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Nursing Resource Guide

 
 
Reflective Writing in Nursing
by Tabatha Hecker, Joe Amon, and Elisa Nickoli

What is a journal, and why is it so important in first-year Nursing? How do students incorporate clinical theories and classroom information into their personal writing? And how does the Nursing student incorporate him/herself into the reflective writing required? These are only a few of the many questions that we are struggling to answer for students thinking about, or even registered in, the Nursing program. Since it is a good idea to know and understand what is expected before one enters such a specific field, we hope that the below information will better prepare students interested in the Nursing occupation. For the following article, we have decided to use the format (such as headers) and style (including that of APA documentation) of a Nursing article, or scholarly paper. Our sources range from interviews to educational Nursing articles, as very few books dedicated even so much as a chapter to personal writing, reflective writing, or journalling.

Introduction

Upon conducting interviews with Nursing instructors and students at the University College of the Cariboo, we discovered that a large portion of the curriculum involves detailed and reflective writing, more specifically referred to as Journalling. The reasons for requiring students to do reflective writing are many, and the results are equally important. Journalling is a crucial aspect of Nursing scholarship, culminating personal experiences, clinical practices, and theoretical approaches; it requires students to make links between thought and action, concept and praxis. Students are encouraged to incorporate themselves into their journals without inhibitions: desires, opinions, emotions, or disapproval. "Writing skills are thinking skills", and through journalling students inform their instructors of information that is not issued in other writing assignments: the student’s attitude, ideological cognitive awareness, personality, and ethics when dealing with human problems. (Heaslip, 1999)

Journals can be thought of as "public discourse" because reading aloud, group discussions, and feedback in class are encouraged by Nursing instructors. This exercise "organizes thought and thereby facilitates analysis and synthesis." (Heinrich, 1992) As a pedagogical tool, journals and reflective writing create connections for students, and allow them to create connections for themselves on their own terms.

What is Journalling and Why

"Journals are written dialogues between the self and a chosen audience member", usually to a classmate or instructor, which is "used as a diagnostic tool to assess students’ reading abilities, writing skills, problems with adjusting to the student role, study habits, or reading and study problems not apparent with testing"; its main objective is to get students to "write themselves into understanding." (Heinrich, 1992) Along with incorporating theories and practices into their personal writing, students are also asked to write about their personal experiences, as student Nurses, to better help the instructor understand their experiences and perspective. "Students are required to write weekly journals about their reaction to experiences in class, to readings, and to clinical practices", which is a way for students to reflect on their means of personal growth, understanding, and development. (Magnussen & Trotter, 1997)

The Principles of Reflective Writing

  • Reflective journal writing is an opening: a way to explore what we can become without being judged. Stories are a gift to ourselves and others, and express the uniqueness of individuals and their circumstance as well as the common ground they share.
  • What we bring to an experience is essential to our understanding of what occurs. This is influenced by our past, our future, and out present world-views.
  • A deeper understanding enables us to integrate former learning with experiences, to form relationships between parts of knowledge, and to search for meaning.
  • We reflect because issues arise that need to consideration both before and after we act. As nurses, we are agents of history for ourselves and others.
  • Critical reflection promotes an understanding of diversity in beliefs, values, behavior, and social structures. Any claims to a universal truth or total certainty are questioned. The more we share our thoughts and feelings, the more we challenge accepted views of traditions and myths, which have kept alternate interpretations from becoming possibilities.
  • Reflection is not a political act.
  • Because reflective writing is a personal journey, students are to write only what they feel comfortable sharing.
  • Journal writings are not right or wrong, simply places to discuss movement in thinking.
  • Journal entries are reflections, which often evoke more questions than answers. The purpose of forming questions is to help focus on personal meaning and interpretation in the reflective moment.

  • Journals are confidential between the student and the instructor.
  • Change is the only constant, and writing reflectively offers a way to examine the meaning of change.

(Collaborative Curriculum Guide, 1996)

Journal Guidelines and Evaluation

The purpose of the journal is shaped by the guidelines that students follow when writing journals. There is more emphasis on the "qualitative" than the "quantitative" approach to journalling, meaning that quality is more important than quantity. "Journal entries should be about two-three hundred words an entry and concise in frequency and length", says Heinrich, and the time spent writing and re-reading these journals, "for a three-credit course would approximate six hours per week." (1992) This may seem like a lot of time (or too much time, as some argue) but the assignment is to help the student’s understanding and developing as a Nurse, and is not for the instructor to mark.

