Yonago Acta medica 2014;57:15–22

Original Article

Changes Resulting from Reflection Dialogues on Nursing Practice
Reiko Okuda and Mika Fukada
Department of Fundamental Nursing, School of Health Science, Tottori University Faculty of Medicine, Yonago 683-8503, Japan

ABSTRACT

looked at the meaning and possibilities of learning during adulthood from an epistemological perspective.3 She
questioned the frameworks composed by habitually conforming to assumptions, values, and beliefs, and stressed
the importance of critical reflection for adult learners.
Reflection is defined here as a process by which, throughself-conversation and critical reflection, one’s self andone’s behavior acquire meaning. Repetition of the reflection process fosters a mental state in which one can learn
from experience. For this reason, educational methods
that use the concept of reflection to confer experiential
learning have become increasingly common in basic
nursing training and continuing education.4, 5, 6, 7, 8
Reflection requires one to re-examine experiencesin detail, directly facing all facts and emotions. According to Ota4 and Nakamura,9 people have limitations interms of what they can express and be aware of duringreflection. This finding points to the importance of facilitators. The roles of reflection dialogues and facilitatorsin promoting learning in clinical nurse training havebeen investigated,10 with results suggesting that reflection not only promotes conversation and helps one toexpress emotions, but helps draw out profound thoughts
and underlying factors. Reflection also encourages nurses
to use different values and perspectives to understandevents differently. Muramatsu and Watanabe11 investigated reflection dialogues as used in the workplace forpublic health nurses. They reported that newly appointed
public health nurses achieved growth through conversations with experienced public health nurses, who played
the role of mentors. However, to date there has been little
research in the use of reflection dialogues in the medical
workplace with nurses. Therefore, this study will explore
what changes can be brought about in nursing practiceusing reflection dialogues.
These dialogues are compared with self-reflection,
which is conducted alone by the individual. This study
does not aim to merely hypothesize about individualreflection abilities, but to establish an approach that supports nurses’ growth. It also provides suggestions for supporting workplace learning among nurses.

Background

Reflection is defined here as a process
by which, through self-conversation, one’s self and one’s
behavior acquire meaning. However, people have limitations in terms of what they can express and be aware ofduring reflection. This finding points to the importanceof facilitators. The purpose of this study was to determine what changes can be brought about through reflection dialogues on nursing practice.
Methods The Participants were 9 nurses who worked
at three institutions in City A, each with about 200 beds.
Workplace topics were examined through self-reflections
and reflection dialogues. The depth of reflection was assessed using the three levels of reflection described by
Mezirow—{reflecting on the content}, {reflecting on theprocess} and {reflecting on the assumptions}.
Results
In reflecting on nursing practice, the participants were also divided into those who had alreadyreached the highest level, {reflecting on assumptions},
via self-reflection, and those who remained at the levelof {reflecting on processes}, despite the use of reflection
dialogues.
Conclusion The development of reflective thinking on
nursing practice was connected not only to the participants’ desire to explore ways of accepting their individual experiences, but may also be connected to whether
or not they are able to question themselves about theirthoughts and preconceptions about nursing work.
Key words

dialogue; nursing; practice; reflection; reflection dialogue
Nursing demands professionalism, and the ability topractice nursing accurately requires decision-making
skills based on specialized knowledge appropriate to thecircumstances. According to Benner,1 quality of experience is an important part of attaining mastery in nursing practices. According to the educational philosopher
John Dewey,2 reflection is an important way of fostering
individual growth and learning to increase the qualityof one’s experiences. Dewey argued that reflection isimportant for learning and individual growth,2 improving the value and quality of experiences. Mezirow (1991)

SUBJECTS AND METHODS
Subjects

Corresponding author: Reiko Okuda, MNS
reokd@med.tottori-u.ac.jp
Received 2013 November 8
Accepted 2013 December 5This study was qualitative, descriptive, and exploratory
in nature. Participants were nurses who worked at 3 insti15

R. Okuda and M. Fukada

guide based on Gibbs’ reflective cycle.12 The following 6
points were suggested as a path for reflective thinking:i) What were the specific circumstances of the situation?
ii) When the situation occurred, how did you feel andwhat were you thinking?
iii) What was good and what was bad about the situation?
iv) How did your feelings and thoughts at that time affect your behavior?
v) How did your values and beliefs regarding nursing
affect your behavior?
vi) If you encounter similar circumstances again, what
would you do?
During the reflection dialogues, the researchers
acted as facilitators and reflected on nursing practice together with the participants (Table 1).

