Developing the usefulness of reflective practice for professional development from within eLearning
This publication describes a range of eLearning packages designed to support reflective practice for nurses.
Anne Stevens and Robyn Boladeras, Bay of Plenty District Health Board
This publication describes the process of developing, reviewing and noticing the usefulness of reflective practice within an eLearning environment. The practice of reflection offers nurses a tool to critically assess their practice. It is through analysis of practice that nurses can engage in a process of continuous professional development for the best possible practice outcomes.
- The PDRP Coordinator's process
- Organisational and professional importance
- Making a package deal
- Meeting expectations
- Evaluations - reflective practice resources
- Learner benefit
- Lessons learnt
- Organisational value
‘Harry stared at the stone basin. The contents had returned to their original, silvery white state, swirling and rippling beneath his gaze.
“What is it?” Harry asked shakily.
“This? It is called a Pensieve,” said Dumbledore. “I sometimes find, and I am sure you know the feeling, that I simply have too many thoughts and memories crammed into my mind.”
“Er,” said Harry who couldn’t truthfully say that he had ever felt anything of the sort.
“At these times” said Dumbledore, indicating the stone basin, “I use the Pensieve. One simply siphons the excess thoughts from one’s mind, pours them into a basin, and examines them at one’s leisure. It becomes easier to spot patterns and links, you understand, when they are in this form’ (Rowling 2000).
In this excellent description of reflection, from ‘Harry Potter and the Goblet of Fire’, Dumbledore, the chief wizard and head teacher, describes the problem of what to do with excess thoughts.
Health professionals in New Zealand are governed by the Health Practitioners Competency Assurance Act 2003. A primary intent of this act is to assure the public that Health Practitioners are maintaining professional competency. Each professional group has a governing body /professional organisation that have their own requirements for demonstrating continuing competency. For nurses, the process of demonstrating evidence for continuing competency occurs, within the renewal of an annual practising certificate.
The Bay of Plenty District Health Board (BOPDHB) Professional Development and Recognition Program (PDRP) is a tangible way of confirming individual nurse’s expertise and ongoing competence, and ensuring quality client care. Competence is assessed within the PDRP by submitting a professional portfolio. A portfolio is a tool used to record learning from practice and create opportunity for reflection, including analysis supporting future practise change/professional development opportunities.
Historically, the teaching of reflective practice has been delivered within a didactic traditional teaching environment. Over the last year the BOPDHB has responded to a range of eLearning experiences. Criteria exist within the BOPDHB in the selection and provision of eLearning and in this instance, two significant factors were present:
- Increasingly, a changing professional cohort of newly graduated professionals with capacity and experience of professional development within the eLearning environments of the tertiary institutes.
- The New Zealand Government’s encouragement of District Health Boards to develop processes of collaboration, in particular shared resources contributing to efficient and cost-effective outcomes.
In part, the second point links to the provision of educational opportunities accessible from a range of settings, and offers the flexibility of 24-hr access.
Within this changing context and in response to ongoing professional development opportunities, a range of eLearning packages have been developed. This paper focuses on a new eLearning initiative – reflective practice for nurses. The eLearning reflective practice site was shared with Lakes District Health Board (LDHB) supporting Midland Regional collaboration.
Reflective writing is one way nurses describe, discuss, and critically analyse their practice to demonstrate evidence of continuing competency within a portfolio. One of the primary aims of PDRP coordinator Robyn Boladeras was to create an opportunity to support nurses through the eLearning site as they demonstrated their practice through reflective writing in their ePortfolio.
There is a wealth of literature on reflective practice (Hannigan, 2001, Kennison, 2006, McGready, 2007) and increasing literature relevant to technology in nursing, including the use of ePortfolios (Skiba, 2009a; Anderson et al., 2010).
The intention of the site was twofold:
- Provide an opportunity for nurses to complete the eLearning package and develop their capacity to use reflective writing to demonstrate competency.
- Create a resource that nurses can access at anytime from work or home supporting their capacity to meet one of the continuing competency requirements of demonstrating 60 hours of professional development within a 3-year period.
