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Introduction
From the first day of clinical experience, the student and teacher are working and learning together. In this learning process, a relationship is being established between the student and the teacher to facilitate learning. The clinical experience involves learning to solve problems, practicing new skills, improving on previous nursing skills, and applying information learned in the classroom to what is being observed and practiced in the clinical setting.
The first part of this chapter includes vignettes from nursing students who have written about their experiences in the clinical setting. The descriptions were taken from the first day of clinical experience, the middle of the quarter, and the last day of the clinical experience. The purpose of sharing these vignettes is to capture the lived experience of the students as they problem solve during the 9 weeks of the clinical experience. The middle part of the chapter includes statements of reflections the students made in their journals. Journal writing was a method incorporated during the quarter to assist the student in problem solving and in thinking reflectively. The statements made by the student are presentations of the process of reflection. The last part of the chapter describes the themes that emerged from the students' written journals. Because clinical experience is a complex learning experience, as evidenced in the shared themes, the reader will catch glimpses of this complex process.

Clinical Setting
Students were divided into two groups, one group met on Wednesday and the other group which met on Thursday. The clinical day started at 2:30 p.m. in a conference room at the hospital which is located about 6 miles from the college campus. From 2:30 p.m. to about 3:00 p.m. (pre-conference time) the students shared the care plans they had written from information they had collected from the chart the night before clinical experience. I usually posted the assigned patients about 4:00 p.m. the previous evening. I would arrive about 20 minutes before pre-conference to review the condition of the patients and to verify that the patients were still in the hospital. Because of decreased patient time in the hospital, there was no guarantee the patient would still be there by clinical time. If the student's patient had been discharged, I would assign a new patient to the student. During the pre-conference time I discussed with the students changes in the patient's condition, skills needed to be preformed during the shift, and new assignments that had arisen. I would also answer questions about the patients that the students would have from the information that was gathered. Most of the time the questions involved medications that could not be found in the drug books or a procedure that the student had never performed or perhaps never seen before. The first 2 weeks the students had only one patient. By the third week, this increased to two patients for a 9-hour period.
After pre-conference the students would proceed to their assigned area to review the chart, medication sheet, and kardex (a form that had the patient's activities, procedures, intravenous solutions, and laboratory tests ordered by the doctor), and to ascertain what changes had arisen since they had last collected the data. The student would introduce him or herself to the nurse in charge of the patient and receive a short report about the condition of the patient. Students would organize their time on a schedule form based on the information just obtained.
The student would then go and introduce him or herself to the patient. The rest of the evening would include patient-care activities such as medications, treatments, and preparing the patient for bed, assessment of the patient's condition, and charting the activities and events that may have developed during the time the student was there. The student also spent time conversing with the patient and the family as well as collaborating with the nurse on problems as they arose throughout the evening.
After pre-conference, I made rounds to the four areas (intensive care unit, cardiac care unit, medical-surgical unit, and transitional care unit) where the students were located. During the first part of the shift, I reviewed the care plans and the schedule the student had designed. I had the student give me a short report about the condition of the clients and discuss any problems.
I spent the rest of the evening in problem-solving activities such as what to do with an elevated blood pressure, observing procedures, validating the medications that were to be given to the patient by the student, physical assessment of the patient with the student, collaborating with the nurses and doctors, and reviewing the charting the student had written. The last activity before post-conference was a review of the charts and the medication records to make sure all activities were completed.
Post-conference was about 45 minutes to an hour based on the time we arrived to the conference room. At the beginning of the quarter, I allowed the students to write in their journal the last 15 minutes of the time together. I discovered that the students ended up spending more time talking together instead of writing so I changed the writing activity to the middle part of the conference. Post-conference also included time for the group members to review what they had learned and what problems they had struggled with during the night. I would spend about 10 to 15 minutes demonstrating a procedure such as tracheostomy care. We ended at 11:30 p.m. Because post-conference was late at night, students struggled to stay awake. I often wondered how beneficial the time was because of the lateness of the hour. I was concerned with the drive home since some students lived 30-60 miles away.

