 Okay, so let me first introduce the speaker for the closing keynote and we have Selin Leme. She has been a midwife for more than 30 years in Quebec and was actively engaged for legalization of the midwifery practice. She is the past president of Quebec's Midwives Association and actually a member of the Board of Law of the Sarge Farm du Québec. She has a baccalaureate nursing, MA in Anthropology and a PhD in Applied Human Sciences at the University of Montreal. She is teaching as a senior lecturer in baccalaureate and practical sarge farm for 10 years at the University of Quebec, Troyes-River in Quebec, Canada. She has three children and four grandchildren. So over to you Selin. Thank you very much Selinie. Hi everyone, do you hear me? Is it okay? So I'm sorry for my accent because I'm a French speaking person but still I really want to share with you some of the things I did recently. So okay, let's go to do that. So I want to consider the evidence and the wisdom in professional reality of midwives. So what will we go? I want to talk about the context and a problem faced by midwives. Then why I did start to review about wisdom which is practical wisdom and not philosophical wisdom and in the Greek many, many years ago it was called phronosis. So what is it and how we can talk about that? And finally I want to do some reflection for midwifery and maybe I will sing a song to you just if I feel like it because I think it's worth it. So what is the context? You know we are living mostly in most areas in an increasing dominance of technosystems in healthcare. Evidence based practice or medicine is a new paradigm and we can see it's a lot of guidelines and protocols and rules and algorithms and routine. But the reality of midwifery practice is that midwives are facing two different injunctions. First following protocols and guidelines and at the same time providing a woman-centered individualized care. So how can we do that? How to make the best decision for the patient and what is a good quality of care? So let's get into evidence based practice. It's a very good example of technical rationality which we can see that it's focused in procedures and protocols and standardization of practice. It has its own strengths because now practice can be based on science but not just on habits and beliefs which is not a bad thing. And we can see how it was used by the Lancet journal and finally finding how midwifery and midwives are playing a key role globally for the health of women and babies. So it's good. But at the same time it has its limits because it doesn't recognize the inherent uncertainty and imprevisibility of any professional practice. You know, there's some kind of confusion in the language because evidence is presented as truth and as certainty which is scientifically not true. We can see that the relation of correlation is often interpreted as a causal relation. And we can see that the recommendations are interpreted as prescriptions. We expect to apply recommendations. And for me it's like what they say it's as this manufacturing consent. We expect midwives to consent to use and to apply recommendations. And in fact if we just apply recommendations it's the same thing as considering the woman as an object of care which is for me the contrary of the ethos of my profession. It leads to a cookbook practice where you see that good practice is determined before any situation which is bizarre and it's overriding individual. It's amazing how with ecological discourse we value diversity in nature in order to protect mother nature and mother earth. It works for the nature but it doesn't work for women. You know, it's like Convary belt and industrialized and productive way of thinking about childbirth is how come, you know, physiology is about diversity and singularity but it's like it's competing paradigms. And then the guidelines are coming from research which are reductive and empty of reality because it's about like in a laboratory without any context of cultural, historical, society for women it's just, you know, it's too reductive. So guidelines are like a map we have to follow but in fact the map is not their territory. We are working with people, human beings with a lot of values and cultural and making meaning and searching meaning. So often like guidelines doesn't fit for midway free practice because it's not our reality and the standardization leads to some dishumanization not only of the patient, the woman, but also to the carer. We are just providing care. So and the evidence-based practice is not suitable for complexity and wholesome and individualized care. So what do we have to do? So it was time to look, to have a look at the wisdom which means practical wisdom of phronosis. So three things happened in Quebec where I live in Canada over the recent years. First phronosis or practical wisdom was mentioned in a PhD thesis to help the profession, midway free profession to evolve and continue to flourish. And then there was a research on professional identity and one group of midwives mentioned that wisdom will have to be considered as the content value of all the shared values of the profession which was very good. And recently the order the College of Midwives in Quebec revised the standards of care and mentioned specifically wisdom and linking to professionalism. So they say that midwives has to practice with wisdom as a professional and is the only one profession have mentioning wisdom in the clinical and as a professional. So this is a good reason to make a literature review about wisdom in healthcare and with all professionals. So I find out 37 articles mostly written in the medical discipline which they try to want to have more