“…Until We Reflect”

1. “…Until We Reflect” Sharon I. Decker, RN, PhD, ANEF Professor, Director of Clinical Simulations Covenant Health System Endowed Chair in Simulation and Nursing Education

2. “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,…

3. Objectives 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.

4. Time of Challenge • 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.

5. Challenge: Transform Education • Faculty “Competence” • Evidence-based • Changes • Teaching • Evaluation • Focus on student learning • Active participants • Integrate technology • Work with regulator & accrediting bodies to support innovation

6. Our Challenge • 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

7. Time of Innovation • Identify essential competencies • Validate assumptions • Be creative But, grounded in evidence • Develop and evaluate new educational pedagogies AACN, 2006; NLN, 2003, 2009

8. Time of Turbulence • Nursing Faculty Shortage • Increased use of adjunct and part time faculty • Budget constraints • An aging faculty • Competition with service • Competing clinical sites

9. Time of Turbulence • 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

10. Time of Turbulence • Institute of Medicine Competencies (2003) • Provide patient-centered care • Work in interdisciplinary teams • Employ evidence-based practice • Apply quality improvement • Utilize informatics

11. Time of Turbulence 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”

13. A Time for Change • Clinical Education • Determined by learning outcomes and goals • Involve student accountability • Active learning • Planned well with debriefing NLN, 2008

14. Benner, P., Sutphen, M., Leonard-Kahn,V., Day, L. (2009). Educating nurses: A call for radical transformation. San -Francisco: Jossey–Bass and The Carnegie Foundation for the Advancement of Teaching • Nurses use multiple forms of critical, creative, and imaginative (which includes reflective) thinking • Facilitating the learners ability to “Learn to Think Like a Nurse”

15. Hypotheses • “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).

16. My argument: • Learning is dependent upon the integration of experience and reflection. • Because, experience alone does not guarantee learning – nor clinical competencereflection promotes the transfer of experience to learning and knowledge

17. Change is Mandatory • Evidence Based and Requires • Creativity • New pedagogies • Flexibility • Reflection

18. Reflection: Defined • Conscious consideration of the meaning and implication of an action • Assimilation of: • Knowledge (Concepts) • Skills • Attitudes (Values & beliefs) • With pre-existing knowledge

19. Reflection: Etymology • Reflexio (Latin) • The act of bending back

20. Reflection: Etymology A “wave motion or energy” Reflectivity dependent on: • Angles of incidents

21. Reflection: Etymology A “wave motion or energy” Reflectivity dependent on: • Texture of the reflective surface

22. Reflection: Etymology A “wave motion or energy” Reflectivity dependent on: • Wavelength

23. Looking back….to move forward 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

24. Socrates (B.C. 470-399) • 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”)

25. Dewey (1910, 1916, 1933) • Active, persistent, and careful consideration • Learning is dependent upon integration of experience with reflection • Reflection promotes understanding of relationships

26. Schön, 1987 • Reflection-on-action • Reflecting after – thinking through • Reflection-in-action • Being aware • Reflecting while doing • “They ‘feel’ where the music is going and adjust their playing accordingly.” (pg. 30)

27. Schön • Knowing-in-action (Expert) Professional knowledge Skills competence • Applying theory while problem solving • Responds or “makes new sense” of uncertain, unique situations

28. Kolb Reflecting (Reflective Observation) Experiencing (Concrete Experience) Learning Cycle Thinking (Abstract Conceptualization) Applying (Active Experimentation)

29. Johns, C. (1995) • A window through which a practitioner can view self • “Stepping-stones” • To confront, understand, and resolve contradictions between desired and actual practice • Self-discovery

30. Reflection: The Art of Nursing • 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

31. Reflection • Requires • Active involvement • Realist environment • Authentic experience • Assistance (guidance) • Time

32. Reflection • Outcomes • Insight • Development of new knowledge • Application of that knowledge Promotes innovation, transformation, and change

33. Reflection • Does not happen automatically • Requires guidance to clarify • Can be taught • Learners expanded their repertoire of possible solutions • Boyd & Fales, 1983 • Henderson & Johnson, 2002

35. Outcome of Reflection • Increased clinical reasoning skills • Increased use of focused reflection • Engaged in abstract thinking • More self-regulated in learning Murphy, 2004

36. Simulation • Prepares students for clinical practice • Educators responsibilities • Flexible • Change Agent • Risk Taker • Learn/Practice • http://sirc.nln.org/

37. Simulation: Topology • Partial Trainers • Role Playing • Computerized Case Studies • Advanced Patient Simulators • Standardized Patients • 3D Immersive (virtual worlds) • Virtual Reality • Haptic Devices • Robotics

38. Could high-fidelity simulation be an alternative for limited number of patient clinical experiences? Hicks, Coke, Li (2009)

39. Methodology • Simulation only (30 hours) • Simulation (15 hours) and clinical (15 hours) • Clinical only (30 hours) • Results • Knowledge Acquisition and Retention • Pre – • Post – • No significant difference

40. 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

41. Facilitating Reflective Thinking Through Simualtion • [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

42. Simulated Experience • 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

43. Debriefing is the “heart and soul” of the simulated experience…Rall, Manser, & Howard, 2000 Knowing how to debrief is as important as knowing how to create and initiate a simulated experience. Jeffries, 2005

44. Facilitation • Reflective process is influenced by the effectiveness of facilitator • Requires trust • 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

45. Degree of Facilitation • Depends on • The objectives • The learner • The facilitator • The experience • Time allowed for the process • Relationships between participants

46. Degree (Leveling) of Facilitation • High – “debrief themselves” [Critical Reflectors] • Intermediate – “assistance” needed to analyze the experience [Reflectors] • Low – learners demonstrate little initiative [Non-Reflectors]

47. Need for a Guide or Coach • Difficulty developing reflection-in-action • Learner may have a distorted “view” • Could lead to repeating mistakes • Learners may only view the negative • Fixations • Outcome influenced by facilitator’s skills Boud, Keough, & Walker, 1985; Boud, 2001; & Paget, 2001

48. Techniques • Socratic Questioning - Guided questions – Strategically integrated “what if’s”, students find this difficult • Requires active learning • Encourages logic – making connections • Facilitates critical thinking • Integrated and debrief session Lambright, 1995; Schoeman, 1997

49. Techniques • Plus-Delta

50. Techniques • “Debriefing with Good Judgment” – (Advocacy-Inquiry) Debriefing leads to new frames Debriefing changes later actions