Effect of holistic reflective learning program on development of nursing students’ professional competency in geriatric clinical practice: a quasi-experimental study | BMC Medical Education

Effect of holistic reflective learning program on development of nursing students’ professional competency in geriatric clinical practice: a quasi-experimental study | BMC Medical Education

Study design & participants

This study was a quasi-experimental design with two groups, pre-test and post-test, conducted at two nursing schools under the Mashhad University of Medical Sciences in Iran in 2020. This University has four nursing and midwifery schools, and in this study, we focused on two of these nursing schools. Participants were recruited using probability-sampling methods of cluster random sampling. Nursing students were in their final year of education (internship stage), during which they completed their clinical rotations. The study took place between February and May 2020, and the students were enrolled at the university in the academic year 2019/ 2020 in professional practice for two BSN in MUMS, Iran. Inclusion criteria were students who had registered for a course, had no previous experience with reflective training, had a smartphone with internet access, and could attend a geriatric internship for four months. Exclusion criteria were failing to complete the professional holistic reflective learning program or being absent from more than one session. (Fig. 1).

Fig. 1
figure 1

Flow chart of data collection process

Sample size

The sample size was calculated based on a similar study by Liu et al. (2019) [20] on nursing education interventions, considering a power of 80%, a significance level of 0.05, and a moderate effect size. Using the G*Power software for sample size estimation, the required sample size was determined to be 160 participants, with 80 students in each group.

Research instruments and data collection

The study collected data through a two-section survey. The first section gathered respondents’ demographic information, such as gender, age, marital status, clinical experience, nursing interest, and GPA. The second section used the Geriatric Nursing-Specific Mini-CEX (GN-Specific Mini-Clinical Evaluation Exercise) to measure professional geriatric competency (PGC), a tool initially developed by Mohajer et al. (2022) [2]. The American Board of Internal Medicine (ABIM) first developed the Mini-CEX in 1972 [21], and Liu et al. (2019) later developed a specific nursing mini clinical evaluation exercise (Mini-CEX) for nursing students. Our study used a further adapted version specifically designed for assessing geriatric nursing competencies. The GN-Specific Mini-CEX consisted of 40 items with seven components: communication skills and history taking, physical examination skills, clinical judgment/nursing intervention, consultation/health education, nursing professionalism and organization/efficacy, and overall nursing geriatric competence. The questionnaire used a 9-point Likert scale (1–3: “unsatisfactory,” 4–6: “moderately satisfactory,” and 7–9: “satisfactory”), with a total score ranging from 40 to 360. Higher scores indicated higher PGC for nursing students. The validity and reliability of the tool were established in previous studies [20, 22, 23]. A pilot test using a test–retest design was conducted to assess consistency among 20 students using the Interclass Correlation Coefficient (ICC). The Cronbach’s alpha for the GN-Specific Mini-CEX in this study was 0.92, indicating high internal consistency and confirming the reliability of the instrument for measuring nursing students’ PGC [2].

Data collected in this study included both continuous and categorical variables. Continuous variables such as age and GPA were measured, while categorical variables included gender, marital status, and clinical experience.

Evaluation of clinical competencies

Students’ professional geriatric clinical skills were evaluated through geriatric case studies, direct observation by evaluators, and constructive feedback. For example, students were assessed through case studies that involved managing the care of elderly patients with multiple comorbidities, including dementia and diabetes, requiring them to demonstrate their clinical judgment, communication skills, and nursing interventions. The rating of clinical competencies was based on the GN-Specific Mini-CEX, ensuring a standardized approach to evaluating students’ interactions with elderly patients. Evaluators rated all competencies based on observed clinical practices for selected elderly patients in medical-surgical wards, providing a 15-min snapshot of student-geriatric patient interactions. Both groups completed the questionnaires at baseline, after the intervention, and four weeks post-intervention. Data collection was conducted by both participants and evaluators. Participants filled out self-assessment questionnaires, while evaluators gathered observational data using structured forms to assess participants’ clinical competencies. This dual approach ensured a comprehensive evaluation of the intervention’s effectiveness.

Designing the professional holistic reflective (PHR) learning intervention

The professional holistic reflective (PHR) learning program was a blended teaching–learning approach that incorporated learning theory and model domains. In this study,designing and implementation blended learning modalities for the intervention was underpinned by the “blending with purpose” The multimodal conceptual model by Picciano.(2017), which carefully separated face-to-face and online modalities while allowing for some overlap. The model contained six pedagogical goals and approaches forming learning modules: content, social/emotional, dialectic/questioning, reflection, collaborative learning, and senthesis/evaluation/assessing learning [24]. Reflective learning was based on the Holistic Reflection Model by Bass et al. (2017), consisting of six measurable domains for reflective writing: self-awareness, description, reflection, knowing, evaluation, and synthesis [16]. The components of program included lectures, group work sessions, clinical practice, case studies, reflective writing reports, student-led simulation seminars with debriefing, and online learning and discussions moderated by the researcher. Accordingly, this blended learning program had three online components, reflecting the domains of learning theories and models: asynchronous discussion groups; a teaching–learning environment facilitating social and emotional interactions with students, peers, and researcher presence to assess and feedback, and a professional portfolio facilitating personal and professional learning goal aspects. These blended components were employed during the four months of clinical geriatric practice in medical surgical wards, allowing nursing interns to develop their professional reflective portfolios and achieve professional competency skills (Fig. 2).

