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Gibbs Reflective Cycle Example

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• Undergraduate 1st
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Critically reflect on an encounter with a service user in a health care setting

This essay aims to critically reflect on an encounter with a service user in a health care setting. The Gibbs’ Reflective Cycle will be used as this is a popular model of reflection. Reflection is associated with learning from experience. It is viewed as an important approach for professionals who embrace lifelong learning (Jasper, 2013). In general terms, reflective practice is the process of learning through and from an experience or activity to gain new understandings of self and/or practice (Bout et al., 1985; Jasper, 2013). This method is viewed as a way of promoting the personal and professional development of qualified and independent professionals, eventually stimulating both personal and professional growth (Jasper, 2013). Dating back to 1988, the Gibbs’ Reflective Cycle encompasses six stages of reflection which enable the reflector to think through all the phases of an activity or experience (Gibbs, 1998). The model is unique because it includes knowledge, actions, emotions and suggests that experiences are repeated, which is different from Kolb’s reflective model (Kolb, 1984) and thus, the model is wider and a more flexible approach in examining a situation in a critical light to enable future changes (Zeichner and Liston, 1996).

1. Description

The incident I will be reflecting on occurred whilst I was placed on the oncology ward during my first year of qualified nursing. We had an elderly service user on the ward, who had been admitted due to stomach cancer. Upon his arrival, we read his notes which highlighted that he had significant learning difficulties, meaning that he also had problems with verbal communication. The main areas of reflection are how both myself and the other nurses used communication to calm the patient and show compassion, as well as how we adapted our care to address their individual needs. A nurse came onto the ward with three members of the public, who were viewing the ward as part of a job advertising process. When the nurse entered the patients bay, she informed the members of the public that the service users in that bay were currently receiving radiotherapy treatment. Upon hearing the nurse’s words, the service user became overtly distressed and began crying, shrieking and hitting his head backwards against his pillow –it took time; however, another nurse managed to calm him down by talking in a soothing manner.

2. Feelings

Prior to the incident occurring, I was mindful that the nurse was showing the three members of the public around the oncology ward, as part of a job advertising process. At the time of the incident, I had only been working on the oncology ward for six months so still felt slightly unsure of my position within the team. Ultimately, I did not feel confident or experienced enough to deal with this situation independently. I think that my increased level of anxiety meant that I struggled to intervene, however it is still clear that both my colleagues and myself should have intervened more quickly to ensure that the patient was dealt with effectively. Moreover, I was very surprised when the nurse failed to take into consideration the individual needs of the service user during the visit of the ward, as the distress caused to both the service user and the members of the public was very unnecessary.

3. Evaluation

In hindsight, the experience had both good and bad elements which have led to an increased understanding of the service user experience and my role as a nurse practitioner within the oncology team. My role was to give physical examinations and evaluate the service user’s health, prescribe and administer medication, recommend diagnostic and laboratory tests/read the results, manage treatment side effects, and provide support to patients – this includes acting in their best interests. I feel that I did not fulfil the latter responsibility completely. This duty to protect service user’s full confidentiality and ensuring that the nurse who was showing the members of the public around the ward was aware of the service user’s communication difficulties and resulting anxiety was not fulfilled. Our failure to act as a team, by sharing information and stepping in before a situation escalated, shows that there was a low level of group cohesiveness (Rutkowski, Gruder and Romer, 1983).

4. Analysis

According to the Nursing Times Clinical (2004), people with learning difficulties often have a struggle with adapting to new situations, which means that there is a potential for problematic behaviour when dealing with something outside of their comfort zone. Nevertheless, as suggested by the Nursing Times Clinical (2004), healthcare staff should be aware of how to effectively interact with people who have a learning disability and this can be aided through regular and valuable reflection. Prior to admission into the hospital, it is advised that professionals find out about the patient's communication and their likes and dislikes; address any potential fears either through discussion or by allowing the patient to visit the ward to meet the nursing staff (Nursing Times Clinical, 2004). Moreover, the day to day communication towards patients with learning difficulties should involve patient-centred/holistic care in addressing patient needs, which incorporates both verbal and non-verbal forms of communication. Therefore, professionals should make eye contact, look and listen, allocate more time for the patient, be interactive and communicative, remain patient and in some cases, enable any professionals who may have had experience with people with a learning difficulty to care for the patient (Nursing Times Clinical, 2004).

If you need assistance with writing your reflective practice, our professional Reflective Practice is here to help!

MENCAP states that one of the most common problems when accessing healthcare for people with learning disabilities is poor communication (n.d). This can be aided by offering the service user an advocate to communicate on their behalf and by providing information in a variety of ways including visual. They further this with the notion that healthcare professionals should equally value all people, adapt their service so that it meets different needs and understand that each individual will have different needs (MENCAP, n.d). The Nursing and Midwifery Council (NMC) (2015) further this in 'The Code', which states that all registered nurses and midwives must abide by the professional standards which are to: prioritise people, practise effectively, preserve safety and promote professionalism and trust. Therefore, the incident whereby another nurse did not take into consideration the individual needs of the patient does not abide by the professional code of conduct; ultimately, they did not recognise when the patient was anxious or in distress and respond compassionately, paying attention to promoting the wellbeing of the service user and making use of a range of verbal and non-verbal communication methods (NMC, 2015). Compassion is one of the '6cs' introduced in 2012 - which are the values and behaviours that are viewed as the quality markers of a health and care service - these being: care, compassion, competence, communication, courage and commitment (Department of Health, 2012). The 6Cs carry equal weight and should be a part of all service delivery - ensuring that patients are always placed at the heart of the provision (DoH, 2012).

5. Conclusion

From this experience, I am now more mindful of the importance of being assertive and exert professionalism in practice (and not feel as though I cannot do something because of my position within the team or length of experience) if similar situations were to arise in the future. The insight I have gained from this experience means that I am now more aware of the implications of not acting immediately and the importance of acting in the best interests of the patient, even when this may take courage. Strong working relationships between healthcare professionals should also be given a greater emphasis within the oncology ward, so to increase levels of group cohesiveness (Rutkowski, Gruder and Romer, 1983).

Action Plan

In the future, I aim to be more proactive in dealing with a situation face on regardless of my role within the team or level of experience; this includes dealing with a stressed service user, ensuring that information is passed on to the relevant staff and intervening when I believe that is a risk to a service user’s health or mental wellbeing. Moreover, I will address the needs and alter how I approach a patient with learning difficulties in the future by ensuring that I use the different methods of communication and undertake some independent research on their specific needs; the information of which I can use in my nursing practice.

I will not assume that other members of staff will always be aware or mindful of the individual needs and/or triggers of a service user, and I will not presume that other members of staff will always act in a wholly professional way. I will continue to undertake regular professional reflective practice, using the on-going model proposed by Gibbs (1988). I also aim to consistently and confidently implement the principles and values as set out by the National League for Nursing, relating to the individual needs of service users, these being:

• To respect the dignity and moral wholeness of every person without conditions or limitation.
• To affirm the uniqueness of and differences among people, their ideas, values and ethnicities. (National League for Nursing, 2017, n.d).

These are furthered by the National Health Service (NHS), which was created out of the ideal that quality healthcare should be available to all and should meet the individual needs of everyone.

Reference List

Boud, D., Keogh, R. and Walker, D. (1985) Promoting reflection in learning: a model. In D. Boud, R. Keogh and D. Walker (eds.) Reflection: turning experience into learning. London: Kogan Page.

Department of Health (DoH). (2012) Compassion in Practice. London: Department of Health.

Gibbs G (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.

Jasper, M. (2013) Beginning Reflective Practice. 2nd edition. Andover: Cengage.

Kolb, D. (1984). Experiential learning: experience as the source of learning and development. New Jersey: Prentice Hall.

MENCAP. (n.d) Communicating with people with a learning disability. Online. Available at: https://www.mencap.org.uk/sites/default/files/2016-12/Communicating%20with%20people_updated%20(1).pdf

National Health Service (NHS). (2015) Principles and values that guide the NHS. Online. Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx

National League for Nursing. (2017) Core Values. Online. Available at: http://www.nln.org/about/core-values

Nursing and Midwifery Council (NMC). (2015) The Code. London: Nursing and Midwifery Council.

Nursing Times Clinical. (2004) Managing the needs of people who have a learning disability, Nursing Times 100 (10) pp. 28-29.

Oxford Brookes University. (2017) Reflective writing: About Gibbs reflective cycle. Online. Available at: https://www.brookes.ac.uk/students/upgrade/study-skills/reflective-writing-gibbs/

Rutkowski, G. K., Gruder, C. L., & Romer, D. (1983). Group cohesiveness, social norms, and bystander intervention, Journal of Personality and Social Psychology, 44(3), pp.545-552.

Zeichner, K. and Liston, D. (1996) Reflective Teaching: an introduction. New Jersey: Lawrence Erlbaum Associates.

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How to Write a Nursing Reflective Essay (Guide for Nurse Students)

If you are a nursing or medicine student, you are aware that you will come across or have already come across assignments requiring you to write a nursing reflection essay. At first, such a task always appears challenging, but given the understanding of the steps, things flat out, and you can write reflective essays and get better grades.

Reflective practice is highly encouraged in nursing. Reflection entails making sense of situations, events, actions, and phenomena in the workplace.

As a nursing student, you will be asked to write a reflective essay on your clinical placement, practicum, shadowing experience, shadow health DCE activities, personal nursing philosophy, why you want to become a nurse, nursing program, ethical dilemma, knowledge, skills, and abilities, systems, and processes.

The easiest way to complete the reflective essay assignment is by first determining what reflective writing entails, its significance, its steps, and some of the best tips that form the core of this ultimate guide.

Basics of Reflective Writing in Nursing

Reflective writing is an analytical writing practice where the writer describes a real or imaginary event, scene, phenomenon, occurrence, or memory, including their takeaway. It entails the critical analysis of an experience, including recording how it has impacted you and what you intend to do with the new knowledge or how to act when such an occurrence recurs.

As you document the encounter, you can use first-person pronouns and write subjectively and objectively. This means that you can decide to either use personal experiences alone or support these experiences using citations from scholarly sources.

When writing a reflective essay in nursing, you must recount the events and give critical detail of how the events shaped your knowledge acquisition. Reflection helps nursing students develop skills in self-directed learning, which is directly associated with high motivation and improved quality of care .

In most cases, reflection occurs on what went well and what went wrong. It could be a successful operation, a thank you note from a patient, a patient who regained their health faster, or a new nursing care plan that worked. However, it can also be about adverse events such as death, postoperative complications, death of an infant at birth, dissatisfied patient, medical error, or a failed procedure.

As a nursing student, when you learn to reflect on situations, you grow to become a professional nurse who diligently does their noble duty.

When writing a reflective essay, you begin by setting the scene (explaining what, where, how, and who-the situation), detailing how you felt (emotional state), why it happened (making sense of the situation), critical review and development of insights, a note on what was learned, and strategies to address future recurrence.

Your professor may ask you to write a nursing reflective paper about various topics in your course or your experience working in a group, how you solved a problem, a healthcare issue, or clinical practice. Consider the following example of a reflective statement in nursing; in my clinical practices, I realized I focused more on the technical aspects but failed to explain what it was doing to improve their health. I would like to understand more about listening to patience and their concerns to better care for them.

As you will notice later, these reflective stages are structured into different reflective models and frameworks that we will explore in-depth. So, with the understanding of what comprises reflective writing and its importance in nursing, let's now get solid on the structure.

