Personal and Professional Role Development Reflection Directions and Guidelines 

Directions:

Module 6 Lesson 1 the purpose of reflection and provides visual cues to assist you in developing your ideas on the Patterns of Knowing and reflexivity. Please refer to and use the content and material in Module 6 Lesson 1 as you write your reflection. Refer to Module 1 Lesson 1 for the information on Patterns of Knowing. Remember you completed a Reading Guide in Module 1 Lesson 1. Now is the time to use it.

Requirements for the reflection paper are:

1. 1. Define each Pattern of Knowing and reflexivity in your own words. Do not use direct quotes from articles but rather paraphrase, cite appropriately, and make meaning of the term for you. Include each pattern in your reflection. Include reflexivity as a summary.
2. 2. Use the reflective questions/cues provided in the Module 6 lesson 1 to stimulate your thinking for each Pattern of Knowing. 
3. 3. Write a summary of your reflection using the reflexivity prompts from Module 6 Lesson 1 to guide you.
4. 4. Use the outline provided below. Download it and save to your computer so you can fully use the outline as a tool to assist you in developing your ideas. 
5. 5. Write the reflection as an essay adhering to APA for format and style. First person voice is appropriate for the reflection paper. It is expected that an introduction and conclusion are included as well as references as cited in the paper. A title page is required. You may want to use headers to organize your ideas. The paper should be double-spaced, 12-point font, and no more than 6 pages excluding the title page and reference page. 
6. 6. Read the Personal and Professional Role Development Reflection Grading Rubric before submitting your paper. Correct grammar, spelling, APA format and style is expected. Your instructor may deduct points for repeated errors

Outline: The outline does not constitute the final paper but rather is a worksheet and guide for you. You do not submit the outline. It is for your use only.

Definitions 

(See M1L1)

Reflection notes based on prompts/cues 

(See M6L1)

Personal Knowing

Aesthetic Knowing

Ethical Knowing

Empirical Knowing

Emancipatory Knowing

Reflexivity

ABSTRACT
Nursing students in the 21st century are entering highly

complex health care systems that require advocates for so-
cial justice and human rights on behalf of patients. Nurses
are well positioned as patient advocates. This article pres-
ents a brief overview of the historical and theoretical per-
spectives underpinning emancipatory knowing and pro-
poses several methods nursing faculty can use to empower
nursing students to provide care informed by this way of
knowing. Nursing faculty are urged to adopt a curriculum
that supports an emancipatory and caring praxis and to
mentor students to provide care supportive of social jus-
tice, particularly for the vulnerable and marginalized mem-
bers of society. Nursing students who learn to embrace and
value emancipatory knowing during their educational pro-
gram may likely continue this praxis after they graduate.
[J Nurs Educ. 2014;53(2):65-69.]

T
he complexity of the health care system and chaotic clin-
ical environments beckons nurses who can conceptual-
ize and integrate emancipatory knowing into their clini-

cal practice. A praxis of emancipatory knowing offers nurses a
means to refl ect and act in a manner that advocates for social
justice and human rights on behalf of the patients for whom
they care each day (Chinn & Kramer, 2011; Cowling, Chinn,
& Hagedorn, 2000; Falk-Rafael, 2005; Harden, 1996). Specifi –
cally, emancipatory knowing is the aptitude to acknowledge
social and political “injustice or inequity, to realize that things
could be different, and to piece together complex elements of
experience and context to change a situation as it is to a situ-
ation that improves people’s lives ” (Chinn & Kramer, 2011,
p. 64). Understanding the concept of emancipatory knowing
and its theoretical basis is essential to knowing how to integrate
it into practice. This way of knowing, derived from multiple
perspectives and theories, offers a relevant addition to nursing
research, theory, and practice (Chinn & Kramer, 2011). For
many nurses, the basis for understanding this concept may or
may not commence during their educational program, as it may
depend on their program philosophy, curriculum structure, and
the philosophical values and beliefs of the nursing faculty who
teach them. Given these different variables, contextualizing
emancipatory knowing may vary among nurses. Nursing stu-
dents, who learn to embrace emancipatory knowing as praxis,
may likely continue doing so after they graduate. The purposes
of this article are to present a brief overview of the historical
and theoretical perspectives that led to the conceptualization of
emancipatory knowing, to discuss its signifi cance to nursing,
and to offer examples of how nursing faculty can empower stu-
dents to integrate emancipatory knowing into clinical practice.

HISTORICAL OVERVIEW

Historically, nurses have confronted power imbalances
throughout their educational programs and careers. Emancipa-
tory efforts in nursing history are often blended with feminist
views, particularly during the feminist movement of the 1960s
and 1970s and as characterized by Jo Ann Ashley in her book
Hospitals, Paternalism, and the Role of the Nurse (1976; Chinn

Emancipatory Knowing: Empowering Nursing
Students Toward Refl ection and Action
Marianne Snyder, MSN, RN

Received: February 19, 2013
Accepted: September 11, 2013
Posted Online: January 7, 2014
Ms. Snyder is Assistant Professor of Nursing, Department of Nursing,

University of Saint Joseph, West Hartford, Connecticut.
The author thanks her doctoral academic advisor, Dr. Carol Polifroni,

University of Connecticut School of Nursing for her support.
The author has disclosed no potential confl icts of interest, fi nancial

or otherwise.
Address correspondence to Marianne Snyder, MSN, RN, Assistant

Professor of Nursing, Department of Nursing, University of Saint Joseph,
1678 Asylum Avenue, West Hartford, CT 06117; e-mail: msnyder@usj.edu.

doi:10.3928/01484834-20140107-01

Journal of Nursing Education • Vol. 53, No. 2, 2014 65

EMANCIPATORY KNOWING

& Kramer, 2011). In this book, Ashley (1976) traced the histori-
cal roots of oppression in nursing through a feminist lens and
presented a laudable critique of a patriarchal health care system
and the ongoing struggles of nurses who strive to gain control
over their education and practice. It was also during this period
that the concept of empowerment entered the nursing literature
(Bradbury-Jones, Irvine, & Sambrook, 2007; Hage & Lorensen,
2005; Kuokkanen & Leino-Kilpi, 2000; Manojlovich, 2007;
McCarthy & Freeman, 2008) and stimulated lively debate and
discourse within the nursing community. Despite more than
30 years later, these struggles persist, but not without the per-
severance of those who believe that change initiated through
emancipatory efforts does occur. Emancipatory knowing is a
call to action to advocate for social justice in a system that con-
tinues to permeate inequities and oppression among the masses
(Chinn & Kramer, 2011).

Throughout history, nurses have consistently advocated
for improved health conditions for individuals, families, and
communities, with a primary focus on addressing immediate
health care needs and educating people about health promo-
tion. Nursing care in the 21st century requires nurses to practice
with a broader emphasis on the historical, social, and political
structures in society (Clare, 1993; Falk-Rafael, 2005; Ford &
Profetto-McGrath, 1994; Harden, 1996; Kagan, Smith, Cowl-
ing, & Chinn, 2010; Kuokkanen & Leino-Kilpi, 2000; Rose &
Glass, 2008) to understand the impact of these factors on the
health and well-being of individuals, groups, and communities.

Chinn and Kramer (2011) introduced emancipatory know-
ing to the nursing literature and credited the infl uence of several
theories and perspectives when they developed this concept.
The following discussion about these infl uential theories and
perspectives aims to explicate the importance of integrating
emancipatory knowing into the curricula to help broaden nurs-
ing students’ awareness about hegemonic beliefs embedded in
the sociopolitical system and to support their capacity to ques-
tion the status quo.

THEORETICAL INFLUENCE

The concept of emancipatory knowing was developed
through an eclectic process that integrated concepts from other
theories and perspectives, namely critical theory, the postmod-
ernist and poststructuralist views of Freire (1995) and Foucault
and Gordon (1980), and White’s (1995) sociopolitical pattern of
knowing (Chinn & Kramer, 2011). Important to the process of
helping a student develop this way of knowing is a caring and
transformative teacher who guides students to learn beyond a
technical model of health care and instead uses an emancipa-
tory model to emphasize refl ection and action (Ford & Profetto-
McGrath, 1994; Owen-Mills, 1995).

