Reflective thinking in clinical nursing education : a concept analysis

Over decades nursing had an interest in clarifying and developing its knowledge base and its conceptual foun­ dation. Reflective thinking has become a popular word in nursing education world wide, but its meaning and effective use remains debatable because of lack of clar­ ity in its meaning (Mackintosh, 1998:553). The researcher engaged in the concept analysis of reflective thinking so as to fully understand its meaning and interpretation, hence the research question to be addressed by this article is: “What is the meaning of reflective thinking in clinical nursing education?” This article seeks to explore and describe the concep­ tual meaning of reflective thinking in clinical nursing education using the method of concept analysis as out­ lined by Wilson (1963:23-39) and Gift (1997:75,76). Con­ cept analysis of reflective thinking constitutes the first phase of a study to develop a model to facilitate reflec­ tive thinking in clinical nursing education, thus ensur­ ing theoretical validity of the model. An extensive examination of domain specific and vari­ ous disciplines’ literature was explored as part of the concept analysis. A selection of information regarding variations and similarities in the use and interpretation of reflective thinking across clinical nursing education was drawn from com puterised data bases. This in­ creased the rigor and the findings of the analysis. Through deductive reasoning and drawing of infer­ ences, attributes were clustered in an attempt to iden­ tify the apparent essence of the concept. Three categories and the related connotations emerged as follows: • Antecedents (Cognitive and affective thinking skills) • Process (The three phases of reflective think­

This article seeks to explore and describe the concep tual meaning of reflective thinking in clinical nursing education using the method of concept analysis as out lined by Wilson (1963:23-39) and Gift (1997:75,76).Con cept analysis of reflective thinking constitutes the first phase of a study to develop a model to facilitate reflec tive thinking in clinical nursing education, thus ensur ing theoretical validity of the model.
An extensive examination of domain specific and vari ous disciplines' literature was explored as part of the concept analysis.A selection of information regarding variations and similarities in the use and interpretation of reflective thinking across clinical nursing education was drawn from computerised data bases.This in creased the rigor and the findings of the analysis.Through deductive reasoning and drawing of infer ences, attributes were clustered in an attempt to iden tify the apparent essence of the concept.Reflective thinking was considered from the result of concept analysis as a cyclic, interactive constructing mental process to improve practice in a specific con text.It is recommended that a model to facilitate reflec tive thinking in clinical nursing education be developed

Introduction
Reflective thinking has become a buzz-word in the educa tional arena nationally and internationally.It has become a thorny issue in clinical nursing education as an educational tool to improve clinical practice, especially in the event of outcome-based education, community-based education, problem-based learning and evidence-based practice.
The South African Education System is faced with key chal lenges with regard to provision of quality assurance in edu cation, as well as the quantity and quality of graduates in line with the best practice internationally.Central to the outcomes-based education system, community-based edu cation and problem-based learning, is learner-centred meth ods of teaching and evaluation that facilitate reflective think ing through interaction.
Nursing, as a practice-orientated profession should pay considerable attention to the development and clarifica tion of its knowledge base in general and in clinical nursing education in particular.Confusion in facilitating clinical nursing education arises due to conceptual problems, yet concept clarification plays an important role in the intellec tual development of knowledge, skills and values of every day existence.
Reflective thinking has become a popular word in nursing education world wide but its meaning and effective use remains debatable because of lack of clarity in its meaning (Mackintosh, 1998:553).The researcher engaged in the con cept analysis of reflective thinking so as to fully under stand its meaning and interpretation, hence the research question to be addressed by this article is: "What is the meaning of reflective thinking in clinical nursing educa tion?" The results of the concept analysis could provide a con ceptual framework as a point of departure to guide the em pirical phase of a study to develop a model to facilitate reflective thinking in clinical nursing education.
An overview of the method of concept analysis is described, followed by the description of the results in accordance with the identified categories and the related connotations of reflective thinking.A theoretical definition is formulated and theoretical validity is thus ensured.

M ethod: concept analysis
The method of content analysis as outlined by Wilson (1963:23-39) and Gift (1997:75,76) provided a framework to conduct a concept analysis of reflective thinking in clinical nursing education.Of the eleven steps described by Wilson (1963) in concept analysis, only seven steps appropriate to the study were used, based on the assumption that the concept under study should be "mature".This means that the concept should be clear and distinct, clearly defined and well differentiated from other concepts (epistemological principle), and that concepts should be applicable to the world and be appropriate to their use in the context (pragmatic and linguistic principle) Gift (1997:75,76).The method of concept analysis used is indicated in figure one.
Wilson (1963:23-39) suggests that the best way to conduct a good concept analysis is to follow all the steps in their order.The author contends that in some cases one or more steps may be omitted according to the sensitivity of the analysts, which will enable them to make good use of the appropriate steps of the strategy.The researcher made use of all the steps except the contrary, related, borderline and the invented cases.A brief overview of the method is de scribed according to the selected steps, as applied to the concept of "reflective thinking" within the context of clini cal nursing education.

