on a general model of classification is then presented in detail to introduce its terminology and the unifying framework for interpreting all types of decisions. The classification model is used to provide the context for relating alternative philosophical approaches and to define decision-making activities common to all clinical domains. This may benefit nurses by improving multidisciplinary collaboration and weakening clinical elitism.
Article
Background: Emotional intelligence has been correlated with performance, retention, and organizational commitment in professions other than nursing. A 2006 pilot study provided the first evidence of a correlation between emotional intelligence and performance in clinical staff nurses. A follow-up study was completed, the purpose of which was to explore emotional intelligence, performance level, organizational commitment, and retention. Methods: A convenience sample of 350 nurses in a large medical center in urban Hawaii participated in this study. This article reports the findings pertaining to the subset of 193 clinical staff nurses who responded. The Mayer-Salovey-Caruso Emotional Intelligence Test instrument was used to measure emotional intelligence abilities. Performance was defined as ranking on a clinical ladder. Commitment was scored on a Likert scale. The following variables measured retention: total years in nursing, years in current job, total years anticipated in current job, and total anticipated career length. Conclusions: Emotional intelligence scores in clinical staff nurses correlated positively with both performance level and retention variables. Clinical staff nurses with higher emotional intelligence scores demonstrated higher performance, had longer careers, and greater job retention.
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Informed consent to medical procedures tends to be construed in terms of principle-based ethics and one or other form of expected utility theory. These constructions leave problems created by imperfect communication; subjective distress and other emotions; imperfect knowledge and incomplete understanding; complexity, and previous experience or the lack of it. There is evidence that people giving consent to therapy or to research participation act intuitively and assess consequences holistically, being influenced more by the magnitude of outcomes than their probability. People avoid decisions they may regret, but modern regret theory has received little attention in discussions of informed consent. This essay suggests ways in which regret may be acknowledged in the consent process and in the assessment of the information that is an intrinsic part of it.
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The aim of this study was to critically examine the impact of nursing research on the development of health care policy using UK health visiting research as an example. We used established methods to evaluate research impact. This included a documentary review of over 30 policy documents, citation analyses on 19 papers and interviews with health visiting researchers. Although there were examples of policy documents being informed by health visiting research it was not always clear what role research had played in the development of recommendations. Information from researchers provided examples of local, national and international impact, although the extent to which papers may have impacted upon policy was less clear from the citation analyses. Many of the UK studies cited in policy documents were qualitative, observational or reflexive and a lack of evaluative research, in particular randomised controlled trials and other controlled evaluations, may limit the impact of health visiting research on health care policy in the UK. There is evidence that health visiting research has influenced health care policy but this has been limited and there is a need for more research to underpin and inform the role of the health visitor.
Article
To review relevant literature on expert practice in nursing to assess common characteristics across the breadth of nursing specialties and work settings. An integrative literature search was conducted with inclusion criteria: (a) primary studies of how clinical staff nurses develop and demonstrate expert practice; (b) subjects from variety of specialties, employment settings, and countries of origin; and (c) studies of clinical staff nurses and not nurses in advanced practice roles. Literature published between 1996 and 2009 was reviewed using MEDLINE and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) using the key words "nursing,"expert," and "practice." The characteristics of expert practice as explicated across a variety of specialty areas of practice and international settings included the following: knowing the patient, intuitive knowledge, reflective practice, risk taking, and skilled know-how. Involvement and engagement of the expert nurse with her or his patients underpin these characteristics. Themes were illustrated in a star model of nursing expert practice surrounded by support and grounded in emotional involvement. Expert practice develops as nurses gain experience in a specialized practice setting, reflect on and learn from their experience, and develop meaningful relationships with their patients, families, and colleagues. The findings provide an understanding of expert nursing practice that can serve as a foundation for efforts to transfer knowledge from expert nurses to less expert nurses in all practice settings to reduce the expertise gap that is now widening.
