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Journal of Orthopaedic Nursing (2006) 10, 4955

Journal of Orthopaedic Nursing

www.elsevierhealth.com/journals/joon

Using reection in everyday orthopaedic nursing practice


Josephine Moloney RGN, B.Sc(Hons), HDip Nursing Studies (Orthopaedic Nursing) Staff Nurse a, Sinead Hahessy RGN, BA (Hons), MA (Soc Sc) Lecturer in Nursing Studies b,*
a b

Croom Orthopaedic Hospital, Co. Limerick, Ireland Centre for Nursing & Midwifery Studies, National University of Ireland, Galway, Ireland

KEYWORDS
Reective practice; Orthopaedic nursing; Casting information

Continuing professional education


As orthopaedic nurses and healthcare professionals we provide care to individuals with neuromuscular and skeletal disorders and injury that requires a specic body of knowledge to ensure high quality. Such knowledge is acquired, maintained and advanced through lifelong learning in practice and research. Articles included in this section aim to provide you with a sound knowledge base and help meet some of the professional, organisational and

individual demands of being a safe and competent orthopaedic practitioner. Examples of how this may be achieved and possible evidence for inclusion in your professional prole are given throughout the article. Other ways to demonstrate your continuing professional development (CPD) may be to:  Use the article as a vehicle for your own reections and subsequent personal or professional development of orthopaedic practice.  Use aspects of this article to help you become more condent in situations where you need to present your professional development ideas to others in a more formal way.

* Corresponding author. Tel.: +353 91 524411x2012. E-mail address: Sinead.Hahessy@NUIGALWAY.IE (S. Hahessy).

1361-3111/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.joon.2005.11.001

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Summary Saylor [Nurse Educator 15(2) (1990) 811] considers the ability to reect as an imperative component for the development of competency. This paper highlights the benet of reection as demonstrated by a student undertaking an orthopaedic nursing programme, at higher diploma level. It will demonstrate that by using reection as a learning tool the progression from the level of experienced practitioner (at point of entry to the course) to procient practitioner (at point of departure) can be developed (Benner, P., 1984. From novice to expert. Excellence and Power in Clinical Nursing Practice. Addison-Wesley, California). c 2006 Elsevier Ltd. All rights reserved.

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50  Use this article as an agenda or discussion item with a manager or in a meeting to consider ways of promoting practice development in orthopaedic nursing.  Approach a colleague or other signicant person (perhaps in education) to support you becoming more involved in promoting an evidence base for the way you and your team work in practice.  Keep a copy of this article together with the notes you make as evidence of completing reection items from the text.

J. Moloney, S. Hahessy overlook the power of intuition in guiding practice. Nurses are often unaware of how they know something, or why they do something in a certain way. This intuitive knowledge is less ambiguous when documented or verbalised. Reecting on ones practice, it allows the practitioner to make the knowledge learned, explicit and tangible. Reection is not a new concept. It dates back to the time of Aristotle who mentions its use in his work on practical judgement and moral action (De Botton, 2000). Dewey (1933) is thought to be one of the rst and most inuential educational theorists to explore the process and product of reective thinking. He believed that reective thinking arose from situations of doubt, hesitation, perplexity, and or mental difculty, which encouraged the person to search, hunt or inquire to nd material that will resolve this doubt (Teekman, 2000). Dewey (1933) acknowledged the importance of past experience for reection and argued that ideas and suggestions are dependent on retrospection, as they do not arise out of nothing.

