reflective practice and nursing

Reflective practice and nursing

Peter Jarvis

Keflective practice is a frequently used but in-frequently defined concept in nursing at the present time. Part of the reason for the lack of definition lies in the fact that there is no theory of practice. This paper lays the foundations for a theory of practice and paves the way for one useful way in which the relationship between theory and practice can be understood. It is suggested that thoughtful practice is often mistaken for reflective practice, but that the latter can only exist where practice is not taken for granted and so the outcome of practice is more learning from experience. The paper also maintains that for reflective practice to be practised within the profession it is necessary both to have the structures within which it can be encouraged and the theoretical foundation whereby efficient practice need not only be judged in terms of ‘value for money’.

Ever since the popularisation of Schon’s (1983) seminal book, reflective practice has been a

constant theme among some groups of pro-

fessionals, which is not surprising since they had

lost some confidence in themselves as a result of

the attacks on the professions in the 1970s by

such writers as Illich (1977). Yet reflection was no new idea when Schon wrote his book; Dewey (Wirth 1979) had emphasised it and Freire

(1972), Habermas (1972) and Mezirow (1981), for example, had all been writing about it before this work was published. Freire, for instance, discussed the relationship between reflection and action and argued that congruence between the two was a form of praxis and there are certain similarities here to Argyris’ and Schon’s (1974) espoused theory and theory in use: Habe- rmas had explored reflection in a variety of forms in his ‘Knowledge and Human Interests’ in

Peter Jarvis PhD University of Surrey, Dept of Educational Studies, Guildford GU2 5XH. UK (Requests for offprints to PJ) Manuscript accepted 20 November 1991

174

which he argued that self-reflection is a form of science, and here he combined critical sociology

with Freudian analyses: Mezirow was inHuenced by Habermas and he produced a typology of

refection with seven different levels. Yet it was

Schon’s book, focusing as it does on the profes-

sions and professional practice, which attracted a tremendous amount of attention - an important

study which has raised so many ideas about retlection as a result.

It might even be claimed that the idea of reflective praclice is a bandwagon, upon which

many professionals have jumped because it pro- vides a rationale for their practice. At the same time it has not really helped to solve the problem of the relationship between theory and practice, even though some had hoped that it would. For others, the ideas provide justification for their practice, as if it is something unique. Cervero (1988), for instance, claims that

. . to reflect-in-action, is the core of professional artistry. Professionals reflect in the midst of action without interruption; their

NURSE EI)L’(:A-I-ION TOD.i\’ 175

thinking shapes what they are doing whilst

they are doing it. The goal of‘ reflection-in-

action is to change indeterminate situations

into determinate ones, and the key to success-

fully completing this problem-setting activity

is to bring past experience to bear on current

action’ (p 44).

But consider this statement:

‘Kepetitive thinking and praxis can be seen as

disengagement in that our capabilities are thus

liberated so that they can be applied to the

solution of‘tasks which can only be tackled via

inventive praxis (or thinking)’ (Heller 1984, p

12’If).

In very dif’ferent language, Heller seems to be

communicating a very similar set of‘ sentiments

IO those of‘ Cervero - the idea is to reflect in

action in order to problem solve. Cervero may be

a little easier to understand - and he is writing

about the professions; Heller is certainly more

difficult, more technical - only she is writing

about everyday lif‘e!

The point is that both of‘ them are writing

about action, or pref’ormance, and they are

doing so from very different perspectives. That

they are writing about the same phenomenon -

action - is significant in itself‘. It does point to the

fact that, while there is not yet a theory of

prof’essional practice, there has been consider-

able research into action which might f’orm the

basis of’such a theory. Before one is formulated.

howe\,er, it is impossible to discuss in a meaning-

ful rnanner the relationship between theory and

practice, since neither term is clearly dehned.

The purpose of this paper, therefore, is

3-f’old: first ot’all to discuss a theory of’ practice.

then to ask what is reflective practice and, finally.

to ask whether reflective practice can exist in a

profession.

