The Advantages and Disadvantages of Reflection in Nursing

Introduction

In this assignment the discussion on the advantages and disadvantages of using reflection in nursing practice is undertaken. Boyd and Fales, 1983 states reflection is “the process of internally examining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self, and which results in a changed perspective”(p 3). Reflection entails identifying a predicament, asking questions, analysing evidence, examining suppositions and prejudices tackling emotional unease, taking into account other explanations and putting up with uncertainty (Boyd and fales’83). Reflection gives nurses a legitimate opportunity to regularly stop and think, in the midst of practice, with the intention of enhancing what already goes on in clinical practice.

In this assignment the author will use evidence from literature and a few examples from practice to support the advantages and disadvantages of reflection. The author will discuss these points under many different headings, which will be noted as the essay proceeds.

Reflective practice

Bulman (2000) suggests that reflection coerces nurses to confront incongruity and uncomfortable facts about their nursing practice, the organizations they work in and themselves. Reflective practice is an intentional event and takes both time and commitment. It permits the nurse to contemplate their experiences through the combination of theory with practice (Atkins and Murphy 1993, Rich and Parker 1995). The purpose of reflective practice is to take learning from either a positive or negative incident so as to prevent or promote the likelihood of similar situations happening again and to see how such incidents could be managed more effectively. Reflection can be commenced on an individual basis or through clinical supervision. Reflective practice may have its advantages and disadvantages. Nurses are most likely to benefit from considering some of these aspects before embarking on a reflective journey through practice ( Atkins and Murphy’93).

Advantages

Learning by mistakes through reflection

Reflective practice can contribute to the continuing professional development of nurses by learning from mistakes and from accomplishments. Johns (1995) comments that the nurse can evaluate infer and gain knowledge from their experiences through reflection.

Learning by mistakes through reflection means taking time to think about the way practice has been completed, what was successful and what the nurse might have done differently. By reviewing a process after it has happened a nurse can learn to reflect not only on the expected outcomes, those identifiable before the process, but also on the unexpected. This can be summarised as prospective and retrospective learning. It can be extremely rewarding to analyse working practice and systems (Johns ’95).

A personal reflective incident occurred, when I was asked by a staff nurse to record

a patient’s blood pressure and another patient’s peak flow. I misheard the nurse and understood it as carrying out both procedures on the same patient. On reporting the result, the nurse then proceeded to inform me of my mistake. I was embarrassed to have made such a simple mistake. The peak flow reading had not been urgent but I was aware that if the patient’s condition was more severe that the mistake could have been harmful to the patient.The learning from this incident was, to clarify instructions as they are given so as to avoid any doubt or misinterpretation of them.

Different approaches

Reflective practice enhances traditional forms of knowledge for nursing practice by finding different approaches to procedures. Street (1995) claims that one would be able recognise problems in practice and establish new approaches to practice through reflecting in journals.

Gibbs reflective cycle (1988) was meant for the nurse to be able to reflect on a procedure and through doing this would be able to come up with different approaches to future situations.

Before giving my first injection, the staff nurse took time to assess my knowledge on this procedure. Time was taken to create an awareness of using distracting tactics as part of the approach. He told me to ask the patient to cough or wiggle their toes as I gave the injection. I carried out the procedure as the nurse had advised me and found the patient didn’t feel the injection. On reflection on what made the difference for the patient on receiving an intramuscular injection and experiencing minimal pain, was the distracting tactics. This facilitated the hypodermic needle entering a relaxed muscle and hence no resistance to the injecting procedure. I was satisfied that I had carried out my first injection extremely well. This was a positive experience and gave me confidence in carrying out injections.

More Confident

Reflective practice gives nurses more confidence in what they do and why they do it.

A nurse can learn and become confident through reflecting on an incident. When a procedure has not gone to plan, they can reassess and improve on their skills the next time they carry out a procedure. The nurse can also reflect on a positive incident and look at how well the carried out the procedure and therefore become more confident.

Qualified nurses using reflective practice as a tool, have more confidence in challenging themselves and others with a non-threatening approach, therefore, transforming practice as a result of reflective practice (Glaze, 1998).

When asked to change a dressing on a fungating malignant tumour, I was fearful. There was a vast supply of blood to the tumour and the aim was to avoid causing a haemorrhage while changing the dressing. My reflection before starting the procedure was to be gentle while taking off the dressing causing no undue stress to the tissue. Taking time when necessary to loosen to dressing when adhere to tissue and cleaning and redressing the tumour. I had watched the staff nurse carry out this procedure before and I was confident I would be able to do it. I asked the nurse for assistance and this added to my confidence. Through reflecting on the experience I feel I carried out the procedure well and would not alter anything I did. Carrying out wound dressings using a no touch aseptic approach is now a procedure I can do with confident.

