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Margaret McAllisterSTAR : A Transformative Learning Framework for Nurse Educators

  

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STAR: A TransformativeLearning Frameworkfor Nurse Educators

Margaret McAllister1

AbstractContemporary nursing education in Australia needs to respond to the imperatives

facing clinical practice (A* that nurses be work-ready, resilient, multi-skilled, good

team communicators, compassionate and responsive to the diverse needs of clients

and families. Transformative learning principles combined with effective, action-

based learning experiences can provide a focused pedagogical basis for cultivating

and achieving these graduate outcomes. In this paper, a novel framework is pre-

sented that provides a structure to support educators and curriculum development.

The STAR framework, which stands for Sensitivity, Taking action and reflection,

is easily remembered and embodies key aspects of transformative learning.

Keywordscritical reflection, transformative education, transformative learning

Introduction

Australia, like the rest of the world, has been experiencing a severe shortage of

registered nurses for over three decades (Australian Institute of Health and Welfare

[AIHW], 2010). While this is a multifaceted problem, there has been recent

1 School of Health & Sport Sciences, University of the Sunshine Coast, Maroochydore DC, Queensland,

Australia

Corresponding Author:

Margaret McAllister, School of Health & Sport Sciences, University of the Sunshine Coast, Locked Bag 4,

Maroochydore DC, Queensland 4558, Australia

Email: mmcallis@usc.edu.au

Journal of Transformative Education9(1) 42-58

ª The Author(s) 2011Reprints and permission:

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acknowledgment that the crisis has deepened to include a shortage of nurse educators

(Benner, Sutphen, Leonard, & Day, 2009). Many are reaching retirement age and the

numbers of qualified educators replacing them are inadequate (Sayers & DiGiacomo,

2010). There has tended to be an overreliance on part-time educators, usually clinical

experts, who have had little preparation for an education role (Halcombe, Andrews,

Peters, Salamonson, & Jackson, 2009).

At the same time as developments within health care and the consumer movement

have added complexity to the nursing role, the challenges for nurse educators have

also increased.

There is a regulatory- and industry-driven imperative to equip nursing graduates

with specialized techniques needed in a highly complex technological health care

environment; and also interpersonal effectiveness so that they can work in and lead

teams, problem-solve ethical dilemmas, and communicate respectfully with clients

and families (Morison, Johnstone, & Stevenson, 2010).

There is also awareness that nursing education needs to play a more active role in

resolving the widening health inequities, particularly within vulnerable populations

such as those who are ageing, who have mental health problems, or who are living

with enduring and multiple health conditions (De Chesnay, 2007). Furthermore, edu-

cators are teaching to a more diverse student body and larger class sizes because of the

widened access to university education (Potempa, Redman, & Landstrom, 2009).

Thus, nursing educators need to alter the curriculum to prepare graduates for this

more complex health environment and yet not overwhelm students with content

knowledge and swiftly engage, captivate, and inspire nursing students to commit

themselves to a challenging and changing health career. For all of these reasons, the

principles of transformative learning resonate soundly for nurse educators.

Originally coined by Mezirow (2000), transformative learning can be defined as

the process by which we call into question our taken-for-granted frames of reference,

or habits of mind, to make them more inclusive, open, and reflective so that they may

generate beliefs to guide action (Taylor, 2009). In nursing education, these habits of

mind may include technorationalist discourse, teaching as transmission, and learning

to understand. Transformative learning theory helps to problematize such habits of

mind and stimulates awareness of other ways of knowing.

Over time, transformative learning theory has been developed and applied by

many educationalists, with different implications for instructional design and facil-

itation (Brookfield, 2000; Cranton, 2006; Dirkx, 2001). This article will primarily be

working from the perspective that Mezirow elaborates, particularly in relation to his

notion of critical reflection.

The Learning and Teaching Context

At the University of the Sunshine Coast in Queensland, Australia, a 3-year under-

graduate nursing program produces approximately 200 entry-to-practice nursing

graduates annually. Over 40% of these students are mature-aged and others are

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recent high school leavers. Approximately 90% are female. This program, like most

others offered across the country, relies on input from a range of nurse educators.

