View
1.350
Download
3
Category
Preview:
Citation preview
15
Reflective Account of Nursing
Introduction
Nurses practicing in today's rapidly changing health care environment are increasingly becoming
aware of the need to evaluate and improve their practice as well as consider the political, social
and structural issues affecting it (Bettie et al 1996:28). Because the changes are occurring all
around us, it is important for the nurses to be able to analyze and respond to the new and the
different challenges in a proactive way. Developing critical thinking and reflective skills will
assist the nurses to meet the challenges of providing care in a context of the rapid changes and to
become a critically reflective practitioner.
There are several issues about the reflective account of nursing can be discussed where it seems
to bind nursing practice with questions of ethics, sociology and management. Reflective practice
is an important aspect of nursing management. Greenwood (1993) suggests that “reflection is
about considering what one is doing whilst doing it and is often the result of something that has
surprised the practitioner”. Fitzgerald (1994) believes that “the individual is retrospectively
considering practice undertaken through recall, thereby uncovering the knowledge used in that
particular incident or situation”.
During the practice the nurses can apply to few of reflective account model, it is depending on
related to the environment and situation both on the workplace or patient. There are some
popular models of the reflective account start from the most famous is the Gibbs reflective cycle
(1988), Johns’ model of reflection (1994), Kolb’s Learning Cycle (1984), Atkins and Murphy’s
model of reflection (1994). There are many more of reflective account model can be found,
however the most important thing the nurses have to do is to use it wisely on which model is
most related to the situations in their clinical work where they feel they have learnt something
1
that is of value to their practice and future career. It may be a positive experience when
something went well or a negative one where one’s need to think about what has happened.
Definition
Reflection is a generic term with many definitions. Boyd and Fales (1983) define it as the
process of examining an experience that raises an issue of concern, as an internal process that
individuals use to help refine their understanding of an experience, which may lead to changes in
their perspectives. Boud D. (1985) define reflection as the cognitive and affective behaviors in
which individuals engage that result in new insights and deeper understandings of their
experiences.
Nurses, medical students, residents, and alike are continually faced with unique and ambiguous
problems in the clinical setting, during which they are forced to stop, think, and problem solve in
the midst of activity. Schon (1987) terms this “reflection-in-action.” In practice, Westberg and
Hilliard (2001), note that reflection-in-action requires physicians to function on two levels
simultaneously, attending to the task of treating the patient while continually questioning,
observing, assessing, and adjusting throughout the session. In addition, after each patient or
family interaction, the nurses may reflect on what can be done to improve each patient's
outcome. Schon refers to this as “reflection-on-action” and suggests that reflective nurses revisit
their experiences and further analyze them to help improve their skills and enhance their future
patient care.
Killion and Todnem (1991) extended Schon's concepts to include “reflection-for-action.” It is
through reflection-for-action that both novice and expert pediatricians can begin to anticipate
situations and plan through mental preparation before being faced with different clinical
problems. They state that it is not sufficient to reflect-in-action and on-action; rather, reflecting-
for-action is also crucial to professional development and quality care. These very skills are
integral to competent pediatric practice yet must be learned by novices in the clinical setting
Jensen G (1991, 1997).
2
Mezirow JA (1990) states that reflection is not simply stopping to think and problem solve or
plan for future action based on what you already know; rather, it is critically questioning the
content, process, and premise underlying the experience in an attempt to make meaning or better
understand the experience. He contends that reflection is a higher-order, conscious thought
process. He suggests that using all the three elements of reflection, the content, the process, and
premise will result in changes in behavior that reflect changes in underlying values, attitudes, and
beliefs as new nurses move toward becoming professionals.
Content reflection involves the analysis of the problem or situation itself. The nurses in acute
pain ward are routinely required to analyze situations from the perspectives of all those involved
in a patient’s care, the parents, the medical officer, third-party payers and others who related to
the patient. Mezirow JD (1990) would term this “content reflection.” They then look to
determine what strategies they might choose to address the patient's situation, which is what
Mezirow terms “process reflection.”
Process reflection requires the nurses or the trainees to analyze the problem-solving strategies
they chose, determine the efficacy of the strategies chosen, and perhaps explore what other
strategies might be available. Finally, premise reflection is the most difficult of Mezirow’s
reflective constructs because it requires the nurses or trainee to question and analyze his or her
own assumptions and the basis for the existence of the problem or the assumptions underlying
the problem itself. Assumptions are taken-for-granted beliefs, and as a result it is often difficult
to recognize personal assumptions.
In addition, premise reflection often requires the individual to question why a particular problem
exists. For example, when a nurse begins to question why a particular the patient is not entitled
to certain medical treatment or why certain differences exist in health care, the pediatrician is
using premise reflection. For trainees to begin to recognize their own assumptions and biases and
how they might impact their clinical decision-making process, as well as their role in social
advocacy, significant skill in premise reflection in required.
3
Atkins and Murphy (1993) performed a meta-analysis of the many definitions of reflection
present in the literature and noted that there are three common elements essential to this process.
First is a trigger event, which is typically an awareness of some uncomfortable feelings or
thoughts either positive or negative. Second is a critical analysis of these feelings and thoughts
and the experience itself. Third is the development of new perspectives as a result of this
analysis. For trainees, this analysis could mean the development of new perspectives on their
lived experiences, which may result in more informed clinical decisions.
Kolb D (1984) defines reflection as an element of the learning cycle and Brookfield SD
(1987) suggests that it is the link to critical thinking. Brookfield defines critical thinking as a
direct outcome of the reflective process described by both Mezirow JA (1990, 1991) and Schon,
(1987, 1983) critical thinking is the result of trainees taking time to revisit their experiences and
process them from a number of different perspectives before drawing conclusions. According to
Brookfield (1987), critical thinking is the trainee's ability to recognize assumptions, beliefs, and
values that underlie their decision-making processes as they solve problems, anticipate
outcomes, and justify their actions. Critical thinking uses the analytic process of reflection to
extract deeper meaning from experiences.
Reflection is particularly important in medicine, in which evidence-based practice and client-
centered care require both the nurse and the physician to analyze best evidence while considering
his or her values and assumptions of the values, beliefs, and goals of each patient. It enables
trainees to recognize their own assumptions and how those assumptions might impact the
therapeutic relationship and their clinical decisions. Reflection also helps practitioners develop a
questioning attitude and the skills needed to continually update their knowledge and skills, which
is essential in today's rapidly changing global health care environment. The importance of the
reflective process is further acknowledged by the Accreditation Council for Graduate Medical
Education (ACGME -2004) as underlying a number of the expected competencies is the
development of reflective practitioners.
Reflective Account Models and Theory
4
As there are various models that can be used to reflect on learning and practical experience, one
of it has been develop by Graham Gibbs and popular known as the Gibbs reflective Cycle
(1988), provides a useful framework or reflect on the nurses practice and learning activities.