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Introduction
The concept of reection has emerged as a means of learning from experience and has gained signicant momentum in professional practice in an era of increasing accountability and professional development. Most notably, practice based professions such as nursing have been heavily inuenced. Despite the varied approaches, reection ostensibly enables nurses to look at actions, thoughts and feelings (Newell, 1992) and is considered to be a means of learning from practice. Learning from practice from this perspective is the cornerstone of professional development and it is a vital component of sustaining professional growth (Gustafsson and Fagerberg, 2004). If practitioners do not challenge their practice there is a danger that practice will become habitual or ritualised (Carper, 1978; Andrews, 1996). The following reective account acknowledges this component of clinical nursing reality that so often presents contradictions and tensions in daily practice. The experience of utilising the reective process in educational practice can contribute to a sense of ownership of established knowledge for nurses as they undertake the accumulation of new knowledge thus bridging the theory practice gap in a creative and experiential manner. The paper also addresses the specialist nature of orthopaedic nursing knowledge and demonstrates that during a reective account this experiential learning is at its most vivid. Providing practitioners with opportunities to develop their ability to reect is crucial, giving learners the skill to develop professional expert practice in their specialist area. Benner (1984) has addressed the issues of knowledge embedded in clinical nursing practice, asserting that graded qualitative distinctions can be elaborated and rened only as nurses compare their judgements in actual patient care situations (p. 5). The issues addressed in this account are relevant to the clinical reality of orthopaedic nursing and suggest that even as specialists we can never

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Reection in action and reection on action


Schon (1983) coined the term reective practice, emphasising the signicance of the role of practice for the development of professional knowledge. He identied two types of reection: reection-inaction and reection-on-action. Reection-in-action occurs while the nurse is practicing and inuences the decisions made and the care given. It has been said by Schon (1991) that experienced nurses are able to reect-in-action whereby they may show the ability to explore and examine responses to a situation while actually being involved in it, and may adapt their actions in response to identiable thought processes and reections. Reection-on-action is retrospective contemplation of practice taken to uncover the knowledge utilised during a particular event (Carroll et al., 2001). Practitioners are encouraged to become self-aware and identify feelings in relation to certain nursing events after they have happened (Dearman, 1996). For educational development to happen the reective nurse must see knowledge attainment as part of a developmental cycle where new knowledge is mixed with existing knowledge and practice, in order for a change in practice to occur. This is in accordance with Schons (1987) notion of integrating formal and espoused theory to develop personal knowledge. Similarly, Benner (1984, p. 36) acknowledges this in a discussion on the meaning of experience in nursing where preconceived

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Using reection in everyday orthopaedic nursing practice notions and theory are only rened through encounters with actual practical situations. Carper (1978) suggests that there is a need to examine the kinds of knowing that provide nursing with its particular perspective and signicance, and that understanding the four fundamental patterns of knowing:     personal ethical empiric aesthetic

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makes possible an increased awareness of the complexity and diversity of nursing knowledge. Therefore, for Carper (1978), each pattern of knowing in nursing is required for mastery of the discipline yet each pattern cannot exist in isolation (Silva et al., 1995). Through reection, the practitioner can begin to understand the way the personal, ethical, and empiric ways of knowing have informed the aesthetic response (or the story being told).

Critical analysis
On that morning when I set about my workload, I thought the patients discharge would have been one of the easiest tasks of the day. However, it turned out to be the one that gave the most cause for thought. I could easily have missed the cue of his impending air ight and failed in my duty of care. All nurses have a duty of care to the patients entrusted to them (Tschudin, 1994). In this situation, because I had taken the time to communicate with the patient I had learned valuable information in relation to his aftercare. This could easily have been missed, as there is no mention of air travel on the cast instructions. Ideas and their application to practice are the basis for reection (Astor et al., 1998; Hancock, 1998). In this case I had the condence and knowledge to implement good practice and this resulted in a positive incident with a positive successful outcome. It made my intuitive and specialist knowledge explicit (Jarvis, 1992). Provision of support and adequate preparation of student/ learners need to be put in place in the form of guidelines for the reaction and utilisation of reective practice (Haddock, 1997; Jasper, 1999; Neary, 2000; Hannigan, 2001; Suhre and Harskamp, 2001; Williams, 2001). Williams (2001) found that when supports were in place students engaged in reection more readily. However, for successful utilisation to occur one needs to be part of a community of reectors (Kyriacou, 1998; Johnson and Tinning, 2001; Rogers, 2002). In reality, this has not yet happened but has been advancing (Page and Meerabeau, 2000). In the clinical area where I work, reection is carried out in an informal way and information is accessed and exchanged on a regular basis. Constant evaluation of care is carried out and patient care

