The context in which nursing occurs has changed markedly in the last two decades. As a result of advances in nursing and medical knowledge, and reduced government spending (which has led to a reduction in hospital beds, shorter hospital stays, and more rapid patient turnovers), workers in healthcare institutions are spending much more of their time dealing with acutely ill patients who require specialised care (Usher et al 2001). This can cause feelings of concern or confusion, but we must also recognise that it offers us an opportunity to reconceptualise our profession by making it more responsive and reflective of the needs of society (Lauder et al 2004). The role of the nurse is also influenced by cultural, social, economic, historical and political constraints that all affect the ways in which nurses approach and react to certain situations (Taylor 2000). It is a given that society expects nurses to practise safely and to undertake what is necessary to remain current. Reflection helps us to self-correct where the notion of continuous improvement becomes habitual to our practice (Usher et al 2008).

As a consequence of the changing healthcare arena, today’s nursing graduates must not only be clinically competent practitioners, but also need to be adept at critical thinking in order to understand the complexities of the world and the rapidly changing practice arena, even though this can itself be challenging (Johns, 2004 and Usher et al., 1999). Critical thinking, or the practice of questioning, is necessary so that practitioners integrate relevant information from various sources, examine assumptions, and identify relationships and patterns (Parker & Clare 2000). Reflective practice and critical thinking are often used interchangeably, but, while not identical, there is a reflexive relationship. After all, as Lumby (2000:338) explains: ‘to adopt a critical approach to the world, it is necessary to reflect on the world and one’s experiences in it’.

We begin this chapter by introducing you to the why of reflection, and explaining why reflection is a useful strategy for undergraduate nursing students, as well as registered nurses. We will also provide an overview of the related legislation that requires the use of reflective thinking in practice by registered nurses and makes it a requirement for all students exiting undergraduate university degrees. The next section of the chapter addresses the why and what of reflective practice, including an overview of the definitions of reflection.

Every workplace presents a complex environment to the new recruit. It is often difficult to understand and appears to abound with multiple decisions, each coupled to a host of different ways in which the desired outcomes could be achieved. Nursing is no different. When you first enter a nursing context, perhaps during your first clinical placement, you will be confronted by discrepancies, such as those between ‘ideal’ and ‘real’ practice, and you will experience or witness difficult interpersonal relationships. It is important that these situations do not distract you from your nursing goals or from seeking to provide the best possible care. Reflection can help you during these times, as it will assist you to recognise and set aside the emotional content and enable you to learn from otherwise negative experiences. Reflection can take on an even more important role when you find yourself faced with difficult working conditions and environments (Usher et al 2008). It will help you identify alternative ways you could react in the future, hopefully resulting in more positive outcomes.

Johns (1998) explains how reflection offers a way to bring to the surface the contradictions between what you intend to achieve in a situation and how you actually practise. In other words, being faced with contradiction opens the possibility for change and offers the practitioner the opportunity to achieve desired practice. One of the outcomes of reflection is thus a process of continuous monitoring and improvement of practice. Reflection is a legitimate activity or process, as it can generate knowledge in the way that nursing theory, for example, can.

Regulatory authorities in Australia have embraced the need for practitioners who are reflective, and require that all nurses engage in some form of reflective activity. This is indicated by their adoption of the Australian Nursing and Midwifery Council (ANMC) competency standards for registered nurses (2005). These are a set of competencies representing the minimum core standards for registration as a nurse in Australia. The competencies are organised into four domains: professional practice; critical thinking and analysis; provision and coordination of care; and collaborative and therapeutic practice. The domain of relevance to reflection includes self-appraisal, professional development, research for practice, reflecting on practice, feelings and beliefs, and the consequences of these for individuals. These competencies have been extended to apply to enrolled nurses and also specialty groups, such as critical care nurses and nurse practitioners. The National Competency Standards for the Midwife (Australian Nursing and Midwifery Council 2006) also has reflective and ethical practice as one of its four domains, and the codes of professional conduct for nurses and for midwives in Australia likewise require that they practise reflectively and ethically (Australian Nursing and Midwifery Council (ANMC), 2008a and Australian Nursing and Midwifery Council (ANMC), 2008b).

