Joumal of Advanced Nursmg, 1995,21,1167-1174

Nurse educators' perceptions of reflection andreflective practice: a report of a descriptive study

Philip Bumard PhD MSc RGN RMN DipN CertEd RNTDirector of Postgraduate Nursmg Studies, Uruversity of Wales College of Medicine.Heath Park, Cardiff, CF4 4XN, Wales

Accepted for publication 6 September 1994

BURNARD P (1995) fournal of Advanced Nursing 21,1167-1174Nurse educators' perceptions of reflection and reflective practice: a report of adescriptive stndyThe concepts of reflection and reflective practice have been widely discussed inthe nursmg literature Only a small amount of that hterature reports researchstudies This paper offers the findmgs of a quahtative and descriptive study mwhich 12 nurse educators from various teaching institutions were interviewedabout reflection and reflective practice The report identifies the findings of thestudy imder the following headings reflection m nurse education, reflectivepractice in nurse education, nursmg and the use of reflection, advantages anddisadvantages of reflection and teachmg reflective practice While many oftherespondents reported positively and enthusiastically about reflection, a numberalso expressed views about its being a 'fashionable' concept and one, as yet, ofunproven value Various suggestions are made for further research m this field

INTRODUCTION

In recent years, there has been considerable mterest m thenotions of reflection and refiective practice m nursing(Gray & Pratt 1991, Bodley 1992, Johns 1993a, Reid 1993)The literature on the topic often traces the roots of thoseideas to the work of Schon (1983), although previous com-mentators have written at some length on the topic (forexample Freire 1972, Wirth 1979, Meziro 1981)

James & Clarke (1993) offer a detailed analysis of theconcept of reflective practice and its implications for nurseeducation, and Lauder (1993) discusses some of the philo-sophical issues that need to be considered by nurse edu-cators and practitioners who are drawn to the conceptsJohns (1993a, 1993b) has developed vanous frameworksfor applpng a reflective approach to educational andclimcal practice

Much of the literature on the topics of refiection andrefiective practice in nursmg remains at a discursive levelor offers reports of nurses' and nurse educators' expen-ences of usmg refiection m their practice (for example,Saylor 1992, Jarvis 1991, Reid 1993), and empincal workon the topic is difficult to find Powell (1989) reported astudy of eight practismg registered nurses and their use of

refiection-m-action m their everyday life, whileMcCaugherfy (1991) descnbed an evaluation programmethat considered the outcomes of an educationed pro-gramme aimed at promotmg reflection amongst first-yearnursing students It is mterestmg to note that Atkms &Murphy (1993), in a paper entitled 'Refiection a review ofthe literature', identified these two papers only as evidenceof research m the field In a later paper, Snowbedl, Ross &Murphy (1994) descnbed a small research study designedto explore refiection as a tool of learmng They identifiedvanous stages in the supervision of dissertations, emdpointed to the need for constructive support in the edu-cational process

The study reported here was a qualitative emd descnp-tive one in which nurse educators were interviewed aboutrefiection and refiective practice Any study of this sort isalways haunted by the larger question 'but does (refiec-tion) make a difference to clmical practice'' Whilst manyof the respondents m this study comment on their beliefsabout this issue, that question remains an open one

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THE STUDY

A qualitative study was ceimed out to explore nurse teach-ers' perceptions of refiection Given the fact that refiectionIS a relatively 'new' educational approach, it was decidedto mvite a range of nurse teachers to descnbe their viewson the topic

Sample

The sample was a purposive one (May 1993) Purposivesamplmg is a non-probabihfy seimpling method in whichthe respondents are chosen for the study accordmg to thelikelihood of their being able to talk with some msight onthe topic m hand If a researcher is explonng refiectionwith nurse educators then it is appropnate that 'nurse edu-cators' become the population from which that sample isdrawn In this sense, they are self-selectmg or selected bythe researcher This means that findings from studies thatuse a purposive sample cemnot be generalized to a largerpopulation This is generally true ofall qualitative studies,however

The sample was also a 'snowball' sample (Sarantakos1993) Each educator interviewed was asked to rec-ommend one or two other educators for mterview on thetopic In this way, a range of difierent educators fromdifferent institutions and areas was identified

