N U R S I N G T H E O R Y A N D C O N C E P T D E V E L O P M E N T O R A N A LY S I S

Informational basis for expert intuition

Judith A. Effken PhD RN
Assistant Professor, University of Arizona College of Nursing, Tucson, Arizona, USA

Submitted for publication 14 July 2000

Accepted for publication 7 December 2000

Correspondence: E F F K E N J .A . ( 2 0 0 1 )
Journal of Advanced Nursing 34(2), 246±255
Judith Effken, Informational basis for expert intuition
University of Arizona College of Nursing, 1 Aim. Intuition has been cited as an integral part of nursing clinical expertise.
PO Box 210203, Tucson,
Responding to the recent scholarly debate over the status of expert nursing intuition
AZ 85721±0203,
as part of the art or science of nursing, this article proposes an alternative view that
USA.
E-mail: jeffken@nursing.arizona.edu
may provide an informational basis for what has been described phenomenolog-
ically as intuition.
Rationale. Two reasons for the dispute over the status of nursing intuition as `art' or
`science' are proposed: The ®rst is methodological. The second relates to intuition's
close link with perception and underlying assumptions about perception. By
examining intuition through an ecological psychology framework, the problem
takes on a different character, one that is no longer focused solely on the expert's
cognitive (or perceptual) processes, but also on the information provided by the
patient and the context of care.
Conclusions. This perspective has several implications for nursing. By investigating
information sources (i.e. higher order variables or constraints) in the nurse-patient
encounter, the problem of intuition may be clari®ed, and perhaps simpli®ed. We
may ®nd that what nurse researchers have called `intuition' is what Gibson (1966,
1986) termed `direct perception.' Intuition as direct perception is information-based
and lawful. Finally, although some aspects of intuition may be hard-wired through
evolution, intuition as direct perception can be developed through education and
extensive, deliberate practice with appropriate exemplars. Characterized as direct
perception, intuition is an observable, lawful phenomenon that is measurable,
potentially teachable, and appropriately part of nursing science.

Keywords: intuition, expertise, perception, ecological psychology, expertise, infor-

mation, nursing science, nursing art, theory, measurement

re¯ective practice (Clarke 1986, Paul & Heaslip 1995,

Introduction
Recently, the role of intuition in nursing practice has become
a subject of considerable debate (English 1993, Darbyshire
2 1994, Johnson 1994, Paley 1996). On the one hand, intuition
has been identi®ed as a key component of nursing expertise
(e.g. Benner 1984, Agan 1987, Rew & Barrow 1987, Benner
3 et al. 1996). Proponents assert that experts' intuition is not a
magical sixth sense, but a sophisticated form of reasoning
(Preitula & Simon 1989) acquired through years of deliberate
practice (Ericsson 1996) and that it plays a critical role in
Berragan 1998). Others argue that intuition is subjective,
nonscienti®c, unmeasurable, and perhaps unteachable.
Indeed, English (1993) has called intuition a `subjective and
questionable entity and hence, until empirically and unequi-
vocally validated, [one that] has limited applicability in a
nursing profession which is attempting to develop a research
base to support its actions' (p. 390). Consequently, intuition
is more often included in the `art' than the `science' of nursing
(Pyles & Stern 1983, Gordon 1986, Rew & Barrow 1987,
Hampton 1994, Johnson 1994, Johnson 1996a, b). In an

246 Ó 2001 Blackwell Science Ltd

Nursing theory and concept development or analysis
attempt to reconcile the intuitive-humanist research approach
of Benner with the more traditional systematic-positivist
research approach, some have argued for the two approaches
as different ways of knowing (e.g. Berragan 1998) or as two
poles of the clinical decision making continuum (e.g.
Thompson 1999).
One reason for the ongoing dispute is methodological.
Although the intuitive component of nursing expertise
has been described phenomenologically (e.g. Benner 1984,
Benner & Tanner 1987, Hanneman 1996), structured meas-
urement has been elusive because of the complexity of the
domain and the degree to which skill is embedded in a
particular situation. Given the measurement dif®culty, nurse
empiricists who assume that `to be observable requires that
measurement is possible' (Gortner 1990, p. 104) will have
dif®culty accepting intuition as a key aspect of nursing
science. For empiricists, a careful description of a phenom-
enon must be followed by measurement if scientists are to
achieve a predictive or causal level of understanding.
However, recently many complex systems (e.g. cardiac
dysrhythmias) have proved amenable to measurement and
prediction using new techniques (e.g. nonlinear dynamics or
methods derived from chaos theory) (Kasper 1996).
A second reason for the dispute, but perhaps unrecognized,
is intuition's link with perception. Of the six key aspects of
intuitive judgement (Dreyfus & Dreyfus 1986) that Benner
and colleagues have observed in expert nurses, three (pattern
recognition, similarity recognition, and sense of salience) are
well-known perceptual skills, suggesting that the essence of
intuition is perception, or `perceptual knowing.' In tradi-
tional views of perception, the initial stimulus is discrete and
without meaning. It is up to perceivers to select relevant
stimuli, integrate the stimuli, and assign meaning based on
previous knowledge. This perception requires that people
have considerable foreknowledge and ultimately leads to an
in®nite regress. However, Gibson (1966, 1986) provides an
alternative view in which perception is characterized as the
direct detection of environmental information ± complex
relationships and patterns that are inherently meaningful. If
the essence of intuition is perceptual knowing in the Gibson
sense, we may have a reason to argue that intuition is, in fact,
more science than art.
I propose that: First, expert nursing intuition is a form of
what Gibson (1986) termed `direct perception' and therefore
is information-based and lawful. Second, although some
aspects of direct perception are hard-wired through evolution,
much of perception, and by extension, intuition, is learned
through years of practice. Third, ecological psychology may
serve as a theoretical and methodological bridge between the
phenomenological and empiricist paradigms.
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(2), 246±255
Expert intuition
Intuition as the essence of nursing expertise
In the 1980s, nursing expertise became a popular topic of
investigation, stimulated by Benner's (1984) phenomenolog-
ical study of clinical expertise. Expert practice is character-
ized by a speci®c mode of thinking evolved from the merger
of knowledge, skill and experience (Benner & Tanner 1987,
Field 1987). This mode of thinking enables experts to develop
heuristics for responding to situations without reverting to
overt diagnostic principles (Woolery 1990, Jasper 1994). This
automatic response to situations has been called variously
`intuition' (Benner & Tanner 1987), `tacit knowledge'
(Polanyi 1958), `perceptual awareness' (Field 1987), `know-
4 how' (Gatley 1992), `artistry' (Meerabeau 1992), and `term
association' (Broudy et al. 1964).
The de®nitions of intuition in Table 1 capture the imme-
diacy and holistic character of perceptual knowledge, as well
as its accuracy; but they are notably vague on its informa-
tional basis, calling it `consensually inadequate' (Westcott
1968), `subconscious' (Agan 1987), or `undetermined'
(Young 1987). From these de®nitions, one may conclude
that intuition is rather magical and more art than science.
5 However, Benner and Tanner (1987) claims that the essence
of intuition is recognition of previously experienced patterns
and detection of subtle clinical changes. This suggests that
patient information (patterns of x; subtle changes in y) exists
on which nurses base their clinical judgements. Hanneman
(1996) provides a useful example:
He was banging the side rails, making gurgling sounds and pointing to
his endotracheal tube. He was diaphoretic, gasping, and frantic. The
[nonexpert] nurse put her hand on his arm and tried to ascertain
whether he had a sore throat from the tube. While she was away from
the bedside retrieving an analgesic, the expert nurse strolled by,
hesitated, listened, went to the man's bedside, rein¯ated the endo-
tracheal cuff, and accepted the patient's look of gratitude because he
was able to breathe again. The expert reviewed the signs of a leaky
cuff with the nonexpert and pointed out that banging the side rails and
panic help differentiate acute respiratory distress from pain (p. 333).
In Hanneman's example, the basis for the expert's perform-
ance seems neither undetermined nor subconscious. The
expert nurse situates her general clinical knowledge within
the context of a particular patient situation (cf. Perry 2000).
But the difference seems to go beyond incorporating context.
In fact, the expert uses speci®c information to distinguish
pain from acute respiratory distress, but the nonexpert fails to
detect it. Why then has there been so much emphasis on the
nurse's perceptual and conceptual processes (cf. Carper 1978,
Belenky et al. 1986, Wong 1998, Doona et al. 1999, Nelms
& Lane 1999) and so little on identifying the underlying
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J.A. Effken

