Reflective practice: a guide

Reflective practice is an important concept to the development of nursing as a profession. Nurses need to become reflective practitioners, especially within the current changeable climate. Many practitioners however, find reflective practice confusing and feel unsure how to proceed. This paper attempts to remove some of the mystery surrounding this issue. The skills needed for reflection are identified from a review of the literature. These include self-awareness, critical analysis, synthesis and evaluation. A suggested activity for developing reflective skills is provided as well as a format for keeping a learning diary.     

Reflective thinking in clinical nursing education: a concept analysis

Over decades nursing had an interest in clarifying and developing its knowledge base and its conceptual foundation. Reflective thinking has become a popular word in nursing education world wide, but its meaning and effective use remains debatable because of lack of clarity in its meaning (Mackintosh, 1998:553). The researcher engaged in the concept analysis of reflective thinking so as to fully understand its meaning and interpretation, hence the research question to be addressed by this article is: "What is the meaning of reflective thinking in clinical nursing education?" This article seeks to explore and describe the conceptual meaning of reflective thinking in clinical nursing education using the method of concept analysis as outlined by Wilson (1963:23-39) and Gift (1997:75,76). Concept analysis of reflective thinking constitutes the first phase of a study to develop a model to facilitate reflective thinking in clinical nursing education, thus ensuring theoretical validity of the model. An extensive examination of domain specific and various disciplines' literature was explored as part of the concept analysis. A selection of information regarding variations and similarities in the use and interpretation of reflective thinking across clinical nursing education was drawn from computerised data bases. This increased the rigor and the findings of the analysis. Through deductive reasoning and drawing of inferences, attributes were clustered in an attempt to identify the apparent essence of the concept. Three categories and the related connotations emerged as follows: Antecedents (Cognitive and affective thinking skills). Process (The three phases of reflective thinking). Outcome ( New insight and changed perspective). Reflective thinking was considered from the result of concept analysis as a cyclic, interactive constructing mental process to improve practice in a specific context. It is recommended that a model to facilitate reflective thinking in clinical nursing education be developed based on the results of this concept analysis.     

Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self-regulated learning theory

BACKGROUND: Effective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skills. While a number of strategies have been implemented and tested to promote these skills, educators have not been able consistently to predict their development. Self-regulated learning theory suggests that this development requires concurrent attention to both the cognitive and metacognitive dimensions of reasoning in nursing care contexts. AIMS: This paper reports on a study to explore the impact of self-regulated learning theory on reflective practice in nursing, and to advance the idea that both cognitive and metacognitive skills support the development of clinical reasoning skills. METHODS: Integrative review of published literature in social science, educational psychology, nursing education, and professional education using the Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resource Information Center (ERIC), and American Psychological Association (PsychInfo) Databases. The search included all English language articles with the key words clinical reasoning, cognition, critical thinking, metacognition, reflection, reflective practice, self-regulation and thinking. FINDINGS: Reflective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skill acquisition. This skill acquisition is best accomplished through teaching-learning attention to self-regulation learning theory. A critical analysis of the literature in the areas of critical thinking and reflective practice are described as a background for contemporary work with self-regulated learning theory. It is apparent that single-minded attention to critical thinking, without attention to the influence of metacognition or reflection, is but one perspective on clinical reasoning development. Likewise, single-minded attention to metacognition or reflection, without attention to the influence of critical thinking, is another perspective on clinical reasoning development. While strategies to facilitate critical thinking and reflective practice have been used in isolation from each other, there is evidence to suggest that they are inextricably linked and come together with the use of self-regulated learning prompts. CONCLUSIONS: Students and practising nurses are able to improve their cognitive and metacognitive skills in clinical contexts by using self-regulated learning strategies. The self-regulated learning model in nursing is offered to support teaching and learning of reflective clinical reasoning in nursing practice contexts.     

A guide to nursing students' written reflections for students and educators

Experiences from the clinical setting are ideal for building critical thinking skills if reflection is used as a teaching tool. Reflective writing is the purposeful and recurring inspection of thoughts, feelings, and occurrences that coordinate with experiences during practice. Reflecting on clinical experiences develops critical thinking ability, fosters self-understanding, facilitates coping, and leads to improvement in clinical practice (Kennison, 2006). Reflective writing allows students to combine clinical experiences and takeaways with didactic material to better understand both practice and instruction. Reflective writing is defined as an assignment that is focused on students’ experiences, like textbook readings, clinical experiences, or group activities, that highlights what the student has taken from the activity (McGuire et al., 2009). This study will explore reflective writing from the perspective of the nursing student and the nurse educator. The following questions will be answered: What are the benefits of reflective writing? Why would nurse educators want to use reflective writing in their nursing courses, both clinical and didactic? What are the barriers to using reflective writing for students and educators? What is the role of the nurse educator in student reflection?     

