Today's registered veterinary nurses (RVNs) are expected to function in dynamic, complex, and ever changing environments. As professionals, they are required to refresh and update their skills and knowledge to maintain their competence. They must also be able to solve a myriad of patient, client and practice problems in order to deliver high standards of care (Royal College of Veterinary Surgeons, 2018). An individual RVN's professional and tacit knowledge may not always be adequate to allow them to handle the complex, uncertain, and unique situations within a practice environment. An important element of practice is therefore being able to ‘think on one's feet’ or to ‘learn by doing’. Adult learners have been shown to favour this type of experiential learning, and it has been described that this type of learning can be supported and improved through the use of reflection (Kolb, 2015).
Reflection is defined as ‘serious thought or consideration’ (Oxford University Press, 2018). It is a technique that can be used to evaluate practice in order to develop an understanding of what it is to be a veterinary nurse (VN), and to develop critically thoughtful approaches to providing patient care in sometimes challenging environments (Pierson, 1998). This literature review serves to provide VNs with the knowledge to understand what reflection is and why it is important for them to develop this skill. Methods of introducing reflection into one's practice will be discussed.
A brief history of some theories of reflective practice
The concept of reflection has been around for a very long time, being described by the philosopher Aristotle as far back as the 300s BC (Kraut, 2012). The contemporary discussion about reflection and reflective practice (RP) has largely been derived from the seminal works of the educational philosophers John Dewey and Donald Schön. Dewey (1910, p.9) described reflective practice as:
‘the active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends’.
He believed one must have a questioning approach and consider why things are the way they are, and how else they might be. The later work by Schön (1983) described the reflective practitioner as having the capacity to reflect on their actions so as to engage in a process of continuous learning. Schön (1983, p.54) described professional practice as dichotomous with one end being the ‘high, hard ground’ where practitioners make use of research-based theory and scientific technique, and the other end being the ‘swampy lowland’ where practitioners are faced with confusing situations and ‘messy’ problems which are difficult to solve with technical know-how alone. Schön (1983, 1987) believed this division could be bridged through the use of RP and described two different elements to this concept: reflection-in-action and reflection-on-action.
Reflection-in-action is the quick thinking and reaction that occurs while you are doing, and is essentially ‘shop-floor’ problem solving. Importantly it does not interrupt the action you are taking or interfere with the flow of work. Reflection-in-action is more likely to occur when there is an element of surprise, when you are nervous about performing a task, or doing something new. Schön (1983, p.70) theorised that:
‘…when intuitive, spontaneous performance yields nothing more than the results expected for it, then we tend not to think about it. But when intuitive performance leads to surprises, pleasing and promising or unwanted, we may respond by reflecting-in-action.’
Reflection-in-action allows you to see what is happening as it is happening, to consider why it is happening, and to respond by doing something differently (Figure 1). This type of reflection occurs often within the workplace, but is usually not recognised as such by the individual. It is therefore rarely formalised or recorded.
Reflection-on-action is to reflect about the practice that you have undertaken, usually after the event, to turn that information into new knowledge and learning (Figure 2). Schön (1987, p.26) defined it as:
‘…thinking back on what we have done in order to discover how our knowing in action may have contributed to an unexpected outcome. We may do so after the fact, in tranquillity, or we may pause in the midst of action (stop and think).’
During this process practitioners ask themselves questions to explore the event more deeply and their responses will depend on their existing level of knowledge and experience, and to some extent their values and beliefs. This type of reflection is much more purposeful and structured and may be easily recorded informally or formally.
Greenwood (1993) felt the Schönian model of RP was flawed as it failed to recognise the importance of reflection-before-action. This is the process of thinking about what and how you are intending to do something, before you actually do it (Figure 3). Greenwood (1993) believed this to be an important time for reflection in order to integrate previous experiences and knowledge into current practice, and that failing to reflect before action could lead to error, or to not achieving the desired outcomes. Reflection-before-action also provides an important opportunity for feedback to be obtained from colleagues and clients. This feedback may result in a change or improvement to the intended process, and for an appropriate action plan to be created. It can also facilitate learning within the practice environment (Green-wood, 1998). This type of reflection is more likely to occur in anticipation of a challenging situation (Mann et al, 2009).
