Reflection in Nursing: Benefits, Types, Skills, Barriers, and Frameworks

This article discusses the importance of reflective practice in nursing, including its benefits, two types of reflection, skills required for effective reflection, different purposes of reflection, and barriers that affect reflective practice. It also covers different frameworks for reflection, such as Gibbs model and John's model. The article is relevant for nursing students, practicing nurses, and nurse managers.

Running head: REFLECTION IN NURSING
REFLECTION IN NURSING
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Contents
Introduction:....................................................................................................................................3
Benefits of reflection in nursing field:.............................................................................................4
Two types of reflection:...................................................................................................................5
Skills important for effective reflective practice:............................................................................7
Different purpose of reflections:......................................................................................................8
Different barriers that affect reflective practice:.............................................................................9
Frameworks for reflection:............................................................................................................11
Gibbs model of reflection:.............................................................................................................11
John’s model of reflection:............................................................................................................16
Conclusion:....................................................................................................................................19
References:....................................................................................................................................20

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Introduction:
Reflective practice is a term that is widely used in nursing and healthcare industry.
Recent evidences are of the opinion that healthcare professionals use reflection as their valuable
tool to identify their weakness and strength. These help them in taking initiatives to overcome
the barriers and come out victorious in different critical situations (Donalsdon et al., 2016).
According to researchers, reflective practice can be defined as the continuous cycle where the
healthcare professionals can get the opportunity to reflect on their daily practices and hence
develop their professional skills. This ensures enhanced nursing care and greater patient safety.
This ensure enhanced nursing care as they get the scope of developing a better understanding of
the actions they undertake which in turn results in better development of the attributes required
in healthcare (Grinslade et al., 2016). The nurses should develop the ability of examining
themselves in the actions and experiences with the outcome of developing their practice and
clinical knowledge. Reflective practice is essential for all level of nursing professionals starting
from students to that of practicing nurses and nurse managers. Some of the main skills that are
very important for effective reflection are open mindedness, courage as well as willingness to
accept (Anderson, 2016). They should have the capability to accept criticism in a positive way
and thereby take part in effective reflection. Reflection is also seen to turn the knowledge, skills
and attitudes of healthcare professionals into their future actions and thereby increase the elf
awareness of the professionals. This is of great importance because as the nurse becomes more
aware of his or her own activities, strengths and capabilities, he or she can be able to practice
human care in better ways (deVries & Timmins, 2016). Different number of sources can be used
by the healthcare professionals that can provide them an insight about the aspects that they need
to develop in the future days. Therefore, these assignments would be mainly based on the

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different aspects of reflective practice and how these aspects are helpful for the nurses to develop
as healthcare professionals. It will shed light in the benefits of reflection, the skills and attributes
required during reflection, models used in reflection and many others.
Benefits of reflection in nursing field:
Reflective practice has huge number of benefits that had made it an important part in
curriculum for nursing students and in continuous professional development courses for the
senior nurses. This procedure helps in enhancing self-esteem of the individuals through proper
learning with the integration of theories and practices. It also encourages holistic, individualized
as well as flexible approach of caring (Eng & Pai, 2015). It also leads to acceptance of
professional responsibility by the nurses for whom they tend to become more serious and careful
in their practices. It also helps in providing opportunities for rapid as well as progressive
refocusing of work activity. It also gives the scope to nurses for understanding and exploring the
nature and boundaries of their roles as well as other health professionals (Johns, 2017).
Moreover, it also gives scope to practice effectively and improve clinical knowledge and skills.
These mainly take place as reflective practice enhances the opportunity for evaluation of their
own performance, acknowledging their strengths, identifying their own learning needs. It also
encourages nurses in ways that make them to take conscious attempt to identify and thereby
learn what is happening (Lestenader, Leheto & Engstorm, 2016). Viewing clinical situations
with different perspectives, motivating nurses to be a self-directed learner, enabling nurses to
identify their learning needs, fostering their responsibility and accountability in their activities
and improving decision-making are some of the benefits that reflective practice incorporates.
Nurses get scope of reviewing both positive and negative experiences that in turn encourages
critical thinking procedures (Scmhidt & Brown, 2016). With the help of reflections, the nurses