A concept analysis of reflective practice: determining its value to nurses

Reflective practice has been welcomed into nursing education with open arms. However, practitioners are cautious of its perceived benefits and limitations considering the evidence-based literature has not been adequately tested. Concepts are well established as the building blocks of theory. It therefore follows that a primary step in building a theoretical base is undertaking a concept analysis. While there is an abundance of anecdotal literature available on reflective practice, it was deemed necessary to analyse the concept, define the attributes, antecedents and consequences, in order to identify a model case of reflective practice for clinical practice. This article uses Rodgers' (1989) methodology to gain a better understanding of what reflective practice actually is, and whether the concept is in fact useful to the practising nurse.     

Promoting reflection in mental health nursing practice: a case illustration using problem-based learning

Reflective practice in nursing has been shown to improve both client care and nurses role satisfaction. Students require regular and guided opportunities to learn the necessary reflective skills that underpin best practice. Problem-based learning (PBL) processes based on comprehensive learning packages developed from actual clinical cases provide a contextualized and realistic means for students to develop and hone their reflective skills for use as mental health practitioners. This paper uses a case illustration to demonstrate the usefulness of PBL as a mechanism for developing reflective practice in the mental health context. Students analysed five cases drawn from actual documented clinical materials that included nursing, medical and allied health professionals' assessments, treatment regimes, and progress notes. One student's written analysis of the five cases and an interview with the student is presented as a case illustration. The case illustrates the student's reflections on the theme of 'hope' for the clients and identified three obstacles. These were: (i) a lack of acknowledgement by health professionals of traumatic life events; (ii) overlooking less tangible losses; and (iii) a central focus on drug treatment. Reflective learning strategies can be incorporated in on- and off-campus learning environments and used to assist the learner to practise critical reflective skills in a controlled and safe manner. Reflective processes are more meaningful if the PBL package that students encounter represents real clinical scenarios with comprehensive resource materials.     

Reflective journaling: developing an online journal for distance education

Reflective journal writing can be a useful heuristic tool to foster critical thinking skills and develop reflective clinical practice in nursing. When combined with a distance education delivery format, the online journal helps to leverage the strengths of reflective learning with educational technology as well as provide a seamless record of learning outcomes across the curriculum. The authors discuss the incorporation of an online reflective journal into a distance education clinical course and provide guidelines for educators considering a similar approach.     

Completing Reflective Practice Post Undergraduate Nursing Clinical Placements: A Literature Review

Reflective practice post clinical placement in nursing education is essential to integrate knowledge, skills, attitudes, and experiences. Many nursing programs in-cooperate reflective practice to permit the integration of core nursing education with clinical experiences to develop safe and component nurses. The purpose of this literature review is to examine the current trends in nursing education around reflective practice post clinical practice experiences.     

Reflective practice and clinical supervision: meticulous rituals of the confessional

BACKGROUND: Reflective practice and clinical supervision are progressively asserting hegemony upon nursing practice with claims of emancipation and empowerment. However, this is being achieved in an environment where there is little critical debate about the assumptions on which these practices are based. AIM: This paper sets out to challenge the basis upon which reflective practice and clinical supervision are promoted within nursing discourse by employing Michel Foucault's (1982) concept of governmentality. Theme. A broad Foucauldian perspective is used to demonstrate how the technologies of reflective practice and clinical supervision have been accommodated within modern forms of government. These technologies are consistent with the flattened hierarchies and increasing dispersal of practitioners in contemporary health care. In this context reflective practice and clinical supervision can be shown to function in two independent but interrelated ways. First as modes of surveillance disciplining the activity of professionals. Second, as "confessional" practices that work to produce particular identities--autonomous and self-regulating.     

