Barriers and Facilitators of Intuitive Decision-Making among Psychiatric Nurses: A Cross-sectional Study

Introduction: Due to the type and nature of hospitalized psychiatric patients, nurses encounter many ambiguous and complex clinical situations that require intuitive decision-making. The present study was conducted to determine the use of intuition and its barriers and facilitators among psychiatric nurses. Methods: This study adopts a descriptive cross-sectional design and employs 123 nurses using convenience sampling in 2022. Demographic characteristics, the use of intuition in clinical practice, and the barriers and facilitators of intuition in clinical practice questionnaires were used for data collection. Results: The results of this study showed that the mean (SD) of intuitive decision-making among psychiatric nurses was 58 (13.07) out of a range from 25-125. The use of intuition had a statistically significant correlation with age and work experience in the psychiatry ward. The use of intuitive decision-making has a statistically significant difference in gender, work shift, and education level. The biggest barrier to the use of intuitive decision-making among psychiatric nurses was "The limitations of nursing role which restrict the use of intuition in the clinical setting". The most common facilitator in the use of intuition among psychiatric nurses was "having experience and clinical knowledge leads to the use of intuition in patient care". Conclusion: Given the low level of the use of intuition and the important role of intuitive decision-making in the quality of nursing care, nursing managers should provide some strategies for reducing the barriers to the use of intuition among nurses.


Introduction
Humans use two general approaches, 'analysis' and 'intuition, ' to process information, know, recognize, decision-making, and problem-solving. 1 The 'analysis' approach is accompanied by high cognitive control and low information processing speed, and due to the linearity of this process, people are fully aware of the subject.However in the 'intuitive' process, cognitive control is low, and information processing is done quickly, and these actions are related to the unconscious system of the person.In the analytical approach, there is less confidence in the judgment, but the information processing method is entirely objective in intuition.While confident in a decision, the process of knowing and receiving data is unclear. 2Intuition means presence, insight, revelation, observation, and a kind of ability and sense of guidance for a person's movement without understanding the exact cause of something.Also, another expression describes it as the feeling of understanding and knowing that something unpleasant is happening.This knowledge is obtained directly and immediately and is mainly used when there is a need for creativity and innovation or in new, complex, and dangerous situations. 3From a cognitive psychological point of view, intuition is a nonanalytical method of human information processing that operates through complex pattern recognition and fast and unconscious associations based on empirical knowledge. 4n many professions, such as health care workers, decisionmaking has been cited as critical for managers and leaders. 5urses usually play a crucial role in care because they have the most direct contact with the patient, which requires high communication skills.An essential aspect of this caregiving role is the decision-making that comes from assessing and monitoring patients to carry out effective treatment plans and coordinating the participation of other health professionals. 6They encounter many complex clinical situations that need decision-making skills.These skills are crucial for optimal patient outcomes in critical care settings.Decision-making is a complex process that includes a series of decisions, including making observations of clinical data, validating the observed data, making inferences, and taking actions to meet desired outcomes. 7Intuitive decision-making is one of the types of decision-making strategies in nursing that refers to the perceptual, rapid recognition of significant clinical cues. 4linical practice nurses must make critical decisions, often under complex and ambiguous conditions.These decisions must be completed correctly and repeatedly with incomplete, contradictory, or imprecise data.Such situations require that nurses not only develop accurate analytical skills but also consider the use of intuition in clinical decision-making. 8Among nurses, nurses working in psychiatric departments, due to the type and nature of hospitalized patients, including lack of insight, behavioral violence and communication problems, suicide, and escape, the need for risk assessment and management in these cases inevitably requires the appropriate use of "intuitive" thinking methods.They need analytical thinking. 9,10n the other hand, intuition and tacit forms of knowledge are often ignored due to fear of prejudice and concern that they are 'unscientific' . 11In a study, psychiatrists defined intuition as the defining characteristic of suddenly knowing the truth about something without having specific data or using a linear reasoning process. 12Psychiatric nurses inevitably need the appropriate use of intuitive and analytical thinking to assess and manage risk. 9The studies showed that the nurses relied on their knowledge to be alert in psychiatric departments, resulting from the relationship between their formal and tacit knowledge.Some relied on their intuitive ability to recognize the signs of suicide. 13,14][17][18][19] The present study is one of the few quantitative studies on the use of intuitive decision-making and its obstacles and facilitators in psychiatric nurses.The present study was conducted to determine the use of intuitive decisionmaking and its barriers and facilitators among nurses working in the psychiatry department in Tabriz city.

