RN-BS Students' Reports of Their Self-Care and Health-Promotion Practices in a Holistic Nursing ...

26 Pages·2017·0.25 MB·English

657226
research-article2016 JHNXXX10.1177/0898010116657226Journal of Holistic NursingPadykula
1
n
Qualitative Research
h
RN-BS Students’ Reports of Their Self-Care
j
and Health-Promotion Practices in a Holistic
Journal of Holistic Nursing
Nursing Course American Holistic Nurses Association
Volume XX Number X
XXXX 201X 1 –26
© The Author(s) 2016
10.1177/0898010116657226
Bozena M. Padykula, EdD, APRN, PMHNP-BC, APHN-BC, MSN, RN http://jhn.sagepub.com
Western Connecticut State University
Purpose: This study explored RN-BS students’ self-care and health-promotion (SCHP) practices in a
semester-long holistic nursing course with emphasis on the utility of self-reflection through journal
writing. Design: A qualitative single case study blended in practical action research. Method: Fifteen
RN-BS students enrolled in the holistic nursing course completed (a) three reflective journal entries
(beginning, midterm, and conclusion); (b) two IHWA-short form surveys (beginning and conclusion);
and (c) one demographic form (beginning) of the course. Findings: Three reflective journals indicated
that students’ understanding of their SCHP practices progressed from novice, to advanced, and finally
to competent from the beginning, middle, and at the conclusion of the course. Four findings emerged
in relation to reports of their SCHP practices: (a) new awareness of self, (b) application of SCHP prac-
tices knowledge, (c) role modeling, and (d) dedication to SCHP practices beyond the semester. Four
findings emerged in relation to participation in the reflective journaling about reports of their SCHP
practices: (a) self-discovery, (b) retrospective self-evaluation, (c) useful intervention for SCHP, and (d)
beneficial learning tool in academic environment. Conclusions: Reflective journaling enhanced stu-
dents’ SCHP practices and was recognized as useful instructional strategy to improve learning in the
classroom.
Keywords: nursing education; self-care; reflection; RN-BS nursing education
Background and Significance enced and newly licensed nurses leaving the
profession due to dissatisfaction with their jobs or
The nursing shortage has reached global propor- burnout (Dossey & Keegan, 2013; Health Resources
tions and is projected to continue through at least and Services Administration, 2010; Mariano, 2013;
2030 in the United States (Juraschek, Zhang, McElligott, 2013; Robert Wood Johnson Foundation,
Ranganathan, & Lin, 2012). Addressing the nursing 2012; Wieck, Dols, & Northam, 2009).
shortage and finding creative approaches to stabilize Health care organizations must continue to not
the workforce is crucial because of the potential only find ways to recruit nurses into the profession
impact on the health and well-being of the popula- but also to retain those who are presently working.
tion nationally and globally. Leaders in nursing often Finding ways to retain practicing nurses would appear
confront the shortage by focusing primarily on stu- to be a viable way to stem the shortage without the
dent and faculty recruitment into the profession expense associated with continuously training new
(American Association of Colleges of Nursing
[AACN], 2014; American Nurses Association [ANA],
2013; National League of Nursing, 2010). However, Author’s Note: Please address correspondence to Bozena M.
Padykula, EdD, APRN, PMHNP-BC, APHN-BC, MSN, RN,
the retention of practicing nurses is not given prior-
Western Connecticut State University, 181 White Street,
ity despite the significant numbers of both experi- Danbury, CT 06810; e-mail: [email protected].
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2 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX
nurses to replace those who have left. One potential There is agreement that reflective practice con-
way to retain practicing nurses is to help them find tributes to the development of professional knowl-
balance in their work and manage job-related stress. edge on different levels of nursing practice (Atkins &
This may be achieved by teaching nurses and nursing Murphy, 1993; Mann, Gordon, & MacLeod, 2009).
students how to actively engage in self-care and There is also significant research on the effective-
health-promotion practices. People have a lifelong ness of self-reflection in nursing education.
responsibility to participate in self-care and health- Specifically, self-reflection has been found to be
promotion practices, which are activities and behav- effective in professional development (Barterö,
iors that maintain a healthier lifestyle, enhance 2010; Johns, 2009; Kim, 1999; ter Maten-
wellness, increase well-being, and “actualize human Speksnijder, Grypdonck, Pool, & Streumer, 2012),
health potential” (McElligott, 2013, p. 827). Nursing personal growth (Glaze, 2002; Jasper, 1999), per-
educators are clear that nurses need to integrate basic sonal self-understanding in connection to practice
self-care activities into their professional practice (Scanlan & Chernomas, 1997; ter Maten-Speksnijder
because these skills offer the nurse growth, wisdom, et  al., 2012), and promoting life-long learning
self-awareness, and deeper understanding of self, (Ruland & Ahern, 2007). Notably, Drick (2014) con-
both personally and professionally (American Holistic cluded that when nursing professionals engage in
Nurses Association & American Nurses Association ongoing self-reflection and self-care, they become
[AHNA & ANA], 2013; Dossey & Keegan, 2013; self-aware of the professional development that is
Drick, 2014; Mariano, 2013; McElligott, 2013; essential “for giving care to others, for personal well-
McElligott, Capitulo, Morris, & Click, 2010). Yet self- being, and for appreciating one’s personal journey”
care is often shortchanged because other life activi- (p. 47).
