Chun-Ming Yuan,Jing-Rong Xiao,Wei-Jun Zhou

1Department of Orthopaedics,Sichuan Provincial Medical Academy of Science Hospital.Sichuan Provincial People's Hospital,Chengdu,Sichuan,China; 2Department of nursing service,Sichuan Provincial Medical Academy of Science Hospital.Sichuan Provincial People's Hospital,Chengdu,Sichuan,China.

Abstract

Keywords:Critical reflection,Role,Senior,Nurse

Introduction

Reflection refers to an action in which an individual can identify the ‘truth’ from what they are doing(reflection-in action) or have done (reflection-on action),the purpose of reflection is to make sense on one’s action and necessary changes might be taken place thereafter [1,2].Critical reflection enables individuals to exam their take-for-grant assumptions in the daily practice,strive for making a link between their assumptions and beliefs about the social world[3].Theories and personal knowledge could be used for articulating and analyzing about their issues [3].Reflection in nursing is adopted as means of encouraging nurses critically analyses their action from the past experiences and thus make positive changes in the practice [4].It is evident that reflection can help to improve job satisfaction,patients’outcome in nursing practice [1].Critical emancipatory reflection will be chosen to guide the reflection in relation to one of my practice issues in the ward [1].Critical emancipatory reflection enables me to free myself from take-forgrant assumptions and oppressive forces in daily practice,the purpose of my reflection is to make changes from the discovered constraints[1].

Methods

Smyth’s reflective framework will be used to guide my reflection [5].It includes four steps:describe the practice issue,informing about the take for grant assumptions and analyzing its meaning,confronting the personal assumptions and identifying constraints,reconstructing and transforming the practice issue.

Results

Describe

To begin with my practice issue,I worked as a senior staff nurse at orthopedic department in one of tertiary hospital.Senior staff nurse in here refers to a nurse who are responsible for higher and more important job than younger nurses,and they usually had longer work experience and more skillful.As a senior in the ward,I undertook different roles in the department,such as role of clinical educator for internship nursing students,being a preceptor of new graduates and overall in-charge.The toughest role was be an overall in-charge in the ward,the job description for overall in-charge entailed implementing doctors’ order,admitting and discharging patient,answering phone call and call bell,responding to visitors and patients’relatives and so on.I and other senior hardly off duty on time while taking overall in-charge.Sometimes,while I lied in bed,still thought about whether there were uncompleted works during my shift.Although I felt tired and stressful very often in my work,I still accepted whatever job assigned to me.

Inform

Being a senior,I was made feel stressful and overwhelmed in work.To my personal knowledge,I understand that senior nurses are quite important in the ward,especially senior nurses’ in-charge [6].Because senior nurses are usually more experienced,skillful and knowledgeable compare with junior nurses,therefore,they share more responsibility for patients’safety and supervision for junior nurses [6,7].Although the job description of nurse in-charge may vary in different countries,one thing can be assured that senior nurses are under more stress due to their positions [7].I,myself as a senior staff nurse,was made to feel quite stressful and lack of self-accomplishment in my work,sometimes even questioning myself“Am I capable to be a senior in this ward?”.Being in such working condition,I feel that I should have done something to make myself feel better or bring some changes to the working environment.Looking back my working behavior,it is necessary for me to ask myself why I have been kept quiet in such working environment for years.Critical emancipatory reflection can therefore enable me to make sense of my behavior and action in practice [8],leading me to uncover my take-for-grant assumptions[1].

