Psychiatric Self-Reflection Journal Tool

Psychiatric Self-Reflection Journal Tool

Psychiatric Self-Reflection Journal Tool

Clinical Day 1
Date: 04/06/2025

Today’s clinical experience deepened my understanding of psychiatric nursing through direct patient interaction, teamwork, and safety awareness. Reflecting on this shift, I can clearly identify how I demonstrated the QSEN competencies of patient-centered care, teamwork and collaboration, and safety, while also recognizing areas for improvement and setting goals for continued growth.

1. Patient-Centered Care

During this clinical day, I cared for a patient diagnosed with major depressive disorder who presented with low energy and passive suicidal ideation. I demonstrated effective communication by using therapeutic techniques, including broad openers and reflection. For example, I asked, “Can you tell me more about how your morning has been?” This technique allowed the patient to express frustration without feeling pressured. I also reflected their concerns by acknowledging how fatigue impacted their routine, which helped validate their experience. The use of open-ended questions and reflection is supported in current nursing literature as essential therapeutic communication strategies that promote patient expression and trust (Ernstmeyer & Christman, 2022).

I integrated care by addressing both emotional and functional needs. When the patient initially refused to attend an art therapy session, I respected their autonomy while encouraging participation by suggesting they sit in for just five minutes. This compromise honored the patient’s preferences while gently promoting engagement. Additionally, I observed a psychiatric medication review where the provider adjusted medication timing based on reported side effects. This correction reinforced the importance of collaborative, patient-centered decision-making in improving outcomes. Mersha et al. (2023) note that patient-centered communication and collaboration between providers and patients are key factors in improving therapeutic outcomes and overall quality of care.

2. Teamwork & Collaboration

I actively participated as a member of the healthcare team by attending the morning huddle and reporting key observations, including that the patient did not finish breakfast. This information helped the nursing staff prioritize further assessment. I also supported a fellow student during a de-escalation by encouraging a calm tone and appropriate body posture. However, I noticed communication barriers within the team, particularly inconsistent handoff practices. Conflicting information about a patient’s visitor status caused delays and highlighted the importance of accurate, standardized communication. I also observed a coping skills group session where group dynamics initially limited participation. The facilitator effectively redirected the discussion to include quieter members, demonstrating how structured communication can improve group outcomes.

3. Safety (Evidence-Based Practice)

Safety remained a central focus throughout the shift. I contributed to physical safety by identifying and removing a potential hazard, a plastic bag left in the common area, and reporting it to the nurse. I also assisted in enforcing unit safety protocols by ensuring patient belongings complied with safety guidelines, including removing items that could pose a ligature risk. I observed critical safety measures, including 15-minute patient checks and close monitoring of high-risk individuals. These interventions reflect evidence-based practices designed to prevent harm and maintain a therapeutic environment. Additionally, I provided psychological safety by sitting with an anxious patient without forcing interaction. This presence helped the patient feel accepted and reduced their distress. One area of concern was my positioning during medication administration. I stood too close to the medication cart while a patient was agitated, which could have compromised my safety. This experience emphasized the importance of maintaining appropriate boundaries and situational awareness.

Strengths and Areas for Improvement

Two strengths I identified in my practice include my ability to build rapport through therapeutic communication and my comfort with using silence as a supportive intervention. These skills helped patients feel heard and respected. However, I also recognized areas for improvement. First, I tend to hesitate when patients become emotionally overwhelmed, which affects my response. Second, I need to improve my documentation skills, particularly when recording patient refusals, to ensure clarity and continuity of care.

SMART Goal for Next Clinical Day

Specific: On my next clinical day, I will manage at least one episode of patient tearfulness using two therapeutic communication techniques, such as validation and silence, and accurately document one patient refusal using the SOAPIE format. According to Ramón and Amores (2023), the SOAPIE format is a structured method used in psychiatric nursing to organize patient observations, interventions, and evaluations.

Measurable: My clinical instructor will observe my interaction and review my documentation for accuracy.

Achievable: I have already studied these techniques and practiced SOAPIE documentation; I need to apply them in real situations.

Relevant: These skills are essential for safe, effective psychiatric nursing care and improve both patient outcomes and team communication.

Time-Bound: I will accomplish this goal during my next clinical shift.

New Insights & Preparation

A key insight I gained today is that safety in psychiatric care extends beyond physical protection to include emotional and psychological safety. Simply being present with a patient can be a powerful intervention. To prepare for my next clinical day, I reviewed de-escalation strategies and practiced documentation techniques. I also plan to arrive early to review patient assignments and identify potential safety risks. This preparation will help me feel more confident and improve my overall performance. Overall, today’s experience strengthened my understanding of holistic psychiatric nursing care. I am continuing to develop into a more competent and reflective nurse by combining patient-centered communication, effective teamwork, and strict safety practices.

References

Ernstmeyer, K., & Christman, E. (2022). Foundational Mental Health Concepts. In Nursing: Mental Health and Community Concepts. Chippewa Valley Technical College.

Mersha, A., Abera, A., Tesfaye, T., Abera, T., Belay, A., Melaku, T., Shiferaw, M., Shibiru, S., Estifanos, W., & Wake, S. K. (2023). Therapeutic communication and its associated factors among nurses working in public hospitals of Gamo zone, southern Ethiopia: application of Hildegard Peplau’s nursing theory of interpersonal relations. BMC Nursing, 22(1), 381. https://doi.org/10.1186/s12912-023-01526-z

Ramón, V. L. P., & Amores, F. B. C. (2023). Use of SOAPIER format in rotating interns of the Nursing career. Sapienza: International Journal of Interdisciplinary Studies, 4(1), e23016-e23016. https://doi.org/10.51798/sijis.v4i1.630

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NSG 187 Psychiatric Self-Reflection Journal Tool

(Instructions & Rubric)

After the clinical day, at home on Moodle, students will be required to be self reflective on which aspects of the care they have provided are in line with the QSEN nursing competencies and self-identify areas that need improvement. They should also include new insights they have gained from the clinical day and what they have review to be prepared for their next clinical day. The SMART format is a good format to orient student to for journaling professional progress -(S) Specific; (M) Measurable; (A) Achievable; (R) Relevant; (T) Time-Bound. Instructors should review journal entries to familiarize themselves with what their students’ goals are, especially if they are with a new student assignment.

Your journal entry will be double spaced.

Reflect on your clinical experience today and journal a short entry as to how you demonstrated each QSEN domain or reflect on an area that your clinical instructor suggested you improve. Set at least one S.M.A.R.T goal for your next clinical.

1. Patient Centered Care:
2. Teamwork & Collaboration:
3. Evidenced Based Practice:

Please refer to rubric below for grading expectations. (500 word minimum, double spaced)

There will be a 25-point automatic deduction for less than 500 words. There will be 10 % deducted from the final journal grade for 3 or more grammatical, spelling, and punctuation errors.  Be sure to avoid run-on and fragmented sentences or inappropriate sentence structure, as well as any failures to capitalize appropriately.

NO LATE WORK WILL BE ACCEPTED AND WILL RESULT IN A ZERO

Self Reflection Journal Grading Rubric

Final Grade: