Article from ejc/rec
Electronic Journal of Communication
Volume 9 Numbers 2, 3, 4 1999
Reflective Thinking in Nursing Practice
A SENSE-MAKING EXAMINATION OF
REFLECTIVE THINKING IN NURSING PRACTICE
Palmerston, NEW ZEALAND
Abstract. Reflective thinking is
heralded as the method
par excellence for (student) nurses to learn from the complexities
of professional practice. However, there is a lack of clarity in the nursing
literature as to what is the nature of reflective thinking, how it is utilized
by practitioners, how it connects to nursing practice, and how it contributes
to the development of nursing knowledge. Using the Sense-Making Methodology,
this study explored the nature of reflective thinking by investigating
how ten qualified nurses made sense of unusual clinical situations in three
New Zealand hospitals. The study examined whether or not learning occurred
and proposed a new definition of reflective thinking.
The concept of reflective practice has been identified
as an effective learning strategy for nurses in clinical practice (Fisher,
1996; French & Cross, 1992;
Jarvis, 1992; Johns, 1996 & 1995;
Reid, 1993; Richardson & Maltby,
1995; Saylor, 1990). There appears to be a general
consensus in the nursing literature that reflecting on problematic situations
helps individuals understand and make sense of them by examining parts, possible
connections between these parts, as well as links to previous situations. It
is assumed that the fruits of this mental activity result in an increased knowledge
level that, in turn, will contribute to improved nursing practice. So influential
is the concept of reflective thinking, that it has now been identified as a
prerequisite competency for beginning nurse practitioners in Australia (ANRAC,
1990). Professional nursing bodies, such as the English National Board (ENB,
1989), and more recently the Nursing Council of New Zealand (NC
of NZ, 1996), have advocated the development of what has become generally
labelled as "reflective practitioners." However, there is a lack of
clarity as to what is the nature of reflective thinking, how it is utilized
by practitioners, how it connects to nursing practice, and how it contributes
to the development of nursing knowledge. The aims of this research project were
to clarify the nature of reflective thinking and to explore how qualified nurses
think reflectively in clinical practice.
As very little is known about reflective thinking in nursing practice, a qualitative
research approach is not only an appropriate, but an essential, first step in
uncovering what the focus is of reflective thinking and how qualified nurses
make use of it when they reflect in/on their practice. The approach to qualitative
studies taken here was exploratory, focusing on the phenomena without attempting
to control in any way the context in which the phenomena took place. Within
the profession of nursing, the growth of qualitative research methods for theory
development is not a coincidence but a reflection of, and consistent with, nursing's
philosophical beliefs in the inter-relatedness of subjectivity of meanings,
the existence of multiple truths, shared languages, shared experiences, human
interpretations, and contextual realities. As noted by McCaugherty
(1991), the descriptions and "classical" pictures of nursing care
and diseases, as described in medical and nursing textbooks, rarely, if ever,
occur in practice: reality is much more untidy and disorderly.
Studying reflective thinking in qualified nurses required the researcher to
centre on the nurse-in-context, because people perceive and interpret their
worlds from their own particular perspectives. As reflective thinking was said
to be at its strongest in non-routine situations (Dewey, 1933;
Schön, 1983, 1987), the focus
should be on how nurses perceived and interpreted an unusual/uncommon situation
or phenomenon. It should take into account the nurses' feelings and emotions
that resulted from the situation at the time. The research also needed to include
the conclusions the nurses arrived at as a result of reflective thinking and
incorporate how the outcome connected to, or influenced, their nursing practice.
Dewey (1933) was one of the first
and most influential educational theorists to explore the process and product
of reflective thinking. Dewey started his exploration of reflective thinking
by discussing one particular mental process in which thought patterns were focused
and controlled. Dewey labelled this "reflective thought," and he argued
that it is not simply a sequence of ideas, but a consecutive ordering in such
a way that each idea/thought refers to its predecessors as well as determines
the next step. Thus, all successive steps are linked. They grow out of one another,
support one another, and contribute to a sustained movement towards a common
Since then many authors have contributed to the debate by defining and redefining
aspects of reflective thinking. Kolb and Fry (1975) incorporated
reflective thinking in an experiential learning model generally known as Kolb's
Learning Cycle. Boyd and Fales (1983) defined reflection
as: ". . . the process of creating and clarifying the meaning of experience
(present or past) in terms of self (self in relation to self and self in relation
to the world)" (p. 101). Their central concern was to describe the essential
nature, or process, of reflection. The authors stressed that the outcome of
reflection is a changed conceptual perspective.
Among the contemporary writings, perhaps the most significant study on reflective
thinking has been Schön's work (1983, 1987)
even though he never produced a definition of the concept. Schön founded
his theories on Dewey's work, but introduced a range of new terminology. He
labelled Dewey's situations of doubt and perplexity the fuzzy zones of professional
practice, and he described the concept of reflection as the method par excellence
for professionals to learn from practical situations. As Schön (1983)
so aptly put it: "The situations of practice are not problems to be solved
but problematic situations characterized by uncertainty, disorder and indeterminacy"
(pp. 15-16). Almost every nursing publication refers to Schön's study,
and his concepts are widely accepted by nurse educators.
An extensive review of the nursing literature revealed that there is no single
definition as to what constitutes reflective practice. Furthermore, it was not
uncommon to find such terms as reflective thinking, reflective practice, and
reflection-in or on-action all mixed together in one article that examined critical
reflection. Concern regarding this perceived lack of coherent and/or consistent
use of concepts has been expressed by a number of authors (Atkins
& Murphy, 1993; James & Clarke, 1994; Jarvis,
1992; Newell, 1994; Rich & Parker,
1995), and raises questions as to whether there is a shared and common understanding
of the concept of reflective thinking. As a result, the discourse in the literature
and among nurse-educators has become increasingly muddled. This is of concern,
in particular as reflective thinking is seen by many as the panacea for the
preparation and education of nurses and for continuous professional growth once
formal education ceases.
Sense-Making Methodology was selected as the research
approach to study reflective thinking in nursing practice. Sense-Making
is foremost a coherent set of concepts to study how people create sense
of their worlds, how they construct information, and how this information
is used in the process of making and unmaking sense. The approach has been
in development by Dervin and colleagues over the past 27 years and has been
widely used in applied fields such as library and information science, social
work, education, and health communication.
In line with other interpretive approaches to research, Sense-Making Methodology
assumes that any human use of information should be studied from the perspective
of the information user and not from the perspective of the researcher (Dervin,
1992, 1983; Shields &
Dervin, 1993). The questions asked should tell us something about the participants
by illuminating what is real to them, how they make sense of, and manage, their
world. There is an assumption that studying the steps that people take to make
sense of, and act in, their worlds at a particular point in time, will give
us insight about human use of information.
Linking Sense-Making with Reflective Thinking
The Sense-Making approach focuses on developing understandings
of dynamic process conditions and has been used to study ". . . human sense-making
in situations where humans reached out for something they called information,
used something they saw as a potential source and judged whether it helped or
not, or created an idea about an institution based on experience with the institution"
(Dervin, 1992, p. 68). Sense-Making is an applied research
approach that is suitable to study all situations that involve communication
and sets out explicitly to develop theoretical understandings useful to practice.
Sense-Making Methodology is based on reflection being an inherent potential
in human situation-facing and, indeed, there are considerable similarities with
the concepts usually associated with reflective thinking.
Reflective thinking is a cognitive activity and continuous process that can
be conceptualized as a spiral, building and expanding on past and current experiences
for the benefit of, and contributing to, better situational understandings.
In regards to nursing, reflective thinking is said to contribute to increased
professional expertise and improved practice. Many authors, when describing
the goals of reflective thinking, literally refer to this need to make sense
or create meaning/understanding (Clarke, James & Kelly,
1996; Conway, 1994; Fernandez,
1997; Jarvis, 1987; Johns, 1995;
Palmer, Burns & Bulman, 1994; Schön,
1992). While it is important to acknowledge that a whole range of individual
and environmental conditions may influence reflective thinking, i.e., the person's
emotional state and feelings and environmental factors such as the availability
of time and a physical space that is conducive and supportive, the focus of
this research was mostly on the cognitive processes. Because the focus of the
Sense-Making approach is on all these dynamic and interrelated processes, rather
than static conditions, it is argued here that the Sense-Making Methodology
was ideally suited to examine reflective thinking in nursing practice. The Sense-Making
approach allowed the researcher to incorporate dynamic movements by studying
what impact the situation had on the nurse in terms of cognitive, emotional,
spiritual processes, how the nurse perceived the specific situation within his/her
practice, and how the nurse built cognitive constructings in order to make sense
of and bridge the discontinuities that are an inherent part of nursing practice.
Sense-Making Methodology maintains that reality is neither complete nor constant,
but rather filled with fundamental and pervasive discontinuities. Such a view
of reality resembles very much the "swampland situations" as described
by Schön (1983) and makes the Sense-Making approach
particularly suitable for exploring reflective thinking in nursing practice.
