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Reflection in and on nursing practices- how nurses reflect and develop

knowledge and skills during their nursing practice

Article · January 2010

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International Journal of Caring Sciences 2010 September-December Vol 3 Issue 3 85

SPECIAL ARTICLE

Reflection in and on nursing practices- how nurses reflect and develop

knowledge and skills during their nursing practice

Carina Berterö, RNT, BSc, MScN, PhD, Professor

Department of Medical and Health Sciences, Division of Nursing Science
Faculty of Health Sciences, Linköping University, Sweden

Corresponding author: Carina Berterö, RNT,BSc, MScN, PhD, Professor

Department of Medical and Health Sciences,Division of Nursing Science
Faculty of Health Sciences, SE-581 85 Linköping , Sweden
Tel +46 10 1037768 Fax +46 13 123285 e-mail: [email protected]

ABSTRACT

Introduction: This paper present some theoretical foundations for reflection and also present some findings
from some studies including nurses’ reflections in and on nursing practice in various areas of nursing care.
Aims: The aim of this paper was to critically discuss and analyze the application of reflection to nursing practice
and how it could become visible and understandable.
Method: A secondary analysis was performed on some studies whereas the author had been involved in. This
secondary analysis on all data focused on identifying reflection in nursing practice.
Results: Data was abstracted and analyzed in order to making reflection in nursing practice visible. The results
show that reflection in nursing practice could be identified as reflection on action, reflection in action and
reflection as self-discovering. Sometimes the nurses made good caring activities by intuition; they made some
actions that they by experiences knew will function, but they had difficulties to verbalize this, in other words;
they have what we call silent knowledge.
Conclusion: Using reflections can access our theories in use so enabling others to learn. In this way the risk of
taking practice for granted has the potential to be reduced. So what nurses’ do- can be explored and shared –
nurses can share and develop knowledge and experiences- nurses will be able to learn from each other as well as
from ourselves.

Key words: reflection, nursing practice,

INTRODUCTION Nursing is a profession that is being continuously

developing and demands a lifelong learning and it
In this paper, I will highlight and present some
also requires special knowledge and skills.
theoretical foundations for reflection and also
Nursing profession is generally differentiated
present some findings from some studies
from other types of occupations by its necessity of
including nurses’ reflections in and on nursing prolonged, specialized training to acquire a body
practice in various areas of nursing care adding of knowledge sufficient to the role to be
my own reflections on this subject. performed.

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International Journal of Caring Sciences 2010 September-December Vol 3 Issue 3 86

The profession has also an orientation towards Learning through reflection is a difficult and
service to individuals, families and communities conscious process. It is nothing that just occurs; it
(NBHW 2005) is something that is processed in your head (Burns
& Bulman 1994/2001). Schön (1983/2000; 1987),
The standards of education and practice for the
an educational theorist, differentiated between
nursing profession are regulated by statues and
reflection in action and reflection on action.
laws, but also determined by the members of the
Reflection in action occurs during practice when
profession. The education of a professional nurse
the nurse watches, interact and adjust reactions
involves a total socialization process more
and approaches through thinking in a systematic
extensive in its social and attitudinal aspects as
way while working. This reflection in action is
well as its technical features than is common in
according to Schön similar to what we sometimes
other types of occupations. The nurse’s
call silent knowledge—a practical knowledge that
professional role no matter the working area and
only becomes accessible when we are practicing.
nursing care is impressed by ethical approaches,
Reflection on action occurs after the action when
grounded in science and well-tried experiences
details and information are recalled through
and shall be conducted according to laws, statues
descriptions of the situation. The situation and
and instructions. Safe patient handling is a skilled
actions are analysed through carefully
activity, which necessitates a good underpinning
reconstruction of all aspects of the situation in
theoretical knowledge, no matter in what country
order to gain new insights and make amendments
the nurses are working (NBHW 2005).
if necessary. This latter reflection is distancing
Nursing is a complex combination of theory and and critical analytic, it is accordingly self
practice (Corlett 2000; Kohl 2000). It is an discovering. Reflection in and on nursing practice
immense challenge for nurse education is necessary and important to alert clinicians to the
programmes to identify research/evidence-based complexity of nursing practice and the knowledge
knowledge and to transform it to knowledge and imbedded in it (Johns & Mc Cormack 1998).
skills for use in everyday practice by the student
Schön (1987) argues that the vital process in the
nurses as well as the registered nurses (Ela et al
development of knowing in action (that is
2006). Nurses make decisions constantly about
developed trough practice itself) and theories in
how to in the best way reach clinical goals.
use is reflection in action; a process by which the
Every day the nurses make decisions and uses professional person/ the nurse modifies and
problem solving methods including assessing, develops her ideas by thinking in a rational and
planning, implementing and evaluating the best problem-solving manner.
course of action given in different situations in
Nurses work with people throughout the various
order to reach the most effective care.
phases of their lives; and faces the normal but also
Methods of problem solving might include divergent, abnormal and all that unpredictable in
intuition. Intuition is a part of expert clinical human lives. Through the nurses’ knowledge and
practice and is obtained through years of skills, nurses assist those conditions in which
knowledge and experience when patterns and cues people are assisted to obtain wellbeing and /or to
from previous similar situations rapidly and die peacefully and with dignity. There is a
completely present itself to an expert’s multiplicity in nurses working area and a broad
consciousness. Making sense of experiences and variety of nursing practice, embracing inpatient
phenomena and making changes in future and outpatient care and with a variety of different
situations, if appropriate, is the value of reflection. specializations such as oncology, haematology,
Marton and Säljö (1976) two Swedish medicine, surgery paediatrics and so on (Johns
educationalists and researchers describe deep 2000).
approaches to learning as striving towards
Schön (1983/2000; 1987), emphasised the idea
understanding, evaluation and relating knowledge
that reflection is a way in which professionals can
to own experiences, which in itself promotes a
bridge the theory practice gap, based on the
motivation to learn. This emphasises the fact that
potential of reflection to uncover knowledge in
clinical competence is not just about doing and the
and on action.
development of technical skills, but that it
incorporates knowledge and attitudinal Now, let us take a look at this reflection process
components as well. via six steps. The first step is description; whereas
the nurses need to put words on what happened in

