Reflective practice and its role in mental health nurses’ practice development: a year-long study

Journal of Psychiatric and Mental Health Nursing, 2000, 7, 109–117

© 2000 Blackwell Science Ltd 109

Introduction

This paper describes and analyses how a group of quali-

fied mental health nurses, of various years of experience,

entered into a structured period of reflection in order

to explore the nature of their nursing. The nursing team

were all located within a Kings Fund-designated Nursing

Development Unit (NDU) in the north of England and

I was asked to facilitate a reflective group in my role as

their academic link person. I had been utilizing reflec-

tion with undergraduate student nurses at the time and

had come to the belief that reflection does help define

practice.

It is the intention of this paper to discuss the process and

outcomes of the reflective group along with its conclusions,

which highlight the benefit of adopting a reflective group

approach in order to help practitioners articulate their

practice and role. This was achieved by focusing upon

reflective story telling and analysing the metaphors con-

tained within the narratives.

The format of the reflective group required the partici-

pants to (1) reflect upon their clinical work for the pur-

poses of academic endeavour, and (2) to integrate reflected

awareness into their practice for the purpose of enabling

professional maturity and practice development.

The project work took place within an assessment facil-

ity for the elderly mentally ill, serving a client population

of 65 years and more. In being identified as an NDU, the

ward team had declared themselves willing to have their

practice examined both from an internal and external per-

spective. The team felt it was appropriate to examine the

nature of their nursing practice because they wanted to

clarify how they provided individualized patient care. The

team consisted of a wide range of nursing grades from

service manager to junior staff nurses.

Reflective practice

The aim of reflective practice, according to Powell (1989),

is to ‘advance one’s thinking at a conceptual level’, and

Reflective practice and its role in mental health nurses’ practicedevelopment: a year-long studyI. W. GRAHAM p hd med msc bsc rn rmn

Professor of Nursing Development and Head of Nursing, Institute of Health and Community Studies, Universityof Bournemouth, Bournemouth, Dorset, UK

Graham I. W. (2000) Journal of Psychiatric and Mental Health Nursing 7, 109–117

Reflective practice and its role in mental health nurses’ practice development: a year-long study

The study reported in this paper lasted over a year, and identifies a conceptual framework

of nursing practice based upon a relationship-building process. It also identifies six char-

acteristics of nursing roles inherent within the practice of mental health nurses on a Nursing

Development Unit. The paper presents a structure and process of reflection for nursing

practice as illustrated by the work of a group of nurses working in a NDU. The purpose

of the study was to help them better understand their work with patients. The findings

from the study are used to explore how the nurses described and implemented individual-

ized, patient-focused care. This care was based upon the ability of the nurse to communi-

cate well and to build a relationship with a patient, bound within a context of change.

Keywords: conceptual framework, metaphor analysis, patient-centred care, reflective

narrative, role characteristics

Accepted for publication: 29 November 1999

Correspondence:

I. W. Graham

Institute of Health and

Community Studies

University of Bournemouth

Bournemouth

Dorset

BH1 3LT

UK

I. W. Graham

110 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 109–117

thus be better able to change, in this case mental health

nursing practice, at a professional, social and political

level.

The literature provides a variety of understandings, as to

what reflective practice means to and for nurses. (Clarke

1986, Burnard 1991, Emben 1991, Darbyshire 1993, Jones

& Williams 1993, John & Freshwater 1998). Atkins &

Murphy (1993) suggest there is a lack of definition and

clarity with regard to the concept of reflection, and they

postulate that it may be difficult to find a common under-

standing of the term ‘reflection’, or make clear com-

parisons as to the central thinking from any of the current

papers on the subject.

Atkins & Murphy (1993) identify certain key stages in

the reflective process gleaned from their reading of the

literature, and these stages seem to represent a model

from which the process can be steered.

The central component of their model seems to be the

use of self and an individual’s ability to develop their self-

awareness, as a practitioner, in order to achieve a changed

perspective. The key stages are:

1 awareness of feelings and thoughts;

2 critical analysis of the situation;

3 development of new perspectives.

