Elsevier

Nurse Education Today

Volume 97, February 2021, 104709
Nurse Education Today

Reflection-in-action during high-fidelity simulation: A concept analysis

https://doi.org/10.1016/j.nedt.2020.104709Get rights and content

Abstract

Objectives

Our primary aim was to complete an in-depth analysis of the concept of “reflection-in-action” during high-fidelity simulation. We sought to identify what is currently known about the topic and establish a strong foundation for theory development regarding cultivating reflection-in-action during high-fidelity simulation.

Design

Walker and Avant's (2011) systematic approach to concept analysis was used as a framework to develop a comprehensive understanding of reflection-in-action during high-fidelity simulation.

Data sources

We conducted a review of literature on reflection-in-action (with open date parameters) in PubMed, Eric, PsychInfo, ABI/Business Premium Collection, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) electronic data bases using key terms “reflection-in-action” AND “simulation”. In addition, we hand-searched reference lists from key articles in the journals Simulation in Healthcare, Simulation and Gaming, and Advances in Simulation.

Results

Our search resulted in 22 articles, from 1998 to 2019, that met the inclusion criteria. Four defining attributes of the concept were identified: (1) reflection-in-action must occur during high-fidelity simulation and cannot be captured within post-simulation debriefing; (2) a critical learning juncture must occur and be identified by the learners; (3) a pause in student action must occur during the high-fidelity simulation; and (4) knowledge sharing must occur through out-loud discussion. Antecedents, consequences, and empirical referents of reflection-in-action were also identified.

Conclusions

The insights from this review may enhance the ability of nursing educators to effectively support reflection-in-action within high-fidelity simulation nursing education. This concept analysis also establishes a foundation for reflection-in-action strategy development, as well as suggestions for future research in high-fidelity simulation nursing education.

Introduction

High-fidelity simulation is a widely used teaching modality in healthcare, aviation, nuclear power, business, military, education, and police training (McMullen et al., 2016; Rutherford-Hemming, 2012; van den Heuvel et al., 2014). This broad utilization of high-fidelity simulation may be attributed to its effectiveness in promoting learning through active hands-on experience in a risk-free environment; while promoting teamwork, communication, and the development of critical thinking skills (Maran and Galvin, 2003; Mayville, 2011). Despite high-fidelity simulation being utilized for hands-on experiences, experience alone does not result in learning. Rather, learning happens through reflection. Ideally simulation educators, who use high-fidelity simulation, have adequate training and knowledge to support students in reflective practice (Sawyer et al., 2016).

Boyd and Fales (1983) defined reflection as “the process of creating and clarifying the meaning of experience (present or past) in terms of self” (p. 101). Schön (1987) further studied the area of reflective practice, discussing the importance of “reflection-before-action…reflection-in-action…and reflection-on-action” (p. 34), which can be simplified into reflecting on actions in the future, present, and past, respectively. Debriefing is considered the essential step to learning in high-fidelity simulation, therefore the literature on high-fidelity simulation focuses heavily on the later reflection-on-action through debriefing (Kang and Yu, 2018; Ha, 2020; Zhang et al., 2020). However, the literature is starting to shift to include a focus on reflection-before-action, and the importance of pre-briefing in high-fidelity simulation (Chamberlain, 2017; Page-Cutrara, 2014; Page-Cutrara and Turk, 2017). Although Schön (1987) believed in the importance of reflection-before-action and reflection-on-action, he thought the hallmark of mastery or artistry of a subject depended upon an individual's ability to reflect in the moment (reflect-in-action). In this process, knowing moves beyond what is tacit, and individuals can make changes to their actions during the event. Educators can support students to engage in reflection-in-action to help them develop the mastery and artistry of nursing.

Our purpose in writing this paper is to provide an in-depth analysis of reflection-in-action during high-fidelity simulation-based learning. We sought to identify what is currently known about the topic and establish a strong foundation or building blocks for theory development regarding cultivating reflection-in-action during high-fidelity simulation. In this paper, we define the concept of reflection-in-action and identify the key attributes, antecedents, consequences, cases, and empirical referents of this concept, using Walker and Avant's (2011) framework.

Section snippets

Methods

Walker and Avant's (2011) approach to concept analysis is a well-used framework in nursing literature on high-fidelity simulation (Bland et al., 2011; Cohen and Boni, 2018; Sabei et al., 2016; Turner and Harder, 2018), and is often used to guide comprehensive concept development and clarify ill-defined concepts. This framework consists of an eight step approach: 1) selecting the concept; 2) determining the purpose of the analysis; 3) discovering all uses of the concept; 4) determining the

Results

Our search yielded 296 articles, spanning 1998–2019. The abstracts were reviewed; articles that did not focus on high-fidelity simulation or reflection-in-action, and duplicate articles were removed. This left 117 articles that were reviewed in full text for potential inclusion. After excluding articles that did not focus on high-fidelity simulation, or reflection-in-action, we were left with 22 articles that met our inclusion criteria. Table 1 provides an overview of the results.

Discussion

Educating reflective practitioners is a goal of higher education. Every interaction with students must be considered an opportunity to form knowledge and develop reflective practitioners (Bloom, 1971; Kwan and Leung, 2006). This concept analysis of reflection-in-action during high-fidelity simulation education provides valuable insights for nursing educators and researchers. The defining attributes, antecedents, and consequences as well as the case examples may guide nursing educators to

Conclusion

In this paper we define the concept of reflection-in-action during high-fidelity simulation as the moment within high-fidelity simulation in which students are challenged to demonstrate their knowledge and skills beyond mechanical action. It is the point at which students bridge didactic learning and clinical practice, gaining understanding, new skills, flexibility, speed, and self-confidence. Simulation educators should have a strong understanding of how to identify when and encourage students

Funding source

Not applicable.

Ethical approval

Not applicable.

Declaration of competing interest

None declared.

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