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

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

The lost path to emancipatory practice: towards a history of reflective practice in nursing

This paper historicizes the taken‐for‐granted acceptance of reflection as a fundamental professional practice in nursing. It draws attention to the broad application of reflective practice, from pedagogy to practice to regulation, and explores the epistemological basis upon which the authority of reflective discourse rests. Previous work has provided a series of critiques of the logic and suitability of reflective practice across all domains of nursing. The goal of this paper is to commence a history of nursing's reflective identity. The paper begins with a discussion of Dewey and Schön then focuses on Habermas's Theory of Communicative Action as the epistemological basis of reflective practice's standing as a authoritative discourse in nursing.     

Correlates of Reflective Practice in Medicine

Background: The ability of physicians to critically reflect on their professional practice has been increasingly valued. Previous research brought to light the multidimensional structure of reflective practice in medicine. It comprises at least five sets of behaviours in response to complex medical problems encountered in professional practice. Factors associated to reflective practice among physicians have, as far as we know, not yet been explored by empirical study. Purpose: To study factors correlated to reflective practice among physicians. Methods: A questionnaire exploring characteristics of professional practice and educational experiences was administered to primary health care physicians. Measurements were related to scores on a reflective practice measuring instrument developed previously. Associations between variables were examined by statistical analysis with tests of correlation and analysis of variance. Results: Reflective practice is negatively correlated to physician’s age and number of years of clinical practice. Working mainly in hospitals and attendance to medical residency programmes in some specialties apparently have a positive effect on reflective practice. Conclusion: Reflective practice tends to decrease with experience. Findings are consistent with the literature on medical expertise that shows a decline of analytical reasoning in proportion to the increase in experience. Some specialty programmes seems to enhance concerns with the scientific basis to professional practice, thereby favouring reflective approaches. Local features of primary health care settings probably explain their negative effect on reflective practice. Strategies to develop reflective practice among physicians should be explored by further research.     

Medical and nursing clinical decision making: a comparative epistemological analysis

Abstract The aim of this article is to explore the complex forms of knowledge involved in diagnostic and interventional decision making by comparing the processes in medicine and nursing, including nurse practitioners. Many authors assert that the practice of clinical decision making involves the application of theoretical knowledge (acquired in the classroom and textbooks) as well as research evidence, upon concrete particular cases. This approach draws on various universal principles and algorithms to facilitate the task. On the other hand, others argue that this involves an intuitive form of judgement that is difficult to teach, one that is acquired principally through experience. In an exploration of these issues, this article consists of three sections. A clarification of terms commonly used when discussing decision making is provided in the first section. In the second section, an epistemological analysis of decision making is presented by examining several perspectives and comparing them for their use in the nursing and medical literature. Bunge's epistemological framework for decision making (based on scientific realism) is explored for its fit with the aims of medicine and nursing. The final section presents a discussion of knowledge utilization and decision making as it relates to the implications for the education and ongoing development of nurse practitioners. It is concluded that Donald Schön's conception of reflective practice best characterizes the skilful conduct of clinical decision making.     

Honesty in critically reflective essays: an analysis of student practice

In health professional education, reflective practice is seen as a potential means for self-improvement from everyday clinical encounters. This study aims to examine the level of student honesty in critical reflection, and barriers and facilitators for students engaging in honest reflection. Third year physiotherapy students, completing summative reflective essays on clinical encounters using the modified Gibbs cycle, were invited to participate in an anonymous online survey. Student knowledge and beliefs about reflective practice, and disclosure of the truthfulness of their reflections, were assessed using a mixed method approach. A total of 34 students, from a maximum possible of 48 (71 %), participated in the study activities. A total of 68 % stated that they were at least 80 % truthful about their experiences. There was general student consensus that reflective practice was important for their growth as a clinician. Students questioned the belief that the reflection needed to be based on a factual experience. Reflective practice can be a valuable addition to the clinical education of health care professionals, although this value can be diminished through dishonest reflections if it is not carefully implemented. Student influences on honest reflection include; (1) the design of any assessment criteria, and (2) student knowledge and competency in applying critical reflection.     

About the theoretic, philosophical, epistemological bases of scientific research: the case of nursing

As indicated by the title, this paper discusses the theoretic, philosophical, epistemological basis of scientific research--the case of nursing. The author points out the fundamental questions in nursing--science and art. Nursing is considered both as a social practice and as a profession that encompasses scientific practice and the construction of knowledge. Thus, Nursing is understood as a "science under construction" or as specific knowledge, even if it is imprecise and, therefore, on its way to become scientific due to its evidences. In other words, knowledge that is justified not by total precision, on the contrary, by the need to find answers to the question about raising the epistemological reach of nursing research results--its knowing and knowing what to do. The discussion emphasizes the crucial nature of nursing care.     

