CITATION AND COPYRIGHT INFORMATION:
Cite as: Teekman, B. (1999, May). Using Sense-Making to explore reflective thinking processes in nursing practice. Paper presented at a non-divisional workshop held at the meeting of the International Communication Association, San Francisco.
© Bert Teekman (1999).

ESSENCE OF PROJECT:
The concept of ‘reflective practice’ has received considerable attention in the nursing literature, where it is described as the method par excellence to learn from clinical situations and advance the art and practice of nursing. So influential are the writings on reflective practice, that it has now been identified as a prerequisite competency for beginning nurse practitioners in Australia and New Zealand. To date, few empirical studies have been undertaken to examine what reflective practice actually is, how individuals use reflective thinking, and how it contributes to learning. The discourse in the literature, particularly among nurse-educators, has become increasingly muddled and justifies the question as to whether there is a shared and common understanding of the concept of reflective thinking. As educator and manager of the clinical component of the Bachelor of Nursing programme that emphasises reflective practice in its curriculum I felt compelled to research this concept in an attempt to create conceptual clarity.

THE REASONS I TOOK THIS ROAD:
As an educator, I am interested in theories of learning and in developing strategies that assists students to learn more effectively. As mentioned above, there appears to be a lack of common understanding of the concept of reflective thinking even though it has become one of the pillars on which many nursing curricula are built. As a result there are many assumptions being made, not only in regard to reflective thinking but also in regard to the benefits of it. For example, there is an assumption that all individuals are capable of reflective thought. Further more, as all students go to a whole variety of different clinical settings for short periods (usually 3 weeks only), there is a hidden assumption that ‘all’ environments or situations are suitable and/or conducive to reflective thinking. Little attention is paid as to the pre-requisites of reflective thinking. It is assumed that reflective thinking equates to learning and the development of knowledge, and that lecturers can teach and encourage reflective thinking in students. What’s more, the nursing literature emphasised not only that ‘journaling’ encouraged reflectivity, but also that this activity could be used as a tool to ‘measure’ or assess reflective thought.

These assumptions, as well as the general lack of understanding of what reflective thinking is all about, has led to students being provided with different instructions regarding the requirements as well as the intended outcomes of journaling. Many students challenged the use of journals for the purpose of assessing their level of reflection and they argued that the focus of journaling has shifted from a tool to encourage reflection to a means of getting a higher mark by writing what the lecturer would like to read. As such, students viewed journaling at best as very time consuming and at worst as a power tool used by lecturers for oppression and control. I was interested in analysing aspects or processes that are thought to make up what is considered reflective thinking. There is an underlying assumption that identifying and understanding these processes will allow an informed re-examination of all educational strategies that use reflective thinking as a tool for learning. As very little was known about reflective thinking in nursing practice, a qualitative research approach was not only appropriate but also essential in uncovering how individuals make use of reflective thinking. Qualitative research is hypothesis generating rather than hypothesis testing and has the ability to attend to factor-isolating and factor-relating levels of reflective nursing practice which are the beginning steps of theory development as it attempts to answer questions such as; What is reflective thinking in the nursing context? How do nurses think reflectively? What is the focus of reflective thinking in clinical practice? How does reflective thinking contribute to clinical practice?

The literature suggested that reflective thinking arises in situations where individuals experience a disjunction that prevents them from making meaning of the situation. Sense-Making studies how people create sense, or make meaning, in order to understand the world in which they live. The Sense-Making Methodology was selected because of its ‘natural’ affinity to reflective thinking. Sense-Making is a powerful approach because of its relative ‘simplicity’ and its acceptance of the existence of gaps between times, spaces, objects, and persons, and acknowledgement that discontinuity exists at intrapersonal and interpersonal level. S-M stresses the importance of communication within that process, a point clearly supported by Giddens who suggested that the study of communication should be the focus, and central to the study, of social science as a whole. The research participants illustrated this too by being engaged in discourse-with-self in order to built constructings that helped them to move on. Further more, I felt that the Micro-Moment Time-Line interview was particularly suited to explore reflective thinking. The interview technique anchors the participant in the context, which is all important during an experiential disjunction.

