clinical · research · education
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Reflective practice: a meaningful task for students
Smith A, Jack K (2005) Reflective practice: a meaningful task for students. Nursing Standard. 19, 26, 33-37. Date of acceptance: October 18 2004. Abstract Aims To ascertain whether students found reflection to be a meaningful activity, whether there are perceived benefits associated with reflective practice and whether it is a valid process on which to assess the outcomes of a course relating to the competencies of specialist practice. Method The attitudes of students attending a one-year degree course were examined using a focus group interview and a web discussion board. The evaluation of the focus group interviews and web-based discussion postings are discussed. Findings Reflective writing is considered a key component of portfolio assessment because it provides evidence of skills development and increasing clinical competence. There was no consensus on whether or not reflection is a meaningful activity. The students’ learning style is pertinent to their perception of the usefulness of reflection. Conclusion The findings indicated the scepticism with which some students approached the task, but they also identified that reflection had a positive impact on the practice of students more able to embrace the process in a meaningful way. There is scope to extend this work to examine the use of reflection in developing the growing body of practice knowledge that underpins nursing. HE STUDY was conducted in 2003 with volunteers from a student group in their final year of a degree course in community health care nursing. This degree also incorporated a professional award in specialist community practice in either district nursing or general practice nursing. The learning outcomes for the course were those prescribed by the United Kingdom Central Council (UKCC) (2001). The curriculum comprises 50 per cent theory and 50 per cent practice, and the course is concerned with developing skills of critical thinking on practice issues. For the practice component to be assessed the student must compile a portfolio of evidence and complete a practice placement document. The practice placement document contains 28 competencies that are required to be assessed in practice, based on the Standards for Specialist Practice (UKCC 2001). These include a broad range of competencies relating to clinical, management and leadership skills that enable the student to adopt the role of specialist practitioner. The practice portfolio guidelines state that both the student and the mentor are required to keep a reflective journal for the duration of the course. The student’s journal should provide a record of learning and also enable the student to develop skills in reflection by adopting and using a reflective cycle to guide the process. Each student is allocated a mentor who supervises the student for the duration of the course and is responsible for assessing the practice component of the course and the student’s ability ‘to exercise higher levels of judgement, discretion and decision making’ (UKCC 1994). It is also anticipated that recording experiences will encourage students to develop skills in critical analysis and self-appraisal. The student’s journal entries will aid in diagnosing ongoing learning needs and provide an account of his or her development as the course progresses. It is also a personal and private document which the student may or may not choose to share with the mentor, although a meaningful dialogue between the student and mentor is encouraged. Anne Smith BSc(Hons), RN, is director of nursing studies, School of Health and Social Care, University of Reading; and Kirsten Jack RN, BA(Hons), MSc, PGCE, is senior lecturer adult nursing, Manchester Metropolitan University. Email: firstname.lastname@example.org
■ Education: methods ■ Reflective practice
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The journal can be effective in determining the student’s progress and development. The recording and analysis of experiences enable the student and mentor to explore the nuances of practice, their own perceptions and interpretations of these experiences, and, ultimately, the appropriate professional response (Shardlow and Doel 1996). Students were invited to participate in focus group interviews to evaluate whether the journal or the process of reflection was effective. The mentors were canvassed as to whether reflection was an effective tool for examining their clinical practice to reinforce good practice or to effect change. Literature review Evidence from the literature is not conclusive in appraising reflection as a positive activity. Some authors suggest that the process can be manipulated according to the desired outcomes (Cooney 1999, Mackintosh 1998). There is some question about its use for exploring the nuances of practice, and further debate over the process of decision-making and reflection when determining the process adopted by expert practitioners (MacLaren et al 2002). Experienced mentors often resort to using intuitive knowledge or make decisions intuitively. According to MacLaren et al (2002) the use of intuitive knowledge (Benner 1984) is difficult to capture or explain, thus leaving the student confused about how decisions are made. However, they are being asked to examine these very skills. The mentor is