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Introduction

The purpose of this dissertation is to describe reflective processes when used by nursing students while working individually and in pairs. The secondary purpose is to describe my experience as I initiated journaling individually and in pairs while students were working in the clinical setting. This study is conducted to inform nurse educators about creative strategies that can be used to link theory and practice together and to improve problem-solving abilities, reflection (critical thinking), and team work.
This chapter presents the following: (1) reasons for using case study research as an appropriate methodology, (2) a description of the persons involved as a part of the context of the research, (3) a description of how the data were collected and analyzed, and (4) a discussion of the importance of being researcher, teacher and person sharing this experience as a part of learning about and understanding the phenomenon as it unfolds.

The Big Approach

In studying the clinical setting, it is difficult to separate one particular strategy that will assist students in functioning safely and in developing strong clinical problem-solving skills. There are many complex as well as confounding activities the students must learn to surmount while learning to care for the patients. As an educator wanting to develop strategies for assisting nursing students learning in the clinical setting, I agree with Leininger's (1985) statement "that the goal of qualitative research is to document and interpret as fully as possible the totality of whatever is being studied in particular contexts from the people's possible viewpoint or frame of reference" (p. 5). Qualitative research aids in capturing the essence or nature of the students and their activities as they change over time.
There are many types of qualitative research, and I have chosen case study method to be used in this dissertation because it matches the purpose of the study. There is very little information in the literature that describes strategies useful in the clinical setting, particularly, strategies that promote multiple skills (i.e., problem solving, reflection, critical thinking, and teamwork) such as this dissertation intends to do. Thus, this dissertation fits the definition of case study by Stake (1985): "The study of a single case or bounded system, it observes naturalistically and interprets higher order interrelations within the observed data" (p. 277). And also Yin's (1994) definition of case study: "A case study is an empirical inquiry that investigates a contemporary phenomenon within its real-life context, especially when the boundaries between phenomenon and context are not clearly evident" (p. 13).
Because it is difficult to separate the many "variables" in studying a class in a real-life context (the clinical setting), case study is the most appropriate method to use. Merriam (1998) states, " A case-study design is employed to gain in-depth understanding of the situation and meaning for those involved" (p. 19). In this dissertation
understanding about the methods of journal writing and being paired will be gained by studying students in the clinical setting.

Context of the Study

The participants of both case studies were nursing students enrolled in a seven-credit, third quarter, Nursing III course. The course is offered through the Department of Nursing in a liberal arts college. The college offers an opportunity for a liberal arts education in a variety of programs in the arts and sciences and professional fields. The college recognizes the importance of critical thinking as stated in the mission statement. "Beyond giving information, the disciplines of the liberal arts create the environment for students to develop their abilities to think analytically, critically, and independently" (College Bulletin, 1996-1998, p. 12).
The Department of Nursing has three programs—a Licensed Vocational Nurse (LVN) to Registered Nurse (RN) program: an Associate of Science Degree (ADN) program, and a second-step Bachelor's of Science in Nursing Degree program. The students in this study are enrolled in the Associate of Science Degree program. At the end of the program the students may take the National Council of Licensing Examination (NCLEX) for registered nurse licensure. The mission of the ADN program agrees with the college mission: "to create an environment that fosters critical thinking and instills a desire for ongoing inquiry" (ADN Student's Handbook, 1998, p. 2). The philosophy of the Department of Nursing regarding education states,
Each student brings a unique life experience to the learning situation and has individual potential and goals. The educational system provides a variety of resources which include creative teaching and learning partnerships. These interactions enhance the spirit of inquiry, encourage critical thinking and lead to acquisition of knowledge. (ADN Student's Handbook, 1998, p. 3)

