FOR the past 2 decades, nurse clinicians and nursing scholars have acknowledged that intuition is a component of clinical judgment and decision making. Differentiating novice from expert, Benner described the "intuitive grasp" of the expert nurse as a salient component of managing complex clinical data.1 In a concept analysis of intuition in nursing, published in Advances in Nursing Science a full 20 years ago, Rew identified 3 defining attributes of intuition: "knowledge of a fact or truth, as a whole; immediate possession of knowledge; and knowledge independent of the linear reasoning process."2(p23) In 1987, Benner and Tanner defined intuition as "understanding without a rationale."3(p23) As the discipline of nursing has evolved, clinicians and scholars have approached this topic through anecdotal testimonials, instrument development, and research.
Much of the nursing literature published in the past 2 decades has focused on the use of intuition in nursing practice,4,5 teaching students about using intuition,6-8 and applying intuition to nursing management.9,10 In particular, the concept has been addressed in unique areas of practice such as critical care,11 neonatal intensive care units,12 pediatrics,13 community health,14 and psychiatric mental health,15,16 or with specific types of patients such as those with brain injury17 and those with dementia.18 In 1987, we published the findings from our analysis of the concept of intuition in the American Journal of Nursing from 1900 to 1985. We concluded that intuition was imperative to complex decision making in nursing and neglected in the nursing literature.19 A decade later, King and Appleton20 wrote a critical review of the research and rhetoric on the concept of intuition in nursing. They traced Benner's work on the intuitive grasp of the expert and critiqued several other articles and research reports published between 1983 and 1996. They concluded that many who still deprecate intuition as a valid component of nursing judgment and practice have done so in the light of increasing evidence from research.
Intuition is a common topic in other disciplines. For example, computer searches for the term yielded 2311 items in PsychInfo from 1980 to 2006, 1137 in Medline, and 807 in Educational Resources Information Center for the same time period. Psychologists have studied this phenomenon as a component of making various types of judgments.21-23 Similarly, medical researchers note that it is needed in making decisions that are complex,24 and educators have shown that it has an important place in learning mathematics.25 Recently, the HeartMath Research Center in California provided compelling evidence that both the brain and the heart are involved in intuitive experiences. Researchers used a counterbalanced, crossover design to measure cortical events in the brain and heart rate variability in the heart as well as skin conductance under 2 experimental conditions. They concluded from their analysis that together the brain and heart receive, process, and decode intuitive or prestimulus information. Moreover, they found significant gender differences, indicating that women are more attuned to the intuitive information provided by the heart than are men.26,27
The issues of what intuition is, and whether its presence plays a significant role in decision making, appear to be well established. Still open to question are its prevalence, utility, and efficacy. Twenty years would seem sufficient to observe evolution and growth in both concept and the theories that extend it. Such work can become scattered through time and specific context, lessening its usefulness to the community as a whole.
The purpose of this article is to discuss the state of the science on intuition in nursing practice and nursing education. Specifically, this is a report of the findings from a comprehensive and systematic review of the nursing literature on intuition from 1981 to 2006. We first describe the types of articles published during this time, and then we provide a fuller description and analysis of research reports that address the science of intuition in nursing practice and nursing education.
METHODS
To avoid the pitfalls of subjectivity and bias in reviewing the literature on intuition, we conducted a systematic review.28 Key benefits of a systematic review are that inclusion and exclusion criteria for the population and sample are clearly identified, results are quantified, and the process can be replicated. To assure that the review was comprehensive as well as systematic, we chose not to delimit the starting date for inclusion of published literature. The population of literature we examined included all entries found in the electronic database of the Cumulative Index of Nursing and Allied Health Literature (CINAHL) through June of 2006 using only the search term of "intuition."
Sample
From a population of 611 unique articles published between 1981 and 2006, we selected a scientific sample of 45 articles that met the following inclusion criteria:
1. Research reports about nurses or nursing
2. Published in a nursing journal (ie, the word nurse or nursing appeared in the title or the journal was identified as primarily for nurses rather than interdisciplinary in focus)
3. Published in English language
4. Contained "intuition" in the title and/ or abstract and contained intuition as a major term
Articles were excluded from scientific review if:
1. Described in the CINAHL as anecdotal, books, book chapters, brief item, case study, commentary, editorial, theory, philosophy, or any other article not specified as research.
