Intuition in nursing

By Gooske Douw, PhD, nurse.

Introduction

In nursing, not gut feeling but intuition is the concept that has been studied since the eighties of the last century. Most nursing research has been conducted in hospital settings with nurses from general wards, critical care units and emergency departments participating, and have qualitative designs.
Below you find an overview of the descriptions of the concept intuition, followed by an overview of systematic reviews with different aims.
The systematic reviews include literature until 2016. Since than at least 18 studies were found that study the role of intuition in the nursing process. An update of the results of these studies is in progress.

The concept of intuition

Intuition is described as ‘nurse’s wisdom’ (Wiedenbach, 1970), ‘personal knowledge’ (Carper,1978), ‘understanding without a rationale’ (Benner& Tanner,1987), ‘an aspect of nursing knowledge’ (Rew, 1987), ‘a direct perception that grasps both the objects themselves and their ‘affordances’ or their opportunities for action’ (Effken, 2001). Benner & Tanner (1987) describe intuition characterized by five aspects previously identified by Hubert Dreyfus: (1) pattern recognition; (2) similarity recognition; (3) common sense understanding; (4) a sense of salience and (5) deliberative rationality. Green (2012) uses accounts from philosophy and neurophysiology to argue that nursing intuition is a valid form of knowledge and is composed of four distinct aspects: (1) embodied knowledge rather like that knowledge we have when we have learned to ride a bicycle; (2) well-trained sensory perceptions attentive to subtle details of complex, often rapidly changing situations; (3) a significant store of pertinent conceptual knowledge; and (4) a history of habitual actions intentionally directed towards achieving the best outcomes for our patients.

Systematic reviews

Chilcote (2017) used the Walker and Avant’s framework to identify the importance of intuition in nursing education, clinical practice, and patient care. Literature was searched from 1987 to 2014. 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.

Melin-Johansson et al. (2017) conducted an integrative review with the aim to review the characteristics of registered nurses’ intuition in a) clinical settings, b) in relationships and c) in the nursing process. They searched the databases CINAHL, PubMed and PsycINFO for literature published between 1985-2016. Sixteen studies were included resulting in the categories:
a) Application, assertiveness and experiences b) Unique connections, mental and bodily responses, and personal qualities c) Support and guidance, component and clues in decision-making, and validating decisions. They conclude that 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 analysis and synthesis of intuition alongside objective data when making decisions. Nurses 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.

Douw et al. (2015) searched the literature to identify signs that trigger nurses to worry about a patient’s condition. They systematically searched the databases PubMed, CINAHL, Psychinfo and Cochrane Library (Clinical Trials) from the start of the databases until 14 February 2014. Eighteen studies were included in the review, resulting in 37 signs which were summarized in 10 general indicators, reflecting the nature nurses’ worry. These signs can be present in an early stage, when vital signs do not (yet) deviate from normal values, suggesting potential for improving care in an early stage of deterioration. Nurses may incorporate these signs in their assessment of the patient and their decision to call for assistance.

Odell et al. (2009) aimed to identify and critically evaluate research investigating nursing practice in detecting and managing deteriorating general ward patients. They searched the literature between 1990 and 2007. Fourteen studies were included. The findings suggest that intuition plays an important part in nurses’ detection of deterioration, and vital signs are used to validate intuitive feelings. The process is highly complex and influenced by many factors, including the experience and education of bedside nurses and their relationship with medical staff.

Rew & Barrow (2007) conducted a systematic review to determine the state of the science with respect to the use of intuition in nursing practice and nursing education. The Cumulative Index for Nursing and Allied Health database was used and 45 research articles were analysed. Findings show that most studies are descriptive, exploratory in design. Nurses affirm that intuition is salient to expertise in clinical practice and should be carefully taught to students and novice nurses.

Rew & Barrow (1989) discuss, based on the literature published in the American Journal of Nursing from 1900 to 1985, that until the early 198Os nursing research did not directly address the concept of intuition as a legitimate component of clinical nursing practice. The intuitive process has been neglected, either wilfully or unconsciously. We found that even though direct reference to intuition was lacking in the literature, the concept remained prevalent and stable over the period of time studied. For instance, the word intuition was found in only one of 14,971 titles studied, but key words such as empathy, insight, and instinct were identified more frequently. We concluded that nursing literature shies away from the word intuition but includes the use of concepts that are related to intuition.

References

Benner P. & Tanner C. (1987) Clinical judgment:how expert nurses use intuition. The American Journal of Nursing, 87(1), 23–31.

Carper B. (1978) Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–23.

Chilcote DR. (2017). Intuition: A Concept Analysis. Nurs Forum. Jan;52(1):62-67. doi: 10.1111/nuf.12162. Epub 2016 May 17.

Green C. (2012). Nursing intuition: a valid form of knowledge. Nurs Philos. Apr;13(2):98-111. doi: 10.1111/j.1466-769X.2011.00507.x.

Douw G, Schoonhoven L, Holwerda T, Huisman-de Waal G, van Zanten AR, van Achterberg T, van der Hoeven JG. (2015). Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review. Crit Care. 2015 May 20;19:230. doi: 10.1186/s13054-015-0950-5.

Effken J.A. (2001) Informational basis for expert intuition. Journal of Advanced Nursing, 34(2), 246–255.

Melin-Johansson C, Palmqvist R, Rönnberg L. (2017). Clinical intuition in the nursing process and decision-making-A mixed-studies review. J Clin Nurs. 2017 Dec;26(23-24):3936-3949. doi: 10.1111/jocn.13814. Epub 2017 Jun 22. Crit Care. 2015 May 20;19:230. doi: 10.1186/s13054-015-0950-5.

Odell M, Victor C, Oliver D. (2009). Nurses’ role in detecting deterioration in ward patients: systematic literature review. J Adv Nurs. Oct;65(10):1992-2006.

Rew L. (1987) Nursing intuition:too powerful and too valuable to ignore. Nursing, 17(7), 43–45.

Rew L. & Barrow E.M. (1987) Intuition: a neglected hallmark of nursing knowledge.Advances in Nursing Science, 10(1), 49–62.

Rew L & Barrow EM. (1989.) Nurses’ Intuition CAN IT COEXIST WITH THE NURSING PROCESS? Aorn journal

Rew L & Barrow EM. (2007). State of the science: intuition in nursing, a generation of studying the phenomenon. ANS Adv Nurs Sci. 2007 Jan-Mar;30(1): E15-25.

Wiedenbach E. (1970) Nurses’ wisdom in nursing theory. The American Journal of Nursing, 70(5), 1057– 1062.