Content area
Aim
This study examined whether a cognitive behavioural approach to critical reflection could facilitate transformative learning in nursing students compared with a traditional reflective model.
Background
Critical reflection is essential in nursing practice and education. While transformative learning theory (TLT) has the potential to facilitate deeper learning, its application in nursing education remains underexplored. Cognitive behavioural approaches have successfully promoted critical reflection in other clinical professions but have yet to be used in nursing education.
Design
A quasi-experimental mixed methods design was employed. This paper reports the quantitative findings.
Methods
Two groups od second year undergraduate nursing students were compared: the experimental group received a cognitive behavioural approach, while the control group received a traditional reflective model. The Self-Reflection and Insight Scale (SRIS) measured outcomes at baseline, post-intervention and follow up. Response rates were 88.5 % (n = 139) for the experimental group and 93 % (n = 169) for the control group. Data were analysed using Linear mixed-effects models.
Results
Significant differences were observed in insight, engagement in reflection and perceived need to reflect. The cognitive behavioural approach led to a highly significant increase in reflective insight, with scores improving by 5.54 units from baseline to follow-up (p < 0.001).
Conclusions
These findings indicated that the cognitive behavioural approach facilitated critical reflection, particularly in developing insight and metacognitive skills. A separate qualitative analysis examining the utility of the approach will offer further insight into how this approach supported transformative learning.
1 Introduction
Critical reflection is an important skill for nursing practice – it is embedded in nursing standards and seen as imperative to promote professional growth. It is also a crucial skill to facilitate autonomy, critical thinking and sensitivity in nursing practice ( Bulman et al., 2012; Crowe and O'Malley, 2006). However, the challenges of teaching nursing students to develop the necessary self-awareness and critical thinking skills required for critically reflective practice have been well recognised ( Smith and Trede, 2013; Timmins et al., 2021; Tsimane and Downing, 2020). Nursing students struggle to understand and practise critical reflection due to the rigidity of the models being taught, unclear terminology attached to these models leading to a lack of motivation, knowledge and confidence. ( Andrews et al., 1998; Cotton, 2001; Hannigan, 2001; Platzer et al., 2000; Timmins et al., 2021; Tsimane and Downing, 2020). As a result, nursing students may graduate with limited understanding of critical reflection and underuse this skill in their nursing practice.
Transformative Learning Theory (TLT), a critical learning theory developed by Jack Mezirow, highlights the potential for critical reflective practice to shape transformative teaching and learning experiences in nursing education ( Mezirow, 1997, 2000, 2008, 2018). Although arguably not used to its full potential ( Ryan et al., 2022) TLT has been increasingly used by nurse educators as it emphasises that critical reflection is central to meaningful, transformative learning. TLT enables students to extend beyond knowledge acquisition and promotes profound changes in their perspectives, beliefs and values ( Kitchenham, 2008). Nursing scholars assert that through critical reflection and perspective change, students can develop a greater self-awareness and understanding of how their beliefs and assumptions influence their clinical practice. This self-awareness and understanding empowers them to excel both academically and personally ( Bass et al., 2017; Beer, 2019; Cernusca et al., 2018; Ryan et al., 2022; Tsimane and Downing, 2020).
Cognitive behavioural reflection, often referred to as self-practice/self-reflection (SP/SR), is widely used across various professional disciplines that apply cognitive behavioural approaches. This reflective process enhances clinical skills, improves therapeutic effectiveness and deepens understanding of client experiences ( Thwaites et al., 2014). SP/SR involves using cognitive behavioural models to critically reflect on thoughts, behaviours and clinical practice, facilitating greater insight of the cognitive processes that influence interactions and decision-making ( Chaddock et al., 2014). Integrating cognitive behavioural reflective techniques into nursing education could provide a valuable framework for developing critical reflection skills. A core component of SP/SR is the use of conceptual models, which illustrate the connections between thoughts, emotions, behaviours and physical sensations. These models provide a structured, visual approach to reflection conceptualisation that helps individuals recognise patterns in their experiences and responses, similar to reflective models such as Gibbs’ reflective cycle ( Gibbs, 1988). Despite the proven effectiveness of self-practice/self-reflection (SP/SR) and its clear alignment with nursing education, cognitive behavioural conceptual models had not been widely integrated or tested in nursing curricula before this study.
