Developing critical reflection for professional practice through problem-based learning

AIMS: To explore the influence of current learning traditions in nursing on the development of reflection and critical reflection as professional practice skills and to offer suggestions for nursing education that will specifically facilitate the development of critical reflection. ORGANIZATIONAL CONSTRUCTS: Mezirow's transformative learning theory, Barrows conceptualization of problem-based learning (PBL). METHODS: Integrative literature review of published literature related to nursing, health science education and professional education from 1983-2000. FINDINGS: Professional education scholars concur that specialized knowledge is clearly essential for professional practice, however, they also suggest that self-consciousness (reflection) and continual self-critique (critical reflection) are crucial to continued competence. While strategies to facilitate reflection have been outlined in the literature, specific strategies to facilitate the development of critical reflection and implications for nursing education are much less clear. Advocates of reflective and critically reflective practice suggest that the development of these abilities should be inextricably linked to professional development and can be developed through active repeated guided practice. In health care, PBL based on constructivism, has been identified as one way to facilitate the development of these skills. CONCLUSIONS: Nursing learners exposed to PBL develop the ability to be reflective and critically reflective in their learning and acquire the knowledge and skill within the discipline of nursing by encountering key professional practice situations as the stimulus and focus of their classroom learning. The learners' ability to be both reflective and critically reflective in their learning is developed by critical questioning of the faculty tutor during situational analysis, learning need determination, application of knowledge, critique of resources and personal problem-solving processes, and summarization of what was learned.     

A descriptive survey to identify the perceived skills and community skill requirements of mental health staff

Throughout the 1990s mental health care has shifted from a hospital to a community-based service. Government policy indicates that staff require further education as a result of the shift to community care. However, none of the United Kingdom policy documents or mental health literature prescribes what education is required. Consequently this multidisciplinary study aimed to identify what skills, if any, were required by hospital-based staff to move to a community-based working environment. Study findings suggest advantages in perceiving skills as overlapping and interconnecting. Five common core skills and skill differences between professional groups are identified. It is argued that core skills are central and common to all groups and specialist skills are those that distinguish professional groups one from another and different grades of staff within professional groups. While problems of multidisciplinary education are considered, nevertheless a case is made for educating staff in core skills within a multidisciplinary environment which may be beneficial in achieving community care goals.     

Assessment of the quality and applicability of an e-portfolio capstone assessment item within a bachelor of midwifery program

Education programs leading to professional licencing need to ensure assessments throughout the program are constructively aligned and mapped to the specific professional expectations. Within the final year of an undergraduate degree, a student is required to transform and prepare for professional practice. Establishing assessment items that are authentic and able to reflect this transformation is a challenge for universities. This paper both describes the considerations around the design of a capstone assessment and evaluates, from an academics perspective, the quality and applicability of an e-portfolio as a capstone assessment item for undergraduate courses leading to a professional qualification. The e-portfolio was seen to meet nine quality indicators for assessment. Academics evaluated the e-portfolio as an authentic assessment item that would engage the students and provide them with a platform for ongoing professional development and lifelong learning. The processes of reflection on strengths, weaknesses, opportunities and threats, comparison of clinical experiences with national statistics, preparation of professional philosophy and development of a curriculum vitae, whilst recognised as comprehensive and challenging were seen as highly valuable to the student transforming into the profession.     

Is there a place for reflective practice in the nursing curriculum?

Within this paper a review of the literature on the area of reflection and reflective practice is presented. Lecturers at Trinity College Dublin currently face a dilemma with regard to including these concepts in the nursing curricula. They are faced on the one hand with national recommendations for the use of reflection and reflective practice, and on the other with personal and professional concerns about the practical, legal, ethical and moral implications raised in teaching and assessing this subject. The literature reveals that there is little consensus of opinion regarding the exact nature of reflection. There is also little empirical evidence to support the benefits of teaching and assessing of reflection or reflective practice from either an educational or clinical perspective. This, together with the practical difficulties of teaching and assessing reflection, may negate against the incorporation of reflection and reflective practice into the nursing curriculum. It is suggested that, rather than isolate reflection as a distinct topic, that the skills of critical thinking, problem-solving, self-awareness and analysis be developed within the curriculum.     

