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The Electronic Journal of Communication / La Revue Electronique de Communication


Volume 9 Numbers 2, 3, 4 1999

Reflective Thinking in Nursing Practice


A SENSE-MAKING EXAMINATION OF
REFLECTIVE THINKING IN NURSING PRACTICE

 

Bert Teekman
Manawatu Polytechnic
Palmerston, NEW ZEALAND
e.teekman@clear.net.nz

 

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.

Introduction

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.

Literature Review

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 end.

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.

Research Methodology

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 Dewey (1933).

Research Procedures

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. [1]

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' Involvement

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.

Interviewing Method

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.

Interview Questions

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 tapped situation:
*What impact did the experience have on you?
*What emotions or feelings did you have? What led to them?
*What in the situation challenged you?

Question added during second interview that tapped situation:
*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 tapped gaps:
*How did this event relate to previous experiences?
*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 tapped gaps:
*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 tapped uses:
*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
nursing practice?
*How did the outcome of this experience connect to, or influence you as a person?

Question added during second interview that tapped uses:
*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, and perceptions.

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 situation.

Research Findings

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 data.

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.

Situational Gaps

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)

Previous Experience. 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 or features.

Discourse-with-Self

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 move on.

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 condition:

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 actions.

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.

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Figure 1. The reflective thinking hierarchy with estimated proportions of activity.

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Reflective Thinking-For-Action

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.

Reflective Thinking-For-Evaluation

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 narrative:

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.

Reflective Thinking-For-Critical-Inquiry

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. (Clare)

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" (p. 143).

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 future behavior.

Conclusion

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.

Notes

[1] This article is drawn from the author's unpublished M.A. thesis "Reflective thinking in nursing practice," Massey University, Palmerston North, New Zealand.

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