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Reflexivity Nursing Essay Questions

By

Heather D’Cruz, B.S.W., M.S.W., Ph.D.
Senior Lecturer in Social Work
School of Health and Social Development, Deakin University, Waterfront campus
Geelong, Victoria, Australia

Philip Gillingham, B.A. (Hons), M.S.W., CQSW
Lecturer in Social Work
School of Health and Social Development, Deakin University, Waterfront campus
Geelong, Victoria, Australia

Sebastien Melendez, B.S.W. (Hons)
Social Worker
Bethany Community Support
North Geelong, Victoria, Australia

 

 

Abstract

Reflexivity is a concept that is increasingly gaining currency in professional practice literature, particularly in relation to working with uncertainty and as an important feature of professional discretion and ethical practice. This article discusses how practitioners working in child and family welfare/protection organisations understood and interpreted the concept of reflexivity for their practice, as one of the outcomes of larger, collaborative research project. This project was conducted through a series of workshops with practitioners. The overall research that aimed to expand practitioners’ practice repertoires from narrowly-defined risk assessment, to an approach that could account for the uncertainties of practice, included the concept of reflexivity as an alternative or a complement to instrumental accountability that is increasingly a feature in child welfare/protection organisations. This article discusses how the concept of reflexivity was explored in the research and how practitioners interpreted the concept for their practice. We conclude that while concepts like reflexivity are central to formal theories for professional practice, we also recognise that individual practitioners interpret concepts (in ways that are both practically and contextually relevant), thus creating practical meanings appropriate to their practice contexts.

Introduction

Reflexivity is a concept that is increasingly gaining currency in professional practice literature, particularly in relation to working with uncertainty (Parton & O’Byrne, 2000a; 2000b) and as an important feature of professional discretion and ethical practice (Fook 1996, 1999; Taylor & White, 2000). In an earlier article (D’Cruz, Gillingham & Melendez, 2007), the authors critically reviewed the social work literature to explore the many meanings of the concept of reflexivity for social work theory, practice and research. In our previous article, we demonstrated how terms such as ‘reflexivity’, ‘reflectivity’ and ‘critical reflection’ are used by different authors to mean very different things (sometimes interchangeably) ( for example, Jessup & Rogerson, 1999, p. 176; Leonard, 1999,p. vii; Pease & Fook, 1999, pp. 13, 17, 231; Boud, 1999; Briggs, 1999; Rea, 2000; Mosca & Yost, 2001). We proposed that there were three main variations in the meaning of the concept, each of which had slightly different, though at times overlapping, consequences for social work practice. These variations are summarized below.

In the first variation, reflexivity is regarded as an individual’s considered response to an immediate context and is concerned with the ability of service users to process information and create knowledge to guide life choices (Roseneil & Seymour, 1999; Kondrat, 1999; Elliott, 2001; Ferguson, 2003, 2004). In the second variation, reflexivity is defined as a social worker’s self-critical approach that questions how knowledge about clients is generated and, further, how relations of power operate in this process (White & Stancombe, 2003; Taylor and White, 2000; Parton & O’Byrne, 2000a; Sheppard, Newstead, Caccavo & Ryan, 2000). In the third variation, reflexivity is concerned with the part that emotion plays in social work practice (Kondrat, 1999; Mills & Kleinman, 1988; Miehls & Moffat, 2000; Ruch, 2002).

We surmised that the diversity of meanings that emerge from a critical analysis of terms such as ‘reflexivity’ and ‘reflection’ is indicative that such concepts are relatively new to social work and their meanings for the profession are still being debated. Further, that the diversity of meanings increases the possibilities for expanding practice repertoires and debate should be encouraged rather than some form of closure sought.

In this article we discuss how practitioners working in child and family welfare/protection organisations understood and interpreted the concept of reflexivity for their practice, as one of the outcomes of a larger, collaborative research project. The overall research aimed to expand practitioners’ practice repertoires from narrowly-defined risk assessment, to an approach that could account for the uncertainties of practice through a range of concepts (D’Cruz, et al., 2004; D’Cruz and Gillingham, 2005; D’Cruz et al., in press). Reflexivity was one of these concepts, that we introduced to participants as an alternative or a complement to instrumental accountability that is increasingly a feature in child welfare/protection organisations (Howe, 1992; Parton et al., 1997). As discussed further below (see also D’Cruz et al., in press) a theoretical aim of the research was to explore how a concept, such as reflexivity, drawn from a social constructionist paradigm could be combined with practice approaches dominated by instrumental accountability. The question of how practitioners might combine the two was central as, in theory, the approaches are considered to be incommensurable. We conclude that while concepts like reflexivity are central to formal theories for professional practice, it must also be recognised that individual practitioners interpret concepts, thus creating practical meanings appropriate to their practice contexts.

Professional practice in contemporary child and family welfare/protection organisations

From the mid-1980s to the end of the 1990s, child and family policy and practice in many western countries such as the UK, the US and Australia became increasingly proceduralised and bureaucratised (Howe, 1992) following coronial and public inquiries into the deaths and serious injuries to children in the care of their parents/caregivers. Risk management through risk assessment checklists was the preferred approach that aimed to minimise “practice mistakes” (Walton, 1993) seen as consequences of professional discretion and autonomy, and “subjective” decision making (Reder, Duncan & Gray, 1993). Risk assessment criteria as prescriptive checklists represented rationality that could manage the uncertainty and unpredictability associated with ensuring the care and protection of children living with their parents (Parton, 1998), and thus minimise or eradicate “practice mistakes” (Walton, 1993). Professionals including social workers were expected to adhere to procedures, with “substantive accountability” to clients (children and families) replaced by “instrumental accountability” to the organisation (Bauman, 1987).

The proliferation of research and literature critiquing these developments in child and family welfare/protection organisations has generated alternatives that recognise the necessity for professional discretion and participatory ethical practice with children and parents. These alternatives include the recognition of both the “dangers” and “opportunities” presented by protective practice (Ferguson, 1997), the importance of critically-reflective practice and “dialogue” (Parton & O’Byrne, 2000a) between parents, children and practitioners, and reflexive practice that foregrounds the connections between professional knowledge and professional power in situated practice (Taylor & White, 2000). The theoretical perspective informing many of these critiques and practice alternatives is social constructionism, that offers justification for re-introducing professional discretion and autonomy, on the grounds that all social practices including professional practice, involve people making meaning through social processes (Parton et al., 1997; D’Cruz, 2004). This perspective challenges the implicit assumption of instrumentalist risk assessment approaches that there is an objective truth about the care and protection of children that can be established if prescribed assessment procedures are followed. In some contexts, such as in Britain, these critiques have influenced changes in child and family policy and practice so that instrumentalist forms of risk assessment have been replaced by broader family-focused approaches (Ferguson, 1997; Parton, 1997). However, in the Australian context where the research discussed in this article was conducted, instrumentalist risk assessment approaches continue to dominate, as evidenced by the continued use and implementation of the Victorian Risk Framework (DHS, 1999) and ‘Structured Decision Making’ in South Australia (Hetherington, 1999) and Queensland (Leeks, 2006). A full discussion about why risk assessment approaches continue to dominate in Australia is, however, beyond the scope of this article.

Exploring an expanded practice repertoire: a summary of the research

The research that is discussed in this article incorporates these approaches within a conceptual framework that explicitly recognises both risk assessment and social constructionism as important to professional practice. We have not dismissed the necessity for risk assessment in some form, nor do we believe it is productive to dismiss the organisational contexts in which practitioners work. Instead we have explored the possibilities of an approach that accepts the practical, ethical, professional and legal bases for risk assessment, and the opportunities for the space of practice that is silenced organisationally and for individuals – namely, the discretionary aspects of practice.

