Figure 1. Conceptualization of Institution in Nursing
Intuition has been defined by a variety of sources and used in many ways since the early days of philosopher Kant and mathematician Einstein. However the term 'intuition' remains quite vague in description, as varying disciplines have interpreted the meaning, use, and significance differently. Nurses use intuition frequently when caring for patients, both sick and well. Intuition often guides decision-making and can influence all phases of the nursing process. A further understanding of this concept may help define what intuition in nursing means and can enhance our ability to recognize its use in care settings. The purposes of this concept analysis are to further understand of the concept of intuition and to increase the general awareness of its use in nursing, to help care providers and educators recognize intuition as an important form of nursing knowledge, and to discern whether the use of intuition should be encouraged in nursing practice. Methods for analysis included comprehensive searches of medical literature databases and other library databases for sources outside of nursing or medical literature, and hand searches of reference lists. Using a constructivist view, with theory development as the major goal, the use of constructed borderline, related, contrary, invented, and illegitimate cases of intuition are analyzed.
Intuition has been defined by a variety of sources and used in many ways since the early days of philosopher Kant and mathematician Einstein (Shabel, 2003). Merriam-Webster dictionary defines intuition as coming from the Latin inuitio, meaning “the act of contemplating” or “to look at”. It further defines the term as quick and ready insight, immediate apprehension or cognition, and the power or faculty of attaining to direct knowledge or cognition without evident rational thought or inference (Merriam Webster, 2011). The use of the term intuition, and what it entails, remains quite vague in description, as varying disciplines have interpreted the meaning, use, and significance quite differently.
Nurses use intuition frequently when caring for patients, both sick and well. The use of intuition often guides decision-making and can influence all phases of the nursing process. Understanding this concept more thoroughly will help to more specifically define what intuition is and will further our comprehension of when intuition is being used personally and among others. Professionally, a grasp on the concept of intuition may further nursing education by enabling schools to actually teach nursing students how to properly trust, and in turn use, their intuition to further their thought process at the bedside and in the community.
The purpose of this concept analysis is to further understand of the concept of intuition and to increase the general awareness of its use in nursing. Additional aims are to help care providers and educators recognize intuition as an important form of nursing knowledge, and to discern whether the use of intuition should be encouraged and used as a part of nursing practice. As a Neonatal Intensive Care Nurse, experiences with intuition arise frequently. Indeed, nurses who work with other vulnerable populations or groups who cannot fully vocalize their needs are prone to have intuitive experiences as well. My personal interest lies in the under-5 vulnerable populations and how to use intuitive moments that I have experienced to their full advantage for the benefit of my patients. Learning to be open to intuition as a way of knowing, and to trust it, could be invaluable in the patient care setting.
The search for the literature on intuition included the terms intuition, intuitive knowledge, intuitive judgment, concept, concept analysis, and intuition in nursing. The search included the use of medical literature databases (Pubmed, CINAHL, and Medline), VIRGO library database for sources outside of the nursing or medical literature, and Google Scholar for additional sources not owned by the University of Virginia libraries. Additionally, a hand search for relevant sources found in article reference lists was conducted.
Initial search findings produced over 17,000 sources that used the term intuition, though a vast majority of these used intuition as a descriptive term for studies focusing on other topics. The search was limited to research studies, which still produced hundreds of sources that did not focus on intuition as the primary concept. A majority of the nursing and medical sources were literature reviews, personal exemplars, or case studies. Very few studies, approximately 20, actually referred to intuition as the concept of interest. These were a combination of medical/nursing studies, along with other disciplines such as quantum mechanics and cognitive science.
Potential areas for strengthening this literature search include limiting the review to the use of intuition in clinical settings, and limiting the concept map to examine intuition from the angle of process versus outcome. Regarding limiting the review to the use of intuition in clinical settings, the empirical literature in medicine and nursing all examined the use of intuition in a clinical setting. Therefore, the search was really pre-limited to what was available, which were clinical studies. Though potentially unwieldy, a broad understanding of the concept requires a full review of any available literature or perspective. Finally, the concept map presented here intentionally minimizes antecedents to focus more on other questionable variables. The “intuitive moment” portion of the map was placed centrally for more emphasis on its importance. Using Walker and Avant's method, it would be incomplete to study intuition as exclusively a process or an outcome, because this system of concept analysis seeks to study both what happens before (antecedents) and what happens after (consequences) intuition occurs. Perhaps future concept analyses would do best to use a different analytic approach that acknowledges intuition as a process instead of an outcome, and allows the author more flexibility in determining the desired light in which to understand intuition.