The benefits of reflective practice
RP is fundamentally a learning tool that can help professionals to integrate theory with practice (Champion, 1991; Hatlevik, 2011). It can also influence professional decision-making and can help one to develop emotional intelligence (O'Donovan, 2006; Butler, 2016). Boud et al (1985) proposed that the outcome of reflection is both emotional and cognitive changes, which have the potential to lead to behavioural changes. If behavioural changes arise then these can actively enable one to modify their current practice for the better. Because of these potential benefits to practice, RP has attracted considerable attention within nursing education over the last three decades. A strong proponent of RP within nursing is Christopher Johns (1995, p.226) who defined that the purpose of RP:
‘…is to enable the practitioner to access, understand and learn through, his or her lived experiences and, as a consequence, to take congruent action towards developing increasing effectiveness within the context of what is understood by desirable practice.’
It is clear from his definition that Johns believes that reflection can help nurses to examine events in order to understand the meaning of practice with a view to developing desirable or best practice.
It has been suggested that when practitioners follow routine or habit their actual practice conflicts with their espoused theories of best practice and they operate at a less than effective level (Argyris and Schön, 1974). The more repetitive and routine practice becomes, the more likely it is that practitioners will miss opportunities to consider what they are doing and why, and may be drawn into patterns of error that can be difficult to correct (Schön, 1983; Taylor, 2010). RP can help practitioners to identify the habits they fall into in the workplace which get them through their day, it can help them to improve the quality of care they deliver, and can stimulate personal and professional growth (Jasper, 1999; Kim, 1999; Taylor, 2010).
The skills of effective reflective practice
RP is especially useful in helping to facilitate professional motivation through learning from experience and critically examining oneself in order to perform better within practice (Bulman et al, 2012). Activities to promote reflection are commonly included in student veterinary nurse (SVN) education, and Clarke (2010) proposed that this is essential in order for SVNs to develop professional competence. However, there is currently no formal requirement for RVNs to reflect on their practice, as there is within other healthcare disciplines. The Royal College of Veterinary Surgeons (RCVS) has proposed changes to their continuing professional development (CPD) structure to include evidencing learning through reflection (RCVS, 2016). There is clearly perceived importance of RP in the veterinary profession, and this highlights the need for the skills of RP to be learned by RVNs. It has been recognised, however, that the use of RP as a learning tool in practice is a complex activity that requires conscious development by both pre- and post-qualifying professionals over time (Atkins and Schutz, 2013).
Atkins and Murphy (1993) identified specific underlying skills that need to be developed in order to successfully undertake reflection-on-action. These include self-awareness, description, critical analysis, synthesis, and evaluation:
The process of reflection
It has been suggested by Clarke et al (1996) that nurses may choose to reflect on the technical or practical aspects of practice, the wider context of practice, and the knowledge of self (including personal qualities, experiences and attributes), though any event in practice can be a source of reflection and learning. Although it is much more common to explore negative events, as they often have a bigger impact, it is also important to remember to explore positive events to identify why they went well and what you would want to repeat in future.
Regardless of what one chooses to reflect on, there are three common steps in the process of RP (Atkins and Murphy, 1993):
These common steps have been utilised in many models of reflection. Models encourage a structured approach to the act of reflection and help guide the individual through the process. They can be beneficial as they help the practitioner achieve a deeper level of exploration and understanding of the event, to see the event from different perspectives, and to recognise the wider organisational or external influences (Ashby, 2006; Taylor, 2010). Some models help the practitioner to explore the event through the use of broad questions, e.g. Gibbs' (1988) reflective cycle (Figure 4), and others provide a comprehensive framework of cue questions, e.g. Johns' (1995) model of structured reflection (Figure 5). Which model an individual uses is ultimately a personal choice and may be dictated by preference, by the level of experience with performing RP, or by the complexity of the event being explored. Models are only there to provide guidance however, and are not meant to be the ‘rules’ of reflection. As such, RVNs should be encouraged to develop a flexible approach to the use of a model of reflection and utilise the parts that are most useful (Heath, 1998).