This research emerged from the first author’s PhD research, which explored how meanings and identities were constructed in child protection practice (D’Cruz, 1999; 2004), rather than being predictable outcomes as absolute ‘realities’ achieved by heavily proceduralised and instrumental practice informed by the risk paradigm (Howe, 1992; Parton et al., 1997). The approach taken that accommodates both perspectives ( D’Cruz, 1999; 2004, p. 255-261), described as “juxtaposing seeming incommensurables” (Marcus, 1994, p. 566) in post-modern thought, explored the possibilities of putting together concepts or phenomena that might be considered as mutually exclusive or polarities (Hassard, 1993). For example, ideas of “realism” (as absolute, objective reality) and “relativism” (reality is relative, being constructed by participants) (Edwards, Ashmore & Potter, 1995) are usually seen as mutually exclusive and oppositional concepts. This approach is known as “dualism” (Heap, 1995), that accepts a physical reality that may generate a variety of plausible, and relative explanations and meanings depending on the situated positioning of participants (Reason and Bradbury, 2001, p. 6). For child welfare/protection, a dualist position allows for an acceptance of children’s lived experiences that include material disadvantage, oppression and trauma, and the necessity for ‘risk assessment’, while also acknowledging that these experiences may be explained and understood from many, competing perspectives (D’Cruz, 2004; D’Cruz et al., 2004). Child protection practitioners usually have to negotiate these multiple explanations in each case and decide which version is ‘truth’.

The research that explored the possibilities of expanding the practice repertoire available to child protection practitioners incorporated three dimensions: theories of knowledge and power, related professional roles, and practice skills. The second and third dimension are beyond the scope of this article and here we focus on one part of the first dimension, the concept of reflexivity. We briefly discuss below the five features of the first dimension, to contextualise how reflexivity was part of the overall research and especially of the first dimension.

The first dimension, theories of knowledge and power, draws on assumptions about knowledge and the practitioner’s relationship to knowledge represented as practice decisions informed by the risk paradigm and social constructionism. This dimension begins from the position that the risk paradigm and social constructionism are represented in theory as mutually exclusive, each with particular defining features. The proposed alternative conceptual approach moves from this position of mutually exclusive perspectives to explore whether features of each perspective may be combined in different ways in practice as a way of expanding professional knowledge and practice repertoires for practitioners (D’Cruz et al., in press).

Overall, the five features of the first dimension of the conceptual framework related to how theories of knowledge and power may be represented in regard to views about ‘reality’, ‘truth’ and ‘knowledge’ and expertise and authority. For example, whether knowledge is objective and absolute (real) or an outcome of alternative, contestable meanings (relative); and the relationship of knowledge to the speaker/author/knower (privilege/positioning). Instrumental rationality and reflexivity were the first feature of this dimension and, as explained below, reflexivity seemed to have the greatest resonance for the practitioners in terms of how they could relate it to their practice.

Methodology

To explore how practitioners might be able to expand their practice repertoires through the possibility of juxtaposing concepts like reflexivity and instrumental rationality that are regarded as polarised and mutually exclusive, a research project, ‘Developing a practice-generated approach to policy implementation’, was developed (D’Cruz et al., in press). The aim was to develop an alternative approach for child protection practice that would account for ethical, legal and bureaucratic demands while providing “child centred, family focused” services (e.g. Ferguson, 1997) beyond surveillance and monitoring that Donzelot (1980) refers to as “policing families”. Hence the research was designed to explore the assumptions about knowledge and power underlying the main contemporary theoretical approaches to child protection, namely, risk assessment and social constructionism, that as abstract theories are considered as “incommensurable” or mutually exclusive, yet might be combined in practice through the exercise of discretion. In this article, we focus specifically on how practitioners who were research participants were engaged in regard to the concept of reflexivity as either an alternative to or complement for instrumental rationality that was/is the norm in their organisational contexts.

Generally, “incommensurability” is taken to mean that different paradigms cannot be compared as each has self-contained criteria that include what is relevant to the paradigm and simultaneously demarcates what is not (Feyerabend, 1975; Lee, 1994; Jacobs, 2002a; 2002b). Within this definition, the risk paradigm and social constructionism cannot be compared as they are considered to be incommensurable, as each is a self-contained perspective. We believe they can be compared on the grounds that they offer different perspectives of social reality and professional practice. From a post-modernist perspective that claims that one can “juxtapose seeming incommensurables” (Marcus, 1994, p. 566) we have taken an approach that does not claim to combine entire self-contained paradigms. Instead, we have identified a few key features of each paradigm as being important for professional discretion and ethical practice and have incorporated these into our overall conceptual framework. This approach also draws from Feyerabend’s (1975) conceptualisation of the need for “pluralism” of apparently conflicting theoretical perspectives so that theories can better explain/understand “realities” that may not be adequately addressed through single approaches .

Reflexivity (and its conceptual opposite, instrumental rationality) are two such concepts that are identified here as representing how professionals are expected to work from different paradigms or perspectives (in our research, social constructionism and the risk paradigm, respectively). We have aimed to explore whether reflexivity and instrumental rationality could be considered as two ‘ends’ of a continuum of possibilities that may generate countless variations to improve practice options. The idea of a conceptual continuum from a professional practice perspective, is similar to the “grey areas” of practice that are well known to practitioners, as the vast majority of cases do not fit neatly within prescribed official categories and related theories (Parton, 1991). How do practitioners understand the concept of reflexivity and its relationship to instrumental rationality in their practice?

Research Participants and Procedures

The research was conducted in 2002 and 2003. There were ten participants in the first cohort, and seven in the second. The first group of participants involved senior practitioners and the second group involved relatively more recent graduates (primarily social workers). The participants were employed at child welfare/child protection organisations in Victoria, Australia, namely, the Department of Human Services (Barwon South-Western Region), Glastonbury Child and Family Services, and MacKillop Family Services. Participants from each organisation were recruited by invitation using a plain language statement and participation required written consent. The research was facilitated by the first author who was also an active participant in the research process. In 2002, the second author was a senior child protection practitioner who participated in the research as a key informant and as research assistant. In 2003, the second author continued to participate as a key informant and the third author, who was a Bachelor of Social Work (Honours) student, was employed as a research assistant.

The particular challenges and opportunities of conducting collaborative research across a range of agencies are discussed more fully in D’Cruz & Gillingham (2005), as are the ethical and practical dilemmas of (and the particular insights gained from) the multiple roles occupied by the researchers. Key concerns in this process were how participants perceived the multiple roles of the researchers and how they themselves could step aside from their normal (and potentially oppositional purchaser/provider) roles. In order to address these concerns, rules about the confidentiality of comments made and written were clarified at the beginning and during the workshops. The participants were also drawn from an area where practitioners move from one employer to another and so have to accommodate the changing roles of colleagues. Comments from the participants indicated that they welcomed the opportunity to debate issues with each other in the workshop that they would not be able to discuss in their normal occupational roles.

Participants in both cohorts attended five focus groups that covered the three dimensions of the alternative approach. These were referred to as “workshops” in order to reflect the collaborative and dialogic nature of the research and the participation, rather than just facilitation, by the researchers in the sessions. The first workshop (half-day) introduced the research and explored participants’ perceptions of the context in which they worked, and the extent of discretion and professional power they believed they had (and sought to exercise) in their organisations and in relation to clients. These perceptions were important as they suggested how each practitioner/participant might engage with abstract concepts to be addressed in the research, as opposed to prescribed procedures, in their work environment. Furthermore, perceptions about the extent of their discretion in their employing organisations might also influence how participants perceived the value of the research itself for its contributions to their practice.

