Reflective practice: using the action learning group mechanism lain W Graham

lain W Graham MEd MSc BSc RGN RMN, Associate Dean, Institute of Health and Community Services, Bournemouth University, Bournemouth House, 17 Christchurch Road, Bournernouth BHI 3LG, UK

(Reprint requests to IWG) Manuscript accepted 9 March 1994

Many practising nurses, midwives, health visitors and their educators recognise the phenomena of the theory-practice gap. Due to social, economic and political developments it is now crucial for the gap to be closed. This paper provides a commentary on how one mechanism, called an action learning group (ALG), has been utilised in a post-registration diploma/degree programme in Nursing and Midwifery Studies as a method to secure that closure.

Presented within the introduction to the paper is a discussion on reflective learning and its understanding by an academic team. The paper then considers the ALG formula with discussion upon its uses and an example of student experience. The paper concludes by discussing the aspirations of the academic team with regard to ALGs and their role in post-registration nurse, midwife and health visitor education.

The paper was presented at the 3rd Yorkshire Regional Health Conference on Nursing Development Unit activity on 19 March •993. This was because the proforma has been utilised not only in curriculum development and delivery but also with various Nursing Development Units within the Yorkshire Region in an attempt to help the nurses in those units identify and close their respective practice-theory gaps.

I N T R O D U C T I O N

According to Grey & Pratt (1992):

To be a reflective practitioner suggests pro- fessional maturity and a strong commitment to improving practice.

This statement formed the essence of devel- opment for an academic team of nurses and midwives with regard to their curriculum en- deavours at both under- and post-graduate level. It was believed by the team to be an essential learning device to aid their overall strategy ofempowerment and emancipation for qualified nurses, midwives and community nurses. Such a development, could, it was believed, enable a registered practitioner to improve and advance their practice by incorpo- rating reflection into their everyday work at a conscious level. The aim of reflective practice - according to the literature (Powell •989, SchrSn 1983) - is to advance one's thinking at a conceptual level, and thus be better able to change, in this case nursing, midwifery or health visiting, at a professional, social and political level.

REFLECTIVE L E A R N I N G

It is perhaps the work of Dewey (1933) and Schrtn (1983, 1987) which have heightened the awareness o f nurse educationalists to the issue o f theory in practice. It is perhaps crucial therefore, if the nursing professions are to suc- cessfully negotiate their future in health care as practice disciplines, that they successfully link their theories to their practice or perhaps utilise their practice to generate new theories. This may require though, some mechanism to allow experience to be reflected upon and thereby allowing theory and practice to be linked, in a more realistic and pertinent way. It seemed to the academic team that the curriculum should take into account the experiences o f practice that the post-registration students have already had, during their careers, and make use of them so to inform future practice.

Experience is, according to Benner (1984):

... not just the mere passage of time [but] is the refinement of preconceived notions and theory through encounters with situations ....

Practitioners, it can be argued, have many 'situations' with their patients/clients. Each 'sit- uation' is filled with much potential learning and development, yet often this learning goes unlearned and the development is not acknow- ledged. Benner (1984) discusses these 'situations' as paradigm cases and states how they can be developed by the 'expert' nurse into useful learning. Yet for many practitioners having the experience alone will not necessarily mean that one will have learned something, a structure is required to facilitate an understanding of the experience and therefore define the learning. The academic team were more than aware that

Nurse Education Today (I 995) 15, 28-32 © 1995 Pearson Professional Ltd

Reflective practice 29

people utilise reflection often in their everyday lives and many consider it to be an important human activity. Should not the utilisation of reflection as a learning mechanism, to make sense of experience, therefore be included within an academic programme? This is in order that students could be encouraged to ponder upon their nurse/patient experience, and therefore in turn their practice, and then in turn have that practice validated by peers. The end goal would be to see reflection as an important part of learning and self-develop- ment for a registered nurse, midwife or health visitor.

Boud et al (1985) argue that reflection is a sub-conscious activity so the team considered in detail how this sub-conscious activity could be formalised and have the process facilitated. Reflection is not a new concept and many theorists have included the concept in their writing on learning theories (Lewin 1947, Kolb 1984). Yet what was missing was a detailed description of the mechanism of reflection. After much debate within the team it was in the end two mental health nurse team members who recalled how they themselves had used reflection techniques with clients in the form of group work. This led the team to the conclu- sion that a combination of group therapy skills and the work of Dewey (1933) would perhaps provide the team with the process mechanism of reflection for the post-registration diploma/ degree curriculum.