Some are experienced, educationally qualified academics, but the majority are

clinical experts who lack educational preparation and who also tend to lack an

explicit pedagogy to drive their practice (McAllister, Mosel Williams, Gamble,

Malko-Nyhan, & Jones, 2011). It was within this context that a teacher-oriented tool

encapsulating transformative learning principles, and termed the sensitizing, taking

action, and promoting reflection (STAR) framework, was developed. The frame-

work’s aim is to provide a useful tool for developing curriculum experiences that inte-

grate the principles of transformative learning.

It was developed because the theory of transformative learning, while arguably

well fitting for nursing and health programs, is unfamiliar to many educators

working within health, and important concepts may be difficult to remember. When

educators have difficulty with new concepts, they tend to revert to that which is

familiar, such as the ‘‘chalk-and-talk’’ method, didactic lectures, and the like (Iron-

side, 2004). Therefore, the STAR framework aims to be a simple, easily memorized

framework that assists educators to apply the principles of transformative learning.

It brought together a number of concepts discussed in transformative learning and

relevant to empowered action in nursing and health care.

Transformative Learning for Nursing Students

A meta-review of educational research articles found transformative learning to be

the most researched and discussed topic in the field of adult education (Taylor,

2007). Despite wide variations in approaches, this theoretical perspective on adult

learning usually emphasizes a process of (a) awakening or sensitizing students to

issues of social justice and impressing upon them their role in making a difference;

(b) engaging students with innovative, action-based, powerful learning modes that

develop critical, creative, and constructive cognitive skills; and (c) reflection to

make meaning of the learning experience and to revise and replace unhelpful habits

of mind (Cranton, 2006).

The value of transformative learning for nursing students lies in its ability to

awaken them to issues of injustice that lead to and sustain health inequities and to pro-

mote in them critical thinking and questioning of previously held assumptions,

beliefs, values, and perspectives, so that they may be part of systemic change. Exam-

ples include exploring the health and well-being of vulnerable populations, people

who experience marginalization, and those who are not well served by the health ser-

vices. Transformative learning experiences fit well with the pursuits of nurses because

both entail applied humanism; the use of liberal educational strategies such as narra-

tive, poetry, metaphors, film, and literature can evoke imagination, empathy, and care

(O’Sullivan & Morrell, 2002). These qualities are vital for the contemporary nurse.

The concept of taking action, as it is explained by Mezirow (2000), also

offers important insights for health and nursing educators. Nursing is inherently

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action-based. Indeed, the noun and title itself draw on the verbs ‘‘to nurse’’ and ‘‘to

be nursed.’’ Without a theoretical lens to help identify when, and what kind of,

action is needed in client care, students may be tempted to ‘‘nurse’’ a client, regard-

less of need and without attention to the facilitation of empowered action.

According to Mezirow (2000), it is not all action that precipitates transformative

learning, only that action that evokes disorienting dilemmas among the learners.

Establishing an environment of reflective discourse is therefore vital to the educa-

tor–student relationship in nursing so that the students are encouraged to reflect

on what actions, if any, are needed and who should be the change agent. A simple

example is the student working with a new mother who is tentative about bathing

her baby. It could be that the mother simply requires from the nurse supportive

words. Alternatively, it may be that hidden within this situation is a deeper dilemma

that reflective dialogue may help to uncover—that health workers who take control

may be encouraging dependence and miss opportunities to foster parental self-

efficacy. By encouraging hesitation, contemplation, and questioning the very idea

of action in nursing, learners may be able to move beyond understanding toward the

achievement of new insights that facilitate empowered action—be that within them-

selves, colleagues, clients, or communities.

In Mezirow’s (2000) view, individuals and groups experience disorienting dilem-

mas that can become a trigger for deep learning. Thus, it is not the objective for edu-

cators to protect students from these dilemmas but rather to assist them to reflect on

them and arrive at new understandings to better equip them for future practice and

for the advancement of the profession. For example, one dilemma frequently expe-

rienced by students is that nursing was once the main profession that laid claim to the

central place of care (Watson, 1979), but there are now many professions who incor-

porate caring theory into their practice (Gilligan, 1982; Noddings, 2003). Students

often experience a disconcerting threat to a once firm social role. Experiencing this

dilemma for the first time may challenge students’ identity within the health care

team (Bandali, Parker, Mummery, & Preece, 2008), but it may also lead to new

insights about shared care and collaboration and the importance of continuing to

develop nursing’s role.

