BACHELOR OF NURSING SCIENCE WITH HONOURS (BNS)

SEMESTER SEPTEMBER / YEAR 2021

NBNS 3603

REFLECTIVE THINKING AND WRITING

MATRICULATION NO : 910305135954001

IDENTITY CARD NO. : 910305135954

TELEPHONE NO. : +6 016 874 7818

E-MAIL : tracellia53@oum.edu.my

LEARNING CENTRE : JOHOR LEARNING CENTER

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CONTENTS PAGE NO

1. INTRODUCTION 3

2. TYPES OF REFLECTION 4

3. SKILLS HELPFUL FOR REFLECTION 5

4. GIBBS’ REFLECTIVE CYCLE MODEL IN REFLECTIVE WRITING 6

5. WRITER’S REFLECTIVE JOURNAL 7-9

6. CONCLUCSION 10

7. REFERENCES 11 - 12

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Introduction

Reflection has gained increased recognition in recent years as an important component of professional
nursing practice as well as an educational strategy for acquiring knowledge and learning through practice.
(Asselin & Fain, 2013; Kim, 1999; Perry, 2000). Reflection is commonly defined as the deliberate process of
critically thinking about a clinical experience that results in the development of insights for potential practice
change. (Asselin & Fain, 2013). Recent research suggests that pauses may prolong nurses' reflective thinking
and that they may require assistance in moving insights to practice change in a systematic manner. (Asselin &
Fain, 2013; Asselin et al., 2013). As a result, continuing education in reflection and reflective practice is seen as
a means of improving professional practice, promoting evidence-based practice, and potentially improving
patient outcomes. Reflection, as an educational strategy, allows nurses to explore clinical experiences and the
thoughts and feelings that come with them, allowing for a shift in beliefs and assumptions, the emergence of
new knowledge, and the transformation of clinical practice. (Asselin & Fain, 2013; Dube & Ducharme, 2014;
Horton-Deutsch, 2012; Johns, 1995; Perry, 2000). Reflection is the cornerstone of professional nursing practice.
Through reflection, nurses are able to make meaning of experience (Hartrick, 2000), connect theoretical
knowledge to the context of clinical practice (Jenkins, 2007), develop fresh insights, and modify clinical
practice (Bailey & Graham, 2007). There are few empirical studies that investigate the use of reflection as an
educational strategy in the context of nursing professional development. Because there is a scarcity of empirical
evidence, we should take a closer look at how we are currently using reflection in nursing professional
development and what outcomes are being reported.

The House of Delegates of the American Nurses Association approved a resolution in 1974 to establish
an Accreditation Program for continuing nursing education (CNE). Early CNE standards were heavily focused
on process measures. Educational activities were frequently designed solely to improve knowledge, and
evaluation was primarily based on learner satisfaction. Credit for CNE participation was only given if
knowledge was gained from the educational activity.

In this writing, the writer would reflect on a continuing nursing education (CNE) session that was
attended by the writer and their experience based in a reflective journal.

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Types of Reflection

Valli (1997) identifies 5 types of reflection: technical reflection, reflection-in-action and reflection-on-action,
deliberative reflection, personalistic reflection and critical reflection. One of the famous quotes by Donald A.
Schon: “The reflective practitioner allows himself to experience surprise, puzzlement, or confusion in a
situation which he finds uncertain or unique. He reflects on the phenomenon before him, and on the prior
understandings which have been implicit in his behaviour. He carries out an experiment which serves to
generate both a new understanding of the phenomenon and a change in the situation”. Schon’s (1983) work
places great emphasis on reflection-in-action and reflection-on-action in his publication on character and
development of professional development. Just like the writer in this writing, it will be further explained on the
2 process of said reflection.

1. Reflection-on-action (after-the-event thinking)

This type of reflection entails carefully replaying events from the past in one's mind. A focus is being
placed on identifying negative aspects of personal behaviour in order to improve professional
competence. This would entail saying things like, "I could have been more effective if I had acted
differently" or "I realized that I acted in such a way that there was a conflict between my actions and my
values."
2. Reflection-in-action (thinking while doing)
This type of reflection entails acting as a participant observer in situations that provide learning
opportunities, paying attention to what you see and feel in your current situation, and drawing
connections to previous experiences. Take, for example, attending a ward meeting and fully
participating in what is going on. Simultaneously, a 'fly-on-the-wall' part of your consciousness can
accurately observe what is going on in the meeting. (Cowan, 2012).

As a nurse, the writer has to reflect on the following sequence such as what, so what, and now what?

 What - What happened? What did I do? What did others do? What was I trying to achieve? What was
actually achieved?
 So what - So what is the importance of this? So what more do I need to know? So what have I learnt?
 Now what – Now what do I need to do? Now what different options have I got? Now what will be the
consequences?

