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Reflective Practice in Nursing: A Guide to Improving Patient Care

Reflective Practice in Nursing: A Guide to Improving Patient Care -Reflective practice is an important aspect of nursing that involves the critical analysis of one’s own experiences and actions to improve nursing practice. It is a process of self-reflection and self-evaluation that can lead to personal and professional growth. This article will explore the concept of reflective practice in nursing, its importance in nursing practice, and the strategies and tools that can be used to facilitate reflective practice.

Table of Contents

Understanding Reflective Practice

The definition and concept.

Reflective practice refers to the intentional process of evaluating one’s experiences, thoughts, and actions to gain a deeper understanding of their impact. In nursing, it’s about analyzing the why and how behind every action taken, allowing for a comprehensive assessment of one’s performance.

Historical Context

The roots of reflective practice in nursing can be traced back to the work of influential theorists like Donald Schön, who emphasized the significance of “reflection-in-action” and “reflection-on-action.” These concepts laid the foundation for integrating self-reflection into nursing practice.

Concept of Reflective Practice in Nursing

Reflective practice in nursing is a process of self-reflection and self-evaluation that involves analyzing one’s own experiences and actions to improve nursing practice. It is a way of learning from experiences, both positive and negative, to improve future practice. Reflective practice is based on the assumption that nurses can improve their practice by reflecting on their experiences and critically analyzing their own actions.

Importance of Reflective Practice in Nursing

Reflective practice is important in nursing practice for several reasons. Firstly, it helps nurses to improve their practice by identifying areas for improvement and developing strategies to address them. Secondly, it can enhance nurses’ critical thinking skills by encouraging them to analyze their own experiences and consider different perspectives. Thirdly, it can promote self-awareness and personal growth by encouraging nurses to reflect on their own values and beliefs and how they influence their practice .

There are many benefits to reflective practice in nursing. It can help nurses to:

• Improve patient care outcomes
• Develop critical thinking skills
• Enhance communication skills
• Increase self-awareness
• Promote professional growth and development
• Cope with stress and burnout

Strategies and Tools for Facilitating Reflective Practice

There are several strategies and tools that can be used to facilitate reflective practice in nursing. Some of these include:

• Journaling: Journaling is a common tool used in reflective practice. Nurses can use a journal to record their thoughts and experiences, and then reflect on them to identify areas for improvement.
• Critical Incident Analysis: Critical incident analysis involves reflecting on a specific event or experience in practice and analyzing it to identify strengths and areas for improvement.
• Reflection on Action and Reflection in Action: Reflection on action involves reflecting on past experiences and analyzing them to identify areas for improvement. Reflection in action involves reflecting on experiences as they are happening and making adjustments to practice in real time.
• Peer Reflection: Peer reflection involves discussing experiences and actions with colleagues to gain different perspectives and insights.
• Feedback: Feedback from colleagues, supervisors, and patients can be a valuable tool for reflective practice, providing insight into areas for improvement.
• Professional Development: Professional development activities, such as attending conferences and workshops, can provide opportunities for nurses to learn and reflect on their practice.

Implementing Reflective Practice

Models of reflective practice.

Several models guide nurses through the reflective process. The Gibbs’ Reflective Cycle, for instance, involves stages like description, feelings, evaluation, analysis, conclusion, and action plan. These models provide a structured framework for introspection.

Steps in the Reflective Process

• Description: Recount the situation or experience in detail.
• Feelings: Examine your emotions during the event.
• Evaluation: Assess the positives and negatives of the situation.
• Analysis: Dig deeper into the factors influencing your actions.
• Conclusion: Sum up the insights gained from reflection.
• Action Plan: Define steps for future improvements.

Example of Reflective Practice in Nursing

As a registered nurse working in a busy hospital, I recently had an experience that highlighted the importance of reflective practice in improving patient communication and overall care. This incident prompted me to consider my approach to patient interactions and how it could be refined for better outcomes.

In this particular situation, I was assigned to care for a patient who was admitted for a complex surgical procedure. The patient, Mrs. Johnson, appeared anxious and had numerous questions about the upcoming surgery. Due to the high patient load, I felt a sense of time pressure and inadvertently rushed through her questions, providing concise answers without fully addressing her concerns.