Another dilemma students may experience once they have mastered the suite of

technical procedures needed for health care monitoring and treatment is to notice

that technical rationalism has its value but also its limitations (Dirkx, 2001),

especially when procedures are not sufficient to help clients and families accept and

integrate their health problem into their lives (Smythe, 2003). Simply administering

an insulin injection into a newly diagnosed adolescent diabetic who feels anger or

distress about having the disease illustrates this insufficiency. Thus, challenges for

educators are many and include efforts to develop and enact positive professional

identity, interprofessional respect, and competent technical abilities as well as

psychosocial capabilities.

Rather than it be the case that technical know-how is unnecessary, it is more help-

ful to see that technical and communicative knowledge are useful. Thus, educators

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can assist students to notice, discuss, and work through dialectical tensions and

the need for both—and thinking, rather than binary thinking (Nelson, Palonsky, &

Carlson, 2007).

Transformative learning also sees that the crowded curriculum is not an inevita-

ble or insurmountable problem but rather a challenge that is powerfully reframed by

considering threshold concepts. As Meyer and Land (2006) explained, there is a ten-

dency among educators to stuff their curriculum with content, and this is an issue

often discussed in the nursing education literature (Diekelmann, 2004; Ironside,

2004). Meyer and Land argue that this additive approach, closely connected to trans-

mission models of learning, ultimately burdens both the educator with the task of

transmitting vast amounts of knowledge bulk and the students with the imperative

to absorb and then reproduce it. By examining threshold concepts in the curriculum,

nurse educators are provided with a strong rationale for including learning

challenges on topics that are particularly troubling or debated in nursing, and where

unlearning, interruption or reenvisioning is required.

The STAR Framework

The STAR framework encapsulates these notions from transformative learning the-

ory. The educator’s orientation toward the learner is in Sensitizing, Taking Action,

and promoting Reflection (see Figure 1). These elements are not designed to neces-

sarily be used in sequential steps, although this is not precluded. It is possible, for

example, that students could be encouraged to reflect after being sensitized and

before taking action. Similar to Kolb’s (1984) theory of experiential learning, learn-

ing is deepened and linked to future action when the three elements of the framework

are included. The idea is that educators design learning experiences so that all three

aspects are emphasized, the learner’s experience is foregrounded, and educators are

assisted to resist inadvertently slipping into a transmission orientation (Pratt, 2001).

Recently, the framework has been introduced, applied, and evaluated by nursing

and other health educators in an action research study currently underway. Examples

of how STAR is being utilized by educators are being collected so that they may be

disseminated to other educators and thus build capacity in educational creativity and

effectiveness within the University and advance the discourse of transformative

learning.

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•Awake too human issues

Take Acti

•Knowledlinked toac�on

ion

dge learned is o appropriate

Promote

•Habits ochalleng

•New peemerge

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of mind are ged

erspec�ves e

Learn

•Empath•Skilled•Though

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Figure 1. The sensitizing, taking action, and promoting reflection (STAR) framework.

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Sensitizing

The first principle of the STAR framework is the value in sensitizing students to

issues of social import. Unfortunately, many students of nursing are not aware of

important historical, political, and social issues that have shaped and continue

to influence health care, patient participation, and their own professional practice

(Nelson & Gordon, 2004). This leads to fragile self-identity and self-confidence

(Madsen, McAllister, Godden, Greenhill, & Reed, 2009). Frequently, students do

not understand why they are studying particular concepts and are instead eager to

go out to the clinical world to practice (Gallagher, 2004). They are also not suffi-

ciently sensitized to the impact that health inequalities are having on peoples’ lives

and as a result have not been galvanized into committed action (Daiski, 2004;

Farmer, 2004; Reutter, Sword, Stewart, & Rideout, 2004). As a result, there has been

a disappointing lack of progress by nurses in effecting health system change

(Lynam, 2009; Vonfrolio, 2006).

According to the principles of transformative learning, it is these health inequi-

ties, as well as nursing’s lack of progress in addressing them, that ought to become

threshold concepts and be explored in depth. Cousin (2010) explains that educators

have an important role in identifying threshold concepts in disciplines and also in

listening to students’ misunderstandings about these, providing a holding environ-

ment for the toleration of confusion, and expecting that it may involve a number

of takes for such a concept to be learned by students. The STAR framework, with

its appreciation for needing to sensitize learners about issues that they may have

become inured to, or ignorant about, is a succinct explanation of why and how

threshold concepts are necessary to explore within a curriculum.

