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Student Nurse and Reflective Health Promotion Learning in Hospital

Leena Liimatainen

Marita Poskiparta

Auli Sjögren

Department of Health Sciences
University of Jyväskylä, Finland

Paper Presented at the European Conference on Educational Research, Lahti, Finland 22 - 25 September 1999

Introduction and Purpose of the Study

Nurses have a key role in promoting health of the people they care for (Latter 1998a, Mc Donald 1998, WHO 1989). The competence of health care personnel is based on their education and the knowledge and skills it provides. Naidoo & Wills (1998, 3) argue that practitioners should be aware of the underpinning knowledge base of health promotion and the values implicit in the approach they adopt. Nurses have regarded communication skills and the quality of the nurse-patient relationship as the most significant contribution to health promotion. (Naidoo & Wills 1998) Latter (1998a, ii) proposes that nurses in health promotion should be at least able to understand the principles of ethical and effective health promoting interactions and to demonstrate a degree of competence in applying these in practice. It is time to shift from education about principles and concepts to assessment of competence and practices in the field of health promotion. Evidence based practice in health promotion (Tones 1997) challenges also nurses to illuminate and evaluate their health promotion work. However, very little evaluation research has been carried out in Finland to find out how the theoretical health promotion concepts and skills have transferred into practice. In contrast, several studies have explored Project 2000 education in the UK (Robinson & Hill 1995, Macleod Clark & Maben 1998, McDonald 1998, May & Veitch 1998).

In nursing education clinical training offers a possibility to integrate health promotion knowledge and development of a reflective practitioner. Naidoo & Wills (1998) propose that Schön´s (1983) concept of reflective practitioner and Kolb´s (1984) experiential learning are useful frameworks also in the field of health promotion in facilitating the development of a health promoter.

This study is part of a larger three-year follow-up research project "Health promotion teaching and learning in Finnish polytechnics" which aims at exploring the development of health promotional abilities and skills of nursing students, investigating the structures and contents of health promotion in multidisciplinary curricula of health care in Finnish polytechnics and developing pedagogical methods used in them. The aim of this study is to produce illuminating data about the knowledge base and factors affecting student nurses' decision-making in health promoting interaction situations during their clinical training in hospital in the second term of their nursing education. The data are collected using stimulated recall interviews with student nurses reflecting on their videotaped health promoting interaction situations according Johns´s (1994) model of structured reflection.

The Theoretical Basis of the Research

Empowerment Health Promotion in Hospital

Health promotion in hospital refers to engagement in 1. structural change, 2. health education and 3. health promoting interaction. In this study, the focus of health promotion is on health promoting interaction, which means any interaction with a patient carried out in a health promoting way, that is, promoting holism, equity, participation, collaboration, individualisation, negotiation, facilitation and support. (Latter 1998b) Nursing practice in hospital largely involves interactions with individuals and therefore an ability to understand and practise an empowerment approach is a necessity (Latter 1998a,b). Empowerment in health promotion can be defined as a process through which people gain greater control over decisions and actions affecting their health (Nutbeam 1998). Empowerment approach in health promotion has two elements: the facilitation of the process of individual growth and development and a commitment to challenge and combat injustice and oppression (Williams 1995). Empowerment health promotion practice in hospital requires a process that both attends to the principles and tenets of health promotion and incorporates patient empowerment as the underlying process of health promoting nursing practice (Latter 1998).

Reflection and Reflective Practice - The Central Components of Empowerment Health Promotion Learning in Clinical Training

Empowerment approach in health promotion has its roots in Freire's (1972) critical pedagogy, which places emphasis on problem posing and dialogue that is designed to promote critical reflection (Wallerstein & Burnstein 1988, Williams 1995). Kolb´s (1984) experiential learning model provides a framework consistent with empowerment, reflection and Freire´s ideas of learning. Reflection is also the cornerstone of uniting theory and practice in health promotion because the building together of the past and the present determine future health promotion actions (Naidoo & Wills 1998). Schön (1987) suggests that the constitutive components of reflective practice are reflection-in-action and reflection-on-action, in which students reflect on their own theories and actions in an attempt to make tacit theories explicit for critical examination and to integrate different sources of knowledge. (Hokanson Hawks 1992)