Description
It was Monday and the operating theatre list was getting longer. The trauma ward is the busiest ward in the hospital and I was in for a 12 hour day. Another staff nurse and I were assigned to the care of 8 patients. One patient had been involved in a road trafc accident and had an external xator, there were two elderly patients with fractured necks of femur awaiting surgery, a lady with a Colles fracture, two patients for investigations of back pain, a lady post insertion of a Dynamic Hip Screw awaiting transfer and the young man who is the subject of this essay with a fracture of the lateral malleolus of his right ankle. The patient was an extremely active, athletic 25 years old and had been playing indoor soccer and during a strong tackle had sustained a fracture. The fracture had been reduced and he was now the proud bearer of a below knee cast. He was well able to mobilise on his crutches, there was no swelling, neurovascular assessment was ne and he was ready for discharge. It was extremely busy but the discharge letter and prescription had to be completed. The doctor was bleeped and arrived to full the task. An out patient appointment was arranged and I got out the plaster instruction card for the patient in readiness with all his other discharge paperwork. I went down to him and gave him the paperwork and began to verbally explain the plaster instructions to him. He signed for them and we began to chat. After a short while he mentioned

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that it would be his birthday the weekend after next and his girlfriend had organised a weekend in Barcelona. I asked him did he intend going and he replied yes. Realising a potential problem I explained that the consultant had to be informed and that he would not be able to go home until I made contact with the team. A member of the team came to the ward to see him and explained that the cast would have to be bi-valved before the ight and checked on return. Also the possible complications of this line of action were explained and all relevant documentation completed. Mike was happy to take responsibility and I went back to the nurses station and set about organising the extra appointments for him.

52 is expedited in an efcient and caring way, utilising evidence-based practice. I would not have changed any aspect of the care given here and it felt good to make a difference to the on going care of patients in casts. It also resulted in uniformity of care no matter who is giving the cast instructions.

J. Moloney, S. Hahessy process of reection-in-action occurred here as I used my clinical expertise and experiential learning to assess and deal with the situation (Benner, 1984; Schon, 1987; Johns, 1995; Rolfe, 1998; Burns and Bulman, 2000). I had the knowledge and needed to impart that to the patient to the best of my ability. I also had to inform my line manager of the incident. Following this, a new set of cast instructions are being developed and notices have been placed in very prominent positions in all areas telling patients that they need to inform the health care team if they intend to travel by air while in a cast. This showed my wealth of knowledge of the situation and utilisation of that knowledge to ensure that handling of a similar situation in the future would be successful and uniform (Rolfe, 1998). The reective practitioner endeavours to ensure that the outcome of any action is close to what is anticipated by the theoretical base and the previous lived experience combined (Jarvis, 1992). This highlights the necessity of constant evaluation of the care given in light of outcomes. This incorporates the use of reective practice and evidence based practice. A combination of these is needed to become critically reective (Osmond and Darlington, 2005), at all times striving for excellence while adhering to the Scope of Professional Practice (2000). Every day I care for my patients to the best of my ability. I actively engage in on-going professional development to improve my practice. I endeavour to care for patients in the way I or one of my family would wish to be cared for should the need arise. In the case of the foregoing incident the patient received optimal care and I was happy to be part of the care team.

