Chapter 2 Literature review
2.4 Theme 2 Intuition based on aesthetic knowing, patterning, tacit knowledge,
This second theme carries the greatest level of complexity. Whilst the combination of so many concepts within one theme may be questionable, the justification of their
inclusion is their interrelatedness. Aesthetic knowing is a generic term for tacit knowledge, whereas habitus, patterning, and heuristics are terms aimed at explicating the concept of tacit knowing or knowledge. Reflexivity and reflection are similarly linked to tacit knowledge however whilst they are not used as a concept to explain this form of knowing they have been included within this theme as they are a suggested means of unleashing intuition for practitioners. It is acknowledged that complexity is increased however through the debates concerning whether or not it is possible for intuition or tacit knowledge to be released. These concepts and debates will now be explored in this second theme of the conceptual review. Juxtaposed to this thematic analysis will be how this theme resonates or disagrees with the first theme, intuition and psychology.
There is no consensus in the literature concerning health care in terms of the role and meaning of intuition. It has however been debated at great lengths by nursing theorists. Within any discourse on nursing knowledge, including intuition, Carper’s seminal work as far back as 1978 is frequently cited (Johns 1995; Jacobs 2013). Carper recognised over thirty years ago that there was a fragmented approach to nursing epistemology and that it was biased by a scientific paradigm. To ameliorate this state of affairs she conceptualised four forms of knowing comprising: empirical (or scientific), aesthetic (or artistry), personal knowing and ethics. Carper’s form of aesthetic knowing or artistry however is the most resonant with intuition. Carper (1978) defined aesthetic knowing as a process of perceiving or grasping the nature of a clinical situation.
Hunter (2008) similarly, in her hermeneutic study of midwives’ from the USA ways of knowing in poetry, has conceptualised different forms of knowledge to inform midwifery practice. She asserted that the midwives from her study utilise three
forms of knowledge to inform their practice. These included: self-knowledge that was derived from personal belief systems. This is comparative to Carper’s notion of personal knowing. Hunter’s second form of knowledge was identified as informed or scientific knowledge, resonant with Carper’s empirical knowing. The final form of knowledge conceptualised by Hunter is grounded or experiential knowledge. This could be considered comparable to Carper’s aesthetic knowing. This is however only in terms of a form of knowing that realises:
“the particulars of a situation instead of universal components of the situation”
(Hunter 2008, p. 412). Hunter (2008) is a strong advocate of intuition and asserts that it is an integral component of the knowledge paradigm within midwifery. Her study however, whilst mentioning artistry does not specifically mention intuition, or ascribe it to a form of knowing. Hunter (2008, p. 413) does however conclude that there is a need for midwifery researchers to pursue future studies that explore “intuition and experiential knowledge as legitimate forms of truth”.
Returning to Carper’s (1978) seminal work on nursing knowledge, she asserted that empathy was the core skill necessary for aesthetic knowing. Johns (1995) has however subsequently challenged this viewpoint and asserts that intuition is a more fitting ‘skill’ to enable the process of aesthetic knowing. Johns (1995, p. 228) conceives intuition as a core skill which is “based on an understanding of the situation as perceived”. Johns (1998, p.2) concurred with Jung’s conception of intuition as ‘tacit knowing’. He does not however, state whether intuition is perceived via the senses or through the unconscious.
Intuition has similarly been defined as ‘know how’, consisting of tacit knowledge associated with a created understanding of a situation without having a rationale (Benner and Wrubel 1989, p. 6). Bourdieu (1990) concurs with this notion, however has coined the term ‘habitus’ to describe the tacit knowledge members of a culture or health professionals create within complex practice. Bourdieu (1990) makes some attempt to explicate why practitioners’ knowledge is tacit by explaining that as practitioners develop a ‘habitus’ which involves taken for granted meanings, knowledge and skills it recedes to the background. This appears to concur with Jung’s (1954, p. 165) notion of the “of the background”, however, this remains an abstract term. Paley (1996, p. 669) however questions whether background information is always useful and asserts that this may include “deeply ingrained, taken for granted and yet inappropriate” information.
Benner et al. (2010, p. 178) and Wickham (2004) have attempted to cement the term intuition more rationally with the psychological term “patterning”. Benner et al. (2010) have described patterning as recognition of a pattern which occurs when the signs and presenting symptoms of a problem are compared with patterns recognised from an individual’s memory. This pattern is then matched to the presenting trend.
Wickham (2004) has defined patterning as the subconscious recognising the situation but the rational brain not recognising the same signs or pattern, which aligns with Jung’s and other psychological theories of intuition as being associated with differing levels of consciousness and pattern recognition. Benner (1984, p. 2) however, coins patterning as “expert know how” based on an experiential knowledge base. She based her notions of expertise from the works of Dreyfus and Dreyfus (1986) who were working in the field of artificial intelligence and came to the
conclusion that human ‘experts’ process information entirely differently from computers.