The process

The team and I decided to utilize these key stages in order

to structure the reflective process. I first of all facilitated a

self-awareness workshop with the NDU team and used the

Atkins & Murphy (1993) paper for focused discussion

and debate. The workshop also allowed us to discuss the

‘rules’ of participation. Issues such as membership, power,

control, confidentiality and commitment were aired before

duration, frequency and contribution/workload of the

groups were agreed.

The ‘key stages’ advocated by Atkins & Murphy (1993)

were used as the ‘rule of thumb’ for personal development

by the team throughout the reflective process. They are

implicit in the process of reflection but also serve as a useful

tool for a facilitator of a reflective group to enable one to

ground feelings and thoughts in a critical framework. This

provided material from which the facilitator could assess

change and development within the group members and

how the dynamics of interaction were managed. Each

group session required group members to describe events

they wished to reflect upon and they were encouraged to

critically analyse themselves and the perspectives which

surrounded the nursing events they raised, thereby hoping

to achieve an informed and broader perspective of the

event. The groups would always finish with an exploration

of one’s self-awareness, a synthesis of new learning and an

evaluation of both the reflected event and the reflective

process.

The intent of the process was to expose how the team

conceptualized themselves and their roles. The sessions

were tape-recorded and the analysis of the recordings

focused upon how metaphors were used by the team to do

the conceptualizing. Metaphors were used to explain their

experience and define activity, and thereby allowed con-

ceptualizations to be uncovered, but also provided the

means to critically reflect. Having agreed on the con-

ceptualization, they could stand back and re-look. In the

process of re-looking at something, changes to activity or

role could be made.

The covert aim of the reflective group was to help the

nurses to move to a scholarly position wherein they could

engage in a process of reflection both on and in action.

Authors such as Gray & Forsstrom (1991) advocate theo-

rizing nursing from a position that is grounded in nursing

practice. The process that we engaged in was reminiscent

of Schön’s (1983) theory of reflection, which considers the

concept of reflection both in and on action to increase one’s

knowledge of practice. Therefore the whole process was

geared towards enabling the nurses to better understand

how they interacted with patients at a practical level. In

particular, they moved more to a process of reflecting in

action as the group developed over time. This was high-

lighted by the fact that the nurses often spoke, in the group

interactions, of how the debate from the groups infiltrated

their thoughts when engaged in other activities pertaining

to patient care.

Research rigour was addressed using criteria con-

sistent with interpretative enquiry (Guba & Lincoln 1981,

Sandelowski 1986). These criteria require the interpreta-

tions to identify credibility, fittingness, audibility and

confirmability.

The schedule of reflection

Once the group-rules were agreed, the group drew up a

plan of the reflective schedule. The group was committed

to the process and all agreed to attend at least 80% of the

sessions.

The schedule consisting of three 12-week phases, known

as phases I, II and III, commencing in January 1994. It was

agreed to meet every 2 weeks for a 90-minute session, con-

cluding the schedule in December 1994. The work of the

group, therefore, would be held over a calendar year, and

after each phase an evaluation activity would take place.

This evaluation consisted of an interview with the members

with the aim of getting an appreciation of how the process

of reflection was aiding practice development in terms of

clarifying and describing the role of a mental health nurse.

Reflective practice

© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 109–117 111

The findings from such interviews were fed back into the

third phase.

Initial findings — a compilation of commentson structure and process

Phase I — reflection upon their current reality of

nursing

This phase was rather prescriptive and provided the group

with the chance to explore the relationship between them-

selves and the organization in which they worked. Ten

themes were used as structures in which the nurses reflected

upon the events of their nursing and understood their per-

sonal situation within the NDU:

• historical perspectives;

• the nature of our nursing;

• the education system to prepare us for our role;

• the theoretical underpinning to our practice;

• professional/personal accountability;

• ethical concerns;

• professional culture;

• professional ideology;

• quality of practice;

• purpose of caring.

Evaluation of phase I

These themes had emerged from my reading of current

topical literature and government policy papers which pro-

vided an opinion of the current and future view of nursing

and its practice, e.g. Vision for the Future (DoH 1993). In

addressing these topics, interrelations and overlaps from

one group to the next provided both a very dynamic

interplay of concepts and debate, and a focused and struc-

tured group discussion. The lively debates which ensued

revealed the following themes to be at the underpinning of

the social reality of the team’s mental health nursing on the

NDU:

• responsibility;

• job purpose;

• autonomy;

• power;

• focus of activity.

