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Over the years, the roles of the nurse have been rapidly changing in health care industry. Nurses are expected to fulfill the fundamental needs of the patients and at the same time, handling complex situation. Thus with rapid changing role of the nurse, nurses of today need to evaluate, improve their nursing practices and make appropriate clinical judgments to the best of their ability for their patients (Chirema, 2007). Nurses also need to focus on their knowledge and skills, so that they are able to meet the demands and expectation made by the patients/family members. These pose a challenge for the nurses. In order to face the challenge, Deutsch and Sherwood (2008) mentioned that reflection could help in the context of theoretical learning, narrow the gap between theory and practice. Hence, it has turned the education point from a traditional teaching using lecture format to more on learning of practice based on reflection (Jeffries, 2000, as cited in Badeau, 2010 and Henderson et al, 2012). Bowden (2003) also mentioned that developing critical reflective skills would assist nurses to reflect on the incidences based on their experiences, to meet the challenges and ultimately to become a better critical reflective nurse.
There are few definition stated about critical reflection. Mann et al (2009), defined reflection as "the actions, ideas, meanings, or implication of experiences that are integrated into an individual's cognitive framework." It is a thinking process that links from theoretical knowledge and clinical experiences, to form a new knowledge and gain insights from previous experiences. Another definition of reflection by Taylor 2000 (as cited in Deutsch and Sherwood, 2008), defines reflection as "practically, cognitive acts such as thinking, contemplation, meditation or other forms of attentive consideration are systematically reviewed and analyzed for sense-making that can lead to contextually appropriate changes." Both definitions stated the similar points of reflection that reflection has prepared nurses to think not only current practices, but also for the future practices. Nevertheless, a proper reflection is not just a thinking experience, but also more of a learning experience through a rational process and intuitive process, that leads to positive changes (Deutsch and Sherwood, 2008). Reflection also allows nurses to question themselves to develop a deeper understanding of the practices, identify gaps and seek changes based on current evidence (Badeau, 2010). It is a common tool used especially in healthcare environment to examine and transforms practice (Finlay, 2008).
There are varies models used to promote critical reflection. Most reflective practice models are activated by the awareness of a need and disruption in usual practice (Mann et al, 2009). Models such as reflection-in-action, reflection-on-action and Gibbs reflective cycles are the common models used for reflection (Bowden, 2003; Mann, 2009 and Thorpe, 2010). These models are based on both theory and clinical experience.
Somerville and Keeling (2003) define reflection-in action as "examining your own behavior and that of others while in a situation." It is to think what we are doing while doing it. This can be used to develop into practice by reflecting the previous experience and think of a new way to handle the situation if the same incident occurs. Reflection-on-action refers to a reflection occurs after a situation had happened. It is a process of reflecting the past situation that may contribute unexpected event, where actions need to be taken to prevent affecting future practice (Somerville and Keeling, 2003). It is a useful strategy to learn for future practice, as it does not require immediate actions, which allow us to think and reflect slowly. In Gribbs reflective cycle, there is a structure to provide for reflection on a nursing experience or situation. It allows to reflect a recent clinical nursing situation that involved in, described the feeling that encounter in that situation, analysis and action plans applied for future practice (Bowden, 2003). With the models illustrate above, we know that critical reflection involves "new look" at our practices. Reflection allows viewing the practices through a different angle and questioning our previously accepted, taken for granted, values, belief systems and routines (Bowden, 2003). It involves thinking beyond own opinion to a wider healthcare environment.
In my next section of my essay, I will discuss on how critical reflection as a learning theory can be applied in clinical education to a small group of nursing students. I will touched on the assessing the appropriateness of critical reflection to nursing students in clinical education, the readiness and learning environment for the nursing students to use reflection, the barriers to implement critical reflection towards nursing students, and the success of this theory used for nursing students.
Clinical education is an essential element for nursing students in their undergraduate nursing program (Maginnis and Croxon, 2010). It is not just an area for clinical skill development, but for students to learn about practice in the 'real' world (Henderson et al, 2012). It also enable students to develop their clinical skills using their theoretical knowledge and prepares them to be able of "doing" as well as "knowing" the clinical principles in practice and the kind of work they will have to do as practicing nurse (Lau et al, 2002). In clinical practice, it stimulates students to use their critical thinking skills such as critical reflection to solve problem (Sharif and Masoumi, 2005). The idea of critical reflection has come to have an influence on the practice in clinical education (Hannigan, 2001). It has viewed as an important academic outcome and developing a valuable life-long skill (Zimmerman et al, 2007). Zimmerman et al (2007) mentioned that such skill like critical reflection couldn't be taught in lecture and assessed in the examination. It is a transferable skill to develop in clinical education (Badeau, 2010). Nursing students are appropriate to learn critical reflection in clinical education, as it is a learning strategy to facilitate the development of the cognitive and affective domains of learning in pre-registration students' competencies (Donovan, 2007). Students tend to develop insights not only into the concepts but also the learning skills to understand themselves, improve the learning process or solve the problem which enables them to be more competent (Thorpe, 2004).
