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),
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social/emotional neglect: insufficient or unprofessional communication (not being attentive, lacking empathy and compassion, rude and unkind behavior, being unwilling to listen),
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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),
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disappointed, sad (because of poor relationship, unprofessional communication with the resident, lack of empathy shown by the staff, etc.
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indignation (because of nurses’ inappropriate behavior (e.g. humiliating a resident),
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pity (for the resident because of nurse’s inappropriate behavior),
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surprised, shocked, humiliated (by the event/situation),
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agitated, appalled (because she found the event unhuman and humiliating),
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worried (because of staff member’s lack of knowledge of precautionary measures),
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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
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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.)
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the importance of professionalism in nursing (Nobody deserves this kind of treatment. There should be disciplinary measures against such staff members.)
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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.)
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the importance of feelings and doing one’s job with love for another human being (We should prevent suffering and offer support …)
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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.)
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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.)
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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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