ties take priority (Drick, 2014; Mariano, 2013). Drick In spite of strong advocacy for reflective practice
(2014) noted that “while nurses are experts at caring in nursing education (Atkins & Murphy, 1993;
for others we are certainly novices when it comes to Bulman & Schutz, 2013; Johns, 2009; Kim, 1999;
taking care of ourselves” (p. 51). Indeed, for practic- Kinsella, 2007; Scanlan & Chernomas, 1997), there
ing nurses, such as those enrolled in an RN-BS pro- is a gap in the literature related to studies focused
gram, learning techniques to manage professional on the use and effectiveness of self-reflection,
and personal challenges could potentially help them through journal writing as a teaching and learning
become harder and more resilient, and by extension, strategy for enhancing RN-BS nursing students’ self-
remain in the nursing workforce longer. care and health-promotion practices. Since self-
Self-reflection and the notion of self-care are reflection and self-care are foundational elements
foundational elements of nursing. Over 100 years that comprise the core values of nursing (AACN,
ago, Florence Nightingale advocated the importance 2008; AHNA & ANA, 2013; ANA, 2010), it seems
of self-care for nurses and directed nurses to use important to gain an understanding of whether the
reflection for self-discovery and understanding oth- application of reflective practice in nursing educa-
ers (Dossey & Keegan, 2013). Nightingale’s vision of tion could transform nursing students’ knowledge
nurses caring for themselves through ongoing self- about self-care and health-promotion practices.
reflection is integrated into the core values deline- Therefore, the purpose of this single case study
ated in Holistic Nursing: Scope and Standards of action research investigation was to explore the util-
Practice (AHNA & ANA, 2013). Schön (1987) sug- ity of reflective journal writing for enhancing RN-BS
gested that health care organizations and educa- students’ self-care and health-promotion practices
tional institutions guide professionals to become during a semester-long holistic nursing course.
reflective practitioners so they can understand the Fifteen RN-BS students enrolled in a holistic nurs-
self in practice and formulate new knowledge from ing course wrote focused reflections three times dur-
their experience. Schön’s reflective practitioner the- ing the semester (at the beginning, midway through,
ory significantly influenced professional education and at the conclusion of the semester) to determine
and many disciplines of the health and social sci- RN-BS students’ insights into their self-care and
ence professions (Kinsella, 2007), including nursing health-promotion practices. In addition, the results
education (Bulman & Schutz, 2013; Scanlan & of two administrations of the Integrative Health and
Chernomas, 1997). Wellness Assessment–Short Form (IHWA; Dossey,
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RN-BS Students’ Reports in a Holistic Nursing Course / Padykula 3
Table 1. Reflective Practice Constructs and Descriptions (Schön, 1983, 1987)
Construct Description
Technical Instrumental epistemology to professional knowledge development grounded in systematic evaluation of scientific
rationality evidence-based knowledge separate from practical knowledge (Schön, 1983)
Reflective Alternative epistemology to professional knowledge development in which professionals evaluate professional
practice knowledge; examine individual experiences, thoughts, feelings, and perceptions; and formulate new knowledge by
bridging thinking with doing (Schön, 1983)
Reflection- Thinking actively in practice that activates silent knowledge and spontaneously reshapes professionals’ decisions
in-action (Schön, 1983)
Reflection- Professional knowledge development occurs retroactively and can be interpreted as to the postmortem evaluation that
on-action takes place after an experience (Schön, 1983, 1987)
Luck, & Schaub, 2013), one at the beginning of the on scientific and research-based methodologies to
semester and one at the end of the semester, were the exclusion of experience-based methodologies,
used to complement data collected in the reflective which often fails to prepare professionals to face
journal writing. The IHWA complemented data col- real-life situations. Thus, he proposed that it is
lected by allowing participants to reflect and com- essential to guide professionals to become reflective
pare their self-care and health-promotion practices practitioners so they can understand the self in their
at the beginning with their practices at the conclu- professional practice and formulate new knowledge
sion of the semester. Thus, the lessons learned from their experience. Schön’s (1983) model com-
through this study shed light on the application of prises four main constructs: technical rationality,
reflection in teaching and learning in a holistic nurs- reflective practice, reflection-in-action, and reflec-
ing course to enhance self-care and health-promo- tion-on-action. Each is explained briefly in Table 1.
tion practices of RN-BS students. In sum, Schön’s (1983, 1987) model of reflective
practice introduces richer insight into professional
knowledge by guiding professionals in the develop-
Conceptual Framework
ment of expertise through reflective examination of
actions, beliefs, thinking, feelings, and perception.
