Facilitation of Reflective Learning in Nursing: Reflective Teaching Practices of Educators

The ability to reflect meaningfully may help practitioners or students to maintain competence and keep abreast with the latest trends in their practice. Practitioners who are more self-aware or self-discovered are more effective and competent in practice. However, unless educators are trained to practise reflection and to facilitate activities that promote the development of reflective learners, the role of the educator in promoting reflective learning by students will be limited. The purpose of this study was to explore and to describe the role of educators in the facilitation of reflective learning by students. A quantitative, explorative, descriptive study was conducted at nine nursing education institutions in South Africa. A total of 121 nurse educators (n = 121) was selected through a multi-staged probability sampling method. Data were collected using a structured questionnaire. The findings revealed that educators recognise the value of reflective practice but did not necessarily strive to develop their own reflective practices. Although reflective learning was not a formal learning approach in most programmes, the educators included reflection in the teaching and learning activities they facilitated. Educators need formal training to facilitate reflective learning activities to create a reflective learning environment that is conducive to reflection. Reflective learning should also be a formal teaching and learning approach in nursing curricula as reflective practices promote students’ critical and creative thinking.


Introduction
Reflective learning is a learning approach adopted by education institutions, including nursing education institutions, to assist students in learning to adapt in a fast-paced dynamic healthcare environment.Students learn to effectively review and evaluate their actions with the aim of learning from their own acts and omissions.Within many of the current nursing education programmes it is a clear requirement that students engage in reflective practices during the learning process.Clarke (2014) highlights that reflection is a nursing competence that needs to be demonstrated before student nurses become professional nurses.She further states that there is a lack of research on how training in reflective learning and practices is provided.A reflective learning approach requires structured and relevant facilitation by an educator who understands the reflective process.The educator must be able to plan lessons that support and guide students in this process.Reflective teaching is also an invaluable approach for educators to use to improve their practice and assist students in their learning (Jacobs, Vakalisa, and Gawe 2011).
Therefore the study aimed to conceptualise the assumption that educators are expected to facilitate reflective learning in students, however, the educators are not necessarily prepared to effectively deliver learning activities that promote reflective learning.The study also sought to determine the extent to which educators use reflective teaching in their own practice, as well as whether the learning environment is conducive to promoting reflective teaching and learning.

