LEARNING FEEDBACK DIARY: A REFLECTIVE EXPERIENCE

IN A STUDENT NURSE'S CLINICAL EXPERIENCE

Jose Mari Louis G. Alforque
College of Nursing, Cebu Normal University, Philippines
Corresponding Author's Email: jomy_5@yahoo.com / purplescrub05@gmail.com

ABSTRACT
The objective of the study is to understand the lived experiences of nursing students in selected clinical area
through the Learning Feedback Diary. This research has utilized the qualitative research method of
phenomenology to allow for an exploration of the student nurse's reflective interpretation of their clinical
experience. The purpose of a phenomenological approach is to illuminate the specifics of a phenomenon to
identify phenomena through how they are perceived by the actors in a situation. There were 26 participants
who consisted all of which are 1.) Bona fide nursing student who is currently enrolled in the College of
Nursing of Cebu Normal University; and 2.) Alevel 2 nursing student who is about to be exposed in the
Delivery Room. Respective journal entries were gathered, and transcribed responses are then analyzed
using Colaizzi's descriptive phenomenological method of data analysis. Three major themes emerged: (1)
Limitations in Learning, with one subtheme, Emotional Circumstances heightened with Stress; (2)
Facilitating Learning, with two subthemes, Established Functions and Responsibilities heightened with
Organized Coordination and Effective Learning heightened with Good Mentors, and (3) Developing
Learning, with three subthemes, Enhanced Group Cohesion heightened with Selfless Acts of Kindness,
Eagerness to learn heightened with Social and Environmental Keenness, and Earnest Respect heightened
with Patient Interaction. It is discovered that there is an “LFD” phenomenon experienced by student nurses
in their first clinical area. An increased understanding of the lived experiences from these students' points
of view can develop a wider understanding of their perceived experiences, which would be of good help to
nurse educators supervising students in the clinical area as they are able to understand their students more,
as to their concerns or experiences in the clinical area that were able to be expressed verbally.
Keywords: Learning feedback Diary, Learning, Nursing Students, Phenomenology, Reflective
experience

INTRODUCTION encounters with patients, be it in the hospital or

community setting, must properly be documented in
Learning without the heart is not learning itself.
their Learning Feedback Diary or LFD.
Nursing, as a caring profession, needs to embody the
essence of being selfless in meeting the needs of all A Learning Feedback Diary or LFD is a journal
patients from all walks of life. For a student nurse, they wherein students are to write their significant learning
will be apprehensive in caring for every patient that in the day's clinical exposure. Aided with guide
they will meet. They are somehow uncertain of the questions, they organize their thoughts to make their
character of their patients, and they are on a phase of outlook more meaningful and are something to look
building up their confidence in dealing with different forward to. The LFD encompasses all the experiential
people. Every good and bad experiences they will have learning that they have gone through in a day's exposure
from their very first patient until the succeeding in the clinical area. Experiences are the essentials and it
patients they are to handle will create different impacts is through reflection that they find meaning in all that is
on their clinical experience and to their nursing life as happening.
well. That is why it is very important that their daily According to Quinn & Hughes (2007), within the

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 STUDENT NURSE'S CLINICAL EXPERIENCE

