reflection as a transforming process: student advanced nurse practitioners’ experiences of...

ISSUES AND INNOVATIONS IN NURSING EDUCATION

Re¯ection as a transforming process: student advanced nurse

practitioners' experiences of developing re¯ective

skills as part of an MSc programme

Jane E. Glaze RN RNT BSc PhD

Senior Lecturer, School of Nursing and Midwifery, University of Wolverhampton, Dudley, West Midlands, UK

Submitted for publication 4 July 2000

Accepted for publication 15 February 2001

Background

Advanced nursing practice originated in the United States of

America (USA) and Canada in the late 1960s, early 1970s, in

response to a shortage of primary physicians. The aim was to

help meet North America's health care needs by combining

the caring role of the nurse with the traditional clinical role of

the physician (Hicks & Hennessy 1998). In the USA, practice

advanced along two related, but distinct directions: that of

the nurse practitioner and the clinical nurse specialist.

This division arose `in response to social demands for

increased access to affordable, quality primary health care'

and to the requirements for specialist nursing care in complex

nursing care situations (Dunn 1997, p. 814). In North

Ó 2001 Blackwell Science Ltd 639

Correspondence:

Jane Glaze,

14, Russett Way,

Bewdley,

West Midlands DY12 2PY,

UK.

E-mail: [email protected]

G L A Z EG L A Z E JJ .EE . (2 00 1 )(2 0 01 ) Journal of Advanced Nursing 34(5), 639±647

Re¯ection as a transforming process: student advanced nurse practitioners' experi-

ences of developing re¯ective skills as part of an MSc programme

Aim of the study. The aim of this study was to explore student advanced nurse

practitioners' (ANPs) experiences of re¯ection.

Background. The implementation of a National Health Service (NHS) Executive

initiative to develop a Master's Course in advanced nursing practice at Wolver-

hampton University provided the background to the study. The course was designed

to enable experienced nurses to take on activities previously considered the province

of physicians. The aim was to extend practice within a holistic nursing framework.

Re¯ection was perceived as central to this process. A pre-entry degree level re¯ective

practice module and a re¯ective component for the level 4 (Master's level) Practice

Module were devised to enhance practitioners' re¯ective skills.

Rationale. The rationale for the study was that it should explore student ANPs'

perceptions of re¯ection following completion of these modules, to evaluate their

experiences and inform curriculum development.

Design/Methods. A qualitative methodology was used. The sample comprised 14

ANP students. Interviews and re¯ective learning contracts were used to collect the

data. Colaizzi's (1978) seven-stage model guided data analysis.

Findings. The ®ndings indicated that all but one of the students described the

development of their re¯ective skills positively. Changes are described in students'

thinking and behaviour.

Conclusions. The conclusions have implications for ANPs, for patient care, and for

others seeking to develop the ANP role.

Keywords: re¯ection, advanced nurse practitioner, awareness, assertiveness,

empowerment, perspective transformation, valuing nursing, deepening re¯ection

qualitative research

America, Australia and the United Kingdom (UK), major

management changes to health care over the past 15 years

have been driven by technological advances, re-allocation

from secondary to primary care and increasing nursing and

medical specialization which results in a need for cost

containment (Offredy 2000). Restructuring of the workforce

resulted in support workers undertaking jobs previously

carried out by nurses (Offredy 1995). Shortage of junior

doctors (Greenhalgh 1994) along with professional factors in

nursing contributed to a need for new roles for experienced

nurses. It was against this backdrop that the introduction of

advanced nurse practitioners (ANPs) in the UK took place in

the 1990s.

In the West Midlands, the introduction of the ANP role

was perceived positively by the NHS Executive. They decided

to develop a framework for advanced practice to ensure

that role development was carried out systematically (Dunn

& Morgan 1998). Following widespread consultation

with physicians, nurses and educationalists, a Master's

programme in advanced nursing practice was developed.

The course was designed to enable experienced nurses to take

on activities previously considered the province of doctors.

The aim was to extend practice within a holistic nursing

framework. As part of this initiative the University of

Wolverhampton offers a number of routes including health

visiting, community nursing, practice nursing and accident

and emergency nursing. Curriculum development was about

much more than substituting for junior doctors. Rather, it

was an opportunity for experienced nurses to extend their

practice for the patient's bene®t within a nursing focus.

