the value of reflective journaling in undergraduate nursing education: a literature review
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International Journal of Nursing Studies 45 (2008) 1379–1388
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The value of reflective journaling in undergraduatenursing education: A literature review
Sheila Epp
Master of Nursing Candidate, Faculty of Health and Social Development, School of Nursing, University of BC Okanagan,
3333 University Way, Kelowna BC, V1V 1V7, Canada
Abstract
Objectives: The purpose of this literature review was to ascertain the evidence for the use of reflective journaling as a
tool to promote the pedagogical strategy of reflection for the purpose of learning from practice for practice in
undergraduate nursing education.
Design: Concept-centric.
Data sources: The literature review involved structured searches of all OVID gateway databases, EBSCO host
databases, and Blackwell Synergy. Qualitative and Quantitative Studies from 1992 to 2006 were included if they focused
on reflective journaling in undergraduate clinical education.
Review methods: Due to the vast plethora of literature on reflection, keywords were utilized to focus the search.
Approximately 150 abstracts were reviewed for primary sources of research. A total of nine studies met the inclusion
criteria. The review subsequently divided the literature into four content themes allowing for appraisal and analysis of
the findings, followed by summary and key recommendations for nursing education and research.
Results: There was evidence that educators struggle to incorporate reflective processes into education; however, the
research provided rationale and support for engaging undergraduate students in the reflective process. Researchers
found reasonable levels of reflection in undergraduate students’ journaling and educators reported students’ learning as
a result of reflective journaling. Further to this, there was evidence that writing reflectively improved over time; a
learned skill also dependent on a good facilitator and trust. Unfortunately, there was a paucity of research that explored
the undergraduate nurses’ experiences with the process of having to create written communication, with a critical
reflective focus on practice.
Conclusion: Nursing educators are correct in pursuing the teaching and learning of the reflective process in
undergraduate nursing education. Nurse educators need to utilize various tools and strategies for facilitating the growth
of undergraduate students into reflective practitioners. Indeed there was only limited evidence to support reflective
journaling as an appropriate tool to promote reflection for the purpose of learning from practice for practice in
undergraduate nursing education. Research that provides insight into the undergraduate student experience and
perceptions of reflective journaling is needed to facilitate the structuring and use of reflective journaling as a tool in
undergraduate nursing education.
r 2008 Elsevier Ltd. All rights reserved.
Keywords: Reflective journal; Journal writing; Reflective practice; Undergraduate education; Clinical education; Nursing education
e front matter r 2008 Elsevier Ltd. All rights reserved.
urstu.2008.01.006
ess: [email protected]
ARTICLE IN PRESSS. Epp / International Journal of Nursing Studies 45 (2008) 1379–13881380
What is already known about the topic?
�
Nursing licensing boards include reflective practice asa compulsory competency of practicing nurses.
�
Nursing education has enthusiastically adopted thenotion of reflection as an essential part of learning.
�
Nurses in practice utilize the process of reflection.�
Reflective writing is part of both theory and practicecourses.
�
Reflective journaling, as part of practice courses, isbeing used for both self-appraisal and reflection-on-
action within education.
�
No literature review in the area of utilizing reflectivejournaling in undergraduate nursing was located by
writer.
What this paper adds
�
Limited research reported nurse educator’s as sup-portive of the use of reflective journals as a tool
for engaging undergraduate students in the reflective
process.
�
Research showed that undergraduate students tendedto mainly journal at lower levels of reflection but
were not inept of reflecting at higher levels.
�
Reflective journal writing is a skill that is learnedover time and flourishes in a environment of trust
�
No study identified the extent to which reflectivejournaling has been utilized in undergraduate nursing
education in Canada.
�
No research explored undergraduate nursing stu-dents’ perspectives and experiences of reflective
journal writing for practice.
�
No research identified what factors act as facilitatorsor barriers to reflective journaling for undergraduate
nursing students.
1. Introduction
How often, in humanness, do persons replay situa-
tions or events in their minds? Thinking back on what
occurred, reviewing relational aspects of encounters,
maybe even second guessing what was said or done.
Further understanding of this human activity came out
of the work of Dewey (1933). He described two types
of mental processes: one of uncontrolled thought and
one of controlled, focused thought. The latter he coined
as reflective thinking. Dewey believed that the need for
reflective thinking came out of situations of perplexity;
uncertainty within situations triggered the person to
inquire and find information to resolve the tension.
