In this essay, I will discuss several issues that seem to bind nursing practice with questions of ethics, sociology and management. Reflective practice is an important aspect of nursing management and in this essay we discuss implications of discrimination in nursing care and examine the importance of anti-discriminatory perspectives in nursing. In this paper, the case study I will elaborate is of an elderly woman who was of a non-British ethnic origin and spoke little English. A junior nurse visited her home to provide care but her attitude towards the patient has been discriminatory and abrupt, a situation that calls for serious reflection on the issues of racial discrimination at the clinical setting. The patient was apparently treated with leg ulcer. The questions that have to be considered here are:
Where in the observation did discrimination occur and how this could have affected the delivery of care given? And how has discrimination influenced the lady’s care?
The concept of anti-discriminatory practice as a contemporary issue within adult nursing is discussed here considering observational evidence and similar case studies.
Reflection in Nursing:
Reflective practice in nursing is guided by models of reflection. Reflective practice model serves as a framework within which nursing or other management professions can work. Reflective practice model is also a structural framework or learning model that serves the purposes of a profession and is particularly applicable to health related professions. Any portfolio of practice includes a model of reflection as reflection helps in determining what was positive or negative or a learning experience within the profession. Reflective practice highlights the importance of learning from experiences after thinking about it and relates the practical experiences to the theoretical learning approaches. The four important reflective models that form part of the clinical and nursing portfolio are:
Gibbs Model of Reflection – 1988
Kolb’s Learning Cycle – 1984
John’s Model of Reflection – 1994
Gibbs Model of reflection is shown in a cyclical manner and is represented a follows:
Gibbs’ model of reflection (1988)
Given by Gibbs, 1988.
Source: CPSU, 2005
Unlike Gibbs’ model that has five stages, Kolb’s Learning cycle with four stages is shown as follows:
Source; CPSU, 2005
In the Gibbs’ model, the event is reflected upon and includes a description of what happened followed by feelings about the situation, and reflection on what the thoughts and feelings were at that time upon being into the situation. The nursing professional then personally evaluates whether the experience has been good or bad for her and analyses whether she can make any sense to the situation. The conclusions are drawn depending on alternative and what else could have been done with the situation and what were the other options available to tackle the situation better or more appropriately. Proposed and future action plan is thought of and how the situation will be acted upon in the future is also determined. Kolb’s model however stresses on the importance of generalizations of concrete experiences testing the implications in similar situations.
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Whereas John’s model of reflection emphasizes on the stages of description of the event, reflection on what was aimed at, the factors influencing strategies, alternative strategies to what have been used, and learning from the experience, Atkin’s and Murphy’s model of reflection is on analysis and identification of the learning experience and action planned based on awareness and evaluation of this relevance of knowledge.
Considering these models of reflection, we will use only the more popular Gibbs model to evaluate the case study discussed here and the situation of discrimination against the elderly lady Mrs. B as observed.
Background and Literature Survey:
The importance of reflection as part of the learning experience and using reflection as a means of improving one’s professional skills and future performance by evaluating the situation and the mistakes has been emphasized in many professions including teaching and nursing. In the Kolb cycle, reflective observation is the second phase. Reflection in action or while doing something in the job and reflection on action or some form of evaluation after the job is done, are included within reflective practice. Reflection includes several phases from simple problem solving of individual cases, to analysis of the situation considering relevant literature as well as broader social and political factors.
Gustaffsson and Fagerberg (2004) emphasizes on the advantages that could be gained from reflection mainly among registered nurses or RNs. They examine the questions on the implications of nurses’ reflections, the subject matter of their reflection and how they are able to deal with their reflection and how they improve their professional approach through reflection. The authors describe the experiences of the nurses and their reflection in relation to the nursing situations to understand how the nurses use reflection in their daily work. The study included interviewing four registered trained nurses and the qualitative differences of the nurses reflective experiences were categorized. One of these is the category of reflection itself; but the ethical considerations within the nursing care situation and consequence of facing the situation or meeting the requirements of empathy or professional development are also important. The nurse attitudes and opinions on their reflective practice, what they thought about the situation and how they feel they will control similar future situations serves a model of future professional development. Gustaffson and Fagerberg point out that reflective practice has relevance for clinical practice as by understanding the contents of nurses’ reflections, it is also possible to understand the advantages of reflective practice and how and when such measures should be used by the nurses for further professional development.
Fairley (2005) gives a consultant nurse’ perspective of a clinical role in critical care unit that has evolved as a central feature of all surgical high dependency units (SDHU) in large teaching hospital trusts. Advanced nursing practice is perceived not as the acquisition and application of technical procedures which are usually undertaken by doctors, but also an integration of medicine and nursing where holistic nursing assessment and symptom focused physical examination go hand in hand. Fairley presents a reflective account of practical problems encountered relating to role integration, professional autonomy, legal and consent issues, non-medical prescribing, and role evaluation (Fairley, 2005). The paper successfully describes a model of nursing applied to high dependency units integrating the role of the advanced nurse practitioner within the medical and clinical team an reflective practice plays an important role by being the main method of evaluation of a consultant nurse’ perspective.
