Reflection as an Educational Strategy

Reflection as an Educational Strategy
in Nursing Professional Development
An Integrative Review
Robbin Miraglia, MSN, RN ƒ Marilyn E. Asselin, PhD, RN-BC
Reflection is a critical component of professional nursing
practice and a strategy for learning through practice. This
integrative review synthesizes the literature addressing the
use of reflection as an educational strategy and reports
outcomes from the use of reflective strategies. Reflection
education is primarily nested in programs to meet specific
clinical goals, structured with group facilitation. Findings
suggest that reflective strategies stimulate learning in
practice, enhance readiness to apply new knowledge,
and promote practice change.
INTRODUCTION
In recent years, reflection has gained increased recognition
as a critical component of professional nursing practice and
as an educational strategy to acquire knowledge and learn
through practice (Asselin & Fain, 2013; Kim, 1999; Perry,
2000). Although there is no agreed upon definition, reflection is generally understood as the deliberate process of
critically thinking about a clinical experience, which leads
to development of insights for potential practice change
(Asselin & Fain, 2013). Scholars contend that reflection offers nurses the opportunity to build on existing knowledge
through clinical experiences (Johns, 1995; Kuiper & Pesut,
2004; Perry, 2000), develop clinical judgment (Nielsen,
Stragnell, & Jester, 2007; Tanner, 2006), promote strong
communication skills, build collaborative practice, and improve patient care (Horton-Deutsch, 2012; Peden-McAlpine,
Tomlinson, Forneris, Genck, & Meiers, 2005).
Although it is generally assumed that nurses know how
to reflect, findings from recent studies suggest that nurses’
reflective thinking may be prolonged by pauses and they
may need assistance in systematically moving insights to
practice change (Asselin & Fain, 2013; Asselin, SchwartzBarcott, & Osterman, 2013). Consequently, continuing education on reflection and reflective practice is viewed as a
vehicle to enhance professional practice, promote evidencebased practice, and potentially improve patient outcomes.
As an educational strategy, reflection allows nurses to explore clinical experiences and the thoughts and feelings
associated with the experience, allowing for a change in
beliefs and assumptions, emergence of new knowledge,
and a transformation of clinical practice (Asselin & Fain,
2013; Dube & Ducharme, 2014; Horton-Deutsch, 2012;
Johns, 1995; Perry, 2000). Although numerous articles have
been published exploring the concept of reflection and the
use of reflection as an educational strategy, there has been
no attempt to synthesize existing literature presenting the
use of reflection as an educational strategy in nursing professional development (NPD). This article provides an
integrative review of the literature addressing the use of reflection as an educational strategy for nurses. The review is
focused on ways that reflection has been used as an educational strategy in NPD and reported outcomes from the
use of reflective education strategies.
BACKGROUND
The concept of reflection is not new to education; it has
long been appreciated as a means to develop knowledge,
beginning with the ancient philosophers Aristotle and Socrates. Modern day understanding of reflection has been
informed by the works of philosopher and educator John
Dewey. Dewey (1933) believed that learning took place as
a result of experiences and that reflecting on experiences
allowed connections to be made between thoughts, beliefs,
and actions. The work of Donald Scho¨n (1983) extended the
work of Dewey, focusing the concept of reflection on professional practice and further expanding the understanding
of how professionals think and develop insights as a result of
reflecting on experience. Scho¨n also introduced the notions
of reflection-in-action and reflection-on-action. Reflectionin-action is defined as the thought process that occurs as
an experience unfolds, guiding action with the experience
(Scho¨n, 1983). Reflection-on-action is defined as the process
of thinking back on an experience to gain new knowledge
or come to a new understanding (Scho¨n, 1983). Reflective
Robbin Miraglia, MSN, RN, is Doctoral Student, College of Nursing,
University of Massachusetts Dartmouth, North Dartmouth, and Clinical
Educator, Beverly Hospital, Massachusetts.
Marilyn E. Asselin, PhD, RN-BC, is Associate Professor, College of
Nursing, University of Massachusetts Dartmouth, North Dartmouth.
The authors have disclosed that they have no significant relationship with,
or financial interest in, any commercial companies pertaining to this article.
ADDRESS FOR CORRESPONDENCE: Robbin Miraglia, MSN, RN, 292
Putnam Street, Danvers, MA 01923 (e<mail: Rdmiraglia@verizon.net).
