International Journal of Nursing Practice 1995; 1 : 26-3 1

HC R E S E A R C H P A P E R

ReJective midwfery practice: Facilitating midwives’ practice insights using a distance

education reyective practitioner model

Bev Taylor RN RM MEd PhD Foundation Chair o f Nursing, Centrefor Nursing and Health Care Practices, Faculty of Health Sciences, Southern Cross University,

Lismore, New South Wales, Australia

Julia Stewart RN RM BSc DipNEd MA MEd University Health Liaison Officer, Centre fo r Professional Development, Health Sciences, Faculty o f Health Sciences,

Southern Cross University, Lismore, New South Wales, Australia

Virginia King RN RM BA BHA MNA Lecturer in Nursing, Centre f o r Nursing and Health Care Practices, Faculty o f Health Sciences, Southern Cross Universiq

Lismore, New South Wales, Australia

Accepted for publication April 1995

Taylor B, Stewart J & King V. InternationalJournal $Nursing Practice 1995; 1: 26-31 Reflective midwifery practice: Facilitating midwives’ practice insights using a distance

education reflective practitioner model A study was undertaken to evaluate a reflective practitioner model with midwives, who self-selected into the project when they were studying the Bachelor of Health Science (Nursing) unit NR278, Advanced Nursing Practice, Midwifery. The theoretical assumptions that influenced the research were those forwarded by Schon (1983) and Boud, Keogh and Walker (1985), who argued that practitioners are often unaware of the sophisticated knowledge they have regarding the intrica- cies of their practice, but that this personal knowledge can be made explicit through reflective processes. The aim of the study was to research the use of a distance education reflective practitioner process that encouraged midwives to examine their practice with a view to making changes where necessary. All the research objectives were met to some extent, although each experience of the research process was particular to the individual participant. Analysis consisted of: inter- pretation of the participant’s insights into their individual experiences; the researcher’s interpretations of participant’s experiences; and collective themes arising out of the research. This paper concentrates mainly on the participant’s insights into their individual experiences of practising midwifery, using a reflective practitioner model.

Key words: distance education, midwifery, midwives’ experiences, reflective practitioner model, reflective practitioner processes.

INTRODUCTION the Faculty of Health Sciences, Southern Cross University, since 1989. In 1994, three members of the Faculty undertook a study to evaluate the theory and process components of reflective practice. The theoretical assumptions that influenced the research were those for- warded by Schon’ and B o d Keogh and Walker,’ who argued that practitioners are often unaware of the sophis-

Reflective practice has been used as a teaching and learn- ing strategy for students undertaking nursing courses in

Correspondence: Bev Gylor, Centre for Nursing and Health Care Practices, Southern Cross Universiiy, Lismore, New South Wales 2480, Australia.

ReJlective midwfey practice 27

ticated knowIedge they have regarding the intricacies of their practice, but that this personal knowledge can be

made explicit through reflective processes. Although areas relating to the definitions, processes

and rationale for reflection, and the need for practitioners to reflect, are generally well represented in the literature, there is a dearth of information about reflection and mid- wifery, with most of the professional literature focusing

on nursing and reflection. The distinction here is in the emphasis made by midwives that midwifery practice is dif-

ferent from nursing practice, so that although the amount of literature is growing in nursing it is not about mid- wifery.

Health services in Australia (and Britain) are moving toward ‘the introduction of a purchaser-provider split or market economy, and the refocusing of health care away from large hospitals and into primary health-care settings’ (p. 60).j As a result of this move in ‘an effort to improve

the quality of health care, professional practice has come under scrutiny, and serious questions are now being asked

concerning treatment inputs and patient outcomes . . . and that there is an expectation that health care should be informed by research as well as practice-based knowl- edge’ (p. 60).’ Midwives by nature of their work were particularly encouraged to respond to this change and also provide a client-driven service.‘ The literature generally supported the view that reflective practice may be one

way for midwives to monitor and improve professional outcomes.

Reflection is perceived by some professionals as one

way to bridge the theory-practice gap, based on the potential of reflection to uncover knowledge in action.’ Using the process of reflection in the context of learning, Atkins and Murphy’ endorsed the Boud et al. view of reflection as ‘a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations’ .’ This view was supported by Blumberg, who argued that practitioners need ‘to change

how they think (as in value) about their work’ (p. 236).6 Atkins and Murphy developed a model that summarized three common phases: an awareness of uncomfortable feelings and thoughts; a critical analysis of the situation involving an examination of feelings and knowledge; and a development of a new perspective of the situation.’

