the clinical learning spiral: a model to develop reflective practitioners

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  • NurseEd~rnkm T&J (1994) 14,363-371 0 Longman Group Ltd 1994

    The Clinical Learning Spiral: a model to develop reflective practitioners

    Lynette Stockhausen

    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.

    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.


    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

    Lynette Stockhausen RN DipTeach-Nsg BEd-Nsg MEdSt, Senior Lecturer, School of Nursing, Griffith University-Nathan Campus, Kessels Road, Nathan, Brisbane, Australia 4111

    (Requests for offprints to LS) Manuscript accepted 9 February 1994

    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).

    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



    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.

    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).

    Reflection as perceived in this context suggests

    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

    clinical experience.


    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

    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.

    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.

    The Clinical Learning Spiral was developed utilising other models of experiential learning with particular reference to the Action Research Cycle (Carr & 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.

    An overview of the development of the Clinical Learning Spiral with reference to the previous models are contained in the following discussion.

    The Action Research Model (Carr & 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.


    Constructive Phase

    Reflective Phase

    Reconstructive Phase



    Fig. 1 The Clinical Learning Spiral

    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

    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.

    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).



    the parameters of the

    Fig. 2 The Clinical Learning Cycle

    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.

    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.

    During the first phase, students undertake sev- eral preparatory activities. This may include ori-

    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.

    The second phase involves the facilitation of the learning experience. There are five stra