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REVIEW

A new model of reflection for clinical practice

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Reflecting on practice and critical incidents is valuable, but complex frameworks can be hard to remember. A new model has been created to simplify the process

Abstract

Reflection is a tool that is commonly used as part of student nurse education and in clinical practice, and is often supported by the use of reflective models. It can help demonstrate everyday learning and is also useful for processing thoughts after a critical incident. This article describes a new model of reflection that ensures a thorough reflective process is followed and yet is easy to remember: users do not need textbooks to remind them what each stage covers and what they are required to do.

Citation: Barksby J et al (2015) A new model of reflection for clinical practice. Nursing Times; 111: 34/35, 21-23.

Authors: Justine Barksby is lecturer in learning disability nursing at the University of Nottingham; Nick Butcher and Andy Whysall are trainers at Sherwood Training, Nottingham.

Introduction

Reflection is a tool that is used extensively in health and social care, particularly in education but also in practice. While it is argued that reflection is a difficult concept to define (Clarke et al, 1996; James and Clarke, 1994, both cited by Bulman in Bulman and Schutz, 2008), Bulman (2008) describes it as “reviewing experience from practice so that it may be described, analysed, evaluated and consequently used to inform and change future practice”.

Reflection is used as part of portfolio development and evidence of practice-based learning. It is recognised as being a beneficial tool for use after critical incidents have occurred to help practitioners and students reflect on experiences and generate new knowledge. “Reflective writing is a valued tool for teaching nursing students and for documentation, support and generation of nursing knowledge. Reflection should be considered in a framework of self-awareness, context and in the domain of a broader perception of health and healthcare issues.” (Craft, 2005)

Current nurse education has a significant focus on research and evidence-based practice but often the reality that students face is “increasingly complex, uncertain and multifaceted realities of practice” (Fish 1991, cited in Burrows, 1995), which do not always neatly fit into existing research. Reflection can help you - no matter whether they are student nurses or qualified practitioners - to make sense of these realities. It can also help them gain new knowledge but, in some cases, it raises or highlights many researchable topics (Elliott, 2004) and new questions, rather than answers.

Most theories about reflection mention learning from the process as being an important element of it and state that this is one reason why the activity is incorporated into nurse education (Hannigan, 2001). Many models of reflection incorporate a stage of planning for future events as a way of illustrating that learning has taken place.

Problems

Despite the benefits that reflection can garner for those who engage in it, it is not without potential barriers or criticism. These include:

  • Inadequate preparation;
  • Excessive structure;
  • Concerns about who will read it, especially for student nurses (Craft, 2005).

The last point is of particular concern when the reflection is being used as part of a graded assignment or to demonstrate the achievement of outcomes for students in practice settings (Burrows, 1995). In striving to do well academically or gain approval from their mentors, student nurses may feel discouraged from taking part in honest reflection (Hargreaves, 2004) and, instead of recording their true experiences, are more likely to write what they believe their tutors or mentors want to read (Hannigan, 2001).

Further barriers include time - both the time required to develop the necessary skills and the time needed to record everything thoroughly. Some studies also suggest younger students have not yet developed the cognitive abilities necessary to be able to reflect (Burrows, 1995). Nevertheless, despite these concerns, reflection continues to be a regularly used requirement of many pre-registration courses for health professionals.

Why use a model?

Using a model when reflecting can help users focus on learning and self-awareness after an incident, and avoid simply retelling the events. Several reflective models already exist, many of which consist of similar stages. The model individuals choose to use is often based on their personal preference; however some are over-simplified and do not address all the relevant issues (they allow users to approach the process in a superficial way), while others are overly complex, more structured and prescriptive, and difficult to remember without a textbook in hand (Forrest, 2008).

One popular choice is Gibbs’ (1988) model, comprising the following stages:

  • Describe the event;
  • Identify your feelings;
  • Evaluate the experience;
  • Analyse the experience;
  • Draw conclusions;
  • Draw up an action plan.