Isolating questions of concept
Wilson ( 1963:23) states that before embarking on a concept analysis, the analyst should ensure that the question be ing answered is one that requires the meaning of the con cept.The analyst should ask 'what counts' as the concept or 'what criteria' are being used to determine the meaning of the concept.The way in which questions of concepts are answered depends entirely on the angle from which the analyst is looking at them (Wilson, 1963:23).
Questions are often raised about the nature of reflective thinking in nursing education, nursing practice and nurs ing research.Should reflective thinking be used as an edu cational tool in nursing education?Should reflective prac tice be used to evidence efficient practice?Can reflective thinking be measured or evaluated in practice?These are some of the questions that raise the underlying anxiety in nursing.The study particularly isolated the concept of re flective thinking in order to answer the question: "what is the conceptual meaning and nature of reflective thinking within the context of clinical nursing education?"

Finding the right answers
The step of finding the right answers requires the analyst to determine which elements are essential to the 'core' of the concept and which are not.Wilson (1963:25) points out that there are no final right answers in a concept analysis, but emphasises that there are primary and central uses for the concept that can be distinguished through a thought ful analysis.
From the analysis of the concept of reflective thinking, the essential attributes/connotations are identified.Wilson's method of concept analysis is an inductive, descriptive means of enquiry used to clarify the current status of the concept by identifying a consensus in the use and inter pretation of the concept.A number of connotations for reflective thinking are identified from both primary and sec ondary sources such as dictionaries, thesauruses, books, articles, related conceptual and theoretical frameworks as well as data drawn from computerised databases.Through deductive analysis, synthesis and drawing inferences, at tributes were clustered in an attempt to identify the appar ent essence of the concept.

M odel case description
To identify the attributes and their related connotations in order to apply reflective thinking meaningfully in clinical nursing education, a model case was identified and de scribed as adapted from Benner et al (1999) using the at tributes as indicated in table 2. According to Wilson (1963:28) model cases are the paradigm or exemplary cases of the concept under study.A model case of a concept enhances the degree of clarification offered as a result of analysis by providing an everyday example that includes the attributes of the concept (Rodgers, 1989:333).(1963:33) states that language only occurs within a social and cultural context.Thus concepts take on mean ing within that particular context.A sensitive analyst must take into account the social and cultural milieu in which the concept under study is used.Wilson suggests that the analyst might ask who might use the concept, when, why, how and so forth as a way of determining the context in which it is likely to be used.

Wilson
Reflective thinking may provide different interpretations across cultures, regions and even disciplines.The clinical nursing education context in which reflective thinking of learners has to be facilitated, provided the researcher with insight into the essential nature of the concept.To under stand the nature of reflective thinking and how it has to be facilitated, one must understand the complex nature of clini cal nursing education as the context occurring within the legal, ethical and professional boundaries in the country.

Underlying anxiety
Closely associated with considering the social and cultural context of a concept is examining the underlying anxiety associated with it (Wilson, 1963:34).To determine the feel ings, the tone and important insights about the concept, Wilson suggests that the analyst should ask questions such as: has the concept generated strong feelings or con troversy?Is there a debate about the issue?Is it generally positive, or is it negative?These questions may provide the analyst with insight that may emerge concerning the concept under study.Reflective thinking has become a buzz word in the educational arena nationally and internation ally.It has become a thorny issue in clinical nursing educa tion as an educational tool to improve clinical practice, es pecially in the event of outcome-based education, commu nity-based education, problem-based learning and evi dence-based practice.
Concept analysis in this research will contribute to the un derlying anxiety by clarifying the conceptual meaning of reflective thinking to be able to use it in developing a model to facilitate reflective thinking in clinical nursing educa tion.(1963:34,35) argues that analysing a concept should have some practical results.It ought to make some differ ence in our lives.The authors are of the opinion that if the results of concept analysis are not useful, analysis was a waste of time -then something is seriously amiss with the language in which the question of the concept was ex pressed.

