Journal of Nursing Education

Educational Innovations Supplemental Data

Reflective Journaling for Critical Thinking Development in Advanced Practice Registered Nurse Students

Ginger Raterink, DNSc, ANP-C

Abstract

Background:

Critical thinking, clinical decision making, and critical reflection have been identified as skills required of nurses in every clinical situation. The Educating Nurses: A Call for Radical Transformation report suggested that critical reflection is a key to improving the educational process. Reflective journaling is a tool that helps develop such skills.

Method:

This article presents the tool of reflective journaling and the use of this process by educators working with students. It describes the use of reflective journaling in graduate nursing education, as well as a scoring process to evaluate the reflection and provide feedback.

Results:

Students and faculty found the journaling to be helpful for reflection of a clinical situation focused on critical thinking skill development. The rubric scoring tool provided faculty with a method for feedback.

Conclusion:

Reflective journaling is a tool that faculty and students can use to develop critical thinking skills for the role of the advanced practice RN. A rubric scoring system offers a consistent format for feedback. [J Nurs Educ. 2016;55(2):101–104.]

Abstract

Background:

Critical thinking, clinical decision making, and critical reflection have been identified as skills required of nurses in every clinical situation. The Educating Nurses: A Call for Radical Transformation report suggested that critical reflection is a key to improving the educational process. Reflective journaling is a tool that helps develop such skills.

Method:

This article presents the tool of reflective journaling and the use of this process by educators working with students. It describes the use of reflective journaling in graduate nursing education, as well as a scoring process to evaluate the reflection and provide feedback.

Results:

Students and faculty found the journaling to be helpful for reflection of a clinical situation focused on critical thinking skill development. The rubric scoring tool provided faculty with a method for feedback.

Conclusion:

Reflective journaling is a tool that faculty and students can use to develop critical thinking skills for the role of the advanced practice RN. A rubric scoring system offers a consistent format for feedback. [J Nurs Educ. 2016;55(2):101–104.]

Critical thinking has been identified as the foundation of the problem-solving thought processes that people use in everyday situations. The Carnegie Foundation's report, Educating Nurses: A Call for Radical Transformation (Benner, Sutphen, Leonard, & Day, 2010), called for a paradigm shift from the concept of critical thinking in nursing to one that expands thinking skills and habits for clinical judgment or reasoning. A shift to critical reflection was suggested, where students would pose questions about an event, a patient, or a clinical situation on which they can draw attention to deconstructing the situation to evaluate the thinking processes used. Critical reflection is a way of developing clinical reasoning and imagination to help students examine what happened and what to consider when confronted with another similar clinical situation. However, it remains unclear how nurse educators can incorporate critical reflection into clinical and classroom learning. If educators are to enhance this thoughtful process, they need tools to analyze and interpret students' thinking through reflection and provide feedback related to the effectiveness of this process. This article will discuss some of the basics of critical thinking and critical reflection and propose a method for educators using journaling to guide students in the critical reflection process.

Background

Both the nursing and social science literature have attempted to define critical thinking. Nursing and other social science educators have developed methods for teaching and evaluating the critical thinking skills, when defined, of their students (Brookfield, 1987; Dewey, 1933; Ruthman et al., 2004; Scheffer & Rubenfeld, 2000). However, before teaching and evaluation tools can be developed, those definitions must be better understood. In reviewing the definitions provided in the literature, some common characteristics identified include that critical thinking is a process of reflection, analysis, decision making, and awareness, as well as the ability for the appraisal of assumptions, inquiry, interpretation, and consideration of contextual perspective (Riddell, 2007).

The concept of critical thinking has its origins in the social sciences. As early as the 1980s, the literature related to general education describes a recognition of critical thinking as the foundation of the educational process. In 1990, the American Philosophical Association conducted a Delphi study that was spearheaded by a psychologist and nurse team (Facione, 1990). That team focused on a cross-disciplinary definition of critical thinking. The resulting definition has been used as the basis for student evaluation by educators at all levels (Facione, 1990).

As early as 1932, the National League for Nursing recognized critical thinking as being an important concept for nursing education (Urch, 1932). Over time, several nurse educators attempted to define critical thinking for nursing; however, there was no consensus on how it was applied to nursing. Therefore, in 2000, two nurse educators, Rubenfeld and Scheffer (2010), conducted a second Delphi study built on the work of Facione (1990). That study was designed to formalize their original definition of critical thinking, making it specific to nursing. The results included the following consensus statement:

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, seeking information, logical reasoning, predicting, and transforming knowledge. (Scheffer & Rubenfeld, 2000, p. 357)

From this definition, Rubenfeld and Scheffer (2010) developed educational and evaluation tools for implementation in nursing education. That work is based on their earlier consensus statement and supported the themes identified as they related to the habits of the mind and cognitive skills. Those educators highlighted the value of a purposeful reflective process to evaluate critical thinking in clinical situations (Scheffer & Rubenfeld, 2000). Using their earlier consensus statement, they suggested that reflection may be the one tool that is best suited for student learning and assessment (Rubenfeld & Scheffer, 2010).