By looking back my behavior in the practice issue,it seems as though I am acting according the belief that senior nurses are vital in the ward practice.Senior nurses in-charge took more responsibility in their positions [6,7].Therefore,I thought it was my responsibility to train the internship nursing students,junior nurses and be an overall in-charge.However,in terms of daily habits and routines in the working place[9],it appears as though I act according to my belief that the work patterns for overall in-charge should include implementing doctors’ order,admitting and discharge patient,answering phone call and call bell,respond to visitors and patients’ relatives and dealing with other issues.Although I know I have the right to advocate for myself since I felt stressful and low accomplishment,even began to doubt my own abilities.I did not stand for myself with regard to the work stress,just quietly accepted the assigned tasks.Furthermore,rest of senior nurses in my ward were acting very much on the same,they did not question about the assigned job,so did I.Based on social learning theory,people intend to learn each other by observing others’behavior[10].

Confront

Values and beliefs.I value engagement,respect,perfection and versatility,self-accomplishment and work-life balance.As a senior staff nurse,I engage myself with my position,mentoring nursing student and guide junior nurses,taking the role of overall in-charge.I am also looking forward to achieving self-accomplishment.Work engagement is important,high level of engagement positively influences nurses’job satisfaction,helps improve quality of care [11],builds on nurses’ wellbeing [12].In addition,work engagement was identified relate to nurses’self-accomplishment [12,13].High standard nursing care requires nurses to be as perfect as possible,we are not allowed to having any negligence while facing people’s health [9].Moreover,nurses are called for to be versatile in dealing with complex working situation[1].Therefore,there might be different roles on one nurse.The study showed that quality of care can be improved by encouraging work-life balance within the department [14].Furthermore,I was raised by valuing respect,consequently also thought to respect the authorities.These values had been developed ever since I started my education in nursing school and being reinforced in my nursing career.According the process of professional socialization that the development of a nurse entails a sense of personal commitment and internalization of values[15].When I became a nurse,I had already embodied with values of engagement,respect,perfection and versatility,self-accomplishment and work-life balance and admitted that these values are good features for nurse.Therefore,I uphold these values in my practice.However,my practice issue demonstrates that I also embodied with passivity to authoritative power,it seems as though I also have the issues of being assertive and advocate for my personal rights.

In my nursing career,I have embodied with the values of engagement,respect,perfection and versatility,self-accomplishment and work-life balance in my practice.These values work most of the time,which make me feel valuable and indispensable in the team.When patients and patients’ relatives showed appreciations to my work and watching patients’recovery day to day,it gave me the reason to continue upholding these values and beliefs.I firmly believe that the more I engage with my work,the stronger professional accomplishment I can achieve; the more perfect I will be,the higher standard nursing care I can meet.I respect everyone,as well as the authorities.I am quite convinced that if I act according to my values and beliefs,then my colleagues and people around me would learn from me [10].However,in my practice issue,these values seemed not functioning well.As a senior,I undertook different roles at same time,it seemed out of my capacity which directly affect my engagement to the work,developed sense of low self-accomplishment.Role overload can be used to explain my situation,the job expectation and demand are beyond my ability could reach [16].Additionally,as a role of overall in-charge,it requires nurses to be versatile to handle the difficult and complex situation,meanwhile,in order to do the job perfectly,which lead me think about the work most of the time [1].It seems as though there is loss of work-life balance.I chose to respect authority,obeyed whatever tasks had been assigned to me.I felt that the authority did not put respect on me,they never even asked whether I was willing to take the assigned tasks.They just used their power to put me in that work situation.

Constraints.Looking back my practice issue,there are some constraints exiting in the practice.Which is the historical constraint,social culture constraint,political and policy constraint and personal constraint.

First of all,in relation to historical constraint,it can be dated to the development of nursing.Our modern nursing was first developed by Florence Nightingale in the Crimean war,therefore,her concept regarding nursing was strongly influenced by her experiences with caring for soldiers [16].She worked under the hierarchies of power,in addition,people’s social status were marked by gender and social position during her times [17].Thus,nursing was historically embedded with hierarchy [17].Nursing practice in China was also inevitably influenced by the historic hierarchy.When there is a hierarchy exiting,there might be hegemony accompanied.Hegemony is usually occurred when there is an unequal positions in terms of power relations,in which one position is dominant over another [18].In the case,people in the inferior position are quite often oppressed,consequently,it is difficult for them to be assertive on owns’ rights.In examining my practice issue,the hierarchy and hegemony were also influence my behavior in asserting my personal right to voice my stress to the head nurse.

