Is Reflective Practice a Useful Task for Student Nurses? Reflective Practice a Useful Task ... despite the perceived barrier to good reflective ... Is Reflective Practice a Useful Task for Student Nurses?
<ul><li><p>111Asian Nursing Research September 2009 Vol 3 No 3</p><p>ORIGINAL ARTICLE</p><p>Is Reflective Practice a Useful Task for Student Nurses?</p><p>Mei Chan Chong*</p><p>Nursing Sciences Unit, Department of Allied Health Sciences, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia</p><p>Background Reflective practices have been advocated as a method to bridge the gap between nursingtheory and practice, and as a tool to develop knowledge embedded in practice.Aim The aim of this study was to examine the perceptions of student nurses towards reflective practicein their clinical practice.Methods A cross sectional descriptive survey was carried out to examine the perception of a cohort of108 final year, pre-registration Diploma of Nursing students towards reflective practice. A structured ques-tionnaire was used to collect the quantitative data. The questionnaire consisted of two parts; part A: per-ception of students towards reflective practice; and part B: issues reflected by students. Data collectedwere analyzed using descriptive statistics. All (n = 98) students completed the questionnaire.Results The mean score of perception to reflective practice was 4.07. Students found reflective practiceuseful to them with a mean score of 3.82, despite the perceived barrier to good reflective practice with amean of 3.60. The perception on the appropriateness of reflective practice as a tool to assess was 3.47. Thevalidity of reflective practice as an assessment tool for practical examinations was not conclusive, as themean score was only 3.47.Conclusion The results indicated that even though some students were skeptical with reflective prac-tice, they found it useful. The College of Nursing should review the content of reflective practice and pre-pare nurse educators for their role in teaching this subject more effectively. [Asian Nursing Research 2009;3(3):111120]</p><p>Key Words nursing students</p><p>*Correspondence to: Mei Chan Chong, Department of Nursing Science, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.E-mail: email@example.com</p><p>INTRODUCTION</p><p>Reflective practice has become a key issue which ismentioned regularly within the context of nursing andnurse education programs (Smith, 1998; Gustafsson,Asp, & Fagerberg, 2007; Howe, 2006). There hasbeen a great increase in interest of reflective practice</p><p>in the field of nursing and many researchers haveemphasized and enlighten us on the advantage ofreflective practice (Smith, 2005; Chamney, 2008;Clouder & Sellars, 2004; Platzer, Blake, & Ashford,2000). Reflective practice has been used to over-come the gap between nursing theory and practices,and to articulate and develop nursing knowledge</p><p>Received: June 18, 2009 Revised: June 18, 2009 Accepted: September 9, 2009</p></li><li><p>embedded in practice (Johns, 2002). Reflectioncould be the means to challenge and change valuesor beliefs (Green, 2002). Gustafsson et al. assertedthat the capability of reflective practice is vital indelivery and improving ethical and holistic nursingcare. The definition of reflective practice and reflec-tion remains debatable despite regular citations in theliterature of practice professions. What is reflectivepractice?</p><p>DefinitionThe definition of reflection is thinking deeply andcarefully, especially about possibilities and opinions(Cambridge International Dictionary of English,1995). In the area of education reflection, JohnDewey (1933) as cited by Cotton (2001), haddefined reflection as the active, persistent and care-ful consideration of any belief or supposed form ofknowledge, in light of the grounds that support it andthe further consequences to which it leads. Deweysconceptualization of reflection is supported by Schon(1987), that it is an important learning strategy tohelp professionals become aware of their implicitknowledge base. Maclean (2006), describes reflectionas involving thinking about, and critically analyzingour experiences and actions, with the goal of improv-ing our professional practice.</p><p>As for nursing, Johns (2002), has defined reflec-tion as, a window through which the practitionercan view and focus themselves within the contextof her own lived experience in ways that enable herto confront, understand and work towards resolvingthe contradictions within her practice, between whatis desirable and actual practice. Through the conflictof contradiction, the commitment to realize desirablework and understandingwhy things are as they are,the practitioner is empowered to take more appro-priate action in future situations. In short, reflectivepractice is associated with relationships and to indi-vidual needs and to a larger extent emotional andpersonal feelings that have impacted on the intel-lectual reflective learning (Boud & Walker, 1998;Mezirow, 1998). Nurses could be empowered throughreflective practice (Issitt, 2003), to enable them torender nursing care with better understanding, foster</p><p>self awareness, become more competent, and tomotivate changes and improve the quality of holisticnursing care (Gustafsson & Fagerberg, 2004; Marrow,Hollyyoake, Hamer, & Kenrick, 2002).