A model for facilitation of critical reflective practice

The impressive growth in the extent and range of psychi­ atric services provided by general hospitals in South Af­ rica creates stress among nurses employed in these set­ tings who are not psychiatric trained. This manifests it­ self in negative attitudes displayed towards mentally ill people. The aim of this paper is to discuss the process followed in the development of the model of facilitative communica­ tion. A theory generative design was used. The research methods were dealt with in four steps of theory genera­ tion as set out below. Step 1 entailed concept analysis. This step was dealt with in two phases, namely concept identification and concept definition. During concept identification, a quali­ tative research strategy that is explorative, descriptive and contextual was used. This was achieved through field re­ search conducted in an urban general hospital. A sample of twelve professional nurses was selected from a popula­ tion of 800 professional nurses employed in a general hos­ pital using the purposive sampling technique. This sam­ ple size was determined by saturation of data in themes. Both semi-structured individual phenomenological inter­ views and observations were used as methods of data col­ lection. Giorgi’s method of descriptive data analysis (1985) was used. Four themes emerged from the results of the study. The main concepts of the model were identified and classified using a survey list of Dickoff et al. (1968). Step 2 dealt with the creation of interrelationship state­ ments between concepts identified in Step 1, while Step 3 dealt with the description of the model using strategies proposed by Chinn and Kramer (1991). In Step 4, the description of guidelines for operationalising in practice was ensured. To ensure valid results, a model for trust­ worthiness proposed by Guba (Lincoln & Guba, 1985) was used. The following criteria for trustworthiness were ap­ plied in all the steps of theory generation: truth value, applicability, consistency and neutrality. Background and motivation Over the past two decades, there has been an impressive growth in the extent and range of psychiatric services pro­ vided by general hospitals. This growth has been particularly evident in the increasing number of psychiatric patient units operated by the general hospitals. The American Hospital As­ sociation has recorded an increase in the number of such units from 664 in 1970to 1 432 in 1990(01fson, 1993:273). In South Africa, the researcher has noticed that almost all urban-based general hospitals possess psychiatric units, whereas in rural areas one finds medical-surgical units that admit psychiatric emergencies in the case of relapsed patients. The expansion of general hospital in-patient care is attribut­ able to a number of problems, some of which as yet remain unresolved. Solombela and Uys (1994:24) identify a high rate of relapse among Transkeian patients owing to distance from clinics and a lack of insight on the part of these patients into their condition. Olfson (1993:277) highlights the reduction in the number of beds in public mental hospitals, the changing role of general hospital psychiatric emergency rooms, and a growing emphasis on medical treatments, whilst NkonzoMtembu (1994:50) reveals the use and abuse of alcohol among African adolescents residing in KwaZulu-Natal as a cause of increased admissions to hospitals. Therefore, an increase in patient admissions in these settings is a distinct likelihood. In spite of the expansion of general hospital in-patient care, the education of general practitioners in psychosomatic medi­ cine remains steeped in controversy. Sivik (1992:375) argues that the education of medical students and physicians is still within a dualistic and reductionistic paradigm that not only refutes the concept of a human being as constituting a unit, but also sets apart the body from the mind. Although this approach persists in the training of physicians, a study of internal and family medicine residents has revealed that they experience difficulties in identifying psychosocial distress, despite having received training in behavioural medicine (Rosenberg, Commerford & Driever, 1991:529). 7 Curationis M arch 2001 Poor education coupled with the inability of physicians to identify psychosocial distress has resulted in poor mental health services world-wide. Therefore, Abiodun (1990:273) argues that from this dearth of mental health personnel and facilities has emerged an urgent need to integrate mental health care with general health services in African countries. He sees this strategy as a viable method of extending mental health services throughout the African continent. In South Africa the integration process is currently being implemented, albeit without appropriate support for nurses employed in these set­ tings. Whilst the health providers are responding well to the call to integrate mental health care into the general health services, the attitudes displayed towards mentally ill people in these settings are getting worse. Mavundla (1993:30) reveals that about 90% of nurses in general hospital settings harbour nega­ tive attitudes, and less than 10% have a positive attitude to­ wards the mentally ill. These findings are supported by Khanyile’s argument (1992:27), in which she states that fellow nurses and physicians not employed in the psychiatric unit tend to refer to patients as “mad people”. She further refers to this as causing stress and the increase in the incidence of “ burnout” syndrome among nurses attached to the psychiatric unit. The seriousness of the existing situation in these set­ tings cannot be overstated. Apart from negative attitudes displayed towards the mentally ill, intra-institutional relations present yet another disturbing problem. One critical factor is the collegial relationship be­ tween psychiatric staff on the other hand and non-psychiatric consultants and nurses on the other. This has resulted in pa­ tients with ambiguous dual diagnoses being refused admis­ sion at psychiatric units despite stable vital signs (Dolinar, 1993:14). Dolinar further indicates that if such patients had been in the psychiatric unit they would have received inten­ sive psychiatric care, which is impossible or unavailable in medical-surgical units. Given the magnitude of these problems, one wonders how the prevailing situation may be rectified. In an effort to resolve these issues, health professionals responded with an array of strategies, some of which integrated the psychiatric compo­ nent with basic educational programmes, while others led to the development of models intended to improve the situation. In South Africa, psychiatric nursing has been phased into the basic educational programme (Mavundla, 1993:3). Several stud­ ies conducted in Europe and Africa revealed a slight but posi­ tive change in the attitudes of health personnel following the introduction of a psychiatric component in the nursing cur­ ricula (Olade, 1989:93; Chinnay y a etal., 1990:307). Apart from the integration of mental health into the general health component, several models have been developed to improve practice. Among these, a model of counselling medi­ cally ill people proposed by Pollin (1992: IS), and one of inte­ grating mental health and primary care services for families with HIV proposed by Feingold and Slammon (1993:23) were developed. In South Africa, a model for psychiatric nursepatient interaction facilitating mental health has been devel­ oped by Poggenpoel (1994:51), while Greef and Poggenpoel (1993:23) developed a model of psychiatric nursing accompa­ niment of patients with mental discomfort. While it is true that these models are appropriate for general settings, they cannot be used for mobilising support for general hospital nurses nursing the mentally ill. Therefore, a gap in the body of knowl­ edge still ex ists . The researchers believe that the conceptualisation of a model of support to assist general hos­ pital nurses to mobilise appropriate resources in the process of nursing mentally ill people will facilitate the promotion, maintenance and restoration of mental health as an integral part of health/wholeness. This background led to the follow­ ing statement of the research problem.

The model for facilitation o f critical reflective practice postualates that practitioners have the inherent potential to change from auto-pilot practice to critical reflective practice.The purpose o f the model is the facilitation of heightened awarenss of the self, to enable health care pro fessionals to consciously m eet community needs and ex pectations.The desired outcom e is transform ative intel lectuals who will strive to em power others to become criti cal reflective learners and practitioners themselves.
The process followed during the construction o f the model and the constructed model will be discussed in three (3) articles, namely:

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A model for facilitation of critical reflective prac tice: Part I -Introductory discussion and explanation o f the phases followed to construct the model.

Introduction
The overall purpose o f this inquiry, within the naturalistic paradigm, was to construct a m odel for facilitation of criti cal reflective practice (see figure 2).The model evolved from empirical observations, intuitive insights o f the inquirer and from deductions com bining ideas from various disciplines.The model provides a specific frame of reference for mem bers of 'caring' disciplines, telling them what to look at and to speculate about.The utility o f this conceptual model comes from the organization it provides for thinking, for observa tions and for interpreting critical reflective practice.The model for facilitation o f critical reflective practice is only a general guideline and requires further specification by rel evant and logically congruent theory.

Naturalistic Inquiry
Naturalistic inquiry for the purpose o f this inquiry is defined not at the level o f m ethod but at the level of a paradigm , as research is seen as "more a craft than a slavish adherence to m ethodological rules" (Miles & Huberm an, 1994:5).H ow ever, some recurring features can be stated for this inquiry: ( 1 ) the inquiry was conducted through an intense and pro longed engagem ent with the field o f study, (2 ) the inquirer attem pted to gain an encompassing, integrating and systemic overview o f the main concept under study, (3) the data lead to new integrations as it enabled the inquirer to get beyond ini tial conceptions and to construct a conceptual fram ework, (4) the inquirer explicitly stated personal assum ptions, (5) the inquirer opted for thoroughness, explicitness, data richness and holism, (6 ) the inquirer, during data collection, revised the preliminary fram ework to make it more precise and mean ingful.

