Hi Belbab - here's the essay, courtesy of Mrs Clam
Use a model of reflection in an elementary way to reflect on practice
Reflecting on practice is not a new concept, but within midwifery education the importance of reflection has become increasingly emphasised. Reflection has been described as a learning tool (Clarke, 1986) and a way of aiding integration between theory and practice. Student midwives undertake supervised educational training in clinical placements and due to the characteristics of the work will regularly encounter new, complex and challenging circumstances. To both understand the art of reflection and develop the ability to reflect results in learning being enhanced. Indeed some theorists, (Benner, 1984, Champion, 1991) have suggested that for learning to occur from experience, reflection is vital.
In this essay I will use Gibbs (1988) reflective cycle to support my reflective process. A copy of which can be found in appendix A. This is a commonly used model and the one which I felt most appropriate for this essay. As a first year midwifery student currently on my first clinical placement, I will be reflecting on an event which I observed. I have chosen an experience, which for me, was incredibly emotive and raised many issues and was therefore appropriate and necessary for me to reflect upon. The experience involved my mentor discussing a birth plan with primigravida lady at thirty-six weeks gestation, who in accordance with codes of confidentiality (NMC, 2002) I will call Mary.
Where I am currently gaining community experience the birth plan is usually discussed and written with the mother at her home around thirty-six weeks gestation. The birth plan can be described as a list of the mothers’ preferences for labour, birth and postnatal care (
I had no prior information regarding Mary except that she was thirty-six weeks pregnant and the purpose of this home visit was to discuss her birth plan. As this was not my first experience of this I expect I had some preconceived ideas about what the visit would entail. Mary invited my mentor in and had no objection to a student being present.
Firstly my mentor asked Mary if she would like to write the birth plan herself and turned to the appropriate page in her antenatal notes, to which she declined and said she would prefer a midwife to write it. I did not think that this was unusual as I had seen other ladies ask my mentor to write the plan.
However, as my mentor began to go through the sections on the birth plan (see appendix B) Mary’s responses to every part portrayed disinterest. Responses included, “I don’t care”, “I don’t really mind”, “I haven’t thought about it” and “what does everyone else do” followed all of my mentors’ questions. Mary admitted she had not read any of the information that had been given to her and she had not attended and did not want to attend any antenatal or parentcraft classes. I noticed that her non-verbal communication was closed. Mary tried to avoid eye contact and sat in a manner that suggested she was uncomfortable with discussing anything.
As my mentor continued to progress through the birth plan Mary became increasingly distant and this appeared to worsen whenever my mentor offered explanations of the terminology. An example of this was when my mentor explained what is meant by the third stage of labour and the choice between active or physiological management. Mary interrupted my mentor saying that she didn’t mind which she had even though my mentor had not had the chance to continue giving all of the information.
After all the sections of the birth plan had been mentioned, all that Mary had actually decided upon was that she wanted her partner or mother with her and that she would like to try and breast feed. Next to every other section in the birth plan, my mentor could only write ‘discussed’. To conclude this visit, Mary was asked if there was anything she was concerned about or if she had any questions, to which she shook her head and said, “No”. Upon leaving her house my mentor commented that it had been one of the quickest birth plans that she had ever done.
These events that I had observed evoked many mixed feelings. My initial reaction was one of frustration. It seemed ludicrous to me that a woman would not be interested in what happened to her during labour and birth. As Mary said that she had not read any information or attended any antenatal classes, my feelings changed from frustration to concern. I began to worry about how unprepared she is and any repercussions this might in turn have for her newborn baby; if she had no knowledge of labour and birth, did she have knowledge of how to care for a baby?
Following this I began to feel guilty. Perhaps I was being too judgemental. I knew that I was probably biased, not only because I had seen other mothers actively write a birth plan, but also because I am a mother of three children and knew that I wrote several birth plans when pregnant to cover all eventualities! In addition, I had read about the importance of birth plans and am a firm believer in empowering women. I was aware that this could have given me an altered view of the situation.
Nevertheless, I was worrying about why Mary was uninterested and why her responses were so indifferent that she almost appeared apathetic. This was supposed to be a time when a discussion could occur and she could make informed choices concerning her body and her baby, but I could see that the more information given to Mary, the more withdrawn she became, and the more frustrated and concerned I became.
Succeeding recognition of my feelings, I began to evaluate them. Firstly I felt angry that we had not done more to help her by alleviating any fears or by spending more time with her. She still seemed completely unprepared for labour and birth, and importantly did not want to be prepared and I felt that we should have tried to find out why. I decided at this point that the best thing I could do was to trust the instincts of my mentor. She did not seem unduly concerned and obviously had years of experience within the community and I supposed it was not uncommon. Again, I knew that I was perhaps having a biased opinion of the situation coupled with my naivety as a new student that was clouding my judgement.
Writing a birth plan is a significant part of midwifery care. It gives the midwife the opportunity to explain all of the terms and the research or evidence base underlying the woman’s options, especially with areas that the woman may be unfamiliar. In addition it allows time to discuss any particular concerns or fears that the mother might be experiencing.
In turn, it gives the mother the chance to express her choices and preferences for labour, birth and aftercare. This clearly encompasses issues surrounding informed choice where there has been much emphasis and legislation so as to ensure that women can exercise choice in their delivery of care (Bennett, 1999). However, formulating a written birth plan goes beyond a simple list of desires. Price (1998) suggests that writing a birth plan has an important role in preparing the mother emotionally and mentally for labour and birth. Further, it can empower the woman, making her feel more in control because she has actively participated in the decision making.
