Journal of Clinical Nursing 1992; 1: 339-344

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Intuition: concept analysis and application to curriculumdevelopment. I. Concept analysis /,

BRENDAN McCORMACK BSc(Hons)Nursing, DPSN, PGCEA, RGN, RMNClinical Lecturer in Nursing, Institute of Nursing, Oxford and Oxford Community Hospital,

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Accepted for publication 18 June 1992 -•: b-f^tltTij -jd V.'.H

Summary

• This is the first of two articles which address the subject of intuition and itsrelevance in practice and to curriculum development.

• Few words used by philosophers and educators arouse as much confusion asthe term 'intuition', yet it is recognized that few terms embrace such promisingconcepts. The nature of what is meant by intuition is discussed in this paper.

• The relevance of intuition to nursing is discussed and its importance in decisionmaking addressed.

Keytpords: intuition, concept analysis, decision making, tacit knowledge.

Introduction

This paper proposes to analyse the concept of intuition andto examine the role of intuitive thinking when nurses makedecisions. . iun lo VM;

Part 2 of this paper focuses on a qualitative researchstudy undertaken with student nurses, in order to contex-tualize and support the analysis. Possible directions forcurriculum development will be offered.

Purpose of concept analysis

Concepts are mental constructions: they are our attemptsto order our mental stimuli (Walker & Avant, 1983).Concepts can be seen as the foundation for all advances inscience and represent the basic ideas involved.

Over the past decade the body of nursing research hasgrown and has been directed towards developing andclarifying the knowledge base of nursing. Theory genera-

Correspondence: Oxford Community Hospital, The Churchill Hospital,Old Road, Headington, Oxford 0X3 7LJ UK.

tion provides one base from which nursing's body ofknowledge may grow. Concepts are the basic elements oftheory and the major part of theory evaluation is theidentification and assessment of underlying concepts.These concepts act as the primary building blocks oftheories from which new terms are derived (Hardy, 1974).

Concept analysis can be seen as a process of determiningsimilarities and differences between concepts. When thedefinition or attributes of a concept are not clear, theability of the concept to assist in the fundamental tasks oftheory generation and clarification is impaired. Therefore amajor use of concept analysis is to communicate knowledgethrough a common language.

A second purpose of concept analysis can be to offer an'operational definition' which seeks to determine theanswer to the question, 'How will I recognize this conceptwhen I see it in action.'' It is at the theoretical level thatthis analysis will be undertaken. ni. oJ j

There are many frameworks available for concept analy-sis. Norris (1982) criticized many of these approaches forutilizing primitive methodologies and lacking instrumen-tation. They do not facilitate concept clarification.

339

340 B. McCormack

The method of analysis chosen here is based on the

framework described by Walker & Avant (1983) who

presented the stages of analysis in a structured and

sequential format. However, Rodgers (1989) criticized this

approach for supporting logical positivism whereby con-

cepts are clarified within clear and distinct boundaries and

for valuing a reductionist approach rather than concentrat-

ing on the complex interrelationships that exist between

concepts. In recognizing the criticisms proposed by

Rodgers (1989), some modification has been made to the

sequence of presentation and the following integrated

approach will be utilized:

• selection of the concept; : ..•<:-..:.._

• determine the aims or purpose of analysis;

• identify all uses of the concept and surrogate terms;

• determine the defining attributes; - uj.: i,,

• identify antecedents and consequences of the concept;

• define empirical referents;

• identify related concepts;

• construct a model case.

Selection of the concept

Intuition has been a neglected concept within nursingpractice and research. In an attempt to build a 'scientific'body of nursing knowledge which legitimizes professionalpractice, nurses have adopted a linear model of analysis(nursing process) as a superior model. However, morerecent work suggests that decision making in nursing doesnot necessarily adhere to a linear model, but insteadincorporates a more intuitive, holistic mode of thinking(Pyles & Stern, 1983; Benner, 1984; Young, 1987). Beliefin the nursing process as the archetype of reasoning anddecision making in professional nursing practice ignoresintuition as a component of scientific method (Kuhn, 1970)and a legitimate way of knowing in nursing (Carper, 1978).: Furthermore, adherence to formal linear models ofteaching further devalues intuition and fails to recognizeholistic modes of thinking. In an extensive literaturereview, Rew & Barrow (1987) postulated that the intuitiveprocess has suffered neglect, wilful or unconscious, in theprofessional development of nurses. The work of Benner(1984) has initiated the re-addressing of the emphasis onlinear models of thinking and problem solving, therebycausing a shift towards more holistic modes. In order toexploit the framework as presented by Benner, it isimperative to analyse and clarify the underlying conceptsthat espouse the theory. For this reason the concept ofintuition has been chosen for this analysis.