Later that day, I engaged in reflective practice, realizing that my approach might not have been the most effective way to support Mrs. Johnson during such a critical time. I used the Gibbs’ Reflective Cycle to guide my self-examination:

• Description: I recalled the interaction with Mrs. Johnson and the rushed manner in which I answered her questions.
• Feelings: I acknowledged that my actions might have contributed to her anxiety and dissatisfaction.
• Evaluation: I assessed the negative impact of my approach on patient communication and the potential consequences for her overall well-being.
• Analysis: I delved into the factors that influenced my behavior, such as time constraints and a high workload.
• Conclusion: I concluded that while these factors were present, they should not have compromised the quality of patient care and communication.
• Action Plan: I determined that in future interactions, I would allocate dedicated time to address patient concerns, ensuring they feel heard and valued.

This reflective process led me to take actionable steps to improve my patient communication skills. In subsequent interactions with Mrs. Johnson, I intentionally created a calm and attentive environment. I provided her with detailed explanations about the surgery, and potential outcomes, and addressed her concerns with empathy. I also encouraged her to ask questions and clarified any doubts she had.

The impact of this reflective practice was profound. Mrs. Johnson’s anxiety visibly decreased, and she expressed gratitude for the time I spent addressing her concerns. Her positive feedback not only boosted her confidence but also reminded me of the significant role effective communication plays in fostering trust between nurses and patients.

This experience taught me that reflective practice isn’t just a theoretical concept but a practical tool that can transform patient care. By taking the time to analyze our interactions, understand our emotions, and make conscious efforts to improve, nurses can create meaningful connections with patients and enhance their overall well-being.

Barriers to Reflective Practice

Despite the importance of reflective practice in nursing, there are several barriers that can make it difficult to implement. Some of these include:

• Time constraints: Nurses may feel that they do not have enough time to engage in reflective practice due to heavy workloads.
• Lack of support: Nurses may not receive support from colleagues or supervisors for engaging in reflective practice.
• Fear of judgment: Nurses may feel uncomfortable reflecting on their experiences and actions for fear of being judged.
• Lack of training: Nurses may not have received adequate training in reflective practice, making it difficult to engage in the process.

Reflective practice is an important aspect of nursing that can lead to personal and professional growth. It involves the critical analysis of one’s own experiences and actions to improve nursing practice. Strategies and tools for facilitating reflective practice include journaling, critical incident analysis, peer reflection, and professional development. However, there are several barriers that can make it difficult to implement reflective practice, including time constraints, lack of support, fear of judgment, and lack of training. Despite these barriers, it is important for nurses to engage in reflective practice to improve their practice and promote positive patient outcomes.

Please note that this article is for informational purposes only and should not substitute professional medical advice.

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Using reflection in a critical care unit, catherine ganner staff nurse, cardiothoracic intensive care unit, walsgrave nhs trust hospitals, coventry.

This article describes how reflective practice can be used to ensure the best care is given to patients under difficult circumstances

Reflection is an aptitude which can be used and refined by nurses to underpin their practice. It can also help nurses develop their practice by identifying and analysing nursing events to produce an understanding that will strengthen or change actions. This enables practice to become grounded in theory, thus narrowing the theory- practice gap.

Nursing Standard . 10, 15, 23-26. doi: 10.7748/ns.10.15.23.s34

> REFLECTIVE PRACTICE - > INTENSIVE CARE - > DEATH AND DYING - > RELATIVES

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09 January 1996 / Vol 10 issue 15

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Requirements for reflection in the critical care environment

Celia j filmalter, tanya heyns.

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Correspondence to: Celia Filmalter Email: [email protected] , Postal address: Private Bag 667, Pretoria 0001, South Africa

How to cite this article: Filmalter, C.J. & Heyns, T., 2015, ‘Requirements for reflection in the critical care environment’, Curationis 38(1), Art. #1202, 4 pages. http://dx.doi.org/10.4102/curationis.v38i1.1202

Received 2014 Jul 4; Accepted 2014 Dec 2; Collection date 2015.

Licensee:AOSIS OpenJournals. This work is licensed under the Creative Commons Attribution License.

Reflection is recognised as an important method for practice development. The importance of reflection is well documented in the literature, but the requirements for reflection remain unclear.

To explore and describe the requirements for reflection in the critical care environment as viewed by educators of qualified critical care nurses.

A focus group interview was conducted to explore and describe the views of educators of qualified critical care nurses regarding requirements for reflection in the critical care environment.