DOI: 10.1097/NND.0000000000000151
2.5 ANCC
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teaching strategies utilize the concept of reflection-on-action
or thinking back to structure new knowledge and understandings and to gain insights for practice change.
Reflection is the cornerstone of professional nursing
practice. Through reflection, nurses are able to make meaning of experience (Hartrick, 2000), connect theoretical
knowledge to the context of clinical practice (Jenkins,
2007), develop fresh insights, and modify clinical practice
(Bailey & Graham, 2007). There is a limited number of empirical studies that explore the use of reflection as an
educational strategy in the NPD setting. The paucity of empirical evidence warrants a closer examination of how we
are currently using reflection in NPD and what outcomes
are being reported.
PURPOSE/AIM
The purpose of this integrative review is to explore the
literature on the use of reflection as an educational strategy
in the postlicensure nursing population. The following two
questions guided the review: (a) In what ways has reflection been used as an educational strategy in NPD? (b) What
outcomes are reported for reflective educational strategies?
METHODS
The integrative review method outlined by Whittemore and
Knafl (2005) was used to synthesize the literature on reflection. This method allows for exploration of both empirical
and theoretical literature and has the potential to inform
evidence-based nursing practice and direct future research.
Steps in the integrative review include problem identification, literature search, data evaluation, and data analysis
(Whittemore & Knafl, 2005). As stated earlier, there is a
need to identify the ways in which reflection has been used
as an educational strategy, explore the outcomes of reflective educational strategies, and identify recommendations
for future research.
Search Strategy
Literature published between 1985 and December 2013
was reviewed using the Cumulative Index to Nursing and
Allied Health (CINAHL), Education Resources Information
Center (ERIC), and MEDLINE databases. The search terms
‘‘reflection,’’ ‘‘professional development,’’ ‘‘staff development,’’ and ‘‘nursing’’ were used. Hand searching of the
Journal for Nurses in Professional (Staff) Development
and Journal of Continuing Education in Nursing was also
done. Ancestry searching was completed from the reference lists of identified key articles.
Search findings were reviewed for primary empirical
studies exploring the use of reflection as an educational
strategy in NPD and publications that discussed the use
of reflection as a defined process and a deliberate educational strategy in the clinical practice setting. Gray literature
(conference proceedings and dissertations) was not
reviewed for inclusion. Simulation literature was not included in the review; although the debriefing component
has threads of reflection, reflection is often not described as
a defined and deliberate process within the debriefing. Inclusion criteria for published works included (a) works in
English and (b) empirical and nonempirical works that explored the application of a reflective educational strategy
with postlicensure nurses in a clinical setting. Publications
were excluded that (a) focused on the use of reflection in
the student nurse population; (b) described personal reflective exemplars; and (c) discussed the process of reflection,
without application of reflection as an educational strategy
in a clinical setting.
Five hundred fifty-three articles were reviewed using
the stated inclusion and exclusion criteria; 179 records
were excluded after a review of titles and abstracts. The first
author assessed 326 full-text articles for eligibility, consulting with the second author when there was a question about
eligibility; 301 full-text articles were excluded. Twenty-five
articles subsequently met inclusion criteria, serving as the
sample to address the research questions (see Table 1 for
a summary of articles included in the review).
Quality Appraisal
The quality of the empirical data was evaluated using a tool
developed by Hawker, Payne, Kerr, Hardey, and Powell
(2002). The revised appraisal tool scored nine methodological criteria as ‘‘good,’’ ‘‘fair,’’ ‘‘poor,’’ or ‘‘very poor’’ with
the authors attributing numerical scores of 1 (very poor)
to 4 (good). The scores from this tool were converted to
‘‘high’’ (4.0Y3.0) or ‘‘low’’ (2.9Y1.0). The nonempirical articles were evaluated on their relevance in answering the
questions guiding the search and analysis and were classified as ‘‘high’’ or ‘‘low.’’ The first and second authors
independently rated one third of the articles and compared
scores; high interrater reliability was established. The first
author then independently evaluated the remainder of
the articles, consulting the second author if there was a
question about the quality or relevance of an article.
The range of quality scores for the empirical studies was
3.33Y4.0, and the range of relevance scores for the nonempirical studies was 2Y4. None of the reviewed studies
were excluded from the review because of rank. Articles
scoring ‘‘high’’ were used to develop the main themes
throughout the analysis; articles scoring ‘‘low’’ were used
to support and further develop the themes to answer the
questions.
