Intuition: an important tool in the practice of nursing

Prevalence and characteristics of the 'bad feeling' among healthcare professionals in the context of emergency situations: A Bi-Hospital Survey

INTRODUCTION

Clinical decision-making is based on objective and subjective criteria, including healthcare workers impressions and feelings. This research examines the perception and implications of a 'bad feeling' experienced by healthcare professionals, focusing on its prevalence and characteristics.

METHODS

A cross-sectional paper-based survey was conducted from January to July 2023 at the University Medicine Greifswald and the hospital Sömmerda involving physicians, nurses, medical students and trainees from various specialties. With ethics committee approval, participants were recruited and surveyed at regular clinical events. Data analysis was performed using SPSS® Statistics. The manuscript was written using the Strobe checklist.

RESULTS

Out of 250 questionnaires distributed, 217 were valid for analysis after a 94.9% return rate and subsequent exclusions. Sixty-five per cent of respondents experience the 'bad feeling' occasionally to frequently. There was a significant positive correlation between the frequency of 'bad feeling' and work experience. The predominant cause of this feeling was identified as intuition, reported by 79.8% of participants, with 80% finding it often helpful in their clinical judgement. Notably, in 16.1% of cases, the 'bad feeling' escalated in the further clinical course into an actual emergency. Furthermore, 60% of respondents indicated that this feeling occasionally or often serves as an early indicator of a potential, yet unrecognised, emergency in patient care.

CONCLUSIONS

This study demonstrates the relevance of clinical experience to decision-making. As an expression of this, there is a correlation between the frequency of a 'bad feeling' and the number of years of experience. It is recommended that the 'bad feeling' be deliberately acknowledged and reinforced as an early warning signal for emergency situations, given its significant implications for patient safety. Future initiatives could include advanced training and research, as well as tools such as pocket maps, to better equip healthcare professionals in responding to this intuition.

Clinical decision making in physical therapy - Exploring the 'heuristic' in clinical practice

Clinical decision-making (CDM) plays an integral role in the work of a physical therapist and has ramifications for patient outcomes and experience. Rational decision-making - acting in a manner that helps us achieve our goals - is influenced by cognitive, emotional, and social variables. The dual process theory helps us understand how clinicians make what they perceive to be rational decisions. Within dual process is the use of cognitive decisional shortcuts, commonly referred to as 'heuristics,' which are either developed through experience or the use of fast and frugal trees (FFT). The use of heuristics in physical therapy practice has yet to be explored. This paper aims to describe this subset of physical therapy decision-making and to identify the typical cognitive biases - the error in heuristic-driven decision making - inherent in this style of reasoning. Common heuristics and their related biases are described and illustrated with vignettes, including the anchoring, availability, confirmatory, and representative heuristics. The authors conclude by proposing interventions to optimize physical therapists' awareness of their use of heuristics in clinical decision-making and to identify and minimize the influence of potential bias.

Community nurses' perspectives on a novel blended training approach: a qualitative study

Background

Transiting into the community setting often presents novel difficulties for nurses because the role demands skills that might not have been obtained through usual clinical experience or training. The Ageing-in-Place Community Care Team (AIP-CCT) Community Nurse Basic Training programme was developed to address this learning gap. This training programme prepares nurses to lead in a multi-disciplinary team in delivering patient-centred care to patients with progressive or life-limiting conditions in the community setting. This study evaluated the inaugural training programme provided to a group of nurses from an acute hospital in Singapore.

Methods

Qualitative in-depth interviews were carried out with 13 participants from the training programme three-months after completion of the AIP-CCT Community Nurse Basic Training programme provided by an acute hospital to understand the programme’s impact on their knowledge, skills and clinical practice, as well as barriers and facilitators to learning.

Results

Overall, perception towards the training course was mixed. Course content was found to be relevant, and participants reported that training led to improvement in their practice. However, experienced nurses felt that the content of some modules were lacking in depth. This could have explained why only junior nurses tended to hold favourable attitudes and felt that the training led to increase in their confidence level. Although medical content was assessed favourably, the course was not able to address some of the constraints faced by community nurses such as managing expectations and handling difficult patients in the home care setting. For some modules, face-to-face training was preferred and e-learning components can be improved to increase communication and interaction.

Conclusion

This study provided insights into how a community nurse training programme could be developed to meet the needs of community nurses. The training was able to reinforce skills and knowledge, address knowledge gaps and provide new clinical care approaches and communication strategies. These incremental effects on experienced community nurses could be extrapolated to have greater benefits for inexperienced community nurses. Based on findings of the study, potential changes to the training programme were discussed to improve training outcomes.

Person- and job-specific factors of intuitive decision-making in clinical practice: results of a sample survey among Hungarian physicians and nurses

Objective: To assess the prevalence of intuitive decision-making (IDM) among health care practitioners (HCPs) and explore its person- and job-specific factors. Design and Outcome Measures: We used on-line survey data from a cross-sectional sample of Hungarian physicians and nurses (N = 460) to assess their reliance on IDM. In a second survey we asked physicians (N = 104) to rate medical specialties on dimensions of 'emergency' (necessity of making instantaneous decisions in unforeseeable situations) and 'complexity' (necessity of considering multiple perceptual and diagnostic aspects of patients' health condition along with diverse treatment options). Results: Altogether 40% of participants reported ever relying on IDM. Using logistic regression analysis, we found the estimated probability of IDM was 0.24 greater for physicians than for nurses, 0.10 greater for females than for males, and 0.11 greater for advanced level HCPs than for novices. Reaching expert level further increased (by 0.31) the probability of IDM for physicians, but not for nurses. Concerning physicians, practicing in a medical specialty of 'high likelihood of emergency' or 'high complexity' increased the probability of IDM by 0.25 and 0.23; the same effects for nurses were 0.20 and 0.07. We found some (inconclusive) evidence for education positively influencing HCPs' propensity for IDM. Additionally, we performed content analysis of participants' free-text answers to explore the psychological background of IDM instances. HCPs educated in the subject of IDM were found more disposed to perform or request further medical investigation, less prone to deviate from medical protocols, apter to reflect on their mental processes, and more inclined to rely on a large scope of information for their decisions. Conclusions: The associations between job- and person-specific factors and HCPs' propensity for IDM may have implications for their training and allocation in the health care system. Education has great potential for enhancing the quality of IDM in clinical practice.