Exploring reflective thinking in nursing practice

While it is claimed in the nursing literature that reflective thinking is the approach par excellence for learning and advancing the art and practice of nursing, few empirical studies have been undertaken in this area to date. Sense-Making, a qualitative research method, was utilized to obtain and analyse data from interviews with 10 registered nurses in order to study reflective thinking in actual nursing practice. Ten non-routine nursing situations were analysed for the presence of reflective thinking. Time-line interviews of the events resulted in a total of 59 micro-moments, each of which was explored in terms of the thinking processes utilized to make sense of the situation as well as the focus of their thought. 'Pre-perceptions' played an important part in how the respondents perceived their situation. Reflective thinking was extensively manifest, especially in moments of doubt and perplexity, and consisted of such cognitive activities as comparing and contrasting phenomena, recognizing patterns, categorizing perceptions, framing, and self-questioning in order to create meaning and understanding. Self-questioning was identified as a significant process within reflective thinking. By exploring and analysing the type of questions respondents were asking themselves, the study uncovered three hierarchical levels of reflective thinking. Respondents most often engaged in reflective thinking-for-action which centred on the here and now in order to act. Reflective thinking-for-evaluation focused on creating wholeness and contributed to the realization of multiple perceptions and multiple responses. Reflective thinking-for-critical-inquiry could not be demonstrated in the study sample. The findings of this study resulted in the development of a model of reflective thinking, which is discussed in terms of the implications for learning in nursing practice.     

Integrating critical thinking strategies into nursing curricula

Critical thinking has been a focus in nursing education for more than 20 years. Promoting student competence in critical thinking skills is essential for nurse educators. Fostering critical thinking ability involves planning and implementation of strategies throughout the nursing curriculum. Reflection, concept mapping, and questioning are some of the best practices identified as effective in developing the critical thinking dimension. Developing a framework of best practices for promoting critical thinking in nursing education can assist nurse educators with integrating critical thinking strategies into nursing curricula.     

Assessing the level of student reflection from reflective journals

The concept of reflective learning has been widely adopted in many of the nursing curricula today Reflective learning is of particular relevance to the education of professionals, as it encourages students to integrate theory with practice, appreciate the world on their own behalf, and turn every experience into a new potential learning experience While nurse educators have widely accepted the educational benefits of reflection, research into reflective learning is hampered by the lack of reliable and widely accepted methods for assessing whether reflection takes place and the level of any reflection This study attempted to develop and test coding systems for written reflective journals based on two well-known models of reflective thinking The reflective journals submitted by the students were subjected to content analysis at two levels The findings of this study suggest that student writing can be used as evidence for the presence or absence of reflective thinking The process of allocating students to three categories of non-reflector, reflector and critical reflector was straightforward and reliable Identifying textual elements within journals and allocating them to the finer levels of reflection within a more complex model of reflective thinking was, however, more problematic and considerably less reliable     

How reflective practice improves nurses' critical thinking ability.

Purposeful reflection is consistent with adult learning theory. It is known to lead to a deeper understanding of issues and to develop judgment and skill. Required by law to ensure members' competence in their professional practice, the College of Nurses of Ontario recommends and has developed a tool for evaluating reflective practice. The tool focuses on key attributes said to be demonstrated by competent practitioners, including critical thinking (CT) and job knowledge. This study aimed to determine whether nurses engage in reflective practice and whether they perceive that it enhances their CT ability. Surveys were sent to 60 gastroenterology nurses at a large teaching hospital; 34 surveys were anonymously returned. All respondents engaged in reflective practice, and 24 reported using the college's tool. Nineteen respondents strongly agreed that their nursing practice had improved as a result. Critical thinking is difficult to assess because of a lack of clear-cut performance criteria. Improvement of CT was difficult to evaluate from the responses, even though all respondents participated in reflective practice. Both CT and reflective practice need to be better defined in order to examine and explain their relationship.     

Critical thinking skills of baccalaureate nursing students at program entry and exit

Most nurse educators would agree that critical thinking is an essential competency for the professional nurse in today's ever-changing health care environment. In fact, critical thinking has been identified as an integral component of professional nursing practice and has been incorporated in accreditation guidelines (1-3). As a result of this imperative, professional programs of nursing must explicate a clear definition of critical thinking, identify specific learning outcomes reflective of critical thinking abilities, and select appropriate ways to measure the achievement of these outcomes in graduating students. Although much has been written about the need for critical thinking skills, the concept and measurement of critical thinking within the context of nursing education has not yet been clearly defined (4-6). As a result, nursing programs are developing their own conceptual definitions of critical thinking and using a variety of methods to measure outcomes (5). The authors caution that to ensure validity of findings, the instruments used must reflect the individual program's definition of the concept. In most cases, outcomes have been assessed using a cross-sectional design that compares students at different levels or types of programs or are measured as an end-of-program outcome. While such designs can provide educators with knowledge of students' critical thinking abilities at a particular point in the educational process, longitudinal data are needed to assess the effects of the educational program.     