Nursing students can be made aware of these and other issues and hopefully be

inspired to contribute to change. They also need to appreciate that much of what

nurses do and learn to do operates at an unconscious or tacit level. This awareness

can, in itself, be liberating because it helps them see how the dominant paradigm in

health care—medical science—sets the agenda, creates hegemony, and co-opts

many nurses into unwittingly supporting practices that are ultimately self-

defeating and that constrain change. Freire (1972) and other critical theorists would

term this conscientization.

An engaging way to apply the transformative aim of awakening students to issues

of importance in nursing is the idea of ‘‘sensitizing’’ students to patients’ health care

experiences and nurses’ parts in either exacerbating or ameliorating distress.

The key to sensitization is to engage learners’ senses in listening, observing, feeling,

and touching through using powerful media such as first-person testimonials, film,

music, poetry, and novels (Infinito, 2003). The aim for nursing students is to

appreciate the (a) significance of a learning issue on peoples’ lives and (b) to expe-

rience a disorienting dilemma that challenge habits of mind that tend to be routinely

taken by nurses and by students that would have ordinarily been used to understand

the situation. In this way, the objective is transformation.

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Consider this example: The issue of nursing the person experiencing schizophrenia

is raised. Students may be asked to draw upon and reveal their feelings, concerns, and

aspirations about this work. Frequently, this elicits discussion around fear, stigma,

feeling out of one’s depth or concern about exacerbating symptoms in clients. Next,

a 2-min video advertisement, located through YouTube and part of the ‘‘Time to

change’’ U.K. media campaign to end discrimination can be played. One production

is entitled ‘‘Schizophrenic man terrifies kids at party’’—a headline familiar to students,

often used by journalists, and which subtly yet insidiously reinforces the notion that

people with mental illness are terrifying and unsafe. Yet the video goes on to dismantle

this habit of mind, by showing a gentleman entertaining children at a party by ‘‘scaring’’

them with balloons and a game of hide-and-seek (http://www.time-to-change.org.uk/).

Playing the video sensitizes students on the issue of stigma, creates some levity in the

classroom and a freedom to speak about other fears and uncertainties.

In other words, auditory, visual, kinesthetic, or immersion experiences can

sensitize students in novel and powerful ways to significant health and social issues

such as marginalization of minority groups, sexism, the poverty cycle, inertia, fear,

loneliness, disability, and the journey of living with a chronic illness. As Dirkx

(1997) has explained, learning can be transformative when we open our minds to

feeling rather than logically interpreting—what he has termed soulful learning. The

STAR framework, with its emphasis on sensitizing reminds educators of the impor-

tance of taking the time to nurture this soulful learning, and develop in students, not

just dispassionate logic, but an engaged empathic stance, for both will be important

in their work as nurses.

The process of sensitization assists students to make meaning of the learning and

to see its relevance to the nurse’s role and to life. In this way, students can be awa-

kened to issues of social and health inequities and they can be assisted to identify

their role in making a positive difference in professional practice.

Taking Action

Taking action is the second principle in the STAR framework. This relates to the idea

that there is value in educators making space within the learning experience for stu-

dents to take action or put into practice newly learned knowledge or skills. Without

this space, students may simply learn for understanding, achieving accumulation of

knowledge, and this may do little to effect social change. In a transformative class-

room in nursing the aim is to produce clinicians who are committed to take action—

be this in the stance that they take with clients, or with their colleagues, in actions

that they choose not to take, or in new behaviors. Several educational theorists

(Hooks, 1994; Freire, 1972; Brookfield, 2000) have powerfully argued that theoriz-

ing and reflecting can also be radical actions because they lead to social change.

Thus, students in nursing who are assisted to theorize and reflect are also in a sense

taking relevant and radical action that can ultimately change the health care world.

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Similarly, when actions are not linked to knowledge in nursing, they are downright

dangerous. For example, proceeding to take routine blood pressure measurements

when the client has a more important need for pain relief can be harmful, and requires

the nurse to think first, before acting.

In order for new educators in nursing to remember this notion and convey this to

students, STAR emphasizes the importance of ‘‘taking action,’’ but stresses that

action needs to be linked to knowledge and theory and students need time to discuss

and invent new ways of taking action around an issue.

Unfortunately, however, literature and local experiences indicate that nursing edu-

cation continues to emphasize a one-way flow of knowledge, usually emanating from

the active educator (Ironside, 2004), and this leads to at least two deficiencies.