Phase II — identifying the characteristics of nursing

This phase aimed to develop these first phase themes

further by focusing more directly upon individual practice

using a case study approach. Each group member pre-

sented a case study of one of their current patients to the

group.

Evaluation of phase II

Constructs, such as the following, emerged from this

evaluation:

• the nurse–patient relationship;

• what is and what is not therapeutic;

• assessment criteria (actual and real as opposed to

official);

• who holds primacy;

• supervision;

• feelings about nursing;

• partnership in care advocacy.

This phase often raised new questions, not previously con-

sidered, particularly in relation to the skill set and knowl-

edge-base needed in order to function in one’s role as a

mental health nurse on the NDU. For example, the nurses

began to debate how their power status and Trust employ-

ment status often impeded their role and activity. Their

clinical activity with patients may well be asking them to

pursue certain paths of giving care, but Trust policies and

procedures often worked against them. This was a real

dilemma for the group. The reflective process had raised

their awareness of their lack of control over their nursing

activities with patients. They were becoming much

more politically aware of their role as nurses within the

hospital structure but felt, as yet, unable to challenge that

structure.

Field notes were kept by myself about each session

during phases I and II, and a transcript analysis of the field

notes was completed. It was from the analysis of my field

notes and analysis of the typical narratives that six char-

acteristics, as important aspects of the NDU nurses’ prac-

tice, emerged. Nursing on the NDU means one is:

• an effective communicator;

• a teacher/facilitator to client, students/others;

• a change maker;

• a health promoter/ill-health preventer;

• a manager/leader of practice;

• possessing an area of specific skill and expertise with

regard to patient care.

These characteristics were common to all of the nurses

who presented their case-studies. It could be argued that

these roles and characteristics are the cornerstone to expert

mental health nursing practice on the NDU, however,

further research is required to substantiate this opinion.

The metaphors used to describe the lived experience

define these emerging characteristics of their nursing: such

metaphors as, ‘I walk a tightrope’, ‘I feel I’m the polyfilla

in the hospital system’, ‘I have to behave like Sherlock

Holmes’, ‘I’m like a conductor of an orchestra’, ‘a chief

cook and bottle-washer’. All demonstrate the imaginative

way the nurses explained their situation. Further analysis

I. W. Graham


explored these to a deeper level, some of which are

addressed further within the paper. There is also a prox-

imity to Macleod’s (1996, p. 89–102) work on PractisingNursing — Becoming Experienced; where she defines the

characteristics of surgical nursing to be about ‘noticing’,

‘acting’ and ‘understanding’. I would argue a similar

process was involved here.

Phase III — identifying the conceptual framework of

nursing

Phase III focused upon the further development and the

exploration of these six characteristics, with the emphasis

on how the characteristics helped or hindered the individ-

ual nurses to carry out their work. The aim of this phase

was to help the team members to acquire new personal

knowledge about nursing practice and the skills needed to

actualize it. It was during this phase that a more complete

understanding of the nature of the NDU’s nursing

was made by the reflective group. This understanding

enabled the group members to describe how they commu-

nicated with patients and built relationships. They also

realized how change and its management was a major

aspect of their role as nurses. The following analysis will

illustrate these points further.

Evaluation of phase III

Phase III led to deeper analysis of the reflective findings on

the Nurses’ understanding and description of their defin-

ing further practice.

Profiling their practice required individuals in the NDU

to internalize their perceptions about nursing and then to

accord ownership of the feelings and opinions this pro-

moted. Each individual entered and moved along this

process at their own rate and level. Confidence, positive

self-regard and true belief in the purpose of nursing were

required aspects of this identification. This personal pre-

sentation, when coupled to the analysis of the findings of

my complimentary field notes and the evaluation inter-

views, revealed two constructs which provided some

clarity to the nature of the team’s mental health nursing.

These are:

• making sense of me and my role;

• nursing is relationship/role-based.

Construct 1 — Making sense of my and my role

The nurses all acknowledged that they were on individual

journeys of development with regard to their nursing. The

process of development was affected by their individual

understanding of such things as personhood, health, ill-

health, illness and disease and dis-ease, nursing and

healing, curing and caring within the context of a chang-

ing social and physical environment. Increased awareness

and clarification helped participants make sense of them-

selves and their role. It was when I fed back to the group

a diagrammatic representation of their descriptions that I

realized its closeness to Lewin’s Model of Change.

