Introduction

Reflective practice is described as a process in which practitioners gain skills to change assumptions and biases in a methodical approach to increase perception, competency, and effectiveness in the context of educational and professional experiences [1]. Nursing students can be empowered through reflective practice to enable them to articulate and build nursing knowledge. A common connection is needed across all types of curriculum at many different levels to support the implementation of reflective practice as an instructional methodology to shape and heighten both the didactic and clinical learning processes. The concept of reflection is critical for nurse educators to consider when developing curriculum [2-4].

Reflection permits the student to realize their knowledge deficits and inaccuracies resulting in modifications of future decisions and actions. Reflection supports assessment and selfevaluation to guide students to understand an experience, create higher level thinking, deeper experiential insight, and improve professional practice. Thoughtful contemplation during reflection of an experience builds new knowledge [5] decisiveness, and an unassuming professional [6,7]. Midwifery students who used reflection demonstrated intense analysis of the clinical experience that fostered their professional growth [8,9].

Gibbs [10] Model of Reflective Practice supports methodical thinking about a practice-based situation to comprehend the experience at a deeper level. This model is used as a framework that guides students’ perception of their behaviors in experiential learning situations. Using a structured model of reflection to achieve learning outcomes and improve undesirable clinical experiences supports successful reflective writing. Reflective writing can be used effectively to assess and measure the progression of critical thinking skills [11]. Improved critical thinking, decision-making skills, and self-awareness were enhanced among Registered Nurses (RN) who used reflection prior to, during, and post clinical experiences. Students who used reflective writing had improved abilities to formulate management strategies for their patients, and demonstrated self-growth [6,7]. Typically, educators are not inspired to include reflective writing as an assignment for students. Educators view writing assignments as monotonous, onerous, and lack appreciation for this method to build student’s knowledge and skills [12]. Academic nurse educators struggle with how best to develop a safe decision maker and critical thinker.

Reflective writing assignments allow the student to integrate and acknowledge essential theoretical and clinical aspects of a learning experience. Educators are positioned to be reflective enablers and create assignments that promote reflection whether it is written, dialogue, or both for clinical and classroom experiences. However, they continue to struggle with how best to apply, execute, and score reflective assignments [7]. There is limited research associated with the use of reflective practice among Nurse Practitioner (NP) students. Exploration and evidence are needed to understand the perceptions, use, barriers, role of preceptors, and whether using reflection is a valid method to assess course concepts, and clinical skills. It is essential to clearly understand if critical thinking and decision-making manifests when reflective practice is integrated into graduate level didactic and clinical courses. Research is needed to discover the value of reflective practice to inform academic nurse educators how best to facilitate graduate students learning using reflection.

Review of Literature

According to Sweet and Glover [9] reflective practice has been identified as a core competency for midwifery practitioners. Teaching activities using continuity of care experiences can result in students having a highly valuable learning experience. The central characteristic to these experiences is to implement teaching activities that provide the student with the opportunity to reflect in and on their practice experiences. Billet, et al. [8] identify reflective writing as a post-practicum educational exercise that enables students in the healthcare discipline to develop skills for coping in the workplace, enhance critical thinking, and improve clinical practice. Naber and Markey [7] found that nursing students who use reflective practice are better able to assess their personal biases, assess, share, and compare their experiences, grow professionally, and most significantly develop critical thinking skills.

Sweet, et al. [9] conducted an education design-based study to explore midwifery students’ ability to improve post-practicum experiences. The focus of this study was to identify whether students understood the importance of using reflection and if a guided method of reflection would augment reflective capacity and the clinical experience. Sweet, et al. [9] found the application of the structured Model of Holistic Reflection facilitated students to look deeply into their practical experience and strengthened understanding of how the experience Valuable for clinical experiences but has limited evidence to support it's use across NP curriculums.

Glaze [13] conducted a qualitative study among 14 Adult Nurse Practitioner (ANP) students to explore reflective experiences. This study found students required a non- threatening and supportive clinical environment, understanding of reflective process, and time to cultivate reflective skills. Students felt faculty feedback was open-minded during the reflective process, and respected. Glaze [13] concluded growth of reflective skills is a multifaceted and transitional process. The ANP students who used reflective practice were able to think in different ways that was associated with effective clinical practice.