past 30 years, experiential learning has become firmly that are better written than said.
established in nursing, midwifery, and specialist
Review of Related Literature
community public health nursing curriculum. At its
simplest, experiential learning is learning that results Clinical experience has always been an integral part
from experience, but, since almost everything in life of nursing education which promoted the learning
constitutes experience, this becomes an impossibly avenue for student nurses (Sharif & Masoumi, 2005).
global notion. Essentially, experiential learning is It prepares student nurses to be able of “doing” as well
learning by doing, rather than by listening to other as “knowing” the clinical principles in practice a
people of reading about it. This active involvement of clinical practice stimulates students to use their critical
the student is one of the key characteristics of this form thinking skills for problem-solving (Dunn & Burnett,
of learning, together with student-centeredness, a 1995). Lack of clinical experience, unfamiliar areas,
degree of interaction, some measure of autonomy and difficult patients, fear of making mistakes and being
flexibility and a high degree of relevance. evaluated by faculty members were expressed by the
students as anxiety-producing situations in their initial
Everyday a man's life is a learning experience, but
clinical experience. A study by Hart & Rotem (1994)
this can never be realized if he doesn't engage in
focused on stressful events for nursing students during
reflection. Heath (1998) pointed out that reflection is a
clinical practice and it was found that the initial
means of surfacing experiential knowledge, and
experience was the most anxiety producing part of their
students may begin to use reflection as their experience
clinical experience.
of nursing accumulates. It is through this that one can
fully savor the taste of every experience. Reflection is A study by Sharif & Masoumi (2005), revealed that
another form of learning in which it is a personal researcher came to realize that nursing students have a
response to experiences, situations, events, or new great deal of anxiety when they begin their clinical
information. It is a 'processing' phase where thinking practice in the second year. It is hoped that an
and learning take place. Quinn & Hughes (2007) noted investigation of the student's view on their clinical
that the significance of reflection in nursing lies in its experience can help to develop an effective clinical
close relationship to learning in professional practice teaching strategy in nursing education.
setting, and the concepts of reflective practice in
nursing. Loo & Thorpe (2002) stressed out that reflective
journals are not just simply a “diary” or a “log” but an
This study aims to understand the lived experience of articulated narrative that follows from the reflective and
nursing students in selected clinical area through the critical thinking about one's learning experiences or
Learning Feedback Diary. Changes are bound to occur specific learning event. Reflective learning journals are
that will mold them to become better individuals, while an important tool in translating theory into practical
for others will help them in maximizing their potentials. action, that is, praxis. It has been used for some years,
This is one way to ascertain as to how those students, particularly in the nursing and teacher education
with difficulty in handling people, were able to disciplines, to enhance individual learning
overcome this struggle and was able to find meaning in effectiveness, including critical and creative thinking.
such experience. The information's that will be gathered In an early application, (Hahnemann, 1986) had nursing
from the written responses of the nursing students in the undergraduates spend 10 - 15 minutes in class time
LFD will bear more meaning, as there are students who doing their journal entries over the semester. She
are able to express their concerns and learning through reported that journal writing has been a valuable tool
writing. This is also one way for instructors to be less that encourages clearer thinking and better learning.
judgmental of the capacity of his/her students and be Jasper (2003) noted reflective practice has been
more understanding and adaptive to the needs and identified as one of the key ways to learn from
concerns of their students that are left unsaid. The experiences and education recognizes it as an essential
learning feedback diary is not just a mere requirement tool for helping health care students to make links
expected of every clinical exposure but is also a lived between theory and clinical practice. (Spouse, 2001)
testimony of all clinical and value-formative experiences argues that for many years the theory-practice gap has

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 STUDENT NURSE'S CLINICAL EXPERIENCE

