A pilot project developed a method of enabling nurses on an acute care ward to engage in reflective practice during their working day
In this article…
- Why reflective practice is important
- Development of a model of reflective practice
- Results of a pilot implementing the mode
Liz Markey is a chaplain in the department of spiritual care; Rachel Farvis is palliative care clinical nurse specialist at Edinburgh Cancer Centre; both at NHS Lothian.
Markey L, Farvis R (2014) Reflective practice in an acute setting. Nursing Times; 110: 24, 16-18.
This initiative was undertaken to find a realistic and sustainable approach to reflective practice in an acute hospital ward. A questionnaire was distributed to staff on an oncology ward to discover their thoughts on finding an approach that could be used on a daily basis. The results were collated and a reflective tool was developed; a pilot study was carried out, which found the tool to be usable. Communication improved between staff and a more reflective culture began to develop.
- This article has been double-blind peer reviewed
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5 key points
- Clinical supervision is recommended as a way of enabling nurses to reflect on their practice
- In busy clinical areas, it can be difficult to sustain supervision as nurses may be unable to leave the care area
- Reflective practice in groups aids staff development by enabling nurses to think about their work and discuss it with their peers
- Giving staff time to engage in reflective practice during their working day can help to make them feel valued
- Research has found that the quality of care is higher if staff feel valued
While the value of clinical supervision is widely acknowledged, the practicalities of implementing and sustaining it can be challenging.
A member of our spiritual care team had offered supervision to nursing staff on a group and an individual basis over the past few years in one of the acute wards in the directorate of clinical oncology at the Edinburgh cancer centre. More recently, this proved challenging and it became unsustainable, so we decided clinical supervision needed to be offered in another form. We also decided to change the emphasis and approach to make it more appealing to nurses who may associate supervision with a management function.
The study was carried out on an acute ward with support from a member of the hospital’s spiritual care department.
Literature review: reflective practice
We defined reflective practice as an activity where staff reflect on their work in an environment conducive to enabling them to gain insight and awareness from their work that will improve future practice. Engaging in reflective practice shows commitment to ongoing personal and professional development; it enables nurses to examine their practice, which in turn benefits their future work.
Personal development and looking after the self is important in healthcare - health professionals need to pay attention to their own needs to be able to care for others. It has been suggested that staff wellbeing can affect patient experiences of care; staff cared for at work will perform better (National Nursing Research Unit, 2013).
It could be argued that when staff are given the time to do this, they feel more valued by their organisation.
One way of showing staff they are valued is by prioritising reflective practice and enabling them to take part in it. Reflecting on their work enables staff to connect with their deeper selves and their needs as well as challenging themselves to understand their patients’ perspectives and experiences. One issue found to influence engagement in reflective practice is access to supervisor support (NNRU, 2013).
Thompson and Thompson (2008) describe Schon (1983) as one of the most influential thinkers in this area and say his work has contributed to present-day thinking regarding reflective practice. They suggested some approaches to reflection, which they described as motivators and guides to help staff find their own way of undertaking reflection to suit their own practice. The activity can be engaged in alone or with others, although engaging with others can make it a more rewarding and stimulating experience (Thompson and Thompson, 2008).
Dewey (1933) suggested that reflective practice requires courage and open-mindedness, as staff can feel exposed after sharing their feelings, and stressed the importance of reflecting with trusted colleagues. This was confirmed by Duke (2000), who was surprised when she noticed her feelings on keeping a journal and wondered how many times she had felt exposed and vulnerable without realising it. Reflective practice offers great potential for learning both personally and professionally. Hargreaves (1997) supported reflective practice as a way to improve professional development and patient care. The early references above illustrate how long the importance of reflecting on practice has been discussed.
The Care Quality Commission (2013) has produced guidelines on various forms of supervision, and suggested that clinical supervision gives staff an opportunity to reflect on their practice, discuss cases and identify and make changes necessary to their practice. The guidelines outline the benefits for staff, service users, carers and service providers.
The Nursing and Midwifery Council (2014) is developing its revalidation process and, while it has not referred explicitly to reflective practice or clinical supervision, it does say nurses must show that they have used feedback to review and improve the way they work - although it does not suggest how this might be achieved (NMC, 2014).
We received funding for this project under an NHS Education for Scotland initiative to support the use of the NES Effective Practitioner site (www.effectivepractitioner.nes.scot.nhs.uk). This has enabled project team members and ward staff to access and review a range of online resources that could be used to support practitioners to reflect and develop in their roles, and has funded folders and posters to provide further information for staff.
Although the literature discussed above is only a small proportion of the evidence base, we decided that it justified supporting staff to engage in reflective practice, and to find an approach that could be used on an acute ward.
The acuity and busy nature of the area meant it was important that the approach was realistic in that it could be done during the working day. It was also important for it to be sustainable over time to ensure it did not fall by the wayside, and that the resulting approach was replicable and pertinent so it could be disseminated.
We hoped the team involved in the pilot would work and develop together and that a reflective culture where staff were accustomed to reflecting daily and a culture where everyone felt valued and listened to would evolve.
A questionnaire was given to 20 staff, both nurses and clinical support workers, on an acute ward to ascertain their commitment to reflection and what they thought was realistic for their ward (Box 1). They were asked what reflection meant to them and how important they thought it was for their work, and given choices on the time of day to reflect - for example at morning handover - and what approaches they might use.
