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Intuition: a critical review of the research and rhetoric
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.
... 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. ...
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.
... 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). ...
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.
... 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 ...
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.
Background: Patients with profound intellectual and multiple disabilities (PIMD) cannot clearly express themselves. Therefore, tacit knowledge (TK) is crucial in caring for individuals with PIMD, while it possibly also plays a significant role in medical consultations. Method: A qualitative inductive, thematic analysis was performed of 14 audio-taped consultations with intellectual disability physicians for patients with PIMD to explore how TK is represented and considered between parents and physicians. Results: Parents conveyed their TK by sensing and perceptions of changes of their child's behaviour. Our findings demonstrate that parents of individuals with PIMD primarily shared TK concerning pain, sleeping issues, and epilepsy. Physicians recognised and incorporated parents' TK, highlighting its significance in patient care. Conclusion: This study underscores the important role of TK in consultations for patients with PIMD. Parents' TK help to shape medical-decisions, urging physicians to validate parents' TK while relating this TK to other types of medical knowledge.
Background:
Caring for persons with profound intellectual and multiple disabilities (PIMD) demands specific expertise. Tacit knowledge seems to play an important role, but little is known about its nature, including what is necessary for its development and transfer.
Aim:
To gain understanding of the nature and development of tacit knowledge between persons with PIMD and their caregivers.
Method:
We conducted an interpretative synthesis of literature on tacit knowledge in caregiving dyads with persons with PIMD, persons with dementia or infants. Twelve studies were included.
Results:
Tacit knowledge is about caregivers and care-recipients becoming sensitive and responsive to each other's cues and together crafting care routines. Learning takes place in a constant process of action and response that transforms those involved.
Conclusion:
Building tacit knowledge together is necessary for persons with PIMD to learn to recognise and express their needs. Suggestions are made for ways to facilitate its development and transfer.
Objectives
Experienced coaches profess using intuition in their work. Practitioner literature positions it as a critical coaching tool. Yet minimal empirical data supports using intuition in evidence based coaching practice. This study looked to: add detail to the map of how experienced coaches work with their intuition in their practice, and to the interplay between ‘gut’ and ‘reason’; and to co-create a language, theory or model to support and legitimise discussion about intuition in coaching.
Design
A qualitative approach rooted in social constructionism was chosen to accommodate the enquiry, grounded theory to provide structure.
Methods
An abbreviated form of grounded theory method (GTM) was developed to explore how four experienced executive coaches talked about intuition and worked at the boundary between intuitive and rational ways of knowing. Data was generated during the iterations of focus group, online discussion and follow-up conversations. Purposive sampling was used.
Results
Findings suggested that: dialogue sharpens and extends individual understandings of intuition in coaching; and expertise and developmental maturity facilitate more choiceful and effective decisions about using intuitions. A model, ‘Working at the boundary’, symbolises the potential in the moment between a coach noticing and responding to an intuition. It captures four ways of working with intuition, mapping the impact of these interventions on the coaching relationship.
Conclusions
Expertise and maturing as a coach have an impact on the quality of interventions at the intuitive/rational boundary, and dialogue extends understandings of intuition. More research is needed – and ‘Working at the boundary’ kick-starts conversations about intuition and provides a tool for coaching psychologists and their supervisors.
Background: Clinical deterioration and adverse events in hospitals is an increasing cause for concern. Rapid response systems have been widely implemented to identify the deteriorating patient.
Aim: The purpose of this paper was to examine the literature highlighting major historical trends leading to the widespread adoption of RRS, focussing on issues in Australia and identifying areas for future focus.
Method: Integrative literature review including published and grey literature.
Results: The search strategy generated 78 sources; 46 journal articles were identified, 8 of which were systematic reviews. In addition, 25 Australian government sources were also identified consisting of 21 federal and state resources and four state initiated commissions of inquiry into health system failures. Policy documents from professional organisations and government bodies were also included to provide a contextual background. Increasing acuity and aging of the population, proliferation, evolution and standardisation of these systems were identified as themes as well as the importance of hospital cultures and the emerging role of the consumer.
