A conceptual model for nurse educators to facilitate presence in large class settings through reflective practices: A theory synthesis

doi:10.21203/rs.3.rs-1741584/v1

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A conceptual model for nurse educators to facilitate presence in large class settings through reflective practices: A theory synthesis

https://doi.org/10.21203/rs.3.rs-1741584/v1

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Background: Nurse educators are required to facilitate presence by implementing creative, innovative and reflective ways in interacting with and involving nursing students more directly in the teaching-learning process. Managing large class groups of nursing students and the nurse educators’ daily workload demands, including teaching, clinical supervision and research priorities could hinder facilitating presence through reflective practices.

Methods: Walker and Avant’s strategy of theory and statement synthesis was followed. Theory synthesis included three iterative steps: identifying, defining and classifying main and related concepts, defining relational statements, and organising the main and related concepts, relational statements and conceptual framework into an integrated and efficient representation. Conclusion statements were formulated through statement synthesis.

Results: A model to facilitate presence in large class settings through reflective practices was developed as a theoretical framework to guide nurse educators in their teaching-learning practices. Six conclusion statements for “presence and reflective practices in nursing education” emerged.

Conclusions: This model addresses the gap in the literature and contributes substantially to deepen the body of knowledge in the nursing education domain of the South African context as well as the nursing education domain internationally, to serve as a model for guiding nurse educators in their teaching-learning practices.

Large class settings

Model

Nurse educators

Nursing students

Presence

Reflective practices

In literature, various models are available focusing purely on improving presence in nursing science [1, 2] or the nurse as a reflective practitioner [3]. McMahon and Christopher [2] developed a mid-range theory of presence whereby strategies were identified to facilitate presence skills in the undergraduate curriculum. In addition, literature reveals conceptual frameworks from various authors on reflection. The educational reformer Dewey [4], the founder of reflection that relates to personal learning and constructor of the model of reflective inquiry, emphasised what it means to think reflectively. Schőn’s [5] theory on reflective practices, built on the work of Dewey, linked reflection to professional development and professional practice. The model of reflection in the learning process added that emotions associated with the event are required for reflection to be a valid way of learning [6]. Furthermore, the American sociologist Mezirow [7] developed the transformative learning theory to facilitate the learning and transformation of adults in the business environment which describes how people develop and use critical self-reflection to consider their beliefs and experiences. Black and Plowright [8] developed a multi-dimensional model of reflective learning that contributed to the understanding of reflection for learning with the focus on professional development.

From the above, it is clear that no model exists that includes and focuses on both “presence” and “reflective practices” addressing how nurse educators can facilitate presence in nursing students through reflective practices in a teaching-learning context of large class groups of nursing. Nurse educators working in the North West Province, faced with the challenge of large class settings, need a meaningful guide to facilitate presence through reflective practices as a teaching-learning strategy. A model can be meaningful in this regard as it will guide nurse educators, providing them with a theoretically grounded schematic framework that they will be able to apply in the teaching-learning situations they encounter [9].

Nurse educators are required to implement creative, innovative and reflective ways in interacting with and involving nursing students in the teaching-learning process and to facilitate presence [10, 11, 12]. In the light of COVID-19, when a blended teaching-learning approach is followed, including face-to-face classes in the virtual environment, the class groups of nursing students remain large. This could hinder facilitating presence through reflective practices. The classroom context brings along its own challenges such as managing large class groups of nursing students and the nurse educators’ daily workload demands, including teaching, clinical supervision and research priorities [12, 13]. In addition, having large class settings also creates other challenges such as nurse educators’ lack of knowledge about alternative teaching approaches; time demands for designing, implementing and testing new teaching approaches; a lack of confidence in implementing new teaching approaches in the classroom; selecting and grading assessments; as well as feelings of discomfort and anxiety [11, 12]. Teaching large class groups effectively requires nurse educators to implement more interactive teaching-learning strategies to optimise opportunities for student engagement in the content as well as their learning [10] that will embrace the standard and quality of nursing education [14, 15, 16].

A multi-phased process was followed during the research for model development (Fig. 1). In model development phase A: concept analysis, the main and related concepts were identified, defined and classified. Relational statements were formulated leading to the formulation of a conceptual framework that depicts the relationships between the main and related concepts. During model development phase B: development and description of the model, the model was conceptualised, structured and contextualised through statement and theory synthesis, followed by a complete description of the model. In the final model development phase C: evaluation of the model, the model was evaluated by a panel of experts in step 1. During step 2, the refined model was evaluated through online semi-structured focus group interviews with nurse educators and virtual World Café sessions with 4th-year nursing students enrolled in the undergraduate nursing programme at accredited NEIs.

The developed model have been conceptualised and validated as a framework to guide nurse educators to facilitate presence in large class settings through reflective practices, as overall aim of this study. This paper presents a description of the model developed concerning its overview; the purpose; the identified assumptions of the model; clarifying the context; the structure which includes the identified, defined and classified main and related concepts as well as the designed relational statements which were linked with the process of the model.; the structural components followed by the process description of the model. This model addresses the gap in the literature and contributes substantially to deepen the body of knowledge in the nursing education domain of the South African context as well as the nursing education domain internationally, to serve as a model for guiding nurse educators in their teaching-learning practices.

