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Nursing education, like any other professional education process, needs to develop tools to assist the student in thinking, whether in the classroom setting or the clinical experience. "Neither the hand nor the mind alone would amount to much without aids and tools to perfect them" (Bacon, 1623, cited in Brown, 1994, p. 4). This task is not always easy, but developing tools supported by theories can assist students to be active constructors of knowledge within their educational experience (Brown, 1994). In this case study, that is what I set out to do—develop tools that will assist nursing students to reflect on problems in the clinical experience. I endeavored to do this by having the students journal in response to focused questions related to problem solving. Because I wondered if collaboration and journal writing were "tools" that might influence reflection and problem solving, I set up two different scenarios: (1) clinical nursing students using journals as individuals and (2) clinical nursing students functioning as pairs both on the hospital floors and in the reflective/journaling process. In this chapter, I answer the research questions by describing how the two case studies are alike and different in the use of reflection as a critical component of the learning process.

The Clinical Experience
In this section, I answer Research Question 1: How does the journaling process influence reflection on problem solving in the clinical setting?
With the belief that problem solving, reflection, and critical thinking are related, I implemented journal-writing strategies with unpaired and paired nursing students to promote these processes. In the following paragraphs, I describe the expected and unexpected results of the case studies I observed.

One of the first things I noticed in the case study where students functioned both on the floor and in journaling as independent individuals was the high anxiety level on the 1st day of the clinical assignment. Repeatedly, anxiety, fear, intimidation, and overwhelming feelings of doubt were described in the unpaired journals. Over the 9-week period there were 46 expressions of emotions stated in the unpaired journals. Fifty percent were classified as negative, and the other 50% were classified as positive emotions. In my personal notes while studying the unpaired group, I wondered if there would be less anxiety or negative feelings in the paired group. When reviewing the writing of the paired students' journals of the 28 expressions of emotions, 30% of the comments were negative. Students exhibiting anxious feelings was not new to me. I have observed it in previous clinical experiences. It is documented in research studies in nursing that anxiety in students is present in the clinical setting (Chamberlain, 1997; Erler, 1995; Oermann & Standfest, 1998; Wilson, 1994).
The relationship between emotions and the ability to think is described by Goleman (1994). When an individual is in a good mood, it enhances the "ability to think flexibly and with more complexity, thus making it easier to find solutions to problems, whether intellectual or interpersonal" (p. 85). The opposite is true for "bad moods." Moods such as moderate to high anxiety, fear or rage shut down the thinking processes of the brain and impede the intellect. Negative emotions (bad moods) then become barriers to learning (Goleman, 1994). Caine and Caine (1997) calls this process "downshifting" of the brain. According to Boud and Walker (1993) there are two key factors that help an individual overcome barriers to learning which negative emotions create. These factors are previous experience and assistance from another individual. Perhaps this explains why there was a decreased amount of negative emotions in the paired students' responses. The paired students felt support from each other and were able to describe their feelings to each other. This explanation was supported by a comment from Diane and Rogenia. We supported each other. When we thought things were getting rough during a shift, we would take a breather and talk about it and what would be the best way to approach the problem (Journal 122, p. 18). Carol and Matt also stated: It is stress relieving not to be alone in the clinical setting (Journal 128, p. 8). Crystal particular noticed the difference when she was working by herself when her partner was sick. I'm feeling a little lonely tonight with out my partner. Bouncing ideas off each other is fun and helpful. Working with Michael is good because we check each other and cover needs that might otherwise go unmet temporarily or at all. I will look forward to working with Michael next Wednesday (Journal 124, p. 9).
One of the benefits of paired collaboration is the affective effect that develops. Through shared experience, students are more likely to identify with and support each other. This appeared to happen in the paired situation. Tracia and Marie represented this decreased anxiety in their statement: Working with a partner makes learning more fun and less stressful (Journal 123, p. 9). For Crystal and Michael, teamwork created a positive reinforcement for each other (Journal 124, p. 13). The process of journaling and working together decreased negative feelings in an intimidating environment. These comments connect with Johnson, Johnson, et al.'s (1998) description of increased psychological health and self-esteem when students are working together in a learning environment.