tutions in City A (about 150 thousand people), each with
about 200 beds. After the researchers explained the intent
of the study to the head nurses at the participating medical institutions, they were introduced to 3 or 5 nurses at
each institution who were recommended as participantsby the head nurses. In order to observe the differences inreflective thinking in participants of differing experienceand ability, there were no limits placed on the numberof years of nursing experience or practical nursing ability. The nurses who agreed to participate in the study
received a written explanation of the purpose of the study
and confirmed their willingness to participate.
Definition of terms

Reflection dialogue: reflecting on day-to-day nursing
practice while talking with another registered nurse.
Reflection on the practice of nursing: thinking reflectively; looking back on one’s nursing practice to uncover
new knowledge that one had not realized at the time.

AnalysisFirst, the transcribed data from the 2 interviews selfreflection and reflection dialogue were read for generalcontent. The data were then organized into the components of the reflection process: [reconstruction of thescene], [hidden intentions behind the conduct] and [newself-realizations in the circumstances].10
Then, the depth of reflection on the practice of nursing was assessed using the three levels of reflection
described by Mezirow3 —{reflecting on the content},{reflecting on the process} and {reflecting on the assumptions}. Level I, {reflecting on the content}, involves
reflecting on the content of the problem and the specificcircumstances through [reconstruction of the scene]and [hidden intentions behind the conduct]. Level II,{reflecting on the process}, entails a search for problemsolving methods, through <specific points of reflection
regarding nursing conduct, a search for specific solutions
and a transition from theoretical to practical knowledge>. These three elements are all part of [new selfrealizations in the circumstances]. Level III, {reflecting
on assumptions}, is the questioning of the assumptions,beliefs and values behind the problem. This comprises<realizations about one’s tendencies, new appreciationof the role of nurse, reexamining one’s attitude toward
work and clarifying one’s nursing perspective> under thelarger category of [new self-realizations in the circumstances]. Level III can be differentiated from Level II inthat it involves the investigation of fundamental thoughts
about oneself. The depth of reflection on the practice ofnursing during self-reflection and in the reflection dialogue were compared and categorized.
We showed the participant the data in which thecontents of self-reflection verbalized the external validity of data. We then got the contents of the narration to

Interview protocol

Participants completed a preliminary survey on theirage, years of nursing experience and highest level of
education to obtain a nursing license. Then, 2 interviews
were conducted in which participants were encouraged
to reflect on the practice of nursing. Interviews focusedon situations in which participants felt concerned, overwhelmed or unconvinced when dealing directly withpatients. In the first interview, the researcher did notprovide any follow-up questions or comments after initial prompts, allowing the participants to engage in selfreflection. In the second interview, the researcher asked
follow-up questions to encourage participants to talk.
This resulted in a reflection dialogue with the researcher.
The reflection dialogues examined the same workplace
topics as the self-reflections.
Data collection

The data collection period was between February andMarch 2010. Two interviews were conducted, with the
2nd interview being conducted within 2 weeks of the
1st so that the content of the 1st interview was still freshin the participant’s mind during the reflection dialogue.
During interviews, researchers communicated sincere
interest in what the participants were talking about, affirming the participants’ thoughts and feelings without
judging or imposing their own values. Interviews wereconducted in private rooms and recorded using voicerecorders with the participants’ consent. Interviews werethen transcribed for data analysis.
Participants were asked to prepare notes before
their interviews to help them recall the nursing situations they wished to reflect on and to follow a reflective
16

Reflection dialogues in nursing practiceTable 1. Facilitator questions
Question

Operational definitions

Verification challenges

Ask what participants thought pro- To understand the emotional effects that happened throughout thisscene; to consider what made them aware of challenges
pelled the scene
To relive the thoughts and emotions of the situation at the time; to noAsk about events and situations
tice the intentions of their behavior patterns and actions

Recall the situation
Narrative feedback
Iterative

Aim

Repeat words and phrases used byparticipant
Grasp the summary of the contentsof what participants said
Offer one’s own thoughts and understanding of participants’ stories