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International Journal of Caring Sciences 2010 September-December Vol 3 Issue 3 87

the situation in order to describe, and clarify it. practice and how it could become visible and
Second, what feelings did this situation bring understandable.
forth? What did you think about it and how did
you feel? The third step is about evaluating the
situation. What was positive and what was METHODS
negative in this situation? – and why. Fourthly, A secondary analysis (Heaton 2004) was
the analysis; what can you learn from this performed on some studies whereas the author
situation? The fifth step is about conclusion had been involved in. This secondary analysis on
drawn; can you act in another way? Lastly, the all data focused on identifying reflection in
sixth step is an action plan; if it happened again nursing practice. In this secondary analysis study,
what would you do? (Gibbs 1988). the research question fit well with that of the
Awareness of the experience and an ability to original study, even though the focus is more on
describe it are difficult through essential skills. the nurses own reflections and actions.
This model of structured learning/reflection is
composed of a series of questions helping the RESULTS AND DISCUSSION
reflective practitioner to tune into an experience
and provide structure and meaning to the process Nurses working at wards with different forms of
of reflection. This process is not static- it should cancer diagnosis could be seen as a challenge; a
not been used stepwise all the time. personal challenge. Cancer is often associated to
death and sorrow; there are a lot of human
The outcome of reflective practice is that it can destinies occurring at a ward. In a study on nurses
enable nurses to express what it is they know and working with patients with haematological
how they have come to know it (Burns & Bulman diagnosis, lung cancer diagnosis and oncology
1994/2001). Nurses engaged in daily practice diagnosis reflected upon caring situation. They
have the advantage of living their practice, in that reflected upon caring situations when they
they have opportunities to look at their practice to manage to provide good nursing care and
learn from it. This reflection can make sense of situations when they did not manage (Berterö,
their practice and /or bring about changes (Johns 1999).
2000).
The findings were that the nurses reflected upon
There are three dependent elements included in relationships with patients and next of kin,
reflection. First, the focus of reflection, which is interactions with patients and next of kin,
quite easy to understand-we need to have a fulfilling needs and feeling frustration. They
situation to reflect upon. Second, we have a identified and described the situation, were aware
process of reflection, this is quite clear and of their feelings, they evaluated the situation and
systematic presented so this is not a big deal for made some analysis and had some thought about
nurses to understand and use. However, the third if they could had act in another way. This study
element is attitudes to reflection and this need showed that the nurses seemed to use reflection in
some clarification, open mindedness; in which their everyday work.
things are not taken for granted, and self
questionings promoted by the nurses Often there were situations that were not in
responsibility: to make sense of diverse ideas and agreement with their knowledge or experiences.
to move beyond questions of immediate utility Every person is unique and may react- interact in
wholeheartedness; in which self esteem and different ways on treatments and in
commitment are seen as important and enabling in communication with the nurse. It happened once
risk taking (Goodmann 1984). and then that caring activity performed by the
With this view of reflective attitudes and the need nurses did not reach desirable outcomes. The
of congruency, it helps to extend the relationship nurses then had to think about the situation and
formation to the clarification of practical roles of how to find solutions; they tried to remember if
nurses. there had been a similar situation previously. So
now we are looking at the term:
AIMS knowing/reflection in action.

