A colleague flagged up a minor error to another member of staff recently. The patient was unharmed but she needed to remind him to take extra care to prevent it from happening again.
The nurse who made the error came back a few days later having reflected upon the scenario and decided that the outcome was not the potential danger to the patient, nor that he should take extra care, but that the nurse highlighting the problem should have been more respectful and less challenging in their approach.
When I heard about this I began to reflect myself, mainly on how we as nurses place great emphasis on the process of reflection.
Students cannot escape it as it’s embedded in nurse education from the start, continues through to master’s degree level and is encouraged throughout our career.
“We are inundated with different models and theories”
We are inundated with different models and theories; Gibbs, Johns, Driscoll and Carper’s ‘ways of knowing’, all of which provide us with structure and theory to underpin our reflection.
The recommendation to reflect is clear, reaching back as far as Aristotle in the 4th century BCE and continuing throughout history with such illuminaries as Schon, Kolb, Habermas and Dewey, to name but a few.
“The modern day world would be all the poorer had these theories not developed”
Indeed, the modern day world would be all the poorer had these theories not developed as they provide the key for change.
Reflection in nursing is the process of thinking about our actions and analysing them in order to improve in the future, the ultimate goal being to improve care.
Brookfield (1993) describes the difficulties of reflection and how it can evoke anxieties as well as emphasising the importance of a supportive ward culture. Reflexivity is worthy as this takes into account one’s own personal perspective.
“How deeply in tune are we as nurses, or indeed human beings, to dive into the murky depths of our own psyche?”
And yet how deeply in tune are we as nurses, or indeed human beings, to dive into the murky depths of our own psyche? I wonder how my personal reflections as a white British female will enable me to understand and make sense of the world in a holistic way to that of say someone from a different ethnicity, gender, nationality and sexual orientation.
This highlights how every scenario can be reflected upon in a myriad of ways with no ‘right’ answer, yet the dangers of reflection are well documented; lack of time or inclination, resulting in nurses who feel they must shoulder the blame and bear the responsibility for negative outcomes as a result of organisational and political shortcomings.
“This scenario highlights the dangers of reflection”
In today’s world of evidence based practice, is such an abstract cognitive process valid? If not, then what are the alternatives?
This scenario highlights the dangers of reflection. Inexperienced or nervous practitioners can use it to build confidence by finding ways to rationalise their actions and shift the burden of responsibility to others, feeling justified by having undergone a recognised and recommended process.
Melanie Klein described how negative energy can be passed around organisations through a process known as projective identification, promulgating a downward spiral of communication which is what I suspect may have happened in our scenario.
Despite the dangers, I feel that reflection has a part to play in the development of personal and professional excellence.
“Quality care is paramount and we must use all the tools at our disposal to strive for change”
Quality care is paramount and we must use all the tools at our disposal to strive for change. The current pressures in the system may result in nurses not having the time or inclination to reflect on practice.
The danger is that new and inexperienced nurses may distort their reflections without support and time, leading to a stagnant situation where developing oneself and the quality of care will nudge off course into a different direction.
Reflection is a useful tool, the only caveat being that we must polish the lens of our inward gaze with the cloth of a supportive culture for healthy personal and professional development to occur and so improve the care of our patients.
“We must polish the lens of our inward gaze with the cloth of a supportive culture”
Used in conjunction with clinical supervision in a strong, supportive ward culture with good leadership & a bottom up organisational structure underpinned by supportive policies and a positive political agenda will set the scene for meaningful and positive change.
Reflection is an important and powerful tool that nurses can use to improve their practice and subsequently the care of patients with one caveat, namely, in order to maximise its usefulness we need to tread carefully, use it with caution and not as a means of scapegoating others for our own shortcomings.
Liz Charalambous is a staff nurse at Queens Medical Centre, Nottingham
Brookfield, SD (1993) On impostership, cultural suicide, and other dangers: how nurses learn critical thinking. Journal of Continuing Education in Nursing; 24 (5), 197–205.