Furthermore,the wounded named Florence Nightingale “The Lady with the Lamp”,which is used to confirm her highly engagement spirit [19,20].Therefore,engagement was considered as one of important trait for nurses since the beginning of modern nursing.In addition,work engagement is encouraged in nursing,as it gives meaning to improve quality of care and reduce the turnover rate [11].The notion of high work engagement lead to strong sense of self-accomplishment drives me to take the most responsibilities [12,13].I took the assumption that more engagement investing in the work will lead me to the most fulfillment,thus I automatically accepted the different roles.

Secondly,with regards to the social culture constraints,social constraints are related to the habitual activities within a given settings [1];on the other hand,culture refers to the way people do things in settings[21].Therefore,both are very much in the same and closely related to historic constraints as well[1].In the Chinese society,the culture of Confucianism is rooted among people for long time,Confucian culture exhibits in working environment which are applied to in regulating the relationship between superior and subordinate[22].The culture of respecting for superior,teacher,parents and friends,challenge or question authorities’ decisions is considered impolite and rude[22].However,no one wants to be thought as impolite and rude,therefore,people are commonly withhold their decisions and obey what the authority decide for them.

In addition,the psychological theory of persuasion was developed by one of great ancient scholar named Han Feizi,which was used as a strategy for the subordinates to maintain good relation with their superiors [22].This theory is still evident in current society describing as face saving strategy [22].By applying the strategy,subordinates tend to please the superior; on the other hand,if the subordinate tell the truth,the superior will think they lose face.In the case,the subordinate may have the threat of losing their job or incurred other form of persecution owing to not persuasion [22].Therefore,in this situation,people learnt to be silent while facing the hierarchy.Nonetheless,this culture has been extended to current nursing field.The study results revealed that nurses in order to adapt to their wards cultures,they learned to be silent and assimilating themselves into the existing hierarchy[23].

To sum up with social culture constraints,people’s attitudes and behaviors are potentially influenced by their culture [1].Reflexivity offers the potentials for individuals to realize the different aspects around us as well as the significant meaning of our social context influence on our actions[3].Hence,reflexivity enables me understand how the Chinese culture and organization culture,as well as the ward culture exert influences on me.By looking back my practice issue,I was quite convinced that the head nurse did not like me to make suggestion to change the working practice.Since the practice as part of organization culture has been carried out for decades.I also took the grant to accept whatever task assigned to me,even I was made to feel stressful most of the time,I still think this is the job I should do.On the other hand,I had the concern of being persecuted.Thus,I kept silent in front of authority.

Thirdly,the policy in relation to the responsibility of senior nurses also constrained me at certain extent.It was suggested that clear and accurate specification of nurse role will assist nurse in performing their work more efficiently and effectively [24].In my setting,there is a policy statement with regard to the nurses’responsibility that a senior staff have the responsibility of guiding junior nurses and nursing student,working as an assistant of head nurse.It can be seen through the statement there is lack of specific description regarding the role of nurse assistant to head nurse,which would cause a confusion about senior nurses’ role.Nonetheless,role conflict and role ambiguity occurred when there is role confusion[16].This confusion leads me take for grant that I should accept whatever tasks assigned to me.

Lastly,personal constraints are thought as inherent obstacles as such ways we display ourselves externally and lead lives internally with or without knowing it,it can be revealed through critical reflection [1].According to reflexivity theory,critically engaging with reflection will be help us in recognition all aspects of ourselves [3].Through my behavior in the practice,I displayed ambition in achieving self-actualization in my nursing career.Therefore,I persistently strive for perfection in the work practice.Self-actualization is based on the Maslow’s Hierarchy of Needs theory,it is explained as realizing personal potential,self-fulfillment,seeking personal growth and peak experiences[25].The desire of moving up toward a level of self-actualization has been motivated myself from everyday practice [25],thus I feared of making mistakes by showing chronic anxiety in doing my work [1],especially while undertaking the overall in-charge.Thus,I still concerned about my job after duty.I have internalized the notion of self-actualization by hard working.On the other hand,my ambition of self-actualization also stresses on me.