Critical theory initially emerged during the 1920s from a
synthesis of ideas offered by philosophers from the Institute
for Social Research in Frankfurt, Germany, commonly referred
to as the Frankfurt School (Harden, 1996; Ray, 1992). The un-
derlying premise of critical theory includes three basic tenets
about knowledge—specifi cally, knowledge must be practical,
emancipatory, and have the potential to liberate the oppressed
(Kagan et al., 2010). In the 1960s, Habermas (1987) restruc-

tured critical theory by blending philosophical and sociological
perspectives to develop critical social theory (CST) grounded
in rational communication, as described in his theory of com-
municative action. Habermas’ (1987) theory offers a framework
to explain how modern society creates many social injustices.
A principle tenet of CST is to help oppressed people liberate
themselves from known and unknown societal oppression;
hence, CST offers a framework to study and conceptualize the
social and political factors infl uencing society (Chinn & Kramer,
2011; Ray, 1992; Wells, 1995).

Much of the CST literature is rooted in the work of Freire and
his pedagogy for liberation of the oppressed masses (Bradbury-
Jones et al., 2007; Freire, 1995). Freire (1995) contended that
the oppressed often subsume the worldview of their oppressor,
thinking that doing so will lead to greater power and control. In
reality, this social conformity often leads to marginalization of
the oppressed group and results in low self-esteem and low self-
worth (Roberts, 1983). Dialogue that asks questions of “how,”
“what,” and “why” as related to the various power structures
and relationships that exist in society helps frame a contextual
basis for nurses to understand the infl uence of these affi liations
on certain individuals and groups in society.

Discourses or symbolic representations in our culture shape
how we view our world and learn what is socially valued or dis-
counted (Chinn & Kramer, 2011). For example, White (1995)
expanded on Carper’s (1978) empirical, ethical, personal, and
esthetic patterns of knowing and added sociopolitical knowing
as a means to understand the sociopolitical and cultural contexts
that infl uence perceptions of health and illness, identity, lan-
guage, and relationship with society. Chinn and Kramer (2008)
developed emancipatory knowing and distinguished it from so-
ciopolitical knowing because it “embrace[s] a wide[r] range of
historical and contextual considerations, and… emphasize[s]
the fundamental intent to seek freedom from conditions largely
hidden that restrict the realization of full human potential”
(pp. 87-88). Foucault’s poststructuralist philosophy about power
imbalances created through discourse provides additional in-
sight to understand emancipatory knowing (Chinn & Kramer,
2011). When new knowledge and power gain momentum and
infi ltrate the prevailing discourse, they can serve once again to
infl uence thought and alter future actions.

These theoretical and philosophical perspectives elucidate
how sociopolitical, cultural, and historical factors can infl uence
human action. Developing an awareness of these factors, as
well as a belief in personal capacity to change, is an important
step toward advocacy and social action. Nurses are well posi-
tioned as health care leaders to advocate for social changes that
mitigate oppression. To support this call, nursing students need
support to exercise their power to apply an emancipatory praxis
throughout their profession.

CALL TO ACTION

Some believe that nursing is not as prepared as it could be
to address the plethora of health care challenges faced each day
by individuals and groups (Chinn & Kramer, 2011; Falk-Rafael,
2005). Nursing education programs would do well to heed this call
to action by adopting a curriculum that supports a caring praxis

66 Copyright © SLACK Incorporated

SNYDER

and mentors students to provide care supportive of social justice,
particularly for the vulnerable and marginalized members of so-
ciety. To acquire an aptitude for emancipatory knowing, nurses
need to develop a broader understanding of the sociopolitical
forces that compromise the ability of a person, family, or commu-
nity to fl ourish, free from oppression, within their world. Interest
and support for integrating emancipatory approaches into nursing
education and curriculum development have increased (Bevis &
Murray, 1990; Fontana, 2004; Ford & Profetto-McGrath, 1994;
Glen, 1995; Harden, 1996; Lipp, 2003; Parker & Faulk, 2004;
Randall, Tate, & Lougheed, 2007; Schreiber & Banister, 2002).
Nursing is called to closely examine the disciplinary practices
that suppress, rather than support, nurses who question assump-
tions and challenge the status quo (Kagan, Smith, Cowling, &
Chinn, 2010). Nurse educators can support this call to action by
examining current pedagogical practices that minimize student
critical thought and action pertaining to the curriculum or clinical
experiences. Teaching guided by emancipatory action may help
create a foundation for nursing students to integrate similar ap-
proaches into clinical practice.

FACILITATING STUDENT EMPOWERMENT

The following section presents a variety of methods that ed-
ucators can integrate into nursing curricula to guide students to-
ward an emancipatory praxis. The Table outlines each method
and the dimensions of emancipatory knowing to facilitate the

outcomes. It is anticipated that these approaches will inspire ad-
ditional dialogue about other effective strategies to help nursing
students embrace a broader understanding of the environments
in which they practice.

Randall et al. (2007) suggested using critical questioning as
an emancipatory method in teaching and learning, where the
teacher and student engage in a “co-creating dialogue meant to
serve as a trigger for thinking” (p. 61). This form of questioning
aims to guide the student through open and nonjudgmental dia-
logue to explore what specifi c knowledge guided their actions
while caring for a patient (Randall et al., 2007). In addition,
students who are able to share their experience of caring for a
patient using exploratory dialogue and questioning are likely
to increase their inquisitiveness as related to factors outside the
patient’s immediate diagnosis (Bevis & Murray, 1990; Randall
et al., 2007). Students who are empowered to refl ect critically
about clinical situations and ask questions about why certain
problems exist, how they can be resolved, why they occur, and
who benefi ts will learn to develop a deeper understanding of
their patients’ circumstances (Chinn & Kramer, 2011; Harden,
1996; Kagan et al., 2010). Use of critical questioning can help
nursing students to incorporate principles of emancipatory
knowing into their practice and offers those for whom they care
a voice to navigate the complexities of the health care environ-
ment.

Another strategy to enhance emancipatory knowing is to use
fi lms to stimulate refl ection and action. Films provide a platform

TABLE

Methods to Support an Emancipatory Praxis Among Nursing Students

Method Dimensions of Emancipatory Knowing Outcome

Engage in dialectical communication Critical questions; creative processes Explore potential discord between personal
preconceptions and others

Maintain a critical, refl ective journal Critical questions; creative processes Develop critical thinking and self-awareness to
increase one’s capacity as a refl ective practitioner

View fi lms for implicit and explicit themes
related to social justice

Critical questions; creative processes Broaden personal perspectives through critical
refl ection of movie themes and identify similarities
and diff erences in own practice

Participate in focus groups Formal expressions of knowledge;
authentication processes

Deepen understanding of self and others’
thoughts and actions when sharing multiple
perspectives about an issue

Write letters to newspapers, journal editors,
and state legislators concerning matters of
health care and professional practice

Formal expressions of knowledge;
integrated expression in practice

Increase confi dence advocating for patients and
self through praxis

Attend State Board of Nursing public
meetings

Formal expressions of knowledge;
authentication processes; integrated
expression in practice

Expand awareness of professional practice
issues and events within own state to advocate
intelligently on issues of social justice as they
impact patients and nursing

Join local and state student nurses’
associations and attend state legislative
sessions

Formal expressions of knowledge;
integrated expression in practice

Develop understanding of political processes
and empower self to take action and support the
health and well-being of others

Create blogs to share and communicate
views on particular social issues

Critical questions; creative processes; formal
expressions of knowledge

Discover personal voice and learn to communicate
personal views that advocate for action to address
injustices

Journal of Nursing Education • Vol. 53, No. 2, 2014 67

EMANCIPATORY KNOWING

from which dialogue and critique can stimulate discussions and
create greater insight into the meanings embedded in the story.
Parker and Faulk (2004) explained how they used the fi lm My
Life, starring Michael Keaton and Nicole Kidman, to encourage
nursing students to share their perspectives on the superfi cial and
underlying meanings conveyed throughout the story. Students
received several preliminary questions to think about prior to
viewing the fi lm, and they were asked to provide evidence from
the literature to support their understanding of family systems,
complementary health care, and dysfunctional communities
(Parker & Faulk, 2004). Although students were able to explore
and evaluate their feelings and attitudes as related to the real-life
circumstances portrayed in the movie, they were limited because
it was a situation in which none of them had any direct involve-
ment (Parker & Faulk, 2004; Randall et al., 2007). The use of a
similar approach based on real-life stories from personal experi-
ences and those reported in the news or from patient situations
students encounter during clinical rotations provides a realistic
platform to develop emancipatory knowing.