The conceptual framework for this study is based
on the works of Schön (1983, 1987). Schön (1983)
asserted that professional education is deeply Review of Literature
grounded in technical rationality, where scientific,
evidence-based knowledge contributes to profes- This review of the literature includes research rel-
sional knowledge development. Certain professional evant to three conceptual areas: (a) professional and
situations are unique, cannot be presented in a personal concerns of registered nurses and issues in
book, and are challenged by the dilemma of rigor or the nursing profession, (b) nurses’ and nursing stu-
relevance. Schön (1983) argued that professional dents’ perceptions of self-care and health-promotion
decision making is often guided by one of two para- practices after introduction to a holistic nursing cur-
digms: rigor, which he described as high hard ground, riculum, and (c) the role of reflection as a supportive
or relevance, which he described as swampy low- teaching and learning strategy in education.
land. Rigor in this context refers to decisions based
solely on scientifically developed knowledge that has
Professional and Personal
been subject to review by the profession. Professionals
Concerns of RNs and Issues in the
who subscribe to the relevance paradigm “deliber-
Nursing Profession
ately involve themselves in messy but crucially
important problems and, when asked to describe In Holistic Nursing: Scope and Standards of
their method of inquiry, they speak of experience, Practice (AHNA & ANA, 2013), nurses are reminded
trial and error, intuition, and muddling through” to treat and heal the whole person by recognizing
(Schön, 1983, p. 43). Schön (1983) argued that tra- the interconnectedness of body, mind, spirit, and
ditional professional education in all fields focuses environment. Nurses are further reminded to foster
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4 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX
their own health. Nevertheless, nurses often advo- A review of the literature revealed that nurses
cate for others while neglecting their own self-care and nursing students, despite their varying degree of
practices (Dossey & Keegan, 2013; Mariano, 2007, initial skepticism, were receptive to the concept of
2013; McElligott, 2013; Stark, Manning-Walsh, & self-care and health-promotion practices and inte-
Vliem, 2005). The long-term effect of neglecting grated new practices and knowledge in both their
self-care and health-promotion practices has been professional and personal lives (Delaney, 2009;
found to contribute to negative health outcomes of Downey, 2007; McElligott et al., 2009; McElligott
nurses. The research reports that when nurses lack et al., 2010; Stark et al., 2005). According to the
self-responsibility to advocate for their own health, authors of three studies that explored perceptions of
they commonly experience physical and psychologi- nursing students enrolled in a course focused on
cal exhaustion (Huntington et  al., 2011; Vahey, understanding a holistic approach to self-care and
Aiken, Sloane, Clarke, & Vargas, 2004); generalized health-promotion practices, the concept of self-care
pain, tiredness, and altered sleep (Gabrielle, Jackson, and health-promotion practices transformed partici-
& Mannix, 2008); musculoskeletal discomforts pants personally and professionally (Delaney, 2009;
(Geiger-Brown et al., 2004); and depressive symp- Downey, 2007; Stark et  al., 2005). Additionally,
toms (Yoon & Kim, 2013). Stark et al. (2005) noted that nursing students who
Additionally, nurses indicated that their were required to develop self-care plan strategies as
demanding work environment, due to long work part of their nursing course showed increased moti-
hours, downsizing, and higher acuity of patients’ vation to integrate self-care practices, especially
illnesses, requires nurses to perform under con- when they actively formulated their plan. At the
stant stress (Geiger-Brown et al., 2004; Huntington same time, Stark et al. observed older nursing stu-
et al., 2011; Vahey et al., 2004). Nurses’ dissatis- dents had a deeper interest in integration of preven-
faction with their work environment gradually tive health strategies than younger nursing students.
contributes to the development of compassion Delaney (2009) and Downey (2007) added that self-
fatigue (Maytum, Heiman, & Garwick, 2004; care and health-promotion practices had stronger
Robins, Meltzer, & Zelikovsky, 2009). In addition, use in nurses’ personal lives and that the profes-
nurses often lack motivation to engage in neces- sional environment was more restricted and offered
sary self-care and health-promoting practices limited opportunities for nurses to engage in self-
(Geiger-Brown et al., 2004; McElligott, Siemers, care and health-promotion practices.