Re¯ection was presented as central to this process (Dunn &

Morgan 1998). A pre-entry degree level re¯ective practice

module and a re¯ective component for the Master's level

Practice Module were devised to facilitate enhancement of

re¯ective skills. The curriculum was developed from ®ndings

of a doctoral study of nursing expertise carried out by the

module leader (Conway 1995). The motivation for this study

arose from a desire to ascertain students' experiences of

re¯ection in relation to their developing role as ANPs. It was

hoped that the ®ndings could inform future curriculum

development.

Review of the literature

The bene®ts of re¯ection for professional practice are

increasingly being recognized in the UK (Chambers 1999,

Redfern & Norman 1999, Wilkinson 1999), the USA (Kim

1999), Canada (Boychuk 1999, Hartrick 2000), New

Zealand (Teekman 2000), Australia (Greenwood 1998),

Finland (Kuokkanen 2000) and Hong Kong (Wong & Lee

2000, Yam et al. 2000). At national and international level

professional nursing bodies such as the English National

Board for Nursing, Midwifery and Health Visiting (1989)

and the Nursing Council of New Zealand, are advocating the

development of re¯ective practitioners (Teekman 2000).

These practitioners need to cope with competing demands

and respond to a variety of social, technical and professional

factors (Pierson 1998). This has resulted in curricula

development, which have moved from traditional positivistic

and behaviourist paradigms to:

¼more qualitative approaches, based on emancipatory philosophy

and critical social theory. Re¯ection, in these new curricula, is often

considered an appropriate vehicle for¼fostering not only an under-

standing of nurses' work, but also the development of the critically

thoughtful approaches essential for providing nursing care in

complex environments (Pierson 1998, p. 165).

Re¯ection encourages practitioners to keep a nursing

focus to practice (Platzer et al. 2000a) rather than being

subsumed by the medical model and turning into technolo-

gical experts (Conway 1998, Glaze 1998). In the past nurses

adjusted to medical dominance by becoming more like

doctors (Johns 1996). The inclusion of re¯ection within the

ANP programme may moderate this trend. Critical re¯ection

encourages practitioners to free themselves from ideological

constraints (Habermas 1970, 1971, Kuokkanen 2000) and

ensure a caring perspective in practice (Watson 1998, Benner

2000, Yam et al. 2000), alongside the therapeutic paradigm

of medicine (Richmond & Keane 1996 cited by Mick &

Ackerman 2000).

Burton (2000) questions whether nurses are ready for the

demands of developing critical theory and achieving eman-

cipation. These sentiments are supported in part by Conway's

(1996) study of nursing expertise. She found that expertise

develops in response to the worldview held by nurses.

Worldviews were in¯uenced by the prevailing conditions.

Some nurses felt constrained and oppressed, and re¯ected

on their practice at a super®cial level. However, others,

described as Humanistic Existentialists were critically re¯ec-

tive, passionate about nursing practice, con®dent and

assertive and able to challenge themselves and colleagues

openly and nondefensively (Conway 1998, Glaze 1998).

Platzer et al. (2000a) in a recent evaluation study of devel-

oping re¯ection through group supervision found that

through re¯ection, students developed an increased ability

to empathize with others whilst also being able to challenge

the status quo. The aim of the re¯ective module is to assist

students to develop such abilities (Conway 1998, Platzer

et al. 2000a) whilst bearing in mind the constraints imposed

by their respective world views (Conway 1998).

J.E. Glaze

640 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(5), 639±647

It was important that the re¯ective approach used encour-

ages ideological challenging, as there are considerable differ-

ences between the theoretical approaches that underpin

re¯ection (Burton 2000, Teekman 2000). The Frankfurt

School of Social Research and Habermas (19712 ), in partic-

ular, inspired a critical science concept of re¯ection as self-

determination. Of particular importance to the development

of ANPs re¯ective abilities is Habermas's (1971) emancipa-

tory level, which is concerned with self-knowledge and

self-re¯ection. This type of re¯ection can be de®ned as

`critical' in that practitioners question the ideologies that

shape their daily practice (Teekman 2000). Goodman's

(1984) levels of re¯ection provide a useful starting point for

developing such abilities. He identi®ed three levels to deepen

re¯ections. The ®rst involves simple problem solving, and is

fairly super®cial. The second level is concerned with using

literature and theories to illuminate the analysis of the

scenario under review. The third level requires consideration

of broader social forces, of issues such as justice and

emancipation and of political factors.