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can develop their practices from descriptive to more critical as well as analytical practices. It also
helps in development of autonomy and skill. It provides a tool as well as mechanism through
which they can communicate and at the same time justify the importance of practice and develop
knowledge (Scheel et al., 2017). Researchers are therefore of the opinion that effective reflection
can promote professional development within the nurses which will help them to care for the
patients in effective ways by reducing the chances of errors and patient dissatisfaction (Brown &
Schimdt, 2016).
Two types of reflection:
The nurses can take two types of reflection. These are called reflection in action and
reflection on actions. Reflection in action happens in the moment of practice and reflection in
action happens after the practice.
Reflection in action helps nursing professionals by providing them a particular procedure.
Here, the nurses get the chance of reshaping what they are acting on while they are still engaged
in the tasks. It is a kind of ongoing experimentation, which helps the nurses to find a viable
solution. In this type of method, the nursing professionals do not have to use trial and error
method but rather take actions that are more reasoned and purposeful in the immediate situations
(Ramos et al., 2015). Researchers are of the opinion that reflection in action procedure is a
hallmark for experienced professionals where they can examine and evaluate their own behaviors
and that of others in the situation and thereby take initiatives to perform the needful to meet the
requirement of the situation (Miraglia & Asselin, 2015). Several important skills are required by
the individuals in order to successfully conduct reflection in action. The nursing professionals
need to be participant observers in all situations that offer learning opportunities. The

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professionals should also attend to what they see and feel in the current situation. This can be
achieved by focusing on the responses and thereby making connection with the previous
experiences faced by them. Researchers are of the opinion that being “in the experiences” and
“adopting a witness chance” at the same time by thinking as an outsider help to reflect
successfully in this procedure (Pai, 2015).
Another procedure is called the reflection on action that is mainly done after the practice.
Here the nurses get the scope of evaluating their own process of working after the situation has
been over. Here, the nurses need to reflect on their actions, thinking back on what they could
have done better in the situations to ensure safe practice and patient satisfaction. This is the most
common form of reflection that actually involves carefully rerunning of the events that occurred
in the past in the mind (Hawkins et al., 2017). The main purpose of this form of refection is that
it gives the nurses the opportunity to value their strengths and at the same time develop different
and more effective ways of responsible acting in the future. This form of reflection also involves
close monitoring and evaluation of one’s own behavior in order to improve professional
competence (Lu & Kitt , 2018). Examples of such types of reflections involve “ I could have
handled the task more effectively if I had acted differently” or “ I did not take the right decision
for which there arose a conflict between the two parties” and several others. This type of
reflection gives the scope to the healthcare professionals to develop their clinical knowledge base
as well as new set of skills and advancement of the previous skills. It is also helpful in changing
or refining of the attitudes and values as well as in undertaking different clinical practice
development initiatives.

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Skills important for effective reflective practice:
Researchers are of the opinion that effective reflection can only take place when nursing
professionals have a set of skills. One of the most important skills that are required in developing
nursing practice and safe treatment is self-awareness. It involves becoming aware of one’s own
feeling in every situation and finding out what attributes are demanded by every situations (Daly,
Speedy & Jackson, 2017). This skill helps nursing professionals to be involved in exploration
and evaluation about how a situation has affected them and how the nursing professionals had
affected the situations. Once the professionals develop self-awareness skills, they would be able
to be more careful and responsible in their approach and hence would be able to handle critical
issues successfully (Camarillo, 2016). The next skill is the description capability of the nursing
professionals. This skill is exceptionally important for the nurses as it provides the ability to
them to effectively recognize as well as recollect all the sequences of the situation effectively.
Significant events and different types of key features of the experiences should be properly
described, dissected and criticized for effective reflection. Successful description of the events in
the mentioned way assures successful knowledge development (Dahl & Erikson, 2016). Proper
description skills of the nurses would help to give a comprehensive yet concise account of the
situations. The third skill important for effective reflection is the critical analysis skill. This
capability would help the nursing professional in examining the components of the situation that
is very important for properly understanding the requirement of the situation. After examining
the components, nurses should learn to identify their existing knowledge, challenge assumptions
and thereby imagining and exploring alternatives (Hodges, 2015). With proper critical analysis
skills, nursing professionals will be able to conduct an in-depth analysis in comparison to just
developing superficial ideas. Such in-depth analysis will help them to understand what attributes

