Countless Theories Regarding the Effective

¶ … countless theories regarding the effective manner in which nursing practice might be conducted and developed. The value of theoretical frameworks has in fact been foundational to the development of nursing practice. Many models have been developed to put into perspective the importance or reveres of the actions taken by nurses in the direct practice arena as well as in a broader place in community, i.e. how their work affects the individual, community and world to some degree. Each framework is developed, discussed and possibly adopted, given the slant of the educational institution, the facility in which the nurse works or even the individual nurse. Adopting a theoretical framework can in fact be one of the most foundational things a student nurse and a practicing nurse does, as it offers a guide for action and interaction that puts into perspective the role and efficacy of the nurse. Many also argue that to much of nursing theory focuses on direct patient care and needs and/or the development of physical and emotional skill on the part of the nurse but does not respond to the broader community, and the nurses role in it.

This work on the contrary, will serve as a review of a theory or framework which has effectively responded to the above concern as well as the practical aspect of nursing practice and patient care. The theory that will be discussed at length in this work is Goodman's theory of reflection, often titled Goodman's Levels of Reflection. Goodman's work is generally reflective of other research theorists, but most specifically Van Manen (1977) and Dewey (1933) but has developed into a set of levels (3) which respond effectively to practical as well as theoretical issues surrounding nursing practice. The theory can serve as a template to help focus retrospective views on nursing practice events and help build a comprehensive set of goals to improve the narrow and broad impacts of nursing practice. The work will first broadly define Goodman's Theory of Reflection and then address each level of the theory independently offering critical examples of focus material that could be used and applied to the theory level.

Goodman's Theory:

Goodman expands on these other theorists' (Van Manen 1977 and Dewey 1933) ideas to create a comprehensive, reverse pyramid reflective process that addresses the broad range of nursing practice. According to Goodman (1984) there are three levels of reflection which can be achieved. The levels can serve as a "broad guide" for assessment of depth and quality of reflective work. Goodman stresses that focus of the reflection needs to be clarified, or students while likely focus in an unbalanced manner on one over another, most often on level one, as it is the most applicable of levels. (Bulman & Schutz, 2004, p. 169)

The reason an individual might focus more on 1st level reflection is that level one is most applicable to the physical act of completing nursing tasks, which often demands the lion's share of attention in nursing practice. Realistically it is for this very reason, i.e. The fact that nurses frequently work in rapidly moving environments with many physical needs to be met in short periods of time, that Goodman's theory is most useful as it works as a framework to or as Bulman and Schutz claim, as a "way of thinking and being," (p. 169) that forces individuals and groups to expand thinking to a local and then global perspective, beyond the physical practice of nursing.

The 1st level of reflection as was pointed out above, demonstrates an individual or group reflecting on how the nursing tasks work or works in a practical and technical sense. The 2nd level or the aspect of the local, i.e. how particular nursing practices work or do not work with the principles of the practice and lastly the 3rd level which is global is a reflection defined as the reflection on how the nursing practice works and responds in a political and social scale, with regard to ethics and a broader social structure. Each of the three then works together and independently to help focus best practices and develop a practice that is responsive on the individual, local and global levels and congruent with principles of the nursing, medical and broader societies. (p. 169)

According to Bulman and Schutz it is also important to note that Goodman stresses that reflection is not simply a tool to be used to problem solve. It has a broader purpose, as a way of thinking and responding to practical and theoretical concepts faced in nursing and in education. Goodman stresses that the opportunity to reflect in a focused manner can and will likely offer insight and intuition that is invaluable to the process and can probably help create innovation as a result. (p. 170) Collaborative thinking and even one independent actor reflecting in a systematic manner on these three levels could potentially create changes that have been long overdue, but where previously not suggested or simply never thought of before. The process could serve to help create better physical products and procedures as well as practices that are mort in line with the principles of the local and global society. This work will now move forward to provide and in depth critical analysis of each level of the triad.

1st level

Reflection to reach given objectives: Criteria for reflection are limited to technocratic issues of efficiency, effectiveness and accountability. The worth of objectives is taken for granted; reflection criteria are limited to accountability, efficiency and effectiveness. Students are worried about what works in maintaining the status quo." (Bulman & Schutz, 2004, p. 169)

As was stressed before first level thinking can be most closely associated with the practical. Reflecting on how or why a certain procedure is done and how it worked or did not work for a particular patient can be an essential aspect of reflection. The process can help the nurse and other staff put into perspective how mistakes occurred or how the results were affective for a patient or the system in general. The medical industry is a highly technical industry and nurses fulfill both mundane and technical roles that are reflective of this. Many nurses fall into the trap of simply working as rapidly as possible to achieve the long list of tasks that must be achieved during the shift. Reflecting on these tasks, could provide for the nurse the information they need to streamline tasks in such as way that the status quo is met but more efficiently and potentially leaving more time for the nurse to provide secondary responsibilities, such as time to actually comfort patients and reflect on care with coworkers. Many people would likely say that such a reflection would be unnecessary for many people as they work in a streamlined manner as a matter of common sense and as an aspect of having done something repetitively over many months or years in the same environment. Yet, reflecting on these very skills could provide a template for actions that another person could easily follow, and therefore improve time if they are filling in or are new to the area. Providing this reflection collaboratively would also help nurses collaborate and give hints to one another about the ways in which they do things in a very technical manner and share techniques that have saved time and provide better physical outcomes. This aspect of reflection could seriously assist any department in a goal of continual learning and as a way of helping individuals feel empowered and in a state of constant learning and teaching. (p. 17)

2nd Level

Reflection of the relationship between (nursing) principles and practice: There is an assessment of the implications and consequences pf action and beliefs as well as the underlying rationale for practice. A debate over principles and goals can be seen." (Bulman & Schutz, 2004, p. 169)

Within the second level of reflection there is a clear sense that there needs to be a reflective link between the practical and principle of actions and policies. This aspect of reflection could also be a collaborative process, and it could be multi-disciplinary as each department involved in nursing could explain aspects of practice and policy so each department will better understand the principles of the other. Even the individual could be helped by focusing on this aspect of reflection, as it is good to constantly challenge the local concepts of practice and how they apply to policy. If policy is not responsive to process the individual then has the opportunity to help resolve the conflict, and vice versa. It is essential to understand that both aspects of this 2nd reflective level can be altered to better serve the whole. In other words if the debate between process and policy shows a discrepancy between the manner in which something is done and an overall reason of action, such as a broader goal then either the goal or the practice can be altered to create congruency. One way to better understand this would be to use a local concept such as the facility's broader goal to be more economical in the manner in which they use resources. If the nurse is aware of an area of waste that can be addressed and does not reflect a legal concern (reusing some things is unlawful) then the nurse can bring this to the attention of the group and a solution can be developed and hopefully acted upon. This is a simple example. A more complex example would be an aspect of patient care that did not reflect the facility's goal to ensure effective home transitions for patients. If a nurse is aware of the fact that an individual patient has met all the healing goals but has no one at home to help them recover and is a party to allowing the individual to leave the facility without intervention, he or she may need to reflect on the overall policy and how he or she could have been involved in making a referral so that the individual patient did not return home without the support they needed, simply as a response to facility demands for beds or cost reduction. Each of these debates, simple or complex can have a serious result in changing policy or applying good policy that has already been supported. The role of the nurse as patient advocate is also seriously invested in this reflective process. Focusing on the ideals of caring and nurturing and looking at discrepancies in personal and/or facility policy and practice could serve as a supportive function for renewed interest in providing the best care possible in the best place possible and with the most reflective policies possible.