reflective practice in nursing: issues and implications for nurse education

Reflective practice in nursing: issues and implications for nurse education

Chris R James and Brenda A Clarke

I Reflective practice is a frequently used but inadequately defined concept in nursing. Part of the reason for this may be the inadequate conceptualisation of the process of reflection. This paper argues that now is an appropriate time to critically examine the notion of reflective practice and maintains that there is a need for more debate and research into the nature of reflection in nursing. This paper reviews recent nursing ideologies and explores the concept of reflective practice in relation to different forms of practical knowledge. It discusses and critically analyses the attraction of reflective practice to different interest groups and concludes by examining the implication of reflective practice models of nursing for nurse educators.

INTRODUCTION

The term reflection used in connection with nursing practice is becoming increasingly promi- nent in nursing and nurse education. Keflective practice figures in the literature on nursing (Saylor 1990, Burnard 1991, Birchenall 1991, Temple 199 1, Meerabeau 1992, Brook & Cham- pion 1992) and in educational and developmental materials (Welsh National Board 1990, English National Board 1991). Promoted enthu-

Chris R. James BSc PhD PGCE CBiol MlBiol Lecturer in Education, Universio/ of Bath, School of Education, University of Bath, Claverton Down, Bath, Avon BA2 7AY. UK, Brenda A. Clarke MN RGN PGCEA Dip N Education Manager (Adult Branch), Bath and Swindon College of Health Studies, Education Centre, Royal United Hospital, Combe Park, Bath, Avon BAl 3NG, UK (Requests for offprints to BC) Manuscript accepted 9 July 1993

82

siastically by practitioners and educators alike, it appears to offer a partial if not total answer to a number of questions and dilemmas in nursing. Is nursing an art or a science? What is the relationship between nursing theory and practice? How do nurses develop professionally?

The emphasis currently placed on reflective practice would suggest that it was fully understood as a concept and that the pre-requisite skills and qualities were known. The central thesis of this paper is that neither of these tenets is true. The conceptualisation of reflective practice in nursing remains problematic and, while that is the case, the skills required for reflective practice remain unclear. This latter point in particular has important implications for nurse education.

RECENT THEMES IN NURSING PRACTICE

Ideologies in nursing have greatly influenced

NUKSE I;I)lK:A-IIOK ‘fOD41 83

nursing practices and changes in ideologies have character (Davis 1966), and was often under-

therefore resulted in changes in practice. taken by those who were not qualified nurses.

However, often such changes are subtle and Gradually, however more and more nurses

poorly evaluated. Few, if any, would deny that began to undertake research studies themselves,

nursing practices have improved over recent primarily following the medical model which is

decades. Tracing changes in practice is however firmly rooted in the scientific method and scien-

somewhat difficult. Abel-Smith commenting on tific philosophy. The underpinning assumption

the scope of his study of nursing history of‘ empirics, ‘what is known is that which is

published in 1960 states: accessible through the senses - that which can be

No attempt is made to provide a history of seen, touched and so forth’ (Chinn & Jacobs

nursing techniques or of nursing as an activity 1987, p7) lead to a ‘knowledgeable doer’ but

or skill. (p9) arguably not a reflective practitioner.

In general, the more recent historical accounts

have also tended to exclude nursing practices.

Such omissions necessitate the scanning of old

textbooks. nursingjournals and the use of anec-

dotal accounts. On this basis three phases of

practice can be identified: habituated practice,

research-based practice and reflective practice.

HABITUATED PRACTICE

It would appear that practice in the 1940s and

1950s was both ritualistic and habituated with

little attention paid to rationale and precious

little encouragement given to nurses to question

or indeed reflect upon practice. During this

phase nursing was characterised by a set of

pre-ordained rituals and routines (Pearce 194 1).

Learning to be a nurse was a matter of learning

the rules and then practicing by them.

RESEARCH-BASED PRACTICE

In the 1940s research would not have been

considered relevant to nursing but by the 1950s

the need for research was beginning to be

recognised. The era of questioning nursing

practices, albeit questioning in a limited way,

dawned in the late 1960s and early 1970s.

Encouraged by the Committee on Nursing,

which in 1972 stated categorically that ‘nursing

must become a research-based profession’, nur-

ses began to accrue research-based knowledge.

