CHAPTER 10

In-Class and Electronic

Communication Strategies

to Enhance Reflective Practice

Lisa A. Davis, Traci D. Taylor, and Deborah Casida

Knowledge emerges only through invention and re-invention, through the restless, impatient, continuing, hopeful inquiry human being pursue in the world, with the world, and with each other.

—Paulo Freire

INTRODUCTION

The purpose of this chapter is to explore reflective practice models for nursing education. Increasingly, electronic communication strategies have been used by nurse educators as a teaching tool. Teaching strategies based on reflective practice can be modified for both traditional classroom activities and for computer-based learning opportunities.

DEFINITION AND PURPOSE

A goal of nursing education is to promote critical thinking, which is a process of reflecting that involves more than just analysis of the facts (Forneris & Peden-McAlpine, 2007; Idczak, 2007) in a way that emphasizes principles or patterns over “coverage” of material (Walsh & Seldomridge, 2006). Nursing students must learn to develop practical knowledge that augments textbook knowledge in order to learn clinical judgment in increasingly complex nursing situations (Tanner, 2006) by engaging in reflective activities.

More than ever, higher education has embraced teaching strategies that extend beyond the traditional classroom. Distance learning programs are prolifer-ating. Today’s learner expects technology and uses technology in all aspects of life, including formal learning. There is now a plethora of software to encourage both synchronous and asynchronous learning opportunities via Webcams, chat rooms, discussion forums, blogs (Web logs), vlogs (video logs), and virtual clinical learning situations. Internet, intranet, electronic databases, and “clicker” technology is available both outside the traditional classroom and in the traditional 147

148 CHAPTER 10 • REFLECTION

classroom, now termed “smart” classrooms because of the extensive electronic enhancements.

“Enhancement” is the operative word. While electronic communication strategies are important, they do not take the place of the teacher. In fact, because of the tremendous explosion of both knowledge and ways to retrieve knowledge, the teacher is even more important. Students can easily become overwhelmed by the sheer volume of information and ways to retrieve and integrate information.

The crucial role of the teacher is to design learning opportunities that incorporate electronic learning strategies that enhance learning by addressing the integration of the four fundamental patterns of knowing (Carper, 1978) in a learning-centered environment (Candela, Dalley, & Benzel-Lindley, 2006; Palmer, 2007) in order to achieve the learning outcomes. Reflective activities should be incorporated in nursing education to facilitate critical thinking (Epp, 2008) and clinical reasoning using a variety of strategies.

In 2005, the National League for Nursing (NLN) published a position statement regarding standards for nursing education. Included in this position was the expectation that nursing educators should incorporate new technology into teaching that is supported by evidence-based practice. This same statement included a call for innovation in teaching strategies that promote student learning and nursing practice based on research (NLN, 2005).

ThEORETICAL RATIONALE (FOUNDATIONS)

Carper (1978) identified four fundamental patterns of knowledge in nursing: empirics, esthetics, personal knowledge, and ethics. Empirics include both theoretical and research-based information geared toward development and evaluation of facts. Esthetics encompasses more than the art of nursing; it relates to the subjective appreciation that leads to understanding. Carper distinguishes esthetic knowing in terms of “knowing of a unique particular rather than an exemplary class” (p. 18).

Personal knowledge involves more than just knowing about the self, it is knowledge of self both as a unique individual and in relation to others. Finally, ethical knowing is the moral component, focused on the deliberation of right and wrong.

While each pattern of knowledge is unique and indeed fundamental in understanding nursing, none are sufficient, independently or exclusively. The integration of these patterns of knowing require reflection. This reflection, as Schön (1983) reminds us, is both reflection in action and reflection on action. For nursing, this means reflection while in the act of caring for another and also reflection on the effect of that care after it has been rendered. Implicit in reflection is mindfulness—continuous appraisal, openness to new information, and awareness of multiple perspectives (Johns, 1995, 2004; Langer, 1997). It is important to note, from both the teacher and student perspective, critical reflection is tantamount Conditions for Learning 149

to action (Freire, 2001). Therefore, reflection is both an ongoing process and a critical evaluation of what has already been done. Reflection involves both thinking and evaluation, creatively and systematically, in order to come to a deeper understanding and to develop praxis (Freire, 2001).

