Reflective journal writing : How it promotes reflective thinking in clinical nursing education : A students ’ perspective

According to the outcomes-based education and training system of education (OBET) in the country and the South African Nursing Council, education should focus on “cre­ ating” reflective learners and practitioners. This article seeks to determine the effectiveness of reflective journal writing in promoting the reflective thinking of learners in clinical nursing education and to validate the guidelines described in a bigger study on how to facilitate reflective thinking using reflective journal writing. A qualitative, contextual, explorative, descriptive research design was used to determine the learners’ perceptions on whether reflective journal writing did promote their higherlevel thinking skills during the six-month placement in a psychiatric clinical practice using the reflective diaries. From a population of seventeen fourth-year students, six volunteered to participate in a focus group interview. The data was analysed by means of the descriptive method of open coding of Tesch (in Creswell, 1994:154-156). Posi­ tive and negative results from the perceptions of the par­ ticipants and a literature review served as a basis for de­ ducing and describing guidelines for the effective use of reflective journal writing in promoting reflective think­ ing in clinical nursing education. The positive perception was the development of problem­ solving skills attained through reflection by using ana­ lytical critical thinking, synthesis and the evaluation of situations. Self-evaluation leading to intellectual growth and self-awareness indicated a positive perception. Nega­ tive perceptions were that reflective journal writing is time consuming, content based with a lack of clear expecta­ tions from the teacher, and distrust of students about the information written. Guba’s model of ensuring trustwor­ thiness in qualitative research as described in Krefting (1991:215-222) was employed. It is concluded that reflec­ tive journal writing in clinical nursing education does pro­ mote reflective thinking and learning. The use of the de­ veloped guidelines will minimise the negative perceptions. It is recommended that the guidelines be used in basic training at all levels of training to attain the objective of nursing education and training, which is to produce a criti­ cal, analytical thinker through reflection to improve prac­ tice. Opsomming Na aanleiding van die stelsel van uitkomsgebaseerdeonderrig (UGO) in die land en van die Suid-Afrikaanse Raad op Verpleegkunde, behoort onderrig te fokus op die “skepping” van reflektiewe leerders en praktisyns. Hierdie artikel poog om die doeltreffendheid van reflektiewe dagboekskrywing te bepaal ter bevordering van reflektiewe denke by leerders in kliniese verpleekunde en om die riglyne wat beskryf is in ‘n groter studie oor hoe reflektiewe denke deur die gebruik van reflektiewe dagboekskrywing fa s ilite e r m oet w ord , te staa f. ’n K w alita tiew e , kontekstuele, ondersoekende en beskry wende navorsingsontwerp is aangewend om die leerders se persepsies te bepaal ten opsigte daarvan of reflektiewe dagboekskrywing hul hoervlak denkvaardighede bevorder het deur die gebruik van reflektiew e dagboeke, gedurende hul ses m aande plasing in psig iatriese kliniese praktyk. Ses studente uit ‘n populasie van sewentien vierdjaar studente het vrywillig in ‘n fokusgroep-onderhoud deelgeneem. Data is deur middel van die beskrywende metode van opekodering van Tesch (in C resw ell, 1994:154-156) ontleed. Beide positiewe en negatiewe resultate van die persepsies van die deelnemers en literatuurstudie het as basis gedien vir die deduksie en beskrywing van riglyne v ir d ie d o e ltre ffen d e g eb ru ik van re flek tiew e dagboekskrywing ter bevordering van reflektiewe denke in kliniese verpleegkunde. Positiewe persepsie was die ontwikkeling van probleem oplossingsvaardighede wat bereik is deur refleksie deur die aanwending van analitiese kritiese denke, sintese en die evaluering van situasies. Selfev a lu e rin g w at lei to t in te lle k tu e le groei en selfgew aarw ord ing , het positiew e p ersepsie aangedui. Negatiewe persepsies was dat reflektiewe dagboekskrywing tydrowend en inhoudgebaseer is, met gebrek aan duidelike verwagtinge van die leerkrag en wantroue onder studente oor die inligting wat geskryf is. Guba se model vir die v e rsek e rin g van b e tro u b a a rd h e id in k w a lita tiew e navorsing, soos beskryf in Krefting (1991:215-222), is aangewend. Daar is tot die gevolgtrekking gekom dat reflektiewe dagboekskrywing in kliniese verpleegkunde wel reflekteiwe denke en leer bevorder. Die gebruik van d ie o n tw ik k e ld e rig ly n e sal n eg a tiew e p e rsep sies minimaliseer. Daar word aanbeveel dat die riglyne gebruik word tydens basiese opleiding op alle vlakke van opleiding om die doelwit van verpleegkunde en opleiding te gebruik d. w.s om, deur refleksie, ‘n kritiese, analitiese denker voort te bring, sodat praktyk verbeter kan word. 35 Curationis August 2002 Background and rationale Thinking skills develop as students make explicit their ways of thinking, hear alternative ways of thinking, and reflect on their thinking. According to Costa (1991:12), the focus of a teacher’s attention should not be on teaching students to think in a particular way, but on helping them explore and reflect on the thinking processes they already use. As teachers, he stated, our challenge is to understand the way students are making sense of things, the logic they are using, and the sources of information they are drawing upon. There are nu­ merous ways in which we can create an atmosphere that al­ lows students to reflect on their own thinking and promote reflective learning, and reflective journal writing is one of them. Reflective learning, according to Boyd & Fales (1983:100), is the process of internally examining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of the self, and which results in a changed conceptual perspective. Reflective learning is the key element in learning from experience. Reflective learning places the emphasis on the self as the source of learning and is inherently an individual and interactive process. According to Wong; Kember; Chung & Yan (1995:50) re­ flective journal writing involves a reflective process that is initiated when the learner documents the experience encoun­ tered, returns to the experience, recollects what has taken place and replays the experience, and re-evaluation takes place. Wong et al (1995:53) view the process of re-evaluation as involving association (relating new information to that which is already known), integration (seeking relationships among the data), validation (determining the authenticity of the ideas and feelings that have resulted) and appropriation, which entails making knowledge one’s own. From the explanations of reflective learning and reflective journal writing, it becomes clear that the underlying dynamic of reflective journal writing is interaction. This is in line with the expectations of outcomes-based education and training. Central to OBET is reflective learning, in which the empha­ sis no longer falls on memorising factual knowledge, but on collaborative interaction to develop reflective thinking skills and learning in clinical nursing education to improve prac­ tice and develop lifelong learning skills. The emphasis falls on embedding quality problem-solving skills rather than on memorising a given amount of scientific information. The teaching and evaluation methods at all levels and in all pro­ grammes of education and training should encourage reflec­ tive and critical thinking, the ability to ask thought-provok­ ing questions, to stimulate an enquiring mind, to develop rea­ soning skills, to communicate effectively and to form judge­ ments (Pretorius, 1998:3,5). The South African Nursing Council policy on nursing educa­ tion (1993:6) states that the purpose of nursing education pro­ grammes should be the development of the learners’ ability regarding analytical, critical, evaluative and creative think­ ing and the continuing stimulation of the learners’ capacity to interpret scientific data for nursing actions, to draw con­ clusions and to exercise independent judgement. They expect nurse who can practise independently and take responsibility for their actions; nurses who can evaluate themselves and who can develop themselves personally and professionally; and who can question and approach problems scientifically for the purpose of effective practice. Thus, professional edu­ cation should aim at preparing professionals who can ulti­ mately apply theoretical knowledge to practice in the real world (Wong et al 1995:48). From literature, we learn that reflective journal writing is one of the learner-centred teaching strategies that can promote the learner’s critical and reflective thinking (Rolfe; Freshwa­ ter & Melanie, 2001:23; Costa & Lowery, 1989:90; Wong et al, 1995:53 and Chabeli, 2001:269). Final-year students fol­ lowing a comprehensive four-year degree leading to registra­ tion with the SANC as a nurse (general, psychiatric and com ­ munity) and midwife where expected to use reflective diaries to enter their daily experiences in a psychiatric unit were they were placed for six months for their clinical practice. Stu­ dents were given guidelines on how to use reflective journal writing as a teaching strategy to gain clinical knowledge. They were expected to submit the dairies at the end of the sixmonth period for evaluation. In spite of the guidelines, the percep­ tions of the students who participated in the study indicated that the students did not use the strategy appropriately. Many students completed their journals only the night before they had to be submitted. They had to remember most of what had happened over six months in one night. Some journals were only summaries of what had happened every day or every week with no details. As a resul

