Journaling : A quasi-experimental study of student nurses ’ reflective learning ability

The use of journaling or journal writing in clinical educa­ tion is one of the strategies used to develop critical think­ ing. Reflective journal writing, as it is commonly known, can nurture many qualities of a critical thinker and promote thoughtful nursing practice. Using a quasi-experimental design in this study, reflective journaling was introduced to a sample of first year Bridging Course student nurses at a Private Nursing Education Institution, to assess its effec­ tiveness in reflective learning. The study design enabled com parisons betw een two groups: one group of students assigned to do journaling (experimental group) and another group of students (con­ trol group) who did not journal. The students in the experi­ mental group were given a period of eight weeks to journal their clinical experiences. At the end of this period, both groups were given an exercise, based on a clinical situa­ tion, to analyse reflectively and a comparison made on their performance. Descriptive statistics were used to analyse data and Fisher’s Exact Test was used to determine the significance of differences observed within and between groups. The results showed that students in the experi­ mental group performed better in exploring alternatives of action (p < 0.10) and formulating responses in similar future situations (p < 0.05) during the process of reflection. There was no significant difference between the groups’ scores with regard to their ability to describe the clinical experi­ ence, to explore their related feelings, to evaluate the expe­ rience and to interpret/create meaning for themselves. Rec­ ommendations are made for continued student support and guidance during clinical education if reflection is consid­ ered to enhance reflective, thoughtful nursing practice.


Introduction
Reflection, as a way of thinking, has been an activity performed by many individuals in their daily lives.Reflection largely re lies on the recall of events.In this instance, it refers to the usual mulling over an event or experience.Reflection has been widely used as a teaching strategy through which nurses could develop their practice.This entails recalling the experience, analysing and evaluating the experience; it involves a con scious analysis o f the event.Several authors on reflection have referred to the works of Donald Schon (1983,1987,1991) who has written extensively about the importance of reflection and has described ways in which educators could facilitate reflec tion in practice.
Proponents like Schon (1991) suggest that reflection can be taught and learnt.Several methods can be used to teach and improve the process of reflection.The most commonly advo cated methods being writing or documenting one's experiences in a reflective diary (Schon, 1991) or in a journal (Atkins and Murphy, 1993).This would enable nurses to make more explicit the knowledge underpinning their actions.Reflective journals have also been widely reported as an effective strategy to as sist students to reflect upon learning experiences in clinical areas (Palmer, Bums and Bulman, 1994;Davies, 1995;Baker, 1996;Fonteyn and Cahill, 1998).The literature review that fol lows includes the meaning and importance o f reflection, the types o f reflection, and reflective journaling as an important strategy to develop reflective learning.