The ADN program is accredited by the National League for Nursing (NLN) and as such meets their requirement for having critical thinking as an expected outcome of the program. The student: "(1) demonstrates critical thinking which enhances the concepts of nursing, humanity, health and environment in a dynamic world. (2) exhibits excellence in clinical judgment in the roles of the Associate Degree nurse" (ADN Student's Handbook, 1998, p. 6).
All students in both class groups were asked to participate, to keep the class intact, and to keep the experience as real as any instructor would encounter. Each student agreed by signing a consent form. There were 19 in the unpaired group, January to March 1998; the students' ages ranged from 19 to 39 with the mean of 25. The cultural backgrounds were eight Caucasians, four Hispanics, two Filipinos, one African/Caribbean, and four Asians. Six of the 19 students entered the programs from high school; the rest entered several years after high school. Two students were male and 17 students were female. There were 20 in the paired group, April to June, 1998, the students' ages ranged from18 to 48, with the mean of 25. The cultural backgrounds were four Filipinos; four Asians; two Hispanics; and 10 Caucasians. Eight of the 20 students entered the nursing program directly from high school, and 12 entered several years after high school. There were five males and 15 females.

Setting
The setting is a weekly clinical experience in an acute care hospital on adult medical-surgical units. The clinical experiences are 9-hour days from 2:30 p.m. to 11:30 p.m. There were a total of 9 clinical days. Two of the clinical days were spent in the operating room observing surgeries and in respiratory therapy learning to assess lung sounds. Patient care responsibility included head-to-toe assessment; administration of oral, parenteral, and intravenous medications; conduction of treatments; and charting and assisting patients with p.m. care (e.g., back rubs, mouth care, and peri care). Included in the 9-hour clinical days were a 15-minute pre-conference and a 45-minute post-conference; students were allowed to ask questions and discuss issues that had arisen during the shift. Spiritual care, communication techniques, and problem-solving skills were also discussed. As the clinical instructor, I supervised 10 students on Wednesday evening and 10 students on Thursday evening. Student performance was graded on a satisfactory/unsatisfactory scale.

Pairing of Students
I followed Johnson et al.'s (1994) procedure for grouping of pairs by stratified random assignment. The teacher rank orders the students based on a criteria and then groups the students by high achievers with low achievers and middle achievers with middle achievers. I asked the previous clinical instructors from Nursing I and Nursing II to rank the students' clinical performance and critical-thinking ability using the Holistic Critical Thinking Scoring Rubric (see Appendix A1) (Facione & Facione, 1996a). I then paired the students, based on the information obtained from the teachers (see Appendix A2). Those students with a critical-thinking score of 4 were paired with those with a critical-thinking score of 2, and students with a critical-thinking score of 3 were paired together. Every clinical time with the students gave me the opportunity to observe their work and their efforts to communicate and problem solve together.

Sources of Data

Sources of data to describe students' reflective processes (critical thinking) and the experience of unpaired students and paired students include: (1) weekly reflective journal writing (over 9 weeks), (2) two structured interviews with paired students only, and (3) my observations recorded in journal writing.

Journal Writing

Students' were asked to keep a weekly journal about their clinical experience. Unpaired and paired students answered specific guided questions (see Appendix A3) in their journals. The unpaired case group had one journal book each. For the pair, there was one journal book shared between them to encourage them to discuss together the answers to the questions and then write their answers. Facione and Facione (1996a) explain why the use of journal writing and talking help the observer assess for critical thinking. "To assess critical thinking in either nursing knowledge development or clinical-decision making, one's thinking processes must be externalized for others to observe and evaluate. For example, to permit education to assess clinical judgment in their students, the processes of making those judgments must be readily apparent by being spoken, written, or demonstrated" (p. 135). In others words, in order for me to study the phenomenon of reflection there has to be an observable behavior.
Second, I used guided questions (see Appendix A3) because the students were new to the process of journal writing, and I wanted the questions to reflect the metacognitive process that surrounds the problem-solving process. The metacognitive process is exhibited by: "(1) analyzing and characterizing the problems at hand; (2) reflecting on what one knows or does not know that may be necessary for a solution; (3) devising a plan for attacking the problem; and (4) checking or monitoring progress" (Pesuit, 1992, p. 149). Again, by having an external device such as writing, the teaching can help facilitate the thinking process. Lastly, by having questions similar to "what do I really know about the nursing care situation, and how do I know it?" (Paul & Heaslip, 1995, p. 40), the teacher is assisting nursing students in beginning the process of critical reasoning and facilitating the process of making the nursing knowledge part of their own thinking process.
Questions 1 through 6 were patterned after the steps of the nursing process and problem-solving process, as well as key questions used in critical thinking (Alfaro-Lefevre, 1995). Questions 7 and 8 were taken from Patton et al.'s (1997) list of questions used in journal writing. Question 9 was an open-ended question for the students to identify thoughts and feelings around the clinical experience. This was based on Boud et al.'s (1985) model of reflection with the importance of identifying feelings in the reflective process.

