In the early 1960s nursing adopted "the nursing process" as the method of clinical judgment. It did so in part to establish equality with the "scientific method" used by the "legitimate" sciences. Recently, researchers have found that expert practitioners use intuitive, holistic modes of thinking, as well as linear methods.
Throughout history, intuitive processes have been devalued because they lack a rational base and have been associated with "women's ways of knowing." Greater confidence has been placed in analytical processes, which, though incongruous with women's ways of thinking, are believed to be the preferred route to truth.
Nursing education has thus far not questioned the relevance of linear, reductionist modes of thinking to holistic practice or to nurses' ways of thinking. This article addresses this issue and offers suggestions for change.
Adherence to teaching clinical judgment as an analytical, linear process, exclusive of more holistic modes of thinking, is the result of the refusal or inability of nurse educators to recognize and respond to the influences of an educational system based on the masculine model. "Neglect, willful or unconscious," of the role of intuition in the professional development of nurses has been acknowledged in an extensive review of the nursing literature by Rew & Barrow (1987, p. 50). Belief in "the nursing process" as the prototype of reasoning in professional nursing practice ignores intuition as a recognized component of the perceived view of science and a legitimate way of knowing in nursing (Carper, 1978; Watson, 1981; Webster, Jacox, & Baldwin, 1981).
This article will discuss the issue of intuitive knowledge, followed by an explanation of why our culture emphasizes analytical reasoning. Next, it will suggest that educational methods derived from this belief system stifle the intellectual development of women in general and female nursing students in particular. Last, it will recommend alterations in curricula and use of specific teaching methodologies to remedy the situation.
Recent studies have questioned the merits of exclusive attention to a logical, analytical, linear process of reasoning and knowing in teaching clinical judgment (Benner & Tanner, 1987; Henderson, 1982; Tanner, 1987). Analytical reasoning is useful in structured settings where the relative influence of each element can be weighed and measured relative to desired outcomes. Nursing, however, invariably involves highly complex interacting elements that require analytical and non-linear thinking processes.
Intuition refers to the immediate awareness of past, present, or future events without the conscious use of linear reasoning. It is a non-linear thinking process used by experts ( Agan, 1987; Benner, 1984; Dreyfus & Dreyfus, 1986; Pyles & Stern, 1983), which is an immediate sense of knowing without a rational basis - a gestalt experience based on the perception of cues linked together with basic knowledge and past experiences. Intuition is synthesis rather than analysis.
We contend that failure to acknowledge ways of knowing in nursing education curricula other than linear reasoning impedes the development of the full range of mental abilities brought to the learning experience by all students, especially women. Studies have shown that relationship and connection are fundamental to female development. Evolving from a developmental focus, experiencing and integrating typify women's ways of knowing.
Western culture has defined its values from the perspective of the dominant sex. Thus, masculine characteristics of rationality and objectivity have always been valued, whereas feminine characteristics of intuition and emotionality have been devalued. Such attitudes have been mirrored in the content and processes of education through the years. "Academe has focused on rational calculation to the exclusion of the skills required for intuitive judgment" (Benner & Tanner, 1987, p. 30). Concentrating on rational thinking reveals not only an incomplete conceptualization of ways of knowing, but also disregards the fact that females employ cognitive processes of a more holistic, intuitive nature. Holistic knowing focuses on the whole rather than its parts.
Likewise, the male-dominant basis has affected "traditional pedagogical standards." Freiré (cited in Belenky, Clinchy, Goldberger & Tarule, 1986) likened these to a "banking model" in which the learner is a passive recipient of knowledge "deposited" by the teacher. This model is based on a belief in the teacher as the source of authority and power, whereas the student is only che repository of facts. Teaching methods thus derived emphasize "telling" and deemphasize experiential learning; students are passive recipients.
The male bias has also influenced who was to be educated. Historically, the education of females received far less attention than the education of males. For example, the primary aim of 17th century American education was the training of religious and state leaders, all of whom were males. Nicholson (1980) described the evolution of "gender bias" in post-industrial American schools which upholds the masculine view of reality as "right" and the feminine view as flawed. Education in post-industrial society was intended primarily for young boys who were expected to take their rightful places in public life. "Insofar as young women I were I destined to remain within the private sphere, schooling I was I seen for the most part as unnecessary for them" (Nicholson, 1980, p. 230).
Feminist writers have spoken out against educational institutions set up exclusively by and for males (Belenky, Clinchy, Goldberger & Tarule, 1986; Buerk, 1985; Gilligan, 1982; Maher, 1984; Martin, 1984). "Indeed, recent feminist writers have convincingly argued that there is a masculine bias at the very heart of most academic disciplines, methodologies, and theories" (Belenky, Clinchy, Goldberger & Tarule, 1986, p. 6). They have pointed out that males have constructed "knowledge" and "truth" which have become "the unquestioned guiding principles of men and women alike" (Belenky, Clinchy, Goldberger & Tarule, 1986, p. 5). The possibility that females experience the world differently than males and therefore learn in different ways has seldom been consciously considered.