The themes that emerged from the focus group were buy-in from stakeholders – management, facilitators and critical care nurses, and the need to create an environment where reflection can occur.

Critical care nurses should be allowed time to reflect on their practice and be supported by peers as well as a facilitator in a non-intimidating way to promote emancipatory practice development.

Introduction

Reflection is a pivotal skill for all critical care nurses who have to care for patients in an ever-changing medical environment. The origins of reflection can be traced back to John Dewey, a philosopher of education, who explained reflection as an intentional, active progression of learning (Nelson 2012 ). Reflection forms part of the experiential learning cycle for the purpose of assisting practitioners to make sense of an experience and to seek alternatives and improved actions for practice (Passarelli & Kolb 2011 ). A modern scholar of reflection, Johns ( 2013 ) recognised the value of reflection in a specific context and defines reflection as:

a window through which the practitioners can view and focus self within the context of their own lived experience in ways that enable them to confront and understand and work towards resolving the contradictions with their practice between that is desirable and actual practice. (p. 34)

Practice development applies reflection as a method to integrate work-based learning for sustained development in practice to promote the effectiveness of individuals, teams and healthcare organisations (McCormack, Manley & Titchen 2013 ). Nurses working in different contexts are required to develop their practice and utilise scientific evidence to guide desirable practice to improve patient outcomes.

Efforts to develop practice by educators and organisations focus on technical practice development, which is task orientated and uses top-down approaches to learning (McCormack et al . 2013 ). There is limited literature on the approaches used in South Africa to develop practice; however, in a study conducted in the United Kingdom it was found that if practice development was conducted by using traditional teaching strategies, the nurses became passive recipients of information only (Williams 2010 ). The resources spent using traditional teaching strategies for practice development make no significant change in how nurses practise in their work context (Duff, Gardner & Osborne 2014 ; Williams 2010 ). In order for practice development to bring about sustainable change and positive outcomes for both patients and the nursing profession, McCormack et al . ( 2013 ) advocate the use of emancipatory practice development.

Emancipatory practice development focuses on improving outcomes and self-understanding of nurses and assisting them to become critics of their social and educational situations, as well as their work context and workplace culture (Manley, McCormack & Wilson 2008 :268). Emancipatory practice development is divided into three phases: enlightenment, empowerment and emancipation. Wilson and McCormack ( 2006 ) describe enlightenment as the phase where nurses are made aware of the changes that are required; through empowerment nurses gain information that enables them to act on the changes identified. Emancipation is achieved when enlightened and empowered nurses take action to reform their practice in the context of their work (Boomer & McCormack 2010 ).

For nurses to become enlightened about their unarticulated assumptions about themselves and their practice, reflection can be used to improve their practice. Reflection is a method to assist nurses to take personal responsibility for actions and practice development for sustainable change (Boomer & McCormack 2010 ).

Problem statement

Shifting qualified critical care nurses from being passive recipients of information to being active participants in their practice development requires them to engage in reflection. Reflection is, however, a taught skill and requires a necessary shift in the education and training of qualified critical care nurses (Berterö 2010 ; McCormack et al . 2013 ). Evidence of reflection being used for practice development is scarce.

Black and Plowright ( 2010 ) are of the opinion that vagueness and the popularisation of reflection, as well as perplexing theories and inconsistent study results on the topic of reflection, have presented problems for teaching, training and use of reflection in practice. Boomer and McCormack ( 2010 ) confirm that reflection is a learned skill that requires development.

The views of educators involved in the practice development of qualified critical care nurses, that were responsible for introducing and facilitating reflection in the practice setting, were explored to reveal requirements for realising reflection in the critical care environment.

Research method and design

An explorative, descriptive, qualitative design was used to gain insight into the requirements for reflection. Educators from private and public healthcare facilities involved in the practice development of qualified critical care nurses were invited to participate in a focus group discussion (FGD). Participants for the FGD were identified through the use of snowball sampling. Seven participants were identified during the sampling process and invited to the FGD, which was conducted at a venue which was central for all the participants. Informed consent was obtained from participants and their right to withdraw from the FGD at any time was reiterated before commencement.

After permission was obtained to audio-record, the FGD began. The FGD was used to collect data through social interaction and to build upon the answers of the other participants. An independent expert in FGDs facilitated the interview, since the researcher was also involved in the practice development of qualified critical care nurses. The facilitator ensured that the interview remained focused on the topic and asked questions to clarify meanings.