More recently the works of Schon (1983, 1991) have
permeated the nursing literature related to reflection.
Schon (1983) described a theory of knowledge acquisi-
tion known as reflective practice: reflection-in-action
and reflection-on-action. Schon (1991) challenged the
notion of science and technical knowledge as the
prevailing hegemony, suggesting that such knowledge
might be effective where there is ‘high, hard ground’ but
pointed out that professionals work in ‘messy swamps’
filled with uncertainty, where artistic and intuitive
practices are essential (p. 34). Schon (1991) suggested
that much of what professionals know is learned by
doing in practice, through a process of shifting back and
forth between reflecting-in-and-on-action.
Further, the works of Benner (1984) successfully
placed the conceptual notions of intuition and reflection
into a competency framework that has been widely
accepted within the nursing profession. The framework
delineates the cultivation of a novice nurse to the expert
nurse who possesses diverse competencies that are
embedded with intuitive knowing; attained after years
of reflective practice (Butler in Nelson and Purkis, 2004).
Academia has embraced the concept of reflection as
valuable to critical thinking, insight, and learning; a
source of truth, knowledge, and self regulation. Reflec-
tive processes have been credited with being a medium
to nudge students from engaging in just basic thinking to
critical inquiry (Pond et al., 1991; Callister, 1993;
Cameron and Mitchell, 1993). Moreover, engaging in
reflection has been credited with providing opportunity
for students to explore judgments and clinical decisions
that have been acted on in practice (Mantsoukas and
Jasper, 2004); further providing a chance to change
practice as the student nurse ponders the integration of
theory and practice (Burton, 2000; Duke and Appleton,
2000).
Additionally, the valuing of the reflective process has
found fertile territory in Canadian nursing beyond
the realms of academia. Many registration boards of
various provinces in Canada include reflective practice
as a compulsory competency of a registered nurse
(Nelson and Purkis, 2004). Most registration boards in
Canada also require the nurse to utilize the reflective
process to appraise their own practice (Nelson and
Purkis, 2004). Furthermore, the appeal of reflective
practice is not confined to Canada; there is endorsement
of the concept by regulatory bodies in other countries:
United States, England, and Australia (Burnard, 1995;
Burton, 2000; Duke and Appleton, 2000). The identifying
of reflective practice as an expectation of a practicing
nurse, illustrates the extent to which the concept of
reflection has been accepted by the profession of nursing.
Nursing education can teach to change practice;
however, if in the context of the real world, nurses do
not employ reflection, the theory practice gap widens.
Earlier studies found nurses concurred that they drew on
reflection for planning and evaluating care, but allege
they did not exercise reflection for learning (Powell,
ARTICLE IN PRESSS. Epp / International Journal of Nursing Studies 45 (2008) 1379–1388 1381
1989; Teekman, 2000). Conversely, more recent studies
were able to identify that nurses used reflection for
learning (Gustafsson and Fagerberg, 2004; Peden-
McAlpine et al., 2005). Gustafsson and Fagerberg
(2004) found that nurses looked back and contemplated
negative situations; to see the situation differently and to
consider alternate perspectives. Through dialogue and
reflection on narratives, nurses demonstrated shifting
their perspectives about families; altering their values
and beliefs (Peden-McAlpine et al., 2005).
The purpose of this literature review was to ascertain
the evidence for the use of reflective journaling as a tool
to promote reflection for the purpose of learning from
practice for practice in undergraduate nursing education.
The aim of the literature review was to explore research
seeking rationale and support for utilizing reflective
journaling in undergraduate nursing education as one
tool to encourage engagement with the reflective process.
2. Methods
A literature review can serve to advance knowledge
by identifying what is known and what is not known
about a particular phenomenon (Griffin-Sobel, 2003).
Large unmanageable amounts of data are published
each year; a review reduces the data into focused usable
pieces (Mulrow, 1994). Approximately 150 abstracts were
reviewed for primary sources of research. A summary
table was created to assist in organizing and evaluating
the research articles (Polit et al., 2004). The inclusion
strategies were utilized to determine the nine eligible
studies; these studies were reviewed using the protocol as
outlined by Polit et al. (2004) (Table 1).