The Sense-Making approach rejects the idea that any experience/situation can
be seen as a single entity. Rather, it is assumed that every experience/situation
is made up of a whole range of interrelated and interconnected micro-experiences/situations
called steps. Each micro-experience is the result of the outcome of the previous
step, while influencing in turn the next step. This notion of interrelated micro-moments
is strikingly similar with the steps in reflective thinking as discussed by
The literature on reflective thinking indicates a widely
held acceptance that reflection commences with a description of the whole experience
(Johns, 1995). Following from this general description,
key issues within the experience are identified and focused on for reflection.
Thus, there is a dynamic movement from the whole to the particular, to the parts,
and subsequent movements between the parts and the whole, resulting in varying
degrees of unfolding links and understandings of this experience in the light
of previous perceptions and experiences. 
Participant Selection and Settings
Ten participants were drawn from three New Zealand
hospitals. Snowballing did occur on a number of occasions and was considered
an acceptable method of recruitment. Participants needed to be qualified
practicing nurses, preferably with a minimum of two years' experience, and
needed to be able to discuss nursing experiences in the English language.
The age of the ten participants ranged from mid-20s to mid-50s, while their
years of nursing experience ranged from 2 years to more than 30 years.
Participants in the study were asked to share one
non-routine experience with the researcher and to focus on those processes
that helped them to make sense of the situation and the type of learning
that resulted from the experience. Thus, the focus of the interview was
not on the content of the situation or event itself, but rather on how the
participants saw their situation, how they felt about it, and in particular
the cognitive processes and strategies employed to make sense of the situation
or event. All research participants were involved in a minimum of two and
a maximum of three interviews. Interviews were conducted individually and
each interview lasted between 55 to 80 minutes.
The present study used Sense-Making's Micro-Moment
Time-Line interviewing approach to obtain the data. The method involved
asking the participant to detail what happened in a particular self-selected
situation step-by-step to place it firmly in context. For each step the
participant was asked what questions arose as a result of the given situation,
what needed to be learned, and how the participant understood or made sense
of the unique situation in order to bridge the gap between the theoretical
knowing and the practical doing.
To ensure that the participants could tell their stories uninterrupted,
the researcher used two tape recorders. On the first tape the participant
shared the entire event/situation with the researcher. After recalling his
or her event, the participant and the researcher discussed and identified
together the micro-events, or steps, within the event/situation. Keeping
these steps in mind, the tape containing the entire event was replayed while
the second recorder was activated. After completion of each identified step,
the event tape was temporarily stopped while the second tape continued running.
The participant was then asked a range of questions related to the identified
step. Once this step was explored in-depth, the event tape was reactivated
and the process repeated. The advantage of using two tapes was two-fold:
the participants didn't lose track of their initial stories because there
were no interruptions caused by the researcher asking questions, and the
participants had the opportunity on the second tape to correct themselves
if they had forgotten to mention something while listening to their story
on the first tape.
Focus of Interviews
The Sense-Making interviewing method focuses on three
classes of measures: situation, gap, and uses. The point of convergence of all
three measures is to identify dimensions of human sense-making in a useful and
valid manner, focusing on the process rather than any particular content. The
latter requirement does not deny or ignore the importance of content in a given
instance of sense-making, but emphasizes the focus on what sense-making processes
a participant employs. Sense-Making interview questions thus focus on movement
or what Sense-Making calls verbing, rather than focusing on content or what
Sense-Making calls nouning. This allowed participants to remain free to fill
in their representations of, and/or thoughts about, the situation, express their
views, and focus on those elements of their experiences that they perceived
as important (Dervin & Dewdney, 1986).
Although the interview style was open and informal, it was not entirely
non-directive and unstructured. All participants were informed of the focus
of the study and were aware of the type of questions that would be asked.
As can be expected, when interviewing registered nurses regarding self-selected
non-routine nursing situations, the experiences described were highly unique
in every aspect. The situations were unique, not only in terms of the events
experienced, but also in regards to the intensity and impact of the event
on the nurse, the number of people and personalities involved, as well as
the physical, social, and political contexts that surrounded the described
situations. As mandated by Sense-Making, the focus in analysis was placed
not on the nouns or substantive details of the unique situations but rather
on the verbs or processes of observing, thinking, acting, and learning.
After the first interview, the transcripts were assessed for evidence of reflective
thinking processes. As would be expected from an extended interview about non-routine
nursing situations, much material was generated that clearly did not emphasize
reflective thinking in practice, such as general nursing routines or procedures
within a particular area of work. The researcher thus selected passages from
the interview transcripts that fit the criterion of showing evidence of reflective
thinking processes. Condensing the transcripts helped to retain a clear focus
on the sense-making processes while ensuring that, in line with Stevens' recommendation
(1989), substantial passages of verbatim text were left
intact. This data reduction procedure provided participants with focused material
for a second Sense-Making interview. Prior to the second interview, all participants
read the condensed version and were asked to comment on its correctness.
