Making sense of reflective practice

Current guidance from the NMC on revalidation places great store on reflective practice – but what is it, and is it as daunting as it sounds?

In a previous article we discussed the importance of reflective practice when it comes to revalidating with the Nursing and Midwifery Council (NMC).¹ In this article we explore the concept of reflection in a more detailed yet simple way and try to clear up some of the confusion that surrounds this subject.

The NMC Code² describes reflection on the key aspects of the code as being central to maintain good standards of practice and facilitating revalidation. The four elements that underpin the Code are the 4 Ps:

• Prioritise people
• Practise effectively
• Preserve safety
• Promote professionalism and trust

These objectives can be met through working in practice, maintaining continued professional development, getting feedback from others regarding performance and reflecting on and discussing these topics. This means that nurses who are planning to complete the revalidation process in order to stay on the Register will need to show evidence of keeping up to date through ongoing education underpinned by reflective practice. Although many professions encourage and endorse the use of reflective practice (teaching and the legal profession among others) it can still feel like a challenge and as if this is yet another ‘to do’ on an ever increasing to do list.

However, it will be a rare nurse who isn’t already engaging in some form of informal reflection. A typical example is that situation when you are standing in the shower, driving home from work or trying to get to sleep when you suddenly start thinking about that patient you saw earlier today. You start to ponder: ‘Was the advice I gave correct? Could I have suggested something else? What if it wasn’t “just a virus”? Maybe I could have given that depo contraception injection after all – aren’t there new guidelines about that? Why did I feel so annoyed with that patient today and ignore some of their concerns?’ Thoughts like these can swim around in your head, making you question and reflect on your practice. So for most nurses, reflection is already happening, at least in its initial stages.

However, the point of reflection is to ensure that this pondering is taken a step further – that any possible gaps in knowledge are investigated, that current evidence is sought out and that other ways of consulting are considered for the next person that comes into the surgery with a similar issue. Taken to its full conclusion, the next step of reflective practice is clinical supervision, that inappropriately named intervention which allows nurses to discuss these issues with others in a structured way and which can ultimately lead to improved quality of care delivery.³

REFLECTION – HEAD OR HEART?

Much has been made of the academic approach to reflection, with reams written about the various models of reflection which might or might not need to be followed. This begs the question: is reflection something that’s done with the head or with the heart? The answer must surely be both. The heart says that something might have been done better, that maybe there was another approach that could have been taken; the head goes and looks for it. However, trying to turn reflection into an academic piece of work per se seems rather at odds with the essence of reflection. It may even be the very thing that puts people off the concept of reflection and stops them from realising that they are already doing it. I hear many people saying they don’t know how to reflect, don’t know which model to use and get put off by the large academic tomes written on the subject. So, let me try to make this a bit easier and offer you a broad approach to reflection that you can then make your own.

Taking a simple approach to reflection, using Driscoll’s ‘What’ model of reflection⁴ (which may be the most down to earth approach to consider if you are new to reflective practice, or think you are). I will go on to describe a ‘freestyle’ approach, which may seem less daunting to some. The most important thing is to remember that whatever you might think, you are already reflecting. We’re just going to provide a little bit of structure and then encourage you to follow it through.

THE ‘WHAT’ MODEL OF REFLECTION

The ‘What’ model simply says: What happened? So what? What now?

I imagine that if I asked you to think of a recent consultation with a patient when you were left feeling slightly dissatisfied with the outcome, you could name one without too much thought. It doesn’t have to be a major issue, just some element of the time spent with that individual that made you think at the end ‘that could have gone better’. Certainly my experience of asking colleagues this very question is that that the discussions begin in earnest! Most of us can always find something at the end of the day that needs a bit more thought – from the consultation with the worried parent bringing their child for their first immunisations asking for an explanation of what they all are, to the woman recently discharged from hospital after an exacerbation of COPD holding a new inhaler that you don’t recognise, there are always opportunities to consider possible gaps in our knowledge or handling of any given situation. So – let’s take this model and put it into practice, then, with a fictional example of a situation which warrants reflection.

Reflective case study – clinical

Stephanie is seeing a patient for a diabetes review as the lead nurse for diabetes in the practice. Her patient, Lucy, has been started on a new therapy by the hospital after a recent admission for a hypoglycaemic event. She says she has been told these won’t cause hypoglycaemia like her old tablets did but she wants to know more about them. Stephanie realises that she has no experience of the newer therapies as the practice tends to stick to the same types of older medication which they feel more comfortable with and which are included on the local formulary. She feels unable to answer some of Lucy’s questions so looks up the new drug on the Internet; however, she feels as diabetes lead she should have been better informed. She goes home that evening and mulls it over in her head.

