Japan Journal of Nursing Science (2011)

doi:10.1111/j.1742-7924.2011.00178.x

ORIGINAL ARTICLE

Experiences of a critical reflection program for mid-career nurses

jjns_178

1..10

Kyoko OYAMADA
Ministry of Education, Culture, Sports, Science, and Technology, Tokyo, Japan

Abstract
Aim: The aim of the present study was to describe the experiences of Japanese nurses who participated in
a critical reflection program for mid-career nurses. Critical reflection is one method that is appropriate for
the professional development of mid-career nurses. However, its implementation is difficult because of the
need for educational resources. Of the numerous reports on critical reflection outcomes, few delineate the
underlying process and none relates to Japanese nurses.
Methods: A program was developed, based on Mezirows transformation theory, to facilitate nurses critical
reflection. The program was implemented at three hospitals in Japan with 14 mid-career nurses. The
data-collection period was from 2006 to 2007. The grounded theory approach was used to describe the
results.
Results: Two participants experienced a transformation in their frame of reference after undergoing critical
reflection during the program. One participants viewpoint began to change and the others habit of mind
(social norms and personality characteristics that provide one with a general orientation) changed. Both
participants met the conditions that were necessary for transformation, such as having an open attitude
toward change, and compared to the other participants, their critical reflection progressed markedly on the
worksheets that were designed to promote critical reflection. The process of change in the frame of reference
that was experienced by the two participants followed eight of the ten phases of Mezirows transformation
theory.
Conclusions: The characteristics of the experiences of the two participants who underwent changes in their
frame of reference were described and discussed. The conditions for such transformation and the effects of
critical reflection on the participants were consistent with those reported by previous studies.
Key words: continuing education, narration, program evaluation, qualitative research, staff development.

INTRODUCTION
The number of mid-to-late-career nurses in Japan is
expected to rise in the future as a result of measures
that were made to support nurses re-employment in
response to a shortage of nursing staff. Continuous professional development (CPD) is crucial for mid-career

Correspondence: Kyoko Oyamada, All Japan Federation of

Social Insurance Associations Nurse Training Center,
1-1042-2 Kaijinchonishi, Funabashi-Shi, Chiba 273-8566,
Japan.
Email: oyamada1996@uu.em-net.ne.jp
Received 18 October 2010; accepted 6 December 2010.

nurses as they take on many roles, including those of

role model, instructor, and team leader, within their
daily work. However, there is no licensure renewal
system that facilitates CPD for nurses in Japan and the
work environment is not conducive to voluntary professional development.
Various institutional training programs to supplement
the work environment are available in Japan, but they
are not popular at small- and mid-sized facilities, where
many mid-career nurses are employed. Furthermore,
much of the institutional training that is carried out
requires the availability of adequate resources, which is
difficult for small facilities, and clear outcomes for practise have not been shown (Oyamada, 2006). A literature
review revealed that Japanese mid-career nurses face

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many dilemmas in their work and private lives and that

there are large individual differences in their level of
professional development (Oyamada, 2009).
The importance of reflection in CPD for nurses
became widely recognized after the 1980s. Various
anecdotal accounts of reflection in practise have been
reported since countries, such as the UK and Canada,
began to take measures to implement it at a national level
(Duffy, 2007; Nelson & Purkis, 2004; Ruth-Sand, 2003).
In Japan, after the work of Schn (1984) was introduced
in the 1990s, the number of such anecdotal accounts has
been increasing (Meguro, 2004; Tamura, Nakata,
Hirano, Ishikawa, & Tsuda, 2003). The field of CPD
contains abundant examples of professional development programs that implement reflection through group
discussion, discussion with a facilitator or study partner,
and reflection journal entries (Duffy, 2007; Kim, 1999;
Ruth-Sand, 2003; Stuart, 1998). In addition, beginning
with the facilitation method, various instructional strategies have been proposed (Crowe & OMalley, 2006;
Nielsen, Stragnell, & Jester, 2007). Diverse findings in
qualitative research include changes in practise due to
enhanced knowledge and problem-solving skills,
self-transformation and development, changes in perspective, improved self-esteem, achievement of job satisfaction and a sense of comfort in nursing situations,
feelings of solidarity with other specialists, and learning
from others (Arvidsson, Lfgren, & Fridlund, 2001;
Bulman & Schutz, 2004; Cheyne, Niven, & McGinley,
2003; Duffy, 2007; Eisen, 2001; Platzer, Blake, &
Ashfold, 2000). However, the introduction of programs
has proved to be difficult when there has been no consideration of the educational resources that are available
at the facilities. In fact, the majority of the reported
programs for CPD were a part of the regular course
material at graduate schools, were long-term (lasting
from 6 months to 1 year), and were operated by university faculty members or full-time teaching nurses.
In quantitative studies, no significant effect has been
reported (Forneris & Peden-McAlpine, 2007; Spencer &
Newell, 1999). A preliminary study found that there
were limitations in the benefits of reflection in the professional development of mid-career nurses, suggesting
the need for critical reflection on nurses frame of reference (Oyamada, 2007). The conditions that are essential
for critical reflection include cognitive skills, such as
learning ability, critical analysis, synthesis, and evaluation (Bulman & Schutz, 2004), as well as affective
readiness, such as motivation for development, and
open-mindedness (Williams, 2001). As for the learning
environment, the literature suggests that mutual support

