Journat of Clinical Nursing 1993; 2: 11-17

Intuition: concept analysis and application to curriculumdevelopment. II. Application to curriculum development

BRENDAN McCORMACK BSC (Hons) Nursing, DPSN, PGCEA, RGN, RMNClinical Lecturer in Nursing, Institute of Nursing and O.xford Community Hospital, Oxford, UK

Accepted for publication IS June 1992

Summary

• This is the second of two articles which addresses the subject of intuition andits relevance in practice and to curriculum development,

• Ways by which nurse educators can learn to value the concept of intuition andintegrate it into the curriculum are discussed,

• Following examination of the concept of intuition, some solutions are offered,

• Research concerning the measurement of intuition in nursing practice isanalysed, .̂ ,

• Concepts of intuition and the role of intuitive thinking in nursing practice arepresented.

Keywords: nurse education, decision making, case study, intuition, curriculumdevelopment, knowledge.

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Methods

The purpose of this research was to establish the role ofintuitive decision making in nursing practice and to estab-lish methods of enhancing intuitive thinking in the cur-riculum.

With the advent of Project 2000, nurse educators/practitioners are examining and utilizing curriculummodels which represent the reality of practice. One suchmodel is that of Benner (1984) whereby the nurse is seen toprogress along a continuum, from that of novice to expert.Within this framework, Benner (1984) recognized thevalue of inluition in nursing decision making and high-lighted it as a significant element of decision making byexpert nurses. Formal analytical models are seen as useful.

Correspondence: O.vford Community Hospital, I he Churchill Hospital,Old Road, Ucadington, Oxford 0X3 7LJ, UK

but Benner & Tanner (1987) suggested that continuing to'slavishly' use formal analytical tools limits the develop-ment of more flexible ways to collect and assimilate patientinformation.

A case study approach has been adopted for this study,with diary keeping and a group semi-structured interviewas the data collection tools utilized. This design was chosenfor two reasons:• it gives students the opportunity to record and reflect on

critical incidents in practice;• group interviews have the potential to promote wider

discussion ofthe issues raised.This approach is conducive to the purpose ofthe study, asit allows nursing to be viewed in the context in which itoccurs.

Consent for the study was gained from participatingstudents, their personal tutor and course director forprofessional preparation in the college.

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Sample

The study consisted of 10 student nurses who had com-pleted 18 months of nurse education, on a 'traditional'course, i.e. pre-Project 2000. The .sampling techniqueemployed can be seen as 'opportunistic' (Agar, 1980 p.120), as informants were selected according to the qualityof their relationship with the researcher and for theirability to articulate and provide explanations on the area ofstudy.

Following a discussion on the purpose and process ofdiary keeping, the students were happy to maintain thediaries, and viewed the activity positively, as a means forreflecting on their practice. Guidelines for maintaining thediaries were given and the students were asked to maintainthe diaries over a 3-week period. A date for the follow-upinterview was also arranged at a venue convenient to thestudents.

Data analysis

The diaries were analysed using the intuitive knowledgescale as developed by Young (1987). The intuitive know-ledge scale is a qualitative scale for evaluating the amountof intuition involved in the judgement process. A detaileddescription of this tool with an example of an intuitiveincident as coded using this framework is outlined inAppendix I.

Following analysis of the diaries, categories and topicsemerged which required clarification and further discus-sion. These topics were utilized to formulate a topic listwhieh formed the basic structure of the interview.

Following the interview, analysis of the data was carriedout using latent content analysis (Field & Morse, 1985), inorder to understand the meaning of the communicationwithin the context of the respondents' own frame ofreference. The defining attributes of intuition as outlinedin the concept analysis (Part I, McCormack, 1992) wasutilized as the framework of analysis. Therefore the datawas organized under four headings: '•-''•''' -*'̂ ' •''•• definition(s) of intuition;• knowledge that is immediate;• holistic knowledge representing synthesis;• knowledge independent of the linear reasoning process.

Discussion of findings

DEFINITION(S) OF INTUtTION

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The students in the study were broadly able to define whatthey m e a n t by in tu i t ion . ' '!•- iiv:iL!i.<[-rir[ unn!^;. j u i ^ j

STUDENT Ii. 'A feeling of knowing something that had norelation to past experience—or any sort of, um, pre-vious knowledge'.

STUDKNT D. '. . . it comes up very unexpectedly, um,—youare not aware that you are thinking intuitively'.

.STUDENT C. '. . . a feeling that doesn't appear to have anyorigin, but you're very much aware of it. . . .'