THE BEST OF WHAT I HAVE ACHIEVED:
1) As far as I know S-M as a research method had not been used in NZ before. Being able to collect sufficient information on a ‘new’ research method and apply it successfully in my research project was a major achievement, especially when one takes into account that I was strongly discouraged of using the S-M method. I believe that the initial resistance displayed by my supervisors was the result of the ‘gap’ that I had created by selecting the unknown research method. As creatures of habit, people don’t like situational discontinuities and those in power and control might first attempt to change rather than bridge these unknown situations. Through trial and error I have been able to develop more than a basic understanding of the S-M method.

2) Although the contemporary literature does not mention the existence of levels of reflective thinking, my research clearly uncovered that individuals not only reflect at different levels but also that there is a hierarchical structure of reflection. It was found that at the most fundamental level reflective thinking was used to create meaning in order to respond and act in an informed/intelligent manner to perceived stimuli from one’s environment. This was labelled ‘Reflective Thinking for Action’. At the second level, ‘Reflective Thinking for Evaluation’, the individual was concerned with a deeper and more holistic understanding of the experience and one’s own role within that particular context. The third and highest level, ‘Reflective Thinking for Critical Inquiry’, transcends from the actual experience in order to expose ideological and hegemonic conditions and challenge the status quo that serves the dominant class. Clear links could be drawn between the 3 levels of reflective thinking and Habermas 3 types of interest, the technical, the practical and the emancipatory interest.

3) The research outcomes challenged the long held beliefs that reflective thinking is an effective tool for theory development in practice. The findings do suggest that reflective thinking contributes to learning but that it relates to ‘practical knowing’ rather than ‘theoretical knowledge’. Practical knowing is the situational ‘know how’ that is typically inherent in the actions of the practitioner who has ‘learned from experience’. When asked how he/she understood the nature of the situation or how he/she knew what specific action was required, the practitioner is unable to verbalise this ‘know how’ other than to say, for example, that it was ‘intuition’, or that he/she could ‘sense’ or ‘feel’ what was wrong and what needed to be done to remedy the situation. Knowledge on the other hand can be verbalised and described in terms of ‘facts’, ‘rules’ and ‘theories’.

4) The research findings established clear conceptual links between the writings of Habermas (1972), Schön (1983, 1987), Benner (1984), and Giddens (1989).

WHAT HAS BEEN HELPFUL:
1) E-mail has been tremendously helpful, as it was my ‘life-line’ to Brenda Dervin. It was so good to know that I could contact her and that I would receive, most times within 24 hours, personal comments and suggestions that helped me to continue my journey. I believe that this was the single most helpful factor and as such incredible valuable. 2) Information about S-M in New Zealand was restricted to two items only with none of the other libraries being able to help me with additional information. Besides the many articles and book chapters sent to me by Brenda, I felt the dialogue on PROJECTI very useful as it challenged from time to time my own thinking about certain issues. It also directed me to other resources that were helpful. 3) Dewey’s 1933 writings on patterns of human thinking were very helpful in establishing a solid base from where to depart. Giddens (1989) introduced the notion of ‘monitoring’, which was of special interest to this study because of possible parallels with reflective thinking. Giddens maintained that human agents routinely monitor what they are doing at two different levels of consciousness; discursive and practical. Discursive consciousness refers to the ability to put things into words (Schön called this ‘knowledge-in-action’) while the practical consciousness consists of all the things that the agent knows tacitly without necessarily being able to give them discursive expression (Schön called this ‘knowing-in-action’). As a consequence, people who are asked about why they acted in a certain way often provide reasons that seem inadequate to the observer. Giddens’ writings explained the phenomenon encountered in my research that participants had difficulties discussing their learning.