Background
Over the last 20 years the nursing profession has widely accepted reflective practice and reflective learning as effective measures to help students develop competence and provide patient care in a frequently changing context (Kuiper, Pesut, and Kautz 2009;Miraglia and Asselin 2015).The academic world has embraced the concept of reflection as a valuable measure for self-awareness, the development of critical thinking and insight (Epp 2008;Sullivan and Wiessner 2010).Frick, Carl, and Beets (2010) refer to the importance of educators' reflecting on their own practice to help improve and promote student learning.This suggests that educators should not only promote reflective practice in their students but should themselves be reflective practitioners.This is a vast responsibility for educators to embrace and manage since it would be necessary to view reflection differently by providing a structure (through opportunities and support) within which to reflect.This will require a revision of the pedagogical methods, developed from exploration of the educators and students' teaching and learning experiences of reflective practices (Clarke 2014).
Reflective learning is regarded as a powerful tool that promotes self-directed learning (Kuiper, Pesut, and Kautz 2009), and is an effective approach in preparing practitioners to apply theory to practice in the real world (Frick, Carl, and Beets 2010).This form of learning can be very useful in helping students connect new and existing knowledge, skills and affective-reflexive aspects of learning (Mann, Gordon, and MacLeod 2009).However, reflective learning has for long been described as difficult and too complex to achieve without guidance and support from experienced reflective practitioners (McCarthy, Cassidy, and Tuohy 2013;Stoddart et al. 1996).Frick, Carl, and Beets (2010) recommend that educators demonstrate reflective abilities in teaching and learning so that students can see the modelling of good reflective practices and recognise its value in the real world.Smith et al. (2014) maintain that educator competence in reflection is necessary when developing students' reflection skills.Critical reflection on one's own teaching practices is particularly valuable during student support (Horton-Deutsch and Sherwood 2017).
Professional practice has to constantly modify and adjust to the frequently changing healthcare systems; therefore the ability to reflect meaningfully may help the practitioner or student to maintain competence and keep up to date (Mann, Gordon, and MacLeod 2009;Newton 2004). McCarthy, Cassidy, andTuohy (2013) identified the development of reflective practitioners as being an integral part of rendering quality healthcare.Pultorak (2010) states that reflection coupled with experience results in professional growth.Reflective practice may be a key factor in helping nurses to bridge the gap between theory and practice.In fact, if nurses in the current context of healthcare do not reflect while planning and evaluating patient care, the theory-practice gap will widen (Hatlevik 2011).The role of reflection in assisting students and practitioners to become more self-aware is hence well documented by experts.The influence that educators have on reflective practices relates to the style of feedback, targeted teaching and corrective support.Creating opportunities for peer mentoring and a learning environment that is conducive enhances student participation (Fernandez-Fernandez et al. 2016).Educators should therefore embrace the importance of reflective selfdiscovery and create opportunities for students to practise and develop their skills.
Reflective learning should be an integral part of all aspects of learning and not just an "add on" to the curriculum.This requires a collaborative environment that is promoted by the education institution and educators (Pultorak 2010).Adequate time must be allocated for practising reflective activities because reflective learning develops over time.Reflective learning requires deep thinking and more educator-student interaction, therefore reflection has to be intentionally planned and built into the daily education programme (Pultorak 2010).If reflective learning is to be effective, the educator has to be skilled in using diverse learning activities that promote reflection.The educator has to be prepared and supported in creating a learning environment that is conducive.To establish such an effective reflective learning environment educators need to understand their own beliefs and intentions when facilitating reflection (Betts 2004;Schaubde Jong et al. 2011).Educators who fail to understand their own beliefs and reflective practice abilities may consequently limit the true reflective practice abilities of their students.
Unless educators are trained to practise reflection and to facilitate activities that promote the development of reflective learners, the role of the educator in promoting reflective learning by students will be limited (Horton-Deutsch and Sherwood 2017;Levett-Jones 2007).Educator training programmes should include reflective learning as a teaching and learning approach and develop a positive attitude to reflective thinking in student educators (Pultorak 2010).This requires educators to practise reflection on a daily basis to become comfortable with the process (Rogers 2001).Educators should reflect on their roles and actions to enhance the provision of effective quality facilitation (Fernandez-Fernandez et al. 2016;Karban and Smith 2006).Finally, reflective practise also improves the relationship between educators and students, ultimately improving the quality of teaching and learning (Mann, Gordon, and MacLeod 2009).
Although education institutions in South Africa promote the development of reflective practitioners (Friedrich-Nel 2010, 24;Ross and Kitching 2010, 91), the preparation of students to correlate nursing theory with practice remains a concern.In an attempt to help students in this regard, education institutions have adopted learning by reflection as a learning approach to encourage self-awareness and to promote evaluation of own practice based on similar issues of poor integration between theory and practice in nursing.The need therefore arose to explore the role of the educator when facilitating reflective learning by their students.

Design and setting
A quantitative, explorative, descriptive design was used to determine the more generalised practices and views of educators about their role and the learning environment when facilitating reflective learning by their students.The study was conducted at nine nursing education institutions in one of the nine provinces in South Africa.This province was selected for its size (one of the largest provinces in South Africa) and its accessibility to the researchers.In South Africa there are three types of education institutions that provide nursing education programmes.These are public government nursing colleges, nursing departments at universities and privately owned nursing colleges, all of which are accredited by the South African Nursing Council (SANC), the regulatory body for the professional education of nurses.

Study population
A probability sampling method was chosen and the accessible population was nurses with an additional qualification in education, registered with the professional registration body and practising at a nursing education institution (NEI) that offered a programme leading to registration as a professional nurse.All NEIs in the particular province that offered the programme leading to registration as a professional nurse were included in the stratified random sampling method that was used.Thereafter to select the NEI within each stratum, the researcher used an unrestricted random sampling method.The sample comprised six private colleges, one university and two public colleges.All educators working at these nine institutions were included in the study.
The researcher handed out 231 questionnaires of which 121 completed questionnaires were returned, giving the study a 52 per cent return rate.

Ethical considerations
The study proposal was approved by the Research Ethics Committee of the University of South Africa.Permission to conduct the study was sought from each institution selected to participate in study.The institutions were furnished with the ethical clearance certificate as well as the study proposal.The ethical principles of beneficence and non-maleficence, respect and justice were adhered to (Naicker 2014).

Data collection
The data collection method selected for this study was a self-report method as the method described the population more fully and provided quantitative data that gave the researcher more opportunity to generalise the findings to the accessible population.This method also allowed the respondents privacy when answering the questions and more assurance of maintaining their anonymity.

