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Securing the oral tradition: Reflective positioning and professional conversations in midwifery education
Collegian (2008) 15, 109—114
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Securing the oral tradition: Reflective positioning and professional conversations in midwifery education Diane J. Phillips, RN (Midwife), BApp.Sci., MEd., DEd. FRCNA a,∗, Barbara A. Hayes, RN (Midwife), BA (Hons.), M.Sc., DNSc., FRCNA b,1 a
School of Nursing, Faculty of Health, Medicine, Nursing and Behavioural Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia b James Cook University, School of Nursing, Midwifery and Nutrition, Townsville, QLD 4811, Australia Received 20 April 2007; received in revised form 24 August 2007; accepted 24 September 2007
KEYWORDS Reflective positioning; Professional conversations; Midwifery
∗ 1
Summary We postulate that positioning is a powerful tool in guiding and transforming student professional learning and practice development. In our experiences with students enrolled in the Graduate Diploma of Midwifery, we determined that positioning elaborates individual scholarship and identity formation of the learner midwife in practice settings. Positioning Theory, developed by Harr´ e and other authorities, is a psycho-sociological ‘ontology’ or concept of how individuals metaphorically position or locate themselves, and others, within institutions and societies. Three key components of positioning theory include ‘position’, ‘speech act’ and ‘storylines’, developing from the everyday social interactions of professional conversations. Reflective positioning can be applied as an analytical tool for the moment-to-moment exchanges inherent in practice related conversations, occurring between midwives and midwifery students. These moment-to-moment interactions of professional conversations can be used by students to complete or fill their learning gaps. Positioning therefore, provides a novel, contemporary theoretical framework to ‘unpack’ or understand the complexity of midwifery practice and yet is complementary with reflective practice. Excerpts are used to demonstrate reflective positioning applications by students. Midwives are encouraged by health services and by the University to provide student support through a ‘preceptorship’ program to supervise, work with and assess students for competence in midwifery practices. We claim that reflective positioning by students within professional conversations with their preceptor/midwives, are the construction sites for learning and where identity formation of each student as a future midwife is both shaped and transformed. Both academics and managers of health services need to embrace the value of workplace conversations, the sites of rich oral traditions of nursing and midwifery. Thus, in seeking claim to our rich oral traditions, all students will benefit
Corresponding author. Tel.: +61 3 9244 6119. E-mail addresses: [email protected] (D.J. Phillips), [email protected] (B.A. Hayes). Tel.: +61 3 4781 5340.
1322-7696/$ — see front matter © 2008 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.colegn.2007.09.002
110
D.J. Phillips, B.A. Hayes from engagement in reflective positioning to promote their professional learning and practice development. © 2008 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Introduction Reflective practices have served both midwifery and nursing well, but it is now time to move on, by accessing the innate oral traditions of both midwives and nurses further. This theoretical paper on reflective positioning and professional conversations in midwifery education has been developed from our experience with students enrolled in the Graduate Diploma of Midwifery at a University in Victoria. The application of positioning is deeply embodied and embedded in the context of conversations and it is within these conversations that the persona of each student emerges as an individual being. In the enactment of positioning within the momentto-moment interactions of professional conversations held in midwifery practice settings, the very different and unique requirements of each individual student’s knowledge and practice development becomes apparent. While positioning is separate from that of reflective practice, both approaches employ similar skills such as analysis, critical thinking, interpretation, evaluation and synthesis: all cognitive skills required for higher thinking level abilities. Students are encouraged to be active agents in their learning by assuming responsibility for their psychosocial determinations within the social cultural world of professional midwifery practice by ensuring for example, satisfactory completion of both academic and practice requirements of the course. The practice requirements include those of the curriculum and for those of the legislating authority, the Nurses Board of Victoria, where each graduating student applies for the additional qualification of ‘midwife’, Division 1 register. Health services undertake the development of rotational rosters for students so that they work with their preceptor/midwife in midwifery practice settings and where conversations are innate. The notion of ‘preceptorship’ is principally drawn however, from Benner’s model of skill acquisition for nurses (Benner, 1984; Benner, Tanner & Chesla, 1996). Benner (1984) pioneered research into the knowledge base of nursing and midwifery developed from their conversational reflective practices. Preceptor/midwives provide supervision, support and assessment of their students for competence in practice. These activities are supported through reflective positioning within the moment-to-moment interactions of professional conversations in practice settings to influence professional learning. Sources such as CINAHL, Academic Search Premier, Science Direct, PsycINFO, Expanded Academic ASAP, ERIC and Medline were used with key words such as ‘positioning theory’, ‘conversations’, ‘discursive analysis’, ‘midwifery education’, ‘education’, ‘midwifery curriculum’, ‘reflective practice’, and ‘student supervision’. In addition, manual searches were conducted within book chapters written by the positioning theory authorities. These searches were fun-
damental for the conduct of a critical critique of literature related to elaboration of professional learning and practice development.