2. Dissertations.
3. Published in languages other than English.
4. Published in nonnursing or interdisciplinary journals.
Procedure
The initial list of 611 entries was entered into an Excel spread sheet, indicating for each article an identification number, author, year of publication, type of journal, whether or not the word intuition was found in the title or abstract, whether or not the word intuition was a major or minor concept, the type of article as documented in the CINAHL, the country from which the article came, and the language in which it was written. For those articles designated as research, we recorded research design, sample, and major findings. From this spreadsheet, frequencies were computed to describe the overall population and the scientific sample used in this analysis.
FINDINGS
The percentage of citations that were published in peer-reviewed nursing journals declined steadily from 100% in 1981 to 30% in 2006. A total of 287 (46.9%) citations were in nursing journals. Table 1 indicates the number of publications in each of CINAHL categories for each 5-year increment: anecdotes, books, book chapters, brief items, case studies, critiques, reviews, dissertations, editorials, research reports, miscellaneous or unspecified types, and those written in languages other than English. The majority of entries were unspecified types of articles. Of the 16 articles written in other languages, 6 were in Portuguese, 3 in Spanish, 3 in German, 2 in Afrikaans, and 1 each in French and Finnish.
The scientific sample consisted of 45 research reports shown in Table 2. Using the inclusion and exclusion criteria above, 95 research reports were excluded from the final scientific sample because (a) they were not about nurses or nursing, (b) they were not written in English, (c) they were not published in nursing journals, or (d) intuition was not a central concept in the study. Among the 45 included in the analysis, a variety of definitions of intuition were provided. Six of those that specifically focused on nurses' intuition cited the defining attributes published by Rew2 (Kosowski, 2000; Rew, 1988a, 1988b, 1990, 1991, 2000), 4 studies cited the description of the intuitive grasp of the expert published by Benner and colleagues1,3 (King & Clark, 2002; Leners, 1992; Stockhausen, 2006; Welsh & Lions, 2001), and 7 studies cited definitions provided by both Benner and Rew (Lauri & Salantera, 1998; Lin, 2003; Miller, 1993, 1995; Minick, 2003; Polge, 1995; Ruth-Sahd, 2005). Walthew's (2004) exploration of nurse educators' critical thinking was based on a definition of intuition by John Dewey. The remaining 6 authors defined intuition as shown in Table 3.
Nearly one half (n = 21; 46.6%) of the investigators in the scientific sample did not provide definitions of the concept, or they did not define intuition directly although intuition appeared in the title, in the abstract, or as a major term in the CINAHL (Andrews & Waterman, 2005; Arslanian-Engo, 2000; Beck, 1995; Cader et al, 2003; Carroll, 1988; Cone, 2002; Crandall & Getchell-Reiter, 1993; Fernandes, 2005; Gray & Smith, 1999; Grossman & Wheeler, 1997; Haines, 2005; Hogston, 1995; James, Simpson, & Knox, 2003; McCormack, 1993; Meehan, 2005; Ohrling & Hallberg, 2000; Panniers & Walker, 1994; Scheffer & Rubenfeld, 2000; Smith, 1988; Trenoweth, 2003; and Turkel, 2003).
Various designs were used to study some aspect of intuition in practice or education. The majority (N = 36) was qualitative in design: 16 qualitative description (broadly defined), 8 grounded theory, 8 phenomenology, and 4 ethnography. Five studies were methodological, describing instrument development, 2 used Delphi surveys, and 2 were correlational. Four of the articles, 2 of which were methodological, each combined reports from 2 studies.
Most qualitative analyses were conducted with data collected from small convenience samples that ranged from 6 nurse managers to 56 staff nurses. Specialty groups that were sampled included critical care nurses, emergency department nurses, postoperative nurses, labor nurses, mental health and psychiatric nurses, home health nurses, nurse practitioners, and nursing faculty. The methodological and correlational studies included larger samples ranging from 179 critical care nurses to a random national sample of 349 senior baccalaureate and associate degree nursing students. Seven researchers sampled nursing students, one of whom focused on graduate students only, and 3 researchers sampled parents or mothers.
Qualitative descriptive studies
The 16 qualitative descriptive studies were conducted from 1988 through 2004. Many of these focused on how nurses described their intuitions in various clinical practice settings or nursing specialties, including public hospitals (Carroll), home health (Rew, 1988), critical care settings (Smith; Rew, 1990), and psychiatric nursing (Rew, 1991). Others were designed to describe and examine how nurses and nurse practitioners (Offredy) made decisions in special areas such as the neonatal intensive care unit (Crandall), emergency department, and labor. Others were descriptions of how nurses used several ways of knowing and to develop critical thinking, intuitive thinking, and clinical judgment in nursing students (McCormack). Overall, these researchers concluded that intuition was a component of expert decision making in nursing, particularly in highly complex clinical settings. It is interesting that in the study of teaching clinical judgment in Taiwan, Lin and colleagues noted that owing to differences in cultures, the term "intuition" was not used, but the phenomenon was described in terms of experience. These studies were sufficiently rigorous for the times when they were published and investigators recognized the limitations of small samples and subjective data.
