Reflection: a flawed strategy for the nursing profession

Experiential Learning Program to Strengthen Self-Reflection and Critical Thinking in Freshmen Nursing Students during COVID-19: A Quasi-Experimental Study

This article focuses on the unique needs and concerns of nursing educators and nursing students in the face of the COVID-19 pandemic. During social distancing, interacting with other human beings has been restricted. This would undermine the experiential learning of nursing students. Hence, it is important to develop and evaluate an experiential learning program (ELP) for nursing education. A pre-test and post-test design were used. The study was conducted in a university in Central Taiwan. A total of 103 nursing students participated in the study from February to June 2019. The study intervention was the experiential learning program (ELP), including bodily experiences and nursing activities with babies, pregnant women, and the elderly. After the intervention, the students completed the self-reflection and insight scale (SRIS) and Taiwan Critical Thinking Disposition Inventory (TCTDI) as outcome measures. An independent t-test showed that there was a significant difference between pre-test and post-test in both SRIS and TCTDI (p < 0.01). The Pearson product-moment correlation analysis showed that SRIS and TCTDI were significantly positively correlated (p < 0.01). ELP has a significant impact on the self-reflection and critical thinking of first-year nursing students, which can be used as a reference for the education of nursing students. During these turbulent times, it is especially vital for faculties to provide experiential learning instead of the traditional teaching concept.

Different perceptions of narrative medicine between Western and Chinese medicine students

BACKGROUND

Western medicine is an evidence-based science, whereas Chinese medicine is more of a healing art. To date, there has been no research that has examined whether students of Western and Chinese medicine differentially engage in, or benefit from, educational activities for narrative medicine. This study fills a gap in current literature with the aim of evaluating and comparing Western and Chinese Medicine students' perceptions of narrative medicine as an approach to learning empathy and professionalism.

METHODS

An initial 10-item questionnaire with a 5-point Likert scale was developed to assess fifth-year Western medical (MS) and traditional Chinese medical (TCMS) students' perceptions of a 4-activity narrative medicine program during a 13-week internal medicine clerkship. Exploratory factor analysis was undertaken.

RESULTS

The response rate was 88.6% (412/465), including 270 (65.5%) MSs and 142 (34.5%) TCMSs, with a large reliability (Cronbach alpha = 0.934). Three factors were extracted from 9 items: personal attitude, self-development/reflection, and emotional benefit, more favorable in terms of enhancement of self-development/reflection. The perceptions of narrative medicine by scores between the two groups were significantly higher in TCMSs than MSs in all 9-item questionnaire and 3 extracted factors.

CONCLUSIONS

Given the different learning cultures of medical education in which these student groups engage, this suggests that undertaking a course in Chinese medicine might enhance one's acceptance to, and benefit from, a medical humanities course. Alternatively, Chinese medicine programmes might attract more humanities-focused students.

Addressing ethical concerns arising in nursing and midwifery students' reflective assignments

BACKGROUND

Written reflections on practice are frequently requirements of nursing curricula. They are widely accepted as necessary for improving critical thinking and problem-solving skills. Faculty, are expected to review reflections and provide feedback that helps professional development and facilitates good practice. It is less clear what the actions of nurse educators should be when ethical infractions are revealed in the narratives.

OBJECTIVES

We had two aims: 1) To combine insights from a literature review of empirical and theoretical research related to responding to ethical issues revealed in student reflections with our experiences reviewing the reflections of undergraduate nursing and midwifery students, and 2) to construct and analyze a hybrid case from these insights in order to develop guidelines for nurse educators.

RESEARCH DESIGN

A literature review was conducted using CINAHL, MEDLINE, PsycINFO, SocINDEX and ERIC databases and pertinent key words. A hybrid case was constructed of commonly encountered ethical issues using insights from the literature review and the authors' experiences. The case was analyzed by combining Beauchamp and Childress' principlist approach with Campbell and McCarthy's ethical decision-making tool (Table 1). Participants and Research Context: No human participants Findings: A gap in the literature exists related to addressing ethical issues revealed in student practice reflections. However, a combination of insights from the literature and the authors' experiences facilitated the development of a hybrid case. Subsequent case analysis facilitated the development of a series of guidelines that can be utilized to address a range of issues commonly emerging in the reflections of nursing students during practice experiences.

DISCUSSION

A number of recommendations and guidelines are provided to enable the safeguarding of students and staff and support them in practicing ethically.

CONCLUSION

Structured ethical analysis of a constructed hybrid reflection of commonly revealed ethical issues was useful in developing guidelines for educators.

Self-Evaluation and Occupational Therapy Fieldwork Educators: Do they Practise what they Preach?

