Transcript Until We Reflect” - National League for Nursing

Sharon I. Decker, RN, PhD, ANEF
Professor, Director of Clinical
Simulations
Covenant Health System Endowed
Chair in Simulation and Nursing
Education
“It was the best of times, it was the
worst of times, it was the age of
wisdom, … we had everything before
us, …”
Dickens, C., 1859, A Tale of Two Cities
It is a time of challenge, a
time of turbulence, an age of
innovation…we have constant
change before us,…
1. Explore the current challenges impacting
nursing
2. Discuss the evolution of reflective
thinking.
3. Discuss reflection as the art of nursing.
4. Explore the importance of reflection
during and after a simulated learning
experience.
5. Review strategies to promote reflective
thinking.
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Patient safety issues
Dynamic health needs of our society
Complex health care environment
Dynamic political climate
Our world is challenging,
unpredictable, complex yet,
interconnected and exciting.
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Faculty “Competence”
Evidence-based
◦ Changes
◦ Teaching
◦ Evaluation

Focus on student learning
◦ Active participants
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Integrate technology
Work with regulator & accrediting bodies to
support innovation
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To prepare practitioners who are competent
◦ Critical and reflective thinkers
 “Thinking-in-Action” – “Think like a nurse”
◦ Yet,
New graduates have difficulty transferring
knowledge and skills to the practice setting
Clarke & Aiken, 2003
Del Bueno, 2005
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Identify essential competencies
Validate assumptions
Be creative
But, grounded in evidence
Develop and evaluate new educational
pedagogies
AACN, 2006; NLN, 2003, 2009
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Nursing Faculty Shortage
Increased use of adjunct and part time
faculty
◦ Budget constraints
◦ An aging faculty
◦ Competition with
service
◦ Competing clinical
sites
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Clinical Placements
◦ Apply theoretical content to patient care
(NLN, 2008)
◦ Investigate nontraditional clinical experiences
 Case studies
 Clinical simulation
◦ Clarify relationship of simulated experiences
 Clinical
 Laboratory
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Institute of Medicine Competencies (2003)
◦ Provide patient-centered care
◦ Work in interdisciplinary teams
◦ Employ evidence-based practice
◦ Apply quality improvement
◦ Utilize informatics
Our students – “What generation?”
“ It isn’t that they can’t see the solution. It is
that they can’t see the problem.”
G. K. Chesterton
“They don’t know what they don’t know”
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Clinical Education
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Determined by learning outcomes and goals
Involve student accountability
Active learning
Planned well with debriefing
NLN, 2008
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Nurses use multiple forms of critical,
creative, and imaginative (which
includes reflective) thinking
Facilitating the learners ability to
“Learn to Think Like a Nurse”
◦ “Better learning is associated with
improved teaching techniques”
[simulation]
Dunn, 2004
◦ Teaching techniques that are
evidence based and applied
appropriately facilitate successful
learning (and patient outcomes).
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Learning is dependent upon the
integration of experience and
reflection.
◦ Because,
experience alone does not guarantee learning –
nor clinical competence
reflection promotes the transfer of experience to
learning and knowledge
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Evidence Based and Requires
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Creativity
New pedagogies
Flexibility
Reflection
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Conscious consideration of the meaning
and implication of an action
◦ Assimilation of:
 Knowledge (Concepts)
 Skills
 Attitudes (Values & beliefs)
 With pre-existing knowledge
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Reflexio (Latin)
◦ The act of
bending back
A “wave motion
or energy”
Reflectivity
dependent on:
 Angles of
incidents
A “wave motion
or energy”
Reflectivity
dependent on:
 Texture of the
reflective
surface
A “wave motion
or energy”
Reflectivity
dependent on:
 Wavelength
The Road Not Taken
Two roads diverged in a yellow wood,
And sorry I could not travel both
…, long I stood…
Robert Frost, 1916
“Keep on stepping….” B. Malone, 2009
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Reflection - Initiated
through Questioning
…You lead me on by means
of things I know, point to
things that resemble them,
and persuade me that I
know things that I thought I
had no knowledge of.”