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The inquirer purposefully selected to start with a preliminary framework as more effective inquiry is possible if "you make your framework -and associated choices o f research ques tions, cases, sampling and instrum entation -explicit, rather than claim ing inductive 'purity'" (M iles & H uberm an, 1994: 23).The aim o f the inquirer was to construct a model for critical reflective practice that attem pt to account for the 'real' world o f health care practice that is both bounded by theory and perceptually laden.

Research Process
Phases specific to the inquiry and construction o f the model are visualized in figure 1 (see Figure 1.Phases and flow of the inquiry).The phases follow ed w ithin this inquiry are spe cific and unique to this study, as it was developed/selected by the inquirer in order to reach the purpose if the inquiry.In reality the four phases cannot be seen as separate entities, as the inquiry necessitated m oving back and forth betw een the different phases.B ias a n d su b je c tiv e involvem ent o f the model constructer were lim ited and exposed by peer review ers' critique o f each step taken in the four phases.
Purposive sam p lin g was central to the inquiry as it was not the inquirer's major concern to generalize findings to a broader population.The purposive sampling method was used to se lect literature, participants and guided reflective techniques for data-gathering and analysis.For purposive selection of participants the inquirer invited 'information-rich' and 'ac cessible cases' (individuals) to take part in the study.'Infor mation-rich cases' included students who in the opinion of the inquirer could contribute to the purpose of the inquiry.
Purposive sampling was used to include adult students who complied with the following criteria.The participant should: ( 1 ) have given informed consent; (2 ) be a post-basic student; and (3) be willing to participate in critical reflective exercises Regarding sample size, no predeterm ined rules could be fol lowed, as interest centred on information richness rather than information volume.Sample size was determined by the will ingness o f potential participants to enlist in further critical reflective techniques on completion and analysis of selected exercises.Ten (10) students agreed to participate in the study.

Informed consent
The inquirer's explanation included orientation regarding the: ( 1 ) different types o f methods that would be used; (2 ) possible benefits and risks for participants involved; (3) requirements  5) what was to be expected from the inquirer.During the intro ductory explanation it was made clear that: ( 1 ) continuos and summative feedback would be requested from every partici pant to evaluate the methods used, and that (2 ) the data would be used for further publication.

Description of the four phases
The phases followed within this inquiry are specific and unique to this study, as it was developed/selected by the inquirer in order to reach the purpose if the inquiry.

I.
The literature review started in phase one of the in quiry and continued during phases two and three.It was fi nalised after three years as prolonged engagement with avail able literature was seen as necessary to maintain openness in perception.The sources included the opinions o f experts in a variety of disciplines, on the selected concepts, applicable models, theories and strategies.This was necessary as it forced the inquirer to be selective and it provided clarity and focus.The literature review included cross-disciplinary sources (pri mary and secondary).
The central themes, application possibilities and constraints o f the available models, theories and guided reflective strate gies were identified during the first review.The knowledge thus attained was synthesised and enabled the inquirer to: ( 1 ) obtain clarity regarding the nature o f the main concepts and their supporting concepts; (2 ) develop and select w orking definitions for the main bins; (3) develop a w orking defini tion for the umbrella concept (concept: critical reflective prac tice); and (4) to gain insight into the processes involved in critical reflective and creative thinking; the prerequisite for facilitation of critical reflective thinking; and available strat egies or techniques for facilitation o f critical and reflective ability.This resulted in construction o f a conceptual fram e work and preliminary model (diagram) for facilitation o f criti cal reflective practice.

II.
Construction of the conceptual fram ework and pre lim inary m odel forced the inquirer to make some explicit theoretical statements and to decide: ( 1 ) which variables are most important; (2 ) which relationships are likely to be most m eaningful; and (3) which information should be collected and analysed.The conceptual framework in the inquiry was structured according to the survey list of Dickoff, Jam es & W iedenbach (1968), namely: purpose, agent, recipient, fram e work, dynamics and procedure.From the conceptual fram e work a prelim inary model for facilitation o f critical reflective practice was developed.This model was revised as the in quiry continued and new insight was gained.
The inquirer used both inductive and deductive reasoning to construct the conceptual fram ew ork and prelim inary model for facilitation o f critical reflective practice.The confirm a tory m ode was chosen to provide clarity and focus, which prevented diffuseness and data overload.The need for a confirm atory m ode was stated by M iles & Huberman (1994), who are o f the opinion that data collection is inescapably a selective process.The challenge is to be ex plicitly mindful o f the purpose o f the inquiry and o f the con ceptual lenses you are training on it -w hile allow ing yourself to be open to and reeducated by things you didn't know about or expected to find.As data was collected from the partici pants, the conceptual fram ew ork and prelim inary m odel were revised to m ake it more precise.Thus, em pirical feeble con cepts were replaced with m ore m eaningful ones, and rela tionships were reconstructed.

• Phase II
This phase was characterized by:

I.
Thorough study o f available, guided reflective tech niques and strategies.The purpose was to identify strate gies which could be applied and used to evaluate the inquiry and assess students' attitudes tow ards guided critical reflec tive techniques.

II.
The developm ent o f instrum ents and guidelines for the selected techniques: (Socratic Technique & Learning Through Discussion [Dialogical Technique]; Critical Incident Technique; and Guided Critical R eflective Exercises [based on journal articles and the Term ination o f Pregnancy Act, Act 92 o f 1996]).The selected techniques, the m otivation for their use as well as the instrum ents and guidelines for their operationalization w ere subjected to peer critique.

• Phase III
This phase was characterized by:

I. Orientation and selection o f participants.
A pplica tion and evaluation o f the selected guided reflective techniques were limited to students registered for post-basic and post graduate courses, as prolonged engagem ent w ith this group of students was possible.O rientation was done at the begin ning o f the 1997 academ ic year, and the techniques w ere ap plied and evaluated for a period o f nine m onths.Feedback regarding the effectiveness o f the techniques took place on a continuous basis and after com pletion o f the nine m onth pe riod.

Phase IV
The selection o f peer reviewers to review the constructed model, was purposefully done.The inquirer identified peers according to specific criteria.The selection was based on their expertise, ability to remain objective, personal interest in the topic o f the inquiry and willingness to undertake com prehensive evaluation of the constructed model.Seven (7) peers reviewed the constructed model in February 1998: (1) three reviewers with a doctorial degree (D.Litt.et.Phil.) and (2) four reviewers with a master degree (M Cur and M Soci ology).
In phase four, the inquirer's critical reflection on the critique and recom m endations o f the peer reviewers, revealed that no major changes were suggested.Overall feedback indicated acceptance of the proposed model for facilitation of critical reflective practice.

Data-gathering sources and data-analysis
In order to obtain a holistic qualitative portrayal of each unit (incident, event, exercise or participant) was treated as a unique entity with its own particular meaning.Data-analysis took place as an ongoing process and included the partici pants' self-analysis and the inquirer's analysis o f the com pleted incidents and exercises which were submitted.More than one approach or one set o f techniques were used in the analysis.The m ethodological tools used for the data analysis included 'm em ber checking', 'peer debriefing' and 'linking' o f concepts to codes.Criteria forjudging the adequacy o f the naturalistic inquiry included: credibility, transferability and dependability.

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Credibility in this inquiry "refers to the truth as known or experienced by the people being studied" (Leininger, 1993, In: Talbot, 1995:528).It refers to establishment of a match between the constructed realities o f the participants and those realities as represented by the inquirer (Guba & Lincoln, 1989: 237).In this inquiry the following techniques were used to increase credibility: i.
Prolonged engagem ent.This was possible in that the in q u ire r is a s ta ff m e m b e r o f the se le c te d site .Immersement in and understanding o f the context's culture thus was not a problem.The trust and rapport necessary to uncover constructions, m isinform ation, distortion and pre sented fronts, were integral to the situation.

ii.
Persistent observation.Sufficient observation were possible, which enabled the inquirer to identify those charac teristics and elem ents in the situation that are most relevant to the topic being pursued and to focus on it in detail.The purpose o f persistent observation is, according to Guba & Lincoln (1989: 237), to add depth to the scope which pro longed engagement affords. iii.
Peer debriefing.The process o f engaging with disin terested peers, in extended and extensive discussion o f the study findings, tentative analyses and problems experienced were utilized in this study.

iv.
M em ber checks.The process consisted o f verifying data, preliminary categories and interpretations with the par ticipants.The process occurred continuously during both datagathering and data-analysis.M em ber checks were both for mal and informal (for example: after Socratic & LTD discus sion; after critical incident reporting and analysis; and after completion o f critical reflective exercises).
• Transferability.This refers to whether particular find ings from the inquiry can be transferred to another similar context or situation, and still preserve the particularized mean ings, interpretations and inferences from the completed in quiry (Leininger, 1993, In: Talbot, 1995: 528).The major technique for establishing the degree o f transferability is thick description: setting out all the working hypotheses for this study, and to provide an extensive and careful description of the time, place, the context, the culture in which those hy potheses were found to be salient (Guba & Lincoln, 1989: 242).W ithin this inquiry the inquirer provided as complete a data base as humanly possible in order to facilitate transfer ability judgem ents on the part o f others who may wish to apply the study in other situations.

