Nursing intuition: a valid form of knowledge

Nursing intuition: a valid form of knowledgenup_507 98..111

Catherine Green RN PhD MSNProfessor, Department of Philosophy, Rockhurst University, Kansas City, MO, USA

Abstract An understanding of the nature and development of nursing intuitioncan help nurse educators foster it in young nurses and give cliniciansmore confidence in this aspect of their knowledge, allowing them torespond with greater assurance to their intuitions. In this paper, accountsfrom philosophy and neurophysiology are used to argue that intuition,specifically nursing intuition, is a valid form of knowledge. The paperargues that nursing intuition, a kind of practical intuition, is composed offour distinct aspects that include: (1) embodied knowledge rather likethat knowledge we have when we have learned to ride a bicycle; (2)well-trained sensory perceptions attentive to subtle details of complex,often rapidly changing situations; (3) a significant store of pertinentconceptual knowledge; and (4) a history of habitual actions intentionallydirected towards achieving the best outcomes for our patients. Contem-porary neurophysiology research strongly suggests that human personsexperience other persons such that they directly understand the meaningof a variety of different human actions, intentions, emotions, and sensa-tions in immediate, non-reflective, and non-conceptual perceptions. Thisresearch is supported by the philosophical theories of Jacques Maritainand Yves R. Simon found in their accounts of practical knowledge.Together, these accounts offer us a rich view of the reality of nursingintuition that helps us understand why we find intuitive actions in somebut not all nurses and gives us some specific information about how todevelop intuition in young nurses. Finally, this research shows us a pathfor further research.

Keywords: intuition, embodied knowledge, intentional attunement, prac-tical judgment, intentional action, intersubjectivity.

Introduction

In this paper, I will use accounts from philosophy andneurophysiology to argue that intuition, specificallynursing intuition, is a valid form of knowledge.

Correspondence: Dr Catherine Green, Professor, Department of

Philosophy, Rockhurst University, 1100 Rockhurst Road, Kansas

City, MO 64110, USA. E-mail: [email protected]

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Nursing Philosophy (2012), 13, pp. 98–111

I will argue that it is composed of four distinct aspectsthat include: (1) embodied knowledge rather like thatknowledge we have when we have learned to ride abicycle; (2) well-trained sensory perceptions attentiveto subtle details of complex, often rapidly changingsituations; (3) a significant store of pertinent concep-tual knowledge; and (4) a history of habitual actionsintentionally directed towards achieving the best out-comes for our patients. I will begin with a briefaccount of the meaning of the important terms usedhere and then give a brief history of some of thearguments against and for nursing intuition. Next, Iwill identify the philosophical assumptions underly-ing this theory. I will then give a limited review of theresearch of several contemporary neurophysiologistswhose research strongly suggests that human personsexperience other persons such that they directlyunderstand the meaning of a variety of differenthuman actions, intentions, emotions, and sensations inimmediate, non-reflective, and non-conceptual per-ceptions which provide support for the philosophicalaccount of intuition, particularly that it is embodiedknowledge (Gallese et al., 2002; Gallese, 2009b). Next,I will review the understanding of connatural knowl-edge developed by philosophers Jacques Maritainand Yves R. Simon found in their accounts of practi-cal knowledge. Both understand connatural knowl-edge to be a kind of intuition (Maritain, 1952; Simon,1991, 2002). I will end by showing how one importantaspect of the philosophical account is supported bythe neurophysiologic theory and how similaritiesbetween the two accounts give us a more nuancedunderstanding of the nature of nursing intuition. Thiswill help us see why we might find intuitive actions insome but not all nurses and gives us some specificinformation about how we might develop intuition inyoung nurses.

Important terms

What I mean by knowledge is the consciousness orawareness of an object.An object is the thing to whichthe knowledge refers, and can be any kind of being,either mental or material. Thus, one can have knowl-edge of ideas, theories, materially existing things suchas quarks and horses as well as actions and the like.

Presumed in this discussion is the awareness that,while knowledge can be vastly creative in one sense, itis also related to realities that most often are firstencountered in the outside world. For example, onecan have an idea of a centaur, where the idea isformed from the prior knowledge of a horse and aman. The Pythagorean Theorem, then, is not an ideadivorced from reality; it is an articulation of the rela-tionship between the hypotenuse and the sides ofsquares, existing either in the mind or in the world. Inthe words of philosopher Robert Sokolowski, con-sciousness is always ‘of something’ (Sokolowski,2000).

Practical knowledge is knowledge that directsaction. The hallmarks of practical knowledge are: (a)its goal is the guidance of action that arises from theknowledge; (b) it is a synthesis or union of bothknowledge and action; (c) it accepts probability inthe face of motion and contingency; and (d) its truthis a truth of direction rather consonance with fact.Jacques Maritain and Yves R. Simon argue thatpractical knowledge, as such, is ‘connatural’ or ‘affec-tive’ knowledge. They mean by this that the knowerand the known share their nature in a way and thatthe knowledge arises through an inclination of theknower towards the known. While examining thisissue in an earlier essay, I point out that Simon andMaritain describe this knowledge as non-conceptualand not rational as such (Green, 2002). ‘Simon saysthat that the “[a]nswer to the ultimate [practical]question was obtained by listening to an inclination.The intellect here is the disciple of love” (Simon,1961 p. 21). Maritain suggests variously that suchknowledge is “not rational knowledge” “non-conceptual” it is “obscure and perhaps unable togive an account of itself” (Maritain, 1952). Simonsuggests that “[i]nasmuch as the ultimate practicaljudgment admits of no logical connection with anyrational premises, it is, strictly speaking, incommuni-cable” (Simon, 1961, p. 27)’ (Green, 2002, p. 44).

