Reflective practice: a iearningtool for student nurses

Peter Mark Wilding

AbstractReflection is a vital skill in contemporary nursing with student nursesexpected to engage in reflective learning from the very beginningof the nurse educational programme. This article demonstratesthe meaningful learning that resulted as a consequence of usingcritical reflection on practice. Gibhs' (1988) cycle aided the processhiglilighting the practical application of this cyclical framework to theauthor – a first-year student nurse. Matters concerning gender issuesin nursing and professional conduct emerged from the analysis andwere inherently explored. The article concludes hy demonstrating thepersonal henefits of using Gibbs' (1988) cycle to varying situationsand thus promoting its excellence as a learning tool for student nursesworldwide as a consequence.

Key words: Gender • Intimate treatment • Learning • Reflection •Student nurse

The novice first-year degree nursing studentencounters a steep learning curve in a relativelyshort amount of time. I am a first-year male studentnurse who found the reflective process a cathartic

exercise which helped me cope with a practice-related issueexperienced during my first clinical placement. Reflectionis a vital skill in modern nursing and its use is expectedfi-om the beginning of the programme.

This article highlights the deep learning that resulted as aconsequence of using Gibbs' (1988) cycle, thus demonstratingthe practical application of reflective practice to a first-yearstudent nurse's clinical placement. Furthermore, the articlealso explores how the cycle was adapted and used to providean effective learning experience, through which the authordcnionstrates that reflection is of worth – rebutting anyclaims regarding the learning potential of reflection, as somelearning is better than no learning, particularly if it providesa vital step toward.s greater knowledge. The inclusion of theauthor's reflective piece within the text serves to evidenceits efficacy in informing practice and provides the contextfor this critique.

Peter Mark Wilding is Second-Year Student Nurse, School of Health

and Social Care, University of Lincoln. Brayforil Pool

Accepted for publication: May 2008

BackgroundBenner (2001) explains chat nurses 'have not been carefulrecord keepers of their own clinical learning'. Reflectionprovides a thorough record, and it is a well-established toolfor learning. O'Donovan's (2007) review of the literatureclarified the success of reflection as an aid to learning innursing. Guided reflection has been defined as:

*… a journey of self-inquiry and transformationfor practitioners … to realize desirable practice asa lived reality. The journey is written as a narrativethat reveals the transformative drama unfolding.Along the journey, the vision of desirable practiceis constantly explored and shifting as newunderstandings emerge' (Johns, 2006 p36).

Moreover, reflective practice and guided reflection are nowa respected and required learning and assessment methodin many nursing programmes worldwide. The Nursingand Midwifery Council's (NMC) The Code: Standardsof Conduct, Performance and Ethics for Nurses and Midmves(NMC, 2008), states that nurses must keep knowledge andskills up to date throughout their working life. In particular,they should regularly engage in learning activities todevelop and maintain clinical competence and performance.Reflection can aid the maintenance and achievement ofclinical competence, hence an important tool in the nurse's'repertoire of skills' (Matthews, 2004). Reflection has beenused to explore and learn from issues concerning ethics,confidentiality, communicating with patients and relatives,and other critical matters (Keen, 2000).

There are numerous definitions of reflection withdifferent purposes in mind (Chirema, 2007). Whateverdifferences exist around the definition, there appears to be aconsensus relating to the importance of reflection in nursing.Reflection 'has maintained a high profile on the nursingagenda' (Williams and Lowes, 2001); this is further illustratedthrough advocacy for reflection by nursing and governmentprofessional bodies. Reflection requires self-awareness andanalysis (Schutz et al, 2004), thus it is a skill that needs to beacquired, developed and maintained.

The personal nature of reflection and the fact that it issometimes used as an assessment method for learning canbe a barrier to truthfully accounting the story (Schutz etal, 2004). This was a major dilemma in my own reflectivewriting. I therefore made a pact with myself to let go of thebarriers and inhibitions, so as to permit full reflection andallow a more expansive learning experience. Williams andLowes (2001) described a lack of definition for reflection

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Figure 1. Reflection practice of the author based on Gibbs' (1988) Reflection Cycle.

