The clinical diary is a restricted diary. It is a personal account of the writer's thoughts and feelings about the events of the day, written for a known and limited audience, and restricted to one phase of the writer's fife- her experiences in the clinical setting in relation to the objectives of one course in nursing. The purpose of the clinical diary from the teacher's point of view is to provide continuous, first-hand data upon which to base decisions for directing energies in the teaching-learning endeavor.
Unless the nature of the clinical diary and its purpose as a teaching tool are clearly understood by both teacher and student, the diary readily becomes "busy-work" for the student and an ineffective instrument for the teacher.
During the past three years, we have used clinical diaries in teaching the final nursing course in a nine-semester basic baccalaureate nursing program. To achieve course objectives, four hours of lecture, one hour of clinical discussion, and fifteen hours of clinical practice each week are provided for planned learning experiences. The course carries eight units of upper-division credit. The emphasis in the course is on practicing nursing as a professional person within existing systems of formally organized nursing services. The lecture content is directed toward an analysis of the practice of nursing both within the context of the structure of the health professions and within the context of the structure of an existing system of nursing service. Clinical practice periods provide the student with an opportunity to: (1) experience the impact of the professional and institutional structure on nurse practitioners, (2) work within the system of organized nursing service to provide care for groups of patients, and (3) practice working with other persons involved in the care of the patients for whom she has nursing responsibility. A minimal amount of on-the-spot supervision in the clinical area is provided by the teacher. Most of the teacher's time in this course is devoted to working with students on a tutorial basis and to working with the nursing service staff to facilitate the conduct of the course.
We have used clinical diaries as an integral part of the teaching-learning process with approximately fifty students over the course of this three-year period. The students were those who had selected either medical, surgical, neurological, or neurosurgical units for practice during the course. The purpose of the diaries was explained to students at the beginning of the semester, and they were asked to record their thoughts and feelings about their experiences each day. They were asked to try to focus their thoughts on events that had occurred in the clinical unit and to consider these events in the light of both the content currently being discussed in class and the objectives of the particular phase of the clinical experience.
As might be expected, there was considerable variation in the apparent ease with which students expressed thoughts and feelings which were close to them, the detail in which they discussed daily events, and the consistency with which they gave tangible evidence of having reflected upon questions raised, comments made, or suggestions offered by the teacher in respect to the preceding diary entry. Nevertheless, most students were remarkably consistent in writing perceptive and detailed accounts of their "day."
Since the primary purpose in assigning the diary was to provide data upon which to base decisions concerning the kinds of assistance the students might need in exploring and testing knowledge, the entries were read, responded to, and returned to students promptly. We believe the response of the instructor to diary entries is important. In any form of communication, there is need to know that what one has said has been received, understood, and considered. The instructor's comments in the margin or at the end of the entry served as an immediate form of acknowledgment and as an important avenue for individual teaching or counseling. Even more important in sustaining communication is the knowledge that what one is communicating is having some effect. The diaries did profoundly affect teaching.
First of all, they painted a vivid picture of the clinical milieu as seen and experienced by the students. Through my own experience in the clinical area and through contacts with the nursing staff other views of the clinical setting were obtained. Sharing this knowledge was most useful in promoting mutual understanding between students and staff and in correcting many of the problems that arose during the clinical experience. This, in turn, offered tangible evidence to students that what they were communicating was having an effect. Even when some problems could not be solved, the knowledge that both the staff and the instructor were concerned seemed to be helpful.
Secondly, the diaries gave valuable evidence as to how much and in what way each student was assimilating and using concepts being considered in class and encountered in reading assignments. The keeping of the diary may also have encouraged more systematic efforts to relate lecture and reading content to clinical practice than students might otherwise have attempted. It is probable, however, that students were mainly aware of the contribution being made in this respect when their own accounts of experiences in clinical practice could be used to illustrate, explore, or expand implications as was done in the clinical discussion periods.
In reality, the privilege of reading the diaries is an important one, whether the student writes:
I'm beginning to feel snowed - maybe I've bitten off more than I can chew!
Today I took the responsibility of a team leader -at last I really felt as if I knew what I was doing! .... I feel that I've grown inches.
I enjoyed having the junior students on the ward today. I am reminded of my own experiences two years ago. I'd forgotten that I'd come so far... The difference between the student's first semester perspective and her last is that in the first semester the student has only herself to offer the patient; and she offers herself with great zeal .... She has little nursing knowledge or experience to base this on. She is not familiar with the resources ... of the hospital. I feel I am part way along the road to being a competent nurse. I have nursing knowledge and some experience in how to use it. I am becoming familiar with the channels and resources of the hospital. I have knowledge and skill in nursing in addition to myself to offer my patients.
The instructor's knowledge of the diary contents can often be used to encourage students to share their experiences in class discussions. Since the diary contents represent private communication between the student and her teacher, it is important either to seek the student's permission to use a diary incident or to ask her if she would be willing to share the incident in a class discussion or group conference. When diaries can be used to provide examples, they seem to be especially helpful in assisting the student to see relationships and to raise critical questions in regard to what she reads, observes, and hears.
From the standpoint of the teacher, we have found that the clinical diary is one of the most useful tools which we have employed in clinical teaching. It is not a substitute for clinical supervision or for bedside teaching, but it is a valuable adjunct to them. It provides the teacher with a perspective and a fund of information which is not ordinarily accessible to a teacher. Many of the thoughts expressed in the diary are very private thoughts -thoughts which a student thinks are not important enough to express in class or even in an individual conference, but which, nonetheless, are important to her. Sharing these thoughts with a student gives the teacher a much more realistic view of the consequences of her teaching and the rate at which knowledge is actually assimilated than she is apt to get from tests or through observation of fragments of the clinical practice periods. Ultimately, the use of clinical diaries will give us a better knowledge of the manner in which the values, ideals, and attitudes of the nursing service group are assimilated by students in the clinical setting.
Since The Journal of Nursing Education is circulated on a complimentary basis and subscriptions are necessarily limited to nurse educators who are actively teaching, or who are otherwise actively participating in nursing education, we have found it necessary to accept only professional addresses for our mailing list. Exception will, of course, be made for subscribers who are doing graduate work or whose professional address is such that delivery may be difficult A change in professional address, title, and/or teaching area should be reported promptly since subscriptions are automatically cancelled when non-delivery of any issue of the Journal is reported. Renewal for JNE subscriptions are not required unless specifically requested.