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Dependability.M ethodological changes and shifts in constructs are expected products o f an emergent design (naturalistic inquiry) dedicated to increasingly sophisticated constructions (Guba & Lincoln, 1989: 242).Far from being threats, within this inquiry, the inquirer treated such changes and shifts as hallmarks o f a m aturing inquiry.The changes and shifts, in this inquiry, were docum ented in the reflexive journal kept by the inquirer.Outside review ers can thus ex plore the process, judge the decisions made and understand which salient factors in the context led the inquirer to the decisions and interpretations made.

Ethical implications
The inquirer, influenced by the values and complexity o f the naturalistic paradigm sought to: i.
em power all who participated in the inquiry through development of a true partnership with the participants.This ethical requirem ent was met through the process o f member checking (Erlandson, Harris, Skipper & Allen, 1993).
ii. educate all participants.Opportunities to share, con front, criticize and learn from one another's constructions were a central feature o f the inquiry.Each participant involved in the inquiry emerged w ith better self-insight and under standing than he or she initially had.The inquirer in this study sought to develop each participant through guided re flective techniques.The techniques enabled the participants to critically reflect on incidents, problems, experiences, per sonal actions, and implicit and explicit theories.In addition the techniques provided an educative opportunity for the in quirer in that it resulted in better understanding of the par ticipants' personal realities and the process o f critical reflec tive thinking (Erlandson, Harris, Skipper & Allen, 1993). iii.
recognise the inquirer's frame o f mind.The inquirer attempted to meet this requirement through 'reflexive jo u r nal' writing.Thoughts, assumptions, values and reflections noted in the journal were challenged during 'peer debriefing' sessions (Erlandson, Harris, Skipper & Allen, 1993).

iv.
recognise the inquirer's com petence boundaries.In this inquiry the inquirer was supported by more experienced colleagues in the field o f qualitative research.A thorough study of available literature on qualitative research, natural istic paradigm, model and theory construction was utilized to overcome the inquirer's acknowledged lack o f experience in the area.

v.
obtain inform ed consent.Although the major topic and data collection m ethods in a naturalistic inquiry may change during the data-gathering period, the inquirer ex plained: ( 1 ) the focus o f the inquiry and reasons for the in quiry; (2 ) the methods o f data collection and why these tech niques were used; (3) how the participants may benefit from participation; (4) the role of the participants' in the inquiry; (5) how the participants' confidentiality would be protected; (6 ) the participants role in verifying the correctness of the analyzed data; (7) that the participants may find their involve ment in critical thinking and reflection inherently disruptive, as well as measures to support participants; (8 ) the duration o f the study; (9) that the study would end when saturation of the data is reached, or when it no longer follow the standards formulated during the planning phase; and ( 1 0 ) that any par ticipant may: [i] choose what experiences he or she wishes to share during critical incident reporting or during personal journal writing; and [ii] end participation if wished, despite initial consent to participate.

vi.
ensure research integrity and quality.In this in quiry the inquirer utilized peer debriefing sessions, m em ber checks and rich descriptions to improve quality.

Conclusive remarks
This article provided the necessary orientation and motiva tion for the phases distinguished in the inquiry that resulted in construction o f The M odel for Facilitation o f Critical Reflective Practice.It is, however, important to rem em ber that the specific phases were not linear in that the inquirer continuously m oved back and forth between the literature re view, application and evaluation o f the selected techniques and construction and critique o f the framework and model.
The following article, "A M odel for Facilitation o f Critical Reflective Practice: Part II -Conceptual analysis within the context of constructing the model", reflects on the process of creating conceptual m eaning as basis for the constructed model.The process o f conceptual analysis was followed to: ( 1 ) refine am biguous concepts, (2 ) clarify overused vague concepts, and (3) to construct precise working definitions.However, within the context of this study and the require ments o f the naturalistic paradigm, this phase (Phase I: con struction o f conceptual meaning) was viewed as the inquir e r's 'first cut' at making some explicit theoretical statements.T he in q u ire r so u g h t to te st and fu rth e r e x p lic a te the conceptualizations during the empiric inquiry.D uring the data-gathering and analysis phase (Phase II), the inquirer was mindful to be open to the unexpected.Thus, as the inquirer gathered feedback from peer review ers' and participants', the working definitions were revised to make it more precise.In spite o f this, the inquirer wishes to draw the reader o f this article attention to the fact that critical reflective practice is a social construction o f the mind.As such it enables the reader to reach some level of understanding and not precise predic-SO U T H A F R IC A (R E P U B L IC ) 1996 : Choice on Termi tion in sim ilar or different contexts o f transferability.
nation o f Pregnancy Act, (Act 92 o f 1996).Pretoria : Gov ernment Printer.The last o f the three (3) articles, "A M odel for Facilitation of Critical Reflective Practice: Part III -D escription of the m odel" , describes the constructed model and em phasizes the need for a tra n s fo rm a tiv e in te l lectual whose aim is to em pow er developing health care prac titioners to attain the highest possible level o f professional care.

Condensed Bibliography
BARN UM B JS 1994: N ursing Theory.A nalysis, applica tion and evaluation.Philadelphia: L ippincott Company.

Introduction
Conceptual m eaning within the context o f the model con struction was obtained through the m ethod o f conceptual analysis.Conceptual analysis allowed the inquirer to exam ine the attributes and characteristics o f the main concept (criti cal reflective practice) and supporting concepts.The pur pose of concept analysis was not to provide a final viewpoint on the attributes or characteristics o f the concepts being stud ied.It was an attempt at capturing the critical elements of the chosen concepts in a moment o f time, in order to encour age com m unication and promote understanding.Through the process of creating conceptual meaning a tentative defi nition of the concept(s), and a set o f tentative criteria were formulated to determine if the concept(s) exists in a particu lar situation.
Conceptual analysis within the context o f model construction was deemed necessary, as it helped to provide clarity and fo cus.It also provided a method to exam ine the ways in which the concepts are used in existing writings.The concept criti cal thinking, for example, frequently appears in cross-disci plinary literature with diverse meanings.The meanings con veyed reflect different assumptions about the phenomena of critical thinking.By becoming aware o f these meanings, the model constructor could explore the extent to which the m ean ings were consistent with this inquiry's purpose.
Resulting from this conceptual analysis phase (Phase I), the inquirer, for example, attempted to construct tentative, 'new ' concepts, that of: ( 1 ) critical reflective p ractice, and (2 ) the tran sfo rm a tiv e intellectual (discussed in Part III of the arti cles).These concepts were tentative in that, the inquirer rec ognized that the em pirical findings may lead to redefinition of the concepts or refinem ent of it.

Discussion of the literature reviewed
According to Schw artz- Barcott & Kim (Rodgers & Knafl, 1993:112) a successful review o f the literature requires a broad systematic, cross-disciplinary approach.Therefore, the in quirer within the context o f this analysis extensively reviewed behavioural, educational, sociological, social psychological, nursing and m edical literature.
The initial review o f the literature focused on central ques tions o f meaning, definition and measurement.Once a few definitions were in hand, the inquirer looked for m ajor points o f contrast and similarity.It immediately became clear that concepts, such as critical thinking and reflection, were used differently by various scholars.For some scholars ( Stern berg, 1986;Siegel, 1985;Peters, 1972;Gavier, 1985;Blair, 1985), critical thinking and reflective practice is an aspect o f cognitive functioning or logical reasoning, a way o f think ing.For others (Siegel, 1988;Beyers, 1983;Saarman, Freitas, Rapps & Riegel, 1992;Brookfield, 1987;M ezirow, 1990;Hester, 1994), it is a personal and interpersonal process.This type o f com parison provided some idea o f the degree o f con sensus among users o f the particular concepts and led to an understanding o f the intersubjectivity of meaning.A lthough actual definitions provided helpful, important data regarding the m eaning and attributes o f the selected concepts, these authors rarely provided such definitions in their w ritings.Consequently, the inquirer identified and included statements that provide a clue about how the author defines or views the selected concepts.

