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Advances in Nursing Science


Vol. 30, No. 1, pp. E15E25
Copyright
c
2007 Wolters Kluwer Health | Lippincott Williams & Wilkins
State of the Science
Intuition in Nursing, a Generation
of Studying the Phenomenon
Lynn Rew, EdD, RN, AHN-BC, FAAN;
Edward M. Barrow, Jr, MS
A systematic review of nursing literature was conducted to determine the state of the science
with respect to the use of intuition in nursing practice and nursing education. The Cumula-
tive Index for Nursing and Allied Health database was used to identify the priority population.
Fromthis database, 45 research articles that were written in English, published in nursing jour-
nals, and that contained the word intuition in the title and/or abstract and in which intuition
was a major term were analyzed. Findings show that, to date, most studies are descriptive,
exploratory in design. Nurses affirm that intuition is salient to expertise in clinical practice
and should be carefully taught to students and novice nurses. Keywords: decision making,
intuition, intuitive judgment, systematic literature review
F
OR the past 2 decades, nurse clinicians
and nursing scholars have acknowledged
that intuition is a component of clinical judg-
ment and decision making. Differentiating
novice from expert, Benner described the
intuitive grasp of the expert nurse as a
salient component of managing complex clin-
ical 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 posses-
sion of knowledge; and knowledge indepen-
dent 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, clini-
cians and scholars have approached this topic
through anecdotal testimonials, instrument
development, and research.
From The University of Texas at Austin School of
Nursing (Ms Rew). Mr Barrow is retired from the
Keller Graduate School of Management, Chicago, Ill.
Corresponding author: Lynn Rew, EdD, RN, AHN-BC,
FAAN, The University of Texas at Austin School of Nurs-
ing, 1700 Red River, Austin, TX 78701 (e-mail: ellerew@
mail.utexas.edu).
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,
68
and apply-
ing intuition to nursing management.
9,10
In
particular, the concept has been addressed
in unique areas of practice such as criti-
cal care,
11
neonatal intensive care units,
12
pediatrics,
13
community health,
14
and psychi-
atric mental health,
15,16
or with specific types
of patients such as those with brain injury
17
and those with dementia.
18
In 1987, we pub-
lished 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 de-
cision making in nursing and neglected in
the nursing literature.
19
A decade later, King
and Appleton
20
wrote a critical review of
the research and rhetoric on the concept
of intuition in nursing. They traced Benners
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 depre-
cate intuition as a valid component of nurs-
ing judgment and practice have done so in the
light of increasing evidence from research.
E15
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E16 ADVANCED IN NURSING SCIENCE/JANUARYMARCH 2007
Intuition is a common topic in other dis-
ciplines. For example, computer searches
for the term yielded 2311 items in Psych-
Info from 1980 to 2006, 1137 in Medline,
and 807 in Educational Resources Informa-
tion Center for the same time period. Psy-
chologists have studied this phenomenon as
a component of making various types of
judgments.
2123
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 Re-
search Center in California provided com-
pelling evidence that both the brain and
the heart are involved in intuitive experi-
ences. 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 ex-
perimental conditions. They concluded from
their analysis that together the brain and heart
receive, process, and decode intuitive or pres-
timulus information. Moreover, they found
significant gender differences, indicating that
women are more attuned to the intuitive in-
formation 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 suffi-
cient 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 compre-
hensive 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 nurs-
ing 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 bene-
fits of a systematic review are that inclusion
and exclusion criteria for the population and
sample are clearly identified, results are quan-
tified, and the process can be replicated. To
assure that the review was comprehensive
as well as systematic, we chose not to de-
limit the starting date for inclusion of pub-
lished literature. The population of literature
we examined included all entries found in
the electronic database of the Cumulative In-
dex 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 se-
lected 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 pri-
marily for nurses rather than interdisci-
plinary in focus)
3. Published in English language
4. Contained intuitionin the title and/ or
abstract and contained intuition as a ma-
jor term
Articles were excluded from scientific re-
view if:
1. Described in the CINAHL as anecdo-
tal, books, book chapters, brief item,
case study, commentary, editorial, the-
ory, philosophy, or any other article not
specified as research.
