Continuing professional development
Reflection, return to practice and revalidation NOP692 Robinson J (2015) Reflection, return to practice and revalidation. Nursing Older People. 27, 6, 31-37. Date of submission: February 19 2015. Date of acceptance: April 4 2015. Correspondence jane.robinson@ addenbrookes.nhs.uk
Abstract This article explores the use of reflection and critical thinking during a return-to-practice programme, demonstrating both concepts and their value in developing insight. The aim of the article is to provide insight into a learner’s reflection about nursing older people and encourage nurses to reflect and think critically about their own practice, which is a requirement of forthcoming revalidation. Lessons learned as a result of reflection must be demonstrated in order for registered nurses to revalidate. Reflection and insight gained from critical thinking can have a positive effect on individual nurses and the quality of patient care they provide.
Aims and intended learning outcomes
This article aims to provide insight into a learner’s reflection about nursing older people and encourage nurses to reflect and think critically about their own practice. It highlights factors influencing a learner’s experience and how reflection aids development of knowledge, skills and insight. It demonstrates that reflection is more than telling a story: it requires deep examination of every aspect of the story in order to learn and to be able to apply that learning in practice. The article explores reflection and critical thinking through the use of a case study, demonstrating both concepts and their value in developing insight and skills. After reading this article and completing the time out activities, you should be able to: ■ Describe what reflection and critical thinking are. ■ Understand a learner’s reflection and critical thinking during a clinical placement. ■ Discuss the pros and cons of Rolfe’s model for reflection (Rolfe et al 2011). ■ Choose a model to use when reflecting on your own experience and observations. ■ Explore what may be involved so that registered nurses comply with Nursing and Midwifery Council (NMC) revalidation from the end of the year.
Introduction
I recently completed a return-to-practice (RTP) programme (Health Education England 2015), along NURSING OLDER PEOPLE
with 23 other people. We had let our registrations lapse for different reasons, but we all wanted to be registered nurses again. The programme was based in one clinical specialty with 20% being in an alternative placement to broaden our experience. I chose to focus my alternative placement in care of older people, specifically dementia care. I had cared for older patients in my RTP specialty during the programme and was aware that I lacked the knowledge and skills to do so well. My approach to the RTP programme was to stretch myself by working in areas in which I had little or no experience. My personal aim was to improve my understanding of the care needs of older patients, particularly those with dementia. I have chosen this case study to demonstrate the processes and value of reflection and critical thinking, in order to highlight the learning process. Goleman (2014) argued that self-awareness drives empathy. Self-awareness is integral to reflection and critical thinking. This article describes how I learned about best practice and myself during this combined process. My memories of care of older people during initial nurse education are mixed. As a first-year student, I spent three months working on a busy Nightingale ward with 33 medical patients. During late shifts there would usually only be one staff nurse and one student present. I went home exhausted after completing the 2pm and 6pm observation rounds, back rounds and two-hourly toileting rounds. They were not the ‘good old days’ for patients or for staff. I also worked in a residential
Jane Robinson is senior co-ordinator to the chief nurse, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust Conflict of interest None declared Keywords Critical thinking, dementia, reflection, return to practice, revalidation This article has been subject to double-blind review and has been checked using antiplagiarism software. For related articles visit our online archive and search using the keywords Author guidelines journals.rcni.com/r/ nop-author-guidelines Acknowledgements I would like to thank the ward staff, trust and higher education institution who supported me during my return to practice and the patients, from whom I learnt so much
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Continuing professional development unit for people who were either physically unable to care for themselves or had dementia. This unit provided planned activities each day, as well as encouraging residents to have mealtimes together. Residents wore their own clothes. It was a happy unit. I recall spending Remembrance Sunday with the residents watching the service on television. I can still see one resident who was not able to have a conversation or go to the toilet without being reminded and she was crying. That morning she and her fellow residents were all aware of what they were watching and what day it was. Dementia will affect one third of people aged 65 or over and it is costly in human and financial terms. The implications for nursing practice cross every NMC (2010) standard of competence for registered nurses. Nurses must keep up to date with developments in diagnosis and care of patients with dementia to ensure that care planning is effective. Care is multiprofessional and this requires leadership and team working. Communicating and working with patients and carers are vital. The prime minister’s challenge on dementia (Department of Health (DH) 2012) aimed to embed the achievements of the National Dementia Strategy (DH 2009). There are three elements to the challenge: ■ Improving health care, such as improving diagnosis rates. ■ Creating dementia-friendly communities by raising awareness of the condition. ■ Increasing research and implementing findings about care or cure.
Reflection
Reflection can be defined as ‘a process of thinking, feeling, imagining and learning by considering what has happened in the past, what might have happened if things had been done differently, what is currently happening and what could possibly happen in the future’ (Rolfe et al 2011). It is a way of ‘establishing a distance from the person and the practice’ (Gustafsson and Fagerberg 2004). It also enables individuals to consider their own performance and promote the process of continuous development (Gustafsson and Fagerberg 2004). This is especially important when caring for older patients or those with dementia. It is difficult to Box 1 Reflection and critical thinking combined Reflection ■ What do I sense? ■ What do I feel? ■ How might this seem to others? (Adapted from Price 2004)
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Critical thinking ■ Are there risks here? ■ What do we know about these circumstances? ■ How do we achieve desired outcomes?
