reflective practice in nursing

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REFLECTIVE PRACTICE IN NURSING

Bagian Keperawatan KlinikFAKULTAS ILMU KEPERAWATAN

UNIVERSITAS PADJADJARAN

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IntroductionIntroduction�� The complexity of nursing The complexity of nursing (so many tasks, roles, (so many tasks, roles,

relationships, expectations) relationships, expectations) �� practice has a practice has a tendency to become chaotic and unpredictable tendency to become chaotic and unpredictable

�� Nursing should be a researchNursing should be a research--based profession based profession (DHSS, 1972) (DHSS, 1972) �� technical rationality (evidencetechnical rationality (evidence--based practice) has been claimed as necessary based practice) has been claimed as necessary because it can be observed and verified (Kikuchi, because it can be observed and verified (Kikuchi, 1992) 1992) �� historically, nursing has accepted the historically, nursing has accepted the superiority of technical rationality over tacit or superiority of technical rationality over tacit or intuitive knowing (intuitive knowing (SchonSchon, 1983,1987), 1983,1987)

�� Expert practitioner Expert practitioner �� clinical judgment is largely clinical judgment is largely intuitive, learnt through holistic pattern intuitive, learnt through holistic pattern appreciation and past experiences (Dreyfus & appreciation and past experiences (Dreyfus & Dreyfus, 1986)Dreyfus, 1986)

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The pathway from Novice to expertThe pathway from Novice to expert

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�� Organization as work settingsOrganization as work settingsOrganization has changed over time: Organization has changed over time: “centralized control of bureaucracies “centralized control of bureaucracies (1950s(1950s--1960s)” 1960s)” �� “shared decision“shared decision--making through consultation and making through consultation and participative management (1970sparticipative management (1970s--1980s) 1980s) �� “best practice, customer“best practice, customer--focused action and outcome, and the focused action and outcome, and the manager’s role as a researcher, teacher, manager’s role as a researcher, teacher, enabler of creativity (Anderson, 1996) enabler of creativity (Anderson, 1996) �� conflict between autonomy and conflict between autonomy and authorityauthority

IntroductionIntroduction

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�� Reflective practice is associated with learning Reflective practice is associated with learning from experience, and is viewed as an from experience, and is viewed as an important strategy for health professionals important strategy for health professionals who embrace life long learningwho embrace life long learning

�� The act of reflection is seen as a way of The act of reflection is seen as a way of promoting the development of autonomous, promoting the development of autonomous, qualified and selfqualified and self--directed professionalsdirected professionals

�� Engaging in reflective practice is associated Engaging in reflective practice is associated with the improvement of the quality of care, with the improvement of the quality of care, stimulating personal and professional growth stimulating personal and professional growth and closing the gap between theory and and closing the gap between theory and practice. practice.

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�� The process of reflective writing leads to The process of reflective writing leads to more than just a gain in your knowledge; more than just a gain in your knowledge; it should also challenge the concepts and it should also challenge the concepts and theories by which you make sense of theories by which you make sense of knowledgeknowledge

�� When you reflect on a situation you do When you reflect on a situation you do not simply see more, you see not simply see more, you see differentlydifferently. This different way of viewing . This different way of viewing a situation is reflected in statements a situation is reflected in statements about a commitment to actionabout a commitment to action

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�� Learning through our everyday experiences Learning through our everyday experiences towards realizing one’s vision of desirable towards realizing one’s vision of desirable practice as a lived realitypractice as a lived reality

�� As a mirror to see images or impressions of As a mirror to see images or impressions of self in context of the particular situation in a self in context of the particular situation in a careful and realistic waycareful and realistic way

�� Awareness of self within the moment, having Awareness of self within the moment, having a clear mind, wisdom that help us to see a clear mind, wisdom that help us to see things clearlythings clearly

(Johns, 2009)

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�� ReflectionReflection--inin--action: occur during practice when action: occur during practice when the attentive practitioner watches, interacts, the attentive practitioner watches, interacts, and adjust reactions and approach through and adjust reactions and approach through thinking in a focused way while workingthinking in a focused way while working

�� ReflectionReflection--onon--action: occur after the action action: occur after the action when details are recalled through rich when details are recalled through rich description and analyzed through careful description and analyzed through careful unpicking and reconstructing of all the aspects unpicking and reconstructing of all the aspects of situation, to gain fresh insights, and make of situation, to gain fresh insights, and make amendments if necessaryamendments if necessary

(Schon, 1987)

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�� LifeLife�� WorkWork�� ArtArt�� ReligiousReligious

(Johns, 2009)

Why we should reflect?Why we should reflect?�� Reduces the theoryReduces the theory--practice gap practice gap

�� (Perkins 1996; Fonteyn & Cahill 1998; (Perkins 1996; Fonteyn & Cahill 1998; GetliffeGetliffe 1996; Foster 1996; Foster & Greenwood 1998; Smith 1998; Burton 2000; Carney 2000; & Greenwood 1998; Smith 1998; Burton 2000; Carney 2000; Duke & Appleton 2000; Duke & Appleton 2000; MaudsleyMaudsley & & ScrivensScrivens 2000b; Stewart 2000b; Stewart & Richardson 2000; & Richardson 2000; KohKoh 2002). 2002).

�� Encourages critical thinking ability Encourages critical thinking ability �� (Patton et al 1997; (Patton et al 1997; DurgaheeDurgahee 1998; Foster & Greenwood 1998; Foster & Greenwood

1998; Burton 2000; 1998; Burton 2000; MaudsleyMaudsley & & ScrivensScrivens 2000b; Cotton 2000b; Cotton 2001) 2001)

�� Helps practitioners to make more sense Helps practitioners to make more sense of difficult and complex practice of difficult and complex practice �� (Driscoll & (Driscoll & TehTeh 2001) 2001)

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Why we should reflect?Why we should reflect?