Dewey (1933) states that the qualities neces- sary to undertake reflection include: having an open mind; being responsible; having a whole- hearted approach in order to consider all sides of an argument; being able to consider the out- comes of actions you might wish to undertake; and taking active control over your own edu- cation and practice. It was most apparent to the two mental health nurses that Dewey's criteria were similar to the ones they had met before when they had undertaken group therapy training and had studied the work of Irvin Yalom (1983).

In learning how to run an in-patient group psychotherapy session, issues like past experi- ence of life, opinions and expectations are dealt with along with personal responsibility and self-awareness. These issues were felt by the team to be transferable to post-registration stu- dents where along with post-clinical experiences and post-educational experiences a wealth Of information from which new learning can take place could be identified. This is a similar fea- ture for mental health clients too, if they are undertaking psychotherapeutic interventions - what Schr6n (1983) describes as 'reflection in action'.

The student therefore needs, like the mental

health client, to be able to conceptualise what ' know-how' knowledge is required in order to understand experience. Benner's 0984) work which describes this ' know-how' knowledge, within the novice to expert framework, was also utilised to enable the mechanism of reflect- ing to be given structure. The framework in turn enabled the students to identify and name their ' know-how' knowledge, gained from dis- closure of current experience, within the ALG discussion, supported by the keeping of a learn- ing journal. The team felt that by providing a group-therapy mechanism, reflective practice could be initiated in a collaborative manner with all post-registration students (i.e. Health Visitors, District Nurses, Communi ty Psychi- atric Nurses, Nurses, Midwives, Occupational Health Nurses, School Nurses and Practice Nurses), sharing in the process and therefore revealing to each other not only individual responses to practice issues but generic issues of practice which are germane to the discipline of the nursing professions as a whole.

It is perhaps the Australians (Grey & Pratt 1992) who lead the way on reflective practice with regard to nurse education and practice. Many Australian scholars in nursing see it as a means of bringing nursing theory and practice together through praxis (reflection and action). It is seen, by such scholars, as a most viable means by which to increase self-understanding and nursing knowledge. The academic team believe that reflection in practice is an ideal means of understanding the human condition which after all is the reason nurses nurse and patients entrust nurses to make them not only better but also healthier. The team believe the purpose o f nursing, midwifery and health visit- ing is to manage the person as he/she negotiates the health-illness continuum. This requires that the practitioner reflects on each individual as they negotiate this continuum, for each indi- vidual will experience the negotiation differ- ently and what may work for one will not nec- essarily work for another.

The academic team has encouraged reflec- tive learning within a number ofpre- and post- registration modules. This learning style is wide and varied and ranges from care plan writing and reflective assignments to syndicate and action learning group initiatives. They all have, as a theme issue, emancipation and empower- ment and raise the concepts of accountability and ethical concern within the domain o f the new professional ideology and professional cul- ture o f the nursing professions and their respec- tive areas of practice. Figure 1 displays the many topic areas of debate and discussion which take place within the ALG format. An insight to its potential can be understood by considering the following example.

30 Nurse Education Today

SOCIAL TO VERBALISE AND JUSTIFY ROLE/AC'TIVITY SELECTION

i f ' N . SUPPORT THROUGH x~.xEARNING DIFFICULTIES

A s AN ANTIDOTE

TO "TAKE STOCK

~ U N d ~ '

FOR STRAY DURING "HIATUff f PERIODS 1N THE RESEARCH

FIME! TO HELP FORMULATE THEORY

~ TO ELABORATE FURTHER CLARITY OF FIELD NOTES

RATOR" OF CTICE ISSUES

OF

~ . ~ ~ AS A TEST BED" FOR POTENTIAL \ N RESEARCH OR NEW PRACTICE

AS A "SOUNDING BOARD" TO CHALLENGE j J / OR BRAKE ON LEARNING CONCEPTS, ASSIST

/ " ~ CONCEPTUALISATION TO PREPARE FOR (RE) INTERVENTION TO PROVIDE ADVICE INTO "FIELDWORK" / ~ " ~

J / TO ENCOURAGE THE DEVELOPMENT ~ ' ~ / OF LINKS BETWEEN THEORY AND PRACTICE LOCATING LEARNING

INTRODUCE, SHARE, DISCUSS ~ . / IN LOCAL/NATIONAL LITERATURE TO "CRYSTALLIZE n CONTEXT

IDEAS

Fig. I, Potential uses of an action learning group.

An example of the use of an ALG

Within one ALG, one health visitor student, decided to reflect upon the activity of weighing babies at the Well-Baby Clinic when she was on placement.