While reflection is by definition about looking back, a forward-looking step is fundamental to make its use worthwhile to encourage learning. Although popular, Gibbs’ (1988) model is not easy to recall in the practice setting, and some of the stages are unclear and appear to repeat others. We decided, therefore, that a new framework was needed, which should be complex enough to have a thorough reflective cycle yet easy to remember so users do not need to have a textbook to hand. The REFLECT model (Box 1) was developed by Nick Butcher and Andy Whysall through their work as trainers in their company Sherwood Training; it forms part of the Positive Behaviour Support training package.

Box 1. The REFLECT model

The model comprises seven stages:

  • R - RECALL the events (stage 1) - Give a brief overview of the situation upon which you are reflecting. This should consist of the facts - a description of what happened
  • E - EXAMINE your responses (stage 2) - Discuss your thoughts and actions at the time of the incident upon which you are reflecting
  • F - Acknowledge FEELINGS (stage 3) - Highlight any feelings you experienced at the time of the situation upon which you are reflecting
  • L - LEARN from the experience (stage 4) Highlight what you have learned from the situation
  • E - EXPLORE options (stage 5) - Discuss options for the future if you were to encounter a similar situation
  • C - CREATE a plan of action (stage 6) - Create a plan for the future - this can be for future theoretical learning or action
  • T - Set TIMESCALE (stage 7) - Set a time by which the plan outlined in stage 6 will be complete

The seven stages of the model ensure a thorough reflective learning cycle takes place, while the mnemonic makes it extremely easy to understand and remember each stage. As a result, the model can be used from memory, making it more useful in the practice setting than those requiring textbooks.

Recommendations for use

This new model for reflection can be used in a range of ways:

  • To form the framework for a written piece of reflection so students can demonstrate learning to their mentors;
  • In practice;
  • As part of academic writing;
  • By both practitioners and students after a critical incident to help them explore their experience.

The term “critical incident” can mean any situation that generates strong feelings in those involved. It does not refer only to an extremely negative situation or an extremely positive one, where they “saved the world” (Elliott, 2004).

REFLECT in use

The following incident occurred at a service where Colin Green (name has been changed), a young man with autism, was receiving one-to-one support in his own one-bedroomed flat. It occurred at 3pm in the kitchen of his home. Mr Green assaulted Mary, a female support worker, by punching her repeatedly. She received superficial injuries - bruising to the face, arms and upper abdomen - but managed to get out of the flat and call the area office for support. Another member of staff was assigned to offer support. Mary was allowed to go home - she was shocked and upset, as well as being in discomfort from her injuries. The following day, the service manager, Steve, arranged and facilitated a debriefing session with Mary; this took place at the area office and followed the REFLECT model. Steve ensured the session took place in a private, comfortable room, and there would be no interruption.

Recall the events

Mary was encouraged to tell her story in her own words. Steve encouraged her to start from the beginning of her shift and describe in detail the events leading up to the incident. She reported:

“It was apparent that Mr Green had been preoccupied on my arrival. I had spoken to him, asking if he was alright. He said he was upset with the support worker [Jim] who had previously been supporting him earlier that day. After some discussion, it appeared that he was upset with Jim because he had unplugged Mr Green’s DVD player to charge his mobile telephone.

Mr Green became increasingly agitated during the conversation - he appeared tense and restless, his speech becoming repetitive. I offered him reassurance and to make him a cup of tea. I went to the kitchen and could hear Mr Green shouting “Jim is a bastard… bastard… bastard.” At this point Mr Green rushed into the kitchen screaming, his arms flailing. I was struck a number of times. I was unsure exactly how many or how long it lasted. I attempted to protect myself by blocking the blows with my arms.

“At some point Mr Green withdrew to his bedroom and I took the opportunity to leave the apartment. I went to my car and locked myself in. I then phoned the area office for support.”