Dialogue in a social environment was important to both unpaired and paired students. In the unpaired case study, the students appreciated their fellow students more when they could dialogue with them in problem solving. Dialogue with the nurse was equated to learning if the dialogue was beneficial. To Kathy talking with the nurse helped her to gain knowledge and to feel comfortable in contributing her own thoughts: The nurse and I had a long talk about comfort care and keeping the patient comfortable. I really enjoyed talking to her and gaining her knowledge, thoughts, and being able to contribute my thoughts to the conversation (Journal 101, p. 4). For Steve talking with the nurse helped him learn many nursing activities. The nurse Ann was extremely helpful. She took time to help me out and taught me a lot of new procedures (Journal 104, p. 2). If the dialogue, however, was hostile or the student felt he or she was in the way, the student did not perceive that she or he had learned or communicated well. Linda wrote: I had a hard time communicating with one of my early shift nurses. She seemed to ignore me and gave me the impression that I was in the way. So I got timid around her which I shouldn't have (Journal 106, p. 10). This student was normally quite talkative in class and very inquisitive, being unable to communicate probably decreased the opportunity of learning through dialogue. In my personal notes, I noted that students from the unpaired group would rather talk with each other at post-conference regarding activities of the evening than write in their journal.
For the paired students, dialogue early on was important in solving problems. First, students preferred to talk with each other before discussing the issue with the nurse. Ching and Abe wrote: When we came into the problem we consult our partner first then with the RN or Rita [which was me] (Journal 120, p. 4). Abe and Ching wrote this statement on the 2nd week of the quarter. They used each other as resources for knowledge needed in solving the problem. Nora and Rhonda when faced with what they felt was an overwhelming situation and needed to organize their time wrote: First we stopped, we communicated with each other to figure out what we needed to do and better ways to prioritize our time so that we could get everything accomplished correctly. Then we implemented our plan and correctly accomplished our goals regarding everything we had to do (Journal 121, p. 7). They were able to successfully complete the care because they had each other to plan and the lab became an enjoyable experience for them. Michael and Crystal during the second week wrote: We planned out our care for both patients and discussed our progress frequently (Journal 124, p. 3).
One of the most recognized proponents of dialogue in a social context is Vygotsky (Cole et al., 1978) . He believed that children arrive at a common understanding by socially negotiating meaning via problem-solving activities. When a person collaborates with a more competent peer or adult, the distance between this potential for development through problem solving determines his zone of proximal development. Through social interaction with peers, students gain different perspectives about a problem. In analyzing Vygotsky's work, Jaramillo (1996) felt that his conceptual framework contributed to the development of constructivist theory. Constructivists believe that the mind creates its own reality, based on experiences and interaction with the environment (Piaget, 1932).
Baxter Magolda (1992) concluded that the "ways of knowing and patterns within individuals are socially constructed" (p. 20). Depending on the stage of knowing, peers are important in "explaining what they have learned from each other; providing active exchanges; being a source of knowledge; and enhancing learning via quality contributions" (p. 106). Caine and Caine (1997) emphasize in their research on the brain that learning is influenced by social relationships.
Johnson et al. (1994) believe that through the process of dialogue in a group, new ideas or solutions are generated more frequently than if the individual were working alone. In cooperative learning classrooms, beside having students talking together when working with projects, the teacher encourages the students at the end of a lesson to process with each other what they learned.
A number of specific studies have recently documented the importance of "talk" in a learning situation. In Cicala's (1997) study on the relationships between involvement and reflective judgment, the statistical analysis showed significant positive correlation between reflective judgment and the frequency with which students participated in asking questions concerning points learned in the reading or discussed in class. It appears dialogue is important in problem solving and construction of knowledge.
When using a social-constructive framework for students in social work to assist in understanding culture and self, Lee and Greene (1999) concluded that there is an increase in reflective learning when there is dialogue. Through social interaction, individuals co-construct different ways of categorizing reality.
In studying the significance of talk, Teasley (1995) concluded in his research that talk dyads produced more talk overall and more interpretive types of talk than when the child was encouraged to talk aloud when by him or herself. Children with partners produced more highly rated hypotheses than did children alone. His research was consistent with the research on talking aloud and its positive effect on learning and problem solving. He states: "The answer to the question, ‘Why are two heads better than one?' may fundamentally rest on the interdependency of cognition and social relations in communication" (p. 219). Land (1998) further supports the importance of talk among children. Kindergarten children who talked and shared journals in story formation were able to develop an understanding of a story with an increase of ability over time.
In reviewing my personal notes, I observed how I was a facilitator of dialogue with the students. I would remind myself to talk aloud when I was problem solving with the unpaired students, as well as with the paired students. I felt that I could role model problem-solving techniques if they could "hear" me think. With the paired students, not only did I try to remember to think aloud, I also tried to remember to turn the question back to one of the members of the pairs instead of answering the question directly. I felt that would facilitate the process of learning when they listened to each other's reflections. When the partner could not answer the question, then I would ask related questions to encourage his or her thought processes. When a student seemed to have a greater understanding than her partner and it was difficult to stimulate answers to questions from the partner, I then attempted to further facilitate the learning by trying to respond to the student's questions.
This practice was consistent with Vygotsky's belief in experiential learning—the teacher is the facilitator of experiential learning within the social context. Brookfield (1993) in describing his own journey in teaching, describes experience as a transaction between the learner and the milieu in which he or she operates—it is relational. Teachers need to acknowledge the agency of the learner and construction-learning activities that will assist the students in the learning process.
In summary, dialogue emerged as a theme for students in the unpaired and paired setting. What is surprising is that this aspect of the clinical experience has not been previously ascertained.