In 1982, Gilligan published research results supporting the contention that females develop differently from males in the psychosocial-emotional realm. This view contrasted sharply with widely accepted theories of development offered by Kohlberg, Piaget, and Erikson. Until Gilligan's (1982) findings were published, it was assumed that principles of developmental theories generalized to all humans, regardless of gender, despite the rather important methodological flaw inherent in the fact that subjects used in research on which theories were based, were predominantly males. Gilligan (1982) showed that the female developmental focus is toward responsibility, relationship, and connectedness, while the male focus is on rights, independence, and separateness. Persistence in teaching analytical (separate) modes of thinking using the "banking model" of instruction, to the exclusion of more holistic (connected) modes indicates that this difference is still considered an unimportant issue.
Buerk (1985) related Gilligan's (1982) conclusions to her findings about women's attitudes toward mathematics. She noted that the popular misconception that knowledge in mathematics is dualistic in nature and analytically derived belies the creative, intuitive strategies mathematicians have used through history to develop the discipline, processes which have been kept hidden from public awareness (p. 62). Buerk (1985) suggested that the disparity between the reality and the myth is what keeps women from entering the field. She determined, as did Belenky, Clinchy, Goldberger & Tarule (1986) that two styles of reasoning are associated with two different epistemologica! orientations: "separate knowing" and "connected knowing;" the former belongs to the analytical mode of reasoning, the latter to the kind of intuitive knowing observed in women. This distinction carries implications for the education of women in a system based predominantly on the masculine model of knowing - a model which perpetuates belief in the exclusiveness of analytical reasoning in processes of knowing.
"Connected knowing" is a way of knowing whereby the individual attempts to integrate intuitively felt knowledge with knowledge learned from others: an integration of rational and subjective knowing. It is holistic rather than reductionist. Holistic knowing means valuing the whole as more than the sum of its parts, unlike the reductionist analysis inherent in "separate knowing" which relies on breaking things into component parts to understand them. Essentially, teaching "the nursing process" as a series of linear analyses focuses on reductionism and excludes the holistic perspective.
We submit that the potential of both male and female students of nursing to learn is not fully tapped by teaching methods designed, in the main, for males; neither gender is challenged to develop perceptual awareness, a prerequisite for working with the "whole" person and for development of intuition (Bastick, 1982; Benner & Tanner, 1987). How much better might females develop their intellectual/feeling modes of learning and knowing if they were educated in ways that enhance rather than detract from their uniqueness? Might not males gain a new perspective on ways of knowing if exposed to such methods?
While practicing analytical thinking, students are cautioned to withhold judgment until all the data are gathered (a task beyond anyone's ability), and are discouraged from using intuitive processes that cannot be substantiated by scientific evidence. This contradicts the multiple patterns of knowing which, in addition to the science of nursing, include ethics, personal knowledge, and esthetics (Carper, 1978). Esthetics is that knowledge "gained by subjective acquaintance, the direct feeling of experience" (Carper, 1978, p. 16). It is esthetics to which Dewey (cited in Carper, 1978) referred as "perception . . . [which] includes an active gathering together of details and scattered particulars into an experienced whole" (p. 17).
It is time for nursing education to focus on holistic as well as analytical ways of thinking. Recognition of the disparity between women's ways of knowing and traditional pedagogical standards can lead to changes in curricula and teaching methods in nursing education. Changes should come in the form of enlightened attitudes about processes in nursing, greater awareness of the unique qualities women bring to the learning situation, and greater attention to experiential forms of learning with emphasis on the problem and process rather than on the solution.
The dualistic view of reasoning must be challenged if the disparity between traditional education and women's ways of knowing is to be recognized. Though the nursing literature is virtually devoid of the term intuition, its implicit value appears in accounts of reflective, creative thinking in nursing (Rew & Barrow, 1987). Educators need to become aware of such omissions in the content and process of education, and should discuss intuitive thinking with their students as a legitimate way of knowing (Noddings & Shore, 1984).
Another method advocated by Noddings and Shore (1984) is deliberate warming-up exercises to "reduce the strain and stress of the instrumental world and make it more likely that the world of relation will open up" (p. 94). They recommend, for example, "communal silence," soft music, and physical exercise to ready the mind and set the tone for reflective thinking.
Students can also be helped to develop their intuitive processes through group experiences and mind-quieting activities (Rew, 1986).
In contrast to the regimentation of nursing students, which stifles intuition, group brainstorming sessions, group visualization, and quiet thinking time are necessary if nurses are to respond creatively ... (p. 27).