Also relevant to development of ANP skills is the work of

Schon (1983, 1987). He describes framing and reframing

whereby the expert solves problems by examining them in

new and unique ways. Advanced nurse practitioners will be

extending their practice as independent autonomous practi-

tioners (Hicks & Hennessy 1999) within a frequently chan-

ging politically determined arena where multiple agendas

impinge on the nursing role. The development of critical

re¯ective abilities may be crucial to ANPs in managing these

demands effectively, whilst pushing forward the boundaries

of practice (United Kingdom Central Council for Nursing,

Midwifery and Health Visiting 1998) in a caring holistic

manner.

The study

Aim

The aim of this study was to access ANP students' experi-

ences of re¯ection.

Research design

A qualitative research approach was used. Qualitative

research provides useful description when little is known

about a group of people, an organization, or some social

phenomenon (Polit & Hungler 1987). Qualitative research

provides a means for capturing context speci®c situations, by

focusing on human beings within their social and cultural

context.

Research tools

Data triangulation using interviews and re¯ective contracts

was used (Polit & Hungler 1987). Whilst there was some

structure in the interviews this was limited to ensuring that

participants were focused on the topic under investigation.

The aim was to obtain participants' perceptions of their

world without imposing the researcher's views on them.

At the beginning of each interview participants were asked to

tell their story of re¯ection by starting at the beginning of the

re¯ective module and working through to the present with

emphasis being attached to what the experience was like for

them as individuals. They were assured that there were no

right or wrong things to say, the aim was to capture the

experience in its totality. Questions were used to act as

prompts, to clarify points and to probe deeper. When the

students had told their stories, issues from their learning

contracts relating to their re¯ective experience which needed

clari®cation or elaboration, were raised. Permission was

obtained to tape the interviews, which lasted between one

and a half and two and half-hours. In total 707 pages of

data from the interviews and 405 pages from the learning

contracts were analysed.

Pilot study

A pilot study was carried out with an ex-student from a

previous cohort. No modi®cations to the research design

were considered necessary. The data was so rich that it was

decided to include it in its own right within the main

study.

Sample

It is recognized that sampling procedures in qualitative

studies need quite different considerations to quantitative

approaches (Patton 1987). It was decided to use purposeful

sampling.

The power of purposeful sampling lies in selecting information-rich

cases¼from which one can learn a great deal about issues of

central importance to the purpose of the evaluation (Patton 1987,

p. 51).

All students in the 1999 cohort were asked to participate as

they were `information rich cases' (Patton 1987, p. 51) with

particular attributes and experiences relevant to the enquiry

(Polit & Hungler 1987). They had all completed the pre-entry

re¯ective module of the MSc programme, and the re¯ective

component of the Practice Module. A total of 16 students

were written to requesting participation and a reply slip was

included. Thirteen agreed to participate. With the inclusion

of the student from the pilot study this made a total of 14

participants.

Issues and innovations in nursing education Developing re¯ective skills

Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(5), 639±647 641

Ethical issues

The School and University research committees approved the

research. Feelings of coercion can arise when participants and

researchers have built up a relationship over a period of time.

Also the issue of the researcher also being the students'

lecturer can be problematical. Students may feel reluctant to

participate but not wish to say so, or they might feel under

pressure to say good things about their experiences (Macduff

1998). Four main measures were taken to counter-act this

situation. First, students were assured that participation was

entirely voluntary and that they could withdraw at any stage

without explanation. Secondly, they were assured that there

were no right or wrong answers, that the aim of the study was

to ascertain their experience. Thirdly, they were assured that

all information would be con®dential and that anonymity

would be maintained by ensuring no identifying information

was declared. Fourthly, the interviews were not carried out

until the MSc Course was completed. Three students

exercised their freedom of choice by not participating in the

study.