Positioning theory Positioning theory was developed by the contemporary philosopher, Rom Harr´ e, who developed this psychosociological ontology from the positions and gender differentiation by Hollway in the 1980s (van Langenhove & Harr´ e, 1999a). In addition, the constructionist psychology theories used to underpin positioning theory have been drawn from the work of, for example, Wittgenstein (mind and language) and Vygotsky (thought and language) (Davies & Harr´ e, 1990; Gillett & Harr´ e, 1994; Howie & Peters, 1996). Harr´ e has undertaken collaborative work with other positioning theory authorities such as Luk van Langenove. A ‘position’ is a metaphorical term to describe how an individual positions or locates themself within three social entities of ‘people’, ‘institutions’ and ‘societies’. Harr´ e and van Langenhove (1999a) argued that the discursive nature of conversations, conducted either privately or publicly, do occur within these three entities. The application of the word ‘position’ brings attention to interpersonal encounters rather than of a ‘role’ (Moghaddam, 1999). Harr´ e and van Langenhove (1999b, p. 196) supported Moghaddam’s claim, stating that ‘‘adopting or being assigned a role fixes only a range of positions, positions compatible with that role’’. The notion of ‘position’ in an institution or society has a more fluid connotation in regard to participation in conversations (Davies & Harr´ e, 1990; Gillett & Harr´ e, 1994; Tan & Moghaddam, 1995; van Langenhove & Harr´ e, 1999a). Davies & Harr´ e (1999, p. 37) explained that positioning ‘‘. . . is the discursive process whereby people are located in conversations . . .’’ and where there are jointly produced storylines. The concept of positioning is manifested by a certain set of rights, duties, and obligations by the individual who is presenting the story line within the speech act of a conversation (Gillett & Harr´ e, 1994; van Langenhove & Harr´ e, 1994). The importance of local moral orders or obligations, implicit within social structures and interactions, are manifested through the speech acts of conversations identified as the construction sites of personal identity formation (Davies & Harr´ e, 1999; Gillett & Harr´ e, 1994; Harr´ e & van Langenhove, 1999a; Moghaddam, 1999; van Langenhove & Harr´ e, 1999b). van Langenhove and Bertolink (1999) argue that social constructionism is fundamental for the generation of social phenomena developed through conversations. As such, conversations are considered to be the place where many, if not most, psychosocial constructions are jointly created (Harr´ e & van Langenhove, 1999a). Positioning theory
Securing the oral tradition focuses on understanding how psychological phenomena are produced in the moment-to-moment interactions of conversations. This means that positioning enables a study of the relationships between the participants (such as the preceptor/midwife and student) as well as the rich detail emerging from conversations. Even the subjective responses that occur from a single fleeting moment of an interaction between individuals are considered as invaluable opportunities for positioning (Winslade, 2005). Positioning is promoted by van Langenhove and Harr´ e (1999a) as an effective tool for the analysis of every day language used in the professional conversations.
Language and conversation Davies and Harr´ e (1990) stated that language is a public institution and is the foundation upon which social structure and interactions are developed. Further, language is referred to as either a social or illocutionary force (utterances) of speech acts. Midwives use their own language which is easily recognised by colleagues, quickly embraced and enacted by students but often very confusing for those outside of the discipline. The act of positioning involves a reconstruction of articulated biographies related to the individual being positioned and of the positions that may be subject to rhetorical re-descriptions. The following three methods assist in the expression of personal identity within conversations: (a) Agency (assuming responsibility); (b) making a statement on the point of view; and (c) evaluating a past event, as a contribution to one’s biography (Harr´ e & van Langenhove, 1999a; Howie & Peters, 1996). Position, storylines and relatively determinate speech acts are three key factors inherent within conversations, and play an influential part in human behaviour (Harr´ e & van Langenhove, 1999a; van Langenhove & Harr´ e, 1999a). Conversation is considered to be a central concept in the theoretical development of social constructions where powerful influences such as psychic and social phenomena must be acknowledged. In addition, factors that should be considered when engaging in conversations include history, culture and social differences that are individually unique and requiring thoughtful, sensitive negotiation by others (Carbaugh, 1999; Berman, 1999; Moghaddam, 1999; Sabat & Harr´ e, 1999; Tan & Moghaddam, 1999). Moral orders or obligations are upheld within conversations through the application of metaphors and images (Howie & Peters, 1996) to facilitate conversational positioning according to the ‘rules’ of people, speech acts and storylines. These rules are applied as descriptions on how to operationalise the range of possible responses that are unique to participating individuals within specific situations, language and communication processes (Gillett & Harr´ e, 1994). Howie (1999) emphasised the relationship between moral capacity to position another individual and skill applied to undertake this effectively. Both midwives and nurses in their everyday practice face unexpected and major ethical dilemmas such as the care of the sick or dying newborn infant or the indigenous woman and her family whose cultural beliefs are dismissed as inconsequential in the pro-
111 cess of childbearing. If the rhetoric of caring is applied in practice it is essential that variables such as the individual concerned, situation, intended outcomes and issues associated with power and parity are consciously incorporated (Johnston & Kerper, 1996). Interactive positioning can occur, but generally positions are relational. For example an individual, such as a preceptor/midwife, is positioned as powerful whereas students may be positioned less powerfully. Davies and Harr´ e (1999) cautioned that it is an error to assume that positioning is only intentional but rather dependent upon the situation an individual finds themselves in and how they manage. Conversations frame the social world of midwifery practice and midwives, as cultural agents, enact and embody cultural ideological resources and institutional rules and regulations to uphold safe practices. The disciplines of midwifery and nursing both possess a very strong oral tradition which is essential for effective practices. An important component of midwifery practice is information exchange (McKenzie, 2004) conducted through professional conversations and where midwives are ‘agents’. Through the notion of ‘agency’, midwives in their function as preceptors engage in professional conversations with students and, in doing so, create institutions through structures. Structures include institutional behaviour and dynamics that influence the structure of each student’s psychology through rules, policies and procedures to influence their professional identity formation (Phillips, 2002). Examples such as time and place for meetings and who initiates the meetings between the preceptor/midwife and their students reflect this reality. It is within conversations that the construction sites of professional learning for students enrolled in a Graduate Diploma of Midwifery emerge. It is well known and understood by midwives that practice settings are prominent strongholds of professional support and socialization, of which conversations are the cornerstone. Students frequently report to academics the impact of their conversations with midwives and how their professional identity formation as a student of midwifery is shaped and transformed due to this influence (Phillips & Hayes, 2006). In midwifery practice settings, conversations related to the delivery of care are ongoing, dynamic and essential for each woman’s care. Parker and Gibbs (1998, chap. 7, p. 85) provided an eloquent description of a midwife being a ‘social actor’ in the context of midwifery’s position in Western medical science. Such descriptions focus on the centrality of the midwife and project the importance for socialization in professional practice. One of these responsibilities is the sharing of information through professional conversations, enhanced by midwives positioning themselves to ensure that colleagues have appropriate comprehension of each woman’s care. The word ‘position’, therefore, takes on a specific meaning in regard to differing standpoints such as a personal one as opposed to membership of a group and where the position of the group is upheld over an individual stance.