Literature review
Reflection is not a new concept.As early as 1933, Dewey (in Palmer et al" 1994:66) was the first educationist who wrote about reflection on experience and defined it as "looking back on what has been achieved to obtain meaning in order to intel ligently deal with further experience" (Klopper, 2000:33).Boyd and Fales (1983) suggest that reflective learning is the process of internally examining and exploring an issue of concern, trig gered by an experience, which creates and clarifies meaning in terms o f self, and which results in a changed conceptual per spective.This is similar to the explanation by Boud and Walker (1991), who consider reflection as intellectual and effective activities that individuals engage in to explore their experiences in order to lead to new understandings and appreciations.Re flection can therefore be seen as involving the self and a changed conceptual perspective or new understanding.
The importance o f reflection is reported in various studies (Patterson, 1994;Palmer, et al., 1994;Wong, Kember, Chung and Yan, 1995;Wellard and Bethune, 1996;Wong, Loke, Wong, Tse, Kan and Kember, 1997;Fonteyn and Cahill, 1998).Reflec tion can foster deep, holistic learning in students, develop criti cal thinking and promote thoughtful nursing practice.In clini cal education reflection enables nursing students to relate to aspects o f their experiences that most profoundly speak to them at that moment.Tapping into the central concerns creates the greatest potential for professional growth (Baker, 1996:22).In relation to critical thinking, which has been described as a developmental process no different from the growth develop mental process, such skills should be nurtured from early on in the professional lives of students.Critical thinking also in cludes thinking in relation to feelings, values and beliefs; it is a way of life.It involves "rationally deciding what to do or be lieve" (Norris, 1990).It has also been interpreted as "the exten sion of logic to the rational examination of controversial social, ethical, political, economic, and religious issues, such as abor tion, euthanasia and terrorism " (Bandm an and Bandm an, 1988:2).Developing critical thinking through reflection is viewed as important to promote thoughtful nursing practice and to prepare nurses as caring, em pathetic indiv id u als (Irvin, 1996:109).Reflection is im portant for holistic nursing educa tion, which prepares students for efficient moral practice as they are increasingly confronted with ethical dilem mas during their nursing practice.Teaching in a reflective environment that stimulates students to express their opinions and where they are encouraged to draw from their own experiences can achieve this.Hence encouraging students to write reflectively could improve their critical thinking skills, which are the skills necessary for ethical decision-making.
Three types of reflection can be identified: reflection-in-action, reflection-on-action and reflection-with.Reflection-in-action involves the learners challenging assumptions about their work, critically examining their present-tim e actions, and testing al ternatives that reshape what they are doing w hile they are doing it (Carkhuff, 1996:212).W hile reflecting-in-action, the individual can draw upon knowledge and experience in order to make professional judgem ents/decisions during practice.Reflection-on-action is a process through which learners look back on an action or event, critically analysing the event/ac tion and evaluating it, leading to a new perspective for future reference (Schon, 1991;Atkins and Murphy, 1993).Reflectionon-action can help an individual to make sense o f the experi ence and as such could result in learning (M ashaba and Brink, 1994;Palmer, etal., 1994;Carkhuff, 1996;Andrew, 1996).Re flection-with is done through dialogue, discourse and narra tives and focuses on the development of thinking skills.The focus of this study was on "reflection-on-action".With reference to reflective strategies, dialogue journals and journaling have been reported in the literature as effective in assisting students to reflect on their learning experiences in the clinical area (Fonteyn and Cahill, 1998).Journaling is said to enable more objective reflection of one's experiences in that it can assist the writer to distance him self/herself from the situ ation and to differentiate between what has happened and what they think has happened (Patterson, 1994;Palmer, et al., 1994;Wong, et al., 1995).Because reflective ability is necessary for practitioners to effect m eaningful developm ent and change in nursing practice, Patterson (1994) is o f the opinion that it is worthwhile for nurse educators to continue to grapple with alternative solutions and preventative m easures for the diffi culties, which may arise in the use of reflective journals.

Statem ent of the problem
Authors generally agree that reflective journaling could be uti lised to improve critical thinking skills, and hence reflective learning in student nurses.The development of these skills is an essential need since professional nurses are increasingly required to make independent decisions regarding patient man agement.Nurse educators are exploring various ways to meet this need; the use of reflective journaling reputed to be a use ful strategy during clinical education.As a clinical instructor at the time, the researcher deemed it necessary to assess the ef fectiveness o f journaling as a strategy to help students reflect on their clinical learning experiences.
Purpose and objectives of the study

Definitions
Clinical experience: The exposure of student nurses to situa tions where they encounter patients or clients.

Journals:
A notebook in which the student records experi ences encountered.In this study journals were pocket note books size A6.

Journaling:
The act o f writing in the notebook/journal.

Reflection:
The act of internally examining and analysing a clinical experience in order to lead to a new understanding or a new perspective of the situation.Reflection is integral to re flective journaling and reflective learning.

Reflective journaling:
The act of writing the experiences re flectively i.e. recalling, reviewing and analysing an event/expe rience.
Reflective learning: Occurs, upon reflection, when an indi vidual acts on a feeling induced by a clinical experience, recap tures the experience, and makes inferences, generalisations and evaluations.In this study reflective learning involved the use of the six steps in Gibbs' Reflective Cycle (Palmer, etal., 1994:66).