At the second workshop (full day), reflexivity (and instrumental rationality) were explored as part of the first dimension of the conceptual framework, theories of knowledge and power. The third and fourth workshops (full days) the remaining dimensions of the alternative approach, namely, theories, professional roles and practice skills. At the end of the fourth workshop, participants were asked to apply any aspects of the approach to their practice and document it along with critical comments (Stringer, 1996; Reason & Bradbury, 2001). Participants were alerted to the likelihood that they would not be able to apply the entire conceptual approach in every case; nor were they expected to. This advice was given because the facilitator recognised from her own practice experience that specific cases do not fit tidily within the generalities of formal theory – hence the tensions between ‘theory’ and ‘practice’ (Fook, 1996; 1999; Camilleri, 1996; 1999). At the fifth and final workshop (half-day) participants discussed their examples of how they applied the approach to their practice and offered critical feedback.

Methods of Inquiry

Each workshop discussion relied on plain language definitions and semi-structured questions that had been mailed to participants prior to the workshop to facilitate their engagement with particular dimensions of the alternative approach. The conceptual features of each dimension and their plain language definitions were refined in discussion between the Principal Researcher (also first author) and the second author who, at the initiation of the research, was employed as a senior child protection practitioner in a large statutory organisation. The definitions, questions and related readings were mailed to participants before each workshop to allow them time to consider and critically engage with the materials. Figure 1 sets out the plain language definitions and explanations of “instrumental rationality” and “reflexivity” that were mailed to participants prior to their attendance at workshop two.

Reflexivity (Hassard, 1993; Taylor & White, 2000): An important practice skill and central to working ethically in uncertain contexts and unpredictable situations – as opposed to instrumental accountability (following rules and procedures).
 

  • Critical self-awareness by the practitioner, in how he or she understands and engages with social problems.
  • Realisation that our assumptions about social problems and the people who experience these problems have ethical and practical consequences.
  • Questioning of personal practice, knowledge and assumptions

The following questions were provided to facilitate practitioners’ engagement with questioning their practice assumptions and their interpretation of the concept of reflexivity:
 

  1. How do I know what I think I know about this person and their problem?
  2. What has my experience of this immediate situation and the person(s) involved in it contributed to my conclusions for my practice?
  3. Is there at least one other way of understanding this situation and the people involved?
  4. Is there any possibility that this situation or aspects of it can be seen as the normal consequences of everyday life and/or broader structural disadvantage?
  5. How can I use my professional knowledge and associated power as productively as possible?

Figure 1: Plain language definitions and critical questions about “reflexivity” and “instrumental accountability”

During the workshops, data were generated by engaging the participants in discussion about the questions (in Figure 1). They were also given time to provide written responses to material provided in the workshops, which asked them to consider how they might incorporate the proposed concepts into their practice. In 2002, the workshop discussions were tape-recorded and transcribed but this proved to be less than satisfactory. A particular problem was that participants, in the heat of the debate, tended to speak over each other (and at the same time), making the transcription fragmented and difficult to follow. Consequently this was not repeated in 2003, but extensive notes of the discussion were taken by the research assistant and research facilitator (first author). During the workshops in both 2002 and 2003, an electronic whiteboard was used to capture salient points during the discussions with the participants at the workshops and these were printed off. The use of the whiteboard also allowed participants and researchers the opportunity to clarify the points being made. Participants were encouraged to comment on whether the researcher using the whiteboard had adequately captured their meaning, This approach to data recording, known as “member checking” (Rubin & Babbie, 2005) was concerned with the point that “(t)he central meanings attached to objects or relations should reflect the beliefs that the insiders hold about these” (Kellehear, 1993, p. 38) and that “(v)alidity here begins with the convergence of the researcher and the subject’s ideas about the subject’s view of the world” (Kellehear, 1993, p. 38).

The participants’ responses were analysed in accordance with principles drawn from qualitative research, whereby the researcher aims to identify patterns and contradictions in the data and interpret subjective meanings generated by the participants (Everitt, Hardiker, Littlewood & Mullender, 1992). “Open coding” (Strauss & Corbin, 1990) was used to start analyzing the data and involved reading through the range of documents generated by participants through their written responses and the discussions. Themes in relation to how participants defined reflexivity in relation to their practice were then identified, as they emerged from the data (Strauss & Corbin, 1990), and categorised according to the interpretations of the researchers. Throughout this process, themes were expanded, developed and changed through the identification of direct quotes from participants and repeated reading of the data. This process continued until no new themes emerged.

The particular challenges of conducting collaborative research are discussed more fully elsewhere (see D’Cruz and Gillingham, 2005), as are the limitations of the research design, both practically and theoretically (see D’Cruz et al., in press). Particular limitations can be summarised as follows. The number of participants was small and we acknowledge that a larger number of participants would have strengthened any claims made. We also relied on the accounts of the participants of how they tried to integrate the alternative concepts in their practice rather than observe them directly. We also acknowledge that the findings of the research are closely linked to the context in which it was conducted, a context which changes (and has changed since the research was conducted) continually and sometimes swiftly.

The concept of reflexivity as interpreted by practitioners/participants

Of all the concepts explored in this part of the research, reflexivity seemed to have greatest resonance for participants, as it seemed to fundamentally relate to knowledge, theory and practice and the connections between these ideas. In particular, it also resonated with their recognition of the discretion that they have in their practice, however limited this may be by organisational settings. (The other concepts that had greatest resonance for the participants seemed to relate more specifically to the other two dimensions that have not been addressed in this article, namely, professional roles and practice skills.) In fact, the richness of the data related to reflexivity enabled us to develop a detailed analysis (D’Cruz et al., 2004), which we now present below. Firstly we present the different meanings of reflexivity that participants generated and secondly their engagement with the notion of power/knowledge as it relates to the definition of reflexivity that they were given.

We were able to identify six themes that represented the participants’ conceptualisations of reflexivity in relation to their practice:
as self-reflection, distinct from reflection
as a way to combine objectivity and subjectivity
as a critical appraisal of action and knowledge creation, in the moment
reflexivity as a tool for practice/an introspective process
reflexivity as a learning tool/critical practice approach
as a process of critical reflection on policy (D’Cruz et al., 2004)

These six themes are considered in more detail below. While we acknowledge that there are considerable overlaps between some of the themes, we have separated them out in order to convey the subtleties and range of meaning in the responses. Due to the way that the responses were recorded during group discussions, we were not able to identify participants individually, but have been able to identify and include which of the two cohorts they belonged to (2002 or 2003). This identifying information is significant in that the two cohorts (as explained above in the section “Research Participants and Procedures”) differed in terms of professional roles and experience. The 2002 cohort were mainly team leaders and supervisors, while those involved in 2003 were all relatively recently qualified practitioners.

