The use of assisted performance within an online social network to develop reflective reasoning in undergraduate physiotherapy students

Abstract

Background: The development of practice knowledge is an important component of clinical education and reflective reasoning is known to play a role in its development. Online social networks may have some potential for developing practice knowledge by providing tools for clinical educators to guide students’ reasoning practices.

Aim: To determine if an online social network could be used to facilitate reflective reasoning in clinical contexts, as it relates to developing practice knowledge.

Method: The study was conducted within a South African university, physiotherapy department, using an online social network to facilitate engagement. Tharp and Gallimore's theory of assisted performance was used as a framework to conduct qualitative analysis of students’ reflective blog posts within the network.

Results: The lecturer was able to use strategies within the assisted performance framework to facilitate reflection among students. These included modelling, contingency management, feedback, instruction, questioning and cognitive structuring. The features of the social network enabled enhanced communication between teacher and student, as well as promoted engagement around clinical scenarios.

Conclusion: Online social networks can be used to facilitate reflective reasoning as part of the development of practice knowledge by exposing students’ understanding of clinical practice. However, careful facilitation using sound pedagogy is still necessary to guide students to deeper understanding.

Background

The scientific method has helped physiotherapists move from a craft tradition based on experiential knowledge to one based on research and evidence. However, an emphasis on hard science within the healthcare professions does little to take into account the personal, complex and multi-factorial nature of clinical reasoning (Higgs et al. 2004). Schön (1987) argued that this approach could not in itself effectively develop practice knowledge and emphasised the need for artistry to be developed alongside technical proficiency. In other words, a purely technical approach does not adequately prepare students for the complex reasoning they need to resolve clinical problems (Strohschein et al. 2002; Kember et al. 2008). In addition, there is still a systemic problem within health education that emphasises a narrow technical focus that lacks a broader contextual understanding (Frenk et al. 2010).

Practice knowledge should be seen as a dynamic relationship between questions and answers in a context of meaning that is often intuitive and hidden. Indeed, the culture of a profession hides as much from its practitioners as it reveals, and if students can be exposed at an early stage to the culture that influences clinical practice (i.e. the language, norms and values of the profession), it may impact their professional development (Higgs et al. 2004). Developing this practice knowledge is challenging, as it requires insight into the reflective and reasoning processes of experienced clinicians. However, there is some evidence that sharing experiences among peers in a collegial environment may go some way towards developing critical reflective thinking (Welch & Dawson 2006). Unfortunately, there is rarely space in the formal curriculum for the development of these skills.

Table

Practice points

The development of practice knowledge is complex, and is often hidden from the undergraduate health professional student. Practice knowledge can be developed by exposing students’ understanding of complex ethical and clinical issues, and then guiding critical reflection around those issues. The Theory of Assisted Performance can be used to provide a teaching framework that structures reflective practice as part of developing practice knowledge. Online social networks can be used to expose students’ practice knowledge and to structure students’ critical reflection.

Human beings learn most effectively in social contexts where they are guided towards higher cognitive functioning by someone who knows more than they do, that is, a more knowledgeable other (MKO). The conceptual distance between what a person understands on their own and what they could potentially understand with guidance is known as the zone of proximal development (ZPD) and it is within this space that effective teaching and learning takes place (Vygotsky 1978). In order to help students’ development, educators should seek to guide them to a point at which they are able to take over and direct their own learning (Gallimore & Tharp 1993).

Tharp and Gallimore's (1991) theory of assisted performance provides a framework for teaching activities that help guide the student through their ZPD towards self-regulated learning. Within contextualised learning activities that are grounded in actual experience, the teacher seeks to model desired behaviour, reward and correct student activity, provide feedback on performance, instruct the process, stimulate thoughtful responses through questioning and create a framework for cognitive development. These activities could be collaborative shared experiences that stimulate “teacher to student”, “student to teacher” and “student to student” interactions (Tharp & Gallimore 1991).

