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NurseEd~rnkm T J (1994) 14,363-3710 Longman Group Ltd 1994

The Clinical Learning Spiral: a model to developreflective practitionersLynette Stockhausen

Reflective practice in clinical nursing is an exciting concept. Much of the literatureon reflection has been derived from education. Recently the Australasian NurseRegistering Authority Committee (ANRAC) endorsed reflective practice as aregistering prerequisite competency for beginning nurse practitioners. This paperexamines the concept and development of an action research clinical learning spiralto foster reflective practice of both undergraduate students and their clinical teacherin the practice setting. The innovation of a mutual group, that is, teacher andstudents interacting through reflection to create a cooperative learningenvironment is explored. In designing the spiral a number of models were consultedand incorporated.

The action research clinical learning spiral adds structure and focus to the processof reflection-on-action and provides an avenue for students and the clinical teacherto set mutual goals of action to trial for future experiences. This process of reflectionallows the clinical facilitator to be an integral component of success to the studentslearning in the clinical context.

REFLECTIVE PR CTICEReflective practice in nursing is an exciting con-cept. Although practised by nurses for manyyears, only recently has available literature regard-ing reflective practice in nursing emerged(Garrett 1991, Jarvis 1992). However, the conceptof reflection is not new. Philosophers, education-alists and practitioners have been developingviews of reflection since Aristotle first introducedpractical judgement and moral action (McKeonLynette Stockhausen RN DipTeach-Nsg BEd-NsgMEdSt, Senior Lecturer, School of Nursing, GriffithUniversity-Nathan Campus, Kessels Road, Nathan,Brisbane, Australia 4111Requests for offprints to LS)Manuscr ip t acc epted 9 February 994

1974). Since then much has been written andresearched regarding reflection. Some of the sig-nificant contributors to this school of thoughtinclude Dewey (1933), Kolb and Fry (1975))Kemmis (1985), Boud, Keogh and Walker (1985))Zeichner (1983), Schon (1983) and Benner(1984).

The process of reflection is an integral factor inthe organisation of our daily activities. From thefirst time we look in the mirror, to when we retireat night, we replay on our minds the days events,often analysing them and reexamining what hasoccurred in our lives. Boud et al (1985) note thatreflection comprises of those intellectual andaffective activities in which individuals engage toexplore their experiences in order to lead to newunderstandings and appreciation. Their defini-tion implies that reflection is goal orientated and

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364 NURSE EDUC TION TOD Ythat feelings and cognitive abilities are interwo-ven. The underlying assumptions being that indi-viduals are in control of the activity, that reflec-tion can take place in isolation or in associationwith others, such as peers or the clinical teacher,and finally that reflection is not an end in itself,but, preparation for new experiences.

Learning through practice and reflective pro-cesses have been expounded by Kolb (1984)within the terms of his experiential learning the-ory. The theory suggests that learning, changeand growth are facilitated by cyclic processes.Such experiences involve direct experiences,reflection on the experience, and abstract con-cept formation from which behaviour may bemodified to aid new experiences. Similarly, reflec-tion has been viewed as the link between theoryand practice (Schon 1987).

Reflection as perceived in this context suggeststhat learning is facilitated by early active engage-ment in practice. Without reflection, experienceswould remain unexamined, with the full potentialfor learning by the participants not fully realised.Within the education literature on reflective prac-tice there is a dimension of an elusiveness tolearning that is persona , developmental andembedded in the experience of the learner(Boud 1988). In order to actualise these learningepisodes the role of the clinical teacher becomesan integral part of the reflective process. As such,the clinical teacher, rather than being external tothe process of learning, is an essential and strate-gic component to that learning. The clinicalteacher has the opportunity to become capturedin the developmental and cyclic nature of thetotal experience, facilitating, not controlling, theclinical experience.

