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Introduction

Clinical teaching and learning are important aspects of practice within the discipline of nursing. Educators are challenged to explore pedagogical methods that will enhance clinical learning (Tanner, 1994). The instructional method studied in this case study was pairing nursing students in the clinical setting. I focused on the paired students journaling about their experiences when they were involved in problem-solving activities. Journal writing provided the students the opportunity to seek answers, examine alternatives, and assist in the transfer of theoretical knowledge to the clinical practice.
The first part of the chapter includes vignettes of paired students working together in the clinical setting. The purpose of sharing these vignettes is to capture the lived experience of paired students as they learn to work together so that the reader could gain an understanding of this instructional method. The second section of the chapter describes the paired students' ability to problem solve in the clinical setting. Because clinical experience is a complex learning experience, by sharing these written experiences, the reader will be able to encounter glimpses of this complex process. The reader will be stimulated to think about how to meet the challenge of assisting students to problem solve and to think reflectively in a clinical setting. The last part of the chapter describes the paired nursing students' reflective process over time when examined with the use of a rubric. The purpose is to demonstrate that reflection does increase over time when students dialogue and write together about the problem-solving activities.

Clinical Setting
Student assignments were posted by 4:00 p.m. the day before the clinical experience. The paired students were expected to arrive at the clinical setting together and gather the information about their patients and then develop the care plan based on the information they had obtained.
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 students' patient had been discharged, I would assign a new patient to the students. Sometimes two or all three patients assigned to the paired students were discharged. As the quarter progressed I noticed the nursing students would also arrive early to review charts and material together. They would review the knowledge they needed about drugs as well as ask each other questions regarding the best care for the patient.
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 care plans they had written from information they had collected from the chart the night before. During pre-conference time I discussed with the students changes in the patient's condition, skills needed during the shift, and new patient assignments. I answered questions the students had about the patients. These often concerned medications they could not find in the drug books. The first week the students had two patients. I had intended they would care for the patients together, but they split the assigned patients, between the two of them, and it became "your" patient and "my" patient instead of "our" patient which lessened the goals of collaboration. The students did not learn about each other's patient nor feel comfortable working together in the same room. This fortunately started to change during the second week when there was an increase to three patients for a 9 hour period, and students needed to organize care for all three patients.
The rest of the evening proceeded like the unpaired case study in chapter 4. Except in addition to giving me a short report about the condition of his or her clients, sometimes I would have one of the students report to me on all three patients to verify that the students were indeed collaborating together and knew about all three patients.
The last 15 minutes of the post-conference I allotted time for the students to write in their journals and to finish the evaluation section of the care plan. This gave me the opportunity to observe how they dialogued together. Some of the students became more organized with time, and the journals were written by the time they arrived in conference. Two of the groups often stayed after post-conference to write in the journals together. The reasons they gave me for this were (1) the information was fresh in their minds, and (2) one member of the pair lived a long distance away, and they would not be able to collaborate together the next day to finish the information to hand in to me. We ended at 11:30 p.m.

The Paired Experience
Being paired was a new experience for these nursing students. They had a difficult time explaining to the nurses the reason for being paired. I overheard one student tell the nurse, It was not because we are dumb, but we are learning to work together (Journal 130, p. 5).
Being paired did require learning to work together. According to Tuckman (1965), there are four phases in developing and functioning as a group: "(1) forming, (2) storming, (3) norming, and (4) performing" (p. 396). These phases are sequential, but the duration of each phase is dependent upon the reasons the group is being formed and other reasons that may effect the group. For Tuckman's analysis of the research on groups, the groups consisted of 5 to 15 people. For this case study research I used the definition of groups from cooperative learning: A group is considered two to four people (Johnson et al., 1998).
In the formation phase, the group is developing relationships. Individuals are looking for commonalities and avoiding controversies. The ground rules and boundaries are tested and established. In the storming phase, conflicts of interest appear. There may be control issues, difficulties in communication, wanting to opt out of the relationship, or feeling stuck in the relationship. During this phase there is resistance to becoming a group. In the norming phase, the group is starting to develop collaborative skills and accepting each other's idiosyncrasies. They are starting to become cohesive. During the performing stage, the group members start to work together on the goals and tasks outlined in phase three. They are feeling more secure with positive and negative emotions in the relationship. In short-term groups the performing phase may not be clearly visible and it may be part of the storming and norming phases (Arnold & Boggs, 1999; Northouse & Northouse, 1998).
Being paired requires learning new skills of organization, communication, and collaboration. I observed Ching and Abe working separately on their 1st day of clinical. There were two handwritings in the journal as they functioned individually and the comments made used "I" statements. I feel satisfied giving a patient quality care, and I know I did my best doing so (Journal 120, p. 2). They wrote about the problem in two different sections of the journal. The students were to answer specific questions about the problem-solving process. Question 2 through 5 specifically asked about the problem the students had identified and how they went about solving it. Ching wrote about the problem under question 2: The medications for M. G. could not be given because she was NPO [could not have anything by mouth] and was sedated. M. G. had a peg tube placement at the beginning of the shift in the special procedure unit. The problem was urgent because she could not have medications due to general anesthesia (Journal 120, p. 1).
Abe wrote about the problem after answering question 9: The problem that came up during the shift was that the patient had been NPO for two nights already and had not received any food or liquid. She did not have an I.V. [intravenous fluid] started, and all of her medications were withheld. Her mouth and skin were very dry. The nurse finally got the I.V. from pharmacy, and the patient was started on the I.V. fluids. When I left, she seemed to be peaceful and calm, and her vital signs were all normal (Journal 120, p. 2). They seemed to function individually at this point. In post-conference that evening I gave a math problem for them to calculate. Ching and Abe did the math problem separately, and when they came up with different answers, they could not decide who was right.
Ching and Abe were from different Asian backgrounds. I found that the female student always could answer my questions, but the male student had a difficult time. She stated to me that he may have felt intimidated by her because she was detailed-oriented and assertive. As the quarter progressed, their statements indicated that they were starting to collaborate together in the problem-solving process. The problem we found was that C.L. had a personal care taker and our role as a care giver was being altered (Journal 120, p. 3). (Students planned ahead how they were going to care for a patient. When they arrived at the hospital unit, this patient had a private duty nurse who was caring for the patient's basic needs. Since this was the first time they had encountered this, it forced them to rethink how they were going care for this patient.) The resources that helped solve the problems include our partner first and then the RN on duty. Our thinking was influenced by each other. I remembered that nurses need to be aware of both psychosocial and physical aspects of patients when care is being provided. Then we tried to evaluate the patient's spirituality and implement interventions accordingly (Journal 120, p. 5).
Teamwork has been nice because the other partner can double check your work and recall what you forgot. Two heads are always better than one. You can depend on each other when the other one needs help (Journal 120, p. 14). By the statements in their journal and to me they were able to make it through the storming phase to the norming phase.