The results were collated (details below), and a “prompt card” was developed containing four open questions on one side and an adapted quality improvement tool from the Effective Practitioner site, known as the 3Cs, on the other (Box 2). The card was piloted in the ward over a two-month period to ascertain the appropriateness of both the cards and the questions. Evaluation of the pilot revealed that staff responded positively.
Twelve questionnaires were completed, giving a response rate of 60%. All respondents understood the term reflective practice; descriptions included:
“Having time to reflect on practice - good and bad.”
“Let go of issues.”
All respondents felt reflective practice was important to their work, with nine (75%) saying it was very important and the remaining three (25%) saying it was quite important. Eleven had had some experience of reflective practice/clinical supervision and found it successful; reasons included it being structured time to reflect and supportive. Those who had not found their experience helpful said this was because it was difficult to get away from the ward, and one felt more comfortable with peers than in a one-to-one situation.
When asked about a convenient time to reflect, seven said a mid-afternoon meeting or “huddle” was realistic. Two suggested the end of a shift and one said morning handover. Eight stated a preference for small teams, three suggested the whole team and three suggested an external facilitator, although one to one was still the ideal for six staff members. From various options, 10 suggested open questions. The pilot showed that the cards were popular and that the questions were appropriate. Box 3 gives a selection of comments from respondents.
While we were pleased with the 60% response rate for the questionnaire, it would have been more useful to hear from the whole team.
It was useful and affirming to learn that work done in the past in this area had been beneficial for staff, and gratifying that all respondents understood the concept of reflective practice and saw it as very important or quite important to their practice. This supports the work of Van Ooijen et al (2003) who acknowledge the importance of engaging in reflective practice.
We were also gratified to find that those who had completed the questionnaire responded positively to the project; during the pilot study, the whole team - both nurses and clinical support workers - responded favourably, including those who had not completed a questionnaire.
The importance of having colleagues to reflect with has been emphasised (Thompson and Thompson, 2008; Dewey, 1933) and four respondents acknowledged the importance of being able to reflect with their peers.
During the months after the pilot ended in May 2013, it has become apparent that taking time to reflect together has had a positive effect on team communication. Deeper communication has enabled staff to get to know each other in a more meaningful way; this was supported by some of the comments from the pilot study.
We felt it was not ethical to ask staff to engage in daily reflection unless a backup was in place for those left with issues for which they needed more support. With this in mind, the team was made aware of where they could access further support, for example during individual supervision.
The open questions on the prompt card were popular. It was also acknowledged that there was support for debriefing after major events and but this area needed some work.
The NNRU (2013) supported the principle of access to supervisor support, while the CQC has outlined the benefits of clinical supervision for all concerned. However, while nurses had supported individual clinical supervision and many of those who responded to the questionnaire acknowledged its importance, it had not been sustainable over a long period for various reasons including difficulty in leaving the ward, especially at busier times.
While this was only a small local project, our results confirm the desire among nurses for reflective practice. It was easier to achieve and sustain than individual or group supervision and it fulfilled the NMC (2014) requirement that nurses should “have used feedback to review and improve the way they work” (NMC, 2014).
When staff perceive that they are cared for, patient care improves, so we recommended that the hospital makes it a priority not only to value staff but also to ensure that they feel valued. Prioritising reflective practice and enabling nurses to take part in it by making time for it in the working day could be one way of demonstrating to them that they are valued.
We also recommended that the reflective practice prompt cards be disseminated to other areas. Other wards are using them, in the area where the research took place and in other wards and sites.
It will be an ongoing challenge to keep staff motivated to engage in reflection, especially during busy times, and to commit to following up how staff are managing to do this. It will also be challenging to ensure wards are adequately supported for reflective practice and that those who support staff are adequately supported too.
This project has provided an approach to reflective practice that can be used on a busy acute ward, is both realistic and sustainable and has enabled a reflective culture to evolve.
Nurses have benefited because they feel valued when given time to say how they feel, and the team has benefited because one effect of engaging in reflective practice is that staff get to know each other in a deeper and more meaningful way.
Patients also benefit from being cared for in an environment where staff feel cared for, because staff who are cared for perform better (NNRU, 2013).
Care Quality Commission (2013) Supporting Information and Guidance: Supporting. Effective Clinical Supervision.
Dewey J (1933) How We Think: a Restatement of the Relation of Reflective Thinking to the Educative Process. Boston MA: DC Heath.
Duke S (2000) The experience of becoming reflective. In: Burns S, Bulman C (eds) Nursing. The Growth of the Professional. Oxford: Blackwell Scientific.
Hargreaves J (1997) Using patients: exploring the ethical dimension of reflective practice nurse education. Journal of Advanced Nursing; 25: 223-228.
Nursing and Midwifery Council (2014) Revalidation.
National Nursing Research Unit (2013) Does NHS staff wellbeing affect patient experience of care? Policy+; 39, May.
Schon D (1983) The Reflective Practitioner : How Professionals Think in Action. New York, NY: Basic Books.
Thompson S, Thompson N (2008) The Critically Reflective Practitioner. Basingstoke: Palgrave Macmillan.
van Ouijen E (2003) Clinical Supervision Made Easy. Edinburgh: Churchill Livingstone.