required to examine the development of higher level decision-making skills in the student. Can reflection be relied on as an instrument for measuring and articulating these decision-making processes? There is a paucity of literature on students’ perspectives, both positive and negative, and about the processes involved in becoming a reflective practitioner (Wilkinson 1999). Writing is considered an integral part of the reflective process (Atkins and Murphy 1994, Johns 1995). Wilkinson (1999) recommends some practical tips to enhance journal writing and includes issues such as linking new learning to prior knowledge, challenging assumptions and debating the implications of a range of actions. Critical incident analysis offers the opportunity to undertake a deeper analysis of the particular aspects of nursing that unite the scientific facts with the aesthetic elements of nursing practice, which differentiate it from medical practice (Rich and Parker 1995). Critical thinking ability may be encouraged through the reflective process (Andrews 1996, Durgahee 1996). Wong et al (1995) reviewed reflective accounts for evidence of reflective thinking. The accounts of non-reflectors were found to be descriptive with invalid assumptions and unsupported opinions. Critical reflectors integrated experience with 34 nursing standard march 9/vol19/no26/2005 discussion, contextualised the problem, reviewed possibilities and drew on a wide number of resources. Barriers to reflection have been identified, one of which is previous educational experience (Mountford and Rogers 1996). Traditionally, nursing education did not encourage nurses to question stated concepts (Conway 1998) and led the students to expect tutors to be responsible for the student’s learning. Platzer et al (2000) found that the socialisation of nurses and their previous educational experience made the self-directed approach associated with the adult learning process difficult, as nurses had not been encouraged to think for themselves. Students can feel vulnerable when asked to reflect, which may be another barrier to the process (Cameron and Mitchell 1993, Hargreaves 1997). Nurses may be selective when remembering experiences (Newell 1992) and selective memory and vulnerability can make reflection seem like a negative process, if it focuses on the gaps in skills and knowledge (Cooney 1999). Somatic changes may occur if feelings are denied and suppressed (Freund 1990), which could potentially have a harmful effect. Newell’s (1992) article discusses the psychological stress that can be associated with reflection. He argues that recall may be distorted by repression. He suggests, therefore, that the process of reflection may be inherently flawed. However, he contends that there may be merit in the actual process in that it has the potential to increase self-awareness and professional expertise. Accuracy may be an issue but the process itself can be therapeutic. He explores the pivotal role of the mentor in these situations. Skill in adopting techniques in the interaction in modelling, self-disclosure and rehearsal enable the mentor to assist the student in confronting and explaining difficult experiences in a supported environment. Hulatt (1995) also acknowledges the ability to ‘brush things under the carpet’ which may be necessary to maintain a healthy mental state, and this should be appreciated as a coping mechanism. This implies that certain issues may be best left unexplained or forgotten. It may be better to deny feelings associated with negative experiences. However, participants questioned in a study by Wallace (1996) stated that even painful feelings should be re-experienced. Reflective ability may be formally assessed although students may feel inhibited when writing about practice (Glaze 2002), and may launder reflective diaries, writing what they think is expected rather than what they truly feel. It could be concluded from the literature that although reflection may be an activity open to criticism, the process enables practitioners to examine their actions, and also that this is achieved more effectively in a supportive environment. However, as educationalists we must also ensure that students are educated to critically appraise their practice through this route. Purposeful reflection can provide an opportunity to examine
practice and identify new knowledge. It is through this activity that practice theory will be generated to contribute to the nursing profession’s body of knowledge (Shardlow and Doel 1996). Newell (1992) suggests that educationalists should evaluate the process with students, offering practical tips and encouraging them to apply critical consciousness. Aims The study aimed to ascertain whether students found reflection to be a meaningful activity, whether there are perceived benefits associated with reflective practice and whether it is a valid process on which to assess the outcomes of the course relating to the competencies of specialist practice. Data collection methods A variety of methods were used to determine the students’ and mentors’ views on whether reflection was valid or was a useful tool for examining practice. ■ A cohort of 50 students was invited to take part in this study. Eight volunteered to attend a semistructured focus group interview. The nature of the study was explained to all participants. The proceedings were recorded using audio tape and were later