This paper aims to consider clinical decision-making within midwifery and critically analyse three decision-making approaches—the hypothetico-deductive approach, the intuitive-humanistic approach and the dual process theory—in relation to a chosen case. Using a modified decision-making tool, a tripartite decision (Box 1) will be discussed and the key elements involved in decision-making within midwifery explored. Pseudonyms have been used when discussing the tripartite decision in order to maintain confidentiality (Nursing and Midwifery Council (NMC), 2015).
There is a great deal of controversy over the definition of what a decision is (Raynor et al, 2005). Cross (1996) takes the perspective that a decision is the point at which a course of action is determined, with the internal processes by which a course of action or inaction is chosen known as decision-making (McFall, 2015). Clinical decision-making is a process that is fundamental to good professional practice (Thompson and Dowding, 2002). However, the complexity of the decision-making process is well known (Mok and Stevens, 2005) and within the clinical setting decisions must be made, frequently with missing or ambiguous information (Rew, 2000). The quality of the care that is provided by midwives is directly related to the quality of the decision-making process (Jefford, 2012). Poor decision-making is a theme evident in confidential enquiries and audit reports, indicating that poor clinical decision-making contributes to poor maternal and neonatal outcomes (Draper et al, 2015; Knight et al, 2015). In 2001, the Nursing and Midwifery Order stated that there was to be a professional body, the NMC, that would determine standards of education, training, conduct and performance for midwives and ensure that these standards are maintained (HM Government, 2001). In turn, the NMC outlines a midwife's scope of practice in order to determine procedures, actions and processes which midwives are licenced to perform, in order to regulate the decision-making process (Kennedy et al, 2015).
Decision-making models
The plethora of decision-making models and tools available to aid an individual in their decision-making may be categorised into three theoretical approaches: normative, descriptive and prescriptive. Table 1 highlights the differences between the three approaches.
| Approach | Explanation | Application |
|---|---|---|
| Normative | This approach assumes the individual is rational and logical, and is concerned with how decisions should be made. What is important is how ‘good’ the outcome is | Social judgement theory; Baye's decision tree (Thompson and Dowding, 2002) |
| Descriptive | This approach describes how individuals reach their decisions and is process-focused | Information-processing theory; Elstein's four-stage process |
| Prescriptive | This approach attempts to improve decisions | Cognitive continuum; National Institute for Health and Care Excellence clinical guidelines |
Most decision-making models appear to focus on decision-making being either rational and logical, or intuitive. This notion that there are two cognitive routes is described by Kahneman (2011), who proposes that individuals possess two ‘thinking’ systems, namely system 1 and system 2 – terms coined by psychologists Stanovich and West (Kahneman, 2011). According to Kahneman (2011), system 1 is quick to act and does so without great (or any) effort, whereas system 2 purposefully directs attention to cognitive activities. Kahneman implies that although separate systems, the two processes can work cooperatively as system 1 generates impressions or feelings about stimuli/situations and system 2 then uses these to create explicit beliefs and deliberate choices. However, popular decision-making theories tend to refer to the decision-making process involving only one of these two systems. For instance, analytical approaches claim that clinical reasoning, which follows rational logic akin to system 2, contributes to clinical decision-making (Banning, 2006), while intuitive/humanistic approaches, similar to system 1, claim intuition is the process by which decisions are made (Ménage, 2016a).
One branch of analytical/rational decision-making is the hypothetico-deductive theory, thought to be the dominant decision-making approach within health sciences (Jefford et al, 2011). Based on the descriptive analysis of reasoning by medical interns, Elstein et al (1978) proposed that the reasoning process comprises four stages (Table 2).