Gut feeling: A grounded theory study to identify clinical educators' reasoning processes in putting students on a learning contract

AIM

To develop a substantive theoretical explanation that makes sense of the decision-making process that clinical instructors use to place students on a learning contract.

BACKGROUND

Clinical instructors are challenged with the task of objectively evaluating students using subjective tools such as anecdotal notes, diaries, unstructured observations and verbal feedback from other nurses. Clinical instructors' assessment decisions have a considerable impact on a variety of key stakeholders, not least of all students.

DESIGN

Grounded theory method and its heuristic tools including the logic of constant comparison, continuous memoing and theoretical sampling to serve conceptualisation were used in the process of data collection and analysis.

METHODS

Seventeen individual semi-structured interviews with clinical instructors in one university in Western Canada were conducted between May 2016-May 2017. Data were analysed using open, axial and selective coding consistent with grounded theory methodology. The study was checked for the Standards for Reporting Qualitative Research (SRQR) criteria (See Appendix S1).

FINDINGS

Three subcategories, "brewing trouble," "unpacking thinking" and "benchmarking" led to the study's substantive theoretical explanation. "Gut feeling" demonstrates how clinical instructors reason in their decision-making process to place a student on a learning contract.

CONCLUSION

Placing a student on a learning contract is impacted by personal, professional and institutional variables that together shift the process of evaluation towards subjectivity, thus influencing students' competency. A system-level approach, focusing on positive change through implementing innovative assessment strategies, such as using a smart phone application, is needed to provide some degree of consistency and objectivity.

RELEVANCE TO CLINICAL PRACTICE

Making visible the objective assessments currently being done by clinical instructors has the potential to change organisational standards, which in turn impact patient and clinical outcomes.

The rapid response system: an integrative review

Background: Clinical deterioration and adverse events in hospitals is an increasing cause for concern. Rapid response systems have been widely implemented to identify deteriorating patients. Aim: We aimed to examine the literature highlighting major historical trends leading to the widespread adoption of rapid response systems, focussing on Australian issues and identifying future focus areas. Method: Integrative literature review including published and grey literature. Results: Seventy-eight sources including journal articles and Australian government matierlas resulted. Pertinent themes were the increasing acuity and aging of the population, importance of hospital cultures, the emerging role of the consumer, and proliferation, evolution and standardisation of rapid response systems. Discussion: Translating evidence to usual care practice is challenging and strongly driven by local factors and political imperatives. Conclusion: Rapid response systems are complex interventions requiring consideration of contextual factors at all levels. Appropriate resources, a skilled workforce and positive workplace cultures are needed for these systems to reach their full potential.

Antibiotic prescribing for acute respiratory tract infections in primary care: an updated and expanded meta-ethnography

BACKGROUND

Reducing unnecessary prescribing remains a key priority for tackling the global rise of antibiotic-resistant infections.

AIM

The authors sought to update a 2011 qualitative synthesis of GPs' experiences of antibiotic prescribing for acute respiratory tract infections (ARTIs), including their views of interventions aimed at more prudent prescribing. They expanded the original scope to encompass all primary care professionals (PCPs) who can prescribe or dispense antibiotics for ARTIs (for example, nurses and pharmacists).

DESIGN AND SETTING

Systematic review and meta-ethnography of qualitative studies.

METHOD

A systematic search was conducted on MEDLINE, EMBASE, PsycINFO, CINAHL, ASSIA, and Web of Science. No date or language restrictions were used. Identified studies were grouped according to their thematic focus (usual care versus intervention), and two separate syntheses were performed.

RESULTS

In all, 53 articles reporting the experiences of >1200 PCPs were included. Analysis of usual-care studies showed that PCPs tend to assume multiple roles in the context of ARTI consultations (the expert self, the benevolent self, the practical self), depending on the range of intrapersonal, interpersonal, and contextual situations in which they find themselves. Analysis of intervention studies identified four possible ways in which PCPs may experience quality improvement interventions (compromise, 'supportive aids', source of distress, and unnecessary).

CONCLUSION

Contrary to the original review, these results suggest that the use of the same intervention is experienced in a totally different way by different PCPs, and that the same elements that are perceived as benefits by some could be viewed as drawbacks by others. Acceptability of interventions is likely to increase if these are context sensitive and take into account PCPs' varying roles and changing priorities.

Relationship between the use of intuition in clinical practice and the clinical competence of critical care nurses

INTRODUCTION

Clinical competency has been the main focus of nurse educational systems. To further it, the concept of intuition was introduced into nursing in the 1970s. Benner's theory proposed that greater use of intuition was linked to higher clinical competence; however, there is still a paucity of data to verify this theory. Therefore, the current study was conducted to assess the relationship between the use of intuition in clinical practice and the clinical competence of critical care nurses.