2. Dissertations.
3. Published in languages other than
English.
4. Published in nonnursing or interdisci-
plinary journals.
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State of the Science E17
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 pop-
ulation and the scientific sample used in this
analysis.
FINDINGS
The percentage of citations that were pub-
lished in peer-reviewed nursing journals de-
clined 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: anec-
dotes, books, book chapters, brief items, case
Table 1. Type of document citing intuition in Cumulative Index of Nursing and Allied Health
literature, 19812006
Frequency (%) by date of publication
Type of article 1981--1985 1986--1990 1991--1995 1996--2000 2001--2005 2006 Total
Anecdote 0 0 9 13 7 0 29
Books 0 0 0 2 0 0 2
Book chapters 0 3 3 1 0 0 7
Brief items 0 0 0 5 9 0 14
Case studies 1 0 3 4 8 0 16
Commentaries 0 0 4 6 4 1 15
Dissertations 0 10 17 18 11 0 56
Editorials 0 2 3 1 7 0 13
Research reports 0 10 25 40 61 4 140
Reviews 0 2 8 10 9 0 29
Unspecified type 5 29 49 92 110 5 290
Totals 6 56 121 192 226 10 611
studies, critiques, reviews, dissertations, ed-
itorials, research reports, miscellaneous or
unspecified types, and those written in lan-
guages other than English. The majority of en-
tries 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 re-
search reports shown in Table 2. Using the
inclusion and exclusion criteria above, 95 re-
search 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 pub-
lished 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 pub-
lished by Rew
2
(Kosowski, 2000; Rew, 1988a,
1988b, 1990, 1991, 2000), 4 studies cited the
description of the intuitive grasp of the ex-
pert published by Benner and colleagues
1,3
(King & Clark, 2002; Leners, 1992; Stock-
hausen, 2006; Welsh & Lions, 2001), and 7
studies cited definitions provided by both
Benner and Rew(Lauri &Salanter

a, 1998; Lin,
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E18 ADVANCED IN NURSING SCIENCE/JANUARYMARCH 2007
Table 2. Scientific data set of intuition in nursing, by research design, setting, and sample size

Study design (number of studies) Setting Sample size


Qualitative descriptive studies (N = 16)
Arslanian-Engoren C. Gender and age bias in triage
decisions. J Emerg Nurs. 2000;26(2):117124.
Urban and
suburban
emergency
departments
12 registered nurses
(RNs)
Carroll E. The role of tacit knowledge in problem solving
in the clinical setting. Nurse Educ Today.
1988;8(3):140147.
5 hospitals,
Australia
610 patients
Cone KJ, Murray R. Characteristics, insights, decision
making, and preparation of ED triage nurses. J Emerg
Nurs. 2002;28(5):473478.
Emergency
department
10 expert nurses
Crandall B, Getchell-Reiter K. Critical decision method: a
technique for eliciting concrete assessment indicators
from the intuition of NICU nurses. Adv Nurs Sci.
1993;16(1):4251.
NICU & ICU 24 RNs
James DC. How do expert labor nurses view their role?
JOGNN. 2003;32(6):814823.
Labor & delivery 54 RNs with 5
years experience
Lin P. Teaching clinical judgment in Taiwan. J Nurs Res.
2003;11(3):159165.
Nursing school
(NS)
10 nursing faculty
McCormack B. Intuition: concept analysis and
application to curriculum development. J Clin
Nurs.1993;2(1):1117.
NS 10 student nurses
Offredy M. The application of decision making concepts
by nurse practitioners in general practice. J Adv Nurs.
1998;28(5):9881000.
Primary
healthcare,
England
20 nurse
practitioners
Rew L. Intuition in psychiatric-mental health nursing. J
Child Adolesc Psych Men Helthc Nurs.
1991;4(3):110115.
Community 16 psychiatric
nurses
Rew L. Intuition in critical care nursing practice. Dim
Crit Care Nurs. 1990;9(1):3037.
Community 25 critical care
nurses
Rew L. Nurses intuition. Appl Nurs Res.
1988a;1(1):2731.