Lewin’s Model of Change (Lewin 1951, p. 241), recog-

nizes that resistance to change is a natural phenomenon

and therefore it is worth examining in detail when resis-

tance is likely to occur, both highlighting what is occurring

and indicating what could be done to bypass problems.

The purpose of the model aims to focus on the forces, for

individuals, for and against change. By describing these

forces and assigning them different weights, it is possible

to draw up a grid of areas, groups and individuals and to

identify how much resistance is likely to be felt. The result-

ing grid enables a strategy for defeating or lessening indi-

vidual strands of resistance to be developed.

This was an important ‘discovery’ for the NDU nurses.

For it allowed them to perceive their activities within a

theoretical context. Lewin’s model provided them with a

structure to see, understand and describe the nature of their

nursing. Suddenly it became clear to them that dealing with

patients was the same as dealing with resistance to change.

It required them to develop strategies so to deal with the

resistance. Such strategies were dependent upon them

developing skills and knowledge which were relevant, to

help them manage the change process. Nursing therefore

took a gigantic leap forward for them in terms of its

purpose and role within the NDU.

Viewing the natural phenomenon of the NDU’s nursing

practice through Lewin’s Model of Change, one can

identify that the process of nursing on the NDU revolved

around the creation of a working relationship between

nurse and patient. This created the purpose and role for

nursing. The forces for and against change can be seen as

the forces for and against the relationship being established

and developed. The strategy for change that unfolds fea-

tures aspects of role and purpose by which the nurse nego-

tiates the nursing, its style and activity, with the patient.

Patient and nurse may commence the relationship with a

status quo definition of their historical role and purpose.

This could be seen as resistance. The nurse has to work at

discovering how to unblock that resistance by both self-

reflection work and assessing how the patient presents their

needs. If successful, the relationship moves to a period of

unfreezing and there is a time when the new experience

causes a shift away from historical definitions and a greater

understanding of both the role of the nurse and of who and

what the patient is. Movement then occurs with both

Reflective practice


Exit point of relationship

achievement non-achievement – Back to entrance

Healing, Well-Being, Coping

Characteristics of NDU’sNursing to bring aboutchange and identification CHANGE CONTINUESof needs

1. Effective Communicator2. Change maker3. Teacher/Facilitator Identification4. Promoter of of individual

positive health/ needs/wantsill-health preventer of patient and

5. Specific skill nurse constantlye.g. counselling evolving

6. Leader of practice

Communication

CHANGE BEGINS

Needs Wants

The Aim The relationship building process is the nursing

The Entrance The Nurse Nursing The Patient

Values, behaviours, attitudes, feelings, personalities, identities, roles, beliefs

‘Coming together’

Figure 1Conceptual framework of mental health nursing practice: explanation and analysis.

I. W. Graham


the nurse and patient taking up new positions within the

relationship, gaining a different sense of purpose and

direction.

The fundamental basis for the resistance to change being

erased was the formation of the nurse–patient relationship.

It was through the reflective activity that the nurses gained

the insight into how important it was for them to achieve

a working relationship with the patient. Once such a rela-

tionship was developed then the nurse and patient could

alter their behaviours, attitudes and expectations of each

other and themselves. Movement could commence and the

work of caring, healing and coping could be achieved. The

relationship and its achievement decided the purpose and

role of the nurse.

For example, the nurses spoke about how the patient

and the nurse come together on admission as relative

strangers to each other. They have perceptions and expec-

tations of each other though, often based upon past ex-

periences. The nurses debated how these past experiences

could be either ‘blockers’ or ‘promoters’ in their attempt

to build a relationship. The building of a relationship with

the patient by the nurse was crucial because without it the

nursing would have no real purpose of focus, but would

remain only a set of unrelated tasks. This was crucial

to the understanding of the NDU nursing, because it

somehow clarified for the Senior Charge Nurse what being

a mental health nurse working on the NDU was all about.

This is perhaps further explained by understanding con-

struct 2.

Construct 2 — Nursing is relationship/role bound

The nurses often talked about getting into the process of

building a relationship with their patients. Some statements

which illustrate this are:

1 ‘The relationship takes you into advanced practice’;

2 ‘Turn patients into people’;

3 ‘Journeying to know the person’.