LoBiondo-Wood & Haber (1994) confirm that samplesizes m qualitative studies tend to be small, and suggestthat interviewing should contmue until 'data saturation'has occurred, that is, until no 'new' ideas or thoughts areidentified by the respondents In this study, this occurredby the eighth mterview, and the research continued until12 interviews had been completed

The 12 nurse educators, from a range of institutions,were interviewed using a semi-structured mterview sched-ule The semi-stnictured mterview allows the researcherto become an active peirticipant m the interview while, atthe same time, making sure that certeun key areas eirediscussed (Gilbert 1993)

Data analysis

All the interviews were taped and each mterview lastedbetween 30 minutes emd one hour The interviews weretranscnbed and the content then emalysed Content analy-sis, of the type used here, mvolves ldentifymg a range ofthemes withm the transcnpts and then re-ordenng the textto refiect those themes (Sapsford & Abbott 1992, May1993) This IS by no means a foolproof process for, asAtkinson (cited by Silverman 1985) notes, researchers

often expect, if only at a subconscious level, to 'find' educational,sociological or psychological concepts starmg them m the fece orleaping out at them from the data

Content analysis is both time-consummg and frustratingThe researcher must be careful to 'stay with' the contentof the transcnpt and not to attempt prematurely to 'inter-pret' the data In this sense, the data are allowed to 'speakfor themselves' although this pomt should not be takentoo literally It would be hard to argue that there necessar-ily are 'hidden meamngs' or messages buned vnthm thetext Given that the researcher is workmg only with pnntedtext and not with human bemgs (with whom he or she cemcheck details) means that he or she must take a 'conserva-tive' view of the meanings of passages of text He or shecan edso only work with the explicit, and not the implicit,meamng of the text

The aim of the analysis is to account for all of thedifferent points of view discussed by the respondents emdto try to avoid 'researcher bieis' While the total elimin-ation of the latter is impossible, veinous checks andbalances can be used, such as returning to vanous mter-viewees to check meanmgs This was done on threeoccasions m this study

The iterative processThe process of emalysis was also an iterative one(Huberman & Miles 1994) The researcher read and rereadthe interview transcripts and developed first, 'large' categ-ones into which large sections of text could be placedThen, by revisiting the transcripts, lower-order categoneswere developed Finally, an attempt was made to cut away'dross' (Field & Morse 1985) those aspects of the text thatdid not bear, directly, on the research topic The notion of'dross' does, of course, beg the question of what mightcount as dross and here the researcher has to make fairlyautocratic decisions about what to leave m the report andwhat to leave out

Repetition of ideasAn attempt was also made to cut out repetition of ideasalthough, m another form of anedysis, such repetitionscould be teiken eis validating a particular category It mightbe argued, for example, that an idea that was talked aboutby many respondents was an important one This issue isdealt vnth, in this report, by noting that 'a number ofrespondents referred to the idea of x', or 'many respon-dents felt that '

In the end, the tjrpe of study reported here is a qualitativeone and frequencies of the occurrence of items of text orof categones is not a pnmary issue This pomt is some-times made m the literature by noting that quantitativeresearch tells us how many thmgs there are and qualitativereseeirch tells us what sort of things there are (Bryman1988) This study offers a report of the sort of ldeeis thatsome researchers had about reflection emd refiectivepractice

1168 © 1995 Blackwell Science Ltd, Joumal of Advanced Nursing, 21,1167-1174

Perceptions of reflection and reflective practice

Validity checks

Traditionally, in this type of study, the researcher isencouraged to return to one or more of his or her respon-dents and ask those respondents to venfy, or otherwise,the researcher's analjrsis (Field & Morse 1985) Clearly, thisIS not a watertight check for the validify of the analysisThe respondents can be influenced by the 'new readmg'of the data, or they can have forgotten what they said ormeant dunng an mterview, and so on On the other hand,the validation check edlows the respondent to review whatit IS he or she has descnbed and, as appropnate, allowshim or her to add to the data (Silverman 1985)

In tbe study descnbed here, three respondents wereapproached to discuss the analysis of their interviews andagreement about the validity of the analysis was reachedthrough face-to-face meetmgs

FINDINGS

The findings are offered under a senes of headings and areinterspersed with commentary about the vanous pointsthat arose

Reflection m nurse edncation

A number of the respondents defined refiection m muchthe same way as the definitions found in the literature(Schon 1983, Atkms & Murphy 1993) They mcludeddescriptions of refiection as mvolvmg looking back overcliniced practice and thmkmg about what they did asnurses dunng that penod of practice Examples of tjrpicalresponses are as follows