Benner (2001) identifies expert nurses as those who are able to understand, tacitly, a complex nursing situation using current knowledge and intuition gained from experience. This tacit knowledge results from reflection in clinical practice and is an example of reflection in action. The goal, in the development of novice nurses, is to develop this reflection in action by fostering learning situations that require reflection on action.

TYPES OF LEARNERS

Reflective practices integrate the fundamental patterns of knowing. Nursing students, as novices, all need experience in reflective practices. Most students come to higher education with a great working knowledge of computer-based technologies. Therefore, engaging in reflective activities using electronic communication strategies is appropriate to all levels of nursing students.

Because electronic communications transcend the boundaries of the classroom or clinical setting, it is possible to foster relational knowing between levels of nursing students. For instance, first semester students could interact with fourth semester students in reflective activities, allowing the more experienced students to model both reflective learning and relational learning. In the same vein, teaching/learning strategies of nursing faculty could be enhanced by relational learning via electronic communications. Here again, experienced faculty could mentor junior faculty in an ongoing discussion thread, sharing classroom experiences with new teaching/ learning strategies.

In addition, these strategies could be used effectively in staff development activities. Online blogs, for example, could provide a forum for expert nurses to model reflective practices for more novice nurses. This relational learning enhances reflection, particularly in personal knowledge. It is important to remember that nurses are developing, not only as practitioners of care, but as individuals (Newman, 2008; Silva, Sorrell, & Sorrel, 1995).

CONDITIONS FOR LEARNING

Reflective learning opportunities via electronic communications rely on trust, and a safe environment for disclosure. Because it is an ongoing process, interaction between members enhances appreciation and learning from various perspectives.

The facilitator role is essential, first, to frame reflective questions for the learners 150 Chapter 10 • refleCtion

and, second, to monitor the quality and collegiality of the discussions. While there are philosophical differences between faculty members regarding whether or not reflective activities should be graded, it is important, if graded, to provide students with both the grading rubric and objectives for reflective activities.

Finally, because of the nature of discussions and the need to maintain confidentiality, the Health Insurance Portability and Accountability Act (HIPAA) requirements should be meticulously kept. Most electronic communications, even those password protected, are not considered secure. Any discussion of specific patient information is not appropriate, which could limit discussion of actual clinical incidents. Additionally, if access is not limited to the class and faculty (such as with the use of Blogspot), outside influences such as other nurses responding to postings could become distracting for the student and overwhelming for the instructor to address. It is important for faculty to develop guidelines for discussion and strictly monitor for issues of confidentiality. Many of these particular issues are minimized or eliminated with the use of authorware commonly utilized by nursing schools and universities, such as Angel, WebCT, or Blackboard.

RESOURCES

In a traditional classroom setting, reflective activities can be facilitated by small group discussion. Classroom arrangement needs to be nontheatre in style (rows of desks facing a podium). Optimally, the classroom can be arranged so that students can face each other, or the desks can be rearranged to allow for several small discussion groups.

For any computer-assisted teaching strategies, technological support is an imperative. Ensure that whatever Web-based instructional strategy or software you intend to use is supported by the technical support of your institution. Both faculty and students involved in computer-enhanced learning activities need to be familiar with the equipment. Faculty need to have access to appropriate software, and the time and support to develop expertise with any new software or programs.

Specific computer requirements should be conveyed to the students as required so student financial aid can help defray the cost of the equipment/software, or students should have access to computers at school.

