When nursing faculty are introduced to service-learning, they often are puzzled. They may say, "Isn't this just another name for what we do already? We have always involved our students in patient care, in providing service." However, service-learning has a somewhat different goal than clinical teaming. Service-learning is designed to help students develop an understanding of the context in which clinical skills are used. Students should complete a servicelearning experience with a better understanding of the policy context of health care; the cultural differences in healthrelated beliefs, nutrition, and hygiene practices; and barriers confronted by some patients in obtaining health care and following medical advice. Exposure alone to diverse patients in a clinical setting does not guarantee better understanding of their situations or points of view and may simply reinforce prejudice and stereotypes. It is in the quality of reflection, of thinking about these complex health care issues and using experience to suggest questions for further exploration, that service is transformed into service-learning.
Reflection is the hyphen that links service to learning. Although there is reason to think that service-learning for nursing students is more effective if it involves projects such as patient education rather than clinical care (Gelmon, Holland & Shinnamon, 1998), the key to success in either setting is in the quality of the questions students learn to ask as a result of their experience. If nurse educators want to move students beyond simple assumptions, such as "Why don't they just...," when confronted with a stressful situation with a community member, they need to design reflection activities that help students become more insightful. Building effective reflection into courses and clinical experiences for nursing students is essential but not difficult or complicated. The key is to plan carefully to ensure reflection is well integrated into the program and not just an afterthought.
This article describes a cycle that can be used as a foundation on which to build a variety of reflection activities and provides a map to guide faculty in thinking about when and where to implement reflection activities. Most faculty have many good ideas for reflection after they take time to consider the matter. These two tools can help them do so.
The following is an example of one student's experience with reflection in a service-learning course. Karen, whose name was changed for anonymity purposes, was based at a community health center and assigned to facilitate patient education with a teenage girl with brittle epilepsy who had repeatedly failed to take her medication. Karen met with the patient and reviewed the girl's medication schedule, telling her, as she had been told by her physicians, how important it was to take her medication on schedule. Later that week, the patient was admitted again to the emergency room with seizures because she had failed to adhere to the medication protocol.
Karen had conferences with her health center supervisor, nursing professor, and peers. She described the situation, and the group explored possible reasons for the patient's noncompliance, including:
* The patient hated how the medication made her feel.
* The patient was self-destructive or seeking attention.
* The patient's family did not support her or ensure she took the medication.
* The patient's family could not afford the medication.
In this reflection session, it became clear to Karen that another round of "just tell her how important it is" was probably not going to work with the patient. Karen clearly did not know what the problem was and needed to understand her patient's situation better. She needed to listen and not to tell. When Karen met with the patient again and began to explore and listen, she discovered the patient became lethargic when she took the medication, which made her unable to avoid assault by her mother's boyfriend. Therefore, when he was around, the girl did not take her medication, which then often led to seizures. Karen found a different form of intervention was needed, rather than the patient education she had been assigned to conduct.
Cycle of Reflection
Karen engaged in a cycle of action, in which she counseled her patient, and reflection, in which she interpreted her patient's behavior and planned for future action. KoIb (1984) argued that this cycle represents the process of experiential learning, and there are four steps in the cycle that can be used to structure reflection about service-learning experiences designed for nursing students. In the first step, concrete experience, Karen met the patient, provided instruction, and discovered that patient education failed to affect the girl's behavior. In the second step, reflective observation, Karen described these events to the team, avoiding characterizing them or explaining them. In step three, abstract conceptualization, Karen and the team explored possible reasons this behavior was occurring. Their explorations were based on their experiences, theories of behavior studied in their nursing courses, and other material from their nursing program. In step four, active experimentation, Karen devised a new plan based on her interpretation of the situation and tried it in her next meeting with the patient. This meeting resulted in new experiences to describe, interpret, and act on, and the cycle began anew.