Wilson
The results of the concept analysis of reflective thinking could be helpful in that the attributes could be used in the C ura tio n is description of a theoretical definition of reflective thinking.The application in this research is as follows (refer to re sults): phases of the reflective thinking process are identi fied, influenced by the cognitive and affective thinking skills as antecedents in their level of complexity as fol lows: The first phase is the awareness and disequilibrium phase where acquisition of knowledge guided by the re ceptive attitude takes place.This knowledge has to be com prehended for positive response to take place.The second phase is characterised by an interactive constructing proc ess in which learners should critically analyse information, taking into consideration the value system of the self and others, and synthesise the information creatively in an or ganised manner to make meaningful interpretation of the situation.The third phase is when the consolidated knowl edge and experience are evaluated and internalised and used for rational clinical decision-making and problem solv ing.The outcome of reflective thinking is demonstrated by the development of new insight and a changed perspective in order to improve practice.Use of the accumulated knowl edge and experience enables the learner to function inde pendently and autonomously in practice, and to develop skills for lifelong learning.These phases with their related cognitive and affective thinking skills will help the facilitator to select appropriate teaching, assessment and evaluation methods that are learner-centred to facilitate reflective think ing in accordance with the learner's level of training.

Results in language
Wilson (1963:36-38) suggests that in defining a logical struc ture for a concept, one should choose the essential at tributes of a concept that are most sensible and useful to make the definition meaningful so that the concept shall be used to the fullest advantage.For the concept of reflective thinking, the following are the most useful criteria applied in this research to describe the theoretical definition: 1.
A state of awareness and disequilibrium triggered by the uncomfortable feelings and thoughts.

2.
A cyclic, interactive constructing mental process influenced by cognitive and affective thinking skills in their hierarchical order as antecedents.

3.
The use of the consolidated knowledge and experi ence.

4.
Acquisition of new insight and a changed perspec tive to be used for rational decision making and solv ing of clinical problems as a subsequent outcome.A theoretical definition will be formulated after the re sults of concept analysis have been described.

Description of results
Three categories and the related connotations emerged: • Antecedents (cognitive and affective thinking skills in their hierarchy as adapted from Blooms' taxonomy 1956) • Process (three phases of reflective thinking proc ess.Phase one: awareness and disequilibruim; phase two: interactive constructing process; phase three: consolidation for rational decision making and prob- Reflective thinking is considered as a cyclic interactive constructing mental process to improve practice in a spe cific context.
The results of the concept analysis of reflective thinking demonstrate the antecedents influencing the reflective thinking process resulting in new insight and changed per spective as the outcome of reflective thinking displayed in figure two.
A brief description of antecedents (cognitive and affective thinking skills) followed by the process (phases of reflec tive thinking), and the outcome (new insight and changed perspective) to make rational decisions and solve prob lems in practice will be made in accordance with table two.Lastly, the theoretical definition of reflective thinking is formulated using the identified attributes.
Antecedents: cognitive and affective thinking skill Walker and Avant (1988:43) define antecedents as neces sary skills and events that must occur prior to the occur rence of the event or phenom enon, w hilst Rodgers (1989:330) describe antecedents of a concept as events or phenomena that are generally found to precede an instance of the concept.Almost all the literature sources explored revealed that the primary antecedents, or situations pre ceding reflective thinking process are the cognitive and affective thinking skills as demonstrated in the writing of Beyer (1988:47-49) The researcher found it appropriate to adapt the educa tional objectives in accordance with Bloom's taxonomy ( 1956).The cognitive thinking skills are, from the lowest to the highest: knowledge, comprehension, application, analy sis, synthesis and evaluation.The affective thinking skills are as follows: receptivity, responding, valuing, organisa tion and internalisation.The adaptation of the cognitive thinking skills comes in where the researcher omits applica tion as the third level of reasoning since the application of knowledge in this study occurs when the learner has inter nalised the professional values and demonstrate the ability to make rational decisions and solve problems.To avoid repetition, both the cognitive and affective thinking skills as antecedents influencing the process of reflective think ing will be described simultaneously in relation to the phases of reflective thinking.

