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.

Those Who Can’t, Teach


A familiar phrase, and one that I think about often as I teach. It is appropriately humbling, an antidote to hubris. The phrase originates from George Bernard Shaw’s play “Man and Superman: A Comedy and a Philosophy,” from the main character’s “Maxims for Revolutionists.” The phrase is included in a section on education and reads, “He who can, does. He who cannot, teaches.” It is accompanied by: “A fool’s brain digests philosophy into folly, science into superstition, and art into pedantry. Hence, a university education.”  In his lengthy introduction to the play, Shaw writes, “(…) what we call education and culture is for the most part nothing but the substitution of reading for experience, of literature for life (…).” Shaw had a very unhappy childhood educational experience in Dublin, Ireland, was largely self-taught while living in London, and became a life-long ardent believer in socialist reforms.

In a practice discipline such as nursing, the tension between education and practice—between teaching and doing—is ever present. Further complicating this tension is the emphasis on nursing research in university-based nursing schools. Nursing is considered a minor (or wanna be) profession. As Patricia Benner and her co-authors state in their book Educating Nurses: A Call for Radical Transformation (Jossey-Bass, 2009), for the past thirty years nursing faculty and administrators have focused most of their attention on developing nursing research. Benner attributes this to the pressure to increase the prestige of nursing within academic settings. I am still unclear just what “nursing research” does to increase the prestige of nursing—or even what it means. Is nursing research any research having to do with nursing practice or workforce issues? Is it any research having to do with anything as long as it is led by a nurse?  I gave up teaching nursing research because I felt like a hypocrite since I didn’t understand or value it. In my experience, research methods classes taught in schools of nursing are not very rigorous, especially when compared with research methods courses in schools of public health or psychology.

Now nursing practice I do understand and value. I am an accidental nursing educator, and an occasional health services researcher. My first and real love is clinical work as a nurse practitioner. To apply Shaw’s maxim: I can and I do, but I also can’t and I teach. While my students value this clinical relevance, it isn’t valued within my school of nursing. This isn’t unique, as I hear a similar lament from my nurse educator colleagues at other top-rated schools of nursing. It also isn’t unique to nursing, as my academic physician friends tell me the same thing happens in schools of medicine.

Both the Educating Nurses and the IOM Future of Nursing Report emphasize the need for lessening the existing disconnect between classroom theory and clinical practice in nursing education. They point out that many nurse educators have not practiced nursing in many years and, therefore, have a hard time including appropriate classroom experiential learning. Much of nursing theory courses are taught with an overreliance on endless PPTs, busy work, and an emphasis on rote memorization. Nurse educators teach the way they were taught. It is not teaching; it is torture.

One of the most influential books on my own teaching of nursing is Donald Shon’s Educating the Reflective Practitioner (Jossey-Bass, 1987).  It doesn’t mention nursing at all, but is nonetheless applicable to nursing education. In the book he talks about professional practice as more of an art that a science, and emphasizes the teaching of reflection-in-action, a sort of higher-level critical thinking.

Here is his opening paragraph from the book:

“In the varied topography of professional practice, there is a high, hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the application of research-based theory and technique. In the swampy lowland, messy, confusing problems defy technical solution. The irony of this situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest might be, while in the swamp lie the problems of greatest human concern. The practitioner must choose. Shall he remain on the high ground where he can solve relatively unimportant problems according to prevailing standards of rigor, or shall he descend to the swamp of important problems and nonrigorous inquiry?”

Contrast this with an unfortunate statement in Educating Nurses: “Critical thinking alone cannot develop students’ perceptual acuity of clinical imagination; and cynicism and excessive doubt are often the by-product of the over-use of critical thinking.” The authors have obviously misunderstood the definition of “critical” as applied to critical thinking, where “critical” is understood to be the “exercising of careful judgment or observation.” It is having an inquisitive spirit, questioning underlying assumptions—including one’s own assumptions—of being able to think about thinking. Critical thinking is the opposite of Shaw’s fool’s brain and is necessary for effective swamp work, the terrain of most nursing practice.