2 Aims
The study aimed to evaluate if compared with a traditional reflective model, a cognitive behavioural approach to critical reflection could:
1. Facilitate transformative learning in undergraduate nursing students
2. Enhance students' understanding of critical reflection
3. Increase self-awareness
3 Definition of key terms
Critical reflection is the process of examining and questioning one's beliefs, assumptions and experiences in the context of broad social, cultural and political influences. It aims to deepen self-awareness and foster personal and professional growth.
Transformative Learning Theory (TLT) proposes that learning involves profound changes in one's perspective, beliefs and values through critical reflection. It emphasises that meaningful learning occurs when individuals critically examine and reframe their assumptions, leading to perspective transformation.
Cognitive Behavioural Reflection is the approach taken in this study which uses cognitive behavioural techniques to conceptualise and understand thoughts, emotions, behaviours and physical sensations in clinical situations. It involves identifying patterns and links between these elements to gain insight, using a cognitive behavioural model to guide the reflective process.
4 Methods
A quasi-experimental mixed methods design was used for this large study, conducted at a university in Western Australia, with participants recruited from this institution. The study was divided into two phases: the first phase involved a longitudinal, repeated measures survey, analysed using linear mixed models; the second phase was a qualitative component, employing a constructivist grounded theory approach to explore the underlying mechanisms and processes, which is not reported in this paper. Given the substantial scope of the study and the distinct nature of the two sets of data, the quantitative results confirm the efficacy of the intervention, while the qualitative findings provide deeper insights into how and why the intervention worked in relation to transformative learning. The integration of both data sets is integral to the final theory generated by the complete study. However, the two elements were sufficiently separate in their aims and methodologies to warrant separate reporting for clarity and focus.
4.1 Participants
Participants comprised the total cohort of second year undergraduate nursing students enrolled in a core nursing pre-practicum unit at the commencement of Semester 1, 2020, at Murdoch University, Western Australia. 421 students were enrolled in this unit across two campuses. Student characteristics across both locations were comparable in terms of number and demographics (age, sex and socio-economic status), justifying their allocation to either the intervention or control group. The impact of both models was measured using the Self Reflection and Insight Scale (SRIS) survey, administered at baseline, post-intervention and follow-up. The baseline response rate was 88.5 % (n = 139) for the cognitive behavioural group and 93 % (n = 169) for the control group.
4.2 Measurement tool
The Self Reflection and Insight Scale (SRIS) was selected as the measurement tool. The SRIS was developed and validated to measure the metacognitive processes of empathy, emotional intelligence and reflective insight in students undertaking undergraduate clinical education ( Grant et al., 2002). The tool measures three variables:
• Engagement: How often/likely the participants are to engage in reflection (RE)
• INSIGHT: The participant’s reflective insight (RI)
• NEED: The participant’s perceived need to reflect (NR)
The SRIS has been extensively validated with test-retest reliability of the instrument initially established as.77 (p < .001) and.78 (p < .001), respectively ( Grant et al., 2002). It has been used extensively in clinical educational research including occupational therapy ( Lowe et al., 2007), psychology ( Silvia et al., 2023), medicine ( Carr and Johnson, 2013; Roberts and Stark, 2008) and nursing ( Asselin and Fain, 2013; Pai, 2016). In this study, Cronbach's alpha of internal consistency reliability was 0.85 for the overall scale.
4.3 Data collection and analysis
Follow-up data collection was scheduled to occur during the final week of student’s scheduled clinical placement, approximately one month after the initial intervention session. This timing was chosen to capture students’ application of reflective skills in a clinical setting and to align with the completion of their final reflective accounts. This final follow-up measure also marked the endpoint of the study and the conclusion of data collection.
The mean (M) and standard deviation (SD) of the SRIS scores were calculated at each measure point. Data analysis was conducted using Predictive Analytical Software (PASW), SPSS Statistics version 21. Longitudinal analysis using linear mixed models assessed changes in self-reflection and insight immediately before and after the intervention and at follow-up. It was assumed that the measurement of the SRIS variables on the same participants would be correlated and that linear mixed models would estimate any co-variance parameters within and between the two groups ( West, 2009). Significance was established as .05 across all measures.
