Nursing
72013, Vol. 17, No. 3
Key Words: reflective practice, reflective
pedagogies; RN-to-BSN students,
nursing education
The Making of a Butterfly: Reflective Practice in Nursing Education
A butterfly gracefully flutters from
one flower to the next, taking nectar from
each flower, but also leaving pollen behind.
Imagine the expert nurse effortlessly
floating around the unit, meeting the needs
of the patients with her knowledge and
intuition and prepared for any setback.
The expert nurse gains a bit of knowledge
with each patient cared for, taking a piece
of the experience with her, while leaving
a part of herself with the patient in the
holistic care provided.
Nursing is truly a work of art that
requires a balance of many ways of knowing
at once. The transformation of caterpillar
to butterfly or student to nurse is part of
a process. The nursing student learns and
experiences the nursing world through
classroom and clinical education. The
student goes to a safe and comfortable place
to reflect on and explore self, newly gained
experiences, and knowledge. Eventually,
with time, reflection, and practice, the
student nurse will evolve into a nurse.
Therefore, the question becomes, what
is the nurse educators’ role in this
transformation and in what ways might we
assist in this journey? This paper explores
the phenomenon of reflective practice in
RN-to-BSN students. With reflective
practice being the cocoon in which nursing
students truly mature and prepare to spread
their wings.
What is Reflective Practice? There are different epistemologies and
ontologies in reflective practice. Reflective
practice was first documented with the work
of Greek philosopher, Socrates. Socrates
would lead exploratory discussions, in
which a group or person would examine
their knowledge on a topic and their
personal beliefs about it. This technique is
still used in many classrooms and is known
as Socratic discussions (McEntee et al.,
2003). Socrates’ most famous student,
Plato, continued this philosophical inquiry
by urging students to perform ontological
investigations by questioning their ideas
and values (Kuiper & Pesut, 2004). In the
nineteenth century, Florence Nightingale
wrote her reflections on nursing, thereby,
introducing reflective practice to the
nursing profession and forever changing
it (LaSala, 2009).
Reflective practice goes beyond the
revisiting of an event by taking the
practitioner on a journey of self-discovery
to become a better practitioner (McEntee
et al., 2003). This journey allows for the
exploration of knowledge, skills, values,
beliefs, experiences, myths, and needs that
ultimately lead to clarified conceptual
meanings and heightened self-awareness
(Asselin, 2011; Durgahee, 1997; McEntee
et al., 2003; Palmer, Burns, & Bulman,
1994). Reflective practice can be a form of
self-assessment (Cook, 2011). Reflective
practice can also be a spontaneous action
wherein the nurse pauses to consider a
decision regarding patient care, in what
Watson (2008) calls “caring consciousness”
(Palmer et al., 1994).
Reflective practice is the cyclic process
of internally examining and exploring an
issue of concern, triggered by an experience,
which creates and clarifies meaning in terms
of self, existing knowledge, and experience;
resulting in a changed conceptual perceptive
and practice (Asselin, 2011; Beam, O’Brien,
& Palmer, 1994). Palmer et al. (1994) and
Beam et al. (2010) suggest the use of Gibb’s
reflective cycle (Figure 1) to guide students’
reflections (Gibbs, 1988). Gibbs (1988) uses
the reflective practice process as a guide
for experimental learning. For the purposes
of this study, a form of guided reflective
practice was used, in which reflective
thoughts are articulated in words, either
written or verbal, with the assistance of
guiding questions or other tools.
Reflective Practice in the Literature Critically thinking is an essential skill for
a nurse. In the fast-paced nursing world,
nurses need to be able to think-on-the-fly
and be confident in their decision-making.
Nurses must have the courage to nurse and
The Making of a Butterfly: Reflective Practice in Nursing Education Jessalyn F. Barbour, MSN, RN, OCN Notre Dame of Maryland University
Abstract Reflective practice is the cyclic process of internally examining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self, existing knowledge, and experience. This is a descriptive phenomenological study that explores the guided reflections of eighteen RN-to-BSN students. The themes derived from the student text include (a) reflection in-action; (b) reflection on-action in daily nursing practice; (c) time, autonomy, experience, and fear were identified as barriers. By integrating reflective pedagogies into nursing curriculum, nurse educators can help students develop competence in reflective practice and enhance their learning for a lifetime.
