An Action Research Study into the Development of Nurses as Reflective Practitioners

Evolving from Didactic to Dialogic: How to Improve Faculty Development and Support Faculty Developers by Using Action Research

Problem: Since competency-based medical education has gained widespread acceptance to guide curricular reforms, faculty development has been regarded as an indispensable element to make these programs successful. Faculty developers have striven to design and deliver myriad of programs or workshops to better prepare faculty members for fulfilling their teaching roles. However, how faculty developers can improve workshop delivery by researching their teaching practices remains underexplored. Intervention: Action research aims to understand real world practices and advocates for formulation of doable plans through cycles of investigations, and ultimately contributes to claims of knowledge and a progression toward the goal of practice improvement. This methodology aligns with the aim of this study to understand how I could improve a faculty development workshop by researching my teaching practices. Context: In 2016, we conducted four cycles of action research in the context of mini-Clinical Evaluation Exercise (mini-CEX) workshops within a faculty development program aiming for developing teaching and assessment competence in faculty members. We collected multiple sources of qualitative data for thematic analysis, including my reflective journal, field notes taken by a researcher-observer, and post-workshop written reflection and feedback in portfolio from fourteen workshop attendees aiming to develop faculty teaching and assessment competence. Impact: By doing action research, I scrutinized each step as an opportunity for change, enacted adaptive practice and reflection on my teaching practices, and formulated action plans to transform a workshop design through each cycle. In so doing, my workshop evolved from didactic to dialogic with continuous improvement on enhanced engagement, focused discussion and participant empowerment through a collaborative inquiry into feedback practice. Moreover, these processes of action research also supported my growth as a faculty developer. Lessons Learned: The systematic approach of action research serves as a vehicle to enable faculty developers to investigate individual teaching practices as a self-reflective inquiry, to examine, rectify, and transform processes of program delivery, and ultimately introduce themselves as agents for change and improvement.

Development of an existential support training program for healthcare professionals

Objective:

Our aim was to describe the developmental process of a training program for nurses to communicate existential issues with severely ill patients.

Method:

The Medical Research Council (MRC) framework for the development and evaluation of complex interventions was used to develop a training program for nurses to communicate about existential issues with their patients. The steps in the framework were employed to describe the development of the training intervention, and the development, feasibility and piloting, evaluation, and implementation phases. The development and feasibility phases are described in the Methods section. The evaluation and implementation phases are described in the Results section.

Results:

In the evaluation phase, the effectiveness of the intervention was shown as nurses' confidence in communication increased after training. The understanding of the change process was considered to be that the nurses could describe their way of communicating in terms of prerequisites, process, and content. Some efforts have been made to implement the training intervention, but these require further elaboration.

Significance of results:

Existential and spiritual issues are very important to severely ill patients, and healthcare professionals need to be attentive to such questions. It is important that professionals be properly prepared when patients need this communication. An evidence-based training intervention could provide such preparation. Healthcare staff were able to identify situations where existential issues were apparent, and they reported that their confidence in communication about existential issues increased after attending a short-term training program that included reflection. In order to design a program that should be permanently implemented, more knowledge is needed of patients' perceptions of the quality of the healthcare staff's existential support.

Web-based apps for reflection: a longitudinal study with hospital staff

BACKGROUND

Reflection is an important cognitive process in workplace learning; however, it occurs only rarely on its own and therefore needs additional support.

OBJECTIVE

In this study, we investigated the effect of software applications (apps) that aim to support reflection on hospital staff's actual reflection behavior. In doing so, we also analyzed the relationship between reflection and the job satisfaction of health care professionals.

METHODS

Reflective learning was introduced in the ward of a neurological hospital by providing apps that aimed to foster particular aspects of individual and collaborative reflection. Data were collected repeatedly: once before the introduction of the apps and again 2 years after the initial measure. We used a questionnaire with subjective ratings of reflection and job satisfaction. Response rates were 34.4% (167/485) for the first and 40.6% (210/517) for the second measure.

RESULTS

Collaborative reflection was increased (P=.047) after the provision of the apps (2010: mean 2.84, SD 0.72; 2012: mean 3.06, SD 0.63) in contrast to a control group of other wards of the same hospital (2010: mean 2.68, SD 0.67; 2012: mean 2.63, SD 0.68). In addition, we revealed a positive correlation between collaborative reflection and job satisfaction (r=.61, P<.001).