and trust between the group members, a sense of camaraderie (Taylor, 2000), and discourse and inquiry are
important to encourage critical reflection (Ruth-Sand,
2003).
Although there are multiple reports that describe the
effects of critical reflection, few studies have attempted
to delineate the process and there has been no anecdotal
account of a program for critical reflection in practise in
Japan. Evidence-based, concrete guidance methods are
still in the process of development (Fujii & Tamura,
2008). In the meantime, further research clearly is
needed to address how mid-career nurses can participate
in, and benefit from, critical reflection programs.
Therefore, the aims of this study were to construct a
critical reflection program to target mid-career nurses
that can be introduced, regardless of the structure and
educational resources of the affiliated organizations, and
to examine the effects of the program on learners and
their practise. This article reports on the implementation
of such a program and describes the experiences of the
participants whose frame of reference changed as a consequence.
The key terms that are used in this article are defined
as follows:
1 Mid-career nurse: a staff nurse with 515 years of
experience as a registered nurse.
2 Critical reflection: rational thoughts that involve
evaluating and requestioning the truth and validity of
events while taking into account the possibility of
limits and errors.
3 Frame of reference: the framework from which individuals experience the world and make judgments
and decisions. It involves two aspects: habit of
mind, which are the social norms and personality
characteristics that provide one with a general orientation, and point of view, which is the aggregation
of certain beliefs and expectations that form individual interpretations of the self and the world.

METHODS
Design
The present study took Mezirows (2000) transformation theory as its theoretical premise and used the qualitative, descriptive design of Yins (2003) case-study
method.
Mezirows theory was used because it focuses on
adult learners, emphasizes the importance of dialogue
with others, and describes the phases of transformation
(Appendix I), which were confirmed by several studies
(Mezirow, 2000).

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The case study is a method of investigating an existing phenomenon in its actual circumstances and is
appropriate in order to explain hypothesized causal
relationships and their link to actual interventions in
complex situations where empirical methods are not
feasible. Yins (2003) case-study method clearly specifies the procedure for conducting program evaluations
by integrating individual case reports and comparing
the outcomes to those that were predicted. However,
because Yins method does not specify how to produce
case reports using qualitative data, the researcher
referred to the grounded theory approach (Strauss &
Corbin, 1998) in order to produce case reports in
an explorative manner and to make the processes
clear.
These methods were adopted because the evaluation
of the program could be conducted along with the delineation of the critical reflection process by Japanese
nurses, a process that has yet to be described.

Critical reflection program and its

implementation
The critical reflection program (hereafter called the
program) was designed based on transformation
theory and the results of the preliminary study
(Oyamada, 2007). The aims of the program were to help
learners to recognize aspects of their practise, as well
as the values and assumptions that form that practise.
Also, the program was intended to broaden the learners
self-image through a requestioning of the truthfulness
and validity of their values and assumptions.
The program was implemented as follows. The participants met for six-to-seven sessions of group work of
6090 min per session every week or every other week.
At each session, except for the first and last sessions
(which were for orientation and summary), one nurse
presented his or her narrative and the group discussed
the exemplary qualities of the nurse in the context of
the narrative. The participants then engaged in critical
reflection on their own frame of reference by completing
a worksheet that was recognized through the group
discussion. The questions and prompts on the worksheet
were as follows:
1 What did you learn through todays session?
2 Did you become aware of any views that you had that
you had taken for granted and had paid little attention to before?
3 Recall how and when you first developed those
views.
4 Do you think you will continue to hold those views?