Over the last several decades, the study of intuition has gained interest and has been the subject of papers in a variety of disciplines. In the more recent past, nursing has taken an interest in intuition as a potential source of knowledge that should not be denigrated or ignored and that has an important place in the care of patients (King & Appleton, 1997). While much of the earlier nursing literature focused on intuition as solely an expert trait, newer rhetoric explores intuition as a trait that is present, although possibly under-used, in the novice nurse as well (Smith, 2009). Several qualitative studies have examined intuition in a variety of nursing care settings to determine its elements and attempt to gain a firmer grasp on the concept. Yet and still, a majority of the literature focuses on defining intuition, first and foremost.
Perhaps the most difficult and least developed approach to understanding intuition lies in the definition itself. A review of the literature reveals that most of the sources and writings, dictionaries included, have varied definitions for the term. Indeed, the majority of the nursing literature focuses on simply attempting to define intuition in such a way that it can be generalized to a variety of situations, and discussions on the topic can, at least, be based on the same inclusion criteria. Little headway has been made. In identifying the uses of “intuition” and the defining attributes, several dictionary sources have been reviewed to draw out the varying uses of the term. These varying definitions and uses are discussed in further detail in the concept analysis that follows.
The ontological uses of intuition come from a variety of disciplines. French Philosopher Bergson defined intuition as a method by which absolute knowledge can be gained in The Creative Mind: an Introduction to Metaphysics (Bergson, 1946). Bergson discussed intuition in terms of its use as a philosophical method and distinguished between intuitive and conceptual thinking. He defined intuition as a mode of reflection that is fluid and occurs over time.
Andrea Disessa discusses intuition in Phenomenology and the Evolution of Intuition, touching upon cognitive science and explaining intuition as “primitive notions which stand without significant explanatory substructure or justification” (Disessa, 1983). He described intuition as a function of the cognitive system, best explored from a physics standpoint, in which intuitions function without context. In the field of education, Nel Noddings wrote about intuition in Awakening the Inner Eye: Intuition in Education. She discussed intuition in terms of its conceptual history, development as a philosophical/psychological concept, and distinction from analytical thinking (Noddings, 1998). Of particular interest to this author was the use of intuition in the teacher-student relationship. One of the first to examine intuition from a nursing standpoint was Patricia Benner, who discussed intuition in terms of the expert knowledge required to properly use the information received (Benner & Tanner, 1986).
As discussed, nurses often use intuition in caring for their patients. Whether this use of intuition at the bedside and in the communities is acknowledged and/or used in a methodical way is subject to question. Care decisions are either made, or not made, based on a combination of subjective data, objective data, and other less concrete ways of knowing. Combining these with experience and personal knowing may help the nurse to begin assimilating an assessment and possibly reach a conclusion about the situation utilizing all of her resources. Particularly in the case of fragile populations and those who are unable to provide spoken accounts of their conditions and concerns, nurses are obliged to use whatever combination of information they can, in order to achieve an assessment of the client.
Much of the research into the use of intuition in nursing is in the form of literature reviews, case presentations, and observational studies. In 1987, Patricia Benner examined the use of intuition in the clinical decision-making skill of expert nurses using interviews and observation. The article evaluated the intuitive experiences of expert nurses against Dreyfus's key aspects of intuitive judgment (Benner & Tanner, 1987). In nursing research, qualitative studies using semi-structured interviews have analyzed intuition in terms of the decision-making process and thinking strategies that nurses and physicians employ (Goransson et. al., 2007) (Taylor, 2005) and how intuition relates to emotional intelligence (Codier et al., 2010). The current literature demonstrates the similarities in methods and study variables that have been carried out in nursing research surrounding intuition. The studies all focus on some variation of the term intuition, relying on retrospective information from structured and semi-structured qualitative designs to elicit data (Traynor, Boland, & Buus, 2010) (Brien, Dibb, & Birch, 2009). A major limitation of most of the studies is the limited number and selfselection of study participants.
As well, research studies have been conducted in a variety of other disciplines. A study using quantum mechanics inquired about the source of intuitive knowledge and concluded that there is a “first sight” intuition that precedes sensory awareness (Radin, 2008). Neuropsychologists have examined ways of self-knowing (intuitive vs. evidencebased) using functional MRI to compare sites of neural structure activation (Leiberman et. al., 2004). The study of feelings, both cognitive and affective, and their use in decision-making was determined to be a valid judgmental strategy by researchers in the field of sociology (Greifeneder, Bless, & Pham, 2011).
Due to the potential for frequent use of intuition in individual nurses, between nursing specialties, and amongst varied professions, the continued concept development of intuition is warranted. The significance of this concept is that it can, and has been, defined broadly and used divergently. Consequences to the use of intuition can be either negative or positive on the outcomes of patient care, and therefore are most important facets to understand. Nursing research and nursing literature examine the use of intuition as a decision-making tool in providing carebut do not truly address what happens after an intuitive moment occurs (McCutcheon, 2001; Smith, 2007; Taylor, 2005).