In the current climate of lifelong learning and continuing professional development, the importance of self-evaluation is discussed. A cross-sectional survey was carried out to identify the strategies used by fieldwork educators to evaluate their own supervisory skills. It further examined the fieldwork educators' attitude towards, and understanding of, self-evaluation.

One hundred self-administered questionnaires were posted to a random sample of Glasgow Caledonian University fieldwork educators. A response rate of 74.5% was obtained. The respondents claimed to use a wide range of self-evaluation techniques, with the majority using between three and five strategies. While the respondents were found, overall, to view self-evaluation positively, only 55.2% of them appeared to understand this concept fully. Statistical analysis of association indicated that those respondents who understood self-evaluation were more likely to have a positive attitude towards it than those who did not fully understand this concept.

It is recommended that future fieldwork education update courses should focus on informing fieldwork educators about the concept of self-evaluation and reinforcing its benefits. Fieldwork educators should be encouraged to continue to use self-evaluation and be made aware of the advantages of using a variety of strategies.

Conclusion

The respondents in this study supported self-evaluation and used a range of strategies to evaluate their own abilities as fieldwork educators. While 44.8% of the respondents lacked a full understanding of self-evaluation, overall the respondents had a positive attitude towards it.

More research is needed to confirm and expand on the results of this study. It is recommended that this study be replicated with a larger sample from a cross-section of universities. The chi-square tests of association carried out found the expected frequencies to be quite low in some cases. Had the sample been larger, these tests could, perhaps, have been put to more use. Further studies should also concentrate on fieldwork educators' understanding of other concepts taught to and used by students on placement, and on the relationship between the visiting lecturer and the fieldwork educators.

Critical reflexivity: A politically and ethically engaged research method for nursing

Traditional interpretations of research tend to bifurcate research knowledge and practice knowledge, with knowledge derived from practice and direct interaction with patients being perceived as knowledge that is not formally admissible by the traditional scientific model. This paper proposes a research method that legitimises practice as a source of knowledge. Building upon the concepts of situational understanding and contingent knowledge, we advocate an integral research methodology, one which draws on the notion of the researcher-practitioner.

Beginning with an analysis of knowledge and power we explore the contribution of reflexivity to the development of a politically and ethically engaged research process in nursing. In discussing critical reflexivity as a research method, we will outline the focus of reflexive research and the role of the reflexive researcher.

Arguing against the superiority of theoretical research over practitioner research, we present a challenge to technical rationality, suggesting not only a new approach to research but also a new approach to practice.

Towards a nursing science of the unique

In this paper we attempt to counter the tendency for reflection and reflective practice to be marginalised by the growing dominance of evidence-based practice in nursing. We resist the assimilation of reflection into a hierarchy of evidence dominated by the findings from ‘hard science’, and argue instead for an alternative science of nursing based on the premise that nursing is a series of individual and unique encounters which cannot be described by a science of large numbers. The resulting ‘science of the unique’ is concerned with persons rather than people, with wet data from the clinical setting rather than dry data from the laboratory and clinical trial, and with the individual practice encounter as the site of reflexive research. In particular, we argue that the traditional concept of evidence from formal research is merely the starting point for the on-the-spot generation of reflective/reflexive evidence by nurses themselves as part of everyday practice.

Australian Nurse Practitioner Practice: Value Adding through Clinical Reflexivity

The role of the Australian Nurse Practitioner (NP) is in its infancy and at a crossroads where extensive research demonstrates effective quality care and yet the role remains underrecognised and underutilised. The translation of practice into “value” is critical for the sustainability of NP roles and requires the practitioner to adopt a systematic method of inquiry. Kim's (1999) “Critical Reflective Inquiry” (CRI) method was adapted by two Australian NPs who specialise in diabetes and chronic disease management. Kim highlights the intent of CRI as understanding the meaning of practice, delivering improvements to practice through self-reflection, and the critique of practice that can lead to practice changes and development of new models of care translated to “products” of value. Based on the thematically analysis of 3 years of CRI application, the authors formed 5 headings that represented the NP's practice as Specialised Care Access, Complications and Diagnostics Interventions, Pharmaceutical Treatment, Vulnerable Populations, and Leadership. The utility of CRI demonstrates how NP practice is integral to a continuous cycle of addressing health care services gaps, and the conversion of “products” into “value” and positions the NP to assimilate the role of the practitioner-researcher.

