Reflective Practice: A Critical Analysis of Data-Based Studies ..., Summaries of Nursing

Download Reflective Practice: A Critical Analysis of Data-Based Studies ... and more Summaries Nursing in PDF only on Docsity! 488 Journal of Nursing Education ABSTRACT Reflective practice has become part of the discourse of nursing education classrooms, conferences, and journals, and are popular features of nursing continuing education programs. Yet, the idea of reflective practice has become increasingly more disparate. This critical analysis exam- ines data-based studies and provides an overview of reflective practice, discusses common themes that emerged from the studies, and identifies implications for reflective practice in the field of nursing education. During the past decade, terms and phrases such as reflection, reflective practice, reflective teaching, and the teacher as a reflective, inquiring profes- sional have become part of the discourse of nursing edu- cation classrooms, nursing conferences, and journals, and are popular features of nursing continuing education pro- grams (Boud & Walker, 1998). When these terms and phrases are heard, they can bring about a range of responses from excitement and positive enthusiasm to gross ambiguity and bewilderment (Burton, 2000). Since Dewey introduced the concept of reflective prac- tice to the field of adult education more than 60 years ago, various investigations and theoretical critiques have been completed to explore the role of reflection and reflective practice in nursing (Boud, Keogh, & Walker, 1985; Mezirow, 1990; Schön, 1983, 1990; van Manen, 1977). In addition to data-based (both quantitative and qualitative) and theoretical studies, a growing body of instructional literature suggests how nurse educators may become more self-reflective and foster reflective practice in their students. In the broadest sense, reflective practice is a means of self-examination that involves looking back over what has happened in practice in an effort to improve or encourage professional growth. It is an imaginative, cre- ative, nonlinear, human act in which educators and stu- dents recapture their experience, think about it, and eval- uate it. Boud et al. (1985) stated that “we experience as we reflect, and we reflect as we experience” (p. 18). Reflective practice helps remedy what T.S. Eliot meant when he stated, “We all had the experience but missed the meaning” (cited in Tomlin, 1988, p. 42). Although the rhetoric of reflective practice has perme- ated education literature in recent years, the idea of reflective practice has become increasingly more dis- parate. Authors and researchers define reflective practice by using their own lenses, worldviews, and experiences. In addition, various related concepts exist, such as action theory, critical social theory, praxis, problem solving, and cognitive learning theory. This conceptual and method- ological umbrella only serves to further mystify and blur a consensus of meaning (Atkins & Murphy, 1993; Jarvis, 1992; Morrison, 1995). In essence, practitioners and educators are being encouraged to engage in or promote reflective practice in their students but are shown very little evidence that it actually improves practice or results in learning. Despite Reflective Practice: A Critical Analysis of Data-Based Studies and Implications for Nursing Education Lisa A. Ruth-Sahd, MSN, RN, CCRN, CEN Received: January 29, 2003 Accepted: April 30, 2003 Ms. Ruth-Sahd is a member of the nursing faculty, Lancaster Institute for Health Education, School of Nursing, Lancaster, Pennsylvania. This article was written as a course requirement at Penn State University. The author thanks Dr. Ed Taylor for his comments on ear- lier versions of this article. Address correspondence to Lisa A. Ruth-Sahd, MSN, RN, CCRN, CEN, 25 Wynwood Drive, Mountville, PA 17554; e-mail: LSAHD961@earthlink.net. RUTH-SAHD November 2003, Vol. 42, No. 11 489 continued interest in reflective practice, little is known about the development of reflective capabilities, the pos- sible negative outcomes of reflection, how reflection actu- ally looks in practice from a data-based viewpoint, and what kind of learning results from reflective practice (Burnard, 1995; Durgahee, 1998; Greenwood, 1993; Henschel, 1999; Johns, 1995; Jones, 1995; Lowe & Kerr, 1998; Mallik, 1998; Newell, 1994). Therefore, this critical analysis examined data-based studies to identify the scope of reflective practice, fill in the gaps in the litera- ture, discuss practical implications for fostering reflection in the educational process of nursing, and encourage nurse educators to practice reflection as a way to examine and enhance their teaching practices. The following questions must be addressed regarding reflective practice: • What are the conditions necessary to foster reflec- tion in the nursing education classroom? • What are the nurse educators’ responsibilities and risks? • How does reflective practice affect learning out- comes? In addressing these questions, this analysis will initially provide a brief overview of reflective practice; secondly, describe how the data-based studies were selected; third- ly, identify common themes that emerged from the stud- ies; and finally, identify implications for reflective prac- tice in the field of nursing education. OVERVIEW OF REFLECTIVE PRACTICE Dewey first introduced the idea of reflective practice in 1933, stating that “reflective thinking is closely related to critical thinking; it is the turning over of a subject in the mind and giving it serious and consecutive consideration” (p. 