Rew L. Intuition in decision-making. Image J Nurs Sch.
1988b;20(3):150154.
Community 37 registered nurses
Smith SK. An analysis of the phenomenon of
deterioration in the critically ill. Image J Nurs Sch.
1988;20(1):1215.
Hospital 6 critical care
nurses
Walthew PJ. Conceptions of critical thinking held by
nurse educators. J Nurs Educ. 2004;43(9):408411.
NS, New Zealand 12 nurse educators
Welsh I. Evidence-based care and the case for intuition
and tacit knowledge in clinical assessment and decision
making in mental health nursing practice: an empirical
contribution to the debate. J Psych Ment Health Nurs.
2001;8(4):299305.
Psychiatric
hospital
8 staff members
Wikstr om B. Intuition and visual art: student nurses
projection into experiences of elderly women. Aust J
Holistic Nurs. 2002;9(2):2431.
NS, Sweden Student nurses
(continues)
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State of the Science E19
Table 2. Scientific data set of intuition in nursing, by research design, setting, and sample size

(Continued)
Study design (number of studies) Setting Sample size
Grounded theory studies (N = 8)
Andrews T, Waterman H. Packaging: a grounded theory of
how to report physiological deterioration effectively. J
Adv Nurs. 2005;52(5):473481.
Hospital 30 nurses, 7
physicians, and 7
support workers
Cader R. Criteria used by nurses to evaluate
practice-related information on the World Wide Web.
CIN Comp Inf Nurs. 2003;21(2):97102.
University 7 graduate student
nurses Internet
Gray M, Smith LN. The professional socialization of
diploma of higher education in nursing students
(Project 2000): a longitudinal qualitative study. J Adv
Nurs. 1999;29(3):639647.
NS, Scotland 17 nursing students
Grossman SC, Wheeler K. Predicting patients
deterioration and recovery. Clin Nurs Res.
1997;6(1):45467.
Hospital 33 ICU nurses
Hogston R. Evaluating quality nursing care through peer
review and reflection: the findings of a qualitative study.
Int J Nurs Stud. 1995;32(2):162172.
England 18 RNs
McCutcheon HHI. Intuition: an important tool in the
practice of nursing. J Adv Nurs. 2001;35(3):342348.
NS & Health
Agencies,
Australia
262 RNs
Trenoweth S. Perceiving risk in dangerous situations: risks
of violence among mental health inpatients. J Adv Nurs.
2003;42(3):278287.
London 10 mental health
nurses
Young CE. Intuition and nursing process. Holistic Nurs
Pract. 1987;1(3);5262.
7 healthcare
agencies
39 RNs and 2
nonnurses
Phenomenology studies (N = 8)
Beck CT. Perceptions of nurses caring by mothers
experiencing postpartum depression. J Gyn Neonat
Nurs. 1995;24(9):819825.
Private homes 10 mothers
Fernandes JRH. The experience of a broken heart. Crit
Care Nurs Clin N Am. 2005;17(4):319327.
Private homes 10 parents (5
couples)
Kenny C. Nursing intuition: can it be researched? Br J
Nurs. 1994;3(22):11911195.
England 11 nurses with 5
years experience
Kosowski MM. When protocols are not enough: intuitive
decision making by novice nurse practitioners. J
Holistic Nurs. 2003;21(1):5272.
Educational
program
10 novice nurse
practitioners
Meehan DR. Mothering a 3- to 6-year-old child with
hemiparesis. J Neuro Nurs. 2005;37(5):265271.
Community 5 mothers
Minick P. The early recognition of patient problems
among medical-surgical nurses. Medsurg Nurs.
2003;12(5):291297.
Urban hospital 14 RNs
Ohrling K. Student nurses lived experience of
preceptorship. Part 1in relation to learning. Int J
Nurs Stud. 2000;37(1):1323.
University NS,
Sweden
17 student nurses
Turkel MC. A journey into caring as experienced by nurse
managers. Int J Hum Caring. 2003;7(1):2026.
