From the analysis of qualitative data, three main themes emerged, which formed the basis of the quantitative data collection and the order in which the results will be presented: 1) the recognition and possible definitions of intuition in decision-making in the CYHC-system, 2) attitudes of CYHC-professionals towards intuition and 3) different ways in which CYHC-practitioners use intuition in cases of child abuse. The outcomes of both data collection processes will be presented in an integrated manner.
Recognition and definitions of intuition
The results of both types of data collection suggest a high recognition rate of intuitive feelings by CYHC-professionals: all interviewees and 96.7% (n=329) of survey participants stated that they recognise and experience this intuition or gut feeling in their daily work, of whom 48% stated that they experience it ‘sometimes’ and 30.1% experiences it ‘often’ (n=326). All interviewees recognised and experienced intuitive feelings:
Yes, [I recognise intuition] in the sense that you try to make an assessment of a situation. And because of the questions you ask and the answers you get, you naturally get a bit of an idea on whether what you're told is correct, or not. And you can’t always put your finger on it, so you call it intuition (CYHC-practitioner, 17 years of experience).
Even though they recognised intuition, the majority of interviewees struggled to give a definition to these feelings, suggesting that it is personal and influenced by experience:
I would describe intuition as a feeling with which you make decisions that are based on experience. So it may be something unconscious, but it is secretly something conscious and based on previous experiences (CYHC-practitioner, 35 years of experience).
The abovementioned quote links intuition to experience. Interviewees also linked intuition to implicit knowing, assessment of situations and decision-making processes:
Intuition sounds as if you are guessing or something, while I think that intuition plays an important role. I would prefer to describe it as a sort of sensitivity, rather than intuition. You pick up a lot of signs that give you a certain feeling (CYHC-practitioner, 15 years of experience).
Definitions and opinions on intuition differed, but most interviewees experience it as an uncontrollable feeling or sensation that occurs regularly and originates from the senses: “I think that your intuition is always on, even when you don’t want it to be. You see, hear and smell things and you form an image right away”(CYHC-practitioner, 32 years of experience). All interviewees agreed that intuition stems from signs that they picked up, for example smells, verbal and non-verbal communication or the stories that they have been told by others in the network of a family.
Attitudes towards the use of intuition
As participants generally acknowledged the concept of intuition, the next step was to look at the attitudes towards intuition and intuitive decision-making. The survey measured these attitudes using Likert scales, of which the responses are summarized in figure 1. Respondents mainly considered it to be ‘fairly useful (nuttig)’ (49.8%, n=319), ‘fairly difficult (moeilijk)’ (39.9%, n=323, ‘fairly good (goed)’ (39.5%, n=319) and ‘fairly pleasant (prettig)’ (35, 8%, n=324). These responses show ambivalences towards intuition: it is experienced as useful, good, yet it is difficult and not everyone enjoys using it. This also became apparent in the interviews. Often, a question of intuition prompted an initial positive response, after which CYHC-practitioners expressed their concerns. All participants affirmed that steps need to be taken when intuition is sensed: “Certainly, you are obliged to do something with [intuition], otherwise you are negligent. […] To me, that is the most important thing. Otherwise you ignore your duty of care. After all, I’m a doctor for a reason” (CYHC-practitioner, 25 years of experience). When asked what action needs to be taken, they responded that they will look for facts, as mentioned in the guidelines:
What you try to do is to get rid of that gut feeling as quickly as possible, and replace that intuition with facts. Because my feeling says it's not quite right, but which questions should I ask to check that? […] Is my intuition incorrect? So [intuition] is a bit like your compass in the conversation (CYHC-practitioner, 17 years of experience).
CYHC-practitioners thus aim to ‘get rid’ of intuition by checking it with facts and state that ignoring intuition would be negligent. When asked about these ‘facts’ and what they consist of, CYHC-practitioners mentioned that they are difficult to determine and to define. They stated that facts could be tangible elements such as a “black eye or clothes that are too small” (CYHC-practitioner, 14 years of experience), but that ‘facts’ are often constructed when comparing narratives of the people involved in the (suspected) case, such as the family themselves, the children’s teachers, trainers, GPs or other healthcare professionals who interact with the family on a regular basis. These people form the “eyes and ears of the CYHC-practitioners” (CYHC-practitioner, 14 years of experience) and can deliver input to test the factual soundness of intuition.
