Written daily reflections during clinical practice on birthing units have been used during several years in midwifery education at Lund University, Sweden. However, the usefulness of these reflections for evaluation of progression in learning and professional development of students has to date not been evaluated. In order to analyse written reflections, two taxonomies developed by Bloom and Pettersen have been applied to the texts. Progression in the professional development of midwifery students can be seen through levels of complexity in cognitive and psycho-motor learning areas and also in the description of learning situations. Progression can be seen from a basic description of facts in simple situations at the beginning of the students' practice to a complex description of complicated situations towards the end of the practice. Written daily reflections appear to be a suitable method to help students to reflect in a structured way, thereby helping their professional development. Reflections can help clinical supervisors to understand the needs of the individual student and to support their knowledge accruement. Daily written reflections on clinical practice can be of use in other health education programs.
Reflection in midwifery education and practice: an exploratory analysis
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Reflection in midwifery education and practice: an exploratory analysis
EBM: Dec 2006
Val Collington1 PhD, MSc, DipN, MTD, RN, RM. Sheila C Hunt2 PhD, MBA, MScEcon, RGN, RM.
1 Acting deputy dean and head, School of Midwifery, Kingston University and St George’s University of London, Cranmer Terrace, London SW17 0RE England.
2 Dean, School of Nursing and Midwifery, City Campus, 11 Airlie Place, Dundee DD1 4HJ Scotland. Email: email@example.com
Background. There is a perceived acceptance in the literature that reflection is appropriate in analysing midwifery practice, but the extent to which its potential is realised by midwives and students in education and practice contexts is generally unknown.
Aim. To explore students’ and midwives’ perceptions of how critical reflection is facilitated.
Method. An ethnomethodological approach was adopted to investigate a purposive sample of students’ and midwives’ day-to-day experiences of reflective practice in a holistic way. Qualitative data was gathered through multiple methods, including group discussions, semi-structured interviews and analysis of journal entries.
Results. Interpretive analysis of the data revealed that both midwives and students had a superficial understanding of reflection and that there was some inconsistency in approaches to reflective practice. However, midwives who had undertaken reflective journal writing during their midwifery education programme had adopted and maintained reflective practice.
Conclusion. The transition toward reflective practice has been slow and incomplete, and needs to be reinforced. For midwifery students, journal writing had a positive influence in promoting this kind of practice, and further strategies are needed to facilitate it among qualified staff.
Key words: Midwifery research, reflective practice, reflection, journal writing, learning from experience
Reflection is known to be of benefit in experiential learning, developing critical thinking and enabling integration of theory and practice. As part of a larger study, the aim here was to ascertain midwives’ and students’ perceptions of how critical reflection was facilitated in education and practice contexts.
The role of reflection in enhancing learning is widely debated. As a transforming process (Mezirow, 1991; Brockbank and McGill, 1998; Glaze, 2001), it offers a means of examining actions in practice (Schon, 1983, 1991; Rich and Parker, 1995). Some assert that the use of a reflective journal helps students to assimilate their experiences into professional knowledge (Taylor et al, 1995; Button and Davies, 1996; Moon, 1999; Glaze, 2002). Reflection is one of the main learning methods endorsed by professional, statutory and regulatory bodies (NMC, 2002; RCM, 2003) to promote the development of knowledgeable and competent practitioners. Some argue that reflection needs structure to enable the disciplined activity to take place (Johns, 1994; Fish and Coles, 1998; Moon, 1999). Moon offers a definition based on the different applications of reflection found in the literature, construing reflection as ‘a form of mental processing with a purpose and/or anticipated outcome that is applied to relatively complex or unstructured ideas for which there is not an obvious solution’ (Moon, 1999: 23).
Knowing that student midwives in this study context utilised journals to develop reflective skills, and that there may be variations among midwives as reflective practitioners, this paper reports on the findings of an investigation of attempts to promote reflection.
A review of literature that identified reflection and/or reflective journal learning strategies was undertaken using databases such as BNI, British Educational Index, CINAHL, ERIC, EMBASE, MEDLINE and MIDIRS. The main focus of the review was in healthcare and teacher education because they had a long history of promoting reflective practice. Limited literature had been published on the subject in relation to midwifery education in the UK or internationally. A selection of the findings relating to the definitions and key features of reflection are presented below.
