who had devised it and when. I asked one of my colleagues who had worked in the department for many years as to the origin and author of the philosophy; she looked at me blankly and said ‘I am sorry, I did not know we had one duck’.
In my next management supervision I raised this issue with my manager who also was ignorant of these facts but thought it might have been based upon the acute services philosophy. I compared the department’s philosophy with one of the acute inpatient wards, only to discover that it was exactly the same. Johns ( 2013 ) draws attention to the difficulties caused by having an imported philosophy imposed on a practice: it denies articulation of the practitioner’s own beliefs and values and is easily forgotten. What then is the point in having a generic philosophy devised by someone else, locked away in a filing cabinet? None‐whatsoever. Reflecting upon this, I established that the team believes that we provide a high standard of individualised care for patients within the department. However, we lack evidence to validate this. By not having a philosophy of care constructed on our collective beliefs and objectives of our practice, how do we know where we are going and the rational for the journey?
Barriers
The practitioner strives to understand the nature of creative tension and what must be done to resolve it. Pinar (1981, p. 177) notes that ‘it is only when practitioners truly understand themselves and the conditions of their practice, can they begin to realistically change and respond differently. To understand, the reflective practitioner creeps underneath habitual explanations of his actions, outside his regularised statements of his objectives’. The practitioner must question ‘what constrains me from responding in more desirable ways?’ These constraints or barriers may not be easy to recognise and shift because they form the fabric of everyday practice and are largely taken for granted. Some guidance may be helpful (see Chapter 7). If practitioners were rational, they could change their practice on the basis of evidence that supports the best way of doing something. However, we do not live in a rational world.
Fay (1987) identifies three barriers as tradition, authority, and embodiment (Table 1.1) that govern the fabric of our social world. Fay (1987, p. 75) writes from a critical social science perspective that gives reflection its critical nomenclature:
The goal of a critical social science is not only to facilitate methodical self‐reflection necessary to produce rational clarity, but to dissolve those barriers which prevent people from living in accordance with their genuine will. Put in another way, its aim is to help people not only to be transparent to themselves but also to cease being mere objects in the world, passive victims dominated by forces external to them.
TABLE 1.1 Barriers to Rational Change (Fay 1987)
| Tradition | – a pre‐reflective state reflected in the assumptions and habitual practices that people hold about the way things should be. |
| Authority and power | – the way normal relationships are constructed and maintained through authority’s use of power. |
| Embodiment | – the way people have been socialised to think, feel, and respond to the world in a normative and pre‐reflective way. |
The influence of these barriers lies thick within any experience. They are evident in patterns of talk that are deeply embodied to serve the status quo (Kopp 2000). It is obvious that to bring about desirable change, these barriers need to be understood, and practitioners are skilful and empowered to overcome them. Thus reflection is concerned with un‐concealing these barriers. Greene (1988, p. 58) writes:
Concealment does not simply mean hiding; it means dissembling, presenting something as other than it is. To ‘unconceal’ is to create clearings, spaces in the midst of things where decisions can be made. It is to break through the masked and the falsified, to reach toward what is also half‐hidden or concealed. When a woman, when any human being, tries to tell the truth and act on it, there is no predicting what will happen. The ‘not yet’ is always to a degree concealed. When one chooses to act on one’s freedom, there are no guarantees.
Tradition
Tradition is reflected in the way practice gets done. It is handed down, perhaps shifting slightly to prevailing ideas and directives. It constitutes ‘normal practice’ and, as such, is largely taken for granted. When tradition is dissected, it can be viewed as the assumptions and attitudes that govern everyday practice. Bohm (1996, p. 69) writes:
Normally, we don’t see that our assumptions are affecting the nature of our observations. But the assumptions affect the way we see things, the way we experience them, and consequently the things we want to do. In a way we are looking through our assumptions; the assumptions could be said to be an observer in a sense.
Practice is contextual set within particular organisational settings. Dawson (2015, p. 25) notes that ‘context refers to the grand societal narratives, those clusters of beliefs and cultural norms that give shape and meaning to the human cultures within which we live’.
Responding in more desirable ways to a situation is likely to disrupt normal practice and require a shift in cultural norms and assumptions and, as such, may be resisted by those who have an investment in maintaining normal practice and its status quo. You might say, ‘I believe in treating patients with dignity and compassion’ and believe your practice reflects that. However, on reflection you may acknowledge that your responses lack these qualities leading to uncaring behaviours what Jameton (1992) and Corey and Goren (1998) have labelled the ‘dark side of nursing’. So next morning you may set out to remedy this in your own practice and get criticised by other staff for getting too involved with your patients. The pressure is immediately put on you to conform to normal practice. You feel the creative tension and the difficulty in resolving it.
Authority and Power
One aspect of tradition is the way authority works through power. Power is embodied through socialisation processes and reinforced through everyday patterns of relating. Hence it is normal and largely unchallenged. Subordinates get told what to do. Play the game, do as you are told, keep your head down to avoid sanction, and then one day you too will gain authority with power over others.
Force is the negative aspect of power used to ensure people conform to certain ways of behaviour endemic within transactional organisations such as the NHS whereby people are subordinate to authority transmitted down through its hierarchy where power is invested in positional roles. Positional power is laced with a coercive threat of sanction if resisted (French and Raven 1968) that can constrain the practitioner from taking desirable action. This works at every level of the organisation. Hence those who exert power at one level have power exerted on them from a higher level.
Power is also invested in professional roles – so for example, doctors often perceive themselves as superior to nurses, coining the expression nurses are the ‘doctor’s handmaiden’.
It can be argued that nursing, as a largely female workforce, has been oppressed by patriarchal attitudes that have rendered it docile and politically passive and thus limits its ability to fulfil its therapeutic potential. If so, then realising desirable practice would require an overthrow of oppressive political and cultural systems. The link between oppression and patriarchy is obvious, considering the way nursing has been viewed as women’s work, and the suppression
