© 2002, Elsevier Sciedoi10.1054/nepr.200

Margaret Carroll,Liz Curtis, AgnesHiggins, HonorNicholl, RichardRedmond andFiona Timmins,Lecturers/CourseLeaders, School ofNursing andMidwiferyStudies, TrinityCollegeDublin,TrinityCentre for HealthSciences, StJames’s Street,Dublin 8, Ireland.

(Requests for offprints to FT.Tel.:�35316083699/6082692; E-mail:timminsf@tcd.ie)

Manuscriptaccepted: 22January 2002

Article

Is there a place for reflectivepractice in the nursingcurriculum?Margaret Carroll, Liz Curtis, Agnes Higgins, Honor Nicholl, Richard Redmond and Fiona Timmins

Within this paper a review of the literature on the area of reflection and reflective practiceis presented. Lecturers at Trinity College Dublin currently face a dilemma with regard toincluding these concepts in the nursing curricula. They are faced on the one hand withnational recommendations for the use of reflection and reflective practice, and on the other with personal and professional concerns about the practical, legal, ethical and moral implications raised in teaching and assessing this subject. The literature reveals thatthere is little consensus of opinion regarding the exact nature of reflection. There is alsolittle empirical evidence to support the benefits of teaching and assessing of reflection orreflective practice from either an educational or clinical perspective. This, together with the practical difficulties of teaching and assessing reflection, may negate against theincorporation of reflection and reflective practice into the nursing curriculum. It issuggested that, rather than isolate reflection as a distinct topic, that the skills of criticalthinking, problem solving, self-awareness and analysis be developed within the curriculum.© 2002, Elsevier Science Ltd. All rights reserved.

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IntroductionNurse education has undergone significantchanges in the last decades. In Ireland theintroduction of a diploma programme fornurse education nationally resulted in thedevelopment of closer links with third levelinstitutes. In 2002, nursing will face a furtherchallenge with the introduction of a 4-yearundergraduate degree programme and fullintegration into the third level sector. TheCommission on Nursing (Government ofIreland 1998) indicated that graduate educationfor nurses would contain both education andreflective practice.

In order to meet the challenges of thedelivery of an all-graduate profession, An BordAltranais (the regulatory body for nursing inIreland) identified the need for newpartnerships and alliances to be developed atboth local and national level to strengthen ties

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between the profession and third levelinstitutes. To guide the transition of nurseeducation towards third level, An BordAltranais (1999) published Requirements andStandards for Nurse Registration EducationProgrammes which clearly outlines therequirement for undergraduate programmes to have curricula that are dynamic, flexible and responsive. It also suggests that thecurriculum be based on a wide range ofteaching strategies to equip the knowledgeablepractitioner with the life-long skills ofproblem-solving and self-directed learning (An Bord Altranais 1999, p. 25).

Further recently published nursingdocumentation have emphasized the need for the development of competent practitionerswho are flexible, adaptable and reflective. The Scope of Nursing and Midwifery in Ireland (AnBord Altranais 2000) highlights competence as

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an important consideration for determiningscope of practice. A competent practitioner isdeemed to have many attributes includingcritical thinking skills and the ability to problemsolve (An Bord Altranais 2000), which somewould argue are sub skills of reflective practice.It is suggested that continued professionaldevelopment is essential in nursing, andreflective practice is suggested as one method ofachieving this (An Bord Altranais 2000, p. 31).Reflective practice is also referred to in theReport of the Nursing Education Forum(Government of Ireland 2000) which indicatesthat nurse graduates should be prepared to beflexible, adaptable and reflective.

Given this increased focus on reflectivepractice, it is intended within this article toreview the implications of these directives.

There is agreement that the nurse needs tobe competent in many skills includingreflection, critical thinking and problemsolving, and reflective practice is cited as asuitable teaching methodology to achievethese. However, the teaching of reflection posesa challenge for nurse educators. Within theliterature on curricula, reflection is eitheridentified as a discrete module (Heath 1998), orintegrated within modules on personal andprofessional development or developingnursing practice. This situation is reflected inthe School of Nursing and Midwifery Studies,Trinity College, where reflection is integratedinto personal and professional developmentmodules contained in Access, Degree andDiploma in Midwifery programmes. Theoryand models of reflection are taught to studentsundertaking the post graduate programmesand they are incorporated as a discrete modulein the MSc in Nursing/Midwifery.