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Structure of a Reflective Essay in Nursing

A reflective essay is an analytical writing piece describing and evaluating encounters or experiences. When asked to write one, you should know that an excellent reflective essay consists of different parts, just like a typical academic essay. It comprises the cover or title page, introduction, body paragraphs, conclusions, and a references page.

The title page contains information about the assignment. If you are writing the reflective essay in APA, include these on the title page:

• Title of the reflective essay
• Course code and name
• Instructors name
• Name of your institution
• Date of submission

When writing in Harvard format, the title or the cover page will consist of the following:

• Title of the essay in title case and the page number (upper right margin),
• Title of the essay in CAPS,
• Name of class or course,
• Name of the instructor,
• Name of your school,
• City and state where your school is located and,
• The date of submission.

Introduction

The introduction begins with an attention grabber or a hook sentence to attract readers' attention. It should then explain the essay's purpose and signpost the ideas that will come later in the essay. The introduction also has a thesis statement at the end of the paragraph- the last sentence. The thesis is concise, clear, and relatable and should reflect your position.

Body Paragraphs

The body paragraphs of a reflective essay can be three or more, depending on the length of the essay. Essentially, the body comprises 80% of the total word count.

The first paragraph is where you describe the situation, including the events, why they occurred, how they occurred, and those involved.

The second paragraph entails your personal feelings or reaction to the situation and how it made you feel.

The third paragraph can include making sense of the situation. You have to think about why things happened the way they did. You should also critically review and develop insights based on the situation. Finally, think of the factors that could have influenced the situation.

The next paragraph should explain how the event or situation will change your practice, approach, decisions, perspective, or perception. This is where you evaluate the experience by detailing the knowledge and skills you took from the experience.

The last body paragraph should entail a critical reflection on the learning opportunities. First, describe the situation and what it made you learn. Next, elaborate on how you intend to make yourself better poised to address such situations.

Mostly, you should structure the body of your essay as per the preferred nursing reflective model.

After everything else falls into place, you need to summarize the information you presented in the essay. Then, finally, restate your thesis and have a call to action to bring a sense of closure to your readers.

Steps for Writing a Nursing Reflection Essay � The Guide

When assigned to write a reflective essay for your nursing class, here are the surefire steps to get you to success.

Read the instructions

The first step after receiving an assignment is to begin reading the instructions. as you read, note what your instructor or professor expects in the paper you will submit for marking.

Reading instructions helps you to get informed on the scope of the paper, word count, number of references and pages, and the formatting style to use.

Besides, you also get to plan your paper with the deadline highlighted in the instructions.

You need to get a conducive environment where you can start writing.

The first step of writing is to brainstorm about situations during your clinical hours when you were shadowing a Nurse Practitioner or one you have read about.

Assess whether the situation or scenario you have thought, encountered, or chosen can help you write a reflective essay that meets the requirements.

Research and Plan

After choosing a scenario, the next step is researching the best reflective model.

You can use your class text, the instructions, the college library, course readings, and online nursing journals to get articles and resources with information about specific reflective models.

Select the best reflective model and take notes on the steps it entails.

As you research, write down notes on how to address your paper based on your selected framework or model of reflection . Additionally, research nursing journal articles with information you can use when critically analyzing a situation.

Plan how you will handle the paper as well. For instance, as you research, develop a thesis statement that grounds your entire paper, then draft an outline on how to develop the thesis.

Write an Outline

Outlining is a crucial aspect of writing. It helps you envision how you will meet the objective of writing a reflective essay. As an essential part of the essay writing process, outlining helps create a good flow of ideas and can come in handy in helping you overcome writer's block. Your outline should comprise the following:

• The hook or attention grabber
• Thesis statement
• Main points of each body paragraph (topic sentence, evidence, examples, illustrations, etc.)
• Conclusion (restated thesis and call-to-action)

With the outline done, you should take a break and resume writing your first draft of the nursing reflection essay. Writing with an outline helps avoid mistakes and also helps you write faster.

Describe the Experience

Once you have identified the relevant experience, begin describing it chronologically.

Describe the experience that prompted you to consider nursing your ideal career goal. Think of this experience's key elements, such as the setting, patient demographics, and significant events that impacted you.

Show how these events changed your perspective on life. Ensure you are as descriptive as possible to paint a clear picture for readers.

Consider the following questions to come up with a good description:

• What happened?
• Was there someone involved? If yes, what part did they play?
• Where did the event take place?
• What actions did you take?

Set the context of this experience by giving relevant background information. Ensure you are objective and pay attention to the facts.

Provide a Reflection

Talk about your feelings and thoughts concerning the particular experience you went through. You have to be honest and open up about your initial expectations and challenges you faced at each stage of the experience. The following questions can help you come up with a good reflection:

• What was I trying to achieve?
• What prompted me to act the way I did?
• Are there any consequences for my actions? If yes, what are they?
• How did I feel about this event as it was happening?
• How did those around me react to it?
• How do I know how those around me felt about it?

Analyze the Experience

Description of an experience is essential, but so is analysis. You have to move beyond the surface and give a critical analysis of your experience.

State your actions, and your overall experience will give insights into your experience. Think of how the experience has impacted your actions, feelings, and thoughts.

Give an Evaluation

Evaluate the skills and knowledge you got from the experience. Show how you can apply these skills and knowledge in your nursing practice. Also, state the actions and interventions you took during the nursing experience.

State whether you achieved the desired outcome and if there are any specific areas that you need to improve on.

Talk about how you built or improved skills like communication, teamwork, and critical thinking.

As you evaluate the experience, identify what you believe to be your strengths and weaknesses in the nursing experience. What have you learned from the experience? State the areas where you excelled and what abilities contributed to your success.

Talk about how those you were with during the clinical experience complimented you. Similarly, acknowledge your weaknesses.

What kind of mistakes did you make, and how did you improve them? Talk about the tasks that drain you most during the experience.

Illustrate Learning

Demonstrate elements of deeper thought and reflection levels. This is a great point to include nursing theories in your reflection essay to support analysis of your experience.

Relate your experiences to the theoretical frameworks you were taught in class. This is effective learning and will demonstrate your ability to apply knowledge to real-life nursing situations.

Doing this will also show that you can effectively deduce different things from observations made during the reflection process.

Ensure you also demonstrate a change in perspective, as this will prove that you learned something from the experience.

Write Your Conclusion

Conclude by summarizing your points and highlighting the lessons learned.

The lessons you reached as part of your reflection should support your overall conclusion.

Also, restate your thesis statement.

Come Up with an Action Plan

Now that you have learned from your reflection develop an action plan for future nursing practice.

This part should contain all the details you have learned and actions needed to improve when faced with a similar situation. Consider the following questions:

• What would I change if faced with a similar situation?
• How can I develop the necessary skills needed to face this situation?
• How can I act differently in a similar situation?  

Ensure you identify areas to improve and set realistic goals to enhance your nursing skills. Discuss how you intend to seek additional education, training, or mentorship to address your shortcomings.

Finally, end the essay with a happy note so readers know you learned something from the experiences.

Proofread, Edit, and Polish

After doing your first draft, take a break to relax and get out of the writing mood - it helps you to become objective.

You can then resume reading out loud to yourself, make necessary tweaks, and ensure that every part you include meets the rubric requirements.

Edit for grammar, punctuation, tenses, voice, spelling, and use of language. You should also proofread the essay to adhere to the style, organization, and presentation requirements.

Ensure that all the in-text citations are accounted for in the reference list and are up-to-date. You are good to go when you have an essay that meets all the instructions.

Finally, you can submit the paper for grading.

Writing is not everyone's cup of tea. For that reason, you can hire a nursing reflection essay writer from our website to assist you in crafting a top-grade paper. In addition, we have nursing writers whose forte is writing various nursing papers.

Choosing the suitable Reflective Model or Framework

As you can see above, many reflective models are used for your reflective essay. We have not exhaustively listed and expounded on all of them. Other reflective models and frameworks you can also consider when writing a reflective essay in nursing include:

• Bouds Reflective Model
• Brookfield Reflective Model
• Pender's Health Promotion Model
• Roper Logan and Tierney Model
• Driscoll Reflective Model
• The Johari window model

Note that most nursing instructors will often suggest the models they prefer for you to use in your essay.

For example, in most nursing reflective essays. Whichever the case, readily available information expands on each model to make it easier to write a reflection essay on a specific aspect of nursing education or practice.

Read the assignment rubric and instructions to understand the specific model. If it is unclear, ask for clarification from your instructor early enough.

Tips for Writing a Good Nursing Reflective Essay

As you try to figure out how to write a nursing reflective essay, keep the following tips in mind.

Choose the Right Topic

If the instructions from your professors involve choosing a topic for the reflective essay, you must select one that is meaningful to you.

This will ensure you can easily write and easily develop relevant elements about the topic. Therefore, take time to pick a topic that you find interesting.

As you write, ensure you stay on topic, whether sharing a one-off event or a recurrent story.

Use the Right Tone

A reflective essay is more personal, unlike other types of academic essays. This means you don't need a strict or formal tone.

Since this is about your experiences, use personal pronouns such as I and Me.

Be Vulnerable

You must be extremely vulnerable to learn how to write a reflective essay in nursing.

Be open about your thoughts, feelings, and beliefs about something you went through that sparked an interest in nursing.

It's okay to share mistakes or things you did wrong that eventually led you to this career path.

Choose the Right Focus

A reflection essay is all about narrating your experience during the nursing experience.

While including other people in your experience is okay, please let them not be the center of your reflection.

This is your essay, so you should be the focus of attention.

Keep it Brief

A good nursing reflection essay should be between 300 and 800 consciously written words. Because of this length, you must only write relevant information about your reflection. Refrain from lengthy reflections, as they make it difficult to pass your points across.

Convey Your Information Wisely

Even though a nursing reflection essay is about your personal experiences, it doesn't mean you should reveal everything about yourself. Ask yourself whether something is appropriate before including it in your paper.

Mistakes to Avoid When Writing a Reflection Essay in Nursing

A good reflection essay involves reflecting on your nursing studies and practices throughout school and career to demonstrate your competence. For this reason, there are certain mistakes you should be aware of when writing an essay.

Not including a Personal Story

Like food tastes bland without salt, so does a reflection essay without a personal story. At the center of a reflection essay is You. This means the essay should focus on your personal story that led you to want a nursing career. A lot of times, students miss out on this instead of talking about their story. You need more than just the personal qualities you think will be a great fit for the nursing program; you must also share a story that shows how well you contributed to nursing care.

Failing to Share Your Experience

You will lose points when you fail to include nursing-related experiences in your reflection essay. Mentioning that you want to be a nurse is great, but failing to show specific events that led to the desire will cost you a great point.

Plagiarizing Your Essay

Plagiarism is a serious academic offense because it is considered taking other people's ideas and using them as your own without crediting the author. So, provide relevant citations and references for any ideas that aren't your own. Also, an AI will not write your essay as a human writer would. 

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• How to write a student nurse resume with no experience.
• PICOT examples and guides

Sample of a Nursing Reflective Essay 

The following is a sample of a nursing Reflective essay using Gibb's Model of Reflection. Use this sample to guide you when writing your own.

