Reflective practice is part of the NMC revalidation process and can be a critical way to improve occupational health practice. Elizabeth Griffiths advises on how to make the most of it and avoid the pitfalls.
Many years have passed since I last wrote a piece on reflection in this journal (Griffiths, 2004), and much has happened within the profession since then. Not least the requirement for revalidation every three years for all qualified practitioners, introduced by the Nursing and Midwifery Council (NMC) and in force since April 2016.
Part of the process, as Helen Kirk points out in a previous article on the subject (Kirk, 2015), is for an OH nurse to find someone with whom they can have a reflective discussion to confirm CPD activity, and this should be with another NMC registrant.
This may not be as straightforward as it sounds for some OHNs, such as those who are lone workers or work as the only nurse within a team.
By now, many OHNs will have gone through the revalidation process and Karen Coomer outlines her experience in OH (at work) (Coomer, 2016).
Regarding the reflective writing component, you need five written pieces of reflection covering the previous three years. These then form the basis of the subsequent reflective discussion. It would seem to make sense that this recording of learning experiences becomes an ongoing process, not something that is seen as a chore when the due date is looming.
The NMC has produced helpful guidance and information is available on the website. The rationale behind the system is indicated by this point in the NMC’s step-by-step guide: “CPD Point 44 – As a professional, you have duty to keep your knowledge and skills up to date through a continuous process of learning and reflection”.
The NMC suggests that the reflection is structured as follows:
- What was the nature of the CPD activity or experience in your practice?
- What did you learn from the activity?
- How did you change or improve your practice as a result?
- How is this relevant to the Code?
Practitioners should be mindful of the following: prioritise people; practise effectively; preserve safety; and promote professionalism and trust.
The guidance stresses that the reflective discussion should be a positive experience that enables both practitioners the opportunity to think about their everyday practice and to identify learning.
However, I know from my experience of working with OHN students for a number of years that the discipline of writing reflectively to capture learning is difficult at first and needs practice, otherwise it becomes just a description of events.
NMC revalidation and reflective practice: avoiding pitfalls
Here are some of the pitfalls to avoid: being too descriptive; listing events rather than collating ideas together; not presenting a balanced account of positive and negative experiences; presenting problems but blaming others rather than taking ownership; and discussing solutions and making no plans for the future.
It is very likely that action planning will be an important feature of the reflective discussion, and something that could be published in journals or presented at conferences. The literature on this subject has consistently shown that some practitioners prefer to reflect on their own or through discussion alone.
However, it has also been noted that written reflection is longer lasting and gives a different understanding than just discussing an issue (Jasper,1999).
Another challenge may be the potential intrusiveness of using reflection for formal assessment. Platzer et al (2000) caution that vulnerability in a culture where openness to ideas and challenge is not encouraged may prevent nurses from openly discussing practice in a critical manner for fear of the consequences.
We don’t have to look very far to see that this may well be the case, as the events that led to the Francis enquiry (2014) springs to mind.
Sometimes it is difficult to identify the relevant experience in the first place or to focus mainly on formal study time rather than on situations that are routine and ordinary. There are many triggers in everyday practice that can be used successfully for this purpose. For example, reflecting on an intervention that made a difference to a client, or your input at a meeting that went well. We can learn just as well from positive experiences as from negative ones.
There are also reflective tools that can be used to help structure the reflection. Most people will be familiar with reflective models such as Gibbs and the Kolb learning cycle, but there are others that could work just as well. Rolfe et al (2001) developed a useful model.
It is worth looking at the helpful online guidance, which follows a model produced by the University of Cumbria. You could also try an alternative approach that some students find easy to use following a similar structure (see table, above).
One of the many experiences in OH practice where reflection could be useful is when thinking about case management. However experienced we are, there are always opportunities to increase knowledge and understanding. If a reflective framework is used, it could be very effective when presenting challenging cases to a multi-professional team or during opportunities for peer review.
It might also be very helpful for supporting students or during induction of new employees to have some case material that could be shared.
The literature on reflection as we have seen has largely focused on its role in education and training. The role of workplace reflection and learning for managers and practitioners in work has received far less attention.
The emphasis on evidence-based practice has highlighted the relevance of this type of reflection as OHNs are expected to critically appraise research studies and to integrate new findings into practice.
There is also the real possibility that this reflection will uncover the need to unlearn outdated or ineffective habits that have become custom and practice over time. This could be a challenge to manage within a team situation.
Nilsen et al (2010) discuss the fact that the evidence-based practice agenda has tended to focus mainly on practitioners’ use of knowledge such as actual changes in work practices. However, they suggest that there may be an additional benefit to reflective learning that deals more with enhanced awareness in management and time to think away from the workplace.
So there seems to be strong arguments in favour of the activity, but this is counterbalanced by the pace and demands of the modern workplace. The latter can prevent meaningful engagement with the process if the activity is not supported.
I am pleased to read in the recent Public Health England document “Educating Occupational Health Nurses” that the translation of theory into practice is highlighted, during placements and after employment.
OH nursing finds itself at a time of change, therefore it was timely to review priorities for educational programmes to consolidate and develop a new approach going forward.
OHNs recognise that their educational programmes must continually evolve and adapt to meet new workplace challenges as well as to continue the valuable work of the profession (Public Health England, 2016).
There are two categories that relate specifically to reflective activity that are relevant to this discussion, which is picked up in the “Professional practice” section of the guidance: “Lifelong learning – maintaining professional accountability, self-directed learning, CPD, training and development, on the job learning.” Lifelong learning is to be evidenced by the following:
- It can identify importance of lifelong learning and able to develop goals and ambitions.
- It is able to identify the requirements to meet NMC revalidation standards.
There is no doubt that as revalidation becomes embedded in ongoing professional development, then reflective writing and subsequent discussion has the potential to enhance OH nursing and provide more opportunities for sharing good practice.
Elizabeth Griffiths is SCPHN programme leader, clinical sciences, at Brunel University London.
Coomer K (2016). “OH nurses and revalidation: A practical experience”. Occupational Health (at Work) June/July 2016, vol.13(1).
Francis Report (2013). The Mid Staffordshire NHS Foundation Trust Public Enquiry, chaired by Robert Francis QC.
Griffiths E (2004). “Time for Reflection”. Occupational Health, vol.56(5).
Jasper M (1999). “Nurses’ perceptions of the value of written reflection”. Nurse Education Today, vol.19, pp.452-463.
Kirk H (2015). “Lead role in public health”. Occupational Health, vol.67(4).
Nursing and Midwifery Council. “Revalidation guidance“.
Nilsen P, Nordstrom G, and Ellstrom P (2010). “Integrating research-based and practice-based knowledge through workplace reflection”. Journal of Workplace Learning, vol.24(6).
Platzer H, Blake D, Ashford D (2000). “Barriers to learning from reflection: a study of group work with post-registration nurses”. Journal of Advanced Nursing, vol.31(5), pp.1001-1008.
Public Health England (2016). “Educating occupational health nurses: An approach to align education with a service vision for occupational health nurses”.
Rolfe G, Freshwater D, and Jasper, M (2001). “Critical reflection in nursing and the helping professions: a user’s guide”. Basingstoke: Palgrave Macmillan.