Enhancing The Clinical Practicum Experience Through Journal Writing

A qualitative analysis of radiation therapy students’ professional placement journals

Purpose

Student experience on clinical placement is not well captured with traditional program evaluation tools. This study aims to complete a qualitative analysis of the reflective clinical journals completed during professional placement by radiation therapy (RT) students in order to uncover the issues that affect students on placement and how these change as the student's progress through the program.

Materials and methods

A qualitative descriptive analysis (QDA) was undertaken on the descriptive content of student journals completed by 97 students over 3 consecutive years while undertaking professional placement in Radiation Oncology Treatment Centres within Australia. Two coders used a QDA sourcebook specifically designed for the research to independently analyse the descriptive content of the reflective journals for four main categories and 18 subcategories.

Results

The result revealed a statistically significant increased tendency to discuss clinical environment and a decreased tendency to discuss the patient, 92·9–12·5% (coder 1) and 85·7–18·8% (coder 2), as they progressed through the program.

Conclusions

The results of this study showed some similarities with studies completed in other health professions; however, the breadth of issues explored within the content of these RT student journals demonstrates the true diversity of the RT student experience on professional placement.

Risks with Older Adults in Acute Care Settings: Occupational Therapists' and Physiotherapists' Perceptions

Introduction:

In acute care hospitals, risk assessments are integral to therapy practice. However, to date, this area has not been explored in any specific depth within occupational therapy or physiotherapy, although there is evidence that the management of risk causes uncertainty and anxiety among professionals. Different perspectives of risks may have an influence on the discharge end point.

Method:

This study explored the self-reported risk-taking behaviours of occupational therapists and physiotherapists. A qualitative approach was taken, with reflective diaries used to record the self-reported risk-taking behaviours of therapists in a teaching hospital. Eight therapists recorded 16 reflections in total, which were analysed using template analysis.

Findings:

The findings suggest that support from members of the team, collegiality and clinical confidence were important to manage risks. Therapists were willing to take risks in order to meet patient goals, to facilitate the rehabilitation process or to enhance the patient's quality of life. However, there may be instances of interprofessional differences that need to be managed.

Conclusion:

This research has highlighted the need for therapists to reflect continually upon risk situations in professional practice. There is a need for support and guidance to be put in place to enable positive risk taking.

The educational effects of portfolios on undergraduate student learning: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 11

INTRODUCTION

In recent years, the use of portfolios as learning and assessment tools has become more widespread across the range of health professions. Whilst a growing body of literature has accompanied these trends, there is no clear collated summary of the evidence for the educational effects of the use of portfolios in undergraduate education. This systematic review is the result of our work to provide such a summary.

METHODS

We developed a protocol based on the recommendations of the Best Evidence Medical Education (BEME) collaboration. Citations retrieved by electronic searches of 10 databases were assessed against pre-defined inclusion/exclusion criteria by two independent reviewers and full texts of potentially relevant articles were obtained. Studies were identified for inclusion in the review by examination of full text articles by two independent reviewers. At all stages, discrepancies were resolved by consensus. Data relating to characteristics of the student population, intervention, outcome measures, student design and outcomes were collected using a piloted data extraction form. Each study was assessed against 11 quality indicators designed to provide information about how well it was designed and conducted; and against the Kirkpatrick hierarchy as modified for educational settings. Comparisons between different groups were carried out using the Kruskal-Wallis test (non-parametric ANOVA) or the Mann-Whitney U test as appropriate.