The question posed to the participants during the FGD was: What are the requirements for reflection in the critical care environment?

The FGD was transcribed verbatim and studied using content analysis. The transcriptions were read and re-read to allow the researcher to become immersed in the data and sensitised to important issues. The data were analysed and coded by the researcher and an independent coder who signed a confidentiality agreement. The independent coder, with experience in coding of qualitative research, was utilised to enhance the quality of analysis of the data and in this way strengthen credibility and trustworthiness. The researcher and independent coder held a contact session in which consensus on the themes was reached.

Ethical considerations

Written permission was obtained from the Ethics Committee of the University of Pretoria and the research board of a private hospital group. Participants were invited to an FGD a month in advance of the set date to enable them to make prior arrangements that could ensure minimal interruption of their work. Participants signed written consent prior to their participation in the data collection, and were informed of their right to withdraw at any stage. Each participant was given the opportunity to voice their view. During the transcription of data participants were assigned random names. Only the researcher had access to the true identities of the participants. Transcripts of the FGD and field notes were stored at a different location from that of the results and discussion.

Trustworthiness

The trustworthiness of the study was ensured through the use of Lincoln and Guba's model ( 1985 ).

Credibility was ensured by referential adequacy. Data must be adequate to allow for later analysis and interpretation (Lincoln & Guba 1985 ). The data were audio-recorded and transcribed, ensuring that raw data could undergo further analysis and interpretation. Member checks added to the credibility (Polit & Beck 2006 ), as participants gave comments on the preliminary study findings.

Transferability refers to the extent to which the findings could be applied to other contexts (Lincoln & Guba 1985 ). The findings of this study could be applied to other contexts, as they address the requirements for realising reflective practice in the clinical setting.

Dependability entails truthfulness and reliability (Topping 2010 ). The use of an independent coder ensured that the data analysis was objective and accurate. Confirmability refers to the objectivity of the data (Topping 2010 ), and using the skills of an independent coder and an expert supervisor helped to ensure this in this study.

Results and discussion

Healthcare organisations and patients demand critical care nurses who are innovative and use the latest knowledge in their daily practice. Reflection might provide some guidance to critical care nurses in order to meet these demands (Mann, Gordon & MacLeod 2009 ). Participants identified that buy-in from stakeholders and settings which are conducive to reflection are necessary for reflection to occur in the critical care environment.

Buy-in from stakeholders

The stakeholders that were identified were organisational management, clinical facilitators and critical care nurses. The participants identified organisational management and made specific reference to the unit manager, as the unit manager who is the supervisor of critical care nurses has a direct impact on the extent to which reflection could be practised. Furthermore the unit manager could appoint a facilitator to act as a guide for reflection. Participants stated that facilitators were important stakeholders who could activate reflection that would contribute to learning. The participants agreed that: ‘… you need a facilitator to drive learning and reflection’ and ‘reflection is very difficult; not all critical care nurses know what reflection is so you have to guide them how to reflect.’

Emancipatory practice development necessitates a skilled facilitator (McCormack et al . 2013 ). The facilitator plays a pivotal role in enabling critical care nurses to engage in reflection and reflective practice. According to Johns ( 2013 ), a facilitator can create a space for critical care nurses to reflect on their practice. With facilitated reflection the critical care nurses are guided by the facilitator to internalise the knowledge from the experience and discuss how the knowledge was gained and how it could prepare them for a variety of situations in the future (Berterö 2010 ). However, for facilitators to be credible they too should engage in reflection and reflective practice to enhance their facilitation skills. According to Tomlin, Weatherston and Pavkov ( 2014 :74) facilitators should be ‘compassionate, tolerant/non-judgemental, self-reflective, reliable and predictable’ in order to be effective. A facilitator that portrays the above characteristics could be capable of building a trusting and supportive relationship with the critical care nurse.