The positive perception was the developm ent of problem solving skills attained through reflection by using ana lytical critical thinking, synthesis and the evaluation of situations.Self-evaluation leading to intellectual growth and self-awareness indicated a positive perception.Nega tive perceptions were that reflective journal writing is time consuming, content based with a lack of clear expecta tions from the teacher, and distrust of students about the information written.G uba's model of ensuring trustw or thiness in qualitative research as described in Krefting (1991:215-222) was employed.It is concluded that reflec tive journal w riting in clinical nursing education does pro mote reflective thinking and learning.The use o f the de veloped guidelines will minimise the negative perceptions.It is recom m ended that the guidelines be used in basic training at all levels of training to attain the objective of nursing education and training, which is to produce a criti cal, analytical thinker through reflection to im prove prac tice.
Opsomming N a aanleiding van die stelsel van uitkom sgebaseerdeonderrig (UGO) in die land en van die Suid-Afrikaanse Raad op Verpleegkunde, behoort onderrig te fokus op die "skepping" van reflektiewe leerders en praktisyns.Hierdie artikel poog om die doeltreffendheid van reflektiew e dagboekskrywing te bepaal ter bevordering van reflektiewe denke by leerders in kliniese verpleekunde en om die riglyne wat beskryf is in 'n groter studie oor hoe reflektiewe denke deur die gebruik van reflektiewe dagboekskrywing f a s ilite e r m o et w o rd , te sta a f.'n K w a lita tie w e , kontekstuele, ondersoekende en beskry wende navorsingsontwerp is aangewend om die leerders se persepsies te bepaal ten opsigte daarvan of reflektiewe dagboekskrywing hul hoervlak denkvaardighede bevorder het deur die gebruik van reflektiew e dagboeke, gedurende hul ses m aande plasing in p sig ia triese kliniese praktyk.Ses studente uit 'n populasie van sewentien vierdjaar studente het vrywillig in 'n fokusgroep-onderhoud deelgeneem.Data is deur middel van die beskryw ende metode van opekodering van Tesch (in C resw ell, 1994:154-156) ontleed.Beide positiewe en negatiewe resultate van die persepsies van die deelnemers en literatuurstudie het as basis gedien vir die deduksie en beskrywing van riglyne v ir d ie d o e ltre ffe n d e g e b ru ik van re fle k tie w e dagboekskrywing ter bevordering van reflektiewe denke in kliniese verpleegkunde.Positiewe persepsie was die ontw ikkeling van probleem oplossingsvaardighede wat bereik is deur refleksie deur die aanwending van analitiese kritiese denke, sintese en die evaluering van situasies.Selfe v a lu e rin g w at lei to t in te lle k tu e le g ro ei en selfg e w a a rw o rd in g , het p o sitie w e p e rse p sie a an g ed u i. Negatiewe persepsies was dat reflektiewe dagboekskrywing tydrowend en inhoudgebaseer is, met gebrek aan duidelike verwagtinge van die leerkrag en wantroue onder studente oor die inligting wat geskryf is.Guba se model vir die v e rs e k e rin g van b e tro u b a a rd h e id in k w a lita tie w e navorsing, soos beskryf in Krefting (1991:215-222), is aangewend.D aar is tot die gevolgtrekking gekom dat reflektiewe dagboekskrywing in kliniese verpleegkunde wel reflekteiwe denke en leer bevorder.Die gebruik van d ie o n tw ik k e ld e rig ly n e sal n e g a tie w e p e rse p sie s minimaliseer.Daar word aanbeveel dat die riglyne gebruik word tydens basiese opleiding op alle vlakke van opleiding om die doelwit van verpleegkunde en opleiding te gebruik d. w.s om, deur refleksie, 'n kritiese, analitiese denker voort te bring, sodat praktyk verbeter kan word.

