Informational basis for expert intuition

The role of patient preferences in nursing decision-making in evidence-based practice: excellent nurses' communication tools

AIM

To develop an understanding of how nurses take account of patient preferences in nursing decision-making in evidence-based practice to provide individual tailored nursing care.

DESIGN

Qualitative grounded theory.

METHODS

Semi-structured interviews were conducted with 27 nurses in four medium-sized hospitals in the Netherlands. Furthermore, seven nurses were observed during their shift. Constant comparative analysis underpinned by Strauss and Corbin's framework was used.

RESULTS

Three communication tools of nurses were identified to discern and attend to patient preferences: (a) a click-making tool enables to build rapport instantly; (b) antennae monitor individual patient's needs; and (c) asking empathic questions to fine-tune to individual patient preferences. Participants emphasized that giving individual attention enhances the patient's experienced quality of life.

CONCLUSIONS

Excellent nurses in evidence-based practice consciously spend time to discover patient preferences using the set of implicit and intuitive communication tools to attune their professional care. The use of these tools leads to individual tailored nursing care and appears to be part of the nurses' practical wisdom. Further studies on how nurses balance patient preferences in nursing decision-making in the evidence-based practice are recommended.

IMPACT

The findings fill a gap in the literature on how nurses discover and balance all three aspects of the evidence-based practice in their decision-making: evidence derived from science, best practice, and patient preferences. Moreover, the use of this implicit knowledge in nursing deserves further research and attention in practice and education.

Registered Nurses (RNs)' knowledge sharing and decision-making: the mediating role of organizational trust

AIM

This study study aimed to investigate the effects of explicit and tacit knowledge sharing on clinical decision-making abilities and the mediating role of trust among registered nurses at Korean hospitals.

BACKGROUND

Decision-making abilities comprise a key area of nursing practice and link nurses' perceptions with behaviours.

INTRODUCTION

Tacit knowledge is embedded within an individual and cannot be expressed or transmitted to other people in a specific form. Over time, new nurses gradually gain experience and tacit knowledge and become experts. Trust, an organizational characteristic, may serve as a potential mediator in the association between knowledge sharing and decision-making abilities among nurses. However, few studies have investigated the mediatory role of trust in this association.

METHOD

The data were collected from 210 nurses selected via random sampling. The research instrument in the model included Knowledge-Sharing Behavior, Trust, and Clinical Decision-Making in Nursing Scale. Structural equation modelling was used to analyse the collected data.

FINDINGS

The study findings showed that explicit knowledge sharing directly affects decision-making abilities, whereas tacit knowledge sharing is only associated with decision-making abilities when trust plays a mediating role.

DISCUSSION

A higher level of organizational trust can improve clinical decision-making abilities via tacit knowledge sharing.

CONCLUSION

This study demonstrated that unlike explicit knowledge, which is shared more easily, tacit knowledge sharing does not directly lead to clinical decision-making abilities. A higher level of organizational trust leads to a stronger beneficial effect of tacit knowledge sharing on clinical decision-making abilities.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

These findings concerning the mediatory role of trust on the association between knowledge sharing and clinical decision-making abilities provide new knowledge that will allow nurses, managers, and researchers to support the clinical decision-making abilities of nurses.

NHS managers’ use of nursing workforce planning and deployment technologies: a realist synthesis

Background

Policy and reviews of health-care safety and quality emphasise the role of NHS managers in ensuring safe, good-quality patient care through effective staffing. Guidance requires that NHS managers combine professional judgement with evidence-based workforce planning and deployment tools and technologies (WPTs). Evidence has focused on the effectiveness of WPTs, but little is known about supporting their implementation, or the impact of using WPTs across settings.

Objectives

The review answered the following question: ‘NHS managers’ use of workforce planning and deployment technologies and their impacts on nursing staffing and patient care: what works, for whom, how and in what circumstances?’.

Design

A realist synthesis was conducted. A programme theory was formulated and expressed as hypotheses in the form of context, mechanisms and outcomes; this considered how, through using WPTs, particular conditions produced responses to generate outcomes. There were four phases: (1) development of a theoretical territory to understand nurse workforce planning and deployment complexity, resulting in an initial programme theory; (2) retrieval, review and synthesis of evidence, guided by the programme theory; (3) testing and refinement of the programme theory for practical application; and (4) actionable recommendations to support NHS managers in the implementation of WPTs for safe staffing.

