Nursing Intuition: How to Trust Your Gut, Save Your Sanity and Survive Your Career

Chapter 1:

The Game

IT BEGAN AS A game. A simple game. Both were to kill time and amuse me while I worked twelve-hour triage. Many of my co-workers refer to triage as story time. It’s someone’s first contact with nursing staff as they enter the ER. They sit and wait to be triaged, and in the meantime, they’re in pain, scared, worried and running the worst-case scenarios through their head. People don’t usually come to the ER unless they’re in a fair amount of pain or have been told by a friend or relative (sometimes medical, sometimes not) that they should get that checked out. They arrive to sit in close quarters, awaiting their turn to see the nurse for their assessment. At triage, we classify people from sickest to those who can wait. This determines how fast they need to see the doctor. Every person who comes to the hospital usually assumes they are the sickest or most pain and should be seen the fastest. Or think they get caught in the order they come in. The emergency department is not urgent care, and sometimes people get confused. But anyway.

It was a game.

A game I was good at.

It was a game to look at someone walking in through the door and guess what they were coming for. I would look for cues as to what was happening – are they holding their stomach or chest? Are they bleeding, or do they look unwell? I would make my predictions based on what I thought was happening and then wait until that person came into my triage booth so I could ask them what brought them to the emergency room that day. The number of times I was close to the correct answer grew more and more. Because I was getting good at this game, I was addicted to playing.

Over the years, I got better and better. I focused on making my guesses more specific – from abdominal pain to gallbladder issues to appendicitis. Once the person got in the triage booth, it was my job to determine what was going on to place them within the department best. I aimed to be accurate with how sick they were, figuring out their path through the emergency department, the amount of nursing care they needed, what lab work and medical directives would then follow, how quickly they needed medication and then, finally, leading to their assessment by the doctor or nurse practitioner. I challenged myself to be spot-on here. Some cases were more straightforward than others to predict. Many people were evident with their complaints; a laceration is a laceration; a broken arm is a broken arm, but usually, at least once a shift, someone would come in, and my gut would scream at me that there was more going on, that something much deeper and more concerning was happening, though the evidence didn’t suggest this. Something was wrong, and I knew it even though I didn’t know how I knew it. Even if the points didn’t lead to that, I knew it. I mean, it wasn’t that they didn’t have a common complaint - they did. They had a concern, but their vitals looked good. They seemed okay on paper. – but something was wrong.

This person usually had good vital signs, yet their colour was off. From pale to grey to green-tinged, something about their colour cued me into the fact that something more was happening—those people I checked in on through their journey within the ER. Half my concern was ensuring their condition wasn’t deteriorating, and they were still okay to confirm that my gut instinct was right. Sometimes I was wrong, and the doctor would give me a funny look regarding my over-concern, but I was usually right. The person traditionally deteriorated quickly, and thankfully we already had this patient in the right area of the ER with lab work done and the doctor potentially having seen them with further diagnostics completed (CT and X-rays).

This game became an obsession – the more I listened to my gut, the more often I was right! A mix of experience, knowledge and an unknown gut instinct made me a great triage nurse. When I finally started talking to other nurses about my game, they said they either did it as well or were going to start. Talking to other nurses about their experiences with their gut instincts and their internal knowing when something was off was freeing! I wasn’t nuts! I wasn’t alone in feeling what I felt. I began to understand just how powerful this was when it came to taking the best care of my many patients.

It’s now a conscious part of the assessments of my patients, whether I’m in triage or simply working in a part of the ER. I take into consideration just how I feel about the patient’s condition. Do I think they’re improving? Are the current treatments improving the presenting illness and symptoms? Do I think this patient will harm me? Am I at risk of violence? Will this person give me trouble - either medically or behaviorally? Do I see their vitals trend in the wrong direction, and does their care plan need to change? Do I need the doctor with this patient later in the shift?

I began asking all these questions at the beginning of the shift for each patient, and I recommend you do too. Some of your answers will be directed by the report you received. Experience will also play a role but listen to see if your gut feels heavy or if you don’t get good vibes about a patient. The more you’re open to listening to more than just the physical picture, the more information you can discern from someone just by trusting your assessment with all your senses. Nursing knowledge is achieved through practical, aesthetic, personal and ethical expertise; while intuition is demonstrated as the art of nursing, others believe in intuition or intimate expertise.[1] This leads many of us to think about what our patients may need in the shift and what we can expect going forward.

