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The challenge of providing family-centred care during air transport: An example of reflection on action in nursing practice

Brenda E Hewitt
Master of Nursing student, Dalhousie University, Halifax, Nova Scotia, Canada

Abstract

This article explores reflection with regard to the nursing practice of a transport nurse in caring for ill newborn patients and their family. It examines the issue of reflective nursing practice, institutional obstacles, and angst in promoting the model of family-centred care, as it applies to newborn infants being transported for tertiary care to a hospital some distance away from the family's home community. Reflective practice is explored as an epistemological link between practice and research, locating one nurse's clinical experience in reflection and subsequent action, through clarification of thought-provoking issues and generation of research questions.

Keywords

transport nursing, reflection, family-centred care, rural nursing, childbirth

Article Text

Reflection has been touted in nursing literature for its potential to enhance professional development, promote critical thinking, lead to heightened self-awareness, contribute to learning and enhance patient care (Cotton, 2001). Reflection provides a forum in which practitioners can view experiences "by systematically exploring meaning and applying new insights to new situations within a reflexive spiral of being to become an effective practitioner" (Johns, 2001, p. 237). In paying attention to and exploring subtle meanings in everyday events and interactions, a new understanding is revealed. This, simply stated, is reflection. Reflection on professional experiences has the potential to reveal a deeper understanding of the problematic issues, which merit further study in the form of research. Thus, closing the gap between the intuitive behaviours of practice and professional knowledge grounded in rigorous discovery (Tomlinson et al. 2002). The process of reflection has the potential to encourage the reframing of a clinical circumstance, to name the issues, and to delineate an area for inquiry though research.

Genesis of reflective professional practice

Reflection in practice is not a new concept. Newell (1994) pointed out that introspective examination of daily activities and the moderating of future action predates the practice of religion. Philosophers Dewey (1933), Freire (1972), and Habermas (1972) each discussed the concept and activity of reflection, and heavily influenced the work of educational theorists, such as Donald Schön. Schön has been credited over the last three decades with bringing the concept of reflection in professional education to greater prominence (Atkins & Murphy, 1993). Subsequently, discussions about reflection in professional practice have become increasingly popular in professional nursing literature (Hannigan, 2001). Essentially, the work of Schön (1983, 1987) has brought the idea of learning through reflection on action and experiences to the forefront of the literature on professional learning, though he was not the first to write about reflection and professional practice.

Schön (1983) suggested that knowledge informing professional practice is broad, multi-faceted, and frequently difficult to articulate. Clarke, James & Kelly (1996) comment that Schön explained that the difficulty in describing professional practice is that daily reality of professional practice is more complex than the sole use of specialized skills. There is a tacit type of knowledge held and exercised by experienced professional practitioners, which eludes verbal communication. Essentially, professional practitioners base their practice, in part, on previous experiences in a particular situation; this process is known as reflection in action. In doing so, the practitioner possesses knowledge in action.

Learning by reflection in and on action: Link to research?

In the nursing literature, reflective practice, its meaning, merits and downfalls are fodder for much discussion (Atkins & Murphy, 1993; Cotton, 2001; Hannigan, 2001). The timing and tense of reflection and of actions are meaningful in locating whether the reflection occurs simultaneously or in hindsight of a nursing practice event. Clarke, James and Kelly (1996) describe Schön's view; they reiterate that in reflection in action "there is no stopping to think; acting and thinking are fused" (p. 174). Essentially, practitioners think about what they are doing while they are carrying out an action. In these situations, knowing and doing are inexplicably intertwined.

Reflection on action for nurses can occur following a clinical situation, as well as outside the reflection which occurs during the moment of taking action in practice. As Cotton (2001) explains, reflection on action occurs after the meaningful event and allows the practitioner to review, describe, and analyse the situation, in order to gain insights for future practice. Newell (1992) describes reflection in and on practice as reconstructive processes, wherein one revisits her behaviour in a particular act. Acknowledging that there is some degree of bias in hindsight, events, thoughts, and feelings are revisited (Jones, 1995). Reflection on action is frequently part of clinical education for nurses; its goal being to facilitate learning (Hannigan, 2001). Conversely, I will give an example of the development of a research focus through reflection on practice experiences. Personal reflection on experience in practice can link reflection to the genesis of a research idea. This linkage of reflection to research question is not as clear in the nursing literature as the link of reflexivity in the research process, which generally describes the action of the researcher to exploring personal values and beliefs around an issue. Therefore, reflection on action to conceive research topic is not to be confused with reflexivity in the research process.

Reflexivity has been described as thoughtful, conscious self-awareness (Finlay, 2002). Actions to explore reflexivity, such as journaling, are "a method embraced by feminist scholars as a way of situating themselves within research through reflection upon the research process, and reflection upon how they themselves are affected by that process" (Walter, Glass & Davis, 2001, p. 269). By explorating their reflexivity, the researcher locates themselves in the process of qualitative inquiry, they are situating themselves by delineating personal beliefs and experiences relevant to the research process.

