Using Structured Reflection to Enhance Student Engagement and Professional Growth

  Using  Structured  Reflection  to  Enhance  Student  Engagement    and  Professional  Growth         Slavko  Cvetek,*  Faculty  of  Health  Scien...
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Using  Structured  Reflection  to  Enhance  Student  Engagement    and  Professional  Growth        

Slavko  Cvetek,*  Faculty  of  Health  Sciences,  University  of  Maribor,  Slovenia  

    Abstract   This  paper  presents  the  findings  of  a  small-­‐scale  study  that  aimed  to  identify  areas  of   concern  to  students,  future  nurses,  during  their  clinical  practice  in  homes  for  the  elderly.   For  this  purpose,  the  author  used  a  simplified  version  of  critical  incident  analysis  (Tripp,   1993).  The  study’s  findings  confirmed  the  value  of  structured  reflection  as  a  pedagogical   tool  in  professional  nurse  education.  Some  potential  areas  of  concern  were  identified  in   students’  reflective  writings,  such  as  lack  of  professionalism  by  some  of  the  staff,  and   also  maltreatment  and  neglect  of  care.       Keywords:    medical  education,  nursing,  self-­‐reflection,  critical  thinking               *    Corresponding  author.    Email:    [email protected]        

 

Introduction   The  thing  being  made  in  a  university  is  humanity.  (Wendel  Berry)     The  role  of  higher  education  curricula  (study  programs)  in  the  process  of  preparing   students  for  their  various  future  professional  roles  cannot  be  overestimated.  It  is  now   generally  agreed  that  graduates  of  these  programs  are  expected  to  have  developed,   during  the  course  of  study,  the  higher-­‐order  skills  and  abilities  such  as  reflection  and   critical  thinking,  as  well  as  a  commitment  to  providing  best  possible  service  to  clients  or   public.  In  nursing  and  health  professions  in  particular,  they  should  be  able  to  recognize   and  respond  to  moral  and  ethical  dilemmas  and  issues  that  arise  in  day-­‐to-­‐day   professional  practice  (see,  for  example,  nursing  competences  defined  in  the  EU  Tuning   Project,  2005).     In  order  to  help  students  develop  these  skills  and  abilities,  nurse  educators  and   curriculum  designers  should  as  much  as  possible  provide  students  with  opportunities  to   engage  in  realistic  activities  and  tasks  that  demand  their  active  involvement  and   response  (as  persons  and  developing  professionals)  to  problematic,  intriguing  or  in   some  other  way  challenging  situations  (e.g.  Johns,  1994;  Kim,  1999;  Hannigan,  2001).   This,  however,  can  be  achieved  only  to  a  minor  extent  in  the  academic  environment  of   the  faculty.     Far  more  useful  are  settings  where  students  have  their  clinical  practice.  Here   students  are  exposed  to  a  multitude  of  experiences  (events  and  situations)  which,  if   appropriately  utilized,  contribute  to  their  professional  learning  and  to  their  academic   and  personal  growth.  One  way  of  utilizing  these  experiences  is  by  subjecting  them  to   reflection  and  critical  thinking.     2

  The  Role  of  Reflection  in  Nurse  Education   The  role  and  value  of  reflection  in  nurse  education  (and  professional  education  more   broadly)  is  now  widely  recognized  and  supported  with  research  evidence.  Reflection  not   only  contributes  to  improved  nursing  care  of  patients  but  is  a  necessary  condition  for   providing  professional  health  service.  Reflective  practice  is  now  considered  a  key   characteristic  and  a  key  competence  of  nurses  and  other  health  professionals  (e.g.   Mantzoukas  and  Jasper,  2004;  Tate,  2004;  McKenna,  2009).  Both  reflection  and   reflective  practice  have  become  a  standard  part  of  education  for  the  nursing  profession   (Hannigan  (2001:  280).   It  has  been  agreed  that  clinical  practice  (placements)  play  a  key  role  in  educating   future  nurses  (and  health  professionals  overall).  Through  clinical  practice,  students   acquire  practical  knowledge,  develop  their  clinical  (nursing)  skills,  and  integrate   theoretical  with  personal  knowledge  as  future  (and  developing)  practitioners  (Kim  et  al.,   2010:  160).  While  there  are  also  other  methods  of  teaching  that  serve  the  purpose  of   developing  clinical  skills,  such  as  clinical  simulations  and  laboratory  practice,  it  is  only   during  clinical  practice  (placements)  that  students  are  put  in  real  situations  in  which   nursing  is  practiced  as  profession.   In  clinical  settings,  reflective  training  typically  involves  activities  for  stimulating     focus  on  one’s  professional  activities  such  as  questions  and  mentor-­‐student   conversations,  reflective  diaries,  etc.,  and  use  of  various  models  for  structuring   reflection  (e.g.  Gibbs’  reflective  cycle,  John’s  model,  Borton’s  model,  etc.)  One  particular   technique  which  has  proved  particularly  useful  in  clinical  training  of  nurses  is  critical   incident  analysis,  a  technique  originally  developed  by  Flanagan  (1946),  and  further   developed  by  several  authors  from  professions  such  as  teaching  (e.g.  Tripp,  1993),   3