However, none of the definitions offered encapsulated thecomplete concept. This probably reflects the complexity ofthe concept and the fact that the use of intuition is notmade explicit in nurse education and practice—a view thatYoung (1987, p. 54) supports. She suggests that the idea ofintuition as part of nursing knowledge has been viewed asantithetical to empirical, rational, factual knowledge.

The students had difficulty finding the appropriatelanguage to describe their experiences and relied on the useof synonyms such as 'gut feeling', 'instinct' and 'feelingswithout an origin'. Even when the students were able tooffer a personal view and belief about the concept, theyoften followed it up with expressions of self-doubt in usingthe term. This highlights Visintainer's (1986) view thatnurses place little credihility in their feelings and beliefs—the'soft stufT of nursing. •

KNOWLEDGE THAT IS IMMEDIATE

The immediate nature of intuitive knowledge was recog-nized by the students, 'f̂ hcy suggested that it was this'initial feeling' that made them examine something moreclosely.STUDENT D. '. . . I mean there are some things in there

(diary) that are just feelings that you can't put yourfinger on . . . but the initial feeling you got made youlook into something a bit deeper than maybe you mighthave done with anybody else. You know that's what Ifound I did —or I just suddenly thought I'm going toask this question, um, which I wouldn't usually ask tothis sort of patient. . . .'

This comment by Student D highlighted and representedthe majority of comments made regarding the immediatenature of intuitive feelings. This finding was similar to thatof Benner & Tanner's (1987) study.

Although the students recognized this initial feeling,they also highlighted the need for safety in decisionmaking. The use of intuition was related to 'cuttingcorners' in practice and students suggested that experiencewas needed to do this safely. H'"' '• '''• '̂ ^STUDENT c. '. . . you Wouldn't do anything that would go

against all the knowledge that you have already builtup, um, without seriou.s thought. . . .'

It was in relation to safety that the students valued

Intuition: application to curriculum development 13

intuition, as when these two areas were combined, it led towhat they called 'cutting corners'.STUDENT D. '. . . although there are rules, you do question

yourself quite often, — what you are doing and why youare doing it. Sometimes you can cut corners and as longas they are safe corners you can do that.'

It was at this stage that the students related intuition andcutting corners to experience.STUDENT E. '. . . you don't think about it as often as when

you're a first warder . . . as a second or third year youknow the principles so well that you no longer have tothink about them.'

The students talked of many examples of 'experienced'ward sisters whom they had seen make intuitive decisions,and this they related to experience and past knowledgewhich was subconscious.STUDENT E. 'I feel a lot of what we call intuition is actually

based on past experience . . . She (a particular wardsister) has had so many experiences of people in criticalsituations, means she can assess them quickly.'

This student went on to clarify that this area of experiencewas the difference between experienced nurses' and stu-dents' intuition: '. . . sometimes as students you might notfollow an intuitive thought because you haven't got theconfidence to carry it through. . . .' However on otheroccasions: '. . . you have it (intuitive thought) so stronglythat you think, I've got to do something about that'(Student B).

It is evident that these students are highlighting theirown lack of confidence in their practice, which reflectstheir stage of training.

HOLISTIC KNOWLEDGE REPRESEN I'INCi SYNTHESIS

Although the students did not talk extensively aboutholistic knowledge, the accounts of critical incidents asdescribed in their diaries highlighted this area in practice.

The holistic nature of intuitive knowledge was notclearly understood by these students, although they recog-nized that when they thought intuitively, it was usuallywith patients they had come to know very well.STUDENT E. 'If you know them you know what's different

for them. . . .'This knowledge was seen to enable the student to make

decisions which were important to the person as anindividual, rather than 'a person in general' (Student E).

The students did relate holistic knowledge to overallknowledge of the patient as an individual. While theydisagreed on whether this knowledge of the patient wasassociated with length of time or the initial assessment ofthe patient, they all agreed that 'if you know them (the

patients) you know what's different for them'.STUDENT D. '. . . knowing the patient stimulates you to

think further and come up with a thought towardssomething.'

This knowledge of the patient was highlighted in a studyby Brykczynski (1989) who suggested that it was essentialfor nurses to be able to keep track of the whole picture andput the total person back together again.

Intuitive knowledge was seen as a good base on which tobuild knowledge and to categorize and prioritize theknowledge gained.STUDENT D. ' . . . you intuitively think something and you go

away and find out a bit more about it.'The students highlighted holistic intuitive knowledge intheir diaries, through the critical incidents described.