wisdom in their practice very few in midway free and just maybe two and two for nurses. So it was not a big it was enough you know for me to be able to understand. So what is how can we understand practical wisdom? What is the place in professional practice and can we learn it? Can we teach it? Can we develop it and can we cultivate practical wisdom? So let's see. So you know it's a complex concept which is a lot of discussed but even if the understanding it varies a lot usually it's conceived as a process and not a procedure to make decision. It's about using deliberation and discernment during a situation in a situation in order to make the best decision for the good of the patient in a context and for the good of this person and in this concept and I was surprised that the texts are talking about always the goal of the the mean of the profession is for the good of the patient and not just the health. So for me it's larger than just you know having a healthy mother and a healthy baby. So that that was a good surprise for me. It needs that they come from a deep comprehension of a situation the context and the situation and this particular person and it's a disposition you know to act in a situation where it is uncertainty and is certainly working with complexity as we do and it's a form of knowledge you know for the Greek you have three form of knowledge episteme which is science and then you have a technique which is a skills and phronosis and practical wisdom is a form of knowledge which is experience knowledge knowledge from experience. So for me it has a lot of potential so what is this place this the place in health care it was unanimous you know it's a central to meet the challenge of complexity and it has a key role to meet ethical challenges of practice but not to use like formula which sometimes we we have rules you know for ethical problems it's not like that it is an indispensable for quality of health care practice it's we need that and it's in one on of a mature professional and when there was a thesis about you know doctors talking about what is practical wisdom and they know they can identify and recognize what is wise professional I will talk to it soon and it has a crucial role in all face of health care not just maternity care or obstetrical in all phases so it's a place to think to feel to talk to discuss the dialogue and make the best do you know it's there's no certainty but we have to to to to reflect and and before taking a decision you know so how can we recognize you know they all the texts are talking about virtue it's a virtue which is an attitude on aptitude so there's a lot of things but we can I can talk about you know it's a kind of emotional intelligence it's a capacity to say great to see the gray which is very frequent in our practice it is related to self-confidence the use of emotions a person who is not afraid afraid to of change and innovation and the person who know how to improvise because if a person is a situation is unique the decision can be unique too we have to create something it takes a receptivity and adaptation to a situation it takes core courage because sometimes it's you cannot just apply or rules or the algorithm and all that so you make the decision and it takes courage not to just to follow the the truth and this is a person who is want to talk and also communicate with others which means it's just not between midwives but it's as a group we can they were taking texts were talking about you know personal and professional wisdom but they are talking about a group of professional that can value reflection around the situation so let me see so what is the place can we learn it it's not innate we cannot be born wise you know it's not a theory it's not a resolve it's a process and it goes exclusively with experience in a working environment you know we cannot learn the theory and then apply the theory it doesn't work like that so it's a knowledge which takes time and we learn it absolutely by reflection on work on beliefs on dialogues and sharing stories I will talk to you about sharing stories in a while and so can we teach it because well it's if it's important and valuable we should be able to to learn it but to teach it most of the texts they say it needs to be included in undergraduate programs they have to teach students how to make decisions in conditions of uncertainty and not who have the recipe you know what do we have to do I know I teach two students with wives they all want to have the recipe what do I have to do and this is this tricky because you have to think you have to be able to analyze and all that and feel so it cannot be teach as a procedure so and most of the text they they talk about the central place of narratives so for the students to be able to from stories from the field they can learn and practice to reflect on their own values and the emotion in the stories and the best teachers are not the origins the it comes from maturing experiment and practitioner that should share stories and come from the field and meet the students so and uh when you have a clinical placement you teachers need to create a space uh for students to share and reflects in stories and feel safe as students not to be judged because they are asking questions and don't feel that uh they don't know you know they are not okay if they don't have the answers uh wisdom uh is not there for always finding the answers it's not easy but it's a way to put uh in the best way the problem to put the problem so let me see so can we cultivate wisdom absolutely and this is where they talk essentially by reflexive practice you know uh Sean was uh did a very good uh and and many others of reflective being