Enhancing reflective practice through online learning: impact on clinical practice
Medical Radiations, School of Medical Sciences, RMIT University, Victoria, Australia
Purpose: Traditionally, radiographers and radiation
therapists function in a workplace environment that is protocol-driven with
limited functional autonomy. The workplace promotes a culture of conformity and
discourages practitioners from reflective and critical thinking, essential
attributes for continuing learning and advancing workplace practices. As part
of the first author�s doctoral study, a continuing professional development
(CPD) educational framework was used to design and implement an online module
for radiation therapists� CPD activities. The study aimed to determine if it is
possible to enhance healthcare practitioners� reflective practice via online
learning and to establish the impact of reflective learning on clinical
Materials and methods: The objectives of the online
module were to increase radiation therapists� knowledge in planning for
radiation therapy for the breast by assisting them engage in reflective
practice. The cyclical process of action research was used to pilot the module
twice with two groups of volunteer radiation therapists (twenty-six
participants) from Australia, New Zealand and Canada.
Results: The online module was evaluated using
Kirkpatrick�s four-level evaluation model. Evidence indicated that participants
were empowered as a result of participation in the module. They began
reflecting in the workplace while assuming a more proactive role and increased
clinical responsibilities, engaged colleagues in collaborative reflections and
adopted evidence-based approaches in advancing clinical practices.
Conclusion: The study shows that it is possible to
assist practitioners engage in reflective practice using an online CPD
educational framework. Participants were able to apply the reflective learning
they had developed in their workplace. As a result of their learning, they felt
empowered to continue to effect changes in their workplace beyond the cessation
of the online module. � 2008 Biomedical Imaging and Intervention Journal.
All rights reserved.
Keywords: Education; reflective practice; clinical practice;
Traditionally, Medical Radiation Science (MRS)
practitioners (radiographers and radiation therapists) function in a workplace
environment that is protocol-driven and has limited functional autonomy [1-4].
The workplace promotes a culture of conformity and discourages practitioners
from reflective and critical thinking, essential attributes for continuing
learning and for advancing workplace practices. Although such a workplace
culture promotes development of competent clinical practitioners, it will not
lead to reflective-thinking practitioners.
Reflective thinking can assist MRSpractitioners in their
current roles. In a workplace that is protocol-driven, reflective thinking can
assist practitioners to break away from the protocol-driven workplace culture
. Reflective thinking empowers practitioners by highlighting best practice
that enhances clinical performance, thereby increasing professional self-esteem
. Knowledge that is empowering and satisfying is locally generated and
attained via reflective dialogues conducted with peers . Reflective thinking
empowers MRS practitioners to move beyond a subservient mindset and conformity
while motivating them to continue learning . Reflective practitioners assume
responsibility for their own learning, are open to new ideas and constantly
seek to advance workplace practices [8-10]. They collaborate with their peers
and adopt a holistic approach towards problem solving . They engage in
critical reflection of their practice and examine their values, leading to
transformative learning that not only transforms perspectives of themselves as
healthcare practitioners but also results in new insights into their practice
The current focus of continuing professional development
(CPD) programs has been on updating practitioners� clinical knowledge [13-15]
with little emphasis on assisting practitioners to develop the attributes that
are necessary for reflective practice and advancing clinical practice [14,16].
As part of the first author�s doctoral study, an online module was designed
using a CPD educational framework and implemented as part of radiation
therapists� CPD activities. The study aimed to determine if it is possible to
enhance healthcare practitioners� reflective practice via online learning and
to establish the impact of reflective learning on clinical practice.
Educational framework underpinning the online module
Constructivism, learner-centred teaching and situated
learning are three major learning and teaching approaches that form the
educational framework for CPD in this study, with reflective thinking chosen as
one of the main learning strategies for CPD learning.
Constructivist learning requires learners to integrate
past experiences with current experiences in order to make sense of their own
learning . Instead of memorising and regurgitating facts, learners
question, analyse, negotiate and construct their own knowledge. Social
constructivism involves the construction of knowledge through collaborative
learning with learners pursuing shared learning goals [18-19]. Collaborative
learning promotes reflection, since learners are required to discuss, explain
and defend ideas thereby assisting them to reflect and to improve on their own
understanding. Learners are exposed to multiple perspectives, making the
resultant learning broader than what would have resulted from individual
In learner-centred teaching, the emphasis is on the
process of learning and on developing learners� competence, as opposed to just
knowledge acquisition based on teacher-centred teaching . This shift of
responsibility and power from teacher to learners is consistent with the
current focus on lifelong learning, which places greater emphasis on learners
assuming more responsibility for their own learning .
While much of the formal learning that occurs in
institutions is decontextualised , situated learning focuses on the social
and cultural aspects of learning, making learning an authentic and meaningful
experience [25-27]. Situated learning involves engaging �learners in tasks that
reflect practices encountered in professional workplace settings� . Here,
knowledge and skills are best learned by reflecting on how they are applied in
everyday situations . Thus, situated learning is particularly suitable for
These approaches to learning shaped a learning environment
that is constructive, socio-culturally mediated, learner-centred and authentic.
The instructional frameworks of Salmon�s 5-stage model and constructive
alignment helped to achieve the aims of the CPD program.
A feature of good education design is to create and
facilitate a supportive learning environment that enables learners to engage in
meaningful learning in a structured manner . Salmon�s 5-stage model of
teaching and learning online provides an appropriate instructional framework in
guiding participants through their online learning [30-32]. Stage 1 (access and
motivation) focuses on getting learners to familiarise themselves with the
online learning environment, in preparation for their active participation in
subsequent activities [31-33]. Stage 2 (online socialisation) is concerned with
establishing the trust and repertoire between learners in order to lay the
foundation for future collaborative work . The next three stages are the
most �productive and constructive for learning and teaching purposes� .