Trustworthiness

To achieve rigour, the framework devised by Koch (1994)

(Table 1) was used. This was based on Guba and Lincoln's

(1985) creditability, transferability and dependability.

Credibility is enhanced when researchers describe and

interpret their experience as researchers (Koch 1994).

Validity in new paradigm research (e.g. qualitative research) lies in

the skills and sensitivities of the researcher, in how he or she uses

herself as¼an inquirer. Validity is more personal and interpersonal,

rather than methodological (Reason & Rowan 1981, p. 244).

A re¯ective diary was kept by the researcher in order to

promote self-awareness, encourage consciousness-raising and

explore feelings about issues encountered. Whilst this process

cannot guarantee objectivity, it did encourage the develop-

ment of insight into factors that were in¯uencing the

researcher and, by implication, the study. This is particularly

important in relationships where there is a danger of over-

rapport, which may damage the researcher's objectivity

(Holloway & Wheeler 1996). The diary also provided a

place to test out ideas and to ensure that constructions were

built on veri®able evidence.

It is essential that interviewing techniques are correctly

carried out as the amount and depth of data gained is

largely dependent on the researchers interpersonal skills

(Field & Morse 1985). The researcher's previous experience

in carrying out qualitative work was helpful (Conway

1995). This had enabled her to enhance her interviewing

skills and data analysis abilities and to become familiar with

issues concerning rigour in qualitative studies. Veri®cation

with source is seen as `the backbone of satisfying the truth-

value criterion' (Guba & Lincoln 1981, p. 110). A period of

time was set aside at the end of each interview for

clari®cation.

Interviewer: So are you saying that in your organization there's very

little respect for nursing and little support for pushing the boundaries

of nursing forward?

Interviewee: There's no respect for that at all. And there is no

managerial support either, which is very frustrating. With the

particular manager we have here now,¼he's got his own agenda

and he sticks to it.

Sandelowski (1986) suggests that

A qualitative study is credible when it presents such faithful

descriptions or interpretations of human experience that the people

having the experience would immediately recognize it from those

descriptions or interpretations as their own (Sandelowski 1986,

p. 30).

Each student was sent a 20-page sample from their transcript

with categories identi®ed for veri®cation. They all con®rmed

that the categories generated re¯ected their meanings.

Holloway and Wheeler (1996) suggest that data should be

linked to their source so that readers can establish the

conclusions and interpretations drawn arise directly from

them. Whilst every attempt has been made to do this, the

constraints imposed by word limits when preparing the study

for publication (Morse 1994, Smith 1998) curtail the amount

of data that can be provided.

Guba and Lincoln (1981, p. 116) suggest the use of the term

transferability instead of applicability (Table 1). Transfera-

bility has limited application, is dependent upon the degree of

`®t' or similarity between two contexts. Data are interpreted

`in terms of cultural norms and mores, community values,

deep-seated attitudes and motives, and the like' (Guba &

Lincoln 1981, p. 119). No claim for generalisability in the

Table 1 Establishing trustworthiness*

Scienti®c paradigm

criteria

Constructivist paradigm

criteria

Truth values Internal validity Credibility

Applicability External validity Transferability

Consistency Reliability Dependability

*Adapted from Guba and Lincoln (1989). Constructivist is the term

used by Guba and Lincoln (1985) to describe their `qualitative'

paradigm. Source: Koch (1994).

J.E. Glaze


statistical sense is made for this work but, there could be a

degree of ®t between this work and other studies undertaken

with similar purposive samples and in similar settings. Whilst

acknowledging the possibility of ®ttingness, the intention of

this research is not generalisability, but to inform curriculum

development and to provide descriptive information about a

subject that little investigation has taken place in.

Dependability can be established through external audit

(Koch 1994). A panel of experts carried out an audit of the

data analysis. They con®rmed that the categories identi®ed

re¯ected the data provided.