CONCLUSIONS

The findings provide evidence for an effect of the apps on hospital employees' reflection behavior. Apps that foster reflective learning can increase health care professionals' reflection about work experiences and support them in discussing experiences in teams or with their supervisors. The relationship between collaborative reflection and job satisfaction suggests that opportunities for joint reflection on work experiences in a hospital have further impact over and above fostering reflective learning per se. We discuss the limitations of our study and provide suggestions for both future research and the development of Web-based apps.

The development and implementation of a hospital based paediatric orthopaedic nursing transition program

Within Australia and the rest of the world paediatric orthopaedic nursing as a subspeciality nursing workforce faces challenges due to a lack of formal education programs that support the development of knowledge. Despite these challenges the need to ensure the availability of competent and knowledgeable nursing staff to positively contribute to health care outcomes remains unchanged. Thus a need has arisen to develop locally implemented education programs. A multi-tiered paediatric orthopaedic nursing transition program which incorporates work based learning processes combined, with formal assessment components, has been designed utilising Benner's "theory of novice to expert" to facilitate the growth of experts in the clinical setting driven by the requirements of individual clinical settings. The implementation of this program has led to increased confidence in the clinical setting for nursing staff which has positively influenced the care of children and their families in the orthopaedic service.

Development and validation of reflective inventories: assisting radiation therapists with reflective practice

Objective:Freeform reflective writing is one way that radiation therapists can document their development. Barriers to this form of writing include the fact that some radiation therapists do not know what to write or how to begin this writing process. This paper outlines the development and validation of guided inventories called the Newcastle Reflective Inventories and the validation of the Newcastle Reflective Analysis Tool as an effective tool for assessing short-form guided reflective writing.

Method:The Newcastle Reflective Inventories consist of a series of questions that guides the user through the reflective writing process. Validation of the Newcastle Reflective Inventories involved comparing the evidence of reflection in 14 freeform journals to that of 14 inventories completed on the same topic. Validation of the Newcastle Reflective Analysis Tool included the assessment of 30 Newcastle Reflective Inventories.

Results:There was a highly statistically significant difference (p< 0.001) in the high levels of reflection evident in the inventories when compared to the lower levels of reflection in the freeform journals. Good levels of agreement were achieved between the coders.

Discussion:These results show that the Newcastle Reflective Inventories are effective tools in promoting reflective writing when compared with freeform journaling.

Evaluating nurses' knowledge, attitude and competency after an education programme on suicide prevention

The aim of this study was to evaluate an education programme on suicide prevention for nurses working in general hospitals. A mixed method design that included a single group pretest-posttest analysis and focus group interviews was used. A convenient sample of 54 registered nurses was recruited from the medical and surgical units of two regional general hospitals. An 18-hour education programme on suicide prevention based on reflective learning principles was provided to the participants. The outcome measures used included participants' attitudes towards, knowledge of, competence in and stress levels arising from suicide prevention and management. Eighteen participants joined the focus group interviews. There were statistically significant positive changes in the pre- and post-test measures of participants' attitudes and competence levels. Qualitative data showed that participants had applied the new knowledge they acquired in clinical practice. They perceived themselves as being more aware of the problem of suicide and more competent in managing suicide risk. Participants highlighted certain barriers that exist to providing optimal care, including inadequate manpower, lack of support from senior staff and a lack of guidelines. Ongoing education may be necessary to expedite changes. The education programme provided can be delivered to other health care professional groups and the results further evaluated.

How reflective practice improves nurses' critical thinking ability

Purposeful reflection is consistent with adult learning theory. It is known to lead to a deeper understanding of issues and to develop judgment and skill. Required by law to ensure members' competence in their professional practice, the College of Nurses of Ontario recommends and has developed a tool for evaluating reflective practice. The tool focuses on key attributes said to be demonstrated by competent practitioners, including critical thinking (CT) and job knowledge. This study aimed to determine whether nurses engage in reflective practice and whether they perceive that it enhances their CT ability. Surveys were sent to 60 gastroenterology nurses at a large teaching hospital; 34 surveys were anonymously returned. All respondents engaged in reflective practice, and 24 reported using the college's tool. Nineteen respondents strongly agreed that their nursing practice had improved as a result. Critical thinking is difficult to assess because of a lack of clear-cut performance criteria. Improvement of CT was difficult to evaluate from the responses, even though all respondents participated in reflective practice. Both CT and reflective practice need to be better defined in order to examine and explain their relationship.

