Discovering and affirming knowledge in nursing practice

This paper discusses how the use of care stories or stories derived from clinical nursing practice were used to elucidate the knowledge used in nursing practice. In addition, the processes used to elucidate this knowledge are described and consisted of reflective and critical reflective activity undertaken in both individual and group forms. In describing the processes used the concepts of reflection, critical reflection, narrative and story are discussed with reference to contemporary literature. It is the contention of the authors of this paper that nurses can, by verbalizing care stories with peers, identify knowledge that is either unique to nursing or highly valued by nurses. An additional value, that is concluded in this paper, is that nurses, by the verbalization of care stories, assist other nurses to see what they do, to hear what they do and also to value what they do. By using reflective conversation, as described by D.A. Schon, as a teaching-learning strategy the authors believe that this process may also enable the generalization of such knowledge and its transmission to peers as well as assisting students to record their knowledge and, in so doing, maintain it within the discipline.     

Reflective practice and daily ward reality: a covert power game

Background. The concept of reflection is propounded in the literature as an epistemology for practice that enables practitioners to solve their daily problematic situations through conscious thought processes which eventually leads to practice‐based knowledge. Hence, reflection became a central tenet of both theory development and educational provision in nursing. Furthermore, this centrality of reflection was reinforced by statutory nursing bodies and service providers by adopting it as the means for carrying out adequate professional practice. Although this may be the case, issues of implementation of reflection within the daily reality of practitioners are frequently overlooked within the literature. Moreover, little consideration appears to be given on the impact that the organizational culture and the politics of power may exert on the implementation of reflective practices within daily ward reality. Aims. This paper explores how reflection is viewed by nurses within their daily reality in the medical wards, examines the relationships between the organizational culture of these wards and the practitioners and investigates whether reflective methods of practice were being implemented when the study was conducted. Methods. An interpretative ethnographical methodology was implemented and the data collecting methods used were observation, interviews and qualitative content analysis with a group of 16 practising nurses from four medical wards of one NHS Trust in England. Two interviews were conducted with each nurse within 3‐week intervals. The content of these interviews evolved from the analysis of episodes of practice observed when the nurses were giving nursing care. These data were supplemented by narratives from the nurses’ in the form of written reflective accounts that were analysed via qualitative content analysis techniques. Findings. Four themes were generated: (i) relationships between nurses and doctors; (ii) relationships between nurses and managers; (iii) nursing practice; and (iv) nurses’ input in the outcome of a clinical situation. Conclusions. The concept of reflection appears to be invalidated by the organizational hierarchy of the wards on the basis of a power struggle game. The ward structure portrays reflection as an abnormal method of practice and knowledge development. This belittlement of reflection does not mirror the practitioners’ reality. Instead, it is an intelligent and intentional act on behalf of the dominant professional groups in the wards to create an illusionary picture of ward reality to allow them to survey and define nursing practice and thus maintain and remain in power. This is explicated by using Foucault's analysis and critical social theory framework. Hence, reflective processes are constrained by this covert power game; reflection, where used, is confined to nurses’ personal time and space. Relevance to clinical practice. The realization of this covert power game by individual clinical nurses can become the incipient point for formally using reflective methods in the practice setting.     

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.     

Developing critical reflection for professional practice through problem-based learning

AIMS: To explore the influence of current learning traditions in nursing on the development of reflection and critical reflection as professional practice skills and to offer suggestions for nursing education that will specifically facilitate the development of critical reflection. ORGANIZATIONAL CONSTRUCTS: Mezirow's transformative learning theory, Barrows conceptualization of problem-based learning (PBL). METHODS: Integrative literature review of published literature related to nursing, health science education and professional education from 1983-2000. FINDINGS: Professional education scholars concur that specialized knowledge is clearly essential for professional practice, however, they also suggest that self-consciousness (reflection) and continual self-critique (critical reflection) are crucial to continued competence. While strategies to facilitate reflection have been outlined in the literature, specific strategies to facilitate the development of critical reflection and implications for nursing education are much less clear. Advocates of reflective and critically reflective practice suggest that the development of these abilities should be inextricably linked to professional development and can be developed through active repeated guided practice. In health care, PBL based on constructivism, has been identified as one way to facilitate the development of these skills. CONCLUSIONS: Nursing learners exposed to PBL develop the ability to be reflective and critically reflective in their learning and acquire the knowledge and skill within the discipline of nursing by encountering key professional practice situations as the stimulus and focus of their classroom learning. The learners' ability to be both reflective and critically reflective in their learning is developed by critical questioning of the faculty tutor during situational analysis, learning need determination, application of knowledge, critique of resources and personal problem-solving processes, and summarization of what was learned.     