Discussion: In spite of the evidence generated from experimental methods, translating evidence to usual care practice is challenging and is strongly driven by local factors and political imperatives.
Conclusion: Rapid response systems are complex interventions requiring consideration of contextual factors at micro, meso and macro levels. Appropriate resources, a skilled workforce and positive workplace culture are needed before effective uptake and utilisation of RRS can reach their full potential.
Impact Statement: The RRS model is evolving and adapting to practice models. Considering contextual factors and patient, provider and health system elements are crucial for ensuring intervention fidelity.
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.
Background:
nurses play a crucial role in the early recognition and management of the deteriorating patient. They are responsible for the care they provide to their patients, part of which is the monitoring of vital signs (blood pressure, pulse, respiratory rate and temperature), which are fundamental in the surveillance of deterioration. The aim of this study was to discover what factors influence how nurses assess patient acuity and their response to acute deterioration.
Methods:
a generic qualitative approach was used. Some 10 nurses working in an acute NHS trust were interviewed using a semi- structured approach, with equal representation from medical and surgical inpatient wards.
Results:
the main themes identified were collegial relationships, intuition, and interpretation of the MEWS system (Modified Early Warning Score). Collegial relationships with the medical staff had some influence on the nurses' assessment, as they tended to accept the medical peers' assessment as absolute, rather than their own assessment. It was also highlighted that nurses relied on the numerical escalation of the MEWS system to identify the deteriorating patient, instead of their own clinical judgement of the situation. Interestingly, the nurses found no difficulty in escalating the patient's care to medical staff when the patient presented with a high MEWS score. The difficulty arose when the MEWS score was low-the participants found it challenging to authenticate their findings.
Conclusion:
this study has identified several confounding factors that influence the ways in which nurses assess patient acuity and their response to acute deterioration. The information provides a crucial step forward in identifying strategies to develop further training.
This article draws on ethnographic data from a Norwegian emergency primary care clinic (EPCC) to explore nurses' discretionary application of guidelines. Specifically, it analyses nurses' discretionary use of the Manchester Triage System (MTS) when performing face-to-face triage, that is, assessing the urgency of patients' complaints. The analysis shows how nurses assessed patients at odds with MTS prescriptions by collecting supplementary data, engaging in differential diagnostic and holistic reasoning, relying on emotion and intuition, and allowing colleagues and patients to influence their reasoning. The findings also show how nurses' reasoning led them to override guidelines both overtly and covertly. Based on this evidence, it is argued that nurses' assessments relied more on internalised 'triage mindlines' than on codified triage guidelines, although the MTS did function as a support system, checklist and system for supervisory control. The study complements existing research on standardisation in nursing by providing an in-depth analysis of nurses' methods for navigating guidelines and by detailing how deviations from those guidelines spring from their clinical reasoning. The challenges of imposing a managerial logic on professional labour are also highlighted, which is of particular relevance in light of the drive towards standardisation in modern healthcare.
Aim and objectives:
To review what is characteristic of registered nurses' intuition in clinical settings, in relationships, and in the nursing process.
Background:
Intuition is a controversial concept and nurses believe that there are difficulties in how they should explain their nursing actions or decisions based on intuition. Much of the evidence from the body of research indicates that nurses value their intuition in a variety of clinical settings. More information on how nurses integrate intuition as a core element in daily clinical work would contribute to an improved understanding on how they go about this. Intuition deserves a place in evidence-based activities, where intuition is an important component associated with the nursing process.
Design:
An integrative review strengthened with a mixed studies review.
Methods:
Literature searches were conducted in the databases Cinahl, PubMed and PsykInfo, and literature published 1985 - 2016 were included. The findings in the studies were analysed with content analysis, and the synthesis process entailed a reasoning between the authors.
Results:
After a quality assessment 16 studies were included. The analysis and synthesis resulted in three categories. The characteristics of intuition in the nurse's daily clinical activities include application, assertiveness and experiences. In the relationships with patients' intuition include unique connections, mental and bodily responses, and personal qualities. Intuition in the nursing process include support and guidance, component and clues in decision-making, and validating decisions.