Clinical Experience

The First Day
At the beginning of lab, I was really scared and overwhelmed. I felt a little lost in orientation which led to a lot of stress and anxiety. As a result, I think we students got frustrated and started to doubt ourselves. I know I did, at least. I did not think I was going to make it. I have noticed that in the past two quarters, I have been "scared" of my teachers. It does ruin, or at least slows down my learning (Journal 107, p. 3).
Since I have clinical experiences on Wednesday and Thursday, I had two beginnings. In both groups there was an aura of anxiety. This is normal, but the students do not think so. I sometimes feel like a mother bird nudging her children out of the nest. It is a long way to the ground. The students are reluctant to go out the door of the conference room to get started. I had to lead the way.
The first 2 hours of the shift were busy for me. I was concerned whether the students would page me when they needed assistance, or would they work on their own trying to solve problems beyond their scope of practice. For these two nights I was supervising students over only two areas of the hospital. What a difference that was for the students! Because of close proximity with each other, I noticed the students were able to more easily collaborate with each other. Carol made this statement in her journal indicating the importance of being with other students. I am really thankful for my classmates tonight. They did not get tired of my questions. Their smiles and their explanations helped me to care for the patients (Journal 107, p. 1). This did change in 2 weeks. The students were placed into four different areas on three different floors of the hospital increasing the distance for me to observe and making collaboration with each other difficult.
I am very timid with my patients and have too small of vocabulary. Somehow I need to build up my vocabulary and learn to communicate with the patients (Journal 107, pp 1, 2). As an instructor I had tried to assure the students that I would be available to assist them when they paged me on a beeper and I would answer their questions when they talked to me, I am so afraid that I will make medication errors and this made me more nervous (Journal 103, p. 2). Students had commented to me that they hoped they would get a good nurse to talk with, one who would understand their feelings and answer their questions, one who would not think their questions were stupid.
After assessing my patient's breath sounds, the patient complained of having trouble breathing especially after waking up. I know patients complaining of shortness of breath need assistance very soon. I put the head of the bed up and contacted the respiratory therapist. I explained to him the problem. After he and I assessed breath sounds and checked the oxygen saturation level, we put her on oxygen. The problem was solved (Journal 102, p. 1).
Although some anxiety is normal, I looked for severe symptoms which could lead a student to be nonfunctional and unable to think in the problem-solving process. These first 2 nights the students had their anxiety under control. By post-conference time, they were smiling and stating they were feeling better.
It is the end of the shift and I made it. I was able to set some of my fears aside and put my knowledge into use. I am realizing that the clinical experience is one of learning experiences, and tonight I had a really good experience and feel nursing can be a very exhilarating career as well as rewarding, I think. I was able to step out of myself and concentrate on the patient and this was most helpful (Journal 102, p. 3).
There was a difference in the two groups (Wednesday and Thursday) in regard to personality and responsiveness. Wednesday's group was more talkative and asked more questions. In fact, Linda asked many questions—often before I had time to finish explaining information—that I wondered if this was evidence of her fear and at the same time I was somewhat irritated. In spite of my feelings about the multiple questions Linda asked, I found Linda well-prepared for clinical experience. Thursday's group was quieter. There was a difference in the journals of the Wednesday group versus the Thursday group. The Wednesday group seemed to express more statements of confusion and anxiety. This disparity may have resulted because I explained the information differently to Thursday's group in response to the questions the Wednesday Group asked. I am amazed at the differences, but I realize that I must address the groups according to their differences.
Problem solving was seen in different forms on the first day. There were two incidences of shortness of breath exhibited by the patients. The first incident is described above in Joan's vignette (Journal 102). The second one occurred when I was assisting Terry. In the second incident, there was a difference in my perception and Terry's perception as to how the problem was solved and what events had actually transpired. Terry mentioned only the shortness of breath in her description in her journal, but there was chest pain accompanying the shortness of breath that was more serious. In evaluating the differences in both students' journals (Joan and Terry), I believe the knowledge used in solving the problem and the ability to assess the patient was a weakness in Terry. Terry did not use her knowledge base and exhibited poor assessment skills in gathering data in order to solve the problem. This is of great concern to me because if a student is weak in an area such as using their knowledge, that student may make an incorrect decision that could harm the patient. This was averted because I was there to guide the student in alleviating the shortness of breath problem.