Hospital 6 nurse managers
(continues)
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Table 2. Scientific data set of intuition in nursing, by research design, setting, and sample size

(Continued)
Study design (number of studies) Setting Sample size
Ethnography studies (N = 4)
Bailey PH, Colella T, Mossey S. COPD-intuition or template:
nurses stories of acute exacerbations of chronic
obstructive pulmonary disease. J Clin Nurs.
2004;13(6):756764.
Canada 10 nurses
King L, Clark JM. Intuition and the development of
expertise in surgical ward and intensive care nurses. J
Adv Nurs. 2002;37(4):322329.
4 surgical wards
and 2 ICUs,
England
61 nurses
Leners DW. Intuition in nursing practice: deep
connections. J Holistic Nurs. 1992;10(2):137153.
Regional Medical
Center, Colorado
40 nurses
Stockhausen L. M etier artistry: Revealing
reflectionin-action in everyday practice. Nurse Educ
Today. 2006;26(1):5462.
3 Universities
Acute Care
Wards, Australia
11 RNs and 40
students
Methodological studies (N = 5)
Lauri S, Salantera S. Decision-making models in different
fields of nursing. Res Nurs Health. 1998;21(3):443452.
15 Health Facilities,
Finland
500 nurses
Miller VG. Characteristics of intuitive nurses. West J Nurs
Res. 1995;17(3):305316.
Community, Texas 228 registered
nurses
Miller VG. Measurement of self-perception of intuitiveness.
West J Nurs Res.1993;15(5):595606.
Community, Texas 228 registered
nurses
Rew L. Acknowledging intuition in clinical decision
making. J Holist Nurs. 2000;18:94108.
Community 218 registered
nurses
Smith AJ, Thurkettle MA, dela Cruz FA. Use of intuition by
nursing students: instrument development and testing. J
Adv Nurs. 2004;47(6):614622.
National 20 senior students
and 349 BSN &
ADN students
Delphi survey studies (N = 2)
Panniers TL, Walker EK. A decision-analytic approach to
clinical nursing. Nurs Res.1994;43(4):245249.
National 31 staff nurses
Scheffer BK. A consensus statement on critical thinking in
nursing. J Nurs Educ. 2000;39(8):352359.
9 Countries 55 expert nurses
Correlational studies (N = 2)
Polge J. Critical thinking: the use of intuition in making
clinical nursing judgments. J NY State Nurses Assoc.
1995;26(2):49.
Critical care 179 RNs
Ruth-Sahd LA, Hendy HM. Predictors of novice nurses use
of intuition to guide patient care decisions. J Nurs Educ.
2005;44(10:450458.
Nursing schools 323 student
nurses
*NICU indicates neonatal intensive care unit; ICU, intensive care unit; and NS, not significant.
2003; Miller, 1993, 1995; Minick, 2003; Polge,
1995; Ruth-Sahd, 2005). Walthews (2004) ex-
ploration of nurse educators critical thinking
was based on a definition of intuition by John
Dewey. The remaining 6 authors defined intu-
ition 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
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State of the Science E21
Table 3. Definitions of intuition in scientific data set of intuition in nursing practice and edu-
cation, arranged chronologically
Investigators (date) Definition of intuition
Young (1987) Clinical intuition is defined as a process whereby the nurse knows
something about a patient that cannot be verbalized, that is
verbalized with difficulty or for which the source of knowledge
cannot be determined.
(pp5253)
Kenny (1994) Cognitive intuitive experiences are initially low key, as the thinker
quietly draws together the various threads of theory in order to
understand.
(p1192)
Offredy (1998) Intuition is an individuals opinion justified by their authority of
experience.
(p992)
Scheffer et al (2000) Intuition: insightful sense of knowing without conscious use of
reason.
(p358)
McCutcheon et al (2001) . . .knowledge, expertise and experience are mutually dependent and
have mutual and reciprocal effects, as well as interacting to yield an
effect greater than their sum, referred to as syner gy. The synergy
that occurs through the interaction of knowledge, experience and
expertise results in intuition and is the core category that links the
other categories.