The early research tended to be sociological in

REFLECTIVE PRACTICE

It could be argued that the era of nursing as

reflective practice began with the debate as to

whether nursing is an art or a science. Prac-

titioners of science-based professions are usually

seen as technical problem solvers. This model of.

technical rationality suggests that applied

research dictates all necessary procedures, but

this is not always true within nursing (Saylor

1990). Schon (1983) argued that a rational,

technical, problem solving description of what

professionals do is incomplete, and stressed the

importance of the artistry of professional action.

Keflective practice which he saw as an essential

component of professional action can therefore

be seen to be redressing the balance between the

science basis and artistry basis within nursing

(Saylor 1990). Schon goes further, bv arguing

that the ‘hard’ knowledge of science and the ‘soft

knowledge’ of’ artistry or intuition are both

essential components of professional action.

This holistic view of professional activities

diffuses the debate about whether nursing is a

science or an art. However, influential though

Schon’s work has been in promoting reflective

practice, it is in fact only part of a much wider

movement. In day-to-day practice, nurses make

innumerable judgements of quality for which

they cannot state adequate criteria, and thev

display skills for which they cannot state the rules

or rationale. Micheal Polanyi (1964) acknow-

ledging such situations within professions has

termed this tacit knowledge, the notion that

professionals know more than they are able to

84 NURSE EDUCATION TODAY

say. This movement has very important impli-

cations for the way professional activities such as nursing are conceptualised.

CONCEPTUALISING REFLECTIVE PRACTICE

What is reflection? How do we conceptualise reflective practice for the purpose of helping

qualified and student nurses to become reflective practitioners? Conceptualising reflective prac-

tice is problematic. It has many dimensions and

facets and describing it adequately and for all

contexts presents difficulties. One of the con- sequences of this is that descriptions of reflective

practice suffer from the apple pie effect. This is,

anything good and vaguely appropriate is included. So, for example, reflection apparently

includes mulling over recent events, thinking about what you are doing while you are doing it, trying to discover why things went wrong, con-

sidering what helped to make something go

really well and so on. Definitions are equally unhelpful in assisting in the conceptualisation of

reflection. For example, Dewey (1933) in one of

the earliest and most frequently quoted definitions saw reflection 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. (p9)

The problem with this and all other definitions

is that it leaves one with the task of deciding exactly what is meant in the nursing context by

‘active’, ‘persistent’, ‘careful’, ‘considerations’

and so on. Forming a conceptualisation of reflective

practice may be assisted by considering the processes and content of reflection. Schon

(1983) identified two aspects to the process: reflection-in-action and reflection-on-action. He saw reflection-in-action as ‘reflection on phe- nomena and on one’s spontaneous ways of thinking and acting, undertaken in the midst of action to guide further action’ (Schon 1988, ~22) while reflection-on-action is reflection after the event and reflection on the reHection-in-action.

It is these processes that elevate the actions of the refective practitioner above those of the techni-

cal expert. An example of reHection in action would be the consideration of the content and

style of a transaction with a patient during the

conversation. Reflection on action in that case

would be the reviewing of the conversation some time later and an analysis of the reasons for your action during it.

The content of reflection can be viewed as comprising various areas or domains each of

which serves particular cognitive interests. The concept of cognitive interest refers to the roots

and practical function of forms of knowledge and to their origin. Habermas (1974) distin-

guishes three cognitive interests in practical activities:

production and technical control;

communication and interpretive understanding;

emancipation and liberation.

Practical action can be understood in terms of

the cognitive interest of the science that pro- motes it. The empiric-analytic sciences e.g.

maths, physics etc. serve the cognitive interest of productive and technical control. They develop

knowledge which, for the purpose of practical action is technically exploitable. For example, if

such a theory in nursing can explain and predict

improvement in the well-being of the patient under controlled and controllable conditions then the theory can be used by nurses for the benefit of patients. This notion of the practical would be associated with ‘techniques’ of nursing,

and with ‘efticiency and effectiveness’ in nursing

practice. van Manen (1977) described reflection at this

level as technical. In this domain, reflection is concerned with enhancing the efficiency and effectiveness of technical aspects of practice. In the nursing context this could be a consideration of minimising the time it takes to administer drugs to patients in the ward and reviewing the ways of ensuring that this was carried out accu- rately. The limitations of explaining nursing practice on the basis of practical knowledge generated by the empirical-analytical sciences and reflecting on practice solely at the technical

level will be obvious to all practicing nurses.