Case Study:

I once had an elderly lady come in one afternoon with paramedics after being found at the bottom of a set of steep stairs at her quaint 1950’s style home. The paramedics (EMS) stated that she fell after missing the last step and could not get up. EMS said they weren't sure how long she had been on the floor. I assessed the patient and saw the thin outline on my stretcher, covered in EMS's thin dark grey sheet. She was a bit bruised and a little cool to the touch. Her pale, delicate skin let the icy blue of her tiny veins peek through. She seemed well enough, but my gut said something more was happening. She was breathing on her own, tiny little breaths that barely moved her chest up and down. Her vital signs were stable. She looked like she’d seen better days at her prime, but again, something deep in my gut kept pushing me that something more was going on than what I was seeing in front of me.

I ordered basic bloodwork within our medical directives, but something told me I needed to add on a CK (creatine kinase – a marker of muscle breakdown). CK isn’t something we usually order, but I felt the need to call it for some reason. Knowing the emergency doctors I routinely worked with, we had a bit of leeway when ordering more tests than are included in the medical directive. Around thirty minutes later, the doctor approached the desk and asked who had ordered the CK. I felt sheepish as I had not worked with that specific doctor before and said I was so sorry, but I did. The doctor then thanked me as he would not have generally ordered that bloodwork, but it showed that her CK was highly elevated, and she was now in rhabdomyolysis*. Because I had ordered the CK, we could be avoided further and saved her kidneys.

I was shocked. I thought about the CK as I had heard that the patient was on the floor of her home for an unknown time. I remember hearing about patients on the floor with muscle breakdown and elevated CK related to these extended periods on the ground. To this day, I can’t differentiate between whether it was my gut or because of something I had overheard someone else say before, but honestly, the how didn’t matter. What mattered was that that patient’s kidneys would be spared because we caught the problem early enough and therefore treated it appropriately.

It was a win. I didn’t care at the time how I knew what to do; I just trusted that there was a reason it popped into my head when it did. I am so thankful I went with my gut because the patient was the mother of a prominent doctor who had retired from the same department years prior. This has no bearing on the patient’s treatment, but his son was very thankful I had gone above and beyond to care for his mother.

This is how it all started. I began to listen to the things that popped into my head. I started paying attention to my gut when something felt off or didn’t add up. Most importantly, I stopped questioning how I knew what I knew and instead started to lean into my gut’s telling me, trusting it more and more with each win.

*Rhabdomyolysis is when the muscle breaks down and leaks CK into the bloodstream. This can damage the kidneys if the patient isn’t over-hydrated with IV fluids to try and flush out the excess CK. If Rhabdomyolysis is left untreated, severe kidney damage can lead to kidney failure.

Chapter 2:

What is That Gut Feeling?

INTUITION HAS BEEN DEFINED by Merriam-Webster’s Dictionary as “the power or faculty of attaining direct knowledge or cognition without evident rational thought and inference.”[2] That’s the official definition. Many other descriptions of intuition have included a heaviness in the gut, a feeling of just knowing something was off, your breath quickens, goosebumps (or as I like to call them, truth-bumps), a shiver down your spine, or your heart suddenly racing. I feel the heaviness in my gut and a sense of knowing when something is off. Alternatively, I get goosebumps all over my forearms when I’m on the right track. This signifies that I have either said something or thought about an action that needs more attention. Then suddenly, I will get entire body tingles and then goosebumps.

Intuition is defined as presence, visible, and clear insight. In other words, it is a human ability to know or do without adequate reasons and is a way to recognize truths without rational thinking1. Intuition is an intangible thing that many experienced nurses rely on without realizing they are doing it. Without realizing it, nurses are drawn to specific patients and have those gut feelings about their condition and whether something is going well. It’s that niggling voice in your head saying that you must be careful in a particular situation, look closer or reassess your patient. If you feel comfortable discussing this with a nursing friend or if the topic comes up on the floor in conversation, pay attention to those who know exactly what you are referring to. Ask them who has examples and why they did in those instances. The following key point is listening and learning from other people’s experiences.

Many experienced nurses know this feeling well and have integrated it into their practice without realizing it. The nurse who, when they give you handover on a patient (or transfer of accountability), will tell you flat out, “I don’t have a good feeling about this…keep an eye out.” The patient they ask you about the next day will see how the night went. They will want to check if their gut instinct was right. Talk to these experienced nurses and ask them why! Why were you so concerned about the patient? Was there a lab value that did not sit right with you? Can you explain that feeling and when you learned about that patient?