The aim of this paper was to critically discuss and There were also reflections that were more critical
analyze the application of reflection to nursing analytic when looking at the nurses own

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International Journal of Caring Sciences 2010 September-December Vol 3 Issue 3 88

behaviour and actions— the reflection then related to a certain problem. The nurse is
became more self discovering. sensitive, interacting and adjusting her actions
during the activities-there is a clear focus for the
Something that was made visible in this study was
actions. Judgements are done in order to find
that the nurses find it harder to tell about caring
solutions. This reflection is built upon previous
situations were they performed well and
experiences, knowledge (theory) and values.
succeeded. It was a lot easier to tell about
Reflection on action comes afterwards; details,
situation were they did not manage. This could be
actions are scrutinized and reflected upon built on
due to that reflection is aiming for learning. So if
a clear description- The activity can be re-
there are situations where you do not manage, you
constructed in mind and all different aspects of the
need to reflect upon this several times in order to
situation is analyzed: all in order to gain deeper
find a solution to the problem or find knowledge
knowledge and be able to improve actions . In
that could be useful in future situations. We could
these reflections in and on actions, reflection
say that there were: knowing/reflection in action
became self discovering- the district nurses gained
and reflection on action. It could also be so that
an insight and learned a lot about life, death,
nurses made good caring activities by intuition;
relations and about themselves as human beings.
they made some actions that they by experiences
knew will function, but they had difficulties to Nurses working with severe ill patients reflect
verbalize this, in other words; they have what we upon their role and high lights different themes.
call silent knowledge. They talked about the value of experiences,
understanding the search for meaning, the value of
The nurses seem to work/reflect according to the
time, the relationship involved, caring and skilled
different steps in the reflection process. The
used and difficulties to continue this role as a
nurses had practical knowledge that was
nurse competency and skills they need in order to
accessible when they were performing their caring
provide good care is engagement and knowledge.
activities and they reflect upon their own actions
When they reflect upon their role as a nurse and
from their experiences whereas they try to find
what they are doing and how they are doing
different solutions on the problems. Afterwards,
different caring activities they will be able to
when the situation has passed, the nurses reflect
increase their competency. They will
upon their own behaviour and action, what
also discover their weak points as well as their
consequences it brought forward and what values
strong points. This reflection is much about self
was the basis for their actions.
discovering. All these reflections and competency
District nurses have a broad working area; they identification is in agreement with Quinn (2003)
have health promoting issues for the population statements.
and caring issues for both the child and the elderly
By reflecting on their experiences on life and on
person but also taking part/or being responsible
nursing, the nurses had gained further insights into
for the palliative caring activities.
the support they offered and had developed skills
So it is an interesting issue how do district nurses to support patients.
reflect upon their work within palliative care. The
Nurses working at surgical wards reflected upon
district nurses reflected upon the challenge to care
relieving postoperative nausea and vomiting
about and for, relationships with patients and
families, the frustration they felt, but also the The nurses describe that they in the caring
insight they gained. They meant that their work situation have a set of different tools at their
was a commitment. It is a challenge to care for disposal. These tools are listening and understand,
patients in palliative care at home. There are no information, the clinical eye and availability- all
instructions or guidelines for every situation. They these tools can be used in solving several needs of
need to trust their experiences and their reflection the patients. Some nurses have better skills or
about how to solve different problems. Palliative more opportunities to use the available tools than
care in the home can not be performed just others. The nurses came aware of their own
technical or as a routine, there is a need to reflect abilities and possibilities to use the different tools
upon consequences of behaviour and action -and how to use them (Börjeson, Arweström,
(Berterö 2002). The district nurses were using Baker, & Berterö, 2010).
knowing/reflection in action but also reflection on
The nurses are trying to solve the problem and
action. Reflection in action here is when
find solutions by using the clinical eye tool, which
something different appears, there is reflection

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International Journal of Caring Sciences 2010 September-December Vol 3 Issue 3 89

means that the nurse can see and distinguish the So what nurses’ do- can be explored and shared –
patient’s need from her theoretical and practical nurses can share and develop knowledge and
skills. She is observant of the patient’s signals and experiences- nurses will be able to learn from
acts by using her knowledge and natural each other as well as from ourselves. Reflection
readiness. The nurses became aware of the on action is retrospective contemplation of
situation, their skills and knowledge but also practice in order to uncover the knowledge used in
about how they by themselves reacted and acted. a particular situation, by analysing and
This was reflection as; knowing/reflection in interpreting the information/description recalled.
action and reflection on action as well as
As a nurse in one of the studies expressed it:
reflection as self discovering.
It is interesting; since there is a lot of variation,
This study is a good example of pointing out
there is no standard for them…it is very different,
silence knowledge. When nurses are aware of
they are very different….I think that I am learning
their unexpressed knowledge and are given the
all the time, something that is useful even in
chance and the means for using their toolbox they
another situation (nurse 1) (Berterö 2002)
can make a difference in their caring activities.
Acknowledgement:
Now I want to mention something about the Meno
paradox. The most essential and important things The Department of Medical and Health Sciences,
are not possible to teach, they need to be Faculty of Health Sciences, Linköping University,
discovered and be suitable to the person (Schön Sweden
1983/2000; 1987),
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