Storming
Sometimes students get stuck in the storming phase. Faculty can assist the students out of the "status quo" by being flexible in the "ground rules." For instance, I expected the pair to collaborate on all three patients, however, in the case of Nora and Rhonda this did not work. Nora seemed to have a stronger knowledge base than Rhonda. Nora was more assertive and took control of organizing the clinical experience. Rhonda had a quieter nature and allowed Nora to do procedures. This caused frustration for Nora. In reading their journal, I found that most of the problems they identified in the clinical setting focused around them, for instance, an RN being rude to them, lack of organization and priority setting, and uneasiness when they changed units. Only the 1st clinical day and the last 2 clinical days did the students write about patients' problems. Although they stated in their journal, we influence each other by asking each other questions when we do not understand (Journal 121, p. 16), through observation I felt they were just tolerating each other. There seemed to be a decrease in the amount of communication time together compared with the other groups, and in the classroom they sat on opposite sides of the room except during collaboration activities.
In collaborating with another faculty regarding my concern about this pair, it was decided that I would deliberately assign a particular patient to each of the students and the third patient the students were to collaborate on this patient's care. The results were that Rhonda's patient was very verbally abusive and confused, and she was scared of him. Rhonda needed assistance and asked Nora to assess the patient's condition. When Nora observed the condition of the patient, she was also afraid to take care of him. Since both knew that the patient needed to be cared for, they collaborated together as to what to do and decided that they were going to team up in caring for this patient. By the end of the shift they were collaborating on all three patients.
The comments in their journal were: Our strengths were each other and being more comfortable about ourselves and being more aware of our surroundings. We feel as if this was a positive clinical experience. We both feel that having a partnership strengthened our confidence in ourselves as far as our abilities. It was easier to collaborate on paper work to amplify our understanding of what needed to be done and intensify our experience as a team (Journal 121, pp. 21, 22).
I think what made their relationship end positively was that they were able to focus together on one goal. That goal was that they needed to work together in order to succeed in caring for the patient and overcoming their own anxiety.

Frustrations
Being paired creates frustration within the individual that can be overcome when talking and reflecting together. When setting up the pair, I used the concept of stratification from cooperative learning by Johnson et al. (1994) and assigned a higher-level student with a lower level student. I hoped that there would be an increase in the lower-level student's knowledge as suggested by Vygotsky's (Cole, John-Steiner, Scribner, & Souberman, 1978) concept of the zone of proximal development. Students were paired together after being classified by Facione and Facione's rubric scale for critical thinking (1996a) (see Appendix A1). This rubric was a scale of 1 to 4. Level 1 represents inadequate thinking by the individual and level 4 represents the individual using critical thinking most of the time. Using this scale I had asked the instructors from quarter 1 and quarter 2 of nursing to rate each of the students. I then averaged the score and assigned each student a score. For the following scenario Becky was a level 4 and Lauri was a level 2.
While sitting with Becky one evening, I asked her how her experience of being paired with Lauri was. Becky was concerned about the inconsistency in her partner. Lauri seemed to "just go do her own thing". Becky would ask her a question, and Lauri just did not seem to know how to answer or to even care to help make a decision. Becky felt that she was not learning anything from this partnership.
Since the paired situation is a reciprocal process, there was no doubt in my mind that Lauri would learn, but I was concerned about Becky. If their zones of proximal development are far apart, would Becky learn? So to assist Becky in her learning development, I told her it is important to keep asking questions, and if she did not get an answer, then she should save the question until I arrived again to the unit then ask again so I could assist her in getting the answer. Throughout the quarter I observed the interaction between Lauri and Becky. When Lauri did not answer questions for Becky, I would assist Becky in learning the answers.
As the quarter progressed, a comment in the journal indicated that they were working together. This clinical experience was a very good one because both my partner and I felt as though we were real nurses. We kept busy and were doing things like injections, hanging I.V. bags, and resetting machines (Journal 129, p. 10).
By mid-quarter when I asked Becky how her partnership was going, she felt that the paired situation was getting better. The benefit of it was that she was able to explain to her partner what information was important in solving a problem. Thus, by talking out loud and reflecting on what she knew, she felt she was obtaining knowledge and understanding of the patients for whom she was caring. In my personal notes I stated that I thought the reason why their partnership improved was because Lauri's knowledge base had increased because she was putting effort into learning; therefore, she was able to add her knowledge to the discussions with her partner. Maybe her learning zone was getting closer to Becky's.
When I interviewed Lauri the last week of the quarter, her comments to me were:
I enjoyed being paired because I learned a lot of skills from my partner. Because I had observed my partner consistently checking the identification band of the patient, I was able to internalize that skill by consistently checking my own patient's identification band (Journal 130, p. 30).