Study Design and Sampling
The current study is a descriptive correlational study with the participation of 123 nurses working in the various wards of Razi Psychiatric Hospital in Tabriz in 2022.Sampling was done by using the convenience method.The center is the largest psychiatric center in the northwest.The method of patient' assignment in the center is functional nursing.Inclusion criteria were being interested in participating in the research, completing the questionnaire, and having at least one year of direct participation in the nursing care of psychiatric patients.The nursing department prepared the list of the nurses working in the mentioned wards.Sampling was randomly performed in all three shifts.The sample size was calculated as 123 nurses using Morgan's table, considering the number of the statistical population, and the probability of a 10% attrition in samples.

Data Collection Tools
Data were collected using a three-section questionnaire of demographic information, the use of intuition in clinical practice, and barriers and facilitators of using intuition in clinical practice in nurses based on review literature. 12,20he demographic information questionnaire contains age, gender, marital status, education level, and work experience in the psychiatric ward.The questionnaire on the use of intuition in clinical practice has three factors: intuition as a judgment factor, intuition as a predictor of the patient's condition, and intuition as a communication channel in 25 statements on a 5-point Likert scale from very low to very high.It is 25-125.The higher the score, the more intuition is used.This questionnaire was created by Hosni and colleagues. 20The questionnaire of barriers and facilitators of the use of intuitive decision-making in clinical practice in psychiatric nurses has 22 items in the form of yes-no.This questionnaire results from a qualitative study on the use of intuition by psychiatric nurses. 12o determine the reliability of the tools, the questionnaires were distributed among ten professors and ten experienced psychiatric nurses at Tabriz University of Medical Sciences for the pilot study.To evaluate the reliability of the questionnaires, after collecting information from 20 nurses and using Cronbach's alpha coefficient, the internal consistency of the Intuition in Clinical Practice questionnaire and the barriers and facilitators of use of intuitive decision-making in clinical practice questionnaires were calculated as 0.90 and 0.85, respectively.The data were collected during two months from April-May 2022.

Data Analysis
Data were analyzed using SPSS v.11.5 (SPSS11.5,Inc, USA).Descriptive and inferential statistics were used to analyze the data.
The results of this study showed that the average use of intuitive decision-making among psychiatric nurses was 58 ± 13.07 out of a range from 25-125.The use of intuitive decision-making had a statistically significant correlation with age and work experience in the psychiatry ward (r = 0.183, 0.311; P ≤ 0.05).On the other hand, intuitive decision-making has a statistically significant difference in gender, work shift, and education level.Statistically, there was no significant difference between marital status and psychiatric ward (Table 1).
The biggest barriers to the use of intuitive decisionmaking among psychiatric nurses were "The limitations of nursing role limit the use of intuition in the clinical setting." and "Documenting patient care information on intuition is difficult" (Table 2).
The most facilitating use of intuitive decision-making among psychiatric nurses was "having experience and clinical knowledge leads to the use of intuition in patient care." and "Willingness to take risks leads to its use in patient care" (Table 3).

