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Reflective model: Marks-Maran and Rose, 1997

 

Introduction

Reflection is an important aspect of professional development and much literature comments on the importance of reflection using a range of models, however, very few provide the tools to apply a reflection at practice level. Over the past several decades, reflection proved to be an invaluable tool to nursing development mainly because it can raise an individual nurses’ awareness of practice.  Reflective activities in practice contribute to a deep development of more personal, practical, and intuitive knowledge. However, in order to achieve this greater in-depth learning through reflection, nurses must closely engage in reflective activities in order to enhance meaningful learning from experience. Often, a reflective activity involves a personal confrontation where a practitioner seeks to solve issues revolving around what should be achieved and what must be practiced. This conflict promotes necessary empowerment that fuels the urge to take action. The most common reflective model is that of Marks-Maran and Rose (1997) (Nobile, Noviello, Cobellis, and Carnielli, 2015, pp. 279). The authors of this model argue that the existing difference between the knowledge an individual brings into a situation and the knowledge one takes from that same situation is defined as learning. In essence, it is mainly through reflection that this existing difference, i.e. learning, is achieved. For Marks-Maran and Rose (1997) reflection was simply a reflexive model of gaining a deeper understanding of an experience and then through the experience gained, initiate personal action on the arising situation.  In this case, reflective approaches in nursing encourage a critical analysis of clinical aspects and allow an individual to personally make appropriate decisions. The Marks-Maran and Rose (1997) model of reflection has four stages: incident, reflective observation, related theory, and future action. In this paper, I will use this reflective model to give care provision to a family in need of transitional care. Reflection occurs after an event which challenges the perception of a nurse and is used as a tool for learning. It is an ongoing process within nursing to continuously improve practice through reflection, but reflection must be undertaken critically and be well-focused. It is a method by which practiced knowledge is reinforced or challenged for the better.

 

The incident

A home visit to a terminally ill cancer patient was made. The cancer patient was well taken care of by a female caregiver who I understand to be his wife. The woman was well articulated in her thoughts and knowledge surrounding the care provided and appeared to me as a smart individual, similar to what I would have thought to be a professional caregiver. She made the whole place look neat and rose to the occasion when necessary. However, the patient’s condition was deteriorating, and from looking into his eyes, you could see the immense pain he had been enduring. I felt a sense of uneasiness about the whole situation. On one occasion, outside of the patient’s room, I told her, “This must be really tough”. Immediately she started crying and expressed her real feelings of being overwhelmed with the care she was having to provide. She was exhausted and appeared in need of a respite.  Her ability to cope was failing, and she needed a period of distance to recover. I could now see from her face that the husband’s situation was affecting her deeply even though she was unable to show it initially. As a nurse, I was not conscious of her feelings at the time and this only triggered unexpected grief, disorganisation, and fatigue.

The reflective observation

With the complexity of this situation, there was a lot to learn and reflect upon. Reflective action should have played a critical role in this caregiver’s situation. Considering her perseverance to care for her ailing husband tirelessly, she seemed to be wounded on the inside. On the one hand she may have been feeling tired and close to giving up. On the other hand, she may have been questioning why the deadly disease had been inflicted upon her husband. Looking at her situation critically, she needed care just as her husband does and even though she did not show it physically or emotionally at first, it was necessary to factor in this possibility. With this in mind, I realised that in reflective action self-awareness is a vital component in learning, especially at a practice level (Cooney, 1999, pp.1530). Through self-awareness, an individual is in a position to remain conscious of his or her values in different situations and furthermore identify the impact of his or her perceived actions in different situations. Realising the impact of one’s action-especially “cues” is of upmost importance in the medical setting. One should have the ability to critically asses a situation and explore alternatives when faced with that situation. Rather than rushing to complete a task, there is a greater need to consider a patients situation and reconsider the choice of words before engaging him or her, and the possible reactions. With reflective action, the nurse becomes in a position to adopt necessary knowledge and develop expertise to manage any emerging difficult situation without using mere assumptions (Nobile, Noviello, Cobellis, and Carnielli, 2015, pp. 279). On reflection, the approach to this incident described was not very professional at all. From a developing nurses’ perspective, I should have been in a position to integrate new and old knowledge and engage the woman without putting her in an uncomfortable situation. A nurse should have first evaluated the situation critically and made a judgment upon the whole situation without injury to any of the parties involved or causing any negative feelings. A further development would be to have asked a more suitable question, for instance “how have you been coping?”, a statement which takes into account of range of possible feelings the caregiver has and offering them the opportunity to ask for help which they may require.

