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A reflective account of a
consultation in abortion care
Astbury-Ward E (2009) A reflective account of a consultation in abortion care. Nursing Standard.
23, 35, 35-39. Date of acceptance: December 1 2008.
Summary
This article presents a reflective account of a consultation in a
pre-assessment clinic for women requesting abortion. The reflection
is based on Johns’ model. Reflection enabled the author to address
important issues that the consultation raised. These included the
realisation that nurses do not always have to understand why
patients make the choices they do, and the importance of allocating
sufficient time for sensitive consultations.
Author
Edna Astbury-Ward is contraceptive and sexual health specialist
nurse, Western Cheshire Primary Care Trust, and doctoral research
fellow, Centre for Health and Community Research, Glyndwr
University, Wrexham. Email: e.astburyward@glyndwr.ac.uk
a six-year-old and a one-year-old, from previous
relationships. She is a vibrant, lively and
articulate person. She smiled easily and
maintained good eye contact with me during the
consultation. Jane requested her fourth abortion
at the clinic and attended with her children. She
estimated her current pregnancy to be between
eight and nine weeks, but was unsure of her dates.
Results of the ultrasound dating scan revealed a
twin pregnancy of seven weeks’ gestation.
I chose to reflect on this consultation because
the circumstances of the case provoked a wide
range of feelings and emotions in me, which
broadened the scope for reflection.
Keywords
Introduction
Abortion; Communication; Consultation skills;
Reflective practice
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at nursingstandard.rcnpublishing.co.uk. For related
articles visit our online archive and search using the keywords.
The process of reflection is not new; Dewey
(1933) suggested it is a process of active,
persistent and careful consideration, which
supports further conclusions. It has also been
described as the internal examination and
exploration of issues resulting in changes of
thought (Boyd and Fales 1983) and as a process
of review that informs learning (Reid 1993).
Additionally, Clarke and Graham (1996)
suggested that reflection allows us to make sense
of experience and enables us to reach reasoned
decisions. In some instances such a reflection
might enable us to decide on distinctive and
well-reasoned ways to progress, in other
instances it can help us understand conundrums
encountered. Reflection may help us to
understand what we feel and identify our
strengths and limitations.
After careful consideration of the reflective
process, I chose to use Johns’ (2000) model to
structure my reflection as it offers the reflective
practitioner greater capacity for exploration and
expression of feelings. Johns’ (2000) model
THE FOLLOWING EVENTS took place in
a pre-assessment clinic (formerly known as a
termination of pregnancy clinic) where patients
are seen on an appointment basis. Routine tests
include height, weight, blood tests, body mass
index, blood pressure measurement, self-swab
for Ch l a m y d i a and gonorrhoea, and ultrasound
scanning. Consultation between the nurse and
patient includes discussion of the various
options for the current pregnancy, including
adoption, and future contraceptive advice.
The patient discussed in this article will
be given the pseudonym of Jane. Jane is a
25-year-old single woman with two children,
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covers a variety of issues that may arise during
reflection. It provides a clear and guided
approach, which allows the practitioner to
structure his or her thoughts in a more detailed
way than Gibbs’ (1988) reflective cycle. Johns’
(2000) model for reflection can be used as a guide
for analysis of a critical incident or for general
reflection on experience. It could also be useful
in complex decision making and analysis. Johns
(2000) considered that, by sharing reflections on
learning experiences, greater understanding of
those experiences could be achieved than by
reflection alone. A reflective learning cycle was
used in addition to the Johns’ (2000) model to
assist with integrating new information into
practice and evaluating its effect (Figure 1).
The amount of care given in any therapeutic
setting is governed by, among other factors, the
amount of time spent interacting with the patient.
However, this does not necessarily correspond to
the quality of care given. When providing health
care, time constraints may prevent the delivery of
optimum care and may result in other areas of
care being compromised and even neglected.
Sub-standard care may have a long-term negative
effect on the patient and family members, but may
also affect the provider of that care.
