Journal of Nursing Education

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Reflective Practice: A Focus for Caring

Elizabeth Davies, RN, BSc, Dip App Sc (NEd), MEd, FRCNA

Abstract

ABSTRACT

Nurse education has long been plagued by a perceived disjuncture between theory and practice. This paper explores the use of reflection as a mechanism to enable students of nursing to overcome this problem. A grounded theory approach is used to study a group of first-year students undertaking a 3-year undergraduate nursing course. Results of the study indicate that the use of the reflective processes of clinical debriefing and journaling does impact on the environment, the process, and the focus of learning. Anxiety associated with the learning environment was reduced through peer support and cooperation. In addition, students moved from a passive to a more active mode of learning. The most significant finding was that, over time, reflective processes resulted in the emergence of the client as the central focus of care.

Abstract

ABSTRACT

Nurse education has long been plagued by a perceived disjuncture between theory and practice. This paper explores the use of reflection as a mechanism to enable students of nursing to overcome this problem. A grounded theory approach is used to study a group of first-year students undertaking a 3-year undergraduate nursing course. Results of the study indicate that the use of the reflective processes of clinical debriefing and journaling does impact on the environment, the process, and the focus of learning. Anxiety associated with the learning environment was reduced through peer support and cooperation. In addition, students moved from a passive to a more active mode of learning. The most significant finding was that, over time, reflective processes resulted in the emergence of the client as the central focus of care.

Introduction

It has often been suggested that an effective way to move beyond the technical, rational model of education, where theory informs practice, is to provide learners with the opportunity to engage in reflective practice (Schon, 1983, 1987; Smyth, 1988; Speedy, 1989). Through this process, it should be possible to create a learning environment in which theory and practice can inform each other.

Such an approach to learning is not novel. The early work of Dewey (1933) legitimized the fact that experience led to learning through trial and error and through reflection. Building on this work, KoIb, Rubin, and Mclntyre (1971) developed a well-known model of learning, which demonstrated that, following experience, observation and reflections could lead to the formation of concepts that could be applied and tested in new situations. In a further refinement, Boud, Keogh, and Walker (1985) illustrated the application of a reflective model in practice which proposed that, to be engaged in reflection, learners must actively draw on their past experience, describe the experience, work through their attitudes and emotions relative to the experience, and then order and make sense of new ideas and information. The use of such an approach must be based on the recognition that learners themselves can learn, that reflection is a complex process in which feelings and cognition are closely linked, and that it must be pursued with intent.

Two reflective activities can be used in nurse education to engage students in reflection on learning: clinical debriefing sessions and journaling. Clinical debriefing is usually organized to occur toward the end of each clinical day and is described as: *. . . a process whereby group members (nursing students) discuss and work through ideas, issues, feelings or concerns generated by individuals in the group" (Horsfall, 1990, p. 3). It is a technique that differs markedly from classroom or clinical teaching in that it is a group process, emotions are acknowledged and worked with, and students determine the pace and content of discussion (Horsfall). It is also different from classroom teaching in relation to the type and choice of topic for discussion. In clinical debriefing, the topic is usually client based, is initiated by the student, and is not subject to classical textbook-type divisions that are often a feature of classroom teaching (McCaugherty, 1991).

Journaling, used as an adjunct to organized reflective activities, provides students with an opportunity to return to experiences in an attempt to develop new perspectives that may guide future actions. Journaling can be a dialogue between faculty and student or it can be undertaken as an individual activity. As a much more private activity than debriefing, journaling enables students to make explicit those things they may not be prepared to share.

