FULL LENGTH ARTICLE

 

Perceptions of student nurses on the writing of reflective journals as a means for personal, professional and clinical learning development

 

 

Hazel Thokozani Mahlanze; Maureen Nokuthula Sibiya^*

Nursing Department, Durban University of Technology, South Africa

 

 

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ABSTRACT

BACKGROUND: Reflective journals are used by the students to voice their views on the daily activities during clinical placement. Reflective journals are aimed at helping the student to observe and record as many facts about daily practice as the student finds relevant. Reflective journal writing can therefore be used as a tool to evaluate that clinical learning is actually taking place and what challenges students are experiencing which may influence their learning. Findings by Harris (2006:460-461) are encouraging that through journaling students will develop ability to identify and analyse their difficulties, make suggestions for solving problems and ask and pursue questions on their own. Some of the participants confirmed improved values clarification, self-valuing and personal growth. Bulman & Schutz (2008: 172) recommends journal writing for recording processes the student observe, copy and internalize in her journey towards professional development.
OBJECTIVES: This study aimed to determine student nurses' perceptions of reflective journal writing as a means for personal, professional development and clinical learning development.
METHOD: A quantitative and descriptive survey was conducted in September 2013. Forty participants were recruited from second year student nurses of a University of Technology in uMgungundlovu District of KwaZulu-Natal. Purposive convenience sampling strategy was used. A structured questionnaire was designed by the researcher from literature reviewed. The questionnaire was piloted and modified, then used after permission had been granted by the Ethics Committee of the university concerned. The Statistical Package for Social Sciences (SPSS 17) programme was used for data analysis.
RESULTS: Results indicated that the participants generally experienced writing of reflective journals to be a valuable tool enhancing personal development, professional growth and clinical learning. A significant number (n = 24/60%) confirmed that they improved in making proactive decisions and taking on the spot corrective actions; 52% (n = 21) of the participants were empowered to examine their attitudes and perspectives to a given situation and 55% (n = 22) participants increased in active involvement and ownership of their learning.

Keywords: Clinical learning, Reflective thinking skills, Registered nurse/professional nurse, Self-awareness, Student nurse

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1. Introduction and background

Nursing students are placed in clinical facilities to correlate classroom learning with real life situations to learn nursing skills and to socialise students into professional behaviours and practice (SANC, 2005). Nursing students are being prepared to become future competent registered nurses who are not only clinically competent but personally and professionally developed to meet their leadership role in nursing. Theory can easily be assessed through tests and examinations, clinical skills through well-developed clinical checklists. The challenge lies in monitoring personal and professional development of a student. Reported cases of poor attitudes of nurses and professional misconduct are indicators of a decline in personal and professional development of nurses (SANC, 2008; Bloom (2013). Nurse educators need to explore innovative teaching strategies such as reflective journals, to address these challenges facing the profession.

Some of the benefits of writing reflective journals include professional, cognitive and affective development; making connections through text and journals; increased awareness of contextual 'space'; active engagement with issues; connecting with self and others (Bolton, 2005; Bulman & Schutz 2008; Chabeli & Muller, 2004; Harris, 2005; Mezirow & Associates, 2000). Lasater and Nielsen (2009) state that reflection provides an excellent opportunity for students to analyse their actions and increase their capacity to make sound clinical judgments.

The writing of a reflective journal is commonly done by the student individually and during their own private time away from the intimidating presence of seniors and nurse educators. In addition, students will develop the ability to identify and analyse their difficulties, make suggestions for solving problems and ask and pursue questions on their own Harris (2006:460-461). It becomes a platform for voicing out opinions, feelings and disturbing issues that concerns the student (Bulman & Schultz, 2008: 86). Thorsen and DeVore (2013) and Chabeli (2006:82) add that journals can be utilised to teach and guide students to develop higher order thinking skills e.g. reflection, critical thinking and problem solving skills.

1.1. Problem statement

Reported cases of negligence and poor nursing staff attitude have been steadily rising and reported in a number of cases. South African Nursing Council investigated 629 professional misconduct cases by Registered Nurses (SANC, 2008). Health departments are facing billions of rands in litigations resulting from cases of negligence (Bloom, 2013; Bauer, 2011). The Minister of Health has admitted the attitude of professionals within public healthcare to their work was a major stumbling block to transforming the sector (Bauer, 2011). Poor attitudes of nurses and professional misconduct are indicators of a decline in personal and professional development of nurses. This highlights the need for reflective practitioners who will be able think and consider their actions carefully or reflectively to make sound clinical reasoning and judgements, preventing such occurrences (Lasater & Nielsen, 2009).