Introduction  Communication is an important element in healthcare practice as it determines patient satisfaction and treatment outcomes. This essay will focus on reflecting on an experience I went through with a 40-year-old diabetic patient who also had a foot infected with an ulcer. When I approached the patient to sign the consent form, I noticed that he wasn't happy because of the news given to him about his health. I concluded that there must be a communication dilemma. I will reflect on the experience using Gibb's Model of Reflection. Using this model, I will identify and discuss the actions taken to resolve the issue. Description  This incident happened a few months ago when I was working as a wound nurse in a Methodist hospital in my hometown. I was part of a care team handling the case of a 40-year-old male patient with diabetes and an infected diabetic foot ulcer. After careful examination, a team comprising various specialists concluded that his leg needed amputation below the knee. After making this decision, the team left, and I was asked to give the patient a consent form to sign. When I came back from retrieving the form, I noticed the patient looked sorrowful because of the news given to him. Feelings  As soon as I saw the patient, I knew what he was going through. He perceived the situation to be irreparable, but I wasn't sure whether to console the patient or not. I was powerless and couldn't imagine what he was going through. At the same time, I was startled that the team left without showing any compassion. They could have handled the situation more delicately. I, on the other hand, could have relayed the information better. I wasn't sure whether my approach would be acceptable or appropriate. Evaluation  I always go back to that particular situation and wonder whether I could have acted better. The situation helped me better understand the importance of good communication in patient care, particularly in therapeutic care. Before the incident, I didn't acknowledge the role of nurses play in caring for patient's emotional needs. I realized nurses must show compassion and console patients in their low moments.  Analysis  Most healthcare professionals do not know how to deliver bad news to patients. They find the process extremely challenging and always feel psychologically unprepared. This has a negative impact on patients and could lead to bad health outcomes. Furthermore, how information is relayed could impact a patient's adherence to treatment. Because of these effects, multiple protocols and approaches were developed to help with communicating bad news to patients. One of the approaches that was proposed is emotion-centered. This proposes that a healthcare provider acknowledges how sad the patient is and builds a professional relationship based on empathy and sympathy. Action Plan I now understand the essence of communicating bad news with compassion. The experience allowed me to look closely at different aspects of my professional development that needed more improvement. Thus, I plan to be more empathetic and speak up in support of patient's emotional and psychological well-being, especially when presented with traumatic news about their health. Additionally, I now understand I am not powerless when dealing with a sorrowful patient. I believe I have learned from my experience, and I'm not able to communicate well with patients any more. Conclusion  The experience allowed me to value good communication in nursing and the need to incorporate it into daily nurse-patient interaction. Nurses must learn how to deliver bad news and manage patient's sorrow. This has been and will continue to be my biggest priority in patient care. References Street Jr, R. L., Makoul, G., Arora, N. K., & Epstein, R. M. (2009). How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient education and counselling, 74(3), 295-301. Buckman, R. (1992). Breaking bad news: why is it still so difficult? BMJ: British Medical Journal, 304(6842), 886. Ptacek, J. T., & Eberhardt, T. L. (1996). Breaking bad news: a review of the literature. The Journal of the American Medical Association, 276(6), 496-502.

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• Research article
• Open access
• Published: 09 November 2005

A qualitative study of nursing student experiences of clinical practice

• Farkhondeh Sharif 1 &
• Sara Masoumi 2  

BMC Nursing volume  4 , Article number:  6 ( 2005 ) Cite this article

361k Accesses

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Metrics details

Nursing student's experiences of their clinical practice provide greater insight to develop an effective clinical teaching strategy in nursing education. The main objective of this study was to investigate student nurses' experience about their clinical practice.

Focus groups were used to obtain students' opinion and experiences about their clinical practice. 90 baccalaureate nursing students at Shiraz University of Medical Sciences (Faculty of Nursing and Midwifery) were selected randomly from two hundred students and were arranged in 9 groups of ten students. To analyze the data the method used to code and categories focus group data were adapted from approaches to qualitative data analysis.

Four themes emerged from the focus group data. From the students' point of view," initial clinical anxiety", "theory-practice gap"," clinical supervision", professional role", were considered as important factors in clinical experience.

The result of this study showed that nursing students were not satisfied with the clinical component of their education. They experienced anxiety as a result of feeling incompetent and lack of professional nursing skills and knowledge to take care of various patients in the clinical setting.

Peer Review reports

Clinical experience has been always an integral part of nursing education. It prepares student nurses to be able of "doing" as well as "knowing" the clinical principles in practice. The clinical practice stimulates students to use their critical thinking skills for problem solving [ 1 ]

Awareness of the existence of stress in nursing students by nurse educators and responding to it will help to diminish student nurses experience of stress. [ 2 ]

Clinical experience is one of the most anxiety producing components of the nursing program which has been identified by nursing students. In a descriptive correlational study by Beck and Srivastava 94 second, third and fourth year nursing students reported that clinical experience was the most stressful part of the nursing program[ 3 ]. Lack of clinical experience, unfamiliar areas, difficult patients, fear of making mistakes and being evaluated by faculty members were expressed by the students as anxiety-producing situations in their initial clinical experience. In study done by Hart and Rotem stressful events for nursing students during clinical practice have been studied. They found that the initial clinical experience was the most anxiety producing part of their clinical experience [ 4 ]. The sources of stress during clinical practice have been studied by many researchers [ 5 – 10 ] and [ 11 ].

The researcher came to realize that nursing students have a great deal of anxiety when they begin their clinical practice in the second year. It is hoped that an investigation of the student's view on their clinical experience can help to develop an effective clinical teaching strategy in nursing education.

A focus group design was used to investigate the nursing student's view about the clinical practice. Focus group involves organized discussion with a selected group of individuals to gain information about their views and experiences of a topic and is particularly suited for obtaining several perspectives about the same topic. Focus groups are widely used as a data collection technique. The purpose of using focus group is to obtain information of a qualitative nature from a predetermined and limited number of people [ 12 , 13 ].

Using focus group in qualitative research concentrates on words and observations to express reality and attempts to describe people in natural situations [ 14 ].

The group interview is essentially a qualitative data gathering technique [ 13 ]. It can be used at any point in a research program and one of the common uses of it is to obtain general background information about a topic of interest [ 14 ].

Focus groups interviews are essential in the evaluation process as part of a need assessment, during a program, at the end of the program or months after the completion of a program to gather perceptions on the outcome of that program [ 15 , 16 ]. Kruegger (1988) stated focus group data can be used before, during and after programs in order to provide valuable data for decision making [ 12 ].

The participants from which the sample was drawn consisted of 90 baccalaureate nursing students from two hundred nursing students (30 students from the second year and 30 from the third and 30 from the fourth year) at Shiraz University of Medical Sciences (Faculty of Nursing and Midwifery). The second year nursing students already started their clinical experience. They were arranged in nine groups of ten students. Initially, the topics developed included 9 open-ended questions that were related to their nursing clinical experience. The topics were used to stimulate discussion.

The following topics were used to stimulate discussion regarding clinical experience in the focus groups.

How do you feel about being a student in nursing education?

How do you feel about nursing in general?

Is there any thing about the clinical field that might cause you to feel anxious about it?

Would you like to talk about those clinical experiences which you found most anxiety producing?

Which clinical experiences did you find enjoyable?

What are the best and worst things do you think can happen during the clinical experience?

What do nursing students worry about regarding clinical experiences?

How do you think clinical experiences can be improved?

What is your expectation of clinical experiences?

The first two questions were general questions which were used as ice breakers to stimulate discussion and put participants at ease encouraging them to interact in a normal manner with the facilitator.

Data analysis

The following steps were undertaken in the focus group data analysis.

Immediate debriefing after each focus group with the observer and debriefing notes were made. Debriefing notes included comments about the focus group process and the significance of data

Listening to the tape and transcribing the content of the tape

Checking the content of the tape with the observer noting and considering any non-verbal behavior. The benefit of transcription and checking the contents with the observer was in picking up the following:

Parts of words

Non-verbal communication, gestures and behavior...

The researcher facilitated the groups. The observer was a public health graduate who attended all focus groups and helped the researcher by taking notes and observing students' on non-verbal behavior during the focus group sessions. Observer was not known to students and researcher

The methods used to code and categorise focus group data were adapted from approaches to qualitative content analysis discussed by Graneheim and Lundman [ 17 ] and focus group data analysis by Stewart and Shamdasani [ 14 ] For coding the transcript it was necessary to go through the transcripts line by line and paragraph by paragraph, looking for significant statements and codes according to the topics addressed. The researcher compared the various codes based on differences and similarities and sorted into categories and finally the categories was formulated into a 4 themes.

The researcher was guided to use and three levels of coding [ 17 , 18 ]. Three levels of coding selected as appropriate for coding the data.

Level 1 coding examined the data line by line and making codes which were taken from the language of the subjects who attended the focus groups.

Level 2 coding which is a comparing of coded data with other data and the creation of categories. Categories are simply coded data that seem to cluster together and may result from condensing of level 1 code [ 17 , 19 ].

Level 3 coding which describes the Basic Social Psychological Process which is the title given to the central themes that emerge from the categories.

Table 1 shows the three level codes for one of the theme

The documents were submitted to two assessors for validation. This action provides an opportunity to determine the reliability of the coding [ 14 , 15 ]. Following a review of the codes and categories there was agreement on the classification.

Ethical considerations

The study was conducted after approval has been obtained from Shiraz university vice-chancellor for research and in addition permission to conduct the study was obtained from Dean of the Faculty of Nursing and Midwifery. All participants were informed of the objective and design of the study and a written consent received from the participants for interviews and they were free to leave focus group if they wish.

Most of the students were females (%94) and single (% 86) with age between 18–25.

The qualitative analysis led to the emergence of the four themes from the focus group data. From the students' point of view," initial clinical anxiety", "theory-practice gap", clinical supervision"," professional role", was considered as important factors in clinical experience.

Initial clinical anxiety

This theme emerged from all focus group discussion where students described the difficulties experienced at the beginning of placement. Almost all of the students had identified feeling anxious in their initial clinical placement. Worrying about giving the wrong information to the patient was one of the issues brought up by students.

One of the students said:

On the first day I was so anxious about giving the wrong information to the patient. I remember one of the patients asked me what my diagnosis is. ' I said 'I do not know', she said 'you do not know? How can you look after me if you do not know what my diagnosis is?'

From all the focus group sessions, the students stated that the first month of their training in clinical placement was anxiety producing for them.

One of the students expressed:

The most stressful situation is when we make the next step. I mean ... clinical placement and we don't have enough clinical experience to accomplish the task, and do our nursing duties .

Almost all of the fourth year students in the focus group sessions felt that their stress reduced as their training and experience progressed.

Another cause of student's anxiety in initial clinical experience was the students' concern about the possibility of harming a patient through their lack of knowledge in the second year.

One of the students reported:

In the first day of clinical placement two patients were assigned to me. One of them had IV fluid. When I introduced myself to her, I noticed her IV was running out. I was really scared and I did not know what to do and I called my instructor .

Fear of failure and making mistakes concerning nursing procedures was expressed by another student. She said:

I was so anxious when I had to change the colostomy dressing of my 24 years old patient. It took me 45 minutes to change the dressing. I went ten times to the clinic to bring the stuff. My heart rate was increasing and my hand was shaking. I was very embarrassed in front of my patient and instructor. I will never forget that day .

Sellek researched anxiety-creating incidents for nursing students. He suggested that the ward is the best place to learn but very few of the learner's needs are met in this setting. Incidents such as evaluation by others on initial clinical experience and total patient care, as well as interpersonal relations with staff, quality of care and procedures are anxiety producing [ 11 ].

