The ability to perform thorough and focusedassessments of patients’ signs and symptomscombined with an objective examination of

physiological and psychological systems to arrive at adiagnosis is a critical skill for nurse practitioners (NPs).Further, based upon the diagnosis, the NP must deter-mine the best plan of care, often involving pharmaco-logical and non-pharmacological strategies. Becausepatients rarely present as straightforwardly and sim-plistically as they do in textbooks, it is incumbent uponeducators to ensure that NP students have the abilityto think critically, particularly in novel situations. Thesestudents must learn how to ask the right questions,perform the right physical examination, and order theright diagnostic tests to arrive at a reasonable and logi-cal working diagnosis. The practitioner must developthe ability to consider and rule-out other possible diag-noses (differential diagnoses) and develop an appropri-ate and tailored plan of care to achieve the optimal anddesired health outcomes.

The purpose of the clinical journal is to honeassessment skills, enhance critical thinking in diag-nosis and management, discriminate between dif-ferential diagnoses, demonstrate practiceapplication, help students to learn to adequatelyand accurately organize and document a patientencounter, and use writing to reflect on one’s feel-ings about practice, roles, challenges, and rewardsrelated to clinical situations.1-3 The clinical journalaffords students the opportunity to dialogue withtheir clinical faculty, address ethical and profes-sional issues at their practice sites, and practiceself-discovery.

Clinical journals allow faculty the opportunity tounderstand the student’s experience in the clinicalsetting because many students work with precep-tors who are not the faculty of record. According toRitchie, journaling adds to students’ personal andprofessional development through self-reflection,builds the student-teacher relationship, and allowsfor validation of the students’ learningexperiences.4 We encourage students to alsoaddress ethical or professional issues in the

journal.5 For example, if the preceptor ordered dif-ferent diagnostic tests or used different manage-ment strategies than the student would have,students are prompted to address those issues inthe clinical journal. This kind of insight is not anindictment of the preceptor but rather teaches stu-dents that there are often multiple approaches forreaching a desired outcome, and it also helps stu-dents develop their own practice styles.

Further, as Hays explains, writing is learning.6 In agraduate clinical situation, writing should promote

thinking, analyzing, synthesizing, and cementing. Thenotion of using clinical journals to foster critical think-ing in advanced practice nursing students is notnew. For example, Degazon and Lunney discussedthe use of the clinical journal to improve clinical deci-sion-making with clinical nurse specialist students.7

In the era of electronic medical records, fewer stu-dents have the opportunity to process their thoughtsin an organized fashion through traditionally acceptedwritten formats such as SOAP notes. Clinical jour-nals provide an opportunity for students to practicethe proper documentation of their thoughts andactions related to clinical encounters.8 The ability toapply evidence-based literature to clinical action isfurther enhanced through the clinical journal, as stu-dents have the opportunity to think through theirpatient case, critically evaluate the managementplan, and educate themselves toward the best planof action. In this way, life-long learning is alsoenhanced, as NP students learn the dynamicprocess of improving the quality of care throughreflection, review of literature, and professional cri-tique of practice issues.

www.npjournal.org The Journal for Nurse Practitioners - JNP 699

Debra J. Barksdale and Laura C. Nasir

The Clinical Journal: PromotingCritical Thinking, Applying Theory

AWESOME ASSIGNMENT

Table 1. Clinical Journal Guidelines and Grading Criteria Case Analysis With Application of Theory to Practice

S [10 pts] Chief complaint and history should include history of present illness (HPI), past medical history(PMH), and review of systems (ROS) as appropriate to problem. Include relevant developmental,behavioral, psychosocial, and cultural data.

O [10 pts] Focused physical examination and pertinent laboratory data.

A [20 pts] Patient problems and prioritized differential diagnoses; include a discussion with citations andreferences in appropriate format that support/refute the diagnosis.

P [30 pts] Outline the management for this case including further diagnostic assessment, pharmacologicaltherapy, patient/parent education, developmental and cultural considerations,consultation/referral, and plans for follow-up and evaluation of your care. If you saw the patientback for follow-up, include that encounter and any revisions to the plan and why. Includecitations that support/refute the plan. Include references from the literature using theappropriate format. Among your references, you must include references citing currentevidence-based practice. Discuss the applicability of the evidence-based article to practice.

Reflections [5 pts] Reflect on your clinical practice at this time, clinical observations, system issues or problemsthat you encounter in your practice site, and/or interesting/puzzling patient encounters.

Application of Theory Theories, models, and frameworks are used to explain or describe behavior and to indicate to Practice [25 pts] ways that behavior might be changed. For example, one who uses the Fear Appeals Theory

believes that fear motivates behavior or lifestyle changes and communications and interventionswith the patient would reflect the use of fear as a motivator for change. You should have atheory in mind before, or as, you assess and treat the patient. Describe a theoretical frameworkthat you find most useful in your practice. Describe how it guided your practice in relationship tothe patient/case presented. This section should be approximately 500 words (2 double-spacedpages). Include references.