BackgroundWhile critical thinking and problem solvinghave been described in some detail in theliterature, agreement on what constitutesreflection and reflective practice is less clear.Additionally, assessing students’ ability inreflection may be fraught with difficulty. Giventhese concerns, an exploration of the value ofteaching and assessing reflection and reflectivepractice within the nursing curricula of theSchool of Nursing Studies was undertaken.The initial impetus for this work emanated

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from lecturers’ experience of teaching andassessing reflection on one particularprogramme. Evaluations revealed that studentsheld negative views on the reflective diariesused and the volume of work generated for thestudents was of particular concern.Additionally, for lecturers, the use of thesediaries in practice and assessing them raisedethical, legal and professional concerns.Lecturers also had some concerns about thetime involved in supporting diary submissionand about the overall benefit of diaries forimproving clinical care.

The subject of teaching reflective practicestimulated much debate among the lecturers,many of who are committed to the notion ofreflection and reflective practice. Concernsemerged with teaching a concept where there islittle agreement upon definition, and wherethere is sparse empirical evidence to support itsuse in practice. Particular concerns were raisedabout the assessment of reflective skillsthrough the use of diaries completed bystudents. Other issues that emerged indiscussions pertained to the ethical, legal andprofessional issues in assessing academicsubmissions of diaries.

As a result of these discussions and theconcerns raised, a working group wasestablished to undertake a review of the subjectand to make recommendations about theteaching of reflective practice in the school. Thegroup consisted of six lecturers, and allspecialties within the school were represented.In order to progress the work, the issues raisedin discussions were divided into four maincategories: defining, teaching, assessing,legal/ethical/moral implications of reflectionand reflective practice. These categories werealso reflective of the emerging themes from theliterature.

An overview of the current literature in eachof these categories provides an insight into theissues that emerge in teaching and assessingreflective practice.

Defining the concept ofreflection and reflective practice

Reflection on and in action

Learning by thinking about experience is not anew concept (Burns & Bulman 2000), and is

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commonly focused on the work of Dewey(1933) who is deemed to be the firsteducationalist to write on the topic of reflectionon experience. Nurses became interested inreflection during the development of nursingeducation in the UK (Burns & Bulman 2000).Schön (1983 & 1987) described reflection in and on action. Reflection in action is theprocess whereby the practitioner recognizes anew situation and thinks it out while stillacting. It is believed that it is possible toimprove an individual’s ability to reflect inaction. Reflection on action is the retrospectivecontemplation of practice taken to uncover the knowledge used in a particular situation.The reflective practitioner may speculate how the situation might have been handleddifferently and what other knowledge wouldhave been helpful (Schön 1987).

Further work on reflection and reflectivepractice emerged in nursing literature in thelate 1980s and early 1990s (Benner 1984, Kolb1984, Clarke 1986, Powell 1989, Johns 1995,Reed & Proctor 1993, Street 1992). Much of thiswork is based on the seminal writings ofDewey (1933) and Schön (1983). Effectivereflection on practice is thought to generatenursing theory and answer questions thatemerge regarding the nature of nursing (Schön 1983 & 1987, Boud et al. 1985). Theusefulness of reflection has become embeddednot only in professional nursing literature butalso in guidelines for the profession. TheEnglish National Board (1994), for example,advocate that student nurses should usereflection to learn from experience (Jarvis1992). For registered nurses, the NationalHealth Services Management Executive (1993)and United Kingdom Central Council forNursing Midwifery and Health Visiting(1996a,b) advocate the use of reflection tosupport professional practice. In Ireland, theconcept is supported in the Report of theNursing Education Forum: A Strategy for the Pre-registration Nursing Education Degree Programme(Government of Ireland 2000).