Johns´s (1994) model of structured reflection is one of the models developed for promoting learning through reflection (Plazer et al 1997). The model can be used to help the practitioners to see themselves in the context of their health promotion practice and to develop the essential skills and knowledge base, which characterise empowering health promotion. Originally Johns (1993) developed his model to help the practitioner to carry out therapeutic work and interventions beneficial to patients. Johns´s model evolves as a sequence through which student examines her experiences under guided supervision. The model consists of a series of questions covering four core areas. The core areas are (1) description of the experience, (2) reflection of what the student was trying to achieve and reasons for that as well as an explanation of the consequences of her actions, (3) influencing factors, for example, sources of knowledge and decision-making process and (4) learning, in which the student focuses on current emotions that relate to the experience. (Johns 1994) In the study reported here Johns´s model (1994) has been used as a framework to investigate health promotion learning as a dynamic, reflective process.

Significance of the Research in the Field of Vocational Education and Training

There has been relatively little research concerning health promotion education and professional development in health promotion (Rivers et al 1999). The reform of Finnish polytechnics has brought about changes also in health promotion teaching. It is important to explore what kind of health promoters polytechnics educate.

The integration of theory and practice has been a problem in health promotion and nursing education. This study design provides information on how student nurses use their knowledge and skills when practising health promotion in real working contexts. The study design is relevant to the recommendations made based on the review of the studies exploring professional development in health promotion. Three key points were identified: (1) the importance of conceptual development and the capacity to reflect critically on practice, (2) coherent integration of theory and practice using more often work based systems of professional development and (3) the need to specify more clearly the health promotional role of health professionals so as to facilitate the development of appropriate methods for initial and continuing education (Rivers et al. 1999)

Procedures and Methods

The aim of this study is to produce illuminating data about the knowledge base and factors affecting health promoting interaction situations between student nurses and patients during students' clinical training in hospital in the second term of their nursing education. The study group consisted of 20 voluntary second-year nursing students from two Finnish polytechnics and their voluntary patients during their training. Twelve students had a professional diploma in health care, while eight of the students were high school graduates. All students were women, while eleven of the patients were women and nine were men. The ages of the students were between 18 and 23 years. Patients' ages ranged from 26 to 90 years.

The data were collected in spring 1998 using stimulated recall interviews, in which student nurses reflected on their videotaped health promoting interaction situations with patients according Johns´s (1994) model of structured reflection. The stimulus for the interviews was provided by videotaping health promoting interaction situations between patients and student nurses in geriatric, rehabilitation, medical and surgical wards in three different hospitals in Finland. The situations were very different including counselling/conversation situations (7) and nursing interventions (13). The student nurses selected the situations to be videotaped. Johns´s (1994) model of structured reflection was adapted to investigate the factors affecting health promoting interaction situations and used as a framework to analyse the data. The stimulated recall method was chosen because it enabled us to capture health promoting interaction situations and student nurses' reflection from a naturalistic viewpoint in a real, complex and entangled environment.

The stimulated recall sessions took place as soon as possible after the videotaping. The audiotaped interviews were transcribed verbatim into computer text files. The data were examined using content analysis and categorisation approach for meaning generation (Kvale 1996, 196-199). Each transcript was examined and meaning units were identified. A meaning unit was defined as "a discrete phrase, sentence or series of sentences, which covers one perception". These meaning units were then divided into appropriate data categories.

Findings and Conclusions

Factors Influencing Student Nurses' Decision-Making and Health Promoting Interaction Situations

Five categories of knowledge influencing students' health promoting interaction situations were identified in this study: 1. Previous experience 2. Knowledge from school 3. Knowledge from practice 4. Patient 5. Critical thinking

1 Previous Experience

Every other student had previous experience of health promotion practice and patients, while for the rest of the students the situation was new. Students with earlier experience had a professional diploma when entering the polytechnic. It was possible to find four essential elements in students' actions in health promoting interaction situations that were based on their experience. The key elements influencing health promoting interaction were: (1) the role of the student, (2) the role of the student's learning objectives in the situation, (3) the rules the student nurse follows in the situation and (4) the focus of reflection (table 1).