Reflection in Nursing Education

Reflection is defined as “contemplation upon a subject, especially one's assumptions and thinking, for the purposes of deeper understanding and self-evaluation” (Scheffer & Rubenfeld, 2000, p. 358). Mezirow (1991) indicated that becoming aware of the assumptions one makes in thinking and action involves recognizing the influence of culture and life experiences, as well as learning how to compensate for one's limitations. Mezirow suggested that reflection becomes an important element in the development of critical thinking. Foundational to those assumptions is the work of Dewey (1933), who defined reflection, or reflective thought, as a process that is active, persistent, and requires careful consideration of any belief or supposed form of knowledge to support and develop further conclusions about it. Dewey further suggested that the process is sequential and begins with questioning knowledge in a deliberate format.

The use of reflection to foster critical thinking is not a new concept. In 1987, Brookfield wrote about developing critical thinking in adults in all disciplines and professions. In those writings, Brookfield (1987) suggested that critical thinking is a process of identifying assumptions, challenging those assumptions, and finding alternatives, while understanding the importance of the context within which the assumptions or alternatives are made. Brookfield suggested that to be a critical thinking adult, one must ask questions about one's normal ways of thinking by probing, questioning, and reflection. He called the process reflective skepticism and suggested that ideas must be subjected to testing against experiences through a process of reflection.

Schön published works on the development of character and professional knowledge as early as 1983. His focus was on reflective practicum, in which he suggested that practical knowledge related to the actions of the professional was essential to knowledge development. Schön spoke about both knowing in and on actions but defined each as unique and specific. He used the term reflective practicum to support knowledge acquisition from practical experience, (Schön, 1987). Using concepts from these and other educators, nurse educators have suggested that critical reflection and analysis in relation to practice is essential to critical thinking skill development (Benner et al., 2010).

The Reflective Process

Throughout nursing education, reflection has been used to enhance knowledge and refine action to improve care delivery. However, questions remain about the methods used for reflection in nursing education, whether undergraduate or graduate. In the report by Benner et al. (2010), several suggestions were made regarding improvements to nursing education. Point 17 suggests that educators foster student learning opportunities for practice reflection (Benner et al., 2010). Benner et al. described student-generated accounts of their experiences with patients and families as a method of identifying students' strengths and weaknesses related to the patient care in which they had been engaged during the student experience. This can occur as classroom discussions, small-group case conferences, or journaling.

In a study by Ruthman et al. (2004), clinical journaling was described as a teaching tool to help undergraduate students develop their critical thinking skills. The focus, as defined by those authors, was to allow students to begin to express in written form their attitudes, feelings, and cognitive learning experiences from the clinical settings. It allows the student to link prior knowledge, observation, description, critical thinking, and clinical decision making to the clinical experiences so they can connect theory and practice and then reflect on the process. Ruthman et al. suggested a format for the journaling to help define and enhance the reflection so that a consistent framework supports learning, evaluation, and feedback.

In their book, Critical Thinking Tactics for Nurses: Achieving the IOM Competencies, Rubenfeld and Scheffer (2010) discussed the role of reflective thinking as a method for educators to assist students in reviewing clinical situations and drawing from what they learned. They proposed a process of reflective thinking through structured journaling as one method to help students focus on thinking, related to the actions of the clinical situation. On the basis of the consensus statement of critical thinking developed from their Delphi study, Rubenfeld and Scheffer formulated a series of questions that students should ask themselves as they reflect. The questions are based on the critical thinking habits of the mind and skills, as outlined in their consensus statement, which then guides the student to identify the knowledge used for learning.

The Application Process

Rubenfeld and Scheffer (2010) suggested that for this reflective journaling to be useful, students need feedback to close the loop in the reflective process and support the assumptions. They described a process whereby students would journal about various clinical experiences, using a three-step, structured format that encourages students to reflect in a more formal way. The format calls for the students to frame the vignette or clinical scenario as a description of one element of the critical thinking definition from their consensus statement (habit or skill). The first step simply describes how the vignette represents the selected element. The second step offers the students the opportunity to support the actions of the vignette as a demonstration (or, in some cases, not a demonstration) of the element. The third step provides a format for the students to decide on how they would act in another similar situation to demonstrate the critical thinking skill or habit. Each step is only one paragraph, and the entire journal entry is only one page, forcing the students to identify the key elements of the situation or vignette and be succinct in their discussion.

