On Reflection

Noonday Taking A Horse To Water
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In August people check out. While sitting in various meetings this past week, I noticed that even the people who show up in August are mentally checked-out. This was an even more pronounced pattern when I lived on the east coast—for us lefties, every month is a laid-back sort of month. Luckily for me my (noisy) neighbors have checked-out for the week, all packed away on a camping trip. I can hear my bamboo growing. I can hear myself think.

I’m metacogitating: thinking about thinking. If it is anything like thinking about walking up stairs while walking up stairs (and tripping as a result), this could be dangerous. That leads me to reflection and what it means to be a reflective practitioner (of any sort), and why reflective practitioners are important to have in health care.

Two things led me to this topic this week. First, I am on an interprofessional health sciences service-learning group where we discussed ways to encourage meaningful student reflection. Donald Schon’s The Reflective Practitioner was invoked, along with reflective journaling, Rita Charon’s parallel chart, and various narrative medicine sorts of activities. Second, I had a psych nurse ask me why we don’t have nursing students do IPRs anymore. I had to reach back into the scary dark recesses of my brain to even know what he was talking about. Interpersonal Process Recordings—a long and tedious process of reconstructing a nurse-patient interaction, complete with dialogue and non-verbal cues—and then written self-reflection on what went well/didn’t, why, and what could be done better next time. I remember writing IPRs for my psych BSN course. Typically, five minutes of conversation resulted in at least seven pages of writing and reflection and hours of work. Not surprisingly, IPRs originated in psychology and social work counseling programs and were then adopted by nursing. IPRs are intended to be used within counseling supervision—trainees meeting with seasoned clinicians to develop self-assessment and communication skills. IPRs in nursing education have been more in line with creative writing—confabulation—made up dialogue—and aren’t typically discussed with, but are merely written up and handed to the instructor. I don’t remember confabulating my IPRs, but I didn’t discuss them with my instructor—thankfully, as my psych clinical instructor wasn’t exactly a model of good communication (or of good mental health for that matter). I am intrigued by research findings I ran across indicating that the more nursing education students have, the worse their communication/interpersonal skills become. (Harrison, et al. “Assessing NursesCommunication” Western Journal of Nursing, 1989). I’m not sure if this study has been replicated on a larger scale and using longitudinal data, but it would explain so much in my life….

Proponents of reflective thinking go way past Schon, to Dewey and Lewin, and back to Socrates. Reflection is a key component of critical thinking—critical thinking being outcome-oriented analysis and an ability to examine a situation from multiple perspectives. Critical thinking and reflective thinking are essential skills for nurses. Health care workers have to make numerous complex decisions affecting patient care. Generally these decisions have to be made quickly, with incomplete and imperfect information. Thinking on your feet or reflection-in-action is a necessary clinical skill—and not lapsing into short cuts or inattention, because that’s where medical errors often occur. Reflective practice contributes to self-assessment and life-long learning—essential for continuing competence of health care workers.

But how do you really teach critical thinking and reflective thinking? By looking through many nursing school syllabi and reading the course objectives, you’d think that critical thinking skills were well covered. However, when you look at what is actually done in those classes and how students are evaluated, it is almost exclusively targeted at ‘lower-order thinking’ in Bloom’s revised taxonomy of thinking: remembering. In clinical nursing courses, the learning goes higher from understanding to applying—and sometimes eking into analyzing. This leaves the ‘higher order’ levels of thinking of evaluating and creating untouched. These are the levels of learning where reflection really kicks in. In my experience teaching nursing at the BSN level, there simply is not enough time or space for teaching to higher order thinking. Basic skills (“Bedpans 101”) of med-surg types of things—the remembering and the applying take precedence. Then there is the issue of raw material to work with, the leading a horse to water sort of conundrum. You can’t encourage the development of higher order thinking in nursing students if they don’t want to drink from that trough.

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