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Intuition in clinical decision-making by the nurse in ICU.



ABSTRACT

This research article follows on a previous article where the results of a concept analysis of intuition intuition, in philosophy, way of knowing directly; immediate apprehension. The Greeks understood intuition to be the grasp of universal principles by the intelligence (nous), as distinguished from the fleeting impressions of the senses.  were reported. The purpose of this article is to debate the role of intuition in clinical decision-making by the nurse in ICU ICU intensive care unit.

ICU
abbr.
intensive care unit



ICU

see intensive care unit.

ICU 
. Clinical decision-making has been noted by many critical care nurses and nurse researchers See also
  • List of nursing journals
 as one of the most critical elements of critical care nursing. Minute by minute, the critical care nurse is bombarded with a vast array of data that is, in part, derived from numerous monitoring devices employed in modern ICUs. Although interpretation of the data begins with an understanding of the physiology or pathophysiology pathophysiology /patho·phys·i·ol·o·gy/ (-fiz?e-ol´ah-je) the physiology of disordered function.

path·o·phys·i·ol·o·gy
n.
1.
 being monitored, the ultimate application of the monitoring of this data depends on the ability of the critical care nurse to make clinical decisions.

Clinical decision-making refers to a reasoning process that the critical care nurse employs in order to care for the critically ill patient. The purpose of clinical decision-making in ICU is to promote the health of the critically ill patient through more complete and effective problem solving problem solving

Process involved in finding a solution to a problem. Many animals routinely solve problems of locomotion, food finding, and shelter through trial and error.
. Based on experience and observation of decision-making in ICU, it was observed that nurses in critical care units make clinical decisions, some of which they can justify, and others that they cannot justify. The latter type of clinical decision-making is sometimes referred to by nurses in critical care units as "gut-feeling" or intuition. Furthermore, it appears from this observation that clinical decision-making based on intuition is effective and contributes to better and more complete problem solving in critical care units. Therefore, the following question arises:

What is the role of intuition in clinical decision-making by the nurse in ICU?

From the debate on the role of intuition in clinical decision-making in ICU, the conclusion is drawn that in order to facilitate better and more complete problem solving in ICU, both clinical decision-making based on the nursing process and intuition are necessary.

OPSOMMING

Hierdie artikel volg op 'n vorige een waarin die resultate van 'n konsepanalise van intuisie beskryf is. Die doel van hierdie artikel is om die rol van intuisie in kliniese besluitneming deur die verpleegkundige in die kritiekesorgeenheid te beskryf. Kliniese besluitneming word deur sommige kritiekesorgverpleegkundiges en verpleegnavorsers as 'n kritiese element van kritiekesorgverpleging beskou. Die verpleegkundige in die kritiekesorgeenheid word op 'n minuut-tot-minuut basis met 'n magdom data, wat deur middel van talle moniteringsapparaat bekom word, gebombardeer. Alhoewel die interpretasie van die data begin met 'n begrip van die fisiologie of patofisiologie wat gemonitor word, hang die uiteindelike toepassing van die monitering van hierdie data af van die vermoe van die verpleegkundige in die kritiekesorgeenheid om kliniese besluite te neem neem (nem) Azadirachta indica, a large evergreen tree having antifungal, antibacterial, antiviral, and antimalarial activity; long used medicinally for a wide variety of indications. .

Kliniese besluitneming dui op 'n denkproses wat deur die verpleegkundige in die kritiekesorgeenheid ingespan word om die kritieksieke pasient te verpleeg. Die doel van kliniese besluitneming in die kritiekesorgeenheid is om die gesondheid van die kritieksieke pasient deur middel van effektiewe en meer volledige probleemoplossing te bevorder. Vanuit ervaring en waarneming t.o.v. besluitneming in kritieksorgeenhede, is daar waargeneem dat die verpleegkundiges in kritiekesorgeenhede sommige kliniese besluite neem wat hulle kan verantwoord, en ander besluite neem wat hulle nie kan verantwoord nie. Laasgenoemde besluite word dikwels deur verpleegkundiges in kritiekesorgeenhede na "gut-feeling" of intuisie verwys. Dit blyk verder uit die waarneming dat kliniese besluite op grond van intuisie effektief is, en bydra tot beter en meer volledige probleemoplossing in kritiekesorgeenhede. Die vraag kan dus gevra word:

Wat is die rol van intuisie in kliniese besluitneming deur die verpleegkundige in die kritiekesorgeenheid?

Die gevolgtrekking waartoe daar vanuit die debat oor die rol van intuisie in kliniese besluitneming in die kritiekesorgeenheid gekom is, is dat beide kliniese besluitneming op grond van die verpleegproses en intuisie nodig is ten einde beter en meer volledige probleemoplossing in kritiekesorgeenhede te fasiliteer.

INTRODUCTION AND PROBLEM STATEMENT

This article follows on a previous article entitled en·ti·tle  
tr.v. en·ti·tled, en·ti·tling, en·ti·tles
1. To give a name or title to.

2. To furnish with a right or claim to something:
 "Concept analysis of intuition"(Arries, Botes & Nel, 1999:88-99). The purpose of this article is to debate the role of intuition in clinical decision-making by the nurse in ICU.

Intuition is defined as a goal-directed, holistic, synthetical-analogical rather than an analytical process, whereby the critical care nurse interprets or makes decisions derived from incomplete data, in uncertain situations, with the goal of solving problems based on knowledge, experience and empathy empathy

Ability to imagine oneself in another's place and understand the other's feelings, desires, ideas, and actions. The empathic actor or singer is one who genuinely feels the part he or she is performing.
. Because of the speed at which intuition occurs, the nurse is unable to justify his/her decisions or interpretations at that moment. Only after the problem is solved the nurse is, by means of reflection, able to justify his/her interpretations or decisions based on intuition (Arries, Botes & Nel, 1998:54). Minute by minute the critical care nurse is bombarded with a vast array of data that is, in part, derived from a multitude of monitoring devices employed in modern ICUs. Although interpretation begins with an understanding of the physiology or pathophysiology being monitored, the ultimate application of the data monitored depends on the ability of the critical care nurse to make clinical decisions.

