Nursing Practice Keywords: Reflective practice/

Reflective cycle/Professional
Discussion development
Professional development ●This article has been double-blind
peer reviewed

Reflective practice can be used to help nurses to make sense of work situations
and, ultimately, to improve care. A simple, three-stage model is proposed

Using reflective practice

in frontline nursing
In this article...
he theoretical basis for reflective practice
T
A three-stage model for practical reflection
An example of the model in practice

Author Natius Oelofsen is consultant much-needed support to staff, and facili-

5 key
points
clinical psychologist, learning disabilities tating team members’ professional devel-
service, Norfolk and Suffolk Foundation opment. In this article I offer a simple
Trust and director of Reflective Learning, a
consultancy dedicated to advancing
reflective practices in health and social
reflective method, which can be used in
frontline settings to support effective
reflective practice, together with its theo-
1 Reflective
practice is a key
skill for nurses
care settings.
Abstract Oelofsen N (2012) Using
reflective practice in frontline nursing.
retical rationale. I conclude by offering a
simple example of how such a reflective
process might look and the kinds of out-
2 It enables
nurses to
manage the
Nursing Times; 108: 24, 22-24. comes that can be expected from using the impact of caring
Reflection on practice is a key skill for model in everyday practice. for other people
nurses. Engaging in regular reflection on a daily basis
enables practitioners to manage the
personal and professional impact of
addressing their patients’ fundamental
Theory of reflective practice
In frontline settings such as hospitals,
mental health wards and community serv-
3 Reflective
practice can be
defined as the
health and wellbeing needs on a daily basis. ices nurses have important roles in process of making
This article briefly reviews the addressing basic human needs related to sense of events,
theoretical background underpinning the the physical and mental wellbeing situations and
idea of reflective practice. A simple, of patients and service users. Working actions in the
three-step model for practical reflection is reflectively in these settings is important workplace
presented, which is based on theory and
grounded in practice. The three-stage
cycle is illustrated with a fictional clinical
for nurses for a variety of reasons,
including:
» There is an emotional cost to nurses of
4 A range of
models are
available for nurses
example to show how this reflective caring for others who are vulnerable. to use to support
method can make a difference in busy This is a result of nurses being reflective practice
practice settings. confronted with deep-seated human in clinical practice

5
R
needs and anxieties on a daily basis; Effective
eflective practice can be defined » They need to be change agents in the reflection
as the process of making sense lives of people who use their services. can take place
of events, situations and actions Interpersonal skills, self-awareness and individually, in
that occur in the workplace the ability to influence others towards pos- facilitated groups,
(Oelofsen, 2012; Boros, 2009). Although itive change are, therefore, key skills for or a mix of both
many, if not all, initial nurse education nurses. Reflective practice facilitates the
programmes (leading to registration) development of these skills by fostering an
include modules on reflective practice, understanding of practice events and
organised opportunities to reflect are rare how one’s own approach, personality and
in the busy, pressurised world of frontline personal history contributed to the way
practice. situations arose and how they were dealt
I believe that scheduling time for reflec- with (Oelofsen, 2012; Somerville and
tion in practitioners’ busy day-to-day lives Keeling, 2004).
in frontline services is essential for Theoretical approaches to reflective Examining clinical
improving service quality, providing practice draw on, among others, ideas practice is beneficial

22 Nursing Times 12.06.12 / Vol 108 No 24 / www.nursingtimes.net

“Paracetamol was a near
impossible medication to obtain”
Jonny Briggs 29

from adult learning theory (Kolb, 1984), Fig 1. The three-stage Step 1: Curiosity
and the work of educationist John Dewey reflective cycle This step involves noticing things, asking
(1933) who came up with the concept of questions and questioning assumptions.
“reflective thought”. According to Dewey, In step 1, nurses ask those questions that
this consists of: Step 1: Curiosity will support making sense of the situation
» Developing a sense of the problem at on which they want to reflect. Questions
hand; include:
» Enriching that sense with observations » What exactly happened?
of the relevant conditions; » Why did we deal with the situation in
» Elaborating a conclusion; that way?
» Testing that conclusion in practice. Step 3: » What else could be happening?
Reflective thinking therefore serves to Transformation Step 2: Looking » What was it like from the patient’s
“transform a situation in which there is closer perspective?
obscurity, doubt, conflict and disturbance » What are my feelings about the
of some sort into a situation that is clear, situation?
coherent, settled and harmonious” » How did it affect me?
(Dewey, 1933). » What was the impact on us as a team
At its heart, reflective practice therefore when that happened?
starts with curiosity about a puzzling situ-
ation and, ideally, should conclude with a Source: Oelofsen (2012) Step 2: Looking closer
Reproduced from Fig 1.1 with permission of the publishers
sense of clarity and understanding. In This step involves actively engaging with
frontline settings this often involves the questions from step 1. Reflective prac-
making sense of human frailties such as titioners do what is needed to find out
physical and mental ill health, the is important to purposefully prepare more, “zoom in” on experiences and feel-
dynamics of the relationships between oneself for the process by cultivating ings, “slow down” their own thinking and
people and the systems in which they an internal silence – even if only momen- actions for further contemplation, and
function, and practitioners’ own responses tary – which enables thought processes open themselves up to a variety of dif-
to the situations they encounter in the to begin. ferent (perhaps contradictory) perspec-
course of their work. Thinking involves a number of actions tives. In this step, reflective practitioners
Looking back at Dewey’s original obser- in which practitioners do not routinely try to find ways to articulate the phe-
vations, developing a sense of the problem engage, such as: nomena that were noticed in step 1 and to
at hand and enriching that with careful » Drawing on personal experiences and be aware of all the relevant underlying
observation hint at a process of looking memories; assumptions that are prevalent in their
closer, which involves finding ways of » Asking difficult, sometimes technical, own practices.
answering the questions that were raised questions;
by an “obscure” situation. The reflective » Thinking about broader aspects of the Step 3: Transformation
process ends with conclusions that are situation at hand, for example social or This phase is all about turning sense-
tested in practice – a process that involves political factors. making into action. Using observations
transforming puzzles and questions into These actions all form part of this from the first step in conjunction with the
practical action. aspect of reflection. insights gained from “looking closer”, the
A large number of models of reflective Taylor’s next phase involves being open transformation phase is about finding
practice are available for nurses to choose to answers and, perhaps in contradiction ways to articulate content and process in a
from (Ghaye and Lilyman, 2006; Driscoll, to Dewey’s ideas mentioned above, also format that allows positive changes to be
2000; Gibbs, 1988). Many, if not all, of these being open to partial or incomplete made. Like all useful reflective practices,
fundamentally encourage nurses to answers. As she stated: “Some questions the aim of this phase is to take action that
engage in the process described above. For may remain puzzles” (Taylor, 2006). The leads to better practices and, ultimately,
example, Gibbs (1988) proposed a reflective reflective process concludes with service improvement.
cycle that starts with describing a practice embracing insights from a variety of
event and then cycling through the fol- sources that serve to change practitioners’ Format
lowing stages in turn: awareness. Finally, there is encouragement Effective reflective practice can take place
» Identifying your feelings; to remain tenacious in engaging in reflec- individually or in facilitated groups or,
» Evaluating the experience; tive processes. best of all, as a combination of both.
» Analysing the experience; Having access to a reflective group with a
» Drawing conclusions, including A framework for practice skilled, independent facilitator who is not
alternative actions, that you could have Drawing on these ideas, I propose a simple, involved in the team’s work can have a
taken; practical framework for reflection that number of advantages, including:
» Drawing up an action plan for the nurses at all levels of the profession can » The ability to share similar experiences
future. use. The model was developed in practice, with colleagues;
Taylor (2006) proposed a similar while working with teams of practitioners » Gaining others’ perspectives and
model, and added a number of helpful, in a range of health and social care set- support;
practical perspectives about the emotional tings, across a range of professional » Feedback in a non-threatening setting;
processes surrounding reflective practice. groups. The reflective cycle I propose has » Opportunities for guided practice
SPL

In order to begin reflecting, she felt it three stages (Fig 1). (Oelofsen, 2012).

