International Journal of Africa Nursing Sciences 12 (2020) 100195

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International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Scaffolding in reflective journaling: A means to develop higher order T

thinking skills in undergraduate learners
Mary-Ann Jarvis⁎, Olivia B. Baloyi
School of Nursing and Public Health, Floor 4, Desmond Clarence Bldg., Howard College Campus, University of KwaZulu-Natal, Durban, South Africa

ARTICLE INFO ABSTRACT

Keywords: Background: Reflection through reflective journaling has the potential to assist learners to enhance their un-
Higher order thinking skills derstanding, enrich lifelong learning, reduce clinical errors and develop professional autonomy grounded in
Reflective journalling expert clinical judgement. Aim: The study presents an analysis of scaffolding in reflective journaling as a means
Scaffolding to develop higher order thinking skills (HOTS) in Bachelor Nursing fourth year students, psychiatric component.
Undergraduate students
Methods and analysis: The study adopted a qualitative exploratory approach, underpinned by social con-
structivism. Non-probability purposive sampling was used. Data collection methods included two focus group
discussions and document analysis. Content analysis using Elo and Kyngäs (2008) approach was followed for
both sources of data. Data evaluation was done using Lincoln and Guba’s methods of trustworthiness. Results:
The following categories emerged: conscious incompetence, intervening conditions and simultaneous unin-
tended outcomes. Conclusion: A phased introduction of reflective journaling (linked entries) supported by
scaffolding is a strategy that can move the learner from the Zone of Proximal Development to that of an in-
dependent critical thinker able to use HOTS as an autonomous professional.

1. Introduction and background
Reflective thinking is a strategy to promote critical thinking and clinical
reasoning skills, which are both higher order-thinking skills (HOTS) (Baloyi
& Mtshali, 2018a). Critical thinking is a cognitive process used to analyse
knowledge, while clinical reasoning is a meta-cognitive process which en-
gages reflective thinking when analysing a clinical situation (Victor-Chmil,
2013). Together the two processes lead to a sound clinical judgment (Victor-
Chmil, 2013). The concepts of reflective thinking and reflection were coined
by Dewey, the father of educational reflection, in the 1900s, through his
belief in developing reflective thinking patterns (Dewey, 1933). In keeping
with Dewey (1933) conceptualization of reflection as an active process,
subsequent scholars (Schon, 1983; Thompson & Pascal, 2012) have used
such terms as reflection-in-action, reflection-on-action and reflection-for-
action which are all built on evidence driven toward effective patient care.
Imperative to nursing is reflective practice (Harrison & Fopma-Loy, 2010;
Miller, 2017) which enhances the development of HOTS such as critical
thinking skills (Estrada & Rahman, 2014) and clinical reasoning
(Oluwatoyin, 2015; Regmi & Naidoo, 2013; Rochmawati & Wiechula,
2010). Clinical situations offer an opportunity for reflection to occur at
different points such that the nurse can navigate her thought processes;
firstly, in anticipation of a situation in the form of clinical fore-thought
(reflection–for-action) (Thompson & Pascal, 2012); secondly during the
activity (reflection-in action); and thirdly retrospective contemplation is
possible following a situation (reflection–on-action) (Fitzgerald, 1994).
Reflection has the potential to assist learners to enhance their under-
standing, enrich lifelong learning, reduce clinical errors and develop pro-
fessional autonomy grounded in expert clinical judgement (Kinsella, 2010;
Kolb & Kolb, 2005; Rochmawati & Wiechula, 2010). As much as reflection
involves action, it commences with the learner consciously stopping and
thinking before the start of synthesis (Vygotsky, 1978). Through the process
of synthesis, learners explore their experiences, analyse situations, handle
uncertainty and gain in-depth knowledge and a better understanding of the
experience (Smith & Trede, 2013; Regmi & Naidoo, 2013; Kinsella, 2010;
Estrada & Rahman, 2014). Furthermore, Moon (2013) recognized the re-
levance of reflective practice as enabling practitioners to logically organize
ideas and integrate pre-existing information with new information.
