Writing better reflective practice essays in nursing: examples of different levels of reflective reasoning paragraphs

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Writing better reflective practice essays in nursing: examples of different levels of reflective reasoning paragraphs

The example assignment paragraphs presented in this guide relate to work discussed in chapter 10 (Writing the Reflective Essay) of Price, B and Harrington A (2016) Critical Thinking and Writing for Nursing Students, 3rd ed. London SAGE. The guide should be read in conjunction with this textbook.

In this guide we illustrate for you different levels of reflective reasoning as represented within paragraphs of writing. In chapter 3 of our textbook we note that there are four levels of reflective reasoning, extending from the least sophisticated (absolute thinking) to the most sophisticated (independent thinking). We can summarise those levels in the following table (see Table 3.2, Chapter 3 for a more detailed breakdown).

Table 1: Broad characteristics of reflective writing by level

Absolute reasoning

(little or no reflection)

Transitional reasoning

Contextual reasoning

Independent reasoning

(significant reflection)

The author seems content with their own perspective, treating this as self justified, common sense, or self evidently true. Information is treated uncritically as factual, when in fact it may be open to debate as it refers to perceptions and perspectives, different ways in which a subject or issue could be understood. Observations in extremis may be expressed forcibly, demonstrating prejudice, and suggest that the author has not paused to re examine whether their attitudes, beliefs and values have an adequate moral basis upon which to proceed. The writing lacks emotional intelligence, that is understanding of how others might think or feel.

The author is aware that many issues and subjects in healthcare are subject to differing perspectives and that perceptions may be influenced by a variety of factors, that which can start to shape the narrative that the individual uses to make sense of events unfolding. Knowledge is treated as complex, ideas and experiences as potentially powerful. The author understands that others may think differently to them, but there is a tendency to catalogue the differences and the similarities, without reaching deductions that in some way reveal the authors own conclusions, their perspective on matters in hand.

The author reaches measured deductions about that encountered, and relates these precisely to the context and the focus of the reflective exercise undertaken. There is a clear appreciation of others’ perspectives and an ability to link these to those of the author, him or herself. The author is comfortable with the ‘differences of perspective’ that might exist and reviews the whole in the context of what the reflection has been designed to do (e.g. re evaluate the author’s listening skills, understand a problem that has arisen or a change underway).

The author sees the events unfolding in a fresh new way and one that admits considerable scrutiny into his or her own values, beliefs, attitudes and previous premises relating to the nature of healthcare and nursing within that. The author is able to adopt an overview, one that may be as critical as self as it is inquisitive of the perceived perspectives of others. The author demonstrates an understanding of how powerful the world of ideas, beliefs and values are and how these can be re evaluated in ways that might transform an issue or situation discussed.

Because the format of reflective practice essays may differ, dependent on which reflective model is employed; our sample paragraphs are arranged with regard to the key writing tasks detailed within Chapter 10 of our textbook. You will be presented in each case (save the last) with three possible paragraphs, and, using Table 1, invited to determine which of these represent the least and the most sophisticated examples of reflective practice reasoning. We challenge you to spot mistakes in writing that you should avoid in your future writing. Our notes will follow, but you are encouraged to reach your own judgements on the passages presented and to make notes on why you have reached your conclusions before reading what we offer.

Representing enquiry

At the beginning of your paper you will need to represent your enquiry, what it was all about and why you undertook it. Simply suggesting that it was done to meet assessment requirements is not enough. Reflection in nursing requires a professional and a scholarly purpose. In the following box there are three example paragraphs designed (in the author’s view) to introduce you to what they are doing in the reflection in question. Which is the most sophisticated, and which is the weakest? Decide why and make brief notes.

Example paragraphs: representing enquiry

Example A: My reflection centres on a care encounter that I had with a teenage girl suffering from a sexually transmitted disease and specifically her fears about confidentiality in our consultation. Miss X feared that her health status would be revealed to her parents as a matter of course and that this in turn would lead to censure of her lifestyle. Whilst the encounter involves some particular issues relating to Miss X and where she lived (with her grandparents), the reflection has deeper significance for me, as I have been intrigued by the challenges of building rapport with young patients in the clinic setting. I am especially interested in how I seem to a teenager and how I can build trust so as to better understand their health history and personal needs.

