A difficult year: 2020 and the power of reflection

Nurses and midwives are educated to use reflective practice to evaluate the effectiveness of care and nursing or midwifery interventions. It is part of our professional toolbox. As Ausmed suggest in their guide to Reflective Practice:

“In its simplest form, reflective practice is the ability to reflect on your actions and engage in a process of continuous learning.”

Ausmed cite nurse educator Norman C. Olsen, who compares the act of self-reflection with a spiritual act — taking time out to connect the inner-self with the outer-world. Olsen suggests that this view echoes Florence Nightingale’s belief that providing nursing care to others can be a spiritual act. More importantly, Olsen highlights that reflection is essential to avoid burnout by helping nurses stay connected with their passion for their profession.

According to the Nursing and Midwifery Council of the United Kingdom (NMC), reflection is how health care professionals can assess professional experiences, find insight to aid learning, and identify opportunities to improve.

Reflection is the act of consciously examining our experiences — thoughts, actions, feelings, and responses — and then interpreting or analysing them with the purpose of learning and potentially improving future practices.

When you reflect, you give time and focus to processing your experiences. The practice may help you make sense of challenging events, but it also may help you realise that you have more questions than answers. That’s ok too — identifying confusion is the first step in beginning to navigate your way out of it.

Reflection requires you to pause, connect with feelings and make sense of emotions, psychological and somatic responses associated with your experience. Reflection enables you to identify issues and to take action before unhealthy emotions or illness becomes full-blown.

University of Leeds Nursing Lecturer Philip Esterhuizen says:

“Reflective practice is not something that is switched on and off. Being a reflective practitioner is something you are, and it is especially useful in times of stress, extreme situations and uncertainty”.

So, reflection is something you should back into your practice at a fundamental level. There are a few ways to approach it.

Clinical supervision

Clinical supervision is a formal process that aids supported reflection. It is one tool underutilised by nurses and midwives to support and enable reflection. Clinical supervision is a process of professional support and learning in which nurses and midwives are assisted to develop their practice through regular time spent in reflective discussion with experienced and knowledgeable colleagues trained in providing clinical supervision.

In 2019 the Australian College of Mental Health Nurses, Australian College of Midwives, Australian College of Nursing, released a joint position statement recommending clinical supervision for all nurses and midwives irrespective of their specific role, area of practice and years of experience. The key statement in the position statement outlines:

Self-directed reflection

While we recommend clinical supervision for all nurses and midwives, we know that not all clinicians are in a position to engage in formal supervision. Informal mentorship is also valuable, but self-directed reflection is available to everybody!

There’s no one way to reflect, so do what works for you.

• Keep a journal
• Record voice notes
• Discuss your experiences with a trusted friend, colleague or family member
• Jot some bullet points in your notes app
• Start a support group with some colleagues

A structured questionnaire could help you get started. Here are some questions we suggest asking yourself:

• What happened?
• What emotions and physical responses were experienced?
• What did I do well?
• What didn’t go well?
• What was most challenging?
• What am I grateful for?
• What provided me with support?
• What have I done to care for myself?
• What gives me joy?
• I feel most energised when…
• I feel happiest when…
• Write a list of questions to which you urgently need answers…
• Write the words you need to hear…
• Do I know where to get support?
• What if anything is stopping you from accessing support?

My reflections: Reach out for support sooner rather than later

This has been a difficult year, so it’s been important to me to reflect on the challenges we have faced, as a profession, city, country, and world.

COVID-19 has served up many challenges. Nurses and midwives are at the frontline of this pandemic providing 24/7 care — always there, available and present to care for those affected by the disease. The coronavirus marathon (it’s definitely not a sprint) has meant that many nurses and midwives have continued to make sacrifices. Some have been separated from families or other loved ones for periods of time. Many have been infected with COVID-19 through their work, and we grieve for the healthcare workers who have lost their lives to COVID-19 worldwide. Some experience ongoing health issues.