TOWARDS A THEORY OF PRACTICE

Perhaps the most significant thing about the two

quotations f’rom Cervero and Heller is that they

were both writing about action. Professional

practice is about action in a specihc type of

location, and everyday life is also about action

which can occur in any location. Therefore, in

order to understand professional practice it is

necessary to understand action-it is necessary to

have a theory of action in order to hate a theor\,

of professional practice. Indeed. Schutz (1972)

uses the idea of‘meaningful social action and this

might be considered to be an adequate descrip-

tion of professional practice. Mariv t+.riters havr

expounded theories of action (Rerger &

Luckmann 1967; Giddens 1979 inter alia; Gof’f-

man 1959: Merton 1968: Parsons 195 1; Schut/

1970, 1972) and it would he impossible to

explore them all here. However, SOII~C of‘ thr

ideas are taken here in order IO fornrulale A

theory of practice. Once it is accepted that it is

essential to have a theory of‘action. it mlust also be

recognised that it is also necessar) to understand

why actions do not occur in professional prac-

tice, and so it is necessary also to have a ttieor,k of

non-action. Unfortunately. fewer scholars have

explored non-action, but it is also ;I social

phenomenon wllich is as w,orthy of 4tudF ;IS is the

study of action.

Understanding action does not onI!, ret’er to

the type of‘ action or non-action which is

occuring; a number of‘ other factors enter the

equation including - the relationship betiveen

thought and action. the level of‘consciousness of

the actor, the social context within which the

action is perf’ormed. and also such phenomena

as the intended outcome of‘the action. and so tm.

Thus it ma)- be seen that to de\,isc a theory of

practice is a complicated process and that it is not

possible within this paper to work it out f‘ullv.

S&ice to note that the theoretical basis of this

has been de\,eloped more thoroughlv in ‘Prcrcr-

done.\ of L~rt~ir~~~‘ (Jarvis. in press) which starts

f’rom the theoretic,al perspectil,e of ‘Ad/t// Lrcrr~

2?lg 111 !/w SOCW/ Conl~/’ (Jar\ih 1937) and

develops this aspect much more full). However,

in the f’ollowing paragraphs this position is

outlined.

Berger and Luckmann (1967) claim that all

‘human action is subject to habitualisation’, that

is that when actions are repeated they become

more taken l’or granted. There in <III almost

176 NURSE EDUCATION TODAY

predetermined order through which the actors move as the following sequence suggests:

1.

2.

3.

4.

5.

creative/experimental actions (which are new and being worked out in practice),

repetitive acts (which are acts that are

thoughtfully repeated during the normal process of’ living),

presumption (where actors presume upon the situation and act almost unthinkingly),

ritualism (where actors merely go through the motions mindlessly) and,

alientation (where the mindless repetition

of actions becomes self-destructive).

Berger and Luckmann claim that all actors

habitualise their activity and in professional

practice there is a sense in which professionals do

repeat many of‘ their performances and so they may feel compelled to habitualise many of their

actions, so that these five forms of‘ action may become the first stage of a theory. In addition, there are at least three forms of non-action:

anemic, when actors do not know how to respond,

prohibited, when they are prevented from responding by other people or circum-

stances

non-response, when actors just do not respond for whatever reason.

Schutz (1970) seeks to relate action to the

thought processes. In the first instances many actions are planned so that actors have a picture

in their mind’s eye about what they want to do (Schutz 1970) and these, Heller (1984) suggests, are based upon probability, that is ‘acting with sufficient ground’. Now this is significant in professional practice because it still occurs even though the practitioner has considerable knowledge and experience. Indeed, there is always a probability f‘actor in planning but its level is diminished as a result of that knowledge and experience. Herein lies a relationship between theory and practice - it is a pragmatic relationship rather than a deterministic one - that is, that

theory may be learned in a classroom situation

and then it constitutes part of the biography that an actor brings to the planning stage of

thoughtful action. Here it is used by the actor in

planning professional perf’ormance, which takes

into consideration the situation within which the

action is performed, the known theory and other

contingencies, and the probability that the action

will achieve the desired results. Theory is valid, then, if’ it can be operationalised reasonably

successfully, but there should never be precise

congruence because action is always based on levels of‘ probability. Even if’ actors feel certain

that their actions will produce specific outcomes, there is always a possibility that this will not

occur. During action itself’there is also a fi)rm of ‘reflexive monitoring of‘ action’ (Giddens 1979),

that is that the actors are consciously aware of

what they are perfbrming and of what is happen- ing, and at the end of‘ an act there is a fbrm of

retrospection (Schutz 1970) which is a review of

what has gone before. However, the level of attention, or conscious-

ness, given to an action can vary from almost zero to a very high level of‘concentration. All of

these factors enter into any discussion about a theory of‘action and Table 1 outlines some ofthe

possibilities that there are for understanding different forms of‘ action.