Proper preparation of students to learn from reflection is essential. There are few factors to assess their readiness of reflection. First is to brief the students on the need of reflection. Through informing the purpose of reflection, the students could understand that reflection is an integral part of practice and requires some time to develop this skill. It is not a process that can be rushed, but a process that can occur at anytime or anywhere. Secondly, students need to locate themselves within the experience and explore available theory, knowledge and experience to understand the experience in different ways. They need to have the basic foundation of what is reflection before it is being used. Thirdly, the students need to be developmentally ready to engage and motivated in critical reflection. They need to be proactive and practice more by doing their own analysis with clinical reasoning to trigger internal motivation (Finlay, 2008). Once students are motivated, they will feel safe to formulate their own learning and comfortable to express themselves (Somerville and Keeling, 2004). Students can able to express and share among themselves or to facilitators /educators during discussion, it may also contribute to the success of reflective learning (Lau, 2002). With that, the students will feel more confidence and ready to challenge any problems or questions.
Besides assessing the readiness of the nursing students, it is important to assess the learning environment. A welcome clinical practice environment is instrumental to learning (Henderson et al, 2012). The balance between learning and adapting the environment does hinder the students' learning process and learning outcomes (Sand, 2009). Students being assigned to different clinical settings for a learning environment may cause them to feel threaten and stress. These maybe due, to the strange and unfamiliar surroundings that they encounter, thus impaired their learning (Lau, 2002). Berglund et al (2012) also mentioned in the article that we need to be aware of the students' life-worlds so that we do not expect them to do reflection that they are not familiar with, in an unfamiliar environment. It is important to give them encouragement and support, to maintain their self-esteem before learning needs is attended to (Lau, 2002). On top of that, a learning environment should also include a good facilitator/educator. A good facilitator/educator must carry a positive characteristic of open-minded, supportive and encouraging students to learn in the clinical environment, which will benefit the students in their learning process (Sand, 2009). A facilitator/educator can also reiterate the theoretical components of reflection, and use their own personal experiences to assist the students into practice while students are sharing their reflection (Maginnis and Croxon, 2010). With that, the students will able to learn more under guidance from the facilitator/educator.
However, there are also barriers when implementing reflection for nursing students. Factors such as lacking of adequate preparation and support to reflect inhibit the use of reflection for students (Donovan, 2007). Students may feel that time is too short and not skillful enough for them to use reflection on the spot, in a busy clinical environment (Thorpe, 2010). According to Henderson et al (2012), "students adopt strategies of 'learning the rules' and 'getting the job done' that 'fit' into the practice environment rather than adopting a critical reflective skill instead." When students taken for granted that reflection is less important compare to practical, they will become unwillingness to engage in reflection (Bowden, 2003). With these barriers that the students faced, it is hard to engage/convince them to use reflection in clinical environment.
Nevertheless, the success of using reflection as their practice to improve still exists. Students are able to use their feeling and self- awareness in delivering quality care to the patients. This indicated that reflection heightened students' awareness of their actions, thoughts, attitudes and feeling (Donovan, 2007). It also enables the students to reflect on their performances and helped them to handle the situation better next time. Studies have also found that reflection can enhance students' improves understanding of context, transforming perspectives, deepening understanding and re-appreciating the values of nursing (Mann et al, 2009). With that, students are able to use reflection to connect theory to practice and practice to theory. These will benefit and facilitates students to have more positive learning. With all these positive outcomes of using reflection, it will further enhances students to continue to use and practice reflection.
Reflection has been identified as important to the development of professional skills and enhancement of professional practice (Zimmerman et al, 2007). It is also valued as a lifelong learning for the students (Thorpe, 2010). The transition from the theoretical setting to the clinical education is a common time of apprehension for nursing students especially their first clinical posting (Maginnis & Croxon, 2010). They are novices that they do not have experience and lack of understanding when situation arises. When reflection is connected to theoretical knowledge and practical skills, students can use reflection to consolidate their experience with knowledge to draw the situation together (Hatlevik, 2012). Therefore, reflection is not merely a generic skill but rather a skill that depends on the relevant professional knowledge and experience (Hatlevik, 2012). Besides knowledge and experience of the students, it is important that cognitive and affective domains to stimulate reflection, which facilitator/educator needs to incorporate to promote reflection (Thompson et al, 2010). In summary, reflection is a beneficial strategy for helping students to learn from experience and merge into education, research and practice (Deutsch and Sherwood, 2008). Reflection also affects learner outcomes, and ultimately is to improve nursing practice, and create competent nurse where most research is needed.