How Reflective Practice Impacts on the Clinical Environment?

The aim of this essay is to prove an understanding of my perception of reflection and how reflective practice impacts on the clinical environment and the learning process. The essay is based on my practice and training in the cardiac ward during my Foundation degree in Health and Social Care. I have selected 5 extracts from my Reflective Journal concerning a patient experiencing shortness of breath which led to a cardiac arrest. In order to be able to use this situation for my reflective process the patient will be referred to as “Jane” for the maintaining of confidentiality according to the Nursery and Midwifery Council (NMC, 2008).

I have chosen to discuss on the case of Jane as the situation I was confronted with at the time made me reflect on issues of decision and the importance of communication and interpersonal skills in the relationship with the patient. I will be using the What? Model of Structured Reflection (Driscoll, 2007) a framework that uses three simple questions as guidance in reflective practice, namely What? So what? Now what? I have chosen this model as I believe is a practical solution that can be applied by health care professionals in a rapid and efficient manner.

It stimulates an in depth meaningful reflective process that leads to an actual plan for future actions. According to Johns (2013) reflection can be viewed as a window through which a practitioner can see himself in the context of his practice and have a clear view of his/her experience, being able to make an analysis between what should be done and the actual practice.

Searching for a deeper understanding of the decisions and actions taken in one’s activity can generate evolution of each professional and the development of his/her work practice (Benner, 2001). The process of reflection can be developed on two levels depending on its complexity and the details it comprises. Therefore reflection can be made in a deep and meaningful manner that considers all aspects of the situation or in a superficial manner that leads to solving problems based on factors such as tradition or work pressure (Lowe, 2007). Another downfall of reflection can be the focusing on the negative aspects of the way a situation has been managed instead of concentrating on the potential for development based on a critical evaluation (Bradbury-Jones,, 2009). When trying to improve knowledge from practice, there are several models of reflection aimed at directing individual reflection.

Among them, the Gibbs’ model of reflection (1988, cited in Callara, 2008) has stages that include the description of the situation, feelings experienced during the situation, an evaluation regarding the positive and negative aspects, an analysis process followed by a conclusion which should include what could have been done in the situation and an action plan for future actions if a similar situation occurs (Gibbs, 1988, cited in Callara, 2008). Johns’ model of reflection (2013) on the other side focuses on questions regarding the intention of the action taken, the reason that was at the base of action, the practical and affective consequences on the patient, the patient’s family, the practitioner and his/her work colleagues. Johns (2013) also highlights the importance of influencing internal and external factors in the decisional process and the possible alternative solutions that could have been found. The reflection process suggested by Johns (2013) ends with a learning phase that aims at understanding the effects of the experience and how it reflects on practice. Although there are numerous reflective frameworks, none of them should be used as a rigid tool which asks questions that need to be answered.

They are all intended to offer a certain structure of the reflective process and guide the practitioner towards deeper understanding (Lowe, 2007). I have chosen Driscoll’s model as I believe it is a practical tool that allows free thinking and rapid understanding of the situation. Coward (2011) states that following a rigid model of reflection limits the thinking process and undermines the reflective process. Throughout my reflective process I have chosen to discuss also on the subject of decision making as the Code of Professional Conduct (NMC, 2008) underlines the fact that nursing practitioners are accountable for their decisions. During a working day in a hospital there are numerous clinical decisions that need to be made and as Dowie (1993, cited in Raynor, 2005) states, the decisional process is manly a choice between several alternatives. According to Burns and Bulman (2000) through reflection we can have a clear understanding of the reasons that lie behind our decision. This is what I have learned during my training and through my clinical experience, that only thinking about the actions I take in different situations helps me evaluate my work and understand what further knowledge I need in order to become a professional.

Writing a journal that detailed my thoughts and worries on specific situations I was confronted with in the cardiac ward helped me learn and develop my skills, as Moon (2004) stated. Jane was a 60 year old lady diagnosed with valvular heart disease. She has been submitted in the hospital several times before as she experienced shortness of breath and released from the hospital when her condition stabilised. On that day I was helping the nurse observing the patients, taking vital signs and recording blood results. Her observations on that day were within normal limits, but even so she complained about shortness of breath. Her husband had just visited half an hour before and the breathing problems appeared after he left. The nurse asked her if she received any unsettling news from her husband because her state changed suddenly after he left. She told us that one of her sons was in town for a short period of time, came to visit not knowing she was in the hospital and left worried back home as he had to be back at work in the same day. The nurse told Jane that her son will be fine and probably will come back to visit very soon. However, I could see that Jane was feeling anxious and had a desperate look in her eyes.

She repeated several times that she couldn’t breathe and the nurse told her that she will be alright if she tried to calm down and relax. The nurse didn’t seem to worry too much as the patient’s observations were within limits. Jane saw the fact that I was gazing at her while wondering if this is more than the observations might show. She took my hand and asked me not leave, because she needed someone by her side. At first I told her I would be there for as long as she wishes, but then I was called to help other nurses because they needed me in the ward. I assured her that I will come back. Unfortunately, the day passed very quickly and time came for me to go home. Before I left, I asked the nurse who was attending Jane about her condition and she said she was still upset about the news her husband have her, but that her medical conditions was within limits. When I returned the next day I was informed by the nurse that Jane suffered a cardiac arrest over the night and although cardiac procedures were made nothing could be done and she was pronounced dead. My first thought after I heard the news was that probably, considering her heart condition nothing could have been done. However, after I read the journal and the notes I made in it about this case and applied the Driscoll model I began questioning about my actions and think about what I should be doing if a similar situations occurs.

