Reflective practice is a core component of nursing. While this can be difficult to define, Jarvis (1992) considers it to be the process of channelling thoughtful practice to learn from situations. There are calls for all nurses to establish positive ‘reflection behaviours’ to improve self-care and ensure that they are better prepared to understand their own strengths and weaknesses (Robinson, 2020). Concept analysis of reflective practice in nursing, advocates for the use of reflection and self-awareness strategies, and the development of different methods that seek to improve reflection before, during, and after clinical experiences (Patel and Metersky, 2022). The Specialist Community Practitioner (SCP) and Specialist Community Public Health Nursing (SCPHN) programmes lead to a recordable qualification and advanced skills. These equip practitioners to lead the delivery of high quality and safe care, and help exercise higher levels of decision making (Nursing and Midwifery Council (NMC), 2001; 2004). SCP/SCPHN students are required to demonstrate and provide evidence of their learning in practice by completing a practice evidence tool (PET). Within the PET document, students must include several reflective accounts to validate their learning in practice and relate to the Nursing and Midwifery Standards for Specialist Practice, to demonstrate competence in practice (NMC, 2001; 2004). The academic team developed a new method of delivery to support reflective practice and evaluated how these were received by students.
Background
Strategies, such as reflective practice and compassionate leadership, are of great importance to positively change behaviour and are regarded as social, moral and economic priorities (Bailey, 2021). Compassionate leadership refers to the creation of structures that promote a healthy containment of anxiety and support for individuals to channel positive and adaptive responses when faced with challenging experiences in practice (de Zulueta, 2015).
An NHS survey (Picker Institute Europe, 2020) indicated that 44% of staff reported feeling unwell due to work-related stress, alongside a decline in mental health (Patel et al, 2021). A Royal College of Nursing (RCN) (2020) survey noted 76% of nurses believed their personal stress levels had increased, leaving them at risk of burnout. Another possible cause of these elevated stress levels was the increased isolated working as a result of the social distancing measures that community nurses had to follow during the COVID-19 pandemic (Queen’s Nursing Institute (QNI), 2020; Public Health England (PHE), 2020).
The QNI (2021) Strategic plan 2021—25 identified that there have been fundamental changes to the demographics in healthcare since 2020. These changes are thought to be caused, in part, by the COVID-19 pandemic, along with an ageing population with progressively complex health needs, insufficient staffing levels and no limit to caseload capacity (NHS, 2019; McKinless, 2020). Consequently, the approach and pace of healthcare services, as well as the work delivered is almost unrecognisable from pre-pandemic levels, putting extra pressure on the workforce to deliver care (Patel et al, 2021).
Introducing reflective cafés to Specialist Community Practitioner and Specialist Community Public Health Nursing students
Reflective teaching sessions are a core component of SCP/SCPHN programmes. Therfore, the academic team developed the notion of the ‘reflective café’ as its pedagogy. These sessions supported students to develop reflective skills through reflective learning activities and debriefing opportunities. Students are encouraged to share, pragmatically critique and learn from reflective stories (over coffee) in a supportive and confidential environment. Previously, students would engage in clinical supervision aligned within their own Trusts and formal reflective sessions were taught in the university setting, with learning outcomes focusing on models of reflection and portfolio documentation.
A total of three sessions, spanning the full academic year, were integrated into the current university programme. Students from community child nursing, school nursing, health visiting and district nursing, were all present and invited to each session. The groups were initially divided to incorporate individuals from all fields, but students were free to circulate during the sessions to discuss their own experiences with others. The second and final sessions allowed students to group themselves into smaller discussion groups and time was provided for students to have individual discussions. Practice assessors (PAs) and practice supervisors (PSs) were present to help maximise the use of this opportunity. Sessions were scheduled as half a day, but extra time was allocated and tutors were made available to address any problems or provide emotional support, should this be required. Common ground rules were established during induction of the programme for all adjoined group sessions. These rules helped the reflective café become a confidential and safe space to learn.
The first session introduced reflective practice, by process of a group workshop session between student and tutors, with some taught materials. This was staged in a relaxed open teaching space, which revisited and explored reflective models and the students’ underpinning baseline knowledge.
Sessions on reflection
At this session, the importance of integrating reflection within the practice portfolio document to support the evidence base for the NMC SCP/SCPHN competencies was launched. The second session gave a clear direction on the methods of reflection that the students could adopt. These were in the form of storytelling, digital reflections by using visual video recordings, verbal narratives or PowerPoint presentations, and aimed to encourage creativity. Examples of these formats were demonstrated to the students, and academic staff also took the opportunity to engage in reflection via recordings, along with the above methods to illustrate how reflection through different formats can be achieved. The final session of the ‘trilogy’ aimed to improve resilience through the medium of reflection and included the tutors, students, PAs and PSs. Inviting PAs and PSs promoted collaboration with NHS practice partners and ensured commitment to the focus on student wellbeing.