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should have to be changes in themselves that would prevent the occurrence of negative
incidences in the future and promote well being of patients through person-centered care.
Another important skill that the nursing professional should also develop is the synthesis skills.
This skill mainly helps the nurses to integrate new knowledge along with that of the previous
knowledge that they already had (Hechemann, Schols & Halfens, 2015). With this skill, they can
enhance their knowledge and can develop their practice that can have positive impact on the
patients. Another important skill is the evaluation skills. The better the evaluation skills, the
better will be their ability to make judgments on the value of different aspects.
Different purpose of reflections:
Reflection helps health care professional in many ways. The main purpose of learning is
that they give scope to the nurses to engage themselves in professional development without
having to join any specific workshops or training classes. Reflective practice makes nurses
responsible and they are able to make decisions and resolve different types of uncertainties. This
process of reflection also helps in empowering individuals or emancipating them as individuals
ultimately helping in self-development (Middleton, 2018). Nurses get to critically review their
own behaviors as well as that of others. Researchers state that reflection is an effective way of
learning as it helps in the process of meta-cognition. Another purpose of reflection is to provide
help to the nurses in developing ideas from observations. They can derive theories from
generalizations that may be sometimes from thoughts, sometimes from practical situations and in
other cases from a mixture of two (Abdolrahimini et al., 2015). The purpose of reflection goes
through four important steps that are experience, reflection, abstraction as well as active testing.
Reflection provides the purpose of deeper learning by looking into varieties of situations through
different forms of lens. It also gives scopes to the healthcare professionals by giving them the

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scope to ask themselves searching questions that challenge the assumptions of the world around
them. Therefore, reflection can be helpful in providing a bridge between practice and continuous
professional development.
Different barriers that affect reflective practice:
A large number of barriers may affect the smooth reflective practice of many healthcare
professionals. It is extremely important for the healthcare professionals to recognize them and
take initiatives against each barrier so that their development is not obstructed.
The first issue faced by the nurses is called the time constraint. With the increase of the
diseases burden and more and more demand of caring patients in the healthcare centers, it has
become nearly impossible to get time for personal activities. Nurses are suffering from burnouts
and are suffering from physical and mental breakdown (Mcmillan, 2017). In such periods of time
constraints, it has nearly become impossible for the nurses to participate in reflective practices
and continuous professional development. For modifying their perspectives and transforming
their reflective abilities, time is considered as an important factor. Absence of time can act as
barriers for nursing professionals to engage in effective reflective practices (Ahmad et al., 2017).
The second issue that is also denoted by the researchers over years is the absence or lack
of support from mentors. This barrier mainly takes place when the mentors cannot provide
sufficient time for the nursing students to help them process their recalled events. Every nursing
professional require mentors in their initial phases until they become experts in reflective
practice (Hunt, 2018). The mentors usually help the nurses in providing guidance about how they
should proceed with the tasks actively. When nurses cannot come under proper guidance, they

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cannot get ideas about how to conduct reflective practices. Therefore, lack of proper mentors or
inability of mentors to teach properly can act as barriers.
Another important barrier that can also act as effective barriers in reflective practice is
their limited power to start any form of changes. Many of the researchers have shown that in the
interviews many of the nurses have complained about restricted power and dignity in the
healthcare centers. Although nurses feel that reflective practice greatly enhances healthcare
knowledge, it cannot help in acting as effective agent for change as the nurses have limited
power for initiating any changes (Patricia, 2018). Many researchers had stated that the power
struggle that thrives between the nurses and physicians is a major barrier. From the different
open-ended interviews conducted by professionals, it was seen that the nurses felt devalued and
belittled by those who experience more power and are on the higher ranks of the hierarchy. This
is considered to be one of the most important barriers as it results in prevention of the nurses
from discussing their thoughts as well as their ideas that impeded the dissemination of the
important knowledge (Burrell, 2014).
Other than these, other major barriers include lack of culture and awareness in reflecting
among different preceptors as well as healthcare nurses in different clinical placements.
Uncertainty of using an unfamiliar learning approach, lack of motivation and commitment, lack
of supportive environment – all result in acting as challenges for which nurses cannot become
experts in professional learning (Carnahan et al., 2018). Therefore, it is extremely important for
the nurse leaders and nurse managers to take an active participation in overcoming such barriers
and making it easier for the nurses to undertake reflective practice. This is not only fruitful for
the professionals but is also helpful in developing an overall working and safety culture in the
healthcare organizations.’

