Reflective education for professional practice: discovering knowledge from experience

Development and Validity of an Intrapartum Self-Assessment Scale Aimed at Instilling Midwife-Led Care Competencies Used at Freestanding Midwifery Units

Building experience in midwife-led care at freestanding midwifery units is needed to enhance assessment, technical, and care competencies specific to midwives. This study aimed to develop a self-assessment scale for midwifery practice competency based on the characteristics of midwife-led care practices in freestanding midwifery units. This study was conducted at 65 childbirth facilities in Japan between September 2017 and March 2018. The items on the scale were developed based on a literature review, discussion at a professional meeting, and a preliminary survey conducted at two timepoints. The validity and reproducibility of the scale were evaluated based on item analysis, compositional concept validity, internal consistency, stability, and criterion-related validity using data from 401 midwives. The final version of the scale consisted of 40 items. Cronbach's α for the overall scale was 0.982. The results for compositional concept validity, internal validity, and criterion-related validity demonstrated that this scale is capable of evaluating a midwife's practice competencies in intrapartum care. Repeated self-assessment using this scale could improve the competencies of midwives from an early stage, maximize the roles of physicians and midwives, and create an environment that provides high-quality assistance to women.

Nurses' perception of knowledge, attitudes and reported practice towards patients with eating disorders: A concurrent mixed-methods study

Eating disorders are complex disorders requiring specialised care, thus knowledge and attitudes are crucial for management. This study aims to examine nurses' knowledge, attitudes, reported practice, and perceptions towards patients with eating disorders in Singapore. A concurrent mixed-methods study was carried out in Southeast Asia's only psychiatric unit with eating disorders programme. Twenty nurses were recruited using census sampling. Quantitative data were analysed with descriptive and inferential statistics, while qualitative data were analysed with content and thematic analysis. Certain personal factors were associated with nurses' levels of perceived knowledge. Different attitudes towards managing these patients were identified during interview sessions.

Workplace culture and the practice experience of midwifery students: A meta-synthesis

AIM

To describe midwifery students' practice experience and to explore facilitators and barriers to positive clinical learning experiences.

BACKGROUND

Practice experience is a vital component of every midwifery course. Course dissatisfaction and attrition of midwifery students has been attributed to sub-optimal practice experiences. Events or actions experienced by midwifery students that trigger dissatisfaction and attrition need to be identified.

EVALUATION

A meta-synthesis was based on that developed by Noblit and Hare.

KEY ISSUES

Students perceive workplaces as poorly prepared for their arrival and subsequent support. Students' experience in the practice setting is influenced by the existing workplace culture. Workplace culture influences institutional functioning and individuals within the culture. Enculturation of students into the midwifery culture and subsequent learning is affected by the support received.

CONCLUSIONS

The practice experience of midwifery students was profoundly influenced by workplace culture. Students tended to have polarized accounts of their experience that were predominantly negative.

IMPLICATIONS FOR NURSING (MIDWIFERY) MANAGEMENT

To provide an optimal environment for midwifery students; midwifery managers and individual midwives need to be aware of the facilitators and barriers to midwifery student development in the practice setting.

Midwives' intrapartum monitoring process and management resulting in emergency referrals in Tanzania: a qualitative study

Background

In the United Republic of Tanzania, the maternal mortality ratio, and neonatal mortality rate have remained high for the last 10 years. It is well documented that many complications of pregnancy are avoidable by providing skilled midwifery care during and immediately after childbirth. However, there have been delays in providing timely and necessary obstetric interventions, most likely due to lack of proper monitoring during labor. Yet, there has been little research concerning how midwives monitor the process of childbirth. Therefore, this study aimed to describe how midwives monitored and managed the process of childbirth to achieve early consulting and timely referral to obstetricians.

Methods

The design was qualitative and descriptive, using data from comprehensive semi-structured interviews of midwives. The interviews were conducted at one hospital and one health center in Dar es Salaam, Tanzania’s largest city. Eleven participants were purposively recruited and interviewed about their experiences managing complicated intrapartum cases. After the interviews, data were analyzed using content analysis.

