Tuesday, February 23, 2010

How do we know what we know?

I have just had this email from a new student midwife in Australia, who is also a registered nurse, who wants to know how we know what we know:

"[is]...professional decision making based on knowledge gained from research, experience, theory or is it simply described as gut feeling or intuition" Taking into account your background as registered nurses write a REPORT on 'How do you know what you know"

... being so novice I am having trouble getting my head around this question. I can argue both sides as common sense prevails however for best practise in midwifery it is important to always be up to date with best practice methods and procedures. I am wondering if you are able to continue a discussion with me..."

As an experienced midwife and educator, I would say that my midwifery knowledge is made up of a number of elements - evidence of research, consensus of what is best practice at a professional level, what I have been 'told' by experienced colleagues and wise women, evidence from my own experience, understanding that has come from personal reflection, knowledge from the women and families I work with.

I also believe midwives 'know' from intuition although I do not fully understand what intuition is. Is it a lightning 'feeling' that comes to you with no rhyme or reason...as if by magic? Or does it come about as a result of experience...a subconscious knowledge or understanding that we do not even know we have?

If you are a midwife, how do you know what you know?

If you are not a midwife, what do you understand about intuition? Have you ever had a situation where your intuition has kicked in and impacted on your actions?

Robbie Davis-Floyd & P. Sven Arvidson. (1997). Intuition: The Inside Story: Interdisciplinary Perspectives. Routledge, New York.

Image: 'reader' JosephGilbert.org


Jo said...

Fascinating subject Sarah I am not a healthcare professional, but am very aware of intuition in myself. I have had many times where I have reached a conclusion and acted in myriad circumstances. For example in coaching horse riders when I acted many times without conscious thought in dealing with potentially dangerous situations. I also find that I do this in classroom situations without any potential threat/risk involved. For me the most interesting thing about these occurrences is that afterwards (I think without exception) I have been able to to justify the action in terms of most or all of those factors (in my context) that you refer to as the basis for subject "knowledge".

In my own very personal opinion "intuition" is largely due to a very rapid synthesis of data, knowledge and experience that occurs in situations where we have extra stimuli. The stimuli are most often physical with risk to someone, but can also be mental as in a teaching situation where we are trying to simultanously meet the needs of a number of different individuals at a time. For me it is one of the times where I unconsciously integrate knowledge and experience across the different contexts in which I work/have worked. In that respect it is for me a very powerful tool for increasing learning and understanding.

Sarah Stewart said...

Wow...fantastic answer, Jo.

I am not a very intuitive person...or at least that's how I see myself...but it may be that I am intuitive but do not recognise intuition for what it is...

academicobgyn said...

What you call intuition cognition experts call Heuristic Thinking.

Heuristics are hard wired patterns that allow very rapid decision making using common and often seen patterns. In many cases, this leads us to the right answer, and in some cases it leads us astray.

As learners we often are taught algorithmic thinking, where we input a certain amount of data into some kind of cognitive machine and based on what we were taught out comes an answer. This is absolutely necessary in the beginning. Over time we make fast pathways in our brain that hardwire some of the more common situations, so that we can respond to these situations very quickly. In a lot of ways this is what intuition is. Usually when you have the feeling of intuition its because you have dealt with a similar situation before and now have some pathways in your brain made just for that. The previous commenter mentioned something very similar

Heuristics can be genetically placed as well. For example, a running cheetah knows how to run down a gazelle even at a very young age, and even if it hasn't been taught. It knows that it has to run way out in front of the gazelle instead of right at it, as if it runs right at it the gazelle will no longer be in that spot when it gets there. This is called Gaze Heuristic, where we are able to use target tracking and horizon information to figure out where something is going to be at a given time. I teach my residents to use this heuristic in order to cut perfectly straight incisions by looking where the incision will end rather than at the scalpel. Baseball players use this to catch balls, instataneously knowing whether it will go overhead or land in front of them as soon as it comes off the bat.

Other heuristics can lead us to make mistakes as well. For example, we tend to make decisions that will lead to a positive emotion - affect heuristic. We also tend to make a decision that has already been made by others - contagion heuristic or contagion bias.

All of these patterns are absolutely required for efficient decision making in the real world, but also lead us to make stupid decisions sometimes. By understanding these tendencies, and in so doing understanding why our "intuition" is our "intuition", we can hope to avoid our bad decisions before we make them permanent.

I talk to my residents about this stuff all the time, particularly after one of us has made a cognitive error. When very intelligent people do something dumb there is often an internal cognition pattern or heuristic that is to blame, and by understanding that one can learn much more from the mistake than if it is just isolated as a single event.

Sarah Stewart said...

Thanks a lot for that, academicobgyn - I have to admit I don't know much about Heuristic Thinking.

In terms of a new student midwife, how much can she rely on heuristic thinking for her 'midwifery knowledge'?

flickabug said...

I find the term “intuition” tremendously difficult to get my head around and I don’t think I will every get my head around it- but then again as a newly commenced Midwifery student I am still having trouble getting my head around the miracle of life and the beauty of childbirth, it is something that blows me away. When I was given the topic and asked to report on ‘how we know what we know’ I thought it would be an easy task, but as I digest the statement I end up in a world of confusion.
Do we call it intuition on the newborns behalf when she/he makes their way to the breast for the first time in order to relieve their feelings of hunger?

