Journal of Nursing Education

Educational Innovations 

Techniques to Promote Reflective Practice and Empowered Learning

Connie Kim Yen Nguyen-Truong, PhD, RN, PCCN; Andra Davis, PhD, RN; Cassius Spencer, DNP, RN; Melody Rasmor, EdD, ARNP-BC, COHN-S; Lida Dekker, EdD, RN

Abstract

Background:

Health care environments are fraught with fast-paced critical demands and ethical dilemmas requiring decisive nursing actions. Nurse educators must prepare nursing students to practice skills, behaviors, and attitudes needed to meet the challenges of health care demands. Evidence-based, innovative, multimodal techniques with novice and seasoned nurses were incorporated into a baccalaureate (BSN) completion program (RN to-BSN) to deepen learning, complex skill building, reflective practice, teamwork, and compassion toward the experiences of others.

Method:

Principles of popular education for engaged teaching–learning were applied. Nursing students experience equitable access to content through co-constructing knowledge with four creative techniques.

Results:

Four creative techniques include poem reading aloud to facilitate connectedness; mindfulness to cultivate self-awareness; string figure activities to demonstrate indigenous knowledge and teamwork; and cartooning difficult subject matter.

Conclusion:

Nursing school curricula can promote a milieu for developing organizational skills to manage simultaneous priorities, practice reflectively, and develop empathy and the authenticity that effective nursing requires. [J Nurs Educ. 2018;57(2):115–120.]

Abstract

Background:

Health care environments are fraught with fast-paced critical demands and ethical dilemmas requiring decisive nursing actions. Nurse educators must prepare nursing students to practice skills, behaviors, and attitudes needed to meet the challenges of health care demands. Evidence-based, innovative, multimodal techniques with novice and seasoned nurses were incorporated into a baccalaureate (BSN) completion program (RN to-BSN) to deepen learning, complex skill building, reflective practice, teamwork, and compassion toward the experiences of others.

Method:

Principles of popular education for engaged teaching–learning were applied. Nursing students experience equitable access to content through co-constructing knowledge with four creative techniques.

Results:

Four creative techniques include poem reading aloud to facilitate connectedness; mindfulness to cultivate self-awareness; string figure activities to demonstrate indigenous knowledge and teamwork; and cartooning difficult subject matter.

Conclusion:

Nursing school curricula can promote a milieu for developing organizational skills to manage simultaneous priorities, practice reflectively, and develop empathy and the authenticity that effective nursing requires. [J Nurs Educ. 2018;57(2):115–120.]

Complexities within the health care environment are fraught with fast-paced, critical demands and ethical dilemmas requiring astute, measured, competent, and decisive nursing actions. Nursing students must be prepared to manage complexity to integrate into practice emerging knowledge with mastery of skills (Benner, Sutphen, Leonard, & Day, 2010). Apart from skill development, the traditional classroom in nursing education primarily uses a singular sensory modality. Incorporating innovative, multimodal teaching–learning techniques enables faculty to role model multisensory ways of knowing to promote deeper learning, expand skills, and increase capacity for compassionate care.

While upholding the standards of nursing education, the authors who are nurse educators strive to dismantle teaching approaches that constrain learning environments and to facilitate individual and collective empowerment through engaged learning. A courageous approach in teaching that promotes aesthetic experiential learning activities is supported by principles of popular education with reflection occurring throughout the learning process. Reflection invites inquiry into one's own thoughts, biases, assumptions, feelings, and behaviors to reconnect with a sense of purpose and commitment to nursing practice (Peterkin & Brett-MacLean, 2016). The six principles of popular education include (a) learning with our heads (cognitive), hearts (affective), and body (psychomotor); (b) creating an atmosphere of trust and allowing students to openly share their voices and experiences; (c) promoting equality between students and educators; (d) validating that knowledge gained through life experience is as important as knowledge gained through formal education; (e) engaging students in their own learning process; and (f) using artistic teaching modalities as important tools for teaching (Nguyen-Truong, Tang, & Hsiao, 2017; Wiggins, 2011).

