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Interventions, tools, approaches and the measurement of nurses’ reflection in clinical settings are highly varied, a new paper has found.

Reflection is a formal process that can help nurses and nursing students develop crucial skills and competencies when undertaking training in clinical practice settings.

The Nursing and Midwifery Board of Australia’s (NMBA) Registered nurse standards for practice state RNs develop practice through reflection on experiences, knowledge, actions, feelings and beliefs to identify how these shape practice.

Research suggests nurses who are able to effectively reflect are better at developing strategies that promote a flexible, individualised and holistic approach to patient care; resolving problems through reasoning; and monitoring and enhancing their professional competence.

A new paper, Reflection as a learning strategy for the training of nurses in clinical practice setting: a scoping review, delved into the tools and approaches used for reflection as a learning strategy for nurses and nursing students in clinical settings.

The scoping review included 17 studies from around the world, conducted between 2007-2020, which aimed to report participants’ competencies in using reflective tools or approaches, such as workshops, journals/diaries, or coaching.

Three questions guided the scoping review:

  1. What tools and approaches are used for reflection (both to facilitate/teach/instruct reflection and to measure the outcomes of reflection) in nursing education by nursing trainees and educators in clinical settings?
  2. What levels of reflection are identified or achieved: low (descriptive), middle (application), or high (evaluative)?
  3. What outcomes are measured in the studies where reflection has been used for nursing education by nursing trainees and educators in clinical settings?

Nursing students or qualified nurses working in clinical settings, such as hospitals and primary care, and involved in patient care, took part in the 17 studies examined. Most studies investigated the differences between tools and educational approaches using structured reflection frameworks, or looked at the differences when dividing participants into paired or unpaired groups.

The scoping review found most studies used physical tools and reflective dialogues in clinical settings. Some tools included specific questions for participants to reflect on, while others included open questions, or no questions.

Reflective approaches included lectures, workshops, or reflection with supervisors or peers in clinical settings. The most used reflection tools among the 17 studies were written cases, narrative, and diaries.

Overall, the review found interventions, tools, approaches and the measurement of nurses’ reflection in clinical practice settings are highly varied. Tellingly, none of the 17 studies examined included the same combination of elements. There was also lack of standardisation in how reflection outcomes were classified.

Significantly, the review found that differences in reflection skills potentially depend upon the type of combination of the tools and approaches used.

As a result, it suggests a guide for education in clinical practice could include consideration of the following: which tool will be appropriate? which approach should be used? which reflection model/frame should be used? how long is the intervention period? how should findings and outcomes be reported consistently?

“The aim of the 17 included studies was to help students and supervisors to fulfil their jobs at the highest possible level,” authors wrote.

“Therefore, more precise, consistent reporting on the outcomes of interventions to promote reflection would help educators and clinical supervisors decide which tools and approaches may fit their specific clinical practice and promote reflection among participants to develop care competencies.”

Ultimately, the authors concluded that while reflection is a core component of nursing education and RN standards for practice, there is little agreement among the research community on how best to assess the measurement and quality of reflection.

Author, Professor Linda Schumann Scheel, from the University of Aalborg, Denmark said: “This review has shown that the use of reflection nurse training and education is widespread, but that further testing and validation is necessary. This will require high quality, standardised, and reproducible research that includes comparable interventions, outcome measures, and study conditions.”

In all of the included studies, it was possible to categorise the level of reflection attained as ‘low’, ‘middle’, or ‘high’, however, comparison between studies was challenging. The review recommended that authors be explicit in their definitions of these categories according to standardised criteria.

“When comparing results between studies, authors should explicitly state the foci or themes reflected on, as well as the length of the intervention period and the level of students’ educational experience.”

Dr Micah DJ Peters, Director of the National Policy Research Unit from the ANMF Federal Office and author of the paper said training and developing competences based on reflection in an evidence-based practice has to be tested and validated.

“This paper has important evidence and implications for nurses, nursing educators, researchers, and regulatory bodies because reflection and reflective practice are so central to education, training, clinical practice, and registration standards and requirements both in Australia and around the world,” Dr Peters said.

“Because we found such variability across the studies we examined in terms of several factors, this shows that despite being fundamental to policy and practice, the research underpinning reflection is still limited by lack of consistency and comparability which should be addressed.”

Access the full paper here