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Skills Helpful for Reflection
According to Wigglesworth (2016), there are 5 essential skills for each nurse to reflect on their actions. The
following are:
1. Self-awareness
It entails an honest examination of how a situation affects an individual and how the individual affects
the situation (identifies nursing practice not individuals).
2. Description
This requires the ability to recognize, recall, and accurately describe significant events and key
features/events, including feelings or thoughts of an experience, as well as to provide an account of the
situation. Describe what occurred. Make no judgments or draw any conclusions.
3. Critical Analysis
This pertains to examining the components of a situation, identifying existing knowledge, challenging
assumptions, and imagining and exploring alternatives to a situation.
4. Synthesis
This skill refers to the integration of new knowledge with previous knowledge in the move towards a
new perspective. It is used to solve problems and to predict likely consequences of actions.
5. Evaluation
This involves in making value judgement involving the use of criteria and standards. What was good
and bad about the experience?

In order to write a reflective journaling, one can include clinical context, a detailed description of the
situation or incident and not the people involved, what you were thinking and feeling during and after the
incident, whether you believe your intervention made a difference in client outcome either directly or indirectly
by helping other colleagues, what you learned in that situation, and references to demonstrate evidence-based
practice.

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 Gibbs’s Reflective Cycle Model in Reflective Writing

Figure 1: Gibbs Model of Reflection (Source: Gibbs, 1988)

Gibbs (1988) describes the reflective cycle as being made up of several components: description, feelings,
initial evaluation of the experience, critical analysis, conclusions and final evaluation and action plan. Gibbs’
reflective cycle emphasises the obligation to deal with both “description of the events” and feelings in order to
be able to continue to the “implication” and “action plans”. One can use the following trigger questions to write
a reflection.

Trigger questions:

1. Description: What happened? Conclusions, simply describe

2. Feelings: What were your feelings and how did you react? Again, do not move to analysing these yet.
3. Evaluation: What was good or bad about the experience? Make value judgements, concentrate on
evaluating the way the experience made you feel and react.
4. Analysis: What sense can you make of the experience ‘situation’? Bring in ideas from outside the
experience to help you. What was really going on? Were other people’s experiences similar or different
to yours? In what ways? What themes, if any, seem to be emerging from your analysis?
5. Conclusion: What have you learnt from reflecting on this experience? In general – what can be
concluded in a general sense, from these experiences and the analysis you have undertaken? Specifically
– what can be concluded by your own specific, unique, personal situation or way of working
6. Action plans: What are you going to do differently in this situation next time? What steps are you going
to take on the basis of what you have learned?

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Illustrations:

In the midst of Covid-19 pandemic, learners around the world have had to adjust their learning process and
it was carried out online in the wake of the COVID-19 pandemic. As a nurse, I am no exception towards this
new concept of “new normal”, especially in educating myself by attending CNE online. CNE helps me by
brushing up on my essential skills; learn about new healthcare procedures as well as keeping myself up with
technological changes. Recently, I have attended an online CNE course conducted by the department of nursing
education and development in the hospital I worked in the city of Singapore. The CNE topic was the 5 rights of
medication administration to inpatient warded patients. As a Malaysian nurse who just recently moved and
work abroad, this topic has given me the desire to learn more especially when the local patients I give the care
and treatment for are more advanced and knowledgeable as a patient. The locals are more specific and detailed
in the treatment that they are receiving for, and they are more likely recognized their own rights as patient.
Other than that, there certain standards that I have to maintain in order achieve a standardize practice or
standard of practice (SOP) and also professional standards of care. As professional, I have to be responsible and
be more alert in carrying my position as a staff nurse towards my patients.

Regardless of the care setting, administering medications to my patients is part of the plan of care in my
nursing practice. Medication administration safety standards are more important than ever in today's healthcare
environment, with ever-expanding nursing roles and practice settings, a wide range of medication classes,
newly created and off-label drugs, and the use of multiple medication therapies per patient. Critical thinking
must be thoroughly and consistently integrated into this area of practice to avoid medication errors and maintain
professional standards of care. Medication administration should not be centred solely on the technical aspects
of drug handling and dispensing. This medication administration CNE course is intended to help most nurses,
including myself, to establish best practices in medication administration safety through the development of
multifaceted critical thinking skills. Nurses will be able to recognize all factors influencing medication
administration safety, as well as prevent negative patient outcomes, with these skills. As a result, I've chosen to
reflect on this because drug administration error is a preventable occurrence.

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Reflections:

1. Descriptions

The first stage of Gibbs’ Model of reflection requires a description of events. In early month of September, I
was invited to attend a CNE conducted by the nursing education and development department in my hospital.
During the CNE, I listened to the speaker in full concentrations on how to administer a drug to a patient
followed by the rights of medication administration. This moment, when the speaker talked on one of the rights,
which is right education, I had realized that on a variety of occasions where many a time, most my patients
were not informed about the action and the side effects of the administered drug.