Reflection involves thoughtful consideration of an experience (Kuiper &
Pesut, 2004). In nursing education, reflection is thought to promote
learning from clinical experiences (Johns, 1995; Kuiper & Pesut, 2004). The
ability to integrate learning and apply HOTS in the clinical setting is re-
levant in the changing landscape of the South African health care system
(van Graan, Williams, & Koen, 2016). The educational need for graduates
capable of higher order thinking raises the question on how to teach re-
flective practice. Students writing a reflection after they have had a clinical
experience is a strategy to help the students to process their experiences

⁎
Corresponding author.
E-mail addresses: jarvism@ukzn.ac.za (M.-A. Jarvis), baloyio@ukzn.ac.za (O.B. Baloyi).

https://doi.org/10.1016/j.ijans.2020.100195
Received 29 October 2019; Received in revised form 18 December 2019; Accepted 28 January 2020
Available online 30 January 2020
2214-1391/ © 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
M.-A. Jarvis and O.B. Baloyi
and learn from them (Lasater, 2011). For decades, in order to enhance
learning, a variety of schools including medicine, pharmacy, psychology
and humanities have used reflective journals (Hashemi & Mirzaei, 2015;
Tsingos-Lucas, Bosnic-Anticevich, Schneider, & Smith, 2017), with positive
outcomes on academic performance, academic writing style and personal
self-reflective growth (Hashemi & Mirzaei, 2015). However despite the
perception of reflective journals as integral for the development of HOTS
(Stocker, Burmester, & Allen, 2014) it was not until the late 1980s through
Schön’s seminal work of reflective practice that they gained popularity
within undergraduate nursing education curricula (Langley & Brown,
2010). The South African Nursing Council qualification framework for
Bachelor degree in Nursing and Midwifery mandates that Nursing Educa-
tion Institutions produce graduates with attributes of a ability to critically
reflect (SANC, 2016), which has resulted in a few nursing education in-
stitutions including reflective practise into the course requirements at
fourth year (Baloyi & Mtshali, 2018a; Kok & Chabeli, 2002). A reflective
journal is a personal space where learners record their unique engagement
with the reflective process triggered by the experience.
Reflective journaling contributes to lifelong learning and hence requires
the learner writing connected entries that spiral from the preceding entry.
Such spiralling involves newly constructing knowledge and skills built on
learning from the previous journal entry and avoids a journal with dis-
connected stand-alone entries. In order to create practise connections, a
supportive relationship with the facilitator is necessary. In line with
Vygotsky’s theory of Zone of Proximal Development, the facilitator, as a
more skilled person, is available to guide and encourage the learner to move
through the proximal zone and develop the ability to create practise con-
nections through scaffolding (Shabani, Khatib, & Ebadi, 2010). Scaffolding
is a temporary supportive process, unique to the learners’ requirements for
assistance that is tapered as the learner becomes more independent in their
learning (Chang, Chen, & Sung, 2002) with a fuelled drive to learn (van Der
Stuyf, 2002). Support can result from a collaborative interaction between
the facilitator and the learner as together they identify the learning needs.
Learners are supported in their development of HOTS through their re-
flective journaling which in turn develops their clinical judgment. Initially
they walk closely together in developing the areas and through reflection-
on-action and reflection-for-action the support is tapered as the learner’s
reflective skills develop. The ultimate outcome of reflection, coupled with
Table 1
Phases in the development of HOTS supported by scaffolding.
Phase Aim
Phase 1 Orientation to To introduce students to reflective
reflective process practice.
Phase 2 Initial feedback To offer feedback and support through
on first paired entries scaffolding in reflective practice involving peer review and facilitator support. Students worked in
HOTS
Phase 3 Ongoing feedback To provide support to the students as the
on first paired entry learnings from feedback are utilised and
allow for a revision of the entries so as to
enhance HOTS.
Phase 4 Feedback on To provide support to the students as the
subsequent paired learnings from feedback of first paired
entries entry are utilised and allow for further
development of HOTS.
International Journal of Africa Nursing Sciences 12 (2020) 100195
scaffolding is a self-regulating, self-monitoring learner who has developed
HOTS in that specific area (Baloyi & Mtshali, 2018b).