Practitioners’ Meanings of Reflexivity

as self-reflection, distinct from reflection
Some of the participants defined reflexivity as the use of intuition or tacit knowledge (Polyani 1967) to make sense of a situation and also as a way of combining the use of the intellect and the emotions to do so. The inclusion of self (including emotional responses) in the critical approach to knowledge creation are conveyed by the following quotes:

reflection is kinda looking out and looking at everything whereas reflexivity is doing that but including yourself in that. (emphasis added) (2002)

Need to be aware of internal (emotional responses and “gut feelings”) and external (things go on around us) factors. . . (2003)

(2) as a way to combine objectivity and subjectivity
The participants engaged with the idea of a continuum between instrumental rationality and reflexivity as a way of combining objectivity and subjectivity, of moving between the two and legitimating both approaches to knowledge creation in practice, as demonstrated by the following quotes:

I sort of saw it as combining objectivity and subjectivity. . . . So you can be both, objective and subjective in the same context. . . (2002)

[At the instrumental accountability end of the continuum] the assumption can only be. . . [that] if you’re objective then you can’t be subjective. . . whereas it’s actually contextually okay to be both. And it’s realistic to be both. (2002)

reflection is kinda looking out and looking at everything whereas reflexivity is doing that but including yourself in that (2002)

These interpretations of the concept of reflexivity, in relation to instrumental accountability resonate with one of the original aims of this research, which was to investigate whether and how two seemingly polarized approaches to social work practice in child protection can be combined. Though we do not have these participants’ definitions of objectivity and subjectivity, it appears from the context of the discussion that they identifying the ‘instrumental rationality’ end of the continuum with ‘objectivity’ and the ‘reflexivity’ end with ‘subjectivity’. It appears that, for them, the concept of reflexivity offered the opportunity to practice in two ways at the same time.

Another participant, however, saw reflexivity as a way of acknowledging his/her personal emotional response and then distancing him/herself from this response in order to increase his/her objectivity:

This helps me make sense of my responses to what I am being told. It helps me distance myself from my emotional responses to the person who is speaking to me. . . . If I figure out that my emotional response is mirroring theirs, or that I am being convinced by their presentation rather than anything else, then I change my emotional response, or put it aside, to become more objective. (2003)

(3) as a critical appraisal of action and knowledge creation, in the moment
For some participants reflexivity allowed questioning of what is a ‘fact’ and a broadening of what might be considered pertinent to an assessment:

Reflexivity for me means being able to more broadly consider the client’s experience of the world rather than through the narrow confines of accountability through procedures (sic) facts and bottom lines. (2003)

One participant gave the example of when the application of reflexivity allowed for alternative explanations for a mother’s behaviour in a domestic violence situation.

Although (I was) very much aware of theory re DV and cycle of violence, the information, context and presentation of mother were quite confronting. Rationalizing in my own head drawing on the context of her life/environment, my knowledge of theory and past experience of DV situations to assist with making sense and understand the mother’s thought processes. . . (2003)

This application of the concept led to a reassessment of the situation rather than the mother’s behaviour being considered as just a breach of procedures. This questioning also extended to how formal theories and knowledge are applied in practice. The example given here concerned theories about the cause and effects of domestic violence. The questioning of ‘fact’, knowledge and theory is exemplified by the following:

valuing and holding fairly highly, the practice of conducting reflexivity. . . bring that sort of ‘third eye’ stuff. . . you keep making explicit the fact that that’s what you’re doing. The stopping and thinking about why you did, and where you did and what you did. And that navel gazing I guess is the notion. (2002)

The reference to ‘navel gazing’ in the above quote could have quite negative connotations in that it could be read that applying the concept of reflexivity could lead to endless, or at least time-consuming, introspection and a lack of action.

(4) reflexivity as a tool for practice/an introspective process
Reflexivity was conceptualized as a practice tool that could be used to change and enhance practice. As in version three, reflexivity was conceptualized as an introspective process, something that a practitioner can engage with on their own:

It’s about change, it’s about changing your own practice in some subtle way or changing something outside the practice which is why we are actually talking to someone. . that the internal conversation goes on . . (emphasis added) (2002)

valuing and holding fairly highly, the practice of conducting reflexivity. . . bring that sort of ‘third eye’ stuff. . . you keep making explicit the fact that that’s what you’re doing. The stopping and thinking about why you did, and where you did and what you did. And that navel gazing I guess is the notion. . . (emphasis added) (2002)

Reflexivity is an ongoing ‘live’ process going on internally as the outside world impacts on me. (2003)

(5) reflexivity as a learning tool/critical practice approach
Reflexivity was conceptualized as a learning tool, as a process for creating rules to guide practice and enhance ‘practice wisdom’. Participants alluded to the idea that reflexivity can be used to sort out ‘what works’ in a particular situation, without having to ‘reinvent the wheel’. This is encapsulated in the following quote:

. . . reflexivity creates a helpful rule in the context, then you might have a . . . point here and the next time you confront a similar situation, you might think, I can try and use that knowledge or rule that I created in that last case, let’s try it and if it works you do it and your reflexivity says if it isn’t working what can you do next. . . (2002)

This quote also refers to the use of reflexivity as a continual and critical process of questioning how knowledge to guide practice is created.

However, reflexivity as a critical approach and as a learning tool was not considered to be easy and generated a level of discomfort:

But even if you don’t say anything about it, you’re just doing the reflecting on yourself, it kind of, it’s not a comfortable feeling for people. (2002)

The process of practising reflexivity and moving to that end of the continuum was considered as also being ‘scary’, while the instrumentalist end of the continuum was associated with safety:

I mean it is that balance between it being scary and discomfort and I mean, I think there is probably a lot of staff that would sort of ‘just tell me what to do, how to do, what is the rule here, what is (sic) the rules to follow, how do I interpret this, whatever else’ and if you go back to them and take them through a different process, but I think it also has, I suppose the other side to that is that it is also rewarding in the long term. (2002)

The extent of challenge in practising reflexively might also be linked to levels of professional experience and expertise:

I think it also has to do with the individuals, where they are at. . . personal development and professional development. (2002)

I think it’s a level of confidence and. . . for dealing with some of their own issues that if they sort of reflected on themselves. . . (2002)

Despite the challenges that reflexivity might pose, it was also considered to be rewarding in the long term:

So the other side of this is the rewarding, for some people it is a difficult process to go through with that, yeah, the mastery that goes with that. (2002)

(6) as a process of critical reflection on policy
Some participants also interpreted the concept of reflexivity as critical reflection on the policies set by their agencies that inform and guide their practice:

. . . you look at policy, you build in reflexivity in individual practice relative to clients, relative to program, relative to annual reviews. It’s at all those different levels. (2002)

I guess I don’t see policies or whatever as set in concrete. I think you still need to keep reflecting on them and seeing if they are still useful because I guess I have seen policies that are being useful to support workers in their practice and if they are not, well then you need to be relooking at them. (2002)

Again, as this quote shows, reflexivity was used as a critical approach to practice, offering a process of engagement with organisational instrumental rationality (rules and procedures) that shapes and guides practice.

Participants also described adopting a reflexive approach to practice as rewarding and as promoting growth and trust in relations with clients. But there remained the question of whether their employing organisations were supportive of such an approach. For example, in that the participants questioned whether organisational culture provided sufficient safety and permission for them to adopt a reflexive stance in relation to their practice:

It is about a culture as well isn’t it, it is the culture that allows that. (2002)

Yeah, I think it is back to the ideal world in a way and it is a thing about how do you fit in organisational culture that allows. . . a relationship to happen rather than the task centred stuff that says we just want another chapter and verse and we don’t really care what your interpretation of that is. (2002)

In the next section, we focus on how the participants engaged with the concept of power, as it relates to their roles and the process of knowledge generation.

Reflexivity as Knowledge/Power in Practice
We have acknowledged previously (D’Cruz et al., 2007) that the concept of reflexivity has been offered as a constructive (Parton & O’Byrne, 2000a; 2000b) and critical (Fook, 1996; 1999; Taylor & White, 2000) approach to social work practice, particularly recognizing the relations of power in the generation of situated professional knowledge. Consequently an important dimension of how the participants in this research engaged with the concept of reflexivity was how they conceptualized and acknowledged the operation of power in their practice.