Research methodology
A  group.Furthermore, a quasi-experim ental design is feasible in the clinical situation where there is a potential for ethical or practical barriers (Behi and Nolan, 1996:756), hence its selec tion for this study.Unlike a true experiment, the two groups were not randomly chosen, neither were the participants ran domly assigned to their groups.

Population and sample
The target population consisted of all the first year students (N=53) registered for the Bridging Course at a Private Nursing Education Institution.These students attended the course at two separate campuses, i.e.Johannesburg cam pus (26 stu dents) and Pretoria campus (27 students).The entire popula tion was proposed for inclusion in the study.
The final study sample consisted of all those students who agreed to participate and gave written consent (n=43).Twenty out of twenty-six students at the Johannesburg campus signed consent and twenty-three out o f twenty-seven students at the Pretoria cam pus signed consent.

Constituting the groups
A non-randomized sample was selected for the two groups.
Students at the Johannesburg campus constituted the experi mental group (n = 20).These students were issued with jo u r nals and were exposed to the activity o f journaling.
Students at the Pretoria campus constituted the control group (n = 23).This separation was to avoid the possibility of cross contamination between the two groups, which was likely to have occurred had the groups been at the same campus.The students in the control group would not journal during the data collection period and would only be exposed to the activ ity o f journaling at the end of the study.The groups were non equivalent although they had similar characteristics.

Ethical considerations
Permission and ethical clearance was obtained from the uni versity's Postgraduate Committee and the Com m ittee for Re search on Human Subjects.Perm ission was requested and obtained from the Head o f the Nursing Education Institution.
Each student was provided with an information sheet explain ing what the study involved and what their role, as partici pants would entail.The participants were informed that any information obtained would be used for the purposes of the study only, and that their names would not be disclosed.Par ticipants were given an opportunity to withdraw from the study at any time without prejudice.Those students who agreed to participate were then requested to sign the consent form.
The researcher was available for consultation by the students throughout the duration of the study.This was mainly for the purpose o f debriefing.

Data collection
Students in the experim ental group were required to write anecdotes, in their jo u r nals, o f their experiences in their respective clinical areas over a period of eight weeks.
The participants were to reflect on one ex perience per week during the clinical place ment period and to analyse each experience using the guidelines provided.Palmer et al. (1994:39) find it useful to refer to G ibbs's Reflective Cycle (Figure 1) to help students to reflect.Exploration o f the cycle enables the students to identify where they are in terms o f their ability to reflect and on the part o f the tutor, reduces the risk of as sum ptions or m isinterpretation.G ibbs's R eflective Cycle (Palmer, et al., 1994) was chosen as a framework to formulate guidelines to assist the participants in reflective journaling.
The cycle involved the students answering six questions about a significant clinical experience: • W hat happened?
• W hat were my feelings and thoughts?
• W hat was good and/or bad about the experience?
• W hat is my personal interpretation o f the situation?
• W hat other ways are there to respond to the event?
• W hat have I learnt from this situation?If it arose again, what would I do?
The researcher's role was that of resource person and also to play a supportive role to encourage students to continue with the exercise despite perceived problem s or barriers.
After the eight-week period o f journaling, students in both the experimental group and the control group, were provided with a paper clinical exercise to analyse reflectively.The purpose of the exercise was firstly, to collect data in relation to the effec tiveness of journaling to prom ote reflective learning in the ex perimental group and secondly, to collect data to compare the performance o f the experim ental and control groups in reflec tive learning.
The students in the control group were introduced to the journaling activity only after they had com pleted analysing the clinical exercise.They too, were provided with guidelines for keeping a reflective journal to assist them through the reflective journaling proc ess.Their journal entries were not evalu ated as part of this study.
nal entries o f students in the experim ental group to assess their ability to journal and to compare their performance in journaling to their performance in the clinical exercise (withingroup comparison).The performance of the experimental group and the control group in the clinical exercise was also com pared (between-group comparison).Fisher's Exact Test was used to determine whether observed differences were signifi cant.The level o f significance was set at .05.

