1. Guided Reflection in Clinical and Simulation Education
Clinical Practicum Project Presentation
Leisa Baldis, BSN, RN
This presentation will review the capstone project for the Masters of Science in Nursing-Education Specialty. The project focus, rationale, goals, methodology, outcomes and implications will be discussed.
Artist: Beth Eadicicco. Used with permission

2. Practicum Project Goals
Provide a guided reflection tool
Encourage reflective practice of students
Facilitate effective student/faculty communication in the clinical/simulation setting
Cal State University at San Marcos BSN program includes patient care simulation and clinical experiences as part of their curriculum. Current reflective practice is mostly verbal, loosely structured with varied approaches. Feedback is general in nature and for the most part is provided verbally in group settings.
The successful outcome of this project is a guided reflection tool and feedback guidelines that users are satisfied with as being easily learnable and effective in encouraging reflective practice and effective student/faculty communication.

3. Practicum Project Rationale
Recommendations and Positions
Critical thinking: a core competency of baccalaureate nursing professionals (AACN, 1998)
Coursework should provide knowledge and skills of reflective practice (AACN, 1998)
Nursing Preparation should incorporate reflective models, theories, processes and methods (Freshwater, 2005)
Reflection is a core competency of critical thinking for Baccalaureate Education for Professional Nursing Practice. Reflection can help students bridge the theory to practice gap (AACN,1998).
Sigma Theta Tau International's resource and position paper recommends the incorporation of reflective models, theories, processes and methods when preparing nurses (Freshwater, 2005).
The goal of reflection is to promote higher level thinking.
Reflection at CSUSM was used inconsistently with a varied approach.

4. Practicum Project Topic: Reflective Practice
Reflection in clinical education allows students to appreciate patient care experiences (Benner, 2001)
Helps connect the pieces and integrate new knowledge into practice (Myrick & Yonge, 2002)
Ungraded formative evaluation promotes student self awareness of performance (Morren, Gorden, Sawyer, 2008)
Guided reflection results in higher clinical reasoning scores (Murphy, 2004).
There is a large body of evidence supporting the use of reflection in clinical nursing education. Reflective practices such as verbal discussions and journal writing allows supportive comments and questioning that encourage development of clinical decision making (Myrick & Yonge, 2002). In reality, Clinical instructor time is often filled with checking preparations, asking key questions to verify patient safety leaving little time for in-depth conversations about the situation.

5. Practicum Project Topic: Journaling
Provides students a way to reflect on what has been learned and gain an appreciation for other perspectives that forms the basis for change and growth (Mezirow, as cited by Jensen & Joy, 2005)
Reflection is an ongoing, developmental process.
Artist: Beth Eadicicco. Used with permission

6. Obstacles to Journaling
Lack of understanding of concepts and practices
Perceptions of time and value of journaling activity
Student comfort and willingness to expose themselves to judgment from others
(Ruth-Sahd, 2003)
Students may not understand the how and why of reflective journaling. They may feel the added burden of more work that is not valuable.
Obstacles can be overcome by providing adequate introduction to concepts and methods, creating a safe learning environment of openness, honesty and trust and allowing time for completion of journaling activities (Ruth-Sahd, 2003).
Artist: Beth Eadicicco. Used with permission

7. Journaling Success Strategies
Common language improves communication and feedback that foster growth and development of clinical judgment (Stevens & Levi as cited by Lasater, 2007).
Depth of reflection improves when subjects are made aware of the significance and value of reflection (Mezirow, as cited by Jensen & Joy, 2005)
Student Development benefits from structured guided reflection (Lasater, Nielsen, 2009)
Adequate explanation of concepts and benefits (Ruth-Sahd, 2003)
Providing dedicated time for reflective practices (Ruth-Sahd, 2003)
Reflective journaling provides faculty insight into student thought processes and an opportunity for dialogic feedback between instructor and student to facilitate professional development (Nielsen, Stragnell & Jester, 2007).
Faculty attitudes that value journaling activity are important for success of journaling activity. Allowing dedicated time to explain and participate in reflective journaling is critical. Multiple reflection strategies such as group discussion, private dialogue and written journal entries are recommended for maximum effectiveness (Ruth-Sahd, 2003).
Grading of journal entries is not recommended as this raises issues of power and control. Feedback should focus on the process rather than the content.

8. Practicum Project Objectives
Analyze current literature
Identify faculty and student perceptions of reflective practice and feedback
Develop guided journal template and feedback guide
Evaluate subjective feedback of students and faculty
A review and analysis of current literature on reflective theories, models, processes and methods of reflective learning, reflective journaling and usability testing informs the development of the guided reflection journaling tools.
A survey of faculty and student perceptions about reflective practice and feedback experiences identifies needs and illuminates potential obstacles.
User centered design principles guide the development of the guided journal template and feedback guide.
Subjective feedback provides formative and summative evaluation about the usability and effectiveness of the guided reflection tools.