Each interview began with the participant sharing
the whole experience or event. From this description both the participant
and the researcher mutually identified natural steps or stages. Subsequently
questions were asked in relation to each step or stage regarding the situation,
the gaps, and the uses. During the second interview four additional questions
were asked to obtain a better understanding of reflective practice.
The analysis of situation was concerned with the identification of the different
ways in which participants saw their situation, or more precisely, the analysis
centered on the variety of ways in which participants perceived their movement
through time-space. The following questions focused on situations:
Questions asked during first interview that
*What impact did the experience have
*What emotions or feelings did you have? What led to them?
*What in the situation challenged you?
Question added during second interview that
*How did you perceive your situation?
Gap has been defined as the questions participants construct
when confronted with a situation that blocked movement through time and space
(Dervin, 1983; 1992). The following
questions were used to identify gaps:
Questions asked during first interview that
*How did this event relate to previous
*What questions or confusions did you have?
*What aspects in the situation prevented you from getting answers?
*What would have helped you, and how would it have helped you?
Questions added during second interview that
*How important were the questions you
were asking yourself?
*How, or in what way did these questions help you? Or
*How did these questions help you to make decisions?
Uses refers to how the information gained helped
(or hindered) the participants' movements through, and/or contributed to
new or better understanding of, the situation. As it was noticed during
the analysis of the first interviews that self-questioning was an integral
component of the reflective thinking process, the researcher encouraged
participants to focus on these questions. It was assumed that examining
and coding the nature of these questions would provide insight into reflective
thinking. The following questions were developed to analyze uses.
Questions asked during first interview that
*What conclusions did you come to as
a result of the experience? What have you learned?
*How did the outcome of this experience connect to, or influence your
*How did the outcome of this experience connect to, or influence you as
Question added during second interview that
*What have you learned from the situation/event you described since
our last interview?
Analysis of Interviews
The researcher was mandated by the Sense-Making
method to attend to what is called the Sense-Making Triangle: how the participant
sees/describes the situation, what gaps the participant sees self as facing
and/or bridging, and what ways the participant sees self as helped by the
constructings he or she built to create meaning about the situation. Because
this study was concerned with exploring reflective thinking, the study did
not focus on the descriptive content of the event, but rather on identifying
what it is that nurses reflect on in their clinical practice. The descriptive
content of the event, important as it may be for the participant, is only
used as a vehicle to expose reflective thinking. The three aims that structured
the analysis were:
1) To identify how participants saw their situation
by describing their emotions and feelings and the ways in which they were
challenged by the situation;
2) To describe the perceived gaps participants
had to overcome to be able to keep on nursing;
3) To identify how information, gained from self-questioning,
helped (or blocked) the participants to make sense of, or better understand,
the client, the situation, and/or themselves.
It is important at this point to acknowledge that
these aims required some sort of structure to guide the project. However,
structure does not imply that the project was constrained by these guiding
aims. Thus, the questions used were adjusted to fit the situation and participants
were encouraged to tell their own story, using their own words, feelings,
It was expected that analysis of these questions would produce a tension
that is inherent in contextualized interpretings of holistic phenomena.
Sense-Making assumes that any interpretings are necessarily bound by the
present and past time-space of the individual. During the second interview,
these interpretive accounts were again shared with the participant. The
focus was on portions of text that addressed specific questions first, followed
by examination of the text as a whole for understanding the complete contextual
The aims of this research project were to clarify
the nature of a cognitive activity, reflective thinking, and to explore
how qualified nurses think reflectively in clinical practice. Throughout
the presentation of the findings patterns that emerged in most, or all,
of the interviews will be emphasized and illustrated by direct quotes from
The research findings confirmed that all participants engaged most actively
in reflective thinking in situations of doubt, hesitation, and perplexity
in order to resolve the experienced uncertainty. Gaps existed between reality
and what the nurse perceived to be his/her reality, between assessment and
interpretation of assessment findings, and between intentions and actions.
Gaps also existed at an interpersonal level, between the nurse and the client,
between the nurse and other members of the health care team, between the
nurse and a whole range of cultures, including the institutional culture,
the use of language and so on. Contextual limitations placed further constraints
on nurses and complicated the bridging of gaps, e.g. the economic constraints
placed on nursing care, the medical dominance of the health system, and
the institutional requirements and needs.