3). Dewey believed that reflection is not only a ratio- nal, intellectual act but also an act that involves the whole person, including his or her emotions. Dewey iden- tified the following three attributes of reflective individu- als: open minded, responsible, and wholehearted. While Dewey was most interested in a monologic, aso- cial reflective process, Habermas (1970, 1971) argued that reflective practice has a social, as well as psycholog- ical, basis that does not stop at the individual, but rather may be dialogic. In addition, Habermas (1971) believed that “reflective practice is neither educationally nor polit- ically innocent” (p. 91). Several key educational theorists have recognized the contributions of Dewey and Habermas and continued the analysis of reflection. van Manen (1977), Schön (1983, 1990), Boud et al. (1985), Mezirow (1990), and Brookfield (1995) have all proposed that reflection is indeed a learn- ing tool with implications for the teaching-learning process. van Manen (1977) identified three distinct stages of the reflective process. The first stage concerns the effec- tive application of skills and technical knowledge in the classroom environment. This stage is primarily concerned with analyzing the effects of the teaching strategies used. The second stage entails reflection about underlying assumptions of a specific classroom practice and its effect on student learning. This implies teachers are evaluating their actions and beliefs. The third stage, one of critical reflection, involves questioning the moral and ethical dimensions of decisions related, directly or indirectly, to the classroom situation. This is where teachers make con- nections between situations they encounter and the broader social, political, and economic forces that influ- ence those actions (Yost, Sentner, & Forlenza-Bailey, 2000). Schön (1983, 1990) argued that professionals in their everyday practice face unique and complex situations, which are unsolvable by technical, rational approaches alone. Consequently, he posited an approach whereby pro- fessional learning could be facilitated by reflection. He differentiated among three different methods of reflec- tion: reflection-in-action, reflection-on-action, and reflec- tion-for-action. Schön (1990) stated that reflection-in- action is a spontaneous reflection in the midst of the action itself, also known as “thinking on your feet” (p. 26). Schön felt it is intuitive knowing implicit in the action that shapes “what we are doing when we are doing it” (Schön, 1990, p. 26). He went on to identify three salient features of reflection-in-action. First, reflection is con- scious, although not often able to be articulated. Second, it is critical, and third, it gives rise to spontaneous, on- the-spot experimentation. In contrast, reflection-on- action involves thinking through a situation after it has happened. In this method, one consciously returns to the experience to reevaluate and decide what needs to be done differently. Reflection-for-action is the desired out- come of the first two methods of reflection and engages one in reflection to guide future action. In defining reflective practice, Boud et al. (1985) described the analysis of feelings and knowledge, empha- sizing the significance of using positive feelings and removing obstructive feelings. The authors proposed four terms to exemplify the process of reflection: association, integration, validation, and appropriation. In the context of learning, they believed reflection is a “generic term for those intellectual and affective activities in which indi- viduals engage to explore their experiences in order to lead to new understandings and appreciations” (Boud et al., 1985, p. 23). Mezirow (1990) identified six hierarchical levels of reflectivity (i.e., discriminant, judgmental, conceptual, psychic, theoretical, affective). Discriminant reflectivity is assessing the effectiveness of one’s perceptions and being able to identify the reason one is reacting in a particular way and which relationships affect one’s actions. Judgmental reflectivity is realizing that all individuals value judgments about perceptions. Conceptual reflectiv- ity is the ability to critique one’s own actions, and psychic reflectivity is acknowledging that one judges people based on limited information. Recognizing the forces that influ- ence the way one thinks and acts, theoretical reflectivity REFLECTIVE PRACTICE 492 Journal of Nursing Education and interacting with one another. Cotton (2001) stated that using reflective practice permits “private thoughts of nurses to enter the public sphere, where they are subject to surveillance, assessment, classification, and control” (p. 512). Reflection as an Ongoing Process A second theme that emerged was that reflection is an ongoing process often initiated by a significant “trigger” event or a feeling of inner discomfort (Boyd & Fales, 1983). In a qualitative study of 12 practitioners, Mott (1994) found trigger events to be uneasy feelings or intu- itive hunches that make one step back and reflect on what is happening in the situation. Mott believed intuitive ways of knowing are central to reflective practice. Bonde (1998) identified that both academic and vocational instructors viewed reflection as an ongoing process impor- tant to improving practice. Other studies also have noted the ongoing nature of reflection (Chandler, 2000; Collier, 1999; Ferry & Ross-Gordon, 1998; Glaze, 2002; McDonald, 2000; Paget, 2001). Based on a qualitative research study involving 82 novice teachers, Pultorak (1996) posited that reflection