P R O C E S S : Phases of reflective thinking in relation to cognitive and affective thinking skills as antecedents
The process of reflective thinking constitutes three identi fied phases of reflective thinking influenced by the cogni tive and affective thinking skills in their hierarchical order.The schematic representation in figure one depicts the re lationship between the phases of reflective thinking and the cognitive and affective thinking process as anteced 40 ents.
Phase one of the reflective thinking process is the aware ness and disequilibrium phase influenced by (knowledge, receptivity, comprehension and responding) respectively in a specific situation.Phase two is the interactive con structing process that requires (critical analysis and syn thesis of information as supported by values and the abil ity to organise information).Phase three is the consolida tion phase where the accumulated knowledge and skills are evaluated and internalised, leading to new insight and a changed perspective as the outcome of reflective thinking, to enable learners to make rational clinical decisions and solve problems to improve practice.
Note that the phases are integrated, and the level of com plexity increases with the phases as the learner's reflective thinking skills develops.Gravett (1996:10) argues that it is important to realise that the suggested phases will not nec essarily feature in a single session.They may not neces sarily be clearly distinguishable and successive.The logi cal order will be determined by the context in which reflec tive thinking occurs.Gravett (1996:10) maintains that the facilitator needs to pay attention to the fact that learners indeed receive the opportunity to confront their existing conceptions and the possible shortcomings or flaws in the conceptions.The phases are described according to their hierarchy from the lowest to the highest phase.
Phase 1 -Aw areness and disequilibrium Awareness, according to Benner et al. (1999:568) The facilitator is challenged by the responsibility to create an environment that will foster thinking through scenarios that cause dissonance and disequilibrium to encourage learners to engage in active construction of their own knowl edge and skills in clinical nursing education.How knowl edge, receptivity, comprehension and responding thinking skills as antecedents influence phase one of reflective think ing will be described.
According to Concise Oxford Dictionary (1995), knowledge is awareness or familiarity gained by experience, whereas Goodwin and Klausmeier (1975:242) assert that knowledge denotes factual information that is learned.Knowledge im plies authority and reliability (Blackburn, 1999:47).Knowl edge of the basic essentials such as facts, ideas, concepts, principles, guidelines, generalisations, methods and theo ries of a discipline form the building blocks on which reflec tive thinking is based.Dewey (1933:104) aptly states that no reflective thinking can occur in a vacuum.Scanlan andChernomas (1997:1139) argue that it would be more useful to think of conceptualisation as the first stage of reflective thinking that one would encounter in practice, since acqui sition of knowledge in a specific context causes one to have a genuine interest in constructing new knowledge.It is from this knowledge framework that learners can con struct knowledge by interpreting perceptions on the basis of prior knowledge and existing beliefs to reach new per spectives (Tynjala, 1997:288).Wong et al. 1995:50) are of the opinion that reflective thinkers will always return to the previous knowl edge and experience, recollect what has taken place, attend to feelings, and relate new data to that which is already known.They will seek relationships between data, deter mine the authenticity of ideas and feelings that resulted and then make the resultant knowledge and feelings their own.Therefore previous knowledge and concepts are an instrument of understanding and explaining things that are still uncertain and perplexing.