METHODS

In this correlational study, 88 critical care nurses were recruited as convenience. The tools included a 'use of intuition in clinical practice' scale devised by the researcher, and a 'clinical competence' instrument. The gathered data were analyzed by SPSS version 20.0 software, using descriptive and inferential statistics.

RESULTS

Of the 88 participants, 73.9% were women and 93.2% were at undergraduate level. The mean and standard deviation of participants' age and work experience was 32.29 ± 6.75 and 7.40 ± 5.68 years, respectively. The Pearson correlation test revealed no significant connection between the use of intuition in clinical practice and the clinical competence of critical care nurses (r = 0.091, P = 0.398), and produced similar results from the various demographic groups (P > 0.05).

CONCLUSION

In this study, no significant correlation between the use of intuition and clinical competence in critical care nurses was found. This could be attributed to intuition as a nursing skill being almost excluded from the educational curriculum of nursing schools, and some background factors.

The embodied nurse: Interdisciplinary knowledge exchange between compassionate nursing and recent developments in embodied leadership studies

AIMS

To report a potential knowledge exchange between nursing studies and the results obtained from a study conducted into the attributes of embodied leadership.

BACKGROUND

Leadership theories have been applied to evaluate, improve, and train nursing practitioners in several previous studies. However, leadership research has entered a new phase where the focus is to produce sustainable leaders through authenticity and compassion, the same two characteristics identified as being of most success in emergent nursing practice. There are few studies that have indicated a knowledge exchange between the latest developments in leadership studies and nursing.

DESIGN

An exploratory and qualitative study.

METHODS

Between February 2012 - July 2012, a focused sample of 14 medical care professionals was interviewed across a chain of hospitals. The aim was to evaluate embodied leadership characteristics and understand the factors that contribute to the manifestation of these characteristics. The transcribed interviews were analysed using thematic analysis.

FINDINGS

Several factors that contribute to the characteristics of embodied leadership have been identified in the interviews and in subsequent literature searches on the characteristics and contributing factors found to be associated with nursing research. These could prompt a knowledge exchange.

CONCLUSION

The results suggest common ground between nursing and contemporary leadership research in the exposition of behaviours; namely, being non-judgmental, listening actively, reflective practice and embracing uncertainty. Several implications can therefore be expected through the exchange of knowledge resulting from collaboration between researchers in the two disciplines.

Intuition: A Concept Analysis

PURPOSE

The purpose of this article is to conceptually examine intuition; identify the importance of intuition in nursing education, clinical practice, and patient care; encourage acceptance of the use of intuition; and add to the body of nursing knowledge.

BACKGROUND

Nurses often report using intuition when making clinical decisions. Intuition is a rapid, unconscious process based in global knowledge that views the patient holistically while synthesizing information to improve patient outcomes. However, with the advent of evidence-based practice (EBP), the use of intuition has become undervalued in nursing.

REVIEW METHODS

Walker and Avant's framework was used to analyze intuition. A literature search from 1987 to 2014 was conducted using the following keywords: intuition, intuition and nursing, clinical decision making, clinical decision making and intuition, patient outcomes, EBP, and analytical thinking.

RESULTS

The use of intuition is reported by nurses, but is not legitimized within the nursing profession. Defining attributes of intuition are an unconscious, holistic knowledge gathered without using an analytical process and knowledge derived through synthesis, not analysis. Consequences include verification of intuition through an analytical process and translating that knowledge into a course of action.

CONCLUSION

This article supports the use of intuition in nursing by offering clarity to the concept, adds to the nursing knowledge base, encourages a holistic view of the patient during clinical decision making, and encourages nurse educators to promote the use of intuition.

Gut feelings in the diagnostic process of Spanish GPs: a focus group study

OBJECTIVES

The gut feelings of doctors can act as triggers and modulators of the diagnostic process. This study explored the existence, significance, determinants and triggers of gut feelings among Spanish general practitioners.

DESIGN

Qualitative study using focus groups. Thematic content analysis.

SETTING

Primary healthcare centres in Majorca (Spain).

PARTICIPANTS

20 purposively sampled general practitioners working in Majorca.

RESULTS

General practitioners were aware of the existence of gut feelings in their diagnostic reasoning process and recognised 2 kinds of gut feelings: a sense of alarm and a sense of reassurance. A previous physician-patient relationship and the physician's experience had a strong perceived influence on the appearance of gut feelings. The physicians attached great significance to gut feelings, and considered them as a characteristic of the primary care working style and as a tool available in their diagnostic process. The physicians thought that the notion of gut feelings and their relevance can be transmitted to students and trainees. They tended to follow their gut feelings, although they were not sure of their accuracy.

CONCLUSIONS

Spanish general practitioners in our study recognise the presence and role of gut feelings in their diagnostic reasoning process. Future research should examine the diagnostic accuracy of gut feelings and how to teach about gut feelings in the training of general practitioners.

Accuracy of intuition in clinical decision-making among novice clinicians

AIMS

To assess the reliance on intuitive and analytical approaches during clinical decision-making among novice clinicians and whether that reliance is associated with accurate decision-making.

BACKGROUND

Nurse educators and managers tend to emphasize analysis over intuition during clinical decision-making though nurses typically report some reliance on intuition in their practice. We hypothesized that under certain conditions, reliance on intuition would support accurate decision-making, even among novices.

DESIGN

This study utilized an experimental design with clinical complication (familiar vs. novel) and decision phase (cue acquisition, diagnosis and action) as within-subjects' factors, and simulation role (observer, family, auxiliary nurse and primary nurse) as between-subjects' factor.

METHODS

We examined clinical decision-making accuracy among final semester pre-licensure nursing students in a simulation experience. Students recorded their reasoning about emerging clinical complications with their patient during two distinct points in the simulation; one point involved a familiar complication and the other a relatively novel complication. All data were collected during Spring 2015.

