Reflective journaling and development of Cultural humility in students.ABSTRACT Cultural humility requires self-evaluation and the awareness that one's own culture is not the only or best one. Teaching health care providers to become culturally humble includes the development of critical thinking skills and the ability to reflect on practice. Journaling as a teaching strategy helps students develop these skills. This article describes the use of reflective journaling as students progressed through four semesters of a community clinical experience. This qualitative, descriptive study was based on the principles of naturalistic inquiry with personcentered written reflections. Two hundred journal entries from 50 students were reviewed, and I I themes were identified. Cultural humility cannot be learned merely in the classroom with traditional teaching methods. Reflection on experiences over time leads to the development of cultural humility.
Key Words Cultural Humility--Reflective Journaling--Cultural Competence--Diversity--Clinical Nursing Education
CULTURAL HUMILITY, AND THE COMMITMENT TO ADDRESS POWER IMBALANCES IN THE PATIENT-CLINICIAN DYNAMIC, REQUIRES LIFELONG DEDICATION TO SELF-EVALUATION AND CRITIQUE (Tervalon & Murray-Garcia, 1998). For faculty, the challenge involves more than teaching concepts and their application in the performance of clinical skills. It expands to include the development of critical thinking skills, self-understanding, and the ability to reflect on one's own practice. Essentially, cultural humility requires embracing the belief that one's own culture is not the only or best culture.
For more than a decade, the Auburn University School of Nursing (SON) in Auburn, Alabama, has been in partnership with the local housing authority (AHA), a low-income public housing provider. This partnership, described elsewhere (Hamner, Wilder, & Byrd, 2007), includes a nursing care clinic staffed three days per week by the nursing outreach instructor and Auburn students. The SON has a community-based curriculum, founded on the belief that nursing is not bound by the four walls of a hospital and that nursing care is a universal need. Part of bringing this belief to life is the requirement that students participate in the partnership as part of their clinical experiences as they matriculate through the curriculum.
When this clinical experience was first introduced, students perceived it as different and somewhat stressful. These students, the vast majority of whom were young, upper-middle-class white women, had little experience with people different from themselves. It also became apparent that learning took place affectively and cognitively in ways that could not be assessed by traditional clinical evaluation tools and formal evaluation of teaching presentations. Faculty determined that reflective writing, a useful mechanism for understanding and internalizing experiences, would be
helpful to students participating in these clinical experiences (Craft, 2005). This article reports on a study based, in part, on the principles of naturalistic inquiry (Erlandson, Harris, Skipper, & Allen, 1993). The primary question was, "What does reflective journaling reveal about the experience of cultural humility in nursing students participating in the community partnership clinical?"
Why Reflective Journaling Journaling helps students develop critical thinking, self-understanding, and reflection (Billings, 2006; Craft, 2005; Daroszewski, Kinser, & Lloyd, 2004; King & LaRocco, 2006). Pedro (2006) stated that writing is a good tool for learning reflection that helps students solve problems and learn about what they do. Journaling involves writing to learn, and the journal becomes a permanent record of thoughts. When a learner writes down a thought, the thought takes shape and form. Journaling helps students engage in introspection and analyze situations critically. It should not be too structured, because students' thoughts and reflections can become be constricted (Craft).
The practice of reflection, making meaning out of life experiences, is inherent in journaling (Kerka, 2002). Diekelmann (2003) described how reflection ultimately fosters thinking in action and encourages students to have a critical eye and promote a safe environment. Reflection fosters thinking that changes practice, and is not merely a rote or routine expeience. When reflective thinking is paired with journaling as a learning activity, students develop self-analysis and an increased awareness of their environment.
Method The Internal Review Board for the Protection of Human Subjects of Auburn University approved this study. For each of the four semesters students had community partnership clinical experiences at the AHA, semi-structured interview questions were assigned. For the first semester experience, students were asked to reflect on their expectations of what the clinical experience would be like before they went and what the reality of the experience was. For the second and third semesters, students were asked to describe and reflect on their clinical time at the AHA. For the fourth and final semester, students were asked to reflect on their thoughts about the entire experience and its impact on their professional development.
All students having experiences at the AHA participated in reflective journaling as they progressed through the curriculum. Course faculty who were not involved in reviewing the journals documented participation. To promote reflection on personal experiences, a major purpose of journaling (Daroszewski et al., 2004), grades were not assigned and names were removed from the journals before the faculty began their review.
Three faculty reviewed the journal entries of 50 students over a period of two years as they progressed through the curriculum. A total of 200 journal entrees were reviewed. Eleven themes emerged in response to the questions asked in the four clinical courses: three from the first semester, four from the second and third semesters, and four from the final semester.