An additional strategy to foster emancipatory knowing in-
volves using focus groups throughout the nursing curriculum
to encourage students to share the experience of being a nurs-
ing student during clinical. This approach invites students to
discuss and analyze institutional and sociopolitical barriers that
may interfere in their ability to provide care free from these
constraints. Jacobs, Fontana, Kehoe, Matarese, and Chinn
(2005) conducted an emancipatory study of nursing practice.
They conducted a series of focus groups over 6 to 10 weeks
with experienced nurses from different regions of the northeast-
ern United States to learn about their views of contemporary
nursing practice. The purpose of their study was to help nurses
recognize various oppressive forces within their work environ-
ments and share their perspectives of nursing practice through
a dialectical process. Throughout these focus groups, the nurses
recognized their individual and collective power to propose
changes in either themselves or their work environments to
address the oppressive forces they experienced (Jacobs et al.,
2005).

The dialectic is another method of communication that en-
courages two or more individuals with differing views to dis-
cuss their perspectives. This communication approach inten-
tionally invites participants to share contradictory viewpoints
and employ rational arguments to discuss and explore existing
power structures in society (Fontana, 2004), and it also enables
nursing students to expand their understanding about emancipa-
tory knowing. Through a process of dialectic communication,
participants are encouraged to express their differing views and
thoughts freely and without fear of retribution (Burns & Grove,
2009). Use of a dialectical approach to teaching a class, rather
than teacher-directed lectures, offers students an emancipatory
approach to collectively express their views and experiences
related to a common issue or concern. Using this form of dia-
logue, faculty could integrate dialectical groups throughout the
curriculum to help students examine the health care needs of
marginalized individuals, groups, and communities. For exam-
ple, sessions could begin with an open-ended inquiry to explore
what marginalization means and whether any members have
ever experienced marginalization. Then, group members could

express their understanding of this concept using stories, poetry,
music, art, or personal experiences. Subsequent sessions may
explore questions related to conditions in society that contribute
to marginalization and actions that can be taken to help mitigate
its occurrence. The experience of such a dialectical process af-
fords each participant an opportunity to develop his or her in-
ner voice and helps encourage the participant to believe he or
she can make a difference through praxis (Chinn & Kramer,
2008; Jacobs et al., 2005). From the beginning of their nursing
program, students could freely participate in these dialectical
groups to broaden their understanding about various topics and
issues of interest.

Students learn to value the knowledge and experience gained
throughout their educational program when provided opportu-
nities to share them with those outside the health care environ-
ments. They usually learn early in their educational program
how to communicate therapeutically with patients and family
members, but not necessarily with elected public and state of-
fi cials. Encouraging students to write letters to newspaper edi-
tors and state legislators to support action for social justice can
help students develop and strengthen their political voice (Falk-
Rafael, 2005). Other supportive activities include having stu-
dents attend sessions at the state legislature and state board of
nursing, speak with lobbyists and representatives of their state
nurses’ association, and join their state and local student nurses’
associations. Given the various social media platforms available
today, students could also develop a professional blog or Web
page from which to express their sociopolitical views. Nursing
faculty who support these endeavors and explore opportunities
with students to broaden their views on power structures that
marginalize certain groups in society help students expand their
understanding of the social and political structures that impact
the health and well-being of these oppressed groups.

CONCLUSION

The profession of nursing is positioned strategically to ad-
vocate for social justice through refl ection and action. Intro-
ducing critical social theory and other emancipatory pedagogy
into a nursing curriculum helps nursing students build a knowl-
edgeable foundation for critical inquiry and praxis guided by
emancipatory knowing. The different methods discussed in this
article support this endeavor, but other approaches also exist.
Nursing faculty who value and practice within a critical theory
paradigm can mentor nursing students through this process
by engaging them in meaningful discourse with an emancipa-
tory aim. Patients and society as a whole benefi t when students
learn early in their educational program that the professional
responsibilities of a nurse include the adoption of an emancipa-
tory praxis to guide education, research, and practice. Nursing
students who learn to question and analyze the sociopolitical
conditions infl uencing the health of their patients may be more
likely to provide nursing care informed by emancipatory know-
ing and develop strategies to mitigate these oppressive forces.
Nurse educators are urged to support nursing practice informed
by emancipatory knowing and are called upon to share their
knowledge of other effective strategies to integrate emancipa-
tory praxis into a curriculum.

68 Copyright © SLACK Incorporated

SNYDER

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Journal of Nursing Education • Vol. 53, No. 2, 2014 69

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.

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I as discove the discipline of nursing. purpose of describing, explaining, and predict- tation of I
ing phenomena of special concern to the disci- t disease i s ,
pline of nursing. Most theory development .!I be thougk

1 IDENTIFYING PATTERNS and research efforts are primarily engaged in which cha
I OF KNOWING seeking and generating explanations which , varies accc

are systematic and controllable by factual evi- a static
Four fundamental patterns of knowing have dence and ~ h i c h can be used in the organiza- change in
been identified from an analysis of the con- tion and classification of knowledge. j tions that 1
ceptual and syntactical structure of nursing The pattern of knowing which is generally i unintelligi

I
knowledge.’ The four patterns are distin- designated as “nursing science” does not , The di
guished according to logical type of meaning presently exhibit the Same degree of highly in- , ceptualize
and designated as (1) empirics, the science of tegrated abstract and systematic explanations ranges a101
nursing; (2) esthetics, the art of nursing; ( 3 ) characteristic of the more mature sciences, al-
the component of a personal knowledge in though nursing literature reflects this as an I I ?e,”iyo~~e

ideal form. Clearly there are a number of co- i a human
existing, and in a few instances competing, and exten:

Source Carper, B. A. (1978) Fundamental patterns of knowing
in nurang. ANS, I ( 1 ) . 13-24. Reprinted w t h pemusslon from and structures-none of which has has sough]
copyright o 1978 Aspen Publ~shers, Inc achieved the status of what Kuhn calls a s ~ i e n – . both physic

i 22 i
1 1 –

used in the
never, since
jing empha-
of urgency,
)ody of em-
:sing. There
at there is a
the empiri-

natically or-
ories for the
and predict-
to the disci-
evelopment
engaged in

tions which
factual evi-

ne organiza-
ge.
I is generally

does not
of highly in-
:xplanations
sciences, al-
j this as an
~mber of co-

competing,
which has

calls a scien-

tific paradigm. That is, no single conceptua
structure is as yet generally accepted as an ex-
ample of actual scientific practice “which in-
clude[~] law, theory, application, and instru-
mentation together . . . [and] . . . provide[sl
models from which spring particular coheren
traditions of scientific r e s e a r ~ h . ” ~ ( ~ ‘ ~ ) It could bl
argued that some of these conceptual structures
seem to have greater potential than others for
providing explanations that systematically ac-
count for observed phenomena and may ulti-
mately permit more accurate prediction an+
control of them. However, this is a matter to bl
determined by research designed to test the va
lidity of such explanatory concepts in the con-
text of relevant empirical reality.

re as cues by which one can infer the range
or normal variations of health. It has also at-
tempted to identify and categorize significant
etiological factors which serve to promote or
inhibit changes in health status.

