nursing intuition: a concept analysis - dana marie...

Running head: NURSING INTUITION: A CONCEPT ANALYSIS 1

Nursing intuition: A concept analysis

Christine Douglas and Dana Hogan

Washburn University

Theoretical Foundations for Advanced Nursing Practice

NU500

December 07, 2011

NURSING INTUITION: A CONCEPT ANALYSIS 2

Nursing intuition: A concept analysis

For 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 Defined

Intuition 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 Attributes

Several 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 Study

On 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 Study

No 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 Study

Using 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.

Consequences

Consequences 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 Indicators

Empirical 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.

Summary

The 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.


References

Encyclopedia Britannica. (2011). Intuition. Retrieved from http://www.britannica.com/

Hodgkinson, 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: 10.1348/000712607X216666

Lyneham, 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.x

Merriam-Webster. (2011). Intuition. Retrieved from www.merriam-webster.com

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.x

Pretz, 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.x

Rew, 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

http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=696813

Smith, A. (2009, April 2). Exploring the legitimacy of intuition as a form of nursing knowledge.

Nursing Standard, 23, 40, 35-40. Retrieved from CINAHL


Smith, 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

CINAHL

Winship, G. (2010). Is emotional intelligence on important concept for nursing practice. Journal

of Psychiatric and Mental Health Nursing, 17, 940-948. Retrieved from CINAHL


Appendix A

As the nurse is receptive to the varies forms of knowledge intuition is formed.

nursing intuition: a concept analysis - dana marie...

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