Stage 3 involves information exchange among learners, and between learners and
the moderator, based on their pre-existing knowledge and the online resources
made available. The role of the moderator is to maintain an intellectual role,
guiding and extending the discussions, facilitating learning by providing
timely feedback, suggesting resources and encouraging learners to reflect on
their work [34-36]. The moderator also steers the discussions by providing
prompts and initiating questions, teasing out multiple perspectives, commenting
on the adequacy and quality of discussions, and if need be, challenges their
contributions in a supportive, encouraging manner and within the stipulated time
frame [21,31,33,35]. In Stage 4, learners start to engage in more active
learning, consider multiple perspectives through negotiation and deliberation
with their online peers, and often assume the role of knowledge constructors
rather than mere assimilators of knowledge [31,33]. By the time learners reach
the final stage (development), they are usually ready to engage in
constructivist learning, becoming more critical and self-reflective. By the
final stage, learners have constructed their own understanding gained from the
extended debate and discussions through the previous stages and are able to
function as independent learners [31,33].
Salmon�s model provides a structured learning environment,
which is sufficiently flexible to allow the education designer to design the
course to meet specific educational goals. Thus, in the MRS online module,
while adhering to the Stage 1 and Stage 2 of Salmon�s model, the first author
contextualised the Stages 3, 4 and 5 as shown in Figure 1.
Action research was the research methodology used in this
study. According to Frost, �Action research is a process of systematic
reflection, enquiry and action carried out by individuals about their own
professional practice� . In action research, practitioners are no longer
�objects� to be studied, but assume the role of contributors . This
inclusive approach reduces researchers� personal biases and is a useful way of
informing research . Dick further defines action research as a �flexible
spiral process which allows action (change, improvement) and research
(understanding, knowledge) to be achieved at the same time� . Action
research narrows the gap between theory and practice and, by alternating
between action and critical reflection, leads to improved practice through
progressive accumulation of practical knowledge [38-39]. In this study, the
cyclical process of action research provided an ideal mechanism to design,
implement, evaluate, reflect on and modify the educational framework used to
guide the design and development of an online CPD module for MRS practitioners.
Data collected during the action research cycle were analysed and reflected on
This study consisted of two major phases. The First
Research Phase included the literature review and data collection. While the
aim of the literature review was to assist in the design of the educational
framework , the purpose of the data collection was to seek input from the
clinical workplace in terms of practitioners� learning needs. Data collection
strategies included a national CPD survey for MRS practitioners and
semi-structured interviews with Heads of Clinical Departments.
Based on reflection on the First Research Phase, the
Second Research Phase aimed to develop an online module based on the CPD
educational framework. This paper focuses on the Second Research Phase. In line
with the participatory nature of action research , other MRS stakeholders
collaborated with the first author in piloting the online module. These stakeholders
included two senior radiation therapists and one MRS academic staff who assumed
the role of facilitators in supporting and facilitating learning amongst
participants of the online module. The online CPD module was first piloted with
a group of 12 radiation therapists from Victoria and Tasmania (1st
pilot module), with the researcher reflecting on and using the feedback to
evaluate and refine the module, which was piloted again with a second group of
14 radiation therapists from Australia, New Zealand and Canada (2nd
For the 1st pilot module, recruitment of
participants was via publicity pamphlets sent to major radiation therapy
centres and satellite branches in Victoria and Tasmania. Due to the uncertain
level of responses, selection was based on a first come first served basis and
limited to one participant per centre or two participants from a larger
clinical centre. For the 2nd pilot module, participation was opened
to radiation therapists from Australia. Volunteers were called for in the
Australian Institute of Radiography National Conference in Cairns, Australia. Clinical educators from New Zealand and Canada who were attending the Conference
approached the first author expressing interest for their staff to participate.
Also included were participants from Canada and New Zealand who would give the
online module an international dimension and be in line with the
internationalisation of higher education. In an effort to accommodate more
Australian participants, the total number of participants was increased from 12
to 14, resulting in eight Australian and six international participants.
The two main learning objectives of the online module were
to increase practitioners� knowledge of radiation therapy planning and to enhance
participants� ability to reflect in the workplace. One of the prerequisites for
an effective online program is the adoption of constructive alignment [42-43]
where learning objectives are aligned with the learning activities and
assessment tasks . Given that one of the main learning objectives is
reflection, it follows that the learning activities would require participants
to engage in a variety of reflection activities, including reflecting on
radiation therapy literature and their planning practices, and engaging in
reflective dialogues with their online peers. Learning outcomes in terms of
radiation therapy knowledge and reflection were assessed through participants�
reflective dialogues and activities, and evidence-based practice (EBP) assignments,
and from the impact of participants� reflection on their workplace practices.
Salmon�s five-stage framework was modified and applied to
the online module. Table 1 provides a summary of the learning activities. The
first two weeks of the module focused on participants knowing their online
peers and familarising themselves with the learning environment. Week 3 to 8
involved information exchange and knowledge construction. Information exchange
involved participants sharing the �what, why and how� of their protocols with
their online peers, thereby providing the foundation for reflection and
consolidation of knowledge. With knowledge construction, participants were
required to read, reflect and respond to their peers on a series of nominated
articles that were selected by the facilitators. In the facilitators� personal
reflective pieces and group discussions that followed, the facilitators shared
why they chose the articles and how the articles impacted on their clinical
practice. This first set of reflective readings was followed by a second series
of articles, which was selected by the participants from the electronic
database. Each participant was required to share his or her personal reflection
on the chosen article, including the article's impact on clinical practice
and/or how the article had further prompted more questions. Each of the week�s
activities was rounded off with online personal and group reflection.
Guidelines and examples were provided by the facilitators to assist
participants in these reflective activities. There were also guidelines to
prompt participants on the reflective process and the possible reflection
outcomes that follow. Although participants were required to read a series of
articles during Week 3 to 8, the learning process went beyond that of didactic
delivery. The focus was on the personal and collaborative reflections that
ensued rather than the selection of the �best� literature. The final four weeks
of the module enabled participants to put their reflection and information literacy
skills into practice by applying EBP at their workplace. The EBP activity was
planned with the aim of enabling participants to see how their newly acquired
skills of information literacy and reflection can be successfully applied in
the workplace. However, due to time and workplace constraints, participants�
EBP outcomes were demonstrated in the form of an EBP assignment.