Clinical decision-making refers to a reasoning process that the ICU nurse employs in order to care for the critically ill patient. The purpose of clinical decision-making is to promote the health of the critically ill patient, through the identification of health needs/problems and by implementing nursing actions in order to solve these problems (Baker, 1997:41). Because the patient in ICU is critically ill, these decisions must sometimes be made within a limited time frame accompanied with a great deal of uncertainty. Uncertainty may occur as insufficient empirically observable ob·serv·a·ble  
adj.
1. Possible to observe: observable phenomena; an observable change in demeanor. See Synonyms at noticeable.

2.
 data is available or because the interaction between the data, social and psychological processes within the individual and the clinical decision-making context is poorly understood.

In order to understand clinical decision-making in ICU, I want to provide the reader with a narrative description of clinical decision-making occurring in ICU.

Mrs Brown, a thirty-year old woman, living in Johannesburg, was admitted to ICU because of an acute asthmatic attack. On admission, Nurse Oliver assessed the health status of the patient and gathered the following data:

* Heart rate of 160 beats per minute beats per minute Cardiac pacing The unit of measure for the frequency of heart depolarizations or contractions each minute–or pulse rate ;

* Blood pressure of 80/50 mmHg;

* Increased work of breathing as reflected in a respiratory rate respiratory rate,
n the normal rate of breathing at rest, about 12 to 20 inspirations per minute.

systemic inflammatory response syndrome A term that '
 of 40 breaths per minute, accompanied with dyspnoea dyspnoea

dyspnea.
 and the patient using extra-accessory muscles to breath;

* Temperature of 36.8[degrees]C; and

* Peripheral saturation saturation, of an organic compound
saturation, of an organic compound, condition occurring when its molecules contain no double or triple bonds and thus cannot undergo addition reactions.
 of 82% on oxygen that is administered via a 40% face-mask at 12 litres flow.

By means of auscultation auscultation

Procedure for detecting certain defects or conditions by listening for normal and abnormal heart, breath, bowel, fetal, and other sounds in the body. The invention of the stethoscope in 1819 improved and expanded this practice, still very useful despite the
 of the patient's air entry, Nurse Oliver noted decreased air entry on the left lower lobe lobe (lob)
1. a more or less well-defined portion of an organ or gland.

2. one of the main divisions of a tooth crown.
 side of Mrs Brown's chest and some wheezing Wheezing Definition

Wheezing is a high-pitched whistling sound associated with labored breathing.
Description

Wheezing occurs when a child or adult tries to breathe deeply through air passages that are narrowed or filled with mucus as a
, indicating bronchospasm bronchospasm /bron·cho·spasm/ (brong´ko-spazm) bronchial spasm; spasmodic contraction of the smooth muscle of the bronchi, as in asthma.

bron·cho·spasm
n.
. Based on this data, Nurse Oliver diagnosed spontaneous pneumothorax spontaneous pneumothorax
n.
A pneumothorax occurring secondary to parenchymal lung disease.


Spontaneous pneumothorax
Air in the chest cavity that occurs because of disease or other naturally occurring cause.
. After notifying Dr Blom, the medical officer on duty in ICU at the time, she prepared for the insertion of an intercostal intercostal /in·ter·cos·tal/ (-kos´t'l) between two ribs.

in·ter·cos·tal
adj.
Located or occurring between the ribs.

n.
A space, muscle, or part situated between the ribs.
 drain.

After an intercostal drain had been inserted by Dr Blom, Nurse Oliver, with the permission of Dr Blom, administered a bolus bolus /bo·lus/ (bo´lus)
1. a rounded mass of food or pharmaceutical preparation ready to swallow, or such a mass passing through the gastrointestinal tract.

2. a concentrated mass of pharmaceutical preparation, e.
 of Haemaccel intravenously to the patient. After the administration of this bolus of fluid, blood pressure increased to 100/60mmHg and the pulse rate pulse rate
n.
The rate of the pulse as observed in an artery, expressed as beats per minute.
 decreased slightly to 155 beats per minute.

Bronchodilators Bronchodilators Definition

Bronchodilators are medicines that help open the bronchial tubes (airways) of the lungs, allowing more air to flow through them.
, in the form of Berotec and Atrovent, were administered to the patient via a nebuliser in the hope of alleviating the bronchospasms. An arterial blood gas arterial blood gas Critical care Analysis of arterial blood for O2, CO2, bicarbonate content, and pH, which reflects the functional effectiveness of lung function and to monitor respiratory therapy Ref range pO2  obtained from the patient after 30 minutes of insertion of the intercostal drain revealed the following: pH of 7.25, Pao2 of 55mmHg, Paco2 of 50mmHg, base excess of 2,8 mmol/L, bicarbonate bicarbonate or hydrogen carbonate, chemical compound containing the bicarbonate radical, -HCO3. The most familiar of such compounds is sodium bicarbonate (baking soda). See carbonate.  (HCO HCO Harvard College Observatory
HCO Hubbard Communications Office (Scientology)
HCO Hearing Carry-Over
HCO Health Care Organization
HCO Helicopter Control Officer
HCO Human Capital Office
3) of 24mmol/L and AaDpo2 of 30 and an oxygen saturation oxygen saturation sO2 The O2 concentration of blood expressed as a ratio of its total O2-carrying capacity; the OS is a measure of the utilization of O2 transport capacity; sO2  of 82%. Based on persistent increased work of breathing accompanied by the use of extra-accessory muscles by the patient in order to commence normal respiration respiration, process by which an organism exchanges gases with its environment. The term now refers to the overall process by which oxygen is abstracted from air and is transported to the cells for the oxidation of organic molecules while carbon dioxide (CO , an inability of the patient to complete a full sentence, together with the results of an arterial blood gas, Nurse Oliver recommended to Dr Blom that the patient needed to be intubated and mechanically ventilated ven·ti·late  
tr.v. ven·ti·lat·ed, ven·ti·lat·ing, ven·ti·lates
1. To admit fresh air into (a mine, for example) to replace stale or noxious air.