manually transcribed and interpreted. The focus group lasted for one hour and was guided by open questions on the subject of reflective practice. The study took place at the University of Bolton. ■ A managed learning environment (WebCT) discussion board was used as a forum for posing a question about the benefits of reflection. This provided some rich data, some of which is presented in this article. ■ Twelve mentors were canvassed informally (when meeting in small groups for the purpose of peer support) and asked their opinions of the use of reflection as a tool to explore practice issues. It was recognised by the authors that data collection methods may influence the results because students may be influenced by other participants’ responses in the focus groups. Responses on the discussion board may be influenced by those made by other contributors. In this instance the student is replying to a single question on the board, rather than participating in a session with ongoing dialogue. Findings Some of the findings that emerged were similar to the findings in the literature. Although everyone suggested that keeping a reflective diary was difficult to do effectively because of the time constraints, many of them agreed that it was beneficial for them. The following comments were made by the students and were transcribed from the interviews or copied from the discussion board: ‘Lack of time often means that the entries are not as good as they perhaps could be.’ (Participant 1) ‘I am busier now due to increased workload and so have reduced the entries to every two weeks as opposed to weekly as it was becoming a bit of a chore.’ (Participant 2) ‘Nurses who are quite experienced are quite good at doing that (reflecting) even on an hourly basis, you might not always write it down.’ (Participant 3) It was also apparent that the experience was more beneficial once students had become more practised at carrying out reflective practice: ‘So my opinion has changed over the course from total waste of time to useful, informative but difficult to do.’ (Participant 4) ‘I now look at particular aspects of practice I want to reflect on.’ (Participant 8) Initially, diary entries were descriptive but as the course progressed the students found that their writing became more critical and analytical. As they became more self-aware and confident with the process, they realised the benefits of reflecting on achievements and celebrating good practice. In returning to the student role to undertake the course, students had tended to devalue their previous knowledge and acquired skills. However, with increasing self-confidence students were able to recognise self-worth and acknowledge good practice, as evidenced by the following remarks on the student discussion board: ‘We need to look at the positive as well as the negative to make ourselves feel good every now and then.’ (Participant 4) ‘As nurses we are good at reflecting on the bad things and not always good at reflecting on the good things.’ (Participant 3) ‘I think I reflected more on the negative aspects of the course and my development than on the positive.’ (Participant 5) Other comments related to the fact that sometimes students have what they perceive as ‘uneventful days’ during which they see no issues to reflect on: ‘Reflection is insightful but, after doing an uneventful diabetes clinic, I feel that I am searching for problems.’ (Participant 6) ‘I keep trying to think of the things that went wrong when things had been going well.’ (Participant 7) One student provided insight into the difficulties associated with recording negative experiences. ‘Reflection (personal views) can be very negative and sometimes actually writing these negative feelings and thoughts down is not as easy as perhaps it is made out to be.’ (Participant 1) There was some concern about the legal implications of documenting reflective thoughts: march 9/vol19/no26/2005 nursing standard 35
‘I read that if an incident occurred anything written could be used as a legal document.’ (Participant 8) ‘I think people are very careful what they write down. Whatever it is could be dragged up in a court of law. You can’t always transfer what is in your head on to paper.’ (Participant 2) Perhaps this illustrates influences in nursing practice that relate to a blame culture, where practitioners are not familiar with acknowledging good practice. Some of the students’ comments questioned whether reflection was a meaningful activity. The comments reflected different reasons for this. The fact that time was ‘protected’ for the student and mentor to reflect was important for the student. This corresponds with Mezirow’s (1981) description of positive unconditional regard, whereby students feel valued because the mentor spends quality time with them. Other students discussed the fact that learning to reflect in a formal way was difficult and required personal discipline but that ultimately it became a useful exercise. Comments also related to the relationship between the student and the mentor. If trust was established then they could be more honest with each other and share reflections on a more personal level. The role of the mentor was also concerned with providing either a catalytic or cathartic response. This was to ensure that issues discussed could be examined effectively and resolved. The dangers of unresolved reflective episodes are discussed as part of