Results

Derived from the data were three activity phases: initial encounter, monitoring, and acting. During these phases, midwives noticed danger signs, identified problems, revised and confirmed initial problem identification, and organized for medical intervention or referral. The timing of taking action was different for each midwife and depended on the nature of the prolonged and obstructed labor case.

Conclusions

For the majority of midwives, the processing of assessments and judgments was brief and without reflection, and only a few midwives took time to continue to monitor the labor after the initial identification of problems and before taking actions. To make a final judgment that the labor was becoming prolonged or obstructed, midwives should consider taking time to review and synthesize all their findings.

Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review

Background

The increasing prevalence of chronic disease and even multiple chronic diseases faced by both developed and developing countries is of considerable concern. Many of the interventions to address this within primary healthcare settings are based on a chronic care model first developed by MacColl Institute for Healthcare Innovation at Group Health Cooperative.

Methods

This systematic literature review aimed to identify and synthesise international evidence on the effectiveness of elements that have been included in a chronic care model for improving healthcare practices and health outcomes within primary healthcare settings. The review broadens the work of other similar reviews by focusing on effectiveness of healthcare practice as well as health outcomes associated with implementing a chronic care model. In addition, relevant case series and case studies were also included.

Results

Of the 77 papers which met the inclusion criteria, all but two reported improvements to healthcare practice or health outcomes for people living with chronic disease. While the most commonly used elements of a chronic care model were self-management support and delivery system design, there were considerable variations between studies regarding what combination of elements were included as well as the way in which chronic care model elements were implemented. This meant that it was impossible to clearly identify any optimal combination of chronic care model elements that led to the reported improvements.

Conclusions

While the main argument for excluding papers reporting case studies and case series in systematic literature reviews is that they are not of sufficient quality or generalizability, we found that they provided a more detailed account of how various chronic care models were developed and implemented. In particular, these papers suggested that several factors including supporting reflective healthcare practice, sending clear messages about the importance of chronic disease care and ensuring that leaders support the implementation and sustainability of interventions may have been just as important as a chronic care model’s elements in contributing to the improvements in healthcare practice or health outcomes for people living with chronic disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0854-8) contains supplementary material, which is available to authorized users.

Satisfactory reliability among nursing students using the instrument PVC ASSESS to evaluate management of peripheral venous catheters

PURPOSE

Nursing students should be given opportunities to participate in clinical audits during their education. However, audit tools are seldom tested for reliability among nursing students. The aim of this study was to present reliability among nursing students using the instrument PVC assess to assess management of peripheral venous catheters (PVCs) and PVC-related signs of thrombophlebitis.

METHODS

PVC assess was used to assess 67 inserted PVCs in 60 patients at ten wards at a university hospital. One group of nursing students (n=4) assessed PVCs at the bedside (inter-rater reliability) and photographs of these PVCs were taken. Another group of students (n=3) assessed the PVCs in the photographs after 4 weeks (test-retest reliability). To determine reliability, proportion of agreement [P(A)] and Cohen's kappa coefficient (κ) were calculated.

RESULTS

For bedside assessment of PVCs, P(A) ranged from good to excellent (0.80-1.0) in 55% of the 26 PVC assess items that were tested. P(A) was poor (<0.70) for two items: "adherence of inner dressing to the skin" and "PVC location." In 81% of the items, κ was between moderate and almost perfect: moderate (n=5), substantial (n=3), almost perfect (n=5). For edema at insertion site and two items on PVC dressing, κ was fair (0.21-0.40). Regarding test-retest reliability, P(A) varied between good and excellent (0.81-1) in 85%-95% of the items, and the κ ranged between moderate and almost perfect (0.41-1) in 90%-95%.

CONCLUSIONS

PVC assess demonstrated satisfactory reliability among nursing students. However, students need training in how to use the instrument before assessing PVCs.

Encouraging reflection: Do professional development workshops increase the skill level and use of reflection in practice?