The aim was to develop a model for nurse educators at accredited NEIs with large class settings to facilitate presence in nursing students through reflective practices as a teaching-learning strategy during teaching and learning. A theory-generative design was followed. The model was conceptualised, structured and contextualised through theory and statement synthesis as proposed by Walker and Avant [17]. The purpose of theory synthesis is to develop the model which is an interrelated system of ideas from evidence and where concepts and statements are organised into a network or whole [17]. The process of theory synthesis consists of three iterative steps. During step1, the main and related concepts were identified, defined and classified which served as anchors for the synthesised model. In step 2, the literature was reviewed to identify and define the main and related concepts and to specify the nature of the relationships between them. Lastly, step 3 ended where the main and related concepts, relational statements and conceptual framework were organised into an integrated and efficient representation, namely the model. Finally, conclusion statements were developed for the two theoretical constructs “presence in nursing education” and “reflective practices in nursing education”. Repeated words, ideas and phrases were categorised together through statement synthesis to develop the final conclusion statements. Conclusion statements for “presence and reflective practices in nursing education” were formulated to strengthen the significance of the model.

The model (Fig 2) was structured and contextualised based on the Chinn and Kramer’s six questions to ensure forming a complete description of the model [18]. The description of the model includes the purpose; identifying the assumptions of the model; clarifying the context; the structure that includes the identified, defined and classified main and related concepts and designed relational statements; and the process description of the model [18].

The purpose of the model

The purpose of this practice model is to provide nurse educators with a theoretically grounded schematic framework to be implemented at accredited NEIs to facilitate presence in large class group settings through reflective practices.

Identifying assumptions of the model

Assumptions are the basic underlying premise from and within which theoretical reasoning proceeds and influence all aspects of structuring and contextualising the model [18]. These assumptions address the basic truths that are believed to underlie theoretical reasoning and will direct the reader as to what we accepts as the truth. The assumptions of the are informed by pragmatism, the “Theory of Presence” [19] and “Promoting reflection in learning: A model” [6]. The practice model for nurse educators to facilitate presence in large class group settings through reflective practices at accredited NEIs is based on the following six assumptions:

Nurse educators and nursing students are multidimensional (physiological, psychological and spiritual) human beings with unique experiences who interact with others and their environment to create reality and together discover presence in the moment and reflect about it.
Nurse educators must be receptive and dedicated to nursing students and enter into the relationship with openness, patience, respect and loyalty.
Nurse educators and nursing students are constantly interacting in an ever-changing world based on experiences. Nursing students’ reactions to learning experiences are influenced by past experiences and the way they perceive the world. They react differently to each learning experience because of different backgrounds and diversity.
Nursing students encounter practical problems in practice and first apply critical thought by considering past experiences before acting and linking them to knowledge.
Nurse educators assist nursing students to manage practical issues by reflecting in different ways at different times and in different contexts maintaining the view that learning objectives are not seen as something that is fixed in advance and which is defined in a strict manner but relates to the development of the other person.
The practice model will be used in the teaching-learning context of large class groups of nursing students and is therefore context-bound.

The context of the model

Contextual placements describe the circumstances within which the model is expected to be empirically relevant [18]. Clear statements about the context is provided to ensure that the model will be useful for practice [18]. In the context of this model, NEI refers to a nursing education institution of learning that provides education and training for nursing students as regulated by the Nursing Act 33 of 2005 [20]. According to R173 of 2013 of the Nursing Act, 33 of 2005, an NEI is an institution with the capacity to offer a prescribed nursing programme upon compliance with the South African Nursing Council prescribed accreditation requirements, criteria and standards for nursing education and training. NEIs can include a university, university of technology, nursing college or nursing school, as well as health establishments [21]. The context in which this practice model will be used is the teaching-learning context of large class groups of nursing students enrolled in the 4-year undergraduate nursing programme at accredited NEIs. The context includes the teaching-learning environment which comprises structured teaching in classroom and clinical practice that includes the conditions and physical areas where teaching and learning of knowledge, skills and values regarding nursing are acquired. It includes the surroundings or conditions in which knowledge and skills are acquired through experiences, the transfer of information and exposure to practical experiences. The “teaching and learning environment” in which this practice model will be used refers to the nursing education environment where nursing students are equipped with needed competencies through interaction with different learning opportunities to enhance the integration of theory and practice. In this environment, a blended teaching-learning approach is followed by nurse educators facilitating presence through reflective practices in large class groups of nursing students which they integrate into their nursing practice to ultimately improve nursing care.

Validation of the model

After the model was contextualised, the developed model was evaluated and refined in two steps. In step 1, the model was evaluated by a panel of experts in model development, reflective practices and presence. They evaluated the model using critical reflection [18] resulting in the refinement of the model. Step 2 involved an empirical phase where the model was evaluated through online semi-structured focus group interviews with nurse educators and virtual World Café sessions with 4th-year nursing students enrolled in the undergraduate nursing programme at accredited nursing education institutions. Recommendations for improvement from the panel of experts and participants were used during the final refinement of the model. The detailed process followed during the evaluation of the model will be presented in another paper.

The structure of the model

The structure of the model is based on the conceptual definitions of the main and related concepts and the relational statements [18] as identified during the concept analysis in phase A.