(Quotes in Xenophon’s “Economics”)
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Active, persistent, and careful consideration
 Learning is dependent upon integration
of experience with reflection
Reflection promotes understanding of
relationships
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Reflection-on-action
◦ Reflecting after – thinking through
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Reflection-in-action
◦ Being aware
◦ Reflecting while doing
 “They ‘feel’ where the music is going and adjust
their playing accordingly.” (pg. 30)
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Knowing-in-action (Expert)
Professional knowledge
Skills competence
Applying theory while problem solving
Responds or “makes new sense” of
uncertain, unique situations
Reflecting
(Reflective Observation)
Experiencing
(Concrete Experience)
Learning Cycle
Thinking
Applying
(Active Experimentation)
(Abstract Conceptualization)
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A window through which a practitioner can
view self
“Stepping-stones”
◦ To confront, understand, and resolve
contradictions between desired and actual
practice
◦ Self-discovery
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A reflective practitioner
 Interested in “what worked”
 Curious “what did not work”
 (what if’s)
 Engage is self-critique
 Modify future actions
Pesut and Heman, 1999;
Rudolph, Simon, Dufresne, & Raemer, 2006
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Requires
 Active involvement
 Realist environment
 Authentic experience
 Assistance (guidance)
 Time
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Outcomes
 Insight
 Development of new knowledge
 Application of that knowledge
Promotes innovation, transformation, and
change
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Does not happen automatically
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Requires guidance to clarify
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Can be taught
Learners expanded their repertoire of
possible solutions
Boyd & Fales, 1983
Henderson & Johnson, 2002
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Increased clinical reasoning skills
 Increased use of focused reflection
 Engaged in abstract thinking
 More self-regulated in learning
Murphy, 2004
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Prepares students
for clinical practice
Educators
responsibilities
◦ Flexible
◦ Change Agent
◦ Risk Taker
◦ Learn/Practice
http://sirc.nln.org/
Partial Trainers
Role Playing
Computerized Case Studies
Advanced Patient Simulators
Standardized Patients
3D Immersive (virtual worlds)
Virtual Reality
Haptic Devices
Robotics
Hicks, Coke, Li (2009)
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Methodology
◦ Simulation only (30 hours)
◦ Simulation (15 hours) and clinical (15
hours)
◦ Clinical only (30 hours)
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Results
◦ Knowledge Acquisition and Retention
 Pre –
 Post –
 No significant difference
•
Results
• Clinical Performance –
– Overall difference – not significant
– (but faculty rated combo and clinical
consistently higher then simulation
alone)
• Self-confidence –
– Simulation and combo had statistically
signification increase in self-confidence
– Clinical alone – no significant increase
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[It is not magic]
◦ Integration of Cognitive, Affective, & Psychomotor
Skills
◦ It challenges
 Faculty
 Students
◦ It provides opportunity
 Learner to practice and demonstrate
 Educator to teach and assess the learner
 Evaluate the curriculum
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Engagement in a realistic
problem
Planned and “scripted”
◦ Require critical thinking
◦ Provide an opportunity to reflect
◦ Divided into three components
 Briefing
 Simulation
 Debriefing and/or Guided Reflection
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Reflective process is influenced by the
effectiveness of facilitator
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Requires trust
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Fostering reflection is a complex skill
◦ Technique and Leveling according to the
learner
◦ Fostering reflection with a group can be
complicated
Johns, 1996; Paget, 2001; Westberg & Jason, 2001
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Depends on
◦ The objectives
◦ The learner
◦ The facilitator
◦ The experience
◦ Time allowed for the process
◦ Relationships between participants
 High – “debrief themselves” [Critical
Reflectors]
 Intermediate – “assistance” needed to
analyze the experience [Reflectors]
 Low – learners demonstrate little initiative
[Non-Reflectors]
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Difficulty developing reflection-inaction
Learner may have a distorted “view”
 Could lead to repeating mistakes
 Learners may only view the negative
 Fixations
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Outcome influenced by facilitator’s
skills
Boud, Keough, & Walker, 1985; Boud, 2001;
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Socratic Questioning - Guided questions
– Strategically integrated
“what if’s”, students find this difficult
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Requires active learning
Encourages logic – making connections
Facilitates critical thinking
Integrated and debrief session
Lambright, 1995; Schoeman, 1997
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Plus-Delta
Alpha
Delta
Examples of What we
good action would like
to change
Gamma
How we
would
change
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“Debriefing with Good Judgment” –
(Advocacy-Inquiry)
Debriefing
leads to new
frames
Frames
Actions
Debriefing
changes
later actions
Results
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Guided Reflection
◦ Johns
“Describe the knowledge and skills you have that
influenced your decision making during this
experience.”
Decker
“Talk to me about experiences you have had
that influenced what you did during this
scenario.”
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Review recorded performance (A-V)
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Completed a “self-assessment”
◦ Debrief checklist
◦ Written Journal
◦ Web-based
If teachers interject their
feedback prematurely learners
stop reflecting, lose confidence,
and become dependent on
faculty
Westberg & Jason, 2001
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Reflection
◦ Study the process
◦ Attend workshops
◦ Practice
 Self-Analysis – critique (Look in the mirror)
 Ask for critique (Clarify the reflection)
◦ Learn from your past
 successes
 mistakes
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Research needed related to
Reflection
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“how to promote”
“when to (timing)”
“how often”
“what are the most effective approaches”
“whom should be included in the process”
“how to structure – what tools/techniques”
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Thoughtful, self-questioning of my
actions, my experiences, and my attitudes
“How has my beliefs influenced my
actions?”
“How does my personality affect the
learner?”
“How has my prior experience impact my
…?”
Risk taker
 Change agent
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◦ Requires:
 New skills and understanding
 Integration of technology - simulation
 Energy, ideas, commitment, time
 Gather and understand the evidence
 Engaging - mentoring others
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Mentor
◦ Success is not about one’s own achievements,
but is measured by fostering success in others
◦ Learn how to be a mentor or mentee
◦ Requires commitment
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Relationships related to learning
through simulation
Transfer of knowledge and skills
from simulation based learning (SBL)
– to the work based environment
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New title, responsibilities,
opportunities
But,
◦ Most rewarding “Mammaw”
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Arrive with flare
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“Can’t” does to exist
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Take a fried along
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Ask for a push
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Swing higher
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Reach for the clouds
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Feel the music
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Use your imagination
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Laugh, Play, Learn
Debbie Spunt –
“Impact on the education of the next
generation of nurses”
Instrumental in the development of the
International Nursing Association for
Clinical Simualtion and Learning
(INACSL)
P. Jeffries – 2007
S.T.E.P. Simulations Take Educator Preparation
J. L. Grady – 2008
Simulation is consistent with best educational practices
It’s time for “Dynamic reform and
innovation in nursing education to
create and shape the future of nursing
practice.”