In engaging with the formal definition of reflexivity as an integral relationship between knowledge and power, participants identified three different forms that power could take in their practice which we have categorised as: (1) constructive power, (2) coercive power, and (3) institutional power.

Constructive power
The participants acknowledged that power enabled them to:

empathize where the client is at … [knowledge/assessment] should not merely be a conflict of views (2003)

Power was also considered as constructive in relation to dealing with the seemingly inevitable conflicts that arise in work with children and families:

Practice starts off with [the] assumption of a power struggle. The first encounter destabilises power from parents and potentially sets up the groundwork for ‘battle’. Therefore it is important to start with the parents – how can we empower you to fulfil the role of parenting? (2002)

The giving of knowledge or information was also seen as a way of empowering clients (parents) and reducing what was considered to be a power imbalance between professionals and families:

Just an equalizing kind of thing, using your own knowledge in a constructive way to help people understand . . . (2002)

It is also worth noting that participants considered the parents as clients rather than their children when they were asked to reflect on the operation of power in practice.

(2) Coercive power
The participants acknowledged the operation of power, in relation to the generation of knowledge, in the relations between themselves, their supervisors (or supervisees) and clients. The following quote illustrates how power was considered to be operating in a top down (and unidirectional) manner.

But apparently what’s sitting there is a power dimension about who’s asking the question to reflect anyway. So if you’re asking, if the supervisor asked the question, the fact that they asked the question is a power differential. That fact that we go out to a client family. . . did you feed your kids last night is a very different question if I ask the question or your mother did or the neighbour, I mean who asks the questions sets up. . . (2002)

Statutory power was also considered as a last resort:

at some point power needs to be used – there are things we can do on the way to avoid reaching this point (2003)

(3) Institutional power
The operation of power as oppressive and as located in the rules and procedures of employing organisations which produce rigid solutions to problems was also identified by the participants, as:

a fixation on appropriate course of action for clients [as defined by the organisation] – often results in neglecting clients’ real needs. (2002)

In summary, power was considered by the participants to be operating in both constructive and oppressive ways in their practice. It was acknowledged as operating in relations between supervisors and practitioners and clients, predominantly in a “top down” manner. Power was also associated with statutory duties. With reference to the process of knowledge creation, at least one of the participants acknowledged the importance of the hierarchical status of the person asking the questions, again with power operating in a “top down” manner. Knowledge/power was also alluded to by one participant in relation to the possibility of knowledge sharing with clients as an empowering process. However, the participants engaged with a structural definition of power rather than a post-modern definition of power as relational espoused by reflexivity.

Participants’ interpretations and the literature

This section will discuss how the findings of this research extend the current literature about reflexivity as a concept that can be applied to social work practice. In order to consider the creative and varying ways that the participants in this research related the concept to their practice, we draw on our critical review of the literature on reflexivity as a concept (D’Cruz et al., 2007) to provide an analytical framework to locate these emergent meanings. In our critical literature review (D’Cruz et al., 2007), we identified three variations in the meaning of reflexivity: as an individual’s considered response to an immediate context, as a critical approach that questions how knowledge is generated and as an approach to practice that is concerned with how emotion is implicated in social work practice. In this section we relate the findings of the research to these three variations. We aim to understand the practitioner/participants’ interpretations within these broader conceptual frameworks in order to bring together “formal theory” (expressed in academic literature) and “informal theory” (as emergent and grounded in the experience of practitioners) (Fook, 1999; Camilleri, 1999).

The First Variation: Individual’s choices in context
In our critical literature review (D’Cruz et al., 2007), the first conceptual variation of reflexivity is regarded as an individual’s considered response to an immediate context and is concerned with the ability of service users to process information and create knowledge to guide life choices (Roseneil & Seymour, 1999; Kondrat, 1999; Elliott, 2001; Ferguson, 2003, 2004). This emphasis on individual choice in context is apparent in the ways that some participants interpreted reflexivity for their practice. They saw it as a means (or skill) for making sense of the situations they faced in practice and deciding on action that they could then take. However, their responses did not suggest that they considered reflexivity to be a skill that can be taught to clients to assist them to make sense of their worlds and to take action to further their own interests (Ferguson, 2004). Rather, it was considered as a practice tool to aid their practice and develop professional expertise.

The Second Variation: Self Critical Professional Practice
In our critical literature review (D’Cruz et al., 2007), the second conceptual variation of reflexivity is defined as a social worker’s self critical approach that questions how knowledge about clients is generated and, further, how relations of power operate in this process (White & Stancombe, 2003; Taylor & White, 2000; Parton & O’Byrne, 2000a; Sheppard, Newstead, Caccavo & Ryan, 2000). This variation in the literature was apparent in the ways that the participants defined reflexivity as a critical approach to their practice, the knowledge generated in practice and the rules and policies that guide practice. As in the conceptual variation in the literature, power was considered as part of the definition of reflexivity, particularly by one participant, in relation to the identity of the knower.

The Third Variation: Emotion, Cognition and Social Work Practice
In our critical literature review (D’Cruz et al., 2007), the third conceptual variation of reflexivity is concerned with how emotion is implicated in social work practice (Kondrat, 1999; Mills & Kleinman, 1988; Miehls & Moffat, 2000; Ruch, 2002). The meanings of reflexivity generated by participants in our research also identified emotions as being an important part of the process of knowledge creation. Participants spoke of their emotional responses when they attempted to apply a critical approach to the generation of knowledge to guide their practice. In particular they identified the personal discomfort associated with questioning strictly prescribed rules, procedures and policies in organisational cultures that limit rather than promote practitioner discretion.

Discussion

Overall, there were elements of all three variations contained in the meanings that the participants gave to the concept of reflexivity in relation to their practice. Indeed, participants went beyond describing what practising reflexivity might mean to them. A key point that emerges from this research with practitioners is the descriptions of how they might engage with the concept of reflexivity in a context that prescribes instrumental accountability. They described the difficulties and discomfort in incorporating a reflexive approach to practice and the easier option of resorting to the relative safety of following rules and procedures. A certain amount of self-confidence is required to engage in critical or reflexive approaches to practice, with confidence associated with practice experience and levels of expertise. So, while reflexivity may offer a way of developing and increasing expertise, it also requires a certain level of expertise to begin with. It is worth noting that it was the 2002 group of participants, the more senior practitioners, team leaders and managers who reflected on this more than the less experienced 2003 group. This also mirrors the conceptualisation of professional expertise and its development by Fook, Ryan and Hawkins (2000), who argue that whereas “novices” in professional practice tend to follow rules, “experts engage with theory in a critically self-reflective process” (p. 189). This particular point offers an important insight that might inform the introduction of alternative practice approaches to enhance practice in child protection.

The participants did not engage quite so fully with the concept of power as it relates to knowledge creation in the definition of reflexivity provided to them. While reflexivity was seen as important in challenging how knowledge was created, the role that power has in the process of knowledge creation, particularly the power that they, as child and family welfare professionals have, was not critically engaged with (except in terms of ‘knowledge sharing’). We conceptualized their versions of power as constructive, coercive and institutional and acknowledged more as an entity or possession than a process that operates in all interactions, namely, a structural version of power. This conceptualisation of power may be associated with the location of the practitioners in human service organisations which are structured as bureaucracies in which ‘legal authority’ is the most evident form of power, and which, in Foucauldian terms establishes a pervasive system of governmentality through hierarchical surveillance (Foucault, 1980). Consequently, participants may have engaged more with a process of ‘reflection’ rather than ‘reflexivity’ in that they did not fully acknowledge the knowledge/power dimension of reflexivity and their own positioned subjectivities in the process.