The communication and interpretive under-

standing of practical action is served by the

cognitive interest of the phenomenological-her-

meneutic sciences such as descriptive social

science, history and literature. The task of these

sciences is the interpretation of ‘lifeworlds’, that

is the teasing-out of the meaning of texts, social

events or structures ofthe world in which we live.

The empirical-analytical sciences are not appro-

priate for this task. The practical significance of

knowledge formed by this cognitive interest lies

in its potential to provide for communication

and practical orientation to action. In the nurs-

ing context, this interpretive approach seeks to

enhance communication and shared interperso-

nal understanding of nursing practice. Nursing

practice analysed through a hermeneutic (inter-

pretive) approach attempts to illuminate the

assumptions, grounds, axioms, bases.

preferences, points of view and pre-conceptions

which underpin nursing practice. The experi-

ence of nursing shared among practitioners

becomes central. The important aspects of nurs-

ing become deliberation and decision-making,

and qualitative and aesthetic aspects of practice

become significant. Importantly, the evaluation

of nursing must reflect these orientations.

Reflection with this cognitive interest was

described by van Manen (1977) as reflection at

the practical level. Here consideration is given to

the appropriateness of the purposes and

objectives of action in the light of one’s experi-

ence, presuppositions, perceptions and under-

standing of the context. An example in nursing

would be an analysis of whether a particular

health education programme is appropriate for

the patient, or whether a particular rehabili-

tation strategy is adequately challenging.

‘I’he cognitive interest of emancipation and

liberation is served by critical reflection of the

social, political and economic constraints on

action. In the view of Habermas (1974) the

hermeneutic sciences are inadequate for dealing

with the systematic distortion of communication

which results from the historical structures of

everyday institutions. The basis for practical

action will always be influenced - or distorted -

by these reified powers such as the capitalist

system, institutionalised racism and sexism, the

communist system or the laws of the land. Put

simply this idea means that our interpretation of

the world is always shaped by our experience of

that world. For example people will tend to view

economic matters within the framework -- the

rules, routines and assumptions - of the econ-

omic systems, which they experience everyday.

In the UK that would be the capitalist syst.em, in

Kussia, until recently this would have been the

communist system. Another example would be

the way a woman might view her career pros-

pects when she looks at her own work orgams-

ation and sees no women in senior management

roles only in servicing roles. Habermas asserts

that only by a commitment to unlimited inquir\.

constant critique and a fundamental self-criti-

cism all of which are encapsulated in the critical

paradigm can the quality of human life be

described, understood and improved. He

further asserts that through this process individ-

ual autonomy will be achieved. It follows there-

fore that the practical as emancipatory action has

the potential to transform the life of the person

who takes-up this critical stance ihlezirow I98 1).

van Manen (1977) described reflection which

relates to this cognitive interest as moral and

ethical reflection. In this aspect of reflection the

values that fundamentally underpin practice,

and the value conHicts that arise from particular

nursing actions are considered in the context of’

the social, political and economic constraints on

action. An example of this in nursing would be a

critical analysis of the implications of a new and

imposed funding policy which adversely affects

the quality of patient care. This might result in

the nurse taking some form of direct action in

order to attempt to rectify this situation, This

moral-ethical aspect is an essential but often

neglected component of’ reflective practice.

To assist the conceptualisation of refection,

James (1992) added a fourth domain of’ reHec-

tion to the three described by van Manen ( I Yi7).

the personal. This also serves principally the

cognitive interest of emancipation and

liberation. An example of reflection in this

personal domain might be a consideration of

how honest the nurse is to herself anti her

colleagues in describing her feelings t’ollowing a


traumatic event, the influences upon her at that time and how she could have behaved differ-

ently. It could include a reflection on what prevents her learning in new situations and

importantly how she might overcome those

barriers and behave differently in the future. Nurses who are reflective practitioners and,

perhaps more importantly, genuinely critical of

their own practice would operate at all four

levels: the technical, the practical, the moral- ethical and the personal. It is only through

reflection in all domains that nurses will come to fully understand their own practice. What the

nature of the relationship between the domains is and whether the domains represent a hier-

archy are questions open to debate as is the

question of whether the domains represent a developmental sequence. The outcome of these

questions about reflection and many others have important implications for nurse educators. If

the conceptualisation of reflective practice is

problematic, educating reflectively practicing nurses is even more so. This point is discussed

later in this paper.

THE APPEAL OF REFLECTIVE PRACTICE

Reflective practice in nursing may appeal in

different ways to different groups for different reasons. The purpose of this section is to explore critically that appeal and some of the impli-

cations.

