NURSE EDUCATORS ’ PERCEPTIONS ON FACILITATING REFLECTIVE THINKING IN CLINICAL NURSING EDUCATION

This article seeks to publish the results of nurse educators with regard to how reflective thinking of learners can be facilitated in clinical nursing education. The results were obtained through a perception survey using an agenda focus group in the second phase of an original study whose aim was to develop a model to facilitate reflective thinking in clinical nursing education. A qualitative, exploratory and descriptive study, which was contextual in nature, was conducted. A concept analysis of reflective thinking was conducted based on the principles described by Wilson (1963:23-39) and Gift (1997:75-76). These results (unpublished) were used to guide the perception survey of nurse educators on how reflective thinking can be facilitated in clinical nursing education. An ‘etic’ approach to qualitative data analysis was used (Morse, 1994:166-167), and categories were placed in the matrices as described by Miles & Huberman (1994:241-243). The results revealed empowerment of the learner through different teaching strategies, assessment and evaluation methods, and the supporting attitudes in accordance with the three phases of the reflective thinking process. Trustworthiness was assured by adhering to Lincoln and Guba’s (1985:290) principles such as credibility, transferability, confirmability and dependability. It is recommended that a model to facilitate reflective thinking in clinical nursing education be developed with guidelines to assist nurse educators with the implementation of the model.


INTRODUCTION
Much has been researched as to what critical and reflective thinking are, but how these higher order thinking skills can be facilitated especially in clinical nursing education, is not addressed.The nursing profession is challenged with the provision of quality assurance in its education and training system and the production of graduates in line with the best practices to meet international standards (National Plan for Higher Education, 2001).Central to quality nursing education is reflective thinking facilitated by learner-centered teaching strategies and evaluation methods that foster collaborative interaction and sharing of ideas and feelings (Van der Horst & McDonald, 1997:127).
Facilitating reflective thinking is the heart of outcomesbased education (Van der Horst & McDonald, 1997:5, 144) since all educational programmes should provide a balanced view by developing the learners' critical and reflective abilities in making rational clinical decisions and solving problems, that is 'fitness for purpose'.
Clinical nursing education is a dynamic, constantly changing, real-life environment where learners are able to marry the theoretical component with practice.Lindsey and Hartrick (1996:107) argue that clinical nursing education requires nurses to truly reflect on the promotion of health and healing.The focus in facilitating reflective thinking should be on learners providing evidential reasoning, justifying their actions, making rational interpretations, deductive inference, weighing evidence and distinguishing between weak and strong arguments in the process of decision-making and solving problems (Miller, 1992(Miller, :1406)).Reflective thinking is a composite of knowledge, skills, attitude and values where, in nursing, a comprehensive and holistic approach to clinical nursing education is imperative, and facilitating reflective thinking becomes a vehicle to realise this aim.Nurses should strive to be reflective practitioners by developing reflective inquiry minds.They should be open-and fair-minded, be flexible, honest in facing personal biases, prudent in making judgements, willing to consider, clear about issues and orderly in complex matters (Facione, 1990:2) The purpose of this article is to describe the results of the perception survey conducted with nurse educators regarding how reflective thinking of learners can be facilitated in clinical nursing education.Before data could be collected in this aspect, a concept analysis to clarify the meaning of reflective thinking was conducted as the first phase of an original study to develop a model to facilitate reflective thinking in clinical nursing education.The perception survey formed the second phase of the study.The results of the concept analysis provided a theoretical definition namely: Reflective thinking is a rational, progressive cyclic interactive mental process influenced by hierarchical cognitive and affective thinking skills.It is triggered by the uncertainty in a situation bringing about a state of mental awareness and disequilibrium which leads to an interactive constructing process followed by consolidation of knowledge, new insight and changed perspective as an outcome for clinical decision-making and problem solving (Chabeli, 2001:107).
The identified attributes from concept analysis that contributed to the formulation of the theoretical definition formed the three phases of reflective thinking as influenced by cognitive and affective thinking skills.
Phase one is the awareness and disequilibrium phase influenced by knowledge, receptivity, comprehension and responsiveness.Phase two is the interactive constructing process influenced by analysis, values, synthesis and organisation.Phase three is concerned with consolidation of knowledge and skills to bring about new insight and a changed perspective for rational clinical decision-making and problem-solving (Figure 1).

Problem statement
In spite of the use of several teaching, assessment and evaluation methods by nurse educators in clinical nursing education, student nurses still demonstrate a lack of reflective thinking in practice as evidenced by a lack of an inquiry mind, and an inability to be reflexive and to adapt to changes for the benefit of the patient.
The following research question emanates: How can reflective thinking of learners in clinical nursing education be facilitated?The objective of the study is to explore and describe the perceptions of nurse educators with regard to how reflective thinking can be facilitated in clinical nursing education.

Nurse educator
A nurse educator refers to a person who is registered with the South African Nursing Council (SANC) as a nurse educator/tutor with expert clinical competence.

Facilitation of reflective thinking
Reflective thinking involves interaction and therefore, in this study, facilitation of reflective thinking refers to a dynamic, interactive process that includes mutual and purposeful involvement between the nurse educator and the learner in clinical nursing education (Department of Nursing, RAU, 1999) with the quest to engage learners to explore knowledge and experiences leading to new understanding and appreciation.