Analysis of Jo u rn a l Entries (Experim ental Group)
Using a tool with assessment criteria categorised according to the six steps in Gibbs's Reflective Cycle (Palmer et al., 1994) the journal entries o f the experimental group were marked to as sess their journaling and reflective learning abilities.The number of journal entries ranged between one and four per student.A total of 68 journal entries were marked according to whether entries were "correct" or "incorrect" .A score was calculated for each individual participant.A score of $50% was regarded as an indicator o f the students' ability to journal.The propor tion of correct responses for each of the six categories was calculated (Table 1).W ith the exception of the last item, "for mulating response in similar situations in the future", a high percentage o f students scored over 50% in the remaining re flective abilities.

W ithin-group comparison (experim ental group)
Students in both groups were required to analyse a paper clini cal exercise, reflecting their opinions and feelings about the

Issues of validity
The use of journals and journaling for data collection was validated by recent litera ture and research studies.Content valid ity o f the m arking tool w as b ased on Gibbs's Reflective Cycle (Palmer, et al., 1994) followed by peer review.

Data analysis
Data analysis involved analysing the jo u r situation.The same tool used to score the journal entries above was used to assess the students' ability to reflect on the exer cise.The performance of students in the experimental group was assessed for any differences between journaling and analy sis o f the exercise with regard to the criteria (Table 2).Although there was an overall improvem ent o f 5%-20% in the different reflective learning categories, this improve ment in scores was not significant (p >0.05).

Categories of Items
Betw een-group com parison (experim ental and control groups) A comparison between the experimental group and the control group was made to determine if there was any difference in their ability to reflect on the clinical exercise (Table 3).This would give an indication of their reflective learning ability.Since the scores in the first three categories o f description o f the experience, exploring feelings and evaluating the experience were equal for both groups, comparisons were made with re spect to the categories of analysis, exploration of alternatives and response only.The results were as follows: * There was no significant difference between the groups with regard to their ability to analyse to create meaning for self or interpret (p = 0.431) * There was no significant difference, at the .05level of significance, between the groups with regard to their ability to explore alternatives (p = 0.065).At a signifi cance level of 0.1 however, the difference would be sig nificant (p<0.1).

*
The ability o f the experimental group to outline a re sponse in future situations was significantly better than the control group (p = 0.047)

Discussion of results
After marking the journal entries of the students in the experi mental group the highest scores were obtained in "description of the event" and the lowest in "response in future similar situations".A high proportion o f students could describe the clinical events and reflect on or explore their thoughts and feelings very well (95% and 91.7% respectively).More than 60% of the students could explore alternative actions but only 45,45% were able to form ulate new responses in sim ilar situa tions in the future.These scores indicate that students had no difficulty in recalling the events in order to describe the experi ence but had increasing difficulty with the higher levels of reflection.Brown and Gillis (1999) are o f the opinion that the developm ent o f higher-level reflective activities such as these requires expanded discussions in groups where students could re-examine their viewpoints and receive immediate feedback.
The absence of group discussion, as was the case in this study, may therefore be a factor to be considered in drawing any conclusions.
The perform ance of students in the experimental group in re flective journaling was compared to how they performed in the clinical exercise.Overall, there was a 10,12% improvement on the scores obtained when analysing the clinical exercise.This improvement however, was not statistically significant (p > 0.05).It may be concluded therefore that the journaling exer cise is not related to the improvement in reflective learning.
The performance o f the control group in the analysis o f the exercise was assessed and com pared to the results of the ex perimental group.The performance of the participants in both groups was equal regarding the first three criteria.A com pari son between the two groups showed a difference in the pro portion o f correct responses obtained by the two groups in the last three categories i.e. analysis to enable interpretation/mean ing to self, exploration of alternatives of action and response in similar situations in the future.Students in the control group performed better than those in experimental group with regard to analysing the experience to create meaning for themselves.This difference however, was not significant (p > 0.05).The students in both groups obtained the lowest scores in the last two criteria, i.e. exploration of alternatives of action and re sponse regarding similar situations in future.This means that students in both groups performed poorly in the higher levels o f the reflective process.With reference to their ability to for mulate a response in sim ilar future situations the experimental group performed significantly better than the control group (p <0 .05).This level o f reflection requires students to view a phenomenon from a different perspective and to translate new knowledge and insights into action.Unless there is evidence of the development of this level o f reflection Boud and Walker (1991) caution that professionals may not be able to deal with clinical problem s intelligently.It may be concluded that journaling assists students to construct responses to clinical problems, which resemble those they have encountered as part o f the learning experience.

