Nurse Education in Practice (2007) 7, 135–140

Nurse

www.elsevierhealth.com/journals/nepr

Educationin Practice

Using reflective models to enhance learning:Experiences of staff and students

de Sales Turner *, Lenore Beddoes 1

Deakin University School of Nursing, 221 Burwood Highway Burwood, Vic. 3125, Australia

Accepted 30 April 2006

Summary In this paper we reflect on a quality activity undertaken with studentsenrolled in a Bachelor of Nursing course who were required to write a 3000-wordreflective paper for a unit called ‘Nursing People Experiencing Long Term Illnesses.’Students were required to select one chronic illness from a list of five suggested bythe teaching team. Having made their choice, they developed their paper in twoparts. Students were first required to briefly discuss the pathophysiology of the ill-ness, and its psychosocial effects on the individual and family. Second, they wererequired to use a model of reflection to discuss how knowledge they gained couldbe applied when working with a person with this condition, within the hospitaland the community.

Highlighted in this paper are the voices of 10 students who accepted an invitationto be involved in a focus group discussion which elicited their views, experiencesand concerns regarding this assessment. Analysis revealed that students found theassignment topic to be challenging, rewarding and an appropriate vehicle to unveilwhat they learned. However, completion of the assessment was not without its dif-ficulties. In this paper, insights gained in using this teaching and learning strategyare shared.

�c 2006 Elsevier Ltd. All rights reserved.

KEYWORDSReflection;Teaching;Learning;Student learning;Learning and teaching;Models of reflection

1d

6

b

Background

When setting assignment topics for students, it isimportant to consider the alignment of the learning

471-5953/$ - see front matter �c 2006 Elsevier Ltd. All rights reseoi:10.1016/j.nepr.2006.04.011

* Corresponding author. Tel.: +61 3 9244 6960; fax: +61 3 9244159.E-mail addresses: desales.turner@deakin.edu.au, lenore.

eddoes@deakin.edu.au.1 Tel.: +61 3 9244 6909; fax: +61 3 9244 6159.

task with the educational pedagogy that shapes thecourse (Davis, 2000). Thus, if the pedagogy is onein which students are expected to demonstratemastery learning, then their assessment tasksshould reflect this. Further, when designing assess-ment tasks, it is also important to acknowledgethat they must enable the learner to demonstrateachievement of the overarching aims and objec-tives that are specified within the curriculum doc-ument. Hence, within courses of study, a variety

rved.

136 de Sales Turner, L. Beddoes

of assessment strategies should be designed andimplemented, to enable students to demonstratetheir capabilities in various domains of learning.

However theoretically sound these suggestionsmay be, as educators we often experience a num-ber of confounding influences which inhibit therealisation of these ideals. These confounders in-clude such things as time pressures related to sub-mission of assessment tasks, lack of stability withinour teaching teams, high teaching loads accompa-nied by large class sizes and lack of time to validatethe assessment items that we develop. Further,within Australia the University sector does notmandate that those who are employed to teachhave an educational qualification. Hence, on occa-sion individuals are appointed into a teaching rolewith little understanding or knowledge of educa-tional theory. Each of these factors contributes tothe development of assessment items that may fallshort of our ideals and professed desire to con-struct valid and reliable and yet innovative assess-ment items.

It is acknowledged that these limitations arecurrently being addressed within the Australianhigher education sector, with a number of Univer-sities seriously addressing issues related to foster-ing excellence within the arena of teaching andlearning. However, until they are satisfactorily re-solved, tensions will continue to be experienced bythose who must develop assessment tasks that arewell aligned to the intent of learning, as well as tothe learning needs of the students. Parentheti-cally, once assessment items are devised, it isimportant to seek the views of the students forwhom such items are developed, to ascertainwhether the assessment task was meaningful andenhanced their learning. Hence, this paper reportson a quality initiative that was undertaken withinthe unit of study called ‘Nursing People Experienc-ing Long Term Illnesses’, which is offered withinthe second year of the Bachelor of Nursing programat Deakin University.

The quality initiative

The context of the quality initiative

The unit of study previously mentioned is a coresubject for all undergraduate students who areenrolled in the School of Nursing, Deakin Univer-sity and who will seek registration by the NursesBoard of Victoria upon successful completion oftheir course. The course uses problem-basedlearning (PBL) as a conceptual framework and as

a strategy for teaching and learning. The nursingcourse is provided on the three campuses (Mel-bourne, Geelong, and Warnambool), of DeakinUniversity, in Victoria, Australia. At the time thatthis quality activity was undertaken, this unit ofstudy was offered to approximately 250 full-timenursing students across the three campuses; how-ever, this report relates to the experiences ofstaff and students located on the Melbourne cam-pus only. The unit is also offered to students whoundertake an international nursing exchange withthe School.