Error in Problem Solving
Being paired does not always prevent students from making errors in problem solving. This was my concern when starting this project. On May 20 an incident occurred where poor judgement on the part of the students led to an incorrect decision, miscommunication with the RN, and conflict between the two students. The RN approached me and stated that the students refused to come assist him during an episode when their patient had an increase in shortness of breath and needed to be transferred to ICU.
One problem we had was with K. B. She had dyspnea [shortness of breath] especially on exertion. Every time too many people were in the room to attend her, she started getting tremors, becoming anxious, and then her respiration rate would go up. It was a very urgent problem because we needed to do our job, but she would become very short of breath. Mari assisted the patient safely onto the bedside commode and then back to bed. When laying the patient down, I noticed that she started getting nervous. She expressed that there were too many people inside her room (Journal 123, p. 18).
At this point the students should have informed the nurse about the patient's increased nervousness, shortness of breath, and the patient's request for not having two students in the room at one time.
Mari and Tracia went to record their initial assessment, empty a Foley (a bag that contains urine) in the next room, and then they both went back to the nervous patient. When they entered the room, the patient was being assisted by a sixth-quarter nursing student. When the patient saw Mari and Tracia, she said angrily, "I do not want you to be around here" (Journal 123, p. 18). The RN entered the room and asked for assistance, but the students took the statement made by the patient literally and stood just inside the door. The nurse then asked Tracia to go to the pharmacy for medication that was needed, and Mari left the room because she needed to take care of her own personal needs (Journal 123, p. 18).
Upon returning to the room, Mari thought she overhead the nurse say:"There is a student nurse in here who is very uncooperative. Her name is Marcy (a name similar, but not really her name). She went closer and heard him continue to say, "Remember, her name is Marcy." Mari felt that his remarks were not only unkind and offensive but also out of character for a nurse (Journal 123, p. 20).
When Tracia came back from the pharmacy with the medication for the patient, the nurse asked Tracia and Mari to help transfer the patient to the intensive care unit. He suggested to them that they stay in the intensive care and observe the patient being intubated (a tube placed into the trachea to provide an airway for a ventilator to be attached). Mari was so upset at what she thought the RN had said in the room, and Tracia was afraid of what had just occurred with her patient that they did not want to stay. So they came back to the unit to care for their other patients.
This was when I arrived in the unit, and the RN told me about what had happened. It took an hour to sort out the stories. In talking with the students, I tried to help them comprehend the relationship between signs of hypoxia which causes agitation and the statement made by the patient, "I don't want you in here." The students could tell me the signs of hypoxia but had difficulty in making the connection between what they knew and what they had seen. Part of the problem was that Mari was upset by the statement she thought she heard the nurse say; therefore, she was having difficulty thinking about the problem from a different viewpoint. Tracia was able to make the connection but was unable to help her partner in contemplating the importance of critically thinking through a situation from the RN's point of view as I was asking them to do. I ended the discussion with the request that they journal that evening from the nurse's point of view in problem solving.
This incident created conflict between the partners. Up until this point they had been working well together. I had observed them collaborating on various problems and in their journal they made "we" statements. We were quite organized in giving care to our patient and attentive to the nurse's instructions. We asked a lot of questions about the nurse's actions, treatment, and the reasons behind them. We learned more about caring for a patient that is total self-care (Journal 123, p. 15).
When I received their journal, Tracia and Mari had written separate accounts of the experience. Tracia was feeling bad that she was unable to assist her partner in overcoming the miscommunication problem that occurred that evening.
This was Tracia's comment: My thoughts and feelings about this experience are very scary. Yes, I wish we could have learned more about the technical aspects of what is going on in the hospital setting, but then we did learn the importance of good communication. I feel really bad about miscommunication occurring. I hope next time I run into a situation like this I will know what are the best steps to perform and what should be said at the right time. What I mean is I hope I have learned from this experience so that next time I can take the right actions to help my patient, the nurse, and my partner (Journal 123, p. 18).
Mari ended her journal with a defensive statement: "It was the RN's fault." Since I had asked them to journal this problem together from the RN's point of view, I asked them to rewrite the situation again. Mari still refused to write with her partner, but she did rewrite the problem-solving steps correctly and left the blame out of the problem. Tracia's statement, which assisted her in solving a problem the next week, was: The knowledge we needed was to know the signs of hypoxia such as shortness of breath, restlessness, tachycardia, tachypnea, and cyanosis. Our patient was experiencing these symptoms. Other knowledge we needed to know was what to do in this kind of situation. The first thing would be to calm ourselves, then hold the patient's hand and tell her, "I know you are distressed and I am here to help you," then ask the patient to take slow deep breaths, and then place the oxygen on or turn the oxygen up (Journal 123, p. 26).
The next week the students were faced with a patient who exhibited shortness of breath. When reading the journal, I realized the importance of encouraging the students to reflect on their previous experience. The problem that arose during the shift occurred while a newly admitted patient started experiencing worsening signs of shortness of breath. Her lungs sounded more wheezy with fluid as time went by, and her oxygen saturation dropped to 72 percent on room air. Even with the nasal cannula oxygen running at six liters, she was still saturating at 85-86 percent. The problem was very urgent, and it was an emergency problem. The knowledge required for us to solve the problem was derived from previous experience with a hypoxic patient and lessons from Fundamental Class on signs of hypoxia. While the RNs were trying to get a hold of the doctor, I sat and held the patient's hand while trying to keep her calm and encourage her to take slow, deep breaths. I accompanied her to ICU where she was monitored and given antihypertensives. My partner assisted me by caring for the other patients while I took the patient up to ICU. Overall, it was a good learning experience (Journal 123, pp. 20, 21).
Because the students had reflected on the problem that happened the previous week, they were able to communicate with each other and with the nursing staff. Since the students had recorded their previous experience making connections from theory to practice, they were able to take action. In rereading their journal, I realized students can learn from errors when they have reflected on their experiences.
Mari and Tracia were able to move from the storming stage to the norming stage when they started to plan how to strengthen their partnership. We need to better communicate about what is going on with our patient. One of us will review the doctor's orders throughout the shift so medications and treatment that are added will be given (Journal 123, p. 32). In the last journal statement of the quarter, there were two handwritings and the "we" statements were included. Our strength for this clinical experience was giving good care for our patients and getting all of our work done on time (Journal 123, p. 32). In interviewing Mari before she finished the class, she stated that she had learned a lot this quarter and she really enjoyed working with her partner. This indicated to me that she overcame the conflict.