Reflection is a way of evaluating best practice and challenging existing norms, while at the same time, considering one’s personal values and assumptions in our personal and professional lives. However, many health practitioners may lack the skills to do this effectively. Through participation in a series of three workshops, practitioners in the Radiation Medicine Program at Princess Margaret Hospital have learned and acquired new skills to encourage reflection and reflective practice in themselves, their colleagues as well as with their students. A pre- and post-course survey was used to ascertain their level of knowledge of reflection and reflective practice. An additional survey at 3 months assessed the frequency of use and ongoing comfort level with reflective practice. Results of the evaluation indicate that the participants’ knowledge of reflective practice has improved their understanding of reflection in clincal practice. They recognize the importance of reflection and anticipate increasing their use of reflection in/on practice. As well, participants have been able to sustain the positive momentum 3 months after the course was delivered.

Midwifery students' demographic characteristics and the effect of clinical education on preparation for professional life in Turkey

This descriptive study was planned for the purpose of evaluating the effect of clinical education at Istanbul University Bakırköy School of Health, Midwifery Division, on the preparation of senior midwifery students for their professional lives. The sample comprised a total of 230 students in the final year of midwifery school who agreed to participate in the research during the academic years 2003-2004, 2004-2005, 2005-2006, and 2006-2007. Data was collected with a 27-item questionnaire prepared by the researcher. Percentages, Fischer and Chi-square tests were used in the data analysis. According to the research findings, the majority of the students had graduated from high school (78.7%) and lived together with their families (52.2%). The majority of the students thought that the choices for clinical areas were appropriate (51/3%), wanted the internship in their last year to continue (92.2%) and thought that having clinical education on night shifts was beneficial (77.4%). There were statistically significant differences in students' opinions about internship according to the Fisher and Chi-square tests. In addition, the students had positive opinions about the integrated clinical practice that was a significant part of their clinical education. Statistically significant differences were determined in their positive opinions according to the Chi square test (X(2) = 70; p < 0.001, DF = 6). The students stated that after graduation, they felt they were most prepared to be a ward midwife (80.9%), a ward head midwife (64.3%), and teacher (56.5%). Statistically significant differences were seen in the statements of the students about what they felt prepared to do after graduation according to the Chi square test (X(2) =227; p < 0.001, DF = 5). It was determined that the students included in the sample had positive opinions and experiences associated with clinical education and that they stated that they were prepared for the profession of midwifery.

The educational effects of portfolios on undergraduate student learning: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 11

INTRODUCTION

In recent years, the use of portfolios as learning and assessment tools has become more widespread across the range of health professions. Whilst a growing body of literature has accompanied these trends, there is no clear collated summary of the evidence for the educational effects of the use of portfolios in undergraduate education. This systematic review is the result of our work to provide such a summary.

METHODS

We developed a protocol based on the recommendations of the Best Evidence Medical Education (BEME) collaboration. Citations retrieved by electronic searches of 10 databases were assessed against pre-defined inclusion/exclusion criteria by two independent reviewers and full texts of potentially relevant articles were obtained. Studies were identified for inclusion in the review by examination of full text articles by two independent reviewers. At all stages, discrepancies were resolved by consensus. Data relating to characteristics of the student population, intervention, outcome measures, student design and outcomes were collected using a piloted data extraction form. Each study was assessed against 11 quality indicators designed to provide information about how well it was designed and conducted; and against the Kirkpatrick hierarchy as modified for educational settings. Comparisons between different groups were carried out using the Kruskal-Wallis test (non-parametric ANOVA) or the Mann-Whitney U test as appropriate.