Gibbs model is most popular among the nurses practice and student nurses, it us covers six
stages as per TABLE I. The Gibbs’ reflective cycle can be rally useful to assist the nurses
through all the phases of an experience or activity.
TABLE I: The reflective cycle (Gibbs 1988)
The situation starting from the described by writing down the event which we want to reflect on,
the event can be shared with others or can be kept by the person itself. At this stage it is very
important to get down as much as you can to the objective. The feelings is the second stage are
need to be considered, try to recall and explore the things of the event either the felling of
happiness or dissatisfied that are residing in one’s mind. AT this stage is quite difficult to share
with others. And from here than it go to the next stage the experiences need to be evaluated. The
evaluation need to be measured and valued to some sort of standard, to arrive on judgment on
what has happened from the good and the bad experiences.
The fourth stage is the situation to analyze for clarity, where things need to breakdown to their
component parts, so that they can be exploring separately. At the conclusions stage are drawn is
5
differ from the evaluation stage where now one’s judgments, from detailed analysis and honest
exploration from the event. It is also important to consider what else could have been done to
affect a different outcome. The action plan is developed so that the individual can consider what
they would do if the situation arose again. However to complete each stage with good outcome
and result there are questions that need to be carried out and completed.
The next model and theory can be discussed here is by the Atkins and Murphy, where they have
suggested that we have a need to reflect from “an awareness of uncomfortable on thought. This
arises from a realization that , in a situation, the knowledge one was applying was not sufficient
in itself to explain what was happening in that unique situation” (1993). And we can also refer
to the Atkins and Murphy’s (1994) model of reflection as in TABLE II which consists of 6
stages as the Gibbs model and there are not much different from each other model and also for
the objective and the result.
Started from the first stage the experience of the new situations and where it will trigger the
event which is typically an awareness of feeling and thought either it is positive or negative.
From the first step the event situation has been described and to be followed by the next stage to
analysis of these feelings and thoughts and the experience. This analysis will challenge the
assumption and will explore the alternative. Third stage is the development of new perspectives
as a result of this analysis. The next stage is the evaluation of the relevance and the use of the
knowledge. The last stage is to identify the learning experience from the event where it will
complete the cycle. Where the new cycle will start for the new situation and experience from
new event.
6
TABLE II : Atkins and Murphy’s stage model of reflection (1994)
Another model of reflective theory is the Bortons model as shown in TABLE III, which is
incorporates all the core skills of reflection. Where the arguably is focused on reflection on
action, but with practice it could be used to focus on reflection during and before action.
What? So What? Now what?
This is the description and self-awareness level and all questions start with the word what
This is the level of analysis and evaluation when we look deeper at what was behind the experience.
This is the level of synthesis. Here we build on the previous levels these questions to enable us to consider alternative courses of action and choose what we are going to do next.
ExamplesWhat happened?What did I do?What did other do?What was I trying to achieve?What was good or bad about the experiences
ExamplesSo what is the importance of this?So what more do I need to know about this?So what have I learnt about this
ExamplesNow what could I do?Now what do I need to do?Now what might I do?Now what might be the consequences of this action?
TABLE III: Bortons` (1970) Framework Guiding Reflective Activities
7
Reflexivity
My description of reflection states that the nurses can gain new insights into self and be
empowered to respond more consistently in future situations within a reflexive spiral towards
realizing one’s vision as a lived reality. Such words reflect the purposefulness of reflection, it is
action oriented towards the development of practical wisdom and realization of vision.
Reflexivity is a looking back and reviewing self’s development over time, the way insights have
emerged and influenced future experience. In this sense, reflection is like a drama unfolding over
time, a systematic and disciplined pursuit towards realizing desirable practice however that is
known. As I shall explore, the nursing can utilize markers to plot the reflexive journey of
development.
Gibbs Reflective Cycle In My Reflective Account
This account uses Gibbs Model as its basis for reflection about pre-operative admission and
assessment. By working around the cycle, it is possible to gain insight and develop practice, this
experience relates to a day surgery unit, where a gentleman is admitted for cataract surgery.
As started with the first stage is the description with a question, what happened?
The patient was an elderly gentleman who was being admitted for a cataract operation, in the
afternoon. I was fairly new to this day surgery unit having only worked two shifts, here,
previously and was concerned about the number of people who were being admitted and my
tasks to be completed for each of the patients, prior to their surgery. I was also unfamiliar with
the unit geography and where to find equipment. I hadn't done this before, without someone in
close proximity, to ensure that I had covered all the requirements and the documentation
paperwork was not the same as I had used on other units.
The second stage is the Feelings, What was I feeling?
8
I was therefore feeling stressed, but also anxious to get everything done, due to the time
pressures. I probably wasn't as empathetic as I should have been. My mind was not solely on the
gentleman being admitted. I wanted to do this right and not have to repeat anything and also I
knew that my mentor would have to overview my patient records before the patient went to have
his operation.
The third stage started with more description and a little evaluation.
The gentleman had not been in hospital before and had enjoyed good health, apart from his
cataract. He was worried about being discharged home and also what he was expected to do,
prior to the surgery. My concerns were with his vital signs and obtaining a urine specimen, to
ensure that he was fit for the surgery. Just from writing this down I can see that we had different
goals, mine to elicit the information as speedily as possible and complete the pre-op. checks, his
to get his operation done and go home as soon as possible. I should have explained the process
and then gone over his discharge plan, but I wasn't feeling very confident about the process and I
was worried about the time.
The fourth stage, some analysis and more evaluation.
He was having a local anesthetic. He did communicate his worries to me and I tried to reassure
him that these operations were carried out every day. How stale that seems as I read it back to
myself, now. It was quite a few years ago when I had to have a minor operation and I knew the
system as I am working as a nurse. I was young and quite able, but worrying about the outcome
of the biopsy and the affect it could have on me and my family.
I knew from the admission documentation that the gentleman had a wife, who was disabled from
a stroke. She was being cared for by a married daughter, while the husband was with us. I
suppose too that he was worried about not being there to care for his wife. They had been
married for 54 years.
I had felt impatient with him for taking time to undress and for the amount of time that he was in
the bathroom. He was not physically disabled, but walking did seem to be something of a chore.
Having taken the time now to re-think what happened, I can see that the area to be covered
between the bed and the lavatory is quite a distance and as he put it, is not quite like being at
9
home. That's true for me too, I have an en-suite bathroom, at home, so can nip to the toilet quite
quickly and privately. The lavatories in the unit are arranged in stalls and he may have found it
difficult to urinate into the container. I also realized that his fingers were not as nimble as they
were once and he probably found buttons difficult. I have replaced my father's fastenings on
shirts with Velcro, which he can manage more easily. Why didn't I suggest that to him? Would
he have found that insulting?