Driscoll has taken the ‘What’ model and filled it out with some suggested questions that might make it easier to structure the reflective process more easily and this is described in the example below.

What?

Stephanie needs to take a calm and considered approach to the situation, using the ‘what’ framework. This is how she approached it:

What happened? I felt out of my depth in a subject area I feel should be my specialist subject.

Why do I need to revisit it? To understand how this happened and what I can do to avoid this happening again.

What about the other people involved? I think Lucy was surprised I had to look the information up on the Internet.

What did I/they see and do? Lucy saw that I wasn’t sure about her new medication; I saw that too! I had to react in the only way I could – to look the information up for now.

How did I react? I felt embarrassed although at least I did find the information for Lucy.

So what?

After setting this information out, Steph needs to move on to the ‘so what’ stage, which allows for analysis of the event.

What is troubling me about this episode? It’s a feeling of embarrassment that I didn’t know about this treatment and that maybe I’ve become a bit stuck in my ways and that this may be affecting patient care. Should I have been more aware of these issues previously and thought about changing her medication myself? Did I ask her about hypos? Is it OK to look things up that I don’t know about?

How did I feel at the time and now? Embarrassed and lacking competence in an area I should know more about – then and now.

What was the impact of what was done/not done? Lucy got her information, but I would have liked to have appeared more up to date and knowledgeable.

What have I learned from this event? That I need to make sure that I know more about my area of specialism; that following formularies is fine some of the time but I need to know more about newer treatments if I am going to offer a wider choice and be the patient’s advocate.

How does this reflection help me learn for future practice? It means that I have realised I need to learn more about these drugs so I can talk to others about when best to use them – others being clinicians within my team and also patients. In future I’ll have a broader understanding of the choices available and be able to support others to make the best choices for them. It also means better joined up care with the hospital if they are using these therapies more.

What now?

Finally we come to ‘what now?’

What are the implications of this event on me and on my future practice? It’s an opportunity for me to learn more about newer treatments and become a better clinician. Lucy was not disadvantaged by me searching for information on the Internet; it’s me who feels as if I have to know more without having to search for information online.

What have I learned? I’ve learned that an incident like this, although embarrassing for me, can lead to me taking an interest in newer therapies and reading up on them so I feel better equipped to answer patients’ questions and support their decision making in the future.

What will I do differently in future? I’ll know more, certainly, but also maybe I should feel less embarrassed about not knowing everything but instead see incidents like these as a trigger to learning and development.

What if I do nothing – what then? In this situation I feel that I’m at risk of not moving forward if I do nothing. As a result, I’m going to ‘safety net’ by putting a time limit on my learning and have it in my diary to have written some basic patient information sheets on these new therapies within the next three months.

How do I learn from this and do I need someone or something else to support me to change or develop my practice? I’ve contacted our local diabetes specialist nurses (DSNs) to see what information, if any, they provide to patients about new therapies. If they don’t have anything suitable we’re going to work together to produce some. Putting something down in writing certainly helps to focus the mind! The DSNs have also offered to come to our practice meeting to talk through the role of newer therapies.

How will I recognise that I have learnt something as a result of all of this? In three months’ time I will have worked collaboratively with our DSNs to understand more about these drugs and to develop simple materials for patients. As I continue to carry out more reviews with patients with diabetes I can implement what I have learned. Maybe when I see Lucy next I can show her how her question spurred me on to do all of these things. I’m sure she’ll be delighted!

REVIEWING THE REFLECTIVE PROCESS USING THE ‘WHAT’ MODEL

The most important thing with reflection is that it encourages constructive thinking and learning. There is no model that will suit everyone and the idea is to have an idea of where you are going with your reflection without being hampered by ticking the ‘boxes’ above. As long as you define the essence of the ‘what’, ‘so what’ and ‘what now’ that’s all that matters. You can use any existing model or you can use your own ‘freestyle’ approach. The key is that you look at something that’s niggling away at you and think constructively about why the niggle is there and most importantly of all how you address it and learn from it.

It isn’t always a clinical issue that might challenge you to reflect, however. Take this case study:

Reflective case study - ethical

Cathy is an experienced practice nurse who attends a nurse meeting in her locality. The subject of the meeting is asthma management and Cathy discusses a real life case that she has had to deal with recently. She keeps the patient’s name secret but includes real information about the patient’s age and diagnosis along with some details about occupation and family circumstances, all of which might identify him to people at the meeting who may who know this person. Afterwards, Cathy begins to worry about the information she divulged, reflecting on the fact that although she maintained the individual’s anonymity in terms of their name, there were other identifying features that could have made the patient identifiable to the other nurses attending the meeting.

Using her own method of reflection, here’s how Cathy might reflect on the situation.

