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.
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
(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.
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.
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.
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.
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.
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."
Essay on Gibbs Nursing Model on Reflection
rodrigo | September 2, 2016
WritePass - Essay Writing - Dissertation Topics [TOC]
There are a number of different models of reflection that are utilised by professionals to evaluate past experiences. The two main types of professional reflection are reflection-on-action and reflection-in-action (Somerville and Keeling, 2004). Reflection-on-action encourages individuals to re-live past events, with an emphasis on developing a more effective action plan for any future, similar events that may occur. However, this type of reflection does tend to focus more on the negative aspects of our actions rather than the positive behaviours that were demonstrated during the event that is being reflected upon (Somerville and Keeling, 2004). Reflection-in-action is a deeper and more interactive form of reflection that encourages individuals to observe and reflect on past situations from the point of view of themselves and of others around them at the time of the event. Self-reflection and reflection upon events that happened within a work environment are important for individuals within the nursing profession (Paget, 2001). Reflection allows medical professionals to challenge and develop their existing knowledge, maximising the opportunity for learning and to avoid mistakes that may have been made in the past (Royal College of Nursing, 2012).
The Gibbs (1988) model of reflection suggests that the process of reflection is systematic and follows a number of specific steps in order to be successful. This model of reflection is a type of formal reflection, which draws on research and puts forward a theory as to how most effectively put into practice to process of reflection. The process can be broken down into six key steps:
- Description: this step explores the context of the event and covers fine details such as who was present at the event, where it happened and what happened.
- Feelings: this step encourages the reflector to explore their thoughts and feelings at the time of the event.
- Evaluation: this step encourages the nurse to make their own judgement about the event and to consider what went well and what went less well about the event.
- Analysis: this step delves even deeper into reflection on the event and encourages the nurse to break the event down into smaller episodes in order to facilitate analysis.
- Conclusions: this step explores the potential alternatives that may be used to deal with the situation that is being reflected upon.
- Action Plan: this is the final step in the reflection process. The action plan is put into place in order to deal more effectively with the situation if or when it may arise again.
The Royal College of Nursing (2012) believes the Gibbs (1988) model of reflection to be particularly superior because emphasises the role of emotions and acknowledges their importance in the reflection process. Nursing can often be an emotionally charged career, especially for nurses working in areas such as psychiatric health and palliative care. Therefore, reflection on these emotions and exploration of how to manage them and improve management of them in the future is of particular importance in the nursing profession.
Step One (Description)
A young male patient aged 16 years came into the clinic around three days ago. He complained of low self-esteem and is feeling fed up and depressed because of pimples and spots on his face. The patient was worried that girls would not be attracted to him because of the spots. The consultation took place with just myself present, no other nurses were in the room at the time of the appointment. The consultation lasted around half an hour, during which time myself and the patient discussed the history of his problems with his skin and the emotional distress that the spots were causing him. The patient disclosed that he had begun to get spots at around age 14 when he had started puberty and that it had begun to make him feel extremely self-conscious. The patient described the negative effect that the acne was having. For example, he has been bullied at school and is feeling apprehensive about starting sixth form in September because he believes that he will be the only sixth former with spots. Based on the reasonably lengthy history of the acne, the presence of acne on the face and the negative emotional effect that the acne was having, a three month dosage of oxytetracycline was prescribed for the patient.
Step Two (Feelings)
During the consultation I had a number of feelings. Primarily I felt sympathy for the client because his situation reminded me of my own time as a teenager. I suffered from bad skin from the ages of 14 to about 20 and it severely affected my own self-esteem. In a review of the literature, Dunn, O’Neill and Feldman (2011) have found that patients suffering from acne are more at risk of depression and other psychological disorders. However, the review also found that acne treatment may lead to improvement of the psychological disorder that are so often co-morbid. This made me feel re-assured that prescribing oxytetracycline had been the right thing to do. My own experiences of acne also meant that I was able to relate well to the patient. I also felt some anger during the consultation. This anger was directed at the patient’s peers who had been cruel enough to taunt and tease the patient because of his acne. I also felt regret and guilt. I regretted not referring the patient onwards for emotional support and for not exploring the psychological impact of the acne in more detail. I also felt a sense of pride that this young man had the courage to come to the clinic by himself to seek help for his acne. I remembered how upsetting acne was as a teenager and I remembered that I would have been too embarrassed to have ever gone to a clinic or to have sought help from an adult. In turn, I also felt happiness. I felt happy that this young man had come to the clinic and I felt happy that I was able to help him.
Step Three (Evaluation)
On evaluation, the event was good in a number of ways. Firstly it added to my experience of dealing with young people and in dealing with the problems that are unique to this population of patients. I have not had many young patients during my nursing career and I welcome the opportunity to gain experience with this group. Furthermore, it re-affirmed my career choice as a nurse. During your career you always have doubts as to whether you have chosen the correct path. However, there are points in your career when you feel sure that you have made the right choice. However, there were also some negative elements. Firstly, the appointment was quite short and I am worried that this may have made the patient feel rushed and uncomfortable. After the consultation I did some research into the effects of acne in young people. Purvis et al. (2006) have found that young people with acne are at an increased risk of suicide and that attention must be paid to their mental health. In particular, the authors found that directly asking about suicidal thoughts should be encouraged during consultations with young people. This information only served to make me feel more anxious and I wished that I had bought this up with the patient.
