While the use of journals in nursing education is commonplace, there is a paucity of examples or empirical data to support its usefulness or effectiveness. The purpose of this article is to highlight integration of classroom and clinical learning, decision-making skills and level of skill acquisition (Benner, 1984) in the Senior Practicum experience through student journal entry exemplars. Senior Practicum students agreed to share exemplars from their journals and co-author this manuscript.
Landeen, Byrne and Brown (1992) found that the use of journals assisted students in exploring and changing their attitudes toward the psychiatric client. Callister (1993) stated that the clinical journal is both an "objective and subjective chronicle" (p. 185) reflecting the student's attitudes, feelings, and cognitive learning throughout the clinical experience. Journals provide an opportunity for the student to reflect on and share the lived experience, allowing the uniqueness of each experience to validate prior knowledge and new learning.
Journaling facilitates the linking of classroom work with clinical experiences and helps define the meaning of a critical incident for the student. Brown and Sorrell (1993) stated that writing in clinical journals is a common assignment in practicums at all levels of nursing education. Brown and Sorrell supported the concept of careful structuring of assignments for the clinical journal rather than a freeresponse format. Clear expectations tend to validate the exercise, provide parameters for faculty response, and reduce both student and faculty time commitments.
Journals are also viewed as dialogue between student and faculty. The journalas-dialogue is not a "...rigid accounting for all practicum hours and experiences" (Brown & Sorrell, 1993, p. 18), but rather an opportunity for students to make sense of their mistakes and successes. A high percentage of the interaction between students and faculty occurred through the journals.
Senior Practicum Journal Writing Assignment Instructions
Although several articles speak to the use of journals as a means of teaching students how to write or find a voice (Allen, Bowers, & Diekelmann, 1989; Gehrke, 1994; Lashley & Wittstadt, 1993) this was not the focus of the Senior Practicum journal assignments. The following instructions for clinical journal writing are utilized:
All students are required to keep a clinical journal. Select a clinical day and write a journal entry describing one clinical incident which you found significant. The clinical incidents should describe patient care episodes which stimulated your thinking.
For each journal entry, discuss five of the following for one point each:
1. Describe what nursing interventions you or others did.
2. Describe your decision-making process.
3. Describe what you would do differently when a similar incident occurs.
4. Describe the clinical incident in relationship to the parts and the whole.
5. Identify previously learned knowledge/clinical experiences(s) that helped you in this situation.
6. Use Benner's competency statements and describe where you view yourself.
7. Describe your areas of strengths and weaknesses. Include your thoughts, perceptions, and feelings.
8. Describe resources you identified and/or utilized and your rationale.
Critical Thinking Exemplars
Callister (1993) stated that journal writing provides a means for students to further critical thinking by establishing fundamental linkages between classroom theory and clinical practice. Similarly, Brown and Sorrell (1993) posited that the use of relevant theory and principles of nursing care to analyze and evaluate subjective and objective data promoted critical thinking in student journal writings. In the following exemplar, Lynn demonstrated critical thinking and integration of learning. In addition, Lynn's exemplar reflects growth and confidence in her knowledge and abilities, an example of Heinrich's (1992) contention that journal writing increases student self-esteem.
Today was a pretty "ordinary" dayuntil one of my patients- right as I was leaving for lunch- yelled out of her room as I passed by that she was having chest pain. The decision-making process that I went through involving my patient's chest pain included the following steps. I obtained subjective data from the patient regarding the pain: describing the pain, location, radiation and nausea. I then obtained objective data by observing if the patient was diaphoretic, vomiting, and I took her blood pressure and pulse. I also made sure the oxygen was intact. I checked the med sheet to see if she had nitro ordered PRN and she didn't. I asked the LPN to sit with the patient while I went to page the doctor. I then told my preceptor what was going on and she spoke to the doctor to obtain orders.
Previously learned knowledge from past clinical courses enabled me to utilize knowledge of the classic signs and symptoms of angina and a myocardial infarction. I acted autonomously, but I wanted to be validated in my assessments by my preceptor. I believe that I made proper decisions in regards to my patient's chest pain. I also believe that I focused on the patient and what the patient was feeling.
Hahnemann (1986) noted that correlating abstract concepts of classroom theory to a concrete clinical incident is essential in promoting critical thinking. Lashley and Wittstadt (1993) reported that the integration of previously learned concepts in various settings enhances concept development. Integration of theory with clinical experience is evident in Tricia's journal.
I was assisting another RN by providing AM care to a middle aged male with prostate cancer. At first he made a few remarks and answered my questions (though he was slow to respond). He had a flat affect but watched me with his eyes. As the bed bath progressed, he began to "shiver" and appeared more lethargic. I went to find the RN to assist me because he wouldn't follow verbal cues.
When I came back into the room, my preceptor and the clinical nurse specialist (CNS) were there. They said he was exhibiting the signs and symptoms of hypoglycemia. My preceptor went and ordered a stat blood sugar level. The CNS explained to me how lethargy, diaphoresis and small seizures usually indicated hypoglycemia, and that it was crucial to monitor his vital signs and get the stat blood sugar level so we can reverse the hypoglycemia. Hie blood sugar level was 31. 1 really learned a lot just watching and listening to those who are experts. I just looked at the symptoms, and even then didn't really identify the changes as symptoms. I felt like I should have known what was happening. Tve read and been taught about hypoglycemia multiple times. Next time, ITl ask myself "why is this happening?" Tm determined to be like those wonderful nurses who knew what to do. There is a reason for the symptoms. It's not enough to identify someone is "shivering." I need to look at the big picture.