Studies have demonstrated that facilitating workplace learning and reflection during nurse education can empower nurses to develop their capabilities and contributes to exceptional patient care (Jantzen, 2019;Walsh et al, 2020). This is something the academic team strive for—to equip SCP/SCPHN students with skills that ensure lifelong reflection and the ability to support others.
A local college specialising in health and beauty were invited to provide complimentary treatments to create a holistic environment, conducive to personal interaction. This was a mutually beneficial arrangement and a welcome face-to-face addition, particularly after the months of isolation during the COVID-19 pandemic. The health and beauty students offered hand and nail treatments, massages and hair styling— all, in a relaxed environment. Areas in the university used for student events were commandeered for the final session to provide privacy and facilitate the necessary equipment to enable therapies to take place. There was no specific reference to the health and beauty interventions during the evaluation, but the team aims to include this in future evaluations.
Aim
To gather information and data to understand the usefulness of the reflective café as a technique to support the process of reflecting on practice. The team would adjust and build on aspects identified by students that worked well and looked at modifying areas that were not well-received.
Method
A questionnaire was used to evaluate the effectiveness of the reflective café teaching sessions for the SCP/SCPHN students to consider teaching and content. An online questionnaire was developed with 10 short questions that aimed to identify the value of the reflective café in relation to students’ learning. Students were sent the anonymous survey link via a block email. The Likert scale—a useful tool for application in the field of social sciences, psychology and nursing, was used to simplify the data collection and guide the questionnaire statements to enable positive or negative responses (Likert, 1932; Pimentel, 2019).
The participants were students enrolled on the SCP/SCPHN programmes in the 2021/22 academic year, there were 34 students comprising of 15 district nurses, 4 community children’s nurses and 15 SCPHNs. A total of 32 students completed the questionnaire, giving a response rate of 94%. Such a high response rate infers that the data represents the views of the whole cohort. The reasons for such a high response rate could have been because students were encouraged via an email reminder to complete the online survey; they were also encouraged to complete this at the SCP/SCPHN annual conference. In addition, the speed and ease of completing the online survey via a website link would have also helped.
Results
Students were asked to rate the statement ‘I enjoyed the reflective café sessions’. Some 72% of students either agreed or strongly agreed, while 6% did not enjoy the sessions and 22% neither agreed nor disagreed with this statement. No student strongly disagreed (Figure 1).
The online survey did not allow for additional narrative; therefore, it is impossible to identify what students enjoyed or did not enjoy about the reflective café sessions. A recommendation to the team is to develop an online questionnaire to gain greater information from the 2022/23 cohort of SCP/SCPHN students.
A total of 92% of students responded positively to the statement ‘ my ability to reflect deeply was enhanced following the reflective café sessions’. Most students indicated their ability to reflect deeply was enhanced either by a lot or by a moderate amount. Only two students did not feel the sessions made any impact to their reflective ability (Figure 2). Without any additional narrative, it is difficult to clarify how students’ reflective abilities were enhanced.
When asked if ‘ the ability to reflect is a key component of specialist practice’, all but one student either agreed or strongly agreed. No student disagreed with this statement. This reinforces the value of supporting reflective practice within the SCP/SCPHN programmes. Thinking about the reflective café sessions, no students felt there were too many built into the SCP/SCPHN programmes. Most students felt the number of sessions was correct. However, eight students felt they would have benefited from additional sessions. The team will consider this feedback for next year and facilitate additional ‘drop in’ sessions and increase online content for students who may benefit from further support.
The next statement asked to be rated was: ‘ Content within the reflective café sessions were relevant to my level of study’. This is an important consideration, given that both level 6 and level 7 students are taught together on the SCP/SCPHN programmes. Some 84% evaluated the content of the reflective café sessions as relevant, while four students neither agreed nor disagreed with the statement, and one student disagreed (Figure 3). Without any additional information, it is difficult to determine if the student who disagreed with the statement felt the content was above or beneath their level of study. This question will be expanded for evaluation of the reflective café in 2022/23, either with a narrative box or with the inclusion of an additional question to determine this.
When asked the statement: ‘Did you attempt a different format for your reflection, for example, video?’, three students indicated they attempted a different format for their reflection; this can include audio, video, a collage or anything creative that would enable students to demonstrate their learning and competence in practice through reflection. Only three students attempted a different reflective format. The team will consider strategies aimed at increasing the number of students attempting a more creative approach to their reflections for the coming academic year.