Participants

NHS managers, patient and public representatives and policy experts informed the programme theory in phase 1, which was validated in interviews with 10 NHS managers. In phase 3, 11 NHS managers were interviewed to refine the programme theory.

Results

Workforce planning and deployment tools and technologies can be characterised functionally by their ability to summarise and aggregate staffing information, communicate about staffing, allocate staff and facilitate compliance with standards and quality assurance. NHS managers need to combine local knowledge and professional judgement with data from WPTs for effective staffing decisions. WPTs are used in a complex workforce system in which proximal factors (e.g. the workforce satisfaction with staffing) can influence distal factors (e.g. organisational reputation and potential staff recruitment). The system comprises multiple organisational strategies (e.g. professional and financial), which may (or may not) align around effective staffing. The positive impact of WPTs can include ensuring that staff are allocated effectively, promoting the patient safety agenda within an organisation, learning through comparison about ‘what works’ in effective staffing and having greater influence in staffing work. WPTs appear to have a positive impact when they visibly integrate data on needs and resources and when there is technical and leadership support. A collaborative process appears to be best for developing and implementing WPTs, so that they are fit for purpose.

Limitations

The evidence, predominantly from acute care, often lacked detail on how managers applied professional judgement to WPTs for staffing decisions. The evidence lacked specificity about how managers develop skills on communicating staffing decisions to patients and the public.

Conclusions and recommendations

The synthesis produced initial explanations of the use and impact of WPTs for decision-making and what works to support NHS managers to use these effectively. It is suggested that future research should further evaluate the programme theory.

Study registration

This study is registered as PROSPERO CRD42016038132.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

State of Science, "Intuition in Nursing Practice": A Systematic Review Study

INTRODUCTION

There were many attempts for introducing "intuition" to nursing practice, But despite the efficacy, it has been ignored as a valid way of knowing. Therefore the current study was conducted for evaluating the state of sciences to intuition in nursing practice.

MATERIALS AND METHODS

In a systematic review study, all researches, published from 1995 to 2014, were searched in the databases of "PubMed", using "intuition" and "nursing" keywords. The abstract of articles were read in scrutiny, then the related researches selected, thereafter the full text of them was assessed carefully.

RESULTS

From searching the databases, 144 articles with "intuition and nursing" were found, 53 as original research, and 15 with inclusion criteria were selected. Most of the studies had qualitative approaches design as phenomenology (N=4), content analyses (N=2) and grounded theory (N=1), six was done for developing the instrument, and two studies have been conducted as descriptive method.

CONCLUSION

The results revealed the researches about intuition in nursing mostly were conducted with qualitative and instrument developing methodology and there is a lack of quantitative and trial studies.

An evaluation of the seminal work of Patricia Benner: Theory or philosophy?

The purpose of this article is to review the seminal work of Patricia Benner, From Novice to Expert, in order to assert it as a philosophy and not a theory. In the literature there is no clear consensus on where this model stands - theory or philosophy. There is no intent to devalue Patricia Benner's work as it is valuable and has become widely used in nursing practice, research, education and administration. However, as a philosophy, Benner's interpretive work is more constructive. Appropriate use of this model requires an understanding of whether it is a theory or a philosophy, its underpinnings and an assessment of its development and testing. This can be accomplished by knowing the differences between a theory and a philosophy and by reviewing the ways of knowing and processes of reasoning which are necessary for skill acquisition. Much of the critique of Benner's work falls into two categories: it is not quantitative research and there are issues with the use of narratives. These will be reviewed. Judgment and understanding of the nature of Benner's model allows for its appropriate use in journal articles, research, or other projects and/or modification as necessary.

