Abstract
Keywords
Intuition is acknowledged as a source of knowledge for practicing nurses (Smith & Glaser, 2008). In addition to being defined as a source of knowing, intuition is identified as an affective component of critical thinking and serves an important role in making clinical judgments (Scheffer & Rubenfeld, 2000; Smith & Glaser, 2008). Understanding the use of intuition in clinical judgment will promote professional practice and favorable patient outcomes (Pretz & Folse, 2011). Critical thinking and clinical judgment are essential outcomes of the educational setting, thus demonstrating the need to foster and promote the recognition of intuitive abilities among nursing students (Smith & Glaser, 2008). Intuition ability directly affects patient care quality and outcomes in nursing practice and is therefore an important aspect of nursing education (Rovithis & Parissopoulos, 2005; Smith, Thurkettle, & Dela Cruz, 2004). For the past 20 years, there have been repeated requests in the nursing literature to include intuition in nursing curricula (Ham, 2000; Smith & Glaser, 2008). Curriculum and pedagogical strategies are suggested for promoting intuition in the nursing program. Ruth-Sahd (2003) identifies 12 pedagogical strategies to include in a multicultural curriculum. One of them is encouraging students to assess patients using their sense and intuitive hunches.
In the nursing literature, intuition is recognized as an important component of decision-making theories (Smith, 2007). Thompson (1999) outlines the two predominant theoretical approaches to decision making: the systematic positivistic approach and the intuitive humanistic approach. Both approaches are valuable, and Thompson (1999) emphasizes the need to quantitatively investigate the intuitive humanistic approach in decision making. To understand the intuitive approach to decision making, nurses must be able to identify intuitive feelings and the use of intuition in their clinical practice. Previous studies have been qualitative in nature but nevertheless demonstrate the use of intuition in expert decision making (Rew, 1988) and label it as a source of knowledge coming from feelings, sensations, and connections (Agan, 1987; Davis-Floyd & Davis, 1996; Rew, 1988; Smith, 2007). Truman (2003) defined intuitive practice “as the merger of knowledge, skill, and practice, which encompasses the broadest knowledge base” (p. 42), whereas Rew (2000) defined intuition in the clinical setting as a sudden awareness of knowledge that is linked to previous experience.
In the literature, most studies related to intuition ability have been tested on experienced nurses with only a limited number of intuition studies tested with nursing students (McCutcheon & Pincombe, 2001; Smith, 2006; Smith et al., 2004: Sublett, 1997). There are data collection/analysis instruments for studying the use of intuition; such analysis of intuitive decision making can eventually lead to improved patient care. Several intuition measures link intuition to decision making. Rew (2000) developed an instrument to measure the acknowledgement of intuition use in decision making, and Himaya (1991) created a semantic scale to measure intuition use in clinical decision making. Both these measures have been tested in samples of registered nurses. The patient care environment is a highly complex domain in which very subtle changes may provide crucial information. But still there is evidence to suggest that practicing nurses use intuition and that its use can change outcomes for patients (Bailey, Colella, & Mossey, 2004; McCutcheon & Pincombe, 2001).
Although the literature addresses the need to include intuition in nursing curricula (Correnti, 1992; Ruth-Sahd & Hendy, 2005; Tatano Beck, 1998), intuition measures designed specifically for nursing students are lacking (Smith, 2007). The Use of Intuition by Nursing Students Scale (Smith et al., 2004) was initially developed to measure the use of intuition by nursing students and to serve as an instructional tool in promoting discussion of intuitive feelings experienced during patient care.
An intuition instrument can serve as a stimulus to promote and foster the intuitive abilities of nursing students. As an instructional tool, it can assist nursing students in identifying their sources of knowledge, whether it is emotional awareness, physical awareness, or making connections at a spiritual or physical level with their patients. This knowledge can then be used in conjunction with the nursing process.
