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Discussion

Using reflective practice in frontline nursing

Reflective practice can be used to help nurses to make sense of work situations and, ultimately, to improve care. A simple, three-stage model is proposed.

 

In this article…

  • The theoretical basis for reflective practice
  • A three-stage model for practical reflection
  • An example of the model in practice

 

Author

Natius Oelofsen is consultant clinical psychologist, learning disabilities service, Norfolk and Suffolk Foundation Trust and director of Reflective Learning, a consultancy dedicated to advancing reflective practices in health and social care settings.

 

Abstract

Oelofsen N (2012) Using reflective practice in frontline nursing. Nursing Times; 108: 24, 22-24.

Reflection on practice is a key skill for nurses. Engaging in regular reflection enables practitioners to manage the personal and professional impact of addressing their patients’ fundamental health and wellbeing needs on a daily basis.

This article briefly reviews the theoretical background underpinning the idea of reflective practice. A simple, three-step model for practical reflection is presented, which is based on theory and grounded in practice. The three-stage cycle is illustrated with a fictional clinical example to show how this reflective method can make a difference in busy practice settings.

Keywords: Reflective practice/Reflective cycle/Professional development

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Related Stories’section of this page

 

5 key points

  1. Reflective practice is a key skill for nurses
  2. It enables nurses to manage the impact of caring for other people on a daily basis
  3. Reflective practice can be defined as the process of making sense of events, situations and actions in the workplace
  4. A range of models are available for nurses to use to support reflective practice in clinical practice
  5. Effective reflection can take place individually, in facilitated groups, or a mix of both

 

Reflective practice can be defined as the process of making sense of events, situations and actions that occur in the workplace (Oelofsen, 2012; Boros, 2009). Although many, if not all, initial nurse education programmes (leading to registration) include modules on reflective practice, organised opportunities to reflect are rare in the busy, pressurised world of frontline practice.

I believe that scheduling time for reflection in practitioners’ busy day-to-day lives in frontline services is essential for improving service quality, providing much-needed support to staff, and facilitating team members’ professional development. In this article I offer a simple reflective method, which can be used in frontline settings to support effective reflective practice, together with its theoretical rationale. I conclude by offering a simple example of how such a reflective process might look and the kinds of outcomes that can be expected from using the model in everyday practice.

Theory of reflective practice

In frontline settings such as hospitals, mental health wards and community services nurses have important roles in addressing basic human needs related to the physical and mental wellbeing of patients and service users. Working reflectively in these settings is important for nurses for a variety of reasons, including:

  • There is an emotional cost to nurses of caring for others who are vulnerable. This is a result of nurses being confronted with deep-seated human needs and anxieties on a daily basis;
  • They need to be change agents in the lives of people who use their services.

Interpersonal skills, self-awareness and the ability to influence others towards positive change are, therefore, key skills for nurses. Reflective practice facilitates the development of these skills by fostering an understanding of practice events and how one’s own approach, personality and personal history contributed to the way situations arose and how they were dealt with (Oelofsen, 2012; Somerville and Keeling, 2004).

Theoretical approaches to reflective practice draw on, among others, ideas from adult learning theory (Kolb, 1984), and the work of educationist John Dewey (1933) who came up with the concept of “reflective thought”. According to Dewey, this consists of:

  • Developing a sense of the problem at hand;
  • Enriching that sense with observations of the relevant conditions;
  • Elaborating a conclusion;
  • Testing that conclusion in practice.

Reflective thinking therefore serves to “transform a situation in which there is obscurity, doubt, conflict and disturbance of some sort into a situation that is clear, coherent, settled and harmonious” (Dewey, 1933).

At its heart, reflective practice therefore starts with curiosity about a puzzling situation and, ideally, should conclude with a sense of clarity and understanding. In frontline settings this often involves making sense of human frailties such as physical and mental ill health, the dynamics of the relationships between people and the systems in which they function, and practitioners’ own responses to the situations they encounter in the course of their work.

Looking back at Dewey’s original observations, developing a sense of the problem at hand and enriching that with careful observation hint at a process of looking closer, which involves finding ways of answering the questions that were raised by an “obscure” situation. The reflective process ends with conclusions that are tested in practice - a process that involves transforming puzzles and questions into practical action.

A large number of models of reflective practice are available for nurses to choose from (Ghaye and Lilyman, 2006; Driscoll, 2000; Gibbs, 1988). Many, if not all, of these fundamentally encourage nurses to engage in the process described above. For example, Gibbs (1988) proposed a reflective cycle that starts with describing a practice event and then cycling through the following stages in turn:

  • Identifying your feelings;
  • Evaluating the experience;
  • Analysing the experience;
  • Drawing conclusions, including alternative actions, that you could have taken;
  • Drawing up an action plan for the future.

Taylor (2006) proposed a similar model, and added a number of helpful, practical perspectives about the emotional processes surrounding reflective practice. In order to begin reflecting, she felt it is important to purposefully prepare oneself for the process by cultivating an internal silence - even if only momentary - which enables thought processes to begin.

Thinking involves a number of actions in which practitioners do not routinely engage, such as:

  • Drawing on personal experiences and memories;
  • Asking difficult, sometimes technical, questions;
  • Thinking about broader aspects of the situation at hand, for example social or political factors.

These actions all form part of this aspect of reflection.

Taylor’s next phase involves being open to answers and, perhaps in contradiction to Dewey’s ideas mentioned above, also being open to partial or incomplete answers. As she stated: “Some questions may remain puzzles” (Taylor, 2006). The reflective process concludes with embracing insights from a variety of sources that serve to change practitioners’ awareness. Finally, there is encouragement to remain tenacious in engaging in reflective processes.