However, what was also becoming clear was the notion

that the nursing and the role the nurse took was totally

dependent upon the nurses ability to pick up cues from the

patient, interpret these cues correctly and then effectively

communicate that interpretation back to the patient.

Later analysis explained the dual role of the relationship-

building process as the means by which cues were given,

interpreted and dealt with. The purpose of ‘journeying to

know the person’ and turn the ‘patient into a person’ also

explained the means by which the nurse achieved success-

ful interpretation. In other words, if individualized care

was to be achieved, the nurse and the patient had to enter

a form of two-way communication process which would

enable a relationship to be developed, which in turn

defined the purpose of the nursing to be clarified. Other

concepts which define construct 2 further are ‘walking

away’, ‘crusader nursing’, ‘negotiating the nursing’ and

‘testing’.

Walking awayThis concept relates to the fact that in theory nurses don’t

‘walk away’ from patients. It was drawn out from discus-

sion when a group member cited an instance when other

members of the multidisciplinary team did ‘walk away’

from the patient after initial referral. These professional

groups felt they had nothing to offer, so could not ‘do’ any-

thing for the referred patient. They therefore ‘walked

away’, leaving the patient as a ‘nurse’s patient only’. The

discussion revealed though that nurses, too, ‘walk away’

from such patients, but perhaps not in a physical way. They

perhaps make a conscious decision to provide only funda-

mental care to a patient, with the consequence that they

choose not to invest emotional or intellectual energy into

such patients’ welfare. This means that they decide not to

be creative or risk-take with regard to their care-giving.

They may engage in caring tasks but elect not to invest in

caring. This concept speculates that nurses chose when to

fully engage themselves as people in the care work they

undertake or suggests there is a qualitative difference, to

the nature of their nursing.

Crusader nursingThis concept is closely related to the former, and it pertains

to when nurses do fully engage themselves in their caring

and nursing. The debate here concentrated upon who

gained the benefit from a nurse’s full engagement? Was the

nurse developing their own ego or were they fully acting

in the patient’s interests? This led us to discuss experience

and professional maturity as strategies which enabled the

nurse–patient relationship to be built and change facili-

tated. Therefore the relationship-building process seems to

suggest that it is a crucial element in defining what is

nursing. This is revealed further by the following two con-

cepts, ‘negotiating the nursing’ and ‘testing’.

Negotiating the nursingThis pertains to the fact that, with experience, professional

as well as personal maturity comes the ability to clarify

one’s clinical effectiveness. Here the nurses discussed how

they ‘fitted in’ addressing the ‘patient as a person’ whilst

at the same time they ran the ward routine and organized

the hospital system. To be able to negotiate both required

the nurse to take risks and feel empowered. They needed

self-assurance in order to be successful in the managing of

two systems, the ward system and the patient-care system.

Both systems could be quite separate.

Reflective practice


TestingThis concept explains how aspects of this empowerment

took place. The nurses spoke of how patients, once they

were receiving the nurses’ full engagement for care, would

act out and challenge the nurse to clarify commitment and

sincerity. This was often a trying time because it required

the nurse to transcend official policy and procedure and

focus solely upon the patient-care system at the expense of

the ward.

Developing a model of understanding

The true nature of nursing within the Unit was constructed

around the relationship-building processes between nurse

and patient and the reflective process allowed a deeper

understanding of this nature to be understood and

described. This true nature was not obvious, it was hidden

and needed the reflective group process to uncover it.

For example, the process of reflection revealed individual

strengths of individual nurses. One’s strengths are often

hidden and not appreciated, particularly within the British

culture. The process helped not only to uncover these

strengths but helped to describe the drives and the beliefs

of the nurses on the Unit also. It also revealed their con-

fusion and weaknesses when trying to provide holistic

patient-focused care. This confusion was described by the

nurses as a dichotomy of their role and is highlighted by

the concept of ‘negotiating the nursing’. The dichotomy

rested within the domain of expectations of both self and

others.

The dichotomy depicts a view of the nature of the

nursing on the unit as a split between the expectations of

others and the view held by the NDU nurses themselves.