USING ThE METhOD

This discussion will be primarily focused on blogs and asynchronous discussions; however, there are increasingly diverse methods of electronic Using the Method 151

communication technologies available that could be equally useful at enhancing learning opportunities. Some of these are identified as additional resources at the end of the chapter.

As with any teaching strategy, use of specific technology depends on expected learning outcomes. Expectations regarding participation should be clearly indicated to students. Case studies, clinical observations, critical incidents from clinical experiences, narrative pedagogy (Diekelmann, 2003; Diekelmann & Lampe, 2004; Ironside, 2003; Scheckel & Ironside, 2006), logic models (Ellermann, Kataoka-Yahiro, & Wong, 2006), problem-based learning, and context-based learning can be developed for both traditional classroom and Web-based courses to support reflective activities.

The significant increase in online learning has changed the way students learn and has prompted a necessary change in the teaching focus and methods of faculty (Ryan, Carlton, & Ali, 2004). This paradigm shift results in the need for faculty to adopt new pedagogies or adapt conventional ones, such as changing to become a facilitator of learning rather than sole subject authority (Ryan et al., 2004). The use of interactive technology within a course encourages this student-centered focus, allowing the learner to actively engage in discussions, reflective journaling, peer review, and other methods that encourage critical thinking; however, nursing faculty often do not have adequate knowledge of the various roles that technology can play within their class.

Advantages of using technology are many. This benefits the educator by encouraging more objective scoring, rather than subjective, as he/she is able to better evaluate responses. There is more time to be with students. Students perceive that there is more interaction with the instructor. It allows freedom of expression within a professional context; all students are given the opportunity to respond even if they are reticent to actively participate in a traditional classroom. The student has the time to reflect rather than simply coming up with a quick answer.

Content of Blogs, Asynchronous or Synchronous Discussion Forums, and Other Methods

Blogs and other technology formats can incorporate multiple methods of learning, such as case studies, reflective journals, and postconference-type information. This would be directed by the project objectives and goals. Any of these methods can additionally help with professional writing and communication as well as application of previous knowledge, such as from prenursing courses.

Students are able to develop insights into learning and nursing concepts if they routinely engage in critical thinking, enhancing their decision-making skills.

152 Chapter 10 • refleCtion

Questions used for any format should allow for more than one correct answer, thus facilitating a richer discussion. It should be clearly articulated to the students that substantive, constructive, and original responses are expected. It is incumbent upon the faculty develop a scoring rubric that reflects substantive and original thought.

Maag (2005), from the University of San Francisco School of Nursing, discussed the use of blogs in nursing education and proposes several advantages of incorporating blogs into learning. The opportunity to write and publish, after reflection and thought, provided an opportunity for students to connect with the topic. Skills such as those required for communication, good writing skills, and computer literacy are all promoted with the use of blogs. Suggestions for the use of blogs include as a discussion board, area for journal posting, electronic portfolios, or for reflective journaling.

SCORING

As previously mentioned, the merits of scoring of any type of reflective journal written by the student are avidly discussed among educators. However, if this is to be accomplished based on the objectives of the activity, a clear, simple scoring rubric should be utilized. This effectively eliminates questions regarding fairness; and although still subjective, is more objective than not. It should be emphasized that the rubric should be simple for the faculty to grade from as well (Table 10-1).

Smaller groups, such as those with 6 to 12 participants, tend to work better both in terms of scoring and in regard to student participation. This makes it easier for faculty to note repeated or unoriginal responses as well as respond in a manner specific for the student. Students do perceive faculty participation in discussion forums as crucial to the success of the forum; however, it does encourage more reflection on the part of the student if he/she is aware that the educator will respond (Mazzolini & Maddison, 2007). Educators are able to monitor responses as well as ask further critical thinking-type questions that, in turn, facilitate more discussion (Table 10-2).