Empathy,emotional intelligence and interprofessional skills in healthcare education

According to the World Health Organization (WHO), health professionals maintain the health of citizens through evidence-based medicine and caring. Students enroled in health professional programmes are required to have successfully attained all core learning outcomes by reaching key milestones throughout the course of their studies, demonstrating they have developed the required graduate skills and attributes upon completion of the programme. While some of the knowledge, skills and competencies that make up these learning outcomes are very discipline specific, there are more general professional skills across all disciplines which are difficult to define, such as empathy, emotional intelligence and interprofessional skills. These are at the heart of all health professional programmes that once defined, can be mapped through curricula and further evaluated.Literature will be presented on these three professional skills: empathy, emotional intelligence, and interprofessional skills, based on studies that focussed primarily in health professional programmes and highlight some of the key findings and issues at undergraduate and postgraduate levels. The paper will present the need for these skills to be defined and then mapped through curricula so that students are better supported in their professional development. Empathy, emotional intelligence and interprofessional skills transcend the discipline specific skills and as such it is important that all educators consider how best these may be fostered. Efforts should also be made to further the integration of these professional skills within curricula to produce health professionals with an enhanced focus on person-centred care.     

Closing the gap: collaborative learning as a strategy to embed evidence within occupational therapy practice

RATIONALE: The principles of clinical governance apply as guidelines for good practice to all practitioners. However, evidence-based practice (EBP) is proving a challenge for practitioners who lack the confidence to consume published research. For therapists not wishing to undertake formal study there is a risk of becoming disempowered within a culture of EBP. Opportunities to develop skills in consuming research have focused on the information dissemination model that has limited effect. Mutual reflective learning processes are recommended to empower practitioners to bridge the theory-practice gap. AIM: An action research approach investigated practice based collaborative learning as a catalyst to increase therapist's competence and confidence in consuming research and to explore the transition toward EB practitioner. METHOD AND RESULTS: A diagnostic survey reaffirmed therapist's lack of confidence in EBP. Formative interviews (n = 5) found an over reliance on professional craft and personal knowledge. Research knowledge was not included in participants' construct of a good practitioner and engagement in higher order critical reflection was limited. Collaborative learning groups (n = 6) embedded in practice integrated research, theory, practice and critical reflection. Supported by the collegial learning environment, a learning package developed participants' confidence and competence in consuming published research. Summative interviews (n = 5) evaluated the group and found that therapists were empowered to incorporate propositional knowledge into their clinical reasoning, engage in critical reflection and challenge their practice. They felt confident to incorporate EBP into their continuing professional development plans. Sustainability of these changes requires commitment from the therapists and the workplace.     

A new perspective on competencies for self-directed learning

In baccalaureate in nursing programs, self-directed methods of education have been used for many decades. A major goal of this type of approach to education is to provide students with the necessary competencies to become lifelong learners. Students must be exposed to self-directed learning competencies to obtain the knowledge, skills, and attributes unique to their personal and professional growth. It has been proposed that six competencies are required for students to become self-directed learners: self-assessment of learning gaps; evaluation of self and others; reflection; information management; critical thinking; and critical appraisal. Each of these skills are not mutually exclusive but are interrelated in such a way that students use all or a combination of them simultaneously to direct and control their learning.     

Practical concerns of educators assessing reflections of physiotherapy students

Abstract

Background: Reflection has become an accepted element of physiotherapy education. Reflection is a cognitive, emotional, and embodied activity that remains largely invisible as individuals undertake their professional work. The use of reflection has been related to a number of positive benefits for practitioners such as to develop their capacity for self-assessment and critique, to challenge their existing knowledge base, to engage in lifelong learning, to make sense of their experiences, and to improve decision making.

Objectives: Although there is an extensive debate in the wider reflection literature about assessing reflection, this has yet to be applied to physiotherapy and developed as a discourse held by the members of the profession.

Major findings: The current body of physiotherapy literature does not offer educators realistic tools to deal with the practical concerns and hands-on educational decisions they face when assessing reflection. The findings from physiotherapy research investigating how reflection is practiced and assessed in physiotherapy implies a need to engage in a dialogue as a profession about teaching and assessing reflective practice.

