585618
research-article2015
NSQXXX10.1177/0894318415585618Nursing Science QuarterlyPayne
Article Nursing Science Quarterly 2015, Vol. 28(3) 223–228 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318415585618 nsq.sagepub.com
Toward a Theory of Intuitive Decision–Making in Nursing Lesle Karns Payne, RN; PhD1
Abstract The author in this article presents a theory of decision-making in nursing, specifically a middle-range theory of intuitive decision-making in nursing created through the synthesis of Patricia Benner’s model of skill acquisition in nursing and Damasio’s somatic marker hypothesis. The author proposes that Damasio’s somatic state is equivalent to what Benner has identified as intuition. When a nurse is faced with a decision, intuition, if developed, is a somatic state that creates a measurable physiological biasing signal (skin conductive response) that helps in making an advantageous decision. Research, educational, clinical and theoretical implications are discussed. Keywords continuing nursing education, decision-making, intuition, nurse education, nursing theory
Sound clinical decision-making is the cornerstone of excellent nursing care. Experienced nurses make fewer errors in decision-making and these nurses tend to report differences in the way they make decisions. Specifically, when compared with new graduate nurses, experienced expert nurses report greater use of intuitive decision-making (Pretz & Folse, 2011; Rew & Barrow, 2007; Traynor, Boland & Niels, 2010). However, the definition of intuition and intuitive decisionmaking vary widely, resulting in ambiguity and a belief that intuitive decision-making is inferior to other forms of decision-making. Intuitive decision-making in nursing has been studied almost exclusively using subjective descriptive studies that utilize written scenarios to gauge decision-making (Rew & Barrow, 2007). While this has resulted in a good description of the phenomenon, science does not yet offer physical methods to measure or test for the presence or absence of intuitive decision-making in nursing. According to Walker and Avant (2011), middle-range theories are to “describe, explain, or predict phenomena…and they must be explicit and testable” (p. 205). Thus the purpose of this article is to present the middle-range theory of intuitive decisionmaking in nursing that is explicit and incorporates a testable physiologic marker for the presence of this phenomenon.
Methods The theory of intuitive decision-making in nursing was developed through the use of theory synthesis (Walker & Avant, 2011) and empirical evidence derived from research. Both inductive and deductive reasoning were incorporated in this process. Development of this theory began with a review of the literature to identify existing theories that could be
applied to intuitive decision-making in nursing. Next, a further review of the literature focused on key concepts discovered in the existing theories identified in the first literature review. Keyword searches of The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medline identified research studies pertaining to the key concepts related to decision-making, intuition and nursing: intuition, somatic state, pattern recognition, memory, and decisionmaking. Finally, key concepts were theoretically and operationally defined and related factors and relationships between these concepts were identified. Finally, a synthesis of findings and an integrated representation of the theory were constructed (Walker & Avant, 2005).
Literature Review: Somatic Marker Hypothesis One of the two existing theoretical frameworks upon which construction of the theory of intuitive decision-making in nursing is based is the somatic marker hypothesis (SMH). The SMH proposes that decision-making is greatly affected by alterations in somatic emotion and feeling, which includes signals that arise from bio-regulatory processes. These regulatory processes manifest themselves as somatic emotion and feeling, are conscious or unconscious, and can occur at multiple stages within the process of decision-making (Bechara, Damasio, & Damasio, 2003). The SMH is an anatomical as well as cognitive framework for the influence that somatic states (emotion) have on decision-making. The term somatic refers to neural 1
Assistant Professor, Baylor University
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activation patterns taking place as a result of a learned connection between stimulus and outcomes (patterns) (Damasio, 1996). The SMH is based on three main assumptions: 1. Human reasoning and decision-making are dependent on varying levels of neural activities both conscious and unconscious. The cognitive (conscious) operations are dependent on sensory input gained from interaction of early sensory neural cortices. 2. These cognitive activities (independent of their content) are dependent on support processes such as memory, attention, and emotion. 