The constructivist view from which Walker and Avant approach concept analysis is particularly relevant to the development of intuition as a concept, as this view argues that humans generate knowledge and meaning from their experiences (Hupcey & Penrod, 2005). The concept of intuition will do well to be evaluated in a constructivist context, since intuition can be described as an experience based upon the mind's perception (the process of obtaining knowledge and understanding). Walker and Avant take a non-essentialist view in recognizing that concepts are not static, but evolving over time (Hupcey & Penrod, 2005).This is true for many concepts—intuition included. This formula for concept analysis seeks the development of theory as its main goal, taking analysis to the next level of learning. Finally, the use of constructed borderline, related, contrary, invented, and illegitimate cases is important in analyzing intuition because of the many parallel and differing meanings that the subject entails. Terms such as “a sixth sense”, a “gut feeling”, and “ visceral emotional reaction” are often used interchangeably without scrutiny about their potential for slight variation in meaning. Utilizing constructed cases will further elicit these subtle variances in meaning. Using the Walker and Avant method of concept analysis, it will be important to further define any words used in the definition of intuition, and educe whether these are related or borderline terms. This concept analysis method, as described by the authors, is best utilized when the concept is unclear (Hupcey & Penrod, 2005), which fits well with examining intuition.
Potential weaknesses of using Walker and Avant's analysis method include that it is a widely used concept analysis method in nursing. Examining this concept using a different method may elicit more information about the topic. Additionally, the analysis method was first described in the late 1980's and was an adaptation of Wilson's method (Baldwin, 2008). Since then Chinn and Jacob's have revised the method, which is a more contemporary approach to analysis. However, with a concept this complex, the straightforward eight step approach based on the components of Walker and Avant's method will produce manageable results for analysis.
The eight steps of Walker and Avant's method include the following: select a concept; determine the aims or purposes of analysis; identify uses; determine defining attributes; construct a model case; construct borderline/related and contrary/illegitimate cases; identify antecedents and consequences; and define the empirical referents (Hupcey & Penrod, 2005). The concept selection, purpose of analysis, and empirical referents have been previously discussed, so the remaining five steps will be discussed here.
Intuition has been used in a variety of manners in both the ontological and empirical literature, and in the dictionaries as well. The term intuition is primarily used as a noun to describe or explain a poorly understood phenomenon. Just as Merriam-Webster defines the term as “quick and ready insight”, other dictionary sources use a variety of terms to describe intuition (Merriam-Webster, 2011). The Oxford English Dictionary (2011) defines intuition as the action of looking upon or into; contemplation; inspection; a sight or view, perception, recognition; or a mental view. Clearly, or quite unclearly, this definition alone includes so many variants of what can be considered intuition. Benner defines intuition as “understanding without a rationale” (Benner & Tanner, 1987). Indeed, likely in an attempt to provide clarity and direction, some writers have chosen to re-define intuition but lack an explanation for how their new definition was created.
While the dictionary and literary definitions of intuition vary, common themes emerge as defining attributes of the concept. Common attributes for the concept of intuition can be described as: i) knowledge of some fact or truth, ii) personal revelation of such knowledge, independent of others, iii) sudden or abrupt attainment of this knowledge and iv) attainment of this knowledge without reasoning or justification (Rew, 1986). Although many other attributes have been described in the literature, these four are thematic across a majority of the uses and definitions of intuition.
A model case describes the situation in which intuition, as perfectly defined by its attributes, can be experienced in a realistic situation. The following is an example of a model case which meets the four defining attributes:
MJ is a NICU nurse with five years experience. “One day, while caring for a patient, she notices that something about the little boy does not seem “right”. She had cared for him the two days prior, but could not quite get a sense of what she felt was wrong. She consulted the physician, letting him know that the patient “may” be very sick, but she could not explain to him why. Within 24 hours, the little patient died abruptly of a gastrointestinal disorder. Upon first visit/examination, she knew that something was “not right” with the patient. She had not consulted with others, and she had no prior knowledge of the infant's illness. She had a sense of salience (enough to notify the physician), but she could not explain her thought process”.
The following is a borderline or illegitimate case that does not meet all four of the requirements for defining attributes. Although the nurse has a personal, salient, and sudden attainment of knowledge, her hunch was based on a reasoning process.