nursing  (e.g.  Kim,  1999)  and  others.  Basically,  it  is  a  guided  process  aimed  to  help   professionals  (and  students  as  future  professionals)  achieve  higher  levels  of  thinking   (analysis,  synthesis,  evaluation),  which  increases  their  professional  and  personal   development  and  leads  to  the  improvement  of  practice.  As  has  been  pointed  out:   [C]ritical  incident  analysis  is  a  valuable  educational  tool  which  enables   nursing/midwifery  students  to  draw  on  past  experiences  and  make  sense  of  them,   not  only  facilitating  learning  from  clinical  practice  but  also  going  some  way   towards  bridging  the  gap  between  theory  and  practice.  (Parker,  Webb  and   D'Souza,  1995).   A  critical  incident,  as  we  know,  is  an  event  or  situation  in  professional  practice,   which  for  some  reason  attracts  our  attention,  or  which  we  find  interesting  or  challenging   in  some  way.  The  following  piece  of  reflective  writing  clearly  illustrates  the  turmoil  that   a  few  carelessly  uttered  words  during  a  routine  situation,  such  as  entering  a  room  in  a   nursing  home,  can  cause  in  the  mind  and  heart  of  a  student,  a  future  nursing   professional:   It  happened  during  my  summer  work  in  a  nursing  home.  In  the  morning,  I  went,   together  with  a  nursing  assistant,  to  perform  morning  care  with  an  elderly,  frail   woman.  When  we  approached  her,  I  said  “Good  morning,  madam.  How  are  you?”   The  nursing  assistant  looked  at  me  and  said  “You  don’t  have  to  be  so  kind.”  I  was   speechless  with  surprise  and,  after  a  minute,  all  I  could  say  was  “Right.”  I  had  little   experience  then  and  did  not  dare  to  say  anything  else.     During  the  event,  I  was  shocked.  Two  questions  kept  coming  back  to  me:   “How  does  the  woman,  who  heard  everything,  feel?  Why  did  this  health  worker   choose  this  profession  in  the  first  place?”  I  kept  thinking  that  kindness  should  

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always  be  a  basic  characteristic  of  a  nurse.  I  was  very  affected  by  the  event   because  of  the  insolence  and  indifference  shown  by  my  assistant.   As  for  myself,  I  find  this  experience  important  because  I  now  know  what   kind  of  health  worker  I  must  never  become.  I  also  think  that  other  students  should   hear  this  story  and  learn  from  it.  This  story  is  also  important  for  this  course   [students  wrote  their  reflections  during  the  “Philosophy  and  Ethics  in  Nursing  and   Health  Care”  course]  because  the  health  worker  acted  in  a  very  immoral  way.   Also,  this  event  throws  a  very  negative  light  on  the  institution  where  it  happened.  I   think  that  an  institution  with  this  kind  of  staff  cannot  have  a  good  reputation.     (Document  in  possession  of  the  author.)   The  above  reflection,  although  short  and  modest  as  regards  the  depth  of   analytical  and  critical  thinking,  confirms  the  value  of  structured  reflection  for  student   professional  and  personal  development  (e.g.  critical  observation,  self-­‐awareness,   reference  to  theory,  etc.).  Also,  it  uncovers  and  brings  to  our  awareness  the  usually   undetected  and  hidden  “facets”  of  quality  and  professionalism  of  elderly  care  in   institutional  settings.   Standard  student  evaluations  of  clinical  practice  (placements)  in  nursing  homes   provide  little  substantial  information.  According  to  their  responses,  a  vast  majority   (90%  or  more)  of  students  are  “satisfied”  or  “very  satisfied”  with  the  experience  and   support  provided  by  their  mentors  and  other  professional  staff.  An  experimental  (ad   hoc)  application  of  the  critical  incident  technique  to  a  group  of  12  nursing  students   during  their  2-­‐week  clinical  practice  in  a  nursing  home  in  Maribor  area,  however,  gave   unexpected  results.  The  majority  of  the  students  chose  to  write  about  events  and   situations  in  which  they  witnessed  unprofessional  care,  poor  communication,  neglect,   and  even  maltreatment  of  the  residents  by  the  nursing  staff.  Surprisingly  (or  not),  the   5