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Frameworks for reflection:
Different researchers have proposed a large number of reflective models and frameworks
over time that is used by healthcare professionals in their reflective essays and journals. These
models help the professionals to follow a proper framework that provides a structured process for
guiding the act of reflection. The healthcare professionals may use any of the models with which
they are most comfortable and assist the professionals in learning from the experiences. Some of
the renowned models that are often used by the different professionals are Gibbs reflective cycle,
john’s model of structured reflection; Kolb is learning cycle, Driscoll’s cycle, Stephenson model,
Goodman’s theory of reflection.
Gibbs model of reflection:
One of the most important reflection frameworks that are often used by nursing
professionals is called the Gibbs reflective model. This model mainly includes six important
stages of reflection. An example will be provided which would help in understanding the six
important stages and how each of the stage would be helpful in conducting proper reflections.
Description:
The first step is the description stage. In this stage, the nursing professionals should
describe the events in a detailed manner. Once during my night shift, a patient was admitted in
the emergency unit. She had bruises all over the body and was admitted by her friend. She was
bleeding heavily and her fiancée stated that her bruises should be taken care of as she is having
blood loss from them at a constant rate. He stated that the patient had been suffering from bipolar
disorders and has rapid mood swings. The patient had tried to harm herself several times and
even had a physical fight with her friend who tried to take the weapon from her hand. When the

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patient entered, she was sobbing heavily. Presence of her fiancés had helped her to cool down.
After requesting them to wait outside, I immediately attended the bruises and tried to dress the
wounds. As there was no physician on the night shift in the emergency department, I decided to
provide her a mild sedative to make her calm. However, I was not sure how to handle the
situation alone and therefore to maintain her safety, applied physical restraints on her. Later in
the middle of the night, she started shouting and wanted me to open her restraints. I got very
scared as I could not understand what to do in that moment. The restraints resulted in further
bruises on her wrists and feet for which my mentor later criticized me.
Feelings:
The second stage is called the feelings stage. In this stage, the healthcare nurses need to
reflect their feelings that they developed at that moment. This steps helps them to recollect the
feelings which they were going through when they were facing the critical situation. I was going
through a very strenuous moment at that time. I was alone on the shift. I could not decide what to
do at that moment. I was feeling helpless. I could not decide how to protect the patient from
further injury. At that moment, my prime aim was to save the life of the patient form any danger.
The only way I thought could protect her was physical restraints. I got very scared at that
moment as the patient had become fierce and was throwing objects. It was the first time I had
faced such a strenuous situation. I got very scared. I was at my wit’s end and my mind totally
stopped working. I was feeling that such harmful behavior is not only risky to me but also for the
patient herself. My fear did not allow me to think rationally and critically and hence, a physical
restraint was the only method that I thought to be most suitable at times.
Evaluation:

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The next stage is the evaluation stage. This stage mainly requires the healthcare
professionals to evaluate the entire incident and point out the bad things of the good things,
which were associated with the incident. The entire incident had a very negative impact on the
patient. She was already stressed from certain personal events in her life and was having rapid
change of mood. The application of the restraints had resulted in affecting her emotionally and
physically. She did not wanted to be restrained and had not given me permission either. I had
gone against her permissions and put restraints on her. In spite of her requesting reportedly I did
not open her restraints. This had affected her emotionally as she felt that her dignity was
affected. She also felt that she was not respected and was not asked for consent before putting
her on restraints. Moreover, she was also physically bruised which resulted in clogging of blood
in many of the areas of her bodies especially in the wrists and the feet. Therefore, being a
healthcare professional I was supposed to maintain her safety but the intervention I took that
time to maintain her safety was proved to be the most insensitive practice conducted by me.
Analysis:
The next stage is the analysis stage. In this stage, the healthcare professionals need to
analyze the situation and make proper senses. This situation showed me that I had not applied by
critical thinking skills. I had to analyze critically the situation and should have thought about the
negative instances that are associated with the use of restraints. From this entire situation, I
realized that although I had done the course of emergency care of patient for 6 months I was not
well prepared. In strenuous moments, I could not analyze situations critically. Moreover, I also
analyzed from the situation that I have no proper decision making skills. Taking decisions in
critical situation by utilizing far sightedness skills, outcomes of situations and thinking for proper
alternatives is an attribute that is very important for healthcare professionals. Besides, I later