FR MEWORK FOR REFLECTIVEPR CTICEReflection has been identified as a prerequisitecompetency for beginning nurse practitioners inAustralia (ANRAC 1990). In order to facilitate stu-dents achievement of this competency, a frame-work to encourage reflection within nursing cur-ricula was reauired. As such. the Clinical

Learning Spiral (Stockhausen 1991) was devel-oped for the purpose of incorporating and devel-oping reflective processes in undergraduate nurs-ing clinical practice. The spiral has been trialedsuccessfully with a cohort of second year studentsand their clinical teachers in a Bachelor ofNursing programme.

The framework of the spiral incorporates thetheoretical elements of clinical education andstructures the management of the clinical experi-ence. Inherent within this framework are thoseelements necessary to successfully prepare,induct, implement and evaluate reflective clinicalpractice experiences.

The Clinical Learning Spiral was developedutilising other models of experiential learningwith particular reference to the Action ResearchCycle (Carr & Kemmis 1986), the ReflectiveProcess Model (Boud 1985) and the CriticalExperiential Learning Model (Chuaprapaisilp1989). Each of these models when integrated pro-vides a framework that incorporates all aspects ofundergraduate clinical experiences. It was feltthat no one model alone consolidated features ofclinical experiences that captures the balance,transference and significance of theory and prac-tice and is uniquely nursing orientated.

An overview of the development of the ClinicalLearning Spiral with reference to the previousmodels are contained in the following discussion.

The Action Research Model (Carr & Kemmis1986) has four cyclic phases of planning, acting,observing and reflecting. These four phases arelinked into a cycle that recreates itself into a selfreflective spiral (Figs 1 8c 2). In this sense no com-ponent of the model can be conducted indepen-dently of the other. The Carr and Kemmis modelpremises that a group and its members, collec-tively and collaboratively undertake the fourphases of the cycle. Practice is viewed within apolitical, economic, historical and social context.From this perspective, examination and reflectionof practice leads to a new social consciousness andchange. Bartlett (1990) suggests that actions areintentional and are to be understood in the socialcontext of their occurrence. As such, delibera-tion and analysis of ideas about nursing as aform of action, based on our changed under-standing, is highlighted.

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NURSE EDUC TION TOD Y 365

Constructive Phase

Reflective Phase

ReconstructivePhase II

Fig 1 The Clinical Learning Spiral

The process of reflective learning as postulatedby Boud et al (1985) involves three stages that areinter-related and cyclic in nature. Following aninitial experience the first stage of the reflectiveprocess is returning to the experience. Here stu-dents recollect the events that have occurred andreexamine their reactions to those events. Thechronological sequence of events is recalled in adescriptive rather than judgemental manner. Thesecond stage is attending to feelings, whichallows for emotions to be identified, examinedand challenged. The focus on feelings heightensthe learners self awareness and enables them toenhance and retain positive emotions and discard

negative feelings. The final phase is that of pro-cessing, where the events that occurred duringthe experiential phase are reconstructed by thelearner in order to make sense of them. Thisphase requires indepth reflection and introspec-tion.

As the learner processes their experiences,Boud et al (1985) suggest that a reevaluationoccurs. During this activity students link new datato what is already known (association), seek rela-tionships amongst this data (integration), deter-mine the authenticity of ideas and feelings (vali-dation) and create a personal understanding orknowledge about the event (appropriation).

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366 NURSE EDUC TION TOD YCONSTRUCTIVE PHASE

the parameters of the

Fig. 2 The Clinical Learning Cycle

Through the use of the Reflective Process Modelstudents are able to actively construct and arrangetheir knowledge of the world thus developingtheir own interpretational schema.The Critical Experiential Learning Model(Chuaprapaisilp 1989) uses elements of the Carrand Kemmis model. It was developed specificallyas a framework for learning from clinical experi-ences in nursing. Chuaprapaisilps model hasthree phases: preparation for practice, managingthe experiential learning process and reflectingon the experience.