 

Related theory

According to Cooney, when considering the caregiver’s situation, there are four ways to know what is the correct action and practice to be taken when related to a situation in nursing (Cooney, 1999). These are empirical theories which comprise; the technical knowledge gained in practice, the aesthetic which is the art of nursing, personal knowledge referring to self-understanding and ethical knowledge of what is right and wrong (Cooney, 1999, pp.1530). All these key elements need to play a role in making a decision in a nursing setting. Science is not the only way to help nurses arrive at a solution, but these key factors must be considered to widen parameters so that a balance between science and art is attained. Reflection can close the widening theory-practice gap as it helps facilitate application of theory practically. Some situations are not always solved using scientific competence but can be facilitated with more personal knowledge. There are a great number of unique situations facing nursing on a daily basis and strictly scientific theories in any case applied will likely fail to deliver the desired results. In this case, nurses should be in positions to explore what works best in given situations, examine the context of such situations, and learn from each and every encountered situation (Sondheimer, 2008, pp. 244). Through this process, nurses will be in a position to utilise all their knowledge and expertise in key areas: technical, aesthetic, personal, and ethical. It is not that scientific or empirical theory is not important, but appropriate service delivery is all about approaching the problem from different angles, encompassing the qualitative and holistic aspects of a person. In essence, reflective theory incorporates theory with practice and in the process makes it easier for nurses to face arising situations with ease and professionalism (Nobile, Noviello, Cobellis, and Carnielli, 2015, pp. 279). Self-awareness is essential in reflection in order to be conscious of other values and be able to analyse their impact on the situation. One also has to describe the situation for critical analysis. This consists of examining the components of the situation in detail, including assessing the current knowledge, identifying and challenging any assumptions made and exploring alternatives. There is the need to synthesise with the situation, which is to integrate new knowledge with existing knowledge and evaluate the incident to develop a new perspective.

Future actions

The outcome of reflection is to face a situation from a new perspective and ultimately change the held notion on nursing practices and in the process, accommodate theory and practice.  From the caregiver’s case, it is important that in the future a nurse makes sure they are in a position to describe, analyse critically, and evaluate a situation before communicating. A reflective session should serve as a starting point for solutions as this helps minimise problems and further considers the patients and families involved and their feelings. Reflection is a matter of arriving at what is more comfortable for the various parties involved. This is why nurses need to incorporate reflection into their practices. Empirical theory will not help to address this woman’s situation but using relevant reflective skills enables nurses to solve dire situations professionally. The reflective model used helps to identify a learning style and is a lifelong learning tool to develop personal skills and provide better care to patients. The critical aspect of the tool is to increase self-awareness and critical thinking. Reflection helps to consider each task and how one feels, evaluate what was right and what could be improved and to provide an action plan for future practice.

 

 

 

 

 

 

 

 

References

Cooney, A., 1999. Reflection demystified: answering some common questions. British Journal of Nursing-London-Mark Allen Publishing Limited, 8, pp.1530-1537.

Koivusalo, A.I., Pakarinen, M.P., Wikström, A. and Rintala, R.J., 2011. Assessment and treatment of gastroesophageal reflux in healthy infants with apneic episodes: a retrospective analysis of 87 consecutive patients. Clinical pediatrics, 50(12), pp.1096-1102.

Loots, C., Kritas, S., van Wijk, M., McCall, L., Peeters, L., Lewindon, P., Bijlmer, R., Haslam, R., Tobin, J., Benninga, M. and Davidson, G., 2014. Body positioning and medical therapy for infantile gastroesophageal reflux symptoms. Journal of pediatric gastroenterology and nutrition, 59(2), pp.237-243.

Mazzetti, S., Corrado, F.M., Corvaglia, L.T., Martini, S., Mariani, E., Legnani, E.L. and Faldella, G., 2014. Effects of non-nutritive sucking on gastroesophageal reflux in symptomatic preterm infants. Digestive and Liver Disease, 46, p.e125.

Nobile, S., Noviello, C., Cobellis, G. and Carnielli, V.P., 2015. Are infants with bronchopulmonary dysplasia prone to gastroesophageal Reflux? A prospective observational study with esophageal pH-Impedance monitoring. The Journal of pediatrics, 167(2), pp.279-285.

Person, E., Rife, C., Freeman, J., Clark, A. and Castell, D.O., 2015. A novel sleep positioning device reduces gastroesophageal reflux: a randomized controlled trial. Journal of clinical gastroenterology, 49(8), pp.655-659.

Sondheimer, J., 2008. Non-pharmacologic therapy may be effective for infants with gastroesophageal reflux. The Journal of pediatrics, 153(3), pp.441-442.

van Wijk, M. P., Benninga, M. A., Davidson, G. P., Haslam, R., & Omari, T. I. (2010). Small volumes of feed can trigger transient lower esophageal sphincter relaxation and gastroesophageal reflux in the right lateral position in infants. The Journal of pediatrics, 156(5), pp.744-748.