examples of reflective writing in mental health nursing

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Reflective journal writing: how can it help?

Discover the benefits of writing down your thoughts and how to get started

Reflective journal writing is a way of documenting what you’re thinking and feeling in the moment, and can be a useful tool to help manage stress and anxiety.

Dr Christopher Westoby, author of The Fear Talking: The True Story of a Young Man and Anxiety, is a strong believer in the power of stories to educate, improve understanding and benefit the wellbeing of the storyteller.

We spoke to Chris about the benefits of writing for your mental wellbeing.

Can reflective writing help nursing staff?

Absolutely. Regardless of your background, and wherever you work, everyone has this universal need to reflect upon their own experiences and one of the best tools we have for that is writing. It is similar to the process of opening the windows to a room and letting some air in.

Everyone has this universal need to reflect upon their own experiences 

We all have so many thoughts and memories whirling round our head at any given time – especially in the current climate. Sometimes the cloud of everything happening at once can be more overwhelming than any one event itself. Reflective journal writing can help with that.

How does it help?

We often struggle to come to terms with whatever it is we’ve been through unless we take a second and address these things head on. And while it may not always be an easy thing to do – or a quick fix – by writing what’s going on internally, what you’re doing is externalising something that has been haunting you or playing on your mind. Once it’s out there on the page, it’s like you can lay it to rest. 

You also now have a choice on what you want to do with it. Are you going to delete it or keep it for yourself? Are you going to let someone else read it? As you make those decisions, you’re taking control of your emotions and the clouds may start to clear.

So, what are the benefits?

The sense of control over your own experiences can be empowering and help relieve any stress or anxiety you’re experiencing. You’ve let it be acknowledged that what you’re feeling is something, it’s being validated and now it’s written down, it may no longer feel quite so insurmountable.

Any tips to get started?

My first tip is to use whatever format works best for you – whatever it is that will help get you in the habit of doing it. Don’t use handwriting if you’d rather type, and vice versa. 

I’ve worked with students before who have talked about using voice memos. They’ve just hit record and then they either deleted it or transcribed it depending on what they’ve found most beneficial. 

My second tip is to think of prompts. Maybe ask yourself questions to help get you started – what am I grateful for? What have I found difficult? Perhaps focus on one part of the day – how did I feel after my shift? On the way to work? Going to bed?

Finally, think about setting yourself some restrictions. Try setting a timer on your phone and then keep writing until it goes off. The more restrictions you set, the less daunting writing can be. You might actually find yourself more inspired.

How often should I write?

It’s a good thing to try and do every day – even if it’s only a few sentences – for as long as you find it useful. I’d suggest giving it a go for two weeks and see how you’re finding it.

What if I find it hard writing about myself?

If it seems too difficult writing about yourself, try writing about someone else or something you observed today – perhaps something you noticed on your journey home or through your window. If you write about something else, you will inevitably find yourself beginning to include elements of yourself. 

If you’re finding it too emotionally draining to revisit certain memories, remember this writing is your property – you can change what you need to, you can change the details and you can just talk about a small part of it. The key is to remember that you’re in control and it’s up to you how you document it.

The key is to remember you're in control

There are fewer ways to offload to one another at the moment, to distract ourselves and to blow off steam, so even if journal writing doesn’t work for you, it’s worth a try.

The benefits might surprise you.

About Chris

Chris is Programme Director of the Hull Creative Writing MA (Online). His book The Fear Talking: The True Story of a Young Man and Anxiety was published in December 2020. He led the RCN’s workshop “Time to Write for Yourself” last year.

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Reflection and mental health nursing. Part one: is reflection important?

In this new series, John Fowler, a noted nursing author, will explore the use of reflection in mental health nursing. Over the next eight issues, John will be examining some of the techniques that mental health nurses can use to aid their own reflection and how reflection can be applied to clinical practice and management. The series will cover portfolios, reflective learning, reflective evidence, the use of feedback and reflection in all aspects of life.

• Related Documents

Measuring therapeutic engagement in acute mental health inpatient environments: the perspectives of service users and mental health nurses

Abstract Background: A key component of caring for service users (SUs) in acute mental health inpatient environments is Therapeutic Engagement (TE). To that end, the Therapeutic Engagement Questionnaire (TEQ) was developed and validated. The TEQ measures TE between SUs and registered mental health nurses (RMHNs) from the perspective of both parties and can quantify and recognise how nurses engage with SUs and monitor this activity as well as its enhancement of SU care and recovery. The aim of this study was to explore the views of SUs and RMHNs in relation to the TEQ and how it could be adopted into clinical practice within an acute inpatient environment.Methods: As part of the validation stage of the development of the TEQ, the views of 628 SUs and 543 RMHNs were collected using a qualitative approach by way of free text at the end of the questionnaire. Two questions required free text response: – ‘what do you think of the TEQ?’, and ‘how can it be utilised?’Results: Following thematic analysis, it was found that both sets of participants stated that such a tool could be utilised to improve the service, could help nurses with reflective practice, be utilised as part of clinical supervision and to aid nurses’ professional development. The nurse participants also stated that such a tool would help track SU participation and enablement in their care. Furthermore, the nurses noted that the tool would help to reinforce the core ‘caring’ value of nursing and the overall goal of recovery. The SUs added that a TE tool would recognise the work of mental health nurses and provide them with a clear opportunity to express their views in relation to nursing staff.Conclusions: Therapeutic engagement (TE) has been identified as part of the repertoire of mental health nursing and both groups of participants identified how a tool to assess this construct may be utilised in day-to-day clinical practice to the benefit of each group.

Reflection and mental health nursing. Part two: reflection in everyday practice

In the second part of this new series on reflection in mental health nursing, John Fowler examines two different perspectives of reflection that are used in everyday clinical practice. He explores how most nurses are aware of their use of reflection following a nursing action or an incident, but are less aware of their ability to use reflection during action. Further articles in the series will be available online and will examine the application of reflection to everyday clinical practice including making time, reflective techniques and reflective learning.

Abstract Background A key component of caring for service users (SUs) in acute mental health inpatient environments is Therapeutic Engagement (TE). To that end, the Therapeutic Engagement Questionnaire (TEQ) was developed and validated. The TEQ measures TE between SUs and registered mental health nurses (RMHNs) from the perspective of both parties and can quantify and recognise how nurses engage with SUs and monitor this activity as well as its enhancement of SU care and recovery. The aim of this study was to explore the views of SUs and RMHNs in relation to the TEQ and how it could be adopted into clinical practice within an acute inpatient environment. Methods As part of the validation stage of the development of the TEQ, the views of 628 SUs and 543 RMHNs were collected using a qualitative approach by way of free text at the end of the questionnaire. Two questions required free text response: – ‘what do you think of the TEQ?’, and ‘how can it be utilised?’ Results Following thematic analysis, it was found that both sets of participants stated that such a tool could be utilised to improve the service, could help nurses with reflective practice, be utilised as part of clinical supervision and to aid nurses’ professional development. The nurse participants also stated that such a tool would help track SU participation and enablement in their care. Furthermore, the nurses noted that the tool would help to reinforce the core ‘caring’ value of nursing and the overall goal of recovery. The SUs added that the TEQ would recognise the work of mental health nurses and provide them with a clear opportunity to express their views in relation to nursing staff. Conclusions Therapeutic engagement (TE) has been identified as part of the repertoire of mental health nursing and both groups of participants identified how a tool to assess this construct may be utilised in day-to-day clinical practice to the benefit of each group.

Sexuality, student mental health nurse and lecturer experience in education and practice

This article presents a critical reflection on an experience relating to sexuality from two perspectives, a mental health nursing student and a lecturer. It took place during stage 1 of a graduate entry nursing 2-year Master of Science mental health nursing programme at a UK university. Student mental health nurses in higher education who identify as lesbian, gay, bisexual or transgender can feel less safe than others, which affects performance. Lecturers can make a difference to the educational experience of student nurses who are lesbian, gay, bisexual or transgender and this can have an impact on clinical practice. The emotional impact of ‘coming out’ in the classroom can have far-reaching consequences for their mental health. The response of educational staff can have a huge impact on the ability to learn and the marks achieved. Student–lecturer relationships can have transformative consequences. Student mental health nurses make meaning from their educational experiences in the classroom and clinical practice. If they do not see themselves represented, this can affect engagement and motivation. Safe nursing practice is role modelled from lecturer to student and has implications for service user experience in clinical settings.