For one of the assessment tasks of this unit, stu-dents were required to write a 3000-word reflectivepaper, where they selected one chronic illness froma list of five that were suggested by the teachingteam. Having made their choice, they were askedto first briefly discuss the pathophysiology of theirselected illness, as well as reflect on the psychoso-cial effects of this illness on the individual and theirfamily. They were then instructed to use a model ofreflection to discuss how the knowledge they gainedcould be applied when working with a person withthis chronic condition, within both a hospital set-ting and the community.

Whilst some authors have argued that studentsdo not have sufficient experiences and acumen toengage in reflection in a meaningful way (Green-wood, 1998; Heath, 1998; Wellard and Bethune,1996) the teaching team who developed this assign-ment task was of the firm belief that reflection is acorner stone of nursing practice. This belief is sup-ported by a number of key authors who have writ-ten rather extensively about reflective practice(Johns, 2002a,b; Taylor, 2000; Ghaye and Lillyman,2000; Durgahee, 1997), as well as through theplethora of articles which have emerged over thelast ten years in particular, which attest to the cen-trality of reflection to practice (Frank, 2002;Glaze, 2001; Charmaz, 1999; Snyder et al., 1997;Johns, 1996). Hence, the teaching team wantedto introduce this skill early in the student’s learn-ing experience, to enable them to develop not onlya reflective attitude towards their learning, butalso to develop some practical skills of reflectionwhich they could subsequently apply in practice,a decision which is supported by the writings ofHeath (1998).

On a practical level, the team decided againstteaching the student’s one model of reflectionand requiring them to use this model to developtheir paper. Instead, they gave the students free-dom to select from the various models that wereavailable in the literature, thereby encouragingthem to find one that resonated with their ownways and styles of learning. The approach of

Using reflective models to enhance learning: Experiences of staff and students 137

enabling the students to select their model ofreflection, as well as the chronic condition theywished to explore, and to undertake independentresearch to assist with the development of theirknowledge, was consistent with the PBL approachused by the School of Nursing. It also resonatedwith our belief that students have an untapped po-tential to construct work that is both creativelyand imaginatively expressed when they are givenminimal instructions on how to go about engagingin the business of learning.

On completion of the assignments they weremarked by the teaching team. Subsequently, 26students whose papers clearly demonstrated thatthey used the model of reflection they selectedto develop their paper, were invited in writing toparticipate in an audio-taped focus group discus-sion, in which they were asked to talk about expe-riences and concerns that arose whilst they wereputting their assignment together. The invitationwas extended using non-coercive language, whichmade it clear that there was no requirement tosay yes to this invitation. Following the invitation,10 students participated in the focus group inter-view, with an additional seven indicating that theywould have liked to be involved, but had work com-mitments which precluded this. It is not known whythe other nine individuals who were invited did notaccept the invitation.

Questions that were explored during the focusgroup centred on:

� experiences that the students had;� their enjoyment, or otherwise, of this assess-ment task;� perceptions of this assignment approach;� their recommendations for improving the assess-ment task; and� the most valuable things that they learned.

Outcomes of the focus group discussion: thestudents speak

Clearly the students engaged in this unit found thisassignment topic interesting and relevant. This wasevidenced by the quality of the papers presented,many of which exceeded the expectations of theteaching team in terms of the depth, breadth andquality of issues raised. When asked to speak aboutthe experiences they had in putting their assign-ment together they voiced:

This assignment really developed my thought pro-cesses. It made me aware of how I learn and what Iknew about my topic (P2).

Using a model of reflection was really good,because it allowed me to think about what Ithought and felt. So I found that it increased mythinking (P1).I’m a person who likes black and white, so reflec-tion really put me out of my comfort zone. Also,before we’d only had assignments that were aboutfacts and figures, not our beliefs and attitudes. SoI really had to think about that one and it was sohard. But, being able to choose our own modelmade it easier and I really liked that I was ableto choose one that matched my own way of think-ing (P3).Assignments to this point haven’t allowed me toresearch and to reflect on where I will work innursing. But [the assignment] increased my passionand motivation for nursing patients (P4).

When asked to express their views on being re-quired to self select their assignment topic and toengage in independent scholarly research, theviews expressed were unanimous that this was agood learning strategy. However, as the dialogueof some participants indicated, choice with limitswas seen as desirable:

I really liked this way of learning. It made meinterested and motivated and I spent a lot moretime on it. I chose something that I wanted tolearn about, so that was really good for me (P1).I really liked being able to choose. I like gettingexcited about learning and this assignment wasgood for that (P5).I hate repeating something that we’ve alreadydone, so I loved the choice that was involved inthis assignment (P6).Well, I really liked having some limits and Ithought it was good to give us five topics to choosefrom. Limited choice and control was good for me(P3).Well, I felt empowered to have control. I didn’tfeel like a sheep in a herd, because I had some con-trol over my own learning (P2).

