Reflective practice

Reflective practice

Ethics in the workplace

The unexamined life is not worth living. -Socrates

This quote, familiar to anyone who has taken a philosophy course, indicate how important critical thinking, selfanalysis and reflection are to philosophers in order to arrive at better knowledge and conduct.

Registered nurses in Alberta are required to take such a philosophical approach to their practice. To meet the requirements of the Continuing Competence Program, they must reflect on their practice. According to the Continuing Competence Handbook reflective practice is the “review of one’s own nursing practice to determine learning needs and incorporate learning to improve one’s own practice.”

The key to this process is “reflection on your practice against the Nursing Practice Standards” (AARN, 2000, p. 8). In other words, you must assess the extent to which your practice meets the Standards.

What does it mean to reflect? A dictionary will show several meanings, all related:

* To throw back (light, heat, or sound)

* To give back an image of (as in a mirror)

* To think seriously (on or upon)

Reflection, then, is serious thinking about something. It reflects back to us what we believe or value, so that we can understand better why we think that way. If we can find no good reasons for our beliefs, then we may need to think about whether we should change them.

Reflection and moral response

THOMAS AND WALUCHOW (1998) use the idea of reflecting to describe three levels of response to a moral question or problem:

* The expressive level

* The pre-reflective level

* The reflective level

At the expressive level, responses are unanalyzed expressions or feelings, which, in themselves, do not constitute any kind of justification or reason for the response.

At the pre-reflective level of response, justification is offered by reference to values, rules and principles that are accepted uncritically. Most often, justification is offered by reference to a conventional or commonly agreed-upon standard or rule, which is uncritically accepted and acted upon. We do not stop to think why we should act or base our judgements upon these rules, or if they are good standards to adopt.

At the reflective level of response our moral judgments are not based entirely on blindly accepted conventional norms, but on principles, rules and values to which we ourselves consciously subscribe. As rational moral agents, we are prepared to offer a reason or a basis for our moral judgment.

Thus, moral reflection serves to concentrate one’s thoughts back upon a problem or an idea. This is not a new activity; it is something most of us have been doing all our lives. However, to be critical thinkers, we have to think reflectively about constructing and evaluating the reasons for our rules and beliefs, and to set out standards we can use to judge these reasons as good or poor ones. We need to direct our attention explicitly toward things that we normally take for granted, to carefully examine our beliefs and opinions and the evidence we have for them.

Reflection and professional integrity

LARRY MAY, a philosopher who has written about morality in groups, lists this kind of critical thinking as one of the three aspects to moral integrity. The development of a critical point of view means, May says, that we need to view moral integrity not as holding steadfastly to a code of conduct or rules that others have provided, even if we approve of the code or rules. Rather, May sees moral integrity “as a form of maturation in which reflection on a plurality of values provides a critical coherence to one’s experiences.” Achieving integrity means developing a critical perspective, a standpoint from which one can examine and then endorse or reject new social influences.

Implicit in this view is the requirement that our choices must be our own: May quotes Gabriele Taylor:

To be a candidate for possession of integrity the person’s choices and evaluations must be her own: her identifications with her desires must be neither subject to unconsidered change nor be distorted or confused. Her reasons for action must be genuine. (May 1996, p.16).

The self matures by becoming committed to certain values and beliefs as a result of critical reflection, not merely as a result of having been socialized to accept certain values and beliefs. May’s account claims that it is the PROCESS rather than the SUBSTANCE of one’s beliefs that is most important for integrity

May also claims that such moral concepts as integrity and responsibility need to be understood as embedded in social structures. For a professional, this means that not only is professional ethics embedded in individual conscience, but it is also a result of the interaction between persons. Thus, to have moral integrity as a professional, individuals must do more than simply adhere to what their conscience tells them. They need to critically evaluate both individually and with others in their profession, the standards that they are to follow.

As Thomas and Waluchow point out, acting at the pre-reflective level is a type of “externally directed behaviour,” the blind following of standards or norms set by someone else. While not necessarily bad (sometimes conventional norms are capable of reasoned defense and can be fully justified morally), our conventional standards and rules must always be subject to scrutiny. Perhaps there are much better rules that we should try to persuade others to adopt. Or, perhaps existing conventions are morally objectionable. For example, the convention of nurses always deferring to physicians and obediently complying with all doctors’ orders, followed strictly until fairly recently, is now seen as unacceptable.

Nurses and professional integrity

IN LIGHT OF THE ABOVE DISCUSSION, to have moral integrity nurses need to assess the standards, codes and rules that they are asked to follow in their practice. They must have good reasons for accepting them. This requires not only reflection on whether or not our practice conforms to the AARN Nursing Practice Standards. It also requires us to reflect on the standards themselves, to determine whether we are genuinely in accord with them and why. Reflective practice means thinking about standards and practice from a critical point of view, and sharing this responsibility with other nurses.

Does reflective practice take time? You bet it does! It takes time to become familiar with the standards and practices we are asked to follow in our professional lives, as well as to subject them to a critical point of view. Do we have time for reflective practice? We need to make it, for we are required by legislation to do so. Our moral integrity as professionals requires it.

Reflective practice might be time-consuming and frustrating, yet it offers the best hope for our work as nurses to be responsive to the needs of our patients and society.

RESOURCES FOR REFLECTIVE PRACTICE

Alberta Association of Registered Nurses. Nursing Practice Standards: Standards for a New Millennium Canadian Nurses Association: Code of Ethics for Registered Nurses

Alberta Association of Registered Nurses: Ethical decision-making for registered nurses in Alberta: Guidelines and recommendations

(All of these documents are available to members at no cost from the MRN library and at www.nurses.ab.ca.)

REFERENCES:

May, L. (1996). The Socially Responsive Self. Social theory and professional ethics. Chicago: The University of Chicago Press.

Thomas, J & W. Waluchow. (1998) Well and good: A case study approach to biomedical ethics, Ad Edition. Peterborough: Broadview Press.

ABOUT THE AUTHOR:

Lorraine (Laurie) B. Hardingham, RN, BN, MA (Philosophy) lives in Calgary, teaches philosophy, and works as a casual nurse.

Copyright Alberta Association of Registered Nurses May/Jun 2001

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