Conceptual definitions of the main and related concepts

After identifying, defining and classifying the main and related concepts, a conceptual definition was formulated for the main concept ‘facilitating presence through guided reflection for transformative learning’. The conceptual definition refers:

‘facilitating presence is leading and assisting the progress of making practicing presence possible, easier and more likely to happen. This is done through (a) making one’s character, appearance and manner felt by being in a place and being with the other holistically in a caring and compassionate manner; and (b) an interpersonal, reciprocal, co-constructed and intersubjective process that is intentional, deliberate and considered in which the parties relate to one another through socialising, interacting, communicating and actively listening and intimately connecting in the moment where it is safe to share needs, leading to the ability to learn to see what is important to the other, respond with compassion, respond with the next best step by doing what can be done and/or being who the other needs one to be. Facilitating presence requires expertise, craftsmanship, openness, adaptation, vulnerability, intimacy, holism, sensitivity, subtlety, practical wisdom, loving fidelity, alertness, awareness, receptivity and a supportive environment and has therapeutic value. This is achieved through guided reflection where the nurse educator leads, influences, directs, accompanies, and supervises nursing students to engage in serious and careful thought using critical thinking skills by reflecting on their state of being through critical examination of experiences that result in self-inquiry, self-reflection, self-analysis and self-evaluation and in changed perspectives, a better understanding, learning and improved practice. The nurse educator facilitates transformative learning during guided reflection by accompanying nursing students in creating a shift in their frame of reference and a positive change in thoughts, feelings, beliefs and behaviour. In this change process of acquiring knowledge, skills and understanding they discover new meanings and perspectives through studying, engaging and interpreting direct and active experiences and critical reflection that leads to a better understanding, learning and improved practice as a nurse in a present way. When deep, constructive, meaningful learning occurs, it generates a complete change in nursing students’ state of being’.

Designing relational statements

This step involved specifying the relationships between the main and related concepts, how the main and related concepts are linked together, the various forms that relational statements can take and how they can give structure to the practice model [18]. Relational statements was deductively formulated to structurally interrelate the main and related concepts of the model which contained several levels of relational statements comprising a reasonably complete explanation of how these concepts interact [18]. The process of designing the relational statements with specific attention to the substance, direction, strength and quality of interactions which occurred between the main and related concepts was followed [18]. The relational statements developed are as follows:

The goal of the nurse educator is to educate nursing students to become present and reflective nurse practitioners in the nursing education context of large class settings comprising external and internal environmental elements.
The nurse educator facilitates presence by establishing a mediated teaching-learning environment through creating an atmosphere that supports purposeful inquiry and meaningful collaboration and encourages interactive participation where nursing students can feel safe, trusted, supported, respected and free to participate.
The nurse educator establishes meaningful relationships based on mutual trust, honesty and dignity by connecting and sharing learning experiences with nursing students.
The nurse educator poses specific attributes of being a role model, demonstrate professional, personal and moral maturity, practicing relational skills, being open and empowering nursing students in facilitating presence.
The nurse educator facilitates presence by regarding nursing students as adult learners who are self-directed with a life-long orientation to learning and who are motivated to learn and experience needs and interests that learning will satisfy.
Facilitating presence through guided reflection for transformative learning is driven by the mutual need for an authentic encounter between the nurse educator and nursing students for developing an interpersonal connection.
The nurse educator facilitates presence in nursing students by being physically, psychologically and mentally present with nursing students. The nurse educator remains present with the large class groups of nursing students by being attentive and aware of their needs and demonstrating consideration towards their feelings.
The nurse educator guides nursing students towards reflection through leading, influence, directing, accompanying and supervising learning during the acquisition of knowledge through study in the classroom, or skills acquisition through experience in practice.
During the authentic reflective encounter, the nurse educator and nursing students connect and interact in a reciprocal process.
Transformative learning is achieved when nursing students demonstrate a positive change in their thoughts, feelings, beliefs and behaviour resulting in transforming the way they learn in the classroom and act in practice.
This contributes to a positive change in the NEI by enhancing professional and personal development and satisfaction as well as improved physical and mental well-being for the nurse educator and nursing students; and improved learning outcomes and positive learning experiences for nursing students that will lead to producing present and reflective nurse practitioners.
The nursing profession will benefit through professional practice development by increasing the physical and mental well-being of the nurse and patient, improving interpersonal communication as well as meaningful relationships between the nurse and patient, and increasing professionalism and enhanced clinical knowledge for the nurse.
The patients will benefit through increased patient satisfaction, improved patient outcomes and, ultimately, improved quality of nursing care.

Each symbol, colour and connecting line was chosen with careful consideration to convey the correct meaning, influence and impact it need to resemble in this model. The structure of the model is explained according to the structural components identified based on the survey list of Dickoff [22] and includes the activity, framework, agents, procedure, dynamics, recipients and terminus as illustrated and applied in Table 1.