empathise with a person from a different generation. Patients’ behaviour can be unpredictable and it can be easy to label them as ‘difficult’. However, time invested in getting to know patients and their situation is valuable to plan and deliver compassionate, person-centred care. Benefits The following quotes about the benefits of reflection are taken from research by Gustafsson and Fagerberg (2004): ■ Reflection ‘engages the self, together with… thoughts, feelings and actions’. ■ ‘Learning alone, see(ing) situations in different ways and from different perspectives.’ ■ ‘Reflection is a kind of evaluation.’ Gustafsson and Fagerberg (2004) concluded that participants in their study thought that reflection had guided and strengthened them. They also thought that reflection had helped them grow professionally and gain courage from talking about poor and good situations. Although the sample size was only four female nurses, Gustafsson and Fagerberg (2004) described the positive personal value of reflection. Wilding (2008) wrote that reflection had an effect on his personal practice, part of which stemmed from searching for and reading literature about the topic discussed in his article, during the reflective process. Barriers and facilitators Space or time out is required for purposeful reflection. This is not always easy in the clinical setting. Reluctance or difficulty in dealing with the emotions associated with the type of situation that students choose to reflect on is another barrier. This may dissuade some from delving too deeply into reflections about negative situations. The effect of the reflection will not be as great if full feelings or thoughts are not acknowledged. Link between reflection and critical thinking Price (2004) connected reflection and critical thinking (Box 1) and argued that both were required to achieve maximum potential from a learning opportunity. I have found that combining reflection and critical thinking enabled deeper exploration and speculation about what a situation was like for each individual involved and therefore greater understanding and the provision of more individualised care. Rolfe et al (2011) alluded to the value of critical thinking by noting that for reflection to be valuable, it must be ‘systematic and robust’. There are many models of reflection that provide a systematic structure to guide the learner through the process and on to action. The process of reflection is important to achieve the true potential from the learning opportunity. Rolfe et al (2011) advocated written reflection, as the process of writing aids deeper thought processes and therefore NURSING OLDER PEOPLE
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greater insight into a situation. They also discussed the process of ‘guided reflection’. Reflection and practice The nurses in Gustafsson and Fagerberg’s (2004) study could not describe the effect that reflection had on their practice, however, the authors observed that reflection empowered the nurses and had a positive effect on practice development. Magnusson et al (2014) concluded that reflection enabled newly qualified nurses to ‘re-contextualise’ classroom theory; that is, apply theory to practice. Magnusson et al (2014) advocated teaching nurses to use reflection and the skills required to reflect. They noted that it was important that ‘reflection is followed by deliberation and action, which supports safe and effective clinical judgement’. As with any learning the lessons learned from reflection should be shared with the whole care team.
own perspective. Identifying the main people made me think about the situation more deeply than I would have done if only making a superficial observation. ■ What does it feel like to be an older person? This was the initial step in developing understanding and empathy for older people. I was encouraged to try out an age-simulation GERontologic Test (GERT) suit (Figure 2) (Wolfgang Moll 2015) bought using Health Innovation and Education Cluster funding. The suit consisted of heavy bands fastened by Velcro around the neck, legs, ankles and arms. I wore a vest and gloves that restricted movement and grip ability and spectacles with part of the lens covered to mimic various eye conditions. Headphones limited my hearing. Figure 1 Rolfe’s model What? (description)
Case study
This case study describes three shifts working in a care of older people setting. I chose to use Rolfe’s model, described by Rolfe et al (2011) and adapted in Figure 1. Its ‘punchy’ style suits my own learning style. There are three steps to the model: ■ What? Description of the situation. ■ So what? Analysis of the situation from every perspective. ■ Now what? Evaluation of the situation and its implications for practice. Other reflection models have more steps, for example, Johns (1995) and Gibbs (1988). I found that an increased number of steps hampered my reflection because I tried to fit reflection into the steps, rather than letting my thoughts flow. Rolfe’s model enabled me to learn about myself. Its apparent simplicity enabled deeper exploration of each step and therefore greater analysis and understanding. It prompts the reflector into acting on their observation and subsequent reflection. Now do time out 1.
Time out
1
Now what? (action to resolve the situation)
So what? (theory and knowledge)
(Adapted from Rolfe et al 2011)
Figure 2 The age-simulation GERontologic Test suit
Models Consider your preferred model for reflection. Why do you prefer this model? How does it focus on action or improving care?
Rolfe’s model What? As preparation for my clinical placement, I spent one day with the dementia nurse specialist and dementia co-ordinator to update my knowledge and seek advice on the practical skills that would help me provide good care during my placement. I considered the first step from the patient’s perspective, the nurse’s perspective and my NURSING OLDER PEOPLE
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Continuing professional development I went for a 15-minute walk around the hospital site wearing the GERT suit. It was difficult and tiring: my mobility was reduced, I could not see well and my hearing was impaired. It was difficult to navigate steps and crossing the road required considerable planning – although I was accompanied by the dementia co-ordinator, so road safety was not an issue. However, it took me longer to cross than it usually would. I had to wait for a longer gap in the traffic. This was not easy to judge. I had to concentrate to remain safe. What would this have been like if I had been confused as well? How could I have increased my confidence without asking for others’ help? How could I have maintained my independence if family and friends projected their fears about my safety onto me? ■ What is it like to be an older patient in hospital? In the afternoon, I visited wards that had been decorated with older patients in mind, including those who were confused. The furniture was similar to bedroom furniture with wardrobes at the bed spaces. It felt homely. There were café-style tables and chairs placed along the corridor to encourage patients with dementia to stop and sit down. Activities were available such as books to look at or read and music to listen to with headphones. Bays for six people provided company and every effort was made to maintain privacy. This was not a residential unit and the people in the ward had healthcare needs. The King’s Fund (2013) has shown how care environments can promote and maintain patients’ independence and reduce aggression/challenging behaviour. One older people’s nurse specialist involved in the King’s Fund programme said that it changed ‘people’s views and perceptions of what an area that cares for people with dementia can be like in the NHS’. How do we know if a patient feels happy or at home? How might anxiety about the institutional environment be expressed? ■ What expertise is required to nurse older patients in hospital? One patient was sitting down and shouting at the nurse sitting with him. He was trying to tell us something. The dementia co-ordinator approached him and started to talk to him. She tried to clarify what was wrong and what he wanted. The patient was dysphasic, so this was difficult. He was tapping his shoulder and shouting. The dementia co-ordinator sensed that the patient was in pain. My main question was how she knew this from looking at him. It made me feel even less experienced. The nurse with the patient assured us that he had already been given analgesia. The patient looked uncomfortable. The dementia co-ordinator looked through the patient’s notes. His interests were gardening and classical music. The ward had some books available for patients with large pictures on all aspects of life. She suggested that 34 July 2015 | Volume 27 | Number 6