Informing the design of hemodynamic monitoring displays

In the ICU, an extensive array of variables from the hemodynamic monitoring display is routinely analyzed. However, the development of new display technologies is proceeding without adequate study of the monitoring tasks and behaviors of a primary user group--critical-care nurses. Semistructured interviews focusing on the cognitive aspects of the hemodynamic monitoring task were conducted with 14 critical-care nurses. A systematic content analysis of qualitative data identified cognitive tasks that had applicability to the design of monitoring displays. The cognitive tasks of hemodynamic monitoring were (1) selective data acquisition, (2) applying meaning to the variables and understanding relationships between parameters, (3) controlling hemodynamics by titrating medications and intravenous fluids, and (4) monitoring complex trends of multiple interacting variables and patient response to interventions. Recommendations include designing the monitoring display to match the mental constructs and cognitive tasks of the user by applying conceptual meaning to the variables, highlighting relationships between variables, and presenting a "big picture" view of the patient's condition. Monitoring displays must also present integrated trends that illustrate the dynamic relationship between interventions and patient response.

Nursing experience and preference for intuition in decision making

AIMS AND OBJECTIVES

This article examines the relationship between domain-specific and domain-general intuition among practicing nurses and student nurses to determine the role of intuition in nurses' decision making.

BACKGROUND

Measures of nursing intuition have not been compared with one another or to measures of general preference for intuition in the psychological literature. Prior research has shown that experienced nurses rely on intuition in clinical judgement, but the various aspects of intuition associated with experience have not been fully explored.

DESIGN

A correlational design was used to examine the factor structures and interrelationships of self-reported measures of intuition, as well as their relationship to experience.

METHOD

A web-based survey was given to 175 practicing nurses and student nurses in the fall of 2007 using measures of intuition from the nursing and psychological literatures. Quantitative analyses employed descriptive and inferential statistics.

RESULTS

Measures of preference for intuition were combined, resulting in the identification of two independent aspects of nursing intuition uniquely related to general intuition and nursing experience. Results revealed that preference for intuition in nursing was not solely due to general preference for intuition and that use of nursing intuition increased with experience.

CONCLUSION

These results strengthen the knowledge base of decision making in clinical practice by examining differences in preference for use of intuition among nurses. Further interdisciplinary collaboration is recommended.

RELEVANCE TO CLINICAL PRACTICE

Understanding the use of intuition in clinical judgement will promote professional practice and favourable patient outcomes. If experience simply leads to increased self-confidence and preference for the use of intuition, this may not actually be related to accuracy in judgement. However, if experience provides valuable information on associations between patient symptoms and outcomes, then the use of intuition in clinical practice should be encouraged.

The use of intuition in homeopathic clinical decision making: an interpretative phenomenological study

While intuition plays a role in clinical decision making within conventional medicine, little is understood about its use in complementary and alternative medicine (CAM). The aim of this qualitative study was to investigate intuition from the perspective of homeopathic practitioners; its' manifestation, how it was recognized, its origins and when it was used within daily clinical practice. Semi-structured interviews were carried out with clinically experienced non-National Health Service (NHS) UK homeopathic practitioners. Interpretative phenomenological analysis was used to analyze the data. Homeopaths reported many similarities with conventional medical practitioner regarding the nature, perceived origin and manifestation of their intuitions in clinical practice. Intuition was used in two key aspects of the consultation: (i) to enhance the practitioner-patient relationship, these were generally trusted; and (ii) intuitions relating to the prescribing decision. Homeopaths were cautious about these latter intuitions, testing any intuitive thoughts through deductive reasoning before accepting them. Their reluctance is not surprising given the consequences for patient care, but we propose this also reflects homeopaths' sensitivity to the academic and medical mistrust of both homeopathy and intuition. This study is the first to explore the use of intuition in decision making in any form of complementary medicine. The similarities with conventional practitioners may provide confidence in validating intuition as a legitimate part of the decision making process for these specific practitioners. Further work is needed to elucidate if these findings reflect intuitive use in clinical practice of other CAM practitioners in both private and NHS (i.e., time limited) settings.

The dimensions of nursing surveillance: a concept analysis

AIM

This paper is a report of an analysis of the concept of nursing surveillance.

BACKGROUND

Nursing surveillance, a primary function of acute care nurses, is critical to patient safety and outcomes. Although it has been associated with patient outcomes and organizational context of care, little knowledge has been generated about the conceptual and operational process of surveillance.

