Intuition is a recognised way of knowing and valued by midwives (Barnfather, 2013). However, what components of midwifery knowledge enable the phenomenon of midwifery intuition? Dr Elaine Moore, a retired midwife from Ayrshire, Scotland, a recent presenter at the MMF Festival in Edinburgh, shares some theoretical findings from her recent study exploring safeguarding midwives’ relationships with pregnant women with substance dependency that may inform how this phenomenon occurs.
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As a midwife or maternity professional, have you ever felt that ‘something just isn’t right’ or a visceral reaction to an event or person that makes you very uncomfortable, but you don’t know why? This intuitive reaction may be challenging to articulate, but it is a valuable aid in practice. One of the midwives in my recent study exploring safeguarding midwives’ relationships with pregnant women with substance dependency highlighted midwifery intuition when describing an experience they had in a child protection meeting.
The concepts of Professional Phronesis and Phronetic Judgement could explain this experience of the ‘Midwives Twitch’ (Kinsella and Pitman, 2012). Kinsella and Pitman (2012) base these concepts on the Aristotelian theory of Phronesis, also known as Practical Wisdom. Phronesis is comprised of episteme, techne and Doxa:
- Episteme is the scientific knowledge underpinning the profession; it is the theory of practice and is the same when applied in any context, and is described by Eisner (2002, p375.) as a ‘true and certain knowledge.‘
- Techne is practical knowledge and context-dependent; it is the know-how and the interaction between science and the craft (Kinsella, 2012).
- Doxa refers to commonly held professional and personal attitudes and beliefs that incorporate values, standards, and a code of ethics (Eisner, 2002).
Aristotle advocates that a key component of practical wisdom is repeated exposure to experiences over time and suggests that practical wisdom comprises two virtues: intellectual and moral. Intellectual virtue is based on wisdom, comprehension and prudence, whereas Aristotelian moral virtue includes human attributes such as truthfulness, courage, gentleness and justice.
The suggestion that moral virtue or virtues could be applied to midwifery practice was deliberated when exploring whether woman-centred care could be taught (Kuipers, 2022). Kuipers (2022, p2) employed eighteen philosophical virtues as described by Comte-Sponville (2002) in ‘A small treatise of great virtues’ (Kuipers, 2022, p. 2). These virtue acts included moral virtues described by Aristotle, such as courage, gentleness and justice; however, others have been added, such as politeness, compassion and love (Kuipers, 2022). Kuipers (2022) reasoned that these virtues were characteristics midwives displayed that guided them to act in certain ways to support woman-centred care.
Midwifery Knowledge Formation
Phronesis is based on knowledge, scientific, technical and one’s attitudes and beliefs. Therefore, how student midwives and midwives gain knowledge is integral to midwifery ways of knowing and how midwives practise the art and science of midwifery (Barnfather, 2013).
Carper (1978), in their seminal work ‘Fundamental Patterns of Knowledge Formation in Nursing’, described four patterns of knowledge formation in nursing. Although nursing is a separate profession from midwifery, the way student education is provided is similar, and there are crossover knowledge and skills. Carper’s (1978) classification involves:
- Empirics – The scientific knowledge underpinning nursing theory
- Aesthetics – The art of nursing where nurses use their scientific knowledge practically when caring for patients
- Personal Knowledge – Constitutes the use of scientific and practical nursing knowledge alongside self-knowledge, creating confidence in their ability to act accordingly and at the right time
- Ethics – The moral component of nursing which dictates what should be done and when, in the best interests of individual patients.
Carpers’ (1978) seminal work was enhanced by introducing the fifth pattern of knowing: ‘Unknowing’ (Munhall 1993). In ‘Unknowing’ nurses recognise and understand they have gaps in their knowledge.
White (1995) further augmented Carper’s (1978) seminal work by suggesting ‘Socio-political knowing’. Socio-political knowing incorporates awareness of how patients’ cultural, social and health backgrounds, along with professional and political health policy, affect care provision (White, 1995).
Midwifery Learning in the Workplace
Eraut (2000) found that most learning in the workplace occurred in a non-formal way and enhanced knowledge gained formally. Non-formal learning can be Explicit, where time is set aside to educate others. Implicit learning happens through observation and absorbing how others are in the workplace (Eraut, 2000). This is particularly useful for knowledge transfer in relational approaches where subjective aspects such as tone of voice and body language could be challenging to explain (Eraut 2010). This leads to tacit knowledge formation as the knowledge gained ‘becomes a taken-for-granted feature in a person’s world’ (Eraut 2010, p39). Therefore, knowledge formation in the workplace is a complex, multifaceted phenomenon (Power, 2015).