Thomas, & Kohn, 2009). As a result, nurses com- The study by McElligott et al. (2009) reported
monly consider leaving the nursing field perma- that approximately 50% of nurses above age 40 who
nently because of burnout, emotional exhaustion, had worked in the profession more than 10 years
and depersonalization (Aiken, Clarke, Sloane, lacked stress management skills and were weakest in
Sochalski, & Silber, 2002; Vahey et al., 2004). the physical activities. In their follow-up study,
McElligott et al. (2010) included both an experi-
mental and comparison group while investigating
Nurses’ and Nursing Students’
the collaborative care model program with hospital
Perceptions of Self-Care Practices
nurses. In this study, nurses were required to develop
After Introduction to a Holistic
a self-care plan that included health-promotion
Nursing Curriculum
practices. Three months after the study, the research-
Nursing schools across the country seek strategies ers found that development of a self-care plan in
to improve nursing retention and recognize that conjunction with the collaborative care model pro-
holistic principles are one important change to gram promoted significant growth in overall self-
nurses’ daily practice that could mitigate the nursing care and health-promotion practices, with highest
shortage (Delaney, 2009; Downey, 2007; O’Brien- growth in spirituality, interpersonal relations, and
King & Gates, 2006; Stark et al., 2005). While nurs- nutrition. The long-term impact of introducing self-
ing schools recognize the need to integrate holistic care and health-promotion practices has also been
principles in nursing, limited documentation exists studied with Delaney (2009) finding lasting effects
describing the implementation of holistic nursing at 4 years and Downey (2007) finding lasting effects
courses in undergraduate nursing programs. at 7 years.
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RN-BS Students’ Reports in a Holistic Nursing Course / Padykula 5
Role of Reflection as a Supportive development of an understanding of their clients’
Teaching and Learning Strategy in issues on an individual basis (Landeen et al., 1995;
Education Langley & Brown, 2010; Williams et al., 2002).
A major concern identified by the researchers
Reflection continues to attract interest in educa-
was that students and faculty lacked proper prepara-
tion generally and nursing education specifically
tion to initiate this teaching strategy in the curricula
(Bulman & Schutz, 2013). Reflection as a teaching
(Gulwadi, 2009; Landeen et al., 1995; Langley &
strategy is widely used in the preparation of health
Brown, 2010; Nicholl & Higgins, 2004; Williams
professionals in postsecondary education (e.g., physi-
et al., 2002). Students who were invited to partici-
cal therapist, nurse, social worker; Landeen, Byrne, &
pate in the reflective journaling did so without any
Brown, 1995; Langley & Brown, 2010; Nicholl &
initial preparation and were only provided with
Higgins, 2004; Scanlan & Chernomas, 1997;
directions about what to do. Likewise, the faculty
Williams, Wessel, Gemus, & Foster-Seargeant, 2002).
indicated a lack of preparation in the teaching of
Reflection improves learning by integrating theory
reflective practice (Gulwadi, 2009; Landeen et al.,
and content from classroom lectures with practice
1995; Langley & Brown, 2010; Nicholl & Higgins,
(Bulman & Schutz, 2013; Scanlan & Chernomas,
2004; Williams et al., 2002).
1997). Plack, Driscoll, Blissett, McKenna, and Plack
(2005), for example, asserted that reflection in health
Literature Review Summary
sciences introduces new “meaning to experience; it
turns experience into practice, links past and present Review of the literature on concerns of registered
experiences, and prepares the individuals for future nurses and issues in the nursing profession revealed
practice” (p. 200). Thus, the process of self-reflective that nurses often experience unsupportive work
thinking strengthens students’ critical thinking skills environments and excessive work demands that con-
in the scope of an academic major. tribute to low satisfaction with the nursing profes-
According to the literature, when nursing stu- sion and negative effects on their physical and
dents are introduced to reflective thinking, they gain mental health. In terms of nurses’ and nursing stu-
deeper understanding and appreciation of clients’ dents’ perceptions of self-care and health-promotion
needs (Landeen et  al., 1995; Langley & Brown, practices, regardless of whether the participants
2010; Nicholl & Higgins, 2004; Scanlan & valued the holistic philosophy, they were receptive to
Chernomas, 1997; Williams et al., 2002). In addi- integrating self-care and health-promotion practices
tion, reflective journaling has been shown to be a in their professional and personal lives. Finally, stud-
valuable teaching strategy for teachers and students ies show that reflective practice can be a valuable
(Gulwadi, 2009; Landeen et al., 1995; Langley & teaching and learning strategy across a variety of
Brown, 2010; Nicholl & Higgins, 2004; Williams academic majors, including nursing.
et  al., 2002). For example, Langley and Brown
(2010) found that faculty were satisfied with the Research Questions
outcomes of reflective journals submitted online;
they reported that this assignment improved stu- There were three primary research questions,
dents’ writing skills and promoted integration of some that contained analytic questions, which
course content with clinical practice. guided this investigation.