The student utilised the group to 'verbalise and justify' the role/activity and then to 'take stock' of the activity, she followed that by 'challenging concepts' and used the group to assist her 'conceptualisation o f the issues' before 'crystallising' them and preparing new 'inter- ventions'. The whole process enabled her to use the group as a 'sounding board' for change. Members o f the group were not just profes- sional colleagues but were also mothers and fathers. The 'sharing' o f ideas and experiences from their respective personal histories helped the student to consider, in depth, the function o f Well-Baby Clinics and the role o f the health visitor. This experiential learning was aided by more formal learning in the form of literature reviews and lectures/tutorials. The end result was that the student felt confident to introduce change to the Well-Baby Clinic routine. She was enabled to do this by using the ALG as a 'test-bed' for debate and the whole learning experience to produce a consultation paper for change. This included a care-protocol of best practice based on her total learning. The stu- dent evaluated the learning in a most beneficial way stressing, in her evaluation, in her own words, the 'realness' of the learning that had taken place. The ALG therefore had provided the student with a means by which to test theory within a safe environment. In fact what it revealed, to the student and her colleagues, was the synergy which must take place be- tween abstract theory and practice reality for any health practitioner. If the practice is to be

meaningful then it must fit the context of human experience and personal expectation.

The action learning group

Within this paper the action learning group mechanism of reflection is shared with the reader by disclosing the aims and objectives (see Appendices 1-4) o f such a learning style along with the proforma of running such a group. This format is based upon the work o fBoud et al (1985) and the dynamics of group processes. This method of reflective learning is chosen to present because its application is not just perti- nent to curriculum work, but because the team believe it is pertinent to practice development in its own right. This view is shared by NHS Service Provider Units who have involved members of the team in facilitating ALGs within clinical practice; as they also see this as a powerful way of helping them achieve better practice.

C O N C L U S I O N

It is hoped by the team, that by synthesising the work of Benner (1984), Schrtn (1983), Dewey (1933) and Boud et al (1985) to formulate guidelines to run the action learning groups, staff members will be able to facilitate students' abilities to change from reflection-on-practice to reflection-in-practice and therefore move the student from novice to expert.

The staff members know that it is their responsibility to make the students aware o f this process and not to glibly accept that practition- ers innately know how to utilise reflection.

Reflective practice 31

Dewey (1966) pointed out that a curriculum for a practice discipline cannot emphasise only

the theoretical, it must also help students to understand the relationship between theory and practice. The staff members themselves need to have regular updating on reflective techniques in order to run successful action learning groups. This is often difficult to arrange and requires much creative work and initiative by the professional head to secure this resource. The staff are commit ted to it as a learning tool, though the change o f learning style has been painful for some. The process is now, after a year of informal piloting, ready to move into the formal requirement for diploma and degree work and subsequent award. Students, on the whole, enjoy the learning, from seemingly anecdotal talking to critical analysis of their practice. What the staff have

discovered is that nurses, midwives and com- munity nurses do use the action learning group to disclose the self-damage that the individual practitioners' careers have involved them with. These disclosures, in themselves, become pow- erful learning devices by which students look at their past experiences and learn how to formu- late strategies for the future in an environment that is secure, rewarding and supportive. The future intention was to carry out some evalua- rive research to discover i f the action learning group proforma does achieve the aims o f reflective learning and improved practice. This research commenced in the new academic year 1993-1994 with two projects looking at the benefits of reflection in practice within two dis- crete clinical teams. Research, which is utilising a critical social science methodology, is also being conducted into the whole issue o f place- ment learning and the reflective learning mech- anisms utilised by the staff to aid pre-registra- tion students bridge the theory-practice gap issues that they encounter. This is perhaps exemplified by Allen (1985) who writes:

The advantage o f critical social science for nursing and nurses is that it offers the oppor- tunity to shatter the ideological mirror that traps us and our clients ... it forces us to question that status quo at every turn ....

One can postulate that the answers to the questions currently being asked about the nurs- ing professions and their practice are to be found within current practice. Therefore it becomes crucial to emancipate that practice so that one can liberate the practitioners so that better patient care can be realised.

Emancipation is a key concern of critical theory analysis and what reflective practice enables one to do is become self-emancipated. It does this by allowing one to become aware o f one's experience. One learns to analyse the

sources o f one's interpretations, to question and resist the predefined meanings one is encour-

aged to adopt. In so doing one can move to a position of autonomy and responsibility because one can take personal accountability for one's actions. These actions are shaped by one's awareness o f self in terms of beliefs and values, feelings and reactions to many situa- 6ons. Reflective practice helps one to centre these feelings and beliefs so that a congruence and understanding o f actions can take place and one can achieve professional maturity and pro- found confidencei

This is achieved with some success by utilis- ing the ALG proforma for it affords a unique opportunity for practitioners to look not only at themselves but also at their practice and the context o f that practice. It is to be hoped that such scrutiny may well enable practitioners to articulate that practice and therefore deliver the

full potential o f the nursing professions, to health care, as a unique service within health care. What we are discovering is the unique ways in which practitioners are practising their skill, knowledge and attitude and thereby 'putt ing the patient in the best position for Nature to act upon him' (Nightingale 1860).