The above challenges facing the nursing profession warrant a revisit of current nursing education strategies because the commonly used clinical evaluation tools are designed to measure observable clinical learning outcomes but fall short in measuring critical attributes of nurses pertaining to behaviours such as personal development and professionalism (DeBrew & Lewallen, 2014:1). Innovative strategies, such as reflective journals, can be utilized to monitoring the personal and professional development of nursing students in order to produce professionals who are clinically-focussed and reflective in their practice. It is with this in mind that the researcher purposed to conduct this study to contribute knowledge voiced out by the nursing students as active participants in the clinical environment.

1.2. Purpose of the study

The aim of the study was to determine student nurses' perceptions of reflective journal writing as a means for personal, professional development and clinical learning development.

1.3. Definition of key concepts

Student nurse refers to persons following the programme leading to registration as a nurse (general, psychiatric and community) and midwife in terms of Regulation R425 of February 1985, as amended (SANC, 2005).

Clinical learning is part of the educational process achieved through clinical placement of students in nursing and midwifery practice settings to acquire and apply knowledge, skills and behaviours and demonstrating competency in the practice of nursing and midwifery (SANC, 2005).

Reflective thinking skills refers to the process of internally examining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self, and which result in a changed conceptual perspective (Chabeli & Muller, 2004).

Self-awareness refers to complex, dynamic integration of conscious and unconscious feelings, attitudes, and perceptions about one's identity, physical being, worth, and roles; how people perceive and define themselves (Bulman & Schutz, 2008).

Registered nurse/ professional nurse is a person registered with the SANC as a nurse under Article 16 of Nursing Act, No 33 of 2005, as amended (SANC, 2005).

Role models are people who usually hold positions that can be observed and followed by those who admire them. In nursing, these are professional nurses who must have the required knowledge, skills, integrity, personal bearing, neatness, empathy, sympathy and willingness to assist wherever their knowledge and skills are needed, and to be collaborative (Lekhuleni, van der Wal, & Ehlers, 2004).

 

2. Research methodology

2.1. Design

A quantitative descriptive method was used. A structured questionnaire was developed to elicit participants' perceptions regarding reflective journal writing in terms of personal and professional development as well as whether reflective journaling has influenced their clinical learning. The questionnaire consisted of a Likert type rating scale which was designed based on the literature reviewed for the study. The rating scale comprised five options as follows: Strongly agree = 1; Agree = 2; Uncertain = 3; Disagree = 4; Strongly disagree = 5. The questionnaire was divided into four categories namely: personal development; professional development; clinical learning; and barriers to writing reflective journals.

2.2. Study setting

This study took place a University of Technology in the uMgungundlovu District of KZN. Reflective learning journals form part of the learning assessment strategies for clinical nursing practice from the second year of study. Reflective journals are written by the nursing students and submitted to clinical facilitators.

2.3. Sampling process

A convenience sample was drawn from the population of 100 s year undergraduate student nurses who had been introduced to reflective journaling in first year. Polit and Beck (2012) suggest that if the group is homogeneous, confounding variables are controlled and internal validity is maintained. The researcher obtained a list of the second year students from the relevant level coordinator. Each name was allocated a number and using a table of random numbers, fifty percent of the students were selected. Closing her eyes, the researcher used a pencil to point on the table of random numbers and stopped when fifty percent of corresponding numbers was reached. The level of significance for the study was accepted at 95%. The researcher followed a face to face recruitment strategy. She approached student nurses in a classroom after consultation with relevant lecturers. The aim of the research was explained as well as voluntary participation. The aims of the research and the right of the student to refuse and confidentiality were highlighted. At the end of the recruitment process, 40 students signed letters of information and consent and were included into the study.

2.4. Data collection

Quantitative data were collected in September 2013 using a structured perceptions questionnaire. The questionnaire consisted of a Likert type rating scale which was designed based on the literature reviewed for the study. The rating scale comprised five options as follows: Strongly agree = 1; Agree = 2; Uncertain = 3; Disagree = 4; Strongly disagree = 5. The questionnaire was divided into five sections namely: a) demographic data; b) personal development; c) professional development; d) clinical learning; and e) barriers to writing reflective journals.