The Psychiatric-Mental Health Nursing Workforce: Large Numbers, Little Data

Managing the supply of psychiatric-mental health nursing labor, determining the financial incentives associated with the provision of services by these providers, and ensuring optimal patient and cost outcomes are critical elements of cost control and patient safety in the current health care market. Knowledge of the psychiatric-mental health nursing workforce is needed to plan and evaluate cost-effective programs to accomplish the aforementioned elements. However, the psychiatric-mental health nursing workforce data are woefully inadequate. This paper will review the extent to which national data sources contain workforce information on psychiatric-mental health nurses.

Mental health nursing in a rehabilitation and recovery context

In this chapter we return to the story of Anthony and his brother David, who we originally met in Chapter 4, and Joyce, who first appears in Chapter 5. Previously we considered the role of the mental health nurse in working with people experiencing acute mental health crisis. This chapter seeks to consider how as mental health nurses we might go on to work with these people to support their rehabilitation and reintegration into the community. The chapter opens by outlining some key principles of recovery and proceeds to demonstrate how these ideas might be implemented in working with both Anthony and Joyce. “The way I was feeling my sadness was mine. When I was in hospital staff rarely took time to find out what this was like for me. Not taking the time often fuelled what I was thinking: ‘I’m not worth finding out about.’ Nigel Short (2007: 23)” This service user describes how it feels to live with mental illness continuously throughout their lives, not just while they are in hospital. Professional staff may contribute to this feeling if care planning becomes too focused upon symptoms and treatment rather than person-centred care and recovery. In this context, recovery should not be seen as a new concept; rather it can be traced back at least 200 years to one of the earliest asylums, the Tuke Retreat in Yorkshire. “For it was a critical appraisal of psychiatric practice that inspired the Tuke at York to establish a clinical philosophy and therapeutic practice based on kindness, compassion, respect and hope of recovery. Roberts and Wolfson (2004: 37).” Later, during the 1960s, The Vermont Project (an American psychiatric facility) also published research on successful rehabilitative practice that was based upon ‘faith, hope and love’ (Eldred et al. 1962: 45). However, much of the current focus upon recovery practices is based on longitudinal studies in America, services in Ohio, service users were asked to identify what was important to them. This resulted in the Emerging Best Practices document that is recommended guidance in the UK today (NIMHE 2004).

Reflection and mental health nursing. Part five: reflection for managers

This series on reflection is examining the place and importance of reflection for all mental health nurses. This article will explore how those two important areas of management and reflection can come together and from a Gestalt view point, be greater than the sum of the parts.

Reflection and mental health nursing. Part three: reflection on the art and science of nursing

In the third part of this series on reflection for mental health nurses, John Fowler examines the analogy of mirrors and lenses in the art and science of reflective nursing practice.

Positive psychology and its role within mental health nursing

This is the second article in a series of articles that explores the meaning of positive psychology and the importance of applying the latest research findings for the wellbeing of the mental health workforce. There will be an historical outline of positive psychology, showing it is not as ‘new’ as people may believe. The article sets the context and explains key terms through the underpinning theoretical work of Martin Seligman. This is followed by an explanation of how it is relevant to mental health nursing, five interventions mental health nurses can use to help encourage positive thinking, and a discussion on making new skills via neuroplasticity. The practical tasks provided in the boxes throughout the article will help the reader to understand what happiness means to an individual and how it can be developed with evidence-based, user-friendly effective exercises.

An Interpretation of Four Men's Experiences of Suicidality

<p>Mental health nurses are frequently called upon to care and provide intervention for suicidal men. While there is substantial literature on male suicide, far less is known about the understandings men have of their suicidal experiences. This study draws upon Gadamer's philosophical hermeneutics to explore the understandings that four men have had of their past suicidal experiences. The interpretations developed in this study, as far as possible, make explicit use of my own particular horizon of meaning as researcher and mental health nurse, and as such, seeks to engage with a tradition of mental health nursing. In addition, by consciously bringing an anti-essentialist perspective of masculinity to this process, I explore the way in which gender impacts on men's suicidality. The primary source of information for this study is in-depth, open-ended conversations with four men of European descent in their middle adult years who were asked to talk about their past experiences of suicidality. The interpretations developed here show that for these men, the hermeneutic fusion of history, language, and sociocultural context, provided limited possibilities with which they were able to construe themselves as 'fitting in' with normative standards. These constraints, that are otherwise taken-for-granted and invisible, became explicit through their experience of ongoing victimisation. Furthermore, early understandings of these experiences became a potent horizon of meaning from which they then came to understand later difficult experiences. Victimisation became constitutive of an understanding of self as fundamentally different and (hierarchically)'less-than' other men. Ultimately, suicidality emerged out of a background of ever-present psychological pain accompanying a construction of self as being unable to see themselves as ever 'fitting in'. These men did not regard themselves as having recovered from suicidality, but remain in a process of recovering. This process did not mean figuring out how to 'fit in', or become 'normal' men, but rather, to live meaningfully as men in spite of not 'fitting in' with the sociocultural ideal. This involved a process of repeated cycles of revisiting and reflecting on their personal histories from vantage points permitting understandings that opened up opportunities for personal growth and learning. Relationships were significant for either enabling or disabling this process. Recovering was therefore a continual and idiosyncratic process, rather than an outcome of a specific technique or knowledge. The position taken in this study is that mental health nursing seeks to engage with people and work with them in collaborative, respectful, human relationships. It is argued that mental health nurses work with an individual's situated understandings rather than delivering prescribed treatment determined by diagnosis. Hence, viewing suicidality as socioculturally situated and historically emergent suggests mental health nurses must closely attend to the way in which we bring ourselves into relationships with our clients so that we are then able to create opportunities for change. The exploration of suicidality in this study also alerts us to the possibility that through fusion with clients' pre-understandings, mental health intervention can inadvertently further constrain choices to survive.</p>

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• Research article
• Open access
• Published: 22 July 2021

Health professionals and students’ experiences of reflective writing in learning: A qualitative meta-synthesis

• Giovanna Artioli   ORCID: orcid.org/0000-0002-1810-0857 1 ,
• Laura Deiana 2 ,
• Francesco De Vincenzo 3 ,
• Margherita Raucci 1 ,
• Giovanna Amaducci 1 ,
• Maria Chiara Bassi 1 ,
• Silvia Di Leo 1 ,
• Mark Hayter 4 &
• Luca Ghirotto 1  

BMC Medical Education volume  21 , Article number:  394 ( 2021 ) Cite this article

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Reflective writing provides an opportunity for health professionals and students to learn from their mistakes, successes, anxieties, and worries that otherwise would remain disjointed and worthless. This systematic review addresses the following question: “What are the experiences of health professionals and students in applying reflective writing during their education and training?”

We performed a systematic review and meta-synthesis of qualitative studies. Our search comprised six electronic databases: MedLine, Embase, Cinahl, PsycINFO, Eric, and Scopus. Our initial search produced 1237 titles, excluding duplicates that we removed. After title and abstract screening, 17 articles met the inclusion criteria. We identified descriptive themes and the conceptual elements explaining the health professionals’ and students’ experience using reflective writing during their academic and in-service training by performing a meta-synthesis.

We identified four main categories (and related sub-categories) through the meta-synthesis: reflection and reflexivity, accomplishing learning potential, building a philosophical and empathic approach, and identifying reflective writing feasibility. We placed the main categories into an interpretative model which explains the users’ experiences of reflective writing during their education and training. Reflective writing triggered reflection and reflexivity that allows, on the one hand, skills development, professional growth, and the ability to act on change; on the other hand, the acquisition of empathic attitudes and sensitivity towards one’s own and others’ emotions. Perceived barriers and impeding factors and facilitating ones, like timing and strategies for using reflective writing, were also identified.

Conclusions

The use of this learning methodology is crucial today because of the recognition of the increasing complexity of healthcare contexts requiring professionals to learn advanced skills beyond their clinical ones. Implementing reflective writing-based courses and training in university curricula and clinical contexts can benefit human and professional development.

Peer Review reports

Education of healthcare professionals supportstheir transformation into becoming competent professionals [ 1 ] and improves their reasoning skills in clinical situations. In this context, reflective writing (RW) is encouraged by both universities, and healthcare training providersencourage reflective writing (RW) since its utility in helping health students and professionals nurture reflection [ 2 ], which is considered a core element of professionalism. Furthermore, the ability to reflect on one’s performance is now seen to be a crucial skill for personal and professional development [ 3 ]. Writing about experiences to develop learning and growth through reflection is called ‘reflective writing’ (RW). RW involves the process of reconsidering an experience, which is then analyzed in its various components [ 4 , 5 ]. The act of transforming thoughts into words may create new ideas: the recollection of the experience to allow a deeper understanding of it, modifying its original perception, and creating new insights [ 6 ]. RWis the focused and recurrent inspection of thoughts, feelings, and events emerging from practice as applied to healthcare practice [ 7 ].