Using a critical reflection process to create an effective learning community in the workplace

Learning circles are an enabling process to critically examine and reflect on practices with the purpose of promoting individual and organizational growth and change. The authors adapted and developed a learning circle strategy to facilitate open discourse between registered nurses, clinical leaders, clinical facilitators and students, to critically reflect on practice experiences to promote a positive learning environment. This paper reports on an analysis of field notes taken during a critical reflection process used to create an effective learning community in the workplace. A total of 19 learning circles were conducted during in-service periods (that is, the time allocated for professional education between morning and afternoon shifts) over a 3 month period with 56 nurses, 33 students and 1 university-employed clinical supervisor. Participation rates ranged from 3 to 12 individuals per discussion. Ten themes emerged from content analysis of the clinical learning issues identified through the four-step model of critical reflection used in learning circle discussions. The four-step model of critical reflection allowed participants to reflect on clinical learning issues, and raise them in a safe environment that enabled topics to be challenged and explored in a shared and cooperative manner.

Reflective practice groups for nurses: a consultation liaison psychiatry nursing initiative: part 1--The model

In the present study, we outline the evolution of a process-focused reflective practice group (RPG) model for nurses working in clinical settings. The groups were initiated at Redcliffe and Caboolture hospitals by the consultation liaison psychiatry nurse and author. An associated article provides an evaluation of these RPG. The literature review identifies the key themes and theories on which the model is based, and the article outlines the process and practicalities of facilitating RPG in critical care, midwifery, and oncology specialties over a 3-year period. The model proposes that the effectiveness and sustainability of RPG arises from adequate preparation and engagement with prospective participants. Group rules, based on principles of confidentially, supportiveness, and diversity, were collaboratively developed for each group. Facilitation utilized a group-as-a-whole approach to manage process and stimulate reflection. While the purpose of RPG was a reflection on interpersonal aspects of nursing, contextual workplace issues were frequently raised in groups. Acknowledgement and containment of such issues were necessary to maintain clinical focus. The literature highlights facilitator credibility and style as crucial factors in the overall success of RPG, and it is proposed that reflective practice as a process-focused model for groups succeeds when nurse facilitators are trained in group process and receive concurrent supervision.

Reflective components in undergraduate mental health nursing curricula: some issues for consideration

After reflective practice took nursing by storm 20 years ago it is timely to re-examine its influence and implementation on undergraduate teaching. Elements of reflection in relation to learning, matters that affect students and teachers in the classroom and on clinical placements, are reiterated. Interpersonal ethical concerns and issues associated with students' emotional responses to the situations on which they reflect also are considered. We have identified a number of elements that must be considered from both the student's and educator's perspectives to ensure safe and appropriate reflection activities are used in mental health-specific or non-specific undergraduate nursing subjects.

Critical reflection to identify gaps between espoused theory and theory-in-use

Critical reflection (CR) is a process by which one may identify the assumptions governing one's actions, question them, and develop alternative behaviors. This article presents two cases that demonstrate the use of CR to raise social workers' awareness of gaps between what Schon and Argryis term social workers' "espoused theories" and the "theories-in-use" that actually guide social workers' practice and to help them to develop more effective models of practice based on the understanding they gain. With this, the cases also show that CR can be a painful, even wrenching, process, in which practitioners confront previously unacknowledged qualities or tendencies in themselves that can evoke strong feelings.

Future nurses' cultural competencies: what are their learning experiences during exchange and studies abroad? A systematic literature review

AIM

This article describes the development of cultural competence among nursing students. The focus is on illuminating the learning experiences of nursing students during their exchange.

BACKGROUND

As the world gets smaller, the demand for culturally competent nurses increases. Future nurses need to be open-minded towards international cooperation and willing to develop the quality of care from a cultural point of view. Nursing education in many countries provides an option for students to learn nursing in different cultures while taking part of their studies abroad.

METHODS

A systematic literature search was conducted. Inductive content analysis was applied to the data consisting of empirical studies (n=7) describing nursing students' studies abroad.

RESULTS

The process of developing cultural competence among nursing students on exchange was found to consist of three main themes, namely: (1) an increased cultural knowledge base, (2) personal growth and (3) the impact of exchange experiences on the nursing student's own practice.

CONCLUSIONS

Studies abroad are a beneficial strategy for the development of future nurses' cultural competence.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing is facing a crucial challenge to recruit culturally competent nurses, because an increasing number of patients are from different cultures. Nurses with experiences of studying abroad can offer employers a resource through their preparedness for culturally competent nursing.