Table 1 De®nitions of intuition

De®nition Source

Process of reaching accurate conclusions on the basis of consensually inadequate information Westcott (1968)
Nonrational process, based on a feeling or sensing level of knowing, an awareness that Agan (1987)
may come from subconscious data
Process whereby nurse knows something about a patient that cannot be verbalized, that Young (1987)
is verbalized with dif®culty, or for which source of knowledge cannot be determined
Knowledge as a whole, immediacy of knowledge, and independent of linear reasoning; inner Rew (1988)
knowing, sensing/feeling/perceiving, and strength of feeling that affects perception
Black-market version of knowledge. Accurate to call such observations skilled pattern Benner and Tanner (1987)
recognition. Intuitive knowledge ± that is, understanding without a rationale, based
on background understanding and skilled clinical observation
Perception of possibilities, meanings and relationships by insight Gerrity (1987)
Universal characteristic of human thought; creativity begins with intuition and is only later Bastick (1982)
shaped by reason
Understanding that effortlessly occurs upon seeing similarities with previous experiences Dreyfus and Dreyfus 1986
Not guessing, but predicated on sound knowledge and experience Schraeder and Fischer (1987), Young 1987
Sophisticated reasoning acquired by expert after years of learning Preitula and Simon (1989)
Immediate knowing of something without using conscious reason Schraeder and Fischer 1987
Speci®c mode of thinking evolved from merger of knowledge, skill and experience Benner and Tanner (1987), Field (1987)
Innate knowledge; immediate cognition, instinct, insight, guesswork, sixth sense, Rew (1996)
understanding, reason, intellect, soul, mind, acumen, presentiment, foreknowledge,
inspiration, feeling
Direct knowing without conscious reasoning; immediate understanding Rew (1996)
Perceptual awareness Field (1987)
Artistry Meerabeau (1991)
Term association Broudy et al. (1964)
Ability to discern a situation without physical evidence and still decide on appropriate action Hansten and Washburn (2000)
Clinical; sensing; based on experience, on accumulated knowledge, not always supported Hansten and Washburn (2000)
by logical evidence; a gut feeling
Observation of subtle nonverbal cues and changes in patient's normal pattern of behaviour Beck (1998)
Tacit knowledge Polanyi (1958)
Understanding without a rationale. Neither mystical nor accidental human capacity. Benner and Tanner (1987)
What distinguishes expert human judgement from a beginner's or a machine's judgement.

environmental information sources that support intuition?
The answer may lie in researchers' assumptions about
perception.
Traditional theories of perception
Traditional theories of perception assume that our senses
receive an impoverished description of the world that must be
elaborated cognitively to arrive at a meaningful perception
(Gregory 1978, Hochberg 1978). As Neisser (1967) describes
the problem related to visual perception,
These patterns of light at the retina are¼ one-sided in their perspective,
shifting radically several times each second, unique and novel at every
moment. [They] bear little resemblance to either the real object that
gave rise to them or to the object of experience that the perceiver will
construct. Visual cognition, then, deals with the processes by which a
perceived, remembered, and thought-about world is brought into
being from as unpromising a beginning as the retinal patterns (pp. 7±8).
It is commonly assumed that the energy media, that are the
source of the proximal stimulus for perception (e.g. the retinal
patterns Neisser describes), cannot convey meaningful infor-
mation about the world because they are not speci®c to the
important properties of the world (objects, clinical problems,
etc.). Consequently, perceivers must have some cognitive
means of making these stimuli meaningful. This is the
underlying assumption of expertise theories that posit schemas
or stored memories as a basis for interpreting sensory data.
Cognitive science assumes that people process data as a
discrete series of sequential computations, but it is dif®cult to
explain the ¯exibility of experts within this paradigm. If
understanding requires linking discrete sensory elements or
®tting the input into an existing schema, how does ¯exibility
enter the picture? It is hard to imagine how memory can play
a role in our ability to deal with previously unseen patient
problems (cf. Shaw & Bransford 1977). Interestingly, robo-
ticists encountered the same problem when they wanted to

