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Assessing practice through reflection

Gaynor Mabbett
BSc(Hons) MSc RGN RM
Lecturer in Public Health and Primary Healthcare
Swansea University

The complex nature of nursing patients in the community setting requires that district nurses have the ability to consider many alternatives and possible solutions in providing care that is context specific. The importance of context in the delivery of care cannot be overemphasised. Decisions about patient care include consideration of an individual's and family's lifestyle, their socioeconomic circumstances and the environment. Added to this is the nurse's knowledge and skills, cognitive, psychomotor and affective attributes, all of which are crucial components in effective decision-making.
As Bechtel et al emphasise, critical thinking skills and mechanical skills are integral to nursing, where one is reliant on the other in providing safe, effective care.(2) Assessing the technical and scientific aspects of nursing without considering the artistic and humanistic aspects such as empathy and attentive listening can reduce nursing to a series of tasks. The complexities of practice, which were described by Donald Schon as the "swampy lowlands", mean that competency in practice requires all of the above, as assessing isolated competencies (such as injection giving) in such situations could be seen as reductionist and limited.(3) The challenge for assessing district nurses for specialist practice was therefore to provide them with an assessment that would prepare them for higher-level practice in the context in which they worked.(1)
Johns writes that reflective practice enables practitioners to confront, understand and work towards resolving the contradictions within practice between what is desirable and actual practice, the consequence of which should be the acquisition of new knowledge.(4) Benner suggests that expert nurses develop personal knowledge of nursing over time and that this knowledge can be applied to inform new situations.(5) Put more simply reflective practice is a process where nurses are able to identify gaps in their knowledge, skills and competence as well as to confirm their knowledge, skills and competence. Jasper suggests that maintaining reflective accounts of our experiences has therefore the potential to promote critical thinking.(6) Reflective practice can also act as a catalyst for growth and can develop student autonomy in promoting lifelong learning. These ideas were congruent with the team's beliefs about adult learning where students would be encouraged to integrate previous learning with new learning to provide new perspectives in developing their practice to a higher level.

A process approach
Within our own curriculum the lecturing team developed a tripartite approach to assessing practice where the student, the lecturer and the community practice teacher all had responsibility for the student's learning. Students were required to reflect on a two-weekly basis and complete eight reflective accounts related to practice situations. Students were expected to consider how their competency had developed in relation to the following role attributes: the promotion of learning, support and involving users, judgement and decision -making, and teamworking. These broad role attributes were developed from the original standards identified by the UKCC.(7)
Students were therefore expected to identify what they had learned as well as providing an action plan as to how they could develop their practice further. The eight reflective accounts were process driven, that is they had to be completed at certain points throughout the course. This approach was formative but fundamental as a method of assessing the student's competence over time. It therefore provided an opportunity for the student and the community practice teacher to evaluate together the student's strengths and weaknesses, and indicate where the student needed to improve. In addition, students, their community practice teachers and individual lecturers met up regularly in college and in the student's clinical placement to undertake reflective sessions.
The college sessions were multidisciplinary, where shared learning with community mental health students, health visitor students and community children's nursing students provided a valuable contribution to each other's learning. The process enabled students to consider different solutions to problems from the perspectives of the other professionals in the group, as well as helping students consider a multidisciplinary approach to care, which included a better understanding of each other's roles.
The summative assignment included two 4,000-word reflective essays to be submitted at the end of the course which gave an account of the whole process of how the student had developed throughout the course. Competency to practice was verified by the community practice teacher.