Ford and Profetto-McCrath suggested that in creating the conditions for teaching critical reflection ‘the nature of the teacher-student relationship must be transformed

from the existing power relationship-superior to subor- dinate-to a more egalitarian one which emphasizes

working with students’ (p. 343).’ The rhetoric of curricula claims that the nature of

teaching has changed from behaviourist models to experi- ential-based models. Lewis and Williams argued that the

move towards using experiential teaching methods was a direct response to changes in ‘our conceptions of learning,

. . . the unprecedented influx of adult learners (into higher education) and . . . the rapidly changing environment where there is an increased need for flexibility and the capacity to leverage previous knowledge and experience in

new and different ways’ (p. 5).* Laurilland, in her discus- sion on the nature of teaching in an academic setting, dif- ferentiated between first order experiential knowledge (that of the world) and second order academic knowledge (that of descriptions of the world). ‘Academic knowledge is not like other kinds of everyday knowledge’ .’ Reflection

is but one strategy to assist learners to ‘change the way they experience the world’ (p. 28).’

Several authors have promoted the need for education in the art of reflection as they considered it spurious to assume that practitioners had already mastered the art of reflection.’w’’ However, adult learners are interested in

building upon the reflections of their life experiences to make learning meaningful, by applying their learning to life situations as part of a continuing professional educa- tion initiative.”

Schon argued that practitioners need coaching to deal with practice problems.I3 Coaching promotes collabora- tive knowing.’”’’ It is referred to by Belenky et al. as ‘con- nected teaching’, which encourages a co-operative com- munication style between the instructor and partici- pants.” Establishing a climate of collaboration during the

learning process prepares learners for the changes they identify as being needed in the workplace.

A range of strategies was suggested in the literature for the documentation of reflection: ‘journal writing, metaphor analysis, storytelling and portfolio develop-

ment’.” Schon suggested the use of reflective diaries as tools for studying personal reflections.” In Newell’s cri- tique of the use of reflection in nursing, he concedes that mentors and support persons need time in training, and support themselves. ‘I’

DESCRIPTION OF THE PROJECT This study was undertaken to evaluate a reflective practi- tioner model with midwives, who self-selected into the

28 B. Taylor et al.

project, when they were studying the Bachelor of Health Science (Nursing) unit NR278, Advanced Nursing Practice, Midwifery. The project intended to: (i) encour- age personal insights into the midwife’s background and workplace, thereby enabling a strengthened sense of self worth as a person and as a professional; (ii) enable self- monitoring of midwifery practice through an experiential learning process, within an external study unit; (iii) enhance the understanding of practice w i h its environ- mental context and thereby empower the midwife to act as an agent of change; (iv) improve practitioner and client satisfaction, as a result of midwives questioning the status quo in clinical contexts; (v) provide an effective practice learning model that may be integrated into postgraduate programmes in nursing; and (vi) foresee the possibilities of developing, in the future, a practice learning model that might be used by other health services practitioners, and by people employed as practitioners generally in a wide range of fields.

METHODS AND PROCESSES Practitioners were encouraged to interpret and share their own practice experiences throughout the process. A facilitators’ guide was prepared which set out some assumptions of reflection and strategies for encouraging reflection on midwifery practice. A learning package for participants introduced them to the process of critical reflection and encouraged them to: (i) complete a learn- ing package that introduced the process of considering one’s personal history in relation to the dynamic of pro- fessional development; (ii) undertake an initial descriptive writing task, which encouraged them to reflect on their motivations for becoming a midwife; (iii) record six to eight clinical incidents in a journal using the process of critical reflection, over an 8 week period; (iv) make tele- phone contact weekly with a designated facilitator, to dis- cuss and analyse their reflections on clinical incidents; and (v) participate in a summative teleconference.

ANALYSIS AND INTERPRETATION Reflective journals were maintained privately by the par- ticipants. Facilitators’ notes of each phone call with par- ticipants and the transcript of a summative teleconference were used as the basis for analysis of reflections and the reflective process. The summative teleconference allowed participants to share their practice stories and to identify the ways in which the reflective processes had helped them in their respective work situations.