In that earlier argument, I examine and show howSimon’s argument ‘that connatural knowledge pro-vides an objective certainty in practical knowledgethat is analogous to the certainty found in scientificknowledge’ (Simon, 1986) can be true. ‘Connaturalknowledge . . . is grounded in existence. The agent

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shares the ontological nature of the good that issought and it is this ontological affinity that allowsthe agent to recognize the good in the other’(Green, 2002, p. 43). Intuition is here understood asprecognitive or non-discursive awareness of orunderstanding of some situation or truth. Whiletheoretical knowledge is usually conceptual, practi-cal knowledge may not be, because it is or can be asynthesis of both knowledge and action. That is,practical knowledge can unite a prior belief to a par-ticular action in an intuitive leap because the goal ofboth the knowledge and the action are directed tothe same goal. As I discuss in the prior article, thegoal does not always have to be a good goal. Forexample, the well-trained scam artist can recognize a‘mark’ because he or she has prior knowledge ofsuccessfully picking pockets and has developed hissenses to recognize that person immediately.However, for affective knowledge to achieve truecertainty, the goal must be good.

Brief history

Ian English argues against Patricia Benner’s accountof intuition as an aspect of the expertise of nurses andoffers alternative accounts of this expert knowledge(English, 1993). Specifically, he argues that what wecall intuition might not exist at all but might simply beunrecognized conceptual knowledge. Furthermore,he argues that the data it gives us are subjective ratherthan objective.Therefore, intuition is not amenable toscientific explanation. Finally, because intuition is notamenable to rational explanation, we cannot use it toeducate young nurses.

More recently, Michael Luntley also offered a cri-tique of intuition arguing for what he calls ‘epistemicconservatism’ where nursing knowledge in itsvarious manifestations is understood as ordinarypropositional judgments that arise from the atten-tion that nurses pay to the subtle details of complexnursing situations (Luntley, 2010). Nursing intuitionas a form of non-propositional knowledge would beunnecessary to account for the phenomena we see.What is not explained by Luntley’s theory, however,is the mechanism that leads a nurse to attend tosome details of difficult situations rather than others.

While it certainly seems to be true that the attentionthe nurse pays to certain facets of a situation leadsto propositional knowledge, one wonders why theexpert chooses to attend specifically to those detailsrather than others. To argue that prior knowledgeanswers that question merely engages one in an infi-nite regress of attentions with no account of theirfundamental origins. Furthermore, Luntley arguesthat the knowledge of the nurse that is complex andrather non-articulable is nevertheless propositionalknowledge. It can be rendered as ‘the nurse knowsthat X is not correct’, without being able to articu-late the exact issues of X’s incorrectness. However,propositional knowledge presupposes language bythe knower. The account of intuition proposed hereis rooted in pre-propositional knowledge, what boththe philosophers and the neurophysiologists dis-cussed call embodied knowledge. An infant can havedirect awareness of its fatigue, or hunger or beingcold which is the reason why it cries. This can bemade propositional post facto, but is not proposi-tional at the time. The same can be said of our ownadult awareness of hunger, pain, fear, joy, etc. Thisawareness is unmediated by language or images. It isthe direct knowledge of one’s own being. It isembodied knowledge.

Alternatively, other nurse theorists have longinsisted on the existence of nursing intuition. Ernes-tine Wiedenbach tells us that intuition is whataccounts for nurse’s wisdom (Wiedenbach, 1970).Barbara Carper included ‘personal knowledge’ as oneof her now famous four modes of nursing knowledge(Carper, 1978). Patricia Benner, of course, argued that‘understanding without a rationale’ is characterizedby five aspects previously identified by HubertDreyfus: (1) pattern recognition; (2) similarity recog-nition; (3) common sense understanding; (4) a senseof salience; and (5) deliberative rationality (Benner &Tanner, 1987). Lynn Rew argues that nursing intuitionis an important aspect of nursing knowledge, worthyof respect, research and support (Rew, 1987, 1990;Rew & Barrow, 1987). Most recently, Judith Effkenhas argued that intuition is a form of direct perceptionthat grasps both the objects themselves and their‘affordances’ or their opportunities for action(Effken, 2001, 2007).

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Underlying assumptions

Philosophical realism and an account of ‘natures’provide important underpinnings for this proposedunderstanding of intuition. Robert Sokolowski arguesfrom a phenomenological position and Norris Clarkeargues from an Aristotelian-Thomistic position thatthere exists a correlative relationship between thingsthat can be known and knowers that can know them(Clarke, 1993; Sokolowski, 2000). As we will see,this account finds support in the neurophysiologicresearch of Vittorio Gallese and others. That is, allbeings, because they exist, present themselves toother beings in the world. All things are in relation-ship to each other and this relationship is the basis onwhich knowledge is founded. For example, a chemicalsuch as sodium presents itself to another ion, forexample chlorine and in the correct relationshipforms the material substance sodium chloride. Therelationship between sodium and chlorine is a simplechemical relationship. Knowers, however, are therather unique creatures who can unite materially withsodium chloride in drinking a sports drink forexample. Furthermore, knowers can also ‘grasp’ themeaning of sodium chloride in the ‘intentional’ rela-tion of knowing without altering their body chemistry.