During my 25-year nursing career I have
endeavoured to give the best care that I can, but
on occasions I feel I have been prevented from
doing so because of external forces beyond my
FIGURE 1
Reflective learning cycle
Evaluate or reflect on the
impact of the decision
Practice
Integrate the
decision into practice
Make a decision
and consider the impact
External triggers
Formulate
a question/s
Seek information
Analyse, interpret or
reflect on the information
(Adapted from The College of Family Physicians of Canada 2009)
36 may 6 :: vol 23 no 35 :: 2009
control, for example time constraints.
Jane’s case was one such occasion.
The following reflection considers how being
short of time in a therapeutically challenging
encounter affected my feelings.
Conflict and incongruence
Because of time constraints I did not have the
opportunity to assess Jane’s feelings fully,
therefore I only observed briefly the depth and
complexity of her situation. I speculated about
the motives and circumstances associated with
her abortion request. I felt frustrated that time
constraints meant I was unable to enquire further
about her circumstances and feelings, which may
have provided further insight into her situation.
On reflection this enquiry might have been an
uncomfortable and intrusive experience for Jane.
Had there been more time in the therapeutic
setting, I would ideally have liked to explore
issues of self-esteem, attachment, intimacy and
loss to gain a better understanding of Jane’s
private and personal functioning.
I may also have explored her childhood
experiences and whether she felt this had any
relevance to her current situation. However,
would retrospective assessment and knowledge
of Jane’s circumstances have had any bearing on
the outcome, and why did I feel the need to know
these things? This after all was not a counselling
session. However, exploring the decision-making
process with Jane may have provided me with
greater insight and understanding and an
opportunity to offer more sensitive support.
Perhaps more relevant to the consultation were
the circumstances of her sexual experiences and
the impact they had on her, for example whether
she was forced into a situation where she was
unable to refuse sex or whether she was able to
access contraception. For Jane, the ‘real’ problem
arose when the results of the unltrasound revealed
a twin pregnancy. Jane had initially made the
decision to terminate the pregnancy based on her
assumption that she had a singleton pregnancy.
Although Jane was shocked by the thought of
being pregnant with twins, this did not change
her decision to have an abortion.
As health professionals it is our duty to
provide advice and information to enable
patients to make informed decisions. However,
it is not always easy to accept situations where
patients have ignored the advice given and put
themselves at risk of further harm.
Jane had made her decisions based, in part, on
the information I had given her. However, I was
concerned and felt that she had exposed herself
to unnecessary suffering and grief, both mentally
and physically. I considered that the key issue
was Jane’s right to exercise choice and free will.
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I began to think about the myriad factors she
needed to consider to enable her to make this
choice, including thinking about what it might be
like to give birth to twins and then to give them up
for adoption.
Choice and decision making
The notion of choice implies the exercise of
free will, which enables a person to arrive at a
considered decision based on the understanding
of all relevant facts. Fox (2002) argued that
people may make a choice based on temperament
or unconscious desire rather than reason or
conscious motivation. Healthcare professionals
need to address the issues associated with clinical
decision making, such as patient autonomy and
the wider psychosocial influences governing
patient choice. Coulter et al (1999) considered
that patients cannot express informed preferences
unless they are given sufficient and appropriate
information including detailed explanations.
Knowledge of this contributed to my feelings that
I had failed Jane, because I was unable to give her
as much information as I thought she needed to
make her decision. The frustration for me was
that I had access to detailed information about
abortion options, but I was unable to deliver it
comprehensively because of insufficient time
available to spend with Jane.
The other aspect of Jane’s situation that
concerned me was the reasons she was requesting
abortion for the fourth time. The decision to
continue with a pregnancy or not is a complex one
(Family Planning Association 2000, Royal College
of Obstetricians and Gynaecologists (RCOG)
2004) and many circumstantial factors affect
women’s abortion experiences (Astbury-Ward
2008). We can only make decisions if we
understand why something is problematic and are
aware of the possible solutions. We will only know
the possible solutions if we have been told what
options exist, or have researched or experienced
them ourselves. Jane may have arrived at her
decision to end the pregnancy because she may
already have felt she knew what the possible
outcomes would be as she had experienced them
previously. Her decision may have been based
on those experiences. If patients choose not to
research their problems or have no previous
experience of them, then they may rely solely on
the quality and accuracy of the information that
is given to them by healthcare professionals.
