If you are just beginning your career in nursing or midwifery, you have an exciting and fulfilling – although challenging – time ahead of you. You will be aware that the NHS is in the midst of radical change, which potentially offers you even more choice of career opportunities than ever before. In fact, change has become the one certainty that we can expect in our professional careers and the way you learn can help you to cope with the change and even harness it to your own benefit. Our regulatory body, the Nursing and Midwifery Council (NMC), acknowledges the increasing complexities of modern professional practice and requires us to be engaged in life-long learning to help us keep pace with the change and increasing expectations of our patients. The NMC (2005) has produced guidance on the principles and values of life-long learning. This can can be downloaded from (http://www.nmc-uk.org/aDisplayDocument.aspx?DocumentID=519).

Life-long learning is seen as crucial to enable you to demonstrate you are taking responsibility for your own learning throughout your career and, as a professional, you are required to articulate this through your personal professional profile (PPP). However, as the NMC acknowledges, life-long learning is more than just keeping yourself up to date. It expects you to take an enquiring approach to your practice, at both the pre-qualifying level of activity, and at the post-qualifying level, through the Post-registration Education and Practice (PREP) standards (NMC, 2008). You can download a copy of the PREP handbook (NMC, 2008) from the NMC website. One of the four key areas of support identified by PREP is to help you to ‘think and reflect for yourself’ (NMC, 2008, p. 2). Guidance on how to develop your own profile can be seen in Chapter 15.

Currently, the process of learning to think and reflect for yourself begins early in your pre-qualifying programme. You can then build on your ability to learn from the range of situations and experiences you find yourself in, up to and beyond the point of registration and throughout your career. Reflection, therefore, plays a vital role in preparing you for your professional life and for the life-long learning that is expected of you. Reflection helps you keep abreast of change as the normal expectation of professional practice. However, despite the ever-increasing body of evidence to suggest that reflective skills are crucial to the provision of holistic nursing care (Gustafsson et al., 2007), reflection is not as universal an activity as we think (Conway, 1998; Mantzoukas and Jasper, 2004).

This chapter sets out to explore what is meant by the term ‘reflection’ and the skills involved in undertaking it. It will also examine ways in which you can develop further the skills of reflection to help you in the study process and to gain more from the experiences you are exposed to, personally and professionally.

The early work of Dewey (1933), an American educationalist, philosopher and psychologist, laid the foundation for our current concept of reflection. Dewey believed that reflection was central to human learning and professional development. More recently, a number of theorists have further developed the concept of reflection (e.g. Brookfield, 1995; Freire, 1996; Habermas, 1974; Mezirow, 1991; Schon, 1983) and helped advance our understanding of how to learn through reflection and facilitate others to learn. If you are interested in finding out more about the contribution of these different theorists, then Redmond (2004) gives a succinct overview of the literature in her first chapter.

It is over 20 years since reflection and reflective practice were first introduced to nursing and midwifery in the UK, with the introduction of Project 2000 (UKCC, 1986) and the move into higher education nationally. Reflective learning has now become an essential element in both pre- and post-registration education programmes globally (Greenwood, 1998; Kember, 2001; Taylor, 2006). The belief is that reflection helps you as a nurse or midwife to learn from your practice. It helps you to make sense of how you and others deal with the complex situations you find yourselves in and it helps you to bridge the gap between the theory you learn in the classroom and your professional practice.

Prior to the introduction of reflective practice, much of the learning in practice and in the education institutions focused on rather traditional teaching styles and all assessments were written in the formal, third person academic style, with the student presenting a rather objective view of how care should be managed. The focus was more on teaching rather than learning. However, Schon (1987) believed that this rather objective, theory-driven approach to learning was inappropriate for education programmes preparing students for a professional career. He recommended that universities re-focus their activity on facilitating students, through reflective methods, to identify and address problematic issues in a more individual way (Mantzoukas, 2007; Schon (1983) and Schon (1987)). He recognized that, in dealing with human behaviour, problems in professional practice are not straightforward. They do not follow a recipe-type approach to decision making. Instead, situations in professional practice are ‘messy’, uncertain, complex, individual and sometimes conflicting. Rather than ‘teach’ theory and expect professionals to bridge the gap between the theory taught to their individual situations, Schon believed that reflective methods would enable them to analyse their unique situation and empower them to confront and address each situation in an individual and holistic way (Mantzoukas, 2007).

As a student of midwifery or nursing, you can use reflective methods to help you to deal with uncertainties and to find new solutions to dilemmas for each individual you care for. Individualized care is now a well-established way of thinking about care. The lists of textbook problems in clinical practice and, even more, the recipe-book solutions to these problems are becoming things of the past. Also, as an adult learner you will bring with you to the learning experience your own individual ways of making sense of the situations. By learning from each situation, you can build up your own portfolio of learning and be able to tailor solutions to meet the individual needs of the patients in your care.