It IS helpmg students to look at their practice in a manner that isdesigned to make the person explore and use what they havefound that is good and understand, perhaps, what was difBcultor problematic and that they could put mto their ongoing practice

It IS the process of auditmg aspects of canng that nurses do As aprofessional that is still involved clinically with using reflectionm my practice, it is very much looking at what I do, why I do itand how it works

It IS an opportunity to stand back, to take stock, to look at a particu-lar incident and to look at what has happened in a professionalway

It IS the opportunity to say 'Well, how did I perform and whatcould I have cheinged What could I have done that was different'What would I do if it happens again^'

It will be noted that the second respondent, above, notedthe lmportemce of her link with clmical practice as a nurseeducator Some respondents linked the use of refiection tothe literature and made it a more 'formal' learning activify,perhaps more m keeping with the hterature that descnbes

expenential leanung (Kolb 1984) For example, onerespondent said

I understand it is a technique used to encourage students to reflecton practice and to read the literature surrounding that practice sothat they become more informed

This respondent is suggestmg that reflection may lead toa desire to leam more a jioint discussed by Wlodkowski(1985) m his discussion of motivation in adult learningThe mam pomt, m this category, however, was the degreeof similanfy between respondents m the way thatreflection was defined

Reflective practice in nurse education

A distinction was sometimes made between reflection andreflective practice, although as the respondents talkedoften these two concepts merged into one, for instance onerespondent said

Actually, I am not clear in my own mmd that there is a distinctionmade by nurses between reflection and reflective practice

On the other hand, other respondents talked about theidea of refiective practice as part of the process of nursmgand as an important aspect of nurse education

[Reflective practice) is thinking about practice during practicethinking about practice after practice in relation to vanous aspectsof the process of nursing

It means thinking about your practice, about your relationshipwith others and about the way you feel about, say, performingcertain tasks Really in a sense it is becoming more self-aware ofyour own practice

Clearly the last respondent had linked reflective practicewith the more general idea of self-awareness although theissue was not elaborated on by the respondent nor takenup by the interviewer Another respondent linked reflec-tive practice to the idea of the nurses' role and suggestedthat

reflective practice is one way, you know, after events, of trying tobreak down what happened and thinking about what role you hadm them and what you did and why you did certain things andtrying to decide 'was that tbe nght thing to do^', 'did it work, wasit effective or perhaps I should have done something else?'

Yet another respondent thought that reflective practicewas perhaps just a new name for somethmg that wasalready bemg done — a point echoed by others, andreported m another section of this report

Well, I suppose it is )ust to do with thinking about what you aredoing and learmng by previous expenence, but under anothername

This respondent agam echoes the st^es of the

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expenential leammg cycle as descnbed by Kolb (1984),Weil & McGill (1989) and others The expenential leam-mg cycle IS usually descnbed as havmg four stages (a) anexpenence, (b) reflection on that expenence, (c) thedevelopment of new theones, emd (d) the application ofthose new theones to 'real life' The respondent's com-ments seem to echo the concepts underlmed by thosewnters on expenential leanung, emphasizmg, as they do,the need to lmk thinking about expenence, vnth expen-ence Itself

Nursing and the use of reflection

Many respondents were excited by the idea of reflectivepractice and felt that it was a very useful way of helpingpeople to improve the work they did as nurses Formstemce one suggested, simply, that

You can't do without it'

The point seemed to be that everyone needs to refiect, bothin and out of nursing Other respondents were similarlyenthusiastic

I think It IS an excitmg opportumty in a professional way tocombine both theory and practice for an improvement inpracticeIt IS a good thing that nurses bave tended to become reflective Ithink that some nurses in the past would 'unpack' the day at theend of the day and talk to their colleagues about things andreflect on actions but I think I have discovered as a teacher thata surpnsmg number of nurses don't or haven't ever re-openedthe box once something has gone by and I thmk that we canonly leam from our mistakes and to try to do things betterplanned in the future

This respondent is clearly seemg reflective practice as away of future planning and of enhancing future practiceHe IS also cntical of more traditional nurses who mightnot stop and thmk about what they did in practice

However not all respondents were equally enthusiasticOne respondent, for example, had ambiguous feelmgsabout the value of reflective practice m nursmg

