Midwives׳ clinical reasoning during second stage labour: Report on an interpretive study

Elaine Jefford, PhD, MSc, Post Grad Dip T&L, BSc(Hons) Midwifery, BSc(Hons) Nursing^a^,^, (Midwifery Lecturer and Midwifery Campus Lead; Honorary Senior Fellow Hull University, UK),
Kathleen Fahy, PhD^b^, (Professor of Midwifery, Editor, Woman and Birth)

doi:10.1016/j.midw.2015.01.006

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Abstract

Background

clinical reasoning was once thought to be the exclusive domain of medicine – setting it apart from ‘non-scientific’ occupations like midwifery. Poor assessment, clinical reasoning and decision-making skills are well known contributors to adverse outcomes in maternity care. Midwifery decision-making models share a common deficit: they are insufficiently detailed to guide reasoning processes for midwives in practice. For these reasons we wanted to explore if midwives actively engaged in clinical reasoning processes within their clinical practice and if so to what extent. The study was conducted using post structural, feminist methodology.

Question

to what extent do midwives engage in clinical reasoning processes when making decisions in the second stage labour?

Methods

twenty-six practising midwives were interviewed. Feminist interpretive analysis was conducted by two researchers guided by the steps of a model of clinical reasoning process. Six narratives were excluded from analysis because they did not sufficiently address the research question. The midwives narratives were prepared via data reduction. A theoretically informed analysis and interpretation was conducted.

Findings

using a feminist, interpretive approach we created a model of midwifery clinical reasoning grounded in the literature and consistent with the data. Thirteen of the 20 participant narratives demonstrate analytical clinical reasoning abilities but only nine completed the process and implemented the decision. Seven midwives used non-analytical decision-making without adequately checking against assessment data.

Conclusion

over half of the participants demonstrated the ability to use clinical reasoning skills. Less than half of the midwives demonstrated clinical reasoning as their way of making decisions. The new model of Midwifery Clinical Reasoning includes ‘intuition’ as a valued way of knowing. Using intuition, however, should not replace clinical reasoning which promotes through decision-making that can be made transparent and be consensually validated.

Keywords

Clinical reasoning;
Decision-making;
Midwifery;
Second-stage labour;
Intuition

: Corresponding author.

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Tuesday, 2 June 2015