DATA SOURCES

A search using the CINAHL, Medline and PubMed databases was used to compile an international data set of 18 papers and 4 book chapters published from 1985 to 2009.

REVIEW METHODS

Rodger's evolutionary concept analysis techniques were used to analyse surveillance in a systems framework. This method focused the search to nursing surveillance (as opposed to other medical uses of the term) and used a theoretical framework to guide the analysis.

RESULTS

The examination of the literature clarifies the multifaceted nature of nursing surveillance in the acute care setting. Surveillance involves purposeful and ongoing acquisition, interpretation and synthesis of patient data for clinical decision-making. Behavioural activities and multiple cognitive processes are used in surveillance in order for the nurse to make decisions for patient safety and health maintenance. A systems approach to the analysis also demonstrates how organizational characteristics and contextual factors influence the process in the acute care environment.

CONCLUSION

This conceptual analysis describes the nature of the surveillance process and clarifies the concept for effective communication and future use in health services research.

The Dreyfus model of clinical problem-solving skills acquisition: a critical perspective

CONTEXT

The Dreyfus model describes how individuals progress through various levels in their acquisition of skills and subsumes ideas with regard to how individuals learn. Such a model is being accepted almost without debate from physicians to explain the 'acquisition' of clinical skills.

OBJECTIVES

This paper reviews such a model, discusses several controversial points, clarifies what kind of knowledge the model is about, and examines its coherence in terms of problem-solving skills. Dreyfus' main idea that intuition is a major aspect of expertise is also discussed in some detail. Relevant scientific evidence from cognitive science, psychology, and neuroscience is reviewed to accomplish these aims.

CONCLUSIONS

Although the Dreyfus model may partially explain the 'acquisition' of some skills, it is debatable if it can explain the acquisition of clinical skills. The complex nature of clinical problem-solving skills and the rich interplay between the implicit and explicit forms of knowledge must be taken into consideration when we want to explain 'acquisition' of clinical skills. The idea that experts work from intuition, not from reason, should be evaluated carefully.

Razão e desrazão nas tomadas de decisão

Tal como se apresenta na atualidade, o campo de Teorias de Tomadas de Decisão reflete a intersecção de três desenvolvimentos teóricos principais: Utilidade Esperada, Heurísticas e Desvios e Intuição Holística. As relações entre estes não são clarividentes, nem estão estabelecidas na literatura sobre o assunto, sobretudo porque algumas das tendências em jogo ainda são muito novas. Meu objetivo é contribuir para o suprimento desta lacuna, oferecendo uma visão geral do campo, particularmente sensível às demandas epistemológicas às quais cada novo desenvolvimento respondeu e às limitações destas respostas. De especial interesse é o fato de que isto irá habilitar o leitor a compreender os fundamentos do novo conceito de intuição decisional que desponta e a se posicionar criticamente em relação ao mesmo.

Models of knowledge in the assessment of postoperative pain

This article illustrates a process of knowledge development and the interrelationship between knowledge and practice using Carper's fundamental patterns of knowing. It explores two kinds of knowledge, theoretical knowledge and practical knowledge, using postoperative pain assessment as an illustration. By using their theoretical knowledge and their practical experience, nurses can maintain and develop their professional knowledge and competence.

Nurse managers' decisions: fast and favoring remediation

How do nurse managers make decisions about quality issues on their units? We asked 10 nurse managers in 3 Arizona hospitals to describe how they resolved a recent quality issue. The managers tended to use a linear, but cognitively expensive strategy, often jumping from problem to solution without a clear goal and selecting solutions biased toward remedial education. Decision support tools should help managers think more systemically and efficiently, while encouraging consideration of more alternatives to reach targeted goals.

Towards an alternative to Benner's theory of expert intuition in nursing: A discussion paper

Several authors have highlighted the role of intuition in expertise. In particular, a large amount of data has been collected about intuition in expert nursing, and intuition plays an important role in the influential theory of nursing expertise developed by Benner [1984. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Menlo Park, CA]. We discuss this theory, and highlight both data that support it and data that challenge it. Based on this assessment, we propose a new theory of nursing expertise and intuition, which emphasizes how perception and conscious problem solving are intimately related. In the discussion, we propose that this theory opens new avenues of enquiry for research into nursing expertise.