I fBel It can be a mixed blessing I am a bit concemed because itseems to bave appeared from nowhere It has obviously got somevalue but I am concemed that it is seen as a panacea I thmk it isvery important there should be certain strategies and safeguardsfor the person's personal, mtimate emotions Otherwise, it is anmvasion of a person's pnvate views Thinking about thmgs isgood, yes, but in a sense I wonder if reflecting on thmgs is notjust a part of being human It may be too introspective In a wayit IS possible for you to get paralysis from analysis by not lookingat what IS happening here and now and what might happen mthe future but by forever looking back

This respondent, whilst acknowledging the value ofreflection, also notes that too pointed a reflective session

might encroach on a person's personal life It was felt bythis respondent to be really important that we respect thatpeople have a choice about the thmgs they talk about andthe feelmgs they express It is vital that no-one feels underpressure to reflect m company about those thmgs theywould prefer to keep pnvate One respondent discussedan expenence m a college of nursing m which student's'pnvate' reflective journals had been discussed, openly, mthe stafEroom

On a similar but different theme another respondent hadthis to say

I've seen and experienced words like reflection before which havebecome a hobby horse or a bandwagon or an academic exerciseand I have really not sufficiently thought through what was clearlyexpressed by educators and practitioners Nurses have developeda very sophisticated oral culture and nurses are incredibly cleverand gifted at oral expression, oral argument and so on but arenotoriously weak at wntmg down their experiences and I thinkthat if reflection can help us do that then we are moving nurs-ing forward

Some respondents described wbat could happen if youdon't encourage nurses to reflect For example, one respon-dent had this to say

I think that if you don't reflect, if you cannot encourage reflectionor debnefing or whatever you call it, if you don't encourage nursesto record incidents or situations and items from their practice andto thmk about those and to share them, to tell their stones and toexamine those stones then nursing will stagnate It will regressand It will really have increasing problems m demonstratmg thatIt has any value m the future

This was a particularly strong response about what mighthappen if refiection didn't occur, and raises tbe rather oddquestion of whether or not there could be any human situ-ation m which no refiection occurred at all As we havenoted, some respondents felt that refiection was anautomatic, human process that 'naturally' occurred

Other respondents were unsure about how reflection'worked' but were convmced from a pragmatic point ofview that it was a useful concept For example, one said

I don't know quite how it works but all I can see is that whensomebody's got it and I can see when they haven't got it Youknow it's quite obvious when you work with them for a coupleof hours and I am very, very positive about it I think it's absol-utely crucial

What IS interesting about this response is that the respon-dent seems to indicate an intuitive element to the reflectiveprocess She acknowledged that she could identify anotherperson who 'had it' and also those that did not This pomtmight usefully have been explored further The samerespondent went on to make very positive statementsabout reflective practice m nursmg

1170 © 1995 Blackwell Science Ltd, Joumal of Advanced Nursing, 21,1167-1174

Perceptions of reflection and reflective practice

WeU, I'm really mto it actuaUy m a big way and it is not becauseof what I have read, it is Imcause of the way I have learnt it mpractice So it comes very much from my work area and the waythat I have leamt from things It was only afterwards that I wentto the books and tbe pumals and read about reflection and modelsof reflection and really saw that this had become formalized andthat was why I became really keen on it because I realised that itwas something I was doing automatically m my work

This IS an mterestmg example of reflection m practiceThis respondent is saymg that she noticed that she wasreflecting on her practice as she worked in clmical settingsShe then went to the literature and made the link betweenher own professional expenence and what had been wnt-ten in the books and the journals This response is also anillustration of how enthusiastic some educators can beabout refiection, a pomt discussed at length in an analysisof the teachmg of reflection by Reid (1993)

Negative viewsDespite generally positive feelings about reflective prac-tice, a few respondents had negative comments about itand one that seems to summanze some of these feelingsIS as follows

I don't see that it has any use m nursmg at all There are otherleaming theories that would be much, much more suited butaren't applied

However, in retrospect, the mterviewee did not elaborateon what those 'other leaming theones' might have been,nor did the researcher explore with her whether or notreflective practice weis bemg counted as a formal leam-mg theory

The advantages of being a reflective practitioner

Many advantages were cited by respondents, althoughmost of them related to improvement of clinical practiceFor example, one respondent said

