3 Reflection and communication
Introduction
Reflection is an important component in the process of becoming a mental health nurse as well as a recommended element of continuing professional de- velopment post-registration. Its value in contributing to mental health nurses’
learning and development is recognized and supported by the nursing profes- sion. This chapter will examine the concept of reflection, its usefulness in enhancing nurses’ learning, as well as its value in developing the skills re- quired for effective communication. We will also outline various strategies that aim to help the mental health nurse to develop his/her ability to become a more reflective communicator in clinical practice.
Learning outcomes
By the end of this chapter, you should be better able to:
1 Describe the concept of reflection
2 Demonstrate an understanding of how reflection can be used to en- hance learning
3 Demonstrate how reflection can be used to enhance effective commu- nication in clinical practice
4 Use reflection in clinical practice
it, mulling it over and evaluating it’ (Boud et al., 1985, p.19). This deliberative activity also entails the person’s ability to examine his/her thoughts, feelings and actions, and think deeply about their experience in order to gain new ideas and perspectives (Atkins and Murphy, 1993). Reflection therefore requires the person to look backwards and to project forwards to the future, which involves the skills of recall and reasoning (Jarvis, 1992). In this way, reflection aims ‘to build bridges between past and present experiences to determine future nurs- ing action’ (Durgahee, 1998, p.158). The following example illustrates how making links between the past, present and future enhanced a specific piece of learning for the mental health nurse.
Clinical scenario
John, a second-year student, listened attentively to Paul as he talked about his ex- perience of hearing voices. John used the probing skills of open questioning and paraphrasing to try to gain a better understanding of Paul’s story and distress. Paul described what the voices said to him and how the voices had interfered with every aspect of his life since he left university more than 20 years ago. When the interaction ended, Paul thanked John and said ‘it was really good to talk; I don’t think I have ever said so much, the staff don’t usually ask me talk about my voices’.
Later that day John discussed his interventions and their effectiveness with his mentor. While thinking more about his interaction with Paul, John recalled his first interaction with Paul over six months ago during his first clinical placement. He re- membered feeling very anxious and unskilled. In fact, he sometimes made excuses to end the conversation, as he was afraid that he might say the wrong thing and upset Paul. Being aware of his behaviours in the past prompted John to feel embarrassed and uncomfortable, yet he decided to disclose this to his mentor. His mentor ac- knowledged John’s recent awareness and subsequent learning. John now recognized that he had acquired knowledge and different communication skills since then, and as a result, he felt more confident and effective as a mental health nurse. His mentor commented that his interventions were appropriate and, more importantly, that the client had experienced them as effective. John was pleased with his learning to date.
However, he also recognized that he had much more to learn; in particular, he wanted to acquire additional skills and strategies that would help Paul to manage his voices more effectively.
Learning by thinking about an experience is not a new concept (Burns and Bulman, 2000). In the 1930s, John Dewey, an American educationalist, pro- vided one of the first explanations of reflection. He viewed reflection as the stepping back from a challenging experience, which allowed the person to think about the experience and then create a more comprehensive plan of action (Dewey, 1933). However, it was not until several decades later that re- flection took on a greater role and importance in professional practice. During this time, a number of writers developed their ideas of reflection and presented various definitions of reflection relevant to nursing. The most frequently
described in the literature are those of Sch¨on (1983, 1987); Boyd and Fales (1983); Boud et al. (1985); Gibbs (1988) and Johns (2000).
Since the 1980s, the concept of reflection has gained increasing momen- tum in nursing practice and nurse education throughout the UK. In clinical practice learning through reflection ‘has become more prevalent because of the processes of change in contemporary society’ (Jarvis et al., 2003, p.9).
Also within many pre-registration nurse education programmes, learning out- comes relating to reflection are an explicit learning requirement and form the basis for many formative assessments (Hannigan, 2001). Similar to other practice-based professions, reflection has become a valued and integral com- ponent in the learning, acquisition and assessment of knowledge and skills in nursing. In nursing, the use of reflection was influenced by Donald Sch¨on’s (1983, 1987) seminal work The Reflective Practitioner. He identified two sep- arate types of reflection, described as reflection-on-action and reflection-in- action, the latter usually being carried out more by experienced practitioners.
Reflection-in-action refers to the reflective thinking that occurs in the process of an experience (Sch¨on, 1987). For example, during a conversation with a client about different anxiety management strategies that he could use when discharged, the nurse observed that the client was clenching his fist as he answered with monosyllabic responses. At the time, the nurse considered pos- sible explanations for the client’s non-verbal behaviour; however she decided not to comment on it until later. Refection-on-action is the retrospective con- templation of practice taken by the nurse to clarify knowledge used in practice.
As such, reflection-in action refers to what is happening in the present, whereas reflection-on action is about what happened in the past.
The value of reflection
Many nurse educators and clinicians advocate the use of reflection as a potent and valuable teaching and learning method, which aims to enhance the following:
r integrate theory with practice, thereby narrowing the theory – practice gap (Nicholl and Higgins, 2004)
r promote critical thinking and problem solving (Cotton, 2001) r maximize clinical learning (Wong et al., 1997)
r facilitate new understanding and learning of nursing (Boud et al., 1985) r develop professional practice (Somerville and Keeling, 2004)
r improve patient care (Cooke and Matarasso, 2005).
Notwithstanding the above, there is a lack of empirical evidence to support these claims, particularly with regard to how the use of reflection improves patient care (Burns and Bulman, 2000). Much of the extensive literature on reflection and reflective practice is theoretical, descriptive and anecdotal. How- ever, in recent years there has been an increase in research studies, albeit that few relate specifically to reflection and mental health nursing (Platzer et al.,
2000; Glaze 2001; Mantzoukas and Jasper 2004; Nicholl and Higgins 2004;
McGrath and Higgins 2006). The mental health nurse needs to be mindful of such limitations when considering reflection in the context of clinical practice and the development of reflective practice. Nonetheless, we believe that the use of reflection in practice can offer the potential for professional and per- sonal development, and learning. However, we are also aware that for learning to occur, the mental health nurse will require structure, guidance and support as well as an openness to use different strategies that foster the ongoing devel- opment of reflective skills and reflective practice.