Reflection Beyond Action: A Modified Version of Tanner's Clinical Judgment Model

The concept of Reflection-Beyond-Action emerged from the data analysis of a recent study that explored internationally educated nurses’ (IENs) experience and understanding of clinical judgment when engaged in a simulated clinical environment. I observed that all participants corroborated that their worldview changed due to their experience in this study; further, participants illustrated this point as, through their participation, they gained a broader and more inclusive understanding of the influence of cultural differences and its overall impact on professional competence and clinical judgment. This understanding stemmed from the participants’ reflection-in-action and reflection-on-action, which ultimately led participants to self-awareness and critical consciousness of the meaning of patient care and overall nursing practice. In the context of this study, I refer to this awareness as reflection-beyond-action. In this context, reflection-beyond-action refers to provide an ability to recognize how the reflection of societal influences and the dynamics of culture and communication impact the way one perceives oneself and others.

Reflection-beyond-action is an approach that provides one with the ability to interpret and view practice as a holistic approach to care. This process of reflection elicited the participants’ interpretations by gaining access to their thoughts, feelings, values, and actions. In doing so, it led participants to recognize the challenges they face as they transition to practice, as illustrated by the notion of unlearning and unknowing. The findings of the study suggest that unlearning is a process of building expertise and that old knowledge is foundational to the creation of new knowledge. Through reflection, participants were able to recognize the need for self-observation in order to be self  informed and to unlearn.  Unlearning brings one closer to developing as a professional and to gaining professional competence, as it provides a broader perception of both the world and the individual’s role in it. Unknowing emerged through participants’ experience of being underexposed or unexposed to circumstances presented in the study and was determined to be a prerequisite to knowing. Both unlearning and unknowing are integral to the education of IENs, as they call upon the learner to examine prior beliefs and assumptions and to consider their implications for practice. This, in turn, impacts practice, as who we are is who we bring to practice.  

The analysis of this study led to a modified Tanner’s Model of Clinical Judgment by adding another layer to the “reflecting” stage. The modified version includes the concepts of unlearning and unknowing.  Ultimately, this integration provides the practitioner with the ability to reflect beyond action.

This paper provides potential approaches to apply the concept of reflection-beyond-action in the context of clinical judgment in both the education of IENs and the nursing profession.