Of the three students who attempted a different format for their reflection, two found the process either easy or very easy. One student indicated they found this neither easy nor difficult. This result provides limited information to the team due to the low response rate. It may be that students who did not attempt a different format for their reflection perceived the process to be difficult. Interestingly, 96% of students felt there was enough guidance and information made available to help them produce a different format for reflection. The team will consider what might be preventing students from attempting a different reflective format if they feel enough support and guidance is made available.
Question 8 asked students to consider if reflective practice can aid staff well-being and resilience. All students either agreed or strongly agreed that reflection on practice can aid staff well-being and resilience.
When asked if the reflective café sessions have prepared them to support junior staff with their reflections, 91% of students agreed, while 69% indicated that the reflective café sessions had prepared them either a great deal or a lot (Figure 4).
Discussion
Reflective formats
How a professional reflects is crucial to learning, as it evolves from this process (Dewey, 1963). Reflective models are known to help guide the process of reflection and there are many to choose from, along with different interpretations. Choosing the right model to guide reflection is key, as it needs to be a good fit, not only to support reflective learning styles, but also the subject being reflected upon, acting as a tool to bridge the gap between theory and the world of clinical practice (Choperena et al, 2019). Arguably, in addition to choosing the right reflective model, the format used to present a reflection is of equal importance and it is suggested that it can make the difference between deep or superficial learning (Urstad et al, 2018). If deep learning is to occur, students should be given the creative space and freedom to not only choose a model of reflection to guide their reflective process, but also the freedom to choose a format to present it that best suits their learning style (Schwind, 2008). Formats for presenting a reflection can include, but are not limited to, digital storytelling, poems, picture collages; videos, PowerPoint presentations; and voice recordings.
Digital storytelling describes a simple, creative process through which people with little or no experience in computer filmmaking gain skills needed to tell a personal story/reflection. The evaluation established that a low number of students attempted a different reflective format, despite the support available. However, the results did not differentiate between the alternative formats used and therefore, cannot be explored further. Nonetheless, there is strong evidence to suggest deep learning occurs following students’ involvement in digital reflective activities (Sandars and Murray 2009; Christiansen, 2011; Goldingay et al, 2018). Digital storytelling, for example, can be a powerful transformative and reflective experience for students. Marin et al (2017) found that it enhanced student learning and enabled them to develop new and differing perspectives, while Urstad et al (2018) found students reflected deeply, effectively integrating theoretical perspectives into reflective accounts. Similarly, Paliadelias and Wood (2016) described how reflective storytelling enabled student nurses to make sense of their experiences and develop a greater understanding of the theory underpinning practice. Digital reflective activities also enhance students’ digital literacy skills, enabling them to realise and appreciate the importance of information and communications technology in practice (Clarke and Adam, 2012; Marin et al, 2017; Coggin et al, 2019).
Poetry can also be a powerful medium to present a critical reflection, particularly when students are reflecting on emotive and stressful events (Jack and Illingworth, 2017). However, poetry writing does not follow a reflective model and this has potential for the reflection to be contemplative, rather than truly reflective (Whitehead, 2002). Nevertheless, students enjoy the creative freedom associated with poetry writing, and, as a result, report personal and professional growth (Jack and Illingworth, 2019). Similarly, students in Sanders’ (2022) study enabled them to see situations from new perspectives and found the production of a reflective collage to be both therapeutic and enjoyable.
Employing a different format for reflection can help support students who struggle academically. By using a more creative format to present their reflections, students are able to focus less on their language and sentence structure and more on their experience and learning (Goldingay et al, 2018; Urstad et al, 2018; Jack and Illingworth, 2019). It is argued that not only does this increase student enjoyment in the activity, but also enhances learning (McLeod et al, 2015) and, therefore, is a useful strategy to employ. Nevertheless, students felt that the reflective café and the methods of reflection used had helped them to reflect more deeply.
Reflection: supporting resilience
The poor mental health and wellbeing of staff is a significant issue present throughout the NHS (2019). Therefore, it is imperative that the SCP/SCPHN programme team continue to support students to develop their reflective skills, with the aim of building resilient practitioners. Resilience is a key developmental area for SCP/SCPHN students; as aspirant NHS leaders, they will be expected to support staff and improve personal wellbeing and efficiency (Chada, 2018). Studies indicate that although resilience is often considered an innate characteristic, some think that cognitive attributes can be taught, and the adoption of behavioural techniques and evaluation of challenging situations may provide opportunities to learn and grow resilience in the workplace (Jackson et al, 2007; Chada, 2018;). Furthermore, reflection in nursing is a mandatory requirement for revalidation for the NMC (2004).