dominated approaches to preparing students for their phenomenological approach of to illuminate the
future role, with an increased emphasis on work-based specifics of a phenomenon, to identify phenomena
learning. However, (Jasper, 2003) further emphasizes through how they are perceived by the actors in a
how the learning that is achieved using reflective situation. The goal of the researcher is to confine the
strategies is different from the theory that provides the lived experiences, to find meanings that may or may
knowledge underpinning practice. In other words, not be known to those experiencing the phenomenon
reflective practice bridges the gap between theory and and illustrate the experience through narrative
clinical practice by providing a strategy that helps to composites.
develop both understanding and learning.
The qualitative approach usually produces
Dix & Hughes (2004) recognized that a considerable descriptions or typologies, along with expressions from
number of learners benefit from reflective practice. subjects reflecting how they view the social world. By
Johns (1995) argued that, to enable learners to this means, the perspectives of the producers of the text
understand and learn through lived experiences, they can be better understood by the investigator as well as
should take congruent action towards developing the readers of the study's results (Berg, 2001).
increasing effectiveness, within the context of what is
understood as desirable practice. Many nursing students Research Participants and Sampling
are expected to keep reflective journals whilst on clinical The participants of this study were purposively
placements, and some are required to submit a reflective chosen using the following inclusion criteria:1.) A bona
essay during each module of the program. It is an fide nursing student currently enrolled in the College of
important attitude for student nurses to take time to write Nursing of Cebu Normal University; 2.) A level 2
down their experiences on their clinical duty, and that as nursing student who is about to be exposed in the
they do such, they will engage themselves in reflecting Delivery Room. Purposive sampling starts with a
on what they have done to their patient for that day. purpose in mind and the sample is thus selected to
The overall objectives of narrative reflective include people of interest and exclude those who do not
journaling is to provide a mechanism to engage in a suit the purpose (Changing Minds, 2012). They are
reflective thinking process as learners recall and selected since they are the most apt source of first hand
document narratives from practice (Forneris & Peden- experiences of being student nurses in their clinical
experiences.
McAlpine, 2006). As art of the contextual learning
intervention, novice nurses used narrative reflective Research Locale
journaling to relay their experiences as new graduate
nurse. These novice nurses were asked to recall an The study was conducted at the Delivery Room of
the Vicente Sotto Memorial Medical Center (VSMMC).
aspect of their work in the past week that resulted in a
The VSMMC is an affiliated hospital of the Cebu
feeling of accomplishment, satisfaction and/or resulted
Normal University – College of Nursing. It is in the
in feelings of discouragement or frustration. They were
Delivery Room of VSMMC wherein the clinical and
asked to describe this experience in the form of a story
hands-on experience of nursing students of Cebu
with a beginning, middle and end being specific as to
Normal University is being enhanced and facilitated.
when, where, what and who was involved. They were
This is a good venue where learning to care for patients
also asked to reflect on their stories using guided
undergoing the labor process and delivery is being put to
questions to write about their reflection.
practice.
RESEARCH METHODOLOGY
Research Instrument
Research Design
The researcher made a semi-structured interview
This study utilized the qualitative research method guide. Listed are the guide questions that will be
of phenomenology to allow for an exploration of the utilized:
student nurse's reflective interpretation of their clinical
1. What main ideas and experiences do I find most
experience. Lester (1999) stated that the purpose of a meaningful and relevant today?

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 STUDENT NURSE'S CLINICAL EXPERIENCE