2.1. Search strategy
The search for literature was done by two structured
approaches: the standard and the network approach, as
described by O’Conner (1992). Using the standard
approach, the following electronic databases were
searched using the above-mentioned keywords: all
OVID gateway databases, all EBSCO host databases,
and Blackwell Synergy. Subsequently, the network
approach identified relevant citations within acquired
articles using the standard approach. All articles cited in
the review are qualitative or quantitative, peer reviewed,
published studies. Findings from the studies are
discussed by themes and particulars of key studies are
included in each section.
2.2. Inclusion criteria
�
Articles from 1992 to 2007;�
both qualitative and quantitative studies;�
the area of study included reflective journaling forpractice courses;
�
participants were either teaching undergraduatesstudents or were undergraduate students.
2.3. Exclusion criteria
�
Articles prior to 1992;�
scholarly, theoretical, and concept articles;�
studies involving verbal reflection;�
studies involving reflective assignments as part ofcourse work;
�
studies involving higher level students (post-registra-tion, graduate, etc.).
3. Findings
Findings, from the nine studies included in the review,
are grouped under the following four themes: educators’
utilization of reflective journaling, perceptions of utilizing
or participating in reflective journaling, teaching innova-
tion with reflective journaling, and levels of reflection
achieved. Particulars of key studies are included in each
section.
3.1. Educators utilization of reflective journaling
Mallik (1998) and team toured ten universities, in the
United Kingdom and Australia and uncovered that
reflecting on practice was actively encouraged at many
universities; however, there were inconsistencies in the
emphasis on reflection at the undergraduate level.
Reflecting on clinical practice by way of reflective
journaling was one of the most common methods drawn
on by educators in these two countries. The researcher
did not provide data as to the percentage of nurse
educators utilizing reflective journaling. The researcher
noted that one innovative strategy was to provide
students with dedicated time at the end of a clinical
day to complete entries in their journals. Nurse
educators were not completely confident with the use
of reflective journals and raised a number of issues:
ethical concerns, the level of reflection being done, and
the learning effectiveness.
In contrast to Mallik (1998), a more recent study by
Nicholl and Higgins (2004), found only 10% of nurse
educators in South Ireland using strategies such as
journal writing to engage students in reflection. The data
was collected from 20 participants via a semi structured
questionnaire. The study discovered educators empha-
sizing models of reflection and inconsistent emphasis
on strategies for focusing on the process of reflection.
The study was limited in generalizability, as the study
ARTICLE IN PRESS
Table 1
Characteristics of Included Research Studies
Study Design Sample Data source Findings Strength and weaknesses
Landeen
et al. (1992)
(part 1 of 2
part study)
Quantitative
controlled
trial
35 3rd year
undergraduate
nursing students in
Canada
Compared journal group to
2 control groups; utilized
previously developed tools.
’ Not conclusive in terms
of ability of journals to
change attitudes
’ Journals allowed
faculty to open
discussions around
attitudes and thereby
increase student self
awareness
’ Self disclosure in
journaling increased as
trust increased
’ Journaling provided a
vehicle to improve trust
’ Too short of time
change to experience
significant growth
(13 weeks)
’ Third year students;
some of this personal
growth may have
occurred prior to third
year
Landeen
et al. (1994)
(part 2 of 2
part study)
Qualitative
thematic
analysis
18 3rd year
undergraduates
nursing students in
Canada
Examined content of
students’ journals.
’ Learned skill
’ Feedback from faculty
(validation and
challenges) facilitated
ability to reflect versus
report
’ Over time trust
increased and with this
so did reflection
’ Some appeared ‘‘unable
to reflect’’ at any
worthwhile depth
(p. 884)
’ Some students
‘‘appeared to write
what they thought
faculty wanted to hear’’
(p. 884)
’ Findings assessed from
journal entries; no
reports of focus groups
or interview with
participants
’ The researchers
reported that most
students found the
journal served to assist
in awareness of
personal reactions.
However, the
researchers did not
share how this data was
obtained
Mallik
(1998)
Qualitative
illuminative
case Study
10 schools of
nursing in the UK
and Australia;
including
undergraduates
Study tour. ’ Reflecting on practice
was encouraged;
however, inconsistent
at the undergraduate
level
’ Reflecting on clinical
practice by way of
reflective journaling
was one of the most
common methods
’ Nurse educators raised
a number of issues
around the notion of
journaling: ethical
concerns, the level of
reflection being done,
and the learning
effectiveness
’ One innovative strategy
was to provide students
with dedicated time at
the end of a clinical day
to complete entries in
their journals
’ The researcher did not
provide data as to the
percentage of nurse
educators utilizing
reflective journaling
’ Further, the researcher
reported that most
students asserted that
journaling provided an
outlet for them and
affirmed that
journaling assisted
them to be aware of
their personal
reactions. However, the
researchers did not
share how this data was
obtained
S. Epp / International Journal of Nursing Studies 45 (2008) 1379–13881382
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Table 1 (continued )
Study Design Sample Data source Findings Strength and weaknesses
Nicholl
and
Higgins
(2004)
Quantitative
and
qualitative
20 nurse educators;
50% response rate;
40 schools of
nursing in Ireland;
pre-registration
education
Semi-structured
questionnaire.
