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REFLECTIVE PRACTICE IN
NURSING
Bagian Keperawatan Klinik
FAKULTAS ILMU KEPERAWATAN
UNIVERSITAS PADJADJARAN
Kusman !brahim, PhD
Introduction Introduction
The complexity of nursing The complexity of nursing (so many tasks, roles, (so many tasks, roles,
relationships, expectations) relationships, expectations) practice has a practice has a
tendency to become chaotic and unpredictable tendency to become chaotic and unpredictable
Nursing should be a research Nursing should be a research--based profession based profession
(DHSS, 1972) (DHSS, 1972) technical rationality (evidence technical rationality (evidence--
based practice) has been claimed as necessary based practice) has been claimed as necessary
because it can be observed and verified (Kikuchi, because it can be observed and verified (Kikuchi,
1992) 1992) historically, nursing has accepted the historically, nursing has accepted the
superiority of technical rationality over tacit or superiority of technical rationality over tacit or
intuitive knowing ( intuitive knowing (Schon Schon, 1983,1987) , 1983,1987)
Expert practitioner Expert practitioner clinical judgment is largely clinical judgment is largely
intuitive, learnt through holistic pattern intuitive, learnt through holistic pattern
appreciation and past experiences (Dreyfus & appreciation and past experiences (Dreyfus &
Dreyfus, 1986) Dreyfus, 1986)
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The pathway from Novice to expert The pathway from Novice to expert
Novice Novice
Linear thinking and acting Linear thinking and acting
view parts in isolation view parts in isolation
from whole from whole
Reliance on external Reliance on external
authorities authorities
See self as separate from See self as separate from
situation situation
Application of knowledge Application of knowledge
Expert Expert
!ntuitive !ntuitive
Holistic or gestalt vision Holistic or gestalt vision
Reliance on internal Reliance on internal
authority authority
See self as integral to the See self as integral to the
situation situation
wisdom wisdom
(Johns, 2009)
Organization as work settings Organization as work settings
Organization has changed over time: Organization has changed over time:
centralized control of bureaucracies centralized control of bureaucracies
(1950s (1950s--1960s) 1960s) shared decision shared decision--
making through consultation and making through consultation and
participative management (1970s participative management (1970s--
1980s) 1980s) best practice, customer best practice, customer--
focused action and outcome, and the focused action and outcome, and the
managers role as a researcher, teacher, managers role as a researcher, teacher,
enabler of creativity (Anderson, 1996) enabler of creativity (Anderson, 1996)
conflict between autonomy and conflict between autonomy and
authority authority
Introduction Introduction
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Introduction Introduction
Reflective practice is associated with learning Reflective practice is associated with learning
from experience, and is viewed as an from experience, and is viewed as an
important strategy for health professionals important strategy for health professionals
who embrace life long learning who embrace life long learning
The act of reflection is seen as a way of The act of reflection is seen as a way of
promoting the development of autonomous, promoting the development of autonomous,
qualified and self qualified and self--directed professionals directed professionals
Engaging in reflective practice is associated Engaging in reflective practice is associated
with the improvement of the quality of care, with the improvement of the quality of care,
stimulating personal and professional growth stimulating personal and professional growth
and closing the gap between theory and and closing the gap between theory and
practice. practice.
(Webb, 2011)
Introduction Introduction
The process of reflective writing leads to The process of reflective writing leads to
more than just a gain in your knowledge; more than just a gain in your knowledge;
it should also challenge the concepts and it should also challenge the concepts and
theories by which you make sense of theories by which you make sense of
knowledge knowledge
When you reflect on a situation you do When you reflect on a situation you do
not simply see more, you see not simply see more, you see
differently differently. This different way of viewing . This different way of viewing
a situation is reflected in statements a situation is reflected in statements
about a commitment to action about a commitment to action
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Definition of reflection Definition of reflection
Learning through our everyday experiences Learning through our everyday experiences
towards realizing ones vision of desirable towards realizing ones vision of desirable
practice as a lived reality practice as a lived reality
As a mirror to see images or impressions of As a mirror to see images or impressions of
self in context of the particular situation in a self in context of the particular situation in a
careful and realistic way careful and realistic way
Awareness of self within the moment, having Awareness of self within the moment, having
a clear mind, wisdom that help us to see a clear mind, wisdom that help us to see
things clearly things clearly
(Johns, 2009)
Two types of reflection Two types of reflection
Reflection Reflection--in in--action: occur during practice when action: occur during practice when
the attentive practitioner watches, interacts, the attentive practitioner watches, interacts,
and adjust reactions and approach through and adjust reactions and approach through
thinking in a focused way while working thinking in a focused way while working
Reflection Reflection--on on--action: occur after the action action: occur after the action
when details are recalled through rich when details are recalled through rich
description and analyzed through careful description and analyzed through careful
unpicking and reconstructing of all the aspects unpicking and reconstructing of all the aspects
of situation, to gain fresh insights, and make of situation, to gain fresh insights, and make
amendments if necessary amendments if necessary
(Schon, 1987)
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Sources of reflection Sources of reflection
Life Life
Work Work
Art Art
Religious Religious
(Johns, 2009)
Why we should reflect? Why we should reflect?
Reduces the theory Reduces the theory--practice gap practice gap
(Perkins 1996; Fonteyn & Cahill 1998; (Perkins 1996; Fonteyn & Cahill 1998; Getliffe Getliffe 1996; Foster 1996; Foster
& Greenwood 1998; Smith 1998; Burton 2000; Carney 2000; & Greenwood 1998; Smith 1998; Burton 2000; Carney 2000;
Duke & Appleton 2000; Duke & Appleton 2000; Maudsley Maudsley & & Scrivens Scrivens 2000b; Stewart 2000b; Stewart
& Richardson 2000; & Richardson 2000; Koh Koh 2002). 2002).
Encourages critical thinking ability Encourages critical thinking ability
(Patton et al 1997; (Patton et al 1997; Durgahee Durgahee 1998; Foster & Greenwood 1998; Foster & Greenwood
1998; Burton 2000; 1998; Burton 2000; Maudsley Maudsley & & Scrivens Scrivens 2000b; Cotton 2000b; Cotton
2001) 2001)
Helps practitioners to make more sense Helps practitioners to make more sense
of difficult and complex practice of difficult and complex practice
(Driscoll & (Driscoll & Teh Teh 2001) 2001)
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Why we should reflect? Why we should reflect?
Enhances personal development by leading Enhances personal development by leading
to self to self--awareness awareness
(Cotton 2001) (Cotton 2001)
The focus of reflection is improvement in The focus of reflection is improvement in
patient care therefore it helps to expand and patient care therefore it helps to expand and
develop clinical knowledge and skills develop clinical knowledge and skills
(Graham 2000; (Graham 2000; Platzer Platzer et al 2000; Driscoll 8 et al 2000; Driscoll 8 Teh Teh 2001; Paget 2001; Paget
2001) 2001)
Slows down activity thereby providing time Slows down activity thereby providing time
to process material of learning and link it to to process material of learning and link it to
previous ideas previous ideas
(Noon 2002) (Noon 2002)
Why we should reflect? Why we should reflect?
Enables greater ownership of the learning taking Enables greater ownership of the learning taking
place place
(Noon 2002) (Noon 2002)
Promotes optimum effectiveness and efficiency in Promotes optimum effectiveness and efficiency in
an ever evolving and complex health care system an ever evolving and complex health care system
through practitioners auditing their own practice through practitioners auditing their own practice
(Degazon 8 Lunney 1995; Carr 1996; Clark et al 1996; (Degazon 8 Lunney 1995; Carr 1996; Clark et al 1996;
Durgahee 1996; Heath 1998; Hinett 8 Weeden 2000) Durgahee 1996; Heath 1998; Hinett 8 Weeden 2000)
Reminds qualified practitioners that there is no Reminds qualified practitioners that there is no
end point to learning about their everyday end point to learning about their everyday
practice" practice"
(Driscoll 8 Teh 2001: 98). (Driscoll 8 Teh 2001: 98).
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Schon (1983) Schon (1983)
The The Effective Effective
reflective reflective
practitioner is able practitioner is able
to recognise and to recognise and
explore confusing explore confusing
or unique ( or unique (positive positive
or negative or negative) events ) events
that occur during that occur during
practice practice
The Ineffective
practitioner is
confined to
repetitive and
routine practice,
neglecting
opportunities to
think about what
he/she is doing
Reflective process Reflective process
There are numerous frameworks for There are numerous frameworks for
structuring the process of reflection. structuring the process of reflection.
All reflective models comprise of three All reflective models comprise of three
fundamental processes: fundamental processes:
Retrospection: thinking back on events Retrospection: thinking back on events
Self Self--evaluation: attending to feelings evaluation: attending to feelings
Reorientation: re Reorientation: re--evaluating experiences evaluating experiences
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Gibbs Reflective Cycle Gibbs Reflective Cycle
The The Gibbs (1988) reflective cycle Gibbs (1988) reflective cycle is is
considered fairly straightforward considered fairly straightforward
It encourages a clear description of It encourages a clear description of
the situation, analysis of feelings, the situation, analysis of feelings,
evaluation of the experience, analysis evaluation of the experience, analysis
to make sense of the experience, to make sense of the experience,
conclusion where other options are conclusion where other options are
considered and reflection upon considered and reflection upon
experience to examine what you experience to examine what you
would do if the situation arose again would do if the situation arose again
Gibbs reflective cycle Gibbs reflective cycle
DESCRIPTION DESCRIPTION
(What happened) (What happened)
Action Plan Action Plan Feelings Feelings
(!f it arose again (What were you (!f it arose again (What were you
what would you do?) thinking + feeling?) what would you do?) thinking + feeling?)
Conclusion Evaluation Conclusion Evaluation
(What was good (What was good
and bad?) and bad?)