In addition, it is becoming more clear that learning is an activity in which students participate in a socio-cultural context, rather than an individualised one (Seely-Brown et al. 1989). If learning is ideally a communal activity, online communities may be useful places for learners to engage more deeply with content and with each other (Gannon-Leary & Fontainh 2007). This approach situates learning within social contexts and relationships rather than within individuals, acknowledging that learning derives from social engagement and collaboration (Engeström 1987). The second generation of the web has created a space for increased interaction, collaboration and creativity that is based on a participatory culture facilitated by online communities (Greenhow et al. 2009; Minocha 2009). There is some evidence that collaborative online tools like wikis and blogs can help expose the upper limits of students’ understanding around a subject, thereby allowing a teacher to help them navigate through their individual ZPD (Luckin 2008). Online social networks can be utilised to promote student interaction and engagement1 with learning materials and with their teachers (Ivala & Gachago 2010). However, there is evidence that, rather than using emerging online tools to facilitate the social construction of knowledge, learners still have a tendency to focus their use on gathering content (Farren 2008; Rowe 2009).

There are several challenges to be addressed when considering the integration of technology into healthcare education in a South African context. These include poor access to computers and the Internet, low levels of digital literacy and socio-economic factors that disadvantage certain groups of students from the outset (Rowe & Struthers 2009). A previous study within this department also found that students had a poor understanding of social software and that they did not make effective use of common online tools. However, the same students also expressed being open to new approaches of teaching and learning, as well as a willingness to engage with lecturers outside the time and space of a traditional classroom environment (Rowe 2009).

These ideas challenge us to find innovative ways of guiding students through a curriculum where the teaching of technical skills and content is only a part of developing professional competence. We must also find ways of helping students to make meaning of their clinical experiences through reflection and knowledge sharing within the often hidden culture of their professional community. Gallimore and Tharp's theory of assisted performance was identified as a framework that could help facilitate the development of reflective reasoning skills among undergraduate physiotherapy students. The aim of this study was therefore to determine if an online social network could be used to expose students’ understanding of complex clinical and ethical issues that arose during their clinical practice experiences, and from there to facilitate the reflective reasoning that forms part of the development of practice knowledge.

Methods

Setting and sample

The research was conducted among all third- and fourth-year students (n = 70) in a university physiotherapy department during 2010, in Western Cape, South Africa.

Research design

The research design was qualitative in nature, making use of Tharp and Gallimore's theory of assisted performance (1991) as a teaching framework to guide the development of reflective reasoning among students’ clinical placements. Student–teacher, student–student and teacher–student interactions were analysed qualitatively by the author.

Procedure

An online social network was created on a private server using a Wordpress multi-user blogging environment with the Buddypress plug-in installed. The network was only accessible by the staff and students within the department and was therefore not indexed by search engines. It was important for both students and staff to know that their work would be private. Students and staff within the department were registered as users on the network and participated in a workshop to familiarise themselves with the relevant features of the social-networking platform. During the workshop, the students were given assignments that were constructively aligned with the module outcomes of clinical practice II and III, as well as the professional ethics in physiotherapy module.

The fourth-year students were required to write two reflective posts on their clinical experiences during their clinical placements during the year. The third-year students were required to write two reflective posts discussing any ethical dilemmas that they had experienced during their clinical placements. These reflective posts formed the basis of their assignments and were in the form of blogs within the social network. All students were required to read and comment on the posts of others within their year level, throughout the duration of their clinical placements. They were also expected to link to additional media and external sources in order to support their claims and statements. The lecturer took the role of facilitator and read through students’ posts, regularly providing comments, suggestions and questions to try and guide students’ reflective engagement with their experiences.

Analysis of results

All assignment-related interactions2 within the network were reviewed by the author, taking into account student–student, student–teacher and teacher–student interactions. The posts were analysed thematically and categorised into pre-determined themes based on the Theory of Assisted Performance. The themes included: modelling, contingency management, feedback, instruction, questioning and cognitive structuring. A second reviewer with experience in clinical education was asked to ensure trustworthiness of the analysis.

Ethical considerations

As this study formed part of a larger project on the use of emerging technologies in clinical education, ethical clearance had already been obtained from the University of the Western Cape ethics committee (registration number: 09/8/16) and the head of the physiotherapy department. Although students were required to participate in the assignments as part of the continuous assessment of the modules, they did not have to participate in the research that took place afterwards. Students were given full control over their data and gave informed consent for their assignment responses to be used for the analysis. Each potential respondent was given an information sheet that allowed them to make an informed choice about how their data could be used. No students asked for their interactions to be removed prior to the start of the research.

Results and discussion

Examples of interactions within the social network are presented below, in order to demonstrate how the theory of assisted performance was used to facilitate the development of clinical and ethical reasoning as part of clinical practice. Each section begins with a statement, and then provides quotes to demonstrate evidence for the statement. Student (S) and facilitator (F) quotes are presented within the pre-determined themes.

