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International Journal of Nursing Studies 45 (2008) 129 139 Towards an alternative to benner s theory of expert intuitionin nursing: A discussion paperFernand Gobet , Philippe ChassySchool of Social Sciences, Brunel University, Uxbridge, Middlesex, UB8 3PH, UKReceived 24 September 2006; received in revised form 26 December 2006; accepted 12 January 2007 AbstractSeveral authors have highlighted the role of intuition in expertise. In particular, a large amount of data has beencollected about intuition in expert nursing, and intuition plays an important role in the influential theory of nursingexpertise developed by benner [1984. From Novice to expert : Excellence and Power in Clinical Nursing Wesley, Menlo Park, CA]. We discuss this theory , and highlight both data that support it and data thatchallenge it. Based on this assessment, we propose a new theory of nursing expertise and intuition, which emphasizeshow perception and conscious problem solving are intimately related. In the discussion, we propose that this theoryopens new avenues of enquiry for research into nursing Elsevier Ltd.

International Journal of Nursing Studies 45 (2008) 129–139 Towards an alternative to Benner’s theory of expert intuition in nursing: A discussion paper

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1 International Journal of Nursing Studies 45 (2008) 129 139 Towards an alternative to benner s theory of expert intuitionin nursing: A discussion paperFernand Gobet , Philippe ChassySchool of Social Sciences, Brunel University, Uxbridge, Middlesex, UB8 3PH, UKReceived 24 September 2006; received in revised form 26 December 2006; accepted 12 January 2007 AbstractSeveral authors have highlighted the role of intuition in expertise. In particular, a large amount of data has beencollected about intuition in expert nursing, and intuition plays an important role in the influential theory of nursingexpertise developed by benner [1984. From Novice to expert : Excellence and Power in Clinical Nursing Wesley, Menlo Park, CA]. We discuss this theory , and highlight both data that support it and data thatchallenge it. Based on this assessment, we propose a new theory of nursing expertise and intuition, which emphasizeshow perception and conscious problem solving are intimately related. In the discussion, we propose that this theoryopens new avenues of enquiry for research into nursing Elsevier Ltd.

2 All rights :Care; Decision-making; Expertise; Intuition; Memory; Nursing; Pattern recognitionWhat is already known about the topic? While the role of intuition in nursing has been thetopic of considerable debate, studies have establishedthat this is a genuine phenomenon. Definitions of experts intuition emphasize fivefeatures: rapid perception, lack of awareness of theprocesses engaged, presence of emotions, holisticunderstanding of the situation, and overall goodquality of the proposed solutions. The literature often refers to Patricia benner s theoryof nursing expertise, which proposes that the road toexpertise encompasses five this paper adds A detailed discussion of benner s theory , which leadsto the conclusion that the theory is too simple toaccount for the complex pattern of phenomena thatrecent research on expert intuition has uncovered. A new theory of expert intuition in nursing, whichprovides mechanisms for explaining how intuitive,perceptual decision-making is linked to more analy-tical problem solving.

3 The suggestion that standard research on expertise(mostly based on the natural sciences) and that onnursing expertise (often based on phenomenology)should start a constructive IntroductionIntuition is often proposed as one of the definingcharacteristics of expertise. From chess masters able toARTICLE IN $ - see front matterr2007 Elsevier Ltd. All rights Corresponding author. Tel.: +44 1895 265484;fax: +44 1895 (F. Gobet).understand a position nearly instantaneously, to physi-cists automatically seeing the deep physical implicationsof a problem, to nurses having a gut feeling about theprognosis of a patient, what impresses the bystander isthe suddenness and nearly magical nature of thesebehaviours. While this last characteristic has sometimesled critics to doubt the psychological reality of intuition,there is currently good evidence that this phenomenon isgenuine. Indeed, empirical support comes from severaldomains including games (De Groot, 1965), sciences(Simon, 1995), the military (Klein, 2003), business(Prietula and Simon, 1989), and nursing ( , benner ,1984; benner et al.)

4 , 1992;McCormack, 1993;McCutch-eon and Pincombe, 2001;Polge, 1995). Given thepervasiveness of the phenomenon, not the least in fieldswhere intuitive decisions may be a matter of life ordeath, it is crucial to understand the mechanismsunderpinning are some differences in the way intuition isdefined in the literature, but there is also a fair degree ofagreement in that most definitions include rapidperception, lack of awareness of the processes engaged,concomitant presence of emotions, and holistic under-standing of the problem situation. It should be notedthat emotions have long been emphasized as part andparcel of intuition, even in domains that may seem toengage only cold cognitions such as chess (Tikhomir-ov and Vinogradov, 1970); the key role of emotion inintuition has recently been buttressed by investigationswith neurological patients showing how the lack ofemotions negatively affects intuitive decision-making(Bechara et al., 1997). To these four features, one canadd the idea that intuitions, while not necessarily alwayscorrect, must be correct more often than not (De Groot,1965, 1992).