Article
This article examines the relationship between domain-specific and domain-general intuition among practicing nurses and student nurses to determine the role of intuition in nurses' decision making. Measures of nursing intuition have not been compared with one another or to measures of general preference for intuition in the psychological literature. Prior research has shown that experienced nurses rely on intuition in clinical judgement, but the various aspects of intuition associated with experience have not been fully explored. A correlational design was used to examine the factor structures and interrelationships of self-reported measures of intuition, as well as their relationship to experience. A web-based survey was given to 175 practicing nurses and student nurses in the fall of 2007 using measures of intuition from the nursing and psychological literatures. Quantitative analyses employed descriptive and inferential statistics. Measures of preference for intuition were combined, resulting in the identification of two independent aspects of nursing intuition uniquely related to general intuition and nursing experience. Results revealed that preference for intuition in nursing was not solely due to general preference for intuition and that use of nursing intuition increased with experience. These results strengthen the knowledge base of decision making in clinical practice by examining differences in preference for use of intuition among nurses. Further interdisciplinary collaboration is recommended. Understanding the use of intuition in clinical judgement will promote professional practice and favourable patient outcomes. If experience simply leads to increased self-confidence and preference for the use of intuition, this may not actually be related to accuracy in judgement. However, if experience provides valuable information on associations between patient symptoms and outcomes, then the use of intuition in clinical practice should be encouraged.
Article
The evidence of experience of intuitive knowing in the clinical setting has to this point only been informal and anecdotal. Reported experiences thus need to be either validated or refuted so that its place in emergency nursing can be determined. The history, nature and component themes captured within the intuitive practice of emergency nursing are described. This study was informed by the philosophy and method of phenomenology. Participants were 14 experienced emergency nurses. Through their narrative accounts and recall of events their experience of knowing was captured. Through a Van Manen process and a Gadamerian analysis, six themes associated with the ways in which the participants experienced intuition in clinical practice, were identified. This paper reveals the six emerging themes as knowledge, experience, connection, feeling, syncretism and trust.
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In acquiring a skill by means of instruction and experience, the student normally passes through five developmental stages which we designate novice, competence, proficiency, expertise and mastery. We argue, based on analysis of careful descriptions of skill acquisition, that as the student becomes skilled, he depends less on abstract principles and more on concrete experience. We systematize and illustrate the progressive changes in a performer's ways of seeing his task environment. We conclude that any skill- training procedure must be based on some model of skill acquisition, so that it can address, at each stage of training, the appropriate issues involved in facilitating advancement.
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1. Uncovering the Knowledge Embedded in Clinical Nursing Practice. 2. The Dreyfus Model of Skill Acquisition Applied to Nursing. 3. An Interpretive Approach to Identifying and Describing Clinical Knowledge. 4. The Helping Role. 5. The Teaching-Coaching Function. 6. The Diagnostic and Monitoring Function. 7. Effective Management of Rapidly Changing Situations. 8. Administering and Monitoring Therapeutic Interventions and Regimens. 9. Monitoring and Ensuring the Quality of Health Care Practices. 10. Organizational and Work-Role Competencies. 11. Implications for Research and Clinical Practice. 12. Implications for Career Development and Education. 13. The Quest for a New Identity and New Entitlement in Nursing. 14. Excellence and Power in Clinical Nursing Practice. Epilogue: Practical Applications. References. Glossary. Appendix. Index.
Article
•This is the first of two articles which address the subject of intuition and its relevance in practice and to curriculum development.•Few words used by philosophers and educators arouse as much confusion as the term ‘intuition’, yet it is recognized that few terms embrace such promising concepts. The nature of what is meant by intuition is discussed in this paper.•The relevance of intuition to nursing is discussed and its importance in decision making addressed.
Article
This paper reports a small exploratory study which identifies what community nurses consider to be the scope of their practice and the sources of influence on their clinical decisions The study was stimulated by the emergence of the nurse prescribing initiative, which is likely to bring clinical decision making to the centre of professional debate The study was earned out over a 5-month period and data were collected from 47 community nurses in four district health authorities A qualitative method was employed and field work involved observation of 40 home visits and five nurse-run clinics, individual interviews and group discussions with the nurses, and scrutiny of nursing records The data were content analysed and classified, and the categories were validated by practitioners Findings suggest that although community nurses consider that a large proportion of their work requires a scientific basis, their practice is largely founded on experiential knowledge, and on the whole they are not positively disposed to research knowledge The findings are discussed in the context of nurse prescribing Questions are raised about the nature of a ‘professional’ knowledge base and the reclassification of scientific knowledge as nursing or experiential knowledge once it has diffused into practice
Article
The purpose of this research was to explore intuitive experiences of nurses in critical care and home care settings. Fifty-six nurses were interviewed and transcriptions of interviews were analyzed for emergent themes. Nurses described their experiences in terms of feeling and knowledge and gave examples of types of intuition. Further analysis showed themes consistent with three attributes of intuition found in the nursing literature. Recognition of intuitive experiences has consequences for communication and decision making in clinical practice.