Journals are initially commented on by the instructor, who gives a few suggestions for the next journal entry, but are used later for the student’s reflective purposes. The instructor gives positive constructive criticism on journals, and they are not recorded for marks. Students must evaluate themselves by what they say in their dialogue journals and how they deal with specific situations. The journal becomes like a diary to themselves, or as Andrews explains: "my journal… became an avenue to another dimension of myself… writing my journal became a reflective, valued space for me each week." (1998) Journals function not only as conversational dialogue between student and instructor, but within the student for reflective purposes.

Critical Analysis

Not only are students asked to write themselves into their work, they are also required to write others into their work, most notably literary critics. As Andrews illustrates in her opening paragraph about the effect of journal writing, she states that, "the connective links between theories presented in the classroom and clinical practices are revealed… encouraging students’ critical thinking." (1998) Critical reflection applies to students who use it as a dialogue between their instructors. As explained in a Curriculum Guide, "it involves raising questions, explicating new thinking, and transforming understandings about practice." (1996) Critical reflection involves the study of the inter-disciplinary aspects on Nursing: psychological, historical, socio-cultural, economical, biological, etc. (Heaslip, 1999) Integrating critical thinking and analysis into journals, pertaining it to experiences and situations, helps students evaluate their world-view and develop a clear understanding of themselves. Students have to make connections between how they act and how they tell others to act: reflection links their theories and practice, helping students prepare for clinical situations.(Guide,1996)

It is critical that students are able to deal with concept in practical situations, because of the work involved in Nursing. "You’re constantly applying theories to practice", as Jessica Chardon explains, "In class we learn about dealing with loss and grieving, sexuality, caring, and health promotion (there’s more), and then we have to apply what we’ve learned in clinical situations. It’s not like business, when you don’t apply what you’ve learned until you graduate and are in the work force. We apply what we are taught weekly." (1999) In hospital and clinical situations, it is important that Nursing students are able to implement concepts and link experiences in their journals.

Kathleen Heinrich discusses a method of incorporating all aspects of learning. It is called the "Triangulation Approach", which is a model of journalling that "helps students link personal and professional experiences in light of the theory emerging from readings and class discussions."(1992) It could be visualized as such:

Interview with a Nursing Instructor

Along with knowledge gained from articles and student’s journals, we also researched writing in first year nursing by interviewing Penny Heaslip, who teaches Nursing communication at UCC. Penny was a strong supporter of reflective writing in first year nursing. "Our purpose," she explains, "is to try to understand the experience a person had and what meaning they’re making of it."(1999)

First-year Nursing, more than many other disciplines, is about molding the ways students think and how they perceive the world. A nurse in training must learn to think as efficiently as s/he must learn to write. S/he must learn to have an open mind, to not be judgmental, and to deal with people from all areas of life. And much of the reflective writing done in first year nursing attempts to make those changes. Penny explains "in school, of course, teachers need to have some way of finding out what the thoughts [of students] are. So, that’s where reflective writing comes in."(1999)

Hence the Nursing journal. This ongoing documentation, written after every Nursing class, is among the most personal writing a first-year student will do. More than a simple account of the work of the day, a Nursing journal is full of anecdotes which are explored and analyzed by the student. Theories that were taught that day are questioned; insights that students gained are recorded. Penny explains journals thusly: "what it really is an integration between classroom and clinical practice."(1999)

It makes sense that the writing of a discipline that involves a large amount of human interaction would take a very personal tone. "If you think of the work of a nurse," explains Penny, "you’re working with people….We want to know what kind of meaning our students are making of those experiences."(1999) Ideally, students writing and reading back in their journals will see their own growth as individuals and Nurses. The writing also can have a cathartic effect, as Nursing students in later years might write about a patients death or her own personal frustration in their clinical experience.