New insights
Good communication skills and observation are of paramount importance in nursing. Vital information can be elicited by asking a key question or picking up on a non-verbal cue. Experienced clinicians will do this naturally following many years of practice. In my experience patients do not always initially tell the full story, and it may take several conversations before the complete picture is known. I was already aware of the guidelines for the care of casts but the patient needed to be educated. Unfortunately airline travel was not included in the instructions. In Ireland today travel has become commonplace especially airline travel. Therefore, inclusion of an instruction relating to this was of paramount importance on the cast instruction leaet as a lot of younger people often need treatment of fractures which necessitate the application of a cast. From experience I was well aware of the imminent complications of ying while in a cast but the patient was not and a junior or more inexperienced orthopaedic nurse would not be aware either. Reection has the potential for less experienced student nurses to learn from experts. Isolation, self-doubt and insecurity are some of the feelings, which may arise during reection (Brookeld, 1987). This is especially pertinent when the incident is negative and causes a questioning of self. Therefore, a development of self is needed before engaging in reective practice (Morton-Cooper and Palmer, 1999). Mature students may nd reection easier due to life experiences and also may be more comfortable with their innermost feelings whereas a younger student may not. It is also important to reect when an incident goes well and this will give condence in the knowledge already amassed. This may also encourage the student to seek out new knowledge in relation to the area of care under discussion, as this may help them see that they have prociency in a certain area of care and they may go on to specialise.

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Evaluation
The effectiveness of interpersonal communication as a means of gaining valid knowledge cannot be overlooked in any nurse/patient interaction. What this account demonstrates is, that sensitive detection of problems that may impede recovery may often and do go unnoticed. Managing patient discharge is an integral component of patient care in hospital. In an exploratory study conducted by Driscoll (2000) the recommendations for nursing practice suggested have resonance for orthopaedic care. Considering patients health and employment status is as important as ensuring they are taking appropriate medication. To extend these recommendations it is suggested that an awareness of patients social activities can also contribute to the holistic picture of the individual. Investigating

Identication of learning
Learning through and accessing lived experiences is the purpose of reective practice (Johns, 1996). A

Using reection in everyday orthopaedic nursing practice information needs of the patient needs to be specic to the population under the care of the orthopaedic nurse. Social habits and participation in hobbies such as travel often go un-noticed in any consideration of discharge planning. Preventing re-admission through adequate discharge planning should commence at the point of admission. Discharge planning has become central in healthcare in an environment characterised by economic rationalisation, case mix funding and pursuits of standards of quality (Driscoll, 2000, p. 2). Being aware of the importance of adequate communication processes is often taken for granted by all grades of nurses and as this reective account displayed valuable information was gleaned from taking the time. The issue of having the experience to act upon given knowledge is also discussed. The reector acted on her intuition and had the condence to see her convictions borne out in practice. In this account the reector acknowledges the variances in the skill required in being aware of the full story. The dimension of time is considered also. A few conversations over a period of time may be required to ensure the full picture is presented. Novices may not be as astute to the cues being presented, however it is the endeavour of educators to ensure that communication skills are developed amongst students at all levels and specialities. The reective practitioner in this account speaks of the emotions surrounding the incident and the importance of acknowledging the positive function of reection. This is connected to a sense of prociency that may assist a novice in deciding what area to specialise in. However, more often than not students have a tendency to focus on negative aspects of their experiences in reective accounts and in instances where a reective account is negative there seems to be an underdeveloped sensitivity to the learning opportunities that may be presented. I am not suggesting that we prescribe for students the experiences that warrant reection, whether positive or negative, the issue here is that reection is cathartic and within this process a new insight should be produced. This reective account also addressed the preventative measures for the client in a cast who may be predisposed to developing compartment syndrome. Where swelling is anticipated bi-valving the cast is required. The procedure refers to cutting the cast in two along its length to ensure that the limb may be lifted out safely if required and any swelling is accommodated. In a cast that is bi-valved it is vital to inform the patient that care must be taken to prevent further damage by displacing operation procedures. Prior and Miles (1999) note that