Literature Review

Within nursing, there is a great deal of support for the use of reflective activities such as these. This support is based on the perceived advantages. A review of current literature reveals that these advantages can be classified as relevant to the student, to theory, and to practice. From the perspective of the student, it is suggested that the opportunity to acknowledge feelings in a nonthreatening environment can lead to a reduction in the anxiety that often accompanies clinical practice experience (Boud et al., 1985; Horsfall, 1990; Howie, 1988; Jackson, 1987). It could reasonably be expected that reduced anxiety levels should enhance the student's ability to learn within the practice setting. Not only is anxiety reduced in relation to specific client care situations, but also in relation to particular organizational and institutional contexts and expectations (Howie; Schon, 1987; Smyth, 1988).

By being explicit and dealing with their own feelings, students should grow in appreciation of the link between feelings and action or inaction, which they may be able to relate to clients in their care. Also, in the affective domain, reflective practice is seen to contribute to student confidence (Copeland, 1990; Horsfall, 1990; McCaugherty, 1991; Smyth, 1988). Confidence is developed as students articulate their achievements, share knowledge they have acquired, and receive the feedback of their colleagues in the reflective activity. The opportunity to evaluate their own performance, to acknowledge their strengths, to ask for help, and to identify their own learning needs gives them a perspective of themselves as central to the learning process. This experience of centrality should assist them in taking responsibility for their own actions and behaviors (Feathers & White, 1987).

Another benefit that can accrue to students through involvement in reflective practice is the opportunity to practice and improve interpersonal skills (Dimino, 1989; Feathers & White, 1987; Horsfall, 1990; Powell, 1989; Saylor, 1990). In particular, development occurs through organizing thoughts and ideas, verbal and written expression, reporting, and developing respect for peers. Advantages relevant to theory are apparent in that ". . . reflection on practice is itself a theoretical act. Indeed, the products of reflection on practice are theories about the nature of that practice and its effects. The reflective practitioner is a theoretician whose theories constitute situational understanding" (Gaynor, 1986, p. 335). By engaging in reflective practice, even if they are not yet able to develop their own theories relevant to particular contexts, students should be able to identify phenomena which they observe that are not explained by existing theory. This should assist them to develop an awareness that "knowledge is available for critique and contestation" (Smyth, 1988, p. 31).

Horsfall (1990) contends that such awareness will equip students to address contradictory components of their curriculum, which become most evident in the clinical setting. This should also provide the freedom necessary to realize that learned theories may need to be adapted in light of the specific practice context (Schon, 1987; Speedy, 1989). In addition, it must be acknowledged that reflection also provides the opportunity to observe that, in some situations, some theories do fit in practice. Also, that synthesis of theories from différent disciplines can be observed through the insights gained as a result of practice and clinical processes (Horsfall).

Reflective processes are also seen to enhance practice in a number of ways. This, in fact, is the very purpose of reflection and is directly enhanced by the advantages in relation to the previously mentioned student- and theoryrelated factors. With specific reference to practice, the major advantages relate to context specificity, increased diversity, and the development of autonomy and skills. The appreciation of the context in determining appropriate practice decisions and actions is perhaps the most critical factor in professional practice, and has been eloquently proposed by Schon (1983, 1987) as the underlying rationale for reflection on practice. This position has been supported by many nurse scholars such as Smyth (1988), Tanner (1988), Benner (1984), Powell (1989), Saylor (1990), and Paterson and Zderad (1970).

Students undertaking clinical practice experience are bound by constraints of available time and accessibility of clients. It is not possible to expose students to every type of clinical problem they may encounter. For these reasons, reflective processes - particularly group processes - can add to the diversity of situations to which students are exposed. By sharing experiences with others, there is the opportunity to become aware of strategies that may be useful in similar situations (Horsfall, 1990; Powell, 1989). Diversity can also be increased from another perspective. Students dealing with similar client care needs can be exposed to different approaches taken by their colleagues, thereby broadening their knowledge of possible future options (Diekelmann, 1988; Hedin & Donovan, 1989; Powell).