For this study, I developed a set of questions that could act as a tool to facilitate student reflection on the clinical experience–in particular, what problems they had faced that day and how they had resolved them. A rubric was developed to evaluate two components, one related specifically to problem solving (the A part) and the other to reflection about the process (the B part). In this section I discuss the responses given to the reflection component (B). There was a total of 7 possible points–1 point for each reflective component in questions 1, 2, 3, 4, 6, 8, and 9. When I began the study, I anticipated that the "tool" of structured journaling would increase the students' ability to reflect as the quarter progressed. However, this did not happen with the unpaired students. When evaluating reflection of unpaired students with the use of journals, there was a drop in the class mean reflective score from 3.5 to 2.2 by the 5th week and then a gradual increase to 3.25 by the 9th week. The score however did not return to the level of 3.5, which was the first score. The possible reason for reflection not increasing to a higher level than the beginning score may be that students did not journal conscientiously because they felt they did not have time or they lacked interest in writing in their journals. One student commented, You must know when we are writing well and when we are not. She pointed to her journal and asked me to look at it. As I did, she remarked, Now, can you see I did not do a very good job last time. She then stated to me that she would try to do better in the future.
Although there was a drop in reflection by the 5th week for the unpaired students, when I read their journals looking for themes that were emerging, over time their comments revealed that there were changes in their behaviors or performance in clinical practice. This represented the last stage of Boud et al.'s reflective model (1985): outcome and action. During this stage a new ability that they had planned for in the previous stage is ready to be incorporated into the learning and applied to the next activity. This was represented when the student's weakness became strengths later in the quarter. For instance at week 2, Joan stated that my weakness is time management. I can do better in this area. I will be more prepared (Journal 102, p. 5). At week 8 she stated My strength for this clinical experience was my organizational skills (Journal 102, p. 21). Joan's self assessment on this point demonstrates that she changed.
Carol had not gotten a report about her patient because she felt intimidated by the nurse. She reflected about the experience in her journal. This lab and the previous lab I am using as a learning experience. I am not happy to have 2 unsatisfactory labs. I will not, on the other hand, let it slow me down in any way. I am not disappointed in myself. I was at the time and I have chosen to learn from it and keep going. Actually, honestly, I consider myself lucky because if this didn't happen now, who would know how much later it will have happened. I'm also lucky my patient did not get hurt (Journal 107, p. 13). The next week Carol felt she had made strides to meeting her goal to overcoming her shyness. I'm proud of this lab. Like I said, I fearlessly approached my RN and got report and started with my work. I found myself being more assertive with my patients—less timid, less shy. I think I took good care of my patient (Journal 107, p.15).
Reflection levels for paired students did show an increase over time. The 1st weeks mean reflective score for the group was 2.7 and by the 8th week there was a gradual rise to 6.2. Paired students also demonstrated changes in behavior as the result of reflecting with dialogue. During the first week, Becky and Lauri had problems with communication. One of our weaknesses was not understanding that assessments, treatments, procedures, etc., were to be done together (Journal 129, p. 3). I had noticed that they were having difficulty communicating. We discussed a plan for improving their communication with each other. The next week their journal statement was, We were able to work together at a higher level because of the better communication we have learned to do (Journal 129, p. 5).
Diane and Rogenia faced the frustration of spending quality time with patients and getting charting and reporting done on time. Our weakness for this evening was not being able to chart on time and give report at the end of the shift. Maybe by giving medication at one time rather than multiple specific times we would make our shift more efficient. We felt we should have spent more quality time with each patient than we were able to do (Journal 122, p. 5). The students asked my advice as to planning the care and I reviewed with them first their own plan before giving suggestions. Later in the quarter because they had planned together they made progress toward meeting the needs of the patients and getting procedures and medications done on time. Our strengths for this clinical experience was being able to get our procedures done on time, handling orders and accommodating our patients needs (Journal 122, p. 15).
In reviewing the research in ERIC, Dissertation Abstracts, and Medline there are no studies or reports on journaling while talking with another individual; however, according to Boud et al. (1985), reflection is enriched when it is not a solitary act:
Reflection is not just an individual activity; engaging in the process with another person or with a group can change the meanings we draw from experience. When a group participates in a common event, each person will experience it in a particular way and will have an interpretation of aspects of that event which may differ from that of others. Formulating and articulating experience transforms it in ways that can allow us to see it anew. (p. 11)