3. Reasoning and decision-making are dependent on the availability of specific knowledge pertaining to the current situation and options for specific outcomes. This knowledge is stored in implicit and organized forms within higher-order cortices of the brain. To support the idea that the emotional apparatus (limbic system) is integral to the process of decision-making, classic research incorporating the SMH involved a novel gambling study comparing controls who had no brain damage with subjects who had damage to the ventromedial area of the brain. Bechara, Damasio, and Damasio (1997) monitored the levels of psychophysiological activity during the administration of the Iowa Gambling Task (IGT) by recording the measurement of skin conductance response (SCR). The results demonstrated that the normal control group and subjects who had damage to the ventromedial area of the brain generated SCRs in reaction to both reward and punishment. However, the normal control group began to generate SCRs in anticipation of the selection of a card while the subjects with ventromedial damage did not. The SCRs became more pronounced in the control group just prior to choosing a card from the “bad” decks, but was absent from the subjects with ventromedial damage. This led to the hypothesis that the anticipatory SCRs were not merely associated with the result of the decision, but were in fact, guiding the decision (Bechara, Damasio & Damasio, 1997). The SMH emerged after the researchers hypothesized that the absence of anticipatory SCRs indicated an individual’s inability to enact a somatic state required to aid in an advantageous decision (Bechara et al., 1997). When subjects faced a situation that required factual knowledge to be categorized and understood, appropriate links were activated in the higher order cortices, as well as the emotional apparatus, leading to the recall of the necessary information, enabling an appropriate decision. It was the combination of these states that prompted the reconstruction of previously learned data, and identification of relationships between data, and in other words, pattern recognition. Damasio (1996) defined one function of emotion in his statement “the somatic state is alerting you to the goodness or badness of a certain option-outcome pair…When the process is covert the somatic state constitutes a biasing signal” (p. 1415). These statements imply that somatic states are
causal in the cognitive recognition of the goodness or badness of a choice. He provided another logical clarifying statement, “Somatic markers participate in process as well as content” (p.1415). The somatic system acts as moderator during decision-making and is not just the result of the decision. Damasio provided further clarification on the nature of somatic states with the following: “Certain emotion-related somatosensory patterns also act as boosters in the processes of attention and working memory…. somatic markers facilitate logical reasoning” (p.1415). This would imply that somatic states not only arise in response to a decision, but also truly aid in the making of a decision. Based on the somatic marker hypothesis, it is theorized that intuitive decision-making in nursing practice results, in part, as a response to observable biological signals.
From Novice to Expert Patricia Benner’s From Novice to Expert (1984) (NTE) is the second theoretical framework on which the theory of intuitive decision-making in nursing is based. Nursing has long recognized that intuition specific to nursing is founded on nursing experience (Benner, Tanner & Chesla, 2009; Pearson, 2013). Nursing experience can be defined as the summation of all exposure to domain-specific nursing knowledge. This knowledge is obtained from formal and continuing education (didactic), as well as from simulated and clinical experience (tacit). However, clinical experience alone is not sufficient for the development of intuition (Benner, 1984). Benner theorized that nurses go through five stages of clinical competence. In the first and novice stage, the nurses are analytical and do not have domain-specific experiences to guide their decisionmaking. Benner said that decisions made by novice nurses are therefore analytical and rule-based. Experienced nurses display early recognition of the clinical problem and quick identification of the nuances of the situation, and exhibit rapid decision-making. Less experienced nurses view clinical situations as procedural or theoretical puzzles, and analyze clinical situations slowly and methodically before making decisions. The nurse progresses through the advanced beginner, competent and proficient stages before reaching the expert stage of clinical competence. In this final stage the nurse does not rely on critical thinking or analytical decision-making, but rather on an intuitive grasp of the situation. In other words, the expert clinician has a deep understanding of the situation and is no longer consciously aware of all the rules governing actions. The expert nurse’s brain has non-consciously combined pattern recognition (based on tacit and didactic knowledge) and memory, to aid in decision-making (Benner et al., 2009).
Definition of Key Concepts Intuition Intuition is universally acknowledged as an integral part of nurses’ decision-making (Benner, Tanner & Chesla, 2009,
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Payne Gobert & Chassy, 2008; Rew & Barrow, 2007; Smith, 2009). The definition of intuition varies from author to author, however, resulting in an unclear and incoherent understanding of an important concept. Much of the nursing literature dealing with intuition relies on the subjective perception of nurses to determine if they used intuition (Bakalis, 2006; Pretz & Folse, 2011). Most of these descriptive studies take the form of literature reviews, are exploratory in nature, and lack seminal research. (Rew & Barrow, 2007). These reviews do enable researchers to know about intuitive decision-making, but they do not give the researcher access to the process of intuitive decision-making itself (Bakalis, 2006; Pretz & Folse, 2011; Rew & Barrow, 2007; Smith, 2009). In this article, intuition is operationally defined as a non-conscious and non-analytical state of knowing.
Somatic State For this theory, somatic state is operationally defined as a non-conscious state in which neural activation configurations have occurred as a result of the learned connection between memory, task specific knowledge, and pattern recognition. This somatic state is congruent with intuition; it is a state of knowing.
