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Introduction
The student was shaking and almost completely white. I am so frightened. What if I do something wrong? Will I make it through the shift? Are these feelings normal? Will I fail because I cannot get my feelings under control? Do others feel the same way I do?
I wished I could share with her one of the first times I felt the terror of a new situation. I was a student in the 3rd year of nursing, and the nurse with whom I was working had to go to a meeting. I was alone in intensive care with a very sick child. There was a registered nurse (RN) in the next room whom I could call for if I needed help, but it is not the same as the RN standing beside me.
"Dear child, do not stop breathing!" I whispered. "I really do not know what to do." My face felt hot and my mouth felt dry. "Yes, the nurse has confidence in my ability to watch you, but why do I feel this way? Should I admit my feelings? Would I fail this course?" I took a deep breath and watched the ventilator methodically deliver breaths of air. The child was slowly turning from a pale color to a pink color. "Lord, help me get through this experience."
The student said, I did not learn anything last quarter. Class was so boring.
I had high expectations of learning to teach nursing. But I, too, remembered the boring classes. Often, the teachers read directly from our textbooks. After 20 minutes I lost interest even though the teacher asked questions, moved about in the room, and even varied her voice. Was this the way I wanted to teach? Are there other methods I could learn to utilize so that my teaching would come alive?
The student said, I have learned more this quarter than I ever have. You really made me think. Learning was so much fun. I loved the group work. I wish every class was like this.
Cooperative learning, what is this? Do you mean students can learn from each other? What do you mean the teacher is not the focus in the classroom, the students are? I do not need to know all the answers! I find students can actually participate in knowing the answers. Accountability, responsibility, positive interdependence—learning together in a group can be fun. Teaching has come alive again. If I can start slowly and gradually build in order to help others to learn to teach this way, what an "awe-inspiring" experience this will be!
The preceding written statements are dialogues from students whom I have taught in the past 6 years. I have included my thoughts. These experiences have spurred me to study pedagogical methods that will enrich the students' experiences so they can achieve their goals of being professional nurses.
In this chapter I discuss issues related to nursing, to nursing education, and,

more specifically, to clinical education. The purpose of this dissertation and the guiding
questions of this study are discussed.

Issues in Nursing
Society is rapidly changing and so are the expectations of the health care system. According to Heaslip (1996): "The health care system is experiencing demands from the public for increased access to nursing and medical care within the constraints of limited financial, physical and personnel resources" (p. 3). It is common for a new graduate to care for clients with multiple medical diagnoses and multiple pieces of technical equipment connected to these patients. Not only is the new graduate to care for many clients, but he or she is to coordinate the care with multiple health personnel as well as to work with less technical personnel such as nurse aides and medical assistants. A registered nurse must have the skills of teamwork, critical thinking, and problem solving as well as self-confidence, flexibility, and innovation (Walton, 1996) while working in this complex changing world of the practical setting. Health care, including hospital administration, is demanding nurses to possess all of these skills.
So where do nurses learn to be flexible and confident? How do they become critical thinkers and team members? It starts with education and the resourceful ways we teach students to interact and think critically in the clinical setting.
Issues in Nursing Education

Education for the clinical setting starts in the classroom. Unfortunately, according

to Pitts (1985), "nursing knowledge is transmitted via passive learning with standards of professional instruction and supervised practice" (p. 37). As a result, nursing education has often been inadequate in preparing students to develop clinical decision-making skills and to become critical thinkers (Jenks, 1992). The sixth objective of the National Education Goal 5 emphasizes that, by the year 2000, "the proportion of college graduates who demonstrate an advanced ability to think critically, communicate effectively, and solve problems will increase substantially" (National Educational Goals Panel, 1994, p. 10). Nursing education recognizes the need to teach critical thinking, and decision-making and problem-solving techniques to students. The National League for Nursing (NLN), the accrediting body for B.S./A.S. nursing schools, has mandated that nursing schools establish outcome criteria for critical thinking as a part of the curriculum (National League for Nursing Association Commission, 1997).
According to Walton (1996): "Old assumptions and methods of educating nursing students must be examined in the light of changing expectations and health care delivery systems" (p. 400). Nursing education needs to find new avenues of approach that will include the use of the increasing amount of knowledge needed to be applied to the curriculum content (Heaslip, 1996).
One of the strategies that may promote critical thinking is cooperative learning. Nurse educators recognize the merits of using cooperative learning to teach nursing content (Boltz, Boltz, & Glenn, 1993; Glendon & Ulrich, 1992), but the research in cooperative learning in nursing is sparse. Ashley and O'Neil (1994) show that nursing students (high risk) who studied cooperatively achieved higher scores on state boards than a control group that had no interventions. Other research has shown an increase in students' knowledge (Hiebert, 1996; Houston, 1990), and an increase in key cognitive activity (Higgins, 1991), an increase in peer socialization and in positive attitudes toward learning (Beck, 1992) as a result of using cooperative learning in the classroom.
As a nursing educator I have used cooperative learning in my classroom. I believe it facilitates problem solving and critical thinking. At first it was a challenging strategy for me to use. Coming from a traditional background, giving up "control" of the knowledge to adopt a collaborative role was new and different for me. After all, I was the imparter of all knowledge, or so I thought. The Johnson, Johnson, and Smith (1998) model taught me the importance of establishing an environment that promotes exchange between the student and the teacher and the student and other students. Gradually, the comments from my classroom changed from this is boring to I really learned a lot from this class. You really made me think. Because of these comments I was driven to continue the search for methods that will help nursing students expand their thinking in applying nursing theory to clinical settings.