Reflective practice in the Accident and Emergency setting

The object of this paper is critically to analyse the issue of reflective practice within the writer's own professional arena. The writer is a senior nurse within an Accident and Emergency (A & E) department.It has long been recognised that a gap exists between theory and practice in nursing. There has been much discussion in the nursing literature about the development of the reflective practitioner and how reflection in practice can assist in closing the theory-practice gap.Nurses have always experienced great difficulty in identifying a theory of practice.Jarvis (1992) states that reflective medicine is a frequently used but infrequently defined concept in nursing at the present time. For both qualified nurses and students alike, reflection can be utilised as a learning process to help them expand and develop their clinical knowledge and skills to directly benefit client care (Dewing 1990).Schon (1987) has identified reflection as a process of knowledge acquisition originating in practice and best suited to solving complex practice based problems. Reflection is an active process of exploration and discovery which often leads to unexpected outcomes (Boud et al 1985).Reflection that occurs in the process of an experience is referred to as reflection-in-action (Schon 1987). Nurses have the ability to think about their actions while they are carrying them out and change the actions should the professional's assessment of the situation change (Schon 1983). Reflection can lead to new understanding and appreciation which can be put to use in future experiences (Dewing 1990).This paper will commence with a brief explanation of how nurse education is developing reflection and experience to assist the student nurse to close the theory-practice gap.     

A framework guiding critical thinking through reflective journal documentation: a Middle Eastern experience

The purpose of this paper is to present a framework to guide critical thinking through reflective journaling, and describe how a group of 20 Middle Eastern nurses used reflective journaling to enhance their practice. Journal documentation was used during clinical practicum to foster the development of critical thinking in order to assist nurses when analysing and evaluating their clinical experiences. The findings from this study demonstrated that nurses accepted the framework for journal documentation because it provided structure for reflection, speculation, synthesis and metacognition of events experienced during clinical practice. Journaling gave nurses the opportunity to transfer thoughts onto paper and write down subjective and objective data, and created dialogue between the nurse educators and nurses. They were engaged in productive and positive activity to enhance their nursing practice. Nurses also commented that writing helped to develop their confidence in writing English.     

The value of reflective journaling in undergraduate nursing education: a literature review

OBJECTIVES: The purpose of this literature review was to ascertain the evidence for the use of reflective journaling as a tool to promote the pedagogical strategy of reflection for the purpose of learning from practice for practice in undergraduate nursing education. DESIGN: Concept-centric. DATA SOURCES: The literature review involved structured searches of all OVID gateway databases, EBSCO host databases, and Blackwell Synergy. Qualitative and Quantitative Studies from 1992 to 2006 were included if they focused on reflective journaling in undergraduate clinical education. REVIEW METHODS: Due to the vast plethora of literature on reflection, keywords were utilized to focus the search. Approximately 150 abstracts were reviewed for primary sources of research. A total of nine studies met the inclusion criteria. The review subsequently divided the literature into four content themes allowing for appraisal and analysis of the findings, followed by summary and key recommendations for nursing education and research. RESULTS: There was evidence that educators struggle to incorporate reflective processes into education; however, the research provided rationale and support for engaging undergraduate students in the reflective process. Researchers found reasonable levels of reflection in undergraduate students' journaling and educators reported students' learning as a result of reflective journaling. Further to this, there was evidence that writing reflectively improved over time; a learned skill also dependent on a good facilitator and trust. Unfortunately, there was a paucity of research that explored the undergraduate nurses' experiences with the process of having to create written communication, with a critical reflective focus on practice. CONCLUSION: Nursing educators are correct in pursuing the teaching and learning of the reflective process in undergraduate nursing education. Nurse educators need to utilize various tools and strategies for facilitating the growth of undergraduate students into reflective practitioners. Indeed there was only limited evidence to support reflective journaling as an appropriate tool to promote reflection for the purpose of learning from practice for practice in undergraduate nursing education. Research that provides insight into the undergraduate student experience and perceptions of reflective journaling is needed to facilitate the structuring and use of reflective journaling as a tool in undergraduate nursing education.     