4.4 Teaching intervention overview
The teaching intervention was designed to ensure consistency across all student groups, with the only difference being the reflective model introduced. The control group revisited Gibbs Reflective Cycle (GRC) ( Gibbs, 1988), while the other group was introduced to a cognitive behavioural model of reflection (CBR) adapted from Greenberger and Padesky (1995). Students first completed a baseline measure using the Self-Reflection and Insight Scale (SRIS). Both groups then received a recorded tutorial that began with an outline of the session structure, progressed through the learning objectives and included a revision of previously taught reflective theory. The CBR group was then introduced to the new model, while the control group revised GRC.
The essence of teaching CBR was to help students recognise the simple principle that their perceptions and the thoughts they produce, shape their behaviour and, in turn, their clinical practice. Learning to distinguish between thoughts, emotions, behaviours, physical sensations and how these interact was the first step. This was achieved by introducing the CBR model, which uses the metaphor of the human body to separate thoughts (head), emotions (gut), behaviour (right arm) and physical sensations (left arm), showing how these elements influence one another ( Supplementary material 1).
Students were encouraged to explore internal responses to clinical events they may have encountered during previous placements. To facilitate this, each domain was paired with reflective prompts to scaffold students’ insights (e.g., "What went through your mind?", "How did you feel?", "What did you do?", "Any physical sensations?"). Key features of the CBR model were introduced step-by-step using narrated slides and visual materials ( Supplementary materials 2–4).
The emotional and cognitive dynamics of reflection were then emphasised further through the case study “Dolly,” which illustrated a scenario involving substandard care of an elderly patient ( Supplementary material 5). This case was deliberately designed to provoke thought and an emotional response. Students then applied either the GRC or CBR model to reflect upon the case.
Finally, the students were invited to discuss the nursing care of the case in relation to their reflections before completing the post-intervention measure of the SRIS.
4.5 Ethical considerations
Approval was sought and received from the ethics committees of Central Queensland University (project approval number 0000022520) and Murdoch University (protocol number 2021/001). The researcher’s subjectivity and theoretical positions were considered in relation to the epistemological positioning of the methodology and the study design and considered in the context of ethical bias and selective advantage. This was particularly important because the researcher had prior knowledge of the abilities of many of the study population and their suitability as participants. A high degree of pragmatic reflexivity was therefore employed, exploring and recording any impact that the researcher’s prior relationship may have had on the participant or on any other elements of the study.
Participation in the study was entirely voluntary, and students were informed that they could withdraw at any time without providing a reason and without any impact on their academic standing, course progression, or assessment outcomes. Confidentiality and anonymity were assured by de-identifying all data at the point of collection, with all identifying information removed or replaced with participant codes.
5 Results
Results are presented for both the intervention (CBR) and control (GRC) groups across the three variables of the SRIS: engagement in reflection (RE), need to reflect (NR) and reflective insight (RI). Descriptive statistics and longitudinal analysis using linear mixed models (LMM) explored changes in SRIS scores across the intervention period and during follow-up.
5.1 Sample characteristics
403 nursing students (n = 197 from Mandurah; n = 206 from Perth) were invited to participate in the study. A final sample of 321 students were recruited (n = 127 from Mandurah; n = 181 from Perth), giving a response rate of 79.65 %. Difference between numbers of students at each campus occurred because of technical issues, resulting in 30 students not being able to provide digital consent and therefore unable to participate.
5.2 Sample demographics
Students in the sample identified predominantly as female (96.5 %). This is representative of female to male nursing student ratios in a profession with a relatively low numbers of males. The mean age of participants was 31.43 years, with a minimum age of 21 years and a maximum age of 53 years.
5.3 Attrition and missing data
Overall attrition between pre and post-intervention was 36.14 % (n = 76) (n = 29 CBR; n = 47 GRC). 63.86 % of the initial participants (n = 88 CBR and n = 117 GRC) completely answered all three questionnaires. Difference in attrition occurred between the groups at post intervention. However, there was no significant difference in attrition observed between the two groups across all three questionnaires. Little's MCAR test was conducted to assess the pattern of missing data in the dataset and its potential impact on the study. The Chi-square goodness-of-fit test yielded a test statistic of 465.030 with 671 degrees of freedom (DF) with a p-value of 1.000. This indicated that the result of Little's MCAR test was not statistically significant and that the missing data in the dataset was considered missing completely at random (MCAR).