Declarative knowledge, modeled by the all-knowing educator, becomes favored by

students over knowing how and why, which are understandings revealed in context and

in action; and students get very little time to develop praxis, or the practice of ideas.

A simple medical example, illustrating the problem resulting from an imbalance

between knowing that and knowing why, is that teaching nursing students to under-

stand oxygen is pointless if students do not know how, why, and when to safely

administer it. Knowing that oxygen is a gas is not sufficient. Knowing when it is

indicated, and how to give it for different conditions are crucial. For students to

come to appreciate this knowledge linked to action, they need time and space within

the learning experience.

Other situations when knowledge might exist, but not be put into action include

knowing about anatomy and physiology, yet failing to interpret signs of pathology

using clinical reasoning (Tanner, 2006); knowing the value of active listening but

failing to utilize it during client distress (Bowles, Mackintosh, & Torn, 2001); know-

ing that professional behavior entails demonstrating respect yet failing to show this

in multidisciplinary teams (Zwarenstein & Reeves, 2006), and knowing self-care is

an important healthy practice yet failing to utilize it themselves (Jackson, Firtko, &

Edenborough, 2007). Unfortunately, opportunities for students to convert knowl-

edge into action are not always a priority for time-pressured nurse educators. How-

ever, if educators appreciate the need to make space for STAR elements within

lectures, then theory would be discussed in the context for how it will be later linked

to nursing actions.

A powerful strategy to assist students to enact the practice of ideas, or praxis, is to

have them use the think-aloud technique (Offredy, 2002), whenever they are practi-

cing a nursing technique. This can be powerfully modeled by educators explaining

what they are doing as they are doing it and can be emulated, critiqued, revised, and

reconstructed by students during laboratory sessions or clinical placements.

Another strategy that may prompt students to challenge habits of mind and put

into action alternatives is to encourage conscientious objection. For example, after

learning about a health inequity, students could be requested to write a letter to a

political organization explaining why they no longer intend to support an irrational

or damaging policy, highlighting the shift in thinking they have undergone. In this

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action, students are revealing the aspects of their thinking that have been trans-

formed and also implementing political action while drawing on research-based

information. In this way, students have been encouraged to notice that inequities

do not need to be accepted and have shown that it is their role to seek to drive sys-

temic change and achieve better health outcomes for all. Such strategies that encour-

age students to take action and put knowledge into use are likely to be far more

engaging than simply listening and absorbing and may trigger the achievement of

transformational objectives.

Reflective Learning

In achieving empowered nursing practice, thinking is bound to action (Freire, 1972).

This is praxis. Therefore, for students to be able to ‘‘Take Action,’’ they need to be

putting into place deep thinking. This comes about through reflective learning. Thus,

the ‘‘TA’’ and the ‘‘R’’ in the STAR framework are inextricably linked. Indeed, the

‘‘R’’ can also be linked to the sensitization phase, for if students are to make sense of

affective learning experiences they need to be reflecting.

However, not all reflection is, or leads to, transformative learning. For example,

students may be asked to recall what happened during a simulation learning experi-

ence and recollect actions, verbal exchanges, and outcomes. But this may not result

in a transformed perspective. On the other hand, activities that provoke meaning

making in students by acting as disorienting dilemmas, and are followed through

with dialogue that produces new ideas, and the possibility for new practices, can

be transformative. This is the critical reflection Mezirow (2000) has discussed.

Critical reflection refers to questioning the integrity of deeply held assumptions

and beliefs that are based on prior experience. Critical reflection may not come natu-

rally to all students (Freshwater, 2002). Indeed for it to be well executed, it may need

to be learned and practiced repeatedly like any new thinking skill. Learning how to

reflect can lead to a transformation in perspective, particularly if students learn to

distinguish reflection that is based on content, processes, and premises (Mezirow,

2000). In content reflection, one reflects on what we perceive or think about the

problem. In process reflection, one reflects on how we problem solve and the stra-

tegies we use. In premise-based reflection, one has an awareness of why we perceive

in this way, and the problem itself is questioned. For example, we may ask, Why is

this problem even important? or Why do you think we created this simulation learn-

ing experience to include paramedics and nurses responding to this home-based

emergency? Why not nurses alone, why not in the hospital emergency department?