Skin Conductive Response Since the 1900’s, electrodermal activity has been theorized to be a measure of the psycho-physiological states of arousal, attention, and emotion. The first observations of connections between the electrical state of the skin and psychological factors were observed in 1879, but it was not until 25 years later that concentrated research began. In 1904, Carl Jung used electrodermal activity as a measureable variable when seeking responses to emotional stimuli invoked by spoken words. He found a significant proportional relationship between level of skin conductance and the type and degree of emotion elicited (Dawson et al. 2000). Classic research has shown that the palmar sweat glands are innervated by the sympathetic nervous system. Studies have provided further validation of central nervous system control by measuring sympathetic action potential in the peripheral nerves and electrodermal activity simultaneously (Dawson et al., 2000). Subtle changes in sympathetic activation result in greater sweat production that elevates skin conductance. The results have shown that when there is normal temperature in the room and the subject is normothermic, there is a high correlation between sympathetic nerve activity and the capacity of the skin surface to conduct electrical currents measurable by SCR. SCR is the measurement of brief, but significant, departures of skin conductance level from a running baseline. Skin conductance level (SCL) is the baseline level of skin surface conduction and can slowly rise or fall over time. While there are several factors that can cause the baseline (SCL) level to vary (for example, changes
in anxiety level), SCRs are produced in response to stimuli, are short in duration, and are unique because an SCR is measured with respect to an individual’s baseline (SCL). Therefore, an SCR signifies sympathetic activation in response to stimuli. These stimuli can be peripheral (for example, a loud noise) or internal (for example, problemsolving) (Dawson et al., 2000). For this theory, SCR is defined as the brief but significant rise in the level of electrical conductance of the skin from the running baseline SCL. It is theorized that intuitive decisionmaking is aided by these signals created by a somatic state.
Nursing Experience Nursing experience is defined as the sum of all exposure to domain specific nursing knowledge. This includes formal and continuing education as well as clinical exposure. Experience alone is not sufficient for the development of intuition (Benner, 1984; Pretz & Folse, 2011). The outcomes of years of nursing experience include pattern recognition and memory development.
Pattern Recognition Pattern recognition is defined as the ability to fully comprehend the relationships between variables. Pattern recognition in nursing is acknowledged as central to nursing expertise and is often studied in relation to intuition (Benner, 1984, Benner et al., 2009; Smith, 2009). It is developed through nursing experience (tacit and didactic) and is dependent on memory. Novice nurses need patterns to be explicitly identified.
Memory Memory is defined as the conscious ability to recall information; it is the reconstruction of previously learned data (Bechara, Damasio, & Damasio, 2003, Damasio, 1996). It is an integral aspect of decision-making (Rew & Barrow, 2007) and is important in the development of intuition and pattern recognition.
Decision-making Decision-making is defined as the process of making a choice. The physiology of decision-making is complex and involves interaction between many areas of the brain. Numerous studies have been undertaken with the intent to localize and define the areas of the brain that are responsible for particular executive functions (Bechara et al., 2003). Decision-making is also influenced by signals that arise from bioregulatory mechanisms (Hinson et al., 2002). These regulatory mechanisms include processes that are both conscious (manifest themselves as tangible feelings), and unconscious. Making a decision requires the integration of sensory, limbic,
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Figure 1. Theory of Intuitive Decision-Making in Nursing.
and autonomic information and is dependent on memory, somatic emotion, and cognition (Bechara et al., 2003).
Theory of Intuitive Decision-Making in Nursing The theory of intuitive decision-making in nursing was developed through the synthesis of NTE and the SMH (Figure 1). According to Benner (1984), as nurses increase their experience through the integration of memory and pattern recognition, they progress through identifiable stages and ultimately develop a deep understanding of phenomena (Benner, 1984). According to NTE, intuition develops after this deep understanding is established. SMH suggests that a somatic state is created when pattern recognition is developed, resulting in a biasing signal that aids in decision-making. The theory of decision-making in nursing proposes that the SMH’s somatic state is equivalent to what Benner has identified as intuition. When a nurse is faced with a decision, intuition, if developed, is a somatic state that creates a biasing signal (SCR) that aids in the making of an advantageous decision (Bechara et al., 2003; Damasio, 1996). Intuitive decision-making is a non-conscious event orchestrated by the
mind. The mind has integrated memory and pattern recognition without cognitive direction. If intuition is not developed, the nurse must cognitively and analytically appraise the situation through the conscious integration of memory and pattern recognition to reach a decision. Analytical decisions require conscious, logical, and sequential thought processes.
Theoretical Assumptions •• Nursing experience produces working memory and pattern recognition (NTE). •• Nursing intuition develops after a deep understanding of the relationship between memory and pattern recognition is established (NTE). •• When faced with a decision, intuition, if developed, is a somatic state (SMH). •• The somatic state creates a non-conscious bias signal alerting one to the required appropriate action (SMH). •• The signal can be objectively measured by the presence of a skin conductive response. •• Intuitive decision-making in nursing is a decision that is guided by a domain specific somatic state (NTE, SMH).
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Empirical Evidence Supporting Assumptions Much research has been conducted on the development of intuition (Benner et al., 2009; Rew & Barrow, 2007, Smith, 2009) and the SMH (Fernie & Tunnery, 2013, Hinson, et al. 2002). A decision-making model developed and tested based on the SMH describes intuitive decisionmaking in fighter pilots (Hoogendoorn, Merk, & Treur, 2009). However, there is only one study that has combined the NTE with the SMH within nursing science. Payne (2013) found physiologic differences between experienced and new nurses during a decision-making exercise. In this pilot study, seasoned nurses generated significantly more SCRs and performed better than recent nurse graduates. Payne hypothesized that new nurses were unable to enact a somatic state to aid in the decision. This study had a small sample size and needs to be replicated to provide stronger empirical evidence for the theory of intuitive decisionmaking in nursing.