2. How do I plan to apply these meanings in my work 3. Meanings should be formulated from these
and personal life? significant statements.
3. What are the questions I wish to ask? What further 4. The formulated meanings should be sorted into
information do I wish to obtain? categories, clusters of themes and themes.
4. What things / factors that helped me learn today? 5. The findings of the study should be integrated into
an exhaustive description of the phenomenon under
5. What things / factors hindered my learning today?
study.
6. My suggestions.
6. The fundamental structure of the phenomenon
Data-gathering Procedure should be described.
A letter of intent was sent to the Dean of the College 7. Finally, validation of the findings should be sought
of Nursing, to inform intent to conduct this research from the research participants to compare the
study to the level 2 nursing students. Furthermore, a researcher's descriptive results with their experiences.
letter of intent was also sent to the RLE Coordinator and
Thematic Analysis
the Level Coordinator and Adviser to inform intent of
this study, and so that to be in close coordination as to Thematic Discussion
the schedule and availability of the students who will
After significant statements were extracted from the
take part in this study, and that there will be initial
transcripts of the responses and the analysis of the
dissemination of information to the clinical instructors
formulated meanings emerged three themes. The three
in the clinical area who will supervise the clinical
themes emerged were: Limitations in Learning, with
exposure of these students in the Delivery Room.
one subtheme Emotional Circumstances heightened
There are 3 scheduled shifts (Am shift, Pm shift and
with Stress; Facilitating Learning, with two subthemes,
Nocturnal shift) in the Delivery Room. These shifts will
Established Functions and Responsibilities heightened
be covered with the respective students exposed in this
with Organized Coordination and Effective Learning
area to be the participants. The clinical instructors in
heightened with Good Mentors; and Developing
the respective shifts are informed of this activity and
Learning, with three subthemes, Enhanced Group
that their students are to make LFD entries as to their
Cohesion heightened with Selfless Acts of Kindness,
exposure to their exposure in the Delivery Room. The
Eagerness to Learn heightened with Social and
students' responses on their LFD will be confidential
Environmental Keenness, and Earnest Respect
and be gathered for the purpose of generating
heightened with Patient Interaction. Each of the
information that will be of great use to the success of the
emergent themes with the respective subthemes will be
aims of this study.
defined and discussed with excerpts from the transcripts
Data Analysis of responses to support and highlight each theme.
Colaizzi's process for phenomenological data RESULTS AND DISCUSSION
analysis (Sanders, 2003; Speziale & Carpenter, 2007)
After the analysis of data utilizing Colaizzi's
will be utilized in the extraction, organization, and
analysis of the narrative dataset. The following steps method, three significant themes emerged from the
will be pursued: shared experiences of the participants being involved in
this study, the three themes that emerged were:
1. Each transcript should be read and re-read in order Limitations in Learning, with one subtheme Emotional
to obtain a general sense about the whole content. Circumstances heightened with Stress; Facilitating
2. For each transcript, significant statements that Learning, with two subthemes, Established Functions
pertain to the phenomenon under study should be and Responsibilities heightened with Organized
extracted. These statements must be recorded on a Coordination: and Developing Learning, with three
separate sheet noting their pages and lines numbers. subthemes, Enhanced Group Cohesion heightened by
Social with Selfless Acts of Kindness, Eagerness to

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 STUDENT NURSE'S CLINICAL EXPERIENCE

learn heightened with Social and Environmental Responsibilities heightened with Organized
Keenness, and Earnest Respect heightened with Patient Coordination
Interaction. A certain level of anxiety is experienced by students
Theme 1. Limitations in Learning as they face their respective patients. However, if there
is coordination within the group and with the nursing
Every time a person is assigned to a new staff as well, the clinical exposure becomes a smooth
environment, it entails a certain level of apprehension. sail. Every nursing student is tasked to perform several
The anxiety levels rises due to what is unknown and activities when attending to several patients, though
what might happen all throughout the duration of the some may be apprehensive and in-doubt of their
exposure. Having to feel all these uncertainties, the capacity, but they are able to perform the task expected
learning will be affected to some extent, causing a of them and learn much from the experience that they
certain level of limitations in the learning process. had gone through.
Emotional Circumstances heightened with Stress “The next time we are exposed in the delivery room
Stress is a something that emerges in the everyday (DR), we should help each other even if the case is not
life of a nursing student. It is there from the beginning ours.” (SS3, Participant 1)
but remains dormant. However, the more the student is “I suggest that we should always start the duty day
exposed to several situations and experiences, a right by praying and when we plan for decking.”
fluctuation in the levels of stress occurs. (SS10, Participant1)
According to participant 1: “Working as a team is another virtue that is very
“We experienced a great deal of pressure in making essential on the care of women in delivery.” (SS7,
no mistakes in anything we do to care for the mother or Participant 12)
the newborn, even in charting, we should be extra sure Subtheme 2. Effective Learning heightened with
with what we write because those are legal documents.” Good Mentors
(SS1, Participant 1)
A component of professionalism is to mentor those
“I think when people become too stressed out they
fail to make themselves an instrument for more learning seeking to enter the profession(Hathorn, Machtmes &
and improvement.” (SS8, Participant 1) Tillman, 2009). A study by Suen & Chow (2001) of
student's perceptions of the effectiveness of mentors
Another participant related: revealed that roles identified as essential to that of a
“I think the things that hindered my learning today mentor were befriending, assisting, guiding, advising,
was the nervousness I felt when I was able to observe and counseling. Effective mentoring could not be
the actual delivery.” (SS13, Participant 13) established without sufficient relationship building
between mentors and mentees.
Theme 2. Facilitating Learning
“The presence of good, nurturing, and guiding
The clinical experience is a good avenue where clinical instructors really helped me learn my mistakes
students integrate their theoretical learning in the actual and strive to do better next time.” (SS6, Participant 1)
setting, to actual patients. Lofmak & Wikblad (2001)
identified certain facilitating factors which includes “My clinical instructor was very helpful and
being allowed to take responsibility, being allowed to patient with her students. Even if we asked a lot of
work independently, having opportunities to practice questions, she entertained them without getting
tasks and receive feedback, collaborating with staff and annoyed.” (SS4, Participant 6)
supervising others, gaining an overview of the setting, “One of the factors that helped me with my learning
and gaining a sense of control. today is the constant assistance and support or our
Subtheme 1. Established Functions and clinical instructor and my classmate / groupmates
because teach me things I do not know and helped me out