Reflecting on the incident made me wonder whether I acted accordingly with the NMC (2008) which states that I am accountable for my actions and omissions even if I follow the advice of other professionals. This is what happened in this situation as well, as I felt and thought that there might be more than unsettling news that could be disturbing Jane. Even so, it is well-known the fact that stress influences the medical condition of patients with heart diseases and this could have been a hint that her condition might get worse (Meterko, et al, 2010). According to Basford (2003) anxiety and fear of the patient can be reduced if he/she receives the affective support of a nurse.

I felt I didn’t do enough for Jane, as the least I could have done was to be there and talk to her and maybe her breathing would have come to a regular level. Basford (2003) highlights the importance of communication and interpersonal skills of nursing practitioners in their relationship with the patient. Being warm and appearing willing to listen and talk to the patients can sometimes make a big difference in someone’s medical condition. I believe that the lack of communication with the patient was the biggest mistake I made in this case. I feel know that if I stayed by her side and tried to comfort her she would have become more relaxed and perhaps wouldn’t have triggered the cardiac arrest. I think that at that time assuring her that it will all be alright and that feeling better was the most important thing for her and her son as well was the best thing to do.

This was a point where the decision I made was not according to NMC (2008) as the relationship between me and the patient was broken because of lack of communication. This situation made me think about my communication skills and how important they are in my profession. Being assertive and saying what’s on my mind if I have a suspicion that more than what meets the eye might happen is what learned I should do in the future. Moreover, I think I still have to work on my empathy and compassion as I believe this would improve also the quality of the observations I make during the time I spend with patients. Reflecting on the action I took made me understand that guidelines cannot prepare me for all types of situations that can be met in the ward. They are very useful s guidance for the majority of cases, but most of the times it is the individual’s responsibility to act as he thinks it’s appropriate at the given time (Scott and Spouse, 2013).

This assertion becomes more relevant especially when it comes to dealing with interpersonal issues that don’t come across as essential tasks in dealing with patients. Focusing on the regular work practices and tasks most of the times takes our mind away from the interpersonal aspect and the fact that we are actually the ones that patients look at for compassion and relief (Rolf, 2001). There are situations, as the case of Jane when listening and being by the patient’s side can bring more benefit than measuring their blood pressure or taking vital signs. Conclusion

Reflection can vary from deep and meaningful to superficial inquiry. As I stated above the care for patients can be improved through reflective practice that leads to a plan of action for future situations. The case of Jane helped me understand the importance of communication and compassion in the relationship with the patient. Also, although I might not be the one most experienced in situation, I should have the courage to speak my mind and raise certain issues if I feel they could make a difference in the patient’s condition. Driscoll’s model of reflection made me understand the situation I was in, identify my learning needs and find ways through which I can improve my performance and patient care. I also believe that reflection also helps health care professionals become motivated and empowered by the feeling that they actually have a word to say in the care of the patient and that they can influence important situations and outcomes for their patients.


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  2. Basford, L., 2003. Theory and Practice of Nursing: An Integrated Approach to Caring Practice.
  3. Nelson Thrones Bradbury-Jones, C., 2009. A new way of reflecting in nursing: the Peshkin Approach. Journal of advanced Nursing, 65 (11), pp.2485-2493 [online] Available at: [Accessed the 15th of February 2014]
  4. Callara, L.E., 2008. Nursing Education Challenges in the 21st Century. Nova Publishers
  5. Coward, M., 2011. Does the use of reflective models restrict critical thinking and therefore learning in nurse education? What have we done? Nurse Education Today, 31(8), pp.883-886 [online] Available at: [Accessed the 12th of February 2014]. Driscoll, J., 2007. Practising Clinical Supervision: A Reflective Approach for Healthcare Professionals.
  6. Elsevier Health Sciences Johns, C., 2013. Becoming a Reflective Practitioner; Oxford: Blackwell Science Ltd
  7. Lowe, M., Rappolt, S., Jaglal, S. and Macdonald, G., 2007. The Role of Reflection in Implementing Learning from Continuing Education into Practice. Journal of Continuing Education in the Health Professions, 27(3), pp.143-148 [online] Available at: [Accessed the 18th of February 2014]
  8. Meterko, M. et al, 2010. Job Satisfaction of Primary Care Team Members and Quality of Care. American Journal of Medical Quality, 26(18), pp.8-9 [online] Available at: [Accessed the 15th of February 2014]
  9. Moon, J., 2004. Reflection in learning and professional development, theory and practice. Oxon: Routledge Falmer Nursing and midwifery Council (NMC), 2008. The code: standards of conduct, performance and ethics for nurses and midwives. London: Nursing and Midwifery Council
  10. Raynor, M.D.,, 2005. Decision Making in Midwifery Practice. Elsevier Health Sciences
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