9. Methodology
Qualitative analysis of reflective practice in simulation education
Prospective non-experimental study
Survey design
User centered design principles
Qualitative synthesis encourages interpretation about the concept by examining essential features and creating a new interpretation of reflective practice (Noblit & Hare, as cited by Flemming, 2007).
User centered design involves the end users in the development process. Prototypes of the tool are tested on small groups and design changes are made iteratively based on feedback.
Artist: Beth Eadicicco. Used with permission

10. Student Perceptions of Reflective Practice
Helps you learn from your mistakes
Allows your instructor to get a “view” of your experiences and thoughts
Helps you bring together the classroom, lectures and book info into the real world
Provides insight into learning and the role personal values play in my thoughts, feelings and actions
First phase of the project involved a survey of student and faculty about their perceptions of reflective practice.
10 student responders and 3 faculty responders
Common themes of students' responses about their understanding of reflective practice in the scope of their nursing education.
Results of this survey are similar to those done by Hong and Chew (2008).

11. Personal Experience with Reflective Practice
All students surveyed identified some experience with verbal reflection in small group discussions
Feedback was described as helpful
Feedback received was mostly verbal
Half had experience with written journaling
One student had received written feedback
Student responses about their personal experience using reflective journaling.

12. Faculty Perceptions of Reflective Practice
Increases depth of understanding and insight
Fosters personal and professional growth
Allows students to look back and use 20/20 hindsight to improve future practice
Three faculty responded to the survey about perceptions of reflective practice.
There was less variability in faculty responses compared to student responses. This may be partly due to a better overall understanding of the concepts of reflective practice.

13. Faculty Personal Experience
All describe using verbal reflective strategies with students in group discussions
All have used or currently use written journaling as a teaching strategy
Feedback was usually provided verbally
Faculty all described difficulty in providing written feedback to students due to the large numbers in a class and an already full workload.

14. Formative Evaluation: User Testing
Three students and three faculty participated in testing the initial prototype. Evaluation looked at Learnability, Effectiveness and Overall Satisfaction
Learnability: 100% felt the directions on how to use the tool were clear and easy to understand.
5 out of 6 felt the question prompts were clear, understandable and stimulated reflection about the experience.
Neutral response comment was that the prompts were "I thought that some of the prompts were a little hard to understand what exactly was being asked. Once I started writing I didn’t really look at the prompts because they confused me more than just writing about my experience and what feelings I had about it"
Faculty comment stated concern that students might be too novice to understand what was being asked of them.
Effectiveness-100% found the journal guide and feedback received effective in encouraging reflective practice and faculty/student communication
Overall Satisfaction- 100% strongly agreed that the guided reflection tool was enjoyable to use, valuable and recommended using the guide as a learning activity.
Minor changes in the question prompts were made to the prototype resulting in the final product.

15. Guided Reflection Tool: Instructions for use
This guide for reflection is provided to help you think about your clinical or simulation scenario learning experience and your nursing responses to that situation. The purpose of reflective writing is to support your development of clinical judgment and critical thinking, both of which are important skills you will need to become competent and eventually, expert practitioners. This framework is adapted from several reflective practice models. It is intended to encourage your reflection while allowing for your creative expression about the experience. The questions are provided as prompts to stimulate your reflective writing. It may not be necessary or appropriate to address each item individually. Use the gray headings to organize your journal entry. Your entries are not graded. Your instructor will read your journal entries and provide feedback to help you develop insight into your progress towards competent clinical judgment. You are encouraged to express your thoughts and feelings freely and honestly.
These are the instructions for use of the final guided reflection tool written at the top of the template. The printing is small, so I will read it out loud.

16. Guided Reflection Template
Students may benefit from structured guided reflection (Nielsen, Stragnell & Jester, 2007).
An example of the guided reflection template. The design was influenced by Nielsen, Stragnell & Jester's (2007) reflection guide using Benner's novice to expert model (1984) as a framework.
Students examine the context of the experience by reviewing experiences and knowledge, identifying values, expectations, feelings etc.
Prompts to elicit student thought processes as they analyze and interpret the data are provided.
Cues to prompt reflection in action and on action are provided. Call for future action/change plans are included.

17. Feedback Guide and Rubric
The faculty feedback response will focus on the reflective process rather than the content per se.
Reflections are neither right nor wrong, but simply a space for self-expression
Feedback is non-judgmental with emphasis on supporting, motivating and guiding student reflections and critical thinking
Feedback responses will include acknowledging personal worth, reinforcing specific concepts, supporting student, recognizing personal uniqueness, identifying with student, personalizing experience.
General feedback guidelines were provided to faculty. Here are some examples of the suggestions. Although the faculty surveyed at the outset of the project had experience is using reflective journaling, suggestions were provided for review. Future faculty users may not have as much experience or understanding of reflective practice concepts.