Similarly, the birth plan ensures that health professionals at the woman’s place of birth understand her wishes. On admission of the women in labour it is common practice for the named midwife to discuss the birth plan so that provisions can be made for her. Knowing that everyone involved in the labour and birth understands her preferences can give comfort to the mother, especially as this is a time when she might be feeling vulnerable or distressed.
I decided to use this experience and my personal feelings as a learning process and a way of developing my own self-awareness. Burnard (1992) proposes that being self aware is being conscious of personal beliefs, strengths and limitations and that self awareness is important, not only for reflective learning, but also for professional practice. I have learned that it is vital to be aware of my own beliefs in order to progress both in my learning and within my profession.
However, I could not see any definite good that had come from this experience for Mary and began mind mapping why she possibly felt the way in which she did, or the way in which she portrayed. Continuing with Gibbs (1988) reflective cycle, I next tried to analyse the feelings and the experience and attempted to make sense of the situation.
My first thought was that Mary was scared, either of something specific or of the labour and birthing process generally. This could offer an explanation to why Mary had not attended parentcraft classes or looked at any of the information that had been given to her. Perhaps, as seems common, other mothers had shared their birth stories with her and this could have frightened her. Fear of childbirth is common and a recent survey (Zur, 2002) stated that three quarters of women who participated were anxious and eighty per cent of women were frightened of giving birth. However, it must be mentioned that this survey could have had a biased sample.
Although labour can be a frightening experience, some of this fear is provoked by fear of the unknown. Information given by midwives could alleviate this fear. When discussing birth plans, midwives have a responsibility to give full explanations of procedures to ensure that expectant mothers can make informed decisions. Difficulties arise when expectant mothers would rather not know. For some mothers, ignorance is bliss and they are confident to let their midwives take the lead.
There are many other explanations why Mary behaved the way she did. She might believe that birth is a natural process and having too much information of what may happen would give her unnecessary worry. The concern here is that if something unexpected does occur during labour Mary would not understand what was happening and this can be awfully distressing. Again, there can be a feeling of loss of control (Raphael-Leff, 1991), which can have long term effects and is deemed to be a precursor to postnatal depression.
It could be that Mary is a very private person who does not feel able to mix at a parentcraft class and whom did not feel completely comfortable with her midwife being in her home. Despite research (McCourt and Page, 1996) finding that the majority of women enjoy home visits, others do not and possibly Mary falls into the latter group. Mary may have found the home visit intrusive or felt that we were prying or evaluating her and making judgements based on her home. Perhaps literacy is a problem for her. This could explain why she had not read any information and why she asked the midwife to write for her.
Following the analysis of the experience, I moved on to the next part in the reflective cycle and considered what else could have been done during the home visit with Mary. It seems fair to say that by asking if she had spoken to other mothers, it might have encouraged her to talk about what she had heard and in turn these fears could have been alleviated. Perhaps it would have been appropriate to mention again the parentcraft classes and tours of the local maternity hospital that are available to her so that she might feel better prepared.
When discussing the purpose of the birth plan, it could have been beneficial to explain that the hospital staff will want to read it upon her admission and it is therefore important that they understand her preferences. A more direct approach might have been acceptable. To ask the question why she had no preferences for childbirth could have been the invitation necessary to tell her midwife how she was feeling. An alternative angle would be to talk about the baby and her expectations of motherhood as a way of achieving conversation before bringing the discussion back to the actual labour and birthing process. This would also address the issue raised that if Mary was unprepared for birth, was she prepared for and did she have the knowledge necessary to care for a new baby?
In addition to the issues that have already been raised, it does appear that changes could be undertaken if a similar situation occurred. The midwife should be aware of any problems, not just socially or physically, but also have the insight to detect any psychological anxieties or fears that the client is experiencing.
Information should be given during pregnancy and any concerns discussed. Similarly, parentcraft classes should be encouraged. It has been detailed (Alexander et al, 1990) how antenatal classes increase women’s understanding and makes them better prepared for events. Parentcraft classes also help women meet others in a similar situation, which alone can be of psycho-social benefit.
When making the actual appointment for discussing the birth plan it might be preferable to give the expectant mother the choice of a home visit or making extra time at a routine antenatal appointment. The midwife could also suggest that if they haven’t already done so, to read and note down any ideas, preferences and questions that the woman has concerning labour and birth and to look at the birth plan in their notes.
Undoubtedly there are going to be expectant mothers who do not want to prepare or discuss a birth plan for whatever reason. If this is the situation, the midwife could use the pre-booked time to discuss other issues and attempt to strengthen the midwife-client relationship. This could possibly lead to the mother feeling able to communicate about any concerns during future home visits such as during the postpartum period.
Although this essay has been a reflective exercise, it has drawn upon many aspects of midwifery that raise ethical issues. For example, the ethical principles concerned with informed consent requires giving information. However, Johnstone (1989) recognises that some clients do not wish to receive information. It is useful within clinical practice to use ethical frameworks and theories such as Edwards (1996) in which judgements, rules, principles and ethics are adhered to in order to assist the midwife with facing dilemmas.
In conclusion, the process of reflection within midwifery brings with it a deeper understanding of what can often be complex and challenging situations. If midwives are to deliver a holistic and personal pattern of care, then individuality must be accounted for and respected. Using models of reflection means appreciating and accepting each experience which often leads to a different perspective. For some women ignorance is bliss and for others knowledge is power. It is important that midwives recognise that within their framework there are vast differences, as each individual woman, pregnancy and birth is different. On a personal level, I have been on a steep learning curve whilst writing this essay and have not only learned about issues that arose, but also developed my self awareness and my ability to see beyond the immediate and the observable.
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