New Perspectives
What seems to be of paramount importance,
at least at this stage in the development of
nursing science, is that these preparadigm
conceptual structures and theoretical models
present new perspectives for considering the
familiar phenomena of health and illness in
relation to the human life process; as sucl
they can and should be legitimately countec
as discoveries in the discipline. The represen
tation of health as more than the absence of
disease is a crucial change; it permits health to
be thought of as a dynamic state or process
which changes over a given period of time and
varies according to circumstances rather than
a static eitherlor entity. The conceptual
change in turn makes it possible to raise ques-
tions that previously would have been literally
unintelligible.

The discovery that one can usefully con-
ceptualize health as something that normally
ranges along a continuum has led to attempts
to observe, describe, and classify variations in
health, or levels of wellness, as expressions of
a human being’s relationship to the internal
and external environments. Related research
has sought to identify behavioral responses
both physiological and psychological, that ma.

h exp
d
– con

, nec
y me1

*rent Stages
lne science of nursing at present exhibits
aspects of both the “natural history stage of in-
quiry” and the “stage of deductively formu-
lated theory.” The task of the natural history
c+nqe is primarily the description and classifica-

1 of phenomena which are, generally speak-
ascertainable by direct observation and in-

~ p e c t i o n . ~ But current nursing literature clearly
reflects a shift from this descriptive and classifi-
cation form to increasingly theoretical analysis
which is directed toward seeking, or inventing,
explanations to account for observed and clas-
sified empirical facts. This shift is reflected in
the change from a largely observational vocab-
ulary to a new, more theoretical vocabulary
whose terms have a distinct meaning and defi-
nition only in the context of the corresponding

lanatory theory.
Explanations in the several open-system
ceptual models tend to take the form com-

monly labeled functional or tele~logical.~ For ex-
ample, the system models explain a person’s
level of wellness at any particular point in
time as a function of current and accumulated
effects of interactions with his or her internal
and external environments. The concept of
adaptation is central to this type of explana-
tion. Adaptation is seen as crucial in the
process of responding to environmental de-
mands (usually classified as stressors), and en-
ables an individual to maintain or reestablish
the steady state which is designated as the goal
of the system. The developmental models
often exhibit a more genetic type of explana-
tion in that certain events, the developmental
tasks, are believed to be causally relevant or

essary conditions for the normal develop-
nt of an individual.

PART ONE: THE NURSING DISCIPLINE AND DEVELOPMENT OF KNOWLEDGE 1 FUND!
Thus the first fundamental pattern of

knowing in nursing is empirical, factual, de-
scriptive, and ultimately aimed at developing
abstract and theoretical explanations. It is ex-
emplary, discursively formulated, and publicly
verifiable.

Esthetics: The Art of Nursing
Few, if indeed any, familiar with the profes-
sional literature would deny that primary em-
phasis is placed on the development of the
science of nursing. One is almost led to be-
lieve that the only valid and reliable knowl-
edge is that which is empirical, factual, ob-
jectively descriptive, and generalizable. There
seems to be a self-conscious reluctance to ex-
tend the term knowledge to include those as-
pects of knowing in nursing that are not the
result of empirical investigation. There is,
nonetheless, what might be described as a
tacit admission that nursing is, at least in part,
a n art. Not much effort is made to elaborate
or to make explicit this esthetic pattern of
knowing in nursing-other than to vaguely
associate the “an” with the general category
of manual andlor technical skills involved in
nursing practice.

Perhaps this reluctance to acknowledge
the esthetic component as a fundamental pat-
tern of knowing in nursing originates in the
vigorous efforts made in the not-so-distant
past to exorcise the image of the apprentice-
type educational system. Within the appren-
tice system, the art of nursing was closely as-
sociated with a n imitative learning style and
the acquisition of knowledge by accumulation
of unrationalized experiences. Another likely
source of reluctance is that the definition of
the term art has been excessively and inappro-
priately restricted.

Weitz suggests that art is too complex
and variable to be reduced to a single defini-
t i ~ n . ~ To conceive the task of esthetic theory
as definition, h e says, is logically doomed to

failure in that what is called art has n o com-
mon properties–only recognizable similari-
ties. This fluid and open approach to the u n –
derstanding and application of the concept of
art and esthetic meaning makes possible a
wider consideration of conditions, situations,
and experiences in nursing that may properly
be called esthetic, including the creative
process of discovery in the empirical pattern
of knowing.

Esthetics versus Scientific
Meaning
Despite this open texture of the concept of art,
esthetic meanings can be distinguished from
those in science in several important aspects.
The recognition “that art is expressive rather
than merely formal or descriptive,” according
to Rader, “is about as weii established as any
fact in the whole field of esthetic^.”^(^^^^’ An es-
thetic experience involves the creation andlor
appreciation of a singular, particular, subjec-
tive expression of imagined possibilities’ or
equivalent realities which “resists projection
into the discursive form of language.”‘ Knowl-
edge gained by empirical description is discur-
sively formulated and publicly verifable. The
knowledge gained by subjective acquaintance,
the direct feeling of experience, defines discur-
sive formulation. Although an esthetic expres-
sion required abstraction, it remains specific
and unique rather than exemplary and leads
us to acknowledge that “knowledge-genuine
knowledge, understanding-is considerably
wider than our

For Wiedenbach, the art of nursing is
made visible through the action taken to pro-
vide whatever the patient requires to restore
or extend his [sic] ability to cope with the de-
mands of his [sic] s i t ~ a t i o n . ~ But the action
taken, to have a n esthetic quality, requires the
active transformation of the immediate ob-
ject-the patient’s behavior-into a direct,
nonmediated perception of what is significant
in it-that is, what need is actually being ex-

press’
need
actiol

T
bach
differ
t i ~ n . ~
the I:
wher
to S(
scher
goes
activc
tered
for tl
perce
resul-
gives

C
” e x p ~
creati
nursi
The ;
devel
modc
are
Dewc
actioi
mear
perie
signe
resul-
inder
dent
the c
total
that c
care
fragn

Esth

Empi
in or
ings-

art has no com-
gnizable similari-
proach to the un-
of the concept of

makes possible ,a
litions, situations,
:hat may properly
ing the creative
empirical pattern

the concept of art,
istinguished from
mportant aspects.
expressive rather
iptive,” according
:stablished as any
i e t i ~ s . ” ~ ( ~ ~ ” ‘ ) An es-
Le creation and/or
)articular, subjec-
d possibilities or
‘resists projection
nguage.Ip7 Knowl-
icription is discur-
cly verifable. The
ive acquaintance,
ce, defines discur-
n esthetic expres-
: remains specific
mplary and leads
wledge-genuine
-is considerably
m23)

jrt of nursing is
:ion taken to pro-
?quires to restore
:ope with the de-
.’ But the action
ality, requires the
e immediate ob-
r-into a direct,
vhat is significant
~ctually being ex-

pressed by the behavior. This perception of the
need expressed is not only responsible for the
action taken by the nurse but reflected i~

The esthetic process described by Wic
bach resembles what Dewey refers to a= ULC
difference between recognition and percep-
t i ~ n . ~ According to Dewey, recognition serves
the purpose of identification and is satisfied
when a name tag or label is attached according
to some stereotype or previously formed
scheme of classification. Perception, however,
goes beyond recognition in that it includ
active gathering together of details and
tered particulars into a n experienced t
for the purpose of seeing what is there. It is
perception rather than mere recognition that
results in a unity of ends and means which
gives the action taken an esthetic quality.

Orem speaks of the art of nursing as being
“expressed by the individual nurse through her
creativity and style in designing and providing
nursing that is effective and ~atisfying.”‘~’P’~~)
The art of nursing is creative in that it requires
development of the ability to “envision valid
modes of helping in relation to ‘results’ which
are a p p r ~ p r i a t e . ” ‘ ~ ‘ ~ ~ ~ ‘ This again invokes
Dewey’s sense of a perceived unity between a n
action taken and its result-a perception of the
means of the end as an organic whole.9 The ex-
perience of helping must be perceived and de-
signed as a n integral component of its desired
result rather than conceived separately as an
independent action imposed on a n indepen-
dent subject. Perhaps this is what is meant by
the concept of nursing the whole patient or
total patient care. If so, what are the qualities
that enable the creation of a design for nursing
care that eliminate or would minimize the
fragmentation of means and ends?