The results reported in these studies indicate
that students from different majors gain similar ben- 1. What are RN-BS students’ reports of their
efits from using reflective journaling, including (a) a self-care and health-promotion practices
deeper understanding of theory, (b) professional while enrolled in a holistic nursing course?
development for the role for which they are prepar- 1.1. What are RN-BS students’ reports of
ing, and (c) a new self-awareness of their individual their self-care and health-promotion
strengths and weaknesses. Nursing and physical practices at the beginning of a holis-
therapy students reported that reflective journaling tic nursing course?
used in clinical practice promoted the building of 1.2. What are RN-BS students’ reports of
therapeutic relationships with their clients and the their self-care and health-promotion
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6 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX
practices in the middle of a holistic Polit and Hungler (1999) noted that case studies
nursing course? explore how and why “individuals think, behave, or
1.3. What are RN-BS students’ reports develop in a particular manner rather than on what
of their self-care and health-promo- his or her status, progress, actions, or thoughts are”
tion practices at the conclusion of a (p. 250). In fact, case studies are frequently used by
holistic nursing course? nurses to discover subjective aspects (e.g., thoughts,
feelings, and desires) that are not extensively
2. What, if any, effect does enrollment in a researched and capture “insights concerning previ-
holistic nursing course have on RN-BS ously unsuspected relationships” (Polit & Hungler,
students’ reports of their self-care and 1999, p. 250).
health-promotion practices? Merriam (1998) described a case study as having
three defining characteristics: particularism, descrip-
3. What are RN-BS students’ perceptions of tion, and heuristics. Case studies are particularistic
reflective journaling in a holistic nursing because the researcher explores a “particular situa-
course? tion, event, program, or phenomenon” (Merriam,
3.1. What, if any, effect does participa- 1998, p. 29). Case studies are descriptive because
tion in reflective journaling have the researcher develops a “rich, thick description of
on RN-BS students’ reports of their the phenomenon under study” (Merriam, 1998, p.
self-care and health-promotion 29). Case studies are heuristic because the researcher
practices? can generate “new meaning, extend the reader’s
experience, or confirm what is known” (Merriam,
1998, p. 30). Case studies formulate a knowledge
Method
base that is “more concrete . . . more contextual . . .
more developed . . . [and] based more on reference
Design of the Study
populations determined by the [researcher]”
A qualitative single case study blended with a (Merriam, 1998, p. 32).
practical action research design (Stringer, 2007) was The case study design was particularly suitable
selected to explore RN-BS students’ self-care and for this study because it allowed the researcher to
health-promotion practices in a semester-long holis- focus on and explore in depth one particular group
tic nursing course with a particular emphasis on the of individuals, RN-BS students in one section of a
utility of self-reflection through journal writing for university course devoted to holistic nursing, and
enhancing these students’ self-care and health-pro- the effect of explicit instruction on reflective prac-
motion practices. tice for those students. The students’ reflective
reports were studied to understand how individual
participants thought, developed, and behaved when
Case Study Research
the content of self-care and health-promotion prac-
Case study design offers unique features not tices was introduced. Single case in this study refers
found in other forms of qualitative research, notably, to the one classroom course in one Northeastern
an in-depth exploration of a “single unit or bounded university. Multiple sources of data, including three
system, such as an individual, program, event, group, reflective journals and two IHWA surveys, were used
intervention, or community” (Merriam, 1998, p. to collect rich, thick descriptions of students’ self-
19). Merriam (1998) advocated the use of case stud- care practices throughout the semester.
ies in educational research because only through a
case study can a researcher “gain an in-depth under-
Action Research
standing of the situation and meaning for those
involved” (p. 19). Foremost, this case study aimed to The application of action research (Creswell,
explore in depth the utility of self-reflection through 2008; Stringer, 2007) to this case study offers new
journal writing for enhancing RN-BS students’ self- insights and new knowledge about a situation and
care and health-promotion practices during a semes- subsequently contributes to formulating new solu-
ter-long holistic nursing course. tions to promote change. In addition, Elliot (1991)
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RN-BS Students’ Reports in a Holistic Nursing Course / Padykula 7
noted that action research in education offers a of observations as a teacher of the course, and a
unique contribution because it “integrates teaching substantive literature review, the inquiry provided
and teacher development, curricula development the opportunity for development of both the
and evaluation, research and philosophical reflec- researcher and her students. In addition, the study
tion, into a unified conception of a reflective educa- informed the researcher’s practice for the future,
tional practice” (p. 54). Moreover, action research is such as to work with the accrediting nursing organi-
dedicated to improving the quality of practice by zations to include self-care and health-promotion
developing practitioners’ individual judgments in a practices in nursing curricula.