18. Journal Entry Rubric based On Benner' Novice to Expert Model
Sharing a model of the stages of professional competence development helps create the expectation for progression and provides for increased depth of discussion (Lasater, 2007).
The use of a rubric and a common language provide students and faculty with tools for communication and feedback to foster growth and development in clinical judgment The use of a rubric and a common language of the clinical judgment development provide students and faculty with tools for communication and feedback to foster growth and development in clinical judgment (Stevens & Levi as cited by Lasater, 2007).
This rubric incorporates Benner's stages of nursing practice development within the organization of the reflection guide. It does not include the expert stage for the sake of brevity.

19. Journal Entry Rubric based On Benner' Novice to Expert Model (cont.)
Students enrolled in the nursing program are expected to be competent practitioners upon graduation. Further development occurs once they are actually working in the full capacity of a nurse (Benner, 2001).

20. Summative Evaluation Results
Summative evaluation of tool: Eleven Students completed a journal entry using the guided reflection tool and received faculty feedback.
Of the eleven students completing the journal entry using the guided reflection tool, only 8 returned the evaluation survey.

21. Student comments: The journaling guide made it easier to stay on track
Definitely stimulated lots of thinking
I feel like this reflective practice is helping me become a good nurse, not just mimic nursing skills.
The guide made journal writing easier
Reflective practice is new to me. I'm glad to have learned this so early in my education.
Instructor's probing questions in her feedback definitely stimulated my thinking
Here are some of the student comments written on their evaluations.

22. Limitations Small test groups
Semester scheduling required remote recall of clinical/simulation experience
Minimal time spent on teaching concepts of reflective practice and journaling
Summative evaluation return rate was low

23. Implications
The use of reflective practice in nursing education is valuable
Issues of time continue to present obstacles
Inclusion of reflective principles, models and strategies from the beginning of nursing education could increase the value and benefits
More research is needed about the usefulness of guided reflective journaling as a tool for facilitating the development of clinical decision making
Reflective practice is a valuable learning strategy when students are adequately prepared and allowed time to participate in journaling activities. Written feedback from instructors is useful and effective.

24. Seeing within changes ones outer vision-Joseph Chilton Pearce
Learning without reflection is a waste; reflection without learning is dangerous-Confucius
We don't see things as they are, we see things as we are-Cicero
Some thoughts to reflect upon.

25. References
American Association of Colleges of Nursing. (1998). The essentials of baccalaureate education for professional nursing practice. Washington, DC.
Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall
Dreifuerst, K. (2000). The essentials of debriefing in simulation learning: A concept analysis. Nursing Education Perspectives, 30(2),
Flemming, K. (2007). Research methodologies. Synthesis of qualitative research and evidence-based nursing. British Journal of Nursing, 16(10),
Freshwater, D., Horton-Deutsch, S., Sherwood, G., & Taylor, B. (2005). The scholarship of reflective practice. Retrieved November 8, 2009, from Sigma Theta Tau International: Hong, L., & Chew, L. (2008). Reflective practice from the perspectives of the bachelor of nursing students: A focus interview. Singapore Nursing Journal, 35(42-48).

26. References (cont.)
Hurlock, M., Falk, K., & Severinsson, E. (2003). Academic nursing education guidelines: Tool for bridging the gap between theory, research and practice. Nursing and Health Sciences, 5,
Jeffries, P., Clochesy, J., & Hovancsek, M. (2009). Designing, implementing, and evaluating simulations in nursing education (D. Billings & J. Halstead, Eds.) (pp ). St. Louis, MO: Saunders Elsevier.
Jensen, S., & Joy, C. (2005). Exploring a model to evaluate levels of reflection in baccalaureate nursing students' journals. Journal of Nursing Education, 44(3),
Lasater, K. (2007). High-fidelity simulation and the development of clinical judgment: Students' experiences. Journal of Nursing Education, 46(6),
Lasater, K., & Nielsen, A. (2009). Reflective journaling for clinical judgment development and evaluation. Journal of Nursing Education, 48(1),

27. References (cont.)
Morren, K., Gordon, S., & Sawyer, B. (2008). The relationship between clinical instructor characteristics and student perceptions of clinical instructor effectiveness. Journal of Physical Therapy Education, 22(3),
Myrick, F., & Yonge, O. (2002). Preceptor questioning and student critical thinking. Journal of Professional Nursing, 18,
Nielsen, A., Stragnell, S., & Jester, P. (2007). Guide for reflection using the clinical judgment model. Journal of Nursing Education, 46(11),
Ruth-Sahd, L. (2003). Reflective practice: A critical analysis of data-based studies and implications for nursing education. Journal of Nursing Education, 42(11),
Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6),