Reflection is an integral part of experiential learning and the development of practical knowledge

Many of the attractions of reflective practice are that reflection is grounded in a growing understanding of forms of practical knowledge (see above) and of experiential learning. Reflection is central in many theories of experiential learning (Kolb 1984) which is arguably the dominant form of learning in nursing. It is significant in the processes of learning in adults (Knowles

19’70,1975, Mezirow 198 1) and it is the subject of an influential body of literature (Schon 1983,

Benner 1984, Powell 1989). As such, at a fundamental level, models of reflective practice

have an appeal because they ground that practice in established theory which can offer prac-

titioners and practitioner educators frameworks

in which to operate. These theories do however

have important implications for the way nursing theory is viewed. Nursing can no longer be seen

(if it ever honestly could) as understandable

solely in technical-rational terms which lead to instrumental answers to practical questions. The relationship between theory and practice in

nursing cannot be understood solely in terms of

rules, principles, techniques and ‘know-how’

derived from empirical-analytical research. It

must now be considered from the interpretive

and critical standpoints in which, through the

process of reflection, the practitioner is central. In other settings, the term ‘living theory’ has

been used to describe the knowledge created in

this way by reflective practitioners (Whitehead 1989). In the nursing context, this means that

individual nurses would have their own individual theory of nursing which is continually updated, extended and modified by a variety of

processes including reflection. Such models have

important implications for nurse education. A further consideration is the question of whether

it is acceptable to demand that all nurses reflect

on their practice in all the domains of reflection and in relation to all cognitive interests. Is it right to ask all nurses, even those who are practically

competent and reflective at the practical level, to review critically their practice at the emancipa-

tory level?

Reflection will lead to better practice

Implicit in the status currently being given to reflective practice in nursing is an accepted view that reflection will lead to better practice and to greater competence, indeed such an argument is implicit in the previous section. There is, in fact, little or no a priori justification for this although in time research-evidence may show this assumption to be correct. It could be argued that

an ‘over-reflective orientation’ could lead to an interpret and synthesise. These are high level

inability to act quickly and appropriately when attributes but despite this fact reflective practice,

the occasion demanded. none the less, is seen as a way of improving

practice across the whole profession. Those who

Reflective practice is necessary for are advocating a reflective practice model of

effective nursing nursing could usefully consider the implications for the profession if the notion that everyone can

There is an implicit assumption in the justification for adopting a reflective practice model of

nursing that reflection is necessary for effective

nursing. Again there is no a priori justification for this and the case remains unproven, particularly with regard to reflection in the moral-

ethical domain.

Reflective practice will bring universal benefits

Even if we assume that reflection will produce benefits, it is likely that not all of them will be equally acceptable to everyone. Improvements in efficiency through reflection at the technical

level could be very attractive to those who are

accountable in a managerial sense for a nurse’s practice. However, outcomes of reflection at

other levels may not be so appealing for that

group. Keflection at the moral-ethical level

could result in nurses coming to understand more clearly through the development of self- knowledge in the emancipatory domain (Habe-

rmas 1974) the constraints and limitations placed upon their practice. These nurses could well begin to challenge those who they see as responsible (i.e. their managers) for exerting those constraints and limitations. A parallel issue

may arise in the relationship between the student nurse and her/his educator.

All nurses can be reflective practitioners

For some, reflection may appear attractive because it is a model of practice which all practitioners can adopt. Although nurses require particular skills and qualities to become reflective, the message appears to be that everyone can acquire them. The list of skills and

qualities could include, self-awareness, percep- tion, imagination and the ability to analyse,

become a reflective practitioner proves not to be

the case.

Reflective practice models enhance professional status

Keflection and reflective practice may be attrac-

tive because they are seen increasingly as a central characteristic of professional action. The

emphasis in attempts to define an occupation as a

profession has changed in recent years. It is broadened from concerns with the place and

role of professions in society to encompass the nature of professional action. As professional practice becomes synonymous with reflective

practice, see for example Schon (1983), the use of reflective practitioner models of action could

have value in enhancing the professional status

of nursing. The notion of reflection particularly

at the moral-ethical level leading to the gener- ation of emancipator-y knowledge is also consis-

tent with notions of autonomy which are often implicit - if not explicit - in explanations of the

nature of professional activity and claims for

professional status.