I give the patient one of the books. I was happy to try anything. On sight of the book with large pictures, the patient became calm and repositioned himself. I could not link distraction with an analgesic effect at the time. Speculating now while reflecting reminded me that I used to try this with my children when they were ill. It usually worked. I am not suggesting that patients are like children, only that distraction can help in a situation where communication difficulties exist. I had never experienced such a transformation in a patient’s mood. It showed me the importance of acknowledging that each patient is an individual and trying to maintain individual preferences. My critical thinking led me to value the dementia co-ordinator’s expertise even more. What would we have tried if it had not helped? How can I learn more? I wanted to know everything immediately to help me understand. How can you transfer all of your experience and expertise to the learner in one day? You cannot. So how can expertise be shared quickly and widely? The dementia co-ordinator showed me other equipment to help patients with dementia who are feeling anxious. One was a therapeutic doll that had been used successfully to reduce anxiety for some patients. Tamura et al (2001) found that the dolls helped reduce anxiety and agitation for patients who showed an interest in them, although they would not be appropriate for all patients. I remembered how I felt as a new mother when my baby finally went to sleep: a sense of peace and having done a good job. The therapeutic doll even smelt of talc. I still find that smell calming by association. I would like to know more about examples when this did not work. Not everyone has children, or a patient’s child may have died. ■ What is it like to be a nurse on a care of older people ward? The ward where I undertook my placement had been part of the transforming dementia care in hospitals programme (Brooker et al 2014). Bay nursing had been introduced. The senior sister arranged the off-duty to ensure overlap so that at least one nurse per shift had worked in the same bay on the previous shift. A dance class had been introduced, as advocated by the Alzheimer’s Society (2013). I saw patients who were stiff and uncommunicative become relaxed and chatty with patients from other bays. Contacts were made for a game of scrabble later. Patients were encouraged to talk about themselves and their lives. I saw older men in pyjamas become young men again, dancing the Charleston and talking about what they did during the war. Social activity is a form of nursing care too. I wonder if there is a cultural element here. How would I feel if I was working in another country with older patients who had lived in that country all of their lives? How could I get to know the person inside the patient? NURSING OLDER PEOPLE
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■ What do patients think about me as a nurse? That morning, I bed-bathed a patient who was unable to move or speak. I talked to him as I shaved him and encouraged him to sip water and, later on, some tea. I was working with a staff nurse in our bay. I was observing all six patients. I did not realise that they were observing us too. Rounding was an integral part of nursing care when I last worked as a registered nurse. I tried to make sure that I spoke to each patient as they required care or in rotation. One patient spontaneously said to me: ‘You are one of the better ones.’ I did not know what to say. My rather embarrassed response was, ‘Thank you.’ I wish now that I had the courage to ask him what he meant. This was a missed opportunity to understand my own performance. Now do time out 2.
Time out
2
Speculation Think about speculation. I was encouraged to speculate while reflecting. I did not understand why at first. I now see it as part of critical thinking. Is speculation about care important to you and, if so, why?
So what? The GERT suit made me realise what it is like to have restricted movement and reduced sensory input. I had no energy left to take part in any other activities. I could see how older people may become socially isolated. Some of the people at the residential unit were able bodied but had dementia. Is there a way of simulating this? After the dance class, I chatted to one of the patients as we walked back to his bed space. I told him how much I had learned from hearing him talk about his life. He thought that I meant I had learnt about the war, but for me it was much more profound. I realised as we talked that I had seen him as the person he was before the illness that brought him into hospital. I pride myself on my nursing skills and compassion. However, I had previously viewed patients as patients, not as the people that they are first. This was a difficult realisation for me. The patient with dementia must have found the book interesting or distracting or both. Perhaps he had enjoyed reading and associated the book with his previous life at home. I did not know. It was a distraction that I have since used with other patient groups. Offering patients a magazine recognises their life outside hospital and offers something that they may be able to do without assistance. It also provides something to talk about other than their illness. This allows patients to lead the conversation on an equal footing with nurses. If they choose to do so, it also allows nurses to show something of themselves: who they are outside of the care setting. NURSING OLDER PEOPLE
I requested time with the dementia co-ordinator and dementia nurse specialist to update my knowledge and skills on how best to care for patients with dementia. The fact that I had given the book to the patient who was uncomfortable was important because I thought that I had made a difference. I had not been able to understand his call for attention. I felt helpless and it was frustrating not to be able to help him in the way that he wanted because I could not understand him. This made me feel more confident in this situation and it confirmed the importance of personalising care and activity. However, this learning is no substitute for expertise, although I now have a ‘toolkit’ of approaches to use to develop rapport with a patient quickly in different situations. So much has changed since I was last a registered nurse. However, the dance class activity was similar to those I had experienced in the residential unit when I was a nursing student. It was good to see that we got some things right in the ‘old days’. The use of baby dolls was frowned on during my earlier nursing experience. I recall visiting a patient with dementia and her family in the community and she was carrying a doll. The district nurse had made a dismissive comment about that. She saw it as patronising; like treating an adult as a child. We disregarded some of the things that felt right and were right. What else did we do back then that was similar: nursing that was disregarded and has now been reintroduced? Bay nursing is another example. Bay nursing helped me feel safe on my second day on the ward; knowing the patients and their relatives. Knowing that coffee was preferred to tea and how patients liked to be addressed. I felt more comfortable and this showed in my interactions with patients. I enjoyed being a nurse on the ward. It was one of the highlights of my RTP. The examples of how I learned how to nurse older patients show the importance of pushing ourselves into unfamiliar territory. Working with mentors supports us to feel safe enough to try to develop new insight and skills. The respect that I have for nurses who care for patients with dementia is based on the experience I had of them ‘just knowing’ what to do when they were with a patient. It was like a foreign language to me at first. I feel now that I have a few basic words to get by. Now what? I used my alternative placement to explore an aspect of care that I had mixed experiences and feelings about. The RTP programme taught me new knowledge and skills, such as formal written reflection. Critical thinking and speculation has increased my understanding of what can be achieved through analysis of a situation and the realisation of how long this can take if all the layers of a situation are to become apparent. It takes several rounds of the cycle to gain deeper understanding, as well July 2015 | Volume 27 | Number 6 35
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Continuing professional development
Time out
3
Reflection Use Rolfe’s model (Rolfe et al 2011) to reflect on an experience. How does this compare to your preferred model? Does it have any disadvantages or advantages for you?
Writing this article has forced me to reflect again on my experiences. This all happened during three shifts. Even typing this final version has increased my self-awareness.
