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Journal of Child Health Care Review : Reflective growth and professional development: an ABC approach for the novice reflector
J Child Health Care 2001; 5; 163 DOI: 10.1177/136749350100500405 The online version of this article can be found at:

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Association of British Paediatric Nurses

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Indeed consumers of health care expect nothing less than this from health care professionals and contemporary nursing rightly demands it from us. this can be difficult and takes time to learn (Burns & Bulman. This is crucial to valuing reflection as a legitimate way of knowing. that does not leave you. Having used reflection both formally on courses and informally as part of my personal development for many years. to express the discipline adequately. nurses are being encouraged to evaluate and evidence learning. Thankfully it is no longer acceptable to become qualified in a domain of nursing and do nothing else to evidence knowledge and understanding over your career trajectory. I had arrived in the USA with pre-. From a personal perspective. Reflection is worth the effort. It also provides a permanent record of my experiences should I wish to utilise them at a later date. In a sense I had to acknowledge the negativity and judgmental opinions that were impacting on my perception of the experience. The UKCC guidelines on mandatory PREP (2001) demands a nursing profession who can evidence analysis of personal growth and development. growth and professional development: an ABC approach for Reflective This step guide acknowledges.portrays the exquisite sensitivity of the art and science of nursing&dquo. Having been invited to observe both roles on ward rounds and ’nursing hand-over’. &squf. This in turn insured a much deeper. originally published in the Journal of Neonatal Nursing. observations. conceived ideas about advanced neonatal nursing practice and the role of respiratory technicians in neonatal intensive care. Indeed an open culture is being encouraged both by government and nursing in which all practitioners should feel able to question their practice (UKCC. has been developed to enable children’s nurses who are novice in the art of reflection. The nursing profession is increasing its emphasis on assessment and competency (UKCC. thoughts and feelings in a diary. I undertook a fast track programme.REVIEW the novice reflector SUMMARY &squf. I kept a record of my experiences. I recently had some study leave in New England USA.. I do acknowledge however from both personal and professional experience. Ways of knowing. once mastered. Watson (1990) believes the articulation of nursing knowledge through the medium of personal reflection enables an understanding of the lived experience of health. &squf. However. not solely to act as a catalyst for formal or informal analysis of experiences but as Lumby (1991) highlights it contributes towards the development of a language of nursing.75) states: &dquo. All rights reserved. my views had to change. KEY WORDS: Reflective practice. 2001). learning from experience in by Catharina Widiartini on November 8. Johns. much needed. reflecting on this experience. 2000. for nurse practitioners in primary care. Reflective frameworks. SAGE Publications.. For example. richer analysis and feedback to my students and peers on return to the UK. As one example.sagepub. &squf. . illness and caring for all those touched by the experience. A language that Palmer et al. The step guide has been developed to enable novice reflectors to develop skills in reflective dialogue and writing. facili- 163 Downloaded from http://chc. (1997 p. I would like to assure you at the outset reflective practice is a skill. WHY REFLECTION? This step guide. Not for commercial use or unauthorized distribution. Language of nursing. 1998). experience or position to develop skills in reflective writing and dialogue (Crathern. whatever their grade. in another context. 2001). than any other time in nursing today more history. 2000). 2007 © 2001 Association fo British Pediatric Nurses. Nurses need guidance in this approach to learning more about themselves and the domain of nursing as for many it is a challenge to more formal modes of learning.