Nursing practice requires focused attention to the complex needs of clients. Competing demands, frequent interruptions, and system requirements challenge the nurse's ability to maintain focus on providing quality, safe client care. Nurses have described coping with the chaotic and painful busyness of the work environment by compromising their professional principles, shielding themselves emotionally, eventually becoming emotionally immune, and experiencing moral distress (Storaker, Nåden, & Sæteren, 2017, p. 9). For nurses and nursing students, a common emotion that arises from moral distress is fear of the cost of an action, the consequences of an intervention, or getting it wrong (Gallagher, 2011). Nursing students need to feel safe in their learning environment to prepare for the challenges of practice. Curricular requirements in a baccalaureate (BSN) completion program (RN-to-BSN) include developing organizational skills to manage simultaneous priorities and practical techniques to sustain reflective, compassionate practice.

The purpose of this article is to describe a collection of techniques that promote reflective practice and engaged learning through diverse experiential learning activities used with RN-to-BSN students. Four creative techniques are presented: (a) poem reading aloud to facilitate connectedness; (b) mindfulness to cultivate self-awareness; (c) string figure activities to demonstrate indigenous knowledge and to practice teamwork; and (d) cartooning to encourage communication on difficult subject matter. Research has long supported the concept that using multiple senses for inputting new information reduces saturation of a single mode of learning and promotes deeper retention (Bagui, 1998; Clark & Paivio, 1991). Drawing on their experiences, the authors implement different teaching–learning techniques by engaging cognitive, affective, and psychomotor domains to facilitate dynamic engagement to emerge in the classroom (Sawyer & Norris, 2016). The intention of these techniques is to promote deep learning of subject matter in ways that can enhance nursing practice.

Creative Techniques

Poem Reading: Facilitating Connectedness

Hahessy (2016) demonstrated that poem reading in nursing education can facilitate an affective connection and understanding between a nursing student and educator, which provides a shared foundation from which to meaningfully speak about characteristics and complexities of nursing knowledge. Nurse educators are encouraged to nurture students in the artistry of clinical practice, where artistry means creative skill and ability (Chan, 2013). Teaching–learning techniques may include facilitating students' awareness and validation of their challenges with the commitment and action to take care of themselves (McCue, 2010). The aim of poem reading aloud by nurse educators is to facilitate and validate students' reflections, and convey a sense of shared experience of complex and difficult clinical situations in a nonhierarchical manner. For example, the original poem, We—The Collective We: Nurses from Yesterday, Today, and Tomorrow, was introduced and performed by a nurse educator in an ethics course classroom. Delivering poetry aloud with voice inflections, rhythm, and pause for effect can be a powerful experience by drawing attention to particular words. The following is an excerpt from the original poem.

We—The Collective We: Nurses From Yesterday, Today, and Tomorrow…Oh yes! Meaningful reflexivitySo the mind can be filled with creative livabilityLove for the people is where it needs to beIt has to come from the bottom, from the collective weEmpowerment as a collective and from withinWhile managing various monkeys, a whole lot of themMoving through that processFor after all, we have this in commonWe are humanConsider this way of thinking and beingSo that love can spread in a contagious meaningWe stand together like how we groove in zumbaUnite to live and speak up because silence killsTruly inspired to be the change agent that we want to seeTo have joy, passion, courage, and resilience in what we want to beTo re-energize—to manage stress—to support one anotherCreating a dual reflection spaceMoving fluidly within a professional and safe spaceSo, then we can do the work that we love—to serve our people with cultural sensitivitySo please listen to understand—fellow nursing students and facultyWe, the collective ‘We’, are nurses from yesterday, today, and tomorrowLike a roller coaster, we journey together through laughter and sorrowFrom raw connections—to deeper empathy—to compassionate collaboration

Recognizing the potential emotions that can arise requires awareness and creating safety for voluntary disclosure of thoughts and feelings (Hahessy, 2016). For example, student reactions have included crying, feeling inspired or deeply moved, validating why one became a nurse, and not feeling alone. Students can be invited to engage in reflective journaling, as well as sharing in small groups, and as a large class using question prompts. For example, “What initial thoughts and feelings come to mind?” (listen to understand); “Your health is important—What comes to mind when you hear self-care? (awareness); and “What have you done or plan to take care of your health?” (action). Nurse educators can guide discussions in a way that addresses ethical complexities in practice. For example, “You may be facing various difficult situations in nursing practice” (validation, empathy); “What people resources are available?” (collaboration); and “What has worked well thus far and what are possible constraints that make it difficult to do the right thing as a client advocate?” Facilitating a nonthreatening discussion may encourage students to address their feelings and engage in self-care to manage difficult experiences.