5.4 Descriptive statistics
Descriptive statistics of individual dependent variables demonstrated effects over time. Group means and standard deviations for each dependent variable are presented in Supplementary material 6. Both groups show comparable mean scores at baseline. At post-intervention, proportionately equal increases in mean scores from both interventions were demonstrated with slightly higher means reported from those receiving CBR. Those undertaking CBR demonstrated predominantly higher mean scores at follow-up, with the most significant increase in means recorded for RI.
5.5 Random effects as predictors of outcome
The random effects of age and gender were controlled for across both locations. Both age (ER: p = 0.66, NR: p = 0.33 and RI: p = 0.48) and gender (ER: p = 0.59, NR: p = 0.78 and RI: p = 0.87) were not found to be significant predictors of outcome.
5.6 Between-group differences at baseline
The results presented below indicates no significant difference in baseline score between students receiving the CBR or GRC teaching interventions in any of the dependent variables (RI:
p = 0.960, ER:
p = .350, NR:
p = .848). This is shown in
5.7 Between-group differences from baseline to post-intervention SRIS measures
The results presented in
6 Between-group differences of SRIS collection at post-intervention
The results below indicate that the between-group differences of SRIS scores at post-intervention collection were significant in favour of the CBR learning approach for RI and NR, but not for RE. RI was found to be 1.85 units lower for the GCR group than the CBR group for Q2 ( p < 0.001) and 1.03 units lower for NR ( p < 0.002). RE was only.548829 units lower for GCR than CBR for Q2 ( p < 0.112). This analysis is illustrated in Supplementary material 7.
Significant substantive findings emerged from post-intervention measurements, indicating a notable rise in the SRIS components immediately following both the CBR and the GRC teaching interventions. Moreover, it was observed that all three component variables of the SRIS exhibited a significant increase in scores for the CBR approach compared with the post-intervention measurement for GRC.
6.1 Between-group differences from baseline to follow-up SRIS measures
A significant difference in scores between both groups across all variable measured in the SRIS between baseline and the follow-up was demonstrated (See
6.2 Between-group differences of SRIS collection at follow-up only
Results indicated that the CBR model consistently demonstrated a statistically significant advantage over the GRC model across all variables at follow-up (See
Key substantive findings from the follow-up measurement indicated that the significant enhancements observed in the SRIS components, from baseline to post-intervention measurements, were not only sustained but further amplified during the follow-up period. Above all, there was a notable increase in the significance of RI, specifically between the post-intervention assessment and the follow-up evaluation, among students who received the CBR intervention.
In summary, there was no significant difference in baseline scores across all measured variables. A degree of significance was found in favour of the students who had engaged in the CBR intervention for the domains of RI and NR at post-intervention collection. However, the observed change in the actual scores was relatively modest. At follow-up however, significance was found between groups in RE or NR. The strong level of statistical significance observed from the effect of the CBR intervention on RI at follow-up is unlikely to be due to chance alone and should be considered as highly noteworthy.
7 Discussion
This study set out to explore whether a cognitive behavioural approach to reflection in nursing education could be used to facilitate transformative learning as described in Mezirow’s theory ( Mezirow, 2008). To do this, the study needed to first determine if a cognitive behavioural approach could be used for reflection by quantitatively comparing the statistical performance of an adapted cognitive behavioural model (CBR) against a traditional model of reflection, Gibbs reflective cycle (GRC).
CBR performed similarly to GRC and outperformed the traditional model on many levels. Comparing the two models at baseline and post-intervention revealed little difference in the measured variables. This confirmed the similarities of the participant groups. However, in-group analysis indicated that CBR performed better in relation to insight, showing a significant increase in this variable compared with GRC. The outcomes obtained from the initial two SRIS questionnaires, conducted before and immediately after the intervention, indicated that both models had a similar impact on enhancing all measured variables except for a notable increase in insight observed in the cognitive behavioural model. These initial assessments confirm that both models were effective in promoting reflection.