Learning from practice--reflections on a critical incident

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

A comparison of North American and European conceptualizations of clinical supervision

Examination of the extant North American and European substantive literature indicates two differing conceptualizations of the purpose and resultant practice of clinical supervision (CS). The North American conceptualization creates the need for all supervisors to be more "expert" in the particular speciality of nursing than the supervisee, and this paper explores some of the hitherto unanswered issues arising from this. The European conceptualization posits supervision as a forum for considering the personal, interpersonal, and clinical aspects of care so as to develop and maintain nurses who are skilled and reflective practitioners. This situation creates the need for supervisors to be effective at supporting nurses in self-monitoring, identifying difficulties in practice, and finding the proper place to make good the deficit, not necessarily to be more expert in the particular nursing speciality.     

A COMPARISON OF NORTH AMERICAN AND EUROPEAN CONCEPTUALIZATIONS OF CLINICAL SUPERVISION

Examination of the extant North American and European substantive literature indicates two differing conceptualizations of the purpose and resultant practice of clinical supervision (CS). The North American conceptualization creates the need for all supervisors to be more “expert” in the particular speciality of nursing than the supervisee, and this paper explores some of the hitherto unanswered issues arising from this. The European conceptualization posits supervision as a forum for considering the personal, interpersonal, and clinical aspects of care so as to develop and maintain nurses who are skilled and reflective practitioners. This situation creates the need for supervisors to be effective at supporting nurses in self-monitoring, identifying difficulties in practice, and finding the proper place to make good the deficit, not necessarily to be more expert in the particular nursing speciality.     

On reflection in action: Unaddressed issues in refocusing the debate on reflective practice

Clinton M. International Journal of Nursing Practice 1998; 4: 197–202
On reflection in action: Unaddressed issues in refocusing the debate on reflective practice
Reflective practice is now widely debated as a means of improving nursing practice. However, assumptions about reflective practice are rarely clarified and seldom subjected to critique. Therefore, the purpose of this paper is to take up Clarke, James & Kelly's suggestion that limits to the scope and depth of reflection be considered. This is achieved by reflecting on what these authors claim it means to reflect in action. Four arguments are presented: (i) that nurses cannot be conscious of all aspects of nursing practice because there are aspects of practice that cannot be represented in consiousness, (ii) that those aspects of practice that can be represented in consciousness can be so only imperfectly, (iii) that all such representations are not reflexive, and (iv) that any representation in the form of an internal dialogue that could be regarded as reflection is overdetermined. Implications for reflexivity are then considered.     

Reflective Practice Enhances Public Health Nurse Implementation of Nurse‐Family Partnership

ABSTRACT Reflective practice is defined as a cyclical process involving a series of phases in which an individual describes a salient event, attends to his/her positive and negative feelings about the event, and ultimately reexamines the experience in an effort to understand and to plan how he or she would act in a similar situation in the future. This paper describes how the concept of reflective practice is integrated into the evidence‐based Nurse‐Family Partnership (NFP) program. The pivotal role of the nursing supervisor in guiding nurses to engage in reflection on their work with families is emphasized. Exemplars drawn from the experience of 2 NFP nursing supervisors are presented to illustrate how reflection in the NFP program is operationalized. The benefits as well as the challenges to the use of reflective practice are also discussed. While anecdotal comments from NFP nurses and supervisors are cited to suggest how the regular use of reflective practice has the potential to improve implementation of the program with families, the authors further propose that research is needed to more rigorously examine the benefits that reflective practice may have on the quality of program implementation, family outcomes, and the retention of nurses working in the NFP program.     

Reflections on the role of the nursing development facilitator in clinical supervision and reflective practice

The notions of clinical supervision and reflective practice are attracting considerable interest across the spectrum of nursing. This paper focuses upon how the two were linked together and, with the support of an independent survey, were used to evaluate the nursing development facilitator role. It is argued that reflective practice, as a model of clinical supervision, may provide a forum for nurses to explore the value of their actions. Linked to this, the personal knowledge that is revealed may mirror reality and as a result it is argued that there is benefit in evaluating practice through reflection.     

