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DISCUSSION

A practical model for reflection on practice

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Models of reflection do not necessarily lead to useful insights. A new triangular model encourages shared reflection to gain deeper understanding of nurses’ practice

Abstract

Although nurses are encouraged to reflect on their practice from pre-registration education onwards, many are anxious about the process and unclear how it is done or what it can achieve. This article discusses approaches to reflection and presents a new, triangular model of reflection that encourages nurses to share their reflections and helps to ensure they gain useful insights from the exercise.

Citation: Lowry M (2016) A practical model for reflection on practice. Nursing Times; 112: 12/13, 12-15.

Author: Michael Lowry is lecturer in nursing at the University of Bradford.

Introduction

In order to continually improve the care they provide, nurses are encouraged to reflect in, and on, their practice. They are given this message from pre-registration studies, while its importance is now emphasised to qualified nurses by the inclusion of reflection as a key element of nurse revalidation (Nursing and Midwifery Council, 2015a).

Nurses are required to use the Code (NMC, 2015b) as a focus for reflecting on aspects of their practice, as part of their ongoing professional development and accountability.

However, reflection causes anxiety among students and qualified nurses alike. Many are unsure how to capture reflective moments and to make sense of them. This, coupled with largely superficial models with which to structure their reflections, means the potential for reflections to lead to meaningful deep learning is, at best, limited.

This article proposes a new model of reflection that is simple to implement and helps users reach constructive conclusions to their reflections.

Models of reflection

The concept of reflection is often considered as two-dimensional, wherein a focus is selected, thought about and then written as a report. However, if the process is to deliver meaningful learning it cannot be merely two-dimensional. An observer who looks into a mirror will see a reflected image. However, it is what is done with that image that aids learning. In order to make changes to what we understand, and by implication to learn, we need to examine the focus from a range of perspectives and not just the one simplistic reflected viewpoint.

Established theoretical models for reflection encourage nurses either to operate in a cycle (Johns, 1995; Gibbs, 1988; Kolb, 1984) or follow a list or linear passage (Barksby et al, 2015). However, it is simply processing imagery back and forth in the same way that a mirror returns a different, though recognisable and otherwise unaltered, image back to the observer. Other models, such as REFLECT (Taylor, 2010), are criticised by Barksby et al (2015) for being too complex, a point raised earlier by Forrest (2008). Theories of reflection range from simple models for structured reflective writing to more elaborate approaches, such as that of Schön (1987), in dealing with the complexities of professional development and the development of expertise.

Where models of reflection are linear or cyclical they miss the point, as to reflect meaningfully means more than to think in an unidimensional way. In order to maximise learning value, reflection must fully engage the reflector and must be reiterative. In fact, if it is to offer any meaningful insights, reflection needs to be multidimensional. This can be illustrated by looking at an object, say a vase of flowers on a table, from one side of the table then the other: this yields very different images of the same object.

In a similar way, increased benefit is likely when reflections are shared and nurses use constructive comments from others to help them develop better insights, a point highlighted by Knight (2015) in an article introducing the benefits of sharing matters for reflection. Students in a study by Reeves et al (2002) were positive about the opportunity to share reflections within a team, especially where they were able to examine issues to do with managing their clinical experiences, and the extent of their emerging practice.

Currently, there is no agreement as to what reflection actually is and, while it is popularly espoused, there is little empirical evidence to support its use in practice, or to demonstrate that a reflective practitioner is any more effective than a non-reflective practitioner (Sumsion and Fleet, 1996). In short, we could have an attractive concept without evidence of value added.

Supporting reflection

Focusing on the practical development of reflection raises issues related to summative assessment, and the question of whether we would be assessing the process or product. Added to this is the question of honesty in reflective accounts, especially in cases where those doing the reflection have a negative view of the process and the volume of work involved. This is particularly important where, for example, neither students nor their mentors or teachers have a clear grasp of what is needed, and is compounded by staff who themselves might be unconvinced of the benefits of reflective writing compared with following a well-trodden, though perhaps ineffective, path.

A key distinction between reflective and non-reflective teachers and nurses is said to be whether they act predominantly on the basis of “routine action” or “reflective action” (Schön, 1987); therefore, it is what is done with reflection that makes the difference.

In education, there are attendant legal, professional and ethical concerns for example whether we should require students to commit their thoughts to print if these may be used in evidence (Craft, 2005). Similarly, simply recording reflection in journals might lead to a safer and more sanitised account than if they are discussed with others, as their one-sided nature misses more honest input from constructive others.

