Aim: The aim of this concept analysis was to describe attributes, antecedents, and consequences of reflection in nursing professional development, as well as surrogate terms and a model case to inform nursing educators, students, and nurses about developing reflective skills.
Methods: Rodgers' evolutionary cycle for concept analysis was used. The published work search was conducted using five databases: Education Resources Information Center (ERIC), Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ichushi, and British Nursing Index. The inclusion criteria were: (i) academic articles; (ii) written in English or Japanese; and (iii) including descriptions about reflection. From the pool of extant published work, 50 articles were selected for the thematic analysis.
Results: For the concept of reflection in nursing professional development, four antecedents were identified: (i) theory and practice gap; (ii) expansion of the role and competency in nursing; (iii) educational and learning needs; and (iv) educational responsibility. The major attribute was the process of learning from experience, and the circular process included emotional reaction, description, internal examination, critical analysis, evaluation, and planning new action. The consequences were transforming new perspective, enhanced communication, professional development, and quality of care.
Conclusion: Reflection is used as a method or tool that connects knowledge and experiences. Through the process of reflection, students/nurses become aware of themselves, which helps them review and improve clinical skills. They also become more able to communicate with patients and colleagues. Reflection enhances self-directed learning and professional maturity. Nurses who use reflection can be better positioned to provide excellent patient care.
In 2007, the World Health Organization (WHO) Western-Pacific Regional Office (WPRO) proposed “People-Centered Health Care (PCHC)”. PCHC was a carefully chosen concept not to be conceptually substituted as patient-centered care (PCC). It is patient care across all levels of healthcare systems (WHO WPRO, 2006). Hence, PCHC includes PCC as the first domain. Healthcare providers empower people to promote their own health and select health care for themselves. In other words, in the new model of health care, people create their health in collaborative relationships with professionals, rather than the more traditional and paternalistic focus of professionals contributing to people's health. This is a fundamental change in the power relationships between clients or patients and healthcare providers. It also requires a shift in responsibilities. Implementing this change in responsibility and power-base, requires that healthcare providers including nurses acquire professional attitudes and skills to empower and to collaborate with people in the community.
In Japan, a leading nursing educational institution began aligning with the concept of PCHC, and in 2009 started a new curriculum for undergraduates with PCHC at its core. This new curriculum aimed at developing nurses in higher education. In addition, graduate programs, especially in the area of advanced practice, expanded widely to develop nurses with specialized skills. This change promoted the expansion of nurses' roles and produced a new challenge in nursing education to develop nurses' autonomy and professionalism. Indeed, the Quality and Safety Education for Nurses (QSEN) project in the USA also identified developing PCC, which recognizes the patient as the source of control and partner in collaboration, as a core competency for both undergraduate and graduate education to improve quality and safety of the healthcare system (QSEN, 2012). In addition, professional development is a recommended strategy to attract nurses to stay in their career (Buchan & Aiken, 2008). Nurses tend to remain in work because of the opportunities to develop professionally (Buchan & Aiken, 2008; Buchan & Calman, 2006).
To promote professional development, the new curriculum included reflective skills as one of the required competencies. Schön (1983) was instrumental in describing the role of reflection in professional education and explained reflection as a significant tool to facilitate learning from one's experiences. Professionals can surface, criticize, restructure, and embody the understandings in further action through reflection on action (Schön, 1983). From an educational viewpoint, Reid (1993) defined reflection as “a process of reviewing an experience of practice in order to describe, analyze, evaluate and so inform learning about practice” (p. 306).
Nursing, as a practical science, has emphasized reflective learning in clinical practice in terms of nurse–patient relationship (Neary, 2000). Reflection has been utilized and researched in nursing education in England and the USA (Bulman & Schutz, 2008; Freshwater, Taylor, & Sherwood, 2008; Johns, 2004; Mezirow, 1991; Mezirow & Taylor, 2009). It has been introduced to Japan and used in clinical practicums at the undergraduate level or for reviewing a specific clinical practice (Ueda & Miyazaki, 2010). However, the concept of reflection within the context of nursing professional development has not been defined adequately to identify educational and research indicators. Therefore, this concept analysis aims to address the broader context: reflection in nursing professional development; it describes attributes, antecedents, and consequences of reflection in nursing professional development, as well as surrogate terms and a model case. The clinical relevance is to add clarity for nursing educators in using the findings for the systematic development of professional nurses from undergraduate to graduate programs for advanced practice.