Section A contained questions pertaining to the demographic data of the respondents. In Section B, respondents responded to aspects of professional development such as problem solving, making proactive decisions and using past experiences to prevent future occurrences. Section C dealt with personal development such as empowerment towards self-examination of own attitudes, coping skills when facing clinical experiences, awareness of own strengths and weaknesses, improving confidence and enhanced writing skills. Section D examined clinical learning and practice, the respondents gave their perceptions to whether their understanding of learning outcomes was enhanced; active involvement and ownership of my own learning was increased; ability in reflection and thinking was improved as well improvement in ability to search for more knowledge in order to be ready for future critical experiences/events. Section E students responded on the challenges they faced when writing reflective journals and included aspects such as time taken for writing and English language as a medium for writing, whether they feared victimization and issues of confidentiality when sharing their views.

A pilot study was conducted to test the survey questionnaire. Five students, who were excluded from selection for the main study and two clinical instructors were randomly selected to participate. Clinical instructors are actively involved with reflective journals and the researcher included them to assist with the structuring for better understanding, however they were not included in the study. The participants expressed their views with regard to the questionnaire language. They requested rewording of Section A - Criteria: 4 for better understanding. Initial wording read; 'the reflective journal helped me to make decisions regarding future occurrences and take actions'. The recommended adjustment was made to read; 'I am able to make proactive decisions and take on the spot corrective actions'. The participants expressed satisfaction with the rest of the questionnaire. The final questionnaire was discussed with the supervisors and the statistician and accepted by the Institutional Ethics Committee.

Questionnaires were distributed by a designated person from the Department of Nursing in a classroom environment.

Students were given 45 min to complete the questionnaire. The researcher stayed at a distance to minimize response bias but within easy reach to clarify problems.

2.5. Data analysis

In consultation with a statistician, the survey questionnaire was analysed using descriptive statistics. The mean and standard deviation were represented in graphs and tables using Statistical Package for Social Sciences (SPSS 17).

2.6. Validity and reliability

To ensure validity, reliability and objectivity of the study, the following measures were considered by the researcher:

• An experienced statistician and supervisor were involved during formulation of the questionnaire, data collection and data analysis phases of the study.

• Simple questions were constructed to prevent misinterpretations and to construct the different sections of the questionnaires in the same manner.

• To ensure objectivity, voluntary participation was emphasized and participants informed that they could withdraw whenever they felt unable to proceed. Pretesting of questionnaire was done and used only after recommended adjustments were approved by the ethics committee. A seasoned supervisor monitored the study throughout.

2.7. Ethical issues

The study was reviewed by the Institutional Research and Ethics Committee, and thereafter an ethics clearance (IREC 53/ 12) was granted. The right to freedom from harm and discomfort was maintained, as participants were not subjected to any risk of harm or injury and participants who declined to participate in the study were not treated in a prejudicial manner.

An information letter explaining the aims of the study was provided to the participants before commencement of the study, and they signed a consent form. Participants were requested not to write their names on the questionnaire in order to maintain confidentiality. Participation in this study was voluntary and participants were informed of their right to withdraw from the study even if they had given their consent. No form of coercion was used on those individuals who refused to participate in the study. Confidentiality of records was maintained by being handled only by the researcher and her supervisors. When records were not being used they were kept under lock and key by the researcher.

 

3. Research findings

3.1. Demographics of participants

A total of 40 s year undergraduate nursing students participated in the study. Of these, 25 (65%) were females and 15 (35%) were males. There were more females than males in the 25 years to less than 30 years' age group as well as in the more than 35 years' age group (2:1). The males dominated in the category of 20-25 years.

3.2. Overall descriptive statistics

A score of 3 is considered neutral, a score below 3 indicates a positive impact and a score above 3 indicates a negative impact. Professional development yielded an average score of 2.03, personal development and clinical learning both yielded 1.93, indicating a positive impact for all three variables. The combined mean score of the three categories of perceptions regardingjournal writingwas 1.98 (Table 1). Considering that a score below 3 is regarded as a positive outcome, these results indicate that participants perceived that writing reflective journals was beneficial in terms of their personal and professional development as well as their clinical learning.

 

 

3.3. Test statistics for professional development

Participants responded to the following variables regarding professional development (see Table 2);

 

 

• Ability to correlate theory with practice.

• Ability to improve in problem solving skills.

• Ability to redefine experiences and problems.

• Ability to make proactive decisions and take corrective actions.

• Ability to use past experiences to prevent future occurrences.

