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15 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), Kolbs Learning Cycle (1984), Atkins and Murphys 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

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 ones 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, reflectingfor-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).

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 patients 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 Mezirows 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.

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 clientcentered 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

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 ones 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 ones 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 Murphys (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.

TABLE II : Atkins and Murphys 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.

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

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

Examples Now 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

Reflexivity My description of reection states that the nurses can gain new insights into self and be empowered to respond more consistently in future situations within a reexive spiral towards realizing ones vision as a lived reality. Such words reect the purposefulness of reection, it is action oriented towards the development of practical wisdom and realization of vision. Reexivity is a looking back and reviewing selfs development over time, the way insights have emerged and inuenced future experience. In this sense, reection 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 reexive 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?

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 patients 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 peoples 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--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 decisionmaking 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 didnt 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 indepth 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; Schn, 1991), with some relation to intuition (Goodman, 1984), Schn, 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. Johns (1994) model of guided reflection integrated Carpers (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 nurses 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 selfawareness 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 parents 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 Johns (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 Gilberts (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 Bonos 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
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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 Mezirows 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 researchers and target audiences 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 problemsolving 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 Schons 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).

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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 nave 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
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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 confessionalreflective 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 nave 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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Reference Practice and practice development (Thorpe & Barsky, 2001; Stickley & Freshwater, 2002; Taylor, 2000, 2002a, b; Johns, 2003) Clinical supervision (Todd & Freshwater, 1999; Heath & Freshwater, 2000; Gilbert, 2001) Leadership and management (Freshwater et al., 2001; Freshwater, 2002; Freshwater, 2004; Johns, 2004; Sherwood & Freshwater, 2005) Education (Cruickshank, 1996; Freshwater, 1999; Kim, 1999; Anderson & Branch, 2000; Clegg, 2000; Platzer, Blake & Ashford, 2000a, b) Research and scholarship (Freshwater, 2001; Taylor, 2001, 2002a, b) Boenink AD, Oderwald AK, De Jonge P, Van Tilburg W, Smal JA. Assessing student reflection in medical practice: the development of an observer-rated instrument reliability, validity, and initial experiences. Med Educ.2004 Pee B, Woodman T, Fry H, Davenport E. Appraising and assessing reflection in students' writing on a structure worksheet. Med Educ.2002 Branch WT Jr, Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med.2002;

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Kolb D. Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice-Hall, Inc; 1984 Mezirow JA. Fostering Critical Reflection in Adulthood: A Guide to Transformative and Emancipatory Learning. San Francisco, CA: Jossey-Bass; 1990 Brookfield SD. Developing Critical Thinkers: Challenging Adults to Explore Alternative Ways of Thinking and Acting. San Francisco, CA: Jossey-Bass; 1987 Plack M, Santasier A. Reflective practice: a model for facilitating critical thinking skills within an integrative case studies classroom experience. J Phys Ther Educ.2004 Yorks L, O'Neil J, Marsick VJ, eds. Action Learning: Successful Strategies for Individual, Team, and Organizational Development.Monograph of Advances in Developing Human Resources. Baton Rouge, LA: Academy of Human Resource Development; and San Francisco, CA: Berrett-Koehler Communications Inc; 1999

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