Advanced practice nursing (APN) requires the application of specialized knowledge in independent or collaborative practice. Community health APN requires the acquisition of complex skills that can be applied to various environments and populations within a community, many outside the structure of traditional health care services. Clinical instruction in community health APN is a challenging endeavor. Students enrolled in a clinical course typically complete their clinical requirements with a preceptor in a variety of settings, agencies, and institutions, with an assortment of populations having diverse needs and providing different experiences.
One of the strengths of having students in multiple community clinical settings is the richness and range of experiences brought back to the classroom. The challenge is to create the opportunity for all students in the class to examine and benefit from these experiences. Sharing and reflecting on wide-ranging clinical experiences allows the application of core principals to different facets of the community, and has the potential to:
- Promote discussions beyond the course objectives.
- Create opportunities for mentoring.
- Foster critical thinking.
- Facilitate change and socialization into APN.
In an attempt to enhance learning, a pilot test of an online, innovative sharing and reflection strategy was incorporated in a two-quarter community health APN clinical course.
Learning strategies using the activity of reflection have long played an active role in nursing education (Hannigan, 2001). Incorporating reflection in courses has been found to influence the environment, processes, and focus of learning in a course, thus reducing anxiety, increasing peer support and cooperation, and moving students from passive to active roles (Davies, 1995). Using in-depth self-reflection in a clinical nursing course can provide an opportunity to explore insights into practice, supporting the development of competence, especially when students have substantial foundational nursing experiences from which to draw, as graduate nursing students often do (Cash, Brooker, Penney, Reinbold, & Strangio, 1997).
Reflection has been combined with peer mentoring in nursing graduate education for the purpose of increasing the relevance of learning experiences (Heinrich & Scherr, 1994). There are many strategies to develop reflection in nursing education. Williams (2001) suggested that one of the best ways to use reflection is through active, repeated, guided practice with problem-based situations. Mentored or directed journals have been purported to help nursing students develop reflection, critical thinking, and higher-order cognitive skills, such as analysis and synthesis (Bilinski, 2002). For this course, reflection was incorporated into the required class activities through directed journaling.
Journaling has long been used as a learning strategy in higher education in a variety of disciplines, including nursing (Kobert, 1995; Palmer, Alexander, & Olson-Dinges, 1999). The advantages to the personal and professional development of nurses through journaling have been described by Bellas (2001), who encouraged all nurses, including students, to develop journaling as a tool for expanding and intensifying self-awareness, while developing nursing knowledge. Journaling helps expand the cognitive and affective domains of learning (Williams, Sundelin, Foster-Seargeant, & Norman, 2000) and has been used to help nursing students in their study of nursing theory (Norris, 2002). The addition of peer group discussion to journaling has been suggested to further augment self-reflection and analysis (Riley-Doucet & Wilson, 1997).
The overall goal of journaling in a practice discipline is to record and reflect on personal experiences, responses, attitudes, and decisions to enhance problem-solving skills, critical thinking abilities, and professional judgment (Patton, Woods, Agarenzo, Brubaker, Metcalf, & Scherrer, 1997; Rooda & Nardi, 1999). To prepare nurses for community health APN, clinical journaling has been used to facilitate development of practice obligations, cultural sensitivity, and social responsibility (Mayo, 1996). In clinical education, journals typically detail how hours were completed and describe how objectives were met, and are submitted at intervals during the course or at the end of the course for the instructor for review. Clinical journals help meet curricular and regulatory requirements for time and activities documentation.
Directed journaling was operationalized for this pilot test as reflective writing, in which students document specific events, then perform some level of analysis and/or reflection on the event. Students were guided in their journaling by a list of topics that represented the clinical objectives for the course. Because clinical journals are a compelling source of clinical information, thought processes, and clinical decision making, we believed they would be a valuable resource to share during the course, and that the option for the entire class and the instructor to read them as they were being written would enhance opportunities for discussion, mentoring, critical thinking, and socialization.