The Concise Oxford English Dictionary (Pearsall, 2002) offers several definitions of reflection, including casting back, showing an image, thinking, meditating, reconsideration and ideas arising in the mind. However, in the professional context reflection is much more than thinking about things and a variety of views are offered on what it means (see Table 1).
Dewey (1933) describes it as a process that enables learning from experience. Similarly, Schon (1983) argues that reflection is an important learning strategy through which professionals become aware of their implicit knowledge base.
Moon (1999) and Burns and Bulman (2000) note that reflection is also a loosely-used concept. Hence, when Reid (1993) explored responses to the concept of reflection, it was frequently ‘but we are doing it already’. According to Moon (1999), there are also common sense meanings that result in a range of conceptualisations. Generally, attempts to promote reflection are through written accounts such as journals, logs, diaries and other writing tasks and a number of key features have been ascribed to this (see Table 2).
Studies of experiences with reflective writing, which mainly use retrospective self-reporting, acknowledge difficulties in students’ reflective journeys that include recognition of unequal power relations between students and tutors or supervisors. Williams and Lowes (2001) examined why qualified practitioners might be reluctant to reflect formally, and suggest that barriers to effective reflection might create a division between practitioners and the professional hierarchy with respect to common practice. They identify constraints of time, inadequate preparation and inconsistency between how reflection was embraced in the academic and practice contexts as adversely influencing its effective use. Glaze (2002) reports similar findings in a study of advanced nurse practitioners’ perceptions of their reflective journeys. One of the barriers to coming to terms with reflection was a lack of insight into their own reflective abilities. These practitioners also assumed they were reflecting as a matter of course, but this was not borne out in the study. It took time for them to overcome barriers to reflective learning.
An ethnomethodological approach was used, as it offered a holistic means to investigate individuals interacting in an ordinary setting. The interpretivist stance adopted asserts that reality is subjective and constructed by individuals through their day-to-day interaction with the social world. Acknowledging multiple realities (Morse, 1994; Cresswell, 1998; Crotty, 1998; Denzin and Lincoln, 2000), this investigation took account of students’ and midwives’ views using multiple research strategies (see Table 3). Drawing on principles of the ethnographic tradition, it entailed interactions with participants in both academic and clinical practice contexts.
The setting was a school of midwifery that offered both a three-year and an 18-month programme, and a range of continuous professional development programmes. One learning strategy used in these programmes was a requirement for students to maintain a reflective journal as a tool to facilitate critical reflection and to aid management of their learning.
Having gained ethical approval from the university ethics committee and local research ethics committees of two NHS Trusts, participants were recruited on a sequential basis as data were gathered and analysed. Given the potential for conflict in the author’s dual role as researcher and a member of the midwifery school, ethical principles adhered to related to respect for autonomy, beneficence, non-maleficence and justice (University Research Ethics Committee, 2002; NMC, 2002).
Data were gathered from a purposive sample of participants based on their accessibility over a three-year research period. Students were recruited from each year group to capture varying experiences of reflective journal writing, clinical practice and reflection in this context. To obtain views of these activities, triangulation of data sources and data gathering techniques proved beneficial.
Participants were approached through whole cohort briefings and invited to opt in, providing signed consent. Apart from agreeing to participate in group discussions or interviews, some consented to having anonymised journal entries analysed, or for extracts to be used in midwives’ interviews. Access to midwives was negotiated with midwifery managers in two maternity units. Information about the study and the voluntary nature of participation was provided, and selection for inclusion was based on their role in mentoring and assessing students.
A systematic, interpretive approach was adopted to analyse the data (Miles and Huberman, 1994; Robson, 2002; Seale et al, 2004) and to identify emergent themes. Understandings of reflection identified in the literature review (see Table 1) provided the basis for analysing the data and for judging demonstration of reflective practice in the study context. In particular, viewing reflection as an active, deliberate process, analysing and thinking about actions and making well-considered decisions. Procedures were adopted to minimise researcher bias and to ensure participants’ voices were captured accurately, and the meanings intended clearly articulated in the findings (see Figure 1).
Excerpts of participants’ voices are embedded in the narrative below to illustrate the richness of data that provided insights into students’ and midwives’ views.
Midwives and students considered reflection to be a useful strategy for learning from experience, but in this study context, the means by which it was facilitated was variable. The themes outlined below relate to midwives’ understanding of reflection, differences in approaches to reflective practice, and newly-qualified midwives’ attempts to maintain reflective practice. The key research findings are outlined under these headings.
