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Reflective Account of Nursing

Introduction

Nurses practicing in today's rapidly changing health care environment are increasingly becoming

aware of the need to evaluate and improve their practice as well as consider the political, social

and structural issues affecting it (Bettie et al 1996:28). Because the changes are occurring all

around us, it is important for the nurses to be able to analyze and respond to the new and the

different challenges in a proactive way. Developing critical thinking and reflective skills will

assist the nurses to meet the challenges of providing care in a context of the rapid changes and to

become a critically reflective practitioner.

There are several issues about the reflective account of nursing can be discussed where it seems

to bind nursing practice with questions of ethics, sociology and management. Reflective practice

is an important aspect of nursing management. Greenwood (1993) suggests that “reflection is

about considering what one is doing whilst doing it and is often the result of something that has

surprised the practitioner”. Fitzgerald (1994) believes that “the individual is retrospectively

considering practice undertaken through recall, thereby uncovering the knowledge used in that

particular incident or situation”.

During the practice the nurses can apply to few of reflective account model, it is depending on

related to the environment and situation both on the workplace or patient. There are some

popular models of the reflective account start from the most famous is the Gibbs reflective cycle

(1988), Johns’ model of reflection (1994), Kolb’s Learning Cycle (1984), Atkins and Murphy’s

model of reflection (1994). There are many more of reflective account model can be found,

however the most important thing the nurses have to do is to use it wisely on which model is

most related to the situations in their clinical work where they feel they have learnt something

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that is of value to their practice and future career. It may be a positive experience when

something went well or a negative one where one’s need to think about what has happened.

Definition

Reflection is a generic term with many definitions. Boyd and Fales (1983) define it as the

process of examining an experience that raises an issue of concern, as an internal process that

individuals use to help refine their understanding of an experience, which may lead to changes in

their perspectives. Boud D. (1985) define reflection as the cognitive and affective behaviors in

which individuals engage that result in new insights and deeper understandings of their

experiences.

Nurses, medical students, residents, and alike are continually faced with unique and ambiguous

problems in the clinical setting, during which they are forced to stop, think, and problem solve in

the midst of activity. Schon (1987) terms this “reflection-in-action.” In practice, Westberg and

Hilliard (2001), note that reflection-in-action requires physicians to function on two levels

simultaneously, attending to the task of treating the patient while continually questioning,

observing, assessing, and adjusting throughout the session. In addition, after each patient or

family interaction, the nurses may reflect on what can be done to improve each patient's

outcome. Schon refers to this as “reflection-on-action” and suggests that reflective nurses revisit

their experiences and further analyze them to help improve their skills and enhance their future

patient care.

Killion and Todnem (1991) extended Schon's concepts to include “reflection-for-action.” It is

through reflection-for-action that both novice and expert pediatricians can begin to anticipate

situations and plan through mental preparation before being faced with different clinical

problems. They state that it is not sufficient to reflect-in-action and on-action; rather, reflecting-

for-action is also crucial to professional development and quality care. These very skills are

integral to competent pediatric practice yet must be learned by novices in the clinical setting

Jensen G (1991, 1997).

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Mezirow JA (1990) states that reflection is not simply stopping to think and problem solve or

plan for future action based on what you already know; rather, it is critically questioning the

content, process, and premise underlying the experience in an attempt to make meaning or better

understand the experience. He contends that reflection is a higher-order, conscious thought

process. He suggests that using all the three elements of reflection, the content, the process, and

premise will result in changes in behavior that reflect changes in underlying values, attitudes, and

beliefs as new nurses move toward becoming professionals.

Content reflection involves the analysis of the problem or situation itself. The nurses in acute

pain ward are routinely required to analyze situations from the perspectives of all those involved

in a patient’s care, the parents, the medical officer, third-party payers and others who related to

the patient. Mezirow JD (1990) would term this “content reflection.” They then look to

determine what strategies they might choose to address the patient's situation, which is what

Mezirow terms “process reflection.”

Process reflection requires the nurses or the trainees to analyze the problem-solving strategies

they chose, determine the efficacy of the strategies chosen, and perhaps explore what other

strategies might be available. Finally, premise reflection is the most difficult of Mezirow’s

reflective constructs because it requires the nurses or trainee to question and analyze his or her

own assumptions and the basis for the existence of the problem or the assumptions underlying

the problem itself. Assumptions are taken-for-granted beliefs, and as a result it is often difficult

to recognize personal assumptions.

In addition, premise reflection often requires the individual to question why a particular problem

exists. For example, when a nurse begins to question why a particular the patient is not entitled

to certain medical treatment or why certain differences exist in health care, the pediatrician is

using premise reflection. For trainees to begin to recognize their own assumptions and biases and

how they might impact their clinical decision-making process, as well as their role in social

advocacy, significant skill in premise reflection in required.

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Atkins and Murphy (1993) performed a meta-analysis of the many definitions of reflection

present in the literature and noted that there are three common elements essential to this process.

First is a trigger event, which is typically an awareness of some uncomfortable feelings or

thoughts either positive or negative. Second is a critical analysis of these feelings and thoughts

and the experience itself. Third is the development of new perspectives as a result of this

analysis. For trainees, this analysis could mean the development of new perspectives on their

lived experiences, which may result in more informed clinical decisions.

Kolb D (1984) defines reflection as an element of the learning cycle and Brookfield SD

(1987) suggests that it is the link to critical thinking. Brookfield defines critical thinking as a

direct outcome of the reflective process described by both Mezirow JA (1990, 1991) and Schon,

(1987, 1983) critical thinking is the result of trainees taking time to revisit their experiences and

process them from a number of different perspectives before drawing conclusions. According to

Brookfield (1987), critical thinking is the trainee's ability to recognize assumptions, beliefs, and

values that underlie their decision-making processes as they solve problems, anticipate

outcomes, and justify their actions. Critical thinking uses the analytic process of reflection to

extract deeper meaning from experiences.

Reflection is particularly important in medicine, in which evidence-based practice and client-

centered care require both the nurse and the physician to analyze best evidence while considering

his or her values and assumptions of the values, beliefs, and goals of each patient. It enables

trainees to recognize their own assumptions and how those assumptions might impact the

therapeutic relationship and their clinical decisions. Reflection also helps practitioners develop a

questioning attitude and the skills needed to continually update their knowledge and skills, which

is essential in today's rapidly changing global health care environment. The importance of the

reflective process is further acknowledged by the Accreditation Council for Graduate Medical

Education (ACGME -2004) as underlying a number of the expected competencies is the

development of reflective practitioners.