Kirkpatrick�s four-level evaluation model was used in
evaluating the online module. Kirkpatrick�s model focuses on the quality,
efficiency and effectiveness of educational programs [45-47]. Due to its
simplicity and practicality, Kirkpatrick�s model is also a useful evaluation
model for online learning . The model allows the evaluation of
participants� reaction to the program (Level 1), participants� learning (Level
2), behavioural change as a result of participation in the module (Level 3) and
evaluation of the impact of participation in the workplace (Level 4) [49-50].
Due to the constraints of this paper, it is not possible to present all the
evaluation criteria for all four levels of evaluation. Given that, this paper
is about reflective practice and its impact on clinical practice with focus on reflection
outcomes in terms of participants' learning (Level 2), behavioural
changes (Level 3) and impact in the workplace (Level 4).
Data were collected from multiple sources using both
quantitative and qualitative approaches, a combination common in action
research [40,51-52]. Quantitative approaches included pre-, mid- and
post-module surveys while qualitative approaches included participants�
postings at online discussion forums and learning portfolio, and minutes of the
researcher�s (first author) meeting with facilitators, as well as the first
author�s reflective journal. Quantitative data provides a summarised and
condensed form of data while qualitative data enhances the data by
demonstrating the links between complex and large amounts of data . Thus,
while quantitative data is useful in presenting an overall picture and snapshot
of a particular phenomenon, qualitative data is able to provide further
descriptive details as to the reason(s) for the phenomenon depicted. In this
instance, the qualitative data collected from multiple sources contributed
towards providing a clearer picture to the links between Level 2 (participants'
learning), Level 3 (behavioural changes) and Level 4 (resultant impact in the
workplace) data. In addition, the use of multiple data collection strategies
allows cross-data validity checks, thereby increasing the rigour, validity and
credibility of the findings [52,54-57]. Table 2 summarises the data collection
strategies used for each level of evaluation, with participants, participants�
workplace supervisors, facilitators and the first author contributing to the
Quantitative data was analysed using SPSS for MS Windows
Version 13.0 while qualitative data was coded and analysed with Nvivo7. Coding
qualitative data provides a framework for subsequent data analysis, enabling
data triangulation and interpretation and conclusions to be drawn .
Qualitative data were coded using Henri�s thematic unit of analysis [58-59].
Meaningful evaluation is only possible when there is good
understanding and successful incorporation of appropriate pedagogy into
evaluation strategies . Thus, an appropriate conceptual model of the
reflective process is needed to inform and guide the researcher as to the
criteria for analysing and evaluating the data obtained from online discussions
. The evaluation criteria for reflection outcomes were based on a paper by
Boud et al on reflective model and a paper by Gunawardena et al. on social
construction model on computer-mediated communication. Consequently, seven
levels of reflective process for coding were identified [62-63].
The online module had two main objectives; to enhance
practitioners� ability to reflect and to increase their radiation therapy
knowledge. The third main objective of empowering participants was not made
known to the participants to avoid the possibility of tainting participants�
reporting of learning outcomes.
The completion rate for the 1st and 2nd
pilot was 58% and 71%, respectively. For both pilot modules, there was a good
spread of participants both in terms of age group and years of experience (see
Table 3). The 2nd pilot participants were much more proactive than
the 1st pilot participants in exchanging and exploring issues raised
in the discussion forum. This was evidenced from the higher number of messages
posted in the 2nd pilot. The inclusion of the international
participants in the 2nd pilot module has also contributed to the
increased exchanges as participants were keen to find out if radiation therapy
practices differ between countries.
Data collected show that learning outcomes included
participants� increased understanding of radiation therapy, motivation for
learning and sharing their learning with colleagues, confidence as
self-directed learners, information literacy skills and understanding of EBP.
For the purpose of this paper, the authors focused on reflection outcomes
(Level 2 and Level 3 data) and the impact of learning on clinical practice
(Level 4 data).
Participants� reflection outcomes
Level 2 Evaluation: Learning data
In this study, Boud et al�s (1985) reflective model was
used as the conceptual framework for coding and evaluation of reflection and
learning outcomes. Boud et al proposed a generic framework of reflection that
describes seven levels of reflection processes that learners might experience .
The foundation level includes returning to experience, which involves
describing the activities, an essential step of recounting past experiences so
that subsequent reflections are based on actual recollection of events.
Attending to feelings (1st level) recognises the importance of
feelings in facilitating or obstructing the learner�s learning experience since
�utilizing our positive feelings is particularly important as they can provide
us with the impetus to persist in what might be very challenging situations�
. Allowing learners to articulate their feelings assists them in
understanding their emotions in the learning context, an important
characteristic of the self-directed learners . The 2nd to 5th
levels consist of association, integration, validation and appropriation.
Association (2nd level) refers to relating new knowledge to
pre-existing understanding, integration (3rd level) involves
synthesising old and new data, while validation (4th level) is
�testing for internal consistency� including the testing of new concepts .
Finally, appropriation (5th level) involves internalising knowledge
into one�s cognition. These levels do not necessarily occur in sequence,
neither do learners need to experience each level of reflective process described.
In fact, validation and appropriation, which form the higher level of the
reflective process, could also be viewed as a form of reflective outcomes.
Reflective outcomes (6th level) ranged from changes in behaviour
(action outcomes), changes in the learner�s affective state (affective
outcomes) and/or perspectives (perspectives outcomes)  (see Tables 4 and
All participants in both pilot modules reported the
initial level of describing, sharing and exchanging information and
association. Most demonstrated integration, with only two participants from
both pilot modules showing evidence of validation and appropriation. One
possible reason why few participants showed the higher levels reflective
processes of validation and appropriation could be that the coded data only
captured the end process of reflection rather than the continuum of
As a result of the reflective dialogues and activities,
all participants had at least one coding that demonstrated an action outcome of
reflection activities in the module. In terms of reflective outcomes, most of
the outcomes came under the action category. This finding refers to explicit
expressions by participants about their commitment to action. The action
assumed the form of participants using their newly acquired knowledge, applying
their reflective and/or information literacy skills, with the ultimate aim of
initiating new projects, or assessing and suggesting changes to their workplace
practices, as illustrated by the following comments:
I am now confident in knowing where to search for
information and I have lots of little projects that I can do in mind.