The individual and group transcripts were analysed by manual thematic analysis, for themes that emerged as indicative of the value of the reflective practice experi- ence. Although it is not possible in this paper to track the progress of each midwife as they benefited through the facilitated reflective practice experience, a summary fol- lows of each participant’s essential insights.

Fleur Critical incidents recorded in Fleur’s journal helped her to reflect on personal and professional issues. Fleur acknowledged that she had gained insights into becoming assertive and non-judgmental and was able to deal better with the politics of midwifery practice. She explained:

I was thinking (as I read through my journal) ‘Oh my god’. I whinged most ofthe time, most o f m y entries are whinges and it’s all about ward politics which is something that surprised me, because I thought I should have been talking about my practice, how 1 get on with the ladies and incidents that have happened with my actual midwgev, but it seems to be all political stuffthat I’ve talked about.

All the participants found the reflective process of value. Fleur formulated her views on best midwifery practice and the reflective process, by saying:

I’ve really enjoyed it. It’s good to makeyourseysit down and reflect

on the things thatyou are doing, and the things that are going on in your life . . . It’s good for bringingyourselfback to realiry because

you have all these ideals foryourseJj but it’s good to reflect on what you are actually doing, to see i f y o u are actually keeping up with your ideals. (I’ve learned to) just stand up for myselfmore. I think

I’ve found that. I think, reflecting back on this and looking at my practice, I have actually, these last f e w months, . . . been standing up

for myseymore.

Heather Over the course of their telephone conversations, Heather and her facilitator explored midwife-administra- tor relations and care issues. An example of the way in which Heather used reflection to clarify misunderstand- ings with senior nursing staff follows:

During the 6 or 8 weeks there were probably three or four matters that I cleared up for myseg-I clar$ed, just through doing so. So

I was really pleased with it.

Heather found the reflective process of value.

Reflective midwfery practice 29

It was only through reflection that 1 realized really that i t was an

unresolved matter for me and 1 thought of i t several times and each

time there was more reflection that went on. Itlust sort f k e p t tum-

bling on and on. That just wouldn’t have happened f 1 hadn’t have

been doing this rejlective practice, at all. I hadn’t thought about

this before.

Iris Critical incidents recorded in Iris’ journal helped her to reflect on personal and professional issues. For example, Iris discussed an incident with her facilitator in which she had not been assertive, and had been manipulated by the client’s partner in the labour ward rather than acting as an advocate for the client. A ward debriefing was held sub- sequent to this issue being raised during the research.

On the reflective process Iris commented:

I have found that, for me, it (reflection) has been a personal growth

thing to look at (problems ) and know that 1 don’t need to put up

with that sort of behaviour. Because, up until now, everyone has

always taken it as being the way he (the doctor) always is, so thatIs

the w y it will a1wyT be. The behaviour and actually the whole

epidural service in our hospital was discussed. We haven’t solved it

yet but it has given me an insight into how I can go about making

it better for everyone, not just me.

Iris also referred to the value of having a facilitator with whom to share her experiences.

... stemming from and talking with (the facilitator) made me feel

more assertive within myseyto be able to stand up and not to let the

doctor/nurse game happen.

Jasmine During the study Jasmine explored professional issues related to her midwifery experience especially in relation to antenatal education (which was one of her interests).

The final conversation summarized some of Jasmine’s insights into her practice and confirmed the value of reflection for her.

Well I found it (reflection) quite interesting, I think it made me

delve more into some problems andfind solutions to them, whereas I probably would have found what I thought were solutions, but I

think I’ve got better solutions now.

Jasmine also indicated that the telephone facilitation process had been of value to her practice.

I thought, ‘Well I’ll prepare mysefand have all the answers’ but i t

didn’t seem to matter how many answers I had, (thefacilitator)

seemed to probe a little deeper.

Marjorie During the study Marjorie acknowledged that critical

incidents helped her to reflect on personal and profes- sional issues, such as the changing role of midwives:

In 1976 husbands had o n b just been allowed in Labour Ward . . . the

nurses owned the babies, close observation was thought to be critical.

Based on her reflections, Marjorie commented:

Probably the biggest jnsight I got out f i t (the study) is that I had

probably dropped out a little from being an involved midwtfe to the

‘doing my job’ midwjfe, while I was doing my degree. 1 think i t was

worthwhile, because perhaps I would not have reflected on my work

and my home l fe , ,and perhaps 1 wouldn’t have noticed things

weren’t quite the same. And so, perhaps when 1 hadfinished that

subject, I moy not have tried to change anything . . .