Instrument description
A structured questionnaire was developed, evaluated by a statistician and piloted before distribution to all educators at the selected institutions.The educators received information about the study and participation was voluntary.The anonymously completed instruments were collected by the researcher.Completion and return of the questionnaire implied consent.The questionnaire consisted of three sections which included closed-ended and open-ended items allowing the respondent to elaborate on or explain responses further in the additional space provided for comments.The development of items was guided by the study research objectives (see Table 1).

Data analysis
The data were analysed using the SAS JMP version 10.1 program.Open-ended items were analysed by identifying emergent themes, whereafter the themes were quantified and integrated into the results.Descriptive analyses were done to explore and to describe the data available so that the information could be organised in a meaningful way and occurrences examined from different angles (Brink, Van der Walt, and Van Rensburg 2018;Polit and Beck 2012).The results were presented as the total number of responses per item and percentages.The data were supplied in fractions and for this study were rounded off to the nearest whole percentage.Cross-tabulation in the form of contingency tables was done on sections B and C in the questionnaire (Table 1), where the frequency of two variables is compared.Variables in sections B and C were also subjected to the chi-square test.The chi-square test is used to determine if there is a significant difference between proportions or, specifically in this study, if there is an association between the proportion of the responses and the different institutions.It is important to note that the chi-square test only informs whether two variables are related or dependent, but does not give the magnitude of dependency.The probability value (p value) is produced, and if this calculated p value is smaller than 0.05 it indicates statistical significance at a 95 per cent level of confidence.

Demographic information of the respondents
There was a distinct indication that the educator population was an ageing one with 57 per cent (n = 71) of the respondents being over 45 years of age.The results also revealed that educators preferred to enter nursing education later in their careers with 31 per cent (n = 36) of the respondents having less than 5 years' experience in nursing education.Most respondents (n = 69) had at least a Bachelor's degree with an education qualification, which is a requirement of the professional registration body in South Africa if one wants to hold a teaching position.A total of 14 per cent (n = 17) of the respondents had a Master's degree, either in nursing education or a clinical discipline.
The educators with a Master's degree were mainly based at the university nursing department.

Educator reflective practices
The respondents were asked if they have studied reflective learning in their educator training programme and only 46 per cent (n = 55) could say with certainty that they did.A further 37 per cent (n = 44) had some form of exposure to reflective learning in their educator training, whereas 16 per cent (n = 19) had no exposure to reflective learning as a teaching and learning approach.The majority of the respondents (63%) did not apply reflective learning in their own studies although 37 per cent (n = 44) consistently used reflective learning in their studies.Of the respondents based at the university, 83 per cent were consistent in using reflective learning in their own studies.The probability value of p = 0.02 indicated a significant association between application of reflective learning during the respondents' basic and post-basic education and the type of institution.
A total of 34 per cent (n = 41) of the respondents always set aside time for daily selfreflection, whereas 63 per cent (n = 76) set aside time in their day for self-reflection, but not as a regular practice.The probability value of p = 0.01 indicates a significant association between setting time aside for self-reflection and the type of institution where they worked.The respondents who were educators at a university were more inclined to do self-reflection.The respondents did reflect on their current practice but the majority were not consistent in their reflective practices.Only 46 per cent (n = 55) stated that they always reflect on their teaching practices and methods.Reflective journals were not predominantly used by the respondents with only 13 per cent (n = 16) attesting to their use.
The respondents were also not fully inclined to seek the appraisal of their peers regarding reflective practice, with 70 per cent (n = 95) stating that they did but not as a regular practice.None of the respondents working as educators at a university as a routine asked the advice of their peers regarding their lessons.The respondents at the public colleges appeared to make the most attempts to ask their peers to evaluate their lessons (35%, n = 18).The respondents in private institutions did not place much emphasis on peer evaluation of their lessons, with only 13 per cent (n = 8) stating that they always asked their peers to evaluate their lessons.There appeared to be a significant association between the perception that respondents ask their peers to evaluate their lessons and the type of institution (p = 0.005).It may be concluded that asking one's peers to evaluate one's practice was not a common practice among the respondents, although the respondents at the public colleges do appear to be more consistent in seeking their peers' opinion.
In comparing the educators' use of reflective journals in their own practice and requiring their students to keep a reflective journal, the following data were obtained.Fewer than 20 per cent (n = 16) of the respondents always use reflective journals in their own practice and also always require their students to keep a reflective journal during their programme of study.Over 30 per cent (n = 37) of the respondents never use a reflective journal and never require their students to do so either.It may therefore be assumed that reflective journals are not the respondents' method of choice for their own and their students' reflective practice.