The identification of the potential value of reflective journals does
not answer the question on how to use them effectively to enhance the
development of HOTS, consequently there is a dearth of literature in
this area. Hence this study aimed to explore the use of scaffolding in
reflective practise amongst undergraduate nursing learners.
2. Problem statement
Learners are more motivated when they are accountable for their
learning and involved in learning activities such as reflective practise which
requires HOTS (Collins, 2014). The development of HOTS is facilitated
through the innovative strategy of reflective journaling goaled at producing
efficient autonomous practitioners. Through scaffolding and reflection, a
learner learns how to learn and become a self-monitoring, self-regulating
practitioner, outlining the need to identify the value reflective journaling
holds to this process. It is important for progressive nursing education to
derive a better understanding on how reflective journals can be used to
enhance the development of learners’ HOTS.
2.1. Context
The study was conducted in the Nursing Department of an urban-based
university in KwaZulu-Natal, South Africa. Approximately 25 years ago, the
department moved from a content driven curriculum to a problem-based,
competency-oriented program (Mthembu, Mtshali, & Frantz, 2014) with the
goal of developing HOTS in its learners (Mtshali & Gwele, 2015). Pro-
gressive, innovative teaching strategies are adopted to stimulate the devel-
opment of transferable life skills, such as reflective practise, within the
learners.
2.2. Use of reflective journaling as a teaching strategy
The undergraduate nursing students, were exposed to reflective
journaling during their psychiatric nursing module. Kolb’s model, a
four-stage learning cycle, provided the structure to facilitate the
transformation of the concrete clinical experience into practise relevant
Process Outcome
At the start of the reflective exercise the students were The students were equipped with written and
introduced to the objectives and process of reflective verbal information on the expectations of
writing. Instructed to write linked (paired) reflections of reflective practise and requested to identify a
their clinical learning experience during their psychiatric clinical situation which stimulated reflection.
nursing placement using the Kolb model and HOTS in They commenced with a paired entry.
each step of the cycle. An explanation given that the
linked (paired) entries needed to spiral to enhance
practise relevant reflections.
Time lines for submission negotiated.
Scaffolding highly visible.
One student offered the draft of her reflective entry for The students experienced “ah-ha” moments
about reflective practise involving HOTS which
groups to critique the draft for application of HOTS they were able to apply to their own drafts.
aligned to the Kolb model. Students showed evidence of self-corrective
Scaffolding strongly visible through collaborative learning. Students encouraged to utilise the
learning, peer coaching, and classroom debates. support from the facilitator to revise their drafts.
Feedback provided in electronic format and face-to-face Difficulty remained in student’s ability to focus
on their first paired reflective journal entry. on the core clinical experience and arrive at
Scaffolding remains visible in classroom discussion. practise outcomes based on HOTS. Scaffolding
needed to continue.
Feedback provided in both electronic format and face-to- Reflective journaling is improving, but difficulty
face on the students’ subsequent paired reflective journal remains to convert learning into practise plans
entries. and to link entries. Scaffolding needs to continue,
Scaffolding starting to diminish. but is tapered off.
2
M.-A. Jarvis and O.B. Baloyi
knowledge, using HOTS (Kolb and Kolb, 2018). In keeping with this
progressive teaching strategy, the interactions progressed through four
phases from orientation to feedback on multiple paired entries. Table 1
outlines each phase’s aim, the processes involved in the development of
HOTS supported by scaffolding, and the outcome. It shows that as
HOTS increased scaffolding was tapered.
2.3. Methodology
Study design: The study adopted a qualitative exploratory approach,
underpinned by social constructivism. This design is considered ap-
propriate in describing and exploring the perceived views, practices and
processes used by the fourth-year Bachelor of Nursing (BN) students
enrolled in the psychiatric nursing module, in order to understand how
reflection through scaffolding enhances the development of HOTS.
Study participants: The study participants were all fourth-year-BN
students currently registered for the psychiatric nursing module at the
study setting, able to articulate in English and had consented to parti-
cipate in the study. Any students who were unwilling to participate in
the study or were registered for any BN module apart from psychiatric
nursing were excluded from the study.
