IntroductionThe purpose of this paper is to examine the concept of intuition and evaluate its place in the emergency room nurse’s collection of skills required to care for critically ill and injured patients. The concept of intuition was chosen for analysis, since nurses often speak about their use of intuition in treating patients but do not often write about these practices. Intuitive reasoning has not been validated in the past, as with more linear modes of analysis. The nursing profession continues to struggle with developing a well recognized body of knowledge specific to nursing that can be viewed by other disciplines as ‘legitimate’. Intuitive thinking, especially in an area such as emergency medicine, may play a more critical role then previously thought. Additionally this type of analysis or reasoning, whether ‘scientific’ or not, can be a crucial part of a nurse’s ability to recognize potential disaster before it happens.Selection of ConceptIntuition has been a debated and a somewhat rejected concept for nurses in clinical practice. Nurses have historically been taught the nursing process, which is a linear model of analysis. The more non-linear methods of analyzing information in patient care have been placed on the back burner, so to speak. As a profession, nursing continues to attempt to establish a ‘scientific’ body of nursing knowledge, while the holistic modes of reasoning in tend to fall by the wayside (Benner, 1984). Intuition was chosen for this analysis in an effort to bring this concept to the forefront and recognize it as a paired method for nurses in decision making, to be used along with linear models of analysis. Purpose of Concept AnalysisThe purpose of this concept analysis is to explore intuition and its use by emergency nurses, whether by the novice, expert, or advanced practitioner. A concept is an idea of something formed by mentally combining all its characteristics or particulars; a construct (Walker & Avant, 1983). Moreover, concepts are basic elements of theory and theory evaluation is identification and assessment of concepts (Hardy, 1974). Analysis of a concept is the attempt to communicate knowledge through a common language. Define the Concept of Intuition The definition of intuition is stated as:• The power or faculty of attaining to direct knowledge or cognition without evident rational thought or inference (Kidney, 1992).• Understanding without apparent effort (“Intuition”, 2010).As will be discussed in the upcoming literature review, many have presented additional definitions of intuition. There are many other terms which are similar to intuition and are used interchangeably throughout the literature: ? Perception? Understanding? Consciousness? Gut feeling? Sixth sense? Instinct? Hunch? Innate knowledge Operational Definition of Intuition in Nursing Benner applied the previous works of Dreyfus and Dreyfus to nursing specifically. Benner defined intuition as ‘understanding without a rationale’ and stated that intuitive judgment is what sets apart experts from beginners (Benner, 1984). The following review of literature will discuss the various applications and interpretations of intuition within the field of nursing. Review of LiteratureThe following seven published studies of intuition are specific to the nursing profession. Each study focuses on a different subgroup of nurses but each discuss intuition’s place in the field of clinical practice. These articles establish intuition as it relates to judgment, interpersonal perception and problem solving.Ruth-Sahd and Tisdell (2007) use a phenomenological research design to study novice nurses in their first year of practice in order to discover the meaning of intuitive knowing and to explore how intuitive knowing is manifested in their practice. Within this study intuition is defined as a “humanistic way to process information that leads to ways of knowing that are perceived through emotions, senses, and/or the nurse-patient relationship” (Ruth-Sahd & Tisdell, 2007, p. 119). Unlike Benner and Rew who analyzed expert or experienced nurses, Ruth-Sahd and Tisdell found novice nurses do not rely on intuition because they are not necessarily able to recognize it, as it was not taught in their formal nursing curriculum. Rew (2000) developed a study to validate and measure nurses’ acknowledgment of utilizing intuition in clinical decision making. She describes three attributes of nursing intuition: knowing as a whole, immediate knowing, and knowing independent of linear reasoning. Rew’s study suggests that only expert nurses draw on intuitive knowing in their practice. She also recognizes that research on intuition has been limited due to lack of valid and reliable scales of measurement as an aspect of clinical decision making. Rew simply defines intuitive judgment as “the decision to act on a sudden awareness of knowledge that is related to a previous experience, perceived as a whole and difficult to