Critical thinking: A two-phase framework

This article provides a comprehensive review of how a two-phase framework can promote and engage nurses in the concepts of critical thinking. Nurse education is required to integrate critical thinking in their teaching strategies, as it is widely recognised as an important part of student nurses becoming analytical qualified practitioners. The two-phase framework can be incorporated in the classroom using enquiry-based scenarios or used to investigate situations that arise from practice, for reflection, analysis, theorising or to explore issues. This paper proposes a two-phase framework for incorporation in the classroom and practice to promote critical thinking. Phase 1 attempts to make it easier for nurses to organise and expound often complex and abstract ideas that arise when using critical thinking, identify more than one solution to the problem by using a variety of cues to facilitate action. Phase 2 encourages nurses to be accountable and responsible, to justify a decision, be creative and innovative in implementing change.

The informational basis for nursing intuition: philosophical underpinnings

In a previous paper, I argued that expert nursing intuition is a form of what James J. Gibson termed 'direct perception' and, as such, is information-based and can be accepted as part of nursing science. In this paper, I explore the philosophical basis for these claims. I begin by describing analogous problems in philosophy and psychology related to how we know the world. After describing the various solutions proposed and the problems they engender, I summarize Gibson's theoretical solution together with some of the supporting empirical evidence, but emphasizing the ecological realism on which it relies. I then use these insights to reconsider nursing intuition and the implications for its further exploration.

Holistic Assessment and Care: Presence in the Process

Holistic assessment and care are inseparable from the nursing process. Holistic nursing practice informed by a philosophy of holism balancing art and science recognizes the interconnectedness of body, mind, and spirit. Holistic practice draws on knowledge, theories, expertise, intuition, and creativity. The purpose of this article is to place nursing in the context of holistic practice; to explicate the role of presence as an essential condition for holistic care; and to provide an example of the holistic caring process that incorporates theory, presence, and practice documented in the standard formats. A holistic approach to nursing integrates process and presence in the provision of care. Process alone is empty without presence. Presence alone is insufficient without the process.

Living with chronic obstructive pulmonary disease (COPD): Part II. RNs? experience of nursing care for patients with COPD and impaired nutritional status

This study is the second part of a project with the main purpose of obtaining a deeper understanding of the consequences of living with chronic obstructive pulmonary disease (COPD) concerning meal-related situations and an impaired nutritional status. COPD is a slowly progressive lung disease that results in several complications, including malnutrition. Nutritional status is an important part of COPD treatment, and there are criteria recommended for nutritional assessment and interventions among patients with COPD. Despite this, patients with extreme malnutrition and unnoticed weight loss are reported. The aim of the study was to investigate how Registered Nurses (RNs) in primary care describe nutritional assessment practices and interventions in COPD patients with impaired nutritional status. An interview approach using semistructured questions and case vignettes was chosen. The sample included 19 RNs working specifically with COPD patients. Data from interviews were analysed using qualitative content analysis, and nine categories corresponding to the aim were identified. The RNs reported that their assessment of nutritional status was based largely on intuition. Assessment also included detection of the patients' current beliefs and being sensible about information provision - When and How. Interventions were supportive eating interventions, practical and cognitive participation, and making patients aware of the illness trajectory. An overall category that influenced nursing was respecting patients' feelings of shame and guilt about a self-inflicted disease. It seems that RNs use intuition because of a lack of knowledge of systematic methods of nutritional assessment. The findings also indicate that the RNs attempted to build a relationship of trust with the patients rather than provide early information on sensitive topics (e.g. nutritional information). The study reports areas of nursing care for COPD patients that must be improved in the future.

A review of clinical decision making: models and current research

AIMS AND OBJECTIVES

The aim of this paper was to review the current literature clinical decision-making models and the educational application of models to clinical practice. This was achieved by exploring the function and related research of the three available models of clinical decision making: information-processing model, the intuitive-humanist model and the clinical decision-making model.