The Middle of the Quarter
By the middle of the quarter, students were gaining more confidence. Rose describes her clinical day: I had a hectic day, but overall this clinical experience by far was the most educational for me. During my shift my patient had a hypoglycemic attack. Her blood sugar was 168, and I had given Regular Insulin, which was ordered. She did not eat very much for supper, and two hours later she was diaphoretic. I had looked up the word diaphoresis in Taber's [Medical] Dictionary before I had come to the hospital so I knew what it was. I did a finger stick for glucose and the result was 38 mg/dl. The LVN [licence vocational nurse] told me to give her juice with sugar STAT [right now] to get her blood glucose up. About 20 minutes later another blood sugar test was performed and the blood sugar was 63 mg/dl. I was told to give her more juice with sugar. But the patient was very weak, lethargic, drowsy, and still sweating. I was afraid she may aspirate. The LVN put sugar under the tongue which would be absorbed faster through the membranes. The LVN also notified the doctor—something I could not do. The doctor changed the sliding scale. About 2200 [10:00 p.m.] her blood glucose was up to 90 mg/dl, but still she was weak and lethargic. At least the blood sugar level was up.
I think that tonight I found out how I handle myself in a situation like this hypoglycemic reaction. I felt that I was more independent and was not anxious over her attack. Even though I was a little unsure about what exactly to do when a hypoglycemic reaction occurs, I handled the problem better than I thought I would be able to.
I feel that even though I had questions for the RN [registered nurse] and LVN, they still gave me the independence and encouragement to be able to react to a crisis. With each clinical experience my confidence with patient care increases (Journal 115, pp. 7, 8).
Sometimes a mistake is made by a student. This mistake can be due to poor problem solving or ineffective thinking. As an instructor, I wonder if the student has learned from her or his mistakes. In reading Marie's journal, I found where she reflected on a mistake that was made during her time with the patient. She gave the reasons for the mistake she had made and what she was going to do next time. The statement from her journal was as follows: I needed to have asked myself why things were going the way they were and I should have asked the nurse a question regarding why the NG [nasogastric tube] was clamped. Although the nurse was busy, I know now that next time I am going to ask, "Why" for everything and try to come up with a solution right away. Even though the staff might have been busy, I should not have felt that my lab instructor or even the staff was too busy to help me solve the problem.
Well, I hate to think that it took a mistake to help me learn something new. I felt that I was not communicating as I should have with my nurse, CNA [certified nurse assistant] or maybe even the patient (I could have asked her about her own care; she was keeping me on track sometimes). Now I understand the nurses a little more when they are having a busy night. But I also realized that many mistakes are more apt to occur on a busy night. From now on, I am "gonna" take as long as I need to analyze things and learn how to work with others even through busy times (Journal 112, pp. 7, 8).
Reading this journal made me realize the importance of journals and the trust factor that is involved in the journal writing. I had talked with the student about the mistake that had been made, but I did not know the impact of the discussion until I read the journal. It took a lot of trust on the student's part to write the information, but I knew then that the student would grow as a result of the experience. The student became very conscientious in asking questions and problem solving.
A different attitude permeates this class, which is something I have not felt before. When I corrected students care plans, they thanked me for the help. I usually get no reply or a grumbling complaint. Appreciation for help was also written into the journals. Cindy had a very anxious day in that she felt that she was not prepared for caring for her patients. Her comment to me in the journal was as follows: Rita, thanks for being so calm and not being impatient with me. It was just what I needed at the time (Journal 117, p. 14). Reading this made me realize the enormous influence the teacher has on students, especially when students are stressed for whatever reason. This statement made by Cindy also made me feel appreciated and willing to continue in my practice.