Sampling and sample size: Non-probability purposive sampling of the
fourth-year BN students registered for the psychiatric nursing module
was used. Purposive sampling continued until data saturation of two
focus groups, each with nine participants, was reached. This was based
on repetition of categories and sub-categories, when no new informa-
tion emerged. The reflective journals linked to the participating stu-
dents were simultaneously sampled.
Recruitment: The fourth-year BN students enrolled in the psychiatric
nursing module were informed verbally by their lecturer about the
study. Thereafter all potential participants were invited to participate in
the study, followed by providing the information sheet and written
consent.
2.4. Data collection methods
In keeping with the principles of richness of data in qualitative
studies (Patton, 1990), data were collected over three months, through
focus group discussions (FGDs) and document review.
The documents reviewed were the reflective journals which both
researchers analysed for evidence of the students’ development of HOTS
through their ability to reflect. This was done concurrently with the
FGDs which were conducted in a well-ventilated classroom, with good
lighting and minimal noise interruptions at a time convenient for the
participants. The researcher not involved in teaching the module con-
ducted the FGD in order to decrease the Hawthorne effect. The fol-
lowing open-ended question/s as indicated in the interview guide, were
asked: “In your own views or opinions how to do think the use of reflective
journals contributed to your abilities to develop HOTS”. Probing questions
were used to ensure that the students provided a step-by-step narrative
of how they used reflective journals to develop HOTS, these included:
“share with us one incidence that you chose to reflect on”… Take us step-by-
step through how you used the incident to develop HOTS”. All FGDs lasted
between 45 min to an hour, were audio-recorded and transcribed ver-
batim by both researchers independently.
2.5. Data analysis methods
A qualitative content analysis process was followed for both the
reflective journal entries and the FGDs, using the approach as outlined
by Elo and Kyngäs (2008). The key data collector listened to the audio-
recording soon after the interview in order to gain a sense of the whole.
This was followed by the transcription process which was done by the
3
International Journal of Africa Nursing Sciences 12 (2020) 100195
observer. Following which both researchers read the transcripts care-
fully line-by-line several times in order to gain a full understanding of
their meaning. Similar sentences and words were identified and coded.
Following which the related codes were allocated into subcategories.
Then the analysis proceeded to the labelling of subcategories which
were then sorted into categories. The preliminary findings were dis-
cussed with the participants in order to confirm their meaning. For
credibility purposes, initially both researchers conducted the analysis
independently, after which they met and discussed their interpretation
of the finalized categories and subcategories. The discussion of the
categories and subcategories was carried out until an agreement was
reached between the two researchers. Literature control was carried out
as a measure to contextualise the study findings (Creswell, 2012).
2.6. Trustworthiness
Trustworthiness was achieved through the criteria postulated by
Lincoln and Guba (1985). The focus group guide was used to generate
rich information and ensure transferability. Verification of the accuracy
of the member’s input was conducted through member checking, and
allowed for credibility of the gathered data (Holloway & Garvin, 2016).
Research participants were provided with an opportunity to make
corrections as indicated. Lastly, the position of the researchers was
appropriate for this study as the researchers were involved in teaching
and understood the reflective process and the role of scaffolding. The
researchers were capable of bracketing to facilitate an objective account
of participants involvement in the reflective process.
2.7. Ethical considerations
All ethical principles were adhered to. The study did not commence
until gatekeeper permission from the University of KwaZulu-Natal and
ethical approval from the University of KwaZulu-Natal Humanities and
Social Sciences Ethics Committee (HSSREC/00000118/2019) were re-
ceived. This was in addition to obtaining written consent from all
participants for participation in the study and audio-recording. One of
the researchers, who was the key data collector, though employed in
the same university/department as an academic, was not part of the
mental health care teaching team. Pseudonyms were used by the par-
ticipants during the FGDs in order to maintain their anonymity and for
confidentially. Reflective journal entries were labelled with the pseu-
donyms.
3. Results
This study aimed at identifying the value of scaffolding as a measure
to enhance HOTS through reflective journaling. The researchers re-
viewed the journals of the same nine participants who participated in
the two focus group discussions. The information gathered from the
focus groups complemented the analysis of the reflective journals.
As displayed in Table 2, participants’ discussion about reflective
practice to develop HOTS as supported by scaffolding generated two
categories of self-awareness and intervening conditions, each with ca-
tegories. Three categories with sub-categories were identified (Table 2).