variety of professional situations. This researcher, as Lewin (1946) proposed a model for action
an educator and health care provider, had a particu- research that defines a sequence of events (or cycles)
lar interest in using action research to inform and through which the researcher first inquires about the
influence teaching and learning of RN-BS students’ problem, then interprets collected data, implements
self-care and health-promotion practices. solutions, and finally evaluates the results of the
Creswell (2008) distinguished between two types selected actions to understand the adjustments that
of action research designs—practical and participa- are required in the future course of action. Lewin’s
tory. Both types of action research seek to solve a work provided the building blocks for action research
particular problem of practice. Practical action as a research paradigm in the social science sector
research is dedicated to improving a small, local and has been adopted by educational researchers
problem that is close to the researcher. Participatory such as Elliott (1991), O’Leary (2004), and Stringer
action research is focused on transforming the needs (2007). Stringer’s (2007) model of action research is
of a wider population, often a population with sup- described as “inquiry or investigation that provides
pressed voices. people with the means to take systematic action to
This study used a practical action research para- resolve specific problems” (p. 8). This study used
digm since the inquiry “focuse[d] on a small scale Stringer’s (2007) action research framework summa-
research project, narrowly focused on a specific rized as “look, think, act” (p. 8). The purpose of each
problem or issue, and [was] undertaken by individ- phase is described below:
ual teachers within a school” (Creswell, 2008, p.
647). Creswell described five characteristics of prac- 1. Look—Build the picture according to col-
tical action research: (a) local focus, (b) individual lected data
or team-based approach, (c) individual development 2. Think—Interpret, analyze, and explain
and student learning, (d) individual need to develop 3. Act—Resolve problem and plan a future
and implement a plan of action, (e) individual as course of action
researcher.
This study used practical action research because During the first phase of this study, look, the
the phenomenon under investigation explored the researcher collected information from a variety of
utility of self-reflection through journal writing for sources to gain an understanding of the “partici-
enhancing RN-BS students’ self-care and health- pants’ experiences and perspectives and to define the
promotion practices during a semester-long holistic problem/issue” specific to participants’ needs
nursing course. The study was local in nature (Stringer, 2007, p. 65). The collection of informa-
because it explored a subject of interest to one edu- tion continued during the course of the study. Two
cator. The study followed an individual approach unique features are found in the look phase that are
because the researcher was conducting the study in not observed in other types of research: (a) focus on
the context of her area of scholarly interest. The participants’ subjective needs to understand their
researcher had been teaching the holistic nursing problem and (b) research questions are not focused
course for 4.5 years, and every semester she heard on finding the answers but are dedicated “to
remarks by RN-BS students about the lack of self- understand[ing] the nature of related events—how
care and health-promotion content at the associate and why things happen the way they do” (Stringer,
degree and diploma-level nursing education curric- 2007, p. 65).
ula and in their professional lives as nurses. Grounded In the second phase, think, the researcher
by the feedback from my RN-BS students, 4.5 years reflected, interpreted, clarified information, and
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8 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX
analyzed information to formulate major key con- data to generate key concepts or themes related to
cepts. Analysis of information offers participants and self-care and health-promotion practices. The pro-
others involved “new ways of thinking about the cess of analysis used credible techniques known to
issues and events investigated” (Stringer, 2007, p. be appropriate for the collected data to identify pat-
95). The key concepts developed through this phase terns and themes from reflective journals and statis-
allow the researcher to formulate reports, organize tical analysis of IHWA-identified behaviors. In the
meetings, or distill information by “providing act phase, the researcher disseminated findings of
accounts of what is happening and how it is happen- the study through publication of her dissertation and
ing” (p. 95). The think phase enables participants to sharing the outcomes with the participants and fac-
understand and evaluate their situation in a clear ulty in the nursing department where the study was
light and to draw conclusions on the impact of this conducted. Since the unique aim of action research
situation on their lives. is to generate knowledge that informs and improves
In the third phase, act, the researcher formu- practice, the results from this study were integrated
lated a future course of action to create sustainable into the researcher’s instructional paradigm to
solutions for change. According to Stringer (2007), improve her classroom teaching. As a result of this
the resulting action plan should list priority inter- action research process, the researcher also collabo-
ventions and how to implement them systemati- rated with university nursing faculty to develop a
cally. It is the researcher’s responsibility to continuing education program in self-care and
collaborate, support, role model, and link the par- health-promotion strategies for undergraduate and
ticipants to a network of resources. This phase also graduate nursing students.
requires the researcher and participants to review, To summarize, the researcher selected a practi-
evaluate, and modify courses of action and cele- cal action research approach because this design
brate accomplishments. allowed the researcher to engage in the “production
Since action research has a cyclical nature, after of greater understanding of the selected groups
the act phase of one inquiry cycle is completed, within the system in order to produce practical prin-
some activities are recycled, and the researcher ciples and strategies for the improvement of that
moves to the next spiral phase of look-think-act. system” (Koshy, Koshy, & Waterman, 2011, p. 23).