It may be seen from Table 1 that any theory of

action is extremely complicated and that this is

but one stage towards constructing it. However, it is important to see that thus far in the theory the idea of‘reflection has not yet entered into the discussion. Professional practice is about meaningful conscious action in a specific field and seeking to learn from practice and so

improve it constantly, and so become experts. Experts are those who have acted f’requently within a specified field of practice and know that the level of‘ probability in their practice is recognised but restricted because of‘ their own knowledge and expertise. Even so, the dangers of habitualisation fbr experts may be greater than for many novices in the field, f’or the latter are still performing experimental and repetitive actions; they are still learning to become professional practitioners but, by contrast, the experts have done it all many times before.

KL’RSE EI)L’(:A-I‘ION l‘ODA1 177

Table 1 A theoretical analysis of conscious action

Category of action

Non-action Anemic Prohibited Non-response

Action Experimental Repetitive Presumptive Ritualistic Alienating

Level of consciousness

Planning

None Low-High None-High

High High-None None-Low None None

Monitoring Retrospecting

None High None None-High None None-High

High High High-Low High-None None-Low None None-Low None-High None-Low None-High

TOWARDS AN UNDERSTANDING OF REFLECTIVE PRACTICE

Professional practice - note the term pruclice -

does mean just that. It is an occupational field in

which actions are repeatedly practised! Exper-

tise is gained through successful practice.

Howe\ier, all actions are subject to habituali-

sation and run the danger of degenerating into

presumption, ritualism and, eventually. alie-

nation. This is certainly true when actions are

perfijrmed in isolation or even upon things - but

it should not occur when there is interaction

between people because people are unique and

inter-personal relationships should mean that

people interact in a unique and humanistic

manner, so that all actions should be carefully

planned and monitored-even though they have

been perf’ormed many times previously. The

danger, however. is when people become cases

they become almost dehumanised in the minds

of‘ the practitioner, and this occured most easily

when professionals were taught, as they used to

be, to be detached from their clients (patients) in

order to protect themselves psychologically and

emotionally, and to treat their clients as cases.

When people become objects then the danger of

actions moving f‘rom the carefully planned to the

taken-f’or-granted is enhanced but. by contrast,

wherl prof’essionals treat their patients as unique

human beings then the danger of the practice

becoming mindless decreases and the level of

consciousness required by practice remains

high.

The idea of’reflection has not vet entered into

this discussion and, perhaps, what many people

mean when they discuss the idea of reflective

practice has already been covered in this discuss-

ion: that is, actions are carefull) planned in

relation to the theory known to the professional

and consciouslv monitored, so that the outcomes

of the action will be beneficial to the patient. But

the question must be asked whether this is

sufficient? What happens when the actions

which are being monitored seem tt) be going

wrong, or when retrospection indicaes that the

action has not produced the anticipated out-

come? Perhaps, then, the theory described above

is no more than the basis upon which thoughtf‘ul

practice can be performed. Schucy. (1970) sug-

gests that:

‘Men [sic] stop and think onlv when the

sequence of’ doing is interrupted, and the

disjunction in the f’orm of‘ 3 problem forces

them to stop and rehearse alternative ways -

over, around or through - which their pat

experience in collision with this problem sug-

gest’ (p 13-3).

Keflection then, occurs when the monitoring

or the retrospecting indicates that the probabi-

lity factor had been greater than was anticipated.

The anticiapted outcome has not materialised.

