Nursing intuition: A concept analysis
Nursing intuition: A concept analysisChristine Douglas and Dana HoganWashburn UniversityTheoretical Foundations for Advanced Nursing PracticeNU500December 07, 2011Nursing intuition: A concept analysisFor many years nursing intuition has been identified as a skill that is learned through practice. Nursing intuition is often used to describe a feeling or gut reaction about a certain patient situation. Nurses and advanced practice nurses often use and rely on intuition or perceptions to direct care for patients. Intuition is not a concept that is traditionally taught in textbooks however most nurses understand and have experienced the concept. Even though nursing intuition is seen and felt by most nurses it has never truly been defined within the practice of nursing. The concept of nursing intuition is important to understand as it assists nurses with recognizing deteriorating patients and applying early interventions when appropriate. As nursing continues to evolve intuition remains a part of nursing practice and continues to gain more notice and interest. The purpose of this concept analysis is to bring recognition and meaning to what nursing intuition is. By defining nursing intuition there may be a more clear understanding of how intuition helps to save patient’s lives and how it is an important part of nursing practice. Intuition will be defined by examining various articles, comparing the different definitions and terminology attached to those definitions, and the experiences of the authors of this paper. Nursing Intuition DefinedIntuition has been clearly defined by several disciplines other than nursing. The meaning of intuition according to Merriam-Webster is a "quick and ready insight, an immediate apprehension or cognition" (Merriam-Webster, 2011). Although the Merriam-Webster definition is very general, it does describe the general basis of nursing intuition. The authors of the article "Intuition: A fundamental bridging construct in the behavioural sciences" define intuition within psychology as “affectively-charged judgments that arise through rapid, non-conscious, and holistic associations" (Hodgkinson, Langan-Fox, & Sadler-Smith, 2008, p. 4). Gobet and Chassy include in their definition of intuition “rapid perception, lack of awareness of the process engaged, concomitant presence of the emotions and holistic understanding presence of emotions” (Pretz & Folse, 2011, p. 2878). Hogarth defined nursing intuition as "thoughts that are reached with little apparent effort, and typically without conscious awareness....they involve little or no conscious deliberation" (Pretz & Folse, 2011, p. 2878). According to the Encyclopedia Britannica intuition within the discipline of philosophy means "the power of obtaining knowledge that cannot be acquired either by inference or observation, by reason or experience" (Encyclopedia Britannica, 2011). In 1987, Benner and Tanner define nursing intuition as a "trait of an expert nurse" who has an "understanding without rationale" (Smith, 2009, p. 35). The definitions taken from different disciplines have many similarities, defining attributes and descriptive words that are used to define intuition. For the purpose of this paper the following definition for nursing intuition has been formulated. Nursing intuition is the presence of receptivity within the nurse that allows an innate nonlinear knowledge to form without reasoning or evidence which is used to form a clinical judgment about a patient's condition. Review of Literature A literature review was completed using the database search engine CINAHL on November 01, 2011. The terms “nurs*” and “intuition” with a date range of January 2007 to January 2012 were used to generate a total of 119 records. The results where then narrowed by date using January 2009 to January 2012 which narrowed the results to 72 records. Those results were again narrowed by removing the search term of “nurs*” and adding the term “nurse” which narrowed the results to 35 records. Of the 35 records, 6 records were selected to include in this literature review.The first article reviewed was published in the Journal of Advanced Nursing titled “Expert nursing practice: A mathematical explanation of Benner’s 5th stage of practice development”. This article used phenomenological research conducted between the years of 2000-2003 along with Benner’s publications to discuss a mathematical explanation of Benner’s Theory in relation to the intuitive processes (Lyneham, Parkinson, & Denholm, 2009). The authors used the thought that a learning curve using practice as the y-axis and reflective time the x-axis while under the curve it reflects the ability of the nurses practice capacity and development (Lyneham et al., 2009). By using this formula of knowledge and reflective time raised to the power of experience it shows that as the curve increases the ability of the nurse also increases