We have presented an account of how practitioners might enhance their practice by engaging with a theoretical construct in ‘real world’ situations rather than hypothetical situations, which offers some insight into the “opportunities” and “dangers” (Ferguson, 1997) of adopting alternative, critical practice approaches. We have shown that it is possible for practitioners to combine an alternative practice approach based in the social constructionist critique of current child protection practice with the “risk paradigm” and that the two approaches are not necessarily “incommensurable” (Marcus, 1994). The consequence for practice is that it offers hope that alternative “constructive” approaches (Parton & O’Byrne, 2000a; 2000b) to child protection practice that aim to move beyond the “policing” (Donzelot, 1980) and “surveillance” (Parton, 1991) of families can be integrated into child protection practice and that their development should continue. The possibility that such alternative approaches might be well received by practitioners has also emerged from this research, as demonstrated by the enthusiasm with which the participants in this research engaged with the concept of reflexivity.

Conclusion

This article has discussed how the concept of reflexivity was applied by practitioners in the field of child and family welfare to expand their current practice repertoires. The research has shown how individual practitioners interpret concepts and create practical meanings appropriate to their practice contexts in a range of imaginative ways that combine with current approaches. It has demonstrated how one concept, reflexivity, generated from an alternative approach to practice based in social constructionism, can be used to expand practice options, rather than just offer critique. Consequently this research supports the further development of alternative approaches to practice in child protection that extend beyond forensic approaches that focus on the identification and management of “risk”.

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Heather D’Cruz can be reached by email at heather.dcruz@deakin.edu.au; Philip Gillingham can be reached by email at Philip.gillingham@deakin.edu.au; and Sebastian Melendez can be reached at smelendez@bethany.org.au

 

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Received 17 April 2014; Revised 12 July 2014; Accepted 16 July 2014; Published 24 July 2014

Copyright © 2014 Jayne Josephsen. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Nursing is a discipline in transition. As the complexity and acuity of patients increase, nurses are taking on a more comprehensive role in health care leadership and patient outcomes. As the discipline has evolved so has the curricular framework of nursing educational programs, moving from being based on a specific nursing theory, to a general metaparadigm, to the current focus on meeting curricular content standards developed by national accrediting agencies. When considering the skills needed to fully engage in critical thinking and patient advocacy there may be room for an additional curricular focus: that of metacognitive development based on critical theory and constructivism. The empowerment of students via metacognitive and self-evaluative practices also supports the critical theory pedagogy. If graduating nurses are presented with a cohesive and comprehensive curriculum that meets the need for competent and critically reflexive nurses the discipline of nursing can continue to expand in function and voice. The use of metacognition, constructivism, competency, and critical pedagogies in a unified and broad curricular framework allows for the development of these essential skills in contemporary nursing practice. This paper presents this innovative curricular framework that embodies these various teaching and learning perspectives.

1. Introduction

Nursing is a discipline in transition. As the complexity and acuity of patients increase, nurses are taking on a more comprehensive role in health care leadership and patient outcomes. As the discipline has evolved so has the curricular framework of nursing educational programs, moving from being based on a specific nursing theory, to a general metaparadigm, to the current focus on meeting curricular content standards developed by national accrediting agencies. In the 1970s there was a call from accrediting agencies and nursing education for each nursing program to choose a specific nursing theory as their conceptual framework for curriculum development, such as Orem’s self-care deficit theory. This was found to be inadequate to meet curricular needs, as specific nursing theories mainly focus upon health issues rather than being a comprehensive curricular theory [1].

Nursing education next moved to utilizing a metaparadigm conceptual framework to focus curricular development upon. In this model the metaparadigm of nursing including concepts of person, environment, health, and nursing was employed to communicate the holistic view of the human experience related to the discipline of nursing. Yet this model was found incomplete as well, as it was so generalized it could be applied to a multitude of health care disciplines [2]. Currently, nursing education programs are utilizing national accrediting agency curricular standards, such as the American Association of Colleges of Nursing (AACN) standards, to organize and develop their curriculum. These standards are focused upon curricular content such as professionalism and professional values and baccalaureate generalist nursing practice competencies [3].

Although these national standards do include a focus on values such as professionalism, continuing education, and use of evidence-based practice, the standards tend to be focused on general roles and actions of the professional registered nurse (RN). For example, the generalist baccalaureate RN is to be able to take on the role of “provider of care, designer/manager/coordinator of care, and member of a profession” [3, page 8]. Essential to these roles is the need for the RN to be able to critically think, to provide sound clinical judgment, and to have the lens of patient advocacy when providing care. The AACN indicates, in the standards, that the development of these skills is to be culminated in a clinical immersion experience that provides the student with the opportunity to develop these clinical reasoning and evaluation skills [3]. The focus then of the AACN accreditation standards is that of competency development related to the discipline of nursing, with skills such as clinical judgment developing somewhat spontaneously with clinical experiences. This is appropriate to an extent, but when considering the skills needed to fully engage in critical thinking and patient advocacy there may be room for an additional curricular focus: that of metacognitive development based on critical theory and constructivism.

It can be argued that the focus on solely competency based curricular theory, that is enmeshed in the rational and behavioristic approaches to knowledge development and integration, has led to a curricular focus in nursing education that ignores the essential aspects of self-awareness and reflexivity in knowledge formation [4]. Yet, thought and mind cannot be separated from the various aspects of society and noetic forces, in this case, nursing curriculum. As Marcuse (as cited in [5]) stated, the critical theory approach desires to bring “to consciousness potentialities that have emerged within the maturing historical situation” (page 158). This brings to question whether curricular theory that is developed in a social framework that supports the focus on facts and competencies, taken out of the context of the relationship of the subjective and objective sphere, promotes development of critical reflection and student potential.

Horkheimer (as cited in [6]) suggested that, for a person to develop their view of reality, insight was needed related to their personal life. This concept of insight is foundational to metacognition. The ability to participate in metacognition, or to think about one’s own thoughts and emotions, links the present to the past, to provide a view for the future and to construct meaning of events [7]. Metacognitive practice in learning is an active event in which links are made between the past (prior knowledge), the present (current context), and the future (building upon new knowledge). Thus, it would appear that metacognitive ability is foundational for participation in critically reflexive curricular theory development as well as development of students who are able to participate in critical thinking avenues and knowledge construction and deconstruction [8].

2. Theoretical Framework

There are several definitions of metacognition, but for the purposes of applying the concept to curricular theory, metacognition is viewed as a three-part construct that includes self-knowledge, self-evaluation, and applicable knowledge [9, 10]. It has been shown that the lack of ability to participate in self-evaluative practice can lead to lower literacy abilities and that teaching students metacognitive skills can assist them in transferring the ability to self-evaluate throughout their lives in a variety of settings [10, 11]. Use of self-evaluative practices puts the power back upon the student to direct and think critically about their learning [12]. The empowerment of students via metacognitive and self-evaluative practices also supports the critical theory pedagogy, which embraces the postmodernist concept of autonomy [13].

Currently, graduating nurses are faced with entering a complex and rapidly changing health care environment in which they are required to work more autonomously [14]. There is a demand for self-evaluative and autonomous learners in the discipline of nursing due to this need for nurses to be able to view situations from a variety of perspectives and to translate their past, present, and future knowledge into effective health care interventions. Therefore, nursing curriculum has been challenged to embrace the need for a critically reflexive curriculum, rather than one that is grounded in subject based learning and behavioristic paradigms [15].

