The inclusion of cognitive behavioural therapeutic components in the undergraduate nursing curriculum. A systematic integrative review of the evidence

BACKGROUND

Despite the increasing evidence base for the use of cognitive behavioural interventions in nursing, the extent to which therapeutic interventions and their components are included in the undergraduate curriculum in Australia remains unclear.

OBJECTIVES

To explore if and how cognitive behavioural components are being taught to undergraduate nursing students to deliver outcome benefits to students and patients.

DESIGN

An integrative literature review reporting links between CBT components and methods taught in pre-registration nurse education.

FINDINGS AND CONCLUSION

Based on an analysis of current literature, it is suggested that evidence-based cognitive behavioural components are being taught to undergraduate nursing students. The study reports that teaching cognitive behavioural components can bring clinical benefits to positive patient outcome, to student wellbeing and study performance. However, the teaching of cognitive behavioural conceptual models as a therapeutic skill was found to be limited. Recommendations to incorporate a simple, evidence based cognitive behavioural conceptual tool, highlights how nurse educators can address the requirement to teach from the current evidence base.

Sexual harassment of nurses by patients and missed nursing care-A hidden population study

AIM

To raise awareness of a patient-related antecedent of missed nursing care.

BACKGROUND

Missed nursing care is negatively associated with patient outcomes; accordingly, hospitals employ strategies to mitigate missed care. While antecedents of missed nursing care resulting from the work environment of nurses are recognized, sexual harassment by patients is not.

METHODS

This study is a hidden population study using respondent-driven sampling. We analysed data from thirty letters of frontline nurses from a tertiary Israeli hospital using the six steps of Aronson's thematic analysis.

FINDINGS

Six themes emerged. Nurses (a) felt objectified and that the sacred nurse-patient therapeutic space was desecrated; (b) felt a lack of support from ward managers; (c) felt unprotected, lonely, and alienated; (d) did not share the experience with managers; (e) coped with sexual harassment by ending treatment quickly and later realized they missed some tasks; and (f) considered leaving nursing.

CONCLUSION (S)

Policymakers are called upon to adopt the eight steps suggested for effectively coping with sexual harassment by patients and thus to reduce missed nursing care.

IMPLICATIONS FOR NURSING MANAGEMENT

Managers are called upon to modify their management style and to provide support to nurses who experience sexual harassment in order to alleviate their stress, which is an also antecedent of missed nursing care.

Triggers for reflection in undergraduate clinical nursing education: A qualitative descriptive study

BACKGROUND

Reflection is a key component of effective teaching in baccalaureate nursing education. However, there are limited empirical studies into the factors which trigger reflection in undergraduate clinical nursing education.

OBJECTIVES

This study aimed to explore reflection triggers in undergraduate clinical nursing education with a specific focus on verbalized reflection in spoken dialogues.

METHODS

This qualitative descriptive study was conducted in 2017-2018. Participants were seventeen clinical nursing instructors, 32 nursing students, and nine newly graduated nurses who were purposively recruited from four universities and two hospitals in Iran. Data were collected via 26 in-depth semi-structured face-to-face interviews with clinical nursing instructors and newly graduated nurses and four focus group discussions with students. Conventional content analysis was used for data analysis.

RESULTS

Reflection triggers fell into the following four main categories: conscious comparison of actions, confrontation with influential realities, emotional and moral involvement in patient care, and demanding accountability.

CONCLUSION

This study suggests triggers for reflection in clinical nursing education. Instructors' use of reflection triggers can help students reflect on their actions and practice.

