1. Introduction

Nursing is a complex discipline that requires nurses to apply various forms of knowledge to guide their practice. At a time when the scientific community relied mostly on the objective, empirical, and analytical explanations of phenomena, Carper (1978) proposed the different patterns of knowing to structure nursing education and evaluate nursing practice. The different patterns of knowing are empirics, aesthetics, ethics, and personal. In her seminal work, Watson (1999) affirmed that in order to provide holistic care to patients, the use of the analytic process can be complemented by the art of nursing which can be promoted by incorporating aspects of the subjective, intuitive, sometimes mysterious, world of humans.

Intuition is a valid form of knowledge that promotes the rapid actuation of nursing decision to promote health and prevent negative patient outcomes. It is a form of aesthetic knowing with three defining attributes: knowledge, nurse-patient relationship, and holistic understanding of the patient situation. Knowledge is characterized as automated, immediate, and independent of linear reasoning process. It is the synthesis of previous, substantive information derived from relevant experiences. The nurse-patient relationship is characterized as a deep and unique connection between the nurse and the patient. Through this unique connection, the nurse is able to examine the patient beyond the scope of physical signs and symptoms that the patient may describe. The nurse’s holistic understanding of the patient situation enables him/her to create a mental picture of a possible patient condition. This mental simulation serves as a distress signal or alarm for the nurse to pay close attention to the patient, to intervene, and to make decisions quickly without conscious awareness.

Traditionally viewed as inapplicable in nursing science, growing evidence from the literature now suggest the fundamental role of intuition in nursing. The use of intuition in decision-making results in increased quality and safety of patient care (Johansson, Palmqvist, & Ronnberg, 2017; Price et al., 2016). Likewise, the use of intuition among nurses results to enhanced and focused care to critically ill patients (Hassani et al, 2016) and increased nurses’ sensitivity to patient needs (Holm & Severinsson, 2016). The contention that intuition is a valid form of knowing and that it has a positive impact in the therapeutic process are prompts to advance the theory of nursing intuition. This paper explicates a theory of nursing intuition including its philosophical underpinnings.

2. Theory of Nursing Intuition

The theory of nursing intuition is a middle-range theory that aims to deepen nurses’ understanding of the legitimacy of intuition as a form of knowing and to contribute to the development of intuitive skills among nurses. Although it is narrower than grand theories with limited number of variables (Fawcett, 2005), it provides the same usefulness offered by grand theories in explicating concepts within a nursing perspective (Walker & Avant, 2005) and in advancing the science of nursing. To promote understanding and appreciation of the theory, a description of the theoretical assumptions, key concepts, propositions, and metaparadigms are hereby discussed.

2.1. Assumptions of the Theory

For the purpose of developing a theory of nursing intuition, the author held the following assumptions:

1) The person is a holistic being composed of the physical, social, aesthetic, and moral dimensions which are interconnected.

2) The person is constantly influenced by events and issues in the environment.

3) The environment provides vast opportunities for experiences.

4) Experience promotes knowledge and understanding of the world.

5) Understanding of the world can be achieved through several patterns of knowing.

6) Nursing influences health outcomes.

7) Intuition is a form of knowing that can be developed among human beings.

2.2. Key Concepts of the Theory

The theory includes the following key concepts:

Intuition. Intuition is a form of knowing that allows the nurse to develop holistic awareness of the patient condition, to create a mental simulation of a possible health outcome, and to make decisions quickly without conscious awareness.

Knowing. Knowing refers to a dynamic process of understanding that results from personal reflection and transformation as the nurse lives and interacts in the world (Bonis, 2009). It provides a rationale which the nurse can rely on to understand the patient’s experience of health and illness and to provide a unique type of individualized, holistic care.

Holistic care. Holistic care is a form of moral commitment towards protecting human welfare and focuses on healing the whole person (Watson, 1999). When the nurse provides care that is holistic in nature, he/she looks at the interconnectedness of all aspects of the person: mind, body, spirit, social/cultural, emotions, relationships, context, and environment. Holistic care leads the nurse to have a deeper understanding of that interconnectedness as well as the nurse's interconnectedness with his/her own world.

Caring attitude. A caring attitude is a response from the nurse which is characterized by an individual and empathetic approach, attentiveness, and sensitivity. It incorporates the nurse’s understanding that health and illness may have deeper meanings to the experiencing patient.

Knowledge. Knowledge is defined as the nurse’s understanding of and information about something which is gained through experience or association, acquaintance with or understanding of a science, art, or technique (Zander, 2000). Halter (2001, in Zander 2002) elucidates that as one gains experience, this form of knowledge increases and the nurse relies less on fact and rules; there is discernment of the whole picture of patient situation rather than of puzzle pieces that need to be organized. It also refers to the patient's understanding of and information about the world that influences his/her present health situation.