Hence, the site offers the potential to develop reflective capacity and contribute to professional development hours. The site provides a comprehensive range of reflective practice resources for nurses and was constructed in seven sections. The topics included in the resources have been developed from the literature, and from the coordinator’s experience as an educator both teaching and assessing reflective writing. The intention was to ensure material was accessible, current and could be viewed within short time frames. Each section was a stand-alone resource supporting self-directed learning styles. The sections were as follows:
|Collection of articles and journals – PDRP Reflective Practice|
|Setting the Context and Introducing Reflection||An introduction to reflective practice and professional development from an individual and global perspective|
|Self-Awareness||Considering the link between reflective practice and self-awareness|
|Noticing the benefits of reflective practice||Literature definitions, critical thinking examples and how personal reflection might differ from professional reflective practice|
|Ethical and legal considerations||Reviewing various legal, ethical and professional codes, policy and procedures|
|Evidence-based practice||Evidence-based practice movement, the hierarchy of evidence, and the relationship between evidence-based practice and reflective practice|
|Frameworks||Selection to review including; Johns' model of reflection (1994), Kolb's Learning Cycle (1984)|
|Reviewing reflective writing||Different styles and models of nurses’ reflective writings|
|Reflective journals, blogs and E- Portfolios||Collection of tools to aid in reflective writing.|
During the developmental phase of the resources the coordinator was aware that nurses in the business of practice work do not always have adequate time to review literature, access reflective frameworks or critique a colleague’s reflective writing. Providing a range of accessible and relevant resources with direct links to international web sites demonstrating reflective practice frameworks and providing a selection of relevant journal readings highlighting reflective practice stories were central to the eLearning site.
This practice has been recognised in a number of ways within this organisation:
- The resource was recognised as a priority in the initial eLearning courses. In this organisation nurses represent 49% of the workforce (around 1400)
- The PDRP reflective writing and practice course has been allocated 4 hours of professional development on successful completion.
- The funding agency Clinical Training Agency (CTA) supports reflective writing as a component of the Nurse Entry to Practice (NETP) programme. All new graduates who come through the NETP programme at BOPDHB now utilise the PDRP reflective writing course to meet this requirement.
The pilot group was a group of NETP graduate nurses who were already using the BOPDHB Midland eLearning site, where they had a space devoted to their programme for the 2010 year. They were introduced to the course PDRP reflective practice through an introductory workshop.
Within the graduates’ eLearning site there was also a site for the submission of the ePortfolio. The reflective writing was to be included with the submission of the ePortfolio, which was due in October 2010.
Once the graduates had attended the introductory workshop they were left to access the site as their learning needs dictated. Online activity indicated the graduates’ initial engagement with the section ‘reviewing reflective writing’. Access to a selection of nurses’ narratives from diverse clinical contexts provided the framework for the graduates’ initial reflections on their practice.
Within the ePortfolio site was a discussion forum. It was up to each graduate to decide how much they wanted to participate in discussion forums. Although the PDRP coordinator was very active in facilitating discussion forums, there was not much participation from the graduates. On occasion discussion would be between the facilitators and graduates; at other times it was solely among the graduates. However, we could see they were using the site and there was much activity in the use of the resource topics.
Graduates were required to submit their ePortfolio, which contained their reflective writing, by 25 October. Another package deal included meeting the assessment processes for the NETP graduates, which were completion of a reflective writing assignment and the use of this work to demonstrate evidence of competency in the PDRP ePortfolio.
In an educational setting, a learner is constantly interacting with an array of variables, such as teachers, peers, physical settings, subject materials and a cluster of factors unique to different learners. Such interactions and variables increase when the workplace is added to the learning/educational environment. For this reason, there was a need to develop suitable learning environment instruments that had the capability of quantitatively measuring the impact of the learning environment on a learner at different settings.
The foundations for this now flourishing field of learning environments was initially laid by two psychologists working independently of one other. The work of Walberg (1976) and Moos (1974) led to the development of a variety of learning environment instruments. Despite the subsequent development of several learning environment instruments over the years, the design is essentially the same. Learning instruments have scales, and within each scale is a series of items that help formulate students’ perceptions of that scale. The construct validity of each scale is determined by gathering qualitative data from respondents.
Evaluations were performed on-line by graduates after they had submitted their ePortfolio containing the reflective writing. The evaluations were anonymous and the tool Survey Monkey was used. The evaluation model used was the Web-based Learning Environment Instrument (WEBLEI) tool (Chang & Fisher, 2003), which was modified and used to gather data quantitatively.
In total 20 learners in the group of 26 completed the survey, giving a 77% response rate.
The data generated through the WEBLEI survey suggested that the students had positive perceptions of their web-based learning environment, as outlined below:
- Flexible, convenient, and promoted autonomy of learning enabling students to work at their own pace.
- Promoted positive interactions between peers.
The Access scale establishes the extent to which variables associated with accessing this eLearning environment meet graduates’ expectations. The Interaction scale explores the extent to which they have interacted on-line with their facilitator and/or peers. The Response scale gives an indication of how they felt about using a web-based medium.
