Fundamentals of Nursing and Midwifery 2e

249 Chapter 13 Thoughtful practice: Self-awareness and reflection

enables learning from practice. For example, if an individ- ual clinician recognises they have provided ineffective or inadequate care, this can be turned into a positive learning experience using clinical supervision. The nurse or midwife can achieve deeper insight, answer questions relating to why things happened, grow in self-awareness, take action and improve the person centredness of care. Group reflection Reflection can also be undertaken as part of a group ( group reflection ), where particular group-based methodologies are used to assist health professionals to consider and improve their person-centred practice. Practice development, for example, uses reflection in groups of clinicians in a continuous process of improvement aimed at increasing effectiveness in patient-centred care. Working in teams, clinicians aim to develop their knowledge and skills and to transform the culture and context of care. Facilitators work with the team to achieve systematic, rigorous and continuous processes of change that are meaningful to the service users (Manley, McCormack & Wilson, 2008). Practice development uses a range of group reflective techniques. These may include active learning groups, which assist individual reflection and facilitate the personal growth of the practitioner (Manley, McCormack & Wilson, 2008), and exercises such as ‘changing places’, which improves understanding of others’ points of view. Focus-group discussions using reflective principles can also foster reflection and understanding of shared experi- ences (Nolan, 2008). For example, students in a tutorial group can use reflective techniques to develop their under- standing of a particular topic, such as ‘breaking bad news to a patient’. In this technique, students draw on their combined knowledge and skills of communication, person-centred care and circumstantial considerations, as well as their experience in the clinical setting, to explore what ‘breaking bad news’ might mean for them. Group reflection may also concentrate on the language used in the setting. Freire (1972) highlights the power of dialogue as a vital component of consciousness- raising, which is crucial to learning and empowerment. These are just some examples of the reflective techniques that you might encounter and find useful. However, reflec- tion also has its critics, as discussed in the following section. Barriers to and criticisms of reflection Many of the barriers to using reflection are the same as those to using research and evidence, as discussed in Chapter 10. According to Burton (2000), the main barriers arise from the poor skill mix (which occurs when the ratio of lower levels of nurses to registered nurses is too high) that has increased the workloads of registered nurses and midwives, and from the lack of resources to support reflection. The lack of skill in reflection has been mitigated through undergraduate edu- cation in which reflection is an essential part of the curriculum. Currently, the three main impediments to effec- tive reflection are lack of time, lack of motivation and lack of energy, as clinicians who are time-poor often reflect only in an ad hoc manner. Reflective practices such as maintain-

ing a journal require discipline and commitment that often cannot withstand competing demands on clinicians’ time, leading to a devaluing of the practice. When journaling is done retrospectively, the memory of the event may be affected by hindsight bias and so may be compromised, thereby detracting from the value of the reflection. Fook, White and Gardner (2006) also summarise some of the criticisms of reflection that others have put forward. One such criticism is that deep reflection, particularly in relation to critical incidents, can be anxiety provoking, counterpro- ductive and harmful. Therefore, when reflection is advocated as part of practice, adequate preparation of the student or cli- nician and availability of supportive services are essential. The lack of empirical evidence of the power of reflection to improve patient outcomes has also been noted. Despite noting these criticisms, however, on balance, they see reflec- tive practice as a way of helping clinicians to think critically about the quality of care they are delivering. Further support for the use of reflection in practice is discussed below. Reflection in practice Figure 13-1 portrays the relationship between personal attrib- utes (such as self-awareness), reflection and critical thinking, illustrating how all these components come together to create reflective practice. As Mezirow also noted, reflective practice is consistent with adult learning theory, and is known to lead to a deeper understanding of issues and to the development of judgement, thus enhancing clinical decision-making skills. Although many studies have been undertaken on the value of reflection, few studies have focused on what clini- cians actually reflect on, what they do with their reflections and what implications these reflections have for their prac- tice. The Research in practice box provides an example of a study that describes how nurses use reflection in practice. Reflective practice can take place anywhere, at anytime, such as in the clinical setting, during meal breaks, in the classroom, in online discussions, at home or during time-out activities. In developing your reflective practice skills using such models as the Gibbs’ or Johns’ models, you might use a variety of experiences including classroom presentations, clinical placements, role-plays, personal experience and so on. Certain kinds of experience generate opportunities for powerful learning through reflective practice. These include making complex decisions where there is a degree of uncer- tainty (such as deciding between differing approaches to care), adverse events (such as drug errors), dilemmas (such as a clash between our values and what is happening in prac- tice) and, on a more positive note, where there has been an innovation (such as a new way of applying a burns dress- ing). In such circumstances, reflective practice can enable us to do any or all of the following: • Analyse the issue at hand

• Identify what is working and what is not • Provide potential solutions to the problem

• Become more aware of how we affect a given situation • Clarify the differences between our values and what is happening in practice