When developing and clarifying the base of knowledge, concepts play a crucial role to promote the organization of practice, to facilitate communication among communities, and to enable the recall of phenomena cognitively (Rodgers, 1989). In nursing, approaches for concept analysis were introduced to advance nursing theory and practice in the early 1980s with Chinn & Jacobs (1983, 1987) and Walker & Avant (1983, 1988) adapting Wilson's approach (1969), and Rodgers (1989) informed by Toulmin (1972) and Wittgenstein (1968). Rodgers' position (1989) that concepts are contextually bound and therefore subject to continuous change as contexts change, rather than being characterized by a fixed set of conditions identified through strict rules was appropriate for examining reflective learning in a new context; therefore, the authors followed Rodgers' (1989) procedure of concept analysis: the evolutionary cycle based on an essentialist orientation. The purpose is not to provide the definitive answer, but to identify a consensus or the “state of art” of the concept. Rodgers (1989) suggested exploring the contexts within which the concept is used, collecting the data from the references of the concept, and identifying antecedents, attributes, and consequences of the concept. The authors adopted the dispositional theory of concepts, described by Rodgers (2000). The context the present authors chose was the scientific use of reflection as it appears in the published work opposed to the colloquial term in everyday speech (Risjord, 2009). Therefore, the authors chose the concept of reflection, as it was understood and researched within specific nursing educational contexts as delineated in the published work search.
Published work search
The authors searched the published work in five databases: Education Resources Information Center (ERIC), Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ichushi (Japan Medical Abstracts Society), and British Nursing Index, using combinations of the key words “reflection”, “nursing”, “nursing education”, “nursing student journaling/journal writing”, “critical thinking”, “e-learning”, and “service learning”. The authors included articles written only in English or Japanese because of their language ability. The authors did not limit or exclude articles from the beginning to collect a wide range of documents. In order to select articles that represented the entire range, the authors listed all the results of their published work search and selected every fifth article using systematic sampling. The authors excluded duplicates, non-academic articles, and unavailable articles. This procedure resulted in a list containing 86 articles. The authors then included those articles containing concepts of reflection including attributes, antecedents, consequences, surrogate terms, and/or relevant aspects in nursing education, and excluded articles that had none. Based on that, the authors chose 50 articles from the list. Rodgers' suggested including at least 30 articles to reach the common use of the concept; therefore, the authors of the current study determine that their sampling was adequate. Additionally, the database was further strengthened by including five landmark scholarly works (Bulman & Schutz, 2008; Freshwater et al., 2008; Mezirow, 1991; Mezirow & Taylor 2009; Schön, 1983) for analysis.
Fifty articles and five books were analyzed using thematic analysis (Rodgers, 2000) and the language used in the relevant published work was examined to determine a trend by asking: “what is common in the use of a word?” From the descriptions of reflection found in the selected published work, the authors picked: (i) antecedents (those events most likely to happen prior to the occurrence of the concept); (ii) attributes (characteristics associated with the definition of the concept); and (iii) consequences (those events or results occurring because of the antecedents and attributes) (Rodgers, 1989). They were put into a matrix format to examine similarities among the published work and continuously organized and reorganized to generate a cohesive, comprehensive, and relevant system of each aspect of the concept. The authors identified a model case of the concept using the antecedents, attributes, and consequences, then constructed a conceptual model based on the findings (Fig. 1).