KNOWLEDGE INDEPENDENCE OF THE LINE.\R REASONING

PROCESS

The students recognized a large number of problems whentrying to describe intuitive thoughts through the linearreasoning process. They raised issues of accountability,whereby intuitive knowledge could not be documentedsafely in a way that could be justified, because '. . .intuition cannot be explained' (Student A).

The students raised the important and pertinent prob-lem in relation to the nursing process—that it fails toencapsulate the essence of nursing practice.STUDENT A. 'I think it's fairly loosely applied and I don't

think people let it stand in the way of what they thinkshould be done.'

This comment highlights the fact that more interactionbetween nurse and patient occurs in practice than isdocumented in nursing records.

The nursing process was seen as a good framework tosafeguard nurses aetions, 'as a legal document'. Thisproblem with proving the validity of intuitive knowledgewas seen as an opportunity for nurses to be accused of'unsafe' or 'incompetent' practices. The nursing processoffered this safety through the documented nursingactions.STUDENT A. 'Being more safe is OK. . . but being less safe or

laying yourself open to the charge of being less safe isnot good.'

Young (1987) concluded from her study that it is essentialto communicate intuitive knowledge. She suggested thatthis should be done through the medium of the nursingprocess.

However this does appear incongruous as the essence ofthe nursing process is a reliance on problem solvingthrough linear reasoning.

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Curriculum development act/

CURRICULUM DEVELOPMENT THROUGH NON-LINEAR

LEARNING

The need for the development and application of intuitiveskills in nursing has been well documented (Benner &Tanner, 1987; Rew, 1988).'̂ The students in this study appeared to have difficulty inrecognizing their intuitive mode and even when they didrecognize it, they experieneed self doubt and mistrust in itsexistence and function. However, when asked if they felt itwas an area that could be developed in their education andpractice, they were emphatically positive in their replies:STUDENT c. 'I don't think you ean use intuition until you

are very much aware of yourself . . .'STUDENT D. 'We need self-awareness workshops. . . .'STUDENT A. 'They (self-awareness workshops) should be

ongoing.'STUDENT E. 'There needs to be more emphasis on holistic

care . . . which in turn may help to develop yourintuition.'

STUDENT B. 'We need to discuss things more openly. . . .'.STUDENT D. 'If they (tutor or a qualified nurse) say it's OK

to use you intuition, then that gives you the freedom* and the confidence to use it.'

Glaser (1984) asserted that schools generally are verycapable of teaching knowledge of the 'basies' withoutencouraging thinking and mindfulness. This assertioncould be equally applied to nurse education, where therelevance of linear, reductionist modes of thinking havenot been questioned. Matched with this is the reliance onbehavioural learning outcomes, which stresses that thosewhich produce a behavioural change are the only desirableoutcomes (Darbyshire et al., 1990). This reliance onassessment through observable behavioural changes ap-pears incongruous, when the results of qualitative studiessuggest that nursing practice is a diverse activity, whichutilizes intuitive data and includes decisions that aregrounded in subjeetivity (Young, 1987). Henderson (1982)questioned the assumption that there is a single process orset of procedures underlying clinical judgement that can bedescribed, measured and taught. In her analysis of thenursing proeess, she suggested that different types ofnursing requires different types of processes, such asintuitive judgement—suggesting that not all nursing prae-tice could be described as an analytical, problem-solvingactivity.

The work of Patricia Benner has highlighted the factthat by the time the nurse reaches the level of 'expert' sherelies on a eombination of intuition, analysis and experi-

ence gained over time. With this in mind therefore, itappears imperative that nurses are educated for expertiserather than knowledgeable doing.

While many colleges of nursing have integrated thework of Benner into their curricula, there is still an over-reliance on objective measurement of learning outcomes.In order to foster the development of nursing expertise itwould appear to be important to eombine a linear model ofanalysis (nursing proeess) with an intuitive problem solv-ing model.

CURRICULUM FRAMEWORK

The model proposed here has been drawn from the workof many authors (Boreham, 1977; Pyles & Stern, 1983;Noddings & Shore, 1984; Blomquist, 1985; Benner &Tanner, 1987; Young, 1987; Burnard, 1989; Miller & Rew,1989). These authors have explored and researchedmethods of promoting and fostering intuition in generaland nurse education. In this study an attempt has beenmade to eombine these methods into the one curriculummodel.

The model presented is based on a spiral curriculummodel with the progression from novice to expert repre-senting the core of the spiral. The model is based on thebelief that the student has the source of knowledge, gainedthrough experience and analysis of their practice andenvironment. Six key development themes are seen tounderpin the model and these themes collectively coinprisethe remainder ofthe spiral (Figure 1).