Improving quality of care

The nurse can create practice-based knowledge and can also improve patient care delivery through reflection on her own experiences.

The attitude of nurses’ presiding over the care that is given to a patient and the general cause of poor care are lack of knowledge and unsuitable attitude. Reflection can increase the nurse’s knowledge, thus, improving the quality of the care received (Clamp, 1980).

Clearer thinking

Through reflecting the nurse can make more sense of difficult and complex practice. Boyd and Fales (1983) state, reflective practice is exploring an element of concern caused by an incident, resulting in change in the nurses thinking of a situation and instigates learning. Holly (1987) discusses the use of journals for more in-depth reflection, hence, giving the nurse a clearer perspective on her experiences and on her practice.

Builds Character

Reflective practice can support nurses by offering an opportunity to talk to peers about practice this can build character as the nurse gains knowledge of different approaches and can educate peers and students on her experiences. Reflection can build character by allowing nurses to be aware of themselves and how they react in situations (Johns, 2000).

Educates

Reflection gives a practice based learning activity and confidence to ask question about practice that can add to the continuing education of qualified and student nurses. Reflection educates the nurse on how to cope with rare and complicated circumstances that they face in practice (Smith, 1995). Mezirow declares that the end result of reflective practice is learning. Reflection reminds the nurse that there is no end point to learning.

When given an article to read on the “Guidance for the psychological care of day case surgery” I discovered that patients vary in the amount of information they require about surgery (Mitchell, 2002). Almost all the patients arriving in Day Services for surgery are rated by the nurses as being anxious (Mitchell, 2000). Over the following days I reflected on the article while watching and listening carefully to how the nurse acted and talked to the patient pre and post operatively and on how much information she gave the patient. The nurse always facilitates the patients’ need for knowledge and will give additional supportive educational leaflets as a back up. I then felt that if asked a question by a patient that I would be able to answer them appropriately. The nurses own knowledge base is imperative when answering questions as misinformation can further increase anxiety.

Rapport

The nurse is also made aware of her behaviour around patients through reflection, hence, allowing the nurse to improve her delivery of care to the patient. The nurse may converse with the patient creating a nurse-patient relationship, subsequently, reducing anxiety and increasing rate of recovery.

When the wards were quiet I would talk to patients. On one of these occasions I was talking to a mother whose baby was in the neo-natal ward. As we were talking about her baby she began to cry. I was uncertain what to do in this situation and reflected on the communications skills we had been taught in personal and professional development lectures. Allowing time for tears I waited for the mother to regain her composure and talk. Listening is part of the communication process and is often what most people need and not just the patients in our care. To listen to somebody is the greatest compliment we can give and demonstrates sensitivity and empathy. I was content that I had handled the incident suitably. I had realised through the lectures that body language was important and I ensured that my body language was appropriate to the situation.

Skills improved

Reflective practice focuses the nurse on ways of becoming more effective in practice. It creates in the nurse awareness to sections of practice that are deficient or could be improved in the area of patient care (Johns, 2000). Nurses learn more about how they cope in situations leading to assimilation of personal knowledge (Johns, 2000) accordingly improving the nurses’ skills.

Reflection uses the nurses’ own experience and results in enhancement of the clinical skills executed by the nurse through new knowledge gained on reflection.

Beneficial to the next patient

The nurse can learn from mistakes through reflection, hence, contributing to education, which is beneficial to the next patient as the nurse, will not make the same mistake. It adds to nursing practice by permitting the nurse to continually query the care they give, thus guaranteeing safety and efficiency (Kenworthy et al, 2002).

Disadvantages

Lower self esteem

“If needs for self-esteem of others are unfulfilled, a person may feel helpless and inferior “(Maslow, 1970 p 12).

Reflective practice can point out flaws in traditional practices, by challenging conformity. The nurse by doing this may stand out from the crowd by being a ‘lone voice’ and may be branded a troublemaker that will lower self-esteem.

Another factor of reflective practice that can lower a nurse’s self-esteem is reflecting on an incident and realising that the mistake was basic and could have been avoided.

I was asked to give an injection; I had carried out this procedure many times before but had not done it in a while. I had forgotten the angle the needle had to go in at and the staff nurse took over the procedure. On reflecting on the incident my self-esteem was lowered, as it was a simple procedure I failed to carry out. I revised on the angles once the procedure had been carried out.