Data analysis

The 14 interviews were transcribed verbatim. Colaizzi's

(1978) seven-stage model guided data analysis. The tran-

scripts were read and reread to gain an impression of the

data. Signi®cant statements were identi®ed and compared

and contrasted with statements generated in other transcripts

to identify similarities and differences. The dimensions of the

statements were explored. This was essential to establish

whether these were isolated experiences or could be applied

more widely (Baillie 1996). A total of 378 signi®cant

statements relating to the development of re¯ective abilities

were identi®ed. Statements were examined for commonalties

and differences. The 378 statements were aggregated into

theme clusters and 23 categories or formulated meanings

were formed (Table 2).

A thematic grid was developed to provide a pictorial

representation of the categories identi®ed. This enabled the

spread of categories per-participant to be identi®ed (Table 3).

The original transcripts were returned to, to validate the

categories identi®ed and numerous quotations were selected

for illustrative purposes. Through this process an exhaustive

description of the essential structures of the phenomenon of

students' experiences of re¯ection was developed. For the

purpose of publication the categories were further aggregated

into (i) major themes identifying re¯ection as a transforma-

tive process, (ii) descriptions of the stages of participants'

re¯ective journeys and (iii) world views. This paper addresses

the ®rst of these, re¯ection as a transformative process. The

female case has been used for reporting the ®ndings in order

to protect the research participants' identity.

Findings

Transformation

All but one of the students' experiences were viewed

positively. The majority perceived themselves as having gone

through a process of transformation. They described

themselves as being more aware, of having developed insight

into how their personal biographies shaped their actions.

Also, they identi®ed increased appreciation of what nursing

can be. They stated that they had become more realistic, and

believed that they were more open and con®dent. Some

perceived their development in terms of speci®c abilities such

as assertion. Others discussed processes of enlightenment.

They described commitment to pushing forward the bound-

aries of practice coupled with a strong desire to empower staff.

The following quotations illustrate some of the perceptions

expressed by the students:

I feel more con®dent because I think I know a lot more.

I'm much more assertive.

Table 3 Excerpt from thematic grid:

numbers of times category mentioned per

participantName Empowerment Political

Nursing

focus

Developing

others

Using

literature

Student 1 9 8 2 7 7

Student 2 10 7 5 11 1

Student 3 3 6 4 3 1

Table 2 Categories and theme clusters from the participants' words

Category Sample of theme clusters

Transformation Greater awareness, increased thinking

Re¯ective thinking moved beyond simple

problem-solving to considering broader

social forces and political and ethical

factors

Perspective transformation, reframing

Deepening re¯ection through models and

literature

Re-appreciation of value of nursing

More assertive, challenging

Empowering others

Thinking politically,

devising strategies

Creates and uses opportunities to in¯uence,

for example through primary care group

(PCG) Boards

Participates in and uses support networks

Takes into account the agenda's of others,

tries to fuse these with the nursing agenda

Cultivation of signi®cant others

Chooses the moment, picks battles



I feel more self-assured, more mature.

I'm much more challenging.

I'm very critically inquiring, but equally I would say I'm sensitive

with it.

I've de®nitely transformed both personally and professionally.

One student did not perceive her experience as transformative.

She felt she was constrained from developing her re¯ective

skills by the oppressive environment that she worked in:

I think a lot of the problems were that I was more concentrating on

problems related to the job area rather than concentrating on

developing my re¯ective skill.

She experienced dif®culties with her general practitioner (GP)

mentor and felt oppressed in her working environment:

You sort of battle against things that you don't agree with, then you

try and work to some sort of compromise and then you are forced to

work within their remit and then you ®nd yourself slowly being

demoralized and de-motivated.

She re¯ected on these dif®culties in her contract but she did

not ®nd this helpful, rather it compounded her sense of

powerlessness. She found exploring her situation painful:

Acknowledging that you didn't know what you were doing or where

you were coming from, or you didn't know yourself. It is always

dif®cult to acknowledge when you don't know what you are talking

about or whether you are making sense or whether you are actually

doing something in your life or getting anywhere.

This student also felt that other factors in¯uenced her

negative experience of re¯ection, for example, she had

dif®culties with her written work and saw herself as having

a negative approach to life.

Awareness

A common theme in relation to transformation was increased

awareness. Students described how this was linked to broader

social forces:

[It's] very empowering, to understand the context¼[of] the

interaction with the client¼it has been a huge shift for me. I don't

think I was ever a bad Health Visitor, but now¼I am much different

¼I feel much more connected with the social context of crime, much

more connected to the clients¼It is more about being honest and

open minded and expanding the truth between the two of you.