Clinical nursing education
Clinical nursing education is a dynamic, multipurpose environment in which the theoretical component is integrated into practice.It provides the learner with meaningful, authentic and humane experience (Chabeli, 2001:150).

Awareness and disequilibrium
Awareness is a skill of recognition stimulated by insufficient knowledge and skills or any uncertainty in a given situation (Benner, Hooper-Kyriakidis & Stannard 1999:568).Disequilibrium refers to a disturbance in search for mental balance.Piaget (in Woolfolk, 1990:46) states that if the situation does not satisfy the learner and is queer, then disequilibrium exists and the learner becomes uncomfortable due to lack of relevant knowledge of the situation.

Interactive constructing process
Interactive refers to reciprocal, mutual, correlative, interchange, exchange and interdependent (Roget, 1991:54).Constructing refers to make by fitting parts together; building; form by interpretation or explanation (Concise Oxford Dictionary, 1995).Process refers to a course of action or a procedure.It is concerned with 'what is happening in the mind, the course of action' (Concise Oxford Dictionary, 1995).

Consolidation
Consolidation refers to integration and synthesis of clinical knowledge, skills, attitude and values they have constructed with the emergence of new insight and changed perspective (Gravett, 1996:13).

Research design and method
A qualitative, contextual, exploratory and descriptive design was used (Mouton & Marais, 1990:43;Mouton, 1996:103-109).The design is qualitative and exploratory as a means of exploring the depth, richness and com- The first session dealt with the first phase, awareness and disequilibrium influenced by knowledge, receptivity, comprehension and responsiveness.The second phase focused on how interactive constructing process influenced by analysis, values, synthesis and organisation thinking skills could be facilitated.Lastly, the third phase dealt with how consolidation of knowledge and skills for rational clinical decision-making and problem solving influenced by evaluation and internalisation thinking skills could be facilitated.Field notes were taken and a consensus discussion took place to arrive at how reflective thinking could be facilitated.An independent coder, purposively selected, was engaged in the analysis of data (Lincoln & Guba, 1985:290).
An 'etic' approach to qualitative data analysis (Morse, 1994:166-167) was used since the data were analysed in accordance to the conceptual framework resulting from the concept analysis.Much as the existing conceptual framework was used to direct the interview, participants did not follow the levels strictly but explored the way in which they would facilitate reflective thinking in clinical nursing education as a whole.Consensus discussion among participants helped with the establishing of relevant categories.The researcher used the matrix approach described by Miles and Huberman (1994:241-243) to categorise the data meaningfully according to the phases of reflective thinking.The independent coder was given the same protocol to analyse the data meaningfully.The researcher and the external coder, held a two-hour discussion to reach an agreement on the categories and the sub-categories as to how reflective thinking can be facilitated through the three phases of reflective thinking.
A final agreement was reached as follows: the main category became the 'empowerment' of learners with reflective thinking skills.The phases of reflective thinking formed the categories.The cognitive and affective thinking skills as antecedents to reflective thinking formed the subcategories whereas the teaching strategies, assessment and evaluation methods, and the supporting attitudes formed the themes (see Table

One in the matrices).
Trustworthiness was ensured by using Lincoln and Guba 's principles (1985:290).Credibility was ensured by five years of prolonged engagement of the researcher in the study and the use of an expert interviewer, purposively selected to conduct the focus group.The probing of information until saturation was reached ensured credibility of the study.The triangulation of primary and secondary sources during the process of concept analysis, the conceptualisation and the use of field notes increased the credibility.Transferability was ensured by the dense description of the study to enable readers to assess the potential transferability and appropriateness for their own settings.A complete audit trial can be followed as the research design and method are described in details.
Ethical measures were taken with reference to the quality of research, obtaining of informed consent, participants' right to confidentiality, anonymity, privacy HEALTH SA GESONDHEID Vol.9 No.1 -2004   1998).

RESULTS
The description of the results will be made in accordance with Table One.First the main category (empowerment of learners with reflective thinking skills) will be described, followed by how this empowerment can be achieved through the phases of reflective thinking (categories) using the teaching strategies, assessment and evaluation methods guided by the supporting attitudes as perceived by participants in Chabeli (2001:116-147).The direct quotations of the participants are in "italics".

EMPOWERMENT OF LEARNERS WITH REFLECTIVE THINKING SKILLS IN CLINICAL NURSING EDUCATION
Empowerment is an enabling process of development and growth through which a person is enabled to take independent decisions and act autonomously with a view to making a contribution towards the development of their particular environment.This process is coupled with the development of applicable skills, attitudes and knowledge within a positive and democratic climate.
These persons are therefore regarded as professionals in their own right as they are able to make a contribution to change through their particular power (Carl, 1995:7).
The educational literature perceives empowerment within the facilitative role of the educator (Schon, 1991).
All the participants acknowledged the fact that the credibility of the profession can only be regained and  1997:58, 59), as a member of the 'teaching for thinking movement', believes that without the ability to think and to reason, learners are intellectually, emotionally and morally incomplete.They lack the ability to make guided decisions drawn from a sound rational basis.
Empowerment of learners with reflective thinking skills in clinical nursing education is described in accordance with the three phases of reflective thinking and their related subcategories and themes (Table One).