’ Educators emphasizing
models of reflection
and inconsistent
emphasis on strategies
for focusing on the
process of reflection
’ Found only 10% of
nurse educators in
South Ireland using
strategies such as
journal writing to
engage students in
reflection
’ Small study size
’ The study was limited
in generalizability, as
the study was
conducted in only one
country and at a time
when nursing education
was transitioning into
degree programs and
universities
Richardson
and Malby
(1995)
Qualitative
descriptive
30 journals of 2nd
year undergraduate
nursing students in
Australia
Analysis of the reflective
journals based on the work
of Powell (1989).
’ Tendency for
undergraduates to
engage at the lower
levels of reflection
’ Found that 94% of the
entries were at the
lower levels of
reflectivity and only six
percent at the higher
level
’ 22 of the 30 students
did attain the highest
level of reflectivity
Riley-
Doucet,
and Wilson
(1997)
Qualitative 10 2nd year
undergraduate
nursing students;
Canada
Pilot of a 3 stage process
for reflective journaling.
’ The first level of
journaling did not have
to be submitted;
students reported liking
the ‘safeness’ of this
’ Found Educators
effective in developing
reflection, leading to
learning, and effecting
change
’ Additionally, students
initially struggled with
the new process but by
midterm were
comfortable with the
process
’ No mention of the
challenges of group
discussion or lack of
willingness to open up
to a group
Smith
(1998)
Qualitative
longitudinal
25 undergraduate
nursing students;
24 female and 1
male; England.
Examined 47 critical
incidents, over a 3-year
period.
’ Professed learning
included understanding
self and the constructs
of professionalism
’ Journal writing was a
learned skill as the
students demonstrated
improved skills
throughout the 3years
’ Student perspective was
not explored in this
particular study
Wessel and
Larin
(2006)
Qualitative 15 undergraduate
physiotherapy
students ; all
female; United
Arab Emirates
Utilized previously
developed and tested tool
on levels of reflection;
reflections from students
first practice placement
were compared to those
from their third.
’ Tendency for
undergraduates to
engage at the lower
levels of reflection
’ Only a slight
improvement in levels
of reflection occured
over time
’ Students possibly
attended to journaling
with more engagement
knowing they were
being evaluated
’ Practice discipline;
findings not necessarily
generalizable to nursing
S. Epp / International Journal of Nursing Studies 45 (2008) 1379–1388 1383
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Table 1 (continued )
Study Design Sample Data source Findings Strength and weaknesses
’ Evidence that the
students had developed
into being increasingly
client focused
’ Some personal
transformation
reported
Williams
et al. (2002)
Qualitative 56 undergraduate
physiotherapy
students; 46
female,; 10 males;
Canada
Utilized same tool as above
study
’ 42 demonstrated a new
understanding as a
result of reflecting
’ Journal writing
demonstrated that
students were reflective
practitioners
’ Students are cited as
finding the experience
as valuable
’ Students possibly
attended to journaling
with more engagement
knowing they were
being evaluated
’ Practice discipline;
findings not necessarily
generalizable to nursing
S. Epp / International Journal of Nursing Studies 45 (2008) 1379–13881384
was conducted in only one country and at a time when
nursing education was transitioning into degree pro-
grams and universities.
3.2. Perceptions of utilizing or participating in reflective
journaling
Three older studies explored undergraduate students
reflecting on practice via journal writing (Landeen et al.,
1992, 1994; Smith, 1998). All three studies depicted
the researchers’ and educators’ perception of utilizing
reflective journaling in undergraduate nursing educa-
tion. Additionally, all three studies provided evidence
that there was value in having undergraduate students
engage in reflective journaling. Educators described
journaling that improved over time, shifts in student
perspectives, and changes in their practice. However,
knowing that the journals were part of a study would
have impacted the students’ engagement with reflective
journaling.