Reflection may be intended as a form of mental processing or thinking used by learners to fulfill a purpose or achieve some anticipated outcome [ 2 ]. This definition recalls Boud and colleagues’ view of reflection as a purposive activity directed towards goals [ 8 ]. For those authors, reflection involves a three-stage process, including recollection of the experience, attending to own feelings, and re-evaluating the experience. This process can be facilitated by reflective practices, among which RW is one of the main tools [ 9 ].

Between reflection-on-action (leading to adjustments to future learning and actions) and reflection-in-action (where adjustments are made at the moment) [ 10 ], RW can be situated in the former. It involves theprofessional’s reflections and analysis of experiences in clinical practice [ 11 , 12 ]. Mainly,RWinvolves the recurrent introspection ofone’s thoughts, feelings, and events within a particular context [ 13 ]. Several studies highlight how RWinfluencespromoting critical thinking [ 14 ], self-consciousness [ 15 ], and favors the development of personal skills [ 16 ], communication and empathy skills [ 4 , 17 ], and self-knowledge [ 3 ]. Thanks to the writing process, individuals may analyze all the components of their experience and learn something new, giving new meanings [ 5 ]. Indeed, putting down thoughts into words enables the individual to reprocess the experience, build and empower new insights, new learnings, and new ways to conceive reality [ 6 , 18 , 19 , 20 ].

Furthermore, RW provides an opportunity to give concrete meaning to one’s inner processes, mistakes, successes, anxieties, and worries that otherwise would remain disjointed and worthless [ 21 , 22 ]. The reflective approach of RW allows oneself to enter the story, becoming aware of our professional path, with both an educational and therapeutic effect [ 23 ].

Reflection as practically sustained by RW commonly overlaps with the process of reflexivity. As noted elsewhere [ 24 ], reflection and reflexivity originate from different philosophical traditionsbut have shared similarities and meanings. In the context of this article, we adopt two different working definitions of reflection and reflexivity. Firstly, we draw from the work of Alexander [ 25 ]: who explains reflection as the deliberation, pondering, or rumination over ideas, circumstances, or experiences yet to be enacted, as well as those presently unfolding or already passed [ 25 ]. Reflexivity at a meta-cognitive level relates to finding strategies to challenge and questionpersonal attitudes, thought processes, values, assumptions, prejudices, and habitual actions to understand the relationships’ underpinning structure with experiences and events [ 26 ]. In other words, reflexivity can be defined as “the self-conscious co-ordination of the observed with existing cognitive structures of meaning” [ 27 ].

Given those definitions,a philosophical framework for helping health trainees and professionals conduct an exercise that can be helpful to them, their practice, and – ultimately – their patients can be identified. There is a growing body of qualitative literature on this topic – which is valuable – but the nature of qualitative research is that it creates transferrable and more generalizableknowledge cumulatively. As such, bodies of qualitative knowledge must besummarized and amalgamated to provide a sound understanding of the issues – to inform practice and generate the future qualitative research agenda. To date, this has not been done for the qualitative work on reflective writing: a gap in the knowledge base our synthesis study intends to address by highlighting what connects students and professionals while using RW.

This systematic review addresses the following question: “What are the experiences of health professionals and students in applyingRWduring their education and training?”

This systematic review and meta-synthesis followed the 4-step procedure outlined by Sandelowski and Barroso [ 28 , 29 ], foreseeing a comprehensive search, appraising reports of qualitative studies, classification of studies, synthesis of the findings. Systematic review and meta-synthesis referto the process of scientific inquiry aimed at systematically reviewing and formally integrating the findings in reports of completed qualitative studies [ 29 ].

The article selection processwas summarized as a PRISMA flowchart [ 30 ]; the search strategy was based on PICo (Population, phenomenon of Interest, and Context),and the study results are reported in agreement with Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines [ 31 ].

Selection criteria

Inclusion criteria for the meta-synthesis were:

Primary qualitative studies published in peer-reviewed English journals.

With health professionals or health studentsas participants.

UsingRW in learning contexts (both pre-and in-service training).

Mixed methods where the qualitative part can be separated.

Articles should report the voice of participants (direct quotations).

Given the meta-synthesis indications, we excluded quantitative studies, non-primary research articles, meta-synthesis of qualitative studies, literature and systematic reviews, abstracts, unpublished reports, grey literature. In addition, we also excluded studies where participants were using RW in association with other learning tools and where the personal experience was not about using RW exclusively.

Data sources and searches

An experienced information specialist (MCB) performed the literature search on Medline, Embase, Cinahl, PsycInfo, Eric, and Scopus for research articles published from Jan 1st, 2008 to September 30th, 2019,to make sure we incorporated studies reflecting contemporary professional health care experience. Additional searchinginvolved reviewing the references or, and citations to, our included studies.

We filled an Excel file with all the titles and authors’ names. A filter for qualitative and mixed methods study was applied. Table  1 shows the general search strategy for all the databases based on PICo.

Four reviewers (GAr, MR, GAm, LD) independently screened titles and abstracts of all studies, then checked full-text articles based on the selection criteria. We also searched the reference lists of the full-text articles selected for additional potentially relevant studies. Any conflict was solved through discussion with three external reviewers (LG, MCB,SDL, and MH).

Quality appraisal

We used the Critical Appraisal Skills Programme (CASP): it provides ten simple guiding questions and examples to examine study validity, adequacy, and potential applicability of the results of qualitative studies. Guided by the work of Long and colleagues [ 32 ] and previously used in other meta-synthesis [ 33 ], we created 30 items from the 10 CASP questions on quality to ensure we could provide a detailed appraisal of the studies. FDV and LD independently assessed the quality of included studies with any conflicts solved by consulting a third reviewer (MCB and LG). Researchers scored primary studies weighingthe proposed items and ranking the quality of each included study [ 34 ] on high ( n  > 20 items positively assessed), moderate (10 <  n  < 20), or low quality ( n  < 10).

Analysis and synthesis

MCB created a data extraction table, GAr, GAm, and MRdescribed the included articles (Table  2 ). Quotations were extracted manually from the “results/findings” sections of the included studies by GAr, MCB, LDand inserted into adatabase. GAr, GAm, MR, and FDVperformed a thematic analysis of those sections, along with participants’ quotations. Then, they inductively derived sub-themes from the data, performing a first interpretative analysis of participants’ narratives (i.e., highlighting meanings participants interpreted about their experience). The sub-themes were compared and transferred across studies by adding the data into existing sub-themes or creating new sub-themes. Similar sub-themes were then grouped into themes, using taxonomic analysisto conceptually identify the sub-categories and the categories emerging from the participants’ narratives. This procedure allowed us to translate the themes identified from the original studies [ 28 ] into interpretative categories that could amalgamate and refine the experiences of health professionalsor health students on the use of RW [ 29 ]. The final categories are based on the consent of all the authors.

Literature search and studies’ characteristics

A total of 1488 articles were retrieved. Duplicates ( n  = 251) were removed. Then, articles ( n  = 1237) were identified and reviewed by title and abstract. We excluded n  = 1152 articles because they did not match the specified inclusion criteria, based on the title and abstract. Consequently, we assessed 85 full-text articles. Sixty-eight records did not meet the inclusion criteria. At the end of the selection process, 17 reportsof qualitative research were selected. Figure  1 illustrates the search process.

PRISMA flow diagram

Table 2 shows the characteristics of the included studies. Eleven studies involved healthcare students (58%, including nurses, midwives, physiotherapists, doctors, dentists, and oral health students), and six (32%, including doctors, occupational and radiation therapists) were referred to health professionals. In thirteen studies, participants were trained on RW before using it: this information could not be retrieved from the remaining articles.

Five articles reported studies conducted in the US, three in Australia, two in Canada, and two in Israel. The other studies were carried out in Italy, UK, Korea, Taiwan, and Sweden.

Critical appraisal results

We critically evaluatedall 17 studies to highlight the methodological strengthsand weaknesses of the selected studies. No article was removed on a quality assessment basis. Results of the quality appraisal are reported in Table 2 .

Meta-synthesis findings

Through the meta-synthesis, we identified four main categories (and related sub-categories): (i) reflection and reflexivity; (ii) accomplishing learning potential; (iii) building a philosophical and empathic approach; (iv) identifying reflective writing feasibility (for the complete dataset, please refer to supplemental material , where we have listed a selection of meaningful quotations of categories and sub-categories).

