Journal of Child Health Care

http://chc.sagepub.com Review : Reflective growth and professional development: an ABC approach for the novice reflector
J Child Health Care 2001; 5; 163 DOI: 10.1177/136749350100500405 The online version of this article can be found at: http://chc.sagepub.com/cgi/content/abstract/5/4/163

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REVIEW

the novice reflector

SUMMARY
▪

growth and professional development: an ABC approach for

Reflective

This step guide acknowledges, than any other time in nursing

today more history,

▪

▪

▪

nurses are being encouraged to evaluate and evidence learning. The UKCC guidelines on mandatory PREP (2001) demands a nursing profession who can evidence analysis of personal growth and development, learning from experience in practice. The step guide has been developed to enable novice reflectors to develop skills in reflective dialogue and writing. Nurses need guidance in this approach to learning more about themselves and the domain of nursing as for many it is a challenge to more formal modes of

learning.
KEY WORDS: Reflective

practice, Reflective

frameworks, Language of nursing, Ways of

knowing.
WHY REFLECTION?
This step guide, originally published in the Journal of Neonatal Nursing, has been developed to enable childrens nurses who are novice in the art of reflection, whatever their grade, experience or position to develop skills in reflective writing and dialogue (Crathern, 1998). The nursing profession is increasing its emphasis on assessment and competency (UKCC, 2001). Indeed consumers of health care expect nothing less than this from health care professionals and contemporary nursing rightly demands it from us. Thankfully it is no longer acceptable to become qualified in a domain of nursing and do nothing else to evidence knowledge and understanding over your career trajectory. Indeed an open culture is being encouraged both by government and nursing in which all practitioners should feel able to question their practice (UKCC, 2001). I do acknowledge however from both personal and professional experience, this can be difficult and takes time to learn (Burns & Bulman, 2000; Johns, 2000). However, I would like to assure you at the outset reflective practice is a skill, once mastered, that does not leave you. For example, I recently

had some study leave in New England USA. Having used reflection both formally on courses and informally as part of my personal development for many years, I kept a record of my experiences, observations, thoughts and feelings in a diary. This in turn insured a much deeper, richer analysis and feedback to my students and peers on return to the UK. It also provides a permanent record of my experiences should I wish to utilise them at a later date, in another context. As one example, I had arrived in the USA with pre-. conceived ideas about advanced neonatal nursing practice and the role of respiratory technicians in neonatal intensive care. Having been invited to observe both roles on ward rounds and nursing hand-over, reflecting on this experience, my views had to change. In a sense I had to acknowledge the negativity and judgmental opinions that were impacting on my perception of the experience. Reflection is worth the effort, not solely to act as a catalyst for formal or informal analysis of experiences but as Lumby (1991) highlights it contributes towards the development of a language of nursing, much needed, to express the discipline adequately. A language that Palmer et al.,

(1997 p.75)

states:

&dquo;portrays the exquisite sensitivity of the art and science of nursing&dquo;.

This is crucial to valuing reflection as a legitimate way of knowing. Watson (1990) believes the articulation of nursing knowledge through the medium of personal reflection enables an understanding of the lived experience of health, illness and caring for all those touched by the experience. From a personal perspective, I undertook a fast track programme, for nurse practitioners in primary care, facili-

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tated by a Health Care Institute in Boston, USA. It could be argued in this clinical situation, the role of the nurse has a potential to conflict with the traditional medical practitioners role in primary care, yet this experience was enriched by an ability to articulate the language of nursing within that context. This happened because both the GP and myself valued a shared dialogue through reflection about the care delivered to patients and their lived experience of health and both of us acknowledged alternative ways of knowing to the dominant perspective. It was certainly a learning experience for my American tutor who eventually accepted my need to submit a reflective journal as part of my portfolio of evidence, even though it was not mandatory for the course, as validated in the USA! I accept not all nurses would have a passion for reflection as I have just described, indeed it has its many critics. Mackintosh (1998) argues against the value of reflection in enhancing competency, stating there is little concrete evidence to support it as a learning tool. However, having facilitated reflective learning for nine years and observing nurses grow in their personal and professional lives listening to them articulate primacy of caring, I struggle with this argument. I do however acknowledge if learning from reflection is to be more than a naval gazing exercise or conversation without a purpose then nurses need very clear and unambiguous guidance in this approach to learning more about themselves and the domain of nursing, for the very reason it is a challenge to more formal ways of knowing.