248 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(2), 246±255
 Nursing theory and concept development or analysis
design robots that could function in novel surroundings.
Their usual approach, programming the robot with a prede-
®ned solution, no longer worked (Effken & Shaw 1992).
Without adaptive reasoning, the robots could operate
successfully only in well-de®ned, already known domains.
As a basis for expert knowledge, traditional views of
perception are troubling: If the energy media that are the
sources of our sensory data (e.g. Neisser's description of the
retinal image) are not speci®c to facts in the world, how can
we know that what we perceive accurately depicts reality? If
learning is essentially a process of concatenating previously
learned steps into a procedure or ®tting them into a schema,
then how do we explain expert performance in which
procedures learned in school are abandoned in favour of a
completely new solution? If this is the kind of `perceptual
knowing' that is the essence of expert intuition, then it may
be dif®cult to construe it as part of nursing science. However,
there is an alternative theory of perception that can change
the way we think about intuition.
The ecological view of perception
Gibson (1966, 1986) developed his theory of perception to
explain the practical success with which people ordinarily get
along in the world. Gibson's theory has been extended by
20 years of theoretical elaboration and testing in what has
come to be called ecological psychology (e.g. Shaw &
Bransford 1977, Turvey 1977, Turvey & Shaw 1979, Turvey
et al. 1978, 1981, Shaw & Turvey 1981, Warren & Shaw
1985, Kugler & Turvey 1987). In this view, the information
available to a perceiver can be characterized as higher-order
variables (i.e. patterns of persistence and change that occur
throughout an ongoing sequence or ¯ow of environmental
stimulation). These higher-order variables, or `affordances',
do not need to have meaning added by an observer, but are
themselves inherently rich and meaningful (Gibson 1986).
`The affordances of the environment are what it offers
animals, what it provides or furnishes, either for good or ill'
6 (Gibson 1986). Put simply, `an affordance is what the
environment means to a perceiver' (Michaels & Carello
1981, p. 42). Which affordances we see depends on the task
at hand and the salience of the available information for
accomplishing that task (Kosslyn 1994). Thus, affordances
are written in the language of action: Chairs afford sitting on,
cups afford drinking, and patients in pain afford opportun-
ities for pain management.
However, affordances can remain opportunities for action
that go unrealized unless the perceiver has the requisite
biological or social capability (effectivity) to distinguish and
execute the affordance (Turvey & Shaw 1979, Shaw &
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(2), 246±255
Expert intuition
Turvey 1981, Shaw & Kinsella-Shaw 1988). Unless a nurse
has the capability to help the patient manage her pain, the
opportunity to do so may go undetected. The detection of
affordances (opportunities for action) is further constrained
by observers' goals and values (cf. Hodges & Baron 1992,
Dreyfus 1993). For example, when a radiologist's goal is to
explain a patient's shoulder pain, she may see the damaged
rotator cuff but fail to notice the mass in the patient's lung.
Recently, I was fascinated by the response of visitors to
several large hassocks in a hospital lobby. Two female
visitors found the hassocks comfortable places to sit. A nurse
pushing a man in a wheelchair avoided the hassocks as
obstacles to navigation. A child found the hassocks a source
of entertainment; they could be run around, climbed on, or
used as a table. Each person had goals and capabilities that
in¯uenced the affordances they detected. Affordances, then,
emerge from the compatibility (or ®t) of perceiver and
environment. It is assumed that this ®t is the result of
coevolution of an animal and its environment (Henderson
1970), as well as the result of learning of the environment by
the animal. For example, humans are hard-wired from birth
to be sensitive to environmental features crucial for their
survival (e.g. smiles and mothers' nipples) (Dreyfus 1993).
Evolution prepares the organism to learn about its envi-
ronment (genetic preattunement), but the organism becomes
attuned to discriminate the speci®cs of its surrounding and
make ®ner adjustments in control through learning (Gibson
1966). Thus, experts are not `mass-storage devices' that must
maintain an ever-increasing number of rules to select and
combine relevant data in memory. Instead, experts are
`special-purpose devices' that have learned through vast
experience to be sensitive to `the relevant [higher order]
dimensions of information that somehow bring new
constraints to bear on the system and, thereby, reduce its
excess degrees of freedom' (Kugler 1985, p. 323). Runeson
(1977) provides a useful metaphor for expertise as special-
purpose device ± the polar planimeter. Here's how it works:
Suppose I want to build a free-form swimming pool and
need to estimate its cost. To calculate the pool's cost, I need to
measure its area. Multiplying length by width is impossible
because of the irregular shape, but I can use a polar planimeter
to measure the area easily. I simply place the pole at any spot
within the pool's outline and trace the perimeter with the arm.
As the wheel under the carriage turns and slides, the dial
displays the area. Although the planimeter calculates area (a
higher order variable) accurately, there is no way to extract
length or width (the lower level properties). Explaining how
experts perceive complex, higher order variables but can't
report accurately the underlying lower order properties has
been dif®cult. However, if experts are actually `smart devices'
249
J.A. Effken
that have learned to detect higher order variables directly,
they may not have access to lower order properties that
didn't enter into the solution (Michaels & Carello 1981).
A colleague of mine whose expertise is in the care of
newborns told me that expert clinicians in that domain
evaluate babies' earlobes to assess their overall oxygenation
status ± not something that we commonly teach our students
to assess. Operating as a `smart device', the expert neonatal
nurse may not be able to describe the underlying values
(colour, capillary ®lling, etc.) or physiological constraints on
the baby's earlobe characteristics that led her to a particular