To encourage a detailed narrative through the repetition of words andphrases
To listen carefully to others; to encourage participants to objectively
examine their actions.
To encourage an expansion of thoughts and feelings; to grasp the situation as understood by others

To discuss difficult situations thatthe nurses find challenging
Offer another perspective to explore the challenges faced by others
To seek a new level of awarenessthrough critique

To encourage noticing additional facts about the issues; to organize
thoughts
To encourage different frameworks for understanding and examining
the core issues based on the opinions and advice of others
To promote the expression of noticing changes in one’s self as a nurse
or changes regarding the view of the situation

check whether it matches with the data. When analyzing, the verbatim record of the data was read from one
certain viewpoint to interpret the deepening of reflection
on many sides. Repeating this process each time, we
returned to the data on the component of reflection andchecked its validity. While receiving an instructor’s supervision in the analytical process, we inquired repeatedly until a common view was acquired.

tient’s condition and some kind of solution was reached.
Nurses C, E, F and I reflected on incidents in which their
nursing exacerbated patient pain or anxiety, and shared
their continuing regret over such an unsuccessful outcome. Nurses B and D reflected on incidents in which
they responded appropriately to a challenging situation,
but around which some uncomfortable self-directed feelings remained (Table 2).

Ethical considerations

Characteristics of reflections on the practice ofnursing

Summary
Interpretation
Focused questions
Offer another point of view
Validation of results

This study was approved (No.1340) by the Ethics Committee of Tottori University and, when necessary, by the
ethics committees at the subject institutions. Participants
were assured that participation was voluntary, that they
could withdraw at any time without facing negative consequences, that their anonymity would be protected andthat the data obtained would not be used for purposes
other than research. Participants gave written informed
consent.

The feedback that participants received on their narratives in the form of researchers’ repetitions, summaries, and interpretations during the reflection dialogues
encouraged participants to relive the emotions andthoughts that they experienced during these situations
and helped them to generate detailed narratives. Researcher questions focusing on the practical experienceof nursing and their perspectives from other viewpoints
not only encouraged the participants to be aware of theirown patterns of behavior and the intentions underlying
their actions, but to discover their own issues and generate new meaning associated with the practice of nursing.
The interview data reflecting on the practice of nursing were analyzed with an eye to whether reflection had
deepened. Results showed that dialogue deepened reflection level in Nurses D, H and I, with each of these participants advancing from Level I or II to level III during
the second interview. For the remaining six participants,
dialogue did not result in a deeper level of reflection. Of
them, Nurses B, E, F and G remained at Level II, thesame level that they had reached during self-reflection.
Nurses A and C remained at Level III, the level that they
had reached during self-reflection (Table 3).

RESULTS
Summary of participants and interviews

Self-reflection and reflection dialogues were conductedwith 14 participants. Five participants were excluded
from the final analysis because of lack of specific episodes to discuss, no direct interactions with patients, etc.
The final sample comprised 9 female participants, henceforth referred to as Nurses A to I. Their mean age (SD)was 30.33 years (5.52 years) (range: 22.0–39.0 years). All
had gone through a 3-year basic nursing course at vocational school. The mean number (SD) of years of experience was 8.56 years (4.61 years) (range: 1.0–13.0 years).
Nurses A, G and H reflected on incidents in which
their nursing resulted in a favorable change in the pa17

R. Okuda and M. Fukada
Table 2. Case summaries and interview duration
Interview Case
Subject time*
information
A
18/40
Male
		 Diabetes
B
10/33
		
		
C
30/60
		
		
D
12/20
		

Male
Amyloidarthropathy
Male
Swallowing
dysfunction
Male
Liver biopsy

E
16/50
Female		 Terminal-stage
		
breast cancer
F
7/40
Male
		 Terminal-stage		lung cancer
G
6/34
		

FemaleMood disorder

H
6/35
		
		
		
