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Contents lists available at ScienceDirect

Women and Birth

journal homepage: www.elsevier.com/locate/wombi

Developing reflective capacities in midwifery students: Enhancing

learning through reflective writing
Linda Sweeta,* , Janice Bassb , Mary Sidebothamb,c , Jennifer Fenwickb,c,d , Kristen Grahama
a
College of Nursing and Health Science, Flinders University, Australia
b
School of Nursing and Midwifery, Griffith University, Australia
c
Menzies Health Institute Queensland, Australia
d
Gold Coast University Hospital. Maternity, Newborn and Families Research Collaborative, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Background: Practice-based or clinical placements are highly valued for linking theory to practice and
Received 9 January 2018 enabling students to meet graduate outcomes and industry standards. Post-practicum, the period
Received in revised form 17 May 2018 immediately following clinical experiences, is a time when students have an opportunity to share,
Accepted 5 June 2018
compare and engage critically in considering how these experiences impact on their learning. Reflective
Available online xxx
practice has merit in facilitating this process.
Aim: This project aimed to optimise the learning potential of practice-based experiences by enhancing
Keywords:
midwifery students’ capacity for reflective practice through writing.
Reflection
reflective practice
Methods: Design-based research was used to implement an educational intervention aimed at developing
midwifery education reflective practice skills and enhance reflective writing. The Bass Model of Holistic Reflection was
competence introduced to promote the development of reflective capacity in midwifery students. Academics and
midwife midwifery students were provided with guidance and resources on how to apply the model to guide
reflective writing. Students’ written reflections completed before (n = 130) and after the introduction of
the intervention (n = 96) were evaluated using a scoring framework designed to assess sequential
development of reflective capacity.
Findings: The pre-intervention scores ranked poorly as evidence of reflective capacity. All scores
improved post-intervention.
Conclusions: The introduction of a holistic structured model of reflection resulted in improved scores
across all five components of reflective writing; self-awareness, sources of knowledge, reflection and
critical reflection, evidence informed practice and critical thinking. While further work is required the
results show that the implementation process and use of the Bass Model enables students to demonstrate
their capacity to reflect-on-practice through their writing.
© 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

What is already known

Statement of significance
Reflection is beneficial in supporting learning from
experience, developing critical thinking, enabling integra-
Problem or issue tion of theory and practice, and the generation of
knowledge in practice.
Reflection in and on practice is valuable pedagogy to
augment the educational worth of practice-based experi-
ences, however it has been shown that when writing What this paper adds
‘reflections’, midwifery students often write descriptively
rather than reflectively. The Bass Model of Holistic Reflection gives structure to
guide and enable students to demonstrate their capacity to
reflect on practice through their writing. Implementation
should be supported with resources for academics to
enable them to promote the effective use of the model by
* Corresponding author at: College of Nursing and Health Sciences, Flinders
students.
University, P.O. Box 2100 Adelaide 5001, Australia.
E-mail address: linda.sweet@flinders.edu.au (L. Sweet).

https://doi.org/10.1016/j.wombi.2018.06.004
1871-5192/© 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: L. Sweet, et al., Developing reflective capacities in midwifery students: Enhancing learning through reflective
writing, Women Birth (2018), https://doi.org/10.1016/j.wombi.2018.06.004
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2 L. Sweet et al. / Women and Birth xxx (2018) xxx–xxx