The participants were also concerned about the reaction of critical care nurses towards reflection. The following quotations summarise this concern:

‘… it is with a type of personality … I found it is very difficult for critical care nurses to reflect and to … um … admit that they did something wrong and could've done something better. They don't respond positively …’ ‘… when it comes to critical care nurses they are not like students and you can anticipate resistance (toward reflection) …’

Nelson ( 2012 ) and Berterö ( 2010 ) claim that most nurses are aware and acknowledge the importance of reflection. For reflection to assist critical care nurses to continuously enhance their practice, they should be open, collaborative, non-defensive, realistic and willing to ask for help (Tomlin et al . 2014 ). However, Johns ( 2013 ) is of the opinion that critical care nurses could be blunted or numbed because of the ‘unsympathetic’ working environments they are exposed to daily, and therefore might act defensively. The approach to be used by the facilitator to introduce reflection to the critical care nurses is, however, unclear and would need further investigation.

Settings conducive to reflection

The next theme identified was that a setting should be created for reflective practice in the critical care environment. During the data collection participants made comments on the role of management to create a setting that is conducive to reflection. Boud and Hager ( 2011 ) agree that organisations and management influence practitioners’ ability to reflect by creating either a restrictive or enabling work environment. The participants agreed on the following comment:

‘… if the management structure and the unit is in such a manner that they will allow them [ critical care nurses ] to have time for reflection, then it will work, but if the environment is not conducive to it, it will not work …’

However, the use of reflection by critical care nurses is not dependent on the organisation and management alone. The setting for reflection is highly influenced by the social environment and relationships amongst critical care nurses and clinical facilitators (Gregory, Hopwood & Boud 2014 ). The participants perceived the relationship between the critical care nurse and the facilitator as very important, as is evident in the next two statements:

‘… if the facilitator doesn't have good relationships with the critical care nurses then reflection will not work …’ ‘… your relationship with the critical care nurse is important. You cannot just come in and say: Listen here, I am now the facilitator and you will learn to reflect and you will do it like this. They [ critical care nurses ] are professionals and adults …’

Henderson et al . ( 2011 ) are of the opinion that a reflective partnership should be formed between the critical care nurse and clinical facilitator to enhance the practice development of both parties.

Limitations

The findings of this study are limited by the small sample size, as this decreased the capacity to generalise the results. However, the participants were of the opinion that the results of the study were a starting-point for realising reflection in the critical care environment.

Implications for education of critical care nurses

Educators involved in the practice development of qualified critical care nurses could enlighten the stakeholders identified in the study regarding the use and benefits of reflection. Educators should actively engage in reflection to develop their own practice. Critical care nurses should be taught the skill of reflection whilst the educators build an open, honest reflective partnership with them.

This article focused on the requirements for reflection into the critical care environment, as viewed by educators of qualified critical care nurses. The ability of reflection must not be assumed but should be developed. The skill to reflect must be nurtured in a pre-established, reassuring environment, enabling critical care nurses to reflect. In order to create such an environment there should be buy-in from stakeholders to develop reflection and the creation of a setting conducive to reflection.

Should reflection not be realised in practice, critical care nurses will remain passive receivers of information and emancipatory practice and sustainable change will be hindered. Considerably more work needs to be done to determine the views and opinions of critical care nurses and management of the healthcare organisations regarding the use of reflection to improve patient outcomes in the critical care environment.

Acknowledgements

We would like to acknowledge the support and guidance provided by Dr S. Meyer and Prof. S. Hatting during the proposal development and research period.

Competing interests

The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.

Authors’ contributions

C.J.F. (University of Pretoria) was responsible for data collection and analysis and prepared and wrote the manuscript. T.H. (University of Pretoria) was responsible for guidance and supervision with regard to the study and assisted in the reworking of the article.

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Critical Reflection Practice in Nursing Health Care Policy Education

• PMID: 36701131
• DOI: 10.3928/01484834-20230105-01

Background: A call to action is in effect for nurses to be change agents and bridge the gaps between the delivery of health care and the social needs of individuals, families, and communities. Response to this charge requires nurses to address long-standing inequity in health care policy and practice realms.

Method: This article describes the creative teaching-learning approach of critical reflection practice as a first step in developing skills and attitude for nurses to do this work.

Results: Early observations of the effect of critical reflection practice on learners show improved appreciation for the intersection of social, economic, and political dimensions operating in health care policy and practice that influence health inequities.

Conclusion: When nurses engage in a practice of critical reflection, they are more likely to identify offensive social determinants, act to ameliorate disparities, and advance the agenda for health equity. [ J Nurs Educ . 2023;62(5):312-315.] .

• Delivery of Health Care
• Education, Nursing*
• Health Equity*
• Health Policy