the next step is approached. This is represented pictorially by entering at step A small and exiting at step C much taller. However it also permits a cycling between levels, as you learn more about theories, research and importantly self that impact on your new or enhanced way of knowing in that particular situation. This permits a return to the situation with a new perspective on the knowledge therein. It is important to note that not all beginning reflections may progress to level C with immediacy. It can and does develop over time and with practice. You can enhance the process by linking up with a mentor who already has skills in reflective dialogue and writing, this person can be crucial in enabling you to see the wood through the trees. I begin by asking learners to write a description of an event or situation that has personal meaning, as the description is read aloud you can begin to help unpick the issues with the learner that will promote growth and development in their practice. Facilitating a novice reflector to move through all three steps, observe their growth and development in their ability to articulate experiences and learn from them, culminating in a deeper understanding of clinical practice and theoretical underpinning, is truly rewarding. This is even more so when you meet up with a nurse who is initially very sceptical about the value of reflection and over time can appreciate its value as a learnas

ing tool.
WHAT TO REFLECT? How do you know what to reflect on? This is a question I am often asked by learners who are sometimes overwhelmed either by the richness of clinical experiences or perceived ordinariness of day to day practice, and find it difficult to single out individual experiences as particularly relevant. It is also a skill in making the initially perceived

WHICH REFLECTIVE FRAMEWORK? There is an abundance of reflective frameworks and guidance in nursing literature that seeks to explain the process of reflection (Carper, 1978; Boud et al., 1985; Gibbs, 1988; Aitkins and Murphy, 1993; Johns, 1993; Palmer et al., 1994;

Johns, 2000). The reader may choose to analyse those referenced in some detail before embarking on a framework that suits personally. In essence they all require an element of self awareness, knowledge of prior experience on the situation, an ability to articulate, either verbally or written, the experience and make sense of the situation for yourself, client(s) and others touched by the experience. There is also an expectation that it will inform future practice to enhance you personally and ultimately the many domains of nursing. However, initially for the novice reflector, it can be difficult knowing which one to choose. The steps to reflective growth presented in this guide are an attempt to adapt a number of models into one eclectic structured framework for reflection. In doing so it is hoped more complex models have been simplified and the least complex given some depth to analysis and adaptation. It must also be noted that the framework is there as a guide (see figure 1). It can be adapted further as you become more skilled at reflection, conceptual frameworks are not meant to be static, they should be dynamic and open to change. As a beginning reflector, each of the steps in the ABC approach (Crathern, 1998) gets bigger than the last (see Figure 1). The model demands increase in intensity and level of reflection as each step is achieved, in doing so it

ordinary experience extraordinary! Importantly, it is not just about waiting for a critical incident to happen to you. A few years ago I heard David Boud, one of the key writers on reflection, when presenting a seminar at the University of Leeds (March, 1998) respond to a similar question,
he stated:

&dquo;Emotion tells you where the learning is to be had. It

points to things impoYtant.&dquo;

I will never forget this response as it is, in my perception, at the same time profound and simplistic, at the very least it demands you begin by harnessing those experiences in which you have personally been moved by emotion such

&dquo;

acknowledges

as

you progress,

developmental growth

anger, sadness, elation, joy, frustration, conflict. argues writing down these experiences enables you to return to it and focus on the situation in a new light. By revisiting all the things, people, events that make up the experiences contextual form you will learn what is key to you personally (Burns & Bulman, 2000; Johns, 2000). In my experience nurses are only too ready to reflect on what went wrong in a situation, less so what went well. Benner (1984, 2000) has been encouraging nurses for almost 20 years to learn from positive experiences. However reflecting on what makes us feel sad is also important and should not be buried for fear of emotion; it is best facilias

Durgahee (1992)

