Reflection

The purpose of this assignment is to discuss the contribution of reflective practice for clinical nursing. Reflection has been defined as a way for individuals to “capture their experience, think about it, mull it over and evaluate” (Boud et al 1985: 19) Argyris and Schon (1974) suggest that practitioners often practice at less than effective levels because they follow routine. Johns (1995) implies that action can be taken through reflection to increase effectiveness in practice as reflection provides opportunities for self development as professionals and individuals (Hinchliff et al. 1993). Bishop and Scott (2001) believe Clinical nursing is fundamental to nursing practice, that it provides expertise that are used to bring high quality care to patient’s that is not likely to be provided by a lay person. During this assignment I will discuss Christopher Johns model of structured reflection and Donald Schon’s model of reflection on and in action and his coaching theory and other methods that contribute to the reflecting process. I will identify how the models then relate to clinical practice and how nursing has changed.

Carper (1978) Identified that as individuals have different ways of thinking and knowledge differentiates it is some times helpful to refer to a framework to assist reflection. Johns et al   (2002)   built on Carper’s theory and constructed a model for structured reflection. His model has a series of cue’s that are set out in a logical order which prompt progression of thought and reflecting to be explored. (Johns 2000) This model is used for analysis of critical incidents as well as more general experiences.

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Over a period of time Johns has continually tested the adequacy of his model and has developed it. Similar to Johns model is The reflective Cycle (Gibbs 1988). This model guides the practitioner through the cycle which encourages the practitioner to describe a situation, analyse their feelings, evaluate experiences, and consider other options and what they would do if the situation arose again. (Palmer et al 1994) Both Johns and Gibbs models are forms of guided reflection.

This form of reflection helps the reflector to go into more detail and pushes the practitioner to critically evaluate their practice. Bulman and Schutz (2004) acknowledge that critical analysis is a key skill in reflective practice as it allows practitioners to identify strengths as well as weaknesses. This type of reflection is beneficial for clinical nurses as it gives them structure ti their thinking and can guide them through a thoughtful process to achieve higher levels of reflection.

Schon built a theory of reflection on and in action. Reflection in action is a process to help you influence what you are working on, while you are working on it. He also strongly believes that when in practice practitioners can learn from the experts around them through the artistry of coaching. Reflection on action is a retrospective process to help you reflect on things you have already done usually involving a critical incident, examining it to find new understanding of the incident and what can be done differently to improve practice.

Although Schon considered reflection on action a useful tool for practitioners he concentrated on the theory of Reflection in action. Where education can combine teaching of applied science with coaching to equip professionals with the skills and knowledge within the realities of practice. (Schon 1987). Eraut (1994) criticizes Schons work, as Schon bases a large emphasis on Coaching from professionals. Eraut points out that not all professional practitioners make good coaches as while In action they are transferring expertise with no supporting evidence.

Eraut goes on to suggest that that Schons reflection on action is less problematic and that one can extend their knowledge base more effectively by reflecting after an action has occurred. Johns model is more theory based and requires more questions to be self answered and evaluated, where as Schons model has a larger emphasis on learning from the environment and the experts around them through coaching. Nursing has changed over the years from a period where nurses were subordinate to physicians and they weren’t able to have an input of there own concerns. By law and custom nurses are subordinate to physicians. At the same time, it captures the nurse’s critical role in executing the physicians work. ” (Melosh, B. 1982, p. 7) As time moved on The United Kingdom Central Council (UKCC) published the document The Scope of Professional practice. Scope allows nurses to undertake new roles and enables them to take on responsibilities beyond the traditional boundaries that no longer than 20 years ago, still existed. Clinical nurses now have a more pro active role that enables them to work autonomously giving them higher responsibility. UKCC 2000) (1992). Jowett et al (1999) found that the impact of scope on practitioners was considerable as they were now exploring the principals of scope and what effects this might have on their practice. Boud and Walker (1991) believe that people need to be able to learn from their experience in order to accept positions of responsibility. Seeing that nurses are taking on a more hands on approach, reflecting in clinical practice enables practitioners to increase self-awareness, initiative, proactivity and personal responsibility for learning and development.