Tentative working definitions
After prolonged engagem ent with cross-disciplinary litera ture the follow ing tentative working definitions w ere con structed and antecedents and consequences selected.For the purpose of this article only selected concepts are included, however, the inquirer analysed thirty-two concepts that were seen as closely related to the purpose o f the inquiry.Identify ing the antecedents and consequences o f a concept was seen as useful theoretically.The antecedents were useful in that it helped the model constructor to identify underlying assum p tions about the selected concepts, and consequences in that it describes those events or incidents that occur as a result of the occurrence o f the concept.
The following tentative working definitions, antecedents and consequences were constructed for the selected concepts:

Reflection
The ideal reflective thinker is more than thoughtful in that his or her reflective skills are internalized and involve a total response to a situation, event or internal feeling.In recaptur ing the experience the reflective thinker m ulls over it, evalu ates it, rationally exam ines it in an open-m inded and insight ful way, effectively form ulates com peting assum ptions, thinks about his or her thinking process itself, adm its the feelings that accom pany the situation and takes control o f the situa tion.Such reflection results in deliberate action (Bareli, 1995;Lukinsky, 1990;M ezirow, 1990;Schon, 1983;Johns, 1993;Boyd & Fales, 1983).

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A n te c e d e n ts i. Conscious involvement.ii.
Response to the situation, event or feeling.iii.
W illingness to learn m ore about the self, the environ ment, the situation and others (open-m indedness).iv.
W ithdrawal (recognizing the need to step back from the incident or situation).
Insight into how personal feelings m ediate response.iii.
U nderstanding o f situational constraints.iv.
C orrection o f distortions in personal beliefs, convic tions and errors in problem -solving.v.

Critical Reflection
The thinker involved in critical reflection challenges the va lidity o f previous learning, questions the prem ises on which problems are posed or defined, is not concerned with the how or the how-to o f action but w ith the why (the reason for and consequences), exam ines the realities o f practice as experi enced while assum ing that m uch is not know n, accepts that there is m ore than one equally acceptable response or answer, and goes beneath the surface structure o f the situation in or der to reveal the underlying assum ptions that constrain open discourse, autonom ous and responsible action.The critical reflective thinker is willing to take risks and, to challenge the status quo in order to obtain a new perspective in existing knowledge (Street, 1991;H edin, 1989;A lexander, 1993;Mezirow, 1990).
A n te c e d e n ts i. Sceptical attitude.ii.
W illingness to becom e involved in risk taking by chal lenging the status quo.iii.
Critical thinking ability in order to go beneath the sur face structure o f the situation.

• C onseq u e nces
i. New perspective on existing know ledge.ii.
Transform ation o f personal fram e o f reference.iii.
Positive or negative response to the environm ent.

Reflective Thought
The thinker involved in reflective thought consciously sus pends judgem ent, maintains a healthy scepticism, focuses on a concern o f central importance to the self, clarifies the m ean ing of experience (present or past) in terms of the se lf (self in relation to self and self in relation to the world) in a rational manner.R eflective thought results in new insight and a changed perspective (Schank, 1990;Boyd & Fales, 1983).

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A n te c e d e n ts i. Self-knowledge.ii.
Detachm ent from personal feelings, in order to think in a rational manner.iv.
Conscious effort to establish beliefs on a firm basis of evidence and rationality. V.
Intense focusing on a particular experience.vi. Self-discipline.vii.
Em ancipation from impulsive or routine activity.iv.
D eliberate and intentional action. V.
Personal meaning.

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A n te c e d e n ts i. Self-discipline.ii.
Self-awareness of feelings.Awareness of the experi ence.iii.
Recognizing the need to reflect on the meaning of the experience.iv.
A bility to observe and take in from a variety o f per spectives. V.
Openness to new information from internal and exter nal sources.vi.
Self-confidence.A trust o f the se lf to discover and recognize relevant information.vii.
Ability to set aside the need for immediate closure in relation to the issue.viii.Reflective environment.

Consequences
i.
Cognitive and affective change in the learner.ii.
Change in personal meaning structure.iii.
Internal change and/or overt action.Decision to act or not to act.

Critical Thinking
The A n te ce d e n ts i.
Awareness of the limits o f personal knowledge.ii.
Sensitivity to personal egocentrism , bias and preju dices.iii.
W illingness to face and assess ideas, beliefs, and view points fairly despite personal negative feelings towards them.iv.
Recognizing the need to im aginatively put oneself in the place o f others in order to understand them.v.
Recognizing the need to be true to one's own think ing, to be consistent in the intellectual standards one applies, to hold oneself to the same rigorous standards o f evidence and proof to which one hold one's antago nists.vi.
W illingness to put personal assum ptions and ideas to the test o f the strongest objections that can be levelled against them.viii.Patience to wait for evidence and weigh evidence, with out being influenced by the confidence with which assertions are made on one side or the other.ix.
Ability to sense difficulties, problem s, gaps in infor mation.x.
Ability to reflect (that is to internally examine and explore issues o f concern).xi.
A reflective environment.xii.
A positive self-image.xiii.Self-discipline.

C onsequences i.
A change in assum ptions about oneself and the world, corresponding with a change in personal behaviour and relationships.ii.
Ability to give justifications for ideas and actions.iii.
Ability to think through, to project, and anticipate the consequences o f actions.iv.
Insight into personal relationships.v.
Rational exam ination of controversial, social, ethical, political, economic, religious and work related issues.vi.
Creative synthesis (consistency in thought and action).vii.
Ability to take a position and change a position when the evidence and reasons are sufficient to do so.viii.Ability to see similarities and analogies that are not superficially apparent. ix.
Understand the difference between winning an argu ment and being right.x.
Recognize that most real-world problems have more than one possible solution.xi.
Can represent different viewpoints without distortion, exaggeration, or caricaturization.xii.
Is sensitive to the difference between the validity o f a belief and the intensity with which it is held.xiii.Habitually questions personal views and attempts to understand both the assum ptions that are critical to those views and the implications o f the views.
Following the conceptual analysis phase (Phase I), the in quirer within the context o f model construction, decided to construct a 'new ' concept, namely that o f critical reflective practice.
This was deemed necessary as the literature reviewed lack a proper definition.During the construction phase the inquirer viewed concepts such as critical thinking, reflection, critical reflection, reflective thought and related concepts as párt o f (intrinsic to) critical reflective practice.

Construction of the concept Critical Reflective Practice
The following tentative, w orking definition for critical re flective practice was constructed: Critical-reflective practice requires ability to consciously and purposefully w ithdraw (internally) from the situation, expe Critical reflective practice involves a level o f thought that incorporates the consideration of moral and ethi cal criteria in addition to reflective thinking proce dures.iii.
Critical reflective practice requires that unexamined practices and beliefs (personal, professional, institu tional, social and political) be subjected to scrutiny and IV . V.
V I.
a continual process o f revision.

Conclusive remarks
In this article the inquirer argued and ju stified the necessity for creating conceptual m eaning through the process o f con xvi. 1. ii.
ceptual analysis.The article highlighted the fact that critical reflective practice is more than mere reflection.It includes careful consideration of a persons actions, and more specific it represents a persons professional actions.Critical reflec tive practice enables systematic analysis and intervention that challenge conventional practices, and facilitates the pursuit tow ards new perspectives and solutions.Through critical reflective practice, the practitioner builds various theories about practice.As practitioners improve their ability to sur vey the knowledge that they accumulate and to apply it to new dilemmas, an increasingly broad repertoire of action al ternative develop.
Through exposé and critique o f ideology, practice and theo ries, critical reflection forces into consciousness the nature and meaning o f conventions used to organize reality.There fo re , th e e x p e rie n c e d p ra c titio n e r and e d u c a to r, as a transformative intellectual, unite the language of critique with the language o f possibility.The M odel for Facilitation of Critical Reflective Practice (Part III o f the articles), attempt to make the reader aware that transformation from auto-pilot functioning to critical reflective practice is only possible if the individual (practitioner/student) and health service m o bilizes (realize) the need to go beyond the usual (habitual) thinking to reconfigure the norm.
The process o f em powerm ent for critical reflective practice, involves transform ational intellectuals (practitioners and educators) who are self-empowered through their critical re flective ability and are willing to empower others to discover and use their unique skills, knowledge, experience and crea tivity.
The last o f the three (3) articles, "A M odel for Facilitation of Critical Reflective Practice: Part III -Description o f the model", describes the constructed model and em phasizes the need for a transform ative intel lectual whose aim is to em power developing health care prac titioners to attain the highest possible level of professional care.