Additionally,in relation to personal constraints,I also assumed that no matter I had a voice about my situation to the head nurse or not,it would not have any alteration.These inaccurate perceptions result in my silence [26],my tacit knowledge has hindered me from speaking up for myself,leading me neglect my right of be a representative for other nurses [23].This can be interpreted as lack of confidence in making changes about the daily routines.

By engaging with emancipatory critical reflection and analysis of constraints relate to my practice,it is apparently there are some discrepancies between my espoused values and my real thoughts.In the process of emancipatory critical reflection,it facilitates me to uncover my take for grant assumptions in this case and raise my awareness in making some necessary changes about my situation.Although,I am still not certain that what changes I can make,since many constraints exit.Emancipatory critical reflection offers me the tool to guide my direction for reconstruct my practice issue.

Reconstruct

Owning to my study nursing master courses in oversea,I am quite sure that there will be some new tasks assigned to me in the future.Clinical nursing practice needs the application of knowledge [27],as nurses’knowledge is important for bringing changes to clinical practice [28].In light of critical social theory,social changes and personal changes are intertwined[3].In other words,personal knowledge can bring changes to departments or organizations.Based on this theory,through emancipatory critical reflection,it helps me build on confidence in making changes for my future practice.While receiving the new tasks,I would critically make an assessment on my competency and ability in doing the assigned job.Providing I have difficulty in handling the tasks or emerging of negative emotion toward my works,asking for assistance from colleagues or manager might help me lighten the burden.There is one saying that as the joy is shared,then the joy will be doubled;while the sorrow is shared,then the sorrow will be halved.On the other hand,I will make a change on myself,more open myself to others and more actively in assisting colleagues with their problems.According to social learn theory,people will learn from each other in their lives [10].I am sure that by doing this,colleagues around me will be influenced by my positive behaviors.In order to achieve effective transformation in the practice,communication skill is another aspect which needs to be addressed.

Communications are happened every day in people lives,however effective communication and peer-sharing opinion are essential in increasing nursing staff’s satisfaction in the work and improving their quality of life in the organizations [23].The study results identified that nurses seemed to have more comfortable feeling with clear expression of work-related issues to the head nurse[23].Therefore,I also need to strive for improving my communication skill in order to effectively communicate with colleagues and head nurse.A suggestion with proper expression to head nurse in specification of nurses’role in the department is considered in the future.It would appear that if I convey my opinions in an acceptable manner that the head nurse would take my suggestion into consideration.On the other hand,this action is also the way for me in asserting my own right of speak up.Additionally,as what was suggested if the senior nurses take the initiative to voice the staff nurses’ opinions to nurse managers [23],then the senior nurses will be gaining more respect from nurses,therefore,self-fulfillment as a senior will be enforced.

Conclusion

In conclusion,by engaging critical emancipatory reflection guided by Smyth’s [5] framework,my personal values,beliefs and assumptions are discovered through this process.I value engagement,respect,perfection and versatility,self-accomplishment and work-life balance,however,in my real practice,I could not as such perfect and versatile as imagined due to take many roles in the work.Highly engagement lead me develop sense of low self-accomplishment and loss of work-life balance.It seems that there are some discrepancy between my espoused values and my take for grant assumption.Through critically analyzing the historical,social culture,policy and personal constraints in detail,it helps me to transform my practice issue into a new way.Critical emancipatory reflection provides nurses with tool to uncover daily practice issue,helps strengthen nursing values and improving care stands[29],it should be encouraged.