Sources of strain between physicians and social workers: implications for social workers in health care settings

This paper analyzes the sources of strain between the professions of medicine and social work. The two professions are compared in relation to (1) the organization and socialization process of professional training; (2) perspectives on patient care, illness and role of the health care professional; (3) attitudes toward knowledge and data; (4) attitudes toward and preparation for team-work; (5) perspectives on the role of the patient; (6) perceptions of social work's function.     

Research assisting nursing practice: a philosophical view

The authors of the present article reflect on the difficulties of nursing research and its relation with its practice, which is based on the philosophy of praxis. Initially, there is a discussion on the relationship between theory and praxis from a philosophical perspective. The authors make a resumed review of nursing knowledge in the last century. Finally, they present the dialectic of interactions as a possibility of advancing beyond the territories of the dialectic of work. According to the authors, complex areas of knowledge related to health/illness/care cannot be exclusively studied by formal sciences or exclusively by biological and social sciences. They believe that a consistent epistemological project has to consider a third area that would include the dialectic of reasoning and the dialectic of representations.     

Knowledge for the good of the individual and society: linking philosophy,disciplinary goals,theory, and practice

Nursing as a profession has a social mandate to contribute to the good of society through knowledge‐based practice. Knowledge is built upon theories, and theories, together with their philosophical bases and disciplinary goals, are the guiding frameworks for practice. This article explores a philosophical perspective of nursing's social mandate, the disciplinary goals for the good of the individual and society, and one approach for translating knowledge into practice through the use of a middle‐range theory. It is anticipated that the integration of the philosophical perspective and model into nursing practice will strengthen the philosophy, disciplinary goal, theory, and practice links and expand knowledge within the discipline. With the focus on humanization, we propose that nursing knowledge for social good will embrace a synthesis of the individual and the common good. This approach converges vital and agency needs described by Hamilton and the primacy of maintaining the heritage of the good within the human species as outlined by Maritain. Further, by embedding knowledge development in a changing social and health care context, nursing focuses on the goals of clinical reasoning and action. McCubbin and Patterson's Double ABCX Model of Family Adaptation was used as an example of a theory that can guide practice at the community and global level. Using the theory‐practice link as a foundation, the Double ABCX model provides practising nurses with one approach to meet the needs of individuals and society. The integration of theory into nursing practice provides a guide to achieve nursing's disciplinary goals of promoting health and preventing illness across the globe. When nursing goals are directed at the synthesis of the good of the individual and society, nursing's social and moral mandate may be achieved.     

Reflection and reflective practice in health professions education: a systematic review

The importance of reflection and reflective practice are frequently noted in the literature; indeed, reflective capacity is regarded by many as an essential characteristic for professional competence. Educators assert that the emergence of reflective practice is part of a change that acknowledges the need for students to act and to think professionally as an integral part of learning throughout their courses of study, integrating theory and practice from the outset. Activities to promote reflection are now being incorporated into undergraduate, postgraduate and continuing medical education, and across a variety of health professions. The evidence to support and inform these curricular interventions and innovations remains largely theoretical. Further, the literature is dispersed across several fields, and it is unclear which approaches may have efficacy or impact. We, therefore, designed a literature review to evaluate the existing evidence about reflection and reflective practice and their utility in health professional education. Our aim was to understand the key variables influencing this educational process, identify gaps in the evidence, and to explore any implications for educational practice and research.     

Exploring UK medical and social work students’ legal literacy: comparisons,contrasts and implications

To ensure acceptable practice standards both doctors and social workers should draw on relevant legal rules when reaching professional judgements concerning, for instance, children requiring protection, people with severe mental distress and adults at risk, information sharing, consent to intervention and service user involvement in their care and treatment. Many practitioners use the law to maintain high standards of professionalism. However, research has uncovered limited awareness of legal rules and poor standards of health and social care. Academic benchmarks and practice requirements for health and social care professions centrally position legal knowledge for secure decision‐making. Model curricula exist. However, the outcomes of the taught curriculum on students’ confidence in their legal knowledge and skills have been relatively overlooked. This article introduces the concept of legal literacy, a distillation of knowledge, understanding, skills and values that enables practitioners to connect relevant legal rules with their professional practice, to appreciate the roles and duties of other practitioners and to communicate effectively across organisational boundaries. It presents the outcomes for a 2006–2009 study of 1154 UK medical and 638 social work students of their law learning for practice, response rates of 46% and 68%. Significant differences were found between medical and social work students’ attitudes towards the law, and in their self‐ratings of legal knowledge and skills. Confidence levels were low and anxiety high, especially among medical students, although law teaching had some positive outcomes on knowledge and skill development. Social work and medical students associated different themes with the law, the latter especially foregrounding ethics, negligence and liability, which could affect inter‐professional working. Students are not fully prepared for legally literate practice, with a consequent need to review the time allocated for, and the content of law learning and the subsequent availability of continuing professional development.     