In Benner’s (1984) seminal phenomenological study, which researched a cohort of nurses from the USA, she concluded that intuition could be diminished if intuitive or ‘expert’ practitioners tried to analyse their performance (Benner 1984). This does however suggest that only ‘experts’ or highly experienced practitioners can experience intuition and as Paley (1996) has asserted having experience or background information does not necessarily constitute expert performance. Experiential knowledge gained may have become ingrained and be inappropriate for some episodes of clinical care. This notion of intuition and expertise has also been contested by Smith et al. (2004) who utilising psychometric testing discovered that nursing students experienced intuition in an equivalent way to experienced nurses. McCutcheon and Pincombe (2001) have similarly confirmed that intuition is not purely the domain of the expert. In their study they identified novice nurses that experienced intuition. It is acknowledged however that due to their lack of experience, the nurses were reluctant to utilise it in their practice.
Benner’s (1984) study and notion of patterning and expertise, or experiential learning has however, in the main gained support by nursing theorists. Aitken (2003) more recently stated that the ability of nurses to undertake pattern recognition will develop as their knowledge base increases. Reichman and Yarandi (2002) concur but maintain that patterning is more likely to occur as nurses gain experience in a specific area of nursing. Hoffman et al. (2004) assert that with experience, pattern recognition will be replaced by more refined recognition patterns and concur that this refinement is often related to competence. Buckingham and Adams (2000) give further definition to pattern definition which subscribes to
intuition being linked to an experiential base. They describe it as a process wherein the learner links a pattern of cues to a given rule and a subsequent response. As more experience is gained, however, neural connections are created between the cues and the response and the rules are made redundant and become unconscious (Buckingham and Adams 2000). This theory connects both heuristics with pattern recognition and intuition with the unconscious which links both the psychological theories in terms of the notion of adequate slicing and parallel processing, with nursing theories. It also illuminates that intuition is perceived by the senses in terms of intuiting a pattern of cues. Buckingham and Adams (2000), however link their conception of intuition solely with experience and expertise.
Benner and Tanner (1987) further asserted that nurses ‘know how’ or intuition consisted of knowledge that did not follow a linear process and could not be expressed in words. Johns (1995, p. 226) has questioned this and asserted that a process of reflection could be implemented as a means of access to previous experiences in order to develop “the reservoir of tacit knowing”. Herbig et al. (2001, p. 690) however, agree with Benner and colleagues and contest the view that tacit knowledge can be identified or clarified:
“As reflection is not possible for tacit knowledge …a lack of awareness of naive or even wrong implicit theories may prevail and therefore cause errors in performance”.
Rolfe (1998, p.28) and Schön (1983) have both previously challenged Herbig et al.’s (2001) notion that intuition is tacit, arguing that intuition is ‘reflection-in-action’ that can become a conscious act. This is termed reflexivity. Johns (1995, p.226) defines reflexivity as a process wherein the nurse:
This subsequently enables practitioners to respond to new clinical situations with a different perspective, or knowledge. Rolfe (1998) develops the notion of reflection- in-action as reflexive and asserts that conscious reflection-in-action entails a reflexivity which modifies the object of reflection and has a direct impact on the practice situation. Rolfe (1998) maintains that adopting this notion of reflexivity commences a repertoire of paradigm cases which can be applied through initially conscious matching and then unconscious matching. Patterning in this sense, encompasses the whole situation rather than reducing the situation to discreet parts (Rolfe 1998). Mok and Stevens (2005) agree with this concept and have discussed how reflexive knowledge can be gained through creative practice. They have formed a theory of praxis where the individual practitioner can eventually create new knowledge through a regime of patterning.
Benner et al. (1999) however have refuted this notion of reflexivity and assert that whilst a practitioner may adopt a process of thinking in action this is related to a narrative understanding, not an intellectual, reflective process. Benner et al. (1999) attest that a reflective process would compromise and deteriorate a practitioner’s performance. Rolfe et al. (2001) dispute this by asserting that Benner‘s original study was underpinned by Dreyfus and Dreyfus’ (1986) model of motor skills acquisition; health practitioners, they maintain however, mainly carry out cognitive activities and reflection-in-action could enhance performance.
Whilst it is evident that intuition is difficult to rationalise, if intuition can be a form of authoritative knowledge in midwifery (Davis-Floyd and Davis 1997) it is vital that it be rationalised or at least explored to provide further learning and knowledge transfer. Latterly, Benner et al. (2010) have changed their terminology of patterning and intuition to a sense of salience which enables the practitioner to attune to each
familiar situation. This will be further discussed in section 2.6 (p.53) concerning the concept of intuition and decision making.
This discussion of the second theme has centred on the nature of intuition and tacit knowledge, much of this analysis has been ascribed to unconscious and conscious patterning and heuristics. Utilising the senses through eliciting cues has also been discussed and the degree to which intuition can be illuminated through the process of reflection and reflexivity. Intuitive decision making based on unconscious patterning has been in the main accredited with ‘expert’ status (Benner 1984; Sullivan 2005), whilst this may enable competent practitioners to begin to see long term goals and wider conceptual frameworks (Sullivan 2005) this devalues students’ and the (childbearing) woman’s own intuition and creates a hierarchy of knowledge. By ascribing all intuition to patterning, practitioners may also be missing an opportunity to explore an area of intuition that is difficult to rationalise and thus disparaged within a deductive framework. This form of intuition comprises a type of relational knowing based on emotion and spiritual awareness which forms the next thematic analysis.