Background and rationale
Thinking skills develop as students make explicit their ways of thinking, hear alternative ways of thinking, and reflect on their thinking.According to Costa (1991:12), the focus of a teacher's attention should not be on teaching students to think in a particular way, but on helping them explore and reflect on the thinking processes they already use.As teachers, he stated, our challenge is to understand the way students are making sense o f things, the logic they are using, and the sources of information they are drawing upon.There are nu merous ways in which we can create an atmosphere that al lows students to reflect on their own thinking and promote reflective learning, and reflective journal writing is one of them.
Reflective learning, according to Boyd & Fales (1983:100), is the process of internally exam ining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms o f the self, and which results in a changed conceptual perspective.Reflective learning is the key element in learning from experience.Reflective learning places the em phasis on the self as the source of learning and is inherently an individual and interactive process.
According to Wong; Kember; Chung & Yan (1995:50) re flective journal writing involves a reflective process that is initiated when the learner docum ents the experience encoun tered, returns to the experience, recollects what has taken place and replays the experience, and re-evaluation takes place.Wong et al (1995:53) view the process of re-evaluation as involving association (relating new information to that which is already known), integration (seeking relationships among the data), validation (determ ining the authenticity o f the ideas and feelings that have resulted) and appropriation, which entails making knowledge one's own.
From the explanations of reflective learning and reflective journal writing, it becomes clear that the underlying dynamic of reflective journal writing is interaction.This is in line with the expectations of outcom es-based education and training.Central to OBET is reflective learning, in which the em pha sis no longer falls on memorising factual knowledge, but on collaborative interaction to develop reflective thinking skills and learning in clinical nursing education to improve prac tice and develop lifelong learning skills.The emphasis falls on embedding quality problem -solving skills rather than on memorising a given am ount o f scientific information.The teaching and evaluation methods at all levels and in all pro grammes of education and training should encourage reflec tive and critical thinking, the ability to ask thought-provok ing questions, to stimulate an enquiring mind, to develop rea soning skills, to communicate effectively and to form judge ments (Pretorius, 1998:3,5).
The South African Nursing Council policy on nursing educa tion (1993:6) states that the purpose of nursing education pro grammes should be the developm ent of the learners' ability regarding analytical, critical, evaluative and creative think ing and the continuing stimulation of the learners' capacity to interpret scientific data for nursing actions, to draw con clusions and to exercise independent judgem ent.They expect nurse who can practise independently and take responsibility for their actions; nurses who can evaluate them selves and who can develop themselves personally and professionally; and who can question and approach problems scientifically for the purpose o f effective practice.Thus, professional edu cation should aim at preparing professionals who can ulti mately apply theoretical knowledge to practice in the real world (Wong et al 1995:48).
From literature, we learn that reflective journal writing is one of the learner-centred teaching strategies that can promote the learner's critical and reflective thinking (Rolfe;Freshwa ter & Melanie, 2001:23;Costa & Lowery, 1989:90;Wong et al, 1995:53 andChabeli, 2001:269).Final-year students fol lowing a comprehensive four-year degree leading to registra tion with the SANC as a nurse (general, psychiatric and com munity) and midwife where expected to use reflective diaries to enter their daily experiences in a psychiatric unit were they were placed for six months for their clinical practice.Stu dents were given guidelines on how to use reflective journal writing as a teaching strategy to gain clinical knowledge.They were expected to submit the dairies at the end of the six-month period for evaluation.In spite of the guidelines, the percep tions of the students who participated in the study indicated that the students did not use the strategy appropriately.Many students completed their journals only the night before they had to be submitted.They had to remember most of what had happened over six months in one night.Some journals were only summaries o f what had happened every day or every week with no details.As a result, the objective of the exercise was not met by some students.Hence, the purpose o f this article is to describe the guidelines to im prove the im plementation of reflective journal writing as a teaching strategy to promote reflective thinking in clinical nursing education in order to have what Shields (1995:452) refers to as "know ledgeable doers" .(1995: 425) is o f the opinion that clinical practice needs "knowledgeable doers".It is therefore imperative that teachers focus on using learner-centred teaching strategies that are learner friendly, such as reflective journal writing to promote reflective thinking and learning to improve prac tice.However, from the perceptions o f the students who par ticipated in the study, it appears that some student nurses in question did not use this method (reflective journal writing) to promote thinking skills properly, as evidenced by:

•
Only completing the diary the night before the sub mission date.
• Only factual content or summaries o f what had hap pened were written.
• They were not motivated to do it -they only did it to obtain examination marks.
The following research questions emerged from the problem statement: 1. W hat is your perception with regard to the use of reflective journal writing to promote reflective thinking in clinical nursing education?2. How can the use o f reflective journal writing prom ote reflective thinking in clinical nurs ing education?
The objectives of the study The objectives of the study are as follows: • To explore and describe the perceptions o f learners regarding the use of reflective journal w riting to pro mote reflective thinking skills in clinical nursing edu cation.

•
To describe guidelines on how to effectively use re flective journal writing to prom ote the learner's re flective thinking skills in clinical nursing education.

Definitions of central concepts Reflection
Reflection is the process o f creating and clarifying the m ean ing o f experience (present or past) in terms o f the self (the self in relation to the self, and the self in relation to the world).
The outcome o f the process is a changed conceptual perspec tive (Boyd & Fales: 1983: 111,112).

Reflective learning
Reflective learning, according to Boyd & Fales (1983:110), is the process of internally exam ining and exploring an issue o f concern, triggered by an experience, w hich creates and clarifies meaning in terms of the self, and which results in a changed conceptual perspective.Reflective learning is the key elem ent in learning from experience.R eflective learning em phasises the self as the source o f learning and is, there fore, inherently an individual and interactive process.