The End of Quarter
By the end of the quarter, students are usually bringing the nursing process problem-solving steps together no matter how small the problem. For my patient J. D., I had picked anxiety as a nursing diagnosis which applied to him, but I think his problem was more than anxiety. He was very confused and saying a lot of things that did not make sense. I believe he needs some psychological help. His problem was a concern about having a bowel movement. He had one in the morning but he stated that he felt pains in his stomach and had the urge to have a bowel movement. The problem was not an urgent one, but if I did not try to solve or address the problem, he would have become very agitated. After I had assessed his symptoms, I checked his chart and kardex to see if there were any PRN [whenever necessary] orders for enemas or laxative. I talked with the nurse. He and I did a rectal examination for impaction. When no impaction was felt, the patient still wanted an enema to relieve his symptoms. I then administered an enema because I knew he would not be comfortable. There was no result from the enema but at least he calmed down (Journal 101, pp. 21, 22). The student identified the correct steps to solve the problem of this patient and then with the assistance of the registered nurse (RN) implemented the plan which relieved the discomfort of the patient.
Rose was able to connect what she had learned previously about steps to take to lower a temperature and apply them to her patient: There were two minor problems on my patient. He had an Aortic Valve Replacement and was running a temperature of 100 degrees. He felt warm to the touch. He was refusing to ambulate which is a requirement post surgery. I knew that his temperature was probably elevated because the room was so warm when I walked in. His respirations were a bit fast probably compensating for his elevated temperature. I also knew that I needed to get him to ambulate to help decrease his temperature. I knew that I did not need to inform the nurse unless the temperature was over 101 so I used what I had learned previously. I rechecked his temperature and gave him a cool wash cloth to cool him down and a towel to wipe his sweat. With these small steps I was able to help lower his temperature with out the use of medications (Journal 115, p. 22).
This is the last lab. There seems to be a feeling of relief in the students tonight. It is a quiet evening for once because the patient count is down. My activities are not as fast and furious as they have been in the past few weeks. This quietness has given the students time to think about what they are doing, and has given me more time to observe more thoroughly and time to ask questions of the students. I was able to visit the students sooner and interact with them about the history of the patients they had and what goals of care the students were planning for their patients. The students seemed to have a good grasp as to what was going on with the patients. Even when I asked them questions about medications and treatment, they were able to answer my questions. I did not see the confusion on their faces as they have had in the past. The RNs had more time to spend in giving a report to the students. This may have led the students to feel more comfortable about their environment. Thus, they responded to me more easily. The students also seemed more at ease with their problem-solving ability. I am expecting them to function at this level by now.
Because it was quieter this evening, I was able to spend more time with the students and their patients. For instance, Bill had already done his assessment and was asking me about the edema on the legs of the patient. He was saying that earlier that day, according to the records, the edema was 4+ pitting. He felt that it had gone down. But he was questioning whether the patient had edema or was obese. Because I had time right then, we were able to go in and assess the patient together. I was able to show him the relationship of theory to the actual patient. I demonstrated for the student how to check for edema. I verified his findings and was able to show him other areas that needed to be evaluated. I felt this opportunity to assess with the student was a good way to help the student connect theory (assessment of the cardiac conditions) with practice.
After the assessment, I was able to give suggestions to the students about the care of a patient with dry, flaky skin on the legs. At this point I was more in a telling mode and I really wished I had spent time asking Bill questions as to how he would assist the patient in the care of the skin. This may have increased this student's problem-solving ability if I had taken the time to do this.
I had the student apply lotion to the patient's flaky skin. I felt this gave the student the opportunity to be with the patient and learn about the patient. This patient was feeling better and was bedridden and probably very lonely. She talked a long time. By helping the student spend time with the patient, he did learn about the psychosocial component of wholeness and made connections in writing in his journal about the care of the patient. Bill wrote: I felt I was able to help her a lot by talking with her. She seemed very lonely (Journal 108, p. 9). Sometimes I wish students could experience learning by osmosis from my brain so they could learn about nursing faster and not miss the opportunities in caring for the patient's real needs.
One of the goals for a student who had not been performing well in the quarter was being met tonight. The student was keeping me informed and problem solving on her own, which she had not done in the past. This was real progress for the student. I assisted the student in a new procedure. Since there was a time span between when the procedure was taught and the performance of this procedure, I reviewed the steps of the procedure with the student. She did a good job performing the procedure. I felt she would be able to do it again with minimal assistance. I could see on her face the feeling of accomplishment.
Because it was a quiet evening and the students are more independent at this point, I observed the activities of the students in their ability to interact with patients, personnel, and each other. People may have thought I was lazy or something just sitting there at the nurses' desk, but it was like being a mouse in the corner hearing and seeing what was transpiring. I observed three students dialoguing with each other. This had not happened in the past except for the very first day of lab. They were looking at each other's materials and they were asking each other questions. Seeing them collaborating with each other gave me a delightful, warm feeling. The students looked more relaxed working together.
Post-conference is an important time to share information and assist students in problem solving. I asked Bill to describe a code that he had seen this evening. A code is when the patient's heart or respiration has stopped and CPR was started. The description he gave the group was quite thorough. He was able to answer the students' questions and to clarify information without assistance from me.
Linda had seen an endoscopy. She was also able to give a thorough description, explaining exactly what she saw—the vocal cords, the esophagus, the stomach, and the pylorus. It was fascinating to hear her just rattle off the terminology and explain the anatomy so well.
One of the students was concerned about seeing surgery the following week. I suggested that she question some of the more experienced students about surgery, so she could feel prepared to succeed. She had genuine fear, but once she started talking with her peers who had observed surgery her anxiety regarding an unfamiliar situation was greatly reduced. This indicated to me that interaction with other peers assist students in learning and decreases stress.

Problem Solving in Journal Writing
I incorporated the use of journals with the expectation that students might become better problem solvers if required to respond to specific questions about their nursing experience. I developed a rubric with A part pertaining to problem solving and B part pertaining to reflection. The following are the criteria used for evaluating the responses:
1. Identifies one major significant problem.
2. Identifies a problem that arose.
3. Identifies one piece of knowledge needed to solve the problem.
4. Uses external resources when appropriate to solve the problem.
5. Identifies all logical steps as a part of implementation process.
6. Uses reliable external reasons to influence thinking.
7. Identifies one strength connect to patient care.
8. Identifies one weakness connected with patient care.
9. Names obvious thoughts and feelings connected to patient experience.
Each of these criterion was allocated 1 point each for a total of 9 points. The mean was then calculated for the group. A simple linear regression analysis was performed. There was no significant change in the means (p>.05) across the 9 weeks (see Appendix A6). Their problem solving skills remained consistent. In evaluating how well the group answered the journal questions, percentages of the answers to the questions were calculated (see Appendix A6). The lowest percentage was question 3 at 78% and 5 at 79%. When reviewing the students answers, the possible reasons for these low percentages are that the students were having difficulty in identifying the specific knowledge needed in problem solving, and, therefore, they were unable to identify the correct logical steps to take in the process.