Modelling of desired behaviour

The online social network was used by the facilitator to demonstrate to students a structured approach to reflecting on their experiences. In the context of this study, modelling desirable behaviour was taken to mean examples of reflection given by the facilitator (F), in order to demonstrate expectations to students. In the example below, the facilitator responds to students’ reflective post, highlighting their own reflection based on what the student has written. Another student (S) then responds with his/her own thoughts, ending his/her comment with his/her own question to stimulate further discussion.

F: Thank you for an honest and thought-provoking post. I think that the issue you’ve raised is something that will need a lot of thought and discussion, and is deeply unsettling when we consider the consequences for some people. I’d like to highlight a few thoughts I had when reading your post, and which may serve to stimulate more discussion:

(1) It's not only children with disabilities who are neglected. I read this story earlier today (URL provided), which really highlights the point.

(2) Children with no disabilities bring about enormous changes in lifestyle … kids with disabilities exacerbate this change even more, and some parents just can’t cope.

(3) Many parents who can’t cope are incredibly frustrated and feel like they have no outlet for their emotions.

(4) Having said that, it's never acceptable to neglect or abuse someone, no matter what the supposed reason is. Thanks again for the post.

S: This is a very interesting topic and it really makes one think! Firstly, I agree with [F] that it is not only disabled children who are neglected or abused. There are parents who have perfectly healthy, beautiful children but still abuse or neglect them. There are children who are being abused by their fathers or mothers physically every single day. I think that a child who has a loving mother should be given a chance to live no matter what his/her condition is. I read an interesting piece where the author states that ‘the right to abortion is denying our right to exist’ [citation]. This author also makes a point that there are people who become ill during their lifetime and need to receive intensive care, physiotherapy, etc., just like a child who is born with a disability and would need that same care. Can we make the decision of whether a child should live or not?

In the example above, the conversation was initiated by a reflective post from a student. The facilitator then took that thought and extended it with additional comments, reflections and questions, which were taken up by another student. This highlights that modelling is an important component of any interaction, as students often lack the confidence and understanding of how to structure reflective work. By narrowing the scope of the process through scaffolding, the facilitator can help reduce frustration for the student, assisting them to move towards self-directed learning (Sharma & Hannafin 2005).⁠

Contingency management

The facilitator used the online social network to praise students’ behaviour during their clinical placements. The asynchronous nature of the online space allowed for this interaction to be followed up after the event, as well as distributed to the entire class who were separated geographically. In the first interaction below, the facilitator (F) rewards desired behaviour through praise and encouragement. This is followed by an example of a different member of staff (F2) giving a student praise in another scenario.

F1: Hi there … I would like to make an announcement to this group. I invited 2 of your classmates to conduct an exercise class to a group of elderly people … . The feedback from the group about the professionalism of the one student who conducted the class was amazing. Everyone was thrilled at how the class was conducted, the concern displayed for participants throughout the session and the continuous education and advice received. As a professor of this department, I was proud to be associated with students of such a high calibre. WELL DONE and THANK YOU for making [us] proud.

F2: … congratulations on a job well done. You noticed something important that everyone else on the team had missed. The patient may be alive today because you picked up on that one small point. That fact that someone else took the credit misses the point. You did something great, and made a real, objective difference in a patient's life.

In the above examples, it is clear that the online social network facilitated an exchange between staff and students in which students were openly congratulated for their professional behaviour. Students often feel that their role within the health system is undervalued at best, and merely tolerated at worst, when in fact they have the potential to play an important role (Nilsson et al. 2010⁠). Their development as clinicians relies in part not only on their understanding of their role within the multi-disciplinary team but also in terms of the value that they perceive they bring to it. Encouraging students’ contributions to patient management develops their confidence in terms of continuing to make those contributions.

Providing feedback to students

The facilitator was able to effectively use the commenting feature of the online social network to provide regular and consistent feedback to all students, regardless of where they were placed. Two of the major issues that arose during the assignments were that students often felt uncertain that they had made appropriate decisions around patient management and potential conflict with others members of the team. Providing feedback is one of the most effective means of assisting students in their formative progress, but it is often neglected (Chowdhury & Kalu 2004)⁠. In the examples given below, the facilitator used student posts as opportunities to give feedback on their original reflections, whereby they were questioning certain actions they had taken within the clinical context.