Radiation therapists’ perspectives of the role of reflection in clinical practice

A recurring theme from the literature is that the definition of reflection is nebulous and/or complex. Many authors have suggested that more research needs to be conducted to better understand an individual’s perception of reflection and reflective practice, and how these concepts affect their clinical practice as well as their personal growth and development. This paper offers the findings of a qualitative study of radiation therapists in Canada. The aim of the study was to explore radiation therapist’s understanding of the concept of reflection, and to understand how they incorporated it into their daily practice. Secondary objectives were to examine some of the perceived barriers to its use, and the possible challenges of implementing reflective writing. Two focus groups were initially conducted, and a follow-up questionnaire was developed using the themes generated from the focus groups. The questionnaire was distributed to radiation therapists at two large cancer centres in Toronto, Canada. Most participants indicated that it is an integral part of their practice and professional lives, and that they use a variety of different methods for engaging in reflection. It is not without its barriers, but many of these can be overcome by providing time, coaching and a supportive work environment. Respondents were divided as to whether they would benefit from being taught reflection; however, small group teaching would be the favoured method. Further study is suggested to determine whether there are any improvements to patient care and in particular patient outcomes.

Raised emotions: A critique of the Peshkin Approach to Reflection

AIMS AND OBJECTIVES

We critique a new approach to reflection in nursing that uses thoughts and feelings as the focus of the reflective process.

BACKGROUND

We have developed the 'Peshkin Approach to Reflection'; so-called because it is influenced by the work of Peshkin and his focus on the 'subjective I'. Whereas most reflective models used in nursing take an incident as the starting point, this new approach focuses on subjective feelings and thoughts.

DISCUSSION

We offer an overview of the stages of the process: preparation; writing, analysis, and application to practice. Central to the paper is a critique of the approach with particular emphasis on the issues raised by focusing on emotions as part of the reflective process. We show that within the emotional labour of nursing, feelings may become repressed. Thus, we suggest that bringing emotions to the forefront of reflective practice in an appropriately supportive environment has significant benefits.

CONCLUSIONS

Emotions are inextricably bound with nursing practice. For that reason, we argue that much can be gained from raising emotions in a manner that helps nursing students - or indeed nurses and other practitioners - gain a deeper self-understanding. In turn, this can enhance therapeutic use of self.

Professional knowledge and the epistemology of reflective practice

Reflective practice is one of the most popular theories of professional knowledge in the last 20 years and has been widely adopted by nursing, health, and social care professions. The term was coined by Donald Schön in his influential books The Reflective Practitioner, and Educating the Reflective Practitioner, and has garnered the unprecedented attention of theorists and practitioners of professional education and practice. Reflective practice has been integrated into professional preparatory programmes, continuing education programmes, and by the regulatory bodies of a wide range of health and social care professions. Yet, despite its popularity and widespread adoption, a problem frequently raised in the literature concerns the lack of conceptual clarity surrounding the term reflective practice. This paper seeks to respond to this problem by offering an analysis of the epistemology of reflective practice as revealed through a critical examination of philosophical influences within the theory. The aim is to discern philosophical underpinnings of reflective practice in order to advance increasingly coherent interpretations, and to consider the implications for conceptions of professional knowledge in professional life. The paper briefly examines major philosophical underpinnings in reflective practice to explicate central themes that inform the epistemological assumptions of the theory. The study draws on the work of Donald Schön, and on texts from four philosophers: John Dewey, Nelson Goodman, Michael Polanyi, and Gilbert Ryle. Five central epistemological themes in reflective practice are illuminated: (1) a broad critique of technical rationality; (2) professional practice knowledge as artistry; (3) constructivist assumptions in the theory; (4) the significance of tacit knowledge for professional practice knowledge; and (5) overcoming mind body dualism to recognize the knowledge revealed in intelligent action. The paper reveals that the theory of reflective practice is concerned with deep epistemological questions of significance to conceptions of knowledge in health and social care professions.

Redressing the balance in mental health nursing education: arguments for a values-based approach

Evidence-based practice (EBP) has become a dominant epistemology in nursing education, and has devalued the complex interpersonal components of mental health nursing. A curriculum for mental health nursing, which values the personhood of service users, should focus on those processes that promote recovery within a therapeutic relationship committed to collaboration and respect for diversity. These relationships become possible where the preparation of mental health nurses for practice includes an examination of self in terms of beliefs and values and their consequences on others. The combination of action and reflection in praxis provides a means by which self-examination and professional obligation can be examined in order to construct a moral identity, which is responsive to the needs of people with mental health problems. Praxis is more than a means of reflecting on practice: it draws together skill, practice knowledge, attitudinal style, and moral reasoning. For this reason, ethical values have a vital role to play in the development of contemporary nursing praxis.