RESULTS

Although most participants relied more heavily on analysis than on intuition, use of intuition during the familiar complication was associated with more accurate decision-making, particularly in guiding attention to relevant cues. With the novel complication, use of intuition appeared to hamper decision-making, particularly for those in an observer role.

CONCLUSION

Novice clinicians should be supported by educators and nurse managers to note when their intuitions are likely to be valid. Our findings emphasize the integrated nature of intuition and analysis in clinical decision-making.

Factors that impact on emergency nurses’ ethical decision-making ability

Background:

Reliance on moral principles and professional codes has given nurses direction for ethical decision-making. However, rational models do not capture the emotion and reality of human choice. Intuitive response must be considered.

Research purpose:

Supporting intuition as an important ethical decision-making tool for nurses, the aim of this study was to determine relationships between intuition, years of worked nursing experience, and perceived ethical decision-making ability. A secondary aim explored the relationships between rational thought to years of worked nursing experience and perceived ethical decision-making ability.

Research design and context:

A non-experimental, correlational research design was used. The Rational Experiential Inventory measured intuition and rational thought. The Clinical Decision Making in Nursing Scale measured perceived ethical decision-making ability. Pearson’s r was the statistical method used to analyze three primary and two secondary research questions.

Participants:

A sample of 182 emergency nurses was recruited electronically through the Emergency Nurses Association. Participants were self-selected.

Ethical considerations:

Approval to conduct this study was obtained by the Adelphi University Institutional Review Board.

Findings:

A relationship between intuition and perceived ethical decision-making ability ( r = .252, p = .001) was a significant finding in this study.

Discussion:

This study is one of the first of this nature to make a connection between intuition and nurses’ ethical decision-making ability.

Conclusion:

This investigation contributes to a broader understanding of the different thought processes used by emergency nurses to make ethical decisions.

Living beyond the Unanticipated Sudden Death of a Partner: A Phenomenological Study

This research project explored grief and its impact upon men and women who have experienced the sudden and unanticipated death of his or her partner.

It included what grief meant to them, how it was manifested in his or her everyday lives and how his or her partner's death had impacted upon his or her relationship with themselves, with others and the world. A Husserlian phenomenological approach was used to explore the experiences of the ten women and five men whose partner had died up to five years prior to being interviewed. The need for the surviving partner to continue to participate in everyday life placed great strain upon the internal resources of the surviving partner. The surviving partner needed to reinvent him or herself, in an attempt to become independent and regain functionality, whilst dealing with the sadness and loss that they had experienced. The surviving partner discovered that a new life order emerged that included hope, optimism, planning for the future and perhaps the prospect of a new relationship. The death of a partner left the surviving partner with a loss that would always be a part of them, with the memories of his or her relationship being maintained within them that will never be replaced by somebody else. The results of this research project reinforce the need for ongoing education of the community in grief and bereavement issues in order to increase the awareness of the support needs of the bereaved person. The length of time and amount of energy required to incorporate the experience into the survivor's life, is greatly underestimated by the community, and perhaps by some of the health and caring professionals. Colonial and hospital based bereavement support services need to be established and be proactive using outreach programs, actively offering the suddenly bereaved partner and family support and information.

Continued Psychometric Evaluation of an Intuition Instrument for Nursing Students

Purpose: The purpose of this study was to evaluate the psychometric properties of a revised intuition instrument developed for nursing students. Method: Principal component factor analysis was used to establish construct validity, and the Cronbach’s alpha was used to examine reliability. Findings: Statistical analysis resulted in a 26-item intuition instrument with 6 factors accounting for 62% of the variance. The factors were labeled as Feelings That Reassure (27.7%), Spiritual Connections (10.9%), Feelings That Alert (8.4%), Feelings That Forewarn (5.8%), Physical Sensations That Alert (4.7%), and Reading Physical Cues (4.2%). Eigenvalues ranged from 1.100 to 7.225, and factor loadings ranged from .572 to .848. The overall Cronbach’s alpha was .89 with a range of .73 to .85 for each factor. Conclusions: The 26-item intuition instrument showed evidence of construct validity and reliability. Implications: The intuition instrument can serve as a stimulus to foster students’ intuitive abilities.

The perception of intuition in clinical practice by Iranian critical care nurses: a phenomenological study

Background

Intuition as a way of learning in nursing is applied to decision making and judgment in complicated clinical situations. Several studies have been conducted on intuition in clinical settings, but comprehension of this concept is unclear. Moreover, there is a lack of information about intuition in critical care nurses caring for more seriously ill patients. This study aimed to explore Iranian critical care nurses’ understanding of intuition in clinical practice.

Methods

In a descriptive–phenomenological study, 12 nurses employed in critical care units of the hospitals affiliated to Kermanshah University of Medical Sciences were purposively recruited to the study. A semistructured interview was administered, and then written verbatim. The data were managed by MAXQDA 10 software, and qualitative analysis was undertaken using the seven-stage approach of Colaizzi.

Results

Of the 12 nurses who participated in the study, 7 (58.3%) were female and married, and 10 (88.3%) held a bachelor’s degree in nursing. The mean and standard deviations of participants’ age, job experience, and critical care experience were 36.66±7.01, 13.75±6.82, and 7.66±3.36 years, respectively. Four main themes and eleven sub-themes were elicited from the qualitative analysis; the main themes including “Understanding intuition as a feeling”, “Understanding intuition as a thought”, “Understanding intuition as receiving signs”, and “Understanding intuition as an alarm”. Because they have trust in their own intuition, the nurses made further assessments and paid more attention to patients. They were also better prepared after receiving intuition alarms to perform the appropriate responses, and acting upon the alarms reduced the nurses’ physical and psychological signs.