When asked to comment on potential educa-tional advantages of being required to engage inindependent learning, the students expressed thatthis opportunity increased their motivation, reten-tion of learning, interest levels and allowed themto express their creativity:

I put a lot of thought into this assignment auto-matically. When you are given a choice you needto think about what you are writing. And I had towork through five models before I selected theone I wanted, so it broadened my horizons (P3).I totally agree that there are advantages becauseyou don’t have to memorize things (P6).

138 de Sales Turner, L. Beddoes

I think that when you do something on your ownyou have a better chance of retaining things (P7).Having an assignment like this keeps you reallyinterested (P8).Well, with this type of assignment, you can bemore insightful and creative. Also, you can beinnovative (P9).Well, there are theories of learning, but if youhave flexibility you can learn differently. When Ihave to think, I don’t feel caged; I can be eclectic– like a tree with a lot of branches. If you haveflexibility, you have the power of choice (P2).Well, I really love reading to inform my under-standing on best practice, so I loved it (P5).

The teaching team were interested in exploringwhether using a model of reflection helped the stu-dents to develop greater awareness of their role asa nurse. Reflections on this question included per-sonal insights, some of which were expressed aslife changing:

Having to undertake reflection really personalisedmy learning. Like I’ve done pathophysiologybefore, but I have never really related it to a per-son (P7).Thinking deeply about the psychosocial impact ofthe illness I explored and how it could lead to abreak down of families, made me realise that peo-ple with [this disease] are stigmatised. And for thefirst time I became ashamed that people ill-treatthose with it (P1).It broadened my reflection of chronic illnesses onthe whole and helped me develop ideas that couldbe used in clinical (P9).Well, using a reflective model made me thinkabout where I got my ideas and I believe that willimprove my ability to be a nurse (P4).I really thought it was good to separate acute fromthe community. It made me think about what hap-pens to people when they go home (P3).Well, I didn’t like personalising the assignment,and being honest about my beliefs was hard. Butthen I realised that something I read had changedmy thoughts (P4).

The teaching team made a decision not to give alecture on models of reflection and were interestedin obtaining the student’s perceptions on the wis-dom of this choice. Although the students validatedthis choice, they did offer some qualifiers.

I don’t think we should have had a lecture. Unlessyou had 20 different lectures, you wouldn’t havemet the needs of the students (P8).I was confused and lost early on, so maybe not alecture, but in the first week of semester it wouldhave been good to clarify expectations (P2).

Initially I thought it might be good to have thatdirection, but later on I changed my mind (P10).Well I think it was good for things to not be tooset, because it steals away from the learning pro-cess. Finding our way and gauging our learning wasgood (P9).

Students reflected on suggestions that theywould make to change the assignment topic andalso the things that they learned along the way.Their suggestions were reasoned and demonstratedmaturity and insight about the learning process.

I learned that there is more to life than just theacute setting. And I learned how people withchronic illness feel, and about the issues they face(P7).What I learned is to keep an open mind and beaware of the community and to question whatyou think and believe (P3).Doing this assignment really drove home to methat people leave the hospital and go back to thecommunity, and I found that was something thatI didn’t think about a lot before (P8).

What we learned from our dialogue withthe students

It is reasonable to say that the students who wereengaged in the focus group discussion describedtheir experiences when undertaking this assignmentas mostly positive. Despite the fact that they attimes found this assessment task difficult, in themain they described it as challenging and growthpromoting. We were gratified to learn that theylinked this assessment task to an opportunity toexercise creativity, as well as to think more deeplyabout the world of nursing practice beyond the hos-pital walls. We were excited that some studentsexpressed thoughts that being involved in thisassignment changed them in some ways, either byexpanding their thinking about the needs of chron-ically ill persons and their families, or that it helpedthem to consider issues such as stigmatisation anddiscrimination as they related to those who werechronically ill. These observations resonate withthose of Greenwood (1998, p. 1051), who writesthat ‘‘By reflecting on the world they are instru-mental in creating, human agents can learn tochange it in ways that are more congruent withthe values and theories they espouse.’’ Further,the reflections of these students seem to contradictassertions by Burrows (1995), that undergraduatestudents lack the capacity to examine specific situ-ations in-depth, because they lack a repertoire of

Using reflective models to enhance learning: Experiences of staff and students 139

practice-based skills. Notwithstanding these obser-vations, we caution that our impressions should beregarded as tentative. In the first instance, weacknowledge that we interacted with a limitednumber of students. Further, their expressed viewsmay not mirror those of fellow students. Hence, weare committed to undertaking further focus groupdiscussions with students, to deepen our under-standing about the value or otherwise of requiringstudents to write a reflective piece for their assess-ment tasks.