judgement about the baby's health status. Similarly, oper-
ating as a `smart device', the nurse who detects that
something has changed with a patient but cannot speci®cally
describe the values that have changed may be identifying the
changes in a complex, or composite variable ± or even the
rate of change in that complex variable. Perceptual
psychology has shown that people are remarkably good in
detecting change, as well as changes in the rate of change.
Invariants: higher order variables that specify
the environment
If perception is to portray reality accurately, then the energy
patterns that serve as stimuli for perception must specify
environmental facts accurately. This speci®cation cannot
occur through discrete stimuli, for they are constantly
changing. Ecological psychology claims that speci®cation
occurs through `patterns of stimulation over time and/or
space that are left unchanged [or invariant] by certain
transformations' (Michaels & Carello 1981). Growth is a
pattern of change (i.e. a higher order variable) in which the
relationship of the various body parts remains relatively
stable; although the actual values of arm length, nose length,
etc. change dramatically.
Johansson (1973) provides an elegant example that
depends on these kinds of relationships. Johansson attached
lights to the major joints (shoulder, hip, etc.) of actors who
were dressed in black and photographed in the dark so only
the lights were visible to an observer. When observers viewed
the point light display of a stationary or moving human
®gure, the stationary ®gure appeared to be a random set
of points, but the moving ®gure was immediately identi®ed
as a person walking. Subsequent research has shown that
patterns created by point light displays can specify the
heaviness of an object to be lifted or the kind of activity in
which the actor is engaging.
Research by Shaw and colleagues (e.g. Pittenger & Shaw
1975, Mark et al. 1988, Kim et al. 1995) provides a second
example. The researchers wondered how we recognize an old
250 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(2), 246±255
friend (now age 25 years), despite not having seen him since
he was 15-year-old. The research showed that growth is an
abstract style of change that remains constant despite changes
in facial features. Subjects were able to judge relative age
accurately when the style of change was applied to facial
pro®les of humans, birds and even Volkswagen `beetles.' In
disease conditions, some patient characteristics change;
others remain stable. If this were not the case, we would be
hard put to recognize a patient from one encounter to the
next. Similarly, speci®c disease characteristics have charac-
teristics in common that allow us to diagnose the disease
process despite its being instantiated in a variety of human
beings of various size, gender, race, and age.
Ecological psychologists have begun to identify the higher
order variables that underlie many skilled behaviours
(Chapman 1968, Lee 1976, Lee et al. 1982, Michaels &
Oudejans 1992, Berg et al. 1994). Others have identi®ed
higher order variables in the social domain (Thines et al.
1991). Still others (Vicente & Rasmussen 1990, 1992, Gaver
7 1993a, b, 1996, Effken et al. 1997) have identi®ed higher
order variables in complex domains (e.g. haemoodynamic
monitoring and thermodynamic systems) and used these as a
basis for computer interface design.
Prospective control: the basis of experts' ¯exibility
People use the information available in their surroundings
and in themselves to control their actions both retrospectively
8 and prospectively (Suchman 1987, Kim & Turvey 1998). In
many situations, operating solely on retrospective control is
largely impossible (Turvey 1992). For example, to provide
patients with effective pain control, anticipatory control is
crucial. Clinicians must recognize possible intervention
options and the constraints the patient might impose on
those interventions before making an informed decision
about what care to provide and when to provide it., From
the ecological point of view, prospective control requires
perceiving environmental affordances. `The theory of affor-
dances implies that to see things is to see how to get about
among them and what to do or not to do with them' (Gibson
1986, p. 223). Research has shown that there is visual
information (as higher order invariants) available that can be
used to: (a) ensure a gentle contact when you kiss a newborn
baby (b) catch a ball, or (c) adjust your stride to cross a
stream on irregularly spaced stones (Lee 1976, Lee et al.
1982, Warren et al. 1986, Kim & Turvey 1998, Kim et al.
1998a, b). We can assume that the same kinds of visual
information help nurses ensure a soft collision while helping a
new hip transplant patient into a chair, and a hard, but not
too hard, collision when they administer an injection, despite
 Nursing theory and concept development or analysis
patients' very different tissue characteristics. In each case, as
the activity progresses, new information about the patient's
response to the nurse's action guides the nurse to change the
amount and direction of force applied. Experts learn to make
these changes almost effortlessly, partly because they are
better judges of the amount and direction of force needed and
partly because they are so attuned to the response of the
patient. Because of this ongoing cyclical process of seeking
and adapting to relevant new information, ¯exibility is the
rule, not an exception to be explained.
How skill is acquired
The ecological approach to skill acquisition views perceptual
learning as the education of attention (Gibson 1969, 1991).
With experience, people learn the most economical strategy
for the task and focus on identifying and using the minimal
number of variables that will successfully discriminate among
the events of interest. Therefore, skill acquisition (i.e. exper-
tise) involves learning to detect the diagnostic higher order
variables that will facilitate the achievement of task goals
(Vicente & Wang 1998).
My colleagues and I (Effken 1993, Effken et al. 1997) have
found that making higher order variables visible in a
haemodynamic monitoring display improves speed and
accuracy of drug treatment for simple clinical problems for
novices and experts alike, although novices improve more.
For clinicians, being able to detect and use higher-order
variables is crucial because it is the higher order variables
(e.g. speci®c combinations of variables and patterns of