The value of a structured journal activity is that the instructor now has a formal process from which to critique and provide guided feedback. Rubenfeld and Scheffer (2010) provided a rubric scoring system to evaluate students' journaling and provide opportunities for feedback on the reflection and use of the critical thinking element in the clinical setting. The expectation was that students would reflect on what they wrote and then learn from their own experience, as well as from feedback from faculty. The result would be recognition of their own critical thinking skills in that particular situation and the application of such skills in a future similar clinical situation.

The Outcomes of Reflection

The journaling activity was implemented as a part of the clinical experience in a master's nurse practitioner program. Using the definitions from the consensus statement of the critical thinking skills or habits of Scheffer's and Rubenfeld's work (2000), students were assigned a clinical scenario or vignette and were asked to reflect on how the described scenario did or did not effectively represent the skill or habit they had identified. Initially, students expressed some confusion with knowing exactly what the skill or habit represented. They also found the reflection to be more difficult than they had initially thought. However, as the students began to look at the scenario more carefully and reflect on what they were thinking and feeling during the experience, they were better able to relate the scenario or vignette to the skill or habit. Finally, with this increased reflection, the students were more likely to describe how they would continue to work toward utilization of the skill or habit in future similar situations. By the end of the two semesters in which they completed the journals, the students expressed a stronger understanding of critical thinking and how it enhanced their clinical decision-making abilities. In addition, the students commented that they felt better equipped to cope with a variety of clinical situations, knowing how to approach the situation through a more structured thinking process. It provided them with a new sense of confidence in their ability to function in the expanded role of the advanced practice RN.

Faculty working with the journaling activity found that the initial scoring rubric was too limited in scope to apply to the advanced practice RN student experience. However, by modifying the scoring system and providing a more detailed rubric, faculty found it easier to score the journal entry and offer constructive feedback. The result was a positive learning experience for the student engaged in reflective journaling and a positive teaching tool for faculty eager to assist their students in enhancing their critical thinking and improving their clinical decision making. Faculty found that it was easy and quick to read just one journal page per student, score the sections, and offer feedback so that students were able to receive the feedback in a timely manner. This helped close the loop on the reflective process. Table A (available in the online version of this article) provides an example of a student's journal entry and shows the rubric score sheet used to grade the student's reflection.

Sample Journaling With Rubric Scoring SheetSample Journaling With Rubric Scoring Sheet

Table A:

Sample Journaling With Rubric Scoring Sheet

Conclusion

The purpose of the journaling exercise described in this article was to help graduate students develop the skills of critical thinking related to habits of the mind and cognitive skills described in the consensus statement by Scheffer and Rubenfeld (2000). In addition, the faculty were provided with a structured format for feedback to assist the student reflection. The students found that as they became more comfortable with the reflection activity, they felt a greater sense of knowledge development related to each of the critical thinking skills or habits.

The instructors felt that the original rubric score sheet was too narrowly defined for graduate students with varied backgrounds in nursing practice. Therefore, with the permission of the original authors (Rubenfeld & Scheffer, 2010), the instructors created a new rubric with a wider range of scores and responses. Students were better able to see how they applied the critical thinking skill or habit to the clinical situation or vignette and believed the second rubric was more informative for their learning and reflection. The students believed they learned a great deal from the journaling process, both regarding their initial actions and thoughts, as well as how to enhance their critical thinking skills and habits to improve their clinical decision making.

The journaling experience enhanced the educational process for all involved and demonstrated a method for advanced practice RN nursing education, using tools of reflection and critical thinking.

References

  • Benner, P., Sutphen, M., Leonard, C. & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
  • Brookfield, S. (1987). Developing critical thinkers: Challenging adults to explore alternative ways of thinking and acting. San Francisco, CA: Jossey-Bass.
  • Dewey, J. (1933). How we think. A restatement of the relation of reflective thinking to the educative process. Boston, MA: Heath.
  • Facione, P.A. (1990). Critical thinking: A statement of expert consensus for purposes of educational assessment and instruction. Millbrae, CA: The California Academic Press.
  • Mezirow, J. (1991). Transformative dimensions of adult learning. San Francisco, CA: Jossey-Bass.
  • Riddell, T. (2007). Critical Assumptions: Thinking critically about critical thinking. Journal of Nursing Education, 46, 121–126.
  • Ruthman, J., Jackson, J., Cluskey, M., Flannigan, P., Folson, V.N. & Bunten, J. (2004). Using clinical journaling to capture critical thinking across the curriculum. Nursing Education Perspectives, 25, 120–123.
  • Rubenfeld, M.G. & Scheffer, B.K. (2010). Critical thinking tactics for nurses: Achieving the IOM competencies (2nd ed.). Sudbury, MA: Jones and Bartlett.
  • Scheffer, B.K. & Rubenfeld, M.G. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, 39, 352–359.
  • Schön, D.A. (1987). Educating the reflective practitioner: Toward a new design for teaching and learning in the professions. San Francisco, CA: Jossey-Bass.
  • Urch, D.D. (1932). What are we doing to improve nursing practice? I. Through better selection of students. The American Journal of Nursing, 32, 680–684.