The fifth Conclusion, What could I have done differently?
I had also forgotten, in my rush to continue, that older gentlemen have problems with their
urinary system and can't always pass urine immediately. I had later found him looking very
carefully at each bed and had realized with embarrassment that he couldn't actually see his bed
label, because of his impaired vision. That was quite thoughtless I could have identified it for
him, as the bed in the corner, next to the sink. That's something to remember for the future, as
I'm sure there are quite a few people attending for this type of operation.
The good thing for me was that the gentleman was compliant and carried out all the requests that
I had made in order to 'process' him through the pre-op checks. He didn't ask me any awkward
questions and was also very easy to talk to, willing to pass the time of day. I stumbled over some
of the paperwork and I do know how important record keeping is and I have taken a blank pack
with me to familiarize myself with it, before I have to use it again. It was lucky that the packs are
pre-assembled and that I didn't have to find each of the different items from the stationery store,
as that would have constrained my time even more.
It makes sense to me in terms of efficiency that the nurse who takes the patients to the eye
theatre is not the same one who triages and admits them, but perhaps it would be better for the
patients if it were? It can be confusing dealing with more than one person, especially when you
may be feeling anxious about the operative procedure. I wonder how I would feel if I were
partially sighted and were passed on like a parcel?
When trying to evaluate the care given during the admission and assessment process, I realized
that the vital signs checks had become 'basic and routine' in my mind and I hadn't thought about
10
'maintaining patient safety' by Roper et al (1981). Of course I had thought about it with regard to
the gentleman finding his bed and walking around the unit, but more in terms of communication
and mobility of what I did not think about while attending him, explaining exactly where his bed
was, but more importantly, the distances involved, when you have impaired sight. Any procedure
carries with it risks to the patient and by taking these physiological measurements and testing the
patient urine, I was ensuring that he was fit for surgery, physiologically. But was he prepared
mentally?
The six stages, the action plan.
I have discussed this account with my supervisor with perhaps answer some of the question that I
have posed. I will make sure that I am familiar with the different documentation used in this unit.
I also have familiarize myself with the layout of the unit. I have try to think more about the task
as I am doing them and respond more appropriately to patient’s priorities that to mine. I am
going to offer the aspects of the action plan to others who are going to work on that unit as part
of their clinical experience with regard to geography and documentation. Learn about the
discharge process in order to be able to explain it to patient, to alleviate their anxieties.
The reflective writing has several aspects which will enable people who are learning their skill to
put their thoughts on paper and thereby improve their writing skills. It may improve the thinking
process by ordering the thought about a particular aspect of care or an incident. This experience
can enhance and sharpen clinical skills and problem solving and also may influence to assist in
the changing attitudes towards people’s abilities, cultures and feelings. And if it is to be shared
with others, it wills than enable other perspectives to be explored within a safe academic
environment.
The Assessing
From the Gibbs reflective cycle scenario above there are always the questions which require for
the answer on every stage of cycle. As at the stage of description where there are a need to
describe in detail the event that we have reflecting on, with the questions as such where were
you; who else was there; why were you there; what were you doing; what were other people
11
doing; what was the context of the event; what happened; what was your part in this; what parts
did the other people play; what was the result. This entire question will bring more explanations,
understandings and the answer for all party involve in our case here it is going to be between the
medical staff and the patient.
The Why? from the Description stage
Journal writing has been used to promote reflection among the medical staff especially the
nurses. However, evidence shows that journaling does not necessarily ensure that the nurses will
use the reflective process in practice. Rather, some may simply describe their experiences and do
not take the critical step toward analysis as some have proposed. Without a mechanism to assess
whether the nurses are truly reflecting, the medical educator has no way of knowing whether
trainees are competent in using reflection to develop deeper meaning and inform their practice.
As Pee et al (2002) suggest, in keeping with the move toward evidence-based practice,
assessment of the efficacy of this strategy in promoting reflection is essential.
The assessment however is controversial although placing judgment on what the nurse write in
journals could potentially impact their writing, one cannot effectively determine if a trainee has
gained the skills necessary to become a reflective practitioner without a mechanism of
assessment. To ease these obstacles, Bourner (2003) proposed separating content and process in
the assessment of journal writing. By solely assessing the process of reflection, competence can
be determined without placing judgment on the subject of the reflection. In addition, while
assessment allows the medical educator to provide feedback to nurses on their learning, it also
provides feedback to medical educators about the efficacy of their teaching strategies.
The literature reports on a variety of assessment mechanisms that enable educators to assess the
reflective process without making a judgment on the content. The feelings, at this stage try to
recall and explore the things that were going on inside your head, for example why does this
event stick in your mind? To include also the question on how you are feeling when the event
started, what you were thinking about at the time, how did it make you feel, how did other
12
people make you feel, how did you feel about the outcome of the event and what do you think
about it now.
The How? At the stage of Feeling
Reflective writing has been evaluated both qualitatively and quantitatively and has been shown
to be an effective means of facilitating the reflective process. To assess both the depth and
breadth of reflection evident, it is helpful to use the elements of reflection as defined by Mezirow
(1990) and Schon (1983) vis-à-vis Bloom's ( 1956) cognitive processes, by looking for evidence
of each of the elements proposed by Mezirow and Schon as such the reflection-in-action,
reflection-on-action, reflection-for-action, content reflection, process reflection, and premise
reflection in the reflective thought processes of trainees, medical educators can determine if the
nurses or the trainees are using all elements of the reflective process effectively in exploring and
critically analyzing the depth and extent of each clinical problem.
Perhaps the nurses are beginning to analyze the problem, but are they effectively considering all
perspectives, or have they fully integrated the information obtained? Perhaps they know of a
strategy to use in approaching a patient problem, but have they explored other options? Perhaps
they are beginning to recognize their own assumptions, but do they recognize the impact of these
assumptions on their decision-making process? By looking for evidence of each of the elements
of the reflective process, the medical educator or manager can better determine what is missing
in the reflective and critical-thinking processes of their trainees or the nurses. By recognizing
which elements of reflective thought are missing, nurses and superior are better equipped to
facilitate the higher-order thinking processes that are essential to effective clinical decision-
making in their trainees.
Facilitating the Process
At the evaluation stage, try to evaluate or make a judgment about what has happened. Consider
what was good about the experience and what was bad about the experience or didn’t go so well.
Questions at the Evaluation Stage
13
Questions encourage critical thinking. They promote self-evaluation, consideration of alternative
perspectives, consideration of alternative solutions, and exposure of ingrained, taken-for-granted
assumptions. Good questions promote higher-order thinking. They not only facilitate a more in-
depth analysis of the situation from multiple perspectives, but they also encourage combination
of these different points of view. Questioning not only enables the individual to evaluate what is
really happening in a given situation but also his or her perceived role in that situation.