[Participant 12: 1st Pilot] (Note: �Participant 12: 1st
Pilot� refers to Participant number 12 from 1st pilot module)
I hope I can look at practices in our department and use
some of the knowledge gained to assess and maybe even change! [Participant 12:
Level 3 Evaluation: Behavioural data
Level 3 refers to participants' behavioural change as a
result of participation in the module. These changes ranged from changes in
radiation therapy practice to changes in attitude and behaviour in the
Data from the Workplace Survey, the 3-month post-module
survey and the EBP assignments were used to establish behavioural changes. The
response rate for the Workplace Survey was 71% and 40% for the 1st
and 2nd pilot modules, respectively. With the exception of two
participants who were reported to have shown no change, responses from the
Workplace Survey showed evidence that participants were empowered as a result
of participating in the modules. Their Supervisors reported them to be
enthusiastic with increased confidence and they displayed a positive attitude
at work and towards learning. Changes in the form of radiation therapy planning
included an appreciation of the complexities of radiation therapy planning with
three participants continuing to implement changes and improvements to their
planning as discussed in the online forum. Other changes included engaging in
literature search, assisting colleagues with online searches and actively
seeking for new challenges at work.
The 3-month post-module survey showed that for both the 1st
and 2nd pilot modules, approximately 53% of the participants
continued to reflect on the literature and engage in reflective practice in the
workplace. Another 53% continued to work towards their EBP activities by either
presenting their EBP assignments or investigating various techniques to advance
Level 4 Evaluation: Impact on clinical practice
Level 4 evaluation refers to the participants� impact on
the workplace as a result of their learning . Data collection methods
included the Workplace Survey, the 3-month post-module survey and the
participants� learning portfolio. Examples of Level 4 success in the MRS
workplace include practitioners' advancing workplace practices, varying
workplace protocols to better treatment plans, and the intangibles such as
increased confidence, enthusiasm and positive attitude.
All participants in both pilot modules were unanimous that
the learning experience had a positive impact on their professional
development. The common response was that the module has given them the added
confidence in attempting new initiatives in their workplace as evidenced by the
Participation in the module has given me greater confidence
[sic] in my skills and this in turn has led to taking on greater
responsibility. I�m starting to check treatment plans for the first time and
acting as a senior, which I didn�t think was ever going to happen! [Participant
11: 1st Pilot, 3-month post-module survey]
I have more confidence in my ability to do things on a
professional level. I have been more keen to do a paper, and to attend
conferences and seminars, and also to eventually have more involvement when we
get our new equipment. [Participant 11: 2nd Pilot; 3-month
In the Workplace Survey, 35.3% of the participants who
successfully completed the two pilot modules were reported by their supervisors
to have made a positive impact on their workplace. This impact ranged from
assuming an infectious attitude towards learning, willingness to share new
ideas and solutions, willingness and ability to contribute towards departmental
projects such as quality improvement studies and information technology
developments. These participants were also proactive in advancing radiation
therapy technique development in their workplace.
In particular, reports from the Workplace Survey were
outstanding for two participants. The attitudinal and behavioural change of
Participant 10 (from the 2nd pilot module) in embracing challenges
was noted by her Supervisor:
I have noticed a change in Participant 10�s enthusiasm,
towards RT planning. She is keen to learn (almost demands to learn new
methods). This contrasts the way she was. She previously used to be a bit more
apprehensive when challenged. [Supervisor of Participant 10: 2nd
The change in attitude and enthusiasm has in turn brought
about a positive learning culture in her workplace, as the following comment
Participant 10 is a good role model in the workplace. Her
positive attitude and willingness to learn of late has had a positive impact.
Especially on the more junior staff and students. [Supervisor of Participant
10: 2nd Pilot]
From ongoing communication with the participant, the first
author is aware that she was promoted to the position of Deputy Head a year
after completing the online module.
Participant 12 from the 1st pilot module was
instrumental in assisting the department in proposing changes to her
Headquarter Clinical Planning Committee, as illustrated by the following
[Participant 12] has been able to make evidence-based
suggestions with regards to our current practices and propose changes and
present ideas to staff in meetings. [Supervisor of Participant 12: 1st
Participant 12 has assumed an active role in disseminating
information she learned from the module through her department�s journal clubs,
as well as making herself available to assist her colleagues in their online
research activities. The supervisor concluded with the following comment:
I believe [Participant 12] has benefited both
professionally and personally from the module. Her willingness to communicate ideas
and source solutions has improved and her confidence in what she is doing has
also increased. [Supervisor of Participant 12: 1st Pilot]
Participants� learning also flowed to the workplace. The
three-month post-module survey showed that more than half the participants
continued to read and reflect on the literature, and to engage in some form of
EBP work such as exploring their EBP topic or choosing a new clinical issue for
investigation. In terms of the reflection in the MRS workplace, the ongoing discussions
between participants and their colleagues have certainly raised their awareness
of the importance of reflection.
Developing a culture of reflective practice in the workplace
Developing a culture of reflective practice in the
workplace does not occur spontaneously or overnight. Rather, the culture of
reflective practice begins with each practitioner reflecting at an individual
level and at a collective level. In terms of the latter, the participants
reflected collaboratively with their online peers as well as with their
colleagues in the MRS workplace.
At an individual level, it is imperative
that practitioners themselves are aware of what constitutes reflection, and the
importance and value of reflecting at the workplace. The learning activities
provided opportunities for participants to reflect on the meaning of
reflection, the risks associated with reflection, and the value of reflecting
in the MRS workplace. The online module was successful in raising participants�
awareness and understanding of the importance of reflecting in the workplace.