Increase in Self-confidence

Being paired together increases confidence in the clinical setting. According to
Johnson, Johnson, et al. (1998), some of the outcomes of cooperative learning are academic success, assisting students to adjust socially to college, and increasing self-esteem in the individuals.
Michael wrote how he felt that being paired assisted him by increasing his self- confidence. This quarter is much more complex for me scholastically as well as socially, and sometimes I do not think I am going to make it, but this teamwork partner program
this quarter makes me feel much more productive and confident in myself (Journal 124, p. 7).
Matt and Carol commented on how being paired increases confidence in performing procedures, decreases anxiety, and enhances learning from each other. Matt and I are working well together in the clinical setting. Neither one of us is very dominant in personality so that aids in our working together. We are able to keep better track of the three patients. It is stress-relieving to not being alone in the situations, and we are learning from each other (Journal 128, p. 8). We are more confident in our ability to take care of the patients. We are confident in giving medications, doing intake and output, giving comforting measure, working well together, and giving prn medications (Journal 128, p. 17). Being paired together has brought benefits to most students as they work together in an active environment.

Teamwork
One of the reasons for pairing the nursing students was to provide an environment to practice collaboration and team work. Collaboration is not a natural process (Gerace & Sibilano, 1984), but remarks written in the journals were quite positive. Diane and Rogenia made the following statements.
I feel very lucky to be paired with Diane. Diane makes sure that I follow through with treatment and procedures in a timely manner. Having a partner like Diane helps my clinical learning experience.
Now it's my turn! It was great having partners this week. It makes the clinical experience much more educational and enjoyable (Journal 122, p. 3). By learning to work together as a team, treatment, procedures, and other activities were completed on time. Second, by working as a team, the students felt their learning was enhanced.
As the quarter progressed, the paired students felt that teamwork had become their strength in caring for their patients. Our strengths were that we worked together on caring for the patients, and when any questions arose, we were able to assist each other in obtaining the answers. Our teamwork is still going strong. We depend on each other a great deal, and we collaborated well on care plans, medications, and procedure (Journal 121, p. 12).

Communication
One of the major elements in health communication is the interaction that occurs between individuals as they communicate health information (Northouse & Northouse, 1998). The results of being paired together strengthen communication which is an important element in teamwork. Becky and Lauri commented in their journal: We were also able to work together at a higher level because of the better communication we have learned to do (Journal 129, p. 6). As the quarter progressed, communication continued to be a strength for Becky and Lauri not only with each other but with the patients and staff. We believe that our strengths include good communication with each other, as well as our RNs and patients (Journal 129, p. 9).