articulate” (Rew, 2000, p. 95). Further, Rew discusses intuition in clinical settings as a piece of complex judgment, within the act of determining what to do in a perplexing or uncertain situation (Rew, 2000).Benner (1984) is thought of as the pioneer in studying intuition within the nursing profession. She states that nursing intuition is a product of years of experience and that only expert nurses have the ability to apply intuition. She describes five levels of nursing practice: novice or beginning practitioner, advanced beginner, competent, proficient, and expert. At the expert level, Benner states that a nurse is not consciously aware of his/her intuitive analysis because it has become part of his/her clinical decision making (Benner, 1984).Lyneham, et al (2008) found that intuition is a developmental aspect of clinical practice. Their phenomenological study explored emergency nursing in particular. Six components within the paradigm of intuitive practice in emergency nursing were identified: ? Knowledge (professional)? Experience? Feeling (physical response)? Connection (with the patient)? Syncretism (undertaking unusual or out of place assessments)? Trust (in one’s abilities) In summary, Lyneham, et al describe the experience of knowing in emergency nursing as an encounter in which the nurse becomes aware of an impending clinical event before it happens. This ‘knowing’ occurs without any understanding as to why the nurse knows what he/she knows. Similar to Benner, Lyneham, et al believe this type of practice does not occur until emergency nurses have been in clinical practice for years (Lyneham, Parkinson, & Denholm, 2008). Kosowski and Roberts (2003) conducted an interpretive phenomenological study to analyze ten novice nurse practitioners (NP) who utilize intuition in clinical settings. They identified a need for NP curricula to include clinical experiences that provide opportunities for students to practice reflective dialogue, critical thinking, and intuitive decision making. They also emphasize that NP students deserve a quality mentoring experience. Kosowski and Roberts reinforce the idea that novice NPs need to be supported in their efforts to uphold a holistic philosophy and caring center to their nursing practice. They discuss difficulty in maintaining holism while trying to stay afloat in a health care setting that does not allow adequate time or personalized attention to patient care (Kowoski & Roberts, 2003). McCutcheon and Pincombe (2000) attempted to create a way for nurses to articulate an understanding of intuition and their perceptions of its use in nursing practice. They surmise that intuition is not something that just happens. Rather, intuition is a result of a complex interaction of traits including experience, expertise, and knowledge. They further describe intuition as incorporating personality, environment, and acceptance of intuition as a ‘valid behavior’, including the presence or absence of a nurse-patient relationship. McCutcheon and Pincombe discuss these relationships as a ‘synergy’ that results in intuitive decision making. This study interestingly found that many experienced nurses do not consider novice nurses to be intuitive. They also stated that female nurses found male nurses to be less intuitive. In this study both male and new graduate nurses indicated that they did experience intuition but rejected these observations (McCutcheon & Pincombe, 2000). In the six studies that were analyzed most recognized intuition as a component of nursing practice; however, each article focused on a different subgroup of nurses. Difficulty remains in constructing valid and applicable tools for measuring intuition. More specifically, for emergency nursing the Lyneham et al (2008) study demonstrated that intuitive practice is an attribute of only expert emergency nurses. All the studies evaluated indicate that experience and expertise are required components prior to applying intuition in clinical practice. Although, Ruth-Sahd and Tisdell (2007) do report that novice nurses recognize intuition but do not feel comfortable relying upon it due to inexperience. Theses studies show that intuition is gaining recognition as an element of critical thinking. However, intuition decision making seems to remain secondary to linear modes of reasoning.Defining Attributes of Intuition In the review of literature there are several defining attributes that are acknowledged (see Appendix for Model Diagram):? Immediate awareness of a concept which is independent of the linear reasoning process;? Intuition is not a ‘hunch’ that occurs without rational explanation, rather a product of the synergy that results from the interaction of numerous factors;? Trustworthy intuitive decision making results from years of clinical experience.Model Case A model case is a real example of the concept’s use, which includes all the defining attributes of intuition and no other concept (Walker & Avant, 