Introducing guided group reflective practice in an Irish palliative care unit

This paper describes the processes involved over one year in introducing, facilitating and evaluating a project of guided reflective practice for a group of eight palliative care nurses in Milford Care Centre, Republic of Ireland. While literature has tended to concentrate on critical discussion relating to reflection, less attention has been directed towards the organisation and facilitation of reflective processes in practice. In addressing this deficit, a detailed account of the collaborative processes and challenges involved in this project are presented. Group evaluation of the project is discussed under the following themes: understanding the process of reflective practice; the value of keeping a reflective diary; guided group reflection and moving forward. The introduction of guided reflection for palliative care nurses has afforded both the facilitators and the participants an opportunity to meet away from the clinical environment, and to work together, finding fresh insights to inform practice. The valuing and promotion of reflective processes by an organisation arguably provides a fundamental strategy to support nurses in a quality palliative care setting.     

A new way of reflecting in nursing: the Peshkin Approach

Title.  A new way of reflecting in nursing: the Peshkin Approach.
Aim.  This paper is a report of a new approach to reflection in nursing and demonstrates its positive outcomes for student learning in clinical practice.
Background.  Reflection is a popular educational tool in nursing and most traditional reflective models take an incident as the starting point. We have developed a new approach that focuses on subjective thoughts and feelings. We were inspired by the work of Peshkin and his focus on the 'subjective I'. For this reason, we have termed this new way of reflecting 'The Peshkin Approach'.
Data sources.  Eight nursing students kept a reflective diary during a 6-week clinical placement in 2008. The focus was on recording their thoughts and feelings. They analysed the diary entries using a systematic approach. The aim was to identify aspects of their subjectivity influencing them in clinical practice.
Discussion.  Through analysis of journal entries, the students became aware of the subjective I's that were influencing their experiences. They found the advantages of the approach to be twofold: increased self-awareness and enhanced learning.
Conclusion.  Maintaining a reflective journal that focuses on subjectivity can enhance the clinical experiences of nursing students. We advocate this new approach as complementary to more traditional forms of reflection and argue for its incorporation into nurse education programmes. In comparison to traditional reflective models that we have used, the Peshkin Approach to Reflection has significant advantages in terms of promoting student learning in clinical practice. We hope the approach can be critiqued and developed further by those interested in enhancing nurse education.     

Reflection and patterns of knowing in nursing

Over the last decade nursing has progressed from a reliance on empirical theory applied to practice to a recognition that experience develops knowledge that can guide the actions of practitioners. Reflection is a means of surfacing experiental knowledge, and students may begin to use reflection as their experience of nursing accumulates. As Carper was a key figure in widening that knowledge accepted as knowing in nursing beyond the empirical, it is both justified and recommended that her work should be incorporated into reflective practice. Johns has integrated Carper's work in his model of guided reflection and this paper briefly examines this combination. The main focus is on two further patterns of knowing: unknowing and sociopolitical knowing. These patterns are examined and the contribution they could make to reflective practice is discussed.     

Reflection,the way to professional development?

Background. Many studies have focused on reflection and the advantages that can be gained from the practice of reflection among Registered Nurses (RNs) but, what are the implications of the nurses’ reflections, what do they reflect about, and how do they deal with their reflections? Aims and objectives. The aim of this study was to describe the RNs’ experiences of reflection in relation to nursing care situations, and to understand how RNs use reflection in their daily work. What are the implications of the nursing care situations that the RNs’ reflect upon? What consequences did the practice of reflection have in nursing care situations in relation to the RNs professional development? Design and method. The study was carried out with interviews and the phenomenographic method. Interviews were carried out with four RNs. The choice of informants was made with purposive sampling with the aim of finding informants who could bring the kind of knowledge that was necessary for the study. Results. The qualitative differences regarding the RNs’ experiences of reflection were categorized as follows: to reflect (to think back – consider, mirroring, to reflect before and reflect after, to use experiences), nursing care situations (ethical considerations, to have courage, to use one's imagination, empathy) and consequences (to meet the unique, empathy, development). Finally, the findings were implicated in the model of professional development. Conclusion. By using reflection as a tool, many advantages can be gained in the development of nursing care. Encouraging RNs to reflect upon nursing situations, in order to promote the nurse's professional development, will imply better nursing care for the patients. The model for professional development implies a simplified representation of the thoughts pertaining to professional nursing development. Relevance to clinical practice. The relevance for clinical practice will be to understand the contents of the RNs reflections, to recognize the advantages of reflective practice and how and when to use such measures. Furthermore, to show how the model for professional development can be used in order to create a framework for evaluating these observations and consequently, for expressing tacit knowledge.