The study, carried out by Victoria University of Wellington nurse researchers, involved analysing 54 reflective essays written by 27 graduate nurses during their nursing entry to practice (NETP) programme.

The research team, led by Professor Jo Ann Walton, said the analysis shed light on the experiences of new graduates and showed that the reflective essay was a “powerful tool” for helping both new graduates (and their lecturers) to learn from clinical practice.

The analysis also backed other researchers who found that new graduates find it “challenging to deal with their own emotional reactions, to stand up for themselves and their patients,to feel part of the team, and to ask for help (which they fear may signal failure)”.

“We suggest that there is scope for more focus on emotional labour, resilience, and professional composure in programmes leading to nursing qualifications,” said the researchers. “Arming new graduates with these skills would ease their transition into a workplace where emotional work is core.”

The researchers identified five key themes (see below) and shared examples illustrating these themes from some of the graduates’ reflective essays.

For example Clare identified a situational challenge ­ that required her to regain her composure and draw on both personal and professional attributes:

It was a typical busy afternoon. I went in to the patient’s bedroom to take

a set of observations. I noticed his breathing appeared laboured and a slight

decrease in consciousness. I had a bad ‘gut feeling’ about the situation. I

called over a nursing colleague and the nurse in charge to assist with my

assessment.

At the time I was feeling anxious, I was not sure how I was going to

objectively describe the slight change nor did I know how to explain my ‘gut

feeling’ to the nurse in charge. I was feeling worried because if I did not act

quickly he may rapidly deteriorate. I knew at that point I was stressed. I

remember my face feeling hot, palms sweaty, thoughts becoming disorganised

and feeling like I just wanted to cry. I knew I needed a minute to

compose myself and so I stepped out of the room while the nurse in charge

waited for me to handover my assessment. I took two deep breaths and wiped

away the tears. I walked back into the room with a smile on my face and

spoke to my nursing colleague, nurse in charge and patient in a concise, kind

and succinct manner.

In another example Lucy reflected on the situational challenge of dealing with a very distressed client with an intellectual disability and her own inexperience in dealing with the distressing verbal assault:

This experience was so emotionally challenging that it shook and tested

my whole philosophy as a genuinely kind and caring nurse. The insults were

extremely derogatory and against my cultural values. I resented the patient

and knew I definitely had disengaged with the patient. I was feeling and

thinking like a victim and not the nurse that I knew I was. 

Through my training I learnt that a good nurse needs to know when to

ask for help. I had to ask for assistance from my mentor who advised administering

a depot [intramuscular injection] to settle the patient for safety

reasons. After the incident I had a good talk with my preceptor which made

me feel better. My colleagues said I had looked defeated, so maybe the client

had noticed as well and responded negatively. It also helped when my colleagues

gave me their maximum support by validating my feelings, sharing

similar experiences and checking on me regularly to give me breaks. I wish I

had talked to them sooner. 

In a third example a pressured new graduate Paula gets spoken to abruptly by charge nurse manager (CNM) after Paula intervened to stop a patient being discharged:

I felt uncomfortable and embarrassed, as she had belittled me, my nursing

practice and rationale in front of the wider multi-disciplinary team

(MDT) who are my professional colleagues. The CNM made me feel as

though I was doing an inadequate job, when in fact I knew I was delivering

safe, kind and patient centred care. 

When discussing the situation privately with a fellow nursing colleague, I

learnt that this outburst was not personal towards me or my nursing practice.

I was able to better understand the ward culture and I felt more positive that

my nursing practice was not inadequate. In hindsight, I realise I could have

requested the RMO (doctor) to review the patient’s pain and whether they

were (ready) for discharge earlier. I had not done this due to the pressure he was also

put under to complete discharge paperwork. I also should have discussed the

concerns I had with the shift coordinator. This could have prevented the

situation from arising, as the coordinator and CNM communicate (about) where

patients are regarding their discharge.

The researchers concluded that their analysis showed the reflective process worked and could be used as a “means of unearthing students’ concerns” and helping them understand what they had done well, could have done differently, why something arose and how to handle challenging events.

“It can be used as a means to bolster their confidence, and to discriminate between personal success (or failure) and systemic strengths and weaknesses,” said the team.  “It also provides teachers with rich data on which to build discussions, support students and aid them in their transition to fully fledged professionals.”