A significant number (n = 24/60%) of participants agreed that the writing of reflective journals positively impacted on their ability to make proactive decisions and take corrective actions; (n = 22/54%) of participants agreed that the writing of reflective journals positively impacted on their ability to improve in problem solving and (n = 22/54%) of participants agreed that the writing of reflective journals positively impacted on their ability to redefine experiences and problems.

Studies by Klimczak (2002), Langley and Brown (2010), Harris (2005) and Callister, Luthy, Thompson, and Memmott (2009) yielded similar results and were in agreement that professional development can be greatly enhanced during clinical practice. Chabeli and Muller (2004) as well as Langley and Brown (2010) concur that professional socialisation of a nursing student can be positively or negatively affected during clinical learning.

When a student nurse joins the profession, she comes with her/his own beliefs and values. Clinical placements afford the student nurse an opportunity to observe how ethical and clinical decisions are taken by professional nurses in real human encounters. The student nurses in this study have demonstrated that they are developing these skills and this is a positive sign for the nursing profession.

3.4. Descriptive statistics for personal development

Participants responded to the following variables regarding personal development (see Table 3);

 

 

• Empowerment towards examining own attitudes and perspectives to a given situation

• Awareness of strengths and weaknesses

• Assistance in developing coping skills towards clinical experiences

• Consciousness to own feelings and emotions to deal with self and others

• Afforded a voice for self-expression

• Improved confidence

• Enhanced writing and recording skills

A significant number of participants (n = 21/52%) agreed that they were empowered to examine their attitudes and perspectives to a given experience; 50% (n = 20) felt the writing assisted them in developing coping skills towards clinical experiences and 49.5% (n = 20) appreciated the writing of journals for giving them a voice for self-expression.

Students in Klimczak's (2002) study agreed that through journaling they were able to re-examine their own perceptions, attitudes and preconceived ideas towards a given situation. Writing of reflective journals was perceived to assist the students with development of coping skills during their clinical experiences.

The results suggest that reflective writing in this study assisted students to improve self-awareness and response to circumstances, consequently developing coping skills. Self-awareness and emotional maturity is imperative for effective clinical learning and development because nurses deal with human beings everyday in the form of patients and other members of the health team. It is therefore a positive step that these nurses are developing in this area.

3.5. Descriptive statistics for clinical learning

Participants responded to the following variables with regard to clinical learning (see Table 4):

 

 

• promoted understanding of learning outcomes.

• increased active involvement and ownership of learning.

• increased ability in reflection and thinking.

• stimulated to search for more knowledge to prepare for future use experiences.

• helped to improve observation skills.

A significant number (n = 22/55%) agreed that the writing of reflective journals promoted their understanding of learning outcomes, 50% (n = 20) agreed that their reflective thinking abilities increased during the writing of reflective journals.

Joubert and Hargreaves (2009) state that the ability to apply theory to practical experiences causes excitement and motivates students towards higher levels of reflection. Langley and Brown (2010) also found that the students favoured reflective journaling as a vehicle to narrow the theory-practice gap. The findings by Davhana-Maselesele, Tjallinks, and Norval (2001) disagreed with this study and those cited above, and found a lack of application of theory to clinical practice by students in their study.

The improvement of clinical learning abilities for student is vital for nursing in order that higher order thinking skills are developed and that theory is correlated with practice. The students in this study have confirmed that they are developing vital reflective thinking skills in nursing and one can only hope that they are becoming reflective practitioners.

3.6. Barriers to effective journaling

Participants responded to the following variables.

• My command of language limited my writing ability.

• Writing the reflective journal took too much time.

• The benefits of journaling are not clear to me.

• I feel uncomfortable writing my personal feelings in the reflective journal.

• I may be victimized when I express my real feelings.

3.7. Command of language as a perceived barrier to writing of reflective journals

A significant number of participants (n = 19/48%), perceived their command of language to be a barrier to writing in their journals. Hendrix, O'Malley, Sullivan, and Carmon (2012) and Harris (2005) support this statement and were concerned that some nursing students experienced difficulty expressing themselves in writing especially if English is their second language. Langley and Brown (2010) found considerable disagreement between students and faculty regarding the use of reflective journaling and improved writing skills.

Students have identified language as a true barrier to writing of reflective journals in this study. This calls for clearer guidelines and support for students during their reflective process as well as allaying their anxiety with regard to the purpose of writing. The students will then be free to write without fear of being graded on their grammar if that is not the purpose. Most universities have writing centres to assist students where there is a need for referral and students should be encouraged to seek assistance before they submit their journals.