I think that It makes you a more confident practitioner and a morecompetent practitioner It makes you a more sensitive practitioneras well It gives you an opportunity to look at your practice andto try emd improve on it

Another respondent lmked it directly to cognitive pro-cesses (and directly to patient care) when he suggestedthat

I thmk tbe benefits are that people become more thoughtful, theymtellectualize the process of nursing more and ultimately it is forthe betterment of the client

Yet another respondent lmked the use of reflective prac-tice to qualify issues Offermg a quote that could have beentaken directly out of a book on quahfy eissurance (see, for

example Mimro-Faure et al 1993) a respondent sug-gested that

you are more likely to get it nght first time, next time

It has to be said however that there is some ambigmfy mthe above phrase If you are going to get it nght first time,then there isn't a next time'

Other respondents identified the fact that refiection actu-ally changed the way in which you felt about the worldOne respondent talked about how it could make nursesless certain about the situation m which they foundthemselves

I thmk that it enables you to realize that nothmg is certain andthere is no nght answer It gives a nuance — a balance It meansthat decisions are being made through evaluating the informationgiven at the tune I think that bemg a reflective practitioner isthinkmg about things as you are doing them or once they aredone After a long time it may be useful The best thing to realizeIS that there is a lot of uncertainty in tbe decision-making processand in practice Tbe nurse's role is to live with uncertamty andto try to make the best decisions even with that uncertamty

The respondent echoes a number of vmters on adulteducation who have stressed the need for adults to adopta critical viewpoint and to resist emy attempt to find 'the'answer to real-life issues (Cleixton 1984, Brookfield 1986,1987)

Another respondent offered the suggestion that reflec-tion could also be an uncomfortable process in as muchas it forced chemge

I thmk that reflection is pamful because what it does is it actuallychallenges and brings to the fore the whole idea of change In asense reflection can speed up change and change is never easy, itIS never comfortable and sometimes it can be very frustrating

Overall, though, the responses were positive about theidea of reflective practice in nursmg Many respondentsdescnbed how the refiective approach could enhancepatient care, although specific examples of how thatenhancement could take place were not offered

I think the advantages are that we get a more thoughtful, purpose-ful, systematic approach to nursmg usmg a reflective approach

WeU I thmk it helps you develop your own practice It helps youto enquire so for mstance you may be able to reflect on somethmgthat has happened and answer all the questions that you have —your own questions — but you might not, so then you go to tbe

library, a book or a journal to find out Or you might ask somebodyelse who you think might know So I think from your knowledgeEmd enquiry it can help you to change the way you feel aboutyour practice

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The disadvantages of being a reflective practitioner

For some respondents there was a sense that we'd 'beenhere before' One respondent summed this up by suggest-mg that

probably tbe biggest difficulty is the assumption that it may takea long tune to do and that m fact we nught be domg it alreadyanyway

Others had specific points that they wanted to makeabout the disadvantages of reflective practice One forexample womed about the structure that it brought tobear

Any structure that you use as a guide to reflection can perhapslimit rather than allow freedom, but it is difficult to get the balancenght, because you need a framework in order to do it I thmk thatprobably one of the major disadvantages is that it is part of thenational profile

The comment about the 'national profile' referred to thefact that national boards for nursmg had mcorporated theidea of reflective practice very readily mto their documentsregarding nurse education It was often noticed m passingthat the national boards tended to adopt what might bedescnbed as 'popular ideas' This idea that reflective prac-tice was a fashionable concept weis echoed by a numberof respondents

There is a flavour of 61itism involved as well, but mamly myconcem is dealmg with the mumbo-jumbo that is bandied aroundabout reflection Wbat, to my mind, we are talkmg about is simplythe process of thinkmg, of reviewing wbat has happened, what islikely to happen

To my mmd the disadvantage is that it has been jumped up tomake it look like something that is much more sophisticated thanIt IS Because it is made almost deliberately complex this wholephenomenon is simply muddying the waters it is making muchmore of what if just a simple human process and really requiresto be one

I thmk It IS time-consuming and it is probably just a popularexercise at the moment which will lose ground or certainly peoplewill lose mterest m it I think that people bave got enough to dowithout reflectmg on every smgle thmg that they do

Other disadvantages include womes about the students'reactions to personal disclosure and the effect that reflec-tion may have on students