As Palmer et al (1994) points out, some times nurses have to make decisions in a patients best interest and may have to deviate from a protocol in some way. This is where Schons reflection in and on action would prove useful. This would show that practitioners are using evidence based clinical nursing to gain a higher standard of awareness of how to tend to the needs of the individual patient, empowering them to link their theory to practice through reflection. Bulman and Schutz (2004) believe to achieve a satisfactory out come from reflection, the skill of synthesis is highly significant.

Synthesis enables clinical nurses, after reflection, to integrate new knowledge, feelings and attitudes with previous knowledge and to devise an action or outcome from their reflection. This may be an action plan, something that needs to change or stay the same. Synthesis involves making decisions based on new ideas but linking them to past beliefs and values. While reflection is perceived to play an important role in the development of effective clinical nursing, there is lack of evidence to prove that engaging in reflective practice actually changes or in any way benefits clinical nursing practice. Andrews et al. 1998) Improvement in clinical practice is clearly the aim of reflection, this is why authors such as Jordan (1988) and Boud et al (1985) have highlighted the need for evaluation strategies. Throughout this assignment it has been exposed that there are models available to guide practitioners through reflective practice. There has been an emphasis based on the need for critical analysis and the need for synthesis after reflection. Both of these are critical to reflective clinical practice to achieve satisfactory outcome.

It has been brought to attention that Clinical practice has progressed over the years from a medically led, task orientated job, to an autonomous, reflective, proactive profession. The contribution of reflective practice has played a major part in this progression, as nurses are learning and building a wider knowledge base. Clinical nurses are there fore able to identify areas of strength and weakness within their practice through reflection and interventions can be made to ensure the highest levels of clinical nursing are being obtained.

References

Argyris, C. and Schon, D. (1974) Theory in Practice. Jossey Bass, San Francisco. Bishop, V and Scott, I (2001) Challenges in clinical practice: Professional developments in nursing. Palgrave. Basingstoke. Boud, D. , Keogh, R and Walker, D. (1985) Promoting reflection in learning: A model in reflection. Pg 19. Kogan Page. London. Boud, D. & Walker, D. (1991) Experience and Learning: Reflection at Work, Geelong, Victoria, Deakin University Book Production Unit. Bulman, C. and Schutz, S. (2004). Reflective practice in nursing. 3rd Edition. Blackwell Publishing. Oxford. Eraut, M. (1994) Developing professional knowledge and competence. Falmer Press. London. Hinchliff, S. M. , Norman, S. E. , Schober, J. E. (1993) Nursing practice and health care. 2nd Ed. Edward Arnold. London. Johns, C. (1995) Framing learning through reflection within Carper’s ways of knowing in nursing. Journal of Advanced Nursing, 22: 226-34 Johns, C. (2000) Becoming a reflective practitioner. A reflective and holistic approach to clinical nursing, practice development and clinical supervision. Blackwell Science. Oxford. Johns, C. (2002) Guided Reflection: Advancing Practice. Blackwell Publishing. Oxford. Jowett, s. , Peters, M. and Wilson-Barnett, J. (1999) The impact of scope – practitioners views on its relevance and potential for service development. Nursing Times Research. 4 (6): 422-31 Melosh, B. (1983). “The Physician’s Hand” Work culture and conflict in American nursing. Philadelphia, Temple University Press, Palmer, A. Burns, S and Bulman, C (1994) Reflective practice in nursing: the growth of the professional practitioner. Blackwell scientific publications. Oxford. Schon, D. A. (1987) Educating the reflective practitioner. Jossey Bass, San Francisco. UKCC. (1992) The United Kingdom Central Council for Nursing. The Scope of Professional practice UKCC. London NHS. Teaching Primary Care Trust. NMC http://www. brentpct. nhs. uk/doxpixandgragix/NP03SCOPEOFPROFESSIONALNUR. pdf. Accessed 04/12/2007 UKCC. (2000) Nursing And Midwifery Council: Perceptions of the scope of Professional practice. http://www. nmc-uk. org/(xsnqskjdq2e5yg55qwq12555)/aFrameDisplay. aspx? DocumentID=659. Accessed 04/12/2007