Article
Communication between hospital staff and in-patients, especially regarding the provision of information, has been found to be inadequate although improving information-giving has been demonstrated to have a number of beneficial effects While the ward round might be a particularly valuable setting for communication, few studies have explored the multidisciplinary nature of rounds This study obtained the views of 33 consultants, 14 nurses and eight patients and observed three ward rounds in order to determine the nature of present round functioning, and the nurse's role in such a round The results showed that the rounds studied were not being conducted in a democratic fashion medical staff dominated and other health care professionals had little involvement Patients received few explanations and had great difficulty understanding the discussion The functions nurses were seen to perform involved primarily providing information for medical staff It is recommended that patients are more involved in rounds and are given more explanations and encouraged to ask questions Nurses should be educated to assert themselves in ward rounds in order to fulfil roles they prescribe for themselves, and all professionals should aim towards more democratic, equal discussion There is a need for further research to determine the effectiveness of nurse intervention on patient involvement and satisfaction with the round
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Three years ago, I read Michael Polanyi's contribution—as a philosopher—to a symposium entitled Scientific Outlook: Its Sickness and Cure. In a brilliant, penetrating, and delightfully humorous criticism of R. W. Gerard's1 biological contribution, he unerringly diagnosed the sickness of medicine: The fact that a so learned, ingenious and imaginative survey of living beings should deal so perfunctorily with some of the most important questions concerning them shows a fundamental deficiency of human thinking.... If a rat laps up a solution of saccharine, the rational explanation of this lies in the act that the solution tastes sweet and that the rat likes that. The tasting and liking are facts that physics and chemistry as known today cannot explain. Nothing is relevant to biology, even at the lowest level of life, unless it bears on the achievements of living beings... and distinctions unknown to physics and chemistry... The current idea of
Article
The purpose of this study was to further explicate the Dreyfus Model of Skill Acquisition in the practice of critical care nursing. For this analysis data were used from a sample of 105 nurses practicing in the adult, pediatric, and newborn intensive care units of eight hospitals in three metropolitan areas. The data were composed of group interviews in which nurses gave narrative accounts of exemplars from their practice and close observations and intensive personal history interviews of a subsample of nurses. Two interrelated aspects were found to distinguish four levels of practice, from advanced beginner through expert. First, practitioners at different levels of skill literally live in different clinical worlds, noticing and responding to different directives for action. Second, a sense of agency is determined by one's clinical world and shows up as an expression of responsibility for what happens with the patient.
Article
This paper reports a small exploratory study which identifies what community nurses consider to be the scope of their practice and the sources of influence on their clinical decisions. The study was stimulated by the emergence of the nurse prescribing initiative, which is likely to bring clinical decision making to the centre of professional debate. The study was carried out over a 5-month period and data were collected from 47 community nurses in four district health authorities. A qualitative method was employed and field work involved observation of 40 home visits and five nurse-run clinics, individual interviews and group discussions with the nurses, and scrutiny of nursing records. The data were content analysed and classified, and the categories were validated by practitioners. Findings suggest that although community nurses consider that a large proportion of their work requires a scientific basis, their practice is largely founded on experiential knowledge, and on the whole they are not positively disposed to research knowledge. The findings are discussed in the context of nurse prescribing. Questions are raised about the nature of a 'professional' knowledge base and the reclassification of scientific knowledge as nursing or experiential knowledge once it has diffused into practice.
Article
Research that addresses intuition as experienced by nurses in critical care settings is rare; however, evidence to support the usefulness of intuition in making complex clinical decisions is mounting. The research reported here suggests that intuition is not a second-rate substitute for intelligent and rational decision-making; rather, it is a legitimate adjunct to empirical observation and linear analysis.
Article
Intuition as a group phenomenon is clarified through the process of concept analysis using the analytical process outlined by Walker and Avant. Intuition as a respectable characteristic of creative and powerful groups is based on uses of the concept; identification of attributes, antecedents, and consequences; construction of various cases; and identification of empirical referents. Suggestions for applications in nursing education, nursing administration, and professional organizations follow.