1. Introduction experience), (2) the affordances provided by the clinical setting

(by individual clinicians and/or the woman herself), (3) the
Midwifery is a practice-based profession. Education and individual engagement of the student, (4) the practical support
preparation for midwifery practice therefore is strongly embedded provided by the education provider, and (5) the post-practicum
in real world practice. Indeed in many higher education courses, activities required to consolidate learning.5,14,17–19 Differences of
practice-based placements are integral for linking propositional this nature can result in highly variable learning experiences for
occupational knowledge, with the requirements for practice, to students.19–21
enable students to meet graduate outcomes.1 In Australia, the In seeking to address possible variations in experiences, Sweet
Australian Nursing and Midwifery Accreditation Council (ANMAC) and Glover5 argued that there were ‘teaching’ activities that could
regulates the educational requirements of programs that lead to be intentionally enacted to support students, promote agency and
registration as a midwife.2 These standards mandate that maximise learning before, during, and after the COCE had occurred.
education providers be required to incorporate learning activities The central feature of these teaching activities was the ability and
into curricula that encourage the development and application of capacity of the student to reflect in and on practice.5 Indeed, as
critical thinking and reflective practice.2 Therefore, the pedagogi- presented above, being a reflective practitioner is a core compe-
cal instructional activities designed to develop reflective capacities tence for midwifery practice, and as such needs to be integrated
represent a very important consideration. into midwifery curricular and the COCE. Therefore, reflection and
Midwifery education in Australia has a mix of traditional reflective writing has merit in facilitating this process.
placements models in maternity services, and Continuity of Care Reflection is beneficial in supporting learning from experience,9
Experiences (COCE), whereby the students follow women through developing critical thinking,7 enabling integration of theory and
their maternity experience. A COCE refers to an ongoing midwifery practice,22 and for the generation of knowledge in practice.12
relationship between a student and a woman from initial contact in Reflective practice is an essential component of one’s personal and
pregnancy, through to the first six weeks immediately after birth, and professional development as a midwife,23 and learning to
occurs across the interface of community and health care settings.2 undertake critical reflection on practice is considered the
COCE are authentic and pedagogically rich learning experiences.3 cornerstone of being an accountable and autonomous practition-
Reflecting in and on practice is valuable pedagogy to augment the er.2 Reflection is therefore a significant post-practicum activity to
educational worth of COCE, but often midwifery students write enhance learning.
descriptively rather than reflectively.4,5 The Bass Model of Holistic
Reflection was developed to guide the development of critical 3. The research project
reflection and reflexivity with the intent to promote transformative
learning within entry to practice midwifery programs.6 The model is The broad aim of the project was to explore and enhance
informed by the literature7–13 and provides students with a reflection through reflective writing as a mechanism to augment
structured approach on how to reflect in and on practice, moving post-practicum experiences. We were concerned with under-
beyond description to deep personal learning. standing whether improved preparation of midwifery students,
This paper reports on a pre/post implementation study of the through education, and use of a guided structured approach to
introduction of The Bass Model of Holistic Reflection to guide reflect on practice, would improve reflective writing, and thus
students’ written reflection on their COCE experiences at one provide evidence of capacity to reflect on practice-based experi-
Australian university. This is part of a larger program of work ences post-practicum. The specific research objective was to
funded through an Office of Learning and Teaching Program Grant optimise the learning potential of practicum experiences by
that collectively sought to explore post-practicum (after clinical enhancing the midwifery student’s capacity to reflect on their
placement/experience) pedagogic activities to enhance learning. COCE through reflective writing. If achievable, the expected long-
term benefit would be enhanced preparation of students for the
2. Background workplace and the complexity of real world clinical practice as a
registered clinician.
Midwifery students are required to undertake extensive
practice-based experiences within their program. Indeed, across 3.1. Methodology
the health professions considerable institutional and personal
resources are directed at clinical placements as embedded Education design-based research, with its problem resolution
educational activities.1,14 Practice-based placements are highly focus,24 was the method selected to address the research aim and
valued for linking theory to practice, and enabling students to meet objective. Educational design based research process includes
graduate outcomes and industry standards. Billett15 argues that defining a problem, identifying solutions from within the available
regardless of pre-determined requirements and profession specific research knowledge, and applying these solutions in the field to
standards, there needs to be pedagogical consideration as to how refine and define the utility of the solution, aiming for increased
best to develop occupationally specific knowledge, including the global applicability.24–26 Educational design based research does
critical and reflective capacities required of health professionals. not ascribe to any particular methodological approach, but rather
Post-practicum is a time when students have an opportunity to uses an iterative approach to address the problem, through
share, compare and engage critically in considering how these intervention testing in the education setting.24 Therefore, a cross
experiences impact on their learning. sectional study using a pre- and post-intervention design approach
The current evidence suggests the COCE is valuable in providing was used. The intervention consisted of four components including
students with an opportunity to learn, develop and practice skills (a) the introduction of a new model of reflection, (b) education to
that enhance their ability and awareness of woman centred care.3 staff on the use of the new model, (c) education and provision of
Indeed Gray et al.16 reported that students felt the learning they educational materials to students on the use of the new model, and
gained from the COCE was ‘profound’, and for many was the (d) a structured writing template.
highlight of their midwifery education. However, clinical experi-
ences alone do not guarantee learning. The clinical opportunities a 3.1.1. Developmental phase
student has are dependent on several factors, including: (1) the For this study, the problem identified was that much of midwifery
level of program they are in (their prior knowledge and students’ post-practicum writing was descriptive rather than

