Editorial
On nursing's 'reflective madness'
Jennifer Greenwood
Professor of Nursing, Western Sydney Area Health Service, University of Western Sydney, Nepean NSW
PP: 3
Article Text
The world of nursing seems to have gone 'reflection-mad' in that its embrace of reflection and reflective practice appears a little unbalanced. Reflection seems to be the answer to all of nursing's and nursing education's ills. It is claimed to enable nurses, among many other things, to develop their individual theories of nursing (Emden, 1991; Reid, 1993), to facilitate the integration of theory and practice (Landeen et. al. 1995), to heighten the visibility of the therapeutic work of nurses (Johns, 1994, 1995) and to lead to an understanding of the conditions under which nurses work and, in particular, the barriers that limit a nurse's therapeutic potential (Emden, 1991; Johns, 1994, 1995). The fact that people claim that reflection can achieve all this has led, in my view, to its sometimes well-intentioned but ill-considered introduction in both undergraduate and post-graduate nursing education.
Training in reflection
To begin with, there is now evidence that nurses require time to reflect (James & Clark, 1994; Scanlon, 1995) and training in reflection. Lack of training is clearly responsible for nurse educators' lack of knowledge on both how to reflect and how to assist students to reflect (Atkins & Williams, 1996; Haddock, 1997). Neither of these important resources are apparently considered when reflection or reflective practice is being introduced into nursing curricula. This is a mistake; reflection is a highly sophisticated intellectual skill and, like all skills, generally requires learning through feedback-governed practice.
A related point is that ill-considered attempts to promote reflectivity may result in single rather than double loop learning. 'Single loop' leaning refers to the learning which occurs when a nurse examines the relative effectiveness of her outcomes in light of her plans. 'Double loop' learning refers to the leaning which results from the examination, of not only outcomes in light of plans, but also, and critically, the appropriateness and propriety of the plans themselves (Argyris, et.al. 1985). A cursory examination of the 'protocols' (Alsop, 1995) currently being offered to facilitate reflection will expose the single loop limitations of a great many of them. The problem with single loop learning, of course, is that it could result in nurses doing wrong or inappropriate things perfectly.
Reflection versus tacit knowledge
Nursing's apparent obsession with reflection and reflective practice is due to the influence of Schon (1993, 1987) and the experientialist education movement (e.g. Boud, 1992) which seeks to address a 'technical rationality' or an applied science view of human skill. Unfortunately, however, the Schonian and experientialist view of reflective practice is tarred with the same rationalist brush that these scholars so eloquently and vehemently criticised. Implicit in their theorisings is the assumption that intelligent action requires conscious thought. This is confirmed the Schonian and experientialist exhortations to reflect; that is, think consciously, before and after action and, in Schon's case, even during it (reflection-in-action). Recognition of the contextual complexity of the work of many professionals may well be implicated here. For when contexts are uncertain and unpredictable, like many clinical nursing situations, the automatic deployment of specific routines, sub-routines and procedures is insufficient for their effective management. What this means is that mere inculcation of habit and/or repeated practice cannot be all there is to the acquisition and exercise of human skill. Rather, unpredictability poses problems for human beings in such situations, these problems require solution and this implies conscious deliberation. On this Schonian and experientialist view, all human learning, including skills learning, is a function of reflection.
It is interesting to note that the deliberative rationalism of the Schonian and experientialist school fails to take account of the seminal work in philosophy of mind which predate it.
Ryle (1994) and Polanyi (1967), in particular, argue that much of the knowledge which inheres in human skill is tacit, that is, inarticulatable, in principle (which means that no amount of reflection will surface it). Tacit knowledge, or much of a certain kind of tacit knowledge, is embedded in action. To drive home this point, Ryle emphasised the distinction between knowing that something is the case and knowing how to do something. It was his view that the 'intellectualist myth' held that the exercise of skill or know-how necessarily entails the separate contemplation of relevant propositions and prescription; that is, know that. The intellectualist myth holds that people do '... a bit of theory and then (...) a bit of practice' (p.30). Ryle insists, however, that intelligent action is one thing only and not two. Indeed, he goes so far as to suggest that people learn their skill by 'practice, schooled indeed by criticism and example, but often quite unaided by any lessons in theory' (p.41).
Explicit versus implicit learning
These Rylean views on the acquisition of human skill are supported by recent work on implicit learning. There is now some evidence that people may learn the simple and most obvious aspects of a task in focused, explicit ways but that the more complex, less obvious aspects are learned implicitly, unconsciously. It has even been suggested that implicit and explicit modes of learning may be mutually inhibitory (Berry & Dienes, 1993).
Balance in education
What all the above means in terms of nursing education seems clear. The current over emphasis on explicit reflection and reflective practice should be balanced with opportunities for appropriate, implicit learning. Maximising the effectiveness of implicit learning may take many forms but they would all require students' repeated exposure to examples of 'good' nursing. Opportunities to observe and work with appropriate role models for sufficiently long periods of time to allow implicit learning to occur should be seen as critically important aspects of undergraduate and post-graduate nursing education. It also mean, of course, that great care should be taken when selecting clinical preceptors, mentors and clinical environments. Such carefully planned clinical experiences should enable students to acquire procedural conceptions of various types of therapeutic nursing at an implicit level. In time, such desirable implicit learning might also lead to the conscious articulation of acquired procedural conceptions, or parts of them, through systematic and disciplined reflection. However, this will only happen in situations where the time, training and feedback-governed practise required for systematic reflection is made available.
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