2.
. Nurse Oliver assisted Dr Blom with the intubation intubation /in·tu·ba·tion/ (in?too-ba´shun) the insertion of a tube into a body canal or hollow organ, as into the trachea.

endotracheal intubation
 of the patient and, based on the patient's weight and vital data, she selected the parameters to initiate mechanical ventilation mechanical ventilation
n.
A mode of assisted or controlled ventilation using mechanical devices that cycle automatically to generate airway pressure.
. To ensure correct placement of the endotracheal tube endotracheal tube
n.
A tube inserted into the trachea to provide a passageway for air. Also called tracheal tube.


Endotracheal tube 
, she checked for equal air entry on both lung fields and confirmed this with a chest X-ray chest x-ray,
n an examination of the chest using x-rays. Routinely performed in patients complaining of chest pain to rule out respiratory or heart disease.

chest X-ray Chest film, see there
.

A few minutes later Mrs Brown was mechanically fully ventilated in the controlled mode, as Dr Blom and Nurse Oliver wanted to control the peak alveolar alveolar /al·ve·o·lar/ (al-ve´o-lar) [L. alveolaris ] pertaining to an alveolus.

al·ve·o·lar
adj.
Relating to an alveolus.
 pressures of the patient that were above 40 cmH20. A positive inspiratory in·spi·ra·to·ry
adj.
Of, relating to, or used for the drawing in of air.



inspiratory

pertaining to or used in the inspiration of air into the lungs.
 pressure of 35 cmH20 was selected to achieve adequate control of intrapulmonary pressures, a rate of 10 breaths per minute with an inspiratory:expiratory ex·pi·ra·to·ry
adj.
Of, relating to, or involving the expiration of air from the lungs.



expiratory

relating to or employed in the expiration of air from the lungs.
 ratio (I:E I:E Inspiratory/Expiratory  ratio) of 1:2. Nurse Oliver knew from her studies in critical care nursing that the goal of ventilating ventilating

Natural or mechanically induced movement of fresh air into or through an enclosed space. The hazards of poor ventilation were not clearly understood until the early 20th century. Expired air may be laden with odors, heat, gases, or dust.
 patients with acute attacks of asthma is to maintain good oxygenation oxygenation /ox·y·gen·a·tion/ (ok?si-je-na´shun)
1. the act or process of adding oxygen.

2. the result of having oxygen added.
 and limit intra-pulmonary pressures. She therefore selected an Fio2 of 1,0, and, as she knew that patients with acute asthmatic attacks develop an auto-PEEP (positive endinspiratory pressure) because of air-trapping in the lungs, she decided against dialling in an applied PEEP PEEP positive end-expiratory pressure; see under pressure.

PEEP
abbr.
positive end-expiratory pressure



PEEP

positive-end-expiratory pressure.
 (positive end-expiratory pressure positive end-expiratory pressure
n. Abbr. PEEP
A technique used in respiratory therapy in which pressure is maintained in the airway so that the lungs empty less completely in expiration.
). To accomplish these goals in Mrs Brown, Nurse Oliver administered a sedative sedative, any of a variety of drugs that relieve anxiety. Most sedatives act as mild depressants of the nervous system, lessening general nervous activity or reducing the irritability or activity of a specific organ.  in the form of Midazolam, prescribed by the doctor to the patient, in order to calm her down and facilitate synchronisation Noun 1. synchronisation - the relation that exists when things occur at the same time; "the drug produces an increased synchrony of the brain waves"
synchroneity, synchronicity, synchronism, synchronization, synchronizing, synchrony
 between the patient and the ventilator ventilator /ven·ti·la·tor/ (ven´ti-la-tor)
1. an apparatus for qualifying the air breathed through it.

2. a device for giving artificial respiration or aiding in pulmonary ventilation.
.

Mrs Brown remained hemodynamically unstable with numerous monitoring devices attached to her body, for example, a cardiac monitor, a ventilator, an oxygen saturation monitor and a baumanometer to objectively measure her vital data. Catheters, for instance, a Foley's urinary catheter catheter /cath·e·ter/ (kath´e-ter)
1. a tubular, flexible surgical instrument that is inserted into a cavity of the body to withdraw or introduce fluid.

2. urethral c.
, an internal jugular jugular /jug·u·lar/ (jug´u-lar)
1. cervical.

2. pertaining to a jugular vein.

3. a jugular vein.


jug·u·lar
adj.
 central venous catheter central venous catheter
n.
A catheter passed through a peripheral vein and ending in the thoracic vena cava; it is used to measure venous pressure or to infuse concentrated solutions.
, a radial radial /ra·di·al/ (ra´de-al)
1. pertaining to the radius of the arm or to the radial (lateral) aspect of the arm as opposed to the ulnar (medial) aspect; pertaining to a radius.

2.
 arterial arterial /ar·te·ri·al/ (-al) pertaining to an artery or to the arteries.

ar·te·ri·al
adj.
1. Of or relating to one or more arteries or to the entire system of arteries.

2.
 catheter to measure a series of arterial blood gases Noun 1. arterial blood gases - measurement of the pH level and the oxygen and carbon dioxide concentrations in arterial blood; important in diagnosis of many respiratory diseases , and serum electrolytes were attached to Mrs Brown. Nurse Oliver assessed the health status of Mrs Brown hourly, using data that she obtained from the various monitoring devices and catheters that were attached to the body of the patient. Based on this data, she identified problems and made further diagnoses, intervening with the necessary actions based on her knowledge of critical care nursing, in order to prevent deterioration de·te·ri·o·ra·tion
n.
The process or condition of becoming worse.
 of the health status of the patient.

Five days after the initial insult on the health status of Mrs Brown, there was a dramatic improvement in her physical condition. So much so, that the mode of ventilation was weaned wean  
tr.v. weaned, wean·ing, weans
1. To accustom (the young of a mammal) to take nourishment other than by suckling.