An evaluation of the appropriateness and effectiveness of structured reflection for midwifery students in Ireland

Midwifery students undertaking the undergraduate midwifery education programme in Ireland participate in facilitated reflective sessions that aim to develop their skills of reflecting on and in clinical practice. This paper presents a qualitative evaluation of the appropriateness and effectiveness of the facilitated reflection sessions for pre and post-registration midwifery students in two large Dublin maternity teaching hospitals. The aim was to evaluate structured reflective practice sessions which sought to assist midwifery students to become competent reflective practitioners. Group reflection sessions were conducted weekly in a clinical practice area at the same time each week over one academic year. After the series of structured reflective sessions, midwifery students and facilitating staff were invited to evaluate the reflective process. This evaluation consisted of a self-completion survey to identify the factors that facilitated and impeded student participation in the sessions. Respondents answered a series of questions about the reflective practice sessions and were also invited to enter qualitative data regarding their subjective experiences of the process in free text boxes. The data were then collated into themes by an independent reviewer. The results of the evaluation clearly indicate that midwifery students and facilitators welcomed the opportunity to engage in group reflection sessions as a form of peer support and as a catalyst for learning from clinical practice. Findings suggest that reflective practice can contribute to the development of skilled, self-aware and engaged practitioners.

Addressing ethical concerns arising in nursing and midwifery students' reflective assignments

BACKGROUND

Written reflections on practice are frequently requirements of nursing curricula. They are widely accepted as necessary for improving critical thinking and problem-solving skills. Faculty, are expected to review reflections and provide feedback that helps professional development and facilitates good practice. It is less clear what the actions of nurse educators should be when ethical infractions are revealed in the narratives.

OBJECTIVES

We had two aims: 1) To combine insights from a literature review of empirical and theoretical research related to responding to ethical issues revealed in student reflections with our experiences reviewing the reflections of undergraduate nursing and midwifery students, and 2) to construct and analyze a hybrid case from these insights in order to develop guidelines for nurse educators.

RESEARCH DESIGN

A literature review was conducted using CINAHL, MEDLINE, PsycINFO, SocINDEX and ERIC databases and pertinent key words. A hybrid case was constructed of commonly encountered ethical issues using insights from the literature review and the authors' experiences. The case was analyzed by combining Beauchamp and Childress' principlist approach with Campbell and McCarthy's ethical decision-making tool (Table 1). Participants and Research Context: No human participants Findings: A gap in the literature exists related to addressing ethical issues revealed in student practice reflections. However, a combination of insights from the literature and the authors' experiences facilitated the development of a hybrid case. Subsequent case analysis facilitated the development of a series of guidelines that can be utilized to address a range of issues commonly emerging in the reflections of nursing students during practice experiences.

DISCUSSION

A number of recommendations and guidelines are provided to enable the safeguarding of students and staff and support them in practicing ethically.

CONCLUSION

Structured ethical analysis of a constructed hybrid reflection of commonly revealed ethical issues was useful in developing guidelines for educators.

Towards a nursing science of the unique

In this paper we attempt to counter the tendency for reflection and reflective practice to be marginalised by the growing dominance of evidence-based practice in nursing. We resist the assimilation of reflection into a hierarchy of evidence dominated by the findings from ‘hard science’, and argue instead for an alternative science of nursing based on the premise that nursing is a series of individual and unique encounters which cannot be described by a science of large numbers. The resulting ‘science of the unique’ is concerned with persons rather than people, with wet data from the clinical setting rather than dry data from the laboratory and clinical trial, and with the individual practice encounter as the site of reflexive research. In particular, we argue that the traditional concept of evidence from formal research is merely the starting point for the on-the-spot generation of reflective/reflexive evidence by nurses themselves as part of everyday practice.

Mandatory continuing professional development in South Africa: Rehabilitation therapists' perspective

Aims:

In 2007, Health Professions Council of South Africa (HPCSA) introduced mandatory continuing professional development (CPD), which enables therapists to acquire new knowledge and skills to improve patient care. To remain registered, therapists must meet CPD standards by formal HPCSA audits; however, latest figures revealed a compliance rate of 35% due to non-attendance of CPD activities. This study reviewed the experiences of therapists to identify barriers and obtain suggestions to improve attendance.

Methodology:

This cross-sectional descriptive study used a questionnaire with closed and open questions to explore the aims from a sample of 138 rehabilitation therapists, comprising speech and language therapists (9%), occupational therapists (21%) and physiotherapists (70%), attending an ethics workshop.

