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Home , Margaret Archer, Social structure, Structure and agency

Big Ideas: , Modes of Reflexivity: The structured of nursing action.

“NOTICE: this is the author’s version of a work that has been sent for publication in Nurse Education Today. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication.

Margaret Archer was a professor of at Warwick University for 30 years. Her theoretical work is devoted to an important problem in the social sciences: the problem of and agency. To what degree are we free agents in deciding a course of action? To what degree does the constrain or enable action? This is a key question to consider when we try to understand why nurses do or do not act to uphold standards in certain contexts. If we wish to understand the limits of agency or the effects of structure upon clinical decision making, Archer’s ‘modes of reflexivity’ could be a very useful starting point. Stenhouse et al (2016) in a recent paper on the ‘compassion deficit’, illustrate the relevance of the discussion.

Archer focuses on ‘reflexivity’ in an attempt to get beyond a binary ‘structure or agency’ explanation for action.

“reflexivity mediates between the objective structural and cultural contexts confronting agents, who activate their properties as constraints and enablements as they pursue reflexively defined ‘projects’ based on their concerns” (Archer 2010).

Obese and overweight people choose ‘freely’ to eat more than they need, but they do so within the structure of the obesogenic environment. Nurses choose ‘freely’ to discharge vulnerable older adults, but they do so within the structure of certain and interprofessional environments.

So we need to see that agency works within a context, e.g. a clinical setting, in which the action is structured by that context but not determined by it. This happens in the following way:

1. The clinical practice setting provides the external, objective, situation and context which the nurse as ‘free agent’ is then confronted with. The agent does not have a choice about this. The clinical setting provides situations of constraint and opportunities for the nurse. This objective situation operates in relation to... 2. ...the nurse who has their own internal, subjective, concerns in relation to their personal nursing theory and values (Biomedical? Humanistic? Recovery? Centred?), social realities (the doctor- nurse-management relationship) and cultural practices (e.g. managerial control practices). 3. The action undertaken by structured free agents, in this case nurses, are produced by ‘reflexive deliberations’, i.e. internal conversations, about the situation and their own concerns. Nurses determine their choices of practical action in relation to their objective circumstances. Margaret Archer argues that the interplay between our internal concerns and our social and environmental contexts is shaped what she calls a ‘mode of reflexivity’. A ‘mode of reflexivity’ is the manner in which we think about our thinking, our ‘inner conversations’ that then shape our actions. Archer then outlines 4 ‘ideal types’ of modes of reflexivity:

1. Meta reflexivity: our inner conversation is subjected to our own criticism. We may then critique whether effective action is possible before we act. This is about self-monitoring, our thinking about how we think, and when dominant results in self questioning such as ‘why did I say that?’, ‘why am I so reticent to say what I think?’ 2. Autonomous reflexivity: our inner conversation requires no confirmation with others, they are self sustained and lead directly to action. Here we have a ‘lone inner dialogue’ which leads to action. 3. Communicative reflexivity: our inner conversations require confirmation and communication with others before we act. A nurse who is predominantly uses communicative reflexivity will consider what their peers are thinking and will want to act in such a way as to fit in. 4. Fractured reflexivity: our internal conversations intensify the disorientation and distress we already feel and this leads to inaction.

Meta reflexives are values driven over and above considering outcomes or consensus. Meta reflexives think about whether there is a correct course of action, what drives thinking before action, and whether their own thinking is free from bias, cognitive errors, or delusion. Meta reflexives will consider paradigms and epistemologies that underpin professional practice. They will seek out an understanding of power and ethical positions.

It could be that in many clinical areas the pressure of work, managerial demands, time constraints, procedures and power structures militate against meta reflexivity. Socratic questioning would be an unaffordable luxury. The meta reflexive nurse in this context could be seen as a nuisance, idealistic, time wasting, inefficient and unrealistic. Meta reflexivity may also come at a personal cost. Greater understanding may lead to a realisation that one’s personal agency is limited. Yet, without it we may end up doing “what we’ve always done”.

