Reflection and reflective practice are professional midwifery requirements and as such form a vital part of each midwives' personal development and practice (Wain, 2017; Bass et al, 2020). Reflection is an educational strategy, improving students' capabilities to engage actively in their learning, to consider their practice learning with a critical and analytical lens and enhance their journey towards competent practice (Carter, et al, 2017; Gallagher et al, 2017). This reflective outlook commences at the outset of the journey to becoming a midwife, with student midwives learning reflective writing from the start of their undergraduate programmes. However, there is little literature about how student midwives experience the process of learning the art of reflection during their training and how they integrate reflective working at the outset of their careers (Gallagher et al, 2017; Bass et al, 2020).
Reflexivity can assist students to negotiate the increasingly complex workspaces of practice and enable an autonomous and independent approach to problem solving and emerging professional identity. This practice has the potential to assist students to develop qualities essential to their role as qualified practitioners, including critical thinking, understanding the impact of human factors on healthcare working practices and self-evaluation. It also allows students to stand at different perspectives in relation to clinical events. As the author, my own process of reflection as a midwife has been hugely influenced by previous arts and drama training and I was keen to explore ways of integrating this as I undertook my MA in Higher Education Practices. This was part of my development as a lecturer at the outset of my own new learning journey.
The midwifery community readily discuss how professional practice is a blend of arts and science, whether a clinician, researcher or educator, these skills together enable practitioners to provide a holistic overview whatever their midwifery role (Wickham, 1999; Power, 2015). However, midwifery education is delivered predominantly in an academic, health science setting, which can create challenges to being inclusive of arts-based practice and therefore, the creative and artistic elements of midwifery learning (Jackson and Sullivan, 1999). This is mirrored in students' experiences of placement education, with many women and birthing people choosing to have babies within the medical environment of the hospital rather than domestic environments, emphasising the prominence on the technocratic model of birth and therefore, the scientific realm of midwifery learning.
Doing reflection as a creative act: the workshop idea
How can midwifery educators embrace these two concepts of art and science and align them for student midwives' training? Prior to midwifery training, I was an arts and drama student, spending much time reflecting on the process of making, via journaling, photography, visual learning and collage (Moon, 2004) and wondered whether this process of reflection could be an inherent part of the midwife studentship. Students require opportunities to explore their emerging professional identity, experiences from placement and their feelings in caring for others, and using arts-based practice activities can provide an alternative way of holistically reflecting on their own practice.
Arts-based practices offer students the chance to engage with the less ‘scientific’ elements of care, such as empathy, politics, spirituality and intuition, which are all crucial elements to their emotional competencies and ability to relate effectively with service users. Reflective work in undergraduate programmes is typically based on formal models of reflection such as Gibbs (1988), Schön (1983), Kolb (1984) and Johns (2009), with students structuring their writing around critical analysis of a practice experience to create links between theory and practice. McCarthy et al's (2018) integrative review shows that practice is a main concern for nursing and midwifery students. Student midwives vocalise nervousness and find clinical placements challenging, worrying about ‘getting it wrong’ with patients (Edwards et al, 2010; Chernomas and Shapiro, 2013; Bagcivan et al, 2015). Throughout my own teaching practice, I noted that students' reflections often focus on elements of practice in which they felt they had done ‘badly’, and their exploration was concerned with how to improve upon their performance.
My own reflection
As I marked students' reflections, their perspective appeared to be one of an external position rather than internal to the experience. It appeared that to effectively analyse their practice experiences, students demonstrated a need to externalise and distance themselves from the experience they were trying to explore. Unused to citing themselves in their academic writing, I observed students struggling with placing themselves within the context of the experience and it was this dissonance that led me to consider whether there might be another way to link theory and practice via reflecting in a different form (Noble and Pearce, 2014). This struck me as the opposite of what was being asked of them, in terms of deepening their understanding of their lived experience of clinical learning, initiating a desire in my own practice to ensure that reflection was seen less of a ‘chore’ where students feel as though they should ‘do better’, and more of a pleasurable way of seeking to understanding their learning (Baid and Lambert, 2010). Academic reflective activities are considered in a linear and written format, often used as a ‘what I did wrong’ tool to amend situations for next time, and I wanted to see if I could facilitate them to reflect as a holistic development opportunity.
The decision to pursue this idea of creatively reflecting was built on a scoping project I worked on with the Royal College of Midwives. Redesigning the evidence/practice connection investigated the gap between the evidence-based information student midwives learn at university and the practice they observe and learn in their clinical placements. There is much discussion exploring students theoretical/practice knowledge-gap (Armstrong, 2009; Jamshidi, 2012) and the inconsistencies between practice and theory teaching, which had previously led me to examine how reflection bridges the theory and practice divide and how to integrate these two learning arenas. During my MA, I worked collaboratively with a medical illustrator to address this gap by generating a set of visual cards following a series of student meetings, a way of students carrying knowledge from theory into the practice area as confidence building tools.