less so what went well. Palmer et al. It must also be noted that the framework is there as a guide (see figure 1). Johns. the role of the nurse has a potential to conflict with the traditional medical practitioners role in primary care. initially for the novice reflector. However it also permits a cycling between levels. It was certainly a learning experience for my American tutor who eventually accepted my need to submit a reflective journal as part of my portfolio of evidence. as the description is read aloud you can begin to help unpick the issues with the learner that will promote growth and development in their practice. Aitkins and Murphy. 2000) has been encouraging nurses for almost 20 years to learn from positive experiences. is truly rewarding. By revisiting all the things. it can be difficult knowing which one to choose. As a beginning reflector. sadness. either verbally or written. yet this experience was enriched by an ability to articulate the language of nursing within that context. at the very least it demands you begin by harnessing those experiences in which you have personally been moved by emotion such &dquo. conceptual frameworks are not meant to be static. It could be argued in this clinical situation. The model demands increase in intensity and level of reflection as each step is achieved. SAGE Publications. It can and does develop over time and with practice. frustration. The reader may choose to analyse those referenced in some detail before embarking on a framework that suits personally. It can be adapted further as you become more skilled at reflection. they should be dynamic and open to change.. acknowledges as you progress. However. 1994. The steps to reflective growth presented in this guide are an attempt to adapt a number of models into one eclectic structured framework for reflection. 1993.&dquo. argues writing down these experiences enables you to return to it and focus on the situation in a ’new light’. This happened because both the GP and myself valued a shared dialogue through reflection about the care delivered to patients and their lived experience of health and both of us acknowledged alternative ways of knowing to the dominant perspective. In essence they all require an element of self awareness. Benner (1984. elation. I do however acknowledge if learning from reflection is to be more than a ’naval gazing’ exercise or ’conversation without a purpose’ then nurses need very clear and unambiguous guidance in this approach to learning more about themselves and the domain of nursing. he stated: &dquo. There is also an expectation that it will inform future practice to enhance you personally and ultimately the many domains of nursing. at the same time profound and simplistic. Boud et al. client(s) and others touched by the experience. It is important to note that not all beginning reflections may progress to level C with immediacy. a developmental growth anger. events that make up the experiences’ contextual form you will learn what is key to you personally (Burns & Bulman. 1978. In doing so it is hoped more complex models have been simplified and the least complex given some depth to analysis and adaptation. Facilitating a novice reflector to move through all three steps. You can enhance the process by linking up with a mentor who already has skills in reflective dialogue and writing.. 1993. This is even more so when you meet up with a nurse who is initially very sceptical about the value of reflection and over time can appreciate its value as a learnas ing tool. even though it was not mandatory for the course.Emotion tells you where the learning is to be had. as validated in the USA! I accept not all nurses would have a passion for reflection as I have just described. in my perception. WHAT TO REFLECT? How do you know what to reflect on? This is a question I am often asked by learners who are sometimes overwhelmed either by the richness of clinical experiences or perceived ordinariness of ’day to day’ practice. the next step is approached. it is not just about waiting for a ’critical incident’ to happen to you. However reflecting on what makes us feel sad is also important and should not be ’buried’ for fear of emotion. 2000). it is best facilias Durgahee (1992) 164 Downloaded from http://chc. conflict. culminating in a deeper understanding of clinical practice and theoretical by Catharina Widiartini on November 8. research and importantly self that impact on your new or enhanced way of knowing in that particular situation. A few years ago I heard David Boud. 1985. this person can be crucial in enabling you to see the ’wood through the trees’. . In my experience nurses are only too ready to reflect on what went wrong in a situation. the experience and make sense of the situation for yourself. 1998) respond to a similar question. in doing so it ordinary experience extraordinary! Importantly. and find it difficult to single out individual experiences as particularly relevant. Johns. for the very reason it is a challenge to more formal ways of knowing. Not for commercial use or unauthorized distribution. an ability to articulate.tated by a Health Care Institute in Boston. as you learn more about theories. I begin by asking learners to write a description of an event or situation that has personal meaning. 2000). joy. It points to things impoYtant. All rights reserved. USA. observe their growth and development in their ability to articulate experiences and learn from them. knowledge of prior experience on the situation. each of the steps in the ABC approach (Crathern. 1998) gets bigger than the last (see Figure 1). one of the key writers on reflection. people. having facilitated reflective learning for nine years and observing nurses grow in their personal and professional lives listening to them articulate primacy of caring. This is represented pictorially by entering at step A ’small’ and exiting at step C much taller. when presenting a seminar at the University of Leeds (March. Mackintosh (1998) argues against the value of reflection in enhancing competency. It is also a skill in making the initially ’perceived’ WHICH REFLECTIVE FRAMEWORK? There is an abundance of reflective frameworks and guidance in nursing literature that seeks to explain the process of reflection (Carper. Johns. stating there is little concrete evidence to support it as a learning tool. This permits a return to the situation with a new perspective on the knowledge therein. 2000. Gibbs. I will never forget this response as it is. I struggle with this argument. 1988. 2007 © 2001 Association fo British Pediatric Nurses. However.sagepub. indeed it has its many critics.