Time consuming

The nurse may find it difficult to reflect as this process causes the nurse to want to find out more about why things are done a particular way and can be time consuming. The use of journals, for reflection, regardless of the advantages is hard to keep, as they require self-discipline. It takes time for the nurse to reflect on her written material (Carr 1996). Street (1995)
notes that nurses may have trouble finding time to reflect on practice and suggests they may also be uncertain on how to initiate the process of reflection.

During placement I would take time for reflective practice. I found this time consuming and although it had benefits would have preferred to be assisting the nurse.

Over thinking

The nurse may become pre-occupied with mistakes made in previous experience, resulting in lack of concentration on the current procedure. The nurse becomes so pre-occupied on previous incidents that it may affect the way she works, plans, relates and decides.

Too self-critical

Reflecting on an event is not always functional and does not necessarily lead to new ways of thinking or behaving in practice, which is the core of effective reflective activity (Andrews et al. 1998). The nurse may become too critical of herself on reflecting on previous experience and see the incident differently to how it happened.

Hinder the quality of care.

The nurse may not have the knowledge of how to proceed with an idea to improve quality of care; therefore the opposite can occur and may hinder the quality of care.

The nurse may discover new approaches to practice thus enhancing the quality of care but may find peer pressure to keep things the same and may fear causing aggravation.

The nurse becomes less satisfied with the quality of care and the way practice is carried out.

Conclusion

Reflective practice is more than thinking, it is an intentional practice with focus on improving and changing practice. It is not an everyday activity thus far; however, there is an increasing impetus for nurses to become involved in reflective practice as a way of substantiating their practice. The result of this method is changed conceptual prospective (Boyd and Fales, 1983).

Overall there are more advantages than disadvantages to reflective practice therefore it is beneficial to the nurse to carry this out either on positive or negative incidents. The reflection can assist the nurse in knowing where she went wrong and where to improve on her skills or on what she did right and giving her confidence to carry out this procedure again.

References

Atkins, S., Murphy, K. (1995) ‘Reflective Practice.’ Nursing Standard. 9; 45:31-35.

Boud, D. Keogh, R. & Walker, D. (1985). Reflection: Turning Experience into Learning. London: Kogan Page.

Boyd, E.M., Fales, A.W. (1983) ‘Reflective Learning: Key to Learning From Experience.’ Journal of Humanistic Psychology. 23; 2:99-117.

Burrows, D. (1995). The Nurse Teacher’s Role in the Promotion of Reflective Practice. Nurse Education Today, 15(5), 346-350.

Carr, E. (1996). Reflecting on Clinical Practice: Hectoring Talk or Reality. Journal of Clinical Nursing, 5 (5), 289-295.

Clamp C (1980) ‘Learning Through Critical Incidents’ Nursing Times Oct 2: 1755-1758

Davies, E. (1995). Reflective Practice: A Focus for Caring. Journal of Nursing Education, 34(40), 167-174.

Glaze, J. (1998). Reflection and Expert Nursing Knowledge. In C. Johns, & D.

Holly, M. (1987). Keeping a Personal – Professional Journal. Victoria, Australia: Deakin University.

Jarvis, P. (1992) ‘Reflective Practice and Nursing.’ Nursing Education Today. 12:174-181.

Johns C (1995) The Value of Reflective Practice for Nursing.J. Clinical Nurs. 4: 23-60

Johns, C. (1999). Reflection as Empowerment? Nursing Inquiry, 6, 241-249.

Kemmis S (1985) Action Research and the Politics of Reflection. In: Boude D et al (1985) Reflection Turning Experience into Learning. Kogan Page, London

Mallik, M. Hall, C. Howard, D. 2004, Nursing Knowledge and Practice, (2nd ed), Balliére Tindall, London.

Mezirow J (1981) A Critical Theory of Adult Learning and Education. Adult Education 32: (1) 3-24

Newton, J. (1999). How Can We Uncover the Theory (the knowledge) Which Supports Practice? Paper presented at the CLWR 7th Annual International Conference on Post-compulsory Education and Training, venue unknown.

Schon D (1987). Educating the Reflective Practitioner. Josey Bass, San Francisco

Shields, E. (1994). A Daily Dose of Reflection. Professional Nurse, 9(11), 755-758.

Smith, C. (1995) ‘Evaluating Nursing Care: Reflection in Practice.’ Professional Nurse. 10; 11:723-724

Street, A. (1995). Nursing replay: Researching Nursing Nurture Together.

Melbourne: Churchill Livingstone.