The use of journals as a method for promoting reflection is well-studied (Saylor, 1990; Sedlak, 1997). "Dialogue" journaling (Mower, 1995; Paterson, 1994) consists of exchanging ideas in writing between the instructor and the student. Deloney, Carey, and Beeman (1998) advocated the use of electronic journal writing to foster reflection and provide feedback in an introduction to a clinical medicine course. Journaling is considered a self process in promoting reflective practitioners (Moss, 1997) and journal writing and then discussion with a group promoted critical thinking reflection (Farrell, 1996). Journaling can be one of the methods a nurse educator uses to help promote reflection and critical thinking within students.

One of the reasons for instituting journals as a method for reflection is to assist students in making a connection between theoretical knowledge and observations made in the clinical setting. Both case studies demonstrated incidents where students were able to specifically make connections between what they had learned in class and what they were observing and doing in the clinical setting. Connection statements were not only seen in response to question three—What knowledge was required for you to solve the problem?—but were described in response to questions 1 and 9. For instance, when Kim was answering question 9, she struggled with what she had learned in Fundamentals of Nursing Class regarding decisions that health care providers are to render in allowing patients to live or die and what she was observing about her patient. I learned about a doctor's moral obligation to a patient. The patient who was having congestive heart failure would have probably gone peacefully but the patient was a full code. There were not family members to change the code status for her so the patient was transported to ICU and put on a ventilator. I wish she was left off the ventilator–her quality of life will probably not improve. This reminds me that so many times we are so driven to make people better if they die it could seem like a failure, but sometimes I feel we as health care providers need to step back and let nature take its course (Journal 101, pp. 15, 16). To me, she was trying to connect what she had learned and her feelings to what she was observing. Ellen made the connection between forms of communication. Words are not the only communication that exists in the world. Using body language, talking with action, and using the most simple words will help everyone a lot with communication (Journal 103, p. 2). Her patient has Spanish speaking and knew only a few words of English.
In answering question 1, Anita made a connection with what she was observing and what she had learned from studying denial. My patient was short of breath when in bed and while ambulating. Her respirations were shallow and slightly labored. I noticed while with her she didn't know why she was in the hospital. She felt like she was in the dark on her condition. She is in denial of having any serious physical problems. She realizes she gets short of breath, but doesn't think it is such a big deal (Journal 110, p. 1).
The paired students made connections as the result of reflecting about the problem that they had identified. Mrs. F. was experiencing anxiety and depression that could be causing insomnia. She wanted to leave the hospital and go back home. She stared crying and sobbing when we came into the room and asked how she was doing. She told us that the doctor might be sending her to ICU [intensive care unit]. She had psychosocial needs even more than her relative visits and phone calls. We think if we had asked her to pray, she could have experienced some peace and then go to sleep (Journal 123, p. 6).
This indicates to me that structured journal writing is an effective pedagogical tool to assist students to make connections as part of cognitive development.
Being able to connect previous experience or previous learned knowledge/theory from class is a goal in making reflection a part of the individual's learning experience. Being able to make the connection or links becomes a part of the reflective process. From this process old knowledge gives way to new knowledge and ideas (Boud et al., 1985).