Table 1: Application of the structural components presented in the model

Process description of the model

This model (see Fig. 2) follows a three-phased strategy of Prepare, Process and Product. The process of the model for nurse educators to facilitate presence in large class groups of nursing students through reflective practices as a teaching-learning strategy at accredited NEIs is as follows:

Phase 1: Prepare:

The preparation phase involves preparation and planning for the educational encounter and includes the external and internal environmental elements. The external environment represents the SANC, NEI as a Higher Education Institution, and the clinical practice that prescribes the legal, ethical and professional frameworks that influence and guide nurse educators’ teaching-learning practices at accredited NEIs. The internal environment exemplifies the nurse educator and nursing students as multidimensional (physiological, psychological and spiritual) human beings with unique experiences interacting with each other and their environment to create reality and together discover presence in the moment and reflect about it. The internal environment includes the teaching-learning environment, meaningful relationships, attributes of the nurse educator and nursing students (Phase 1), the teaching-learning process (Phase 2) and the product (Phase 3).

The nurse educator creates the mediated teaching-learning environment by ensuring an atmosphere that supports purposeful inquiry and meaningful collaboration and encourages interactive participation where nursing students can feel safe, trusted, supported, respected and free to participate. This environment consists of the nurse educator creating conducive physical settings and authentic surroundings by utilising adequate resources and implementing sufficient time management as follows. 1) Conducive physical settings: Ensure adequate lighting, sufficient ventilation, appropriate layout and classroom seating arrangements. Within the clinical practice, the nurse educator establishes a conducive environment through adequate orientation and effective accompaniment of nursing students. 2) Authentic surroundings: Connect with nursing students through active participation, interaction, engagement and meaningful feedback and provide opportunities for self-reflection and self-assessment. 3) Adequate resources: Include relevant study material (study guides, textbooks, handouts, etc.); correct equipment (Proxima, white board, flip charts, manikins, etc.); adequate support (faculty, colleagues, peers and students); the effective use of technology including technological strategies; and design appropriate reflective exercises. 4) Sufficient time management: Allocating sufficient time for specific educational tasks and activities.

The nurse educator establishes meaningful relationships that are open and promote mutual trust, honesty and dignity by connecting with and attuning to nursing students. The nurse educator utilises reflection to examine and transform nursing students through creating a shift in their frame of reference through discovering new meanings and perspectives, aiming for a positive change in nursing students’ thoughts, feelings, beliefs and behaviour, and encouraging nursing students to engage in studying to acquire specific knowledge, skills and understanding needed for nursing practice.

In this process, nurse educators inspire nursing students to engage and interpret direct and active learning experiences by utilising critical reflection. Within this model, the nurse educator and nursing students enter into the educational encounter, each with their own specific attributes. The nurse educator needs to be enthusiastic, communicative, compassionate, sincere and trustworthy through providing stability for nursing students during teaching and learning. The nurse educator must portray certain attributes by being a role model, exhibiting professional, personal and moral maturity, demonstrating relational skills, being open, and empowering nursing students as follows. 1) Role model: The nurse educator role models presence behaviours to nursing students that will help them to internalise the behaviour to do the same during patient care. This is done by sharing experiences and intimately connecting in the moment where it is safe to share ideas. This enables nursing students to learn to see what is important to the other and to respond with compassion, the next best step by doing what can be done or being who the other needs one to be. Further behaviours include portraying professional appearance by adhering to the professional dress code of the institution and profession, and the correct use of non-verbal body language. 2) Professional maturity: The nurse educator remains knowledgeable, skilled and experienced in both theory and practice to guide nursing students through processes of knowledge construction, reflection and discussion in preparing them for professional practice. Personal maturity: The nurse educator demonstrates self-awareness and self-knowing by being open-minded. Moral maturity: The nurse educator bases their teaching practices on understanding the importance of values and attitudes in nursing care. This is achieved through adherence to the moral principles of commitment to help by being available to nursing students and showing respect for individual differences. The moral responsibility refers to the nurse educator’s willingness to engage with nursing students to strive for excellence in nursing practice. 3) Relational skills: The nurse educator demonstrates expertise and craftsmanship in facilitating presence through being accessible and flexible. The nurse educator acknowledges her own vulnerability of having to manage large classes as well as the vulnerability of nursing students being young adults and coping with student and personal lives. The nurse educator connects with nursing students in an intimate way through being who they need her to be in the moment and being present in a holistic way. By being sensitive to and aware of nursing students’ needs, the nurse educator shows practical wisdom in adapting the class and reaching the outcomes according to nursing students’ learning needs. The nurse educator is fully present through being alert, attentive, aware and receptive of nursing students’ needs while engaging in active listening, and demonstrates consideration towards their feelings. The nurse educator is authentic and shows fidelity by keeping to deadlines and expecting nursing students to reach the expected outcomes. 4) Openness refers to the nurse educator being human, honest and open to nursing students by showing interest in their lives and experiences. The nurse educator facilitates presence through an openness to learn, change and acknowledge the perspectives of others. 5) Empowerment includes supporting and guiding nursing students, making them feel valued, involving them in decision making, actively listening to them, and reducing anxiety through continuous encouragement and motivation.