The Clinical/Nursing Experience
The clinical experience provides the opportunity for students to start thinking like a professional. Nursing, like other professions, practices from a problem-solving perspective as opposed to a task-oriented perspective. "The clinical practice experiences enable the students to minister to real clients in the management of real problems inherent in their practice" (Reilly & Ommerman, 1992, p. 10). Problem-solving activities are essential in individualizing a patient's care and are important in assisting the learner to develop discrimination skills when faced with ambiguous choices (Reilly & Ommerman, 1992).
Nursing developed a framework of logical steps that are relevant to holistic nursing care. The framework is comparable to the problem-solving process. This is the framework the students were taught to use when solving problems. The fours steps with their descriptive components are:
1. Assessment Problem recognition
Data gathering
Data analysis
Nursing diagnosis

2. Planning Desired goal setting
Priority setting
Selection of intervention measures

3. Implementation Carrying out of nursing actions
Formative evaluation of actions
Change as indicated

4. Evaluation Relationship of outcomes to defined goals
Consistency of actions in process phases with
Pre-determined criteria and standards of care
Influence of structural variables on outcome and process. (Reilly & Ommerman, 1992, p. 61)

The following is a description of the problem-solving process as reflected in the writing of the paired journals and my personal notes. Included are factors that enhanced or deterred the students' problem-solving ability.

Problem-Solving Process
Because much of the learning and practice of nursing in the clinical setting involves problem solving, deliberately developing questions for the students to cause them to "stop and think" is an attempt at increasing levels of reflection. Dewey (1933) parallels problem solving with reflective thinking because the individual must become aware that a true problem exists and then reflect on the problem in order to make meaning and to provide a course of action in solving the problem. The following is an example of using the four steps of the nursing process.
From the research that we did the night before we had identified that the patient would have pain after surgery. When we arrived at the hospital unit, the patient had already received Demerol for pain but stated that it was not relieving her pain. We asked her to rate the pain level, and she was 9½ on a scale of 1 to 10. We consistently monitored the patient's pain level while on Demerol. We listened to her comments about morphine being more effective for her the last time she had surgery. We researched into her suggestion about morphine by looking at the chart and at the drug book. We talked to the RN, and she contacted the physician. [Students cannot contact the physician at this level]. We received approval for an order of morphine, and we administered the pain medication. Her pain was relieved (Journal 129, pp. 7, 8).
As part of preplanning for care of this patient, the students had identified that pain would be a problem after surgery. Since relief measures were ineffective, they further investigated the problem on how to decrease the pain for the patient by talking together to decide what needed to be done. To them it was not an urgent problem, but with the increased pain level to 9½, they considered the alternatives, which included listening to the patient and then took action. By writing about the problem, the students were able to reflect on the decision that they had made and come to a consensus that it was a good decision.
When first exposed to writing about the problem, some students were very brief in their description of the problem. The following is from Deborah and Jim's 1st clinical day. The problem: Deborah's patient had decreased circulation related to reduced cardiac output. The nurses were aware of it at the beginning of the shift, but nothing was done until near the end of shift. The knowledge we needed was correct positioning of a patient. The nurse told us the best position in which to place the patient. We placed pillows and propped the patient's legs (Journal 127, p. 1). I had written in their journal that the nurse performed more activities then what they had written about, therefore the students needed to think about solving the problem of decreased circulation in relationship to what the nursing was doing for the patient. Because the description was short, I could not tell by their journal how the problem was solved because they included only one intervention for decreased circulation, and there are many more activities important for a patient exhibiting decreased circulation.
As the quarter progressed, there was an improvement in Deborah's and Jim description of the problem. They were able to use the knowledge they had learned in class, and with the use of dialogue they were able to solve the problem. The patient was experiencing pain from the I.V. site. We checked the site and the I.V. was "flopping around" because the I.V. tubing was not taped well. The tissue around the I.V. site was filling with fluid and was hot to the touch. It was the change of shift, and nobody wanted to take care of the problem. The problem was fairly urgent because of pain and the arm filling with fluid. We had learned in class about I.V. infiltration, and we could tell the needle was not in the right place causing the fluid to going into the tissue. If the I.V. was left like it was, it could cause many problems to the tissue. We told the nurse and when he checked it he agreed with us, but it was the change of shift and so the I.V. was not taken out. Because we could not discontinue the I.V. on our own, we contacted the instructor and she assisted us in stopping the I.V. and removing it. Then the next shift's nurse came and started the I.V. again (Journal 127, pp. 10, 11).
The students had gained enough confidence in their knowledge and in their ability to solve the problem when the RN did not respond to them. With the knowledge they knew, they contemplated the consequences of leaving the I.V. so they took action by contacting their instructor.
The first journal question—Looking back, do you think that 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 patient?—was intentionally written to lead the students into the evaluation step of the nursing process. The students gathered data the night before and identified problems that might arise in preparation for caring for the patients. The following is an example showing progression in evaluation for the original nursing diagnosis to the "new" nursing diagnosis.
The nursing diagnosis chosen from V.L. was increased risk for impaired skin integrity. The diagnosis seemed to be an appropriate choice. Other possible nursing diagnoses could be pain, related to status postoperative total knee replacement, and activity intolerance due to limited range of motion (Journal 124, p. 1).
By the 5th week the students included with their nursing diagnosis the reasons for their original nursing diagnosis and the new nursing diagnosis. By including these reasons, they were demonstrating an increase in thinking beyond just identifying the problem. For S. D. the nursing diagnosis was impaired mobility. This was an appropriate diagnosis. She was unable to perform activities of daily living, and had extreme difficulty with ambulating. Client was short of breath and unable to lift her own legs out of the bed due to her morbid obesity. The client had a myriad of problems related to ankle/leg edema and the inability to ambulate without assistance.
For N.N. the nursing diagnosis was pain. This may have been a priority last night; however, today the client seemed to be pain-free. She was somewhat disoriented and forgetful. To address this need I conversed with the client numerous times and reoriented her. She asked four times why her urine was red.
For H. M. the nursing diagnosis was constipation. Today the client had a bowel movement. How quickly things change in 24 hours (Journal 124, p. 10). In analyzing the responses to the journal questions using criteria A, the paired students were quite consistent from week 1 to week 9 in explaining their problem-solving processes (see Appendix A4 and A9).

