Releasing time to share
That’s the gag, and the point really, in homage to the very excellent Productive Ward. It’s essential to release time for staff to share in order to cope with the emotional impact of all the time released to care. Reflective practice groups are a sanity-protecting opportunity for staff to express the very intense and often painful feelings that inpatient care evokes. Confidentiality issues prevent talking about patients outside work, so these groups are essential in order for staff to consider, communicate and process these complex feelings.
Reflective practice groups also:
- play an important role in sustaining safe practice
- help continually improve ward life
- allow staff to examine their thoughts and actions and understand how these elements interrelate within the ward community.
- Help ‘close down’ or at least comfortably compartmentalise feelings about difficult experiences with patients. Among the benefits are preventing these feelings interfering with how staff respond to subsequent similar experiences.
Mutual support is a well-established way of getting advice, comfort, the hilarity that only people who’ve been there can generate, and the insights that we only feel safe in fully sharing with others who will definitely get it. From the companionship of posh Gentleman’s Clubs to the inspiration of peer supporters, it takes the perspectives of others for us to be truly self-aware. We just made that up but it sounds plausible! OK. We’ll try this one. Reflective practice groups are a form of therapeutic feedback for frontline staff.
- Reflective models usually consist of three core processes:
- Retrospection: thinking back on events
- Self-evaluation: attending to feelings
- Reorientation: re-evaluating experiences
- Case formulation group is forum for qualified nurses to get support re: clients emotions and behaviour.
- Clinical psychologist runs drop-in consultations for staff.
- “We have a fortnightly reflective group on our ward. It’s facilitated by a Senior Psychotherapist from our Therapeutic Community. It is an hour long and takes place after the midday handover while more staff are around. It’s utilised to reflect on the challenges we have with our patients with personality difficulties. It’s useful to have a space to reflect on our work (including our own responses and reactions) and to gain a fresh perspective. It’s good that the group is facilitated by someone who isn’t based on the ward, especially when we can’t see the wood for the trees. Both qualified and unqualified staff attend.”
Reflective practice is a way of studying your own experiences to improve the way you work. It is very useful for health professionals who want to carry on learning throughout their lives. The act of reflection is a great way to increase confidence and become a more proactive and qualified professional. Engaging in reflective practice should help to improve the quality of care you give and close the gap between theory and practice.
The following examples of reflective practice will give you some idea of the various methods you can choose from.
Gibbs’ reflective cycle
Gibb’s reflective cycle is a process involving six steps:
- Description – What happened?
- Feelings – What did you think and feel about it?
- Evaluation – What were the positives and negatives?
- Analysis – What sense can you make of it?
- Conclusion – What else could you have done?
- Action Plan – What will you do next time?
It is a ‘cycle’ because the action you take in the final stage will feed back into the first stage, beginning the process again.
Johns’ model for structured reflection
This is a series of questions to help you think through what has happened. You can read the questions here.
This can be used as a guide for analysing a critical incident or for general reflection on experiences. John’s model supports the need for the learner to work with a supervisor throughout the experience. He also recommends that the student use a structured diary. He suggests the student should ‘look in on the situation’, which would include focusing on yourself and paying attention to your thoughts and emotions. He then advises to ‘look out of the situation’ and write a description of the situation around your thoughts and feelings, what you are trying to achieve, why you responded in the way you did, how others were feeling, did you act in the best way, ethical concepts etc.
Rolfe’s framework for reflective practice
Rolfe uses three simple questions to reflect on a situation: What? so what? and now what? He considers the final question as the one that can make the greatest contribution to practice.
- What …is the problem? …was my role? …happened? …were the consequences?
- So what …was going through my mind? …should I have done? …do I know about what happened now?
- Now what …do I need to do? …broader issues have been raised? …might happen now?
A practical approach to promote reflective practice within nursing
This is an excellent article, well worth reading in full, from here.
What is reflection?
Reflection is the examination of personal thoughts and actions. For practitioners this means focusing on how they interact with their colleagues and with the environment to obtain a clearer picture of their own behaviour.
It is therefore a process by which practitioners can better understand themselves in order to be able to build on existing strengths and take appropriate future action. And the word ‘action’ is vital. Reflection is not ‘navel-gazing’. Its aim is to develop professional actions that are aligned with personal beliefs and values.
There are two fundamental forms of reflection: reflection-on-action and reflection-in-action. Understanding the differences between these forms of reflection is important. It will assist practitioners in discovering a range of techniques they can use to develop their personal and professional competences.
