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DISCUSSION

Realising the benefits of reflective practice

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Facilitated reflective practice groups are a good way of equipping NHS nurses to deal with increased work pressures. This article explains how they work

Abstract

Reflective practice is necessary in nursing as the job carries with it a high emotional cost and the difficulties and uncertainties that nurses encounter in their daily work - particularly in the current NHS, which is highly pressured. This article explains the process of reflective practice, the theory behind it and how it can be used to benefit nurses and their practice. Drawing on work undertaken in one trust, it shows that it is reflective practice groups, with particular benefits for multidisciplinary teams.

Citation: Knight S (2015) Realising the benefits of reflective practice. Nursing Times; 111: 23/24, 17-19.

Author: Sarah Knight is counselling psychologist at Psychotherapy for Healthcare, London.

Introduction

The growing needs of an ageing population, increased financial pressures and ever-rising public expectations are placing a heavy burden on the NHS. NHS England’s chief executive, Simon Stevens, describes it as “the biggest challenge in its history’ and emphasises the need to work together on ‘the biggest effort the NHS has ever seen” (Campbell, 2014).

On the front line, nurses are responsible for patients’ physical, emotional and psychological needs but are experiencing unprecedented levels of stress and ill health as a result of these pressures (Ford, 2014). It could be argued that there has never been a greater need for nurses to engage in reflective practice to improve their understanding of themselves and their practice, so they can take better care of themselves and their patients.

Reflective practice has been described as the process of “learning through and from experience towards gaining new insights of self and/or practice”, often by “examining assumptions of everyday practice” (Finlay, 2008). It is a key element of continuing professional development and part of the Nursing and Midwifery Council’s revalidation requirements (NMC, 2015).

Reflective practice is widely assumed to be part of healthcare practice, and its nature and evolution is well documented (Gibbs, 1988; Schön, 1983; Dewey, 1933). However, it is often loosely defined, and may be seen by hard-pressed nurses as just another pressure on their time, rather than something that will help make their job easier. In a world that prizes certainty and speed, assessment and statistics, the idea of pausing, engaging with feelings and staying with uncertainty, is often viewed with suspicion and cynicism.

In this article we will show how reflective practice can be a useful, efficient and valuable element to nursing, especially when carried out in facilitated groups.

The need to reflect

Nurses work in an environment that displays human vulnerability in a striking way and involves witnessing trauma, injury and distress on a daily basis. Nurses are continually exposed to human frailty that could easily relate to themselves or those close to them. What is deemed a critical incident to most people soon becomes the norm in nursing practice, or “just part of the job” - which means the emotional cost of nursing can be neglected.

Nursing is, to some extent, aligned with the medical model, equipping practitioners to address medical matters with a clear intervention to resolve a problem. However, nurses frequently face interpersonal encounters that are uncertain, with no obvious “right” way of doing things. They must respond to patients’ non-clinical needs, families’ demands and emotional needs, and disparity between professionals. This is often when they experience most anxiety, and when they also need support.

What is reflective practice?

Recognising the emotional cost of nursing is core to reflective practice. Nurses’ response to their work may involve difficult thoughts and feelings as a result of working with vulnerable individuals in a highly stressful environment. Reflective practice explicitly considers the emotional effect nurses and patients have on each other, and what practitioners can learn from their thoughts and feelings. Instead of being denied or discounted, their thoughts and feelings are valued and examined carefully and with interest, to gain new insights to inform future work.

In their daily work nurses might want to hide their feelings of uncertainty and unease. However, in reflective practice uncertainty is not something to be avoided or suppressed, but takes centre stage. Learning to tolerate the “not knowing”, and the anxiety this evokes, allows practitioners to reach an authentic place, in which they acknowledge there are often no right or wrong answers. They are able to:

  • Take responsibility for their thoughts, feelings and behaviours;
  • Think how these impact on their work;
  • Think what changes they might make.

The reflective process involves people openly looking at and challenging themselves and increasing their self-awareness. This may feel uncomfortable at first, but the insights it gives can help people make sense of confusing and challenging situations and find better ways to respond. They are able to view their responses with greater compassion, and recognise when they need extra support.

Reflective practice permits involvement of the whole person in their work, rather than separating out acceptable and non-acceptable feelings. This helps nurses fully engage with their work which, as well as increasing their interest and motivation, improves their care of patients. Giving them the opportunity to look more closely at themselves in a safe and nurturing environment allows them to become more present for their patients and more able to respond effectively to individual needs.

How is it done?

A range of different models of reflective practice have been developed for various professional groups (Johns, 2013; Brookfield, 1995; Kolb, 1984). None of the models provides a definitive answer (Finlay, 2008) but most depict a circular process, as in Gibbs’ (1988) example (Fig 1, attached). Typically, engaging in reflective practice involves the following steps:

  • The starting point may be feelings of discomfort relating to a particular patient or concern about the individual’s pattern of responding to certain work scenarios;
  • The person is encouraged to look more closely at these experiences and listen to how they respond internally. This process of looking and listening might involve questioning, exploring and analysing;
  • Consideration is given to the practitioner’s personal history and personality, and to thinking more about the particular patient or colleague involved;
  • Assumptions that may have led to set ways of behaving or responding (for example, about how men or women usually behave) are highlighted and challenged;
  • The person experiences a shift away from feelings of discomfort or concern to making sense of responses and experiences, and can use this to consider applying something new to future practice such as responding differently to situations. Greater self-awareness helps them make sense of difficult feelings;
  • Individuals test out what they have learned as further situations arise.