Research Implications According to Rew and Barrow (2007), the majority of studies that investigate intuition within nursing are of a descriptive, exploratory nature. Rew also stated that she found no physiological method in the literature that attempted to identify and measure the use of nursing intuition. The theory described here helps to fill that gap by providing a much-needed novel and alternate approach to the study of intuition. Other studies like the pilot study would allow for physiological quantification of intuitive decision-making in nursing.
Educational Implications The theory of intuitive decision-making in nursing also provides an avenue to measure objectively the effectiveness of interventions aimed at the development of intuitive decisionmaking. Specifically, one could compare the effectiveness of experience (tacit learning) and explicit instruction on the development of intuitive-decision making. Nurses have recognized that intuition specific to nursing is based on experience (Benner & Tanner, 2009). Hogarth (2001) stated that intuition is domain specific; intuition is only developed in areas in which subjects have acquired great experience. Thus, educating intuition is accomplished by engineering the environment to simulate specific experience. Simulation is generally viewed as necessary in nurse education and several studies have reported that simulation has a great impact on clinical decision-making (Lasater, 2005). The theory described in this article provides a basis for the development of tools to gauge the tangible effect of simulation on the development of intuition in nursing.
Theoretical Implications One of the most recognized frameworks within nursing is Benner’s From Novice to Expert (1984). Benner proposed that nurses develop a mode of intuitive decision-making with experience. She also postulated that experienced nurses who use intuition make better decisions. The middle-range theory of intuitive decision-making in nursing provides a framework in which to support From Novice to Expert. It also may be used to incorporate intuition into cohesive theories and models of practice, including evidence-based practice. By combining this theory with existing theories and with using qualitative and quantitative research, scholars may be able to study the physiological components involved in clinical decision-making in nursing (Banning, 2008, Rew & Barrow, 2007).
Clinical Implications Research has shown that experienced nurses make fewer errors and report the use of intuition in making clinical decisions (Benner 1984; Benner et al., 2009; Traynor, Boland & Niels, 2010). If SCRs, as set forth here can be used to measure sympathetic activity quantitatively, the level of intuition used during decision-making in nursing practice can be discovered. Decision-making models for nursing practice, based on this theory, may have profound effects, not only on understanding the way nurses make decisions, but also on ways in which hospitals can aid in the development of intuitive decision-making in their nurses.
Conclusion The theory of intuitive decision-making in nursing is a logical and cohesive theory that is explanatory, predictive, and testable. The author provided theoretical and operational definitions for key concepts and described the relationship among variables. While it is congruent with what is already known about the phenomenon, further empirical validation is warranted. This theory can be used for theory validation, development of educational frameworks to guide research, and the production of testable hypotheses for practice models. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author received no financial support for the research, authorship, and/or publication of this article.
References Bakalis, N. (2006). Clinical decision-making in cardiac nursing: A review of the literature. Nursing Standard, 21(12), 39-46.
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Bechara A., Damasio H., & Damasio A. R. (2003). Role of the amygdala in decision-making. Annals of the New York Academy of Sciences; 985: 356-369. Bechara, A., Damasio, H., Tranel, D., & Damasio, A. R. (1997). Deciding advantageously before knowing the advantageous strategy. Science, 275, 1293-1295. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Benner P., Tanner C, Chesla C. (2009). Expertise in nursing practice: Caring, clinical judgment, and ethics. 2nd edition. New York: Springer Publishing Company. Damasio, A. R. (1996). The somatic marker hypothesis and the possible functions of the prefrontal cortex. Philosophical Transactions of the Royal Society of London Series B: Biological Sciences, 351(1346), 1413-1420. Dawson, M. E., Schell, A. M., & Filion, D. L. (2000). The electrodermal system. In J. Cacioppo, L. Tassinary & G. Bernston (Eds.), Handbook of psychophysiology (pp. 200-223). Cambridge, England: Cambridge University Press. Fernie, G., & Tunnery, R.J. (2013). Learning on the IGT follows emergent of knowledge but not differential somatic activity. Frontiers in Psychology. 4. 1-13. Doi:10.3389/ fpsyg.2013.00687. Gobet, F., & Chassy, P. (2008). Towards an alternative to Benner’s theory of expert intuition in nursing: A discussion paper. International Journal of Nursing Studies, 45(1), 129- 39. Hammond, K. R. (2000). Judgments under stress. New York: Oxford University Press. Hinson, J. M., Jameson, T. L., & Whitney, P. (2002). Somatic markers, working memory, and decision making. Cognitive, Affective & Behavioral Neuroscience, 2(4), 341-353.