5 This last definitional requirement, whichwas developed by de Groot so that intuition can be seenas an adaptive and rational process yielding behaviourbetter than chance, implies that novices gut feelings areunlikely to count as essential role of perception was identified justafter World War II by the Dutch psychologist Adriaande Groot in the domain of chess (De Groot, 1965). Hehypothesized that the crucial difference between grand-masters and amateurs would be in the way they searchthe maze of possible positions, with grandmastersexpected to search more deeply and consider moremoves. To test this hypothesis, he collected verbalprotocols where players had to try to find the best movein an unknown position while thinking aloud. Contraryto his expectations, De Groot found that there were onlysmall differences in the structure of search, but thatgrandmasters, in a matter of seconds, were able literallyto see potentially good moves and grasp the meaningof the position. The importance of perception, even in agame such as chess that many would describe as logicaland intellectual, was supported by grandmasters abilityto memorize nearly perfectly a position that had beenpresented for a few seconds.

6 It was also supported laterby the detailed analysis of the eye movements of strongand weaker chess players looking at a novel position (DeGroot and Gobet, 1996).The goal of this paper is not so much to review theextensive literature dealing with intuition and expertisein nursing (for pointers to this literature, seeField, 2004;King and Appleton, 1997) as to discuss two theories ofexpert intuition critically. We start by briefly consideringthe role of intuition in nursing practice. Then, we discussBenner s (1984)influential theory , highlighting itsstrengths and weaknesses. We then argue that thetemplate theory of expertise (Gobet and Simon, 1996b)presents the basis for a theory of expert nursing intuitionthat explains all the key phenomena. In the discussion,we provide a direct comparison between benner s theoryand template Intuition in nursing practiceThe role of intuition in nursing has been the topic ofconsiderable debate, with some authors (such asEnglish,1993) considering that this concept should be subjectedto critical scrutiny at best and rejected at worst, whileothers (such asDarbyshire, 1994;Effken, 2001;Kingand Appleton, 1997) considering it central to ourunderstanding of nursing expertise.

7 In particular, thework of Patricia benner and her colleagues ( benner ,1984; benner et al., 1992, 1996) has done much toconvince the field of nursing of the importance number of studies have established that intuition innursing is a genuine phenomenon ( , benner , 1984; benner et al., 1992;McCormack, 1993;McCutcheonand Pincombe, 2001;Polge, 1995). These studies haveused methods such as group interviews, personal historyinterviews, surveys, and detailed observation, and haveoften been carried out within the frameworks ofgrounded theory and phenomenology. A strikingcharacteristic of this research, in comparison to researchon expertise in general (see for example the contribu-tions inChi et al., 1988;Ericsson, 1996), and a fortioriinto medical expertise, is the dearth of experimentalstudies. While researchers into medical expertise haveused standard experimental and quantitative methods tostudy the perception, memory, and decision-makingability of novice and expert physicians (see for exampleNorman et al.)

8 , 1992;Patel et al., 1990;Rikers et al.,2002), researchers into nursing expertise have limitedthemselves to qualitative methods. Whether this reflectsonly a difference in the general research philosophy ofthese fields, or whether this is also due to the empiricaldifficulties of measuring nursing intuition per se,remains to be IN PRESSF. Gobet, P. Chassy / International Journal of Nursing Studies 45 (2008) 129 1391303. benner s theory of skill acquisition in nursingBenner s influential theory of nursing expertise closelyfollows the skill acquisition theory developed byDreyfusand Dreyfus (1986). It proposes that the road fromnovice to expert nurse encompasses five stages. In the novice stage, beginners learn through instruction;they acquire domain-specific facts, features, and important aspect of this stage is that the rulesthat novices learn are context-free ; that is, theirapplication ignores the nuances of the situation, whichresults in an inflexible and limited performance.

9 Aftera large amount of concrete experience within thedomain, novices move to the advanced beginner stage. At this stage, individuals start to use and makesense of situational elements, and commence employ-ing overall characteristics of the situation when theirprevious experience makes it possible. Attributes start todepend on the context. In the competence stage,individuals organize their actions in terms of hierarch-ical long-range plans. This stage sees an increased levelof efficiency, although planning is still conscious,abstract, analytic, and deliberate. In the proficiency stage, situations are perceived as a whole rather than asunconnected aspects, and certain features are perceivedas salient while others ignored. Thus, proficient indivi-duals can organize and understand problem situationsintuitively, but still require analytical thinking to choosean action. Finally, in the expertise stage, not only theunderstanding of the task, but also the decision of whatto do next, is intuitive and fluid.

10 Given their deepunderstanding of the situation, experts act naturallywithout explicitly making decisions and solving pro-blems. This is the case at least in routine may revert to analytic thinking that is, revertto a previous stage with situations for which they haveno experience or in situations in which the intuitivegrasp turned out to be incorrect. They may also reflecton their whole intuitions and try to improve them, aprocessDreyfus and Dreyfus (1986)call deliberaterationality. benner et al. (1996)also emphasized theimportance of knowing the patients and of beingemotionally involved in the development of nursingintuition. While beginners emotions are characterizedby anxiety, which impedes their practice, more advancednurses can rely on a larger repertoire of emotionalresponses, which they use as informative and guidingcues. These cues not only amplify nurses perceptualawareness, but also shape their clinical know-how,ethical comportment, and emotional involvement withpatients and their Strengths of the theoryBenner s theory is simple, and, at least as a firstapproximation, captures some aspects of experts devel-opment fairly well, in particular the progression fromslow and hesitant to fast and fluid problem solvingbehaviour.


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