Mindfulness: Cultivating Self-Awareness

Mindfulness learning activities may enable development of internal resources for reacting and responding with greater awareness when encountering moral distress, working in stressful environments, and caring for people who are suffering. White (2013), in a concept analysis of mindfulness in the nursing literature, identified four core attributes: Being in the present moment, awareness, acceptance, and attention. Mindfulness may improve task performance and enhance productivity (dos Santos, et al., 2016; Levy, Wobbrock, Kaszniak, & Ostergren, 2012). Such practices can foster greater personal and professional satisfaction, resilience, and professional sustainability. The intentions of introducing students to principles of mindfulness practices are to aid in developing patterns to navigate the challenges of the work environment, reduce stress, and foster empathy (Beddoe & Murphy, 2004; Walker & Mann, 2016). For example, a simple meditation exercise (a form of mindfulness) was introduced by a nurse educator in a pathophysiology course. Students' reactions included finding the presentation on meditation toward difficulty in sleeping to be helpful personally and professionally, integrating a plan to incorporate mindfulness strategies into clinical practice, and discovering ways to integrate mindfulness techniques in their other courses. The literature has reported various ways of incorporating these attributes in practice ranging from conducting full-length mindfulness-based stress reduction workshops modeled after Jon Kabat-Zinn's (2005) original 8-week program developed in 1979, to conducting a brief 5-minute mindfulness meditation prior to shift change (Gauthier, Meyer, Grefe, & Gold, 2015; Goodman & Schorling, 2012; Ponte & Koppel, 2015). The Table provides examples of simple ways to integrate mindfulness practice into existing didactic and clinical courses.

Examples of Mindfulness Activities for Classroom Use

Table:

Examples of Mindfulness Activities for Classroom Use

Using String Figure Activities to Demonstrate Indigenous Knowledge

As an innovative technique for nursing education, indigenous knowledge is a multidimensional perspective to observing, understanding, and interacting in the world that honors relationship, interconnectedness, and harmony of all things (Barnhardt, 2005). Further, it accounts for the complex exchange between teaching–learning that includes intellectual, emotional, spiritual and physical domains (Tsianina Lomawaima & McCarty, 2006). Within indigenous communities, elders are held in high regard for their life experiences and historical knowledge, which they share in stories. The concept of elders teaching through oral communication and tactile demonstration is conveyed through storytelling. Indigenous language, for example, cannot be reduced to a process of learning how to pronounce words but requires a commitment to understanding the tribal value system of ideas, beliefs, and feelings. For students, practice of indigenous teaching–learning strategies, through story-telling and string figures, highlights that becoming a professional nurse cannot be reduced to a process of learning how to perform skills but requires a commitment to understanding clients' stories and the professional nursing value system.

String figures are a perceptible method to understand indigenous knowledge and living that can only be accessed through dynamic engagement. String figures are seen by some solely as amusement or recreation, yet the benefits include promotion of manual dexterity, coordination, education, cooperation and transmission of culture, language, and traditions (Jayne, 1906). This activity was common in many indigenous groups throughout the world, with different figures representing different regions. Although Moore (1988) noted that the main objective of string figures is to twist and weave looped string into patterns that represent familiar objects; many indigenous groups coupled string figure activities with specific stories and values to convey cultural knowledge. In the Navajo culture, string activities may be used to teach–learn traditional concepts of walking in beauty (i.e., living in harmony), the purpose of the Hogan (i.e., traditional center of family life), and significance of the four directions (i.e., east, south, west, north). For example, the traditional story of Spider woman, the deity in the Navajo culture known as a protector and master weaver, is told only during winter months while manipulating string into a web figure. Telling of this traditional story in a particular season teaches the importance of being culturally respectful because Spider woman is believed to weave during the other seasons of the year, and that she would be upset if her story is told during these other times. In addition, the story teaches values about living a grateful, aware, intentional and cooperative life. By interactively using string figures, nursing students experience native ways of knowing and better understand how the values of focus, thoughtful communication, and cooperation can positively affect relationships in the teaching–learning process. (Figure 1).

