as the Achilles heel of medical dominance.
Loxley (1997) identifies a number of questions that are useful to inform stages 5 and 6 of ethical mapping:
Who defines the problem?
Whose terms are used?
Who controls the domain or territory?
Who decides on what resources are needed and how they are allocated?
Who holds whom accountable?
Who prescribes the activity of others?
Who can influence policy makers?
FIGURE 4.1 Ethical mapping (adapted from Johns 1999).
Anticipatory Reflection
Given a similar situation, how could I respond more effectively, for the best and in tune with my vision?
The practitioner asks
‘What are my options for responding differently, more effectively, and in tune with my values, given a similar situation?’ Is my vision still adequate in light of this past experience?
What are the potential consequences of responding differently?
How do those influencing factors need to shift so I can respond differently?
The cue opens a creative space to play with possibility and plant seeds of possibility in the practitioner’s mind (Margolis 1993). It is an invitation to throw open the shutters of the mind to see things laterally, to get out of our normal frame of reference and challenge our habitual ways of perceiving and responding to practice. It is like opening different windows in the mind to see things from new perspectives.
O'Donohue (1997, pp. 163–164) writes: ‘Through these different windows, you can see new vistas of possibility, presence, and creativity. ‘Complacency, habit, and blindness often prevent you from feeling your life. So much depends on the frame of vision – the window through which we look’.
Get curious! Responding to this cue may be difficult when the practitioner is stuck in a groove of habitual practice or lacks imagination to see the situation differently. Here guides and peers are most helpful to engender alternatives.
In weighing up the best response given a similar situation, the practitioner considers the potential short and long term consequence of each option.
Am I Able to Respond as Envisaged?
Yet, it is one thing to consider how to respond differently. It is quite another to act in accordance. The creative tension between vision and reality.
The practitioner must respond to four challenges:
Am I skilful and knowledgeable enough to respond differently?
Do I have the right attitude?
Am I powerful enough to respond differently?
Am I poised enough to respond differently?
Am I Skilful and Knowledgeable Enough to Respond Differently?
In envisaging more effective ways of responding the practitioner must see beyond their previous horizon of responses and ask whether their repertoire of responses is adequate and skilful enough. It opens the door to seek new skills and knowledge and challenge the appropriateness of previous ways of responding.
Practitioners tend to respond based on three criteria:
Responses they have used before.
Responses that have worked before.
Responses they are comfortable using.
These criteria reflect a habitual and unreflective practice that may not lead to desirable practice. Other ways may be more appropriate that the practitioner has yet to become aware of. It is a question of opening the mind to possibilities that requires humility that I might not always get it right.
Do I Have the Right Attitude?
Understanding and shifting our attitudes is not easy as often we are not even aware of them, buried as they are deep within ourselves. Research (Stockwell 1972; Johnson and Webb 1995; Trexler 1995) suggests that we are less likely to relate to people who are different from us for whatever reason epitomised in the phrase ‘the unpopular patient’. It is a fact of life and they must be confronted if we are to be truly person‐centred. Through reflection, we become aware of our attitudes and whether they are appropriate to hold in light of responding differently in tune with our vision. Attitudes such as racism are deeply embedded in society. Practitioners may aspire to responding to people with equality and cultural safety but making it a reality requires a massive radical shift that may seem beyond the individual healthcare practitioner. The challenge is to make a personal difference through one’s actions and, in doing so, confronting and influencing colleagues towards ensuring cultural safety can become a collective organisational reality. The time is currently ripe to stand up and voice this message. Perhaps wearing a ‘Black Lives Matter’ badge will help just as professional footballers are wearing this message on the backs of their football shirts.7 Practitioners can take the moral high ground and espouse what person‐centred practice really means in terms of equality and cultural safety.
Am I Powerful Enough to Respond Differently?
It choosing to respond differently may well disturb normal practice with consequences for working with others. Reflection is always an analysis of the way power works within practice notably the way it constitutes relationships. To respond differently may demand an assertive voice, whereby developing an assertive voice becomes a focus of reflection. Reflective tools such as ‘the assertive action ladder’ offer a step by step developmental approach (Table 4.3). The effective practitioner is an assertive practitioner and yet, in a culture where healthcare practitioners such as nurses are not expected to be assertive, asserting self may cause conflict. Yielding (step 10) is a strength, not a weakness. It is an awareness that pushing an issue may have negative consequences. Better to live and fight another day. Retreat with dignity with one’s integrity intact. Blackwolf and Jones (1996, p. 281) note:
Yielding is not passive. It is being sensitive to energy flows and extending wisdom. Allow the winds of change to flow through you rather than against you. Be flexible with what is happening today. Yield to the circumstance, yet rooted with who you are.
Reflection is always concerned with expanding one’s autonomy in order to respond differently. The practitioner weighs up the consequences and plans to succeed. Yet a warning – claiming autonomy to respond differently may challenge normal power relationships with other colleagues, especially those perceived to hold power over you with threats of sanction if you step out of line and forget your place within the system. Autonomy is a contested space that others will also claim the power to act especially where issues of authority are blurred. Reflection helps the practitioner come to appreciate the nature and scope of their power. Nothing gets changed if we afraid to act. In contemplating taking action to bring about organisational change, the practitioner must envisage her or himself as a change agent and become adept at change strategies.9