Boud et al. (in
Basic knowledge is important, especially to the novice since, according to Benner (1982:403), novice students have no experience of the clinical situation.Hence, they have to be taught about the situation in terms of 'objective at tributes' that are features of the task that can be recognised without situational experience.Learners in phase one are taught basic concepts, rules, principles, methods and theo ries to guide their action.Objective attributes (weight, tem peratures, blood pressure) are taught better through lec ture demonstrations, observation and narratives.
Learners must be encouraged to identify, define and de scribe clinical events.Benner et al. (1999:47) assert that acquiring an embodied skill involves learning through the body, through all the senses.It entails learning new em bodied habits of attentiveness, thinking and acting.The knowledge gained will then form what Ausubel (1968:57) refers to as 'cognitive structures' to link future experiences in order to provide a meaningful reality.Ausubel refers to the cognitive structure of an individual as the stability, clar ity and organisation of knowledge in a given discipline that the individual already commands.
However, Ausubel (1968:116) gives a warning that, for one to be able to interpret situations meaningfully, the follow ing aspects have to be considered: a) the nature and avail ability of relevant anchoring ideas in the cognitive struc ture; b) the stability and clarity of these ideas and c) the discriminability of the learning material from its anchoring ideas to motivate the learner.These aspects may have a positive impact on one's readiness for reflective thinking process to occur.Successful knowledge acquisition is in fluenced by the individual's state of receptivity.
Receptivity refers to the ability or readiness to receive im pressions or ideas.It is concerned with receiving stimuli (Concise Oxford Dictionary, 1995).According to Ennis and Krathwohl (in Beyer, 1988:49), positive attitudes and dis positions are significant to the inquiring mind, examining a variety of view points, using credible sources, seeking and giving reasons and evidence in support of a claim.Wong et al. (1995:57) and Boud et al ( in Gray & Pratt 1991:361) assert that to remove uncomfortable feelings in order to acquire knowledge, one has to utilise positive feelings and remove obstructive feelings.Positive feelings need to be identified, explored and enjoyed.This allows the learner to consider events rationally and with good feelings.There fore, the feelings in question need to be discharged or trans formed in a way that enables us to regain our flexibility and creativity in responding to the current situation.This can be made possible through an individual's self-awareness.
Self-awareness makes one consider one's thoughts, feel ings, attitudes and beliefs and the extent to which you ac knowledge prior experience as significant, creating the po tential for each moment to be meaningful (Belensky et al. in John & Freshwaters, 1998:55).It is a building block for per sonality integration, one's private view of one's self, one's w eakness, strength and personality (G oodw in & Klausemeier, 1975:306).Dewey (1933:30,31) argues that self-awareness will be dem onstrated by the possession of attitudes such as: openmindedness, whole-heartedness and responsibility.Openmindedness, according to Dewey (1933:30), includes an active desire and willingness to listen to more sides than one, to heed to the facts from whatever source they come, and to give full attention to alternative possibilities.Palmer et al's (1994:49) opinions are that open-mindedness is a state in which things are not taken for granted, but self questioning and self-awareness is promoted.Ross and Hannay (1986:13), Baron (1988:392) and Boyd and Fales (1983:108) regard open-mindedness as a virtue of reflective thinking.Dewey (1933:31) refers to whole-heartedness as genuine interest involving the analysis of feelings and emotions.It demands interest and an inner strength for genuine reflec tion on the entire experience.Responsibility, according to Dewey (1933:32), is an attitude that is necessary to win adequate support for new points of view, new ideas and enthusiasm.A responsible person will respect the ideas, beliefs, emotions and desire of others.The person will dem onstrate courage, trust, empathy, enthusiasm and commit ment to the existing situation (Boyd & Fales, 1983:110;Wilson &Jan, 1993:8 andKing, in Brooks &Thomas, 1997:52).The supporting attitudes facilitate the compre hension of the learner.It is thus important for the facilitator to establish the learner's prior knowledge and receptivity, forming a strong background in facilitating comprehension and a positive response to clinical nursing education.
Comprehension refers to the ability to achieve a mental grasp of the nature, significance, or explanation of some thing and to have a clear or complete idea of it (Harlock, 1978:354).However, Beyer (1988:59) postulates that the learner's comprehension is demonstrated by the ability to combine translation (paraphrasing a communication while maintaining the intent of the original); interpretation (sum marising or explaining information in own words), and ex trapolation (when information is projected beyond the given data).
As pointed out by Dewey (1933:133) "Without comprehen sion of ideas and meanings, facts would heap-up like grains of sand, they would not be organised into intellectual unity".In search of how comprehension should be achieved, Burrows (1995:348) contends that the ability to reflect on the past assists reasoning and comprehension.Ausubel's (1968:540) opinion is that language also increases compre hension in that the representational properties of the words facilitate the transformational aspects of thought.Language adds meaning.It is a tool through which classifying, clari fying, translation, interpretation and extrapolation to con struct meaning can be done.Dewey (1933:232) argues that through language, concept learning is facilitated, and col laborative meaning-making through discourse is enhanced.Language becomes a resource on which imaginative com binations and variations may be built.Hence Dewey (1933:232) maintains that thinking is impossible without lan guage.Vygotsky (1986) on thought and language reiter ates this assertion.
Culture facilitates comprehension because it provides the basis for language formation.Knowledge, ideas, attitudes and values are shaped mainly through our interaction with others within á specific cultural context, with language be ing the mediating factor (Vygotsky, 1978).Through culture the reasoning of learners is empowered (Ausubel, 1968:540).
It is clear that the facilitator should consider language clar ity and culture as interactive facilitating tools of reflective thinking when creating an environment conducive to learn ing through discourse in clinical nursing education.
Reasoning remains the hallmark in the facilitation of reflec tive thinking.Mulligan and Graffin (1992:181) assert that reasoning determines how we interpret, analyse, synthe sise and evaluate the real world.According to Russow and Curd (1989:1), reasoning is about justification and evidence  Gray & Pratt, 1991:56-58).Strategies such as brainstorming, field trips and simulations in the form of role-play, video games and introducing simple un structured problems would be helpful in facilitating com prehension (King & Kitchener, 1994:75,228).Comprehen sion, according to Harlock ( 1978:356), has an affective qual ity to enable the individual to respond meaningfully to the situation.
Responding is defined as the ability to show answers in words and feelings (The Pocket Oxford of Current English 1961).The kind of response depends on the willingness to share and to listen to others, motivation and enthusiasm on the part of the learner.Willingness, according to Harlock (1978:356), refers to the "emotional weighting", which means how an individual feels about the situation.Inappropriate response indicates that no grasp of the meaning has oc curred.It is important to realise that the first phase of re flective thinking forms the basis for the second phase of reflective thinking that is focused on the interactive con structing process.
Phase 2 : Interactive constructing process The word interactive refers to mutual, reciprocally active, correlative, interchange, exchange and interdependent Roget ( 1991:54), whilst Pietrofesa et al. (1978:4,6) define interactive as a mutual relationship of individuals seeking help..., always facilitative and fostering growth..., it is a mutual enterprise and is based on respect for the indi vidual..., specific skills such as empathy, attending, listen ing, responding and self-awareness are used.Construct ing refers to making by fitting parts together, building, form by interpretation or explanation whilst the word process refers to a course of action (Concise Oxford Dictionary, 1995).
As already indicated, the interactive constructing process of reflective thinking is influenced by higher order cogni tive and affective thinking skills, such as analysis, synthe sis and their corresponding dispositions namely, values and organisation skills.Analysis refers to the act or proc ess of breaking down something into its constituent parts for the purpose of detailed examination of the elements of a substance (Dewey 1933:127).The process of analysis re quires active participation of the learner in the construc tion of own clinical knowledge, skills, attitudes and values through collaborative discourse and the sharing of ideas and thoughts (Wells, 2(XX):6; Clarke et al, 1996:176).Learn ers get the chance to think about how the experience re lates to and/or expands previous knowledge.Unless there is critical analysis that reviews and links the experience to either the past or the future, reflective thinking has not occurred (Scanlan&Chemomas, 1997:1139,1140).
