What? So What? Now What? Critical Reflection Model

The “What? So What? Now What?” model offers a practical framework for incorporating reflection into various aspects of our lives, leading to continuous learning, growth, and improved decision-making.

The “What? So What? Now What?” reflective model, originating from Terry Borton and further developed by Rolfe et al. for healthcare practice, emphasizes a cyclical progression of understanding and action.

The stages are interconnected, with each one building upon the insights gained from the previous stage.

1. “What?” establishes the foundation by focusing on objective description. It prompts the individual to gather the facts and details of the experience without immediate interpretation or judgment.
2. “So What?” transitions from observation to analysis. It encourages the individual to make sense of the “What?” by exploring their emotional responses, connecting the experience to prior knowledge, identifying patterns, and uncovering potential implications. This stage helps individuals move beyond merely recounting events to understanding their significance.
3. “Now What?” propels reflection into action. Drawing upon the insights from the “What?” and “So What?” stages, this stage focuses on developing concrete steps for improvement, future application of learning, and personal or professional growth. It transforms reflection from a passive process of thinking to an active process of planning and doing.

The connection between these stages is crucial as it allows for a deeper level of understanding and more effective action.

By regularly reflecting on our experiences, we can identify areas for improvement and make more informed decisions in the future.

Who are the authors of the Reflective Model?

Originally developed by Terry Borton for teachers and educational settings, it gained popularity as a reflective tool in clinical healthcare settings in the 1980s. Its enduring appeal lies in its simplicity and efficacy.

Rolfe et al.’s reflective model, based on Borton’s “What? So What? Now What?” model, is a framework tailored for healthcare practitioners, particularly in nursing.

While sharing the same three-stage structure, Rolfe et al.’s adaptation emphasizes clinical practice, focusing on developing clinical judgment, communication skills, and patient-centered care.

This model is often integrated into nursing education to help students connect theory and practice.

Stage 1. What? – Describing the Experience

The “What?” stage focuses on objectively describing the experience or event. This involves detailing the facts without interpretation or judgment.

The “What” stage establishes a clear, factual account of the experience, laying the foundation for deeper analysis in the subsequent stages.

It encourages individuals or groups to slow down, step back, and articulate the concrete details of what transpired, without immediately jumping to interpretations, judgments, or emotional responses.

It’s crucial to be as comprehensive and objective as possible during this stage to ensure a solid basis for reflection.

Here’s a breakdown of the key aspects of the “What?” stage:

• Focus on Facts: The emphasis is on providing a neutral and impartial account of the event, sticking to observable and verifiable information.
• Sensory recall: Participants are encouraged to replay the event in their mind as if watching it on a movie screen, focusing on what they saw, heard, or felt.
• Objectivity Over Subjectivity: While personal experiences are acknowledged, the goal is to describe them in a way that minimizes personal biases and interpretations.
• Inclusivity: If reflecting as a group, it’s important to hear from different perspectives, as people may have noticed different things
• Setting the Stage for Deeper Analysis: The “What?” stage provides the necessary context and factual basis for the subsequent “So What?” and “Now What?” stages, which explore the meaning and implications of the experience.

Examples of questions that can guide the “What?” stage, prompting individuals to consider specific details, actions, and observations related to the experience:

• What happened? – This encourages a concise and chronological account of the events.
• What did you observe? – This prompts focus on sensory details and specific observations.
• What was your experience? – This invites reflection on personal involvement in the event.
• What worked well, and what didn’t? – This prompts an initial, surface-level assessment of successes and challenges.
• Who else was involved? – This encourages consideration of the social context and the roles of others.
• What did you do? – This focuses on specific actions taken during the experience.

By thoroughly addressing these “What?” questions and establishing a clear, factual understanding of the experience, individuals and groups can lay a strong foundation for meaningful analysis and the identification of valuable insights in the later stages of the reflection model.