Interviews

Two structured interviews were conducted that lasted 10 minutes, one at midterm and one at the end of the quarter. Each interview was aimed at how the individual was functioning as part of a pair. One question asked: "What problem-solving techniques are you using when a conflict arises while you are working together?" At the last interview a second question asked: "If you were to continue this partnership, what strengths would you carry on and what areas would you need to strengthen as you continue to work as a team?"

Participatory Observation

As a researcher, I did direct observation of the clinical setting. According to Merriam (1998), the reasons for direct observation are "to triangulate emerging findings with interviews and journal analysis" and "to provide some knowledge of the context" (p. 96). Knowledge of the context can be used later in clarifying what you have observed with the interviewee. I kept a journal of my thoughts, feelings, and questions as I worked with the students in both case studies, thus allowing me to practice being a reflective practitioner, as Schön (1991) recommends professionals should be to help generate research.

Protection of Human Subjects

Those participating in the study were asked to sign a consent form (see Appendix B). The consent form and the proposal for the study were reviewed and approved by the Human Subjects Review Board at the institution where I teach and from Andrews University. The signed written consent form indicated the students' desire to participate in this study.
Since journal writing, interviews, and observation can convey students' personal information, and thus lead to stress and anxiety, as well as to feelings of breech of privacy, the following measures were reviewed with the students to reduce the risk of breech of confidentiality.
Measures reviewed prior to the onset of the study were:
1. Students were informed that participation in the study was completely voluntary and they were free to withdraw from the study at any time without reprisal.
2. Students were informed that their decision whether or not to participate would in no way affect their grade in the clinical evaluation. They were also informed that the journals would not be graded.
3. Although their care plans received a group grade, their performance evaluations were graded individually, thereby encouraging individual accountability.
4. Students were told I would keep a journal of my own observations and personal feelings, but, like their journals, their names would not be used in the study or in publications. The material solicited from my journal and from their journals would be carefully written so that the students' identity would not be revealed.
5. Students were informed that only the researcher and persons associated with the research project would have access to the text generated. For other individuals who might be in contact with the research project, all journals would be coded with numbers to ensure anonymity.
Data Analysis
Data analysis was based on the qualitative techniques of Miles and Huberman (1994) and the case study methods of Merriam (1998) and Yin (1994). In this process I analyzed the written journals of both case study groups for ideas and patterns. I clustered the patterns and examined them for themes and then named the categories. For instance words such as anxiety, stress, enjoyed, and great experience, I named as emotions and emotions became the category or the theme. Only the ideas that were found in the majority of the journals were classified as a theme. Although I had done some preliminary review of the literature, during the process of analyzing the themes, I allowed the data to speak for itself and named the themes accordingly. Next the description of the themes were integrated into a case study report. In the cross-case analysis, I compared the themes of the unpaired case study with the paired case study and then answered the research questions.
To determine how students reflect in the clinical setting, a rubric was developed in conjunction with a professor of education to evaluate the growth in reflection over time.
The rubric was based on the types of reflection as described by Mezirow (1991) and the reflective model of Boud et al. (1985) (see Appendix A4). Criteria "A" was considered nonreflective action (Mezirow, 1991) since the student was telling only what happened with little thought involved. Criteria "B" of the question was given a point if there was reflective action. This reflective action included what the student perceived, thought, felt, or acted upon in the process of problem solving (Boud et al., 1985; Mezirow, 1991).