Essentially, qualitative inquiry involves both interpretative and material research practices, which reveal the subjective nature of world (Denzin & Lincoln, 2000). Qualitative researchers study society, people, and events in their natural setting, attempting to make sense of, or to interpret social phenomena, while considering the meanings held by people about these phenomena (Denzin & Lincoln, 2000). Perhaps the espoused subjectivity of the researcher refutes the merit of reflection an inception for integrity and trustworthiness in discovery? It can be argued that the process of reflection on action brings forth the essence of the individual subjective experience, so championed by qualitative investigators (Morse, 2002).

Learning though reflection on practice facilitates the acquisition of new insights for professional nurses and topics for future inquiry. Inherently, participation in reflection implies a certain amount of willingness of the individual. This does not indicate a deficit in professional knowledge and practice, but a desire to address the conflict or contradiction between desired outcomes, professional and personal values and beliefs, and the everyday constraints of nursing practice (Perry, 2000). Viewing patients, their important social attachments, and their environment more completely is inherent in thorough reflection on clinical events (Paget, 2001).

Tomlinson and collegues (2002) reiterate that reflective learning, and I suggest reflective writing guiding the inception of a research process, reframes a problem through language. The reflective process enables inquiry to occur, in order to describe and to appreciate the consequences of current and potential activities. Through the action of research, the nurse explores issues of angst and works to understand and work to ameliorate the lives of their patients.

A nurse's narrative: Reflection on experience

Using reflection has helped me to reshape my understanding of a clinical situation, as well as the nuances and complexities of my role in that situation. The story that follows below is an attempt to explore a clinical challenge, thus developing a deeper understanding of my role and action in it. The clinical situation I reflect upon is not a single event; it is a story of the culmination of various similar experiences. I have had dozens of experiences very much like the one I describe next for the reader. To help the readers understand the context of this clinical example, I will provide some details of the setting.

I practice nursing as a transport flight nurse with an emergency care system, which serves a geographically diverse area in eastern Canada. One branch of the air ambulance programme focuses on the urgent transport and care of critically ill infants and children. As part of a rapid response programme, the infants and children who require urgent transport are retrieved from remote locations and regional health centres by a team comprised of a critical care nurse and a respiratory therapist. We usually travel by helicopter, flown by team of two pilots. Additionally, travel by fixed wing plane and ground ambulance is not uncommon, though the majority of our evacuations are done travelling by rotor wing aircraft.

Much of the population in this area of eastern Canada is spread out over the rural areas. Though infant births occur in many hospitals throughout these provinces, mothers who have serious health problems or complications relating to their pregnancy are brought to a regional health centre for the delivery of their baby. Sometimes, there are unanticipated complications at the time of the baby's arrival. It is at these times when, we, as members of the air ambulance team, are called to assume care of the infant and transport them to the tertiary care facility, where specialized care of critically ill or premature infants is available.

In these occasions, my partner for the day and I are requested, through the provincial emergency dispatch system, to fly to a health facility some distance away. After compiling the necessary equipment, we depart without delay from our air ambulance base by helicopter. Flying times to the regional health centres can range from 20 minutes to more than an hour. This is an opportunity for the team, a critical care nurse and a respiratory therapist, to mentally prepare and to organize our on-board equipment to care for the ill young patient we will soon meet.

After our arrival at the referring health centre, the air medical team works with the local staff to care for the small patient and his or her family. Our role is to work cooperatively and efficiently to stabilize the newborn and prepare them to travel in the helicopter. Ultimately, the infant will receive care at the newborn intensive care some distance away. Time passes during which my partner, a respiratory therapist and I, a critical care nurse, perform necessary procedures to treat the baby's physical health issues and prepare the small patient for the journey to the health centre by air. During this time, our work could involve multiple procedures necessary to stabilize or ameliorate the baby's condition, including performing endotracheal intubation and other ventilatory interventions, placing intravenous lines peripherally or through the umbilicus, and giving medications.

Sometimes, our work is observed by parents or other members of the baby's family. Their visits are usually brief: fleeting glances or short visits. The family is curious, but usually want not to observe the care being given to the baby. Perhaps they want to ensure that we are not encountering complications, or to check on how soon we will depart. As a team, we reassure parents that they will visit with their new baby prior to our leaving and there is no danger that we will depart without their knowing. Yet, they can't help but keep checking on their baby and our work.

During this time, the family's emotions are intense. Most times, complications with the new baby were not anticipated. This time, which was expected to be a joyful climax, followed by elation, rest, and bonding, is filled with uncertainty and distress. The parents are filled with questions: What has happened? Will the baby survive? How long will the helicopter ride take? How soon will they be reunited with their baby? Will he or she have lasting effects of the complicated entry into the world? These are a few of the questions I have been asked by parents. Answers to some of the questions are clear, while others generate uncertainty for all involved.