Grounded theory studies
The grounded theory studies, published from 1987 through 2005, focused on several aspects of nursing that included examining how intuition was perceived (Young), used and affected practice (McCutcheon & Pincombe), how mental health nurses incorporated intuition to assess risk in crisis situations (Trenoweth), how nurses used cues to determine whether the patient was deteriorating (Andrews and Waterman) or recovering (Grossman & Wheeler), and how nurses evaluate quality care (Hogston). The grounded theory study conducted by Gray and Smith was designed to identify changes over time in how student nurses in England were professionally socialized. Cader's study was done to determine how nurses evaluated nursing information found on the World Wide Web. In this study, the author expressed surprise to hear that nurses had stated they used intuition in evaluating this information.
Four of the studies depicted the theoretical links with diagrams (Andrews, Gray, McCutcheon, & Trenoweth). Gray's theory, however, was a theory of how nursing students progress toward the staff nurse role and indicated that mentoring facilitated the development of intuition within this process. Limitations of these studies included convenience samples and focusing on only one type of nursing care environment. Most of the grounded theory studies provided evidence of adequate rigor in using this method, with increasing sophistication noted in the more recent studies where computer software programs were used for data management and reduction. Again, these researchers emphasized the need for further studies that include clearer articulation of intuition as a component of clinical practice and strategies for teaching students and novice nurses to validate and trust their intuition.
Phenomenology studies
The aims of the phenomenology studies, published from 1994 to 2005, were similar to the qualitative descriptions and grounded theory studies. They included a feminist perspective on the development of nurses' intuitive thinking (Kenny), the meaning of caring among nurses whose patients had postpartum depression (Beck), a study of students' lived experience of having a preceptor (Ohrling), how novice nurse practitioners used intuition in making clinical decisions (Kosowski), early problem recognition by medical-surgical nurses (Minick), and the experience of caring by nurse managers (Turkel). These researchers concluded that intuition is a legitimate component of clinical decision making and caring among nurses. Two additional phenomenological studies were conducted to explore the phenomena of how parents experienced having a child with congenital heart disease (Fernandes) and how mothers described their experiences with young children with hemiparesis following a stroke (Meehan). In both of these studies, the researchers emphasized that nurses needed to trust and respect parents' intuitions about their ill children.
Ethnographic studies
The 4 ethnographic studies, published from 1992 to 2006, were conducted to explore how nurses use intuition in complex clinical practice settings. Leners concluded from observing nurses and listening to them describe their intuitive experiences and associated feelings that intuition was a manifestation of caring, which is the moral ideal of nursing. King found that nurses needed to recognize both intuition and analysis in making clinical decisions, and Bailey and colleagues concluded from analyzing nurses' narratives that patient care environments are often very complex with subtle changes that call for using intuition as a component of clinical judgment. Stockhausen reported an unexpected finding from a larger ethnographic study of teaching undergraduate nursing students in Australia. This investigator concluded that nurse educators need to consider new ways of helping students reflect on their practice to develop further the inherent artistry in that practice.
Methodological studies
Five of the studies were methodological and focused on the development of instruments to measure some aspect of intuition in nursing. Two reports (Miller, 1993, 1995) concerned the Miller Intuitiveness Instrument, which was designed to measure a nurse's perceived intuitiveness. Lauri and Salantera developed an instrument for Finnish nurses to identify their decision-making models in a variety of clinical settings. Rew's Acknowledgement of the Use of Intuition in Nursing instrument was designed to measure the use of intuition by nurses in clinical decision making. The fifth report was of an instrument for measuring the use of intuition in nursing students (Smith and colleagues). Each of these studies included a rigorous description of item development and psychometric testing, and all the instruments were found to be valid and reliable. Further studies were recommended to provide additional evidence of the validity of these tools, and authors urged others to develop and use instruments to measure the use of intuition by nurses in clinical practice and strategies for teaching intuition to students and novice nurses.
