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PubMed1998

The application of decision making concepts by nurse practitioners in general practice.

This paper is concerned with the conceptual frameworks which could be applied to nurse practitioners in general practice in reaching decisions during patient consultations. Four strategies of decision making are explained within a practice context: hypothetico-deductive method, decision analysis, pattern recognition and intuition. The study uses retrospective verbalization and observation of 20 nurse practitioners working alongside general practitioners to explore decision making issues. The results of the study show that important factors relating to decision making include: the ability to recognize patterns in clinical situations to fit with patterns previously seen; an appreciation of the consequences of inappropriate action; and the ability to concentrate simultaneously on complex and sometimes masked patient cues as well as multiple treatment options.

Adult↗
PubMed2000

Mental health nurses and qualitative research methods: a mutual attraction?

Mental health nurses and qualitative research methods: a mutual attraction? In response to issues arising out of curriculum developments, the authors wished to examine more closely the potential reasons why psychiatric/mental health (P/MH) nurses appear to gravitate towards certain research methodologies. This paper therefore briefly examines the essential differences between qualitative and quantitative research paradigms, focusing on philosophical, epistemological and methodological issues. It then proceeds to examine some of the essential characteristics and attributes of P/MH nurses and suggests some differences in emphasis between these and other disciplines of nursing. The authors posit that psychiatric/mental health nurses are drawn to the qualitative paradigm as a result of the potential synchronicity and linkage that appears to exist between the practice of mental health nursing and qualitative research. This apparent synchronicity appears to centre around the three themes of: (a) the purposeful use of self; (b) the creation of an interpersonal relationship; and (c) the ability to accept and embrace ambiguity and uncertainty. Given this alleged synchronicity the authors argue that there are implications for nurse education and nursing research. Further it is possible that each nursing situation where the mental health nurse forms a relationship and attempts to gain an empathic sense of the individual's world is akin to an informal phenomenological study, the product of which would be a wealth of qualitative data. However, as this would be a subconscious, implicit process, the data would remain predominantly unprocessed. The authors conclude that perhaps these data are the knowledge that expert practitioners draw upon when making intuition-based clinical judgements.

Attitude of Health Personnel↗
PubMed2003

Non-linearity in clinical practice.

The whole spectrum of medicine consists of complex non-linear systems that are balanced and interact with each other. How non-linearity confers stability on a system and explains variation and uncertainty in clinical medicine is discussed. A major theme is that a small alteration in initial conditions may have a major effect on the end result. In the context of non-linearity, it is argued that 'evidence-based medicine' (EBM) as it exists today can only ever be relevant to a small fraction of the domain of medicine, that the 'art of medicine' consists of an intuitive 'tuning in' to these complex systems and as such is not so much an art as an expression of non-linear science. The main cause of iatrogenic disease is interpreted as a failure to understand the complexity of the systems being treated. Case study examples are given and analysed in non-linear terms. It is concluded that good medicine concerns individualized treatment of an individual patient whose body functions are governed by non-linear processes. EBM as it exists today paints with a broad and limited brush, but it does promise a fresh new direction. In this context, we need to expand the spectrum of scientific medicine to include non-linearity, and to look upon the 'art of medicine' as a historical (but unstated) legacy in this domain.

Biomedical Research↗
PubMedDate not supplied

Definition and identification of child abuse by Finnish public health nurses.

The purpose of this study was to determine how public health nurses in Finland defined child abuse and how they assessed their capability to identify child abuse in the family. Public health nurses described child abuse as consisting of physical and emotional abuse. They described physical abuse as consisting of two categories, direct physical abuse towards children and other acts causing children physical harm. Emotional abuse included neglect, teasing the child, frightening the child, rejecting the child in the family, and forcing the child to assume an adult role. The nurses divided the identification of child abuse into two categories: tools for identifying child abuse and markers indicating child abuse. The tools for identifying abuse included knowledge acquisition and interactive skills, intuition, and the capacity of the nurse to handle problematic situations. Public health nurses identified child abuse in the child's behavior and appearance and in family behaviors. Public health nurses seem to be aware of child abuse, but further research is needed if they need more-specific skills regarding how to apply their theoretical knowledge to nursing practice to provide nursing care for abused children and their families.

Adult↗
PubMed1999

Knowledge in health visiting practice.