FIVE KEY THEMES

• Individual attributes: personal and professional strengths and weaknesses;
• Professional behaviour: actions such as engaging help and support, advocating for patients’ needs and safety and putting their own feelings aside;
• Situational challenges: like communication difficulties (both systemic and interpersonal) and the pressure of competing demands;
• Rewards: the results graduates experienced, such as achieving the nursing outcomes they desired;
• Reflection as a useful tool: graduates commenting on how reflection has helped them.

Source: Jo Ann Walton, Natalie Lindsay, Caz Hales & Helen rook. Glimpses into the transition world: New graduate nurses’ written reflections.  Nurse Education Today. (published online prior to print publication in 2018)

The aims of cultural safety education have remained unchanged since its inception nearly 25 years ago.

The Nursing Council of New Zealand’s guidelines say the aims are to educate student nurses and midwives to “examine their own reality and the attitudes they bring” to practice relationships, to “demonstrate flexibility in their relationships” and to “evaluate the impact of historical and social processes” on populations.

In their 2014 book How to nurse, Canadian nurse scholars Gwen Hartrick Doane and Colleen Varcoe observe that self-knowledge helps us to change the way we think about others, ourselves and society so that our practice can be responsive to the complexity of patient need.

Over the last two years we have been researching student ways of knowing (epistemology) and our learning and teaching strategies when teaching cultural safety in a Bachelor of Nursing degree. In the module called ‘Social Context of Nursing in Aotearoa New Zealand’ we aim to help student nurses to widen their perspectives and think about how they develop and use knowledge.

Following a pilot study in 2013 we undertook a second piece of research analysing student reflective journals. Our participants were first year, second semester nursing students who generously agreed to share their online reflections at the end of the semester.

Mastering reflective practice takes time

It is important to remember that mastering the skills of reflection (see table 2) takes time and will develop with perseverance. In the process of reflecting we can learn to see ourselves, our thinking and behaviours in new ways; we can learn to question our taken for granted understandings of ourselves and others and importantly the ways in which power affects our relationships. A significant finding from our research was the importance of using reflection as a way to support learning and develop self-awareness, an important aspect of cultural safety practice.

For many of our students using reflection for the first time early in their degree was hard and frustrating. However, developing good reflective writing techniques and understanding the relevance helped them to make sense of the material they were presented with in class.

We suggested a number of frameworks to help make the process clearer, as using defined frameworks helped students to stand back from their experiences and critically analyse them for new understandings or views.
There are multiple explanations of what reflective practice is and a number of models can be used. In our research we noticed that using Professor Graeme Gibbs’s Reflective Cycle (1988) framework, though sometimes helpful at the beginning, became limiting as the semester progressed as it forced students into simplistic evaluations rather than true analysis.

Writing a description of an event or a response to something new or different is the beginning point of reflection and that needs to be followed by analysis of feelings. Getting a grasp of the feelings evoked in a situation is very important to the reflective process. The next stage is to think more deeply about the knowledge that has informed your point of view and how this might impact on what you do or think. All this helps to develop self-knowledge.

See the boxed ‘Reflective practice scenario’, which outlines an imagined scenario and how a student might reflect on it using the ‘What’, ‘So What’, ‘Now What’ model outlined in table 2.

Reflection can deepen understanding

The quotes below are from the student journals in our research that demonstrate how students have used the reflective process to deepen their understanding and shape their practice.

• I realised that I must step out of my own “zone” in order to view other important waves (perspectives) in situations that I may face as a future nurse. (Kim)
• I felt I was trying to place pieces of a zig saw [sic] puzzle together at the beginning of this semester. It took me days of deep thinking to be able to write my first reflection regarding my own culture. (Felicity)
• A sound knowledge of who I am, and my own culture helps me to relate to people with similar values and beliefs. Being aware of my own thoughts and feelings also helps me to know how I will react in certain situations, and gives me the ability to take a professional approach rather than a personal one. (Henri)

Developing reflective practice is essential to many of the professions that aim to work with people effectively and has become a significant aspect of nursing practice. It can be framed as a way into considering accountability, verifying ability or noticing development or as a critical process that involves thoughtful analysis and increased awareness of self in relation to others and context.

In this article we have focused on the process and skills of developing reflective writing to support practice. Our next article, based on our research, will develop the connection between self-awareness and practice. ✚

Authors:

• Katrina Fyers MA, RGON, is a senior academic staff member at the Centre for Health and Social Practice, Wintec.
• Sallie Greenwood PhD, MSocSci, RGN, is a principal academic staff member at the Centre for Health and Social Practice, Wintec.