164

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tated with an experienced mentor, it can unearth feelings of unease from prior experiences either in our professional or personal lives. I have facilitated a module on neonatal attachment and loss for almost nine years now and its content still has a huge impact on some nurses who rediscover feelings they may have suppressed over time. It would be unethical for me to leave these nurses feeling raw and exposed in this situation as a result of lecture led content. Therefore time is allocated to this aspect of the learning, with .agreed ground rules and as a result reflection and dialogue is facilitated in a supportive and safe environment where personal knowledge is explored. For example, as a group of neonatal nurses we have come to learn, through our reflections in the classroom, that celebrating the joy of a surviving sibling and sadness of the death of another sibling simultaneously with a family, at or around the time of birth, is an increasingly difficult part of the nurses role in supporting families appropriately. As more families opt for interventions to succeed in pregnancy I have come to learn this is an inevitable aspect of caring and needs addressing in the module content. In essence this example helps articulate Bouds comments on emotion telling you where the learning is to be had and what is important. This personal knowledge is key to reflection; it is by definition different to more formal academic learning but no less valid and it can help you focus on what theory you may need to develop understanding of to support critical analysis of events. Schon (1987 p.3-4) writes on learning from personal practice: &dquo;In the varied topography of professional practice there is a high, hard ground overlooking a swamp. On the high ground manageable problems lend themselves to solutions through application of research based theory and technique. In the swampy lowlands, messy, confusing problems defy technical solution. The irony of the situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, where in the swamp lies the problems of greatest human concern.&dquo;
&dquo;

access a child nursing programme leading to part 15 on the Professional Register (see box 1 for suggestions for reflective evidence) This type of reflection is of course much more formal and would need to be verified through clinical supervision and preceptorship. It is also crucial to link up with a senior paediatric nurse from a childrens unit who could verify your experiences to include in your portfolio, in line

to

with your unit manager.

HOW TO REFLECT?
Before embarking on the ABC steps to reflective growth framework Boyd et al., (1985) define reflection as a dynamic process that involves internally examining and exploring an issue of concern. This concern is triggered by an experience, which creates and clarifies meanings in terms of self and results in a changed perspective. Fitzgerald (1997) does caution that it can appear easy and something you can be sent off to do. Indeed Johns (2000) recent writings reflect that concern also. Nevertheless once embarked on, it will become a process of gradual self - awareness, critical appraisal of the social world and transformation. When embarking on reflection you must be prepared for the fact that it is not necessarily comfortable and, particularly for an assessed element in course work, requires commitment and intellectual effort for the process to work. (See Figure 1 for more detaail of each step).

Step A
Here it is useful to remember Bouds trigger to reflection, that which has stirred the emotions. You must however have an awareness to the potential for learning, acknowledging personal experiences as valid learning. For someone who is grounded in a more formal experience of learning this may well be the first stumbling block! Write a description of the experience, ask what are the key issues within this description I need to attend to (Johns 9th edition 1993). Think about how any previous experiences have an impact on the present e.g. dealing with death and dying, becoming a student again, prior experience of learning, managing conflict or stressful situations. Boud and Walker (1990) refer to aspects of this as enframing, attending to the social milieu (environment). An important aspect when you progress to step B.

This is practice, this is the real world, nurses have a wealth of knowledge emeshed in the swampy lowlands that are messy and do demand exploration and articulation. Lawlers (1991) wonderfully illuminating text Behind the Screens in which she explores the problems of nursing the body is testimony to this. She articulates through dialogue with patients and nurses the real world of nursing and the dilemmas faced with intimacy, touch and personal space. I spend a lot of time and effort initially with learners on a work based learning module enabling them to see that evidencing their every day practice, some of it messy and defying technical rationalisation (Schon, 1987) is of value as a way of knowing. What to reflect on in the real world of childrens nursing may also have implication for further study when a portfolio of evidence is required to accredit practice. A timely example of this could be a neonatal nurse applying

Step

Now you are beginning to analyse events critically, asking what sense you can make of the experience, being honest about the role of self and others on the experience. The

165
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difficult thing to do alone is to be aware of negativity judgemental opinions that impede growth in reflection. I find as a facilitator it is key to open up discussion on this aspect in order to foster growth and honesty. Somemost

tut Has it

changed my way of knowing?

and

times

nurses

need space to

come

to terms with their

own

negativity and judgemental thinking and actions. Again utilising Johns (1993) questions ask:
N What was I
E

Carper (1978) describes four ways of knowing, empirical, personal, aesthetic, ethical, (for a detailed exposition refer to the original paper). Briefly and simplistically empirical knowledge refers to the factual, scientific knowledge, easily verified. Personal knowledge refers to knowledge that is useful for self; it may include insight into ones own behaviours and assumptions as well as effect of self on others. Aesthetic knowledge underpins the art of nursing and encompasses the thoughts, feelings and behaviours, recognises the unique and subjective knowing, acknowledging the grasp of meaning we have on the particular, it demands a connection with the patient and family, in a sense a getting to know at a deeper level. It is this aspect of knowing, I believe, helps articulate the language of nursing. Lastly ethical knowledge explores understanding of moral issues and dilemmas in practice. Within childrens nursing there are at times sources for profound moral conflict and potential human suffering that health care professionals and families are exposed to, sometimes on a daily basis. Reflection that is rigorous and supported by a framework, should change your personal perspective, should change or enhance your ways of knowing since it causes you to reflect on your self, thoughts, actions and beliefs. It is hoped this ABC guide will encourage you to articulate and evidence the rich and varied world of childrens nursing and in some way transform your thinking that will by definition have to impact on the wonderful and unpredictable world of the domain we call childrens nursing.

trying to achieve?
did?