RESULTS

Electronic searches yielded 2,348 citations. A further 23 citations were obtained by hand searching of reference lists. About 554 full articles were retrieved and assessed against our inclusion criteria. Of the 69 studies included in our review, 18 were from medicine, 32 from nursing and 19 from other allied health professions, including dentistry, physiotherapy and radiography. In all professional groups, portfolios were used mainly in the clinical setting, completion was compulsory, reflection required and assessment (either formative, summative or a combination of both) the norm. Three studies used electronic portfolios. Whilst many studies used a combination of data collection methods, over half of all included studies used questionnaires, a third used focus group interviews and another third used direct assessment of portfolios. Most studies assessed student or tutor perceptions of the effect of the use of portfolios on their learning. Five studies used a comparative design, one of which was a randomized controlled trial. Studies were most likely to meet the quality indicators relating to appropriateness of study subjects, clarity of research question and completeness of data. However, in many studies, methods were not reported in sufficient detail to allow a judgement to be made. About 19 of the 69 included studies (27%) met seven or more quality indicators. Across all professions, such 'higher quality' studies were more likely to have been published recently. The median 'quality score' (number of indicators met) rose from two for studies published in 2000 or earlier to seven for studies published in 2005 or later. Significant differences were observed between the quality scores for studies published in or before 2000 and those published between 2001 and 2004 (p = 0.027), those published in or before 2000 and those published in 2005 or later (p = 0.002) and between all studies (p = 0.004). Similar trends were seen in all professional groups. About 59 (85%) of the included studies were assessed at level 1 of the modified Kirkpatrick hierarchy (i.e. 'participation' effects, including 'post hoc' evaluations of student perceptions of the effects of keeping a portfolio on their learning). About 9 (13%) of the studies reported direct measurement of changes in student skills or attitudes and one study reported a change in student behaviour. The main effects of portfolio use identified by the included studies were: Improvement in student knowledge and understanding (28 studies, six at Kirkpatrick level 2 or above), greater self-awareness and encouragement to reflection (44 studies, seven at Kirkpatrick level 2 or above) and the ability to learn independently (10 studies, one at Kirkpatrick level 2). The findings of higher quality studies also identified benefits in these areas. They reported improved student knowledge and understanding, particularly the ability to integrate theory with practice, although a correlation with improved scores in other assessments was not always apparent. Greater self-awareness and engagement in reflection were also noted, although some studies questioned the quality of the reflection undertaken. Higher quality studies also suggest that use of portfolios improves feedback to students and gives tutors a greater awareness of students' needs, may help students to cope with uncertain or emotionally demanding situations and prepares students for postgraduate settings in which reflective practice is required. Time commitment required to collate a portfolio was the major drawback identified. In two of the studies, this was found to detract from other clinical learning.

CONCLUSIONS

At present, the strength and extent of the evidence base for the educational effects of portfolios in the undergraduate setting is limited. However, there is evidence of an improving trend in the quality of reported studies. 'Higher quality' papers identify improvements in knowledge and understanding, increased self-awareness and engagement in reflection and improved student-tutor relationships as the main benefits of portfolio use. However, they also suggest that whilst portfolios encourage students to engage in reflection, the quality of those reflections cannot be assumed and that the time commitment required for portfolio completion may detract from other learning or deter students from engaging with the process unless required to do so by the demands of assessment. Further work is needed to strengthen the evidence base for portfolio use, particularly comparative studies which observe changes in student knowledge and abilities directly, rather than reporting on their perceptions once a portfolio has been completed.

Occupational Therapists' Perceptions of Predischarge Home Assessments with Older Adults in Acute Care

Predischarge occupational therapy home assessments are routinely performed with older adults in Europe, Australia and North America. Their primary aim is to facilitate a timely and safe discharge from hospital. However, there is a lack of published research on this topic, especially studies exploring occupational therapists' perceptions of home assessments. The paper aims to redress this by describing occupational therapists' perceptions of predischarge occupational therapy home assessments with older adults in acute care.

All occupational therapists who undertook home assessments in an acute care hospital with older adults during the duration of the study period were invited to complete a reflective diary. In total, 15 reflective diaries were completed by six therapists. The data were analysed using thematic content analysis.

The findings suggest that home assessments were carried out because of mobility or environmental concerns. Satisfaction and dissatisfaction with the outcome of the home assessment were related to the incidents that occurred during the assessment. Some of the occupational therapists' anxieties were related to the older adults' level of functioning or ill health, and the older adults' own concerns did have an impact upon the therapists' expectations of the home assessment process.