In a study on the importance of reflective practice in family care, Peden-McAlpine (2005) discusses the design, evaluation and outcomes of a reflective practice intervention (RPI) that was used to train critical care nurses on how to incorporate family intervention into their nursing practice. The benefits and problems of reflective practice are many and most beneficial aspects include improvement of professionalism and better ability to tackle similar situations leading to professional development through experience in nursing. Reflective practice is of experiential nature, it relates to a nurse’s experience and learning from the experience. In the study discussed by Peden-McAlpine, interviews were conducted with eight staff nurse participants after the training of RPI to determine changes in family practice when reflective practice was used. Three essential themes were identified on analysis of the interview texts and the authors have given the three themes relating to experiences in nursing after participating in the RPI program as follows: (1) acknowledging, re-framing preconceived ideas about families, (2) recognizing meaning of family stress, and (3) incorporating family into nursing care (Peden-McAlpine et al, 2005). The reflective practice intervention program practices by nurses helped them to change their attitudes towards critical care especially in family and enhanced their communication and ability to build proper relationships with families bringing in a new way of understanding family stress or appreciating family values. The nurses thus had a new perspective of family system after their training of reflective practice on family critical care.
Considering the benefits of changing nursing attitudes and developing professionalism through reflective practice, many authors have emphasized the need to use reflective practice as a training method within nursing education. Chabeli and Muller (2004) use a qualitative contextual and exploratory descriptive design for theory generation that was used to develop model facilitating reflective thing in clinical nursing education. The authors cited Wilson (1963 and Gift (1997) who provided a theoretical framework for a concept analysis of reflective thinking in nursing education. The paper also gives the case o 12 nurse educators who participated in a focus group interview on how reflective practice can be facilitated in clinical nursing education and the consensus was for a classification of reflective practice recognizing the main elements of practice and a deductive analysis and synthesis after conceptualization of each main concept. The importance of a conceptual meaning has been highlighted as theories with well-defined concepts and elements could facilitate reflective practice and can form an important part of clinical nursing education. Guidelines could be developed according to the theoretical framework of reflective practice and can give a new direction nursing education. In a later study, Chabeli and Muller also provided a model of reflective practice that could be used as a theoretical framework in nursing education. However, the authors suggest that ‘
Reflective thinking has become a popular word in nursing education world wide, but its meaning and effective use remains debatable because of lack of clarity in its meaning’ (Mackintosh, 1998:553 cited in Chabeli and Muller, 2004).
The case of our elderly patient Mrs. B suggest that the nurse’s discrimination and ill behavior against the woman, relates to discriminatory practice, something that could be and should be stopped using reflective practice (also see Sheffield et al, 1999). The junior nurse in charge who was responsible for such an incident was given reflective practice as a framework for professional development. She was recommended to go through the Gibbs model of reflection in which she analyzed how and why she behaved the way she did, what she will do in future situations and how she learnt from the experience to not repeat her discriminatory behavior in the future. The implications are that the behavior of the nurse has led to poor quality of care delivery to the patient.
The junior nurse who treated Mrs. B badly was recommended to go through reflective practice intervention to change her attitudes towards other races and ethnic minorities. According she participated in reflective practice sessions when she verbally as well as in writing had to describe the events in which she engaged in discriminatory practice and also evaluated her responses and indicated her future course of action and other alternatives for similar situations.
In this essay I discussed the implications of reflective practice in nursing considering the theoretical frameworks of reflective practice. All the main models of reflective practice have been discussed and the models were used to consider a discriminatory case of an elderly patient who was wronged by a junior nurse. The patient was being treated for leg ulcer and was reportedly badly and disrespectfully treated by the nurse. The nurse was asked to go through reflective practice and mainly using Gibbs model of reflection, had to complete an exercise in which she described the event, indicated her feelings of the event, evaluated whether it was a good or bad experience, analyzed her own response to the situation, concluded what else she could have done for the situation and finally drew up an action plan for future similar circumstances.
Atkins, S. and Murphy, K. (1994) Reflective Practice. Nursing Standard 8(39) 49-56
Gibbs, G. (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit, Oxford Brookes University, Oxford
Johns, C. and Graham, J. (1996) Using a Reflective Model of Nursing and Guided Reflection. Nursing Standard 11 (2) 34-38
Haddock, J. and Bassett, C. (1997) Nurses Perceptions of Reflective Practice Nursing Standard 11(32) 39-41
Kolb, D.A. (1984) Experiential Learning: Experience as the Source of Learning and Development. Prentice Hall, New Jersey
Schon, D.A. (1983) The Reflective Practitioner. Temple Smith: London
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For diagrams, see Clinical Placements Support Unit – UCE Birmingham
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