By its grounding in self-responsibility for learning, reflection on practice has the capacity to encourage inquiry and autonomy in seeking information that is necessary for practice (Boud et al., 1985; Horsfall, 1990; Mezirow, 1981). There is the opportunity to refine problem-solving skills by trying out solutions in a supportive, critical environment (Feathers & White, 1987; Powell, 1989; Saylor, 1990). Reflective practice then, through its proposed capacity to enhance student performance in the affective, cognitive, and practice domains, would seem to be a possible vehicle for integrating the art and science of nursing.

Research Methodology

The main question in this study was to determine what effect reflection on clinical practice experience had on students as learners and care providers. The clinical practice experiences undertaken by the students were three 1-week blocks that occurred in a nursing home, an acute medical/surgical ward, and a home visiting nursing service. All of the students undertook similar experiences at the same time. On only one occasion were two of the students in the same clinical group. This would indicate that there was very little cohesion among the subjects.

The reflective processes of debriefing at the end of each clinical day and journaling during the clinical practice experiences were used. The debriefing sessions were conducted by a different clinical teacher for each of the three blocks of clinical practice experiences. Issues explored were both general and specific to the clinical setting and were largely student driven. Guidelines regarding journaling were given prior to the first clinical practice experience and remained constant throughout.

A qualitative research methodology was seen as appropriate to this research question and the particular approach was grounded theory. Rather than beginning with a theory and collecting data for verification, the grounded theory approach begins with a general question about what is going on within an area of interest. As data are collected and analyzed, a process of discovery and theory generation from the data occurs (Glaser & Strauss, 1967).

Because the research approach was based on the interpretation of personal meanings, personal interview was seen as the most appropriate form of data collection. Subjects were selected from among students undertaking the first year of a 3-year full-time university course to prepare them for beginning nursing practice in Australia. The subjects were students of the researcher. A purposive sample was selected based on the researcher's knowledge of the population. It was acknowledged that such subjective sampling cannot guarantee the typicalness of the subjects (Polit & Hungler, 1993). The six students chosen to participate in the study had previously demonstrated their ability to articulate their experiences from an analytical perspective. The sample size was small, but was considered appropriate for the methodology in that it would enable eventual saturation of data categories to be reached and would contain the volume of data at a manageable level. The students were approached individually, given an explanation of the study, and asked if they would be willing to participate. After a specified time for reflection, each student expressed consent to participate in the study on the understanding that they could withdraw at any time and that they would have full access to the result of the study.

Interviews were conducted within 2 weeks of each week-long block of clinical practice experience programmed into the first year of the course. Each student was interviewed individually. The interviews were largely unstructured and were conducted in an uninterrupted and unhurried environment; extensive notes were taken. The research question determined the broad area of inquiry. The researcher acted as facilitator as the students explored the issues relevant to the study and strived to interpret the meanings that particular events had for them. The content of the interview was documented and a copy given to the student. This was accompanied by comments and questions arising from the data, which were to be explored at the second interview that occurred 4 to 6 weeks later. This cycle occurred three times over a period of 6 months.

The data were analyzed using thematic analysis that searched for similarities leading to major and minor themes within the data. Coding, memo writing, and diagramming were used extensively in the thematic analysis. The four stages of the constant comparative method described by Glaser and Strauss (1967) guided the analysis. In the first stage, broad categories were established based on similarity of incidents and content. Secondly, incidents within each category were compared to the major characteristic of the category to determine the nature of any integration that existed and to search for relationships that might exist between the categories. The third stage comprised a validation process to ensure that categories could not be collapsed further and that saturation of content had been achieved. The final stage focused on the selection of data bits to support the findings.

Results

In reporting the results, the clinical debriefing sessions are discussed first. This is followed by a discussion of the results that emerged from the journaling exercise. In the debriefing sessions relating to the first clinical practice placement, students identified four major processes that occurred. These were describing feelings, sharing experiences, working through and solving problems, and identifying reasons for actions. Participation in debriefing was seen to result in increased involvement in the clinical practice, greater awareness of relevant issues, better understanding of clients' conditions and nursing actions, and a boost in confidence to apply knowledge and skills (Figure 1).