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the art and science of casting not only involves the competent application of the cast but also addresses the needs of the patient. A major issue with reective practice is truth. Are students only writing what they think their tutor wants to hear or is it their true lived experience, or writing items, which will help them achieve academic success? This is a major barrier to strengthening of the knowledge base. Nurse tutors must unravel the intricacy of practice in real care settings to enhance learning and patient care through reective practice (Wilkinson, 1999; Williams, 2001). Also educators themselves must be comfortable and knowledgeable about using reective practice before they can teach students how to utilise it. Students may not recall events exactly as they happened (Andrews, 1996; Mackintosh, 1998; Burton, 2000). Also time constraints and workload impinge on contemporaneous writing of the event and the longer before it is written, the poorer the recall (Gustafsson, 2004). However, as continuing professional development is necessary for the nursing profession, utilisation and knowledge of reection is increasing (Page and Meerabeau, 2000). The issue of truth and its relationship with reective projects is addressed by the reector and warrants further discussion. In educational discourse this matter has been given some attention recently and the concept of truth in this instance is intertwined with procedures of assessment and judgement (Hargreaves, 2004; Lockyer et al., 2004; Grifths, 2004; Ekebergh et al., 2004). Anecdotal evidence would suggest that nurse educators nd assessing reective accounts to be a daunting task, as reection is a personal account of reality in a context pertinent to the person reecting. It is simply not enough to abide by subscribed parameters still in use in standardised formative assessment forms. Reective accounts of merit should consider the personal domain, in keeping with the multifaceted nature of the process. Educators must be actively reective if they are to appropriately assess students accounts of nursing reality. Equally important is the issue of clinical credibility. Keeping up to date with changes in clinical practice should be part of the nurse educators role. There are many innovative ways of doing this such as maintaining clinical links by visiting students on placement or attending clinically orientated orthopaedic conferences. Sometimes a general informal chat with the students can be as fruitful as a trip to the library, just as this reective account displayed the importance of talking to the client, new challenges and knowledge and subsequent action emerged.

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Haddock, J., 1997. Reection in groups :contextual and theoretical considerations within nursing education and practice. Nurse Education Today 17, 381385. Hancock, P., 1998. Reective practice using a learning journal. Nursing Standard 13 (17), 3740. Hannigan, B., 2001. A discussion of the strengths and weaknesses of reection in nursing practice and education. Journal of Clinical Nursing 10, 278283. Hargreaves, J., 2004. So how do you feel about that? Assessing reective practice. Nurse Education Today 24 (3), 196201. Jarvis, P., 1992. Reective practice and nursing. Nurse Education Today 12, 174181. Jasper, M.A., 1999. Nurses perceptions of written reection. Nurse Education Today 19, 452463. Johns, C., 1995. The value of reective practice for nursing. Journal of Clinical Nursing 4, 2330. Johns, C., 1996. Visualising and realising caring in practice through guided reection. Journal of Advanced Nursing 24 (6), 11351143. Johnson, A.K., Tinning, R.S., 2001. Meeting the challenge of problem based learning: developing the facilitators. Nurse Education Today 21, 161169. Kyriacou, C., 1998. Essential Teaching Skills. Simon & Schuster, London. Lockyer, J., Gondocz, S., Robert, L., 2004. Knowledge translation: the role and practice of reection. Journal of Continuing Education in the Health Professions 24 (1). Mackintosh, C., 1998. Reection: a awed strategy for the nursing profession. Nurse Education Today 18, 553557. Morton-Cooper, A., Palmer, A., 1999. Mentoring and Preceptorship, second ed. Blackwell Science, Oxford. Neary, M., 2000. Responsive assessment of clinical competence: Part 2. Nursing Standard 15 (10), 3540. Newell, R., 1992. Reection: art, science or pseudo-science. Nurse Education Today 14, 7981. Osmond, J., Darlington, Y., 2005. Reective analysis: techniques for facilitating reection. Australian Social Work 58 (1), 314. Page, S., Meerabeau, L., 2000. Achieving change through reective practice: closing the loop. Nurse Education Today 20, 365372. Prior, M.A., Miles, S., 1999. Casting: Part two. Nursing Standard 13 (29). Rogers, A., 2002. Teaching Adults, third ed. Open University Press, Bucknigham, Philadelphia. Rolfe, G., 1998. Beyond expertise: reective and refelxive nursing practice. In: Johns, C., Freshwater, D. (Eds.), Transforming Nursing through Reective Practice. Blackwell, Oxford, pp. 2131. Saylor, C.R., 1990. Reection and professional education: art, science and competence. Nurse Educator 15 (2), 811. Schon, D.A., 1983. The Reective Practitioner. Temple Smith, London. Schon, D.A., 1987. Educating the Reective Practitioner. Temple Smith, London. Schon, D.A., 1991. The Reective Practitioner: How Professionals Think and Act. Aldershot, Avebury. Suhre, C.J.M., Harskamp, E.G., 2001. Teaching planning and reection in nurse education. Nurse Education Today 21, 373381. Silva, M.C., Sorrell, J.M., Sorrell, C.D., 1995. From Capers patterns of knowing to ways of being: an ontological philosophy shift in nursing. Advances in Nursing Science 18 (1), 113.