I also take it to be true that beings have particularnatures by which they are what they are, by whichthey have capacities to become what they canbecome, and by which they are identified as this orthat unique whole that can be known as what it is (seeWallace, 1985). It is precisely the natures of things thatare the object of scientific research even as manycontemporary scientists deny that such natures exist.They would argue that because the nature of a thing isnot identifiable as in some way separable from thething itself no such nature must exist. This is, ofcourse, a kind of logical positivism.

Embodied simulation and intentionalattunement

Recent research in neurophysiology has led to aninteresting theory of how humans interact with otherpersons and how they understand the meaning ofother persons’ actions, intentions, emotions, and sen-

sations. Gallese and his colleagues theorize that thereexists a tripartite scaffold on which the human expe-rience of others is understood (Gallese et al., 2002;Gallese, 2005, 2009b). Most fundamental is theremarkably similar activation of neurons called‘mirror neurons’ in the brains of observers andpersons who are carrying out specific actions or inten-tions or who are experiencing specific emotions orsensations. They theorize that this neural responseprovides the ground for human intersubjectivity,empathy, and caring. It is worth noting that a correla-tion between the activation of mirror neurons andspecific external stimuli does not itself provide evi-dence of a causal relation. Gallese points out that theuse of the mirror metaphor here may be a bit mislead-ing. ‘The more we study mirroring mechanisms, themore we learn about their plasticity and dependenceupon the personal history and situated nature of the“mirroring subject” ’ (Gallese, 2009a, p. 494). Theknower is not like a mirror, inert and receptive butrather is active and engaging in a meaningful experi-ence. Thus, the causes of this relationship will likelyend up to be quite complex.They argue, however, thatthere is a real ontological similarity between theobserver and the other person. For example, whenone person raises his hand, the mirror neurons in thespecific parts of the brain that code for hand and armmovement activate similarly in both the actor and theobserver. Gallese and colleagues argue that thisneural similarity provides the material basis fromwhich the observer simulates the observed activityand thus both understands the meaning of the activityin the other person and hones his or her own skill incarrying out the activity (Gallese, 2009b). They callthis ‘embodied simulation’. From this embodied simu-lation, they argue, arises human intersubjectivity andempathy. Empathy here does not simply mean tohave an emotional response to another person, butincludes the more fundamental aspects of thiscomplex process of human experience (Gallese et al.,2002; Gallese, 2008, 2009b).

We will briefly review each of the aspects of thetheory. Mirror neurons were first identified in pri-mates and then sought in analogous structures in thehuman brain. Research has been carried out inanimals at the single neuron level and is supported in



research on children and adults using functional mag-netic resonance imaging and other visualizing tech-niques as well as by direct examination of people withand without specific brain lesions. Significant devel-opmental psychology research with animals andhumans also continues to provide support for thistheory and suggest new avenues of research (Riz-zolatti et al., 2001; Gallese et al., 2002; Kohler et al.,2002; Sommerville et al., 2004; Iacoboni et al., 2005;Gallese, 2009a).

This research has shown that some level of priorexperience in carrying out an activity is a necessaryprerequisite to any mirror neuron activation inresponse to observed behaviour (Gallese et al., 2002;Gallese, 2004, 2005, 2009a). Furthermore, recentstudies suggest that there is more intense mirrorneuron activation where the observer has more andmore recent personal experience with a given activity(Gallese et al., 2009). Mirror neuron system (MNS)activation is significantly greater between members ofspecies, e.g. macaque to macaque or human to human,than across species, and they noted that children donot experience activation of their MNS when observ-ing machines (Gallese, 2001, Gallese et al., 2009).This,of course, supports their contention that this systemseems to be necessary to begin to account for ourhuman ability to experience other persons as ‘like us’.

At the functional level, they argue that the MNSserves as the basis for ‘embodied simulation’.They usethe term embodied here because it is first realized atthe level of the neurons and also because this simula-tion relies on a ‘body schema’ in the brain which is thebasis for our natural capacity of proprioception, i.e.knowing where the various parts of our bodies are inspace (Gallese, 2005). What they mean by embodiedsimulation is that the observer’s awareness of theobserved action stimulates a complex feedbackprocess in which specific neurons are activated. Thisactivation is then associated with the observer’sincreased understanding of the meaning of the actionin the other, increased mastery of the action andperhaps attention to other aspects of the action previ-ously ignored. This may sound as if it is a conceptualprocess, but the research strongly suggests it is specifi-cally precognitive. It could be likened to the complexspatio-temporal feedback loop that allows us to con-

stantly adjust the position of our body in space. Fur-thermore, support for its precognitive nature is foundin the substantial and growing body of evidence fromother areas of physiology and psychology that showsthat new-born infants are able to imitate the smile andsome simple facial expressions of their parent. Theseactions are not a simple reflex since they do not occurevery time. This is a kind of precognitive communica-tion with the parent (Lichtenberg et al., 2002; Gallese,2007, Gallese et al., 2009). There is even some recentevidence to suggest that such actions may be groundedin simple hand and mouth actions of the infant in utero

as early as 22 weeks gestation (Gallese et al., 2009).Embodied simulation then is not driven by a judg-ment, at least not initially. Rather, it begins as a neuralresponse caused by the observation of action in theother. The observer and the agent share the samemotor neuron activation (Gallese, 2009a).