BACKGROUND

Clinical decision making is a unique process that involves the interplay between knowledge of pre-existing pathological conditions, explicit patient information, nursing care and experiential learning. Historically, two models of clinical decision making are recognized from the literature; the information-processing model and the intuitive-humanist model. The usefulness and application of both models has been examined in relation the provision of nursing care and care related outcomes. More recently a third model of clinical decision making has been proposed. This new multidimensional model contains elements of the information-processing model but also examines patient specific elements that are necessary for cue and pattern recognition.

DESIGN

Literature review.

METHODS

Evaluation of the literature generated from MEDLINE, CINAHL, OVID, PUBMED and EBESCO systems and the Internet from 1980 to November 2005.

RESULTS

The characteristics of the three models of decision making were identified and the related research discussed.

CONCLUSIONS

Three approaches to clinical decision making were identified, each having its own attributes and uses. The most recent addition to the clinical decision making is a theoretical, multidimensional model which was developed through an evaluation of current literature and the assessment of a limited number of research studies that focused on the clinical decision-making skills of inexperienced nurses in pseudoclinical settings. The components of this model and the relative merits to clinical practice are discussed.

RELEVANCE TO CLINICAL PRACTICE

It is proposed that clinical decision making improves as the nurse gains experience of nursing patients within a specific speciality and with experience, nurses gain a sense of saliency in relation to decision making. Experienced nurses may use all three forms of clinical decision making both independently and concurrently to solve nursing-related problems. It is suggested that O'Neill's clinical decision-making model could be tested by educators and experienced nurses to assess the efficacy of this hybrid approach to decision making.

Evidence and expertise

This paper evaluates attempts to defend established concepts of expertise and clinical judgement against the incursions of evidence-based practice. Two related arguments are considered. The first suggests that standard accounts of evidence-based practice imply an overly narrow view of 'evidence', and that a more inclusive concept, incorporating 'patterns of knowing' not recognised by the familiar evidence hierarchies, should be adopted. The second suggests that statistical generalisations cannot be applied non-problematically to individual patients in specific contexts, and points out that this is why we need clinical judgement. In evaluating the first argument, I propose a criterion for what counts as evidence. It is a minimalist criterion but the 'patterns of knowing', referred to in the literature, still fail to meet it. In evaluating the second argument, I will outline the powerful empirical reasons we have for thinking that decisions based on research evidence are usually better than decisions based on clinical judgement; and show that current efforts to rehabilitate clinical judgement seriously underestimate the strength of these reasons. By way of conclusion, I will sketch the ways in which the concept of expertise will have to be modified if we accept evidence-based practice as a template for health-care.

Clinical cognition and biomedical informatics: issues of patient safety

Recent developments in biomedical informatics research have afforded possibilities for great advances in health care delivery. These exciting opportunities also present a number of challenges to the implementation and integration of technologies in the workplace. As in most domains, there is a gulf between technologic artifacts and end users, which compromises the culture of safety in the workplace. Because clinical practice is a human endeavor, there is a need for bridging disciplines to enable clinicians to benefit from rapid technologic advances. This, in turn, necessitates a broadening of disciplinary boundaries to consider cognitive and social factors related to the design and use of technology. The authors argue for a place of prominence for cognitive science in understanding nursing factors associated with patient safety. Cognitive science provides a framework for the analysis and modeling of complex human performance. Studies of clinical cognition can meaningfully inform and shape design, development and assessment of information systems. Furthermore, they have a decisive impact on whether information technology has a positive influence on human performance and are especially important in understanding and promoting safe practices. These issues are discussed in the context of clinical informatics with a focus on nursing practice.

The role of the expert patient in the management of chronic illness

The concept of the expert patient is an increasingly important one in healthcare policy and delivery. To date, however, there has been relatively limited consideration of the nature and characteristics of the knowledge and skills underpinning the role of expert patient or the relationship to more traditional health professional expertise. This article considers the emerging concept of the expert patient in the UK, its relationship to the emergence of the expert patient elsewhere (notably in Canada), together with exploration of the supporting rationales, assumptions and possible implications associated with the initiative.