Revalidation
During the writing of this article, the new NMC (2015a) code was published and the revalidation pilots began. Revalidation (NMC 2015b) will require registered nurses and midwives to demonstrate how their practice follows the code. Reflection on feedback from patients, service users, carers or colleagues will be central to revalidation, although the details of what this will look like are not yet known. The NMC code (2015a) has four themes: ■ Prioritise people. ■ Practise effectively. ■ Preserve safety. ■ Promote professionalism and trust. I believe that my reflection touches on all of these aspects. For me, part of professionalism is to share experiences and learn from/with colleagues. This is an essential part of practice. Inclusion of patient, service-user or colleague feedback will be part of the revalidation process. It will be a potentially daunting, yet profound, experience for registered nurses who were educated before inclusion of such feedback became an essential element in nurse education. I had not previously been involved in asking patients or their relatives for feedback on 36 July 2015 | Volume 27 | Number 6
how good a nurse I am. During the RTP programme, I developed a neutral, unbiased way of identifying which patients I approached for formal feedback. I made sure that I approached patients from each type of procedure or care that we nursed on my main specialty ward. I asked patients who I had nursed throughout their stay and included those I thought would give me truthful feedback. I gave them all the opportunity to opt out, but they all accepted and took their time to consider all of the questions asked on the pro forma and tick the smiley faces on the Likert scale of patient satisfaction. The feedback that I was given during my time on the ward was spontaneous. I felt awkward because I had not asked for it, although if a member of my team had done a good job, I would have no problem complimenting them in the way that I had been complimented. We need to find a way of not being embarrassed by good feedback or upset by negative feedback given by patients or their carers. This happens to us all informally and formally. Patients may complain or relatives point out what we said that we would do and then did not. We know when we have done something well: the patient looks comfortable and well nursed. We feel happy. Changes to the code (NMC 2015a) will require us all to reflect on such experiences. We will need to find a way of capturing formal and informal feedback on our care, in order to focus on improvement and demonstrate that we are fit for practice. Now do time out 4.
4 Time out
as prompting from another person to delve deeper into the experience. Reflection has helped increase my self-awareness. I thought that I was a good nurse. I maintain privacy and dignity, involve patients in their care and assist where necessary. I listen to patients’ views about their care. However, I did not view older people as they view themselves. I can honestly say now that I am an advocate for older people in hospital and at home. My increased self-awareness has driven me to take a more active role in my own learning. I have been a passive learner, taking situations at face value. I will try to act as a role model in the future: encouraging learners to keep asking why even when they think they have nothing else to say or learn from an experience. Now do time out 3.
Professional development Begin to think about how reflection could be integrated into your professional development.
Conclusion
By providing such a personal account, I hope that I have given insight into how I felt as a learner before, during and after my clinical placement. The fact that I was returning to practice is relevant. I had previous experiences that were mixed and I recognised that practice would have changed during my time out. I am also older, with more life experience, which made me question more as well as contribute more to discussions. Rolfe’s model (Rolfe et al 2011) facilitated my own reflection and greater understanding of a clinical situation during my RTP. The model’s simple structure should not be dismissed as basic or superficial. The aim of this article was to give insight into what practice can be like when returning. It also provides NURSING OLDER PEOPLE
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Time out
5
Revalidation Keep up to date with the NMC’s progress on revalidation by signing up for the monthly e-newsletter at www.nmc.org.uk/news/ newsletters
findings to adapt our practice in planning and delivering care. We should not be afraid to learn from situations good and bad. We should acknowledge and share our feelings, observations and knowledge. This will have a positive effect on us as professionals, patients in our care and society. Now do time outs 5 and 6.
6 Time out
a framework for others to use in their own practice every day and for revalidation. Our role as registered nurses is to assess and plan care within our scope of practice. We are role models, sharing knowledge and working with others to enhance practice. We are the point of contact for patients and their families. We develop our knowledge from experience, reading and reflection. Reflection is a powerful tool, particularly when combined with critical thinking, and another angle to evidence-based care and practice development. The evidence is our experience as well as feedback from patients and learners. We should use all information available with research
Reflective account Now that you have read the article you might like to write a reflective account. Guidelines to help you are on page 38.
Further reading Vaughan P (2013) The Importance of Reflection with Improving Care and Improving Standards and the 6Cs. tinyurl.com/papeotf (Last accessed: May 29 2015.)
References Alzheimer’s Society (2013) Exercise And Physical Activity For People With Dementia. www.alzheimers.org.uk/factsheet/529 (Last accessed: May 20 2015.)
Goleman D (2014) The Secret Antidote to Apathy. www.danielgoleman.info/daniel-gole man-the-secret-antidote-to-apathy (Last accessed: May 20 2015.)
Brooker D, Milosevic S, Evans S et al (2014) RCN Development Programme: Transforming Dementia Care in Hospitals – Evaluation Summary Report. RCN, London.
Gustafsson C, Fagerberg I (2004) Reflection, the way to professional development? Journal of Clinical Nursing. 13, 3, 271-280.
Department of Health (2009) Living Well with Dementia: A National Strategy. DH, Leeds.
Health Education England (2015) Come Back. http://comeback.hee.nhs.uk (Last accessed: May 20 2015.)
Department of Health (2012) Prime Minister’s Challenge on Dementia – Delivering Major Improvements in Dementia Care and Research by 2015. DH, Leeds.
Johns C (1995) Framing learning through reflection within Carper’s fundamental ways of knowing in nursing. Journal of Advanced Nursing. 22, 2, 226-234.
Gibbs G (1988) Learning By Doing: A Guide To Teaching And Learning Methods. Oxford Polytechnic Further Education Unit, Oxford.
King’s Fund (2013) Developing Supportive Design for People with Dementia. The King’s Fund’s Enhancing the Healing Environment Programme 2009-2012. tinyurl.com/a84792b (Last accessed: June 1 2015.)
NURSING OLDER PEOPLE
Magnusson C, Westwood S, Ball E et al (2014) An Investigation Into Newly Qualified Nurses’ Ability To Recontextualise Knowledge To Allow Them To Delegate And Supervise Care (AaRK). University of Surrey, Guildford. Nursing and Midwifery Council (2010) Standards for Competence for Registered Nurses. NMC, London. Nursing and Midwifery Council (2015a) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. NMC, London. Nursing and Midwifery Council (2015b) Revalidation. tinyurl.com/q8vdfn6 (Last accessed: June 1 2015.)
Rolfe G, Jasper M, Freshwater D (2011) Critical Reflection in Practice: Generating Knowledge for Care. Second edition. Palgrave Macmillan, Basingstoke. Tamura T, Nakajima K, Nambu M et al (2001) Baby dolls as therapeutic tools for severe dementia patients. Gerontechnology. 1, 2, 111-118. tinyurl.com/nr5snpr Wilding P (2008) Reflective practice: a learning tool for student nurses. British Journal of Nursing. 17, 11, 720-724. Wolfgang Moll (2015) Age Simulation Suit GERT. www.age-simulation-suit.com (Last accessed: May 20 2015.)
Price A (2004) Encouraging reflection and critical thinking in practice. Nursing Standard. 18, 47, 46-52.