creating an increase in practice capacity over time (Lyneham et al., 2009). The authors then show how over time when clinical situations occur the nurse uses the power of experience to increase intuitive practice resulting in a positive correlation between the two (Lyneham et al., 2009). The findings suggest that experience is imperative in the development of intuition as a skill of a knowledgeable nurse (Lyneham et al., 2009).The second article, “Nurses’ role in detecting deterioration in ward patients: Systematic literature review” looks at 14 studies over the years of 1990 and 2007 to identify main themes found in detecting deterioration in patients on a general medical ward. The literature search was conducted using electronic databases, reference lists, key reports, and experts in the field (Odell, Victor, & Oliver, 2009). Four main themes where identified from the review of literature: “recognition, recording and reviewing, reporting, responding and rescuing” (Odell et al., 2009, p. 2000). Three processes are identified as used by nurses to identify deteriorating patients including patient or family concerns, recognition through routine observation, and the most frequently reported process the intuition of the nurse (Odell et al., 2009). In the aspect of reporting it was found that experienced nurses tend to call for Rapid Response Teams (RRT) or other additional support more easily than those with less experience (Odell et al., 2009). While responding and rescuing is often initiated by nurses it was found to occur without medical orders however is considered justified in most emergencies (Odell et al., 2009). Recommendations made by the authors based on the findings included education on intuitive reasoning, RRT’s, and advanced nursing assessment skills (Odell et al., 2009). The third article reviewed written by authors Anita Smith and Kelly Cone is a pilot study looking at the Triage Decision-Making Inventory (TDMI), a tool that measures the comfort of Emergency Department (ED) nurses in making triage decisions using 37 Likert-scale items with four subscales that are identified as characteristics of experienced triage nurses: critical thinking, cognitive characteristics, intuition, and experience (Smith & Cone, 2010). The TDMI was administered electronically to 583 nursing students (84% female, 16% male) at one southeastern university including current associate degree, baccalaureate, masters, and doctoral levels of education with a participation rate of 0.2, 71.5, 26.7, and 1.6 respectively(Smith & Cone, 2010). The results demonstrate a link between decision making, knowledge, and intuition with the clinical experience of nurses in ED triage (Smith & Cone, 2010). The results show a content validity of .87 showing that those nurses that score lower may need additional education and experience prior to developing those skills needed to effectively triage patients appropriately (Smith & Cone, 2010).The next article entitled “Exploring the legitimacy of intuition as a form of nursing knowledge” published in Nursing Standard discusses intuition as a form of knowledge instead of just an experts trait (Smith, 2009). The article reviewed studies from multiple disciplines including psychology, computer science, physics, and neuroscience to establish legitimacy of intuition without experience (Smith, 2009). The evidence suggests that inexperienced nurses including nursing students use intuition in clinical situations showing that intuition is a legitimate form of knowing instead of just an expert trait (Smith, 2009).The fifth article reviewed was a mixed methodology data analysis utilizing a research team of four nurses to develop a story analysis of 75 inspirational nursing stories for evidence of emotional intelligence (Winship, 2010). The authors define emotional intelligence as the “perception, assimilation, understanding, and management of emotion” comprised of three concepts: professionalism, performance, and nursing intuition (Winship, 2010, p. 940). Each story was read by the individual researchers and scored for the three concepts. The research team then came together as a group and the stories where read out loud and three out of the four or a 75% agreement rate that the story contained the concept (Winship, 2010). The study found that 14 (19%) of the stories contained intuition which correlated significantly with the concept of performance but not with professionalism (Winship, 2010). The final article reviewed comes from the Journal of Clinical Nursing and looks at nurses experience in relationship to using intuition in clinical decision making. 