2.
 to the assisted mode of ventilation, using synchronised Adj. 1. synchronised - operating in unison; "the synchronized flapping of a bird's wings"
synchronized

synchronal, synchronic, synchronous - occurring or existing at the same time or having the same period or phase; "recovery was synchronous with therapy"-
 intermittent mandatory ventilation intermittent mandatory ventilation
n. Abbr. IMV
Mechanical application of positive pressure at a determined frequency to the airway so as to increase tidal volume.
 with pressure support, to augment the spontaneous respiratory efforts of the patient. The ventilator parameters were as follows: Fio2 of 0,30, pressure support of 10 cmH20 above the level of applied PEEP, a PEEP of 5 cmH20; and a ventilator rate of four assisted mandatory breaths per minute. This implied that the patient made most of the ventilator efforts with very little assistance from the ventilator. Mrs Brown was fully conscious, as sedation Sedation Definition

Sedation is the act of calming by administration of a sedative. A sedative is a medication that commonly induces the nervous system to calm.
Purpose

The process of sedation has two primary intentions.
 was stopped two days before. She was breathing at a spontaneous rate of 18 breaths per minute, and her other vital data remained stable. She stopped wheezing, indicating that the bronchospasms were absent. Her air entry remained clear with good air entry on all four aspects of her lung field, including apexes and bases. Her chest X-ray revealed no signs of a pneumothorax pneumothorax (nmōthôr`ăks), collapse of a lung with escape of air into the pleural cavity between the lung and the chest wall. The cause may be traumatic (e.g.  or atelectasis atelectasis
 or lung collapse

Lack of expansion of pulmonary alveoli (see pulmonary alveolus). With a large-enough collapsed area, the victim stops breathing.
. Negative inspiratory force measurements of above -40 cmH20, together with a good cough reflex cough reflex
n.
The reflex which initiates coughing in response to irritation of the larynx or tracheobronchial tree.
, indicated a dramatic improvement in her respiratory status, and that she could be disconnected from the ventilator in order to commence spontaneous breathing.

However, besides this dramatic improvement in the physical health status of the patient, it was still impossible for the doctors and nurses to wean wean (wen) to discontinue breast feeding and substitute other feeding habits.

wean
v.
1. To deprive permanently of breast milk and begin to nourish with other food.

2.
 the patient from the ventilator. After several efforts to wean the patient from the ventilator, the patient crushed. Two days before the doctors and nurses had even considered crush extubating the patient. When they tried this, it was necessary for them to reintubate the patient after an hour, as she suddenly developed an acute attack of bronchospasm, which did not respond to corticosteroids Corticosteroids Definition

Corticosteroids are group of natural and synthetic analogues of the hormones secreted by the hypothalamic-anterior pituitary-adrenocortical (HPA) axis, more commonly referred to as the pituitary gland.
 and bronchodilator bronchodilator /bron·cho·di·la·tor/ (-di´la-ter)
1. expanding the lumina of the air passages of the lungs.

2. an agent which causes dilatation of the bronchi.
 therapy, and she presented with deterioration in her arterial blood gases.

On day 8, Nurse Andreas, who is also a critical care trained nurse with a diploma in Critical Care Nursing Science, was allocated to nurse Mrs Brown. Nurse Andreas described that on this particular morning, after handover n. 1. The act of relinquishing property or authority etc. to another; as, the handover of occupied territory to the original posssessors; the handover of power from the military back to the civilian authorities s>.  and while she was assessing Mrs Brown's health status, she noticed an underlying anxiety in the patient that was revealed in her beautiful brown eyes Brown Eyes (브라운 아이즈) was a Korean musical duo, specializing in ballads. Although both members have powerful voices, they were initially disregarded because of their physical looks. . [It is appealing to note the amount of compassion with which she describes this experience.] Nurse Andreas also said that, as the patient was still intubated, communication between herself and the patient was based on short sentences that the patient wrote on a piece of paper given to her. She also remarked that throughout this experience with the patient, she kept on wondering why, out of the numerous patients with asthmatic attacks that she had nursed in the past, one out of them responded in such a different way to weaning weaning,
n the period of transition from breast feeding to eating solid foods.


weaning

the act of separating the young from the dam that it has been sucking, or receiving a milk diet provided by the dam or from artificial sources.
 from mechanical ventilation. I know from experience that patients who are ventilated for long periods sometimes develop a dependency on the ventilator, but it is, however, important to consider all the factors that could possibly cause this problem.

Nurse Andreas said "... you know at that moment on that morning, I just knew that this patient was ready to be crushed extubated... and that I also knew that it is the right decision..." After telling the rest of the team, including Dr Blom, who was a bit sceptical, as they had tried this five days previously and it didn't work, Dr Blom consented that I could crush extubate Mrs Brown. After I informed Mrs Brown about this decision, she seemed quite thrilled by it; and I planned to commence the crush extubation of Mrs Brown."

"... You know at 14h00, after I had crushed extubated Mrs Brown, I could not find any data that might have indicated that she was developing respiratory difficulty. And an arterial blood gas measurement I obtained 30 minutes after the crush extubation on oxygen that was administered at 8 litres flow, via a 40% face-mask to Mrs Brown read as follows: pH of 7.39; Pao2 of 85,5 mmHg; Paco2 of 38 mmHg; base excess of 2,2 mmol/L; Bicarbonate (HCO3) of 22,5 moll/L and an oxygen saturation of 95%. Dr Blom's response to this was that he still wondered how I knew that crush extubation of the patient at that moment was the correct solution to a problem that they had struggled with for almost eight days. On the contrary, Mrs Brown was discharged to a general ward the next day."

From the narrative description, it appears that the nurse in ICU makes clinical decisions that he/she can justify, and others that he/she cannot justify. Therefore, it may be argued that nurses in ICU make clinical decisions in two distinctive ways.

On the one hand, it seems that clinical decision-making by the nurse in ICU, for example the decision about the intubation and mechanical ventilation of the patient, is made exclusively on the basis of directly observable and objectively measurable data. The nurse in ICU has gathered this data from an analysis of the health status of the critically ill patient that he/she objectively measured by means of a multitude of monitoring devices attached to the body of the critically ill patient. This way of clinical decision-making by the nurse in ICU corresponds with a scientific-rational way of decision-making (compare Harbison, 1991:404/5). Within a scientific-rational way of decision-making, clinical decisions must be made exclusively on the basis of directly measurable and empirically observable data. The nurse in ICU cannot consider data, for example values and emotions that are not directly measurable during clinical decision-making. Furthermore, clinical decisions by the nurse in ICU within a scientific-rational way of decision-making must be rationally justified based on universal rules and principles (compare Baker, 1997:42). A scientific-rational way of clinical decision-making therefore accords with a modernistic mod·ern·ism  
n.
1.
a. Modern thought, character, or practice.

b. Sympathy with or conformity to modern ideas, practices, or standards.