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Reflection, return to practice and revalidation NOP692 Robinson J (2015) Reflection, return to practice and revalidation. Nursing Older People. 27, 6, 31-37. Date of submission: February 19 2015. Date of acceptance: April 4 2015. Correspondence jane.robinson@ addenbrookes.nhs.uk
Abstract This article explores the use of reflection and critical thinking during a return-to-practice programme, demonstrating both concepts and their value in developing insight. The aim of the article is to provide insight into a learner’s reflection about nursing older people and encourage nurses to reflect and think critically about their own practice, which is a requirement of forthcoming revalidation. Lessons learned as a result of reflection must be demonstrated in order for registered nurses to revalidate. Reflection and insight gained from critical thinking can have a positive effect on individual nurses and the quality of patient care they provide.
Aims and intended learning outcomes
This article aims to provide insight into a learner’s reflection about nursing older people and encourage nurses to reflect and think critically about their own practice. It highlights factors influencing a learner’s experience and how reflection aids development of knowledge, skills and insight. It demonstrates that reflection is more than telling a story: it requires deep examination of every aspect of the story in order to learn and to be able to apply that learning in practice. The article explores reflection and critical thinking through the use of a case study, demonstrating both concepts and their value in developing insight and skills. After reading this article and completing the time out activities, you should be able to: ■ Describe what reflection and critical thinking are. ■ Understand a learner’s reflection and critical thinking during a clinical placement. ■ Discuss the pros and cons of Rolfe’s model for reflection (Rolfe et al 2011). ■ Choose a model to use when reflecting on your own experience and observations. ■ Explore what may be involved so that registered nurses comply with Nursing and Midwifery Council (NMC) revalidation from the end of the year.
Introduction
I recently completed a return-to-practice (RTP) programme (Health Education England 2015), along NURSING OLDER PEOPLE
with 23 other people. We had let our registrations lapse for different reasons, but we all wanted to be registered nurses again. The programme was based in one clinical specialty with 20% being in an alternative placement to broaden our experience. I chose to focus my alternative placement in care of older people, specifically dementia care. I had cared for older patients in my RTP specialty during the programme and was aware that I lacked the knowledge and skills to do so well. My approach to the RTP programme was to stretch myself by working in areas in which I had little or no experience. My personal aim was to improve my understanding of the care needs of older patients, particularly those with dementia. I have chosen this case study to demonstrate the processes and value of reflection and critical thinking, in order to highlight the learning process. Goleman (2014) argued that self-awareness drives empathy. Self-awareness is integral to reflection and critical thinking. This article describes how I learned about best practice and myself during this combined process. My memories of care of older people during initial nurse education are mixed. As a first-year student, I spent three months working on a busy Nightingale ward with 33 medical patients. During late shifts there would usually only be one staff nurse and one student present. I went home exhausted after completing the 2pm and 6pm observation rounds, back rounds and two-hourly toileting rounds. They were not the ‘good old days’ for patients or for staff. I also worked in a residential
Jane Robinson is senior co-ordinator to the chief nurse, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust Conflict of interest None declared Keywords Critical thinking, dementia, reflection, return to practice, revalidation This article has been subject to double-blind review and has been checked using antiplagiarism software. For related articles visit our online archive and search using the keywords Author guidelines journals.rcni.com/r/ nop-author-guidelines Acknowledgements I would like to thank the ward staff, trust and higher education institution who supported me during my return to practice and the patients, from whom I learnt so much
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Continuing professional development unit for people who were either physically unable to care for themselves or had dementia. This unit provided planned activities each day, as well as encouraging residents to have mealtimes together. Residents wore their own clothes. It was a happy unit. I recall spending Remembrance Sunday with the residents watching the service on television. I can still see one resident who was not able to have a conversation or go to the toilet without being reminded and she was crying. That morning she and her fellow residents were all aware of what they were watching and what day it was. Dementia will affect one third of people aged 65 or over and it is costly in human and financial terms. The implications for nursing practice cross every NMC (2010) standard of competence for registered nurses. Nurses must keep up to date with developments in diagnosis and care of patients with dementia to ensure that care planning is effective. Care is multiprofessional and this requires leadership and team working. Communicating and working with patients and carers are vital. The prime minister’s challenge on dementia (Department of Health (DH) 2012) aimed to embed the achievements of the National Dementia Strategy (DH 2009). There are three elements to the challenge: ■ Improving health care, such as improving diagnosis rates. ■ Creating dementia-friendly communities by raising awareness of the condition. ■ Increasing research and implementing findings about care or cure.
Reflection
Reflection can be defined as ‘a process of thinking, feeling, imagining and learning by considering what has happened in the past, what might have happened if things had been done differently, what is currently happening and what could possibly happen in the future’ (Rolfe et al 2011). It is a way of ‘establishing a distance from the person and the practice’ (Gustafsson and Fagerberg 2004). It also enables individuals to consider their own performance and promote the process of continuous development (Gustafsson and Fagerberg 2004). This is especially important when caring for older patients or those with dementia. It is difficult to Box 1 Reflection and critical thinking combined Reflection ■ What do I sense? ■ What do I feel? ■ How might this seem to others? (Adapted from Price 2004)
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Critical thinking ■ Are there risks here? ■ What do we know about these circumstances? ■ How do we achieve desired outcomes?