Discussion
The current study assessed the use of intuitive decisionmaking and its barriers and facilitators among psychiatric nurses.Regarding the use of intuitive decision-making of the nurses, the results of the current study are in line with the results of some studies, including Nuray et al and Masoudi & Alavi which were low. 21,22However, these results were in contrast with the results of the studies of Hassani et al and Miller & Hill and Sari & Akbiyik which were high. 15,18,19Circumstance and context, individual characteristics, cognitive and mental processing, and synthesis are identified factors affecting intuition. 23The difference in the study's environment, tools, size, and type of sampling, and context, individual characteristics of participants can be the possible causes of the difference in the results of the studies.
In the current study, there was a significant positive correlation between the use of intuitive decision-making and age and work experience in the psychiatry ward.The present study found that with increasing age and work experience in psychiatric wards, use of intuitive decisionmaking increased.The current study's results align with the results of some studies, including Ruzsa et al and Kindie Abate et al. 24,25 However, these results were in contrast with the results of the studies of Hassani et al and Noori Tajer et al. 16,26 With increasing age, gaining experience, and being involved in different clinical situations, it can be said that nurses' confidence in themselves has increased; in a way that they can more easily communicate between the theoretical and practical knowledge they have acquired this year. 27Also, the decision-making ability of nurses with experience in the bedside environment increases; So instead of being systematic and going through a linear process, decision-making goes towards intuitive and interpretive intuitive decision-making.Also in the current study, the use of intuitive decisionmaking has a statistically significant difference in gender, work shift, and education level.The current study's results align with the results of some studies, including Sadler-Smith and Sinclair et al that reported women used more intuition, and men used more reason. 28,29However, these results were in contrast with the results of the studies of Delaney et al and Allinson & Hayes. 30,31Women tend to be more emotional, therefore, it is not as huge a leap for them to experience a higher level of awareness with things than the fell. 32The current study's results align with the results of some studies, including Rababa et al revealed that nurses with high educational levels use intuitive decisionmaking more.Nurses with an advanced academic level have more opportunities to strengthen their theoretical and practical skills during their nursing education and clinical rotations. 33Also, the current study revealed that nurses with circulated work shifts use intuitive decisionmaking more.Understanding patients' accurate and complete status is time-intensive and requires nurse presence in different shifts.It is an important and complex part of decision-making for nurses.The nurse must spend more time, collecting physiologic and psychological cues, determining which cues are important, and determining how to respond to the collected information as part of their decision-making process. 34n the current study, the biggest barriers to the use of intuitive decision-making among psychiatric nurses were "The limitations of nursing role limit the use of intuition in the clinical setting." and "Documenting patient care information on intuition is difficult." One of the pivotal factors in clinical decision-making practice among nurses the professional authority and autonomy.It is reportedly associated with the meaningfulness of work, which is promoted by autonomy in performing and scheduling work, clinical decisionmaking, and the freedom to perform nursing work according to nurses' judgment.The studies show that poor professional autonomy is considered an obstacle to clinical decision-making in nurses. 35,36Documenting patient care information on intuition is difficult.Judgments and decisions based on intuition can be difficult to measure because they involve variables such as behavior, risktaking, time, experience, level of training, the complexity of the data, and the maturity of the practitioner, which can affect the outcome of such measurements. 12,37n the current study, the most facilitating use of intuitive decision-making among psychiatric nurses was "having experience and clinical knowledge leads to the use of intuition in patient care." and "Willingness to take risks leads to its use in patient care." Intuition is influenced by various factors out of which clinical experience is the most common element.Experienced nurses have a clearer understanding of clinical situations and symptoms which helps them to interpret patient cues. 38ne of the effective factors in the use of intuitive decisionmaking is the willingness to take new and unconventional approaches to problem-solving. 37,39Intuition might play a critical role in creative thought and creative problem- solving.Constructs of intuitive and creative decisionmaking have in common that before a decision is made, option generation processes are involved, which bring about the options to choose. 40his study has some limitations.The present study tools were based on self-report which can influence the results of the study.The generalization of the results may be limited due to the various contextual factors.There was a lack of a comprehensive and standard questionnaire to assess the barriers and facilitators in the use of intuitive decision-making among psychiatric nurses.Therefore, we used a researcher-made instrument.Using a sample with a limited size due to the limited population and inclusion criteria of the study.

Conclusion
Based on the results of the present study, it can be concluded that the use of intuitive decision-making among psychiatric nurses was at a low level and there were barriers to using intuitive decision-making among these nurses.Given the low level of The use of intuition, the existence of barriers among the nurses, and the important role of intuitive decision-making because of its nature in the quality of nursing care, organizations, and nursing managers should provide some strategies like the implementation of intuitive decision-making training courses, reducing the limitation of the role of nursing in intuitive decision-making, improving the position of intuitive decisions in nursing education, facilitating the documentation of intuitive information in the nursing process, and creating a suitable organizational culture.

Table 1 .
Comparison of demographic characters with use of intuitive decision-making among Psychiatric nurses a Student t test , b Pearson correlation, * Statistically significant.

Table 2 .
The barriers of the use of intuitive decision-making among Psychiatric nurses

Table 3 .
The facilitators of the use of intuitive decision-making among psychiatric nurses