I
3/28
		

Male
Schizophrenia
Cerebral
infarction
FemaleDementia

Case summary
The Outpatient seemed to constantly ask “Is it time yet? Is it time yet?” One day, Nurse A went outof her way to speak to him in the waiting room; after that his words and behavior changed, and his
attitude became more positive.
The patient was due to be discharged from the hospital. During the entire evening, he pressed thecall button frequently. Nurse B attended to him each time, but he always said, “I’m telling you I’m inpain but you don’t do anything about it!” which troubled and confused her.
The patient had been moved from surgery in preparation for at-home care, and had fallen into a low
nutritional state after digestive surgery. A variety of methods were attempted to deal with his swallowing disorder, but he did not recover. Eventually he underwent an enterostomy.
A discrepancy arose between the doctor’s explanation of the examination and the patient’s understanding, and the patient’s facial expression became more and more sullen. In the intensive careward, Nurse D was unable to simultaneously sympathize with the patient and mediate for the doctor.
The patient had been receiving outpatient treatment, but when her condition became terminal andshe began experiencing distressing symptoms such as difficulty breathing and she was admitted tothe hospital. At the time of admission, the doctor believed that the patient’s family understood theseriousness of her condition. Do Not Resuscitate (DNR) procedures were explained and the family
appeared to agree, but when the moment of death came they opted for resuscitation.
The patient was given 4 L of oxygen via cannula, but the level of oxygen saturation was still low (around80%). The patient did not appear to be suffering difficulty in breathing but he agreed to be fitted withan oxygen mask. Afterward, he said with tears in his eyes, “I put up with the mask at first, but I can’ttake it anymore!”
A former inpatient called the ward after coming for an outpatient examination, saying, “I’m thinking about dying. I’m going into the water.” The staff found out where she was and went to search forher. Afterward, the staff discussed how to deal with similar situations and eventually came up with astandard procedure.
Nurse H wondered about how to deal with a patient who was able to engage in rehabilitation on his
own but had become dependent on the hospital ward. Nurse H participated in a review of patient
procedures and worked to unify patient support methods. Then, the patient developed a desire to rehabilitate.
The patient suddenly took off all her clothes and entered a neighboring room. She mistakenly
thought it was the bath and could not be convinced to go back to her room. Eventually she was forcedback into her room and locked inside.

*Self-reflection/dialogue (min).

The 3 features of reflecting on nursing practices are
explained below. Within the nurses’ narratives, meaningful sections were extracted, with the relevant typeof reference presented. The component for the relevant
reflection is shown within parenthesis at the end of thenarration (Tables 4-1, 4-2 and 4-3).

showed a new appreciation for her role as a nurse while
evaluating how nursing practices could be performed ina more timely matter, and expressed how she wanted to
conduct herself as a nurse in the future.
Nurse I, in her self-reflection, gave only a brief summary of the situation and reflected vaguely on a few
points. During the reflection dialogue, she realized somebehavioral tendencies she had that she had taken for
granted when asked about thoughts that formed the basisof her behavior in the aforementioned situation.

Cases in which reflection was deepened to Stage III
through conversation

Nurse D, in her self-reflection, described only the patient’s words and actions, and gave a purely factual account of her own behavior. However, by investigating
the basis for the thoughts that had affected her conduct
in the reflection dialogue, she was able to clarify issues
concerning her role as a nurse through reflecting on her
attitude toward patients.
Nurse H, in her self-reflection, described a transformation from theoretical to practical knowledge by investigating factors linked to what happens when a patient’s
reactions change. During the reflection dialogue, sheCases in which reflection was not deepened throughdialogue

Pattern in which Level III was already attained in selfreflection: Nurse A, in her self-reflection, discussed
thinking about the meaning behind the patient’s words
and actions in a certain situation, and wondered how her
thinking had affected her conduct. She also re-examined
her attitude toward work, looking back on things thatstood out from her everyday routine. During the reflec18

Reflection dialogues in nursing practiceTable 3. Reflection components and reflection level observed in each case			Deepening
			occurred in		Patternreflective dialogue
No deepening in reflective dialogue				Level III						
Level IIIin self-		
Stayed at Level II			in dialogue
reflection
from self-reflection
		