The timeless caring connection

Caring is the essence of nursing. However, one cannot assume that caring is enough, especially if the recipient has not perceived the message of caring. The nursing connection is defined as the successful communication of caring by a nurse, whereby the recipient of care can trust the message of caring and respond to the message in its entirety. The caring connection has special significance today because of the changing societal trends, the domination of chronic illness as the major player in the population's morbidity and mortality, and the need for the public to practice prevention and/or management of chronic disease through lifestyle changes. The challenge for nursing is presented in the role of the nurse as a coach. Key strategies for establishing a caring connection in the nurse-client relationship are identified. An authentic caring connection is an empowering dialogue and exchange of the human spirit-nothing but the sacred ground in nursing practice.

Examining health visiting expertise: combining simulation, interview and observation

BACKGROUND

Resource constraints and the drive towards evidence-based practice are currently prompting the review of health visiting services, which are a costly element of community health services in the United Kingdom. There is a shortage of evidence about effective domiciliary health visiting practice that can inform local and national decisions about developing and reforming this service.

AIMS

This paper is based on a study which aimed to articulate the health visiting expertise involved in recognizing and responding to client need during home visits. The paper describes the innovative, multi-method approach used to articulate this expertise, and presents the rationale for this unusual approach.

DISCUSSION

The study used the complementary methods of a 20-minute simulated visit to an actress-client, a postsimulation focused interview and subsequent observation of actual home visits with 15 study participants. Data-gathering took place between 2001 and 2002. The rationale, strengths and limitations of the methodology are discussed, and recommendations made for further development based on the work.

CONCLUSIONS

The findings confirmed the utility of this unusual combination of methods, with their blend of control and naturalism, for articulating the knowledge and expertise which underpins assessment practice. Further research using a similar approach is recommended for the systematic examination of professional expertise in nursing and multi-disciplinary contexts.

Clinical cognition and embodiment

I first identify two different distinctions: between Cartesian cognition and embodied cognition, and between calculative rationality and intuitive know-how. I then suggest that, in the nursing literature, these two distinctions are run together, to create an opposition between 'Cartesian rationality' and 'embodied know-how'. However, it is vital to keep the two distinctions apart, because 'embodied knowing' is very frequently rational. In separating the idea of embodied cognition from non-rational intuition, I show how 'embodiment' leads to the concepts of distributed cognition and distributed expertise. This has extensive and important implications for how we understand clinical cognition in nursing.

Habilidade intuitiva no cuidado de enfermagem

Este estudo teve por objetivo compreender a habilidade intuitiva de profissionais de enfermagem no cuidado. O método do estudo foi qualitativo, do tipo exploratório descritivo. A amostra foi composta de 78 membros da equipe de enfermagem do sexo feminino, sendo 31 enfermeiras, 29 técnicas de enfermagem e 18 auxiliares de enfermagem. O resultado deste estudo apontou diferentes níveis de habilidades intuitivas, referentes à iniciante, padrão e veterano. Não foi identificada a relação dos três níveis de habilidades intuitivas com os números correspondentes em anos, encontrados em estudo norte-americano. Os fatores que interferiram na experiência intuitiva estiveram ligados aos fatores ambientais e intra-interpessoais (personológicos). As experiências das profissionais retratam a importância da intuição no cuidado de enfermagem, principalmente em situações de dúvidas, conflito e, nesse sentido, sua função primordial foi a tomada de decisão para a melhor qualidade do cuidado de enfermagem.

Observations, confirmations and strategies - useful tools in decision-making process for nurses in practice?

The aim of the study was to describe how nurses make decisions on measures in clinical practice. The data-collection method consisted of audio-taped interviews with six nurses. The interviews were then transcribed verbatim. The questions in the interviews were based on nursing situations observed earlier when the nurses initiated and implemented patient-related measures and the focus was on the nurses' experience of decision making. A content analysis was performed. The results show that the nurses' decisions on measures were based on three themes: observation of cues related to the patient's situation, confirmation of information gathered and implementation of action strategies. The results are discussed in relation to earlier empirical research on decision-making activities in the nurse's clinical practice and the nurse's utilization of knowledge during the decision-making process. It is concluded that the nurse's awareness of the patient's situation, together with a well-founded basis for decisions, can have positive effects on the nursing care provided by the nurse.