| Stage | Description | Application |
|---|---|---|
| Cue aquisition | The collection of information | History-taking, observation |
| Hypothesis generation | Retrieval of problem formulations from memory | Potential diagnosis e.g. early labour |
| Cue interpretation | Interpretation of information in light of diagnosis under consideration | Physical examinations e.g. internal vaginal examination |
| Hypothesis evaluation | Weighing and combining of information to confirm or deny diagnostic hypothesis | Confirm or deny hypothesis of early labour in light of findings |
This systematic approach to decision-making supports the use of the four-stage model within clinical practice, as the agreed process allows for others to review the stages and verify clinicians' knowledge and reasoning (Jefford et al, 2011). The objective nature of the model is congruent with the medicalisation of obstetric-led maternity care (Goodman and Ley, 2012) and the step-by-step process can be applied to everyday decisions. However, the four-stage model focuses purely on the objective and observable cues available to clinicians and does not consider the role of emotion or beliefs and values, all of which play a part in holistic midwifery care and woman-centred decision-making (Barber, 2012).
In light of the criticisms of a hypothetico-deductive approach to decision-making, an alternative intuitive-humanistic theoretical approach may be considered. Although it has previously been argued that intuition forms the basis of guesswork, intuition is now recognised as an essential factor in clinical judgement (Benner and Tanner, 1987). Barnfather (2013) describes how tacit knowledge arises from accumulating a range of different forms of information, including explicit knowledge, aesthetics, self-awareness and personal knowledge—forms of knowledge similar to Carper's (1978) four elements. Applying this approach to the tripartite decision in Box 1, the midwife would make a timely decision regarding Laura's stage of labour by combining her forms of knowledge. An intuitive-humanistic approach prioritises emotion and also allows clinicians to make decisions promptly (Jefford et al, 2011). The use of intuition in clinical decision-making is, however, subjective because it is based on past experience and so can lead to errors in decision-making (Ménage, 2016a).
The dual process theory attempts to combine the use of analytical, rational thought and intuition by proposing that system 1 is responsible for cue acquisition and interpretation, while system 2 is responsible when no existing memory pattern is available. However, Jefford et al (2011) highlight that the dual process theory does not indicate how clinicians move between intuitive and analytic modes of decision-making.
Alternative model
There is limited evidence regarding decision-making in midwifery, so the multitude of influencing factors involved in midwifery decision-making are currently not considered in an existing decision-making model. Therefore, a descriptive decision-making model is proposed, which includes a modified version of Elstein et al's (1978) four-stage process that explains the roles of both system 1 and system 2, and includes the consideration of individual circumstances (Figure 1). The highlighted boxes represent changes or additions to the original four-stage model, and will be elaborated on in this article.
The first two stages occur intuitively and through system 1 thinking. Based on Klein's (2015) distinction, the midwife in the case study used pattern recognition rather than heuristics to arrive at hypothesis generation (Figure 2).
Owing to the professional accountability a midwife has and the trusting relationship formed between the woman and the midwife, the midwife engages her rational, analytic system (system 2) in order to ensure the appropriateness of her hypothesis (Figure 3).
The additional feature in this modified decision-making tool that is fundamental to midwifery is the consideration of individual circumstances—for example, the values, preferences and wishes of the woman. This stage ensures that woman-centred care is provided, and that the individual needs of the woman are considered (Ménage, 2016b) (Figure 4).
This model considers the pivotal role that intuition plays in the experienced professional's decision-making process, while acknowledging the importance of rational thinking in order to make beneficent decisions. The use of Elstein's model allows the logical sequence of decision-making to be maintained, with the addition of a further stage that epitomises the holistic midwifery care to be provided.