Critical theory in conjunction with metacognition offers nursing curriculum a theoretical framework that meets many needs of nursing education, in particular the need to develop critically reflexive students that are able to engage in the professional RN role that includes ethical activities such as advocacy for social justice and health care equity. Critical reflexivity is dependent upon the student being able to connect internally with their biases and assumptions that often direct decision-making and nursing care. Without this awareness, relationships with our patients and colleagues are often “hidden” as there is little awareness of the symbolic and real meaning of the relationships [16].

Furthermore, use of critical theory as a curricular framework to promote the development of metacognitive abilities and relationship with our patients and colleagues also offers a lens in which the rich history of the discipline of nursing can be integrated into the curriculum as well. Nursing curriculum cannot be devoid of historical foundations, even with the emphasis on evidence-based practice that is currently employed. These historical foundations have created the nursing educational structure that is present today and without understanding of their purpose and value there is likely little critical analysis or awareness of our existing nursing educational structures and their development or future application [16].

Nursing curriculum is also often based upon adult learning concepts as the audience being “taught” is in the higher education setting. Constructivist principles are used largely in this educational setting. Constructivism is based upon the concept that learning occurs “when we construct and deconstruct knowledge…” [17, page 17]. This ability to deconstruct knowledge is found in the capacity to participate in metacognitive/self-evaluative practice. Constructivist theory also involves the curriculum in a critical pedagogy, as the student is engaged in use of applicable knowledge, linking new knowledge to past experiences and then connecting the gained knowledge and/or insight to future nursing practice. Learning occurs as the student internalizes and then reconstructs their reality based upon knowledge gained, modified, or changed [18]. The ability of the student to transfer their knowledge to other contexts and to future practice is imperative for sound clinical judgment and reasoning and is an advantage of integrating metacognition into the curriculum.

The increasing focus from accrediting agencies on competency attainment warrants examination of further integration of metacognition into the curriculum [19]. The purpose of the competency emphasis has been to produce students that meet national nursing standards and recommendations, but the difficulty lies in the varied definitions of competency and how this is to be measured. Another issue of the overall focus on competency attainment is that it can create the perception that the nurse is an employee that provides “vocational skills,” rather than a professional with the ability to apply technical skills to a variety of situations appropriately and creatively, based upon sound clinical judgment, reasoning, and application of theory and evidence-based practice [20].

One approach to competency based curriculum that has attempted to address the deficits of the singularly competency focused curriculum is the second-generation competency based approach. In this type of curriculum, competency is viewed as a “know-how” that is founded in the combining and engagement of current knowledge, skills, attitudes, and resources and applying them to a specific situation [21]. This is an improvement upon the sort of checklist approach of historical competency based education and may provide the groundwork of metacognitive development. But the framework appears to be incomplete in metacognitive enhancement, as relevance and applicability of competency attainment to future learning and nursing practice is not explicitly addressed. If metacognition is to be fully employed a curricular focus on this ability is required. The ability for students to develop and cultivate self-evaluative and self-reflective skills in which the student can participate in self-directed learning to address competency deficits as well as an awareness and analysis of their individual thought processes and learning would be foundational to this focus. As it is currently, the second-generation competency based curriculum approach addresses some metacognitive components but may be inconsistently and unpredictably applied.

With these theoretical and conceptual constructs in mind, it may be warranted to develop a nursing curricular theory that employs several theories in a cohesive manner, rather than focusing nursing curriculum on a particular nursing theory or a solely competency based curriculum. The theoretical basis of critical theory, metacognition, constructivism, and competency based curriculum each have a significant role in the development of well-rounded RNs who can meet the demands of contemporary nursing practice. It is a collaborative relationship between the student nurse/RN, curricular theory, and nursing practice. Through these reciprocal relationships the graduating student/RN can contribute to the discipline of nursing and society at large through incorporating the lens of each of these theories into their internal knowledge and meaning processes (see Appendix A for critically reflexive theoretical framework with incorporation of various constructs and sample effects on nursing practice and discipline).

3. Application

Benner posits a developmental paradigm concerning nursing skill development moving from novice to expert. The novice nurse is one whose skills are limited and they view the world of nursing practice in a “black and white” fashion, fraught with inflexibility in decision-making. This could be identified as the person with limited metacognitive abilities, who is unaware of their learning needs, has limited ability to participate in self-evaluation, and makes few links from past knowledge and present context to future nursing practice. Alternately, the expert is the nurse who possesses a large intuitive ability that they can apply regularly and seamlessly to the present context and anticipates future nursing practice needs [22]. This word intuitive identifies the ability of the expert nurse to look within and reflect upon their abilities and the resources at hand and make a suitable decision. This is an exemplar of the nurse using and internalizing metacognitive abilities into their nursing practice.

Typically, Benner’s novice to expert model is viewed from the perspective of the graduate nurse, newly out of school, to the twenty-year veteran nurse. Indeed, Benner has identified that it takes five or more years for the novice nurse to reach expert ability and that some will never reach expert status [22]. Mills (as cited in [23]) suggests that intuition and knowledge are gained via experience and this leads to critical thinking and professional judgment. If some nurses never reach expert status this brings to question the role experience only plays in the development of intuitive expert practice. Is this gap in ability because the novice nurse requires the experience time gives, or is it because we have ill-prepared our graduate nurses for the demands of critically reflexive practice?

Metacognitive ability has been linked to clinical reasoning skills. Throughout clinical reasoning there is “an interaction among the individual’s cognition, the subject matter, and the context of the situation where the thinking occurs” (Fowler as cited in [23, page 179]). This statement supports the use of a critical pedagogy in nursing curricula, as it identifies the need to acknowledge the interaction between the past, present, and future in knowledge development. Reflexivity or reflective practice abilities are essential to student nurse transition to practice. Reflection is at the center of metacognition and the development of sound clinical judgment skills. If clinical judgment is presented as a linear, logical organization of facts only, then the thinking process is halted at the end of the continuum and knowledge gained may not be linked to future nursing practice.

Accrediting agencies have called nursing education to provide a curriculum that produces graduates with critical and reflective thinking skills. Nurse educators have endeavored to provide this through concept definitions and creation of measures of critical thinking ability such as the Watson-Glaser Critical Thinking Appraisal. Yet, these measures do not identify use of metacognitive skills, only the potential ability of the student to engage in critical thinking. Critical thinking in nursing education is often seen as a linear approach related to the nursing process, involving a rational view of the situation, rather than identifying self-reflective practice and knowledge of the individuals thinking process [24]. Thus, although nursing education embraces the notion of metacognitive practice and reflexivity, the curriculum is often left with a more behavioristic version of learning and thinking. Barriers to integration of metacognitive practices in the curriculum have been identified as student resistance, lack of time, content overload, institutional barriers, lack of faculty knowledge and/or self-efficacy on the concept, and faculty resistance to pedagogical changes [24].

Mezirow’s (as cited in [24]) framework of reflective practice proposes that there are three levels of reflection development including absence of reflection, awareness of bias and assessment of decisions, and assessment for further learning and additional perspectives. Often, in nursing education the student is left at the second stage, where the focus is on how personal bias and/or assumptions have affected decisions and then evaluation of the decision. There are few times that the student is required to reflect upon what further learning they may need and what additional world views they may need to become aware of, in order to meet the needs of their patients or to make sense of the reality of nursing practice.