New graduates’ conceptions of and approaches to veterinary professional practice,and relationships to achievement during an undergraduate internship programme

New graduate veterinarians report differing experiences of the transition to practice. Some make a rapid transition to professional autonomy while others require prolonged and extensive support from their colleagues. Factors contributing to this variation are unclear. This study used phenomenography to analyse the conceptions of and approaches to veterinary professional practice (VPP) reported by new graduates in semi-structured interviews (n = 22). Quantitative statistical analysis was used to investigate links between the quality of graduates’ experiences and their achievement during a comprehensive final year internship programme. Strong associations were identified between the quality of graduates’ conceptions of and approaches to VPP. Links were also established between the quality of graduates’ conceptions of VPP and their performance in practice prior to graduation. The outcomes of this research can be used to improve teaching and assessment during final year internships and enhance graduate attribute statements for professional degree programmes. The results also indicate that student learning research methodologies can be used to evaluate the quality of graduates’ experiences in the workplace. This has implications for career outcomes research in a range of healthcare professions.     

Social role and paradigms of qualitative nursing research

Bibliographic research developed among the 24 fascicles from the "Revista Brasileira de Enfermagem" presented in the SciELO database, from 2005 to 2008. The objective was to identify emergent themes on qualitative researches published on a nursing periodic; correlate theses themes with the knowledge production in nursing and reflect about the social role of these qualitative researches analyzed. After analysis, 173 qualitative studies were identified, and three categories arose: nursing training, areas of practice, nursing care basis/ principles/ conceptions, and professional issues. In the relationship among the categories, the patterns of knowledge and the social role highlight the social-political knowledge, reflecting the profession maturation regarding intrinsic social issues, part of it social body; and extrinsic, the demands from society.     

Jamesian pragmatism: a framework for working towards unified diversity in nursing knowledge development

Nursing is frequently described as practical or pragmatic and there are many parallels between nursing and pragmatism, the school of thought. Pragmatism is often glancingly referenced by nursing authors, but few have conducted in‐depth discussions about its applicability to nursing; and few have identified it as a significant theoretical basis for nursing research. William James's pragmatism has not been discussed substantially in the nursing context, despite obvious complementarities. James's theme of pluralism fits with nursing's diversity and plurality; his emphasis on social conscience in our actions matches nursing's fundamental purpose of improving the lives of others; his continuous testing of pluralistic truths in critically reflective practice pairs well with nursing's focus on developing best‐available, holistic evidence; and his conceptualization of truth as being born in practice and becoming an instrument in practice is entirely compatible with nursing's theory–practice identity. The oft‐discussed theory–practice gap is seen to hinder the development of nursing knowledge. If nursing is to find its identity in knowledge development and potentiate the knowledge developed, it is imperative to identify and address that which is impeding progress. By way of the pragmatic tenets of William James, I will argue that a significant part of the theory–practice gap lies in how nursing knowledge development is operationalized, creating a false dichotomy between practice and research. I will also argue that the research–practice schism has been widened by continued philosophical and methodological infighting in the research community. I will describe how Jamesian pragmatism can be ‘what works’ for rebuilding relationships and supporting an engaged plurality within nursing research and bring research and practice together into a collaborative and iterative process of developing nursing knowledge.     

The importance of effective communication in interprofessional practice: perspectives of maternity clinicians

Midwives and doctors require effective information-sharing strategies to provide safe and evidence-based care for women and infants, but this can be difficult to achieve. This article describes maternity care professionals’ perceptions of communication in their current workplace in Australia. We invoke social identity theory (SIT) to explore how these perceptions affect interprofessional practice. A survey was conducted with 337 participants (281 midwives and 56 doctors). Using exploratory factor analysis we developed three scales that measured interprofessional workplace practice collaboration. Results indicated an intergroup environment in maternity care in which the professionals found exchange of ideas difficult, and where differences with respect to decision making and professional skills were apparent. Although scores on some measures of collaboration were high, the two professions differed on their ratings of the importance of team behaviors, information sharing, and interprofessional socialization as indicators of collaborative practice. These results highlight the complexities among maternity care providers with different professional identities, and demonstrate the impact of professional identity on interprofessional communication.     

Caregivers' Epistemological Beliefs in Toddler Programs

One important structural indicator of child care quality identified consistently from research is the educational qualifications and competency of the caregiver. In this focussed qualitative study of 6 caregivers in toddler programs (children aged 18 months to 3 years), caregivers' beliefs about knowing and learning and their conceptions of good caregiving were explored. The caregivers were videoed within their programs and subsequently asked to describe their epistemological beliefs (about knowing and learning) and conceptions of caregiving during stimulated recall interviews. Two of the caregivers described relativistic epistemological beliefs. In contrast, the remaining four caregivers held multiplistic and mixed epistemological beliefs and lacked the same degree of reflectivity in their responses as the two caregivers with relativistic belief systems. Furthermore, the caregivers with relativistic epistemological beliefs held sophisticated conceptions of caregiving which integrated ideas and made more linkages between teaching and learning. The caregivers with multiplistic and mixed epistemological beliefs described caregiving with unrelated ideas and did not identify links between teaching and learning. Implications of the research findings for the education and professional development of caregivers are discussed.     