Feelings that were most commonly expressed included fear, doubt, and inadequacy. The opportunity to discuss these feelings was described by one student as, "My confidence was increased when I realized I wasn't the only one feeling frightened and stupid and doubtful." The sharing of experiences was valued by most students as illustrated by the following extracts from the data: ". . . increased my own awareness and understanding because I had to organize my ideas"; ". . . you gained an increased awareness of your own problem area"; ". . . increased my involvement in the clinical practice"; ". . . broadened my clinical experiences."

The most frequently mentioned aspect of debriefing was problem solving. This was seen as an excellent opportunity to "become aware of emerging problems," "work through the problem-solving process we were applying," and to "look at the outcome [results] of care being given." It was interesting to note that, even though problem solving was mentioned frequently, it was not made as explicit as the other identified processes.

Students attempted to make sense of the experience by trying to identify rationales underlying observed behaviors, practices, and comments. The proposed rationales covered a broad range of issues:

* negative staff attitudes - "clinical experience as sitting down and bludging [not doing a fair share of the work]";

* specific nursing intervention - "why use cream instead of soap?" and

* nurse/client interactions - such as why some clients "wanted to stay in the room and not participate."

Specific benefits of identifying rationales that were mentioned included: ". . . helped to increase my knowledge base"; ". . . helped me to understand the reasons for doing things"; ". . . enabled me to understand the reasons for their behavior, which made me feel better about it and less responsible."

Figure 1. Responses following first clinical practice placement.

Figure 1. Responses following first clinical practice placement.

Overall, debriefing following the first clinical practice experience can be seen as a mechanism for dealing with personal responses to a situation, for working through professional problems, and for making sense of what is happening in relation to the self, the system, and others.

For all students, the most common outcome of debriefing sessions following the second clinical practice placement was an identification of their individual learning needs as illustrated by Figure 2. This identification led to a number of outcomes, namely: working together on common problems, encouraging others to seek specific experiences, and sharing of newly acquired knowledge, all of which contributed to a general broadening of the clinical practice experience.

Initially, most students were not particularly enthusiastic about identifying individual learning needs. They described their responses as: "Not my responsibility"; ". . . Bit of a task at the time"; "... I didn't want to tell the whole group." These responses changed during the clinical practice experience and are encapsulated in the following comment:

It did make us go and find out what we needed to know. Then I began to think it was relevant because of the nature of the profession. If you don't know about a disease, you have to find out, problem solve by asking another person, or referring to a text.

Figure 2. Responses following second clinical practice placement.

Figure 2. Responses following second clinical practice placement.

As well as meeting their identified learning needs, the students were able to articulate other positive outcomes. In describing these, they said:

We helped each other from our experience and reading. Another student had a surgical patient also; we worked together on common needs of our clients, like deep breathing. We used the same resources, and planning for our clients was similar.

We encouraged others to attend procedures we had seen, such as endoscopies . . . You can look at a textbook for 100 years, but it doesn't put it together like seeing the real thing. I could make connections from the endoscopy to the gastrointestinal tract. You could see the bile secretions - the colors and the texture. Instantly enlightening!

On this occasion, participation in debriefing was seen by the students to be instrumental in providing a challenge - identifying their own learning needs - which led to responses such as cooperation, sharing, and self-evaluation. A result of this process was identified as increasing the breadth of experience to which they were exposed, helping them to broaden their knowledge base as a result of this exposure, and increasing their problem-solving skills through identifying and meeting their own learning needs.

In relation to the third clinical practice placement, in contrast to the previous experiences, students presented at debriefing with partially worked-out problems that they needed guidance to resolve. They had gone as far as they could individually and used the debriefing to seek further input. They had accepted more self-responsibility and sought to collaborate with their colleagues (Figure 3).

Figure 3. Responses following third clinical practice placement.