Conclusion: This paper concludes that the assessment of reflection is complex and difficult and explains the practical concerns of educators. Physiotherapy educators are faced with rethinking how reflection is assessed to carefully consider the intentions of reflection in their assessment design and the impact of assessment on how reflection is learnt and practiced.     

The management of depressed elderly care recipients: family perspectives on the skills of professional carers

Recent studies have identified high levels of depression among older people, both those in their own homes and those in residential care. With the world's population ageing, it is timely for health service providers to consider how the escalating population of depressed elderly people will be managed. Although treating general practitioners may be the health professionals most expected to detect, treat, and monitor depression among the elderly, professional carers are well placed to assist in the detection and monitoring of the disorder. This study conducted individual interviews with 15 family members of depressed aged-care recipients to determine their perceptions of the skills and knowledge of depression of professional carers. Family members reported that carers are more likely to avoid than engage with their clients about depressive symptomatology and do not communicate their concerns with managers or general practitioners (GPs). Family members believed that, in general, professional carers were undertrained in these areas. The implications of these findings for health service planning and staff training are discussed.     

Leadership as part of the nurse consultant role: banging the drum for patient care

Aims and objectives. This paper draws upon an evaluation of the first group of nurse consultants in Scotland. The evaluation aimed to identify the extent to which they fulfilled the remit of their posts which comprised four core functions. One of these functions was to provide professional leadership and this paper focuses on this element of the role and aims to explore it in relation to the attributes of transformational leadership. Background. Nurse consultants were introduced in the UK in 2000. Their purpose was to achieve better outcomes for patients and strengthen leadership. Nursing research identifies leadership as a key element of the role, with postholders adopting transformational leadership approaches. Research from the fields of sociology and psychology identifies difficulties in formulating a coherent theory of leadership, arguing for better understanding of leadership processes. Design. Qualitative. Methods. This paper draws on 31 semi‐structured interviews with four nurse consultants who were interviewed twice over six to nine months and 23 other ‘stakeholders’ who worked with them. Results. Varied leadership activity at ward, NHS Trust and strategic levels was identified. Postholders used approaches that resonated with the attributes of transformational leadership. Leadership processes included developing a vision for the service, acting as mediator and champion, and exerting control over complex change initiatives. Techniques of leadership included taking a ‘softly softly’ approach, pacing change initiatives and arguing assertively with those in senior positions. Interview findings also identified the level of preparation that was required to meet the remit of the posts, highlighting the importance of interpersonal skills and intellectual effort in achieving outcomes. Conclusions. Nurse consultants require considerable technical expertise, cognitive and interpersonal skills, and the ability to take risks. The data suggest that the leadership attributes required are transformational in nature but that they also exceed those identified in much of the literature. These posts require appropriate support if they are to be sustainable. Relevance to clinical practice. This paper adds to our understanding of the complexity of the nurse consultant role and highlights the challenge of providing appropriate professional development for postholders.     

The benefits of a ward simulation exercise as a learning experience

This article describes the findings from a pilot study undertaken to identify the potential benefits of a ward simulation exercise in developing the capabilities of newly qualified nurses. Eight newly qualified nurses were recruited to participate in this pilot study which was based in the Clinical Skills Centre, Ninewells Hospital, Dundee. This pilot study was performed in conjunction with NHS Tayside Practice Education Facilitators and the University of Dundee. Data collection methods involved reflective learning logs which were reviewed independently by an expert group of teachers and practitioners. A focus group session was also undertaken to understand the lived experience of the newly qualified nurse during the ward simulation exercise. Core themes (listed in order of importance) related to the professional development of newly qualified nurses that were identified through this pilot study were: an increase in confidence, development of stress management skills, improved management of the acutely unwell patient, the transfer of skills learnt in simulation to the clinical setting, development of communication skills and reflection skills. Participants in this pilot study demonstrated increased levels of confidence in their communication skills, their ability to prioritize care and to engage in collaborative teamworking.     