Critical reflection program experiences

5 Did you feel comfortable during todays session?

Please write down anything you thought about the
session.
The narratives were analyzed from the perspective of
the characteristics of excellent nursing practise, as
described by Benner, Hooper-Kyriakids, and Stannard
(1999), and they were discussed by using positive feedback. This program uniquely differs from pre-existing
programs on reflection in terms of the focus on the
exemplary qualities of the participants and the facilitation by non-specialists. The facilitators underwent a
1 day facilitator workshop that was conducted by an
expert in adult learning theories and practised group
work before the start of the program.

Participants
The participants were 14 mid-career nurses who were
employed at three health facilities and who gave voluntary consent and the facilitators were four nurses (two
nurses participated at one facility) who were associated
with the professional development of nursing staff at
institutions that were affiliated with this research. The
participants were recruited within the facilities through
the nursing departments.

Data collection
The data were collected from participant observations in
the group discussions and from semistructured interviews and the worksheets of the participants. The interviews with the nurses were conducted individually on
three occasions: before the beginning of the program, at
the end of the program, and 1 month after the completion of the program. These interviews were intended to
ascertain the nurses individual knowledge of, and experiences in, the program. Each interview session ranged
from 30 to 60 min. The content of each conversation
was recorded with a digital voice recorder with the
participants consent and a word-for-word transcription
was created.
The worksheet served as the program material while
being used to grasp the process of critical reflection
during the course of the program, as well as the experiences of participation in each groupwork session. Observations were conducted to discern the state of the
groupwork implementation and to gather data about
the participation experiences of the nurses from a different perspective. The researcher observed all the group
work, recorded each conversation with a digital voice
recorder with the participants consent, and created the
word-for-word transcripts. The data collection occurred
between August 2006 and April 2007.

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Japan Journal of Nursing Science (2011)

Data analysis

RESULTS

The status of the groupwork implementation for each

session and the individual experiences of program participation of the mid-career nurses were described
by using the open and axial coding methods of
the grounded theory approach (Strauss & Corbin,
1998).
The individual experiences of the cases were integrated by using the explanation-building method
(Yin, 2003). Explanation-building involves the construction of an initial theoretical statement relating to
social attitudes and principles. The statement is compared to the findings of an initial case and then the
statement is modified to conform to the case. The modified statement is compared to subsequent cases and is
further modified until all the cases are integrated.
The initial theoretical statement in the present study
was the premise and aim of the program and it was
compared with the individual accounts. The theoretical
statement and the results of the explanation-building
will be reported in another paper.

Summary

Rigor
The integrity and validity of the data and analysis were
maintained by using multiple data sources, memberchecking, supervision by three instructors, and an
examination of rival explanations (Merriam, 1998; Yin,
2003). Rival explanation involves identifying the factors
other than the program that might influence the results
and eliminating them.

Ethical considerations
The participants were recruited through public
announcements. The researcher explained the content
of the research to those candidates who were interested
in participating and, on reconfirmation of this interest,
obtained the participants written consent. The participants could withdraw from the program at any
time.
The digital voice recorder was used only when all
the participants gave their consent. The data that identified individuals were coded on transcription of the
recorded data. Only the researcher and supervisors
were allowed to access the data. All of the recordings
were deleted or destroyed once the results of the study
had been determined. Approval for the present study
was obtained from the research ethics committee of the
college that the researcher was affiliated with at the
time.

The participating facilities, A, B, and C, were general

hospitals that provided acute medical care, with bed
counts of 176, 348, and 404, respectively (the average
number of beds in Japan was 183.0 in 2008). Additionally, the standard for nurse placement, as indicated
by the nursepatient ratio, was 10:1, 7:1, and 7:1,
respectively.
Of the 15 nurses who initially participated, one from
Hospital B withdrew from the study, which resulted in
14 final participants. The mean age of the nurses was
35.4 years at hospital A, 33.3 years at hospital B, and
32.4 years at hospital C. While the nurses at Hospital B
voluntarily participated, most of the participants at hospitals A and C were persuaded to participate by their
supervisors.
In terms of the programs implementation, all the
participants attended every session at Hospital A, where
seven sessions of group work were conducted. For Hospital B, the group work sessions decreased by one due to
the withdrawal of a participant, for an end total of six
sessions. Absences due to sickness and work, as well as
the withdrawal, resulted in full attendance by all the
remaining members in two of the six sessions. Aside
from a one-time absence of one participant, all the participants attended all seven sessions at hospital C
(Table 1).