Reflective Account Models and Theory

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As there are various models that can be used to reflect on learning and practical experience, one

of it has been develop by Graham Gibbs and popular known as the Gibbs reflective Cycle

(1988), provides a useful framework or reflect on the nurses practice and learning activities.

Gibbs model is most popular among the nurses practice and student nurses, it us covers six

stages as per TABLE I. The Gibbs’ reflective cycle can be rally useful to assist the nurses

through all the phases of an experience or activity.

TABLE I: The reflective cycle (Gibbs 1988)

The situation starting from the described by writing down the event which we want to reflect on,

the event can be shared with others or can be kept by the person itself. At this stage it is very

important to get down as much as you can to the objective. The feelings is the second stage are

need to be considered, try to recall and explore the things of the event either the felling of

happiness or dissatisfied that are residing in one’s mind. AT this stage is quite difficult to share

with others. And from here than it go to the next stage the experiences need to be evaluated. The

evaluation need to be measured and valued to some sort of standard, to arrive on judgment on

what has happened from the good and the bad experiences.

The fourth stage is the situation to analyze for clarity, where things need to breakdown to their

component parts, so that they can be exploring separately. At the conclusions stage are drawn is

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differ from the evaluation stage where now one’s judgments, from detailed analysis and honest

exploration from the event. It is also important to consider what else could have been done to

affect a different outcome. The action plan is developed so that the individual can consider what

they would do if the situation arose again. However to complete each stage with good outcome

and result there are questions that need to be carried out and completed.

The next model and theory can be discussed here is by the Atkins and Murphy, where they have

suggested that we have a need to reflect from “an awareness of uncomfortable on thought. This

arises from a realization that , in a situation, the knowledge one was applying was not sufficient

in itself to explain what was happening in that unique situation” (1993). And we can also refer

to the Atkins and Murphy’s (1994) model of reflection as in TABLE II which consists of 6

stages as the Gibbs model and there are not much different from each other model and also for

the objective and the result.

Started from the first stage the experience of the new situations and where it will trigger the

event which is typically an awareness of feeling and thought either it is positive or negative.

From the first step the event situation has been described and to be followed by the next stage to

analysis of these feelings and thoughts and the experience. This analysis will challenge the

assumption and will explore the alternative. Third stage is the development of new perspectives

as a result of this analysis. The next stage is the evaluation of the relevance and the use of the

knowledge. The last stage is to identify the learning experience from the event where it will

complete the cycle. Where the new cycle will start for the new situation and experience from

new event.

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TABLE II : Atkins and Murphy’s stage model of reflection (1994)

Another model of reflective theory is the Bortons model as shown in TABLE III, which is

incorporates all the core skills of reflection. Where the arguably is focused on reflection on

action, but with practice it could be used to focus on reflection during and before action.

What? So What? Now what?

This is the description and self-awareness level and all questions start with the word what

This is the level of analysis and evaluation when we look deeper at what was behind the experience.

This is the level of synthesis. Here we build on the previous levels these questions to enable us to consider alternative courses of action and choose what we are going to do next.

ExamplesWhat happened?What did I do?What did other do?What was I trying to achieve?What was good or bad about the experiences

ExamplesSo what is the importance of this?So what more do I need to know about this?So what have I learnt about this

ExamplesNow what could I do?Now what do I need to do?Now what might I do?Now what might be the consequences of this action?

TABLE III: Bortons` (1970) Framework Guiding Reflective Activities

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Reflexivity

My description of reflection states that the nurses can gain new insights into self and be

empowered to respond more consistently in future situations within a reflexive spiral towards

realizing one’s vision as a lived reality. Such words reflect the purposefulness of reflection, it is

action oriented towards the development of practical wisdom and realization of vision.

Reflexivity is a looking back and reviewing self’s development over time, the way insights have

emerged and influenced future experience. In this sense, reflection is like a drama unfolding over

time, a systematic and disciplined pursuit towards realizing desirable practice however that is

known. As I shall explore, the nursing can utilize markers to plot the reflexive journey of

development.

Gibbs Reflective Cycle In My Reflective Account

This account uses Gibbs Model as its basis for reflection about pre-operative admission and

assessment. By working around the cycle, it is possible to gain insight and develop practice, this

experience relates to a day surgery unit, where a gentleman is admitted for cataract surgery.

As started with the first stage is the description with a question, what happened?

The patient was an elderly gentleman who was being admitted for a cataract operation, in the

afternoon. I was fairly new to this day surgery unit having only worked two shifts, here,

previously and was concerned about the number of people who were being admitted and my

tasks to be completed for each of the patients, prior to their surgery. I was also unfamiliar with

the unit geography and where to find equipment. I hadn't done this before, without someone in

close proximity, to ensure that I had covered all the requirements and the documentation

paperwork was not the same as I had used on other units.

The second stage is the Feelings, What was I feeling?

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I was therefore feeling stressed, but also anxious to get everything done, due to the time

pressures. I probably wasn't as empathetic as I should have been. My mind was not solely on the

gentleman being admitted. I wanted to do this right and not have to repeat anything and also I

knew that my mentor would have to overview my patient records before the patient went to have

his operation.

The third stage started with more description and a little evaluation.

The gentleman had not been in hospital before and had enjoyed good health, apart from his

cataract. He was worried about being discharged home and also what he was expected to do,

prior to the surgery. My concerns were with his vital signs and obtaining a urine specimen, to

ensure that he was fit for the surgery. Just from writing this down I can see that we had different

goals, mine to elicit the information as speedily as possible and complete the pre-op. checks, his

to get his operation done and go home as soon as possible. I should have explained the process

and then gone over his discharge plan, but I wasn't feeling very confident about the process and I

was worried about the time.

The fourth stage, some analysis and more evaluation.

He was having a local anesthetic. He did communicate his worries to me and I tried to reassure

him that these operations were carried out every day. How stale that seems as I read it back to

myself, now. It was quite a few years ago when I had to have a minor operation and I knew the

system as I am working as a nurse. I was young and quite able, but worrying about the outcome

of the biopsy and the affect it could have on me and my family.

I knew from the admission documentation that the gentleman had a wife, who was disabled from

a stroke. She was being cared for by a married daughter, while the husband was with us. I

suppose too that he was worried about not being there to care for his wife. They had been

married for 54 years.

I had felt impatient with him for taking time to undress and for the amount of time that he was in

the bathroom. He was not physically disabled, but walking did seem to be something of a chore.