Condensed Bibliography
A L E X A N D E R M F 1993: Promoting analytical and criti cal thinkin in nursing: W ith a particular emphasis on the post registration education o f qualified nurses and m idwives.AJNS, Inaugural Issue, August: 30-35.This model is seen as an attem pt to m ake critical reflective practice and facilitation o f critical reflective practice more understandable, as it cannot be directly observed.The con cepts o f this conceptual model are highly abstract and gen eral, thus, they are not directly observed in the real world nor are they lim ited to any specific individual, group, situation, or event.The propositions o f this conceptual m odel also are abstract and general, thus, they are not am enable to direct empirical testing.This conceptual m odel thus have the ba sic purpose o f focusing, ruling som e things in as relevant, and ruling others out due to their lesser im portance.

A M E R IC A N P H IL O S O P H IC
The utility o f this conceptual m odel com es from the organi zation that it provides for thinking, for observations and for interpreting what is seen.The constructed m odel provides only general guidelines, which m ust be specified further by relevant and logically congruent theory before action can oc cur.

Overall aim/purpose
The purpose o f the constructed model is to facilitate critical reflective and creative practice in students and health care practitioners to enable them to becom e transformative intel lectuals.

Rationale
Health care requires commitment, maturity and ability to as sess and synthesize a great deal o f information consciously, quickly and accurately.Practitioners' need to be self-confi dent enough to be able to adjust and modify their understand ing o f theory, making use o f theory in a way unique to the particular setting in which it occurs.Knowledge of what the various disciplines say is not in itself sufficient.Knowledge through relationship is necessary.Practitioners need to be empowered through critical reflective thinking and creative skills to explicate their implicit theories.
Critical reflective thinking and creative skills enhance the ability to analyze issues and form judgem ents, find solutions and evaluate conclusions, to research and negotiate, and an ticipate the actions o f others.The process of critical reflec tive thinking is seen as the key to conscious awareness.The process involves reflective self-criticism or, thinking about one's own thinking, to make one's own thinking object of one's thoughts and to discover its limitations and weaknesses.Self-criticism results in self-regulation -regulation through choice -an essential characteristic o f autonomous practition ers.
If autonomy is the goal o f professional education, the key is to bring its facilitation from the unconscious (unplanned level) to the level o f conscious awareness.As part of this process, adult learners must be taught to abstract from their immedi ate experiences in order to have a learned conversation with the self.The task is to produce a changed environment for learning -an environm ent in which there is a new relation ship betw een learners and their subject matter, and practi tioners and their work situation -in which knowledge and skill becomes objects o f interrogation, inquiry and reason.
The crucial point is that experienced role models must be come aware o f the variety o f strategies available for cultivat ing affective traits o f mind essential to higher order thinking.
To educate, the educator needs to attend to what learners think and value, otherwise the m ost powerful thoughts and values they possess -affecting all others -will be left un touched.A professional education in the area o f values must expect from learners to embark on a process o f value self reflection and clarification, to provide enlightened action in the professional setting.
The purpose o f the model based on a heightened awareness of the self is to facilitate critical reflective practice in devel oping practitioners.Only by thinking critically and reflec tively, by making a conscious effort to m eet challenges and problems, will health care professionals be able to meet com m unity needs and expectations.The desired outcom e is transform ative intellectuals that will strive to em power oth ers to become critical reflective learners and practitioners.

Theoretical assumptions for the model
The follow ing theoretical assum ptions are stated for this model: • Health care practice in a rapidly changing environ ment necessitates critical reflective, creative and innovative thinking in order to render holistic, contextually-based care.

•
Variables in the external environm ent result in uncer tainty in the health care and education system, therefore, criti cal reflective practice, teaching and learning are required to facilitate development o f the type o f practitioner who can meet the demands of quality health care.

•
A high level o f (self-) consciousness is a prerequisite for critical reflective practice.

•
Critical reflective practice is characterized by praxis which results in authentic knowledge and autonom ous ac tion.

•
The transform ative intellectual (role model) em pha sis the vitality o f critical, reflective practice as the sole means to clearer understandings, developed skills, and improved eth ics o f intellectual freedom.

•
Responsible action is a continuous exercise of criti cal reflective thinking, creative imagination, discretion, judge ment and the ability to make conscious decisions about one's practice.

•
The critical reflective practitioner as transformative intellectual, interacts wholistically with the internal and ex ternal environm ent through conscious use o f critical reflec tive withdrawal and reentry.

•
The transform ative educator enables learners to alter self-limiting beliefs (habits o f mind) by encouraging self-consciousness, reflective withdrawal, reflective self-criticism and self-responsibility (internal locus o f control).

•
The transform ative intellectual recognizes that criti cal reflective thinking has the potential to be emotionally dis ruptive, and will thus, consciously provide a supportive en vironment.

•
T h ro u g h c o m m u n ic a tio n and ro le m o d e lin g the transformative intellectual allows recipients to become stake holders and participants in planned change/ transform a tion of health care practices.

•
The transform ative intellectual is motivated by his/her ability to create vision in others in such a way that they will follow the vision because they see the need for it, thus, accept ownership o f it and be com m itted to achieve it.

•
The transform ative intellectual actively defines health care functions and is prepared to challenge existing prac tices, structures and power relationships.

•
The transform ative intellectual sees critical reflective learning and practice as the invisible act o f caring, in that the secret o f the helping art lies in conscious, careful prac tice.

•
The core o f critical reflective practice is caring.C ar ing is dependent on a critical reflective environm ent (cul ture) which em pow er the individual to look and listen to the self.

•
Facilitation o f lifelong critical reflective learning and p ra c tic e re q u ire s m o tiv a tio n : m o tiv a tio n w ith in the transform ative intellectual to provide a conducive environ ment and motivation o f the recipient to benefit from critical reflective learning.

•
By im plem enting specific behaviours (increasing self consciousness/awareness, building trust through com m uni c a tio n , d e v e lo p in g v isio n and e m p o w e r m e n t) th e transform ative intellectual strives for successful transform a tion from auto-pilot functioning to critical reflective func tioning.

•
Educational practices which enable the process o f criti cal reflection on learning and practice result in a transform a tional process o f intentional learning.Intentional learning involves the structures which give meaning to experience.

•
The learner who constructs knowledge intentionally will consciously control learning metacognitively.

•
A critical reflective environm ent enables individu als to make conscious decisions based on understood and ac cepted feelings, knowledge and motivations.

•
Guided reflective techniques enable the recipients to become conscious of the self and others and to have a learned conversation with the self and with others.Such tech niques result in a critical reflective spirit in the individual enabling him /her to act as role model and to allow the critical reflective behaviour in others.

•
The transform ative intellectual needs to establish defi nite standards for thinking and practising.Learners and practitioners should continuously be rem inded o f their respon sibility to express themselves in reasoning that are clear, spe cific, accurate, relevant, consistent, logical, deep, complete, and open-m inded.

Description of the model
The model encom passes contextuality, visual presentation, concepts and interrelationships.

The context of the model
The context of the model is health care practice and educa tion.The m odel can be im plem ented in any health care and educational situation which is responsible for preparation of professional carers (workers).

Main c o n c e p t: C ritica l R e fle c tive P ra c tic e
Critical-reflective practice requires the ability to consciously and purposefully w ithdraw (internally) from the situation, experience, or issue at stake in order to reflect and critically think about what has happened or what is or will be happen ing.Critical reflective practice is characterized by habitual inquisitiveness; well-informed and multi logical (dialectical) reasoning; open-mindedness; proactive thought; fairminded evaluation; honest self-evaluation; focused inquiry; persist ence; empathy with diverse opposing points of view; devo tion to truth against self-interest; willingness to take risks; deliberate and principled thinking about the thinking proc esses; insight into the social construction o f the situation; creative synthesis; autonom ous, responsible and inform ed action; and reflective learning.Critical reflective practice is portrayed by self-regulation, imagination, innovation, insight, moral integrity, courage and perseverance.
Critical reflective practice is thus more than thoughtful prac tice.It is practice that seeks to analyse the situations o f pro fessional performance so that they can become potential learn ing situations.Critical reflective practice is the utilization of good theory in practice in what must always be a situation of probability.The critical reflective practitioner is continuously trying to ensure that the outcome o f any action is close to what is anticipated by the theory and the previous experience combined.Critical reflective thinking as praxis, requires ac tion, involvem ent and risk taking.

