19: ENHANCING THE DOCTORAL ADVANCED PRACTICE NURSING ROLE ■ 431modes of understanding, doing, and being (Rushmer & Davies, 2004). This intellectual
work of change can naturally create tensions between outside- in or research knowledge,
and inside- out or practice knowledge (Hargreaves, Earl, Moore, & Manning, 2001).
Nevertheless, changes in understanding that do not lead to changes in practice are
meaningless, while changes in practice that are not associated with changes in under-
standing will not lead to meaningful or lasting improvement (MacDonald, 2002). As
advanced practitioners, aspects of your practice can be so familiar that you may spend
a good deal of time on automatic pilot , hardly aware of your responses to routine situa-
tions. Is this intuitive expertise at work, or is it simply unthinking ritual?
■ WHY BOTHER TO REFLECT?
So why, you may be asking, should you bother to reflect? After all, your skills and
knowledge have been developed over many years, and your clinical practice has prob-
ably achieved a high standard. In my experience, APNs who undertake doctoral study
face the unsettling tasks of examining their practice and of challenging many things
they once took for granted. This unpacking of assumptions and questioning of the
evidence base for your practice can be acutely uncomfortable, as customary ways of
working over the years are exposed as perhaps having little justification or theoretical
foundation. It is here that reflection can come to the rescue. Some comments from my
United Kingdom students on the professional doctorate in nursing program may give
you a sense of their experience of reflection:
I question why we do things more in practice, and reflection has opened up
a totally new concept of what nursing means to me.
I cannot believe how many assumptions I held about my practice... strip-
ping these away has been scary but enlightening and empowering!
I ponder and question everything now; nothing is taken for granted, unless
I can give myself a sound rationale for doing that. It’s not comfortable, but
I now see how necessary it is.
I suggest that as a doctor of nursing practice graduate you will be expected to
extend the boundaries of professional knowledge and practice, and that this
contrasts with the role of the MSN graduate, whose role is to demonstrate
mastery of the discipline. Because of this increased expectation of the doctoral
advanced practice nurse , the skills of reflective practice become even more es-
sential. (Dreher & Montgomery, 2009; Teekman, 2000)
In striving to develop and enhance your nursing practice, the function of crit-
ical reflective inquiry is to “correct and improve the practice through self- reflection
and criticism and... [to] generate models of ‘good practice’ ” (Kim, 1999, p. 1206).
By bringing together head, hands, and heart (understanding, application, and emo-
tion), you can develop practical wisdom, or phronesis. Originally used by Aristotle
(trans. 1975), phronesis was one of three ways of knowing or “intellectual virtues,”
the other two being episteme and techne. Episteme is concerned with universal, sci-
entific, and context- free knowledge, whereas techne is related to practical, context-
dependent, and craft- based knowledge. Phronesis , however, involves ethical delib-
eration that is
Based on values, concerned with practical judgement and informed by re-
flection. It is pragmatic, variable... and orientated toward action. (Kinsella
and Pitman, 2012, p. 2)