Cases where poor practice or other potentially problematic incidents are identified, place unacceptable responsibility on the educator, mentor or colleague with whom they are discussed, who could have a professional responsibility to act on them.

Consent guidelines are required if students are discussing patient care outside the clinical area, so they might need to ensure informed consent from patients or be given clear guidelines on maintaining patient confidentiality. Another question arises as to whether we can reasonably demand that students explore emotive issues, without first having in place means for supporting those students in times of trouble.

In my experience, students are often unsure how to start reflection. This can depend on individuals’ preferred learning styles; Honey and Mumford (1986) describe learners as:

  • Activists;
  • Reflectors;
  • Theorists;
  • Pragmatists.

While it is outside the scope of this article to consider learning styles in detail, the concepts do suggest that some people will find reflection more in tune with their preferred ways for learning, while for others it will be less so.

There are a number of other considerations for supporting reflection. In the same way that individuals may find it difficult to begin any piece of set work in comparative isolation, reflecting will benefit from there being someone who can share issues and offer alternative perspectives. A critical friend will, by definition, need to be trustworthy, as some of the thoughts to be reflected on might be sensitive. Feedback ensuing from this critical friendship needs to be honest if it is to bear fruit and, as with any relationship, the friendship needs a sound foundation in order to withstand moments of disharmony.

There is no consensus as to how much time anyone should spend on reflection, nor any idea as to what length of time yields most benefits; as with study in general, this varies with the individual. However, one constant is the need to actually engage in the process (Bulman and Schutz, 2013).

Reflective versus ritualistic practice has long been a focus for debate in nursing (Carney, 2000). Although general support is expressed for reflective practice, it is fair to say that what transpires tends, in some cases, to be more reliant on comfortable ritual rather than the challenges posed by new, and perhaps counter, insights. If the idea is to be sold to students and nurses, all parties need to be willing to honestly recognise inconsistencies in reflection, and be open to change and new ideas.

“Critical incident analysis”, another phrase often associated with the process of reflection, suggests that whatever is to be the focus for reflection needs to carry some significance. It is almost as if every-day matters are too mundane to be a focus, which raises an interesting question about how we identify what is a “critical” as opposed to “significant” or even “interesting” incident. Perhaps, as Elliott (2004) suggested, we place too much emphasis on the need to dramatise an issue before it is deemed worthy as a focus for reflection. It could be argued that it is the mundane that sheds the brightest light on what we understand, and how we interpret ourselves and the world in which we operate.

Student nurses may need to take risks in order to learn about and improve their practice – a point noted by Hannigan (2001) – and can be said to work in what Schön (1987) described as “swampy lowlands”, referring to areas of indeterminate understanding and knowledge, and where there are few if any certainties. This idea of “swampy lowlands” is said to illustrate where nurses are accustomed to thinking on their feet and acting accordingly in response to everyday realities of practice (Hannigan, 2001). If we accept that these everyday realities are often indeterminate, then we have a fertile field for reflection.

New model for practical reflection

The new Reflective Triangle model proposed here (Fig 1 attached) consists of three elements: case, context and variables, which are considered in detail below. It is designed to be reiterative; this involves revisiting each element (in any direction) until a point is reached similar to what some researchers term “saturation”, when no new meaning emerges. Using this model makes clearer those issues that the reflector might otherwise skip over and miss the essence of.

Case

The setting for any reflective process must begin with the simplest understanding; that of the overviewed “case”, which the observer considers to contain elements worthy of examination.

A case is at its most raw when “described” – and this word is important; the reflector must first objectively describe the case without any attempts to deconstruct or interrogate it.

In a philosophical sense, a case can be compared with a legal construct; a number of facts comprising something that could have shared meanings but is yet to be clarified. The concept of “shared” is similarly important; however, the interpretation of meanings from any shared case is driven by experiences – both real and existential – of the person perceiving it; each individual will bring something quite unique to the same case.  The important thing at this stage is for a statement that collects the imagery necessary to form an understanding of the shell of the problem (either a difficulty or matter that demands attention). “Problem” in this sense may be as diverse as which flavour ice cream to choose, whether to drive a car over a bridge that appears unstable, or how to deal with a difficult interpersonal encounter. It is impossible to problematise anything unless a case is identified and described.

