VOL: 98, ISSUE: 09, PAGE NO: 38
Julie-Ann MacLaren, MA, BSc, RGN, DipN, is Macmillan lecturer/practitioner;Mary Woods, BSc, RGN, OncCert, is senior clinical nurse specialist;Jenny Smith, RGN, OncCert, is clinical nurse specialist;Jennie Gilbert, BAppSci, RGN, OncCert, was clinical nurse specialist;Cleo Dlomo, BSc, RGN, OncCert, was clinical nurse specialist;Larisa Villar-Hauser, BA, was manual lymphatic drainage therapist; all at the lymphoedema services, the Royal Marsden Hospital, Sutton
Reflection is a buzzword in nursing. With nurses now required to show evidence of continuing professional education and learning in line with PREP guidelines (UKCC, 1999), reflecting on practice is seen as an accessible form of learning. It aims to bridge the gap between theory and practice and show the interrelation of skills and knowledge. However, many nurses are reticent about reflecting on their practice, despite the potential benefits.
Callister (1993) sees reflection on clinical events as an expansion of cognitive learning. She argues that it can shift the emphasis to the human side of nursing, as opposed to the biomedical model which values only scientific knowledge (Barnett, 1994).
Taylor (1997) comments that personal knowledge and experience are often seen as unwelcome influences that taint professional practice. However, Ramsden (1992) shows that people’s perceptions of tasks, motivation and interest are intrinsically linked to their experiences.
The consensus of writers in this field is that reflection can help to bridge the theory-practice gap (Jasper, 1998).
An evidence-based model of care, which is predominant, requires nurses to show that their patient care is based on research. This implies that they should be able to demonstrate the principles that underpin that care. Callister (1993) advocates the use of professional journals to record events, and reactions to these events, as a way of shaping future care delivery.
Reflection and the specialist nurse
The emergence of the specialist nurse in both nursing practice and literature has highlighted the question of how nurses reach this higher level of practice.
Benner (1984) notes that expert knowledge is the kind of knowledge a practitioner cannot always explain to others, but which is built up through the experience of nursing. It allows the practitioner to circumvent ‘logical’ problem-solving processes to arrive at solutions. This is illustrated by the way in which nurses supposedly working at an advanced level of practice are often unable to explain why they followed a particular course of action.
Rolfe (1998) argues that it is necessary to distinguish between practical knowledge (knowing how) and theoretical knowledge (knowing why). He suggests that, instead of acting on intuition, specialist nurses should reflect on previous events to build new theories, which must be tested and re-tested in practice (Claxton, 1984). In this way reflection becomes an exercise in the critical analysis of care (Atkins, 2000).
This is at odds with Benner’s (1984) notion of specialist nurses as practitioners who may not always be able to tap into the tacit knowledge on which they base their advanced practice. She suggests that asking people to critique the evidence for their work reduces productivity and undermines their ability to function at an advanced level.
However, unless tacit knowledge is made concrete, the possibility of learning from specialist nurses is limited as less experienced nurses may not recognise their authority.
Two members of the lymphoedema services team at the Royal Marsden Hospital in Sutton are involved in administering and teaching a five-month educational module titled ‘Lymphoedema management for health care professionals’. The students are encouraged to maintain a reflective journal documenting their experiences of patient care throughout the course.
Those studying at academic level 3 have to present an assignment of about 1,000 words. The aim is to develop students as competent practitioners who can reflect on previous experience in planning and delivering lymphoedema care.
Having never been involved in marking this type of assignment before, the module leaders were keen to come to grips with the difficulties and benefits of writing reflectively. For this reason a team meeting decided that each member of the lymphoedema services team should attempt to write a short reflective narrative, documenting an experience encountered in their normal working life.
Each team member was asked to document an episode or series of episodes that he or she felt able to reflect on and which had led to increased knowledge or understanding of patient care. Staff members were given the same instructions as those issued to students taking the course. The aim was to familiarise them with different styles of reflection, give them experience in marking reflective practice assignments and aid discussion and feedback on day-to-day experiences in the clinic.