Conclusion

The findings showed how intuition was understood by the critical care nurses; therefore, these results can be considered to form a theoretical basis for designing other studies. Because of the significant role of intuition in enhancing the nursing care of critically ill patients, it is suggested that more qualitative, quantitative, and trials studies be performed to reinforce intuition in nursing; moreover, to incorporate intuition into nursing curriculums, it should be debated in academic settings.

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.

Engaging consumers in the Australian emergency mental health context: a qualitative perspective from clinicians working in the community

Successfully engaging with consumers is seen as an essential component of mental healthcare, yet doing so can be challenging and little is understood about the unique engagement skills and attributes employed by mental health clinicians working in the emergency community context. Consequently, this qualitative study explored the engagement experiences of clinicians to identify the attributes used when engaging with consumers in this unique setting. We conducted two semi-structured focus groups in July and August 2011 with 16 clinicians employed at one metropolitan mental health organisation in South Australia. Using thematic analysis, we identified two key themes pertaining to the skills and attributes used for successful consumer engagement: (i) building trust, through communication style, an honest approach, facilitating choice and locating trust networks; and (ii) portraying genuine care, through showing respect, offering practical assistance and taking the least restrictive pathway. These findings highlight the unique nature of engagement in the emergency community mental health setting, as well as the flexibility and resourcefulness required to facilitate it.

Physician's first clinical impression of emergency department patients with nonspecific complaints is associated with morbidity and mortality

The association between the physician's first clinical impression of a patient with nonspecific complaints and morbidity and mortality is unknown. The aim was to evaluate the association of the physician's first clinical impression with acute morbidity and mortality. We conducted a prospective observational study with a 30-day follow-up. This study was performed at the emergency departments (EDs) of 1 secondary and 1 tertiary care hospital, from May 2007 to February 2011. The first clinical impression ("looking ill"), expressed on a numerical rating scale from 0 to 100, age, sex, and the Charlson Comorbidity Index (CCI) were evaluated. The association was determined between these variables and acute morbidity and mortality, together with receiver operating characteristics, and validity. Of 217,699 presentations to the ED, a total of 1278 adult nontrauma patients with nonspecific complaints were enrolled by a study team. No patient was lost to follow-up. A total of 84 (6.6%) patients died during follow-up, and 742 (58.0%) patients were classified as suffering from acute morbidity. The variable "looking ill" was significantly associated with mortality and morbidity (per 10 point increase, odds ratio 1.23, 95% confidence interval [CI] 1.12-1.34, P < 0.001, and odds ratio 1.19, 95% CI 1.14-1.24, P < 0.001, respectively). The combination of the variables "looking ill," "age," "male sex," and "CCI" resulted in the best prediction of these outcomes (mortality: area under the curve [AUC] 0.77, 95% CI 0.72-0.82; morbidity: AUC 0.68, 95% CI 0.65-0.71). The physician's first impression, with or without additional variables such as age, male sex, and CCI, was associated with morbidity and mortality. This might help in the decision to perform further diagnostic tests and to hospitalize ED patients.

Preferred Thinking Style, Symptom Recognition, and Response by Nursing Students During Simulation

A better understanding of the relationships between symptom recognition, nursing response, and preferred thinking style is needed to improve nursing education practices. Final semester nursing students ( N = 29) completed a high fidelity patient simulation (HFPS) scenario; recognized symptoms (i.e., dyspnea) and responses (i.e., apply oxygen) were recorded, and compared with students’ preferred thinking style using the Rational-Experiential Inventory–40. Relationships between concepts were explored. Significant relationships were noted between preference for Rational thinking styles and symptom recognition ( p < .05). Preferred thinking style was not related to numbers of therapeutic responses. Thirty percent of students delayed application of oxygen until directed to do so by members of the health care team. Students having a stronger preference for rational thinking demonstrate greater accuracy in cue recognition. More nursing research is needed to explore the cognitive processing during simulation .

Conceptualizing the clinical and professional development of child and adolescent mental health nurses

Aspects of mental health nursing and its subspecialties are not easily defined. Child and adolescent mental health (CAMH) nursing is a subspecialty of mental health nursing, and some of its characteristics are tacit. This paper presents a deeper understanding of the meaning that CAMH nurses make of their role and work in the inpatient setting. The research was undertaken through a PhD candidature. The epistemological framework for the research was social constructionism. Interpretive enquiry was the methodology, as it allowed for the interpretation of multiple realities, which resulted in a rich description of the role and work of CAMH nurses. Methods of data collection were document analysis, focus group interviews, and individual interviews. Participants included nurses and multidisciplinary staff. Iterative and aggregative analyses were utilized for the documents. The focus group and individual interview data were analysed utilizing a thematic analysis process. This paper presents the findings of the combined analysis and the resultant holistic conceptual framework for the work of the CAMH nurse in the inpatient unit. The findings have contributed new knowledge to mental health nursing, specifically CAMH nursing, making the parameters of practice more explicit. Implications for practice, education, and research are identified.