The Nursing Council of New Zealand has also incorporated reflection as a key competency for registered nurses. Reflection in the New Zealand registered nurse competencies is included under ‘Competency 1.5: Practices nursing in a manner that the client identifies as being culturally safe’ (Nursing Council of New Zealand 2007). The Nursing Council of New Zealand also has competencies for enrolled nurses, midwives and nurse practitioners. Further information about these competencies is available from the following websites:

Encouragement for reflection is also echoed in the education sector, in the ‘Review of higher education financing and policy (final report): learning for life’, or the ‘West Report’ as it is commonly known (Department of Employment, Education, Training and Youth Affairs 1998), where reflection is listed as an expected attribute of graduates from all undergraduate university degrees in Australia. In other words, it is a requirement of your undergraduate education that you exit the program of study with the ability to reflect. As a result, all undergraduate degree coordinators are now charged with the responsibility of ensuring their graduates have been provided with the opportunity to develop the skill of reflection.

Reflection comes from the verb reflectere, which means to bend or turn backwards (Hancock 1999). This infers that reflection is a process of going back over something after it has already occurred. This might include recalling thoughts and memories, in cognitive acts such as thinking or contemplation, as a way of making sense of the situation so that necessary changes may be identified or made (Taylor 2000). We all reflect on what goes on around us to some extent. If you think about it, we do not generally just walk around in the world without noticing things or thinking about what has happened and how it has impacted on us. Similarly, we all reflect at some level on our practice, but it may only involve thinking about what happened rather than theorising about what happened and looking for ways to improve it in the future.

Thus the type of reflection to be discussed in this chapter is actually a much more purposeful activity that leads to action that is better informed than that which occurred before the reflection took place (Francis 1995). Rolfe et al (2001) argue that not all knowledge for practice comes from textbooks, research journals and lectures, or other classroom activities. Rather, they claim that, in addition to what they call scientific knowledge, practitioners actually ‘pick up’ practical knowledge from their everyday experience, and reflection is the process of theorising about that knowledge. As a result, they claim that reflection provides practitioners with access to the processes by which they make clinical judgments, which can then be used to justify actions to others or pass on expertise to less experienced colleagues.

Taylor (2000) sees it as necessary to alert clinicians to the intricacies of nursing practice and the knowledge embedded in it. However, Johns (1998) claims that being a reflective practitioner is more than just noticing things by chance in a situation. He suggests that it involves a deep sensitivity to what is happening around us, or ‘a constant monitoring of self within the situation that ripples along the surface of conscious thought’ (Johns 1998:14). It is also important not to assume that improved skill in reflective thinking equals learning, which equals improved nursing practice. A study of reflective thinking in nursing by Teekman (2000) demonstrated that learning from reflection is not something that happens automatically. He identified the importance of coaching by a mentor, and a supportive environment, as ways to reduce the uncritical reinforcement of existing patterns of practice.

Much of the contemporary emphasis on reflective practice in nursing can be attributed to the work of the American educationalist Donald Schön (1983, 1987). Even though he was not the first to write about it, he actually coined the term ‘reflective practice’ (Teekman 2000), and has been very influential in the way nursing has embraced the notion. Schön (1983) argued that reflection is a strategy whereby professionals become aware of their implicit knowledge base. While he did not attempt to define reflection or reflective practice, he advocated two distinct types of reflection: reflection-on-action and reflection-in-action. The former, reflection-on-action, occurs after the event or action where details are recalled and analysed in some way with the aim of reviewing practice. It has been referred to as a type of cognitive ‘postmortem’ or an act of looking back at practice (Burton 2000).

Reflection-in-action occurs simultaneously or at the same time as practice. That is, reflection-in-action is said to occur when the practitioner engages in practice and makes adjustments as a result of relevant feedback. Rolfe (2001) claims that reflection-in-action is a more advanced form of reflection and leads to more advanced practice. He describes it as a process whereby the nurse is constantly testing theories and hypotheses in a cyclical process while simultaneously engaged in practice—what he termed ‘nursing praxis’ in an earlier paper (Rolfe 1993).

Boud et al (1985), however, noted an additional step in the reflective process, that of pre-reflection. In other words, they recognised the importance of reflection in anticipation of events. Greenwood (1998:1049) explains how preparing for experience involves the learner becoming aware of what they bring to the event and what they want from it (the personal), the constraints and opportunities the event provides (the context) and how they may acquire what they need from the event (the learning strategies).

This is an important way for you to think about reflection because, as a nurse, you will work in complex systems where you may feel powerless and unable to express your concerns and opinions; in this sense, you too may feel ‘illiterate’. In order to create a sense of control and of having a worthwhile part to play, you can begin by engaging in reflective processes, and out of these should arise constructive courses of action, which constitute ‘praxis’, an idea discussed further by Holmes and Warelow (2000).