Given such categories, we developed an interpretative meta-synthesis model (Fig.  2 ) to illustrate the commonalities of the experience of using RW according to both students and professionals: RWas a vehicle for discovering reflection and allowing users to enter personal reflexivity to fulfillone’s learning potential, alongside the building of a philosophical and empathic approach. In their experience, reflection and reflexivity generate different skills and competencies: reflection matures skills such as professional skills and the ability to activate change and innovation. Reflexivity allows students and professionals to reach higher levels of competencyconcerning inner development and empathy reaching. Finally, from our analysis, participants, while recognizing the value of RW, also defined factors that could encourage or limit its use. Differences among participants’ groups are also outlined.

Meta-synthesis model: RW as experienced by health professionals and students

Reflection and reflexivity

Within this category, we collected the users’ narratives about the experience of applying RW and its disclosing capacity. By using RW, participants confronted themselves with both reflection and reflexivity. This category includes two sub-categories we named: discovering reflection and entering personal reflexivity.

Discovering reflection

The sub-category shows that experiencingRW deepened their reflection on experiences, practice, and profession. Thanks to RW, professionals, and students could explore previously unexplored topics and learn more about themselves.

“ Writing initiated me to think about my experiences … ” (professional) [ 46 ]. “ I think it’s good for physicians to reflect on what we’re doing ” (professional) [ 50 ]

The analysis showed that RW was considered reflective when it provided an opportunity for those who applied it to stop, reflect and conduct an inner discourse on topics never considered before [ 44 , 46 , 50 ]. Some students affirmed:

“ Helped (me) reflect on positive aspects ” (student) [ 40 ]. “ I don’t usually think too much about what happens to me, but through critical reflective journaling, I was able to think carefully about things happening around me. This activity helped me to look into my mind ” (student) [ 44 ]

This sub-category explains transversal meanings coming from uniformly professionals and students.

Entering personal reflexivity

This sub-category includes data about RW enabling users’reflexivity. In this context, RW was considered training for reflexivity as it enabled participants to question themselves more often [ 48 ], reflect on their experiences [ 35 ], attitudes, actions [ 38 , 45 ], and also reconsider their actions and identify their strengths and weaknesses [ 40 , 44 ].

“ The questions in this study do make me stop and think about things – how I feel about what I’m doing in residency ”(professional) [ 46 ]. “ Helped me ID (identify) my strengths and weaknesses ” (student) [ 40 ] RW also helped eradicate the background noise that my mind does not yet know how to filter out [ 51 ] .

Interesting to note that this sub-category is more present in students’ narratives. While professionals referred to self-reflection practices (probably already acquired in other contexts), students often reported how RW helped them discover reflexivity.

Accomplishing learning potential

Our analysis showed how users RW used the technique to “Accomplish learning potential.”

According to the studies’ participants, RWcan enable a learning performancethat would be difficult to reach otherwise. In this context, participants addressed RW as a tool for“accomplishing learning potential.”Within this category, three sub-categories were highlighted: the improvement of skills, personal and professional growth, and assisting the change and development process.

Improvement of skills

Participants agreed that the development of skills and abilities through RWwas aimed at their clinical skills and –in relevant areas such as question asking – encouraged reflection and research [ 35 , 46 ]. Communication skills were also enhanced, as were their relationship with patients, family,colleagues, and friends [ 35 , 38 , 46 ].

Participants said:

“ Through reflective journal writing, my attitude towards learning has changed. I have been encouraged to be a proactive learner. (...) I have been able to identify necessary places for improvement and through research, question asking, goal-setting (...). I have improved my skills in relevant areas” (student) [ 35 ]. “I feel that it [participation in the study] has been a positive experience by motivating me to improve on my clinical, communication skills, and also my relationships with colleagues, patients, family, and friends ” (professional) [ 46 ]

Participants also reported that,in their experience, RWprovided an opportunity to assess and improve themselves and to enhance their self-confidence [ 38 , 40 ]. Cognitive skills, includinggaining more profoundknowledge and problem-solving, along withtime-management [ 35 , 40 , 46 , 49 ], were also enhanced: RW,therefore,represented a learning mode [ 45 ].

“ Without reflection, I absolutely believe these skills would be more unattainable for me ”(student) [ 35 ]

This sub-category applies more to students’ narratives. Health students mentioned the tools helping them most to develop their skills. Professionals focused principally on what RWcould improve (communication skills or organizational skills).

Personal and professional growth

Participantsidentifiedthat RWhad promoted personal [ 51 ] and professional growth [ 35 , 46 ]. RW meant for participants:an ameliorated attitude towards work [ 46 ]; a development path for one’s job potential [ 38 ]; an enhancement of their introspective knowledge [ 51 ]; an enrichment of their expressive capability [ 38 ];an improvement of their interpersonal relationships with patients and colleagues [ 50 ] and developed their use of critical and reflective thinking [ 38 ].

“ Reflecting introduces a new aspect to clinic that focuses on the individual’s learning experience ” (student) [ 35 ]. “I think that it does change the way that you think about the practice of medicine and your own personal tendencies and your interactions with your patients and colleagues. And I think it can be a really powerful driver of culture change ” (professional) [ 50 ]

This sub-category is more represented among students than professionals. Students are ‘surprised’ at how important RW was to their learning. Professionals still recognized how RW was an essential driver of change for their clinic activities.

Assisting the change and development process

We labeledthe third sub-category“assisting the change and development process.”The changeinvolvedintroducing modifications tothe way of working [ 48 ], assessing what needed to be changed to achieve a work-life balance [ 51 ], understanding elements that did not allow change, and how to act on them in the future, and also considering new and important issues [ 46 ], further information [ 51 ] and new ways of thinking. This sub-category equally explained the meaning given to RW by students and professionals.

“ I think writing answer to some of these questions has allowed me to reflect back on the year and think about specific important topics that I might not have thought about again.” (professional) [ 46 ]. (Reflective journaling encouraged) “Assessing and focusing on the changes that need to be done to achieve the balance in my life and being able to integrate that with my family and in my work as a nurse.” (Student 16/RJ2) [ 51 ]

However, thischange process could not be possible without witnessing change and becoming aware of it [ 38 , 46 ]. This allowedparticipants to ‘see one’slearning history and path of growth,‘have a picture of the problem, handle things differently, and broadening their vision of the problem [ 48 ].

Building a philosophical and empathic approach

The “Reflection and reflexivity” category is closely aligned with the “Building a philosophical and empathic approach” category. Participants defined RW as a means for nurturing an intimate and profound level of learning, i.e., a philosophical and empathic approach towards real-life professional issues. The third category consists of three sub-categories: the ability to find benefits in negativity/adversity, assuming an empathetic attitude, and the awareness of things, experiences,emotions.

Finding benefits in negativity/adversity

According to participants, RWexerted a therapeutic effect by encouraging professionals and students to focus on the present (43)strictly. It seemed that RWeventually reduced their emotional stress [ 44 , 51 ]. Likewise,in the contextofnegative experiences [ 49 ], its practice acted as a catharsis [ 46 ] that could even allow them tolook back at those experiencesafresh – enabling a change in perspective [ 39 ].

“While writing the journal entry, I felt like I was unloading something from inside myself and being set free. This process made me feel better ” (student) [ 44 ]. “It is always good to pause to reflect on my experiences. The most cathartic question was a few months back when I got to describe my really bad experience.” (professional) [ 46 ] “Very therapeutic. I wrote on a bad experience, but at the end, we were laughing at it.” (professional) [ 49 ]

This specific approach allowed the practitioner/trainee to improve their self-care and focus on work objectives [ 51 ]:

“Self-reflection and reflective journaling promote self-understanding and is another part of self-care.” (Student 5/RJ3) [ 51 ]

Even if more emerging from students’ voices, professionals appeared genuinely amazed at how learning can be generated out of negativity.

Assuming an empathetic attitude

Study participants stressed the fact that RWhelped them develop empathetic attitudes. It seems that RWemphasized the importance of sensitivity and empathy by trying ‘to be in someone else’sshoes,’ especially that of patients or colleagues [ 36 , 37 , 44 ].

“How reflecting on patient encounters through field notes allowed her to “take a walk in someone else’s shoes ” (student) [ 36 ]. “It helps you see the humanity... ” (professional) [ 50 ]

This approach also applied in contexts outside of work and helped the practitioner take off his/her‘white coat’ and understand that before being a professional,he/shewas a person and a human being [ 36 , 37 , 46 , 50 ].

