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Navigating FtP: reflections

There are a lot of guides out there on how to write a reflection so before starting read up. Reflections should be a routine part of our everyday practice but invariably they are only normally written when things go wrong so we automatically have the assumption that they are linked to negative aspects of our work. Reflections can be done on a wide range of areas as a way of learning what went well, reviewing how relevant certain things are to our practice or just a temperature check to see how we are doing. Like anything the more we do them the easier they become – a really good reflection can say so much more than you ever could say in person. BUT you must ensure you can give reasoning to your written reflection when questioned about it, so make sure you understand what you are writing and why.

The Royal College of Nursing has produced some very good guidance – they summarise by saying:

Eight ways to improve your reflection
  • Get into the habit of reflecting on your work. …
  • Think about when you avoid reflection. …
  • Identify what you are good at. …
  • Structure your learning across three years. …
  • Make the most of learning events. …
  • Keep your portfolio up-to-date. …
  • Familiarise yourself with the Code. …
  • Show what you have learnt.
The NMC also produced a lot of information about how to revalidate and in this is robust guidance on how to do reflections – the templates you use for revalidation can be used for your NMC FtP process too
When reflecting on a clinical incident or a series of allegations it can be difficult to know where to start – we often complication it by trying to give every minute detail as if to validify our actions but the ability to reflect is not about explaining every part of your inner most thoughts when in the situation, it is about being able to step back and say ” what could I have done better”. Remember what the NMC are looking for and what they mention time and time again are INSIGHT and REMEDIATION.

The Midwives Haven have produced a good starter guide here

You can use a researched reflective model if you wish such as Gibbs or and the NMC certainly like the use of this as it gives familiar structure. However some people find these models confusing, particularly if English isn’t your first language or you find writing complex reasoning methodology difficult. The important things is the reflection is yours and fits your individual situation and case.

It is important to not send the reflection to the NMC until  other registrants with experience and your union/legal representatives have read and commented on it. Experienced members of Midwives Haven / Association of Radical Midwives and/or NMCWatch will be available to review preparation of and to read over your reflection with you if you want.
A reflection can be useful at every stage of the process and can often when done correctly at the screening or initial investigation stage but the difference between the case continuing or closing. In June 2019 all of the healthcare regulators joined together to show the importance of effective reflection. All of the chief executives of the regulators produced a joint statement on this topic acknowledging the importance of reflection becoming part of everyday practice.
There are many examples of NMC reflections available on line – have a look to familiarise yourself with what’s needed.
A document produced by University Hospitals Bristol guides further

So what key aspects must be considered when doing a reflection? The following is an extract taken from guidance produced for members of the RCN.

Insight

Having or developing insight is a fundamental aspect of the process of reflection.

Insight has been defined as:

“The understanding of the cause and effect that certain actions have had on others and the nursing profession as a whole, whilst also considering how you would prevent this from happening in the future.”

Your reflection should set out your insight into your conduct and should demonstrate the following:

  1. That you understand what was wrong with your past conduct.

This should be an objective appraisal of what happened and a recognition of what went wrong.

  1. That you accept your role in what happened and take responsibility for it.

It is important to remember that, as a professional nurse, you are responsible and accountable for your own acts or omissions.  Even if other people have not acted well, told you to act in a certain way or if there are other reasons why things went wrong, it is important that you acknowledge your own responsibility and accountability.  It is acceptable to provide background to the circumstances of your actions in order to provide an explanation of what happened.  An explanation is useful as it highlights what can be remediated or put right.

It is important that you make it clear that your explanation is not an excuse for what happened or a way of blaming others and that you still take responsibility for the conduct.

  1. That you appreciate what should have been done differently.

Specific reference to the NMC Code can assist with this.

  1. That you recognise how to act differently in the future to avoid a repetition of the conduct.

This is wide ranging and dependent upon what the conduct was and why it was caused.  It can include training and development to correct any areas of defect in your practice; seeking support for health issues if health issues contributed to your actions, explaining what you would do differently.

  1. That you appreciate the impact that your actions have had or could have had on others.

A reflection is not a place to complain about the impact your actions have had on you, whether it is the loss of your job, the cause of stress and worry or ill health, or the loss of your home.  You need to concentrate on the impact your actions have had or could have had on others.  This includes patients, colleagues, your employer and the reputation of the profession.

Reference to remedial steps

When setting out what you have done to ensure there is no repetition of the conduct, reference to some or all of the following can be useful:

Training

Any training referred to in the reflection should, ideally:

  1. Be relevant to the conduct or failings identified.
  2. Be sufficiently comprehensive.
  3. Be face to face – while on line courses are better than nothing, face to face learning is given more weight by the NMC.
  4. Incorporate some element of assessment.

When a training course is referred to in the reflection, it is helpful to include a reflection on the course itself in order to demonstrate your understanding of it.  Set out what you learnt from the course, whether it highlighted something that you had not previously appreciated; why you consider that it has improved your practice; how you have or will apply what you have learnt to your practice.

Relevant research/reading

Reading articles in nursing journals relevant to the conduct is helpful.  Also helpful is searching for and reading relevant sections of the NMC and/or RCN websites (for example, the RCN learning zone).  It also assists the NMC to refer your conduct to the relevant parts of the NMC Code.

When further reading is referred to in the reflection, set out what you have learnt from it, whether it highlighted something that you had not previously appreciated; why you consider that it has improved your practice; how you have or will apply what you have learnt to your practice.

Action Plan/Personal Development Plan

Setting out and successfully completing an action plan or personal development plan can demonstrate to the NMC that you take the responsibility for improving your practice seriously.

Supervised practice

Successfully completing a period of supervised practice in the area of concern is a good way to demonstrate that any issues have been remedied.  If you cannot find a suitable course with an element of assessment, supervised and assessed practice which is signed off in writing can be very helpful.

Undertaking similar tasks to those that form the allegations

This is a good way to explain how you now deal differently with similar situations to demonstrate the change in your practice.  This is helpful even if the conduct is not practice-related.  For example, if the criticism relates to an adverse reaction when you were under pressure, you can refer to a more recent example of a time or incident when you were under pressure (within or outside the work environment) and how differently you reacted.

Remorse

A willingness to apologise for mistakes or failings is helpful in a reflection.  If you have previously apologised to those involved at an earlier stage, it may be helpful to refer to this fact as well as offering a further apology in the reflection.

Your future as a nurse

To assist the NMC in its assessment of you, it can be helpful to end the reflection with a paragraph about what being a nurse means to you and your hopes for your future career.

Bearing in mind the guidance above, see the following page for a checklist to follow when preparing your reflection.