DATA ANALYSIS
The first author read each article separately, noting patterns
and themes addressing identified questions, and recorded
data in a matrix format. The second author was consulted
with emerging themes and asked to validate content and
synthesis of themes. Articles that ranked low in relevance
Journal for Nurses in Professional Development www.jnpdonline.com 63
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TABLE 1 Summary of Articles Included in Integrative Review
Author/s (Year), Country Sample Setting Reflective Strategy Outcome
1. Asselin and Fain (2013),
United States
Twenty RNs from two acute
care community hospitals in
Northeastern United States
& Three-part reflective practice
CE program
& Structured reflection increases
nurses’ engagement in
self-reflection and enhanced
reflective thinking
in practice.
& Structured reflective narratives
& Researcher-facilitated group
discussions
2. Bailey and Graham
(2007), Ireland
Eight palliative care nurses
(only seven completed)
& Eight 2.5-hour sessions to
introduce, facilitate, and
evaluate guided reflective
practice
& Guided reflection allowed
staff to meet away from the
clinical environment and
work together to ‘‘find fresh
insights to inform practice.’’
& Structured reflective diary
keeping
& Supporting reflective practice
is a strategy to support
palliative care nurses. & Educator-facilitated group
reflection
3. Curry, Middleton, and
Brown (2009), Ireland
Four nurses and eight care
assistants in two
nursing homes
& Four modules based on
palliative care, communication,
pain and symptom management,
and bereavement care
& This project has enhanced
provision of palliative care
to residents.
& Staff reported increased
confidence in their roles;
increased knowledge about
palliative care; improved
morale and motivation; and
change in awareness regarding
value of knowing residents,
importance of listening, value
of building relationships with
families, and importance of
a person-centered approach
in palliative care.
& Facilitated reflective learning
groups
4. Dube and Ducharme
(2014), Canada
Twenty-one nurses at five
medical/surgical care units
at university hospital
& Eight workshops with content
on reflective practice and
interventions relating to
medication, mobilization, and
discharge planning of
older adults
& Experimental group had
significantly more positive
attitudes regarding older
adults after reflective
practice intervention.
& Experimental group
significantly improved
knowledge of older adults
without a significant change
in the control group.
& Structured reflective journal
assignments
5. Edwards, Holroyd,
Rowley, Taylor, and
Unwin (2005), Australia
Four RNs 30Y45 years old,
10Y15 years of clinical
nursing experience
& Embedded into action
research project
& Action research and reflection
are practice processes for
nurses to examine their
practice issues and improve
nursing care. An action plan
was generated for improving
assertiveness at work.
& Written journal reflections of
practice experiences (using
participant observation)
& Researcher-facilitated group
discussions
Continued
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TABLE 1 Summary of Articles Included in Integrative Review, Continued
Author/s (Year), Country Sample Setting Reflective Strategy Outcome
6. Forneris and Peden-McAlpine
(2007), United States
Six novice nurseYpreceptor
dyads
& Embedded into contextual
learning intervention
& Three themes were
developed to describe the
novice nurses’ development
of critical thinking. Contextual
learning can be a model of
clinical learning in nursing
education that develops
components of critical
thinking.
& Structured reflective journaling
& Facilitated discussion groups
7. Gamble (2001),
United Kingdom
Nurses from a large medical
units (medical assessment
unit, cardiac care unit, and
eight medical wards)
& Structured debriefings after a
cardiac arrest
& Debriefing gives nurses the
ability to acknowledge their
emotional response to the
experience and identify
learning needs.
8. Gustafsson and Fagerberg
(2004), Sweden
Four female nurses from
diverse clinical areas
(psychiatry, nephrology,
intestinal surgery, and
vascular surgery)
& Structured interviews focused
on the implications of the
nurses’ reflections
& Reflection may promote
nursing professional
development and develop
nursing care.
9. Hart et al. (2000), Australia Ninety-five RNs at six
different hospitals, 74 nurses
successfully finished one of
the programs
& 14-week program & Participants showed
improvements in their
empathetic responses to
patients, their sense of
hope, and some aspects of
their work environment.
& Peer consultation
& Group discussions
10. Hart, Yates, Clinton, and
Winsor (1998), Australia
Registered nurses working
with terminally ill patients
& Written practice incidents
using reflective framework
& Shared and collaborative
approaches to the planning,
implementation, and
evaluation of nursing care
were emphasized.
& Group discussion & Creative solutions and
collective actions were
developed to address
complex organizational
issues.