Narrative criticism: a systematic approach to the analysis of story

Research reveals that writing about one's experiences offers an individual the opportunity to improve function, develop insight, and foster growth. Storytelling and story writing are pedagogical tools used frequently in practice professions. It is reasonable to see these writings as a rich source for research. They are vehicles for understanding human experience and aesthetic knowing. This article presents an innovation in the method used for analysis of stories. It is a blending of two established methods, those of narrative analysis as described by Riessman (1993), and aesthetic criticism by Chinn, Maeve, and Bostick (1997). The merging of both methods, termed narrative criticism, allows for a rich level of insight into unique human experiences.

Preparing for Practice: Students' Reflections on Their Final Clinical Experience

Nursing students in their last clinical experience before graduating often encounter stressful situations and face unique challenges. To help students prepare for their transition into practice, both faculty and nurses in the clinical setting need a thorough understanding of what nursing students are thinking and feeling as they near the end of their academic program. This study was conducted to explore the cognitive and emotional responses of baccalaureate nursing students during their final clinical experience. Thirty-two senior nursing students wrote "thinking-in-action" reflections weekly during a 6-week period in the last semester of their nursing program. Reflections were analyzed using qualitative methods; seven themes emerged: being aware of human vulnerability, feeling the weight of registered nurse (RN) responsibility, recognizing limits, evaluating self, seeing the patient/family perspective, confronting ethical issues, and facing reality versus expectations. These findings help nurses in education and practice more fully understand the issues that students face in preparing for practice and may lead to strategies to smoothen the stressful transition from being a student to becoming an RN.

Faculty perceptions of critical thinking in student clinical experiences

Critical thinking is an essential skill for nurses who practice in complex health care systems. This study explored nursing faculty members' perceptions of teaching critical thinking to baccalaureate student nurses in clinical settings. Six clinical faculty members were interviewed using an ethnographic approach. Findings focus on two domain analyses that describe the nature of critical thinking and strategies to effectively teach it. Faculty members conceptualized critical thinking as "putting it all together" through information seeking, reflecting, assigning meaning, problem solving, predicting, planning, and applying information. Faculty members perceived that they teach critical thinking through a number of approaches that include asking questions, reviewing written products, conducting clinical conferences, and evaluating student journals. The findings of this study have implications for faculty who seek a clearer definition of critical thinking in nursing and a rich description of strategies to teach this skill.

Reflective Writing and Nursing Education

Reflective writing is a valued tool for teaching nursing students and for documentation, support, and generation of nursing knowledge among experienced nurses. Expressive or reflective writing is becoming widely accepted in both professional and lay publications as a mechanism for coping with critical incidents. This article explores reflective writing as a tool for nursing education.

Online, Directed Journaling in Community Health Advanced Practice Nursing Clinical Education

The sharing of experiences in advanced practice nursing clinical courses allows for application of core principals to different facets of practice, with the potential to promote discussions beyond the course objectives, create opportunities for mentoring, foster critical thinking, and facilitate change and socialization into advanced practice. A pilot test of online, directed journaling, an innovative sharing and reflection strategy, was incorporated in a two-quarter community health advanced practice nursing clinical course in an attempt to enhance clinical learning. Six female graduate nursing students completed the journaling. A 10-item evaluation measure demonstrated that the online journaling strategy was highly effective and valuable for the students. An assessment of the journaling entries found multiple examples of discussion, mentoring, critical thinking, and socialization. Innovative online strategies should become the standard for sharing in advanced practice nursing education.

Thinking Aloud on Paper: An Experience in Journal Writing

Journal writing is one of many strategies that can help promote learning in a process-oriented curriculum. This article explores the experience of implementing journal writing as an expectation of second-year baccalaureate nursing students in a clinical practicum. Faculty had a vital role in facilitating this experience. The journals provided a medium within which students explored in depth significant events that occurred in their practicum. Their analysis of these events included application of theoretical frameworks and concepts that supported and strengthened the arguments made in the journals. Students responded very favorably to their experiences in journal writing. In the evaluation of this experience, students reported increased abilities in critical thinking and self-directed learning. These two important concepts complement each other in the students' learning processes.