PHASE ONE -AWARENESS AND DIS-EQUILIBRIUM
According to Benner et al. (1999:568), awareness refers to the skill of "seeing" -a skill of recognition.Awareness is triggered by insufficient knowledge or the uncertainty in a given situation.Disequilibrium on the other hand refers to a disturbance in search for mental balance (Piaget in Woolfolk, 1990:46).The two terms are related in that insufficient knowledge or uncertainty will disturb the mental balance of an individual in a specific situation.
The participants were of the opinion that this phase is crucial to reflective thinking.They maintain that the purpose of this phase is to make the learners aware of their deficit in knowledge and feelings in a specific situation.The growing awareness of the self with regard to personal strengths and weaknesses in a particular situation will make the learners ask themselves reflective questions with regard to the situation.This assertion is evidenced by "… when you realise that the situation is strange or unique to you, you become uncomfortable and uneasy and this will make you ready to start the reflective process."Readiness, according to Thomson and Jolley (1997:129), is an attitude of mind that encompasses motivation and capability for the manifestation of self-directed learning behaviour.The awareness and disequilibrium phase is influenced by knowledge and the receptive attitude of the learner.knowledge in order to be able to link new experiences and make meaningful interpretations."Dewey (1933:99) asserts that no reflective thinking can occur in a vacuum.

Knowledge and receptivity
In each and every situation or discipline, basic knowledge plays an integral role in the understanding of the situation.As cited by Deits and Burden (1980:8), "We need to have at our finger-tips a great deal of background knowledge to better understand and interpret the situation".Beyer (1988:49)

Teaching strategies
The participants agreed that questioning, observation, lecture demonstration and narratives are appropriate teaching strategies to facilitate basic knowledge acquisition in phase one.These will be described accordingly.

Questioning
The participants felt that one way of acquiring knowledge is through questioning in order to stimulate thinking, as cited: "…encourage students to ask thoughtprovoking questions, eh, higher level thinking questions that will force them to think".Participants also indicated: "…students must be eager to explore all avenues to get information".Beyer (1988:70) identifies the importance of appropriate questioning strategies in the development of reflective thinking.The focus must be on higher levels of thinking in accordance with Bloom's taxonomy (1956).Higher level questioning must be introduced gradually in this phase.

Lecture demonstration
The participants discussed the importance of lecture  et al. (1998:113) argue that this takes long because an explanation of the procedure and the reasons why it is carried out with special reference to the patient must be provided.This could be followed by a questions and answers session.

Interviews
The participants were of the opinion that interviews are not commonly used for assessing clinical competence, but did acknowledge the important role that the interviews played, as indicated: "It is actually a good method of evaluation, though it is not commonly used.It could be a variety to use interviews as an assessment method, but students get intimidated and their thinking gets blocked with this method".Benner et al.
(1999:558) regard interviews as an excellent method of assessment since participants are given the chance to make themselves psychologically free, and a good rapport is established.The learner is encouraged to ask for clarification of the question during the interview.The facilitator is able to track the learner's clinical reasoning during the interview.

Self-assessment
The participants acknowledged the fact that learners should be exposed to the self-assessment method of evaluation at this level.They realised however, that learners need to be guided as indicated: "Selfassessment is good and needs to be introduced early in training, but they need to be assisted.They may be shy or frightened to talk about their performance.Relax the atmosphere.Self-assessment is a very important method of promote thinking because learners reflect back at their trail of thinking to arrive at conclusions.The authors maintain that facilitators should encourage the learners to tell the story completely as is without fear in order to uncover the practical knowledge and their reading of the situation.The perceived assessment and evaluation methods suitable at this level are as follows: direct observation of performance, interviews and self-assessment.

Assessment and evaluation methods
Assessment and evaluation methods that were considered by participants as appropriate in phase one are as follows: direct observation, interviews and selfassessment.

Direct observation
According to the participants, direct observation of the learner's performance is an important assessment and evaluation method as one of them stated: "…you can actually identify the strengths and weaknesses of the learner there and then and make a follow up.Direct observation in the form of the learner demonstrating the procedure is an old method of assessment and evaluation, yet a good one".A demonstration is advocated by many authors as an effective evaluation method.Heidkergen (1946:305) treats demonstrations HEALTH SA GESONDHEID Vol.9 No.1 -2004 undertaken without preparing the students.Gravett maintains that, for learners to accept this method, they first need to understand the rationale for implementing self-assessment.

Supporting attitudes
In response to the question of how the receptive atti-

Self-awareness
With reference to self-awareness, participants acknowledged the fact that the point of departure in order to be receptive is to know yourself in relation to a particular situation.Self-awareness was considered very important in the initial phase of reflective thinking, as evidenced by a citation: "Self-awareness plays an integral  Open-mindedness Beyer (1988:71, 49) states in this regard that a key disposition, such as willingness to engage in reflective thinking, is a disposition to maintain until the goal has been achieved, and an insistence on evidence and reasoning to justify conclusions and assertions directly supports and drives the reflective thinking activity.You can actually put ideas together to clarify a point".
In support, Duminy and Söhnge (1986:35) state that thought requires language for its expression, and language is derived from culture.In the execution of a thinking task, one cannot always stay in the domain of the observational aspect, the vehicle for entering a realm of abstraction is language.In this regard, Van der Stoep and Louw (1984:80) state that mastering a language enables one to address reality communicatively and as such, the appeal of language forms the basis of one's thinking.
Participants believed that culture could either be an obstacle or facilitate the thinking process of learners at all levels of training as cited: "It is in the culture of some students that you may not invade their space.
Coming closer makes them feel uncomfortable and this distracts their attention and thinking.To some students, it is against their culture to look directly into the eyes of a senior person because it is a sign of disrespect.The interaction between students, and that between the student and the teacher will be greatly