a reflective practitioner and it's being able to reflect uh on action but in action so reflexivity is not the same thing as reflection reflexivity is questioning the systems hey gosh and questioning oneself and his actions and it's not easy it takes humility to do that and we have to it's about readiness to learn from experience and reflection so this is the valuing and more than valuing promoting uh narrative uh uh um in in practice but in uh in the formation because sharing stories then we learn the treasures in the stories and experience is not only what happened to us is what we learn from what happened to us so this is a way just not okay what happened in a report no no no we have it takes dialogue uh and it's a way for flourishing as professional and they say that a wise professional are more happy which i was thinking about um midwife um and it can contribute to a working place um which can be and can um uh decide to be friend of wisdom you know uh so let me see here so what can we say what can i share with you what practical wisdom and midwifery you know it can be a guiding force for midwives to develop the essence of their professional identity which is being with women and then to promote health and normality we need wisdom we don't need to be just a good technicians and i i want to um i will see it later it's it's a very important uh way to value a judgment based approach versus technical approach of profession and fronosis will honor the professional ethos of midwives while enabling them to use uh evidence base it's not to be against it but evidence cannot it will be in for my practice but cannot determine it i am the one who know this woman who know the context who know the situation and will find with her uh what's what will be a good thing to do and it's about assuming uncertainty we live in a um intolerance to risk and to uncertainty and i cannot uh if midwifery is welcoming life um we have to learn to to um work and live with uncertainty it's our uh fundamental human condition and um it's about valuing your relational practice versus procedural practice and um we value reflexivity we value the sharing stories and discussion in dialogue and mostly the fundamental role of professional judgment we have to it's it's to honor uh um honored human uh existential situation it's not a problem you know problem based learning is not helping us to to to value existential um and physiology and normality and it has a potential to for emancipation for midwives you know um uh and and it's not about fighting uh the system or even if it ends but it's about finding values it's not about being at war it's a quest you know uh so it's it's not against medicine it's about uh going through uh roots of midwifery so and it's claiming uh the place of wisdom in midwifery care there should be more research and just finding going somewhere else and not just in the system or in the the box no and uh no it's not that oh oh i don't have oh i missed the uh one of the um the quote uh which i will say to you on the other side of right doing and wrong doing there's a field i will meet you there so for me about wisdom is not looking uh what is right or what is wrong what's the best or we or them or this or that the um uh binary thinking is not helping us we work in uh complexity so we stay open and um meet people to um share questions not always find you know finding what is the the the best answer so this is we have to honor transformative process because we are part of that its maternity is part of a life changing process but i think working as midwives is changing us and is is all also transforming so wisdom uh practical wisdom it helps us to to to feel uh that we are part of uh of reality of human life so that's what i want to share with you and uh do i have the oh this is the what i wanted to it was after and do i have the uh because i want to sing something for you uh do i have the words the lyrics this is me oh no yes i will uh i will switch it okay uh for you and for me and it's for us okay we shall be known by the company we keep by the ones who circle around to tend these fires we shall be known by the ones who sow and reap the seeds of change the life from peak within the earth it is time now it is time now that we thrive it is time we lead ourselves into the well it is time by the time to be alive in this great turning we shall learn to lead in love in this great turning we shall learn to lead in love that's what i wanted to share with you so thank you for listening to me so if you have any questions thank you so much selen i have a question from chris so i want to um to uh finalize the uh finalize the review and make an article on that because i think it's it's not always not uh only important but precious for uh midway free wisdom thank you selen thank you so much okay and uh jenny has a question uh how much is intuition connected to uh furnaces it's it's a great part of that because it's uh it's because we we have intuition that we have new questions and we are not sure that it's just this or just that and just following the routine and there's something happening so for sure um it's it's a big part of uh being wise and using wisdom let's see i need to so i hope is uh bringing some something new and something hope with hope uh and have the courage of uh talking about and and practicing wisdom between us and uh between groups of midwives yes go ahead for sure so thank you selen and there's an overwhelming wave of love for you thank you this is about love eh midway free so work of love yeah exactly and yeah i agreed with what shila says let us claim the french name for midwives sage fun absolutely with wisdom yeah thank you okay thank you so much