TL Forum 2005: Alliex and McCarthy - reflective practice - rhetoric or strategies to enhance clinical practice?

Category: Professional practice

Teaching and Learning Forum 2005 [ Refereed papers ]

Reflective practice: Retrospective reality and rhetoric or strategies to enhance clinical practice?

Selma Alliex and Angela McCarthy
The University of Notre Dame Australia

Reflective practice appears to be a "buzz word" in educational circles in present times. It is encouraged and deemed essential in nursing practice and in the teaching of nursing curricula. This paper will attempt to challenge two basic assumptions upon which reflective practice is based. These are the assumptions that reflective practice is objective and that there is action associated with reflection. These arguments will be set within a nursing context. Strategies employed by the School of Nursing, Notre Dame University to enhance clinical practice using reflective practice will be addressed.
This paper will address the main forum theme of "The Reflective Practitioner". An area of the forum that this paper will refer to is theoretical underpinnings of innovative practices in teaching and learning from the perspective of educators in the School of Nursing, Notre Dame University.

Introduction

According to Plato 'the unreflected life is not worth living' (Taylor, 2000, p.10). These are very meaningful words that imply that individuals need to reflect on every aspect of their lives. This is more so whilst leading a professional life as practice in a profession has implications for more that just an individual. The concept of reflective practice has gained momentum in recent times particularly in nursing. It is considered an essential component of undergraduate curricula. Taylor (2000) insists that the ability to reflect is a valuable part of human life. It is this ability that separates humans from other species. She explains reflective practice as, the throwing oneself back to thoughts and memories using thinking, contemplation, meditation and any other forms of cognitive strategies to make changes if they are required. It requires a rational and intuitive process which allows change to occur. These aspects of thinking are integral to reflection, and for making sense of personal and work events and can depend on the demands of the situation and the enormity of the task (Taylor, 2000).

Schon (1983) thought similarly but was able to categorise reflective practice into reflection on action which can be viewed as a retrospective activity, looking back and evaluating ones professional practice. Alternatively, reflection in action, according to Schon (1983) is a more dynamic process of thinking about and coming to an internal knowledge of current professional practice at the time. In practice these distinctions may seem quite blurred at times and the NHS Trust encourages nurses to focus on the process of reflective activity other than individual reflective strategies (NHS Trust, 2003).

There seems to be agreement then that reflection is a cognitive strategy requiring rational thinking wherein, lies the assumption that when we think rationally we think accurately.

Retrospective reality or useful strategy?

This is the assumption I would like to challenge. There are certain key questions we need to consider when we think back to situations. These are:

Is it possible to think back to situations objectively because in essence what we are looking back on is the situation that was real at that point in time?
Does the mere fact of rationalising a situation bring with it the inherent risk of colouring the fact that is being reflected on?
Is it humanly possible to be honest and consistent in thinking back on situations as Wilkinson (1996) suggests? If it isn't then are we promoting a strategy that is flawed by its very existence?
In a profession such as nursing where nursing decisions could impact on a person's well being, are students taught to evaluate a situation retrospectively or merely regurgitate recollection?

Strategies to make reflection relevant to the present

Literature suggests that professionals can use strategies that will minimise the shortcomings of reflection and make it relevant to the present. Gray (1998) asserts that to be able to reflect, one needs to step outside the experience to make the observation comprehensive. White (2002, p.5) suggests that educators and professionals should discern 'why' certain outcomes (positive or negative) are occurring. He recommends that the analytic process should resemble the 'onion peeling' metaphor. This is often portrayed in the Japanese tradition, where the heart of the question lies in asking the 'Why' question. White (2002, p.5) states that the 'why' question is useful to explore the underlying rationale for the initial response.