“ Which has made me more open to other’s ideas and thoughts ” (professional) [ 46 ]

As previously mentioned, according to the participants’ statements, awareness was the cornerstone to effective personal and professional growth [ 40 , 51 ].

This sub-category is equivalently present among the participants’ groups. Nonetheless, different meaningscould also be highlighted. Students appreciated RWby stressing its value of allowing them to enter deeply ‘into the other’ inner world (mainly patients). Professionals claimed they could recognize the profession’s human and relational aspects, whichcould also be helpful for their extra-professional relationships (family members, friends).

Awareness of things, experiences, emotions

Impartially balanced among professionals and students, awareness was cited in terms of ‘how things have affected me rather than simply continuing to work in a robotic manner’ [ 46 ], the awareness of who one was and who one has become thanks to the process of change [ 51 ]. This professional and relational awareness made it possible to think clearly about one’s practice and the health resources present in the context of belonging [ 50 ].

“Just being aware of what I know now and what I’ll know by the end of the semester … is a great way to learn who I am and what I can change about me for the better.” (Student 9/RJ1) [ 51 ]

The process of awareness that was facilitated by how their RW allowedthem to transform shapeless and straightforward ideasinto words and givethem a specific value and emotional charge [ 36 , 47 , 51 ]: it wasan authentic opportunity to turn emotions and feelings into something tangible –a journey of discovery and personal acceptance [ 43 ].

“ After two years or so, when you look back, it’s like, oh,that’s how I was feeling at the time, and right now, I feel differently. There is also this level of satisfaction. Like you have matured out of this thinking ” (professional) [ 47 ]

Identifying RW feasibility

The fourth category consists of three sub-categories: perceived barriers/impeding factors, facilitating factors, and when and how to use RW. Students and healthcare professionals who had the experience of practicing the RW in their work identified both limitations and facilitating factors and indications about when and how to use RW.

Perceived barriers/impeding factors

Some study participants (almost entirely students) identified several barriers to their activity. Some students could not see the benefits and thought RW was a waste of time [ 35 , 38 , 51 ]. However, others, who did see the potential benefits still felt that they lacked the time needed to devote to RW [ 42 ] or, sufficient mental space to report and describe a work situation, an excessive similarity of this activity to the regular working practice and, consequently, a lack ofmotivation to write [ 47 , 51 ]. In addition, some described the strainthey felt in writing down personal/professional experiences [ 47 ]. A lack of privacy was another problem, both for the concern about sharing the reflection and for the respect of confidentialityin writing itself [ 51 ]. Taken together,it appeared that some study participants did not recognizeRW as an effective means of help [ 39 , 50 ]. Althoughrealizing the potential of RW,others felt that their tutors did not provide noticeably clearexplanations of the aim of RW– which they would have found useful and motivating [ 45 ].

“ To be honest, not a great deal ( … ) it wasn’t really some revelation ” (professional) [ 50 ]. “ I got a hard time referring it [my experience] to citations … I could have sat and cried yesterday when I did my essay … when I actually read it [my essay] I thought, oh I don’t know what it means, myself ” (Female 2 - student) [ 42 ]

Facilitating factors

This sub-category was exclusively interpreted from students’ narratives. They valued the perspectives to use RWin their practice seeing it as a valuable tool to be applied throughout their career [ 35 , 45 ],with many students reporting that they would continue with this technique [ 38 ]. Studentssaw RW as a valuable means of staying focused on their own goals and needs [ 40 , 51 ]. They remarked that it helped them reduce stress, gain clarity in one’s life and practice [ 41 ], and spiritually connect with themselves [ 45 , 51 ]. Furthermore, RW enabled studentsto discover more information about their health and well-being, ‘it also helped me tie in ideas and beliefs from different sources and relate it to my own’ [ 51 ]. RWhelped maintain awareness and recall the medical being/human being dichotomy [ 37 ]. It remindedstudentsof the difference between studying literature and refining manual skills and the ability to learn from experience and mistakes [ 35 ].

“ During the interview, I felt an element of being more like a ‘normal person’ having a ‘normal conversation’ with another human being. This was a strange realization because it reminded me of the dichotomy that physicians may experience, being doctor versus human ” (student) [ 37 ]

When and how to use RW

Health professionals (a few) and many students finally mentioned the time considered most appropriate to use RW, underlining its usefulness primarilywas during hardship rather than daily practice [ 47 ].Moreover,RWshould not be forced onto someone in any given moment but instead left to individual choice based on one’s spirit of the moment [ 40 , 46 ].

“. .. like if you had a patient die; that would be the only time you might write it down ” (professional) [ 47 ]

Otherparticipantsconsidered instructions on RW to be too forceful and notapplicable to their own experience of reflection [ 40 ]. ‘Reflection wasn’t just signing on the line.’ It allowed constructive feedback for the trainee or the professional. Constructive feedback could be positive or negative, but it was a powerful tool for thinking and examining things [ 45 ].

In this meta-synthesis of qualitative studies, we have interpreted the experiences of health professionals and students who used RWduring their education and training. Given the number of studies included, RW users’ experience was predominately investigated in students. This result, although not surprising, raises the question of whether RW in professional training is being used. RW is not used in professional training as often as it is in the academic training of healthcare students.

As to this review’s aim, we could highlight continuities and differences from study participants’ narratives. Our findings offer a conceptualization of usingRW in health care settings. According to the experience of both students (from different disciplines) and health professionals, RW allows its exponents to discover and practice reflectionas a form of cognitive processing [ 2 ] and enablethem to develop a better understanding of their lived situation. We also interpreted that RW allows users to make a ‘reflexive journey’ that involves them practicing meta-cognitive skills to challengetheir attitudes, pre-assumptions, prejudices, and habitual actions [ 24 , 26 ]. This was particularly true for students: “entering personal reflexivity” appears to be newer for them than for the professionals who are likely to acquire reflexivity during academic training. Students seemed more focused on tools than RW-related results. This consideration makes us affirm that reflective capacity is in progress for them.

Challenging pre-assumptions and entering reflexivityenabledRWusers to realize how RW may develop their learning potential to improve skills and personal/professional growth. Skills to be enhanced are quoted mainly by students. Conversely, professionals could comprehend the final purpose of learning, achievable through RW, in terms of communication or organizational abilities. Professionals interpreted skills from RW as abilities to apply in the clinical activities to find new solutions to problems.

The category “Accomplishing learning potential”confirms what many authors highlight: putting thoughts into words not only permits a deeper understanding of events [ 6 ], enhances professionalism [ 52 ] but also improves personal [ 16 ], communication, and empathy skills [ 4 , 17 ]. In this context, RW fulfills its mandate by letting human sciences [ 53 ] and evidence-based health disciplines affect clinical practice. As noted [ 54 ], students and health professionals’RW training allowed integrating scientific knowledge with behavioral and sociological sciences to supporttheir learning [ 55 ].

Users understood that RWcould be a powerful means of developing empathy and developing their philosophy of care: this consideration is in line with a recent study from Ng and colleagues [ 24 ]. Additionally, some authors [ 4 , 17 ] stressed these empathetic skills and “humanistic”competencies as essential to care for patients effectively [ 56 ]. Professionals were amazed how negativity could generate learning through RW. On the other hand, by recognizingand writing experienced negative situations, students could free themselves from feelings impeding empathy.

By employing RW, users reported factors that could encourage or limit its use. These findings further illustrate that RW is not always a tool that is easy to use without adequate training [ 57 ]. Almost exclusively, students reported hindering factors (limited time, difficulty in writing and understanding assignments, privacy issues, feeling bored or forced). As to professionals, few describedRW as a very stressful activity. Although students could identify impeding factors, they also recognized many positive ones. For professionals, RW was not to be used every day but in ‘extreme’ situations, requiring reflection and reflexivity to be applied. In general, enhancing motivation to write reflectively [ 58 ] should be the first goal of any training to make the process acceptable and profitable for trainees. If this first stage is not accomplished, it will reduce RW’sapparent professional and personal effectiveness among health professionals and students substantially.

Strengths, limitations, and research relaunches

This review may enrich our knowledge about providing RW as an educative tool for health students and professionals. However, the findings must be applied,taking into account some limitations. We focused our attention only on recent, primary, peer-reviewed studies within the time and publication limits. Qualitative studies often are available as grey literature: considering it may result in a different interpretation of students’ and professionals’ experience in using RW. Therefore, our conceptualization should be read bearing in mind a publication bias and the need to expand the literature search to other sources. Besides limiting the risk of missing published qualitative studies, we reviewed the reference listsof included studies for additional items. Our meta-synthesis is coherent to the interpretation of the included studies’ findings.

