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Advanced practitioners' use of reflexivity in decision-making

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Andrea Bellot, MSc, BSc, RGN, is nurse consultant, Croydon Primary Health Care Trust
Bellot, A. (2006) Advanced practitioners’ use of reflexivity in clinical decision-making. Nursing Times; 102: 45, 33-34. This small study provides an insight into the process of clinical decision-making and raises awareness of the role of reflexivity and intuition in expert practice. This is a summary of the paper - the full version can be accessed at:

Advanced nurse practitioners work across the frontier of care that separates nursing from medicine and caring from curing. In doing so, these practitioners face clinical risks in diagnosing and treating undifferentiated clients - risks that had been outside the realm of nursing until recent years.

This study uses a qualitative paradigm of semi-structured interviews in an attempt to ‘get inside the heads’ of nurse practitioners to test the concept of reflexivity in practice.

The aim of this study was to explore intuition and reflexivity in practice, reflexivity’s impact on clinical decision-making, and to see if expert practitioners recognise the concept in their practice. The research question was: do advanced nurse practitioners use reflexivity to inform clinical decision-making?

The objectives were to:

- Explore the use of intuition and reflexivity in clinical decision-making;

- Explore the impact of reflexive practice on clinical decision-making;

- Ascertain if advanced nurse practitioners recognise reflexive practice in their work.

This study used a qualitative, exploratory paradigm of semi-structured interviews in order to explore the concept of reflexivity in clinical practice with a group of expert nurses who are all advanced nurse practitioners.

Semi-structured interviews were undertaken with four advanced nurse practitioners who were responsible for making decisions about the assessment, treatment and discharge of patients in practice. The interviews were transcribed verbatim and analysed using a structured framework for data analysis.

The study was designed and conducted using the framework developed by Burns and Grove (2001).

Ethical considerations
Local ethics committee approval was granted and the research and development committee of the researcher’s employing organisation was approached for permission to undertake this study.

The process of reflection is individual to each participant and the content of each reflection may have caused the participant to revisit emotive subject matter that they may not otherwise have considered.

In order to provide support for such eventualities, access to confidential, independent counselling outside the study was made available. Potential participants were made aware of the availability of counselling as well as the process of accessing it.

Consent to participate was gained from potential respondents. Random selection revealed five participants - one of whom took part in a pilot interview that was excluded from data analysis. Consideration was given to the problems of maintaining confidentiality and anonymity, as both raise issues when an exploratory methodology is used.

Because of the reliance of this type of study on the use of quotes and lived experiences to contextualise and illustrate meaning, it may have been possible to identify individuals from the findings outlined in this study and an attempt was made to minimise this.

Key themes were identified from the data.

Intuition An important theme in data from all respondents was the impact of intuition on the process of decision-making in clinical practice. This could be divided into:

- Unconscious processing;

- Conscious processing;

- Triggers, filters and cues.

Reflection - All four respondents described a process of reflection undertaken outside the consultation that occurred as a result of an emotional response to a situation encountered within it.

Reflexivity - The four respondents described a process they referred to as ‘reflection during a consultation’ that was triggered by an intuitive emotional response. The process was described as being different from their perceptions and experiences of retrospective reflection, being triggered by a different feeling and as having an impact on their thought process during the consultation rather than after it.

Clinical judgement - All four respondents described the process of making effective clinical decisions about a patient as being based on ‘sound clinical judgement’. Indeed, clinical judgement was a recurring theme through the data collected.

All four respondents indicated a negative emotional response in this situation and three stated that they were more cautious following it. All four stated that the feeling had an impact on their clinical decision-making as they consciously thought for longer and ‘dug deeper for information’ before acting.

Intuition played a key role in the respondents’ processing, taking them from what they described as the unconscious to the conscious during a consultation. Unconscious thought processes were possible for repetitive, familiar aspects of their role but when information failed to fit accepted patterns intuitive feelings took the respondents from unconscious to conscious processing. These conscious thought processes occurred during the consultation, prompting respondents to search for more information and to be more cautious in their decision-making.