Please cite this article in press as: L. Sweet, et al., Developing reflective capacities in midwifery students: Enhancing learning through reflective
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reflective, providing poor evidence of their reflective capacity.4,5 personal agency and ability to shape the process and outcome of a
Anecdotally, this situation had not improved in recent years. situation in action.6 Reflexivity cultivates self-awareness through
The next step in the design based process was to design a recognising one’s own influence on the environment, and what is
potential solution, and to test the outcomes of the educational learned about the self, including strengths, and areas for
intervention.24 This involved first scoping the reflective practice improvement.6,28 By developing reflexivity, the learner reflects
literature to determine a fit-for-purpose model. Historically, at a deeper personal level on the values, beliefs and assumptions
midwifery academics have drawn from models of reflection that influence experience.6 This is facilitated through deep
predominantly designed for nursing and/or education, to guide personal learning that involves moving beyond descriptive
the development of reflective practice.6 These models do not reflection to critically reflect on personal values and beliefs, and
reflect the woman-centred and holistic philosophy that underpins the wider health care system.6 The underpinning premise of the
midwifery practice.6 At the study university, undergraduate model is that if students can work with, and integrate all four
midwifery students were previously provided with the Gibbs27 concepts into their reflections, then they are much more likely to
reflective cycle as a framework to guide their reflection. This was achieve the ability to perform reflective practice (the outer circle in
presented to them in first year and reiterated in a second-year Fig. 2).
assessment activity. The reporting template for their regular COCE As depicted in Fig. 2 the Bass Model6 incorporates six inter-
reflective writing included open boxes titled “Reflection” and dependant phases embedded within a circular design reflecting
“Learning” with minimal guidance on writing expectations. An both the iterative and vertical dimensions of reflection.12,29 When
example of a COCE reflection using the Gibbs model was provided applying the model each phase is integrated to promote critical
to students. During the development phase of this project the reflection at a deep personal level, contributing to the develop-
research team became aware of the Bass Model of Holistic ment of holistic reflective practice throughout the continuum of
Reflection (henceforth the ‘Bass Model’), designed specifically for the learning cycle. The process embedded in the model promotes
midwifery.6 movement from surface to deep learning, and enables integration
The Bass Model6 integrates midwifery and educational of new learning into practice.22,29,30 Furthermore, the model
philosophy, and was designed to promote transformative learning makes explicit the forms of knowing used to make sense of
at a personal and societal level. The model offers a structured, midwifery practice, including Carpers’8 typology and Habermas’31
scaffolded and staged approach within a holistic continuum emancipatory knowing, and reflects the critical theory continuum
incorporating reflection, critical reflection and reflexivity (see to the development of holistic reflective practice.6
Fig. 1).6 The model was therefore thought to promote reflection at a To identify the level of reflective capacity within students
deeper and more critical level than the Gibbs model previously in written reflections a weighted scoring framework was developed
use. by Bass in consultation with co-authors. The framework represents
an amalgam of concepts that relate to the holistic nature of
3.1.1.1. Brief overview of the Bass Model of Holistic Reflection:. The midwifery practice and the sequential development of reflective
Bass Model6 is premised on the belief that reflective practice capacity across six measurable domains for reflective writing. Each
incorporates self-awareness, reflection, critical reflection and year of the program is linked with a deeper level of critical
reflexivity. This is represented as four inter-related concepts (see reflection that informs and reflects the developing epistemology of
inner circles of Fig. 2), situated within an outer circle of reflective midwifery practice6 (see Table 1).
practice (see Fig. 2). The first concept, self-awareness, is about In year one the student focus is on technical reflection31 based
developing understanding of ones’ own inner state, having on empirical, rational and deductive thinking, to discover what
presence and ability to regulate emotional reactions.6 Next is works in the clinical environment. Students are most concerned
reflection, the process of looking back on an experience or a with reflecting on clinical skills and what knowledge to apply in
situation with the intention of drawing insight that may inform the clinical setting to achieve appropriate outcomes. Reflection at
future practice in positive ways.6 Third, is the concept of critical this level involves evaluation of actions taken based on their
reflection, which is a guided process to aid analysis and increase success or inadequacies in the clinical setting. This includes the
the potential for transforming practice to achieve positive students’ and woman’s feelings, thoughts and perceptions about
outcomes.6 The model involves developing the ability to the experience.
critically examine situations from multiple perspectives. Steps In year two the focus shifts to practical reflection with an
include questioning, defining, reflection, analysis and learning. emphasis on human interaction and communicative action. The
Lastly, is the concept of reflexivity that represents awareness of student is concerned with developing ways of understanding

