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1. Introduction

Nursing profession has been applying various theories to recognise the experience that create
knowledge to guide them into their action as practitioners. In achieving this nursing
profession adopted reflective practice to check and balance their experience in daily chores.
This practice is adopted from Carpers knowing the knowledge which is beyond the
empirical but accepted as practice in nursing based on her experience (Carper, 2006).

1.2 Nursing Reflective practices

Reflection is the examination of personal thoughts, feelings, knowledge and actions. For
practitioners this means focusing on how they interact with their colleagues and with the
environment to obtain a clearer picture of their own behaviour. It is therefore a process by
which practitioners can better understand themselves in order to be able to build on existing
strengths and take appropriate future action. And the word action is vital. Reflection is not
navelgazing. Its aim is to develop professional actions that are aligned with personal beliefs
and values. There are two fundamental forms of reflection: reflection-on-action and
reflection-in-action. Understanding the differences between these forms of reflection is
important. It will assist practitioners in discovering a range of techniques they can use to
develop their personal and professional competences.

Reflective practice can actually be an informal nature or formal which examine the nurses
experience in daily chores. The model use persons thought and feelings and eventually
enable the describer to analyse their experience which provide room for experiential learning
(Atherton, 2010). For example, the pain score of patients who are lying on the bed for a
long period of time allow the nurse to reflect on her experience which are initially based of
expressing the event, her own feeling and thought about the event and eventually analyse the
event based on praxis of knowledge mixed with her experience. Based on this a few models
was developed in nursing practices to enhance nurses practices based on their knowledge
through reflection itself.

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There are many models of reflection in nursing practices which are widely used. The most
commonly used in todays nursing practices are Kolbs Experiential Learning Cycle, Gibbs
Reflective Cycle and Johns Reflective Model ( Bulman, 2008)

1.3 Purpose of reflective practices

Present day patients are well versed in many issues pertaining to health and forms of
treatment. The emergence of Internet has made it easier for them, for that matter easier for
all, to gather information and to know more regarding any topic. This puts the nurse to
constantly improve her knowledge in order to provide u to date care and also to satisfactorily
answer queries of the patient (Atherton, 2010).

According to Alfaro-LeFevre (2013), critical thinking as a way of obtaining knowledge by

critically looking at reflective practices, experiences and available current knowledge in
order to seek newer knowledge or better evidence for such knowledge advancement. This
approach is much needed in this era of globalization to keep up to the advancement in the
Nursing profession. (Bulman,, Lathlean & Gobbi 2012)

Johns model of reflective practice and Caspers fundamental way of knowing are two
theories that can provide avenue of critical thinking concerning experiential learning. They
provide pathways to gather knowledge by analyzing the information and associating it with
holistic care. This brings about better and safe care to patients (John, 2005).

John identified the fifth pattern of knowing which, paradoxically, is unknowing. This
unknowing is an awareness that In his tenth model ( Johns 1995) integrated the four patterns
more clearly within the cue questions posed, and the nurse does not and cannot know or
understand the client when they first meet and by recognizing this this could enhance the
completeness of individual reflections on practice. However, Smith (1992) has expressed
concern that the integrated, interdependent and overlap framework and knowledge.

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Furthermore in one to one relationships the expert practices to restore the unity of experience
that transcends the multiple dimensions and sources of knowing (Smith 1992) and
practitioner may need to develop expertise in facilitating the reflections of another. Schon
(1983) attributed some of the blame this on reflective practice, turning experience into an
academic exercise.

Although there is insufficient empirical evidence to prove conclusively that reflection and
reflective practice can help reduce clinical errors or improve clinical outcomes for patients, it
is a logical conclusion to draw (Mamede, et al., 2006). Engaging in reflection promotes
critical enquiry encouraging the practitioner to learn through analysis and evaluation of an
experience thereby preventing practice from becoming habitual and task orientated
(Stonehouse, 2011). Critical reflection helps practitioners focus on improving their
knowledge, skills and behaviour ensuring they are able to constantly update their practice and
meet the complex demands of patients in the health care setting (Somerville & Keeling,
2004).