P Esthetic Pattern of Knowing

1 it.
eden-
.r +La

les a n
scat-

vhole

1 Empathy-that is, the capacity for participating
in or vicariously experiencing another’s feel-

j ings-is an important mode in the esthetic pat-
+

tern of knowing. One gains knowledge of an-
other person’s singular, particular, felt experi-
ence through empathic a~quaintance.”.’~ Em-
pathy is controlled or moderated by psychic
distance or detachment in order to apprehend
and abstract what we are attending to, and in
this sense is objective. The more skilled the
nurse becomes in perceiving and empathizing
with the lives of others, the more knowledge or
understanding will be gained of alternate modes
of perceiving reality. The nurse will thereby
have available a larger repertoire of choices in
designing and providing nursing care that is ef-
fective and satisfying. At the same time, in-
creased awareness of the variety of subjective
experiences will heighten the complexity and
difficulty of the decision making involved.

The design of nursing care must be accom-
.panied by what Langer refers to as sense of
form, the sense of “structure, articulation, a
whole resulting from the relation of mutually
dependent factors, or more precisely, the way
the whole is put t ~ g e t h e r . ” ~ ( ~ ‘ ~ ) The design, if it
is to be esthetic, must be controlled by the per-
ception of the balance, rhythm, proportion, and
unity of what is done in relation to the dynamic
integration and articulation of the whole. “The
doing may be energetic, and the undergoing
may be acute and intense,” Dewey says, but
“unless they are related to each other to form a
whole,” what is done becomes merely a matter
of mechanical routine or of ~ a p r i c e . ~

The esthetic pattern of knowing in nurs-
ing involves the perception of abstracted par-
ticulars as distinguished from the recognition
of abstracted universals. It is the knowing of a
unique particular rather than an exemplary
class.

The Component of Personal
Knowledge

Personal knowledge as a fundamental pattern
of knowing in nursing is the most problematic,
the most difficult to master and to teach. At the

same time, it is perhaps the pattern most essen-
tial to understanding the meaning of health in
terms of individual well-being. Nursing consid-
ered as an interpersonal process involves inter-
actions, relationships, and transactions between
the nurse and the patient-client. Mitchell points
out that “there is growing evidence that the
quality of interpersonal contacts has an influ-
ence on a person’s becoming ill, coping with ill-
ness and becoming i ell.”‘^(^^^^) Certainly the
phrase “therapeutic use of self” which has be-
come increasingly prominent in the literature
implies that the way in which nurses view their
own selves and the client is of primary concern
in any therapeutic relationship.

Personal knowledge is concerned with the
knowing, encountering, and actualizing of the

– concrete, individual self. One does not know
about the self; one strives simply to know the
self. This knowing is a standing in relation to
another. human being and confronting that
human being as a person. This “I-Thou” en-
counter is unmediated by conceptual cate-
gories or particulars abstracted from complex
organic wholes.14 The relation is one of reci-
procity, a state of being that cannot be de-
scribed or even experienced-it can only be
actualized. Such personal knowing extends
not only to other selves but also to relations
with one’s own self.

It requires what Buber refers to as the sac-
rifice of form, i.e., categories or classifications,
for a knowing of infinite possibilities, as well
as the risk of total commitment.

Even as a melody is not composed of
tones, nor a verse of words, nor a stat
of lines-one must pull and tear to tu
unity into a multiplicity-so it is with
human being to whom I say You. . . .
have to do this again and again; but ir
mediately he is n o longer YOU.’^’^^^’

the 1
7

Maslow refers to this sacrifice of form as
embodying a more efficient perception of

reality in that reality is not generalized nor
predetermined by a complex of concepts,
expectations, beliefs, and stereotypes.15 This
results in a greater willingness to accept ambi-
guity, vagueness, and discrepancy of oneself
and others. The risk of commitment involved
in personal knowledge is what Polanyi calls
the “passionate participation in the act of
knOWing.”16(~’7)

The nurse in the therapeutic use of self
rejects approaching the patient-client as an ob-
ject and strives instead to actualize an authen-
tic personal relationship between two persons.
The individual is considered as an integrated,
open system incorporating movement toward
growth and fulfillment of human potential. An
authentic personal relation requires the accep-
tance of others in their freedom to create
themselves and the recognition that each per-
son is not a fixed entity, but constantly en-
gaged in the process of becoming. How then
should the nurse reconcile this with the social
and/or professional responsibility to control
and manipulate the environmental variables
and even the behavior of the person who is a
patient in order to maintain or restore a steady
state? If a human being is assumed to be free to
choose and chooses behavior outside of ac-
cepted norms, how will this affect the action
taken in the therapeutic use of self by the
nurse? What choices must the nurse make in
order to know another self in an authentic re-
lation apart from the category of patient, even
when categorizing for the purpose,of treatment
is essential to the process of nursing?

Assumptions regarding human nature,
McKay observes, “range from the existentialist
to the cybernetic, from the idea of an informa-
tion processing machine to one of a many
jplendored being.”17(P399) M any of these as-
jumptions incorporate in one form or another
the notion that there is, for all individuals, a
characteristic state which they, by virtue of
membership in the species, must strive to as-
sume or achieve. Empirical descriptions and

clas
hur
PSY
enc

to t
req.
els
gen
hav
mol
eve
the
“sel
atio
kno
ized
is CI
pro]
son;
mer
the

Eth

Tea(
con;
pers
corn
choi
mor
witk
pro1
situi
the
to p1
codt
dicti
ical
prin
cept
hum
be a
spor
ing,

:eneralized nor
x of concepts,
: e ~ t y p e s . ‘ ~ This
to accept ambi-
3ncy of oneself
tment involved
3t Polanyi calls
in the act of

utic use of self
-client as an ob-
~lize an authen-
In two persons.
; an integrated,
vement toward
In potential. An
uires the accep-
dom to create
I that eachper-
constantly en-
ling. How then
with the social
ility to control
lental variables
)erson who is a
restore a steady
led to be free to
outside of ac-

ffect the action
of self by the
nurse make in
n authentic re-
)f patient, even
ae,of treatment
.sing?
uman nature,
l e existentialist
of a n informa-
ne of a many
y of these as-
>rm or another
I individuals, a
I, by virtue of
1st strive to as-
:scriptions and

classifications reflect the assumption that being
human allows for prediction of basic biological,
psychological, and social behaviors that will be
encountered in any given individual.

Certainly empirical knowledge is essential
to the purposes of nursing. But nursing also
requires that we be alert to the fact that mod-
els of human nature and their abstract and
generalized categories refer to and describe be-
haviors and traits that groups have in com-
mon. However, none of these categories can
ever encompass or express the uniqueness of
the individual encountered as a person, as a
“self.” These and many other similar consider-
ations are involved in the realm of personal
knowledge, which can be broadly character-
ized as subjective, concrete, and existential. It
is concerned with the kind of knowing that
promotes wholeness and integrity in the per-
sonal encounter, the achievement of engage-
ment rather than detachment; and it denies
the manipulative, impersonal orientation.

Ethics: The Moral Component

Teachers and individual practitioners are be-
coming increasingly sensitive to the difficult
personal choices that must be made within the
complex context of modern health care. These
choices raise fundamental questions about
morally right and wrong action in connection
with the care and treatment of illness and the
promotion of health. Moral dilemmas arise in
situations of ambiguity and uncertainty, when
the consequences of one’s actions are difficult
to predict and traditional principles and ethical
codes offer n o help or seem to result in contra-
diction. The moral code which guides the eth-
ical conduct of nurses is based on the primary
principle of obligation embodied in the con-
cepts of service to people and respect for
human life. The discipline of nursing is held to
be a valuable and essential social service re-
sponsible for conserving life, alleviating suffer-
ing, and promoting health. But appeal to the

ethical “rule book” fails to provide answers in
terms of difficult individual moral choices,
which must be made in the teaching and prac-
tice of nursing.