Fig. 2
figure 2

Blending with purpose: the multimodal model by Picciano (2017)

Implementation of the professional holistic reflective (PHR) learning intervention

The internship program lasted for four months, during which the students participated in six clinical shift per week, either in the morning or afternoon. Additionally, outside of these shifts, students engaged in online interactions as part of the blende holestic reflective learning program. It is important to note that participation in this intervention was entirely voluntary, and the program did not count towards the students’ academic evaluation or grades for the geriatric internship course. To enhance online interaction, students were divided into eight online groups based on different eight medical-surgical wards placment, where they shared and reflected on their blended learning experiences, fostering geriatric knowledge and attitudes. Both nursing students and mentors received reflective skills training to improve geriatric care. Clinical mentors attended a one-day workshop led by the researcher to familiarize themselves with reflective practice and lead students in enhancing geriatric nursing competencies. To minimize the risk of contamination between the intervention and control groups, students from each group were assigned to different clinical shifts and were guided by separate mentors throughout the study. Additionally, online interactions and group discussions for the intervention group were held in a controlled virtual environment, ensuring no overlap with the control group. The control group did not have access to the reflective learning program content during the study, which was made available to them only after the conclusion of the research.

The intervention program of blended PHR, was implemented in three stages: a)workshop, clinical practice, and follow-up, aimed to prepare students for clinical rotations in medical-surgical wards with a focus on older adult care.

Stage 1-professional holistic reflective (PHR) workshop

The F2F four-day holistic reflective learning workshop consisted of four modules: reflective portfolio learning, geriatric case study, reflective writing, and geriatric simulation seminar, and hands-on practice to orient them to professional holistic reflective learning concepts, including definition, benefits, techniques, and strategies of holistic reflection model. Then, students practiced reflective writing based on steps of HRM for samples of scenarios relevant to common geriatric issues and syndromes. At last, the researcher was given a lecture summary of about 15 min and closed the ceremony.The workshops were held twice a day for four days. The briefing notes and teaching contents remained available in the online groups for students.

Stage 2- professional holistic reflective (PHR) learning program in clinical practice

According to six pedagogical goals and approaches of the “blending with purpose” The multimodal conceptual model, modules activity of PHR intervention was implemented during the professional clinical practice for four months in geriatric setting of medical-surgical wards. Nursing internship students were required to simulate and practice the PHR modules and activities such as geriatric case study, reflective writing, and geriatric simulation seminar that would be performed during four months of internship course and developed their reflective portfolio under face-to-face supervision and guidance from their mentors. They received online teaching, activity assessment, and written feedback from the researcher. Clinical mentors were assigned to oversee the PHR learning for nursing interns during the course, in addition to fulfilling their usual student advising responsibilities. Geriatric case studies had chances to lead the student from a holistic perspective of the older patients’ needs of nursing; they could see clear benefits and were satisfied with the case study analyzing [2]. Creating and maintaining a reflective portfolio can also enable nursing students to identify their strengths and learning needs, and to improve a learning plan to address these requirements [25].

Based on the four months clinical program schedule, in the first month students were responsible for the care of their assigned older patients by performing two case studies and preparing two reflective case reports (one in group and one individually) per week to practice professional competency skills. Here the meanings of “reflection “include the reflection of learning in the practice and self-assessment of work performance. Nursing internship students performed two reflective writing based on steps of the Holistic Reflective Model (HRM), including self-awareness, description, reflection, knowing, evaluation, and synthesis [17]. Then, they shared their reports in the online group to and received feedback from the researcher. On the last day of this month, each group of nursing students implemented a reflective seminar and simulated geriatric patient scenarios under supervision of their mentors and received feedback from researcher. The HRM program was continued with duration of two month and nursing internship students implemented four individual sessions of PHR. Each reflective writing report based on HRM were posted to the discussion online group and were reviewed by the researcher after the students finished each section, and relevant feedback and responses were posted for the group. Then, researcher asked students to improve their reflective portfolio constantly and they reviewed their activities regularly with a serious consideration of the researcher feedback and submitted their revised reflective portfolio to the researcher (summative assessment). At the end of the third month, students worked on the posttest assessment section.

Stage 3-follow up

At the last month,students independently continued to utilize professional activities for duration of four weeks. Then, students completed all activities of the PHR program, revised, and compiled the reflective portfolio items. Finally, students developed their professional reflective portfolios and shared them in online groups (Supplementary file 1).

The control group students conducted traditional reflective logbook, while attending routine educational and clinical activities, about their experiences of the geriatric internship course learning process. They received online access to the PHR program content after the study.

Statistical analysis

Data were analyzed using SPSS V25. Descriptive statistics, Chi-Square tests, and Independent T-tests were employed to compare participant characteristics and study results between groups. Chi-Square tests were used to analyze categorical variables, such as gender and marital status, while Independent T-tests were used for comparing continuous variables, such as age and GPA, between the intervention and control groups. This combination allowed us to comprehensively assess differences across various types of data. Generalized Estimating Equations (GEE) were then used to investigate the influence of the Professional Holistic Reflective (PHR) program over time, considering both intervention and control groups, as well as time-group interactions. Significant pre-test discrepancies in professional competence (PC), its dimensions, and age were treated as covariates. The GEE analysis assessed variations in respondents’ professional skills competencies (PSC) and its dimensions, accounting for these covariates to determine group and time effects.

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