�� 2004 Blackwell Publishing Ltd. Learning in Health and Social Care , 3 , 2, 53��� 63 Original article Blackwell Publishing, Ltd. Learning to make sense: the use of critical incident analysis in facilitated reflective groups of mental health student nurses Brian Gould RNMH RMN MSc PGCert 1 * & Hugh Masters RMN MPhil PGCert 2 1 Lecturer, Mental Health Team, Department of Community Health, Napier University, 13, Crewe Road South, Edinburgh EH4 2LD, UK 2 Senior Lecturer, Mental Health Team, Department of Community Health, Napier University, 13 Crewe Road South, Edinburgh EH4 2LD, UK Abstract Encouragement for nurses to utilize reflective approaches has come from a wide range of professional and educational bodies. The benefits of reflection are usually stated in terms of increases in the nurse���s critical abilities and a greater awareness of the complexity of nursing practice. Within mental health nursing, additional benefits are cited in terms of improvements in interpersonal effectiveness. This small-scale study attempted to evaluate practice-based critical incidents brought to reflective groups by mental health nursing students The findings indicated that the ability of students to bring incidents to groups was influenced by the dynamics of the group and the group member���s relationship with their facilitator. The critical incidents themselves were characterized by accounts of difficulties in relationships between students and clients. In particular, students described their concerns in making the transition from a social to a therapeutic relationship with clients. The reflective groups were used by students to give and receive support and in helping them to develop an understanding of what a professional role involved. The conclusion of the study highlights both personal and professional advantages in using reflective groups during practice placements for mental health nursing students. The critical incident approach proved helpful in focusing students on personal experiences of practice, but limitations in utilizing the reflective cycle when exploring critical incidents are highlighted. Training and ongoing support for group facilitators is essential if the learning potential of critical incidents is to be fully exploited. Keywords: critical incidents, facilitation, mental health, nursing, reflection groups *Corresponding author. Tel.: +44 131 455 5320 fax: +44 131 455 5359 email: b.gould@napier.ac.uk

54 B. Gould & H. Masters �� 2004 Blackwell Publishing Ltd. Learning in Health and Social Care , 3 , 2, 53��� 63 Introduction An emphasis on experiential learning in recent years has seen the adoption, by nurse educators, of a variety of teaching methods, based on encouraging student nurses to reflect on their experiences of practice. A review of the literature suggests some disagreement as to a precise definition of reflection, but most authors concur that it involves the ���self���, the world of professional practice and a bias towards action (James & Clarke 1994). Dewey (1933, p. 9) is credited with highlighting the concept of ���reflective thinking��� in the early part of the last century, which he defined as: ��� active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends. The challenge that Dewey posed to accepted ways of thinking and knowing attracted the attention of many educators involved in preparing students for professional practice. Schon (1983), in particular, was concerned with making explicit the knowledge and competence embedded in the day-to-day work of many professionals. He was critical of what he termed ���technical rationality���, where it is assumed that the imposition of generalized theories and concepts developed elsewhere will solve the practi- cal problems encountered daily by professionals. Instead, he sought to help practitioners to identify the patterns of thinking and behaving that they had developed in response to the everyday work pro- blems encountered. Mezirow (1990) describes this learning as ���transformative��� and puts at its centre the desire to construct personal meaning from the circumstances in which we find ourselves. Structured time for reflecting on practice experi- ences has become an important teaching method adopted to help link the worlds of practice and education (Atkins & Murphy 1993 Gould 1997). Palmer et al . (1994) describe how the use of Gibb���s reflective cycle can help to focus the work of reflec- tive groups. Criticism of the widespread enthusiasm for reflec- tion centres on the lack of a common definition, its unproven benefits and the absence of a uni- versally acceptable structure for its implementation. Where agreement does exist, it is that reflective practice should be more than just ���thinking about thinking��� and instead should attempt to bring about a real change in either the outlook or the behaviour of those engaged in the process (Gould 1999). A search of the nursing literature discovered only a small number of studies on the use of reflec- tive groups with student nurses. Stoddart et al . (1996) describe the valuing by students of the support offered by the groups, particularly in relation to problems arising from their practice placements. The lack of a common understanding of the precise purpose of reflective groups was seen to be partly responsible for their failure to move beyond a supportive function into the more difficult area of examining beliefs, ideas and contextual factors in practice. The need for some supportive structure within the groups was identified as an important element for containing anxiety. This is also clear from a study carried out by Franks et al . (1994) with students during their first and second clinical placements. The setting of a theme for each group resulted in the disclosure of more personal issues and led Franks et al . to conclude that the correct balance between ���structure and space��� must be established within a group. Brookfield (1990) suggested that a detailed examination of critical incidents could help students to identify and understand the assumptions that underlay our thoughts and actions. Parker et al . (1995) highlight how critical incident analysis can help students to integrate new knowledge with old know- ledge, and thus identify the implications for future personal and professional development. Research design and methods Background Reflective groups were introduced into a 3-year Diploma in Higher Education in Nursing programme to provide a ���space��� within the syllabus for students to discuss and explore practice experiences. All