The fundamental pattern of knowing
identified here as the ethical component of
nursing is focused on matters of obligation or
what ought to be done. Knowledge of moral-
ity goes beyond simply knowing the norms or
ethical codes of the discipline. It includes all
voluntary actions that are deliberate and sub-
ject to the judgment of right and wrong-in-
cluding judgments of moral value in relation
to motives, intentions, and traits of character.
Nursing is deliberate action, or a series of ac-
tions, planned and implemented to accom-
plish defined goals. Both goals and actions in-
volve choices made, in part, on the basis of
norrrlative j~lrlzments,. both particular and
general. On occasion, the principles and
norms by which such choices are made may
be in conflict.

According to Berthold, “goals are, of
course, value judgments not amenable to sci-
entific inquiry and ~ a l i d a t i o n . ” ‘ ~ ( p ‘ ~ ~ ) Dickoff,
James, and Wiedenbach also call attention to
the need to be aware that the specification of
goals serves as “a norm or standard by which
to evaluate activity. . . [and] . . . entails taking
them as values-that is, signifies conceiving
these goal contents as situations worthy to be
brought a b ~ u t . ” ‘ ~ ( ~ ~ ~ ~ )

For example, a common goal of nursing
care in relation to the maintenance or restora-
tion of health is to assist patients to achieve a
state in which they are independent. Much of
the current practice reflects an attitude of
value attached to the goal of independence,
and indicates nursing actions to assist patients
in assuming full responsibility for themselves
at the earliest possible moment or to enable
them to retain responsibility to the last possi-
ble moment. However, valuing independence
and attempting to maintain it may be at the
expense of the patient’s learning how to live

28 PART ONE: THE NURSING DISCIPLINE AND DEVELOPMENT OF KNOWLEDGE

with physical or social dependence when nec-
essary-for example, in instances when prog-
nosis indicates that independence cannot be
regained.

Differences in normative judgments may
have more to. do with disagreements as to
what constitutes a “healthy” state of being
than lack of empirical evidence or ambiguity
in the application of the term. Slote suggests
that the persistence of disputes, or lack of uni-
formity in the application of cluster terms,
such as health, is due to “the difficulty of deci-
sively resolving certain sorts of value ques-
tions about what is and is not important.” This
leads him to conclude “that value judgment is
far more involved in the making of what are
commonly thought to be factual statements

– than has been imagined.”20’p220)
– — The ethical’pattern of knowing in nursing

requires an understanding of different philo-
sophical positions regarding what is good,
what ought to be desired, what is right; of dif-
ferent ethical frameworks devised for dealing
with the complexities of moral judgments; and
of various orientations to the notion of obliga-
tion. Moral choices to be made must then be
considered in terms of specific actions to be
taken in specific, concrete situations. The ex-
amination of the standards, codes, and values
by which we decide what is morally right
should result in a greater awareness of what is
involved in making moral choices and being
responsible for the choices made. The knowl-
edge of ethical codes will not provide answers
to the moral questions involved in nursing,
nor will it eliminate the necessity for having to
make moral choices. But it can be hoped that:

The more sensitive teachers and practi-
tioners are to the demands of the process
of justification, the more explicit they are
about the norms that govern their ac-
tions, the more personally engaged they
are in assessing surrounding circum-
stances and potential consequences, the

more “ethical” they will be; and we can-
not ask much more.21(p221)

USING PATTERNS
OF KNOWING

A philosophical discussion of patterns of
knowing may appear to some as a somewhat
idle, if not arbitrary and artificial, undertak-
ing having little or no connection with the
practical concerns and difficulties encoun-
tered in the day-to-day doing and teaching of
nursing. But it represents a personal convic-
tion that there is a need to examine the kinds
of knowing that provide the discipline with
its particular perspectives and significance.
Understanding four fundamental patterns of
knowing makes possible an increase:! 2ws:e-
ness of the complexity and diversity of nurs-
ing knowledge.

Each pattern may be conceived as neces-
sary for achieving mastery in the discipline,
but none of them alone should be considered
sufficient. Neither are they mutually exclu-
sive. The teaching and learning of one pattern
do not require the rejection or neglect of any
of the others. Caring for another requires the
achievements of nursing science, that is, the
knowledge of empirical facts systematically or-
ganized into theoretical explanations regard-
ing the phenomena of health and illness. But
creative imagination also plays its part in the
syntax of discovery in science, as well as in de-
veloping the ability to imagine the conse-
quences of alternative moral choices.

Personal knowledge is essential for ethical
choices in that moral action presupposes per-
sonal maturity and freedom. If the goals of
nursing are to be more than conformance to
unexamined norms, if the “ought” is not to be
determined simply on the basis of what is pos-
sible, then the obligation to care for another
human being involves becoming a certain
kind of person-and not merely doing certain

kinds < to be I capacil tive ex projecf lives bc

Nu
know11
in illne
humar
ing of 1
the cay
situatic
ments.
and in1
knowir
cordinj
circum
data it
each pi
and WE

Thl
of nu1
knowil
sions c
matter
referen
the reF
i n q u i r ~
edge g~
validity
of kno.
comple
questio
edge is
solutio:
and un
yet uns
methoc
structu
terns o
shape (
require
and cox
clarifiet

of patterns of
: as a somewhat
icial, undertak-
x t i o n with the
:ulties encoun-
and teaching of
lersonal convic-
3mine the kinds
discipline with

~d significance.
ntal patterns of
wreased aware-
versity of nurs-

zeived as neces-
I the discipline,
d be considered
nutually exclu-
g of one pattern
r neglect of any ‘”
ler requires the
Ice, that is, the
lstematically or-
nations regard-
and illness. But
‘s its part in the
as well as in de- 1
ine the conse- t
hoices.
:ntial for ethical
resupposes per- ..
If the goals of ‘

:onformance to ‘
ght” is not to be
i of what is pos-
are for another i
ning a certain I
ly doing certain I

kinds of things. If the design of nursing care is
to be more than habitual or mechanical, the
capacity to perceive and interpret the subjec-
tive experiences of others and to imaginatively
project the effects of nursing actions on their
lives becomes a necessary skill.

Nursing thus depends on the scientific
knowledge of human behavior in health and
in illness, the esthetic perception of significant
human experiences, a personal understand-
ing of the unique individuality of the self, and
the capacity to make choices within concrete
situations involving particular moral judg-
ments. Each of these separate but interrelated
and interdependent fundamental patterns of
knowing should be taught and understood ac-
cording to its distinctive logic, the restricted
circumstances in which it is valid, the kinds of
data it subsumes, and the methods by which
each particular kind of truth is distinguished
and warranted.

The major significances to the discipline
of nursing in distinguishing patterns of
knowing are summarized as (1) the conclu-
sions of the discipline conceived as subject
matter cannot be taught or learned without
reference to the structure of the discipline-
the representative concepts and methods of
inquiry that determine the kind of knowl-
edge gained and limit its meaning, scope, and
validity; ( 2 ) each of the fundamental patterns
of knowing represents a necessary but not
complete approach to the problems and
questions in the discipline; and ( 3 ) all knowl-
edge is subject to change and revision. Every
solution of an existing problem raises new
and unsolved questions. These new and as
yet unsolved problems require, at times, new
methods of inquiry and different conceptual
structures; they change the shape and pat-
terns of knowing. With each change in the
shape of knowledge, teaching and learning
require looking for different points of contact
and connection among ideas and things. This
clarifies the effect of each new thing known

on other things known and the discovery of
new patterns by which each connection
modifies the whole.

REFERENCES

1. Carper, B. A. “Fundamental Patterns of Know-
ing in Nursing.” PhD dissertation, Teachers Col-
lege, Columbia University, 197 5.

2. Kuhn, T. The Structure of Scientific Revolutions
(Chicago: University of Chicago Press 1962).

3. Northrop, F. S. C. The Logic of the Sciences and the
Humanities (New York: The World Publishing
Co. 1959).

4. Nagel, E. The Structure of Science (New York:
Harcourt, Brace and World, Inc. 196 1 \.

5. Weitz, M. “The Role of he or^ in ~ e s t h e t i c s ”
in Rader, M., ed. A Modem Book of Esthetics 3rd
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– 1960).
6. Rader, M. “Introduction: The Meaning of Art”

in Rader, M., ed. A Modem Book of Esthetics 3rd
ed. (New York: Holt, Rinehart and Winston
1960).