Sample Journaling With Rubric Scoring Sheet

During my most recent day at the dermatology clinic, I experienced personal use of the critical thinking habit intuition. I've been at this site for approximately 48 hours now, so I've developed enough skill to do some skin exams and work-ups on my own. The fact that my preceptor now trusts me to do full skin exams instills a great sense of responsibility in me, as well as a sense of pride. During a routine skin exam in a middle-aged woman with a family history of malignant melanoma, I was astounded at how keen my intuition was at leading me to areas of concern. The woman had been referred by her PCP who noted she had “a lot of moles” on her body that should be assessed. She had multiple areas of concern to her on her face and arms. She was unaware of any other suspicious lesions. As I was examining the skin on this patient's back, however, my eyes were immediately drawn to two lesions. Her back was covered in various moles of different shapes, sizes and colors, and although I hadn't looked closely enough to give objective reasoning for my concern over these two specific moles, I immediately felt that sense of interest in these two lesions. Upon further inspection with my loupes, I noted that one of the moles toward which my eyes had first gravitated had a very irregular border and a red base. The lesion was nonraised, with varying shades of brown in it. Another lesion that struck me was varying shades of darker browns, again, nonraised without a red base. I completed the skin exam, and then I got my preceptor to review the lesions that were of concern to me.
When we returned to the room, it was so astounding to me as I had a fresh glance at this woman's back. It was covered in moles, and everything seemed to blend in, yet I'd had this feeling about the two lesions. I didn't tell my preceptor which two lesions concerned me. Instead, I was curious to see what she thought. She immediately noted the two lesions I had. Then she did a brief assessment of the woman's other areas of concern. Despite that this woman was covered in moles and had many areas with visible photo damage, my preceptor decided only to biopsy these two specific moles. We did shave biopsies that were sent for pathology, and the results are not yet back. I am curious to see what the results show, although I hope some minor atypia is all that is found for the sake of the patient. Regardless, although I wasn't consciously aware of my use of reason, my intuition was guiding me quite accurately.
The scenario clearly demonstrates the use of a very strong sense of intuition, one that was later supported by objective evidence. While it is hard to trust one's intuition, it seems this critical thinking habit has more empirical strength than we like to admit. Of course, it is always necessary to consider all of the ways of knowing, and I would never limit myself to make decisions based on intuition alone.
In this specific scenario, I think I used my intuition the best I could have, and I wouldn't really change anything. However, in retrospect, there are many other situations at this same clinical site where I could benefit from allowing my intuition to take over. For example, sometimes I get so wrapped up in the details of skin assessment that I might fail to notice the intuitive feelings or thoughts I have about a patient's skin. I may be missing the larger picture or tuning out this very strong sense of knowing that exists without the forced, conscious use of reason.
Rubric Score Sheet
Student name:________________  Rater:____________________
Critical thinking definition skill or habit: Intuition

Identification ability to effectively match the action in the vignette to the skill or habit; how well the vignette describes the skill or habit:

4 = clear representation of the skill or habit in the description of actions

3 = partial representation of skill/habit with some difficulty in clear identification

2 = misidentification of the skill/habit based on the vignette - actions are described but they don't match

1 = no evidence of understanding of the skill/habit they thought they were writing about

Score: 4

Justification ability to support the decision about the actions as they match the skill or habit; why the description of the actions matches the skill or habit

3 = incorporates the definition of the skill or habit and applies to the use in the vignette

2 = actions described partially justified as representing the skill or habit but no clear relationship to the definition

1 = actions have not been justified

Score: 3

Specification assessment of the student's ability to clearly explain what changes (or not) to behavior that he or she would take to improve the use of the skill or habit in subsequent patient situations.

3 = detailed description of how the student would use the skill or habit better in the next situation

2 = unclear or partial description of changes for the next situation

1 = no description of changes the student would make to improve the use of the skill or habit in the next situation

Score: 3
Comments of rater: nice reflection! Don't forget to check out the functions to appendix A.
Authors

Dr. Raterink is Associate Professor and Specialty Director, Adult-Gerontology Nurse Practitioner Masters Option, College of Nursing, University of Colorado Denver, Aurora, Colorado.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Ginger Raterink, DNSc, ANP-C, Associate Professor and Specialty Director, Adult-Gerontology Nurse Practitioner Masters Option, College of Nursing, University of Colorado Denver, 13120 E. 19th Avenue, Aurora, CO 80045; e-mail: Ginger.raterink@ucdenver.edu.

Received: December 22, 2014

Accepted: October 26, 2015

10.3928/01484834-20160114-08

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