The B criteria were compared with the stages of Boud et al.'s (1985) reflective model. These stages are: (1) attendance to feelings, (2) association, (3) integration, (4) validation, (5) appropriation, and (6) outcome and action. Questions 1and 2 were related to integration. In the integration stage the "individual begins the process of discrimination" (p. 32). This is the seeking of relationships or prior knowledge. Questions 3, 4, and 6 were closely related to the association stage. During the association phase "there is the connecting of the ideas and feelings which are part of the original experience and those which have occurred during reflection with existing knowledge and attitudes" (p. 42). Questions 8 and 9 best fit stage 4, where in the validation stage, the individual tests what he or she starts to integrate. This can be started by describing what steps can be taken to promote a change in the behavior. Questions 7 and 9, part A, were related to stage 1, but because this entailed more naming of their thoughts and feelings then starting to remove obstructing feelings or utilizing positive feelings, they were not included as part of the reflective process. Because stages 5 and 6 were considered as features more of critical reflection and probably not observed at the beginning levels of reflection, they were not included in the rubric.
Following is the reflective rubric that was developed and used to evaluate each journal:
___ 1. A. Identifies one major significant problem.
___ B. Identifies other related problems; may include reasons for the problem. (Integration)
___ 2. A. Identifies a problem that arose.
___ B. Explains reason for urgency or lack of urgency. (Integration)
___ 3. A. Identifies one piece of knowledge needed to solve the problem.
___ B. Identifies connecting pieces of information needed. (Association)
___ 4. A. Uses external resources, when appropriate, to solve the problem.
___ B. Recognizes personal resources as a resource. (Association)
___ 5. A. Identifies all logical steps as a part of implementation process.
___ 6. A. Uses reliable external reasons to influence thinking.
___ B. Uses internal reason to influence thinking. (Association)
___ 7. A. Identifies one strength connected to patient care.
___ 8. A. Identifies one weakness connected with patient care.
___ B. Explains how to improve on their weakness. (Validation)
___9. A. Names obvious thoughts and feelings connected to patient experience.
___ B. Expands reasons for feelings or thoughts from the experience. (Attendance to feelings and Validation)
For this study, only the B areas were added together for the individuals in the unpaired group and for each set of pairs in the paired group for the total of 7 points possible. Then the means were calculated weekly for the unpaired group and the paired group (see chapters 4 and 5 for the results). To determine reliability there were three coders—the principal investigator; a professor of education; and a nursing instructor in medical-surgical nursing. The formula used to determine inter-rater reliability was from Miles and Huberman (1994). Forty items were analyzed by the professor of education and me with inter-rater reliability of .90, and 1840 items were analyzed by the nursing instructor and me with the inter-rater reliability of .87. Inter-rater reliability was calculated by dividing the number of agreed upon responses by the total possible responses.

Trustworthiness
The questions that faced me like any other researcher using qualitative research were: "Can the results of this research be trusted?" and "How can I convince the reader that what I wrote was an accurate portrayal of the experience?" In order to answer these questions there are strategies that the researcher can use.
One such strategy is structural corroboration. Eisner (1991) describes structural corroboration as "a confluence of evidence that breeds credibility, that allows us to feel confident about our observations, interpretations, and conclusions" (p.110). This is partially accomplished through multiple sources of data. In this study, evidence of themes occur in observations, interviews, and journals.
These themes were written in the case studies in such a way to provide a compelling case. "The tight argument, the coherent case, the strength of evidence are terms that suggest rightness of fit" (Eisner, 1991, p. 111). By including descriptions of what was observed and analyzed, the researcher believes that readers will be able to determine how close the research is to their own situation and will be able to use the information presented to understand and extend their experience. This has already happened with nurse educators who have read or discussed my findings.

Writing Style
In this dissertation I have chosen to write the students' journal comments as an integral part of the text. This promotes active voice as I blend student ideas with my own research. This is consistent with Zeller and Farmer's (1999) argument that "qualitative researchers [need] to develop their own style guidelines—ones more fitting to qualitative assumptions about knowledge, ones more reflective of action practices of qualitative researchers." (p. 1). Thus, instead of using traditional quotation marks, I have used italics to separate students voices from my own.