Understanding the concept of reflection
Students’ understanding of reflection partly mirrored the definitions cited in the literature. In focus groups, there was general agreement that reflection was ‘looking back on something and thinking about it’, and detailed or in-depth thinking was not always apparent. Later evidence from interview data and scrutiny of journal entries showed that two thirds of these participants only had a superficial understanding of critical reflection: ‘I think it can be really positive. If, for example, you did something wrong or you just didn’t like the way you performed, you’d look back and say ‘well, next time I’ll do it differently’. Even if you did things well – a good delivery – and think ‘I was right to do this’... you can learn from it. I think [reflection] is a good way of learning especially at this stage... to look back on things every day when you go home’ (second-year student, focus group).
‘I question the students to help them... I leave a bit of time at the end of the shift to talk... I think practice learning becomes more effective when the mentor talks them through things. The meetings in the community when we discuss cases are also helpful for students’ (midwife 10, interview).
These comments do not indicate the deep thinking associated with critical reflection as conceived by theorists (Schon, 1983, 1991; Boud et al, 1985; Johns, 2000). However, some elements are present such as making sense of experience, standing back and going over something, and weighing up or evaluating practice and making judgements. The descriptions are closer to definitions of debriefing – discussion or interrogation after a mission, recapping about events, restating briefly, summarising, giving substance to what has already been said (Pearsall, 2002).
The midwives held similar views to students about the value of reflection. They were asked to define reflection, comment on whether the culture of their practice environment facilitated a reflective approach, outline their role as mentors, and read and comment on students’ journal entries. Most midwives viewed ‘reflection’ as a means of examining and improving their work and learning and thinking more deeply. In a similar way to students, their conceptualisation of reflection varied from ‘looking back on things’ to deep, disciplined, critical reflection. The majority also thought that ‘we reflect all the time, sometimes subconsciously’. Arguably, it is natural to ponder on activities. To a greater or lesser extent, individuals spend time going over what they have said or done. Often this involved hindsight in realising how things might have been different: ‘I think that reflection is like a tool for examination [of] one’s own work, not your colleagues, your own work, and seeing how to improve things. Looking back sometimes and seeing if you’ve done things well’ (midwife 6, interview).
The midwives interviewed had been practising for between two and 30 years, and those qualified for less than eight years stated that reflection had been included in their initial training. Others had become familiar with reflection during post-registration professional development activities. One student discussed the benefits of group reflection: ‘We would sit in the coffee lounge and talk about a delivery, what happened and how we felt. That was our way of reflecting’ (second-year student, focus group).
There was a general perception that discussion achieved the same outcome as written reflection. One midwife indicated how she came to realise the depth of reflective thinking: ‘I was doing nursing and [reflection] was mentioned during the [teaching and assessing in clinical practice] course... it all came back during midwifery... I was involved in a case about 18 months ago that went quite badly wrong, and as part of my supervision I did a [written] reflection on the experience. That’s when it came home to me what reflective practice was all about and that’s perhaps why I use it often... I was [reflecting] beforehand, but perhaps not doing it the proper way. I hope no one has to go through what I did to realise what reflection is about. I am sure the ‘girls’ nowadays will do it properly as they write more reflections during the training’ (midwife 6, interview).
Having started the interview with the initial view ‘Looking back sometimes and seeing if you’ve done things well’, further exploration of the issue drew out a crucial learning experience of a complicated case where her learning appears to have been maximised through written reflection. Interestingly, students interviewed voiced similar sentiments. Some demonstrated understanding of the need for detailed deliberate considerations of practice issues, adopting a critical approach: ‘[Reflective journal writing] makes you analyse things more... I think you have to be quite dedicated to what you are doing... invest a lot of time thinking... I try to include up-to-date research. Writing the reflections has more effect on me because I question things and it spurs me on to look deeper... you might just want to talk to your friend but this is more’ (third-year student, interview).
This midwife was an example of the kind of practitioner who is well placed to promote reflective practice, because she was able to articulate how she learnt from the process as well as from clinical experience.
