Clinical Education for Nursing Student: Express Journaling and Thematic Analysis

Educators effort in planning for Clinical Education for Nursing Student and Student Perception in educational and clinical settings. And how to toady’s students perception about clinical education and learning.

Express Journaling and Thematic Analysis and Clinical Education for Nursing Student

Expressive Journaling

The nursing student has a reciprocal interaction with the clinical environment. As the student prepares for the upcoming clinical experience (patient assignments, complex procedures, medication administration, etc.), the student appraises the potential for personal growth (challenge) or if the stimulus is incongruent with established goals (threat). For example, the student may be assigned to a client who receives multiple intravenous medications and treatments.

Although the nursing instructor may perceive this assignment as a positive learning experience, the nursing student may feel threatened by the complexity of the assignment (threat apperception) and begin to experience feelings of anxiety or threat. The perception of the experience as incongruent to the successful attainment of positive outcomes can immobilize learning. Basically, the student fears that failure to perform successfully will result in a failing grade.

Expressive writing is an active process that enables the individual to express feelings of stress through affective discharge. It allows the student to “slow down” the velocity and intensity of the perceived threat. Furthermore, expressive writing allows an individual to distance or briefly circuit the emotional intensity of a threatening stimulus through reframing (Eckstein, 1997).

Written language is instrumental in reframing threat apperception. It can change the conceptual or emotional meaning of the context in which threat is experienced. Expressive writing enables the student to simply write about thoughts, feelings, and emotions before clinical education. It also prompts students to think about potential coping strategies and transcribe them into written language (Pennebaker, 1997).

Expressive writing is effective when used before a clinical education experience. Typically, nursing students are given client assignments the day before the experience. Once they have researched the client’s chart, they begin to prepare for the upcoming experience. Based on the complexity of the case, students’ anxiety may increase. They may perceive the complex procedures as a threat. Instructors who use expressive writing ask the students to think about the upcoming experience.

On the evening before clinic, the following prompt is given: Today, I want you to reflect on your deepest feelings and thoughts about going into the clinical setting tomorrow. In writing, you may want to explore your thoughts about what you may experience as you care for your client. Write about those feelings and do not censor your thoughts or emotions. Don’t worry about spelling or grammar. Let your feelings come to life as you transform them into written language.

Write for approximately 20 minutes. Students may become anxious as they identify their anxieties. In order to prevent their anxieties from immobilizing learning, students are asked to approach the day proactively. In order to accomplish this task, they are asked to problem solve by identifying three things they may want to do that will help deal with any stresses, threats, or challenges that may occur during the clinical experience. Students who are able to reframe the experience may perceive the once threatening experience as a challenge. The student may perceive the clinical education experience as a challenge in which mastery and success can occur.

Reflective Journaling

Journaling has long been used by educators as a way to process and assimilate personal experiences into knowledge. In the 1980s, instructors assigned process recordings, which were basically objective logs of the students’ activities during the course of a clinical experience. Once written, students were asked to revisit the written logs and interpret the events in a prescriptive way.

The directives for this assignment were often self-limiting; Consequently, the student fell into the trap of writing for the instructor as opposed to writing for self-understanding. In the early 1990s, Heinrich (1992) developed a model for a dialogue journal. The concept of this model was to encourage students to “write themselves into understanding” (p. 17).

Students are often consumed with the activities within a clinical experience, such as completing procedures, delivering medications, and providing nursing care. Concurrently, the instructor is trying to meet the learning needs of the students and collaborate with the nursing staff. Meaningful dialogue between student and instructor can become almost nonexistent. Post-conferences, a 30 to 45 minute meeting with the nursing students following a clinical practicum, were once thought to be the arena whereby students could process the events of the day.

Ironically, instead of assimilating the experiences, students are often distracted and unable to focus. They can relate a log of their “hands on” experiences and tasks, but they may be unable or reluctant to share the meaningful experiences they have shared with a patient and the family. Possibly, the interaction may have been too personal, and the student hesitates to disclose the experience because of a sense of heightened vulnerability. Inner discomfort may be the result of an unsettling life experience yet, may result in deriving new meaning or knowledge.

The right time to process and reflect may occur on the drive home from the experience or late in the night as the student tries to sleep. Just as nursing students need to reflect, so do instructors. The instructor may be working with a student and an assigned patient and notice connections between the patient and the student to which the student is oblivious. How many times has an instructor made a mental note to share an observation with a student just to forget about it?

The “pearl of wisdom” is lost and the student does not benefit. Unfortunately, instructors may become caught up in praising or criticizing students’ performance as they relate to tasks and fail to see the uniqueness of the student. A reflective dialogue helps both student and instructor to not only process experiences of the day but also to create a unique connection. Both partners in the dialogue assume responsibility for sharing insights, thoughts, and ideas.

Students no longer reflect on their day and submit their reflection to their instructor only to have the instructor make comments on the grammar and end the paper with a “Good job!” Instead, students are told to write with abandon and not censor their thoughts. Concurrently, the instructor must be open to the student’s thoughts and remain nonjudgmental. Also, the objective is not to use this forum as an evaluative process but rather to facilitate learning. Students are given some direction regarding completion of this assignment.