1.4 Importance of Reflective practices in Nursing

In this paper I will highlight the importance of reflective practices in bringing the change
within the nursing profession and how it could be used in strengthening their services to the
patients. According to Carpers (2006) accuquisation of knowledge in nursing profession will
help to bring newer knowledge into the practices (Bonis 2009). Carpers four factors -
empirics, aesthetics, ethics, and personal allows the nurses to understand the concept of
nursing (Cowling 2007). The four has own meaning and seen as independent of each other
(Bonis 2009). According to Polit & Beck (2008) researcher while debates on the term of
evidence in research persist, recent researcher belief evidence based on sensors with
scientific definition is sufficient (Morse, 2006). However it must come from inquiry search
and reviewed by peer systematically.

The nurses acquire their basic knowledge from basic nursing program. The concept of
knowledge in nursing is embedded with caring principles. These themes are embed in
nursing curriculum and taught in the classroom room by the lecturers. Empirical knowledge
is obtained from journals which has objectives and factual data. Personal knowledge is

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acquired through experiences with patients during nursing care. Ethical knowledge acquired
through nursing decision making process and moral codes. Finally aesthetics knowledge is
acquired by integrating all three knowledge and coming to a decision on how to deal with a
situation and why one did make the decision.

Experiential learning involves many factors that come into play while the incident or the
experience is taking place. Those factors such as expectation of patient, expectation of staff,
goal and achievement of the task, the emotions encountered, ethical and cultural issue
involved and time factor maybe some of the predictors of the successful experience. Thus I
would narrate my own experience to highlight how this experience led to new knowledge
(Asselin 2011).

1.5 The description of experiences using Johns Model of Reflection

In this paper I will talk about my experiences using Johns Reflective Model. One day, I had
a chance to investigate and supervise the teaching and learning of my students in the ward.
As a tutor I came well prepared to supervise a exclusive breast feeding counseling session
with the maternal mothers. The counseling session was scheduled to meet 15 patients in that
session. At about 2 pm the student nurses and I walked the counseling clinic and started to
call the patients for the breast feeding counseling session. The counseling started as usual.
The student nurse and a senior nurse started to counsel an Indian lady at her 40s. It was her
third baby. The student nurse was not even looking at the patients eye to see her gesture of
understanding. She was practically reading some information from the pamphlet and
shouting at the patient for keeping quiet. The patient was just shaking her head, and most of
the time kept silence. This was because the patient is coming from the estate nearby the town.
Her education level is only until standard two. She has poor command of language, but my
student nurse was using bombastic English term mixed with Malays slangs. The counseling
session ended in just 10 minutes. Just to assure if she understood the session, I asked the
maternal mother a few question. To shock me, the patient was having severe misconception
about breast feeding. In fact she told me that nurse told her it is fine, not to breast feeding her
baby if she is busy with her job. She feel the student nurses are rude and do not understand
her constrains in breast feeding.

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However, the exclusive breast feeding education protocol was sign and ticked as though the
session finished sucessfully. I realise at that point of time, the student nurses and the senior
nurse are not focused in exclusive breast feeding counseling. They lack in exclusive breast
feeding knowledge (Owoaje, Oyemade, Kolude, 2002) and do not understand the cultural,
educational background of each patient. They just wanted to complete their duty, leading to
rush to complete their work. It made me to feel very frustrated and sad with what is
happening around me. I scolded the student nurses and senior staffs in front of the mothers.

1.5.1 Aesthetics

I was actually trying to improve the knowledge of nurses in breast feeding. I wanted the
entire maternal mother in the clinic to understand the effectiveness of breast feeding. Failure
in the counseling among mother on exclusive breast feeding is due to poor knowledge and
lack in attitudes among the nurses and maternal mothers (Bernaix, 2000). The knowledge
composites include the knowledge in patients social background, knowledge in breast
feeding and knowledge in soft skills in dealing with patients. I expected my student nurses
and staffs to have sound knowledge and able to handle counseling session well. I also
expected all counseling session will bring successful outcome.