Comprehension and responding
Participants acknowledged the fact that comprehension plays an integral part in reflective thinking.Dewey (1933:133) argues that without comprehension no reflective activity would take place.Instead, ideas, meanings and facts would heap up like grains of sand.
Teachers are faced with the challenge of selecting learner-centred and learner-friendly teaching strategies that will facilitate comprehension of learners.

Teaching strategies
Participants felt that comprehension is brought about by the ability to reason, which can be developed through strategies such as brainstorming, field trips and simulations by role-play, gaming and videos.rewarded by the facilitators, the learners involved will perform better academically than they would otherwise.

Brainstorming
However, the authors assert that facilitators must be culture sensitive and acknowledge cultural differences in learners.One participant stated: "Expose learners to different clinical learning situations where they will be able to brainstorm clinical issues under guidance, that is, a hands-on experience".Quinn (1988:176) believes that brainstorming is a way of obtaining creative solutions to a problem because each member can generate as many ideas as possible, especially where criticism is discouraged.

Field trips
This strategy was welcomed by participants who had an opportunity to internalise the sequence of the procedure and the rationale to perform some actions through practice.These strategies need to be assessed and evaluated for their effectiveness.

Assessment and evaluation methods
The participants believed that, among others, the appropriate assessment and evaluation methods that could facilitate comprehension of learners could be poster presentations, workbooks and observations of performance using checklists and rating scales.

Poster presentations
Participants agreed that poster presentations are not commonly used in clinical nursing education yet, they acknowledged their importance as one of them cited: "This is one method that is not common in nursing education, but it can stimulate the student's thinking".et al. (1998:195) are of the opinion that the potential for learning, which is presented when the students construct posters and have to negotiate the criteria for evaluation, is unlimited, especially if they do it in groups.It facilitates the sharing of ideas and feelings to make a meaningful construction.

Workbooks
With regard to workbooks, participants regarded a workbook completion as the traditional method of assessing clinical competence.They noted that if a workbook is used properly, it could become purposeful.
Its worth becomes defeated by dishonesty of the assessor and the learner, as stated: "Workbooks that are just signed for the sake of signing to get the student out of your way serve no purpose.Tutors must be honest for the benefit of the learners".Mellish et al. (1998:123) urge that workbooks should be designed carefully and explained to the learners.These books should be simple, and the learners should be quizzed about the data recorded and the underlying scientific principles in order to promote their thinking.The authors maintain that complete honesty is necessary for the success of this strategy.

Observation of performance by using checklists and rating scales
The participants felt that direct observation remains the hallmark of clinical assessment and evaluation.They

Enthusiasm
Enthusiasm is regarded as the driving force for learning.
A participant stated in this regard: "A good teacher is one who has enthusiasm, not only for his subject but for life itself.He conveys this enthusiasm and vitality to his students in every word he speaks".Pauw (1993:26) regards enthusiasm as the art of combining subject knowledge with humanness.Enthusiastic facilitators will convey the same enthusiasm to the learners and make their teaching lively and interesting.
This motivates the learners to want to be like the facilitator and thus take responsibility for their own learning, to be self-directed, self-monitoring and selfregulating (Knowles, 1980:44).The positive and motivated response of the teacher will encourage the learner to be involved in the critical analysis of whatever clinical situation in order to make a meaningful interpretation and construct knowledge through interactive facilitation.This leads the discussion to the second category, which is the second phase of the reflective thinking process -the interactive constructing process.

Supporting attitudes
Supporting attitudes such as willingness, motivation and enthusiasm were perceived as playing an integral part in facilitating the comprehension of the learners in clinical nursing education.

Willingness
Participants made it clear that these affective components apply in all phases, depending on the  1995).The interactive constructing process phase is characterised by active participation of learners in constructing their own knowledge, skills and values through interaction.It is influenced by the higher order cognitive and affective thinking skills such as analysis, valuing, synthesis and organisation.The teaching strategies, assessment and evaluation methods as well as the supporting attitudes that were perceived to be appropriate in facilitating reflective thinking of learners in clinical nursing education will be described.

Teaching strategies
The teaching strategies in phase two demands much interaction in the form of discussion, discourse and debate to enable learners to meaningfully construct clinical knowledge, skills and values.Participants identified the following teaching strategies as being appropriate: reflective journal writing, use of the nursing process/case studies, peer group teaching and concept mapping.