Nurse
D
H
I
A
C
B
E
F
G
		
Experience* 10
1
13
13
13
5
6
4
13
		
Level ofProcess
Component
reflection† Components contained in talk‡Reconstruction of scene
Facts about what happened as a result
Evaluation of subject’s nursing conduct		
Extraction of issues
concerning the		circumstances
I
Intentions hidden behind the conduct
Subject’s feelings at the time		
Background of circumstancesthat influenced subject’s emotions		Thoughts		that influenced subject’s		conduct
New self-realizations toward self in the circumstances
Specific points of reflection regarding
subject’s nursing conduct
II
Investigation of specific solutions		
Transition from theoretical to practical							knowledge
Realizations about subject’s tendencies
New appreciation of subject’s role as				a nurseReexamination of subject’s attitude
III
		
			
toward work
Clarification of subject’s nursing point					of view		*year(s).
†I, reflection on contents; II, reflection on process; III, reflection on assumptions.
‡ , self-reflection; , reflective dialogue.

tion dialogue, she not only came up with specific points
to reflect on concerning the situation but also thought
constructively about why certain events occurred, thereby attaching further significance to her experiences on
the basis of her self-reflection.
Nurse C’s self-reflection mainly consisted of an explanation of the patient’s condition, along with a vague
reflection on what had occurred and some realizations
regarding her tendencies. A detailed review of her conduct as a nurse during the reflection dialogue allowed
her to analyze the factors involved in what had happened, which led to specific realizations regarding her
cognitive and behavioral tendencies.

scribed how, by understanding the feelings that underlie
patients’ words and actions, a nurse can deepen his or
her reflection regarding his or her conduct during a problematic situation. While her self-reflection was abstract,
she did discuss a possible solution. She also described
how, by listening to the many patients she encounters in
her daily work, she came to understand the importanceof care in bringing about not only physical but also
psychological change. This is an example of theoreticalknowledge being transformed into practical knowledge.
Nurse E, in her self-reflection, mainly talked in detail about the patient’s condition and her conduct in thesituation; however, she also mentioned the confusion thatshe felt when looking for a solution. During the reflection dialogue, she went over the process of her thoughts
and feelings during the situation with the researcher, anddescribed specific points to reflect upon regarding her
conduct. Further, when another point of view was sug-

Pattern of no change from Level II, which was attained
during self-reflection: The situation Nurse B selected
for self-reflection was one that had been discussed in aprevious group-training session. Her self-reflection de19

R. Okuda and M. Fukada
Table 4-1. Nurse D: case example in which reflection was deepened through dialogue
Self“Though, if the doctor’s feelings had been hurt, it could have further destroyed (doctor-patient) trust. There was such a conreflection flict.” <Thoughts that affected one’s conduct>
Reflection Overview
dialogue Discussed the feelings of patients, and confirmed thoughts about the relationship between the patient and health care provider. Looked back at the incident and discussed interest in patients, to perceive the thoughts of the patients. Talked about therole of nurses as a bridge between the doctor and the patient to represent the feelings of the patient. Discussed that intervention procedures would be more appropriate that the derived reflection time. Discussed how to acquire assertiveness skills tosolve future problems.
“I have trouble grasping what patients aren’t understanding, and to what extent they are understanding. There might be amore fundamental problem where the patient doesn’t even know what to ask. Therefore, I thought I had to sense very carefully whether patients could really understand.” <Specific point to reflect on about nursing conduct>“I’ve thought about how I couldn’t intervene between the doctor and the patient for a long time, but thinking about what I
could have said and how I could have said it; I think I could have said something.” <Investigation of specific solutions>“When anger gets involved, I always feel uneasy. If I want to have a calm conversation, I think I should avoid inflaming angry emotions.” <Realizations about one’s tendencies>“The relationship of trust between a patient and a nurse is also important, but when there is misunderstanding or some [trouble]
between the doctor and the patient, it’s difficult to know how not to harm that relationship, how to express myself, and how to
say everything kindly.” <New appreciation for the nurse’s role>* Text in pointy brackets denotes the corresponding factor or component from the assessments.
Table 4-2. Nurse A: case example in which reflection was already at Level III, attained though self-reflection“We have preconceptions about difficult patients, patients that need special attention—we judge them in a glance with the
Selfreflection perceptions we’ve built up over years. But these are just images, and I don’t think one should go about creating images ofpeople through them. So I reflected.” <Investigation of specific solutions>“I want patients in the diabetes treatment center to tell me about themselves. When I wonder if there’s anything I can do, I
think that at least I can think tenderly about each person. So, even when I’m busy, I want to make time to get more involved
with patients.” <Reviewing the attitude toward work>“Kan of watchful/attentive/mindful Kango (Nursing) means to touch by hand, to see carefully and to get rid of preconceptions. If the nurse has in her mind and knows what is truly important, I think she can connect with any patient.” <Clarification of the nursing point of view>

