Background

Various models are available in the nursing science literature focusing purely on improving the presence of the nurse [1, 2] and 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, the literature reveals conceptual frameworks from various authors on reflection. In reforming education, Dewey [4] founded the model of reflective inquiry that emphasised what it means to think reflectively and achieve personal learning. The theory on reflective practices built on the work of Dewey by Schőn [5] that links reflection to professional development and professional practice. The work of Boud et al. identified that for reflection to be a valid way of learning, emotions are required [6]. Furthermore, the American sociologist Mezirow [7] developed transformative learning theory to facilitate the learning and transformation of adults in the business environment; this 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 has contributed to the understanding of reflection for learning with a focus on professional development.

No model has yet been developed for nurse educators that focuses on “presence” and “reflective practices” in the teaching–learning context of large classes. Yet nurse educators are required to implement creative, innovative, and reflective ways of interacting with and involving nursing students in the teaching–learning process and to facilitate presence [9,10,11]. In particular, nurse educators at accredited Nursing Education Institutions (NEIs) in the North West Province who teach large classes need guidance on building presence and reflective practices as teaching–learning strategies; such a model will provide a theoretically grounded schematic framework to apply in teaching–learning situations [12].

COVID-19, has resulted in a blended teaching–learning approach including large online (virtual) classes. Such remote learning could hinder the facilitation of presence through reflective practices. Nurse educators also face heavy workload demands, including teaching of large classes, clinical supervision, and research activities [11, 13]. These educators may also have insufficient knowledge and confidence regarding alternative teaching approaches and may experience time demands for designing, testing and implementing and new teaching approaches; selecting and grading assessments; they may also suffer from feelings of discomfort and anxiety [10, 11]. Teaching large class groups requires nurse educators to implement more interactive teaching–learning strategies that optimise opportunities for student engagement in the content as well as the learning process [9]; such optimisation will enhance the standard and quality of nursing education [14,15,16]. Thus, the research question arises: What does a practice model to guide nurse educators at accredited NEIs with large class settings to facilitate presence in nursing students through reflective practices as a teaching–learning strategy entail?

Research aim

The aim was to develop a model for nurse educators at accredited NEIs with large classes; the model is intended to facilitate the presence of nurse educators as they teach nursing students using reflective practices as teaching–learning strategies.

Methods

A theory-generative design was followed for model development. The model was conceptualised, structured, and contextualised through statement and theory 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 where concepts and statements are organised into a network or whole [17]. The process of theory synthesis consists of three iterative steps. During Step 1, 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, in Step 3 the main and related concepts, relational statements and conceptual framework were organised into an integrated and efficient representation (that is, the model). Finally, conclusion statements were developed for the two theoretical constructs “presence” and “reflective practices”. Repeated words, ideas and phrases were categorised together through statement synthesis to develop the conclusion statements to strengthen the significance of the model.

Results

The model (Fig. 1) was structured and contextualised based on the six questions of Chinn and Kramer to ensure a complete description of the model was formed [18]. The description of the model included 1) statement of the purpose; 2) identifying the assumptions of the model; 3) clarifying the context; 4) clarifying of the structure (identified, defined and classified main and related concepts, followed by design of relational statements); and 5) the process description of the model [18].

Fig. 1
figure 1

A model for nurse educators to facilitate presence in large class group settings through reflective practices

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The purpose of the model

The purpose of this model was to provide nurse educators with a theoretically grounded schematic framework to be implemented at accredited NEIs in the setting of large classes to facilitate their presence for nursing students through reflective practices used as teaching–learning strategies.

Identifying assumptions of the model

Assumptions are the basic underlying premises from and within which theoretical reasoning proceeds. These influence all aspects of structuring and contextualising a model [18]. The assumptions address the basic truths that are believed to underlie theoretical reasoning and will direct the reader as to what the researchers accepts as the truth. The assumptions of the model are informed by pragmatism, the “theory of presence” [19] and the model for “promoting reflection in learning” [6]. The model for nurse educators to facilitate their presence in nursing students through reflective practices at accredited NEIs in the context of large class group settings is based on the following six assumptions, derived for this study by the researchers:

  • Nurse educators and nursing students are multi-dimensional (physiological, psychological and spiritual) human beings with unique experiences who interact with others and their environment to create reality and together discover (and reflect on) presence in the moment.

  • Nurse educators must be receptive and dedicated to nursing students and enter 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 strictly defined but relates to the development of the other person.

  • The model is used in this study in the teaching–learning context of large classes 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 are needed to ensure that the model will be useful for practice [18]. In the context of this model, an NEI 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 prescribed accreditation requirements, criteria and standards of the South African Nursing Council (SANC) for nursing education and training. They can include a university, university of technology, nursing college or nursing school, as well as health establishments [21]. The teaching–learning context consists of large classes of nursing students enrolled in four-year undergraduate nursing programmes at accredited NEIs. Structured teaching occurs in classroom and clinical practice with conditions and settings conducive to knowledge, skills and values necessary for nursing. The transfer of information and skills occurs through exposure to practical experiences. The “teaching and learning environment” for nursing students are thus equipped with needed competencies through interaction with different learning opportunities that enhance the integration of theory and practice. A blended teaching–learning approach by nurse educators facilitates their presence through reflective practices which they integrate into their nursing practice despite the large class sizes; this ultimately improves the nursing care that nursing students and graduates provide.

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 (Step 1 of the study method).

Conceptual definitions of the main and related concepts

The conceptual definition formulated for the main concept “facilitating presence through guided reflection for transformative learning” was developed through considerations outlined below.