Educator's facilitation of reflection
The majority (98%) of the respondents used reflective learning in their facilitation of nursing programmes.The respondents (68%) stated that they had adequate resources available for the use of various reflective learning activities.Most programmes the respondents facilitated did not have formal time allocated for reflective learning.However, the respondents (47%) allocated time in the daily class schedule for reflective activities.The most common activities used to promote reflective learning by students are small group discussions (83%), role-playing (69%), problem-solving (79%) and case studies (71%).The respondents (60%) also preferred simulation and presentations activities but to a lesser degree than those mentioned above.There was not much emphasis on the use of reflective journals by students with only 17 per cent (n = 21) of the respondents requiring their students to keep a journal through the duration of the programme.The respondents were unanimous (98%) in their agreement that reflective learning has a positive effect on student learning.There was also a unanimous (94%) agreement that educators' reflective practice helps to improve their facilitation of learning.The respondents understood their role in facilitating reflective learning as one of guiding, supporting and making time available for students to reflect.They (68%) felt they were successful in establishing a reflective learning environment conducive for their students.A total of 68 per cent (n = 80) of the 118 who responded on this particular item on successfully creating a reflection-friendly environment were in agreement that they did create a learning environment for students that was conducive to reflection.The respondents' comments focused on the use of reflective learning activities like problembased learning and case studies (and one educator mentioned storytelling).The other 32 per cent (n = 38) of the respondents stated that they could not successfully create a conducive environment owing to the lack of time and ability to facilitate reflective learning.

Discussion
Taking into consideration the advancing age and minimal experience in education of most educators, it may be assumed that these findings could also indicate that the respondents have years of experience and expertise in clinical practice, which support their facilitation of student theory-practice integration.The educators should be able to facilitate the students' understanding of theory by referring to a variety of personal experiences and examples in clinical practice that the students are more likely to relate to.
The respondents of the study unanimously agreed that there is value in reflective practice; that reflective practice helped educators improve their facilitation of students.However, despite this belief the respondents did not actually practice reflection on their educational practice as often as they should.The reason for this could be owing to the respondents' inadequate experience of reflective practice.Reflecting on one's practice would be necessary to ensure transformative learning (Sherwood and Horton-Deutsch 2012).Rolfe (2014) explains the primary task of reflective educators as having to form partnerships with the students to identify what they regard as their learning needs.He further maintains that novel and individualised responses to these needs are necessary to meet their learning needs.
Inadequate training in the effective use of reflection to improve teaching practices and skills may affect the educator's ability to reflect and create interest in reflective practices.In order to use reflective practice effectively, the concept has to be understood and developed over time with continuous practice.The development of reflective practice skills over time through formal learning and practice is the cornerstone for effective reflection and is enhanced by daily reflection on action (Atkins and Schutz 2013;Mann, Gordon, and MacLeod 2009).Levett-Jones (2007) states that adequate training to facilitate reflective learning by students is needed otherwise the implementation of the approach will be of limited value.
The respondents were also unanimous in their opinion of the value and importance of reflective learning by students.Despite various challenges attempts were made to promote students' reflective learning abilities.Learning activities that students were familiar with and which they used commonly in classroom facilitation were used.
Although activities such as simulation, role play, problem-solving and projects are endorsed as promoting reflective learning (Bruce, Klopper, and Mellish 2011), more specific reflective learning activities, such as storytelling, guided reflection and journaling with dialogue are recommended by recent literature as more effective (De Swardt, Du Toit, and Botha 2012, 1;Ross and Kitching 2010).According to Johns (2017) storytelling and narratives are core to reflection.The limited use of more specific reflective learning activities may be owing to educators' limited experience and training in the facilitation of reflective learning.In addition, in all the institutions in the study reflective learning was not allocated formal time, built into the programmes.Therefore specific time had to be allocated in their daily teaching schedule for student reflective learning activities.Pultorak (2010) maintains that adequate time must be allocated for practising reflection if any learning is to take place from reflective activities.Johns (2017) refers to the value of reflection within the moment as being valuable to open up opportunities to competing needs and placing these into perspective.Newton (2004) states, however, that if educators value the use of reflective learning in facilitation of student learning, then reflective learning does not need to be included in the curriculum to be used during teaching.From the results of this study it is deemed to be true.
Educators acknowledged the important role they played in promoting students' reflective learning.The responses indicated that, under the circumstances, they tried to motivate, encourage and create opportunities for students' reflective learning in the classroom.The respondents selected small-group discussions as the most common method used for promoting reflective learning; hence the importance of trust, confidentiality, safety and freedom from being judged is paramount.However, the respondents did not refer to their role in establishing a non-threatening, safe and trustworthy environment in which students could feel comfortable with practising reflection.Reflection is a sensitive and self-conscious exercise and especially difficult in the presence of others, therefore the educators have an important role as facilitators of a safe reflective learning environment.Finally, the respondents did not acknowledge the importance of being a role model of reflective practice.Reflective learning is best facilitated when the educator can engage with the students, and anticipate and understand the issues that arise from exploring the self and questioning one's actions and beliefs.This deeper understanding of reflective learning comes with continued personal reflective practices and the development of reflective skills, which the educator should role model when facilitating students' reflective learning (Atkins and Schutz 2013;Pultorak 2010).
The formalisation of reflective learning in a curriculum is supported by Karban and Smith (2006, 4), who state that reflection should not be an "add on" to the curriculum but should be an integral part of all aspects of learning.Yet Newton (2004) states that there is no need for reflection to be part of a curriculum; respondents that believe in the value of reflective practice should include it in the delivery of their programmes or classes.Creating a space in the classroom and the clinical learning environment for mindful and reflective practices has become essential to develop reflective thinkers (Horton-Deutsch and Sherwood 2017).