Gallese and his colleagues theorize that this imita-tive activity allows the observer to meet his or herown needs to develop self-sustaining and self-supportive activities. In fact, they suggest that allhuman actions are goal-directed (Gallese, 2007,2009a, 2009b). Joseph Lichtenberg suggests that bythese interactions infants ‘train’ their parents to meettheir needs (Lichtenberg et al., 2002). These activitieshelp the child develop his sense of self as a self and asdistinct from other persons (Gallese et al., 2002;Gallese, 2009b). Gallese argues that these actions arebest understood as serving the goal of social mastery(Gallese et al., 2002; Gallese, 2009b). We are, ashumans constitutively in relation with other beings,particularly other human beings. Embodied simula-tion seems to be the means by which we open our-selves out to others in order to meet our ownfundamental need to be with, to be like, and even tobecome, in some ways, the other.

While there is a fundamental precognitive, pre-reflective, and pre-inferential response of ‘embodiedsimulation’ with the observation of many activities,that is not to say that all action can be understood atthis level. Rather, the MNS and related embodiedsimulation response in human persons must exist in acomplex relation to cognitive and conceptual knowl-edge (Gallese, 2004, 2005, 2009a). Cognitive activitiessuch as mental imaging increase one’s neural

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response to certain activities while a neural responseseems to increase cognitive exploration (Gallese,2003a). Gallese argues that ‘every instance of mirror-ing or interpersonal resonance, in a word, embodiedsimulation, is always a process in which other behav-iour is metabolized by and filtered through theobserver’s idiosyncratic past experiences, capacitiesand mental attitudes’ (Gallese, 2009b, p. 37).

Finally at the phenomenal level, this complex ofMNS is experienced in human recognition of anotherperson as ‘like-me’. Gallese variously calls this recog-nition ‘intercorporeity’ and ‘intentional attunement’(Gallese, 2009b, p. 35). He argues, it is both a sharedway of being that is fundamental to our human natureand the experience of connectedness with otherpersons. Where our shared experience is greater, oursense of resonance will be greater, yet crucial to ourpersonhood is the recognition of our connectionsimply as human.‘What turns the acting bodies inhab-iting our social world into goal-oriented selves likeus is not first and foremost an explicit inferenceby analogy, but the possibility of entertaining a“we-centric” shared meaningful interpersonal space’(Gallese, 2009a, p. 494). He suggests that this sharedexperience provides the ‘main source of knowledgewe directly gather about others’ (Gallese, 2009b, p.35). This intentional attunement with other personsallows us to read, in a sense, their moods, their actionintentions and the like. This research suggests thathuman intersubjectivity begins with this mirroring ofour neural networks as we interact with each otherand is then augmented by conceptual reasoning as weput our rational skills together with our perceptualskills.

Gallese points out that this knowledge of others isthe work of a whole person, not simply the work ofneurons. Neurons do not have knowledge or evenexperience. Human persons as a complex whole haveexperience and then know. This, of course, supportsthe phenomenology of Husserl (1989) and morerecently Sokolowski (2008). Perception requires theawareness of ourselves as an acting body (Galleseet al., 2002). Thus, we are directly aware of ourselvesas acting and as experiencing these same experiencesincluding emotions, sensations, intentions, and actionseven well before we have language to name them.

Our personal experience of pain, anger, movement,and desires are primary and our knowledge of othersis secondary (Husserl, 1989; Gallese et al., 2002;Gallese, 2005).

Much of our explanation here has concentratedon the intersubjectivity of actions. However, concur-rent research has strongly indicated that this sameprocess is found in our experience of others’ inten-tions, sensations, and emotions (Gallese et al., 2002,2004; Gallese, 2003a, 2004, 2007, 2009b). While it hadpreviously been argued that we think and act interms of specific motions, recent research indicatesthat actions are stored in the brains of both primatesand humans in terms of goals rather than discretelinear motions (Iacoboni et al., 2005; Gallese, 2007,2009a, 2009b). Furthermore, knowledge of theagent’s intention is often given directly with the spe-cifics of a particular action or with the context.Studies by Iacoboni and his colleagues with primatesand humans strongly support this theory (Iacoboniet al., 2005).

What we see then is that there seems to be twolevels of direct perception and knowledge thatsupport action. The most primary is our direct expe-rience and perception of our body states such as pain,hunger, emotion, and desire that provide the groundfor our perception and understanding of these statesin other persons.While we may augment and evaluatethese perceptions using a conceptual process, webegin with the direct perception itself. Other personspresent in our perceptual field make themselvesknown to us in their actions, not just as bodily objects,but also as persons experiencing similar experiencesas our own.

It is worth pausing briefly at this point. Lambie andMarcel remind us that studies of how the brainresponds to various stimuli and experiences do nottell us whether the response is direct or mediated byconscious processes (Lambie & Marcel, 2002). If allwe had to go on were these response studies, wewould still be in a quandary. However, Gallese and hiscolleagues’ research gives us information from avariety of sources including information from patientswith specific lesions which Lambie finds much moreuseful and from data from infants and children priorto language acquisition. Together, they would seem to



support the theory that our beginning experience ofourselves is necessary for non-cognitive and non-predicative experience of other persons.

Our foray into neurophysiology has given a briefaccount of how intuitions seem to begin.We now turnour attention to a philosophical account of intuitionas knowledge by connaturality. Maritain & Simon usethe term intuition to speak of these connatural know-ings in both metaphysical and practical knowledge(Maritain, 1939, 1952; Simon, 2002). Maritain tells usthat intuition here means a direct perception, withoutthe means of discursive thought, of the truth ormeaning of the thing in question (Maritain, 1939).What we hope to show is how this prior philosophicalunderstanding gives us an account of the relevantfeatures of intuition where the recent neurophysiol-ogy theory gives us support for its presence as embod-ied knowledge.

