Reflection is a pivotal skill for all critical care nurses who have to care for patients in an ever-changing medical environment. The origins of reflection can be traced back to John Dewey, a philosopher of education, who explained reflection as an intentional, active progression of learning (Nelson 2012). Reflection forms part of the experiential learning cycle for the purpose of assisting practitioners to make sense of an experience and to seek alternatives and improved actions for practice (Passarelli & Kolb 2011). A modern scholar of reflection, Johns (2013) recognised the value of reflection in a specific context and defines reflection as:

a window through which the practitioners can view and focus self within the context of their own lived experience in ways that enable them to confront and understand and work towards resolving the contradictions with their practice between that is desirable and actual practice. (p. 34)

Practice development applies reflection as a method to integrate work-based learning for sustained development in practice to promote the effectiveness of individuals, teams and healthcare organisations (McCormack, Manley & Titchen 2013). Nurses working in different contexts are required to develop their practice and utilise scientific evidence to guide desirable practice to improve patient outcomes.

Efforts to develop practice by educators and organisations focus on technical practice development, which is task orientated and uses top-down approaches to learning (McCormack et al. 2013). There is limited literature on the approaches used in South Africa to develop practice; however, in a study conducted in the United Kingdom it was found that if practice development was conducted by using traditional teaching strategies, the nurses became passive recipients of information only (Williams 2010). The resources spent using traditional teaching strategies for practice development make no significant change in how nurses practise in their work context (Duff, Gardner & Osborne 2014; Williams 2010). In order for practice development to bring about sustainable change and positive outcomes for both patients and the nursing profession, McCormack et al. (2013) advocate the use of emancipatory practice development.

Emancipatory practice development focuses on improving outcomes and self-understanding of nurses and assisting them to become critics of their social and educational situations, as well as their work context and workplace culture (Manley, McCormack & Wilson 2008:268). Emancipatory practice development is divided into three phases: enlightenment, empowerment and emancipation. Wilson and McCormack (2006) describe enlightenment as the phase where nurses are made aware of the changes that are required; through empowerment nurses gain information that enables them to act on the changes identified. Emancipation is achieved when enlightened and empowered nurses take action to reform their practice in the context of their work (Boomer & McCormack 2010).

For nurses to become enlightened about their unarticulated assumptions about themselves and their practice, reflection can be used to improve their practice. Reflection is a method to assist nurses to take personal responsibility for actions and practice development for sustainable change (Boomer & McCormack 2010).

An explorative, descriptive, qualitative design was used to gain insight into the requirements for reflection. Educators from private and public healthcare facilities involved in the practice development of qualified critical care nurses were invited to participate in a focus group discussion (FGD). Participants for the FGD were identified through the use of snowball sampling. Seven participants were identified during the sampling process and invited to the FGD, which was conducted at a venue which was central for all the participants. Informed consent was obtained from participants and their right to withdraw from the FGD at any time was reiterated before commencement.

After permission was obtained to audio-record, the FGD began. The FGD was used to collect data through social interaction and to build upon the answers of the other participants. An independent expert in FGDs facilitated the interview, since the researcher was also involved in the practice development of qualified critical care nurses. The facilitator ensured that the interview remained focused on the topic and asked questions to clarify meanings.

The question posed to the participants during the FGD was: What are the requirements for reflection in the critical care environment?

The FGD was transcribed verbatim and studied using content analysis. The transcriptions were read and re-read to allow the researcher to become immersed in the data and sensitised to important issues. The data were analysed and coded by the researcher and an independent coder who signed a confidentiality agreement. The independent coder, with experience in coding of qualitative research, was utilised to enhance the quality of analysis of the data and in this way strengthen credibility and trustworthiness. The researcher and independent coder held a contact session in which consensus on the themes was reached.

Written permission was obtained from the Ethics Committee of the University of Pretoria and the research board of a private hospital group. Participants were invited to an FGD a month in advance of the set date to enable them to make prior arrangements that could ensure minimal interruption of their work. Participants signed written consent prior to their participation in the data collection, and were informed of their right to withdraw at any stage. Each participant was given the opportunity to voice their view. During the transcription of data participants were assigned random names. Only the researcher had access to the true identities of the participants. Transcripts of the FGD and field notes were stored at a different location from that of the results and discussion.

The trustworthiness of the study was ensured through the use of Lincoln and Guba's model (1985).

Credibility was ensured by referential adequacy. Data must be adequate to allow for later analysis and interpretation (Lincoln & Guba 1985). The data were audio-recorded and transcribed, ensuring that raw data could undergo further analysis and interpretation. Member checks added to the credibility (Polit & Beck 2006), as participants gave comments on the preliminary study findings.

Transferability refers to the extent to which the findings could be applied to other contexts (Lincoln & Guba 1985). The findings of this study could be applied to other contexts, as they address the requirements for realising reflective practice in the clinical setting.

Dependability entails truthfulness and reliability (Topping 2010). The use of an independent coder ensured that the data analysis was objective and accurate. Confirmability refers to the objectivity of the data (Topping 2010), and using the skills of an independent coder and an expert supervisor helped to ensure this in this study.

Healthcare organisations and patients demand critical care nurses who are innovative and use the latest knowledge in their daily practice. Reflection might provide some guidance to critical care nurses in order to meet these demands (Mann, Gordon & MacLeod 2009). Participants identified that buy-in from stakeholders and settings which are conducive to reflection are necessary for reflection to occur in the critical care environment.

The findings of this study are limited by the small sample size, as this decreased the capacity to generalise the results. However, the participants were of the opinion that the results of the study were a starting-point for realising reflection in the critical care environment.

This article focused on the requirements for reflection into the critical care environment, as viewed by educators of qualified critical care nurses. The ability of reflection must not be assumed but should be developed. The skill to reflect must be nurtured in a pre-established, reassuring environment, enabling critical care nurses to reflect. In order to create such an environment there should be buy-in from stakeholders to develop reflection and the creation of a setting conducive to reflection.

Should reflection not be realised in practice, critical care nurses will remain passive receivers of information and emancipatory practice and sustainable change will be hindered. Considerably more work needs to be done to determine the views and opinions of critical care nurses and management of the healthcare organisations regarding the use of reflection to improve patient outcomes in the critical care environment.