Description Description
(What sense can you make of the situation) (What sense can you make of the situation)
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Stage 1: Description of the event Stage 1: Description of the event
Describe in detail the event you are
reflecting on
Include: where you were; who else
was there; why you were there; what
you were doing; what other people
were doing; what the context of the
event was; what happened; what your
part was; what parts the other people
played; what the result was
Stage 2: Feelings Stage 2: Feelings
Try to recall and explore what was going on Try to recall and explore what was going on
inside your head i.e. why does this event stick inside your head i.e. why does this event stick
in your mind? in your mind?
Include: how were you feeling when the event Include: how were you feeling when the event
started; what you were thinking about at the started; what you were thinking about at the
time; how it made you feel; how other people time; how it made you feel; how other people
made you feel; how you felt about the made you feel; how you felt about the
outcome of the event; what you think about it outcome of the event; what you think about it
now now
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Stage 3: Evaluation Stage 3: Evaluation
Try to evaluate or make a Try to evaluate or make a
judgement about what has judgement about what has
happened. happened.
Consider what was good Consider what was good
about the experience and about the experience and
what was bad about the what was bad about the
experience, or didnt go so experience, or didnt go so
well well
Stage 4: Analysis Stage 4: Analysis
Break the event down into its component Break the event down into its component
parts so they can be explored separately parts so they can be explored separately
You may need to ask more detailed You may need to ask more detailed
questions about the answers to the last questions about the answers to the last
stage stage
Include: what went well; what you did Include: what went well; what you did
well; what others did well; what went well; what others did well; what went
wrong or did not turn out how it should wrong or did not turn out how it should
have done; the way you, or others, have done; the way you, or others,
contributed to this contributed to this
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Stage 5: Conclusion Stage 5: Conclusion
This differs from the evaluation stage in This differs from the evaluation stage in
that now you have explored the issue that now you have explored the issue
from different angles and have a lot of from different angles and have a lot of
information to base your judgement information to base your judgement
It is here that you are likely to develop It is here that you are likely to develop
insight into your own and other peoples insight into your own and other peoples
behaviour in terms of how they behaviour in terms of how they
contributed to the outcome of the event contributed to the outcome of the event
Stage 6: Action Plan Stage 6: Action Plan
During this stage you should think During this stage you should think
about encountering the event again and about encountering the event again and
plan what you would do plan what you would do would you would you
act differently or would you be likely to act differently or would you be likely to
do the same? do the same?
Here the cycle is tentatively completed Here the cycle is tentatively completed
and suggests that should the event and suggests that should the event
occur again it will be the focus of occur again it will be the focus of
another reflective cycle another reflective cycle
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Other models of reflection Other models of reflection
There are other models of reflection and
there are brief explanations for some in
the next few slides
Johns model of reflection
The What? model of structured
reflection by Driscoll
Johns model of structured reflection Johns model of structured reflection
Johns model can be used as a guide for Johns model can be used as a guide for
analysis of a critical incident or general analysis of a critical incident or general
reflection on experience. This would be reflection on experience. This would be
useful for more complex decision making useful for more complex decision making
and analysis at levels 3 & 4 and analysis at levels 3 & 4
He supports the need for the learner to work He supports the need for the learner to work
with a with a supervisor supervisor throughout their learning throughout their learning
experience experience
He refers to this as He refers to this as guided reflection guided reflection, and , and
recommends that students use a structured recommends that students use a structured
diary diary
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Johns model of structured reflection Johns model of structured reflection
John feels that through sharing reflections John feels that through sharing reflections
on learning experiences, greater on learning experiences, greater
understanding of those experiences can understanding of those experiences can
be achieved than by reflection as a lone be achieved than by reflection as a lone
exercise exercise
John also uses John also uses Carpers Carpers (1978) four (1978) four
patterns of knowing, aesthetics, personal, patterns of knowing, aesthetics, personal,
ethics and empirics adding a fifth pattern ethics and empirics adding a fifth pattern
reflexivity reflexivity
Driscoll's Driscoll's `The What?' model (2000) `The What?' model (2000)
A description of events ( A description of events (What? What? trigger trigger
questions) questions)
An analysis of events ( An analysis of events (So What? So What? trigger) trigger)
Proposed actions following events ( Proposed actions following events (Now Now
What? What? trigger) trigger)
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Top tips for reflecting (Taylor 2000) Top tips for reflecting (Taylor 2000)
Be spontaneous Be spontaneous it is from the frank and it is from the frank and
honest self that important insights arise honest self that important insights arise
Express yourself freely Express yourself freely you dont need to you dont need to
observe the normal academic practices observe the normal academic practices
involved in writing involved in writing
Remain open to ideas Remain open to ideas early conclusions early conclusions
can inhibit further insights and solutions can inhibit further insights and solutions
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!ndividual Assignment! !ndividual Assignment!
Recall your experience while you are Recall your experience while you are
practicing nursing (hospital or practicing nursing (hospital or
community), pick up an event that you community), pick up an event that you
impress most, write up as a story, and impress most, write up as a story, and
do reflection based on a selected do reflection based on a selected
framework of reflection framework of reflection
Six of them will be selected randomly for Six of them will be selected randomly for
class presentation class presentation
Do it happily . Do it happily .
Thank You