Nursing students as adult learners enter into the teaching-learning process with their own self-concept, past experiences, readiness to learn and orientation to learning. The nurse educator acknowledges the attributes of the adult learner by regarding nursing students as adult learners who are self-directed with a life-long orientation to learning, are motivated to learn, and experience needs and interests that learning will satisfy. The nurse educator can accommodate the adult learner as follows. Self-directed: Utilise the study guide, use the interactive method (discussions), provide clearly defined goals and criteria for evaluation, continuous feedback, development of critical reflection. Readiness to learn: Point out the relevance and value of application of the study content, use relevant and applicable examples from real-life situations, guide students from the known to the unknown, encourage an attitude of questioning. Experiences: Utilise the experience of students, develop thinking, problem-solving and evaluation skills, develop the ability to correlate theory and practice, develop critical-evaluating thinking and critical self-reflection, provide feedback with regard to achieving the purposes of learning, motivate to study further. Learning orientation: Establish a physical and psychological climate conducive to learning. Involve adult students in decisions about their learning. Plan methods and content with them. Involve them in diagnosing their learning needs or the gap between what they know and what they feel they need to know. Motivate students to identify their learning resources and to find strategies for using these resources in order to achieve the learning outcomes. Support students in carrying out their learning plans. Involve students in evaluating their learning.

Phase 2: Process:

The process phase involves the implementation of the educational encounter. The nurse educator and nursing students engage in an authentic reflective encounter to develop an interpersonal connection where presence can be facilitated using guided reflection to reach transformative learning. This teaching-learning process comprises three steps.

Step 1: Planning for the educational encounter: Presence is facilitated by demonstrating care and consideration in developing the content (plan and structure the lesson plan according to an introduction, the presentation and a structured conclusion); selecting appropriate learning activities such as activities for reading (assignments for nursing students to become engaged), writing (journals, both handwritten and electronic, to stimulate reflection), doing (engage nursing students in doing activities, e.g., portfolios) and telling (telling of an experience to engage nursing students in reflection); selecting suitable teaching strategies such as reflective diaries, reflective journals, mindfulness minute, video discussions, authentic scenarios, role play, critical incidents, simulations, case studies, narratives, rubrics and portfolios; selecting correct assessment techniques by deciding on the type of assessment, e.g., formative or summative; being accessible during assessment time; providing constructive and timely feedback after each assessment; and engaging in regular follow-up for clarifying any concerns.

Step 2: Presenting the educational encounter: In presenting the content, presence is facilitated by being and remaining present in the classroom, being attentive and aware of nursing students’ needs, and demonstrating consideration towards their feelings. The most suitable teaching-learning strategy to facilitate presence is through guided reflection. Guided reflection involves the nurse educator leading, directing and supervising nursing students’ learning during the acquisition of knowledge through study in the classroom or accompanying them during skills acquisition through experience in practice. When presenting the new material, the nurse educator need to follow nine strategies. 1) Engage nursing students in self-reflection by determining prior knowledge: Provide opportunities for them to reflect on the previous teaching by sharing their ideas, feelings, and perspectives. 2) Connect with nursing students: Display a “way of being” by welcoming and greeting your nursing students in a caring, polite and humorous manner. Classroom rules are set during their first encounter to ensure classroom discipline, especially in large class group settings. Know your nursing students by name to show a genuine interest in them. Clearly state the learning outcomes and the outlay of the session in the beginning to ensure that nursing students know exactly what is happening and expected from them. Do not call out students by their name but allow them to participate as they feel comfortable. This makes them feel like an important part of the large class group and free to participate without judgement. Involve them in sharing personal and professional experiences and interpreting real-life clinical experiences. 3) Develop new practice insights: Reflect on learning experiences to change nursing students’ behaviour as well as their way of thinking through making meaningful connections between their previous learning and new ideas and experiences. 4) Develop clinical competence: Use practical examples for integrating knowledge and skills, enabling nursing students to engage in theory-practice integration. 5) Develop critical thinking skills: Encourage nursing students to explore decisions, thoughts and feelings by critically analysing, synthesising and evaluating learning experiences. 6) Guide towards self-discovery: Ask questions and provide opportunity for nursing students to give the answer out loud, and if correct, a mark will be allocated. If the answer is incorrect, the nurse educator demonstrates sensitivity by not telling them it is wrong, but instead guiding and directing them towards discovering the correct answer for themselves. 7) Challenge participation in self-inquiry and self-analysis: Guide nursing students in critically reflecting on their own positive and negative experiences while learning about nursing care through discussing their thoughts, feelings and knowledge. Guide them in practicing self-inquiry and self-awareness by utilising the reflective process. In the first phase, nursing students create an awareness of uncomfortable feelings and thoughts. The second phase includes engagement in critical analysis of the situation. A new perspective for a new situation is developed in the third phase. 8) Provision of timely and constructive feedback: Encourage active listening and communication. Encourage nursing students to listen to what others are saying, help each other to make the experience more explicit, and share certain ways of expressing or understanding specific actions. Provide appropriate feedback after discussions and assessments. 9) Acknowledge nursing students’ contributions: Praise them continuously on their achievement of outcomes to build their morale and to make them feel valued.

Step 3: Evaluating the educational encounter: When evaluating the new material, the nurse educator must consider the following. 1) Acknowledge contributions: At the end of each lesson, the nurse educator summarises the days’ work and completes a five-minute quiz. After nursing students have completed the quiz, they swop theirs with their colleague next to them. This exercise assists them to practice presence by valuing ideas and feedback from others. 2) Engagement in self- and peer-assessment: The nurse educator completes a self-assessment rubric on her teaching practices for improvements. Encourage nursing students to complete a lecturer evaluation to expose them to practices such as self-reflection, self-analysis and self-evaluation that lead to a better understanding, learning and improved practice.