The use of reflective journals in the promotion of reflection and learning in post-registration nursing students

The aim of this qualitative case study was to examine the use of reflective journals in promoting reflection and learning in post-registration nursing students. A purposive homogenous sample of 42 part-time post-registration students who had undertaken a module either as part of the Diploma in Professional Studies in Palliative Care or Breast Care Nursing within a UK University took part in the study. Data were collected from reflective journals and interviews. The students' journals were analysed to determine the extent and level of reflection using a model devised by Boud [Boud, D., Keogh, R., Walker, D. (Eds.), 1985. Reflection: Turning Experience into Learning. Kogan Page, London] and adapted by Wong [Wong, F.K.Y., Kember, D., Chung, L.Y.F., Yan, L., 1995. Assessing the levels of student reflection from reflective journals. Journal of Advanced Nursing 22, 48-57]. A model devised by Mezirow [Mezirow, J., 1990. How critical reflection triggers transformative learning. In: Mezirow, J. et al. (Eds.), Fostering Critical Reflection in Adulthood: A Guide to Transformative and Emancipatory Learning. Jossey-Bass, San Francisco, pp. 1-20; Mezirow, J., 1991. Transformative Dimensions of Adult Learning. Jossey-Bass, San Franscisco] was used to identify non-reflectors, reflectors and critical reflectors. The findings suggest that student writing can be used as evidence for the presence or absence of reflective thinking. Evidence also suggests that journals are a useful tool for promoting reflection and learning. However, some students appear to benefit more from their use than others.

Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self-regulated learning theory

BACKGROUND

Effective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skills. While a number of strategies have been implemented and tested to promote these skills, educators have not been able consistently to predict their development. Self-regulated learning theory suggests that this development requires concurrent attention to both the cognitive and metacognitive dimensions of reasoning in nursing care contexts.

AIMS

This paper reports on a study to explore the impact of self-regulated learning theory on reflective practice in nursing, and to advance the idea that both cognitive and metacognitive skills support the development of clinical reasoning skills.

METHODS

Integrative review of published literature in social science, educational psychology, nursing education, and professional education using the Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resource Information Center (ERIC), and American Psychological Association (PsychInfo) Databases. The search included all English language articles with the key words clinical reasoning, cognition, critical thinking, metacognition, reflection, reflective practice, self-regulation and thinking.

FINDINGS

Reflective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skill acquisition. This skill acquisition is best accomplished through teaching-learning attention to self-regulation learning theory. A critical analysis of the literature in the areas of critical thinking and reflective practice are described as a background for contemporary work with self-regulated learning theory. It is apparent that single-minded attention to critical thinking, without attention to the influence of metacognition or reflection, is but one perspective on clinical reasoning development. Likewise, single-minded attention to metacognition or reflection, without attention to the influence of critical thinking, is another perspective on clinical reasoning development. While strategies to facilitate critical thinking and reflective practice have been used in isolation from each other, there is evidence to suggest that they are inextricably linked and come together with the use of self-regulated learning prompts.

CONCLUSIONS

Students and practising nurses are able to improve their cognitive and metacognitive skills in clinical contexts by using self-regulated learning strategies. The self-regulated learning model in nursing is offered to support teaching and learning of reflective clinical reasoning in nursing practice contexts.

Nursing Reflections from Journaling During a Perioperative Internship

AN IMPORTANT CONCERN in nursing practice and education is the difficulties nurses experience as they transition into a new clinical area. THIS STUDY compared the reflective journals of 26 experienced and inexperienced nurses participating in a nine-week perioperative internship. THE STUDY examined self-regulated learning strategies used to enhance metacognitive critical thinking abilities.

Reflective Practice: A Critical Analysis of Data-Based Studies and Implications for Nursing Education

Reflective practice has become part of the discourse of nursing education classrooms, conferences, and journals, and are popular features of nursing continuing education programs. Yet, the idea of reflective practice has become increasingly more disparate. This critical analysis examines data-based studies and provides an overview of reflective practice, discusses common themes that emerged from the studies, and identifies implications for reflective practice in the field of nursing education.