In working with intuition, ignoring it is thus seen as dangerous, but interviewees also stated that it is unsafe to blindly trust intuition, as it may lead to narrow-mindedness and missing signs. Survey respondents who did recognise gut feeling (n=318) were asked whether they felt that they can trust their gut feeling when making decisions, in which ‘decisions’ were defined “the decision to plan a follow-up appointment, to wait or to discuss the case with a colleague”. Most respondents answered that they could (41.7%, n=314). One interviewee explained that blindly trusting intuition can lead to ‘tunnel vision’: focussing on one explanation of a situation, without taking other possibilities into account. According to the interviewee, this is dangerous as it may damage the relationship with parents, which could lead to misinterpretations and false accusations of child abuse, having major implications for both the families and practitioners involved.
That’s what makes it [intuition] dangerous, if you are convinced it is neglect or abuse, well, see what happens to your body language: you’ll only focus on proving that these parents are no good. For example, because of your approach, the parent will start stumbling, they will lean backwards and that only confirms your thoughts: something is wrong here. Once this happens, you’ll never be able to have a good relationship with this parent anymore. (CYHC-practitioner, 32 years of experience).
CYHC-practitioners aim to avoid tunnel vision by discussing all their cases with peers, nurses and their assistants. To get a sense of the general perception on intuition in CYHC-practices, interviewees were asked whether they thought their colleagues use intuition, to which one replied that they “hope they do:otherwise you won’t be able to function” (CYHC-practitioner, 9 years of experience). They explained that the focus on communication and ‘social medicine’ in the CYHC-system made the use of intuition vital:
I do think that CYHC-practitioners are more sensitive and more social than the average doctor or surgeon. It might be due to how your education raises you and what is allowed in your profession. We talk a lot about feelings and the personal lives of people, so it has a place in our profession. […] So generally speaking, we are more sensitive people (CYHC-practitioner, 15 years of experience).
Intuition is experienced as an integral element of the daily work of CYHC-practitioners, and not as a cause of friction with colleagues or guidelines. Even though, Dutch guidelines for CYHC-practitioners on child abuse discourage decisions based on intuition. When interviewees were asked whether they knew what the guidelines said about intuition, the majority stated that it was not mentioned, but they also stated that they did not regard the guidelines as a useful tool as it is seen as too lengthy and generalised for their specific cases. They explained that child abuse is complex and personal, which requires a subjective approach that they felt was not be captured in the current national guideline.
In order to explore the use of intuition, survey respondents who recognised intuition or gut feeling (n=318), were asked whether they are allowed and enabled to use intuition, to which 48.1% (n=314) responded affirmative. Knowing that feelings of intuition or gut feeling are experienced and used by CYHC-practitioners in their decision-making process in the case of (suspected) child abuse, the interviewees were asked how they use these feelings. It was found that intuition can arise in different stages of the decision-making process and interviewees mentioned five distinct levels of working with intuition in their daily work: 1) to sense that something is off, 2) to normalise deviant or uncommon behaviour, 3) to assess risk, 4) to weigh secondary information and 5) to communicate with parents or caretakers.
The first level of the use of intuition is to sense that ‘something is off’. As one of the interviewees stated: “If you are doing an examination, or look into their [the child’s] development, even if they meet the criteria, there is something that makes me think: something is off. Even though they do just as well as the children who come before them and after them, still there is something that worries you. That’s intuition” (CYHC-practitioner, 35 years of experience). As mentioned by this informant, the source of concern can be unclear, but the sense of ‘something being off’ was often linked to intuition by informants.