Drum string figure activity.

Figure 1.

Drum string figure activity.

The following are descriptions of images A through G as an experiential exercise, where students may be guided to apply indigenous knowledge concepts to make their own drum string figure to practice awareness through an intentional effort and persistence to achieve a goal and symmetry: (a) Take the thumb and index finger of one hand and grab the string on the opposing wrist to loop one time around the wrist; (b) Check string placement after looping the string one time around each wrist.; (c) Take your hand with the thumb and small finger through the string loop of the opposing wrist; (d) After, pull thumb and small finger through the loop string and back to the opposing side; (e) Thumbs and small fingers of both hands have looped through the string; (f) With the index finger of the one hand, loop underneath the string; resting across the palm between the thumb and small finger to be drawn back to opposing side; (g) Loop the opposing index finger of the other hand underneath the string resting across the palm between the thumb and small finger to be drawn back to opposing side.

During the teaching of string figure activities, as in the drum string figure activity, nursing students will display varied styles and paces of learning. Those students who accomplish the drum string figure sooner are encouraged to work together with classmates who have not completed the activity and offer guidance and support until the string figure is achieved; this reinforces the concept of cooperation. A nurse educator can emphasize that it is expected and safe to make mistakes during the creating of a string figure. The educator can ask students to reflect, “How do you feel about learning this activity?” As students are sharing their feelings, the nurse educator can point out similarities or differences between the nursing students and possibly what their clients may be feeling when encountering new health events. This discussion will offer an opportunity for students to reflect on the spectrum of emotions that their clients may experience related to their story of illness. For example, string figure activities were introduced in a population health theory course. Overall, this was regarded by students as a new way of learning and knowing how to intentionally listen to a story while creating a string figure and taking time to process the instructions, drawing parallel to listening to a client's story of illness while providing care.

By the end of the drum string figure activity, students experience obtaining similar skill of the expert weaver as in the traditional story of Spider woman and an increased understanding of indigenous knowledge. This is also a good time for nursing students to reflect and discuss what concepts or values stood out to them after having done the activity. As a final layer of how the concept of indigenous knowledge is used throughout many cultures, a short video clip may be shown of a contemporary automobile engineering team who used string figure activities to develop a full-scale vehicle prototype (Jakubowski, 2006). In the video, indigenous knowledge concepts are evident by individuals cooperatively working alongside one another, without any apparent hierarchy as they approach a complex task. Their process of sharing ideas and trial and error are revealed as they make several attempts to bring together their single string figures into a complete vehicle shape. Finally, after several failed and successful attempts, the group develops their shared goal of a whole vehicle design made of string, while the process creates a group; this is woven together through experience and shared ritual.

Learning string figures is a shared process in which the knower and learner work together, developing and applying intellectual, tactile, and emotional skills to loop and weave the string into form. Enduring through the trial-and-error process to complete the figure demonstrates how practicing awareness, intentional efforts, and persistence achieves a goal and symmetry. Tactile exercises such as this help to deeply embed creative teamwork skills that are directly applicable in the complex nursing practice environment.

Cartooning Difficult Subject Matter

Cartooning can be another effective tool to communicate about shared experiences or complex subject matter. Topics such as reflection in practice, moral distress, leadership skills, health care policy, and ethical decision making can be explicated by asking nursing students to draw their interpretation of the reading assignments, class discussions, and clinical experiences. Sharing of the visual images makes evident that each student has a unique, personal interpretation of content. Benefits of this exercise include creating a means for less verbal students to participate using visual expression and challenging all students to think more deeply about the material to express it in a more creative manner. Sharing of cartoons can lead to rich discussion, thought provoking comments, shared insights, and welcome humor in the class setting. For example, cartooning was introduced by a nurse educator in a critical thinking course and in a community clinical course. Students reactions included being able to identify their strengths in critical thinking, being more creative in problem solving, and finding diverse ideas and opinions to be enjoyable as they viewed each other's cartoons.