Recommendations
Learning to reflect as students promotes the development of future reflective nurse practitioners; therefore reflective learning should be included as a teaching and learning approach in the undergraduate nursing programmes and be facilitated by educators who have had formal training in facilitating reflective learning.Reflective learning should be included as a teaching and learning approach in the curriculum of the educator training programmes so that the educators are able to facilitate student reflective learning based on a good understanding of reflection, reflective activities and establishing an environment conducive to reflective learning.Educators who are trained in reflection as a teaching and learning approach could contribute to more innovative ways of integrating reflection into the teaching and learning processes.The practice of reflection should be included in the educator training programme, with specific predetermined criteria for evaluating as an outcome, thereby enabling the educator to develop self-reflective skills.A model of educator training based on reflective professional education, although a new idea, is supported by Fernandez-Fernandez et al. (2016).A further recommendation is that institutions establish training programmes for current educators to develop their facilitation of reflective learning skills.Nursing education institutions should also adopt a reflective culture, thereby supporting and promoting the reflective practices of educators.A formal allocation of a portion of the nursing curriculum notional hours (credit-bearing hours) allocated for reflective practice and adequate and appropriate resources available for the use of effective reflective learning activities could contribute to reflective practices.

Conclusion
By focusing on the reflective practice of educators, this study has contributed data that will provide more understanding of the value educators place on reflective teaching and the facilitation of reflective learning.An increased awareness of education institutions with regard to their role in supporting and promoting a reflective practice environment and culture in the nursing education environment, could contribute to quality teaching.
Development of a training model to assist educators in their understanding of reflective learning, of the reflective learning activities and the facilitation skills that create a learning environment conducive to reflection is necessary.The findings of this study provide new and relevant information that may assist educators in planning their development of reflective practice and selecting learning activities to promote their students' development of reflective skills.Bulman, Lathlean, and Gobbi (2012) describe reflection as being more than simply being thoughtful.It is concerned with the way that reflection can help professionals to learn from their experiences.This approach to reflection entails critically reviewing experience from practice so that it may be used to inform and change future practice in a positive way.This means openly examining one's practice, and consequently requires courage, open-mindedness, and a willingness to accept, and act on, feedback.Contemporary ideas emphasise educating nurses in ways that develop their autonomy, critical thinking, open-mindedness and sensitivity to others.We wish to conclude this paper with a statement by Mann, Gordon, and MacLeod (2009, 595): "Reflection may be most useful when viewed as a learning strategy.Used in this way, it may assist learners to connect and integrate new learning to existing knowledge and skills."

Figure 1 :
Figure 1: Educators' selection of the learning activities that could assist students with reflective learning (N = 121)

Table 1 :
Description of questionnaire