Statistical analysis showed that both the Gibbs Reflective Cycle (GRC) and the cognitive behavioural reflection (CBR) model increased insight, as well as the ability and motivation to reflect. However, at follow-up, students using CBR demonstrated greater improvements across all measured variables. CBR outperformed GRC on every measure, with the highest gains observed in reflective insight. While GRC continued to show significant increases across all variables, reinforcing its value in nursing education, the between-group differences became more pronounced over time. Students using CBR exhibited notably higher levels of self-reflection and metacognitive clarity ( Grant et al., 2002).
Metacognition and metacognitive clarity are concepts introduced by John Flavell in the 1970s and emphasise clarity of thinking processes and the ability to regulate and organise cognition ( Flavell, 1979). A key aspect of metacognition is the development of insight and an understanding of our own cognitive abilities and limitations. Insight plays a crucial role in metacognitive clarity and metacognitive control (self-regulating learning toward a goal). Drigas and Mitsea (2020, 2021) highlight the importance of insight in metacognition, suggesting various levels of awareness, from basic understanding to deep, goal-directed thinking. Mezirow states that metacognitive reasoning is a process of transformative learning ( Mezirow, 2008) and many nursing scholars have emphasised the link between metacognition and critical reflection, critical thinking and clinical reasoning ( Hsu and Hsieh, 2014; Jin and Ji, 2021; Josephsen, 2014; Levett-Jones et al., 2010; Lovell et al., 2021; Tsimane and Downing, 2020). The ability to reflect critically is seen as essential in transformative learning theory, yet nursing scholars report difficulty in teaching critical reflection ( Lundgren and Poell, 2016; Merriam, 2004). The quantitative results of this study show that cognitive behavioural models could simplify the teaching of critical reflection by conceptualising what cognitive behavioural models were originally designed to do. That is to provide insight into internal psychological states.
Increase in reflective ability was another significant result from the statistical analysis. Reflective ability was measured by the SRIS with questions relating to correctly identifying concepts and the ability to move through the reflective process with an effective analysis and conclusion. Students with high reflective ability were more likely to learn from their experiences and use them as opportunities for personal growth. The results showed that reflective ability was significantly improved, therefore the model facilitated reflection beyond identifying reactions, to analysis and conclusion. This indicates that CBR played a role in guiding students through a more comprehensive process of reflection. This result, when considered alongside an increase in insight and reflective ability, suggests that the conceptualisation of cognitive and behavioural concepts not only enhanced self-awareness and metacognition but also provided a method for analysing triggered emotions. Emotional responses in learning experiences, which are often underexplored, play a pivotal role in developing critically reflective and empathetic healthcare professionals, as recommended for effective practice ( Ryan et al., 2022). Yet it is also commonly observed that nursing students can sometimes find it challenging to differentiate between a thought and an emotion ( Batterbee, 2019; 2020). A lack of awareness of the fundamental difference between the two and the way these components influence each other, and our behaviours (clinical practice) is often misunderstood, understated and often not understood at all. Therefore, a model which clearly distinguishes between these concepts, giving a visual formulation of their influence on each other and a comprehensive analysis of their application to a clinical situation is invaluable to nursing education and in facilitating transformative learning theory.
The results from this study confirm that CBR not only serves as a useful tool for reflection in nursing but also significantly enhances students' metacognition. This isn't entirely surprising, given that cognitive behavioural models were originally designed to provide insight into internal psychological states. What is surprising, however, is that CBR has not been previously applied to nursing education, especially considering the clear evidence from this study that cognitive behavioural techniques can be easily adapted for critical reflection and effectively facilitate transformative learning theory.