Practical knowledge or intuition

Maritain and Simon argue that knowledge by connatu-rality allows for a kind of certainty of our knowledge(Maritain, 1952, 1959/1995; Simon, 1986, 1990, 2002).Connaturality is a sharing of natures and provides animmediate judgment about the truth of a propositionor a situation or the correctness of an action to achievea desired goal. For Maritain, theoretical knowledge isalways objective and thus inclination or connaturalityunderstood as a subjective striving is absent from it(Maritain, 1952). For Maritain then, knowledge byinclination or affective knowledge would refer to prac-tical knowledge but not theoretical knowledge. Simonargues that connaturality is present in all forms ofknowledge. In theoretical knowledge, the inclinationof the agent striving for truth is objectively determinedby the agent’s habitual striving for objective truth andfollows from a habitual attention to finding the truth inmany situations and an openness to understandingthings in perhaps new and different ways. In practicalknowledge, the inclination or subjective nature of thegood agent is determined by the good the agenthabitually strives to enact (Simon, 2002). For Simon,knowledge by inclination would be synonymous withconnatural knowledge while affective knowledgewould refer specifically to practical knowledge. Prac-

tical or affective connaturality is an identity betweenthe desire or goal of the agent who has habituallystriven to achieve the good and a true or real good tobe achieved. Both may defy a rational account, butoften further investigation will uncover a rationalexplanation.

Connatural knowledge is not simply knowledge;however, it is also something of a virtue (Simon, 1991).It is a complex synthesis of accurate subtle perceptionswith well-formed knowledge of the natures of themany related things.These accurate and subtle percep-tions must be trained over time such that they becomesomething of a second nature. One becomes a subtleand accurate perceiver similarly as one becomes apianist,after much training.The senses become trainedto ‘see’ the similarities and differences between thevarious natures in a complex scene, to ‘see’ the natureof these differences and the characteristic actions andreactions that follow from them.However,also neededis a character of openness to perceiving differencesand similarities that are novel and to adjusting one’sconception of meaning in light of novel experience.

Affective intuition is a judgment that ties theaction to the desired goal. Practical judgments are asynthesis of both knowledge and desire to achieve aparticular goal. They involve all the prior work oftheoretical knowledge as well as the desire to usethe knowledge to determine good action. Sincenursing is always at its root a practical endeavour,nursing intuitions always carry with them the goal ofacting or withholding action for the sake of a goodoutcome for patients. Nursing intuition as a practicaljudgment occurs in the context of complex contin-gent situations where sometimes many aspects candevelop in a variety of ways that cannot be com-pletely determined. Additional knowledge maymake the best action more clear, but since nursingjudgment is not simply about the way things are, butabout the way things will be as a result of action orinaction, one can never know with certainty aheadof time how it will turn out.

Objectivity and practical judgments

Simon and Maritain argue that one can achieve a kindof objectivity even in these contingent situations

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(Maritain, 1952, 1959/1995; Simon, 1986, 1991, 2002).What is important in chosen actions is the relationbetween the judgment that determines the action andthe goal towards which the action strives (Simon,1986, 1991, 2002). All humanly chosen actions are forthe sake of some goal, of a good that is desired. Theyargue that a kind of certainty in affective judgmentsmay arise from the steady direction of the agent’sdesires and the actions taken to achieve them. It is asteady direction of the agent towards the good. Forexample, if a nurse desires to prevent medicationerrors, he will follow the five rules of giving medica-tions . . . right medication, right patient, right time,right dose, and right action. At first, it is necessary tocheck each medication against each rule with explicitcare. After awhile, it becomes second nature. Criticalto affective knowledge is this embodied knowledgethat comes from repeated actions (Maritain, 1952;Simon, 2002). The very being of the person has beenformed over time as the person’s repeated actions ofthe same sort have been consonant with the good thatthe agent desires. This is analogous to the way amaster pianist’s hands ‘know’ the keyboard of thepiano such that she does not think about every note,but plays from her heart. After much practice, theperson with affective knowledge has developed anembodied relationship to the good sought in practicalaction. Then, one opens one’s whole self to theproblem at hand and may see the right action withouta clear account of why it is right.

Of course, there are several ways that practicaljudgments can go wrong. The first problem is that theaction judged to be correct may not in fact lead to thedesired goal. Second, the desired goal may be illusoryin some way. The goal might not be truly good. Forexample, the person’s goal might be to induce vomit-ing in order to maintain one’s weight at a desired butunhealthy level. The proximate goal of a specificweight may be in conflict with what is truly good forthe person’s health. Simon argues that, as agents, wealways act for the sake of our good (Simon, 1969).Even when we are mistaken, we are acting to achievewhat we believe to be truly good for us. Third, theagent may be unable to distinguish the primary goalfrom other competing goals. For example, the nursemight not be clear whether the nursing goal is to

provide the best care of the patient or to dischargehim before his financial support is exhausted.The firstexample is an issue of cognition, i.e. the knowledgeneeded to enact the best action.The last two are issuesof direction, what we are calling the affective relationof the agent to the goal.