(p345)
Smith et al (2004) Intuition was conceptualized as a non-linear process of knowing,
perceived through emotional and physical awareness or through the
making of connections at the physical andor spiritual level
(p615)
& 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 de-
sign: 16 qualitative description (broadly de-
fined), 8 grounded theory, 8 phenomenology,
and 4 ethnography. Five studies were method-
ological, describing instrument development,
2 used Delphi surveys, and 2 were correla-
tional. 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 man-
agers to 56 staff nurses. Specialty groups
that were sampled included critical care
nurses, emergency department nurses, post-
operative nurses, labor nurses, mental health
and psychiatric nurses, home health nurses,
nurse practitioners, and nursing faculty. The
methodological and correlational studies in-
cluded larger samples ranging from 179 crit-
ical care nurses to a random national sample
of 349 senior baccalaureate and associate de-
gree nursing students. Seven researchers sam-
pled 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 set-
tings or nursing specialties, including public
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E22 ADVANCED IN NURSING SCIENCE/JANUARYMARCH 2007
hospitals (Carroll), home health (Rew, 1988),
critical care settings (Smith; Rew, 1990), and
psychiatric nursing (Rew, 1991). Others were
designed to describe and examine hownurses
and nurse practitioners (Offredy) made de-
cisions in special areas such as the neona-
tal intensive care unit (Crandall), emergency
department, and labor. Others were descrip-
tions 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 clini-
cal settings. It is interesting that in the study
of teaching clinical judgment in Taiwan, Lin
and colleagues noted that owing to differ-
ences 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 sev-
eral aspects of nursing that included exam-
ining how intuition was perceived (Young),
used and affected practice (McCutcheon &
Pincombe), how mental health nurses incor-
porated intuition to assess risk in crisis situa-
tions (Trenoweth), how nurses used cues to
determine whether the patient was deterio-
rating (Andrews and Waterman) or recovering
(Grossman & Wheeler), and how nurses eval-
uate 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 pro-
fessionally socialized. Caders 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 theo-
retical links with diagrams (Andrews, Gray,
McCutcheon, & Trenoweth). Grays theory,
however, was a theory of how nursing stu-
dents progress toward the staff nurse role and
indicated that mentoring facilitated the de-
velopment of intuition within this process.
Limitations of these studies included conve-
nience 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 pro-
grams were used for data management and
reduction. Again, these researchers empha-
sized the need for further studies that include
clearer articulation of intuition as a compo-
nent of clinical practice and strategies for
teaching students and novice nurses to vali-
date 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 per-
spective on the development of nurses in-
tuitive thinking (Kenny), the meaning of
caring among nurses whose patients had
postpartum depression (Beck), a study of
students lived experience of having a pre-
ceptor (Ohrling), how novice nurse prac-
titioners used intuition in making clinical
decisions (Kosowski), early problem recog-
nition by medical-surgical nurses (Minick),
and the experience of caring by nurse man-
agers (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 phe-
nomena of how parents experienced having
a child with congenital heart disease (Fernan-
des) and how mothers described their ex-
periences with young children with hemi-
paresis following a stroke (Meehan). In both
of these studies, the researchers emphasized
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State of the Science E23
that nurses needed to trust and respect par-
ents intuitions about their ill children.
Ethnographic studies
The 4 ethnographic studies, published
from 1992 to 2006, were conducted to ex-
plore how nurses use intuition in complex
clinical practice settings. Leners concluded
from observing nurses and listening to them
describe their intuitive experiences and asso-
ciated feelings that intuition was a manifes-
tation of caring, which is the moral ideal of
nursing. King found that nurses needed to
recognize both intuition and analysis in mak-
ing clinical decisions, and Bailey and col-
leagues concluded fromanalyzing nurses nar-
ratives that patient care environments are
often very complex with subtle changes that
call for using intuition as a component of clin-
ical judgment. Stockhausen reported an un-
expected finding from a larger ethnographic
study of teaching undergraduate nursing stu-
dents in Australia. This investigator concluded
that nurse educators need to consider new
ways of helping students reflect on their prac-
tice to develop further the inherent artistry in
that practice.
