Reflection in Nurse Education

Reflection has become an invaluable tool for nursing students to learn from Practice. This article presents some of the definitions of the concept of reflection and provides some of the reasons as to why nursing students are at times reluctant to engage with this process. It explores the origin of this concept and how it has become of an important part of professional practice. This process allows nursing students to disentangle the various components of professional practice and linking it to the underpinning theories, promoting better understanding and professional growth. This article explores how reflection can be used to facilitate this process and help the transformation of students into safe and competent professionals.


Learning through Reflection
Nursing education has embraced the concept of reflection as an invaluable tool to help nursing students learn from practice. Research has shown that students see practice as the main place where "real nursing" is learnt [1] and anecdotal evidence from our own students suggest that practice is seen as having primacy over theory for learning nursing. Glenn and Parker state that students' practice experience is now widely acknowledged as being one of the most important parts of their professional preparation and practice-based learning which make up 50% of the course. The ability to apply theoretical knowledge to practice is fundamental in creating competent and highly skilled practitioners. However, the extent to which this happen depends on the quality of the support the students have and the skill they have to integrate theory into practice [2].
The concept of reflection is a key component of transformative learning theory [3] and can be traced to Dewey [4] who described reflection as 'active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusion to which it tends'. Boud et al. (1985) identify reflection as 'a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations'. Mezirow [5] suggests that `reflection is the process of critically assessing the content process or premises of our efforts to interpret and give meaning to our experience'. More recently Johns [6] defines reflection as 'the process of internally examining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self and results in changed conceptual perspective'.
Reflection is used by our students during practice placements as a mode of learning to promote personal and professional growth. Mason-Whitehead and Mason [7] state that even though student appreciate the importance of reflection as a learning tool during practice, they are reluctant to use it because they don't understand the theoretical process and can't relate it to any practical application.
Students find it difficult to articulate the theories that underpin this learning activity as they are embedded in the process itself. Nicholl and Higgins [8] assert that the reflective practice can be used by nurses to overcome the theory-practice divide and articulate the theory rooted within practice.
The use of reflection as a learning tool in nursing stems from the work of Schön [9]. He highlighted the weakness of the theory application approach which has been used by nursing in its quest for academic credibility. Parahoo [10] argues that even though theory is born out of practice, it very rarely returns to inform practice. Furthermore, knowledge generated from research on practice is constructed away from it and when applied may not be totally accurate and applicable. Johns [11] on the other hand sees reflection as a tool that can be used to promote the acceptable standard through the nurse's understanding and learning about her lived experiences. Reflection allows nurses to move from a limited knowledge of knowing what they know without questioning, usually from past experience and theory for a panoramic understanding of new experience. The exploration of the relevant science and artistry for professional practice promotes deep learning and understanding of clinical situations allowing nurses to reframe future nursing interventions for better patient outcomes.
Cooney [12] states that reflective practice is more than just thoughtful practice; it is the process of turning practice into potential learning situations. Equipping nurses with the skills will make them more confident and autonomous to engage in this process. It makes them think about the appropriate required nursing interventions to achieve the desired patient outcomes. By encouraging nurses to learn from practice, it will foster a greater sense of responsibility to identify knowledge deficit and use this process to address same.
Nursing is changing at a fast pace and nurse have to make an effort to keep up to date with the changes. Nurses need to update the currency of their skills and knowledge (NMC 2008). It is no longer acceptable to rely on initial knowledge to care for patients. Through reflection, nurses can review their practice and enhance their professional and personal skills and knowledge, in order to ensure their ability to provide high quality care. There is a greater awareness of the learning opportunities available in practice that can be used to promote professional growth. Nurses will feel a sense of great pride to know that the care they provide can equal the best that is available and confident and motivated to know that their care has been effective in helping patients.
Schön was first to highlight the use of reflection as a means to improve nursing practice rather than the theory-application approaches that has influenced nursing. He described a high hard ground where research findings may easily be applied, but noted that challenges for nurses tend to prevail in the swampy lowland of practice as confusing 'messes' that need the skill of the confident nurse to unravel the meaning for a better understanding. Most nurses tend to focus on substandard care or situations they were not happy with for reflection and missing out on other valuable learning opportunities. Reflecting on good practice allows nurses to disentangle the theory underpinning the practical performance, consolidating existing knowledge to maintain high standard of care delivery.

Professional Growth through Reflection
The concept of reflection as a strategy for personal and professional growth has been well documented since the 1980's [13]. Reflection is a transformational process; it helps to heighten awareness of the nurse on how to improve on practical performance. It is about actively thinking about how you did, what you did well and what you did not do so well. With the aid of a simple prompt question such as 'what might I do better next time?' or 'what could I do differently?'. Provides an opportunity to draw from the past and present to improve performance in the future. It is about analysing your performance in the context of existing evidence on how something should be done to maximize the therapeutic benefit for your patient.
Within our own institution, it is promoted as an essential tool to help student's link theory with practice to enhance the development of clinical knowledge for safe clinical practice. By engaging in the experience and reflecting upon it, students are able to evaluate what was good and bad about their performances. This process encourages the students to work out how they can improve their future practice. Mason-Whitehead and Mason state that students struggle with the cognitive process of linking theory to practice, however, by asking them to reflect on an event which took place in recent clinical practice allows them to begin to provide a structure for what, how and why the event evolved the way it did and how it can be improved [7,11]. A structured reflective process provides scaffolding for the student to make sense of practical experience and build bridges with relevant theory.
Final year nursing students have reported apprehension and a lack of confidence in fulfilling the expectations and responsibilities of becoming a qualified nurse [14] . Within the pre-registration BSc Adult Nursing programme, students are encouraged to reflect in and on clinical practice in order to develop and consolidate their learning [15]. However, feedback from our students states that whilst on placement only some of them are given the opportunity of constructive debriefing and reflecting following a significant event. As a result, nursing students are sometimes unsure of how they performed during such an event and can therefore be uncertain of their level of competence in relation to their stage of training.
To address this, students are encouraged in theory to reflect in depth each element of the event that took place. The student is then encouraged, with peer involvement, to simulate the same event in real time. This process of reliving the experience in an environment where lecturers provide support to link the relevant theory allows students to understand the theoretical basis for competent practice. The process makes their own reflection 'real' and it is only at this point, through simulation, that the student begins to understand how reflection can improve their competence for future practice [16]. This innovative approach to teaching and learning, which is currently being developed within our own institution, builds on existing practice and broadens the student experience by providing the student with ownership of the simulated scenario. Therefore, we suggest that formal reflection on practice, researching the event that took place and replicating it using the resources available within the university will help prepare the student for similar future events that may occur in practice. As a result, this deeper understanding of the event will have greater transferability to the workplace and the student will begin to understand the benefits of the reflective process. Student scenario development using reflection is currently practiced within our institution and so far feedback from our students has been very positive on how it's promoting their professional growth and competence.
Reflection has become an invaluable tool for nursing students to learn from Practice. It helps students to explore personal and professional experiences to make sense of professional practice and link the relevant theory. By our students embracing this learning process and appreciating the benefits, they are able to learn from what they are doing. This does not only promote professional growth and higher level of competence, but equipped them with a lifelong learning skill which can only benefit the nursing profession.