</p><p>Components of reflective practiceReflective practice should be a continuous cycle in which experience and reflection on experiences,are inter-related. This is illustrated by a modeldeveloped by Boud, Keogh, & Walker (1985) thatreflection involves returning to the experience,attending to the feelings and re-evaluating the expe-rience based on current knowledge and intent andintegrating this new knowledge into your conceptualframework. There are more examples of models inthe literature by Burnard, 1991; Gibbs, 1988a, andMezirow, 1998. Burns, Bulman and Palmer (2000),suggest that Gibbs (1988) model is useful becausemany practitioners have used it and found it to besuccessful.</p><p>The reflective cycleReflective practice is a dynamic process whichrequires a cyclical approach. Gibbs (1988) modelillustrates a framework for experiential learning andguides the user through a series of questions whichprovides a structure for a reflective experience.</p><p>Emerging interest of reflective practice, has beenrecognized as an important concept to consider in thereview of the Nursing Diploma Programme curricu-lum by the University of Malaya Medical Centre.Reflective practice based on Gibbs (1988) modelhas been integrated into the three year program,since 2003. The first group of students who wereinvolved in the practice, are now in their final yearof the program. Every semester, reflective practiceis used to assess the students clinical performanceas a continuous assessment of their practical exami-nations.A majority of the students did not do well intheir reflective practice. Only a minority of studentsfelt comfortable with reflection, as the course pro-gressed. The implementation of reflective practicein the Diploma of Nursing Programme has not beenevaluated, hence this study was carried out to exam-ine the student nurses perception and to find out</p><p>M.C. Chong</p><p>112 Asian Nursing Research September 2009 Vol 3 No 3</p></li><li><p>113</p><p>the strengths and weaknesses in implementation ofreflective practice during practicum.</p><p>The aim of this paper is to report on how agroup of student nurses perceived and interpretedreflective practice in a preregistration nursing cur-ricula in a college of nursing, in a teaching hospitalin Malaysia.</p><p>METHODS</p><p>Study settingThe study setting was in the College of Nursing, Uni-versity of Malaya Medical Centre. The college offersa preregistration Diploma of Nursing program witha student population of 600, with three year levels:Year 1, Year 2 and Year 3. Reflective practice wasintegrated into the curriculum and the main concernwas in the clinical area, as it focused on practice.Students were encouraged to write or record as manyreflections as possible with a minimum target ofone every two weeks, with supervision in level oneof one posting per semester. Subsequently, studentswere encouraged to write one report at each postingin the clinical area.There were tutors in each respec-tive area of clinical placement, to assist students.The ratio of tutors to students was approximately1:20. There was no specific time allocated duringclinical hours for reflective writing and studentswere supposed to record/write their reports afterworking hours. Discussion on the outcome of theirreflection was scheduled for students.</p><p>This study setting was chosen because theresearcher had been involved in teaching nursingstudents in the Diploma program and participatedin the advocacy of reflective practices.</p><p>Study designA cross sectional descriptive study was carried outto examine the perception of the final year prereg-istration Diploma of Nursing students towards theusefulness of reflective practice.</p><p>Population and samplingIn this study, the target population was 108 prereg-istration student nurses who were enrolled in 2003and underwent a three year Diploma of Nursingprogram. They were in semester 3 of their final yearand had experienced writing reflectively since year 1,semester 1. They were assessed on reflective prac-tices in year 1, semester 2 and 2 and year 2, semester1, 2 and 3. This cohort was selected because theywere the first group of students to have reflectivepractice integrated in their nursing practice. Studentswho were involved in the pilot study were excludedfrom this study. The sampling method was universalconvenience sampling.The sample selection criterionwas to include students who had written at leastfive reflections.</p><p>Ethical considerationThe Director of the University of Malaya MedicalCentre gave a permission to undertake the study.Approval from an Ethics Committee was not required</p><p>Is Reflective Practice a Useful Task for Student Nurses?</p><p>Asian Nursing Research September 2009 Vol 3 No 3</p><p>Action planIf it arose again</p><p>What would you do?</p><p>ConclusionWhat else could you</p><p>have done?</p><p>FeelingsWhat were you thinking</p><p>and feeling?</p><p>EvaluationWhat was good and badabout the experience?</p><p>DescriptionWhat happened?