Participation experiences and their influence on

the practise of the mid-career nurses
A change in the frame of reference, or habits of mind
and point of view, was identified in three of the 14
participants; namely, A4 of Hospital A, B1 of Hospital
B, and C4 of Hospital C. Of these, the influence of an
event that was unrelated to the program could not be
ruled out for C4.
Ten participants, with the inclusion of C4, reflected
critically on various topics, found their future tasks, and
reported changes in practise, although a change in the
frame of reference could not be confirmed among them.
The practise of C5 changed, despite C5s claim that the
program had no effect.
The following sections describe a portion of the experiences of A4 and B1, who had a change in their frame
of reference, as well as a portion of the experiences of
B3, for whom there were changes in practise but not in
the frame of reference, for comparison. The categories
that were developed during the analysis are enclosed in
brackets and the direct quotations represent evidence for

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Critical reflection program experiences

Table 1 Program implementation data

Participants
(mid-career nurses)

Length of group
work (min)

Amount of time
addressing the
worksheet (min)

Study site

No. of
group work
sessions

Average
age (years)

Average

Range

Average

Range

Hospital A
Hospital B
Hospital C

7
6
7

5
4
5

35.4
33.3
32.4

43.5
52.7
43.0

(3158)
(4756)
(3756)

21.7
10.8
9.6

(1330)
(330)
(816)

the researchers interpretations. The symbols in parentheses after each direct quotation represent the time of
data collection or the type of data: P, A, and 1 M indicate the interview data and W indicates the worksheets.
P denotes prior to program participation, A denotes
immediately after program completion, and 1 M
denotes 1 month after program completion.

Program participation experiences of A4

A4 had 4 years of experience as an assistant nurse and
was in her 15th year of nursing, having taken a 10 year
break to raise children. It was her second year of
working at Hospital A. She received an [order from a
supervisor] to participate in the program, just as the
nursing system of the hospital was being modified and
she had begun to have [thoughts of advancement].
A4 described group work as [a forum to openly share
a variety of opinions], which could not be done with her
coworkers. She thought that the frequency and number
of sessions were appropriate and that it was an [effective
program] for evaluating herself from anothers perspective. However, she could not fulfill her expectation to
draw out her hidden self, which she held after listening
to the descriptions of the program, and thus she felt that
[the program differed from her expectations].
A4 reported [learning how to broaden her view].
When A4s narrative was presented, she listened to a
variety of opinions offered by the group members of
different ages. She realized that persisting with her viewpoint would lead to a failure to broaden it and that
she might notice something new while considering the
other persons opinion. She gained knowledge of care
from other members narratives. She also reported [selfreflection]. When everyone was sharing their own heartfelt personal experiences, she frequently looked back
at herself during the discussion of these experiences,
re-evaluated her past experiences, and searched for the
origins of her viewpoints.

As for the worksheet, the participants misunderstood

the purpose of the questions. She thought that if the
participants had correctly understood the questions,
a conversation about the origins of individuals frame
of reference could have developed [misunderstandings
decreased the effectiveness of the worksheet]:
I thought about what everyone was saying, like How could
you overcome that and still be a nurse?, and I was thinking
Oh, I wonder why for myself. As I was listening to everyones stories . . . I was like, Yeah, thats right. I must like
nursing after all. I was interpreting what they said in
my mind, looking for an answer. This happened several
times (A).

Due to the programs influence, A4 [changed the way

that she perceived phenomena]. She began to tune into
daily information that she had ignored previously and
developed more multidimensional views of others. Similarly, her nursing behaviors were transformed as she
[stopped and took time to think] before getting upset.
For example, in the case of a patient who was suffering
from dementia, she referred to information in a textbook and intentionally treated the patient as a person.
The improvement in the patients state was one [effect
within her practise]:
Thanks to this program, I now pay attention to things that
used to go in one ear and out the other . . . When a lot of
information is coming in, sometimes it hits you something
that you actually thought up or wondered about for a
moment. You get the gist of it and think things like, Oh, I
wonder if this was important, too? The program made me
able to think like this, made me think, and so it was really
good for me (1 M).
I have become able to see more things around me very
clearly. Ah, this person is this way. I noticed that I made
assumptions about other people. From there, I said to myself
No, wait. This person actually has some good traits.
I have become capable of recognizing that . . . A variety of

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information comes in and I learned how to organize it

(1 M).