Table 1

Student nurses (1-20) and the key elements connecting decision-making and health promoting interaction based on students' experience

Key element Students (n=12) with earlier experience (diploma in health care no 1, 2, 3, 5, 6, 10, 13, 14, 17, 18, 19, 20) Students (n=8) with no experience (high school graduate no 4, 7, 8, 9, 11, 12, 15, 16)
The role of the student

Student in expert role (routine situation)


18, 5, 2, 6, 17 ,19, 14, 20, 13, 10


7, 16, 11, 12

Student as an equal participant

1, 3 9, 8, 4, 15
The role of learning objectives in health promotion practice

Student deepens her own learning objectives while promoting patient's health




4, 8

Student's learning objectives come first, patient's needs come second

10, 20 11, 16
Rules for the practice

Student and patient come to an agreement and work together according to it


17, 2, 18, 5, 1


4, 8, 9

Student follows the rules of the ward

20, 6, 13, 14, 10 16, 7, 12
The focus of reflection

Student reflects on her earlier health promotion practice in relation to current practice


1, 2, 3, 18, 14,


Student reflects on the practice in current health promotion situation

10, 5 16, 9, 8

Student reflects on the health promotion situation with the patient. Student is involved in the patient-listening-dialogue, common decision-common action

6 4

2 Knowledge From School

Hislop et al. (1996) have studied the relationship between Project 2000 college course and students' experiences during their clinical placements. They found out that it is difficult for students to integrate the broader aspects of college courses with their practice; theory loses meaning out of context. Moreover, Schön (1983) has argued that practitioners have difficulty in applying knowledge without the context of actual practice. The difficulty to transfer and use the knowledge taught in school was identified also in the present study. One of the students (Student 7) had a counselling situation concerning medication in the geriatric ward. In the interview she talked about having a patient education course few months ago but not remembering issues from the course that would have helped her in practice. The issues taught in school that the students found useful in practice included taking care of patients' needs and carrying out basic nursing interventions aseptically. Only one student mentioned the teacher and wished to see her more in the ward.

3 Knowledge From Practice

The students had mentor nurses during their clinical placements. The role of the mentor varied. Some students experienced that the nurses played a crucial part in their clinical health promotion learning. These nurses had counselled, supported and let the students act independently but controlled with the patients (Student 8). In contrast, some students said that the role of their mentors had not been significant in their health promotion learning. The model and the rules of the wards were important to these students (Table 1). A student training in the surgical ward talked about how she made her decision in the videotaped situation:

"Well, actually I did it the way they usually do it here, I had observed how they tend the wounds here. And I asked the nurse beforehand, I asked what they put in these. That is, I did it the way she told me to do it and then I looked at the wound to find out what it needs and how much it bleeds and if it bleeds." (Student 13) The student did not think that the patient had taken part in the decision-making.

There were also other professionals, especially physiotherapists, who helped students to promote patients' health. The different placements had influenced students' decisions to promote the patients' health differently. For example, students training in a rehabilitation hospital said that the atmosphere, the nursing philosophy and the role modelling of the staff gave them ideas and models for health promotion practice.

4 Patient

Patients influenced students' decisions and actions in two ways: guiding the health promotion situation by moving on and talking a lot. In the interview many students were surprised by the amount of the patient's talk in the video. Some students considered it disturbing and said that it interfered with the counselling. Students working with older people described how important it was to the patients to talk to somebody and how lonely they were. Nevertheless, students felt guilty if they were just talking with the patient because talking was not considered real nursing in the wards. This became obvious when students were choosing the health promotion situation for the interview: " I think it would have been silly if we had just read some paper together, I wanted the situation be of some real benefit" (Student 5). The health promotion situation in question was a physical exercise focusing especially on the patient's hands. In general, students connected concrete benefits to patients with their physical health. This happened also when a student described a situation in which her patient talked about loneliness and said that: "he has been locked up in this room forever". The patient's personality, knowledge, initiative and character influenced especially the actions and decisions of students training with older people. This presupposes that students know their patients and have a confidential relationship with them (Students 1, 9, 8).

5 Critical Thinking

In this study critical thinking is understood as part of a decision-making process, in which the student rationally explores and evaluates ideas, conclusions, principles, beliefs and actions during her clinical training (Bandman & Bandman 1988). Some students (1, 8, 17) criticised the implementation of the principles of nursing and health promotion in practice, the fact that the staff concentrated on patients' physical health at the expense of their social and emotional health and the lack of time and recourses during their placements. These students identified defects in health promotion as well as produced ideas how to change health promotion practice in the wards and tried to act differently. However, it was difficult for student nurses to change things in the wards. Students said that it was easy to disregard the patients' ability to manage on their own by doing things for them. Often patients were put in a passive role of a recipient. (Students 4, 1, 8)