A good clinician always interprets the present situation in terms of the immediate past condition through clinical rea soning in a given situation (Benner et al. 1999:10).Ques tions such as: "What is happening?What is the nature o f... ?What is the experience of...? How might this be dif ferent...?" will stimulate the interactive constructing proc ess.Providing answers to these questions will involve the learner in active participation to construct this knowledge.The questions demand reasoning and justification of ideas, thoughts and feelings (John & Freshwaters, 1998:139,55).
Facilitators can focus on problems that need the learner's ability to reason deductively and inductively in identifying underlying assumptions in an argument through logical reasoning -use less structured problems and more ill-struc tured problems that create dissonance (King & Kitchener, 1997:78).
Reasoning involves justification of ideas, thoughts and feelings based on evidence.Ennis and Norris ( in King & Kitchener, 1997:79) are of the opinion that a measure of the quality of reflective thinking will need to attend to the na ture of the justification of the judgement as well as to the judgement itself in a specific situation.It is important for learners to seek more justification whenever anything seems unclear.Ways to develop the reasoning skills are classify ing, clarifying, interpreting, justification of ideas and thoughts, and to engage learners in strategies such as re flective journal writing, nursing process, case studies, peer tutoring and concept mapping (Gravett, 1996:15,16;Varcoe, 1996:120-125;Riley-Doucet & Wilson, 1997:965-966).
Higher order thinking such as analysis needs support and guidance by dispositions such as empathy, mutual trust and respect, confidence, courage, commitment, willingness, open-mindedness, genuine interest, enthusiasm, empathy, justice, responsibility and accountability (Beyer, 1988:49; Bakan in Clarke et al, 1996:179).Bennette( 1995:138) asserts that empathy is manifested in feelings, thoughts or behav iour.It has an important affective influence on reflective thinking since it enhances the understanding of different cultural values and beliefs.Empathy involves respect and mutual relationship, good listening and communication skills, patience, good rapport, a climate of support, open ness, non-judgemental attitudes and willingness, which value individuals as unique persons in their own right (John & Freshwaters, 1998:46;Me Gill & Beaty, 1995:157-161).
Mutual trust and respect play an integral part during the process of analysis.Pamela and Loriz (1998:20) believe that the interactive constructing process of reflective thinking must occur in an atmosphere of mutual trust and respect.
Trust enables the learner to be open to different perspec tives so that compromise can occur by accommodating di vergent positions through mutual concessions.Trust, ac cording to McGill and Beaty (1995:37), builds confidence and courage to explore the thoughts and feelings of others truly and freely.
Reflective thinking needs courage, a risk taker and good assertive skills to express one's thoughts, to provide justi fication based on evidence so as to establish meaning.Courage leads to commitment and helps individuals direct their thinking and behaviour (Bodrova & Leong, 1996:11;Nelson-Jones, 1989:11).Commitment sustains and en hances the reflective thinking process.It underpins the interactive constructing process in that the learners begin to acknowledge and appreciate the relative merits of choice in making their own clinical decisions (Burrows, 1995:348).Boud et al. (in Wong et al, 1995:49) state that commitment to interaction becomes the life force of the learner in the interactive constructing process of reflective thinking.The information that has been explored through analysis sup ported by values as indicated must be pooled together and harmonised to provide new insight through the process of synthesis and organisation.
Synthesis refers to the process of building up elements and ideas into a connected whole (Concise Oxford Diction ary, 1995).Synthesis and organisation are the pillar compo nents of the interactive constructing process responsible for integrating and constructing new knowledge in relation to the existing conception and experiences (Atkins & Murphy, 1993:1190).The process of synthesis requires the use of creativity and imagination to develop new insight and changed perspectives.Creativity is a process by which something new, either an idea or an object in a new form of arrangement is produced.What is created is always new, unique and goal-directed.It involves a combination of old ideas into new forms that are different and original, but the old form the basis of the new, argued (Harlock, 1978:324).
A creative learner will use analogies, metaphors, models and inferences, and generate hypotheses within any spe cific discourse to express understanding and meaning (Bruni in Klopper, 1994:21).This permits an 'Aha' sense of feeling and a richer flow of ideas, thus opening up the way to solutions of problems, especially complex ethical and moral problems in clinical practice.Learners could be engaged in teaching strategies such as group projects, seminars and workshops and assessment and evaluation methods such as portfolio assessment and reflective tutorials to facilitate reflective thinking.
The success of the learner's ability to synthesise depends on the learner's organisational ability.Organisation refers to maintaining internal order through the inherent tendency to systematise and integrate intellectual structures into coherent order (Bybee & Sund, 1982).Organisation plays an integral part in reflective thinking since construction of meaning is done through organised reasoning of thought processes, feelings and experiences.Putting ideas and feel ings together creatively in perspective to bring up new insight is what Bybee and Sund (1982:194) refer to as "cog nitive organisation to fit the new experience" which is an important component of reflective thinking.Dewey (1933: 47,49) refers to this mental activity as 'intellectual organi sation'.
Developing organisation thinking skills requires one to be systematic, consistent and flexible, and to have persever ance (Dewey, 1933:30;Burrows, 1995:347).The use of exist ing theoretical frameworks can be helpful in organising in formation such as the nursing process or Maslow's hierar chy of needs approach.Dewey (1933:126) warns that syn thesised and organised information needs to be evaluated for acceptance or rejection, based on justified evidence.This leads the discussion to the third phase of reflective thinking.
Phase 3 : Consolidation phase for rational decision m aking and problem solving Consolidation phase aims at assisting learners to integrate and synthesise the knowledge they have constructed.Gravett (1996:13) contends that during the consolidation phase the connection between concepts and principles should be focused sharply.Consolidation phase is influ enced by the highest cognitive and affective thinking skills.It is the phase where reflective thinking is demonstrated, since the learner is able to consolidate all the knowledge and experience gained throughout the course.This knowl edge is evaluated for its worth, accuracy, relevance and acceptability in clinical nursing education.Evaluation in volves the use of criteria and standards in a given situation (Beyer, 1988:173).Evaluation skills require the learner to be able to test the generated hypothesis and to make adequate assessment of the situation in clinical nursing education.
Learners must come to a conclusion of what is right or wrong in a situation (Dewey, 1933:126).It is through evalu ation that the learner will determine whether the prevailing information is to be internalised as professional values to improve practice or not.
Internalisation refers to making the acquired knowledge one's own by learning or unconscious assimilation (Con cise Oxford Dictionary, 1995).Loriz (1998:18) assert that these questions will force the learner to do self-assessment and self-evaluation, and sub sequently go back to the reflective thinking cycle.
Based on the principle of autonomy, people have the right to determine their own actions based on their values and beliefs.Autonomous decisions make use of adequate in formation, are free of coercion, and are reasoned carefully, considering respect for human dignity and uniqueness of each individual (Pamela & Loritz, 1998:17).
In clinical nursing education, learners at this level are ex pected to make astute ethical and moral decisions about a patient's life.The facilitator should promote the autonomy of learners by exposing them to various learning opportu nities such as: taking charge of the unit under the guidance of the professional nurse in the nearby unit.Teaching strat egies such as values clarification, clinical conference, self directed learning contracts and the research/community outreach projects that demand the learner to consolidate all the knowledge and experience gained during training should be used (Quinn, 1988:401).The learner is assisted to assume a sense of responsibility and accountability with confidence.At this level, learners are able to conceptualise reality and to contrast their own comprehensive frame works, which enables them to justify and defend the deci sion they have taken (Gray & Pratt, 1991:128).The frame works emanating from their reflective thinking enhance the learners' feeling of product ownership and greater commit ment to implementation.