As explored earlier in the Heinrich article, journalling can also be a dialogue between instructors and students in Nursing. Since journals are read, but not evaluated, they can be thought of as a building of a trust relationship between a student and his instructor. As Penny puts it "I don’t know how a student could…write what they write without having a certain level of trust."(1999) The trust between instructor and student, created by the journal writing, is the first step toward the trust a Nurse will have to develop with her patients when s/he is practicing in the field.

The interview with Penny Heaslip brought to our attention the expectations of a Nursing instructor. Once those were realized, it was time to interview some first-year students.

Student Interviews

We chose three first-year nursing students as subjects for our interviews, all of whom have different backgrounds. Rhonda Madsen is a Nursing student who entered the program immediately after high school. Jess Chardon joined the program after spending two years in Business studies. And Riley Smith, who has experience as a Licensed Practicing Nurse, is returning to learn how to write as a Nurse.

Question: Why do Nurses do journals?

"To make sure we understand what we’re doing in class."(Chardon, 1999) This seemed to be the general consensus among the nursing students we interviewed. Rhonda’s understanding is that journals are used for reflection, in order for Nursing students to learn from themselves.(1999) Riley’s opinion was similar; she found that journals were to make sure students understood what they were learning.(1999)

The students also responded to the personal investment of the journals and the positive reinforcement they received from them. Riley in particular explained that, because journals were unmarked but were commented on, they could be a source of encouragement to her and other students.(1999)

Do you feel that personal writing is important in Nursing? If so, why?

The student interviewees all agreed that personal writing was very important in first year Nursing. Rhonda explained that, through exploring their own opinions through personal writing, those opinions were opened up.(1999) This leads to a more open-minded student, who still values his own opinions, but understands how people can think differently.

Another reason for personal writing being important to Nursing students, according to the three students we interviewed, is that it leads to critical thinking. "They want to see how we can interpret…," explains Jess(1999). The journal exploration of the theories they’re taught in class is a way of teaching Nursing students to question and explore everything.

How do you integrate yourself into your journals?

The example we heard most from students in response to this question was the use of the ‘I’ pronoun. Even though the journals deal in part with theories and objective experience, they are unabashedly written in the first person. This allows students to put their own personal thoughts and feelings into the journal much easier than if they were limited to third person.

In relation to using ‘I’, journals use personal experience and anecdotes to reveal the feelings of the student writing it. (Riley, 1999) According to Rhonda, instructors "love when you use personal experience to relate to the concepts."(1999) Nursing journals are about integrating the personal with the clinical, and so personal experience melds with students’ observations on their experiences.

How are the personal journals used after they are completed?

At the end of the semester in Nursing Communication, students take their journals and write a paper on personal growth.(Riley, 1999) This paper is intended to be a final reflection on the student’s first year in Nursing. Looking through the past year of their own writing and choosing the insights they think matter the most is a way of running a Nursing student back over what they’ve learned. This extra exploration can draw out insight and show the student that the journals shouldn’t just be written and then never looked at again.

How can students coming into first-year

Nursing better prepare themselves for the personal writing expected?

Rhonda’s suggestion for first-year students was to take a Nursing course in the summer, in order to prepare for what the program will ask in the way of personal writing. Riley suggested taking Nursing 117, a communications course, in order for students to explore their own self-concept.(1999) The ideas that Nursing puts forward aren’t always easy to grasp at first, so extra preparation can be a big help. Jess’ advice was to be open-minded and to remember that "you gotta know how to write."(1999) Not many students are aware how much writing a first-year student is required to do, both clinical and personal.

Discussion on Reflective Writing

There is some debate within the field of Nursing on whether or not reflective writing (specifically journals) is effective as a learning aid, or if it is an all-consuming waste of time. Schon is a leading expert of the theory of the reflective writing; he defines reflection as "learning from events and incidents experienced during a course or practical professional programme."(Durgahee 1998) Carolyn Mackintosh opposes the validity of reflective writing: "there is little evidence that an objective review of reflective practice and its implications for nursing and nurse education has ever occurred." (1998) An objective review is needed with all new theories before they are put into practice. Reflective writing or "facilitating reflection" as Taleb Durgahee calls it, needs a review. And so he conducts a study that does objectively review the aims and objectives of facilitated reflection.