Results:

Eighty five (62%) supported CPD and 97 (71%) supported compulsory ethics. Short 1 to 3 day courses, mini-congresses and journal club activities were the most frequently-attended events. Barriers to CPD were: time, cost of courses, cost of travel due to geographical distance, staff shortages, lack of employee support, and multi-disciplinary or inappropriate courses. Suggestions for improving attendance were: introducing state subsidised and corporate sponsorships, increased in-service journal club activities, tele- and video-conferences, on-line presentations, and profession-specific courses.

Conclusion:

Therapists support mandatory CPD, but stakeholders must take cognisance of the barriers and suggestions to improve CPD attendance and compliance.

Radiation therapists’ perspectives of the role of reflection in clinical practice

A recurring theme from the literature is that the definition of reflection is nebulous and/or complex. Many authors have suggested that more research needs to be conducted to better understand an individual’s perception of reflection and reflective practice, and how these concepts affect their clinical practice as well as their personal growth and development. This paper offers the findings of a qualitative study of radiation therapists in Canada. The aim of the study was to explore radiation therapist’s understanding of the concept of reflection, and to understand how they incorporated it into their daily practice. Secondary objectives were to examine some of the perceived barriers to its use, and the possible challenges of implementing reflective writing. Two focus groups were initially conducted, and a follow-up questionnaire was developed using the themes generated from the focus groups. The questionnaire was distributed to radiation therapists at two large cancer centres in Toronto, Canada. Most participants indicated that it is an integral part of their practice and professional lives, and that they use a variety of different methods for engaging in reflection. It is not without its barriers, but many of these can be overcome by providing time, coaching and a supportive work environment. Respondents were divided as to whether they would benefit from being taught reflection; however, small group teaching would be the favoured method. Further study is suggested to determine whether there are any improvements to patient care and in particular patient outcomes.

An exploration of the current use and benefit of nursing student portfolios

AIM

This study aims to identify the structure and of student portfolios and to ascertain their views on their usefulness.

BACKGROUND

Portfolios are in common use in undergraduate nursing programmes although there are considerable variations in approaches. As a result a wide variety exists in the quality of work presented and students are often unclear as to constituent contents. This latter, while a reflection of the current status and development of portfolio use within the discipline is a source of dissatisfaction for students, and warrants further investigation.

METHODS

This project aimed to quantitatively capture student views using an on line survey approach utilizing a previously validated questionnaire (McMullen, 2006) [McMullen, M. 2006. Students' perceptions on the use of portfolios in pre-registration nursing education: A questionnaire survey. International Journal of Nursing Studies 43 (3), 333-343]. A survey tool is used to examine the structure, process and content of portfolios (n=481) in current use in one school.

RESULTS

The study provides an evidence base for hitherto anecdotal comments and provides useful information for future development. While students see potential value in the portfolio use there are several areas of dissatisfaction including lack of clear guidelines.

CONCLUSION

As an evolving structure within universities and practice there is much room for process improvement.

Assessing undergraduate nursing students in clinical practice: do preceptors use assessment strategies?

Health care organisations such as the World Health Organisation (WHO) and An Bord Altranais (ABA, The Irish Nursing Registration Board) demand higher standards of new graduate nurses than heretofore. This is in conjunction with the implementation of degree programmes for undergraduate nurse education. These organisations stipulate that graduates must be well-educated, accountable, and can demonstrate the skills of a safe, caring and competent decision-making practitioner. The Bachelor of Science (BSc) four-year degree programme for undergraduate nurse education was introduced in Ireland in 2002, and is provided in universities and colleges of higher education throughout The Republic of Ireland. During the implementation process, each university and college of higher education developed a range of assessment strategies to clinically assess students. Preceptor nurses were subsequently assigned the responsibility of clinically assessing students, a remit previously undertaken by Clinical Ward/Unit Nurse Managers. Preceptors are qualified nurses, working in clinical units who are specially prepared to support BSc students during clinical placements. The purpose of this study was to explore to what extent preceptor nurses use the devised assessment strategies to clinically assess BSc students in one university in The Republic of Ireland. Data were collected by using a questionnaire distributed to all known preceptors in General, Psychiatric and Intellectual Disability nursing, during year four of the first cycle of the BSc programme. Findings from this descriptive study revealed that many preceptors were inexperienced, did not fully comprehend the assessment process and were not applying all of the recommended assessment strategies when assessing students in clinical practice. In light of these findings suggestions are made in the context of further research, management and education.