Issues in Clinical Education
The goal of undergraduate nursing programs is to develop "an autonomous, accountable practitioner who has not only the practical skills necessary to deliver high quality nursing care, but also the broad knowledge base and analytical ability to make informed decisions about care" (Jinks, 1991, p. 127). Student nurses spend two-thirds of their hours of nursing education in the clinical setting, and yet it is "the least understood of all nursing education activities" (Infante, 1981, p. 16). Tanner and Lindeman (1987) identified six of the top research priorities related to clinical teaching:
1. What method of instruction best develops clinical problem-solving skills at baccalaureate and master's levels?
2. What is the most effective approach to teaching clinical nursing skills?
3. What clinical teaching strategies are more conducive to the development of professional qualities: e.g., critical thinking, accountability, change agent?
4. What types of clinical performance evaluation strategies are most reliable and valid?
5. What factors enhance the transfer of didactic learning into clinical practice?
6. What factors in clinical experience (e.g., number of hours, rotations, faculty/student ratios) are associated with the level of performance at graduation? (p. 56)
A recent review of literature indicates the concerns regarding clinical teaching are still there. Krichbaum (1994) states:
Professional nursing education is costly, time-consuming, and inundated with methods passed from generation to generation of nursing faculty as practical wisdom about effectiveness in clinical teaching. Few aspects of clinical teaching have been investigated empirically, let alone validated. (p. 314)

Clinical education is a complex activity. The clinical experience is often unpredictable and difficult to control. The nurse-educator not only needs to ensure that the nursing student acquires knowledge and problem-solving ability, but needs to protect the patient from harm by ensuring that the student practices safe care. As a clinical educator, I guide the students through the complex and ever-changing situations of the clinical experience so they can analyze and synthesize information learned in the classroom and connect it to the practical situations they face.
The challenge of teaching nursing students in the clinical setting made me wonder if pairing students as they care for the patients would have the same benefits as pairing students in the classroom setting. Some of the classroom benefits include increasing problem-solving skills, critical-thinking skills, self-confidence, communication, and social interaction (Johnson, Johnson, & Holubec, 1994; Sharan & Sharan, 1990).
In reviewing literature on cooperative learning in the nursing clinical setting, I did not find the term cooperative learning. The closest terms are collaboration, teamwork, dual (two students at the same level working together on one patient; instructor has given a clear specific task for each student to perform), multiple or shared assignments (two students at the same level working together on one patient) and reciprocal learning (students on the same level evaluating each other's skills). Baird, Bopp, Schofer, Langenberg, and Matheis-Kraft (1994) found that in a collaborative activity between a student and an RN mentor there was an increase in self-confidence and a decrease in anxiety. Warner, Ford-Gilboe, Laforet-Fliesser, Olson, and Ward-Griffin (1994) concluded that a shared assignment in a community experience offered students the opportunity to learn about collaboration in the clinical setting. Two articles advocate the use of dual assignments (Fugate & Rebeschi, 1992; Gotschall & Thompson, 1990) as a way to increase faculty quality time with the student and to increase problem-solving skills.

My Pilot Study
Because very little research has been done on the benefits of cooperative learning in the clinical setting, I conducted a pilot study to investigate the feasibility of pairing students in the clinical setting. I used qualitative research processes because they allowed me "to focus on identifying, documenting, and knowing (by interpretation) the world views, values, meanings, beliefs, thoughts, and general characteristics of life events, situations, ceremonies, and specific phenomena under investigation" (Leininger, 1985, p. 5). I wanted the students' viewpoint on their experience which can best be studied by using this method. In the pilot study I formed two pairs, and the paired students reflected on their experiences through the use of journaling. They also shared their experiences with me during two interviews during the quarter. The themes that emerged seemed consistent with previous research on cooperative learning.
The first themes—psychological health, self-esteem and self-confidence—emerged in statements such as:
Working together increased my self-confidence; it made the experience not only fun but also kept the stress level down, which I believe will help us become better nurses (Journals of D. R., p. 1; P. K., p. 11).
Davis (1995) indicated that anxiety associated with the learning environment was reduced through peer support and cooperation.
A second powerful theme that emerged was the use of thinking skills.

