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Use of clinical journals to enhance critical thinking

Walker, PhD, ATC, provided conception and design; acquisition and analysis and interpretation of the data; and drafting, critical revision, and final approval of the article. Address correspondence to Stacy E. Address e-mail to ude. To introduce the process of journal writing to promote reflection and discuss the techniques and strategies to implement journal writing in an athletic training education curriculum. Journal writing can facilitate reflection and allow students to express feelings regarding their educational experiences.

The format of this writing can vary depending on the students' needs and the instructor's goals. Aspects of journal writing assignments are discussed, including different points to take into account before assigning the journals. Lastly, various factors to contemplate are presented when providing feedback to the students regarding their written entries.

Journal Writing as a Teaching Technique to Promote Reflection

Journal writing assignments can benefit students by enhancing reflection, facilitating critical thought, expressing feelings, and writing focused arguments. Journal writing can be adapted into a student's clinical course to assist with bridging the gap between classroom and clinical knowledge. In addition, journals can assist athletic training students with exploring different options for handling daily experiences.

Reflection has been defined as a process regarding thinking about and exploring an issue of concern, which is triggered by an experience. An expert clinician uses information from previous experiences as well as the insights gained from the reflective process to improve decision-making ability.

As students progress through their education, they must practice, enhance, and habitually use their reflection skills. Leaver-Dunn et al 2 stated that athletic training educators should seek to facilitate a student's reflection. Although many strategies exist to promote this process, one teaching method that has been used to encourage reflection is journal writing. I first briefly discuss the process use of clinical journals to enhance critical thinking reflection and the research related to journal writing and then offer strategies for implementing journal writing in an athletic training education curriculum.

Simply put, the practitioner shows competency, or that he or she knows how to perform an orthopaedic assessment, by displaying the appropriate actions. Knowing-in-action assists a student except when a familiar routine produces an unexpected result.

Take an example of a senior-level student who has performed various patellofemoral examinations but, during a recent evaluation, had inconclusive results. A student in this situation can become very frustrated. When students come across a new situation such as this, it would be beneficial for them to reflect-on-action, or reflect on that experience after it has happened. Unfortunately, more often than not, no time is designated for students to engage in the activity of reflection.

Athletic training educational programs are encouraged to not only foster knowledge in students but also to cultivate reflection to enable our students to learn from past experiences. An expert practitioner experiments on the spot with previous data or engages in what is called reflection-in-action. Students, who do not possess an array of previous experiences from which to draw, are not able to reflect-in-action as can skilled practitioners.

We hope that as they progress through their education, students will learn to practice, enhance, and learn to habitually use their reflection-in-action skills. Although many strategies exist to facilitate reflection, one teaching method that has been extensively used is journal writing. No true definitions of journal writing exist due to the vast number of ways journal writing can be used.

PROCESS OF REFLECTION

In the literature, journal writing is described and explained in many different ways. For the purposes of this article, journal writing refers to any writing that students perform during either a clinical or classroom experience that challenges them to reflect on past situations, as well as consider how they might perform differently should similar situations arise in the future. The goal of any journal writing assignment should guide the written content for the student.

For example, a student could reflect on the challenges of designing and administering a rehabilitation program as part of a rehabilitation course. Students can also return to their struggles with matters such as professionalism during any aspect of their clinical experiences. Both assignments encourage the student to reflect on an experience, whether that experience be from classroom content or their clinical experiences. Journal writing has been used with nursing, 4 5 8 11 physical therapy, 9 15 occupational therapy, 7 and teacher certification 16 17 students.

The journal writing topics for this teaching method can range from reflecting on daily clinical experiences eg, assessments and rehabilitations performed to summaries of weekly clinical experiences. Widely used, journal writing has been recognized as a method designed to enhance reflection, 3—11 facilitate critical thought, 18—22 express feelings in writing about problems encountered during clinical experiences, use of clinical journals to enhance critical thinking 23 and practice writing summaries, objectives, and focused arguments.

Davies 3 found that in the process of journal writing, students moved from being passive to active learners during their clinical debriefing sessions. Students would come to debriefing sessions with problems or clinical issues partially solved and look to the debriefing sessions for further input and validation.

This type of paradigm shift was also reported by Sedlack, 24 who found that journal writing aided in placing responsibility with the student for active engagement and self-directed learning.

Critical Thinking: The Development of an Essential Skill for Nursing Students

In addition, the students' self-confidence increased because the journals enabled them to identify their own lack of motivation. Over the course of the 8 weeks, interactions with patients changed students' attitudes and increased students' knowledge about chronic disease.

In another qualitative study, Ritchie 25 reported that after completing 7 weeks of weekly journal entries, physical therapy students were provided with many opportunities for both the student and faculty member to give feedback, ask questions, and offer ideas for further reflection. In addition, bonds of trust were formed, not only between the student and faculty member, but among the students themselves as they learned to begin to trust themselves and the decisions they made.

Last, students valued being able to ask the faculty member questions and receive validation without exposing their own perceived weaknesses to their peers. Ibarreta and McLeod 5 also found this need for feedback. Nursing students using journals wanted more feedback and direction from the instructor to gain more confidence regarding decisions made during their practicum.

Wong et al 11 used dialogue and journal writing to assess a system for test coding the level of any reflection. Each student wrote a reflective paper after developing a teaching plan and then carried out that teaching plan at the clinical assignment.