Although scoring sounds time intensive, and it can be, this can be avoided if the students do not expect the instructor to respond to every posting. Faculty can elect to grade a representative sample of the students’ work, noting this in the syllabus (e.g., “at least 5 blog postings will be graded”). This allows the faculty to provide formative feedback without the time-consuming task of scoring each blog. By indicating “at least,” the faculty reserves the right to grade more if necessary. Also, if the educator clearly defines the expectations of the blogs, she/he may decide to post only at the end of the discussion, using a “wrap-up” format.

Scoring 153

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Evalua

Learning

Outcome

Participation

Collegiality

Empirics

Esthetics

Table 10-1

154 Chapter 10 • refleCtion

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Table 10-1

Potential Issues 155

POTENTIAL ISSUES

Diverse Methods of Learning

Students represent disparate ages and life experiences in a typical nursing program, increasing the need for accommodation for various methods of learning (Billings, Skiba, & Connors, 2005). Undergraduate students, up to about 40 years of age, tend to view the use of technology in education in a positive manner, as they routinely communicate via several methods of electronic communication and are comfortable with different types of technology (Billings et al., 2005). Graduate students, primarily from the generation that includes people over 40 years old, often prefer more traditional classroom settings that involve passive learning.

However, this generation generally has increased need for accommodation in terms of flexibility of class times and locations; online or blended learning classes can address this need through increased use of technology (Billings et al., 2005).

Academic Misconduct

A prime concern that emerges when instructional technology is initiated in a course is concerns from faculty regarding the possibility of plagiarism. An initial approach to the problem may simply be to provide clarity to students regarding examples of plagiarism and consequences of it may deter some students (Embleton & Helfer, 2007). Several sources addressed this issue by encouraging the use of questions that require higher level thinking and analysis rather than simple knowledge-based answers (Teeley, 2007). Another proposal, for lengthier assignments, is to submit questionable works to antiplagiarism software that evaluates phrases or papers for plagiarism (Embleton & Helfer, 2007). Although these sites are not foolproof, they are a way to manage a problem. In addition, requesting that students submit rough drafts of works in progress, research articles, and outlines can prove that they are presenting original work (Embleton

& Helfer, 2007).

Faculty Perceptions

Technology applications for learning, such as blogs and online discussion forums, are a fairly new phenomenon in education despite the general use by the public and are not readily appreciated by many educators for the great potential 156 Chapter 10 • refleCtion

Table 10-2 Sample Questions to Elicit Ways of Knowing and Reflection Empirics

The patient is transitioning from peritoneal to hemodialysis dialysis.

What is the most important thing to teach regarding that transition?

Support or justify your answer.

What is your priority nursing diagnosis for this client?

Esthetics

The patient is concerned about their ability to continue their work as an accountant. Discuss how this transition might affect their ability to continue to work. How would you respond to their concern?

Is this the same issue as

?

Personal

If you were in the position of receiving hemodialysis 3 days a week, what would you personally have to give up to accommodate this schedule?

What are your assumptions?

Ethics

The patient has now been on hemodialysis for a month and has now decided to discontinue it due to “I just feel too bad.” His wife has asked you about a Power of Attorney so that she can force him to continue dialysis, as she believes “he will be killing himself.” How do you respond?

His 16-year-old son is a perfect (and only) match for a transplant. He says, “I’m not going to donate the kidney and you can’t make me.”

How do you respond?

Reflective

Identify a time in your life when you felt helpless. What helped you cope with that situation? Would you respond in the same way today?

Identify a patient you have taken care of who has had to make life-altering decisions based on their new healthcare condition. Reflect on their response to this new condition. How did you respond? If you could do it again, what would you change about that response?

Would you respond in the same way?

they have for education and promotion of critical thinking (Sanders, 2006). Educators must learn how to use this resource as one way to effectively engage learners in the nursing educational process. Although blogs and discussion forums can be implemented easily into a traditional class format or as an addition to online-based learning, faculty is often not comfortable with teaching in a learning Conclusion 157

style different from their own; developing an understanding of the differences in learning is crucial to providing a student-centered learning environment (Billings et al., 2005).