Reflective journal writing
With regard to learners writing down their thoughts, participants were of the opinion that the ability of the learners to demonstrate their thinking process facilitates reflective thinking.The learner is able to link the experience with the previous knowledge while performing the action.They believe the use of reflective teaching methods is a step in the right direction, as cited: "Reflective teaching methods engage the students in active thinking since she can reflect on the experience as it happens or after, and make relevant adjustments as a result.This ability is demonstrated when a student is writing a reflective journal or compiling a portfolio, where they engage in interactive dialogue and discourse, debates and narratives".One of the participants further indicated: "Expose students to more thought-provoking situations that demand interaction to be able to construct their knowledge and skills with guidance".(1995:455), in encouraging the use of reflective journal writing, states the following: "journal writing should be less descriptive and more reflective.Grow for teaching because students learn by exploring and experimenting on her own, and in consultation with the sisters in the ward".Quinn (1988:183) confirms the assertion by stating that case studies can be used to very good effect in bringing theoretical issues closer to the real world of nursing.They can evaluate the care of a patient in the light of their own knowledge and skills.

Shields
They can integrate information from a wide range of perspectives and experience.

Peer tutoring
Participants acknowledged the fact that peer tutoring is not commonly used in nursing.However, they noted the fact that it is a good strategy to use, as quoted: "Peer group teaching is good but is not commonly used.
Students become free in expressing their mind and how they feel, but it can become nasty if students use it to get back at their colleagues by asking nasty and provoking questions".Gravett (1996:17) asserts that peer group interaction can be used to explore and clarify ideas, to solve problems, to generate hypothesis, to discuss questions and much more.It gives learners the opportunity to reflect on their learning as they share and negotiate knowledge in a community of learners.

Concept mapping
Concept mapping was regarded by the participants as one teaching strategy that facilitates learners to think, as stated: "It works out better if you group learners together to map out the concepts of a specific theme or experience.They would argue and debate until they get a meaningful map right".The teacher will have to explain the purpose and the learners' expectations as to how the exercise has to be performed.Quinn (1988:293) argues that the mapping analysis of the concept or theme is important as it draws out the learners' existing knowledge and stimulates their thinking skills.

Assessment and evaluation methods
Like the teaching strategies described, the assessment and evaluation methods for this phase require varied and authentic methods that are learner-centred.The following methods were suggested by participants: peer group assessment and critical incident technique methods.

Peer group assessment
Participants felt that peer group assessment like peer easy with the idea.Get more out of it.

Nursing process and case studies
A participant indicated, "Literature has described the value of nursing process in facilitating reflective thinking.Nursing process challenges the learner to think critically.This can be achieved by encouraging learners to engage in arguments and to justify their opinions".In this regard, Atkins andMurphy (1993:1190) state that critical analysis involves examining the components of a situation, identifying existing knowledge, challenging assumptions, imagining and exploring alternatives.A critical analysis of knowledge is undertaken, which involves examining how relevant knowledge is to an individual situation. However

Supporting attitudes
With reference to the supporting attitudes to facilitate analytical thinking skills, participants mentioned, among others, empathy, mutual trust and respect, confidence and courage.

Empathy
Empathy was considered as the driving force of reflective thinking, as stated: "The bottom line of reflective thinking is empathy, since group dynamics depend on the empathetic understanding of other students' opinions and feelings".Empathy plays an important role in facilitating interaction since it is manifested in feelings, thoughts or the behaviour of others (Bennett, 1995:138).This author asserts that

Confidence and courage
A participant stated: "Students who lack confidence and courage cannot be fruitful in the discussion where arguments are necessary, that is for sure.They sit there like frightened people in need of protection".Indeed, courage and confidence give learners 'the will to learn', confidence in their own ability to achieve, and it determines the intensity, persistency, kind and amount of effort which the learners put forth to accomplish a task (Heidgerken, 1946:88).Heidgerken asserts that courage and confidence in one's own ability means that an individual will initiate new methods of action, sustain long periods of deep thought, and continue trying even after several failures.Having described how analysis and supporting values could be facilitated, it becomes important to describe how synthesis and organisation thinking skills can be facilitated.

Synthesis and organisation
HEALTH SA GESONDHEID Vol.9 No.1 -2004 perspective.This will be achieved by prompting thought-provoking questions to members of the group".

Assessment and evaluation methods
When participants were asked about the assessment and evaluation methods that will facilitate synthesis and organisation thinking skills at this level, they indicated that, among others, portfolio assessment and reflective tutorials could be appropriate.

Portfolio assessment
Participants acknowledged the fact that portfolio assessment is a new strategy that emerged with the outcomes-based education and therefore it is not yet popular in clinical nursing education.Those who were familiar with the method gained the knowledge from the theoretical aspect, as indicated: "Based on the theoretical point of view, portfolio assessment seems to be good in stimulating thinking.We shall have to get more knowledge about portfolios and put them into practice".That was a genuine perception on the part of the participants.From literature, portfolio assessments are regarded as highly effective in facilitating reflective thinking.Van der Horst and McDonald (1997:194)

Teaching strategies
The teaching strategies stated above will be discussed simultaneously as they share common characteristics.

Group projects, seminars and workshops
Synthesis needs one to be highly creative and imaginative so as to be able to generate, invent, compose and design new insight and perspectives, as evidenced by: "You, the teacher, must be highly

Self-directed learning contracts
Participants aptly regarded learning contracts as a strategy suitable for senior learners, as indicated: "Learning contracts can be used for final-year students because they have grown in the profession and can take responsibility and ownership for their independent learning and clinical judgement.Unfortunately, learning contracts are not commonly used in nursing education".
To reiterate this assertion McAllister (1996:201) believes that learning contracts is a strategy that is underutilised by institutions of higher education.According to Biggs and Moore (in McAllister, 1996:201), nurses, like other professionals, need to be self-reflective, self-aware, be able to assess their own work and judge the extent to which objectives have been met.The authors maintain that contract learning would make this possible and promote deeper and more achieving level learning.
Learners are able to identify where their knowledge deficits are.They have a sense of control, encourage creativity and feel independent and autonomous in making decisions.