We learned from each other. We found in working together we could challenge each other to think and to work toward improving our skills (Journals of M. P., p. 8; S. D., p. 9). Because the decisions nurses make affect people's lives, developing critical thinking is the most important and challenging goal a nursing student can accomplish (Alfaro-Lefevre, 1995).
The third theme that emerged was positive relationships and attitudes. The following statements made by the students illustrate this:
I appreciated input from my partner. We could talk things over. I missed my partner when she was sick. There was no one else to share the new experiences with. As we worked together, we discovered that our communication skills increased. We were
able to organize ourselves better and get things done. Clinicals were fun to do (Journals P. K., p. 3; S. D., p. 7). Johnson et al. (1998) have shown that cooperative learning brings about more positive attitudes toward material studied, class instruction, and personal relationships.
While observing the students working together, I found it was quite common for them to be side-by-side discussing how they could prioritize their time and how they could share activities. I also observed eagerness when coming to clinical labs and the regret to go home. They enjoyed learning together.
Because of the pilot study, I was able to set up certain guidelines for using cooperative pairs in the clinical setting, but I did not want to stop there. I agreed with Batson (1997) who said, "to function well in a society of rapid social and technological change, schools need to become teaching-learning communities through which not only the children but also teachers, parents and administrators learn and grow" (p. vii). I had allowed experience to be the teacher of knowledge, but I was still faced with the challenge of continuing to develop strategies that would help students solve problems, make safe clinical decisions, interact as a team member in the clinical setting, and in the process bridge the gap between theory and practice. This led to the purpose of my study.
Purpose

The purpose of this dissertation is to describe students' clinical reflective processes as they problem solve while working individually and in pairs caring for patients. The secondary purpose is to describe my experience as I initiated journal writing individually and in pairs while students worked in the clinical setting.

The Questions
The primary question is: How can clinicals be organized so students link theory to practice? Because this question can have multiple answers, I chose two related major questions for this case study research:
1. How does the journaling process influence reflection on problem solving in the clinical setting?
2. How can the clinical experience be evaluated for the presence of reflective processes?
The Posture of the Researcher

By including my experience with the experiences of the students in this research study, it allows me to bring understanding of "how the environment acts on itself as well as how the inquirer [me] causes it to behave in different ways" (Guba & Lincoln, 1981, p. 129). I bring my knowledge and my way of knowing in describing and interpreting the phenomenon as it is presented. Lastly, by including my experience, the process of being the tool of the inquiry provides an opportunity "to explore new areas of knowledge and to gain a fresh perspective about traditional and new views of the nature of nursing" (Leininger, 1985, p. 22).
Because the experience is mine, I am explaining, describing, and interpreting the information as I view it. Because the knowledge I have gained through reflection, observation, and interaction with the students is a part of this experience, I believe using the first-person voice is the best way to communicate to readers the results of this research study.

Definition of Terms
The following are definitions of terms as they will be used throughout this study:
Critical Thinking: "Reasonable reflective thinking that is focused on deciding what to believe or do" (Baker, 1996, p. 19). "Critical thinking is thinking about your thinking while you are thinking in order to make your thinking better" (Paul, 1993, p. 91).
Clinical Experience: An experiential activity whereby nursing students learn to care for a patient in the hospital setting.
Decision Making: The formulation of a hypothesis based on combined facts from appropriate knowledge bases and from the selection of nursing interventions that best meets the needs of the patient. It includes the thoughts that preceded the choice of the intervention.
Journal Writing: To express personal thoughts in written form, guided by specific questions related to problem solving and thinking.
Nursing Process: "A systematic, rational method of planning and providing individualized nursing care. Its purpose is to identify a client's health status, actual or potential health care problems or needs; and to deliver specific nursing interventions to meet those needs" (Kozier, Erb, Blais, & Wilkinson, 1995, p. 83). The nursing process is an adaptation of problem-solving techniques.
Reflection: "An important human activity in which people recapture their experience, think about it, mull it over, and evaluate it" (Boud, Keogh, & Walker, 1985, p.19).
Problem Solving: "The process used to resolve or answer a proposed question or achieve an answer to a client's need" (Klaassens, 1992, p. 29). It involves defining the problem, gathering information, analyzing the information, developing solutions, making a decision, implementing the decision, and evaluating the solutions.

Summary
Nursing students spend two thirds of their educational time in the clinical setting working directly with patients. Nurse educators realize that in this complex setting, they need to develop strategies to maximize student learning while ensuring patient safety. Because there is very little research on strategies that promote problem solving, teamwork, and reflection (critical thinking) in the clinical setting, this study describes tools developed to promote and evaluate the outcomes of the clinical experience. The following chapters describe the clinical experience where journaling was incorporated into the clinical requirements.