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Purpose of analysis

The purpose of this analysis is to clarify the meaning ofintuition in order to gain a greater understanding of theconcept. By doing this the complexities of decision makingcan be explored and holistic educational strategies investi-gated. It is not the purpose of this analysis to discreditdecision making through the linear analysis mode, but todemonstrate the complementary nature of both models.

Use of the concept and surrogate terms

Noddings & Shore (1984) traced the use of the conceptthroughout history and tentatively concluded that intui-tion is an object-orientated capacity, one that organizes thematerial of inner and outer perception into representationfor both reason and will (p. 202). It therefore acts as thelink between external observation and the internal searchfor understanding. This notion of intuition as a direct formof contact with objects is important, as without this realitythe concept of intuition would become a term whichimplied the mere speeding up of the analytical process-without clear steps (Noddings & Shore, 1984).

According to Westcott (1968) intuition is an individual'sability to solve problems while possessing relatively smallamounts of information. Assagioli (1973) viewed it as anactivity of the superconscious—suggesting that what isimportant is not where the intuitions originate, but torecognize and open oneself to them and welcome them. Indoing so, we can differentiate between genuine intuitionsand impulses that come from other levels of the uncon-scious or from external influences.

Agan (1987) found that non-rational intuitive knowingis a dimension of the art of nursing. While no definition ofintuition is offered, the author relates the concept to thenotion of personal knowledge, which can only be articu-lated through reflection and actualization. Noddings &Shore (1984) suggested that the notion of familiarity andintuition needs to be considered. They suggested thatthere is a need to account for the apparent increase ofintuition that appears to be induced by familiarity. Thisidea of 'experts' being more intuitive than 'novices' hasbeen studied by Dreyfus & Dreyfus and as a result theydeveloped a model of skill acquisition. The Dreyfus model(1980, 1986) proposes that in the acquisition and develop-ment of a skill, a student passes through five levels ofproficiency:• novice,• advanced beginner,• competent, ., ,,,y,• proficient, .A' \ ,V_r. ',.

• expert.

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Intuition: concept analysis 341

The model reflects a movement from reliance on rule-governed behaviour (novice) to performance at a level ofmastery where there is a deep understanding of thesituation.

INTUITION: ITS IMPORTANCE FOR NURSING

Benner (1984) utilized the work of Dreyfus & Dreyfus inher extensive research with nurses. She defined intuition as'understanding without a rationale'. Through her work sheconcluded that intuitive judgement is what distinguishesexpert human judgement from the decisions that could bemade by a beginner or a machine. Jerome S. Bruner (1979)defined intuition as '. . . the act of grasping the meaning orsignificance or structure of a problem without explicitreliance on the analytic apparatus of one's craft'. This viewof intuition is generally seen to be similar to that of MaxWertheimer (1880-1943) who without ever defining theterm, wrote of 'seeing the light' while problem solving—thus representing a notion of spontaneous, non-rationalunderstanding, which may be seen as intuition.

Intuition is seen as a significant element of scientificdevelopment (Kuhn, 1970; Carper, 1978) and has beeninfluential in the area of qualitative research, particularlyphenomenology (Miles & Huberman, 1984).

'Nursology', a concept proposed by Paterson & Zderad(1976) combined intuition and rational analysis as the mostappropriate method for analysing the nursing process.

Pyles & Stern (1983) referred to the symbiosis of logicand intuition involving both conceptual and sensory actsand developed a theory of 'Nursing Gestalt'.

DEFINITIONS OF INTUITION

In addition to those already discussed, the followingdefinitions of intuition are offered:• the power of the mind by which it immediately perceives

the truth of things without reasoning or analysis: a truthso perceived, immediate knowledge in contrast withmediate {Chambers 20th Century Dictionary, 1983);

• the act or process of coming to direct knowledge orcertainty without reasoning or inferring (Webster'sDictionary, 1961).

