The clinical learning spiral: a model to develop reflective practitioners

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<ul><li><p>NurseEd~rnkm T&amp;J (1994) 14,363-371 0 Longman Group Ltd 1994 </p><p>The Clinical Learning Spiral: a model to develop reflective practitioners </p><p>Lynette Stockhausen </p><p>Reflective practice in clinical nursing is an exciting concept. Much of the literature on reflection has been derived from education. Recently the Australasian Nurse Registering Authority Committee (ANRAC) endorsed reflective practice as a registering prerequisite competency for beginning nurse practitioners. This paper examines the concept and development of an action research clinical learning spiral to foster reflective practice of both undergraduate students and their clinical teacher in the practice setting. The innovation of a mutual group, that is, teacher and students interacting through reflection to create a cooperative learning environment is explored. In designing the spiral a number of models were consulted and incorporated. </p><p>The action research clinical learning spiral adds structure and focus to the process of reflection-on-action and provides an avenue for students and the clinical teacher to set mutual goals of action to trial for future experiences. This process of reflection allows the clinical facilitator to be an integral component of success to the students learning in the clinical context. </p><p>REFLECTIVE PRACTICE </p><p>Reflective practice in nursing is an exciting con- cept. Although practised by nurses for many years, only recently has available literature regard- ing reflective practice in nursing emerged (Garrett 1991, Jarvis 1992). However, the concept of reflection is not new. Philosophers, education- alists and practitioners have been developing views of reflection since Aristotle first introduced practical judgement and moral action (McKeon </p><p>Lynette Stockhausen RN DipTeach-Nsg BEd-Nsg MEdSt, Senior Lecturer, School of Nursing, Griffith University-Nathan Campus, Kessels Road, Nathan, Brisbane, Australia 4111 </p><p>(Requests for offprints to LS) Manuscript accepted 9 February 1994 </p><p>1974). Since then much has been written and researched regarding reflection. Some of the sig- nificant contributors to this school of thought include Dewey (1933), Kolb and Fry (1975)) Kemmis (1985), Boud, Keogh and Walker (1985)) Zeichner (1983), Schon (1983) and Benner (1984). </p><p>The process of reflection is an integral factor in the organisation of our daily activities. From the first time we look in the mirror, to when we retire at night, we replay on our minds the days events, often analysing them and reexamining what has occurred in our lives. Boud et al (1985) note that reflection comprises of those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciation. Their defini- tion implies that reflection is goal orientated and </p><p>363 </p></li><li><p>364 NURSE EDUCATION TODAY </p><p>that feelings and cognitive abilities are interwo- ven. The underlying assumptions being that indi- viduals are in control of the activity, that reflec- tion can take place in isolation or in association with others, such as peers or the clinical teacher, and finally that reflection is not an end in itself, but, preparation for new experiences. </p><p>Learning through practice and reflective pro- cesses have been expounded by Kolb (1984) within the terms of his experiential learning the- ory. The theory suggests that learning, change and growth are facilitated by cyclic processes. Such experiences involve direct experiences, reflection on the experience, and abstract con- cept formation from which behaviour may be modified to aid new experiences. Similarly, reflec- tion has been viewed as the link between theory and practice (Schon 1987). </p><p>Reflection as perceived in this context suggests </p><p>that learning is facilitated by early active engage- ment in practice. Without reflection, experiences would remain unexamined, with the full potential for learning by the participants not fully realised. Within the education literature on reflective prac- tice there is a dimension of an elusiveness to learning that is persona!, developmental and embedded in the experience of the learner (Boud 1988). In order to actualise these learning episodes the role of the clinical teacher becomes an integral part of the reflective process. As such, the clinical teacher, rather than being external to the process of learning, is an essential and strate- gic component to that learning. The clinical teacher has the opportunity to become captured in the developmental and cyclic nature of the total experience, facilitating, not controlling, the </p><p>clinical experience. </p><p>A FRAMEWORK FOR REFLECTIVE PRACTICE </p><p>Reflection has been identified as a prerequisite competency for beginning nurse practitioners in Australia (ANRAC 1990). In order to facilitate stu- dents achievement of this competency, a frame- work to encourage reflection within nursing cur- ricula was reauired. As such. the Clinical </p><p>Learning Spiral (Stockhausen 1991) was devel- oped for the purpose