Program participation experiences of B1

B1 had a baccalaureate degree and 5 years of nursing
experience. She came to Hospital B in the year of the
program implementation in order to expand her own
professional ability, thus [seeking active professional
development]. She called herself [an experienced
newcomer].
Nursing was enjoyable for B1 and she was actively
engaged in her work. She was a [nurse in the early stages
of development]: although she was excited about her
potential, she felt that her lack of experience and an
unclear direction for the future inhibited her from taking
the next step. She participated in the program because
she felt that it would be an [opportunity for professional
development]. B1 missed one session of group work
because of job obligations:
My interest just takes off and if someone were to ask what
I have actually done, I think I could say that Im at the level
Im supposed to be, but at the same time, Im wishing I could
do more . . . I now really believe that, in some ways, Ive
become comfortable with my work here. The stress and
anxiety I felt when I first started has disappeared, but now I
feel Im still half-way through (P).

B1 generally had no difficulty in speaking in front of

others and the pleasant atmosphere of the group led to
a [fun groupwork] experience. B1 stated that, through
the question-and-answer sessions with the other participants, more members cases were presented as [discussion of the cases resulted in more case discussions]. In
contrast, the experiences of the presenters could not be
elicited well when the other members knew too much
about the case.
What B1 learned from these experiences was as
follows. First, she could [objectify the experience].
Through the discussions, she was able to look at herself
and evaluate her care from others perspectives, realizing
the degree of impact that her care had on others.
Furthermore, by deepening her [reflection through the
worksheets], she realized that she had a tendency to
perceive phenomena only from the viewpoint of a nurse,
and not as a person. B1 pinpointed this frame of reference as originating in the words of a supervisor at
around the time that she started. B1 experienced [critical
reflection on the frame of reference regarding care]. She
realized, through the cases of others, the need for flexible views.
As a result of these experiences of critical reflection,
B1 felt herself maturing as she gathered more experience

and she gained confidence. The experiences allowed her

to conduct [a rational evaluation of self] that incorporated her strengths and weaknesses.
B1 made use of this learning and generated [a plan for
applying learning to practise], where she increased the
number of viewpoints from which she examined phenomena. This learning also engendered the desire to
bring out the positive points of the case discussions:
B3s case was completely unknown to me. When I asked
questions, the case seemed to quickly take on brilliance . . . The atmosphere for ward training has been rather
scary. They are mainly about criticizing. Now I think about
it, we couldnt even ask about good things or even elaborate
on the cases (A).
As I looked through each and every case . . . I realized that
the comments of older nurses and patients stay with me
rather hard. It became an opportunity to reflect back on
that . . . Things like, I cant do that because I was told to do
it this way. . . . I dont think that its completely bad, but I
do feel that you shouldnt let your thinking get off-balance.
You have to think about each and every case (A).

In trying to be more flexible in how she approached care

in the cases that followed, B1 felt [her frame of reference
crumbling]. She experienced indecisiveness in her clinical judgments, but at the same time, her areas of interest
became increasingly focused. She thought that this
present state of confusion was something that she had to
overcome during her maturation process. As a result,
she created a [professional development plan], where
she confronted unsolved issues, redesigned her frame of
reference, and summarized cases. B1 also recognized her
positive aspects more and had an [expanded self-image]
with more options for the future:
I was told to look at things as a nurse. Its not that Id
never thought about it, but now, when I think about it more
deeply, Im like, What? What am I supposed to do? I feel
as if Im up against the wall a little . . . I think this problem
has meaning for me, so Im going to immerse myself in the
problem until I find some answers (1 M).
I got the feeling that I complimented myself more, pumping
myself up. I think a lack of confidence isnt good. But, isnt
it rather difficult to compliment yourself or admit that you
did something well? . . . I believe that I can now say Ive
done something well when I have (1 M).