During the first phase, students undertake sev-eral preparatory activities. This may include ori-

entation to the clinical environment and thedelineation of structures and procedures (devel-opment of personal learning objectives andundertaking client assessments) at the com-mencement of the experience.

The second phase involves the facilitation ofthe learning experience. There are five strategiesin this phase which provide a plan to the total pro-cess. These are: structuring, organising, control-ling, facilitating and emancipating. In the struc-turing phase of the clinical experience, theclinical teacher assesses the clinical environmentand then facilitates activities within a set timeframe. The second strategy of organising involves

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NURSE EDUC TION TOD Y 367

prioritising activities in order that studentsreceive adequate supervision in meeting theirobjectives. The clinical teacher and students alsodecide at this stage the format of debriefing ses-sions.

During the subsequent facilitating stage theclinical teacher provides ongoing individual con-sultation and explores avenues to provide success-ful clinical experiences for the student. The facili-tation of student learning requires clinicalteachers to control their own teaching within a settime frame. In this sense the clinical teacher doesnot provide all the answers for the students.Instead teaching strategies which foster self-directed learning and critical analysis of issues isencouraged, such as student learning contracts.The final strategy is emancipation which encour-ages students to challenge approaches to nursingcare and make decisions for change.

The final phase of reflection, as outlined byChuaprapaisilp, is similar to the Boud et al (1985)model but with the inclusion and introduction of acritical theory approach to experiential learning.In this phase the clinical teacher attempts tocreate a democratic atmosphere where, together,students and clinical teacher, clarify objectives,structures, processes, roles and assumptions duringdebriefing sessions.

THE CLINICAL LEARNING SPIRALThe Clinical Learning Spiral (Fig. l), developedby the author (1991)) draws on the previously dis-cussed models and personal reflective experienceas a clinical teacher. The model was developed toemphasis the importance of reflective practice tothe professional growth of a beginning nursepractitioner. The integration of Carr andKemmis, Chuaprapaisilp and Boud et als key con-cepts provides a model that is clinically and goalorientated. This acknowledges practice by the selfand others as a central tenet of professional edu-cation for nurses.

The Clinical Learning Spiral detail (Fig. 2) isrepresented by the preparative, constructive,reflective and reconstructive phases.

The Preparative Phase begins as the individualconsiders the demands of the experience ahead,the resources required, the environment (sight,sounds, smells), the people (roles, relations, reac-tions and conflicts), the climate (social, political)and their role as learners in the clinical setting(reflector, participant, observer, facilitator)(Emden 1991).

There are two components to the preparativephase. The first is related to on campus classroomteaching and university laboratory sessions. Thisincorporates the development and exploration ofnursing skills within a controlled learning envi-ronment. The second component is the briefingsession which is conducted before the commence-ment of a clinical experience or day. This firstphase assists the teacher of the clinical experienceand the students to establish the parameters ofthe experience. During the briefing students aregiven the opportunity to identify personal andprofessional objectives to achieve during the clini-cal experience. At this time the clinical teacherfosters a climate for the students to achieve theirobjectives and may explore possibilities for creat-ing new learning opportunities.

The Preparative Phase allows the students toidentify other resources (such as specific clientneeds or specialist departments) within the clini-cal environment that would create learningopportunities. The benefits of student initiatedpersonal objectives highlights the students ownlearning needs and creates motivation to learn.The Preparative Phase can also be conducted on aone-to-one basis between students and the clinicalteacher. Students have identified that this processof individual negotiation has been beneficial inproviding them with the opportunity to set per-sonal goals for their experience and plan the carefor their clients (Stockhausen 1991).

Each phase throughout the spiral is facilitatedby journal writing which has been identified asthe most widely used expression of reflection(Zeichner 1986). Students and clinical teachersare encouraged to write about events of signifi-cance which occur whilst undertaking clinicalexperiences.