of incorporating and devel- oping reflective processes in undergraduate nurs- ing clinical practice. The spiral has been trialed successfully with a cohort of second year students and their clinical teachers in a Bachelor of Nursing programme. </p><p>The framework of the spiral incorporates the theoretical elements of clinical education and structures the management of the clinical experi- ence. Inherent within this framework are those elements necessary to successfully prepare, induct, implement and evaluate reflective clinical practice experiences. </p><p>The Clinical Learning Spiral was developed utilising other models of experiential learning with particular reference to the Action Research Cycle (Carr &amp; Kemmis 1986), the Reflective Process Model (Boud 1985) and the Critical Experiential Learning Model (Chuaprapaisilp 1989). Each of these models when integrated pro- vides a framework that incorporates all aspects of undergraduate clinical experiences. It was felt that no one model alone consolidated features of clinical experiences that captures the balance, transference and significance of theory and prac- tice and is uniquely nursing orientated. </p><p>An overview of the development of the Clinical Learning Spiral with reference to the previous models are contained in the following discussion. </p><p>The Action Research Model (Carr &amp; Kemmis 1986) has four cyclic phases of planning, acting, observing and reflecting. These four phases are linked into a cycle that recreates itself into a self reflective spiral (Figs 1 8c 2). In this sense no com- ponent of the model can be conducted indepen- dently of the other. The Carr and Kemmis model premises that a group and its members, collec- tively and collaboratively undertake the four phases of the cycle. Practice is viewed within a political, economic, historical and social context. From this perspective, examination and reflection of practice leads to a new social consciousness and change. Bartlett (1990) suggests that actions are intentional and are to be understood in the social context of their occurrence. As such, delibera- tion and analysis of ideas about nursing as a form of action, based on our changed under- standing, is highlighted. </p></li><li><p>NURSE EDUCATION TODAY 365 </p><p>Constructive Phase </p><p>Reflective Phase </p><p>Reconstructive Phase </p><p>I </p><p>I </p><p>Fig. 1 The Clinical Learning Spiral </p><p>The process of reflective learning as postulated by Boud et al (1985) involves three stages that are inter-related and cyclic in nature. Following an initial experience the first stage of the reflective process is returning to the experience. Here stu- dents recollect the events that have occurred and reexamine their reactions to those events. The chronological sequence of events is recalled in a descriptive rather than judgemental manner. The second stage is attending to feelings, which allows for emotions to be identified, examined and challenged. The focus on feelings heightens the learners self awareness and enables them to enhance and retain positive emotions and discard </p><p>negative feelings. The final phase is that of pro- cessing, where the events that occurred during the experiential phase are reconstructed by the learner in order to make sense of them. This phase requires indepth reflection and introspec- tion. </p><p>As the learner processes their experiences, Boud et al (1985) suggest that a reevaluation occurs. During this activity students link new data to what is already known (association), seek rela- tionships amongst this data (integration), deter- mine the authenticity of ideas and feelings (vali- dation) and create a personal understanding or knowledge about the event (appropriation). </p></li><li><p>366 NURSE EDUCATION TODAY </p><p>CONSTRUCTIVE PHASE </p><p>the parameters of the </p><p>Fig. 2 The Clinical Learning Cycle </p><p>Through the use of the Reflective Process Model students are able to actively construct and arrange their knowledge of the world thus developing their own interpretational schema. </p><p>The Critical Experiential Learning Model (Chuaprapaisilp 1989) uses elements of the Carr and Kemmis model. It was developed specifically as a framework for learning from clinical experi- ences in nursing. Chuaprapaisilps model has three phases: preparation for practice, managing the experiential learning process and reflecting on the experience. </p><p>During the first phase, students undertake sev- eral preparatory activities. This may include ori- </p><p>entation to the clinical environment and the delineation of structures and procedures (devel- opment of personal learning objectives and undertaking client assessments) at the com- mencement of the experience. </p><p>The second phase involves the facilitation of the learning experience. There are five strategies in this phase which provide a plan to the total pro- cess. These are: structuring, organising, control- ling, facilitating and emancipating. In the struc- turing phase of the clinical experience, the clinical teacher assesses the clinical environment and then facilitates activities within a set time frame. The second