Reflective practise in clinical teaching

The present paper describes the process of reflective practise in clinical teaching through a workshop entitled 'Effective Clinical Teaching'. The clinical teachers were invited to analyze the content of a videotape in which various clinical teaching scenarios were presented. Following this, they discussed a series of questions designed to promote reflective activities and evaluated the interaction among the student, the client and the clinical teachers in each scenario. The teachers also identified the positive and negative aspects of the teaching approaches portrayed on the tape. Finally, the participants made recommendations that would improve the interaction and suggested alternate teaching strategies to enhance the learning outcome. In addition, there was sharing of clinical teaching experiences among the clinical teachers. Through this process of reflection on action, the clinical teachers were able to understand various teaching approaches as perceived by students, and to address the issues that might hinder student learning in clinical settings. Different reflective activities have also been proposed to enhance student's reflective learning skills.

Using journals for community health students engaged in group work

Teaching students concepts integral to community health nursing, such as collaboration and partnership, while providing clinical practica in community agencies, mandates that students address group process and evaluate self-growth. To facilitate reflection on self-learning in the context of collaborative group work, faculty and students use a structured, graded, weekly journal. This teaching and learning tool serves as a mechanism for assisting students with understanding group process.

The senior practicum

Senior practicum offers students valuable time to apply knowledge from the entire nursing program within a supportive setting while having the benefit of direct supervision from an experienced clinician. Benefits to agencies include a well-prepared practitioner who is thoroughly oriented to agency policies and procedures. The authors describe the practicum experience of a baccalaureate nursing program and discuss the benefits from multiple points of view.

The mentored journal

The "writing to learn" paradigm assists students in developing reflection, critical thinking, and the higher order cognitive skills of analysis and synthesis. One common teaching strategy used in this process is clinical journals. Integrating the concepts and underlying theory of journaling, mentoring, and the Circles of Meaning model in the development of the mentored journal, the author discusses a model in which each component acts synergistically to enhance the process of critical thinking within nursing students.

Parameters for adapting journal writing activities

SUMMARY The purpose of this article is to discuss journal writing parameters, which have proven useful in shaping student journal assignments. In a qualitative audit of journal writing activities currently utilized in an occupational therapy curriculum at a midwestern university, the authors used four parameters-focus, temporality, feedback, and sharing-to analyze five student journal strategies: Video Journal, OT/OTA Collaborative Fieldwork Journal, Course Objectives Journal, Subject-Specific Journal, and Activity Response Journal. A student exemplar follows the parameter analysis for each journal writing strategy. Various outcome evaluation methods show journal writing activities to be valuable tools in a curriculum that emphasizes reflection, critical thinking skills, and learner-centered educational approaches. Adaptable by means of the four parameters, these five generic student journal activities can be easily implemented in a variety of courses, allowing for development of professional attitudes, relationships, and skills.

Preparing Culturally Competent Practitioners

Preparing culturally competent practitioners is critical, and evaluating the effect of experiences intended to move students toward cultural competence is important. This research study explored the relationship among short-term international nursing clinical immersion experiences, cultural self-efficacy, and cultural competence. A triangulated research design was used to explore the relationship among the variables with 200 senior undergraduate and graduate nursing students from a university in New England. Quantitative analysis found statistically significant differences in the achievement of cultural self-efficacy for the participants who completed the international clinical experiences versus those who remained in the United States. Qualitative analysis, used to further explain the quantitative results, found that the differences were related to international students' ability to overcome their ethnocentrism, experience a transformative perspective about being culturally aware and sensitive, as well as understand and integrate the patients' cultural practices and beliefs into the students' Western health care practices. It became apparent that something other than cultural self-efficacy had occurred for participants in the international immersion experiences. The students believed they had entered the arena of cultural competence. Short-term clinical cultural immersion experiences have relevance for assisting faculty to move nursing students toward an understanding and achievement of cultural competence in ways currently not possible with nonimmersion community cultural experiences.