The Use of Tacit Knowledge in Professional Phronesis
Kinsella (2012) explained professional phronesis as an expansion of Schön’s reflective practice using Aristotle’s concept of phronesis. Central to professional phronesis is practitioner reflection and tacit knowledge, in particular, a type of tacit knowledge known as embodied knowledge (Kinsella 2012). Embodied knowledge is embedded and can be experienced physically in the body, and many practitioners describe intuition as a ‘gut feeling’ (Davison, 2021). Therefore, it is reasonable to suggest intuition in midwifery is a type of professional phronesis.
The role of Midwifery Continuity of Care in the development of Professional Phronesis
As there is a social aspect to knowledge formation in the workplace, personal relationships with colleagues and women are essential (Eraut, 2000). Midwives’ understanding of people is mainly tacit and built through interactions. Through formal and informal learning, they have gained knowledge over time (Eraut, 2007). Midwifery continuity of care facilitates the building of relationships between women and midwives, which are crucial to the transfer of knowledge, the midwife of their expertise and the woman of her lifeworld.
Conclusion
To build and maintain relationships with women, multidisciplinary and multiagency teams, midwives draw on a myriad of conscious and unconscious knowledge and skills. The midwives demonstrated an extensive epistemic, professional and personal knowledge base, which they used to facilitate a supportive relationship with women. Midwives demonstrated learning in the workplace through formal and non-formal learning. Using the concepts of Carper’s (1978) ‘fundamental patterns of knowing in nursing’, Munhall’s (1993) ‘Unknowing’ and White’s (1995) ‘Sociopolitical knowing’ and personal experiences, midwives demonstrate how they gained knowledge and imparted knowledge to others.
Midwives constantly make decisions using a knowledge bank of personal and professional frames of reference to make phronetic judgements. In each experience, the midwife builds on what has gone before, creating new understandings and frames of reference that are stored for use in similar situations. It could be suggested that Professional phronesis is the mechanism midwives use to employ knowledge in their day-to-day interactions with women, each other, and the wider multidisciplinary team.
References
Davison, C. (2021) ‘Ways of knowing’, British Journal of midwifery, 29(12), pp. 666-667.
Eisner, E. W. (2002) ‘From episteme to phronesis to artistry in the study and improvement of teaching’, Teaching and Teacher Education, 18(4), pp. 375-385.
Eraut, M. (2000) ‘Non-formal learning and tacit knowledge in professional work’, British Journal of Educational Psychology, 70, pp. 113-136.
Eraut, M. (2007) ‘Learning from other people in the workplace’, Oxford Review of Education, 33(4), pp. 403-422.
Kinsella, E. A. (2012) ‘Practitioner Reflection and Judgement as Phronesis: A Continuum of Reflection and Considerations for Phronetic Judgement’, in Phronesis as Professional Knowledge: Practical Wisdom in the Professions. pp. 35-52. Professional Practice and Education: A diversity of Voices [Online]. Version (Accessed: 04-10-2022).
Kinsella, E. A. and Pitman, A. (2012) Phronesis as professional knowledge [electronic book]: practical wisdom in the professions / edited by Elizabeth Anne Kinsella, Allan Pitman Rotterdam
Boston: Sense Publishers. Professional Practice and Education:
A Diversity of Voices. Available at: https://link.springer.com/book/10.1007/978-94-6091-731-8 (Accessed: 18/09/2022).
Kuipers, Y. J. (2022) ‘Exploring the uses of virtues in woman‐centred care: A quest, synthesis and reflection’, Nurs Philos, 23(2), pp. e12380-n/a.
Power, A. (2015) ‘Contemporary midwifery practice: Art, science or both?’, British journal of midwifery, 23(9), pp. 654-657.
White, J. (1995) ‘Patterns of knowing: review, critique, and update’, Advances in Nursing Science, 17(4), pp. 73-86.
November 2024
Dr Elaine Moore, DProf, MM, BSc, RM,
Retired midwife, Ayrshire, Scotland