Example of a “What?” Stage Reflection

Let’s imagine a scenario where a first-year nursing student is reflecting on their first experience assisting a registered nurse in providing wound care to a patient. Here’s how the student might approach the “What?” stage of reflection, focusing on objective description:

• What happened? I assisted a registered nurse in providing wound care to an elderly patient with a diabetic ulcer on their foot. We gathered the necessary supplies, including sterile gloves, saline solution, gauze, and bandages. The nurse explained each step of the procedure to me and allowed me to observe before I helped. I assisted in holding the patient’s leg steady while the nurse cleaned the wound and applied a new dressing.
• What did you observe? The wound was about two inches in diameter and had a yellowish discharge. The patient appeared to be in some discomfort, grimacing slightly when the wound was being cleaned. The nurse was very gentle and patient with the patient, explaining each step clearly and providing reassurance.
• What was your experience? I was initially nervous about participating in wound care, as I had never done anything like it before. However, the nurse made me feel more at ease by explaining the procedure thoroughly and allowing me to observe first. I was surprised by how much care and attention to detail was required.
• What worked well? The nurse’s calm and reassuring demeanor helped to put the patient at ease. I felt that my assistance in holding the patient’s leg steady was helpful in allowing the nurse to focus on the wound care.
• What didn’t work well? I felt a bit awkward and unsure of myself at times, as I was still unfamiliar with the procedure and the supplies. I think I could have benefited from reviewing the steps involved in wound care beforehand.
• Who else was involved? The registered nurse, the patient, and myself were directly involved in the wound care procedure.
• What did you do? I helped gather supplies, observed the nurse, held the patient’s leg steady, and assisted in disposing of the used materials.

This detailed, objective account of the experience provides the foundation for the student to move on to the “So What?” stage, where they can begin to analyze their feelings, reactions, and the significance of the experience.

Stage 2. So What? – Analyzing and Sense-Making

The “So What?” stage delves into analysis and sense-making. This stage encourages you to examine your feelings, thoughts, and interpretations of the experience.

The goal is to uncover insights and identify what difference the event made. This stage is where analysis, critical thinking, and sense-making take center stage.

Here’s a breakdown of what the “So What?” stage entails:

• Connecting the Dots: It involves identifying patterns, relationships, and potential causes and effects related to the experience described in the “What?” stage. Relate the experience to relevant theories, course concepts, or broader ideas
• Exploring Emotions and Reactions: It encourages individuals to examine their feelings, thoughts, and initial interpretations of the experience. Why did they react in a certain way? What assumptions or prior experiences might have influenced their perceptions?
• Evaluating impact: Assess the consequences of the event for yourself and others.
• Identifying Learning Points: The goal is to uncover insights, lessons learned, and areas for potential growth based on the experience.
• Generating Hypotheses: It can involve developing initial explanations or interpretations of why things happened the way they did, which can later be explored further.

Some guiding questions for this stage include:

• Personal Significance:
  • What was important about this situation?
  • How did you feel when it happened?
  • Did anything in particular trigger these emotions in you?
  • What might have been behind your response?
  • Did you learn a new skill or clarify an interest?
  • Are there any implications for you personally or professionally?
• Significance for Others:
  • Who might you have forgotten to consider in that encounter?
  • What might impact the recipient’s views or experience of the project?
• Broader Contextualization:
  • What caused this event?
  • Why might have other people acted the way they did?
  • Was this event part of a broader pattern?
  • How does this experience connect to course concepts?
  • What other insights or hypotheses could be drawn from the experience?
• Evaluating Effectiveness:
  • What is the importance of this?
  • So what more do I need to know about this?
  • What are some of the most pressing needs/issues in the community? How does this project address those needs?
  • What contributes to the success of projects like this? What hinders success?

By thoughtfully engaging with these “So What?” questions, individuals and groups can extract valuable lessons from their experiences, gain self-awareness, and prepare for more informed and effective actions in the “Now What?” stage.

Asking “So What?” questions can also challenge your existing mental models and promote Double Loop Learning.

The “So What?” stage is crucial for moving beyond simple description to critical analysis. It helps you extract meaning from the experience and understand its broader significance.

This deeper understanding then forms the basis for the final “Now What?” stage, where you consider future actions and applications of your insights.

Example of a “So What?” Stage Reflection

Building on the “What?” stage example of a first-year nursing student assisting with wound care, let’s explore how they might approach the “So What?” stage:

• How did you feel when it happened? I initially felt nervous and inadequate because I lacked experience. However, observing the nurse’s expertise and seeing the impact of our actions on the patient’s well-being instilled a sense of purpose and motivated me to learn more.
• What might have been behind your response? My nervousness likely stemmed from a lack of confidence and fear of making a mistake that could negatively impact the patient. Witnessing the nurse’s composure and expertise reassured me and highlighted the importance of experience in building confidence.
• Did you learn a new skill or clarify an interest? I gained practical experience in wound care, which I had only read about in textbooks. This experience also reinforced my interest in pursuing a career where I can make a tangible difference in patients’ lives.
• Who might you have forgotten to consider in that encounter? I was primarily focused on assisting the nurse and the patient. However, reflecting on the experience, I realize that I could have also considered the patient’s family members or caregivers, who might also be affected by the patient’s condition and the care being provided.
• Was this event part of a broader pattern? This experience highlighted the importance of hands-on experience in nursing education. It also illustrated the value of clear communication and a supportive learning environment in developing clinical skills and confidence.
• What is the importance of this? This experience demonstrated that nursing practice requires not only technical skills but also empathy, communication, and the ability to establish trust with patients. It also highlighted the importance of lifelong learning and continuous professional development in providing competent and compassionate care.

This analysis demonstrates how the “So What?” stage encourages the nursing student to examine their emotional responses, identify knowledge gaps, and relate their experience to broader themes in nursing practice.

This sets the stage for the “Now What?” stage, where they can develop action steps for improvement and future learning.

Stage 3. Now What? – Determining Next Steps

“Now What?” focuses on applying your analysis to determine effective next steps. This involves identifying what you can take away from the experience and how you can use those insights in the future.

It focuses on translating insights and learning from the “What?” and “So What?” stages into concrete plans and actions.

This stage also promotes continuous learning and growth by encouraging individuals to:

• Applying Lessons Learned: It encourages individuals to consider how they can use their newfound understanding to make changes in their thinking, behavior, or approach to similar situations. Consider how to share insights or lessons learned with others.
• Identify Knowledge gaps: Recognize areas where further learning or skill development is needed.
• Developing Actionable Strategies: The goal is to create specific, measurable, achievable, relevant, and time-bound (SMART) goals and plans to address the identified learning needs or areas for improvement.
• Experimentation and Testing: It might involve designing small experiments or tests to try out new approaches or validate hypotheses that emerged during the reflection process.
• Continual Improvement: The “Now What?” stage emphasizes that reflection and learning are ongoing processes, and it encourages a cycle of planning, action, observation, and further reflection.

Some guiding questions for this stage include:

• Addressing Challenges:
  • What would you do differently if a similar situation arose?
  • What follow-up is needed to address any challenges or difficulties?
  • How might you prevent negative outcomes or problems in a similar situation?
• Knowledge and Skill Development:
  • What do you need to gain more competence [in], and how will you make this happen?
  • What specific steps you need to take to address this identified deficiency?
• Future Application of Learning:
  • What lessons can you take forward in similar and other contexts?
  • How might you better prepare and resource yourself for a similar situation?
• Continued Engagement and Impact:
  • What information can you share with your peers or community volunteers?
  • If you were in charge of the project, what would you do to improve it?
• Long-Term Professional Growth:
  • How will it affect your future as a pharmacist/midwife, etc.?
  • This process requires reflection on practice, assessing and identifying learning needs and available opportunities, developing and implementing a personal learning plan, and evaluating the outcomes.

By thoroughly exploring these “Now What?” questions and formulating actionable steps, individuals and groups can transform reflection into meaningful change and continuous growth.

They can then apply these insights to similar experiences in the future, ultimately leading to improved decision-making, skill development, and personal and professional effectiveness.

Example of a “Now What?” Stage Reflection

Scenario: A nursing student encounters resistance from a patient while attempting to administer medication. The patient, anxious and in pain, refuses the medication, stating it doesn’t work. The student, feeling flustered, seeks assistance from a senior nurse who skillfully calms the patient and successfully administers the medication.

• Identify Knowledge and Skill Gaps: The student acknowledges that their initial approach lacked the empathy and communication skills needed to effectively de-escalate the situation. They recognize the senior nurse’s expertise in building rapport, active listening, and clear explanation, leading to a positive outcome.
• Develop a Plan for Improvement: The student commits to improving their communication skills by:
  • Seeking further training: Enrolling in workshops or courses on therapeutic communication or conflict resolution techniques.
  • Shadowing experienced nurses: Observing how they interact with resistant or anxious patients, paying close attention to their verbal and non-verbal communication strategies.
  • Role-playing scenarios: Practicing communication techniques with peers or instructors in a safe environment, seeking feedback to refine their approach.
  • Reviewing relevant literature: Consulting nursing textbooks or journals for evidence-based strategies for managing challenging patient interactions.
• Apply Learning to Future Encounters: The student recognizes the importance of:
  • Anticipating potential challenges: Proactively considering potential barriers to care, particularly with patients exhibiting anxiety or pain.
  • Employing active listening: Focusing on understanding the patient’s perspective, validating their concerns, and addressing their fears before proceeding with medication administration.
  • Explaining procedures clearly: Using clear, concise language to explain the medication’s purpose, potential side effects, and expected benefits.
  • Seeking support when needed: Recognizing that it’s okay to ask for assistance from colleagues, particularly in challenging situations.