As Turkish cultural values may influence the measurement of intuition, this study was conducted to determine whether the structure of the intuition scale in its present form taps into these culturally salient values for Turkish nursing trainees and whether it is appropriate for use with Turkish nursing students. Cross-cultural influences such as ethnicity, type of health care system, and nursing curricula affect the use of intuition by nursing students and their instructors. Cultural validation of this instrument will stimulate nursing research on intuitive decision making and the effectiveness of different teaching strategies on intuition awareness development. Therefore, the goal of our research is to culturally validate the Use of Intuition by Nursing Students Scale (UINSS) to enable its use in a Turkish nursing educational setting.
Characteristics of Intuition Instrument
This scale, originally developed by Smith et al. (2004), uses the following Likert-type ratings and consists of 25 items in total: 1 = never (1 point), 2 = rarely (2 points), 3 = sometimes (3 points), 4 = often (4 points), and 5 = always (5 points). The higher the score, the more the students are aware of the role of intuition and the abilities that they can use.
The conceptual framework of intuition for purposes of this scale includes emotional awareness, physical awareness, and connection (physical-spiritual). In this conceptual framework, there are a total of seven lower dimensions used in the scale, namely, physical sensations, premonitions, reading cues, apprehension, sensing energy, spiritual connections, and reassuring feelings (Smith et al., 2004).
Purpose
This study was conducted to test the validity and reliability of the Turkish version of the UINSS, an instrument to measure how nursing students experience intuition.
Method
This study was, as a methodological research, planned to culturally adapt UINSS to the Turkish language and to evaluate the validity and reliability of the Turkish version, and the study was carried out in accordance with the principles of the Helsinki Declaration. After the research protocol was approved by the Ethics Committee of Ege University Nursing College, written permission was obtained from the institutions involved. The principle of voluntariness was taken into account by informing the students taking part about the purpose of the study, and their oral consent was obtained before the questionnaires were completed. Also, required data about the confidentiality and purpose of the study were given on the first page of the forms. The sample group of the study consisted of 250 second-, third-, and fourth-year nursing students, who had at least 1 year clinical practice experience and were registered at Ege University Nursing College or Celal Bayar University Health High School located in western Turkey in the academic year 2008-2009.
Implementation
Permission for translating the UINSS into Turkish and use of the scale was obtained from Smith by e-mail. We followed the various essential steps set out in the literature for validating translation of such an instrument (Carlson, 2000; Erkuş, 2003; Erkut, Alarcon, Garcia Col, Troop, & Vazquez Garcia, 1999; Polit & Beck, 2004). Using a technique known as back-translation, the English version was translated into Turkish and back into English and then content analysis was performed. This was followed by psychometric testing (factor analysis, known group validity, reliability coefficient, and interitem correlations analysis).
Studies on the translation of the scale were carried out to test validity with regard to its adaptation to Turkish society. Each item of the scale was translated into Turkish by the researchers. Translators included eight experts who were familiar with English and also Turkish native speakers. The final form for each scale item was the most suitable statement from among the Turkish translations; these were then retranslated into English by a linguist who was a native speaker of Turkish and who was given detailed information about the topic. Necessary adjustments were made by comparing the translation back into English with the original scale items and then reviewing the Turkish item translation that did not fit with the original text. The final version was approved by the authors.
After its language validity was verified, the Turkish form of the scale was given to seven experts in fields relevant to the subject to evaluate content validity. Content validity is the determination of the content representativeness of the items of scale (Lynn, 1986). The Content Validity Index was calculated by taking the proportion of experts who judged the content of an item as valid with a score of 3 or 4. A 4-point Likert-type scale was used to rate all items independently, where 1 = not relevant, 2 = unable to assess relevance without item revision or item is in need of such revision that it would no longer be relevant, 3 = relevant but needing minor alteration, and 4 = very relevant and succinct (Lynn, 1986). All the remaining items were rated as content-valid by all the experts (i.e., rated as either 3 or 4 on the rating scale). Having reached this final form, pilot testing was performed to test whether the language of the scale was meaningful to a group of 10 students selected as research subjects and to a group of 10 students who had similar characteristics. The students in the pilot group were not included in the research. No item was taken out or changed as a result of pilot testing or analysis by experts.
Data Analysis
Statistical analysis relating to the validity and reliability of the instrument was conducted using the SPSS version 11.0 for Windows.