Butani, et al. [14] conducted a qualitative study using survey data from members (n=147) of the Counsel on Medical Student Education in Pediatrics to assess pediatric undergraduate medical educators’ understanding, perceived value, practices used to teach and the barriers of incorporating reflective practice into medical curricula. More than half of the respondents reported they had a good understanding of the concept of reflection and valued the skill of reflective practice for practicing physicians and learners. Ninetytwo percent felt it was important to teach medical students’ reflective practice. Seventy-nine percent reported it is essential for medical students to receive feedback regarding reflective practice and 94% felt physicians need to model this concept. Sixty-one percent of physicians reported the curriculum encourages reflection, and 31% of educators taught reflective practice in thee clinical setting mainly using narrative writing.

The barriers of using reflective practice perceived by medical students included: (a) lack of skilled educators, (b) time constraints, (c) crowding of curricula, and (d) apprehension about sharing their experiences, and varying levels of confidence. Fifty-five percent of physicians were confident in the medical school’s ability to teach reflective practice efficiently. It was found that faculty development is crucial to support the development of reflective skills and its integration into medical education [14]. Cooper and Wieckowski [15] conducted a qualitative study to investigate the usefulness of a reflective training module for 22 graduate students in a clinical science doctoral degree program at a large public university during their first and fourth practicum year. Didactic training included the review of Gibbs [10] and Senediak’s [16], Model of Reflection prior to clinical practicum. Reflective practice worksheets provided a structured method to foster reflective skills which were implemented within and outside the clinical practicum settings. The faculty encouraged students to model reflective practices, offered guidance, and feedback about the students’ performance for challenging or ineffective interpersonal interactions.

Ninety percent of the participants reported reflective practice was meaningful, improved client outcomes, linked theory and practice, and enhanced personal learning experience. One hundred percent of the participants reported they believed in the benefit of reflective practice and its applicability to professional development.

Chong [2] and Jayasree & Suja [3] research used the same reflection instrument to understand perceptions of reflective practice among RN students (n=98, n=38 respectively). Most students found reflective practice a valuable method of learning. Both studies recognized that reflection allowed: (a) the ability to view clinical situations from different perspectives, (b) motivated self-directed learning, (c) fostered accountability, (d) encouraged critical thinking, and (d) improved decision-making. In both studies most students believed that the process of reflection could be manipulated to meet the expected outcomes of their practice. In contrast to Chong’s [2] study, Jayasree & Suja [3] found students reflected more on positive clinical issues. Both studies identified students felt time constraints and a lack of a supportive environment were barriers to reflection. Students required assistance with identifying issues of reflective practice and needed feedback from their preceptor. Students felt their preparation for reflection was inadequate. Therefore, students were not confident that reflective practice as an assessment method correlated with the student’s actual competency of nursing practice [2]. There is a need for faculty and preceptors to be clear about the use of reflection and its influence in transforming clinical and didactic learning.

Purpose and Aims

The purpose of this research study is to describe NP students’ perceptions using reflective practice and the elements that influence its use. There is a need to examine the perceptions of reflection among student NPs and understand whether reflection is a valid process to assess learning outcomes for clinical course concepts.

Objectives

The objectives of this research is to understand the np students: (a) perceptions using reflection, (b) barriers, and attitudes of using reflection, (c) preceptor’s role in reflection, (d) use of reflective practice as a tool to assess learning outcomes in the clinical setting, and (e) the use of reflection and gender.

Methods

Design

A cross-sectional descriptive correlational design was used to examine NPs students’ perceptions of reflective practice. This design approach allows for the examination of the phenomenon among participants during different stages of development in the AGNP clinical course. This design facilitates examination of students’ perceptions of reflection, and differences between the variables of reflection and gender. Gibbs [10] Model of Reflective Cycle parallels the AGNP curriculum educational objectives and was used in this research as a guide for reflective practice. This model offers a cyclical framework that has been historically used in experiential learning. The Reflective Cycle includes: “(a) Description, (b) Feelings, (c) Evaluation, (d) Analysis, (e) Conclusion, and an (f) Action plan” [3].

The primary focus of this research design was quantitative. The data was collected using a demographic questionnaire, a 31item Reflection Questionnaire and two open-ended questions. The reflection questionnaire is composed of a 5-point Likert Scale rating of 1 (strongly disagree) to 5 (strongly agree) to indicate relative agreement for each item. Exempt status was received from Stony Brook University Institutional Review Board.

Setting and Population

Stony Brook University School of Nursing’s AGNP was the setting for this study. In this program, NP students are encouraged to use reflective practice when encountering patients in the clinical setting and when writing reflective assignments about their simulation experiences. The students have two simulations and two clinical reflective assignments each clinical semester. An NP or Physician act as the student’s clinical mentor in a primary care practice setting, and AGNP faculty for simulation experiences. There was no specific time allocated for reflective writing, students could document their reflection during or outside of their clinical rotation. Reflections are submitted for faculty review and discussion with the student.

Sample

This study used a non-probability, convenience sample of 106 NPs students who self- selected from a target population of AGNP students enrolled in the first and third semester clinical courses that run simultaneously. Using G*power, the minimum total sample size was calculated. TA power of 0.80, effect size of 0.5, and a probability error of 0.05 was used to determine the difference between two independent means using a t-test and required a minimum total sample size of n=102 (www.gpower. hhu.de, 2018).

The inclusion criteria for this study was: (a) students who were enrolled in the first and third clinical AGNP course, attended a primary care clinical rotation, and completed all four reflective assignments. The exclusion criteria included students who withdrew from either clinical course.

Data Collection and Procedures

Recruitment occurred voluntarily and anonymously at the end of the fall 2018 semester. A recruitment email contained a link to Qualtrics (Qualtrics, Provo, Utah) to access the anonymous survey that was deployed using a secured university listserv. The link included a description of the study, purpose, voluntary participation, anonymity, and instructions for the completion of the questionnaires and link to the demographic and Reflective Practice questionnaire and open-ended questions. The link was available at the end of the semester to ensure all students had the opportunity to complete all reflective didactic assignments and clinical rotation. Participants were free to withdraw from the study at any time. A forced exit occurred if the inclusion criteria was not met.

Measurement Demographic Data

A 6-item demographic questionnaire (DQ) developed by the study investigator included the following measurable characteristics: (a) age, (b) gender, (c) Registered Nurse (RN) clinical specialty area, and (d) highest level of education, (e) clinical work setting, and (f) cumulative years of clinical work experience as an RN. The content of the DQ was based on the literature review about the use of reflective practice with emphasis on the studies related to the development of the Reflection Instrument [2,3].

Reflection Instrument

The Reflection Questionnaire [2] was developed to advance nursing knowledge regarding use of reflective practice by nursing students and is valid and reliable. Face Validity was used to determine the construct of the questionnaire as appropriate to measure reflection. The reflection instrument is categorized into four sections: Part I of the instrument is 24-items pertaining to perceptions of reflective practice. This section of the reflective tool has four sections: (a) Usefulness of reflective practice, (b) Undesirable effects of reflective practice, (c) Barriers to good reflection, and (d) Mentors in reflective practice. Part II of instrument is a 7-item measurement of reflective practice to assess the appropriateness of reflective practice to assess learning outcomes in nursing practice. Part III consists of issue that students most commonly reflect upon. Chong’s [2] study yielded a Cronbach’s alpha coefficient value of 0.8, illustrating an acceptable degree of internal reliability. The reflective instrument was used with permission. The present study yielded a Cronbach alpha of 0.74, indicating reliability.

Statistical analysis was conducted using IBM SPSS Statistics Version 25. Descriptive statistics were computed from the scores of the Reflection Questionnaire using measures of frequency, percentages, range, central tendency, and standard deviation. The t test compared the mean between the use of reflection and male and female. A minimum sample of 102 for the t test met the required power for 0.80 for this study (www.gpower.hhu.de, 2018).

Open-ended Question

The open-ended question was used to identify common responses from the participants about the usefulness of the reflective assignments. The participants used free text to provide suggestions to improve the current practice of reflection in the AGNP Program.

Results

Sample

The online survey was accessed by 106 AGNP students, 22 respondents variably answered questions. The respondents varied from 26 to 55 in age (n=106, mean=37.01, standard deviation [SD]=9.00). The majority were female (n=73, 87.9%) with 10 male respondents (12.1%). The normality of gender was skewed to the right (2.3) because of the small sample of male respondents, however this did not affect the results for questions that comprise gender. Medical and surgical areas were the most common clinical specialty reported by the participants (medical, n=53, 50%; surgical, n=36, 35%), with the majority working in an acute care hospital setting (n=57, 53.8%), and community or hospital based ambulatory care center (n=12, 11.3%). The highest level of education is a baccalaureate degree in nursing (n=72, 85.7%), with a small percent having a graduate degree (n=10, 11.9%), other baccalaureate degree (n=2, 2.4%). Cumulative years of work experience ranged from one to greater than 20 years as a Registered Nurse (RN) (n=84, mean=3.43, SD=1.86). Twenty-six percent of the RNs had between four to six years of clinical experience, 36% had seven to 19 years’ experience, and nine percent had greater than twenty years’ experience. The majority of the NPs (n=51, 48% m=3.39, SD=.490) had a physician as their preceptor and reported the clinical preceptors (n=82, 58%, m=4.0, SD=1.06) were receptive to using reflective practice in their clinical rotation.

Using reflective practice, the NP students: (a) were encouraged to make a mindful attempt and learn from the experience at hand (b) viewed clinical situations from different perspectives, (c) were motivated to be self-directed learners, (d) identified their own learning needs, (e) gained responsibility and accountability and, (f) integrated theory into nursing practice. Using reflection triggered the use of analytical processing, supported critical thinking, and improved NP students’ decision-making practices (Table 1).

Undesirable Effects of Reflective Practice

Forty-seven percent (n=50, m=3.65, SD=1.09) of the respondents agreed that manipulation of the reflective practice occurred to meet the expected outcomes. Most respondents reported that reflective practice was not stress provoking while 28% (n=30, m=2.94, SD=1.24) reported that reflective practice may cause psychological stress. Less than half of the respondents (40%, n=43, m=3.38, SD=1.14) reported that they usually reflected on negative issues. Most students were able to solve clinical problems identified by reflection while 35.8% (n=38, m=3.60, SD=1.54) felt frustrated when they could not solve problems using reflection.

Barriers to Good Reflection

The perceived barriers to good reflective practice had a mean of 2.7. Most of the NP students reported that (44%, n=47, m=3.42, SD=1.08) using an unfamiliar learning approach can be a barrier. However, 61% (n=65, m=3.82, SD=.939) reported that the briefing on reflective practice provided was adequate for reflection. Most students reported (61%, n=65) the clinical environment supported reflective practice and 58% (n=79) were able to identify issues to reflect upon. Twenty-eight percent reported that using reflective practice was affected by time constraints in the clinical setting (n=83, m=3.02, SD=1.18).

The Preceptor’s Role in Reflective Practice

The majority of the students reported guidance by their preceptor for the introduction of reflection was essential (51%, n=54, m=3.54, SD=1.04). Only 28% (n=30, m=3.57, SD=1.92) of the students reported that they required assistance from the preceptor to identify issues for reflection, however the majority (45%, n=39, m=3.18, SD=1.07) required assistance to achieve a higher level of critical reflection. Students (46%, n=49, m=3.44, SD=.923) believed that clinical preceptors need consistency when giving information regarding reflection. Sixty-four percent (n=58, m=3.95, SD=.759) responded that clinical preceptors should be equipped with knowledge of reflective practice.

The Appropriateness of Reflective Practices as a Tool to Assess Learning Outcomes

Most of the students reported (45.3%, n=48, m=3.46, SD=.888) the findings of their clinical assessments correlated with nursing practice competency. Reflective practice assignments were clear and did not require clarification (53%, n=79.2, m=3.67, SD=.92). Forty- seven percent (n=51) reported preceptors’ reflective feedback was consistent, and 41% (n=42) sought feedback from the preceptor about their reflective practice. Students (62%, n=66, m=3.96, SD=.813) reported time to complete reflective assignments was sufficient.

Most students reported (51%, n=55, m=2.34, SD=1.00) they write reflection on what is truly felt and not on what is expected. Reflective practice was found to be professionally and personally beneficial (54%, n=59). Most students (55%, n=59) agreed that they would continue to use reflective practice in their nursing practice.

Effect of Gender and Years of Clinical Experience on the Use of Reflection

A t test was used to compare the use of reflection to improve decision making between two independent groups: male and female gender. The mean comparison scores were found to have no significant differences between gender and the use of reflection to improve decision making (t 83=-.613, P > .05; men: n=10 [12.1%], mean=4.1, SD 1.1; women; n=73[87.8%], mean=3.88, SD=1.0) and encourage critical thinking (t 83=-.103, P >.05; men: n=10[12.1%], mean 4.4, SD=1.0; women; n=73[87.9%], mean=4.03, SD=1.0) (Table 2).