Rose Rose explored professional issues that arose from her work in the private sector. On many occasions she com- mented about the pressures of work and expressed a feel- ing of ‘being used’ by the system. ‘How much more can I take?’ she said: ‘Normally I stew but this time I stewed aloud’.

The final conversation summarized some of Rose’s insights into her practice.

I found the biggest benefit to me was that i t (the study) was an out-

let to talk about all the stresses in my l f e and probably come to grips

with what was happening and probably get through it a bit more

because I had sort oflocalized it and lfound that quite helpful with

group situations and studying and all the other things that were

happening at the time. . . . it made me really think about i t a lot

more rather than just push i t under the carpet, which i s probably the

emu with her head in the sand v p e situation. You don’t learn any-

thing like that untilyou come in and have a look around.

Tom Throughout the period of telephone contact Tom acknowledged critical incidents that helped him to reflect on personal and professional issues.

(Rejlective practice) made me reflect back onto the relationship I had

with my workmates and how I thought each o f us should work with-

30 B. Tnylor et al.

in a unit as a working whole, work together and I think that is basi-

cally how l used the process because l rejlected a lot on relationships

and how I worked with the ladies in the unit. The relationships

between people I worked with, doctors, nurses and parents and that

was basically how I reflected on things. I f1 had a good relationship

I could reflect back positive rejlections onto my practice but f i t was

negative I could learn from the experience and go f rom there. The

reflection, I found, has been really worthwhile because i t gave me the

opportunity to look at conflicts that I have come across and dfler-

ences o f opinion and things, that just generally got at me and gave

me a system oflooking at them and thinking about them and then

acting upon them later on.

DISCUSSION AND RECOMMENDATIONS

The analysis of this study included interpretations of the participants’ insights into their experiences, the researchers’ interpretations of the participants’ experi- ences and the collective themes. The collective themes included practice issues and views on the reflective process. The practice issues were concerned with expounding per- ceptions of quality midwifery care, and recognizing and challenging unsatisfactory work conditions. The interper- sonal relationship issues included negotiating role relation- ships and making personal communicative changes. In rela- tion to the reflective process, the themes included emotive responses, views on the usefulness of the process, reactions to active m e n d activity caused by the process, ways of con- fronting practice issues, and possibilities and strategies for future reflective practice.

Project outcomes All of the project’s objectives were achieved to some extent, the most important being the potential for the midwives to reflect on their practice with a view to chang- ing problematic areas that they identified. The researchers assert that it is possible to develop a practice learning model that may be used by other practitioners, based on the structures and processes of this study.

Limitations The study was limited to participants reflecting on their actions. There was always a time delay in discussing their reflections with the facilitator. There is no way of know- ing how this time delay affected the quality of those reflec- tions, or the editing processes discussed by Newell.’ What is known is that some participants commented on being extended mentally by the facilitator in discussing aspects

of their reflections that ‘pushed them beyond normal lim- its’. They acknowledged ‘added pressure, the effects of personal effort, being pushed to think beyond and prob- ing deeper,’ into their practice worlds and activities (p. 37-40).’*

This project assisted midwives to reflect on their prac- tice throughout the duration of the study, although it can- not be claimed that they will continue to use the process as a lifelong approach to their work. During the study, all the participants spoke of personal time constraints that had frustrated their attempts to become fully immersed in the project. These constraints related to working full- time while studying part-time and maintaining family and personal commitments concomitantly. Unless the individ- uals find ways of dealing with the various constraints they have identified, it seems unlikely that they will continue unfacilitated reflective processes.

Recommendations The following recommendations from the study are list- ed.

(1) Reflection can be recommended as a mechanism to encourage personal responsibility and accountability for one’s actions and the outcomes of those actions.

(2) Keeping a journal is a valuable professional devel- opment strategy that should be promoted in order to enhance insights by midwives and nurses into their per- sonal and professional practice.

( 3 ) Written guidelines for learners and facilitators are valuable in assisting in teaching the process of reflection. Such documents would need to be expressed in succinct and plain language.

(4) A combination of strategies can be used for effec- tive reflective practice. These might include journal recording and individual and group telephone discussions with practitioners.

