From Learning into Practice: A Reflective Process

Mary Daly, RN, MCNA (NZ)
           
Attendance at a workshop or course does not necessarily result in a change of practice.  It maybe a reaffirmation that your practice is current, but equally for practice to change there is a requirement for the individual to reflect upon the new information and how it relates to their own practice (Hillard, 2006; Newton, 2004).  For myself, the attendance at a Child Youth and Family (CYF) session organised by Kowhai Health (a PHO Management Trust) led me to reflect more closely upon the safety of the clients I see. 

This session focused on family violence, in particular the welfare of children and their families.  The session was presented in a non-judgemental way that showed a real passion and concern for not only children and young people, but also their families. 

Reflecting upon the high rates of child abuse in our community, I started to wonder if I was asking the right questions or looking in the right directions regarding family violence screening during my contact with the community.  Am I missing opportunities to help keep our clients safe?  Further reading on this subject suggested that my thoughts were correct.  As part of a report for the Families Commission, Fanslow (2005), on examining the literature surrounding family violence, suggested that family violence is greatly under-reported. 

I brought this information back to my workplace and discussed it with my Nurse Manager.  A discussion followed about the most appropriate way to incorporate family violence screening into our everyday practice.  I had been using an opportunistic approach, and some clinicians in my practice felt uncomfortable when asking questions about personal safety.  A decision was reached to use a peer review meeting for doctors and nurses within the health centre, as an education session for family violence. 

A large part of my role as a primary health care nurse, is working with older clients and their whanau to enable them to manage their lifelong conditions.  This comes under the Care Plus programme and puts me in a position of privilege.  Part of the initial assessment involves looking at social aspects of an individual’s and their whanau’s lives.  While the CYF session focused on children and young people, it highlighted the imperative need to ensure that safety was covered for all age groups, including older people. 

In New Zealand there is little literature on elder abuse, but statistics from the USA suggest that it is on the increase, and we should expect it here (Fanslow, 2005).  While I had covered this indirectly within the assessment, the need to be direct was emphasised.  I made a decision that a safety question would be added to the Care Plus template that I used on our computer programme, MedTec 32.  This would then act as a prompt, so when I was exploring a client’s social situation, support network, friends and family, it would be a reminder for me to ask about safety. 

The second decision I made was what question to ask, and how, and also in what circumstances would I ask it.  Age Concern discusses elder abuse and neglect within a wide context including physical, psychological, sexual, financial abuse, and active or passive neglect (Age Concern, 2006).  I gave some thought as to how this wide concept could be encompassed within the Care Plus programme.  The question I finally settled on asking was very broad - “Have you got any concerns about your safety?”  My reasons for settling with this broad and fairly non-specific question includes firstly, that I already explore a client’s social situation including family and friends, and this gives me an opportunity to discuss any concerns about neglect.  Secondly, signs of physical abuse may be identified due to visits to the clinic following injury, and thirdly, by keeping the question broad I have not limited the type of replies, which at times have been surprising.  Common replies include concerns about night time safety in the home, particularly by elderly women who live alone, and concerns about falling.  To date there has been no disclosure of any form of abuse. 

Reflecting upon this non-disclosure, I wondered if the question that I’m asking is appropriate.  Does the fact that there has been no disclosure to date mean that the question is wrong, or merely that clients do not perceive themselves to be at risk of abuse or neglect? 

Timing of the question is another consideration.  I tend to ask the question only if I am seeing a client individually.  My reasoning for this is a requirement not to inflame a potentially dangerous situation.  I encourage clients to bring family and friends with them to their Care Plus appointments and have a tendency to see couples together, or the very elderly with family members.  While this has the benefits of a more inclusive and broader assessment, it reduces the opportunity to check directly about safety. 

Client and professional safety underpins all aspects of my nursing practice, this being a basic right in the delivery of health care, and aligned broadly with the principle of ‘protection’ under the Treaty of Waitangi (King & Turia, 2002).  My view of protection and safety was highlighted as I reflected upon the CYF education session.  I initially felt uneasy asking a question directly about safety, as not having experienced abuse and or neglect on a personal basis, it was an uncomfortable experience.  Since then I have moved forward and now feel some disquiet when I’m not in a situation to safely ask the question.  This education session, along with my research into elderly people’s safety, has changed the focus of my nursing enquiry.  It leads me to think more broadly in terms of what constitutes abuse and neglect.  The adding of the question to the template has been a small but significant step in meeting my commitments to our community under the Treaty of Waitangi. 

This reflective process has raised more questions than answers for me and will lead on to further exploration and research surrounding keeping the older members in my community safe.

References:
Age Concern (2006) Age Concern New Zealand fact sheet on elder abuse and neglect. Retrieved November 15, 2006 from www.ageconcern.org.nz.

Fanslow, J. (2005). Beyond zero tolerance: Key issues and future directions for family violence work in New Zealand. Families Commission: Wellington.

Hillard, C. (2006). Using structured reflection on a critical incident to develop a professional portfolio. Nursing Standard, 21(2), 35-40.

King, A. & Turia, T. (2002). He Korowai Oranga: Maori health strategy. Ministry of Health: Wellington.

Newton, J. (2004). Learning to reflect: a journey. Reflective Practice, 5(2), 155-166.

Self Introduction

Mary Daly is a Primary Health Care Nurse who works in a large health centre in the Hutt Valley.  The main focus of her practice is working along side people with on-going health conditions, in particular diabetes.  She is in the final stages of completing her Clinical Master of Nursing through Massey University.