Stringer (2007) noted that as each phase is com- The problem under study was identified by the
pleted, the researcher should continue to look again, researcher in her capacity as a health care faculty
to reflect and modify existing courses of action, member in higher education working with a group of
sometimes going backward, repeating, upgrading, licensed RN-BS students. RN-BS students were par-
and reshaping those courses of action based on the ticipants in the study, and they were not involved
new understanding that occurred during the action collaboratively in any components of the study (i.e.,
research process. The researcher in action research design of the study, plan for implementation, or data
is the grassroots catalyst who finds techniques to evaluation) as would be required for a participatory
invite participants to the change process. Action action research project. The participants did not
research has a direct connection to the reflective contribute to the design of the study because the
practice of Schön (1983). In Schön’s reflective prac- intent of the study was to understand how RN-BS
tice model, participants reflect throughout their students interpreted the issue under investigation
experiences, integrating the look, think, and act and how the researcher could improve teaching and
steps of action research. Like action research, reflec- learning in nursing education.
tive practice is meant to change participants’
approach to an issue important to them or their
organization. Data Collection Tools and
In the look phase, the researcher collected infor- Procedures
mation from reflective journals and IHWA surveys to
better understand RN-BS students’ perceptions Several means of data collection were employed in
about self-care and health-promotion practices. In this study. Triangulation (Creswell, 2003, 2008) was
the think phase, the researcher reviewed and inter- supported through the use of multiple sources of
preted the information from each of the sources of data during the semester—participant demographic
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RN-BS Students’ Reports in a Holistic Nursing Course / Padykula 9
form (beginning), series of three guided reflective nificance of the holistic nursing course, and (e)
journal assignments (beginning, middle, conclusion), explore perceptions of reflective journaling as a
and two IHWA–Short Form surveys (Dossey et al., teaching and learning strategy. RJ1 differed slightly
2013) (beginning, conclusion). from journals RJ2 and RJ3 in that some questions
from the later journals asked participants to reflect
on changes to their self-care and health-promotion
Participant Demographic Form
practices. For example, in RJ1, one of the questions
The participant demographic form was used to asked the following: How, if at all, do you believe
collect information such as gender, age, race, year enrollment in a holistic nursing course may change
RN license obtained, type of institution (hospital, your thinking about self-care and health promotion?
nursing home, community, other) at which RN-BS But in RJ2, this question changed to the following:
student worked, nursing specialty/unit, shift during How, if at all, do you believe enrollment in a holistic
which the student primarily worked, prior experi- nursing course is helping you to change your think-
ences in holistic nursing, availability of professional ing about self-care and health promotion? Last, in
development in-services in holistic nursing, and RJ3, the question was stated as the following: How,
prior experiences with journaling. This information if at all, do you believe enrollment in a holistic nurs-
was used to describe the participants’ demographics. ing course helped you change your thinking about
This description is particularly important in case self-care and health promotion?
study research as it allows readers to determine
whether the context of a given case study matches
IHWA (Short Form)
the reader’s context to allow for generalization of the
findings. The IHWA (short form; Dossey et al., 2013) is a
33-item psychometric tool that was adopted from
the IHWA (long form) to measure the same compo-
Reflective Journals
nents and to provide an informational assessment of
Three reflective journals (RJ1, RJ2, RJ3) were a respondent’s current state of life, feelings, and
employed as the primary source of data for this study. personal self-care in nine categories of life and well-
An open-ended guide for evaluating the reflective ness: life balance and satisfaction, relationships,
journals (see Table 2) was developed by the researcher spiritual health, mental health, emotional well-
and used to collect evidence related to the reflective being, physical health/nutrition, physical health/
practitioner model (Schön, 1983, 1987) that con- exercise, environment, and health responsibility.
tained the key concepts of the conceptual framework There are between three and five statements for
for this study. The key concepts in Schön’s (1983, each of the nine subscales. Each statement is
1987) description of a reflective practitioner, described worded in the first person, such as “I express my
earlier, are (a) technical rationality, (b) reflective prac- needs in appropriate ways” or “I believe I’m key to
tice, (c) reflection-in-action, and (d) reflection-on- my wellbeing and overall health.” Participants were
action. The open-ended questions were formulated to asked to respond to Likert-type items on a 5-point
elicit reflections about the utility of self-reflection as scale (1 = never, 2 = rarely, 3 = sometimes, 4 = fre-
a teaching and learning strategy. quently, 5 = always) to indicate how often they
Subsequently, three reflective journal assign- engaged in each item. Dossey and Keegan (2013)
ments were developed that aligned with the three pointed out that IHWA has meaningful use in per-
primary research questions. Each journal guided sonal self-development because it “assists people in
students to (a) define selected self-care and health- becoming aware of their human potential in each of
promotion practices according to the literature and these categories, identifying strengths and weak-
individually interpret how they understood these nesses, and considering and creating new health
areas, (b) discuss their personal results from the goals” (p. 164).