11. Hartrick (2000), Canada Multidisciplinary team of
pediatric healthcare
practitioners
& Embedded within four
educational activities
& Team members were able to
make meaning of their
experiences and theoretical
ideals of health promotion
and begin to transform their
understandings and actions.
& Structured questionnaires
and journaling
& Reflective group dialogues
12. Holdsworth, Belshaw,
and Murray (2001),
United Kingdom
Thirteen nurses working in
four A&E departments, two
minor injury units, and two
MAUs
& Embedded within five half-day
workshops
& Increased knowledge and
skill related to the assessment
of an immediate management
of deliberate self-harm.
& Participants completed
‘‘Summary Diary Sheets’’ with
information about patient,
triage, and outcomes where
analyzed.
& Decreased level of
work-related stress
Continued
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TABLE 1 Summary of Articles Included in Integrative Review, Continued
Author/s (Year), Country Sample Setting Reflective Strategy Outcome
13. Jenkins (2007),
United Kingdom
A nurse lecturer and a team
of district nurses
& Embedded within cooperative
inquiry
& Participants linked theory
and practice, made sense of
experience, and improved & Facilitated, structured group work dynamically. reflections
14. Kemp (2009),
United Kingdom
Thirteen and 5 staff nurses
from two adjacent acute
inpatient wards
& Embedded within workshop
with multiple sessions
& Increased team identity,
increased time spent with
service users (patients)
& Reflective diaries & Participants reported feeling
more assertive, increased
level of confidence, and
gaining more effective skills
that allowed them to be
more supportive for patients.
& Facilitated group reflection
15. Kuiper (2002),
United States
Thirty-two new graduate
nurses on clinical units
& Structured, reflective journals & Using self-regulation reflective
strategies would encourage
metacognitive strategies and
implies a benefit for learning
flexibility and adaptability.
16. McDonald, Jackson,
Wilkes, and Vickers
(2012), Australia
Fourteen nurses and
midwives
& Embedded within six
structured workshops
& Outcomes included closer
group dynamics, more
supportive communication,
and assertiveness and
confidence in the
clinical setting.
& Facilitated group discussion & Analysis also suggested growth
in participants’ knowledge of
personal resilience and
willingness and ability to
monitor and maintain resilience
strategies for themselves and
their colleagues.
17. Oyamada (2012), Japan Fourteen midcareer nurses
employed in three hospitals in
Japan(5Y15 yearsof experience)
& Structured reflective narratives & A change in frame of
reference was noted in
two participants.
& Facilitated group discussions & Ten participants reported a
change in practice.
18. Peden-McAlpine,
Tomlinson, Forneris,
Genck, and Meiers
(2005), United States
Eight pediatric critical care
nurses in two children’s
hospitals in the Midwest
& Embedded within reflective
practice intervention
& Stimulated a change in
attitudes about family,
enhanced communication
with families, and an
integration of family care
into nursing practice
& Written narratives
& Reflective discussions
19. Peterson, Hakendorf, and
Guscott (1999), Australia
Fifteen nurses from 10 health
units in rural settings
& Embedded within a six-module,
problem-based course
& Nurses developed a holistic
view of aged care. Journaling
enabled participants in
reflecting on their practice.
Nurses were motivated to
make changes in their
workplace.
& Structured journals
Continued
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were then read and analyzed; data from these articles were
used to support themes developed from the articles ranking high in relevance and rigor. Key patterns identified in
the literature were clustered as appropriate and summarized in narrative format.
FINDINGS
The final sample of articles represented the use of reflection in eight countries: United Kingdom (n = 6); Australia
(n = 6); United States (n = 5); Canada (n = 3); Ireland (n =
2); and one each from Japan, Sweden, and Switzerland.
The population of nurses described had clinical nursing experience spanning a broad range of years. Most articles had
no purposeful sampling of defined years of experience;
however, several articles explored reflection in specific
nursing populations from the new graduate level (Kuiper,
2002), to novice nurses with less than 6 months of experience
(Forneris & Peden-McAlpine, 2007; Rosenal, 1995), to
midcareer nurses with 5Y15 years of experience (Oyamada,
2012).
Eleven articles highlighted the use of reflective educational strategies across diverse clinical practice settings,
TABLE 1 Summary of Articles Included in Integrative Review, Continued
Author/s (Year), Country Sample Setting Reflective Strategy Outcome
20. Rittman (1995),
United States
Nurses working in a hospital
setting; no stated numbers
& Narratives and group
interpretive analysis
& Narratives and interpretive
analysis proved a powerful
staff development approach
as recognition is given to
the expertise and meaning
within clinical nursing
practice.