7. Langer, S. K. Problems ofArt (New York: Charles
Scribner and Sons 1957).

8. Wiedenbach, E. Clinical Nursing: A Helping Art
(New York: Springer Publishing Co., Inc.
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9. Dewey, J. Art as Experience (New York: Capri-
corn Books 1958).

10. Orem, D. E. Nursing: Concepts of Practice (New
York: McGraw-Hill Book Co. 1971).

11. Lee, V. “Empathy” in Rader, M., ed. A Modem
Book of Esthetics, 3rd ed. (New York: Holt, Rine-
hart and Winston 1960).

12. Lippo. T. “Empathy, Inner Imitation and Sense-
Feeling” in Rader, M., ed. A Modem Book of Es-
thetics 3rd ed. (New York: Holt, Rinehart and
Winston 1960.)

13. Mitchell, P. H. Concepts Basic to Nursing (New
York: McGraw-Hill Book Co. 1973).

14. Buber, M. I and Thou. Translated by Walter
Kaufman (New York: Charles Scribner and
Sons 1970).

15. Maslow, A. H. “Self-Actualizing People: A
Study of Psychological Health” in Moustakas,
C. E., ed. The Self (New York: Harper and Row
1956).

16. Polanyi, M. Personal Knowledge (New York:
Harper and Row 1964).

PART Om: THE NURSING DISCIPLINE AND DEVELOPMENT OF KNOWLEDGE

McKay, R. “Theories, Models and Systems for 20. Slote, M. A. ‘The Theory of Important Crite-
Nursing.” Nurs Res 18:5 (September-Octobc ria.” J Philosophy 63 (April 14 1966).
1969). 1. Greene, M. Teacher as Stronger (Belmont, Calif.: –
Berthold, J. S. ‘Symposium on Theory Deve Wadsworth Publishing Co., Inc. 1973).
opment in Nursing: Prologue.” Nurs Res 17:
(May-June 1968).
Dickoff, J., James P., and Wiedenbach, E. ‘Thc
ory in a Practice Discipline: Part I.” N u n Res 1
(September-October 1968).

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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

112013, Vol. 17, No. 3

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

Copyright of International Journal for Human Caring is the property of International
Association for Human Caring and its content may not be copied or emailed to multiple sites
or posted to a listserv without the copyright holder’s express written permission. However,
users may print, download, or email articles for individual use.

How nursing students can be empowered by
reflective practice
Dolphin, Sarah . Mental Health Practice (through 2013) ; London  Vol. 16, Iss. 9,  (Jun 2013): 20-23.

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Headnote

Reflection is not just another chore to complete on the way to qualifying, says Sarah Dolphin. She provides a

detailed description of how this skill helped her to learn from one particular incident during her training

Abstract

Reflective practice is seen as an important skill to develop because it enables a nurse to become self-aware and

provide the best possible patient care.

This article describes how an incident during the administration of an injection caused the author to examine

critically the events that occurred and their effect on patient and practitioner, and to learn from them. It is argued

that reflecting on practice in this way enables nurses to develop professionally and personally and, ultimately,

results in a higher standard of care.

Keywords

Reflective practice, self-awareness, communication, personal development, nursing student

AT UNIVERSITY we are told that reflective practice is crucial to being a good nurse. It allows the practitioner to

understand what occurred and to use the experience to improve care (Jindal-Snape and Holmes 2009, Mann et al

2009). But in my experience many nursing students and practitioners dismiss reflective practice as irrelevant,

perhaps because we are only required to think about it and do not need to evaluate it further.

For my part, as this issue was assessed in a second-year module, I considered it to be something simply to tick

offto pass the course. The critical incident I chose to reflect on leftme feeling terrible. At the time of the incident I

wanted to bury my head in the sand and pretend that it had not happened. If it had not been for someone pushing

me to write a reflective account I would never have realised that the incident was not a disaster but a situation to

learn from.

Here, I examine the incident and reflect on it to try to illustrate how useful the skill of reflection is.

Reflection does not simply mean thinking about a situation: it is the systematic appraisal of events that occurred

and examination of their individual components to learn from the experience and influence future practice. It

requires a high level of self-awareness and conscious efforts. This effort can develop into reflexivity, which can

challenge beliefs and assumptions (Brechin 2000).

Ichheiser (1970) highlighted that ‘the psychologically naïve, unreflective person lives and acts under the silent

assumption that he perceives other people in a factual, objective way’. Reflective practice is crucial to

acknowledge that objectivity is impossible without first understanding that practitioners will have an effect on

patient care, whether directly or through others, via their body language and other non-verbal and verbal

communication, and their thoughts and emotions.

The incident

I have chosen to use Gibbs’s model of reflection (Gibbs 1988), however I have adapted it by combining the

evaluation and analysis steps into a single section. The event I reflect on was the administration of a depot

injection that took place in a patient’s home. The injection was not given as it should have been: the vial shattered

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when I tried to open it and I cut myself. My mentor, who I will call Alison, gave me first aid. I then failed to give the

injection at the next attempt and had to repeat the procedure to give the prescribed dosage.

Description

There were three of us in the house at the time of the incident: the patient, myself and Alison. The purpose of our

visit was to deliver a long-acting antipsychotic injection, which I was going to administer under Alison’s

supervision and with the patient’s consent. We had explained why the medication had been prescribed and had

asked the patient whether there had been any reactions to, or problems since, the previous injection was given.

This was the second time I had given injection – my first was to a different patient the previous day and the

procedure had gone smoothly. The only feedback was that I should try to talk to the patient while giving the

injection because this would help her feel more at ease. It was acknowledged that this would become easier as my

confidence grew.

On the second occasion, I carried out the injection using the Z-track technique at the dorsogluteal site (Dougherty

and Lister 2011). When I met resistance from the muscle I stopped depressing the plunger and withdrew the

needle, but Alison informed me that I had not administered the entire dose. I replaced the needle with a new one to

reduce the risk of infection and gave the remainder of the dose with no problem. I had discussed the re-

administration with the patient, apologised for having to re-administer and obtained consent.

Feelings and thoughts

Throughout the process I was nervous. Despite having given one injection already with no problems, I was still

inexperienced and did not have confidence in my ability to give medication in that form. At each stage of the

process I had conflicting emotions, thoughts and feelings – for example, pride at not having ‘wimped’ out, while also

being apprehensive about being able to continue. I thought I might feel overwhelmed by the process, make a

mistake or have to hand over to Alison. The thought of being overwhelmed was much stronger than the pride I was

feeling. It almost took over my focus on the intervention I was carrying out, and other emotions and thoughts also

distracted me.

When the needle was withdrawn and Alison told me that the patient had not received the full dose I could feel

myself getting flushed and hot. I did not want others to be aware of my stress and embarrassment and think that I

was not competent to administer the injection. However, I found Alison’s presence reassuring in that she could

assist me should I need it, and she was helpful in guiding me through the process. Alison gave me positive

feedback to boost my confidence and put me at ease. This created a good feeling that I was acting and carrying

out the required actions in the appropriate way, and it helped because she would not have given me such feedback

if she thought I was not capable.

Evaluation and analysis

When I was told that I had not administered the medication fully I suddenly became aware of my position in

relation to the patient and Alison’s proximity to me. I became mindful that I was within their intimate space, which

made me feel uncomfortable. The patient was still and quiet, which could be interpreted in different ways: they

were unaware of the situation and of how I was feeling; they were concerned that I might need to administer again;

or they were not concerned and were waiting for me to inform them of what was going on – which I did as I

progressed through the next steps.

At this point, my mind went blank. I froze even though I should have been finding a plaster to put on the injection

site before continuing and was unable to speak. Then I heard Alison move from the sofa, which was about five feet

behind me, and stand next to me. Although I felt reassured by this, I was still anxious, and could feel my heartbeat

quicken.