Reflection Overview
dialogue Nurse A said there were patients who said “I’m still waiting” for a period of one or two years. Nurse A has confirmed the
feeling of looking at the patients in the waiting area. She reflected this feeling in her way of dealing with the patients as anurse. Nurses should re-examine the relationship between patients and their understanding of patients in order to get rid ofany bias. Individual treatment and how to face major events was discussed, as well as self-reflection and conclusions. Nurse
A realized that serving patients every day and cultivating nursing values has led to growth as a nurse.
“I now think my awareness of the patient as a ‘person who can’t wait’ or a ‘nagging person’ took precedence, and I wasn’t
able to respond to him. In this case, the constant ‘Is it time yet?’ maybe programmed me into just wanting to get him treated
and out of the office as soon as possible.” <Specific point to reflect on about nursing conduct>“I think patients are mirrors. If I try to connect with someone with a closed heart, he or she will respond with a closed heart.
Instead of thinking, ‘Why won’t that person open up to me?’ I need to realize that their heart is closed because mine is, too.”<Transition from theoretical to practical knowledge>“I realized that even though this is something I have always placed a lot of importance on, after hearing that time and again,
my preconceptions got in the way of my nursing work.” <Realization about one’s tendencies>“Of course, you have to get rid of all of them (preconceptions) and talk to each individual (patient). Even patients with thesame disease who have gone through the same process, each individual is different, so the intervention needs to vary.”<Clarification of the nursing point of view>* Text in pointy brackets denotes the corresponding factor or component from the assessments.

gested, she came up with several plans to solve the problem by thinking about professionalism in nursing.
Nurse F, in her self-reflection, only gave a simple
description of the event and a vague reflection. In thereflection dialogue, through a discussion of her thinking
and awareness of problems in certain situations, she described some specific points to reflect on.
Nurse G, in her self-reflection, only gave a simple
20

Reflection dialogues in nursing practiceTable 4-3. Nurse F: case example in which reflection remained at Level II, attained through self-reflection
Self“I’m not good at about forcing patients to do things and I don’t think it’s a good thing, but only in that instance I had recomreflection mended considerably (forced the patient).” <Specific point to reflect on about nursing conduct>“He wasn’t having trouble breathing, and I couldn’t think about what was a good thing from his standpoint. Since he was aterminal patient, I couldn’t think about what the most important thing to pay attention to was.” <Specific point to reflect on
about nursing conduct>

Reflection Overview
dialogue Even though the patients had not complained of difficulty in breathing, Nurse F confirmed the instructions for treatment andoxygen administration. The patients wondered why they are made to forcibly wear the oxygen masks. There were also somepatients who believed that wearing oxygen masks to be end of life. Nurse F discussed the measures taken to solve the problem, such as consulting with a doctor. The patient’s feelings were mainly considered only as an afterthought.
However, it has not been described to be coming and to treasure as a way of dealing with the terminally.
“At the time, I was mostly occupied with things like examination data, prioritizing that over the patient’s feelings, and thinking about how I couldn’t send him to the next shift [quasi-night staff] in that state. The patient’s feelings were secondary.”<Specific point to reflect on about nursing conduct>“I didn’t realize how much the patient disliked the mask or that the mask was causing him to suffer. Patients seemed to have
had a part that he have to put up with a lot, and for me could not realize that point or I wasn’t able to read him from his reactions. I feel like I just pushed my own point of view.” <Specific point to reflect on about nursing conduct>“If I had thought a little more about his feelings, I think I could have figured out another method that didn’t require using themask at that point. I could have reported it to the doctor in charge and discussed what to do.” <Investigation of specific solutions>* Text in pointy brackets denotes the corresponding factor or component from the assessments.

description of the event and a vague reflection. Since amanual had been created that provided a solution for her
example, she mainly focused on that. During the reflection dialogue, suggestion of another viewpoint allowed
her to think about the meaning of the patient’s words anddeeds, and connect this to theoretical knowledge.