empathise with a person from a different generation. Patients’ behaviour can be unpredictable and it can be easy to label them as ‘difficult’. However, time invested in getting to know patients and their situation is valuable to plan and deliver compassionate, person-centred care. Benefits The following quotes about the benefits of reflection are taken from research by Gustafsson and Fagerberg (2004): ■ Reflection ‘engages the self, together with… thoughts, feelings and actions’. ■ ‘Learning alone, see(ing) situations in different ways and from different perspectives.’ ■ ‘Reflection is a kind of evaluation.’ Gustafsson and Fagerberg (2004) concluded that participants in their study thought that reflection had guided and strengthened them. They also thought that reflection had helped them grow professionally and gain courage from talking about poor and good situations. Although the sample size was only four female nurses, Gustafsson and Fagerberg (2004) described the positive personal value of reflection. Wilding (2008) wrote that reflection had an effect on his personal practice, part of which stemmed from searching for and reading literature about the topic discussed in his article, during the reflective process. Barriers and facilitators Space or time out is required for purposeful reflection. This is not always easy in the clinical setting. Reluctance or difficulty in dealing with the emotions associated with the type of situation that students choose to reflect on is another barrier. This may dissuade some from delving too deeply into reflections about negative situations. The effect of the reflection will not be as great if full feelings or thoughts are not acknowledged. Link between reflection and critical thinking Price (2004) connected reflection and critical thinking (Box 1) and argued that both were required to achieve maximum potential from a learning opportunity. I have found that combining reflection and critical thinking enabled deeper exploration and speculation about what a situation was like for each individual involved and therefore greater understanding and the provision of more individualised care. Rolfe et al (2011) alluded to the value of critical thinking by noting that for reflection to be valuable, it must be ‘systematic and robust’. There are many models of reflection that provide a systematic structure to guide the learner through the process and on to action. The process of reflection is important to achieve the true potential from the learning opportunity. Rolfe et al (2011) advocated written reflection, as the process of writing aids deeper thought processes and therefore NURSING OLDER PEOPLE
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greater insight into a situation. They also discussed the process of ‘guided reflection’. Reflection and practice The nurses in Gustafsson and Fagerberg’s (2004) study could not describe the effect that reflection had on their practice, however, the authors observed that reflection empowered the nurses and had a positive effect on practice development. Magnusson et al (2014) concluded that reflection enabled newly qualified nurses to ‘re-contextualise’ classroom theory; that is, apply theory to practice. Magnusson et al (2014) advocated teaching nurses to use reflection and the skills required to reflect. They noted that it was important that ‘reflection is followed by deliberation and action, which supports safe and effective clinical judgement’. As with any learning the lessons learned from reflection should be shared with the whole care team.
own perspective. Identifying the main people made me think about the situation more deeply than I would have done if only making a superficial observation. ■ What does it feel like to be an older person? This was the initial step in developing understanding and empathy for older people. I was encouraged to try out an age-simulation GERontologic Test (GERT) suit (Figure 2) (Wolfgang Moll 2015) bought using Health Innovation and Education Cluster funding. The suit consisted of heavy bands fastened by Velcro around the neck, legs, ankles and arms. I wore a vest and gloves that restricted movement and grip ability and spectacles with part of the lens covered to mimic various eye conditions. Headphones limited my hearing. Figure 1 Rolfe’s model What? (description)
Case study
This case study describes three shifts working in a care of older people setting. I chose to use Rolfe’s model, described by Rolfe et al (2011) and adapted in Figure 1. Its ‘punchy’ style suits my own learning style. There are three steps to the model: ■ What? Description of the situation. ■ So what? Analysis of the situation from every perspective. ■ Now what? Evaluation of the situation and its implications for practice. Other reflection models have more steps, for example, Johns (1995) and Gibbs (1988). I found that an increased number of steps hampered my reflection because I tried to fit reflection into the steps, rather than letting my thoughts flow. Rolfe’s model enabled me to learn about myself. Its apparent simplicity enabled deeper exploration of each step and therefore greater analysis and understanding. It prompts the reflector into acting on their observation and subsequent reflection. Now do time out 1.
Time out
1
Now what? (action to resolve the situation)
So what? (theory and knowledge)
(Adapted from Rolfe et al 2011)
Figure 2 The age-simulation GERontologic Test suit
Models Consider your preferred model for reflection. Why do you prefer this model? How does it focus on action or improving care?
Rolfe’s model What? As preparation for my clinical placement, I spent one day with the dementia nurse specialist and dementia co-ordinator to update my knowledge and seek advice on the practical skills that would help me provide good care during my placement. I considered the first step from the patient’s perspective, the nurse’s perspective and my NURSING OLDER PEOPLE
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Continuing professional development I went for a 15-minute walk around the hospital site wearing the GERT suit. It was difficult and tiring: my mobility was reduced, I could not see well and my hearing was impaired. It was difficult to navigate steps and crossing the road required considerable planning – although I was accompanied by the dementia co-ordinator, so road safety was not an issue. However, it took me longer to cross than it usually would. I had to wait for a longer gap in the traffic. This was not easy to judge. I had to concentrate to remain safe. What would this have been like if I had been confused as well? How could I have increased my confidence without asking for others’ help? How could I have maintained my independence if family and friends projected their fears about my safety onto me? ■ What is it like to be an older patient in hospital? In the afternoon, I visited wards that had been decorated with older patients in mind, including those who were confused. The furniture was similar to bedroom furniture with wardrobes at the bed spaces. It felt homely. There were café-style tables and chairs placed along the corridor to encourage patients with dementia to stop and sit down. Activities were available such as books to look at or read and music to listen to with headphones. Bays for six people provided company and every effort was made to maintain privacy. This was not a residential unit and the people in the ward had healthcare needs. The King’s Fund (2013) has shown how care environments can promote and maintain patients’ independence and reduce aggression/challenging behaviour. One older people’s nurse specialist involved in the King’s Fund programme said that it changed ‘people’s views and perceptions of what an area that cares for people with dementia can be like in the NHS’. How do we know if a patient feels happy or at home? How might anxiety about the institutional environment be expressed? ■ What expertise is required to nurse older patients in hospital? One patient was sitting down and shouting at the nurse sitting with him. He was trying to tell us something. The dementia co-ordinator approached him and started to talk to him. She tried to clarify what was wrong and what he wanted. The patient was dysphasic, so this was difficult. He was tapping his shoulder and shouting. The dementia co-ordinator sensed that the patient was in pain. My main question was how she knew this from looking at him. It made me feel even less experienced. The nurse with the patient assured us that he had already been given analgesia. The patient looked uncomfortable. The dementia co-ordinator looked through the patient’s notes. His interests were gardening and classical music. The ward had some books available for patients with large pictures on all aspects of life. She suggested that 34 July 2015 | Volume 27 | Number 6