I felt that Jane had made her choice based
mainly on previous experience rather than on
the information I had provided. It is important
to ensure that an adequate amount of time is
allocated to give each individual the information
needed to enable her to make an informed choice.
New ways of working have now been
NURSING STANDARD
implemented, releasing sufficient time for all
consultations to allow full discussion of options
for the patient. Nurses working in pre-assessment
clinics now obtain consent from patients and
remain with patients throughout the consultation
process. This allows greater opportunity to form
a therapeutic alliance to develop and a full
discussion of all possible options.
As mentioned, Jane made her decision based
primarily on experience. However, other patients
may be entirely dependent on the information
provided at the consultation. If the information
given is either insufficient or inaccurate, it could
be argued that informed consent has not been
gained. In contrast, some people do not
necessarily need (or want) to receive all the facts
before they make a decision, preferring to put
their faith in the medical and nursing professions.
Motherhood and myths
As healthcare providers, we do not need to know
or understand all of the reasons why patients
make the choices that they do. I began to think
about the many reasons, psychological, social
and practical, why a woman may chose to have
an abortion (Walker 2001). I also considered the
issues surrounding pregnancy. I thought that for
some women the desire to be pregnant might not
necessarily be the same as the desire to have a
baby. Pregnancy for some women makes them
feel alive and invigorated – a way of experiencing
their female identity and a way of making them
feel special or the centre of attention. To become
pregnant reminds and perhaps reassures the
woman about her fertility. For these women
perhaps the end of the pregnancy, heralds the
onset of emptiness, and the need for the void
to be filled with another pregnancy. I had many
unanswered questions about Jane. I wondered
if pregnancy made her feel special and about her
experience of motherhood.
The experience of motherhood is complex.
Richardson (1993) believed that in our society
motherhood is considered necessary for full adult
status as a normal and feminine woman, although
this view is arguably changing now. Martin
(1987) suggested that a woman’s body
subordinates her free will to the uniquely female
responsibility of serving the needs of nurturing
the newly conceived embryo. In this sense, by
saying no to the prospect of motherhood Jane
might be saying yes to ultimate control over her
body, to pursuing a career, and to giving her
existing children better opportunities.
Grey (2001) considered that in circumstances
of abortion it may be impossible not to become
critical or judgemental. Abortion provokes
strong feelings; some may not see it as a great
maternal sacrifice, but a drastic rejection of
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motherhood, and an act of selfish and gratuitous
abandonment. Zoja (1997) believed that the act
of abortion may not be directed at the fetus but is
a rejection of motherhood itself and the values
and certainties associated with it at this time.
Jane had already experienced being a mother, so
she knew exactly what she was giving up. She
was also aware that she would again be entering
motherhood alone because she was no longer
with her partner. In some sections of society,
unmarried mothers have been blamed for moral,
economic and psychological decline in the nation
(Roseneil and Mann 1996). I speculated whether
the stigma attached to being a single mother may
have affected Jane’s decision. I wondered if the
negative representation of single mothers as an
underclass in society had affected her decision.
Repeat abortions
Grey (2001) indicated that women who have
repeat abortions – 32% of women, according to
the Office for National Statistics (2007) – present
the greatest challenge. Zoja (1997) claimed that
even the most convinced supporters of the right
to abort felt a certain uneasiness when faced
with women who aborted repeatedly. I also felt
a little uncomfortable about the apparent ease
with which Jane came to the decision to abort
for a fourth time. Requests for repeat abortions
might generate negative feelings in the nurse,
such as anger at the woman’s ‘irresponsibility’,
frustration at her contraceptive choice or lack of
it and distress, confusion and resentment for
‘wasting time’.
