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
Unit III Thoughtful practice and the process of care
246
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
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?
