Facilitating Reflection on Practice
Leading clinical learning
Reflection is an essential element of learning. Learning experiences are as much about students’ construction of what has happened, as they are
about their engagement in them. Thinking back on experience, and carefully re-evaluating it, is an essential part of ongoing personal and
professional development.
Reflective practice is a process of reconstructing one's experiences and identifying possibilities for action within a context of professional practice.
Donald Schön, an influential thinker in the area of reflective practice, has described his own reflective practice as 'a dialogue of thinking and doing
through which I become more skilled' (1987, p.31). Thus learning to be a reflective practitioner includes not only acquiring technical expertise, but
also the ability to establish meaningful connections between theory and practice, providing a rationale for action. In this sense, reflective practice
can be likened to a 'bridge' between theory and practice and a powerful means of using theory to inform practice.
Reflective practice and critical thinking (Price 2004).
‘Reflective practice is an approach to learning and practice development which is patient-centred and which acknowledges the untidiness and
confusion of the practice environment (Burns & Bulman 2000; Johns 2000). That which seems straightforward in the science laboratory or textbook
is not so clear at the bedside (Benner et al 1996). Practitioners deal with illness rather than disease – they work with the perceptions of others and
the ways in which they ascribe meanings to signs, symptoms, treatment and health promotion. Even normal events such as childbirth offer a range
of different definitions of the situation that might prompt practitioners to recommend different actions (Cioffi 1997).
Critical thinking is the ability to deconstruct events and to reason the origins of situations (Brookfield 1987). Like reflection it involves considering
what has gone before and what may yet happen (Clark & Holt 2001). There is a retrospective and a prospective or creative dimension to it (Daly
1998). Critical thinking involves considering the relationship between events – whether this is cause and effect or whether there is a more general
process under way.
What is difficult about encouraging reflection and critical thinking, and especially helping learners to combine them practically, is that reflecting or
thinking critically both involve investigating and imagining alternative scenarios. The individual is an explorer and there are few constraints on the
possible discoveries to be made’. However, in the case of students, the guidance of clinical facilitators is essential to the success of the journey
(Lucas & Tan 2007).
Reflection involves a dialogue between students and
their peers, students and teachers and students and
work placement tutors, all of whom can provide useful
feedback necessary for reflection. To begin to reflect on
their learning students need to be encouraged to make
sense of new knowledge in relation to their existing
understanding. The learning cycle developed by Kolb
(1984) is a useful and simple tool for illustrating to
students the connection between reflection and
improved learning.
A model for thinking about reflective
practice
This model has been developed from two separate but closely related
sources of feedback on reflection - the 5Rs (Bain, Ballantyne, Mills &
Lester, 2002) and PBPL CETL resource (Sclater & Mincoha, 2006).
In order to 'move from' a reflective trigger to a meaningful reflection on
practice it is important to have a systematic method for thinking through
the situation, experience etc. A good way to do that is to use a
framework that prompts deep and purposeful thinking about what
happened. This model incorporates elements of the 5Rs model and the
model for Reflection on Action. The further explication of this model in
the context of clinical education is designed to provide a series of
practical steps in the form of questions that you can pose to yourself
about your own teaching practice with respect to clinical education, or
to your students to guide their own professional development and
clinical reasoning.
The model is presented identifies two distinct phases that form part of
the reflective process. The first is the basic reflective phase, which
consists of observe, notice effects, report self awareness, identify
own position, and improve. A series of questions to accompany each
of these stages is presented in Table 1. The second phase, consists of
a deeper reflective process. In this phase, the five accompanying
stages are contextualise, identify causes, relate to practice,
connect to theory and justify changes. Each of these 5 stages is
linked to a preceding stage of the basic reflective process or cycle. The
relationship between these phases is seen most clearly in Table 1,
where for example, the questions that might be asked of a student
focusing on the observe stage of the reflective process, are juxtaposed
with the questions that might be asked during the contextualise stage.
The 5Rs
The 5Rs are modified from a body of work that has
been undertaken in Queensland by Bain et al. (2002).
The 5Rs are Reporting, Responding, Relating,
Reasoning and Reconstructing. More about each of the
Rs is shown below and sample questions relating to
each part of the 5Rs model are mapped against the
Reflection on Action model in the table below.
Integration of the two models.
The two models have been integrated in this resource to provide a more structured way of thinking about reflection. For instance, key aspects of the
Reflection on Action model are that it highlights a basic round of reflection, followed by a deeper reflective cycle. However, the 5Rs model is well
established, and provided some good questions to pose to students. Combining the two models provided a more specific way of focusing on
reflective practice as well as emphasising the place of critical thinking in professional practice.
Questions to prompt student thinking
Basic reflection
Stage and sample questions for each stage
Observe/Reporting
Deeper reflection/Critical reflection
Stage and sample questions for each stage
Contextualise/Reconstructing
What happened?
Why do we do something this way?
What did the situation or issue involve?
What else was going on? (in the environment, with the patient/client,
etc)
Who was involved?
Who else was involved?