Hogarth RM (2001) Educating Intuition. University of Chicago Press, Chicago. Hoogendoorn, M., Merk, R., Roessingh, J. J., & Treur. J. (2009). Modelling a fighter pilot’s intuition in decision making on the basis of Damasio’s Somatic Marker Hypothesis. Proceedings of the 17th Congress of the International Ergonomics Association. Lasater, K. (2005). Human patient simulation: Impact on the development of clinical judgment. Communicating Nursing Research, 38, 199. Payne, L. K. (2013). Physiological Differences During Decisionmaking Between Experienced and Student Nurses: a Pilot Study. Journal of Nursing Education, 52(11). 649-52. doi:10.3928/01484834-20131017-02 Pearson, H. (2013). Science and intuition: do both have a place in clinical decision making? British Journal of Nursing, 22(4). 212-215. Pretz, Je., & Folse, VN. (2011) Nursing experience and preference for intuition in decision making. Journal of Clinical Nursing, 20, 2878–2889. doi:10.1111/j.1365-2702.2011.03705.x Rew, L., & Barrow, E. M., Jr. (2007). State of the science: Intuition in nursing, a generation of studying the phenomenon. Advances in Nursing Science, 30(1), E15-25. Smith A. (2009). Exploring the legitimacy of intuition as a form of nursing knowledge. Nurs Stan. 23:(40): 35-40. Traynor, M., Boland, M. & Niels, B. (2010). Autonomy, evidence and intuition: nurses and decision-making. Journal of Advanced Nursing, 66(7), 1584-91. doi:10.1111/j.13652648.2010.05317.x Walker, L.O., & Avant, K.C. (2011) Strategies for theory Construction in Nursing, 5th ed. Pearson/Prentice Hall. New Jersey.
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research-article2015
NSQXXX10.1177/0894318415585618Nursing Science QuarterlyPayne
Article Nursing Science Quarterly 2015, Vol. 28(3) 223–228 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318415585618 nsq.sagepub.com
Toward a Theory of Intuitive Decision–Making in Nursing Lesle Karns Payne, RN; PhD1
Abstract The author in this article presents a theory of decision-making in nursing, specifically a middle-range theory of intuitive decision-making in nursing created through the synthesis of Patricia Benner’s model of skill acquisition in nursing and Damasio’s somatic marker hypothesis. The author proposes that Damasio’s somatic state is equivalent to what Benner has identified as intuition. When a nurse is faced with a decision, intuition, if developed, is a somatic state that creates a measurable physiological biasing signal (skin conductive response) that helps in making an advantageous decision. Research, educational, clinical and theoretical implications are discussed. Keywords continuing nursing education, decision-making, intuition, nurse education, nursing theory
Sound clinical decision-making is the cornerstone of excellent nursing care. Experienced nurses make fewer errors in decision-making and these nurses tend to report differences in the way they make decisions. Specifically, when compared with new graduate nurses, experienced expert nurses report greater use of intuitive decision-making (Pretz & Folse, 2011; Rew & Barrow, 2007; Traynor, Boland & Niels, 2010). However, the definition of intuition and intuitive decisionmaking vary widely, resulting in ambiguity and a belief that intuitive decision-making is inferior to other forms of decision-making. Intuitive decision-making in nursing has been studied almost exclusively using subjective descriptive studies that utilize written scenarios to gauge decision-making (Rew & Barrow, 2007). While this has resulted in a good description of the phenomenon, science does not yet offer physical methods to measure or test for the presence or absence of intuitive decision-making in nursing. According to Walker and Avant (2011), middle-range theories are to “describe, explain, or predict phenomena…and they must be explicit and testable” (p. 205). Thus the purpose of this article is to present the middle-range theory of intuitive decisionmaking in nursing that is explicit and incorporates a testable physiologic marker for the presence of this phenomenon.
Methods The theory of intuitive decision-making in nursing was developed through the use of theory synthesis (Walker & Avant, 2011) and empirical evidence derived from research. Both inductive and deductive reasoning were incorporated in this process. Development of this theory began with a review of the literature to identify existing theories that could be
applied to intuitive decision-making in nursing. Next, a further review of the literature focused on key concepts discovered in the existing theories identified in the first literature review. Keyword searches of The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medline identified research studies pertaining to the key concepts related to decision-making, intuition and nursing: intuition, somatic state, pattern recognition, memory, and decisionmaking. Finally, key concepts were theoretically and operationally defined and related factors and relationships between these concepts were identified. Finally, a synthesis of findings and an integrated representation of the theory were constructed (Walker & Avant, 2005).