Having taken the time now to re-think what happened, I can see that the area to be covered

between the bed and the lavatory is quite a distance and as he put it, is not quite like being at

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home. That's true for me too, I have an en-suite bathroom, at home, so can nip to the toilet quite

quickly and privately. The lavatories in the unit are arranged in stalls and he may have found it

difficult to urinate into the container. I also realized that his fingers were not as nimble as they

were once and he probably found buttons difficult. I have replaced my father's fastenings on

shirts with Velcro, which he can manage more easily. Why didn't I suggest that to him? Would

he have found that insulting?

The fifth Conclusion, What could I have done differently?

I had also forgotten, in my rush to continue, that older gentlemen have problems with their

urinary system and can't always pass urine immediately. I had later found him looking very

carefully at each bed and had realized with embarrassment that he couldn't actually see his bed

label, because of his impaired vision. That was quite thoughtless I could have identified it for

him, as the bed in the corner, next to the sink. That's something to remember for the future, as

I'm sure there are quite a few people attending for this type of operation.

The good thing for me was that the gentleman was compliant and carried out all the requests that

I had made in order to 'process' him through the pre-op checks. He didn't ask me any awkward

questions and was also very easy to talk to, willing to pass the time of day. I stumbled over some

of the paperwork and I do know how important record keeping is and I have taken a blank pack

with me to familiarize myself with it, before I have to use it again. It was lucky that the packs are

pre-assembled and that I didn't have to find each of the different items from the stationery store,

as that would have constrained my time even more.

It makes sense to me in terms of efficiency that the nurse who takes the patients to the eye

theatre is not the same one who triages and admits them, but perhaps it would be better for the

patients if it were? It can be confusing dealing with more than one person, especially when you

may be feeling anxious about the operative procedure. I wonder how I would feel if I were

partially sighted and were passed on like a parcel?

When trying to evaluate the care given during the admission and assessment process, I realized

that the vital signs checks had become 'basic and routine' in my mind and I hadn't thought about

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'maintaining patient safety' by Roper et al (1981). Of course I had thought about it with regard to

the gentleman finding his bed and walking around the unit, but more in terms of communication

and mobility of what I did not think about while attending him, explaining exactly where his bed

was, but more importantly, the distances involved, when you have impaired sight. Any procedure

carries with it risks to the patient and by taking these physiological measurements and testing the

patient urine, I was ensuring that he was fit for surgery, physiologically. But was he prepared

mentally?

The six stages, the action plan.

I have discussed this account with my supervisor with perhaps answer some of the question that I

have posed. I will make sure that I am familiar with the different documentation used in this unit.

I also have familiarize myself with the layout of the unit. I have try to think more about the task

as I am doing them and respond more appropriately to patient’s priorities that to mine. I am

going to offer the aspects of the action plan to others who are going to work on that unit as part

of their clinical experience with regard to geography and documentation. Learn about the

discharge process in order to be able to explain it to patient, to alleviate their anxieties.

The reflective writing has several aspects which will enable people who are learning their skill to

put their thoughts on paper and thereby improve their writing skills. It may improve the thinking

process by ordering the thought about a particular aspect of care or an incident. This experience

can enhance and sharpen clinical skills and problem solving and also may influence to assist in

the changing attitudes towards people’s abilities, cultures and feelings. And if it is to be shared

with others, it wills than enable other perspectives to be explored within a safe academic

environment.

The Assessing

From the Gibbs reflective cycle scenario above there are always the questions which require for

the answer on every stage of cycle. As at the stage of description where there are a need to

describe in detail the event that we have reflecting on, with the questions as such where were

you; who else was there; why were you there; what were you doing; what were other people

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doing; what was the context of the event; what happened; what was your part in this; what parts

did the other people play; what was the result. This entire question will bring more explanations,

understandings and the answer for all party involve in our case here it is going to be between the

medical staff and the patient.

The Why? from the Description stage

Journal writing has been used to promote reflection among the medical staff especially the

nurses. However, evidence shows that journaling does not necessarily ensure that the nurses will

use the reflective process in practice. Rather, some may simply describe their experiences and do

not take the critical step toward analysis as some have proposed. Without a mechanism to assess

whether the nurses are truly reflecting, the medical educator has no way of knowing whether

trainees are competent in using reflection to develop deeper meaning and inform their practice.

As Pee et al (2002) suggest, in keeping with the move toward evidence-based practice,

assessment of the efficacy of this strategy in promoting reflection is essential.

The assessment however is controversial although placing judgment on what the nurse write in

journals could potentially impact their writing, one cannot effectively determine if a trainee has

gained the skills necessary to become a reflective practitioner without a mechanism of

assessment. To ease these obstacles, Bourner (2003) proposed separating content and process in

the assessment of journal writing. By solely assessing the process of reflection, competence can

be determined without placing judgment on the subject of the reflection. In addition, while

assessment allows the medical educator to provide feedback to nurses on their learning, it also

provides feedback to medical educators about the efficacy of their teaching strategies.

The literature reports on a variety of assessment mechanisms that enable educators to assess the

reflective process without making a judgment on the content. The feelings, at this stage try to

recall and explore the things that were going on inside your head, for example why does this

event stick in your mind? To include also the question on how you are feeling when the event

started, what you were thinking about at the time, how did it make you feel, how did other

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people make you feel, how did you feel about the outcome of the event and what do you think

about it now.

The How? At the stage of Feeling

Reflective writing has been evaluated both qualitatively and quantitatively and has been shown

to be an effective means of facilitating the reflective process. To assess both the depth and

breadth of reflection evident, it is helpful to use the elements of reflection as defined by Mezirow

(1990) and Schon (1983) vis-à-vis Bloom's ( 1956) cognitive processes, by looking for evidence

of each of the elements proposed by Mezirow and Schon as such the reflection-in-action,

reflection-on-action, reflection-for-action, content reflection, process reflection, and premise

reflection in the reflective thought processes of trainees, medical educators can determine if the

nurses or the trainees are using all elements of the reflective process effectively in exploring and

critically analyzing the depth and extent of each clinical problem.

Perhaps the nurses are beginning to analyze the problem, but are they effectively considering all

perspectives, or have they fully integrated the information obtained? Perhaps they know of a

strategy to use in approaching a patient problem, but have they explored other options? Perhaps

they are beginning to recognize their own assumptions, but do they recognize the impact of these

assumptions on their decision-making process? By looking for evidence of each of the elements

of the reflective process, the medical educator or manager can better determine what is missing

in the reflective and critical-thinking processes of their trainees or the nurses. By recognizing

which elements of reflective thought are missing, nurses and superior are better equipped to

facilitate the higher-order thinking processes that are essential to effective clinical decision-

making in their trainees.