8 International Journal for Human Caring
The Making of a Butterfly: Reflective Practice in Nursing Education
to question the status quo. Every novice
nurse dreams of being Benner’s (1984)
expert nurse, who floats through the day and
can think-on-the-fly to make decisions with
no disruption of care. Reflective practice
is a powerful process that contributes to the
making of a quality, expert nurse. Reflective
nursing practice empowers nurses in both
the educational and professional realms.
There are numerous benefits of reflective
practice. Reflective practice provides
experiential learning opportunities (Benner,
Sutphen, Leonard, & Day, 2010; Palmer,
et al., 1994). A qualitative study of eight
nursing students showed that reflective
practice enhanced learning (Bradbury-Jones,
Hughes, Murphy, Parry, & Sutton, 2009).
Another study evaluated the effects of a
reflective practice bachelor of science in
nursing (BSN) curriculum model, which
resulted in National Council Licensure
Examination (NCLEX) pass rate of greater
than 95% (Walker, Tilly, Lockwood, &
Walker, 2008). Being able to self-teach is
an important skill to have in the nursing
profession. The use of reflective practice
in education can assist nursing students to
learn from practice and to self-teach so that
they are better able to meet the challenges
of the professional nursing world (Benner
et al., 2010).
Reflective practice assists in the
cultivation of critical thinking skills in
students (Benner et al., 2010; Cook, 2011).
It has the ability to strengthen Carper’s
(1978) four patterns of knowing: empirical,
esthetical, personal, and ethical knowledge
(Davis, Taylor, & Casida, 2011). Reflective
practice prepares the nurse to ask the right
questions in the clinical practice setting and
notice slight changes in their patient’s status
(Picard & Henneman, 2007). Furthermore,
reflective practice can improve
communication skills in nursing students
(Durgahee, 1997).
Reflective practice is a journey of self-
discovery that leads to better practitioners
(McEntee et al., 2003). A study by
Bradbury-Jones, et al. (2009) shows an
increase in students’ self-awareness after
the implementation of reflective practice.
Reflective practice increases the likelihood
of the nurse providing ethical and holistic
care (Gustafsson, Asp, & Fagerberg, 2007).
A study on the use of reflective practice in
surgical nurses shows a positive correlation
between reflective practice and authentic
nurse-patient relationships (Flanagan, 2009).
Reflective practice cultivates presence,
which is an essential element of relational
engagement with patients (McMahon &
Christopher, 2011; Picard & Henneman,
2007) and leads to more individualized
nursing practice (Flanagan, 2009). A study
that examines the effects of reflective
practice on RN-to-BSN students shows that
it changed the nurses’ practice perspectives
and actions (Asselin, 2011).
Reflective practice can be used to
help bridge the theory-practice gap by
encouraging examination, exploration,
and connections (Benner et al., 2010;
Davis et al., 2011; Smith & Jack, 2005).
Reflective practice has the potential to
decrease stress in nurses’ professional
lives (Palmer, et al., 1994) and promotes
integrity, balance, and morality (Bjarnason
et al., 2009). It has been shown to promote
the development of intuition, which is the
essence of the expert nurse (Benner, 1994;
Hannigan, 2001).
While reflective practice can be a
beneficial tool and process, it also has
limitations. There is limited research on
reflective practice in nursing education in
the United States. There are also barriers
involving students and reflective practice.
Some students are not open to the idea of
reflective practice (Benner et al., 2007;
Kuiper & Pesut, 2004). They feel vulnerable
exposing their thoughts and feelings to
others, they feel uncomfortable with their
DDeessccrriippttiioonn- What happened?
FFeeeelliinnggss- What were you thinking or
feeling?
EEvvaalluuaattiioonn- What was good & bad about the
experience?