structure  of  “critical  incidents”  largely  corresponded  with  the  findings  of  some  recent   research  on  the  quality  of  institutional  elderly  care  in  Slovenia  (Habjanič  2009,  2011;   see  also  Prevolnik  Rupel  and  Ogorevc,  2011).     According  to  these  findings,  common  forms  of  unprofessional  care  or  neglect  of   care  included  hastiness  in  providing  care  (e.g.  fast  feeding),  postponed  duties,  low   protection  of  intimacy,  poor  or  unprofessional  communication,  and  lack  of  respect  (e.g.   ridiculing)  for  the  residents.  Based  on  these  findings,  a  small-­‐scale  study  was  conducted   in  2014  which  is  briefly  described  below.     The  Study:  Aims,  Participants,  and  Methodology   The  main  aim  of  the  study  was  to  explore  students'  experiences  during  their  clinical   practice  (placements)  in  an  institutional  elderly  care  setting  and  identify  key  areas  of   students’  concerns  arising  from  these  experiences.  Another  aim  was  to  evaluate  the   effectiveness  of  critical  incident  analysis  as  a  pedagogical  tool  in  professional  nurse   education.  Not  lastly,  the  study  aimed  to  look  for  arguments  for  a  wider  use  of  reflection   in  the  nursing  curriculum  at  the  Faculty  of  Health  Sciences  (FHS),  University  of  Maribor.   The  participants  in  the  study  were  25  1st–year  students  enrolled  in  the  3–year   study  program  Nursing  Care  during  their  2–week  clinical  practice  (placement)  in  a   nursing  home.  It  is  worth  noting  that  at  that  time  these  students  had  little  or  no   experience  in  reflective  writing  and  had  received  no  explicit  teaching  about  reflection.   For  the  study,  we  used  a  3–step  version  of  critical  incident  analysis  in  which  the   students  were  asked  to  describe  and  reflect  on  a  critical  (i.e.,  surprising,  conflicting  or  in   any  other  way  challenging)  moment  during  their  clinical  practice  (placement).  More   specifically,  students  were  required  to  (1)  briefly  describe  the  event  or  situation  (the   context,  what  exactly  happened,  how  it  ended,  etc.),  (2)  briefly  describe  their  feelings   6

during  the  event/situation  (how  they  felt  and  why…),  and  (3)  give  the  meaning  of  the   event/situation  (what  was  most  important—for  the  student,  for  the  patient,  for  the   nursing  profession,  for  the  student’s  learning,  etc.).     With  regard  to  the  main  study  aim,  the  following  working  definition  of  “neglect  of   care”  was  proposed:  instances  when  staff  failed  to  provide  appropriate  care  or  provided   care  in  an  unprofessional  or  unethical  manner.  For  the  purpose  of  data  processing,  the   main  category  “neglect  of  care”  was  subdivided  into  three  categories:   •

physical  neglect:  providing  inadequate  or  unprofessional  care  (e.g.  hastiness  during   intervention  and  feeding),  



social/emotional  neglect:  insufficient  or  unprofessional  communication  (not  being   attentive,  lacking  empathy  and  compassion,  rude  and  unkind  behavior,  being   unwilling  to  listen),  



maltreatment:  instances  of  deliberate  hastiness  in  providing  care,  low  protection  of   intimacy,  hasty  feeding  which  causes  pain  and  humiliation,  etc.  