C on cepts w hich provided the building blocks fo r the m ain concept
The following four (4) concepts provided the main building blocks for the concept critical reflective practice.

i.
Critical thinking The ideal critical thinker is "habitually inquisitive, well-in formed, trustful o f reason, open-minded, flexible, fairminded in evaluation, honest in facing personal bias, prudent in mak ing judgem ents, willing to reconsider, clear about issues, or derly in complex matters, diligent in seeking relevant infor mation, reasonable in selection o f criteria, focused in inquiry, and persistent in seeking results that are as precise as the subject and the circumstances o f inquiry permit."(American Philosophical Association, 1990:3) ii.
Creative Thinking The element o f creativity in relation to critical reflective prac tice may be described as the ability to sense gaps or problems within known information; ability to see many relationships among elem ents; flexibility in thinking and reorganization of understanding to produce innovative ideas and solutions; testing ideas and m odifying those ideas in a unique way; and communicating the results.
Creativity within critical reflective practice conjures up sev eral abilities rather than a single characteristic.It involves curiosity, imagination, discovery, innovation, invention, bal ance betw een divergent and convergent thinking, intuitive processes and contem plation o f abstract philosophical issues.

iii.
Critical Reflection The thinker involved in critical reflection challenges the validity of previous learning, questions the premises on which problems are posed or defined, is not concerned with the how or the how-to o f action but with the why ( the reason for and consequences), exam ines the realities o f practice as experi enced while assum ing that much is not known, accepts that there is more than one equally acceptable response or answer, goes beneath the surface structure o f the situation in order to reveal the underlying assumptions constraining open discourse as well as autonom ous and responsible action.The critical reflective thinker is w illing to take risks, to challenge the status quo to obtain a new perspective on existing know l edge.iv.
Reflective Learning Critical reflective learning is the process of making a new or revised interpretation of the meaning of experience to guide subsequent understanding, appreciation and action.It involves critical analysis and interpretation o f an experience, open ness to new inform ation, acceptance o f self-reality, a change in personal meaning, structure, resolution, review o f past val ues in relation to the changed perspective and examination of the implications for future behaviour and others.
The key characteristic differentiating critical reflective learn ing from other types of mental activity (thinking or problem solving) is that the problem is conceptualized in relation to the self.Critical reflective learning often results in knew knowledge, or a new perspective on existing knowledge which is relevant to improving standards o f care.Critical reflective learning results in creative synthesis (consistency in thought and action).Having decided on the worth, accuracy, and va lidity of new ways of thinking, living or practising, the per son integrates these into the fabric o f his/her life.

i.
Transformative Intellectual (Role M odel/Agent) The transform ative intellectual is the person performing critical reflective practice.
The transform ative intellectual is an individual who is educated to rely less on personal fic tions and conventional wisdom for personal and professional conduct and more on critical structures o f knowledge consid ered in the context of ideological possibilities and probabili ties.
In the c o n te x t o f h e a lth c a re p ra c tic e /e d u c a tio n the transformative intellectual is a critical reflective practitioner or educator who functions in an integrated biopsychosocial manner and who role models the specific behaviour of criti cal reflective practice in his or her quest for self-regulated, in d e p e n d e n t, e m p o w e re d an d c a rin g p ra c tic e s .T he transformative intellectual underscores the vitality o f critical reflective learning and practice in that he/she sees critical reflection as a significant step towards developing an anti dote for auto-pilot functioning and reliance on others.
The transformative intellectual as agent, is a critical reflec tive practitioner and role model o f professional maturity in that he/she shows strong com m itm ent to im prove practice and learning.Such an agent engages in continuous observa tion, critical thinking and reflection in order to challenge pre conceived ideas.The transformative intellectual is a change agent.The agent o f critical reflective practice establishes his/her credibility through role modeling competence, objec tivity, high ethical standards and critical reflective ability.The transformative intellectual is a catalyst who accepts respon s ib ility fo r m a n a g e m e n t o f c h a n g e a c tiv itie s .T he transform ative intellectual is self-em powered through criti cal-reflective processes (ability) and is therefore, willing to em pow er others to discover and use their unique skills, knowl edge, experience and creativity.

ii.
Critical Reflective External Environm ent The external environm ent for facilitation o f critical reflective practice is the totality o f patterns existing external to the health care setting and the individual learner/practitioner.It is the context in which the activity o f critical reflective prac tice takes place and includes a complex o f extraneous factors and circum stances w hich are present in every situation.The external environm ent (social, political, legal, econom ical, educational and institutional) has significant im plications for health care.
Contemporary expectations in the external environm ent (com munity) require transform ation which includes review o f all relevant legislation, institutions, organizations, management practices, norms and standards.This suggests the need for a different kind o f health care practitioner and institutional (service) environm ent, as concepts and actions such as de mocracy, transparency, transformation, empowerment, human rights, and accountability are part of the philosophy o f the current South African society.These demands can only be m et w ithin an external environm ent (service/educational) characterized by a supportive culture and praxis.
For the purpose o f the model the critical reflective external environm ent is, defined as a service or educational environ ment characterized by a supportive culture and praxis..

iii.
Guided Critical Reflective Techniques Reflective learning occurs as a result o f the process o f guided reflection.Guided reflection is a combination o f techniques intended to enable practitioners (learners) to reflect on their professional and personal conduct (experiences) in order to become increasingly effective (critical, creative and reflec tive).Guided reflection enables the practitioner to use expe rience and learn from experience in a structured and sup ported way.This is necessary as critical reflection is a pro foundly difficult process.G uided critical reflective techniques include all strategies which enable learners/practitioners to reflect with other peo ple and discover m eaning with others.Guided critical re flective techniques are seen as mutually enabling processes that result in dialogue and revelation o f the self to one an other.It enables the learner/practitioner to become conscious o f and keep an ongoing record of his or her actions, feedback, beliefs, assum ptions and theories.Guided critical reflective technique is purposeful and goal-directed.It begins with the goal of reconstructing individual and social experiences as a basis for understanding the attitudes and emotions which shape the present knowledge o f practice, and for incorporating new ideas and information.The process o f reconstruction requires the learner/practitioner to collect comprehensive, descriptive accounts of his/her experiences.
Exam ples o f guided critical reflective techniques are: Socratic Questioning and Discussion; Analogy and M etaphor; Debate; Critical Incident Reporting and Analysis; Brainstorm ing; Journals; Critical Reflective Exercises (using m edia/ journal reports); and Guided Imagery.

iv.
Conscious Subjective E nvironm ent (Internal E nvi ronment) The internal environm ent in the m odel consists o f each indi vidual learner's/practitioner's personal system (internal en vironment: the self).The self is a com posite o f thoughts and feelings that constituting the individual's aw areness of individual existence, his/her conception o f w ho and w hat he/ she is.The self (internal environm ent) includes, am ong other things, a system o f ideas, attitudes, values and com m itm ents.The self is a person's total subjective environm ent.It is a dis tinctive centre o f experience and significance w hich consti tutes a person's inner world as distinguished from the outer world.

v.
Praxis Praxis is thoughtful reflection and action w hich occur in syn chrony.A ction is inform ed by reflection and reflection is informed by action.Praxis involves a shift aw ay from criti cal thinking as problem solving, to critical thinking as a proc ess in which know ledge and action are dialectically related through the process o f critical reflection.
Action w ithout reflection does not lead to inform ed, inten tional behaviour: action by reflection can ensure that any thing learned from the action can be carried to the next situ ation.

vi.
(Self-) Consciousness/A w areness The self plays a critical role in the m otivation to practice in a critical reflective m anner and to learn from practice.The metacognitive, cognitive, and affective aspects o f the self are subsystems o f the se lf and under control o f the se lf as ag ent The self directs and/or oversees inform ation processing, for mulates intentions, m akes choices, and generates motivation to engage in critical reflective activities.
Consciousness is aw areness.It is understanding and experi ence o f how thought, consciousness, and m ind w ork together.A high level o f self-consciousness is a prerequisite for criti cal reflective practice as it allow s the individual a m ore ob jective perspective.Self-aw areness enables the learner/prac titioner to exam ine the way he/she sees the se lf (self-para digm).A learner/practitioner w ith a positive self-concept will be more likely to engage in exploration o f ideas, which may conflict with personal views.A positive self-concept results in reflective self-criticism w hich requires provisional or hypothetical detachm ent from personal viewpoints.compelling drive to seek evidence, an intense aversion to con tradiction, sloppy thinking, inconsistent application of stand ards and a devotion to truth against self-interest.
A critical reflective attitude or spirit is characterized by re flective scepticism in that the transform ative intellectual's thought involves a certain scepticism, or suspension of assent towards a given statement, established norm or mode o f do ing things.
viii.Reflective (Self-) Criticism Self-criticism derives from a desire within the individual to free the s e lf from the constraints o f conventional (habitual) thinking.Critical reflection involves a highly introspective inquiry involving the process o f observation o f the self and critical reflective thinking about the self with a view to ac tion.By engaging in observation and critical reflective think ing about the self it is possible for the individual to chal lenge all preconceived ideas, principles, theories, policies and "right" ways o f thinking and behaving.Through self-criti cism the individual weighs-up, evaluates and decides upon the validity of something.
Reflective self-criticism requires provisional or hypothetical detachment from the personal viewpoints, through the proc ess o f reflective withdrawal and reentry.Self-criticism in volves a learned conversation with the self.