8 Limitations
The study provides valuable insights into the teaching and practice of reflection in nursing, introducing a cognitive behavioural approach to facilitate critical reflection and transformative learning. The findings support existing research on reflection and demonstrate that a cognitive behavioural approach can be an effective tool for nurses. However, there are limitations. Variations in nursing programs across Australia and internationally, particularly differences in clinical placements may affect replicability. The use of self-report data via the SRIS, while validated, could be influenced by student preconceptions around the influence of high SRIS scores on assessment criteria. Another limitation is the exclusive use of Gibbs’ reflective cycle as the control model, which limits comparison to similar studies. While Gibbs’ model is dominant in nursing education, other models may yield different results. Another limitation may be the use of only one cognitive behavioural model, specifically Greenberger and Padesky’s model. While this model is well-established, other cognitive behavioural conceptual models might produce different results, it is therefore recommended that future studies continue to use Greenberger and Padesky (1995), or the adapted model herein for consistency. These factors combined suggest that while the study offers useful insights, its findings may be more applicable to similar settings and populations and caution is needed when generalising to different educational contexts or conceptual models.
9 Conclusion
The aim of this study was to explore whether a cognitive behavioural model could be effectively adapted and used as a reflective tool, facilitating critical reflection and transformative learning. The statistical data gathered from this research clearly indicated that CBR can be effectively used to facilitate critical reflection in nursing students. When compared with the commonly used Gibbs' reflective cycle, CBR demonstrated comparable results at both baseline and immediately post-intervention. However, at follow-up, CBR showed superior outcomes in promoting deeper levels of insight and reflective ability, suggesting its greater effectiveness when used in practice over time. These findings support the hypothesis that CBR not only facilitates reflection but also encourages transformative learning by increasing metacognitive skills and self-insight for critical self-analysis. Therefore, CBR shows promise as an evidence-based reflective tool in nursing education, aligning with the objectives of promoting critical thinking, reflection, clinical reasoning and transformative learning in the education and professional development of nursing students.
CRediT authorship contribution statement
Andrew Frost: Writing – review & editing, Methodology, Conceptualization. Hunt Sue: Validation, Investigation, Formal analysis. Julie Bradshaw: Writing – review & editing, Supervision, Methodology, Investigation. Robert Batterbee: Writing – original draft, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.
Funding
This paper reports upon research that was part of a PhD funded by the Australian Government through the Commonwealth Government Research Training Program (
Declaration of Competing Interest
The authors declare that there are no conflicts of interest relevant to this work.
Acknowledgements
Participants were selected from the School of Nursing, Perth and Mandurah campuses, Murdoch University, Australia.
Appendix A Supporting information
Supplementary data associated with this article can be found in the online version at
Appendix A Supplementary material
Supplementary material
Supplementary material
Supplementary material
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Supplementary material
Table 1
| SRIS Component | Coefficient | Std Error | z | p | 95 % Conf | Interval |
| RI | − .0337222 | .6785891 | − 0.05 | 0.960 | − 1.296288 | 1.363732 |
| RE | − .4522587 | .4834258 | − 0.94 | 0.350 | − 1.399756 | .4952385 |
| NR | .0892773 | .4643185 | 0.19 | 0.848 | − .8207702 | .9993248 |
Table 2
| SRIS Component | ∆ CBR and GRC | Std Error | z | p | 95 % Conf | Interval |
| RI | 2.714665/40 | .3817847 | 7.11 | < .001* | 1.966381 | 3.462949 |
| RE | .7291828/30 | .2644815 | 2.76 | .006* | .2108086 | 1.247557 |
| NR | 1.122142/30 | .247698 | 4.53 | < .001* | .80254 | 1.924153 |
Table 3
| SRIS Component | ∆ CBR and GRC | Std Error | z | p | 95 % Conf | Interval |
| RI | 5.543278 | .381784 | 7.11 | < .001* | 4.683369 | 6.403188 |
| RE | 2.048695 | .308390 | 6.64 | < .001* | 1.444261 | 2.653128 |
| NR | 1.363346 | .286131 | 4.76 | < .001* | .80254 | 1.924153 |
Table 4
| SRIS Component | Coefficient:
∆ GCR & CBR |
Std Error | z | p | 95 % Conf | Interval |
| RI | − 4.585152 | .5739288 | − 7.99 | < .001* | − 5.7100 | − 3.460273 |
| RE | − 1.090993 | .4003523 | − 2.73 | .006* | − 1.8756 | − .3063171 |
| NR | − 1.03178 | .3727255 | − 2.77 | .006* | − 1.7623 | − .3012511 |
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