Assessment and evaluation methods
With regard to the assessment and evaluation methods at the third phase of reflective thinking, the participants agreed that the strategies that would be appropriate According to Benner (1982:405), a proficient learner is expected to perceive situations as 'wholes' rather than in terms of aspects.At the proficient level, learners should be taught by using strategies in which their ability to grasp the situation is solicited and taxed.The indicated strategies will be described.

Teaching strategies
The teaching strategies stipulated above require extensive interaction between learners and the environment where learners make use of the knowledge, skills and values acquired throughout the entire training.Ausubel (1968:57) refers to this as a valuable and meaningful 'cognitive structure' on which learners could link future experiences when making clinical decisions and solving problems.

Clinical conference
Participants were of the opinion that senior learners should be involved in a clinical conference, as quoted: " Reflective thinking is viewed as a usable educational tool and is widely recognised as an effective and creative vehicle for lifelong learning and to improve practice.accountability in their decisions.They can now make informed clinical decisions and solve problems.

Responsibility and accountability
With regard to encouraging learners to be responsible and accountable for the decisions they take independently, a participant stated: "Allocate senior students to be in-charge of the wards to allow them to exercise their ability to take responsible decisions they can account for based on evidence.They will be in a position to make their own interpretations of events, take risks, exercise their independent thoughts and feelings as they take informed decisions, make clinical judgements and solve problems on their own".
Nursing is generally known to be characterised by a multicultural, pluralistic society, such as in South Africa.
These societies need virtues that will foster learners to be independent practitioners who should make clinical, ethical and moral decisions, and accept responsibility with accountability for their actions, which is actually an outcome of the reflective thinking process.They need to practise independently and autonomously.Botes (1995:23) postulates that the fundamental characteristic of an independent, autonomous practitioner is the ability to reflect on experience.This ability will enable the person to manage eventualities in a specific situation, and his/her own actions and thinking in a criticalanalytical way.The described integrated approaches of clinical teaching, assessment and evaluation are in line with the contemporary requirements of the outcomes-based education that encourages the facilitation of reflective thinking of learners in clinical nursing education.