Exploring Factors Affecting Emergency Medical Services Staffs' Decision about Transporting Medical Patients to Medical Facilities

Transfer of patients in medical emergency situations is one of the most important missions of emergency medical service (EMS) staffs. So this study was performed to explore affecting factors in EMS staffs' decision during transporting of patients in medical situations to medical facilities. The participants in this qualitative study consisted of 18 EMS staffs working in prehospital care facilities in Tehran, Iran. Data were gathered through semistructured interviews. The data were analyzed using a content analysis approach. The data analysis revealed the following theme: "degree of perceived risk in EMS staffs and their patients." This theme consisted of two main categories: (1) patient's condition' and (2) the context of the EMS mission'. The patent's condition category emerged from "physical health statuses," "socioeconomic statuses," and "cultural background" subcategories. The context of the EMS mission also emerged from two subcategories of "characteristics of the mission" and EMS staffs characteristics'. EMS system managers can consider adequate technical, informational, financial, educational, and emotional supports to facilitate the decision making of their staffs. Also, development of an effective and user-friendly checklist and scoring system was recommended for quick and easy recognition of patients' needs for transportation in a prehospital situation.

Kaleidoscopes of Reality

This article addresses the broad context of shifting definitions of how knowledge and reality can be described, including the transition from positivism to postpositivism in the 20th century. It provides an exploration of ways of knowing, from ancient Greek and yogic traditions to Barbara Carper’s Fundamental Patterns of Knowing in Nursing (1978). It examines three reported components of modern care (intuition, cultural knowing, and spirituality) which are simultaneously present and absent in nursing. It concludes with an imaginative exploration of how nursing might be changed by transdisciplinary scholarship and education, new knowledge creation through interactive online communities, and the emergence of collective wisdom.

The cognitive processes underpinning clinical decision in triage assessment: a theoretical conundrum?

High quality clinical decision-making (CDM) has been highlighted as a priority across the nursing profession. Triage nurses, in the Accident and Emergency (A&E) department, work in considerable levels of uncertainty and require essential skills including: critical thinking, evaluation and decision-making. The content of this paper aims to promote awareness of how triage nurses make judgements and decisions in emergency situations. By exploring relevant literature on clinical judgement and decision-making theory, this paper demonstrates the importance of high quality decision-making skills underpinning the triage nurse's role. Having an awareness of how judgements and decisions are made is argued as essential, in a time where traditional nurse boundaries and responsibilities are never more challenged. It is hoped that the paper not only raises this awareness in general but also, in particular, engages the triage nurse to look more critically at how they make their own decisions in their everyday practice.

Nurses' experiences of participation in a research and development programme

AIMS AND OBJECTIVES

To describe clinical nurses' experience of participating in a Research and Development (R&D) programme and its influence on their research interest and ability to conduct and apply nursing research.

BACKGROUND

To stimulate nurses' research interest and to overcome barriers for building research capacity in nursing, there is a need for sustainable research programmes. A two-year programme was designed for nurses, to take part in both an academic education for master and research seminars and workshops to conduct a research project from idea to publication.

DESIGN

A qualitative approach using using focus group interviews.

METHODS

Registered nurses (n=12) with a bachelor's degree in nursing, participated. Data were collected in focus group interviews, after one year and when the programme ended. Content analysis was used to analyse the data.

RESULTS

The findings consist of two themes: being a traveller in the world of nursing research, which included three categories, and experiencing professional growth as a result of nursing research training, in both cases focusing on the experience of students involved in a cohesive programme which included four categories: discovering new dimensions of clinical nursing practice; selected and confirmed; supported by professional others; development of professional self-concept.

CONCLUSIONS

To support early career researchers, there is a need for strong leadership, an organisational and supportive infrastructure underpinning research capability building in nurses. In this context, research strategies, programmes and collaboration between leaders of academia and clinical institutions appear to be essential.

RELEVANCE TO CLINICAL PRACTICE

The R&D programme illustrates an effective way of stimulating nurses' lifelong learning by building the capacity to conduct and apply nursing research in clinical practice. The structure of the programme can be used as a model in other contexts.

Cultural validation of the "use of intuition by nursing students scale - Turkish version"

PURPOSE

It is well known that intuition ability directly affects patient care quality and outcomes in nursing practice and is therefore an important aspect of nursing education. This study tests the validity and reliability of the Turkish version of the Scale of Use of Intuition by Nursing Students.

DESIGN

The sample for this methodological study was composed of 250 nursing students. Each item of the scale was translated into Turkish by the researchers and validated for Turkish use.

RESULTS

The item-total correlation was between .30 and .56 and its Cronbach α coefficient was .86. There was a statistically significant positive relationship between the level of clinical experience and the total points scored on the physical awareness, emotional awareness, and physical sensations subscales and from the total scale.

CONCLUSIONS

Based on these results, the Turkish version of the Scale of Use of Intuition by Nursing Students is valid and reliable.

The Use of Aesthetic Knowledge in the Management of Brain Injury Patients

A patient's recovery from a brain injury (BI) is unpredictable and requires flexible nursing strategies for each stage of recovery. Empirical knowledge provides a framework for delivering nursing care based on scientific principles. Aesthetic knowledge, including intuition, provides a further opportunity to know and understand BI patients and their responses as they progress along the trajectory of recovery. Incorporating both empirical and aesthetic knowledge into the nursing plan of care for this population affords on opportunity for nurses to help patients and their families negotiate the course of recovery with greater success.

The experience of being an advanced practice nurse in Australian acute care settings: A systematic review of qualitative evidence

BACKGROUND

There is a vast amount of international literature which, although agreeing on the need for advanced practice nurse roles, simultaneously debates and discusses the difficulties with nomenclature, definition and subsequent implementation of such roles. Due to this ambiguity it is difficult to equally compare evidence in this field across different countries. A context-specific systematic review on the qualitative evidence of the experience of being an advanced practice nurse in Australia has not been undertaken previously, however it is imperative for nursing managers and leaders to understand the complexities of advanced nursing roles in order to effectively utilise and retain these experienced and valuable nurses. With the creation of a national nursing regulating authority in 2010, it is timely to explore in-depth the experience of being an advanced practice nurse from a national perspective.