21. Rosenal (1995), Canada Novice nurses with less than
6 months of experience
& Structured, reflective narratives & Critical incident methodology
can be used in nursing
education to foster
self-reflection, inform educators
of the reality and impact of
nurses’ experiences, conduct
learning needs assessments,
and gather exemplars for
teaching purposes.
Twenty-five nurses who
served as preceptors
Both populations were
employed in a pediatric
health center.
22. Sewell et al. (2006),
United Kingdom
Two diabetes nursing teams
in two secondary care trusts
in the United Kingdom
& Combined with collaborative
partnership and mentoring
& Regular, critical evaluation
of critical care is important
in care delivery, service
development, and
professional development.
& Structured reflection
23. Turner (2009),
United Kingdom
Twelve psychiatric nurses & Embedded within action research & An audit showed that
children’s needs were
considered and information
was appropriately shared
to safeguard children.
& Reflective sessions
24. von Klitzing (1999),
Switzerland
Seven female nurses on one unit & Nested within Baliant group & Nurses selected terminally ill
patients for group discussions,
reflective functions increased
throughout the year, and
nurses’ reflections about self
declined significantly
over time.
& Group discussion
25. Walker, Cooke, Henderson,
and Creedy (2013);
Australia
Fifty-six nurses, 33 students,
and 1 clinical supervisor in
two acute care hospital
wards
& Embedded within concept of
learning circles
& Learning circles provided
participants the sense of
security enabling them to
voice concerns around
10 identified personal
and professional practice
themes.
& Facilitated, structured group
discussion
Note. RNs = registered nurses; CE = continuing education; A&E = accident and emergency; MAUs = medical admissions units.
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from acute care hospital-based units to clinical office practices. Four articles explored the use of reflection to address
the needs of nurses working in palliative care or with terminally ill patients. Three articles addressed the use of reflective
strategies within the setting of mental health/psychiatric care.
In addition, the use of reflective strategies has been reported
in elder care (Dube & Ducharme, 2014; Peterson et al., 1999),
family practice (Hartrick, 2000), and maternity/pediatric
settings (McDonald et al., 2012; Peden-McAlpine et al., 2005).
Reflection as an Educational Strategy in NPD
Two themes emerged from the synthesis process related to
the goal or intent of the reflective educational strategies:
using a reflective strategy to meet a specific clinical practice
goal and teaching nurses how to reflect to enhance individual reflective practice. Seventeen articles described using a
reflective strategy as a means to meet a specific clinical
practice goal. For example, Turner (2009) developed a mandatory training program that included a reflective strategy
to enhance healthcare providers’ ability to meet patients’
mental health needs. Kemp (2009) developed a workbased initiative that included reflective diaries to enhance
therapeutic communication with service users in acute
mental health settings.
Six articles described the process of teaching nurses
how to reflect to promote reflective practice, insight, and
reflective thinking (Asselin & Fain, 2013); explore the benefit of reflective programs for midcareer nurses (Oyamada,
2012); promote reflective practice through group-guided
reflection (Bailey & Graham, 2007); gain deeper levels of
reflection on clinical practice (Edwards et al., 2005); explore
the impact of reflective journaling on the metacognitive
process (Kuiper, 2002); and describe the experience of reflection in relation to nursing and understand how nurses
reflect (Gustafsson & Fagerberg, 2004).
Three themes emerged regarding the way in which reflection was used as an educational strategy: reflection
nested into multifaceted educational programs, individualversus group-facilitated reflection, and structured versus
unstructured reflection. Although one may argue these are
not mutually exclusive in each reflective strategy, they represented three delivery approaches worthy of discussion.
Nested reflective strategies
Of the articles that addressed the use of reflection to meet a
specific clinical practice concern or to impact individual reflective practice (n= 19), most (n= 12) described multifaceted
educational programs that nested a reflective teaching strategy in the program to meet a program goal. In these programs,
information pertinent to the clinical practice setting and educational goals of the project were presented to participants
and paired with a reflective educational strategy. Although
not all authors explicitly stated why reflective strategies
were added to multifaceted programs, pairing a reflective
strategy with the presentation of new knowledge, mentoring, and other educational strategies were used to stimulate
learning in practice and develop tactic knowledge (Turner,
2009), result in a change in behavior, enhance readiness for
application of new knowledge (Hartrick, 2000; Sewell
et al., 2006), prepare nurses to ‘‘tackle problems in the real
world’’ (Curry et al., 2009, p. 21), and implement practice
solutions (Edwards, Holroyd, Rowley, Taylor, & Unwin,
2005). In addition, Kemp (2009) stated that participants
highly valued reflection on practice experiences to further
enhance learning.