At least two reviewers have conducted each step of this systematic review. We purposely did not exclude studies based on a quality assessment to maintain a robust qualitative study sample size and valuable insights.

During analysis, all possible interpretations were screened by authors, and an agreement was reached. Nonetheless, we did not cover all the possible ways to interpret the voices of students and professionals.

Since RW is not used in professional training as often as it is in the academic training of healthcare students, a research relaunch could be investigatingwhether and to what extent RW is being used in in-service training programs. Moreover, the studies included in this review were conducted within Western countries. Students’ and professionals’ perspectives from Africa and Asia are underrepresented within the qualitative literature about experiences of using RW. Therefore, geographicalgeneralizations from the present meta-synthesis should be avoided, and our paper reveals the necessity for RW research in other cultures and settings. Nonetheless, authors of primary studies have paid little attention to cultural and regionaldiversity. Therefore, we recommend furtherinvestigations exploring the differences between cultural backgrounds and howRW is recognized within training programs in different countries. Finally, additional qualitative and quantitative research is required to deepen our understanding of RW’s clinical and psycho-social outcomes in high complexity health practice contexts.

Our analysis confirms the crucial role of RW in fostering reasoning skills [ 59 ] and awareness in clinical situations. While its utility in helping health students and professionals to nurture reflection [ 2 ] has been widely theorized, this meta-synthesis provide empirical evidence to support and illustrate this theoretical viewpoint. Finally, we argue that RWis even more critical given the increasing complexity of modern healthcare, requiringprofessionals to develop advanced skills beyond their clinical ones.

Practical implications

Two important implications can be highlighted:

students and professionals can recognize the potential of RW in learning advanced professional skills. ImplementingRW in academic training as well as continuing professional education is desirable.

Despite recognizing the effectiveness of RW in healthcare learning, students and professionals may face difficulties in writing reflectively. Trainers should acknowledge and address this.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Critical appraisal skills programme

Enhancing transparency in reporting the synthesis of qualitative research

Population, phenomena of interest and context

Preferred reporting items for systematic reviews and meta-analyses

Reflective writing

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Acknowledgments

We thank Dr. Silvia Tanzi for her insightful feedback about this work and Manuella Walker for assisting in the final editing of the paper.

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Artioli, G., Deiana, L., De Vincenzo, F. et al. Health professionals and students’ experiences of reflective writing in learning: A qualitative meta-synthesis. BMC Med Educ 21 , 394 (2021). https://doi.org/10.1186/s12909-021-02831-4

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Promoting reflection in mental health nursing practice: a case illustration using problem-based learning

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Reflective practice in nursing has been shown to improve both client care and nurses role satisfaction. Students require regular and guided opportunities to learn the necessary reflective skills that underpin best practice. Problem-based learning (PBL) processes based on comprehensive learning packages developed from actual clinical cases provide a contextualized and realistic means for students to develop and hone their reflective skills for use as mental health practitioners. This paper uses a case illustration to demonstrate the usefulness of PBL as a mechanism for developing reflective practice in the mental health context. Students analysed five cases drawn from actual documented clinical materials that included nursing, medical and allied health professionals' assessments, treatment regimes, and progress notes. One student's written analysis of the five cases and an interview with the student is presented as a case illustration. The case illustrates the student's reflections on the theme of 'hope' for the clients and identified three obstacles. These were: (i) a lack of acknowledgement by health professionals of traumatic life events; (ii) overlooking less tangible losses; and (iii) a central focus on drug treatment. Reflective learning strategies can be incorporated in on- and off-campus learning environments and used to assist the learner to practise critical reflective skills in a controlled and safe manner. Reflective processes are more meaningful if the PBL package that students encounter represents real clinical scenarios with comprehensive resource materials.

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The Effect of Reflection on Nurse-Patient Communication Skills in Emergency Medical Centers

Bahman pangh.

1 Department of nursing, Faculty of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Golesatn, Iran

Leila Jouybari

2 Department of Family and Community Medicine, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Golestan, Iran

Mohamad Ali Vakili

3 Department of Community Health Nursing, Nursing Research Center, Golestan University of Medical Sciences, Gorgan, Golestan, Iran

Akram Sanagoo

Aysheh torik.

4 Department of Women Affairs, Gomishan Government Office, Golestan, Iran

Introduction: Reflection is formed through deep reflection on the event or a certain clinical position. The aim of this study was to determine the effect of reflection on nurse-patient communication skills of nurses working in emergency departments.

Methods: This interventional study was conducted on intervention and control groups and with a pretest-posttest design. 142 nurses working in the emergency departments of hospitals affiliated to Golestan University of Medical Sciences were enrolled in the study in 2015, and randomly divided into two groups. During eight weeks of the study, the intervention group was asked to write their clinical experiences with regard to communication issues with their patients. Before the intervention, the communication skills of both groups were compared using a questionnaire. Data analysis was performed, using independent t-test, paired t-test, Mann-Whitney and Wilcoxon tests.

Results: Of the 142 nurses, 122 nurses had full participation. In the intervention group the mean scores of verbal communication skills, non-verbal communication skills, general communication skills and communication skills based on patient safety were statistically significant, but there was no significant difference in the control group.

Conclusion: The results showed that eight weeks of reflection by nurses is an effective intervention in dimensions of communication skills. We therefore suggest that a reflective writing be encouraged as a vital tool for improving communication competency among emergency department nurses.

Introduction

Communication skills are taught to nurses in the educational environment and are an important part of educational programs, but there are many concerns about communication weaknesses and lack of communication skills. 1 Some nursing experts believe that appropriate communication skills are the cornerstone of all nursing care activities, 2 resulting in improved patient care and professional development and personality growth of the nurses. 3

Effective communication has positive effects on the patients, including improved vital signs, decreased pain and anxiety, increased satisfaction, improved treatment outcomes, and enhanced participation in treatment programs. 4 The emergency room is the busiest and most serious part of any hospital. 5 And smooth and organized management of this department can save the lives of many patients. Therefore, in this environment, nurses should be equipped with different capabilities and skills to withstand the pressure and tension, among which communication skills are one of the most important. 6 Many qualitative and quantitative studies have evaluated the nurse-patient relationship. 7 In a study about nursing care in emergency units, communication has been introduced as one of the elements of care in the emergency room. Therefore, special attention should be paid to effective communication between nurses, patients, their companions, and other care providers in the emergency units. 6 Studies conducted in Iran show that the nurse-patient relationship is not quite effective and is even reported to be weak at times. 8 , 9

The art of reflection encourages the person to search for and evaluate solutions in equivocal and complicated situations. 10 The experience of utilizing the reflection process in a clinical setting causes a sense of ownership towards the created knowledge in nurses, because they achieve this knowledge through focusing on their own experience, using creative methods. 11 The process of reflection starts when the person refers to his/her own experience and recollects what has occurred, reconsiders the experience, and reevaluates it. 12 This effective strategy also improves critical thinking and problem-solving skills in nurses. 13 Reflection is regarded as a proof of professionalism and is used as a skill related to clinical performance and professional behavior. 14 Reflective thinking in recent years has been considered as a learning strategy for nursing students while not being used by novice nurses in practice. 15 Studies have suggested that reflective thinking as a skill should be learned and used continuously. 16 , 17 In general, nurses should know how to have reflection on their clinical performance and practice it regularly.Evidence suggests that nurses may not be able to recognize the effects of reflection thinking on their professional development. 18 It seems there are some organizational barriers to hinder the use of reflective thinking. 19 , 20 The study by Asselin and Fain on the effectiveness of a continuing education program using individual narratives and group discussion showed that many of the participants couldn’t complete the process of reflection process. 21 Kim and colleagues in their study about the effects of a work-based critical reflection program for novice nurses recommended doing similar research with larger and more diverse samples.

Considering the effect of reflection on enhancing clinical activities and the importance of communication skills in advancing the therapeutic objectives and patient satisfaction and because patients are in a state of suspension and abeyance in emergency units, the best of the staff should be employed in these wards. Since university students have been the main target group of the studies conducted in Iran, and there has been no empirical evidence on the outcomes of reflective thinking among nurses in the emergency department, in this research we aimed to evaluate the effect of reflection on nurse-patient communication skills in emergency units.