One of the outcomes of reflection is that learning has taken place. In both unpaired and paired students learning emerged as a theme. Learning for the unpaired students was mostly related to the psychomotor skills. I learned how to give report correctly and assisted the respiratory therapist in suctioning my patient (Journal 103, p. 12). Carol wrote about what she had discussed with the group in post-conference. Like I said in post-conference, I really was excited to see placement of a tracheostomy tube.
The respiratory therapist really explained everything to me that I probably wouldn't have had a clue about with out him. It was fun (Journal 107, p. 11).
An unpaired student learned from dialogue with health personnel. I learned so much today. The respiratory therapist and the RN explained many, many things to me that I didn't understand before. Now that I have seen these things (like ventilators), I now have much more knowledge stored in my brain. I am a visual and doing kind of learner and the lab experiences have helped me learn so much into my long-term memory bank. I really appreciated the respiratory therapist who put in the extra time to really explain things to me in detail. This is how I really learn well (Journal 110, p. 18).
Students in the paired case study conveyed that learning came from the social context. Matt and Carol stated: As the result of being paired, we are learning from each other (Journal 128, p. 8). One day when Jim was working alone, he wrote that it is much better to work with a partner. We can point out problems and we can discuss important information with each other (Journal 127, p. 10).
Mari and Tracia wrote that: We were very inquisitive, therefore, we learned a lot. We learned about feeding tubes, blood sugar tests, suctioning a sore mouth, hanging of blood and crushing medications to be put down a feeding tube (Journal 123, p. 12). Because of the reflective process, the paired students were able to identify that they were learning from each other.
Although combining the two pedagogical tools—journaling and dialogue pairs—to promote reflection is not addressed in the literature, my findings support the importance of dialogue and journaling in the construction of knowledge. By combining the two methods this study showed increases in reflection over a 9-week period.

Problem Solving
Problem solving is a skill, and since the clinical setting involves problems that students encounter daily, it is important that instructors use strategies that will guide students in this process (Cholowski & Chan, 1995; Klaassens, 1992). In this study, although both groups were consistent in problem solving by the way they wrote in their journals, in the unpaired group I identified 27 times that they did not write the correct steps for the problem-solving process. In evaluating the scores of the A criteria at week five (this was the lowest mean score for the group), question 3 at 57% and question 5 at 78.5% were the lowest percentage in response to the journal questions (see Appendix A10) by the group. These two questions remained the lowest throughout the 9 weeks. This indicated to me that there may be a relationship between knowledge and interventions in problem solving. I had reflected about two of the students in the unpaired group at the end of the quarter. Although they seemed to have performed safely, I felt that the knowledge they needed for problem solving was weak thus connections were not made many times when they were faced with a problem. As an instructor I need to continue to evaluate strategies that would strengthen the problem-solving process in students.
In the paired group, the details of the problem, identification of urgency, and steps to take in the interventions were readily identifiable. I identified three times that students had not written the correct steps for the problem-solving process. In evaluating the scores to criteria A, the paired students were consistent throughout the quarter (see Appendix A9). For these students question 3 was also the lowest measured response at an average of 90% over the 9 weeks. This indicated to me the pairs had competent problem solving ability. This corresponds with Osana's (1998) study that students in small groups devoted more time to metacognitive activities such as reflection, developed greater cognitive flexibility, and used a larger number of solution strategies than students taught the direct instructional way. Cholowski and Chan (1995) further documented that a "think aloud" strategy and interactive dialogue with an expert nurse assists students in promoting an interconnected knowledge base with problem solving.
Although the independent t-test showed the unpaired and paired group were significantly different t(202)=3.72, p=.00 (see appendix A11), this difference is small which means that practically they are the same. In reading the journals, I noticed both groups used previous problem solving incidents to solve problems they faced in a later clinical experience. This indicated they were internalizing what they had learned by reflecting on their knowledge base (Burrows, 1995; Cholowski & Chan, 1995).


Linking Critical Thinking, Problem Solving, and Reflection
In the literature there are times when critical thinking, problem solving, and reflection seem unrelated. Definitions are not clear. One of my assumptions in this research is that critical thinking, problem solving and reflection are linked together. I also assume that methods can be developed in experiential environments that would promote these three processes. Sedlak (1997), in her study of 1st-year nursing students, linked critical thinking and reflection together in her definition.
Critical thinking is a reasoning process in which the nursing students reflect on ideas, actions and decisions of oneself and others related to clinical experiences. Reflection is recall of clinical experiences that seemed to lead toward critical thinking to gain insights into ones learning, decisions, and professional development (p. 16).

Sedlak concluded that reflection does prompt first-year nursing students to think critically.
Baker (1996) also concluded that reflection improves critical thinking. She believes "reflective journaling offers a teaching strategy which helps provide balance to the objectification and linear thinking skills that we currently have developed in students" (p. 21). Additionally, she states, "reflective journal writing nurtures many dimensions of critical thinking—e.g., affective and cognitive skills—open-minded, flexible and honest that are important to nursing practice" (p. 22).
Mezirow (1990) feels that reflection is generally used as a synonym for high-order mental processes (critical thinking), and reflection corrects distortions in our beliefs and errors in our problem solving.
When we engage in task-oriented problem solving–how to do something or how to perform–we are engaged in instrumental learning; reflection is significantly involved when we look back on content or procedural assumptions guiding the problem-solving process to reassess the efficacy of the strategies and tactics used. This type of learning leads to reflective action. (p. 7)