Taylor (2002) recommends being as spontaneous as possible in recording thoughts and feelings for the best outcome of reflection. She concurs with Imel (2002) in reiterating that important insights will come from a frank and honest self, a view that is supported by Wilkinson (1996). Taylor (2002, p.67) states that "If you try to 'sanitise' these valuable parts of yourself, you will not be able to get to the 'heart' of the matter as effectively". This means that in addition to the courage you need to face other people, is the courage required to face oneself. According to Cox, Hickson and Taylor (2000), comments from nurses include not being able to be honest in case they are not able to handle what they find, and the fear of wrecking the illusion that keeps them sane. These authors suggest that writing honestly ensures that the dialogue with ourselves is authentic, not softened by any social niceties. They alert us to the fact that this is not an easy task, because it is almost impossible to scrutinise our own writing without justifying and rationalising our actions, and resorting to feelings of guilt, blame or victimisation. As a result of the scrutiny we may find examples where there is inconsistency between the 'espoused theories' and 'theories in use' (Cox, Hickson & Taylor, 2000, p.382).

According to Schon (1983) practitioners can either engage only in superficial problem solving according to tradition or engage at a deeper level, which is a potentially more meaningful and difficult inquiry. Other authors have written about this difficulty in engaging in true reflection. Imel (2002) observed that reflective practice involved a personal risk, because of the sensitive nature of self examining one's values and beliefs. Street (1991) cautions us that a reflective analysis could be charged with the emotion of the moment and could provide just one perspective. White (2002) states that this is due to not providing practitioners with the right tools of reflective practice.

According to Boud et al (1985), a mere description of events does not do justice to the practitioner. They suggest that reflection has two aspects of utilising positive feelings and removing obstructive feelings. Wilkinson (1996) describes critical thinking as an attitude and a reasoning process involving many intellectual skills' and places rationality at the head of the list of characteristics. Interestingly, Wilkinson's account of critical thinking states that reflection is made up of a strong emotional subjective side whilst acknowledging that rationality is central to reflection. The attitudes suggested for critical thinking include independent thought, intellectual humility, courage, empathy, integrity and perseverance. Wilkinson (1996) also suggests that other attitudes required are fair mindedness and the need to explore thoughts and feelings. This is also reinforced by Gray & Forsstrom (2000) where they feel that this allows the practitioner to consider the events rationally and with good feeling. This, according to the authors, is a good reflective practice strategy.

Literature related to action based on reflection

The purpose of reflection according to some authors (Schon, 1983; Taylor, 2000; Emden, 2000, White, 2002) is action if needed. Emden (2000) reiterates that reflection is done with a view to action. Practically speaking, according to White (2002) the time consuming nature of reflective activities has often been cited as significant inhibitor to the consistent implementation of reflective practice. His assertion is that the rhetoric surrounding reflective practice has been strong, but implementing reflective strategies in a sustained, focussed manner are relatively rare. Nurses often use the time factor as an excuse according to Gray & Forsstrom (2000). For practising nurses, reflection can be viewed as a link between theory and practice (Emden, 2000).

The undergraduate nursing reflective practitioner

The concept of reflective practice is introduced to undergraduate nursing students at Notre Dame University from semester one of the three-year program. Students are required to maintain a reflective journal throughout their three years. Prior to commencing clinical practice students are given a guideline of questions that enables them to consider their practice reflectively. The guiding questions are:

Student nurses guidelines to reflective practice
Adapted from Johns (1994).

THE SITUATION
What was I trying to achieve?
Why did I respond/react as I did?
What were the consequences or outcomes for the patient, others and me?
How was the patient/others feeling?
How do I know how they were feeling?

PHYSICAL
How did I feel in this situation?
What internal factors were affecting me? eg. nervousness, tachycardia

ME
Did my actions match with my own beliefs? If yes - how? If no - why not?
What are my own beliefs in relation to this situation?

KNOWLEDGE BASE
What knowledge did or should have informed me?

REFLEXIVITY
How does this connect with previous experience?
Could I have managed this situation better? How?
What would be the consequences of alternative action for the patient, others or myself?
How do I feel about the experience?
Can I support others and myself better as a consequence of this incident?
Has this incident changed my ways of knowing?

