Reflective Practice in Nursing

Chris Bulman, Sue Schutz, Chris Bulman, Sue Schutz

• Publisher: Wiley-Blackwell
• Year: 2013
• Print ISBN: 9780470658109
• eBook ISBN: 9781118307779
• Edition: 5
• Topic: Medicine
• Subtopic: Nursing Skills

From reviews of previous editions:

'This excellent book provides useful guidance on the use of reflection in practice.... a helpful addition to any nursing library.' Primary Health Care

'…an excellent investment in any nurses' library portfolio.' Journal of Advanced Nursing

'An extremely welcome addition to nursing's literature on thoughtful, knowledgeable practice.' Nursing Times

'This is an excellent practical guide to reflective practice…I would highly recommend this book to all practice teachers and students.' Journal of Practice Nursing

The ability to reflect on practice has become a competency demanded of every healthcare professional in recent years. It can be a daunting prospect- but this practical and accessible text guides the way, using the latest research and evidence to support the development of skills in reflective practice and provides help and advice on how to get started, how to write reflectively and how to continue to use reflective practice in everyday situations.

This fifth edition of Reflective Practice in Nursing is an indispensable guide for students and practitioners alike who wish to learn more about reflective practice, as well as containing essential information for teachers and lecturers.

Chapter 1

An introduction to reflection

Chris Bulman

Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK

Introduction

Every contributor to this book is motivated by an interest in reflection. Within this fifth edition, we have presented experience, research and ­theory in order to help you get a better grasp of reflection, especially if you are considering it for the first time. This probably means that you are a student but you could equally be a supervisor, mentor or senior nurse furthering your understanding of reflection, or a nurse teacher interested in reflective education. Whilst this is a book that clearly advocates reflection, we are also aware of the difficulties and criticisms associated with it. Thus we offer a book that will give you some help with whatever journey you are taking with reflection, but will also get you thinking critically about the issues involved.

Contemporary challenges for reflective nursing practice and education

There is no doubt that reflection continues to be of interest to nurses and to influence nursing practice and education around the world. It remains a concept that I and fellow authors are committed to. We believe that being reflective is essential for effective and person-centred professional practice. Significantly, current financial concerns and pressures are ­affecting health services across many countries. This has had an impact on nursing education and frontline clinical services. It has unquestionably influenced the amount of time, energy and support that nurses have to constructively consider and learn from their practice. All this has affected learning opportunities, such as provision of clinical supervision for ­practitioners, time for informally reflecting with colleagues, and ­defending the relevance of reflective education for the development of clinical judgement, alongside the juggernaut which is evidence-based practice education. (I’ll return to this later in the chapter.) With these current ­challenges in mind, we believe it is even more vital to continue to write about reflection as a positive way to learn from experience – warts and all!

Explaining the concept of reflection

Starting with Aristotle

Getting to grips with an explanation of reflection is a sensible place to start. The concept of reflection is not as new as you might imagine. At the outset, I will underline the influence of the Ancient Greek philosopher Aristotle and his notion of practical wisdom/judgement or phronesis. Aristotle emphasised the importance of reflecting in the ‘real world’ and developing experience of it. He emphasised the requirement to pay attention to emotions and imagination in order to develop our perception of the world, so that emotion and imagination are not relegated to unwanted self-indulgent urges or corrupting influences that get in the way of ‘good’ rational thinking, but rather are a responsive and elective part of our thinking. In this way, Aristotle believed it was possible to develop real practical insight, responsiveness and understanding (Nussbaum 1990). So you can begin to see how this might be related to the development of practical knowledge, considering how we feel, as well as think, about practice, and finding a way of communicating this sort of knowledge to others.