Outcom e
The outcome or consequences follow an occurrence of the concept (Rodgers, 1989:134).Consolidation phase and the outcome of reflective thinking are closely related since the acquired new insight and changed perspective of the learner in a given situation enable the learner to view clinical situ ations holistically in a comprehensive manner.The learner can demonstrate conceptual change, that is, transforming existing concepts (West & Pine, 1985:2).Dewey (1933:77) asserts that a genuinely reflective activity terminates in declaring just what the outcome is.
The learner is expected to practise independently and au tonomously.The facilitator should create opportunities for self-directed and self-regulating learning activities that will encourage collaborative, co-operative and shared discourse with other inter-disciplinary members of the health-related team (Schapiro & Livingston, 2000:23-35;Mellish et al. 1998:75;Quinn, 1988:401;Ewan & White 1984:119).
Knowledge constructed in this interactive mode is valu able and should improve practice and equip learners with lifelong learning skills.Reflective thinking is never-ending due to the dynamic complex challenges in clinical nursing education.The facilitator needs to keep exploring new learner-centred, learner-friendly methods of teaching, as sessment and evaluation methods that will make the facili tation of reflective thinking of learners a reality.Having described the results of the concept analysis of reflective thinking to give a broader perspective of how the concept could be used in clinical nursing education, a theoretical definition, based on the identified attributes and connota tions will be described.
A theoretical definition of reflective thinking in clinical nursing education From the concept analysis, the following attributes and connotations form the basis of the definition of reflective thinking in clinical nursing education.Three main catego ries were identified as the antecedents, process and out come.The related connotations of antecedents are cogni tive and affective thinking skills in their hierarchical order as adapted from Bloom's taxonomy (1956).The process occurs in three phases influenced by the cognitive and affective thinking skills at different levels of complexity.The initial phase is the awareness and disequilibrium trig gered by the uncomfortable thoughts and feelings.The second phase is the interactive constructing process, and lastly the consolidation phase where learners consolidate and integrate the acquired knowledge and skills to make rational clinical decisions and solve problems.The outcome of reflective thinking is new insight and changed perspec tive to improve practice.Reflective thinking is considered as a rational, progressive and cyclic mental process in na ture.
These characteristics form the boundaries within which reflective thinking is defined as the concluding statement: "Reflective thinking is a rational, progressive, cyclic inter active mental process influenced by hierarchical cognitive and affective thinking skills.It is triggered by the uncer tainty in a specific situation bringing about a state of men tal awareness and disequilibrium which leads to an interac tive constructing process followed by consolidation of knowledge that creates new insight and a changed per spective for clinical decision making and problem solving".