Facilitating the Process

At the evaluation stage, try to evaluate or make a judgment about what has happened. Consider

what was good about the experience and what was bad about the experience or didn’t go so well.

Questions at the Evaluation Stage

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Questions encourage critical thinking. They promote self-evaluation, consideration of alternative

perspectives, consideration of alternative solutions, and exposure of ingrained, taken-for-granted

assumptions. Good questions promote higher-order thinking. They not only facilitate a more in-

depth analysis of the situation from multiple perspectives, but they also encourage combination

of these different points of view. Questioning not only enables the individual to evaluate what is

really happening in a given situation but also his or her perceived role in that situation.

The keys to good questioning are to establish a comfortable learning climate (Boenink AD,

2004), recognize that questioning is an art that needs to be practiced (Pee B, 2002), and

understand and apply Bloom's cognitive taxonomy to improve the trainees' depth of processing

(Pee B, 2003). Questions are most effective if they stimulate the nurses to use higher cognitive

thinking for example, the synthesis and evaluation rather than just recall. Good questions

encourage the nurses to use the extent of reflective elements to fully explore the situation such as

to facilitate questioning of the content, process, and premise underlying the situation). In

addition, the superior who are effective facilitators of the reflective process will encourage the

nurses or the trainees to reflect-in-action, reflect-on-action, and reflect-for-action. It is through

this higher-order reflective process that critical-thinking skills are developed.

Sample questions that facilitate both the depth and extent of the reflective process are provided

in the Appendix I (Jane Williams & Pam Cowley, Mid Devon Working Group Approved DMT,

2004). The authors believe that questioning skills can be taught in faculty-development

workshops, enabling faculty to understand the theory and practical application of the questioning

process. Although questioning is at the heart of the reflective process, different strategies are

available for the medical educator who is using the questioning process to facilitate reflection.

Individuals can engage in the reflective process in writing or verbally and individually or with

others.

Analysis which at the stage four will break the event down into its component parts so they can

be explored separately. You may need to ask more detailed questions about the answers to the

last stage. Including for example what went well, what you did well, what others did well, what

went wrong or did not turn out how it should have done and in what way did you or others

contribute to this

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Written Reflection at the Analysis Stage

Journal writing is a mechanism for individuals to describe their experiences and begin to use the

reflective and analytic or critical-thinking processes for learning (Kalliath T., 2001). Journal

writing encourages the nurses to process critical incidents after they have occurred. After seeing

a very preterm infant in the neonatal intensive care unit, 1 third-year student wrote about how he

questioned the use of limited resources to help an infant with a probable compromised outcome.

A shared reflection of this nature can prompt an important discussion about how personal biases

can impact the clinical decision-making process. This type of discussion might not otherwise

take place in a typical medical administration.

However, without guidance, journals often become diaries that simply contain facts rather than

analytic tools for learning. The nurses may use their journals to record the events of the day

rather than to analyze their experiences to construct deeper meaning from these events. Yet, it is

this analytic process that is closely linked to the development of the critical-thinking skills that

are essential to effective clinical decision-making. For many, reflection and journal writing do

not come naturally, and facilitation is essential. Some even struggle with how to begin their

journaling process. To assist them, the superior can pose reflective questions for new nurses or

the trainees to ponder such as those listed in the Appendix II (Reflective Log from Teignbridge

District Model). Responding to journals by using the questioning process can further facilitate

this process.

New nurses and the trainees often have mixed opinions about journal writing. Some find the

process very effective in helping them to probe into their experiences, whereas others consider it

time consuming and tedious and feel that it has no relevance. However, there are definite

benefits to maintaining a reflective journal (Boud D, 2001). It is a record over time, which allows

the writer to revisit not only experiences but his or her reflections on those experiences. It

becomes a recursive process that allows for deeper learning each time it is revisited and

explored. Nonetheless, it can be time consuming. Alternatively, other less time-consuming forms

of written reflection such as summative essays, critical incidents, and structured questions have

also been used successfully. (Plack M, Santasier A, 2004).

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Written forms of reflection are performed most often in isolation, this can be problematic,

because the writer processes the experience strictly from his or her own perspective. Although a

more experienced reflector will consider multiple perspectives in the analytic process, it is often

difficult to question your own thought processes, recognize your own assumptions, or pose

alternative solutions without prompting. Thus, interactive journals have been advocated in the

literature. The role of the journal reader is to pose questions to the writer and act as a “critical

other” or “devil's advocate.” The reader's role is not to give advice but rather to pose questions to

extend the writer's thought processes, encouraging broader and higher-order critical thinking. By

posing questions using the theories of Mezirow, Schon, and Bloom, the reader can facilitate the

depth and breadth of reflection noted above.

Verbal Reflection

This is an alternative to written reflections is the use of verbal reflective techniques such as

reflective questions, reflective dialogue, after-action reviews, and action learning sets. (Marsick

VJ, 1999). Each of these techniques uses dialogue to facilitate cycles of reflection and action.

The reflective component encourages each individual to share thoughts, feelings, and reactions,

as well as an analysis of his or her experience. The role of the facilitator or other group members

is to pose questions that encourage the individual to think more broadly and more deeply about

his or her experience. The challenge of the facilitator or group is to encourage each other to think

critically, uncover taken-for-granted assumptions, consider multiple perspectives, and explore

multiple strategies before coming to a conclusion. The conclusion reached by the individual, who

is based on a complex analysis of his or her experience, then becomes the basis for future action.

This is an iterative cycle of reflection and action, with members of the group supporting each

other in developing the complex critical-thinking skills essential to quality medical practice.

Again, this can only happen in a safe learning environment established by those in charge.

Future Implications

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Although experience is at the core of learning in medical education, reflection is integral to

deeper learning from experience. Reflection is more than just stopping to think and act based on

what we already know, it requires the nurses and the trainees to view situations or problems from

many perspectives. Reflection can occur in isolation or with others and in writing or verbally.

Viewing situations from multiple perspectives becomes the basis for critical thinking. The nurses

who are skillful questioners can facilitate the reflective process in others. Skillful reflectors are

critical thinkers, and critical thinking is the basis for effective clinical decision-making, which is

at the heart of quality nursing practice. The skill of reflection is not a natural thing it is learned

over time and with practice.