</p><p>AnalysisWhat sense can you</p><p>make of the situation?</p><p>Reflective cycle</p><p>Figure 1. The reflective cycle (Gibbs, 1988b).</p></li><li><p>as there were no patient involvement. A briefing onthe information about the study, its aims, focus andthe rationale was given to all respondents in the lec-ture hall. Instructions for competition of the ques-tionnaire were also given to respondents. Informedconsent was obtained directly from all respondents.</p><p>Data collectionThe survey was conducted in a cohort design and themethod used was quantitative. Data collection wascarried out from 2 November 2006 to 8 November2006. All questionnaires were distributed person-ally to the students at the lecture hall. The studentswere given a brief explanation of the study before thequestionnaires were distributed. The respondentswere kept anonymous and they were given oneweek to answer the questionnaire. A total of 98 setsof questionnaires were distributed and returned.</p><p>InstrumentationThe data was collected based on self explanatorystructured questions. A total of 37 items were usedin this study. A five point Likert scale was used toindicate relative agreement for each item. Responsesranged from 1 (strongly agree) to 5 (strongly dis-agree). The questionnaire was categorized into threeparts: Part One comprised of 24 items relating tostudents perception towards reflective practices.Part Two consisted of seven items related to assess-ment of reflective practice and finally, Part Threerelated to issues that students most commonlyreflected on.</p><p>Validity and reliability testingThe instrument was measured and tested for its sta-tus of validity and reliability to yield a representa-tive date. The questionnaire was tested for validityand reliability. Face Validity was used to determinewhether the questionnaire looked relevant, to mea-sure the appropriate construction (Polit & Beck,2004), student nurses from year 2 were invited toparticipate in the evaluation of the construction.The questionnaire was validating by five nursinglecturers for content validity.The inclusion criterion,to determine the panel of experts, was a minimum</p><p>of five years teaching experience in nursing. Theinvitation letter, the objectives of the study, consentform for accepting to be part of the panel and a setof questions were given to them with a returnaddressed postage paid envelope. Coefficient alphaor Cronbachs alpha was used in this study whichyielded the coefficient value of 0.8, which illustratedan acceptable degree of internal reliability. Minoramendments were made to question wordings tomaximize clarity.</p><p>Pilot studyA pilot study was conducted on 15 October 2006,in the same setting, with 10 students from the samecohort being selected to pre test the instrumentwhich required minor correction on typographicalerrors. The two reproducibility tests that were donewere test-retest validity and inter-rater validity. Thepilot sample was not used in the actual study.</p><p>Data analysisData were analyzed using the SPSS Statistical Pack-age, version 16. Frequency, percentage, mean andtables were used to describe the data. The charac-teristics of the participants perceptions towardsreflective practice were calculated and summarizedby using mean percentages and frequency. Likertscales were recorded using only three points insteadof five points, to make the data more meaningful.Strongly agree and agree were combined as agree.Uncertainty, strongly disagree and disagree werecombined to become disagree.</p><p>RESULTS</p><p>1. Perceptions on reflective practiceAll 98 students participated in this study and theoverall findings have shown a positive perceptiontowards implementation of reflective practice in theDiploma of Nursing Program. The mean score ofperceptions on reflective practice was 4.07. Moststudents found reflective practice useful to themwith a mean score of 3.82, despite the perceivedbarrier to good reflective practice with a mean of</p><p>M.C. Chong</p><p>114 Asian Nursing Research September 2009 Vol 3 No 3</p></li><li><p>115</p><p>Is Reflective Practice a Useful Task for Student Nurses?</p><p>Asian Nursing Research September 2009 Vol 3 No 3</p><p>3.60. Students did not encounter serious undesir-able effects of reflective practice as the mean scorewas only 3.48. The majority of students felt mentorplay was an important role in facilitating reflectivepractice in clinical areas with a mean score of 3.77.The perception on the appropriateness of reflectivepractice as a tool to assess was 3.47. The validity ofreflective practice as an assessment tool for practicalexamination was not conclusive, as the mean scorewas only 3.47.</p><p>As shown in Table 1, the perceptions of respon-dents on reflective practice were divided into fourgroups: 1.1. Usefulness of reflective practice, 1.2.Undesirable effects of reflective practice, 1.3. Barri-ers to good reflection and 1.4 Mentors in reflectivepractice.</p><p>Most of the respondents responded very posi-tively over the subgroup of usefulness of reflectivepractice, with only less than 10 students disagreeingwith all the items in this subgroup, whilst the otherswere uncertain. T...</p></li></ul>