Figure 3. Responses following third clinical practice placement.

In describing their need to bring problems to the group, students made statements such as "I was really worried about my client," "I was not altogether happy," or "I had some trouble with nursing diagnosis." The processes that occurred in debriefing are illustrated by the comments such as: "We thrashed my nursing diagnoses around and asked what's wrong with these. We discussed and clarified until the problems were resolved"; "... I could clear things up. By working through my assessments and care plans, I felt that I knew what I was doing"; "We worked through together . . . made sure I understood what I was doing"; "The clinical teacher made suggestions that I could go away and think about. I found this most satisfying"; "It was good to bounce ideas off someone. It's becoming more important to me to look things up I don't understand, rather than getting others to tell me. I can get a better understanding so I know why I am doing something."

Engagement in debriefing, then, led to clarification, validation, reformulation, and analysis of client-related problems. The relationship that the students established with the clinical teachers in debriefing sessions were based on their acceptance of their own responsibility to find solutions to clients' problems and their recognition of the clinical teachers as people able to assist them in their efforts. In short, they sought collaboration and support within the debriefing context.

Figure 4. Joumaled responses across all clinical practice placements.

Figure 4. Joumaled responses across all clinical practice placements.

As with the debriefing sessions, there was an observable change of focus over time in the journaling of clinical practice experiences. Some students had initial misgivings about the activity, but all persevered in their recording. For the first two clinical placements, the major emphasis was on describing what was happening and evaluating personal ideas, feelings, and responses to situations. By the third clinical practice placement, a différent emphasis had emerged that had the client as the central focus. This process is illustrated in Figure 4.

Misgivings were expressed by some students as: "At first, I thought this was a ridiculous thing to do"; "Keeping a journal wouldn't have occurred to me"; "It was difficult to find what to write." However, by the first interview, the same students were saying: "I found it useful because it enabled me to focus on my feelings about my experience"; "The journal let me summarize my experiences - gave a good overview"; "I had to think about things a lot more. Normally, I would not have reflected as much"; "... I was pleased I had kept the journal because the reflection on my experiences helped to understand feelings and reasons."

Journal entries during the first and second clinical practice placements tended to focus on what the students did, providing care and interacting with clients. As well as descriptions of events, there were also expressions of feelings and opinions surrounding the events. The journal provided a mechanism to search for a balance between positive and negative experiences associated with the clinical practice. For example: "Some things make me feel good. The bad days weren't really so bad . . . Recording positive events increased my self-esteem. It made me keep doing things that had a good outcome and that increased my confidence."

There was evidence of some extension beyond the immediate nurse/client focus to include observations of others within the system. Such observations are encapsulated in one student's discussion of her journaling:

. . . helped me to understand some of the deficiencies in the system that led to negative things happening . . . Nurses talking about clients in their presence. No time - shoveling food and rushed showers - so much to do in a day. One person was nearly naked in the shower chair. They were wheeled through the corridor with their bare bottom poking through. I tried to cover them. Most clients had dementia. Untrained staff didn't know how to communicate with them. There were too few nurses and not enough shower cubicles. We were part of a production line - made to feel like a cash register operator - next please - no time to talk.

In the journaling that followed the third clinical practicum, there was a strongly emerging theme which focused on the client. This took the forms of description, judgments, changes in condition, wondering how they were doing during absences, and insights into family situations. The majority of client-focused reflections extended to broad and more abstract issues such as:

. . . the people I visited - how they were different from those in the nursing home and the hospital . . . These people asked for help. In the hospital and nursing home, they were there because they needed help- they had no choice. Domiciliary clients were more positive in their attitude.

My insights into my clients and how they felt about things. You can just tell - for example, one man who had leg ulcers was really pissed off because of the restrictions on his lifestyle. I can't see anywhere on the care plan where I can write down "this fellow is pissed off"

. . . hopes . . . that tertiary nurse education will improve the status and standing of nursing and that nurses might have more power to address the problems that face them and their clients.