CONCLUSION
The described findings of nurse educator's perceptions on facilitating reflective thinking in clinical nursing education revealed various teaching strategies, assessment and evaluation methods with supportive attitudes that can facilitate reflective thinking through the three phases of reflective thinking as influenced by cognitive and affective thinking skills in their hierarchical order (see Figure 2).These teaching strategies, assessment and evaluation methods with the supporting attitudes should be fully conceptualised within the existing practice-oriented theories with the aim of describing the guidelines of how they should be HEALTH SA GESONDHEID Vol.9 No.1 -2004 se beginsels, soos geloofwaardigheid, oordraagbaarheid, bevestigbaarheid en betroubaarheid, na te volg.Daar word aanbeveel dat 'n model om reflektiewe denke in kliniese verpleegonderwys te fasiliteer ontwikkel word met riglyne om verpleegopvoeders met die implementering van die model te help.
plexity inherent with regard to the perceptions of nurse educators as to how reflective thinking can be facilitated in clinical nursing education.The contextual significance of the study lies in the transformation of education in the country in general, and in clinical nursing education in particular.It is descriptive in that in-depth description of the perceptions of nurse educators, recontextualised within the existing literature, was made in order to deductively analyse the information to arrive at concluding statements that formed the basis for the description of guidelines.Twelve nurse educators with extensive experience (ten years and more) on clinical accompaniment of basic nursing students were purposively selected to participate in the study.The purpose of the study was fully explained and consent of individual participants was obtained.Participants were assured of confidentiality and anonymity.An interactive agenda focus group interview (Krueger, 1994:6-7) was conducted for about three hours with breaks in the interim.The central question was: "How can reflective thinking of learners be facilitated in clinical nursing education in accordance with the three phases of reflective thinking as influenced by the hierarchical cognitive and affective thinking skills?".
maintained through empowerment of learners with reflective thinking skills in the clinical nursing education context.This is evidenced by a citation: "…teachers have a responsibility to empower their students with reflective thinking skills since education and thinking are inseparable, especially in the clinical nursing where things happen".Empowerment of learners with reflective thinking skills in clinical nursing education is the facilitator's most-needed challenging responsibility to improve practice.Paul (in Thomson & Jolley, Knowledge and receptivity as antecedents to the reflective thinking process are the lowest cognitive and affective thinking skills responsible for the formation of the self and basic domain specific knowledge necessary for the reflective thinking process to take place.Participants realised the important role played by knowledge acquisition in a specific situation as the building block on which reflective thinking is based.They indicated: "…the learner needs to have enough relevant HEALTH SA GESONDHEID Vol.9 No.1 -2004 urges learners to use credible sources and to seek as much information as possible related to the discipline as the key component of thinking.The question is how this acquisition of knowledge can be facilitated in clinical nursing education, especially in the first phase of reflective thinking.The following teaching strategies, assessment and evaluation methods and supporting attitudes were acknowledged by the participants and supported by literature: questioning, observation, lecture demonstration and narratives.Assessment and evaluation methods indicated at this level were as follows: self-assessment, interviews, and direct observation whilst supporting attitudes necessary were self-awareness, openmindedness and genuine interest/inquiry mind. demonstrations in clinical nursing education at this level.They stated that lecture demonstration is an ideal teaching strategy to introduce basic clinical knowledge of the discipline as pointed out: "In clinical situation we use lecture demonstration to introduce a clinical theme somewhere in the ward.Basic knowledge is taught to students that way.Remember they are very junior, so we must take it slowly".Mellish,Brink and Paton   (1998:113)  refer to lecture demonstration as a lecture and a demonstration given simultaneously.The authors maintain that lecture demonstration needs careful planning as it involves a series of knowledge related to the procedure.A participant indicated: "That is why they must come with the knowledge such as anatomy, physics and chemistry in order to be able to integrate and use this knowledge in their clinical learning".Mellish Observation is another way of acquiring basic clinical knowledge.One of the participants in this regard cited: "Encourage students to use experience as a source and field of reference to clinical learning.Take note of what is empirically observable, what they see, touch, smell or hear and be able to interpret the experience meaningfully.That is, encourage students to mobilise all sensory experience".Duminy and Söhnge (1986:200)    concur with the participants in that observation or the use of audio-visual aids is the basis of the whole structure of the thinking process.Under observation is understood the perception of the external world through the medium of the senses.In building up from the observational level of thought to the more abstract levels, observation calls for the facilitator to use the necessary appropriate teaching and learning aids, such as models, pictures and films to establish a rich concrete layer of thoughts and feelings.These concrete impressions can be gained through experience of the real object in question.Duminy and Söhnge argue that it would be a pedagogical 'sin' for the facilitator to talk about an object (syringe) at first-year level without making an attempt to implant the necessary visual perception.This places emphasis on the importance of placing learners in a HEALTH SA GESONDHEID Vol.9 No.1 -2004 as one of the important generally used methods of clinical assessment and evaluation on the basis of exhibition and explanation.A demonstration activates several senses and correlates theory with practice.Learners are forced to think and re-think what they were taught and try to demonstrate it back in a meaningful manner.Clinical skills laboratory are helpful in this regard.A participant indicated: "Remember, at this level, students are not yet used to clinical practice, so they panic a lot.They need all the support from the teacher as much as possible.The environment must allow them to want to do, not to do because some authority wants her to do".Jarvis (1987:146)  states that reflective thinking should not be authority driven, it should help liberate the minds of learners to think freely.
tude of learners can be facilitated to acquire clinical knowledge, all the participants were of the opinion that the learners' state of receptivity can have either a facilitative or obstructive influence on the acquisition of clinical knowledge.The participants felt that the facilitators must attend to this affective state, especially since most learners are still in their adolescent stage, what Jenkinson (1997:58) refers to as 'storm and stress, a traumatic and highly volatile stage.A participant stated: "Assist students to take stock of their feelings and emotions.Help them to clear off their negative feelings first in order to concentrate on positive feelings towards acquiring new knowledge.Understand the student's background, feelings and emotions and be there for them when they need your support and guidance".Another participant further indicated: "Help them to be in control of their emotions and avoid disempowering emotions such as anger and frustration for these will only drag them down.Always encourage them to be positive and willing to engage in a situation".The facilitators have a challenging task in this regard.A participant said: "Help the students to develop their self-awareness, to be open-minded, to have genuine interest or inquiry mind, to change their attitudes and feelings towards the learning situation.Clearly describe the learning outcomes, the content, the methods and the evaluation process.Over and above, students want to know why they have to engage in learning certain clinical situations".
Atkins and Murphy (1993:1190)  postulate that selfawareness is the result of self-assessment sparked by an awareness of uncomfortable feelings and thoughts in a given situation when one realises that the knowledge is insufficient to deal with the situation.Lack of knowledge makes one to have no confidence and one can therefore be assertive, as supported by one of the participants who cited: "Assertiveness goes along with knowledge, so, encourage students to gain as much knowledge as they can and develop positive attitudes in the situation".Development of self-awareness needs one to be open-minded.
Participants acknowledged the fact that brainstorming is one teaching strategy that can facilitate the reasoning ability of the learner, as stated: "It is through reasoning that one is able to comprehend issues.A student who can reason logically can save lives because she has good listening skills, gives herself time to reflect back to previous experience in order to make meaningful interpretations".A participant indicated: "Reasoning ability is a pillar to facilitate reflective thinking which teachers must focus on".Learners' reasoning skills have to be facilitated from the beginning and increased with their intellectual development.The facilitators should make explicit the steps they take to order statements logically within an argument and describe how conclusions are reached, and thus demonstrate the value of such deliberative activities to the learners when handling verbal information and written data.It also came out clear that the success of brainstorming is brought about by linguistic clarity, cultural sensitivity and accommodation, which play an important role in facilitating comprehension.This assertion is evidenced by a citation: "Language enables one to think because HEALTH SA GESONDHEID Vol.9 No.1 -2004 indicated the importance of OSCE (objective structured clinical examination) in the clinical evaluation of learners, as indicated: "OSCE can benefit the learner if well planned to test higher order thinking comprehensively, and can produce robot-like nurses if the purpose is not HEALTH SA GESONDHEID Vol.9 No.1 -2004 Participants stated that motivation is actually an important didactic principle of teaching and learning as cited: "When students appreciate their importance in taking active part in learning, then you must know that intrinsic motivation has taken place".Heidgerken (1946:95) asserts that teaching is activating the learners to accept responsibility for learning, instilling within them their proper motives.Heidgerken maintains that the facilitators must be aware that the learners come to the profession with fully established and different motives, some of which are good, and others which must be modified with the facilitator's guidance.The author urges that the facilitators establish the background knowledge of the learner prior to introducing new themes.Motivation, especially intrinsic motivation, goes hand in hand with enthusiasm.
involvement of the strategy and on the individual as well as the facilitator.They believed that the learner would demonstrate comprehension of knowledge by responding positively to the learning situation.They would demonstrate willingness, motivation and enthusiasm to participate actively in their learning, as quoted: "Once the student has understood the learning experience, she wants to satisfy her curiosity by developing the willingness and interest in applying the experience.She wants to try out this and that.She becomes motivated to explore the situation.She willingly becomes open to all situations.She will be initiative, enthusiastic and assertive eh…(thinking).By the way, assertiveness goes together with knowledge.It is therefore necessary to determine what the student already knows".According to the participants, no learning will take place without the willingness to learn.One indicated: "Help the learners to develop the desire and willingness to change their attitude and feelings toward the learning situation.Clearly describe the learning outcomes, the content, the methods, and the evaluation process.Over and above, students want to know why they have to engage in learning certain clinical situations".This notion is supported byKnowles (1980:44)  in stating that learners are adult learners and their receptivity to learning depends on what they feel they need to know and apply the new knowledge and skills right away.Motivation HEALTH SA GESONDHEID Vol.9 No.1 -2004 awareness are used".The constructing process refers to a course of action towards building or forming by interpretation or explanation (Concise Oxford Dictionary, response to the question 'How can the interactive constructing process of reflective thinking be facilitated through the use of analytical thinking skills supported by relevant values in clinical nursing education?' the participants indicated that analytical thinking skills play an integral part in the constructing process of reflective thinking.According to one of them this is so because: "Analysis is where elements are broken down into its component parts for the purpose of better understanding and interpretation.I mean the ability to break information in order to identify, describe, classify, compare and contrast issues and to construct better meaning out of the situation.It is quite involving; learners must actively take part in their learning.Teachers must provide strategies that will facilitate interaction, and cooperation, that is…uhm.. (thinking), working together, arguing and sharing information to better understand the situation".
empathy enhances the understanding of the different cultural values and beliefs of others, while Thomson and Jolley (1997:69) maintain that empathy involves mutual respect and trust, good listening skills and patience, good interpersonal skills and communication skills.Trust and respect These values were also recognised as important in facilitating reflective thinking by the participants, as indicated: "Teachers and students must be flexible and accommodate diverse value systems to promote mutual trust and respect in order to enhance understanding of one another".In this regard, Van Hoozer, Bratton, Ostmoe, Weinholtz, Craft, Gjerde and Albanese (1987:188) argue that successful interactive discussion depends on the teacher creating a good rapport with learners, creating a climate of mutual trust and respect, showing sensitivity to learner's response and stimulating active participation.