2. Feelings

The second stage is a discussion about my thoughts and feelings. Here, I felt unjust towards my patients as they
have not given the rights to know their own medications. Once the speaker had mentioned on one of the first
medications’ rights – patient’s rights, this has made me feel guilty and also self-conscious. The speaker also
questioned if any of us nurses had been doing such action, and he started randomly asked the audiences to
which he pointed at me. That time, I became even more aware of feeling guilty and at the same time feeling
under pressure as I did not want to feel like I have failed to be a good and responsible nurse.

3. Evaluations

Evaluation is the third stage of Gibbs model of reflection and it requires the reflector, which is me, to state what
was good and bad about the event. At this point of time, I am now aware that the 5 rights of medications and
three times checking are essential and as a nurse in all units, I should follow the protocol for drug
administration. But still, explaining the action and side effects of the drugs to my patients were not a usual
practice in my unit.

4. Analysis

Stage four of Gibbs is an analysis of the event whereby it encourages me as the reflector to make sense of the
situation. I will do this by perceiving the speaker’s key points and looking at the evidence underpinning it. The
reflection in practicing explaining to patient is very useful as it helps us nurses to go through the steps or
protocol in administering the drug. At the same time, reflection on practice where I check back whether all the
steps in the protocol are followed would help me in preventing a drug error on the next occasion. In the CNE,
the speaker mentioned that medication error occurs at the stage of prescribing, transcribing, dispensing, or
administration of a drug. The prescribing error includes incorrect drug, error in quantity, and prescribing a
contradicted drug. The second type of error occurs when there is a transcription error which is unclear
handwriting of the nurse, spelling mistake, misconception of the drug name, and over confidence in calculating

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dosage, the third type is dispensing error. This occurs primarily with drugs that have a similar name or
appearance, wrong dose, wrong drug, or wrong patient e.g., Lasix (Frusemide) and Losec (Omeprazole).
Dispensing errors can also occur with look-alike and sound-alike drugs. The fourth type is administering error.
Discrepancy occurs between the drug received by the patient and the drug therapy intended by the prescriber.
Errors of omission when drug is not administered incorrect administration technique and the administration of
incorrect or expired preparations and deliberate violation of guidelines are examples of administering errors. In
the CNE, I have learnt from experience and through experience.  Following this CNE, I will now practice to be
more attentive and cautious during administration of medications in the ward.

5. Conclusion
As a conclusion, after attending the CNE, I am able to identify implications beyond 5 rights which assist in
meeting medication administration safety standards, and define my role in critical thinking and reasoning in
medication administration. Besides that, I am able to recognize the role of utilizing the nursing process in
maintaining best safety practices in regard to medication administration and state the necessary nursing actions
required to safely administer medications in any care-giving situation or location as discussed by the speaker
during the CNE.

6. Action plans
Within my action plan, my aim is to research further into the theory of using reflection on practice and
reflection in practice for the rights of drug administration in view to prevent the four types of error prevention
and management. I am also planning to have a discussion with more senior, experienced nurse or nurse in-
charge in my unit on the subject of Corrective Action and Preventive Action (CAPA).

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Conclusion

Reflection is the deliberate process of thinking critically about a clinical experience in order to develop
new insights and transform clinical practice. Reflective educational strategies combined with the presentation of
clinically relevant knowledge, mentoring, and other educational strategies, which are frequently nested within a
multifaceted educational program, stimulate learning in practice and improve readiness for the application of
new knowledge in the clinical setting. Structured reflection and facilitated group reflective dialogues allow
nurses to go deeper into their exploration and reach a higher level of thinking. According to the findings,
reflection has an impact on clinical practice at both the individual and organizational levels. Reflection
improves knowledge, transforms assumptions, values, and beliefs, and informs clinical practice at the
individual level. Reflection empowers nurses to investigate practice concerns and drive practice change at the
organizational level. Although reflection is valued as a method of learning through practice, more empirical
evidence is required to support its use as an educational strategy. Using this reflective model will help you
realize that learning is something you must do on your own. Furthermore, in practice, reflection is an important
learning tool. Keeping a journal of patient care experiences will assist nurses like me in learning how to
administer medications in accordance with all rights. To sum, reflection provides a method to explore all forms
of nursing knowledge such as Empirical knowing (what knowledge informed me in this situation? What
additional information did I need?) Personal knowing (what were my thoughts and emotions in this situation?
To what extent was I concerned for the person?) Aesthetic knowing (what was I trying to achieve? Why did I
respond as I did? How are others feeling and how did I know this), and Ethical knowing (did I act for the best?
what standards were relevant in this situation?) Engaging in reflection is very individualized and learning to be
reflective takes practice. In this writing, Gibbs’ reflective cycle was used to write a reflective journal for the
writer where the method emphasises the commitment to deal with both “description of events” and feelings in
order to be able to continue to the “implications” and “action plans”.

(2770 WORDS)

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