Students described how they had learned to re-frame situa-

tions (Schon 1983, 1987). For one student her love of

photography had enabled her to understand why others did

not always understand the point she was making:

I¼like¼photography so much, if I had seen something that I thought

was really good or really beautiful and I had managed to convey it to

somebody else¼I thought yes it is re-framing it¼looking at it from a

different angle¼that is what I see in my nursing interactions, that is

what I see, or begun to see with re¯ective practice the value of what

we do, but that is why other people don't see¼what I see¼I see the

bigger system [now] and how people are entrenched in this system.

Valuing nursing

Many ANP students described a new appreciation of nursing:

I think re¯ection¼allows me to focus on patients more to get away

from structures and what is good for Doctors and what is good for

Nurses and [back to] actually what it good for patients.

One thing it (re¯ection) really taught me was to value Nursing and to

really think about Nursing itself.

One ANP student described struggling to devise strategies to

ensure that nursing care was not subsumed within a medical

framework:

I do try to bring in the nursing element but because of the way the

appointments are set¼I¼feel that sometimes it is a medical assess-

ment that is being carried out¼I am trying¼to do that within a

holistic framework but it is not always easy¼The GPs now want me

to run a Hypertension Clinic¼what I am trying to do¼is¼look at

the nonpharmacological methods of treating blood pressure¼I want

to spend more time looking at their diet¼weight control, looking at

some of the other issues¼what I hope to do with that is try and

incorporate a social model of illness prevention.

Clearly this student was striving to keep a nursing focus to

practice and she was aware of the constraints that her new

role placed on her.

Deepening re¯ection by using literature and theories

Students described how the literature used as part of the

re¯ective process can be af®rmative. Reading around a topic

legitimized proposed actions and helped them to see why they

were having dif®culties. It gave them a sense that they were

not `lone voices crying in the wilderness'. `You feel it's not

only me, it's not only me'. Literature helped one student to

explore the dif®culties she was experiencing when working

with women prisoners on remand:

I was¼a health-visitor attached to a station unit where there were

women who¼were waiting to go to court in terms of quite serious

J.E. Glaze


crimes¼[they] were very disempowered¼I had a client¼who had a

child but the child wasn't with her. She was using heroin and had

been¼for a long time¼she told me that her child was very ill in

hospital¼and she wanted to leave the station to go and see her

child¼So I talked to the probation of®cer¼and made¼inquiries

with the health visitors where she lived. Some days later the health

visitor rang me and told me that the child wasn't in hospital¼and

was well and didn't seem to be ill¼In fact, she lied to me and I found

that quite painful. The fact that she could say these things about her

child and the fact that I couldn't understand why she had lied to

me¼When I looked back¼at the history and looked at some of her

behaviour¼her whole life revolved around the need to get heroin and

probably she would have used that opportunity to get some heroin

and saw me as perhaps facilitating that process. I remember feeling

quite angry with her and sort of shocked not understanding it really

and [not] understanding where she was with that¼I hadn't seen that

coming, I hadn't had the insight to predict that¼naivete is the word

to use. [I was] naÈ ive in my practice¼When I looked at the literature

on drug use, if you are a drug addict, that is all that you think

about¼she had one aim. So, I felt OK when I understood this.

Towards empowerment

Many students described attempts to empower their collea-

gues. A student who worked as a community practitioner,

described her work environment as dominated by crisis

management where GPs are all powerful and Trust managers

keep them `happy' so that Trust business is not lost through

contracts being taken elsewhere. She identi®ed that the district

nurses and practice nurses were caught in the middle of this

situation, and were being strongly in¯uenced by the whims of

the GPs. This student described how she had been striving to try

to bring about a culture change. She perceived critical theory

and the work of Habermas (1970, 1971) and Freire (1968) as

having relevance to her work environment. She came to believe

that it was essential that district nurses were totally involved in

decisions affecting their work. She strove to assist them to

become assertive, and to value themselves and what they do:

What I have done is pull together the Team Leaders and started

looking at ways, to empower them, to make¼changes them-

selves¼We are looking at various issues that¼Team Leaders should

be dealing with but can't, because of the crisis management type work

they are doing¼[I am] saying, `well how can we change the way that

you work? How can we change the way GPs think about you?

