First year student midwife at De Montfort University Natalie Boxall explains how reflective writing and looking at past situations and assessing what you have learnt from them, is key when studying midwifery.
Reflection has emerged as a key concept in educational theory and learning in the health and social care professions (Clark, 2009). It involves looking at a past situation, assessing what you have learnt from it, what you could have done differently, realising new approaches to your care and ultimately, how you felt about the whole experience. A 2006 study found that midwives who had undertaken reflective writing during their degree had adopted the approach once qualified, which benefited their practice (Collington, 2006).
Understanding your feelings is a vital skill for reflective writing, and studying for a midwifery degree involves being in a lot of new situations – doing your first antenatal booking; helping a woman with breastfeeding support; witnessing a birth – which can bring new reactions to the surface. It’s important to comprehend what you feel, why you feel that way and to then learn from it, as failing to reflect can lead to poor insight and therefore poor performance in practice (Hays & Gay, 2011).
Writing reflectively requires a whole new approach to academic writing, and to make things easier there are three common models to follow: Van Manen, Gibbs and Durgahee (Giminez, 2011). They all involve thinking systematically about the phases of an activity, using headings including: description, feelings, evaluation, analysis, conclusion and action plan. These theoretical frameworks provide a starting point for the critical skills that all SMs need to develop by the end of their degree.
Newly qualified midwife Amy Hegarty, who studied at De Montfort University (DMU), says she approaches reflections as mini assignments and often uses situations in practice, which have made her question an aspect of care. She says: ‘I have always used the Gibb’s cycle and analysis is always where the most attention is given. It’s where you examine the literature and learn about what you’ve done and why you’ve done it – was there another way you could have done it? Who says you were right? And, are there any alternative models of care you could have considered?’
The next section involves making sense of your analysis and looking ahead to the future, as Amy explains. ‘You need to look at the findings of your analysis and decide how good the care was that you gave. This is where the action plan comes in – what would you do differently next time, how would the women perceive this, and what difference would it make? You can assess this by looking at many elements, including is it cost-effective, is it holistic or would another approach make your job less stressful and therefore give more job satisfaction?’
Midwifery requires developing self-awareness, as university placements involve adapting to new situations, which are challenging, exciting and sometimes daunting. When you’re working outside of your comfort zone, while trying to take in new information and giving quality care to an array of women, there isn’t a lot of time to think about why you’re doing what you’re doing.
SMs are given time every week during placement to reflect on their experiences, which can primarily help to take ownership of the feelings these experiences provoked. It can also give space for an SM to evaluate their actions and ultimately, help them learn from practical experiences, which ideally should help to develop future practice.
SM Sophie Anderson used the process after delivering a stillbirth. She said in an article for the BJM (BJM 2010): ‘I never wanted to think of what had happened again as it was so upsetting. My mentor suggested that I write a reflection of what happened – I was horrified at the thought... but I am grateful to my mentor for helping me through this experience and I want other students to realise the importance of reflection and what a huge help it can be.’
Most SMs will not have had to think this way before, so how do you recognise when you’re in a situation that would make for a good reflection? Amy Hegarty says her top tip is to always take notes on placement. ‘It’s often best to pick a topic randomly and start writing about it while you have time, rather than waiting for an experience to come up. The specific experience will come along at some point – hopefully not on the day before deadline – but at least if it does you only have to write the description and action plan as the main analysis will already be done.’
Once you have drafted an analysis based on an experience when you’re given a relevant assignment to use it, it’s then a case of fine-tuning it to apply to the outcomes for that module. During the first module of the first year at DMU, SM’s need to submit a formative reflection and three summative reflections, which must cover an antenatal skill, breastfeeding support, postnatal skill and a significant event. Your tutor and your placement mentor will read these.
Amy Hegarty suggests that you should not write with a specific audience in mind. ‘Whether it’s knowing your tutor will be marking it, or that your mentor will see it, you can end up stifling your real feelings because you don’t want to upset them. You should try to forget about them and do what you need to do to get through and finish your reflection.’
Writing a reflection isn’t just about learning how to write in a new way academically, it is a covert way of teaching you to assess your feelings, as Amy Hegarty explains. ‘Writing reflections during your degree can lead on to learning to evaluate your experiences in different ways – whether that is to reflect’ over a cup of tea and crying on your colleague’s shoulder, or to writing conference pieces to present to an audience – it teaches you the skills to adequately deal with the array of experiences you will encounter, throughout the rest of your career.’
Anderson, S. (2010) Learning through experience: a student’s reflection of a stillbirth. British Journal of Midwifery, 18 (12): 814.
Clark, P. (2009) Reflecting on reflection in interprofessional education: Implications for theory and practice. Journal of Interprofessional Care23(3): 213-23.
Collington, V. (2006) Reflection in midwifery education and practice: an exploratory analysis. Evidence Based Midwifery4(3): 76-82.
Giminez, J. (2011) Writing for Nursing and Midwifery Students 2nd ed. Palgrave: UK.
Hays & Gay (2011). Reflection or ‘pre-reflection’: what are we actually measuring in reflective practice? Medical Education. 45: 116–118.
Sue Macdonald explains the importance of reflection and the best way to record practice.