Relating concepts i.
Em powerm ent To em pow er learners/practitioners as transform ative intel lectuals mean to educate for critical reflection.Em power m ent is a process which increases learners/practitioners in trinsic m otivation.Em pow erm ent involves taking actions which affect impact, competence, meaningfulness and choice People are em powered by involving them in their work and learning through a process o f inclusion.
Em powerm ent is composed o f two specific conceptual com ponents: ( 1 ) a cultural change process: this means defining new, or revising and reaffirming existing values; and (2 ) a paradigm shift: this means changing what an organization believes about itself and how it thinks and acts.There should be a move from organizational domination to person partici pation through the process o f critical reflective practice -thus, partnership.The paradigm shift results in commitment, as the learners'/practitioners' actions are freely chosen, owned, and critiqued without any requirement to do so.
The learner/practitioner, through guided critical reflective technique and role m odeling, should be em pow ered to be come aware o f personal identity, acts, thoughts, feelings, as sumptions and motives.

vii.
Critical R eflective attitude/spirit A critical reflective attitude or spirit shows w illingness to c o n fo rm ju d g e m e n t a n d a c tio n to p r in c ip le .
T h e transformative intellectual has integrated a host o f rational passions w ith his or her assessm ent skill.Together these constitute and instantiate the critical attitude.R ational pas sion is characterized by a drive for clarity, accuracy and fair mindedness, a fervour for getting to the bottom o f things and for listening sym pathetically to opposing points o f view, a Empowerment enables autonomy.Actions that empower oth ers include: delegating authority, using participative deci sion making, encouraging self-m anagem ent, lessening for malization, creating a supportive culture and encouraging goal setting.Em pow erm ent involves sharing o f pow er and au thorizing learners/practitioners to think critically, reflectively and creatively.It is a process o f focusing on the needs of others and encouraging self-responsibility by altering selflimiting beliefs (habits of mind).

ii.
Caring In this model critical reflective practice is seen as the invis ible act o f caring, in that the secret o f the helping art of health care and education lies in conscious, careful health care prac tice and education for critical reflective practice.Caring in volves an engrossm ent or m otivational displacem ent whereby the transformative intellectual moves away from his or her own viewpoint and looks at things as though from the view point of the other person (recipient) and make the other per son's motives his or her own.Caring involves willingness in the transformative intellectual to move from self-centeredness to other-centeredness.
The caring relationship, in this m odel, assumes the meeting to g e th e r an d m u tu a l p o s itiv e re g a rd b e tw e e n the transformative agent and the recipient (learner/other).This ensures that such factors as m aintaining the integrity and dig nity o f the recipient (cared for) will be part o f caring.The core o f critical reflective practice is caring.Caring is dependent on a critical reflective environm ent (culture) that enables the individual practitioner and learner to look and listen to the self. iii.
Challenging A critical reflective external environm ent challenges in that the transformative intellectual rejects uncompromising, un contested knowledge and skill, and m indless adherence to the status quo.The transform ative intellectual challenges learners and practitioners to obtain insight or see meaning in findings that may not be readily apparent by use of scientific procedure only.A challenging external environm ent invites learners/practitioners to prove and justify something.

iv.
Proactive A critical reflective external environm ent in which there is freedom to choose fosters proactivity in learners/practition ers.Proactive individuals are value driven; and if their value is to produce quality work through critical reflective and crea tive processes they subordinate the influencing environment to their thought processes.Proactive learners/practitioners create or control a situation by taking the initiative.Highly proactive individuals have the ability to choose their response, they do not blame circum stances, conditions, or conditioning for their behaviour.Their behaviour is a product of the m o tivation w ithin the environm ent and their own conscious choice.

v.
Transformative A transformative environm ent is characterized by activities that are intentional and goal directed.The activities are goal intentional and goal directed in that it has as purpose the deliberate transform ation of the individual (psychologically, physically, cognitively and socially) in striving for personal and professional developm ent.W ithin the transform ative environm ent the change agent underscores the validity of critical reflective practice and use persuasive m essages to develop com petence, objectivity, high ethical standards and a changing attitude towards health care practice.
A transform ative environm ent energizes the need to trans form from auto-pilot mode to critical reflective mode.A uto pilot mode is uncritical, unconscious practice, w'hich is char acterized by routine actions that are potentially dangerous.A transformative environm ent opens challenges for the learner and practitioners so that they consciously notice what they think, feel and do.This results in a sense o f agency, in that the individual conceives the self as being in possession o f an ultimate pow er o f decision and action.

vi.
Visionary Vision is a m ental picture o f a possible situation or state o f affairs.The transform ative intellectual enables learners/prac titioners to im agine how things might be different from the way they are.The transform ative intellectual is m otivated by his/her ability to create vision in others in such a way that they will follow the vision because they see the need for itaccepting ownership o f it and is committed to achieve it.

vii.
M otivative A critical reflective external environm ent m otivates learn ers/practitioners to develop a critical reflective spirit.M oti vation is a state o f need-induced tension which m anifests as a 'push' on the individual to engage in critical reflective learn ing and practice.M otivation for critical reflective practice is defined as conditions which influence the arousal and m ain tenance o f behaviour relevant to critical reflective thinking.

viii. Autonomy
In the model intellectual autonom y entails a com m itm ent to analyzing and evaluating beliefs on the basis o f reason and evidence, to question when it is rational to question, to be lieve when it is rational to believe and to confirm when it is rational to confirm.

ix.
R eflective withdrawal Reflective w ithdrawal is the conscious process o f creating a personal resting place to obtain openness to inform ation from internal and external sources.The beginning o f the reflec tive episode is an awareness that something does not fit, or does not sit right within the individual, or a feeling o f unfin ished business.
The events that trigger reflective withdrawal are unique to every individual and result in discomfort which requires a response not yet available to the conscious intent o f the per son reflecting.The trigger event evokes an aw areness in the self, that the self is not in an adequate position to manage the experience or to perceive it fully.This aw areness is the first step in bringing unconscious determinants to a conscious level where they then guide the next stage o f the critical re flective learning process, the identification and clarification o f the concern.
Reflective withdrawal requires a setting aside o f the im m edi ate need for closure in relation to the issue.O penness or receptivity to information from within and/or outside the self is necessary. x.
Learned conversation with the self Critical thinking and reflection involve a learned conversa tion with the self.W ithin this conversation em otive aspectsfeelings, responses, intuition, sensing -are central as the learner or practitioner deliberately breaks with traditional modes o f thought to prom pt forward leaps in creativity.The learned conversation with the self results in em ancipatory learning w hich frees the individual from personal, institu tional and environm ental forces and prevent him /her from seeing new directions and gaining control o f his/her personal life.R eg u latio n th ro u g h choice Critical reflective practitioners experience them selves as the initiators o f their own behaviour, they select desired outcomes and choose how to achieve them The action is self-initiated and grasped as a personal solution.R e g u la tio n th ro u g h choice is characterized by flexibility and the absence o f ex ternal pressure.The behaviour or action is endorsed by the whole self and is experienced as action for which oneself is responsible.
xiii.S u p p o rtiv e c u ltu re A supportive culture for facilitation o f critical reflective prac tice is em p o w erin g , carin g , ch a lle n g in g , tran sfo rm ative, motivative, visionary, im aginative, proactive, creative and autonomous in nature, thus, energizes re g u la tio n th ro u g h choice.