Ob there is a touch of navel-gazmg Tbe disadvantages are thatpeople become more and more introspective and become moreand more anxious about their actions so that they become para-lysed by anxiety

Analysing yourself is not easy and you may dig up lots of thmgsthat you may want to leave buned

I thmk that it can make nurses as individuals rather introspectiveWhat's past is {>ast and if you are forever looking back you m ^ tmiss the here and now Hindsight is an mexact science Everyoneviews tbin^ from a different perspective Practice is here andnow Looking back you may get a distorted view For example, ifyou are climbing a massive mountain, you may be tired, out ofbreath, sweating and not reaUy enjo)ang the expenence But whenyou bave reached tbe top and you can see the view and you areenjoying the expenence you may forget the pain you went throughto get to the top, so thinking back on the climb to the top youmay get a different perspective on the joumey

Is it morally and ethically correct to ask people to reflect ontheir mtimate values' Is that nghf What other professionals askyou to reveal your deepest thoughts has anyone got the ngbt toask' There is the fear of making the professional deal with thepast and not seeing the here and now and looking to tbe futureWhat nurses are asked to reveal is deep and significant At theend of the day I believe that people are selective and tend to chosesafe episodes m education and in practice They tend to chosethings from a superficial level I can see that more trust and safe-guards are needed m practice and m education Effective trust isneeded for significant reflection

This IS an important comment on the way m which ourperspective on thmgs can change with hindsight Theremay be the temptation to believe that when we reflect backon experience we are remembenng things as they actuallyhappened What seems likely is that our recollections arequite different to the flow of events themselves (Claxton1984) The question that needs to be raised here is whetheror not that matters Clearly, for the above respondent, theissue was a vital one

Teaching reflection and reflective practice

Respondents were, at times, vague about exactly how theytaught reflection to students A number of them referredto a range of experiential leaming activities, such as groupwork, and a number referred to using expbcit models ofreflection However many more talked in more generalterms

I think that most of my teachmg is based probably on looking atcnbcal mcidents and looking at reflection and mcorporatmg itinto my teaching So I probably don't teach the theory of it or theframework of it But I do teacb the practical implications of it andwe look at cntical mcidents or scenanos and key concepts

I tend to use an introductory session as a way of finding out wberemy students are I tend to advise them to read certain texts andcertain articles I also use cntical incident technique reporting asan assessment strategy for trjrmg to get people more used toreflecting on their actions

Some respondents seemed doubtful about whether ornot they wanted to teach reflection as a formal topic

1172 © 1995 Blackwell Science Ltd, Joumal of Advanced Nursing, 21, 1167-1174

Perceptions of reflection and reflective practice

I like to think that I don't teach reflection as a subject but I liketo feel that personally it is important for people to think aboutwbat they leam, what it means for them I tbink that I wouldteacb that as a style altbougb I don't teach specifically reflectivepractice or reflective education

On the other hand some respondents were explicit aboutthe t5rpes of methods they used to help people to refiect

I've taught it by settmg up workshops, by pairing off students Imake sure that students have a good understanding of reflectionand reflective practice by usmg expenential leaming methods

The pomt, for a number of respondents, seemed to bethat they did not teach reflection, m a formal sense, butmodelled it by demonstrating refiection-m-action to andwith their students

DISCUSSION

The findings identified above seem to point to a relativeconsistency in defining reflection but to some dispanfyabout (a) 'how it works', and (b) whether or not it is a'passmg fad' On the other hand, most of the respondents,with one or two exceptions, expressed very positive feel-ings about the use and application of refiection in nursingeducation and m practice

The report above also notes some similarities betweenthe refiective process and the expenential leaming cycleas descnbed by Kolb (1984) and others Both processesseem to mvolve observing a situation, realizing that one isin a situation, thinking about it and then making decisionsabout what to do next What remains less clear is thedegree to which it is necessary or appropnate to formalizethis sort of process The respondents m this studyappeared to be ambivalent about this issue

Conclusion

This paper has offered a descnption of some nurse edu-cators' perceptions, feelmgs and thoughts about reflectionand refiective practice As was suggested earlier, what maybe needed next is an attempt to identify the degree towhich such practice does or does not enhance patient careand nursing practice So feir, there has been a considerableamount of rhetoric surrounding the topic What may beneeded is much more empmced evidence, to either shoreup the concept or to ensure that the useful parts of it areextrapolated and taken forward mto new educationalpractices

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