Midwives magazine: Issue 1 :: 2014
‘Reflection’ and ‘reflective practice’ were real buzzwords in midwifery and nursing journals in the 1990s. The concept is based on groundbreaking work by adult educators (Collington, 2006; Kolb, 1984; Schon, 1983), which emphasises the importance of reflection within experiential learning, and how the person can develop and refine their knowledge base. This was translated into requirements for the professional to reflect on their experience, and record this in their professional portfolio or profile record (NMC, 2011).
Prep requirements include a commitment to undertaking continuing professional development (CPD). The Prep (CPD) standard is ‘to maintain a personal professional profile of your learning activity’ (NMC, 2011).
A key component of a professional portfolio is that the clinical practitioner is able to demonstrate the ability to learn from practice, and thereby develop that practice by keeping a reflective journal. It differs from a personal diary in that it does not need to be kept every day and it must focus on incidents from your practice, with an emphasis on both describing and examining events. It should also facilitate further learning to improve or influence practice.
The other reason that you might keep a reflective journal is as a requirement of your study, whether pre-registration or postgraduate. On some courses it might be reviewed by your tutor, or you may be required to share some elements, although this is usually your choice.
You will find that the action of writing or recording events, and then ordering them, will often spark a process of reflection.
What does it look like?
This is your document, therefore you need to choose a format that will suit you best. You may use a notebook, loose-leaf file, video diary or audio tape, computer or tablet or online portfolio (such as RCM i-folio) to enter information.
You must ensure that the journal is safely stored, and that identifiable details (names and places) are kept confidential, by using initials (such as ‘Mrs B’, ‘midwife A’, or ‘Dr X’).
When, how and why?
Find a quiet and private space to write, where you will not be disturbed and are able to think more deeply. Allocate around 30 minutes for the whole activity. After you have written a few entries, it will become easier and you may find you allocate more time as you start enjoying the process.
The topic that you choose is important. It could be something traumatic that you have been brooding about, such as a difficult or challenging situation. Events that you report might also include academic work or attendance at a seminar or study day. This is an important part of recording your CPD and adding it to your portfolio.
Remember to reflect on something positive that you want to think more deeply about too, or something very routine that will challenge your assumptions and ‘taken for granted’ actions, such as a postnatal check.
Finally, you may want to choose a very special event – for example, if you are a new student, you may want to record your experience of the first birth that you attend.
Initially, you might find you get ‘writer’s block’ and struggle to write anything. This is why it is good to start with a simple description of the event: it can be really useful to get you thinking about all the aspects of the event, including the time of day, who was involved, what the incident was, and what you did and said. If you feel able to, you may want to discuss the incident or event with a colleague, mentor, supervisor or even a friend. This may help you to organise your thoughts and feelings.
It can be useful to use a reflective model, or series of questions, which will help you look at the whole event from many different angles (Macdonald, 2011; Driscoll, 1994; Benner, 1984). The Driscoll model has a very simple ‘what’, ‘so what’ and ‘now what’ model, which is easy to remember and write up.
A simple reflective tool is included in Figure 1 – and you may choose to ask additional questions of yourself. It is important to be aware that we all have our own way of reflecting and our own internal model, so adapting someone else’s model can harness that (note that if you use this adapted model in any academic work, you will need to properly attribute the model you adapted, and why you added the prompts you did).
Is it right?
There is no perfect or single way of writing a reflective journal. The important thing is to check the following:
► Have you questioned your actions and justifications?
► Have you been open and honest with yourself?
► Have you identified any new learning you need?
► Have you questioned whether you would do the same again in the same situation?
An important part of completing the journal is to evaluate – looking at the whole of the event, and your actions and outcomes – thinking about what you would do differently, and what knowledge you need to update or access to improve your future practice.
At this point, remind yourself that you do not have to show this to anyone unless you choose to.
You may find that, as you write, your initial views of the event change, and you gain a different perspective – why something happened, and also what you might have done differently. This can be uncomfortable at first, but the result is that your knowledge and practice will improve and continue to develop.
Above all, enjoy writing the journal – it is about you and your reflection and your development as a clinical practitioner.
Simple reflective model
► Why have you chosen this event to reflect on?
► Were you prepared for the event/incident?
► Did you have any concerns or worries beforehand?
► What happened?
► Was it busy?
► Were you stressed?
► Who said/did what?
► Record the ‘wheres and hows’
► What were your feelings?
► What knowledge did you use (textbook/research or from colleagues/routine practice)
► What were you trying to achieve?
► Why did you respond in the way you did?
► What was the outcome for:
• The woman and baby?
• Your colleagues?
• Your student?
► How did others feel about what happened – and how do you know?
► What were the main thoughts/concerns in your mind at the time?
► Thinking about the knowledge you were using, was it based on:
► Was this knowledge enough?
► How could you have dealt with this differently?
► Were you in a position to influence this?
► Would you do the same things if this situation happened again?
• If so, why?
• If not, why not?
► What did you learn (good and bad)?
► What element of practice, or what you did, do you feel was special and must be celebrated?
► Will you use this in your future practice?
► What do you need to update yourself or find out next and how will you do it?
► With whom will you share this (supervisor/mentor or colleague)?
► At this point, what are your views on this event/experience?
► How have you incorporated this into your memory?
To use RCM i-folio, visit: rcm.org.uk/ifolio