The practitioners are f’orced to inquire why this

is so and a new potential learning situation has

arisen t‘rom which they can learn new knowledge

and new skills. Additionally, reflection can occur

as a result of’ practitioners analysing the expec-


ted outcomes of action to see whether they could

have been achieved more efficiently, although this is probably less likely to occur because it

always seem harder to ask why actions have been successful than to investigate why they have

failed to achieve their anticipated ends. Now it has been argued elsewhere fJarvis

1987) that all learning begins from the disjunc-

ture that occurs between people’s biography and

experience, so that the potential new learning situations are created wherever this disjuncture occurs. All learning in practice starts from this

point: paradoxically, reffective practice may

begin at the point where the taken for granted is questioned so that a potential learning situation

is generated. However, that problem need not

only be induced by the experience, by the tact that the anticipated outcome has not occurred, it

can be self-induced or other-induced. In other words, a colleague or a good manager can pose a question that leads a taken for granted situation

to be transformed into a problem and into another potential learning situation. Good man-

agers, then, do not need to supervise in an

oppressive manner, but they do need to be able to recognise when professional performance is

in danger of becoming presumptive or ritualistic

and then they need the ability to create a

situation where reflection can occur - but this calls for specific professional knowledge and

skills from management! In addition, the good reHective practitioners can also ask questions of

themselves and about the taken-fbr-granted in

and reflective knowledge stem f&m disjuncture, that is - from questioning why the outcome has

occurred. Table 2 shows the different types of

learning that may occur. KeHective knowledge is the process of learning

new knowledge from the experience, which is adding to the body of‘ theory, while reHective

skills is creative/experimental action. New skills, new ways ot’doing things are tried out as a result

of‘ reflecting upon why a performance has achieved the outcome it has. This means that the professional performances will consistently be

experimental and creative but this does not

necessarily mean that they will be innovative, because reflective learning can demonstrate the

validity of’ the procedure and the knowledge as

easily as it can show that there are new and better ways of doing things.

Reflective practice then is more than just thoughtful practice, it is the process of‘ turning thoughtful practice into a potential learning

situation and, significantly enough, it is the utilisation of’ good theory in practice in what

must always be a situation of probability - but the professional reflective practitioner is always trying to ensure that the outcome of’any action is

close to what is anticipated by the theory and the

previous experience combined.

REFLECTIVE PRACTICE IN THE PROFESSION

_ their practice which can lead to new learning.

This, then, is where reflective practice begins - The question might be posed as to whether a

where practitioners are problematising their profession, like nursing, can have reflective

practice and learning afresh about both the

knowledge and the skills and attitudes that their Table 2

practice demands. A typology of learning

In contrast, it may be seen that the bad Category of learning

manager seeks conformity of practice, expects Non-learning presumptive or even ritualistic actions and the procedures of practice may result in action being prevented. It is, therefore, necessary to examine a theory of learning in practice at this point. Naturally, this must be experiential - an

approach to learning that has become popular in recent years. However. Jarvis’s (1987) research into learning demonstrated how reflective skills

Type of learning

Presumption Non consideration Rejection

Non-reflective Pre-conscious learning Skills

Memorisation Reflective learning Contemplation

Reflective skills Experimental knowledge

Each of the reflective forms of learning can have two possible outcomes - conformity or change

K\‘URSE EDt~(:Al‘IO~ 'I-'ODAI 179

practice. Jarvis (1983) distinguished between the

structures of‘ the professions and the pro-

fessionals who practise within them. No profes-

sion can be said to have reflective practice,

whatever claims the profession may wish to make

to the contrary - that would be merely a form of

public relations - something to be believed only

af’ter considerable research! Prof’essionals, by

contrast, can practise reflectively. This does not

mean that they all will, only that the possibility

exists that they all might! By contrast, it might be

said of‘ a profession that it has the structures

within which it is possible to practise reflectively,

or even thoughtfully, or that there are pro-

cedures laid down that encourage reHective or

thoughtf’ul practice. This is rather dif’ferent

from claiming that nursing is a fbrm of‘reflective

practice - good nursing might well be - but not

all nurses are necessarily good nurses, nor are all

managers good managers, and so on.

What then is needed to have reHective prac-

tice? In the first instance, it could be claimed that

the ability to reflect is essential. In a major piece

of’ research in America, Carnevale and col-

leagues discovered that learning to learn was

identified as the first new basic skill required in

the workplace (Cheren 1990). Now, everybody

has the natural ability to learn but what they

rnight not have is the opportunity or the

encouragement to learn. Cheren suggests that,

while traditional educational jargon might be

discounted, the significant f’actors include help-

ing practitioners to read more purposef‘ully and

also helping them manage their own learning.