Nursing’s descriptions and adaptations of reflective processes have been clearly explored in a series of chapters in the classic Australian text edited by Gray and Pratt (1991) and you should read these as part of your continuing education as a nurse (Cox et al., 1991, Crane, 1991, Emden, 1991, Gray and Forsstrom, 1991 and Lumby, 1991). The authors explain how reflective processes bring theory and practice together, what forms they can take, and how they can be used by nurses in clinical, educational and research contexts.

The opening remark in Carolyn Emden’s brilliant contribution nicely captures the spirit behind these chapters: ‘Reflective practice is of pre-eminent interest to nurses’, she says, and ‘[t]o be a reflective practitioner suggests professional maturity and a strong commitment to improving practice—a reasonable aspiration for every registered nurse’ (Emden 1991:335). The work of Boud and his colleagues (1985), which was mentioned earlier, plays an important role here. Emden (1991) explains how his three phases of reflective learning—preparatory, experiential and processing—can be undertaken by you, in your workplace, and provides actual examples of nurses’ ‘field notes’, or written reflections. For Emden (1991), as for most nurse authors, reflective processes are inextricably tied to the ‘critical social science paradigm’—that is, the politically informed approach we have noted above, which is interested in identifying and changing irrational, oppressive or counterproductive beliefs and practices (Kemmis 1985).

Historically, the most important exemplars of this approach in Australian nursing were the School of Nursing at Deakin University, where reflective processes and critical social theory were used as the basis for the undergraduate nursing curriculum from 1988, and subsequently formed part of the Master of Nursing Studies degree, and the Flinders University of South Australia, where they formed part of the Master of Nursing degree from 1991. Most Australian nurse scholars who have written about these topics are in some way linked to these two schools.

Emden (1991) summarises the ways in which reflective processes have the effect of ‘educating the emotions’. Reflective processes should be mutually encouraged, and there is an educative element, as you help others by recognising and responding to their needs and sensitivities, as well as your own; reflective processes also help you come to terms with the uncertainty of clinical practice and with its inevitable injustices and inadequacies. Clinical practice is never perfect; it is always constrained by resource shortages and by the failings of the system and those who work in it. It is part of the human condition that we cannot do everything right all the time, and that things sometimes go wrong. Reflective processes enable us to face up to this reality, but at the same time challenge us to overcome the obstacles and aspire to the best possible standards of practice. They contribute to our development as thinkers, practitioners and as people; that is why Emden (1991) referred at the outset to them being the hallmark of the mature professional.

We have referred already to some of the benefits that derive from reflective processes, but let us now discuss these in more detail. Freire (1972) insisted that action and reflection must work together, and we can agree with Emden when she describes action as a ‘key outcome’ of reflection. ‘Action’ can take many forms. For example, when you reflect upon your practice world and become sensitive to its inadequacies and injustices, you are most likely to want to do something about them, especially as you consider them in relation to individuals’ rights. In contrast, action might involve improving your own clinical skills; your reflections having alerted you to shortcomings in your attitudes or skills, and you take action to bring them to a higher standard.

Another benefit of reflection is that it can help you elucidate the theory–practice relationship. Critical social theory insists that this relationship is ‘reflexive’; in other words, theory feeds into your practice, and practice informs your theory. This supports the suggestion by nurse theorists Walker and Avant (1983) that reflective processes can be used to help develop clinical practice by helping you to recognise, evaluate and refine your personal nursing theories (i.e. your beliefs about nursing and clinical practice). Indeed, much of Emden’s (1991) chapter is about how to use reflection to help elucidate and develop your own theory of nursing. Since critical social theory is closely tied to these conceptions of reflection, it is widely argued that any theory of nursing developed in this way should be consistent with critical social theory, and many nursing scholars have attempted to show how this can work (good places to begin exploring this topic are Holter (1988) and Crane (1991)). This link has become more difficult to sustain, however, as critical social theory has been the subject of criticism in light of alternative ways of thinking about social structures and processes, including ‘poststructuralism’ and ‘postmodernism’ (Holmes 1995).

Another positive outcome of reflection, which follows on from its role in the ‘education of the emotions’ noted above, is that it sensitises us to the plight of the less fortunate and marginalised people in society. We become more sensitive to the suffering, courage and determination of people who are faced with serious illness, and to the problems faced by those who are oppressed, such as mentally disordered and intellectually disabled people, and people who belong to ethnic and religious minorities. This increased sensitivity impels you towards greater engagement with such people, and a willingness to become involved in their problems. Not only are you aiming to improve your clinical performance with all your patients, but also to act as their support and advocate. You are not only motivated to question inadequate practices, but also to generate possible strategies for improvement. Even though it may be challenging, you will find that you cannot do otherwise, and you will enjoy increased levels of job satisfaction because this heightened level of engagement is intrinsically rewarding.