Theory-practice gap

The category theory-practice gap emerged from all focus discussion where almost every student in the focus group sessions described in some way the lack of integration of theory into clinical practice.

I have learnt so many things in the class, but there is not much more chance to do them in actual settings .

Another student mentioned:

When I just learned theory for example about a disease such as diabetic mellitus and then I go on the ward and see the real patient with diabetic mellitus, I relate it back to what I learned in class and that way it will remain in my mind. It is not happen sometimes .

The literature suggests that there is a gap between theory and practice. It has been identified by Allmark and Tolly [ 20 , 21 ]. The development of practice theory, theory which is developed from practice, for practice, is one way of reducing the theory-practice gap [ 21 ]. Rolfe suggests that by reconsidering the relationship between theory and practise the gap can be closed. He suggests facilitating reflection on the realities of clinical life by nursing theorists will reduce the theory-practice gap. The theory- practice gap is felt most acutely by student nurses. They find themselves torn between the demands of their tutor and practising nurses in real clinical situations. They were faced with different real clinical situations and are unable to generalise from what they learnt in theory [ 22 ].

Clinical supervision

Clinical supervision is recognised as a developmental opportunity to develop clinical leadership. Working with the practitioners through the milieu of clinical supervision is a powerful way of enabling them to realize desirable practice [ 23 ]. Clinical nursing supervision is an ongoing systematic process that encourages and supports improved professional practice. According to Berggren and Severinsson the clinical nurse supervisors' ethical value system is involved in her/his process of decision making. [ 24 , 25 ]

Clinical Supervision by Head Nurse (Nursing Unit Manager) and Staff Nurses was another issue discussed by the students in the focus group sessions. One of the students said:

Sometimes we are taught mostly by the Head Nurse or other Nursing staff. The ward staff are not concerned about what students learn, they are busy with their duties and they are unable to have both an educational and a service role

Another student added:

Some of the nursing staff have good interaction with nursing students and they are interested in helping students in the clinical placement but they are not aware of the skills and strategies which are necessary in clinical education and are not prepared for their role to act as an instructor in the clinical placement

The students mostly mentioned their instructor's role as an evaluative person. The majority of students had the perception that their instructors have a more evaluative role than a teaching role.

The literature suggests that the clinical nurse supervisors should expressed their existence as a role model for the supervisees [ 24 ]

Professional role

One view that was frequently expressed by student nurses in the focus group sessions was that students often thought that their work was 'not really professional nursing' they were confused by what they had learned in the faculty and what in reality was expected of them in practice.

We just do basic nursing care, very basic . ... You know ... giving bed baths, keeping patients clean and making their beds. Anyone can do it. We spend four years studying nursing but we do not feel we are doing a professional job .

The role of the professional nurse and nursing auxiliaries was another issue discussed by one of the students:

The role of auxiliaries such as registered practical nurse and Nurses Aids are the same as the role of the professional nurse. We spend four years and we have learned that nursing is a professional job and it requires training and skills and knowledge, but when we see that Nurses Aids are doing the same things, it can not be considered a professional job .

The result of student's views toward clinical experience showed that they were not satisfied with the clinical component of their education. Four themes of concern for students were 'initial clinical anxiety', 'theory-practice gap', 'clinical supervision', and 'professional role'.

The nursing students clearly identified that the initial clinical experience is very stressful for them. Students in the second year experienced more anxiety compared with third and fourth year students. This was similar to the finding of Bell and Ruth who found that nursing students have a higher level of anxiety in second year [ 26 , 27 ]. Neary identified three main categories of concern for students which are the fear of doing harm to patients, the sense of not belonging to the nursing team and of not being fully competent on registration [ 28 ] which are similar to what our students mentioned in the focus group discussions. Jinks and Patmon also found that students felt they had an insufficiency in clinical skills upon completion of pre-registration program [ 29 ].

Initial clinical experience was the most anxiety producing part of student clinical experience. In this study fear of making mistake (fear of failure) and being evaluated by faculty members were expressed by the students as anxiety-producing situations in their initial clinical experience. This finding is supported by Hart and Rotem [ 4 ] and Stephens [ 30 ]. Developing confidence is an important component of clinical nursing practice [ 31 ]. Development of confidence should be facilitated by the process of nursing education; as a result students become competent and confident. Differences between actual and expected behaviour in the clinical placement creates conflicts in nursing students. Nursing students receive instructions which are different to what they have been taught in the classroom. Students feel anxious and this anxiety has effect on their performance [ 32 ]. The existence of theory-practice gap in nursing has been an issue of concern for many years as it has been shown to delay student learning. All the students in this study clearly demonstrated that there is a gap between theory and practice. This finding is supported by other studies such as Ferguson and Jinks [ 33 ] and Hewison and Wildman [ 34 ] and Bjork [ 35 ]. Discrepancy between theory and practice has long been a source of concern to teachers, practitioners and learners. It deeply rooted in the history of nurse education. Theory-practice gap has been recognised for over 50 years in nursing. This issue is said to have caused the movement of nurse education into higher education sector [ 34 ].

Clinical supervision was one of the main themes in this study. According to participant, instructor role in assisting student nurses to reach professional excellence is very important. In this study, the majority of students had the perception that their instructors have a more evaluative role than a teaching role. About half of the students mentioned that some of the head Nurse (Nursing Unit Manager) and Staff Nurses are very good in supervising us in the clinical area. The clinical instructor or mentors can play an important role in student nurses' self-confidence, promote role socialization, and encourage independence which leads to clinical competency [ 36 ]. A supportive and socialising role was identified by the students as the mentor's function. This finding is similar to the finding of Earnshaw [ 37 ]. According to Begat and Severinsson supporting nurses by clinical nurse specialist reported that they may have a positive effect on their perceptions of well-being and less anxiety and physical symptoms [ 25 ].

The students identified factors that influence their professional socialisation. Professional role and hierarchy of occupation were factors which were frequently expressed by the students. Self-evaluation of professional knowledge, values and skills contribute to the professional's self-concept [ 38 ]. The professional role encompasses skills, knowledge and behaviour learned through professional socialisation [ 39 ]. The acquisition of career attitudes, values and motives which are held by society are important stages in the socialisation process [ 40 ]. According to Corwin autonomy, independence, decision-making and innovation are achieved through professional self-concept 41 . Lengacher (1994) discussed the importance of faculty staff in the socialisation process of students and in preparing them for reality in practice. Maintenance and/or nurturance of the student's self-esteem play an important role for facilitation of socialisation process 42 .

One view that was expressed by second and third year student nurses in the focus group sessions was that students often thought that their work was 'not really professional nursing' they were confused by what they had learned in the faculty and what in reality was expected of them in practice.

The finding of this study and the literature support the need to rethink about the clinical skills training in nursing education. It is clear that all themes mentioned by the students play an important role in student learning and nursing education in general. There were some similarities between the results of this study with other reported studies and confirmed that some of the factors are universal in nursing education. Nursing students expressed their views and mentioned their worry about the initial clinical anxiety, theory-practice gap, professional role and clinical supervision. They mentioned that integration of both theory and practice with good clinical supervision enabling them to feel that they are enough competent to take care of the patients. The result of this study would help us as educators to design strategies for more effective clinical teaching. The results of this study should be considered by nursing education and nursing practice professionals. Faculties of nursing need to be concerned about solving student problems in education and clinical practice. The findings support the need for Faculty of Nursing to plan nursing curriculum in a way that nursing students be involved actively in their education.

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The author would like to thank the student nurses who participated in this study for their valuable contribution

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Farkhondeh Sharif

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Sharif, F., Masoumi, S. A qualitative study of nursing student experiences of clinical practice. BMC Nurs 4 , 6 (2005). https://doi.org/10.1186/1472-6955-4-6

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Reflective reading group: improving research skills and confidence

22 July, 2024 By Alison Welfare-Wilson and Hayley Beresford

A reflective reading club developed the research confidence, literacy and skills of nurses and allied health professionals

A cross-trust initiative developed a reflective reading club for mental health nurses and allied health professionals, which was delivered online bimonthly. The aim of this collaboration was to increase attendees’ research confidence, skills and literacy. A survey demonstrated that group attendance resulted in increased understanding of terminology, and confidence in reading research and discussing it with peers.

Citation: Welfare-Wilson A, Beresford H (2024) Reflective reading group: improving research skills and confidence. Nursing Times [online]; 120: 8.

Authors: Alison Welfare-Wilson is senior research nurse, Kent and Medway NHS and Social Care Partnership Trust; Hayley Beresford is clinical librarian, Maidstone and Tunbridge Wells NHS Trust.

• This article has been double-blind peer reviewed
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Introduction

Nurses’ work is underpinned by evidence-based practice; this involves identifying and understanding evidence to the point of translating it into practice. However, nurses often do not feel confident about research and think it should be done by people in other health professions (Hare and Whitehouse, 2022). Although nurses are well placed to observe areas for development and research , in our professional experience many have told us that they – and nurses as a professional group – lack the skills and confidence to be involved in research , particularly when compared with their peers from different professional groups.

We have seen that many nurses are interested in research and recognise the importance of evidence-based practice. However, some have qualified with little knowledge of the processes and techniques used to search for and appraise literature (King et al, 2022). This may, in part, lay the foundation for the feelings of embarrassment and inadequacy that some have about a perceived lack of knowledge and skills .

These observations led to a desire to create a nurturing, educational space for nurses to begin to learn about research and develop their skills; the aim was to develop more confidence in research that could be taken back into clinical practice. After observing that many allied health professionals (AHPs) struggle with the same barriers and fears around research, we developed a cross-trust reflective reading club (RRC) for mental health nurses and AHPs of all bands, as well as students . This article explores the RRC’s development, processes, outcomes and future plans.

“We wanted to avoid the idea that journal clubs are for doctors only”

Literature review

Health professionals’ practice may be underpinned by evidence, but an essential prerequisite to using evidence effectively is having the knowledge and skills to search for and appraise it, and consider its applications. However, more important is whether one has the confidence to use these skills – the literature suggests that nurses (Hare and Whitehouse, 2022) and AHPs (Harris et al, 2020) do not.

Whereas evidence-based practice skills are synonymous with professions such as psychology, psychiatry and wider medicine, nurses and AHPs are hampered by the relative unfamiliarity of reading, undertaking and using research (Hare and Whitehouse, 2022; Harris et al, 2020). One way of promoting evidence-based practice is by participating in a journal club.

Journal clubs are “a form of meeting regularly held among health practitioners to discuss recently published related literature” (Xiong et al, 2018). These forums, first created in 1875 by Sir William Osler (Topf et al, 2017), provide a means for health professionals to:

• Keep up to date with relevant literature;
• Develop critical appraisal skills;
• Embed research in clinical practice (Gardner et al, 2016).

Journal clubs are an increasingly popular and effective evidence-based practice teaching strategy in the nursing profession (Lachance, 2014). However, they are more established in postgraduate medical education, where meetings are often integrated into regular, formalised departmental teaching programmes (Gardner et al, 2016). As such, access to a forum to critique, debate and reflect on research with peers is a common and expected feature of professional development for trainee doctors and consultants (Topf et al, 2017).

This history of journal clubs as academic meetings organised and attended by doctors – combined with the characteristic features of structured critical appraisal, formal teaching elements and rostered presenters (Topf et al, 2017) – can make them seem like rigid, intimidating and inaccessible spaces for other health professionals, such as nurses and AHPs.