Social world Harr´ e and van Langenhove (1999a) viewed the social world as being comprised of one basic realm where conversations
112 and interactions can create complex psychological and sociological phenomena developed upon belief systems such as social class. A ‘social world’ is also understood to consist of a network of interactions framed within some relative stable repertoire of rules and meanings. Within this context, Harr´ e and van Langenhove (1999a) promoted positioning theory as an analytical tool to facilitate understanding within many and varied institutional discursive processes. The ‘social world’ according to van Langenhove and Harr´ e (1999a) is formed and shaped through conversations. This means that social actions can be recognised or ‘determined’ by others, whereas some of the other types of actions may not be understood. These misunderstood actions are described within the literature as ‘indeterminate’. Individuals choose whether or not they wish to respond to being positioned within institutional settings. Students who, for example, attempt to position their preceptor/midwife into conversations related to the delivery of care, may find that there is no response or reaction as their preceptor/midwife is concentrating on another activity that requires their complete attention. The mutually determining triad of ‘position’, ‘speech-act’ and ‘storyline’ serve as a guide in the application of positioning within conversations (Harr´ e & van Langenhove, 1991; van Langenhove & Harr´ e, 1999a). Positioning is an imperative for each practitioner’s learning, supported by reflective practices, to assist each student’s journey in developing their personal identity as a midwifery practitioner. Personal identity in midwifery practice is apparent when, for example, an individual assumes accountability for actions. In application of positioning theory, personal accountability is manifested in first person indexical applications such as ‘I’, ‘me’, ‘myself’, ‘my’ or mine’, employed by individuals in everyday midwifery language and conversations. The use of these personal pronouns can be deliberately avoided when for example an individual chooses to position themselves at a distance to remove themself from the consequences of actions related to their accountability and responsibility.
Everyday midwifery language, conversations and indexical applications Harr´ e (2002) identified the indexical applications such as, ‘I’, ‘me’, ‘myself’, ‘my’ or ‘mine’ as defining ‘personhood’. Personhood is another term for personal identity, and is demonstrated when an individual takes responsibility for an action (agency). Within the culture of midwifery practice, use of ‘I’, ‘we’ and ‘you’ demonstrate attitudes and relationships between midwives, students, women and their families. In many episodes of care where students have for example, assisted a woman during labour and birth, they apply the first person of ‘I’ to demonstrate both responsibility and personhood. Harr´ e and van Langenhove (1999a) refer to these applications as ‘personas’ which is applied by all students at various stages throughout their enrolment in the Graduate Diploma of Midwifery. Shared meanings and relationships connected with personal identity, agency and each individual’s autobiography is also referred to as ‘selfhood’ and ‘self’ (Gillett and Harr´ e, 1994). As opposed to ‘personhood’ or ‘self’, individuals may employ ‘intergroup positioning’ (Tan & Moghaddam, 1999)
D.J. Phillips, B.A. Hayes where the pronoun indexical of ‘they’ is used instead. This means that with intergroup positioning, the group takes responsibility for an action, rather than an individual. Students when working with their respective preceptor/midwife, typically report when care is provided that they employ the indexical of ‘they’. In this context, ‘they’ means that the preceptor/midwife or others are responsible for care in a collective context. Excerpts of professional conversations from the doctoral work by Phillips (2002) have been included to demonstrate indexical applications of pronouns. Indexical applications have been through the use of underlined pronouns to emphasize ‘position’, ‘speech acts’ and ‘storylines’, applied by each of the three midwifery students and their preceptor/midwives. Student A: All the midwives have been really good. They have been really good in all of the delivery suites. Like they are always willing to discuss with you, go through all of the history with you and [discuss] what they plan is. The application of ‘they’ in the above demonstrates that the student is aware that the midwife with whom she is working is both responsible and accountable for care. Midwife A: We actually worked three nights together and we managed to get a delivery (birth) on each of those shifts. And she (the student) was just with regard to recognising the second stage of labour. She was quite willing to say you know, ‘‘I think that she was ready to push because she’s showing certain signs’’. In the above the midwife applied ‘we’ to indicate that she fully involved the student in the delivery of care of a woman during the intrapartum phase, birth and the time after birth. Student B: Well, I feel I learnt absolutely heaps during the year and it has been very productive and fulfilling and I can’t wait to get in there and actually be one doing the work. I feel that slight level of frustration at the moment. I want to work, but it is not possible yet. So it is another process of marking time. The application of the first person ‘I’ indicates responsibility and the enthusiasm to commence practice as a qualified midwife. Midwife B: Not a lot of conversations have occurred because the unit has been very busy every time I have worked with her. We had a debrief (discussion) and that was in regard to an incident in delivery suite with shoulder dystocia (difficulty in giving birth due to impacted shoulders of the fetus within the woman’s pelvis). The application of ‘we’ included the student and the use of the first person ‘I’ indicated taking an action to assist the student. Midwife B identified that the opportunity for professional conversations in midwifery practice settings can be a common and problematic occurrence. This highlights a limitation in the application of positioning and where professional conversations are intrinsic. Students however, are encouraged to utilise opportunities to converse with midwives whenever it is possible. In our observations, midwives welcome the prospect to engage in conversations with students, thereby bolstering the rich midwifery
Securing the oral tradition oral tradition and using conversations as a vehicle for support. Student C: . . .I mean it goes from the finish of the delivery (birth) to when we’re checking the placenta and we’re chatting, about, you know, the second degree tear (perineal tear) and how you were right to ask (woman) to give a little push if a primip (woman’s first birthing experience). But the head (fetal head) came through very quickly and, you know, if you were doing it again you would probably just get her to puff. These are the issues that are really highlighted for me at the moment. What’s coming together for me is the coaching part. The student positioned the preceptor/midwife and herself as working together as a team but acknowledged the midwife’s responsibility of also being a clinical teacher. The positioning by this student indicates a close working relationship between the midwife and herself with the application of ‘we’. Midwife C: I’ve worked with her a few times but I haven’t with her heaps. But I’ve worked with her a few times up in delivery suite. I have mainly worked with her just in labour (care of women in labour). And I remember one experience where we had to go for an emergency section (caesarean section). I think I have actually seen her develop quite well through the twelve months. I think her communication skills are fantastic. The preceptor/midwife positioned herself in reference to the student’s experiences and positioned the student according to an expected level of practice development. Midwife C acknowledged that she had not worked with her student very often. This can be a typical outcome for students as midwives are frequently part-time employees engaged in shift work, thereby removing them further from their nominated students. Students are however, encouraged to engage in professional conversations with midwives other than those who have been nominated as their preceptors and where positioning can also be applied. Each student’s practice learning requirements were the focus of discussion in their professional conversations with their respective preceptor/midwife and did not normally include the women in their care as a participant of their conversations. This did not however, exclude students from participating in discussions with women related to their specific care and needs, thereby engaging in woman-centred care. The discussions with women related to their specific needs, delivery of care and expected outcomes conducted under the supervision of the midwife. These excerpts demonstrate positioning assumed by both students and midwives within their conversational reflections related to midwifery practice.