AAnnaallyyssiiss- What sense can you make of this
situation?
CCoonncclluussiioonn- What else could you have done?
AAccttiioonn PPllaann- What will you do if you are in this situation again?
Figure 1. Reflective Practice Cycle (adapted from Gibbs, 1988)
92013, Vol. 17, No. 3
The Making of a Butterfly: Reflective Practice in Nursing Education
own emotions, and/or they are satisfied with
their current level of competence (Asselin,
2011; Benner et al., 2010; Kuiper & Pesut,
2004). Time is a major barrier for nurses
and students to practice reflective practice
(Beam et al., 2010; Bradbury-Jones et al.,
2009; Picard & Henneman, 2007; Smith
& Jack, 2007).
Exploration of RN-to-BSN Students Use of Reflective Practice
A nursing student’s educational journey
can be enhanced with reflective practice,
both spontaneous and guided. In addition,
reflective practice in the nurse can improve
practice. So the question becomes, do
RN-to-BSN students use reflective practice?
How do they use it? What obstacles do
they encounter that discourage
reflective practice?
Study Design This is a descriptive phenomenological
study.
Study Setting The study took place at a private
university in Baltimore, Maryland.
Study Sample The sample included 18 RN-to-BSN
student essays from two accelerated
contemporary nursing trends and theory
courses.
Study Procedure Week two of six in the contemporary
nursing trends and theory course was an
online class. It consisted of a slideshow
presentation on the Nursing Code of Ethics
and various activities, all to be completed
within one week. One of the activities was to
read an article on reflective nursing practice
and then answer the following questions in
a one-to-two page essay:
(a) In what ways do you engage in
reflection about your nursing
practice? Tell a story or two using
rich descriptive language where
you show reflective practice and
what it means.
(b) In your experience, what allows
for and what gets in the way of
reflective practice?
Gathering of Student Text The participants submitted typed essays
that were a response to the above questions.
The essays were not graded, but were a
pass/fail type item for participation in the
online class.
Interpretation of Student Text and Text Analysis
The essays were reviewed and themes
were derived. Themes were validated by a
doctorate-prepared research consultant and
the study participants.
Results Three major themes were identified from
the student text. Only the essays examining
the previously mentioned questions were
included (n=18).
Theme A: Nurses reflecting
in-action/thinking-on-the-fly
Most (n=16) of the nurses in this study
describe what Schön (1983) calls reflection
in-action. The nurses describe situations in
which they reflected while working and
make decisions and/or changes based on
these reflections. These nurses think-on-the-
fly and make decisions on the go. Many of
these nurses are experienced nurses who
have been in the nursing profession for years
and describe a time when they were less able
to perform reflective practice and less
confident in their decision-making abilities.
Jane states, “As a newer nurse, engaging in
reflection, happened after the experience
occurred.” Jane went on to explain that with
experience she was able to reflect while the
experience was happening, think-on-the-fly.
The majority of the reflections in-action
revolves around ethical or moral issues and
the nurses dealing with difficult situations.
Some (n=4) describe asking themselves,
“How would I like to be treated if I were the
patient?” These reflections led to decisions
in which the nurses advocate for their
patients. These reflections also allow the
nurses to provide more individualized
patient care. A few nurses discuss the
exploration of their feeling while in-action,
which allow for improved decision-making.
Reflection in-action is also used by
the nurses to help them prioritize. Many
claimed that this ability came with
experience. Some nurses even describe
reflecting with their peers throughout the
work day. This collegial support aided them
by increasing their confidence in their
decision-making abilities.
A number of the nurses (n=4) stated
that reflection in-action allowed them to
link theory to practice. Many described
the application of theory into their daily
practice and the solidifying of theory
when they actually saw it in action. Shari
describes her nursing education and states
that “during clinical rotations, things began
to become clearer and all the textbook
knowledge became significant” once it
was seen in action.