Transformative learning is achieved when nursing students demonstrate a positive change in their thoughts and behaviour, resulting in transforming the way they learn in the classroom and act in practice. When this happens, it will continue into the final phase of achieving the set targets.

Phase 3: Product:

The product phase involves the recipients who benefit from the outcomes of the practice model and can be grouped into three categories:

Category 1: NEIs: Produce present and reflective nurse practitioners that contribute to personal and professional development, enhanced personal and professional satisfaction through feelings of making a difference in the lives of others, improved physical and mental well-being and positive learning experiences.

Category 2: Nursing profession: Increasing nurses’ awareness of presence can transform the way they think, care and act in practice leading to professional practice development that contributes to physical and mental well-being of the nurse and patient, improved interpersonal communication and meaningful relationships between nurses and patients, improved professionalism of nurses, enhanced clinical knowledge and critical reasoning of nurses as it allows them to engage in internal dialogue to think through and reflect on nursing actions and improved quality of nursing care.

Category 3: Patients: Qualified nurse practitioners who enter the clinical practice as reflective nurse practitioners by being physically, psychologically and emotionally present with the patient will be able to understand and support patients’ needs more effectively, leading to quality patient care. This contributes to increased patient satisfaction, positive patient outcomes, and improved patient care.

Conclusion Statements Of The Model

Conclusion statements were formulated through statement synthesis for “presence and reflective practices in nursing education” to strengthen the significance of the model developed as follows:

Facilitating presence through reflective practices requires a conducive teaching-learning environment that supports purposeful inquiry and meaningful collaboration which are essential to the success of nursing students exploring and challenging practice through reflection. This is made possible by considering various environmental factors such as conducive work settings, authentic surroundings, adequate resources and sufficient time.
The nurse educator establishes meaningful relationships with nursing students that are supportive, respectful and non-judgemental through being open and connecting with nursing students where the nurse educator can challenge, enable and support them for learning to become meaningful. In turn, such relationships model to nursing students how to establish therapeutic relationships, a skill that nursing students can apply with patients.
Attributes of presence embraces the nurse educator being a role model, having professional, personal and moral maturity, demonstrating relational skills, being open, and empowering nursing students.
Facilitating presence through reflective practices contributes to positive learning experiences by ensuring that deep and meaningful learning occurs and requires sufficient time, adequate resources and support from organisation, colleagues, peers and students, and the use of applicable technology.
Presence and reflective practices are an essential component for theory-practice integration in that nurse educators share personal and professional experiences with their nursing students to promote internalisation of knowledge and skills and enable them to apply what they have learnt in practice to develop professional knowledge, understanding and clinical competence that lead to transformative learning.
Presence and reflective practices contribute to continuous professional development and life-long learning, personal and professional satisfaction, and physical and mental well-being for both the nurse educator, nursing student and the patient, leading to improved quality nursing care and, ultimately, positive patient outcomes.

A theoretical synthesis by Walker and Avant [17] was conducted to develop a theoretical model to bridge the gap identified from the literature that available models focus purely on improving presence in nursing science or the nurse as a reflective practitioner. But no practice model exists that includes and focuses on both “presence” and “reflective practices” addressing how nurse educators can facilitate presence through reflective practices in a teaching-learning context of large class groups of nursing students.

This conceptual model can be applied in nursing education, nursing practice and research. Integration of this synthesised model into the teaching practices of nurse educators involved in the undergraduate, postgraduate and continuous professional development programmes could produce present and reflective nurse practitioners through: 1) the development of a short learning programme to present the practice model to assist nurse educators to promote the understanding and importance of the practice model and to assist with guidelines for the implementation thereof and for nurse educators to integrate the practice model into their teaching practices to facilitate presence throughout their training; 2) provision of in-service training programmes to increase nurse educators’ awareness of presence and to enhance their knowledge and skills for facilitating presence through guided reflection for transformative learning; 3) nurse educators to integrate the practice model into their teaching practices of first-, second-, third- and fourth-year undergraduate nursing programmes to facilitate presence throughout their training; and 4) creating awareness campaigns of presence through presentations to emphasise the importance of practicing presence to promote the standard of education, training and practice.

Our conceptual model can also be applied in the nursing practice. The nursing profession will benefit from implementing this practice model in the clinical facilities to increase nurses’ awareness of presence to transform the way they think, care and act in practice through: 1) all categories of nurses to attend a short learning programme to create awareness of presence; 2) in-service training programmes to orientate all categories of nurses in the clinical setting of the practice of presence; and 3) attending continuous professional development programmes on presence.

This synthesised model prompt the need for further research, for example, the development of guidelines to operationalise the practice model within other disciplines such as education. The other venues for advancing research in this arena include: 1) operationalisation and validation of the practice model for nurse educators to facilitate presence in large class settings through reflective practices; 2) the development of a practice model to facilitate presence through reflective practices in the clinical practice environment to contribute to theory-practice integration; and 3) the development of a programme to facilitate presence through reflective practices in other health science disciplines.

The process of developing our conceptual model has a limitation. The literature search was restricted to English language, peer-reviewed journal articles, thereby some information about presence and reflective practices could have been missed. Despite the limitation of our manuscript, the conceptual model laid the foundation for future research and new findings that could provide new insights into the theory construction of facilitating presence in large class groups through reflective practices.