Conclusive remarks
Peer critique o f the model confirm ed its value for the context of education, health care practice and other caring profes sions in general.The constructed m odel is an attem pt by the inquirer to m ake educators and practitioners conscious o f the need for a tra n sfo rm a tiv e in te lle c tu a l w hose aim is to em power developing health care practitioners to attain the high est possible level o f professional care in regard to its science and its practice.
The model should be im plem ented to develop critical reflec tive practice in various disciplines in order to assess its suit ability (its value, m eaningfulness, significance).Im plem ent ing this model in totality -as is desirable -im plies the intro duction o f a 'new ' approach to professional education.The selected theoretical assum ptions and statem ents described in this article can be used to form ulate w orking hypotheses on which to base further em pirical studies.The techniques and strategies for guided critical reflection should be introduced as a requirem ent for basic-, p o st-basic and post-graduate courses.This could bring students to see the techniques and strategies as a 'n o rm a l' w ay o f te a c h in g , le a rn in g and practicing, and could thus, lim it resistance.
• A model for facilitation o f critical reflective prac tice: Part II -Conceptual analysis within the context o f constructing the model.• A model for facilitation o f critical reflective prac tice: Part III -D escription o f the model.

Figure 1 :
Figure 1 : Phases and flow of the inquiry

Figure
Figure 2 : A model for facilitation of Critical Reflective Practice . M odel construction and developm ent o f criteria for peer review o f the m odel.The inquirer reflected critically on the diagram o f the p relim in ary m odel co n stru cted in phase one o f the inquiry, the conceptual fram ew ork, and the application and evaluation o f the selected techniques.This exercise resulted in a revised edition o f the diagram .The revised model encom passed contextuality, visual pres entation, concepts, interrelationships and criteria for peer re view.G uidelines for analysis and evaluation o f the model were adapted from Faw cett (1984), C hinn & K ram er (1995), Maker (1982) & Reigeluth (1983).
eds) 1992: Doing quali tative research.London: Sage.CH IN N P L & K R A M E R M K 1995: Theory and nursing.A systematic approach.St Louis: M osby Company.D IC K H O F F J ; JA M E S P & W IE D E N B A C H E 1968: Theory in a practice discipline: Part I. Practice oriented re search.N ursing research 17(5): 415-435.ER LA N D SO N DA H A R R IS E L S K IP P E R B L & A L L E N SD 1993: Doing N aturalistic Inquiry.N ew York: Sage.FA W CETT J 1984: A nalysis and evaluation o f conceptual models o f nursing.Philadelphia: D avis Company.GUBA E G & L IN C O L N YS 1989: Fourth generation evalu ation.London: Sage.HA G E J 1972: Techniques and problem s o f theory con struction in sociology.London: W iley & Sons.K IR K J & M IL L E R M L 1986: R eality and validity in qualitative research.London: Sage.L E IN IN G E R M M 1993: In: Talbot, LA. 1995.Principles and practice o f nursing research.London: Mosby.LIN C O L N YS & G U BA E G 1985: N aturalistic inquiry.London: Sage.LO FLA N D J & L O F L A N D L H 1984: A nalyzing soicial settings: A guide to q ualitative observation and analysis.Belmont, CA: Wadsworth.M A K E R C 1982: Teaching m odels in education for the gifted.Rockville: Aspen.M A R SH A L L C & R O SSM A N G B 1995: D esigning quali tative research.London: Sage.M IL E S M B & H U B E R M A N A M 1994: An expanded sourcebook: Qualitative data analysis.2nd.ed.London: Sage.R E IG E L T U H C M 1983: Instructional design theories and models: A n overview o f their current status.New Jersey: Lawrence Erlbaum.
learning is the process o f making a new or revised interpretation o f the meaning o f an experience, which guides subsequent understanding, appreciation and action.It involves critical analysis and interpretation o f an experience, open ness to new information, acceptance o f self-reality, a change in personal m eaning structure, resolution, review of past val ues in relation to the changed perspective, and examination o f the implications for future behaviour and others (Boyd & A L A SSO C IA T IO N 1990: Critical thinking: A statem ent of consensus for purpose of educational assessm ent and instruction.The Delphi Report, No, ED 315-423: Research findings and recommendations prepared for the committee on pre-college philosophy.USA: American Philosophical Association.BA IN K & TRAVIS P 1994: Simulating active intellects and "covering the m aterial."Paper presented at the 14th An nual Lilly Conference on College teaching, Nov. 18-20.Ox ford: M iami University.B A R E L L J 1995: Teaching for thoughtfulness.Classroom stra te g ie s to e n h a n c e in te lle c tu a l d e v e lo p m e n t.U SA : Introduction This model was derived from: (1) prolonged engagem ent with available literature in a variety o f disciplines; (2 ) conceptual exploration and analysis; (3) developm ent o f working defini tions and hypotheses; (4) application and evaluation o f se lected critical reflective techniques in an educational setting; (5) construction o f a conceptual fram ew ork and prelim inary model for facilitation o f critical reflective practice; and (6 ) critical reflection on the critique and recom m endations o f peer reviewers and participants.Figure 1:" Phases and flow o f the inquiry" , provides a visual presentation o f the o f the phases and flow o f the inquiry and Figure 2: "A m odel for facilitation o f Critical R eflective P ractice", a visual pres entation o f the m odel after revision.The m odel is based on assum ptions derived from an in-depth analysis o f the literature, em pirical observations, intuitive insights o f the inquirer and from deductions that com bined ideas from several fields o f inquiry.The model for facilitation o f critical, reflective practice pos tulates that health care practitioners have the inherent poten tial for change from auto-pilot practice to critical, reflective and creative practice.Such potential m ay be overt or latent, triggered by internal m otivation or by certain environm ental conditions.
The structure o f the m odel gives overall form to the concep tual relationships within it.and represents the inquirer's per ception of the reality o f facilitation o f critical reflective prac tice, the required conditions, the m ethods and outcom es.The visual presentation of the model is m eant to im prove insight into how ideas are organized and how structure flow s from relationships between the ideas.The central focus o f the m odel is a transform ative intellec tual (prerequisite I), who w ithin a critical reflective exter nal environm ent (prerequisite II) enables conscious use of guided critical reflective techniques (prerequisite III), thus stimulating a conscious sub jective internal environm ent (prerequisite IV) in learners/practitioners.The effect o f the interaction betw een the four prerequisites is critical reflec tive learning and creative synthesis, resulting in change/ transform ation w hich enables fulfilm ent o f the m ain pur pose o f the m odel, nam ely lifelong critical reflective learn ing and practice (praxis)-and a transform ative intellec tual (critical reflective practitioner) who takes responsibility for em pow erm ent o f others to becom e critical reflective and creative practitioners.Definition of the m ajor concepts, related concepts and interrelationships Selection o f concepts and construction o f definitions to in clude in the constructed m odel, w ere influenced by experts in the field o f critical, reflective and creative thinking.Various authors contributed tow ards this vision and should by right be acknow ledge, however, due to printing lim itations it is only possible to list the most influential authors: Basseches, 1984; B ig g s, 1988; B o u d , K e o g h a n d W a lk e r Reentry is possible at the point where the individual experi ences th e self as changed, having learned, or having come to a satisfactory point o f closure in relation to the issue.It is similar to self-insight.The closure is often recognized as not the final answer, but a psychological place w here the indi vidual feels com fortable in relation to the issue.The indi vidual experiences a subjective sense o f rightness, certainty, or adequacy o f the solution or changed perspective.The changed perspective or resolution is self-affirm ing in that the individual experiences a surge o f positive energy at the time o f reentry.As a result the individual is faced with the challenge o f relating his or her c h a n g e d se lf to the past self, to other areas o f his or her present life and to future behav iour.A conscious decision m ay be m ade to im m ediately and completely, incorporate the change into behaviour to test the public reaction, or merely to allow it to exist w ithin th e self without acting overtly on it.N egative reaction from others may force the individual back into reflectiv e w ith d raw al. xii.
a panel of forty-six theoreticians (represent ing several academic fields) from throughout the United States and Canada.This definition was selected for inclusion in the model as it captures what some theorists call 'the critical spirit' -a style, a set o f attitudes that defines a personal disposition to prize and use critical thinking in one's personal and pro fessional conduct: following definition was not constructed by the inquirer, but developed by rience, or issue at stake in order to reflect and critically think about what has happened or what is or will be happening.
Critical reflective practitioners expose their thinking to others and open them selves to criticism from peers as well as from authority.Critical reflective practitioners direct their activities with foresight and plan according to end-in-view, or purposes of which they are aware.Critical reflective practitioners display ability to inte grate new knowledge w ith previous know ledge, and use this know ledge in a creative w ay to solve prob lem s and to predict likely consequences o f actions.Critical reflective practitioners display ability to make explicit the know ledge that is im plicit in their actions.
Authentic caring (based on self-know ledge -knowing the s e lf so well that you understand how you affect others).