Developing and running the group

When Maidstone and Tunbridge Wells NHS Trust’s clinical librarian service was set up in 2021, it was showcased to members of Kent and Medway NHS and Social Care Partnership Trust’s research and innovation department to identify potential areas for partnership. This led to us collaborating, with the goal of engaging more nurses and AHPs in research.

We identified that nurses and AHPs have few opportunities to engage with research and, if they get them, they may be reluctant to get involved due to a lack of familiarity, feelings of inadequacy, and fear of embarrassment. This places them at a disadvantage compared with their medical colleagues – who have access to regular formalised medical education (Taverna et al, 2022) – when it comes to reading, appraising and using evidence and discussing it with colleagues.

As a solution, we proposed an RRC for mental health nurses and AHPs. This would be an informal group to allow like-minded individuals to get together to explore research through literature. Central to this was removing the more formal and intimidating elements of traditional journal clubs that can make them unapproachable for interested beginners.

When developing the RRC brief, we wanted to:

• Focus on research confidence as an outcome;
• Create an informal, friendly and flexible environment;
• Learn together from peer-driven content and discussion;
• Create a distinct, identifiable partnership between the two trusts’ departments.

Additionally, we wanted to avoid:

• The idea that journal clubs are for doctors only, and language that perpetuates this;
• Rigid critical appraisal checklists;
• Anxiety around presenting or participating;
• Rules or requirements about previous experience, education or commitment.

Taking into consideration our experience, vision for the group and knowledge of traditional journal clubs, we conducted an evidence search and contacted library networks for examples that were a close match of what we wanted to create. This exercise yielded two categories of reading groups:

• Journal clubs (described above);
• RRCs aimed specifically at nurse revalidation or preceptorship.

The model for these RRCs arose as a direct response to the introduction of the Nursing and Midwifery Council’s (NMC’s)(2019) requirement for nurses to maintain their professional knowledge and skills through a process of continuous learning and reflection. These RRCs are based on Collins et al’s (2015) searching, reviewing, linking, action (SRLA) tool for professional reading, and they are commonly delivered by NHS librarians as part of a wider library service provision. They provide a structured and focused opportunity for nurses to contribute points to the NMC’s total requirement of 35 hours of continuing professional development over three years.

Our RRC differs from these groups in a number of ways:

• It is open to all nurses and AHPs, regardless of band or role, and students;
• It is a research and innovation initiative, promoted and delivered by the research and innovation team, rather than by nursing teams or the learning and development team;
• We do not choose articles primarily about the nursing role, reflective practice or writing but, instead, choose those that are about clinical topics nurses and AHPs are likely to encounter in their daily practice;
• Our aim is to build research confidence through reflective reading and learning together for fun: we do not promote it only as a vehicle for revalidation.

As such, we view our group as an amalgamation of traditional journal clubs and RRCs for revalidation.

We learnt that monthly, in-person RRC sessions did not work. However, when the Covid-19 pandemic increased the use of virtual technology, we began to run virtual meetings every two months in 2021. This frequency allows ample time for reading and preparation, while retaining group consistency and connectedness. Delivering the RRC via MS Teams minimises time and travel barriers, and maximises reach and inclusivity. This is especially important for a group made up of professionals from two multi-site trusts spread across a wide geography.

The RRC is cofacilitated by staff from the library and knowledge service and the research and innovation team, providing combined expertise across the research cycle. Sessions comprise a dynamic mix of interactive facilitator-led education and group discussion. We use an adapted version of Collins et al’s (2015) SRLA tool as a reflective framework to guide attendees in the process of reflection when reading, assessing and potentially applying what they have read into clinical practice; this allows us to give mental health nurses and AHPs a safe space in which to share experiences and learn from their peers. Fig 1 shows the process of planning and holding each session.

Survey of attendees

One year after launching the RRC, we sent an electronic survey to everyone who had attended; of the 35 attendees, 12 responded. The aim was to measure the RRC’s impact on attendees’ research knowledge and confidence, and the survey asked the following questions:

• To what extent do you feel the RRC has improved your understanding of research terminology?
• To what extent do you feel the RRC has improved your confidence in reading research and academic papers?
• To what extent do you feel the RRC has improved your confidence in discussing research with your peers?
• To what extent do you feel the RRC has improved your use of research in your clinical practice or service?
• Is there anything else you would like to tell us?

For the first four questions, respondents were asked to select an answer based on a Likert scale of “a little”, “some”, “a lot” and “a great deal”.

Responses revealed that 83% of respondents felt the RRC had improved their understanding of research terminology a great deal. Answers to the other questions were also positive, but slightly less so:

• Confidence reading research and academic papers – improved a great deal: 50%, improved a lot: 25%;
• Confidence discussing research – improved a great deal: 8%, improved a lot: 75%;
• Use of research in practice – improved a great deal: 8%, improved a lot: 50%.

In response to the final, free-text, question, comments included the following:

“I like the informal nature of the group and the fact we learn together. Nothing feels too stupid to ask.”

“I like that it is a small group of nurses and AHPs, and that it doesn’t feel threatening at all.”

“This club has helped me enjoy research by making it accessible and fun.”

“I was able to take some evidence back [to the workplace] and suggest how it could improve practice.”

The survey results showed that the RRC was useful and effective at increasing not only research knowledge and skills, but also confidence to use these new skills in practice. Additionally, the regular attendance and engagement of six to eight RRC members indicated that delivering the group virtually was sustainable and effective.

Conclusion and future plans

In response to many nurses’ and AHPs’ lack of skills and confidence in participating in research, we have provided access to a new type of research opportunity via the RRC.

Survey results suggest that the RRC is meeting its aims of improving attendees’ research literacy and confidence. However, to sustain and grow the club, we want to build in additional support that will allow attendees to make the most of the opportunity. We plan to integrate standalone training sessions on topics such as critical appraisal and writing for publication. By providing these training and development opportunities in the RRC, where attendees feel comfortable and learning is contextualised, we aim to encourage continued participation and to produce health professionals who are both consumers and users of research.

Eventually, we hope the RRC will become a space in which many of its attendees are studying or carrying out their own research projects. The group could serve as a space where they can share their own work, practise their presentation skills, navigate feedback, and inspire the next cohort of nurses and AHPs.

• Nurses and allied health professionals often lack confidence in accessing, discussing and using research
• Journal clubs are increasingly popular, but their structure can make them intimidating and inaccessible
• Two trusts collaborated to develop a reflective reading club as an informal space to discuss research
• The reading club takes place online bimonthly, and is for mental health nurses and allied health professionals of all bands
• A survey showed that the club increased attendees’ confidence and research skills

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Reflective practice in nursing: A concept analysis

Affiliation.

• 1 Western University, London, Ontario, Canada.
• PMID: 34626459
• DOI: 10.1111/2047-3095.12350

Purpose: This paper aims to clarify the concept of reflective practice in nursing by using Rodgers' evolutionary method of concept analysis.

Data sources: Literature and references on the concept of reflective practice were obtained from two databases: Scopus and Nursing and Allied health database. Peer-reviewed articles published in English language between 2011-2021 that included the terms 'reflection' and/or 'reflective practice' in the title were selected. Seminal pieces of work were also considered in this analysis. A total of 23 works were included. Most of the selected works addressed the concept of reflective practice in nursing education or nursing practice.

Data synthesis: The data analysis integrated the stages identified in Rodgers' method of concept analysis to analyze the concept of reflective practice. Analysis of selected works provided an understanding of common surrogates, antecedents, attributes, and consequences of the concept of reflective practice.

Conclusions: Reflective practice is a cognitive skill that demands conscious effort to look at a situation with an awareness of own beliefs, values, and practice enabling nurses to learn from experiences, incorporate that learning in improving patient care outcomes. It also leads to knowledge development in nursing. Considering the current circumstances of the COVID-19 pandemic, this paper identifies the need for nurses to go beyond reflection-on-action and also include reflection-in-action and reflection-for-action as part of their practice.

Implications for nursing practice: This analysis identifies the need for future nursing researchers to develop reflective models or strategies that promote reflection among nurses and nursing students before, during, and after the clinical experiences.

Keywords: Rodgers’ evolutionary concept analysis method; nursing; reflective practice.

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Exploring the therapeutic relationship through the reflective practice of nurses in acute mental health units: A qualitative study

Diana tolosa‐merlos.

1 Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona Spain

Antonio R. Moreno‐Poyato

2 Department of Public Health, Mental Health and Maternal and Child Health Nursing, Nursing School, Universitat de Barcelona, L'Hospitalet de Llobregat Spain

3 IMIM (Hospital del Mar Medical Research Institute), Barcelona Spain

Francesca González‐Palau

4 Hospital Santa Maria, Salut/Gestió de Serveis Sanitaris, Lleida Spain

Alonso Pérez‐Toribio

5 Unitat de Salut Mental de l'Hospitalet, Gerència Territorial Metropolitana Sud, Institut Català de la Salut, L'Hospitalet de Llobregat Spain

Georgina Casanova‐Garrigós

6 Department and Faculty of Nursing, Universitat Rovira i Virgili, Tortosa Spain

Pilar Delgado‐Hito

7 Department of Fundamental Care and Medical‐Surgical Nursing, Nursing School, Universitat de Barcelona, L'Hospitalet de Llobregat Spain

8 GRIN‐IDIBELL (Nursing Research Group‐ Bellvitge Biomedical Research Institute), L'Hospitalet de Llobregat Spain

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Aims and objectives

To explore the therapeutic relationship through the reflective practice of nurses in acute mental health units.

In mental health units, the therapeutic relationship is especially relevant for increasing the effectiveness of nursing interventions. Reflective practice is considered an essential aspect for improving nursing care.

Action and observation stages of a participatory action research project.

Data were collected through reflective diaries designed for the guided description and reflection of practice interactions related to the therapeutic relationship and content analysis was applied. A total of 152 nurses from 18 acute mental health units participated. The COREQ guidelines were used.

The results were classified into three categories as follows: (i) Nursing attitude as a core of the therapeutic relationship. For the nurses, the attitudinal component was key in the therapeutic relationship. (ii) Nursing practices that are essential to the therapeutic relationship. Nurses identified practices such as creating a conducive environment, using an appropriate verbal approach, offering help and working together with the patient as essential for establishing a therapeutic relationship in practice. (iii) Contextual factors affecting the therapeutic relationship. The nurses considered the patient's condition, the care dynamics of the unit and its regulations, as well as the structure and environment of the unit, as contextual factors involved the establishment of an adequate therapeutic relationship in daily clinical practice.

Conclusions

This study has provided knowledge of the importance and role of the nurses' attitude in the context of the nurse–patient therapeutic relationship based on the reflections of nurses in mental health units regarding their own practice.

Relevance to clinical practice

These findings help nurses to increase awareness and develop improvement strategies based on their own knowledge and day‐to‐day difficulties. Moreover, managers can evaluate strategies that promote motivation and facilitate the involvement of nurses to improve the therapeutic relationship with patients.

What does this paper contribute to the wider global clinical community?

• An in‐depth analysis of nurses' reflections regarding the aspects that underlie the therapeutic relationship in their clinical practice enables the nurses themselves to become aware and to develop strategies for improvement based on their own knowledge.
• Understanding and confirming how the attitudinal component is a key element for nurses in the practice of the therapeutic relationship allows managers to evaluate strategies that promote motivation and facilitate the involvement of nurses to improve their practice with patients.
• The results point to the need for further studies aimed at identifying and implementing strategies that facilitate mental health nurses to incorporate and improve attitudinal skills related to establishing the nurse–patient therapeutic relationship in clinical practice.