Team members who were not involved in developing the module were initially sceptical about the exercise. They expressed feelings of vulnerability and felt that reflective practice was ‘just another assignment’ and an artificial way to test students’ reflection. Some commented that reflective practice was an exercise in manipulating the facts to suit the story.
Both Hargreaves (1997) and Cameron and Mitchell (1993) acknowledge that feelings of vulnerability can be a stumbling block in eliciting reflection from students.
Members of the team experienced this, with one stating that reflective practice had ‘become a very sophisticated instrument of mental torture’.
Paterson (1995) stresses the importance of supervision, which must be based on a relationship of trust and confidentiality. In this climate the person being supervised is encouraged to challenge the conflict between theory and reality, which can be stressful.
Paterson (1995) also notes that a fear of criticism from lecturers may increase feelings of vulnerability. We wanted to find out whether this could be a barrier to reflection as a tool for professional development, so the team’s reflective articles were peer-reviewed, with each member reviewing another’s reflective practice. Fears and vulnerabilities were aired before, during and after the project to gain some idea of how reflective practice might engender such fears in students.
Despite initial reservations, all team members commented that they had felt reasonably comfortable about documenting their experiences. This was enhanced by the dynamic of the team, which is friendly and non-competitive. However, members acknowledged that students might find the prospect of having their reflections marked more daunting.
Validation of own practice
In general, the team felt that writing down their reflections and reading other people’s had reassured them about their own practice and ability to solve problems. Improved communication on clinical issues also aided team morale by increasing members’ understanding of their colleagues’ working lives.
One team member commented that matching theory with practice had set her on a steep learning curve, but that it had been reassuring to realise that her clinical practice was developing apace with knowledge in the field. The process of applying theory to her own experiences had enabled her to recognise this.
Relevance to practice
Hargreaves (1997) suggests that reflective practice is often included in professional education programmes as a way of encouraging practitioners to critically evaluate their behaviour, beliefs and ideas on practice. She states that this will lead to improved clinical expertise and, consequently, improved nursing care.
Comments from the team on reflective practice included a general consensus that structured reflection was useful to students, but one nurse felt that it was not particularly appropriate for ‘a clinical nurse specialist with two years’ experience in the field’. However, she was aware that reflection was something she did regularly - she just did not feel the need to formalise it by writing it down.
Other team members highlighted the difficulty of selecting one particular moment to reflect on and write about. They thought it was artificial to present an account of a single incident and felt it might be out of the context of their normal working behaviour. However, they acknowledged that suitable incidents might be easier to select if they had to complete a reflective journal on an ongoing basis.
Relevance to the educational module
Both the reflective extracts and the ensuing discussions revealed a range of styles. Some reflection took place while team members were engaged in day-to-day practice. This mirrors Schon’s (1984) concept of ‘reflection in practice’ and probably acts as the mechanism by which certain specialist nurses justify their behaviour and actions.
Reflection after an event (reflection on practice) was also noted. This allows the practitioner to critically examine the experience and respond to it in relation to current theory, literature and research.
There were also significant differences in the style and content of the reflective extracts. This challenged general perceptions of what constitutes a legitimate incident for reflection. As specialist nurses, members of the team tended to reflect on the complexities of ‘expert’ practice.
In this respect, the exercise cannot be used as an indication of students’ practical concerns. The benefit of this exercise in terms of education lies more in highlighting the different styles of reflection and identifying the way in which team members choose to reflect on particular events.
Nurses need to consider their reflections on a regular basis if they are to benefit their practice. While reflection or intuition in practice may be commonplace, it is important to keep checking this against current theory and acceptable practice. Nurses need to be able to justify specialist practice in the light of evidence-based care and accountability. Keeping a journal may also be an accessible way to keep up to date with PREP requirements.
Writing reflective accounts can be a useful way to examine the knowledge underpinning health care professionals’ practice.
Generally, this exercise worked well. The opportunity to practise reflective writing and read colleagues’ accounts gave the team an insight into the use of reflective journals as an educational intervention.
However, the main benefit was in giving team members an opportunity to critique their own responses to their practice and compare experiences with colleagues. This affirmed their skills and experience, and improved team communication and morale.