Program participation experiences of B3

B3 had 10 years of clinical experience and was in her
fourth year of working at Hospital B. She was satisfied
in her current placement, where she was assigned a
variety of [leader and coordinator] roles by her supervi-

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sor. [Resolute nursing values and a tendency to quit]

coexisted in her work: although she was active in
professional development, the fact that she tended to
give up when she could not get her ideas across had
become an issue. She participated in the program
because she thought that it would be a good opportunity
to learn about others and an [opportunity to reflect on
herself].
B3 reported that the group work left an impression of
superficiality because there was not enough understanding of the program itself. She reported that [many areas
of the group work needed improvement], but she personally felt the educational effects of sharing experiential knowledge. She [broadened her knowledge base] by
learning about Benners nursing theories and of methods
for effectively communicating her thoughts to others. In
addition, she [reaffirmed her values and confirmed the
validity of them] regarding her own nursing and
[affirmed her own growth]. She had an interest in training junior nurses from the beginning, and with the effective training methods that she had acquired through the
program, her motivation to train them had increased.
She had developed [a conception of her future plans]:
she wanted to communicate her nursing values to junior
nurses:
When I think about why they arrived at where they did, I
just speculated that they had experienced things like this a
little earlier and its still remaining. But, I just wonder if they
decided that way of thinking was really good . . . It would
have been better if we could talk more about what led to
that behavior (A).
A view I became aware [of] today was that adjusting
patients environment is important. I will continue to hold
this view because a proper environment is vital, not only
in terms of health or illness, but in terms of living daily
life (W).

B3 had [personal success] after the completion of the

program. She elicited experiential knowledge from staff
members at a conference as actual [practise that made
use of experiential knowledge] in problem-solving. As a
result, her self-confidence improved and she reported a
heightened ability to carrying things out, as well as
experiencing a [positive self-image change] in thinking
about her ideals at a behavioral level:
I think I have become more positive about things . . . My
ideals didnt change, but I narrowed them down to specific
behaviors . . . Instead of Im too busy to do this, now I
can be more forward-thinking about my nursing, like Well,
Ill give it a try. (1 M)

Critical reflection program experiences

DISCUSSION
Before discussing the results in detail, it must be noted
that there are some limitations to the present study.
Specifically, the extent of diversity in the results is
obscure because of an arbitrary number of participants
and groups. Also, the views of nurse managers influenced who participated in the study at two hospitals,
possibly biasing the results.
Consideration was given to the experience characteristics of A4 and B1 by comparing them with those of the
participants who did not experience changes in their
frame of reference or with the ten phases of the transformation process that was defined by Mezirow (2000).
First, B1 reported that she experienced indecisiveness
in making clinical judgments when she attempted to be
flexible in her approach to care. In terms of her frame of
reference, transformation began with the [point of view]
that contributed to determining how persons view the
world. In contrast, A4 had not conducted reflection,
behaving according to habit or reflex, [becoming upset]
and [frequently going around in circles]. Although
A4 can be considered to be a non-reflector (Wong,
Kember, Chung, & Yan, 1995), A4 explained that, after
completion of the program, reflection on situations and
emotions became a habit for her, demonstrating the start
of a transformation in her habit of mind. Likewise, a
transformation in her point of view, or framework for
understanding the world, was seen as she mentioned
that information that used to go in one ear and out
the other is now sticking. Based on the phases of
Mezirows transformation in the frame of reference, B1
experienced [disorienting dilemma(s)] through her participation in the group discussions, as well as a [selfexamination with feelings of fear, guilt, or shame] and a
[critical assessment of assumptions] in completing the
worksheets. These resulted in an [exploration of options
for new roles, relationship(s), and actions], [planning
course(s) of action], and the [provisional trying of new
roles].
In contrast to these experiences, A4 already had
experienced [disorienting dilemma(s)] and a [selfexamination with feelings of fear, guilt, or shame]
during environmental changes as the nursing system of
her hospital was reconstructed. Through the group
discussions and worksheets, she underwent a [critical
assessment of assumptions], while the [acquiring of
knowledge and skills for implementing ones plans]
occurred through group work and textbook reading.
Additionally, A4 experienced success through the [provisional trying of new roles] and also experienced the