First year students are required to write in their journal everyday. As can be expected students reflective skills range from description of everyday nursing activities to an in-depth analysis of every aspect of their clinical experience. Students are encouraged to write stories, draw pictures or describe their experiences using poetry. An excerpt of a poem of 15 verses written by a first year student is as follows:

I literally work with crap all day
I work and don't get any pay
I work my fingers to the bone
And finally get to come on home
At the end of the day I'm completely stuffed
I think I've almost had enough
All I do is work and sleep
I feel so tired, I could almost weep
Don't get me wrong I'm having fun
But oh, so glad prac's almost done
The alarm goes off at ten to six
It's dark, freezing cold and there's breakfast to fix
The day starts at seven and I'm there on time
I tell everyone that "I'm feeling fine"
I look at my patients still lying in beds
And envy that they still are resting their heads.
(Toovey, 2003)

Some students have been known to use language that would make a sailor blush, that is not frowned upon as it is considered an expression of the students' feelings albeit a retrospective analysis. This is an example from the journal of a first year student:

Today I saw one of the most distressing things I have ever seen.
I was assigned to the birthing suite. All went well until the lady we were caring for was fully dilated but the baby was in a posterior position. ...a vacuum extraction was tried, this failed, so forceps were used. When the baby eventually came out I thought it was dead. Its head was very deformed....It was terrifying to think that a baby that had been in the mum for 9 months may die....I just wouldn't have known what to do should it have died.

Second year students are encouraged to maintain two separate journals, a personal and a professional one. Students submit the professional journal and maintain the personal one privately. A few students have however chosen to share their personal journals. Students have to write as many critical incidents in the professional journal as they encounter. Depending on the area of clinical practice students have been assigned to, the range of critical incidents can be just few or many. Many of the incidents recounted by students relate to new experiences they have encountered and the strategies they used to deal with these. This is portrayed well in the journal of a second year student:

Today is my second last day. It is amazing what you can achieve in five weeks. At the beginning of the five weeks, I honestly really had no idea what they were talking about or how to care for patients on an orthopaedic ward. But now five weeks later I am well familiar with what I have to do for each patient with different procedures and yes admittedly there are occasional conditions I don't have a clue as to what they are talking about, ... I know common ones. Maybe I am destined to be an orthopaedic nurse like my mum... eeeks, that is a scary thought.

Third year students maintain a journal of one critical incident per week. As third year students, Notre Dame Undergraduates have had skills based experiences before because by the end of the second year these students can perform all the skills that a first year registered nurse is capable of performing. Therefore, traditionally third year students' journals deal with interactions with patients, colleagues and other health professionals with specific reference to any new procedures performed or observed. A third year student wrote in her journal,

I had another patient my age who had become brain damaged due to hypoxia due to diabetic ketoacidosis. It is so sad that this girl will never be the same again. I nursed her for a couple of days this week. On my last night of looking after her when I said goodbye, she gave me the biggest smile. It was so heart warming and it made all that I had done for her seem worthwhile.

So how is the issue of retrospective reality dealt with? As mentioned before the incident is real at that point in time and in hindsight things may appear different. To deal with this discrepancy, third year nursing students have a unit in their final semester entitled, "Role of the professional nurse". This unit is primarily based on the students' reflections of the past two and a half years. Every tutorial in this unit relates to student experiences as nursing students right from semester one to five. The three specific assignments that target the issue of reflecting retrospectively are:

Undertaking a self-evaluation of the registered nurse competencies related to professional and ethical practice and identify areas they need to improve.
Identifying the aspect of learning that they considered changed them the most. Identify the area where they felt they gained most.
A description of two critical incidents they identified in their most recent clinical practice. Students are instructed to look back over the last two and a half years of their nursing education and describe how their nursing practice changed during this time (ie. how they would have dealt with the situation as a novice student nurse and how they dealt with it now).

The academics in the School of Nursing believe that affording students the opportunity to reflect continually throughout the undergraduate program provides them with many chances at reflecting on past experiences and commenting on their legitimacy and accuracy, thus reflecting on their journey and growth as health professionals and individuals. A recent graduand wrote in her journal,

It is amazing reading back over the last three years, and seeing how I have progressed and how much I have learnt. It's funny to read the first time I did things. My first, "BP, injection, shower, suppository, nappy change... Now so many of these things have become second nature. When I do read back I often find myself cringing or laughing at what I wrote. But it really has been worthwhile keeping a journal as I can see where I have come from and it makes me question where I am heading.