The category of intervening conditions had two sub-categories of:
facilitating conditions and hindering conditions.
3.1. Category 1: Conscious incompetence
The participants were aware that they did not understand how to
utilize HOTS in reflective journaling. However, they were aware of the
value of reflective journaling towards becoming competent nurse
practitioners.
M.-A. Jarvis and O.B. Baloyi
Table 2
Summary of results of focus groups.
Categories Sub-categories
1. Conscious incompetence A. Recognition of deeper thinking
2. Intervening conditions
2.1. Facilitating conditions A. Support through scaffolding (guiding
questions)
B. Nature of feedback
2.2 Hindering conditions A. Inadequate time to reflect
B. Delayed introduction of reflective
journaling
3. Simultaneous unintended outcomes A. Development of academic writing
skills
B. Discovery learning
Sub-category 1A: Recognition of deeper thinking
The participants were able to acknowledge that reflective journaling
differed from writing a dairy, which is narrative in nature and does not
require such cognitive activities as critical thinking or, problem solving.
This is illustrated in the following extracts:
“Absolutely there is a difference a diary is just all about writing…..you
write like we used to write at school, storytelling…but with the reflective
journal, like XXX said is all about critical thinking…you think like ser-
iously…like deeper about situations…”(FGD:1)
“…reflective journals …the deeper thinking, coming up with solutions
and all because you don’t just present a situation but you also solve
problems and make decisions in that situation….”(FGD:1)
3.2. Category 2: Intervening conditions
The intervening conditions were comprised of both the facilitating
and hindering conditions.
Category 2.1: Facilitating conditions
The facilitating conditions were comprised of three subcategories
namely: support through scaffolding, nature of feedback and peer supported
learning.
Sub-category 2.1A: Support through scaffolding
Continuous support in the form of scaffolding from the facilitator
emerged from the study findings as imperative in enhancing the de-
velopment of HOTS utilizing reflective journaling. According to the
participants, oftentimes they experienced challenges in understanding
what is expected of them in using a reflective approach. Hence, gui-
dance is crucial in ensuring that the students go beyond narrating a
story in their reflective journals but think and reflect critically thus
developing HOTS, aided by the structure of a model. These were some
of the excerpts from the participants:
“We get a lot support from our facilitator, like after submission of every
entry… (FGD: 1) “… she provided us with guidelines like a structure on
how to write using Kolb cycle…and how to write such that we develop
higher order thinking skills.” (FGD: 2)
“She clearly explained the purpose of reflective journaling to us…most of
us we thought we just have to report on what we saw, something like
storytelling and not like go deep with our thinking and develop higher
order thinking skill.” (FGD: 1)
“Our facilitator assist us on how to write our reflective journals through
her asking us questions and assisting us to think deeper about our own
writing…”(FGD 2).
Sub-category 2.1B: Nature of feedback
Participants in this study explained that regular timeous feedback
sessions during the reflective process, enhanced their self-awareness of
4
International Journal of Africa Nursing Sciences 12 (2020) 100195
their thinking process, their ability to critique, problem solve and thus
develop within themselves HOTS. The participants expressed that
during feedback sessions they received explicit cues and re-
commendations from the facilitators and fellow students on how to
critically reflect. This feedback was perceived as pivotal in enhancing
their ability to develop HOTS. The nature of the feedback enhanced
participants’ ability to link the paired entries. These were some of the
comments from the participants:
“Our facilitator give us regular feedback which allows us to become
aware of our own thinking and writing” (FGD: 1)”…we are also able to
see where our thinking was not deep then we learn how better we could
have written to develop higher order thinking skills (FGD: 2) “…is not
only about the feedback but we also get it on time…” (FGD: 1)
“For I think the feedback assisted me with developing HOTS,…” (FGD:
1) “I think I’m developing HOTS, from the feedback…I’m able to scaffold
like I’m able to link entry one and entry two together.” (FGD 1)
The reflective journal entries improved in Phase 4 compared to
Phase 2, with scope for further improvement. In Phase 2 the majority of
the participants’ journal entries showed no link to the next entry with
experiences described in isolation of each other. However, in Phase 4
the entries began to show tenuous links to each other, with the begin-
nings of building the second entry on the learnings from the first entry
in the pair. It is in this process of developing HOTS that relevant
practise plans can emerge and influence healthcare outcomes.