response to therapy) that de®ne speci®c disease states (Pinsky
1998). For example, septic shock and acute cardiovascular
shock both can present with a similar haemodynamic pro®le,
but those pro®les will differ markedly in response to an
intravascular ¯uid challenge.
Unfortunately, identifying the relevant variables is not easy
because the potentially available information is so complex.
Given this complexity, many scientists have rejected the idea
of ®nding an informational basis for intuition (or direct
perception) and have come to regard it as an inferior way of
knowing. However, there seem to be some very simple,
underlying skills (principles or heuristics) that people use to
detect nature's order out of what might seem to be random-
9 ness (Bohm 1969, Rosen 1988). For example, experienced
clinicians are quick to detect an unexpected patient response
to treatment. The basis for these fundamental perceptual
skills, such as the ability to detect breaks in symmetry seems
to be hardwired biologically. But the same, or similar, skills
may also support the kind of experiential learning that
differentiates expert from novice performance.
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(2), 246±255
Expert intuition
The patient care environment is a highly complex domain
in which very subtle changes may provide crucial informa-
tion. However, because these changes are so subtle, it is
unlikely that many of them will be differentiated without
extensive deliberate practice. Shaw and Wilson (1976)
found that a carefully selected set of core cases could
exemplify core concepts or relationships and help students
detect the relevant higher order information. In today's
compressed educational environment, this may be the only
viable alternative for educators who must cover an
increasing amount of information in ever-shorter time spans
and increasingly unpredictable clinical experiences. Recent
research suggests that novices frequently rely on `nonspe-
ci®c' information and experts on `control-speci®c' informa-
tion (Michaels & de Vries 1998, Jacobs et al. 1999). For
example, when estimating the relative mass of colliding
objects, less skilled observers sometimes use variables such
as exit speed (the speeds that occur after impact), scatter-
angles (the angles between the balls' directions before and
after impact), or a combination of the two. These variables
are highly correlated with, but are not speci®c to the balls'
relative mass. However, relative mass of the balls is speci®ed
by the relative amount of motion change. Jacobs et al.
(1999) have shown improvement in novices' detection of the
most speci®c variable, relative amount of motion through
training with sets of test cases that include the dif®cult to
detect, but speci®c, variables. These results suggest that a
similar approach might be used to ensure that students
encounter cases exemplifying core concepts and relation-
ships that they can then apply to a much wider set of cases.
Computer simulations seem particularly relevant here. The
challenges for educators are two: First, identify the crucial
higher order variables (i.e. relationships) in the area to be
taught; second, make those relationships salient for the
student in the simulation (Effken & Kadar 2001). Neither is
easy, but the payoff in terms of generative knowledge that
transfers beyond the immediate situation is well worth the
effort.
Ecological approach to the study of expertise
Although some researchers are now beginning to explore
differing skill levels in natural settings (e.g. Leprohon & Patel
1995), the vast majority of research has focused on experts
doing tightly constrained tasks in a laboratory setting (Patel
& Ramoni 1997). In contrast, Benner, Dreyfus, and their
successors developed their theory in the clinical environment.
Their phenomenological studies have provided a wealth of
descriptive data. However, the complex concepts they have
identi®ed have seemed to defy the kind of measurement
251
J.A. Effken
required to move beyond descriptive to explanatory or
predictive theory. Until such measurement becomes possible,
intuition may not be appreciated as part of the science of
nursing. The ecological approach offers the potential to
bridge these two paradigms.
Additional concepts and methods may be needed to analyse
a nurse-patient system in a natural setting, but some of the
ecological approaches used in other complex, natural
domains are likely to be applicable (Dreyfus 1993, Shaw
et al. 1995). Measuring the transition from a concretely
based novice to an intuitively based expert requires going
beyond global measures of learning outcomes to capture the
underlying dynamic structure of the learning process, prob-
ably in simulated clinical environments. Current computer-
ized control systems and computer-based learning
environments can capture crucial information about the
transition from novice to expert (Effken & Kadar 2001).
However, we may need to rethink our use of metrics as we
analyse those data. Research shows that experts scale envi-
ronmental information, not in terms of an extrinsic, interval
scale metric, but in terms of their own action capabilities (e.g.
Warren 1984, Mark 1987, Warren & Wang 1987), an
intrinsic, ordinal scale metric. Clinicians do the same thing.
When an expert nurse interviews a community-based client
who needs assistance with meal preparation, the expert scales
his assessment data in terms of the available options for
assisted feeding in the community (e.g. meals on wheels,
communal dining, etc.).
Throughout his career, Gibson believed strongly that
`what' precedes `how' (Vicente & Wang 1998). Ecological
psychology therefore begins by observing the phenomenon of
perception, then looking for information that supports it.
Speci®cally, what are the relevant constraints in the environ-
ment, the expert, and the task that result in expert perform-
ance? In contrast to traditional psychology, which tends to
focus on the expert, ecological psychology begins by focusing
on the environmental constraints, which are more permanent.
There is evidence to suggest that when a careful, goal-relevant
analysis of the environment is done, a more parsimonious
description of human performance is possible (Vicente 1995).
My primary research interest is in designing computerized
displays that facilitate clinical information management in
intensive care. Research tells us that to determine what is
wrong with a patient may require a clinician to evaluate over