In his later book Mezirow (1991) further affirms the link between reflection and problem solving. "As we assess our assumptions about the content or process of problem solving and find them unjustified, we create new ones or transform our old assumptions and hence our interpretations of experience. This is the dynamic of every day reflective learning" (p. 200).
The Lewinian Model (Kolb, 1984) of experiential learning describes the process that students experience. The model begins with a concrete experience and moves through observation and reflection, conceptualization and generalization, testing implications of concepts in new situations and finally back to concrete experience in an ongoing spiraling fashion. In this study students had concrete experiences as they worked in a clinical setting. These experiences were the focal points of their learning. The next step in the Lewinian Model is observation and reflection. In this study the use of journals in the clinical setting focused the students on the problem experienced. In the paired situation, because they were talking with each other, participants received immediate feedback regarding their thoughts. This is an important step in this experiential process. Via this process of reflection, nursing students were primed for procedural steps three and four.
Following reflection students moved toward developing ability to conceptualize and generalize. These concepts and generalizations are then tested when the students were again in the clinical setting. In both case studies, students were able to use the information that they had processed in their journals to solve problems they encountered in the next clinical experience. This is the application phase of Lewin's model.



Assessing Reflection
In this section, I answer Research Question 2: How can the clinical experience be evaluated for the presence of reflective processes?
In reviewing previous research, I heard concerned voices of educators calling for methods that would assist students with critical thinking, problem solving, and reflection in the clinical setting and for tools to evaluate these processes (Alexander & Giguere, 1996; Beck, 1995; Burrows, 1995; Colucciello, 1997; Infante, 1981; Jinks, 1991; Oermann, 1997; Tanner, 1994). Evaluation instruments that have been developed to assess for reflection and critical thinking have often proven ineffective.
Because I wanted to promote reflection and thinking in my students in the clinical setting, I chose journal writing as a method to stimulate reflection. The questions for the journal were specifically developed to provide structure to the reflective process. Other wise, the journal would be a mere catalogue of events (Van Gyn, 1996). Second, a rubric was developed to meet the NLN recommendation for assessment criteria for critical thinking. This rubric yeilded a holistic score (Herman, Gearhart, & Aschbacker, 1996) giving me specific feedback as to the progress of reflection. The criteria were adapted from Boud et al.'s (1985) stages of reflection (see chapter 3) and definition from Mezirow (1991) as to what constitutes a reflector. Mezirow defines non reflector, reflector and critical reflector. The written answers to the journal questions where students only listed the events were considered non reflective. When a student answered with connections or thoughtful ideas, the answers was considered reflective element. To maintain reliability of the rubric, it was used by a professor of education and a nursing faculty at the college where I am employed (Miles & Huberman, 1994). Inter-rater reliability for the nursing faculty and I was .87.
The results of the rubric showed the unpaired students decreased in reflection over time. The total reflective score possible was 7. The first week reflective class mean was 3.5. There was a decrease to 2.2 by the 5th week and then a gradual rise to 3.25 by the 9th week, however, the linear change was not significant. The paired students, however, had a progressive increase in the reflective score which was significant. The beginning class mean was 2.7 and the last score of 5.8. The highest class mean of 6.2 occurred at the 8th week. An independent t-test was performed to determine if there was a difference between the unpaired and paired case study groups. The over all mean for the unpaired group was 3.02 and the overall mean for the paired group was 4.59. The independent t-test showed a significant difference with t(202) = 5.94, p =.00 indicating there was an increase in the reflection in the paired group (see Appendix A11). This simple process–specific question and rubric—indicated levels of reflection in both settings and an increase in reflection over time with the paired students.
By developing specific questions and a rubric, I am meeting the National League for Nursing (NLN) for the Associate Degree of Nursing (ADN) mandates by the year 2000 ADN programs to be accountable for assessing critical thinking in their curriculum and perhaps answering concerns for authentic assessment for evaluating thinking by other health professions such as dentistry (Lim & Chen, 1999) and medicine (Carney et al., 1999), and education (Darling-Hammond, 1994; Malbry, 1999). Traditional methods for assessing the presence of critical thinking have fallen short of their expectations (Scott, Markert, & Dunn, 1998). Facione and Facione (1996b) call for multiple method designs with evaluation that address the diverse contexts present in critical thinking and judgment made by the nurse. Oermann (1997) furthers emphasizes the importance of evaluation of critical thinking in the clinical setting. "Clinical evaluation strategies are also needed to monitor the development of students' thinking skills over time" (p. 25). Thus the development of this rubric will assist me in monitoring the development of students' thinking.
In reading the literature on rubrics, they seem to develop over time as they are used by the teacher and reviewed for validity of information being measured (Herman et al., 1996; Martin-Kniep, 1998). In reviewing the results of the rubric and the qualitative analysis of themes, I asked myself where changes were needed. As a result of using this rubric, I have adapted one question in an effort to probe for the outcome of the problem: "Was it solved? Why or why not?" I also plan to develop questions that would ask the paired students to review their weaknesses from the week before and tell how they have progressed in their plan of action. I feel that the rubric did assess the presence of reflection and growth over time and I continue to use it.