Technology and increased access to information and communication can expand learning experiences and improve nursing education. Online graduate nursing education has proliferated rapidly, and online courses have received positive evaluations from most students (Wills & Stommel, 2002). Course Web sites have been designed as tools for student learning and integrated into traditional courses, and students have found them both important and useful (Zwolski, 2000). In distance learning programs, asynchronous Internet discussions have been used to facilitate group discussion in nursing education with success (Cartwright, 2000).
The idea to use an online environment for the required, directed journaling developed from our desire to increase the sharing of clinical experiences. We did not view the time allotted during weekly class meetings (i.e., 4 hours) as sufficient to allow for thorough presentation, discussion, and processing of clinical experiences. A system of asynchronous, online journaling was designed to permit students adequate time to access, record, and respond to their clinical experiences, including time to analyze and reflect, when they were most receptive.
Both traditional and online discussion and journaling have been positively evaluated in nursing education. Traditional journaling has been used effectively with nursing completion or bridge students to record thoughts and feelings, and discuss them through the reading of the journal in class (Kielinen, 1997). Online, threaded, asynchronous discussions in a baccalaureate-level pathophysiology class promoted greater participation and feedback and a shift to student-centered learning (Teikmanis & Armstrong, 2001). VandeVusse and Hanson (2000) used online course discussions and interaction to facilitate faculty involvement and support for graduate nursing students at distant sites.
An online conferencing strategy with an asynchronous, facilitated discussion format was found to increase individual student participation in a graduate nursing bioethics course (Ellenchild Pinch & Graves, 2000). In addition, Glass and Walter (2000) used reflective journaling, interviewing, and peer mentoring with seven undergraduate nursing students and a course coordinator to foster professional growth through shared learning, shared caring, reciprocity, and friendship.
Critical thinking is essential to improve practice judgment and contributes to personal and professional development through the abstraction of principals from specific contexts and applying them across a range of situations (Chenoweth, 1998). Patton et al. (1997) used journaling in a senior nursing student practicum to integrate classroom and clinical learning, decision making, and skill acquisition, which contributed to critical thinking, observation, discussion, empathy, and sharing of feelings.
Socialization is a complex, diverse, and proactive process that is critical to the development of advanced practice nurses (Howkins & Ewens, 1999). It is also both normative and individualistic (Buckenham, 1998). Nurses who have already been socialized into the nursing profession do not necessarily become resocialized when they return to continue their education. However, they may change or transform their perspective of nursing, nursing’s role, and themselves (Maltby & Andrusyszyn, 1997). The effect of nursing education on professional socialization depends on the students’ past experiences and the reflective processes promoted in the course of study (Howkins & Ewens, 1999). Howkins and Ewens (1999) found that, during the completion of a community APN program, students made radical reappraisals of their perceptions, gained a better understanding of their specialist role, and became less rigid in their thinking.
A key role in the professional socialization of both undergraduate and graduate nurses is the clinical experience (Dunn, Ehrich, Mylonas, & Hansford, 2000). The clinical mentor and the experience of mentoring was found to be the most important factor in the professional socialization of nursing students (Gray & Smith, 1999). Nesler, Hanner, Melburg, and McGowan (2001) found students in a computer-based, distance nursing program demonstrated higher socialization scores, compared to traditional nursing and non-nursing students.
Online, Directed Journaling Design
The goals of this pilot test were to implement and evaluate the effectiveness and value of online, directed journaling, a new educational method, in a two-quarter community health APN clinical nursing course. Using the course management software provided by the university, a course Web site was developed for the class. The course instructor and students had 24-hour access to the Web site. All students were responsible for keeping a weekly, online journal on the Web site discussion board. Students were required to post one in-depth journal entry per week, including goals, objectives, clinical activities, reflection on those activities, and discussion of one of the designated topics. In addition, students were required to read and comment on at least two of their classmates’ journal entries weekly. Students were expected to spend at least 1 hour per week journaling.
Twenty weekly discussion topics were assigned during the two 10-week quarters of the course. Topics were presented five at a time at the beginning of four 5-week intervals (Table 1). Students were allowed to address any of the five topics for the interval in any order, allowing for some flexibility depending on the clinical experiences of the week. All topics were required to be discussed by the end of the course. Discussion topics were selected and ordered to provide a structure for cognitive and clinical practice development as the course progressed.