Conclusion:
Intuition is more than simply a "gut feeling" it is a process based on knowledge and care experience and has a place beside research-based evidence. Nurses integrate both intuition, analysis and synthesis alongside objective data when making decisions. They should rely on their intuition and use this knowledge in clinical practice as a support in decision-making, which increases the quality and safety of patient care. This article is protected by copyright. All rights reserved.
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.
This is a narrative account, drawn from a study by the first author exploring the role of intuition in clinical psychology as self-understood by eight clinical psychologists (Tovey, 2008). We aim to reflect the original analysis by presenting a series of data extracts and our comments and to encourage comments from others.
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.
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.
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?.
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.
Using qualitative data gathered among hospice employees, this study explores the communication of compassion at work, providing an in-depth understanding of one of the most quickly growing healthcare contexts and offering a new conceptualization of compassion. The analysis is framed with emotional labor, burnout, and compassion literature, and shows how communicating compassion emerged as a central theme. The heart of the paper provides a rich description of hospice workers as they engaged in the compassionate communication activities of recognizing, relating, and (re)acting. The study extends past research on compassion, highlighting its holistic nature and providing a model that demonstrates its core communicative action. In doing so, it opens the door for future research and suggests practical implications for practicing compassion at work.
This article discusses the significance of intuitiveness as a component of phenomenological knowing and demonstrates how this way of knowing may exist independently of or coexist collaboratively with rationality and evidence-based practice. By using a holistic approach to knowing, nurses use clinical reasoning skills to prevent adverse patient outcomes from failure to diagnose problems, to establish appropriate treatments, and/or to deal with complications. As the complexity of health care escalates, health care providers must strive to think holistically to advance knowledge and contribute to their discipline. The discipline of nursing requires holistic thought and innovative interventions.
“What lies behind us and what lies before us are tiny matters compared to what lies within us.”
—Ralph Waldo Emerson
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
This article discusses a study exploring the lived experience of family nursing for novice registered nurses. There has been an increased emphasis on including family content in Canadian nursing education curricula. Literature on family nursing is ambiguous about differentiating family nursing at the generalist and specialist level, and acknowledges that there is a blurring of lines between the two. The study utilized a phenomenological approach to examine how nurses with 2 years or less in practice experience family nursing in a variety of settings. Following ethical approval, invitations were sent to all nurses employed in two health authorities, who met the study criteria. Five nurses were interviewed using a semistructured interview. Participants shared how they practice family nursing in the current nursing situation of shortages and constraints. This study adds to our understanding of what happens at a beginning level of family nursing, how nurses understand and experience caring for families in the everyday enactment of their professional role, and barriers and facilitators to including family in nursing care. The findings provide important information for nurse educators in grounding the teaching of family nursing in the real world of nurses.
As a style of information processing, intuition involves implicit perceptual and cognitive processes that can be quickly and automatically executed without conscious mental will, such that people know more than they can describe. Patient intuition can influence patient and clinician decision-making and behavior. However, physicians may not always see patient intuition as credible or important, and its management in the clinical setting is poorly understood. This paper takes a step toward suggesting conditions under which patient intuition should be taken seriously. These conditions relate to the credibility or accuracy of the intuitive beliefs held by the patient, and their significance to the patient. Credibility may be increased when the intuitions of patients (1) reflect their individualized knowledge, (2) can complement the common absence of scientific evidence in managing health problems, and (3) can quickly and effectively process key information in complex cognitive tasks. Even intuitions that lack credibility can be subjectively rational and meaningful to patients, and help to shape the decisions they and clinicians make.
Skepticism about the epistemic value of intuition in theoretical and philosophical inquiry has recently been bolstered by empirical research suggesting that people's concrete-case intuitions are vulnerable to irrational biases (e.g., the order effect). What is more, skeptics argue that we have no way to "calibrate" our intuitions against these biases and no way of anticipating intuitional instability. This paper challenges the skeptical position, introducing data from two studies that suggest not only that people's concrete-case intuitions are often stable, but also that people have introspective awareness of this stability, providing a promising means by which to assess the epistemic value of our intuitions.
This paper is a report of a study of the judgement processes nurses use when evaluating World Wide Web information related to nursing practice.