Article
Material gathered in a qualitative study of seven holistic nurses' perceptions of holistic nursing suggests that nonrational, intuitive knowing is a dimension of the state of the art in nursing. This dimension resonates with emerging theory in nursing and other sciences. Intuitive knowing is an aspect of the pattern of personal knowledge and as such may be found credible through reflection and actualization by individual nurses.
Article
Intuition as a hallmark of nursing knowledge was traced through an analysis of literature published in the American Journal of Nursing between 1900 and 1985. Three questions were addressed: Does the concept appear in the literature; if so, what are its attributes; and how did they evolve through time? Titles of articles (n = 14,971) were examined and from this population only 51 were found to contain intuition or related terms. From analysis of the paucity of literature containing the concept it is concluded that intuition as an essential component of complex decision making is neglected in the professional literature.
Article
An exploratory clinical investigation using qualitative methodology was conducted to identify and characterize the phenomenon of “deterioration” as it occurs among critically ill patients. Six purposively selected, critical care nurses were interviewed regarding their personal, practice-based experience with deterioration. Subjective and objective manifestations of the phenomenon emerged, suggesting a recognizable pattern of empirical descriptors. Deterioration may be identified as a significant process of transition and health-illness patterning, indicating a change in an individual's trajectory toward death. This change can be perceived and is often acted on by experienced critical care nurses.
Article
The aim of this paper is to emphasise the important function of so-called ‘tacit knowledge’ in problem solving in the clinical setting. While education theorists recognise tacit knowledge to be an important variable in information processing and decision making, its relevance to nurse education has not yet been sufficiently appreciated. To illustrate the importance of ‘tacit knowledge’ in prescribing health care and to draw out its implications for nurse education and nurse practice, reference will be made to a study conducted by the author in five public hospitals in the South Western region of Sydney in 1985. The study illustrates how ‘tacit knowledge’ can play a role in determining the likelihood of a patient contracting pressure sores.On the basis of this study it is suggested that nurse education acknowledge the importance of ‘tacit knowledge’ in Nurse Education curricula. This in turn should develop the practising nurse's skill in recognising the importance of integrating ‘tacit knowledge’ in the decision process about patient care.
Article
How do critical care nurses determine if a patient is developing cardiogenic shock? What assessment and decision-making processes do they use, and how do they learn them? To find out, in-depth interviews were conducted with 28 critical care nurses during a study that investigated the practice of critical care nurses in the early detection and prevention of cardiogenic shock in patients with acute myocardial infarction (AMI). Through the analysis and comparison of these interviews, we developed a theory of> Nursing Gestalt to explain the cognitive process used by experienced critical care nurses in making assessments and judgments. Moreover, we discovered that critical care neophytes learn to make assessments, diagnoses, and sound judgments about care from a more experienced nurse who supports and teaches the neophyte the Nursing Gestalt during a mentoring relationship. We call this mentoring relationship The Cray Gorilla Syndrome, for reasons we will explain later. This paper presents selected findings from the study. The origin and properties of Nursing Gestalt are discussed, as well as factors that enhance its development and use–namely, The Gray Gorilla Syndrome.
Making clinical nursing judgements is central to the practice of nursing, and critical thinking skills are essential to making clinical judgments. Qualitative studies have shown that the use of intuition in making clinical nursing judgments is an important part of the critical thinking process. This descriptive correlational study examines the relationships between the use of intuition in clinical judgment-making and characteristics of the nurse, such as level of nursing proficiency and years of clinical experience. Findings support Benner's (1984) model of skill acquisition as well as prior findings of studies on the use of intuition in clinical nursing practice. Thus, as the level of nursing proficiency increases from beginner to expert and as the amount of clinical experience increases, the use of intuition to make clinical nursing judgments increases significantly.