Examine our responses

Steve asked Mary what she did in response to the challenging behaviour. She replied:

I had not anticipated the behaviour. I felt it was appropriate to offer reassurance prior to the incident and to offer to make Mr Green a cup of tea. During the incident, I was only able to attempt to protect myself by blocking some of the blows with my forearms. I had asked Mr Green to ‘Stop it! Please!’ on several occasions during the incident.”

Feelings: discuss emotional responses

Steve observed that Mary was clearly emotional as she recalled the events of the previous day. He asked specifically how she had felt at the time and how she felt now. Steve reported:

Mary explained that she had felt anxious when she had realised how upset Mr Green had been about Jim unplugging his DVD player. When Mr Green assaulted her she explained that she was shocked and frightened - she hadn’t seen it coming. It all felt a bit of a blur now but she did fear for her own safety and did not know how to respond at the time.

“Afterwards she was extremely upset, tearful and shaking. Now, she still feels extremely anxious and unsure of how it will be when she goes back to work. She also felt angry with her colleague [Jim] as, in her opinion, had he not unplugged the DVD player, this incident would never have happened. She stated that she did not blame Mr Green.”

Mary was offered reassurance that the team would work hard together to try to ensure similar incidents would not occur again. She was also reassured that she would not be expected to return to work until she felt confident to do so and when steps had been taken to ensure her safety in the future.

Learn from the experience

Steve asked Mary whether there was anything she felt could be learned from the experience. He reported:

Mary said that all support staff need to ensure that they do not interfere with Mr Green’s possessions - she felt that Jim’s actions showed a lack of respect towards Mr Green and the fact that where they work in his home. She also said that she would call for support if she discovered Mr Green in a similar state of distress/agitation in future and that she definitely would not go into the kitchen (where her exit could easily be blocked) in those circumstances.

“She recalled her training in autism and expressed the thought that Jim clearly had no understanding of the impact of his actions - that Mr Green was very particular about his possessions and, to her, it was no surprise that he had become so upset.

“Mary also said that she felt unable to protect herself and that some training in self-protection skills would help her feel more confident.”

Explore options

Steve discussed with Mary several possible actions including a review of Mr Green’s support plans, discussing his particular needs in team meetings and supervisions, along with the possibility of further training input for the team. Steve also felt it important that Mary receive suitable support as and when she returns to work, with the overall aim of the various options being to avoid similar incidents occurring again.

Create a plan of action

Steve agreed to record formal actions as a result of the debriefing session including:

  • Undertaking a formal review of the behavioural support plans;
  • Reminding the whole team will be reminded at the next team meeting of the importance of respecting Mr Green’s home environment and possessions;
  • Arranging autism awareness training;
  • Arranging accredited training in breakaway and self-protection skills;
  • Meeting again with Mary to discuss arrangements for her return to work.

Set clear timescale

Steve and Mary set dates against each action to ensure the planned actions were completed and in a timely manner.

Conclusion

Ultimately, the REFLECT model for debriefing led to a number of changes to Mr Green’s support plans and the guidance provided to staff. The training further enhanced the team’s understanding of his needs. Mary returned to work after seven days, with a second person to support her for the first two shifts. At this point, changes to the Positive Behaviour Support strategies were already in place and Mary felt more confident having clarity about what to do if Mr Green became distressed in the future.

Although there is already a plethora of models for reflection, REFLECT is a welcome addition due to the ease with which each stage can be remembered. It should be noted that there is an existing model that also uses the REFLECT mnemonic (Taylor, 2010) but this is much more complex and not as easy for users to recall.

This new REFLECT model can be used by students and practitioners in the practice setting or after a critical incident without textbooks being needed to remember each stage. This ensures the focus is on not on the framework, but instead on the process and what one gains from it.

Key points

  • Reflection can be a useful tool for both students and qualified nurses
  • Reflection can demonstrate that learning that has taken place
  • The use of models can help keep reflection focused
  • Models need to be easy to remember so they can be used without the need for a textbook
  • The mnemonic REFLECT makes the framework easier to remember than most existing multistage models
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