The World Wide Web has increased the global accessibility of online health information. However, the variable nature of the quality of World Wide Web information and its perceived level of reliability may lead to misinformation. This makes demands on healthcare professionals, and on nurses in particular, to ensure that health information of reliable quality is selected for use in practice.
A grounded theory approach was adopted. Semi-structured interviews and focus groups were used to collect data, between 2004 and 2005, from 20 nurses undertaking a postqualification graduate course at a university and 13 nurses from a local hospital in the United Kingdom.
A theoretical framework emerged that gave insight into the judgement process nurses use when evaluating World Wide Web information. Participants broke the judgement process down into specific tasks. In addition, they used tacit, process and propositional knowledge and intuition, quasi-rational cognition and analysis to undertake these tasks. World Wide Web information cues, time available and nurses' critical skills were influencing factors in their judgement process.
Addressing the issue of quality and reliability associated with World Wide Web information is a global challenge. This theoretical framework could contribute towards meeting this challenge.
• The purpose of this study was to describe how diabetes nurse specialists perceived their role and function in relation to starting adult patients with insulin dependent diabetes on insulin.
• Using Heideggerian hermeneutic phenomenology as a research method, six diabetes nurse specialists were interviewed and the interviews were analysed according to Colaizzi’s method of phenomenological inquiry.
• Results showed that the diabetes nurses perceived their role to be composed of six themes: educator; promoter of physical skill acquisition; psychological supporter; advocate of individualized care; promoter of self‐care; ‘safeguard’ in assessing and ensuring patient safety.
• These results support findings from other studies, that the diabetes nurse specialist role seems to be more complex than descriptions in the nursing literature offer.
This paper proposes a complementary approach to Rasmussen's taxonomy of the human skill-, rule-, and knowledge-based performance models by combining the ecological concept of affordances with the neural concepts of human emotion and intuition. The classical cognitive engineering framework is extended through the neuro-ecological approach, including personal human attributes important in exercising control over the work environment. The proposed affordance-, emotion-, and intuition-based models correspond to the three types of human performance, namely: learning, adaptive and tuning control, respectively. The new framework is not a predictive model of the operator behaviour, but rather it describes the processes of neuro-ecological control of the human environment.
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.
Background:
Nurses in a graduate programme in Australia are those who are in the first year of clinical practice following completion of a 3-year undergraduate nursing degree. When working in an acute care setting, they need to make complex and ever-changing decisions about patients' medications in a clinical environment affected by multifaceted, contextual issues. It is important that comprehensive information about graduate nurses' decision-making processes and the contextual influences affecting these processes are obtained in order to prepare them to meet patients' needs.
Aim:
The purpose of this paper is to report a study that sought to answer the following questions: What are the barriers that impede graduate nurses' clinical judgement in their medication management activities? How do contextual issues impact on graduate nurses' medication management activities? The decision-making models considered were: hypothetico-deductive reasoning, pattern recognition and intuition.
Methods:
Twelve graduate nurses who were involved in direct patient care in medical and surgical wards of a metropolitan teaching hospital located in Melbourne, Australia participated in the study. Participant observations were conducted with the graduate nurses during a 2-hour period during the times when medications were being administered to patients. Graduate nurses were also interviewed to elicit further information about how they made decisions about patients' medications.
Results:
The most common model used was hypothetico-deductive reasoning, followed by pattern recognition and then intuition. The study showed that graduate nurses had a good understanding of how physical assessment affected whether medications should be administered or not. When negotiating treatment options, graduate nurses readily consulted with more experienced nursing colleagues and doctors.
Study limitations:
It is possible that graduate nurses demonstrated a raised awareness of managing patients' medications as a consequence of being observed.
Conclusions:
The complexity of the clinical practice setting means that graduate nurses need to adapt rapidly to make sound and appropriate decisions about patient care.