If experienced practitioners in Glaze’s (2002) study struggled with the reflective process, how much more difficult must it be for novice student midwives who are learning in clinical environments that did not always promote reflective practice. Some midwives were conscious of difficulty in trying to embed reflective practice in their working environment, commenting on the difference between students’ and newly-qualified midwives’ approach and that of other midwives. One midwife judged the difference between current midwifery training and her own, undertaken ten years ago:
‘... not just doing things because of protocols like the midwives trained years ago... we just do it and say this is the reason why... [students] sit down and think much further... they question... For example, I can see from this [journal extract] that she is questioning the fact that one hour is not enough [for pushing during the second stage of labour]. It is not a matter of fetal distress and as such they should have given the women more time. Maybe the woman wouldn’t have needed an episiotomy. The student could see that. That was good. I feel this is more a problem with practice guidelines. I can see the midwife was sticking to the hospital guidelines... This does not allow the woman to progress... I would have given her more time... It is good that the student was able to pick up on these aspects of practice and question them in the reflection’ (midwife 9, commenting on journal extract).
She also voiced concern about colleagues who appeared reluctant to change or to adopt reflective practice: ‘The students are questioning but not all midwives question their practice... they have just been doing it for many years... they probably think, ‘I have been practising like this and everything has been alright, why change it?’ (midwife 9, interview).
This view highlights the need to encourage in-service education and midwives’ continuing professional development (especially those supervising students) to develop a more critical reflective approach to practice.
Differences in approaches to reflective practice
Although some midwives had not formally used reflection as a learning strategy in initial or post-qualification training, they had adequate understanding of the possible outcomes. The extent of the reflective process was not always recognised: ‘When I trained [overseas 14 years ago] we had a thing called ‘evaluating your practice’, [which] you would call progress notes. At the end of a session, you would actually evaluate to see what you felt was effective or need to improve... or [what] you need to change completely. So I think it is probably that you did reflection but in a different way... it included feedback and making adjustments... so I think it is more or less the same as reflection’ (midwife 15, interview).
This midwife outlined a good strategy for evaluating practice, despite it only being a part of the process leading to critical analysis of the experience. When definitions and models of reflection noted in the literature are taken into account, it would appear that the midwife’s comment shows limited awareness of the extent of the reflective process.
Student midwives in this study also noted differences between individual midwives’ use of reflection and also its emphasis in different clinical areas. Midwives concurred with this view:
‘I think those who tend to do more reflections are the junior midwives more than those who have been qualified for quite a while and I don’t always think [midwives] are encouraged... well, we only seem to be encouraged to reflect if there is a problem’ (midwife 7, interview).
‘Some midwives just do things because they have been doing it for years and it works for them, why bother to change?... For example, when I did research for my MSc, I looked at midwives’ attitude to antenatal HIV testing. I heard some different understanding of universal precautions. I know that what some were telling me is not what they do. That is why in some areas the students may not be exposed to ideal practice and we could be confusing them...’ (midwife 9, interview).
At first glance, these two illustrations appear negative, and also a criticism of fellow midwives. Actually, both midwives were trying to explain the differences between those who had been exposed to reflection, or some other strategy for developing a critical approach to practice, and those who had been qualified for some time and prepared differently. From the analysis, it appears that the statements were positive endorsements of the strategy to encourage students to reflect.
A significant number of students expressed doubt about whether all midwives reflect on their practice, but appreciated general discussions on aspects of care during a shift: ‘I suppose it depends on which midwife you are working with really. Some midwives are more open to reflection on work than others. When I was working with a midwife for a while, we got into a routine and she’d ask me questions and that would sort of bring in reflection. She would ask, ‘What would I do in this situation’ so yeah, I suppose reflection was encouraged’ (first-year student, interview).
The extent to which students found themselves in an environment conducive to reflective practice varied: ‘Certainly in the other hospital I was working at, [reflection] was encouraged... There was a whole culture of reflecting, looking back over things and seeing where you could have done better... At this hospital it is not the same... senior staff stick together and [junior staff are] excluded or they stick together... you don’t get a good level of reflection on practice... some people [reflect] more than others’ (third-year student, interview).
‘I think people who reflect are those who are more aware of what they do, more competent, good practitioners. I am amazed how many ‘sloppy’ midwives there are, doing things badly or [who] are mean. For example, not giving drugs to someone in pain because ‘she’s not my patient’... and those kinds of people aren’t the kind to reflect. They just come in, do, their work and go home and maybe they don’t even think about what they are doing’ (second-year student, interview).