In the cases of Nurses B and G, who remained at{reflecting on processes}, which had reached throughself-reflection, it is hypothesized that their reflection did
not deepen because the discontent they had felt regarding the situations had, to at least to some extent, been
reduced. A new point of view was obtained throughexchanging opinions with others, and the guideline
for the way to deal with a problem situation was clarified through the creation of a manual. Thus, when thereflective thinking occurred, these nurses appeared tothink that they do not need to reexamine their conduct.
However, Nurses E and F did not attain deeper levels ofreflection, despite having ill feelings over having contributed to patients’ pain or anxiety. A possible reason could
be that they are likely to continue to experience a statein which they explore how nurses should conduct themselves at work. When people experience the benefits of abelief as a decision-making tool, they discover the value
in that belief and act to maintain it.14 It is thought thatthe sharing of beliefs with others can subsequently resultin these beliefs being converted into something of one’s
own; these beliefs are the results of one’s own actions
arising from one’s own experiences, and, as a useful
tool for directing attitudes and actions, they lead to thediscovery of value. In particular, for young nurses, it isvitally important that experienced nurses communicate
their beliefs in terms of their thoughts and preoccupations about work in addition to recounting specific stories about their experiences.

DISCUSSION
Nurses D and H, who advanced to {reflecting on assumptions} through conversations, and Nurses A and C, who
had already reached {reflecting on assumptions} throughself-reflection, asked themselves if there were no solutions
for the anxiety they became aware of after reflecting on
their situations. These nurses were observed to behave ina manner so as to play their roles as nurses based on theirown beliefs. Whether nurses can act autonomously hinges
on how they perceive their role while working with otherprofessionals as part of a medical team, and is deeply related to patient care. According to Matsuo,13 feelings anddesires about being a certain kind of professional manifest
in one’s attitude and behavior during nursing practice. In
addition to reflecting on one’s practice, these also influence
one’s psychological growth as a professional aiming tobecome a reflective nurse. The ability to question oneself
to bring about even better results develops out of one’s feelings and particularities about the job of a nurse. A person
who can deepen reflection uses repeated self-questioning
to work towards the level of nursing that he or she aspires
towards; such persons appear to have high professionalism.
21

R. Okuda and M. Fukada

According to Benner,15 the ability to recognize when
one is having problems with patients involves possessing
ideas related to good practice. This plays a key role inprofessional autonomy in nursing, giving nurses interest and confidence in their inner selves, as manifested
through their thoughts and conduct during work. This
reflection also influences how they display their nursing
expertise.16 People who spare no effort in the pursuitof professionalism are thought to be able to ask themselves how they can be better nurses for the sake of theirpatients, to ascertain what decisions are appropriate incertain situations by reflecting on their nursing activities,
and to give meaning to their experiences. The thoughtsthat guide nurses’ work and the ability to discover meaning and significance in work while questioning oneself
are matters that allow professionals to play their roles
well.
The professional growth of reflective practitioners
occurs on the job through mutual reflection and deliberation among practitioners.17 According to Seibert,18 work
environments that enable reflection in the midst of action
have the following characteristics: autonomy; feedback
from others; information and psychological support
from superiors, colleagues and mentors; and the means
to encounter new ideas or different viewpoints. Candid
advice from the seniors and feedback from juniors andcolleagues is valuable for growth at workplace. In doing
so, not only does it produce growth among individual
nurses, but it can also have a major effect on the qualityof nursing throughout the entire workplace. To cultivate
professionalism in nursing, it is important that reflective
learning takes place in workplaces in which practice andreflection are consistent parts of day-to-day activities.
The research participants were limited to nurses
who were willing to actively engage in scrutiny of theirpast nursing practice. The psychological type of individuals, their past experiences of reflection and whether
or not they have received training on reflection may haveaffected the deepening of their reflection. This study indicated that the deepening of reflection is related to one’s
ability to examine one’s feelings and desires about nursing. However, the beliefs one values about work appear
to grow not only on one’s own, but are formed throughrelationships with others at the workplace. We would
like to pursue this area in the future.

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Acknowledgments: We would like to thank the hospital management staff who cooperated with this study, especially the chief
nurses. We also offer sincere thanks to the participants, who took
precious time out of their busy schedules for interviews.
The authors declare no conflict of interest.

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