Reflection itself is said to be a process ofdeep thought that includes looking backwardsto the situation being pondered upon andprojecting forward to the future. It involves theskills of recall and reasoning (Jarvis 1992).However, while reflection is a natural humanthinking process, the deliberate and systematic

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use of reflection as a learning tool inprofessional practice is a complex activity(Burns & Bulman 2000). Several definitions ofreflection and reflective practice emerge withno consensus of opinion. Within professionaleducation, Boud et al. (1985, p. 10) suggest thatreflection has a specific meaning ‘relating to acomplex and deliberate process of thinkingabout and interpreting experience in order tolearn from it’. Reid (1993, p. 305) describesreflection as a ‘process’ that describes, analysesand evaluates an experience.

Moon (1999) suggests reflection is a set ofabilities and skills for problem solving whileKim (1999, p. 4) has indicated that ‘reflection isa process of consciously examining what hashappened in terms of thoughts, feelings andactions against underlying beliefs, assumptionsand knowledge as well as against the backdrop(i.e. the context or the stage) in which specificpractice has occurred’.

The lack of a clear definition of reflectionand reflective practice, together with theplethora of terms used interchangeably in theliterature, make this phenomenon difficult toutilize within nurse education. Teekman (2000,p. 2) supports this view and suggests, ‘much ofthe terminology related to reflective practice isused rather loosely and interchangeably as ifthere is no difference in the terms’.

Within the literature, there appears to be adearth of empirical evidence supporting theusefulness of reflective practice in clinical care.Reflection is taught in many schools of nursing,however, the literature guards against thewholesale application of reflection as alearning tool (Burns & Bulman 2000). Althoughthere is a growth of nursing literature on thetopic, most of this is descriptive and there islittle attempt to evaluate the contribution ofreflection as a means of learning to nurse(Burns & Bulman 2000).

It is recognized that many valuabletheoretical propositions exist, but there is aneed for rigorous research that providesevidence regarding the effectiveness ofreflection and reflective practice in nursing(Burns & Bulman 2000) and indeed in definingthe terms clearly. The lack of empiricalevidence remains an issue of concern for us,and it is difficult to justify the inclusion ofsubjects within the curriculum that appear tohave little benefit for student learning or for

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improving nursing practice. Indeed, in today’senvironment of evidence based practice it isdifficult for educators to justify the teaching ofa subject where little research evidence existsabout its benefits.

Teaching reflection and reflective practiceThe literature on teaching reflection andreflective practice is sparse in terms of researchevidence. Large amounts of descriptiveanecdotal literature exist, but conclusiveanswers to the question of what is reflectionand how it is to be taught/learned are notapparent. The literature available focuses ontwo types of teaching: teaching reflection in theclassroom and teaching reflection in the clinicalarea. Both modalities focus on reflection ‘on’action as opposed to reflection ‘in’ action. Theaim of teaching the skills of reflection is todevelop reflective practitioners who cancritically analyse practice and develop newknowledge in order to change nursing andmidwifery practice.

The skills that are necessary to developreflective practitioners have been identified asdescription, critical analysis, synthesis,evaluation, self-awareness, clinical reasoningskills and problem solving skills (Atkins &Murphy 1993, Fowler 1997, Schön 1983).However, there is a growing debate on howreflective practice differs from critical thinking.Critical thinking represents a rational, linear,problem solving approach that is grounded inthe scientific method, whereas reflection alsoinvolves the humanistic concerns of analysis offeelings and attitudes (Burns & Bulman 2000).However, Brookfield (1993) and Wallace (1996)also, include an affective dimension in the areaof critical thinking.

Strategies that are commonly used to teachthe skills of reflection include both written andverbal processes with individual or groups ofstudents. Reflective journals, learning diaries,emotional diaries, reflective practice groups,mythic journeys and critical incident analysesare some of the ways in which fundamentalskills can be developed within students(Bennett & Kingham 1993, Bolton 1999, Platzeret al. 2000a,b, Ghaye & Lillyman 1997). Otherteaching methods include action-learning cycles,

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group discussions on clinical case scenarios,role-play and problem based learning (Graham1995, Burns & Bulman 2000). Regardless of theteaching strategy used, the central focus is onthe utilization of real experiences from clinicalpractice.