Recommendations Nursing Education
Journaling is encouraged as a strategy to enhance reflective learning and critical thinking.The nurse educator, as facilitator o f learning, should incorpo rate additional techniques to encourage reflection.Poor to av erage scores in higher level reflective abilities were observed in this study.Expanded group discussion (Brown and Gillis, 1999) as an example of an additional technique is recommended to facilitate the process o f outlining future response in similar situations/scenarios. Discussions of ethical dilemmas have to be frequently stimulated and incorporated in ethical decision making relevant to the clinical situations.Apart from enhanc ing reflective learning, discussions afford students an oppor tunity to debrief as well.The discussions would also create an environment in which the students would re-examine their view points and receive immediate feedback from their colleagues.The role o f the nurse educator would be to facilitate the dia logue and encourage participation.It is further recommended that nurse educators reflect with their learners as true partici pants in the learning process in order to develop the necessary expertise to support students.In this regard the role of the nurse educator is sharing experiences in order to construct meaning (Klopper, 2000:38) and giving expert support (Palmer, et al., 1994:71) when difficulties are encountered.

Research
It is recommended that further research be conducted on how the process of reflection could be facilitated to achieve higher levels of reflective thinking since the results of this study show deficient ability at this level.The assumption, as documented in journals, that reflective thinking is transferred to practice (i.e. may improve patient care), needs to be explored em piri cally for any conclusions to be made.
M ore appropriate evaluation tools should be developed to assess reflective learning and critical thinking ability o f stu dents.The assessm ent of "correct" and "incorrect" responses used in this study was inadequate to discrim inate between students' reflective abilities.Authors (Gross, Takazawa and Rose, 1987;Perciful and Nester, 1996;Kim, 1999;Platzer, Blake and Ashford, 2000) concur that critical, reflective thinking is difficult to assess empirically.A more precise, focused approach is needed to assess skills in reflection, as well as patient out comes, as an indication o f the effectiveness o f journaling.

Conclusion
This study was based on the use of journaling as one o f the strategies that could be used to improve reflective learning among nursing students.Reflective practice is a valuable tool in nursing education because independent practice demands continuing development and growth on the cognitive and af fective domains o f learning.Reflective journaling is one of the strategies that could develop learning in these domains and prom ote m indful, thoughtful nursing practice.As nursing changes to meet new societal demands, the need for improved, innovative ways to respond to these demands sensibly and professionally, will become more pressing.Reflective journaling is not the only answ er but it provides the means for profes sionals to prolong the value of knowledge by adapting and transforming knowledge to meet changing circumstances.

Figure 1 :
Figure 1 : Gibbs' s Reflective Cycle (Palm er et a l., 19 9 4 ) T he purpose o f the study w as to investigate the use o f journaling as a strategy to reflect on clinical experiences by two groups of first year Bridging Course student nurses in a Private Nursing Education Institution.The objectives were to: • assess the ability of student nurses to write reflective journals • evaluate the effectiveness of journaling as a strategy to promote reflective learning in the experimental group • compare the reflective learning ability of students who were exposed to journaling (experimental group) to stu dents who were not exposed to journaling (control group).