Taylor (2006) argues that reflection encourages students to think critically. From a process of exploration, often triggered by a sense of the unexpected, reflection encourages you to make sense of an experience and learn from it to help you in the future. As already mentioned, feelings are a crucial element in terms of how they influence your learning from the experience.

To enable you to make the most of your learning, many theorists have described their own process to guide you. Before we consider different guides or ‘frameworks’ to help you look critically at your practice, it is worthwhile considering the relationship between reflection and expert practice.

If you look around you, you can certainly identify a number of practitioners who would fit the title of expert. But what exactly do we mean by the term ‘expert’? Those ‘expert’ practitioners whom you have identified will have a number of different attributes, yet you have identified them all as ‘experts’. Conway (1996) suggests that expertise is not definitive and in her own study she identified four different types of ‘expert’ as illustrated below.

As Conway (1996) acknowledges, reflection in a professional sense for some, is not easy. However, as our understanding of reflective learning develops, Burns and Bulman (2000) acknowledged that, 5 years on, and through support and guidance, there was a more positive recognition by student nurses of the value of reflection and their development as curious and challenging practitioners.

More recently, however, a study (by Mantzoukas and Jasper, 2004) of sixteen nurses in four medical wards in England found that although the nurses used and acknowledged the power of reflection for developing practice, its use was devalued by those perceived as being in more ‘powerful’ roles; for example, doctors and managers. It was the ward culture that invalidated it as ‘normal’ for knowledge development and practice provision, forcing its use as a covert activity rather than an accepted and formal learning tool.

Whether you are a nurse or midwife at the beginning of your career, or returning after a break, it is important that you understand how to reflect and identify tools that will help you in the process. Using your clinical mentors or peers to support you, learning from your experience and not by any practice imposed upon you by others or by rituals or routine, will be crucial to deliver the high standards of professional practice set for us by the NMC (2005). While reflection is now accepted as a learning tool in the academic and research world, this study demonstrates that in fact there are still some barriers to its implementation in practice.

You will have met practitioners who have been in practice some years and have developed their practice, kept themselves up-to-date and become expert practitioners. However, you might also have had the misfortune to work with other practitioners who have been in practice for a number of years but have simply repeated their experience over time and have not learned from it.

With the drive towards more flexible career pathways and greater career opportunities from healthcare assistant to consultant, coupled with the NHS modernization agenda advocating new ways of working and better vocational training opportunities for the wider workforce (Department of Health (1999) and Department of Health (2000a)), the boundaries between professional work and non-professional carers have become blurred. Over 15 years ago, Dewar (1992) found that first-level nurses could not differentiate easily between their own work and that of healthcare assistants, and, with the introduction of assistant practitioners, the boundaries are likely to be less clear now. You may be quite clear in your own mind what the differences are but, if challenged, could you put them into words? Perhaps the development of reflective skills will enable the profession, as a whole, to articulate the value of the professional carer. In turn, this may allow you to distinguish between you, the professional, and your assistant, and encourage you to articulate this difference in practice.

As the concept of reflection has developed in relation to professional practice, a number of different types of reflection have been identified in relation to reflecting before, during or after an event.

In addition to the different types of reflection, there are different levels of reflecting. These levels are of particular importance clinically, especially when you engage in a group discussion of an incident that happened in your work. They are also important when developing your skills of reflection for academia. These are considered in more detail in Chapter 14.

Learning from practice is very important in any programme of professional development, whether pre- or post-registration. After all, the whole purpose of learning is to gain insight from our practice and to develop standards of care. Otherwise, learning and study become sterile activities.

A large number of papers related to reflective practice were published during the 1990s (Hannigan, 2001) and the proliferation of papers has continued. Despite a lack of empirical evidence, reflection is seen as ‘the best tool that nursing has to date for advancing its practice’ (Mantzoukas and Jasper, 2004, p. 926). As a tool, therefore, different theorists have developed their own models of structured reflection to help you to follow a process to allow you to articulate your clinical decision making and learn from your experience (Boud et al., 1985; Gibbs, 1988; Johns, 2006; Rolfe et al., 2001). Jasper (2006) presents a comprehensive overview of a range of published frameworks for reflection as well as a comparison of their presentation and key questions/cues.

One of the most popular frameworks to help you gain the most from your reflective learning is the one developed by Gibbs who uses Kolb’s experiential learning cycle as a basis to help you to gain new insights into learning from your experience. Gibbs’ (1988) framework is presented in Figure 12.1.

Gibbs’ model helps learners work through different aspects of the learning situation and allows to break it down into different parts to make sense of it and gain new insights into how things might be done differently in the future.

You can see from this example of an experienced nurse taking over a new role that she has used Gibbs’ (1988) framework to help her to analyse her situation and try to make sense of it. This abridged extract from her portfolio does show some good insight into her feelings and how she has planned to prepare for a similar situation in the future.