Reflective journal writing
Reflective journal writing is a teaching strategy whereby stu dents w rite their experiences and feelings 'uncensured' in their own w riting style for further reflection and analysis (Heath, 1998:593) The reflective journal is used by both the educator and the student in the clinical setting to learn and assess the progress of the learner towards acquiring the skills o f self-directed learning.This method of teaching invites the student to be creative in identifying personal learning needs and designing learning experiences (Stark in R iley-Doucet & W ilson 1997:965-966).T h e learners thus select aspects of a clinical experience that are noteworthy or m eaningful to them and write them down in diaries (Boykin & Schoenhof in Paterson 1995:211).

Reflective thinking
Reflective thinking is a rational, reasonable thinking im ple mented by m ental discipline.During a reflective activity one turns one's thought back upon an existing idea o f knowledge that may have taken to be some degree dependable (Biggae & Sherm is 1992:276).R eflective thinking em ploys thinking skills such as analysis, synthesis and evaluation to reach a conceptual change (Atkins & Murphy, 1993:1190).

Curationis Clinical context
The clinical context is a dynamic, multipurpose real-life en vironment that is constantly changing, in which theoretical knowledge is integrated with practice.It provides the learner with a meaningful, authentic and humane experience (Chabeli 2001:150).

Learner
In this study, the learner will refer to the final year BCur (bachelor's degree in nursing science) student at a university in Gauteng.On completion o f the four-year comprehensive course, the student will be able to register with the South African Nursing Council (SANC) as a nurse (general, psy chiatric and community) and midwife.

Research design and method
A qualitative, contextual, explorative and descriptive research design was used (Mouton & M arais, 1994:43-44) where the results o f the focus group interview controlled by literature served as a basis for the description o f the guidelines for the effective im plementation of reflective journal writing in clini cal nursing education to prom ote reflective thinking.

Research Method
The research method constitutes the population, sample and sampling, data collection method and data analysis (Bums & Grove, 1993:578-579).From a population of seventeen fourthyear students undergoing a four-year com prehensive course, six students volunteered to participate in a focus group inter view Morgan & Krueger (1998:29-35) to explore and describe their perceptions with regard to the use of reflective journal writing as a teaching strategy to prom ote reflective thinking.
The six students gave a written consent, and their confidenti ality and anonymity were ensured.The group was placed in a psychiatric institution for six months to gain their clinical knowledge and skills.They were given guidelines to use re flective journals to write their experiences and to submit the diaries at the end of their six months clinical placement.
The author of this article was one o f the group members.She decided to conduct the study on the effectiveness o f reflective journal writing in promoting reflective thinking among her peers with the aim of describing guidelines to improve its im plementation in future as part o f the requirement for the research project.The author did not take part in the focus group interview, but collected the field notes as the interviewer, who was purposively selected because o f his expert interview ing skills, conducted the interview.
This method allowed members of the group to describe their perceptions about reflective journal writing as a teaching strat egy to promote thinking skills freely and allowed group in teraction to generate ideas on how reflective journal writing should be used to facilitate reflective thinking.The inter view was conducted in Afrikaans, as all the participants were Afrikaans speaking.The data was later translated to English.Two questions were asked during the focus group session: W hat are your perceptions regarding the use of reflective jour nal writing to promote reflective thinking skills in clinical nursing education?How can the use of reflective journal writ ing promote reflective thinking in clinical nursing education?A tape recording was used with their permission.
The participants were asked not to use their names for the sake of confidentiality.This form ed part o f the ground rules that were established by the participants and the interviewer., 1994:154-156) by the researcher and the independent coder who was purposively selected on the basis of her knowledge of psychiatry and quali-engagem ent over a period of six months involved with w rit ing reflective journals to integrate theory with practice, keep ing reflexive field notes, member checking through a litera ture control by using findings of sim ilar studies on reflective journal writing.Triangulation of sources added to the cred ibility o f the study.
Dependability was achieved through a dense description of the data, audit trail and use of a co-encoder in the data analy sis process by using Tesch's protocol.Transferability was en sured by a sample from volunteered students, dense descrip tion o f the method and a literature control.Confirm ability was ensured by an audit trail and reflexivity (K refting, 1991:215-222).

Findings and discussion of the findings
Table 1 provides an overview of the major themes and sub themes o f the perceptions of the participants with regard to the use of reflective journal writing to promote reflective think-

Measures to ensure trustworthiness
G uba's model (in Krefting, 1991: 215-222) for ensuring trust worthiness based on the suggested strategies of credibility, transferability, dependability and confirm ability was used.
Credibility was ensured through the researcher's prolonged ing in clinical nursing education.Two m ajor themes were identified as positive and negative perceptions with regard to reflective journal writing in clinical nursing education.The main positive sub-theme was that reflective journal writing promotes problem -solving skills through reflection by using critical, analytical thinking skills, synthesis and evaluation.
The second one is self-evaluation, intellectual growth and self awareness.The learners are able to integrate theory with prac tice.The negative sub-them es were that reflective journal writing is time consuming, and content based, the expecta tions from the students are not clear and there is a lack of trust.Direct quotes from the participants will be provided in italics.