Article
A description is provided of the process used to verify characteristics of intuitive nurses that had been reported in the literature. These characteristics supplied the framework for construction of the Miller Intuitiveness Instrument (MII) reported earlier (Miller, 1993). Evidence for validity of the MII was provided in the Miller (1993) study by examining factor analyses and correlations with the intuitive component of the Myers-Briggs Type Indicator (MBTI). The following characteristics were subsequently verified: Intuitive nurses are willing to act on their intuitions, are skilled clinicians, and incorporate a spiritual component in their practices. In addition, intuitive nurses express an interest in the abstract nature of things and are risk takers. Intuitive nurses prefer intuition to sensing (as reflected by the MBTI) as a way to take in information. They are extroverted and express confidence in their intuitions. Likewise, nurses who delay making decisions until all the information is in are more intuitive than those who make decisions abruptly.
Article
In a recent critique of the work of Patricia Benner in relation to expertise, skilled intuitive grasp and the Dreyfus model of skill acquisition, English (Journal of Advanced Nursing 1993, vol. 18, pp. 387-393) uses the tenets of positivism and cognitive psychology to criticize Benner's work for lacking objectivity, validity, generalizability and predictive power. In this response to English's critique I show how he has misread, failed to read, and consequently misunderstood her work, and, equally importantly, its philosophical basis. Benner's work is developed from a philosophical foundation grounded in interpretive and Heideggerian phenomenology. This wholly different 'take' on the world and on human behaviour embodies a strong critique of those very same traditional-science worldviews which English uses to damn her work. English's critique is valuable in highlighting the ways in which Benner's work can be misrepresented and this response tries to remedy this misunderstanding by attempting to clarify the fundamental differences between phenomenological and cognitive understandings. These differences are crucial to understanding Dreyfus's and Benner's work. Here, I also attempt to correct some of English's wilder assertions regarding Benner's work. Finally, I try to show how Benner's work has empowered, enthused and challenged, rather than being 'denigrating to the majority of nurses'.
Article
Decision-making is an essential and integral aspect of clinical practice. Preparation for clinical decision-making is haphazard and unplanned, in part because the process of making clinical decisions is not fully understood. This is one study of how expert nurses, midwives and health visitors make clinical decisions. The project involved a literature review and a series of workshops with expert practitioners to uncover the decision-making process in clinical practice. The study found that decision-making is an essential attribute of the expert practitioner, must be based on sound knowledge, may involve risk-taking and can only flourish in a supportive environment. Most importantly, clinical decision-making must take place within the context of a philosophy of care. Without such a philosophy, decisions will be arbitrary, uninformed and probably unsafe.
Article
Benner's model of skill acquisition is currently receiving considerable interest from nurse educationalists, and promises to form the basis for some curricula offered by colleagues of nurse education. This paper debates the 'novice to expert' model and seeks to explain exactly what an 'expert' is. The Benner model proposes that one component of expertise is working from an intuitive base. This claim is disputed and the definition of intuition is contested. Alternative explanations to account for the intuitive responses of Benner's subjects are suggested.
Article
The rift between "science' and "phenomenology' in current nursing theory is explored through an examination of two recent evaluations of the work of Patricia Benner, who has proposed a model of skill acquisition, latterly within a Heideggerian framework. English offers a critique of Benner's ideas from the perspective of cognitive psychology; while Darbyshire defends them against what he describes as a "positivist' attack. No attempt is made, in this paper, to evaluate Benner's work directly, but Darbyshire's response to the "critique' is analysed; and it is noted that, in making his defence, he invokes a network of concepts which he ascribes to a "traditional notion of objective science', and accuses English of subscribing to it. It is suggested that this "Cartesian' worldview is an outmoded myth, superseded by the philosophy of science during the last 30 years, and based on the rhetoric rather than the reality of scientific practice. Nursing is not, therefore, obliged to choose between "positivism' and a philosophy whose chief virtue is that it represents a "challenge' to positivism. It could instead build a scientific basis for research and theory by drawing, not on mid-century thinking, but on a more contemporary understanding of the nature of science.
Article
This paper examines the work of Benner (From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Menlo Park, CA, 1984) on expertise in clinical nursing. The philosophical foundations of her work are explained as well as the work located within the wider context of the use of Heideggerian philosophy. Various criticisms of her study are developed in relationship to her methodology and her interpretation of nursing. It is argued that she represents a retreat into tradition and authority in nursing.
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An interesting finding of this review of the research is Darbyshire P. (1994) Skilled expert practice: is it 'all in the mind'? the apparent recognition by experienced nurses of the A response to English's critique of Benner's novice to expert importance of considering patients' intuitive feelings model. Journal of Advanced Nursing 19, 755–761.