The five-point scales were coded and rated as 1 (Strongly Agree), 2 (Disagree), 3 (Neutral), 4 (Agree), and 5 (Strongly Agree).
An average mean of four suggested the students agreed with the statements. An average of three implied the students neither agreed nor disagreed (i.e. neutral) with all the items in the scale.
The qualitative responses gathered through survey comments and emails provided additional evidence that supports the figures from the Access, Interactions and Responsiveness scales.
Some survey comments:
- Never felt alone in completing this ePorfoilo and had good support
- Being able to go on at anytime and do it at your own pace
- Trying to get to the workshops and study days from a busy ward became a challenge
- Having access 24/7 is good
- More info is required on how the forums worked and sending messages.
Each of the eight resources topics were also evaluated on their usefulness. The choices for each topic were: Not Used, Less Useful, Functional and Very Useful.
The survey result suggests the group agreed about the usefulness of the topics and articles provided in the resource. The rating for each of the resources was consistent, with only two topics not being used at all by 9.1% of respondents. The two highest rated topics were Benefits of Reflective Practice and Ethical and Legal Considerations: 63.3% of respondents indicated they found both topics very useful.
Interestingly, the Frameworks topic was the most referenced in the groups’ writings. In the graph of results the respondents indicated the topic was functional rather than very useful, yet it was most referenced when the PDRP coordinator reviewed the writings. The NETP group rated the usefulness of each of the categories of resource but unfortunately did not take the opportunity to make further comment on why they found the article useful or not.
The PDRP coordinator assessed a selection of the NETP reflective writing assignments. The assignments needed to consider the following criteria:
- Ethical, legal and professional issues in nursing practice
- Assumptions and knowledge before reflecting
- New knowledge gained through reflection
- How application of the reflective process had developed or enhanced their nursing practice
These criteria contributed to some of the content on the reflective practice site: self-awareness and ethical and legal considerations.
When considering the learner benefits, the coordinator draws attention to the following
1. Increasing reflective capacity
One of the initial drivers for this work had developed out of the coordinator’s work as an assessor of reflective writing. The assessment of reflective writing within the NETP program (over the previous 2 years) and the assessment of registered nurses’ reflective writing has not always provided the evidence required for demonstrating NCNZ competencies.
Reflective writing can be descriptive in nature, which limits nurses’ ability to critically examine practice. A framework creates a tool to develop reflective depth. By providing a selection of reflective frameworks the graduates were able to identify a framework to which they could relate their practice experience. This was significant as many graduates had come from an academic institute where a prescriptive reflective framework was used. It was an observation that graduates often spent more time attempting to make sense of the framework rather than using it as a tool for reflective thinking and writing.
It became apparent during the assessment process that the graduates’ capacity to use a referenced framework from the eLearning site developed their reflective capacity. During the assessment of the assignments (and the review of registered nurses’ reflective writing in their submission of a portfolio) the coordinator noticed that the depth and clarity of the reflective work met the requirements for evidence required for the NC competencies.
2. Integrating evidence-based practice into reflective writing
A further purpose of the site was to provide the graduates with a range of resources to develop their capacity to use evidence-based practice that would support their reflections, thus practising change. Graduates are committed to ensuring their practice is evidenced based. The section provided a selection of prompts to reflect on ways of ensuring practice is informed by research. It provided a selection of direct links, e.g., to the Centre for Evidenced Based Healthcare Aotearoa, and a range of suggestions for integrating evidence into the reflective process.
The graduates’ reflective assignments clearly demonstrated a range of references that were accessed through the eLearning site.
3. Accessibility and range of significant resources
Further benefits relate to the verbal feedback received by the coordinator during the final day of the graduates programme. Points highlighted recognise the variables in seeking feedback through one modality:
- the graduates’ readiness to offer feedback on the completion of all the requirements for the NETP program;
- a limited timeframe to complete the online evaluation;
- submission of an ePortfolio was the end point of the engagement in the site;
- the preferred modes of giving feedback (in this case in a narrative)
- recognition of a group process of building on feedback ideas.
The feedback conversation with the graduates drew attention to their feeling of being snowed under by the initial settling into the clinical practice phase of the NETP programme. Initial involvement in the reflective practice site therefore developed slowly, only building momentum as the assignment was due for submission. As momentum grew, graduates’ access to the online resources increased.
It was apparent that students appreciated the opportunity to access the resources from either their work or home environment, and also that the resources had been constructed in a way that progressed their reflective writing and was aligned to the assignment criteria.