Journaling is a therapeutic and educational process; Therefore, students must complete the writing exercise within 24 hours of the experience. The rationale is that insights and emotions should be put onto paper as soon as possible to enable the student to relive the experience while it is still fresh in her mind. Inner dissonance often triggers meaningful reflection.

Once the student begins to establish preconceptions, the risk for misconceptions increases. Sometimes, the simple process of putting one’s thoughts or anxieties onto paper can help the student distance themselves from the emotion associated with the experience. Self-discovery occurs by “seeing ourselves and our reactions to life experiences as clearly as possible” (Selling, 1998, p. 13). Anxieties may be expressed and new inquiries may be formulated. Students may be encouraged to “journey back” and revisit the entries at a later date.

They may notice that the experience has been reframed and look at the experience from a different perspective. New meaning can be found by looking at an event with a different lens. Students are advised to find a comfortable, private place to write; write with abandon; not censor thoughts, spell check, or count words. This is probably the one scenario where imperfection in writing is allowed. It is imperative that students find the right time to write.

For example, students report being unable to sleep after a meaningful clinical experience and purge themselves of their thoughts through reflective writing. Instructors can share their testimony of electronically receiving their most poignant journals from students during the wee hours of the morning. Electronic journaling may create an ambiance of anonymity. Students may share their innermost thoughts via writing as opposed to delving into their thoughts in a face to face dialogue.

Likewise, instructors are encouraged to respond to the journals in a sensitive and meaningful way. They should mentor the student through the process. For example, if the instructor views a situation differently from the student, it may be best to acknowledge the student’s thoughts and then state his opinion. Instructors may initiate a therapeutic use of self-approach and further guide the student to make meaning of the experience.

There may be some situations where the instructor has made an observation about a connection between student and client and shared this in a dialogue. The fact that an instructor has not only made the observation but shared it with the student may have a significant impact on the student’s learning and self-discovery. Criticisms and evaluative comments should be avoided in this dialogue.

One challenge inherent within journaling is that the instructor must wholeheartedly value the process as worthwhile. The instructor makes a commitment to read and respond to the journals in a thoughtful and insightful manner. Some instructors may assign more value to concrete exercises, such as medication profiles, concept maps, or other common clinical assignments.

Although the educator will affirm the importance of gaining insight into emotions, and feelings, they may not subscribe to the fact that knowledge can be gleaned from this technique. The question arises: “If the journal is not graded, does it have value?” Students’ perceptions may mimic those of the instructor: if there is no grade assigned, it probably is just a waste of time. Unless the instructor fully believes that writing can lead to self-discovery and learning, the exercise is merely a writing exercise without value.

Thematic Analysis

One method to use writing as a paradigm to learn is to use the reflective journals longitudinally as a qualitative learning process. Students may be required to write reflective journals over the course of a semester. For example, in one phenomenology of nursing course, students were assigned to observe professional nurses in the role of educator, clinician, counselor, advocate, and coordinator of care.

The journals described the insights, experiences, and behaviors they encountered while interacting and collaborating with professional nurses. Upon completion of the fifth journal, the students were instructed to “journey back” through the entries and extrapolate themes or patterns that emerged. For example, the student may find that each nurse exemplified intuitive thinking; thus, intuition was a theme. After each student reviewed the entries, they were assigned to collaborative groups of three.

After discussion, the group members identified two emerging themes. These topics were further explored in the literature in a minimum of five peer reviewed nursing journals or books. Such themes as clinical judgment, critical thinking, the novice nurse, and conflict resolution were a few that emerged. The students prepared an oral presentation to discuss both topics and supporting research. Each group distributes the reference lists to all students electronically.

The presentation captured the student/nurse’s lived experience in nursing care of the client/family. This assignment enabled the student to correlate information found in clinical practice with research. This assignment was a graded course requirement. Introspection, self-discovery, and dialogue among peers was established.

Overall, the effectiveness of the use of writing as a method to facilitate learning through self-discovery is well documented in the disciplines of psychology and education (Pennebaker, 1991). Writing techniques specifically linked to learning within the clinical setting have the potential to create connections, facilitate engagement, and create meaning among the nursing student.

Summary

Clinical education has remained relatively constant for many years. The paradigm of the past may no longer prove effective as a result of increasing nursing school enrollments and the skills needed to facilitate critical thinking in students to become reflective practitioners. Clinical education has always held a great potential to threaten students and some students are more prone to threat than others.

Nurse educators can use different teaching strategies to create an environment that enhances learning and promotes professional and personal development of the nursing student. Some of those strategies include using technologically enhanced discussions, participating in grand rounds, and employing expert doctors as preceptors on the clinical unit.

A preventive paradigm shift is needed in clinical education rather than intervening when the student is in crisis. Perceived threat and performance anxiety can be circumvented through expressive writing that is tailored to increase connection and facilitate a positive learning experience for nursing students in any clinical area.