Methodological studies
Five of the studies were methodological
and focused on the development of instru-
ments to measure some aspect of intuition in
nursing. Two reports (Miller, 1993, 1995) con-
cerned the Miller Intuitiveness Instrument,
which was designed to measure a nurses per-
ceived intuitiveness. Lauri and Salanter

a de-
veloped an instrument for Finnish nurses to
identify their decision-making models in a va-
riety of clinical settings. Rews Acknowledge-
ment of the Use of Intuition in Nursing in-
strument was designed to measure the use of
intuition by nurses in clinical decision mak-
ing. The fifth report was of an instrument
for measuring the use of intuition in nurs-
ing students (Smith and colleagues). Each of
these studies included a rigorous description
of item development and psychometric test-
ing, and all the instruments were found to be
valid and reliable. Further studies were recom-
mended to provide additional evidence of the
validity of these tools, and authors urged oth-
ers to develop and use instruments to mea-
sure 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 deci-
sion making in nursing and the nature of crit-
ical thinking. The purpose of Panniers and
Walkers study was to explore how useful
nurses found a decision analysis process in
dealing with a complex emergent problem.
The researchers concluded that decision anal-
ysis allows nurses to quantify their intuitive
choices and document and incorporate them
in practice. The aim of Scheffers study was to
define critical thinking and focused on input
from a panel of expert nurses from 9 coun-
tries and 23 states in the United States. Results
were a consensus definition of critical think-
ing in nursing and 10 habits of the mind, one
of which was intuition.
Correlational studies
Polges descriptive correlational study was
based on Benners
1
model of novice to ex-
pert. The purpose of the study was to exam-
ine the relationship between using intuition
in making clinical judgments and attributes of
the nurse, including years of experience and
clinical proficiency. Findings supported Ben-
ners model with nurses increasing the use
of intuition with increases in years of expe-
rience and proficiency. The study conducted
by Ruth-Sahd and Hendy was similar but sam-
pled novice nursing students and incorpo-
rated 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 Millers 1995 article as instrument
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E24 ADVANCED IN NURSING SCIENCE/JANUARYMARCH 2007
development, this author also included corre-
lations as part of the validation process and
confirmed that nurses who perceived them-
selves 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
nursing
2
and on Benners conceptualization
of nursing expertise.
1,3
DISCUSSION
Despite the systematic nature of this re-
view, we acknowledge that there were lim-
itations. 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 phe-
nomenon. Because we limited our review to
papers published only in English, we may
have missed a broader international perspec-
tive 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 stud-
ies were based on Benners conceptualization
of novice to expert
1
and Rews
2
defining at-
tributes, 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 intu-
ition, but researchers have generally found it
difficult to assess and measure in a quanti-
tative way that would support comparisons
across disciplines or environments. Many of
the researchers acknowledged the limitations
of their studies that included difficulty in ar-
ticulating subjective experiences.
It is promising that there are at least 3 valid
instruments measuring various aspects of in-
tuition. 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 per-
ceived 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 re-
search indicates that nurses value their intu-
ition in a variety of clinical settings. Several
of the studies provide support for Benners
1
work indicating that intuitive experiences in-
crease with experience and expertise. Re-
searchers continue to affirm that intuition
should be combined with objective, empiri-
cal evidence when evaluating a patients con-
dition and in planning care. They also af-
firm 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 re-
mains 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 recom-
mendations for further study are that the next
generation of research should move beyond
description, be based on representative sam-
ples of nurses and nursing students, and in-
clude physiologic measures as correlates of
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State of the Science E25
subjective experiences. We also recommend
that nurses collaborate with members of
other disciplines such as psychology, educa-
tion, and medicine to design more complex
studies that will further our understanding of
this unique phenomenon.
CONCLUSION
The nursing discipline is complex and re-
quires that its members apply knowledge and
skills in a variety of settings. Nurses under-
stand and define intuition as a way of know-
ing something immediately as a whole that
improves with experience, informs their judg-
ments and decisions, and leads them to take
action within the caring relationship. Fur-
ther interdisciplinary study is needed to ex-
pand the state of this science and art. Intu-
ition remains a hallmark of nursing knowl-
edge, but no longer neglected in nursing
literature.
REFERENCES
1. Benner P. From Novice to Expert. Menlo Park, Calif:
Addison-Wesley; 1984.