This is evident from how participants shared their greater appreciation of
reflection and their willingness to apply reflection in the workplace, as
illustrated by the following comments:
I must confess that I have usually taken reflecting for
granted, which generally means that you only revise and analyse situations and
events that have had some major impact on you. From doing this module so far I
have gained a new respect for the value of reflection and hope to incorporate
it more in my professional and social life. [Participant 1: 1st
I think I too have taken reflection for granted. It's not
something I've consciously sat down to do at work, and I tend to be one of the
people that do things "because that's the way it's done." I'm hoping
for this to change - in fact while thinking about our current breast planning
technique I've come up with a question about tattoos I can't answer to my
satisfaction. I'll quiz a few people when we return to work on Tuesday and see
if I can come up with a satisfactory response!! [Participant 11: 1st
At a collective level, the culture of
reflective practice in the MRS workplace was made possible when individual
learning and reflection permeated the workplace. This is evident from the
postings at the discussion forum, which showed that the learning and
collaborative reflection were not restricted to participants� online community
but had also extended to include their colleagues in the workplace. All participants
were involving their colleagues in reflective dialogues at work by sharing
their reflection and literature reading, and by informing and updating them on
the online discussions. Participant 8 commented as follows:
I had a lot of interest from my department in the whole
idea of this type of online discussion forum. I would start talking about one
topic, which may have been mentioned in the discussion forums and it sparked up
further conversations. One thing with RTs [radiation therapists] there is never
any shortage of opinions and passion for our work. Just sometimes there is a
shortage of RTs ;-) [Participant 8: 2nd Pilot]
Participants sought input from colleagues and brought the
workplace discussions back to their online peers. Thus, the reflective
dialogues that started on the discussion forum flowed into the workplace and
then looped back to the online community, as illustrated by the comment below:
Many RTs [radiation therapists] were really interested and
they really helped me look at the practices in our department. Everyone was
keen to help me understand various [sic] aspects of my EBP topic and the more
questions I came up with set them to thinking and reflecting [sic] on why we do
things [Participant 12: 2nd Pilot]
By involving their colleagues in such discussions,
participants were also engaging their workplace colleagues in the Sch�n�s
concept of reflection-on-action . Such exchanges marked the beginning of a
culture of reflective practice in the MRS workplace.
Another way of facilitating and spearheading a reflective
culture in the MRS workplace involved participants, who themselves were
supervisors in the workplace, gaining a better appreciation and understanding
of reflection, as illustrated by the comment by Participant 8:
I am beginning to feel that I need to think about how I
will share the ideas and information I am gaining from this experience with my
workplace. With a positive approach to reflection, a workplace can grow as a
unit. Through reading the article and the repsonses [sic] and thoughts posted
here in the last week I also feel I have a whole new meaning for the word
reflection and it doesn't [sic] involve a mirror ;-) [Participant 8: 2nd
Impact of reflection on adherence to protocol
The strict adherence to protocol in the MRS
workplace promotes conformity of practice and does not encourage regular
reflection on workplace practices. Being able to question and reflect on
workplace practice is certainly a departure from the entrenched MRS culture of
protocol. This explains why Heads of Department (HOD) interviewed in the First
Research Phase spoke of the importance of promoting and encouraging MRS
practitioners to engage in EBP as �evidence-based practice goes towards
benefiting your workplace� [HOD7]. Of the eight HOD interviewed, half
specifically indicated that EBP is a useful avenue for introducing
practitioners to questioning workplace practices and research.
So how did engaging in reflection in the online module
change participants� adherence to workplace protocol? Data showed that the
online discussions and EBP activities were successful in getting practitioners
to question and reflect on their workplace practices. For instance, as a direct
result of the reflective dialogues on planning practices, Participant 11 spoke
of how she took the initiative during one of her planning to modify the
protocol, resulting in a 10% reduction in radiation delivered to the patient,
as the comment below illustrates:
Although the plan I had produced was "acceptable"
- I asked the senior RT checking my plan if it would be considered going
"over the top" to add a lightly weighted 18X beam on the lateral to
further reduce the hotspot in the axilla�It's such a grey area though - if I
hadn't asked, the plan would have been accepted, and the patient would be
getting an extra 10% in the axilla. If I'd asked another RT , they may have
thought the extra work required did not justify the end result. Maybe not...