The keys to good questioning are to establish a comfortable learning climate (Boenink AD,
2004), recognize that questioning is an art that needs to be practiced (Pee B, 2002), and
understand and apply Bloom's cognitive taxonomy to improve the trainees' depth of processing
(Pee B, 2003). Questions are most effective if they stimulate the nurses to use higher cognitive
thinking for example, the synthesis and evaluation rather than just recall. Good questions
encourage the nurses to use the extent of reflective elements to fully explore the situation such as
to facilitate questioning of the content, process, and premise underlying the situation). In
addition, the superior who are effective facilitators of the reflective process will encourage the
nurses or the trainees to reflect-in-action, reflect-on-action, and reflect-for-action. It is through
this higher-order reflective process that critical-thinking skills are developed.
Sample questions that facilitate both the depth and extent of the reflective process are provided
in the Appendix I (Jane Williams & Pam Cowley, Mid Devon Working Group Approved DMT,
2004). The authors believe that questioning skills can be taught in faculty-development
workshops, enabling faculty to understand the theory and practical application of the questioning
process. Although questioning is at the heart of the reflective process, different strategies are
available for the medical educator who is using the questioning process to facilitate reflection.
Individuals can engage in the reflective process in writing or verbally and individually or with
others.
Analysis which at the stage four will break the event down into its component parts so they can
be explored separately. You may need to ask more detailed questions about the answers to the
last stage. Including for example what went well, what you did well, what others did well, what
went wrong or did not turn out how it should have done and in what way did you or others
contribute to this
14
Written Reflection at the Analysis Stage
Journal writing is a mechanism for individuals to describe their experiences and begin to use the
reflective and analytic or critical-thinking processes for learning (Kalliath T., 2001). Journal
writing encourages the nurses to process critical incidents after they have occurred. After seeing
a very preterm infant in the neonatal intensive care unit, 1 third-year student wrote about how he
questioned the use of limited resources to help an infant with a probable compromised outcome.
A shared reflection of this nature can prompt an important discussion about how personal biases
can impact the clinical decision-making process. This type of discussion might not otherwise
take place in a typical medical administration.
However, without guidance, journals often become diaries that simply contain facts rather than
analytic tools for learning. The nurses may use their journals to record the events of the day
rather than to analyze their experiences to construct deeper meaning from these events. Yet, it is
this analytic process that is closely linked to the development of the critical-thinking skills that
are essential to effective clinical decision-making. For many, reflection and journal writing do
not come naturally, and facilitation is essential. Some even struggle with how to begin their
journaling process. To assist them, the superior can pose reflective questions for new nurses or
the trainees to ponder such as those listed in the Appendix II (Reflective Log from Teignbridge
District Model). Responding to journals by using the questioning process can further facilitate
this process.
New nurses and the trainees often have mixed opinions about journal writing. Some find the
process very effective in helping them to probe into their experiences, whereas others consider it
time consuming and tedious and feel that it has no relevance. However, there are definite
benefits to maintaining a reflective journal (Boud D, 2001). It is a record over time, which allows
the writer to revisit not only experiences but his or her reflections on those experiences. It
becomes a recursive process that allows for deeper learning each time it is revisited and
explored. Nonetheless, it can be time consuming. Alternatively, other less time-consuming forms
of written reflection such as summative essays, critical incidents, and structured questions have
also been used successfully. (Plack M, Santasier A, 2004).
15
Written forms of reflection are performed most often in isolation, this can be problematic,
because the writer processes the experience strictly from his or her own perspective. Although a
more experienced reflector will consider multiple perspectives in the analytic process, it is often
difficult to question your own thought processes, recognize your own assumptions, or pose
alternative solutions without prompting. Thus, interactive journals have been advocated in the
literature. The role of the journal reader is to pose questions to the writer and act as a “critical
other” or “devil's advocate.” The reader's role is not to give advice but rather to pose questions to
extend the writer's thought processes, encouraging broader and higher-order critical thinking. By
posing questions using the theories of Mezirow, Schon, and Bloom, the reader can facilitate the
depth and breadth of reflection noted above.
Verbal Reflection
This is an alternative to written reflections is the use of verbal reflective techniques such as
reflective questions, reflective dialogue, after-action reviews, and action learning sets. (Marsick
VJ, 1999). Each of these techniques uses dialogue to facilitate cycles of reflection and action.
The reflective component encourages each individual to share thoughts, feelings, and reactions,
as well as an analysis of his or her experience. The role of the facilitator or other group members
is to pose questions that encourage the individual to think more broadly and more deeply about
his or her experience. The challenge of the facilitator or group is to encourage each other to think
critically, uncover taken-for-granted assumptions, consider multiple perspectives, and explore
multiple strategies before coming to a conclusion. The conclusion reached by the individual, who
is based on a complex analysis of his or her experience, then becomes the basis for future action.
This is an iterative cycle of reflection and action, with members of the group supporting each
other in developing the complex critical-thinking skills essential to quality medical practice.
Again, this can only happen in a safe learning environment established by those in charge.
Future Implications
16
Although experience is at the core of learning in medical education, reflection is integral to
deeper learning from experience. Reflection is more than just stopping to think and act based on
what we already know, it requires the nurses and the trainees to view situations or problems from
many perspectives. Reflection can occur in isolation or with others and in writing or verbally.
Viewing situations from multiple perspectives becomes the basis for critical thinking. The nurses
who are skillful questioners can facilitate the reflective process in others. Skillful reflectors are
critical thinkers, and critical thinking is the basis for effective clinical decision-making, which is
at the heart of quality nursing practice. The skill of reflection is not a natural thing it is learned
over time and with practice.
Here we have identified strengths and gaps in teaching and learning the reflective process. It is
evident from this review that the reflective process is of critical importance for pediatricians to
be able to make informed evidence-based decisions in a client-centered treatment environment.
Incorporating the reflective process may enable the nurses to more effectively attain those
competencies that considers essential to quality care such as nurse-patient interaction and
lifelong learning. However, reflection is an analytic skill that must be mastered as well. Toward
that end, our recommendations are actually challenges that need to be met both head-on and
collaboratively.
To begin, we propose that the reflective process be incorporated into the field of medical
education, from undergraduate through continuing medical education. The curriculum should
include the theoretical foundations of the process and its practical application in the clinical
setting. Using clinical cases enhances relevance to the nurses and will serve to make the process
both authentic and of interest to the nurses and student nurses alike. In addition, the development
of effective questioning skills is essential for facilitating the reflective process both in writing
and verbally. However, an assumption being made is that the nurses understand these issues and
can teach them effectively. If knowledgeable of the nurses are not available, identifying
resources on academic department such as schools of education, organizational development, or
human resource development would be essential for facilitating effective teaching and learning
of this content. Although introducing reflective practice into medical school education is a start,
raising awareness at the residency and admin levels would further reinforce the centrality of this
skill in effective clinical decision-making and quality patient care.
