the clinical learning spiral: a model to develop reflective practitioners

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

Reflective practice in nursing is an exciting concept. Although practised by nurses for many years, only recently has available literature regarding 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 significant 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

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364 NURSE EDUCATION TODAY

that feelings and cognitive abilities are interwo- ven. The underlying assumptions being that individuals are in control of the activity, that reflection 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 processes have been expounded by Kolb (1984) within the terms of his experiential learning theory. The theory suggests that learning, change and growth are facilitated by cyclic processes. Such experiences involve direct experiences, reflection on the experience, and abstract concept formation from which behaviour may be modified to aid new experiences. Similarly, reflection has been viewed as the link between theory and practice (Schon 198’7).

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 practice 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.

A FRAMEWORK FOR REFLECTIVE PRACTICE

Reflection has been identified as a prerequisite competency for beginning nurse practitioners in Australia (ANRAC 1990). In order to facilitate students’ achievement of this competency, a framework to encourage reflection within nursing cur- ricula was reauired. As such. the Clinical

Learning Spiral (Stockhausen 1991) was developed for the purpose of incorporating and developing reflective processes in undergraduate nursing 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 experience. 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 provides 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 practice 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 component 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 understanding, is highlighted.

NURSE EDUCATION TODAY 365

Constructive Phase

Reflective Phase

Reconstructive Phase

I

I

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 students 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 learner’s 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 relationships 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).


CONSTRUCTIVE PHASE

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 experiences in nursing. Chuaprapaisilp’s 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 (development 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 strategies in this phase which provide a plan to the total process. These are: structuring, organising, controlling, facilitating and emancipating. In the structuring 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


prioritising activities in order that students

receive adequate supervision in meeting their objectives. The clinical teacher and students also decide at this stage the format of debriefing sessions.

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 facilitation 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.

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.

THE CLINICAL LEARNING SPIRAL

The Clinical Learning Spiral (Fig. l), developed by the author (1991)) draws on the previously discussed 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 al’s 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 education for nurses.

The Clinical Learning Spiral detail (Fig. 2) is represented by the preparative, constructive, reflective and reconstructive phases.

The Preparative Phase begins as the individual

considers the demands of the experience ahead, the resources required, the environment (sight, sounds, smells), the people (roles, relations, reactions and conflicts), the climate (social, political) and their role as learners in the clinical setting (reflector, participant, observer, facilitator) (Emden 1991).

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 environment. 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 clinical 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.

The Preparative Phase allows the students to identify other resources (such as specific client needs or specialist departments) within the clinical 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 personal goals for their experience and plan the care for their clients (Stockhausen 1991).

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 significance which occur whilst undertaking clinical experiences.

The Constructive Phase allows students to undertake actual nursing skill development. This second phase incorporates the experience or


actual practice of nursing which takes place during 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.

The Constructive Phase is the actual experience the students and the teacher share in the clinical

environment. This phase takes into consideration the dimensions of practice such as care planning, psychomotor skills, attitude and interpersonal communication development and evaluation of care. The establishment and maintenance of relationships, especially with the client and staff of the agency, is also highlighted within this phase.

The third phase of the clinical spiral is the Reflective Phase. Time is allocated for purposeful inquiry so students can deliberate on aspects of their development as a nurse. Consideration is given to others involved in the student’s practice

such as the patient, peers, registered nurses, the clinical teacher and other health care professionals.

The reflective phase is facilitated by a debrief-

ing process. This allows the students the opportunity to ‘return to the experiences’ of the

Constructive Phase and highlight significant exemplars and events from the day. Debriefing may occur at intervals throughout the day, but always at the end of a clinical day or experience.

The reflective phase can be initiated at anytime on a one-to-one basis between a student and clinical teacher, peer or registered nurse. It is particu- larly important to provide a reflective phase for constructive feedback to students following some aspect of their nursing practice development.

This may be, for example, a psychomotor skill, interpersonal interaction or professional enquiry. Later, during the group reflective phase, students have the opportunity to share personal reflections from their previous one-toone reflection or share extracts from their journals. During the group reflective phase the rest of the group share their experiences. The students sense of excitement, anxiety and relief, or how the patient felt or responded is explored. Horsfall (1990) notes that as students ‘share each others’ challenges, achievements and experience’ it is possible that

vicarious learning takes place. This phase also sets the scene to examine complexities, differences and subtleties not found in text books but learnt, or made explicit, as a direct result of being sub merged in the experience.

The learning processes espoused by Boud et al (1985) identify the importance of allocating time during which students can share feelings, thoughts and perceptions of their experiences. In this forum, students have the opportunity to exchange ideas, consider other points of view, draw conclusions and make comparisons from their clinical experiences. As a consequence of this planned reflection students arrive at a deeper and more meaningful understanding of the practice of nursing.