1.5.2 Personnal

I feel the I and my student nurses were wrong in their practices by being rude to patient
without prior knowledge on her background and communication level. I too should have
never scolded my students and staffs in front of the patient. I also feel extremely bad, after
scolding the patient. What made me even worse is to realize that patient has poor command
of language and cared less about her barriers in communication.

1.5.3 Ethics

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I also commented and shouted at my nurse for recording the falsified statement on patient
counseling sheet. The nurses claims that patient understood well the sessions and forced her
to sign such proclaims. However, according to NMC (2004), wrong or falsified recording of
patients would bring severe consequences in future practices of nursing care.

1.5.4 Empirics

The knowledge in exclusive breast feeding is important aspect in maternal child care. It is
proven that exclusive breast feeding is an act that comes naturally from the mother to feed
the baby that not only psychologically creates binding between mother baby relationship
during feeding but also nourishes the baby (Souza , 2010). Thus, educating both nurses and
mothers on exclusive breast feeding is an important task to ensure success of exclusive breast
feeding campaign.

WHO has put up regulations for professionals such as nurses are involved in the care of the
exclusive breastfeeding campaign through its Breastfeeding Friendly Hospital Initiative
(WHO,UNICEF, 1989). According to the organization breastfeeding knowledge alone will
not ensure the success of the campaign but a positive breastfeeding attitude among the
nurses. In evaluating, the knowledge component among the nurses .campaign, WHO
conducted various studies to evaluate the efficacy of breastfeeding training among health
professionals (WHO,UNICEF, 1989).

The practice of exclusive breast feeding is initially implemented in the first hour after birth
and encouraged during the postpartum period until six months or up to two years. In many
situations, however, it causes fear, insecurity, conflicts, anxiety, physical discomfort and even
depression for the lactating women. This will lead to adoption of complementary and/or
artificial breastfeeding, thus damaging the breastfeeding process (Lara and Fernandes, 2010),
Thus, it is important for the nurses to educate the mothers on elevating their negative
experience on breast feeding.

The ministry of Health Malaysia has been promoting the breast feeding campaign through
various health promotions, breast counseling clinic, forum and home visits since 1986.
However, we lack in support from other association such as NGO, private practices to boost
the campaign. This is similar to National Program to Encourage Breastfeeding which was

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initiated in Brazil in 1981 which failed to achieve the recommendation of United Nations
Fund for Children (UNICEF) and World Health Organization (WHO) which propose
exclusive breastfeeding among the maternal mother to continue up to six months and
breastfeeding continued with food supplement up to two years of age or older (Boccolini,
Carvalho, Oliveira, PrezEscamilla cited in Valdecyr Alvies, Diego Pereira, Bruno
Augusto Colombo, Rodriguez, 2011).

Exclusive breast-feeding has many good benefits either to the mother or the baby (Hurst,
2011). It also enhances cognitive and sensory development and help to reduce infant
morbidity such as diarrhoea, respiratory illness and other systemic infection. Breasting
feeding on the long term will help to lower the rates of obesity and risk of chronic illness
(Hurst, 2011). On the other hand breast-feeding gives advantages for the mother such as
early return to pre-pregnancy weight (Kramer and Kakuma, 2002).It reduces risk of ovarian
and breast cancer and promote delayed pregnancies. (Hurst,2011). It provides many
significant benefits to environmental and social economic. It contributes to the attainment
goals of millennium development by reducing neonatal mortality by 22% by decreasing the
Infant Mortality Rate. Research shows ,in India the practice of breast feeding initiation save
250,000 every year(Lauer, Barros and De Onnis, 2006). Only 24% - 26% of babies born in
India, Pakistan and Bangladesh are breastfed within 1 hour compare to Sri Lanka rate of
75% ( Bhatt Shwetal, Parikh Pooja, Kantharia Neha, Dahat Amit and Parmar Rahul , 2012).