1. INTRODUCTION

The nursing discipline is defined as a significant, therapeutic and interpersonal process that acts in conjunction with other human processes that make health possible for individuals (Peplau, 1988 ). The relationship established between nurse and patient is therapeutic, regardless of the setting in which care is provided (Stevenson & Taylor, 2020 ). However, in the mental health unit setting, the therapeutic relationship is especially relevant to increase the effectiveness of any nursing intervention (McAndrew et al., 2014 ). Reflective practice is considered an essential aspect of improving nursing care and generating knowledge (Vaughan, 2017 ). This paper aims to deepen the knowledge of the therapeutic relationship based on the reflections of nurses regarding their practice, in the context of current challenges within the mental health acute care setting.

1.1. Background

Based on Peplau's model of interpersonal relationships by ( 1988 ), which is the most widely held theory in the mental health nursing community, many authors have based their models on person‐centred mental health nursing (Barker & Buchanan‐Barker, 2010 ; O'Brien, 2001 ; Scanlon, 2006 ). All of them identify the therapeutic relationship as the foundation of nursing practice and the pillar upon which mental health nursing has been built (McAllister et al., 2019 ; Moreno‐Poyato et al., 2016 ). The proper establishment of the nurse–patient therapeutic relationship is especially relevant to increase the effectiveness of any nursing intervention in acute psychiatric units (McAndrew et al., 2014 ).

The therapeutic relationship could be defined as a human exchange (Peplau, 1988 ) that is based on effective communication that favours the possibility for a person to help another person to improve their health condition, with the objective that, through such communication, the person will be able to develop interpersonal and problem‐solving skills (Forchuk et al., 1998 ). To this end, concepts such as understanding, interest, availability, individuality, authenticity, warmth, respect and self‐knowledge are basic pillars for the nurse (Moreno‐Poyato et al., 2016 ). The literature points out that mental health nurses seem to be knowledgeable of the importance of the therapeutic relationship in inpatient units; however, the reality of clinical practice leads us to believe that theoretical knowledge is not enough to create a good bond with patients (Moreno‐Poyato et al., 2016 ). In addition, the literature points out that for nurses, the implementation of the therapeutic relationship in the current context of mental health units has suffered a strong impact related to neoliberal policies, with increased management and a risk‐centred approach (Kingston & Greenwood, 2020 ). Thus, today's environments are chaotic, and nurses are committed to therapeutic work, yet they struggle to balance it with the new demands of management (Kingston & Greenwood, 2020 ). In addition, barriers such as lack of time, communication problems (Harris & Panozzo, 2019a ), the physical structures of the units, the ratios or the cultures of care are external factors that limit the therapeutic relationship (Tolosa‐Merlos et al., 2021 ). If nurses are unable to become aware of how they respond to time pressure, frustration or unclear care policies, there is a risk that these barriers will become entrenched, new ones will be created and the patient will perceive their actions as lacking care, presence or involvement (Harris & Panozzo, 2019b ). Thus, although nurses recognise the importance of self‐awareness and knowing how to recognise how their actions can impact the therapeutic relationship and the care provided to patients, they are also aware of the need for self‐awareness (Thomson et al., 2019 ), institutions and, in general, care policies should encourage nurses to be aware of interpersonal influences, as well as the desirability of providing a safe and supportive clinical environment for these relationships (Stevenson & Taylor, 2020 ).

From the patients' point of view, in the complex environment of inpatient units, their interactions with staff are central components to their satisfaction regarding their experience with admission (Molin et al., 2021 ). When staff spend time, engage in daily activities, and recognise patients as individuals, patients seem to find it easier to be physically and emotionally closer to each other and to themselves (Eldal et al., 2019 ; Moreno‐Poyato et al., 2021 ). However, this therapeutic commitment is not always met in practice, and interventions to improve participation are few and far between and ineffective (McAllister et al., 2021 ).

Thanks to the therapeutic relationship, nurses are in a key position to lead the development of customised interventions (Molin et al., 2021 ). However, there is a significant gap in the literature regarding improving the quality of the therapeutic relationship in acute mental health units (Hartley et al., 2020 ). The nursing profession is characterised by its ability to reflect on practice to improve care and provide more person‐centred care, which is why there is a need to increase the use of evidence‐based practice (Vaughan, 2017 ). In fact, reflective practice allows practitioners to learn from their experiences (Bulman & Schutz, 2013 ; Schön, 1987 ). When nurses are given time to reflect through guided reflection questions they are able to gain valuable insight into practice (Bolg et al., 2020 ); therefore, reflective practice helps nurses integrate their emotional response and practical experience into a better understanding of the care they provide, incorporating knowledge and applying theory (Vaughan, 2017 ). Thus, although the nurse–patient therapeutic relationship has been extensively studied, no studies to date provide knowledge on the establishment of the therapeutic relationship and its implications based on the reflection on the nurses' own practice. Consequently, knowing the meaning of the therapeutic relationship together with the elements that facilitate and hinder its implementation in the complex practice of current acute mental health units can be a starting point for both nurses and managers to become aware of the needs and for the design of strategies for improvement, suited to the reality of clinical practice.

In this regard, the aim of this study was to explore the phenomenon of the therapeutic relationship through the reflective practice of nurses in acute mental health units.

2.1. Design

This study is part of a multicentre mixed methods study involving 18 acute mental health units in Catalonia (Spain) (MiRTCIME.CAT). The principal aim of the project is to improve the nurse–patient therapeutic relationship through the implementation of evidence. The project was carried out following a sequential and transformational design. Quantitative methods were used based on a single‐group quasi‐experimental design with baseline and follow‐up measurements in phases I and III of the project. In the second phase, qualitative methodology was used. In its qualitative component, participatory action research (PAR) was proposed, framed within the constructivist paradigm and following the model by Kemmis and Mctaggart ( 2008 ). A two‐cycle process consisting of four stages each was designed to carry out the PAR. Specifically, this work corresponds to the action and observation stages of the first cycle. These stages are basic in the PAR process of change and make it possible to generate relevant knowledge regarding habitual practice (Cusack et al., 2018 ). In fact, it allows nurses to understand their practices as the product of particular circumstances and thus to identify the crucial aspects on which it may be possible to transform the practices they are carrying out (Kemmis & Mctaggart, 2008 ). The study is reported in line with the Consolidated criteria for reporting qualitative research guidelines (COREQ: Tong et al., 2007 ) (File S1 ).

2.2. Participants

All the acute mental health units that were part of the Catalan Mental Health Network ( n  = 21) were informed of the study. The principal investigator presented the research project and its objectives to the management of each centre through informative sessions. Finally, 18 units agreed to participate. A nurse from each unit joined the research team and this researcher was in charge of coordinating the study at their centre and recruiting the nurses from each unit. All nurses employed in the participating units ( n  = 235) were invited to participate in the study. The inclusion criteria for the participating nurses were belonging to the permanent or interim staff and being assigned to the acute unit at the time the intervention began. The following nurses were excluded from the study: nurses who were training to obtain ‘the official qualification of mental health nurse’, staff nurses who were scheduled to be on leave or maternity leave during the intervention. Thus, a convenience sample of 195 nurses agreed to participate in PAR, of which, ultimately 152 nurses completed the action and observation stages of the first part of this study.

2.3. Data collection

During a previous meeting among the entire research team, a guide was agreed upon so that the nurses could self‐observe their clinical practice in relation to the establishment of the therapeutic relationship. The research team sent the self‐observation guide by email to each nurse, along with a reflective diary in which the nurses were asked to record the self‐observation data (File S2 ). The diary was to include the description and reflection of three types of common interactions in their usual clinical practice: (a) a standard situation of welcoming a patient for admission, (b) an interaction in which there was a pre‐agitational state that required verbal de‐escalation and (c) an interaction whereby the patient is approached individually, promoted by the nurse and in the absence of any demand on behalf of the patient. The structure of the diary, together with the instructions for completion, pursued two purposes. First, to enable nurses to reflect on their starting assumptions, to understand their practice, to understand themselves and their patients, and, finally, to understand their profession (Price, 2017 ). Second, to monitor the process of change planned for the PAR, according to the proposals of Kemmis and Mctaggart ( 2008 ). In this sense, for each interaction, the nurses had to record the description of the situation, the type of verbal and nonverbal language they had used, their reflected intervention, their emotions during the interaction and, finally, a reflection on the influence of the environment on the interaction. Once the nurses had completed the diary, they sent it to the research team by e‐mail. The data were collected between April and June 2018.

2.4. Ethical considerations

This study was approved by the Research Ethics Committees of all the participating hospitals. The nurses participated on a voluntary basis, and all participants signed an informed consent form. Nurses did not receive any compensation or incentive for participating in the study. To maintain the confidentiality and anonymity of the data obtained, each nurse received an alphanumeric code that was incorporated into their diary. The diaries were sent to a generic e‐mail of the project that was only accessible to the principal investigator of the project, subsequently, the data were stored on a computer used exclusively for this study.

2.5. Data analysis

The content analysis method was used to analyse the data (Crowe et al., 2015 ). The diaries reached the first author and were coded to preserve the anonymity and confidentiality of the participants. Under their responsibility, the entire coding and categorisation process was carried out in a consensual manner by a collaborative team that formed the backbone of the process of developing a rigorous coding system (Merriam, 2016 ). In the first stage of analysis, the text was fragmented into descriptive codes assigned exclusively according to their semantic content. In a second stage, these initial codes were grouped into more analytical subcategories, which classified the codes according to the meaning of the linguistic units and their combinations. This led to a third hierarchical stage in which, considering the semantic analysis of the previous subcategories, the codes were ranked inductively. The first and second steps were taken iteratively until a more specific understanding of the subcategories was achieved. These steps were carried out primarily by the first author and discussed and reflected upon continuously and critically within the research team. Throughout the process, the QRS NVivo 12 program was used as computer support.

2.6. Rigour

Reflexivity was continuous throughout the process. Most of the researchers were experts in mental health, with training in qualitative methodology and experience in previous similar studies. As this was a multicentre study and a very large research team, neutrality was ensured as team members adopted an open attitude towards sharing, reasoning and discussing the findings as they emerged. In addition, the team became aware of its initial onto‐epistemological positioning, which was reflected in the design of the self‐observation guide for this stage of the process. As the research progressed, team members repeatedly contrasted the experiences identified in the participants' diaries with their own opinions. They asked follow‐up questions for the generation of new knowledge without guiding the participants' responses, so that this initial positioning could not influence the subsequent analysis. Similarly, the credibility and confirmability of the data should be emphasised, given the triangulation of the researchers in the analysis process and the constant auditing of the results by the participants in subsequent groups. In relation to the transferability of the results, in the case of this study, where participation is so high and from so many centres, it ensures that the results are valid for all units.

3. FINDINGS

The diaries of 152 nurses working at 18 centres were collected and analysed. The nurses ranged in age from 22 to 62 years, with a mean age of 33.6 years (SD = 9.4). Over 70% of the nurses were female. Their experience in mental health was a mean of 7.6 years (SD = 7.5). Almost a quarter of them had the official title of mental health nurse specialist and over 25% of the nurses had a doctoral or master's degree. All facility shifts were equally represented in the sample, although 40% of the nurses had rotating shifts or served on an as‐needed basis (Table ​ (Table1 1 ).