Here we have identified strengths and gaps in teaching and learning the reflective process. It is

evident from this review that the reflective process is of critical importance for pediatricians to

be able to make informed evidence-based decisions in a client-centered treatment environment.

Incorporating the reflective process may enable the nurses to more effectively attain those

competencies that considers essential to quality care such as nurse-patient interaction and

lifelong learning. However, reflection is an analytic skill that must be mastered as well. Toward

that end, our recommendations are actually challenges that need to be met both head-on and

collaboratively.

To begin, we propose that the reflective process be incorporated into the field of medical

education, from undergraduate through continuing medical education. The curriculum should

include the theoretical foundations of the process and its practical application in the clinical

setting. Using clinical cases enhances relevance to the nurses and will serve to make the process

both authentic and of interest to the nurses and student nurses alike. In addition, the development

of effective questioning skills is essential for facilitating the reflective process both in writing

and verbally. However, an assumption being made is that the nurses understand these issues and

can teach them effectively. If knowledgeable of the nurses are not available, identifying

resources on academic department such as schools of education, organizational development, or

human resource development would be essential for facilitating effective teaching and learning

of this content. Although introducing reflective practice into medical school education is a start,

raising awareness at the residency and admin levels would further reinforce the centrality of this

skill in effective clinical decision-making and quality patient care.

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Finally, although much is being written about reflection and its importance in the learning

process, what is yet to be fully explored is the impact of reflective practice on clinical practice.

Additional research by practitioners who are competent in the reflective process and can both

facilitate and assess excellence in practice is needed to determine the impact of this process on

practice.

Promote Reflection

The processes of reflection are usually discussed in stages or levels (Mezirow, 1981; Boyd &

Fales, 1983; Goodman, 1984; Boud, 1995; Schön, 1991), with some relation to intuition

(Goodman, 1984), Schön, 1991). Differences are mainly in terminology, detail, and the extent

the processes are arranged in hierarchy. The poor wording literature combination reveals three

stages in the reflective processes: awareness of uncomfortable feelings and thoughts, critical

analysis of feelings and knowledge, and new perspective. They describe the skills that are

required to be reflective: self-awareness, description, critical analysis, synthesis, and evaluation.

Evidence suggests that reflection benefits learning by integrating theory and practice (Astor et

al., 1998). It promotes intellectual growth because it is cyclical rather than linear (Davies, 1995;

Landeen et al., 1995), develops skills that make practitioners more confident (Davies, 1995), and

fosters responsibility and accountability (Wong et al., 1997; Astor et al., 1998).

Reflection-on-action is retrospective and allows practitioners to recount an event in order to

discover the knowledge used by analyzing and interpreting the information recalled. Strategies

are more limited that promote the development of reflection-in-action, a more complex activity

that requires practitioners to be conscious of what they are doing and how they are doing it in

that moment of practice.

Applications of Reflective Practice

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Reflective thinking is integral to curriculum theory (Dewey, 1933), empowering processes in

education (Freire, 1972), human interests and forms of knowledge (Habermas, 1972), and adult

education (Mezirow, 1981). Nursing has applied many of these ideas to the disciplinary areas of

practice, education, research, and leadership. Nursing has used reflective processes for some time

to improve.

Practice and Practice Development

Much of the literature is focused on the work of nursing, as practiced in clinical contexts for

example, (Freshwater, 1998, 2002), (Glaze, 1999), (Heath, 1998), (Johns, 2000, 2003), (Taylor,

2002, 2003, 2004), (Wilkin, 2002). Freshwater (1998) provided an integrative review of

reflection and caring to emphasize the role of reflection in nurses’ personal and professional

development,

Reflective practice can be viewed as the call to awake. It is also a process of becoming, being

with the unfolding moment. Reflective practice helps us to explore what is just beyond the line

of vision, it encourages not to stare straight ahead, but to turn around. Reflective practice can be

seen as a way of viewing the unfolding drama of the nurse becoming (Freshwater, 2002).

Heath (1998) offered practical guidance to clinicians in keeping reflective journals of their

practice. John’s (1994) model of guided reflection integrated Carper’s (1978) patterns of

knowing the empirical, personal, ethical, and aesthetic. Heath (1998) went beyond to include two

further patterns of unknowing and sociopolitical knowing. Heath (1998) suggested that nurses

may have difficulty applying knowledge forms to their practice, seeing it as an academic

exercise not immediately urgent in their busy work settings. Hence, the extension of knowledge

into the unknown and sociopolitical categories creates room for movement in practice that

captures clinical concerns.

Glaze (1999) described reflection, clinical judgment, and staff development “to encourage

perioperative nurses to reflect on their practice” using exemplars of expert practice “to illustrate

how knowledge is used and developed in the practice setting.” The outcomes of reflection

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include practical advice and insights into how perioperative nurses may improve their practice.

Johns (2000) demonstrated through case study of his own practice reflection to draw “out key

issues of practice and refection that enabled him to gain insight and apply to future practice

within a reflexive learning spiral.”

Freshwater (2002) describes the therapeutic use of self in nursing as a means of improving

patient care through self-awareness and reflection. Freshwater connects a nurse’s deeper sense of

self to healing outcomes of a therapeutic nature for patients, and contends that the “practice of

reflection is a central skill in developing an awareness of self”. In creating possibilities for

therapeutic nursing, nurses examine self as workers, learners, and researchers, to transform self-

awareness into a process through which patients feel cared for and acknowledged within “the

context of a therapeutic alliance”.

Freshwater (2002, Johns, 2002) describes the importance of “guided reflection in the context of

post-modern practice.” Self-awareness “is deemed central to the process of successful reflection,

with the ‘self’ being the main instrument of both the practice and guidance of reflection.” In a

post-modern description of the process of guided reflection, Freshwater (2002) explores “some

of the reflections that took place in the pauses between the lines of the text in the act of looking

up from the reading’ in order to ‘bring light to bear in certain elements of the text, whilst

recognizing that this casts a shadow on other aspects of the dialogue.” Freshwater (2002)

skillfully captures the post-modern conundrum of partialities, gaps, silences and shifts in

meaning, while resting on the assurance that an exploration of self is a reflective exercise that

offers some insights into local truths.

Wilkin (2002) explored expert practice through reflection, by focusing on a clinical experience

of caring for a 12-year-old boy diagnosed with brain death, and her experience of remaining on

duty in the unit to facilitate the parent’s wishes concerning his care. Wilkin (2002) used “the

unusual experience to enable self-criticism and expansion of personal knowledge,” in order to

explore the complexity of expert practice and to facilitate holistic care.