RESULTS

Electronic searches yielded 2,348 citations. A further 23 citations were obtained by hand searching of reference lists. About 554 full articles were retrieved and assessed against our inclusion criteria. Of the 69 studies included in our review, 18 were from medicine, 32 from nursing and 19 from other allied health professions, including dentistry, physiotherapy and radiography. In all professional groups, portfolios were used mainly in the clinical setting, completion was compulsory, reflection required and assessment (either formative, summative or a combination of both) the norm. Three studies used electronic portfolios. Whilst many studies used a combination of data collection methods, over half of all included studies used questionnaires, a third used focus group interviews and another third used direct assessment of portfolios. Most studies assessed student or tutor perceptions of the effect of the use of portfolios on their learning. Five studies used a comparative design, one of which was a randomized controlled trial. Studies were most likely to meet the quality indicators relating to appropriateness of study subjects, clarity of research question and completeness of data. However, in many studies, methods were not reported in sufficient detail to allow a judgement to be made. About 19 of the 69 included studies (27%) met seven or more quality indicators. Across all professions, such 'higher quality' studies were more likely to have been published recently. The median 'quality score' (number of indicators met) rose from two for studies published in 2000 or earlier to seven for studies published in 2005 or later. Significant differences were observed between the quality scores for studies published in or before 2000 and those published between 2001 and 2004 (p = 0.027), those published in or before 2000 and those published in 2005 or later (p = 0.002) and between all studies (p = 0.004). Similar trends were seen in all professional groups. About 59 (85%) of the included studies were assessed at level 1 of the modified Kirkpatrick hierarchy (i.e. 'participation' effects, including 'post hoc' evaluations of student perceptions of the effects of keeping a portfolio on their learning). About 9 (13%) of the studies reported direct measurement of changes in student skills or attitudes and one study reported a change in student behaviour. The main effects of portfolio use identified by the included studies were: Improvement in student knowledge and understanding (28 studies, six at Kirkpatrick level 2 or above), greater self-awareness and encouragement to reflection (44 studies, seven at Kirkpatrick level 2 or above) and the ability to learn independently (10 studies, one at Kirkpatrick level 2). The findings of higher quality studies also identified benefits in these areas. They reported improved student knowledge and understanding, particularly the ability to integrate theory with practice, although a correlation with improved scores in other assessments was not always apparent. Greater self-awareness and engagement in reflection were also noted, although some studies questioned the quality of the reflection undertaken. Higher quality studies also suggest that use of portfolios improves feedback to students and gives tutors a greater awareness of students' needs, may help students to cope with uncertain or emotionally demanding situations and prepares students for postgraduate settings in which reflective practice is required. Time commitment required to collate a portfolio was the major drawback identified. In two of the studies, this was found to detract from other clinical learning.

CONCLUSIONS

At present, the strength and extent of the evidence base for the educational effects of portfolios in the undergraduate setting is limited. However, there is evidence of an improving trend in the quality of reported studies. 'Higher quality' papers identify improvements in knowledge and understanding, increased self-awareness and engagement in reflection and improved student-tutor relationships as the main benefits of portfolio use. However, they also suggest that whilst portfolios encourage students to engage in reflection, the quality of those reflections cannot be assumed and that the time commitment required for portfolio completion may detract from other learning or deter students from engaging with the process unless required to do so by the demands of assessment. Further work is needed to strengthen the evidence base for portfolio use, particularly comparative studies which observe changes in student knowledge and abilities directly, rather than reporting on their perceptions once a portfolio has been completed.

Getting the measure of reflection: considering matters of definition and depth

Reflection, reflective learning, reflective writing and reflective practice are used increasingly in higher education and professional development–but we do not work to one definition and there are considerable differences in the views of educationists on issues of definition. Such discrepancies can exist between the staff working with the same student group. The situation can lead to difficulties in indicating to students how to reflect, and what reflective writing ‘should look like’. Once students do manage to represent their reflection broadly in the required manner (usually writing), there is frequently observed to be a further problem because their reflection is superficial and descriptive. A consequence is that their learning from the reflective process is restricted.