Implications and Recommendations

The early results represent a challenge concerning empowerment health promotion learning and teaching in clinical training. The experiences and perceptions of students form the basis of reflective health promotion learning and teaching. Especially the role of the student nurse, the learning objectives, the rules in the health promotion situation and the focus of reflection were important elements leading health promoting interaction situations to the direction of empowerment approach or traditional approach. In addition to Johns´s model, these key elements can be used as a basis for reflection in clinical teaching. Hidden curriculum, health promotion as well as nursing philosophy and role modelling in wards are yet another important features in facilitating or constraining the learning of empowerment approach in hospital. Nursing students should be encouraged to critical thinking and reflection during their training to identify the values and practices taken for granted in wards. They should be able to act as new role models of empowerment health promotion. This paper presents some early results of the three-year follow up study. Reflective learning and students' levels of reflection will be explored more specifically in the next phase of the project.


Bandman , E. & Bandman, B. 1988. Critical thinking in nursing. Connecticut: Appleton & Lange.

Freire, P. 1972. Pedagogy of the oppressed. England: Clays Ltd, St Ives plc.

Hislop, S., Inglis B., Cope P., Stoddart B. & Mcintosh C. 1996. Situating theory in practice: student views of theory-practice in Project 2000 nursing programme. Journal of advanced nursing 23, 171-177.

Hokanson Hawks , J.1992. Empowerment in nursing education: concept analysis and application to philosophy, learning and instruction. Journal of advanced nursing 17, 609-618.

Johns, C. 1995.The value of reflective practice for nursing. Journal of clinical nursing 4, 23-30.

Johns, C. 1994. Guided reflection. In A. Palmer & S. Burns & C. Bulman (ed.)Reflective practice in Nursing. The growth of the Professional practitioner. Blackwell Science Ltd. Cornwall. 110-130.

Kolb, D. 1984. Experimental learning. New Jersey: Englewood Cliffs.

Kvale, S. 1996. InterViews. An introduction to qualitative research interviewing. USA: Sage Publications, Inc.

Latter, S. 1998a. Nursing, health education and health promotion: lessons learned, progress made and challenges ahead. Health education research 13 (2), i-v.

Latter S. 1998b. Health promotion in the acute setting: the case empowering nurses. In Kendall S. (ed.) Health and empowerment, 11-37. London: Arnold.

Macleod Clark J, Maben J. Health promotion: perceptions of Project 2000 educated nurses. Health Education Research 1998: 13: 185-196.

May, N & Veitch, L 1998.Working to learn and learning to work: Placement experience of project 2000 nursing students in Scotland. Nurse education today 18, 630-636.

McDonald E. 1998. The role of Project 2000 educated nurses in health promotion within the hospital setting. Nurse education today 18 (3), 213-220.

Naidoo J, Wills J.1998. Practising Health Promotion. Dilemmas and Challenges. London Baillie`re: Tindall,

Nutbeam, D. 1998. Health Promotion Glossary. Health promotion international 13 (4), 349-364.

Plazer, H., Snelling, J. & Blake D. 1997. Promoting reflective practitioners in nursing: a review of theoretical models and research into the use of diaries and journals to facilitate reflection. Teaching in higher education 2 (2), 103-121.

Rivers, K., Aggleton, P. & Whitty, G. 1999. Professional preparation and development for health promotion: a review of literature. Health education journal 57, 254-262.

Robinson S, Hill Y. 1995. Miracles take little longer: Project 2000 and the health-promoting nurse. International Journal Nursing Studies 6, 568-579.

Schön D., A.1983. The Reflective Practitioner. London: Temple Smith.

ShieldsL.E. & Lindsey A. E. 1998. Community health promotion nursing practice. Adv Nurs Sci 20 (4), 23-36.

Tones, K. 1998. Beyond the randomized controlled trial: a case for ‘judicial’ review. Health Education research 12 (2), i-iv.

Wallace C. & Appleton C. 1995. Nursing as the promoter of wellbeing: the client´s experience. Journal of advanced nursing 22, 285-289.

Wallerstein N, Bernstein E. 1988. Empowerment education: Freire´s ideas adapted to health education. Health education quarterly 4: 379-394.

WHO 1989. Nursing Leadership for health for all. Geneva: WHO.

Williams J. 1995. Education for empowerment: implications for professional development and training in health promotion. Health education journal 54: 37-47.

This document was added to the Education-line database 23 September 1999