2007 Ways of Knowing Symposium

Using Intuition in Clinical Decision Making and Care: Research

Panel:
Lynn Rew, EdD, RN, Professor in Nursing, University of Texas at Austin
Lisa Ruth-Sahd, PhD, RN, Associate Professor, Department of Nursing, York College of Pennsylvania
Anita Smith, PhD, RN, Associate Professor in College of Nursing,
University of South Alabama

Intuition in Nursing

Lynn Rew, EdD, RN, Professor in Nursing, University of Texas at Austin

Lynn’s intention for this topic was to provide perspective on intuition in nursing through both her personal experience and a  review of the current state of the science of intuition in the nursing field today.  As with many others, Lynn’s interest was inspired by a personal experience with a loved one, in this case her mother.  At the time this occurred in 1986, there was little written in nursing literature, apart from the historical context of diagnostic decision-making in nursing.  Subsequently, she decided to pursue a systematic concept analysis looking at the following four aspects:

• Uses of intuition in nursing
• Defining attributes of intuition
• Antecedents and consequences
• Model cases.

She chose the defining attributes of intuition to be:

• Knowledge of fact or truth as a whole
• Immediate possession of knowledge
• Knowledge independent of linear reasoning process

She did a systematic review of the American Journal of Nursing from 1900 to 1985, examining almost 15,000 titles, looking for the presence of intuition as a concept and evaluating how concepts, attributes and utility have evolved through time.  Intuition was found in only one title, and there were related terms in only 0.3% of articles.

Between 1988 and 1990, Lynn performed two qualitative studies: the first with critical care and home health nurses (N=56), and the second with child/adolescent psychiatric-mental health nurses (N=16.)  She found the majority of these nurses used some type of intuition in clinical practice.  Three types of intuition were recognized:

• Cognitive inference
• Gestalt
• Precognitive function.

The nurses described their experiences using affective, cognitive or behavioral terms.  Some nurses noted that they didn’t let the physicians know about these experiences.

The final study discussed was a 2006 state of the science systematic review of the nursing literature from the CINAHL* data base from 1981 to 2006, which focused on 45 research articles.  Lynn found that the majority were qualitative designs (80%), few had methodological instruments (11%), two were correlational, and two were Delphi surveys.  In all, the research did not create a coherent science foundation.  While practicing nurses appeared to value intuition, they need help to differentiate intuition from other sensations, and they found it difficult to articulate.

Lynn recommended that future research 1) include multi-disciplinary collaboration; 2) correlate with physiological variables; 3) use representative sampling; and 4) use longitudinal design.

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Using Phenomenological Research to Explore Intuition in Novice Practice

Lisa Ruth-Sahd, PhD, RN, Asso. Prof., Dept. of Nursing, York College of PA

Lisa Ruth-Sahd’s background as an emergency trauma nurse raised her awareness of the disconnect between the reality of the patient situation and the standardized “severity scores,” which did not take into account either patient or caregivers’ intuitions.  Then as an educator, she was taught to take into account students’ different ways of learning, but not their different ways of knowing.  She found intuition to be commonly neglected in the rationalistic doctrine of education. 

In nursing literature reviews, she found the belief that intuition is a product of experience, and therefore of value only to experienced nurses.  While experience is undoubtedly one mediator of intuition, it is not prerequisite to the “innate, humanistic, non-rational information processing technique that leads to ways of knowing.”  Therefore, she chose the realm of the novice nurse for her studies.

“Intuition allows one to detect missing pieces of information, identify what is going to happen in the future, detect patterns of information that allows one to take quick action.”

Lisa’s first quantitative study in 2002 investigated what past experiences most powerfully predict a novice RN’s use of intuition.  Lisa distributed surveys to novice nurses through the Deans of various BSN programs and received a 23% return (N=323.)    She found that the willingness of novice nurses to use intuition to guide clinical decisions in patient care was most significantly explained by personal and interpersonal experiences, rather than professional ones.

A subsequent phenomenological study looked at the meaning and use of intuition in novice nurses practices, using an inductive approach with the investigator as the primary instrument for data collection.  Ruth used an interpretive Heideggarian structure that included the following: belief in multiple realities; identifying an approach to understanding that supported the phenomenon; commitment to the participant’s views; understanding that the researcher is part of the study; and conveys the phenomenon in a literary style, utilizing participants’ commentaries.  This study involved 2-hour interviews with 16 novice nurses, ages 21-27.  Techniques were followed to assure internal validity and reliability. 

Ruth organized her findings into four categories:

• Influence of prior experience on meanings and uses of intuition
• Importance of connection in making meaning through intuition—connections with spiritual sources, colleagues, patients.
• Ways that time, space, and touch facilitate intuition
• How the culture of nursing education and the nursing profession influence use of intuition

Her findings indicated the following:

• Novice nurses intuitiveness was based on life experiences as well as input from mentors and colleagues
• Intuitive knowing guided their practice
• Intuitiveness was an extension of connected knowing and was enhanced when nurses were relaxed in a supportive environment.
• Novice nurses displayed a need to move beyond positivism to a more inclusive learning theory that integrates diverse ways of knowing.

Ruth feels that the subsequent implications for practice include the need for “time and space” to develop and nurture connections, to share stories between novice nurses, and to foster self-awareness.

Lisa Ruth-Sahd’s work is posted at Google Scholars:
http://scholar.google.com/scholar?q=Lisa+Ruth-Sahd&hl=en&lr=&start=10&sa=N

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Using Instrument Development to Explore Intuition Use

Anita Smith, PhD, RN, Asso. Prof. in College of Nursing, Univ. of S. Alabama

DEFINITION:  “Intuition is a source of non-linear knowledge that originates from emotional awareness, physical awareness, and making connections at the physical or spiritual level.”

Anita Smith’s route for exploring this field has been via the development of a quantitative instrument to explore the feelings, sensations, and connections associated with the use of intuition.  Anita identified the measurable dimensions of intuitions as:  emotional awareness, physical awareness, and making connections.  She subsequently completed four separate evaluations of the instrument she developed.  In all cases her audiences were novice or inexperienced nurses.

Study #1 (N=349) in 2002 analyzed exploratory factors in a young, predominantly female group of senior nursing students.  7 factors emerged:

1. Physical Sensations
2. Premonitions
3. Spiritual Connections
4. Reading Cues
5. Sensing Energy
6. Apprehension
7. Reassuring Feelings

Study #2 (N-326) in 2003 with a similar population, identified just 6 factors:

1. Reassuring Feelings
2. Spiritual Connections
3. Feelings that Alert
4. Feelings that Forewarn
5. Physical Sensations that Alert
6. Reading Physical Cues

Study 1 and 2 were flawed in the factors not containing items with same stems, and in not taking into account the timing of sensations and emotions.

Study #3 (N+421) in Spring of 2005 was a confirmatory factor analysis, with 7 factors emerging:

1. Good Feelings
2. Reading Cues (of patient)
3. Physical Awareness (when something is wrong)
4. Sensing Energy
5. Spiritual Connections
6. Bad Feelings
7. Physical Feelings that Alert (when something is about to go wrong)

Study #4 (N=79, all RNs) in Spring of 2006 engaged an older, much more experienced and diverse group.  In this analysis, 4 factors emerged strongly:

1. Spiritual Connections
2. Physical Sensations
3. Reassuring Feelings
4. Bad Feelings

The experienced nurses were clearer in their intuition than the novices, though causes were not teased out.

These studies raised the following questions:

1. Does nursing specialty impact the clarity of intuition?
2. Are there levels or stages of proficiency in intuition in nursing practice?
3. Do nurses favor certain dimensions of intuition?

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