Nurses attitudes have a role in exclusive breast feeding programme. A study indicated that
nurses with positive attitudes are the key indicator for the success of exclusive breast feeding
programme. (Cruz, Germano, Tomasi, Facchini, Piccini, Thume cited in Valdecyr Alvies,
Diego Pereira, Bruno Augusto Colombo, Rodriguez, 2011 ) but they are also the change to
their attitudes. (Souza, Tesin and Alves , 2010). Another study also shows that postive
attitudes nurses contributes towards successful breastfeeding in promotion (Ministrio da
Sade cited in Valdecyr Alvies, Diego Pereira, Bruno Augusto Colombo, Rodriguez, 2011).

However the study also indicated that nurses lack of knowledge or unfavorable attitudes
result in inconsistent exclusive breast feeding counseling (Lara and Fernandes, 2009).this
may shorten the duration of breastfeeding (Boccolini, Carvalho, Oliveira, Prez-Escamilla in
Valdecyr Alvies, Diego Pereira, Bruno Augusto Colombo, Rodriguez, 2011).

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1.6.5 Reflexivity

The experience with patient gave me a great deal of knowledge to improve the condition,
Instead of shouting at the patients and nurses it is important for me to see to the cause of the
problem, First and foremost, I have failed to ensure student nurses are well trained in breast
feeding counseling. According to (Eva Nisse, 2011) nurses preparedness and communication
during counseling will determine their outcome.As such, I dont have much interpersonal
relationship with student nurses to know if they are mentally prepared for counselling. I need
to be more professional do deal with such situation in future. I have to be more rational and
emotional while making remarks on the patient and nurses. I will advocate the use SWOT
analysis to analyse the problems in counseling of exclusive breast feeding. I will first identify
the analyse all internal and external factors by evaluating its the strengths, weaknesses,
opportunities, and threats into unfavorable and favorable options to achieve change in current
practices of patient education and counseling of exclusive breast feeding using model
adopted from Kurt Levin Change Model.-the unfreeze, change and refreeze (Lewin, 1956). I
will unfreeze the internal inconsistency such as resistance such as attitudes, competency and
confidence level among the student nurses. Then I will unfreeze the entire attitudes problem
among the nurses and educate then to accept the need to change I will advocate the need to
attend intensive course in lactation to the nurses who need to do counseling to breast feeding
mothers. I will encourage my nurses to present evidence based practices through their
reflective practices to enhance their knowledge on breast feeding. This will be done through
initiating Continues Professional Education that gives merits for promotion for the nurses and
students . I will to advocate research to students and qualified nurses on the need to keep
improving our care of breast feeding and breast feeding campaign. Then I will monitor the
progress of the program at its own pace to refreeze its momentum of success.

1.7 How I could further develop my reflective skills.

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Reflective thinking is a multifaceted process. It is an analysis of events and circumstances.

By virtue of its complexity, the task of teaching requires constant and continual
observation, evaluation, and subsequent action. However, to be an effective work-based
supervisor, it is not enough for me to recognize what happens in the work place. Rather,
it is imperative to understand the "why's," "how's," and "what if's" as well. As such the
basis of reflective practices is determined by reflectors self-awareness which includes
belief, values, qualities, strength and his limitation.

1.8 Improve self-awareness to develop reflective practices

In nursing reflective practices, the most important aspect of factor that enhances practice is
through improving the self-awareness of the reflector. Self-awareness is defined as the
consciousness of ones characters on their own belief, values, qualities, strengths and
limitations. This consciousness is shaped by our own culture, education experiences and how
we have experienced our socilaisation. According to Burnard (1997), ones awareness is
influenced by two factors, the inner self and outer self. The inner self is the feeling or
attributes that determine about ones self during an incident or event. On the other hand, the
outer self is what others are seeing or perceiving on our verbal and non-verbal behaviour.
Having this two factors built, one can develop his or her reflective practices. This attributes
will help nurses to further develop their interpersonal skills and build therapeutics
relationship with the patient and their family members (Bulman,., Lathlean, and Gobbi,.
2012).