A coding scheme was developed to analyze the reflective papers. Students were categorized as nonreflectors, reflectors, or critical reflectors. Of the 45 students in the study, 34 demonstrated reflection and were able to relate their experiences and turn them into new learning opportunities.

In a similar study, 10 during 2 semesters, each student engaged in dialogue 5 times and wrote 4 journal entries in addition to a reflective paper. Not described were the specific data analysis methods and the specific breakdown of nonreflectors, reflectors, and critical reflectors. Students moved from a more narrative or descriptive writing style nonreflector to expressing frustration and offering solutions to problems critical reflector. It was felt that journal writing and dialogue were essential to student learning.

One common use of journal writing is to promote reflection and thought through one-on-one dialogue between the student and instructor.

  • These journals can be a commitment for the student as well as the instructor, but they can potentially provide valuable insight and reflection;
  • The nurses will also be applied to investigate the views of people from different cultures, religions, social and economic levels, family structures and different ages;
  • The health care is setting the priorities of the day to apply critical thinking 14;
  • Athletic training educational programs are encouraged to not only foster knowledge in students but also to cultivate reflection to enable our students to learn from past experiences;
  • It is an essential process for a safe, efficient and skillful nursing intervention;
  • Holist Nurs Pract 1996; 10 2:

Hahnemann 20 felt that journal writing assignments encourage exploration and risk taking on the part of the student. Before trying solutions to problems in real life, the student can be creative and express feelings and frustrations on paper. Ibarreta and McLeod 5 reported that their students, through journal writing, were expected to apply knowledge gained from prior classroom content and literature relevant to their clinical experiences.

Recently, reflective journals 7 were used to emphasize connecting clinical content with thought process and self-awareness. Holmes 23 stated that by recording and describing experiences, feelings, and thoughts, students are able to recreate their experiences for additional exploration.

A student who had a difficult encounter with a student-athlete could write in the journal about the situation and think about what happened. He or she could describe why decisions were made and actions taken, along with feelings and future thoughts and directions. As educators, we must push our students to reflect more deeply.

  • When students come across a new situation such as this, it would be beneficial for them to reflect-on-action, or reflect on that experience after it has happened;
  • Critical thinking in nursing;
  • As stated by Riley-Doucet and Wilson, 8 one of the limitations of this type of assignment is the student who procrastinates and doesn't take responsibility for coursework.

Pushing students to continuously ask themselves why a decision was made or why they feel the way they do about a topic or situation will cause them to look deeper for answers. Why did they perform a certain special test? Why was ultrasound used in the treatment of that injury, and how will that ultrasound affect the inflammation process? What changes could be made to this patient's treatment or future encounters with a specific injury?

Davies 3 stated that journal writing provides students with an opportunity to return to their experiences in an attempt to develop new perspectives that can guide future clinical actions.

For example, a student, after performing a knee examination and discussing it with the Approved Clinical Instructor, could later write about the entire experience. What would he or she do differently? What did he or she learn? Writing encourages and provides an opportunity for students to reflect on an experience, connect, and think critically about ideas or situations.

Dialogue Between Instructor and Student As stated previously, journal writing provides a one-on-one dialogue between the instructor and student.

This dialogue, facilitated by the instructor, should be designed to challenge the student to reflect on his or her experiences. A student who has accomplished a goal or had a positive rehabilitation experience with a patient is allowed to share that information. In addition, this dialogue can also assist with conflicts in a confidential manner. For example, a student could reflect in the written journal about a difficult situation with a coach.

Upon reading the journal, the instructor may provide feedback and ask questions, which will ideally push the student to think about future decisions if again faced with a similar situation. Not only does this one-on-one dialogue assist in challenging the student, but also students valued the feedback to validate their thoughts on new endeavors. This unfamiliar problem can leave students feeling that they have no control or power in the situation.

Although students may experience cognitive dissonance when engaging in a written dialogue about a challenging experience they had, the discourse can facilitate different use of clinical journals to enhance critical thinking of thinking 27 and empower students to handle themselves differently after reflection in the future.

Instead students, after reflection, have thought about their actions and how they would handle themselves or the situation differently in the future, which is reflection-for-action. The journal writing process, however, should be well planned and have explicit student expectations. These questions will provide focus to enable the student to concentrate on the writing and not feel insecure about how the instructor will grade the journal.

As stated by Kobert, 29 every effort should be made to ensure that the journal writing is seen as nonthreatening and satisfying. Identifying expectations before starting the first journal will prevent some confusion.

It is also imperative for the instructor to consider many facets of the use of clinical journals to enhance critical thinking process. The following section discusses factors to consider when planning for the use of journals, including setting student expectations, identifying appropriate topics, journal utilization strategies, and grading systems.

Table 1 Open in a separate window Journal Utilization Techniques Depending on the method of use daily, weekly writing and the journal's purpose to enhance critical thinking, promote reflection, etcthe way in which journal writing is used can take many different forms. Table 2 presents general topics followed by subtopics for possible student assignments in the classroom or clinical education setting.

These topics can vary depending on the level of student, classroom content, location and type of clinical experience, and deficiencies or needs of the student. Topics may be decided solely by the instructor or through more egalitarian methods with the students' input.

Burnard 30 stated that one democratic method of determining topics for journal writing is to discuss this with the class.

Preassigned or spontaneous topics could also be used. The advantage of preassigned topics is that the student is aware of the topic and can be thinking about it before writing. On the other hand, some students may have certain spontaneous experiences during their clinical education about which they wish to write.