In Midwifery, in order to act PROFESSIONALLY and to achieve ultimate outcomes and goals it is essential that we as nurses/midwives are up to date with current policies, procedures and clinical guidelines which are based on current research and theory to support decision making. The knowledge bases that are acquired over the years through personal and professional experience are also essential elements of “knowing what we know”. In a sense not everything we know and learn has to be back up by a text book or journal – however in this day and age with the legalities and ethics surrounding the medical system it is paramount to be backed by evidence.

As a child a term quite often used in my family by my mother was “…it’s a motherly instinct/ intuition..” until today I have never really dissected that term – it was an answer that I always accepted from my mother and never questioned, but now 24 years later I wonder if that so called instinct was something that she had spent time researching to back her decisions up on evidence?????? I’m guessing not, I think people in general, not just midwives, have a “button” inside them that in times gets unconsciously pressed into overdrive and that’s when our intuition kicks in and that’s when our sub-conscious minds of unknowingly knowing takes over.

I find myself in a circular motion when thinking about this topic as I cannot conclude on a decision and to confuse me even more my flat mate made the statement to me that “..there is no such thing as intuition its all about educated guesses..”

JC said...

Very interesting question. Heuristic thinking is based upon 'rule of thumb' guidelines and therefore subject to approximation. This would suggest the more experience one has the less chance there is of making an error of judgment, assuming all things are equal.

To improve the validity of heuristic thinking it is necessary to introduce boundary questions that guide our thinking and focus us on the important factors.

Roger Martin, Dean, Rotman School of Management, , proposes a model of Integrative Decision Making which is partly a structure process which I believe allows experience and intuition to form a part of our decision making processes. Paul Thargard (2001) proposes there are two forms of intuitive thinking; gut instinct and informed intuition.

Gut instinct is simply complete reliance upon experience and stored knowledge. Informed intuition requires some form of decision making framework or boundary to be put into place.

It is my belief that regardless of whether one uses heuristic type thinking or formal decision making processes, our prior experience and knowledge either informs or biases our thinking processes.

Argryis's double loop learning model proposes that when we fail to achieve our desired outcome that instead of simply changing our behaviour we firstly return to the beginning and ask ourselves what am I thinking? What have I observed that causes me to think in this way? How are my observations impacting upon my thinking? A form of metacognition.

Formal education can teach us best practices, derived from a mixture of research and case studies. What formal learning often fails to achieve is it fails to teach us how to think. Thus we risk regurgitating formal learning without questioning the assumptions that are inherent in the learning.

It is our ability to ask questions that provides us with an in-built process for minimising error or harm. I suggest it is about ability to ask questions, to explore, to challenge assumptions, to propose an alternative perspective that forms our ability to act intuitively - while being fed by our experiences. This is valuable data and not to be ignored.

Intuitive thinking is a sensing process. It is where we form linkages between two or more seemingly unrelated events. Formal learning may inform you how to undertake a procedure however your senses may inform you that the situation is different or changing leading you to fall back upon experience and collective wisdom in your choice of action.

Anyway, I guess I haven't really answered the question, though I do hope I have given your friend in Australia something to think about.

John Coxon

Gurmit said...
This comment has been removed by the author.
Gurmit said...

Hi Sarah
Have you looked at literature on ways of knowing, in education and in medicine?

For example:
Candib, Lucy (1988). Ways of knowing in family medicine-contributions from a feminist perspective, in Family Medicine & Cmty Health, 1988, 672-676.
available at:

Let us know what you think!


Bronwyn hegarty said...

This is a fascinating topic alright. Patricia Benner has written about the difference between an expert and a novice practitioner.

A novice does not usually have sufficient experience on which to base intuitive decisions whereas an expert practitioner may do - depending on the situation of course. Therefore, whereas the expert can react or act quickly using their intuition or professional judgement, a novice generally needs to reference back to rules, regulations, protocols, accepted ways of doing something etc.

Heuristic thinking involves a set of rules which govern behaviour, and these can assist practitioners to stay within acceptable parameters. However, if evidence-based practice is being adhered to, heuristic thinking could block best practice because it may not enable flexible responses to clinical research. Can you see that difference?

Sarah Stewart said...

Email fro Jillian:

Hi Sarah,
Intuition to me is an internal knowing that occurs, as you said without rhyme or reason. For myself, it causes a physical feeling / awareness that I need to act on. Sometimes the feeling is stronger than others and I am unsure why, sometimes I trust it more times than others. I feel as I get older and more experienced, the physical awareness is louder/ more pronounced or maybe it is just that I am listening more intently or trusting myself more???? I agree with your list of things that cause me to know: evidence of research, consensus of what is best practice at a professional level, what I have been 'told' by experienced colleagues and wise women, evidence from my own experience, understanding that has come from personal reflection, knowledge from the women and families I work with. I believe there are many elements to 'knowing what we know' but one that I have discovered over the years is that I will only know what my eyes / ears / heart allow me to know. Being open to knowing is just as important as the evidence, experience and reflection. The old cliché' - "if I knew back then what I know now" Why didn't I know back then, because my eyes, ears and heart did not allow me or were not ready??? There is no way to make this happen other than to be open and willing to learn and I have found it continues your whole life as long as you are open to it. Not sure if this makes sense to you but would be interested in your thoughts.

Sarah Stewart said...

Thanks to everyone for your comments and contributions. I am sure there is heaps of information and 'food for thought' to help the student get started on her essay.

Here are another couple of references to get students started in their thinking about midwifery knowledge.

Sara Wickham. To feel or not to feel?

Sara Wickham. Feminism and ways of knowing. In M. Stewart (Ed). Pregnancy, birth, and maternity care: feminist perspectives. 2004.