the initial training given before this activity. As the student and the mentor are together for the duration of the course there is scope to develop a close relationship and, therefore, it is important to explore the possible implications of poorly managed or facilitated supervision. The students also found it helpful when they were able to lead the agenda during reflective episodes, as this ensured that topics of relevance were covered. The mentors believed that discussion of issues and topics with the student helped them to understand the students’ thought processes and decision-making, and was useful in assessing the student’s progress. The reflection was generally in the form of verbal communication, although this was not always the case. The dialogue enabled mentors to examine the student’s perspective and interpretation of situations, and thus provided an insight into their development along the continuum towards the learning outcomes for the course. Mezirow’s (1981) framework can act as a tool for guidance in assessing the student’s ability to reflect at a higher level, as it relates to seven levels that correspond with description at the lower end, progressing along a continuum to higher levels of critical analysis. A requirement of the course is for students to write an essay of 1,500 words using what is termed ‘reflective writing’. The assignment is then assessed and graded by the mentor. The rationale for this is that it is important for the mentor to be involved in the assessment of the student’s practical work. As this piece of written work is concerned with practice it was considered appropriate for the mentor to undertake the assessment. However, the benefits of this activity are still being debated. There is a great deal of tension caused by the process because the mentors do not always feel that it is within the boundaries of their role to assess an academic piece of work. One student acknowledged that having to complete an assignment on the topic encouraged her to read around the subject of reflection. Consequently, she commented: ‘That is where I have found a lot of backing for my thoughts in that it is not the “be all and end all” at the end of the day. It quite surprised me and I was quite pleased to find that many learned people agreed with me.’ As previously stated, the process of reflection can offer a flawed perception. Retrospective interpretation can be selective or misleading (Newell 1992). Some students were not convinced that the process was useful and were cynical about its value: ‘There’s not necessarily a correlation between reflection and good practice. You can be a really good nurse but you don’t have to be a formal reflector; that is not to say that it doesn’t go on. I don’t think the two necessarily go hand in hand.’ (Participant 2) Another student supported this view by stating that, after completing the course, when formal reflection was no longer a requirement, she would ‘go back to just thinking things through’. This view was not shared by all students: ‘It has definitely moved my practice forward and changed my attitude. I see it as an agent for change really, because you can look at every situation and see the positive and the negative in it.’ (Participant 8) ‘Reflection can cause changes and ensures that you have done all you could have done.’ (Participant 7) ‘[Reflection] does help me link theory to my practice. Like Benner says, “invisible knowledge becomes visible”, and my actions are more purposefully directed.’ (Participant 10) This student alludes to the fact that by undertaking facilitated reflection with her mentor, certain elements of practice and clinical decision-making were illuminated. She therefore uses reflection to explore her practice and clarify the rationale for decision-making. Benner’s (1984) work has been criticised for lacking empirical rigour, as it relates to the view that expert practitioners are not always able to articulate the knowledge base from which they are drawing their information. In nursing practice, there has been emphasis on using evidence from research to underpin decision-making activity (Le May 1999). However, nurses may need to use an eclectic mix of sources
REFERENCES Andrews M (1996) Using reflection to develop clinical expertise. British Journal of Nursing. 5, 8, 508-513. Atkins S, Murphy K (1994) Reflective practice. Nursing Standard. 8, 39, 4954. Benner P (1984) From Novice to Expert: Promoting Excellence and Power in Clinical Nursing Practice. Menlo Park CA, Addison-Wesley. Cameron B, Mitchell A (1993) Reflective peer journals: developing authentic nurses. Journal of Advanced Nursing. 18, 2, 290-297. Conway J (1998) Evolution of the species ‘expert nurse’. An examination of the practical knowledge held by expert nurses. Journal of Clinical Nursing. 7, 1, 75-82. Cooney A (1999) Reflection demystified: answering some common questions. British Journal of Nursing. 8, 22, 1530-1534. Durgahee T (1996) Reflective practice: linking theory and practice in palliative care nursing. International Journal of Palliative Nursing. 2, 1, 2225. Freund P (1990) The expressive body: a common ground for the sociology of emotions and health and illness. Sociology of Health and Illness. 2, 4, 452-474. Glaze J (2002) Stages in coming to terms with reflection: student advanced nurse practitioners’ perceptions of their reflective journeys. Journal of Advanced Nursing. 37, 3, 265-272.
