Achieving change through reflective practice: closing the loop

Consensus views on an advanced breast cancer education curriculum for cancer nurses: A Delphi study

BACKGROUND

Specialist nursing care is a core indicator of quality care for people living with advanced breast cancer. However, access to and quality of nurse education programmes in advanced breast cancer is variable.

OBJECTIVES

This study aims to define the topics for inclusion in an international curriculum for an advanced breast cancer education programme.

METHODS

A modified four-round Delphi study was undertaken with experts by profession and experience in advanced breast cancer. Thirty-four topics related to advanced breast cancer and six online teaching and learning methods were pre-selected following a systematic review. Between September 2021 and March 2022, the expert panel determined the importance of topics for inclusion in the education programme. Consensus was defined by at least 80 % agreement on the highest three points on a 9-point Likert scale.

RESULTS

A total of 31 experts participated in rounds 1-3 of this study, and 156 experts by profession and experience participated in an additional fourth round, including people living with advanced breast cancer (n = 72, 46 %), healthcare professionals (n = 46, 29 %), family members or caregivers of a person diagnosed with advanced breast cancer (n = 30, 19 %) and advocacy professionals working in the area of advanced breast cancer (n = 8, 5 %). In round 4, 36 topics and five of six learning methods reached consensus.

CONCLUSIONS

The results of this study provide a framework to develop education programmes in advanced breast cancer, defining the essential elements of curriculum content for such programmes. The results highlight the need for advanced breast cancer education programmes to use multiple teaching and learning methods to promote nurses' understanding of person-centred supportive care and the physical, psychosocial and spiritual issues experienced by people living with advanced breast cancer.

Malaysian dental therapists' job motivation, job satisfaction, intention to leave and perceived future roles

OBJECTIVE

To assess Malaysian dental therapists' job satisfaction, motivation, turnover intention, and perceived future roles, following recent changes in the regulations that allow them to provide dental care within their scope of practice in the private sector.

METHODS

A self-administered questionnaire was distributed to public dental therapists who were selected using a stratified random sampling technique. Questions included items on social structure, job satisfaction and motivation (based on the Warr-Cook-Wall scale), turnover intention (based on four cognitive processes) and perceived future roles. Multiple logistic regression was used to assess the predictors of dental therapists' turnover intention.

RESULTS

Overall, a majority (> 90%) of participants had high job satisfaction and job motivation, with total mean scores of 45.70 ± 6.86 and 21.16 ± 2.63, respectively. A total of 8.3% intended to leave the public sector to work in a different organisation. Of those who chose to remain as a dental therapist in the next five years, only 7% considered working in the private sector. The significant predictors for turnover intention were educational attainment, years of working experience, job satisfaction level and future preferred working sector.

CONCLUSION

Although the newly introduced Dental Act allows dental therapists to expand their roles to the private setting, very few intended to do so. This could be related to them having a high level of job satisfaction and job motivation while serving in the public sector.

I-Hydrate training intervention for staff working in a care home setting: An observational study

BACKGROUND

Dehydration is a complex and well-recognised problem for older people residing in care homes. Within the social care sector support staff provide the majority of direct care for residents, and yet receive minimal training.

OBJECTIVES

To design, deliver and evaluate a hydration specific training session for care home staff to develop their knowledge and skills in supporting the hydration of care home residents.

DESIGN

An observational study comprising a pre-test post-test survey of staff knowledge following a training intervention.

PARTICIPANTS AND SETTINGS

Training of care home staff took place in two care homes in North West London.

METHODS

An interactive training session was developed and delivered, with content informed by observations of hydration care within the two homes and evaluated using CIRO model. Participant self-evaluation forms were used to collect data after the session regarding satisfaction and usefulness of the session, and pre and post levels of self-reported knowledge across six facets of hydration care. Training facilitators captured qualitative data in the form of field notes. Observations of hydration care explored the impact of training on practice.