There are often real limits to the amount ofknowledge of the particulars of a situation that maybe available to the deliberating nurse. Some factspertinent to the situation may be unavailable. Onemay not know that there exists a bit of informationthat might be important. Alternatively, one might berequired to make a judgment and act almost instan-taneously, thus precluding the possibility of adetailed deliberation. Simon calls these situationsthe limitations of ‘involuntary ignorance’ (Simon,1991). Recognizing this, we see that the certaintythat might arise in practical intuition cannot comefrom conceptual knowledge alone. Simon points outthat the agent is not usually held responsible whenother less intuitive practical judgments go wrongfrom a lack of knowledge that is beyond the agent’scontrol. Take the researcher who has developed anew protocol for the treatment of a disease forexample. He has thoroughly tested the hypothesis in

vitro and in vivo, set up strict guidelines regardingwhat kinds of persons can participate in the trials toinsure patient safety, carefully evaluated the candi-dates in light of all the known actions and reactionsof the protocol. Suppose one person has a raregenetic trait such that the person responds badly tothe treatment. The bad outcome cannot be attrib-uted to any failure of the researcher because thegood goal of the action is clear in all the actionstaken to achieve it. This example highlights the factthat the best preparation to make a good judgmentmay still lead to an unwanted outcome.

Truth in affective connaturality is in its directionrather than its outcome. The intuitive nurse, then,may ‘see’ that something about a particular patientdoes not seem right although all the objective dataand the patient’s self-assessment indicate no diffi-culty. His abiding desire and prior actions to achievethe good of his patients might lead him to act byalerting the physician on call to come immediately ifpaged to that patient’s room. Because intuitive



knowledge in nursing is always for the good of ourpatients and because ones’ knowledge in a particularsituation is almost always incomplete, actions in theface of intuitions, like all prudent nursing actions,will be determined to be that one that will mostlikely effect the good of the patient without risk ofharm.

The second problem is to have a clear view of thegoal. In nursing, the goal is always the best outcomefor patients. There has been much discussion aboutthe problems associated with identifying what is goodfor patients. Many argue that only the patient canidentify his or her own particular good.There is muchtruth in that position. Nevertheless, there are alsomany guidelines that help nurses in this determina-tion. I have argued elsewhere that if we have a goodunderstanding of what it means to be a human personwe are much more able to see what is good for our-selves and for others (Green, 2009). Because we areembodied biological beings, various establishedparameters of temperature, heart rate, blood pres-sure, blood chemistries and the like help us identifysituations that are likely to be a problem for ourpatients. Because we are agents who can makechoices for ourselves, we know that, wherever pos-sible, patients do better when they are able to maketheir own choices in the light of good and completeinformation. Because we are beings who can haveknowledge, we know that patients do better whenthey understand more rather than less about theirown healthcare situation. Because we are socialbeings, we know that patients do better when theyhave access to family and friends for support andcomfort. Because we are living beings with awarenessof our mortality (at least from age 3 or so), we knowthat health concerns often bring with them concernsabout death with concomitant concerns about reli-gion, afterlife, punishment and the like. It is certainlytrue that there are patients whose vital signs differfrom the norm without consequence or who prefer toknow little or nothing about the treatment options.Thus, the deliberating nurse must remain attentive tothese possibilities. Nevertheless, the more we knowabout what it means to be a person, the more we areable to identify possible patient issues and respond tothem.

Simon calls the steady direction towards the gooda ‘habitus’ (Simon, 1986).1 The difference betweenhabitus and what we commonly call a habit is that ahabit may be, and often is, rather thoughtless. Forexample, a distracted driver might head for workonce on the road that leads there even though nowshe means to go to the grocery store. Habitus, on theother hand, includes a consciously chosen directiontowards a specifically rational goal that may bemissing from a simple habitual act. Think again ofthe nurse giving medications and desiring to preventerrors. The ‘rights’ were developed precisely toprevent medication errors, to assure patient safety.After this process has become second nature, thenurse no longer lists each separately, but these‘rights’ are still actively guiding her actions suchthat something out of the ordinary brings her upshort to examine it more carefully. This habitus is asecond nature developed on top of her first natureand developed specifically to achieve a particulargoal.

The habitus that supports nursing intuition, then,includes the training of the senses to register a mul-titude of subtle data in the sweep of the situation. Itincludes physical training of the senses, developmentof the neural synapses, expansion of the memoryand the like in order to facilitate the assessment. Itincludes the careful study of and memory of a greatdeal of factual information about biology, pharma-cology, disease processes, normal patient responses,chemistry, psychology, physics, mathematics, evenperhaps art and poetry. It requires the training ofone’s emotions to be objective, yet empathetic andcompassionate, the overcoming of one’s naturalinclinations towards laziness, prejudice, fear, over-simplification and over or under reactions. Simonargues that this affective connaturality requires thesupport of the virtues, courage, moderation, wisdom,

1The term ‘habitus’ here is not used in the way it has recently

been used by Pierre Bordieu to speak about the rather uncon-

sciously accepted dispositions that one acquires as a result of

participation in ones’ culture or society. Rather, it is a quite

consciously acquired way of acting that is directed to achieving

a particular goal. See Yves R. Simon’s (1986) Moral Virtue,

pp. 55–61.

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and prudence (Simon, 1991). We can see now whythis must be true. He does not argue that the intui-tive agent must possess all the virtues in all theirfullness, but that their ability to be truly intuitiveand to trust their affective inclinations will beenhanced by whatever of the virtues they possess. Iwould argue that particularly in the contemporaryhealthcare climate the nurse must exercise a signifi-cant amount of courage in following through withintuitions in the face of scepticism and the demandsto cut costs.