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realized from this situation that I also suffered from conflicts of different ethics of healthcare. On
one side, I was trying to maintain beneficence by providing interventions that ensure safety of
patients and on the other hand, I was trying to maintain dignity and autonomy of patients.
Although I settled for maintaining beneficence by protecting the patient from self-harming
herself and myself, I broke the other ethical rule. Therefore, I understood that I suffer from
ethical dilemmas in crucial times and cannot take initiatives that would help me develop
interventions that would to overcome any ethical dilemmas.
Conclusion:
The next stage is called the conclusion stage. This stage mainly describes what else the
healthcare workers could have done in that particular situation to avoid the consequences that
occurred. This is one of the most important stages of reflection as it helps the healthcare
professionals, the right initiatives he should have taken in the crucial moment. With the help of
my mentor, I understood the different interventions which I needed to take in such situation. I
should have frequently assessed client’s behaviors for identifying any signs of hyperactivity and
agitation. Experts are of the opinion that early detection of escalating mania prevent the
possibility of self-harm or harming others and thereby decrease the need of seclusion of physical
restraints (Frank et al., 2015). I should have undertaken a calm and form approach as it helps in
providing a structure and controlling the client who is out of control. Moreover, I should have
used short, brief and simple sentences. This is mainly because short attention span limits the
understanding of the clients to small pieces of information (Mccormick, Murray & McNew,
2015). Rather than shouting on the patients, I should have neutral and should not have argued
with the patient. Researchers advise so because the patients suffering from bipolar disorders can
use inconsistencies and value judgments as justification for their arguing and escalating mania.

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One of the important steps that I could have taken is to redirect the agitation of the patient and
her violent behaviors with physical outlets in an area of low stimulation like in case of using
punching bag. This is helpful as it helps in relieving pent up hostility and relieved the patient
from muscle tension (Yesefu et al., 2015). I should have also decreased the environmental
stimuli such as like providing a calming environment as it helps in decreasing escalation of
anxiety and maniac symptoms. I could have encouraged the client to express her feelings in a
calm and composite manner and established bond with her by being friendly and trustworthy.
Talking about feelings and providing her with coping solutions could have helped her to rely on
me as a well-wisher preventing her chances of self-harm. All these would have helped me to
handle her effectively rather than using physical restraints. I could have also disclosed the issue
of absence of staff with the family members and asked their help for constant monitoring of the
patient until I could have arranged for help from other departments. This could have reduced the
necessity of physical restraints use for maintain her safety .
Action plan:
The last stage of this cycle is called the action plan stage. In this stage, the healthcare
professionals should decide what the initiatives that would take if such situations occur again. If
such a situation occurs again, I would never let fear to control my activities. I would have stayed
calm and would though of the situation critically. I should taken decisions that are in benefit for
the patients at that particular moment and in the future. I would immediately inform her family
members who are present and keep her under constant monitoring. I should communicate with
her compassionately with a soft but confident approach for developing trust in the patient. Once
the patient relies on me, the danger can be avoided. Moreover, I should never use physical

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restraints. I would take the interventions discussed by my mentor so that I do not get involved in
legal and ethical complications.
John’s model of reflection:
John proposed this model in the year 1995 that is based on five cue questions. These
questions mainly help in breaking down the experiences and thereby reflecting on the different
outcomes.
The first stage of the reflection is called the ‘description of the events’ stage. In this stage,
the healthcare professionals need to disclose the experience in details and denote the different
significant factors. It was during my initial days of being promoted as a head nurse in the
emergency department. I had no proper experiences of leading teams. I was assigned to lead the
nursing professionals in the rehabilitation ward as the head nurse had been on leave and there
was admission of a very crucial patient who had undergone severe accidents. The patient was an
old woman who had not taken her insulin in proper doses and on the right time. She had a fall on
the staircase resulting in wounds and bruises and severe pain in her limbs and back. Because of
the fall, she had mini stroke that had impaired certain parts of her speeches. There was a
complete loss of teamwork among the healthcare members. This affected the health of the
patient. There was no proper communication among the team members. This resulted in
medication error like repeated medication administration resulting in double doses. There were
also instances when the physiotherapist and speech therapist visited the patient together and got
engaged in a struggle. The junior and senior nurses of the team suffered from complexes and did
not bond with each other. Every of the healthcare professional used to write their observation
without conducting any meetings, as all were busy in their own respective fields. Whenever I