REFERENCES

Allen D 1985 Nursing research and social control: alternative models of science that emphasise understanding and emancipation. Image -Journal of Nursing Scholarship XVII (2): 58-64

Benner P 1984 From novice to expert. Addison-Wesley, Memlo Park, p 36

Bear&haw V, Robinson R 1990 New for old: Prospects for nursing in the 1990's, King's Fund Project Paper. King's Fund, London

Boud D, Keogh R, Walker D 1985 Promoting reflection in learning. In: Reflection: turning experience into learning. Kogan Page, London

DeweyJ 1933 How we think. DC Health, Boston DeweyJ 1966 The relationship of theory to practice. In:

Borrowman M (ed) Teacher education in America: A documentary history. Teacher College Press, New York

Department of Health 1993 The nursing, midwifery and health visiting contribution to health and health care. Nursing Division, Department of Health, London

Grey G, Pratt R 1992 Towards a discipline of nursing. Churchill Livingstone, Edinburgh, p 335

Kolb D A 1984 Experiential learning experience as the source oflearning and development. Prentice Hall International, New Jersey

Lewin K 1947 Frontier in group dynamics: social planning and action research. Human Relations 1:143-153

Nightingale F 1860 Notes on nursing: What it is and what it is not. Harrison 86 Sons, London, p 142

PowellJ 1989 The reflective practitioner in nursing. Journal of Advanced Nursing 14:824-832

Schr~Sn D 1983 The reflective practitioner: how professionals think in action. Basic Books, New York

Schr~Sn D 1987 Educating the reflective practitioner. Jossey-Bass, San Francisco

Yalom I D 1983 Inpatient group psychotherapy. Basic Books, New York

32 Nurse Education Today

APPENDIX I

Action learning group

Aims To, along with the learning journal, reflection on one's own personal development and to encourage one to share the development.

G o a l s

1. To provide a forum where the record of significant learning experiences can be shared.

2. To help the participant come into touch and keep in touch with the self-development process that is taking place.

3. To provide the participants with an opportunity to express - disclose in a personal and dynamic way their self- development.

4. To foster a creative interaction in a trusting environment. - between the participant and the self-

development process that is taking place. - between the participant and other partici-

pants who are also in the process o f self- development.

- between the participant and the facilitator whose role it is to foster such development.

5. To provide a means of reflecting on one's commitment to and involvement in the discipline of nursing, midwifery or health visiting.

APPENDIX 2

P h a s e O n e

A preparatory phase in which the individual considers the demands of the experience ahead and the resources required. The anticipation of the experience. Criteria for consideration by group members

- the environment itself, where practice occurs: both social and physical.

- the roles o f significant players, client groups and practitioners.

- the climate of the workplace: professional, political, social.

- your feelings, fuelled by experience, reality and academic learning, historical perspectives.

N.B. Complementary reading is required around these subjects, with students drawing information from nursing theory and the sup- porting disciplines.

APPENDIX 3

P h a s e T w o

An experiential phase in which practice occurs. Criteria for reflection. Select the placement. Select the nursing role/activity. Select processing time: time to write out the experience. Aim for completeness of the recording provid- ing a beginning - middle - end. Record process straight away. Be flexible. Aim to write thoughtfully, deliberately and considerately. Remember the purpose of the enquiry is to reflect upon your own practice as a nurse, and the practice o f others, in order to arrive at a deeper and more significant under- standing of nursing.

APPENDIX 4

P h a s e T h r e e

A processing phase in which the preceding events are reconstructed in order to make sense of them. Criteria for discussion with the ALG. Write out in full the process - utilise your field notes, memories, thoughts and feelings about the role/activity and yourself Return to the experience by re-reading the transcription. Revisit the placement. Attend to new feelings. Re-evaluate in the light of the above. This re-evaluation will require the following:

- association (relating new data to that known).

- integration (seeking relationships amongst the data).

- validation (determining authenticity of ideas and feelings).

- appropriation (making knowledge one's own).

All the above to take place within the action learning group.

N.B. There is no right and wrong way. One aims to develop a personal conceptualisation or theory from as wide a range of reading and observation as possible.