WHAT WOULD HELP NOW:
I believe that the S-M method, with its special interview technique, is an ideal approach to encourage reflective thinking. As I have been a bit ‘isolated’ here in NZ I think that being able to talk and dialogue with others who have an interest in reflective thinking and a good working knowledge of S-M would help me to conceptualise a model that could be used for/by students to gain more knowledge from their practical experiences.

PROJECT ABSTRACT:
After exploring the seminal works of Dewey and Schön, the concept of reflective thinking was explored and clarified in order to arrive at an operational definition. Each participant was asked to share a recently experienced ‘non-routine’ nursing situation. Time-Line interviews of the ten events resulted in a total of 59 Micro-Moments, each of which was explored in-depth in terms of how the participants engaged in reflective thinking: i) how the participant perceived his/her particular situation; ii) the participant’s emotions and feelings; iii) the impact of the event on the participant and how it related to previous experiences; iv) the questions and confusions the participant identified at the time; v) the importance of those questions and how these questions helped; vi) those aspects within the situation that helped or hindered to find answers or reduce the confusion experienced; vii) what would have helped to clarify the situation and how/in what way; viii) what participants had learnt as a result of the experience. As the initial analysis found that self-questioning was an integral component of the reflective thinking process, participants were encouraged during the second interview to revisit every micro-moment and focus on their own self-questioning: i) How important were the questions you were asking yourself? ii) How, or in what way did these questions help you? iii) How did these questions help you to make decisions? iv) What have you learned from the situation/event you described since our last interview?

The study found that reflective thinking was extensively manifest in non-routine nursing situations, especially in moments of doubt and perplexity. Reflective thinking consisted of such activities as comparing and contrasting phenomena, recognising patterns, categorising perceptions, framing, and self-questioning as part of discourse-with-self. The latter activity was identified as a significant process within reflective thinking. Further more, by exploring and analysing the types of questions participants were asking themselves, the study uncovered three hierarchical levels of reflective thinking. Participants most frequently engaged in thinking processes that centred on the here and now in order to act: reflective ‘thinking-for-action’. On the second level, reflective ‘thinking-for-evaluation’ participants’ focused on creating wholeness of the situation and their reflective thinking contributed to the realisation of multiple perceptions and multiple responses. Reflective thinking-for-critical-inquiry is the highest level of the ‘Reflective Thinking Pyramid’ even though its occurrence could not be demonstrated in the study sample. The findings of this study resulted in the development of a ‘Dynamic Process Model of Reflective Thinking’, and are discussed in terms of the implications for nursing practice and nursing education. Finally, Sense-Making and in particular the Micro-Moment Time-Line approach is suggested as a framework to encourage and guide reflective thinking in nursing practice.

REFERENCES:
(For references to works by Dervin and colleagues, see Dervin’s writings: Chronological listing.)

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.

Dewey, J. (1933). How we think: A restatement of the relation of reflective thinking to the educative process. Boston, MA: D.C. Heath.

Giddens, A. (1989). The orthodox consensus and the emerging synthesis. In B. Dervin, L. Grossberg, B.J. O’Keefe, & E. Wartella, (Eds.), Rethinking communication, volume 1: Paradigm issues (pp. 53-65). London: Sage.

Habermas, J. (1972). Knowledge and human interest, 2d ed. London: Heinemann Educational.

Schön, D.A. (1983). The reflective practitioner. New York: Basic Books.

Schön, D.A. (1987). Education the reflective practitioner. San Francisco, CA: Jossey-Bass.

Street, A. (1990). Nursing practice: High hard ground, messy swamps and the pathways in between. Geelong, Victoria, Australia: Deakin University Press.

OTHER MATERIALS BY THIS AUTHOR ON THIS WEB SITE:
See:http://communication.sbs.ohio-state.edu/sense-making/AAauthors/authorlistteekman.html