Chances are they may not be able to give you many answers, and no one has likely ever asked them before about what they’ve been feeling and why. Try not to be upset when they cannot give you any specifics. They may come back to you after a day or two wondering why you were asking those questions. You could provide them with answers or say that you heard about nursing intuition or were reading a book on nursing intuition. When they mentioned that they felt something was just off about the patient, it opened you to ask them why. Intuition has been defined in the expert stage into three distinct phases; “cognitive intuition, where assessment is processed subconsciously and can be rationalized in hindsight; transitional intuition, where a physical sensation and other behaviours enter the nurse’s awareness; and embodied intuition when the nurse trusts the intuitive thoughts.”[3] Using this knowledge, we can look deeper into the science of intuition and its relation to nursing practice.

There have been countless studies done from the 1980s to the present about nursing intuition and how it’s an untapped resource, but back then, we couldn’t test those theories since they were just that – theories. Recently, advances in brain imaging have led to the testing hypothesis in intuition and the subtle physical changes it can produce. Electrophysiological studies confirmed the existence of intuition and proved its emanation from the brain's frontal cortex. In this case, the brain and heart interact to receive, process and decode intuitive messages.3 It is with these advances in medical science that we can further prove the existence of intuition and start to figure out a better way to cultivate the feelings of intuition.

For all the constant focus on evidence-based practice and the push to continue to update our knowledge on any given topic in nursing, there is a subtle undertone of the “art of nursing.” While it follows evidence-based practice, it also understands that while working with people and dealing with life and death, there are things we cannot understand or comprehend. I was truly fortunate in my nursing education to have the core value of trusting your gut to be at the forefront of the conversation. If it wasn’t the teachers in my lectures bringing up the subject, it was being brought up by the clinical instructors or nurses we were paired with for clinical placements. It seemed at the time to be that unspoken rule for as often as we were being reminded to trust our gut. The fact that, at the time, they could not prove a link between intuitive nursing concerns and evidence-based practices meant it was sometimes talked about in very hushed tones.

Speaking now in the emergency department that I work in, we occasionally talk about a patent, chatting about why we were not sold on the idea that they would do well. It seems slightly less judgemental when I say it now vs. when I told it thirteen years ago. If I tell my doctor that I don’t know about a patient or that I’m concerned, I’m lucky to have support from doctors who ask me why. When I tell them that I don’t know, they tend not to push me further for answers but usually go and take a second look at the patient. Which is all I ask.

I am fortunate to have the support of these doctors I had worked with throughout the years who never bat an eye when I said I was concerned or just wanted them to reassess the patient. Inevitably, you will get a doctor who sneers at you or does not understand what you are saying. Usually, these doctors are younger medical residents who need the experience or opportunity to feel their intuition. It is not until they have a patient whom the nurse(s) have told them and called them about before the patient takes a severe turn for the worse that they start to listen to both nurses. They quickly wonder what they missed in earlier assessments, growing their intuition.

Case Study:

This case is from when I was a new graduate in an exceedingly small rural hospital - a town of fewer than 5000 people. We didn’t have access to CT scans or specialists, as it was usually just the emergency doctor (a family medicine doctor) providing care to the clients of the tiny rural town.

I walked onto my unit to listen to the taped report (I’m talking cassette and recorder). I listened to the information about my patient, who had a longstanding history of alcohol abuse and chronic pancreatitis. Nothing in the report was overly pressing, and no new concerns were present as the patient had already been admitted for a few days. I walked down the short, sparse hallway to Room Three. My patient was lying in his hospital bed in the second bed closest to the window. The man looked much older than his stated age, his leathery skin belying his life spent outdoors in the sun. This morning I greeted him and took his vitals. His vital signs at that time were within normal range, but before I could get too deep into my assessment, he suddenly doubled over in pain, grabbing at his abdomen and crying out. I quickly rechecked his vitals and found that, unexpectedly, everything was slightly out of rage and quite abnormal. His heart and respiration rates had jumped, and his blood pressure had dropped. The man seemed in agony, grabbing his abdomen and rocking. I called his doctor, who had yet to come into the hospital, to assess him and make her rounds. She finally answered, sounding like I had just woken her up.

“Yes,” she piped out, slightly aggravated by my sudden wake-up call.

“Hi there, it’s Jenn. So sorry to call you,” I continued sheepishly, “but your patient in room three, who was admitted with pancreatitis, isn’t doing well. I saw him right around 8 a.m., and now he’s doubled over in agony. His vitals are everywhere, and I don’t know what to do,” I stammered, my voice seemingly hurried and forcing out the words faster than I could speak to them.