The emotional labour of nursing -- Defining and managing emotions in nursing work

Emotions in health organisations tend to remain tacit and in need of clarification. Often, emotions are made invisible in nursing and reduced to part and parcel of 'women's work' in the domestic sphere. Smith (1992) applied the notion of emotional labour to the study of student nursing, concluding that further research was required. This means investigating what is often seen as a tacit and uncodified skill. A follow-up qualitative study was conducted over a period of twelve months to re-examine the role of the emotional labour of nursing. Data were collected primarily from 16 in-depth and semi-structured interviews with nurses. Key themes elicited at interviews touch upon diverse topics in the emotional labour of nursing. In particular, this article will address nurse definitions of emotional labour; the routine aspects of emotional labour in nursing; traditional and modern images of nursing; and gender and professional barriers that involve emotional labour in health work. This is important in improving nurse training and best practice; investigating clinical settings of nurses' emotional labour; looking at changing techniques of patient consultation; and beginning to explore the potential therapeutic value of emotional labour.

Focus group study of student physiotherapists' perceptions of reflection

CONTEXT

The reflective practice module in the physiotherapy programme at the University of Limerick, Ireland represents the first incidence of the inclusion of such a module within physiotherapy curricula in Ireland. However, research examining the contribution of reflection as a means of learning is limited, particularly from the student perspective.

OBJECTIVES

This study sought to explore students' perceptions of reflection and its potential contribution to their development before and after the module.

METHODS

A qualitative research methodology using focus groups was employed to evaluate physiotherapy undergraduate students' perceptions of the module. Three focus groups were held in total. Two were held with Year 3 students, before and after their reflective practice module, respectively, to examine any changes in their perceptions of reflection. A third was held with Year 4 students to determine their perceptions after both the module and subsequent clinical placements. Sessions were audiotaped, transcribed and subjected to in-depth thematic analysis to resolve the significant themes that emerged from the data.

RESULTS

Students reported a more advanced level of reflective ability post-module completion. They perceived personal and professional benefits to practising reflection and recognised these skills as strategies with which they could continue to facilitate their professional development. For students, time constraints in the clinical setting represented a barrier to reflection.

CONCLUSIONS

Students support inclusion of the module in their training, acknowledging its role in improving their confidence and clinical reasoning, and facilitating continuing professional development. Further studies are required to generalise these findings to a wider population.

The evaluation of an approach to reflective learning in the undergraduate dental curriculum

Students in higher education are being encouraged to become active, independent and life-long learners. The use of progress files has been endorsed to encourage this approach. A portfolio intended to fulfil the role of a progress file and to promote student-centred learning and reflection was introduced as a central component of the revised undergraduate degree at the Glasgow Dental School in 2004. This article evaluates its role in promoting reflection. Students following the Bachelor of Dental Surgery (BDS) programme completed three written reflections per year using structured proformas, and discussed them with their mentor and mentoring group. Their views of the portfolio and of reflection were gathered using a five-point Likert scale. In BDS1 2004-5, 84% completed a questionnaire, as did 89% in BDS1 2005-6 and 99% in BDS2 2005-6. Most students did not enjoy reflecting (a finding commonly reported elsewhere) or feel that reflection identified their learning needs. It appears that students disliked writing reflections, rather than reflecting per se. In contrast, they took a positive view of mentor group discussions and of having a mentor, both essential components of the portfolio model described. Comparisons of BDS1 2004-5 and BDS2 2005-6 data suggest that students are becoming more comfortable with reflection. The data provide some limited encouragement that students are beginning to acquire the skills which will enable them to reflect purposefully in their professional lives, although it will be some years before this assertion can be substantiated.

Getting the measure of reflection: considering matters of definition and depth

Reflection, reflective learning, reflective writing and reflective practice are used increasingly in higher education and professional development–but we do not work to one definition and there are considerable differences in the views of educationists on issues of definition. Such discrepancies can exist between the staff working with the same student group. The situation can lead to difficulties in indicating to students how to reflect, and what reflective writing ‘should look like’. Once students do manage to represent their reflection broadly in the required manner (usually writing), there is frequently observed to be a further problem because their reflection is superficial and descriptive. A consequence is that their learning from the reflective process is restricted.

This paper addresses the issue of definition of reflection initially through clarifying the different words used around the notion of reflection (e.g., reflection, reflective learning, reflective writing) and providing some suggested definitions. It then addresses the matters both of how we should help students to start with reflection, and with the problem of the superficiality of much of their work. The ‘depth’ of reflection is a concept that has not been much discussed in the literature of reflection and yet it seems to be closely related to the quality of reflective work. The paper discusses the concept of depth and then introduces a style of exercise in which a scenario is reproduced at progressively deeper levels of reflection. The exercise is related to a generic framework for reflective writing. The rationale and justification for the exercise and the framework are discussed and suggestions are made for its manner of use. The exercise and the generic framework for reflective writing are in Appendices 1 and 2.