Figure 2 provides an example of a cartoon drawn by a nursing student about ethical dilemmas of nutritional school lunch. Cartoon shows layers of complexity that a nursing student encountered while attempting to provide nutrition education centered around school lunches in a large underfunded school district.

Ethical dilemmas of nutritional school lunches.

Figure 2.

Ethical dilemmas of nutritional school lunches.

As nursing students progress in clinical practice experiences, difficult topics begin to emerge—for example, issues around sexuality, professional boundaries, implicit bias, cultural safety, end-of-life care, and medical error (Stuber, 2016). The advantage of encouraging cartooning about the intimacy of client care with novice as well as seasoned nurses returning for academic progression (RN-to-BSN programs) is that visual impact is immediate and enables engagement among students of all ages, cultural backgrounds, and clinical expertise (van Wyk, 2011).

Conclusion

Nurse educators have exciting opportunities to enrich their teaching–learning toolkit in ways that activate individual and collective learning outside of a traditional didactic format. Apart from skill development, the traditional classroom in nursing primarily uses a single sensory modality. Multisensory training in education may enhance learning and may support development of a successful, creative, and sustainable career in complex work settings. Using diverse approaches to cognitive, affective, and psychomotor domains of learning empowers and engages different teaching–learning styles and enriches the learning environment (Clark & Paivio, 1991). The authors have presented purposeful innovations for nurse educators to integrate multiple domains of knowing to facilitate connectedness through poetry, to enhance self-awareness through mindfulness, to transmit culture and develop team building through storytelling using string figure activities, and to discuss difficult topics through cartooning. Adding innovation in teaching–learning to the nursing academic environment incorporates creative strategies aimed toward deeper learning, complex skill building, and developing empathy and compassion toward the experiences of others. Based on well-established evidence and the authors' own experiences, nursing students who are educated in this way may be well prepared for the rigors of practice.

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Examples of Mindfulness Activities for Classroom Use

TechniqueRationaleSetting or Context
Presentation on mindfulnessDefining mindfulness; Creating foundation of understanding of the scientific evidence and impact of mindfulness.Classroom: Integrate into topics such as palliative care; compassion fatigue; self-care; resilience; professional sustainability.
Use of bellSound symbolic reminder to notice where our thoughts are, returning to the present.Classroom: Anytime to reconnect.
5-minute breathing exerciseGuided focus on breath, sound, body, thoughts; Practice of paying attention in present moment without judgement.Classroom or clinical: Beginning or ending of class.
Walking meditationPractice of present awareness of body and mind.During class breaks.
2-minute STOP meditationS = Stop; T = Take a Breath; O = Observe thoughts and feelings; P = Proceed into the next activity.Classroom: Prior to any stressful event–presentation, examination. Clinical: Prior to entering a patient room.
Authors

Dr. Nguyen-Truong is Assistant Professor, Dr. Davis is Assistant Professor, Dr. Rasmor is Clinical Assistant Professor, and Dr. Dekker is Emeritus Clinical Associate Professor, College of Nursing in Vancouver, Washington State University; and Dr. Spencer is Indigenous Community Member, Indigenous Community, Vancouver, Washington.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Dr. Renee Hoeksel, PhD, RN, ANEF, Executive Associate Dean and Professor, and Dr. Dawn Doutrich, PhD, RN, Emeritus Associate Professor, College of Nursing in Vancouver, Washington State University, for content editing assistance. They also thank the journal's anonymous peer reviewers for their assistance.

Address correspondence to Dr. Connie Kim Yen Nguyen-Truong, PhD, RN, PCCN, Assistant Professor, College of Nursing in Vancouver, Washington State University, 14204 NE Salmon Creek Avenue, Vancouver, WA 98686-9600; e-mail: c.nguyen-truong@wsu.edu.

Received: May 27, 2017
Accepted: September 21, 2017

10.3928/01484834-20180123-10

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