Not for commercial use or unauthorized distribution. confusing problems defy technical solution. A timely example of this could be a neonatal nurse applying Step B Now you are beginning to analyse events critically. I spend a lot of time and effort initially with learners on a work based learning module enabling them to ’see’ that evidencing their every day practice. asking what sense you can make of the experience. particularly for an assessed element in course work. HOW TO REFLECT? Before embarking on the ABC steps to reflective growth framework Boyd et al. it will become a process of gradual self .agreed ground rules and as a result reflection and dialogue is facilitated in a supportive and safe environment where personal knowledge is explored. some of it messy and defying technical rationalisation (Schon. this is the real world.awareness. It would be unethical for me to leave these nurses feeling raw and exposed in this situation as a result of lecture led content. at or around the time of birth. Fitzgerald (1997) does caution that it can appear easy and something you can be sent off to do. For someone who is grounded in a more formal experience of learning this may well be the first stumbling block! Write a description of the experience. as a group of neonatal nurses we have come to learn. The irony of the situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large. Step A Here it is useful to remember Boud’s trigger to reflection. it can unearth feelings of unease from prior experiences either in our professional or personal lives. is an increasingly difficult part of the nurses role in supporting families appropriately. that celebrating the joy of a surviving sibling and sadness of the death of another sibling simultaneously with a family. Indeed Johns’ (2000) recent writings reflect that concern also. This is practice. Therefore time is allocated to this aspect of the learning. being honest about the role of self and others on the experience. This personal knowledge is key to reflection. requires commitment and intellectual effort for the process to work. access a child nursing programme leading to part 15 on the Professional Register (see box 1 for suggestions for reflective evidence) This type of reflection is of course much more formal and would need to be verified through clinical supervision and preceptorship. As more families opt for interventions to succeed in pregnancy I have come to learn this is an inevitable aspect of caring and needs addressing in the module content. prior experience of learning. In the swampy lowlands. ask what are the key issues within this description I need to attend to (John’s 9th edition 1993). All rights reserved. In essence this example helps articulate Boud’s comments on emotion telling you where the learning is to be had and what is important. managing conflict or stressful situations. 1987) is of value as a way of knowing. Nevertheless once embarked on. which creates and clarifies meanings in terms of self and results in a changed by Catharina Widiartini on November 8. &dquo. What to reflect on in the real world of children’s nursing may also have implication for further study when a portfolio of evidence is required to accredit practice. that which has stirred the emotions. Think about how any previous experiences have an impact on the present e. acknowledging personal experiences as valid learning. She articulates through dialogue with patients and nurses the real world of nursing and the dilemmas faced with intimacy.tated with an experienced mentor. where in the swamp lies the problems of greatest human concern. You must however have an awareness to the potential for learning. On the high ground manageable problems lend themselves to solutions through application of research based theory and technique. SAGE Publications. critical appraisal of the social world and transformation. attending to the social milieu (environment). . An important aspect when you progress to step B. 2007 © 2001 Association fo British Pediatric Nurses. (1985) define reflection as a dynamic process that involves internally examining and exploring an issue of concern. through our reflections in the classroom. (See Figure 1 for more detaail of each step). in line to with your unit manager. Schon (1987 p. It is also crucial to link up with a senior paediatric nurse from a children’s unit who could verify your experiences to include in your portfolio. Boud and Walker (1990) refer to aspects of this as enframing. with . This concern is triggered by an experience.sagepub.g. dealing with death and dying. messy. For example. hard ground overlooking a swamp.3-4) writes on learning from personal practice: &dquo.&dquo.In the varied topography of professional practice there is a high. touch and personal space. I have facilitated a module on neonatal attachment and loss for almost nine years now and its content still has a huge impact on some nurses who rediscover feelings they may have suppressed over time. nurses have a wealth of knowledge emeshed in the ’swampy lowlands’ that are messy and do demand exploration and articulation. When embarking on reflection you must be prepared for the fact that it is not necessarily comfortable and. The 165 Downloaded from http://chc. becoming a student again. Lawler’s (1991) wonderfully illuminating text ’Behind the Screens’ in which she explores the problems of nursing ’the body’ is testimony to this. it is by definition different to more formal academic learning but no less valid and it can help you focus on what theory you may need to develop understanding of to support critical analysis of events..