Why did I act as I

0 What were the consequences of my actions for patient, family, others I work with? 0 How did I feel about experience when it was happen-

ing ?
0 How do I know how others felt? 0 What external or internal factors affected my decision making e.g. prior experience, staffing, resources? Be aware of negativity and judgement colouring your thought processes. Asking difficult questions and being sceptical of routine and ritual, in particular, is key to becoming a reflective practitioner. It is the beginning of empowerment and emancipation through critical awareness (Emden 1991), so important for Step C. Step C When critically analysing all components of the situation it is important to acknowledge existing scientific or theoretical knowledge which influences what has happened. It requires exploration and challenge of assumptions made and imagining or suggesting alternative ways of dealing

with the situation. It also requires intellectual effort for this process to work. Johns (1993) asks:
0 Could I have dealt better with the situation? N What would be the consequences of other choices? 0 How can I now make sense of this experience in the

REFERENCES
Aitkins S, Murphy C. (1993) Reflection — A review of the literature. Journal of Advanced Nursing; 18 (8): 1188-1192.
Benner P.

light of past experience and future practice?

(1984) From Novice to Expert. Excellence and Power in Clinical Nurs-

ing Practice California: Addison Wesley.

166

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Benner P. (2000) The wisdom of 32-37.

(10): caring practice Nursing Management; 6

Johns C. (1993) Professional

18.

supervision. Journal of Nursing Management;

1: 9-

Boud D. (1998) Seminar on reflective practice University of Leeds Boud D, Keogh R, Walker D. (1985) (Eds.) Reflection, Turning Experience into Learning. London: Kagan Page Boud D, Walker D. (1990) Making the most of experience Studies in Continuing Education; 12 (2): 61-80. Burns S, Bulman C. (2000) Reflective Practice in Nursing. Oxford: Blackwell Science.

Johns C. (2000)

Lawler J. (1991) Behind the Screens: Nursing Body. Melbourne: Churchill Livingstone.

Becoming a Reflective Practitioner. Oxford: Blackwell Science. Cosmology, the Problem of the

B. (1978) Fundamental patterns of knowing in nursing. Advances in :13-23. Nursing Science; 11 Crathern L. (1998) Steps to reflective growth. An ABC approach. Journal of Neonatal Nursing; 4 (6): insert. (5): 42-44. Durgahee T. (1992) The knowledgeable doer. Senior Nurse; 12 Emden C. (1991) Becoming a reflective practitioner. In: Gray G, Pratt R. Towards a Discipline in Nursing. pp.11-30. Melbourne: Churchill Livingstone. Fitzgerald M. (1997) Theories of reflection for learning. In: Palmer A, Burns S, Bulman C. (Eds) Reflective Practice in Nursing: The Growth of the Reflec-

Carper

Lumby J. (1991) Threads of an emerging discipline. In: Gray G, Pratt R. Towards a Discipline of Nursing. pp. 461-484. Melbourne: Churchill Livingstone. Mackingtosh C. (1998) Reflection: A flawed strategy for the nursing profession. Nurse Education Today; 18: 553-557. Palmer A, Burns S, Bulman C. (1997) Reflective Practice in Nursing. Oxford:
Blackwell Science.
Schon D. (1987)
Bass

Educating the Reflective

Practitioner. San Francisco: Jossey —

United Kingdom Central Council. (2001) PREP and You. UKCC Publication: Register 35

tive Practitioner. pp. 63 -84. Oxford: Blackwell Science Gibbs G. (1988) Learning by Doing. A Guide to Teaching and ods. Further Education Unit, Oxford Polytechnic: Oxford.

Learning Meth-

(1990) Caring knowledge and informed moral passion. Advances in :13-23. Nursing Science; 1 Acknowledgement: An earlier version of this paper first appeared in the Journal of Neonatal Nursing (1998)
Watson J.

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