17
Finally, although much is being written about reflection and its importance in the learning
process, what is yet to be fully explored is the impact of reflective practice on clinical practice.
Additional research by practitioners who are competent in the reflective process and can both
facilitate and assess excellence in practice is needed to determine the impact of this process on
practice.
Promote Reflection
The processes of reflection are usually discussed in stages or levels (Mezirow, 1981; Boyd &
Fales, 1983; Goodman, 1984; Boud, 1995; Schön, 1991), with some relation to intuition
(Goodman, 1984), Schön, 1991). Differences are mainly in terminology, detail, and the extent
the processes are arranged in hierarchy. The poor wording literature combination reveals three
stages in the reflective processes: awareness of uncomfortable feelings and thoughts, critical
analysis of feelings and knowledge, and new perspective. They describe the skills that are
required to be reflective: self-awareness, description, critical analysis, synthesis, and evaluation.
Evidence suggests that reflection benefits learning by integrating theory and practice (Astor et
al., 1998). It promotes intellectual growth because it is cyclical rather than linear (Davies, 1995;
Landeen et al., 1995), develops skills that make practitioners more confident (Davies, 1995), and
fosters responsibility and accountability (Wong et al., 1997; Astor et al., 1998).
Reflection-on-action is retrospective and allows practitioners to recount an event in order to
discover the knowledge used by analyzing and interpreting the information recalled. Strategies
are more limited that promote the development of reflection-in-action, a more complex activity
that requires practitioners to be conscious of what they are doing and how they are doing it in
that moment of practice.
Applications of Reflective Practice
18
Reflective thinking is integral to curriculum theory (Dewey, 1933), empowering processes in
education (Freire, 1972), human interests and forms of knowledge (Habermas, 1972), and adult
education (Mezirow, 1981). Nursing has applied many of these ideas to the disciplinary areas of
practice, education, research, and leadership. Nursing has used reflective processes for some time
to improve.
Practice and Practice Development
Much of the literature is focused on the work of nursing, as practiced in clinical contexts for
example, (Freshwater, 1998, 2002), (Glaze, 1999), (Heath, 1998), (Johns, 2000, 2003), (Taylor,
2002, 2003, 2004), (Wilkin, 2002). Freshwater (1998) provided an integrative review of
reflection and caring to emphasize the role of reflection in nurses’ personal and professional
development,
Reflective practice can be viewed as the call to awake. It is also a process of becoming, being
with the unfolding moment. Reflective practice helps us to explore what is just beyond the line
of vision, it encourages not to stare straight ahead, but to turn around. Reflective practice can be
seen as a way of viewing the unfolding drama of the nurse becoming (Freshwater, 2002).
Heath (1998) offered practical guidance to clinicians in keeping reflective journals of their
practice. John’s (1994) model of guided reflection integrated Carper’s (1978) patterns of
knowing the empirical, personal, ethical, and aesthetic. Heath (1998) went beyond to include two
further patterns of unknowing and sociopolitical knowing. Heath (1998) suggested that nurses
may have difficulty applying knowledge forms to their practice, seeing it as an academic
exercise not immediately urgent in their busy work settings. Hence, the extension of knowledge
into the unknown and sociopolitical categories creates room for movement in practice that
captures clinical concerns.
Glaze (1999) described reflection, clinical judgment, and staff development “to encourage
perioperative nurses to reflect on their practice” using exemplars of expert practice “to illustrate
how knowledge is used and developed in the practice setting.” The outcomes of reflection
19
include practical advice and insights into how perioperative nurses may improve their practice.
Johns (2000) demonstrated through case study of his own practice reflection to draw “out key
issues of practice and refection that enabled him to gain insight and apply to future practice
within a reflexive learning spiral.”
Freshwater (2002) describes the therapeutic use of self in nursing as a means of improving
patient care through self-awareness and reflection. Freshwater connects a nurse’s deeper sense of
self to healing outcomes of a therapeutic nature for patients, and contends that the “practice of
reflection is a central skill in developing an awareness of self”. In creating possibilities for
therapeutic nursing, nurses examine self as workers, learners, and researchers, to transform self-
awareness into a process through which patients feel cared for and acknowledged within “the
context of a therapeutic alliance”.
Freshwater (2002, Johns, 2002) describes the importance of “guided reflection in the context of
post-modern practice.” Self-awareness “is deemed central to the process of successful reflection,
with the ‘self’ being the main instrument of both the practice and guidance of reflection.” In a
post-modern description of the process of guided reflection, Freshwater (2002) explores “some
of the reflections that took place in the pauses between the lines of the text in the act of looking
up from the reading’ in order to ‘bring light to bear in certain elements of the text, whilst
recognizing that this casts a shadow on other aspects of the dialogue.” Freshwater (2002)
skillfully captures the post-modern conundrum of partialities, gaps, silences and shifts in
meaning, while resting on the assurance that an exploration of self is a reflective exercise that
offers some insights into local truths.
Wilkin (2002) explored expert practice through reflection, by focusing on a clinical experience
of caring for a 12-year-old boy diagnosed with brain death, and her experience of remaining on
duty in the unit to facilitate the parent’s wishes concerning his care. Wilkin (2002) used “the
unusual experience to enable self-criticism and expansion of personal knowledge,” in order to
explore the complexity of expert practice and to facilitate holistic care.
20
Taylor (2004) offers advice for technical, practical, and emancipatory reflection for practising
holistically. Emancipatory reflective practice is overcoming complexities and constraints in
holistic health care (Taylor, 2003a, b), giving guidance in technical reflection for improving
nursing procedures using critical thinking in evidence based practice (Taylor, 2002b), and on
becoming a reflective nurse or midwife, using complementary therapies while practising
holistically (Taylor 2000).
Clinical Supervision
Reflective practice has been applied effectively to clinical supervision (Todd & Freshwater,
1999; Heath & Freshwater, 2000; Gilbert, 2001; Clouder & Sellars, 2004). Rolfe et al. (2001)
provides an in-depth exploration of reflection in clinical supervision.
Todd and Freshwater (1999) examined a model of reflection, particularly the parallels and
processes, in individual clinical supervision with ways to guided discovery. In clinical
supervision, reflective practice provides a safe space that facilitates a relationship that both
collaborates and empowers the practitioner in experiencing the discovery found in everyday
practice.
Heath and Freshwater (2000) demonstrated application of John’s (1996) intent-emphasis axis as
a method to explore detractions to the supervisory process derived from technical interest,
misunderstanding of expert practice, and confusion of self-awareness with counseling. Clinical
supervision within reflective practice is especially effective when supervisors are reflective about
their roles, so the clinical supervision is a guided reflection that enables deeper insights for both
supervisee and supervisor.