Secondary Purpose
The primary purpose of my study was to develop tools that assist students in linking theoretical knowledge with clinical problem solving. The secondary purpose was to tell my experience as I try to facilitate increased reflection in the clinical setting. I felt that I needed to bring theory together with my own practice and then describe what I learned from implementing methods for promoting reflection in the clinical setting.
As an educator faced with demands of accrediting bodies to evaluate the presence of critical thinking, I used journal writing and paired students in the clinical setting to promote reflection. I developed structured questions and a rubric to facilitate and evaluate the process of thinking. Like the students, I kept a journal of my thoughts and actions so that when I reviewed the material that I studied I could decide what to maintain or what areas to change to strengthen the process of problem solving and reflection.
For both case studies, dialogue was important in learning from the environment. In the unpaired students, I changed the journaling time from the end of post-conference to the middle because I was concerned that students would not have enough time writing in their journals. Past experience had taught me that I needed to allow enough time for journal writing otherwise I would receive journals with unanswered questions. Inspite of the change in journaling time the students enjoyed telling each other about their experience and asking questions that they still did not spend as much time writing. From these students I learned the importance of dialogue. The next quarter I allocated the journal writing at the end of post-conference and encouraged students to talk about their experience with the whole group before they journaled. I noticed also after the paired students had been writing and talking together they would share a thought with the group that had just come out of the dialogue that was taking place.
For the unpaired students, dialogue with their fellow classmates was important to gather information and for decreasing the stress that they felt. Later in the quarter, I noticed that the unpaired students were spontaneously collaborating with each other regarding problems or activities that needed to be done.
I have used cooperative learning in my classroom for 5 years even though many educators told me that cooperative learning in college classrooms was not feasible. I wanted to expand this method to the clinical setting. As a result I conducted a pilot study, I concluded that cooperative/collaborative learning opportunities should be provided for all of the students in the clinical setting.
The process in bringing a new method into the clinical setting was not an easy one. Change is challenging. I discovered that although I gave what I thought were clear explanations, because this process was new to both students and staff, it was important to repeat the explanation and expectations frequently. During my discussion time with the staff, they began to see the importance of students learning to collaborate with each other. It seemed that my explanation of the process was getting through to them. In the intensive care unit the registered nurses mentioned to me that the collaborative experience of the students seemed to decrease the students' anxiety as they entered the critical care area.
For the students, learning to trust each other's knowledge was a new concept, and as a teacher, I worked at facilitating this process by returning the questions asked by a student back to the other member of the pair. If the student told me that he or she had already dialogued with the partner then, I would use questioning techniques to elicit a response as opposed to just giving an answer. This was not always easy for me to do. I noticed in my personal notes that it was easier to slip back into a telling mode or into just answering the questions. For me this experience helped to build skills and reinforce what I had learned previously in educational methods classes.
In trying to apply learning strategies, it was easier to be rigid in what I had learned than it was to be creative in solving a problem that arose. I had to remind myself to be flexible. This flexibility was used when paired nursing students had difficulty getting along with each other as they worked together. I did not want this difficult time to be a barrier to learning, so I collaborated with someone who had used paired strategies to solve the problem amiably.
I felt that because students were paired I was able to spend more time with more students because of the close proximity and because I was dialoguing with two individuals at once. It was easier to pull students together for learning moments or for viewing infrequent procedures because they were working together. Students had to learn to share new procedures and felt that it would be better for them if they could individually perform the procedures. I would remind the students that because they were working together it increased the opportunity of observing a procedure that they would probably not get to do or even view if they had been working individually.
Most of the time having two student care givers created an atmosphere of comfort and support for the patients. Patients liked the attention that students were giving them. I found that I needed to ask the students about how the patient was perceiving their attention. If a patient was feeling uncomfortable, the students and I problem-solved to meet that patient's needs. If there was a new procedure that needed to be performed on a patient who was not their assigned patient, I would secure permission from the patient to have more than one student in the room. This was to protect the patient's right for privacy.
During post-conference I observed the students dialoguing together while writing in their journal. This was important because I needed to know that both students were doing the work and that dialogue was occurring. The process of dialoguing seemed to energize the room. I noticed that students wanted to share with the group what they were discussing and what they had learned.
Like many others who conduct research using qualitative methods, I often had doubts concerning what I was observing. However, D. Schön (1983) emphasizes in the following statement the importance of going into the "swamp":
In the varied topography of professional practice, there is a high, hard ground where practitioners can make effective use of research-based theory and techniques, and there is a swampy lowland where situations are confusing "messes" incapable of technical rationality. The difficulty is that the problems of the high ground, however great their technical interest, are often relatively unimportant to clients or to the larger society, while in the swamp are the problems of greatest human concern. (p. 42)