Summary
These three "snap-shots" taken from the beginning, middle and end of the quarter capture the progression of problem-solving ability in this nursing clinical. At the beginning students lack confidence in their ability and are very anxious. The last day of clinical, everyone is more relaxed and they tend to meet the challenges of nursing with greater ease.

Reflection
Refection is a process whereby a person revisits a lived experience. There can be a sense of inner discomfort as the individual revisits the experience. Removing the obstructing feelings is the beginning of the reflective process. As a result of "mulling" over this experience, the individual becomes open to new information (Boud et al., 1985). This is when the individual reassesses prior knowledge, feelings, and attitudes towards the problem and determines the relationship of the old knowledge to make way for new information. The person may choose to make a decision or postpone the decision because of what has influenced the thinking. When the individual reaches the "aha" experience, learning has taken place and takes on a personal context (Boyd & Fales, 1983). Being committed to action is the outcome of refection (Boud et al., 1985).
The following was taken from Andrea's journal: A problem arose not with my patient but my patient's roommate. The roommate was in restraints and he was very confused. Every time I was in the room, he wanted my help or wanted to talk to me. He kept telling me that he was feeling very closed in and needed the restraints off. I wanted to help him. The whole time I was there I do not believe anyone helped this man. I knew that a patient in restraints needed to be checked more often, and just because he was confused, I felt he needed someone to talk to him and help orientate him. I tried to get help from the nurse, but she was busy with an admission and another patient who was in great pain. I knew the patient needed the restraints but he needed his other needs addressed.
The patient's discomfort and distress was what influenced my thinking. He kept calling out and talking out-loud when I was in with my patient. I talked with the registered nurse, and she helped me understand the patient but nothing was done. Finally around 5:30, I found the CNA who came in to talk to the patient and assist him to the bathroom. The problem was solved by the CNA taking him to the bathroom and allowing him to sit up in bed. The lights were turned on, and his mind was put at ease (Journal 101, pp. 2, 3).
Because of the inner sense of discomfort (conflict) within the mind and knowledge that had been taught to her from Nursing 1, the student was able to solve the problem. When we talked about the experience in post-conference, she was determined not to let this happen to any of her patients whom she would care for. This statement by her was an outcome of reflection. I feel that if she would encounter any patient with this kind of problem again she would act upon the problem based on the previous reflection.
Reflection is considered a process and can be intentionally taught (Boyd & Fales, 1983). As an educator, I assigned each student to write in a journal answering specific questions. Following are the questions (see chapter 3 for reasons for questions and explanation for reflective score) answered by the students in their journals and the criteria and in brackets stages of reflection for questions 1, 2, 3, 4, 6, 8, and 9.
1. Looking back, do you think the problems that you identified were the most important ones for the patient? What additional problems do you now identify as the result of caring for the patients?
Criteria: Identifies other related problems which may include reasons for the problem. (Integration)
2. Identify a problem or a need that arose during the shift. Explain the circumstance of this problem including whom, what, when, where, and how urgent was the problem?
Criteria: Explains reason for urgency or lack of urgency. (Integration)
3. What knowledge was required for you to solve the problem?
Criteria: Identifies connecting piece of information needed. (Association)
4. What resources helped you to solve the problem?
Criteria: Recognizes personal resources as a resource. (Association)
5. What steps did you take to help solve the problem?
6. What influenced your thinking about this problem?
Criteria: Uses internal reason to influence thinking. (Association)
7. What were your strengths for this clinical experience?
8. What were your weaknesses and tell how you will strengthen these weaknesses the next clinical experience?
Criteria: Explains how to improve on his or her weakness. (Validation)
9. What were other thoughts and feelings about your clinical experience today?
Criteria: Expands reason for thoughts or feelings from the experience. (Attendance to feelings and Validation)
In order to determine the presence of reflection, I developed a rubric (see Appendix A4 and chapter 3) that assessed the reflective elements by the questions that were asked. The students responded to 9 questions. Seven questions were given a reflective score of 1 point each, making a total possible reflective score of 7 points. Each student was given a reflective score based on the analysis of answers to the questions. The mean was calculated for the 19 students for each week during the clinical experience (see Figure 1 and Appendix A5). A simple linear regression analysis for change was performed. There was no significant change in the means (p>.05) across the nine weeks (see Appendix A7).
To assist in understanding which questions the students may have had difficulty in reflecting upon, the percentages of each B criteria for the 19 students were calculated. For the first week, the percentage answered for each reflective element (see Appendix A7) was: question 1 at 56%, question 2 at 50%, question 3 at 31%, question 4 at 19%, questions 6 at 44%; question 8 at 69%; and question 9 at 53%. By week 5 (the lowest

Figure 1. Mean weekly reflective score of unpaired students over 9 weeks.