Dewey

The educationalist and philosopher John Dewey has been extremely influ­ential in contemporary discussion about the concept of reflection. Dewey developed his ideas on thinking and learning and focused on the concept of thinking reflectively. He defined reflection as:

’Active, persistent and careful consideration of any belief or ­supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends.’ (Dewey 1933, p.9)

Dewey saw reflective thinking as thinking with a purpose and focused strongly on the need to test out and challenge true beliefs by applying the scientific method through deductive reasoning and experimentation. He implied that emotions and feelings are part of reflective thinking but, in contrast to Aristotle, this is not something that he expanded on. He made some important assumptions about people, emphasising our ­tendencies towards quick solutions, custom and ‘mental ruts’ and the pervading influence of culture and the environment upon our thinking:

’External monotony and internal routine are the worst enemies of wonder.’ (Dewey 1933, p.52)

Dewey also emphasised the need for thinking to be directly linked with action, demonstrating the pragmatic nature of his philosophy, and suggested that any thinking can be intellectual, thus emphasising the importance of the practical as well as the theoretical. He has influenced the work of many others, for example, Clarke and Graham (1996), who have also helpfully described the complexity of experiences, and reflection as a reasoning out process.

’By engaging in reflection people are usually engaging in a period of thinking in order to examine often complex experiences or ­situations. The period of thinking (reflection) allows the individual to make sense of an experience, perhaps to liken the experience to other similar experiences and to place it in context. Faced with ­complex decisions, thinking it through (reflecting) allows the ­individual to separate out the various influencing factors and come to a reasoned decision or course of action.’ (Clarke and Graham 1996, p.26)

Schön

The philosopher Donald Schön has been a huge influence on the development of reflection in professional education. Importantly, Schön (1983, 1987) believed that practice should be central to professional curricula; consequently he saw learning by ‘doing’ becoming the core of programmes rather than an add-on, with students investing in practice and time, in order to learn from it. This implies that students need to develop a commitment to practice and the motivation to learn from it (Bulman 2004).

Schön defined reflection-on-action as:

’… thinking back on what we have done in order to discover how our knowing in action may have contributed to an unexpected outcome. We may do so after the fact, in tranquillity, or we may pause in the midst of action (stop and think).’ (Schön 1987, p.26)

This focuses on retrospective critical thinking, to construct and reconstruct events in order to develop oneself as a practitioner and person. Significantly, his concept of reflection involves more than ‘intellectual’ thinking, since practitioners’ feelings and an acknowledgement of an interrelationship with action are also important. (Can you see a link back to Aristotle’s practical wisdom?) Yet Schön’s work focused more on ­reflection-in-action which he saw as a distinguishing feature of expert practitioners who were able to experiment and think about their practice whilst they were doing it:

’… where we may reflect in the midst of action without interrupting it. Our thinking serves to reshape what we are doing while we are doing it.’ (Schön 1987, p.26)

As you can see, this is a different concept from reflection-on-action since it is not about carrying out a ‘post mortem’ (however speedy) on an experience but concerns thinking and knowing in the midst of action. Schön saw reflection-in-action as a distinguishing feature of expert practitioners who are able to experiment and think about their practice whilst they are doing it; this idea is fundamental to his theory of professional expertise. It is difficult to conceptualise, and you will find it is sometimes misrepresented by those who view reflection-on-action and reflection-in-action as the same. Essentially, it is a different concept to that explored in this book, which largely focuses on reflection concerned with the construction of knowledge after an experience and the teaching and learning associated with it.

Contemporary descriptions of reflection

Other authors’ contributions are also useful in developing an appreciation of the concept of reflection. Wong et al. (1997) have described the central point of reflection on experience, with the trigger point of the process usually starting with an emotional response (Dewey 1933), which can be both positive (Boud et al. 1985) and uncomfortable (Atkins and Murphy 1993). More recently, Freshwater et al. (2008, p.4) have described reflection as retrospectively making sense of experience in order to influence future practice. Similarly, O’Donovan’s (2007) research describes reflection as a process of deliberative thinking, looking back, examining oneself and one’s practice in order to improve future practice. Like Clarke and Graham (1996), all these authors have described the reflective process as one of making sense of an experience and consequently learning from it.