www.nursingtimes.net / Vol 108 No 24 / Nursing Times 12.06.12 23

Nursing Practice
Discussion

The model in practice potential to lead to service improvements. from managers. In my experience, this
Box 1 features a fictional example of how Reflective processes such as the three- can best be achieved by organising regular
the three-step reflective model can be used stage cycle can support this as shown in facilitated group work that is carried
in practice to support staff practice and the example. out in team contexts with trained facilita-
development. As the example in Box 1 also illustrates, tors. These facilitators should be inde-
Even this relatively straightforward it is not uncommon for reflection to pendent of the team in question (although
example shows how having a personal involve practitioners being confronted they may still work in the same general
reaction to a patient that directly relates with personal issues that relate to their setting).
to an aspect of the practitioner’s personal work lives. These should not be swept
life can have profound implications for under the carpet but, rather, dealt with Conclusion
their ability to work effectively and safely supportively. As such, reflective practice Finally it is worth noting that reflective
but, if dealt with properly, has the needs organisational support and “buy in” processes such as the one described here
are often open-ended and iterative – the
conclusion of one reflective cycle leads to
the inception of another as practitioners’
Box 1. admission. No one else about my aunt. Perhaps awareness of their own processes
Fictional case coming in bothered me times were different a few increases. As the answers to one question
study of and she did not either, years ago? lead to further questions for reflection, so
reflective really, but why do I feel so It’s important to me the reflective process gathers momentum,
practice upset going in to work that something in my thereby sustaining itself. NT
ever since she came in? family and my history
Cassius Smith is a student Why am I so tired at the that I almost forgot about References
Boros S (2009) Exploring Organisational
nurse on placement in a end of my shifts? Actually, had such a powerful Dynamics. London: Sage.
learning disability what am I feeling? impact on my work life. Dewey J (1933) How We Think. Boston, MA: DC
assessment unit for people I think I am very sad I will need to make sure I Heath.
Driscoll J (2000) Practising Clinical Supervision:
with challenging when I think of Ms R – it’s deal with this as soon
A Reflective Approach. London: Bailliere-Tindall.
behaviour. Last week as though everyone has as possible. Ghaye T, Lilyman S (2006) Learning Journals and
Jenny Rogers, aged 23, forgotten her. The way her Critical Incidents. London: Quay Books.
who has moderate carers talk about her, even Transformation Gibbs G (1988) Learning by Doing: A Guide to
Teaching and Learning Methods. Oxford: Oxford
learning disabilities and they appear to only notice Thinking about the issues Brookes University Further Education Unit.
autism, was admitted to her when she hurts others raised for me by Ms R’s Kolb D (1984) Experiential Learning: Experience as
the unit due to increasing or harms herself. And her admission has opened my the Source of Learning and Development.
Englewood Cliffs, NJ: Prentice Hall.
levels of self-harm and family is completely off eyes to how easily even
Oelofsen N (2012) Developing Reflective
aggression towards her the scene. I hate seeing forgotten parts of my own Practice: A Guide for Health and Social Care
carers. The staff noted that. But what is it in me history can intrude on my Students and Practitioners. Banbury: Lantern
that links these feelings work life. I am so glad I Publishing.
that no family members
Somerville M, Keeling J (2004) A practical
had any involvement to Ms R, rather than to remembered about my approach to promote reflective practice within
with Ms Rogers. some of the other people aunt, because if I didn’t, nursing. Nursing Times; 100: 12, 42. tinyurl.com/
Cassius has never on the unit? this would always have NT-reflective
Taylor B (2006) Reflective Practice: A Guide for
worked with people who stayed a puzzling situation Nurses and Midwives. Maidenhead: Open
have learning disabilities Looking closer for me. University Press.
Authors
before. Xxxx
Since Ms Rogers’ I spent some time I am going to take my
Abstract
admission,
Xxxxhe found reflecting in the library this personal reactions to my

X
himself dreading going on morning and suddenly supervision, but it might
xxxxx
to the unit and was tired realised with a shock that also help others if I share
after his shifts. Xxxx
While on one of my mother’s sisters this with the reflective
shift, he was professional was disabled. I’d forgotten group at college. I won’t
and treated Xxxxx
all patients with about that. No one in the be the only one who has
respect, butXxxxx
something family ever talked about had the experience of my
»about
X his experience there her much – I think the last own life affecting my

»step
work. I also wonder if I can
Xxin trying to make
bothered him. As a first time she was mentioned
was more than five years do some work at the unit
»sense
Xxxxxx of what was ago and I recall they looking at how patients
»happening,
Xxxxxxxx he tried to use mentioned she was placed can be helped to remain in
Xxxxx
the three-stage reflective in a home. I think she had touch with the people
Xxxxx
cycle . NT him, and
to help died there a few years who are important to
made the following entry previously, but I am not them. I’ll ask the staff
References
in his reflective
Xxxxjournal: sure. Perhaps something nurse about what the unit
about Ms R reminded me is already doing and
Curiosity of her, although I never whether there is scope for
I am really upset about my met her. I think it’s sad me to do my assignment
reaction to Ms R’s that our family forgot on this topic.

24 Nursing Times 12.06.12 / Vol 108 No 24 / www.nursingtimes.net