The remaining seven articles explored the impact of
reflection as a stand-alone educational strategy to meet
an educational goal or improve individual reflective practice (Asselin & Fain, 2013; Bailey & Graham, 2007; Gustafsson
& Fagerberg, 2004; Hart et al., 1998; Kuiper, 2002; Oyamada,
2012; Walker et al., 2013).
Individual versus group reflection
Twenty articles discussed the use of group dialogues or discussions as the foundation of reflective educational strategies.
In roughly half of the 20 articles presenting the use of group
discussions (n = 11), participants were first asked to write a
reflective narrative on a clinical situation about which they
had given considerable thought; the written narrative was
then discussed in a group setting. In the remaining articles
presenting the use of group discussions (n = 9), participants reflected on clinical stories or experiences supplied
by the educator or researcher. The remaining three articles
presented reflective interventions focused on individual
written narratives designed to explore a clinical experience
(Kuiper, 2002; Rittman, 1995; Rosenal, 1995). The reflective
narratives were only shared with the researcher or educator and resulted in learning or expanded understanding for
the individual who contributed the narrative.
An additional notion within the theme of reflective
group discussions was the use of a facilitator to guide
and direct the reflective dialogue. Twelve articles discussed
the use of facilitators to guide, direct, and expand the reflective exploration of shared narratives in the group
setting. Of these 12 articles, one used participants from
within the peer group to serve as facilitators, rotating the
role of the facilitator among group members (Jenkins,
2007). In four articles, educators (n = 3) or nurse leaders
(n = 1) served as facilitators. Four articles discussed the role
of the facilitator being filled by nurse researcher (n = 3) or
external clinical nurse specialist (n = 1). The remaining
three articles did not clearly describe who served in the role
of facilitator for the group dialogues.
Structured versus unstructured reflection
Prescriptive models or frameworks, including structured
questions cues, can be used to provide guidance and structure to the reflection exercise. Of the articles that asked
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participants to reflect on a clinical narrative (n = 24), nine of
the articles described the reflective strategy without mention of a guiding reflective framework or model. Most (n
= 15) articles described the use of a reflective model or
structured questions to provide guidance with the exploration of a clinical experience.
Nine articles described researcher- or educator-developed
questions created to guide the reflective process. For example, Oyamada (2012) developed structured reflective
questions aimed at encouraging midcareer nurses in Japan
to uncover the validity of their own values and assumptions. Peterson et al. (1999) developed questions to focus
on issues and concerns embedded within the context of
their clinical practice. Gustafsson and Fagerberg (2004) developed guiding questions based on findings from nursing
literature and critical thinking attributes to prompt novice
nurses in reflective journaling.
Six articles described educational interventions shaped
around existing reflective frameworks or models. Bailey
and Graham (2007) and Dube and Ducharme (2014) utilized Johns’ (2006) model for structured reflection as the
guiding framework for reflective narratives. Sewell et al.
(2006) and Hart et al. (2000) each presented reflective processes that were informed by the work of Boud, Keogh,
and Walker (1985). Asselin and Fain (2013) developed
their reflective intervention based on the Critical Reflective
Inquiry Model (Kim, Lauzon Clabo, Burbank, Leveille, &
Martins, 2010). Finally, Walker et al. (2013) adapted and
relabeled the four-step model of critical reflection (Noble,
Macfarlane, & Cartmel, 2005) and used it as a framework for
reflection in group discussions.
What Outcomes are Reported From Reflective
Educational Strategies?
Outcomes of the reflection education were reported in
11 research-based articles and 14 articles describing reflection education. Authors of four articles, one quantitative
and three mixed methods research, reported the use of measurement tools that captured the outcome data needed to
explore the impact of reflection on the identified research
question (Asselin & Fain, 2013; Dube & Ducharme, 2014;
Hart et al., 2000; von Klitzing, 1999). One secondary analysis
developed qualitative themes using research study field
notes (Walker et al., 2013). The six qualitative articles
reported thematic outcomes developed and synthesized
from qualitative data provided by study participants (Edwards
et al., 2005; Forneris & Peden-McAlpine, 2007; Gustafsson &
Fagerberg, 2004; Kuiper, 2002; Oyamada, 2012; PedenMcAlpine et al., 2005).