The Management of Depressed Elderly Care Recipients: Family Perspectives on the Skills of Professional Carers

Recent studies have identified high levels of depression among older people, both those in their own homes and those in residential care. With the world's population ageing, it is timely for health service providers to consider how the escalating population of depressed elderly people will be managed. Although treating general practitioners may be the health professionals most expected to detect, treat, and monitor depression among the elderly, professional carers are well placed to assist in the detection and monitoring of the disorder. This study conducted individual interviews with 15 family members of depressed aged-care recipients to determine their perceptions of the skills and knowledge of depression of professional carers. Family members reported that carers are more likely to avoid than engage with their clients about depressive symptomatology and do not communicate their concerns with managers or general practitioners (GPs). Family members believed that, in general, professional carers were undertrained in these areas. The implications of these findings for health service planning and staff training are discussed.     

Evaluation of the clinical supervision and professional development of student nurses

severinsson e. & sand å. (2010) Journal of Nursing Management  18, 669–677
Evaluation of the clinical supervision and professional development of student nurses Aim The aim of the present study was to evaluate the clinical supervision and professional development of student nurses during their undergraduate education. Background Nursing education has undergone radical changes as a result of improvements in the academic-based clinical education required for the Bachelor’s degree. Methods The sample consisted of student nurses (n = 147) and data were collected by means of questionnaires. Results The results demonstrated that the frequency of sessions and the supervision model employed influence the student nurses’ professional development. Several significant correlations were found, most of which were related to the development of the student nurses’ professional relationships with their supervisors and reflection on the development of their skills. From the patients’ perspective, a high correlation was found between the factors ‘preserving integrity’ and ‘protecting participation by patients and family members’. Conclusions Clinical supervision strongly influences the student nurses’ development of a professional identity, enhancing decision-making ability and personal growth. However, development of documentation skills should include a greater level of user involvement. Implications for nursing management The findings highlight the need for management and staff nurses to engage in on-going professional development. Transformative leadership, which is value driven, can facilitate and enhance the supervision and development of student nurses.     

Barriers to learning from reflection: a study of the use of groupwork with post-registration nurses

There are few studies which describe the use of groups to facilitate reflection and even fewer which evaluate the effectiveness of such groups. Much of the literature discussing the techniques used to facilitate reflection suggests that learners willingly engage in such processes and find them enjoyable. This paper reports on a qualitative study of the use of groups to develop learning through reflection on a part-time post-registration diploma programme for nurses. The findings suggest that there are many barriers to learning which must be overcome before practitioners can use the opportunities to reflect on and learn from their experience. It is also contended that such learning may not necessarily be an enjoyable experience. The findings suggest that previous educational experience and the current culture in which nurses and midwives work, impose tremendous barriers to reflecting on, and learning from, experience. In particular these affect the willingness of learners to expose themselves to the judgement of others and their ability to be open to taking responsibility for their own learning. Other barriers to learning in groups are the effects of other group members, their commitment or resistance to shared learning, the ways in which group members interact with each other and facilitation styles.     

The establishment of a nurse consultant role in paediatric intensive care: a reflective analysis

Through a review of literature and research, together with reflection on clinical practice, this article reflectively analyses and evaluates the concept of the establishment and development of a nurse consultant post in paediatric intensive care. Manley's (1997) conceptual framework is used as a structure for the reflection, which has enabled a detailed and logical approach and allowed both reflection and analysis of the role in relation to the speciality. It is evident that nurse consultant posts have been developed in a variety of clinical specialities and are providing a real opportunity to improve patient care, progress nursing as a profession and provide a clinical career framework for nurses. The concept of the nurse consultant in paediatric intensive care is both innovative and strategic: Manley has identified many sub-roles, skills and processes necessary to influence and develop the role. The elements of 'transformational leadership', 'change agent' and 'collaborator' identified by Manley appear to hold the key to the ability to influence and develop paediatric intensive care nursing from a practice perspective.     