1500 data points per day (Saba & McCormick 1986). For a
novice, this presents a formidable challenge because each of
those 1500 data points is seen as equally useful and the
relevant relationships between variables are as yet unknown.
ICU ¯owsheets include a myriad of values for parameters
related to the patient's oxygenation, haemodynamic, ¯uid
252 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(2), 246±255
balance, and neurologic status, for example. To assess the
patient's status, we have found that novices commonly
review the sheet from top to bottom. In contrast, experts
focus in on one or two key values; for example, to assess
oxygenation status, experts look at SVO2. If that value is
normal, oxygenation is likely to be adequate for tissue needs.
If not, then the experts evaluate the constraints on SVO2, such
as the relationship between the patient's oxygen delivery and
oxygen consumption (a higher order variable). We are
currently developing computer displays that will make those
underlying constraints visible in ways that facilitate clinical
decision making.
Conclusions
The assumptions underlying Gibson's theory of direct
perception differ markedly from those that underlie the
traditional information processing view. In both cases,
the perceptual experience is regarded as rich; but in the
ecological view, the source of that richness lies in the
stimulation, not in the perceiver. In the cognitive science
paradigm, traditional stimuli are described in terms of low-
level physical variables (intensity and wavelength of light,
for example). However, Gibson described stimuli in terms of
information (higher-order patterns of persistence and change
that occur over time). Because the information itself is rich
and speci®c, no elaboration by the perceiver is required.
Gibson's direct, information-based perception provides a
basis for the realism that expert `intuition' demands and
offers solutions to the problems encountered by other
theoretical approaches.
By looking at intuition through an ecological psychology
framework, the problem takes on a different character, one
that is no longer focused solely on the expert's cognitive (or
perceptual) processes, but also on the information provided
by the patient and the context of care. By investigating
information sources in the nurse-patient encounter, the
problem of intuition may be clari®ed, and perhaps simpli-
®ed. We may ®nd that what nurse researchers have called
`intuition' is what Gibson termed `direct perception.' Intu-
ition as direct perception is information-based and lawful.
Finally, although some aspects of intuition may be
hard-wired through evolution, intuition as direct perception
(i.e. the differentiation of relevant higher order variables for
a particular domain) also can be developed through educa-
tion and extensive, deliberate practice with appropriate
exemplars. Characterized as direct perception, intuition is
an observable, lawful phenomenon that is measurable,
potentially teachable and appropriately part of nursing
science.
 Nursing theory and concept development or analysis
Acknowledgements
The author gratefully acknowledges the critical reading and
helpful suggestions of Endre Kadar, Nam-Gyoon Kim,
Pamela Lee, and an anonymous reviewer on an earlier
version of this manuscript.
10 References
Agan R.D. (1987) Intuitive knowing as a dimension of nursing.
Advances in Nursing Science 10, 63±70.
Bastick T. (1982) Intuition: How We Think and Act. Wiley, New
York.
Beck C.T. (1998) Intuition in nursing practice: sharing graduate
students' exemplars with undergraduate students. Journal of
Nursing Education 37, 169±172.
Belenky M., Clinchy B., Goldberger N. & Tarule J. (1986) Women's
Ways of Knowing: The Development of Self Voice, and Mind.
Basic Books, New York.
Benner P. (1984) From Novice to Expert. Excellence and Power in
Clinical Nursing Practice. Addison-Wesley, Menlo Park, CA.
Benner P. & Tanner C. (1987) Clinical judgment: how expert nurses
use intuition. American Journal of Nursing 87, 23±31.
Benner P.A., Tanner C.A. & Chesla C.A. (1996) Expertise in Nursing
Practice: Caring, Clinical Judgment and Ethics Springer, New
12 York.
Berg W., Wade M.G. & Greer N.L. (1994) Visual regulation of gait
in bipedal locomotion: revisiting Lee, Lishman, and Thomson
(1982). Journal of Experimental Psychology: Human Perception
and Performance 20, 854±863.
Berragan L. (1998) Nursing practice draws upon several different
ways of knowing. Journal of Clinical Nursing 7, 209±217.
Bohm D. (1969) Some remarks on the notion of order. In Towards a
Theoretical Biology, Vol 2 (Waddington C.H. ed.), Aldine
Publishing Co, Chicago, pp. 18±40.
Broudy H., Smith B. & Burnett J. (1964) Democracy and Excellence
in American Secondary Education. Rand McNally, Chicago.
Carper B.A. (1978) Fundamental patterns of knowing in nursing.
Advances in Nursing Science 1, 13±23.
Chapman S. (1968) Catching a baseball. American Journal of Physics
36, 868±870.
Clarke M. (1986) Action and re¯ection: practice and theory in
nursing. Journal of Advanced Nursing 11, 3±11.
Darbyshire P. (1994) Skilled expert practice: Is it `all in the mind'? A
response to English's critique of Benner's novice to expert model.
Journal of Advanced Nursing 19, 755±761.
Doona M.E., Chase S.K. & Haggerty L.A. (1999) Nursing presence:
as real as a milky way bar. Journal of Holistic Nursing 17, 54±70.
Dreyfus H.L. (1993) What computers still can't do. A Critique of
Arti®cial Reason. MIT Press, Cambridge, MA.
Dreyfus H.L. & Dreyfus S.E. (1986) Mind over machine. The Power
of Human Intuitive Expertise in the Era of the Computer Free
Press, New York.
Effken J.A. (1993) Coordination of Hemodynamic Monitoring and
control Performance. Unpublished PhD Thesis, University of
Connecticut, Storrs, CT.
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(2), 246±255
Expert intuition
Effken J.A. & Kadar E.E. (2001) Learning as progressive biasing of a
random walk process: toward an ecological theory of exploratory
learning. Ecological Psychology 13, 1±30.
Effken J.A., Kim N.-G. & Shaw R.E. (1997) Making the constraints
visible: testing the ecological approach to interface design. Ergo-
nomics 40, 1±27.
Effken J.A. & Shaw R.E. (1992) Ecological perspectives on the new
arti®cial intelligence. Ecological Psychology 4, 247±270.
English I. (1993) Intuition as a function of the expert nurse: a critique
of Benner's novice to expert model. Journal of Advanced Nursing
18, 387±393.
Ericsson K.A. (1996) The acquisition of expert performance: an