Example B: Working in a clinic poses several challenges, the most notable of which is that care is transitory. You have limited time in which to understand the patients concerns and to arrive at solutions to what they deem as their problems. It is important then to think about the consultation process and how you conduct business in a way that helps you secure the necessary information to guide them.

Example C: This reflection concerns my encounters with a patient (I will call him Mr Blake) who suffered from chronic emphysema and who visited our clinic several times during the course of December and January. On each occasion I made reflective notes regarding my impression of this gentleman and then summed them up here in preparation of the paper I present. In total, my reflections cover five meetings during that period of time.

Both Example B and Example C paragraphs are weaker than example paragraph A, but for different reasons. We wonder whether you spotted the shortfalls? If we look at paragraph C it is clear that the reflection focuses on a particular patient and care encounters with him (Mr Blake). There is no reason why a reflection should not span several encounters. Indeed, that can be innovative, as some issues only start to emerge as care consultation progresses. But what this paragraph lacks is a clear purpose for the reflection. What is it about Mr Blake that interests the author? Did he have particularly complex needs? Was he more difficult to understand or to work with? Did he show remarkable progress as a result of care agreed, something that seems worthy of critical reflection? You will need to state a purpose, the context for your reflection, so that the examiner can better understand the precision of your reflections later on in your essay. The more precisely you attend to the purpose of your reflection in the main text of your paper, the more likely you are to demonstrate contextual reflection or better in Table 1. Be sure to indicate why you are reflecting on this particular subject, or this particular patient.

Paragraph B does have a focus for reflection, the author’s interest in consultation process and the gathering of necessary information during clinic consultations. This seems a promising theoretical interest in practice as nurses understandably wish to gather information in an efficient as well as a sensitive way. But here, we don’t exactly know what sort of reflection took place. Is the author going to describe a series of consultations say with four or five patients, or is the approach much more eclectic - the nurse noting down interesting points about consultation with patients over several months and possibly with many more patients? You will need to set the scene, outlining how the reflection was conducted, so the examiner can understand afterwards whether your observations seem credible. If you don’t clarify how reflection proceeded, the reader might deduce that you are simply stating opinions.

Paragraph A is the best piece of writing because it includes both a purpose and a short description of what the reflection focused on. The author is writing about a particular teenage patient, but using this to muse about the wider business of establishing rapport with those who visit the clinic. Whilst the student will need to be careful about what she extrapolates from one care encounter, the paragraph has the merit that it focuses strongly on a personal practice matter. It is completely professional that the nurse should seek to improve her rapport building skill and so this reflection sounds very promising indeed.

A single representing enquiry paragraph cannot readily predict what level of reflective reasoning you will exhibit (Table 1), but we do think that paragraph A shows promise. Remember, to write in a contextual way you need to have a clear purpose available at the start of the paper and you need to stand ready to think honestly about your own values, attitudes and approach as you work with others. Independent reflective reasoning is characterised by your ability to think of yourself as an actor in this situation and to examine the interplay between your and other people’s words and behaviour. In paragraph A we might anticipate the nurse will write about her efforts to build rapport with this patient and the limits that get set on the same, either by the teenager or the situation prevailing (a sexually transmitted disease).

Distinguishing between facts, perspectives, perceptions, narratives and discourses

In Chapter 10 we defined each of the above key terms and emphasised the importance of distinguishing between them in your reflective writing. If you muddle them up, then your writing will seem less precise and it will also be less clear what you are arguing. Check back to our definitions now.

Here are three more paragraphs to evaluate. This time we would like you to spot where the student has mishandled one or more of the above terms. Once again, please make a note of what seems problematic in the paragraphs, before you turn to our notes below.

Example paragraphs: using terms correctly

Example A: As far as patient X was concerned all nursing care was meant to be tailor made, she had read somewhere that the local service was now ‘client centred’. Her perception was that nurses had to enquire at length about care preferences and design care plans that were signed off by the patient. Nurses would have to regularly seek patient approval for care measures proposed, making informed consent active and enacted moment by moment. The net effect of this was that progress with patient X was very slow, cautious and quite formal.

