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