Such questions cannot produce certainty in answers and may act as a disorienting

dilemma—to carry on learning in single-disciplinary ways may build up nursing

knowledge but not collaboration skills. Answers from students are likely to be ten-

tative and to yield insights on the benefits of students learning with other health/

emergency workers, and how and why this might work to produce social changes.

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According to the literature and my experience, in nursing education, there is a

tendency for reflection to be delimited to content reflection (Ironside, 2004). Educa-

tors, particularly those who lack confidence, preparation, or explicit pedagogy, may

lack the repertoire of questioning strategies to facilitate critical reflection. Therefore,

dialogue among educators about how to cultivate deeper levels of reflection in nur-

sing students is important. Educators need to claim the space for collegial dialogue

because it is likely to enrich the learning experience for nursing students and propel

reflection into deeper layers.

The STAR framework explains that reflection ought to form part of every learn-

ing experience. Reflection activities are those that challenge students’ habits of

mind, invite a rethink on existing nursing practices, or provide thinking tools that

empower students to be able to resist oppressive work practices and resist becoming

dominating agents themselves in the future. Examples for when and how they can be

used are discussed next.

During After-Action Reviews

In military culture, the mission is not over until the after-action review (AAR)

process is complete because soldiers know that errors cost lives, and uncorrected errors

will cost more lives. AAR is a structured review for analyzing what happened, why it

happened, and how it can be done better. AARs are more commonly termed debriefing

sessions in nursing and routinely follow simulation or clinical learning experiences.

By attributing a new name to what has become a taken-for-granted practice in nur-

sing education, raises the possibility of deconstructing the notion of the ‘‘debrief.’’

Debriefing connotes the removal of something from students, rather than an active

meaning-making process that students and educators engage in. AARs can encour-

age students to transfer the learning acquired to other contexts (Dreifuerst, 2009).

For example, a common learning activity is for students to learn suctioning skills

on a manikin. Following the experience, students may be prompted to reflect on

what they think and feel about doing the suctioning therapy. They may be able to

recall modes of administering suction; and they may have felt clumsy, uncertain,

or afraid of hurting the patient. After reflecting on the self, they may now feel more

able to reflect on how the patient might have felt, what other experiences of having

your basic bodily drives (to breathe, to move, to urinate, etc.) controlled by another.

With prompting, they may reflect that uncertain feelings are generated whenever

they are reminded of being a novice or by being with a seriously ill patient, or by

not having a colleague to provide support. These premise reflections, which can

be difficult to elicit, could be prompted by asking learners: Why do you find yourself

becoming clumsier when there is a lack of support?

In this way, students are assisted to appreciate the limits of their own abilities and to

understand the connection between feelings and actions. These insights can be lifelong

learnings for students. Too often, novices fail to realistically appraise their own abil-

ities, and dangerous mistakes, mistakes that may remain uncorrected, can occur.

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A more abstract strategy, known as synectics exercises (Joyce & Weil, 2009), that

can be useful in prompting critical reflection after actions is to provide students with a

metaphorical image, such as a tour guide or a lighthouse keeper, and assist them

through careful questioning to reflect on what happened, could have happened, or

what might happen differently in the future in the clinical situation. Students can be

challenged to find similarities and differences between a nurse’s actions in assisting

a client’s journey of recovery (or illness adaptation) and the actions of a good tour

guide or lighthouse keeper (McAllister, 1995). The power of the use of metaphor is

in making the familiar strange, and the strange familiar and thus in prompting novel

associations between ideas and developing in students constructive thinking abilities.

Throughout the Student’s Journey

Activities that prompt learners to write, either online or in reflective journals, can also

be useful (Boyer, Maher, & Kirkman, 2006). Indeed, the written format potentially

strengthens the reflective experience by creating an actual object of what were previ-

ously ideas of the mind. Writing requires learners to externalize their reflective expe-

rience. Writing also provides a means for sharing with others and helps to consolidate

one’s beliefs. However, journals require caution as they are quite difficult to assess

(Cranton, 2006, p. 147), and one needs to clarify the difference between reflective

learning and mere personal reflections (Bradbury-Jones, Sambrook, & Irvine, 2008).

Learning to be critically reflective is a mature cognitive skill (Merriam, 2004).

Thus, to assist students to understand the difference between personal reflections and

learning, it may be helpful to provide frameworks for students so that they reflect on

nursing issues using a particular lens.