Open Ended Questions

The main theme of the responses of the open-ended questions was to have more opportunities to discuss students’ reflections. Although NP students believed that feedback from both preceptor and faculty was consistent and necessary; students suggested setting up a blog or having faculty meet with students in groups to discuss reflections to enhance experiential learning from each other.

Discussion

It was evident from the results of this study that NP students supported the use of reflective practice and had positive perceptions using reflective practice in clinical education settings. The results of this study are consistent with previous studies conducted among RN students and graduate level students in clinical settings [2,3,15]. The key findings of this study found that reflective practice encouraged critical thinking, improved decision-making skills, and integrated theory into clinical practice among NP students. As reflective experience increased students felt they were better able to apply a critical and analytical process for the clinical experience. The use of reflection enhanced thinking critically about clinical experiences and guided transformation of thinking to support decision making. Most significantly there was no difference of critical thinking and decision making between male and female participants. The literature reviews lacked findings comparing gender and these qualities.

The NP student’s perceived reflective practice cultivated: (a) accountability, (b) responsibility, (c) the ability to review both positive and negative clinical experiences, (d) recognition of self-learning needs, and (e) critical thinking similar to studies conducted among RN students [2,3,6]. Some NP students found that reflection could be manipulated to meet expected outcomes of practice. Qualitative studies found that reflective practice is associated with professional learning, and development of skills that promote improved clinical outcomes [9,13,15].

Interestingly, NP students reflected on negative clinical issues comparable to findings among RN students in Jayasree & Suja’s [3] study. Only 36% of the NP students required preceptor assistance to achieve a higher level of critical reflection compared to 75% of student RNs in Chong’s [2] study. NP students were able to identify issues for reflection compared to RNs students who required more guidance from their preceptor. An explanation for this could be that NP students learn to think differently and use clinical reasoning focused on patient’s negative complaints to formulate a diagnosis.

It is apparent that reflective education and preceptor engagement support reflective practice. However, NP students agreed that lack of knowledge about using reflection, for both the student and the preceptor is a barrier. Education about the process of reflective practice for both the preceptor and the student in addition to executing a structured reflective practice model is necessary to engage the student [14] and nurture the development of reflective practice [9,15]. Faculty development and having a non-threatening environment to develop reflective skills is supported in this study. Quantitative and qualitative studies among graduate and undergraduate students have found it essential for preceptors, and educators to attain education pertaining to the use of reflective practices [2,3,9,13]. Student NPs believe the use of reflective practice does not cause psychological stress similar to RN students in Chong [2] and Jayasree & Suja’s [3] study. Time constraints and lack of preceptor support did not influence reflective practice among the NP students however, this was a barrier for RNs students in Chong [2] and study.

Limitations for this study included using a convenience sample of NP students and having a limited number of male participants. Although bias is difficult to control using convenience sampling, these methods allowed for the opportunity to have many participants, and to examine a phenomenon that is unexplored among this population. Self-selected participants are more likely to be committed and can provide a greater insight into the phenomenon studied, however there was likely to be a degree of bias. This study was only done in one graduate program at one university; therefore, the results may not be generalizable. Obtaining a larger sample of male NPs is recommended to support the statistical findings between genders to increase generalizability. Not all respondents answered every question in the survey which may be due to its length.

Conclusion

This study broadens the understanding of the perceptions of reflection specifically among NP students. The findings support that NP students have positive perceptions about the use of reflection, and that there is no difference between the perceptions of reflection to support critical thinking, improvement of decision making, and gender. Further quantitative research is recommended to confirm the use of reflection and gender to validate reflection as a method to assimilate nursing theory into practice, encourage critical thinking, improve decision making, and enhance the process of reflecting critically and analytically among graduate NP students.

There is a scarcity of research among NP students and perceptions of reflective practice. Even if reflective practice cultivates knowledge, critical thinking, and decision making, the question remains if the use of reflective practice leads to improved clinical outcomes. It is crucial to further examine the perception and use of reflection among student NPs to determine its value in the academic setting.

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