My role as an educator is to foster an outlook of facilitation and promote deep learning processes (Biggs, 2003; Rieger et al, 2016). Using techniques of spiral learning (Kolb and Kolb, 2005) as well as scaffolding understanding (Allan et al, 2009; Nabaho et al, 2017) by building up layers of different knowledges from different epistemological viewpoints, the possibility for new knowledge creation is generated. Blending these strategies with visual communication by applying arts-based research to midwifery practice enriches perceptions and promotes new modes of engagement (Barone and Eisner, 2008; Lampum, 2018). Arts-based research has an aesthetic focus (Lampum, 2018), challenging health science norms of certainty and definite knowledge, instead offering multiple ways of seeing (Meizirow, 1990). Arts-based research resists the structured, orderly systems in health sciences that rely on definite outcomes. Using visual communications for student midwives can loosen students' understanding of these systems and offer the opportunity for challenging existing practices, and as Lampum (2018) suggests ‘invites the knowledge user into an alternative epistemology’. This can promote critical thinking strategies for independent learning, in turn leading to new routes for knowledge acquisition.
During the mastery of concepts, students occupy a liminal space in their learning (Meyer et al, 2006), a position of becoming competent as a practitioner, but this experience is uncertain and can feel unsafe; a process ever-present in arts-based research practices where there is no definite answer, but rather the focus remains on the process. Students must move through impersonating their supervisors to the security of self-assured knowledge possession, which can create the opportunity for interpreting information for themselves, making as Lampum (2018) states ‘the knowledge user crucial to the creation of meaning’. This is vitally important for student midwives in the process of autonomous clinical decision-making (Power, 2015). The understanding that knowledge retrieval improves learning (Karpicke et al, 2009), as well as visual communication engaging the knowledge-user in an emotional way (Colantonio et al, 2008; Lampum et al, 2012; Lampum, 2018), demonstrates further application and relevance to this kind of learning in midwifery practice. Learning the instance of care the ‘art’ or creative elements of midwifery provides students with a range of learning strategies to scaff old their emotional transition during the process of mastery as well as facilitating them to uncover the interrelatedness of the knowledge they are developing.
College as reflective practice: the innovation
I intended to integrate more creative teaching methods, attempting to become what Brookfield (2015) describes as the critical reflective teacher, acting from an inert knowledge that learning to learn is important for both student and teacher alongside being willing to engage in new teaching methods. Offering new problem-based learning provides a chance for both student and teachers to be actively creative, promotes metacognitive learning and enhances learning processes (Rance and Sweet, 2016). As an educator, it was important to try and consider how to engage students in reflective practice from a different perspective.
The idea of a collage workshop felt ‘risky’ as a relatively new midwifery lecturer, and so initially it was offered as an optional session before becoming part of what is now a core component of a module exploring complex childbearing. This ‘risk taking’ can be interpreted as what Hensley (2018) describes as ‘trickster teaching’. This type of trickster teaching can help students think pluralistically and help sustain life-long learning by nurturing the whole student rather than formal teaching methods, which can feel fragmented and disjointed. Hensley (2018) argues that a transmissive education ethos is skill driven and efficiency focused and removes teachers from the individual student needs. By stepping outside teaching norms, transformation is possible in a class, and this is what I experienced during the creative sessions I have facilitated. Because of my own creative background, this is a way of using an existing skillset to add something new to the midwifery team and incorporating my learning about academic pedagogies surrounding creative practice into the classroom.
The workshop introduced ideas of collage, giving examples from text, textile and visual-based collage from a range of artists. I wanted the students to immerse themselves in the experience rather than externalising their experience so they could examine it. I asked them to recall the environment, leading them through a basic relaxation and guided visualisation asking them which sounds they could remember, what the lighting was like, what could they smell, hear, see? Using creative imagination generating imagery from a clinical episode linked to the module content set the scene for the workshop, asking students to seek insights rather than judge their actions at the time. I ensured that if they wanted, they could stop the creative imagination exercise when they wished, as some of the topics had the potential to be quite challenging.
When this exercise was completed, we created a relaxed learning environment together, giving them space to consider materials to use, the size of their collage and reiterating not to worry if they were not sure where to start. We played music, with students moving tables and chairs to create a more relaxed atmosphere, and students had decided to bake and bring food to share, making a creative picnic party atmosphere. We spent the next hour and a half developing collages together (Figure 1), as I went around discussing their ideas, why they were choosing words, colours and other aspects of their work. Some of the students were very unsure, stating that they were not ‘arty’ and asking why we were undertaking this in their midwifery module. Because of this reticence, I felt it was important to join them by creating my own collage, placing myself in a vulnerable position alongside them, and sharing in their process as a way of reassuring and confirming that this was not an assessment of their artistic ability but just a way of exploring ideas.
After collages were complete, those who wished remained in the classroom and shared the ideas behind their pieces, explaining the clinical experience, or the motivation behind wanting to explore the care episode further. This was perhaps the most interesting part of the workshop for me, not knowing what to expect and being surprised and emotionally very moved by their discussion. Students reported that making their collage had allowed them to see the situation from a new perspective, to consider themselves in that situation differently and to really acknowledge how they had been touched and changed by alternative reflecting.