Rhetoric or action as a consequence of reflection

The general consensus is that without action, reflection becomes only an intellectual exercise (Schon, 1983; Emden, 2000; Taylor, 2000, White, 2002). The key questions that need to be considered in relation to the consequence of reflection are:

Does reflection really lead to action? Do we pay lip service to the "reflecting with a view to action" theory?
Are two given situations ever the same? Are the contextual conditions often not different?

In our experiences as academic staff, it is often noticed that students comment on how they would do things differently should the same situation occur again. But do they? There is no way of knowing whilst students are still enrolled in the undergraduate program. To overcome this issue, the School of Nursing is undertaking a longitudinal study to research graduates practice up to two years following graduation. Consent was sought from the first cohort of graduands to use their reflective practice journal in this study. Graduates were sent a questionnaire a year following graduation in relation to their practice as registered nurses. The questions related to transfer of knowledge from the undergraduate program into their practice as registered nurses and the barriers and facilitators to this transition.

These nurses were asked if they were willing to be interviewed. Most of the nurses consented. Interviews will be conducted within the next few months. The focus of these interviews will be to allow students to comment on the usefulness of teaching them reflective skills and the change in their practice because of reflective practice exercises in the undergraduate program. Informal discussions with the students have indicated that they have been in a position to make a difference to their practice and therefore function as reflective practitioners. They attribute this ability to the strategies implemented in their undergraduate nursing program. Questionnaires will be sent to the nurses two years following graduation in order to ascertain factors that enhanced their transition to professional nursing from being undergraduate students.

Conclusion

In conclusion, is it possible to reflect objectively or is it retrospective reality, which in hindsight loses some of its accuracy? Is reflective practice merely "rhetoric" or is practice really affected by reflecting on it?

Knowledge per se is constructed cognitively and affectively for example, by personal biases and coloured by context. Our study of case has demonstrated that this can be minimised by reflection that is focused and encouraged. It has been found that scaffolding students to reflect on some very personal experiences provides them with the "courage" to do so as accurately as is humanly possible.

It is believed that in many cases reflection will remain a "rhetoric" as no two situations will be exactly alike but focusing and encouraging people to do what can be done to change or alter the situation by "throwing thoughts back" to why the situation needs to change will get people motivated to make a difference to their own practice and therefore become truly reflective practitioners. Educational leaders need to embrace the old adage that an experience not evaluated is an experience wasted (White, 2002)

References

Boud, D., Keogh, R. & Walker, D. (1985). Reflection: Turning experiences into learning. London: Kogan Page.

Cox, H., Hickson, P. and Taylor, B. (1998). Exploring reflection: Knowing and constructing practice. In G. Gray & R. Pratt (Eds.), Towards a discipline of nursing (pp. 373-389). NSW: Churchill Livingstone.

Emden, C. (1998). Becoming a reflective practitioner. In G. Gray & R. Pratt (Eds.), Towards a discipline of nursing (pp. 335-354). NSW: Churchill Livingstone.

Gray, J. & Forsstrom, S. (1998). Generating theory from practice: The reflective technique. In G. Gray & R. Pratt (Eds.), Towards a discipline of nursing (pp. 355-372). NSW: Churchill Livingstone.

Gray, C. (1998). Reflection and reflective practice. The Research Centre in Human Sciences and Business UoA: 68. [viewed 28 May 2003, verified 16 Jan 2005] http://www.gre.ac.uk/~wn14/raecentreall/raecentre/educatFQ3.htm

Imel, S. (1992). Reflective practice in adult education. ERIC Digest No. 122. [viewed 18 Nov 2000 at http://www.ed.gov/databases/ERIC_Digests/ed346319.html, verified 16 Jan 2005 at http://www.ericdigests.org/1992-3/adult.htm]

Johns, C. (1994). Guided reflection. In A. Palmer, S. Burns & C. Bulman (Eds), Reflective practice in nursing: The growth of the professional practitioner, pp. 110-130. Oxford: Blackwell.