The final stage of the Clinical Learning Spiral involves the reconstruction of the learning experience. The Reconstructive Phase provides the students and the clinical teacher the opportunity to plan for change. The change may be in the form

of alternate nursing strategies/interventions in patient care, or changes in behaviour that foster interpersonal relationships or personal and professional development. There is a commitment to action as a result of the constructive and reflective phases. This is akin to the Action Research Cycle (Carr & Kemmis 1986) _ Reevaluation of the experience helps expand views and develop strategies

for future action (Boud 1988). The Reconstructive Phase ideally develops into

a set of negotiated, mutual goals set by the group as a consequence of reflections on experiences, journal entries and discussions during debrief- ings. Hedin (1989) notes that at the heart of clinical practice is ‘the development of meaning to the learner and the avoidance of imposing an other meaning on the learner’. It is the participants of the clinical experience who decide if reflections develop into action. Not every day will produce a new action as some reflections will not lead to any new consequences. Mutual goals are reconstructed from the constructive and reflective phases of the clinical learning spiral, as a direct result of practice. The intention is to make modi- fications to, or develop goals that can be acted upon. It is imperative that a commitment to action as a consequence of reflection is realised. For action to occur without reflection leads to


uninformed, unintentional behaviour. Reflection prior to and subsequent to action can ensure mutual goals are carried forward to the next situa- tion or spiral.

THE CLINICAL LEARNING SPIRAL IN ACTION

Using the Clinical Learning Spiral has provided structure to promote and develop reflective practitioners, enabling the ANRAC competencies within the reflective practice domain to be achieved. With active participation in all phases of the spiral students have begun to develop the art of reflection. Through self expression using journal writing and involvement in debriefing sessions students have had the opportunity to examine their practice, feelings and beliefs, and the consequences of these for patient care. This has been achieved through active participation in all aspects of the spiral. Students and the clinical teacher reflect on what is important to them and then contribute towards the maintenance of a supportive group as they pursue mutual goals of clinical practice.

The phases of the spiral and the processes involved are highlighted by using an example from previous research, by the author, for which the spiral was developed.

Spiral 1

Preparative phase During the briefing students identify their anxi- eties at being accepted by the staff of the organisation. Some students have used their journals to write about their impending experience. Students also explore strategies to overcome their fears. To help establish the parameters of the experience and rapport with the organisation and ward staff, as clinical teacher, I undertook the hospital’s orientation programme and introduced myself to the ward staff prior to the students’ first day.

Constructive phase A number of registered nurses are asked either by the charge nurses or myself (the clinical teacher) to assist students with their learning goals.

Students, registered nurses and clinical teacher interact throughout the day.

Reflective phase Students record in their journals learning inci- dents related to interactions and establishing interpersonal relationships with the registered nurses. Some of these reflections are shared with the group at debriefing, ‘I found the staff extremely friendly’. As the students’ clinical teacher I also wrote and shared my experiences with the students as I had received positive feedback from the staff regarding the students’ cour- tesy and attentive patient care. During debriefing the students were aware that their fears regarding the staff had been unfounded.

Reconstructive phase The students and clinical teacher decide to set a goal to: ‘Maintain and foster the collegial relationships established on the first day’.

Spiral 2

Preparative phase The students discuss the implications of the previous set goal to their nursing practice development. Students write and discuss their expected interactions with registered nurse. Objectives for the day are identified that incorporate these ideas.

Construction phases Students and registered nurses interact throughout the day providing patient care and fostering student skill development.

Reflective phase ‘I found “my RN” willing to help me, show me procedures’, ‘The Registered Nurse was receptive and open to my questions’ and ‘The RN took the time to explain the procedure to me’. These were some of the journal or spoken comments of the reflective phase. Students discussed the significant impact the Registered Nurse, as a role model, made to a perceived positive or negative clinical experience.


Reconstructive phase catalyst for their next learning experience. The Students and clinical teacher examine the impli- spiral is dynamic and flexible. It is not meant to be

cations of their debriefing and aim to: ‘Respect static or followed strictly from one step to the the Registered Nurses knowledge and input into next. There is no limit to the number of spirals the clinical experience’. Action from this goal was that can occur. Reflection and reconstruction recorded as: provide feedback to the Registered may occur between a student and clinical teacher Nurses for their invaluable input into student throughout the experience and may only take a learning.

Whilst the process did not finish after the second spiral it is evident from the example provided

that the Spiral is a worthwhile framework to be utilised in the clinical education. It provides the

students with evidence of the significance of their

lived experience. If students had only been

informed about the contribution the Registered Nurse can make to clinical practice this may not

have meant as much to the students as actually being immersed in the context. Students experi-

enced first hand that the Reeistered Nurse can

matter of minutes.

Developing reflective practitioners becomes an avenue to generate explanations of practice situa- tions and build upon practice knowledge. Aligning and complementing student and clinical

teachers’ reflections on clinical experiences has

the potential to provide more meaningful learn-

ing for students and rewarding teaching experi-

ences in the practicum.

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the clinical learning spiral: a model to develop reflective practitioners

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