Summary of Negative View-Point

The exact definition of reflective writing is what seems to be Durgahee’s concern in the article. Other scholars in this field such as Dewey, Mezirow, and Schon seem to have contradictory explanations of the reflective writing process. Dewey divides reflective writing into five stages: "suggestions for a solution; clarification of the essence of the problem; the use of hypothesis; reasoning about the results of using one of the hypothesis; and testing the selected hypothesis by imaginative or event action."(Durgahee1998) Mezirow ‘s concept is different in that reflectivity is itself divided and does not take place at a uniform level. Schon claims that reflection is important to Nursing as a technical practice, which is utilized and then analyzed in reflection.

Mackintosh points out these ambiguities and discusses reflective writing in the classroom. She points out that Cavanagh et al., in a study of 192 Nursing students, found that only 46.3% were classed as reflective thinkers. Subsequently, writing in journals is "time consuming, repetitive, . . . superficial descriptive content, leading to boredom for those using them." (1998)

Summary of Affirmative View-Point

Duragahee conducts a study to "identify and explain the concepts used while facilitating reflection and identify the skills required by the teacher to make reflection a learning experience." (1998) Reflective writing is "used to develop the critical thinking of the students through writing (diary keeping) . . . to become more aware (Durgahee 1992, 1996) of their patients’ needs, the impact of context on the quality of care given, and appreciate and develop their own nursing philosophies."(1998) Concrete findings show reflective writing in action: "some [students] became unsure of why their past and present experiences and their diaries were at the center of the timetable and were the focus of learning." (Durgahee 1998) Resistance from students was encountered because of the uncertainty but, "students feel encouraged and reassured when reflection is explained and demonstrated as a purposeful exercise with clear direction." (Durgahee 1998) These anxieties are calmed by showing established research on the reflective process, and explaining the curriculum of nursing to the students. Reflective writing is an active process that "enables the students to think about their practice, experience, skills, knowledge and attitudes. It requires them to be actively involved in the process and to develop independence of thought." (Durgahee 1998) The act of reflection actually teaches the student to think reflectively; "facilitation is providing a framework for thinking, feeling and developing insight." (Durgahee 1998) Interpretation of experiences is crucial because it forces the student to rethink their actions in the next clinical situation.

Summary of Our View-Point

We agree with the affirmative point of view. After a student Nurse has experienced discussion of a theory in class or an emergency situation in practicum, reflection is essential for psychological reasons. Even if students do not at first "think reflectively" the nursing profession obviously requires this skill and therefore will be taught to in nursing courses such as Nursing 117/127. Reflective writing helps the students gain insight into the profession and the clinical practices. From our student interviews we can see that reflective journal writing is useful and a valid learning strategy.

Analyses of Sample Student Journals

These journal entries, taken from two students in first year Nursing, are good examples of a typical journal entry. Journals reflecting clinical practice could not be used because of confidentiality reasons. For the communications course (Nursing 117) students are encouraged to reflectively write after every class and the journals are handed in at the end of the semester. Theories discussed in class such as "Touch" are reflected upon and integrated into the student’s own personal experiences. Testing concepts by using them everyday is also encouraged as a student reports in her entry. Many Nursing theories involve communicating effectively in all forms (writing, body language, and verbal) and therefore can be practiced constantly.

Teacher comments are also included exemplifying the opportunity for dialogue between the Nurse educator and the students. The journals are not evaluated in terms of punctuation, grammar, sentence structure, and spelling. The writing is not formal, but simply a reflection of the class and the students personal thoughts always using the first person pronoun "I". Students are asked to correct or re-write their journals if the teacher feels they did not fully understand the theories discussed in class.

Conclusion

Reflective writing is an important, if not crucial, aspect to first-year Nursing. It is a powerful technique that incorporates the personal experiences and the knowledge gained through readings, classroom discussions, and clinical practices. Students find journalling especially helpful because it gives them an opportunity to have an intimate dialogue with their instructors. Through writing weekly entries and reflections, students learn how to organize their thoughts and actions according to their own world-view. It is a practice that searches for new mediums of discourse for Nurses, and attempts to integrate past and present experiences to determine future Nursing actions. Journals are personal, as well as the Nursing program, but as Riley Smith stated, "it is only as personal as you want it to be."

Click here to see our works cited.

 

origanal from http://cariboo.tru.ca/disciplines/eng309/nursing/nursing.htm
 
 

 


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