Impact of Reflective Journals on Nursing Students' Performance, Study notes of Nursing

Download Impact of Reflective Journals on Nursing Students' Performance and more Study notes Nursing in PDF only on Docsity! The Use of Guided Refl ective Journals in Clinical Nursing Courses Valerie Taylor-Haslip, Health Sciences Research has shown that the regular habit of journal writing can deepen students’ thinking about their course subjects by helping them see that an academic field is an arena for wonder, inquiry, and controversy rather than simply a new body of information. John C. Bean Introduction In nursing courses, lecture and discussion have been the primary methodologies for teaching theoretical principles, and the standard measurement tool for evaluating academic success in the classroom has been pen-and-paper testing. As a result, nursing students have tended to memorize factual material in order to pass their exams, but then found it diffi cult to apply their newly acquired theoretical knowledge to the clinical area. With a more complete understanding of the rela- tionship between theory and practice, nursing students could not only improve their performance in both classroom and clinical settings but also become more competent nurses upon graduating. For learners who must demonstrate the practical application of didactic knowledge, it is important that they become “aware of their attitudes toward learning” (Rosenbaum, Lobas, and Ferguson 1187). With nursing students, this task appears to be most effectively accom- plished by encouraging them to refl ect on the larger context, meaning, and implications of their actions and experiences in the clinical area. Through this process, which fosters the internalization of concepts that have been encountered in the classroom, nursing students can gain better insight into the areas in which they need additional theo- retical grounding, thereby improving both their academic and clinical success. Guided refl ective journals are a form of exploratory writing whose purpose is to stimulate student thinking about both theoretical and clinical concepts (Bean 102). They provide the opportunity for a student-centered written conversation between learner and instructor regarding signifi cant experiences that have occurred in the clinical area. In the journal, students can pose questions, seek clarifi cation of specifi c 28 • In Transit The Use of Guided Refl ective Journals • 29 items, fi nd meaning, and discuss matters of concern and interest with the instructor (Paterson 211). Dye states that journaling with “a structured journal format with clear instructions and ongoing feedback has been found to be most successful in maintaining student engagement” (1). Increased student engagement leads to a better understanding of course content, and this improved understanding strengthens student ability to apply theo- retical concepts to the performance-based skills required of competent practitioners. For students entering the nursing profession, the abil- ity to link theory with practice through ongoing refl ection is of vital importance. As Dye points out, “An essential component of expert professional practice is the practitioner’s ability to critically refl ect on his or her performance” (1). As a strategy to encourage nursing students to refl ect upon their performance, guided reflective journals were introduced into the Parent-Child Nursing course (SCR270) in LaGuardia Community College’s PN-RN Advanced Pathway program. The students who enter the PN-RN Advanced Pathway are Licensed Practical Nurses already in possession of technical skills that can be applied under the proper supervision. Their goal, however, is to assume the role of a Registered Nurse, which carries with it a much greater level of responsibility and requires practitioners to think critically rather than rely on the guid- ance of others. This study explores the use of guided refl ective journals in helping nursing students achieve this goal. Sample Population The students involved in this study were Licensed Practical Nurses studying in the PN-RN Advanced Pathway program for the purpose of becoming Registered Nurses. There was a total of thirty students, twenty-eight of whom were female. Ranging in age from their mid-20s to their mid-50s, most of the students were returning to school while continuing to work full time. All of the students were enrolled in the evening section of the course, Parent-Child Nursing, which requires both classroom and clinical work. For their clinical work, the thirty students were divided into three groups of ten students each. Their maternity and pediatric clinical rotations were carried out at three locations: Bellevue Hospital Center, Jamaica Hospital Center, and Flushing Hospital Center, all in New York City. 32 • In Transit Table 1: Sample Student Journal Entries Categorized According to the Hatton and Smith Criteria Student journal entry Descriptive Descriptive refl ective Dialogic refl ective Critical refl ective Student 1 Today I was assigned to 34 year old patient who had a C-Section done. She also had Sickle Cell Disease and was concerned about her newborn baby getting the disease. My goal was to teach her about the disease and also how to care for her wound to prevent infection. I was able to inform her that for her daughter to get the disease the father would have to have the disease and the newborn