Materials and methods

This single-blind, randomized, controlled clinical trial was conducted in nurses working in Sayyad Shirazi and Panj-Azar educational hospitals and west healthcare centers (Aqqala Al Jalil Hospital, Bandar Torkaman Imam Khomeini Hospital, Kordkuy Amir-Al-Momenin Hospital, and Bandar-e Gaz Shohada Hospital) with two parallel arms in 2015. The protocol of the study was approved by the ethics Committee of Golestan University of Medical Sciences (code: R.GOUMS. REC. 1394.73) and registered in the Iranian Registry of Clinical Trials (IRCT201501277821N1). The inclusion criteria were a minimum of 6 months’ experience in the emergency units, holding B.Sc or M.Sc. Degrees in nursing, and a negative history of acute stressful events in the past six months (death of fist-degree relatives, use of drugs related to psychotic disorders).

Leaving the emergency units or working in other units for any reason during the study, acute physical or mental crisis during the study (death of relatives, divorce, hospitalization), and incomplete recording of the reflection notebook (less than 4 reflections) were regarded as the exclusion criteria of the study. The participants were given information on the protocol and aims of the study, data anonymity, and confidentiality of the results. Informed consent was obtained from all the participating nurses. The sample size of the study was calculated, using the following formula, considering a study conducted by Hemmati Maslakpak et al., 22 With regards to the above study and an estimate of 80-80% for desirable verbal and non-verbal communication in ICU nurses of Urmia (Iran), an increase of at least 20% in desirable verbal communication was expected to occur after the study. Therefore, considering P1=0.75 and P2=0.95, confidence interval of 95%, and power of 90%, 62 nurses were required in each group (a total of 124 nurses); however, all nurses were included in the study to increase the precision of the study. The participants were allocated to the intervention or control group, using random blocks with block sizes of 4 and 6 and an allocation ratio of 1:1. For allocation concealment, the type of intervention was written on a piece of paper, placed in dark envelopes and numbered sequentially.

The allocation sequencing was done by a person who was not involved in the recruitment, data collection, and analysis. If a participant met the inclusion criteria, his/her name was written on the envelope. The envelopes were opened by the researcher to allocate the participants to either the intervention or control group.

The census method was used to invite all eligible nurses (142 out of 158) who met the inclusion criteria to participate in the study. A random number table generated by the SPSS software was again used to allocate the nurses to intervention and control groups. After obtaining informed consents and before the intervention, the nurse-patient communication skills questionnaire developed by Hemmati Maslakpak et al., 22 was completed by the nurses in both groups. In their study the average content validity index (0.887) and reliability coefficient of the questionnaire (alpha-coronbach = 0.96) were confirmed.‏ In the present study the total Cronbach's alpha coefficient‏ of questionnaire was 0.919 and for different dimensions were as verbal: 0.884, non-verbal: 0.848, and patient-based safety skill: 96.03, which indicates an acceptable homogeneity.

The participants in both groups were requested to complete the questionnaire once more after eight weeks. Special notebooks were designed based on the Gibb’s reflective cycle, and were given to the intervention group for reflective writing. Code 0 was assigned to the control group (n=71) and code 1 was given to the intervention group (n=71). Blinding: This study was a single-blind trial; in other words, the research assistant who collected the questionnaires was not aware of the allocation. After coordination with the nursing office of the afore-mentioned health centers, the schedule of the rotating shifts of the nursing staff of emergency units was obtained and then a briefing session was held about the process of work. The participants completed the nurse-patient communication skills questionnaire. Nurses in the intervention group practiced reflection at least once a week for 8 weeks. Since the purpose of this study was not to analyze the participants' notes in detail, the handwritten notes were only checked for relevance in relation to the communication skills with patients. There was no specific guideline to determine the length of reflective writing and national and international studies have reported different periods, so their average was used in this study. In reflection, based on the Gibb’s model, although there is no need to require the participants to adopt a certain framework, the following guide may help a person organize their thoughts and feelings:

• What happened?
• What were your reactions and feelings?
• What was good or bad about the experience?
• What did you learn from this situation?
• What else could you do?
• What will you do if it occurs again? 23

According to the Gibb’s reflective cycle, the participants were asked to reflect on their clinical experiences and write their best and worst experience of communication with the patient and their companions, the most difficult moment, and the best moment. No intervention was applied in the control group. The participants completed the nurse-patient communication skills questionnaire before the study and also at the end of eight weeks, and then they were asked to complete the questionnaire. The collected data included demographic (age, sex, ethnicity, marital status) and occupational characteristics (work experience, type of employment, position, ward).

The questionnaire had three sections including verbal and non-verbal communication skills (21 questions) and patient safety-related communication skills (27 questions). The questions were scored, using a 5-point Likert scale as always (5 points), often (4 points), sometimes (3 points), rarely (2 points), and never (1 point).According to the total score, the verbal and non-verbal communication skills were categorized as weak (score: 21-48), moderate (score: 49-76), and good (score: 77-105), and patient safety-related communication skills were categorized as weak (score: 18-41), moderate (score: 42-65), and good (score: 66-90). A higher score indicated a better communication performance. The Cronbach’s alpha was 0.96 for the whole questionnaire, 0.87 for verbal communication section, 0.92 for non-verbal communication section, and 0.95 for patient safety-related communication section. 22 The SPSS software, version 13 (IBM, Armonk, NY, USA) was used for analysis. The Kolmogorov-Smirnov and Shapiro-Wilk tests were applied to evaluate data normality. To determine the difference between quantitative variables in each group, independent t-test and paired t-test were used if the data were distributed normally and Mann-Whitney and Wilcoxon tests were used if the data distribution was not normal. P- values less than 0.05 were considered significant

The present study was conducted from September 2015 until January 2016. Of 158 eligible nurses, 142 met the inclusion criteria of whom 71 were allocated to the intervention group and 71 were allocated to the control group. Finally, the data of 122 participants were analyzed ( Fig. 1 ). The mean age of the participants was 29.97 (6.14) years, with 64.5% of the nurses in the control group and 60% of the nurses in the intervention group being female. There was no significant difference in demographic characteristics between the two groups ( Table 1 ).

Flow chart of the participants through each

a Mean (SD), b Mann–Whitney U, c Chi square, d n (%), e Chi-square for trend, f Fisher's exact test

The Shapiro-Wilk test was used to evaluate the normal distribution of quantitative continuous variables. Age, total work experience in hospitals, work experience in the emergency units, and nurse-patient communication skills had a non-normal distribution (P>0.05). A significant difference was observed in the score of verbal communication skills before and after the intervention in the intervention group (P<0.001) while the difference was not significant in the control group (P<0.418).

The difference in the score of non-verbal communication skills before and after the intervention was significant in the intervention group (P<0.001) while no significant difference was observed in the control group (P<0.413).

Moreover, there was a significant difference in patient safety related communication skills before and after the intervention in the intervention group (P<0.001); however, the difference was not significant in the control group (P<0104).

In general, a significant difference was seen in the total score of communication skills before and after the intervention in the intervention group (P<0.001) while no significant difference was observed in the control group (P<0.872) ( Table 2 ).

a Mann–Whitney U, b Wilcoxon

The main findings of this study show that the reflective writing had a positive effect on the nurses’ clinical communication abilities. A significant difference was observed in verbal, non-verbal, and patient safety-related communication skills before and after the intervention while the difference was insignificant in the control group.

This study assessed the effect of reflection on communication skills of clinical nurses for the first time in Iran. Most national studies on reflection, such as those conducted by Sedaghti et al., 24 Abedini et al., 25 and Dehghany et al., 26 have mainly been of observational types. Moreover, most of the studies investigating the nurses’ communication skills were descriptive or related to reflection in the students. The results of the present study are in line with previous research findings according to which work-based critical reflection program or reflective journaling by hospital nurses (through fellowship program) improved critical thinking skills, communication abilities, and job performance. 27 , 28

Fukui et al., showed that communication skills training improved the patients’ quality of life and increased the nurses’ job satisfaction. 29 With regards to weak communication skills in clinical environments and their potential effects on the nurses, interventions are required to enhance these skills. It seems that the traditional teaching methods are not effective enough. A study by Heaven et al., revealed that despite the effectiveness of educational workshop, it was comparatively less effective in clinical environment, indicating the need for more clinical supervision and intervention in practice. 29

Reflection enables the learners to search for their roles and responsibilities in an interdisciplinary context and enhance their verbal and teamwork skills. In the present study, among the three types of skills, verbal skills had the highest mean score after the intervention. Verbal communication skills are behaviors such as greetings, introducing to patients, and using open questions. It seems that the nurses had the highest score in their verbal skills because such behaviors are common in the practice.

The reflective writing helped nurses pay more attention to such apparently simple behaviors. Consequently, reflective thinking promoted positive social behaviors in communicating with their patients.