Experience. Experience relates to the nurse’s life experiences in caring for patients. Some authors agree that experience is a form of knowing through repeated exposure to situations leading to refinement of earlier ideas and thoughts (Zander, 2002; Benner 2001). A sincere interpersonal relationship between the nurse and the patient is said to create a meaningful nursing experience leading to the development of intuitive knowledge. In the theory, experience also relates to the patient’s life experiences which can impact his/her present health situation.

Nurse-patient relationship. The nurse-patient relationship is defined as a therapeutic helping relationship that aims to support the patient, to promote healing, and to enhance functioning. It is based on the principles of mutual trust and respect, genuineness, empathy, active listening, and confidentiality. Through the nurse-patient relationship, the nurse is able to understand the patient beyond the scope of physical signs and symptoms that the patient may describe.

Receptivity. Receptivity connotes a person’s ability and willingness to take in information or ideas. It implies the nurse’s willingness or openness to intuition. It has been said that intuition is further developed when the nurse is receptive to this form of knowing.

Events and Issues. Events and issues refer to significant occurrences in the environment that provide opportunities for nurses to nurture their intuitive skill. At the same time, events and issues are conditions that can impact patient situation.

Patient situation. A patient situation is a health condition of the patient that is either positive or negative, good or bad. It is a situation that requires the intervention of the nurse.

Health need. A health need refers to the patient’s potential or actual failure to adjust to the external or internal environment.

Health outcome. A health outcome may mean a maintained or improved patient functionality, protected or unharmed patient, or comfortable or satisfied patient (Liu, Avant, Aungsuroch, Zhang, & Jiang, 2014). This is the result of nursing actions which the nurse implements to assist the patient in meeting a health need.

Nursing actions. These are nursing interventions carried out by the nurse to meet the health needs of patients.

2.3. Propositions of the Theory

The following propositional statements are constructed to represent the author’s view of how the concepts are interrelated in the theory of nursing intuition:

1) Intuition is a valid form of knowing that complements the empiric, analytic form of knowing in nursing.

2) Relevant nursing experiences and genuine nurse-patient relationship contribute to the development of intuition.

3) Nursing intuition is further promoted when there is a deeper connection between the nurse and the patient.

4) A caring attitude is important for the nurse to establish a deep connection with the patient and to understand holistically the patient situation.

5) The integration of intuition in nursing practice promotes the delivery of holistic care to patients.

6) Intuition directs nurses to perform nursing actions that meet the health needs of patient and yields positive health outcome.

7) Nurses’ intuitive skill becomes more acute when they are more receptive about it.

Figure 1 presents the interconnectedness of the different concepts that make up the theory of nursing intuition. The environment includes the internal and external variables, as well as events and issues that influence both the nurse and the patient. The external variables provide nurses with significant opportunities to hone their knowledge, gain relevant experience, and create a unique relationship with the patient. The internal conditions include variables within the nurse that can impact the outcome of the care provided to the patient. These variables include the nurse's knowledge and experiences, sincere interest to care or a caring attitude for the patient, and receptivity to different forms of knowing. The synergy of these variables in the external and internal environment affect the nurse by facilitating the development and use of the nurse’s intuitive skill (as shown by the arrow connecting the environment and the nurse).

Figure 1. Conceptual Framework of the Theory of Nursing Intuition

Variables in the patient's internal and external environment are all part of the patient's experience which can bring about either a positive or negative patient situation (as shown by the arrow connecting the environment and the patient). Favorable events and issues, correct knowledge, and good experience result in a positive patient situation while unfavorable events and issues, faulty knowledge, and bad experience result in a negative patient situation. The latter gives rise to a health need or situation that requires the intervention of the nurse.

To enhance the use of intuition, a deep connection between the nurse and the patient is crucial. This connection is built through a genuine nurse-patient relationship which enables the nurse to understand the patient’s situation holistically. Intuition, therefore, is a valid form of knowing that guides the nurse in performing nursing actions to address the health needs of the patient (as shown by the arrow connecting the nurse and the patient) and result to positive health outcomes (as shown by the arrow connecting the patient and the health). It is the ultimate goal of the nurse to bring about positive health outcomes.

Lastly, when the patient is able to meet his/her needs through the help of the nurse, a positive health outcome is achieved. A positive health outcome resulting from nurses’ intuitive skill serves as a positive feedback and a motivation for nurses to further develop and promote this form of knowing in their practice (as shown by the arrow connecting the health and the nurse).