Positive perceptions Problem-solving skills
The participants were of the opinion that reflective journal writing facilitates their problem -solving skills in integrating theory with practice as evidenced by: "7 fe e l the writing o f a reflective journal is important and it works " The participants further stated: " Costa, (1991:4,5) believes that reflective journal writing in creases the opportunity for problem solving during the verbal interaction of experiences between the teacher and student peers.Students develop listening skills, co-operative learn ing, thought-provoking enquiring discussion, dialogical rea soning and brain-storming abilities.Costa (1991:27) further states that to process data acquired or observed into m eaning ful relationship, the student must be drawn to the higherorder thought processes, such as critical analyses, synthesis and evaluation.
The teacher must provide an enabling and a motivating envi ronm ent o f support and guidance that is non-judgem ental, an environm ent in which a student can verbalise innovative ideas that she/he has experienced by using all the senses, the main purpose being to develop their intellect.C osta (1991:5) places more emphasis on more time spent on dialectic discussion im m ediately after the experience is w ritten in the diary to facilitate student growth in reflective thinking.
The use o f reflective journal writing has been widely reported in nursing literature as an effective strategy for assisting stu dents to reflect about learning experiences in the clinical area (Paterson, 1995:211).The central point of reflection in learn ing is experience (Reid, íq Wong et al 1995:49).Experience alone is, however, not the key to learning.Learning from experience involves reflection (Wong et al, 1995).The cog nitive activities include making inferences, discriminating and associating relationships, and validating assumptions.R e flection generally involves higher-order mental processes at the conscious level M ezirow et al (in Wong et al 1995:49), which should be used in the discussion period of reflective journal writing.
• Self-evaluation, intellectual growth and self-awareness Many learners thought that reflective journal writing had value for themselves and that it could be useful in self-evaluation, intellectual growth and self-awareness, as indicated: "It is personal; it is about your personal intellectual growth, over coming your own problems "A t the end o f the da,y I benefit from it... it makes me grow intellectually and personally "; "I also think it makes you more mature and it helps you to han dle a situation more professionally...

"Self-assessment plays an integral part in the facilitation o f reflective thinking because it forces the learners to reflect back on their thoughts and actions. It is important fo r self regulated learning since it prom otes the lea rn er' s sense o f ownership and responsibility", stated the participants. " When you reflect back on your reflective journal, you fe e l good that you were able to write yo u r experience and feelings. Whether it is the correct information or not, that will be clari fie d by the teacher and other students during the discussion session
The progressive skills of self-reflection and critical thinking are fundamental to the developm ent of the self-directed learn ing process (Newell in Riley-Doucet & W ilson, 1997:964 965)."We develop analytical critical thinking skills as we debate and argue situations in an effort to connect and relate different experiences by different students.When we justify our thinking, we verbalise our thinking loudly, and fellow students can criticise you and thus growth in thinking devel ops ".
Self-awareness means having a deep understanding of one's emotions, strengths and weaknesses, because individuals have the ability to stand back and look at themselves.However, the issue is not so much about w hether we have the ability to understand ourselves, but rather how we use the information available to us to reflect on our actions (Palmer; Bums & Bulman, 1994:102).Walker (in Shields 1995:453) states that students are visited by their own moral dilemmas in the course of their work and they have to resolve them in a way that they find satisfying in a free and supporting environment.The resultant learning will be of a personal nature and will not be easily predicted.Self-directed learning prom otes proactive rather than reac tive thought and reactions, and leads to greater personal and professional self-awareness of growth and development.It can be concluded that reflective journal writing should promote reflective thinking skills which will be used for the integra tion of theory and practice, to develop sound problem -solv ing skills by using the process of reflection through the em ployment of critical and analytical thinking skills, synthesis and evaluation.
It can also be inferred that reflective journal writing, when used correctly, should lead to self-evaluation, intellectual growth and self-awareness.Riley-Doucet & Wilson (1997:965 966) describe the three-step m ethod o f self-reflection using reflective journal writing encom passing the critical appraisal phase, peer group discussion and the self-awareness phase.The guidelines for em ploying reflective journal writing will be described fully by using the empirical data controlled by literature using the three phases as described by (Riley-Doucet & Wilson 1997:965-966).