For example, students can be encouraged to analyze their own practice using a

framework such as Tanner’s (2006) clinical reasoning model. Frameworks such as this

may be beneficial because they provide the structure needed to move students beyond

their usual habit of mind and to use a new lens to broaden perspective. Tanner’s frame-

work consists of four consecutive phases in thinking critically about effective clinical

care: noticing, interpreting, responding, and reflecting. Tanner explains that the frame-

work embodies ‘‘thinking-in-action’’ and ‘‘thinking-on-action.’’ She views the frame-

work as a means to promote learning by guiding students to break down the components

of clinical judgment. In this way, thoughts and actions, which would otherwise be impli-

cit, hidden, and not open to review, critique, or revision, are made explicit.

This process of converting the implicit to the explicit is potentially transformative

because disorienting dilemmas may be revealed that prompt a new way of thinking

about the world. For example, students may begin to appreciate that they are noticing

signs (outward manifestation of illness) but not symptoms (the patient’s personal

experiences of illness). They may then appreciate that discussion with clients is nec-

essary to be able to achieve sound clinical reasoning.

Learners are first asked to ‘‘think out loud’’ the cues that they have noticed in

the environment. For example, ‘‘the patient looks pale, her respiratory rate has

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increased, and she has had no medications for 3 hours.’’ The cues can then be sorted

to make an interpretation, such as, ‘‘I think this patient is in pain.’’ The student can

then be encouraged to respond by taking action, such as to discuss with the patient

preferred comfort and pain-relief measures. Finally, students can be reminded to

reflect on the expected effects, and then proceed to take further action; for example,

to evaluate the patient’s response within a specific time period, and to seek further

assistance from the team should the pain not be relieved.

Many other theoretical frameworks can similarly be provided to prompt students’

critical thinking and clinical reasoning. Examples include the CARE framework that

assists nurses to recognize the treatment paradigm and to move beyond it to promote

patient empowerment (McAllister & Walsh, 2003); Kotter’s (1990) change frame-

work that differentiates qualities needed as a leader or a manager; and Kanel’s

(2007) applied behavior change framework, which provides a simple method for

showing clinicians how to first attend to a person’s problem, then to break down

goals into manageable tasks, and finally to facilitate coping during crisis. Each

framework can trigger transformation, if they are used to challenge previous habits

of mind and assist students to appreciate new perspectives on an issue.

Throughout All Educator–Student Dialogical Encounters

The transformative learning literature asserts the importance of creating the possibility

for meaningful dialogue with students (Taylor, 2009). Ideas are generated, shared,

tested, and changed during meaningful dialogue (Hooks, 1994). However, educators

need to be reminded that dialogue is not necessarily debate, and nor is it simply discus-

sion. Dialogue is trustful communication, in which two-way self-disclosure is sup-

ported. Self-knowledge may also be enhanced through gentle challenging, with

mutual consent and on the understanding that suggestions will be validated.

Gentle challenging, also called interruption, is an important part of the transfor-

mative educator’s role (McAllister, Tower, & Walker, 2007). Educators have a

responsibility to take learners to the edge of their knowledge and then to prompt

them to learn something new. In this way, deeply held assumptions and beliefs based

on prior experience are challenged, and critical reflection is achieved. Reaching the

space at the edge of one’s knowledge can be uncomfortable—nobody likes to be in a

position of not knowing something—so educators need to be aware, supportive,

respectful, and encouraging. Challenges can be put to students, such as, Has this

practice always been done like this? What’s the history behind it? Would it always

be the right thing to do? What would be the limits around this practice? Then, stu-

dents need to be given voice. Here, it is important for educators to self-reflect and

consider: Is my voice really needed? Can I make more space for students to speak?

Students also need affirmation that being wrong sometimes is normal, that to occa-

sionally not know something is acceptable, and that changing your mind about what

you believe is permissible. Importantly, students need to understand the expectations

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that are placed on nurses. They then have every opportunity to live up to those

expectations and to learn how to meet established professional standards.