Landeen et al. (1992) utilized a previously developed
tool to measure 35 undergraduate nursing students’
attitudes toward mental illness before and after their
clinical experience. One group of students was expected
to engage in reflective journaling after each clinical day
and a control group was excused from the assignment;
the group that participated in reflective journaling
experienced only a slightly greater shift in attitudes
and increased comfort working with mental health
clients. One factor that may have limited personal and
professional growth, as a result of reflective journaling,
might be related to the short time frame of this study;
13 weeks.
Landeen et al. (1994) further explored the journal
entries of 18 of the above undergraduate students
to determine themes students tended to focus on in
their reflective journals. In this process the researchers
discovered that journal writing was a learned skill as
the students demonstrated improved journaling skills
throughout the 13 weeks. For example, most students
moved from describing an event to reflecting on events
and analyses of their reactions. This shift required a few
weeks and feedback from faculty despite students having
explicit instructions before beginning. The researchers
also concluded that as time went on, trust was
established between faculty and students, and students
became more open in their writings. Further, the
researchers reported that most students asserted that
journaling provided an outlet for them and affirmed that
journaling assisted them to be aware of their personal
reactions; however, the researchers did not share how
this data was obtained. It is interesting to note that ‘‘a
few students appeared unable to reflect on an experience
in any depth’’ (p. 884). Additionally, the researchers
thought some students ‘‘appeared to write what they
thought faculty wanted to hear’’ (p. 884).
Smith’s (1998) purpose was also to identify the themes
which undergraduate nursing students tended to journal
on. One part of the study involved the researcher
examining 47 critical incidents, written by 25 under-
graduate students, over a 3-year period. The findings
supported Landeen et al. (1994) position that journal
writing was a learned skill as the students demonstrated
improved skills throughout the 3-years. The study
revealed early entries had personal and professional
involvement enmeshed and that later entries demonstrated
ARTICLE IN PRESS
Table 2
Levels of Reflection utilized in Richardson and Maltby’s (1995)
study developed by Powell (1989) built on Mezirow’s levels of
reflectivity
Level Criteria
Level 1: reflectivity Discuss and describe experiences and
observations
Level 2: affective
reflectivity
Demonstrate expression and awareness
of feelings
Level 3: discriminant
reflectivity
Demonstrate the ability to assess and
evaluate their activities
Level 4: judgemental
reflectivity
Demonstrate awareness of value
judgements and their subjective nature
Level 5: conceptual
reflectivity
Demonstrate awareness that further
learning is required
Level 6: theoretical
reflectivity
Demonstrate either learning from the
experience or a change in perspective
Table 3
Levels of Reflection utilized in Williams et al. (2002) and Wessel
and Larin (2006) developed and tested by Williams et al. (2000)
Level Criteria
Level 1 Describes learning
Level 2 Analyses learning
Level 3 Verifies learning
Level 4 Gains a new understanding
Level 5 Indicates future behaviour
S. Epp / International Journal of Nursing Studies 45 (2008) 1379–1388 1385
a disentangling of these attachments. The researcher
concluded reflective journal writing beneficial. Student
perspective was not explored in this particular study.
The affirmative results may be related to the long-
itudinal design of this study; it may be that reflective
journaling is a learned skill so that evidence of higher
reflection would require a student to have an extended
period of time of reflective journaling.
3.3. Teaching innovation with reflective journaling
Riley-Doucet and Wilson (1997) piloted an innovative
strategy for reflective journaling; a three step process
that undergraduate students found positive and effective
in developing reflection, leading to learning, and
effecting change. The three step process included:
private critical appraisal, peer group discussion, and a
formal written self-reflection. The process involved the
students writing and critically analyzing critical inci-
dents in confidential anecdotal notes, followed by group
discussions of the events, with the final step being a
formal written reflection documenting their own learn-
ing. It is imperative to note that the first level of
journaling did not have to be submitted; students
reported liking the ‘safeness’ of this and the ability to
write anecdotal notes in privacy. Additionally, students
initially struggled with the new process but by midterm
were comfortable with the process and were able to
engage in critical reflection and learning occurred.
3.4. Levels of reflection achieved
Three recent studies (Richardson and Maltby, 1995;
Williams et al., 2002; Wessel and Larin, 2006) analyzed
and rated the level of reflection in undergraduate
students’ journal entries. The studies found that most
of the journal entries of undergraduate students were at
the lower levels of reflection; however, large percentages
of students made entries at higher levels.