Health visiting is a practical discipline, hence knowledge in health visiting practice cannot be thought of as inert, that is merely as items of information merely; rather, it must be thought of in terms of a dynamic interplay among the individuality of the knower (the practitioner), the sources whereby knowledge may be acquired, and the contexts in which it must be applied. This discussion is an exploration of that interplay. Thus, in the discussion, the distinctive demands on the practitioner (and the kinds of personal qualities these entail) in acquiring and applying knowledge are highlighted, as are the sources of knowledge and the constraints of context. Three sources of knowledge are noted: authority, personal experience, and intuition. Context is conceived both in terms of the macro, sociopolitical, level and in terms of the micro level, i.e. the individual homes and interpersonal relationships in and through which health visiting is typically practised. Conclusions are drawn relating to the education of health visitors. The discussion draws on a distinction between three kinds of knowledge: factual or propositional knowledge, knowledge by acquaintance, and practical knowledge, or know-how.

Clinical Competence↗
PubMed2005

Unsupervised categorization and category learning.

When people categorize a set of items in a certain way they often change their perceptions for these items so that they become more compatible with the learned categorization. In two experiments we examined whether such changes are extensive enough to change the unsupervised categorization for the items-that is, the categorization of the items that is considered more intuitive or natural without any learning. In Experiment 1 we directly employed an unsupervised categorization task; in Experiment 2 we collected similarity ratings for the items and inferred unsupervised categorizations using Pothos and Chater's (2002) model of unsupervised categorization. The unsupervised categorization for the items changed to resemble more the learned one when this was specified by the suppression of a stimulus dimension (both experiments), but less so when it was almost specified by the suppression of a stimulus dimension (Experiment 1, nonsignificant trend in Experiment 2). By contrast, no changes in the unsupervised categorization were observed when participants were taught a classification that was specified by a more fine tuning of the relative salience of the two dimensions.

Association Learning↗
PubMed2003

Teaching clinical judgment in Taiwan.

Clinical judgment is a process that nurses use during the course of their daily practice to gather and to evaluate data, define the needs of the clients, and to judge the outcome of patient care. Such judgment is also a critical ability used to assess the progress of nursing students. The purpose of this qualitative research was to describe the clinical judgment teaching in nursing education in Taiwan and provide baseline data for future nursing students to learn in a more effective way. Data was collected by in-depth individual interviews of 10 participants, all of whom were senior nursing faculty members from different nursing subspecialties. Two findings were reached. First, clinical judgment included not only the cognitive and the psychomotor domain of learning, but also the affective domain of reasoning. Second, due to cultural differences, " intuition " had never been mentioned in Taiwan, but a similar concept was substituted by use of the term " experience ". The findings suggested a holistic and integrative perspective was needed when teaching clinical judgement in Taiwan.

Decision Making↗
PubMed2001

Nonlinear models of clinical judgement: communal nonlinearity and nonlinear accuracy.

Despite our intuition that representative expert judgments are highly nonlinear, previous studies have shown only little, if any, nonlinearity in such judgments. The current study presents a method for assessing nonlinearity in judgment that is based on estimating communal nonlinearity--the systematic nonlinearity shared by the community of judges. The article also examines the predictive accuracy of communal nonlinearity, and compares it with the corresponding linear accuracy.

Adult↗
PubMed2006

From expert to tasks, expert nursing practice redefined?

AIM: The aim of this paper was to explore the concept of expertise in nursing from the perspective of how it relates to current driving forces in health care in which it discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. BACKGROUND: Expert nursing practice can be argued to be central to high quality, holistic, individualized patient care. However, changes in government policy which have led to the inception of comprehensive guidelines or protocols of care are in danger of relegating the 'expert nurse' to being an icon of the past. Indeed, it could be argued that expert nurses are an expensive commodity within the nursing workforce. Consequently, with this change to the use of clinical guidelines, it calls into question how expert nursing practice will develop within this framework of care. METHOD: The article critically reviews the evidence related to the role of the Expert Nurse in an attempt to identify the key concepts and ideas, and how the inception of care protocols has implications for their role. CONCLUSION: Nursing expertise which focuses on the provision of individualized, holistic care and is based largely on intuitive decision making cannot, should not be reduced to being articulated in positivist terms. However, the dominant power and decision-making focus in health care means that nurses must be confident in articulating the value of a concept which may be outside the scope of knowledge of those with whom they are debating. RELEVANCE TO CLINICAL PRACTICE: The principles of abduction or fuzzy logic may be useful in assisting nurses to explain in terms which others can comprehend, the value of nursing expertise.