Fig. 1. Conceptual framework Bass Model of Holistic Reflection Model (Bass et al., [6,p. 230]).

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Fig. 2. The Bass Model of Holistic Reflection (Bass et al., [6,p. 231]).

Table 1
Relative weighting of each section of scoring framework by year level.

Self-awareness Evidence of midwifery Reflection and Evidence informed Critical thinking Style, language
& insight knowledge reflexivity practice & integrity
Yr 1 20% 20% 20% 15% 10% 15%
Yr 2 + RN 1 10% 20% 25% 15% 20% 10%
Yr3 + RN 2 5% 20% 30% 15% 25% 5%

human behaviour and the practical aspects of the learning and critically reflects on practice, incorporating ethical and socio-
experience, specifically reflection on the relationship between political ways of knowing. This is motivated by transformative
theoretical principles and the realities of clinical practice. The action and commitment to reflect critically on the socio-political
student is expected to reflect on the relationship between actions and cultural constraints that prevent emancipation.32 Through
and their consequences, and beliefs, as well as the underlying critical reflection and reflexivity, the student begins to explore
rationale for practice. This extends beyond technical-rationality alternatives and plan future actions because of analysis and
into investigating, questioning, and interpreting the end objectives synthesis. To capture the progressive development expected with
and assumptions behind what is happening in the clinical setting. iterative and vertical reflection, different weightings are applied to
This involves the student in discourse and practice conversations final year students to assess their higher level reflective writing
that create opportunities for dialogic reflection.30 The scoring with an increased focus on reflexivity and critical thinking.
framework is therefore adjusted to assess the student’s increasing
ability to (1) interpret the significant factors influencing an 3.1.2. Preparation, implementation and evaluation phase
experience, (2) adopt a dialectical and dialogic approach to
exploration, (3) see the experience differently, and (4) exercise 3.1.2.1. Setting:. At the study setting, the Bachelor of Midwifery
integrative thinking to combine multiple perspectives and ways of has two pathways leading to registration; (1) Pre-registration or
knowing. direct entry for individuals without nursing or midwifery
In year three the focus is on critical and emancipatory experience, and (2) Registered Nurse (RN) entry or post-
reflection. This includes the ability to critically reflect on the registration pathway. During the program all midwifery
factors that impact on women’s choices, including ‘informed’ students are required to present written reflections across all
choices and how they are made. The focus is on what knowledge is years of their program. Whilst there were brief opportunities to do
of value and why, and builds on the interpretive knowledge this on their clinical placement records, the primary sources of
referred to earlier as practical reflection. The student is concerned reflective writing were the COCE records, and one critical reflective
with not only what happens in clinical practice, but also questions essay in second year. Given that students in all year levels, and both