What would you do If thesituation arose again?

tWhat other options were

open to you?

What happened (story)?

What were you thinkingand feeling?

What were the thoughts andfeelings of others involved?

and an anibitiiious approach as barriers to effective reflection.These authors purport'the true process oí" reflection is onlyinitiated once the primary stage of writing has finished'(Williams and Lowes, 2001). which suggests that reflectionis a journey and not an ending (see Figure I for oudine ofmy personal reflective journey).

By engaging with Gibbs' (1988) model, I found manybenefits and it suited niy personal style of learning. Havingthe right reflective process has bonuses for the patient,nurse, and student. Hilliard (2006) also found Gibbs' modelprovided her with a focus by promoting her awarenessof the skills she possessed, thus building confidence andenhancing her professional autonomy. In contrast to this, ifreflection reveals a lack of skill, it may potentially leave thestudent feeling insecure and demotivated. O'Callaghan's(2005) reflective piece related to helping a student escapethe bonds of ritualistic practice in wound dressings andmake progress with evidence-based practice to benefitthe patient. These statements mirror Mooney and Nolan's(2(K)6) comments that reflection is seen as a method ofliberating nurses and creating better understanding andbuilding a greater body of nursing knowledge, whichbenefits the profession.

What happened (my story)?IJuring the course of my clinical placement, 1 encountereda patient, a middle-aged woman, who had recentlyundergone a vulvectoniy and an operation on her inguinal

lymph node. The nursing care required the daily cleansingand dressing of the excised area. I was introduced to thepatient, and verbal consent was obtained from the patientfor me to observe the dressing procedure.

For the first stage of the cycle, Gibbs encourages adescription of the eventsThe story was very simple and easyto convey. Gibbs' learning cycle is appropriate for accountssuch as mine, as my thoughts and feelings were importantaspects of this reflection. Following the description of thestory I was in a position to concentrate on the importantelements. Not all narrative accounts of incidents are succinct,but I consciously endeavoured to edit the description inorder to benefit from an integrated approach dealing withmy thoughts and feelings directly after the explanation ofthe incident. Othervise I believe the complexity of writingand reading would be overwhelming and more time wouldbe spent matching the story to the outcome and seekingclarity, rather than reflecting and learning.

What was I thinking and feeling?On the way to the patient's house the staff nurse gave me abrief history of the patient. 1 was able to determine what avulvectomy was for myself and the nurse simply confirmedit. It dawned on me that the cleaning would require thepatient to be partly undressed. My first feeling was thatof slight shock and I wondered how it would go. Manyquestions entered my head: Where should I look? Whenshould I look? What body language and approach would be

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most appropriate? Particularly because I am male. What arethe implications that flow from this? How will I deal withthis situation when I am a registered practitioner and mighthave to deal with this on my own? What will it be like?How will I respond? What is the paradigm of professionalconduct in this area? All of which I thought, but I did notknow the answers to all those questions, so my approachwas a cautious one.

The Nursing and Midwifery Council's (NMC) Tlic Code:Standards of Conduct, Performance and Ethics for Nurses andMidwives (NMC, 2008) states that the professional nurseis personally accountable for protecting the interests anddignity of patients and clients regardless of their personalcharacteristics or circumstances. Paramount in my mind waspreserving the patient's dignity, not only because the Codesays so, but human decency requires it. Dignity appearsto be the guiding light of intimate treatment, guidingnursing practice. 'Dignity must he protected at all times'(Peatc, 2005). One of Coller's (2006) four core values isrespecting and protecting patients' dignity and sense ofself-respect, especially when illness or other circumstancesmakes them particularly vulnerable and powerless (Coller,2006). The Code is there to protect the public, and servethe client, including protecting their dignity. Withoutfurther experience on how best to act in these situations, Irecognized and acknowledged my own limitations, mainlythat I am only equipped to observe thus far and to takeinstruction from the qualified nurse, spraying dressings withsaline solution, for example. I am still at the novice stage inlearning and doing (Benner, 2001).