Findings REFLECTIONS FROM THE FIRST SEMESTER
Students began to see the importance of nursing in the community, but were more interested in practicing psychomotor skills, such as injections typically performed in traditional hospital settings. However, even in this first clinical experience, students were beginning to develop cultural humility.
Analysis of journal entries revealed three broad themes as students reflected on their expectations prior to the clinical at the AHA and described the reality as it was experienced. Even though their instructions for journaling did not mention the practice of psychomotor skills, students often wrote of having the chance to practice these skills; for example, "I learned how to take a manual blood pressure" and "I got to do finger sticks" were mentioned repeatedly.
The second broad theme that emerged was a beginning understanding of the importance of culture in the lives of clients.
"The open discussion regarding cultural differences helped a lot. We, as nursing students, must be constantly aware that our personal culture is not the only one. We must provide culturally competent care not only to individuals of racial or ethnic minority groups, but also to individuals belonging to groups held together by factors such as sexual orientation, socioe-conomic status, and religion."
"I noticed that the clinical was also a social gathering for clients. A lot of them sat around talking to each other after getting their assessments. Being there seemed to lift a lot of their spirits and all asked when the next time the clinic would be held."
Finally, it was clear that this first semester experience taught students to begin to understand and value community nursing. One student put it clearly:
"When offering health care in this setting, big impacts can be made. The client is more likely to participate in primary prevention if they are close to the location of health care. The nurse in the community cannot only do screenings and prevention, she can also teach the clients about healthy lifestyle choices. The nurse sees the environment the clients are living in and is able to adjust interventions to the unique aspects of the clients' lives. The community nurse also understands and grasps a better picture of the community as a whole unit and how to fix the health problem on a larger scale."
REFLECTIONS FROM THE SECOND AND THIRD SEMESTERS
As students progressed through the curriculum, their journals revealed a maturity and self-understanding not seen in earlier writings. The majority of students at the SON come from socioeconomic backgrounds where experience with lack of health insurance or the inability to afford medicine and basic health care is unlikely. Although students are exposed in class to the fact that some people must literally choose between medicine and food, this notion became a reality in the clinical experience and helped students see the impact of health care disparities. Students showed creativity in meeting the needs of the population they were teaching. Clearly, students learned by doing that teaching benefits when the culture of the audience is considered.
With the simple instruction to reflect on what they learned during the clinical, students were free to express what they were thinking and feeling. Four themes became apparent. First, students expressed an awareness of health disparities for those experiencing poverty and a concern about the health care delivery system in the United States. They frequently made comments such as these:
"I became more conscientious of the great need for accessible health care for the elderly and poor. Two main factors which I found to interfere with optimal health care for clients were the lack of transportation to seek health care, and the inability to afford medications as needed."
"It was upsetting to me that some of the residents' blood pressure was so high. When I asked if they were taking their blood pressure medicine, they replied they were not because they couldn't afford it. That was the only part of the day that I did not like. It seems so unfair and cruel not to provide adequate health care and medications at a reasonable price."
A major assignment at the clinics was designing and implementing health promotion teaching projects. Students described how they critically examined their teaching and learning to tailor their teaching to the audience. Comments included:
"These clients could not afford a gym membership and many did not have transportation to it. We taught them how easy it is to apply exercise techniques in their lives, you don't have to go to a gym to do it. We gave examples of easy ways to get your heart rate up such as walking, playing with grandchildren, or doing housework. We also gave the example of lifting a can of beans or bags of flour if they wanted to work their arm muscles."
"Our group went to Wal-Mart and picked out some items that would make a nutritious, low calorie, but extremely inexpensive meal. This was to demonstrate that if you plan ahead, you can eat a good meal for very little money."
Another theme that emerged revolved around identifying trust as an important component of community health nursing.
"As a nurse, you have to be able to form a trusting relationship with clients. This is not done through taking vital signs and doing procedures. This is done through talking and listening to the concerns of our patients. There will be many times in our career that we won't be able to physically do something for our patients to make them better, but I can always give of my heart, time, and knowledge and understanding to help someone, whether it is at the bedside of a hospital unit or in the community. This is what the clinics ... have helped me learn to do."
Students reflected on the importance of encouragement, support, and being nonjudgmental when working with clients. They wrote:
"One client is currently trying to lose weight and is also attending classes at the community college. She confided that several of her friends and family have been telling her that she is too old and too heavy to do these things. I talked to her about dealing with discouragement and then tried to encourage her by helping her to focusing on how far she had come from where she started."
"One way we could improve our presentation would be to go back and take out the negative connotations. For instance, one of the things we said was that tobacco users can be stinky. We should have said something like, some people believe that tobacco product users tend to carry the smoky smell with them even if they are not actively using at that point. Next time, when we are presenting as a group, we must remain as nonjudgmental as possible."