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entry pathways, undertake COCE, this form of practicum eighteen-month registered nurse (RN) pathway were shown as RN
experience was selected as the most suitable medium to test 1 or 2. The allocation of being RN 1 or 2 was directly aligned with
the intervention. The COCE also provides multiple episodes of the topics the student was enrolled in and writing for. The RN
practice over time, and therefore are rich experiences that students students do not undertake the clinical topics as year 1 students in
can draw from to reflect upon.3 the pre-registration pathway. If enrolled in the clinical topic also
Prior to the implementation of the Bass model, a series of done by year 2 students of the pre-registration pathway they were
professional development sessions were conducted for staff and identified as RN1 and similarly, when doing the clinical topic also
students on the purpose, and process of using the Bass Model6 by done by year 3 students of the pre-registration pathway, they were
the principal author of the model. To support these sessions, identified as RN2. Writings from the RN pathway students were
webinars and explanatory documents were created and made assessed using the second and third year weighted framework as it
available to staff and students through the university learning was assumed they would have developed a capacity for reflective
management system. practice in their education for, and role as, registered nurses. The
students were not provided the scoring framework, only the model
3.1.2.2. Ethical considerations:. Approval to undertake the project and supporting materials.
was received from the University’s Human Research Ethics
Committee. As data was drawn from reflective writing produced 4. Results
in the normal course of study, individual recruitment or consent
was not required. Taking this approach was considered to reduce The outcome of the reflective writing marking is shown in
the ‘Hawthorne effect’, whereby participants may consciously Table 2. Pre-intervention scores ranked poorly as evidence of
change their behaviour/output knowing they were in a research reflective capacity, with the more experienced students, Yr3 and
study.33 To ensure anonymity all data collected were de-identified RN2, scoring lower than their less experienced student counter-
and allocated a study code prior to distribution to the research parts.
assistant. Following the evaluation and scoring, the study code was All student scores improved post-intervention. Table 3 shows
then matched to the student’s program year level by the chief the per cent variation of scores for each year level.
investigator and the final score calculated with the relative
weightings to minimise potential bias during the evaluation phase. 5. Discussion

3.1.2.3. Data and data analysis:. Data was in the form of the This project set out to investigate whether implementation of a
students’ submitted reflective writings. All students submit their structured, guided and holistic reflective model designed specifi-
written work through the university online learning management cally for midwifery students would enhance their written
system or as a component of their hard copy Midwifery Practice reflections, therefore provide evidence of reflective capacity. The
Portfolio submission. In semester one 2016 a convenience sample importance of introducing midwifery students to the discipline of
of submitted reflections across all year/program pathway groups structured reflection through writing is supported by Collington
were collected. No more than two reflective pieces were sought and Hunt23 who found that students continued to embrace
from any individual student. This resulted in the collection of 130 reflection as part of their continuing midwifery practice upon
reflective pieces, based on the Gibbs model, for analysis pre- registration. Through collection and analysis of academically
intervention. Similarly, post intervention (semester 2 2016) a required reflective pieces we were able to demonstrate that the
convenience sample of 96 reflective pieces based on the Bass intervention improved midwifery students’ capacity to demon-
Model were collected for analysis. strate reflection on practice in their writing. This was achieved
All de-identified data were subjected to assessment using the
Bass reflective writing scoring framework. To ensure correct use of
Table 3
the framework, the research assistant and the author (JB) of the
Percent variation for scores for each year level.
framework independently assessed four papers across each year
group. These were then moderated to reach a consensus on Student level Pre-intervention Post-intervention % Variation
application of the framework. Subsequently any reflections that RN1 59.2 67.3 +14%
were difficult to assess were further moderated. Once all analysis RN2 49.2 67.7 +37%
was completed the scores were entered into an Excel© spread sheet Yr1 59.9 74.0 +24%
Yr2 55.9 69.4 +24%
and grouped by year level. Students undertaking the three-year Yr3 38.8 60.8 +57%
Pre-registration Bachelor program were identified using the
identifier of Year (Yr) 1, 2 or 3 while students enrolled in the

Table 2
Outcome of marking against scoring framework (note relative weightings vary per year level as per Table 1).