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 STUDENT NURSE'S CLINICAL EXPERIENCE

with some clarifications I asked.” (SS5, Participant 8) “Put great effort in every challenge of life so that I
could gain for the greater good.” (SS3, Participant 2)
Theme 3. Developing Learning
“I wish to obtain information about the vital spots /
Learning is essentially a changed behavior brought
weak points of the baby during delivery.” (SS6,
about by exposure to various stimuli and that certain
Participant 2)
elements be accomplished for learning to take place
(Tan, 2009). And participant 2 added:
Subtheme 1. Enhanced Group Cohesion “I wish to ask if there could be any fracture on the
heightened with Selfless Acts of Kindness baby if it is handled mistakenly.” (SS4, Participant 2)
For the learning experience to be optimal the “It takes much effort but when the baby's out it is
learning environment must also be optimal which very slippery, and that we have to be cautious.” (SS2,
means that there should be cooperation of everyone Participant 2)
involved, including the healthcare team (Mlek, 2011).
There are also other participants that shared
“I also learned that for us to prevent “GGB” by the their learning observations:
end of the shift, whenever we are free we should help
“Also, in handling delivery, as a student nurse, one
with the charting of our groupmates who are
must always have presence of mind.” (SS3, Participant
performing the handling, assisting, or cord care to save
11)
time and to hasten things.” (SS2, Participant 1)
“I was able to learn today because of being observant
“We should help others grow and learn, and we
and paying attention to what's happening around.”
should not think of ourselves only.” (SS4, Participant 1)
(SS12, Participant 11)
“In work, I should be calm and quick especially on
“Observing proves to be helpful – from this, you
my last hour of the shift, because the other staffs need
familiarize the techniques and you can decide out your
the forms ASAP.” (SS3, Participant 5)
own strategies how others work.” (SS9, Participant 16)
It is an important realization that every act of
Subtheme 3. Earnest Respect heightened with
a member of a group will affect the entire group. There
Patient Interaction
are times in which the entire group will be in a difficult
situation, and that there will be other members who In a qualitative study conducted by Atack et al.,
would finish their task ahead of time. The oneness of a (2000), Comacu, Kenny, Labelle & Miller (2000)
group depends on how one shows and extends his revealed that to gain an understanding of the lived
support to other members of the group, as this can experience of staff, and students within a clinical
influence group dynamics and cohesion. practice model, the most important factor recognized
by students in the student-staff relationship was open
Subtheme 2. Eagerness to learn heightened with
communication founded on mutual courtesy and
Social and Environmental Keenness
respect. The presence of nursing staff with good and
According to (Bandura, 1997), one's efficacy approachable attitudes influences the work attitude of
beliefs contribute “to the development of intrinsic nursing students, as this gives them much respect to the
interest”, wherein people who initially lack skill, such nursing profession. However, constant interaction of
as in the case of nursing students' lack clinical skills, nursing students with their respective patients creates
persevere despite all the stress associated with trying to an influence on their own perspectives of every patient
master it. It is not only the behavior which they that they need to attend.
eventually perform that is rewarding to them, nor the
The more they interact, the more they develop a
positive feedback they may get from other. People are
sense of understanding and respect for all the patients,
interested in activities “at which they feel efficacious”,
regardless of category.
but also in those which give them the satisfaction.
One participant said that it made her realize the

