Is there a place for reflection in the nursing curriculum?

COMMENTARY Commentary on Carroll M, Curtis L, Higgins A, Nicholl H, Redmond R, Timmins F. Is there a place for reflection in the nursing curriculum? In my editorial to the December 2001 issue of Clinical Effectiveness in Nursing, I expressed regret, not for the first time, at an apparent lack of concern in nursing, midwifery and health visiting, with research into patient outcome, and a commensurate over-concern with educational research. Almost contemporaneously, Long and Johnson (2002) noted their concern over the comparative lack of outcome studies in nurse education. In this context, it is extremely welcome to have the opportunity to comment on Carroll et al.’s paper, which suggests how issues of education practice, assessment and outcome might (or might not) be related to matters of patient outcome. Reflective practice has a high profile in nurse education, but Carroll et al. draw our attention, in their convincing review, to the fact that little evidence exists to support the notion that so-called ‘reflective practitioners’ are more effective than others. Likewise, it is suggested that methods of assessing reflection are poorly researched. These are key issues for students, who presumably aspire to be effective practitioners, and the patients they serve, who have a right to expect expert care from health professionals. Both these expectations may be compromised if there are doubts about whether education for reflective practice leads to better clinical practice. The nature of this relationship is crucial. Proponents of reflection very often want to assert that reflection in some way improves patient care and the ability of practitioners to deliver it. In so doing, they are asserting a cause–effect relationship. I have argued elsewhere (Newell 1994) that some of the language of reflection impedes the transparency of this assertion, and that this may be part of an attempt to avoid refutation of the claims made for reflection – in other words, that reflection has been constructed as a pseudo-science. In the same issue of Nurse Education in Practice as that in which Carroll et al.’s paper originally appeared, Rolfe (2002) suggests reflection may have been reduced ‘from a radical alternative to technical rationality into merely an adjunct to it’. I have considerable sympathy for this view, since reflection, as envisaged by Schon (1983), described a far-reaching alternative to a world in which experts exerted power over clients, whilst many current formulations of reflection seem to view it merely as another element in the professional expert’s therapeutic armamentarium. Even so, I find Rolfe’s position ultimately unconvincing for two simple reasons. First, if we are to believe that reflection results in benefits to patients, whether these be defined narrowly in terms of clinical outcomes or more broadly in terms of patient empowerment in the care process, then we (and patients) will need convincing, and this requires studies using methods capable of teasing out these effects. Second, if reflection is to be a powerful critique of nursing and medical orthodoxy, it must be trustworthy, and this trustworthiness comes, I argue, once again from the results of studies which demonstrate that reflection actually makes a difference to professionals and their patients. If it didn’t, why should we bother to do it at all, and why should we hold that its ‘critique’ had any validity? In my 1994 paper, I argued that proponents of reflection should tell us if they were interested in patient outcomes or not, and that if they were, considerable work needed to be done in terms of operationalising what was meant by reflection. Carroll et al. seem quite clear, in their review, that this work has not gone much further over the years, and that, as a result, we should employ caution in our espousal of reflection as part of professional education and practice. Here, I feel, they hardly go far enough. Let us consider, in conclusion, two consequences of the inclusion of reflection in nursing curricula without clarity as to its meaning, or evidence as to its effect on patients. First, in my clinical practice (and, incidentally in my personal experience as a patient and a carer), patients seem actually to be quite keen on outcomes of care, usually more so than with process. I wonder how confident we might feel about telling patients that a major part of our curriculum was based on almost no evidence that it made a difference to their well-being, and that almost no research was being done to establish whether such an effect might exist. I see no reason why reflection should be a special case in this matter. Second, how will we explain to a student who has failed an assignment in personal reflective practice that they must redo this work (or even be terminated from the course), because they have failed an assignment examining something for which there is no evidence of client improvement, no evidence that it will make them a better practitioner, no consensus as to how best to assess it and no consensus on how it is to be defined. C 2002 Published by Elsevier Science Ltd. Clinical Effectiveness in Nursing (2002) 6, 42–43 °

doi:10.1054/cein.2002.0263, available online http://www.idealibrary.com on

43 REFERENCES Long T, Johnson M 2002 Research in Nurse Education Today: do we meet our aims and scope? Nurse Education Today 22(1): 85–93 Newell R 1994 Reflection: art, science or pseudoscience. Nurse Education Today 14(2): 79–81 Newell R 2001 What future for outcome research in nursing? Clinical Effectiveness in Nursing 5(4): 141–142 Rolfe G 2002 Reflective practice: where now? Nurse Education in Practice 2(1): 21–29 Schon DA 1983 The Reflective Practitioner: How Professionals Think in Action. Temple Smith, London

Rob Newell RGN, RMN, RNT, BSc PhD Professor of Nursing Research, School of Health Studies, University of Bradford, Unity Building, 25 Trinity Road, Bradford BD5 0BB Tel.: 01274 236474; e-mail: [email protected]