Results
Results Relating to Sample Description
Of the students forming the research sample, 93.4% were female and 6.6% were male. The average age of student participants was 21.45 ± 1.54 years; 70% were between 21 and 25 years old, 97.3% were single, and 52.7% of the students stated that they had not chosen nursing as a profession of their own volition. However, 62.8% stated that they had positive attitudes toward the profession. In the present study, 27.5% of the students had 1 year of clinical practice experience, 39.9% had 2 years, and 32.6% had 3 years.
Reliability
To test reliability, we first used split-half analysis. The α value was .78 for the first part (13 items) and .76 for the second part (12 items). The Spearman–Brown coefficient was .80 for the whole scale.
The Cronbach α value (the internal consistency coefficient) of the UINSS was high at .86 for the whole scale. The item–total correlations of the scale ranged between .30 and .56 and were thus statistically significant (p < .000). Results are shown in Table 1.
Item–Total Score Correlation and Alpha Value of UINSS
Validity
The Kaiser–Meyer–Olkin measure of sampling adequacy (KMO) was .82, indicating that the sample was large enough to perform satisfactory factor analysis and that the sample size was sufficient for psychometric testing of a 25-item scale. Accordingly, for the first step we used principal component analysis to examine the factor structure of the scale. Four factors were acquired, which had an eigenvalue more than 1 and explained 58.51% of the total variance when principal component analysis was applied to scale items (Table 2).
The Results of UINSS Principal Component Analysis
Analysis of the Scree plot testing graph revealed that the sharpest refraction occurred after the fourth factor (Figure 1).
Scree plot of Use of Intuition by Nursing Students Scale
The ages of the students and total scores on the scale were examined for known group validity in terms of creating evidence for UINSS construct validity. The results of these statistical analyses are shown in Table 3. There was no statistically significant relationship between student age and the score in each of the lower dimensions and on the total scale (Table 3).
Comparison of Students’ Point Averages Obtained From the Use of Intuition in Nursing Students Scale in Terms of their Age Variables
The average level of clinical practice experience of the student participants was 3.05 ± 0.77 years. There was a statistically significant positive relationship between the level of clinical experience and the total points scored on the physical awareness, emotional awareness, and physical connection subscales and from the total scale (Table 4).
Comparison of Students’ Point Averages Obtained on the Use of Intuition in Nursing Students Scale in Terms of Their Clinical Practice Experience
p< .05
Discussion
Our results show that the psychometric characteristics of the Turkish version of the UINSS are adequate. This study presents a cultural adaptation of the UINSS, following international methodological procedures (Aksayan & Gözüm, 2002, 2003; Burns & Grove, 1997; Erefe, 2002; Erkuş, 2003; Polit & Beck, 2004). The language translation used for assessment of intuition use by practicing nurses was previously tested; thus, there was no need to modify the translation or any other content. In addition, internal consistency reported in other studies was sufficient in terms of item correlations (Clark & Watson, 1995; Erkuş, 2003). Split-half reliability of the scale was high.
In the literature, it has been suggested that the correlation coefficient in item analysis may be higher than .25 (Clark & Watson, 1995; Ozdamar, 2003; Tezbaşaran, 1996) for this scale. In the present study, the breakpoint was .30 for the item–total correlation level, as in the original study (Smith et al., 2004). Accordingly, it was decided that all the items in the instrument are reliable. Significantly high internal consistency values were found, as well as partially lower points when the reliability findings of the scale were evaluated as a whole and compared with the original scale. Several studies report that Cronbach α coefficient should be at least .70 (Erefe, 2002; Erkuş, 2003; Polit & Beck, 2004; Polit & Hungler, 1995). Cronbach’s alpha coefficients of the UINSS achieved acceptable standards for reliability. The homogeneity of the UINSS was seen to be at an adequate level in terms of item correlations (Clark & Watson, 1995).