The study data identified three main factors that
contributed to the formation of situational gaps: lack of situational information,
lack of appropriate propositional knowledge to process situational information,
and overload of situational information.
Lack of Situational Information. This type of gap occurred in those
situations where the practitioner needed to make sense while not having
all the data to create a full picture as was illustrated by Isabel's narrative.
Isabel worked in the neonatal unit and cared for a baby who required special
treatment to prevent dehydration, but whatever treatment she suggested to
the mother, it was turned down:
I didn't know the mother, I had never met her
before. I could see that the baby needed the treatment, but you could just
tell from the way the mother was behaving that she was anti- everything.
I just wished that I could have a good talk with her, but it seemed out
of the question. I couldn't work out where she was coming from, why she
was so difficult. (Isabel)
Lack of Appropriate Propositional Knowledge
to Process Situational Information. Lack
of knowledge of specific medical conditions and the related care requirements
typically contributed to this type of gap as is illustrated by Ann's narrative:
I don't have any real experience with dermatological
conditions. I have never seen a skin condition as presented by Chris. I
didn't have knowledge of the skin condition the doctors were considering,
and I cannot recall the name of the condition. I don't understand the relationship
between the skin condition and the observations I was asked to perform;
I felt rather confused about the situation. (Ann)
Overload of Situational Information. Often this involved a combination of factors such as a
unique, non-routine crisis situation, limited knowledge of the client's
history and background, pressure to act, and feeling overwhelmed by the
situation. Jane had been involved in cardio-pulmonary resuscitations before,
but she had never seen a client who had produced such enormous quantities
of pulmonary oedema as the client in her narrative:
I just couldn't understand the pulmonary oedema
one. That was the biggest question to me, you know, it just seemed so foreign
to me. I couldn't understand why there was so much fluid, I mean I was,
you know, I was covered in it. It was all over my uniform, it was on my
hands, it was on my arms. I'm normally pretty careful about where body
fluids go in relationship to my working environment but it was on the floor,
it was everywhere. (Jane)
Situationally Useful Factors
The study data suggested two situational factors
that participants found useful, collegial support and previous experience.
Collegial Support. Seeking collegial support was identified as an important
factor that enabled participants to make sense of the situation. Participants
used colleagues to bounce off ideas, to get confirmation of the correctness
of their assessment, and to obtain second opinions as demonstrated in the
following narrative from Helen:
I could see that what was happening in this
situation was outside the parameters of what I'd dealt with before. I knew
that it was beyond my scope of knowledge, so I needed to have the input
of people with a greater experience in the mental health area. The fact
that there were no suitable resource-people available right there and then
when I needed them. The psychiatrist wasn't in any mood to talk to anyone
. . . There wasn't time to sit down with the members from the crisis team
and talk to them at all. (Helen)
The use of previous experience for the benefit of the here and now has been
extensively commented on in the literature (Benner, Tanner
& Chesla, 1996; Schön, 1983, 1987)
and was clearly illustrated by Isabel's and Helen's narratives:
I've never seen a baby quite like this before.
From previous experiences you learn the different ways to feed the babies,
but also the different ways in which you can sell these feeding methods
to mothers. You sometimes think: "Oh yes, I used this channel of communication
for such and such a mother and it worked, I'll try it again this time."
Yeah, I think subconsciously I'll do this and I think: "No, I won't
do that because I did that once before and that mother reacted quite negatively
and this mother's a bit like her so perhaps I won't do that because it's
wasting time. I'll try the more positive way first so we keep the other
way up our sleeve." You do definitely call upon experience. (Isabel)
I've dealt with similar situations where I've
had very agitated, upset people and there's no way to explain it other
than that you get a feeling for the situation. You get, from previous experiences
inside and outside of work, a feel for where the person is at, and just
how far you can actually go. Those previous experiences are invaluable
when you're confronted with a situation like this, because you've got so
much history to go by. It helped in dealing with this particular situation.
It helped immensely in knowing when to push a little, when to pull back,
and when to get the outside [help]. . . . because the previous experiences
have given you a bit of an insight into how people work when they're distressed. (Helen)
Previous experiences were actively compared and contrasted
with the current situation in a process that Bruner (1974)
labels as perceptual categorisation and pattern recognition. In doing so, participants
were able to build up a picture or mini-paradigm of the event. Schön
(1983) labelled this activity framing even though he didn't provide a definition.