Gilbert (2001) focused on potential for reflective practice and clinical supervision to be
confessionals, acting as a mode of surveillance to discipline professionals. Gilbert argued that,
like governments, health settings act as “forms of moral regulation” in which professionals
exercise power through “the complex web of discourses and social practices that characterize
their work”. In critiquing the discourses of empowerment (Gilbert, 2001) that underlie the
21
emancipatory intent of reflective practice and clinical supervision, he identifies the tendency of
empowerment discourses to assume “the existence of a damaged subject-traditional and rule
bound who requires remedial work to achieve forms of subjectivity consistent with modern
forms of rule.”
Clouder and Sellars (2004) wrote from the perspective of a physiotherapist, using research
conducted with undergraduate occupational therapy and physiotherapist students, to “contribute
to the debate about the functions of clinical supervision and reflective practice in nursing and
other health care professions.” The authors responded to Gilbert’s (2001) criticism of the
sterility of debates about reflection and clinical supervision, and the potential for moral
regulation and surveillance. They concluded that although both strategies make individuals more
visible within the gaze of the workplace, Gilbert “overlooked the possibility of resistance and the
scope for personal agency within systems of surveillance that create tensions between personal
and professional accountability”.
Leadership and Management
The emerging links between effective clinical and academic leadership and reflective practice
can help eliminate the gaps in contemporary nursing leadership (Freshwater et al., 2001;
Freshwater, 2002; Freshwater, 2004; Johns, 2004; Sherwood & Freshwater, 2005). McCormack
(1995) explored the issue of clinical leadership through a model of collegiality that integrates
spheres of clinical leadership and incorporates elements of reflection throughout. Freshwater
(2004) links reflective practice and transformational leadership and emotional intelligence, yet
reflection can facilitate the challenge of institutional attitudes and provide opportunities to
confront organizational and professional cultures of coping and knowing.
In a study involving prison nurses, Freshwater et al. (2001) and Freshwater (2002) implemented
reflective practice through clinical supervision groups and evaluated the development of clinical
leadership skills as a direct outcome of the interventions. Findings suggest that not only does
reflective practice enhance clinical leadership abilities, but also that it is a crucial element of any
leadership and management program.
22
Education
Reflective practice in nurse education is integral to effective outcomes (Cruickshank, 1996;
Freshwater, 1999; Kim, 1999; Anderson & Branch, 2000; Clegg, 2000; Platzer, Blake, &
Ashford, 2000a, b; Lian, 2001; Kenny, 2003). Various literature sources describe a variety of
strategies for educators presented in the following references.
Cruickshank (1996) used the medium of drawing to allow students working in small groups to
express clinical learning that occurred on their clinical placement. The themes that emerged from
the process were representative of the technical, practical, and emancipatory forms of knowledge
they observed within nursing practice and experienced within their curriculum.
Kim (1999) presented “a method of inquiry which uses nurses’ situated, individual instances of
nursing practice as the basis for developing knowledge for nursing and improving practice.”
Using ideas from action science, critical philosophy, and reflective practice, she described a
critical reflective inquiry method and process that allows nurses to raise awareness of their work
constraints to free themselves toward more informed and liberating insights about their work.
Freshwater (1999) guided a research project to explore the lived experience of student nurses on
how their personal stories interfaced with those of the patient. The students and tutor kept a
reflective journal pertaining to their experiences of moving from perceived levels of novice to
expert nurse and demonstrated how self-awareness through reflective practice, clinical
supervision, and experiential learning can enhance personal and professional development.
Anderson and Branch (2000) endorsed storytelling to promote critical reflection to enable
nurses’ students talking about past actions and outcomes to give voice to experiences. Revisiting
the past is thus used to shape the future. Clegg (2000) explored reflective practice statements as
data sources to provide insight into the sub context of organizations, especially in light of
“reflective practice taking on the veneer of educational orthodoxy.” In spite of suspicion that
advocates of reflective practice in nursing, social work, and teacher training may have inflated
23
the positive claims of reflective practice, Clegg (2000) supports reflective practice as a useful
and insightful method for knowledge production in higher education.
Platzer, Blake, and Ashford (2000) established reflective practice groups in a post-registration
nursing course so that students could reflect on and learn from their experiences evaluated
through in-depth interviews. Students did identify barriers to their learning, yet some students
significantly advanced their critical thinking with transformations in perspectives that led to
changes in attitudes and behaviors.
Problem-based learning (PBL) can help develop reflection and critical reflection as professional
practice skills (Williams, 2001). Learners who participate in PBL are more reflective and
critically reflective in their learning experiences derived from professional practice encounters.
Critical questioning in the PBL scenario propels the learners’ ability to be both reflective and
critically reflective during situational analysis, determining learning needs, knowledge
application, critiquing resources, and problem-solving, and summarizing what was learned.
Kenny (2003) described a creative thinking game used to stimulate critical thinking and
reflection. Edward de Bono’s six hats game was used with qualified health professionals
undertaking relaxing care education because many reflective practice models did not fit the
practice. They were either too simple or too complex. Students used a variety of thinking
techniques that unleashed their creative and critical thinking processes to be more effective in
reflection.
Although the value of reflection in nurse education has been debated for some time (Driscoll,
1994; James & Clarke, 1994; Newell, 1994; Palmer, Burns & Bulman, 1994; Burrows, 1995;
Hulatt, 1995), these examples and other resources conclude reflection is a valuable aid in
teaching and learning (Posner, 1989; Atkins, 1995; Johns, 1995; Smith, 1998; Hannigan, 2001;
Noveletsky-Rosenthal & Solomon, 2001; Freshwater, 2002; Lau, 2002; Evans, 2003; Kuiper,
2004).
Research
24
Knowledge derived from reflection has only recently been formally recognized as a pragmatic
methodology for evaluating and inquiring into clinical nursing practice (Rolfe et al., 2001).
Traditional models of research tend to separate research and practice into discreet domains, thus
expanding the already substantial split between theorists and practitioners. Some nursing authors
argue for the notion of a practicum, fostering an integral approach to research, building on
researcher-practitioner models by way of managing this false dichotomy (Rolfe et al., 2001;
Taylor, 2001; Freshwater & Rolfe, 2001; 2004).
Reflective methods and processes not only guide practice, practice development, education and
leadership, they can also provide research evidence for supporting changes in these areas.
Reflective processes may be used solely as the research approach, or they may be integrated into
other research approaches. This section describes these options, to open up the potential for
creative reflective processes in research.