4. Site construction, cultural change, and not a linear process
Not all registered nurses within the BOPDHB (average age of 43) are familiar with online activities for professional development. For many the reflective practice site was their first encounter with an eLearning professional development activity. ELearning contact occurred either through the nurses’ role as preceptor to NETP graduates or by accessing the site for their own reflective practice professional development. The construction of the site recognised that introducing a cultural change for professional development activities must respect the range of needs of the learner group.
Site support for individual learning options was a highlight for the students, who appreciated there was no expectation that all sections be reviewed or that the process be linear. The reflective practice site clearly provided a large range of resources (around 30 in total) to support the graduates achieve the assessment criteria for reflection.
Each section was a stand-alone resource related to the topic and no longer than two pages. Ensuring the sections were relevant, comprehensive and easily accessible (particularly the direct links) was significant in the changing culture of professional development.
The purpose of this survey was to assess the effectiveness of the eLearning activity in a health education environment for this cohort of graduate nurses. These results could then be used for the further refinement of the eLearning site and the development of the next year’s course to ensure alignment with BOPDHB business requirements and the requirements of the governing professional body, New Zealand Nursing Council.
While our evaluations indicate the group agreed about the usefulness of the resources and found the eLearning environment convenient, we also asked for one suggestion on what to include for the next group in 2011.
From the graduate nurses’ feedback we will action the following changes:
- Stagger the workshops so staff can attend at different times when their ward work is not so busy
- Include timelines each month rather than just a deadline date
- Integrate discussion forums as part of the group rather than for one course.
Further developing and blending eLearning as a complementary method of training delivery at the Bay of Plenty District Health Board add value to the organisation in many ways.
However, the following three strategies will return the best investment:
- Structure eLearning to match strategic needs and organisational goals (e.g. The Nursing Strategic 2008-2011 sets a target of a 10% annual increase in nurses’ engagement in PDRP)
Stop reinventing the wheel
- Cut costs by reusing content, graphics and objects
- Increase the value of our objects by allowing others to use
Reduced time to effectiveness
- Link and build on nursing knowledge from undergraduate degree and support continuous integration of reflective practice as a lifelong learning tool.
A hurried conversation that began in a corridor almost eighteen months ago, between the eLearning Facilitator Anne Stevens and the PDRP Coordinator Robyn Boladeras, grew into the development of a successful learning resource. Admittedly, difficulties remain – the complexity of a large organisation functioning 24/7, the diversity of the workforce, and the skill mix employees bring with them. To these can be added the fact that our work environment is subject to change at short notice. But progress is visible. Most important, through our continuous improvement cycle, the suggestions from our target audience will be a legacy the graduates of 2010 leaves for next year’s group.
- Anderson, D., Gardner, G., Ramsbotham, J., and Tones M. (2010) E-portfolios: Developing nurse practitioner competency and capacity. Australian Journal of Advanced Nursing, 26(4), 70–76.
- Chang, V. & Fisher, D.L. ( 2003). The validation and application of a new learning environment instrument for on-line learning in higher education. In M. S. Kline & D. L. Fisher (Eds.), Technology-rich learning environments: A future perspective (pp. 1–20). Singapore: World Scientific.
- Hannigan B. (2001). A discussion of the strengths and weaknesses of reflection in nursing practice and education. Journal of Clinical Nursing, 10(2), 278–283.
- Kennison, M. (2006 ). The evaluation of students’ reflective writing for evidence of critical thinking. Nursing Education Perspectives, 27(9), 269–273.
- McGready, M. (2007).Portfolios and the assessment of competence in nursing: A literature review. International Journal of Nursing Studies, 44(1), 143–151.
- Moos, R. H. (1974). The social climate scales: An overview. Palo Alto, CA: Consulting Psychologists Press.
- Rowling, J.R. (2000). Harry Potter and the Goblet of Fire. London, UK: Bloomsbury.
- Skiba, D. (2009a). Nursing Practice 2.0: Should we as educators be crafting the next generation of nursing practice? (Emerging Technologies Center). Nursing Education Perspectives, 30(1), 48–49.
- Walberg, H. J. (1976). Psychology of learning environments: Behavioural, structural, or perceptual? Review of Research in Education, 4, 142–178.
This work is published under the Creative Commons 3.0 New Zealand Attribution Non-commercial Share Alike Licence (BY-NC-SA). Under this licence you are free to copy, distribute, display and perform the work as well as to remix, tweak, and build upon this work noncommercially, as long as you credit the author/s and license your new creations under the identical terms.