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Abstract: Reflection is the mindful (and prayerful) consideration of professional or personal actions in such a way as to transform present and future experience. Nurses will find ways to create transformation in patient care through reflection in practice, clinical supervision, leadership, education, and evidence-based practice. This article discusses models and processes for reflective practice for professional, personal, and Christian spiritual transformation, making application to case studies in nursing practice.
Susan's* morning on the oncology unit was not going as planned. She had been assigned to care for Mrs. Greenfield, one of her dearly loved patients. But today Susan was unprepared for the challenge ahead. Her patient had been in and out of the hospital for chemotherapy to treat metastatic breast cancer. Now, late in the disease process, Mrs. Greenfield was dying. Mrs. Greenfield's usual optimism and sense of humor had been replaced by severe pain and the grogginess that accompanies high doses of morphine. Close family members surrounded the bed while her daughter held her hand, feelings of frantic grief on their faces.
Susan longed to comfort the family. She found herself, however, with her arm around the shoulder of Mrs. Greenfield's daughter, tears slipping down her own cheeks and an uncomfortable knot in her throat. What could or should she say? Susan felt confused, and unable to utter a word to the grieving family. Feeling she was losing emotional control, Susan left the room. Later that day after her beloved patient had slipped away and the family had left the hospital, Susan took a few moments to reflect. A sense of failure overpowered her ordinarily objective thought process. Suddenly, memories edged into her mind of a recent hospital conference on Reflective Practice. What had she learned about reflection that could help her now?
Reflection gives nurses the ability to combine "theory and practice" (Sherwood & Horton-Deutsch, 2008, p. 142). Author and theorist, Donald A. Schon (1983, 1991), the primary non-nursing leader in the area of reflection and reflective practice, realizes that professional actions include much more than mere skill and book knowledge. He describes a type of intuition that he calls "knowing-in-action" (1991, p. 50), a recognition of knowing that goes beyond the rules where one finds she or he is engaging in actions one doesn't remember having learned. With this type of knowing one doesn't have to consciously think about his actions; he responds spontaneously.
In addition to "knowing-in-action" is "reflecting-in-action" (Schon, 1991, p. 54). Here, thinking takes place while one is performing a task. In the beginning, the professional is seemingly startled when approaching a unique and different situation. A sense of initial disorientation may accompany trying to solve the problem, but then very quickly a new solution appears in the midst of the experience. This comes by distinct reflection on the present, based on past knowledge and experience. The nurse, who is able to reflect-in-action, is on the road to becoming an expert who is exceptionally adept at clinical judgment in the midst of complex situations (Benner, Tanner, & Chesla, 2009).
Johns (2004), a nurse scientist, writes of "reflection-within-the-moment" (p. 2). He describes this phenomenon as follows:
Being aware of the way I am thinking, feeling [,] and responding within the unfolding moment and dialoguing with self to ensure I am interpreting and responding congruently to whatever is unfolding. It is having some space in your mind to change your ideas rather than being fixed to certain ideas (p. 2).
Reflection-within-the-moment leads to a type of "mindful practice" where the nurse solves difficult problems and, at the same time, exhibits extraordinary caring toward patients. For the Christian nurse, this may include openness to the Holy Spirit's direction in the situation, asking, "What would Jesus do?" and breathing a prayer for instantaneous divine guidance.
Such a sense of reflection in practice may come from what Schon calls "reflection-on-action" where the nurse looks at specific experiences and documents, thinks, prays about the experiences, and comes to a conclusion that will transform future practice for the betterment of patient care. Wilson (2008) broadens this concept to include "reflecting on the future" (p. 177), a step that includes imagining how one would handle the same or similar situation at a later time. The result should lead to more effective reflection-in-action (Wilson).
For the purpose of this article reflection will be considered as: Mindful (and prayerful) consideration of professional or personal actions in such a way as to transform present and future experience.
How does one go about reflection in nursing practice? There are many different processes, depending on the depth of reflection chosen. These may depend on available time, the skill level, and the experience of each nurse. A relatively simple way to reflect on one's practice is outlined by Beam, O'Brien, and Neal (2010) in Table 1. When the nurse has more time and energy to reflect upon a particular action, Johns' Model for "Structured Reflection" (2004, p. 18) may be effective in guiding reflection as the nurse learns from experience (Table 2). Johns' model incorporates Carper's (1978) celebrated "ways of knowing" (now called "patterns" of knowing which include "emancipatory knowing," according to Chinn and Kramer, 2008).