“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 through (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 results in self-inquiry, self-reflection, self-analysis and self-evaluation and in changed perspectives, a better understanding, learning and improved practice. Transformative learning, changed perspectives, gives a better understanding and creating a shift in students frame of reference, with a positive change in thoughts, feelings, beliefs and behaviour as a nurse in a present way. Deep, constructive, meaningful learning generates a complete change in nursing students’ state of”.

Designing relational statements

Relational statements were 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 by 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; demonstrating professional, personal, and moral maturity; practising 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 who 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, influencing, directing, accompanying, and supervising learning during the acquisition of knowledge through study in the classroom, or skills acquired 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.

  • The transformative learning 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 in this model was carefully chosen to convey the correct meaning, influence and impact. 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
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Process description of the model

The model (see Fig. 1) follows a three-phased strategy of prepare (Phase 1), process (Phase 2) and product (Phase 3). The process of the model for nurse educators to facilitate their presence in large class groups of nursing students through reflective practices as teaching‬–learning strategies at accredited NEIs is outlined in Table 2.

Table 2 Process description of the model
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Concluding statements of the model

To strengthen the model developed, concluding statements were formulated through statement synthesis for “presence and reflective practices in nursing education” as follows:

  • Facilitating presence through reflective practices requires a conducive teaching–learning environment that supports purposeful inquiry and meaningful collaboration. These two elements are essential to implement by nursing students exploring and challenging practice through reflection. Various environmental factors such as conducive work settings, authentic surroundings, adequate resources, and sufficient time enhance presence through reflective practice.

  • The nurse educator establishes meaningful relationships with nursing students that are supportive, respectful, and non-judgemental through being open and connecting with nursing students. The nurse educator can challenge, enable, and support them for learning to become meaningful. In turn, such relationships provide a model for nursing students on how to establish therapeutic relationships, a skill that nursing students can apply to patients.

  • Attributes of presence embrace 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; this requires sufficient time, adequate resources and support from organisations, colleagues, peers and students, and the use of applicable technology.

  • Presence and reflective practices are essential components for theory–practice integration in that nurse educators share personal and professional experiences with their nursing students to promote the internalisation of knowledge and skills. Such practices enable them to implement what they have learnt, and develop professional knowledge, understanding and clinical competence; these elements in turn 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 the nurse educator, nursing student and the patient. In turn, this leads to improved quality nursing care, and ultimately, positive patient outcomes.

Validation of the model

After the model was developed and contextualised, it was evaluated and refined in two steps. In Step 1, the model was evaluated by a panel with expertise 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 NEIs. 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 is the subject of another paper.

Discussion and recommendations

A theory synthesis in line with Walker and Avant [17] was conducted to develop a model to bridge the gap identified in the literature, namely that available models focus purely on improving presence in nursing science or the nurse as a reflective practitioner. Until the current paper, there has been no known model that implements both “presence” and “reflective practices” in teaching–learning strategies for nurse educators interacting with large classes of nursing students.

To meet the aim of this study, the current model has been conceptualised and validated as a framework to guide nurse educators at accredited NEIs with large classes to facilitate their presence in nursing students through reflective practices as teaching–learning strategies. This paper describes the model by providing an overview, defining the purpose, identifying assumptions, clarifying the context and detailing the model structure. This model addresses the gap in the literature and substantially deepens the body of nursing education knowledge in the international and South African contexts; it thereby serves as a model for guiding nurse educators in their teaching–learning practices.

This conceptual model can be applied in nursing education, practice and research. Integration of this synthesised model into the teaching practices of nurse educators involved in undergraduate, postgraduate and continuous professional development programmes could produce present and reflective nurse practitioners by:

  • 1. implementing a short-term learning programme to assist nurse educators with understanding the importance of the model and to present guidelines for implementation by nurse educators throughout their training;

  • 2. presenting 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. integrating the model into the teaching practices of nurse educators for each year of undergraduate nursing programmes to facilitate presence throughout their training; and

  • 4. creating awareness campaigns in other fields (such as education) of the importance of presence through presentations to emphasise the importance of practising presence to promote the standard of education, training and practice.

The conceptual model developed by the researchers can also be applied by nurses in practice in clinical facilities. It is suggested that: 1) all categories of nurses attend a short learning programme to create awareness of presence; 2) in-service training programmes are held to orientate all categories of nurses in the clinical setting of the practice of presence; and 3) continuous professional development programmes on presence should be made available.

This synthesised model prompts the need for further research outputs. Other venues for research into facilitating presence through reflective practices include: 1) validation of the model presented in this paper and a set of guidelines for operationalisation; 2) refinement of a model contributing to theory–practice integration; 3) the development of a similar programme to be applied in other health science disciplines; and 4) guidelines for operationalising the model within other disciplines such as education.

A limitation in the process of developing the conceptual model was limited in that the literature search was restricted to peer-reviewed journal articles written in English; relevant research the presence and reflective practices written in other languages may therefore have been missed. Despite the limitations of the manuscript, the conceptual model has laid the foundation for future research and new findings that could provide further insights into the theory of facilitating presence in large classes through reflective practices.

Conclusions

The presence of nurse educators at North-West University has elicited the intuitiveness of nursing scholars and researchers and has created awareness of intuitiveness in the field of nursing science. It was necessary to capture insight into this phenomenon, and the newly synthesised conceptual model of the researchers provides an effective way of approaching this goal. Theory synthesis proposed and developed by Walker and Avant [17] was used as a strategy to develop the conceptual model for nurse educators to facilitate their presence in a large class of nursing students through reflective practices. This paper contributes substantially to deepening the body of knowledge in the nursing education domain of South Africa and internationally, to serve as a model for guiding nurse educators in their teaching–learning practices. The researchers’ proposed model can be used as a foundation for further research and can be utilised across nursing education, practice, and management.