Secondly, intuition is used to differentiate between ‘normal’ and ‘abnormal’, in which interviewees subdivided abnormality in ‘abnormal cases that can be normalised’ and ‘dangerously abnormal cases’. Normalities and abnormalities become more challenging when CYHC-practitioners work with people with different backgrounds. When actors external to the family circle, such as school teachers, share their concerns about the well-being of a child, they communicate using their own norms and values, which can differ from those of the family. CYHC-practitioners juggle their own norms and values, those of society and the opinion that they are expected to have as a CYHC-practitioner:
Dealing with different cultures makes you act differently, whether they are refugees or not, or just people with different ways of behaving. I think norms and values are very important in our profession and sometimes you have to set them aside and not judge people. Communicating with refugees is more difficult, so then you’ll have to trust your intuition even more (CYHC-practitioner, 9 years of experience).
When CYHC-practitioners deal with families with different ideas of normality, regardless of background, they have to make a decision on whether a situation is to be considered dangerous or risky for a child, or not. When there are risk factors or dangerous elements in a family situation, CYHC-practitioners need to make decisions on next steps that need to be taken. This leads to the third use of intuition: the assessing of risks and the ability of the family to cope or solve problems. “The role of intuition is: the moment I see a mother with a baby who cries a lot, I have to assess whether the mother is able to cope with this or not” (CYHC-practitioner, 37 years of experience). CYHC-practitioners assess the urgency of a case, in order to decide what kind of care they have to arrange for a family. Interviewees stated that intuition is fast and useful in this process.
Fourthly, secondary information is weighed with the use of intuition. CYHC-practitioners do not only rely on information and signals provided by the child and their families, but also on information and narratives coming from others in the environment of the child, such as teachers, sport coaches or general practitioners. Based on their opinions and stories, CYHC-practitioners aim to construct a truthful image of the child’s situation and decide whether it is considered to be harmful or not.
To solely make objective observations is very difficult, because we always interpret, we aren’t objective. And if so, then you’ll get some facts, some signs, and how will you measure those? I don’t think you could do that without intuition. Or when you have to decide whether people tell the truth or not: if you have to judge someone on their words, you won’t be able to do that without intuition (CYHC-practitioner, 32 years of experience).
CYHC-practitioners use intuition to sense which statements are truthful and to reconstruct a complete picture of the situation. As child abuse is often hidden and occurring behind closed doors, CYHC-practitioners rely on the information of others and consensus amongst those others on what is going on in the family. They gather information from the family members themselves, their files and the stories of the people who are working closely with the subjects. As one of the interviewees described, after sensing that there might be something wrong or that she feels like there is a risky situation, she will start gathering additional information, mainly by asking everyone involved more questions. She wants to ensure that there are no gaps in the information, or friction between different sides of the story, as they can be clues to something being wrong (CYHC-practitioner, 25 years of experience). When CYHC-practitioners realise that someone is not telling the (full) truth, or they find friction or different interpretations in the narratives of the people involved, this is seen as a sign to raise alarm. Within EBM, is it often assumed that uncertainty can be eliminated by gathering more information [27, 43, 44]. However, interviewees state that while gathering more information is their first response to uncertainty as well, the irregularities or uncertainties they find when triangulating narratives are embraced as evidence as well. CYHC-practitioners use their intuition to weigh the incoming information and to eliminate or embrace the uncertainty that follows.
Lastly, intuition is used to communicate with parents and to negotiate their ideas or solutions. Each family and each case of suspected child abuse is unique and CYHC-practitioners need to sense how they can work with the different actors involved. As communication is “the only tool CYHC-practitioners have” (CYHC-practitioner, 32 years of experience), they need to know how to use it. Trainings are focused on conversational techniques, but interviewees said that it is not only techniques, but that it is also necessary to ‘feel’ the situation in order to know what to do. Interviewees mentioned intuition as a means to sense this: “That’s also intuition, that you hear something that makes you think: wait, stop, I have to ask about that” (CYHC-practitioner, 35 years of experience).
The interviews show that intuition plays an influential role within decision-making in cases of (suspected) child abuse. CYHC-practitioners use intuition to assess and judge a situation and to communicate their opinion with the family and colleagues. Intuition becomes a practice, rather than a feeling, through which CYHC-practitioners can find issues and discuss them with parents or carers of children. It helps them to identify, assess and communicate, allowing them to act upon signs earlier and discuss it appropriately with parents/carers. This is important, as early detection and discussion of problems saves both parents and children from harm or severe consequences.