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confronted them, they played blame games. Finally, I was called by the higher authority and was
criticized as my contribution as a head nurse because the patient’s family complained about me.
They complained that the team is not providing patient centered care to the patient affecting her
health and leading to prolonged treatment.
The next phase is the reflection phase. This phase helps the nurses in identifying what
they were trying to achieve and the different consequences associated with the trials. From the
entire incident, I understood that there was no proper teamwork and therefore it was affecting the
health of the patient. I tried to solve things between the nurses and other professional by
interacting with them but they were constantly blaming each other. I was trying my best to find
out the main source of the problem between the members but I had no proper leadership skills.
Therefore, even if I was trying to make things better, I failed miserably in taking proper
initiatives.
The third stage is called the influencing factors. In this stage, the nursing professionals
need to identify the factors that affected their decision-making. The main factor that affected my
decision-making was my novice and improper initiates that I took to overcome the situations.
Although I was concerned about the situation, I could not understand what initiatives I need to
take, as I had no proper practical and theoretical knowledge of effective leadership. Moreover, I
also asked them to open up about each other where they blame each other than accepting their
mistake. I realized that there was no proper communication and bonding among the members.
However, my lack of knowledge of handling such issues and fear to be perceived in a wring
sense by other affected my decision-making. I had not critical reasoning skills and confidence to
lead a multidisciplinary team. These factors affected decision-making.

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The next stage mainly helps the nursing professionals to understand what other steps
could she had taken and what would have been the consequences then. The first initiative that I
could have taken is the arrangement of training sessions. Proper mentors should have been
allocated who would have helped the professionals in developing knowledge on effective
communication and proper team working on patient safety (Weller & Civil, 2017). I could have
also arranged for meetings where every member would provide constructive feedback about
others that would help in developing unity. I should have encouraged both the senior and junior
nurses in informal communication activities so that they develop bonding among themselves.
Effective bonding and relationship building would help in overcoming blame games and would
help in providing better patient care (Weller, Boyd & Cumin, 2014). Moreover effective
discussion sessions about the health of patient with all members of multidisciplinary teams and
knowing each of their suggestions are important in taking correct decision of the health of the
patients. These would have assured proper patient care and maintenance of her safety (Casimiro
et al., 2015).
The last stage is called the learning stage. This stage helps the individual to identify what
would change as the result of the experience. It also states how the experience has changes their
way of thinking. I developed knowledge that teamwork requires effective communication,
bonding, and trust, open discussions of stressful situations and exchange of effective feedback
(Rosen et al., 2014). Therefore, as the head nurses, I would try to take initiatives that would
boost all the factors thereby helping in maintaining uninterrupted communication and proper
teamwork. This would ensure patient safety.

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Conclusion:
Reflective practice can be defined as the actions taken by nursing professionals for
successfully engaging themselves in procedures of continuous learning. It mainly helps the
nurses to manage different impacts of caring for patients on a daily basis. It helps in making
sense of the events, situations and workplace that take place in the healthcare organizations and
thereby critically analyzing the events to learn about the best or worst parts of the incidents. This
is then followed by taking initiatives that would help in promoting successful patient care in the
future. It helps in building skills like self-regulation and self-awareness. These give the ability to
understand emotions, strengths, values, goals, and weakness and thereby help in recognizing
their impact on others. Reflective practice also helps nursing professionals to learn from their
mistakes, be more confident, improves their quality of care, develops clear thinking and
decision-making skills, builds characters and educates nurses. There are two types of reflective
learning. Reflection on action helps the nurses to reflect about their activities after the incident.
Another is reflection in action that helps the nurses to reflect about their activities while they are
conducting the task in the moment. Healthcare professionals follow different models of
reflection as framework for writing reflections. These are Gibbs reflective cycle, john’s model of
structured reflection; Kolb is learning cycle, Driscoll’s cycle, Stephenson model, Goodman’s
theory of reflection. Reflection has become an integral part of nursing practice as it helps in
development of knowledge and skills of nurses and thereby helps to ensure patient safety and
satisfaction largely.

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