The influence of critical theory

The use of reflection within professional practice and education has also been heavily influenced by critical theory stemming from the work of Habermas (1977) and the early work of such leading educationalists as Van Manen (1977), Mezirow (1981) and Brookfield (1987). Mulhall and Le May (1999) explain that critical theory enquiry argues that society is ­structured by meanings, rules and habits. Its purpose is to reveal aspects of society that confine human freedom and maintain the status quo. The theory’s central contention is that each of us is located historically and socially, and consequently, objective knowledge is dismissed. You can see how critical theory has influenced the descriptions of influential authors below.

’Reflective learning is the process of internally examining and ­exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self and which results in a changed conceptual perspective.’ (Boyd and Fales 1983, p.113)

’Reflection in the context of learning is a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations.’ (Boud et al. 1985, p.19)

’I describe reflection as being mindful of self, either within or after experience, like a mirror to which the practitioner can view and focus self within the context of a particular experience, in order to confront, understand and move toward resolving contradiction between one’s vision and actual practice. Through the conflict of contradiction, the commitment to realise one’s vision, and understanding why things are as they are, the practitioner can gain new insight into self and be empowered to respond more concretely in future situations within a reflexive spiral towards developing practical wisdom and realising one’s vision as Praxis. The practitioner may require guidance to overcome resistance or to be empowered to act on understanding.’ (Johns 2009, p.12)

’These emancipatory influences of critical theory are timely for ­contemporary nursing. If we want to educate and support critically responsive and sensitive practitioners, then reflection offers the potential for nurses to develop in their responsiveness and ability to take action in an often chaotic word of practice.’ (Bulman and Schutz 2007).

Similarities and differences in explanations of reflection

You can probably appreciate by now that reflection is a difficult concept to explain. However, I hope you will notice some similarities; for instance, the exploration of experience, the analysis of feelings as well as oneself to inform learning. You will also see that many are influenced by critical theory where there is an assumption that reflection will involve a changed perspective and action. It is also possible to notice elements of ­experimentation and review, and purposeful learning through experience. There are inevitably differences too; not all emphasise the signi­ficance of feelings and emotion or explicitly recognise the inclusion of change, for instance. Additionally, some do not overtly mention the importance of having someone to reflect with, suggesting a more solitary interpretation of reflection.

Some key points about the concept of reflection

Essentially, reflection is more than simply being thoughtful (Jarvis 1992). What is clear is that the process of reflection has the potential to help nurses and other professionals to learn from their experiences. I have described it as reviewing experience from practice so that it may be described, analysed, evaluated, and consequently used to inform and change future practice in a positive way (Bulman 2008). I also believe that reflection involves opening up one’s practice for others to examine, and consequently requires courage and open-mindedness, as well as a willingness to take on board, and act on, criticism (Dewey 1933). In addition, reflection involves more than ‘intellectual thinking’ since it is ­intermingled with practitioners’ feelings and emotions, and acknowledges an interrelationship with action (Brockbank and McGill 1998). Ultimately and importantly, I would suggest that reflection in nursing is connected with a professional motivation to ‘move on’ and ‘do better’ within practice in order to learn from experience and critically examine ‘self’ (Bulman et al. 2012).

Noteworthy concepts for a deeper understanding of reflection

Praxis

You will have noticed that the quote by Johns (2009), describing ­reflection, mentions praxis. The concept of praxis originates from Greek philosophy and can be seen in the work of the educationalist and educational ­philosopher Paulo Friere, who has been influential in education throughout the world. He suggested that we need to reflect and act in the world in order to transform it and to develop our own critical awareness of it. Friere’s (1972)...

Table of contents

• Cover
• Dedication
• Title page
• Copyright page
• List of Contributors
• Preface
• Chapter 1: An introduction to reflection
• Chapter 2: Developing skills for reflective practice
• Chapter 3: Writing to learn: writing reflectively
• Chapter 4: Reflecting in groups
• Chapter 5: An exploration of the student and mentor journey into reflective practice
• Chapter 6: Supervision for supervisors: icing on the cake or a basic ingredient for the development of clinical supervision in nursing?
• Chapter 7: A personal exploration of reflective and clinical expertise
• Chapter 8: Assessing and evaluating reflection
• Chapter 9: Getting started on a journey with reflection
• Index