is not only ongoing but also developmental. For 3 years Pultorak observed teachers and involved them in group work, journaling, and reflective interviews. He found that, according to van Manen’s levels of reflectivity, novice edu- cators progressed from Level I toward Level III after they were informed of the significance and value of the reflec- tive process and after they gained experience as an educa- tor. Pultorak concluded that “reflectivity is a viable part in the growth and development of novice teachers” (p. 284). The Issues of Time and Value Several studies identified challenges surrounding the issue of time and valuing the reflective process. Finding time to reflect (Bonde, 1998; Collier, 1999), as well as the timing of the reflection in relation to the issues being reflected on (Coombs, 2001) were identified. Is there an ideal amount of time to be allowed between the experi- ence and the initiation of reflection? At what time during the educational process do students have the ability to reflect? In their quantitative study of RNs, Duke and Appleton (2000) found that reflective abilities developed over time and that some reflective skills are harder to achieve than others. Therefore, encouraging new stu- dents to participate in the reflective process may be unre- alistic if they have had no previous experience with reflec- tion. Given the busy nature of nursing education and the fact that many nursing courses are content laden, finding the time to reflect, and to overcome the barriers related to reflective practice, challenges teachers and students (Teekman, 2000; Wellard & Bethune, 1996). Regarding time and valuing the reflective process, educators them- selves do not take the time to pause and reflect, primari- ly because they do not see the value in taking the time to do this, either educationally or personally. Teaching Strategies for and Educator Responsibilities in Facilitating Reflection Journal writing (Burrows, 1998; Hiemstra, 2001), reflective teaching portfolios (Huebner, 1997), and dia- logue (i.e., a form of reflective conversation) (Chandler, 2000) are common strategies used to promote reflective learning. Paget (2001), Sax (1999), and Scanlan et al. (2002) found that when many strategies are used togeth- er they elicit reflection and help students make connec- tions between content and practice. Wolf and Langner (2000) used stories and poems; Brown and Gillis (1999) used reflective thinking to develop personal professional philosophies; and Chandler (2000) used reflective conver- sation about educators’ own practices and social situa- tions to foster technical, contextual, and social reflection. As a result of a qualitative study using grounded theo- ry to examine 6 first-year nursing students, Davies (1995) identified that “the reflective processes of clinical debrief- ing and journaling did impact the environment, the process, and the focus of learning” (p. 167). She also found that anxiety was reduced through peer support and coop- eration. In addition, students moved from passive learn- ing to more active learning when these strategies were implemented. Nurse educators have many responsibilities in foster- ing the reflective process. They must begin by first seeing value and relevance in the reflective process. Second, they must explain the purpose of reflective practice and create an environment in the classroom and clinical set- tings that is safe so reflective practice will be increased. Third, Wong et al. (1997) suggested that teachers and students should be partners in the promotion of reflec- tive learning, thereby fostering a collaborative effort to meet the established goals. Finally, time should be set aside not only for students but also for educators to reflect on their practice. Levels of Reflection and How They Affect Learning Several of the studies reviewed for this article verified the levels of the reflective process as first defined by Boud et al. (1985), Mezirow (1981), Schön (1991), and van Manen (1977). In a qualitative study on conversation as a way of knowing, Chandler (2000) found that conversa- tions moved from technical to interpretive (or contextual) and then finally to critical levels when reflecting on edu- cational practices. Wong, Kember, Chung, and Yan (1995) found that reflective journals submitted by students evi- denced three levels of reflection: nonreflector, reflector, and critical reflector. The nonreflectors, although very descriptive, reported only what happened. They did not demonstrate awareness of contextual factors and tended to be concrete, offering minimal evidence of abstract thinking. The reflectors attended to feelings, association, and integration. The critical reflectors were students who had attained reflection at the level of validation, appro- priation, and/or outcome of reflection. Students in this category continuously examined the experience and themselves in a critical manner. RUTH-SAHD November 2003, Vol. 42, No. 11 493 In a qualitative study of 6 high school principals, Coombs (2001) suggested the levels of reflective process be considered in terms of these developmental phases: suggestion, problem, hypothesis, reasoning, and testing. An Affective Component to Reflection Another finding that continues to build on the quali- ties of reflection is the affective component of reflection. Affective learning, including emotions, feelings, and intu- ition, was found to be essential in many studies (Clouder, 2000; Collier, 1999; Duke & Appleton, 2000; Glaze, 2001; Johns, 1995; Mott, 1994; Sax, 1999). According to Brookfield (2000), critical