Discussion Practice and research in professional education such as the Graduate Diploma of Midwifery embrace the social ontological levels of cultural purposes of semiotics, agency, possibilities or structure. This is specifically in reference to the location of agency in the social world of mid-
113 wifery practice and the way social structures are reproduced and transformed (Phillips, Fawns & Hayes, 2002), but still grounded in conversations (Harr´ e, 1976). Positioning is therefore, an effective tool for analysing the dynamics of conversations through the emerging patterns of speech acts and storylines (Harr´ e, 2005). In contrast, reflective practice is usually based on individualistic conceptions of cultural agency in professional education that may either ignore or overlook the demands, nuances of professional practice (Phillips, 2002). Conversely, positioning offers a greater emphasis on the interactions of professional conversations conducted between individuals. These conversations can be analysed through ‘unpacking’ or understanding the learning opportunities of the moment-to-moment events in midwifery practice and wherever reflective practice is encouraged. Other disciplines such as psychology and counselling have embraced positioning to analyse discourse to promote professional development and learning. Midwifery and nursing professions are complex practices, compared to most other disciplines, but both provide fertile ground for reflective positioning to be applied as an analytical tool to promote individual student learning. It is within midwifery practice settings that identities (individuals), societal issues and culture may be determined for students (Phillips et al., 2002). The sociological and psychological background of the social world occurs when individuals are active in the production of social relations conducted through conversations. All students who have identified specific learning needs in practice settings can support their learning through professional conversations and positioning (Phillips & Hayes, 2006). Positioning can be applied in debriefing activities and students’ reflective practice journals where academics can identify how students position themselves to meet their learning needs or identify their emerging practice development through use of indexical applications. The conversations and the positioning that occurs in practice settings are linked with reflective practice. It is important for students, as active learners, to realise their learning achievements and how they can ‘value add’ them into their professional practice development. Ottesen (2007) stated that a process of reflective practice through narrative use is also imperative for both moral and ethical issues, to encourage students to use their imagination and creativity in developing their professional learning. In consideration of these points, positioning encourages an individual to analyse each situation in practice, particularly those moment-to-moment interactions and where life changing events occur.
Conclusion Like midwives, nurses as cultural agents in their practice settings, enact and embody cultural ideological resources and institutional rules and regulations to uphold safe practices. Academics however, have limited this organised social life of professional practice where interactions are both intentional and interpersonal, simply to reflective practice which is just one stepping stone. Students are encouraged to be active participants in their learning and should be able to monitor their learning through the moment-to-moment interactions of professional conversations with midwives
114 related to the delivery of care. Positioning theory can therefore be applied as an analytical tool for the complexities of everyday conversations conducted between students and their preceptor/midwife. Importantly, these professional conversations can make a powerful contribution to the personal and professional identify formation of students as learner midwives or nurses. Academics need therefore, to shift from didactic approaches and fully embrace the tacit potency of the moment-to-moment frontline professional conversations into strategic teaching and learning activities. Reflective positioning is therefore, the way forward in professional education and in securing the oral traditions of both midwifery and nursing.
References Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley Publishing Company. Benner, P., Tanner, C. A., & Chesla, C. A. (1996). Expertise in nursing practice: Caring, clinical judgment, and ethics. New York: Springer Publishing Company. Berman, L. (1999). Positioning in the formation of a ‘national’ identity. In R. Harr´ e & L. van Langenhove (Eds.), Positioning theory: Moral contexts of intentional action (pp. 138—159). Oxford: Blackwell Publishers Ltd. Carbaugh, D. (1999). Positioning as display of cultural identity. In R. Harr´ e & L. van Langenhove (Eds.), Positioning theory: Moral contexts of intentional action (pp. 160—177). Oxford: Blackwell Publishers Ltd. Davies, B., & Harr´ e, R. (1990). Positioning: The discursive production of selves. Journal for the Theory of Social Behaviour, 20(1), 43—63. Davies, B., & Harr´ e, R. (1999). Positioning and personhood. In R. Harr´ e & L. van Langenhove (Eds.), Positioning theory: Moral contexts of intentional action (pp. 32—52). Oxford: Blackwell Publishers Ltd. Gillett, G., & Harr´ e, R. (1994). The discursive mind. Thousand Oaks: Sage Publications. Harr´ e, R. (Ed.). (1976). Life sentences: Aspects of the social role of language. London: John Wiley & Sons. Harr´ e, R. (2002). Public sources of the personal mind: Social constructionism in context. Theory & Psychology, 12(5), 611—623. Harre, R. (2005). Positioning and the discursive construction of categories. Psychopathology, 38, 185—188. Harr´ e, R., & van Langenhove, L. (1991). Varieties of positioning. Journal for the Theory of Social Behaviour, 21, 393—407. Harr´ e, R., & van Langenhove, L. (1999a). The dynamics of social episodes. In R. Harr´ e & L. van Langenhove (Eds.), Positioning theory: Moral contexts of intentional action (pp. 1—13). Oxford: Blackwell Publishers Ltd. Harr´ e, R., & van Langenhove, L. (1999b). Epilogue: Further opportunities. In R. Harr´ e & L. van Langenhove (Eds.), Positioning theory: Moral contexts of intentional action (pp. 195—199). Oxford: Blackwell Publishers Ltd. Howie, D. (1999). Preparing for positive positioning. In R. Harr´ e& L. van Langenhove (Eds.), Positioning theory: Moral contexts of intentional action (pp. 53—59). Oxford: Blackwell Publishers Ltd.
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Securing the oral tradition: Reflective positioning and professional conversations in midwifery education Diane J. Phillips, RN (Midwife), BApp.Sci., MEd., DEd. FRCNA a,∗, Barbara A. Hayes, RN (Midwife), BA (Hons.), M.Sc., DNSc., FRCNA b,1 a
School of Nursing, Faculty of Health, Medicine, Nursing and Behavioural Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia b James Cook University, School of Nursing, Midwifery and Nutrition, Townsville, QLD 4811, Australia Received 20 April 2007; received in revised form 24 August 2007; accepted 24 September 2007
KEYWORDS Reflective positioning; Professional conversations; Midwifery
∗ 1
Summary We postulate that positioning is a powerful tool in guiding and transforming student professional learning and practice development. In our experiences with students enrolled in the Graduate Diploma of Midwifery, we determined that positioning elaborates individual scholarship and identity formation of the learner midwife in practice settings. Positioning Theory, developed by Harr´ e and other authorities, is a psycho-sociological ‘ontology’ or concept of how individuals metaphorically position or locate themselves, and others, within institutions and societies. Three key components of positioning theory include ‘position’, ‘speech act’ and ‘storylines’, developing from the everyday social interactions of professional conversations. Reflective positioning can be applied as an analytical tool for the moment-to-moment exchanges inherent in practice related conversations, occurring between midwives and midwifery students. These moment-to-moment interactions of professional conversations can be used by students to complete or fill their learning gaps. Positioning therefore, provides a novel, contemporary theoretical framework to ‘unpack’ or understand the complexity of midwifery practice and yet is complementary with reflective practice. Excerpts are used to demonstrate reflective positioning applications by students. Midwives are encouraged by health services and by the University to provide student support through a ‘preceptorship’ program to supervise, work with and assess students for competence in midwifery practices. We claim that reflective positioning by students within professional conversations with their preceptor/midwives, are the construction sites for learning and where identity formation of each student as a future midwife is both shaped and transformed. Both academics and managers of health services need to embrace the value of workplace conversations, the sites of rich oral traditions of nursing and midwifery. Thus, in seeking claim to our rich oral traditions, all students will benefit
Corresponding author. Tel.: +61 3 9244 6119. E-mail addresses: [email protected] (D.J. Phillips), [email protected] (B.A. Hayes). Tel.: +61 3 4781 5340.
1322-7696/$ — see front matter © 2008 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.colegn.2007.09.002
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D.J. Phillips, B.A. Hayes from engagement in reflective positioning to promote their professional learning and practice development. © 2008 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Introduction Reflective practices have served both midwifery and nursing well, but it is now time to move on, by accessing the innate oral traditions of both midwives and nurses further. This theoretical paper on reflective positioning and professional conversations in midwifery education has been developed from our experience with students enrolled in the Graduate Diploma of Midwifery at a University in Victoria. The application of positioning is deeply embodied and embedded in the context of conversations and it is within these conversations that the persona of each student emerges as an individual being. In the enactment of positioning within the momentto-moment interactions of professional conversations held in midwifery practice settings, the very different and unique requirements of each individual student’s knowledge and practice development becomes apparent. While positioning is separate from that of reflective practice, both approaches employ similar skills such as analysis, critical thinking, interpretation, evaluation and synthesis: all cognitive skills required for higher thinking level abilities. Students are encouraged to be active agents in their learning by assuming responsibility for their psychosocial determinations within the social cultural world of professional midwifery practice by ensuring for example, satisfactory completion of both academic and practice requirements of the course. The practice requirements include those of the curriculum and for those of the legislating authority, the Nurses Board of Victoria, where each graduating student applies for the additional qualification of ‘midwife’, Division 1 register. Health services undertake the development of rotational rosters for students so that they work with their preceptor/midwife in midwifery practice settings and where conversations are innate. The notion of ‘preceptorship’ is principally drawn however, from Benner’s model of skill acquisition for nurses (Benner, 1984; Benner, Tanner & Chesla, 1996). Benner (1984) pioneered research into the knowledge base of nursing and midwifery developed from their conversational reflective practices. Preceptor/midwives provide supervision, support and assessment of their students for competence in practice. These activities are supported through reflective positioning within the moment-to-moment interactions of professional conversations in practice settings to influence professional learning. Sources such as CINAHL, Academic Search Premier, Science Direct, PsycINFO, Expanded Academic ASAP, ERIC and Medline were used with key words such as ‘positioning theory’, ‘conversations’, ‘discursive analysis’, ‘midwifery education’, ‘education’, ‘midwifery curriculum’, ‘reflective practice’, and ‘student supervision’. In addition, manual searches were conducted within book chapters written by the positioning theory authorities. These searches were fun-
damental for the conduct of a critical critique of literature related to elaboration of professional learning and practice development.