Entry #1 (Concrete experience): We went outside where we had to
narrate to our partners our safe chapter of life of our story ….. We
started staring at each other not knowing who was going to start and tell
his/her story…
(Reflective observation) As we were going outside, I wasn’t happy with
the person I was grouped with even worse it was a male that lives with me
at the same residence….. I was even thinking of changing my drawing,
create my own story that is not there not existing yet not emotional but I
said to myself let me do what is right and expected from me …
(Abstract conceptualisation) Narrative therapy …aims to create new
positive life narratives that focus on alternative stories instead of negative
stories …
(Active experimentation) … Educate them about disclosure that when
telling other MHCU’s about your story it is not always about judgement
but you help yourself. I will conduct a group of a small number of
MHCU’s (Entry #1 reflective journal 1)
Entry #2: (Concrete experience) …I got the opportunity to sit with
several MHCU’s, [mental health care users] do a small circle for us and I
explained to them the importance of disclosing and how are they going to
benefits from it… (Entry #2 reflective journal 1)
Furthermore, the participants highlighted their preference of face-
to-face classroom feedback as opposed to written feedback, which not
only afforded them the opportunity to develop HOTS, but it also al-
lowed for peer supported learning. The participants expressed the key
role that peer supported learning played in the learning process and the
development of HOTS. As the students engaged and reflected together
in small groups, they exchanged ideas through challenging one an-
other’s thinking and reasoning abilities, and tended towards seeing the
others’ points of view, which allowed them to self-correct and thereby
develop their HOTS as illustrated in the following extracts:
“Yes feedback is good but for me I like face-face feedback the most….it
allows for discussions as a group, we debate in class… our facilitator chal-
lenges us through asking questions…this encourages us to think critically,
solve problem …” (FGD: 1)”… we self-correct as we listen to differing
viewpoints of other students and develop higher order thinking skills…jaa
face-face classroom feedback I think is very nice…”. (FGD: 2) “We are able
to debate it’s like sometimes other students challenge you when your answer
is not satisfactory and now you forced to explain more…this is how we learn
critical thinking and we develop higher order thinking skills”(FGD:1)
M.-A. Jarvis and O.B. Baloyi
“In the feedback the facilitator highlighted some of the wrong things that I
wrote in phase 1, I was able to see the gaps where I did not critically
reflect…which I will improve in the upcoming phase.” (FGD 1). “…be-
cause now you think of what is happening in the situation and what
theory can you use…and how can I prevent future mistakes or improve in
clinical work” (FGD 2).
Category 2.2: Hindering conditions
The category of hindering conditions was derived from the two sub-
categories namely inadequate time to reflect and delayed introduction
of reflective learning.
Sub-category 2.2A: Inadequate time to reflect
The participants recognized that an inadequate amount of time
hindered their ability to carry out reflective journaling that involved
HOTS. The participants evidence this hindrance in the extracts below:
“time…time…there is a lot…we juggle work with classroom…assign-
ments, tests …honestly I sometime do not have enough time to think
deeply or look for more sources as I’m writing…I just write to submit and
not miss the submission date (FGD: 1).”..it is this just writing to submit
which prevent us from developing higher order thinking skills as we write
our journals”. (FGD: 2)
In the journal entries it became evident that time was a hindrance
for some participants when they were tasked to do more than one
paired entry (Phase 4). This was shown in participants’ journal entries
where the first entry of the paired entries showed HOTS, but not the
subsequent entry. The abstract conceptualization stage in the Kolb model
that required seeking evidence based practice specific information
(McClure, 2005) was approached broadly and consequently limited the
formulation of a practice driven outcome with practice specific plans
inclusive of the “what”, “where”, “to whom”, “when” and “how” that
would allow for meaningful active experimentation This is shown in the
below extracts from the reflective journal entries:
… I realized that schizophrenia is a broad condition, it doesn’t have a
distinct cause and how it manifests from patient to patient differs, I plan
on understanding the condition better and the people living with schi-
zophrenia…. (Reflective journal 3)
…I plan on using collaborative learning to better my communication and
socializing skills and also my conflict management skills. (Reflective
journal 4)
Sub-category 2.2B: Delayed introduction of reflective learning
Through the participants’ ability to self-monitor they became
mindful of the value of HOTS and how an earlier introduction of re-
flective learning into the nursing programme would have allowed
greater proficiency in these skills. The extracts below give evidence to
the relevance of early introduction of reflective journaling.