3.8. Regarding the time taken to write reflective journals

There was little difference between participants who agreed (n = 19/48%) and those who disagreed (n = 17/43%). Lack of time for reflection was observed in the study by Langley and Brown (2010) and by Glaze cited by Chong (2009) where students believed they needed more time especially if they were to change their perspective, further asserting that transformation is a process which develops over time.

Students demonstrated very little difference regarding the time taken to write reflective journals. Nevertheless this should not be ignored. Students should be given a week or two following their clinical placement to organize and write their reflective journals to the best of their abilities. Deadlines must be jointly worked out between students and facilitators to minimize pressure.

3.9. Regarding clarity of benefits of journaling

Half of the participants (n = 20/50%) disagreed with the statement 'The benefits of journaling are not clear to me'. Langley and Brown (2010) stated that student motivation may be affected if they do not understand the purpose and benefits of writing reflective journals. Furthermore, they state that this may lead to passivity during the process and cause students to remain non-reflectors.

Guidance and clear guidelines must be given before each placement to avoid misunderstandings between educators and students on expectations. Although students in this study were guided, it is evident that they needed more than what the researcher gave them. When students change clinical placements, specific guidelines may assist to align with clinical placement outcomes.

3.10. Regarding writing personal feelings in reflective journals

A significant number of participants (n = 19/48%) were comfortable with writing their personal feelings in their reflective journals. Students need to trust the person who will read their reflective journals and this develops over time. When giving feedback, nurse educators must guard against attaching comments to students to foster free expression of personal feelings. Consent from student to divulge sensitive and personal information must be obtained. It may serve as an opportunity for counselling and must be used carefully by nurse educators. Study participants were at second year student nurses and one hope if supported will develop in their communication skills.

3.11. Regarding fear of expressing real feelings in reflective journals

It is worth noting that half of the participants (n = 20/50%) disagreed with the statement 'I may be victimized when I express my real feelings'. However, the number of 'Uncertain' answers (n = 12/30%) is disconcerting.

Similar feelings were expressed by students in the study by Bagnato, Dimonte, and Garrino (2013) where students expressed feelings of embarrassment and uneasiness about what they wrote. Gustafson and Bennett (2002:3-10) assert that students will not fully divulge information if they feel insecure. To avoid such occurrences, students verbalised withholding some of the 'truths' in their journals.

Careful consideration must be taken when sharing reflective journal entries with group of students so that an atmosphere of free expression is fostered. Students must be encouraged to write what they freely want to share until they are ready to divulge sensitive and personal issue.

The findings regarding barriers to effective journaling are summarised in Table 5.

 

4. Conclusion

It was evident from the results of this study that participants supported the use of reflective journals and appreciated it for the improvement in their personal and professional development and clinical learning. The challenge of writing in English was identified by participants as the main barrier to journal writing.

 

5. Limitations of the study

The study was conducted in a single university and the study findings may therefore not be generalised. The researcher recognises the limited sample as a limitation and could only work with the forty who gave their consent to the study. The timing of the study coincided with first time clinical placements in midwifery and mental health and this may have affected clinical learning and reflection as students were 'beginners' in these specialised areas.

 

6. Recommendations

Clinical staff and clinical educators must have a common understanding that they are jointly responsible for the development of the student. It is hoped that this will facilitate a conducive clinical learning environment where the student feels welcome and confident. Student writing and language abilities must be considered in order to give appropriate guidance to students. The students' voice must be taken seriously in order to foster open communication channels through reflective journaling. Their views and concerns must be considered. The nurse educators can benefit from the reflective journals to improve their teaching in the classroom and practice. This will also improve student-centeredness in the nursing curriculum. Students can be assisted with their writings where they are struggling with language without interfering with the content. If reflective journals are for grading purposes, students can be encouraged to approach writing centres which are available in some universities.

 

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Received 29 January 2015
Accepted 20 May 2016

 

 

* Corresponding author. Department of Nursing, Durban University of Technology, PO Box 1334, Durban 4000, South Africa. E-mail address: nokuthulas@dut.ac.za (M.N. Sibiya).
Recommendations: It is recommended that clinical staff be reminded of their responsibility as role models for student nurses so as to enhance their personal, professional development and clinical development. The writing of reflective journals must be encouraged in nurse education and students given guidance and constructive feedback.