Barriers to Reflection
Sometimes there are barriers that prevent the student from further progressing in the learning experience or even identifying that there is a problem. Boud and Walker (1993) define barriers as "those factors which inhibit or block learners' preparedness for the experience, their active engagement in it, and their ability to reflect rationally on it with a view to learning from it" (p. 80). These barriers limit the learners' awareness of the learning environment, can cause them to fail to focus on the knowledge that is needed in the problem-solving process, or can paralyze the learner to even actively perform in the situation.
Barriers can be external such as people, hostile environments, culture, or written expectations; or internal such as negative emotions (anxiety, anger, or fear), lack of awareness or unconscious oppressed behaviors (Boud & Walker, 1993). Whichever type of barrier, it can create non-reflection in the learner, and learning does not take place (Mezirow, 1991).
The following statement from Nora and Rhonda's journal demonstrates how people and a hostile environment can act as a barrier to learning. Upon arriving on the floor, we get the report first thing from the assigned nurse; however, the first patient whom we decided to see had a busy nurse at the time so the CNA [certified nursing assistant] gave us the report. As we were assessing the patient, the assigned nurse came in, and in a lecturing, upset tone, told us never to do that again without seeing her first. After we were done, we went to get a report on the other patients. Searching for the nurse, we found the nurses in a meeting and were abruptly told to wait. At this time, we had medication to be given and charting to be done on the previous patient, but could not get to the charts because the meeting was going on.
We were influenced by not being able to get our things done for our patient and failing the lab. [The students felt that if they did not get their work started on time, the instructor would fail them for lab.] We would like to have been more knowledgeable so that we would know what to do in certain situations. For a while we felt really belittled by the way some of the nurses were talking to us (Journal 121, pp. 3, 4).
The students did page me, and when I arrived on the floor, they had stopped doing all activities—not knowing what to do. Nora was very anxious about the way she thought she had been treated. She was concerned about failing lab. Neither one of them could supply a possible solution to the problem they were facing. As a teacher I was able to "soothe" their fears and intervene on their behalf in order to get them working again. In my journal that evening I noted the patient's blood pressure was elevated, and we had to problem solve together regarding the patient's blood pressure. I wondered if they would address this problem in their journal. Because of the high anxiety they faced on the unit, this problem was a higher priority for them than writing about the high blood pressure of their patient.
However, the students did overcome their anxiety and the next week Rhonda and Nora wrote: We enjoyed tonight's lab because we were more experienced; we had a lot to do so time went much faster than the first two weeks. We were more comfortable with the unit and the staff. All our patients were awesome. Our strengths were collaborating with each other and were not afraid to ask anyone for help or assurance with the treatments and procedures we had to be doing (Journal 121, p. 9). The students were able to relax and start problem solving together.

Emotions/feelings
Emotions take on different forms in the clinical setting. They can be negative or positive. As I stated above, negative emotions are barriers to reflection and problem solving. Negative emotions can create low self-esteem or the inability to think when problem solving. Positive emotions create a catalyst for reflection. They help the
individual focus on the event and see it more sharply (Boud et al., 1985). Positive emotions serve to create the avenue for new learning to occur.
We enjoyed clinicals today. The biggest blessing we got out of this clinical experience is from a 92-year-old patient who insisted on walking again after her stroke. She prayed with us which gave us a lesson. As long as you have the will, you can over- come the problem. The amount of faith that she exhibited gave us courage to not give up on hope and dreams. She gave us a lesson in spiritual care (Journal 120, p. 6). Because of the pleasantness of the experience Ching and Abe were open for learning.
Although students journaled together, sometimes one of the partners would make personal statements. The following statement is important because the student acknowledges her partner as part of the wonderful experience. She also acknowledged the instructional method that is helpful in her learning. Crystal talked about her positive experience in clinical. I had a wonderful experience tonight. As usual, my partner was pulling his weight, helping to fill in the gaps, and pointed out needs that required attention. Rita [the instructor] was helpful in directing patient care. I enjoyed her instructional assessment and assistance with the glucoscan. She did not tell me every step, but allowed me to act and answered question prn [when necessary] (Journal 124, p. 14). Because of the positive experience, the student could figure out what she is learning.