  The  students  wrote  their  reflections  on  two  separate  occasions  (14  students  in  January   and  12  students  in  February  2014)  on  their  last  day  of  the  2-­‐week  clinical  practice   (placement)  in  one  of  the  nursing  homes  in  Maribor.     Results   Altogether  26  student  reflections  on  critical  incidents  during  the  2-­‐week  clinical  practice   (placements)  were  obtained.  Of  these,  10  were  reflections  on  positive  and  16  on   negative  experiences  (events/situations).  With  regard  to  the  study  aims,  only  the  latter   (negative  experiences)  were  further  processed,  and  are  presented  and  discussed  here.     7

  1.    Instances  of  neglect  of  care  and  typical  contexts:   Of  the  16  recorded  student  experiences  of  neglect  of  care,  6  were  related  to  physical   neglect  (e.g.  when  administering  medications,  making  an  occupied  bed,  washing,   feeding,  toileting,  etc.),  12  to  social/emotional  neglect  (e.g.  when  administering   medications,  making  an  occupied  bed,  washing,  feeding,  getting  up  from  the  bed),  and  9   to  maltreatment  of  a  resident  (e.g.  when  making  an  occupied  bed,  administering   medications,  responding  to  residents‘  needs,  doing  personal  care;  washing,  etc.).  More   than  a  half  of  student  reflections,  however,  related  to  more  than  one  subcategory,  some   of  them  to  all  three.   2.  Students’  feelings:     The  following  are  most  common  students’  feelings  during  the  event  or  situation  —  the   student  was  /  had  a  feeling  of:   •

guilt  (because  of  possible  consequences  due  to  medical  error  and  because  of  being   forbidden  to  talk  about  the  error),    



disappointed,  sad  (because  of  poor  relationship,  unprofessional  communication  with   the  resident,  lack  of    empathy  shown  by  the  staff,  etc.  



indignation  (because  of  nurses’  inappropriate  behavior  (e.g.  humiliating  a  resident),  



pity  (for  the  resident  because  of  nurse’s  inappropriate  behavior),    



surprised,  shocked,  humiliated  (by  the  event/situation),  



agitated,  appalled  (because  she  found  the  event  unhuman  and  humiliating),  



worried  (because  of  staff  member’s  lack  of  knowledge  of  precautionary  measures),  



moved,  appalled,  terrified,  ashamed,  angry  (because  of  nurse’s  unprofessional   behavior).  

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  3.  Impact  and  meaning  of  event/situation:     In  their  reflections  and  comments,  students  demonstrated  an  awareness/understanding   of  the  following:   •

the  importance  of  being  attentive  when  doing  care  



the  importance  of  verbal  communication  and  the  need  for  good  human  relationships.   (Had  the  nurse  focused  her  attention  on  the  resident  and  not  on  herself,  this  incident   wouldn’t  have  happened.    There  should  be  more  verbal  &  nonverbal  communication   during  training.)  



the  importance  of  professionalism  in  nursing  (Nobody  deserves  this  kind  of  treatment.   There  should  be  disciplinary  measures  against  such  staff  members.)  



the  importance  of  being  human  and  not  hurt  people  with  our  actions  (I  will  never   hurt  a  resident  or  anybody  in  this  way  …  At  the  Faculty,  we  should  give  more   importance  to  relationship,  to  feel  what  is  right  and  what  is  not.)  



the  importance  of  feelings  and  doing  one’s  job  with  love  for  another  human  being   (We  should  prevent  suffering  and  offer  support  …)  



how  bad  relationships  within  a  nursing  team  affects  nurses‘  work  (I  learned  from  this   incident  that,  before  we  act,  we  should  first  think  about  consequences  for  those  who   suffer  most  and  need  help.)  



the  importance  of  putting  the  residents’  needs  first  »Now  I  respect  older  people  even   more  because  one  day,  I  might  be  in  their  place.  Only  now  I  know  why  people  resist  life   in  the  nursing  home.)  



how  these  (negative)  experiences  reflect  a  wider  problem  in  institutional  elderly   care  (Are  other  nurses  also  like  this?).  