30 Bachelors of Science in Nursing (BSN) students and other licensed nurses including diploma (1), associates (1), BSN (78), masters (49), and doctoral degrees (6) took a 45 minute long survey via web site (Pretz & Folse, 2011). The survey was then coded and the results showed that the characteristics of skilled innovator and physical/spiritual intuition were a distinct category that differed from general intuition (Pretz & Folse, 2011). It also found that the preferrance for the use of intuition increased with the experience of the nurse however also identified that greater research is needed to determine if it is due to expertise or something else all together (Pretz & Folse, 2011).The main differences found in the literature review point to the thought of experience as a major factor in the development of intuition. With Benner's thought that intuition is a trait only seen in "expert" nurses many of the studies done on the subject use her theory to justify the findings. Other studies, usually not linked to a theory, find that intuition is something that is more knowledge based and should be taught from the entry point of initial education. One thing that is agreeable by all articles reviewed is the existence of nursing intuition and the use of intuition in nursing care. Defining AttributesSeveral different defining attributes for nursing intuition have been identified in different research articles that have been published over the years. A few of those attributes along with those identified by the authors of this paper have been included. The authors of "State of the science: Intuition in nursing, a generation of studying the phenomenon" identified three defining attributes: "knowledge of a fact or truth, as a whole; immediate possession of knowledge; and knowledge independent of the linear reasoning process” in regards to nursing intuition (Rew & Barrow, 2007, p. E15). Even with those attributes a major one identified by the authors of this paper is the attribute of receptivity (Rew & Barrow, 2007). For a nurse to truly gain full knowledge through the use of nursing intuition those four attributes must be present. This thought is further illustrated in Appendix A. Case StudyOn a medical-surgical unit a 60 year old male patient had been admitted for a diagnosis of weakness and fatigue. On the patients first night on the unit his Registered Nurse (RN) did a review of the patients past medical history, current labs, and vital signs (VS) prior to assessing the patient. In review of the charts the RN found a positive history of hypertension, hyperlipidemia, substance abuse, and depression. Current lab values show that the patient has impaired liver function, slight dehydration, and his white blood cell count was slightly elevated. The patients VS had been stable since admission and his blood pressure was within normal showing that his HTN is well controlled on his current medication. Telemetry monitoring shows the patient in normal sinus rhythm (NSR) with a heart rate between 70-80 beats per minute. Upon assessment of the patient by the RN he is found to be resting in his bed. The patient is easily awaken with verbal stimuli, orientated times three, and his only complaint is that of being constantly fatigued for greater than one weeks time. Patient denies any pain. Assessment shows slight skin tenting secondary to dehydration for which intravenous (IV) normal saline at 125 milliliters per hour is running into a 20 gauge IV in the patients right forearm. Neurological assessment shows strong and equal grips bilateral, pupils equal round and reactive to light. Lung sounds clear to auscultation, non-labored equal chest rise and fall is noted bilateral, and no shortness of breath is reported by the patient. Model Case StudyNo significant findings other than the slight skin tenting are found with a head to toe assessment however the RN was not comfortable with the patient's condition, something was just not right. The RN's receptivity to the patient gave an uneasy gut feeling. The RN reassessed the patients vital signs and although the vital signs are all within normal limits contacts the provider. The RN explains, that something is not right however they are unsure as to what it is. The provider agrees to see the patient. As the provider enters the room the patient's condition worsens and the patient's heart stops. A code was immediately started and the patient's heart beat returned. Because the RN was open and receptive to their own feelings, quick interventions saved the patients live.Alternative Case StudyUsing the same case study the alternative would have been much different if the RN would not have listened to the unexplained gut feelings. As no significant findings are found on assessment other than the sign of dehydration which is being treated with IV fluids. The RN continues to assess the other patients and complete other assigned tasks. A little while later the unit receives a call from the telemetry monitor technician asking that the RN go check the patient because they have fallen off of the monitor. The RN enters the room to find the patient unresponsive, not breathing, and without a pulse. The RN calls a code and starts CPR. This RN's block in receptivity resulted in a delay in