Negative perceptions • Time Consuming
Two o f the participants were of the opinion that: "It was a big waste o f tim e...I have better things to do than to write a jo u r n a l"; "A t the end, we fe lt we d id n 't want to make time f o r it".For learners to appreciate reflective journal writing, the allocation o f sufficient time and space for reflecting on experiences is impor tant and would enhance the reflective process accord ing to (Boud et a lJn Wong et al 1995:50).
It seems reasonable to hold that writing immediately after the experience can help a student capitalise on the experience of having been in the situation.It helps the student to differen tiate between what she/he thinks happened and what really happened, because the student "revisits" the experience later while the experience is still freshly rem embered to be dis cussed at the end of the working shift.However, if the stu dent depends on memory, potential learning is likely to be lost (Shields. 1995:453).

• Lack of clear expectations
Some participants experienced negative feelings to wards writing reflective journals, because they did not have a clear picture o f the goals, objectives or their expectations regarding reflective journal writing.Fur thermore, they felt that they did not have a choice in the situation and it had no meaning to them, as stated: "I didn't have any need to complete it"; "I only wrote it because we had to hand it in "; "I experienced it as a sclilep... "; "It is an effort to fill it in "; "I looked at it and realised that I d id n 't understand...I d o n 't think they ever explained to us exactly how to do it, I had no clue... ".
In a study on reflective journal writing conducted by Cameron & Mitchell;Carswell & Fulw iler ( in Paterson, 1995:211), it is stated that not all students responded positively to journal writing as a learning tool.Some students complained bit terly about the requirements that they write and submit weekly journals to their teachers.Others begin by writing enthusias tically in their clinical journal, but after several weeks, they become noticeably indifferent to the activity (Cassidy & Luxton in Paterson. 1995:211).Some students regard journal writ ing as "busy work", unworthy o f attention or effort usually reserved for examinations and academic papers (Blough & Berman in Paterson. 1995:211).The negative feelings o f stu dents concerning the use o f reflective journal writing may be overcome by the effective use o f the strategy using the de scribed guidelines.
The reflective process involves both feelings and cognition, which are closely interrelated and interactive.The feelings may be positive or negative.Intensive personal feelings are also present towards the end stage of the reflective process (Mezirow et al in.W ong et al 1995).It is therefore imperative that, for learning and thinking skills to be promoted, teachers should explain the purpose of the journals with clear instruc tions in a language the learners can understand and set ex pectations for both the teacher and the learners.This can be practised in class before the actual experience in the clinical setting.By doing this the learners are likely to feel positive and confident about the writing o f the journals.1995:212).
The researcher's interpretation o f this situation is that when learners do not understand the purpose and process o f reflec tive journal writing, the reflective journal only becomes a di ary of events and not a journal in which to reflect and from which to learn.This can be addressed by explaining the proc ess and purpose o f reflective journals and giving examples of reflective entries from previous years for learners to under stand what is expected from them.Another way is to conduct debriefing sessions and give continuous support, guidance and feedback.The learners will feel at ease to write what they feel if they know that it will be dealt with in a non-intimidating environment.It will also help if they know it will not affect their exam ination marks, that the content will not be used against them, especially their em otions and there will be no discrimination against them because of what they wrote.It is therefore concluded that reflective learning and thinking can take place only in an environment that is conducive to thinking and learning.Such an environment can be created by keeping the journals anonymous and confidential; build ing a relationship o f trust before requesting a reflective jo u r nal to be written and informing the learners on who is going to read the journal.The learners should develop a sense of trust, independence and ownership of their learning.

Description of guidelines for the effective use of reflective journal writing to promote reflective thinking
As indicated in the text, guidelines will now be described according to the identified perceptions by the participants and supported by literature.The guidelines will be described within the fram ew ork of Reilly-Doucet & W ilson, (1997:965-966) in three phases (critical appraisal, peer group discussion, self awareness and self-evaluation).

Critical appraisal
• The teacher should explain the purpose o f the journal with clear expectations in a language that the learners will understand.Set expectations for both the teacher and the learner.

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The teacher should give the learners guidelines and a good exam ple o f a reflective journal entry from previ ous groups ju st to give them insight into w hat is ex pected from them.A scenario can be developed and role-played for more clarity on the expectations.

•
The teacher should conduct a briefing session with the learners to make them feel com fortable in using the strategy.Explain that they are given freedom to in clude descriptions, emotional reactions and cathartic reflections o f their experiences.Their know ledge and feelings will be respected.
• Learners should be allowed to use their own individual writing styles.
• There must be no refinem ent for an academ ic format.
• Emphasis is placed on writing for the sake of the learn e r's own intellectual growth."Write your thoughts, feelings and em otions according to your interpreta tion o f the situation" .
• The teacher should allow adequate time and space for the learners to com plete the journal entries im m edi ately after they have experienced the learning event or activity, which will be discussed later at the end o f the working shift.