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on which to base their practice, a view supported by Muir Gray (1997). The idea that practitioners cannot always articulate the knowledge base from which they work supports MacLaren et al’s (2002) view that expert practitioners act intuitively and those observing cannot always perceive their decision-making processes. This is not necessarily accepted as rigorous. As this is a mandatory element in the course it is necessary to provide a clear rationale for its inclusion. It is interesting to note that certain students seem more comfortable with the process than others. Perhaps one explanation for this is the student’s preferred learning style: ‘Having realised that I am a reflector by my learning style questionnaire you will not be surprised that I feel that reflection is a useful tool.’ (Participant 10) Students completed a learning styles inventory devised by Honey and Mumford (1989) to diagnose their preferred learning style. One theme that has become apparent is that those students who had already self-assessed their learning style as being reflective in nature find this activity more useful. This could form the hypothesis for a further study in this area. Discussion The reason for undertaking this study was to find out whether students feel that reflection is a meaningful activity, and if it can provide evidence of achieving the course learning outcomes. Therefore the discussion centred on two themes: first, whether reflection as an activity was meaningful in exploring clinical practice and; second, whether it was a suitable assessment tool. The focus group discussed these points from varying perspectives. There was no real consensus of opinion on this. The students felt that reflection was not necessarily linked to being a ‘good nurse’, and that a student or practitioner could be effective without formally reflecting. However, some students made the link between reflecting on practice and subsequently changing it. The students and the mentors agreed that reflection was a positive activity, although not all of them felt it necessary to document their experiences. Perhaps this activity, if not written down, is more of a problem-solving activity, rather than a true reflective process. Wilkinson (1999) advocates the importance of recording experiences, suggesting that the distinction needs to be made between reflection and recollection. Reflection should be considered in a framework of self-awareness, context and in the domain of a broader perception of health and healthcare issues. This view is supported by Neubauer (1995). Conclusion Findings with one cohort of students neither fully support nor refute the usefulness of reflective practice. However, one point of particular interest emerged. It became apparent that the student’s learning style was pertinent to his or her perception of the usefulness of reflection. Those that found it useful were students who seemed to exhibit learning styles that were more inclined towards reflectors rather than any other. Further studies may investigate whether the learning style of the student has any influence on his or her ability to reflect meaningfully. The findings have wider implications for the continuing debate surrounding the existence of the theory-practice gap. One of the secondary purposes of this work was to find out whether reflection could be meaningful in generating practice theory which when recorded could be accessible to ‘support the growing body of knowledge to inform nursing practice’ (Wilkinson 1999). It was only by examining the students’ attitudes on the usefulness of the process and its effect on their practice that this question could begin to be addressed
Implications for practice ■ Reflection can be a useful tool for exploration of nursing practice ■ Reflection should be used to examine both positive and negative experiences ■ It should not only be viewed as a theoretical exercise but also as a means to reduce the theory-practice gap ■ Nurses may require assistance to reflect in a meaningful way
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(2001) Standards for Specialist Community Education and Practice. London, UKCC. United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1994) The Future of Professional Practice: The Council’s Standards for Education and Practice Following Registration. London, UKCC. Wallace D (1996) Experiential learning and critical thinking in nursing. Nursing Standard. 10, 31, 43-47. Wilkinson J (1999) Implementing reflective practice. Nursing Standard. 13, 21, 36-40. Wong F et al (1995) Assessing the level of student reflection from reflective journals. Journal of Advanced Nursing. 22, 1, 48-57.
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