I'm just trying to think of alternatives! [Participant 11: 1st
The impact of the EBP assignment on the protocol-driven
culture is also evidenced by participants� adoption of a more critical approach
at work, as illustrated by Participant 4�s comment below:
I definitely have gained a lot from doing this assignment
and the module. In relation [sic] to my assignment [sic], I planned to treat? a
young lady today and decided to omit the wedge on the medial field, using
instead a larger wedge on the lateral and adjusting the weightings. Also, the
module has helped me look a lot more laterally at things and be more
inquisitive. [Participant 4: 2nd Pilot]
Facilitator 2 also noted in his reflective journal how the
online reflective course has impacted on workplace practices, as illustrated by
the following comment:
It was extremely rewarding, however, to note that a simple
point like not including medial wedges on tangents has emanated from this
module and already impacted on department�s practice around the world. Very
cool to think, that patients are directly benefiting from this module, with
feedback from participants. [Facilitator 2]
Participant 1 gave an example of how her enhanced critical
thinking had allowed her to be more proactive in advancing patient care, as
illustrated by the following comment:
I think working on the EBP (which I can't seem to get
finished) has got me thinking more critically about other issues with breast
and other treatments at work. Last week I was working on a new machine with
dynamic wedging and MLC, where you would expect less scatter from the machine
... and I noticed a remarkable number of breast patients with a brisk skin
reaction - something I haven't been seeing elsewhere. Despite having seen these
patients daily, the usual staff on that machine wasn�t concerned, and didn't
notice a trend. I did mention it to our physicists however, to see if there
could be an explanation. We're planning on watching for notable skin reactions
for patients on the new machines versus old, and we may do some TLD
measurements to check the skin doses on patients with bad reactions. This is
something I probably wouldn't have pursued before doing this module and
project! [Participant 1: 2nd Pilot]
Perspective transformation: Impact on workplace practice
Perspective transformation is only possible
if practitioners are given the opportunity to construct and de-construct the
social context in which they work. Participant 12 was one of the participants
who experienced perspective transformation. Realising that EBP is not just the
responsibility of oncologists, but also of the radiation therapists,
Participant 12 was able to demonstrate in her EBP assignment her understanding
of the challenges facing EBP implementation in her workplace. Facilitator 2 was
particularly impressed with her perspective transformation, as illustrated by
the following comment:
I know of Participant 12�s department. It is extremely
protocol-driven, with a culture of �nati [sic]-change�. She has recognised
this, is not perturbed by it, has thought through the [EBP] process required
and has a great chance of implementing her change and procedure. [Facilitator
Facilitator 2 also reflected on the impact this module had
on another Participant:
To give an example of the impact [this module] has had on
one of the participants � she now is willing to offer an opinion at the unit
audit, sharing the information and knowledge that was garnered through the
online module. Further example is a patient on treatment recently who was
prescribed a fractionation schedule different to the norm. Participant 11
conducted a literature search, researched the basis for the fractionation, and
then presented to the whole department a synopsis of the article, in an attempt
to open a dialogue with the prescribing radiation oncologist. The fact that she
would never have done this prior to the online module is a clear indication of
the impact that it has had on her in the workplace. [Facilitator 2]
Empowerment of participants
Another important outcome of this online module is the
empowerment of participants. Providing opportunities for participants to
reflect on their workplace contribution and to claim ownership of their
learning allows them to be empowered in the process, as illustrated by the
It's been an incredible time - I've learnt that my opinion
is valued and appreciated and that I can analyse and reflect on what I read
instead of being told what to think. [Participant 11: 1st Pilot]
As a result of undertaking the EBP assignment,
participants realised that they were able to contribute to workplace practices,
thereby making a difference in their workplace, as the comment by Participant 4
I have a much clearer idea of EBP now, and hope to get more
opportunity to use it in the department. I find I can think of lots of projects
that I want to do! I think it is possible to make a difference - most of my
colleagues are reasonably open-minded. I shall be giving them a presentation on
this course in a few weeks, and hopefully I shall have some results of my EBP
from this project by then. [Participant 4: 1st Pilot]
Empowered and with increased confidence in their ability
to contribute to the workplace, participants were able to transcend their
negative mindset of �I am only a radiographer� and began to be more proactive
in seeing how they could contribute to advancing workplace practices.
Facilitator 3 noted the effectiveness of the online module in bringing about
empowerment of participants, as the following comment illustrates:
I don�t think it was until this second module that I really
started to notice that participants were getting involved in the workplace and
involving other staff in finding evidence to justify themselves. It was great
to hear that people were beginning to realise the importance of EBP. It only
felt like a small beginning, however these are often people who have not
studied, let alone really been involved in facilitating change within their
departments, you could see the realisation starting to occur to them that they
had the knowledge and skills to bring about these important changes. The most important
thing that I think I saw some people get out of the program probably was a
certain level of professional self-empowerment. It was really gratifying to be
a part of. [Facilitator 3]
While the MRS literature shows practitioners to be
unwilling to accept increased clinical responsibility in the workplace, there
is evidence that the online learning experience described in this paper has
transformed participants� attitude towards EBP while increasing clinical
responsibility, as the following comment illustrates:
I didn't think much about EBP. I briefly understand what it
is but thought this has more to do with the doctors where they have to keep up
with all the clinical changes�I used to think it is not my problem. After
reading the article, I found this is of everyone's concern. Technology is
moving rapidly, if it is the doctors' [sic] responsibilities to improve the
treatment outcome clinically then I guess it would be the responsibilities of
the RT to ensure this happens. Stabilisation [sic] and optimisation of dose
would be the areas that need to be constantly developed. Each of us has a role
to play here. [Participant 12: 1st Pilot]
The EBP assignment enabled participants to put into
practice their learning, validating their newfound confidence.
Transformative learning is the key to empowerment. Through
critical reflection and reflective discourse, participants obtained new
perspectives, which enabled them to �think beyond the square�. Empowered and
armed with newfound confidence and changed perspective, participants began
pushing their professional boundary. They began to believe in their own
capabilities and started to assume a more proactive role in the workplace,
adopting evidence-based approach to making suggestions. Abandoning the negative
mindset and subservient attitude, participants started on literature search to
keep abreast of the latest RT updates, while others started participating in
ongoing department projects.
The following comments encapsulate the impact of
participants� learning in the MRS workplace:
I feel like I'm in a much better position to offer input
after this module. I also think I've gained some confidence in approaching our
physics staff and senior RTs with ideas (i.e. removing medial wedges and moving
younger patients to our newer machines). It was great to have a reminder that
there are always new and interesting articles out there. Since we do work in an
EBP environment, it's important that we keep up to date ourselves and not just
rely [sic] on the doctors to do so. [Participant 1: 2nd Pilot]
Working on the EBP assignment has been inspiring - perhaps
I'll never lead a trial in a prone breast board at our department, but there
are always other opportunities. At the very least as [Facilitator 2] has
reminded me, I'll be doing my very first presentation to the rest of the staff
about this course - who knows, you might see me at my first conference next
year as a presenter! Anything's possible :) [Participant 11: 1st
Against a workplace culture that promotes conformity and
that is protocol-driven, data from the study show that the online module
succeeded in assisting participants to engage in reflective practice in the
workplace. Findings from this study are in line with the educational literature
on reflective learning and practice. Evidence from the study shows that it is
possible to bring about empowerment, transformative learning and reflection
outcomes that go beyond just mere acquisition of clinical knowledge online.