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�� The The Effective Effective reflective reflective practitioner is able practitioner is able to recognise and to recognise and explore confusing explore confusing or unique (or unique (positivepositiveor negativeor negative) events ) events that occur during that occur during practicepractice

� The Ineffectivepractitioner is confined to repetitive and routine practice, neglecting opportunities to think about what he/she is doing

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Gibbs Reflective CycleGibbs Reflective Cycle

�� The The Gibbs (1988) reflective cycle Gibbs (1988) reflective cycle is is considered fairly straightforwardconsidered fairly straightforward

�� It encourages a clear description of It encourages a clear description of the situation, analysis of feelings, the situation, analysis of feelings, evaluation of the experience, analysis evaluation of the experience, analysis to make sense of the experience, to make sense of the experience, conclusion where other options are conclusion where other options are considered and reflection upon considered and reflection upon experience to examine what you experience to examine what you would do if the situation arose againwould do if the situation arose again

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Stage 1: Description of the eventStage 1: Description of the event

� Describe in detail the event you are reflecting on

� Include: where you were; who else was there; why you were there; what you were doing; what other people were doing; what the context of the event was; what happened; what your part was; what parts the other people played; what the result was

Stage 2: FeelingsStage 2: Feelings

�� Try to recall and explore what was going on Try to recall and explore what was going on inside your head i.e. why does this event stick inside your head i.e. why does this event stick in your mind?in your mind?

�� Include: how were you feeling when the event Include: how were you feeling when the event started; what you were thinking about at the started; what you were thinking about at the time; how it made you feel; how other people time; how it made you feel; how other people made you feel; how you felt about the made you feel; how you felt about the outcome of the event; what you think about it outcome of the event; what you think about it nownow

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Stage 3: EvaluationStage 3: Evaluation

�� Try to evaluate or make a Try to evaluate or make a judgement about what has judgement about what has happened. happened.

�� Consider what was good Consider what was good about the experience and about the experience and what was bad about the what was bad about the experience, or didn’t go so experience, or didn’t go so wellwell

Stage 4: AnalysisStage 4: Analysis

�� Break the event down into its component Break the event down into its component parts so they can be explored separately parts so they can be explored separately

�� You may need to ask more detailed You may need to ask more detailed questions about the answers to the last questions about the answers to the last stage stage

�� Include: what went well; what you did Include: what went well; what you did well; what others did well; what went well; what others did well; what went wrong or did not turn out how it should wrong or did not turn out how it should have done; the way you, or others, have done; the way you, or others, contributed to thiscontributed to this

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Stage 5: ConclusionStage 5: Conclusion

�� This differs from the evaluation stage in This differs from the evaluation stage in that now you have explored the issue that now you have explored the issue from different angles and have a lot of from different angles and have a lot of information to base your judgementinformation to base your judgement

�� It is here that you are likely to develop It is here that you are likely to develop insight into your own and other people’s insight into your own and other people’s behaviour in terms of how they behaviour in terms of how they contributed to the outcome of the eventcontributed to the outcome of the event

Stage 6: Action Plan Stage 6: Action Plan

�� During this stage you should think During this stage you should think about encountering the event again and about encountering the event again and plan what you would do plan what you would do –– would you would you act differently or would you be likely to act differently or would you be likely to do the same?do the same?

�� Here the cycle is tentatively completed Here the cycle is tentatively completed and suggests that should the event and suggests that should the event occur again it will be the focus of occur again it will be the focus of another reflective cycleanother reflective cycle

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There are other models of reflection and there are brief explanations for some in the next few slides

� John’s model of reflection�The What? model of structured

reflection by Driscoll

John’s model of structured reflectionJohn’s model of structured reflection

�� John’s model can be used as a guide for John’s model can be used as a guide for analysis of a critical incident or general analysis of a critical incident or general reflection on experience. This would be reflection on experience. This would be useful for more complex decision making useful for more complex decision making and analysis at levels 3 & 4and analysis at levels 3 & 4

�� He supports the need for the learner to work He supports the need for the learner to work with a with a supervisorsupervisor throughout their learning throughout their learning experienceexperience

�� He refers to this as He refers to this as guided reflectionguided reflection, and , and recommends that students use a structured recommends that students use a structured diary diary

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John’s model of structured reflectionJohn’s model of structured reflection

�� John feels that through sharing reflections John feels that through sharing reflections on learning experiences, greater on learning experiences, greater understanding of those experiences can understanding of those experiences can be achieved than by reflection as a lone be achieved than by reflection as a lone exerciseexercise

�� John also uses John also uses Carper’sCarper’s (1978) four (1978) four patterns of knowing, aesthetics, personal, patterns of knowing, aesthetics, personal, ethics and empirics adding a fifth pattern ethics and empirics adding a fifth pattern ‘reflexivity’‘reflexivity’

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�� Be spontaneous Be spontaneous –– it is from the frank and it is from the frank and honest self that important insights arise honest self that important insights arise

�� Express yourself freely Express yourself freely –– you don’t need to you don’t need to observe the normal academic practices observe the normal academic practices involved in writing involved in writing

�� Remain open to ideas Remain open to ideas –– early conclusions early conclusions can inhibit further insights and solutions can inhibit further insights and solutions

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�� Recall your experience while you are Recall your experience while you are practicing nursing (hospital or practicing nursing (hospital or community), pick up an event that you community), pick up an event that you impress most, write up as a story, and impress most, write up as a story, and do reflection based on a selected do reflection based on a selected framework of reflectionframework of reflection

�� Six of them will be selected randomly for Six of them will be selected randomly for class presentationclass presentation

�� Do it happily ….Do it happily ….

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reflective practice in nursing

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