Tips for the Discussions. Please include a discussion for each section. It is imperative that you show your outstanding ability to thinkcritically on paper through writing as you begin to think independently in your new role. Comment on areas of assessment and planningthat you would have included had this been your patient in your practice. For example, you may have wanted to do another laboratorytest, consider another diagnosis in the differential, or include different management strategies in the plan. You may have wanted to try acompletely different approach than your preceptor. This is not criticism of your preceptor, but rather a way to emphasize that there isfrequently more than one correct way to treat a problem. Be sure to give rationale for the additions you wanted to include.

Technical Guidelines. The journals must be typewritten in black ink, double-spaced, in a 12-point font with 1-inch margins. Referencesshould be cited using APA (5th edition) format. All references should be within the past 5 years unless they are considered “classic”articles. Appropriate abbreviations and incomplete sentences are acceptable for the SOAP portion of the journal. Spelling and grammaticalerrors are unacceptable and may cause a paper to be returned, failed, or to receive a lower grade.

JNP

Application of Theory to PracticeMany nurse educators believe that theory shouldguide practice.9 Although theory is believed to beintegral to practice, students are not always adeptat applying various theories, models, or conceptualframeworks to their practice. While NP students inmaster’s programs may be given an overview ofvarious theories in their didactic coursework, it ismore likely that they will be encouraged to use the-ory in research rather than in practice. In our cur-riculum, students are introduced to theories inseveral courses but there had been little opportuni-ties for them to actually practice using the theoriesdeliberately in their clinical settings.

The Process

Family NP and family psychiatric-mental healthNP students who are enrolled in the course ChildHealth in Primary Care are required to complete aseries of clinical journals based upon actual casesseen in their pediatric practice rotations.Throughout the semester, the content of the jour-nals builds in complexity, and students areexpected to demonstrate that they can apply atheory to their clinical practice by the final journal.Students are also formally evaluated on their abil-ity to apply theory to practice later during theiroral comprehensive examination in their finalsemester, prior to graduating from the program.

700 The Journal for Nurse Practitioners - JNP Volume 5, Issue 9, October 2009

The guidelines for case analysis, reflection,and application of theory to practice for the journal are included in Table 1. We have also provided the grading scale, as well as tips for discussion for students. Although the final reflection is only awarded 5 points, studentsare encouraged to discuss and reflect on eachmajor part of the journal separately as theywrite. The clinical faculty member reads andresponds to the student throughout the paper.Faculty might request a conference with studentswho demonstrate difficulty with organization,writing, synthesizing clinical data, or any otherproblems or issues related to the journal ortheir practice.

In summary, the clinical journal plays an impor-tant role in helping NP students to think critically,write, reflect on their practice and professionalrole issues, and become confident in theirprovider roles. Further, faculty is able to assessstudents progress and problem-solving abilities inthe clinical setting.

References

1. Waldo N, Hermanns M. Journaling unlocks fears in clinical practice.RN. 2009;72(5):26-31.

2. Billings D. Journaling: a strategy for developing reflectivepractitioners. J Contin Educ Nurs. 2006;37(3):104-105.

3. Blake TK. Journaling: an active learning technique. Int J Nurs EducScholarsh. 2005;2:Article 7.

4. Ritchie MA. Faculty and student dialogue through journal writing.J Spec Pediatr Nurs. 2003;8(1):5-12.

5. Callister LC, Ravert P, Stoneman E, Matsumura G. Ethical reasoningin capstone students. Int J Human Caring. 2004;8(2):54-60.

6. Hays MM. Writing for self-discovery: a semester-long journey at thegraduate level. J Prof Nurs. 2005;21(1):52-58.

7. Degazon CE, Lunney M. Clinical journal: a tool to foster critical thinkingfor advanced levels of competence. Clin Nurse Spec. 1995;9(5):270-274.

8. Ruthman J, Jackson J, Cluskey M, et al. Using clinical journaling tocapture critical thinking across the curriculum. Nurs Educ Perspect.2004;25(3):120-123.

9. Cody WK. Nursing theory as a guide to practice. Nurs Sci Q.2003;16(3):225-231.

1555-4155/$ see front matter© 2009 American College of Nurse Practitionersdoi: 10.1016/j.nurpra.2009.07.018

Both authors are employed at the University of North Carolinaat Chapel Hill. Debra J. Barksdale, PhD, FNP-BC, FAANP, is anassociate professor and a certified nurse educator. She main-tains an active NP practice and a NIH-funded program ofresearch on stress and cardiovascular disease. She can bereached at djbarksdale@unc.edu. Laura C. Nasir, MSN, FNP-BC, is a clinical assistant professor. In addition to teaching,she practices at the Caswell County Health Department in NC.

www.npjournal.org The Journal for Nurse Practitioners - JNP 701

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