Intuition
A key component of the proposed modified model is the role of intuition in recognising pattern formations to arrive at a hypothesis. The definition of intuition in terms of decision-making is ambiguous and, therefore, intuitive decision-making may be seen as substandard (Payne, 2015). However, despite the midwife in the case study being unable to articulate her intuitive response regarding Laura's condition, her practical wisdom—or phronesis (Bajwa et al, 2015)—was based on more than ‘gut feeling’. Klein (2015) outlined two alternative views concerning the basis of intuition. The notion of fast and frugal heuristics (Klein, 2015) regards heuristics as the foundation of intuitive thinking. Heuristics—mental shortcuts to simplify information (Muoni, 2012)—can be applied quickly to situations in order to arrive at decisions, although they are generic (Klein, 2015) and subject to biases (Dale, 2015). Blumenthal-Barby and Krieger (2015) argued that many studies investigating the use of heuristics in medical decision-making use hypothetical situations and, therefore, evidence regarding the use of heuristics in real-life decision-making is lacking. An alternative viewpoint, held by naturalistic decision-making (NDM) theorists—who attempted to understand how individuals make decisions in applied, natural settings as opposed to laboratory settings—is that of intuition as an expression of pattern recognition (Klein, 2015). Klein et al (1988) examined the way in which fire ground commanders made decisions under extreme pressure and detailed the recognition-primed decision model, which focused on the use of pattern recognition rather than systematic calculation for rapid decision-making. Klein (2015) explains how individuals match a given situation to patterns they have learned and follow the expected course of action, allowing for prompt decision-making. In contrast to heuristics, patterns are more specific and are representations of tacit knowledge (Klein, 2015), the kind of knowledge fundamental to intuition. It is this pattern recognition that describes the intuitive process undertaken in stages 1 and 2 of the modified model, as specific tools are required for clinical decision-making in midwifery to avoid errors and biases. The NDM approach of the modified model strengthens the intuitive argument as it recognises the high level of experience and tacit knowledge required for the midwife to recognise Laura's behaviour pattern and make a prompt judgement. Crucially, Cervone (2015) argued that 80% of decisions are not strategic and lack importance, so the use of intuition is sufficient; however, he goes on to suggest that for the 20% of decisions that have a real impact, more systematic and rational decision-making methods should be employed. This notion discourages the use of intuition in an early labour assessment, as such a decision has a large impact on the care the woman will subsequently receive. The modified model overcomes this issue by suggesting that both intuition and reasoning are to be used in conjunction.
Intuition at varying levels of competence
Benner (1982; 2000) argues that it is only the expert who is able to accurately use his or her intuition to guide decision-making. The Dreyfus model of skill acquisition (Dreyfus and Dreyfus, 1980), based on the skill acquisition of pilots and chess players, proposes that a student progresses through five levels of competency, from a novice to an expert. Benner applied this model to nursing and, through interviews and participant observations, arrived at a description of the passage of the nurses from novice to expert (Table 3).
| Level | Application to nursing | Application to midwifery |
|---|---|---|
| Novice | No experience of situations in which the nurse is expected to carry out tasks. Performance governed by context-free rules which are inflexible and limited | First-year student midwife who is restricted to theoretical knowledge, or a primigravid woman who has no tangible experience of early labour |
| Advanced beginner | Encountered enough real-life situations to recognise important characteristics (which Dreyfus calls aspects). The advanced beginner requires support in prioritising care as still reliant on generic guidelines | Second-year student midwife or a multiparous woman who has experienced/witnessed similar situations previously but lacks the foresight to set priorities |
| Competent | Typically a nurse who has worked for 2–3 years and is aware of which aspects of a situation are more important; however, still requires conscious, deliberate planning | Third-year student midwife or newly qualified midwife who is able to formulate plans with a long-term goal in mind but decision-making is still a calculated, lengthy process |
| Proficient | Views situations as a whole and recognises deviation from normality, hones in on most important feature. Recognition of maxims (undetectable differences within situations) separates competent from proficient | The proficient midwife is an experienced practitioner able to promptly and accurately make decisions, owing to a deep understanding of the situation |
| Expert | No longer relies on conceptual framework to comprehend situation, focuses on integral part of situation. Does not solely rely on intuitive element as during new situations analytic reasoning may be required | The expert midwife uses this intuition obtained through experience and formal education to guide decision-making |
In terms of the tripartite decision outlined in Box 1, the three individuals involved were at varying levels of ability. In this scenario, the midwife's expertise was weighed against the student midwife's and woman's lack of experience in making such decisions. The student midwife demonstrated competent characteristics, as the National Institute for Health and Care Excellence (NICE, 2014) guidance regarding definitions of the latent and established first stage of labour were considered. The student midwife focused on the findings from the vaginal examinations, but consideration of other significant factors was slow and deliberate and this process was not intuitive, as it occurred after the consideration of available information. The cognitive architecture of the experienced midwife allowed her to initially assess the situation and access her knowledge (Okoli et al, 2016) to hone in on the important feature—which she considered to be the lack of strong, regular, painful contractions—and she therefore hypothesised that Laura was, in fact, in early labour. The midwife, as the expert, was able to access a wide range of stored patterns and generate the most plausible course of action (Klein, 2015). Although the novice-to-expert continuum appears applicable to midwifery (Table 3), Cook (2015) highlights a flaw in comparison studies that appear to support the novice-to-expert distinction. Cook argues that there are various explanations for observed differences between novices and experts, and these confounding variables reduce the validity of any novice-to-expert studies, such as those by Benner (1982; 2000). A further criticism of the novice-to-expert argument is that the Dreyfus model and Benner's work are now outdated, so many contemporary driving forces in clinical decision-making may not be considered within the model.