The use of reflection to enhance formal learning has become increasingly common in the past 7 years. From the principle beginnings of its use in the professional development of nurses and teachers, its use has spread through other professions. Now, in the form of personal development planning (PDP), there is an expectation that all students in higher education will be deliberately engaging in reflection in the next 2 years.1 In addition, there are examples of the use of reflective learning journals and other reflective techniques in most, if not all, disciplines.2

Reflection is not, however, a clearly defined and enacted concept. People hold different views of its nature, which only become revealed at stages such as assessment. For example, what is it that differentiates reflective writing from simple description? There are difficulties not only with the definition itself but also in conveying to learners what it is that we require them to do in reflection and in encouraging reflection that is deeper than description. In this paper, we consider some issues of definition and then focus on the means of encouraging learners to produce a reflective output of good-enough quality for the task at hand. The latter is presented as an exercise for staff and learners (Appendix 1) with a framework that underpins it (Appendix 2).

Implementing reflection: insights from pre-registration mental health students

Reflection and reflective practice continues to be contentious issues in nursing. The focus of this article is the use of reflection by pre-registration mental health students. The broad aim of this preliminary study was to discover student mental health nurses' perceptions of reflection as a learning strategy during clinical placement. Using a constructivist grounded theory methodology [Charmaz, K., 2000. Grounded theory: Objectivist and Constructivist Methods. In: Denzin, N., Lincoln, Y. (Eds.), Handbook of Qualitative Research, second ed. Sage, Thousand Oaks, California], five students were interviewed individually in their clinical placements. Data analysis revealed three major categories: understanding the process of reflection, using reflection in clinical practice, and needing support and guidance. Findings indicated that students were primarily using reflection-on-action, but to varying extents. Overall, students felt that reflection facilitated their learning. Factors were discovered that both helped and hindered students' use of reflection. These included level of preparation to reflect, a limited culture of reflection and the level of support from preceptors, clinical staff, clinical placement co-ordinators, and lecturers. In conclusion, it appears that a collaborative approach between students, Health Service Providers and institutes of nursing is vital for the successful development and implementation of reflective learning strategies in clinical placement. Suggestions are made as to how a collaborative approach may be developed to enhance this process.

Reflective practice in nursing care: Embedded assumptions in qualitative studies

Qualitative nursing researchers have long recognized that reflective practice (RP) seems to be a valuable tool in nursing care. The aim of the present meta-study was to analyse current qualitative research on RP in nursing care, in order to create and synthesize the knowledge and the understanding of registered nurses' RP. Using a meta-study synthesis approach, embedded assumptions were identified in qualitative studies that have influenced the way researchers have interpreted and made sense of RP in nursing care. Despite empirical focus in research on RP in nursing care, it was found that assumptions about RP were predominantly based on theory. The reflective movement within the practice of nursing care has mainly a constructivist epistemology, based on learning from experience. The individual nurse's RP capability is essential in providing and improving ethical and holistic nursing care.

Learning from practice--reflections on a critical incident

Reflective practice is considered not only as a valuable tool for providing appropriate levels of care but also as an important prerequisite for the provision of professional nursing. Indeed, there appears to be consensus in the literature that reflections have the potential to assist practitioners to tap into knowledge gained from experience and connect theory to practice. However, evidence suggests that nurses, including emergency nurses, neglect reflective techniques. This paper outlines how the processes of reflection led to one emergency nurse developing new insights and understandings on nursing practice.

Technical rationality in Schön's reflective practice: dichotomous or non-dualistic epistemological position

Donald Schön's theory of reflective practice has received unprecedented attention as an approach to professional development in nursing and other health and social care professions. This paper examines technical rationality in Schön's theory of reflective practice and argues that its critique is a broad and often overlooked epistemological underpinning in this work. This paper suggests that the popularity of Schön's theory is tied in part to his critique of technical rationality, and to his acknowledgement of the significance of practitioner experience and indeterminate zones of practice in the development of expertise. Schön tapped into a growing disillusionment with technical rationality that coincided with a crisis of knowledge across a range of disciplines. The question is raised as to whether Schön's critique sets up a dichotomy between technical rationality and experience, or overcomes it. The conclusions suggest that Schön is not discarding research-based professional knowledge, but rather challenging conflated views of its practical significance. In this way, it is proposed that his critique of technical rationality can be interpreted as an attempt to overcome dualistic thinking as it pertains to professional knowledge.