Presence has elicited the intuitiveness of nursing scholars and researchers to create an awareness of it in the field of nursing science, which made it necessary to capture a comprehensive insight into this phenomenon. Our newly synthesised conceptual model provides an effective way of approaching this goal. Theory synthesis proposed and developed by Walker and Avant [17] was used as strategy to develop our conceptual model for nurse educators to facilitate presence in large class settings through reflective practices. This paper contributes substantially to deepen the body of knowledge in the nursing education domain of the South African context as well as the nursing education domain internationally, to serve as a model for guiding nurse educators in their teaching-learning practices. Our proposed model can be used as a foundation for further research and can be utilised across nursing education, practice and management.

HREC: Health Research Ethics Committee; NEI(s): Nursing Education Institution(s); RDGC: Research Data Gatekeeper Committee; SANC: South African Nursing Council.

Acknowledgements

Not applicable.

Authors’ contribution

KF conducted the literature review and conceptualised, structured and contextualised the model. KF drafted the manuscript. EDP and AVG reviewed and approved the final manuscript.

Funding

North-West University Postgraduate bursary.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed for this study.

Ethics approval and content to participate

Ethical approval (NWU-00404-20-A1) was obtained from the Health Research Ethics Committee (HREC) and the Research Data Gatekeeper Committee (RDGC) of the North-West University. All methods describe herein were performed in accordance with the relevant guidelines and regulations of the North West University’s HREC and RDGC. All participants who participated in the evaluation of the conceptual model signed informed written consent approved by the HREC.

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Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author details

¹School of Nursing Sciences, Faculty of Health Science, North-West University, Potchefstroom, South Africa. ²School of Nursing Sciences, Faculty of Health Science, North-West University, Potchefstroom, South Africa. ³School of Nursing Sciences, Faculty of Health Science, North-West University, Potchefstroom, South Africa.

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Table 1: Application of the structural components presented in the model

