The purpose of this presentation is to report the results of an IRB approved qualitative descriptive research study exploring the use of reflective journaling as a pedagogical strategy to evaluate the attainment of clinical reasoning among a targeted population of diverse RN-BSN students in a residency program at a public university in the United States. The following qualitative research question is answered in this presentation: What is the RN-BSN residency students’ experience and perception of evolvement of clinical reasoning and clinical judgment through the process of reflection and reflective journal writing? Purposive sampling of seven RN residency program students were obtained through informed consent.
Emerging complexity in healthcare practice settings inclusive of global arenas for care and the mandate for a stronger collaborative interdisciplinary nursing practice (Ironside, 2015) have significantly contributed to the need for sustained exploration of educational paradigms in nursing practice preparation. Educational paradigms must be aimed at the development of not only technical skills but the ability to critically identify a holistic foundation for nursing practice, based upon different forms of knowledge or ways of knowing (Carper, 1978). Engagement in reflective practice is noted to facilitate the development of multiple ways of knowing in nursing practice (Sherwood & Horton-Deutsch, 2012), leading to the development of critical thinking (Zori, 2016). Research encompassing a variety of transformative educational strategies designed to address contemporary educational needs is evinced in the literature. However, despite advances in the epistemology of nursing knowledge and practice, continuing research into educational preparation modalities records evidence of a widening theory-practice gap (Hickerson, Taylor & Terhaar, 2016; Epp, 2008). Significantly, this disparity lends to a diminishment of safe, quality patient care. Therefore, contemporary educational practices must address these concerns.
A review of the literature notes the significance of the model of residency nursing education and reflective practice in the development of an epistemology founded upon multiple ways of knowing in nursing practice. Residency programs, described by the American Association of Colleges of Nursing [AACN] as a model intended to provide supplemental education within the context of the workplace through the provision of mentored, individualized clinical experiences, have demonstrated to provide benefits through a variety of ways including overall improvement (Rush, Adamack, Gordon, Lilly, & Janke, 2013); additional attainment of knowledge through skills training, debriefing, and hands on self-care knowledge (Pine & Tart, 2007); and culturally congruent care based upon evidence (Letourneau & Fater, 2015).
Evidence of the use of reflection as pedagogical strategy is well documented over decades in the nursing literature. Many models of reflective practice exist. Reflective practice, “a means of self-examination that involves looking back over what has happened in practice to improve or encourage professional growth” (Ruth-Sahd, 2003, p. 488) is cited as a conscious, dynamic process of thinking about, analyzing, and learning from an experience that gives one insights into Self and practice (Freshwater, 2008; Kim, Lauzon, Burbank & Martins, 2010; Asselin, 2011) and is an essential element of evidence-based practice through questioning (Thompson & Burns, 2008). Reflective practice allows a forum for opening to a holistic nursing practice through the embracement of diverse arenas of knowledge. Evidence of this is noted in the seminal work of Benner (1984) which documented a lessening of the theory-practice gap through the development of personal knowledge with technical or empirical knowledge and more recently though aiding in the internalization of ways of thinking (Kennison, 2012). Guided reflective journaling is one strategy frequently employed to assist in the development of reflective practice. Most recent evidence for the use of reflective journaling as an effective teaching-learning strategy in the development of clinical judgment is offered by Brussard (2015a, 2015b).
An extensive review of the literature entailed exploration of critical conceptual definitions as well as an examination of evidence-based educational strategies using reflective journaling. Succinctly, the theoretical basis for this study is noted within the conceptual analysis of the significant concepts of critical thinking, clinical reasoning, and clinical judgment. For the purpose of this study, critical thinking is maintained as a precursor to both concepts of clinical reasoning defined “as a complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information and weigh alternative actions” (Simmons, 2010, p. 1155) and clinical judgment described as, “an interpretation about a patient’s needs and/or the judgment to take action (or not), the use of standard approaches or modification of standard approaches or improvising of a new one as deemed appropriate to the patient’s response” (Tanner, 2006, p. 204). The evidence of application and identification of a variety of forms of nursing knowledge, noted in the seminal work of Carper (1978) and further refined and expanded upon by Chinn & Kramer (2014) provided additional theoretical foundations in this study.
Methods:
Methodology in this qualitative descriptive study utilized reflective journaling as an educational strategy created through active reflective dialogue with research faculty investigators through an anonymous secured electronic journaling platform. Following journal submissions, written insightful electronic feedback was created by each researcher independently, allowing for diverse reflective insights to the study participants. Cue questions inviting deeper reflection were created using the Johns (1995) model of structured learning to reveal multiple ways of knowing and learning (Carper, 1978). The Johns (1995) model promotes exploration of four fundamental patterns of knowing: ethical, personal, aesthetic, and empirical, adding an additional pattern of knowing, reflexivity, that assists the writer in knowing about themselves in the experience. Additional cue questions using emancipatory knowing (Chinn & Kramer, 2014) further reflecting contemporary nursing practice roles and identities, were also constructed.
Results:
Rigor of data analysis process, was maintained utilizing the framework of Lincoln and Guba (1985). This framework incorporates methods to address rigor through the review of data credibility, transferability, dependability, and confirmability, in which the qualitative thematic analysis of journal entries was independently ascertained by the two researchers following the study completion. Following independent analysis, researchers met to compile mutual evidence of clinical reasoning as revealed in reflective journaling. A thematic analysis was structed around the framework of patterns of nursing knowledge (Carper, 1978; Chinn & Kramer, 2014). Study findings noted authentication of all ways of knowing embodied in student reflective journals. A continuum of expansion of the framework of nursing knowledge is distinguished by the evolvement of the study participants’ reflective journaling from the technical or empirical ways of knowing in nursing practice as a single, foundational way of providing nursing care toward the attainment of emerging emancipatory thinking and nursing practice as corroborated through the emancipatory concepts of an opening to voice, vulnerability, holism, community of caring, and disparity.
Conclusion:
Results of this study further indicate the significance for curricular and educational implications of reflective journaling and reflective narrative explorations as a warranted pedagogical strategy. The importance of this strategy is noted through the reflective journal of one participant in which a true “seeing” of the community of nursing was facilitated in this study (Study Participant, 2016). This pedagogical strategy, as based upon active constructivist learning theories and models of education and feasibility of use, continue to be validated for applicability of use in contemporary nursing education in global arenas. Models of clinical learning for the novice nurse in conjunction with reflective journaling offer many potential implications for safe, quality patient centered nursing practice.
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