Most CPD programs of the profession focus on enhancing clinical competence.
While reflective practice is not new to the health profession, the success of
this MRS study offers a challenge to the MRS profession to embrace reflective
practice and to support CPD that focuses on developing reflection. This study
represents a small but significant step towards enhancing reflective practice
via online learning in Medical Radiation Science.
Figure 1 Summary of learning activities in the online module using Salmon�s 5-stage teaching and learning model. [Source: Adapted from 34 p.11]
Table 1 Online module learning activities
Table 2 Kirkpatrick�s four level evaluation model and corresponding data collection strategies
Table 3 Demographics of participants from 1st and 2nd pilot
Table 4 Level 2 learning data: Coding results of reflection outcomes for 1st pilot participants
Table 5 Level 2 learning data: Coding results of reflection outcomes for 2nd pilot participants
Baird M. The preparation for practice as a diagnostic radiographer: The relationship between the practicum and the profession [PhD Dissertation]. Melbourne: La Trobe University, 1998.
Campeau FE. Radiography: Technology, Environment, Professionalism. Philadelphia: Lippincott Williams & Wilkins, 1999.
Shephard J. Changes in roles and responsibilities: a personal view. Synergy 2000; 20-1.
Witz A. Professions and patriarchy. London: Routledge, 1992.
Clouder L. Conclusion. In: Tate S, Sills M, eds. The development of critical reflection in the health professions. Bristol, United Kingdom: University of Luton, 2002: 101-8.
Ghaye T, Lillyman S. Reflection: Principles and practice for healthcare professionals. London: Mark Allen Publishing, 2000.
Sim J. Continuing Professional Development in Medical Radiation Science: Journey towards reflective practice in cyberspace [PhD Dissertation]. Melbourne: RMIT University of Technology, 2006.
Baird M, Winter J. Reflection, practice and clinical education. In: Rose M, Best D, eds. Transforming Practice through Clinical Education, Professional Supervision and Mentoring. Vol. 143-59. Edinburgh: Elsevier, 2005.
Bolton G. Reflective practice: Writing and professional development. London: Paul Chapman Publishing, 2001.
Dewey J. How we think. A restatement of the relation of reflective thinking to the educative process. Lexington, Massachusetts: D.C. Heath and Company, 1933.
Brookfield SD. Transformative Learning as Ideology Critique. In: Mezirow J and Associates, eds. Learning as Transformation: Critical perspectives on a theory in progress. San Francisco: Jossey-Bass, 2000: 125-48.
Mezirow J. Preface. In: Mezirow J and Associates, eds. Fostering critical reflection in adulthood: A guide to transformative and emancipatory learning. San Francisco: Jossey-Bass, 1990: xiii-xxi.
Jeeawody B. Continuing Professional Education: A Critical Review. In: King R, Hill D, Retallick J, eds. Exploring Professional Development in Education. New South Wales, Australia: Social Science Press, 1997: 41-60.
Sim J. Profile of Medical Radiation Science Practitioners as Lifelong Learners: Implications for the Design of Undergraduate Programs [Masters Dissertation]. Perth: Curtin University of Technology, 2000.
Titchen A, Higgs J. A dynamic framework for the enhancement of health professional practice in an uncertain world: the practice-knowledge interface. In: Higgs J, Titchen A, eds. Practice Knowledge & Expertise. Oxford: Butterworth Heinemann, 2001: 215-25.
Gold J, Rodgers H, Smith V. The future of the professions: are they up for it? Foresight 2002; 4:46-53.
Marlowe BA, Page ML. Creating and Sustaining the Constructivist Classroom. 2nd edition. Thousand Oaks, California: Corwin Press, 2005.
Brophy J. Introduction. In: Brophy J, ed. Social Constructivist Teaching: Affordances and constraints. Amsterdam: Elsevier Science, 2002: ix-xxii.
University of California Graduate Division. Social Constructivism [Web Page]. 2005; Available at gsi.berkeley.edu/resources/learning/social.html. (Accessed 18 October 2005).
Cheetham G, Chivers G. How professionals learn in practice: an investigation of informal learning amongst people waiting in professions. Journal of European Industrial Training 2001; 25(5):248-69.
Weller M. Delivering Learning on the Net: the why, what & how of online education. London: Kogan Page, 2002.
Gibbs G. Assessing Student Centred Courses. Oxford: Oxford Centre for Staff Learning and Development, 1995.
Sparrow L, Sparrow H, Swan P. Student centred learning: Is it possible? In: Herrmann A, Kulski MM, eds. Flexible Futures in Tertiary Teaching. Proceedings of the 9th Annual Teaching Learning Forum.
Wenger E. Communities of Practice. Learning, Meaning and Identity. USA: Cambridge University Press, 1998.
Kearsley G. New Developments in Learning [Web Page]. 2000; Available at home.sprynet.com/~gkearsley/Learning.htm. (Accessed 5 February 2005).
Lave J, Wenger E. Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press, 1991.
Stein D. Situated Learning in Adult Education [Web Page]. 1998; Available at www.ericdigests.org/1998-3/adult-eduation.html. (Accessed 3 August 2005).
Herrington A, Bunker A. Quality teaching online: Putting pedagogy first. In: Goody A, Herrington J, Northcote M, eds. Quality Conversations: Proceedings of the 2002 Annual International Conference of the Higher Education Research and Development Society of Australasia (HERDSA). HERDSA.
Buchanan EA. Online Assessment in Higher Education: Strategies to Systematically Evaluate Student Learning. In: Howard C, Schenk K, Discenza R, eds. Distance Learning and University Effectiveness: Changing Educational paradigms for Online Learning. Hershey, USA: Information Science Publishing, 2004: 163-76.
Salmon G, Giles K. Creating and implementing successful online learning environments: a practitioner perspective [Web Page]. 1998; Available at www.eurodl.org/materials/contrib/1999/salmon/#Staged%20Development. (Accessed 28 September 2007).
Salmon G. E-tivities - The key to active online learning. London: Kogan Page, 2002.
