Time for reflection

How reflective practice has been adopted within a variety of workplaces to
help illustrate its value for OH.  By Liz
Griffiths

The concept of reflective practice has become enormously influential in the
world of professional education.

The Nursing and Midwifery Council (NMC) Post-Registration Education and
Practice (PREP) requirements advocate reflection on practice in order to
enhance career progression and lifelong learning.1 This is further endorsed in
the Code of Professional Conduct in the maintenance of professional knowledge
and competence,2 and in the guiding principles supporting the need for clinical
supervision, an important part of clinical governance, with the aim of
improving standards.3

Courses designed to prepare students for specialist practice in occupational
health nursing may encourage reflection on critical incidents in the practice
environment to inform learning, and use reflective writing as part of the
assessment process.

The significance of reflection in nursing rests in its close relationship to
learning in professional practice settings, where learning develops from
experience. Reflection is an important component of this experiential learning
because it can promote the ability to engage in self-assessment, to adapt to
change and develop autonomy.

However, professional practice is not always clear-cut and learning
situations are often unpredictable. Schon uses the phrase "indeterminate
zones of practice" to highlight the spheres of professional action that
are characterised by uncertainty, uniqueness and possibly conflict – a
description that must seem very real in many OH settings.4

An expert professional should be able to create different possibilities as
the result of reflecting on what could be routine practice, an unexpected
outcome or even some uncertainty. By drawing such experiences together, a
meaningful pattern may emerge as a means of transforming practice. Johns sees
reflection as a window through which the practitioner can view experiences,
working towards the resolution of contradictions between what may be desirable
and what is realistic in actual practice.5

It may be worth considering if the concept, like many fashionable ideas, has
become distorted with use, or has retained its relevance in practice
development, particularly for occupational health nurses (OHNs).

One criticism of the emphasis that is placed on reflection in courses of
study has been the lack of evidence exploring successful outcomes in practice
as a consequence of reflection.

Although much has been written about the apparent advantages and benefits,
Quinn cautions that as professional practice is demanding and stressful, it may
be unrealistic to expect practitioners to reflect systematically, unless they
are given time and support to do so effectively.6

Nevertheless, there is evidence that although reflective writing is challenging,
the scope of development is more valuable and longer lasting when the activity
is structured through a written account.7 Jasper’s study – exploring how nurses
from a variety of settings were using reflective writing skills as a tool for
practice learning – concluded that nurses were able to identify personal and
professional growth being facilitated by reflective writing.

An investigation recently carried out with students undertaking a specialist
practitioner programme confirmed that links with practice could be made through
reflection to enhance professional development. Students were asked to consider
whether undertaking a piece of reflective writing prior to beginning the course
had been of value to them. The comments relating to the application of
reflection in practice were spontaneous and unprompted. One student commented:
"It was beneficial to explore how and why I practiced what I did",
and another that it "allows and enables changes".8

By referring to several examples where the reflective process has been
adopted in a variety of workplaces, it is clear that the value for OH practice
development can be identified. This is not only shown from an individual
perspective, but also demonstrates the wider implications in management and
organisational matters for students and more experienced practitioners. It is
common to focus on the negative aspects of practice in reflection, but these
examples highlight a few of the more positive features.

Return-to-work interview following maternity leave

The practitioner had prepared well for the interview in terms of information
regarding organisational factors and practical issues, but the interview did
not proceed in the way she expected. The client was much more concerned with
the emotional impact of her immediate return to work rather than those issues
that had been anticipated by the nurse.

On reflection, the OHN realised that she had not considered this aspect in
her preparation. She also found that identifying her thoughts and feelings
about the experience was relatively easy. What was much more difficult was
trying to make sense of the experience through analysis. However, by using a
reflective cycle to structure her thinking, she found that she could develop a
plan of action for future encounters of this kind, and so learn from a routine
situation.

Attendance management interview

One aspect of the role of OH in assisting management to manage attendance
effectively is to ensure that any policy is applied consistently and fairly.

An experienced practitioner found it helpful to reflect in a group with
colleagues, after the interview. This is particularly relevant to ensure a
consistent approach among the team and within the organisation, where concerns
of policy and procedure are apparent. In this case, the employee had attended
the department reluctantly, because the line manager had not adhered to the
company referral procedure.

The OHN’s view was that sharing experiences brings differing perspectives to
incidents. This also boosts confidence by endorsing decisions made in clinical
practice. This group approach to reflecting on learning was adopted by the team
and became a regular feature at staff meetings.

An observer at pre-employment health interviews

When faced with practice in a new setting, many experienced practitioners
find that keeping a reflective journal can help make sense of the transition
into a new field. It also serves as a permanent record to reflect on for future
occasions. Adjustments can then be made to practice, or action plans modified
as experience develops.

For an OH student in a new role, keeping a journal was not only found to be
essential, but the importance of returning to the reflective writing and
reviewing it with new knowledge was found to be extremely helpful. The student
noted that previous work history seemed to be an important factor explored by
practitioners during pre-employment health interviews, but did not initially
appreciate the significance of the questioning.

As knowledge and experience increased, this was recorded and reflected upon,
and the student was able to set their learning within a public health,
legislative and professional framework.

A case for referral

This OHN had been supporting a departmental manager through a personal
crisis over a period of time. In line with custom and practice in her setting,
she was seeing the client weekly at pre-arranged appointment times. However,
she was beginning to feel increasingly uneasy as the visits continued.

On reflection, her analysis examined several aspects that she identified
from the experience. Her own professional accountability and competence, an
identification of her need for specific training, departmental procedures
regarding counselling and referral, opportunities for collaborative working,
possible alternative courses of action, and the referral of the client to an
appropriate agency. In addition to these factors, she reviewed the evidence on
the relevant topic area and the existing company policy. This analysis led to a
satisfactory resolution both for the client and the practitioner, and a
proposed change of practice for the rest of the OH team.

Conclusion

These examples provide evidence of using the reflective process
retrospectively, to analyse critical incidents that occur frequently in
practice to inform learning. The outcome may not always be a resolution, but
the key element is the learning, both professionally and personally, that has
been gained from reflecting on the experience. This ability to reflect is seen
as an essential part of becoming an expert practitioner.9

Although reflection should not be seen as a panacea for professional
development, the benefits should be considered by OHNs in practice and, in
particular, as a means of increasing professional competence and confidence.

Liz Griffiths is a lecturer in OH nursing at Brunel University, and part of
the community health nursing team in the Department of Health and Social Care

References

1. The PREP handbook – NMC (2002) London

2. Code of professional conduct – NMC (2002) London

3. Supporting nurses and midwives through lifelong learning – NMC (2002)
London

4. Educating the reflective practitioner – Schon D (1987), California:
Jossey-Bass

5. Becoming a Reflective Practitioner. A reflective and holistic approach to
clinical nursing practice development and clinical supervision – Johns C
(2000), Oxford: Blackwell Scientific

6. Continuing Professional Development in Nursing. A guide for Practitioners
and Educators – Johns C (2000), Cheltenham: StanleyThornes Ltd

7. Nurses’ perceptions of the value of written reflection – Jasper M (1999),
Nurse Education Today 19 pp 452-463

8. An investigation into the student experience of APEL – Griffiths E
(2003), research project. (unpublished)

9. Learning Human Skills: 4th edition – Burnard P (2002), Oxford:
Butterworth

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