This study defined the concept of framing as the cognitive activity of building
mental constructings that enable the person to further analyse a particular
situation for increased understanding. A frame is the outcome of the exploration
and manipulation of perceptual categories and the search for recognizable patterns
The study found that discourse-with-self occurred
in all those micro-moments where participants were confronted by gap-producing
situations that prevented them from moving on. Discourse-with-self was a
cognitive activity whereby the individual engaged in a debate with him/herself
searching for the answers required to bridge perceived gaps in order to
Self-questioning was an important component within this cognitive activity,
as it not only triggered off discourse-with-self, but it also kept the discourse
active and alive until the questions were answered and the perceived gaps
eliminated. Participants maintained that self-questioning assisted the structuring
of their thought processes, enabling them to think ahead, clarify issues,
and make meaning as illustrated by the following two narratives. Diana had
to decide whether to inform the house surgeon of her client's deteriorating
I guess, like I said earlier, you need to be
fairly confident that they (the doctors) truly do need to come and see
the patient, and you need to know just how sick they are. I was thinking
whether or not I should be having a look, what else there was. So all those
questions run through your mind and also your previous experiences. Yeah,
questions are important, I think that's part of nursing. It helped me feel
more confident about ringing the doctor, I guess, knowing that I'd run
through most things in my mind so that I knew that I would have the answers.
You need to be able to think of a whole lot of things and those questions
helped me and just confirmed that he (the client) did need seeing. (Diana)
Betty, like Diana, believed that discourse-with-self
enabled her to go through a mental checklist:
They said, "Someone said the mother could
do the observations," and so I did own up to that and said: "Well
that was me." I explained why, but I felt in a very vulnerable situation.
I had to question myself whether the decisions I had made had led to this
child being placed in an unsafe situation. I had to be sure in my own mind
that I had made the right decision in the first place. By asking myself
these questions I made a decision, I guess based on previous experiences,
and the way that I'd thought things through before. So, in asking myself
those questions, I'm working through what the options were and justifying,
very aware of the medical/legal side of nursing, asking myself was it a
safe thing to do. By asking these questions you're just clarifying in your
mind what your decision was. You can't reach a decision without asking
those questions. (Betty)
Focus of Self-Questioning
This study found that self-questioning was extensively
used, and it was assumed that examining the questions that arose during
discourse-with-self would provide information as to the nature and focus
of reflective thinking.
Time-Focus in Self-Questioning. In terms of time-focus, self-questioning
centered almost exclusively on the here and now. It most frequently focused
on eliminating gaps involving the client and attempted to create understanding/meaning.
The bulk of the questions were therefore related to the client as a unique
individual and the nature of his/her situation, for example: What is wrong,
or what is happening with my client? Why does this symptom occur and what
does it mean? Self-questioning also focused on self and the major questions
related to the procedures or skills required to continue the journey, such
as: How am I going to deal with this? Am I doing the right thing? What should
I do next? Most questions in this category focused on action, on doing what
needed to be done, and, to a lesser degree, to question one's own knowledge
or skill level. Participants also engaged in self-questioning in regard
to the system. Here the major questions related to the (un)availability
of human resources, the existing support systems, and a range of aspects
within the physical environment in which the nursing situation occurred.
Reflective Thinking in Self-Questioning. The analysis of self-questioning
activities identified three hierarchical levels of reflective thinking.
The analysis of 59 micro-moments resulted in the identification of three
different foci in reflective thinking at consecutive levels:
At the first level (micro-level) reflective thinking-for-action was
used to make sense or create meaning in order to respond and act in an informed/intelligent
manner to perceived stimuli from one's immediate environment.
At the second level (macro-level) reflective thinking was concerned with
a deeper and more holistic understanding of the experience and one's own
role within that particular context. The outcomes of reflective thinking-for-evaluation
contributed to the participants' ability to make judgments about the value
of their actions, ideas, or solutions, which in turn may influence future
The third and highest level of reflective thinking transcends from the actual
experience and is supposed to expose ideological and hegemonic conditions
that served the dominant class. The current study found, in fact, no evidence
of reflective thinking-for-critical-inquiry.
Figure 1 below displays the estimated proportional representation of foci
in regards to reflective thinking as drawn from this study of nursing practice.
The broken lines between the different levels reflect the potential of reflective
thinking to flow from one level to the next and vice versa.
Figure 1. The reflective thinking hierarchy with
estimated proportions of activity.
Reflective thinking-for-action required participants
to focus on the nature of the situation, as well as on resolving the situation
by selecting and choosing from a range of options what they considered to
be the most appropriate intervention. This is demonstrated by Fred's narrative:
The questions that I ask myself in these situations
help me to come to certain decisions in regard to the tasks that need to
be performed. The questions that I ask myself do two things: firstly they
remind myself of what the tasks are that need to be done, and secondly,
whether or not these tasks can be achieved. . . . The questions that I
asked myself allowed me to try and deal with the situation. (Fred)
Reflective thinking was first of all used for
action, no matter whether this thinking occurred prior to, during, or after
the action. Participants realized that they were facing a situation of doubt
or perplexity, but they also felt obliged to act, to provide care, and /or
to intervene in order to change the situation.