Communication among professionals, or in this case a nursing student and mentor, is essential to maintain good

patient care and safe practice; a lack of communication can lead to problems in the patientprofessional

relationship (Shah 1993, Washer 2009).

Alison told me that I had not administered the full dose and I responded by becoming physically rigid. I turned my

head to look at her with an expression of apprehension, anxiety and fear. I felt my face flush red, my eyes widened

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and I opened my mouth slightly to help take a deep breath as I realised I had been holding my breath. Although I

perceived this reaction as a negative communication at the time, I took solace in the notion that many emotions

are ‘expressed best by non-verbal language’ (Hosley and Molle-Matthews 2006).

When Alison knelt beside me, she was square on to me so I could see without having to turn my body that her

posture was open. She was leaning in towards me as she guided me, making eye contact whenever it was

appropriate, and appeared to be relaxed and confident. Although at the time I did not notice this, because I was

focused on the task in hand, I was reassured that she was close by to help me through the next steps. Her

movement from the sofa was also a method of communication. The message I received was that she was there for

me. I communicated my relief by looking at her and acknowledging her presence.

She made gestures to indicate what I needed to do while talking to me in a low, quiet tone that conveyed she was

calm. I could hear her clearly but the patient would not have been able to do so. She talked me through what I

needed to do next, using unambiguous language – for example: ‘Right, so what you need to do now is attach a new

needle to the syringe. Good. Next you need to…’ This allowed me to go through her instructions one step at a time.

Doing so prevented me from becoming more confused and anxious, and forgetting what she had said and having

to ask her to repeat it. I acknowledged what she said by paraphrasing, summarising, reflecting and clarifying

(Stickley and Stacey 2009). Although I did not recognise this at the time, I was practising active listening skills.

After the patient had consented to me administering the injection again and I carried out Alison’s instructions, I

was upset that I needed her help in the first place. I felt like a failure for not being able to administer the injection

when I had done so before without any problems. I was also nervous about what else might go wrong, which added

to my anxiety. However, as I completed each step of her instructions I noticed I was not feeling any particularly

strong emotions because I was concentrating so much on the task.

I then became aware that the patient had not been spoken to for a while. It seemed like minutes but had in fact

only been a few seconds. I broke the silence by telling them that we were nearly done and Alison then turned to

look at me, nodded and gave me a smile. This reassured me that I had done the right thing and I felt less tense.

As I finished the final step of putting the plaster on the injection site, I felt a wave of relief, I wanted to show that I

was calm and that nothing remarkable had happened. However, this could not have been reflected in my body

language because the patient informed me that I had not hurt them and that I had done well. This revealed that I

was not as in control of my body language as I had thought and that I needed to find a way of being more aware of

myself. I took comfort in Hosley and Molle-Matthews’s assertion (2006) that many emotions are ‘expressed best by

non-verbal language’. But I was still embarrassed and upset.

During this experience, I had a certain degree of power over the patient. I was aware of this to an extent, in that if

the patient refused to have the injection then this would be reported, and if it continued it could result in them

being recalled to hospital. However, when the incident took place, there was a noticeable shiftin power from me to

the patient. The patient could have insisted that I stop administering the medication and that it was given by the

qualified nurse. The patient could also have refused to let me return for any future visits. Alison had power over me

at this point, too, and I could feel myself submitting to this in my body language, slouching slightly as she moved

towards me even though I had stiffened my muscles. At that point she also had power over me in terms of holding

the knowledge about what steps I should take to continue with the administration. I was also aware that I now felt

vulnerable, when before I had perceived the patient to be the vulnerable one.

But as I continued with the drug administration, I felt empowered. By being given instructions about what I should

be doing, I was able to take greater control (Norman and Ryrie 2009) of what was happening, and not simply give

up. I gained a greater understanding of why it is important to empower patients; being empowered myself showed

me how much it can help increase confidence.

Success and failure

I believe the incident as a whole was a success and a failure. It was a success because the medication was

administered as prescribed. On the other hand, breaking the vial, withdrawing the needle too soon, the lack of

communication and my nervousness, were all negative aspects of the process. On reflection, though, it did not go

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as badly as I thought it had, and I am embarrassed about my reactions to the events. The communication that

occurred during this incident was positive. It was effective in that it conveyed to me what I needed to do next and

that the situation could be rectified through communication, co-operation and collaboration between the three of

us. Although the main focus of the communication was between two individuals, there were three of us involved,

and all of us were communicating in some way.

There were many aspects of the situation described that I believe I could have carried out in a more positive way.

When I realised that I had not given the full dose, I should have placed the syringe back onto the tray following

removal of the needle and communicated verbally with Alison about what the next action should be. This would

have helped me to relax and I could have turned to face her. This would also have shown that I was listening

intently. I would then have demonstrated this through my communication with her. Although I believe I did this

during the incident, I could have done it more effectively if I had been making eye contact.

I could also have been more assertive by asking Alison to move closer to me when carrying out the injection. Her

physical presence would have reassured me. But when the procedure was being undertaken, I was aware that she

was in the room and was happy for her to stay on the sofa as she could observe well from there. This is because I

was feeling confident following the success of my previous injection I had administered.

I should also have checked visually to see that all of the medication had been administered, if I had done so the

incident that followed would not have taken place. Paradoxically, I would then not have had the experience of

having to re-administer the medication and would not have become aware of how much my body language

conveys my emotions and the importance of using active listening skills to enhance communication among

practitioners.

Action plan

In future, if I think that the process of administering medication is not being carried out perfectly, I will try to

remain calm. I will take a deep breath and speak to the nurse who is supervising me. I must also practise trying to

maintain a professional demeanor and remain in control of my body language. If I become injured and I am unsure

of how to act, I will ask a member of staffimmediately or as soon after the event as is possible to receive any

necessary treatment or first aid. I will then complete any relevant paperwork. Furthermore, I must ensure that I

acknowledge the patient who is being given the injection because throughout the process described here, my

focus was on the task in hand and not on the patient.

Discussion

The reflection I undertook required me to identify the individual components of this incident, explore my feelings

and my selfawareness surrounding those components, and critically examine them to improve my practice. This

highlighted all aspects of the incident and helped me to develop professionally. It also helped me develop my

personal way of carrying out some aspects of my practice, such as administrating intramuscular injections while

adhering to best practice guidelines.

Since carrying out this reflection, I have administered many injections successfully. Using reflective practice has

been beneficial because I have been able to tell my supervisor whether I wanted him or her to move next to me or if

I needed help. This feeling of empowerment and the confidence it gave me took me by surprise and made me want

to reflect thoroughly in the future.

Conclusion

Initially, I thought reflection was irrelevant, but through experience I have learned that this is not the case.

Reflection allowed me to examine an incident and turn what I had believed to be a negative experience into a more

positive one. It has had a positive effect on my self-awareness and communication, and has strengthened my

practice. It has also given me pride in the skills I have developed. Nursing students should regard reflection as a

valuable tool.

Sidebar

Alison made gestures to indicate what I needed to do while talking to me in a low, quiet tone that conveyed that

she was calm

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Online archive

For related information, visit our online archive of more than 7,000 articles and search using the keywords

Conflict of interest

None declared

References

References

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Gibbs G (1988) Learning by Doing: A Guide to Teaching and Learning Methods. Oxford Further Education Unit,

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AuthorAffiliation

Correspondence

sarah.dolphin@humber.nhs.uk

Sarah Dolphin is a staffnurse, Westlands Inpatient Assessment and Treatment Unit, Humber NHS Foundation

Trust, Hull

Date of submission

August 1 2012

Date of acceptance

October 18 2012

Peer review

This article has been subject to double-blind review and has been checked using antiplagiarism software

Author guidelines

www.mentalhealthpractice.co.uk

DETAILS

Publication title: Mental Health Practice (through 2013); London

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Volume: 16

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Publication date: Jun 2013

Section: Art &science | self-awareness

Publisher: BMJ Publishing Group LTD

Place of publication: London

Country of publication: United Kingdom, London

Publication subject: Medical Sciences–Nurses And Nursing, Medical Sciences–Psychiatry And Neurology

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