Introducing guided group reflective practice in an Irish palliative care unit

This paper describes the processes involved over one year in introducing, facilitating and evaluating a project of guided reflective practice for a group of eight palliative care nurses in Milford Care Centre, Republic of Ireland. While literature has tended to concentrate on critical discussion relating to reflection, less attention has been directed towards the organisation and facilitation of reflective processes in practice. In addressing this deficit, a detailed account of the collaborative processes and challenges involved in this project are presented. Group evaluation of the project is discussed under the following themes: understanding the process of reflective practice; the value of keeping a reflective diary; guided group reflection and moving forward. The introduction of guided reflection for palliative care nurses has afforded both the facilitators and the participants an opportunity to meet away from the clinical environment, and to work together, finding fresh insights to inform practice. The valuing and promotion of reflective processes by an organisation arguably provides a fundamental strategy to support nurses in a quality palliative care setting.

Implementing reflection: insights from pre-registration mental health students

Reflection and reflective practice continues to be contentious issues in nursing. The focus of this article is the use of reflection by pre-registration mental health students. The broad aim of this preliminary study was to discover student mental health nurses' perceptions of reflection as a learning strategy during clinical placement. Using a constructivist grounded theory methodology [Charmaz, K., 2000. Grounded theory: Objectivist and Constructivist Methods. In: Denzin, N., Lincoln, Y. (Eds.), Handbook of Qualitative Research, second ed. Sage, Thousand Oaks, California], five students were interviewed individually in their clinical placements. Data analysis revealed three major categories: understanding the process of reflection, using reflection in clinical practice, and needing support and guidance. Findings indicated that students were primarily using reflection-on-action, but to varying extents. Overall, students felt that reflection facilitated their learning. Factors were discovered that both helped and hindered students' use of reflection. These included level of preparation to reflect, a limited culture of reflection and the level of support from preceptors, clinical staff, clinical placement co-ordinators, and lecturers. In conclusion, it appears that a collaborative approach between students, Health Service Providers and institutes of nursing is vital for the successful development and implementation of reflective learning strategies in clinical placement. Suggestions are made as to how a collaborative approach may be developed to enhance this process.

User participation in mental health nurse decision-making: a co-operative enquiry

AIM

This paper is a report of a study to encourage participants to work together to identify strategies for increasing user participation in clinical decisions and to evaluate the value of co-operative inquiry as a vehicle for supporting learning in practice.

BACKGROUND

Service user participation in the clinical practice decisions of mental health nurses is considered essential for good practice. Methods need to be found which enable opportunities for shared learning, facilitate practice development and empower service users.

METHOD

A co-operative inquiry design engaged all participants (n = 17) as co-researchers and involved repeated cycles of action and reflection, using multiple data collection methods. The research was conducted over a two year period in 2004-2005, with mental health nursing students collaborating with service users.

FINDINGS

Factors inhibiting participation included stigmatizing and paternalistic approaches, where clinical judgments were made solely on the basis of diagnosis. Enhancing factors were a respectful culture which recognized users ''expertise' and communicated belief in individual potential. Inquiry benefits included insight into service users' perspectives, enhanced confidence in decision-making, appreciation of power issues in helping relationships and deconstruction of decision-making within a safe learning environment.

CONCLUSION

Learning from novel approaches which enable nursing students to develop their reflective and reflexive ability is essential to avoid practice which disempowers and potentially harms service users' recovery. Co-operative inquiry is a valuable vehicle for developing professional practice in higher education and practice environments.