SURROGATE TERMS * , , ,

rii i s i . ' i i r r i :-! . i i-n(, ," l o U"nin>i..i'i! '

These refer to those terms which serve as manifestations ofthe concept, or terms which may be used to convey morethan one concept. Examples of such terms include:• perception, •-•= /Tf̂ adia: •:..

representation,receptivity,understanding.

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• will, <̂• consciousness, s'• gut feeling,• sixth sense,• instinct, '*'• r e a s o n , •. :•:^' ">'• •''' '

• feeling,• innate knowledge,• women's feelings,• cognitive inference,• precognition.

While these terms are associated with intuition andcognition, they do not reflect the nature of the concept andindeed are sometimes confused with intuition.

Defining attributes ' ii:-'>-' .iq "»;> nori^a ni

From the review of the literature and the definitions of theterm offered, four defining attributes of intuition can bepresented:• immediate, unjustified true belief which is not preceded

by inference;• non-propositional knowledge which is holistic in nature,

i.e. focuses on the whole rather than its parts;• immediate knowledge of a concept which is independent

of the linear reasoning process;• represents synthesis rather than analysis.

Antecedents and consequences

Through determining the antecedents and consequencesof intuition, the social context in which the concept is usedcan be determined. They are also helpful in refining thecritical attributes of intuition, 'Something cannot be anantecedent and an attribute at the same time' (Walker &Avant, 1983, p. 33).

Antecedents are those events that occur prior to theconcept. In intuition these include:• quest for understanding of, or insight into a global truth

or concept that is not immediately available through thelinear analysis mode;

• acknowledgement of intuitive capacity and the reality ofintuitive modes;

• receptivity of intuitive thoughts which feel safe and areacted upon directly by external or internal stimuli.By combining these three antecedents of intuition the

individual can safely trust his intuitions, welcome them

342 B. McCormack

into his mode of thought and take immediate action asnecessary.

The consequences of intuition are those events thatoccur as a result of the concept—including the verificationof the action through the process of linear analysis and thetranslation of the intuition into operational and functionalknowledge, thus clarifying and communicating that whichis understood.

Empir ical referents

How can we measure the existence of intuition in the realworld? The theoretical basis for the study of intuitionappears to view intuition as a behaviour or complex ofbehaviours in which accurate or useful conclusions arereached on the basis of obscure or apparent insufficientevidence.

As a result, studies of intuition in nursing have concen-trated on areas of interpersonal perception and judgement,clinicians in action and problem solving.

MEASURING INTUITION IN NURSING PRACTICE

Pyles & Stern (1983) studied intuition in clinical decisionmaking. They interviewed 28 critical-care nurses, to deter-mine what assessment and decision-making processes wereutilized to prevent the occurrence of cardiogenic shockamong hospitalized patients. Through the analysis andcomparison of these interviews the researchers developed atheory of Nursing Gestalt (a process of linking togetherbasic knowledge, past experiences, patient's intuitions andtheir own 'gut feelings') to explain the cognitive processesused by experienced critical-care nurses in making assess-ments and judgements.

Benner (1984) analysed the clinical practice of expertand novice nurses. The researcher concluded that much ofthe practical knowledge utilized by nurses did not conformto scientific principles and the expert nurse engages intuit-ive skills to aid decision making. Intuitive judgement isseen to be that which distinguishes expert human judge-ment from other decisions or computations that might bemade by a machine.

In a further study, Benner & Tanner (1987) interviewed21 nurses who were perceived as experts by their peers.The authors concluded that intuitive knowledge and ana-lytic reasoning are not in an either/or position but they can(and often do) work together.

Gerrity (1987) utilized the Meyres-Briggs Type Indi-cator (MBTI) in order to assess perception and judgementin decision making. While discovering valuable data on thecomplex nature of problem solving and the importance of

non-linear learning techniques, the authors asserted thatintuition permits perception beyond what is visible to thesenses, including possible future events.

Young (1987) interviewed 41 nurses and tried to estab-lish the role of intuition in the nursing process. Using agrounded-theory approach, she established that nursinginteractions encompass both intuitive and deliberate quali-ties. Therefore the intuitive knowledge gained by nurses isa legitimate part of the nursing process.