introduction to some of the issues. In The Road to Excellence: The
Acquisition of Expert Performance in the Arts and Sciences,
Sports, and Games (Ericsson K.A. ed.), Lawrence Erlbaum Asso-
ciates, Mahwah, NJ, pp. 1±50.
Field P.A. (1987) The impact of nursing theory on the clinical
decision making process. Journal of Advanced Nursing 12,
563±571.
Gatley E.P. (1992) From novice to expert: the use of intuitive
knowledge as a basis for district nurse education. Nurse Education
Today 12, 81±87.
Gaver W.W. (1993a) How do we hear in the world? Explorations in
ecological acoustics. Ecological Psychology 5, 285±314.
Gaver W.W. (1993b) What in the world do we hear? An ecological
approach to auditory event perception. Ecological Psychology 5,
1±30.
Gaver W.W. (1996) Situating action II: affordances for interaction:
the social is material for design. Ecological Psychology 8, 111±130.
Gerrity P. (1987) Perception in nursing: the value of intuition.
Holistic Nursing Practice 3, 63±71.
Gibson E.J. (1969) Principles of Perceptual Learning and Develop-
ment. Appleton-Century-Crofts, New York.
Gibson E.J. (1991) An Odyssey in Learning and Perception. MIT
Press, Cambridge, MA.
Gibson J.J. (1986) The Ecological Approach to Visual Perception.
Lawrence Erlbaum, Inc., Hillsdale, NJ (First published 1979).
Gibson J.J. (1966) The Senses considered as Perceptual Systems.
Houghton Mif¯in, Boston.
Gordon D.R. (1986) Models of clinical expertise in American nursing
practice. Social Science in Medicine 22, 953±961.
Gortner S. (1990) Nursing values and science: toward a science
philosophy. Image: Journal of Nursing Scholarship 22, 101±105.
Gregory R.L. (1978) Eye and Brain: the Psychology of Seeing (3rd
edn). McGraw-Hill, New York.
Hampton D.C. (1994) Expertise: the true essence of nursing art.
Advances in Nursing Science 17, 15±24.
Hanneman S.K. (1996) Advancing nursing practice with a unit-based
clinical expert. IMAGE: Journal of Nursing Scholarship 28,
331±337.
Hansten R. & Washburn M. (2000) Intuition in professional
practice: executive and staff perceptions. The Journal of Nursing
Administration 30, 185±189.
Henderson L.J. (1970) The Fitness of the Environment. Peter Smith,
14 Gloucester, MA (Original work published 1913).
Hochberg J.E. (1978) Perception (2nd edn). Prentice Hall, Engle-
wood Cliffs, NJ.
253
 J.A. Effken
Hodges B.H. & Baron R.M. (1992) Values as constraints on
affordances: perceiving and acting properly. Journal for the Theory 19 ed), Lawrence Erlbaum Associates, Inc., Hillsdale, NJ, pp. 11±49.
of Social Behaviour 22, 263±294.
Jacobs D.M., Runeson S. & Michaels C.F. (1999) Fostering infor-
mation detection in the visual perception of relative mass. In
Studies in Perception and Action V (Grealy M.A. & Thomson J.A.,
15 eds), Lawrence Erlbaum Associates, Mahwah, NJ, pp. 193±197.
Jasper M.A. (1994) Expert: a discussion of the implications of the
concept as used in nursing. Journal of Advanced Nursing 20,
769±776.
Johansson G. (1973) Visual perception of biological motion and a
model for its analysis. Perception and Psychophysics 14, 201±211.
Johnson J.L. (1994) A dialectical examination of nursing art.
Advances in Nursing Science 17, 1±14.
Johnson J.L. (1996a) The perceptual aspect of nursing art: sources of
accord and discord. Scholarly Inquiry for Nursing Practice. An
International Journal 10, 307±327.
16 Johnson J.L. (1996b) Dialectical analysis concerning the rational
aspect of the art of nursing. Image: Journal of Nursing Scholarship
28, 169±175.
Kasper C.E. (1996) Pragmatism: the problem with the bottom line. In
In Search of Nursing Science (Omery A., Kasper C.E. & Page G.G.
eds), Sage Publications, Inc., Thousand Oaks, CA, 35±40.
Kim N.-G., Effken J.A. & Carello C. (1998a) Perceiving the severity
of contacts between two objects. Ecological Psychology 10, 20 eds), MIT Press, Cambridge, MA, pp. 67±99.
93±127.
Kim N.-G., Effken J.A. & Carello C. (1998b) Optical speci®cation of
time-to-contact between two objects. Ecological Psychology 10,
128±156.
Kim N.-G., Effken J.A. & Shaw R.E. (1995) Perceiving persistence
under change and over structure. Ecological Psychology 7, 217±256.
Kim N.-G. & Turvey M.T. (1998) Optical ¯ow ®elds and Bernstein's
`modeling of the future'. In Progress in Motor Control, Vol 1:
Bernstein's Traditions in Movement Studies (Latash M.L. ed.),
17 Human Kinetics, Champaign, IL, pp. 221±265.
Kosslyn S.M. (1994) Elements of Graph Design. W.H. Freeman,
New York.
Kugler P.N. (1985) Perspective II: information as dynamic form. In
Persistence and Change: Proceedings of the First International
Conference on Event Perception (Warren W. & Shaw R. eds),
Lawrence Erlbaum Associates, Inc., Hillsdale, NJ, pp. 315±327.
Kugler P.N. & Turvey M.T. (1987) Information, Natural Law And
the Self-Assembly of Rhythmic Movement. Lawrence J. Erlbaum
Associates, Inc., Hillsdale, NJ.
Lee D.N. (1976) A theory of visual control of braking based on
information about time-to-collision. Perception 5, 437±459.
Lee D.N., Lishman J.R. & Thomson J.A. (1982) Vision in action: the
control of locomotion. In Analysis of Visual Behavior (Ingle D.,
Goodale M.A. & Mans®eld J.W. eds), MIT Press, Cambridge,
MA., pp. 411±433.
Leprohon J. & Patel V.L. (1995) Decision making strategies for
telephone triage in emergency medical services. Medical Decision
Making 15, 240±253.
Mark L. (1987) Eye height scaled information about affordances: a
study of sitting and stair climbing. Journal of Experimental
Psychology: Human Perception and Performance 13, 361±370.
Mark L.S., Shaw R.E. & Pittinger J.B. (1988) Natural constraints,
scales of analysis, and information for the perception of growing
254 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(2), 246±255
faces. In Social and Applied Aspects of Perceiving Faces (Alley T.R.
Meerabeau L. (1992) Tacit nursing knowledge: an untapped resource
or a methodological headache? Journal of Advanced Nursing 17,
108±112.
Michaels C.F. & Carello C. (1981) Direct Perception. Prentice Hall,
Englewood Cliffs, NJ.
Michaels C.F. & de Vries M.M. (1998) Higher-order and lower-
order variables in the visual perception of relative pulling force.
Journal of Experimental Psychology: Human Perception and
Performance 24, 526±546.
Michaels C.F. & Oudejans R.R.D. (1992) The optics and actions of
catching ¯y balls: zeroing out optical acceleration. Ecological
Psychology 4, 199±222.
Neisser U. (1967) Cognitive Psychology. Appleton-Century-Crofts,
New York.
Nelms T.P. & Lane E. (1999) Women's ways of knowing in
nursing and critical thinking. Journal of Professional Nursing 15,