interventions and the team is unable to revive the patient resulting in the patient's death.Antecedents Antecedents or events that must occur prior to the incidence of nursing intuition include the presence of nursing receptivity. Without receptivity the nurse may not be able to recognize subtle changes in the patients condition. In addition to receptivity the nurse must possess knowledge and intuitiveness. The nurse must be able to rely on one's own clinical knowledge not only what is read in textbooks. Without the present of these antecedents nursing intuition may not be effective or even present in that nurses practice resulting in the possibility of delayed interventions and negative patient outcomes. ConsequencesConsequences are the result of an occurrence citation. The main consequences of the presence of nursing intuition is early recognition of patient changes, early interventions, and improved patient outcomes. While the main consequences of the absence of nursing intuition is the deterioration of a patient's condition, delayed interventions, and negative patient outcomes including death. Without nursing receptivity subtle and pertinent patient changes may be missed resulting in the absence of nursing intuition and negative outcomes. In the presence of nursing intuition a patient's life may be saved or long term effects may be minimized.Empirical IndicatorsEmpirical knowing is defined as "the science of nursing that focuses on formal expression, replication, and validation of scientific competence in nursing education and practice" (Montgomery-Dossey & Keegan, 2009, p. 24). Empirical knowing uses empirical indicators established by "direct observation, measurement, and verification" to test the validity of evidence base practice (Montgomery-Dossey & Keegan, 2009, p. 24). As previously discussed, the presence of nursing intuition is agreed upon by many nurses however nursing intuition has yet to be clearly defined or validated with in nursing practice. It is the authors opinion that further research be done to better understand the presence of nursing intuition and establish more of a useable indicator to measure intuition within nursing practice.SummaryThe concept of nursing intuition is important to understand with in nursing practice. Using a concept analysis has helped to identify that the current research and validation of the presence of nursing intuition is underrepresented within the literature. This along with the understanding that this concept is one that is identifiable by most nurses leads to the recommendation that further research is needed. The difficulty in researching nursing intuition is mostly due to the fact that intuition is more objective and based on the individual nurses attributes which makes it difficult to truly measure. Regardless of the measurement of validity the authors of this paper believe that nursing intuition is present in all nursing practice in varying degrees depending on the degree of receptivity on behalf of the nurse involved. ReferencesEncyclopedia Britannica. (2011). Intuition. Retrieved from , G. P., Langan-Fox, J., & Sadler-Smith, E. (2008). Intuition: A fundamental bridging construct in the behavioural sciences. British Journal of Psychology, 99, 1-27. doi: 10.1348/000712607X216666Lyneham, J., Parkinson, C., & Denholm, C. (2009). Expert nursing practice: A mathematical explanation of Benner’s 5th stage of practice development. Journal of Advanced Nursing, 65(11), 2477-2484. doi: 10.1111/j.1365-2648.2009.05091.xMerriam-Webster. (2011). Intuition. Retrieved from merriam-Montgomery-Dossey, B., & Keegan, L. (2009). Holistic nursing: A handbook for practice (5th ed.). Sudbury, MA: Jones and Bartlett.Odell, M., Victor, C., & Oliver, D. (2009). Nurses’ role in detecting deterioration in ward patients: Systemic literature review. Journal of Advanced Nursing, 65(10), 1992-2006. doi: 10.1111/j.1365-2648.2009.05109.xPretz, J. E., & Folse, V. N. (2011). Nursing experience and preference for intuition in decision making. Journal of Clinical Nursing, 20, 2878-2889. doi: 10.1111/j.1365-2702.2011.03705.xRew, L., & Barrow, Jr., E. M. (2007). State of the science intuition in nursing, a generation of studying the phenomenon. Advances in Nursing Science, 30(1), E15-E25. Retrieved from , A. (2009, April 2). Exploring the legitimacy of intuition as a form of nursing knowledge. Nursing Standard, 23, 40, 35-40. Retrieved from CINAHLSmith, A., & Cone, K. (2010, January/February). Triage Decision-Making Skills: A necessity for all nurses. Journal for Nurses in Staff Development, 26(1), E14-E19. Retrieved from CINAHLWinship, G. (2010). Is emotional intelligence on important concept for nursing practice. Journal of Psychiatric and Mental Health Nursing, 17, 940-948. Retrieved from CINAHLAppendix AAs the nurse is receptive to the varies forms of knowledge intuition is formed. ................
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