Variation in approach to learning and practice development is to be expected, but the view that ‘some midwives do not even think about what they are doing’ was raised by a few participants. Midwives’ level of experience would affect whether demonstration of levels of thinking that influence their actions might be obvious. The overt activity of discussion was perceived as openness to reflection, but could have been intended to trigger students’ thinking. Questioning may have been part of the mentor’s strategy for making sure the student understood and learnt what to do. In this study context, lecturers were responsible for supporting students with reflective writing while midwives supervised clinical experience and learning, and this separation of roles was not ideal for promoting reflective practice.
Maintaining reflective practice
To ascertain whether, having kept a journal during the course, reflection and questioning of practice had been incorporated into midwives’ day-to-day practice, a survey was undertaken of newly-qualified midwives approximately six months into their first post. They felt that reflection had continued influence on their practice. To varying degrees, they all referred to questioning and thinking more about practice:
‘I am continually questioning care provided and linking it to evidence-based knowledge. It assists with formulating own practices and professional standards’ (newly-qualified midwife 6, questionnaire).
Also, the requirement to integrate evidence and/or theory when analysing practice experiences in written reflections was regarded as an effective component of their professional education. According to others:
‘I have developed from my student reflections to constantly searching for evidence to aid myself and others in the process. It has given me a new role and also confidence in my practice. As a student, reflections can be tedious and appear meaningless when vast amounts are required. Regular, thorough and relevant reflections have initiated a lasting enthusiasm to use the skill. It has almost become a daily routine for me’ (newly-qualified midwife 10, questionnaire).
‘Reflection brings you to the point of finding things out. For instance, when you make a mistake, you go and read about the current evidence on it, you talk to colleagues and think about how to improve on that area of care... the transition from student to qualified midwife has not been easy. Using a reflective diary, I can see the improvement in care that I give, now I have worked six months. I can see the competencies achieved and confidence in working as a trained midwife’ (newly-qualified midwife 3, questionnaire).
Paget (2001) found that reflective practice was highly regarded and most participants could identify significant changes to clinical practice resulting from it. In this present study, newlyqualified midwives recognised the benefits of reflection, particularly during the transition from student to qualified midwife. In relation to reflective journal writing, one midwife said:
‘I must say, once you qualify it becomes difficult to write in a reflective journal. Having said that, I think having the basis does encourage one to reflect daily about the care given to women’ (newly-qualified midwife 7, questionnaire).
In addition to some midwives’ lack of understanding of the reflective process, similar barriers to embedding reflective practice noted in the literature were found. The need for ongoing support and in-service education, including reflective discussion, was identified strongly by participants. Overall, newly-qualified midwives responded positively to reflective practice. However, there was a gap between how students were facilitated to develop reflective skills – through journal writing – and the support available to practising midwives to develop such skills. Students shared reflective writing with lecturers, who encouraged them to think critically about practice, consider alternatives and justify their actions through journal writing, while midwives did not always mirror reflective practice. Although some mentors did not model reflective practice or fully understand reflection (as defined in the literature), they asked questions, clarified situations and challenged students in a constructive way.
Practice forms the basis for professional learning and development, but simply because students have experienced something does not guarantee learning. Therefore, attempts to analyse the experience, actively trying to make sense of it, find meaning in it, via reflective discussions and/or journal writing require guidance and support to enhance effectiveness (Johns, 2000; Glaze, 2001). This study identified differences in the emphasis on reflective practice between the academic and practice contexts, and this was equally problematic for student midwives who experienced inconsistency in the adoption of reflective practice.
Professional regulation (NMC, 2002) and NHS policy imperatives (Department of Health, 2002) require ‘reflective midwifery practitioners’ to provide high-quality services. Yet in this study, readiness to utilise reflection was variable. Some midwives and students demonstrated only a superficial understanding of reflection when compared to key features noted in the literature. Despite this, students and newly-qualified midwives’ acknowledgement of the value of reflective journal writing in initiating engagement with reflective practice was noteworthy. From the evidence, there is need for a better understanding of reflection per se, and particularly for continuing professional development if a shift towards reflective practice as a lifelong learning strategy is to impact upon care provision.
