Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

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Stephenson’s (1994) framework for applying a critical approach to reflection uses a similar approach to Mezirow, as shown in the example in Box 13-5. Reflection, transition and continuing practice One of the most important reasons for students to develop sound reflective skills and to participate in guided reflection is to prepare them for transition to practice, because there is often a divide between what is taught and what is experi- enced in actual practice (Duchscher, 2009). This is often referred to as ‘the real versus the ideal’, and recognition of this can be so profound that Kramer termed it ‘reality shock’ (Kelly, 1998). It is also referred to as the theory–practice gap, and was found by Kelly to result in significant moral distress for new practitioners. Teekman (2000) identified some of the reasons for this gap as being institutional culture, economic constraints on health systems and dominance of the medical profession. Reflection on this gap, and on the reasons for its existence, can help the new graduate to make sense of the practice environment and assist in the transition from student to professional. Further- more, it can continue to assist clinicians in future practice (see the Research in practice section). However, for reflection to be effective it must be active and conducted in a supportive envi- ronment. Many universities include reflective skills in their curricula and many organisations conduct mentoring relation- ships for this purpose, so that transition is less confronting and professional growth continues throughout a career. Reflection on empowerment In addition to the recognition of the reality of practice, sound reflection skills can assist you to understand the concept of empowerment, the giving or taking of power, and how it BOX 13-5 Stephenson’s framework: The critical approach to reflection Choose a situation, and ask yourself: • What was my role in the situation? Did I feel comfortable or uncomfortable? Why? • What actions did I take? How did I and others act? Was it appropriate? • How could I have improved the situation for myself, for the patient and for the others involved? • What can I change in the future? • Do I feel as if I have learnt anything new about myself? • Did I expect anything different to happen? If so, what and why? • Has this situation changed my way of thinking in any way? • What knowledge from my theory and research can I apply to this situation? • What broader issues, such as ethical, political or social, arise from this situation? • What do I think about these broader issues?

influences many of the aspects of modern healthcare. Previ- ous chapters discuss the influence of power in certain aspects of practice. In Chapter 9, the knowledge that comes from the socio-political world of nursing and how this knowledge is used in ‘practice development’ is discussed. In Chapter 10, the critical paradigm that underpins research methodologies such as action research is explained. Considerations of power and the impact that power can have on ethical decision making are discussed in Chapter 11, and the legal implica- tions of power in the therapeutic relationship and in professional boundaries are discussed in Chapter 12. On a practical level, for care to be person centred, it is imperative that clinicians have an appreciation of how empowerment affects the relationships they encounter day to day. A deep understanding of the use and misuse of power can only come with experience (Fulton, 1997). This concept is therefore simply introduced in this chapter through the two most fre- quently encountered relationships you will experience in clinical placement with the patient and with your colleagues. This introduction should open your mind to the concept so that it becomes a part of your developing reflective skills. Clinician–patient interface There are considerable differences between the levels of power experienced by clinicians and by patients. All clini- cians have some power; in comparison, patients have little power, as illness and disability make them vulnerable (Hunt- ington et al., 2008). Not only do nurses recognise this imbalance, but they are often reluctant to rectify it, using their need to complete tasks to justify it (McCarthy & Holbrook- Freeman, 2008). Clinicians sometimes act in a manner that they think is in the best interests of patients without actually consulting them. In Chapter 7, the necessity of patient involvement in person-centred communication is discussed. Often the misuse of power is subtle, but it can alter the clinician–patient interface (Carpenito-Moyet, 2003). The level of self-awareness required for this degree of understand- ing of self is of a high order, and may only come through profound reflection and examination of personal action and behaviour undertaken routinely as an integral part of practice. Clinician–other interface and interdisciplinary care Much has been written of the misuse of power in nursing between nurses themselves, where nursing has been described as hierarchical and including horizontal violence (Daiski, 2004). This detracts from harmonious working relationships and prevents nurses fromworking effectively in teams. In addi- tion, the power differential between medical colleagues and nurses and midwives has often led to instances of, at best, dis- content and, at worst, poor practice (Huntington et al., 2008). These issues of power and its use are important consider- ations for contemporary nurses and midwives. However, these issues are not explicit, often being unspoken, unac- knowledged and accepted without question. Understanding may only come through examination, reflection and acute awareness of your own use of power. When power is under- stood, you are able to ensure that care becomes person