The questioning of intuition; a post structural analysis of nurses’ stories

Abstract

Aim. The aim of this thesis is to question intuition, and analyse factors which influence Registered Nurses decision making, when recognising and responding to an acutely ill patient. Background. Two models of decision making are historically identified in the literature, the Hypothetical - Deductive reasoning and Intuitive-Humanist (Banning, 2008), with the Hypothetical - Deductive reasoning model initially adopted, to offer authority to nursing as a science (Dowding, 2008; Krishnan, 2018). The Intuitive-Humanist model came to the fore through the work of Benner (1984) and Benner and Tanner (1987), who stated that intuition is an essential part of clinical decision making, emphasising the importance of person-centred nursing care. Intuition in nursing is afforded credibility as a legitimate form of knowledge (Benner, 1983; Green, 2012), particularly in relation to the ‘expert’ nurse, who is able to demonstrate an “intuitive grasp” of each situation, utilising a wealth of experience (Benner, 1983). But intuition is an abstract notion (Green, 2012), in order to study the role of ‘intuition’ in nursing practice, and the rhetoric that affords it legitimacy, means questioning how it is viewed in the current nursing paradigm, which I aim to do in my thesis. Because much of the current data on expert intuition is based on nurses caring for acutely ill/deteriorating patients, this became a point of reference, to ensure a focus for the data collection, and the application of the findings from the data analysis to the discussion and conclusion. Methodology. Data was collected using a naturalistic focus group, with a group of experienced nurses on a Continuous Professional Development programme, with the University of Wolverhampton. The participants were asked to consider a time when they had cared for an acutely ill patient, they were then given one minute to write down ten words related to the scenario, this gave a focus for the subsequent paragraph they were asked to write, and stories they were asked to relate. Analysis. The data analysis was completed using the post structuralist philosophy of Roland Barthes, diachronic evidence from the literature review, was compared to the synchronic evidence from the data analysis, interrogating the text to potentially present an alternative perspective, from what is already ‘known.’ Dissemination of findings. Socratic questioning facilitated interrogation of the text, the data analysis was summarised into four themes, for the summary of findings, What knowledge means to nursing and the impact this has on decision making. Nursing feeling vulnerable and isolated, and the link between the two. Emotion is associated with intuition, the manifestation of emotion and its meaning to nursing. Patients or protocols? The diachronic evidence of the literature review was compared to the synchronic evidence of the interrogation of the text to address the questions, whilst there is some agreement, mostly the synchronic evidence contradicted the diachronic evidence. Conclusion. Despite the drive to identify specific nursing knowledge, particularly when involved with an acutely ill patient knowledge, knowledge is an assumed and expected attribute of nursing. Knowledge is tied up, in the culture of nursing as a societal group, which as long as this is understood by the members of the societal group, the need to understand it, particularly with its link to intuition becomes irrelevant. Personal agency and salience are tied up in being a member of the societal group, not just nursing, but also part of a recognised team. Judgement of others comes from not having the same cultural values, as nursing, despite being in a societal group, in a clinical placement area. Knowledge, to nursing, is not related to evidence-based practise, but being up to date and informed about the patient. The relationship between the patient, the relatives, and the nurse is significant, with shared values and expectations, although the relationship is not one sided, with the nurse being the can giver, and the patient being dependent on the nurse. There is a sense of co-dependency which strengthens the relationship, but also leads to a sense of vulnerability for both the nurse and the patient. The sense of vulnerability, also occurs, not from being faced with a new situation, but being outside a societal group, with a sense of isolation. Nurses are not scared of ‘getting it wrong’, but being isolated, because of the humanistic element of their approach. Actions and behaviour are what define nursing practise, knowledge is locked up in these, and are related to cultural norms and language. This is how nursing should be defined, by what is done, the actions and behaviours which indicate what nursing is, and the knowledge and language that informed this. Emotion is frequently linked to intuition, but again this is physical, a response, behaviour, and actions. Patient focused care is fundamental to nursing, most policies and procedures are valued, mainly as legal protection, the moral obligation to the patient, and to self, are fundamentally more important than the risk of not adhering to policies and procedures. Gathering policies, understanding their use, is linked to the notion of an expert, but the linear trajectory of novice to expert, is challenged due to elements of uncertainty, mainly related to being outside the societal group and a loss of shared cultural values.