By working through the “Now What?” stage, the nursing student transitions from simply reflecting on the experience to actively shaping their future practice.

This stage highlights the importance of continuous learning, self-improvement, and a commitment to providing compassionate, patient-centered care.

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Comparing Rolfe et al.’s Reflective Model and Gibbs’ Reflective Cycle

While both Rolfe et al.’s model, adapted from Borton’s “What? So What? Now What?” framework, and Gibbs’ Reflective Cycle are popular reflective models, they differ in their structure and emphasis.

Understanding these differences can help you choose the most appropriate model for your reflective needs.

Structural Differences:

• Linear vs. Cyclical: Gibbs’ Reflective Cycle follows a more structured, cyclical format, guiding the reflector through six distinct stages: Description, Feelings, Evaluation, Analysis, Conclusion, and Action Plan. This cyclical structure emphasizes the iterative nature of reflection, encouraging repeated cycles of reflection and action. In contrast, Rolfe et al.’s model, while inherently encouraging ongoing reflection, presents a more linear, three-stage process.
• Number of Stages: The six stages of Gibbs’ Cycle allow for a more comprehensive and in-depth exploration of the experience. Each stage prompts the reflector to consider different facets of the situation, fostering a holistic understanding. Rolfe et al.’s three-stage model, while concise, might not provide the same level of detailed guidance.

Emphasis and Focus:

• Emotional Exploration: Gibbs’ Cycle explicitly includes a stage dedicated to exploring “Feelings.” This encourages individuals to acknowledge and process their emotions related to the experience, which can be crucial for personal growth and self-awareness, particularly in emotionally charged professions like healthcare. Rolfe et al.’s model, while not explicitly excluding emotions, places less direct emphasis on their exploration.
• Evaluation and Learning: Gibbs’ Cycle incorporates dedicated stages for “Evaluation” and “Conclusion,” promoting critical analysis of the experience’s successes, challenges, and potential areas for improvement. This structured approach can lead to more concrete learning points and action plans. While Rolfe et al.’s model encourages analysis and action planning, it doesn’t delineate these steps as distinct stages.

Application in Nursing and Healthcare:

• Rolfe et al.’s Model in Nursing Education: Rolfe et al.’s model is frequently integrated into nursing curricula. Its emphasis on connecting theory and practice, developing clinical judgment, and fostering patient-centered care aligns well with the goals of nursing education.
• Gibbs’ Cycle in Healthcare Practice: Gibbs’ Reflective Cycle, with its focus on detailed description, emotional processing, and structured analysis, can be particularly beneficial for healthcare practitioners reflecting on complex or challenging clinical encounters.

Choosing the Right Model:

The choice between these models depends on the specific context and the reflector’s goals.

• Gibbs’ Cycle, with its comprehensive structure, might be more suitable for:
  • Reflecting on complex experiences.
  • Individuals seeking a deeper understanding of their emotional responses.
  • Situations requiring detailed analysis and evaluation.
• Rolfe et al.’s model, with its concise and action-oriented approach, might be more appropriate for:
  • Quick reflections on everyday experiences.
  • Individuals seeking a straightforward framework to guide their learning.
  • Promoting rapid integration of theory and practice, as often seen in nursing education.

Ultimately, the most effective reflective model is the one that best suits the individual’s learning style and the specific demands of the situation.

Sources

Borton, T. (1970). Reach touch and teach: Student concerns and process education. New
York, NY: McGraw-Hill.

Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Further Education Unit.

Rolfe, G. (2014). Big ideas: Reach touch and teach: Terry Borton. Nurse Education Today,
34(488-489).

Rolfe, G., Freshwater, D., & Jasper, M. (2001). Critical Reflection for Nursing and the Helping
Professions: A user’s guide. London: Palgrave Macmillan.

Rolfe, G., & Jasper, M. (1993). Some strategies for curriculum development in nurse education. Journal of further and higher education, 17(3), 105-111.