I kept my eyes down for most of it, looking could easilybe misinterpreted and I kept a good distance back so as notto be too invasive. I looked now and then, so as to see andlearn, but I reduced it to the bare minimum. Nurses mustwork together to bring about healthcare environments thatare conducive to safe, therapeutic treatment and all withinthe gamut of ethical practice (NMC, 2008). My conduct,therefore, had to be ethical and this was achieved by directlyobserving periodically w îthout staring.

1 did feel slightly protected by my uniform and the factthat my uniform has meaning to others, thus requiring meto uphold the highest standards. Despite the uniform, mygender does make a difference. Women are seen as natural-born carers, and thus good nurses; the experience of menin nursing, in stark contrast, is a different story (Seed. 1995).Seed's study found that 'female nurses found it difficult toaccept the fact that their male colleagues should be fullyinvolved in the care of women'. Even though there arereports of instances where female patients see a male nurseas a breath of fresh air (Smith, 1992), societal expectationsand stereotypes are in full force. Did the patient see astereotype of a nurse observing the procedure or did shejust see a caring person training to be a nurse before her?Does she have faith in my professionalism? Did I liveup to the unspoken professional promise? I think that Idid; I certainly endeavoured to. It reflects upon me as anindividual as well as a future professional, as according toFagermoen (1997), 'the nurse provides care in a form ofself-presentation through which nurses actualize their values

and communicate their personal meanings' (Fagermoen,1997). Therefore, it follows that it is impossible to predicthow gender plays a part in the professional nursing role andmoreover it is impossible to generalize gender equity incaring relationships (Smith, 1992: Seed, 1995).

This second stage of the Gibbs cycle provides a sectionto explore how I felt and the thoughts 1 had. This andits complementary section were the most important partof my exploration and learning process. My commentswere not directly restricted to my 'thinking' and 'feeling',accompanying them were some elucidation of the storyand also evaluation, supported by evidenced-based research.This seemed to be the most natural and productive way oflearning from the experience and enabling me to presentthe information in an informed manner. Gibbs' cycle,therefore, has undergone some expansion here, such anapproach was necessary for learning to emerge and toenable the flow of accounts.

What were the thoughts and feelings of othersInvolved? How do you know?My intuition led me to believe that the nurse I accompaniedhad no discernable feeling one way or the other about thesituation. She acted as a professional, i.e. a task had to bedone and she did it. In many ways it is just another woundto be cleaned and dressed, albeit in close proximity togenitalia. On the other hand, the patient must have beenembarrassed; in today's society, private parts remain privateand exposure to others is restricted. Permitting strangers tosee her genital area must have felt invasive. Especially withme observing the dressing procedure, and as a male studentnurse, I felt superfluous to the process and only added to thepatient's discomfort. But she seemed to accept my presence;more than likely because her priorities at that time were tomake a full recovery and take life day by day. Professionalcaring properly understood, is a moral imperative, borne ofaltruism and a sense brotherhood (Dowling, 2004), a senseof which I had on this occasion. This poses no problem solong as the patient understands and has faith in her carers asprofessional practitioners.

The third section of the Gibbs process required meto delve into what others thought. As such it demandedan empathie view, putting myself in their shoes. Thisstage was useful because it allowed the fusion of what 1observed: their body language, the things that were said,and the way I might have viewed things if 1 was in theirsituation. This stage of the cycle permitted me to analysehow I perceived the motives and reactions of others. I wasenabled to tease out the 'commonalities and differences'in other's views (Benner, 1994), which is the very goal ofinterpretive phenomenology. It is here where personhoodand individuality can be examined.