The emphasis on a spiral curriculum is important, as itallows for each theme to be revisited and no theme istreated in isolation. The six themes included are as follows:• development of self-confidence and courage based on

knowledge;• reduction of strain and stress of experience;• creative problem solving;• validation of the expert nurse;• teacher as role model;• role of the mentor.It is not the intention of this study to prescribe specificteaching methods to be included in the model, as manyexperimental and group methods can be used. There nowfollows a deseription of the aims of the themes of thecurriculum model.

Development of self-cnnftdence and cotirage based onknowledge

'The purpose of this theme is to promote and develop self-eonfidenee through the aequisition of knowledge. Exer-

Intuition: application to curriculum development 15

Deveiopment ofself-confidence

and courage

Figure 1 Curriculum framework.

eises in developing positive self-concepts in the learner,discussion and exploration of creativity in nursing andexploration and recognition of intuition in decision makingcould be included.

Reductton of strain and stress of e.xperience

The learner needs to be able to divorce himself from thestrains and stresses of experience. In order to gain access towhat Noddings & Shore (1984) call 'the world of relation',i.e. the intuitive mode. Exercises such as:• communal silence,• soft music,• mind quieting aetivities, such as group brainstorming,

group visualization, quiet tbinking time, can set tbescene for reflective thinking;

• creativity, can be promoted through the sharing of ideasand use of diaries to reflect on critical incidents.

Creative problem solving

While recognizing the use of problem solving throughlinear analysis, the learner needs to be able to look moredeeply at problems and recognize that all cases andsituations eannot fit into mechanistic frameworks.

Exercises such as:• mental imagery,• problem solving focusing on the question rather than the

answer (understanding) is the goal, not necessarily find-ing the right answer,

• pattern-recognition to recognize relationships, withoutprespecifying the components of the situation: such ascase studies and enriched feedbaek with mentors (Ben-ner & Tanner, 1987), can help the learner to foster theuse of intuition in their work.

Validation of the expert nurse

Recognizing expert nursing in action and reflecting onstrategies by which expert nurses judge clinical situations.Exercises can be used sucb as:• reflection on practice, through case study presentation

and feedback;• free and informed decision making.••i;

Teacher as role model

The role of the teacher should be that of helping thestudent identify, explore and expand on his or her ownlatent knowledge (Miller & Rew, 1989). Teaching stra-tegies should promote verbal interaction between theteacher, mentor and student. The teacher needs to be seento 'struggle' to solve problems with the group, instead ofonly providing answers. Through this approach studentsand teachers alike can learn to cultivate and respect theirintuitive abilities. Exercises such as, problem solving instudent groups, being sensitive to intuitive thinking,recognizing the structure and connectedness of knowledgeand heuristics and algorithms, are useful for fosteringintuitive thinking.

Role of the mentor

Pyles & Stern (1983) recognize that the mentor (anexperienced nurse), has a key function to play in thesocialization of student nurses. The mentor acts as ateacher, advisor, counsellor and role model for the novicenurse. The role of the mentor is important throughout thismodel, as it is they who can assist the 'novice' nurse indeveloping and reflecting on their intuitions.

EVALUATION

Evaluation is the process of ascertaining the worth orsignificance of something by detailed appraisal and study(Quinn, 1988). It is imperative within this model that

16 B. McCormack nc

attempts are made to evaluate as objectively as possible.

Self-evaluation by students of their own knowledge, skills

and performance by reflecting on the thinking processes

utilized and feelings experieneed in differing care situa-

tions. Recording of critical incidents and anecdotal de-

scriptions of behaviour related to learning objectives

should be encouraged.

Concluding c o m m e n t s

The language and documentation associated with the

nursing process can severely limit nursing intuition.

Therefore acknowledging its existence and fostering quali-

tative means of recording it can promote expert, holistic

nursing.

While this paper has attempted to translate an abstract

concept into language that can be applied to nursing

praetiee many of the issues raised require further analysis

and research. If nurse educators continue to utilize sueh

models as that offered by Benner (1984) then it is impera-

tive that greater clarity of the underlying concepts is

achieved.

References

Agar M.H. (1980) The Professional Stranger: An Informal Introduc-tion to Ethnography. Academic Press Inc., London.

Benner P. (1984) From Novice to Expert: Excellence and Power inClinical Nursing Practice. Addison & Wesley, Co. London.

Benner P. & Tanner C. (1987) How expert nurses use intuition.American Journal of Nursing 87(1), 2.3-31.