RESULTS

Eighteen training sessions were delivered. A total of 161 participant evaluation forms were returned. There was a significant increase in self-reported knowledge across all six facets of hydration care (p = 0.000). The majority of participants found the training enjoyable and useful, and expressed an expected change in their practice. Participants enjoyed the interactive components of the training. A lack of reflective practice skills meant participants were unable to reflect realistically about the hydration care provided in the home.

CONCLUSION

Focused training on hydration in the care home environment benefits from being interactive and experiential. Although such training can be effective in increasing staff knowledge, inclusion of skills in reflective practice is required if this knowledge is to be translated into practice.

Managing performance and learning through reflective practices

Purpose

– The purpose of this paper is to study the role of performance management (PM) in the use of reflective work practices.

Design/methodology/approach

– The empirical evidence was collected during a one-year, action-oriented research project.

Findings

– According to the results, PM can support the use of reflective work practices by affecting and guiding the human behavior in an organization. In this study, five roles of PM are emphasized in order to support reflective practices at work: making reflective work practices visible, supporting reflective dialogue, creating a favorable measurement culture, clarifying the goals at all organizational levels and motivating employees to use reflective work practices by means of compensation and rewards.

Practical implications

– The results of the study can help professionals realize that reflective work practices may benefit organizational performance.

Originality/value

– There is limited research and discussion on how a PM process through the use of reflective practices contributes to human resource management (HRM) and organizational effectiveness. In addition, PM literature has neglected the potential of reflective work practices in achieving performance at different levels (individual, group and organization). Reflective work practices, where individuals learn from their own and from each other’s professional experiences, may be the most important source of professional development and improvement. This paper argues that PM can also support this type of learning, and thus guide and motivate people in attaining business goals.

Reflective practice as a determinant of performance outcomes in services

Purpose

– The purpose of this paper is to examine the outcomes of reflective practices in services. The paper contributes to the current understanding of the relationship between reflective practice and outcomes by presenting a description of the internal (i.e. what kind of reflection is required to attain the desired outcomes) and external (i.e. under what kind of circumstances does reflection result in the desired outcomes) factors of reflective practices.

Design/methodology/approach

– The results of this investigation are based on a mixed-method research approach that utilises both quantitative and qualitative data collection methods.

Findings

– According to the results, reflective practices are indeed connected to outcomes. Reflective practices foster better outcomes when they are more explicit and targeted through different organisational levels. The role of performance management and measurement is important in connecting the reflective practices with performance. Performance management must be considered as a communication and social system that allows the employees to discuss the learning and development process as a part of the results.

Practical implications

– As a practical contribution, the results of the research may help professionals begin to understand that leveraging reflective practices may aid an organisation in achieving its desired outcomes.

Originality/value

– Hitherto, studies that discuss the interphase of reflective practices and outcomes have mainly been theoretical considerations or surveys that lack an in-depth understanding of how the different methods operate in a real-life context. When focusing on the previous research, it is clear that in-depth empirical studies are needed to achieve a deeper understanding of the mechanisms and arrangements that connect reflective practice and outcomes. This research addresses this research gap by examining the outcomes of reflective practices in services.

Reflective writing: the student nurse's perspective on reflective writing and poetry writing

BACKGROUND

Reflective writing is a mandatory part of nurse education but how students develop their skills and use reflection as part of their experiential learning remains relatively unknown. Understanding reflective writing in all forms from the perspective of a student nurse is therefore important.

OBJECTIVES

To explore the use of reflective writing and the use of poetry in pre-registered nursing students.

DESIGN

A qualitative design was employed to explore reflective writing in pre-registered nursing students.

SETTING

A small university in Scotland.

PARTICIPANTS

BSc (Hons) Adult and Mental Health Pre-registration Student Nurses.

METHODS

Two focus groups were conducted with 10 student nurses during March 2012. Data was analysed thematically using the framework of McCarthy (1999).