The Reflective Research Approach
The eight basic steps in a reflective research approach are firstly is to identify the issue, problem
or phenomenon for the reflection, the second steps is to decide on the reflective method, clarify
its intent. The third steps are to plan the stages in the research proposal and to follow the method
and use the process at the fourth steps. The fifth steps is to generate the insights, the six steps is
the institute changes and improvements and continue to reflect on the outcomes. The step seven
is to report the outcomes and the last steps is to use the outcome in practice as evidence (Taylor,
2000).
Reflective Processes
Reflective processes can be used in conjunction with other research approaches, for example,
quantitative, qualitative, or mixed methods of quantitative and qualitative research. There is no
prescription as to how these approaches might be used, as it is up to the researcher to make those
choices, based on the fit of the approach to the research aims and objectives. A quantitative
25
project using a survey or questionnaire might also use the technical reflection process in a focus
group to develop scientific reasoning to support or oppose the continuation of a clinical policy or
procedure.
A qualitative interpretive research approach using ethnography might also include participants’
journals, in which descriptions of the research context are written for later analysis and
interpretation, thus adding richness to the description of the culture being studied. The practical
reflection process may also be used to explore communicative aspects of the culture of interest.
A qualitative critical research approach using action research based on critical theory may use
the action research cycles, with a special emphasis on reflection. The emancipatory research
process could be used in any form of critical research that intends to question the status quo and
to bring about change in people and organizations.
Reflection is more than a research method in its own right are called reflexivity, a number of
research studies have explored the value of reflection in various forms and forums. Landeen et
al. (1995) and Davies (1995) examined student reflections through the use of self-reflective
journals. Landeen and colleagues’ (1995) phenomenological study found that students wrote
about meaning learning, issue of novice, relationships control, self-reflection, and identification
with clients. Davies (1995) examined the use of journaling and clinical debriefing and found that
these reflective processes do impact the environment, process, and focus of learning. Anxiety
was reduced through peer support. Students moved from passive to more active modes of
learning and over time, reflective processes resulted in the emergence of the client as the central
focus of care.
In other research, Richardson and Maltby (1995) studied the use of reflective diaries in
undergraduate nursing students in Australia and found that the highest number of reflections
occur at the lower levels of reflectivity based on Mezirow’s levels of reflectivity. Jones (1995)
“studied hindsight bias and its consequences on the reflective practice process. Findings
indicated that nurses are susceptible to hindsight bias, which questions the validity of reflection
as a way to enhance patient care”.
26
Reflective processes in research approaches have been admirably demonstrated (Freshwater,
1999; Hancock, 1999; Johns, 2000, 2003; Glaze, 2001). Researchers may use reflective
journaling in any project, they are undertaking, as a means of demonstrating rigor or
trustworthiness, through documenting the detailed life of the project, and the researcher’s and
target audience’s responses to the process and the findings. Students enrolled in research
programmes may use reflective processes in the design of their projects. They may also keep a
reflective account of their experience as a research student, of the project itself, of the learning
that comes about through supervisory meetings, of their reactions to literature, and of any
insights along the way that add richness to the research.
Reflection and Action Research
Reflection and action research combine well to create an effective collaborative qualitative
research approach for identifying and transforming clinical issues, because reflection is part of
the action research method. Action research involves a four-stage phase of collectively planning,
acting, observing, and reflecting (Dick, 1995; Stringer, 1996). Each phase leads to another cycle
of action, in which the plan is revised, and further acting, observing, and reflecting is undertaken
systematically to work toward solutions to problems of a technical, practical, or emancipatory
nature (Kemmis & McTaggart, 1988; Taylor, 2000). The planning and acting phases may include
any appropriate methods of gathering and analyzing data, such as participant observation,
reflective journaling, surveys, focus groups, and interviews. Cycles of action research lead to
further foci and co-researchers can keep an action research approach to their work for as long as
they choose, to find solutions to their practice problems.
Nurses have been using action research successfully in a variety of settings with differing
thematic concerns (Chenoweth & Kilstoff, 1998; Keatinge, Scarfe, Bellchambers, McGee,
Oakham, Probert, Stewart, & Stokes, 2000; Koch, Kralik, & Kelly, 2000). Taylor (2001) and
Taylor et al. (2002) used action research and reflection to work on thematic concerns common to
the nurses’ research group. Both projects gave nurses a regular forum in which to discuss their
27
reflections on practice and to generate an action plan to bring about change. The benefits of
action research and reflection are that there are immediate, practical outcomes for participants,
because they can share their experiences with peers, work together on thematic concerns, and
bring about local changes in their practice. Thus, co-researchers experience participatory
research, while developing their reflective skills, and in this sense the research offers them
personal and professional gains in lifelong appreciation for their participation.
Taylor (2001) aimed to facilitate reflective practice processes in experienced registered nurses in
order to: raise critical awareness of practice problems, work systematically through problem-
solving processes to uncover constraints, and improve the quality of care given by nurses in light
of the identified constraints and possibilities. Twelve experienced female registered nurses
working in a large Australian rural hospital shared their experiences of nursing during three
action research cycles. A thematic concern of dysfunctional nurse-nurse relationships was
identified, as evidenced in bullying and horizontal violence. The negotiated action plan was put
into place and co-researchers reported varying degrees of success in attempting to improve
nurse-nurse relationships. This project confirmed the necessity for reflective practice and
continued collaborative research processes in the workplace to bring about cultural change
within nursing.
Taylor et al. (2002) used a combination of action research and reflective practice processes to
explore idealism in palliative nursing care. Six experienced registered nurses identified their
tendency toward idealism in their palliative nursing practice, defined as the tendency to expect a
hundred percent effectiveness all the time in their work. Participants collaborated in generating
and evaluating an action plan to recognize and manage the negative effects of idealism in their
work expectations and behaviors. Participants expressed positive changes in their practice, based
on adjusting their responses to their idealistic tendencies toward perfectionism.
Reflective Limitations
The benefits of reflective practice have been highlighted previously in each section of this
resource paper, relating to the positive applications in all fields of nursing. Critics have perceived
28
limitations in reflective practice, even as reflective practice has become more accepted and
commonplace in nursing. The nursing profession has been criticized for actively embracing
reflection (Jarvis, 1992). Greenwood (1993) argued that the underpinning of Schon’s model of
reflection is founded on theories that are difficult to articulate, as they are embedded in the
activity itself. Thus, Greenwood saw the attempt to access these imbedded theories through
verbal means as inconsistent.
Newell (1994) and Burnard (1995) observed “the lack of empirical studies to demonstrate the
value of reflective practice to nursing”. Jones (1995) argued that “reflection is colored by
hindsight bias”. Heath (1998b) stated that “initial blocks to knowing occur as expertise grows in
the denial of not knowing and satisfaction with current performance”. Hancock (1999) suggested
that “certainty creates premature closure on situations and blocks further development toward
expertise”. Rich and Parker (1995) warned that “reflection on negative situations can lead to
helplessness, hopelessness, a loss of self-confidence, and damage to self-esteem. Further, they
maintain there is little guidance on what to do when critical incident analysis or narratives
demonstrate unsafe care, the telling of lies, and inter-professional conflict”. Mackintosh (1998)
also criticized “reflection on ethical grounds related to confidentiality and questioned whether
students write what they actually thought and did, or what they perceive their teachers wanted to
read”.