Clinical Competence↗
PubMed2005

Nursing practice as bricoleur activity: a concept explored.

The debates concerning the nature of nursing practice are often rooted in tensions between artistic, scientific and magical/mythical practice. It is within this context that the case is argued for considering that nursing practice involves bricoleur activity. This stance, which is derived from the work of Levi-Strauss, conceives elements of nursing practice as an embodied, bricoleur practice where practitioners draw on the 'shards and fragments' of the situation-at-hand to resolve the needs of the individual patient for whom they care. This conceptualisation of nursing practice will be analysed with a particular emphasis on its implication for nursing epistemology, pedagogy and praxis. The evidence to support this argument is drawn from empirical work that investigated nurses' use of intuition, the work of Levi-Strauss, and issues in nursing epistemology and ontology. The paper itself is written from the perspective of a bricoleur who uses 'bits and pieces' from the domains of nursing, philosophy, psychology, education, sociology and anthropology.

Adaptation, Psychological↗
PubMed2006

Diagnostic practise in nursing: a critical review of the literature.

The purpose of this article is to critically review and synthesize the literature related to the general concepts and the process of diagnosing the client's condition, and the possible variables which influence diagnostic practise in nursing. It is suggested that statistical theories are capable of capturing the diagnostic process and offer an effective means to predict diagnostic decisions. Studies underpinned by information-processing theory argue that diagnosing a patient's condition follows a hypothetico-deductive model that consists of specific stages. Those who hold a phenomenological perspective remark that there is yet another form of diagnostic practise: intuitive reasoning, which plays an important role in diagnosing the patient's clinical condition. Other related studies suggest that diagnostic practise is contingent on some personal, psychosocial, and structural variables. Regrettably, these studies offer no conclusive explanation to delineate diagnostic practise in nursing. Based on the literature reviewed, a conceptual framework is suggested to help articulate the underlying structures and processes of diagnostic practise in nursing.

Acute Disease↗
PubMed2004

Psychic phenomena and early emotional states.

This paper examines the relationship between severe early trauma and the development of psychic intuition. A case presentation with extensive dream work helps to illustrate this connection by exploring the psychological meaning of one patient's acute receptivity to unconscious communications. The paper includes a historical overview of Freud's attitudes toward occultism, as distinct from later psychoanalytic views, including those of Wilfred Bion. Many of Bion's views have more in common with Jung's perspective than with Freud's, with particular reference made to spiritual and religious differences. Bion clearly states that Freud and psychoanalysts have focused on phenomena, not on noumena, which Bion considers to be the essence of the psychoanalytic point of view.

Adult↗
PubMed2006

Evidence for practice, epistemology, and critical reflection.

Evidence-based practice (EBP) has become a critical concept for ethical, accountable professional nursing practice. However, critical analysis of the concept suggests that EBP overemphasizes the value of scientific evidence while underplaying the role of clinical judgement and individual nursing expertise. This paper explores the empiricist position that valid evidence is the basis for all knowledge claims. We argue against the positivist idea that science should be regarded as the only credible means for generating evidence on which to base knowledge claims. We propose that the process of critically reflecting on evidence is a fundamental feature of empirical epistemology. We suggest that critical reflection on evidence derived from science, arts and humanities and, in particular, nursing practice experience can provide a sound basis for knowledge claims. While we do not attempt to define what counts as evidence, it is argued that there is much to be gained by making the processes of critical reflection explicit, and that it can make a valid contribution to expert nursing practice, without recourse to irreducible concepts such as intuition.

Art↗
PubMed2006

Intelligent nursing: accounting for knowledge as action in practice.

This paper provides an analysis of nursing as a knowledgeable discipline. We examined ways in which knowledge operates in the practice of home care nursing and explored how knowledge might be fruitfully understood within the ambiguous spaces and competing temporalities characterizing contemporary healthcare services. Two popular metaphors of knowledge in nursing practice were identified and critically examined; evidence-based practice and the nurse as an intuitive worker. Pointing to faults in these conceptualizations, we suggest a different way of conceptualizing the relationship between knowledge and practice, namely practice as being activated by contextualized knowledge. This conceptualization is captured in an understanding of the intelligent creation of context by the nurse for nursing practice to be ethical and effective.