This paper addresses the issue of definition of reflection initially through clarifying the different words used around the notion of reflection (e.g., reflection, reflective learning, reflective writing) and providing some suggested definitions. It then addresses the matters both of how we should help students to start with reflection, and with the problem of the superficiality of much of their work. The ‘depth’ of reflection is a concept that has not been much discussed in the literature of reflection and yet it seems to be closely related to the quality of reflective work. The paper discusses the concept of depth and then introduces a style of exercise in which a scenario is reproduced at progressively deeper levels of reflection. The exercise is related to a generic framework for reflective writing. The rationale and justification for the exercise and the framework are discussed and suggestions are made for its manner of use. The exercise and the generic framework for reflective writing are in Appendices 1 and 2.

The use of reflection to enhance formal learning has become increasingly common in the past 7 years. From the principle beginnings of its use in the professional development of nurses and teachers, its use has spread through other professions. Now, in the form of personal development planning (PDP), there is an expectation that all students in higher education will be deliberately engaging in reflection in the next 2 years.1 In addition, there are examples of the use of reflective learning journals and other reflective techniques in most, if not all, disciplines.2

Reflection is not, however, a clearly defined and enacted concept. People hold different views of its nature, which only become revealed at stages such as assessment. For example, what is it that differentiates reflective writing from simple description? There are difficulties not only with the definition itself but also in conveying to learners what it is that we require them to do in reflection and in encouraging reflection that is deeper than description. In this paper, we consider some issues of definition and then focus on the means of encouraging learners to produce a reflective output of good-enough quality for the task at hand. The latter is presented as an exercise for staff and learners (Appendix 1) with a framework that underpins it (Appendix 2).

An exploration and description of student midwives' experiences in offering continuous labour support to women/couples

AIM

to explore and describe the student midwife's experiences in offering continuous labour support.

DESIGN

a qualitative research design was chosen. Each student midwife offered continuous labour support to five women/couples and wrote narratives about each of these occasions. Written narratives from 11 student midwives were analysed using qualitative content analysis.

FINDINGS

when student midwives offer continuous labour support to women/couples, they try to establish rapport. When this works, their presence, their sense of confidence and their ability to offer reassurance increase. If establishing rapport does not work, students experience a sense of powerlessness, a need for reassurance and a lack of confidence.

KEY CONCLUSIONS

offering continuous labour support to women and/or their partners made the students aware of the importance of establishing rapport, and it made them realise the impact that their mere presence in the room could have. The students had a need for reassurance which could hamper their efforts to establish rapport. Experiencing a lack of confidence made students focus more strongly on their clinical skills and on their perceived role as a student midwife.

IMPLICATIONS FOR PRACTICE

this study can initiate discussions about how student midwives learn to be supportive, as well as about the role models that students encounter during their clinical training in Sweden.

Development and testing of a Clinical Learning Environment Diagnostic Inventory for baccalaureate nursing students

Aim. This paper reports the development and testing of the psychometric properties of the Clinical Learning Environment Diagnostic Inventory for baccalaureate nursing students. Background. The quality of the clinical learning environment is an essential factor in determining the quality of nursing students' clinical experience. It is also well-recognized that the clinical setting can be a source of stress and anxiety for students. To design an optimal clinical learning environment for students, instruments based on the cognitive and socio-emotional aspects of the learning process are necessary. Method. The hypothetical construct of the clinical learning environment was derived from a comprehensive review of the literature, including experiential learning theory and the epistemology of practice. Developing the instrument involved the collection of items through semi-structured interviews, assessing content validity and determining the scaling. After a pilot study, the instrument was tested with 312 undergraduate students and 157 preceptors between September and December 2004. The factor structure was determined by exploratory factor analysis. Results. Exploratory factor analysis produced a five-factor solution that was similar to the hypothetical model. Cronbach's alpha internal consistency reliability coefficients ranged from 0.65 to 0.77 across the five factors. Three-week test-retest reliability coefficients ranged from 0.59 to 0.74. Criterion-related validity and construct validity were estimated by the correlation between the Clinical Learning Environment Diagnostic Inventory and appropriate other instruments and a set of comparison data obtained from the students and preceptors. Conclusion. The findings yielded acceptable estimates of reliability and validity of the Clinical Learning Environment Diagnostic Inventory. Therefore, this instrument is considered useful for assessing learning environments in clinical settings.