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Taylor (2004) offers advice for technical, practical, and emancipatory reflection for practising

holistically. Emancipatory reflective practice is overcoming complexities and constraints in

holistic health care (Taylor, 2003a, b), giving guidance in technical reflection for improving

nursing procedures using critical thinking in evidence based practice (Taylor, 2002b), and on

becoming a reflective nurse or midwife, using complementary therapies while practising

holistically (Taylor 2000).

Clinical Supervision

Reflective practice has been applied effectively to clinical supervision (Todd & Freshwater,

1999; Heath & Freshwater, 2000; Gilbert, 2001; Clouder & Sellars, 2004). Rolfe et al. (2001)

provides an in-depth exploration of reflection in clinical supervision.

Todd and Freshwater (1999) examined a model of reflection, particularly the parallels and

processes, in individual clinical supervision with ways to guided discovery. In clinical

supervision, reflective practice provides a safe space that facilitates a relationship that both

collaborates and empowers the practitioner in experiencing the discovery found in everyday

practice.

Heath and Freshwater (2000) demonstrated application of John’s (1996) intent-emphasis axis as

a method to explore detractions to the supervisory process derived from technical interest,

misunderstanding of expert practice, and confusion of self-awareness with counseling. Clinical

supervision within reflective practice is especially effective when supervisors are reflective about

their roles, so the clinical supervision is a guided reflection that enables deeper insights for both

supervisee and supervisor.

Gilbert (2001) focused on potential for reflective practice and clinical supervision to be

confessionals, acting as a mode of surveillance to discipline professionals. Gilbert argued that,

like governments, health settings act as “forms of moral regulation” in which professionals

exercise power through “the complex web of discourses and social practices that characterize

their work”. In critiquing the discourses of empowerment (Gilbert, 2001) that underlie the

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emancipatory intent of reflective practice and clinical supervision, he identifies the tendency of

empowerment discourses to assume “the existence of a damaged subject-traditional and rule

bound who requires remedial work to achieve forms of subjectivity consistent with modern

forms of rule.”

Clouder and Sellars (2004) wrote from the perspective of a physiotherapist, using research

conducted with undergraduate occupational therapy and physiotherapist students, to “contribute

to the debate about the functions of clinical supervision and reflective practice in nursing and

other health care professions.” The authors responded to Gilbert’s (2001) criticism of the

sterility of debates about reflection and clinical supervision, and the potential for moral

regulation and surveillance. They concluded that although both strategies make individuals more

visible within the gaze of the workplace, Gilbert “overlooked the possibility of resistance and the

scope for personal agency within systems of surveillance that create tensions between personal

and professional accountability”.

Leadership and Management

The emerging links between effective clinical and academic leadership and reflective practice

can help eliminate the gaps in contemporary nursing leadership (Freshwater et al., 2001;

Freshwater, 2002; Freshwater, 2004; Johns, 2004; Sherwood & Freshwater, 2005). McCormack

(1995) explored the issue of clinical leadership through a model of collegiality that integrates

spheres of clinical leadership and incorporates elements of reflection throughout. Freshwater

(2004) links reflective practice and transformational leadership and emotional intelligence, yet

reflection can facilitate the challenge of institutional attitudes and provide opportunities to

confront organizational and professional cultures of coping and knowing.

In a study involving prison nurses, Freshwater et al. (2001) and Freshwater (2002) implemented

reflective practice through clinical supervision groups and evaluated the development of clinical

leadership skills as a direct outcome of the interventions. Findings suggest that not only does

reflective practice enhance clinical leadership abilities, but also that it is a crucial element of any

leadership and management program.

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Education

Reflective practice in nurse education is integral to effective outcomes (Cruickshank, 1996;

Freshwater, 1999; Kim, 1999; Anderson & Branch, 2000; Clegg, 2000; Platzer, Blake, &

Ashford, 2000a, b; Lian, 2001; Kenny, 2003). Various literature sources describe a variety of

strategies for educators presented in the following references.

Cruickshank (1996) used the medium of drawing to allow students working in small groups to

express clinical learning that occurred on their clinical placement. The themes that emerged from

the process were representative of the technical, practical, and emancipatory forms of knowledge

they observed within nursing practice and experienced within their curriculum.

Kim (1999) presented “a method of inquiry which uses nurses’ situated, individual instances of

nursing practice as the basis for developing knowledge for nursing and improving practice.”

Using ideas from action science, critical philosophy, and reflective practice, she described a

critical reflective inquiry method and process that allows nurses to raise awareness of their work

constraints to free themselves toward more informed and liberating insights about their work.

Freshwater (1999) guided a research project to explore the lived experience of student nurses on

how their personal stories interfaced with those of the patient. The students and tutor kept a

reflective journal pertaining to their experiences of moving from perceived levels of novice to

expert nurse and demonstrated how self-awareness through reflective practice, clinical

supervision, and experiential learning can enhance personal and professional development.

Anderson and Branch (2000) endorsed storytelling to promote critical reflection to enable

nurses’ students talking about past actions and outcomes to give voice to experiences. Revisiting

the past is thus used to shape the future. Clegg (2000) explored reflective practice statements as

data sources to provide insight into the sub context of organizations, especially in light of

“reflective practice taking on the veneer of educational orthodoxy.” In spite of suspicion that

advocates of reflective practice in nursing, social work, and teacher training may have inflated

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the positive claims of reflective practice, Clegg (2000) supports reflective practice as a useful

and insightful method for knowledge production in higher education.

Platzer, Blake, and Ashford (2000) established reflective practice groups in a post-registration

nursing course so that students could reflect on and learn from their experiences evaluated

through in-depth interviews. Students did identify barriers to their learning, yet some students

significantly advanced their critical thinking with transformations in perspectives that led to

changes in attitudes and behaviors.

Problem-based learning (PBL) can help develop reflection and critical reflection as professional

practice skills (Williams, 2001). Learners who participate in PBL are more reflective and

critically reflective in their learning experiences derived from professional practice encounters.

Critical questioning in the PBL scenario propels the learners’ ability to be both reflective and

critically reflective during situational analysis, determining learning needs, knowledge

application, critiquing resources, and problem-solving, and summarizing what was learned.

Kenny (2003) described a creative thinking game used to stimulate critical thinking and

reflection. Edward de Bono’s six hats game was used with qualified health professionals

undertaking relaxing care education because many reflective practice models did not fit the

practice. They were either too simple or too complex. Students used a variety of thinking

techniques that unleashed their creative and critical thinking processes to be more effective in

reflection.