Transforming Preprofessional Health Education Through Relationship-Centered Care and Narrative Medicine

Issue: The Institute of Medicine identified health care education reform as a key to improving the error prone, costly, and unsatisfying U.S. health care system. It called for health care education that no longer focuses exclusively on the mastery of technical skills but teaches students the human dimensions of care and develops their ability to collaborate with patients and colleagues to alleviate suffering and improve health. When should this educational reform begin, by what frameworks should it be guided, and which methods should it employ are important questions to explore. Evidence: There is increasing evidence that practitioners' relational skills, such as empathy and reflection, improve patients' health outcomes. Efforts to shift education toward patient-centered care in interprofessional teams have been made at the professional level, most notably in medical schools. However, reform must begin at the preprofessional level, to start cultivation of the habits that support humane care as early as possible and protect against empathic decline and the development of counterproductive attitudes to collaboration. The conceptual basis for reform is offered by relationship-centered care (RCC), a framework that goes beyond patient-centered care and interprofessional teamwork to focus on the reciprocal human interactions at the micro, mezzo, and macro levels of care. RCC identifies practitioners' relationships with patients, colleagues, community, and self as the critical interpersonal dimensions of healthcare and describes a foundation of values, knowledge, and skills required for teaching each dimension. The teaching of these foundations can be facilitated with techniques from narrative medicine, a compatible care model that conceptualizes health care as a context in which humans exchange stories and thus require narrative competence. Implications: We suggest beginning the educational reform at the preprofessional level with the implementation of a formal curriculum based on the 4 RCC dimensions with students expected to gain beginner levels of competency on these dimensions in addition to evidence-based principles of health sciences. This requires interprofessional collaboration among health professions, social science, and liberal arts faculty and training of health professions faculty in narrative medicine. Next, we suggest engaging in incremental change in the organizational culture with professional development and team-building activities. Although we need systematic research on the efficacy of the components of the transformation, their impact on students' learning, and their costs, it is important to engage in efforts to prepare professionals who are able to respond to the complex health needs of individuals and society in the 21st century.     

Educating the reflective practitioner: graduates in practice

This paper draws on interview research exploring how recently graduated acupuncturists and homeopaths construct their professional identities, with a goal of assessing whether the processes and values developed in the program are carried forward into practice. The interviews were designed to engage the participants in telling stories about their work and were analyzed through discourse analysis. Although the two practitioners at the focus of this paper show considerable difference in the sophistication of their client management, both can be seen to use reflection to identify problems and find solutions in their work with clients.     

Competencies and skills for remote and rural maternity care: a review of the literature

AIM: This paper reports a review of the literature on skills, competencies and continuing professional development necessary for sustainable remote and rural maternity care. BACKGROUND: There is a general sense that maternity care providers in rural areas need specific skills and competencies. However, how these differ from generic skills and competencies is often unclear. METHODS: Approaches used to access the research studies included a comprehensive search in relevant electronic databases using relevant keywords (e.g. 'remote', 'midwifery', 'obstetrics', 'nurse-midwives', education', 'hospitals', 'skills', 'competencies', etc.). Experts were approached for (un-)published literature, and books and journals known to the authors were also used. Key journals were hand searched and references were followed up. The original search was conducted in 2004 and updated in 2006. FINDINGS: Little published literature exists on professional education, training or continuous professional development in maternity care in remote and rural settings. Although we found a large literature on competency, little was specific to competencies for rural practice or for maternity care. 'Hands-on' skills courses such as Advanced Life Support in Obstetrics and the Neonatal Resuscitation Programme increase confidence in practice, but no published evidence of effectiveness of such courses exists. CONCLUSION: Educators need to be aware of the barriers facing rural practitioners, and there is potential for increasing distant learning facilitated by videoconferencing or Internet access. They should also consider other assessment methods than portfolios. More research is needed on the levels of skills and competencies required for maternity care professionals practising in remote and rural areas.     

Delphi technique: identifying the generic competence required for doctors and nurses working in a primary health care

This study aims to identify the generic competence required of doctors and nurses working in a primary health care. It was based on a series of 3 round of the Delphi technique which identified 8 generic competencies: ability to communicate, ability to be community oriented, ability in teamwork, management skills, educational skills, ability to problem solving, professional skills, ability to make-decision. Only the competence management skills there was not consensus by doctors. They disagree that this competence is required by them working in primary health care.     

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.