179±186.
Paley J. (1996) Intuition and expertise: comments on the Benner
debate. Journal of Advanced Nursing 23, 665±571.
Patel V.L. & Ramoni M.E. (1997) Cognitive models of directional
inference in expert medical reasoning. In Expertise in Context:
Human and Machine (Feltovich P.J., Ford K.M. & Hoffman R.R.
Paul R. & Heaslip P. (1995) Critical thinking and intuitive nursing
practice. Journal of Advanced Nursing 22, 40±47.
Perry M.A. (2000) Re¯ections on intuition and expertise. Journal of
Clinical Nursing 9, 137±145.
Pinsky M.R. (1998) Hemodynamic pro®le interpretation. In Princi-
ples and Practice of Intensive Care Monitoring (Tobin M.J. ed.),
Health Professions Division, McGraw-Hill, New York, pp.
871±888.
Pittenger J. & Shaw R.E. (1975) Aging faces as visco-elastic events:
implications for a theory of non-rigid shape perception. Journal of
Experimental Psychology: Human Performance and Perception 1,
374±382.
Polanyi M. (1958) Personal Knowledge. Routledge & Kegan Paul,
London.
Preitula M.J. & Simon H.A. (1989) The experts in your midst.
Harvard Business Review 67, 120±124.
Pyles S.H. & Stern P.N. (1983) Discovery of nursing gestalt in critical
care nursing: the importance of the gray gorilla syndrome.
IMAGE: Journal of Nursing Scholarship 15, 51±57.
Rew L. (1996) Intuition: concept analysis of a group phenomenon.
Advances in Nursing Science 8, 21±28.
Rew L. (1988) Nurses' intuition. Applied Nursing Research 1, 27±31.
Rew L. & Barrow E.M. (1987) Intuition: a neglected hallmark of
nursing knowledge. Advances in Nursing Science 10, 499±462.
Rosen R. (1988) Similarity and dissimilarity: a partial overview.
Human Movement Science 7, 131±153.
Runeson S. (1977) On the possibility of `smart' perceptual mecha-
nisms. Scandinavian Journal of Psychology 18, 172±179.
Saba V. & McCormick K. (1986) Essentials of Computers for
Nurses. Lippincott, Philadelphia.
Schraeder B.D. & Fischer D.K. (1987) Using intuitive knowledge in
the neonatal intensive care nursery. Holistic Nursing Practice 1,
45±51.
Nursing theory and concept development or analysis
Shaw R. & Bransford J. (1977) Introduction: psychological approa-
ches to the problem of knowing. In Perceiving, Acting and
Knowing (Shaw R. & Bransford J. eds), Lawrence J. Erlbaum,
Associates, Hillsdale, NJ, pp. 1±39.
Shaw R.E., Flascher O.M. & Kadar E.E. (1995) Dimensionless
invariants for intentional systems: measuring the ®t of vehicular
activities to environmental layouts. In Global Perspectives on the
Ecology of Human-Machine Systems, Vol 1 (Flach J.M. &
Hancock P.A. eds), Lawrence J. Erlbaum Associates, Hillsdale,
NJ, pp. 293±357.
Shaw R.E. & Kinsella-Shaw J. (1988) Ecological mechanics: a
physical geometry for intentional constraints. Human Movement
Science 7, 155±200.
Shaw R.E. & Turvey M.T. (1981) Coalitions as models for ecosys-
tems: a realist perspective on perceptual organization. In Percep-
tual Organization (Kubovy M. & Pomerantz J. eds), Lawrence
J. Erlbaum Associates, Inc., Hillsdale, NJ, pp. 343±415.
Shaw R.E. & Wilson B.E. (1976) Generative conceptual knowledge:
how we know what we know. In Cognition and Instruction (Klahr
D. ed.), Lawrence Erlbaum Associates, Inc., Hillsdale, NJ, pp.
197±221.
Suchman L.A. (1987) Plans and Situated Actions. Cambridge
University Press, Cambridge, England.
Thines G., Costall A. & Butterworth G. (eds) (1991) Michotte's
Experimental Phenomenology of Perception. Lawrence J. Erlbaum
Associates, Inc., Hillsdale, NJ.
Thompson C.D. (1999) A conceptual treadmill: the need for `middle
ground' in clinical decision making theory in nursing. Journal of
Advanced Nursing 30, 1222±1229.
Turvey M.T. (1977) Preliminaries to a theory of action with reference
to vision. In Perceiving, Acting, and Knowing (Shaw R. &
Bransford J. eds), Lawrence Erlbaum Associates, Inc., Hillsdale,
NJ, pp. 211±266.
Turvey M.T. (1992) Affordances and prospective control: an outline
of the ontology. Ecological Psychology 4, 173±187.
Turvey M.T. & Shaw R.E. (1979) The primacy of perceiving: an
ecological reformulation of perception for understanding memory.
In Perspectives on Memory Research (Nilsson L.G. ed.), Lawrence
Erlbaum Associates, Inc., Hillsdale, NJ, pp. 167±222.
Turvey M., Shaw R.E. & Mace W. (1978) Issues in the theory of
action: degrees of freedom, coordinative structures and coalitions.
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(2), 246±255
Expert intuition
In Attention and Performance VII (Requin J. ed.), Lawrence
Erlbaum Associates, Inc., Hillsdale, NJ, pp. 557±595.
Turvey M.T., Shaw R.E., Reed E.S. & Mace W.M. (1981) Ecological
laws of perceiving and acting: in reply to Fodor and Pylyshyn.
Cognition 9, 237±304.
Vicente K.J. (1995) A few implications of an ecological approach to
human factors. In Global Perspectives on the Ecology of
Human-Machine Systems, Vol 1 (Flach J., Hancock P., Caird J.
& Vicente K. eds), Lawrence Erlbaum Associates, Hillsdale, NJ,
pp. 54±67.
Vicente K.J. & Rasmussen J. (1990) The ecology of human-machine
systems: II: mediating `direct perception' in complex work
domains. Ecological Psychology 2, 207±250.
Vicente K.J. & Rasmussen J. (1992) Ecological interface design:
theoretical foundations. IEEE Transactions on Systems. Man and
Cybernetics 22, 589±605.
Vicente K.J. & Wang J.H. (1998) An ecological theory of expertise
effects in memory recall. Psychological Review 105, 33±57.
Warren W.H. Jr (1984) Perceiving affordances: visual guidance of
stair climbing. Journal of Experimental Psychology: Human
Perception and Performance 10, 683±703.
Warren W. & Shaw R.E. (1985) Psychophysics and ecometrics.
Behavioral and Brain Sciences 4, 209±210.
Warren W.H. Jr & Wang S. (1987) Visual guidance of walking
through apertures: body-scaled information specifying affordances.
Journal of Experimental Psychology: Human Perception and
Performance 13, 371±383.
Warren W.H., Young D.S. & Lee D.N. (1986) Visual control of step
length during running over irregular terrain. Journal of Experi-
mental Psychology: Human Perception and Performance 12,
371±383.
Westcott M.R. (1968) Antecedents and Consequences of Intuitive
Thinking. Final report (Bur. Nol BR-5±0735, Contract no.
OEC-3±10±072). Of®ce of Education, Bureau of Research, US
Department of Health, Education, and Welfare, Washington, DC.
Wong S.T. (1998) Outcomes of nursing care: how do we know?
Clinical Nurse Specialist 12, 147±151.
Woolery L. (1990) Expert nurses and expert systems. Computers in
Nursing 8, 23±28.
Young C.E. (1987) Intuition and nursing process. Holistic Nursing
Practice 1, 52±62.
255