Proust (as cited in [25]) postulates that there are two levels of metacognitive ability, one utilizing the emotional reaction (e.g., intuition) and the second level using reasoning. In this view, use of metacognitive processes allows the student to interpret the context in a corrective fashion based upon their conceptual and factual knowledge, as well as their emotional reactions. This view integrates the use of emotional or nonanalytical processes, metacognition, and the fact oriented clinical decision-making model. This model is supported, as there is a social aspect to metacognitive practices since individual cognition is influenced by social context and experience [26].

When developing the nursing curriculum then, it is essential to integrate all of these components into the coursework and learning process so that the student can take these skills with them into the workplace and promote lifelong learning and building of individual potential. The faculty cannot assume the student will automatically engage in metacognition. In fact, research has shown that these essential metacognitive skills are best introduced within the instructional setting, in order that the student has an opportunity to develop the skills [27, 28]. Metacognitive prompting through question or word stimulus can be used as an instructional adjunctive in nursing education and has been shown to enhance student self-evaluation of comprehension and greater decision-making abilities [29].

Lifelong learning is an internally motivated and enacted outcome of full application of metacognition to the graduate nurses professional development, and thus it has to be a somewhat self-regulated activity. The foundation of self-regulation is metacognitive capacity, reflective strategies, and an understanding of the social, personal, and historical influences upon learning [14]. Self-regulatory ability embodies the critical pedagogy and the potential for self-efficacy.

Furthermore, the ability to coregulate, or to create, meaning in a dynamic process with a multidisciplinary team is essential in the nursing setting. The graduating nurse needs to have the metacognitive awareness to self-regulate as well as an awareness of the other members of the health care team in order to provide quality patient care. For the graduating nurse to engage in this part of the professional nursing role it is vital that they are able to take on various perspectives and engage in a variety of communication techniques, social cognition, and construction and deconstruction of knowledge. The ability to engage successfully in these professional nurse role components requires the individual ability to participate in metacognitive practice [26].

Merriam and Caffarella state that “Metacognition is often viewed as the highest level of mental activity and is especially needed for complex problem solving” [30, page 206]. As the health care setting becomes more complicated, nurses are required to participate in complex problem solving on a daily basis. The ability to engage in clinical judgment and critical thinking is essential to problem solving in this setting, just as metacognitive practice is essential to become an expert nurse who participates in reflective nursing practice. Critical theory supports the connection of the noetic, emotional, and creative knowledge on the individual and societal level as an avenue to address the inherent injustice in our social systems. Pinar suggests that “Busywork may distract us from the facts we face, but serious educational work-academic study-can reconstruct the reality we experience” [31, page 136].

This concept can be translated to our nursing educational systems as well. If educators are not promoting the development of metacognitive capacity in our nursing students, rather focusing on content or behavioristic concepts and skills alone, the student’s long-term professional practice needs are not being met. As ideally the professional nurse is able to make connections between all aspects of knowledge, they will be able to identify what they know, what goals for learning they may have, and what they envision their future nursing practice to be, connecting the past, present, and future. Nursing educators ought to examine traditional curriculum with a critical eye and consider the relevance for the traditional content laden, behavioristic focus and if this curricular design is meeting the needs of our graduate nurses and the discipline of nursing as a whole.

Introduction of metacognitive practice and skills throughout nursing curriculum ideally will offer a more holistic view of the students personal nursing practice as well as the discipline of nursing. With the graduating nurses grounded in metacognitive capacity delivered through the nursing curriculum the use of applicable knowledge, self-knowledge, and self-evaluation will be introduced into the health care setting on a personal, organizational, and professional level. Through this engagement in individual and discipline development we can address critical theory and work towards social justice, which is a basic tenet of nursing ethics [32]. Moreover, with the introduction of constructivist concepts such as knowledge construction and deconstruction and a foundation on competency attainment, critically reflexive nurses who provide quality patient care and contribute to the discipline of nursing and the health care system at large can be produced (see Appendix B for sample application of critically reflexive curricular theory to an AACN competency).

4. Discussion

There are many factors in determining appropriateness of curricular frameworks and application of these constructs to nursing education. Ultimately, nursing educators are given the responsibility to educate and produce nurses who are able to meet the challenges of current nursing practice as well as meet the demands of the discipline’s future. Although there is a need for focus on competency and factual knowledge in nursing curriculum, without a comprehensive curricular framework that includes integration of metacognitive skills, constructivist frameworks, and critical theory tenets, graduating nursing students will likely not have developed the internal critically reflexive skills and knowledge to positively impact the future of nursing.

If we are relying on experience to be the teacher of these skills, we are inadequately preparing our students, as without the framework to become a critically reflexive practitioner introduced to them early on in their careers they may not be able to integrate the benefit of experience fully. Thus, as nursing educators we are left with the challenge to prepare our students not only with nursing skills and knowledge but also with the internal skills of self-evaluation, reflexivity, awareness of thinking and decision-making processes, and instilling of the values of the discipline which include social justice and health care equity. These are considerable requisites of nursing education, yet there are theoretical frameworks available to meet these curricular demands. The theoretical framework proposed in this paper is one that may be able to meet these demands and assist nursing educators in designing curriculum that meets the present needs of our graduating students and the future of nursing.

This paper presents an introduction to a theoretical framework that will require vetting and research for applicability to a variety of nursing educational settings. Implications for research may include introduction of critical theory pedagogy into courses related to professional concepts and leadership. Examination of metacognitive skills and tools application may be appropriate to be introduced and researched in skills, health assessment, and simulation based courses. Constructivist pedagogy can be applied throughout the nursing program, with research to ascertain whether these principles are assisting students to construct and deconstruct knowledge. Lastly, examination of the curricular theoretical framework and its efficacy in producing critical reflexive graduating students can be a focus of research.

If graduating nurses are presented with a cohesive and comprehensive curriculum that meets the need for competent and critically reflexive nurses the discipline of nursing can continue to expand in function and voice. The use of metacognition, constructivism, competency, and critical pedagogies in a unified and broad curricular framework allows for the development of these essential skills in contemporary nursing practice. Just as nursing students are required to participate in critically reflective practice for their individual development and quality patient care outcomes, faculty too are obliged to examine the traditional rational and behavioristic focus of nursing educational curricula and reflect upon whether it is adequately preparing our nursing students for the future of nursing.

Appendices

A. Critically Reflexive Theoretical Framework with Incorporation of Various Constructs and Sample Effects on Nursing Practice

See Figure 1.

Figure 1

B. Sample Application of Critically Reflexive Curricular Theory to an AACN Competency

See Figure 2.

Figure 2

Critically Reflexive Theory Sample Objectives Related to Leadership Competency(i)The student will reflect upon biases and values related to end-of-life care and identify how these might affect the quality of patient care and the patient’s safety.(ii)The student will deconstruct prior knowledge and apply it contextually and through dialogue with the interprofessional team.(iii)The student will identify strategies to address knowledge or skill deficits related to sterile procedure.(iv)The student will predict resources needed and patient response to care provided and reflect upon and identify assumptions made in the process.(v)The student will identify quality improvement techniques that match their learning style and strengths.(vi)The student will identify improvement strategies that address any self-identified weaknesses concerning patient safety.(vii)The student will create a learning portfolio identifying how they have met the leadership competency. Portfolio will include reflection on values and assumption related to the competency, what the competency means to them individually for their future nursing practice, and exploration of how they will address issues of commitment to outcomes and strategies for informed choice.(See [3, 33].)

Conflict of Interests

The author declares that there is no conflict of interests regarding the publication of this paper.

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