Unravelling the unknowns of reflection in classroom teaching

BACKGROUND

The use of reflection in education has emerged as an effective means of connecting theory with practice. However, the literature reveals limited empirical work on the conceptualization of reflection.

AIM OF THE STUDY

The purpose of this qualitative research study was to understand more fully the meaning and use of reflection in teaching, and how reflection contributes to the development of teaching expertise in the classroom. Ethical approval. The study received ethical approval from the Faculty of Nursing Ethical Review Committee, University of Manitoba. Issues related to confidentiality of information, and power relationships between the investigators were addressed. Students were reassured that no data were collected about them during participant observations in the classrooms.

METHODS

The investigators were the sources of data. Data were collected using five different methods over the course of two academic years, including written autobiographies, critical incident journals, classroom observations, debriefing following classroom observations and research team meetings.

FINDINGS

The data were analysed using content analysis, and four themes were identified (i) making connections, (ii) developmental aspects, (iii) influence of context on reflection, and (iv) influence of emotions on reflection. Study limitations. The interpretation of the findings of this study should be used with caution given the qualitative design and small number of participants.

CONCLUSION

Participation in the study increased the awareness of the investigators' personal use of reflection. The process of studying our own use of reflection allowed us to step outside the performance treadmill to better understand, accept and reshape what we do over and over in the classroom. This study supports an examination of one's experiences as a means of understanding reflection and its use in the classroom.

Enhancing Metacognition Through the Reflective Use of Self-Regulated Learning Strategies

BACKGROUND

An important concern of nursing practice and education is the difficulty new graduates experience while making the transition from graduate nurse to practicing nurse.

METHOD

Using a comparative descriptive design, self-regulated learning strategies were used to enhance metacognitive critical thinking abilities as 32 new graduate nurses reflected during 8-week preceptorship programs.

RESULTS

Verbal protocol analysis revealed the majority of noun referents as metacognitive with thinking nouns increasing in rank from Week 1 to Week 8, present tense verbs were used most frequently with lower-level thinking phrases. Common themes in the narrative were knowledge observation, thinking strategies, judgments of self-improvement, judgments of competence, judgments of resources, self-reactions, and self-correction strategies.

CONCLUSIONS

New graduate nurses have unique circumstances to overcome in making a transition to the workplace, and having self-regulatory skills would enable this process. The data suggest nursing education and practice consider self-regulated learning prompts with new graduates to promote thinking strategies.

The use of reflection in a palliative care programme: a quantitative study of the development of reflective skills over an academic year

The use of reflection in a palliative care programme: a quantitative study of the development of reflective skills over an academic year Reflection has gained a reputation for encouraging the integration between theory and practice within professional education. However, this reputation is based on an evidence base that mostly consists of theoretical debate. The aim of this study was to test our experience that the ability to reflect is developmental and that some reflective skills are harder to achieve than others. The research was undertaken by assessing the degree to which registered nurses achieved reflective criteria within assignments submitted for a variety of palliative care undergraduate modules. A total of 160 assignments were analysed using a marking grid constructed from a literature review and the results were compared between students and across academic terms. The results suggest that students are able to describe their practice but find it harder to analyse knowledge, the context of care and to action plan. Nevertheless, reflective abilities developed over time with significant developments made between each term. However, the development of skills indicative of critical reflection was less evident and confined to the ability to raise implications for future learning. The lack of multivariate analysis limits the study. However, the findings build on previous research and prompt questions for future work, particularly with respect to the process of reflection and how this can be supported in order to encourage the development of critical reflective skills.

A phenomenological study of early nursing experiences in Hong Kong

The experience of primary professional socialization is crucial for neophytes to learn to become a nurse. These early nursing encounters may also have long-term effects on professional development of individual nurses. However, research into the early experiences of nurses has been poorly documented. This study endeavours to reveal the early lived nursing experience amongst a group of nurses in Hong Kong. This study adopts a phenomenological approach which involves the thematic analysis of the critical incidents provided by 77 subjects. Findings revealed that incidents associated with death and dying, and clinical learning embracing interpersonal relations and professional development, were the most memorable events. Nurses were in general not equipped adequately to communicate with the dying and the grieving relatives. The subjects disclosed that positive clinical encounters confirmed their value of nursing work and motivated them to stay in the profession. Conversely, the negative experiences made them seriously consider leaving nursing. A number of implications for nursing education have been drawn from the research findings.