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The present research is among the first to examine the nature of intuitive and analytical reasoning strategies among nursing students within a clinical simulation learning environment. It is generally accepted that clinicians rely upon both approaches to reasoning but this primarily reflects anecdotal reports and survey evidence. For this study, we assessed final semester ASN students during their regular clinical simulation exercises. Students were randomly assigned to one of several roles in the simulation: primary nurse, auxiliary nurse, family member or observer.
During the simulation, two distinct states unfolded. The first, deemed highly familiar, required students to identify and address the patient who was experiencing shortness of breath. The second, which was relatively novel content, required students to identify and address the development of uncontrolled atrial fibrillation in the patient. Within each state, students were stopped and asked to complete the Decision Assessment Tool, which asked them to respond to the following questions: a) What are you noticing about the patient?, b) What do you think is going on with the patient?, and c) What action(s) should the nurse take at this point?. These questions respectively correspond with the cue acquisition, diagnosing and action phases of CDM. Then, students responded to two separate 10 point Likert scales from
“not at all” to “completely” indicating agreement to each of the following questions: “My decision was based primarily on logical reasoning” and “My decision was based primarily on my gut feelings”.
To score students’ decision making performance, two doctorally-prepared, certified nurse educators reviewed students’ responses to each of the three CDM questions for each phase. The scorers determined each question to be correct or incorrect based upon a rubric developed by the research team. The two scorers exhibited high inter-rater reliability so their two sets of scores were averaged together. We then conducted a series of correlations to evaluate whether decision making accuracy varied with students’ reported reliance on intuition and analysis, as determined by their responses on the two Likert scales of “gut feelings” and “logical reasoning”, respectively.
A key goal of the present study was to examine whether reported reliance on intuition, or analysis, was associated with one’s decision making accuracy. On the familiar situation, those reporting higher reliance on intuition exhibited stronger CDM performance. In contrast, within the novel situation, those reporting greater reliance on intuition exhibited either comparable or weaker performance relative to other students. These empirical data indicate that even among novice nurses, sufficient familiarity and experience exists to support effective use of intuition during CDM; this is consistent with concept analyses asserting that nursing intuition depends upon extensive prior experience with a situation (e.g. Greene, 2012; Robert, Tilley & Petersen, 2014). It should be noted, that the familiar situation (shortness of breath) required students to integration a complex set of cues from multiple sources in order to begin the CDM process. This is consistent with previous, qualitative, research suggesting that when a situation demands integration of a complex set of cues, nurses are more likely to use intuition (Dowding et al., 2009).
Notably, the benefit of intuition within the familiar situation emerged only for those students who were most highly engaged in patient care, namely those in the nurse roles; among those in the observer or family member roles, reliance on intuition was either unrelated or associated with lower accuracy. Whereas those engaged in patient care experience greater pressure and distraction, those in observer and family roles have ample time and cognitive resources to reflect on the situation since they are not actively engaging with the patient and his unfolding challenges. On the novel situation, the negative association of intuition with accuracy emerged only for the observers; no association emerged for those in other roles. Taken together, these data indicate that within a familiar situation, intuition can enhance decision making, particularly for those directly engaged with patient care, but can disrupt decision making for those who are occupying more passive roles in the simulation.
The potential benefit of intuition appears to vary with the type of decision at hand. Clinical decision making involves multiple components; here we examined students’ ability to identify relevant cues, ability to generate accurate diagnosis(ses), and ability to identify appropriate course(s) of action. On the familiar situation, performance with the initial component of cue acquisition was higher for those reporting higher reliance on intuition, demonstrating that the more diffuse, holistic nature of intuition is helpful when gathering relevant cues in a complex situation. The other CDM phases, diagnosis and action, were not associated with reliance of intuition within the ambiguous situation. During the novel situation, by contrast, those reporting greater reliance on intuition exhibited weaker performance on the cue acquisition and diagnosis phases of CDM; intuition was not associated with action decisions.
These findings emphasize the value of intuition for certain types of clinical decision making, even among pre-licensure nursing students. Although Benner (1984) asserted that intuition is a mark of expertise, our findings indicate students make effective use of the process, particularly when a situation is familiar. Educators are encouraged to address the value of intuition in familiar clinical situations, recognizing that a student who reports relying “on her gut instinct” may indeed be using a valid and reliable way of knowing and not simply guessing. Our findings emphasize, however, that intuition may be detrimental when students solely observe a clinical scenario. When a student is directly involved with patient care and under considerable cognitive pressure, intuition can be advantageous. These variations indicate that a student’s reasoning experience during clinical decision making will qualitatively differ depending upon the nature of their role in clinical simulation; educators must be mindful of these differences when engaging the students during debriefing. Further, students should be provided experience with both passive and active roles during simulation. Finally, we were able to gather ample information regarding the students’ reasoning by having them record their thoughts during the simulation and recommend that educators incorporate this process into the simulation experience. This provided students the time to reflect on their own reasoning and gave educators a “real-time” window into the students’ thinking.