Many of the reviewed articles cited definitions of older works, such as Dewey (1933), Schön (1983), Kolb (1984), Boud, Keogh, and Walker (1985), Johns (1995), and Alfaro-LeFevre (1995) Some landmark published work noted that the concept of reflection was difficult to define, and consequently scholars interpreted it in slightly different ways (Bulman & Schutz, 2008; Freshwater et al., 2008). The authors of the present study needed to be clear that their purpose was to describe the current trend of reflection. A proposed definition was provided using the major pattern formed from descriptions in the current published work grounded in the earlier works noted above. The results are presented based on the conceptual model (Fig. 1).
Theory and practice gap
When nursing students enter into the practice environment, they soon face a gap between what they have learned in the classroom and what they see in the real world (DeBourgh, 2002). This gap triggers perplexity or dilemmas that lead to the process of reflection (Epp, 2008). Many authors mentioned use of reflection because of the need to integrate theory and practice. Grant, Kinnersley, Metcalf, Pill, and Houston (2006) stated that, as students, they “can examine their understanding for any gaps or inconsistencies”, and they “address any identified gaps” (p. 379–380).
Hence, reflective learning does not necessarily occur when students just review clinical or other experiences. One needs to inquire about the difference between the reality and what they have learned. When they realize the theory–practice gap, a reflective process begins. Therefore, the theory–practice gap is the core antecedent of reflection. Tamura (2008) pointed out that the gap must come from interactions with others. The following includes more background of nursing education that potentially widens the theory–practice gap and heightens the need for reflection.
Expansion of the role and competency in nursing
As nurses expand and shift their role in advanced practice and community-focused approach, the theory–practice gap that they experience may be wider than before because they are required to act more autonomously and make the appropriate clinical judgments (Chirema, 2007). Daroszewski, Kinser, and Lloyd (2004a) point out that in advanced practice, nurses are required to apply specialized knowledge independently or collaboratively, and that it is more complex in community health as their skills need to be used in various environments and with different populations within a community. This change leads to increased needs for reflection in nursing education.
Educational and learning needs
Traditional educational approaches based on the positivist paradigm and its methodologies of inquiry became less effective in promoting those professional skills that recognized “self” and others required in developing more complex assessments (Cash, Brooker, Penney, Reinbold & Strangio, 1997). Nakata et al. (2002) also emphasized “self-awareness” of nurses so that they can properly assess others and situations surrounding them so that they provide care based on the assessment. Maeda and Tsuda (2008) further discussed that nurses need to understand that caring is a product of the interaction with others and practiced intentionally to achieve their own self-actualization. The authors stated that nursing professional development requires enhancement of self-efficacy and self-respect. The new approach, reflection, is about pasts, presents, and individual and collective futures, containing the possibilities for nurses individually and collaboratively in their relationship with others (Cash et al., 1997).
As healthcare complexities such as aging societies and people-centered care increase, the educational side of responsibility also becomes larger to meet this demand. For nurses to function in more complex situations that may require new pattern recognition or strong collaborative skills to gain necessary data, they need to be able to think critically. Reflection is a necessary component of critical thinking (Lindeman, 1999). Numerous authors discussed the nursing educator's responsibility to enable students to learn from their experience, which requires reflective skills. Palmer et al. (cited in Parker, Webb, & D'Souza, 1995) said that “nursing educators must ensure that students learn from their clinical experience and must be well versed in the use of reflection” (p. 111). To this end, nursing education has shifted from traditional educational approaches based on the positivist paradigm to methodologies of inquiry (Cash et al., 1997). It is a necessary and preferable change that nurse educators respond to the needs of education.
Attributes of reflection
Tools or methods of educational approach
Many authors described reflection as a method or tool for education with various educational approaches used to promote students' reflective learning. The majority of educators used reflective journals including e-journals, portfolio, and narrative reflection. Horn and Freed (2008) used journaling and dialogue pairs. Several authors used unique teaching strategies. For example, Bradbury-Jones, Hughes, Murphy, Parry and Sutton (2009) used the “Peshkin approach” to reflection, which asked students to reflect on a situation based on their emotions and thoughts systematically, focusing on six “subjective I's”. Daroszewski, Kinser, and Lloyd (2004b) used the “Socratic method”, in which a teacher does not give information directly but asks a series of probing questions to elicit meaning and truth. Oterholm (2009) used a collaborative e-learning method in which students exchanged comments on challenging incidents during their fieldwork. Some authors incorporated reflection in service learning (Bailey, Carpenter, & Harrington, 2002; Eyler, 2002).
