Fundamentals of Nursing and Midwifery 2e

247 Chapter 13 Thoughtful practice: Self-awareness and reflection

centred and that patients are enabled to act in partnership with you (Williams, 2002). This concept introduces the notion of critical reflection that follows. Critical reflection Although reflection is seen as a required skill for all nurses and midwives, some advocate that reflection must also be critical in order to enable the nurse or midwife to understand empow- erment and promote change (Crowe & O’Malley, 2006). Critical reflection uncovers the dynamics of power in a rela- tionship and critically questions the sociocultural assumptions in practice (Brookfield, 1995). This level of reflection is based on critical social theory , an important theory that has influ- enced contemporary education, nursing and midwifery, and which advances the belief that no social phenomenon can be understood in isolation from the cultural, historical, economic and political context in which it exists. In more recent times, researchers have applied critical social theory to research methods such as action research (Schneider et al., 2013) and practice development (Manley, McCormack &Wilson, 2008). These methodologies enable us to identify and redress inequities related to unequal power relations more specifi- cally related to our everyday lives. The following is one model of critical reflection. Reflective techniques Now that we have explored the basics of reflection, we will review a number of techniques that you can use as part of your own reflective practice. There are a range of reflective techniques that can be used to meet the needs of individuals and groups of practitioners. Developed by a number of theo- rists, these techniques vary in their depth of reflection and in their complexity. They can involve a guided approach or may be part of a creative process in which free thinking enables the individual to focus on the elements of the situation that was of most importance to them. Reflection can be under- taken as an individual activity (self-reflection), or can be done with a companion (mentoring or clinical supervision). It can also occur as a group exercise such as in practice develop- ment, when techniques such as active learning groups are used (Manley, McCormack & Wilson, 2008). Reflecting alone helps you to build confidence in reflective processes and to focus on self (an important component of self-awareness). Teekman (2000) discusses this kind of self- reflection and highlights the significance of self-questioning as a reflective technique. Asking yourself such questions as ‘What has happened?’, ‘Am I doing the right thing?’ and ‘Could this assist me in structuring my thought processes and in making meaning?’ can assist in highlighting gaps. However, this technique does have limitations, especially in the level and intensity of reflection, and in the level of challenge we provide for ourselves. One type of reflection that may be undertaken either alone or as part of a group is critical incident analysis . In Chapter 14 you will learn how to apply a clinical reasoning framework to a patient situa- tion, thinking through the situation in order to come to a

clinical judgement and decision that will then lead to a par- ticular action. This is a forward-thinking process for a situation that is still in development. Critical incident analy- sis is the opposite. It is a retrospective reflective process that examines a situation that has already happened, in order to learn from the situation and so improve on individuals and systems in the future. In the following section on critical incident analysis, Table 13-1 shows an example of Stephen- son’s framework applied to a clinical situation. Critical incident analysis In practice, reflection is often triggered by a particular event in which an error or omission in care is encountered by you or by others. These ‘critical’ incidents do not necessarily result in harm for the patient, although there may be the pos- sibility of adverse effects. However, critical incident analysis offers real potential for learning from such events. The following scenario demonstrates how critical incident analysis and critical reflection may be applied. Jenny Smith, 38, has been given an intravenous dose of antibiotics that she was not prescribed. This has resulted in a drug error being recorded on the incident file, and has activated a reflective practice session in the ward. This session has provided staff with the opportu- nity to reflect on the event, to ask questions about how and why it occurred, to think about any knowledge deficits that may have contributed to the incident, and to reflect on future action. Gillian, who administered the drug, completed her degree six months ago and had been working on the ward for one month when the incident occurred. Table 13-1 includes some examples of the type of reflec- tive questions that will enable Gillian to uncover what happened and why, and to learn from the incident. While this learning is attributed to the three aspects of reflective practice, you can see that the types of question overlap and that the learning in one section applies to each component of reflec- tive practice. (You might find it helpful to read the section on critical thinking in Chapter 14 before starting this exercise.) You may find that sharing reflective techniques with a fellow student, colleague, mentor or supervisor helps you to increase your level of reflective challenge and develop your critical questioning techniques as a skill that you can use in your clinical practice. Working with another person, espe- cially one who is more experienced in reflective practice, can help you to find meaning, uncover contradictions and challenge assumptions in order to develop new insights about the situation and a higher level of understanding (McBrien, 2007). Examples of this type of reflection are mentorship and clinical supervision. These two reflective techniques and group reflection will now be discussed. Mentorship The benefits of guiding reflection through mentorship have been acknowledged by many advocates of the practice.