Contemporary midwifery practice: Art, science or both?

Intuition: fact or fiction?

Intuitive practice has been described as ‘artistic and magical/mythical’ (Gobbi, 2005: 117) and, as a result, there has been much debate in the literature as to how to define the indefinable and rationalise the irrational. Dreyfus and Dreyfus (1980) define it as the holistic processing of the brain and mind; conversely, Gherman et al (2006) take an empiricist view, defining it as simple mechanisms based on pattern recognition. There are definitions that encompass both theories, with McCutcheon and Pincombe (2001) stating that it is neither mystical nor irrational but a product of the interaction of knowledge, expertise and experience, and King and Appleton (1997) suggesting it occurs in response to knowledge, is a trigger for action and/or reflection and thus has a direct bearing on analytical processes in care. There is, therefore, an argument to suggest intuition could be described as a cyclical learning process with ongoing reinforcement from expert knowledge, recognition and reflection to inform future practice.

Benner's (2001) intuitive–humanistic decision-making model distinguishes between theoretical knowledge and experiential knowledge in nursing, which can be applied to midwifery practice, and suggests five levels of proficiency: novice, advanced beginner, competent, proficient and expert. Progression through the phases is dependent on a combination of depth and range of knowledge and the time spent in a particular practice area to achieve expert status and practise intuitively. Such ‘understanding without a rationale’ defines practice as an art, not a science. Cox (2002) and Leap (2000) talk of ‘clinical perception’ or ‘knowing without thinking’ where expert practitioners automatically use perceptual observation to notice overt and covert clues from women, which they compare with a library of stored knowledge. Differences trigger ‘gut feelings’ that there may be a problem warranting more careful examination of evidence and appropriate management. Raynor et al (2005) suggest this is ‘professional artistry’—the involvement of experiences of a more intuitive or reflective nature that are then applied to a different but similar set of circumstances, with the aim of enriching the context within which a decision needs to be made. Information that will link to these sources of knowledge may arise from non-verbal behaviour, specific use of words and what has been described as ‘ways of knowing’, including expert memory (the template theory) (Gobet and Chassy, 2008).

This recognition of previous experiences to apply to practice links with the theory of reflective practice as advocated by Schön (1987), who believed practice was fundamental to the acquisition and development of clinical knowledge and expertise. He advocated professional artistry in a constructivist paradigm rather than a theory-based positivist approach. Schön acknowledged the difference between novice and expert by identifying two types of reflection: reflection on action undertaken by the novice retrospectively, and reflection in action by expert practitioners, which occurs in real time, bringing intuition and previous experience into play to resolve a problem; with experience, the practitioner will reflect more and more in action as he or she moves from novice to expert.

It is unacceptable for midwives to use the knowledge gained at the point of registration throughout their career without constant re-evaluation and updating, and this is why reflective practice and continuing professional development (CPD) or ‘Prep’ are critical to the provision of high-quality care (NMC, 2011). Midwives must be reflective practitioners in order to learn from experiences, mistakes and successes to improve practice (Kolb, 1984; Boud et al, 1985; Gibbs, 1988; Nakielski, 2005) and consequently reflection should be acknowledged as a legitimate source of knowledge to influence future practice, much like other forms of knowledge such as evidence-based practice (Bulman, 2004). The importance of the relationship between reflection and practice is explicitly acknowledged in the revalidation process due to be introduced in April 2016, where midwives will be required to record a minimum of five written reflections on the Code, CPD and practice-related feedback over the preceding 3 years (NMC, 2015b).

There is compelling evidence regarding the merits of a positivist approach to midwifery practice where midwives use a wealth of experiential and tacit knowledge reinforced by lifelong reflection to provide intuitive care meeting the needs of the individual. This approach has been established over time as midwives move from the novice reflecting on action to the expert reflecting in action.

Evidence-based practice: Doctor knows best?

The constructivist paradigm which began with evidence-based medicine (EBM) or ‘the process of systematically reviewing, appraising and using clinical research findings to aid delivery of optimum clinical care to patients' (Besley, 2009: 1) should also be explored to appraise its relevance to contemporary midwifery practice. This medical paradigm of ‘authoritative knowledge’ (Hunter, 2008) advocates practice based on research, scientific review and evidence-based clinical guidelines (Royal College of Anaesthetists et al, 2008).

EBM evolved into evidence-based practice (EBP) in a midwifery setting and is seen as a key component for quality midwifery care (Cluett, 2005). Sackett et al (1996: 71) define it as ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients'. At first sight, this appears to concur with the medical model; however, the difference lies in the definition of ‘current best evidence’.

EBP should be a balance between clinical expertise (art) and best available external evidence (science) in the form of systematic research, with the clinician providing care using a balance between the two paradigms. Using either one in isolation does not meet the needs of the individual being cared for: clinical expertise or ‘embodied knowledge’ (Hunter, 2008) alone may be outdated, ritualistic practice and external evidence alone could provide prescriptive, standardised care which does not take into account the needs of the individual (Sackett et al, 1996; Tarlier, 2005; Purkis and Bjornsdottir 2006; Thornton, 2006; Braude, 2009).

EBP revises the medical model by including the woman in the decision-making process, along with research findings and expert knowledge as identified in Rycroft-Malone et al's (2004) definition of knowledge generation, which identifies four different types of evidence: research; clinical experience; patients, clients and carers; local context and environment.

Evidence versus intuition: Can they co-exist?

There is evidence to support both a constructivist and positivist approach to midwifery care, dependent on the prevailing circumstances; however, neither paradigm appears to meet all requirements to support high-quality individualised care: ‘best evidence’ may inhibit creative thinking (Hudson et al, 2008), and routine ritualistic practice could be based on informal or anecdotal knowledge which has never been examined to assess its effectiveness. Paley et al (2007) term the opposing paradigms ‘on-line’ (constructionist) where care is automatic, intuitive and holistic and ‘off-line’ (positivist) where care is deliberate, rule-based and analytical. It could be argued that these fundamental differences between the two paradigms are too great to reach a compromise and, as a result, clinicians’ practice is dictated either by guidelines and protocols or practice entrenched in rituals and routines, meaning the quality of care and service-user satisfaction could be compromised.

More recently, a flexible and less dogmatic approach to knowledge acquisition and dissemination has been developing (Thompson and Dowding, 2002; Fry, 2007; Standing, 2007) where the emphasis is placed on the use of a continuum paradigm rather than using exclusively either evidence-based practice or intuition. This approach, which has much in common with Carper's taxonomy of knowledge (1978), advocates a synthesis of rival and complementary approaches dependent on the situation, with the defining factor being the midwife's clinical judgement (Traynor et al, 2010). This new model is identified by a range of terms in the literature which all acknowledge its complexity and multi-dimensional nature: ‘intellectual intuition’ (Levi-Strauss, 1966); ‘contextualised knowledge’ (Purkis and Bjornsdottir, 2006) and a ‘tripartite of knowledge’ (Thornton, 2006).

Conclusion

This article has explored whether contemporary midwifery care should be based on policies and guidelines or the acquisition and implementation of ‘evidence’ by other means such as experiential knowledge and intuition. By reviewing relevant literature, it is clear that a single epistemological approach is too inflexible and one-dimensional. It is important to recognise intuitive knowledge and its influence on clinical decision-making, as well as scientific knowledge, to ensure midwives are reflecting in and on practice with the benefit of the most up-to-date, reliable and comprehensive evidence.