“Oh, yeah, it’s okay. What was his lipase* this morning?” She asked. I provided her with what seemed to be an alarmingly high lipase. “Oh, okay, well, he’s been admitted here before for this, and his lipase has been higher than before, so don’t worry too much. I’ll be in when I can,” she said. Before I could answer back and continue to voice my concern, she hung up on me.

“Oh,” I sighed to myself now. “Well, if she’s not that concerned, maybe I’m overreacting.”

*Lipase – a bloodwork value that reflects if there has been damage to the pancreas.

I left the tiny oblong nursing station with its glassed-in area and returned to the vast hall to reassess my gentleman in room three. Going up the hall towards his room, I stared down the hallway, my eyes trailing to the end, falling on an emergency exit door with a window. The sun was starting to shine, but my mood was still sour. Something about being hung up on wasn’t a very professional move, and it just didn’t sit well with me. Still, I continued up the hallway, turning into my patient’s room. He continued to roll side-to-side in agony; his pain-stricken face skewed up. I kept the vital signs machine at his bedside with the blood pressure cycling every five minutes. His blood pressure continued to dip, his heart rate and respiration rate slowly increased, and now he was paler with the tiniest little beads of sweat appearing on his forehead. I knew something was off, but what?

Satisfied after my reassessment that something was still wrong, I ensured fluids ran as fast as they had been ordered through the intravenous. I gave him what pain medications I could as they were called and waited for the doctor to arrive, being very cautious of the number of pain medications I was given concerning his blood pressure and the effect they could have on it.

Nervously, I paced up and down the short hallway, continuing to check if she had arrived yet. My anxiety must have been palpable as I continued to pace the halls, seemingly wearing down a track on the floor. Thirty minutes had passed before the doctor arrived, but it felt like an eternity in my mind. I continued to repeat vitals, and the concerning trend continued. His heart rate and respiration rate continued to increase while, ever so slowly, his blood pressure continued to fall. At the doctor’s arrival, the vital signs were not abnormal. The blood pressure was normal now, even though the patient had been hypertensive all night. I continued to press the Doctor once she arrived to please see the patient but again continued to brush me off in favour of reviewing the bloodwork. Another forty-five minutes ticked away slowly before the Doctor finally saw the patient. She agreed that he seemed in pain and blamed the changes in vital signs on that. Pain medications were given again while the Doctor completed her assessment. At this time, I felt I finally had a minute to assess my other patients.

Another forty-five minutes later, I, once again, trudge quickly up the short hallway to Room Three, the sun continuing to shine through the back door. I turn the corner and into the room and see my patient no longer writhing in pain. He seems more comfortable and is lying back in bed. It was now that I noticed his colour was off, and his abdomen was quite distended. Once again, repeating his vitals, the trend of high heart rate, lowering blood pressure, and temperature is now climbing. On reassessment, I thought his abdomen was quite distended, rounded, taught, and firm, which changed his earlier condition. This was a significant change from his abdomen earlier this morning, and again my gut screamed at me that there was more going on than what was being seen at face value.

I (once again) seek out the doctor who is now reassessing her other patients on the teeny, tiny medical floor. I mention to her the changes in his abdomen and the continuing trend of his vitals.

“Oh, good, that means his pain is better managed,” she says casually. “The pain medication is causing him to relax, and that’s what’s causing the drop in blood pressure.”

“Oh,” I say, “but what about his heart rate and temperature rising?”

“Just run the fluid bolus that I ordered, and that should help,” she said and turned away from me, seemingly to end the conversation.

At that moment, I felt two feet tall, my shoulders slack, and I hunched over, feeling utterly defeated. What else could I do? I felt like I had repeatedly raised my concerns only to be cast aside. I felt like a brand-new nurse was the real reason I was not being taken seriously. I felt so disrespected. To be treated that way after doing what I thought was my job, notifying the doctor of all concerning status changes, is a truly awful feeling.

With very few new orders to process for my patient, I was forced to sit, wait, and watch. His colour got worse –from deathly pale to pale grey to a grey-green undertone. His vitals continued to become more unstable as the morning went on, and he developed a full-blown fever of 38.5°C. His abdomen continued to become firmer and rounder. It was around eleven when the doctor finally decided to reassess the patient. At this time, she finally felt that something wasn’t right.

