Reflective practice

CASE STUDY “ The measures I had taken so far were just not going to cut it. It wasnt just a simple matter of putting more blankets over Mr. McGillicuddy to keep his extremities warm; at his age, with his erratic pulse, not to mention sluggish metabolism, his body was just too weak to generate the heat that it needed to keep itself going.
At the time, a number of solutions had presented themselves, the most logical being the acquisition of two heating blankets to plug into the room directly to add the temperature boost that the patient needed, but could no longer provide himself. And it worked. His vitals did improve. But nonetheless, what should have been simple became needlessly complicated when my Nurse-Supervisor took me to task for not filling out the proper requisition forms based on the new state-mandated policy for fire-hazard safety that had already been established. But it was established by doctors; and the administration, and according to the buzz, with only the most token representation of the nursing staff. But I knew that I wasnt doing myself any favors by snapping like that. If I wanted any hope getting through the program, Id need to make nice.
So I sat back to analyze what I had done, and how – what the actions of others combined with my own actions had made me feel. I concentrated on a reflection of the days events, my responses to them, and my own responses to the responses of others towards my own actions. Then I repeated the process in my own mind. “
INTRODUCTION
Reflection is a central therapeutic meta-cognitive approach advocated by Freudian and behaviorist schools of thought. Other pioneers have incorporated the concept of professional reflection as integral to a daily repertoire utilized not only in the resolution of professional problems, but as a means of ongoing professional development towards the objective of enhancing the effectiveness of practice.
An objective becomes the verbalization of clinical decisions after active, cognitive processing of the days choices and judgments. In effect, the practitioner becomes a researcher of themselves and their own professional conduct. (Freshwater & Rolfe, 2001.) In this context, reflection becomes a problem-solving exercise towards the objective of addressing challenges that may not have had a clear resolution during the hectic work-hours in which they occurred, but self-willed study after hours can easily advance the quest of ongoing improvement.
REFLECTION
Adkins and Murphy provide a description of the thought-model they judge most effective in this form of professional reflection:
The professional must acknowledge the presence of uncomfortable thoughts and emotions from a new experience.
Describe the thoughts and feelings that the most relevant features and events of the situation provokes.
Analyze the feelings that seem relevant to the work situation under question, identifying knowledge gained that day, while challenging familiar assumptions to allow the exploration of alternatives.
Evaluate the relevant knowledge for solutions encountered at work, and think of ways to utilize that knowledge.
Identify every item learned through the experience and the reflection.
At this point, the cycle repeats with an awareness of uncomfortable feelings relating to the experience. (Atkins & Murphy, 1994)
WEAKNESSES
But it is worthwhile to investigate the challenges inherent in the practical implementation of reflective study as a guided policy for the medical workplace; often mired with generations of institutional inertia as an impediment towards operational changes and innovations. While more experienced nurses are encouraged to provide their mentorship in a generic sense, the effectiveness of these measures may be curtailed by apathy on the part of the medical organization in terms of embracing novel practices. As a result, few nurses are able to devote their full effort to reflective practice, creating an atmosphere where the advantages inherent in this approach can get crowded out of a nurses daily routine.
Adding to the dilemma is a sense of frustration on the part of nurses who feel that they are at the bottom of the proverbial totem-pole, with doctor/managers implementing strategies that effect them, about which they may feel they have little input. With nurses getting the distinct impression they are being trod on. Then of course, there are nurse-supervisors and head-nurses that seem to lose touch with the practicalities with which they once grappled; shifting their burden of thought solely into the managerial sphere.
Among doctors most obviously, there will exist a power imbalance – even though doctors no longer possess direct employment control over any particular nurse. In the nurses favor are the practicalities of dealing daily with patient needs, and the valuable experience that entails which proves crucial to the hospitals function. Yet, this knowledge can nonetheless be undervalued to the extent that a nurses expertise does not stem from the academic domains of scientific research. This creates a disparity in which a nurse may have personal knowledge of a superior treatment or alternative modality more advantageous to that particular patient; but may find herself ( or himself) over-ruled by doctors at the top of the prevailing power structure. This corporate culture has a tendency to suppress critical thinking in certain nurses, and to express confidence in their own practical experience; believing that doctors are more knowledgeable than themselves. (Mantzoukas & Jasper, 2004)
While nurses are arguably more respected than in years past, the inevitable hospital hierarchy does favor doctors, creating a ward mentality in which nurses become – or feel, obligated to seek doctors permission even for activities, planning, and overall strategy that might otherwise qualify as routine. One challenge in particular, is controversy over reflective practice itself. The doctor-dominant ward-culture typically considers reflective practice as an insufficient method of learning and development, thus taking no steps to promote or support the practice. While nurses themselves can attest to the validity of the reflective method, for developing the full scope of their professional knowledge, the prevailing ward-culture has a commitment to more didactic, evidence-based practices.
STRENGTHS
Some nurses perceive reflective practice as an activity capable of promoting a higher level of consciousness concerning the profession, and the influences that nurses do undoubtedly possess. The awareness could serve to promote a new unity among the nursing profession; which arguably has the potential to upset the prevailing establishment power-structure within most hospitals; which could provide an incentive for hospital management to seek to block measures that change the way nurses think and unite.
RECOMMENDATION
Reflective methods need not be entirely devoid of the rigors of evidence-based methodology, and a number of other researchers have also theorized their own models of reflective thought-cycles for professional development. The practice has a history in the scientific literature going back as far as 1933, with Deweys constructivist studies on problem-based learning. Other investigators have developed their own models; which include Marchels model of a three-level, structured hierarchy on reflexive writing and thinking. (Marchel, 2004)
Despite the efforts of investigators over the decades, nurses that do make a point to study reflective techniques as an avenue of professional development often find the practice dismissed by those in power within the hospital hierarchy. The rebuttals may prove subtle in nature, but the entrenched tendency to cast a skeptical eye on reflective practices due to the commitment to evidence-based positivism is itself unjustified; due to the lengthy expanse of psychological investigations exploring the personal, and professional benefits of this methodology.
But no one has any logical reason to try and restrict or directly oppose anyones attempts at reflective introspection; but the general medical establishment will do nothing to encourage the development of the practice; nor are they likely to grant any acknowledgment or professional credentials on the basis of reflective studies.
REFERENCES
Atkins S, Murphy K (1994) Reflective Practice. Nursing Standard 8(39)49-56.
Dewey, J. (1933) How We Think, New York: D. C. Heath. Classic and highly influential discussion of thinking. in Smith,
M. K. (1999). Reflection. article in the Encyclopaedia of Informal Education. [3]
Mantzoukas, S. Jasper, M. A. 2004. Reflective practice and daily ward reality: a covert power game. Journal of Clinical
Nursing 13, 925-933.
Marchel, Carol A. (2004). Evaluating Reflection and Sociocultural Awareness in Service Learning Classes, Teaching of
Psychology, 31 (2) 120-123
Rolfe G., Freshwater D. & Jasper M. (2001) Critical Reflection for Nursing and the Helping Professions: A User’s
Guide.
Schön D (1983) The reflective practitioner. Basic Books: New York