Considering that the basis of autonomous practice is critical decision-making, well-structured reflective discussions between midwives, students and/or lecturers might be an appropriate method for encouraging this. Clouder (2000) would support such a strategy because she argues that the introspective nature of reflective practice means that it denies benefits to the profession at a wider level. Clouder believes that the internal deliberations promoted by proponents of reflective practice ignore the potential for dialogue to enhance learning among a community of practitioners. Cotton (2001) disagrees and argues that nurses’ private thoughts have been made public through the hegemonic discourses of reflection and are therefore subject to surveillance, specifying what and how they should think. On the contrary, midwives in this study did not perceive students to be constrained, but questioning.
The findings of this study showed some differences in midwives’ and students’ manner or behaviour judged to be evidence of reflective or non-reflective practice. The findings concur with Jones and Cookson (2000) who discuss how paramedics, like other practitioners, assert that they apply reflection as a matter of course. While acknowledging that informal reflection has its value, they suggest that such a view was simplistic, postulating that true reflection on practice is not automatic, but a deliberate focused activity pursued with the intent to examine, learn and develop practice in a more structured way.
Some of the evidence portrays an appropriate learning environment where practitioners generally adopted a critical approach to their work. If midwives and students share the view that there was an expectation that individuals would vocalise their thinking or provide justification for action, and this is not forthcoming, the conclusion might be drawn that ‘they do not even think about what they are doing’. Knowledge being used was not always made explicit, and students might misread a midwife’s motive and action or may not have the holistic view, sufficient experience or knowledge to decide whether a practitioner’s actions were appropriate. Students might not recognise when the critical thinking required for making clinical judgements was taking place, and reflection may result in a decision to continue as before. Glaze (2001) found that, for advanced nurse practitioners, reflection was sometimes affirmative, often justifying planned action and decisions.
Eraut (2000) provides an explanation for the above view that some midwives do not think about their practice. He identifies the problematic nature of tacit knowledge, with respect to both detecting it and representing it. He identifies three types of tacit knowledge that come together when professional performance involves sequences of routinised actions punctuated by rapid intuitive decisions, based on tacit understanding of the situation. An external observer can only guess at the cognitive activities and may wrongly assess that reflection had not taken place while the midwife concerned might have made a conscious decision not to change her practice in a given situation.
Development of reflective skills is a complex process (Moon, 1999; Glaze, 2001) and the rationale for implementing reflective journal writing during this midwifery course was to lay the foundation for habitual reflective practice, once reflective skills had been embedded. Having implemented journal writing for a similar reason, Wellard and Bethune (1996) later questioned the process, concluding that reflective practice was possible, but that time and space to develop the skill must be afforded in nursing courses and beyond. Glaze (2001) concurs with this view. She found that students needed to overcome misconceptions of their reflective abilities before realising transformation. In the qualitative study exploring advanced nurse practitioner students’ experience of reflection, Glaze (2001) found that the integration of reflection within the masters degree programme was beneficial to the majority of students. Students described perspective transformation and viewed reflection as part of their lives, assisting them with the implementation of their advanced practitioner roles. The habit of reflecting in day-to-day practice was also found to have been formed.
Evidence from this present study shows that although many did not continue journal writing, a critical approach became an in-built component of recently qualified midwives’ professional practice. As they model reflective practice, it places them in a good position for supporting learners.
This is important because, firstly, if students are encouraged to reflect on practice experiences, midwives need to utilise critical reflection as a learning strategy when mentoring students. How could they carry out this function with the superficial understanding evident in some? Secondly, the perceived differences highlighted by participants will be perpetuated if both the philosophy and practicality of reflective practice does not fully infiltrate the practice-learning environment. In other words, midwives need to understand and believe in reflection as a useful strategy for development, encouraging such practice among colleagues and students. The importance of reflective practice in enhancing professional development requires reinforcement within both the educational and practice contexts.
This study explored midwives’ and students’ views of how critical reflection was facilitated in the educational and practice contexts. To achieve this, systematic data gathering and analysis using multiple research techniques was employed to uncover the realities of these participants’ experience of reflective practice.
The study highlighted different understandings and approaches to reflection. Some midwives recounted recapping on a situation, debriefing and reflection as if they were the same activities. All are purposeful, but the meaning attached to reflection and reflective practice indicates deeper thinking with an intention to improve practice or justify decisions made. Inconsistency in embracing reflective practice was identified as an area for improvement in the practice context studied. Crucially, the study showed that where the discipline of structured reflection was encouraged (in this case, through journal writing) during the programme of study, these practitioners continued to embrace reflection as a necessary part of their midwifery practice.
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