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 STUDENT NURSE'S CLINICAL EXPERIENCE

importance of mothers, after witnessing an actual experienced by student nurses in their first clinical area,
delivery for the first time: wherein there is the “Limitation Phase”, the “Facilitating
Phase” and the “Developing Phase”. The LFD is a good
“My experience today is very meaningful, and it
avenue where the nursing students are able to relate their
made me realize how much effort and sacrifice a mother
personal experiences in the clinical area that they are not
put into action during delivery just to save their babies,
able to express upfront to their clinical instructors. This
and it made me realize how important every mother is.”
strategy enabled the participants to recall the highlights
(SS1, Participant 3)
of their clinical experience and was able to vividly
“It can be applied in my work and personal life by express the details, particularly those that have a positive
giving more importance and respect to those mothers and a negative impact to them. The LFD serves also as
and also by giving and sharing love to my co-workers an imaginary link between the clinical instructor and the
since we are hand-in-hand with them in delivering the nursing students where they are able to communicate
baby.” (SS2, Participant 3) without having to verbalize concerns. It is discovered
Furthermore, there are other participants who that sometimes, when one is learning, experiences are
shared related experience to Participant 3, as mentioned better put into writing rather than it be spoken.
above: RECOMMENDATIONS
“I should not hesitate to help people when I know I Based on the study findings, the researchers would
won't have any gains.” (SS10, Participant 5) like to recommend the following:
“It simply struck me to give more respect and love 1. Nurses and other health care providers must learn to
for mothers and my co-workers who were also part of recognize the presence of nursing students as members
the endeavor the mother has to go through.” (SS3, of the health care team in the clinical area, and should
Participant 7) treat them with utmost respect, not taking advantage of
In summary, it is discovered that there is an “LFD” their novice state, since these nurses and health care
phenomenon experienced by student nurses in their first providers are a valuable contribution to the nursing
exposure in the clinical area, specifically in the Delivery students' learning process.
Room. These nursing students lived and described their 2. Nurse educators must commit to a high level of
rich experiences from a phase of the LFD: Limitations clinical practice for nursing students. Theoretical
in Learning, Facilitating Learning, and Developing learning in the classroom setting should be reinforced
Learning as they went through the responsibilities for accordingly in the clinical setting by providing a positive
them. An increased understanding of the lived learning environment that will help the students get a
experiences from these level II nursing students' point grasp of the real-life scenario. The presence of a clinical
of view (exposed in the Delivery Room for the first instructor with a less stressful characteristic, supportive
time) can develop a wider understanding of their attitude is very important since they are better facilitators
perceived experiences, which would be of help to nurse of learning to students in the clinical settings, and that
educators supervising for nursing students experiencing these students should be treated according to their level
this phenomenon. Moreover, this study guides not just of competency not expecting too much from them most
the nurse educators, but also other members of the especially if they are new to a certain clinical area.
health care professionals, parents, nurse practitioners,
and future researchers as well. Each nursing encounters 3. The continued use of a learning feedback diary
experienced by the student nurse with different patients (LFD) is important in such a way that it is an avenue for
enhances his capacity to care for different patients and nursing students to reflect on what they have done and
makes them more appreciative of their profession of what they have accomplished for the day's clinical
caring. exposure, and that clinical instructors handling students
in the clinical area be able to understand their students
CONCLUSION
more, as to their concerns or experiences that they are
It is discovered that there is a “LFD” phenomenon not able to relate verbally.

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 STUDENT NURSE'S CLINICAL EXPERIENCE

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