I give the patient one of the books. I was happy to try anything. On sight of the book with large pictures, the patient became calm and repositioned himself. I could not link distraction with an analgesic effect at the time. Speculating now while reflecting reminded me that I used to try this with my children when they were ill. It usually worked. I am not suggesting that patients are like children, only that distraction can help in a situation where communication difficulties exist. I had never experienced such a transformation in a patient’s mood. It showed me the importance of acknowledging that each patient is an individual and trying to maintain individual preferences. My critical thinking led me to value the dementia co-ordinator’s expertise even more. What would we have tried if it had not helped? How can I learn more? I wanted to know everything immediately to help me understand. How can you transfer all of your experience and expertise to the learner in one day? You cannot. So how can expertise be shared quickly and widely? The dementia co-ordinator showed me other equipment to help patients with dementia who are feeling anxious. One was a therapeutic doll that had been used successfully to reduce anxiety for some patients. Tamura et al (2001) found that the dolls helped reduce anxiety and agitation for patients who showed an interest in them, although they would not be appropriate for all patients. I remembered how I felt as a new mother when my baby finally went to sleep: a sense of peace and having done a good job. The therapeutic doll even smelt of talc. I still find that smell calming by association. I would like to know more about examples when this did not work. Not everyone has children, or a patient’s child may have died. ■ What is it like to be a nurse on a care of older people ward? The ward where I undertook my placement had been part of the transforming dementia care in hospitals programme (Brooker et al 2014). Bay nursing had been introduced. The senior sister arranged the off-duty to ensure overlap so that at least one nurse per shift had worked in the same bay on the previous shift. A dance class had been introduced, as advocated by the Alzheimer’s Society (2013). I saw patients who were stiff and uncommunicative become relaxed and chatty with patients from other bays. Contacts were made for a game of scrabble later. Patients were encouraged to talk about themselves and their lives. I saw older men in pyjamas become young men again, dancing the Charleston and talking about what they did during the war. Social activity is a form of nursing care too. I wonder if there is a cultural element here. How would I feel if I was working in another country with older patients who had lived in that country all of their lives? How could I get to know the person inside the patient? NURSING OLDER PEOPLE
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■ What do patients think about me as a nurse? That morning, I bed-bathed a patient who was unable to move or speak. I talked to him as I shaved him and encouraged him to sip water and, later on, some tea. I was working with a staff nurse in our bay. I was observing all six patients. I did not realise that they were observing us too. Rounding was an integral part of nursing care when I last worked as a registered nurse. I tried to make sure that I spoke to each patient as they required care or in rotation. One patient spontaneously said to me: ‘You are one of the better ones.’ I did not know what to say. My rather embarrassed response was, ‘Thank you.’ I wish now that I had the courage to ask him what he meant. This was a missed opportunity to understand my own performance. Now do time out 2.
Time out
2
Speculation Think about speculation. I was encouraged to speculate while reflecting. I did not understand why at first. I now see it as part of critical thinking. Is speculation about care important to you and, if so, why?
So what? The GERT suit made me realise what it is like to have restricted movement and reduced sensory input. I had no energy left to take part in any other activities. I could see how older people may become socially isolated. Some of the people at the residential unit were able bodied but had dementia. Is there a way of simulating this? After the dance class, I chatted to one of the patients as we walked back to his bed space. I told him how much I had learned from hearing him talk about his life. He thought that I meant I had learnt about the war, but for me it was much more profound. I realised as we talked that I had seen him as the person he was before the illness that brought him into hospital. I pride myself on my nursing skills and compassion. However, I had previously viewed patients as patients, not as the people that they are first. This was a difficult realisation for me. The patient with dementia must have found the book interesting or distracting or both. Perhaps he had enjoyed reading and associated the book with his previous life at home. I did not know. It was a distraction that I have since used with other patient groups. Offering patients a magazine recognises their life outside hospital and offers something that they may be able to do without assistance. It also provides something to talk about other than their illness. This allows patients to lead the conversation on an equal footing with nurses. If they choose to do so, it also allows nurses to show something of themselves: who they are outside of the care setting. NURSING OLDER PEOPLE
I requested time with the dementia co-ordinator and dementia nurse specialist to update my knowledge and skills on how best to care for patients with dementia. The fact that I had given the book to the patient who was uncomfortable was important because I thought that I had made a difference. I had not been able to understand his call for attention. I felt helpless and it was frustrating not to be able to help him in the way that he wanted because I could not understand him. This made me feel more confident in this situation and it confirmed the importance of personalising care and activity. However, this learning is no substitute for expertise, although I now have a ‘toolkit’ of approaches to use to develop rapport with a patient quickly in different situations. So much has changed since I was last a registered nurse. However, the dance class activity was similar to those I had experienced in the residential unit when I was a nursing student. It was good to see that we got some things right in the ‘old days’. The use of baby dolls was frowned on during my earlier nursing experience. I recall visiting a patient with dementia and her family in the community and she was carrying a doll. The district nurse had made a dismissive comment about that. She saw it as patronising; like treating an adult as a child. We disregarded some of the things that felt right and were right. What else did we do back then that was similar: nursing that was disregarded and has now been reintroduced? Bay nursing is another example. Bay nursing helped me feel safe on my second day on the ward; knowing the patients and their relatives. Knowing that coffee was preferred to tea and how patients liked to be addressed. I felt more comfortable and this showed in my interactions with patients. I enjoyed being a nurse on the ward. It was one of the highlights of my RTP. The examples of how I learned how to nurse older patients show the importance of pushing ourselves into unfamiliar territory. Working with mentors supports us to feel safe enough to try to develop new insight and skills. The respect that I have for nurses who care for patients with dementia is based on the experience I had of them ‘just knowing’ what to do when they were with a patient. It was like a foreign language to me at first. I feel now that I have a few basic words to get by. Now what? I used my alternative placement to explore an aspect of care that I had mixed experiences and feelings about. The RTP programme taught me new knowledge and skills, such as formal written reflection. Critical thinking and speculation has increased my understanding of what can be achieved through analysis of a situation and the realisation of how long this can take if all the layers of a situation are to become apparent. It takes several rounds of the cycle to gain deeper understanding, as well July 2015 | Volume 27 | Number 6 35
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Continuing professional development
Time out
3
Reflection Use Rolfe’s model (Rolfe et al 2011) to reflect on an experience. How does this compare to your preferred model? Does it have any disadvantages or advantages for you?
Writing this article has forced me to reflect again on my experiences. This all happened during three shifts. Even typing this final version has increased my self-awareness.