The Constructive Phase allows students toundertake actual nursing skill development. Thissecond phase incorporates the experience or

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368 NURSE EDUC TION TOD Yactual practice of nursing which takes place dur-ing the practicum. The clinical experience isviewed from a perspective of completeness(beginning, middle and end). Observation of thestudents during this phase is crucial as reflectionsbetween the observer and the observed canheighten the experience and reveal different per-spectives of the same experience.

The Constructive Phase is the actual experiencethe students and the teacher share in the clinicalenvironment. This phase takes into considerationthe dimensions of practice such as care planning,psychomotor skills, attitude and interpersonalcommunication development and evaluation ofcare. The establishment and maintenance of rela-tionships, especially with the client and staff of theagency, is also highlighted within this phase.The third phase of the clinical spiral is theReflective Phase. Time is allocated for purposefulinquiry so students can deliberate on aspects oftheir development as a nurse. Consideration isgiven to others involved in the students practicesuch as the patient, peers, registered nurses, theclinical teacher and other health care professionals.

The reflective phase is facilitated by a debrief-ing process. This allows the students the opportu-nity to return to the experiences of theConstructive Phase and highlight significantexemplars and events from the day. Debriefingmay occur at intervals throughout the day, butalways at the end of a clinical day or experience.

The reflective phase can be initiated at anytimeon a one-to-one basis between a student and clini-cal teacher, peer or registered nurse. It is particu-larly important to provide a reflective phase forconstructive feedback to students following someaspect of their nursing practice development.This may be, for example, a psychomotor skill,interpersonal interaction or professional enquiry.Later, during the group reflective phase, studentshave the opportunity to share personal reflectionsfrom their previous one-toone reflection or shareextracts from their journals. During the groupreflective phase the rest of the group share theirexperiences. The students sense of excitement,anxiety and relief, or how the patient felt orresponded is explored. Horsfall (1990) notes thatas students share each others challenges,achievements and experience it is possible that

vicarious learning takes place. This phase also setsthe scene to examine complexities, differencesand subtleties not found in text books but learnt,or made explicit, as a direct result of being submerged in the experience.

The learning processes espoused by Boud et al(1985) identify the importance of allocating timeduring which students can share feelings,thoughts and perceptions of their experiences. Inthis forum, students have the opportunity toexchange ideas, consider other points of view,draw conclusions and make comparisons fromtheir clinical experiences. As a consequence ofthis planned reflection students arrive at a deeperand more meaningful understanding of the prac-tice of nursing.

The final stage of the Clinical Learning Spiralinvolves the reconstruction of the learning experi-ence. The Reconstructive Phase provides the stu-dents and the clinical teacher the opportunity toplan for change. The change may be in the formof alternate nursing strategies/interventions inpatient care, or changes in behaviour that fosterinterpersonal relationships or personal and pro-fessional development. There is a commitment toaction as a result of the constructive and reflectivephases. This is akin to the Action Research Cycle(Carr & Kemmis 1986) _Reevaluation of the expe-rience helps expand views and develop strategiesfor future action (Boud 1988).

The Reconstructive Phase ideally develops intoa set of negotiated, mutual goals set by the groupas a consequence of reflections on experiences,journal entries and discussions during debrief-ings. Hedin (1989) notes that at the heart of clini-cal practice is the development of meaning to thelearner and the avoidance of imposing an othermeaning on the learner. It is the participants ofthe clinical experience who decide if reflectionsdevelop into action. Not every day will produce anew action as some reflections will not lead to anynew consequences. Mutual goals are recon-structed from the constructive and reflectivephases of the clinical learning spiral, as a directresult of practice. The intention is to make modi-fications to, or develop goals that can be actedupon. It is imperative that a commitment toaction as a consequence of reflection is realised.For action to occur without reflection leads to

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NURSE EDUC TION TOD Y 369uninformed, unintentional behaviour. Reflectionprior to and subsequent to action can ensuremutual goals are carried forward to the next situa-tion or spiral.