The main focus here was on creating understanding
and wholeness of the situation. Reflective thinking-for-evaluation is concerned
with analyzing and clarifying individual experiences, meanings, and assumptions
in order to evaluate both actions and beliefs, as illustrated by Ellen's
I suppose it structures my thought processes
as to where am I going, you know. I think the more I asked [self-questioning]
the more confused I got. The more I asked the more I realized that yes,
my knowledge was very much lacking in this area [surgical]. (Ellen)
Reflective thinking-for-evaluation was placed at
the second level because it can only occur after reflection-for-action,
thus after the practitioner has created meaning out of the situation.
In much of the nursing literature reflective thinking
was directly linked to the concept of being critical and it was argued that
nurses were "critical reflective practitioners" (Powell,
1989; Reid, 1993; Richardson &
Maltby, 1995; Shields, 1995). Despite this, the concept
of critical is by no means clear, and as yet there is no consensus as to what
it is. Smyth (1989) for example, maintained that critical
reflection focused at a personal level on such processes as describing, informing,
confronting, and reconstructing situations. Other authors argued that critical
reflective thinking advocates for an end to the status quo by challenging
entrenched positions and inequalities, by emphasizing the consequences of actions,
and by arguing the need for emancipatory actions leading to social reconstruction.
Thus, Cox, Hickson, and Taylor (1991) maintained that critical
reflection provides a way to: ". . . examine our practice world in order
to locate within it hidden elements of power and domination that we have not
recognized or not challenged, and that failed to serve the interests that we
would wish to acknowledge as legitimate" (p. 384). Interpreted in this
way, critical reflection goes beyond questions of learning and proficiency towards
a thoughtful examination of how contexts determine health and influence the
allocation of nursing resources.
While the literature maintained the frequent occurrence of critical reflective
thinking in nursing, there was little evidence in this study that this indeed
occurred. A number of participants indicated awareness of the power imbalances
within their places of work, yet none questioned why this might be so. Nowhere
is this better illustrated than in Clare's narrative:
I saw myself as powerless. I thought, I'm right
back at square one again, there was nothing I could do. This consultant
said: "He (the client) doesn't have the right for a second opinion"
when I told him he did. Nobody sort of stuck up for me in that room and
I was completely powerless. I felt absolutely useless. I felt I'd let my
patient down dreadfully. I could tell Peter was really disappointed. He
had tears in his eyes and he said to me: "I just do not want to see
that consultant." I was upset with myself but there was nothing I
could do, I mean it's the way it was.
Although discourse-with-self appeared to be an
integral part of reflective thinking, this study does not claim that this
in itself was sufficient to make sense of a situation because clearly this
is not so. Discourse-with-self cannot compensate for or replace dialogue
with colleagues, the value of which should not be under-estimated. Neither
can discourse-with-self compensate for or eliminate gaps that are essentially
the result of lack of information or from information overload. Last but
not least, discourse-with-self is unable to contribute significantly to
increased understanding of the event in those situations where the person
is unable to recognize patterns or categorize perceptions due to lack of
experience or a lack of propositional knowledge.
Discussion of Findings for Reflective
Thinking in Nursing Practice
Nursing is a practice profession and cannot be completely
objectified or formalized because its complex social, practical, geographical,
and historical bases make any description of discrete objective elements impossible
(Draper, 1991). Reflective thinking was described in the
literature as an excellent strategy for learning in and from these context-specific
situations. Interestingly, the study found that participants experienced difficulties
identifying what they had learned from their situation. Clearly, reflective
thinking at the micro-level was concerned with action, with doing things. However,
reflective thinking at the macro-level involved evaluation of the participants'
own performance and their own professional as well as personal role within the
event. It was a surprise to find that the participants themselves couldn't identify
what they had learned, especially as it was claimed in the literature that reflective
thinking contributed to an informed body of knowledge (Emden,
1991; McCaugherty, 1992; Snowball,
Ross & Murphy, 1994). Carr (1981) offered a possible
explanation for the difficulties participants experienced when asked to express
what they had learned. Carr maintained that practical knowing is "knowing
how" or "knowing what to do" and that practical knowledge was
wrongly construed as concerning theoretical knowledge. Carr's proposition explains
that participants were unable to assess their own learning in theoretical terms
because their learning related to the practical. Thus, participants did not
assess their own learning in terms of consciously reviewing and updating their
existing propositional knowledge base, but rather participants evaluated their
gains in terms of the practical, e.g., whether they would do the same thing
again under similar, but not necessarily identical, circumstances. Kemmis
(1985) argued along similar lines when he maintained that reflective thinking
is always action-orienting within a particular context and he noted that: "In
no case can reflection be understood without reference to action or context"
The study findings in regard to learning and the development of nursing knowledge
are significant for nurses and especially for nurse-educators. As reflective
thinking relies heavily on experience, the quality of the clinical experience
is extremely important. Experiential learning involves at all times a degree
of uncertainty and variability since it takes place in an uncontrolled environment,
spanning the affective and behavioral as well as the cognitive domains. As noted
before, this study focussed in particular on the cognitive activities. Although
clinical experiences may provide opportunities for learning, this does not mean
that all experiences are genuinely or equally educational. Greenwood
(1993) for example, argued that reflective practice could reinforce rather
than eliminate inappropriate clinical interventions.