We moved him into room five, our one cardiac room. This private room was rarely used and usually only considered when there wasn’t room elsewhere on the floor to put a patient. We moved the patient into this room, and he became less responsive, only occasionally opening his eyes when we put him on telemetry or started another IV. We repeated bloodwork; then IV fluid boluses were created as his pressure dipped into the low 80 mmHg’s systolic. He was becoming less and less responsive as the minutes progressed. We ran levophed and dopamine (inotropic agents used to maintain blood pressure). These were our last lines of defence to keep his blood pressure above 70mmHG systolic. He had stopped responding to us and the treatments that we had started. Ultrasound wasn’t available as it was a Saturday. We had called the X-ray technician to do an ultrasound and X-ray, but they were not in the hospital yet. Bloodwork was repeated, and now it wasn’t looking good.

By noon, we were doing compressions as his heart had stopped. Code blue was called overhead, and a few other staff in the hospital came to help. It felt like round after round after game of CPR. It was another 45 min before he was pronounced dead, and we pulled the white linen sheet over his body. The Doctor called his family and tried to explain what had happened.

I was shell-shocked.

Things had happened so quickly, and I was so mad that the doctor had not listened when I began to be concerned. All I could do was a chart to cover myself and continue the day as I still had other patients to attend to.

Later that day, we prepped his body to go down to the morgue after the little bit of family he had come to say their goodbyes. I watched the family as they filed through the hall, entered Room Five, surrounded him and wailed. They were upset; I think they were caught off guard about what had happened. It was all I could do not to break down into tears of frustration myself as they came to thank me for all I’d done. What did I do? Could I have done more? Should I have pushed harder? Could I have changed his outcome? I was going crazy with the “what ifs.”

I was shaking by the time I got home that night, still so angry that I was brushed off repeatedly –potentially because of that, a man had died.

It was several long, agonizing years before I got any validation for my efforts that day. I could finally quit that job and was about to move eighteen hours away to what seemed like a brand-new start to my career. It was only then that the doctor told me to trust my gut. She told me not to let anyone tell me I didn’t know what I was doing. It took five agonizing years and a lot of pain, suffering, and wondering and second-guessing myself if I had made the right decisions for her to say those words that day.

It took five excruciating years to hear it after I quit that hospital, but I finally got my validation.

After all these years, even if the doctor had listened to me when she did, I don’t know if it would have made a difference as we were in a remote Northwestern Ontario location. I don’t honestly know if we would have even been able to get him out to a more prominent centre in time. Maybe or maybe not, but all that matters now is that I have learned to stand my ground, watch for a change in the patient's status and trust myself when I feel something is off. That day I learned to trust myself more than someone else’s opinion. There may have been nothing more I could have done, but it was a big nursing life lesson, that’s for sure.

After this specific incident, I decided to pursue as many certificates in nursing as I could get my hands on. I knew that one day I would leave that hospital for one reason or another. I decided to be the most educated nurse to quit that hospital that day.

Chapter 3:

Intuition and What it Feels Like.

INTUITION CAN FEEL LIKE a lot of different things all at once. Someone could say something, or you could be assessing your patient, and suddenly something hits you that something feels wrong. It could come over you like a cramp or heaviness like a pit in your stomach. It could feel like someone in your head is yelling at you to look again, and reassess because something feels off. You could know that the outcome for this patient will not be good without much-supporting evidence for that conclusion. You may get a flash of a scene in your head of something happening to the patient, or it could be that you can smell death. I am unsure if everyone or just a portion of us can smell death.

I was a personal support worker during the summers between university semesters. It was in a long-term care home in my hometown. It paid better than my Canadian Tire job and was closer to becoming a nurse’s career end goal. It provided hands-on care to people and helped them better understand how hard personal support workers and healthcare aids work. I would show up to work, walk through the door and a smell like damp moss mixed and an acrid smell I still cannot describe very well would hit me. All I could think when I smelled that smell was, who died? Or who was dying? I was right nine times out of ten; one of our residents had killed the night before. I never considered it anything more than a simple smell until I talked to people in nursing school who had yet to work somewhere where death could happen at any given moment. When I mentioned the smell, those people would look at me funny and ask what scent I was talking about. It was not until someone else who had been in those situations would come up behind me and say, “You know, the smell.” People would continue to be confused, and there was nothing more you could do to explain how it smelled other than the smell of death.

I think about the conversations I have had with different nurses through the years, and if I ever heard one of them mention that they did not know something was going the right way or they felt off about a patient, I would tend to strike up a conversation with them and ask them the why’s.

“Why don’t you think this is going the right way?”

“What makes you think something bad is going to happen?”

“What do you think is behind that gut feeling?”

“When that feeling hit, where did you feel it?”

[1] Hassani (2016)

[2] Mirriam-Webster

[3] Hassani et al. (2016)