Weekly Topics for the Online, Directed Journaling
Graduate nursing students enrolled in a sequenced, two-quarter community health APN clinical course completed the online, directed journaling as part of the course requirements. An evaluation of the journaling was completed on the last day of the course. The evaluation was reviewed and approved by the university Institutional Review Board. All students gave informed consent for their evaluations and journaling to be examined.
The journaling evaluation form was developed by the course instructor and reviewed by two other experienced nurse educators to support content validity. The evaluation consisted of 4 demographic questions and 10 items that students rated on a 5-point, Likert-type scale ranging from 1 = “strongly disagree” to 5 = “strongly agree.” The demographic questions assessed students’ gender, age, ethnicity, and length of time licensed as an RN. The 10 evaluation items assessed the effectiveness and value of the journaling activity. The final item on the evaluation form was an open-ended request for any additional comments students wanted to express about the journaling experience. All journaling data, except the names of the students who completed the entries or any other potentially identifying information, were extracted from the course Web site by the course instructor. All journal entries were evaluated by three independent, doctorally prepared nurse educators for evidence of discussion, mentoring, critical thinking, and socialization.
Six female nursing graduate students who completed the two-quarter community health APN clinical course participated in the journaling and evaluation. Their average age was 46 (range 27 to 57). The group contained four White, one Asian, and one Native American students. Their average number of years of nursing practice was 21.2 (range 5 to 37).
Each student was required to post a minimum of three entries weekly, one original entry and two responses to others’ entries, resulting in a minimum of 15 entries every 5 weeks, or 90 total entries for the entire class for each 5-week period. A minimum of 360 total entries were required to be posted by all students during the two quarters of the course. Students posted 487 total entries; 119 entries were posted the first 5 weeks (19.8 per student), 122 entries were posted the second 5 weeks (20.3 per student), 127 entries were posted the third 5 weeks (21.2 per student), and 119 entries were posted the last 5 weeks (19.8 per student). The mean scores for the 10-item student evaluation of the journaling experience, as well as student comments, are listed in Table 2. Evaluation scores ranged from 4.7 to 5.0. No item received less than a “4” rating.
Online, Directed Journaling Evaluation and Comments (N = 6)
Entries demonstrating discussion and critical thinking were abundant throughout all 20 weeks of the course. Discussions and critical thinking focused on variety of clinical issues. Entries demonstrating mentoring and socialization also occurred throughout the course but were most concentrated in the last 5 weeks of each quarter. As each quarter progressed, and as students read and commented on others’ entries, it became clear that the students were developing a mental picture and understanding of other students’ clinical settings. This shared insight prompted journaling that provided assistance and support and sought meaning in the context of APN for that setting. Examples of journaling entries representative of discussion, mentoring, critical thinking, and socialization are presented in Table 3.
Examples of Discussion, Mentoring, Critical Thinking, and Socialization Entries from the Online Journals
Discussion and Recommendations
All 6 students who participated in the pilot test perceived the journaling as highly effective and valuable. The following discussion was included in the journaling:
I like the journaling because we don’t get that much time to compare what’s going on in our clinical settings in class. I don’t think we got as much information when we met in seminar either.
I absolutely agree. I really dreaded doing the previous journals, but I find this much more interesting. It’s been nice to read and see what others are doing.
I agree the journaling is more thought out by those who write it, and more informative for others to read!
In addition, the themes derived from the text of the journaling supported the use of this method to promote discussion, mentoring, critical thinking, and socialization in APN clinical education. The journaling may have been more successful with this group of students due to their ages and length of experience as nurses, and because the students had been together, although not as the same group, in previous classes. Therefore, the students who participated may not be representative of other graduate nursing students.
Additional evaluation is needed to validate the effectiveness of online, directed journaling with other groups of graduate nursing students. Online, directed journaling may prove to be an effective learning method for non-clinical graduate nursing courses or in other nursing educational settings, such as undergraduate courses, and should be evaluated in these settings as well. The effectiveness of the journaling also needs to be assessed with larger groups of students.