One suggestion from the literature is to use learning technology as a method of nursing faculty development to become comfortable with the technology before classroom implementation. Blogs can be established quickly, at no expense, and can be a way to communicate topics to educators both experienced and new to teaching (Shaffer, Lackey, & Bolling, 2006). Online discussion forums can be utilized as a communication tool for nursing departments and schools, not only facilitating communication between faculty members, but also raising the comfort level of that same faculty with the method.

Faculty, in our experience, perceived an increased time involvement for the students when using blogs as an alternative clinical postconference activity. However, one could use synchronous or asynchronous learning activities to take the place of postconference or simply augment clinical learning—the advantages are many. The students are able to rest after clinical and gather their thoughts, then

“meet” online for conference when they are not as tired or overwhelmed. This has the advantage of allowing reticent students to actively participate in discussions, engaging them in a way that face-to-face discussions may not. Anecdotally, one student stated “[blogs] allow for ‘extra’ learning outside [the classroom] and it is not perceived as extra work.” Even students of the older generations easily learn to use the technology, as most have experience with it through previous university courses. It prepares them as well for the new informatics-centered culture of the day.

CONCLUSION

In this chapter, reflective learning activities specifically using electronic communications (blogs) were explored as a way to promote critical thinking and enhance professional practice. Reflective activities are imperative to developing clinical judgment in increasingly complex nursing situations.

The theoretical framework was Carper’s fundamental patterns of knowing: empirics, esthetics, personal knowledge, and ethics, which is reflected in the grading rubric. Today’s learner uses technology and expects it in all aspects of life, including formal education. Reflective learning activities using electronic communication are appropriate for all learners at all levels of nursing education. It is appropriate and supported by nursing organizations, such as the NLN, which calls for innovations in teaching strategies to promote learning, practice, and research.

158 Chapter 10 • refleCtion

EXAMPLE OF THE RESULT OF BLOGS

Blogs were instituted in a junior-level medical–surgical nursing class with the intent of increasing application and synthesis of the class content and providing an alternative to traditional postconference. The rationale was that students were tired at the end of 2-day clinical and not actively participating in postconference. In addition, the students were failing the end-of-course case study exam. The faculty believed that more rested students in an environment that required active participation from all students would be more successful. Also, observation of the ease with which students routinely used various electronic communications outside the classroom indicated that blogs would provide an appropriate learning activity. When initiated, scoring rubrics and expectations (including col egiality, time frame, substantive remarks, and objectives) were provided in writing and communicated to students during orientation to the course.

While this was a significant learning experience for both students and faculty, the direct, immediate result was the substantial improvement of final examination scores. On average, students who participated in blogging scored 15% higher on the course case study examination than students who previously took the class. No other change in course delivery was initiated. Initially, the blogs were in a case study format with very directed, knowledge-based questions. As the semesters progressed, the questions regarding the case studies were modified to include more application-type questions, decreasing ability of students to copy and paste responses. In addition, ethical issues were discussed more fully. The scoring rubrics were also simplified to decrease grading time for faculty and al ow for increased time for participation in discussions. The format then became more reflective, requiring students to use more resources than just the textbook. Students were required to give more original, substantive responses. That went beyond the empirics and included all of Carper’s ways of knowing.

Initial y, al students enrol ed in the course were included in one blog, which became too cumbersome. Some faculty were skeptical of the efficacy of using blogs in place of traditional postconference and time required to grade responses. As the grading tool was refined, this became less of an issue. Also, students were divided into smal er groups of 10–12, creating a more intimate learning environment that benefited both the student and faculty. This size of a group seems to be optimal, al owing for increased responses from students and more discussion from faculty. As the process evolved, students began to ask questions that they would not have asked in the didactic and clinical environments, also al owing for substantive responses from peers and anecdotal y encouraging empathy and col egiality (esthetic knowing) among peers. This gave opportunity for faculty to have a “teachable moment.”