OBJECTIVE

To identify the experience of being an advanced practice nurse working in Australian acute care settings.

INCLUSION CRITERIA

Registered nurses working in advanced practice roles in acute care settings throughout Australia.The experience of being an advanced practice registered nurse working in an Australian acute care setting, as reported by the nurses themselves.Interpretive qualitative studies including designs such as phenomenology, grounded theory and ethnography.

SEARCH STRATEGY

A three step search strategy was used to identify published and unpublished studies. The search process was conducted from August to October 2011 and considered published and unpublished studies from 1990 to October 2011.

METHODOLOGICAL QUALITY

Studies were appraised for methodological quality by two independent reviewers using the Joanna Briggs Qualitative Assessment and Review Instrument.

DATA EXTRACTION

Data was extracted from the papers included in the review using the standardised Joanna Briggs Institute Qualitative Assessment and Review Instrument data extraction tool.

DATA SYNTHESIS

Research findings were pooled using the Joanna Briggs Institute Qualitative Data and Review Instrument.

RESULTS

Three published studies and one unpublished dissertation were included in the review. From these four studies, 216 findings were extracted, forming 18 categories which were then analysed to create six synthesised findings. Six meta-syntheses under the headings of expert knowledge, confidence, education, relationships, negative experiences and patient centred experience were formed from the findings.

CONCLUSIONS

The synthesised findings confirm that the experience of advanced practice nurses in Australian acute care settings is complex and greatly influenced personally and professionally by the organisation as well as the unpredictable nature of working with people.

IMPLICATIONS FOR PRACTICE

A deeper understanding of the essence of being an advanced practice nurse may be of benefit for recruitment and retention planning. Health care organisations must also be aware of the impact they have on the nurse's experience if they are to commit to retention of nurses and to patient safety.

IMPLICATIONS FOR RESEARCH

If the topic of advanced practice is to remain current in the Australian nursing profession then ongoing research must be conducted to identify if the title is being used more frequently within the nursing research. Nurses must be supported in publishing quality research if they are to improve articulation of their experiences.

Intrinsic and extrinsic factors important to manual therapy competency development: a delphi investigation

A learner's development of orthopaedic manual physical therapy (OMPT) psychomotor skills may be influenced by selected intrinsic and extrinsic factors. The purposes of this study were to identify the factors that influence learners' development of manual physical therapy competencies and to define each factor as intrinsic or extrinsic. A 3-round Delphi method survey and a retrospective review of the data were used to develop composite scores and rankings. Eighty manual physical therapy educators participated in the 3 rounds. Thirty-six factor descriptor statements associated with manual physical therapy competency were established and further categorized as intrinsic (19 total), extrinsic (10 total), or conceptual outliers (7 total). Cognitive Processing ranked as the most important factor influencing manual physical therapy competency development. Adaptation ranked second, followed by Science Knowledge. This study is the first to establish manual physical therapy educational factors associated with attainment of competency. The majority of the factors distill into the theory of extrinsic and intrinsic factors identified by Schmidt and Lee. The outcomes of this study identify the factors to which OMPT educators should give particular attention when developing and executing the learning experiences for their learners.

The impact of intuition and supervisor-nurse relationships on empowerment and affective commitment by generation

AIM

  This article reports a generational cohort and leader-member exchange theoretical frameworks-guided study of the influence of the supervisor-subordinate relationship on three generational nurse cohorts' use of intuition, perceptions of empowerment and affective commitment.

BACKGROUND

  Within a global context of nurse shortages, knowledge about factors influencing nurse retention is urgently sought. We postulated that nurses' use of intuition is the key to their empowerment and consequent commitment to the organization, and that impact would vary among the three large nurse generations.

METHODS

  A self-report survey was used to gather data in 2008, which were then analysed using correlations, regression analysis, manova and path analysis. Data were obtained from 900 Baby Boomer and Generations X and Y nurses, randomly chosen from seven private hospitals across Australia.

RESULTS

  The findings confirm the important impact of supervisor-nurse relationships upon all three generations' use of intuition. The findings add new knowledge about the differing importance of using intuition for Generation X, Generation Y and Baby Boomer nurses' perceptions of empowerment, suggesting it is more important to Baby Boomers and Generation X than to Generation Y. Further, the impact of using intuition differs significantly among the generational cohorts.

CONCLUSIONS

The findings suggest the need for a more differentiated tailored style - sensitive to varying needs of the generations. Improving supervisor-nurse relationships is also critical, because of their impact upon nurses' use of intuition, perceptions of empowerment and affective commitment. Poor relationships lead to increased nurse replacement costs.

A Hypothesis about the Biological Basis of Expert Intuition

It is well established that intuition plays an important role in experts’ decision making and thinking generally. However, the theories that have been developed at the cognitive level have limits in their explanatory power and lack detailed explanation of the underlying biological mechanisms. In this paper, we bridge this gap by proposing that Hebb's (1949) concept of cell assembly is the biological realization of Simon's (1974) concept of chunking. This view provides mechanisms at the biological level that are consistent with both biological and psychological findings. To further address the limits of previous theories, we introduce emotions as a component of intuition by showing how they modulate the perception-memory interaction. The idea that intuition lies at the crossroads between perception, knowledge, and emotional modulation sheds new light on the phenomena of expertise and intuition.

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.

Gut feelings as a third track in general practitioners' diagnostic reasoning

BACKGROUND

General practitioners (GPs) are often faced with complicated, vague problems in situations of uncertainty that they have to solve at short notice. In such situations, gut feelings seem to play a substantial role in their diagnostic process. Qualitative research distinguished a sense of alarm and a sense of reassurance. However, not every GP trusted their gut feelings, since a scientific explanation is lacking.