At the time I didn’t even think about the fact that I might be breaching patient confidentiality. I was among fellow nurses and we were in a professional meeting, after all. It was only afterwards, when driving home, that it suddenly dawned on me that I had, in fact, acted unprofessionally. I was mortified and felt that I’d let myself down but had also let my patient down. I was worried that others at the meeting may have spotted my breach there and then and may have been appalled at my behaviour, especially as I am supposed to be a role model for some of the younger nurses in the area. I wasn’t sure what to do. Should I wait and see if anyone contacted me to complain? Should I contact all attendees to express my concerns and regret? Maybe I ought to contact the patient to explain what I’ve done? But if no-one actually picked up on it, then am I going to actually cause more trouble and distress all round by raising it? I need a plan of action. I need to contact the nurse who organised the meeting and explain my concerns and engage her in a clinical supervision session. I need to review the NMC guidance on confidentiality and find out what it says – I’ve realised I don’t know enough about what to do in a situation like this. Once I have done this I need to consider the other issues I’ve mentioned here. One thing I have learned immediately is to be much more careful about what I say in meetings like this. Breach of confidentiality is one of the most fundamental rules of nursing and I need to be much, much more respectful of this and aware of my huge responsibility to protect patients in my care.

REVIEWING THE REFLECTIVE PROCESS USING A ‘FREESTYLE’ APPROACH

This example is clearly different. However, although it does not formally follow any model of reflection, it has all the elements of the ‘what, so what, now what’ model described above. For Cathy, writing freestyle in this way is much easier and allows her to write intuitively about an incident which is clearly troubling her. It is also different in that it is a non-clinical situation and the issues raised are more complex and have an ethical and, potentially, medico-legal slant to them. It is also less complete than our clinical example. Cathy needs support from a trusted and knowledgeable colleague who can help her negotiate this tricky situation. She’ll need to revisit her reflection once she has more information available to her about how she should proceed – for example by reviewing the NMC’s position on the duty of candour. At this stage it is not all nicely tied up with a bow on top – and that’s the reality of reflecting in and on real life. The key, though, is that she does get the support and further information that she has identified herself as needing and that she works things through. Even at this stage, however, there is evidence of learning.

Other reflective models are available and include Gibbs⁵ and Johns⁶. In each case, there is something that some people might find more useful and easier to implement than others.

REFLECTING ON GOOD PRACTICE

It is human nature to tend to ruminate over things that didn’t go so well. Job interviews, relationships with partners and children, the failed diet (again). However, reflective practice can also be used to celebrate what has gone well, too. An example of this might be attending a study day – lets’ say a respiratory update day. The sessions cover a range of respiratory conditions, investigations and treatments and you find as you go through the day that you actually know most of the information that the day covers. This is a cause for reflective celebration – recognition that you are keeping up to date, that you know about new guidance and treatment options and that you can support your respiratory patients through your enhanced and advanced skills and knowledge. Record this in your reflective diary too.

If a consultation goes really well and a patient thanks you for your care, think about why it went well. Was it an explanation you gave? Was it the fact that you respected their right to autonomy? Maybe you just listened… Take time to think about what it was that made the consultation a successful one and try to think about how you might bring that element into other consultations. Record your thoughts in your reflective diary.

SUMMING UP

The point of this article was to clear the fog around reflective practice and show how it can improve the quality of care delivery and produce more thoughtful practitioners. I hope it shows how reflective practice can also be enjoyable – an opportunity to take those 2am ‘thoughtmares’ that keep you awake and turn them into something constructive. As a result, I’d like to make a suggestion. Once you’ve finished reading this article, pick up a pen and paper and jot down a few lines about that incident that has been bugging you in the last week or so. Big or small, just jot it down. Add three subheadings – what, so what and now what. Without even going back to the suggestions above, write a few words alongside each heading. There. You’re now formally a reflective practitioner.

REFERENCES

1. Bostock-Cox B. The Nursing and Midwifery Code: Making it work for you and your patients. Practice Nurse 2015;45(04):34-37

2. Nursing and Midwifery Council. Code of Conduct, 2015. http://www.nmc-uk.org/

3. Care Quality Commission. Supporting information and guidance: Supporting effective clinical supervision, 2013. https://www.cqc.org.uk/sites/default/files/documents/20130625_800734_v1_00_supporting_information-effective_clinical_supervision_for_publication.pdf

4. Driscoll J. Practising Clinical Supervision: A Reflective Approach for Healthcare Professionals. 2nd ed. Edinburgh: Bailliere Tindall Elsevier, 2007

5. Gibbs G. Learning by Doing: A guide to teaching and learning methods, 1988. Further Education Unit, Oxford Brookes University, Oxford.

6. Johns C. Nuances of reflection. Journal of Clinical Nursing 1994;3:71-75