STUDENT COMMENTS AT END-OF-COURSE EVALUATION

Responses to Supplemental Evaluation Question,

“Do you prefer traditional postconference or blogs?”

“Blog, the student is able to think on their own and use critical thinking which promotes better understanding of the disease or condition the patient is in.”

“Blog helps with clinical exams and real life experience with what we learned—application.”

“Blogs—I found it to be most beneficial. It gave me time to think about my responses and was interesting to read other responses.”

Conclusion 159

“Blogs, by the time postconference comes most of us are tired and ready to go home and don’t pay attention, plus, the blog gives us another opportunity to apply what we’ve learned to an actual clinical problem.”

“Blogging was good, and I learned more because I actually had to look things up.”

“Blog are a better learning experience and we tend to remember more.”

Additional Feedback

“ . . . having to look up the info helped to engrave into my mind why things occur and what can be done.”

“ . . . it helps to wrap everything we have learned into one package and . . . helps you to analyze the problem.”

“ . . . it encourages al of us to think . . . sometimes in postconference, one person runs the show . . . now everyone else has a chance to come to conclusions on their own.”

“They allow for “extra” learning outside [the classroom] and it is not perceived as extra work.”

teaChing example

Student Use of Reflective Practice Journal

Using the format for clinical supervision outlined earlier in the Using the Method section, a student submitted a journal entry for discussion in seminar. The journal topic was her clinical encounter with a woman regarding a sexual health issue. The student was aware of a barrier between herself and the client but was unable to identify the origins of the barrier. In the reflective process of describing the encounter in writing, the student started to uncover a reoccurring theme for herself. The student noted that the large age discrepancy between the client and the client’s significant other had been an issue for the student.

The writing process gave the student the time and context in which to sort and organize her thoughts regarding the experience in order to be able to present them in a systematic manner. This in turn helped the student to uncover the reoccurring issue of age discrepancy that kept surfacing during her reflections. Once the underlying issue of age discrepancy was identified, the seminar leader was able to direct the group discussion around the student’s knowledge, personal beliefs, and feelings concerning age discrepancies within intimate relationships. The student’s and the other seminar participants’ personal experiences and views were shared and examined using Johns’s framing perspectives and reflective cues.

As a result of the discussion, the student became more aware of her own biases regarding age discrepancies within intimate relationships. She was able to identify some misconceptions and identify some beliefs and values that were important to her. There was a shift in the student’s level of acceptance of such relationships without a complete revision of her underlying belief system. The shift was related to her becoming more aware of her own personal biases and the impact that they had on her interactions rather than a shift in her own personal value system. However, awareness of one’s biases and being able to partially or completely bracket them off within the context of an interaction may represent a subtle shift in the intensity of one’s value system with regard to the issue at hand.

160 Chapter 10 • refleCtion

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ELECTRONIC RESOURCES

E-learning Software

http://www.flextraining.com/default.asp?st=all&source=Goog http://www.saba.com/products/centra/details.htm#virtual_classes

Create a Blog

Use resources on distance learning authorware such as WebCT and ANGEL.

http://moodle.com/

http://blackboard.com/products/Academic_Suite/index

http://www.angellearning.com/

https://www.blogger.com/start?utm_campaign=en&utm_source=en-ha-na-bk&utm_medium=ha&utm_term=blogger&gclid=CM_ug4Gyw5c-CFQsQagodoFKrRA

https://www.blogger.com/start

http://www.bloghelp.org/

Twitter

http://googleblog.blogspot.com/

Virtual Media

http://www.massively.com/2008/02/25/cisco-opens-virtual-hospital-in-second-life-and-ibm-doesnt/

http://secondlife.com/

Anti-plagiarism Software

http://www.turnitin.com (also available through many universities)

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