2. Rew L. Intuition: concept analysis of a group phe-
nomenon. Adv Nurs Sci. 1986;8(2):2128.
3. Benner P, Tanner C. Clinical judgment: how expert
nurses use intuition. Am J Nurs. 1987;87:2331.
4. Bartol GM. A study of the meanings assigned to
the term psychosomatic among health professionals.
Persp Psych Care. 1995;31(1):2429.
5. Gerrity PL. Perception in nursing: the value of intu-
ition. Holist Nurs Pract. 1987;1(3):6371.
6. Blomquist KB. Evaluation of students intuition is im-
portant. Nurse Educ. 1985;10(6):811.
7. Miller VG, Rew L. Analysis and intuition: the
need for both in nursing education. J Nurs Educ.
1989;28(2):8486.
8. Ruth-Sahd LA. Intuition: a critical way of knowing in
a multicultural nursing curriculum. Nurs Educ Per-
spect. 2003;24(3):129134.
9. Barker AM, Young CE. Transformational leadership:
the feminist connection in postmodern organiza-
tions. Holist Nurs Pract. 1994;9(1):1625.
10. Davidhizar R. Intuition and the nurse manager.
Healthc Superv. 1991;10(2):1319.
11. Arries E, Botes A, Nel E. Concept analysis of intuition.
Curationis. 1999;22(3):8899.
12. Bosque EM. Symbiosis of nurse and machine through
fuzzy logic: improved specificity of a neonatal
pulse oximeter alarm. Adv Nurs Sci. 1995;18(2):67
75.
13. Winland-Brown JE, Maheady DC. Using intuition to
define homesickness at summer camp. J Ped Health
Care. 1990;4(3):117121.
14. Crow R, Spicer J. Categorisation of the patients med-
ical conditionan analysis of nursing judgement. Int
J Nurs Stud. 1995;32(5):413422.
15. Fahy P. Autonomy and decision making in com-
munity psychiatric nurses. Int J Psych Nurs Res.
1994;1(2):4149.
16. Godin PM. You dont tick boxes on a form: a study
of how community mental health nurses assess and
manage risk. Health Risk Soc. 2004;6(4):347360.
17. Alverzo J. The use of aethetic knowledge in the
management of brain injury patients. Rehabil Nurs.
2004;29(3):8589.
18. Athlin E, Norberg A, Asplund K. Caregivers percep-
tions and interpretations of severely demented pa-
tients during feeding in a task assignment system.
Scand J Caring Sci. 1990;4(4):147155.
19. Rew L, Barrow EM. Intuition: a neglected hallmark
of nursing knowledge. Adv Nurs Sci. 1987;10(1):49
62.
20. King L, Appleton JV. Intuition: a critical review of the
research and rhetoric. J Adv Nurs. 1997;26(1):194
202.
21. Kardes FR. When should consumers and man-
agers trust their intuition? J Consumer Psych.
2006;16(1):2024.
22. Bolte A, Goschke T. On the speed of intu-
ition: intuitive judgments of semantic coherence
under different response deadlines. Mem Cogn.
2005;33(7):12481255.
23. Piha H. Intuition: a bridge to the coenesthetic
world of experience. J Am Psychoanal Assoc.
2005;53(1):2349.
24. Highleyman L. A guide to clinical trials. Part II: in-
terpreting medical research. BETA Bull Exper Treat
AIDS. 2006;18(2):4147.
25. Hamdan M. Nonlinear learning of linear algebra: ac-
tive learning through journal writing. Int J Math
Educ Sci Tech. 2005;36(6):607615.
26. McCraty R, Atkinson M, Bradley RT. Electrophysiolog-
ical evidence of intuition: part 1. The surprising role
of the heart. J Alt Compl Med. 2004;10(1):133143.
27. McCraty R, Atkinson M, Bradley RT. Electrophysio-
logical evidence of intuition: part 2. A system-wide
process? J Alt Compl Med. 2004;10(2):325336.
28. Stumbo NJ. Systematic reviewpart I: howto conduct
systematic reviews for evidence based practice. Ann
Ther Recreation. 2003;12:2942.