Reflecting during clinical placement - Discovering factors that influence pre-registration psychiatric nursing students

As the debate surrounding reflection continues there are recommendations that Irish pre-registration nurses should use reflection as a strategy to facilitate the development of competencies. In one School of Psychiatric Nursing, diploma student psychiatric nurses were already using reflection as an aid to develop their competencies in the course of their clinical placements. The aim of this study was to explore student psychiatric nurses' perceptions of reflection as a learning strategy during clinical placement. Using a constructivist qualitative methodology third year students were interviewed individually in their clinical placements. Data analysis revealed three major categories: understanding the process of reflection, using reflection in clinical practice, and needing support and guidance. The latter category, which is explored in this paper, indicated that a number of factors influenced how students engaged in reflection during clinical placement. Findings also indicated that the mentor, the clinical placement co-ordinator and the lecturer have key roles. It is suggested that as students need more adequate preparation and ongoing support to reflect that a collaborative approach between health service providers and the learning institution, regarding the development of reflective strategies, is vital if reflection is to be an effective learning tool in clinical placements.

Assessment of clinical practice in intensive care: a review of the literature

Nursing is a practice-based discipline, with clinical practice forming the heart of any programme of study. The major goal of all programmes should be on facilitating students to develop the skills necessary for competent and compassionate practice. Assessment of clinical competence is a fundamental aspect of programme development and as such deserves attention during the curriculum design process. The literature on assessment of students in clinical practice suggests that the tools used have evolved through various stages, ranging from the use of simple check list and rating scale to the development of competence assessment tools. Each stage has been fraught with difficulties and has taxed nurse educators, clinical assessors and students alike. The literature also indicates that there is a limited range of research available on clinical assessment tools, especially with an intensive care context. In part one of this two-part paper, the literature on assessment of clinical practice is explored, with specific emphasis on the assessment of competence with the Intensive Care environment. Part two of the paper reports on the findings of a study on students perceptions on a clinical competence assessment tool, used in an Intensive Care environment.

The deconstructing angel: nursing, reflection and evidence-based practice

This paper explores Jacques Derrida's strategy of deconstruction as a way of understanding and critiquing nursing theory and practice. Deconstruction has its origins in philosophy, but I argue that it is useful and relevant as a way of challenging the dominant paradigm of any discipline, including nursing. Because deconstruction is notoriously difficult to define, I offer a number of examples of deconstruction in action. In particular, I focus on three critiques of reflective practice by the meta-narrative of evidence-based practice (EBP) and attempt to show how those critiques can be directed back at EBP itself. I conclude with the observation that EBP is open to many of the criticisms that it directs at other discourses, including problems of a lack of empirical evidence, of distortions due to memory, and of falsification of the 'facts'.

Reflection in preregistration nursing curricula

BACKGROUND

The concepts of reflection and reflective practice are increasingly popular themes in the nursing literature. Reflective practice has been advocated as a method for overcoming the divergence between nursing theory and practice, and as a means of articulating and developing knowledge embedded in practice. However, these claims are based more on theoretical debate than research evidence. In common with other regulatory bodies, the Irish regulatory nursing body advocates the need for reflective nurses, and curricula are being adapted to reflect this. These changes are taking place when there is still little guidance on the teaching or assessment of reflective practice. Given the lack of research on the topic and the need for evidence on which to base the teaching of reflective practice, a descriptive exploratory study was undertaken.

AIM

The aim of this paper is to report how a group of nurse teachers perceived and interpreted reflective practice in preregistration nursing curricula in schools of nursing in The Republic of Ireland.

METHODS

Data were collected using a postal questionnaire distributed to all schools of nursing involved in the preregistration diploma in nursing (n = 40).

RESULTS

The results indicate variation between institutions in the number of hours allocated to the subject and where reflective practice was included in the curriculum. Emphasis was placed on theoretical models of reflection as opposed to the process or the skills required to become a reflective practitioner. Lecture and group discussion were the dominant teaching methods. Additionally, a number of teachers expressed dissatisfaction with the preparation they had received to teach the subject, and identified some of the challenges they experience when teaching reflective practice.

CONCLUSIONS

The results provide a focus for further debate amongst nurse educators involved in implementing reflective practice in the curriculum. The results are limited by a response rate of 50% and by the geographic setting. Further research is needed to substantiate the findings of the study. However, there results do suggest that there is a need to clarify curricular content in relation to reflective practice and prepare nurse tutors for their role in teaching this subject more effectively.