'Do not ask who I am...': confession, emancipation and (self)-management through reflection

AIM

This study explores and extends some recent Foucauldian critiques of reflection and clinical supervision in nursing.

BACKGROUND

Although reflection is often accepted uncritically, several writers have claimed that it is being employed (albeit perhaps unwittingly) as a management tool to facilitate the governmentality of the workforce by establishing conditions whereby so-called reflective practitioners monitor and regulate their own practice in an essentially self-repressive way.

EVALUATION/EXAMINATION

We evaluated these critiques and extended them with reference to Foucault's later writing, particularly on the 'care of self'.

KEY ISSUES AND CONCLUSIONS

Our exploration of these critiques prompted us to distinguish between two different projects of reflection, which we term the ontological and the epistemological. The ontological project regards the aim of reflection as personal growth under the direction of an enlightened guide, and we argue that there is a real danger that such an approach might degenerate into what one critic has termed 'a subtle but persuasive exercise of power'. The epistemological project, on the other hand, is concerned with an exploration by practitioners of their own methods of thinking about their practice, and as such, has the potential to become truly emancipatory.

Case reviews: promoting shared learning and collaborative practice

This article identifies the way a hospice team and their community colleagues are taking a different approach to the case review process, aimed at enhancing professional development and palliative care practices by fostering multiprofessional relationships. Case reviews or studies are a traditionally recognized teaching and learning strategy. This group takes a different view of the case review process and uses it as a proactive learning tool, valued by the participants. The audit of the process highlights how this forum assists in the development of mutual trust and respect among teams. The formal evaluation has shown evidence of improved communication and challenged thinking in relation to changing practice. The results of this experience could be considered in other areas where multiprofessional teamwork is essential.

Reflecting during clinical placement - Discovering factors that influence pre-registration psychiatric nursing students

As the debate surrounding reflection continues there are recommendations that Irish pre-registration nurses should use reflection as a strategy to facilitate the development of competencies. In one School of Psychiatric Nursing, diploma student psychiatric nurses were already using reflection as an aid to develop their competencies in the course of their clinical placements. The aim of this study was to explore student psychiatric nurses' perceptions of reflection as a learning strategy during clinical placement. Using a constructivist qualitative methodology third year students were interviewed individually in their clinical placements. Data analysis revealed three major categories: understanding the process of reflection, using reflection in clinical practice, and needing support and guidance. The latter category, which is explored in this paper, indicated that a number of factors influenced how students engaged in reflection during clinical placement. Findings also indicated that the mentor, the clinical placement co-ordinator and the lecturer have key roles. It is suggested that as students need more adequate preparation and ongoing support to reflect that a collaborative approach between health service providers and the learning institution, regarding the development of reflective strategies, is vital if reflection is to be an effective learning tool in clinical placements.

Relearning how to learn: enrolled nurse transition to degree at a New Zealand rural satellite campus

The demise of enrolled nurse (EN) training in New Zealand hastened the development of transition to registration/degree programmes for enrolled nurses. A North Island tertiary institution developed a flexible course to enabled ten enrolled nurses working in rural settings, the majority of whom were Māori, to continue working while studying at a small satellite campus. An exploratory, descriptive, qualitative research study utilizing focus group interviews was undertaken to examine the factors that assisted or hindered their transition. Two major categories emerged from comparative analysis of the data. One category entitled 'relearning how to learn', demonstrated the cognitive and behavioural adaptations made and is the focus of this paper. The other category 'barriers and catapults', demonstrated the physical and environmental factors that influenced the students' transition but is outside the scope of this paper. Recent changes in New Zealand nursing education have witnessed the clarification of scopes of nursing practice and the controversial development of a new Certificate in Health Science (Nurse Assistant). Currently enrolled nurses are again facing threats to employment and it is envisaged that many will be seeking to undertake transition to registered nurse in the near future.

The deconstructing angel: nursing, reflection and evidence-based practice

This paper explores Jacques Derrida's strategy of deconstruction as a way of understanding and critiquing nursing theory and practice. Deconstruction has its origins in philosophy, but I argue that it is useful and relevant as a way of challenging the dominant paradigm of any discipline, including nursing. Because deconstruction is notoriously difficult to define, I offer a number of examples of deconstruction in action. In particular, I focus on three critiques of reflective practice by the meta-narrative of evidence-based practice (EBP) and attempt to show how those critiques can be directed back at EBP itself. I conclude with the observation that EBP is open to many of the criticisms that it directs at other discourses, including problems of a lack of empirical evidence, of distortions due to memory, and of falsification of the 'facts'.