Delphi studies
Delphi studies sought consensus on decision making in nursing and the nature of critical thinking. The purpose of Panniers and Walker's study was to explore how useful nurses found a decision analysis process in dealing with a complex emergent problem. The researchers concluded that decision analysis allows nurses to quantify their intuitive choices and document and incorporate them in practice. The aim of Scheffer's study was to define critical thinking and focused on input from a panel of expert nurses from 9 countries and 23 states in the United States. Results were a consensus definition of critical thinking in nursing and 10 habits of the mind, one of which was intuition.
Correlational studies
Polge's descriptive correlational study was based on Benner's1 model of novice to expert. The purpose of the study was to examine the relationship between using intuition in making clinical judgments and attributes of the nurse, including years of experience and clinical proficiency. Findings supported Benner's model with nurses increasing the use of intuition with increases in years of experience and proficiency. The study conducted by Ruth-Sahd and Hendy was similar but sampled novice nursing students and incorporated multivariate analyses. The researchers completed multiple regression analyses and found that nursing students were more likely to use intuition in practice if they were older, had experienced more hospitalizations, and had more social support. Although we classified Miller's 1995 article as instrument development, this author also included correlations as part of the validation process and confirmed that nurses who perceived themselves as intuitive were skilled, interested in the abstract, willing to act on their intuition and take risks, and felt a spiritual connection with their clients.
The majority of research articles (95.6%) provided at least some support for the value of intuition in nursing education and clinical practice. Conclusions from 2 studies (4.4%) were equivocal. Many of the studies were based on previous definitions of intuition in nursing2 and on Benner's conceptualization of nursing expertise.1,3
DISCUSSION
Despite the systematic nature of this review, we acknowledge that there were limitations. We searched only 1 database, the CINAHL, and we used only 1 term, intuition. Other significant studies may have been in other databases such as Medline or PubMed. Our approach could have prevented us from reviewing other publications of related phenomenon. Because we limited our review to papers published only in English, we may have missed a broader international perspective on this state of the science. We also may have missed studies of nurses or nursing published in nonnursing or interdisciplinary journals.
Overall, our analysis shows that studies of intuition in nursing have remained primarily at a descriptive, exploratory level for more than 20 years. Although many of the studies were based on Benner's conceptualization of novice to expert1 and Rew's2 defining attributes, there is little other evidence that recent studies have built on the findings of earlier ones. As shown in Table 3, there is a broadly based, working definition of intuition, but researchers have generally found it difficult to assess and measure in a quantitative way that would support comparisons across disciplines or environments. Many of the researchers acknowledged the limitations of their studies that included difficulty in articulating subjective experiences.
It is promising that there are at least 3 valid instruments measuring various aspects of intuition. These are self-reports that can be used with samples of nurses and nursing students. These instruments could be used to advance the science by conducting more correlational and predictive studies and, therefore, building a more solid theoretical base for further study.
Unlike the research of McCraty and colleagues,25,26 we found no reports of physiologic measures that correlated with the self-reports of nurses' intuitions or perceived intuitiveness. Such studies would help validate the use of intuition in nursing and provide objective evidence that this skill can be taught, increased, or facilitated. The correlation of subjective perceptions with objective physiological changes in both the brain and the heart would help us advance the study of this phenomenon and lend it scientific credibility.
Much of the evidence from this body of research indicates that nurses value their intuition in a variety of clinical settings. Several of the studies provide support for Benner's1 work indicating that intuitive experiences increase with experience and expertise. Researchers continue to affirm that intuition should be combined with objective, empirical evidence when evaluating a patient's condition and in planning care. They also affirm that nurses need to communicate clearly about how they incorporate their intuitive judgment in making decisions in clinical practice.
It is clear that nurses are publishing many accounts of their clinical intuitions through anecdotes and informational articles. What remains unclear is how nurses can be taught to differentiate intuitions that are based on truth from vague, subjective feelings that do not represent this phenomenon. Our recommendations for further study are that the next generation of research should move beyond description, be based on representative samples of nurses and nursing students, and include physiologic measures as correlates of subjective experiences. We also recommend that nurses collaborate with members of other disciplines such as psychology, education, and medicine to design more complex studies that will further our understanding of this unique phenomenon.
CONCLUSION
The nursing discipline is complex and requires that its members apply knowledge and skills in a variety of settings. Nurses understand and define intuition as a way of knowing something immediately as a whole that improves with experience, informs their judgments and decisions, and leads them to take action within the caring relationship. Further interdisciplinary study is needed to expand the state of this science and art. Intuition remains a hallmark of nursing knowledge, but no longer neglected in nursing literature.
REFERENCES