I feel the greatest angst in these situations over the separation between new babe and parents. The nature of our aircraft, equipment required for transporting a newborn and aviation restrictions prevent us from being able to transport a member of the family, along with the baby. If a father is part of the family configuration, we encourage him to stay with and to support the new mother. The mother, having recently gone through childbirth, is rarely fit to travel. In this regionalized health care system as it presently exists, the baby must be transported separately from family members, forced to be separated from his or her parents in order to receive life-sustaining treatment. Essentially, the alternative to separating the family is to leave the ill baby behind, where in most circumstances the local health care personnel are not able to sustain curative care of the infant over the long term.

Family-centred care

It is important to further explain my standpoint of forced separation of family members in this narrative with a description of the health care philosophy of family-centred care (FCC). FCC has become the prevalent care philosophy to the care of ill children, infants, and their families. The family-centred care approach has come to increasing prominence as a goal in many health care settings, especially those focused on the care of infants and children. FCC is a holistic model of caring, which strives to fully involve families in all aspects of the care of their infants and children in a respectful and supportive manner (Bruce et al. 2002). Inherent in this approach is the understanding that the illness of a family member adversely affects other family members. Likewise, the family can play an invaluable role in an ill young patient's recovery.

Reflecting on the narrative

The nature of the narrative I have written is more descriptive of typical events in my practice and less reflective of practice decisions and actions, than would be requested by many advocates espousing reflection on action. I share with the reader a clinical situation, which causes me to feel a degree of malcontent. Indeed, recounting this situation in a descriptive narrative has led me through and illuminated for me a self-guided internal dialogue of my feelings and opinions about forced separation of parents and their newborn babies. It is a situation germane to the regionalized nature of tertiary health care. It is the product of a system which, at least for a short time, prohibits care of the family as whole, the very philosophy the system espouses! The family is certainly reunited within days, but timing of the reunion is determined by various factors including the mother's health, family resources, ability to arrange transportation, and making necessary arrangements for the family home they will vacate to be with their ill baby. As a result, physical family unity is temporarily interrupted at a time when it may be most significant, that is, during the health crisis of its most vulnerable member.

Private thoughts in public spheres?

Reflection can focus on technical aspects of practice, practical aspects of practice, self-knowledge, and on socio-political context of practice, as suggested by Clarke, James and Kelly (1996). Self-exploration is integral to my reflection on the clinical challenge, though I have not been particularly revealing of my emotions in the narrative. Self-exploration affords a heightened understanding of personal qualities and attributes I might bring to professional practice. In this way, I have a greater appreciation of my role in changing the experience of families in crisis within the social, political, and economic aspects of an environment that prevents them from being together during a time of crisis.

I have chosen to recount an experience and, in doing so, to personally recall my place in those experiences. I have purposely chosen to personally reflect on this clinical circumstance, while conveying an inkling of my personal angst. Cotton (2001), in challenging the hegemonic approach to reflection; cautions exposure of nurses' personal reflections to public scrutiny (also in Finlay, 2002). It may be relevant to nurses currently practicing to appreciate diverse perspectives taken in and on reflection and to use those reflective skills they feel are most relevant to them. Being mindful of the power relationships and reflecting on them propels the nurse into a heightened understanding of her current and potential role within challenging clinical situations.

Summation

Writing this narrative for reflection has been personal reflection on action. In exploring the subtleties of this recurring situation, I have gained a deeper understanding of my professional role and a more holistic appreciation of our patients and their families. Our local health care institutions aim to preserve life and improve wellness, yet this is a long-term goal. In the short term families in crisis are separated. The challenge for me lies in communicating in a way that fosters hope, pride, and a connection between the imaginings of the baby that the parents were hoping for and the ill infant in front of them, to make a connection, between the baby who will be air-lifted away and the baby whose arrival has been idealized in their minds for months. In paying attention to and exploring subtle meanings in everyday events and interactions, a new understanding is revealed. These are the stages of reflexive learning delineated by Schön (1983): conscious reflection, criticism, and action.

Reflecting on the area of proposed research and my motivations, assumptions, and interests relating to this topic are essential to the integrity of such an investigative project. Reflecting on action, as Schön suggests, has facilitated personal, experiential learning with regard to clinical practice with families in crisis. This deeper appreciation of the family in crisis has fostered the development of an impetus to explore the lived experiences of families of ill newborn babies who require urgent air evacuation. The action component of reflexive learning described by Schön is forthcoming; I am drawn to investigate means to further understand, to describe this phenomenon of forced separation of family members and to potentially ameliorate the care that these families of air-lifted newborns receive.

Acknowledgement

The author wishes to acknowledge the wise advice and editorial assistance of Dr. Barbara Keddy in the development of this article.

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