A theme that was apparent in journaling through all three placements was that of self-evaluation. Typical examples are reflected in comments such as: "... increased my awareness of things I must not forget to do for my residents - especially with regard to communication, reassurance"; "I felt good when I knew I had accomplished everything I wanted the best I could"; "I identified my strengths and the things I could have done differently or better the next time I had to do them"; ". . . how I thought my communication and interviewing skills were going, I was happy with my progress"; "I have to work hard in this area, therefore, I note my own performance."

The reflective process of journaling, in relation to clinical practice experiences, was a positive one for the students in the study. The most noteworthy result was the shift of focus from self in the system to client in context. While there was a similar focus on the client observed in debriefing, it tended to focus more on particular and immediate client problems. In journaling, the perception of the client was broader and more abstract issues were considered.

Discussion

A feature of the early reflective processes of the students in the current study was their need to share their personal responses by describing their feelings and experiences. For many students, learning in the clinical setting is accompanied by a degree of stress (Horsfall, 1990; Howie, 1988; Jackson, 1987). The major stressor seems to be anxiety, which Horsfall (p. 4) proposes may be due to: ". . . unknown aspects of the setting, stafY, facilities, patients, worker practices, and the prevailing ethos."

The position would seem to be relevant to and supported by the current study in which students expressed feelings of fear, doubt, and inadequacy. A number of writers suggest that the anxiety and stress related to the unknown aspects of clinical practice can be diminished through the use of peer group and teacher support as part of the reflective process (Boud et al., 1985; Horsfall, 1990). In the current study, it was articulated that confidence increased on learning that other students were experiencing similar anxieties. The sharing of experiences, which resulted in increased awareness, understanding, and involvement, was identified by the students in the study as a feature of their reflection on clinical practice. The opportunistic aspects of sharing varied and similar experiences are identified by Schon (1983), Benner (1984), Jackson (1987), Smyth (1988), Powell (1989), and Horsfall.

Using reflection on practice to assist with solving clinical problems and in understanding rationales for observed practices were other features found by the study. Schon (1983, p. 303) expounds that the essence of reflective practice is the ability to "frame problems within the messy zones of indeterminacy in practice." The frequency of comment by students in the study on reflective sessions as a forum for problem solving indicates the high value placed on this aspect. Powell (1989), Saylor (1990), and Horsfall (1990) all designate reflective sessions as valuable in facilitating clinical problem solving. Powell suggests that reflection on similar past experiences leads to the trying out of solutions that were effective in these instances. The value of reflection in facilitating clinical problem solving is seen by Saylor to be vested in the opportunities it provides to invent novel responses to unique problems.

Reflection as an opportunity to make sense of their experience by searching for rationales was identified by students in the study and has been addressed to some extent in the literature. Such questioning can focus on general and specific issues. Gaynor (1986, p. 335) takes a broad approach in proposing that ". . . the products of reflection on practice are theories about the nature of that practice and its effects."

The focus is narrowed by Mezirow (1981) and Smyth (1988) who see reflection as useful in understanding what is happening at the institutional level through questioning related to the context, routines, and taken-for-granted practices. A further narrowing, to the personal level, is effected by Boud et al. (1985) and Horsfall (1990). In such instances, questioning focuses on the values and opinions of practitioners, and attempting to make sense of the present personal experience. In this study, most searching for rationales was directly related to the present personal experience.

The predominant feature that emerged from reflection related to the second clinical practice experience, identification of individual learning needs, has been commented on by a number of authors. Mezirow (1981) indicates that the reflective process enables the assessment of further learning that is required before decisions can be made. He also suggests that reflection provides an opportunity to correct distortions in beliefs and errors in problem solving (Mezirow, 1990). The opportunity to reflect on inquiry processes and to examine changing understandings of situations is seen by Schon (1987) as an important aspect of reflection on practice. Similarly, Feathers and White (1987) identify the opportunity that reflection on practice gives to engage in intellectual experimentation in a supportive and nonthreatening environment. Smyth ( 1988) contends that the provision of opportunities for inquiry leads to an increased reliance on and ownership over learning. Horsfall (1990) and Saylor (1990) describe reflective sessions as a forum for outlining and achieving individual learning needs through a process of selfevaluation.