(5) Reflective practice can be considered a valid expe- riential learning tool that promotes self-monitoring and improvements in practice in any nursing programme, or for professional development at course, group or individ- ual level.

(6) Reflective practice can be considered a valid prac- tice experiential learning tool that lends itself to the edu- cation of experienced nurses and midwives in both under- graduate and postgraduate programmes.

(7) Reflective practice can be used by health service practitioners other than nurses, and by people employed as practitioners in a wide range of fields. It is a process

ReJlective midwt fey practice 31

that is relatively simple to employ, yet one that will

enhance responsibility and accountability in any profes- sional practice. The model developed in this research can

be applied across a wide range of fields, through its use in a teaching programme or for professional development purposes.

CONCLUSION The aim of this study was to research the use of a reflective

practitioner process, which encouragcd midwives to examine their practice with a vicw to making changes where necessary. All of the research objectives wcre met, although each experience of the research process was par-

ticular to the individual participant. Analysis consisted of: interpretation of the participant’s insights into their indi- vidual experiences; thc researcher’s interpretations of par-

ticipant’s experiences; and collective themes arising out of the research. This paper has concentrated mainly on the participant’s insights into their individual experiences.

Although the research demonstrated the relative com- plexity involved in setting up and maintaining reflective

processes with busy practitioners, the recommendations of the research attest to the need for midwives to foster a reflective approach to their work. This approach would enable midwives to give the kind of care to their clients that they would ideally choose to give, even in the face of practice and personal relations issues.

ACKNOWLEDGEMENTS The researchers acknowledge the central importance of the midwives who participated in this study, and the research grant from the Evaluative and Research Skills Development Scheme at Southern Cross University for the opportunity to undertake this important research.

REFERENCES Schon DA. The Rejlective Practitioner: How Practitioners Think in Action. Basic Books, New York, 1983. Boud D, Keogh R & Walker D. Reflection: Turning Experience into Learning. In Atkins S & Murphy K.

Reflection: a review of the literature. Journal af Advanced Nursing 1993; 18: 1188-1 192. Lucker & Henrick. Towards knowledge-based practice: An evaluation of a method of dissemination. International Journal ofh’ursing 1995; 32: 59-67. Maternity Services in New South Wales. Midwt fey Review. Sydney: New South Wales Department of Health, 1989. Atkins S & Murphy K. Reflection: A review of the literature. journal ofildvanced Nursing 1993; 18: 1188-1 192. Blumberg A. Toward a scholarship of practice. Journal af Curriculum and Supervision 1990; 5: 236-243. Ford J & Profetto-McGrath J. A model for critical thinking within the context of curriculum as praxis. Journal .f Nursing Education 1994; 3 3 : 341-344. Lewis L & Williams C. Experiential Learning: Past and Present. New directions fo r Adult and Continuing Education 1994; 62: 5-6. Laurilland D. Rethinking university teaching: Afrarneworkfor the effective use of educational technology. Routledge: London, 1993.

10 Newel1 R. Anxiety, accuracy and reflection: the limits of professional development. Journal $Advanced Nursing 1992; 17: 1326-1333.

11 Von Wright J. Reflections on reflection. Learning and

12 Knowles M. The Modern Practice af Adult Education: From Pedagogy to Andragoa 2nd Edn. Cambridge Book Co: New York, 1980.

13 Schon DA. Educating the Rejlective Practitioner fiwards a New Designfor Teaching and Learning in the Professions. Jossey Bass, San Francisco, 1987.

14 Greenwood J. Reflective practice: a critique of the work of Argyris and Schon. Journal .f Advanced Nursing 1993; 18: 11 83-1 187.

15 Conway J. Reflection, the art and science of nursing and the theory-practice gap. British Journal af Nursing 1994; 3 : 114-1 18.

16 Belenky M, Clinchy B, Goldberger N & Tarule J. Women’s Wys afKnowing. Basic Books: New York, 1986.

17 Caffarella R & Barnett B. Characteristics of Adult Learners and Foundations of Experiential Learning. New directionsfor Adult and Continuing Education 1994; 62: 29-32.

18 Taylor B, Stewart J & King V. Report a f t h e Research Project: Experiential Learning Through Reflective Midwj f ey Practice. Lismore: Southcrn Cross University, 1995.

Instruction 1992; 12: 59-68.