Using reflection to enhance the teaching and learning of midwifery students

129British Journal of Midwifery • February 2014 • Vol 22, No 2

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Using reflection to enhance the teaching and learning of midwifery students

The role of the preceptor is important to both the nursing and midwifery professions. Preceptors aim to provide

students with a safe and encouraging learning environment in the real clinical context. To be an effective preceptor, it is valuable to recognise differences in styles of learning and how effectively learning can be applied to practice. Through the application of adult learning principles, the preceptor can choose the most suitable teaching strategies to use in the clinical area for optimal learning by the student. Literature describes the preceptor as ‘a nurse who teaches, supports, counsels, coaches, evaluates, serves as a role model and aids in the socialisation to a new role’ (Case Di Leonardi and Gulanick, 2008:7)

The teaching and learning approaches used in the following case scenario were based on theoretical concept of constructivism in learning (Bruner, 1960), setting clear learning objectives (Bastable and Doody, 2008), developing a trusting relationship with the preceptor (Carlson et al, 2009; Smedley and Penney, 2009; Smedley and Morey, 2010) using evidence-based practice (Melnyk and Fineout-Overholt, 2012), and critical or ref lective learning (Rolfe, Jasper and Freshwater, 2010; Lucas, 2012). With the support of literature, strategies used will be discussed and it will be demonstrated how to promote independence by improving problem-solving abilities (Chikotas, 2008), critical thinking skills (Brookfield, 2010) and lifelong learning approaches (Jarvis, 2010). On reflection of the case scenario presented, recommendations will be provided for additional teaching methods.

Clinical scenarioIn Australia, the student midwife can undertake a Bachelor of Midwifery programme through a direct-entry course, or alternatively, they may complete a Graduate Diploma or Master of Midwifery after completing a Bachelor of Nursing degree. In this case scenario, the student is

undertaking a Graduate Diploma of Midwifery, having already completed a Bachelor of Nursing and a new graduate year working as a registered nurse (RN) in the general nursing area.

During a shift in the special care nursery, the registered nurse midwife (RNM) worked with Sally (pseudonym) a 24-year-old RN and student midwife (SM) who was completing a clinical placement in maternity. After welcoming her and completing a handover of the care needs in the nursery, the treatment care plan for baby X was discussed. Baby X was a 38-week gestation infant who had respiratory distress and was currently being nursed in 35% crib oxygen (O2). The paediatrician had reviewed the infant and set parameters for weaning to air as able.

Having worked together many times before, the midwife knew Sally had experienced managing the care of babies in a humidicrib, feeding via an intragastric tube, and undertaking and recording observations, but was aware she

AbstractPreceptorship is a vital role in the development of both undergraduate and postgraduate midwifery students who require input and guidance from more experienced midwives. The preceptor acts as a professional role model to the student: teaching and supporting; providing a learning environment that enables confidence to develop through supervised safe practice; and assisting them to develop knowledge and skills, and adapt to new contexts and new roles within an ever-changing midwifery environment. Using reflection and critical analysis within clinical scenarios is a useful way to provide effective teaching and learning for students. This can also assist the preceptor to develop alternative teaching strategies and develop confidence to try new teaching approaches with students in future encounters. As the role of preceptor comes with great responsibility, the need for flexibility in teaching approaches, according to varied student learning styles, promotes new teaching approaches and confidence in the preceptor. This paper analyses a clinical teaching and learning scenario within a midwifery context and critiques the various teaching strategies utilised to recommend alternative approaches for the registered midwife preceptor.

Karen VeloMidwifeSydney, Australia

Alison SmedleySenior Lecturer Avondale College of Higher Education, Sydney

British Journal of Midwifery.Downloaded from magonlinelibrary.com by ${IPAddress} on May 28, 2014. For personal use only. No other uses without permission. . All rights reserved.

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had never cared for a baby in O2. Sally was somewhat hesitant to care for baby X but agreed after some encouragement and reassurance of supervision from the midwife.

The RNM, as the facilitator, recommended Sally review the policy and procedure manual about the care of the neonate requiring O2 therapy, the baby’s notes, care plan and the doctor’s protocol. Together, the RNM and the SM planned the required care, set objectives and outcomes for the shift which included weaning the infant safely into air.

Initially, Sally asked many questions and needed advice on adjusting O2 levels. The RNM directed Sally to use the ward resources and to ref lect on her own knowledge to find the answers to questions. As the shift progressed, Sally grew more confident in making independent changes when the observations were outside set parameters under the watchful eye of the midwife. Sally weaned baby X to air and, after the shift, the RNM and the SM reflected on Sally’s care management.

DiscussionThe teaching strategies utilised in this case scenario, based on adult learning principles, are aimed to encourage the self-directed learning of the student which can promote lifelong learning

(Jarvis, 2010). By acknowledging that adults have different learning styles, preceptors can choose appropriate teaching techniques to suit different individual learning approaches (Jarvis, 2010).