Triage, as a concept, is relatively new in Sweden and means 'sorting'. The triage process was developed to grade patients who needed immediate care. Triage is currently important for the emergency treatment system, and nurses are expected to work with it professionally. The aim of this study is to describe how nurses implement triage when patients arrive at the emergency department of a county hospital, situated in a rural area of Sweden, as well as to highlight the factors considered when prioritizing, in connection with nurses' decision-making. The method used was observations of 19 nurses, with minimal disturbance in their triage work, followed by a short tape-recorded interview, during which the nurses were asked to reflect upon their decision of priorities. Qualitative content analysis of data has been used. The results were divided into two areas, internal factors and external factors. The internal factors reflect the nurse skills and personal capacity. The external factors reflect work environment, including high workload and practical arrangements, and should always be perceived and taken into consideration. Using these factors as a basis, the patients' clinical condition, clinical history, various examinations and tests form an assessment, which subsequently results in a prioritization.
To review and reflect on the literature on recognition-primed decision (RPD) making and influences on emergency decisions with particular reference to an ophthalmic critical incident involving the sub-arachnoid spread of local anaesthesia following the peribulbar injection.
This paper critics the literature on recognition-primed decision making, with particular reference to emergency situations. It illustrates the findings by focussing on an ophthalmic critical incident.
Systematic literature review with critical incident reflection.
Medline, CINAHL and PsychINFO databases were searched for papers on recognition-primed decision making (1996-2004) followed by the 'snowball method'. Studies were selected in accordance with preset criteria.
A total of 12 papers were included identifying the recognition-primed decision making as a good theoretical description of acute emergency decisions. In addition, cognitive resources, situational awareness, stress, team support and task complexity were identified as influences on the decision process.
Recognition-primed decision-making theory describes the decision processes of experts in time-bound emergency situations and is the foundation for a model of emergency decision making (Fig. 2).
Decision theory and models, in this case related to emergency situations, inform practice and enhance clinical effectiveness. The critical incident described highlights the need for nurses to have a comprehensive and in-depth understanding of anaesthetic techniques as well as an ability to manage and resuscitate patients autonomously. In addition, it illustrates how the critical incidents should influence the audit cycle with improvements in patient safety.
The aim of this paper was to explore the concept of expertise in nursing from the perspective of how it relates to current driving forces in health care in which it discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas.
Expert nursing practice can be argued to be central to high quality, holistic, individualized patient care. However, changes in government policy which have led to the inception of comprehensive guidelines or protocols of care are in danger of relegating the 'expert nurse' to being an icon of the past. Indeed, it could be argued that expert nurses are an expensive commodity within the nursing workforce. Consequently, with this change to the use of clinical guidelines, it calls into question how expert nursing practice will develop within this framework of care.
The article critically reviews the evidence related to the role of the Expert Nurse in an attempt to identify the key concepts and ideas, and how the inception of care protocols has implications for their role.
Nursing expertise which focuses on the provision of individualized, holistic care and is based largely on intuitive decision making cannot, should not be reduced to being articulated in positivist terms. However, the dominant power and decision-making focus in health care means that nurses must be confident in articulating the value of a concept which may be outside the scope of knowledge of those with whom they are debating.
The principles of abduction or fuzzy logic may be useful in assisting nurses to explain in terms which others can comprehend, the value of nursing expertise.
Reflective practice is considered not only as a valuable tool for providing appropriate levels of care but also as an important prerequisite for the provision of professional nursing. Indeed, there appears to be consensus in the literature that reflections have the potential to assist practitioners to tap into knowledge gained from experience and connect theory to practice. However, evidence suggests that nurses, including emergency nurses, neglect reflective techniques. This paper outlines how the processes of reflection led to one emergency nurse developing new insights and understandings on nursing practice.
Holistic assessment and care are inseparable from the nursing process. Holistic nursing practice informed by a philosophy of holism balancing art and science recognizes the interconnectedness of body, mind, and spirit. Holistic practice draws on knowledge, theories, expertise, intuition, and creativity. The purpose of this article is to place nursing in the context of holistic practice; to explicate the role of presence as an essential condition for holistic care; and to provide an example of the holistic caring process that incorporates theory, presence, and practice documented in the standard formats. A holistic approach to nursing integrates process and presence in the provision of care. Process alone is empty without presence. Presence alone is insufficient without the process.
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.
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.
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.
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.
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
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.
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
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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'.
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.
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.
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.
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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