THE CLINICAL LEARNING SPIRALIN ACTIONUsing the Clinical Learning Spiral has providedstructure to promote and develop reflective prac-titioners, enabling the ANRAC competencieswithin the reflective practice domain to beachieved. With active participation in all phases ofthe spiral students have begun to develop the artof reflection. Through self expression using jour-nal writing and involvement in debriefing sessionsstudents have had the opportunity to examinetheir practice, feelings and beliefs, and the conse-quences of these for patient care. This has beenachieved through active participation in allaspects of the spiral. Students and the clinicalteacher reflect on what is important to them andthen contribute towards the maintenance of asupportive group as they pursue mutual goals ofclinical practice.

The phases of the spiral and the processesinvolved are highlighted by using an examplefrom previous research, by the author, for whichthe spiral was developed.

SpiralPreparative haseDuring the briefing students identify their anxi-eties at being accepted by the staff f the organisa-tion. Some students have used their journals towrite about their impending experience. Studentsalso explore strategies to overcome their fears. Tohelp establish the parameters of the experienceand rapport with the organisation and ward staff,as clinical teacher, I undertook the hospitalsorientation programme and introduced myself tothe ward staff prior to the students first day.onstructivephase

A number of registered nurses are asked either bythe charge nurses or myself (the clinical teacher)to assist students with their learning goals.

Students, registered nurses and clinical teacherinteract throughout the day.

Reflective phaseStudents record in their journals learning inci-dents related to interactions and establishinginterpersonal relationships with the registerednurses. Some of these reflections are shared withthe group at debriefing, I found the staffextremely friendly. As the students clinicalteacher I also wrote and shared my experienceswith the students as I had received positive feed-back from the staff regarding the students cour-tesy and attentive patient care. During debriefingthe students were aware that their fears regardingthe staff had been unfounded.

ReconstructivephaseThe students and clinical teacher decide to set agoal to: Maintain and foster the collegial rela-tionships established on the first day.

Spiral 2Preparative haseThe students discuss the implications of the previ-ous set goal to their nursing practice develop-ment. Students write and discuss their expectedinteractions with registered nurse. Objectives forthe day are identified that incorporate theseideas.

Construction phasesStudents and registered nurses interact through-out the day providing patient care and fosteringstudent skill development.

Reflective phaseI found my RN willing to help me, show meprocedures, The Registered Nurse was receptiveand open to my questions and The RN took thetime to explain the procedure to me. These weresome of the journal or spoken comments of thereflective phase. Students discussed the signifi-cant impact the Registered Nurse, as a rolemodel, made to a perceived positive or negativeclinical experience.

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370 NURSE EDUCATION TODAYReconstructivephase catalyst for their next learning experience. TheStudents and clinical teacher examine the impli- spiral is dynamic and flexible. It is not meant to becations of their debriefing and aim to: Respect static or followed strictly from one step to thethe Registered Nurses knowledge and input into next. There is no limit to the number of spiralsthe clinical experience. Action from this goal was that can occur. Reflection and reconstructionrecorded as: provide feedback to the Registered may occur between a student and clinical teacherNurses for their invaluable input into student throughout the experience and may only take alearning.

Whilst the process did not finish after the sec-ond spiral it is evident from the example providedthat the Spiral is a worthwhile framework to beutilised in the clinical education. It provides thestudents with evidence of the significance of theirlived experience. If students had only beeninformed about the contribution the RegisteredNurse can make to clinical practice this may nothave meant as much to the students as actuallybeing immersed in the context. Students experi-enced first hand that the Reeistered Nurse can

matter of minutes.Developing reflective practitioners becomes an

avenue to generate explanations of practice situa-tions and build upon practice knowledge.Aligning and complementing student and clinicalteachers reflections on clinical experiences hasthe potential to provide more meaningful learn-ing for students and rewarding teaching experi-ences in the practicum.

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