2.
 (positivistic pos·i·tiv·ism  
n.
1. Philosophy
a. A doctrine contending that sense perceptions are the only admissible basis of human knowledge and precise thought.

b.
) scientific view, which is highly regarded in ICU and still dominates the way in which clinical decision-making occurs in ICU.

On the other hand, clinical decision-making in ICU, based on a scientific-rational way of decision-making, is relatively simple and has restrictions. These restrictions concern a holistic view of the critically ill patient as a bio-psychosocial being, functioning within an internal and external environment that is constantly interacting with each other. Therefore, a holistic perspective on the critically ill patient implies that both data from the internal and external environments of the critically ill patient should be taken into account during clinical decision-making. This means that both directly and indirectly measurable and observable data, for example emotions and values, must be included during clinical decision-making. Therefore, it seems that clinical decision-making from a holistic perspective on the critically ill patient is much more complicated.

The nurse in ICU is accountable for his/her clinical decisions, and because the life of the critically ill patient in ICU is at stake during clinical decision-making, the nurse in ICU must be able to justify his/her decisions. Justification has to do with reasonableness and, by implication, refers to the justification of clinical decisions by the nurse in ICU by means of argumentation. Therefore, it may be argued that the justification of clinical decision-making by the nurse in ICU implies not only a justification of clinical decisions, based on directly measurable and empirically observable data, but also the justification of clinical decisions by means of negotiation and consensus through discourse between the members of the multidisciplinary mul·ti·dis·ci·pli·nar·y  
adj.
Of, relating to, or making use of several disciplines at once: a multidisciplinary approach to teaching. 
 health team in ICU.

In addition to clinical decisions that need to be justified, it further appears from the narrative that there are clinical decisions that the ICU nurse cannot justify. These clinical decisions are sometimes referred to as "gut-feelings" or intuition (compare Benner & Tanner The code name for the Xeon version of the Pentium III chip. See Xeon. , 1987:23). It further seems from the literature that clinical decisions, based on intuition, are effective and contribute to better, more complete problem solving in ICU.

[FIGURE 1 OMITTED]

From this problem and argument it appears that the following question is important in this article, namely:

What is the role of intuition in clinical decision-making by the nurse in ICU?

PURPOSE OF THE ARTICLE

The purpose of this article is to debate the role of intuition in clinical decision-making by the nurse in ICU.

THE ROLE OF INTUITION IN CLINICAL DECISION-MAKING

In order to debate the role of intuition in clinical decision-making by the ICU nurse, I would like to draw the reader's attention to figure 1.1.

The debate on the role of intuition in clinical decision-making will be based on the central concepts within figure 1.1. The debate will proceed as follows: firstly, an explication ex·pli·cate  
tr.v. ex·pli·cat·ed, ex·pli·cat·ing, ex·pli·cates
To make clear the meaning of; explain. See Synonyms at explain.



[Latin explic
 will be given of the nature of the problem with which the critically ill patient presents in ICU. Secondly, the nurse, as an independent practitioner during clinical decision-making in ICU, will be discussed. Thirdly, clinical decision-making as it occurs both during scientific-rational decision-making and intuition will be discussed. Lastly, I shall conclude with some statements on the role of intuition in clinical decision-making and make some recommendations based on this discussion.

The nature of the problem

The nature of the problem with which the critically ill patient presents determines the way in which the ICU nurse solves it. The nature of the health problem reflects on the critically ill nature of the patient as a biological, psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects.

psy·cho·so·cial
adj.
Involving aspects of both social and psychological behavior.
 being. Based on a literature study, it appears that health problems with which critically ill patients in ICU present have certain common dimensions (compare figure 1.1). The first dimension deals with clinical decisions that have been based on empirically observable and directly measurable data, for example, laboratory results of serum and electrolytes, and several other data that is measured by means of a multitude of monitoring devices attached to the body of the critically ill patient (compare Jacobs & Pelfrey, 1995:46; Bryan & McIntosh, 1996:27-28).

Secondly, from a holistic perspective on the critically ill patient, the identification and the solving of health problems in the critically ill patient must be viewed holistically. This implies that both data from the internal and external environments of the critically ill patient, as a holistic being, must be considered by the nurse in ICU during clinical decision-making. Therefore, the nurse should take into account both data that is empirically observable and directly measurable on the one hand, and data that is not directly measurable on the other during clinical decision-making.

The third dimension is that the problems diagnosed by the nurse in ICU in the critically ill patient must be solved within a limited time frame in order to prevent complications from developing in the health status of the critically ill patient. Taylor (1997:330), for instance, mentioned that problems with which the critically ill patient in ICU presents must be solved quickly (compare Ellis, 1997:325). This implies that a reduction and systematic analysis of the health status of the critically ill patient is sometimes not feasible, because there is sometimes, metaphorically stated, a race between life and death in ICU, in order to save the life of a critically ill patient.

According to according to
prep.
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

3.
 the fourth dimension, clinical decision-making by the ICU nurse is sometimes accompanied with a great deal of uncertainty. This uncertainty stems from incomplete data with which the critically ill patient presents and in itself further contributes to an uncertainty in the clinical decision-making situation (compare Shin shin (shin) the prominent anterior edge of the tibia or the leg.

saber shin  marked anterior convexity of the tibia, seen in congenital syphilis and in yaws.
, 1998:415; Cioffi & Markham, 1997:267; Jacobs & Pelfrey, 1995:48-49; Miers, 1990:32-33). The critically ill patient, as a holistic human being in ICU, presents mostly with a myriad of data. Some of this data can be objectively measured and is empirically observable, whilst other data, for example the values and emotions of the patient, is indirectly measurable. This incompleteness of data, with which the critically ill patient in ICU presents, leads to a difficult situation where the diagnosing and solving of these problems are very complex (compare Kendrick & Cubbin, 1996:157; Soderberg & Norberg, 1993:2008). However, in order to solve problems in ICU completely and effectively, it is important to consider both directly and indirectly measurable data.