thinking is a process of active inquiry that combines reflective analysis with informed action and has an emotive or affective component that is pivotal to the process. Brookfield contended that emotions are essential to the process of critical reflection. Yet, when discussing cognitive process, emotions and feelings are often denigrated in educational settings, despite their qualifying nature in the process of reason (Damasio, 1994; Goleman, 1995; LeDoux, 1998; E.W. Taylor, 2001). Davies (1995) stated that reflection is a complex process in which feelings and cognition are closely linked. Dewey (1933), Mezirow (1981), and Schön (1983) all confirmed that reflection is more than a cognitive process and involves emotions and feelings. In many of the studies examined for this article, both emotions and reason were found to affect reflective prac- tice. Atkins and Murphy (1993) posited that the internal environment of the individual who is reflecting must be in a mindful state to allow identification of feelings and emo- tions. Scanlan et al. (2002) performed a qualitative study to unravel the unknowns about reflective practice in classroom nursing education and found that emotions highly influenced reflection. When fostering critical reflection, nurse educators must also foster affective learning and ways of knowing. They must recognize that affective ways of knowing are helpful during times of uncertainty and conflict, when rational ways of knowing are less informative. Issues Related to Power Issues related to power between teachers and students are real and may present some obstacles to those inter- ested in reflective practice. Brookfield (2000) noted that power is omnipresent in adult classrooms, inscribed in the practices and processes that define the field. He stat- ed that the flow of power can be redirected, but it can never be denied or erased. Critical reflection on practice, as defined by Brookfield (2000), should focus on uncover- ing submerged power issues, as well as hegemonic assumptions that influence one’s practice. Because education is a social interaction between indi- viduals, it is likely that teachers’ and students’ values and opinions will differ. How is this addressed if one is attempting to foster reflective practice? Argyris and Schön (1974) suggested that reflection should be open; involve genuine thoughts and feelings, both positive and negative; and be firmly derived from personal and profes- sional integrity and honesty. Based on these suggestions, how do nurse educators evaluate reflective practice? Should reflective assignments be evaluated and graded? Wellard and Bethune (1996) addressed grading and issues of power in their study using the lenses of critical pedagogy and feminist poststructuralism. They believed reflective journaling is problematic when used as a peda- gogical strategy. One of the problems they found was grading journal entries. Therefore, they moved away from grading the journals and, instead, provided feedback with written comments. In addition, because students were given a voice in the process of journal writing, the authors had several power relationships with which to cope. After students’ journals are written, their real concerns are how educators are going to accept the information; how honest they can be; and how educators can hold this information against them. Cotton (2001) argued that little attention has been paid to the negative aspects of reflection and that “con- ceptualizations of reflection are ambiguous and confusing and entail repressive forms of power that effectively silence and devalue individuals and groups that are viewed as marginal to the dominant discourse” (p. 518). Cotton contended that there is a need to problematize reflection as a historically and culturally specific con- struct to recognize the diversity of reflection among vari- ous individuals. Although negative aspects of reflective practice were discussed in several studies, they were not the main focus of any studies. Page and Meerabeau (2000) noted that private issues may be inappropriate for reflection in a classroom, and Doty (2001) indicated there are ethical issues that should be addressed, such as inappropriate disclosure. In addi- tion, Duke and Appleton (2000) indicated it may be prob- lematic if students reflects beyond the teachers’ expertise. Another issue of power identified in these studies was the excessive use of educator power. Ferry and Ross- Gordon (1998) found that educators may pursue their per- sonal agendas at the learners’ expense. Educators also must realize their perspective is not the only perspective and recognize they may also learn from their students. Issues Related to Reflection in Novice Practitioners Schön (1990) posited that reflective practice is a criti- cal process by which beginners in a discipline can recog- nize consonance between their individual practices and those of successful practitioners. From the studies exam- ined for this article, it appears that novice nurse educa- tors neither value the reflective process nor see it as sig- nificant in improving their practice (Pultorak, 1996). Several studies suggested reasons novice educators do not practice reflection. Novice educators may be: • Mandated to participate in reflective practice as a way to evidence the ways their practice meets the stan- dards set forth by their professional associations (Hardingham, 2001). REFLECTIVE PRACTICE 494 Journal of Nursing Education • Encouraged to practice a particular teaching approach that is poorly defined and understood, especial- ly in a classroom teaching