Positioning theory Positioning theory was developed by the contemporary philosopher, Rom Harr´ e, who developed this psychosociological ontology from the positions and gender differentiation by Hollway in the 1980s (van Langenhove & Harr´ e, 1999a). In addition, the constructionist psychology theories used to underpin positioning theory have been drawn from the work of, for example, Wittgenstein (mind and language) and Vygotsky (thought and language) (Davies & Harr´ e, 1990; Gillett & Harr´ e, 1994; Howie & Peters, 1996). Harr´ e has undertaken collaborative work with other positioning theory authorities such as Luk van Langenove. A ‘position’ is a metaphorical term to describe how an individual positions or locates themself within three social entities of ‘people’, ‘institutions’ and ‘societies’. Harr´ e and van Langenhove (1999a) argued that the discursive nature of conversations, conducted either privately or publicly, do occur within these three entities. The application of the word ‘position’ brings attention to interpersonal encounters rather than of a ‘role’ (Moghaddam, 1999). Harr´ e and van Langenhove (1999b, p. 196) supported Moghaddam’s claim, stating that ‘‘adopting or being assigned a role fixes only a range of positions, positions compatible with that role’’. The notion of ‘position’ in an institution or society has a more fluid connotation in regard to participation in conversations (Davies & Harr´ e, 1990; Gillett & Harr´ e, 1994; Tan & Moghaddam, 1995; van Langenhove & Harr´ e, 1999a). Davies & Harr´ e (1999, p. 37) explained that positioning ‘‘. . . is the discursive process whereby people are located in conversations . . .’’ and where there are jointly produced storylines. The concept of positioning is manifested by a certain set of rights, duties, and obligations by the individual who is presenting the story line within the speech act of a conversation (Gillett & Harr´ e, 1994; van Langenhove & Harr´ e, 1994). The importance of local moral orders or obligations, implicit within social structures and interactions, are manifested through the speech acts of conversations identified as the construction sites of personal identity formation (Davies & Harr´ e, 1999; Gillett & Harr´ e, 1994; Harr´ e & van Langenhove, 1999a; Moghaddam, 1999; van Langenhove & Harr´ e, 1999b). van Langenhove and Bertolink (1999) argue that social constructionism is fundamental for the generation of social phenomena developed through conversations. As such, conversations are considered to be the place where many, if not most, psychosocial constructions are jointly created (Harr´ e & van Langenhove, 1999a). Positioning theory
Securing the oral tradition focuses on understanding how psychological phenomena are produced in the moment-to-moment interactions of conversations. This means that positioning enables a study of the relationships between the participants (such as the preceptor/midwife and student) as well as the rich detail emerging from conversations. Even the subjective responses that occur from a single fleeting moment of an interaction between individuals are considered as invaluable opportunities for positioning (Winslade, 2005). Positioning is promoted by van Langenhove and Harr´ e (1999a) as an effective tool for the analysis of every day language used in the professional conversations.
Language and conversation Davies and Harr´ e (1990) stated that language is a public institution and is the foundation upon which social structure and interactions are developed. Further, language is referred to as either a social or illocutionary force (utterances) of speech acts. Midwives use their own language which is easily recognised by colleagues, quickly embraced and enacted by students but often very confusing for those outside of the discipline. The act of positioning involves a reconstruction of articulated biographies related to the individual being positioned and of the positions that may be subject to rhetorical re-descriptions. The following three methods assist in the expression of personal identity within conversations: (a) Agency (assuming responsibility); (b) making a statement on the point of view; and (c) evaluating a past event, as a contribution to one’s biography (Harr´ e & van Langenhove, 1999a; Howie & Peters, 1996). Position, storylines and relatively determinate speech acts are three key factors inherent within conversations, and play an influential part in human behaviour (Harr´ e & van Langenhove, 1999a; van Langenhove & Harr´ e, 1999a). Conversation is considered to be a central concept in the theoretical development of social constructions where powerful influences such as psychic and social phenomena must be acknowledged. In addition, factors that should be considered when engaging in conversations include history, culture and social differences that are individually unique and requiring thoughtful, sensitive negotiation by others (Carbaugh, 1999; Berman, 1999; Moghaddam, 1999; Sabat & Harr´ e, 1999; Tan & Moghaddam, 1999). Moral orders or obligations are upheld within conversations through the application of metaphors and images (Howie & Peters, 1996) to facilitate conversational positioning according to the ‘rules’ of people, speech acts and storylines. These rules are applied as descriptions on how to operationalise the range of possible responses that are unique to participating individuals within specific situations, language and communication processes (Gillett & Harr´ e, 1994). Howie (1999) emphasised the relationship between moral capacity to position another individual and skill applied to undertake this effectively. Both midwives and nurses in their everyday practice face unexpected and major ethical dilemmas such as the care of the sick or dying newborn infant or the indigenous woman and her family whose cultural beliefs are dismissed as inconsequential in the pro-
111 cess of childbearing. If the rhetoric of caring is applied in practice it is essential that variables such as the individual concerned, situation, intended outcomes and issues associated with power and parity are consciously incorporated (Johnston & Kerper, 1996). Interactive positioning can occur, but generally positions are relational. For example an individual, such as a preceptor/midwife, is positioned as powerful whereas students may be positioned less powerfully. Davies and Harr´ e (1999) cautioned that it is an error to assume that positioning is only intentional but rather dependent upon the situation an individual finds themselves in and how they manage. Conversations frame the social world of midwifery practice and midwives, as cultural agents, enact and embody cultural ideological resources and institutional rules and regulations to uphold safe practices. The disciplines of midwifery and nursing both possess a very strong oral tradition which is essential for effective practices. An important component of midwifery practice is information exchange (McKenzie, 2004) conducted through professional conversations and where midwives are ‘agents’. Through the notion of ‘agency’, midwives in their function as preceptors engage in professional conversations with students and, in doing so, create institutions through structures. Structures include institutional behaviour and dynamics that influence the structure of each student’s psychology through rules, policies and procedures to influence their professional identity formation (Phillips, 2002). Examples such as time and place for meetings and who initiates the meetings between the preceptor/midwife and their students reflect this reality. It is within conversations that the construction sites of professional learning for students enrolled in a Graduate Diploma of Midwifery emerge. It is well known and understood by midwives that practice settings are prominent strongholds of professional support and socialization, of which conversations are the cornerstone. Students frequently report to academics the impact of their conversations with midwives and how their professional identity formation as a student of midwifery is shaped and transformed due to this influence (Phillips & Hayes, 2006). In midwifery practice settings, conversations related to the delivery of care are ongoing, dynamic and essential for each woman’s care. Parker and Gibbs (1998, chap. 7, p. 85) provided an eloquent description of a midwife being a ‘social actor’ in the context of midwifery’s position in Western medical science. Such descriptions focus on the centrality of the midwife and project the importance for socialization in professional practice. One of these responsibilities is the sharing of information through professional conversations, enhanced by midwives positioning themselves to ensure that colleagues have appropriate comprehension of each woman’s care. The word ‘position’, therefore, takes on a specific meaning in regard to differing standpoints such as a personal one as opposed to membership of a group and where the position of the group is upheld over an individual stance.