What the individual learns from an experience depends on how he/she internalizes
and builds on the opportunities presented. Knowing, be it personal or professional,
is a continuous process that is the result of the individual's interactions
with the environment through internalizing observations, perceptions, and experiences-in-the-world.
Past experience provides (student) nurses with a stock of practical knowing,
a storeroom full of memorized situations, which could be accessed to evaluate
the current situation and mobilized to produce ideas and new understandings.
Thus, the value of knowing is found in its practical implications and in its
usefulness for solving problems encountered during experiences. The findings
of this study confirmed the research results from Pardue (1987)
that experiential knowing rather than knowledge was the most important factor
in clinical decision making. Focussing on, and expecting practitioners to extract,
empirical patterns of knowing (knowledge) might therefore be inappropriate as
it ignores other patterns of knowing (e.g., practical know-how) and perpetuates
the values characteristic of the positivistic worldview.
Redefining Reflective Thinking
The findings of this research indicated that participants
engaged in reflective thinking when confronted with a gap that prevented
them from creating meaning of the situation/event. Furthermore, the study
demonstrated that reflective thinking consisted of a range of mental activities.
These activities, which included strategies such as comparing and contrasting,
perceptual categorization, and pattern recognition, used past experiences
and therefore tended to be conservative in approach rather than creative.
Thus, individuals were more likely to apply a previously used remedy as
opposed to something entirely new. Participants first and foremost engaged
in reflective thinking in order to act in the situation at hand in a well-informed,
or intelligent, manner. Secondly, but to a lesser extent, the participants
engaged in reflective thinking to evaluate the situation in its totality
as well as their own role within it. Lastly, although no evidence was found
for this in the current study, it was assumed that some individuals may
critically inquire into the wider context underlying health and wellness,
for example the hidden power structures, the allocation of resources, and
equity issues related to the delivery of health care services. The above
findings have led to the following definition of reflective thinking:
Reflective thinking is a highly adaptive and
individualized response to a gap-producing situation and involves a range
of cognitive activities in which the individual deliberately and purposely
engages in discourse-with-self in an attempt to make sense of the current
situation or phenomenon in order to act. Furthermore, reflective thinking
contributes to better contextual understandings and as such may influence
Despite being claimed as the method par excellence
to learn from the complexities of professional practice, reflective thinking
remains an under-researched phenomenon in nursing practice. This study used
Sense-Making, a research methodology developed by Dervin and colleagues,
to explore reflective thinking and focussed in particular on the cognitive
processes and strategies involved. After reviewing the existing literature
on reflective thinking, the study examined how ten qualified nurses made
sense of non-routine nursing situations. Reflective thinking consisted of
cognitive activities such as comparing and contrasting phenomena, recognizing
patterns, categorizing perceptions, framing of situations, and discourse-with-self.
By exploring and analyzing the type of questions participants were asking
themselves, the study uncovered three hierarchical levels of reflective
thinking: thinking-for-action, which centered on the here and now in order
to act; thinking-for-evaluation, which focused on creating wholeness of
the situation and contributed to the realization of multiple perceptions/responses;
and thinking-for-critical-inquiry, which was considered to be the highest
level of reflective thinking (even though no evidence of this was found
in the present study).
Participants experienced difficulties in identifying and verbalizing what
they had learned as a result of the experience. This finding poses a challenge
to some of the common notions related to learning from experience and the
adoption of this particular style of education by nursing schools in New
Zealand without sufficient empirical evidence to support this position.
 This article is drawn from the
author's unpublished M.A. thesis "Reflective thinking in nursing practice,"
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