Although it is a common nursing educational method, journaling has not been used to its fullest potential. Traditional journals are not designed to convey the essence of clinical experiences and often result in isolated writing and unshared entries. Journal sharing expands the dissemination of relevant clinical experiences and facilitates both cognitive and professional growth for students. In addition, online journaling increases access and expands the opportunity for reflection. Innovative, online strategies should become the standard for journaling in nursing graduate education.
- Bellas, R.A. (2001). Nurses and personal journal writing. Creative Nursing, 7(3), 11–13.
- Bilinski, H. (2002). The mentored journal. Nurse Educator, 27(1), 37–41. doi:10.1097/00006223-200201000-00018 [CrossRef]
- Buckenham, M.A. (1998). Socialization and personal change: A personal construct psychology approach. Journal of Advanced Nursing, 28, 874–881. doi:10.1046/j.1365-2648.1998.00746.x [CrossRef]
- Cartwright, J. (2000). Lessons learned: Using asynchronous computer-mediated conferencing to facilitate group discussion. Journal of Nursing Education, 39, 87–90.
- Cash, P., Brooker, J., Penney, W., Reinbold, J. & Strangio, L. (1997). Reflective inquiry in nursing practice or “revealing images.”Nursing Inquiry, 4, 246–256. doi:10.1111/j.1440-1800.1997.tb00110.x [CrossRef]
- Chenoweth, L. (1998). Facilitating the process of critical thinking for nursing. Nursing Education Today, 18, 281–292. doi:10.1016/S0260-6917(98)80045-2 [CrossRef]
- Davies, E. (1995). Reflective practice: A focus for caring. Journal of Nursing Education, 34, 176–174.
- Dunn, S.V., Ehrich, L., Mylonas, A. & Hansford, B.C. (2000). Students’ perceptions of field experience in professional development: A comparative study. Journal of Nursing Education, 39, 393–400.
- Ellenchild Pinch, W.J. & Graves, J.K. (2000). Using web-based discussion as a teaching strategy: Bioethics as an exemplar. Journal of Advanced Nursing, 32, 704–712. doi:10.1046/j.1365-2648.2000.01531.x [CrossRef]
- Glass, N. & Walter, R. (2000). An experience of peer mentoring with student nurses: Enhancement of personal and professional growth. Journal of Nursing Education, 39, 155–160.
- Gray, M. & Smith, L.N. (1999). The professional socialization of diploma of higher education in nursing students (Project 2000): A longitudinal qualitative study. Journal of Advanced Nursing, 29, 639–647. doi:10.1046/j.1365-2648.1999.00932.x [CrossRef]
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- Howkins, E.J. & Ewens, A. (1999). How students experience professional socialization. International Journal of Nursing Studies, 36(1), 41–49. doi:10.1016/S0020-7489(98)00055-8 [CrossRef]
- Kielinen, C.E. (1997). Journaling: An opportunity for reflection. The Association of Black Nursing Faculty Journal, 8(1), 8–10.
- Kobert, L.J. (1995). In our own voice: Journaling as a teaching/learning technique for nurses. Journal of Nursing Education, 34, 140–142.
- Maltby, H.J. & Andrusyszyn, M.A. (1997). Perspective transformation: Challenging the resocialization concept of degree-seeking registered nurses. Nurse Educator, 22(2), 9–11. doi:10.1097/00006223-199703000-00008 [CrossRef]
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- Riley-Doucet, C. & Wilson, S. (1997). A three-step method of self-reflection using reflective journal writing. Journal of Advanced Nursing, 25, 964–968. doi:10.1046/j.1365-2648.1997.1997025964.x [CrossRef]
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- Teikmanis, M. & Armstrong, J. (2001). Teaching pathophysiology to diverse students using an online discussion board. Computers & Nursing, 19, 75–81.
- VandeVusse, L. & Hanson, L. (2000). Evaluation of online course discussions. Faculty facilitation of active student learning. Computers & Nursing, 18, 181–188.
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- Williams, R.M., Sundelin, G., Foster-Seargeant, E. & Norman, G.R. (2000). Assessing the reliability of grading reflective journal writing. Journal of Physical Therapy Education, 14(2), 23–26.