Although the value of reflection in nurse education has been debated for some time (Driscoll,

1994; James & Clarke, 1994; Newell, 1994; Palmer, Burns & Bulman, 1994; Burrows, 1995;

Hulatt, 1995), these examples and other resources conclude reflection is a valuable aid in

teaching and learning (Posner, 1989; Atkins, 1995; Johns, 1995; Smith, 1998; Hannigan, 2001;

Noveletsky-Rosenthal & Solomon, 2001; Freshwater, 2002; Lau, 2002; Evans, 2003; Kuiper,

2004).

Research

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Knowledge derived from reflection has only recently been formally recognized as a pragmatic

methodology for evaluating and inquiring into clinical nursing practice (Rolfe et al., 2001).

Traditional models of research tend to separate research and practice into discreet domains, thus

expanding the already substantial split between theorists and practitioners. Some nursing authors

argue for the notion of a practicum, fostering an integral approach to research, building on

researcher-practitioner models by way of managing this false dichotomy (Rolfe et al., 2001;

Taylor, 2001; Freshwater & Rolfe, 2001; 2004).

Reflective methods and processes not only guide practice, practice development, education and

leadership, they can also provide research evidence for supporting changes in these areas.

Reflective processes may be used solely as the research approach, or they may be integrated into

other research approaches. This section describes these options, to open up the potential for

creative reflective processes in research.

The Reflective Research Approach

The eight basic steps in a reflective research approach are firstly is to identify the issue, problem

or phenomenon for the reflection, the second steps is to decide on the reflective method, clarify

its intent. The third steps are to plan the stages in the research proposal and to follow the method

and use the process at the fourth steps. The fifth steps is to generate the insights, the six steps is

the institute changes and improvements and continue to reflect on the outcomes. The step seven

is to report the outcomes and the last steps is to use the outcome in practice as evidence (Taylor,

2000).

Reflective Processes

Reflective processes can be used in conjunction with other research approaches, for example,

quantitative, qualitative, or mixed methods of quantitative and qualitative research. There is no

prescription as to how these approaches might be used, as it is up to the researcher to make those

choices, based on the fit of the approach to the research aims and objectives. A quantitative

25

project using a survey or questionnaire might also use the technical reflection process in a focus

group to develop scientific reasoning to support or oppose the continuation of a clinical policy or

procedure.

A qualitative interpretive research approach using ethnography might also include participants’

journals, in which descriptions of the research context are written for later analysis and

interpretation, thus adding richness to the description of the culture being studied. The practical

reflection process may also be used to explore communicative aspects of the culture of interest.

A qualitative critical research approach using action research based on critical theory may use

the action research cycles, with a special emphasis on reflection. The emancipatory research

process could be used in any form of critical research that intends to question the status quo and

to bring about change in people and organizations.

Reflection is more than a research method in its own right are called reflexivity, a number of

research studies have explored the value of reflection in various forms and forums. Landeen et

al. (1995) and Davies (1995) examined student reflections through the use of self-reflective

journals. Landeen and colleagues’ (1995) phenomenological study found that students wrote

about meaning learning, issue of novice, relationships control, self-reflection, and identification

with clients. Davies (1995) examined the use of journaling and clinical debriefing and found that

these reflective processes do impact the environment, process, and focus of learning. Anxiety

was reduced through peer support. Students moved from passive to more active modes of

learning and over time, reflective processes resulted in the emergence of the client as the central

focus of care.

In other research, Richardson and Maltby (1995) studied the use of reflective diaries in

undergraduate nursing students in Australia and found that the highest number of reflections

occur at the lower levels of reflectivity based on Mezirow’s levels of reflectivity. Jones (1995)

“studied hindsight bias and its consequences on the reflective practice process. Findings

indicated that nurses are susceptible to hindsight bias, which questions the validity of reflection

as a way to enhance patient care”.

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Reflective processes in research approaches have been admirably demonstrated (Freshwater,

1999; Hancock, 1999; Johns, 2000, 2003; Glaze, 2001). Researchers may use reflective

journaling in any project, they are undertaking, as a means of demonstrating rigor or

trustworthiness, through documenting the detailed life of the project, and the researcher’s and

target audience’s responses to the process and the findings. Students enrolled in research

programmes may use reflective processes in the design of their projects. They may also keep a

reflective account of their experience as a research student, of the project itself, of the learning

that comes about through supervisory meetings, of their reactions to literature, and of any

insights along the way that add richness to the research.

Reflection and Action Research

Reflection and action research combine well to create an effective collaborative qualitative

research approach for identifying and transforming clinical issues, because reflection is part of

the action research method. Action research involves a four-stage phase of collectively planning,

acting, observing, and reflecting (Dick, 1995; Stringer, 1996). Each phase leads to another cycle

of action, in which the plan is revised, and further acting, observing, and reflecting is undertaken

systematically to work toward solutions to problems of a technical, practical, or emancipatory

nature (Kemmis & McTaggart, 1988; Taylor, 2000). The planning and acting phases may include

any appropriate methods of gathering and analyzing data, such as participant observation,

reflective journaling, surveys, focus groups, and interviews. Cycles of action research lead to

further foci and co-researchers can keep an action research approach to their work for as long as

they choose, to find solutions to their practice problems.

Nurses have been using action research successfully in a variety of settings with differing

thematic concerns (Chenoweth & Kilstoff, 1998; Keatinge, Scarfe, Bellchambers, McGee,

Oakham, Probert, Stewart, & Stokes, 2000; Koch, Kralik, & Kelly, 2000). Taylor (2001) and

Taylor et al. (2002) used action research and reflection to work on thematic concerns common to

the nurses’ research group. Both projects gave nurses a regular forum in which to discuss their

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reflections on practice and to generate an action plan to bring about change. The benefits of

action research and reflection are that there are immediate, practical outcomes for participants,

because they can share their experiences with peers, work together on thematic concerns, and

bring about local changes in their practice. Thus, co-researchers experience participatory

research, while developing their reflective skills, and in this sense the research offers them

personal and professional gains in lifelong appreciation for their participation.

Taylor (2001) aimed to facilitate reflective practice processes in experienced registered nurses in

order to: raise critical awareness of practice problems, work systematically through problem-

solving processes to uncover constraints, and improve the quality of care given by nurses in light

of the identified constraints and possibilities. Twelve experienced female registered nurses

working in a large Australian rural hospital shared their experiences of nursing during three

action research cycles. A thematic concern of dysfunctional nurse-nurse relationships was

identified, as evidenced in bullying and horizontal violence. The negotiated action plan was put

into place and co-researchers reported varying degrees of success in attempting to improve

nurse-nurse relationships. This project confirmed the necessity for reflective practice and

continued collaborative research processes in the workplace to bring about cultural change

within nursing.