Systematic reasoning
The second phase of the modified decision-making model outlined above involves systematic, rational thought. This is required to ensure that initial intuitive-based hypotheses are tested and other factors are considered before arriving at a decision, to ensure safe and holistic care is delivered. It is necessary for the midwife to engage in this analytic processing because of the responsibility and accountability he or she has. Accountability is defined as having to answer to a higher authority for one's actions, whereas responsibility refers to an individual's authority over someone else (Griffith, 2011). In this tripartite scenario, the midwife and student midwife had a responsibility to consider Laura's values and priorities when making a decision about her plan of care. However, the midwife was also accountable for the diagnosis of early labour; accountable to Laura, to society as a whole, to her own employer and to the profession (the NMC) (Griffith, 2011). The NMC (2012) outlines in its Midwives Rules and Standards that a practising midwife is responsible for providing care to a woman and that through doing this, the needs of the woman and her baby are the midwife's primary focus. The NMC (2015)Code states that midwives must be accountable for their decisions and, if this is not adhered to, a midwife's fitness to practise is called into question. Midwives have a duty of care (Griffith, 2012) to ensure no harm is caused through their practice. As accountable and responsible professionals, the midwife and the student midwife discussed with Laura the evidence-based guidance and her high-risk labour status, while also considering Laura's fear of intervention during her labour. It is these more deliberate thought processes and discussions that require rational, systematic thought, and ensure shared decision-making is achieved through the sharing of information.
Jordan (1997) talks of authoritative knowledge and how frequently one kind of knowledge gains superiority and dismisses other forms of ‘knowing’. This model balances different forms of knowledge and allows evidence-based knowledge and emotional intelligence to be weighted equally. Through this equal weighting of clinical and individual needs, shared decision-making is achieved (Freeman and Griew, 2007). In the case study in Box 1, the midwife was able to progress through all the stages of decision-making and consider all of these aspects in order to arrive at a decision in partnership with the student midwife and Laura. If in a similar situation again in clinical practice, the modified tool detailed in this article would be helpful to ensure all important features of the decision-making process are considered, while giving weight to the intuition the expert possesses. If a member of the decision-making team lacks the expertise required for successful intuition, the process can occur more systematically, allowing the individual to gain experience and, in turn, develop his/her intuition.
Conclusion
There are a range of decision-making approaches and theories that outline different methods for arriving at a decision. The holistic nature of midwifery and the lack of current evidence regarding midwifery decision-making mean that a modified tool is necessary to demonstrate how clinical decisions are made. The midwife possesses the expertise to use his or her intuition to guide the decision-making process; however, as responsible and accountable professionals, it is necessary for midwives to follow-up intuitive thought with rational, systematic processing. Through the combination of intuition and rationality, and the consideration of evidence as well as individual emotions, values and beliefs, clinicians are able to successfully make shared clinical decisions.