“We should be exposed to reflective journaling from first year, not only in
the fourth year, this will ensure continuous practice during training,
hence we will know how to critically reflect and develop problem solving
skills and decision making skills from reflective journaling”. (FGD: 2)
“Reflective journals should be included throughout the entire curri-
culum… with repeated practice and feedback during our training, I’m
sure by now this critical reflection would be very easy”. (FGD: 1)
3.3. Category 3: Simultaneous unintended outcomes
The sub-categories of the development of academic writing skills
and discovery learning emerged in the category of simultaneous unin-
tended outcomes
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International Journal of Africa Nursing Sciences 12 (2020) 100195
Sub-category 3A: Development of academic writing skills
The participants expressed that due to the continuous feedback and
the need to utilise academic journals their fluency in English and their
vocabulary improved. The extracts below illustrate this development:
‘With repetitive writing and feedback …my English has improved so well”
(FGD: 1) “…like with grammar, sentence structure and choosing the
correct words…” (FGD: 2) my writing skills are improving as well…”
(FGD: 2)
“I have improved in my ability to do literature search, I have learnt to use
the latest articles”. (FGD1)
“I have also improved in the reading and the searching of literature…I
can now use search for latest articles with confidence”. (FGD 1)
Sub-category 3B: Discovery learning
The sub-category of “discovery learning” emerged from the parti-
cipants’ expression that the literature search exposed them to dis-
covering new learning which was unintended. This is indicated in the
following extracts:
“…we have grown as discoverers of own information”. (FGD: 1)”… we
have to support the facts in our journals with literature…we have do
scholarly searches on our own…we discover our own knowledge”. (FGD: 2)
4. Discussion
Vygotsky identified the significance of the Zone of Proximal
Development in the joint co-construction of collaborative learning be-
tween the more skilled person and the learners (Mishra, 2013). This
held relevance in the development of HOTS through reflective jour-
naling guided by scaffolding. Scaffolding is tapered according to the
learner’s needs (McLeod, 2012) in the transitions out of the Zone of
Proximal Development and it can facilitate the movement from con-
scious incompetence to conscious competence in HOTS as well as the
ability of the learner to develop nursing practise relevant plans. In the
1970s while employed at the Gordon Training International, Noel
Burch described the four stages of competence development as the
learner progresses from unconscious incompetence to unconscious
competence (Burch, 1970). It is in the Zone of Proximal Development,
through scaffolding with the necessary support and presence of the
more skilled person (Mishra, 2013), that the learner can feel comfor-
table enough to identify their level of incompetence and what is not
known in the skill of reflective practise. Amongst the participants in this
study there was a conscious self-awareness of their incompetence,
which they expressed in their recognition of the deeper thinking re-
quired in reflective practise. The self-awareness of conscious in-
competence is essential in the reflective process (McClure, 2005) and
the development of HOTS. Although there was no evidence in the study
of the participants having reached the stage of unconscious competence
as described by Noel Burch (Lynch, 2017) it can be suggested that
regular authentic reflective practise coupled with support (Coulson &
Harvey, 2013) can strengthen the development of HOTS, such that it
becomes an internalised process contributing to efficient nursing out-
comes.