~I‘his is something that managers, if’ they are

aware. could do and it is also something that

nurse educators should also be doing (Jar+

1991). Indeed, if‘practitioners do not learn in the

situation of’ professional practice, those non-

learning situations might also lead to mere

ritualism in the professional performance, and

this might actually move into situations of non-

action. because the practitioners do not know

what to do in specific situations.

Naturally, to have thoughtf‘ul and reHective

practice takes time. Heidegger (1968) has a

wonderf’ul example in his book on /hinki~~~ t‘rom

which this discussion might commence:

‘A cabinetmaker’s apprentice. someone who is

learning to build cabinets and the like. will

serve as an example. His learning is not mere

practice, to gain facility in the use ol‘tools. Nor

does he merely gather knowledge about the

customary forms of‘the things he is to build. 1 f

he is to be a true cabinetmaker, he makes

himself’ answer and respond above all to the

different kinds of wood and to the shapes

slumbering within wood - to wood .:IS it enters

into man’s dwelling with all the hidden riches

of‘its nature. In fact, the relatedness to wood is

what maintains the whole craft. Without that

relatedness, the craf’t will nevrr bt’ anything

but empty busywork, an)’ occupation with it

will be determined exclusiveI\ b\, business

concerns. Every handicraf‘t, ail human

dealings are constantly in that tlanger

Whether or not a cabinetmaker’:, appren-

tice, while he is learning, will come to respond

to wood and wooden things, depends obvi-

ously on the presence of‘some teacher who can

make tfleapprenticecomprehend’(pp 14-1.5).

He goes on to explain why teaching is more

difficult than learning since il requires the

teacher- to create a situation in which the learner-

learns. so that it might be argued that. the

management of practice is a highly skilled

occupation. Two other things in this passage

seem most important about ref1ectii.e practice:

the first is that there must be time to perform the

craft and set’ the possibilities that lie v+ithin the

wood or else it will be merely ‘busvI\ork’ and the

second is that, il’ there is not time. it will be an

occupation determined exclusiveI\, bv business

concerns. Here then are elemerlts about the

structure ofthe occupation, not onI\ does it need

people trained to help others learn ir practice

but it requires the time to alloy, practitioners IO

do so or else it will mereh be likt% some other

business.

KeHective practice t.akes time, but todav’s prac-

tice often appears to be conducted in an ethos

which encourages both the perfi)rmanc-e of

‘correct’ procedures and ef’ficiencv. E.f‘ficiency

sometimes seems to be equated with trleating as

man! patients as possible within specified period


of time, rather than taking time to consider all the possibilities of‘ care. Both procedures and CONCLUSION

efficiency appear to demand a form of action which is closer to presumption or ritualistism

The purpose of this paper has been to address

than to experimental practice. The occupational two questions - what is reflective practice and

structures within which much nursing, and can it exist within a profession? Keflective prac-

teaching and other professions, are conducted tice is something more than thoughtful practice.

today seem to preclude the opportunity for It is that form of‘ practice which seeks to prob-

reflective practice. Nursing is, therefore, faced lematise many situations of professional per-

with a dilemma - it wants to encourage reflective formance so that they can become potential

practice, even to claim that it has it but, like some learning situations and so the practitioners can

other professions, the structures within which it continue to learn, grow and develop in and

is conducted seem to inhibit regular reflection in through their practice. Can this exist within a

practice. profession? What should exist are the structures

One might, therefore, ask how nursing can within which this reflective practice can occur

introduce the structures which encourage reflec- and is encouraged - trained and aware man-

tive practice. Two elements seem significant: agers and mentors, educators who understand

firstly, nursing needs its own theory of practice the relationship between theory and practice

and, secondly, it needs to train both mentors and and who can assist practitioners to learn in

managers to help students and qualified staff’ to practice, and the time and opportunity for

take the time to question and to reflect upon practitioners to think. If’ these are all in place,

their own practice. Clearly there are implications then reflective practice may become a frequent

here - economic, political and others, that lie 0ccurrence’

beyond the scope of‘ this paper, but they do need to be recognised since all aspects of practice have wider implications. It is not the purpose of this

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