Reflections from the Fourth Semester At this time in their education, students' writings suggested an ability to reflect on their own practice. They now understood that nursing was not just about doing something to the patient, such as taking a blood pressure, but nursing is about interacting with patients in the way that meets the patient's needs. As part of this final experience, senior students mentored juniors. By doing this, they were able to see how far they had progressed. Students not only began to reflect on how people are alike, but also on how differences in culture are interesting and special.
Three themes emerged. First, it was obvious students gained confidence in themselves as they matriculated through the curriculum.
"Out of all of my clinic experiences, this one was the most rewarding. During my first year, I was eager to talk to residents, but I was scared at the same time. I did not have the same comfort level asking them about their health as I do now. I felt as though I was following a list of criteria that I had to meet. Now, it was just part of our conversation. I was just being the nurse."
"One of the junior students was satisfied when she asked a patient what day it was and he replied, 'It's Wednesday.' She had charted that he was oriented to time, but I was able to show her that just because he knew what day it was, didn't mean that he was oriented to time at all. Upon further assessment, we found that he didn't know the season, the month, the year, or even who was the current president (interestingly enough, he said Coolidge). Through more thorough assessment, I was able to show the junior nursing students how important it is to ask several questions and not just settle with the first answer that they get from patients."
Another theme expressed in the fourth semester writings was an understanding of the importance of health promotion and disease prevention.
"I have learned a lot about the importance of early intervention. I have seen with my own two eyes how patients have benefited from heath promotion."
"Many of the residents that came into the clinic expressed lifestyle changes that they are currently involved in such as exercising more and making better food choices. By making these choices, positive results are bound to happen."
The fourth-semester journal entries reflected how students had changed their thinking and feelings about people from a different culture. Students wrote:
"When I first started going to the housing authority, I had negative thoughts about violence and so on as being apart of living there. When I started interacting with clients I was able to see how alike we all are. I think about how they feel when they are judged by people every day just like I used to do. This experience has taught me to be more accepting of people and cultures different than mine."
"In thinking back to my times at the clinic, I remember one very interesting client who believed in some kind of metaphysical religion and did some sort of prayer meditation with arm motions before I pricked his finger. At the time it freaked me out, but now I am able to understand and accept a client's culture that is different from mine."
"I couldn't believe what I put in my first journal entry. I was so judgmental. I talked about people wearing old clothes that needed to retire and said their appearance looked a little diminished compared to persons of a higher socioeconomic status. After working there all this time, I now know that some of the best people I will ever meet live at the housing authority. You surely can't judge a book by its cover."
Discussion What reflective journaling reveals about the experience of cultural humility in nursing students participating in the community partnership clinical was the broad question guiding this study. Cultural humility development begins in the first semester as students practice thinking and self-reflection in their journals and begin to recognize the importance of culture. These students are new to interaction with clients, and interaction with clients of a different culture has a tremendous impact on them. For the first time, they have conversations with people different from themselves about the meaning and experience of being from a certain culture. Beginning to understand that their culture it not the only one is an eye-opening experience.
Enhancement of cultural humility continued in the second and third semesters. Students were no longer novices to nursing and the environment of the nursing care clinics. Two concepts grasped by students promoted cultural humility. First, students saw firsthand that poverty creates health care disparities. They left these clinical experiences fully aware of the imbalance in power in the patient-health care provider relationship brought about by lack of resources. Second, the health promotion teaching projects they undertook drove home the fact that Culture must be considered when teaching clients.
Although the development of cultural humility is a lifelong process, cultural humility appeared well developed in students during the fourth semester. Students saw the beauty of differences as well as how all human beings are alike. They began to understand that health care is best delivered through a respectful partnership with the patient. Students realized that judgmental attitudes, based on stereotypes, are faced almost daily by housing authority residents. They were determined to fight judgmental thinking and behavior in themselves.
In summary, reflective journaling helps students progressively develop their critical thinking, self-reflection skills, and cultural humility. Cultural humility cannot be learned solely in the classroom with traditional teaching methods. Rather, it requires reflection on experiences over time. Attentiveness to cultural issues and applying self-awareness and reflection in the care of patients helps students understand and address health care disparities.
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About the Author The authors are faculty at Auburn University School of Nursing, Auburn, Alabama. Jenny B. Schuessler, DNS, RN, is associate dean and professor. Barbara Wilder, DNS, CRNP, is coordinator of the nurse practitioner program and professor. Lynda W. Byrd, PhD, CRNP, is a clinical assistant professor. For more information, contact Dr. Schuessler at JBS0016@auburn.edu.