1983). ‘Jane’ is a 54 year old female who came into the emergency room with complaints of abdominal pain and vomiting. Her vital signs were within normal limits upon arrival and triage into the department but the nurse assigned to the patient had an initial “gut feeling” that something more was going on. After returning from radiology, ‘Jane’ was screaming in pain with her husband at her bedside stating, “this is not normal for her”. Her vital signs were re-evaluated but the nurse was unable to obtain a blood pressure (BP) reading in the right arm. Intravenous access was obtained, pain medications were administered, and the patient was placed on the telemetry monitor. After finally obtaining an accurate BP reading, ‘Jane’ was found to have a BP in the left arm of 60/30. The physician was called into the room to re-evaluate the patient, due to the current vital signs and the nurse’s persistence that something was very wrong. Lab results revealed a very low hemoglobin and the BP in the left was continuing to fall, with inability to obtain any BP reading in the right arm. An emergent CT was performed, which revealed a dissecting abdominal aortic aneurysm. The patient was prepared for emergent surgery and transferred to the operating room. ‘Jane’ survived. The emergency room nurse relied upon her intuitive thinking and acted quickly to address the patient’s evolving illness. This is an example of utilizing intuition, which resulted in lifesaving intervention for this patient.Illegitimate Case A novice nurse was caring for a patient who presented to the emergency care center after falling eight feet from a ladder. In her brief assessment, she noted minor abdominal pain but failed to do a thorough head-to-toe physical assessment. This nurse had virtually no trauma experience. She notified the physician of the patient’s arrival and went to continue caring for her other patients. A CT scan was ordered by the physician and the patient was sent to radiology for an abdominal CT. While the patient was in radiology, the novice nurse turned over the care of her patients as she left her shift. Upon returning from CT, the patient was experiencing increasing abdominal pain. The nurse who took over care of this patient was fortunately a seasoned emergency nurse who had extensive experience with trauma patients. This nurse performed her own assessment and found the patient had not been placed on any monitoring devices, nor re-assessed since his initial presentation. The nurse noted the patient’s increasing pain and generally ‘concerning’ appearance. The first thought that came to mind for this nurse was an immediate feeling of doom. Although the patient’s vital signs remained somewhat stable, she reported a ‘gut feeling’ that her patient was going to make a turn for the worse. In fact the patient’s vital signs began to deteriorate rapidly and his condition became very grave. Radiology results revealed had a ruptured spleen with massive internal hemorrhage. The nurse had fortunately placed intravenous lines (IV), started IV fluids, and began preparing the patient for surgical intervention and blood transfusion. This contrary case exemplifies the novice nurse’s inexperience and inability to recognize and apply intuitive thinking in her care for this emergent patient. Antecedents and Consequences An antecedent is something that happens or exists before something else (Kidney, 1992). In intuition these encompass:? Desire for understanding of truth that is not immediately obtainable through modes of linear analysis;? Recognition of intuitive capacity and reality of intuitive methods;? Acceptance of intuitive thoughts.By merging these antecedents of intuition, the nurse may safely trust his/her intuitions in clinical practice and take immediate action when necessary. The consequences of intuition are those actions that occur as a result of the concept including:? Confirmation of the action through linear analysis;? Translation of intuition in operational and functional knowledge;? Illustrating and communicating that which is understood.Empirical Indicators As mentioned previously, the measurement of intuition is challenging since the study of intuition is viewed as a behavior. As a result, research studies on the concept of intuition in nursing have focused on personal perception, judgment, and problem solving in the clinical setting. Conclusion The acknowledgment of intuitive thinking in nursing does not come easily to an occupation that is struggling to achieve professional credibility. Since intuitive analysis is holistic rather than linear, acceptance of this method of reasoning remains challenging. An attempt has been made in this article to examine the concept of intuition with regards to nursing and provide information on its use in the emergency care setting. Further research is necessary to blend intuitive thinking with linear modes of reasoning, in order to achieve a more comprehensive patient examination.