centred and that patients are enabled to act in partnership
with you (Williams, 2002). This concept introduces the
notion of critical reflection that follows.
Critical reflection
Although reflection is seen as a required skill for all nurses and
midwives, some advocate that reflection must also be critical
in order to enable the nurse or midwife to understand empow-
erment and promote change (Crowe & O’Malley, 2006).
Critical reflection
uncovers the dynamics of power in a rela-
tionship and critically questions the sociocultural assumptions
in practice (Brookfield, 1995). This level of reflection is based
on
critical social theory
, an important theory that has influ-
enced contemporary education, nursing and midwifery, and
which advances the belief that no social phenomenon can be
understood in isolation from the cultural, historical, economic
and political context in which it exists. In more recent times,
researchers have applied critical social theory to research
methods such as action research (Schneider et al., 2013) and
practice development (Manley, McCormack &Wilson, 2008).
These methodologies enable us to identify and redress
inequities related to unequal power relations more specifi-
cally related to our everyday lives. The following is one
model of critical reflection.
Reflective techniques
Now that we have explored the basics of reflection, we will
review a number of techniques that you can use as part of
your own reflective practice. There are a range of
reflective
techniques
that can be used to meet the needs of individuals
and groups of practitioners. Developed by a number of theo-
rists, these techniques vary in their depth of reflection and in
their complexity. They can involve a guided approach or may
be part of a creative process in which free thinking enables
the individual to focus on the elements of the situation that
was of most importance to them. Reflection can be under-
taken as an individual activity (self-reflection), or can be done
with a companion (mentoring or clinical supervision). It can
also occur as a group exercise such as in practice develop-
ment, when techniques such as active learning groups are
used (Manley, McCormack & Wilson, 2008).
Reflecting alone helps you to build confidence in reflective
processes and to focus on self (an important component of
self-awareness). Teekman (2000) discusses this kind of self-
reflection and highlights the significance of self-questioning
as a reflective technique. Asking yourself such questions as
‘What has happened?’, ‘Am I doing the right thing?’ and
‘Could this assist me in structuring my thought processes and
in making meaning?’ can assist in highlighting gaps.
However, this technique does have limitations, especially
in the level and intensity of reflection, and in the level of
challenge we provide for ourselves. One type of reflection
that may be undertaken either alone or as part of a group is
critical incident analysis
. In Chapter 14 you will learn how
to apply a clinical reasoning framework to a patient situa-
tion, thinking through the situation in order to come to a
247
Chapter 13 Thoughtful practice: Self-awareness and reflection
clinical judgement and decision that will then lead to a par-
ticular action. This is a forward-thinking process for a
situation that is still in development. Critical incident analy-
sis is the opposite. It is a retrospective reflective process that
examines a situation that has already happened, in order to
learn from the situation and so improve on individuals and
systems in the future. In the following section on critical
incident analysis, Table 13-1 shows an example of Stephen-
son’s framework applied to a clinical situation.
Critical incident analysis
In practice, reflection is often triggered by a particular event
in which an error or omission in care is encountered by you
or by others. These ‘critical’ incidents do not necessarily
result in harm for the patient, although there may be the pos-
sibility of adverse effects. However, critical incident
analysis offers real potential for learning from such events.
The following scenario demonstrates how critical incident
analysis and critical reflection may be applied.
Jenny Smith, 38, has been given an intravenous
dose of antibiotics that she was not prescribed. This has
resulted in a drug error being recorded on the incident
file, and has activated a reflective practice session in the
ward. This session has provided staff with the opportu-
nity to reflect on the event, to ask questions about how
and why it occurred, to think about any knowledge
deficits that may have contributed to the incident, and to
reflect on future action. Gillian, who administered the
drug, completed her degree six months ago and had
been working on the ward for one month when
the incident occurred.
Table 13-1 includes some examples of the type of reflec-
tive questions that will enable Gillian to uncover what
happened and why, and to learn from the incident. While this
learning is attributed to the three aspects of reflective practice,
you can see that the types of question overlap and that the
learning in one section applies to each component of reflec-
tive practice. (You might find it helpful to read the section on
critical thinking in Chapter 14 before starting this exercise.)
You may find that sharing reflective techniques with a
fellow student, colleague, mentor or supervisor helps you to
increase your level of reflective challenge and develop your
critical questioning techniques as a skill that you can use in
your clinical practice. Working with another person, espe-
cially one who is more experienced in reflective practice,
can help you to find meaning, uncover contradictions and
challenge assumptions in order to develop new insights
about the situation and a higher level of understanding
(McBrien, 2007). Examples of this type of reflection are
mentorship and clinical supervision. These two reflective
techniques and group reflection will now be discussed.
Mentorship
The benefits of guiding reflection through mentorship have
been acknowledged by many advocates of the practice.