2.4. Metaparadigms of Nursing

The four metaparadigms that determine the domain of the nursing discipline are the person, environment, health, and nursing. The person is a human being who is the recipient of nursing care. He/she is a whole being with integrated parts; however, the whole is different and more than the sum of parts (Chinn & Kramer, 1995) The person has thoughts and feelings that need to be understood, valued, cared for, respected, nurtured, and assisted (Watson, 1999). Each individual person presents to the nurse, either directly or indirectly, his/her own life experiences as well as a unique set of health needs. The environment refers to internal and external conditions that influence life and development. It consists of external and internal variables that impact health by influencing the atmosphere of both the nurse and the patient. Health is defined as a dynamic life experience which includes continuous adjustment of individuals/persons to the external and internal environment. Individuals make positive adjustments to balance the different realms of their being and to meet their health needs. When this is not possible, there is a perception or an experience of imbalance or dysfunction, a disease or an illness. It is in this context or situation that the nurse mediates so that the patient achieves a positive health outcome. Nursing is a practice discipline that utilizes various forms of knowing to assist the person to maintain or regain health or achieve his/her maximum potential. Watson (1999) asserts that the goal of nursing as a caring profession is to help persons gain a higher degree of harmony with the mind, body, and soul. This definition reflects a holistic approach of nursing care by viewing the entire nature of the person in his/her physical, social, aesthetic, and moral realms.

3. Philosophical Underpinnings of the Theory

The crucial aspect in developing a theory is a consideration of the researcher’s stance and philosophical viewpoint (Jackson, 2013). The development of the theory of nursing intuition was based on the author’s philosophy that human phenomena can only be fully explicated by the persons who experience them. Persons gain knowledge and achieve a higher sense of consciousness from their lived experiences. Such level of consciousness fosters deeper understanding of self, others, and the world. Likewise, the author was influenced by Watson’s (1999) worldview that values subjectivism and meanings of interhuman events, processes, and relationships.

The author’s philosophy conforms to the philosophical view of constructivism that is contingent on agreement, human perception, and social experience (The Basics of Philosophy, 2018) and defines reality based on context, time, and culture (Holloway & Galvin, 2017). Constructivists explicate that knowledge is created by the interactions of human beings within society (Schwandt, 2003 in Andrews, 2012). These interactions create meaningful experiences that serve as a foundation of more complex and expert forms of knowledge. A person's intuitive skill is developed through the synthesis of knowledge and experiences, deep human-to-human relationship, and receptivity to intuition. The knowledge described in here does not refer to a single knowledge obtained through the analytic process but it is the form of knowledge that the person gains by understanding the meaning of his/her existence and his/her connection with other beings (Green, 2012). It is through this mechanism that the person is able to grasp the meaning of a particular situation and acts to promote positive patient outcome. Further, the relationship between the person and his/her desire for positive patient outcome cultivates an affective knowledge that allows him/her to recognize the "what" and "how" of a situation beyond what the eyes can perceive (Green, 2012).

Further, the author’s philosophy fits a post-positivist paradigm specifically the postmodernism which denies a unified approach to knowledge (Welch & Polifroni, 1999) but recognizes multiple views and methods in understanding different aspects of reality (Munhall, 2012). The concern of postmodernists is on relativity and subjectivity of knowledge and truth in relation to one’s own time and space (Holloway & Galvin, 2017). Nursing knowledge is drawn from a multifaceted base. Nursing experience, both clinical and personal, is a source of essential knowledge that is as reliable as science (Moule & Goodman, 2014). Intuition is categorized as a form of personal knowing derived from the nurses’ awareness of a current situation, including a view of the patient and his/her circumstances, and of the wholeness of the situation (Holm & Severinsson, 2016). It is an expression of transpersonal caring in the art of nursing practice and is deeply connected to caring as the moral ideal of the nursing profession (Turan, Kaya, Ozsaban, & Aydin, 2016). Intuition can inform the development of personal knowledge which forms part of the knowledge that informs professional practice (Moule & Goodman, 2014).

4. Conclusions

The theory of Nursing Intuition is a middle-range theory that is anchored on the philosophical thoughts of constructivism and postmodernism. Intuition is a form of personal knowing that occurs as a result of the interaction of a sound knowledge base, relevant experience, genuine nurse-patient relationship and receptivity to intuition. Through these processes, nurses are able to elucidate the meaning of health and illness within the context of the nurse-patient encounter. Therefore, the use of intuition as a form of knowing and as an adjunct to analytic reasoning in all levels of the nursing program as well as in practice should be promoted if nursing is to flourish as a caring discipline.

ACKNOWLEDGMENTS

The author gratefully acknowledges the generous and kind guidance of her mentors, Dr. Annabelle R. Borromeo and Dr. Ludivina C. Ramos, in improving this manuscript.