Social world Harr´ e and van Langenhove (1999a) viewed the social world as being comprised of one basic realm where conversations
112 and interactions can create complex psychological and sociological phenomena developed upon belief systems such as social class. A ‘social world’ is also understood to consist of a network of interactions framed within some relative stable repertoire of rules and meanings. Within this context, Harr´ e and van Langenhove (1999a) promoted positioning theory as an analytical tool to facilitate understanding within many and varied institutional discursive processes. The ‘social world’ according to van Langenhove and Harr´ e (1999a) is formed and shaped through conversations. This means that social actions can be recognised or ‘determined’ by others, whereas some of the other types of actions may not be understood. These misunderstood actions are described within the literature as ‘indeterminate’. Individuals choose whether or not they wish to respond to being positioned within institutional settings. Students who, for example, attempt to position their preceptor/midwife into conversations related to the delivery of care, may find that there is no response or reaction as their preceptor/midwife is concentrating on another activity that requires their complete attention. The mutually determining triad of ‘position’, ‘speech-act’ and ‘storyline’ serve as a guide in the application of positioning within conversations (Harr´ e & van Langenhove, 1991; van Langenhove & Harr´ e, 1999a). Positioning is an imperative for each practitioner’s learning, supported by reflective practices, to assist each student’s journey in developing their personal identity as a midwifery practitioner. Personal identity in midwifery practice is apparent when, for example, an individual assumes accountability for actions. In application of positioning theory, personal accountability is manifested in first person indexical applications such as ‘I’, ‘me’, ‘myself’, ‘my’ or mine’, employed by individuals in everyday midwifery language and conversations. The use of these personal pronouns can be deliberately avoided when for example an individual chooses to position themselves at a distance to remove themself from the consequences of actions related to their accountability and responsibility.
Everyday midwifery language, conversations and indexical applications Harr´ e (2002) identified the indexical applications such as, ‘I’, ‘me’, ‘myself’, ‘my’ or ‘mine’ as defining ‘personhood’. Personhood is another term for personal identity, and is demonstrated when an individual takes responsibility for an action (agency). Within the culture of midwifery practice, use of ‘I’, ‘we’ and ‘you’ demonstrate attitudes and relationships between midwives, students, women and their families. In many episodes of care where students have for example, assisted a woman during labour and birth, they apply the first person of ‘I’ to demonstrate both responsibility and personhood. Harr´ e and van Langenhove (1999a) refer to these applications as ‘personas’ which is applied by all students at various stages throughout their enrolment in the Graduate Diploma of Midwifery. Shared meanings and relationships connected with personal identity, agency and each individual’s autobiography is also referred to as ‘selfhood’ and ‘self’ (Gillett and Harr´ e, 1994). As opposed to ‘personhood’ or ‘self’, individuals may employ ‘intergroup positioning’ (Tan & Moghaddam, 1999)
D.J. Phillips, B.A. Hayes where the pronoun indexical of ‘they’ is used instead. This means that with intergroup positioning, the group takes responsibility for an action, rather than an individual. Students when working with their respective preceptor/midwife, typically report when care is provided that they employ the indexical of ‘they’. In this context, ‘they’ means that the preceptor/midwife or others are responsible for care in a collective context. Excerpts of professional conversations from the doctoral work by Phillips (2002) have been included to demonstrate indexical applications of pronouns. Indexical applications have been through the use of underlined pronouns to emphasize ‘position’, ‘speech acts’ and ‘storylines’, applied by each of the three midwifery students and their preceptor/midwives. Student A: All the midwives have been really good. They have been really good in all of the delivery suites. Like they are always willing to discuss with you, go through all of the history with you and [discuss] what they plan is. The application of ‘they’ in the above demonstrates that the student is aware that the midwife with whom she is working is both responsible and accountable for care. Midwife A: We actually worked three nights together and we managed to get a delivery (birth) on each of those shifts. And she (the student) was just with regard to recognising the second stage of labour. She was quite willing to say you know, ‘‘I think that she was ready to push because she’s showing certain signs’’. In the above the midwife applied ‘we’ to indicate that she fully involved the student in the delivery of care of a woman during the intrapartum phase, birth and the time after birth. Student B: Well, I feel I learnt absolutely heaps during the year and it has been very productive and fulfilling and I can’t wait to get in there and actually be one doing the work. I feel that slight level of frustration at the moment. I want to work, but it is not possible yet. So it is another process of marking time. The application of the first person ‘I’ indicates responsibility and the enthusiasm to commence practice as a qualified midwife. Midwife B: Not a lot of conversations have occurred because the unit has been very busy every time I have worked with her. We had a debrief (discussion) and that was in regard to an incident in delivery suite with shoulder dystocia (difficulty in giving birth due to impacted shoulders of the fetus within the woman’s pelvis). The application of ‘we’ included the student and the use of the first person ‘I’ indicated taking an action to assist the student. Midwife B identified that the opportunity for professional conversations in midwifery practice settings can be a common and problematic occurrence. This highlights a limitation in the application of positioning and where professional conversations are intrinsic. Students however, are encouraged to utilise opportunities to converse with midwives whenever it is possible. In our observations, midwives welcome the prospect to engage in conversations with students, thereby bolstering the rich midwifery