Narrative criticism: a systematic approach to the analysis of story

Research reveals that writing about one's experiences offers an individual the opportunity to improve function, develop insight, and foster growth. Storytelling and story writing are pedagogical tools used frequently in practice professions. It is reasonable to see these writings as a rich source for research. They are vehicles for understanding human experience and aesthetic knowing. This article presents an innovation in the method used for analysis of stories. It is a blending of two established methods, those of narrative analysis as described by Riessman (1993), and aesthetic criticism by Chinn, Maeve, and Bostick (1997). The merging of both methods, termed narrative criticism, allows for a rich level of insight into unique human experiences.

The role of reflection in implementing learning from continuing education into practice

INTRODUCTION

Although the use of reflection to facilitate learning and its application in practice has been widely advocated, there is little empirical research to establish whether or not health professionals use reflection to integrate learning into clinical practice. Particularly troublesome is the lack of empirically based theory underlying strategies to promote reflection and understand factors that influence its use in translating learning into practice. Occupational therapists participated in this case study, in which reflection and implementation of learning from a short course into practice were examined using a multimethod approach.

METHODS

In phase one (n = 41), quantitative data were collected from a practice survey, the Self-Reflection and Insight Scale (SRIS) and Commitment to Change (CTC) statements. In phase two (n = 33), follow-up CTC data were collected to quantify the extent of achievement of CTCs. Data from phases one and two were analyzed descriptively to inform the selection of interview participants (n = 10) in phase three of data collection.

RESULTS

Two models were generated. One model describes when reflection was used, and the second model explains factors influencing its use. Participants used reflection before, during, and after the course, and reflection was influenced by a range of factors associated with the course, practice context, and the individual.

DISCUSSION

The theory and models depicting the use of reflection may guide educators' use of reflective learning before, during, and after short courses.

Marking criteria for assessing practice-based portfolios at masters' level

Whilst portfolios have increasingly been used to assess attainment and competence in nursing and other health care professions for over a decade, the assessment processes and criteria for assessing them have remained largely rudimentary and undeveloped. In fact, assessment often remains localised, impressionistic and dependent upon the interpretation and adaptation of criteria developed generically for work at this level within individual Higher Education Institutes (HEIs). This paper presents Masters' level marking criteria for portfolios from practice-based healthcare disciplines developed from the Quality Assurance Agency (QAA) descriptors of Masters level achievement and graduateness [Quality Assurance Agency for Higher Education, 2001. The Framework for Higher Education Qualifications in England, Scotland, Northern Ireland] in combination with practice-based outcomes. A six-stage methodology was devised to analyse these descriptors, develop, re-order, test and refine them in order to enhance their applicability to portfolios from practice-based disciplines. As part of this process the emerging criteria were tested against existing portfolios. Extracts from these are presented to illustrate the criteria. Two case study sites from diverse areas of England are used where Masters' courses in nursing and healthcare disciplines are offered. For portfolios to be effective in demonstrating Masters' level academic criteria, learning outcomes and advanced professional practice they need to demonstrate coherent structure, conclusions drawn from reflection on practice and a body of evidence that is coherent with, and linked to their reflective commentaries. The marking criteria presented to assess these attributes incorporate features of the structures, processes and outcomes of both practice and learning. The strategy can be used by both assessors and students, in formative and summative assessment, to identify student attainments, strengths and weaknesses.

Development of situation-specific theories: an integrative approach

One type of "ready-to-wear" theories that can bring about better nursing care outcomes regardless of their philosophical bases is situation-specific theories proposed by Im and Meleis in 1999. In this paper, some propositions for an integrative approach to the development of situation-specific theories are made. First, situation-specific theories are described as practice theories while they are compared with middle-range theories. Then the integrative approach is detailed, which includes (a) checking assumptions for theory development; (b) exploring through multiple sources; (c) theorizing; and (d) reporting, sharing, and validating. Finally, the paper concludes with suggestions for further development of the integrative approach.