Participants' sociodemographic and professional characteristics ( n  = 152)

Data are shown as absolute number (percentage).

Abbreviation: MH, mental health.

The nurses, by describing and reflecting on their interactions with patients, expressed what the therapeutic relationship was for them and how it was carried out in their usual clinical practice. In this sense, three main categories were identified that responded to how they gave meaning to what the therapeutic relationship represented in practice and what limitations they identified in it (Figure ​ (Figure1 1 ).

Nurses' reflections on the practice of the therapeutic relationship in acute mental health units

3.1. Nursing attitude as a core of the therapeutic relationship

After reflecting on their practice, the nurses stated that attitude was a key element in establishing a quality therapeutic relationship with patients in the units. In this regard, they identified different attitudinal components. In the first place, the nurses considered the attitude of openness to the relationship. This meant being open and available, offering time, letting the patient talk and being attentive to the person's needs.

Patients are confused when they are first admitted and need the staff to listen to them and spend time with them. I always try to use an empathetic approach and be honest from the very beginning. I think it is very important for the patient to know that they can count on me, I try to convey that I am available if they need me. (01DR101)

However, they also identified that, in order to maintain this attitude, they had to be aware of barriers such as the presence of prejudice, the unavailability of other team members, the belief that the therapeutic relationship is useless, or lying to the patient.

The first contact already gives me the feeling that there may be a personality background, a victimizing attitude, excessively correct at times, totally inadequate at others, in spite of which I stay on track and treat him with the utmost respect. (10DR101). Certain users only perform certain actions to push you to the limit. (13DR103)

Secondly, they referred to the communicative attitude as another basic element in the therapeutic relationship. In this case, the nurses considered that special attention should be paid to both their verbal and nonverbal language when interacting with patients. In this sense, they pointed out the need to establish a dialogue with the patient by means of clear and concrete messages, with an appropriate tone and without shouting, as well as showing interest in the conversation, listening attentively, without showing tiredness or boredom, and adapting their distance and physical contact to each situation.

I try to be aware of my gestures, I avoid being invasive, respecting the safety distance with the patient at all times. Regarding verbal language, I use neutral terms, a friendly and calm tone of voice. (04DR115). In a polite but firm manner, I explain to the patient his situation and the alternatives I can offer him instead of smoking. The language is clear and concise, responding directly to what he asks. Saying NO if necessary, as sometimes vague answers upset the patient even more. (04DR104)

In addition, they considered it extremely important that, as caregivers, they should adapt to the other person, that is individualise the care they provide in the context of the therapeutic relationship. This implies considering the patient's psychopathological and emotional state at any given moment, as well as the patient's age, language or culture. This often meant postponing interviews, adapting language, using sign language to communicate, agreeing on a special type of diet, or even relaxing the rules and letting the patient make a call outside the usual hours.

I try to be flexible and adapt things as much as I can to the patient and his or her characteristics. (03DR109). Sometimes the stigma in mental health appears from the self‐stigma and the treatment that the mental health professional gives to patients. Personality is lost by prioritizing the disorder, people talk about the schizophrenic, the depressive, the BPD… obviating the fact that there is a person behind it all, with a context and a manner of understanding and living their life. (05DR104)

Finally, the nurses emphasised the role of their own emotional experience of caregiving. This meant having self‐confidence, feeling they were able to help the patient and do their job well, feeling satisfied with their work and remaining calm, at ease, and relaxed with the patient during their interventions. Nurses also identified emotions that, conversely, had a negative effect on the therapeutic relationship, such as feeling fear, insecurity, tension, patient rejection, grief, helplessness and frustration when the interventions had not been resolved as expected.

To feel fulfilled in my daily work (18DR101). Calm and confident, well supported by the team. Satisfied to have successfully completed an admission. (16DR112). Then I felt helpless, as I could not find a way to reverse the situation. (12DR111)

3.2. Essential nursing actions for the therapeutic relationship

This category refers to the nurses' reflections on their actions in the context of the therapeutic relationship with patients. In their diaries, the nurses were describing and reflecting on different interventions and activities that were carried out in their usual practice and they detected certain actions that were common to all of them.

First, the nurses pointed out the importance of generating an appropriate environment to build a bond and facilitate the relationship with the patients. A calm, intimate, comfortable, unhurried environment without external stimuli or interruptions.

The room is quiet with the door closed and without any interaction from the environment…A pleasant and silent environment favors the therapeutic relationship between the professional and the patient. (04DR110)

In relation to the establishment of a good therapeutic bond, the nurses agreed that the welcome provided on admission was a fundamental intervention. This was viewed as one of the situations in which the therapeutic relationship took on a greater relevance, since this first contact was considered the key to the success of the subsequent relationship with the patient.

Without welcoming the patient when he or she enters the unit, a better quality of the patient/professional relationship cannot be achieved. (01DR113)

Secondly, the nurses felt that the verbal approach was also a relevant aspect of their practice in the context of the therapeutic relationship. For them, it was an essential step in order to be able to carry out any intervention, such as when welcoming a patient when they are admitted to the unit, the use of verbal de‐escalation techniques to ease the tension with very demanding and uncooperative patients or, on the contrary, to approach isolated patients who hardly interact with the environment, although the use of words is not always as effective as they would like it to be.

Verbal containment is one of the most relevant parts of our work. In a pre‐agitation situation, we may be able to transition a patient from pre‐agitation to calmness or from pre‐agitation to psychomotor agitation. (09DR108)

In this sense, the nurses described that the act of offering the patient their assistance was at the heart of the therapeutic relationship. They stated that this action was carried out in the context of being present, listening or through agreement with the patient by proposing alternatives to the demands and needs that they cannot meet.

As he speaks I give him my support with non‐verbal language. I take his hand and he hugs me. I offer my help. We agree that he will make an effort to eat some solid food at dinner and that I will give him a supplement (he has it prescribed if he needs it). (01DR101)

The nurses also acknowledged that interventions such as mechanical restraint were sometimes the only measure to reduce stimuli or were implemented because of patient aggressiveness, risk of escape or even medical indication. However, the nurses reflected that, although this intervention was performed relatively often, it could be seen as a failure and a deterioration in the therapeutic relationship.

(…) avoid as much as possible the adoption of measures that restrict the mobility of the people under our care, since we are aware that this produces a significant deterioration of the therapeutic relationship, adding to the patient's mistrust and suspicion (…) (07DR105)

Finally, the nurses pointed to therapeutic work as another fundamental aspect of the therapeutic relationship. This meant working with the patient on positive reinforcement and other aspects such as pharmacological adherence, identification of symptoms or awareness of the disease, explaining the objectives of admission and the importance of asking for help, respecting the patient's decisions and involving the person in their care and recovery.

The attitude is one of interest, I keep an eye on her so that she doesn't get distracted and can talk calmly. I ask her what she thinks we can do for her to explore her expectations with the admission. (07DR101)

3.3. Contextual factors affecting the therapeutic relationship

The nurses identified contextual factors that facilitated or, on the contrary, acted as barriers to the therapeutic relationship. Indeed, they described that the type of admission could already condition the therapeutic bond, with voluntary admission being a facilitator. The same is true of other factors such as knowing the patient from previous admissions, and whether the patient remembers having a good experience in those previous admissions. However, the nurses also considered elements that are intrinsic to the patient, such as language, culture or bad experiences of previous admissions, as factors limiting the establishment of the therapeutic relationship.

He is open to help and agrees to the admission (03DR110). I must admit that the fact that I know the user from previous admissions has helped the situation to unfold smoothly. (14DR106)

Similarly, the nurses identified barriers that hindered or prevented the establishment and maintenance of a good therapeutic relationship, related to both the environment and the physical structures of the units. In this sense, the structural barriers were related to the lack of adequate spaces to carry out interventions with patients with the intimacy that the nurses considered necessary. Other environmental factors were noted, such as environmental noise and tension, the unpredictability of some patients, the presence of the family or the multiple interruptions were elements that added to the difficulty of the therapeutic relationship.

That afternoon the environment allowed me to dedicate some time to the patient, since there were no emergencies, other admissions, or complicated situations in the unit that required nursing intervention, apart from the "scheduled" or "usual" activities such as the control of vital signs, medication, etc. (03DR105)

Finally, the nurses also expressed how the regulations and care dynamics of the units also conditioned the therapeutic relationship in daily clinical practice. Thus, unit regulations were recurrently brought up by the nurses as a major barrier, due to the numerous limitations and prohibitions.

I explain the rules of the unit: no cell phones, no smoking, no entering other rooms, no belts, no glass objects, etc. and the established schedules… (10DR104)

Nonetheless, the greatest source of difficulties was the care dynamics at the unit, ranging from lack of time, high workload, administrative tasks, staff rotations or the night shift.

Even so, there are barriers that hinder the therapeutic relationship. Sometimes, our language is influenced by the tension in the unit, the lack of time, excessive administrative tasks, etc.… (01DR101)

4. DISCUSSION

This study aimed to explore the phenomenon of the therapeutic relationship from the reflective practice of nurses in acute mental health units. The nurses highlighted that attitude was the core aspect of the therapeutic relationship after reflecting on their practice. Similarly, they also reflected on the actions that were customary in the habitual interventions carried out in the context of the therapeutic relationship, identifying the most common barriers encountered in practice. Finally, the nurses reflected on those aspects of the context of care that conditioned the therapeutic relationship in the clinical practice of acute mental health units.

These findings offer knowledge about relational competence, a competency of professional nursing that is highly relevant in mental health (D'Antonio et al., 2014 ). This competence is directly linked to participation in practice and incorporates not only knowledge and skills, but also attitudes and professionalism that involve applying evidence and learning to practice (Casey et al., 2017 ; Moreno‐Poyato, Casanova‐Garrigos, et al., 2021 ). Specifically, the attitudinal component highlighted in the results and its importance in the context of the nurse–patient therapeutic relationship has been described from a theoretical perspective by authors such as Peplau or Orlando (Forchuk, 1991 ), Travelbee ( 1971 ) and Watson (Turkel et al., 2018 ). Similarly, the empirical literature has collected multiple studies that study the importance of nurses' attitudes towards more general aspects of mental health, such as stigma (Young & Calloway, 2021 ), recovery (Gyamfi et al., 2020 ), coercion (Doedens et al., 2020 ; Laukkanen et al., 2019 ) or severe mental disorder (Economou et al., 2019 ). However, there is hardly any empirical evidence that explicitly shows the relevance and identifies the specific attitudinal skills of nurses in the context of the practice of the therapeutic relationship. Thus, it is likely that the fact that the nurses were able to reflect on their practice made them more aware of the importance of attitude in the context of the therapeutic relationship (Harris & Panozzo, 2019a ), as they were able to respond to the real challenge of establishing an adequate therapeutic relationship in their day‐to‐day work in the acute mental health units (Choperena et al., 2019 ). Moreover, the attitudinal capacity identified by the nurses encompassed aspects already empirically recognised in the context of the therapeutic relationship, such as availability, communication and individualisation (Delaney & Johnson, 2014 ; Harris & Panozzo, 2019b ; McAllister et al., 2019 ; Moreno‐Poyato et al., 2016 ). However, the nurses also highlighted other aspects that have been less empirically studied, such as the importance of self‐confidence and self‐assurance, both in a positive way in order to be able to establish an appropriate therapeutic relationship, (Roche et al., 2011 ; Van Sant and Patterson, 2013 ) as well as negatively, in the form of limitation (O'Connor & Glover, 2017 ; Van Sant and Patterson, ). These results confirm the relevance of Peplau and Orlando's theoretical approaches and the use of the nurse's awareness as a fundamental part of the nursing relationship (Forchuk, 1991 ; Thomson et al., 2019 ).