Step Four (Analysis)
On reflection, being able to relate to the patient increased my ability to deal more effectively with the situation. I feel that the patient was able to open up more to me because he sensed my sympathy for him and his situation. Randall and Hill (2012) interviewed children aged between 11 and 14 years about what makes a ‘good’ nurse. It was found that the ability to connect to them was extremely important and so I think this is why the patient felt comfortable opening up to me. On reflection, I am also now convinced that the patient coming to see me was a very positive event. The patient could have chosen to go on suffering and could have chosen not to open up and talk about the problems his acne was causing. In a review of the literature, Gulliver, Griffiths and Christensen (2010) found that young people perceived embarrassment and stigma as barriers to accessing healthcare. Therefore, it could have been very easy for the patient to have avoided coming and seeking help. I felt a range of both positive and negative emotions during the consultation, and I think this re-affirmed for me that I enjoy nursing and enjoy helping others. It is important to genuinely care about patients and to provide them with the best care possible. This would be hard to do if you did not feel empathy for patients. The experience also helped me realise that I need to actively search out training and learning opportunities regarding working with young people with mental health issues.
Step Five (Conclusion)
If the same situation was to arise again I think that I would approach it in a slightly different way. In particular, I would have offered to refer the patient to further support services. During the consultation the patient mentioned that he felt that the spots on his face made him unattractive to the opposite sex. In addition to providing medication to get to the biological and physiological roots of the problem, on reflection I think it would have been beneficial to the patient to have provided information about charities that offer self-esteem and confidence building. Such charities that offer these services include Young Minds (http://www.youngminds.org.uk/) and Mind (http://www.mind.org.uk/). In retrospect, I also believe that I should have given the patient a longer consultation time in order for us to have explored the psychological impact of his acne in more detail. Coyne (2008) has found that young people are rarely involved in the decision-making process when it comes to their consultations. Therefore, giving the patient more time to discuss his problems may have improved his sense of wellbeing as he felt more involved in his care process.
Step Six (Action Plan)
There are a number of elements to my action plan. Firstly, I will make sure that in the future the consultation room has leaflets and information pertaining to mental health problems in young people. This way, young people can access the information if they perhaps feel too embarrassed to talk about it. Hayter (2005) has found that young people accessing health clinics put a high value on a non-judgemental approach by health staff. Therefore, in future I would be sure to be aware of my attitude and make sure that either subconsciously or consciously; I am not making any judgements about the patient. Hayter (2005) also found that young people had serious concerns regarding confidentiality, especially during busy times at the clinic. Therefore, in the future I would be certain to reassure young people that their details and consultations are kept completely confidential. To re-assure young patients, I may ask them to sign a confidentiality form, which I will also sign in front of them. Furthermore, my action plan will include improving my knowledge and awareness of working with young people as a nursing professional. This will allow me to increase the tools and skills I have for dealing with young people with complex needs. During the consultation I felt anger toward the patient’s peers who had teased him. In the future, I will focus on being more objective when dealing with a patient who has been the victim of bullying.
Coyne, I. (2008) Children’s participation in consultations and decision-making at health service level: A review of the literature. International Journal of Nursing Studies, 45(11), pp. 1682-1689.
Dunn, L.K., O’Neill, J.L. and Feldman, S.R. (2011) Acne in adolescents: Quality of life, self-esteem, mood and psychological disorders. Dermatology Online Journal, 17(1). Available at: http://escholarship.org/uc/item/4hp8n68p [Accessed 20 October 2013].
Gibbs, G. (1988) Learning by Doing: A guide to teaching and learning methods. Oxford: Further Education Unit.
Gulliver, A., Griffiths, K.M. and Christensen, H. (2010) Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. BMC Psychiatry, 10(1), pp. 113.
Hayter, M. (2005) Reaching marginalised young people through sexual health nursing outreach clinics: Evaluating service use and the views of service users. Public Health Nursing, 22(4), pp. 339-346.
Paget, T. (2001) Reflective practice and clinical outcomes: practitioner’s views on how reflective practice has influenced their clinical practice. Journal of Clinical Nursing, 10(2), pp. 204-214.
Purvis, D., Robinson, E., Merry, S. and Watson, P. (2006) Acne, anxiety, depression and suicide in teenagers: A cross-sectional survey of New Zealand secondary school. Journal of Paediatrics and Child Health, 42(12), pp. 793-796.
Randall, D. and Hill, A. (2012) Consulting children and young people on what makes a good nurse. Nursing Children and Young People, 24(3), pp. 14.
Royal College of Nursing (2012) An exploration of the challenges of maintaining basic human rights in practice. London: Royal College of Nursing.
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