Richardson and Maltby’s (1995) study utilized an
instrument developed by Powell (1989) built on Mezir-
ow’s levels of reflectivity (Table 2). The researchers’
analysis of the reflective journals of second year under-
graduate nursing students found that 94% of the entries
were at the lower levels of reflectivity and only 6% at the
higher level; however 22/30 students (73%) made entries
at the highest level.
Williams et al. (2002) used five levels of reflection
developed and tested by Williams et al. (2000) (Table 3).
The study involved 56 third semester undergraduate
physical therapy students at a Canadian University who
engaged in reflective journaling via reflecting on at least
one learning event from practice per week. The journal
entries were evaluated for level of reflection; 75% of
students made entries at level 4 and 39% reached level 5.
This study captured students consistently journaling at
higher levels. The researchers suggested the higher level
might be attributed to the curriculum and the students’
prior experience with reflective journaling.
Wessel and Larin (2006) also utilized the five levels of
reflection developed and tested by Williams et al. (2000)
(Table 3) to evaluate the level of reflection over time in
clinical placements. The study included 15 undergradu-
ate physical therapy students from the United Arab
Emirates. The journal entries from two time periods,
semester one and semester three, were rated for level and
compared; students demonstrated slightly higher levels
of reflection in the third placement.
The students in both semesters demonstrated reflec-
tion at levels one to four; no entries were at level five.
The researchers concluded that journaling improved
over time; a learned skill.
4. Discussion
The aforementioned research has clearly confirmed
that nurse educators report value in the process of
reflection. Three older studies (Landeen et al., 1992,
1994; Smith, 1998) explored undergraduate students
reflecting on practice via journal writing and all three
ARTICLE IN PRESSS. Epp / International Journal of Nursing Studies 45 (2008) 1379–13881386
studies provided evidence that there was value in having
undergraduate students engage in reflective journaling.
Interestingly, there was a void in the literature in
terms of undergraduate experiences and challenges with
reflective journaling on practice experiences for their
clinical educators. However, there was a paucity of
research that reported on post-registration nursing
students’ experiences with reflective journaling (Jasper,
1999; Smith and Jack, 2005). Jasper’s (1999) study
suggested that students’ perceptions switched from
thinking that writing was to show what you learned,
to writing was learning. These students testified to
developing critical and analytical thinking skills; claim-
ing that the process of reflective writing provided
confidence building that then supported them in their
decision making. On the other hand, Smith and Jack
(2005) found many students did not believe that
completing a formal reflective journal was a meaningful
activity or that it was required to be a good nurse;
however, they believed there to be a link between
reflection and quality practice. It cannot be assumed
that undergraduates experience and learn from reflective
journaling in the same way as their senior counterparts.
Exploring and gaining understanding of the under-
graduate student experience and perceptions of partici-
pating in the scheme of reflective journaling is required
to provide nurse educators with the confidence and
direction on the use of reflective journaling in under-
graduate nursing education.
Further, three studies (Richardson and Maltby, 1995;
Williams et al., 2002; Wessel and Larin, 2006) supported
that even though most journal entries of undergraduate
students were at the lower levels of reflection, under-
graduate students were indeed able to reflect at higher
levels. There was some evidence that learning to write
reflectively was a learned skill that developed over time
with facilitation by faculty and trust development
between nurse educator and student (Landeen et al.,
1994; Smith, 1998). Paget’s (2001) research, involving
600 mainly post-registration nursing students, supported
the notion that the facilitator was the pivotal factor as
he found no correlation between experience or academic
level and level of reflection.
Conversely, the hypothesis of reflective writing being
developmental has been supported in research involving
reflective writing assignments. Duke and Appleton’s
(2000) research involved various levels of students and
they uncovered that students were able to describe their
practice, but had difficulty critically analyzing their
practice and learning from it; nevertheless, over time
students demonstrated improved reflective skills. Kem-
per et al. (1999) noted undergraduate students who were
concurrently taking theory courses, whose main themes
included the concept of reflection, demonstrated higher
levels of reflection in a written assignment. Expecting
first year undergraduates to write a reflective journal at
the critical inquiry level, may not be realistic. It can be
reasonably concluded that students need to be given an
opportunity to develop reflective skills through out their
undergraduate education.