Observation and Description Exemplar
Heinrich (1992) stated that journals provide "...a wonderful place for students to make sense of and to learn from their mistakes" (p. 19). As a result of her journal writing, Tricia was able to reflect on this incident and establish relationships between the abstract and the concrete. She also identified a need to look "at the big picture."
Heinrich (1992) and Canister (1993) noted that journal writing assists students to develop observational skills and describe clinical practice. These principles are evident in Tina'e exemplar.
I did total care on a patient who was 91 years old with a diagnosis of lower GI bleeding. What made this situation challenging was that the patient had a tracheostomy. I had never cared for a patient with a trach before. I asked questions before and during the procedure for suctioning the trach. I remained aware of the importance of mamtaining sterility throughout the procedure. A week ago I did a procedure for the first time that made me so nervous that I forgot to talk to the patient throughout the procedure. I learned from that situation and this time I recognized the patient's needs. For example, between suctioninge I would comfort the patient and give the oxygen so that he could relax and catch his breath. I also made sure to tell the patient when I was going to suction again. I explained to the patient what I would be doing and made sure the patient was oxygenated sufficiently. I then prepared a work area, did the procedure, made sure oxygen was in place and that the patient was comfortable. Lastly, I charted the procedure.
Empathy and Release of Feelings Exemplar
Canister (1993) stated that two of the benefits of journaling for students are an increased ability to empathize and an opportunity to release feelings. In addition, journaling helps students reflect on lived experiences and validates thoughts and memories when revisited. Empathy is apparent in Cynthia's journal entry when she described caring for a 22-year-old first-time mother on her first practicum day in labor and delivery.
I had a patient who was admitted right before I got to the hospital at 7 AM and who did not deliver her child until 10:15 PM that night. My patient was in labor the entire day. She was getting an epidural about 3 PM.. .She was in a lot of pain and was having strong contractions at this time. She slept for awhile and at about 6:45 PM she was fully dilated and ready to deliver. I helped her push for 2 1/2 hours, along with her husband, while the staff nurse continued to check her to see how far down the baby was coming. The baby wasn't coming down!
To make a long story short, I chose to stay 4 extra hours after I was already there 12 because I did not want to leave my patient. After 2 112 hours of bearing down the doctor decided to take the baby cesarean and we prepped her for surgery. It was the most beautiful baby boy Fve ever seen. He was 7 pounds 7 ounces and 20 inches long. He was pink as pink could be right away and had a 9 & 10 apgar. He was finally here!! I couldn't help but feel for him, his little cone-shaped head showed us all how difficult it was for him to come down the birth canal. It was a long day! I gave my all today, plus some, and Tm pretty proud of myself!
Benner's Competency Statements Exemplars
Most students chose to journal about Benner's competency statements which are threaded throughout our curriculum. Students expressed satisfaction with being able to link levels of skill acquisition to their own development. In addition, they often identified multiple levels of competency at any given point in time.
Lynn: I believe that I am an advanced beginner in the area of assessing chest pain. In order to be competent in this area, I need to experience many more situations autonomously, gain insight, and be comfortable with my assessments and interventions instead of needing someone to validate me.
Tricia: I was at the novice level in this area. I took in very little of the total situation. I did recognize a deviance from the norm, but I was unsure of what the norm was for this man. My goal for next time is to be an advanced beginner, recognize most aspects of the situation, and demonstrate advancing clinical judgment.
Tina: I considered myself a novice because I did not have any previous experience with the procedure. I was very focused on following the instructions and maintaining sterility. This made it more difficult for me to take in the whole situation.
Cynthia: I am not where I would like to be with regards to Benner's competency scale but I certainly feel like I made a difference to my patient and her family. Throughout the course of the day, I felt like I moved from novice to competent as I became oriented to the unit, recalled prior knowledge and cared for my patient.
Additional Benefits to Journal Writing
One student stated that journal writing helps her reduce the stresses that surface after a challenging clinical day. She gave the example of working with a dying patient and not having the opportunity to discuss her reactions during the clinical experience. Writing about it in her journal helped her gain perspective and alleviate some of the anxiety created by the situation.
Journal writing allows students the opportunity to ask faculty questions, share thoughts that they might never have verbalized and let the faculty know about learning experiences. One student stated that she asked questions about hospital policy and lab values in her journal entries. Another student used a journal entry to talk about the AIDS patient she had cared for. Yet another student discussed an uncooperative, hostile patient.
Cameron and Mitchell (1993) stated that "...recent literature calls for the use of reflection in developing an effective practitioner" (p. 293). One student stated that the whole process of journaling was self-evaluative as she reflected on the activities of the day. All four students agreed that revisiting prior journal entries helped them track their progress.
The students and faculty who shared their journal writing exemplars validated the importance of journaling during a Senior Practicum clinical experience. The four exemplars are distinct, dealing with a variety of situations, reactions, and learning. The linkages with prior knowledge, skill acquisition, decision-making, critical thinking, observation, description, empathy, and/or the release of feelings was evident in each journal entry. Journal writing has enhanced the clinical practicum experience in this curriculum.
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