In educational settings that focus on competency and skill acquisition, or as ‘educationalism’ as Philip Darbyshire puts it, or settings rooted in instrumental rationality and biomedicine, Meta reflexivity may run counter to the need for learning procedures, processes and facts. It also runs counter to the epistemology of much of evidence based practice if it is rooted in often taken for granted empiricism. In clinical practice where the focus is on getting the work done, a student who is a ‘meta reflexive’ may run the risk of ‘not fitting in’. When a nurse does not challenge the discharge of a vulnerable patient, when the care pathway is clearly poorly thought out or is nonexistent , whose interests feature in their thinking? Is a nurse able to critically reflect upon the whole process to understand why they have just colluded in a that is systemically abusive by default if not by design?

An 'autonomous reflexive' (AR) does not stop to consider how their decisions will be thought of by others, they act because they think it is the correct course of action for themselves. They act decisively, trusting themselves sufficiently to commit to the conclusions they have come to. They are outcomes driven, over and above issues of and consensus. These outcomes must align however with their own interests. If an autonomous reflexive has a 'bank' of and meta reflexivity to draw upon they may fearlessly challenge power structures and ways of doing things unafraid of personal consequences. However they may in all likelihood not engage in meta reflexivity and thus don't have this benchmark of critical self analysis. They do not consider it useful to think about what other people think of them or their action. If the autonomous reflexive nurse does not have this political-philosophical 'bank' they operate within their own interests and ethical standpoints that support them.

The autonomous reflexive can be a leader for change, they can be disruptive of social orders, they don't consider the emotional needs of others necessarily as relevant. They can be focused on particular goals whether they be good or ill. They do not require the validation of others before they act. Their thinking is self- referential, that is they refer to themselves for judgment as to the worth of acting. They may reinterpret professional codes, and ethical practices, to fit in with what they have decided is right. They may use manipulative measures to steer other people into action that meets their own interests. Coaching and counselling skills would be very useful in meeting their own ends in this regard. Student nurses who display autonomous reflexivity may have experienced criticism, and chastening during their education, as they don't play by the rules just because they are rules.

The nurse who is an autonomous reflexive may have developed a thick skin, and may act according to whatever rules they see as right. If the discharge of a vulnerable patient is viewed as being in their own interests (if the following fits their goals: the work gets done, the team is appeased, management targets are achieved, it makes them feel good) then they will just get on with it. If the AR's interests are in line with patient's interests, include acting with an ethical code that puts the vulnerable patient first, over and above the needs, wishes and requirements of the team, the management and the process, their action will gladly disregard what others think. Communicative reflexives (CR) consider the needs, wishes and thoughts of others. They will require validation by other people before acting. They rely on trusted others to complete and confirm their tentative decisions. They consider how any action will affect other people, and the opinions of other people become very important. They are consensus seekers and value this over and above outcomes or values. They refer and may defer to others' thinking and action and will not readily rock the boat. They are team players and value the smooth running of the team even if that team has lost sight of the purpose of action. Leading change will be through consensus building rather than personal affirmative action. At worse they may collude with what Hannah Arendt called the banality of evil (‘not thinking’).

The context of many clinical placements for the student nurse will affirm consensus and validate the thoughtful consideration of other's needs. Mentors may look favourably upon a communicative reflexive if the boat is not being rocked. They are particularly open to professional socialisation and developing the consensus of professional identity. A nurse working in a toxic clinical environment may well feel unease, but if their communicative reflexivity is dominant they may be very reticent to challenge and fall back on post hoc rationalisation for action that may be sub optimal.

There is one last mode: the fragmented reflexive. One's thinking is so disoriented and unclear that thought and action are difficult or impossible. Thinking about action or the matter at hand brings them no nearer to an answer, this then intensifies the feeling of distress. Values, consensus or outcome thinking is secondary to personal survival in an uncertain world. Fragmentary thinking may be rooted in mental problems, psychological disturbances or disadvantaged social status. This requires someone to lead them, to look after them, to tell them what is right. If they are 'high functioning', self caring and independent living, they may require a good deal of supervision and control to prevent harm to themselves and to others. Occasionally a student nurse gets recruited with a degree of fragmentary reflexivity. A registered nurse, if they got that far would be a danger to themselves and to patients.