Reflection-on-action is perhaps the most common form of reflection. It involves carefully re-running in your mind events that have occurred in the past. The aim is to value your strengths and to develop different, more effective ways of acting in the future. In some of the literature on reflection (Grant and Greene 2001; Revans 1998), there is a focus on identifying negative aspects of personal behaviour with a view to improving professional competence. This would involve making such observations as: ‘I could have been more effective if I had acted differently’ or ‘I realise that I acted in such a way that there was a conflict between my actions and my values’.
While this is an extremely valuable way of approaching professional development, it does, however, ignore the many positive facets of our actions. We argue that people should spend more time celebrating their valuable contributions to the workplace and that they should work towards developing these strengths to become even better professionals. We are not advocating, of course, that they should neglect to work on areas of behaviour that require attention.
Reflection-in-action is the hallmark of the experienced professional. It means examining your own behaviour and that of others while in a situation (Schon, 1995; Schon, 1987). The following skills are involved:
- Being a participant observer in situations that offer learning opportunities;
- Attending to what you see and feel in your current situation, focusing on your responses and making connections with previous experiences;
- Being ‘in the experience’ and, at the same time, adopting a ‘witness’ stance as if you were outside it.
For example, you may be attending a ward meeting and contributing fully to what is going on. At the same time, a ‘fly-on-the-wall’ part of your consciousness is able to observe accurately what is going on in the meeting. Reflection-in-action is something that can be developed with practice. Some techniques are described later.
Critical reflection is another concept commonly mentioned in the literature on reflection (Bright, 1996; Brookfield, 1994; Collins, 1991; Millar, 1991). It refers to the capacity to uncover our assumptions about ourselves, other people, and the workplace. We all have personal ‘maps’ of our world. These develop across our lifetime and our early experience plays a vital role in their development. Like geographical maps, our personal maps help us make sense of our environment but are representations only. Personal experience determines how much of our environment we actually ‘see’.
It can be surprising to hear two people’s descriptions of the same event. Each may be astonished to hear how the other experienced the situation. Critical reflection involves uncovering some of the assumptions, beliefs and values that underlie the construction of our maps. Critical incident analysis offers useful tools to facilitate critical reflection (Fivars, 1980).
Ten Approaches For Enhancing Empathy In Health And Human Services Cultures
An extract from here.
The Balint training program was developed by Michael Balint at the Tavistock Institute in London for general practitioners. It is based on the notion that medical trainees often spend their entire training in the laboratory and the hospital ward, without sufficient opportunity to develop skills in interpersonal aspects of patient care (Balint, 1957). The program provides opportunities to enhance understanding of patients’ experiences and concerns.
Activities in the original Balint method included one to two hours unstructured, open, and supportive small group meetings every one to three weeks, for one to three years. The primary focus in these meetings was on behavioral, cognitive, and emotional issues related to communication between patients, physicians, and other personnel. The discussions (often coordinated by a psychoanalyst or psychologist) focused on the patient as a person rather than his or her disease as a case, and on difficulties experienced in patient-resident encounters. In addition to patient-physician communication, participants were also encouraged to discuss issues related to interprofessional collaboration and hospital administration.
Reflective practice and its role in mental health nurses’ practice development: a year-long study
Full article from here
The study reported in this paper lasted over a year, and identifies a conceptual framework of nursing practice based upon a relationship-building process. It also identifies six characteristics of nursing roles inherent within the practice of mental health nurses on a Nursing Development Unit. The paper presents a structure and process of reflection for nursing practice as illustrated by the work of a group of nurses working in a NDU. The purpose of the study was to help them better understand their work with patients. The findings from the study are used to explore how the nurses described and implemented individualized, patient-focused care. This care was based upon the ability of the nurse to communicate well and to build a relationship with a patient, bound within a context of change.
Resources and references
Productive Mental Health Ward
RCN’s reflective practice tool
In Organising and Delivering Psychological Therapies (Department of Health, 2004), reflective practice is seen as a valuable contribution to maintaining safe practice and improvement of service provision. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4086097.pdf
A practical approach to promote reflective practice within nursing. David Somerville and June Keeling.
Ten Approaches For Enhancing Empathy In Health And Human Services Cultures. Mohammadreza Hojat. http://findarticles.com/p/articles/mi_m1YLZ/is_4_31/ai_n56979792/?tag=content;col1
Reflective practice and its role in mental health nurses’ practice development. I. W. Graham
Journal of Psychiatric and Mental Health Nursing. April 2000