group mean reflective score) the percentage answered was: question 1 at 50%, question 2 at 29%, question 3 at 07%, question 4 at 21%, question 6 at 14%, question 8 at 71%, and question 9 at 50% answering the questions reflectively. The questions that seemed to have the greater amount of change downward were questions 3 and 6. Questions 1 and 8 had the highest percentage. Calculation of the average of the percentages for the nine weeks revealed that question 3 at 21%, question 4 at 25 % and questions 6 at 35% were the lowest for the quarter. These results may indicate that students have difficulty in connecting knowledge needed in solving problems, that they do not recognize themselves as a source of knowledge, and do not always know what influences their problem-solving decisions. This would be consistent with Baxter Magolda's (1992) findings on reasoning and knowing in college students.
A 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 interest in writing in their journal. 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't 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.
A possible second reason may be because I chose not to give extensive feedback in the journals. I wanted to remove my influence in the reflective process for both the unpaired and paired students. In Lewinian's (cited in Kolb, 1984) Model of Experiential Learning in order for students to move from the observation and reflection level to the formation of abstract concepts and generalizations, they need immediate feedback. Lack of improvement in reflection may not have taken place since feedback was infrequent.

Themes
The themes emerged from the written journals and personal notes for this case study. The themes include emotions, ways of knowing, collaboration and dialogue, communication, learning, connecting theory with practice, and professional role.

Emotions
As a part of the learning process and critical thinking, emotions can motivate or inhibit what is being learned and what is being reflected upon. "Good moods, while they last, enhance the ability to think flexibly and with more complexity, thus making it easier to find solutions to problems, whether intellectual or interpersonal" (Goleman, 1994, p. 85). In the journal writing the students freely expressed their feelings.
Positive emotions motivated the student to continue in the clinical experience. It gave them a relaxed warm feeling, making the day a worthwhile experience. Positive emotions made the student willing to come back again and learn in the clinical setting. Positive feelings were expressed in statements such as: I was inspired by the hope and tenacity of my patient (Journal 109, p. 15). I enjoyed my clinical experience. I feel that when I am at my clinicals that I learn the most about nursing (Journal 110, p. 4). Feelings of affirmation: The nurse told me that she was glad that I was there this evening (Journal 115, p. 3). Often these positive feelings were expressed in post- conference when the students were discussing the events of the day. I could almost see the positive feelings in the students' faces and hear it in their voices.
These positive feelings promoted self-esteem: This lab helped me to bring up my confidence level from last time. And I also felt I got a lot accomplished with the help of the rest of the health care team (Journal 112, p.11).
Negative feelings bring the opposite effect to the student. Negative feelings can be barriers to reflection (Boud & Walker, 1993). "Being in a foul mood biases memory in a negative direction, making us more likely to contract into a fearful, overly cautious decision. Emotions out of control impede the intellect" (Goleman, 1994, p. 86). Because an individual is in a foul mood, this mood can effect self-esteem and the confidence to make a correct decision. Although anxiety can promote a state of alertness, it often brings the feelings of disorientation, confusion, and discouragement (Alfaro-Lefevre, 1995). Negative feelings such as: I was feeling really overwhelmed before lab. I came a little too close to using this lab as my drop lab. Just the psychological impact of having two patients really affected me (Journal 108, p. 3). When I started my patient care today, I was a little bit nervous. I did not want to make the same mistake that I made last time (Journal 112, p. 8). I felt disorganized and a little disoriented before change of shift for p.m. shift. Two patients add a lot of paper work I was not used to (Journal 106, p. 4).
The feeling of anxiety coupled with expectations of how the student should perform affects how the student performs throughout the clinical day. I was not aware of my patient's post-operative status. I was unprepared and the nurses were too busy to help so I had an anxiety attack. Terrible!!! I allowed my anxiety to influence my whole night and all following procedures. It exhausted me to be so emotional, and I consequently became very disorganized. This can be dangerous as a nurse and is unprofessional (Journal 117, pp. 12, 13). The negative feeling of anxiety led to decrease in confidence in her abilities to think through the problem. Fortunately for her, the nurse and I influenced her thinking so that she could calm down and function the rest of the evening.