RESULTS

Students found the process of reflective writing daunting but valued it over time. Current educational methods, such as assessing reflective accounts, often lead to the 'narrative' being watered down and the student feeling judged. Despite this, reflection made students feel responsible for their own learning and research on the topic. Some students felt the use of models of reflection constricting, whilst poetry freed up their expression allowing them to demonstrate the compassion for their patient under their care.

CONCLUSIONS

Poetry writing gives students the opportunity for freedom of expression, personal satisfaction and a closer connection with their patients, which the more formal approach to reflective writing did not offer. There is a need for students to have a safe and supportive forum in which to express and have their experiences acknowledged without the fear of being judged.

Enhancing the effectiveness of the teaching and learning of core clinical skills

Over the last decade there has been great deal of debate about pre-registration nursing students' lack of confidence and ability, in performing core clinical skills in the UK [P. Elliott, Locality based teaching, Senior Nurse 13 (2) (1993) 35-39; S. Jowett, I. Walton, S. Payne, Challenges and Change in Nurse Education - A Study of the Implementation of Project 2000 Slough: NFER, 1994; P. Hilton, Clinical Skills Laboratories: teaching practical skills, Nursing Standard 10 (37) (1996) 44-47; , Integrating theory and practice: Professional Letter from the Chief Nursing Officer for England London; , Making a difference. Strengthening the nursing, midwifery and health visiting contribution to health and health care, London.]. A variety of solutions have been suggested in attempting to address these perceived deficits. One such initiative within the University of Sheffield was the introduction of the Clinical Demonstrator role, whereby clinicians were seconded to the School of Nursing for a fixed period of time to provide additional support to neophyte students in the classroom, laboratory and clinical settings. An action research approach was adopted where ongoing evaluation influenced further developments [W. Carr, S. Kemmis, Becoming Critical: Education Knowledge and Action Research, Falmer Press, London, 1986]. Formal and informal evaluation was therefore undertaken throughout and this influenced the evolution of the role. The methods used included; questionnaires; reflective diaries; focus group interviews; and ongoing dialogue with lecturers, students, demonstrators, clinicians and trust representatives. Since the start of this 5 year project there have been 25 Demonstrators in post who have in total supported 10 pre-registration nursing student cohorts undertaking the Common Foundation Programme (N=1496). As the study progressed they also provided support to more senior Adult Branch students undertaking the final year of the course (N=76). The outcomes have been exceptionally positive, though a number of lessons have been learnt along the way. This paper outlines this innovative project and shares a number of broad conclusions that can be drawn from the study.

A healthcare case study of team learner style and change management

Purpose

The purpose of this paper is to explore the learner styles of a healthcare institution transition team and its respective members within a change management context. In particular we focus on the role of learner style in the success of change efforts within a team setting.

Design/methodology/approach

This paper presents a case study that employs a questionnaire survey, non‐participant observation, and semi‐structured interviews as part of a larger study of healthcare change management.

Findings

Findings suggest that a mix of learning styles is ideal for successful healthcare change management. Specifically, this limited study suggests a learner ratio that favors convergers and assimilators over divergers and accommodators may be the most effective staffing strategy for change leadership teams in a healthcare environment.

Originality/value

Managing change in healthcare has been researched from a process perspective but few studies examine the individual team members' learner styles and the impact of these learning styles over time. Implications for human resources and change implementation are discussed.

Towards the development of a reflective radiographer: challenges and constraints

Currently there is overwhelming support from the health professions for universities to devise curricular approaches that lead to the development of undergraduate reflective skills, and over time, reflective practice. However, in the case of radiography, irrespective of the degree to which radiographers might engage in reflective practice they constantly struggle to shed the perception they are little more than technical operatives. The four-year Bachelor of Radiography and Medical Imaging was introduced by Monash University in 1998 with an overt commitment to the development of a reflective radiographer. Findings from student and supervisor surveys generally support the program and its aims. However, as the findings and student feedback will attest, many challenges and constraints continue to face educators who seek to situate their curriculum within the reflective practice paradigm.