Securing the oral tradition oral tradition and using conversations as a vehicle for support. Student C: . . .I mean it goes from the finish of the delivery (birth) to when we’re checking the placenta and we’re chatting, about, you know, the second degree tear (perineal tear) and how you were right to ask (woman) to give a little push if a primip (woman’s first birthing experience). But the head (fetal head) came through very quickly and, you know, if you were doing it again you would probably just get her to puff. These are the issues that are really highlighted for me at the moment. What’s coming together for me is the coaching part. The student positioned the preceptor/midwife and herself as working together as a team but acknowledged the midwife’s responsibility of also being a clinical teacher. The positioning by this student indicates a close working relationship between the midwife and herself with the application of ‘we’. Midwife C: I’ve worked with her a few times but I haven’t with her heaps. But I’ve worked with her a few times up in delivery suite. I have mainly worked with her just in labour (care of women in labour). And I remember one experience where we had to go for an emergency section (caesarean section). I think I have actually seen her develop quite well through the twelve months. I think her communication skills are fantastic. The preceptor/midwife positioned herself in reference to the student’s experiences and positioned the student according to an expected level of practice development. Midwife C acknowledged that she had not worked with her student very often. This can be a typical outcome for students as midwives are frequently part-time employees engaged in shift work, thereby removing them further from their nominated students. Students are however, encouraged to engage in professional conversations with midwives other than those who have been nominated as their preceptors and where positioning can also be applied. Each student’s practice learning requirements were the focus of discussion in their professional conversations with their respective preceptor/midwife and did not normally include the women in their care as a participant of their conversations. This did not however, exclude students from participating in discussions with women related to their specific care and needs, thereby engaging in woman-centred care. The discussions with women related to their specific needs, delivery of care and expected outcomes conducted under the supervision of the midwife. These excerpts demonstrate positioning assumed by both students and midwives within their conversational reflections related to midwifery practice.
Discussion Practice and research in professional education such as the Graduate Diploma of Midwifery embrace the social ontological levels of cultural purposes of semiotics, agency, possibilities or structure. This is specifically in reference to the location of agency in the social world of mid-
113 wifery practice and the way social structures are reproduced and transformed (Phillips, Fawns & Hayes, 2002), but still grounded in conversations (Harr´ e, 1976). Positioning is therefore, an effective tool for analysing the dynamics of conversations through the emerging patterns of speech acts and storylines (Harr´ e, 2005). In contrast, reflective practice is usually based on individualistic conceptions of cultural agency in professional education that may either ignore or overlook the demands, nuances of professional practice (Phillips, 2002). Conversely, positioning offers a greater emphasis on the interactions of professional conversations conducted between individuals. These conversations can be analysed through ‘unpacking’ or understanding the learning opportunities of the moment-to-moment events in midwifery practice and wherever reflective practice is encouraged. Other disciplines such as psychology and counselling have embraced positioning to analyse discourse to promote professional development and learning. Midwifery and nursing professions are complex practices, compared to most other disciplines, but both provide fertile ground for reflective positioning to be applied as an analytical tool to promote individual student learning. It is within midwifery practice settings that identities (individuals), societal issues and culture may be determined for students (Phillips et al., 2002). The sociological and psychological background of the social world occurs when individuals are active in the production of social relations conducted through conversations. All students who have identified specific learning needs in practice settings can support their learning through professional conversations and positioning (Phillips & Hayes, 2006). Positioning can be applied in debriefing activities and students’ reflective practice journals where academics can identify how students position themselves to meet their learning needs or identify their emerging practice development through use of indexical applications. The conversations and the positioning that occurs in practice settings are linked with reflective practice. It is important for students, as active learners, to realise their learning achievements and how they can ‘value add’ them into their professional practice development. Ottesen (2007) stated that a process of reflective practice through narrative use is also imperative for both moral and ethical issues, to encourage students to use their imagination and creativity in developing their professional learning. In consideration of these points, positioning encourages an individual to analyse each situation in practice, particularly those moment-to-moment interactions and where life changing events occur.
Conclusion Like midwives, nurses as cultural agents in their practice settings, enact and embody cultural ideological resources and institutional rules and regulations to uphold safe practices. Academics however, have limited this organised social life of professional practice where interactions are both intentional and interpersonal, simply to reflective practice which is just one stepping stone. Students are encouraged to be active participants in their learning and should be able to monitor their learning through the moment-to-moment interactions of professional conversations with midwives
114 related to the delivery of care. Positioning theory can therefore be applied as an analytical tool for the complexities of everyday conversations conducted between students and their preceptor/midwife. Importantly, these professional conversations can make a powerful contribution to the personal and professional identify formation of students as learner midwives or nurses. Academics need therefore, to shift from didactic approaches and fully embrace the tacit potency of the moment-to-moment frontline professional conversations into strategic teaching and learning activities. Reflective positioning is therefore, the way forward in professional education and in securing the oral traditions of both midwifery and nursing.
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