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[building (of) competence and self-confidence in new

roles and relationship(s)].
Neither A4 nor B1 reported on phase 4, or the [recognition that ones discontent and the process of transformation coexist]. Nor did they experience phase 10, a
[reintegration into ones life on the basis of the conditions that are dictated by ones new perspective]. Opportunities for recognizing that ones discontent and the
transformation process coexist were not built into the
structure of the program. It is also possible that the
participants were unable to speak of their experiences
with this phase during the interviews. As for the reintegration phase, the timing of the interviews might have
made it difficult for the participants to address this
topic, considering that the period for data collection
continued only up to 1 month after the programs
completion.
Both A4 and B1 desired personal growth. They
decided to participate because the program represented
professional development opportunities. They actively
participated in the group work and had many opportunities to receive questions during the presentation of
their cases. In other words, they participated with an
open attitude toward change and, on many occasions,
verbalized their experiences with others during the discussions. Thus, the conditions that promote a transformation in the frame of reference (Williams, 2001) were
present for both A4 and B1. These conditions also were
observed in relation to several other participants, including B3. However, advanced critical reflection on the
worksheet responses or a [critical assessment of assumptions] was a characteristic that was observed only in
relation to A4 and B1. B1 understood the intention of
the worksheets and always reported on content that
coincided with the worksheet items. In contrast, A4
thought that it was difficult to understand the intention
of the worksheet items. She spent a long time being
actively engaged in completing the worksheets and
stated in the last entry that she now understood their
intention. In the telling of her transformation in her
frame of reference and the reasons for it, she stated that
she learned how to organize various information. For
A4, it is less likely that she furthered the critical reflection process by following the worksheet items. Rather,
critical reflection might have resulted from her repeated
entries in the worksheets and from training herself to
organize her thoughts and past experiences and to find
meaning in them.
B3 did not experience a change in her frame of reference, although as with B1 and A4, she met the conditions that promote it. Although she understood the

items and completed the worksheets, her average

completion time was 7 min, the second-shortest time of
the 14 participants. A reconfirmation of the viewpoints
with which she was already familiar was the bulk of the
content. Thus, based on the amount of time that she
spent on her worksheet entries and their content, she did
not show critical reflection of her frame of reference.
B3 did transfer her learning to practise, although it
was not done as an attempt at self-transformation. In
fact, it was an attempt to change the methods of her
supervisee(s). As the attempt was remarkably successful,
she probably did not have the opportunity to question
the appropriateness of her frame of reference. Mezirow
(2000) called the learning that B3 experienced an [elaboration of a pre-existing frame of reference], one that
adds meaning and interpretations that match the preexisting frame of reference. It is categorically distinct
from learning that brings about changes in the frame of
reference.

CONCLUSION
Developed with a consideration for feasibility in clinical
practise, the program in this study was conducted with
14 mid-career nurses at three hospitals. A change in the
frame of reference was observed in two of the participants. The conditions that promoted a transformation
in their frame of reference were their open attitude
toward change and opportunities to verbalize their
experiences during the discussion sessions with others.
Furthermore, their progress in critical reflection through
the worksheet responses was considerably more
advanced than that of the other participants. Of the ten
phases in Mezirows transformation theory, the change
in the frame of reference that was experienced by these
two participants involved eight of these phases.
The modification of the program is necessary in order
to improve the effects of the program, as mentioned by
the participants. The data-collection period should be
longer in order to capture the transformation process
more fully. Considering that A4 was in her late 40s,
examining the effects of this program with late-career
nurses is also worthwhile.
The programs efficacy and the integration of the
experiences of all the participants will be reported in the
future.

ACKNOWLEDGMENTS
Financial support for this study was provided by Tokyo
Nursing Association, Tokyo, Japan.

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Japan Journal of Nursing Science (2011)

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APPENDIX I
Phases of transformation
1 A disorienting dilemma.
2 Self-examination with feelings of fear, anger, guilt, or
shame.

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K. Oyamada

Japan Journal of Nursing Science (2011)

3 A critical assessment of assumptions.

4 Recognition that ones discontent and the process of
transformation are shared.
5 Exploration of options for new roles, relationships,
and actions.
6 Planning a course of action.
7 Acquiring knowledge and skills for implementing
ones plans.

10

8 Provisional trying of new roles.

9 Building competence and self-confidence in new
roles and relationships.
10 A reintegration into ones life on the basis of conditions dictated by ones new perspective.
Reproduced from Mezirow (2000, p. 22), with permission from John Wiley & Sons, Inc.

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Japan Journal of Nursing Science 2011 Japan Academy of Nursing Science