Structural components:
*Framework: External and internal environment*
Meaning of the symbol	Meaning of the colour	Application in the model
The framework is presented by a rectangle which is a geometric shape that symbolises structure and order [23]. It is associated with rationality, practicality and conformity [23]. The rectangle is used to portray safety and containment with the purpose of appearing efficient, grounded and accessible to a wider audience [24].	“Green” is a secondary cool colour [25] that represents balance, renewal and growth. It is the symbol of prosperity and progress [24]. It is a healing colour associated with security [24]	The green rectangle represents the framework and includes both the external and internal environment by bringing a sense of visual balance within this environment, illustrating the dynamic influence of the environmental elements. The centre gradient moving outwards in circles illustrates the dynamic and complex nature as well as the interconnectedness between the internal and external environment. The outside represents the external environment that includes the governing acts, mandatory rules and specific regulations as set out by the regulatory bodies. This provides for the legal, ethical and professional frameworks in which the nurse educator practices and must be adhered to when planning, presenting and evaluating the educational encounter. The larger inner circle represents the internal environment consisting of the mediated teaching-learning environment, meaningful relationships, attributes of the nurse educator and nursing students, the teaching-learning process as well as the outcome of the model.
*Agent 1: The nurse educator*
Meaning of the symbol	Meaning of the colour	Application in the model
The nurse educator is resembled by a star symbol. “Stars” are regarded as protective and guiding symbols and are widely used as a symbol of something good, positive and associated with conveying positive messages [26]. In this model, the symbol of a “star” is associated with conveying positive messages that symbolise new beginnings, a “symbol of hope and truth” [26].	The colour “blue” is the colour of the ocean and the sky, resembling endless opportunities. As the saying goes, “the sky is the limit”. Blue is a primary cool colour [25] that symbolises serenity, stability, inspiration and reliability. It is associated with intelligence, responsibility, professionalism and trust [27]. The colour blue also resembles certain personality strengths.	The agent is the person(s) who performs the activity. In this model, agents are nurse educators (agent 1) and nursing students (agent 2) who are co-constructers in the educational encounter. The nurse educator (agent 1) is resembled by the blue 5-point star because they are the first line of contact when nursing students enter the nursing profession. The nurse educator is a role model associated with this symbol of “hope and truth” for creating new beginnings and life-long learning in the lives of nursing students. When nursing students feel lost and do not know what to do or where to go, they turn to nurse educators for guidance and protection. The 5-point star represents the attributes of the nurse educator when practising a “way of being”. These attributes are grouped under five categories associated with each point of the star and include (1) role model, (2) professional, personal and moral maturity, (3) relational skills, (4) openness, and (5) empowerment.
*Agent 2: The nursing student*
Meaning of the symbol	Meaning of the colour	Application in the model
The sun is a symbol of power, growth and health. The sun represents new beginnings and hope, and demonstrates a sense of unity and perfection [24]. Nursing students are the next generation of professionals who are a symbol of hope for new beginnings in the nursing profession.	The colour “yellow” is associated with the sun and symbolises optimism, energy, joy, happiness and friendship [27]. Yellow is a primary warm colour [25] that represents happiness, hope, positivity and spontaneity.	The agent is the person(s) who performs the activity. In this model, agents are nurse educators (agent 1) and nursing students (agent 2) who are co-constructers in the educational encounter Nursing students (agent 2) need to be present during the delivery of quality patient care by remaining hopeful despite being confronted with sad moments, demonstrating positivity in difficult circumstances, and the ability to appreciate happiness in the moment. The yellow sun represents nursing students as new beginnings, full of hope, demonstrating a sense of unity, happiness, positivity and remaining in the moment. Nursing students as adult learners enter into the teaching-learning process with their own self-concept, past experiences, readiness to learn and orientation to learning.
*Procedure: The teaching-learning process*
Meaning of the symbol	Meaning of the colour	Application in the model
A spiral is a geometric shape with three-dimensional curves with one or more turns around a centre point. It represents transformation. It moves in an anti-clockwise direction and symbolises change and development [23]. The procedure is represented by the spiral shape to illustrate the connection and community between the nurse educator and nursing students in the teaching-learning process.	“Red” is a primary warm colour [25]. The colour red is associated with physical energy, courage and will. It symbolises stability, security, action, physical and emotional survival [27].	The red spiral represents the procedure for facilitating presence through guided reflection for transformative learning. It is a continuous and ongoing process taking place between the nurse educator and nursing students to achieve set targets. The nurse educator facilitates presence by being attentive and aware of their needs and demonstrating consideration towards their feelings. Using reflection in the educational encounter leads to transformative learning. This is achieved when nursing students demonstrate a positive change in their thoughts, feelings, beliefs and behaviour resulting in transforming the way they learn in the classroom and act in practice.
*Dynamics: An authentic reflective encounter*
Meaning of the symbol	Meaning of the colour	Application in the model
An arrow is a sign consisting of a straight line with an up and down V shape at both ends of it pointing in a particular direction. It symbolises reaching your goals and achieving your targets. The up-and-down pointed arrow resembles the direction in which the process moves to achieve the set targets.	“Orange” is a secondary warm colour [25]. Orange is an energetic and creative colour that stimulates action [27]. It symbolises feelings of excitement, enthusiasm, warmth and determination [27]. Orange represents strength and endurance.	The dynamics are the energy that drives the process. In this model, it is the mutual need for an authentic reflective encounter between the nurse educator and nursing students where they develop an interpersonal connection. The orange up-and-down-pointed arrow resembles the direction in which the process moves and symbolises nurse educators and nursing students’ determination and endurance to achieve their goals and set targets. It represents the potential nurse educators have to facilitate presence through guided reflection that leads to transformational learning in an energetic and creative manner. The energy that drives the process in this practice model is the constant authentic reflective encounter that takes place between the nurse educator and nursing students enabling the nursing students to grow into safe, caring and reflective nurse practitioners who are present during the delivery of patient care by transforming the way they feel, think, care and act in practice.
*Recipients and terminus: NEI: Producing present and reflective nurse practitioners; Nursing profession: Professional practice development; and Patients: Quality nursing care*
Meaning of the symbol	Meaning of the colour	Application in the model
A vertical scroll is a roll of paper that varies in length and has been written on. It is used for the purpose of transmitting information. The scroll resembles a partly unrolled sheet of paper having a spiral form at both ends and can be attached to a wooden stick to make it easier to handle. The intention of a scroll is to be used repeatedly.	The “blue-yellow” gradient colour illustrates a linear diagonal-top left to bottom right gradient representing a gradual blending from one colour (blue) to another (yellow) from colours of two different tones. “Blue” is a primary cool colour that symbolises stability, inspiration and reliability and is associated with responsibility, professionalism and trust [25, 27]. “Yellow” is a primary warm colour that represents happiness, hope, positivity and spontaneity [25, 27].	The benefits and outcome of the model revealed interconnectedness. The recipient and terminus are combined into one structure. The recipients are the persons who will benefit from the activity. In this model, the NEIs (recipient 1), nursing profession (recipient 2) and patients (recipient 3). The terminus is the outcome of this authentic reflective encounter comprising present and reflective nurse practitioners, professional practice development and quality nursing care. The blue-yellow vertical scroll represents the progressive transition of nursing students resulting from the authentic reflective encounter between the nurse educator and nursing students. It symbolises the transformation of nursing students into present and reflective nurse practitioners produced by the NEI. By increasing nurses’ awareness of presence, one can transform the way they think, care and act in practice leading to professional practice development. Qualified nurse practitioners who enter the clinical practice as reflective nurse practitioners by being physically, psychologically and emotionally present with the patient will be able to understand and support patients’ needs more effectively, resulting in quality nursing care.
Connecting line
*The orange up-pointed curved arrow*
Meaning of the symbol	Meaning of the colour		Application in the model
The up-pointed curved arrow consists of a curved line with an upside-down V shape at the end of it pointing in a particular direction. It symbolises reaching your goals and achieving your targets. The curved line creates familiarity, comfort and is interesting to follow.	The colour “orange” is a secondary warm colour [25]. Orange is an energetic and creative colour that stimulates action. It symbolises feelings of excitement, enthusiasm, warmth and determination [27]. The colour orange also represents strength and endurance.		The orange up-pointed curved arrow illustrates the outcome of the authentic reflective encounter where the nurse educator facilitates presence through guided reflection for transformative learning. It points out the direction in which the process moves to achieve the set targets. These targeted recipients include the NEIs, nursing profession and patients who will benefit from this activity.

No competing interests reported.

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A conceptual model for nurse educators to facilitate presence in large class settings through reflective practices: A theory synthesis

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