Fundamentals of Nursing and Midwifery 2e

239 Chapter 13 Thoughtful practice: Self-awareness and reflection

Professional context for thoughtful practice In Chapter 5, the context of contemporary nursing and mid- wifery in modern healthcare is discussed. The healthcare environment is now one of rapid turnover of patients, shorter hospital stays, alternative patient care settings, increased technology and medical knowledge, and greater patient acuity. These changes in the culture, economics and politics of healthcare have deeply influenced the roles of nurses and midwives. The practice of all healthcare profes- sionals is now required to encompass clinical competence as well as developed reflective skills that enable personal and professional growth through heightened self-awareness. These skills complement the clinical reasoning that enhances sound clinical judgement and decision making related to patient care. The following section explores this professional context through the consideration of profes- sional attributes and how they can be demonstrated in professional portfolios that capture the individual practi- tioner’s personal professional journey. Professional attributes The ability to reflect and grow through self-awareness has been recognised as an essential skill for registered nurses and midwives in Australia and New Zealand. In contempo- rary practice, the professional registered nurse or midwife is expected to be able to analyse his or her own practice through reflection and self-assessment. The Nursing Council of New Zealand (NCNZ) and the Midwifery Council of New Zealand (MCNZ) have included reflection as a key competency for registered nurses. One of the com- petency domains of the Nursing and Midwifery Board of Australia (NMBA), which comprise the minimum standards for practice, also recognises this. The domain of Critical Thinking and Analysis includes reflective practice as it: … relates to self-appraisal, professional development and the value of evidence and research for practice. Reflect- ing on practice, feelings and beliefs and the consequences of these for individuals/groups is an important profes- sional benchmark (Australian Nursing and Midwifery Council, 2006, p. 4). Modern professional nurses and midwives are required to engage in reflection to identify their own needs, to seek out and use supportive networks to enhance their profes- sional growth, and to share these experiences with others to aid in their professional development. These professional attributes are now being recognised as part of the require- ments for formal authority to practise through professional registration. There are now national competency frame- works in use in both countries, which guide registering authorities in assessing the competence required for both registration and maintenance of an ongoing standard of pro- fessional practice. These frameworks outline the process for nurses and midwives to systematically evaluate their practice against a set of national competency standards.

misused in relationships. This chapter introduces the concept of empowerment in order for you to commence your consid- eration of empowerment through reflection; however, a deeper understanding may only come with experience. THOUGHTFUL PRACTICE A thoughtful practitioner, in the context of clinical practice, is a clinician who is considerate and compassionate, keeping the person at the centre of all deliberations in order to promote the humanity and dignity of the person being cared for, while at the same time preserving respect for the person providing the care, and examining the situation in order to learn. A thoughtful practitioner acts as a moral agent. Moral agency is described in Chapters 1 and 9 as the responsibility of translating an ethical principle into action. This is the basis of thoughtful practice. Inherent in thoughtful practice is an acknowledgement of the influence of power within institu- tional systems. Thoughtful care seeks to empower individuals to choose their own health pathway. To achieve this, practical or essential care is delivered through processes that are holis- tic and tailored to meet the individual needs of the person. Care-related decisions are based on sound and systematic reasoning processes that are evaluated and reviewed through reflective practice, so that there is continual learning in and from practice for the benefit of future care encounters. Although the term ‘thoughtful’ can be applied to clinical practice, this description does not always apply in reality. Chapter 9 outlined the rich history of nursing and midwifery. Over time, many of these work practices have become enshrined in habit or ritual practice. Research and evidence- based practice have had an impact on the use of ritual in practice; the use of evidence as the rationale for decision making has reduced ritual in many aspects of practice. However, there are still many areas that have not been researched where ritual persists. Ritual practice is described as ‘carrying out a task without thinking it through in a problem-solving way. The nurse does something because this is the way it has always been done’ (Walsh & Ford, 1989, p. 9). Not all ritual practice is unwarranted, however; many researchers have explored both good and bad rituals in practice (Philpin, 2002). Other researchers refer to ritual thinking, or ‘habits of the mind’, linking these to individual attributes of the clinician (Scheffer & Rubenfeld, 2000). An appreciation of the need to review the ways in which care is delivered and thought about in order to relinquish outdated practices has led to the ‘emergence of the new nurse, the thinking nurse and the reflective practitioner’ (Cotton, 2001, p. 515). Some commentators have concluded that individuals can improve their practice through reflec- tion (Paget, 2001), while others have attributed improvement to critical thinking as a component of clinical reasoning (Heffer & Rudy, 2008). Thoughtful practice com- bines the powerful effects of these processes and the influences they bring to the processes of care, in order to create person-centred care for the benefit of the person, as illustrated in Figure U3-1.