How could this information about reflection help Susan? As Susan later perused her notes from the conference on reflective practice, she was reminded that one way of processing reflection is writing in a journal (Billings, 2006; Johns, 2004; Somerville & Keeling, 2004). This should be done as soon as possible after an incident for the sake of accuracy of events and identification of feelings. Journaling could be a start for Susan, using Beam et al.'s, framework (2010) or Johns' Model (2004), or designing her own reflective process as there is no prescription that works for everyone (Johns, 2004). Prayer and meditation on Bible passages also can guide her reflective thinking about the incident. Reflecting on her actions enhances her "self-awareness" and helps her know whether or not change may be needed in her future practice (Morgan, 2009).
How does a busy nurse find the time to reflect on his or her actions and experience? Lack of time can be a major barrier to reflective practice (Cirocco, 2007). Susan will need to prioritize her work to set aside time for reflection, or she may need to reflect after work hours.
Nurse managers can help create an atmosphere that encourages reflective practice by supporting and/or being available for "one-to-one" meetings to discuss a particular incident or practice decision. Time is spent discussing the nurse's concern, with "the supervisor using active listening skills and open-ended questions" (Beam et al., 2010, p. 134). The supervisor's role is to lead the nurse down the path of self-awareness and problem solving by having the nurse describe what has happened, explore accompanying feelings, evaluate strengths and weaknesses, and analyze the situation. Then the supervisor can help the nurse prepare for future events by creating a plan based on what they imagine the same issue would be like next time. In concluding, the supervisor can ask the staff nurse to summarize the immediate feelings that exist at the end of the discussion (Beam et al., 2010). In a trusting relationship with her supervisor, Susan could find such a meeting helpful.
Another avenue of reflection is a "case conference," where a situation is discussed by the entire team (Beam et al., 2010). This reflection requires vulnerability from the nurse and trust of coworkers and colleagues. It opens the door for a variety of professional opinions as well as shared expertise. Susan could present the case of her patient and her response, looking to others for encouragement and knowledge to deal with a similar situation in the future. She also might find that her colleagues empathize with her, helping her realize she is not alone, and giving her confidence to face another dying patient.
How does Christian faith make a difference for Susan in her process of reflection?
The Apostle Paul instructs to "pray without ceasing" (1 Thessalonians 5:17, NASB), or "pray continually" (NIV). Nurses can reflect "in-action" as well as "about action" about daily nursing practice through their moment-by-moment prayer life. Brother Lawrence in The Practice of thePresence of God (1895/2009) puts it like this:
It is a great delusion to think our times of prayer ought to differ from other times;we are as strictly obliged to cleave to God by action in the time of action as by prayer in the season of prayer (pp. 25-26).
Nurses in any practice arena can pray about patient care, staff relations, teaching, student interactions, their research, conflicts, mistakes, challenges-in essence any and everything work related.
Of course, prayer is subjective, seemingly guided more by emotions than by rationality. How does one pray most effectively? Knowledge from Scripture and books on prayer can guide ones' prayer life, yet Paul explains in Romans 8:26 that "the Spirit also helps in our weaknesses. For we do not know what we should pray for as we ought, but the Spirit himself makes intercession for us" (NKJV). The nurse's prayers about daily practice can be guided by the Holy Spirit.
One of the most important reasons for reflective practice is the desire for improvement in patient care. There are other areas, however, in addition to direct patient care, where reflective practice can make a positive difference in the healthcare setting.
The reflective nurse leader. All nurses are not nurse managers, but as leaders, each has a sphere of influence. Every leader faces changes in the environment while having a duty to transform "self, groups, and organizations" (Rosenberg, 2010, p. 10). Leadership can be seen as "an inner journey of the self" (Sherwood & Horton-Deutsch, 2008, p. 137) where reflection is used to produce transformative change in the surrounding patient care environment by initially generating self-awareness. The process of reflecting on the strengths of oneself and colleagues produces a more positive atmosphere and may actually create happiness for both leader and followers while generating desired change (Rosenberg, 2010).
Leaders must ask questions of themselves and their coworkers, questions that concentrate on getting to know the other individual(s) rather than gaining power over them. True leaders will ask pertinent questions of self-discovery, such as: "How do I typically respond to situations and events like this? What about this inspires me and gives me joy? What can I learn that will change my responses?" (Sherwood & Horton-Deutsch, 2008, p. 139). Reflection as a leader may be more complex than that of the individual because it involves learning to think before speaking. It may involve guiding a reflective conference about a challenging experience, entailing both reflection-in-action and reflection-on-action, as well as reflection-on-the-future.