Literature Review: Somatic Marker Hypothesis One of the two existing theoretical frameworks upon which construction of the theory of intuitive decision-making in nursing is based is the somatic marker hypothesis (SMH). The SMH proposes that decision-making is greatly affected by alterations in somatic emotion and feeling, which includes signals that arise from bio-regulatory processes. These regulatory processes manifest themselves as somatic emotion and feeling, are conscious or unconscious, and can occur at multiple stages within the process of decision-making (Bechara, Damasio, & Damasio, 2003). The SMH is an anatomical as well as cognitive framework for the influence that somatic states (emotion) have on decision-making. The term somatic refers to neural 1
Assistant Professor, Baylor University
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activation patterns taking place as a result of a learned connection between stimulus and outcomes (patterns) (Damasio, 1996). The SMH is based on three main assumptions: 1. Human reasoning and decision-making are dependent on varying levels of neural activities both conscious and unconscious. The cognitive (conscious) operations are dependent on sensory input gained from interaction of early sensory neural cortices. 2. These cognitive activities (independent of their content) are dependent on support processes such as memory, attention, and emotion. 3. Reasoning and decision-making are dependent on the availability of specific knowledge pertaining to the current situation and options for specific outcomes. This knowledge is stored in implicit and organized forms within higher-order cortices of the brain. To support the idea that the emotional apparatus (limbic system) is integral to the process of decision-making, classic research incorporating the SMH involved a novel gambling study comparing controls who had no brain damage with subjects who had damage to the ventromedial area of the brain. Bechara, Damasio, and Damasio (1997) monitored the levels of psychophysiological activity during the administration of the Iowa Gambling Task (IGT) by recording the measurement of skin conductance response (SCR). The results demonstrated that the normal control group and subjects who had damage to the ventromedial area of the brain generated SCRs in reaction to both reward and punishment. However, the normal control group began to generate SCRs in anticipation of the selection of a card while the subjects with ventromedial damage did not. The SCRs became more pronounced in the control group just prior to choosing a card from the “bad” decks, but was absent from the subjects with ventromedial damage. This led to the hypothesis that the anticipatory SCRs were not merely associated with the result of the decision, but were in fact, guiding the decision (Bechara, Damasio & Damasio, 1997). The SMH emerged after the researchers hypothesized that the absence of anticipatory SCRs indicated an individual’s inability to enact a somatic state required to aid in an advantageous decision (Bechara et al., 1997). When subjects faced a situation that required factual knowledge to be categorized and understood, appropriate links were activated in the higher order cortices, as well as the emotional apparatus, leading to the recall of the necessary information, enabling an appropriate decision. It was the combination of these states that prompted the reconstruction of previously learned data, and identification of relationships between data, and in other words, pattern recognition. Damasio (1996) defined one function of emotion in his statement “the somatic state is alerting you to the goodness or badness of a certain option-outcome pair…When the process is covert the somatic state constitutes a biasing signal” (p. 1415). These statements imply that somatic states are
causal in the cognitive recognition of the goodness or badness of a choice. He provided another logical clarifying statement, “Somatic markers participate in process as well as content” (p.1415). The somatic system acts as moderator during decision-making and is not just the result of the decision. Damasio provided further clarification on the nature of somatic states with the following: “Certain emotion-related somatosensory patterns also act as boosters in the processes of attention and working memory…. somatic markers facilitate logical reasoning” (p.1415). This would imply that somatic states not only arise in response to a decision, but also truly aid in the making of a decision. Based on the somatic marker hypothesis, it is theorized that intuitive decision-making in nursing practice results, in part, as a response to observable biological signals.
From Novice to Expert Patricia Benner’s From Novice to Expert (1984) (NTE) is the second theoretical framework on which the theory of intuitive decision-making in nursing is based. Nursing has long recognized that intuition specific to nursing is founded on nursing experience (Benner, Tanner & Chesla, 2009; Pearson, 2013). Nursing experience can be defined as the summation of all exposure to domain-specific nursing knowledge. This knowledge is obtained from formal and continuing education (didactic), as well as from simulated and clinical experience (tacit). However, clinical experience alone is not sufficient for the development of intuition (Benner, 1984). Benner theorized that nurses go through five stages of clinical competence. In the first and novice stage, the nurses are analytical and do not have domain-specific experiences to guide their decisionmaking. Benner said that decisions made by novice nurses are therefore analytical and rule-based. Experienced nurses display early recognition of the clinical problem and quick identification of the nuances of the situation, and exhibit rapid decision-making. Less experienced nurses view clinical situations as procedural or theoretical puzzles, and analyze clinical situations slowly and methodically before making decisions. The nurse progresses through the advanced beginner, competent and proficient stages before reaching the expert stage of clinical competence. In this final stage the nurse does not rely on critical thinking or analytical decision-making, but rather on an intuitive grasp of the situation. In other words, the expert clinician has a deep understanding of the situation and is no longer consciously aware of all the rules governing actions. The expert nurse’s brain has non-consciously combined pattern recognition (based on tacit and didactic knowledge) and memory, to aid in decision-making (Benner et al., 2009).