Findings from all of these studies indicate the value ofintuitive judgement in nursing. However, all of thesestudies offer differing definitions for use of the concept,suggesting a need to operationalize the definition. Perhapsthis is one of the reasons why physicians have difficulty inaccepting this method of knowing. Further studies need tobe carried out in order to understand more fully hownurses synthesize objective and subjective data in order toarrive at and act on their decisions (Rew, 1988).

Related concepts

The concept most closely related to intuition is tacitknowledge, described by Polanyi (1969) as fundamental toall knowing. He described a complementary role of intel-lectual drive and the tacit dimension, in that perceptualawareness precedes conceptual awareness, i.e. the clini-cian's knowledge is founded in perceptions rather thanconcepts. Polanyi (1966) justified this by suggesting thatwe always know more than we can tell.

Two systems are seen to function in tacit knowledge.Firstly there is the process that involves perceptions ofparticulars, i.e. we know more than we can tell. Secondly,there is the part involving intuition and imagination.Polanyi (1969) suggested that it is intuition that helps formour hunches and which eventually helps us to integrate therelevant pieces of evidence into the solution of the prob-lem.

A model case

A model case is a real life example of the use of the conceptwhich includes all the critical attributes and no attributesof any other concept (Walker & Avant, 1983).

Mike is a 75-year-old man, admitted to the accident andemergency department having been found in a collapsedstate on a side street of the local town. He had a longhistory of alcohol abuse and was known to the departmentfor treatment of various minor injuries. Nurse Pigottreceived Mike into the department and took him to acubicle for assessment. She knew Mike as a regularattender to the A & E department. Mike was a labourerwho had travelled around the country working where he

Intuition: concept analysis 343

could. In 1984 Mike had fallen from some scaffolding andsustained serious injuries resulting in 8 months of hospital-ization. Following this his marriage had broken up due toMike's heavy drinking.

Nurse Pigott did some observations of Mike's vital signsand found: pulse 100 per min, blood pressure 160/90 andtemperature 36.5°C (ax). His pupils were equal and react-ing to light. There were scars on his left arm and leg. Mikewas very talkative as usual, although his voice was veryslurred. Nurse Pigott 'felt' that his speech sounded dif-ferent this time, although she knew he had been drinkingheavily.

Mike was examined by the department's doctor, whoalso attempted to perform a neurological examination. Dueto Mike's inebriated state he was unable to co-operate fullywith this examination. However, the doctor felt sure thatMike's fall was due to his alcohol consumption andtherefore felt that Mike could be discharged 'when he hadslept it off'.

Nurse Pigott was not convinced about the doctor'sdiagnosis and discussed her anxieties about Mike's speechwith him. The doctor could not see any grounds for nursePigott's concerns and insisted that Mike be discharged assoon as possible. Nurse Pigott took her case to the seniornurse, who intervened on her behalf and eventually per-suaded the doctor to allow Mike to stay in the assessmentward overnight, to be re-assessed the following morning.

Next morning Mike tried to get out of bed to visit thetoilet and fell to the floor. He was unable to supporthimself on his left leg and he was 'carrying' his left arm.The physicians were called to see Mike, and on examin-ation diagnosed him with having a left-sided cerebrovascu-lar accident.

This model case has all the defining attributes of theconcept of intuition. Nurse Pigott grasped knowledge ofthe case as a whole, by considering all the signs presentedto her. Her unjustified true belief in her observations andfeelings led her to take immediate action. She activated herknowledge independently of the linear reasoning process(had no real 'grounds' on which to prove her decision tothe doctor).

The antecedents of a search for understanding of a truthand receptivity of intuitive thoughts which feel safe areevident. The consequence of verification of intuitivethoughts through linear reasoning is seen in operation(final diagnosis made).

Conclusion

In this article an attempt has been made to analyse theconcept of intuition and to examine the role of intuitive

thinking in nursing decision making. Every effort has beenmade to minimize the reductionist approach in this analy-sis, and focus on the complex interrelationship between theelements.

The acceptance of the intuitive mode of thinking innursing does not come easy to a discipline that is strivingfor professional credibility. However, it is well docu-mented that slavish adherence to formal analytical toolslimits nurses' creativity in the collection and assimilationof patient information (Benner & Tanner 1987).

Intuitive thinking is holistic in nature and therefore is anessential process for articulating what Brykczynski (1989)called 'keeping track of the whole person'. While it issometimes necessary to concentrate on particular elementsof the patient's being, it is also essential to 'put the totalperson back together again'.

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