Time Student N Self-awareness & Evidence of midwifery Reflection and Evidence Critical Style, language & Total
group insight knowledge reflexivity informed thinking integrity score
practice
Pre-intervention RN 1 16 5.9 11.8 15.9 7.1 11.9 6.6 59.2
RN 2 21 2.2 11.0 15.3 6.4 11.2 3.1 49.2
Yr 1 10 12.4 11.9 12.2 8.2 4.8 10.4 59.9
Yr 2 39 5.4 11.9 14.1 8.1 9.8 6.6 55.9
Yr 3 44 2.1 8.2 12.7 5.0 7.8 3.0 38.8
Post-intervention RN 1 24 6.8 13.4 17.5 9.7 12.8 7.1 67.3
RN 2 33 3.5 14.0 20.1 10.4 15.9 3.8 67.7
Yr 1 11 15.1 14.4 15.7 9.9 6.9 12.0 74.0
Yr 2 24 7.1 14.0 17.9 9.7 13.4 7.3 69.4
Yr 3 4 3.3 12.5 20.8 9.4 11.2 3.6 60.8

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without students being aware of the pre-and post-intervention philosophy underpinning the concept of ‘being with women’ in
project, to minimise any chance of their purposefully writing midwifery care.36 This requires the development of a holistic
differently for the study alone. midwifery approach that draws on multiple ways of knowing
Pre-intervention scores across the student cohort were low and gained through experiential, contextual and intuitive knowledge. It
ranked poorly as evidence of reflective capacity. Of note is the may be that the reflective model only speaks to this experience.
identified downward trend in pre-intervention scores as students Alternatively, the increase may simply be that the new structured
progressed through the program. The lowest scores, were achieved writing template, where the expectation was to write something in
by students with the most experience (final year students in both each box and therefore address each aspect of reflection, may have
entry pathways). Furthermore, had both groups of final year prompted students to increase their effort for the non-graded pass.
students’ scores been measured in this way in the curriculum they This result alone may be evidence enough to suggest a structured
would have failed to achieve the standard expected. This is an approach enhances learning and therefore should be introduced.
interesting finding given that it would seem reasonable to assume Another key finding that emerged from the project was the
that as a final year student they should have had a higher level of effectiveness of the scoring framework to assess reflective capacity.
reflective capacity and ability to translate this into reflective The pre- and post-intervention scores demonstrated the utility of
writing, especially as some of the assessed pieces of work were the framework in assessing reflective capacity. The framework was
their final written reflections. In addition, it was expected that the specifically developed to assess the five concepts that underpin the
cohort who were already registered nurses would have developed development of reflective practice, with the inclusion of language
reflective capacity as part of their pre-registration nursing and integrity for professional writing. The ability for students to be
education. This was not the case with final year students in the self-aware, insightful, critically reflective and reflexive within a
RN pathway returning scores lower than first and second year holistic midwifery philosophy that acknowledges midwifery ways
students in the pre-registration pathway. Why this would be the of knowing creates the potential for perspective transformation.
case is difficult to say. The low scores may have been the result of Weighting the concepts to reflect the expected levels of reflection
diminished student effort. For example, the COCE reflections were as the student progresses through the program from technical,
a component of the student’s Midwifery Practice Portfolio practical to emancipatory reflection is important.31,32 Pursuing this
submission, which is a non-graded assessment. As such, minimal approach ensures that each phase of the reflective process is
effort could still have achieved the non-graded pass required. assessed in a holistic and integrative manner, and students are able
Conversely, first-year students may have been more diligent in this to demonstrate development of reflective capacity over time. Each
aspect of their program, being new and enthusiastic, whereas the year of the program is linked with a deeper level of critical
third-year students may have felt pressured with the multiple reflection and reflexivity that informs and reflects the developing
demands of study and practicum, therefore strategically prioritis- epistemology of midwifery practice.6 The framework was able to
ing graded over non-graded work. quantitatively demonstrate students’ strength and weaknesses in
The subsequent improvement in scores across all year groups their reflective writing. The framework will be used in future as a