Freshwater (2008) has outlined a three-stage model for growth in nursing leadership where a leader asks questions in stages that increasingly progress more deeply into a situation. First, one portrays the event as dispassionately as possible, asking questions such as "who, what, when, where, and why?" Secondly, a leader begins to explore the experience while thinking about how her actions fit with her professional goals. Thirdly, one evaluates the wisdom that results in changing the future in terms of answers and reactions. A fourth stage may be added by the Christian nurse leader, where questions about spiritual values and how Christ's example can influence future actions are asked.
Reflection in nursing education. Reflection emerges as a cornerstone of nursing education in its ability to tie practice with theory. Nursing students must be adept at making use of content gained in the classroom with clinical experience in the healthcare setting. This requires that students have ample opportunity to reflect on their practice early in their education (Sharp & Maddison, 2008). Reflection must be built into the nursing curriculum in a manner that is "safe, organized, and structured" (Esterhuizen, Freshwater, & Sherwood, 2008, p. 181).
Directed self-assessment can be one of the first attempts at reflection for students (Sharp & Maddison, 2008). As nursing students grow to reflect on actual clinical experiences, they will need a mentor or professor who is an expert in nursing practice and also an expert in reflection on and in practice (Esterhuizen et al., 2008). Guided journaling about students' clinical experience is especially valuable. Students may write about values (i.e., love, joy, peace, integrity, courage) they see exhibited or experience in the clinical setting. Reflection on best practices is vital for nursing students at any level.
The term "critical reflection" is used to describe the type of reflection needed to improve practice, but its importance requires that not all reflection become negative and full of criticism (Esterhuizen & Freshwater, 2008). Encouragement and support by the instructor is crucial at all times. Keeping a portfolio of student reflections is valuable for student self-evaluation and overall institutional appraisal.
Reflection and evidence-based practice. The relationship between reflection and evidence-based practice (practice based on research) impacts education and practice. The term, "reflexivity" is critical to this discussion, and "involves researchers locating themselves within political and social positions, so that they remain mindful of the problematic nature of knowledge and power inherent in human relationships and organizations" (Taylor, 2008, p. 23). Evidence-based practice has been influenced mainly by quantitative research in support of scientific knowledge that is descriptive, correlative, explanatory, and predictive. Conversely, reflexivity appears to be mostly relevant within qualitative research, where the lived experience of the patient, family, or nurse is the primary topic of interest (Taylor, 2008). Best for the profession, however, would be to safeguard the idea that reflexivity and evidence-based practice centered upon the quantitative domain are balanced "ways of knowing" for nursing practice (Mantzoukas & Watkinson, 2008, p. 133).
Interest in reflection is increasing, with a variety of interpretations throughout international nursing practice settings. "For many years, nursing has battled with its identity, unsure whether it is an art or a science or indeed both" (Freshwater, 2008, p. 1). Reflection may be an avenue combining both the art and the science of nursing as well as guiding the individual nurse into transformation of patient care and clinical practice.
Although proponents of reflective practice observe that reflection is done "for the good of the patient, the good of the practitioner, the good of the profession(s), and the good of society" (Kinsella, 2009, p. 5), the secular model of reflective practice does not seem intended to encompass the nurse's personal spiritual life. However, application of spiritual reflection promises the potential and power to bring about personal spiritual transformation and improve practice. Rosenberg (2010) declares, "we have the capacity to change the world by changing ourselves" (p. 11). For the Christian nurse, this change may take place through spiritual reflection.
Reflection on biblical themes. Although the Bible does not use the words "reflective practice," or "reflection," it does contain words rich in reflection such as "consider," "think," and, "meditate," indicating instances where the reader is asked to "reflect upon" a certain inspirational suggestion. Reflection upon Scripture is life changing (Hebrews 4:12), as can be seen by the reflective themes outlined in Table 3.
Stories of spiritual reflection. The Bible is full of engaging stories about reflection. What Christian nurse cannot relate to the story of Job? His complicated ordeal of suffering reveals a need to reflect during times of physical or mental pain, or when caring for others who, like Job, are full of questions. Although Job's friends often seem confused in their counsel to Job, one helpful piece of advice that emerges from their reflective dialogue is, "Listen to this, O Job; Stand still and consider the wondrous works of God" (Job 37:14, NKJV). Following this is a dialogue with God where Job indeed reflects upon the awesomeness of God's character and relationship with Job's terrible suffering. Regardless the outcome, Job's reflections make him able to say with conviction: "For I know that my Redeemer lives, and he shall stand at last on the earth; and after my skin is destroyed, this I know, that in my flesh I shall see God" (Job 19:25-26, NKJV).
A compelling story in the life of Jesus shows the value he places on reflection. After his death and resurrection, two of his followers are walking to the city Emmaus. They are reflecting upon the recent events of Christ's betrayal and death. Unbeknownst, Jesus suddenly falls in step with them and asks questions about their experience. Jesus listens, inserting insightful questions and comments as they tell their story of despair.