Hayter (1996) suggested that nurses are not
removed from the social forces that create and
reinforce negative stereotypes of individuals, and
implies that nurses are not immune to feelings or
to prejudice. I too had formed assumptions about
Jane before I met her. I assumed that she would be
of low intelligence, lacking in communication
skills, sad, vulnerable, needy and emotionally
affected by previous abortions.
In the clinical setting, nurses should put aside
any prejudices if they are to provide objective,
sensitive and non-judgemental care. This is a
skill that requires self-analysis. Atkins (2004)
suggests that a process of self-analysis should
be encouraged without making people feel
threatened. The process of self-analysis and
reflection makes the nurse aware of his or her
prejudices, enabling the provision of unbiased
information in a manner which will not influence
the patient’s decision. For some staff who have
deep religious convictions the right to
38 may 6 :: vol 23 no 35 :: 2009
conscientious objection enables them to
withdraw from treating or caring for individuals
in certain circumstances. Some individuals
believe that a legal obligation compelling them
to act contrary to their religious convictions is
a profound violation of their ethical and human
rights (Dickens and Cook 2000). Although we
might like to consider that we treat everyone
in the same way, Rose (2004) argued that the
complexity of human nature often leads to
confusion when our beliefs and values are
challenged in clinical practice.
Walker (2001) commented that the irrational
nature of human reproduction is not easy to
quantify scientifically, and that there are a number
of problems associated with research on
psychological responses to abortion, partly
because women are often reluctant to participate
in this research (Howie et al 1997), and because
of the secret nature of abortion (Boorer and Murty
2001). However, Bennett (2004) argued that the
irrationality of a choice does not make the choice
immoral. He suggests that if we value individual
freedom to determine our own lives, then we
should also accept those decisions even if they
appear to have no rational justification.
Accordingly, if we accept abortion as a woman’s
right, the nature of that right does not alter despite
the number of times it has been exercised.
Whatever the women’s reasons for choosing
abortion, the role of the nurse is to provide
informed, up-to-date, objective care for those
involved. Most women, though not all, have
already made their decision to end the pregnancy
before approaching the health service and they
expect non-judgemental support, information
and prompt referral (Kumar et al 2004).
There is still much to improve in relation to
the quality and level of support given to women
throughout the pre and post-abortion period.
Discrepancies in access to abortion services in the
UK were highlighted in the House of Commons
health committee’s (2003) report on sexual health
with a postcode lottery for accessing NHS funded
abortions which varied between 46% and 96%
in some areas. The RCOG (2004) identified
that there are still large geographical variations
in access to NHS-funded abortion, and there is
much that we do not know about women’s
experiences in the long and short-term
following abortion.
Conclusion
Reflection has changed my way of thinking and
broadened my perspectives. For me the journey
through the reflective process has been difficult
because initially I was a little hostile to it, not
because of my beliefs and value systems, but
because the process and skill of reflection need
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to be learnt (Wampold and Holloway 1997).
Gordon (2004) concluded that whatever stage
of professional development practitioners are
at, they may benefit by occasionally trying out a
less familiar reflective strategy. Comfort with a
particular model or process of reflection might
not always challenge the person sufficiently to
think beyond the confines of the model and
therefore move forward.
Reflection enabled me to recognise that it
is not necessary that I know or understand all
of the reasons why patients make certain
decisions. Focusing on Jane’s situation helped
me to understand that not all patients will
agree with the advice or information offered
by healthcare professionals. Jane has changed
my way of thinking – not because of her
situation, but because the process of reflecting
on her case has shown me that I do not have to
spend more time searching for the reasons why
people do what they do. However, I do need
to accept their right to bodily integrity and
autonomy and I have found this liberating.
Reflection provided me with the opportunity to
assess how I deal with women requesting repeat
abortions and I now feel better equipped to
provide care that is objective yet sensitive to the
needs of the individual NS
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