Taylor et al. (2002) used a combination of action research and reflective practice processes to

explore idealism in palliative nursing care. Six experienced registered nurses identified their

tendency toward idealism in their palliative nursing practice, defined as the tendency to expect a

hundred percent effectiveness all the time in their work. Participants collaborated in generating

and evaluating an action plan to recognize and manage the negative effects of idealism in their

work expectations and behaviors. Participants expressed positive changes in their practice, based

on adjusting their responses to their idealistic tendencies toward perfectionism.

Reflective Limitations

The benefits of reflective practice have been highlighted previously in each section of this

resource paper, relating to the positive applications in all fields of nursing. Critics have perceived

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limitations in reflective practice, even as reflective practice has become more accepted and

commonplace in nursing. The nursing profession has been criticized for actively embracing

reflection (Jarvis, 1992). Greenwood (1993) argued that the underpinning of Schon’s model of

reflection is founded on theories that are difficult to articulate, as they are embedded in the

activity itself. Thus, Greenwood saw the attempt to access these imbedded theories through

verbal means as inconsistent.

Newell (1994) and Burnard (1995) observed “the lack of empirical studies to demonstrate the

value of reflective practice to nursing”. Jones (1995) argued that “reflection is colored by

hindsight bias”. Heath (1998b) stated that “initial blocks to knowing occur as expertise grows in

the denial of not knowing and satisfaction with current performance”. Hancock (1999) suggested

that “certainty creates premature closure on situations and blocks further development toward

expertise”. Rich and Parker (1995) warned that “reflection on negative situations can lead to

helplessness, hopelessness, a loss of self-confidence, and damage to self-esteem. Further, they

maintain there is little guidance on what to do when critical incident analysis or narratives

demonstrate unsafe care, the telling of lies, and inter-professional conflict”. Mackintosh (1998)

also criticized “reflection on ethical grounds related to confidentiality and questioned whether

students write what they actually thought and did, or what they perceive their teachers wanted to

read”.

“Some view reflection as a fundamentally flawed strategy citing concerns and criticisms”

(Mackintosh, 1998). “There may be a high degree of personal investment required by nurses with

minimal successful practice outcomes” (Taylor, 1997). “Effective reflection requires participants

to overcome barriers to learning”, (Platzer, Blake & Ashford, 2000b). “Nurses need to beware of

producing dogma”, (Heath, 1998c). “There may be cultural barriers to empowerment through

reflection”, (Johns, 1999). “Negative consequences may ensue when practitioners are pressured

to reflect”, (Hulatt, 1995). Other concerns include the potential dangers of promoting “private

thoughts in public spheres” (Cotton, 2001), the failure of reflective processes to “address the

postmodern, cultural contexts of reflection” (Pryce, 2002), and the “lack of research evidence to

support the mandate to reflect” (Burton, 2000).

29

Ghaye and Lillyman (2000) critically reviewed the foundations and criticisms of reflective

practice to question whether reflective practitioners were simply following a trend, concluding

that reflective practice has a place in the postmodern world because of its ability to explore micro

levels of human interaction and personal knowledge. In contrast, Taylor (2003, p. 244) states that

“reflective practice tends to adopt a naïve or romantic realist position and fails to acknowledge

the ways in which reflective accounts construct the world of practice.”

Scholarly critiques are signs of healthy discourses and maturity in nursing developments and

help point out areas needing attention and well-reasoned defense. Markham (2002), Rolfe

(2003), and Sargent (2001) respond to the critics with conviction that although reflective practice

has its limitations, and it requires time, effort, and ongoing commitment, it is nevertheless worth

the effort to bring about deeper insights and changes in practice, leadership, clinical supervision,

and education. In counterpoint, perhaps its most important contribution is the potential for

personal transformation of the individual nurse to achieve maximum potential (Sherwood &

Freshwater, 2005).

Conclusion

The notion of the reflective practitioner is an enticing one. To assert the importance of the

experiential knowledge and creative practice, from the started to the embrace in fact, the

messiness and unpredictability of practice and then to unpick what is going on by generating

inductive hypotheses which are dispassionately analyzed to reveal the nature of expertise and

judgment these are ideals to strive towards. And there is much about the reflective paradigm to

hold on to. Indeed it seems an essential counterbalance to the school of evidence based practice

which sees certainty and technical rationality as its highest ideals.

Reflective practice takes account of the mix of rationalities that underpin judgment, so that we

do not take scientific evidence for granted but weigh it in the balance along with other

competing versions of events (Taylor & White, 2001). It raises practitioners above the status of

mere technicians, emphasizes the richness and creativity of their practice and leads to persuasive

new formulations of professionalism based on diversity and flexibility (Fook, 2000). By

unsettling dominant, modernist conceptions of knowledge and expertise it enables many new

30

perspectives to develop. An example of this is the development of clinical supervision in nursing

which by seeking to “de-medicalise” nursing (Butterworth et al, 1998) and emphasize its

expressive role has contributed to studies of the gendered nature of healthcare which have

rethought traditional working practices and hierarchies (Davies, 1998; Parton, 2003).

The reflective paradigm has led to important developments in teaching and learning it has also

created some problems. Reflection is notoriously difficult to define and loose definitions and

uncertainty about how to assess it can lead to oppressive practice (Ixer, 1999). Educators should

be much more aware of the issues in requiring less powerful people to perform confessional-

reflective tasks and not be so quick to assume that reflective learning is always a good thing.

Practitioners’ reflective accounts are often extolled as giving access to the raw material of

practice but this is a naïve approach (Taylor, 2003) that fails to take account of the imagistic and

metaphorical nature of language which constitutes rather than reflects reality (Gould, 1996b).

Reflective accounts are as artfully constructed and performative as any other uses of language.

They give access to how professionals construct their identities and those of service-users and

their practices but they are not by themselves enough. Service user perspectives are essential and

so is the kind of ethnographic research which seeks to analyses day to day practice realities and

professionals’ verbal and written accounts (Taylor & White, 2000; White & Featherstone, 2005)

If reflective practice has become the new orthodoxy, the dominant discourse within professional

education, it is essential that we keep a critical perspective so we are as alive to its problems and

limitations as to its strengths.

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