Theme B: Nurses reflecting
on-action/retrospectively
All (N = 18) of these nurses practice
reflection on-action, which is the examining
of an event after it has occurred (Schön,
1983). This type of reflection does not
appear to be related to experience. Many
nurses also use this method to deal with
ethical or moral issues. However, this
retroactive reflection rarely changed the
event reflected on, but rather allowed the
nurses to make changes to their practice and
methods in the future. Reflection on-action
allowed the nurses to change and improve
their nursing practice. They describe being
able to learn from experience. Amy
describes reflective practice as “simply
learning from my experiences and providing
the best possible care based on those
experiences…I reflect to grow professionally
and personally.”
Reflection on-action allows these nurses
to examine themselves and explore their
feelings. This produces a self-awareness
and confidence within the nurses. Self-
assessment allows the nurses to make
appropriate changes and to be aware of their
limitations in practice. Reflection on-action
allows the nurses to have a more holistic
and open-minded view. Many nurses discuss
the concept of authentic nurse-patient
relationship and the importance of their
presence in their patients’ care. Mary states,
“I will remember that patients and their
families need us so the pumps can blare,
and the phones can continue to ring.” Mary
discusses the importance of just being there
for her patients when they need her and not
allowing tasks to get in the way. Some even
state that this action helps prevent burn-out
syndrome. All of these products of reflection
on-action lead to higher quality and more
holistic nursing care.
Theme C: Barriers
One obvious barrier is experience;
practice makes perfect. Those nurses with
more experience were better versed in
reflective practice. Other barriers include:
fear of emotions and self-exploration; time;
and lack of autonomy.
Time appears to be the most common
obstacle for nurses trying to engage in
reflective practice. Many described a fast-
paced and hectic environment in which they
had no time for reflective practice. Others
described heavy workloads and high acuity
patients, which left little time for anything
else. High nurse-patient ratios were also
mentioned as a barrier to reflective practice.
A few nurses report that having to perform
multiple roles and being pulled in many
directions was time consuming and left
little time for anything else. Bethany states,
“New technology and experimental life
sustaining techniques also add a complexity
to caring for our patients that leaves little
time for reflection.”
Another barrier that is frequently
mentioned is the lack of autonomy in
nursing. Many of the nurses in this study
feel that policies and procedures dictate
how they practice; they feel restrained by
organizational rules and regulations. Allison
said, “With so many rules and regulations
that require enormous amounts of time spent
on documentation, it is not hard to see why
many nurses have become so focused on
completing tasks in nursing and lose sight
of the caring aspect nursing was founded
on.” This leads into another barrier that the
nurses discuss, nursing’s obsession with
tasks and documentation, which takes the
focus off the patient, caring, and reflective
practice. Lastly, the nurses discuss the lack
of autonomy due to administration and
physicians. These limitations and barriers
can be hard for nurses to overcome,
especially when they are inexperienced and
lack the tools needed for reflective practice.
Discussion It is well known that the gaps between
theory and practice in nursing need to be
bridged and that a curriculum revolution in
nursing education is underway. In order for
nursing education to produce holistic nurses,
its curriculum must be balanced. One
possible way to aid in this journey is the
use of reflective practice.
This study has shown that practicing
nurses in a RN-to-BSN program use
reflective practice on a daily basis. This
skill has aided them in many ways. It allows
nurses to learn from experience and make
changes to their practice to provide higher
quality care. Reflective practice assists the
nurse to be truly present and aware of
themselves and the patients they care for.
It promotes the unification of theory and
practice. Reflective practice supports nurses
in being morally and ethically sound in
their care. It encourages continued growth
by way of self-assessment and self-
awareness. Lastly, it fosters a more holistic
nursing approach.
Reflective practice should be taught
during nurses’ initial education. It is an
important and valuable skill to have.
Reflective practice should be used and
developed throughout the nursing program
curriculum, that way the novice and
beginning nurses are able to use it
immediately upon entering practice. “The
process of learning to learn from experience
is as important as the end product of the
learning, namely an ability to view a
phenomenon from a different perspective
and translate new knowledge into action
(Palmer, et al., 1994).” Learning to learn
is a valuable gift that nurse educators can
bestow upon nursing students to use in the
rapidly changing nursing world.