The men are so submerged in their grief that they are unable to grasp the significance of what is taking place. Jesus takes the two on a reflective journey through the Scriptures, explaining to them the prophecies concerning him. The story ends triumphantly. Christ is invited to dine with his friends and they realize his identity when he raises his hands to bless the food. More reflection takes place as Jesus disappears, and the men question each other about their experience that night as they rush back to Jerusalem to share their news with the other followers (Luke 24:13-35).
The process of spiritual reflection. A vital prayer and devotional life is important in spiritual contemplation. Helpful to nurses who do shift work, God requires no particular time of the day for spiritual reflection. David remarks, "When I remember you on my bed, I meditate on you in the night watches" (Psalm 63:6, NKJV). Christian nurses can reflect on their practice during quiet off hours whether day or night, relating experiences to their spiritual life.
Journaling is a way of critically reflecting upon patient care or work experiences, as well as life experiences and private prayer. Some find it helpful to journal by writing long hand, others through use of the computer (Ayer, 2008). Writing prayers verbatim and recording specific answers to prayer build faith in documenting God's willingness to respond to our needs and questions.
Just as the nurse in public practice benefits from group input, so the individual in private life profits from reflection on a regular basis with others in small group settings or at church. Being a recipient of encouragement and spiritual reflection from other Christians will assist in changing one's personal life. When particularly deep and crucial reflection is needed, engaging with a trusted mentor, spiritual director, or pastor is especially helpful.
A week after Mrs. Greenfield's death, Susan came to work and looked at her patient assignments. Mr. Gonzales, who had been her patient on previous hospitalizations, was on her list. As she listened to report, Susan learned Mr. Gonzales was breathing irregularly, was in and out of semiconsciousness, and surrounded by immediate and extended family members. His blood pressure had dropped considerably since the previous night and he was not expected to live through the day. Susan took a deep breath and then relaxed, realizing that today she was ready to face this situation in bringing comfort to the patient and his family as well as coping effectively with her own sadness and loss.
Susan had spent the past week reflecting over her reaction to the death of Mrs. Greenfield. Taking to heart what she had learned about reflection at a recent nursing conference, Susan spent time at home the evening Mrs. Greenfield died, journaling about her thoughts, feelings, and reaction. The next day she arranged a meeting with her supervisor who was happy to meet with her. Susan took her write-up and the two discussed the situation in-depth. Susan felt supported enough at the end of their meeting that she agreed when the supervisor asked her to share her experience at staff meeting the next day.
Because of the recent conference, nursing administration and staff were prepared to form an atmosphere that was supportive of reflective practice. Consequently, time to discuss Susan's thoughts and feelings as well as similar expressions by other nurses met with success. The group discussed how best to handle a situation where the nurse is emotionally attached to the dying patient. Each nurse volunteered to encourage others in difficult situations, especially the care of a dying patient. The idea of "being present" (being at the bedside with the patient, without speaking, and perhaps holding a hand or touching a shoulder) as a nursing intervention was noted as the supervisor shared from articles she had recently read on the topic (La Cava Osterman, Schwartz-Barcott, & Assselin, 2010; Rex Smith, 2007).
As a Christian, Susan realized spiritual reflection on her everyday life gave her a lift. As she thought of her tears in response to the immediate loss of Mrs. Greenfield, she reviewed the story of the death of Lazarus and how Jesus "wept" when he realized how the loss of his dear friend affected sisters Mary and Martha (John 11). She came to understand that her tears were not a mistake, but her emotional paralysis was a problem to address. The next time she had a dying patient she wanted to be a source of comfort and courage to the family. With her educational background, she had the needed knowledge, but she wanted to put this into practice during a future time of stress. Susan decided that along with the steps for reflection she would take, she would be more conscious of praying silently when she felt overwhelmed in a patient care situation, asking God for wisdom as well as strength to carry out the best type of patient and family care. Today, Susan knew would be a new day as she provided the care and comfort Mr. Gonzales and his family needed. For another example of applying reflection in practice, see Case Study in Reflective Practice: Medication Error, Supplemental Digital Content, http://links.lww.com/NCF-JCN/A9.
Nurses will find ways to create transformation in patient care through reflection in practice, clinical supervision, leadership, education, and evidence-based practice. Christian nurses can and should be supportive of reflective practice. They will discover personal transformation as they take time to reflect on spiritual themes through private as well as communal Bible study and prayer. Most importantly, nurses can experience wholeness in their daily lives through reflective practice combined with personal spiritual reflection.
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