Connections
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 connections 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).
Last night after a review of the chart Michael and I thought pain would be an apt nursing diagnosis. After I thought about it at home, I decided fatigue would be better because the patient's pain level would not be a priority as evident by the fact that she was receiving pain medications infrequently. The order is written prn for Versed and Morphine Sulfate. Further consideration led me to the nursing diagnosis of fatigue. This was applicable and a better choice than pain. But, low and behold, after we observed the patient, the diagnosis that better suited the patient was actually anxiety related to her inability to communicate as evidenced by placement of a new tracheostomy tube. This was a perfect example of how conditions evolve and new adaptations can be made to suit the changes (Journal 124, p. 19).
Because of the process of reflection, Crystal and Michael were able to evaluate what they had written and what they were observing while caring for the patient. They were able to link this process to nursing process and the way patients change through the course of their stay in the hospital.
Discussing the different alternatives for the care of the patient helped the students care for the patient in a different manner than they might have expected. Carol and Matt were caring for a patient in the intensive care unit who had a tracheostomy tube with a ventilator and who was completely dependent on the nurses for her care. This was a new experience for the students, and they reflected on what they had learned regarding spiritual care and maintaining the patient's identity while caring for a patient. After talking to the patient, we discussed that we hope that we will not make the patient feel ignored or feel like her care or treatment is less than is to be desired. We did pray with the patient and actually communicated with her instead of just treating and caring for her all day. That is another kind of care we are very sure of (Journal 128, p. 11).

Dialogue and Learning
It is my assumption that dialogue is important in problem solving and reflection which leads the student to learning. Freire (cited in Kolb, 1984) talks about the importance of dialogue in reflection.
Human existence cannot be silent, nor can it be nourished by false words,
but only by true words, with which men transform the world. To exist,
humanly, is to name the world, to change it. Once named, the world in
its turn reappears to the namers as a problem and requires of them a new
name. Men are not built in silence, but in word, in work, in action-
reflection. (p. 31)

Candy, Harri-Augstein, and Thomas (1985) call this process of dialogue with reflection—learning conversation. They felt that reflection "often begins with someone talking over his or her ideas with another person and using them as a ‘sounding board'. In everyday language we talk about ‘thinking out loud'" (p. 102).
This learning conversation is illustrated by the following statements: We influenced each other's thinking and got feedback from one another. Every time we came to a problem we reminded each other to think carefully about what we should do. After we cannot figure out what to do, then we would ask the nurses and review our procedures (Journal 120, p. 18).
Before asking our instructor for a solution, Diane and I consulted with each other to identify consequences of our options (Journal 122, p. 16). These statements demonstrate a mature ownership of the learning process. The students believed they were better off trying to solve the problem first between themselves before asking the nurses or the instructor.
We planned out our care for both patients and discussed our progress frequently throughout the evening (Journal 124, p. 3). In my journal I had noted that Michael and Crystal were discussing their journal together when I made rounds during the evening. This shows that their reflections began with learning conversations with each other.
Dialogue also included the students talking with the nurse to learn more about charting and organizing their time. We had also some interesting conversations with the nurses regarding organization and patient charting. This quieter time during the shift offered more time for conferring with the nurses (Journal 124, p. 3). With the use of dialogue, students were able to problem solve and reflect together on their thoughts and feelings while in the clinical setting.

Caring
Learning to "care" is important in the problem-solving process. "Educational theories from the humanistic sciences, theories of ethics, and theories of the phenomenon of care are now cognitively studied and incorporated into the problem solving and experiential components of learning" (Reilly & Ommerman, 1992, p. 48). Davies (1995) in her study indicated that the reflection assisted students in focusing on patients' needs. The theme caring was integrated into how the students attended and solved problems for their patients.
As the result of caring for the patient, the student could see changes in the patient's behavior. The additional need that was identified for H.M. was psychosocial. Basically, the patient needed someone to talk with as she was likely feeling lonely or out of sorts due to her hospital stay. I tried talking with her whenever I could, even if it was a momentary check in and a quick hello. I noticed an increased change in her spirits (Journal 124, p. 4).
Disorganization creates frustration in meeting the goal of caring for the patient. We felt we should have spent more quality time with each patient than we were able to. If we could spend more time with each patient, we would be able to write up a more comprehensive assessment of the psychosocial and spiritual aspects of our patients (Journal 122, p. 5). I had discussed with Rogenia and Alisa about their disorganization and their feelings of frustration in meeting the quality care of the patient. Because of the dialogue and their reflections in their journal, they were able to organize themselves the next week to provide the care they felt the patients needed. We felt we were more on top of the prn drugs and request from our patients. NOBODY DID WITHOUT! (Journal 122, p. 10).
While Matt was caring for a patient, the patients influenced the student's perception of him. My patient surprised me when he said that he was a deacon and happy. He had missionaries and family visiting him all the time. He knew he was loved and cared for. Even with the loss of his leg he was still useful and could live a normal life (Journal 128, p. 7). The impact of meeting the patient left an impression on the students' lives so much so that the students wondered how the patient was progressing. They were very happy to see the patient again. One really special thing happened. Cheri's patient, who was discharged, was Matt's and my patient from a few weeks ago. He was really sick when we had him, and I have thought of him several times, and it was so great to see him sitting in the wheelchair on his way home. He was doing well (Journal 128, p. 17).