Reflective practice and daily ward reality: a covert power game

BACKGROUND

The concept of reflection is propounded in the literature as an epistemology for practice that enables practitioners to solve their daily problematic situations through conscious thought processes which eventually leads to practice-based knowledge. Hence, reflection became a central tenet of both theory development and educational provision in nursing. Furthermore, this centrality of reflection was reinforced by statutory nursing bodies and service providers by adopting it as the means for carrying out adequate professional practice. Although this may be the case, issues of implementation of reflection within the daily reality of practitioners are frequently overlooked within the literature. Moreover, little consideration appears to be given on the impact that the organizational culture and the politics of power may exert on the implementation of reflective practices within daily ward reality.

AIMS

This paper explores how reflection is viewed by nurses within their daily reality in the medical wards, examines the relationships between the organizational culture of these wards and the practitioners and investigates whether reflective methods of practice were being implemented when the study was conducted.

METHODS

An interpretative ethnographical methodology was implemented and the data collecting methods used were observation, interviews and qualitative content analysis with a group of 16 practising nurses from four medical wards of one NHS Trust in England. Two interviews were conducted with each nurse within 3-week intervals. The content of these interviews evolved from the analysis of episodes of practice observed when the nurses were giving nursing care. These data were supplemented by narratives from the nurses' in the form of written reflective accounts that were analysed via qualitative content analysis techniques.

FINDINGS

Four themes were generated: (i) relationships between nurses and doctors; (ii) relationships between nurses and managers; (iii) nursing practice; and (iv) nurses' input in the outcome of a clinical situation.

CONCLUSIONS

The concept of reflection appears to be invalidated by the organizational hierarchy of the wards on the basis of a power struggle game. The ward structure portrays reflection as an abnormal method of practice and knowledge development. This belittlement of reflection does not mirror the practitioners' reality. Instead, it is an intelligent and intentional act on behalf of the dominant professional groups in the wards to create an illusionary picture of ward reality to allow them to survey and define nursing practice and thus maintain and remain in power. This is explicated by using Foucault's analysis and critical social theory framework. Hence, reflective processes are constrained by this covert power game; reflection, where used, is confined to nurses' personal time and space.

RELEVANCE TO CLINICAL PRACTICE

The realization of this covert power game by individual clinical nurses can become the incipient point for formally using reflective methods in the practice setting.

Evaluating student paediatric advanced nurse practitioners' experiences of a paediatric pharmacology module: in the context of reflective learning

An evaluation of the first paediatric pharmacology module at Master's level was undertaken. The broad aims were: to ascertain whether the participants had achieved the modular learning outcomes; how their pharmacological knowledge base had altered as a result of the module; and whether their professional practice had been influenced subsequent to undertaking the module. The findings of the 12 participants who registered on the module are reported. Three tools were utilized to generate the data for this broadly qualitative study. The findings indicated that reflective thinking at the evaluative level enabled the participants to monitor their professional and personal performance and that their critical thinking skills and confidence had increased. The questionnaire survey had some limitations, but was seen as the only feasible method of achieving a representation as to whether the module had subsequently influenced the professional practice of the participants. The data presented convincing evidence of the relevance of study of a paediatric pharmacology module at Master's level for the professional and personal development of practitioners.

The client as educator: learning about mental illness through the eyes of the expert

Increasingly, educators are asking clients who have a mental illness to make a contribution to nursing students' learning as a way of informing their attitudes towards persons experiencing mental illness and thus enhancing care delivery. The nature of clients' involvement in the classroom and the quality of learning by students through this approach has rarely been questioned. This paper discusses a model of client/nurse educator collaboration in a mental health course with undergraduate nursing students. It draws on the nursing education experiences of the first author, and the personal views of the second author, a user of mental health services. Specifically, it addresses positive features of collaboration as perceived by students, client, and nurse educator and analyzes some of the challenges/issues for the nurse educator. In addition, it outlines helpful aspects of the collaborative process for both nurse educator and client, in particular, its impact on the client's personal well being. This kind of analysis is essential if we are to develop education models of such collaboration that are beneficial for all partners in the learning process.