following the introduction and expectation of use of the Bass marking rubric to further enhance student learning through
Model is an important finding. For example, third-year students’ structured feedback to promote deep personal learning and
writing improved by 57%, despite the activity remaining as a non- development of reflective capacity.
graded pass. It is also noteworthy that students achieved higher In summary, we suggest that when compared to other models
post-intervention score across all criteria used to assess reflective of reflection, the design of the Bass Model has potential for
capacity (self-awareness, evidence of knowledge, reflection and facilitating the development of self-awareness and insight, critical
critical reflection, evidence informed practice, critical thinking, reflection and reflexivity, midwifery ways of knowing and critical
language and integrity). The preparation taken and process of thinking. Whereas Gibb’s iterative reflective cycle emphases
implementing the model is also important to highlight. An learning by doing, and reflection on action,27 the Bass Model6
essential aspect of the project was not only the introduction of incorporates a holistic approach to developing skills of critical
the model of structured reflection to students but to ensure they reflection, involving integration of existing knowledge with new
had access to educational resources to facilitate their learning insights and understanding within a framework of holistic
including guides and a writing template. Taking this approach is midwifery philosophy. The focus of the Bass Model is on the
supported by literature that clearly identifies that if students are to generation of knowledge through reflection on practice experi-
develop the habit of reflecting on actions, and construct meaning ences that occur before, during and after clinical practicum. In this
from those experiences, they need to be taught strategies to help way students can develop insights into what they think they
cultivate reflection.34 Reflection is a specialised form of thinking believe as espoused theory compared to theory in use.37
and learning that challenges routine thinking and action11 and Undertaking this process helps learners avoid ritualistic or routine
does not develop automatically.35 As such health care educators approaches to care as a result of unexamined knowledge and
should look for educational strategies that promote the develop- experience.38
ment of reflective capacity as early as possible in the education Such a model also recognises the complexity of reflection and
process. Low pre-intervention scores were possibly a reflection of the developmental nature of reflective capacity.12,39 Introducing
students being provided with minimal guidance on how to reflection early in pre-registration programs has been shown to
incorporate the Gibbs 22 framework into their COCE reflective develop self-awareness and insights into limitations,40,41 assist in
writing, and not necessarily the model itself. While more work is the generation of individual learning needs,40 develop solution
required the findings do suggest that the Bass Model and its focused thinking,10 and develop sustainable approaches to the
accompanying educational resources assisted students to reflect resolution of feelings and contradictions practitioners frequently
and write in a more holistic manner. face in clinical practice.10 Moreover, introducing reflection to
Having said this, the increased post intervention scores may students early in pre-registration programs has been shown to
have been an artefact of reflecting on the COCE itself, as opposed to have a direct relationship to continued use of reflection upon
another clinical learning experience. The COCE is specially graduation.42 What is evident from our study is that when
designed to help midwifery students understand how to practice scaffolded reflection is also combined with a staged approach to
holistically. Being able to be emotional, physical, spiritual and guide learners, the depth and breadth of reflective capacity is
psychological present in the COCE relationship is central to the enhanced.43 This is an important design feature of any model of

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writing, Women Birth (2018), https://doi.org/10.1016/j.wombi.2018.06.004
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Please cite this article in press as: L. Sweet, et al., Developing reflective capacities in midwifery students: Enhancing learning through reflective
writing, Women Birth (2018), https://doi.org/10.1016/j.wombi.2018.06.004