Promoting reflective learning
After many years of teaching and facilitating reflective practice I agree with Taylor, who writes that it takes time and effort to undertake reflection and to develop the skills to reflect.(8) In my experience some students will readily engage in the process whereas others will find the process problematic. The difficulties appear to arise from students finding difficulty in applying theory to practice and practice to theory, including analysing their feelings and beliefs in practice situations. Scholes et al suggest that students with academic and professional maturity are more able to develop their personal experiences of nursing and see this evolving through their writing; whereas those students with less experience and rudimentary theoretical knowledge find it more difficult to make the connections between theory and practice.(9) It is important therefore for lecturers to be mindful of these issues when supporting students and to consider the student's stage of development in their career. I have found that attributes such as being more open to learning, self-awareness and flexibility were helpful for engaging in reflective work. Having a supportive and skilled community practice teacher was also seen as essential in developing the student's skills.
I agree with Snadden and Thomas, who identify that some students write what their assessors want to read, as the work is dependent on them passing the course.(10) Reflection as an assessment strategy in these situations can reduce its relevance as a learning tool.
Harris et al suggest that students can also be reluctant to use personal incidents if they are problematic or difficult, despite the fact that these incidents trigger real learning.(11) Ethical issues of privacy and confidentiality must also be assured in relation to the reflective content as the entries could become censured.
Another important aspect in writing up reflective accounts is concerned with the student's cognitive (thinking) skills where some students are better than others in recognising the relevance of the practice situation in relation to their learning needs. Some students are also more able to recognise their feelings, which makes it easier for them to analyse what influences the outcomes of caring experiences.
In order to promote the students' reflective skills they were introduced to a variety of reflective models and frameworks. Students particularly found Christopher Johns' cue questions in conjunction with Carper's "fundamental ways of knowing in nursing" helpful in developing these skills (see Box 1).(12) Johns' cue questions were useful during reflective sessions with their community practice teacher and Carper's model provided a philosophical underpinning to their written work. It is important also that students and community practice teachers are given clear guidelines on the process and purpose of the assessment strategy and on the assessment itself.

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As a team of lecturers we provide ongoing support for the students and community practice teachers. This includes community practice teacher preparation before the commencement of the course, particularly for new community practice teachers, and ongoing reflective sessions as described above. Regular feedback for the students is essential in relation to the process of reflection with their peers and community practice teachers and in relation to their written work.

Conclusion
District nurses are confronted with demanding and complex problems on a day-to-day basis that are not amenable to off-the-shelf solutions. The role of educationalists and community practice teachers is therefore to develop competency in district nursing students that includes skills of critical analysis. Having a critical approach to practice situations promotes problem solving skills that are essential to effective decision making. From the lecturing team's perspective the use of reflective practice as an assessment strategy has been helpful in developing students' ability to be critical of their practice from an aesthetic appreciation of the different situations they are faced with in community nursing. There will always be some students who find reflection difficult; therefore it is important to assess the student's level of attainment in relation to their career development. Ongoing support over time is therefore essential in enabling students to develop academically as well as professionally.

References

  1. NMC. Standards for specialist education and practice. London: NMC; 2004.
  2. Bechtel GA, Davidhizar R, Bradshaw M. Problem based learning in a competency - based world. Nurse Educ Today 1999;19:182-7.
  3. Schon DA. The reflective practitioner. London; Temple Smith; 1983.
  4. Johns C. Becoming a reflective practitioner. Oxford: Blackwell Publishing; 2000.
  5. Benner P. From novice to expert. California: Addison-Wesley; 1984.
  6. Jasper M. Nurse Educ Today 1995;15:446-51.
  7. UKCC. Standards for specialist education and practice. London: UKCC; 1998.
  8. Taylor BJ. Reflective practice. A guide for nurses and midwives. 2nd edition. Maidenhead: Open University Press; 2006.
  9. Scholes J, Webb C, Gray M, et al. Making portfolios work in practice. J Adv Nurs 2004;46:595-603.
  10. Snadden D, Thomas ML. Portfolio learning in general practice vocational training - does it work? Med Educ 1998;30:148-52.
  11. Harris S, Dolan G, Fairbairn G. Reflecting on the use of student portfolios. Nurse Educ Today 2001;21:278-86.
  12. Johns C. Framing learning through reflection within Carper's fundamental ways of knowing in nursing. J Adv Nurs 1995;22:226-34.