Becoming political ± devising strategies

Becoming politically aware was a theme common to many of

the ANP students:

Developing¼re¯ective skills¼enlightened me on how necessary it

was to be political if you want to push nursing practice¼You have

got to work with them¼It is just a case of learning to use the

situation as it is, not get angry and work against it.

They described devising strategies and taking into account the

agendas of others such as GPs so that they could try to fuse

these with the nursing agenda. Another strategy used by

students was the cultivation of like-minded colleagues, agen-

cies and organizations, to enable practitioners to provide a

nursing in¯uence on the health agenda. One student identi®ed

her reasoning for choosing to work with Women's Aid:

I look at people who are very politically driven and I look at

Women's Aid and they are driven by their feminist values and their

regard for women¼is very strong¼I have started to un-pick¼how

come they are so clear [about things] and it is about their beliefs, their

moral beliefs, ethical beliefs. So by working with them I feel that's

going to empower me to start shifting my organization.

Students described being more thoughtful about their

responses to situations. A lecturer-practitioner explained

her thinking in relation to problematic situations:

I pick my battles now¼I have learnt not always to stick my head

above the parapet, sometimes to say, `®ne that is what you believe,

you stand your ground there but it is not an issue at the moment so

let's move on'.

Clinical Governance (Department of Health 1998) was seen

as a means to improve practice. Students described working

in Primary Care Groups (PCGs) in their attempts to push

forward the boundaries and to bring about change in nursing

practice. However, these PCG groups are dominated by GPs

and students identi®ed that change may take time.

Discussion

This study has thrown new light on students' experiences of

developing re¯ective skills. They described changes in their

behaviour resulting from perspective transformation. Whilst

the degree of transformation varied, for all but one of these

students this was described as a liberating process. The

dif®culties experienced by this student share commonalties

with those experienced by students in the study of Platzer

et al. (2000b). They found that previous education, social-

ization and the culture of the organization were all in¯uential

in determining students' responses to learning from experi-

ence (Platzer et al. 2000b).

Some students described increased con®dence and

assertiveness and others moved beyond this to politicization

and empowerment. These students appeared to be re¯ecting



on the level of critical-inquiry as described by Teekman

(2000). They presented themselves as political animals stri-

ving to in¯uence the nursing agenda in the interprofessional

debate about practice.

Kuokkanen (2000, p. 236) identi®es empowerment as `an

abstract concept that is fundamentally positive, referring to

solutions rather than problems'. Empowerment in this

context is important because these students were striving to

push forward the boundaries of practice. They described

themselves as devising strategies and acting in politically

astute ways in order to ensure that the nursing voice was

heard. Also, they strove to ensure they maintained a holistic

focus to care rather than being subsumed by the medical

model. Students' perception that they have at least partly,

thrown off the oppressive in¯uence of their nursing histories

is a signi®cant step forward.

Re-af®rmation of the value of nursing, with the patient

placed centre stage augurs well for any extensions of practice.

Re¯ection appears to have brought a new legitimacy to

proposed nursing actions. Platzer et al. (2000a) identi®ed

similar ®ndings regarding re¯ection acting as a legitimizing

process and enabling students to act in clients' best interests.

Commentators describe dif®culties encountered in devel-

oping re¯ective skills in students (Wellard & Bethune 1996).

In addition, the clinical environment has been identi®ed as

not always being favourable to learning and effective practice

(Conway 1996, Wong & Lee 2000, Platzer et al. 2000b).

Findings suggest that the development of re¯ective skills is a

complex process, and depends partly on the student being

willing to re¯ect as well as feeling suf®ciently supported to

look at dif®cult issues.

Conclusion

The ®ndings from this study suggest that the integration of

re¯ection within the ANP Master's degree programme was

bene®cial for the majority of students. They have painted

a picture of personal and professional development.

They viewed re¯ection as now part of their lives, assisting

them with the implementation of their roles as ANPs and

leading them to more astute political behaviour.

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