Content validity measure was ensured by making changes to improve language validity and incorporating the experts’ opinions and suggestions. Sample sufficiency calculated by KMO coefficient (Kaiser, 1974) was used as the criteria of sample sufficiency for application of factor analysis in the validity content of the study. Furthermore, the results of Barlet test were found to be significant at an advanced level. These result shows that the current sample size was sufficient and that data were suitable for analysis to accomplish the factor analysis (Akgül, 1997; Büyüköztürk, 2002).
For the purpose of observing the possible effect of cultural differences, eigenvalues of more than one were used in the principle component analysis with varimax rotation. When results of factor analysis are applied to factor loads, the scale items varied between .40 and .80, and four factors explained 58.51% of the total variance. Thus, when eigenvalue results of the data group were considered, the items measured characteristically with four dimensions. This result supports the idea that the scale used for the present study in Turkey differs from the original one.
In the original study, the Cronbach α coefficient ranged between .69 and .84 for each scale item, and was .89 for the entire scale. Analysis of internal consistency coefficients of the factor groups resulted in Cronbach α value of the first factor at .85, the second factor.82, the third factor.84, and the fourth.75. The number of items in the measurement instrument affected the internal consistency coefficients obtained, and the alpha coefficient in the scale with fewer items showed a value lower than the original value (Çimen, Bahar, Öztürk, & Bektaş, 2005; Ergül & Temel, 2007). The fourth factor alpha coefficient may be lower than the other factor groups because of the number of items. Naming of the factor groups was undertaken to keep within the seven lower dimensions in the original study and considers the theoretical framework on intuition.
The emotional awareness factor was defined as awareness arising from feeling sensitive and using the capacity for empathy. This group included diagnosing the patient’s condition as well as the emotions experienced in patient care, both positive and negative (Philipp, Philipp, & Thorne, 1999; Rew, 1988; Young, 1987). The “emotional awareness” factor group was so named because the items in this group expressed the intuition at an emotional level.
Physical awareness involves the sensory organs. Physical awareness is used as part of patient care as well as in the process of decision making regarding patient care (Agan, 1987; Khatri & Ng, 2000). Intuition is described in the literature as connection at physical and emotional levels, or the sensing of a relationship. Physical connections are the relationships that form between two individuals and include understanding of body language and so-called nonverbal conversation (Smith et al., 2004). Consequently, this factor is called physical sensations. In the nursing literature, experienced nurses describe physical connections as (a) identifying cues of the patient, (b) feelings of relatedness, (c) direct patient contact, and (d) early recognition of patient problems (Minick & Harvey, 2003; Smith 2006; Young, 1987). Spiritual connections are abstract and involve the universal or spiritual connectedness of humans (Rew, 1988). They are of a universal nature and may involve an energy exchange or energy fields (Agan, 1987; Davis-Floyd & Davis, 1996; Leners, 1992; Smith, 2006). Nurses define intuition as knowledge occurring through these bonds and speak about it as “a deep bond” or “the ability of having a relationship with another individual at an emotional level” (Leners, 1992). Human beings as a whole have needs at physical, emotional, social, cultural, spiritual, and intellectual levels. These needs must be met for a human being to be healthy. In this sense, a person’s spiritual dimension, which plays an important role in the process of problem solving, is also important in nursing care, in addition to biological, psychological, and social needs of the individual (Kostak, 2007). For Rew (1989), intuition can be experienced as a spiritual connection between the patient and the nurse. This factor is therefore called the spiritual connections, and it follows that items in this factor group are related to emotional bonding.
The translation into Turkish of this scale is based on the factor construction used by Smith and his colleagues; of note, two lower dimensions in the original study were combined in this study. In the original study, while spiritual connections and sensing energy were evaluated as separate dimensions, those two were combined into one factor called the spiritual connections dimension for purposes of this study. We found this format to be more effective for Turkish nursing students than using the two separate dimensions. Similarly, although reading cues and reassuring feelings were evaluated as separate dimensions, those two lower dimensions were combined into one factor called emotional awareness. The items in the original study belonging to the dimension physical sensations were also combined into one factor for the Turkish culture and given the same name as in the original scale.