Process of learning from experience
The most common attribute of reflection among the reviewed published work was a process of learning from experience. Tamura (2008) stated that, conceptually, reflection is a systematic cognitive process originating from Dewey's educational philosophy. In reflection, one deeply understands their experience through internal examination so that one can improve their behavior or practice. The model and/or framework of the process varied among the authors.
Freshwater et al. (2008) described that Gibbs's (1988) and Kolb's (1984) non-linear, circular nature of reflection illustrated the ongoing development of the practitioner and then, by synthesizing some of the former authors' work, identified three stages of the reflective process: (i) awareness of uncomfortable feelings and thoughts; (ii) critical analysis of the situation; and (iii) development of a new perspective.
Whereas other authors finished the process at the acquisition of a new perspective or action plan stage, Mezirow (1991) and Mezirow and Taylor (2009) identified 10 steps for transformation, which included building competence and confidence in new roles and reintegration of one's new perspective into one's life. The components of models and frameworks depended on how the authors categorized or conceptualized sets of factors in the reflective process.
Overall, the authors of the present study identified six components that are essential for reflection: (i) emotional reaction; (ii) description; (iii) internal examination; (iv) critical analysis; (v) evaluation; and (vi) planning new action (see Fig. 2). They are presented next in more detail.
On many occasions, the theory–practice gap triggers emotional reactions. Mezirow (1981, 1991) named the first step of reflection a “disorienting dilemma”, which is caused by some pressing external events that are likely to facilitate a perspective transformation. Nursing professionals often encounter tragic events, such as struggles, concerns, depression, and deaths of patients (Maeda & Tsuda, 2008). They sometimes encounter their own mistakes, incidents, and accidents, as well as disagreements with colleagues or other healthcare providers. Recognition or awareness of one's emotional reactions is the first step of reflection (Freshwater et al., 2008). This kind of emotional reaction and questioning spirit underpins reflective practice (Bradbury-Jones, Hughes, Murphy, Parry, & Sutton, 2009), characterized by inquiry and finding information to resolve the tension (Dewey, 1933, cited in Epp, 2008).
Educational approaches, such as narrative reflection or journaling, encourage students/nurses to identify and describe orally or through writing what happened in the situation. This requires the ability to recognize and accurately recollect salient events and key features of an experience (Atkins & Murphy, 1993). Good description illustrates the situation clearly and accurately, enabling an understanding of the whole situation (Nakata et al., 2002).
After describing the situation, students/nurses need to internally examine their cognitive and affective domains, namely, consider what they think and feel about the situation they described. Some of the authors cited Boud et al.'s (1985) explanation of internal examination as: “intellectual and affective activities that individuals engage in, to explore their experience, which leads to new understandings and appreciations” (cited in Chirema, 2007; Cooper, Taft, & Thelen, 2005). Bradbury-Jones et al. (2009) also agreed that “thoughts and feelings are the core foci” (p. 2486) of reflective process. Johns (2004) also described reflection as “being mindful of self . . . as if a window through which the practitioner can view and focus self” (p. 1). Providing further rationale for this type of internal examination, James and Clarke (1994) noted that examining both thoughts and feelings redresses balance between the science basis and artistry.
After describing and examining their internal state, students/nurses need to re-examine and analyze the situation, including external factors, from different perspectives. Mezirow's (1991) called this the third step of transformation, which was critically examining the epistemic, sociocultural, or psychic assumptions underlying the experience. Lasater and Nielsen (2009) cited Dewey and said that reflection is essential to learning from experience, particularly in those situations in which the issues are ill defined, multilayered, and complex. As described above, issues that nursing deals with have become more complex and complicated due to societal changes and nurses' role expansion. Hence, it is necessary to deeply assess and analyze what happened and what influenced the particular issue. Freshwater et al. (2008) named this stage critical analysis of the situation, which includes openness to new information and perspectives.