Conclusion and recommendations
A theoretical definition on reflective thinking, within the context of clinical nursing education was formulated, based on the method of concept analysis.Challenges in clinical nursing education demand the use of reflective thinking in order to attain quality assurance in nursing education to improve practice and to restore and maintain the credibility of the profession in the eyes of the consumers of health care.It will force learners to remain lifelong learners and to practice responsibly with accountability.Learners will prac tice independently and autonomously, will gain a meaning ful experience through the process of deconstruction, con struction and reconstruction of meaning (Rossouw et al. 1994:70).
It is recommended that an empirical concept analysis of reflective thinking be conducted.It is also recommended that a model to facilitate reflective thinking in clinical nurs ing education be developed based on these results of con cept analysis.

Figure 2 :
Figure 2 : Results of the concept analysis of reflective thinking Figure 1: P hases of reflective think ng in relation to cognitive and affective thinking skills as antecedents It refers to the state where one adapts to the value system of the profession.It directs the way of life automatically (Van Hoozeret al. 1987:220).In retrospect, did I choose the best course of action?Would an alternative solution have been better and why?What went right and what went wrong and why?" Pamela and states that, because of the internalised professional knowl edge, skills and values, clinical decision making is now 'less laboured' since the learner is able to recognise the most important salient aspects needed for the situation at hand.Pamela and Loriz(1998:18)advocate the re-evaluation of performance in clinical nursing education.To reflect on the performance by asking reflective questions such as: "