My Presence as a Researcher
Being both researcher and teacher, my relationship to the students took on a new dimension. When I first asked students to participate in my research, they were very hesitant. Their picture of research was composed of rats running around a maze or a laboratory attendant doing something painful to them. They may have first felt inhibited or anxious about their experience. Could they really trust me? After all, could their words in writing and their actions cause them to fail? Developing a trusting relationship was important. I knew from my previous experience with the students in my pilot study that by my giving clear explanations with no judgmental statements the students would soon become more expressive of their feelings. Their confidence, also, would grow as they could see that they were actually having a part in real, live research. Their opinions could make a difference in how I could strengthen the strategies for the clinical setting.
I entered the study with my own unique context. This context allowed me to respond to the situations that I encountered. It helped me to interpret and explain what was seen, and, as a result, gave my own signature to the study (Eisner, 1991). My professional background includes experiences in medical-surgical nursing. I have a Master's of Science degree with an emphasis in Adult and Aging. I taught in Africa for 4 years, during which time I was also the director of a nursing diploma program. For the last 6 years I have taught medical-surgical nursing at the college where I am presently employed. For the last 5 years I have incorporated cooperative learning principles into the classroom, thus bringing experience and knowledge to the study.
Second, in case study inquiry, Eisner (1985) suggests that the researcher is a teacher. Stake (1994) expands this concept further:
Teaching didactically, the researcher teaches what he or she has learned. Arranging for what educationists call discovery learning, the researcher provides material for readers to learn, on their own, things the researcher does not know as well as those he or she does know. (p. 240)
My students and I bring to the reader knowledge of the phenomenon of learning in the clinical setting as it unfolds in its naturalistic experience. The bringing of self and the experiences of the students to the reader helps the reader to see the experience from several points of view and thus to see a different perspective (Eisner, 1991). Therefore being a teacher, researcher, and the instrument of research, I "assist the reader in the construction of knowledge" (Stake, 1994, p. 240) thereby making the study subjective. But without the subjectivity, the voices of the students and the researcher are not heard. Those voices make the experience meaningful and understandable to all who read the research. Consequently, biases are present in a qualitative study and, as such, I need to be aware of them and make them known to the reader.
When I entered the study one of my biases was that I believed students are interested in participating in their learning and, as such, they could make that experience meaningful to themselves. They can provide a view of their learning situation that will contribute to the development of my pedagogical methods. Another bias was that I had been using cooperative learning in the classroom and I believe that cooperative learning would work in the clinical setting.

Strengths of the Study
With case study research, the case allows the researcher to examine the complexities of the situation. It allows the researcher to make a connections of ordinary practice in its natural setting to the academic setting (Stake, 1994). There was no attempt to control the external environment and thus the researcher can then describe the behavior occurring naturally (Merriam, 1998).
The strength of case study research is to provide an understanding of the complex phenomenon in its natural setting. The clinical setting is very complex. Students have only a short time to learn, to function, to start to think as a nurse. By using case study inquiry, I, the teacher and researcher, can provide an insider's perspective of a pedagogical method that can assist students to function safely and competently in the clinical setting.
In order to provide description and interpretation of a lived experience as it emerged, all students were included in the study.
Summary
There are many complex and confounding activities that nursing students must learn as they care for the patients in the hospital setting. The intent of this case study is to describe the lived experience of the students and the teacher as they work together. The context of this study took place in a nursing program at a liberal arts college. The method chosen was journal writing individually and in pairs. These journals were analyzed for themes and by a reflective rubric which was developed and adapted from Boud et al.'s (1985) reflective model. Included in this chapter is a description of how the human subjects were protected, my presence as a researcher, strengths and limitations.
In the following chapter, the lived experience of nursing students as they work individually in the clinical setting will be described as it unfolds in the emergence of themes. The results from the analysis of the journals by the reflective rubric will be explained.