What other options were open to me?Not many other options were open to me. I could havebeen less sensitive and stood closer, thus enabling me toobtain a more detailed view of the nursing care applied.However, at what cost? The patient's dignity could havebeen needlessly intruded upon, violating tbe principles

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in the NMC (2008) Code. Hence, I felt that no betteraltcrndtc options were open to me. This fourth stage ofCiihbs" cycle therefore provided only the opportunityto explore the negative consequences of my presence.Learning, through reilectioii, enhances an ethical senseof the morals of nursing practice, and thus provides theanswers to why. In the world of nursing knowing why is thedifference between mechanistic repetition, and acting as aconsequence of knowledgeable decision-making.

What would I do If the situation arose again?My conduct would be similar. Patients are people and:i\ people are different, some are indifferent, others areconcerned. In the times subsequent when I revisited thepatient my approach was similar (and will be in the future).To safeguard the dignity, respect and trust of the patient itis better to err on the side of caution and be aware of thesensitive nature of intimate nursing care. It seems that achaperone, in any intimate examination/treatment, can beuseful to both patient and nurse {Peate, 2005), especially inthis age of lawsuits. The Royal College of Nursing (RCN,2002) recommends actively providing a chaperone whenattending to intimate nursing care procedures.

On balance, initially I need not have been so demure.It is easy to intrude upon a patient's privacy, especiallyif their preferences are not known (Back and Wikblad,Í99H). Caution was appropriate here because space, touchand interaction are seen differently by different people(Edwards, 1998). Such views relate to varied criteria, suchas gender, age and even height, more often unknown to thestranger (Edwards, 1998). My own personal values can havea profound influence on the way 1 interact with patients onwhatever level, one must be aware of this and the potentialfor problems to arise, hence my cautious interaction withthe patient in this case. Although, I think my inherent valueshelped, they could be a hindrance in other circumstances,for example, being needlessly cautious. But, by numerousvisits and observing a tittle at a time, I have been able to putthe treatment together in my head, like a jigsaw puzzle, so 1have been learning without being too obtrusive.

One easily adjusts to situations. For example, in the areaof leg ulcers, what at first repulsed, is now just anotherwound. Applied to this situation, one could easily lose sightof the sensitive nature of wounds such as this; the activity isloaded with great risk of becoming ritualized, habitualizedand insensitive when applying treatment, at great cost tothe patient.

At my latest visit, the nurse removed the dressing, thewound had healed, and we thus noted in the paperwork.Aware of the need to re-assess patients, as their situationcould alter, the patient remains on file and we remain 'oncall'. In areas related to this. I will try and keep an 'empathieattitude" (Rogers, 1980) to enable me to better tailor myresponse and better address the chent's needs.

In the fifth and final stage of the Gibbs reflective process,I was able to explore the potential situations 1 could foreseearising again, perhaps with different patients. I could thenapply what I learnt to those future situations. I am now, asa consequence of critical reflection, able to examine my

philosophy as it applied to this event and how it couldcascade to other future events. I was facilitated to look atmyself and see where any impediments may be and thushow a remedy might be fashioned.

Critical reflection (commentary)I feel I need to learn and understand more about theplight of patients in this situation. Dealing properly withthe aftermath of gynaecological surgery is important, it hassignificant imphcations, not only for physiological reasons,but also from a psychological perspective considering theloss of womanhood, femininity and sexuality for patientsundergoing such evasive surgery. It is essential that nursesare aware of the consequences of vulvectomy surgery fromboth a physiological and psychological perspective. Sexualexpression and self-esteem may be impaired as a result.

Almost 15 years ago a qualitative study was conductedthat concluded some surgeries physically 'disfigure' thetreated area (Corney et al, 1992). However, the fear ofrecurrent cancer in the future remained constant as 60% ofpatients in the study stated that fear of cancer recurrencedid not dissipate over time. Potential for major distresswas also uncovered, with 68% feeling markedly or severelydistressed about their postoperation life, younger womenespecially. Sexual problems presented in 76% of the sexuallyactive patients within 1 year of the operation, in contrastto 19% before operation (Corney et al, 1992). Hence, itseems to me that even those who are not sexually activemay have trouble forming relationships, for fear of problemsbeing encountered. The study concluded that support ofemotional needs and information are the best tools to tacklethese problems, and counseUing should be freely available(Corney et al, 1992).