The findings suggest that each respondent had an ‘accepted picture’ for each clinical situation, which constitutes their own situation repertoire. It appears that it is this accepted picture that the respondents try to piece together with the information gained from the patient during the consultation.

Benner (1984) stated that intuition requires a deep understanding of the background of a situation and that this is what makes an expert different from a novice. What the findings show, however, is that intuitive responses appear to occur where information does not fit the accepted pattern. While an understanding of the accepted pattern is required, the intuitive response occurs precisely because information does not fit the pattern, not because the expert understands it.

Benner (1984) suggested that the expert’s personal body of knowledge is built upon through a process of reflection. The findings support this notion that retrospective reflection is used to explore the processing and outcome of a consultation, but this only implies that learning occurs and does not prove it. The findings suggest that retrospective reflection is triggered by a negative feeling that occurs after the consultation. Reflection therefore appears to rely on the practitioner recognising the feeling and being willing to act upon it.

Conversely, intuitive feelings during the consultation appear to be different, and prompt conscious processing. It appears that conscious processing from intuitive responses is not a matter of choice, unlike reflection, and affects the decision-making process because it cannot be ignored.

This more readily reflects the process of reflexivity as Rolfe (2001) defined it. The findings appear to support this as the respondents described a process of filtering and sifting of information and further questioning of the patient.

This filtering and sifting method appears to be fundamental to the process, as triggers and intuitive responses rely upon it and enable the practitioner to focus on the individual characteristics of the patients’ presentation. The findings suggest that it is in filtering and sifting information that the ‘bits’ that do fit are identified and intuitive responses are generated.

- Benner (1984) suggested that intuitive experts think about what they are doing while they are doing it to inform the decision-making process.

- Rolfe (2001) argued, however, that there is a stage beyond this, suggesting that reflexive practitioners not only reflect on the situation they are dealing with but also reflect on the process of that reflection.

- Benner (1984) defined the beginner or ‘novice’ as one who follows the rule book. The expert, on the other hand, uses a set of unseen rules based not on what can be seen or measured but on what is perceived (Rolfe, 2001).

- Dreyfus and Dreyfus (1979) referred to this as intuition.

- Fitzgerald (1994) defined reflection as the retrospective contemplation of practice in order to uncover the knowledge used in a particular situation, by analysing and interpreting the information recalled.

- Rolfe (1997) hypothesised that there is a sixth level of practice, a level beyond what Benner describes as the expert practitioner.

- The concept of expertise is nebulous and hard to define and means different things to different people.

- Many authors recognise that intuition is a part of the way expert practitioners work.

- Some authors argue that, while an expert practitioner may function subconsciously, a reflexive practitioner uses a process of conscious hypothesising, testing and modifying in order to influence their decision-making.

Implications for practice
- Intuition plays a key role in decision-making and in moving thought processes from the sphere of the unconscious into that of the conscious.

- Reflection and reflexivity were both experienced but appeared to differ in their course of action and impact.

- Reflection involved a conscious process in response to a negative feeling, often after the consultation. Reflexivity, conversely, appeared to be in response to an intuitive feeling during consultation and clearly influenced the process of decision-making.

- The study gives some insight into reflexivity and enabled a brief exploration of it in practice. However, as a small study, it needs to be built upon to enable a fuller exploration.

This article has been double-blind peer-reviewed

Benner, P. (1984) From Novice to Expert. California, CA: Addison-Wesley Publishing.

Burns, N., Grove, S. (2001) The Practice of Nursing Research: Conduct, Critique and Utilisation (4th ed). Pennsylvania, PA: Saunders.

Dreyfus, H.L., Dreyfus, S.E. (1979) What Computers Can’t Do: The Limits of Artificial Intelligence. New York, NY: Harper and Row.

Fitzgerald, M. (1994) Theories of reflection for learning. In: Palmer, A., Burns, S., Bulman, C. (eds) Reflective Practice in Nursing. Oxford: Blackwell Science.

Rolfe, G. et al (2001) Critical Reflection for Nurses and the Helping Professions. Basingstoke: Palgrave.

VOL: 102, ISSUE: 45, PAGE NO: 33

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