Communicability

The certainty of affective knowledge comes from thesteady relationship between the agent and the goodpatient outcome that is desired. It is a kind of prac-tical wisdom. The training of the intellect, senses,emotions, and desires changes the nurse in his verybeing, allowing him to identify the good action to becarried out because its being is ontologically similarto his own. What is identical here is not the cogni-tion with the thing known, but rather the being ofthe nurse with the good of the patient. The nurse hasan ontological recognition of the good. The intuitivenurse has developed her own nature in order to beable to consistently pursue the good of the patient.Beyond seeing the ‘what’ of a situation, she can alsosee the path forward, the ‘how’ of it. While thissounds somewhat implausible, it is precisely thisaspect of intuition that has been so nicely supportedin the current neurophysiologic research (Gallese,2003a, 2003b, 2007).

Certainty, however, is not the same as communica-bility (Simon, 1991). One can know that somethingwould be a good action to carry out without knowingwhy one believes it to be so. Gaskin speaks of severaldifficult labour situations where ideas ‘came to her’that proved very helpful in allowing the mother toprogress in labour (Gaskin, 1996). One such intuitionlater became a standard tool in midwifery. However,she did not have any indication of why she thoughtthey might work. Because intuition is rooted in thedeveloped nature of the nurse, his or her specificbackground, experience, knowledge, and characterwill all be important factors in the intuitive recogni-

tion of the best action or reaction. Simon notes thatindividual practical judgments must always be madein the context of a rather radically unique set of cir-cumstances (Simon, 1991). Given this radically uniquecircumstance, it makes more sense to think that onewould never be able to explain why one made a par-ticular judgment. However, because there are manyfeatures about human action and reactions that aresimilar, these similarities often outweigh the dissimi-larities and allow us and others to recognize the basisand the wisdom of a particular judgment. In themoment, however, it is often difficult, if not impos-sible, to isolate the particulars of the situation thatwere important in making the particular judgment.Furthermore, there is likely to be a significant numberof situations where the particularities and contingen-cies are significant enough to preclude adequate rec-ognition of their precise meaning and consequence.These are the situations that call for courage on thepart of the intuitive nurse and patience among hiscolleagues if the best patient outcome is to beachieved. Nevertheless, reflection often allows one togain a better understanding.

From this investigation it becomes much clearerwhy nursing intuition is not a universal characteristicof nurses. Because the development of intuitionrequires time, knowledge, discipline, skill, and a clearunderstanding of the goals of nursing together withconsistent action in concert with these goals, it isbeyond the ken of most inexperienced nurses andeven many experienced ones such as ones who maysee nursing as a steady paycheck rather than as a‘vocation’ in its more entitative meaning. It is reallythe goal that determines the intuition along with allthe work that goes into developing that characteristicnature, the intuitive nurse. Thus, we regularly comeinto contact with nurses who possess superior intelli-gence and skills and yet lack something of the caring,the desire to always act to help patients secure theirgood. Clearly, nurses whose education, training, cog-nitive, or sensory abilities are limited will find it diffi-cult, if not impossible, to develop significant nursingintuition. However, it does not seem clear that afailure to develop intuitional judgment means onecannot be a good nurse. Yet, it does seem to add onefacet to the nurse’s armamentarium.



Points of similarity

We can see many parallels between these theories. Inboth theories, intuition, called ‘intentional attune-ment’ in Gallese’s writings and ‘affective knowledge’in Simon’s, is grounded in a desire to achieve a goal.However, for Gallese and colleagues, this is always aradically self-referential goal, to achieve what sup-ports the existence and development of the self. Sincethe self is by its nature open to and in need of acommunity of others, the good of the others must be,in some ways, also necessary to the self. For Maritainand Simon, the goal is always to achieve an objectivegood through action. Since what is good for people isin some important ways common to all people, thegood for the other and the good of the agent will insome ways coincide. Crucial to intuition is a knowl-edge that is acquired as a result of our human desireto achieve goals. I argue elsewhere that affective con-naturality can be found in the thief trying to identifyhis ‘mark’ as well as in the virtuous person trying toachieve what is truly good (Green, 2002). What isimportant is the nature of the goal that is identifiedand steadily pursued through one’s actions. RobertSokolowski takes ethical action to occur when onetakes the good of the other as one’s own (Sokolowski,1985). In nursing, of course, the goal is always what isgood for the patient. Insofar, as a nurse is practisingnursing rightly, the good of the patient will coincidewith his or her good. By acting to achieve the good ofthe patient, the nurse will support and develop hisown self, as a nurse and as a person.

In both theories, intuitions are rooted in actionexperience. Gallese and colleagues have seen a strongcorrelation between repeated, familiar, and recentaction with the activation of the MNS and the expe-rience of social consonance. Maritain and Simonspeak about the habitus of action, the goal-directedhabit of acting or rationally derived second naturethat is crucial to practical wisdom. Both speak of thisidentity between the observer and the other thatallows for the immediate recognition of the meaningof the action or experience. Both note that intuition issupported by and enhanced by conceptual knowl-edge. Gallese notes that complex knowledge will nec-essarily be comprised of both intentional attunement

and the interplay of a complex of prior experience,conceptual knowledge and the like. For Maritain andSimon, this complex of prior experience, knowledgeand action must include a steady direction of knowl-edge acquisition to understand the true meaning ofthings, a steady direction of actions to achieve what istruly good for themselves and others, reasonablecontrol of one’s passions in order to be able to under-stand meaning accurately and adequately and ahistory of acting for what is good regularly and withdetermination. For both accounts, these intuitions areimmediate, precognitive and therefore may not beavailable to immediate analysis, although systematicreview of such intuitions may lead to some generalunderstanding. Both accounts argue that what beginsas subjective experience has a strong correlation withwhat objectively exists in both the observer and theobserved or the agent and the goal he or she isseeking. Both argue that by means of one’s subjectiv-ity a kind of objective knowledge is possible.