NHS Trust (2003). Portfolio management and reflective practice: Introductory guidelines. [viewed 14 May 2003, verified 16 Jan 2005] http://www.northbristol.nhs.uk/nursing/reflective.asp

Schon, D. (1983). The reflective practitioner: How professions think in action. London: Basic Books.

Schon, D. (1987). Educating the reflective practitioner. San Francisco: Jossey-Bass.

Street, A. (1991). From image to action: Reflection in nursing practice. Geelong: Deakin University Press.

Taylor, B. (2000). Reflective practice: A guide for nurses and midwives. St Leonards: Allen & Unwin.

Toovey, A. (2003). Untitled poem. Unpublished manuscript, Notre Dame University at Fremantle, Australia.

White, D. (2002). Reflective practice: Wishful thinking or a practical leadership tool? In The vision and the reality. International Conference to study the issues and challenges facing Catholic educational leadership, August, Sydney, Australia. [verified 16 Jan 2005] http://www.ceo.parra.catholic.edu.au/ pdf/publications/c_papers/dan_w.pdf

Wilkinson, J. (1996). Nursing Process: A critical thinking approach. Menlo Park, California: Addison-Wesley.

Authors: Selma Alliex is currently employed as Senior Lecturer and Coordinator of Postgraduate studies. As part of her undergraduate teaching commitments Selma coordinates the unit "role of the professional nurse" for third year undergraduate nursing students which are based entirely on reflective practice skills. Selma is also a co-investigator in the longitudinal study being undertaken at Notre Dame in relation to new graduates' transition to nursing practice from being undergraduate students.

Dr Selma Alliex, Senior Lecturer, School of Nursing
Notre Dame University, 18 Mouat Street, Fremantle WA 6160
Phone: (08) 9433 0215 Mob: 041 062 1784 Fax: (08) 9433 0210
Email: salliex@nd.edu.au

Angela McCarthy is currently writing her PhD thesis at the University of Notre Dame Australia. She is Clinical Coordinator and Health Agency Consultant for the School of Nursing, and teaches in Nursing Education as well as Theology. Her interest in nursing education has been enlivened while working at Notre Dame and she has a particular interest in the efficacy of the current clinical practice being pioneered by the School of Nursing.

Mrs Angela McCarthy, Coordinator of Clinical Placements, School of Nursing
Notre Dame University, 18 Mouat Street, Fremantle WA 6160

Please cite as: Alliex, S. and McCarthy, A. (2005). Reflective practice: Retrospective reality and rhetoric or strategies to enhance clinical practice? In The Reflective Practitioner. Proceedings of the 14th Annual Teaching Learning Forum, 3-4 February 2005. Perth: Murdoch University. http://lsn.curtin.edu.au/tlf/tlf2005/refereed/alliex.html

Copyright 2005 Selma Alliex and Angela McCarthy. The authors assign to the TL Forum and not for profit educational institutions a non-exclusive licence to reproduce this article for personal use or for institutional teaching and learning purposes, in any format (including website mirrors), provided that the article is used and cited in accordance with the usual academic conventions.

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THE SITUATION	What was I trying to achieve? Why did I respond/react as I did? What were the consequences or outcomes for the patient, others and me? How was the patient/others feeling? How do I know how they were feeling?
PHYSICAL	How did I feel in this situation? What internal factors were affecting me? eg. nervousness, tachycardia
ME	Did my actions match with my own beliefs? If yes - how? If no - why not? What are my own beliefs in relation to this situation?
KNOWLEDGE BASE	What knowledge did or should have informed me?
REFLEXIVITY	How does this connect with previous experience? Could I have managed this situation better? How? What would be the consequences of alternative action for the patient, others or myself? How do I feel about the experience? Can I support others and myself better as a consequence of this incident? Has this incident changed my ways of knowing?