Revisiting the evaluation of clinical practice

The evaluation of patient care is an ongoing process that is aimed at improving clinical outcomes, as well as advancing clinical practice. However, a number of elements need to be taken into account when evaluating clinical practice, including social, structural and process factors. Consideration of these factors, together with comprehensive and holistic assessment, clinical expertise, reflective thinking, and valid and reliable instrumentation, will allow practitioners to better evaluate clinical care, and in effect, improve client outcomes.

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.

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.

Relationships with undergraduate nursing exchange students--a tutor perspective

BACKGROUND

Student exchange has been used increasingly in nursing education throughout Europe as a method of learning intercultural sensitivity. In the host country, each foreign student is assigned a personal tutor to enhance learning.

AIM

The aim of this study was to describe tutor-student relationships between Finnish nurse teachers and British exchange students from the tutors' perspective.

ETHICAL ISSUES

The researcher's close relationship with the study context and participants caused some ethical concerns, which will be discussed.

METHODS

The data consisted of tutorial session observations, research diary notes, group interviews and background questionnaires. They were analysed using Spradley's developmental research sequence method for ethnographic data.

FINDINGS

The tutoring relationship was pastoral and clinical rather than academic. The pastoral aspect of the relationship was essential in assisting the students to adjust to the stress of studying in a foreign country. On the other hand, tutors were unable to support all the students to overcome their culture shock. Tutors were uncertain about their role and did not integrate Finnish culture or practice into theory, but found their role pleasant.

CONCLUSIONS

A dialogic tutor-student relationship is important for learning intercultural sensitivity. Tutoring strategies should be developed to assist students' adjustment to the differences in the host culture and to encourage their reflection on personal, experiential and scientific cultural knowledge during their study abroad.

Facilitating perception and imagination in generating change through reflective practice groups

This paper describes the process of facilitating groups of registered nurses to generate change in themselves and their practice through guided reflection. The concept of perception is explored in respect of individual interpretations of personal experiences where perception becomes reality for that individual. Such perception is subject to bias and without supported guidance in the reflective process inappropriate conclusions are easily generated. Through facilitating group deconstruction of the perceived experience the individual is able to identify the elements of bias emerging and subsequently reaches valid conclusions by reconstructing the experience with reduced elements of subjectivity which are more appropriate to personal and practice development. Within the reconstruction process, imagination is stimulated by steering individuals within the group towards visualising outcomes of planned actions. Use of imagination allows internal acting out of events and the identification of consequences of following a particular course of action. This process enables generation of appropriate actions to take place through development of insight and deeper awareness of influences on personal change. Through appropriate developments in personal approaches the ensuing changes generated in practice take place through considered strategies, which will enhance nursing and care provision.

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.

Reflection: possible strategies to improve its use by qualified staff

Reflection is now a prerequisite for all nurses, midwives and health visitors (UKCC, 2001). It is the method endorsed by the UKCC to promote the development of informed, knowledgeable and safe practice, and qualified practitioners are required to maintain a personal professional profile containing evidence of reflection on practice. The aim of this article is to examine why qualified practitioners may be reluctant to reflect formally, to speculate on the possible barriers to reflection, and to suggest how reflection can be promoted positively as an integral part of nursing practice. The article begins with an examination of definitions of reflection, reflective theory and the purpose of reflection, and continues by questioning whether the concept of reflection has been embraced as eagerly by nurses at 'grass roots' as it has by academia, the nursing press and the UKCC. It is suggested that several barriers to effective reflection may create a division between practitioners and the professional hierarchy regarding the conceived common practice of reflection, and strategies are proposed that may help to overcome these barriers. The discussion concludes by prioritizing the need for a clear definition and concept analysis of reflection, supported by long-term investment into research that explores the effect of reflection on clinical practice and patient care.