This evaluation found that all students felt this teaching strategy supported resilience in practice. With growing pressures of jobs and responsibilities, it could be argued that reflection is necessary as a tool for resilience (Thomas and Asselin, 2018). For example, reflection permits individuals to revisit episodes of care, incidents and good practice. By using structured reflective models, it can break down the event into categories that can support decision-making, leadership and give direction on how to move forward in job roles (Finley, 2018).
Using reflection as a tool for resilience is important for practitioners, as this gives time to process the event safely and effectively. This may be done individually, where the practitioner can reflect during their working day and look at prioritising their tasks, organising themselves and thinking about what the next steps are. This helps them feel in control when the task may be overwhelming. Alternatively, reflection with peers groups during a supervision session may be beneficial, as this shares practice and promotes a supportive team (Williams and You, 2021).
For SCPHN/SCP students, using reflection can strengthen confidence in a new role, and may also spark questions or ideas about future working. This can inspire students and facilitate a good working relationship with their supervisor/assessor. This, in turn, can equip students for prospective roles by enhancing the learning experience and increasing their confidence (Wareing at al, 2018).
Supporting nurses to reflect
Reflection on practice is anticipated from an undergraduate level, moving into qualification and is critical in improving communication, clinical abilities and personal confidence (Kim et al, 2018). The questionnaire highlighted that the students felt more prepared to support junior staff in practice after attending these sessions. The NMC requirements for revalidation feature reflection to encourage a sharing culture, which seeks to improve care (NMC, 2021). However, Hunter and Cook’s (2018) study focused on professional socialisation for new graduate nurses, observing that role modelling and a ‘hidden curriculum’ was significant in the formation of professional identity. Therefore, the skills learnt from assessors and supervisors can shape the inclusion of reflection in nurse practice. This may uphold the notion that reflection is essential to practice effectively. A curative, biomedical framework devoid of emotion can mean nurses are at risk of losing themselves emotionally (Hendricks-Thomas and Patterson, 1995; Smith, 1998). Strategies such as self-regulated learning models, can support teaching and learning to reflective clinical reasoning, while team-based interdisciplinary learning can foster positive professional behaviours and active learning styles, in addition to theoretical models that support reflective processes (Kuiper and Pesut, 2004; Oldland et al, 2017). The assumption that once qualified, nurses know how to constructively reflect should not be made. On the contrary, reflection is a lifelong journey and further education is required to ensure this message is passed on to students (Lubbe and Botha, 2020; Grech, 2021). A structured learning plan endorsing reflection, such as the ‘reflective café’, is known to prepare students for higher level of clinical practice and the transformational leadership required for the specialist practitioner qualification (Ginger and Ritchie, 2017).
Limitations
The sample size was small but the volume of students on the SCP and SCPHN programmes were fewer. An online survey did not allow for additional narrative. Therefore, it is impossible to identify what students enjoyed or did not enjoy about the reflective café sessions. The multiple-choice element meant that there was little scope for narrative to gain a deeper understanding behind the reasons for the responses.
Recommendations
Exploration of the alternative formats used by other students for reflection would be helpful to establish if these approaches can encourage other students who favour traditional methods. Further recommendations are to continue the partnership with the local college to ensure that holistic treatment and wellbeing events are maintained. There is opportunity to evaluate students’ experiences of such wellbeing events and the potential benefits they have had of combining holistic treatments to enhance reflective practice. Collaborative working must be valued beyond the university setting, with networking between other organisations. The introduction of NHS practice partners to the sessions was vital to upskill the clinicians assessing and supervising students on other modes of reflection that they may not have used themselves, thereby creating an inclusive environment. Overall, a further qualitative study is necessary to give students scope for expansion on their answers and gain a deeper understanding of how to improve prospective sessions and participant experiences.
Key points
- Evidencing reflective practice is a vital part of Nursing and Midwifery Council proficiencies for Specialist Community Practitioner (SCP) and Specialist Community Public Health Nursing (SCPHN) students
- SCP/SCPHN students recognise the value of reflective practice and other methods can encourage deeper reflection
- The use of innovative educational approaches can help SCP/SCPHN students develop and sustain reflection on practice
CPD reflective questions
- Consider the current methods of reflection you currently use to support your practice. Do you consider a reflective model the key to deeper reflection in practice?
- What support structures are needed to support positive ‘reflective behavours’ in clinical practice?
Conclusion
This evaluation reinforces that the reflective café sessions are an invaluable addition to the SCP/SCPHN programmes. It is also recognised that reflection remains an essential tool to support nurses in their role and can be used to enhance their practice, which links to better patient outcomes. The correlation between reflection and wellbeing is evident, and the reflective café offers an opportunity for community clinicians to develop positive reflection habits to share as best practice with others.