19: ENHANCING THE DOCTORAL ADVANCED PRACTICE NURSING ROLE ■ 433a clinical situation unfolds around you, you may be thinking on your feet and making
apparently instant decisions (reflection- in- action), and then later, thinking over what
happened in order to make sense of it (reflection- on- action). In this way, Schön (1983)
argued that each practitioner builds a situational repertoire that is forever being ex-
panded and modified to meet new situations. Often, the alternations from practice
to theory and back to practice, and so on are so fast that it seems like one integrated
process, and
It is this entire process of reflection- in- action which is central to the ‘art’ by
which practitioners sometimes deal well with situations of uncertainty, insta-
bility, uniqueness, and value conflict. (Schön, 1983, p. 50)There is also the concept of “reflection- for - action,” which refers to the process of
anticipating, planning, and thinking about what is to come in the clinical situa-
tion (Thompson & Pascal, 2012). As a doctoral advanced nurse practitioner (NP)/
clinician, you have accumulated a huge practice repertoire of knowledge, skills, and
actions, most of which you may be largely unaware. In short, as an expert, you
possess “a deep background understanding of clinical situations based upon many
past paradigm cases” (Benner, 1984, p. 294), and “know more than you can tell”
(Polanyi, 1983). In your clinical setting, you may practice intuitively , which probably
involves a complex recognition of patterns within the situation, to which you can
respond without conscious deliberation. You just know what needs to be done, and
when called upon to explain your actions, you can be at a loss to provide a rational
justification.
This is where structured reflection can help to unpack your tacit knowledge,
bring it into awareness, and explicate it for others. There are many published mod-
els of reflection to use (e.g., Atkins & Murphy, 1993; Johns, 2004, 2007; Taylor, 2000),
but three simple questions can be used to explore any event or experience: What?, So
What?, and Now what? This sequence of questioning moves us through the processes
of description, analysis, and synthesis. If you wish, please work through the critical
questions at the end of this chapter, which will guide you through this process and are
relevant for all levels of reflection. These simple questions are based on Johns’s (2007)
model of structured reflection shown in Exhibit 19.1.
Many nurses (in my experience) complain that their work situation allows very
little space and time for reflection: “we’re just too busy... patients can’t wait for us
to reflect!” My response would be that reflective practice does not demand extra
time or energy, but an altered relationship to one’s work. Although in many settings,
groups of nurses reflect together on specific clinical incidents and may keep reflec-
tive journals to assist in making sense of their experience; however, these structured
methods are not always necessary. I encourage all my doctoral nursing students
in the United Kingdom to maintain a reflective research journal that helps to cap-
ture their changing thoughts and feelings as they progress through their program.
The journal entries act as an excellent resource for student/ supervisor meetings, a
guide for the reflective elements of their final thesis, and also a way to reinforce the
students’ reflexivity throughout the research process. If you (as a doctoral APN)
can make sense of your practice as you go about your daily work using system-
atic and thoughtful reflection, not only will this reflection increase your personal
understanding, it will also likely result in your continued professional growth and
self- empowerment.