Cultural safety and the challenges of translating critically oriented knowledge in practice

Cultural safety is a relatively new concept that has emerged in the New Zealand nursing context and is being taken up in various ways in Canadian health care discourses. Our research team has been exploring the relevance of cultural safety in the Canadian context, most recently in relation to a knowledge‐translation study conducted with nurses practising in a large tertiary hospital. We were drawn to using cultural safety because we conceptualized it as being compatible with critical theoretical perspectives that foster a focus on power imbalances and inequitable social relationships in health care; the interrelated problems of culturalism and racialization; and a commitment to social justice as central to the social mandate of nursing. Engaging in this knowledge‐translation study has provided new perspectives on the complexities, ambiguities and tensions that need to be considered when using the concept of cultural safety to draw attention to racialization, culturalism, and health and health care inequities. The philosophic analysis discussed in this paper represents an epistemological grounding for the concept of cultural safety that links directly to particular moral ends with social justice implications. Although cultural safety is a concept that we have firmly positioned within the paradigm of critical inquiry, ambiguities associated with the notions of ‘culture’, ‘safety’, and ‘cultural safety’ need to be anticipated and addressed if they are to be effectively used to draw attention to critical social justice issues in practice settings. Using cultural safety in practice settings to draw attention to and prompt critical reflection on politicized knowledge, therefore, brings an added layer of complexity. To address these complexities, we propose that what may be required to effectively use cultural safety in the knowledge‐translation process is a ‘social justice curriculum for practice’ that would foster a philosophical stance of critical inquiry at both the individual and institutional levels.     

Towards a model of the expert practice educator – interpreting multi-professional perspectives in the literature

The health and social care professions all rely on the use of practice placements for a substantial element of their pre-qualifying professional education, and these practice-based professions have roles for existing practitioners to oversee the education and training of students when they are on practice placements. Practice educators play a vital role in the development of new practitioners and also in the development and perpetuation of professional values and standards. In this paper, we argue that the practice educator role is thus fundamentally an ethical function, requiring moral commitment from the practice educator but also playing a critical role in maintaining the ethical values of the profession.     

Evidence-based practice: a review of theoretical assumptions and effectiveness of teaching and assessment interventions in health professions

Health care professionals are expected to use a systematic approach based on evidence, professional reasoning and client preferences in order to improve client outcomes. In other words, they are expected to work within an evidence-based practice (EBP) context. This expectation has had an impact on occupational therapy academic programs’ mandates to prepare entry-level clinicians who demonstrate competence in the knowledge, skills and behaviors for the practice of evidence-based occupational therapy. If the EBP approach is to be entrenched in the day to day practice of future clinicians, a pedagogically sound approach would be to incorporate EBP in every aspect of the curriculum. This, however, would require a comprehensive understanding of EBP: its basis, the principles that underpin it and its effectiveness in promoting core professional competencies. The existing literature does not elucidate these details nor does it shed light on how requisite competencies for EBP are acquired in professional education in general and in occupational therapy education in particular. Drawing from educational psychology and EBP in the health professions, this paper provides a critical review of the evidence that supports EBP and the effectiveness of EBP teaching and assessment interventions in professional heath sciences programs and offers suggestions for the design of EBP instruction, grounding recommendations in educational theory for the health professions.     

Caregivers' Epistemological Beliefs in Toddler Programs

One important structural indicator of child care quality identified consistently from research is the educational qualifications and competency of the caregiver. In this focussed qualitative study of 6 caregivers in toddler programs (children aged 18 months to 3 years), caregivers' beliefs about knowing and learning and their conceptions of good caregiving were explored. The caregivers were videoed within their programs and subsequently asked to describe their epistemological beliefs (about knowing and learning) and conceptions of caregiving during stimulated recall interviews. Two of the caregivers described relativistic epistemological beliefs. In contrast, the remaining four caregivers held multiplistic and mixed epistemological beliefs and lacked the same degree of reflectivity in their responses as the two caregivers with relativistic belief systems. Furthermore, the caregivers with relativistic epistemological beliefs held sophisticated conceptions of caregiving which integrated ideas and made more linkages between teaching and learning. The caregivers with multiplistic and mixed epistemological beliefs described caregiving with unrelated ideas and did not identify links between teaching and learning. Implications of the research findings for the education and professional development of caregivers are discussed.