Reflective practice values each nurse’s professional knowledge

Implicit in the concept of reflective practice is the valuing of the individual practitioner’s own per-

sonal knowledge (see above). As such, reflective

practice models of nursing appear to value individual nursing practitioners and the contri- bution each practitioner has to offer. Reflective practice is apparently grounded in ‘high-level’ values such as democracy and equality and may pose a consequent attraction for many. A conse- quence of reflective practice is that nursing knowledge is not possessed by an elite group who have sole access to it. Each nurse holds her/his own theory of nursing. This could well have


implications for the way nursing theory is conceptualised and generated. It could also have implications for the resolution of problematic and contentious issues in nursing. Reflective practice could allow these issues to be side-step- ped. Good practice could be judged in terms of the quality of the analysis and decision-making processes rather than the best outcome. An over-emphasis on reflection could result in a failure to agree on ‘best practice’ and to assert it. In nurse education an inappropriate stress on reflection could result in a neglect of ‘content’ which ironically could result in decreased competence.

Through reflection, practice can be understood at a fundamental level

Reflection may appear attractive to its advocates because it offers development in the form of personal growth at a fundamental level. The knowledge gained by reflecting in the moral/ ethical and personal domains can result in a deeper understanding of practice. Reflection can lead to self-knowledge and emancipation as nurses come to understand the personal, social, economic and political context of their work. As alluded to earlier, it is questionable whether this has universal appeal to all nurses and whether therefore it should be made obligatory for all.

Reflective practice redirects the responsibility for professional development

One attraction for those with the responsibility of funding nurses’ professional development could be that reflective practice models of nursing change the responsibility for professional development from them to the individual nurse. As reflective practitioners, nurses can still develop their skills regardless of, for example, an inappropriate management structure, the inadequate provision of time for further education, or the lack of financial resources for professional development. One view of reflective practice is that it offers development which is cheap in institutional terms, and if nurses choose

not to develop through reflective practice it is their responsibility.

This section has reviewed critically some of the reasons why reflective practice has an appeal to its advocates. The following section examines some of the implications of reflective practice models of nursing for nurse education.

IMPLICATIONS OF REFLECTIVE PRACTICE MODELS OF NURSING FOR NURSE EDUCATORS

Nurse educators have been given a difficult task to perform educating the new reflective practitioner. Such a task is complicated by a backdrop of implied criticism that they have in the past not been producing nurses who have reflected on their actions. The complex nature of reflection makes such a criticism difficult to refute, yet if it is true, the implications for nursing could be far reaching.

This paper has attempted to demonstrate the problematic nature of reflective practice. These problems are multiplied for the nurse educator faced with the challenge of teaching students and practitioners the art of reflection. Implicit in any course which has reflection as a theme, must be a view that every student and practitioner can become a reflective nurse. At the present time there is no evidence to support or refute such an idea; however should this prove not to be the case it would have implications for both nurse students and educators in the future. If reflective practice has the acclaimed and important benefits for patient/client care, nurse students could be asked to leave a nursing course by virtue of their inability to reflect. Furthermore, it could be argued that all nurse teachers should be reflective practitioners themselves. By virtue of the nature of reflection it may be seen to be necessary to experience reflection and its multi- faceted complexity in order to be able to teach the skills of reflective practice and enable students to develop such skills.

How can students be taught to be reflective practitioners? What strategies do nurse educators have available to them in order to facilitate

such learning? With the advent of Project 2000 challenge to the way they view the practice of

courses colleges of nursing have undertaken to produce reflective practitioners. A number of teaching strategies are being employed in order to achieve this task, for example, reflective journals, and group sessions in which students are encouraged to reflect upon their nursing practice. Whilst all of these strategies may be commended as a means by which learning can take place, there is no evidence to suggest that these strategies develop and promote reflective skills amongst the students. The literature in nurse education journals frequently quotes Schon’s work in connection with reflective practice (Saylor 1990, Temple 199 1, Meerabeau 1992). However, Schon offers little practical

nursing and the process of becoming a nurse. This paper began by outlining recent ideolo-

gies in nursing practice before exploring the concept of reflection. The attractions of reflective practice were discussed as well as the possible implications for nurse educators in relation to developing reflective practitioners. In order that reflection within nursing can be better understood there is a need for more debate and research. Only by such means can the nature of reflection in nursing be truly understood and educational strategies evolve for the development and promotion of reflective skills.

guidance on teaching strategies for the development of reflection. Furthermore by its nature,

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