Allowing for questions and givingjargon-free explanationscan also help the patient (Peate, 2005), As my clinicalplacement is in the community, 1 have noticed thatnurses do play a counselling role in some way. offeringinformation and support. I believe this is exactly whatnurses should do and furthermore be observant of non-verbal communication, adopting a holistic approach, andoffering support at the early stages of care. These needsshould be recognized and addressed,

American sources claim that of gynaecologicalmalignancies, 4% of them are vulvar cancer (Di Saia etal, 1979; Venes, 2005). Unfortunately, it is unlikely thatprevention of this disease is possible, it is rare and as of yetthere is no available effective screening method for vulvalcancer (RCN, 2005).

I have learnt a lot from this experience, not just from mypersonal reflection but also from reviewing the evidenced-based literature, in particular relating to a topic I wouldotherwise not have researched. Gibbs' model does notadvocate a concluding critical commentary. Although 1 hadweaved critical elements into the actual reflection, I wascompelled to add this section in order to evaluate the biggerpicture, as in this case, to the related aspects 1 witnessed. Iwas looking to turn this learning experience into knowledgeapplicable in other situations related to intimate treatment.The critical reflective process permitted me to examine and

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reflect on the psychological aspects of this type of surgeryand thus transported me beyond this stage to engage in thethoughts and feelings of others involved, as that was basedupon contemporaneous assessment and some afterthoughtand interpretation. My analysis uncovered real studies ofreal people exploring knowledge beyond what I couldobtain from the patient. The efficacy of the Gibbs processstimulated me to learn more. Perhaps an interesting additionto the cycle would be a section that is updated at a later date,so progress can be gauged.

ConclusionThe foregone discussion demonstrated the potential powerof reflection as a tool for discovery and possible learning.It is clear to me that Gibbs' cycle is of use in manycircumstances. The cycle is cyclical, it can be altered andadapted to the varying situations and crises nurses are facedwith, which means the cycle can be applied to ahnost anyevent or issue. Thus, such a structure is ideal for first-yearstudent nurses, with the lack of complexity permittingbetter engagement with the process. It also follows thatreflection should not be bound in a cast-iron structure, itmay be better to have no structure at all in some cases.More than likely different reflective cycles will benefitdifferent situations, much like a plumber selecting the righttool for the job. There is evidence of Gibbs' framework inmany reflective models (Jasper, 2003), which illustrates thatmany models share a commonality, which implies a sharedknowledge base, thus knowledge obtained from the Gibbscycle would more than likely similarly emerge with the useof other reflective frameworks.

Reflection occurs as a result of a critical thought process;the written word will not fade and can be consulted to aidlearning or mark progress. Reflection is the perfect mediumto evaluate the 'what and how' of nursing care and the widerimplications of inter-professional relations; thus informingother discreet issues. Reflection can be written evidenceand the product of an inquiring mind. The time needed toeffectively reflect is immense, and not withstanding theenergy invested in recalling the experience, writing,researching, reading, synthesising, thinking, followed withmore writing, is significant. But it is a worthwhile exercise,considering the theory-practice gap that Kyrkjebo and

KEY POINTS

Reflection is a well-established tool in learningand is common to nursing programmes nationally.

I The Gibbs* cycle is ideally suited to the reflectiveneeds of student nurses because of its simplicityand malleability.

I Gender plays a role in the application of intimatetreatment.

Reflection stimulates deeper exploration of topics.

Hage (2005) found students witness in practice. Reflectioncan be used as a quality assurance method to evaluate botheflective and poor practice. Moreover, as demonstrated frommy personal reflection on my novice nursing practice,reflection is a potent weapon in the armoury of learningand development. DH

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The author ¡muid like lo liiaiik Paul Liiiilcyfor his support in writing this

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