When individuals add to their epistemology of practice the use of reflection-in-action, a relevancy to the research emerges (Schön, 1983). This has been my experience throughout this study. As I reflected, made changes, and reflected again, the importance of what I am practicing and learning became relevant to me.

Suggestions for Clinical Instructors
The experience and knowledge I gained from this research allows me to make the following recommendations to the reader.
1. There is a richness of knowledge when people come together and share their experiences to plan for better pedagogical methods. As educators we need to have a "good talk about good teaching" (Palmer, 1998, p. 144). These talks should include ways of knowing, definitions of critical thinking, and classroom environment.
2. Nursing educators need to identify and analyze the components of critical thinking and their relationship to reflection and problem solving (nursing process). Often nursing has general objectives for critical thinking and problem solving; these objectives are not specific to the each level the students are presently in. Nursing educators should establish at which level of nursing education that specific components of critical thinking should be emphasized, and then build on each level as the student progresses through the program.
3. In talking aloud as instructors we should be naming the processes that we are using. This will assist the students to establish the habits of the mind and promote understanding of the processes they are performing.
4. We should give feedback in students journals. I had deliberately chosen not to give much feedback in the journals. As the result of assessing and analyzing the journals, this turned out to be a weakness in the refection process. Because of this realization, I have started giving feedback in the journals.
A second weakness I feel I found in the journaling process used in my study was not having the students review their journals and comment on their growth. Therefore, in the future I will have the paired students review their journals at the end of the quarter and dialogue with each other as to how they view their growth in thinking and problem solving. They will then submit a summary of their thoughts to me.
5. Even though students were paired, sometimes mistakes were made. This meant that two people were making the error. Nursing educator could spend time teaching students how to check each other for accuracy. This includes how to communicate in such a way that one individual is not just giving in to his or her partner with the stronger opinion. Learning to negotiate is an important skill when students are paired and a decision needs to be made.
6. When I was asked if pairing the nursing students should be used every nursing class in the Associate Degree program, I gave an emphatic "Yes!" As students would advance they could build upon the different components of teamwork, critical thinking, and reflection.

Recommendation for Further Research
As the result of this study, the following are recommendations for further research:
1. Further development of rubrics that would assess the level of reflection as students progress through the nursing program is needed.
2. There is a need for longitudinal studies assessing for the qualities of reflection and critical thinking.
3. Faculty need to continue to conduct research on methods that can be used in the clinical setting that would assist students in problem solving, reflection, and critical thinking.
4. Broader methods should be developed that encourage multiple ways of viewing a problem.
5. There is a need for further study on how reflecting together in the form of journal writing promotes higher-order thinking.
6. There is a need for further study with triads or a pair of pairs on how reflecting together increases reflection.

My findings are:
1. The problem-solving process was documented in reflective journals in both cases.
2. The rubric indicated the presence of reflection in unpaired students and paired students.
3. Paired nursing students had a growth in reflection when they journaled and worked together.
4. Themes emerging from the journals demonstrate dialogue effectively reduced anxiety and increased perception of learning.
5. Journal writing as unpaired and with paired classmates assists students to link theoretical knowledge with clinical experience.
6. Though reflection has been traditionally considered a self process, this study indicated that benefits in reflecting together in a journaling process appear to be greater.
This study suggests that students writing in a reflection journal can be used as evidence for the presence reflective thinking. The teacher can facilitate the process of reflection by pairing students to create a dynamic, caring environment which promotes feelings of connectiveness to the learning experience, thus increasing the opportunities of reflection, critical thinking, and problem solving.