Although we were not surprised that the stu-dents expressed that they liked being independentlearners, we were glad to learn this, especially aswe work within a PBL curriculum. In some ways,what the students shared affirmed our decision totake some ‘risks’ in mounting this assignment, interms of our decision to not directly teach aboutmodels of reflection and to trust that the studentswould rise to the occasion of having to learn aboutand apply a model of reflection whilst simulta-neously learning about the chronic illness that theyselected and its effect on the individual and theirfamily. Their ability to reflect on their practice af-firms the importance of reflection-before-action,which ‘‘involves think(ing) through what one wantsto do and how one intends to do it before oneactually does it’’ (Greenwood, 1998, p. 1049).One outcome of this assessment task that we hadnot contemplated was that quite a few studentswrote outstanding papers, which we believed wereworthy of publication and we are currently workingwith a selected number of students to help themachieve this end.

However, despite these assertions, which led toa decision to retain this assessment task in aslightly modified form with the next cohort of stu-dents, we cannot claim that the experiences of thefocus group students were typical of the entire co-hort of students. Anecdotally, as well as throughformal evaluation of the unit at the end of thesemester, we were aware that some students didnot like this assessment task. Some found it veryconfusing and frustrating to use a model of reflec-tion when they had little or no clinical experienceof caring for a person with the chronic illness thatthey selected, observations that are consistentwith the findings of Burrows (1995). However,through discussion prior to the completion of theassessment task we helped students to reframe thisissue as one in which they could reflect on whatthey had learned and how they might apply theirknowledge when caring for patients in the future.Seen from this perspective, students were able tomake sense of and see the benefit in this assign-ment topic. To add clarity to our understanding

though, it is our intention to undertake another fo-cus group discussion at the completion of thesemester with students who did less well with theassignment topic, to explore experiences and con-cerns that arose whilst they were putting theirassignment together. It is our hope that such explo-ration will lead to identification of strategies thatwe can put in place to assist students who maybe struggling with assignment writing or who mayhave difficulty developing the skills required ofthe reflective practitioner. In this sense we demon-strate our commitment to praxis of nursing.

As members of the teaching team we spent alarge number of hours meeting individually withstudents to clarify the intent of the assignmenttopic and to provide suggestions as starting pointsfor their work. Whilst this was intensive and dra-matically increased our teaching load, it shouldnot be assumed that only students who did not han-dle the assignment topic well were the recipientsof 1:1 learning facilitation. Indeed, it was ourexperience that even students who handled theassignment topic very well sought clarificationabout the topic and ways to answer it. As membersof the teaching team, we sometimes found itexhausting to reflectively answer questions and toidentify resources students could use to resolvethe many and varied individual concerns that theybrought to the learning table.

These admissions probably lead to a question ofwhy we recommended retaining this assessment,albeit in a modified form, in the next semester thatthe unit was offered. Our answer to this question isthat we believe all too often that nursing curriculaare content laden, to the detriment of posing ques-tions that require students to adopt criticallyreflective attitudes whilst exploring their learningand how they might shape the world of nursingpractice. It is our view that failure to expose stu-dents to the concept and skills of reflective prac-tice, together with failure to demonstrate nursingas praxis, could ultimately lead to the perceptionthat the skills of critical reflection are not valuedand do not need to be adopted in nursing practice,sentiments echoed by Kim (1999) and Greenwood(1998).

In conclusion, if one accepts that reflection is acornerstone of professional nursing practice, thisraises questions regarding when this mode of beingshould be introduced to nurses. Whilst it is commonto include reflective practice as central to postgraduate education, we argue that waiting for stu-dents to engage in post graduate education is toolittle, too late. Instead we plead for its inclusionin every undergraduate program of nursing through-out Australia. If the question that you ask is ‘‘was it

140 de Sales Turner, L. Beddoes

hard?’’ the answer is ‘‘yes’’; but if you ask the ques-tion ‘‘was it worth it?’’ the answer is ‘‘we wouldn’thave missed it for the world.’’

Acknowledgements

We formally acknowledge and thank all studentswho generously gave of their time and effort toparticipate in the focus group discussion. Theirparticipation in this quality initiative enabled usto develop insights into the impact that thisassessment task had on them. Subsequent to ourdiscussion, we invited all students who contrib-uted to be listed by name within this article.Those who accepted this invitation are: JenniferGallagher, Kim Guenther, Cara Hammond, MaggieLouise Holt, Andrey Levak, Samantha Moulday,Ellenie Pond.

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