strategy of organising involves </p></li><li><p>NURSE EDUCATION TODAY 367 </p><p>prioritising activities in order that students </p><p>receive adequate supervision in meeting their objectives. The clinical teacher and students also decide at this stage the format of debriefing ses- sions. </p><p>During the subsequent facilitating stage the clinical teacher provides ongoing individual con- sultation and explores avenues to provide success- ful clinical experiences for the student. The facili- tation of student learning requires clinical teachers to control their own teaching within a set time frame. In this sense the clinical teacher does not provide all the answers for the students. Instead teaching strategies which foster self- directed learning and critical analysis of issues is encouraged, such as student learning contracts. The final strategy is emancipation which encour- ages students to challenge approaches to nursing care and make decisions for change. </p><p>The final phase of reflection, as outlined by Chuaprapaisilp, is similar to the Boud et al (1985) model but with the inclusion and introduction of a critical theory approach to experiential learning. In this phase the clinical teacher attempts to create a democratic atmosphere where, together, students and clinical teacher, clarify objectives, structures, processes, roles and assumptions during debriefing sessions. </p><p>THE CLINICAL LEARNING SPIRAL </p><p>The Clinical Learning Spiral (Fig. l), developed by the author (1991)) draws on the previously dis- cussed models and personal reflective experience as a clinical teacher. The model was developed to emphasis the importance of reflective practice to the professional growth of a beginning nurse practitioner. The integration of Carr and Kemmis, Chuaprapaisilp and Boud et als key con- cepts provides a model that is clinically and goal orientated. This acknowledges practice by the self and others as a central tenet of professional edu- cation for nurses. </p><p>The Clinical Learning Spiral detail (Fig. 2) is represented by the preparative, constructive, reflective and reconstructive phases. </p><p>The Preparative Phase begins as the individual </p><p>considers the demands of the experience ahead, the resources required, the environment (sight, sounds, smells), the people (roles, relations, reac- tions and conflicts), the climate (social, political) and their role as learners in the clinical setting (reflector, participant, observer, facilitator) (Emden 1991). </p><p>There are two components to the preparative phase. The first is related to on campus classroom teaching and university laboratory sessions. This incorporates the development and exploration of nursing skills within a controlled learning envi- ronment. The second component is the briefing session which is conducted before the commence- ment of a clinical experience or day. This first phase assists the teacher of the clinical experience and the students to establish the parameters of the experience. During the briefing students are given the opportunity to identify personal and professional objectives to achieve during the clini- cal experience. At this time the clinical teacher fosters a climate for the students to achieve their objectives and may explore possibilities for creat- ing new learning opportunities. </p><p>The Preparative Phase allows the students to identify other resources (such as specific client needs or specialist departments) within the clini- cal environment that would create learning opportunities. The benefits of student initiated personal objectives highlights the students own learning needs and creates motivation to learn. The Preparative Phase can also be conducted on a one-to-one basis between students and the clinical teacher. Students have identified that this process of individual negotiation has been beneficial in providing them with the opportunity to set per- sonal goals for their experience and plan the care for their clients (Stockhausen 1991). </p><p>Each phase throughout the spiral is facilitated by journal writing which has been identified as the most widely used expression of reflection (Zeichner 1986). Students and clinical teachers are encouraged to write about events of signifi- cance which occur whilst undertaking clinical experiences. </p><p>The Constructive Phase allows students to undertake actual nursing skill development. This second phase incorporates the experience or </p></li><li><p>368 NURSE EDUCATION TODAY </p><p>actual practice of nursing which takes place dur- ing the practicum. The clinical experience is viewed from a perspective of completeness (beginning, middle and end). Observation of the students during this phase is crucial as reflections between the observer and the observed can heighten the experience and reveal different per- spectives of the same experience. </p><p>The Constructive Phase is the actual experience the students and the teacher share in the clinical </p><p>environment. This phase takes into consideration the dimensions of practice such as care planning, psychomotor s...</p></li></ul>

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