F: Nice comments. You’ve definitely looked at many alternatives and considered the outcomes of each. And I think the way you began your comment sums it up … ‘Is it really that simple?’ I think you showed clearly that it's not. Well done.

I like the way you handled the situation. Making the call from the nurse's station made your point way more powerfully than if you had merely confronted the nurse. Well done for both doing the right thing, but also doing it in a way that didn’t lead to confrontation.

Well done for standing up for yourself. It's OK to disagree with someone else … . As long as you’re respectful, you’re free to disagree with other members of the team.

Students viewed this assignment as an opportunity to seek validation with regards their decision-making processes around patient management and teamwork. In fact, writing about their clinical decisions has been demonstrated to help students develop a deeper understanding of their interactions with patients and colleagues (Williams et al. 2002). It was clear from their posts that students needed to feel that an appropriate clinical decision was made; thereby, helping them to feel that they were contributing something useful to the team.

Instructing the learning and reflective processes

The online social network was effective in allowing the facilitator to convey instructions to the students, both prior to and during the assignment. The facilitator gave the students information on the tasks to be undertaken as part of the assignment, both within the social network and as a handout in class during the workshop. In addition, further instructions were posted online as questions arose, using a “just-in-time” approach to provide relevant information to students as they needed it (Higdon & Topaz 2009). This was done to prevent overloading the students with information that may or may not have been important to them in the beginning (Greenhalgh 2001). In the example given below, the instructions were related to technical problems that several of the students had encountered and that they subsequently asked about.

F: Hi everyone. Here's a quick note on how to add hyperlinks to your blog posts …

– Copy the URL (the bit of text at the top of your browser that begins with ‘http://www…’) of the page you want to link to i.e. the external source you want to use

– Highlight the word/phrase in your blog post that you want to use to create the link … [remainder of instructions left out for the sake of brevity].

Let me know if you have any problems”

In the example above, the instructions to the students can be seen as a voice directly telling them to “do” something, which is important in order for them to develop their own voices as self-directed learners (Tharp & Gallimore 1991). As the student develops their capacity for filling in the gaps in their own knowledge, the direct instructions of the facilitator can be reduced. This scaffolding can then be reduced as the student develops a better understanding of the process (Sharma & Hannafin 2005).

Stimulate thoughtful responses through questioning

The facilitator used thoughtful questions in an attempt to encourage further reflection, creative responses and alternative viewpoints from the students. This strategy is used not to elicit information from students, but rather to expose the logic of one's thinking process in order to stimulate critical, independent thinking (Paul 1990). In the first example below, the student has made a statement in response to a situation they had encountered. The facilitator then uses questioning to highlight some of the issues that the student has not considered as part of the original post. In the second example, the facilitator poses question that might challenge the students’ thinking around deeply held belief systems. Again, the idea is not to elicit actual information but rather to have students expose their own thinking to critical reflection within the context of the online social network (Sharma & Hannafin 2005).

S: I personally feel that in a country like South Africa at times when done in the first trimester abortion is the right option and the mother and father should have this option available to them. Poverty is a big problem in this country and often unwanted babies are left of [sic] the streets or worse to die … [remainder of the post left out for the sake brevity].

F: Nice idea [S], I’m looking forward to this conversation. I have a few questions for the group. (1) Is it appropriate for the father to have a right to assert his beliefs re. the reproductive health of the mother? What happens in cultures when the women is subservient to the man? Will he have the only say in the matter? What does the [South African] constitution say about this (i.e. what is the legal stance)? Is poverty a reasonable reason to consider having an abortion? What other reasons can you come up with?

F: [In response to a students’ statement about the role of religion and culture in ethical decision-making] But religion (or any other belief) makes something ‘right’ or ‘wrong’, so how can [we] not take it into account? … We’re trying to be objective so that we can treat everyone fairly, but for many people it's impossible to be objective because their beliefs run so deeply and they feel them so strongly. Can we ignore the beliefs of others? Should we?

The questioning from the facilitator highlighted in the examples above led to further reflective posts from the original students, as well as from other students who then joined the conversation. The use of questions allowed the facilitator to develop a better sense of students’ level of understanding, while at the same time involving them in the construction of their own knowledge⁠ (Graffam 2007). The social network was therefore used effectively to elicit critical reflection by posing questions in response to students’ blog posts and comments.