The outcomes reported in the 14 articles describing reflection education were most often linked to the goals of
the education and frequently gathered through program
evaluation questionnaires and self-report measures. Findings from this review highlighted an increase in knowledge
and two additional themes within the reported outcomes of
reflective strategies: the role of reflection in changed attitudes,
values, beliefs, and assumptions of individual participants and
the potential for group reflective strategies to make a meaningful impact at the organizational level.
All of the articles within the final sample reported outcomes at the individual participant level; the use of reflective
strategies resulted in increased knowledge (Bailey & Graham,
2007; Curry et al., 2009; Dube & Ducharme, 2014; Peterson
et al., 1999; Rosenal, 1995; Sewell et al., 2006); enhanced
clinical skills (Curry et al., 2009; Dube & Ducharme, 2014;
Holdsworth et al., 2001; Kemp, 2009; Peterson et al., 1999;
Turner, 2009); and/or changed attitudes, beliefs, or assumptions (Hart et al., 2000, Hartrick, 2000; McDonald et al.,
2012; 1998).
Beyond the transfer of knowledge and the enhancement of clinical practice, reflection allows participants the
time and space to explore the values, beliefs, and assumptions that drive clinical action. Twelve of the articles discussed
the impact that the educational intervention had on the participant’s values, beliefs, and assumptions. Hartrick (2000)
found that reflection education supported the development of health promoting family practice. Authors reported
that critical reflection allowed practitioners to explore the personal biases they carried into practice and the ways in which
these biases impacted their practice of providing familycentered care. The transformed understandings led to transformed practice.
Authors reported that, when reflection occurred as a
group process, there was the potential to enhance teamwork and impact organizational-level practice. In a supportive,
collaborative practice environment, group reflection aided in
exploration of practice issues and concerns and empowered
staff to own individual practice and drive practice change
(Curry et al., 2009). Hart et al. (1998) presented the belief
that group reflective discussions about practice contribute
to the collective culture of nursing care and that the outcome
of reflection has the most organizational impact when
shared experiences, rather than individual experiences,
are the focus of reflection.
DISCUSSION AND IMPLICATIONS
FOR NPD
As noted in the findings, reflection is often nested in multifaceted educational programs making it a challenge to
identify key articles through database searches. Despite
reviewing an extensive number of articles for inclusion, it is
possible that key articles addressing the research questions
were not identified through utilized search methods.
The findings from this integrative review offer several
important implications for NPD specialists. Nurses reported
positive impact from participating in reflective education
(Bailey & Graham, 2007; Kemp, 2009; Rittman, 1995); however, not all nurses are equally skilled in reflection (Asselin &
Journal for Nurses in Professional Development www.jnpdonline.com 69
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Fain, 2013; Clark, 2009; Perry, 2000; Rosenal, 1995). Many of
the articles within the final data set explored a reflective
component within an educational program without teaching
nurses about reflection or how to reflect on clinical experiences. Perhaps, it has been assumed that reflection is an
intuitive process. To achieve intended outcomes from reflective strategies, it may be beneficial to expose nurses
to content focusing on the process and benefits of reflection
before expecting them to engage in reflective learning
(Walker et al., 2013). NPD specialists should consider including education on reflection in orientation, preceptor/
team leader training (Asselin & Fain, 2013), new graduate
nurse programs, and educational programs that contain reflective strategies.
NPD specialists may find that providing nurses with a
guiding reflective framework, or model, will facilitate a reflective process that can be incorporated in practice and
ultimately result in enhanced learning, improved professional practice, and better patient outcomes (Asselin &
Fain, 2013; Johns, 1995; Peterson et al., 1999). In addition
to providing a guiding structure for exploring a clinical experience, a reflective model or framework may prevent
nurses from getting stuck in the reflective process (Asselin
et al., 2013; Jenkins, 2007). In the absence of a formal reflective framework, providing individuals with guiding
questions or prompts may assist in the development of
higher level thinking (Kuiper, 2002).