Defining the case should take very little time compared with other elements of the process involving reflection, subsequent to which is deeper meaning and enhanced understanding.

Context

Having defined the case, the next part of the reflective process involves placing this in context. Context will be multifaceted and cannot be moved on until described in sufficient detail that all salient features affecting the case can be teased out. These factors will have moved the reflector into the current position. For example, if the case is ‘why am I reading this article?’, then the context could include, for example:

  • My intrinsic interest in the concept of reflection;
  • Needs driven by expediency – for example, I have to present an account of my reflective writing;
  • My need to prepare an account of a problem for my employer.

At first, the context will often seem to be relatively straightforward; however, when the focus begins to clarify this, many relevant issues often emerge that seemed invisible at the start of the process. Narratives – brief stories of events related to the initial case – can help to set it more clearly into context.

Variables

Having determined the nature and extent of the case and made explicit the context within which it exists, it is necessary to determine which variables are relevant  to understanding the case in context. Variables can include anything that impinges on the case or problem. For example, if I had to reflect on a work-based case such as awareness of a difficulty between myself and a close-working colleague, the variables might include:

  • Our relative position in the workplace hierarchy;
  • The amount of experience relevant to the nature of our employment;
  • Qualifications and personal work credits, such as how well we understand ourselves to be viewed by others;
  • Our track record of achievements in the job;
  • Feelings for the other person;
  • And how I think the other person perceives me.

Having exhausted all input to determining the nature and extent of the case, prepared an inventory of the constituents of the context, and identified all relevant variables, we are already beginning to reflect. The case might remain a relatively constant construct, at least initially, but our understanding of it will change; this is the rationale behind why we are to reflect on it – if the case remains constant then the reflection is a fruitless journey. The only reason to reflect on a case is to better understand it.

Conclusion

Reflection as a reiterative process has no finite parameters; therefore, at some point – usually when nothing new emerges – the process must be declared complete, at which point we can make a declaration of new meaning and enhanced understanding. Reflection need not be onerous and, with a simple framework, can lead to better understanding of issues. At the same time, the process encourages more critical thinking that, in turn, aids development of the individual.

Box 1. Sample reflection

Below is a set of circumstances that will be familiar to most people; the example is not intended to be exhaustive, but to aid insight into the process.

Case: I find myself becoming increasingly irritable and making mistakes at work.
This is as far as it needs to go at this stage.
Context: I have been dealing with a complaint by an angry relative of a vulnerable patient. I feel it is unreasonable. Lately I have had concerns over my competence at managing my job. There are shortages of staff at work.
This sets the issue in context.
Variables: I have not had a holiday for a year; I have worked lots of overtime due to staff shortages; I am not sleeping very well; people keep telling me I am looking tired and unhappy.

So now think again and try to clarify the issue(s) and revise the case. I might discover I am feeling under-confident and resentful, over tired and lacking in personal resilience. The encounter with the angry relative has knocked back my confidence, and I feel unsupported by managers due to inadequate staffing at work. If we start to explore the above we get a revised case.

Revised case: I am feeling fatigued at work, prone to mistakes and less able to deal with challenging encounters.
Revised context: I am aware of being overworked due to shortages of staff; I am becoming resentful towards my managers, this leaves me tired and prone to mistakes. My lack of confidence makes me prone to take difficult encounters personally, which further damages my confidence.
Revised variables: I have the option to be in control; I need to resume control over my work; I have the wherewithal to take a break; My friend is ready to take a break; I can request leave due. I need to confide in someone and can make an appointment with staff counselling.
Further revisions leading to constructive/positive change: I am aware of being overworked and at risk of error. I have become dispirited and realise the need for time out. I have an opportunity to take a holiday with my friend. I can afford to take this break, which will enable me to refresh. I will keep an appointment with staff counselling next week.

As a result of the above process, a new and clearer picture emerges that can help to set the initial problem into focus and make it more manageable. This process would go through a series of iterations until a point is reached where nothing materially new emerges.

Key points

  • Nurses are encouraged to reflect on their practice both before and after qualifying, and are required to do so to revalidate with the Nursing and Midwifery Council
  • Many students and nurses are unclear about the reflection process 
  • Reflection on and in practice can enable nurses to develop deeper understanding of their work
  • Shared reflection can help nurses gain greater insight
  • Current reflective models fail to encourage the deeper reflection needed to understand how to improve practice 
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