Remembrance of things past: the utilisation of context dependant and autobiographical recall as means of enhancing reflection on action in nursing

Reflection on action is widely accepted as a means of developing an individual's experience and professional and scientific knowledge [Accident and Emergency Nursing 4 (1996) 135]. Reflection can occur when a nursing event is examined and explored which may lead to the individual acquiring new perspectives and new knowledge regarding the event. This paper contends that the exploration of an event in practice can be better understood if viewed in the context of previous similar experiences. A five stage structured process is suggested whereby the nurse intentionally returns to former places and recreates previously experienced affective states with the purpose of accessing context and state dependent memories. These rediscovered remembrances can then serve as the raw material for reflection on nursing problems and dilemmas. A comparison of the current problem with the past experience may lead to new learning and a deepening of the reflective process. The seminal work of Marcel Proust is referred to in order to illustrate the process and examples from practice are also identified.

Reflection in preregistration nursing curricula

BACKGROUND

The concepts of reflection and reflective practice are increasingly popular themes in the nursing literature. Reflective practice has been advocated as a method for overcoming the divergence between nursing theory and practice, and as a means of articulating and developing knowledge embedded in practice. However, these claims are based more on theoretical debate than research evidence. In common with other regulatory bodies, the Irish regulatory nursing body advocates the need for reflective nurses, and curricula are being adapted to reflect this. These changes are taking place when there is still little guidance on the teaching or assessment of reflective practice. Given the lack of research on the topic and the need for evidence on which to base the teaching of reflective practice, a descriptive exploratory study was undertaken.

AIM

The aim of this paper is to report how a group of nurse teachers perceived and interpreted reflective practice in preregistration nursing curricula in schools of nursing in The Republic of Ireland.

METHODS

Data were collected using a postal questionnaire distributed to all schools of nursing involved in the preregistration diploma in nursing (n = 40).

RESULTS

The results indicate variation between institutions in the number of hours allocated to the subject and where reflective practice was included in the curriculum. Emphasis was placed on theoretical models of reflection as opposed to the process or the skills required to become a reflective practitioner. Lecture and group discussion were the dominant teaching methods. Additionally, a number of teachers expressed dissatisfaction with the preparation they had received to teach the subject, and identified some of the challenges they experience when teaching reflective practice.

CONCLUSIONS

The results provide a focus for further debate amongst nurse educators involved in implementing reflective practice in the curriculum. The results are limited by a response rate of 50% and by the geographic setting. Further research is needed to substantiate the findings of the study. However, there results do suggest that there is a need to clarify curricular content in relation to reflective practice and prepare nurse tutors for their role in teaching this subject more effectively.

Narrating practice: reflective accounts and the textual construction of reality

BACKGROUND

Two approaches dominate current thinking in health and welfare: evidence-based practice and reflective practice. Whilst there is debate about the merits of evidence-based practice, reflective practice is generally accepted with critical debate as an important educational tool. Where critique does exist it tends to adopt a Foucauldian approach, focusing on the surveillance and self-regulatory aspects of reflective practice.

AIM

This article acknowledges the critical purchase on the concept of reflective practice offered by Foucauldian approaches but argues that microsociological and discourse analytic approaches can further illuminate the subject and thus serve as a complement to them.

METHODS

The claims of proponents of reflective practice are explored, in opposition to the technical-rational approach of evidence-based practice.

FINDINGS

Reflective practice tends to adopt a naive or romantic realist position and fails to acknowledge the ways in which reflective accounts construct the world of practice.

CONCLUSIONS

Microsociological approaches can help us to understand reflective accounts as examples of case-talk, constructed in a narrative form in the same way as case records and presentations.

Facilitating perception and imagination in generating change through reflective practice groups

This paper describes the process of facilitating groups of registered nurses to generate change in themselves and their practice through guided reflection. The concept of perception is explored in respect of individual interpretations of personal experiences where perception becomes reality for that individual. Such perception is subject to bias and without supported guidance in the reflective process inappropriate conclusions are easily generated. Through facilitating group deconstruction of the perceived experience the individual is able to identify the elements of bias emerging and subsequently reaches valid conclusions by reconstructing the experience with reduced elements of subjectivity which are more appropriate to personal and practice development. Within the reconstruction process, imagination is stimulated by steering individuals within the group towards visualising outcomes of planned actions. Use of imagination allows internal acting out of events and the identification of consequences of following a particular course of action. This process enables generation of appropriate actions to take place through development of insight and deeper awareness of influences on personal change. Through appropriate developments in personal approaches the ensuing changes generated in practice take place through considered strategies, which will enhance nursing and care provision.