Salmon G. E-Moderating: The key to Teaching and Learning Online. London: Kogan Page, 2003.
Salmon G. E-Moderating: The key to Teaching and Learning Online. London: Kogan Page, 2000.
Alexander S, Boud D. Learners still learn from experience when online. In: Stephenson J, ed. Teaching & Learning Online: Pedagogies for New Technologies. London: Kogan Page, 2001: 3-15.
Kearsley G. Online Education. Learning and Teaching in Cyberspace. Australia: Wadsworth, Thomson Learning, 2000.
Mayes T. Learning technology and learning relationships. In: Stephenson J, ed. Teaching & Learning Online: Pedagogies for New Technologies. London: Kogan Page, 2001: 16-26.
Frost P. Principles of the action research cycle. In: Ritchie R, Pollard A, Frost P et al., eds. Action Research: A Guide for Teachers - Burning Issues in Primary Education. Birmingham: National Primary Trust, 2002: 24-32.
McNiff J, Lomax P, Whitehead J. You and Your Action Research Project. London: Routledge, 1996.
Dick B. Action research: action and research [Web Page]. 2002; Available at www.scu.edu.au/schools/gcm/ar/arp/aandr.html. (Accessed 28 March 2005).
Schwalbach E. Value and Validity in Action Research: A Guidebook for Reflective Practitioners. Lanham, Maryland: The Scarecrow Press, 2003.
Borbasi S, Emden C. Is a PhD the best career choice? Nursing employers' views. Contemp Nurse 2001; 10(3-4):187-94.
Goodyear P. Psychological Foundations for Networked Learning. In: Steeples C, Jones C, eds. Networked Learning: perspectives and Issues. London: Springer, 2002: 49-75.
Radloff A, de la Harpe B. Applying assessment principles and expanding the focus of assessment to enhance online learning. In: Naidu S, ed. Learning & Teaching with Technology: principles and practices. London: Kogan Page, 2003: 209-19.
Biggs J. What the Student Does: teaching for enhanced learning. Higher Education Research and Development 1999; 18(1):57-75.
Guskey TR. Evaluating Professional Development. Thousand Oaks, California: Corwin Press, 2000.
Kirkpatrick DL. Evaluating Training Programs: The Four Levels. San Francisco: Berrett-Koehler Publishers, 1998.
Turner S. Kirkpatrick's Model [Web Page]. 1999; Available at www.arches.uga.edu/~srturner/seminars/kirk.html. (Accessed 4 December 2002).
Bastiaens T, Boon J, Marten R. Evaluating integrated e-learning. In: Jochems W, Van Merrienboer J, Koper R, eds. Integrated E-Learning: Implications for Pedagogy, Technology and Organization. London: RoutledgeFalmer, 2004: 187-98.
Baskin C. Using Kirkpatrick's four level evaluation model to explore the effectiveness of collaborative online group work. 2001. Available at www.ascilite.org.au/conferences/melbourne01/pdf/papers/baskinc.pdf.
Kirkpatrick DL. Revisiting Kirkpatrick's four-level model. Training and Development 1996; 50(1):54-9.
Mcpherson M, Nunes MB. Developing Innovation in Online Learning: An Action Research Framework. London: RoutledgeFalmer, 2004.
Miles MB, Huberman AM. An Expanded Sourcebook: Qualitative Data Analysis. 2nd edition. Thousand Oaks, California: Sage Publications, 1994.
Gibbs G. Qualitative Data Analysis. Explorations with NVivo. Buckingham: Open University Press, 2002.
Brannen J. Combining qualitative and quantitative approaches: an overview. In: Brannen J, ed. Mixing Methods: Qualitative and Quantitative Research. Aldershot, England: Ashgate Publishing, 1992: 3-37.
McMillan J, Schumacher S. Research in Education: Evidence-based Inquiry. 6th edition. Boston: Pearson, 2006.
Yegidis BL, Weinbach RW. Research Methods for Social Workers. 2nd edition. Boston: Allyn and Bacon, 1996.
Patton MQ. Qualitative research and evaluation methods. 3rd edition. California: Sage Publications, 2002.
Rourke L, Anderson T, Garrison R et al. Methodological Issues in the Content Analysis of Computer Conference Transcripts. 2001. Available at aied.inf.ed.ac.uk/members01/archive/vol_12/rourke/full.html.
Schellens T, Valcke M. Fostering knowledge construction in university students through asynchronous discussion groups. Computers & Education 2004.
Reeves TC. Evaluating What Really Matters in Computer-Based Education [Web Page]. 1997; Available at www.educationau.edu.au/archives/cp/reeves.htm. (Accessed 8 April 2003).
Breakwell G ML. Basic Evaluation Methods: Analysing performance, practice and procedure. Leicester, Great Britain: The British Psychological Society, 1995.
Boud D, Keogh R, Walker D. Promoting Reflection in Learning: a Model. In: Boud D, Keogh R, Walker D, eds. Reflection: Turning Experience into Learning. London: Kogan Page, 1985: 18-40.
Gunawardena C, Lowe C, Anderson T. Analysis of a global online debate and the development of an interaction analysis model for examining social construction of knowledge in computer conferencing. J Educational Computing Research 1997; 17(4):397-431.
Patterson C, Crooks D, Lunyk-Child O. A new perspective on competencies for self-directed learning. J Nursing Education 2002; 41:25-31.
Seale J, Cann A. Reflection on-line or off-line: the role of learning technologies in encouraging students to reflect. Computers and Education 2000; 34:309-20.
|Received 30 September 2007; received in revised form 30
October 2007, accepted 5 November 2007
Correspondence: RMIT University, School of Medical Sciences, Medical Radiations, PO Box 71, Bundoora 3083, Victoria, Australia. E-mail: firstname.lastname@example.org (Jenny Sim).
Please cite as: Sim J, Radloff A,
Enhancing reflective practice through online learning: impact on clinical practice, Biomed Imaging Interv J 2008; 4(1):e8
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