Using journals for community health students engaged in group work

Teaching students concepts integral to community health nursing, such as collaboration and partnership, while providing clinical practica in community agencies, mandates that students address group process and evaluate self-growth. To facilitate reflection on self-learning in the context of collaborative group work, faculty and students use a structured, graded, weekly journal. This teaching and learning tool serves as a mechanism for assisting students with understanding group process.

Tanzanian midwives' views on becoming a good resource and support person for postpartum women

OBJECTIVES

to explore midwives' views in relation to the provision of systematic postpartum care.

DESIGN

qualitative focus group study using grounded theory approach.

SETTING

Dar es Salaam, Tanzania.

PARTICIPANTS

49 nurse/midwives in five focus group discussions, each having 9-11 participants.

FINDINGS

eight categories were identified: 'reflecting', 'getting ready', 'defining abilities', 'networking', 'integrating', 'balancing', 'dealing with reality', and 'caring'. The identified core category that integrated and encapsulated all other categories was 'becoming a good resource and support person for postpartum woman'. The mediating factors found to have potential for influencing how a midwife can function in order to become a good resource and support person were: a) the structure and approach in maternal and child health services, b) midwives' knowledge, attitude and skills, c) informal sources of knowledge to parents, and d) cultural beliefs and practices.

CONCLUSION

the findings of this study provide an understanding of the way midwives feel and think about the provision of postpartum care. The findings demonstrate that midwives need support in their efforts to achieve what they consider necessary for postpartum care. Interventions for educating and supporting midwives should be targeted at enabling them to deal with all the factors that influence their role and help them to identify and use better strategies to provide quality care.

The value of intelligent multimedia simulation for teaching clinical decision-making skills

This paper examines the value of using intelligent multimedia simulation for the teaching of nursing clinical decision-making skills. The possibilities of multimedia-based educational resources are examined and the rapid growth and questionable effectiveness of current multimedia computer-based learning applications for nursing students are discussed. The advantages and disadvantages of this technology and the problems developing intelligent agent-based systems are examined. A case study is presented which uses a modular design with an integrated intelligent agent and knowledge base. It is argued that by using this type of approach, the real value of intelligent CBL to provide individual formative advice to students in a simulated experience can be realized.

Training Performance Raters Through Error-based Experiential Learning

Human resource managers need to understand issues relating to rater error. There are well-established ways to introduce these concepts to those training in the field. However, they require a substantial period of training to be successful. Their use in a tertiary setting can be severely constrained by time limitations. An alternative approach to these traditional training styles is that of error-based experiential learning. This training strategy immerses students in erroneous experiences that are then explored and used as a learning platform to build models of good practice. The training process used to structure the exercise is described in detail, illustrating the various errors committed by the trainees. Student feedback from the exercise and some likely risks attached to the activity are also discussed.

Psychodynamic sources of resistance among student nurses: some observations in a human relations context

Psychodynamic sources of resistance among student nurses: some observations in a human relations context The nurse-patient relationship is considered to be a crucial part of the daily routine for many nurses; however, little evidence is available regarding how student nurses cope with learning human skills. Few researchers have considered how students engage with or resist the learning process. The aim of this study is to examine interpersonal matters and explore psychodynamic sources of resistance encountered among student nurses in an interpersonal skills context. A qualitative approach was adopted with a focus on individual case studies, using the in-depth interview as the major mode of data collection combined with observation. The four types of student that emerged from the data are emphasized, ranging from type 1 who were extremely reluctant to self-disclose, to type 4 who were more confident and free-flowing. The major characteristics pertaining to each type of student are outlined. While some characteristics seem to be related to childhood struggles and years of over-adaptation, others relate to factors that influence the learning climate. Particular attention is given to the psychological understanding of their predicament, including accounts of childhood and self-image. The implications for nurse education and limitations of this study are also considered.