Definition of Key Concepts Intuition Intuition is universally acknowledged as an integral part of nurses’ decision-making (Benner, Tanner & Chesla, 2009,
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Payne Gobert & Chassy, 2008; Rew & Barrow, 2007; Smith, 2009). The definition of intuition varies from author to author, however, resulting in an unclear and incoherent understanding of an important concept. Much of the nursing literature dealing with intuition relies on the subjective perception of nurses to determine if they used intuition (Bakalis, 2006; Pretz & Folse, 2011). Most of these descriptive studies take the form of literature reviews, are exploratory in nature, and lack seminal research. (Rew & Barrow, 2007). These reviews do enable researchers to know about intuitive decision-making, but they do not give the researcher access to the process of intuitive decision-making itself (Bakalis, 2006; Pretz & Folse, 2011; Rew & Barrow, 2007; Smith, 2009). In this article, intuition is operationally defined as a non-conscious and non-analytical state of knowing.
Somatic State For this theory, somatic state is operationally defined as a non-conscious state in which neural activation configurations have occurred as a result of the learned connection between memory, task specific knowledge, and pattern recognition. This somatic state is congruent with intuition; it is a state of knowing.
Skin Conductive Response Since the 1900’s, electrodermal activity has been theorized to be a measure of the psycho-physiological states of arousal, attention, and emotion. The first observations of connections between the electrical state of the skin and psychological factors were observed in 1879, but it was not until 25 years later that concentrated research began. In 1904, Carl Jung used electrodermal activity as a measureable variable when seeking responses to emotional stimuli invoked by spoken words. He found a significant proportional relationship between level of skin conductance and the type and degree of emotion elicited (Dawson et al. 2000). Classic research has shown that the palmar sweat glands are innervated by the sympathetic nervous system. Studies have provided further validation of central nervous system control by measuring sympathetic action potential in the peripheral nerves and electrodermal activity simultaneously (Dawson et al., 2000). Subtle changes in sympathetic activation result in greater sweat production that elevates skin conductance. The results have shown that when there is normal temperature in the room and the subject is normothermic, there is a high correlation between sympathetic nerve activity and the capacity of the skin surface to conduct electrical currents measurable by SCR. SCR is the measurement of brief, but significant, departures of skin conductance level from a running baseline. Skin conductance level (SCL) is the baseline level of skin surface conduction and can slowly rise or fall over time. While there are several factors that can cause the baseline (SCL) level to vary (for example, changes
in anxiety level), SCRs are produced in response to stimuli, are short in duration, and are unique because an SCR is measured with respect to an individual’s baseline (SCL). Therefore, an SCR signifies sympathetic activation in response to stimuli. These stimuli can be peripheral (for example, a loud noise) or internal (for example, problemsolving) (Dawson et al., 2000). For this theory, SCR is defined as the brief but significant rise in the level of electrical conductance of the skin from the running baseline SCL. It is theorized that intuitive decisionmaking is aided by these signals created by a somatic state.
Nursing Experience Nursing experience is defined as the sum of all exposure to domain specific nursing knowledge. This includes formal and continuing education as well as clinical exposure. Experience alone is not sufficient for the development of intuition (Benner, 1984; Pretz & Folse, 2011). The outcomes of years of nursing experience include pattern recognition and memory development.
Pattern Recognition Pattern recognition is defined as the ability to fully comprehend the relationships between variables. Pattern recognition in nursing is acknowledged as central to nursing expertise and is often studied in relation to intuition (Benner, 1984, Benner et al., 2009; Smith, 2009). It is developed through nursing experience (tacit and didactic) and is dependent on memory. Novice nurses need patterns to be explicitly identified.
Memory Memory is defined as the conscious ability to recall information; it is the reconstruction of previously learned data (Bechara, Damasio, & Damasio, 2003, Damasio, 1996). It is an integral aspect of decision-making (Rew & Barrow, 2007) and is important in the development of intuition and pattern recognition.
Decision-making Decision-making is defined as the process of making a choice. The physiology of decision-making is complex and involves interaction between many areas of the brain. Numerous studies have been undertaken with the intent to localize and define the areas of the brain that are responsible for particular executive functions (Bechara et al., 2003). Decision-making is also influenced by signals that arise from bioregulatory mechanisms (Hinson et al., 2002). These regulatory mechanisms include processes that are both conscious (manifest themselves as tangible feelings), and unconscious. Making a decision requires the integration of sensory, limbic,
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Figure 1. Theory of Intuitive Decision-Making in Nursing.
and autonomic information and is dependent on memory, somatic emotion, and cognition (Bechara et al., 2003).