Examples of student evaluations of the workshop
- ‘I really enjoyed the collage reflection the other day-it was so refreshing and a unique way to explore reflecting on practice. It is something I will definitely do again.’
- ‘I found it very relaxing and reflective. Loved hearing everyone's ideas and thoughts.’
- ‘[It] was a good way to relax but reflect at the same time.’
- ‘I explored my fears over emergency situations and the scary red buzzer… Thanks again’
- ‘Quite therapeutic and was lovely to be able to think about, reflect and show things in a creative way.’
- ‘It is very soothing.’
- ‘I thoroughly enjoyed the visual reflection session, it is something I have used since and I think allowed us to explore our thoughts and feelings without the need of formal reflection.’
- ‘Loved how innovative and new some sessions were eg art session and role play sessions.’
- ‘The collage session was such a nice way to reflect with peers.’
- ‘Also this morning's session was amazing! It really opened my eyes to new ways of reflecting which will greatly benefit my practice. Having a new way of expressing all my placement experiences/thoughts/ideas will be very helpful. I particularly look forward to sharing my visual reflections with my practice assessor as I often get very flustered and anxious in my meetings with her and lost for words when she asks me to reflect on how everything is going.’
- ‘Thank you so much…for…this morning, I was very dubious, but it's been more beneficial to me than I could've imagined. Thank you!’
Discussion
Following the first workshop, students voiced that it had been a ‘different’, yet beneficial experience and some participants in subsequent workshops have requested that this should be offered in each of the modules, with a chance to link the creative practice to module content. Spurred on by this vote of student confidence, I am currently integrating the workshop into a professional practice module, developing a series of creative learning workshops to support this desire for alternative reflection.
Students commented that much of the value of the workshop was also in the sharing of the process with other students, suggesting that this should become a mandatory part of the session. Students who were reluctant to share because they did not feel confident in their artistic outputs were supported by their peers and encouraged to share their process, resulting in an empathetic and collegial environment in which to take risks.
Those who were unsure reported that it had been more helpful than they envisaged, commenting that they had to put their reluctance and doubt aside and try and embrace the learning, likening it to embracing new experiences in the clinical learning environment.
Some students stated that they felt ‘reluctant’ and ‘unsure how useful they would find it’. When I revisited their feelings after the workshop was complete, they discussed how their assumptions of its value were based on their fear of not being able to ‘do it well’ (Chan, 2013), but how in fact, through the process of creative practice they had become invested in the ideas and thoughts they wanted to convey, which took the pressure off the ‘finished product’.
As the workshop has developed over the last 4 years, I have learnt as a facilitator that it needs time for students to engage in the sharing element to enable all participants to take part, and to encourage those who may feel less confident to share their work, and that this discussion has learning value as much as the collage creation. During the pandemic, we persevered and moved the workshop online, which also worked well, with a good level of engagement and students sourcing their own materials, motivated to take part in a ‘fun’ session in what had been described as a module full of ‘heavier’ topics.
Student feedback and evaluation has consolidated my feelings as a facilitator that there is good reason to include creative methods in midwifery teaching, allowing students to explore political, emotional spiritual and wider cultural aspects of their emerging development and feeding their notions of developing a professional identity.
Conclusions
Learning from experience, both in terms of the practicalities of my teaching role as well as the development of knowledge, tacit and otherwise, are challenging concepts to teach. Many student midwives are invested in the notion of life-long learning and reflection is central to this professional attitude. However, reflection is often presented to students as a form of improving their performance in the practice setting and as a structured piece of written work, rather than as a holistic and creative tool that can take on many forms.
Reflective thinking develops students challenging ‘routine thinking’ and assisting the bridge between theory and practice integrating knowledge into action. I will continue to pursue creative opportunities and take risks alongside the students creating a collaborative learning environment.
There is a need for better understanding of reflection if a shift towards reflective practice as a lifelong learning strategy is to be achieved in midwifery.
Key points
- Educators, in both clinical and academic settings, need to consider how they enable reflective skills when working with student midwives.
- To provide opportunities for transformative learning, it can be necessary for both educators and students to be willing to try new teaching strategies and step outside usual teaching methods.
- Arts-based practice offers an alternative opportunity for students to relate to the emotions experienced in their placement learning.
- To continue to be reflective practitioners, it may be necessary to engage in reflection from alternative perspectives to that of a written process.
- It is important to acknowledge that students learn in different ways and that the written reflection is only one way to facilitate student understanding of their own developing practice.
CPD reflective questions
- How do you currently view your own reflective practice?
- Do you embrace and look forward to reflecting or do you find it hard to embed reflection into your own everyday practice?
- What obstacles do you encounter when considering reflection about your own practice?
- What are the factors that enable you to reflect and learn from this reflective experience?
- How do you currently facilitate student midwives to reflect, whether in clinical or academic environments?