Gupta (2007) suggested that an initial assessment of the student identifies what they already know which, in turn, identifies the gaps in knowledge. This approach greatly assisted the design of assessment and strategies to improve learning. Falchikov (2005) believed it was helpful for the student to be involved in their assessment approach as the motivation to succeed could inf luence their desire to learn. This initial assessment should include considering the learning or performance need of the student, their willingness to learn, cultural, personal or generational differences, and any disabilities that might impact on learning.

A preceptor who wants to motivate and encourage students to learn must attempt to engage them, and maintain motivation and interest through encouragement of learning (Burns, 2002). Ideally, the preceptor aims to provide appropriate teaching strategies for the graduate student to enable them to apply their learning in practice (Myrick and Yonge, 2001).

Bruner (1960) suggested that learning is gained through the construction of thoughts, skills and abilities to organise and categorise learning. Through this process, learning for knowledge and skills is part of a spiral process of learning. Consider the spiral staircase analogy —as more complex knowledge is taught the staircase continues upward, building on the basic concepts previously learned; a spiral of knowledge constructed through individual learning which should enhance problem solving. Bruner (1960) also suggested that the concept of discovery learning is useful to enhance the construction of knowledge.

In the midwifery or nursing context, rather than the preceptor using a rote learning approach with learners, the student should be encouraged to search or discover answers for themselves to facilitate their learning process. The preceptor can provide information and directions for where to obtain appropriate information, but should not organise the student. This is known as the constructivist approach to learning (Bruner, 1960).

On reflection of the case scenario, the RNM preceptor used a variety of teaching strategies to provide valuable learning experiences for the student. The RNM preceptor asked the SM at the beginning of the shift what she already knew about caring for a baby in oxygen therapy

The student midwife in this clinical situation was tasked with caring for an infant with respiratory distress

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(establishing knowledge and skills already known). The preceptor based this teaching on Bruner’s (1960) constructivist approach or building on prior knowledge. The student can improve critical thinking and problem solving skills ‘as they construct new knowledge based on prior experiences, resources and the current environment’ (Chikotas, 2008:361). This technique made it easier for the preceptor to facilitate learning by guiding the student to find the relevant resources needed without wasting time on topics already known. This strategy was promoted by first identifying learning needs of the SM and by setting objectives for the shift, which was beneficial to both the SM and the RNM preceptor. According to Bastable and Doody (2008:389), setting realistic behavioural objectives gives the learner ‘very clear statements about what is expected of them’. Having learning objectives will also help the preceptor choose appropriate teaching strategies to keep the student on track and aid them in achieving the set objectives.

Sally planned to wean the baby to air by the end of the shift and was able to achieve this by using the parameters set by the paediatrician, her own knowledge and other resources on the ward under the supervision of a more experienced midwife with whom she had built a trusting relationship. Developing a friendly and trusting relationship with the student is another teaching strategy used by the preceptor. A study by Carlson et al (2009) showed that building trust was very important in the teacher–student relationship as this promoted confidence and the ability to question more easily and students were more likely to use initiative when they were in a safe and trusting environment. Trust can also be enhanced by providing continuity with the same preceptor where possible. Zilembo and Monterosso (2008) also suggested that consistency and leadership from preceptors is seen as a vital attribute for developing effective preceptorship–student relationships.

Having worked together before, the RNM preceptor was already aware of Sally’s prior learning as a RN and of her experience in the midwifery unit. The two were comfortable communicating with each other and although Sally was hesitant to care for baby X, she felt supported enough to move out of her comfort zone. Developing the preceptor–student relationship in this way can help both the RNM preceptor and the SM to clarify their expectations and develop a mutual understanding of what needs to be achieved (Case Di Leonardi and

Gulanik, 2008) during a shift. The SM could also integrate her knowledge into practice and ‘bridge the theory–practice gap’ (Zilembo and Monterosso, 2008:204).

By building an effective relationship, the preceptor can more confidently allow the student to work independently. The RNM preceptor was able to give Sally a great deal of responsibility through the shift because she was aware of Sally’s prior knowledge and experience. It allowed the preceptor to act as ‘the invisible presence’ (Carlson et al, 2009:524) and continue to care for other patients in the unit. This gave Sally room to make more independent decisions about weaning oxygen, knowing the support of the RNM preceptor was in the background if required. In addition to using these strategies, the RNM preceptor directed the SM in the use of critical ref lection on her practice and evidence-based practice throughout the shift.

Encouraging students to use evidence-based practice in the workplace is an effective teaching and learning technique. Ireland (2008:90–1) suggested that students needed to learn to use evidence in their reflection on practice and stated that ‘evidence use requires the parallel process of critical thinking, which involves reflection, evaluation, and critical appraisal’. The preceptor can also facilitate self-directed learning by advising the student to use research and evidence when making decisions. Today, students are more comfortable using the various types of technology available to access information quickly and easily. Sally found referring to doctor’s orders and accessing the policy and procedure manual routine practice when weaning the infant from oxygen. This process assists students to become accustomed to incorporating evidence-based practice into their critical thinking when making everyday decisions about patient care (Melnyk and Fineout-Overholt, 2012).