Students in service-learning placements confront situations that surprise them and pique their curiosity. The experiential learning cycle of reflection offers a structure for deepening understanding by pursuing that curiosity through interpretation and testing that interpretation. Effective reflection is continuous, so learning builds and deepens. It is also challenging, which helps students confront and explore their assumptions. Effective reflection is connected, asking students to link theoretical subject matter to experience. Much unstructured reflection in service-learning programs consists of students sharing experiences and feelings. Using Kolb's (1984) cycle of reflection pushes students beyond first impressions and feelings to thinking more deeply about the experience and connecting it to their knowledge and broader experience. In addition, it encourages an experimental and open attitude toward testing their knowledge with further experience.
This cycle forms the basis of easily applied reflection activities. It can be used to design written assignments, facilitate discussion, or structure role playing or oral presentations. In a popular version of the model, the "What? So What? Now What?" process, students are asked to describe what they experienced, make sense of it in the context of their instruction and experience, and suggest what steps to take next either in action or further research. This questioning is so easy to remember and use many instructors use it to have students lead analyses of the service-learning experience, raising these three questions during their travel from a service-learning site or taking turns facilitating classroom discussions.
Role Play and Discussion
In a variation on the discussion/oral presentation technique, students role play incidents from their service-learning experiences and invite discussion from peers who have not shared the same experience. For example, one student shared a conversation she had with a mother and her 8year-old child, both of whom were HIV positive. The woman, whose late husband had abused drugs and infected his family with HIV, was bitter because her Social Security benefits placed her at an income level too high to receive medical help, yet she did not have the resources to pay for treatment. Her life was a constant struggle to identify medical resources for herself and her son, and she was particularly upset that "gays [sicl have all these services and programs, and it is so hard for us to find help."
This experience led to a class discussion, which included questions about how the United States medical system is organized to provide and finance care. It also led to some interesting insights about political influence and the importance of being well organized to affect policy and allocation of resources. Helping students raise fundamental questions about health care is one of the important outcomes of service-learning in nursing education,
Many faculty use journals as reflection tools. This method is particularly popular for encouraging continuous reflection when students are in field assignments and meet only occasionally with the instructor. However, without structure, these journals may not challenge student learning. Simply asking students to use the "What? So What? Now What?" format as they write forces them beyond description to integration and further exploration.
One nurse educator has students select a quote from the textbook reading for the "So What?" phase of their journal entry and relate their own observations to the reading. One student reflected on whether it was essential to be a nurse to be a midwife, stating:
These words of [nurse midwife) Helen Varney Burst have been torturing me for weeks now.... I feel that this concept wouldn't be readily accepted by the faculty. Indeed, we have been warned by those who came before us to be careful to include the word "nurse" with any mention of the midwivee that [our school] traine. Obviously, this is a sore spot. I am tempted to think that it is generational-women who have had to fight so hard for themselves and their profession would surely hold onto the word "nurse" with all their hearts if [it] has helped legitimize their life's work. Yet, Helen Varney Burst has been at this for quite some time herself She doesn't seem to care if midwifery wanders onto its own playing field outside of the nursing coliseum.
This student examined the pros and cons and the cultural context of the development of nurse midwifery, using the quote from Helen Varney Burst as a starting place and drawing on her knowledge of history, contact with midwivee, and experience in her program to develop her perspective on the issue. The result is a much richer discussion than a simple report on her field experience.
Essays and Presentations
A similar structure can undergird an essay assignment or presentation where students share their experience with others and draw conclusions about its meaning. For example, students whose study of maternal health care involved providing support to a family throughout a pregnancy, including doula support during the birth, were asked to present their cases using this format. Students not only shared the details of their experience but also presented the experience in the context of material being studied in class about cultural differences in perceptions of pregnancy and birth, and each student was able to suggest issues for further consideration related to policy and practice. This common template helped students benefit not only from their own experience but from the experiences of their peers because they had a common analytic framework with which to work.
As faculty plan for students' servicelearning experiences, there are many practical demands on their time and their students. Meetings with students often do not occur as frequently or regularly as would be ideal. It is important to think about how to structure the service to maximize learning. Planning service-learning in itself is an exercise in experiential learning where instructors can try approaches, reflect on those approaches, and then actively experiment with new approaches for their next class.