The results indicate that by reflecting on their practice, the nurses were able to identify those skills (practices) that are essential for the development of the therapeutic relationship and which were transversal to any intervention. The nurses emphasised the importance of generating an adequate environment for the relationship, considering the environment not only as an element of context typical of many acute care units, but also as an element that is essential for the development of the therapeutic relationship (Kingston & Greenwood, 2020 ), also considering that it was their responsibility to be able to build the space where the relationship could take place (McAllister et al., 2021 ; Raphael et al., 2021 ). As in other studies, nurses also identified skills such as verbal engagement, offering help or working with the patient as basic practices for the development of effective interventions in the context of the relationship with their patients (Harris & Panozzo, 2019a ; McAllister et al., 2019 ; Molin et al., 2018 ). Furthermore, in relation to specific interventions, reflection on practice allowed nurses to identify and become aware of nursing admission assessment and mechanical restraint as two common interventions in mental health units that were particularly influential in the therapeutic relationship with the patients. In this sense, for the nurses, welcoming the patient on admission was considered an essential intervention determining a large part of the success in building the therapeutic relationship with the patients (Forchuk et al., 1998 ; Peplau, 1997 ). However, the use of mechanical restraint compromised the therapeutic relationship and the patient's trust (Kinner et al., 2017 ), although they understood that, even if this measure was undesirable, at times it was necessary (Doedens et al., 2020 ).

In addition, the nurses reflected on the contextual factors that directly affected the therapeutic relationship with the patients. In this sense, the nurses paid attention to patient aspects such as voluntariness or involuntariness regarding admission (Moreno‐Poyato, El Abidi, et al., 2021 ) or being previously acquainted with each other from previous admissions and the experience of the relationship (Van Sant and Patterson, 2013 ). The nurses also emphasised the role of the environmental and structural conditions of the units (Staniszewska et al., 2019 ), as well as the regulations and the dynamics of care that were automatically generated in the intense day‐to‐day routine of the units (Adler, 2020 ; Kingston & Greenwood, 2020 ).

4.1. Strengths and limitations

This study has several strengths and limitations. First, it should be noted that this project faced major challenges from a methodological point of view as well as during its execution. Initially, a research group had to be formed with representation of the institutions to assess the feasibility of the project. Next, a balanced team of researchers, consisting of methodologists and clinicians had to be assembled to ensure that the different stages of the research project could be completed. The team had to be formed in several initial working sessions and, subsequently, there was a process of constant mentoring by the principal investigator to the rest of the team. In addition, a considerable volume of data had to be managed. For management and storage, a secure on‐line space was created, guarded and accessed only by the principal investigator of the project. All data were collected electronically to facilitate the circuit. In relation to the analysis, a team was set up under the responsibility of a researcher. This team had to work in a collaborative and consensual manner. Regarding more specific limitations, it should be mentioned that the nurses' reflections in the diaries could be subject to the Hawthorne effect and their responses may have been biased by social desirability. In this sense, the research team insisted on the importance of honesty in the nurses' responses and on the team's handling of the confidentiality of the data. Secondly, another limitation inherent to the use of diaries is related to memory bias and the stress associated with reflective practice. In relation to this, the team recommended specific instructions, both verbally and through the guide provided to the nurses, to prevent this from occurring. Furthermore, the representativeness of the participating nurses and the number of diaries obtained should be highlighted as strengths of the study. These facts enable the findings of this study to be transferred to similar contexts.

5. CONCLUSIONS

The present study contributes to the understanding of the phenomenon of the therapeutic nurse–patient relationship by reflecting on the actual practice of nurses in acute mental health units. The attitudinal component is at the heart of the therapeutic relationship, and, in this sense, it is fundamental for nurses to believe in themselves and their attitude to communicate, adapt and open up to the relationship with the patient. In addition, there are actions that are essential for nurses to establish a TR in practice such as creating a conducive environment, using an appropriate verbal approach, offering help and working together with the patient. Finally, nurses should consider the patient's conditions, the dynamics of care and regulations of the unit, as well as the structure and environment of the unit, as contextual factors to be able to establish an adequate TR with patients in daily clinical practice.

6. RELEVANCE TO CLINICAL PRACTICE

These findings have important implications. The study findings demonstrate that participatory methods stimulate nurses' reflection, motivation and critical thinking. By learning from the reflection of the nurses themselves about the aspects that underlie the therapeutic relationship in their clinical practice, this enables the nurses themselves to become aware and to develop strategies for improvement based on their own knowledge. Moreover, the individual reflection involved in these first stages of a participatory process provides the nurses with an intrinsic knowledge of how they approach the therapeutic relationship and shows that the attitudinal component is basic for them. In this sense, understanding and confirming how the attitudinal component is a key element for nurses in the practice of the therapeutic relationship allows managers to evaluate strategies that promote motivation and facilitate the involvement of nurses in improving their practice with patients. Moreover, these results point to the need to conduct mixed or qualitative studies aimed at exploring the aspects that facilitate the motivation, empowerment and attitudinal training of nurses in greater depth, rather than studies that only seek improvements in the theoretical knowledge of the therapeutic relationship.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

AUTHOR CONTRIBUTIONS

Study design: ARMP and PDH; Data collection: APT, FGP and GCG; Data analysis team: DTM; Final report draft: DTM, ARMP and PDH; Supervision the process of data collection and analysis and provide support and feedback during all study phases: ARMP; Contribution of the manuscript, and read and approved the final manuscript: All authors.

Supporting information

Acknowledgements.

We would like to acknowledge all the participants of MiRTCIME.CAT project.

Tolosa‐Merlos, D. , Moreno‐Poyato, A. R. , González‐Palau, F. , Pérez‐Toribio, A. , Casanova‐Garrigós, G. , & Delgado‐Hito, P. ; MiRTCIME.CAT Working Group (2023). Exploring the therapeutic relationship through the reflective practice of nurses in acute mental health units: A qualitative study . Journal of Clinical Nursing , 32 , 253–263. 10.1111/jocn.16223 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

College of Nurses of Barcelona (PR‐218/2017)

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Readers respond to essays on philanthropy and nursing schools, opioid overdoses, and more

By Patrick Skerrett July 20, 2024

F irst Opinion is STAT’s platform for interesting, illuminating, and maybe even provocative articles about the life sciences writ large, written by biotech insiders, health care workers, researchers, and others.

To encourage robust, good-faith discussion about issues raised in First Opinion essays, STAT publishes selected Letters to the Editor received in response to them. You can submit a Letter to the Editor here , or find the submission form at the end of any First Opinion essay.

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“Why aren’t philanthropists stepping up to make nursing education free?” by Tracy R. Vitale and Caroline Dorsen

The shortage of nursing faculty at both the associate degree in nursing and the bachelor of science in nursing levels, primarily due to salary structures, has been well documented for at least a couple decades within nursing and health care access advocate circles. Where it’s not known — at least not with a powerful and energized message — is within the circles of college and university development offices and community foundation fundraisers. People of wealth have both personal and professional connections to nursing, whether as practitioners, patients, family members, or community leaders. The full-bore messaging and cultivation of these donors and funders just isn’t out there. Without an active change in strategies, the current pleas aren’t going to get us where we need to go. Time to regroup!

— Allen Smart, PhilanthropywoRx

It’s a shame that more philanthropists don’t support nursing education. But nursing schools are also to blame due in part to the arrogance of the requirement that a prospective nurse repeat anatomy and physiology 1 and 2 and microbiology if it’s been more than 5 years since she or he has taken those courses. I have repeated those courses once and earned “A” grades in them. I was in my nursing clinicals when Covid-19 shut everything down. Now I can’t afford the tuition and I refuse to repeat those classes. There is no such requirement for medical school. It’s the nursing school and society’s loss: I would have been a great nurse!

— Thomas Martin

A major issue has to do with the lack of nurse educators. I obtained my MSN-Ed with the idea of becoming a nursing school educator, but was unable to financially make this transition. Nursing school educators make significantly less than patient care nurses. Lack of instructors is why many who are interested in becoming nurses are turned away.

— Kim Blanton, retired

“Functional neurological disorder is not an appropriate diagnosis for people with long Covid,” by David Tuller, Mady Hornig, and David Putrino

I have struggled with a neurological disability for 21 years. It came to a head following an adverse reaction to the Covid-19 vaccine and development of long Covid (though I am grateful that the vaccine protected me from earlier strains of the virus). Since that fateful day in February 2021, I have been rushed to an emergency department 29 times. And while I have been shown true humane and compassionate care by professionals working during the Covid pandemic, I was also repeatedly gaslit, mislabeled, and prevented from receiving the care I should have.

I’m not alone: An April 15, 2024,  research letter in JAMA  reported that nearly 1 in 4 patients in more than 29 hospitals had misdiagnoses or delays in diagnostic work-ups because of stigmatizing language in their medical records.

As a social worker who believes in social justice, I wonder how many people with long Covid symptoms — like those with chronic fatigue syndrome and Lyme disease and post-viral illness — have been dismissed, and their symptoms overlooked, and their care options missed. In hope for change, I rest my heart on the wisdom from a moving self-reflective medical narrative by Dr. Wes Ely in his book, “Every Deep Drawn Breath.”  He wrote, “Many people believe medicine is grounded in  benevolence , which is  wishing good . It is more than that. The target principle of medicine must be a higher standard:  beneficence .  Doing good .” As he shares this, it is the covenant of all health care professionals to practice with self-reflection, humane connection, and compassion, make diagnostic queries with curiosity and care, and avoid labeling and words that harm, pathologize and damage.

— Kate Nicoll, LCSW

“Medicare drug pricing rules will delay access to promising therapies,” by Peter Rheinstein

Yes. We already have a problem with the lack of incentives to improve the use of drugs approved decades ago before we had the current tools of modern pharmacology. We fail at personalized medicine for such drugs which can improve both safety and efficacy. Research costs money and price controls will discourage more of the real-world evidence that requires better measurement for better dosing decisions in individuals.

— Peter T. Kissinger, Purdue University + Inotiv + Phlebotics

“Doctors ‘overprescribing’ opioids isn’t the cause of the overdose epidemic — and it never was,” by Richard A. “Red” Lawhern

Casey Heely of Brandeis University has protested what she believes is “over-simplification” on my part of the causes of the U.S. opioid crisis. In response to her concern, I would observe that major pharma companies clearly overpromoted the safety of prescription opioids. But data published by the U.S. Centers for Disease Control and Prevention establish beyond any rational contradiction that any contribution of prescriptions opioids was strictly at the margins of a much larger crisis driven by street drugs. Restrictions on the availability of prescription opioids have actually made the crisis worse, by driving desperate patients into street markets.

Over-prescribing was never the major factor in the rising rates of opioid overdose deaths. That distinction belongs to illegally manufactured fentanyl and heroin. Prescription opioids get lost in the noise.

— Richard A. Lawhern, Ph.D.

About the Author Reprints

Patrick skerrett.

Acting First Opinion Editor

Patrick Skerrett is filling in as editor of First Opinion , STAT's platform for perspective and opinion on the life sciences writ large, and host of the First Opinion Podcast .

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