OBJECTIVE

This paper explains how gut feelings arise and function in GPs' diagnostic reasoning.

APPROACH

The paper reviews literature from medical, psychological and neuroscientific perspectives.

CONCLUSIONS

Gut feelings in general practice are based on the interaction between patient information and a GP's knowledge and experience. This is visualized in a knowledge-based model of GPs' diagnostic reasoning emphasizing that this complex task combines analytical and non-analytical cognitive processes. The model integrates the two well-known diagnostic reasoning tracks of medical decision-making and medical problem-solving, and adds gut feelings as a third track. Analytical and non-analytical diagnostic reasoning interacts continuously, and GPs use elements of all three tracks, depending on the task and the situation. In this dual process theory, gut feelings emerge as a consequence of non-analytical processing of the available information and knowledge, either reassuring GPs or alerting them that something is wrong and action is required. The role of affect as a heuristic within the physician's knowledge network explains how gut feelings may help GPs to navigate in a mostly efficient way in the often complex and uncertain diagnostic situations of general practice. Emotion research and neuroscientific data support the unmistakable role of affect in the process of making decisions and explain the bodily sensation of gut feelings.The implications for health care practice and medical education are discussed.

A Grounded Theory of Intuition among Occupational Therapists in Mental Health Practice

Objectives:

This study aimed to explore occupational therapists' understanding and use of intuition in mental health practice.

Method:

Using a grounded theory approach, a theoretical sample of nine occupational therapists practising in mental health settings participated in semi-structured interviews. Data were analysed using the constant comparative method.

Findings:

Intuition was found to be embedded within clinical reasoning. From the data, intuition was defined as knowledge without conscious awareness of reasoning. The participants viewed intuition as elusive and underground, and suggested that professional experience led to a more comfortable use of intuition. Using intuition relied on therapists' understanding of their own and others' emotions, and intuition partnered analysis within their clinical reasoning. A grounded theory of the use of intuition in mental health settings is proposed.

Conclusion:

Occupational therapists practising in mental health settings understand intuition to be an instinctive understanding of situations, resulting from their professional experience and the understanding of emotions.

Professional approaches in clinical judgements among senior and junior doctors: implications for medical education

BACKGROUND

Clinical experience has traditionally been highly valued in medical education and clinical healthcare. On account of its multi-faceted nature, clinical experience is mostly difficult to articulate, and is mainly expressed in clinical situations as professional approaches. Due to retirement, hospitals in Scandinavia will soon face a substantial decrease in the number of senior specialist doctors, and it has been discussed whether healthcare will suffer an immense loss of experienced-based knowledge when this senior group leaves the organization. Both senior specialists and junior colleagues are often involved in clinical education, but the way in which these two groups vary in professional approaches and contributions to clinical education has not been so well described. Cognitive psychology has contributed to the understanding of how experience may influence professional approaches, but such studies have not included the effect of differences in position and responsibilities that junior and senior doctors hold in clinical healthcare. In the light of the discussion above, it is essential to describe the professional approaches of senior doctors in relation to those of their junior colleagues. This study therefore aims to describe and compare the professional approaches of junior and senior doctors when making clinical judgements.

METHODS

Critical incident technique was used in interviews with nine senior doctors and nine junior doctors in internal medicine. The interviews were subjected to qualitative content analysis.

RESULT

Senior and junior doctors expressed a variety of professional approaches in clinical judgement as follows: use of theoretical knowledge, use of prior experience of cases and courses of events, use of ethical and moral values, meeting and communicating with the patient, focusing on available information, relying on their own ability, getting support and guidance from others and being directed by the organization.

CONCLUSION

The most prominent varieties of professional approaches were seen in use of knowledge and work-related experience. Senior doctors know how the organization has worked in the past and have acquired techniques with respect to long-term decisions and their consequences. Junior doctors, on the other hand, have developed techniques and expertise for making decisions based on a restricted amount of information, in relation to patients' wellbeing as well as organizational opportunities and constraints. This study contributes to medical education by elucidating the variation in professional approaches among junior and senior doctors, which can be used as a basis for discussion about clinical judgement, in both pre-clinical and clinical education. Further research is required to explain how these professional approaches are expressed and used in clinical education.

The meaning of mental health nurses experience of providing one-to-one observations: a phenomenological study

There has been much recent literature about the need for appropriate policies and approaches to ensure that patient's rights and standards of care are safeguarded. The focus from national policy is on suicide reduction and prevention, and the nursing literature has concentrated on the importance of engaging the patient and ensuring that there is the least amount of restriction possible. A research study was carried out to explore the perspective of mental health nurses working in these intensive situations, using a purposive sample of nursing staff from the local National Health Service Trust's acute units. A phenomenological approach to the study was chosen to allow an in-depth exploration of the issues--'seeing things up close'--using the philosophy of Husserl as a base. The key areas of enquiry were: to explore and amplify the experiences of nurses undertaking constant observations, including any effects that may have on nurses; to gain further understanding of the dynamics and processes involved; to discover information that can inform and support development needs. Individual taped interviews were carried out with six nurses working in an acute admission ward, and these were then transcribed and analysed using Giorgi's method of analysis. The results of this analysis showed that nurses are keenly aware of some of the professional and ethical tensions involved in the process of keeping patients safe while trying to promote recovery. Results have implications for policies, preparation and support of staff, and provide some further insights into the nature of this experience for nursing staff who are caring for patients who are presenting with risks to themselves.