environment. • Too busy and lack the time to reflect. • Influenced by school cultures that do not encourage reflection (Day, 1993). • Unable to see the results of reflective practice being acted on or prioritized (Page & Meerabeau, 2000). Collier (1999) conducted a qualitative study of stu- dents during their student-teaching experience and found that 75% of them typically functioned from a reactive, rather than proactive, stance and, consequently, only par- ticipated in reflection if there was a problem. Therefore, Collier challenged teacher educators to capitalize on the university philosophy that educators are reflective deci- sion makers who facilitate student learning. She found that experienced educators must orient and “sensitize” novice educators to be active, critical, and progressive reflective thinkers, and suggested that teacher education programs prepare individuals to reflect on their practice in the broader context of an ever-evolving personal world- view of teaching and learning. By doing this, novice edu- cators may gain a more holistic perspective of their prac- tice, as well as an understanding of what it is that guides their actions (Collier, 1999). The studies reviewed in this article recommend that reflection begin with novice educators. Although few researchers examined the development of reflectivity in novice educators, many studies suggest novice educators can critically and holistically reflect and can be helped to learn the value of reflection in teaching and learning (Loughran, 2002; Pultorak, 1996) by using reflective jour- nals (Hiemstra, 2001), reflective interviews (Durgahee, 1996), peer-observation conferences (Jay, 2001), and group seminars (Snowball, Ross, & Murphy, 1994). As novice educators gain experience, they become able to move from accepting information to questioning and critiquing arguments, and become active learners (Duke & Appleton, 2000; Glaze, 2002). This process involves a questioning of practice, which is risky, may be painful and stressful, and is not easy. However, Argyris and Schön (1974) contended that this process promotes individual accountability. DISCUSSION AND IMPLICATIONS FOR NURSING EDUCATION This analysis suggests nurse educators have the poten- tial to facilitate reflective practice in both their students and themselves. When educators maintain trust, create a collaborative relationship with learners, focus on learner- centered education, engage learners both cognitively as well as affectively, and have sufficient classroom time, learners will be ready for reflection. Although many issues related to reflective practice were addressed in this article, Higgins (2001) believed reflective practice is “blind to moral issues” and suggest- ed moving toward cultivating a “practical wisdom” (simi- lar to Aristotle’s phronesis) that addresses the moral and ethical issues previously neglected by Schön. Bleakley (1999) suggested moving toward holistic reflexivity, criti- cal reflexivity, or reflexive awareness, to reformulate reflection as action and consider the ethical components previously not brought into focus. STRATEGIES FOR NURSING EDUCATION What does all this mean for the teaching-learning process of nursing students? Nurse educators may begin by stepping back and embarking on their own reflective journeys to identify what guides their practice. Before nurse educators can facilitate reflective practice in their students, they must first believe in the value of reflective practice and then act as role models for their students and colleagues. Several studies reviewed for this article noted how expert practitioners’ role modeling of reflective practice was found to significantly affect practice (Coombs, 2001; Davies, 1995; Doty, 2001; Ferry & Ross- Gordon, 1998; Genor, 2001). Nurse educators who understand that students are able to critically engage in an accurate analysis of the world, thereby gaining a greater understanding, political clarity, and self-awareness (Brookfield, 2000), are better able to prepare students for the complex world of nursing practice. Educators who define reflective practice, facili- tate safe environments, openly communicate with stu- dents, and recognize the key to reflective practice is for students to recognize its value are more successful at facil- itating reflection in their classrooms. However, at the same time, educators must not assume students know how to reflect, and must realize it is not easy to do. Students require guidance about how to be reflective. In addition, nurse educators who recognize that reflective practice is not the same as thinking, does not always lead to learning, and requires making judgments about what actions will be taken in a given situation were also found to be more suc- cessful, as evidenced in the studies reviewed. Although everyone has the ability to be reflective (Schön, 1983), it is important for nurse educators to rec- ognize that reflective practice may only work for some or in some contexts. Therefore, reflective practice should not be considered the only way to improve performance (Clouder, 2000). Finally, a challenge for nurse educators is to stop requiring students to list or talk about their reflective journeys in a linear, modernist way. Instead, it is recom- mended that nurse educators take a more postmodernist perspective in which students are free to express their reflective journeys creatively in ways that makes sense to them. FUTURE RESEARCH This article demonstrated that reflective practice is underresearched (Wilkinson, 1999). Future research must continue where these studies left off and examine