Asking difficult questions and being sceptical of routine and ritual. I believe. is key to becoming a reflective practitioner. Benner P. it may include insight into ones own behaviours and assumptions as well as effect of self on others. personal. should change your personal perspective. thoughts. empirical. Step C When critically analysing all components of the situation it is important to acknowledge existing scientific or theoretical knowledge which influences what has happened. Journal of Advanced Nursing.g. it demands a connection with the patient and family. acknowledging the grasp of meaning we have on the particular. Lastly ethical knowledge explores understanding of moral issues and dilemmas in practice. SAGE Publications. sometimes on a daily basis. feelings and behaviours. Murphy C. recognises the unique and subjective knowing.difficult thing to do alone is to be aware of negativity judgemental opinions that impede growth in reflection. 166 Downloaded from http://chc. It is the beginning of empowerment and emancipation through critical awareness (Emden 1991). A review of the literature. It also requires intellectual effort for this process to work. Personal knowledge refers to knowledge that is useful for self. It is this aspect of knowing. Within children’s nursing there are at times sources for profound moral conflict and potential human suffering that health care professionals and families are exposed to. Excellence and Power in Clinical Nurs- ing Practice California: Addison Wesley. Briefly and simplistically empirical knowledge refers to the factual. Not for commercial use or unauthorized by Catharina Widiartini on November 8. aesthetic. in particular. (for a detailed exposition refer to the original paper). family. Aesthetic knowledge underpins the art of nursing and encompasses the thoughts. Reflection that is rigorous and supported by a framework. I find as a facilitator it is key to open up discussion on this aspect in order to foster growth and honesty. Somemost tut Has it changed my way of knowing? and times nurses need space to come to terms with their own negativity and judgemental thinking and actions. . resources? Be aware of negativity and judgement colouring your thought processes. so important for Step C. prior experience.sagepub. Johns (1993) asks: 0 Could I have dealt better with the situation? N What would be the consequences of other choices? 0 How can I now make sense of this experience in the REFERENCES Aitkins S. Again utilising Johns’ (1993) questions ask: N What was I E Carper (1978) describes four ways of knowing. others I work with? 0 How did I feel about experience when it was happen- ing ? 0 How do I know how others felt? 0 What external or internal factors affected my decision making e. trying to achieve? did? Why did I act as I 0 What were the consequences of my actions for patient. staffing. in a sense a ’getting to know’ at a deeper level. 2007 © 2001 Association fo British Pediatric Nurses. helps articulate the language of nursing. All rights reserved. ethical. actions and beliefs. should change or enhance your ways of knowing since it causes you to reflect on your self. scientific knowledge. 18 (8): 1188-1192. It requires exploration and challenge of assumptions made and imagining or suggesting alternative ways of dealing with the situation. (1993) Reflection &mdash. light of past experience and future practice? (1984) From Novice to Expert. It is hoped this ABC guide will encourage you to articulate and evidence the rich and varied world of children’s nursing and in some way transform your thinking that will by definition have to impact on the wonderful and unpredictable world of the domain we call children’s nursing. easily verified.

Bulman C. Schon D. (1987) Bass Educating the Reflective Practitioner. SAGE Publications. Keogh R. 167 Downloaded from http://chc. 6 Johns C. (1992) The knowledgeable doer. An ABC by Catharina Widiartini on November 8. Burns S. Towards a Discipline in Nursing. 18: 553-557. pp. (1990) Making the most of experience Studies in Continuing Education. (1985) (Eds. In: Gray G. Fitzgerald M.Benner P.11-30. (2000) Reflective Practice in Nursing. Turning Experience into Learning. A Guide to Teaching and ods. Pratt R. Becoming a Reflective Practitioner. (2001) PREP and You.) Reflection. 2007 © 2001 Association fo British Pediatric Nurses. 63 -84. United Kingdom Central Council. (1998) Steps to reflective growth. 1: 9- Boud D. Walker D. London: Kagan Page Boud D. (1998) Reflection: A flawed strategy for the nursing profession. Mackingtosh C. Learning Meth- (1990) Caring knowledge and informed moral passion. 12 Emden C. Melbourne: Churchill Livingstone. Oxford: Blackwell Science. pp. (Eds) Reflective Practice in Nursing: The Growth of the Reflec- Carper Lumby J. (1998) Seminar on reflective practice University of Leeds Boud D. 11 Crathern L. (1997) Reflective Practice in Nursing. Further Education Unit. UKCC Publication: Register 35 tive Practitioner. Bulman C. Advances in :13-23. Not for commercial use or unauthorized distribution. (2000) The wisdom of 32-37. Oxford: Blackwell Science Gibbs G. Senior Nurse. supervision. Johns C. In: Palmer A. Bulman C. Melbourne: Churchill Livingstone. Durgahee T. (10): caring practice Nursing Management. (1991) Threads of an emerging discipline. 12 (2): 61-80. (1991) Becoming a reflective practitioner. 461-484. Walker D. Nursing Science. (1988) Learning by Doing. (1991) Behind the Screens: Nursing Body. pp. Burns S. Nurse Education Today. Journal of Neonatal Nursing. (1978) Fundamental patterns of knowing in nursing. Nursing Science. (1997) Theories of reflection for learning. (2000) Lawler J. Melbourne: Churchill Livingstone. 4 (6): insert. Journal of Nursing Management. Advances in :13-23. In: Gray G. San Francisco: Jossey &mdash. (5): 42-44. Cosmology.sagepub. Oxford: Blackwell Science. (1993) Professional 18. . Oxford Polytechnic: Oxford. Palmer A. 1 Acknowledgement: An earlier version of this paper first appeared in the Journal of Neonatal Nursing (1998) Watson J. Towards a Discipline of Nursing. Oxford: Blackwell Science. All rights reserved. Pratt R. Burns S. the Problem of the B.