Reflective Practice: Narrative Pedagogy Can Transform the Educational Paradigm

Oct 12, 2012, 9:00 AM, Posted by Gwen Sherwood

The Robert Wood Johnson Foundation Human Capital Blog is asking diverse experts: What is and isn’t working in health professions education today, and what changes are needed to prepare a high-functioning health and health care workforce that can meet the country’s current and emerging needs? Today’s post is by Gwen Sherwood, PhD, RN, FAAN, professor and associate dean for Academic Affairs at the University of North Carolina at Chapel Hill School of Nursing, and co-investigator for RWJF’s Quality and Safety Education for Nursing (QSEN).

Never have so many forces converged to compel transformation in nursing education. The revealing reports in the Institute of Medicine (IOM) Quality Chasm series identified serious gaps in patient safety and quality-of-care outcomes and fueled a debate on changes required in health care professions education if we are to improve. Changes in health care delivery systems and financing, advancements in knowledge, and breakthrough reports on the future of nursing ignite discussions on implementing changes in nursing education necessary to change patient care outcomes.

In the forefront of transforming the paradigm of nursing education, the Quality and Safety Education for Nurses (QSEN) project defined the competencies for integrating a quality and safety framework for nursing (Cronenwett et al, 2007; Cronenwett et al, 2009). Funded by the Robert Wood Johnson Foundation (RWJF), QSEN identified the knowledge, skills and attitudes for the six competencies identified by the IOM: All health professionals must be able to deliver patient-centered care using teamwork and collaboration, within a framework of evidence-based practice, quality improvement, and safety using informatics.

As faculty integrated the knowledge, skills and attitudes that define these six competencies into curricula, it became clear that it is more than just what we teach, but also how we teach that creates the necessary changes in attitudes and behaviors. Lecture alone rarely achieves sustained changes in behavior and attitude. Furthermore, faculty grapple with content overload from explosions in knowledge and technology.

The recent Carnegie report on nursing (Benner, Sutphin, Leonard & Day, 2010)  called for an educational renaissance by infusing innovative approaches into nursing education that replace reliance on PowerPoint presentations focused on medical model disease taxonomies. What kind of educational models do we need to prepare learners who can help lead redesigned health care institutions focusing on new paradigms of quality and safety?

To change the outcomes of nursing practice, we must re-shape the educational process; continuing on the same path will continue to produce the same result. A focus only on rational science limits how illness impacts the human response and how this is enacted in the chaotic practice environment.

There are many questions that we must answer: How do learners make sense of content overload for application into patient-centered care? With one or two days of clinical learning per week, how do learners see the results of the care they deliver? How do they make sense of the contradictions evident in practice, between good care and compromised care, between conflicting ethical models and between the conflicts among diverse members of care delivery teams? 

Do nurse educators have preparation for integrating other forms of knowledge that derive from aesthetics, ethics, personal and other ways of knowing? How do these converge for making sense of practice and understanding the broad dimensions of humanness relevant to health? How do we prepare learners in making sense of practice and build resiliency to sustain them to balance the challenges in practice?

The QSEN Pilot School Learning Collaborative (Sherwood & Barnsteiner, 2012) revealed two gaps. First, faculty development is paramount to transform nursing education. Faculty were eager to implement the QSEN competencies but needed resources and support to help change the prevailing paradigms entrenched over the past 30 years.

A second lesson was that narrative pedagogy, particularly unfolding case studies, was an effective way to close the gap between the didactic classroom experience and clinical practice. Classrooms based on real-world clinical experiences used short theory bursts as the basis to examine unfolding case studies and simulated learning to stimulate learners’ clinical imaginations. Sharing the classroom with patients and families helps share stories that highlight the human response to illness and health.

Interactive strategies that help students understand the full scope of a case study encourage a spirit of inquiry to continually ask questions and to seek evidence-based best practices; to assess patient needs and preferences for patient-centered care; and to increase situational awareness of the potential for error. Reflective practice is the foundation for analyzing these real-world situations.

Reflective practice can help create a new learner-centered paradigm for nursing education. Reflection is a systematic way of thinking about one’s actions and responses to improve future actions and responses (Sherwood & Horton-Deutsch, 2012). It is a change process that incorporates experiential learning by considering what one knows, believes and values within the context of an event.

Tanner (2006) described a clinical judgment model in which learners integrate knowledge from the empirical sciences with knowledge from experience. Learners begin with noticing what is happening in a clinical situation, interpreting what it means, responding to the situation, and reflecting on how to improve. Clarity on how the learner is constantly analyzing what they see, hear, and know develops the practical tacit knowledge important in clinical judgment.

Reflective practice helps nurses cope with the emotional labor of nursing as they make sense of events; they can choose alternative actions in the future so they feel more effective and experience satisfaction. Our current nurse education system does not prepare nurses to cope with confusing workforce issues, increasingly complex patients, and the complicated context of health care that depletes energy and motivation.

Reflective practice as a habit of the mind can help change the nursing paradigm by helping develop professional maturity through the continued development of practice knowledge, constant quality improvement and attention to safety, and renewal of the human spirit.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey Bass.
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., Sullivan, D. T.,
Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55 (3), 122-131.
Cronenwett, L., Sherwood, G., Pohl, J, Barnsteiner, J., Moore, S., Taylor Sullivan, D., Ward, D. &
Warren, J. (2009). Quality and Safety Education for Advanced Practice Nursing Practice. Nursing Outlook. 57(6), 338-348.
Institute of Medicine. (2003). Greiner AC, Knebel E, eds: Health professions education. A bridge to quality, Washington, DC: National Academies Press.
Sherwood, G. & Barnsteiner, J. (Eds.), Quality and safety in nursing: A competency approach to improving outcomes. Hoboken, NJ: Wiley-Blackwell
Sherwood, G. & Horton-Deutsch, S. (Eds.) (2012). Reflective Practice: Transforming Education and Improving Outcomes. Indianapolis: Sigma Theta Tau Press.
Tanner, C. A. (2006). Thinking like a nurse: A research based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.