So, we have internal conversations, a ‘mode of reflexivity’. Our inner speech is rapid and often contracted into single words or phrases that contain a rich complexity of meaning. Words and phrases have, in Archer’s phrase, ‘semantic embedding in our biographies’. The word ‘compassion’ has recently undergone a change in its richness of meaning as it newly embeds into the biographies of nurses. Biographies however are not individual, we live them out with others in a context. This context becomes a ‘contextual resource’. Biographies become ‘intertwined’ (e.g. as student/mentor) in which the idiosyncrasy of shared meanings also become intertwined. This eases the sharing of inner conversations because we all share that idiosyncratic meaning. Hence we talk in short cuts, in jargon, half sentences. Archer calls this shared biographical context ‘similars and familiars’: “they speak the same way, share the same meanings, draw upon a commonwealth of references and a common fund of relevant experiences”. The autonomous reflexive nurse who says of patients: “(they) can fucking wait” because “I don’t give a flying fuck” (Darbyshire, 2014: 888), can only get away with that in a ‘similars and familiars’ context, but also may express such sentiments regardless of others judgements. The communicative reflexive will require the support of others to express, in public, such sentiments.

A note: these are ideal types of reflexivity and may be open to change within certain sets and status. The status of Clinical Manager may be more fertile ground for an AR to flourish, if it allies with a role set that is based on command and control directives. The status of student nurse may be fertile ground for the CR to flourish especially if its role set includes the giving of 'compassionate care' and meeting the emotional and physical needs of others.

The professional context in which whistleblowing is a very dangerous activity, in which parallel prevail, where stress, burn out and high turn over is prevalent, where high patient acuity and demand is common, in which care pathways are absent, poorly designed, supported and resourced, in which clinical leadership runs in parallel with managerial leadership, in which risk management and rational action based on managerial demands take priority, in which resources are scarce, in which skill mix and professional are damaged, where clinical leadership is either absent or denigrated, all of this might affect the expression of one’s reflexivity and thus one’s actions.

Any nurse who cannot even begin to think about this (the non meta reflexives) will probably be socialised into certain practices and take their lead from those they work with. An hypothesis is that many students come into nursing already as communicative reflexives and thus are vulnerable to social, professional and political pressures. Positive comments of the student's practice by mentors are not necessarily, and always, oriented to evaluations of the students' leadership capacities. Many mentors themselves may lack leadership qualities and critical reflexivity and thus do not have the tools of analysis to engage in this.

These modes are ideal types and a critique is that they need empirical verification and require embedding into the complexity of experience. For example, already mentioned is a consideration of status, role set and organisational context. In addition we may need to consider psychopathy or other mental health issues for why we act. We need also to consider that we are social and relation beings with personal narratives and that this impacts on how reflexivity is manifest. When exercising clinical leadership, it may assist a nurse’s personal and professional development to consider what their inner conversations actually are, to lead the inner voices rather than be led by them. If there is a tendency always to get thoughts verified by others before acting, and to worry about what others may think of one’s actions, this may need addressing. Similarly, if there is a tendency to act without the consideration about the impact of that action on others and self, then personal development may be required. A problem may be that this will also require what Peter Senge calls a ‘learning organisation’ to allow this to flourish. Archer, M. (2010) Conversations About Reflexivity , London and New York:

Archer, M. (2007) Making Our Way Through the World: Human Reflexivity and Cambridge: Cambridge University Press

Archer, M.(2003) Structure, Agency and the Internal Conversation Cambridge: Cambridge University Press

Archer, M. (2000) Being Human: The Problem of Agency , Cambridge, Cambridge University Press

Darbyshire, P. (2014) in Stenhouse et al (2016)

Stenhouse, R., Ion, R. Roxburgh, M., Devitt, P., and Smith, S. (2016) Exploring the compassion deficit debate Nurse Education Today 39 12 - 15