Conclusion
The key to reection is, understanding that it is not complete without action and the goal of reection is to challenge and ultimately change practice. A new perspective on the dynamics of a seemingly every day occurrence, such as patient discharge, has been presented. The importance of appropriate communication has been highlighted and how a simple conversation with the client helped to prevent serious complications.

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References
Andrews, M., 1996. Using reection to develop clinical expertise. British Journal of Nursing 5 (8), 508513. Astor, R., Jefferson, H., Humphrys, K., 1998. Incorporating the service accomplishments into pre-registration curriculum to enhance reective practice. Nurse Education Today 18, 567 575. Benner, P., 1984. From novice to expert. Excellence and Power in Clinical Nursing Practice. Addison-Wesley, California. Brookeld, S.D., 1987. Developing Critical Thinkers: Challenging Adults to Explore Alternative Ways of Thinking and Acting. Open University Press, Milton Keynes. Burns, S., Bulman, C., 2000. Reective Practice in Nursing The Growth of the Professional Practitoner, second ed. Blackwell Science, London. Burton, A.J., 2000. Reection: Nursings practice and education panacea?. Journal of Advanced Nursing 31 (5) 10091017. Carroll, M., Curtis, L., Higgins, A., Nicholl, H., Redmond, R., Timmins, F., 2001. Is there a place for reective practice in the nursing curriculum? Nurse Education in Practice 2, 13 20. Carper, B., 1978. Fundamental patterns of knowing in nursing. Advances in Nursing Science 1 (1), 1323. De Botton, A., 2000. The Consolations of Philosophy. Hamish Hamilton, London. Dearman, A., 1996. Reective practice. Paediatric Nursing 8 (2), 2933, Nursing 8(22), 15301534. Dewey, J., 1933. How We Think: A Restatement of the Relation of Reective Thinking to the Educative Process. Henry Regnery, Chicago. Driscoll, A., 2000. Managing post-discharge care at home: an analysis of patients and their carers perceptions of information received during their stay in hospital. Journal of Advanced Nursing 31 (5). Ekebergh, M., Lepp, M., Dahlberg, K., 2004. Reective Learning with drama in nursing education: a Swedish attempt to overcome the theory praxis gap. Nurse Education Today 24 (8). Grifths, C., 2004. Remembrance of things past: the utilisation of context dependant and autobiographical recall as means of enhancing reection on action in nursing. Nurse Education Today 24 (5). Gustafsson, C., 2004. Reection, the way to professional development? Journal of Clinical Nurisng 13 (3), 271280. Gustafsson, C., Fagerberg, I., 2004. Reection the way to professional development. Journal of Clinical Nursing 13, 271280.

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Using reection in everyday orthopaedic nursing practice


Teekman, B., 2000. Exploring reective thinking in nursing practice. Journal of Advanced Nursing 31 (5), 11251135. Tschudin, V., 1994. Deciding Ethically: A Practical Approach to Nursing Challenges. Balliere Tindall, London. Wilkinson, J., 1999. Implementing reective practice. Nursing Standard 13 (21), 3640. Williams, B., 2001. Developing critical reection for professional practice through problem based learning. Journal of Advanced Nursing 34 (1), 2734.

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Further reading
An Bord Altranais 2000. Final Report of the Review of Scope of Practice for Nursing & Midwifery in Ireland. An Bord Altranais, Ireland. Van Manen, M., 1977. Linking ways of knowing with ways of being practical. Curriculum Inquiry 6, 205 228.

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