Methods of reflection
There are many ways that one can utilise RP within veterinary nursing, both individually and in a group context. Informal and formalised opportunities for reflection occur regularly within practice, often without being recognised as such (Table 1).
| Individual activities | Group activities |
|---|---|
| Writing in a journal or diary | Tearoom discussions |
| Annual appraisal | Rounds/handovers |
| Reviewing clinical case notes | Team meetings |
| Mentoring others | Mortality and morbidity rounds |
| Reviewing complaints | Critical incident analyses |
| Reading a journal article | Significant event analyses |
| Undertaking continuing professional | Journal clubs |
| development activities | Clinical audits |
Personal reflection can be successfully performed through keeping a journal, which is a collection of handwritten or electronic notes built up over time recording one's thoughts, observations and experiences. It is personal to the practitioner and can enhance learning through the action of writing and critically exploring experiences (Gillis, 2001). To make the best use of the journal, each entry should end with conclusions, things learned, and an action plan of things to implement (Gillis, 2001). Table 2 describes some examples of what might be included in an action plan.
| Action identified | Ways to achieve/implement |
|---|---|
| Learning needs (knowledge/skills) | Reading |
| Practice protocols/guidelines | Find and evaluate the evidence |
| Additional resources | Purchase equipment/materials |
| General staff training | In-house |
| Clinical audit | Measure processes or outcomes |
A journal can be kept using a two-phase process (Ashby, 2006):
The challenges to RP
Although widely reported to be a beneficial practice, critical reflection can cause practitioners to start questioning long-established belief systems, which can create strong feelings within the individual and make them less satisfied with the way practice is carried out (Driscol and Teh, 2001). The novice practitioner may end up feeling negative or overly critical about their performance, or experience a range of negative emotions (Driscoll and Teh, 2001). RP can also present many personal challenges, and Bolton (2014) described the different blocks and limitations that can occur:
Different strategies can be employed to overcome these negative feelings and challenges. A mentor, critical friend, or group who participates in guided reflection can be very beneficial to provide support and encouragement, to maximise learning in the novice practitioner, and to provide constructive feedback (Platzer et al, 2000). It is also important that the environment in which the reflection is conducted is inclusive, supportive, non-judgemental, and confidential (Platzer et al, 2000).
Conclusion
Reflective practice may help RVNs tackle the complex and difficult aspects of practice, to identify facets of themselves that can be improved, and understand more completely the organisations they work in (Bulman et al, 2012). However, despite the published benefits of RP, the author could find no published qualitative or quantitative research describing its use in the field of veterinary nursing. There have been many barriers and perceived constraints to RP identified in other professions including a lack of skills or knowledge of the process, limited time within the working day to conduct the process, lack of power to implement any changes identified, and a fear of judgement if reflections are to be shared with others (Driscoll and Teh, 2001; Heath, 1998; Pierson, 1998). The author would propose that similar barriers currently exist within veterinary practice. There is a need to legitimise reflection and for organisations to regard it as an important and intentional activity, rather than something that is done in an adhoc way. Managers need to understand that reflective activities can and should be part of routine clinical practice and allot appropriate resources to help support its action (Driscol and Teh, 2001). The proposed CPD changes by the RCVS may help to encourage its uptake and encourage RVNs to utilise RP for professional development. However, for this change to be fully embraced, the concept of RP and the benefits to practice that it can provide need to be fully understood by everyone within veterinary practice. For this to occur opportunities to increase knowledge and skills in RP need to be made available. This could include inclusion within pre-registration and post-registration education, publications within the veterinary literature, CPD activities, and research to evidence the benefits to VN practice. The biggest barrier to RP is undoubtedly oneself, and if an individual has a positive attitude towards the process then it will be successful (Caldwell and Grobbel, 2013).