How was I involved?
How has the context contributed to the outcome in this case?
What seems significant to pay attention to?
Notice effects/Responding
Identify causes/Reconstructing
How did you feel?
What contributed to the event, process, or incident?
What questions do you have about the process, issue, trigger or
incident?
What evidence do you have for this?
What were the outcomes?
Was it positive or negative?
How do you think the client/patient felt?
Report self awareness/Relating
Relate to practice/Relating
What was your role in the situation?
Have I had sufficient opportunities to observe the practice in a clinical
setting?
How did you contribute to the situation?
What feedback have I had about my clinical competence?
What are the connections between the situation and your
experience, skills, knowledge and understanding?
What alternative practices are their?
Identify own position/Relating
In which areas do I feel I would benefit from further development?
Connect to theory/Relating
What is your opinion about the issue, trigger, incident, or
situation?
What does the theory tell you about this situation?
What are the links between theory and practice?
What further knowledge, skills or experience might your analysis
suggest that you need?
What other perspectives might there be?
Improve/Reconstructing
Justify changes/Reconstructing
What is it about my/your work I/you most want to improve?
In summary, what do you think about this situation / issue?
What kind of action plan or learning plan do I/you need to
develop?
What case can you make for any changes you think you need to make
to your practice?
How can I/ you/ we maintain/ improve/ performance? (depending
on whether it was a positive, negative or neutral experience)
What conclusions can you draw? How do you justify these?
With hindsight, would you do something differently next time and why?
What has this taught you about professional practice? about yourself?
How will you use this experience to further improve your practice in the
future?
A sample reflection
The following is an adapted version of a written reflection from a second year student.
While I was working on a busy surgical ward during my final prac one of the RNs handed the keys of the
DD cupboard to me and asked me to look after them until she returned from tea break. I tried to explain
that it is not legal for me (as an unauthorised person) to carry the keys, but she continued saying ‘you’re a
few months off being an RN - get used to it”. She then walked away leaving me with the keys. I felt very
uneasy about this and inadequate in terms of the response that I had made. I immediately went and found
another RN and handed over the keys to her. Perhaps the RN was not familiar with the legal
requirements for storage of drugs? Sometimes there is confusion about organizational guidelines and
procedures with what is required according to relevant legislation. However, I felt that I should do
something to prevent this kind of event happening to another student. To this end I reviewed current
information on the legal aspects of drug storage as per the Health (Drugs & Poisons) Regulations (1996).
In collaboration with the CN of the ward, my facilitator encouraged me to present a short 10 minute inservice on the topic following handover a week later. I also prepared simple handouts for the staff which
were well received. This experience taught me about the importance of ‘knowing the law’ related to
nursing and applying it to practice. I also think it is important to have the courage to be assertive about
resolving conflicts that arise in the practice context, and this is something that I’m going to work further on
in the future.
Observing/Reporting
Notice
effects/responding
Reasoning
Identify causes
Report self awareness
Relating
Relate to practice Relate
to theory
Reconstructing
Contextualise
Improving
Justify changes
In light of your own thinking about reflection, and the model presented, what are your comments on this example?
References:
Bain, J.D., Ballantyne, R., Mills, C. & Lester, N.C. (2002) Reflecting on practice: Student teachers' perspectives, Post Pressed: Flaxton, Qld.
Benner, P. et al (1996) Expertise in Nursing: Caring, Clinical Judgement and Ethics. New York, Springer.
Brookfield, S. (1987). Developing Critical Thinkers: Challenging Adults To Explore Alternative Ways of Thinking and Acting. Milton Keynes,
Open University Press.
Burns, S., Bulman, C. (2000). Reflective Practice in Nursing: The Growth of the Professional Practitioner. (2nd Ed.). Oxford, Blackwell Science.
Cioffi, J. (1997). Heuristics, servants to intuition, in clinical decision making. Journal of Advanced Nursing. 26 (1): 203-208.
Clark, D. & Holt, J. (2001). Philosophy: a key to open the door to critical thinking. Nurse Education Today, 21(1): 71-78.
Daly, W. (1998). Critical thinking as an outcome of nursing education. What is it? Why is it important to nursing practice? Journal of Advanced
Nursing, 28(2): 323-331.
Johns, C. (2000). Becoming a Reflective Practitioner: A Reflective Holistic Approach to Clinical Nursing, Practice Development and Clinical
Supervision. Oxford, Blackwell Science.
Lucas, U. & Tan, P. (2007). Developing a reflective capacity within undergraduate education: the role of work-based placement learning. Report
of a research project funded by the Higher Education Academy and the Charitable Trusts of the Institute of Chartered Accountants in England
and Wales.
Price, A. (2004). Facilitating reflection and critical thinking in practice. Nursing Standard 18 (47): 46-52.
Sclater, N. and Minocha, S. (2006) Reflection on Action http://www.open.ac.uk/opencetl/files/opencetl/file/ecms/web-content/Sclater-and-Minocha(2009)-Leaflet-Reflection-on-action.pdf