Lastly, the fifth dimension of the problem with which the critically ill patient presents as a holistic human being reflects on the interrelatedness in·ter·re·late  
tr. & intr.v. in·ter·re·lat·ed, in·ter·re·lat·ing, in·ter·re·lates
To place in or come into mutual relationship.



in
 and interaction between the aforementioned dimensions of the problem. This implies that all of these dimensions can be present at the same time during clinical decision-making in ICU.

The nurse in ICU

The nurse in ICU is an independent practitioner whose practice is endorsed by the Nursing Act (Government notice, Nursing Act, Act number 50 of 1978, as amended). As an independent practitioner, the nurse in ICU works in collaboration with the multidisciplinary team in ICU, within a legal-ethical framework, in order to promote the health of the critically ill patient (Botes, 1994:63-66). This legal-ethical framework provides guidance to the nurse in ICU during clinical decision-making. As an independent practitioner, the ICU nurse is responsible and accountable for his/her decisions. Accountability implies that the nurse should be able to justify his/her clinical decisions. The responsibilities and accountabilities of the nurse in ICU are respectively spelled out in the practice regulation (Government Notice, Regulation 2598 of 30 November 1984, as amended) and the regulation about acts and omissions regulations (Government Notice, Regulation 387 of 15 February 1985, as amended). For the nurse to be accountable for his/her clinical decisions implies that he/she must be able to justify his/her decisions based on knowledge, skills and values congruent con·gru·ent  
adj.
1. Corresponding; congruous.

2. Mathematics
a. Coinciding exactly when superimposed: congruent triangles.

b.
 with the legal-ethical framework of nursing practice in the country.

CLINICAL DECISION-MAKING

The four phases of the nursing process, namely, assessment, planning, implementation and evaluation describe how clinical decision-making occurs by the nurse in ICU.

Assessment

During this phase of clinical decision-making, the nurse in ICU assesses the health status of the critically ill patient, based on knowledge and experience through the application of thinking skills such as analysis. Through analysis and deductive de·duc·tive  
adj.
1. Of or based on deduction.

2. Involving or using deduction in reasoning.



de·duc
 logic, the nurse in ICU gathers data from the multitude of monitoring devices attached to the body of the critically ill patient, medical records, laboratory and diagnostic test results, in order to diagnose a health problem.

Assessment during intuition

Employing intuition, the nurse in ICU also carries out an assessment of the health status of the critically ill patient. However, this assessment takes place without the use of conscious reasoning processes. Using intuition, the nurse in ICU gets "an intuitive grasp of the situation" (Benner, 1982 in English, 1993:390). Based on a perceptual per·cep·tu·al
adj.
Of, based on, or involving perception.
 awareness that singles out relevant information from irrelevant information, the nurse in ICU recognises patterns (Benner & Tanner, 1987:24; Cioffi, 1997:205) in the clinical situation, based on previous experience and knowledge. During this phase, the nurse in ICU also recognises fuzzy fuzz·y  
adj. fuzz·i·er, fuzz·i·est
1. Covered with fuzz.

2. Of or resembling fuzz.

3. Not clear; indistinct: a fuzzy recollection of past events.

4.
 resemblance, despite marked differences in the objective data of the current situation (compare Benner & Tanner, 1987:24; Lauri, Salantera, Callister, Harrison, Kappeli & Leod, 1998:134).

Diagnosing

During the diagnostic phase of clinical decision-making, the nurse identifies the commonalties from the data collected in the assessment phase. These common features lead to the synthesis of related data that reveal the existence of a health problem in the critically ill patient, through the contemplation Contemplation
Compleat Angler, The

Izaak Walton’s classic treatise on the Contemplative Man’s Recreation. [Br. Lit.: The Compleat Angler]

Thinker, The

sculpture by Rodin, depicting contemplative man.
 of the current data amongst existing scientific knowledge. Through the application of reasoning skills such as synthesis and inductive inductive

1. eliciting a reaction within an organism.

2.


inductive heating
a form of radiofrequency hyperthermia that selectively heats muscle, blood and proteinaceous tissue, sparing fat and air-containing tissues.
 logic, the nurse in ICU diagnoses the existence of a health problem and establishes the need for some nursing or medical intervention in order to solve the problem (compare Thelan, Davie, Urden & Lough Lough (lŏkh, lŏk). For names of Irish lakes and inlets beginning with "Lough," see second part of element; e.g., for Lough Corrib, see Corrib, Lough. See lake. , 1993:7).

Diagnosing during intuition

Intuitive diagnosis takes place simultaneously with the assessment of the critically ill patient's health status by the ICU nurse. Based on synthesis rather than analysis (compare Miller & Rew, 1989:85), the nurse in ICU gets an immediate sense of what is wrong with the patient. This is based on a perceptual awareness (compare Benner & Tanner, 1987) that begins with a vague "hunch hunch  
n.
1. An intuitive feeling or a premonition: had a hunch that he would lose.

2. A hump.

3. A lump or chunk: "She . . .
" or "gut-feeling" and a global assessment that initially bypasses critical analysis (Benner, 1984 in English, 1993:390). During this perceptual awareness, the nurse singles out relevant information from irrelevant information (Cioffi, 1997:205), recognises relationships (pattern recognition) between data without pre-specifying the components of the situation and recognises similarities, despite marked differences in the objective features of past and present situations (Benner & Tanner, 1987:24). Awareness that a patient reminds the nurse of a similar patient raises new questions and possibilities. Based on a deep understanding of the situation at a meta-cognitive level and empathy, the nurse develops a common sense understanding of what is wrong with the critically ill patient (compare Benner & Tanner, 1987:25). Linking together data about the health status of the critically ill patient and the situation at a meta-cognitive level, based on previous knowledge and past experience, the nurse in ICU arrives at a solution for the problem with which the critically ill patient presents.

Planning

Once the nursing diagnosis is established, the planning component of the clinical decision-making process begins. Through retroductive argumentation, which implies a logical inference about the best possible explanation for the observable events, the nurse plans what the best possible solution would be for the diagnosed problem. This also entails the assignment of priorities to the nursing diagnosis, specifying the intermediate and long-term goals Long-term goals

Financial goals expected to be accomplished in five years or longer.
 through the interpretation of the nursing diagnosis, and deciding on specific nursing actions to be implemented, in order to attain these goals (compare McCarthy, 1981:175; Alfaro-LeFevre, 1994:127).