Create a framework for cognitive development

The nature of the online social network allowed students to pose complex clinical scenarios that they had experienced, and for the facilitator to then help guide the students’ thinking process around the resolution of the problem. The facilitator tried to provide a framework for thinking and acting in order to develop a cognitive structure for the students to establish conceptual relationships between ideas. This then helped the student to move forward and resolve the particular problem they were having. In the example below, the student has asked for help in how they should have dealt with a complex situation on the ward. The facilitator then used the opportunity to explain how they would have acted in the same scenario, thus exposing their clinical reasoning and thinking processes to the student.

F: This is a very difficult situation to have found yourself in and there are no easy answers. I agree with what you say about giving the mother (your references are all about the patient, not the family/guardian) realistic expectations of the outcome … I would’ve first gone to the nurse/doctor and asked for a patient prognosis/update. Then I would’ve gone to the mother and said something like the following (obviously this is shortened):

– Mrs. so-and-so, this is what has happened to your baby …

– These are the probable outcomes …

– However, without having all the information, recovery is also possible, although the chances are small …

– Do you have any questions? Is there anything I’ve said that you don’t understand?

Often, families (and patients) just want to know what is going on. Doctors and nurses often don’t have the time to spend explaining things to relevant stakeholders, and it falls to allied health professionals to do this. I [sic] think it's important for a patient's family to have the time to prepare themselves for the worst outcome, while at the same time being open to the best outcome. Thanks for sharing this story.

In the above example, the facilitator provided a framework for the student to help them get a better understanding of the clinical problem they had encountered. It was also clear that the students struggled to find relevant and authoritative content that they could use to develop their own knowledge and understanding. The online social network made it easy to provide students with links to relevant content that would address the problems they identified, but it could also be accompanied with context from the facilitator rather than just a link to content.

Limitations and recommendations

Care should be taken to not over-interpret the results of the study and conclude that students’ understanding and clinical reasoning was actually improved. Quantitative outcomes were not evaluated, so while the study demonstrated that it was possible to use an online social network as a platform for developing reflective practice, further research is needed to determine whether or not social networks have a role to play in the development of real clinical competence. It would also have been useful to include a short survey following completion of the assignment, in order to evaluate students’ perceptions of the process. This may have provided insightful information in terms of improving the process for any further studies in this domain.

It should also be noted that although students self-report was that they were regular users of online social networks in the context of their social lives; this did not transfer well into the educational context. Significant feedback was required by the facilitator in order to guide students in terms of referencing, structuring of their posts and using features of the network to strengthen their arguments (e.g. by embedding images or linking to external sources). The workshop held at the beginning of the assignment was essential for many students to get a better understanding of how to use the network. Educators should not make assumptions about students’ ability to engage with each other using online social networks. In addition, any use of a technology for teaching and learning should take place within the context of a constructively aligned task, rather than merely for its own sake.

Finally, it would have been useful to have students from both year levels read and comment on the posts of students in other classes, that is, for the third-year students to read and comment on fourth-year experiences. This may help them to prepare for the challenges to be expected in their final year. It would also give the fourth-year students opportunities to provide feedback to third years, helping to guide the less-experienced students by using their own personal experiences.

Conclusion

It seems that online social networks can be used to facilitate teaching and learning in the context of clinical education, even among students with limited Internet access in a resource-constrained environment. However, constructive alignment of the learning task and its assessment must be integrated with effective teaching practices in order to bring this about, and a focus on the technology misses the point. Using this framework (i.e. the theory of assisted performance) within a social network clearly demonstrated that online social networks can be used to develop reflective practices among undergraduate physiotherapy students. It also helped expose individual students’ levels of knowledge and understanding of complex clinical situations, thereby allowing the teacher to guide them through their ZPD towards a deeper understanding of appropriate professional responses. In addition, the features of the social network made it relatively simple to engage with students in an active, dynamic system that allowed for multiple viewpoints and perspectives to be integrated. Clinical educators should therefore consider the use of online social networks to facilitate the reflective practices that are so important in the development of practice knowledge among healthcare professionals.

Acknowledgements

The author wishes to thank the National Research Foundation for funding which made this research project possible. In addition, this research project was carried out with support and guidance from the Southern Africa FAIMER Regional Institute (SAFRI).

Declaration of interest: The author reports no conflict of interest.

Notes

Notes

1. Engagement = energy devoted to academic activity; Astin 1984.

2. Students and staff members also engaged with each around other assignments and course-related work. These interactions were not reviewed as part of this study.