Nursing education, transformative learning, and critical reflection: A cognitive behavioural approach.

Background: Despite evidence indicating the benefits of transformative learning theory (TLT) for nursing education, its full potential remains untapped. Central to TLT is the concept of critical reflection, the process of actively analysing one's experiences, actions, and beliefs in a systematic and critical manner. In nursing education and practice, critical reflection holds a widely accepted role. Therefore, it is essential that the reflective models utilised, adequately facilitate critical reflection. Psychological therapists specialising in cognitive behavioural therapy, commonly employ cognitive behavioural approaches to critical reflection. Therapists have found the integration of cognitive-behavioural principles with reflective practice to be a highly effective approach. However, these approaches are not commonly used in nursing education. Hence, research is required to explore if a cognitive behavioural approach could improve the transformative potential of critical reflection in nursing education. 

Aims: This study had two primary objectives, each serving to explore a cognitive behavioural approach's effectiveness and its transformative potential in nursing education. Firstly, the study sought to assess the effectiveness of using a cognitive behavioural model for reflection by comparing it to a commonly used reflective model. Secondly, the study aimed to investigate if a cognitive behavioural approach could promote transformative learning. The overarching goal was to explore the potential of a cognitive-behavioural approach to facilitate meaningful personal and professional growth in nursing students, ultimately contributing to the advancement of nursing education and practice. 

Methods: A quasi-experimental mixed methods design was utilised. The quantitative aspect of the study involved a repeated measures survey using the Self Reflection and Insight Scale (SRIS) at three distinct time points: baseline, during, and post-intervention. This was done to assess and compare the effectiveness of the cognitive behavioural approach with a commonly employed model of reflection. It was also conducted to determine the appropriateness of the approach for its intended purpose. The qualitative component of this mixed methods study adopted a grounded theory approach to gain a deeper insight into the practical application of the model by the students. In this component of the research, students’ texts were analysed to ascertain whether transformation had been achieved. 

Results: The quantitative measures demonstrated significant improvement in reflective insight among those utilising the cognitive behavioural approach. The baseline response rate was 88.5% (n=139) for participants using the cognitive behavioural approach and 93% (n=169) for the control group, with attrition rates of 24% (n=106) and 27% (n=122) across the surveys, respectively. Linear mixed-effects models were utilised to examine the relationships between three interdependent variables, namely 'Insight,' 'Engage,' and 'Need,' as measured by the Self Reflection and Insight Scale (SRIS). Significance in scores for all independent variables between the baseline and the follow-up assessments favoured the cognitive behavioural approach and showed a marked increase in 'Insight.' Specifically, the measure of reflective insight exhibited a substantial increase of 5.54 units between baseline and follow-up with a highly significant p-value (p < 0.001). A qualitative analysis of nursing students' reflections during their clinical practicum indicated that the cognitive behavioural model enabled students to accurately identify their internal (psychological) responses and the interrelated influences on their practice. Qualitative analysis also suggested that students used the model as a heuristic framework to provide structure and meaning to reflection, rather than a rigid algorithmic process leading to a predetermined conclusion. Ultimately, the qualitative findings demonstrated that reflective practice using the cognitive behavioural model facilitated transformative learning. 

Conclusions: The introduction of a cognitive behavioural approach to reflection facilitated a transformative learning experience for undergraduate nursing students, incorporating various key elements identified by Mezirow (1997) as central to transformative learning theory. These elements include heightened self-awareness, improved emotional regulation, enhanced problem-solving skills, and the ability to consider diverse perspectives. The findings from this study reinforce the value of a cognitive behavioural approach as a catalyst for personal growth and transformative learning, offering students a pathway to deeper self-understanding and a more nuanced perspective on their experiences. Essentially, the study's results underscore the potential of a cognitive-behavioural approach to significantly enhance critical reflection in nursing students.