Ways of Knowing
There are many ways of knowing. All of them are important in problem solving and critical thinking. One of the ways of knowing is knowing/caring for the patient (Jenks, 1993). When a student gets to "know" his or her own patient, the student can converse and intervene more readily in the care of the patient.
Crystal felt knowing the patient was her strength. My strength this evening was knowing the patient's history. It helped me to understand any other problems they might be going through (Journal 105, p. 14).
Getting to know the patient and spending time communicating help patients to relax. I needed patience with J. D. He could be very demanding at times, but when I could talk to him calmly and take time to listen to him. I think it made him relax (Journal 101, p. 23).
Students felt that they were able to get acquainted with the patients even if it was for a short period of time. Although I was only with my patient for three hours, I felt I was able to get to know him better (Journal 112, p. 12).
A second way of knowing is the use of previous knowledge. Without a "base" knowledge of some kind, students cannot problem solve or even learn. "One of the most important principles of educational psychology is that the most important single factor that influences learning is what the learner already knows" (All & Havens, 1997, p. 1218). Cholowski and Chan (1995) in describing the "Knowledge Driven Model" of problem solving, concluded the more existing knowledge the student has, the better he or she can integrate the clinical data in making appropriate clinical decisions. Although I had specifically asked what knowledge was brought to the problem-solving process, the responses to this question can be divided into three areas:
1. Information the students learned from Nursing I and II and from the sciences: Knowledge to check intake and output [from Nursing 1] (Journal 106, p. 2). Knowledge that was required was the fact that I knew diversion is a good way to help with pain [Nursing II] and also the knowledge of helping to reduce anxiety by giving the patient reassuring statements of help calm the patient [Psychology and Nursing II] (Journal 102, p. 5). I needed the knowledge of the function of the bowels to solve the problem [anatomy] (Journal 101, p. 2).
2. Knowledge the students learned this quarter (Nursing III): Third quarter nursing knowledge (Journal 119, p. 5); I had to know that the I.V. sites should not leak fluid or blood, and when they are puffy or swollen, this is not normal. The I.V. solution could be leaking into subcutaneous tissue and the needle dislodged from the vein (Journal 101, p. 13).
One of the "problems" I had was that I thought I had heard a murmur. I heard it over the right second/third intercostal space. The S2 was stronger than the S1 and I heard a sh—sound similar to the one I had heard in the cardiac assessment video (Journal 112, p. 16). The student is comparing the sound that she heard in the patient to what she had heard from a video that was required for class that week.
3. Common sense: Common sense basically helped me to identify the problem (Journal 119, p. 1). I think that with these problems it was mainly common sense I used to solve the problems (Journal 114, p. 2).
Knowledge was an important factor in influencing the students' thinking. Determining what influences your thinking is important in problem solving. The techniques we learned about communication in Nursing Fundamentals and Nursing 154 is what influenced my thinking (Journal 102, p. 9). My thinking was influenced by what I had learned from class with patients with elevated temperatures (Journal 105, p. 19).

Collaboration and Dialogue
Dialogue is important in making learning an active process (Lambright, 1995). Being able to feel comfortable as a part of the team and a nurse interested enough to dialogue with the student made the student feel important and needed. I had a nurse who expected a lot from me—which was good for me. He had time to explain and help me. Other nurses can be too busy sometimes. I was happy that he wanted to help me take out a JP drain. I liked it when nurses were willing to let me help even if it was not my patient (Journal 101, p. 24).
It can be detrimental to the student if she feels like she cannot communicate with the nurse. I need more confidence when communicating with the others nurses. I tended to just listen, [not] sharing my thoughts and feelings. When it is time to give report at night, I tend to freeze and forget the important things to mention to the nurse (Journal 101, p. 23).

Communication
One of the questions the students answered was: What are your strengths? The most repeated strength was communication, especially with the patient. "Critical thinkers are good communicators, realizing that mutual exchange of ideas is essential to understanding the facts and finding the best solutions" (Alfaro-Lefevre, 1995, p. 10). It was important for the student to use communication in getting to know the patient. I felt like I had good communication skills with my client. I obtained the information I needed in a way that did not threaten or belittle my patient (Journal 110, p. 4).
Marie felt that communication with the nurse helped in solving the problem. My strengths for this clinical experience were 1. Good communication with nurse, 2. Good communication with patient, and 3. Good communication with patient's family. When a problem arose, I would inform the nurse and try to solve the problem by the end of my shift (Journal 112, p. 2).