Peer group discussion
The purpose of this phase is to enhance reflective learning by strengthening the link between the learning experience and the reflective activity through dialogic discussion.
• The teacher should explain to the learners what is ex pected in this stage o f peer group discussion.

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The teacher should provide a supportive climate for the discussion, a climate of trust, respect and empathetic understanding.
• Allow the learners to discuss the practical and realis tic aspects of their experiences freely.
• Stimulate the learners' cognitive activities by allow ing them to make their own interpretations and infer ences.Discriminate and distinguish what has happened with what was supposed to happen.Make associations o f relationships and validate assumptions.
• These reflective processes will be made possible by encouraging dialogue, discourse and argumentation to justify their opinions in a rational manner.
• The teacher should act as a resource person encourag ing the learners to express their views and to help with the integration of a theoretical perspective with their experience.
• The teacher must be available for student guidance and support at all times

Self-awareness to self-evaluation
This phase concludes the process of reflective journal writ ing.The learners undertake a self-assessment and evaluation o f their experience and consider the experience from a differ ent dimension, that is, they adopt a holistic approach to the learning experience.
• After the discussion, the teacher should allow the learn ers to complete their reflective journals meaningfully and independently.

•
The learners are expected to document aspects of their own learning as an outcome o f group discussion.They use subject-related references, their textbooks, subject experts and documents in the unit to analyse clinical incidents in relation to their own learning.This pro vides a higher-order reflection by the learners as they engage in the dynamics of self-reflections and acquire the skills o f self-evaluation.

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The learners use the w ritten document for the final evaluation and measure their progress in meeting the expected clinical learning outcomes of a specific con tent.

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The facilitator and peers provide a positive and con structive feedback from their knowledge and perspec tive to add value to the experience.
• Reflective journals should be learner friendly.Learn ers should feel free to exam ine and reflect on their experiences thoughtfully and honestly without fear of judgem ent or reprisal by the teacher.
• Reassure learners that what they have written will not be used against them.They will not be discriminated against because o f what they have written.
• The content of the reflective journals will be kept con fidential by the teacher.Learners should have hope and a sense of trust and ownership of their work.

Lim itations of the study
The entire population did not participate in the focus group, other themes that could have emerged.The population con stituted only six students at one university in Gauteng, which makes the generalisation o f the findings difficult.The re searcher experienced a lack of tim e to spend on the research, as she also had other subjects and practical work to do during the research period.

Recommendations
The researcher recomm ends that this study be replicated at other universities and on learners of different year groups to determine the effectiveness of reflective journal writing in promoting reflective thinking in clinical nursing education, and that the guidelines be implemented in order to have knowl edgeable and reflective practitioners.

Conclusion
This study has a significant contribution in nursing educa tion.The researcher has described the perceptions of finalyear nursing students on the use o f reflective journal writing in prom oting reflective thinking skills in clinical nursing education.A literature review to control the findings was used.G uidelines on how this teaching strategy could be im ple mented to promote the learner's reflective thinking are de scribed.Teachers and students should reach out to assure quality education by using varied learner-centred teaching strategies such as portfolios that could facilitate reflective thinking and consequently im prove practice.The time has come to stop the lip-service and to promote action.More of the evidence-based guidelines of other reflective teaching strat egies are welcom ed in nursing education.
The interview er used probing, follow -up questions, openended questions, unplanned and serendipitous questions, nod ding, minimal verbal responses, and encouraged the less ac tive participants while conducting the interview.The inter viewer continued with the interview until saturation of data was reached.The researcher took comprehensive field notes, noting the participants' group dynam ics, such as verbal and non-verbal com m unication, key issues, facts and opinions, feelings and emotions.The entire focus group lasted approxi mately one hour.Data was analysed by means of the descriptive method of open coding as described by Tesch (in Creswell

Table 1 :
An overview of major themes and sub-them es of perceptions with regard to the use of reflective journal writing to promote reflective thinking skills in clinical nursing education the skill o f reflection.A safe en vironment is one in which the students are free to ex amine and reflect on their work with patients thought fully and honestly, without fear o f judgem ent or re prisal.There should be trust, respect for and support and an empathetic understanding o f the students' ef-forts.Reflective journal writing is described as being student friendlyIshida et al (in Riley-Doucet & W ilson, 1997:965)and it should establish a co-operative, educator-student rela tionship built on a model of mentorship (M cAlpine inRiley- Doucet & W ilson, 1997:965).