Introduction

Reflecting on your learning is an essential skill to establish early on in your programme of study, to discus with your personal tutor at university and with your mentor in practice. During your time on placement, you will be assessed in accordance with your programme requirements and, most importantly, the Nursing and Midwifery Council (NMC) standards in the four domains and their generic and field-specific competencies.

This chapter explores the above aims through a range of exercises, references to other chapters and new learning experiences. To begin with, we can re-visit what reflection means and how you do this, in particular reflection on being a student nurse, reflection in the practice of actually ‘doing’ nursing and what goals you now need to set for the future.

Reflection

Most of you will have come across the term ‘reflection’ in your programme of study, but what does it mean in the context of learning in clinical practice? How important is it to your learning to become a nurse? We consider these two questions in the context of undertaking any placement experience and also a surgical one.

At the beginning of your programme of study, you will have been given a practical assessment document to be used by yourself, your mentor and personal tutor to assess, record and discuss your learning in practice to meet the requirements of your course and, most importantly, to meet the requirements of the NMC. Along with this document will be some kind of personal portfolio and personal and professional development documentation in which to document your learning experiences throughout your journey to becoming a qualified nurse. You will be expected to continue this practice following successful registration as a qualified nurse, as maintaining your professional development is an NMC requirement to remain a registered nurse, as well as being part of your annual appraisal requirement by your employer if you work in the NHS.

Timmins (2008:1) offers the following definition of what a portfolio is:

The key words, highlighted in bold, link to the idea of learning from your experiences in clinical placement (workplace learning), evidencing this in some way as written work but, most importantly, reflecting on what you have written about your learning through analysing the experience rather than just describing it. Describing your experiences and what you have learnt from them are both important, but considering them in relation to previous experiences and/or theoretical knowledge can help you to understand what took place or what you felt during the experiences.

It is beyond the scope of this book to discuss reflection and reflective practice in full, but you will find specific texts and articles, such as Timmins (2008) and Hart (2010), to help you at the end of the chapter.

Your portfolio will contain a range of important documents that you are required to have in order to become a nurse registered with the NMC as well as evidence of your personal and professional growth over the course of your programme of study.

What then is reflection? Schon (1983) wrote that there are two types of reflection in relation to clinical practice learning: reflection-in-action and reflection-on-action. The latter is the one we focus on in this chapter but it is also important to consider reflection-in-action as well. Consider the definition of reflection offered by Price and Harrington (2010:25):

Reflection, then, involves thinking about what you have done, taking the activity ‘out of the box’ and looking at it both in terms of how you felt about it when looking at it and actually experiencing or doing it. This is reflection-on-action, the one which you will be asked to write about if doing this for an assignment, to critically review it in terms of evidence, i.e. supporting the rationale for why you did what you did through theoretical concepts or supporting research.

For example, imagine you wrote the following as part of your reflection on an experience with a patient who was going to theatre: ‘I asked the patient whether she had any concerns about going to the operating theatre. She wanted to know what would happen in the theatre and so I explained to her the procedure that would be carried out. She seemed relieved to know that it was perfectly normal to feel afraid that she wouldn’t wake up’. We know from previous Chapters the importance of talking to patients and reassuring them before surgery, and the importance of explaining what will happen, for example we would add to the above reflection in the following way to demonstrate critical reflection or reflection based on evidence.

Critical reflection: evidence based

‘… She wanted to know what would happen in the theatre and so I explained to her the procedure that would be carried out.’

Miller and Webb (2010:59) refer to this as ‘attending’ to the patient, whereby ‘active listening and attending rely on being able to communicate to the other person that we are listening, understanding, remembering, and even interested in what they are communicating.’

Examining the reflection in ‘real time’ is actually harder to contemplate, as it is reflection-in-action, not actually visible to others nor easily expressed, and refers to looking at what you are doing as it actually happens. What you might be reflecting –in-action on may well involve personal feelings of your own or something related specifically to the patient or the situation you have not dealt with before. Imagine a scenario where someone on your ward is having a cardiac arrest. You have never seen one before and only know the key steps to take when it happens, such as calling for help, phoning the right number for the cardiac arrest team and helping the team as required. You watch all the nurses and doctors immediately taking action to save the person’s life and it seems as if they know exactly what to do. Nobody is talking out loud; they are all just ‘doing’ things. You wonder how they can do this and how they know what the right thing to do is. What you can’t see is the nurses or doctors ‘reflecting-in-action’. They may be:

In other words, they are using previous knowledge and experiences to influence their actions in the present situation. All of this probably takes place in a very short space of time – but you can see how much reflection-in-action is taking place. Speaking your thoughts out loud is not appropriate in a cardiac arrest situation or in other situations such as breaking bad news. Reflecting-in-action involves private and personal thoughts and feelings.

Banning (2008) suggests that a ‘think out loud’ approach may be an excellent way to get student nurses to learn as they problem-solve a case study, just as they would in real life practice.

However, reflection-on-action requires a set of skills that can be learned, such as self-awareness which is fundamental to learning from experiences in practice, as is being able to recognise what you did well or need to work on should you experience a similar situation in the future. Using a framwork to guide you in writing your reflection of an event or an observation is helpful.

Models/frameworks to help you reflect on practice learning

There are a number of models that can be used based on theories of reflection. We can consider two here that may be useful to you or that your University asks you to use to reflect on your learning.

Situations that have a significant impact on your experience and learning are often known as ‘critical incidents’ – which can be so-called positive or negative situations – hence the word ‘critical’, in the sense of being important. This is not to be confused with ‘critical incident recording’ in the clinical area whereby an incident is critical in the sense of being important which has also triggered a serious situation requiring investigation. For example, say a patient had been left on their own in the bathroom when the nurse went to get something. The nurse didn’t make sure there was someone to stay with the patient and they later became dizzy, collapsed and broke their leg. This led to them having to go back to the operating theatre, move to an orthopaedic ward and stay in hospital for a further 2 weeks. Such an incident would have to be reported, written down in a factual way and then signed by the nurse, and subsequently investigated by a senior member of staff.

A helpful model for reflecting on practice learning (upon which many others are based) is Gibb’s (1988) ‘reflective cycle’ (see Fig. 14.1).

Fig 14.1 The reflective cycle

adapted fromGibbs (1988)with permission

A simpler version of this model for reflection is that by John Driscoll (1994). His framework is based on three stages: What? So what? And now what?

(See http://www.supervisionandcoaching.com/pdf/reflectivelearning.pdf.)

In brief, you have an experience in practice and then ask yourself the three questions relating to this experience:

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