It is relevant in nursing education that conditions which hinder the
development of HOTS are considered. A hindering condition to the
learning is the delayed introduction of reflective practise. An earlier
introduction of reflective practise into the curriculum could allow for
unconscious competence in HOTS such that the learner could be well
practised in these skills contributing to their inherency in their nursing
practise. A further hindering condition is inadequate time to reflect as
confirmed by various authors (McClure, 2005; Langley & Brown, 2010;
Estrada & Rahman, 2014; Mahlanze & Sibiya, 2017). McClure (2005)
devoted a specific section to “time”, in her tool to provide guidance in
reflective practice, highlighting the importance of its availability, so as
not to rush the process. Despite this study following Mahlanze and
M.-A. Jarvis and O.B. Baloyi
Sibiya (2017) suggestion for joint agreement on submission time lines
between the facilitator and the learner, with an allowance for adequate
time to plan the reflective entries, the participants singled out time as a
hindrance.
In the provision for facilitating conditions that act as a counter to
the hindering conditions, there are simultaneous secondary gains re-
cognised as unintended outcomes to the learner engaging in reflective
journaling, such as discovery learning. In the learners’ attempt to close
the theory practise gap (Kok & Chabeli, 2002), during the active con-
ceptualisation cycle (Kolb & Kolb, 2005) their searches did not limit
them to findings on the specific evidence based practise, but it directed
them down new avenues of learning, ultimately leading them to
meaningful life-long learning (Baloyi & Mtshali, 2018a, 2018b). Kolb
and Kolb (2018) highlighted that as the spiral of learning deepens so
too does the expansion of the complexity of learning. In the partici-
pants’ discovery learning, their immersion in the reading material ex-
posed them to liturgically well-written material which offered an in-
fluence on their academic writing skills, a positive outcome also
identified by numerous authors (Burrows, McNeill, Hubele, & Bellamy,
2001; Estrada & Rahman, 2014; Adam & Babiker, 2015).
The Zone of Proximal Development provides a context for feedback
(McLeod, 2012) and an opportunity to transition the learner from
conscious incompetence to conscious competence (Lynch, 2017) in
HOTS and reflective practise. In the stage of conscious competence the
provision of structure in the form of the Kolb model offers a framework
within which learners can consciously craft their reflective entries. In
the process of reflective practise peer, supported learning through
classroom debates and collaborative learning (Baloyi & Mtshali, 2018b)
plays a significant role in the development of HOTS. Feedback from
peers and an experienced person who add their knowledge and per-
spective, promotes self-reflection (Omer & Abdularhim, 2017; Qureshi,
2017). In this climate of learning involving self-reflection self-correc-
tion occurs (Baloyi & Mtshali, 2018b) which can spiral positively to
improve practice outcomes.
5. Conclusion
It is imperative to nursing practise that its practitioners are capable
of HOTS in order to make efficient and effective clinically reasoned
decisions that positively influence healthcare outcomes and contribute
to the attainment of the Sustainable Development Goals 2030 (Baloyi &
Mtshali, 2018a, 2018b). However, such skills need to be developed
before they can become located at a level of unconscious competence. A
phased introduction of reflective journaling (linked entries) supported
by scaffolding is a strategy that can move the learner from the Zone of
Proximal Development to that of an independent critical thinker, able
to use HOTS as an autonomous professional. In order to draw the
greatest value from this strategy in the strengthening of undergraduate
nursing education, consideration needs to be given to the time to re-
flect, the nature of the feedback and an early introduction of reflective
journaling into the curriculum.
6. Recommendations
In South Africa the re-circulation of the undergraduate nursing
curriculum has a lesser emphasis on psychiatric / mental nursing and a
greater focus on midwifery and general nursing which suggests that
reflective journals could also be used in these sub-disciplines, or pos-
sibly in the post graduate programme for psychiatric/mental health
nursing
7. Limitations
Only one institution was used for the purpose of this study, which
limits generalizability of the study findings. Secondly, the study was
limited only to fourth-year BN students in the psychiatric nursing
6
International Journal of Africa Nursing Sciences 12 (2020) 100195
module, which may also impact negatively on the generalizability and
transferability of the study findings.
8. Source of funding
There was no specific grant from any of the funding agencies in both
the public and the private sector.
Ethical approval
University of Kwa Zulu-Natal Humanities and Social Science
Research Ethics Committee reviewed the study following which the
protocol: (HSSREC/00000118/2019) was granted.
Authors statement
MAJ and OB contributed equally in the conceptualisation of the
study through to data collection, analysis, critical reading and writing
of the original draft of the manuscript.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.ijans.2020.100195.
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