Conclusion

What this examination strongly suggests is that intui-tions are real responses to real experiences and situ-ations that are immediate and non-inferential inlogical terms. They are grounded in the shared expe-rience of a reality and they are certainly possible innursing encounters. It is clear that some nurses,perhaps many nurses, will experience few if any intui-tions for many reasons including inadequate experi-ence or conceptual knowledge, a lack of adequateclarity about the goal of their practice or of what isactually good for patients, or a lack of desire or com-mitment to achieving the best for themselves or theirpatient.

Before we finish, however, it is important to thinkfor a minute about the relationship between nursingintuition and evidence. Evidence-based practice is anincreasingly important issue in nursing. While thisemphasis is both welcome and necessary, Jairath et al.point out that it is important that evidence-basedpractice does not limit nursing practice to only thoseactivities that are supported by empirical research. Todo so would carry the risk of overlooking otheraspects of nursing practice that are also beneficial to

Catherine Green108


our patients (Jairath et al., 2006). The strength ofevidence-based practice is found in the fact that it isgrounded in the recognition that all aspects of nursingpractice need to be examined with a critical eye toassure that nursing practice is based in rationalityrather than simply in tradition or expediency. I wouldargue that nursing intuition is an important adjunct tosuch rational and scientifically based practice. Nursingintuition is grounded in learned experience which isprecisely for the goal of maximizing the benefit ofaction for both the patient and the nurse. Galleseargues that initially intentional attunement is directedtowards self-support and -preservation and I haveargued that such self-support is in many ways directlyconnected with helping others achieve their good aswell. Such self-preservation as practised by a nurse,however, would not necessarily assure what is goodfor patients. But nursing intuition is not simply Gall-ese’s intentional attunement. It is much more.While itbegins in intentional attunement, it is perfected whenrationally developed knowledge and skills are system-

atically paired with such attunement. All facets ofSimon’s account of affective knowledge are neces-sary: (1) embodied knowledge; (2) well-trainedsensory perceptions attentive to subtle details ofcomplex, often rapidly changing situations; (3) a sig-nificant store of pertinent conceptual knowledge; and(4) a history of habitual actions intentionally directedtowards achieving the best outcomes for our patients.Thus, the knowledge that comes from attention to thebest science arising from evidence-based practiceamong other sources along with the knowledge, skills,and critical reasoning that follow from simulationexercises provide crucial aspects of nursing intuition.Hands-on practice in the clinical setting then providesthe young nurse opportunities to develop the habitusof putting all this together for the sake of particularpatients. The neurophysiology research strongly sug-gests that significant direct patient contact is neces-sary to allow young nurses to advance the training oftheir MNS such that they can immediately recognizeissues that may make a difference between life anddeath.

Finally, we can now respond to English’s concernsabout nursing intuition. While intuitions are rootedin subjective experience, they can be closely corre-

lated with objective reality both in terms of sympa-thetic MNS and in terms of achieving good nursingactions, seen in patient outcomes. English is prob-ably right that we cannot teach intuition conceptu-ally. Nevertheless, it seems reasonable to suggestthat there are several ways intuition can be sup-ported and enhanced in young nurses. First, we canbegin by teaching them the relevant features of intu-ition and encourage them to systematically work todevelop these characteristics. Second, it is also nec-essary to strongly support their direct experience ofmany and varied nursing and other human interac-tions. Haggerty and Grace point out that clinicalwisdom of which tacit knowledge or intuition is oneaspect ‘can be cultivated but not taught’ (Haggerty& Grace, 2008, p. 239). Direct nurse–patient interac-tions will be essential to help young nurses developtheir MNS response in relation to actual patients.Third, we must continue to help them train their per-ceptions of complex situations to be accurate andcomplete (that automatic visual, audio, olfactoryassessment of the situation as one enters a patient’sroom). Here, the use of patient simulations willlikely be one important pedagogical tool. Fourth, wemust continue to teach a significant amount of rel-evant conceptual knowledge along with appropriateevaluative techniques so that young nurses can rec-ognize what is most relevant in various situations.Finally, we must also continue to emphasize theirconstant attention to both the identification of andcommitment to achieving what is truly good for thepatient and concomitantly for the nurses themselves.

As for scientific study, it seems clear that here as inthe science of ethics, it is possible to examine both thedata about nursing intuitions as they are experiencedand specific nursing activities that are supportive ofgood patient care in order to support their develop-ment. It will be necessary to gather data about thekinds of nursing intuitions that nurses experience aswell as the background of the nurses who experiencethem. Furthermore, it will be important to begin tocorrelate the actions that are conducted in light ofspecific intuitions with specific patient outcome data.It will be helpful to also track intuitions notresponded to, for whatever reason, with the subse-quent patient outcome. In light of these discussions, I



would argue that nursing intuition is a valid form ofknowledge and is worthy of further research andconsideration.

Acknowledgements

The author gratefully acknowledges the generous andthoughtful help of Drs. Janet Pierce, Curtis Hancockand Martin Lipscomb in reading and commenting onthe several drafts of this paper. The author is gratefulfor the La Croix Summer Research Grant that sup-ported the final revisions of the paper.

Some of the material from this paper was presentedunder the titles “Nursing Intution: A Valid Form ofKnowledge” at the International Philosophy ofNursing Annual Conference, Bristol, UK, September2009 and “The Nature of Intuition” at the AmericanMaritain Association meeting in Houston, Texas inOctober, 2009.

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Nursing intuition: a valid form of knowledge