chances would be 25%. I also taught her about hand washing technique to pre- vent infection and also to walk as much as she can to prevent constipation. Today I was assigned to the newborn nursery. Since I am repeating this course, I decided to explore all of the areas of newborn as- sessment so that I can get a better understanding. I was more comfortable in doing a thorough assessment along with my professor and I am sure this will help me in my exam. Student 2 Today I was assigned to my fi rst clinical task and duties [and] I was a little nervous when professor gave me the assignment. Although I am a nurse for 5 years I never worked on a maternity unit. I was glad to get this experi- ence so in the future I can think of working the maternity unit at times. My patient today was a 7 year old boy diagnosed with Status Asthmaticus. I have learned that Status Asthmaticus can cause severe respiratory distress and without immediate care the child may progress to respiratory failure and die. After receiving treatment [with] solumedrol, which I administered with my professor, my patient was able to walk around without any respiratory distress. I wrote a note, gave report to the nurse and I was very happy I got the opportunity to help. In addition to evaluating the students’ weekly entries in their guided refl ective journals, the instructor also examined two other measures of student performance. One measure was the unit exams based on material covered in class and graded with a percentage score. Evaluations of the The Use of Guided Refl ective Journals • 33 students’ clinical performance constituted the second measure. For the formal clinical evaluations, the students received one of three grades: “satisfactory,” “needs improvement,” or “unsatisfactory.” At the end of the semester, data from Weeks One, Four, Eight, and Twelve was compiled and plotted on a graph so that trends could be examined. These data included (1) the percentage of students writing at a descriptive refl ective level or higher, (2) the average exam score, and (3) the percentage of students receiving a clinical performance assess- ment of “satisfactory.” The question being posed was whether any cor- relation might be observed between the students’ ability to refl ect and their academic performance in class and in the clinical area. Results The most signifi cant result of the study was that most students showed clear evidence of being able to use their instructor’s feedback to increase the level of refl ection found in their journal writing over the course of the semester. During the fi rst week, as shown in Graph 1, only 27% of the students were writing at even the descriptive refl ective level (the second lowest level in Hatton and Smith’s hierarchy) in their journal entries. The large majority wrote only descriptive passages, with little or no evidence of refl ective thought. By the fourth week, the number of students writing at the descrip- tive reflective level had more than doubled, reaching 57%. By the eighth week, 90% of the students were using their journals for refl ec- tive purposes, and of these, nearly half had reached the level of dialogic refl ection. Graph 1: Comparison of Students’ Level of Refl ection, Exam Grades, and Clinical Performance 120 Descriptive reflective level of reflection or higher Average exam grade Satisfactory level of clinical performace from Week 4100 80 60 40 20 0 Week 1 Week 4 Week 8 Week 12 34 • In Transit Although no students were able to attain the highest of Hatton and Smith’s levels, that of critical refl ection, the number writing at the descriptive refl ective and dialogic refl ective levels held steady until the end of the semester. In Week Twelve, only three of the thirty students (10%) continued to limit themselves to simple descriptions. Fourteen students (47%) were demonstrating an ability to engage in descriptive refl ection, while another thirteen students (43%) had reached the level of dialogic refl ection. There was also some indication that the students’ increasing ability to use their journals for refl ection might be related to improved results on both their written exams and their clinical performance. As a group, the students had their lowest average exam grade, 75%, during the fi rst week, when their journal writing was almost entirely limited to simple description. By the fourth week, when a majority (57%) of the students had begun to write refl ectively in their journals, the average exam grade had increased to 82%. In the eighth week, the average student exam grade slipped to 77%, even though 90% of the students had reached at least the descriptive refl ective level of journal writing. This apparent contradiction can be explained, however, by the fact that the class had just concluded the part of the course dealing with maternity and was taking the fi rst exam devoted to pediatrics; the change in subject matter could easily account for the lower exam scores. By the twelfth week, the average exam grade had risen to 85%, the highest average during the entire semester. At this point, not only were 90% of the students continuing to write refl ectively in their journals, but nearly half of these had reached the level of dialogic refl ection. In the area of clinical performance, where the effects of refl ective writing might be expected to be most observable, the results were even more consistent. In the fi rst week, the students’ clinical performance had been only at the beginning stages and was not formally assessed. In the fourth week, however, 90% of the students received an evalua- tion of “satisfactory,” while 10% got a grade of “needs improvement” or “unsatisfactory.” As the percentage of students writing refl ectively in their journals increased from 57% in the fourth week to 90% in the eighth week, the percentage receiving a grade of “satisfactory” on their clinical performance also increased, from 90% to 96%. As noted, the level of refl ection in the student journals remained high in the twelfth week, as did the students’ clinical performance, with 96% once again receiving a grade of “satisfactory” during that week. a search for answers, which in turn leads to a greater appreciation for what has been covered in class. The process of keeping a guided refl ective journal moves the stu- dent through this process to higher levels of refl ection. Refl ection in the clinical setting forces nursing students to acknowledge their own strengths and limitations as they attempt to make decisions concerning patient care. When students receive instructor feedback in the form of increasingly demanding refl ective questions, they begin to utilize more complex processes that result in higher levels of critical thinking and more effective decision-making. Appendix: The Guided Journal Assignment SCR 270 Parent-Child Nursing Clinical Rotation Guided Journal The clinical rotation for maternity nursing will take place the fi rst six weeks of the course and each week you will rotate to a different area of maternity. The pediatric nursing clinical rotation will take place the last six weeks of the course. To optimize your personal clinical experiences, you will keep a journal to record your learning objectives and learning experiences throughout the semester. Purpose: To provide you with an opportunity to focus on a personal learning objective apart from the assigned clinical learning objective. Description: Your journal should be kept in a small notepad and carried to the clinical area each week. Write your personal objective and the date as the title of your entry. Use the informal narrative style of writing for all entries and proceed in the following manner: 1. Prior to reporting to the clinical area, write down your own per- sonal learning objective for the day. 2. At the end of the clinical day, record your experiences in your journal. 3. Explain if you were or were not able to meet your personal learning objective. 4. Describe what you would do the same or differently to ensure you met your objective during the next clinical experience. 5. Write a refl ection of the entire clinical rotation experience as your fi nal entry in your journal at the end of the semester. The Use of Guided Refl ective Journals • 37 Below are suggestions you may use as learning objectives; however, you are encouraged to develop your own personal goals. Week 1 Personal expectations for orientation to the maternity units Week 2 Personal organization of your clinical tasks and duties Week 3 Prioritization of your work day Week 4 Communication and interaction with a maternity client Week 5 Communication with another healthcare professional (MD, Pharmacist, etc.) regarding your client Week 6 Formal report to the nurse responsible for your client Week 7 Personal expectations for orientation to the pediatric units Week 8 Understanding the drug interactions of medications you will be administering to the pediatric clients Week 9 Patient education for the parents of an infant Week 10 Patient education for the parents of a toddler or pre-schooler Week 11 Patient education for the parents of a school-age child or adolescent Week 12 Refl ections on the entire clinical experience Works Consulted Bean, John C. Engaging Ideas: The Professor’s Guide to Integrating Writing, Critical Thinking, and Active Learning in the Classroom. San Francisco: Jossey, 2001. Print. Jossey-Bass Higher and Adult Educ. Ser. Dye, Deanna. “Enhancing Critical Refl ection of Students During a Clinical Internship Using the Self-S.O.A.P. Note.” The Internet Journal of Allied Health Sciences and Practice 3.4 (2005): 1–6. Web. 17 Aug. 2009. Hatton, Neville, and David Smith. Refl ection in Teacher Education: Towards Defi nition and Implementation. Master of Teaching, Faculty of Educ. and Social Work, U of Sydney, 1994. Web. 11 Sept. 2009. <http://alex.edfac.usyd.edu.au/LocalResource/originals/hattonart.rtf>. Jensen, Sharon K., and Christina Joy. “Exploring a Model to Evaluate Levels of Refl ection in Baccalaureate Nursing Students’ Journals.” Journal of Nursing Education 44.3 (2005): 139–42. CINAHL Plus with Full Text. Web. 18 Aug. 2009. 38 • In Transit London, Marcia L., et al. Maternal & Child Nursing Care. 2nd ed. Upper Saddle River: Pearson, 2007. Print. Paterson, Barbara L. “Developing and Maintaining Refl ection in Clinical Journals.” Nurse Education Today 15.3 (1995): 211–20. Print. Pee, Barbel, et al. “Appraising and Assessing Refl ection in Students’ Writing on a Structured Worksheet.” Medical Education 36.6 (2002): 575–85. Academic Search Premier. Web. 17 Aug. 2009. Rosenbaum, Marcy K., Jeffrey Lobas, and Kristi Ferguson. “Using Refl ection Activities to Enhance Teaching About End-of-Life Care.” Journal of Palliative Medicine 8.6 (2005): 1186–95. Academic Search Premier. Web. 18 Aug. 2009. The Use of Guided Refl ective Journals • 39