Implications for Practice There are numerous ways that reflective
pedagogies can be used in nursing curriculum.
In order to be successful, reflective practice
must be interwoven throughout the curriculum.
Much of the nurse’s clinical education is
experimental learning. To be effective, the
environment must be safe, rich, and provide
opportunities for reflection (Benner, et al.,
2010). Many times reflective practice is
completed orally during clinical post-
conference or simulation de-briefing. Wherein,
the clinical instructor will ask the students to
talk about their experience while offering
questions for the group to reflect upon
(Diekelmann, 2003). Another method is
reflective journaling. Usually, students will
require some guiding questions for their
journals, but eventually reflective journaling
becomes like second nature. Reflective journals
are used to encourage the students to analyze
an experience and determine the best approach
to use in the future by examining the literature.
Students can be transformed by these
experiences, but only if they are able to notice
and acknowledge the experiences (Benner
et al., 2010). Nursing students must be engaged
and play an active role in their learning.
These methods of reflective practice can
also be used in the classroom. The nurse
educator can facilitate Socratic discussions,
where the students are encouraged to open
themselves to new ideas and knowledge
and to question the status quo. A case study
or a lived experience that expands a student’s
boundaries of knowledge can be reflected upon
through group activities or narrative papers.
Blogs and discussion boards can be used to
have reflective conversations in the online
classroom (Davis, Taylor, & Casida, 2011).
10 International Journal for Human Caring
The Making of a Butterfly: Reflective Practice in Nursing Education
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The Making of a Butterfly: Reflective Practice in Nursing Education
There are many other ways of using
reflective practice in the classroom setting.
The possibilities are endless. Reflective
practice assignments can assist the nurse
educator in knowing whether the student is
truly comprehending content and making
the appropriate connections between theory
and practice. Reflective practice is not an
ends to a means, it is a cyclic process that
should continue throughout a nurse’s career.
Reflective practice must be used in
combination with other student-based and
practice-based teaching strategies (Benner
et al., 2010; Palmer et al., 1994). Reflective
practice must be integrated into an entire
program’s curriculum in order to obtain
holistic results (McEntee et al., 2003).
Nursing instructors must be well versed
in reflective practice, in order to lead and
guide students thru the reflective process
(Palmer et al., 1994). Reflective practice
has immense potential in nursing academia.
Conclusion Reflective pedagogies should be
integrated into nursing curriculum. The
literature, the experts, and this study elucidate
the potential that the reflective practice
phenomenon has for enhancing nursing
education and practice. While technology
and procedures may change, reflective
practice is a skill nurses can use for their
entire career. By guiding students through
the process of reflection and providing them
with a safe space for reflection, nurse
educators can help them develop competence
in reflection and enhance their learning for
a lifetime. Nurse educators are in a position
to provide nursing students with the tools
needed for self-learning. There are numerous
reflective practice techniques that can be
used in nursing education and some can even
be used as a means of assessment. Reflective
pedagogies have the ability to transform
nursing education and nursing practice.
Reflective practice can assist in the
transformation of a student into a balanced
nurse. Essentially, reflective practice supports
the making of a butterfly – an expert nurse.
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12 International Journal for Human Caring
The Making of a Butterfly: Reflective Practice in Nursing Education
Author Note Jessalyn Barbour, MSN, RN, OCN is an oncology clinical educator at Anne Arundel Medical Center in Annapolis, Maryland and an
adjunct professor at Notre Dame of Maryland University’s School of Nursing.
This research was not supported financially by any grants or organization. Many thanks to Mary Packard, PhD, RN and Nadja Muchow,
MS, RN, CBN for their support and assistance with this study.
Correspondence concerning this article should be addressed to Jessalyn Barbour, 4th Floor - Oncology, Anne Arundel Medical Center
2001 Medical Parkway, Annapolis, MD 21401. Electronic mail can be sent via Internet to: JessaBarbour@verizon.net
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