The expression by students in the study that reflective sessions increased their involvement, understanding, and confidence and enabled them to broaden their knowledge and skills relates positively to themes in the literature. Boud et al. (1985) indicate that reflective sessions enable learners to become actively engaged in the learning process, which results in a high level of involvement. Student confidence can also be increased through reflection by focusing on the positive aspects of learning and delivery of care (Copeland, 1990), by articulating achievements and developing respect for peers (Horsfall, 1990), and by sharing and discussing insights (Saylor, 1990). Improved understanding and the acquisition of new knowledge and skills as a result of reflection are identified by Saylor (1990) and Powell (1990). Horsfall's (1990, p. 7) statement, "The aim is to empower students by developing new understandings and/or skills," succinctly summarizes the broadening and enabling possibilities of reflection on practice.

Reflective sessions as a forum for professional collaboration and support emerged as a theme from reflection related to the third clinical practice experience. There was little comment on this particular aspect of reflection in the literature. Instead, emphasis seems to be placed on what individuals can do for themselves. The authors that do comment on this aspect see the teacher in the roles of stimulator of learning (Boud et al., 1985), coach (Schon, 1987), and facilitator (Little & Ryan, 1988). The current study results indicate that students need the support of someone they perceive as knowledgeable to enable them to clarify, validate, analyze and, if necessary, reformulate client problems and plans of care. The emergence of the client as the major focus of reflection during the third clinical practice placement cannot be explained by reference to the literature.

Conclusion

It must be acknowledged that the results of this study represent the experiences of a small group of students in a particular context. There is no suggestion that the results can be extrapolated to the general population of nursing students, but the insights gained may be of interest to those involved in the educational preparation of beginning level nurses. Similarly, the nature of the practice settings and the client groups and the fact that the study concentrated on the first year of the program would have impacted on the findings. In fact, the findings were seen by faculty as a justification for maintaining the sequence of clinical practice experiences in the first year program.

In addressing the research question, "What effect does reflection on clinical practice experience have on students as learners and care providers?" a number of statements can be made with respect to this study. From the perspective of students as learners, reflective sessions influenced the environment of learning, the process of learning, and the focus of learning. The major environmental effect was a reduction in the anxiety related to the clinical setting as a forum for learning. This occurred through peer and faculty support and led to increased levels of confidence among the students. Another environmental effect was the atmosphere of cooperation that was created as students shared experiences, achievements, and disappointments. This resulted in a general broadening of exposure to clinical situations and assisted individual students to make meaning out of what was happening to themselves and others within the particular clinical practice setting.

The process of learning was also affected by reflective practice. Students, after initial misgivings, began to accept responsibility for identifying their own learning needs and actively seeking information and resources to meet those needs. There was, however, some degree of continuing reliance on the clinical teacher to provide information that was required immediately and to be able to provide expert advice once student resources were exhausted. Reflective sessions provided a forum for examining and working on client problems that were real and in context, an aspect that students found extremely valuable.

The most significant finding of the effect of reflective practice was the emergence of the client as the central focus. This was equally evident in each of the two reflective processes, group debriefing and journaling. This is a highly desirable outcome as the essence of nursing is interaction with clients to help them maintain or regain optimal levels of health. The students in this study perceived the client as the individual to whom they were assigned to provide care; they did not extend the concept of client to mean a group or community. This is appropriate to the level at which they were functioning. However, concepts of holism in relation to client were evident. By the final reflective practice, they focused not only on the immediate health problem, but also on the client as a person who is part of the wider community.

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