Planning during intuition

Intuitive planning occurs simultaneously with the previous two phases, namely, assessment and diagnosis. The ICU nurse is often able to leap directly into implementation, as planning, based on knowledge and previous experience, has become automatic (Casebeer in Marquis & Huston, 1994:9-10; Hampton, 1994:16). Therefore, it may be inferred that problems intuitively diagnosed are solved much faster, because of the speed at which diagnosis occurred. The speed at which intuitive decision-making occurs has to do with its bypassing of the so-called rational thinking processes at an unconscious level (Isaack, 1978:919; Rew, 1986:23; Mitchell, 1994:2).

Implementation

Implementation refers to the carrying out of the proposed plan of nursing actions. Nursing actions are co-ordinated by the nurse so that the planned activities facilitate solving of the health problem to promote the health of the critically ill patient. The nurse also draws an analogy between the current clinical decision-making situation and similar clinical decisions he/she has made in the past, by looking for Looking for

In the context of general equities, this describing a buy interest in which a dealer is asked to offer stock, often involving a capital commitment. Antithesis of in touch with.
 similarities. These actions might include technical clinical procedures, such as intubation and initiating mechanical ventilation, the manipulation of an intra-aortic-balloon pump, pulmonary arterial catheter, a ventilator or inotropic inotropic /in·o·tro·pic/ (in´o-tro?pik) affecting the force of muscular contractions.

in·o·trop·ic
adj.
Affecting the contraction of muscle, especially heart muscle.
 support, or consulting with other members of the multidisciplinary health team in ICU, in order to solve the health problems with which the critically ill patient has presented (Nel, 1993:74-76; Alfaro-LeFevre, 1994:180).

Implementation during intuitive decision-making

This phase proceeds in a similar way as during the nursing process. Benner (1982), however, is of the opinion that clinical decisions based on intuition made by the expert ICU nurse can be observed when he/she demonstrates them in action only. According to Schraeder and Fisher (1986:161-162) the nurse in ICU is empowered during intuition to come into direct contact with a solution for a problem that he/she has encountered in the clinical situation based on knowledge and experience (compare Corcoran, 1986:107-112; Cioffi, 1997:203-208; Ellis, 1997:325-332). When the nurse in ICU is asked to justify his/her actions, he/she is unable to do so, as the so-called rational thinking processes are bypassed. Therefore Benner and Tanner (1987:23) refer to intuition as knowing without a rationale. The nurse can only justify his/her actions after the decision is made and some authors such as Benner and Tanner (1987:26) refer to this as "deliberative de·lib·er·a·tive  
adj.
1. Assembled or organized for deliberation or debate: a deliberative legislature.

2. Characterized by or for use in deliberation or debate.
 rationality".

Evaluation

Evaluation refers to a critical analytic process whereby the nurse assesses the patient's response to the nursing actions that have been implemented and to what extent goals have been achieved, based on certain criteria formulated during the planning phase In amphibious operations, the phase normally denoted by the period extending from the issuance of the order initiating the amphibious operation up to the embarkation phase. The planning phase may occur during movement or at any other time upon receipt of a new mission or change in the . The nurse also evaluates the effectiveness of his/her decisions in order to justify them through the application of reflective and logical thinking skills (McCarthy, 1981:176; Swansburg, 1993:182; Alfaro-LeFevre, 1994:206).

Evaluation during intuitive decision-making

During intuitive decision-making the nurse also carries out an evaluation after the decision has been made. This implies that the nurse must be able to reflect in order to be able to arrive at an understanding of the nature of the problem, the process implemented and how he/she arrived at the solution. In this way the nurse in ICU develops a deep understanding of the process and the outcome of clinical decisions based on intuition, develops a changed and new perspective about his/her clinical decision-making and justifies them (compare Clarke, James & Kelly, 1996:172; Greenwood, 1993:1185; Schon, 1987:70), It is, therefore, imperative for the nurse to be able to develop reflective thinking skills.

CONCLUSION

I shall now proceed to draw a conclusion from the aforementioned arguments on the role of intuition in clinical decision-making by the nurse in ICU.

From the aforementioned arguments, it clearly seems that the nature of the problem with which the critically ill patient presents in ICU is a critical determinant determinant, a polynomial expression that is inherent in the entries of a square matrix. The size n of the square matrix, as determined from the number of entries in any row or column, is called the order of the determinant.  of the way the problem will be solved. It further appears that, should only a scientific-rational way of clinical decision-making be employed in ICU, with its central requirements of clinical decision-making, based only on directly observable and objectively measurable data, then certain dimensions of the health problem with which the critically ill patient might present cannot be addressed. It may therefore be argued that the solving of health problems in the critically ill patient will be incomplete. The dimensions of the health problems that seem not to be addressed during clinical decision-making in ICU deal with a holistic perspective of the critically ill patient in ICU. From a holistic perspective on the critically ill patient, data that cannot be directly measured during clinical decision-making by the ICU nurse, for instance values and emotions, also form part of the health problem with which a critically ill patient presents. To demonstrate this, the reader's attention is drawn back to the narrative. It seems from the narrative that the problem that the doctors and nurses in ICU encountered during the weaning of the mechanical ventilation of the patient have to do with their failure to consider data such as the critically ill patient's ability to take responsibility for his/her illness. By Nurse Andreas taking data, such as the internal motivation of Mrs Brown to survive, into consideration, she seemed to have found a solution for a problem that the rest of the health team in ICU had been struggling with for almost a week.

In order to prevent deterioration in the health status of the critically ill patient in ICU, clinical decisions by the nurse in ICU must sometimes be made within a limited time frame. A scientific, rational approach with its emphasis on the carrying out of a systematic analysis of the health status of the critically ill patient and the clinical decision-making situation all at once seems not to provide a suitable solution to this dimension of the problem. Taking into consideration the critically ill nature of the patient in ICU and carrying out a systematic analysis of the health status of the patient are time consuming. Any delay in solving problems with which the critically ill patient might present, might potentially be detrimental to the health of the patient and may even cause his/her death, especially if a problem must be solved quickly and effectively. It seems that intuition, as a way of clinical decision-making, accommodates this dimension of the problem. Intuition is a speedy process during clinical decision-making, which is based on knowledge, perceptual awareness, empathy and experience of similar problems that the ICU nurse has encountered in the past, enabling him/her to focus directly on the myriad of data with which the critically ill patient presents, in order to find a solution to the problem. The speed at which intuitive decision-making occurs is made possible as so-called rational thinking processes are bypassed (compare Rew, 1986:23; Isaack, 1978:919). Furthermore, it seems from the literature and experience in clinical decision-making in ICU, that these clinical decisions, which are based on intuition, are effective (compare Cioffi, 1997:203-208; Mitchell, 1994:2-3; Doering, 1992:23-33; Benner & Wrubal, 1982:11-17).