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Based  on  the  above,  we  can  establish  that  the  three  aims  that  were  set  for  the  study   have  been  achieved.  As  regards  the  main  aim  (to  explore  students'  experiences  during   their  clinical  practice  in  an  institutional  elderly  care  setting  and  identify  key  areas  of   student  concern  arising  from  this  experience),  the  study  identified  several  areas  of   students’  concerns  such  as  inadequate  and  unprofessional  communication,  lack  of   empathy  and  respect  for  the  residents,  and  inadequate  compliance  with  standard   procedures  (e.g.  the  prevention  of  infections).  These  results  correspond,  to  a  large   degree,  with  the  findings  of  some  previous  research  on  the  quality  of  institutional   elderly  care  in  Slovenia  (Habjanič,  2009,  2011).   Also,  the  study  confirmed  the  value  of  critical  incident  analysis  as  a  pedagogical   tool  for  stimulating  reflection  in  nurse  education  and,  in  particular,  during  clinical   practice  (placements).  The  students’  reflections  on  critical  incidents  that  we  obtained   represent  a  convincing  argument  for  including  this  and  other  techniques  for  stimulating   reflection  in  clinical  training  of  future  nurses.  Not  lastly,  the  study  proved  its  usefulness   for  obtaining  relevant  data  and  information  about  day-­‐to-­‐day  realities  of  elderly  care  as   practiced  in  nursing  homes  around  the  country.     Conclusion   In  modern  societies  and  their  health  systems  we  cannot  think  of  the  work  of  nurses  (and   health  professionals  in  general)  without  using  higher-­‐level  thinking  processes,  such  as   reflection,  self-­‐awareness,  critical  thinking,  etc.  These,  as  we  know,  are  also  the   constituent  elements  of  education  for  reflective  practice,  which  is  now  considered  a  key   component  of  professional  nurse  education.  For  students,  future  nurses,  and  health   professionals,  the  skill/ability  to  engage  in  (critical)  reflection  represents  the  most   precious  educational  capital  that  a  higher  education  institution  can  provide.  This  does   10

not  mean  that  we  should  deny  the  role  of  theory  and  theoretical  knowledge  in  education   for  the  nursing  profession;  instead  it  means  a  change  in  the  way  theory  and  practice  are   represented  and  connected  in  the  nursing  curricula.  In  short,  it  means  less  attention  to   practicing  theory  and  more  attention  to  theorizing  practice.   We  began  this  paper  with  Wendel  Berry’s  (1987)  reference  to  humanity  as  “the   thing  being  made  in  a  university.”  Berry  continues  as  follows:   Given  the  current  influence  of  universities,  this  is  merely  inevitable.  But  what   universities,  at  least  the  public-­‐supported  ones,  are  mandated  to  make  or  to  help   to  make  is  human  beings  in  the  fullest  sense  of  those  words  —  not  just  trained   workers  or  knowledgeable  citizens  but  responsible  heirs  and  members  of  human   culture.     References   Berry,  W.  (1987).  The  Loss  of  the  University.  In:  Home  Economics.  New  York:  North  Point   Press.     Habjanic,  A.  (2009).  Quality  of  institutional  elderly  care  in  Slovenia.  Dissertation.  Oulun   Yliopisto,  Oulu,  2009.     Habjanič,  A.  (2011).  Zdravstvena  nega  v  domovih  za  starejše  z  vidika  stanovalcev,   sorodnikov  in  negovalnega  osebja  [Care  of  the  Elderly  from  the  Viewoint  of  the   Residents,  family  members  and  Nursing  Personnel].  Obzornik  zdravstvene  nege,  45(1),   39–47.     Hannigan  B.  (2001).  A  discussion  of  the  strengths  and  weaknesses  of  ‘reflection’  in   nursing  practice  and  education.  Journal  of  Clinical  Nursing,  10,  278-­‐283.       Kim,  H.S.  (1999).  Critical  reflective  inquiry  for  knowledge  development  in  nursing   practice.    Journal  of  Advanced  Nursing,  29  (5),  1205-­‐1212.     Mantzoukas,  S.  and  Jasper,  M.  A.  (  (2004).  Reflective  practice  and  daily  ward  reality:  a   covert  power  game.  Journal  of  Clinical  Nursing  13,  925–933.     Parker,  D.  L,  Webb,  J.  and  D'Souza,  B.  (1995).  The  value  of  critical  incident  analysis  as  an   educational  tool  and  its  relationship  to  experiential  learning.  Nurse  Education  Today,   15(2),  111-­‐6.   11

Prevolnik  Rupel,  V.  in  Ogorevc,  M.  (2011).  Quality  country  report  for  Slovenia  (Working   paper  No.  56).  Ljubljana:  Inštitut  za  ekonomska  raziskovanja.         Shulman,  L.  S.  (2005).  Pedagogies  of  Uncertainty.  Liberal  Education,  91  (2).  Available  at   http://www.aacu.org/publications-­‐research/periodicals/pedagogies-­‐uncertainty     Tripp,  D.  (1993).  Critical  Incidents  in  Teaching:  Developing  Professional  Judgement.   London:  Routledge.     Tuning  Educational  Structures  in  Europe,  Nursing  -­‐  Specific  Competences.  Available   from:  http://www.unideusto.org/tuningeu/competences/specific/nursing.html    

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