Important considerations for the teaching ofthis concept include clear aims and objectives,the use of structured frameworks (Johns 1996,Gibbs 1988), allowing time for discussion,adequate support structures for students andpreparation of teachers. Scanlan (1997) alsosuggests that many educators have participatedin educational programmes where reflectionwas not necessarily part of the curriculum;hence their teaching is based on literature asopposed to experiences. In order to teachreflection, it is argued that teachers need topractise reflection in a planned and systematicmanner and model reflective thinking. Burnsand Bulman (2000) question the extent towhich the literature can provide advice onteaching methodologies for such a personaltype of learning, although several imaginativeexamples exist. They also highlight potentialdifficulties as highlighted by educationalists;students need a high degree of support fromteachers, who need to be prepared for this role.Given the lack of clarity that emerges from theliterature about the specific teachingmethodologies that may be used to facilitatethe development of reflective practice skills, wefeel that there needs to be greater evaluationand discussion of the methodologies to beused.

Assessment of reflection andreflective practiceAssessment and evaluation of reflection areemerging as crucial activities for generatingevidence to confirm or refute the link betweenreflection and improvement in nursingpractice. While reflection has become widelyaccepted in nurse education as an importantmethod of developing practice, there appearsto be a lack of empirical evidence to supportthe belief that actually engaging in reflectionimproves patient care (Burns & Bulman 2000). At a more fundamental but important level arethe comments by Sumsion and Fleet (1996),

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who suggest that there is little evidence toindicate that a reflective professional is moreeffective than a non-reflective professional orthat programmes promoting reflection lead to better outcomes.

While there is some general agreement inthe literature on the importance of reflectionand the methods of engaging in reflectivepractice within nursing, there is less agreementon how it can or should be assessment (Moon1999, Platzer et al. 2000a). From a review of theliterature, it was found that evidence does existon the assessment of reflective practice. This isprincipally achieved through the media ofdiaries, journals or logs (Mountford & Rogers1996), but there is little empirical research onhow this is operationalized. Moreover there isa conspicuous absence of implementationstudies dealing with how students’ journals areassessed or the assessment processes involved(Platzer et al. 2000a).

The assessment of reflective practicesubmissions, which include journals anddiaries, and assigning grades to them, iscarried out sporadically in nurse education(Burns & Bulman 2000). One of the difficultiesto emerge in relation to the assessment isidentifying whether it is the ‘process’ or the‘end product’ that is the focus of assessment(Moon 1999). Other difficulties in assessingreflective practice include differentiatingbetween formal and informal assessment(Platzer et al. 2000), and the lack of clarityregarding the purpose of assessment and thenature of criteria used (Moon 1999). Otherissues that emerge in the literature are thevalidity, reliability, accuracy and honesty ofdiary/journal entries (Rich & Parker 1995,Paterson 1995, Richardson & Maltby 1995).Experienced nurse lecturers would alsoquestion the authenticity of submission, andquestion whether there is a value to givingacademic credit when authenticity andaccuracy may be an issue.

Burns and Bulman (2000) outlined a strategyfor the assessment of what was primarily alearning contract, which the students founddifficult and cumbersome to use. In addition,clinical staff and mentors expressed concernabout the intensity of support required forlearners during this process. A pilot study inwhich students and mentors were interviewed,

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involved obtaining their views about reflectivelearning contracts. The students felt that thecontract actually deflected their energy awayfrom practice, indicating that the volume ofwriting involved was a particular concern forthem.

These experiences of assessment of reflectionare similar to the experiences of the lecturers inschool where reflective diaries are used tocollect critical incidents that occurr while inclinical practice. Students found these diariescumbersome and expressed much difficultywith their use. In addition, lecturers foundassigning a grade difficult and expressedacademic concerns about subjectivity, reliability,validity and authenticity within academicsubmissions and their assessment.

Legal/ethical and moralimplications for reflection and reflective practiceIn the literature on reflective practice andassessment of reflective skills, several legal,ethical moral and professional issues emerge.The use of diaries or any other methodologythat commits the student’s views to paperwhen engaging in reflective processes is acause of concern to many nurse educatorsbecause of the potential professional, legal,moral and ethical issues that may arise (Burns &Bulman 2000). The use of diaries, journals andcritical incident analyses may encouragestudents to subjectively and possiblyinaccurately report information on patients,clinical staff and their activities, poor practicesand other incidents that place an onerousresponsibility on the lecturer who may have aprofessional responsibility to act on thisinformation. Unless systems are in place for themanagement of this, the lecturer may be left inthe position of either condoning or colludingwith reported behaviour. Advice related topatient and staff confidentiality is provided forstudents in submission guidelines, howeverthe understanding of these by the students,particularly at a junior level, is often lacking inthe experience of some lecturers.