To be able to ensure the ward was organized as a whole

with the hospital system represents nursing as defined by

others in the wider health-care team. The nurses called it

‘the factory face of nursing’, where the nurses are perceived

as the fulcrum of the hospital, doing servicing work for

others and receiving direction to do that work.

Yet the real work of giving care to patients in the form

of relationship-building was not obvious to these others, it

remained private and confidential. This was exacerbated

by the fact that other nurses failed to appreciate the nature

of the work their colleagues were involved in.

The lived experience of nursing revealed how the nurses

balanced the private and public aspects of their work on

the NDU. All the nurses had to manage the ward func-

tioning, while at the same time providing patient-focused

care of an individual nature. This individual care was not

thought central to the ward functioning, but it required the

nurse to engage in many activities with patients based upon

a personal, not organizational, view of nursing. It was as

if the nursing consisted of individual journeys of care, all

of which remained private and not connected to the ward-

functioning of the NDU; nor was it organized centrally,

and therefore it lacked authority.

One could argue that, in general, the nurses were

journeying in the overall direction of individual care,

i.e. attempting to provide individual care, which was

person–focused, humanitarian in nature and required pos-

itive attitude and endeavour. Nevertheless, the nurses felt

insecure and unsure with regard to their overall direction

due to the fact that this particular care ideology and the

activities which defined it were not recognized between the

individual nurse and the wider organization. Many felt that

these personal views of nursing were not legitimate to the

work of the NDU or the Trust and therefore felt compro-

mised and chose to not disclose their private or ‘behind the

screens’ (Lawler 1991) work with patients to other nurses

or the wider organization.

The reflective process revealed for participants an indi-

vidualistic interpretation of the NDU ideology, and how it

could be advantaged further, by becoming a group ideol-

ogy. It also revealed that sharing experiences and gaining

support and clarification with regard to providing patient-

focused care was not occurring. There was a difficulty with

regard to having one’s individual practice with patients

sanctioned and understood by peers. The primary nurse

system that they had operated had somehow failed to

enable cohesion of direction and activity with regard to

patient care. What was needed therefore was a different

conceptual model which facilitated individual practice but

also provided a point of reference by which one’s identity

and purpose as a nurse on the NDU could be achieved —

such a model is advocated in Fig. 1, and arose from the

total analysis of the reflective study.

The creation of a conceptual model from this reflective

exercise was, I believe, the most exciting aspect of the

work. The model had the value of not only providing the

individual nurses with a clear reference point from which

to gauge their practice; but provided a philosophical base

for the nursing team as a whole. Through the identification

of the characteristics of practice and how the infrastruc-

ture of care was constructed, via the relationship-building

process, a cohesion and legitimacy for their nature of

nursing was revealed. The nurses could now make a strong

argument concerning the uniqueness of nursing and its

essential role in patient care, with nursing no longer casti-

gated as only a resource for other professionals or the hos-

pital service. Patients now had an active nursing resource

to help them deal with their needs and wants.

The inductively created model of nursing on the NDU

could be described as a process-centred activity where

patients enter the main NHS system and come into

I. W. Graham


contact with a number of systems including the nursing

care system.

The entrance to the system of care on the NDU requires

note and understanding of the values, behaviours, attitudes

and feelings of the patient and nurse to be acknowledged

and incorporated into the relationship-beginning process.

The aim of the care is to form and build a relationship

which is at first dependent upon the identification of an

individuals’ needs and wants, for both the nurse and the

patient.

Once this identification has taken place, a process of

communication develops, change begins and issues as

described through Lewin’s model of change and its appli-

cation in this setting became apparent. The nurse, through

a process of thorough communication, engages in one of

several roles over a period of time in an attempt to help

the patient make changes and adaptations in order to

achieve healing, wellbeing and coping, from a medium of

caring.

The process of change and achievement of healing, well-

being and coping may or may not occur straight away. The

patient may require several admissions to the NDU for the

relationship-building activity to be successful, or the nurse

might visit the patient at home for a period after their

medical discharge from the NDU. Understanding the dif-

ference between medicine and nursing in this context, in

terms of different activities and outcomes, was a powerful

learning point for the NDU nurses. It was by being able to

describe how the relationship-building activity occurred to

the wider multidisciplinary team, that they gained their

confidence in the purpose and role of mental health

nursing.