Group discussions capitalize on women's needs to experience new elements to make them meaningful, to connect them within themselves. Focusing on the question instead of the answer "encourages reflective personal thinking; it provides time to make connections" (Buerk, 1985, p. 67); "understanding" is the goal, not necessarily finding the "right answer." Students should be urged to share ideas, use their intuitive sense, and propose creative alternative solutions. "The connected class provides a culture in which ideas can grow. It is a 'yoghurt' class as opposed to a 'movie'. . . Members actively nurture each other's ideas" (Elbow cited in Clinchy, Belenky, Goldberger & Tarale, 1985, p. 41).
Another method, advocated by Vargiu (1977) is that of mental imagery. Students sit quietly, with eyes closed, and think of images associated with feelings of trying to find creative solutions. They tap emotional energy and rid themselves of feelings which are obstructive to creative problem solving.
Teacher behaviors can enhance or interfere with the development of intuitive thinking. Insistence on finding the "right answer" sets up a power grathent between teacher and student and stifles creative risk-taking:
One reason our students so seldom engage subject matter wholeheartedly is that we take away their opportunities to do so. In our enthusiasm for "direct instruction," we suppose that everything is best taught directly ... If the external, teacher voice always silences the inner voice . . . our students may indeed become passive, waiting halfmindedly to be told what to do, what to hear, what to see. (Noddings & Shore, 1984, p. 109)
The "teacher as midwife" metaphor describes the appropriate role of one who helps the student identify and expand on his or her own latent knowledge. This is the teacher women "praised and the kind for which they yearned" (Belenky, Clinchy, Goldberger & Tarale, 1986, p. 217).
Finally, men and women need to see both male and female professors straggling to solve problems and not only in the position of stating answers. The focus of intuitive knowing is understanding, whereas the focus of linear analysis is finding the right answers. Research into teaching methods designed to enhance the development of perceptual abilities is needed. Conceptions of nursing processes must expand to include both analytical and intuitive ways of knowing. Both are prerequisite to expert clinical practice.
- Agan, R. D. (1987). Intuitive knowing as a dimension of nursing. Advances in Nursing Science, 10(1). 63-70.
- Bastick, T. (1982). Intuition: How we think and act. New York: John Wiley & Sons.
- Belenky, MR, Clinchy, B.M., Goldberger, NR., & Tarule, J.M. (1986). Women's ways of knowing: The development of self, voice, and mind. New York: Basic Books.
- Benner, P (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison- Wesley Publishing Company.
- Benner, R & Tanner, CA. (1987). Clinical judgment: How expert nurses use intuition. Am J Nurs. 87(1), 23-31.
- Buerk, D. (1985). The voices of women making meaning in mathematics. Journal of Education, 167(3), 59-70.
- Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13-23.
- Clinchy, B.M., Belenky, MR, Goldberger, N., & Tarule, J.M. (1985). Connected education for women. Journal of Education, 167(3), 28-45.
- Dreyfus, HL. & Dreyfus, SE. (1986). Mind over machine: The power of human intuition and expertise in the era of the computer. New York: Free Press.
- Gilligan, C. (1982). In a different voice: Psychological theory and women's development. Cambridge, MA: Harvard University Press.
- Henderson, V. ( 1982 ). The nursing process - Is the title right? J Adv Nurs, 7, 103-109.
- Maher, R (1984). Appropriate teaching methods for integrating women. In B. Spanier, A. Bloom, & D. Boroviak (Eds.). Toward a balanced curriculum: A sourcebook for initiating gender integration projects (pp. 101-108). Cambridge, MA: Schenkman Publishing.
- Martin, J.R. (1984). Bringing women into educational thought. Educational Theory, 34(4), 341-353.
- Nicholson, L.J. (1980). Women and schooling. Educational Theory, 30(3), 225-233.
- Noddings, N. & Shore, RJ (1984). Awakening the inner eye: Intuition in education. New York: The Teachers College Press.
- Pyles, S.H. & Stern, RN. (1983). Discovery of nursing gestalt in critical care nursing: The importance of the gray gorilla syndrome. Image, 15(2), 51-57.
- Rew, L. (1986). Intuition: Concept analysis of a group phenomenon. Advances in Nursing Science, 8(2), 21-28.
- Rew. L. & Barrow, E.M. (1987). Intuition: A neglected hallmark of nursing knowledge. Advances in Nursing Science, 10(1), 49-62.
- Tanner, CA. (1987). Teaching clinical judgment. In R.L. Taunton & JJ. Fitzpatrick (Eds.), Annual review of nursing research. Volume 5 (pp. 152-173). New York: Springer Publishing.
- Vargiu, J (1977). Creativity. Synthesis, 3(4), 17-50.
- Watson, J ( 1981 ). Nursings scientific quest. Nurs Outlook, 29. 413-416.
- Webster, G., Jacox, A., & Baldwin, B. (1981). Nursing and the ghost of the received view. In JC McCloskey & HK. Grace (Eds.), Current Issues in Nursing (pp 26-35). Boston: Blackwell Scientific Publications.