The literature also indicates that a high levelof teacher/student support is also required tooperationalize the use of diaries. If reflectivepractice is valued as core nursing skill, then

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adequate support structures need to bedeveloped. Lecturers working within currentstructures face a moral dilemma when unableto devote sufficient time to the development ofthese skills.

One further issue that emerges with diaryuse is the ability and right of the teacher todemand student exploration of emotive issuesthat may be potentially stressful and/oremotionally damaging to the student and thelecturer.

Hargreaves (1997) suggests that anydiscussion of patient care outside the clinicalarea for the purpose of reflection requires a‘code of ethics’ that is not currently available.In the Irish context, the discussion of patientinformation within diaries and journals isacceptable where discussions/written entriesare for teaching/learning purposes only andpatient confidentiality is maintained. However,due consideration must be taken to ensure safestorage of this information, which has bothpractical and legal implications for the nurselecturer.

The use of student diaries may also havefurther legal implications. Although Burns andBulman (2000) suggest that informed consentfrom the patient is a prerequisite for use of theirpersonal information within a diary, this is notcurrently legally required in Ireland if absoluteconfidentiality can be maintained. Informationregarding aspects of patient care and unsafepractice, potentially contained within writtensubmissions, is potentially ‘discoverable’through a court order. This highlights theeducator’s responsibility to take appropriateaction if incidences of concern emerge throughthe use of diaries. In Ireland, failure to act inthese cases could result in the educator beingfound negligent or a party to the act.

In addition, professional nursing codes ofconduct require all nurses to identify andreport unsafe practices or situations, wherepractices may put patients and staff at risk.

ConclusionNo clear definition of reflection emerges withinthe literature, and there appears to be littleclarity with regard to its teaching andassessment. There is recognition that thedevelopment of skills of critical thinking,

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problem solving, self-awareness and analysisare essential to the development of aresponsive, dynamic nurse. Perhaps it is thesecore skills that should be taught and developedwithin nursing programmes, as opposed to‘reflection’ per se. This proposition wouldprevent reflection becoming what Richardsonand Maltby (1995) describe as an elitist subjectthat can only serve to widen the theory practice gap.

The literature suggests that the skills ofreflection need clarification, and cautionagainst its widespread adoption until theconcept has been further clarified andinvestigated. Validity and reliability of thisassessment method are difficult to establish. A variety of methodologies are suggested, withlittle empirical evidence to support their use.The use of written submissions on reflectivepractice raises many legal, ethical, moral andprofessional issues for the student, the teacherand the organization.

It appears from the available literature thatthere is a requirement, for all those involved inteaching nursing, whether clinical or universitybased, for a focus to be established on thedevelopment of the reflective practitioner andthe development and enhancement of the skillsrequired to be reflective. Given the lack ofclarity of the term and the skills involved inreflection, its widespread adoption must beimplemented, in our view with some caution.Reflection is a process that requiresprofessional support both clinically andacademically, and is not an easy task for astudent to do alone. If students are to berequired to be reflective, then the theoreticalcontent, skills involved and processes toevaluate the development of these skills needgreater consideration. If reflective practice is tobecome part of the nursing curriculum then itmust be underpinned by a sound theoreticalbase, and the practical implications thatsurround its teaching and implementationneed greater consideration.

It is recognized as important that nursesdevelop the skills of flexibility, creativity, self-awareness and problem solving; but theseskills should not be lost within this increasedfocus on reflective practice. We suggest thatnurse educators must not be unknowingly orunwittingly swept along on a tide of change

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without careful consideration of the theoreticalbase that underpins that direction.

In conclusion, there may well be a place forreflective practice within nursing curricula.However, until there is greater clarity about theconcept, its skills and sub skills, methods ofmeasurement and its benefits to in-patient caredelivery, then caution should be used in itsimplementation. Nurse educators must acceptthis challenge.

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