The effect of reflective practice on the individual and their practice is illustrated in the fictional example described in Box 1. Here, the nurse gains a better understanding of what causes her discomfort and why she responds as she does. This increases her tolerance of the situations that cause her anxiety and allows her to be more present for those who need her help.

Box 1. Reflective practice in action: an example of how using reflective practice can help a nurse

Mrs Green is in her 70s and has a cancer that is difficult to treat. Her daughter, Mary, visits regularly and often questions me about her mother’s prognosis. I encourage her to stay positive, but I am never sure what to say. When I see her I feel a bit trapped and on edge. In my reflective practice group, I have been able to explore my experience further.

I hate not having answers. The doctors do not know what the outcome will be and I know Mary has been told this. Not being able to give her any clear information makes me feel powerless and inadequate. I avoid her when she is visiting, but I don’t think I should behave in this way. The anxiety I feel is the same as when I am under pressure - like being put on the spot in a meeting. But I also feel the added pressure of responsibility for Mary. I think she might be on her own, as no one ever visits with her.

I have worked in a caring role for a large part of my life. Making people feel better is important to me, which means I want to protect people from painful experiences. I do this outside work too, often assuming people can’t cope and I need to keep them safe.

I realise I wanted to protect Mary from the prospect of losing her mother and felt it would be unbearable for her to talk about the uncertainty of the future. I associated “having all the answers” with being “good at my job”, whereas I now realise my job involves a lot more than this.

Through the insight the reflective practice group has given me, I have decided to be transparent with Mary about her mother’s situation and the lack of information. I can’t protect her from fear, frustration and sadness, but I can let her know that I understand how hard it must be.

I now feel more confident dealing with situations where someone is putting me under pressure and there are no clear answers. I am more aware of why I sometimes feel anxious and uncomfortable and, rather than trying to respond quickly to keep people’s hopes up, I am more open and honest. I know I can’t make everything better, but I can be there to offer valuable support.

Elements of reflective practice may already be present in nursing teams, perhaps in private self-reflection or during supervision. However, making it part of a regular, ongoing facilitated group gives the process greater focus, structure and depth.

A group offers individuals the support of others and a shared experience that can help normalise difficult feelings. It also gives a variety of different inputs and insights, which can make discussion more fruitful. The feeling of cohesion and identity given by the group is important at a time when work pressures can make nurses feel isolated or undervalued.

The theory of containment

Containment is a process, whereby a person conveys their state of mind to others, so it is transformed into something tolerable and meaningful (Spurling, 2004). Far from being about restriction or limitation, containment is an enabling process. It happens when people show by their response, tone of voice and expression that they are listening with care to what the person says (Spurling, 2004). In this way, the person’s emotions are “held” by the listener, making them easier to bear and to think about (Winnicott, 1945).

In our example in Box 1, the nurse’s feelings are “contained” through the process of reflection, and this makes her more able to contain the feelings of the relative who needs support.

A facilitated reflective practice group allows the facilitator and the group to fulfil the containing function. This increases the capacity of the individual to share and contain their experience, so difficult feelings are less likely to spill over at work. The group experience allows tolerance of uncertainty and difficult feelings to be felt and talked about, so people become more self-aware. This experience of being contained not only makes individuals more able to contain themselves but also enables them to be a better container for others.

Putting it into practice

The reality of implementing reflective practice groups in the NHS is shown by the experience of Elmien Brink, a health professional who runs multidisciplinary reflective practice groups as part of her staff support role (Box 2).

Box 2. Implementing reflective practice groups

I cofacilitate multidisciplinary reflective practice groups when there is a crisis or difficult case within the trust’s four intensive care teams. I started this work after attending a training day on how to be a reflective practice facilitator.

Many staff have attended the groups, and there has been a lot of positive feedback. During the group meetings, there is a validation of feelings and the opportunity to gain insight into how colleagues work and what they feel and think about their practice. When reflecting on a particular incident, staff find it especially helpful to hear supportive words from people who were not themselves involved, and can therefore look at the situation more objectively.

Setting up the groups takes careful preparation and there are obstacles. Shift patterns mean people have to come early or stay late to attend the groups. This is not ideal, but in the absence of a reflective culture at work, it is a necessary compromise.

The ground rules have to be very clear. The groups must not become “moaning” sessions or be about problem-solving, as this stops the reflective process and can prevent people addressing problems with their managers or other professionals. The groups take time to embed and for all the staff to trust in them.

We have won a grant for research into the effectiveness of reflective practice in preventing staff burn-out, which will help us build up a case to run regular monthly reflective practice groups. All participants are asked to complete a questionnaire at the start of the groups, and then a gain after a year of attending so we can justify starting the monthly meetings.

Elmien Brink, palliative care worker, intensive care, King’s College Hospital, London

Her work suggests there is a demand for reflective practice, with facilitated groups fulfilling an important function for staff. She shows the benefits to staff and their practice, as well as highlighting how resistance to implementing reflective practice groups can be overcome through initiative, perseverance and creative thinking.

Conclusion

Reflective practice is necessary in nursing due to the high emotional cost of the work, especially in today’s high-pressured NHS. It is a structured process that benefits staff and their practice, and is most effective in facilitated groups. Trying it out in individual teams is a useful first step in showing the benefits and establishing an evidence base before rolling it out more widely and embedding it into NHS culture.

Key points

  • Reflective practice is vital in nursing because of the emotional cost of the work, particularly in today’s high-pressured NHS
  • The reflective process is structured and focused with an aim to improve practice
  • It is most effective in facilitated groups, where it can give significant benefits for staff and their practice
  • There is still cultural resistance to a process that means talking about feelings and lacks an evidence base
  • Trying out reflective groups in individual teams is a useful first step to gain people’s confidence and show the rewards
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