Theory of Intuitive Decision-Making in Nursing The theory of intuitive decision-making in nursing was developed through the synthesis of NTE and the SMH (Figure 1). According to Benner (1984), as nurses increase their experience through the integration of memory and pattern recognition, they progress through identifiable stages and ultimately develop a deep understanding of phenomena (Benner, 1984). According to NTE, intuition develops after this deep understanding is established. SMH suggests that a somatic state is created when pattern recognition is developed, resulting in a biasing signal that aids in decision-making. The theory of decision-making in nursing proposes that the SMH’s somatic state is equivalent to what Benner has identified as intuition. When a nurse is faced with a decision, intuition, if developed, is a somatic state that creates a biasing signal (SCR) that aids in the making of an advantageous decision (Bechara et al., 2003; Damasio, 1996). Intuitive decision-making is a non-conscious event orchestrated by the
mind. The mind has integrated memory and pattern recognition without cognitive direction. If intuition is not developed, the nurse must cognitively and analytically appraise the situation through the conscious integration of memory and pattern recognition to reach a decision. Analytical decisions require conscious, logical, and sequential thought processes.
Theoretical Assumptions •• Nursing experience produces working memory and pattern recognition (NTE). •• Nursing intuition develops after a deep understanding of the relationship between memory and pattern recognition is established (NTE). •• When faced with a decision, intuition, if developed, is a somatic state (SMH). •• The somatic state creates a non-conscious bias signal alerting one to the required appropriate action (SMH). •• The signal can be objectively measured by the presence of a skin conductive response. •• Intuitive decision-making in nursing is a decision that is guided by a domain specific somatic state (NTE, SMH).
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Empirical Evidence Supporting Assumptions Much research has been conducted on the development of intuition (Benner et al., 2009; Rew & Barrow, 2007, Smith, 2009) and the SMH (Fernie & Tunnery, 2013, Hinson, et al. 2002). A decision-making model developed and tested based on the SMH describes intuitive decisionmaking in fighter pilots (Hoogendoorn, Merk, & Treur, 2009). However, there is only one study that has combined the NTE with the SMH within nursing science. Payne (2013) found physiologic differences between experienced and new nurses during a decision-making exercise. In this pilot study, seasoned nurses generated significantly more SCRs and performed better than recent nurse graduates. Payne hypothesized that new nurses were unable to enact a somatic state to aid in the decision. This study had a small sample size and needs to be replicated to provide stronger empirical evidence for the theory of intuitive decisionmaking in nursing.
Research Implications According to Rew and Barrow (2007), the majority of studies that investigate intuition within nursing are of a descriptive, exploratory nature. Rew also stated that she found no physiological method in the literature that attempted to identify and measure the use of nursing intuition. The theory described here helps to fill that gap by providing a much-needed novel and alternate approach to the study of intuition. Other studies like the pilot study would allow for physiological quantification of intuitive decision-making in nursing.
Educational Implications The theory of intuitive decision-making in nursing also provides an avenue to measure objectively the effectiveness of interventions aimed at the development of intuitive decisionmaking. Specifically, one could compare the effectiveness of experience (tacit learning) and explicit instruction on the development of intuitive-decision making. Nurses have recognized that intuition specific to nursing is based on experience (Benner & Tanner, 2009). Hogarth (2001) stated that intuition is domain specific; intuition is only developed in areas in which subjects have acquired great experience. Thus, educating intuition is accomplished by engineering the environment to simulate specific experience. Simulation is generally viewed as necessary in nurse education and several studies have reported that simulation has a great impact on clinical decision-making (Lasater, 2005). The theory described in this article provides a basis for the development of tools to gauge the tangible effect of simulation on the development of intuition in nursing.
Theoretical Implications One of the most recognized frameworks within nursing is Benner’s From Novice to Expert (1984). Benner proposed that nurses develop a mode of intuitive decision-making with experience. She also postulated that experienced nurses who use intuition make better decisions. The middle-range theory of intuitive decision-making in nursing provides a framework in which to support From Novice to Expert. It also may be used to incorporate intuition into cohesive theories and models of practice, including evidence-based practice. By combining this theory with existing theories and with using qualitative and quantitative research, scholars may be able to study the physiological components involved in clinical decision-making in nursing (Banning, 2008, Rew & Barrow, 2007).
Clinical Implications Research has shown that experienced nurses make fewer errors and report the use of intuition in making clinical decisions (Benner 1984; Benner et al., 2009; Traynor, Boland & Niels, 2010). If SCRs, as set forth here can be used to measure sympathetic activity quantitatively, the level of intuition used during decision-making in nursing practice can be discovered. Decision-making models for nursing practice, based on this theory, may have profound effects, not only on understanding the way nurses make decisions, but also on ways in which hospitals can aid in the development of intuitive decision-making in their nurses.
Conclusion The theory of intuitive decision-making in nursing is a logical and cohesive theory that is explanatory, predictive, and testable. The author provided theoretical and operational definitions for key concepts and described the relationship among variables. While it is congruent with what is already known about the phenomenon, further empirical validation is warranted. This theory can be used for theory validation, development of educational frameworks to guide research, and the production of testable hypotheses for practice models. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author received no financial support for the research, authorship, and/or publication of this article.
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