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Weekly Topics for the Online, Directed Journaling
|1 to 5|
Practice philosophy of the preceptor.
Components, players, and roles of the political environment of the clinical site.
Barriers to advanced practice at the clinical site.
A legal issue encountered.
An ethical issue encountered.
|6 to 10|
Tools for practice and how they are used.
Problem in the targeted population not being addressed.
Resources to address the problem.
Process to secure resources.
Physical and emotional effects of practice.
|11 to 15|
Preceptor role in decisions.
Preceptor role in policy development.
Types of data collected at the clinical site.
Data collection system.
Data not being collected that would be important to collect.
|16 to 20|
Challenge to implementation of a selected intervention.
Preparation process for intervention implementation.
Easiest part of the intervention implementation.
Something unexpected that occurred.
Change in implementation design or implementation for the future.
Online, Directed Journaling Evaluation* and Comments (N = 6)
|Evaluation Items||Mean (SD)|
|Effective sharing of clinical experiences||5.0 (0)|
|Increased understanding of course content||4.8 (.4)|
|Increased understanding of clinical issues||4.8 (.4)|
|Effective documentation of clinical hours||4.8 (.4)|
|Important part of the course||4.7 (.5)|
|Effective discussion of clinical issues||4.7 (.5)|
|Increased critical thinking ability||4.7 (.5)|
|Increased clinical problem-solving ability||4.7 (.5)|
|Allowed others to help me||4.7 (.5)|
|Increased social interaction||4.7 (.5)|
“Extremely interesting and user-friendly concept. More computer online processes should be used in the program. Thanks for this.”
“Online journaling was very helpful in understanding the perspectives of my other classmates and their work experiences.”
“Would like to know findings and subsequent class reactions.”
Examples of Discussion, Mentoring, Critical Thinking, and Socialization Entries from the Online Journals
|Discussion||“In regards to the...clinic project, [the preceptor] is collecting accurate information to describe the population’s characteristics and their available health care services…. By extracting information on several levels, the data can be structured, organized, proceeded, and interpreted to describe...the need.”
“There’s no doubt about it, data collection is essential to nursing practice. Gone are the days (hopefully) when nurses or other professionals did something because that was the way it was always done. Now data show us what is needed and what is effective—makes much more sense really. It is interesting to hear about the evolution of the...clinic and the painstaking research that is laying the foundation.”|
|Mentoring||“...your collaborative approach is what we have learned that advanced practice nursing is all about! Collaboration is the assertive, cooperative approach to find solutions that best achieve goals. In this respect, planning and implementing policies prior to a bioterrorism event sounds relevant to what the country is facing today.”
“I, too, used to take problems home with me and worry about these families, but you can’t carry on like that, or you burn out. It’s not that you don’t care any more; it’s because you realize that you can’t do everything, and as long as you have fulfilled your professional responsibilities, you need to hand back responsibility to others.”|
|Critical thinking||“The fact that they [single mothers] are making a contribution to the system could well be therapeutic in itself in building self-esteem in their ability to improve theirs and their children’s lives.”
“If we aren’t going to remove the children because of substance abuse or prenatal exposure, then we should be offering a realistic, effective, all-encompassing alternative that meets the needs of the family.”
“For instance, nutrition classes would benefit many, but where will they get the money, and where will they find a grocery store to buy all the healthy food that they just learned about? The markets in the area are mostly liquor stores.”
“...but how long will the grant of $100,000 last?... How will you be able to provide the education needed for each of the areas you addressed?”|
|Socialization||“Your observations of respect versus nonrespect among medical professionals become evident in how each displays leadership behaviors. Your preceptor must possess the qualities of a good leader. We must remember that leadership is defined as the use of personal traits to constructively and ethically influence and inspire others. The nurse leader engages in relationship building to empower those being led toward a vision of optimal organizational achievement in the workplace and the optimal well-being of our patients.”
“I don’t disagree with anything you say, including the part about ‘nursing is not about money,’ but...I think it’s a reality that nursing tries to avoid dealing with. We do focus on getting money to help people, but one of the reasons nursing as a profession has struggled as a profession is that we downplay our own worth.”|