Results of construction-concept validity analysis for this study showed that factor construction of the UINSS for use in Turkish culture partially and theoretically agreed with the required lower dimensions, although it did not correspond to the construct determined by Smith and his colleagues. The Turkish scale is four-dimensional. It is to be expected that the scale would have different factor construction for each country since it is known that when psychometric characteristics are evaluated, intuition capability measurement and the capability for intuitive decision making are perceived differently because of variables such as culture, ethnicity, health system type, and curricula differences. Results of research done by using adaptive scales for different cultures cannot be found in the literature at the moment. Only results of a research related to use of scales adapted for Korean culture can be found; however, it is a summary part (Jang & Smith, 2008). This research is related to UINSS validity study among Korean nursing students. In this study, three factors were factor analyzed based on the results of the responses from Korean nursing students. These are connections, bad feeling, and sensations and good feelings. From the review of literature, three measurable dimensions of intuition were identified—emotional awareness, physical awareness, and making connections—at the physical and/or spiritual level (Smith et al., 2004). Having a view in this respect, in this study we can consider similar results obtained as in Turkish culture.
Studies conducted on this subject have shown that intuition in patient care is used more in older, more clinically experienced nurses; in such cases, intuition guided nurses in planning patient care and was a part of analytical decision making at that level of proficiency (King & Clark, 2002; Ruth-Sahd & Hendy, 2005; Smith et al., 2004). In this study, there was no statistically significant relationship between student ages and all lower dimensions and the total scores they obtained on the scale. This result may be because of the fact that the ages of the students participating in the study were within a narrow range (age range = 18-27 years; X = 21.45 ± 1.54). Therefore, it would be useful to examine the UINSS again in samples with a wider range of student ages.
There was a statistically significant positive relationship between the level of clinical practice completed by student participants and the physical awareness, emotional awareness, and physical bond dimensions as well as total scores. This may indicate that as the nursing students’ clinical practice level increases, intuition ability also increases. Similarly, Sublett (1997) analyzed the relationship between cognitive development and intuitive decision making in nursing students with clinical experience and reported that the students with more clinical practice experience also showed improved intuitive decision-making ability. This result is evidence for the construct validity of the Turkish version of the scale.
One of the core values of holistic nursing is the holistic caring process. As Potter and Guzzetta (2005) noted in their discussion of this process, nursing often discounts data that are not derived through the scientific method. As noted in previous research, intuitive skills are one component of complex decision making and should be included when teaching students critical thinking skills (Rew, 2000). Nursing instructors may tend to discount intuitive thinking and send a message to their students that discourages them from trusting and developing this essential skill. Holistic nursing educators who are willing to acknowledge intuition as another aid in data analysis related to patient care may find this instrument useful in teaching students this important skill (Rew, 2006). We suggest that this instrument may help nursing students become aware of using intuition as part of the nursing process and it may therefore serve as a springboard for discussing connections between nurses and their patients. More study is needed about intuitive decision-making use in the nursing profession for students. Tools such as the one described in this study will be useful in different countries and cultures.
Conclusion
In conclusion, the Turkish version of the UINSS has shown statistically acceptable levels of reliability and validity. The UINSS is very important as it can provide standardized data in nursing student research. As Smith and his colleagues, who developed the scale suggested, it will be useful to revise the instrument’s psychometric characteristics and especially its factor construction by applying the scale to different sample groups.
In addition, the reliability and validity study conducted with the UINSS can be used as a guide for the development of new instruments that can more adequately measure the use of intuition by nursing students in our culture. The application of a methodology accepted by the scientific literature makes available the comparison of the data obtained in different languages. It is recommended that this scale should be further evaluated both in different regions of Turkey and in diverse populations. Once a valid and reliable scale is ready to be used, it can be used to measure outcomes in an intervention study and, as mentioned above, be tested in different cultures. Also, during replication using a sample of the same population, the same scale and its dimensions mentioned here can be used. However, it is recommended that at the end of statistical evaluation of the results we consider that the dimension called spiritual connections can be divided into two subdivisions. These are spiritual connections and sensory energy subdivisions. Therefore, within this scale we can examine spiritual connections either as a single dimension or as two subdivisions called spiritual connections and sensing energy. This point of view must be considered by the other researchers planning to use this scale.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.