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: [email protected]

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