The reflection map is a tool for planning that helps instructors manage complexity (Eyler, 2001). There are two dimensions of the map, each with three components that together produce a nine-cell grid (Figure). Ideally, instructors include reflection activities in each cell. The first dimension is time. Instructors need to think about what needs to be done in preflection (i.e., reflection before service), as well as during and after service, The second dimension is the social context for reflection. Students may complete reflection assignments on their own, with their peers in class or teams, or with community partners.
It is easy to overlook preparation for reflection in the rush to orient students to the practical procedures for their servicelearning placement and to organize the process. However, students need to be oriented intellectually, as well as practically, to their experience to make the most of it. Critical to learning from experience are the abilities to observe and monitor one's own learning. Activities that help students discover their own assumptions and expectations prepare them for learning, and those that help them become aware of differences in perspectives among their peers help sensitize them to greater awareness when they enter the field. Students sometimes are asked to write a letter to themselves articulating their expectations, which is put away and reviewed at the end of the field placement. Students also can work to plan the service with representatives from the site where they will serve, creating a contract with their community partner.
Figure. Reflection map: Planning reflection activities. Adapted from Eyler (2001).
Another technique that can be used in the classroom is the Giant Likert Scale activity (Eyler, Giles, & Schmiede, 1996), The instructor develops a set of items about the health care topic of concern. Likert anchors (e.g., strongly agree to strongly disagree) are posted on the wall of the room. The items are projected one at a time and students are asked to stand under the anchor that represents thenposition. Students often will cluster at both the agree and disagree points, so students' beliefs, why they hold those beliefs, why they may disagree, and what steps could be taken to determine which position is most valid can be discussed. This activity highlights diverse opinions, issues in need of empirical study, criteria for arriving at an opinion, and areas of uncertainty, which are useful to open students' minds for further observation and inquiry. Sample items for a group planning to work in a family health clinic include:
* Parents who do not vaccinate their children believe vaccinations cause autism or other damage to children.
* Parents who do not vaccinate their children are negligent and do not care about their children's health.
* Children often are overweight because their parente do not allow them active play outside because they fear violence.
* The perception of a healthy weight for children varies among cultures.
Reflection activities during the servicelearning course are sometimes a challenge because of the amount of subject matter to be covered during class time or because students at service sites rarely meet. For these reasons, finding ways to encourage continuous reflection by students individually or establish reflective opportunities at the service site is valuable. In addition to journals, some instructors establish mentor teams to interact with each other or Web-based discussion groups for students who are located at widely dispersed sites. Encouraging community partners to include students in debriefings or case discussions at the site also can provide reflective opportunities. It also is important to integrate service experiences into class discourse. For example, teams of students or individuals can present case material for discussion to demonstrate selected concepts from the curriculum as a way to integrate traditional learning goals with the service activity.
Finally, activities at the close of the service-learning course also are important, although if effective preflection and continuous reflection during service occurs, this may be something instructors can delegate to the students. Faculty are often surprised at how much better developed even traditional final papers and presentations are when students culminate a semester of continuous and challenging reflective activity.
Reflection is what transforms service and learning into service-learning. These simple tools- Kolb's (1984) cycle of reflection steps and the map for planning occasions for reflection- can start faculty on their own cycle of experiential learning and increase the power of community experiences for students.
- Eyler, J. (2001). Creating your reflection map. In M. Canada (HkI.), Service-learning: Practical advice and models (pp. 35-43). San Francisco: Jossey-Basa.
- Eyler, J., Giles, D.E., Jr., & Schmiede, A. (1996). A practitioner's guide to reflection in service-learning: Student voices and reflections (pp. 36-43). San Diego: Learn & Serve America National Service-Learning Clearinghouse.
- Gelmon, S.B., Holland, B.A., & Shinnamon, A.F. (1998). Health professions schools in service to the nation: Final evaluation report. San Francisco: Community-Campus Partnerships for Health.
- KoIb, D. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cufie, NJ: Prentice Hall.