Evaluation is making a judgment based on a value (Bulman & Schutz, 2008). When students/nurses analyzed and understood both the internal and external factors, they could objectively evaluate the situation. They could make sense of what happened in a calm manner. Cash et al. (1997) stated that reflection could be “a process of healing and enlightenment” (p. 246). Students might have felt pain as they made a mistake, but it could have been something inevitable. In evaluation, students/nurses reach their own conclusion and understanding of the situation.
Planning new action
In many cases, nurses reflect on their practice because they want to find what could be done differently for the next time (Cash et al., 1997). Drevdahl and Dorcy (2002) quoted Johns (2004) that reflection is “a process of personal deconstruction and reconstruction” (p. 226) to take necessary steps to change their perspectives and practices. This new plan of action may cause emotional reactions and triggers the circular reflective process again (see Fig. 2).
Transforming new perspective
Many authors stated that after students/nurses experienced reflection, they experienced changes in themselves through self-awareness and self-actualization. Many of the educational approaches in undergraduate nursing programs are aimed at developing student's self-awareness. Ando et al. (2008) stated that by becoming aware of their beliefs, values, grounding, strengths, and weaknesses, students become conscious of their personalities and learn about themselves. They also gain new perspectives on their own skills, abilities, and practice (Drevdahl & Dorcy, 2002; Lauder, 1994). By understanding the self, students build values and feelings associated with the conduct of care and a view with which they can strongly agree (Langan & Prendergast, 2008). Hence, understanding of the self, influences students/nurses toward self-actualization (Epp, 2008), helps to improve clinical competency (Kessler & Lund, 2004), and promotes mindful, thoughtful, caring, and holistic nursing practice (Fakude & Bruce, 2003; Waldo & Hermanns, 2009).
The process of reflection has potential for not only self-awareness, but also knowledge construction by identifying knowledge and skills that may address practical problems which cannot be solved by a “technical rationale” (Maeda & Tsuda, 2008). Through the process of reflection, students/nurses identify the gap and reduce it (Langan & Prendergast, 2008). It pushes students/nurses beyond first impressions and feelings to thinking more deeply about their experience and by connecting it to their knowledge and broader experience (Eyler, 2002). Hence, what they first considered as a gap may be viewed differently as they gain a new perspective. Tamura (2008) stated that the consequence requires attitudinal or behavioral changes that shows personal value and intellectual growth of the self or of both the self and others.
In reflection, students/nurses learn not only their own values and feelings, but also how these factors influence others (Nakata, Tamura, Fujiwara, Ishikawa, & Tsuda, 2004). As a result, it improves communication and relationships with others. In nursing, students/nurses find a way to establish relationships with patients. At the same time, reflection connects them with the community of nurses “united through common interest and need in caring for each other as well as humanity” (Lauterbach & Hentz, 2005, p. 34).
Reflection is a way to promote the development of autonomous, qualified, and self-directed professionals (Stoddart, Cope, Inglis, McIntosh & Hislop 1996; Epling, Timmons, & Wharrad, 2003). It provides the means for nursing professionals to realize the value of nursing knowledge by adapting and transforming knowledge to meet changing circumstances (Fakude & Bruce, 2003). As a result, nurses become able to contribute more to the multidisciplinary team as a result of their enhanced knowledge (Chirema, 2007). Tamura and Tsuda (2008) identified eight consequences of reflection in nursing professional development: (i) identifying their own learning needs; (ii) personal growth; (iii) professional growth; (iv) growth out of conventional practice; (v) awareness of their own behaviors; (vi) theory construction by observational judgment; (vii) support for solving and deciding uncertain phenomena; and (viii) self-empowerment and emancipation.