However, the greatest challenge in building this attributes is our prejudices and assumptions
during care of patient. Thus, to develop the awareness during patient care, the nurses require

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a great deal of effort and mental energy. In developing this attributes a practising nurse must
identify and clarify the belief, values and feelings. This is done by reflecting or writing down
her values that are important during the care of patient. (Wong, et.al , 1997 ).Upon clarifying
these values, she could explore the values herself or with the help of her friends. The values
are important in determining nurses coping with her action during her nursing care. Then a
nurse could analyse her motivation level for becoming reflective practitioners. She could
even do check and balance with the help of other nurses either in group or pair.

18.1 Improving attributes in reflective practices through :

i. Possessing a repertoire of experiences

This can be done through bringing the past experiences to new situation by
recalling them from repertoire of experiences. The reflection practitioners will
differentiate between these experiences. By doing this one could have variety of
repertoire and be conscious in new and unfamiliar situation (Schon, 1983).The
practisoneer will be able to handle any new situations and keep his mind open to
any new situations in future.

ii. Develop the art of artistic practice.

A nurse practisoneer must develop artistic practice ability. This means the nurse
practisoneers has ability to see events in practices in different perspectives. This will
allow a nurse to choose the best of practice facing new situations. Such act is known
as knowing in action (Schons, 1983).

iii. Being able to frame problem and experiment in practice

This means a nurse should possess experiences of new problem solving behaviour and
encompasses of the new and one ones. This provides experience to the practitioner on
what has happen before and what was done to solve the problem. Such act is different
normal way of problem solving. Practitioners will be able to reshape a problem and

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group them into hypothesis. The hypothesis which were tested will provide a new
guidelines and rules instance (Schons, 1983).

iv. Having an ability to articulate reflective practices

In this context, practising nurses should be able to articulate the problem in words and
be able to describe what is the differences between the practices and not alone the
norm (Schons, 1983).

1.8.2 Develop reflective practices skills

On the questions of how to develop effective reflective thinking, Schons (1983,1987) says
such skills will come through the consistent practice of reflective thinking either by
written, drawing or spoken. Bolton (2010) quotes that narrative and structured reflective
practice is restrictive and less productive in providing creativity in reflective practice.
The following are some examples of exercises or practices on reflection that may be help
to develop the skills of reflections. It can be done in group, individual or with partner. In
developing reflective practising skills nurses must always adopt any of above skills
during their practices as below:

Think Aloud:

Intentionally express out loud thinking about my learning. This method uncovers the
reasoning behind making decisions. Another component of the think aloud is describing and
analysing positive and negative experiences as they surface. Describing should include the
context of incidents the events as they unfold the situation, what I was thinking at the time,
how was my feeling and outcome of the situation. Such description from thinking should be
able to provide reader actual situation of the problem or incident using appropriate word and
term.

Reflective Journal:

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This is a process of recording and analysing events in a prescribed manner and it can be a
productive strategy to foster reflective thinking. The journal process may be formal or
informal. It can be a description of a significant event or an aspect of learning on which a
student is asked to focus (Asselin, 2011).

Competency Continuum:
Think about the areas in teaching identified in the students learning outcomes. Begin by
identifying the factors that inhibit the students ability to be more competent and identify
what would be most helpful to gain more competencies. Use this continuum as a tool for
discussion and action planning between you and your student.

Data Collection/Action Research:

Consider a problem area such as student motivation that concerns you. Intentionally design a
procedure for collecting information (data) to learn more about the problem. Use this data to
further analyse the situation, to act on the problem, or to re-evaluate.

Video/Audio Tape and Reflective Analysis:

Video or audio tape your teaching. View or listen to the tape for the purpose of analysing
your instruction and student response. The video or audio tape may be used as a tool for
reflective dialogue between the student and you. It could be combined with a journal entry.

