Critical thinking & reflective practice

Critical thinking and reflective practice are components of constructivist education. They are particularly suited to adult learning and complex higher order thinking required in nursing as the context of nursing is complex with often competing priorities. Critical thinking is the process of analysis and evaluation in order to form a judgement (Chenoweth, 1998; Morrall & Goodman, 2013).

In nursing critical thinking is often relegated to clinical decision making in its more restrictive sense of ensuring safe and ethical practice (Chenoweth, 1998). Such thinking is found in the ‘Nursing Process’ developed by Ida Orlando which reflects steps in the scientific process. Figure 3.4 shows the similarities between the nursing process and the scientific process cycles.

56

Figure 3.4 The nursing process & the scientific process

(Morrall & Goodman, 2013; Orlando, 1972)

Reflection on the other hand requires deeper thinking than systematic and logical thinking. It requires additional processes to deeply consider feelings, responses, actions and experiences in order to analyse them and learn from them (Atkins & Murphy, 1994; Siles-González & Solano-Ruiz, 2016). Reflection is enhanced by the ability to think critically (Tutticci, Lewis, & Coyer, 2016).

There are examples of successful use of reflective practice in clinical settings (Marlow, Spratt, & Reilly, 2008; Mason, 2003); however, there is a paucity of Australian nursing education research in this field. No articles were found in a literature search with the parameters ‘reflective practice in nursing education in

Australia 1/1/2020 – or ‘critical thinking in nursing education in Australia 1/1/2020 – ’.

The literature cautions the use of education methods which are not proven (Smith & O’Neil, 2003) and adds that it is reasonable to use these methods if they are valid. It suggests that the presumption of validity is perilous in contexts that are increasingly complex and ambiguous (Smith & O’Neil, 2003). It seems reasonable therefore to draw from acknowledged international sources in this field in the development of a PD program for nurses.

Four theorists are discussed below: Bolton, Kolb, Bloom and Maslow.

Bolton (2001) Figure 3.5 suggested a simple to remember three stage reflective practice model.

57 The reason for the need for reflection is that stimulus alone does not necessarily lead to learning. It is the engagement with/about the experience that leads to learning. The ever broadening and deepening cyclical process of stimulus, engagement and commitment provide a means of incorporating new knowledge (knowledge, comprehension) in practice (application) and considering the applicability of that knowledge (analysis, synthesis and evaluation) in and to practice (Bolton, 2001).

The cyclical process of learning which David Kolb popularised in the mid-1970s is similar in that it is considered to be a step wise cyclical approach, Figure 3.6.

Figure 3.6 Kolb's learning styles and experiential learning cycle

(McLeod, 2017)

Kolb did not believe that two things on the same axis could be done at the same time (feeling and thinking or doing and watching) (McLeod, 2017).

Reflective practice has been used in nursing education to develop higher order cognitive thinking skills (Rolfe, Freshwater, & Jasper, 2001). Higher order cognitive thinking skills and reflection occur at Kolb’s reflective observation and abstract conceptualisation stages. The process is limited in that the cycle does not allow for the creation/discovery of knowledge and this is something which is seen as fundamental to caring nursing practice in many theories of caring (Ray & Turkel, 2014; Watson, 2007; Watson Caring Science Institute, 2017; Wolf & France, 2017).

Higher order thinking may use the same step as found in Bolton and Kolb; however, the processes differ in so far as they may move beyond experience and practice to ‘creation’. Although Blooms taxonomy has been taught as a stepwise process for some time using the pyramid familiar to educators to depict the process (Cornwell, 2011) the process is iterative and at the same time cyclical, refer Figure 3.7.

58

Figure 3.7 Blooms taxonomy

(Vanderbilt University, 2020)

Maslow’s motivational model indicates the growth needs of the individual in relation to learning (Figure 3.8). These growth needs are reported to indicate needs which move beyond cognition to transcendence.

Figure 3.8 Maslow’s motivational model

(McLeod, 2020)

New research into brain function shows a stepwise progression this is not necessarily the case (Schoenberg et al., 2018). Research literature shows that at each

59 point during the lifespan any one or all of these processes may work in any circumstance (Doidge, 2017) and that evaluative thought in one domain of life does not necessarily mean evaluative thought occurs in all domains in life. Praxis assumes that reflection in action and on action can occur simultaneously and are mutually creative (Schoenberg et al., 2018). For this to happen, the individual must be capable of critical and reflective thinking (Ford & Profetto-McGrath, 1994) and be motivated to think in this way (Maslow, 1970a, 1970b).

When considering Kolb (1984), Bloom (2001), Bolton (2001) and Maslow (1970a), it can be seen that a PD program on caring nursing practices moves the nurse through increasing levels of commitment and praxis with ever broadening reflective practice at each incremental PD event. This requires consideration of teachers and learners needs as motivations in the teaching learning process (Figure 3.9).

Figure 3.9 From practice to praxis

The figure above shows use of the three theorists as learning moves participants from remembering (Bloom) concrete facts (Kolb) to higher order thinking which integrates thought and action (praxis) through the use of a critical thinking and reflective practice (Bolton). It considers the motivation of human needs in relation to education and the movement towards praxis.

In summarising this section on critical thinking and reflective practice it is important to note that not all these processes are ‘active’. As Mayeroff (1963) and nursing theorists acknowledge ‘the quiet dimension of experience’ the essence of ‘being’ as opposed to critical thinking makes room for an ‘awareness’ as opposed to a ‘making sense’. Watson (2005) takes the analysis of ‘being’ further and describes the transcendent primary state of ‘belonging’. Almost 60 years later Mayeroff’s (1963) conclusion to his essay on the ‘quiet dimension of experience’ is worthy of consideration by nurse educators, “It might even be more sensitive to contemporary stresses and strains precisely because it would see them in the light of a more

60 inclusive background, which perhaps remains constant and always relevant to [wo]man” (p. 153).

Developing the reflective practitioner from undergraduate education has been difficult (Mallik, 1998). Mallik (1998) recognises that in order to develop reflective practice in students there is a need for reflective practice to be integrated to all aspects of nursing: (1) pre-registration nursing education at educational institutions and in clinical practice, (2) education of registered nurses, (3) clinical educators and mentors. This research will engage nurses at aspects (2) and (3) above. Pre- registration students are specifically excluded from this research as they are not employed by hospitals in WA.

3.5.4.4 Educational content and methods for PD programs on caring nursing

practice.

Philosophy, nursing, sociology, and educational theory indicates that the content and methods of a PD program designed for nurses should be based on adult learning principles which enhance praxis; committed action informed by critical reflection, which positions practice and theory as mutually creative (Carr & Kemmis, 1986). In order to achieve praxis the learner is encouraged through the use of instructivist and constructivist teaching and learning methods to use critical thinking and reflective practice. The educational content, therefore, requires information on relevant theories and their application, together with; an opportunity to think about nursing practice, and to implement and practise new ways of thinking and doing.

This concludes the review of the four elements of the conceptual framework, philosophy, nursing, sociology and education.

The next two sections will first integrate the four theoretical approaches from the previous sections on philosophy, nursing, sociology and education to guide selection of PD content and approach to teaching and learning. It will include a summary of the key literature supports and deficits in the provision of PD in hospitals in WA. The next two sections consist of five key areas:

1. Factors affecting PD

i. Overarching factors affecting provision of PD. ii. Organisation of the hospital learning environment.

iii. International and Australian PD programs: Caring Nursing Practice.

2. PD in nursing

iv. Caring as emancipatory praxis in education. v. Caring in nursing education services.

61