Blomquist K.B. (1985) Evaluation of students: intuition is import-ant. Nurse Educator 10(6), 8-11.

Boreham N.C. (1977) The use of case histories to assess nursesahility to solve clinical prohlems. Journal of Advanced Nursing 2, •57-66.

Brykczynski K.A. (1989) An interpretive study descrihing theclinical judgement of nurse practitioners. Scholarly Inquiry jorNursing Practice; An International Journal 3(2), 75-104.

Burnard P. (1989) The sixth sense. Nursing Times 85(50), 52-53.Darbyshire P., Stewart B., Jamieson L. & Tongue C. (1990) New

domains in nursing. Nursing Times 86(27), 73-75.Field P.A. & Morse J.M. (1985) Nursing Research: The Application

of Qualitative Approaches. Croom Helm, London.Glaser R. (1984) Education and thinking the role of knowledge.

American Psychologist 39(2), 93-104.Henderson V. (1982) The nursing process—is the title right} Journal

of Advanced Nursing 7, 103-109.Le Compte M.D. & Goetz J.P. (1982) Problems of validity and

reliability in ethnographic research. Review of Educational Re-search 52(\), 31-60.

McCormack B. (1992) Intuition: concept analysis and application tocurriculum development. I. Concept analysis. Journal oj ClinicalNursing 1, 339-344.

Miller V. & Rew L. (1989) Analysis and intuition: the need lor hothin nurse education. Journal oj Nursing Education 28(2), 84—86.

Noddings N. & Shore P.J. (1984) Awakening the Inner Eye: Intuitionin Education. Teachers College Press, New York & London.

Pyles S.I I. & Stern P.N. (1983) Discovery of nursing gestalt incritical care nursing: the importanee of the gray gorilla syndrome.Image: The Journal of Nursing Scholarship 15(2), 51-57.

Quinn F.M. (1988) The Principles and Practice of Nurse Education.Chapman & Hall, London.

Rew L. & Barrow K.M. (1987) Intuition: a neglected hallmark ofnursing knowledge. Advance in Nursing Science 10(1), 49-62.

Rew L. (1988) Intuition in Decision Making. Image: Journal ofNursing Scholarship 20(3), 150-154.

Visintainer M.A. (1986) The nature of knowledge and theory innursing. Image: Ilie Journal of Nursing Scholarship 18, 37.

Young C. E. (1987) Intuition and the nursing process. HolisticNursing Practice 1(3), 52 62.

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Intuition: applieation to curriculum development 17

Appendix 1 Intuitive knowledge scale

In utilizing this framework, the descriptive incidentsdescribed by students become what Young (1987) calls the'functional dimensions of clinical intuition'. Two codedcategories emerge from this, called 'the judgement pro-cess', and 'the intuitive knowledge scale'. The judgementprocess represents the phases of making a nursing decision,while the intuitive knowledge scale qualitatively evaluatesthe amount of intuition used in the judgement process.This is achieved by determining the amount of subjectivity(intuition) and objeetivity in each decision.

Both categories are coded into three sub-categories:• Cues: the information utilized by the nurse to make a

decision, from subjective feeling cues to objective physi-cal signs;

• Judgement: what each nurse knew or did as a result ofthe information received;

• Validity: the correctness of the decision.

This framework was found to be useful for categorizing thedata presented in the diaries and helped limit personalbias, therefore enhancing what Le Compte & Goetz (1982)referred to as the 'construct validity' of the data. Anexample of an intuitive incident as coded using thisframework is outlined below.

INTUITIVE INCIDENT

A 40-year-old man, admitted to accident and emergencydepartment having had an epileptic fit (he had a knownhistory of epilepsy). The nurse felt there was something'strange' about this man that did not fit the diagnosis. Thenurse decided to examine the patient's ^kin and foundmarks that resembled 'pin pricks'; the doctor wasinformed. Further exatnination revealed that this man wasa drug addict and was suffering from withdrawal. Thedoctors then took appropriate action.

Functional dimension Judgement Intuitive knowledge

Cue: nurse felt there wassomething strange about thisman odd manner

Judgement: nurse decided toexamine his skin. Observed'pin pricks and blotches'

Action-, reported to Dr whowas able to take appropriateaction/give appropriate advice

Feeling cue of something No knowledge of cue source,'odd' about clinical picture. Subjective and intuitivemade her check his skin

The nurse took action

Appropriate action —made a difference totreatment

No logical relation betweencues and action. Probablyintuitive

Cues, action and result aret-elated

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