IHWA and how they planned to address areas with The IHWA (short form) was examined in a
low scores, (c) evaluate personal and professional quasi-experimental study exploring the effect of an
implications of their current self-care and health- integrative wellness program on control and study
promotion practices, (d) explore meaning and sig- groups. The IHWA demonstrated good reliability
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10 Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX
Table 2. Reflective Journals: Instructions for RN-BS Students
This guide for Reflective Journaling is intended to help you think about two areas of self-care and health-promotion practices. Self-care and health-
promotion practices are defined as the behaviors and activities that maintain a “healthier lifestyle and enhance wellness . . . [and are] motivated by the
desire to increase well-being and actualize human health potential” (McElligott, 2013, pp. 827-828). Specifically, the Integrative Health and Wellness
Assessment (IHWA) survey that you completed in class can be used as an example of self-care and health-promotion practices. The IHWA provides
useful information about your current state of life and personal self-care in nine categories of life and wellness: life balance and satisfaction,
relationships, spiritual health, mental health, emotional well-being, physical/nutrition, physical/exercise, environment, and health responsibility.
Questions that you will see in this guide are dedicated to help you move through the reflective process and use them as headings in your journals.
Each reflective journal should be 3.5 to 4 pages in length and typed using Times New Roman, 12-inches font size. The reflective journal entries
will not be graded on the quality of their reported experiences but on the level of their reflection. Reference in text and at the end of each journal
entry the resources, classroom experiences, assigned readings, surveys, or consultations with other professionals that helped you understand
selected self-care and health-promotion practices.
RJ1 RJ2 RJ3
1. How does the literature define self-care and 1. How, if at all, is the literature helping you 1. How, if at all, does the literature
health promotion? Where does this definition reshape your definition of self-care and summarize the definition of self-care
come from? health promotion? Where does this definition and health promotion? Where does this
come from? definition come from?
2. How do you define self-care and health 2. How, if at all, is your definition of self-care 2. How, if at all, do you summarize the
promotion? and health promotion changing? definition of self-care and health
promotion?
3. Reflect on your completed IHWA survey at 3. Reflect on your completed IHWA survey at 3. Reflect on your completed IHWA survey
the beginning of the semester. the beginning of the semester? at the end of the semester?
3.1. What were the two areas that you scored 3.1. What were the two areas that you 3.1. How, if at all, have your two lowest
lowest on your IHWA survey at the scored lowest on your IHWA survey at areas on the IHWA survey changed
beginning of the semester? Why do you the beginning of the semester? from the beginning of the semester?
believe you received those scores? Why do you believe you received
those scores?
3.2. How, if at all, are you considering 3.2. How, if at all, are you addressing these 3.2. How, if at all, are you considering
addressing these specific two areas at specific two areas at the middle of addressing these specific two areas
the beginning of semester? semester? at the end of the semester?
4. What implications, if any, does self-care and 4. What implications, if any, does self-care and 4. What implications, if any, does self-care
health promotion have for your professional health promotion have for your professional and health promotion have for your
performance and/or personal life at the performance and/or personal life in the professional performance and/or
beginning of the semester? middle of the semester? personal life at the end of the semester?
5. In the future, what implications, if any, does 5. In the future, what implications, if any, does 5. In the future, what implications, if any,
self-care and health promotion have for your self-care and health promotion have for your does self-care and health promotion
professional performance and/or personal life? professional performance and/or personal have for your professional performance
What new strategies do you plan to maintain life? What new strategies do you plan to and/or personal life? What new
or integrate in your professional performance maintain or integrate in your professional strategies do you plan to maintain or
and/or personal life? performance and/or personal life? integrate in your professional
performance and/or personal life?
6. How, if at all, do you believe enrollment in a 6. How, if at all, do you believe enrollment in a 6. How, if at all, do you believe enrollment
holistic nursing course may change your holistic nursing course helped you change in a holistic nursing course helped you
thinking about self-care and health your thinking about self-care and health change your thinking about self-care
promotion? promotion? and health promotion?
7. Have you used reflective journaling in prior 7. If at all, how do you think that reflective 7. If at all, how do you think that reflective
academic coursework? If so, in what journaling is helping your learning about journaling helped you in your learning
course(s), and briefly describe your self-care and health-promotion practices? about self-care and health-promotion
experiences using reflective journals? practices?
8. How, if at all, do you think that reflective
journaling may help in your learning about
self-care and health-promotion practices?
with Cronbach’s alpha of .93 for the control group Research Site and Participants
and .88 for the treatment group. Thus, the research-
ers concluded that the analysis of the IHWA short The procedure for selection of participants in this
form suggested that the tool was valid and reliable study required logical consideration of who the par-
(McElligott, Mishanie, Okane, Friedman, & Nelson, ticipants will be, how they will be selected, time
2014). when they will participate, and what will be the
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