128 Chapter 5 Reflective practitioner Our study suggests that the knowledge and skills of midwives who utilize low rates of interventions as part of their clinical practice resemble those of a reflective practitioner. A reflective practitioner is someone who ‘lives’ reflection as a way of ‘being’ rather than just ‘doing’ (26). Reflective practice is linked to the concept of learning through and from experiences, by actively analyzing and questioning choices and decisions. Individual healthcare practitioners who are aware of what they are doing and critically evaluate their own responses to situations are reflective practitioners. This reflectivity helps them to provide appropriate interventions, to the right person at the right time (26, 27). This also emerged in our study, where midwives with a higher tendency to reflect on provided care were less inclined to provide standardized care. Reflection on practice is an important skill for a reflective practitioner, however, reflection in practice is also important. Lake and McInnes (2012) describe that critical thinking skills help midwives in their clinical judgment and clinical decision-making, and enable them to provide appropriate, womancentred and evidence-based care (28). In our study, midwives who utilize low rates of interventions as part of their clinical practice described reflective moments in care, where they consciously consider different options for clinical decision-making. During this reflection-in-action, they used critical thinking skills to make a balanced decision whether the intervention is beneficial at that moment. Previous studies have shown that higher interventions rates do not automatically lead to better perinatal outcomes [30]. The reflective approach towards interventions can help in the pursuit for appropriate use of interventions. Important elements of reflection on practice is the recognition of non-evidence based care, and to search and interpret evidence for clinical decision-making (30). These skills are crucial to practice physiological care with an appropriate use of interventions (30, 31). In our study, midwives who utilize high rates of interventions as part of their clinical practice did not describe using scientific literature in their clinical decision-making process. It is possible that they lack skills to assess evidence and to recognize non-evidence based care. Another element of reflective practice are the skills to discuss and debate within the multidisciplinary setting of maternity care (30, 31): the ability to speak up and to persuasively communicate the wishes of women, and the advantages of a physiological birth. Midwives should be able to effectively communicate considerations in clinical decision-making, including available evidence with other healthcare professionals (6). These skills seems less present in the group with a more interventionist approach. When a midwife is less skilled to speak up and advocate the midwifery philosophy of care, the risk philosophy of obstetrician-led care will be predominant, making it more likely that a higher use of interventions will occur (32).
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