Group reflective discussions have been found to assist
individuals in reaching a deeper level of exploration (Asselin
& Fain, 2013; Hart et al., 2000; Jenkins, 2007). Although there
is some risk in sharing personal experiences in a group setting (Holdsworth et al., 2001), findings from this review
highlighted the belief that group reflection in a safe and secure setting (Jenkins, 2007; Peterson et al., 1999; Walker
et al., 2013) can validate (Jenkins, 2007) and empower
(Hart et al., 2000) nurses. Group reflection can also lead to
individuals uncovering more objective truths (Jenkins, 2007).
Hart et al. (1998) suggest that group reflection on practice
contributes to a culture of nursing care, with the potential
for eventual organizational change.
In the reviewed articles, authors noted that the support
of a facilitator was valuable in reflective group discussions
(Bailey & Graham, 2007). To create the safe and supportive
environment necessary to encourage open and engaged
learning in a group setting, it is critical that the facilitator
be skilled and sensitive (Kemp, 2009). The role of facilitator
was filled by a broad range of individuals, including peers,
nurse researchers, and clinical educators. Whereas Jenkins
(2007) found that peer facilitation was valued by the group,
others found that the role of the facilitator would be best
filled by an outsider (Kemp, 2009). Facilitators who are perceived to have power or authority over the group may impact
comfort level of the group and may hinder the openness and
sharing that occurs during reflective discussions (Bailey &
Graham, 2007). The role of facilitator is critical in developing the safe and secure environment necessary to engage
staff in a transparent exploration ofself. In selecting afacilitator,
it will be important to consider the skill, training, and perceived power of the individual chosen (Bailey & Graham,
2007; Gamble, 2001; Kemp, 2009; McDonald et al., 2012).
Including reflective strategies within educational programs
may assist staff to make meaning of experience (Hartrick,
2000), gain fresh insights, and inform practice (Bailey &
Graham, 2007). As a nested strategy, reflection enables
nurses to link new knowledge to the context of clinical
practice and facilitate practice change (Peterson et al.,
1999). Reflection enables individuals to explore and challenge the beliefs, assumptions, and values that guide their
clinical practice (Hart et al., 2000, Hartrick, 2000; McDonald
et al., 2012; 1998). Ultimately, it is this transformed awareness that leads to fresh insights and informed practice
(Bailey & Graham, 2007).
IMPLICATIONS FOR FUTURE RESEARCH
Although it is generally understood that reflection offers
nurses the ability to learn from their clinical experiences,
there is a dearth of empirical evidence to support the use
of reflection as an educational strategy. There is a need for
rigorous, well-designed empirical studies exploring the impact of reflection on individual professional practice, organizational change, and patient outcomes. This integrative
review illuminated some questions that could be explored
more thoroughly. Examples include such questions as follows: Does individual reflection promote the same level
and depth of reflection as group reflection? What is the role
of the facilitator in guided reflection? What role is most effective for NPD specialists in assisting staff to gain skill in
reflective practice? What is the role of reflective models in
framing the clinical experience? What reflective frameworks
or models are most effective in transforming a clinical experience into a learning event? In what ways can reflection
enhance patient safety or nurse sensitive outcomes? Does
interprofessional reflection enhance team communication
and collaboration? Is interprofessional reflection more effective than discipline-specific reflection in achieving
patient outcomes? In what ways can reflection impact
organizational change?
There is also a need to develop a measurement tool to
assess reflection. Developing tools that effectively measure
the impact of reflective educational strategies would enable
findings to be generalizable beyond the specific setting and
educational goal explored.
CONCLUSION
Reflection is a deliberate process of critically thinking about
a clinical experience to develop new insights and transform
clinical practice. Frequently nested within a multifaceted
educational program, reflective educational strategies paired
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with presentation of clinically relevant knowledge, mentoring, and other educational strategies stimulate learning in
practice and enhance readiness for application of new
knowledge into the clinical setting. Structured reflection
and facilitated group reflective dialogues offer nurses the
opportunity to reach a deeper level of exploration and
arrive at a higher level of thinking.
Reported outcomes suggest that reflection impacts clinical practice at both the individual and organizational level.
At the individual level, reflection enhances knowledge;
transforms assumptions, values, and beliefs; and informs
clinical practice. At the organizational level, reflection empowers nurses to explore practice concerns and drive practice
change. Although reflection is appreciated as a way to learn
through practice, more empirical evidence is needed to support the use of reflection as an educational strategy. As stated,
future nursing research could focus on developing rigorous
studies to explore the design, impact, and utility of reflective
learning strategies within the context of NPD and interdisciplinary patient care.
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go to NursingCenter.com\CE.
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