A framework for practice

Drawing on these ideas, I propose a simple, practical framework for reflection that nurses at all levels of the profession can use. The model was developed in practice, while working with teams of practitioners in a range of health and social care settings, across a range of professional groups. The reflective cycle I propose has three stages (Fig 1).

Step 1: Curiosity

This step involves noticing things, asking questions and questioning assumptions. In step 1, nurses ask those questions that will support making sense of the situation on which they want to reflect. Questions include:

  • What exactly happened?
  • Why did we deal with the situation in that way?
  • What else could be happening?
  • What was it like from the patient’s perspective?
  • What are my feelings about the situation?
  • How did it affect me?
  • What was the impact on us as a team when that happened?

Step 2: Looking closer

This step involves actively engaging with the questions from step 1. Reflective practitioners do what is needed to find out more, “zoom in” on experiences and feelings, “slow down” their own thinking and actions for further contemplation, and open themselves up to a variety of different (perhaps contradictory) perspectives. In this step, reflective practitioners try to find ways to articulate the phenomena that were noticed in step 1 and to be aware of all the relevant underlying assumptions that are prevalent in their own practices.

Step 3: Transformation

This phase is all about turning sense-making into action. Using observations from the first step in conjunction with the insights gained from “looking closer”, the transformation phase is about finding ways to articulate content and process in a format that allows positive changes to be made. Like all useful reflective practices, the aim of this phase is to take action that leads to better practices and, ultimately, service improvement.

Format

Effective reflective practice can take place individually or in facilitated groups or, best of all, as a combination of both. Having access to a reflective group with a skilled, independent facilitator who is not involved in the team’s work can have a number of advantages, including:

  • The ability to share similar experiences with colleagues;
  • Gaining others’ perspectives and support;
  • Feedback in a non-threatening setting;
  • Opportunities for guided practice (Oelofsen, 2012).

Box 1. Fictional case study of reflective practice

Cassius Smith is a student nurse on placement in a learning disability assessment unit for people with challenging behaviour. Last week Jenny Rogers, aged 23, who has moderate learning disabilities and autism, was admitted to the unit due to increasing levels of self-harm and aggression towards her carers. The staff noted that no family members had any involvement with Ms Rogers.

Cassius has never worked with people who have learning disabilities before. Since Ms Rogers’ admission, he found himself dreading going on to the unit and was tired after his shifts. While on shift, he was professional and treated all patients with respect, but something about his experience there bothered him. As a first step in trying to make sense of what was happening, he tried to use the three-stage reflective cycle to help him, and made the following entry in his reflective journal:

Curiosity

I am really upset about my reaction to Ms R’s admission. No one else coming in bothered me and she did not either, really, but why do I feel so upset going in to work ever since she came in? Why am I so tired at the end of my shifts? Actually, what am I feeling?

I think I am very sad when I think of Ms R - it’s as though everyone has forgotten her. The way her carers talk about her, even they appear to only notice her when she hurts others or harms herself. And her family is completely off the scene. I hate seeing that. But what is it in me that links these feelings to Ms R, rather than to some of the other people on the unit?

Looking closer

I spent some time reflecting in the library this morning and suddenly realised with a shock that one of my mother’s sisters was disabled. I’d forgotten about that. No one in the family ever talked about her much - I think the last time she was mentioned was more than five years ago and I recall they mentioned she was placed in a home. I think she had died there a few years previously, but I am not sure. Perhaps something about Ms R reminded me of her, although I never met her. I think it’s sad that our family forgot about my aunt. Perhaps times were different a few years ago?

It’s important to me that something in my family and my history that I almost forgot about had such a powerful impact on my work life.

I will need to make sure I deal with this as soon as possible.

Transformation

Thinking about the issues raised for me by Ms R’s admission has opened my eyes to how easily even forgotten parts of my own history can intrude on my work life. I am so glad I remembered about my aunt, because if I didn’t, this would always have stayed a puzzling situation for me.

I am going to take my personal reactions to my supervision, but it might also help others if I share this with the reflective group at college. I won’t be the only one who has had the experience of my own life affecting my work. I also wonder if I can do some work at the unit looking at how patients can be helped to remain in touch with the people who are important to them. I’ll ask the staff nurse about what the unit is already doing and whether there is scope for me to do my assignment on this topic.

The model in practice

Box 1 features a fictional example of how the three-step reflective model can be used in practice to support staff practice and development.

Even this relatively straightforward example shows how having a personal reaction to a patient that directly relates to an aspect of the practitioner’s personal life can have profound implications for their ability to work effectively and safely but, if dealt with properly, has the potential to lead to service improvements. Reflective processes such as the three-stage cycle can support this as shown in the example.

As the example in Box 1 also illustrates, it is not uncommon for reflection to involve practitioners being confronted with personal issues that relate to their work lives. These should not be swept under the carpet but, rather, dealt with supportively. As such, reflective practice needs organisational support and “buy in” from managers. In my experience, this can best be achieved by organising regular facilitated group work that is carried out in team contexts with trained facilitators. These facilitators should be independent of the team in question (although they may still work in the same general setting).

Conclusion

Finally it is worth noting that reflective processes such as the one described here are often open-ended and iterative - the conclusion of one reflective cycle leads to the inception of another as practitioners’ awareness of their own processes increases. As the answers to one question lead to further questions for reflection, so the reflective process gathers momentum, thereby sustaining itself.

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