Fundamentally the nature of the nursing on the NDU

depends upon the ability of the nurse to communicate in

order to develop a nurse–patient relationship.

The nature of the communication, its depth, its charac-

teristics and its purpose, begins to give style to the rela-

tionship being built. The patient exhibits individual wants

and needs and, depending on how these are communicated

and how willing the nurse is to receive the communication,

the nature of the nursing interaction changes. The nurse

will engage in a number of practice activities and profes-

sional roles in order to give care.

If the communication is superficial and the client does

not describe needs and wants for intervention, then the

nursing may stay at the hospital servicing level of

functional activity. If the communication deepens, the

nurse may venture into the more demanding roles charac-

terized by the six characteristics. How this process is ter-

minated depends upon many factors, but what is hoped for

is an exit point that achieves healing and wellbeing for both

nurse and patient. If non-achievement occurs then the

nurses intuitively know that the patient’s care has been

incomplete and they will soon be re-admitted to the Unit,

or further attempts at relationship-building will be initiated

with the patient as an out-patient. The NDU has com-

menced a process of Primary Nurse liaison visiting after

discharge.

It is interesting to conclude that, as the conceptual base

of nursing practice became established as the relationship-

building process, then it became evident that peer support

and clinical supervision needed to be provided so to ensure

that isolation and fear do not inhibit direct care. This

would also enable clinical effectiveness to be better

achieved, with the model acting as a template for nurses to

judge and be judged in terms of their work with their

patients.

Conclusion

The reflective process overall proved to be highly success-

ful, both in terms of enabling the nurses to gain insights

into the nature of their nursing and what they are as nurses,

and also as a process of investigating nursing’s hidden

agendas and depths of practice. By adopting the reflective

group approach the nurses developed a strong professional

cohesion and identity because they had to share with one

another values and beliefs, and have these questioned and

negotiated within the group. This was very powerful learn-

ing which the nurses dealt with well, developing increased

knowledge relevant to their role and purpose and an

answer to the question they posed for themselves at the

beginning of the reflective group about their practice and

its meaning. They now had a conceptual framework on

which to base their nursing practice and this in turn iden-

tified the meaning of their nursing to be about relationships

and relationship-building with individual patients.

This process was how the nurses achieved individual

patient-focused care. The findings from this work have

implications not only for these mental health nurses, but

for other groups of nurses and midwives as well. The

power of the nurse–patient relationship and its effects upon

a patient’s wellbeing needs to be further investigated, but

it is suggested from this work that it is a very necessary

aspect of health care for the future millennium. How

nurses persuade financial managers to resource such

nursing depends upon nursing’s ability to articulate this

aspect of health care in an evidence-based way.

With regard to my own development, I found the work

most rewarding and beneficial. My own understanding of

nursing practice deepened and I was able to draw upon my

wider reading and understanding greatly when I facilitated

the group. I found myself to be something of a conduit

between the world of practice and the world of theory. As

Reflective practice


my colleagues voiced their metaphors and ideas, I was able

to refer them to literature to help them explore the con-

cepts further. The whole process was one of richness and

mutual growth.

My personal reflection upon the process has to be that

of acknowledging that this process enabled these nurses to

articulate the theories which underpin their practice. They

were a living testament to Cox’s et al’s (1991, p. 373),

claim, ‘isn’t it interesting how nurses who are engaged in

the world of everyday practice are theorisers of their own

practice’. What the process did was to allow Greenwood’s

(1995, p. 117) phrase, ‘fuzzy representations’, to become

organized so that description and explanation of practice

could occur. It was through this, that experience of a

situation could be focused into a particular action and

a particular understanding could be acknowledged. This

personal reflection on this process has taken me into other

work of this nature. This is because I was somewhat sur-

prised that these nurses didn’t share their experiences of

working with patients with each other. It was as if a pro-

fessional taboo prevailed and couldn’t be broken.

I believe that it is only through exploring the nurse–

patient relationship that the identity of nursing will be

discovered and nurses will be able to prove their effec-

tiveness in health care. I also believe the advent of

reflective practice provides a medium for nurses to share

their experience with one another, and if facilitated

well, can be a vehicle for health care improvement and

development.

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Documents

Reflective practice and its role in mental health nurses’ practice development: a year-long study