Learning
It may seem unconventional to have learning as a theme, but the words I learned a lot in clinical today were expressed in most of the journals. According to Kolb (1984), "learning is the process whereby knowledge is created through the transformation of experience" (p. 38). As the result of reflecting on the clinical experience, student learning took place. Because of the perceived learning process, knowledge is created and recreated in the minds of the learner (Kolb, 1984). Learning in an experiential climate like the clinical setting "involves the whole learner in cognitive, psychomotor and affective aspects of the learning event" (Reilly & Ommerman, 1992, p. 165). For the students, the psychomotor domain was often identified in the procedures that they participated in and what they perceived as learning.
They believed they learned by "doing": This clinical session was a great learning session. I was able to observe the nurse pull the sheath of a patient who was post angiogram test [a test to view the coronary arteries of the heart]. I got to take vitals during the procedure (Journal 118, p. 3).
I feel that I really took some steps in this clinical in applying theory to practice. I got to perform procedures such as injection and giving a bath. I was surprised at how sure I was when I helped the nurse change an occupied bed. I had organized everything we needed and was quite confident and even took charge (Journal 117, p. 11).
An example of learning in the cognitive domain was: I really loved this clinical experience. I learned a lot about the monitors and found that I remembered what I had learned in first and second quarters (Journal 109, p. 2).
An example of learning in the affective domain was: I learned a lot about care of the patient post cardiac surgery. I also found out how it would affect me if a patient died. I did not know if I could handle that part of nursing. Now I know I can get through it (Journal 109, p. 7).
These learning experiences portrayed an eagerness to be in the clinical setting because the students felt they learned a lot. The day may have started out as anxiety producing but ended up as a gratifying experience. Bill was overwhelmed in ICU (Intensive Care Unit). He felt out of his element. Because the nurse assisted him in learning, it ended up being fun, I learned a lot and feel more confident (Journal 108, p. 5). I believe that these learning experiences are what motivated the students to learn more and to come back to the clinical setting. I had a great clinical experience last night, and it is not only challenging but fun. I think I am actually beginning to look forward to clinicals rather than being afraid of them. A lot of what I have learned this quarter and past quarters is beginning to make sense (Journal 102, p. 13).

Connecting Theory With Practice
One of the reasons for having students reflect is to provide the opportunity to assist the student in connecting theory with practice. The clinical setting is the place where students can apply theory to real clients and real problems (Reilly & Ommerman, 1992). Through exposure to real-life situations the students were able to grasp the concept of caring for the individual's whole being.
The students integrated the concept of spiritual care: I appreciate that we talked about the power of prayer in post conference. I truly believe in the power of prayer as mentioned. There are many things you can do with patients if you do not feel comfortable about praying with them, such as listening while they pray. Last night I told my patient that I would remember her in my prayers before I went to bed. I guess a small gesture like that is also therapeutic for the patient as well as myself (Journal 111, p. 8).
The students also applied concepts of trust and compassion: It is a shame how some patients can feel lonely and neglected because the nurses or CNAs are way too busy dealing with more than two patients at a time. I think that to be able to spare more than a few minutes to sit and just talk to my patient felt really good. I was able to grasp the concept of compassion and trust with my patient (Journal 115, p. 19).
Students learned about culture in the care of their patient: The patient could only speak Spanish. If the patient does not understand his treatment or the rationales behind them, he may not cooperate to the fullest extent, thereby putting him at risk for possible non-compliance. Beside the inability to communicate, the Hispanic culture, I believe, has a need for a man to be very independent and self-reliant. This factor may play a major role in the future outcome of this patient's well-being. I used a CNA to interpret for me, but I wonder if they were understanding me. This experience really taught me a lot about how cultural beliefs are a big part of nursing and a patient's well-being (Journal 102, p. 17).
Giving the reason for treatments to a patient with respiratory problems relieves anxiety and the feeling of helplessness. I found the patient close to tears when I entered the room. Upon investigating, I discovered that he wanted his tracheostomy tube out. I explained to him the reason he had the tracheostomy was to ensure that he could breathe on his own, working towards strengthening his respiratory muscle so that they eventually could take the tracheostomy tube out. I think that this really helped him feel better (Journal 118, p. 10).

Professional Role
The clinical experience provides an avenue through which the student becomes socialized into the profession, its values, and accepts professional responsibility (Reilly & Ommerman, 1992). Some of the students were able to acquire an understanding of the role and responsibilities of the nurse as a result of participating in and reflecting about the hospital setting.
Becoming a nurse: I am struggling with self-confidence. I can see myself growing, though, and with each clinical experience I find myself falling more and more into the role of the nurse, not Joan only, but Joan as a nurse, and I really am starting to believe I am capable of this (Journal 102, p. 13).
Role modeling: I thought how nice certain nurses are and how I would like to be nice too (Journal 106, p. 11).
Meeting the goals of what the student perceives a nurse doing is exemplified in: I went into nursing wanting to help people, and I feel that I really try to do this. People really appreciate it (Journal 110, p. 113). I cannot wait to move up and be more of a leader in my field. Successful knowledge is so important. It is the key into being the kind of person I want to be! (Journal 119, p. 7).

Summary
In this chapter, I told the stories of nursing students as they learn to problem solve and care for patients in the hospital setting. Journal writing was the method used to assist students to think about their clinical experience. The students gave their perspective of the problems they encountered and the factors that affected them. The themes that emerged from the students' journals were emotions, knowing the patient, collaboration and dialogue, communication, learning, connecting theory with practice, and professional role. The analysis of the journals by the reflective rubric showed that the reflective process remained consistent during the nine weeks.
The following chapter shares the lived experience of paired nursing students as they worked and journaled together in the clinical setting. The results from the rubric analysis of the paired nursing students' journal will be explained.