We are still unaware of the potential long-term health impact. Nurses have and are experiencing grief and bereavement because of the death of residents in aged care facilities. Many residents have been in their care for years. If this is you, reach out for support sooner rather than later. These experiences will stay with you.

Over 30 years after being a young nurse through the Acquired Immune Deficiency Syndrome (AIDS) epidemic of the 1980s, I continue to reflect on my experience, the profound loss and prejudice experienced by many who died, and also those who lived. On occasions when I’m triggered by a memory, or remember a friend or patient who died prematurely in tragic circumstances, I take time out to reflect on that time and note my emotions. The grief, loss and selfless devotion to caring for those affected by AIDS is worn by many as a badge of honour.

It’s still difficult for me to make sense of all that happened during those grim years. In those early days, we knew little about HIV. Many patients presented to hospital with advanced medical conditions that the most experienced nurse hadn’t seen before. We wore personal protective equipment, practiced universal precautions, and nursed our patients to the best of our ability often feeling like aliens in a foreign land. Many COVID-19 nurses will have had a similar experience. Reflection has supported me to make sense of the complexity of that experience in my life and career.

The impact of COVID-19 is vast

Millions world-wide infected, more than a million dead. Many more will die. Our elders significantly at risk, many infected and hundreds dead. The economic impact to be experienced for years to come. Chances are you know and cared for people who contracted COVID-19, who died as a result of COVID-19 or others who have lost their job, home and are separated from loved ones. If you need support, Nurse & Midwife Support is available Australia wide 24/7, anonymous, confidential and free: 1800 667 877 or email us. You may have had a career experience that structured reflection has supported you to understand and reconcile. Or perhaps you don’t feel you have the inclination or time to engage in reflection. Maybe the last thing you want to do is spend more time thinking about your COVID-19 experience. It may be too raw, too new, too difficult or just something that you don’t need to do. That’s ok. We are here if and when you need to talk.

Finding resilience

On Episode 17 of the Nurse & Midwife Support podcast, I spoke to Professor Kim Foster about resilience. Kim is an internationally recognised mental health nurse academic, researcher and educator widely published in resilience, mental health and psychosocial research.

Kim told me that resilience is a protective factor against the negative impacts of the emotional and physical rollercoaster many of us are on. If these impacts aren’t acknowledged you may experience a range of negative outcomes such as heightened stress, anxiety, lowered mood, social isolation, anger, substance misuse and burnout. Kim believes that anyone can build resilience, and reflective practice and clinical supervision are key components of resilience for nurses and midwives.

Reflection can assist us to get to the core of the issue, dissect it, toss it around and make sense of it. Enabling a deep understanding of the what, why and impact of our experiences. Reflection can support us to understand and acknowledge feelings that may be challenging and painful. Creating clarity that hopefully leads to a sense of peace and wellbeing.

What sustains you?

I recently read ABC journalist Julia Baird’s book Phosphorescence. This honest and insightful book on awe, wonder and things that sustain you when the world goes dark has been the most comforting book that I read this year. Julia describes her experience of being in intensive care for eight days following surgery to remove a cancerous mass. She reflects:

“I grew intensively attached to the nurses, grateful for their kindness, and lay wondering if there was a more important job.”

As a proud nurse, I reflect on Julia’s acknowledgement and know there isn’t a more important job. In the International Year of the Nurse and the Midwife as 2020 draws to a close I pause and reflect on the contribution of nurses and midwives. I honour, acknowledge and salute you, my colleagues, for being the incredible nurses and midwives you are. I encourage you to take some time for YOU, pause, reflect, pat yourself on the back for a job well done and reach out if while reflecting you recognise you need support. After all, you are only human. If you feel 2020 has overwhelmed you, reflecting on your experience and emotions may support you to remain on solid ground. And Nurse & Midwife Support is available to support you 24/7, 1800 667 877.

Now perhaps more than ever: your health matters.

Mark Aitken RN

Nurse & Midwife Support Stakeholder Engagement Manager