“Some view reflection as a fundamentally flawed strategy citing concerns and criticisms”
(Mackintosh, 1998). “There may be a high degree of personal investment required by nurses with
minimal successful practice outcomes” (Taylor, 1997). “Effective reflection requires participants
to overcome barriers to learning”, (Platzer, Blake & Ashford, 2000b). “Nurses need to beware of
producing dogma”, (Heath, 1998c). “There may be cultural barriers to empowerment through
reflection”, (Johns, 1999). “Negative consequences may ensue when practitioners are pressured
to reflect”, (Hulatt, 1995). Other concerns include the potential dangers of promoting “private
thoughts in public spheres” (Cotton, 2001), the failure of reflective processes to “address the
postmodern, cultural contexts of reflection” (Pryce, 2002), and the “lack of research evidence to
support the mandate to reflect” (Burton, 2000).
29
Ghaye and Lillyman (2000) critically reviewed the foundations and criticisms of reflective
practice to question whether reflective practitioners were simply following a trend, concluding
that reflective practice has a place in the postmodern world because of its ability to explore micro
levels of human interaction and personal knowledge. In contrast, Taylor (2003, p. 244) states that
“reflective practice tends to adopt a naïve or romantic realist position and fails to acknowledge
the ways in which reflective accounts construct the world of practice.”
Scholarly critiques are signs of healthy discourses and maturity in nursing developments and
help point out areas needing attention and well-reasoned defense. Markham (2002), Rolfe
(2003), and Sargent (2001) respond to the critics with conviction that although reflective practice
has its limitations, and it requires time, effort, and ongoing commitment, it is nevertheless worth
the effort to bring about deeper insights and changes in practice, leadership, clinical supervision,
and education. In counterpoint, perhaps its most important contribution is the potential for
personal transformation of the individual nurse to achieve maximum potential (Sherwood &
Freshwater, 2005).
Conclusion
The notion of the reflective practitioner is an enticing one. To assert the importance of the
experiential knowledge and creative practice, from the started to the embrace in fact, the
messiness and unpredictability of practice and then to unpick what is going on by generating
inductive hypotheses which are dispassionately analyzed to reveal the nature of expertise and
judgment these are ideals to strive towards. And there is much about the reflective paradigm to
hold on to. Indeed it seems an essential counterbalance to the school of evidence based practice
which sees certainty and technical rationality as its highest ideals.
Reflective practice takes account of the mix of rationalities that underpin judgment, so that we
do not take scientific evidence for granted but weigh it in the balance along with other
competing versions of events (Taylor & White, 2001). It raises practitioners above the status of
mere technicians, emphasizes the richness and creativity of their practice and leads to persuasive
new formulations of professionalism based on diversity and flexibility (Fook, 2000). By
unsettling dominant, modernist conceptions of knowledge and expertise it enables many new
30
perspectives to develop. An example of this is the development of clinical supervision in nursing
which by seeking to “de-medicalise” nursing (Butterworth et al, 1998) and emphasize its
expressive role has contributed to studies of the gendered nature of healthcare which have
rethought traditional working practices and hierarchies (Davies, 1998; Parton, 2003).
The reflective paradigm has led to important developments in teaching and learning it has also
created some problems. Reflection is notoriously difficult to define and loose definitions and
uncertainty about how to assess it can lead to oppressive practice (Ixer, 1999). Educators should
be much more aware of the issues in requiring less powerful people to perform confessional-
reflective tasks and not be so quick to assume that reflective learning is always a good thing.
Practitioners’ reflective accounts are often extolled as giving access to the raw material of
practice but this is a naïve approach (Taylor, 2003) that fails to take account of the imagistic and
metaphorical nature of language which constitutes rather than reflects reality (Gould, 1996b).
Reflective accounts are as artfully constructed and performative as any other uses of language.
They give access to how professionals construct their identities and those of service-users and
their practices but they are not by themselves enough. Service user perspectives are essential and
so is the kind of ethnographic research which seeks to analyses day to day practice realities and
professionals’ verbal and written accounts (Taylor & White, 2000; White & Featherstone, 2005)
If reflective practice has become the new orthodoxy, the dominant discourse within professional
education, it is essential that we keep a critical perspective so we are as alive to its problems and
limitations as to its strengths.
31
Reference
Practice and practice development (Thorpe & Barsky, 2001; Stickley & Freshwater,
2002; Taylor, 2000, 2002a, b; Johns, 2003)
Clinical supervision (Todd & Freshwater, 1999; Heath & Freshwater, 2000; Gilbert,
2001)
Leadership and management (Freshwater et al., 2001; Freshwater, 2002; Freshwater,
2004; Johns, 2004; Sherwood & Freshwater, 2005)
Education (Cruickshank, 1996; Freshwater, 1999; Kim, 1999; Anderson & Branch,
2000; Clegg, 2000; Platzer, Blake & Ashford, 2000a, b)
Research and scholarship (Freshwater, 2001; Taylor, 2001, 2002a, b)
Boenink AD, Oderwald AK, De Jonge P, Van Tilburg W, Smal JA. Assessing student
reflection in medical practice: the development of an observer-rated instrument—
reliability, validity, and initial experiences. Med Educ.2004
Pee B, Woodman T, Fry H, Davenport E. Appraising and assessing reflection in
students' writing on a structure worksheet. Med Educ.2002
Branch WT Jr, Paranjape A. Feedback and reflection: teaching methods for clinical
settings. Acad Med.2002;
Kolb D. Experiential Learning: Experience as the Source of Learning and Development.
Englewood Cliffs, NJ: Prentice-Hall, Inc; 1984
32
Mezirow JA. Fostering Critical Reflection in Adulthood: A Guide to Transformative and
Emancipatory Learning. San Francisco, CA: Jossey-Bass; 1990
Brookfield SD. Developing Critical Thinkers: Challenging Adults to Explore Alternative
Ways of Thinking and Acting. San Francisco, CA: Jossey-Bass; 1987
Plack M, Santasier A. Reflective practice: a model for facilitating critical thinking skills
within an integrative case studies classroom experience. J Phys Ther Educ.2004
Yorks L, O'Neil J, Marsick VJ, eds. Action Learning: Successful Strategies for
Individual, Team, and Organizational Development.Monograph of Advances in
Developing Human Resources. Baton Rouge, LA: Academy of Human Resource
Development; and San Francisco, CA: Berrett-Koehler Communications Inc; 1999
33
Recommended