Written Self-Evaluation:
This is a structured self analysis. Use of the Problem Solving Process: This six step process
may be used for any problem situation in or out of the classroom setting. It is intended as a
tool for collaborative or individual problem solving and reflective thinking as well as a
design for action.
1. Identify the problem
2. Generate possible solutions
3. Evaluate the solutions
4. Design an action plan
5. Implement the plan

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6. Evaluate the results

Coaching and Conferencing Process:
This is a process that occurs on a regular basis during the student teaching experience. It
provides an opportunity to talk about teaching and learning and should be a natural flow of
conversation that includes sharing ideas, giving and receiving formative feedback. This
process may be ongoing and informal, or scheduled and structured. It may or may not include
an observation. The intent of the process is to engage in an activity that promotes dialogue
about teaching effectiveness, and encourages reflective thinking about teaching, learning, and
performance.

Development of a Professional Portfolio:

The process of creating and selecting documents for inclusion in the portfolio requires a
significant amount of reflective thinking about yourself as a teacher and your growth related
to the performance standards for student teaching. It is an opportunity to talk about your
experience and performance with the individuals who form your mentoring team. It can be
one of the most intensive processes for reflection.

Individual Reflection

The presence of others can support individual learning in many ways, but it is also good to
provide individuals with some personal time and space to reflect - away from the distractions
of others. However, being alone is no guarantee of high quality reflection: when alone,
attention can wander or people get stuck in a rut as they keep going through the same
patterns of thought or visiting the same dead ends. Below are some of the techniques.

i.Unstructured Reflective Writing

using log books, diaries, journals, notebooks.
ii.Structured Reflective Writing
responding to a questionnaire or to a standard template of questions or headings following a
particular sequence.
iii.Graphic Reflection Techniques

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creating diagrams, charts, graphs, maps, patterns, drawings, collages or photos to capture
reflections.
iv.Scavenger Hunt
searching for symbolic objects that answer reflective questions

v.Solo
time alone without distractions and space to think, or to read feedback notes from
other group members, or as a challenge in itself - to live alone and close to nature with time
to reflect.
vi.Guided Reflection
listening to a monologue that includes pauses for thought
vii.Silence
context is all important, but well timed silences in suitable settings can result in deep
reflection.
viii.Reflection Time
following a stimulating story, performance or experience.

x.Thinking Time
before making a reflective statement about recent events.

xi.Preparation Time
before making a presentation about personal learning to the group.
Some of the above individual reviewing techniques can work surprisingly well, but often the
best way to make a breakthrough is reviewing with another person, for example a colleague.

Reviewing for Two: Roles For Reviewing In Pairs

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Talking things through with another person can be more dynamic and productive than being
left with your own thoughts. Sometimes the other person is just a listener, but there are many
other useful roles the other person can adopt - such as a sounding board, a summariser, a
buddy, a coach, or even a devil's advocate. There is no guarantee that the other person will be
good at assisting the process of reflection. The other person may be too intrusive or
challenging, or may stumble into 'no go' areas, or offer insensitive advice. There is always the
risk that the other person (even a skilled facilitator) will spoil, distort or disrupt the process of
reflection. The risk of ending up with an 'unhelpful' listener can be reduced by providing
clear briefings and by providing an easy way for the 'speaker' to change the rules or pt out if
they find the process is not working well.

Conclusions

Reflection is a critical thought practice. Purposeful reflection provides an opportunity to

examine nursing practice and identify new knowledge (Jasper, 2003). Reflection is a
professional motivator to move on and do better within practice with the goal of learning
from experiences and examining oneself (Bulman, Lathlean, & Gobbi, 2011). The field of
nursing can be emotionally draining and reflection was seen as an outlet to disperse those
feelings. Reflection allowed nurses to discuss or write journal entries about their feelings to
better understand why they felt a certain way. Mentor support was identified as a crucial
theme related to reflection. Students partaking in reflection require appropriate guidance and
adequate time. A safe, nonjudgmental environment also needs to be provided to facilitate
open communication. The role of the preceptor needs to be given proper support and
guidance to provide optimal results. Although barriers exist with reflection, taking the time to
discover which reflection style works best for each nursing student or practicing nurse will
open the door to amazing learning opportunities. Reflection has the opportunity to enhance
clinical reasoning while having a positive impact on patient care. Further studies are needed
to explore he impact of reflective practice and the quality of care received by patients.

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