These findings are consistent with the results of a study by Lestander et al., in which the participants stated that their verbal communication skills with patients improved after three reflection sessions (two individual sessions and one group session), leading to their increased efficacy in the nursing profession. 30 A study by Pai et al., showed that simulated learning opportunities with feedback, debriefing, and guided reflection enhanced critical thinking, clinical judgment, verbal communication skills and caring skills. Therefore, self-reflection may play an effective role in improving the nurses’ verbal communication skills. 31 In that study, the participants also stated that reflective thinking helped them to use proper phrases to encourage patients to express their feelings or to try to provide training in plain and intelligible language. In a study by Abedini et al., on the effectiveness of reflection in clinical education, most of the students believed that reflection increased their communication and social skills. 25 Therefore, verbal skills are an important part of nurse-patient communication skills and accurate identification of factors affecting verbal skills is required to improve them. The results of the present study also showed the high score of non-verbal communication skills (such as proper eye contact with the patient, body gesture and head movements or listening to the patient) of the nurses working in the emergency rooms. In a study by Thomas et al., the majority of patients needed non-verbal communication. 32

Heinerichs et al., assessed the effect of non-verbal communication skills through videotaping and debriefing of clinical skills. The results showed non-verbal communication skills improved in 96% of the students and 98% of the students mentioned non-verbal communication skills as a proper means of communication. 33 Although, in the present study, before and after the intervention, the non-verbal communication skills of the nurses increased in the intervention and control groups, this difference was only significant in the intervention group, which could be due to the rethinking and contemplation of nurses in their daily experiences of communicate with patients. The results of the present study also showed that nurses had good patient safety-related communication skills. Similarly, the results of a study by Hemmati et al., showed that from the perspective of the nurses, patient safety was in a good level for most patients hospitalized in the intensive care units of educational hospitals. 22 However, some studies have reported contradictory results regarding patient safety. 33 , 34 The domain of patient safety-related communication skills has a direct association with clinical competency of the nurses and their professionalism, 27 which was significantly enhanced through reflection in our study. Pearson et al., noted that reflection by surgical residents improved their medical performance, communication, and professionalism. 35 Moghadami et al., evaluated the effect of reflection on nurse-patient communication skills in nursing students, but found no significant difference in the students’ therapeutic communication skills between the two groups. Although clinical reflection was associated with an increase in the mean score of therapeutic communication skills, the difference was not significant. 36 It is important for all nurses to possess communication abilities; therefore, those nurses working in the emergency unit are not exempt from this requirement. So, it is critical to help them improve their communication verbal and non-verbal abilities and patient safety through reflective writing, which is an easy and non-expensive approach.

The present study had certain limitations. Since the previous studies had not suggested a specific period for performing the narrative writing, a period of “eight weeks” was considered for the intervention based on the available evidence,. So it has to be admitted that a decrease or increase in this period could have been accompanied by other consequences not found in the present study. Due to mandatory rotating work shifts, the communication between the intervention and control groups was inevitable and there was a possibility of transmission of intervention into the control group. However, the fact that the participants had been selected from different hospitals (teaching hospitals, governmental hospitals), and from different cities of the same province can be considered as a strength of this research. Suggestions for further studies: It is suggested that in the future studies, the effect of group oral reflection on communication skills of nurses working in emergency units be investigated. Also, the effect of reflective narration on the patients’ safety and clinical errors and the other core clinical competencies can be studied. Exploring the effect of self-reflective narration through e-mail sounds interesting too. Implication for nursing: Every health care system should equip its nurses with good communication skills. Since reflective thinking leads to the development of critical thinking, it is expected that better decisions can be made by nurses in relation to patients, and better communications with patients can thus be established. It is, thus, recommended nurses’ administrators incorporate reflective writing into in-service training and use that as a tool for making sense in emergency units, learning and art in care practices.

The reflective writing not only had a positive effect on verbal, non-verbal and general communication skills, but also helped nurses to have better communication skills based on patient safety. In other words, reflection enables the nurses to support the patients more effectively in each stage and have a more prominent role in the health despite limitations in resources and the high work load. For these reasons, such a program could be considered an important tool for improving communication competency among nurses in emergency units. This educational approach emphasizes health, hopefulness, and positive thinking; therefore, it is consistent with the philosophy of nursing care and may be used in different situations like routine clinical care.

Acknowledgments

The authors wish to thank the education development center and deputy of Research, Golestan University of Medical Science, as well as the officials and emergency wards’ staff of the hospitals for their participations. This article was derived from a master thesis of at Golestan University of Medical Sciences, Gorgan, Iran.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study.

Citation: Pangh B, Jouybari L, Vakili MA, Sanagoo A, Torik A. The effect of reflection on nurse-patient communication skills in emergency medical centers. J Caring Sci 2019; 8 (2): 75-81. doi: 10.15171/jcs.2019.011 .

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How to write a reflective account for revalidation, lyn middleton senior nurse, revalidation team, aneurin bevan university health board, royal gwent hospital, newport, south east wales, denise llewellyn executive director of nursing, aneurin bevan university health board, headquarters, st cadoc’s hospital, caerleon, south east wales.

Rationale and key points

This is the fifth in a series of eight articles providing information about the Nursing and Midwifery Council (NMC) revalidation process. This article focuses on preparing five written reflective accounts for revalidation.

Reflective practice encourages nurses and midwives to use their learning to identify areas for improvement.

Reflective practice encourages nurses and midwives to relate their learning to the NMC code of professional standards of practice and behaviour.

Reflective activity

‘How to’ revalidate articles can help to update your practice and provide information about the revalidation process, including how you can record and evidence CPD for revalidation. Reflect on and write a short account of:

How recording and evidencing CPD will demonstrate the skills, knowledge and experience you have gained in practice.

How you could use this article to educate your colleagues.

Subscribers can update their reflective accounts at: rcni.com/portfolio

Nursing Standard . 30, 46, 42-44. doi: 10.7748/ns.2016.e10520

[email protected]

All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

None declared.

Received: 11 April 2016

Accepted: 18 April 2016

NMC - Nursing and Midwifery Council - portfolio - professional development - reflective practice - registration - revalidation

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Last Updated 26/05/2021

In this guide

Requirement, meeting the requirement, resources and templates.

You must have prepared five written reflective accounts in the three year period since your registration was last renewed or you joined the register.

Each reflective account must be recorded on the approved form and must refer to:

• an instance of your CPD, and/or
• a piece of practice-related feedback you have received, and/or
• an event or experience in your own professional practice

and how they relate to the Code .

We want to encourage nurses, midwives and nursing associates to reflect on their practice, so they can identify any improvements or changes to their practice as a result of what they have learnt.

Each of your five reflections can be about an instance of CPD, feedback or an event or experience from your work as a nurse, midwife or nursing associate – you can even write a reflection about a combination of these.

It's important to think about the Code when you write your reflections, and consider the role of the Code in your practice and professional development.

If you’re a midwife, you may find it helpful to use our reflective aid when thinking about your reflective accounts.

Recording your written reflective accounts

You must use the reflective accounts form  to record your written reflective accounts. 

These accounts don't need to be lengthy or academic-style pieces of writing. You can simply note down what you learnt, how it improved your practice, and how it relates to the Code.

You may choose to store the completed form either electronically or in paper format.

Be careful not to record any information which may identify another person. You may find the section on non-identifiable information in How to revalidate with the NMC  useful.

Reflective accounts form  (mandatory)

You must use this form to record your five written reflective accounts.

Examples of completed forms and templates

See pages 27-28 in our 'How to revalidate with the NMC' guidance for more details.

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• Health and character
• Professional indemnity arrangement
• Confirmation
• Find out your revalidation date
• Submit your revalidation application
• Verification
• Information for confirmers
• Information for employers
• Guidance and information
• Forms and templates
• Training materials
• Introduction
• Amanda and Claire's revalidation story
• Amrit's revalidation story
• Caroline, Labour Ward Coordinator
• Carol, registered nurse and care home manager
• Catriona, interim lead midwife
• Gemma's revalidation story
• Hayley, community mental health nurse
• Heather, learning disabilities nurse
• John, Head of Undergraduate Studies
• Julie, GP practice nurse
• Lynne's revalidation story
• Marcela, GP practice nurse
• Miranda, self-employed aesthetic nurse
• Nina, midwife
• Sally, registered nurse
• Sarah, health visitor
• Susie, nursing associate
• Thulani, agency mental health nurse
• Victoria, senior consultant admiral nurse
• Anne, Head of Clinical Services
• Cate, clinical skills tutor
• Julie, social worker
• Hywel Dda University Health Board
• Western Health and Social Care Trust
• Central Manchester FT