The critically ill patient in ICU presents with a myriad of directly and indirectly measurable data most of the time. This as well as the unavailability of directly measurable data lead to great uncertainty in ICU. Therefore, the nurse in ICU must sometimes make clinical decisions based on incomplete data in uncertain situations (compare Schraeder & Fischer, 1986:161). Again it seems that intuition provides an answer to this dimension of the nature of the problem. Intuitive decision-making occurs mostly when clinical decisions must be made based on incomplete data in uncertain situations (Tversky & Kahnemann, 1973:207-232; Tversky & Kahnemann, 1974:1124-1131; Kehoe, 1997:46-47; Orme & Maggs, 1993:270-276; Benner & Tanner, 1987:23-31; Benner, 1982:402-407).

I therefore conclude this debate by stating that without intuition during clinical decision-making, certain problems in ICU cannot be solved. In order to achieve better, more complete problem solving in ICU, clinical decisions, both based on a scientific-rational way of clinical decision-making, as it is for example, applied in the nursing process, and on intuition are necessary.

RECOMMENDATIONS

I now conclude with some recommendations to clinical practice and nursing education.

The nurse in ICU is responsible and accountable to justify his/her clinical decisions. This counts for clinical decisions, both based on a scientific-rational way and on intuition. However, clinical decisions based on intuition can be justified after the problem has been solved only, and that will require the nurse to reflect. Therefore, reflective thinking skills seem to be a crucial requirement to be able to justify both clinical decisions based on intuition and those based on a scientific-rational way of decision-making. Reflective thinking skill refers to a cyclic cyclic /cyc·lic/ (sik´lik) pertaining to or occurring in a cycle or cycles; applied to chemical compounds containing a ring of atoms in the nucleus.

cy·clic or cy·cli·cal
adj.
1.
, hierarchic and interactive construction process. This is initiated, extended and continued because of personal cognitive-affective interaction (individual dimension) as well as interaction with the social environment (social dimension) (Van Vuuren & Botes, 1999:33). I therefore plead plead v. 1) in civil lawsuits and petitions, the filing of any document (pleading) including complaints, petitions, declarations, motions, and memoranda of points and authorities.  with nurse educators A nurse educator is a nurse who teaches and prepares licensed practical nurses (LPN) and registered nurses (RN) for entry into practice positions. Nurse Educators also teach in graduate programs at Master’s and doctoral level which prepare advanced practice nurses, nurse  to facilitate this ability in the nursing student during their training and education. Through the use of narratives, reflective journals and case studies, these reflective thinking abilities could be facilitated in the nursing student.

In addition to reflective thinking skills, the facilitation Facilitation

The process of providing a market for a security. Normally, this refers to bids and offers made for large blocks of securities, such as those traded by institutions.
 of knowledge together with experience seems to be crucial in order to be able to make clinical decisions based on intuition. In this way clinical decisions based on intuition will be distinguished from those of trial-and-error. Trial-and-error problem solving requires that the nurse in ICU attempt several different approaches until a solution is found for a problem (Taylor, 1997:329). This method is not efficient and is dangerous in ICU, as it might lead to deleterious deleterious adj. harmful.  outcomes in the health status of the critically ill patient. However, intuition is based on knowledge, which through experience becomes densely interwoven in·ter·weave  
v. in·ter·wove , in·ter·wo·ven , inter·weav·ing, inter·weaves

v.tr.
1. To weave together.

2. To blend together; intermix.

v.intr.
 within the knowledge framework of the expert nurse (Jasper, 1994:771). It is therefore recommended that, through methods such as continuous education and in-service education, the knowledge of the nurse in ICU be extended and advanced in order to improve clinical decision-making abilities.

Besides reflective thinking ability, knowledge and experience, the nurse should also be able to demonstrate empathy in the clinical decision-making situation. The distinctive characteristics of empathy, according to Wiseman (1996:1165), are to see the world from the perspective of someone else, to understand the emotions of other people, to have an unbiased view of other people, and to communicate understanding of the world of other people (compare Botes, 1997:12). Therefore, in order to truly experience the world of the critically ill patient, nurses in ICU (and possibly others as well) must be able to demonstrate empathy. Through the demonstration of empathy in the clinical decision-making situation, the nurse in ICU will be able to develop a common sense understanding of the patient and of what is really wrong with him/her, helping the nurse to better diagnose and solve problems in ICU more completely and effectively.

I therefore conclude that, in order to consider the role of intuition in clinical decision-making in ICU, the development of reflective thinking ability, combined with knowledge, experience and empathy, should form part of the nursing education system in the country.

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Part of the United Kingdom of Great Britain and Northern Ireland occupying the northeastern portion of the island of Ireland. Area: 5,461 sq mi (14,144 sq km). Population (2001): 1,685,267.
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RAAD Rapid Architected Application Development
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1.
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Eben Arries

RICN, MCur (Lecturer)

Rand Afrikaans University Rand Afrikaans University (RAU) was founded as an Afrikaans language university in 1967 with just over 700 registered students. The campus is situated in Auckland Park, Johannesburg, South Africa. Today, approximately 22 000 students are registered.  

Annatjie Botes

DCur, MA (Philosophy) (Professor)

Rand Afrikaans University

Elsabe Nel

DCur, RICN (Senior Lecturer senior lecturer
n. Chiefly British
A university teacher, especially one ranking next below a reader.
)

Rand Afrikaans University
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Title Annotation:RESEARCH
Author:Arries, Eben; Botes, Annatjie; Nel, Elsabe
Publication:Health SA Gesondheid
Date:Jun 1, 2001
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