Revalidation
During the writing of this article, the new NMC (2015a) code was published and the revalidation pilots began. Revalidation (NMC 2015b) will require registered nurses and midwives to demonstrate how their practice follows the code. Reflection on feedback from patients, service users, carers or colleagues will be central to revalidation, although the details of what this will look like are not yet known. The NMC code (2015a) has four themes: ■ Prioritise people. ■ Practise effectively. ■ Preserve safety. ■ Promote professionalism and trust. I believe that my reflection touches on all of these aspects. For me, part of professionalism is to share experiences and learn from/with colleagues. This is an essential part of practice. Inclusion of patient, service-user or colleague feedback will be part of the revalidation process. It will be a potentially daunting, yet profound, experience for registered nurses who were educated before inclusion of such feedback became an essential element in nurse education. I had not previously been involved in asking patients or their relatives for feedback on 36 July 2015 | Volume 27 | Number 6
how good a nurse I am. During the RTP programme, I developed a neutral, unbiased way of identifying which patients I approached for formal feedback. I made sure that I approached patients from each type of procedure or care that we nursed on my main specialty ward. I asked patients who I had nursed throughout their stay and included those I thought would give me truthful feedback. I gave them all the opportunity to opt out, but they all accepted and took their time to consider all of the questions asked on the pro forma and tick the smiley faces on the Likert scale of patient satisfaction. The feedback that I was given during my time on the ward was spontaneous. I felt awkward because I had not asked for it, although if a member of my team had done a good job, I would have no problem complimenting them in the way that I had been complimented. We need to find a way of not being embarrassed by good feedback or upset by negative feedback given by patients or their carers. This happens to us all informally and formally. Patients may complain or relatives point out what we said that we would do and then did not. We know when we have done something well: the patient looks comfortable and well nursed. We feel happy. Changes to the code (NMC 2015a) will require us all to reflect on such experiences. We will need to find a way of capturing formal and informal feedback on our care, in order to focus on improvement and demonstrate that we are fit for practice. Now do time out 4.
4 Time out
as prompting from another person to delve deeper into the experience. Reflection has helped increase my self-awareness. I thought that I was a good nurse. I maintain privacy and dignity, involve patients in their care and assist where necessary. I listen to patients’ views about their care. However, I did not view older people as they view themselves. I can honestly say now that I am an advocate for older people in hospital and at home. My increased self-awareness has driven me to take a more active role in my own learning. I have been a passive learner, taking situations at face value. I will try to act as a role model in the future: encouraging learners to keep asking why even when they think they have nothing else to say or learn from an experience. Now do time out 3.
Professional development Begin to think about how reflection could be integrated into your professional development.
Conclusion
By providing such a personal account, I hope that I have given insight into how I felt as a learner before, during and after my clinical placement. The fact that I was returning to practice is relevant. I had previous experiences that were mixed and I recognised that practice would have changed during my time out. I am also older, with more life experience, which made me question more as well as contribute more to discussions. Rolfe’s model (Rolfe et al 2011) facilitated my own reflection and greater understanding of a clinical situation during my RTP. The model’s simple structure should not be dismissed as basic or superficial. The aim of this article was to give insight into what practice can be like when returning. It also provides NURSING OLDER PEOPLE
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Time out
5
Revalidation Keep up to date with the NMC’s progress on revalidation by signing up for the monthly e-newsletter at www.nmc.org.uk/news/ newsletters
findings to adapt our practice in planning and delivering care. We should not be afraid to learn from situations good and bad. We should acknowledge and share our feelings, observations and knowledge. This will have a positive effect on us as professionals, patients in our care and society. Now do time outs 5 and 6.
6 Time out
a framework for others to use in their own practice every day and for revalidation. Our role as registered nurses is to assess and plan care within our scope of practice. We are role models, sharing knowledge and working with others to enhance practice. We are the point of contact for patients and their families. We develop our knowledge from experience, reading and reflection. Reflection is a powerful tool, particularly when combined with critical thinking, and another angle to evidence-based care and practice development. The evidence is our experience as well as feedback from patients and learners. We should use all information available with research
Reflective account Now that you have read the article you might like to write a reflective account. Guidelines to help you are on page 38.
Further reading Vaughan P (2013) The Importance of Reflection with Improving Care and Improving Standards and the 6Cs. tinyurl.com/papeotf (Last accessed: May 29 2015.)
References Alzheimer’s Society (2013) Exercise And Physical Activity For People With Dementia. www.alzheimers.org.uk/factsheet/529 (Last accessed: May 20 2015.)
Goleman D (2014) The Secret Antidote to Apathy. www.danielgoleman.info/daniel-gole man-the-secret-antidote-to-apathy (Last accessed: May 20 2015.)
Brooker D, Milosevic S, Evans S et al (2014) RCN Development Programme: Transforming Dementia Care in Hospitals – Evaluation Summary Report. RCN, London.
Gustafsson C, Fagerberg I (2004) Reflection, the way to professional development? Journal of Clinical Nursing. 13, 3, 271-280.
Department of Health (2009) Living Well with Dementia: A National Strategy. DH, Leeds.
Health Education England (2015) Come Back. http://comeback.hee.nhs.uk (Last accessed: May 20 2015.)
Department of Health (2012) Prime Minister’s Challenge on Dementia – Delivering Major Improvements in Dementia Care and Research by 2015. DH, Leeds.
Johns C (1995) Framing learning through reflection within Carper’s fundamental ways of knowing in nursing. Journal of Advanced Nursing. 22, 2, 226-234.
Gibbs G (1988) Learning By Doing: A Guide To Teaching And Learning Methods. Oxford Polytechnic Further Education Unit, Oxford.
King’s Fund (2013) Developing Supportive Design for People with Dementia. The King’s Fund’s Enhancing the Healing Environment Programme 2009-2012. tinyurl.com/a84792b (Last accessed: June 1 2015.)
NURSING OLDER PEOPLE
Magnusson C, Westwood S, Ball E et al (2014) An Investigation Into Newly Qualified Nurses’ Ability To Recontextualise Knowledge To Allow Them To Delegate And Supervise Care (AaRK). University of Surrey, Guildford. Nursing and Midwifery Council (2010) Standards for Competence for Registered Nurses. NMC, London. Nursing and Midwifery Council (2015a) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. NMC, London. Nursing and Midwifery Council (2015b) Revalidation. tinyurl.com/q8vdfn6 (Last accessed: June 1 2015.)
Rolfe G, Jasper M, Freshwater D (2011) Critical Reflection in Practice: Generating Knowledge for Care. Second edition. Palgrave Macmillan, Basingstoke. Tamura T, Nakajima K, Nambu M et al (2001) Baby dolls as therapeutic tools for severe dementia patients. Gerontechnology. 1, 2, 111-118. tinyurl.com/nr5snpr Wilding P (2008) Reflective practice: a learning tool for student nurses. British Journal of Nursing. 17, 11, 720-724. Wolfgang Moll (2015) Age Simulation Suit GERT. www.age-simulation-suit.com (Last accessed: May 20 2015.)
Price A (2004) Encouraging reflection and critical thinking in practice. Nursing Standard. 18, 47, 46-52.
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