反思性学习法对实习护生评判性思维能力的影响

目的 探索反思性学习法对实习护生评判性思维能力的影响,为临床护理教学模式的改革提供参考依据.方法 将本科和专科实习护生共102人随机分为实验组和对照组各51人,对照组按常规实习程序实习;实验组在常规实习的基础上,对其进行反思性学习相关知识培训,并要求书写反思日记及定期召开小组讨论会.实习前和实习结束时均采用"评判性思维能力量表"(CTDI-CV)对2组护生进行测试.结果 实习前对照组CTDI-CV总平均分为(286.26±28.15)分,实验组为(285.79±30.52)分,2组比较无显著差异;实习结束时,对照组CTDI-CV总平均分为(289.34±32.53)分,实验组为(305.63±22.46)分,2组比较差异显著.结论 反思性学习法有助于培养实习护生的评判性思维能力,值得临床护理教育工作者借鉴使用.     

Evaluation of a reflective learning intervention to improve critical thinking in novice nurses

AIM: This paper reports a study to determine if a reflective contextual learning intervention would improve novice nurses' critical thinking skills during the first 6 months of their practice. BACKGROUND: Nursing research evaluating the development of critical thinking in novice nursing practice is limited. The continual struggle by nurse educators to improve critical thinking demonstrates the need for innovative educational interventions that assist in the development of critical thinking as novice nurses enter into practice. METHOD: This small case study was conducted in the United States of America in 2004 with six student/preceptor dyads. The contextual learning intervention was the case through which the novice nurses' critical thinking were analysed using Stake's phases of data analysis. Specific questions (i.e. novice nurses' use of reflection, context, dialogue, time) guided the analysis. Repeating patterns were coded and isolated and later collapsed/enhanced as the analysis moved forward. FINDINGS: Three main themes describe the novice nurses' development of critical thinking: (1) influence of anxiety and power on critical thinking; putting pieces together; (2) questioning as critical thinking: sequential thinking to contextual thinking; and (3) emergence of the intentional critical thinker. CONCLUSION: Used as a reflective practicum, contextual learning can be a model of clinical learning in nursing education that develops the contextual, reflective nature of critical thinking.     

Reflection: a casualty of modularisation?

INTRODUCTION: The use of reflection in nursing and midwifery is well-established and reflective skills are taught on both pre- and post-registration courses as a way of integrating theory and practice, and of developing students' critical and analytical skills. Reflection is generally regarded positively with an assumption that reflective skills benefit both practitioners and patients. The aim of this study was to identify the educational strategies used to develop reflective skills in one pre-registration diploma in nursing curriculum. METHODS: The survey was cross-sectional in design. A questionnaire was designed for the study to explore perceptions of both students and lecturers in one educational establishment. Curriculum documentation was analysed to examine where in the curriculum the development of reflective skills was prominent. The sample consisted of two student cohorts from the adult branch and all senior lecturers within the Institute who taught on the pre-registration programme. RESULTS: The findings revealed a complex picture of students' and lecturers' views of the teaching and learning strategies used to develop reflective skills. Lectures and group work were the strategies cited most commonly by the students, whereas the lecturers felt the strategies used most often were personal tutorials, group work and case scenarios. The documentary analysis revealed that out of the 13 modules, there was explicit reference in only three modules to reflective practice. Furthermore, it was evident that the majority of lecturers were not clear where in the curriculum reflective skills were taught which suggested that an overview of the whole curriculum is not always evident. CONCLUSIONS: Modularisation may have contributed to a fragmentation in the way in which some key health practitioner skills are developed and built upon throughout a curriculum. There needs to be agreement on the nature of the skills which are central to the development of reflective practitioners and clear thinking on how these are developed and assessed within a curriculum.     

Developing clinically savvy nursing students: an evaluation of problem-based learning in an associate degree program

Faculty in an associate degree nursing program at a community college in NewYork City noted that nursing students lacked critical analysis, problem-solving, and decision-making skills and the reflective ability essential to applying nursing knowledge in clinical situations. This study reports on the use of problem-based learning as a teaching strategy and its impact on the development of critical thinking and communication skills in nursing students.