Professional Role
One of the goals of clinical experience is for students to learn the professional role of the discipline of nursing. Students do observe how nurses practice and react in caring for patients and how they collaborate with other health personnel. Although observation may be considered a passive activity, the use of the journal writing turns this passive activity into an active learning process. By actively thinking about the nurses' role, the student can incorporate this knowledge into his or her own learning activities.
Registered nurses are considered to be a role model by the students. Crystal and Mari had inquired from the nurse about how to get an order of Tylenol from the pharmacy. After conversing with the nurse, the nurse realized that she had already charted the Tylenol but had forgotten to give it to the patient. The Tylenol was given to the patient by the students. Their comment about the incident was: RNs do make major mistakes, and we learn from what they do and what they do not do (Journal 123, p. 5). I suspect the students were surprised that RNs do make mistakes, but they learned the importance of following through on a normal action a nurse performs and not to let distraction lead them to making a mistake.
The role of the RN is to be a facilitator of respect for each level of health-care worker working with the patients. Rogenia overheard the CNA complaining about her to the RN. The two individuals were talking in a language other than English, and Rogenia understood the language, but the RN and CNA did not realize this. Rogenia was upset because the RN seemed to support the complaint of the CNA but did not directly communicate the complaint to Rogenia. We talked with the group about this incident in post-conference giving time for the students to reflect on solutions to be given to Rogenia. This discussion seemed to relieve the angry feelings that Rogenia was experiencing. Rogenia's comment in the journal was that it is important to respect each other and each role in this field and to be able to let go of hard feelings—to be professional (Journal 122, p. 12). I think when Rogenia becomes a nurse, she will remember this incident and treat each member of the profession with respect.
The role of the nurse is to meet the needs of the patient. By reflecting about the role of the nurse, Crystal and Michael made connections between a competent nurse and identifying the needs of a patient. The best part of the shift was meeting N.N.'s spiritual needs. Being a good nurse requires competency and a megadose of caring for patient's psycho-social and spiritual needs (Journal 124, p. 14).

Process of Reflection
"Reflection is an important human activity in which people recapture their experience, think about it, mull it over, and evaluate it. It is this working with the experience that is important in learning" (Boud et al., 1985, p. 19). Exposing students to an experience does not equate it with a learning experience. Unless students are actively involved in the learning process, learning will not take place. According to Boud et al (1985), it takes active reflecting to benefit an individual's learning from experience. Reflection is considered a process and can be intentionally taught (Boyd & Fales, 1983). Therefore, as an educator, I assigned paired nursing students to write in a journal together. My assumption was that talking and journal writing together would increase their level of reflection, which in turns leads to additional learning. The following are the questions (see chapter 3 for reasons for questions and explanation of the reflective score) answered by the students in their journals; included is the criteria and in brackets the stages of reflection for each question:
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.
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? (Validation)
Criteria: Explains how to improve on his or her weakness.
9. What were other thoughts and feelings about your clinical experience today?
Criteria: Expands reasons for thoughts or feelings noted 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 for the reflective elements of the questions that were asked. There were 9 questions the students were asked. Seven questions were given a reflective score of 1 point each making a total reflective score of 7 points. Each pair was given a reflective score based on the analysis of their answers of the questions. The mean was then calculated for the ten pairs for each week during the clinical experience (see Figure 2 and Appendix A8). A simple linear regression analysis for change was performed. There was a significant increase (p<.01) in the level of reflection across the nine weeks (see Appendix A10).
To assist in understanding which questions were answered more frequently, the percentage of the 10 pairs answering reflectively was calculated (see Appendix A10). The first week the percentage for each question was: question 1 at 43%, question 2 at 43%, question 3 at 28%, question 4 at 0%, questions 6 at 43%; question 8 was 43%; and

Figure 2. Mean weekly reflective score of paired students over 9 weeks.

question 9 was 0%. By week 8 (the highest mean reflective score) the percentage of answered questions was: question 1 at 100%, question 2 at 100%, question 3 at 80%, question 4 at 80%, question 6 at 80%, question 8 at 100%, and question 9 at 80% in answering the questions reflectively. The greatest increase in reflection was in questions 4 and 9. This progression of an increase in reflective scores indicates to me that when students dialogue together in writing a journal, there is an increase in reflection over time.
To evaluate the questions that the paired students may have had difficulty in reflecting upon, the averages of the percentage for the 9 weeks were calculated. Questions 3 was 52%, question 4 was 47%, and question 9 was 46%. One of the reasons the paired students may have had difficulty with questions 3 and 4 maybe due to not recognizing each other as a source of knowledge. The concept that the partner has knowledge to share was new to the students. The possible reason that question 9 was lower maybe the fact that the pairs talked with each other regarding their emotions which may have satisfied their need to share with someone and, therefore, the thoughts and feeling were not explained in written form.

Summary
The clinical setting is an important environment in which students learn to problem solve and to think critically as a part of becoming a professional. The methods used were to pair students in the clinical setting and to have them write about the problem-solving process. This helped the nursing student to think reflectively. Although being paired created frustration and conflict between partners, students were able to move on to the norming stage. Students stated that working together increased their self-confidence and strengthened their teamwork and communication skills. Themes that developed as the result of reflecting about their problem-solving process were barriers to reflection, connections made between theory and what was observed, dialogue and learning, caring, and professional role.
If students are to learn how to reflect, it must start early in their education (Boud et al., 1985). When paired nursing students were exposed to the reflective process specifically aimed at problem solving, there was measurable growth in their reflective process over the nine weeks.
Chapter 6 will describe the themes that were present across both case studies. The secondary purpose of this study will be discussed. Suggestions for applying what was learned from this study will be given and recommendations for further study will be discussed.