Regardless of method employed to encourage reflec-
tion, concerns about the moral and ethical risks inherent
in the process of reflection have been discussed by nurse
educators: students may be disadvantaged or positioned
at risk from having disclosed, soliciting students to share
intimate values was an infringement on the students’
right to privacy, and that reflecting might be painful or
uncomfortable because of reflection’s capacity to identi-
fy a need for change (Burnard, 1995). There was some
evidence that undergraduate students found writing, as a
mode of reflecting, challenging and at times problematic
(Landeen et al., 1994). Riley-Doucet and Wilson (1997)
showed that using conversations and writing concur-
rently was beneficial. Another educator took journals
from paper format to electronic format; journaling for a
communication class via a web log (blog) (Bouldin et al.,
2006). Students complained about having to think about
course content outside of class; ironically, this was the
engagement educators valued and believed facilitated
learning. The development of innovative strategies for
the reflective journaling is paramount. With technology
advancing and students becoming more ‘computer
attached’, nursing educators should capitalize on the
utilization of technical modes of learning.
Reflection is multifaceted, so it stands to reason that
more than one strategy could be employed to teach and
encourage reflection. Nurse educators described the
reflecting they most often engaged in as a mental or
conversational exercise (Burnard, 1995). Nurses in practice
concurred, declaring thinking and talking as their preferred
venues of reflection as they look back and contemplate
(Gustafsson and Fagerberg, 2004). The notion that
reflection can occur conversationally was supported by
Wong et al. (1995) when the post registration students’
levels of reflection were similar in both interviews and
written work. Additional researchers concurred that rich
reflection occurs in discussion groups (Platzer et al., 2000;
Ling Lau and Cheung Chuk, 2002; Heidari and Galvin,
2003; Gould and Masters, 2004). In relation to under-
graduate students, post-conference meetings were found
valuable for facilitating reflection when practice and
specific cases were discussed (McCaugherty, 1990).
Intriguingly, much of the literature on reflection speaks
of the nurse educators’ responsibilities for facilitating
reflection but fails to identify what students have that
facilitates reflection; exploration of strategies and strengths
of students who are able to reflect at high levels could
spawn strategies to build strengths in all students. The
research has begun to discover some of the barriers that
students find thwart the process of reflection; unfortu-
nately, there is a void in the research as to what facilitators
and barriers exist for the undergraduate nursing student.
ARTICLE IN PRESSS. Epp / International Journal of Nursing Studies 45 (2008) 1379–1388 1387
5. Conclusion
Indeed there was only limited evidence to support
reflective journaling as an appropriate tool to promote
reflection for the purpose of learning from practice for
practice in undergraduate nursing education. Researchers
found reasonable levels of reflection in undergraduate
students’ journaling and educators reported learning as a
result of reflective journaling. Further to this, there was
evidence that writing reflectively improved over time; a
learned skill also dependent on a good facilitator and
trust.
Unfortunately, there was a paucity of research that
explored the undergraduate nurses’ experiences with the
process of having to create written communication, with
a critical reflective focus on practice. Inviting students to
reflect is asking students to share their deepest thoughts;
nurse educators are entrusted with this information.
Nurse educators need to be respectful of this privilege;
the building of trust will provide permission for the
student to explore their own thoughts in a deeper,
meaningful way. Research that provides insight into the
undergraduate student experience, perceptions, and
outcomes of reflective journaling is needed to validate
the continued use of reflective journaling as a way to
develop reflective skills. Further to this, understanding
undergraduate student experiences and perspectives
could inform guiding principles and strategies that
would serve to make reflective journaling more valuable
and desirable.
Educators need to hold onto their ideals and continue
to ‘‘teach to change the world’’ (Brookfield, 1995, p. 1).
Nurse educators are correct in pursuing the teaching and
learning of reflection in undergraduate nursing educa-
tion and it behooves them to utilize various tools and
strategies for facilitating the growth of undergraduate
students into reflective practitioners. Reflective activities
provide students with opportunities to critically think;
but just as importantly, reflective activities are an
invitation to be true to nursing and shift away from
the medical model of viewing the world (Johns, 1995;
Glaze, 2001; Platzer et al., 2000). Reflection can provide
personal learning and transformation; understanding
self serves to influence the student nurses’ values and
assumptions and builds self-actualization (Richardson
and Maltby, 1995). A nurse who has improved personal
attributes will be the improved nurse, and be better
positioned to provide excellent patient care.
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