KM is a PACU nurse with 11 years of experience. “While she was caring for her post-anesthesia patient after a total hysterectomy, she had a hunch that she should recheck the patient's medication list. She felt that there may be errors, as the nurse before her was prone to making medication changes without reporting them during shift change. She knew she needed to do this quickly, as the wrong medication could really delay the patient's recovery. She found that the patient was receiving twice as much IV pain medication than she should have, which was due to a calculation error”.
This case, as described below, does not match any of the defining attributes of intuition and therefore is considered contrary (or the opposite) of intuition. Though the case is atypical, the Nurse Practitioner's expert knowledge helped him to recognize the pattern and presentation of the patient's illness as an atypical process.
“While caring for his patient in the primary care clinic, CM realizes that the patient is suffering from atypical pneumonia. Using the previous history and physical data and discussing the case with his senior physician at the practice helped him to reach his decision. He had been suspecting that the patient had a mild case of pneumonia during previous a visit a few days prior, but his symptoms did not “add up”. He needed more data to confirm the diagnosis”.
Perhaps the most difficult piece in analyzing the concept of intuition lies in defining the antecedents. Because the definitions of intuition vary so greatly, defining the antecedents has been quite a debate, particularly in the empirical literature. Dreyfus describes the antecedents as pattern recognition, similarity recognition, commonsense understanding, skilled know-how, sense of salience, and deliberative rationality (Benner & Tanner, 1986). Leiberman, Jarcho, and Satpute (2004) propose that activation of certain neural systems in the brain is the antecedent to intuition. Indeed, other aforementioned empirical referents have defined antecedents as some varied combination based on their chosen definition (Figure 1). Although highly important, it should be recognized that much of the debate (and lack of progress) in understanding intuition lies in the attempt to define the antecedents. What is more important, particularly in nursing, are the consequences when one uses (or fails to use) intuition.
Little has been written about the consequences of intuition in nursing. However, an abundance of literature has been written on how to define or describe it. Perhaps the key to furthering research and discussion on the topic is to focus critique and review on the outcomes of using intuition in nursing. By understanding the consequences, we may further our understanding of the antecedents and defining attributes. The consequences of intuition in nursing can be broadly defined into two categories: positive and negative.
First, the nurse who has an intuitive moment must decide if s/he is going to acknowledge the information received (Figure 1). Once acknowledged, s/he must decide if s/he will trust the intuition enough to act upon it. Does s/he notify the other nurses and/or tell the physician? What if the work environment does not support this type of judgment? If s/he is a less-experienced nurse, will the other nurses trust him or her? And what if his/her intuition is wrong? This decision can lead to either positive or negative consequences for the nurse. Second, what are the consequences to the patient from the nurses' decision to ignore or acknowledge the intuitive moment? If s/he decides to ignore it, but s/he was correct, could s/he have intervened to help the patient? If s/he decides to ignore it, and s/he was indeed wrong, s/he may perceive this as a positive and be relieved s/he did not speak up. The negative and positive feedback loops in these types of situations are the ultimate consequences. If a nurse repeatedly speaks up when having intuitive moments and is correct about the situation, this may lead him/her to use and trust his/her intuition more freely. Conversely, if a nurse repeatedly ignores intuitive moments due to environmental or personal constraints, this may lead to continued self-distrust.
Figure 1. Conceptualization of Institution in Nursing
The opportunities to learn more about the consequences of intuition in nursing, and the potential empirical uses in research are considerable. Perhaps what we now consider to be antecedents to intuitive moments (such as an expert practice level) should be considered as variables in the results. If all nurses are capable of having intuitive moments, isn't it possible that the expertise leads a nurse to trust, and therefore voice, his/her intuition more freely? The consequences or results of an intuitive moment need to be further studied to elicit the true significance of what it means to use intuition in nursing. What is clear is that consequences for both the nurse and the patient do exist. Exactly what those consequences entail is an important subject for future research.
Intuition has been defined by a variety of sources and used in many ways throughout the ontological and empirical literature. A majority of literature, to date, has focused on further defining intuition and developing a theory surrounding the concept. Nursing has focused on intuition as a potentially valuable means of obtaining knowledge that should be channeled when used appropriately. While there has been an increase in attention paid to the importance of intuition in nursing, and research to support this, there remains a major area where the research and discussion is lacking. Previous studies have addressed the potential consequences and benefits of using intuition in nursing briefly, but do not delve much deeper. It is quite possible that the importance of the consequences of an intuitive moment far outweighs simply defining the concept. More studies that examine nurses' knowledge, attitudes, and beliefs about intuitive moments in nursing care need to be conducted. More empirical data needs to be gathered in order for this difficult topic to be well-defined, operationalized, and analyzed from the perspective of the value it holds for nursing. If nursing can obtain a better grasp on what it means when we say to 'use your nursing intuition', nursing clinical educators will be in a better position help novice nurses harness this skill.