Attitude of Health Personnel↗
PubMed2004

The Swedish version of the PACU-Behavioural Pain Rating Scale: a reliable method of assessing postoperative pain?

One of the obstacles to effective pain management in the Post-Anaesthesia Care Unit (PACU) is the lack of systematic and comprehensive methods for assessing and treating postoperative pain. Nurses' intuitive knowledge of pain were verbalized and divided into four categories of pain behaviours in the PACU-Behavioural Pain Rating Scale. The aim of the present study was to test the reliability of the Swedish version by performing test-retest and interrater reliability in clinical conditions. Materials for this study were gathered through patient observations. The results showed poor agreement in the item restless, fair agreements in both items tense muscles and frowning and grimacing, while patients' sounds showed moderate agreement. Interrater reliability showed moderate agreement in the item restless, very good agreement in tense muscles and patient sounds, and good agreement in frowning and grimacing. A refined classification of the separate categories and a careful review of the category of behaviours is suggested. A more detailed manual for the categories needs to be developed to establish more acceptable reliability.

Adult↗
PubMed2006

Explanation and understanding.

The study of explanation, while related to intuitive theories, concepts, and mental models, offers important new perspectives on high-level thought. Explanations sort themselves into several distinct types corresponding to patterns of causation, content domains, and explanatory stances, all of which have cognitive consequences. Although explanations are necessarily incomplete--often dramatically so in laypeople--those gaps are difficult to discern. Despite such gaps and the failure to recognize them fully, people do have skeletal explanatory senses, often implicit, of the causal structure of the world. They further leverage those skeletal understandings by knowing how to access additional explanatory knowledge in other minds and by being particularly adept at using situational support to build explanations on the fly in real time. Across development and cultures, there are differences in preferred explanatory schemes, but rarely are any kinds of schemes completely unavailable to a group.

Affect↗
PubMed2006

The persistence of mind-brain dualism in psychiatric reasoning about clinical scenarios.

OBJECTIVE: Despite attempts in psychiatry to adopt an integrative biopsychosocial model, social scientists have observed that psychiatrists continue to operate according to a mind-brain dichotomy in ways that are often covert and unacknowledged and suggest that the same intuitive cognitive schemas that people use to make judgments of responsibility lead to dualistic reasoning among clinicians. The goal of this study was to confirm these observations. METHOD: Self-report questionnaires were sent to the 270 psychiatrists and psychologists in the Department of Psychiatry at McGill University. In response to clinical vignettes, the participants rated the level of intentionality, controllability, responsibility, and blame attributable to the patients, as well as the importance of neurobiological, psychological, and social factors in explaining the patients' symptoms. RESULTS: A total of 136 faculty members (50.4%) responded, and 127 were included in the analysis. Factor analysis revealed a single dimension of responsibility regarding the patients' illnesses that correlated positively with ratings of psychological etiology and negatively with ratings of neurobiological etiology. Psychological and neurobiological ratings were inversely correlated. Multivariate analyses of variance supported these results. CONCLUSIONS: Mental health professionals continue to employ a mind-brain dichotomy when reasoning about clinical cases. The more a behavioral problem is seen as originating in "psychological" processes, the more a patient tends to be viewed as responsible and blameworthy for his or her symptoms; conversely, the more behaviors are attributed to neurobiological causes, the less likely patients are to be viewed as responsible and blameworthy.

Algorithms↗
PubMed1997

Predicting patients' deterioration and recovery.

The purpose of this study was to identify patient cues that expert nurses identify as a patient moves to/from deterioration and/or recovery. The sample of 33 nurses was drawn from a medical intensive care unit (MICU). Data were collected through interviews regarding nurses' knowledge about caring for patients with acute gastrointestinal bleeding, heart failure/post-myocardial infarction, and pulmonary edema. Using the constant comparative technique, cues were identified and grouped into early, imminent, and late patterns for deterioration and into categories of early, midway, and complete for recovery. Rationales for the nurses' decisions included memories of patients with similar cues, using multiple not single cues, and clustering both physiological and psychological cues together. This study is a beginning effort toward validating nurses' intuitiveness and provides knowledge about expert practice that can be taught to novice practitioners and incorporated into protocols for care.

Adult↗