When Critiquing Performance of Self or Other

Dialectical critique is another strategy to promote reflection that produces new per-

spectives. Dialectics is a term coined by Hegel (Nicholson, 1950), a German philo-

sopher and was originally used to explain the reality of tensions in all things

coexisting. For example, all people have feminine as well as masculine traits, but

to recognize this, one needs to engage in conscious analysis, such as to ask, ‘‘In what

way am I feminine? In what way am I not feminine? In what way am I masculine? In

what way am I not masculine?’’ These sets of opposing questions offer a way to see

both sides of an issue, to examine the thesis and antithesis. Students are thus aided to

see new complexity in issues. Simple examples to use after a learning experience are

to ask, In what ways was that a successful/helpful intervention? In what ways was it

not? In what ways is this patient making good progress, and where are his obstacles?

What were my strengths in that intervention? Where have I room for further

improvement? Deliberately looking for the antithesis is one way of revealing hidden

or unconscious aspects of the self and others (Dirkx, 2001) and may yield a deeper

understanding and appreciation for complexity.

When Leaving the Clinical Field

Commonly in nursing, memorable experiences occur for students during clinical

placement. It is here where students encounter real people experiencing real-life

crises and where nursing work is undertaken in the context of dynamic, busy health

care settings. These experiences have transformative potential when meaning is

made about and with them. Questions posed by the educator to encourage not just

a retelling, but an interpretation of the significance of the events help to achieve

transformative learning. Asking students to share what, how, and why events hap-

pened may be good discussion triggers. But questions that prompt premise reflec-

tions or affective knowing can deepen the learning. Students could be asked to

paint the experience, write a haiku, or choose a symbol that illustrates the lessons

about the nursing role they will take with them from that experience. Then students

can be asked to explain their choices. Importantly, students do not have to directly

experience these events to learn from them. Even by discussing events with each

other during end of day groups, students may share in the experience of transforma-

tion, drawing lessons, and enduring meaning from those events.

Conclusion

The STAR framework summarizes complex concepts such as multiple ways of

knowing, threshold concepts, praxis, and critical reflection. It may be a useful guide

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in prompting educators to apply transformative learning theory. It also may become

a useful tool for curriculum development, helping to influence decisions about

which topics to select within a crowded curriculum, and in what experiences stu-

dents may require longer periods to practice newly learned concepts and skills.

Faculty and industry-based nurses can have meaningful discussions to renew nursing

programs by considering the issues around which students are not sufficiently sen-

sitized, or that nurses seek to avoid discussing, developing, or rethinking (threshold

concepts). They can then go on to consider how learning in academic and clinical

fields can be oriented toward accepting that these concepts may require unlearning,

holding, reiteration and repeated practice. Together they may consider strategies to

develop reflection at critical junctures throughout the nursing program. This may be

a more valuable discussion than to consider only what procedural skills should be

taught and therefore risk overloading an already crowded curriculum (Tanner,

Gubrud-Howes, & Shores, 2008).

Alternative pedagogies such as transformative learning are much needed because

health care systems all over the world are in crisis, a major cause of which is the

continuing nursing shortage. There may be many reasons for the nursing shortage,

but an important remedy is the production of new graduates who are informed and

committed agents of change. The simple STAR framework, which summarizes the

transformative learning philosophy, may be a useful tool to remind educators to cre-

ate powerful, transformative learning experiences and to incorporate them into their

everyday teaching practices. Such experiences should aim to sensitize, engage, and

radicalize students to commit to changed actions in future practice. The experiences

should include active student participation and opportunities to observe, ponder, cri-

tique, and reflect, in order that nursing practices are not simply accepted and blindly

followed. Capabilities beyond treatment, monitoring, or those related to psychomo-

tor tasks should be cultivated in students at every opportunity. These capabilities

include team work, leadership, delegation, communication, and problem-solving

skills, all of which align well with the principles of transformative learning: shifts

in perspective and knowledge linked with action.

Acknowledgments

The author acknowledges Julie Hanson for assistance with the literature review, and Dr. Leigh

Findlay for editorial assistance with an early version of the manuscript.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship,

and/or publication of this article.

Funding

The author disclosed receipt of the following financial support for the research, authorship,

and/or publication of this article: The Office of the Vice Chancellor, University of the

Sunshine Coast, provided funding for this project.

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Bio

Margaret McAllister is professor of Nursing at the University of the Sunshine Coast. She is

the program leader of the Master of Mental Health Nursing, and is a credentialed mental

health nurse with higher degrees in Arts and Education. Her research areas include solution

focused therapy, resilience, self-injury, the history and future of nursing and enhancing the

quality of education through transformative learning and inter-professional learning.

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