Quality of care
Although it is not a direct outcome, reflection is assumed ultimately to improve the quality of care given by independent, thoughtful, and knowledgeable practitioners (Durgahee, 1996; Epling et al., 2003; Lepp, Zorn, Duffy, & Dickson, 2003). Epp (2008) stated that a nurse who has improved personal attributes will be an improved nurse, and better positioned to provide excellent patient care.
Mezirow (1991) used the term “transformative learning”, which is equivalent to “reflective learning”; however, the two terms differ in terms of their foci. The term “transformation” was derived from the area of cognitive studies focused on “emancipatory” learning and action (1981, p. 5) described by Habermas. The concept of emancipatory action is the same as perspective transformation, or critical self-awareness, in the sense that people recognize the correct reasons for their problems.
Fowler (2008) indicated that all learning lies in the way of processing experience, namely, the critical reflection of experience. He cited Kolb (1984) to explain that the “experiential learning cycle” is the grasping of experience, which would result in “transformation” of that experience. He also mentioned Dewey (1933) who had suggested that “experience plus reflection equals learning”.
The authors of the present study identified antecedents, attributes, and consequences, as well as surrogate terms of reflection in nursing professional development. Figure 2 contains a circular model of reflection, but the process from theory–practice gap and reflection to consequences, as described in the reviewed published work, is overall more linear.
Reflection in nursing professional development is an active process triggered by the theory–practice gap, in which nursing students or nurses describe the situation, realize their emotional reaction, examine their thoughts and feelings internally, critically analyze their behavior and the situation, evaluate them, and thus plan a new action. Through the circular process, they become increasingly more aware of themselves and their clinical skills, able to produce experiential knowledge, and able to communicate better with patients and colleagues. They acquire self-directed learning skills and obtain professional maturity. Students or nurses who use reflection can be better positioned to provide excellent patient care, and therefore reflection should ultimately lead to improvement of quality of care.
A second year student nurse has been taking her first clinical course that requires journal writing to reflect her experience. She had difficulties in communicating with nurses in the clinical site because nurses seemed to be very busy. Whenever she had to report to nurses about her plan or practice, she felt nervous and intimidated (emotional reaction). She wrote about her feelings in the journal (description). When she wrote and read it by herself (internal examination), she thought that it was not unusual to feel this way, as this was her first time communicating with working nurses (critical analysis). She recognized that she needed to practice how to report to nurses (evaluation). She asked her faculty to practice with her (planning new action). The faculty responded quickly, complementing her on her autonomous action and practiced with her. She gained confidence and positive attitudes about reporting and she became more able to communicate with nurses as the clinical course proceeded. She became aware that good communication is important as part of teamwork.
The need for reflection in nursing professional development is increasing following the global trend in which nurses are required more to have autonomy and critical thinking skills to reach appropriate decisions within the context of complex social health issues. Developing professional identity and maturity is needed as nurses confront ethical issues, recognize limits, and perceive the weight of nurses' responsibilities (Cooper et al., 2005).
There were several limitations in the present study's database that must be noted. Although the authors aimed to collect a wide range of published work, they could not retrieve some articles listed. More rigid inclusion and exclusion criteria was needed to collect published work that focused specifically on nursing professional development and then to only select articles that met rigorous research standards as opposed to selecting every fifth article. As a next step, it is necessary to apply the concept to education and research of reflective learning in nursing professional development.
In this global and changing society, the role of nurses is shifting from traditional institution-based medical assistance to community-based people-centered care. It requires more autonomy and responsibility as a professional. As the current authors identified, reflection as a potential tool or method of educational approach can help students and nurses transform their perspectives, enhance communication with patients and colleagues, develop as professionals, and ultimately improve quality of care. The identified factors can guide future studies on reflection in nursing education. The authors hope these results of concept analysis will inform the nursing faculty in addressing the changing needs of society and help students and nurses to become professional nurses.
This study was a part of the research project funded by Grants in Aid for Scientific Research (KAKENHI) in Japan from 2009–2011. The authors appreciate Sue Schutz and Dr Chris Bulman for supporting them and providing valuable information on reflective practice.
CONFLICTS OF INTEREST
No conflict of interest has been declared by the authors.