In more recent times, reflection and reflective thinking has been encouraged as part of the learning process through noticing what is happening in one’s own practice or the practice of others, recalling thoughts or memories from past experiences and making sense of the situation so that changes can be identified and made where necessary (Taylor, 2010). Driscoll (2007) identified that reflection is defined in many ways in the literature and he points out that the importance of reflection and reflective practice is how it is used in an experience. In the clinical environment, reflection can assist the practitioner to improve care delivery and or change the way care is provided in the future.


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The RNM preceptor incorporated the further teaching approach of reflective thinking into the learning session that worked well alongside other strategies used.

Throughout the shift the RNM preceptor guided the SM in the art of ref lective thinking and questioning to improve practice. Sally was asked to think about her actions and provide the rationale for her decisions. At one stage, the infant had started vomiting and Sally was unsure whether to reduce the oxygen concentration further although observations were stable. The RNM preceptor ref lected on a previous experience when an infant had developed an infection unrelated to its respiratory distress. By thinking back over that shift and reviewing all the evidence, the RNM preceptor helped SM to examine how the treatment could have been improved. This example gave the SM insight into how ref lective practice can be an effective tool in problem solving. By using this technique, Sally was able to identify a link between the infant not coping with increased feeds and reducing oxygen, which brought her to conclude that the baby would benefit from no change in treatment. Ref lection can be especially difficult for students who worry about exposing themselves to ridicule (Driscoll, 2007) but during this encounter, the RNM preceptor openly shared her prior experience which may give the SM the confidence to try this approach.

These approaches and strategies to assist the learning of the SM worked well and provided her with a safe learning environment in the clinical setting. Other teaching strategies that may have positively enhanced the development of learning in this scenario include the use of mind mapping to lead Sally to think more critically, developing the process of self-sharing throughout the shift and offering constructive feedback to evaluate performance (Buzan, 2011). Buzan (2011: online) proposes that mind mapping is a ‘... powerful graphic technique which provides a universal

key to unlock the potential of the brain. It harnesses the full range of cortical skills … in a single, uniquely powerful manner … [which] can be applied to every aspect of life where improved learning and clearer thinking’ is required.

The RNM preceptor directed the SM to use the traditional nursing care plan when planning the objectives and outcomes for the shift; similarly, mind mapping can also be used in care planning (Kern et al, 2006). Based on the nursing process the care plan is used to assist nurses in planning care (Kern et al, 2006). However, to promote critical thinking, Buzan (2011) suggests that mind mapping is a creative thinking process to enable the connection of concepts and ideas to a central image.

Mind mapping is also suggested to combine both left and right brain thinking and may be a useful strategy to help students use both logic and creativity in their thinking. However, ultimately it would be more effective for the preceptor to use a combination of both these tools to give the student a ‘holistic view of patients’ (Kern, 2006:113). Another approach the RNM preceptor could have pursued in this teaching experience was encouraging the SM to self-share.

Self-sharing is described by Stein-Parbury (2013) as more of an interactive ref lection involving the student opening up and sharing their ideas with others. During the shift the RNM preceptor used an example of self-sharing to relate an experience. In time, Sally may find the confidence to expose her thoughts and ideas and use self-sharing as a learning tool. The RNM preceptor could encourage Sally to also use the think aloud approach as suggested by Banning (2008).

Constructive feedback is easier for the preceptor when there is a trustful and supportive relationship with the student. Oermann and Gaberson (2006) believe that evaluating the student and providing feedback is a very important process for professional development. Although offering feedback can be difficult, it is necessary to for the student improve practice and focus on areas in need of development. When providing feedback, it is useful for the preceptor to be specific about issues and feedback to the student soon after the event. In this way, the student can learn from the experience and improve performance. Carlson et al’s (2009) study suggests some strategies for correcting practice that include praising, criticising and praising again. The important point is to always finish with a positive comment.

Key points l Preceptorship is a vital role in the development of both undergraduate and postgraduate midwifery students

l Preceptors should enhance their skills to embrace varied teaching approaches for optimal student learning

l Using reflection as an approach to teaching and learning in the clinical environment can assist in increased learning for student

l Developing skills in reflection on practice assists nurses with lifelong learning



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ConclusionRef lecting on this case scenario has provided an example for all preceptors supporting graduate students in clinical midwifery contexts to explore their approaches to teaching and learning. Various strategies are easy to use and can impact on the student’s learning in positive ways. Trying new approaches and varied strategies, such as ref lective learning, mind mapping or self-sharing, can also help the preceptor to develop personally as a teacher as well as providing a positive experience for the student to enhance the development of learning in the long term. To be effective in the clinical area, the preceptor must recognise the different learning styles of students and provide aligned creative learning opportunities. The various teaching strategies discussed have been shown to promote independence and improved problem solving and critical thinking skills. Benefits of the use of adult learning principles and self-directed learning include lifelong learning in any student. In the clinical setting these techniques will help learners to link theory to practice and give them a sound foundation to perform safely in the clinical setting. BJM

All names given in this article are pseudonyms

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Using reflection to enhance the teaching and learning of midwifery students