Table 1 : Results of the perceptions of nurse educators with regard to the facilitation of reflective thinking of learners in clinical nursing education MAIN CATEGORY CATEGORIES SUB- CATEGORIES THEMES STRATEGIES ASSESSMENT/ EVALUATION METHODS SUPPORTING ATTITUDES
) refers to genuine interest as 'wholeheartedness', where the learner will have an active desire to listen to more sides of the story than one.One will have genuine interest to analyse the feelings and emotions of the whole experience.Positive receptivity plays an important role in the comprehension of learners in order to respond appropriately in a given situation.
stated by proponents of multicultural education inBiehler and Snowman (1997:252)is that cultural values and experiences predispose learners to thinking and behaving in particular ways.When these values and experiences are understood and accepted as worthwhile, incorporated into instructional lessons, and(1933:30

Simulations (role-play, games, videos)
indicated: "Field trips are a pleasure to use if you have planned them well.Students get the first-hand experience and are able to correlate theory to practice.They are a pain if not well-planned for you will be refused entry to start with -which is quite embarrassing at times".According to Heidgerken (1946:379) field trips are an educational procedure by which the learner studies first-hand objects and materials in their natural environment.The learner comes into direct contact with the world of nursing.The author warns that without proper planning, field trips will serve no purpose.The same warning applies to simulations in the form of role-plays, gaming and videos.be simulated in the form of a role-play or shown on the video.The learners should have enough practice before they can perform the procedure.The learner should have You don't have to write about all the observations you did or saw, but what is of significance to nursing at that time.Read and reflect on what you have written and say, 'Well, I'll handle it differently next time'.Go and read up about it and get other people's opinions about it.Think… I would work out how it would be best to handle the situation again".Shields asserts that learners would show signs of developing skills of self-analysis and 'critical knowing'.
, the objective of this study is not to describe