Example B: Mrs Raheem spent time each morning telling us a little more of what it was like to live with renal disease in Yemen. She explained that the hot climate and the worries that she and her family had about the cleanliness or otherwise of water supplies meant that it was tempting to under hydrate her body, something that was ‘bad for my kidneys’. The more she proceeded with her perspective the more she built a discourse on why her renal disease was the fault of environment. She struggled to see her condition as arising from many different factors, past urinary tract infections, a damaged kidney after a road traffic accident and the fact that she was of advancing age.

Example C: Mr Arnold had a problem. He was smoking too many cigarettes and failing to consider the explanations given by us about how this exacerbated his asthma and might lead incrementally to emphysema in the future. The fact was that Mr Arnold was more stubborn that he was willing to concede. Yes, he admitted to being a ‘bit set in his ways’, but he didn’t think himself an unreasonable man. He was simply ignorant of what ‘a fag in the morning’ really meant for his health.

How did you get on? None of the three example paragraphs are fault free; each has a definitional problem hidden within it. We share examples of poor writing though to alert you to mistakes that are easily made. In paragraph A patient X has developed a perspective on nursing care, not a perception. Remember, perspectives refer to much more concerted positions, they suggest an attitude on a topic. This patient has formulated a view on how nursing care should be, based upon her enquiries and now that seems at odds with what the nurses think care should be. As a result, the care relationship is strained. When perceptions transform into perspectives may be a moot point, but here there are a series of concerted views on care that suggest that this patient is pretty sure about what she expects of nurses. Perceptions are much more transitory, impressionistic and tentative, and it is once they have been tested and confirmed over and over that perspectives start to form.

There are two key terms used with regard to Mrs Raheem in paragraph B and one is used correctly and the other is not. It is correct to say that a patient here is developing a discourse on her illness and why it exists. It is a pronounced view, a set of explanations that justify her stance on the illness. In this instance, the discourse might be that her renal problems are the fault of others or of circumstances beyond her control. Discourses are often used to articulate who or what is responsible for something, what is wrong and therefore what is justifiably done next. Discourses may be expressed individually (as here) or shared between people (when nurses define particular sorts of care as patient centred). The term that is incorrectly used here is perspective. The better word to use is narrative. Mrs Raheem narrates her history, that series of circumstances and events that she sees as bringing about her renal condition. What distinguishes a discourse from a narrative is that in a discourse there is an explanation of events, an attribution of cause and effect. So here Mrs Raheem’s narrative is already being put to this purpose. If she simply said, ‘this happened, and then this, and after that, this….’ She would be narrating. When she uses events to explain something, then she is discoursing.

The problem with paragraph C is the quick assumption that Mr Arnold is stubborn. The author assigns him a label and has failed to completely substantiate their argument. What the author is working with here is their perception of Mr Arnold. He seemed stubborn. This is an important issue and especially if you wish to demonstrate writing that operates well above the absolutist level in Table 1. It is necessary to remember that, before you can argue a fact, you have to share evidence that confirms your assertion. Mr Arnold concedes that he is a ‘bit set in his ways’, but this is arguably insufficient proof that he is stubborn. We might all concede this about ourselves, perhaps alluding to familiar habits, but it’s not a proof that he is stubborn. Better evidence would be examples of where he has refused to discuss the effects of smoking with the nurse or doctor. Better still, if he has done so on several occasions. Does ignorance equate to stubbornness? An individual might be ignorant as regards a risk, but it is a distinctly different thing whether or not they will then do something about the risk when recognised. So this account is the weakest of the three accounts in the box.

What is important here is that you make careful use of the word fact and that you use ‘seems, seemed, appeared’ and similar words in a more strategic way. The impression that you should wish to convey is that you are tentatively exploring behaviour. Remember that you infer things from behaviour, mood, attitude, emotion, but that you cannot see these directly. It necessary to be cautious before inferring things before you look for corroborating evidence of what you think might be the case.

Demonstrating insight

Insight is critical within a reflective practice essay and that usually refers to discoveries that you are making through your encounters with others. Insight is about recognising something new, attending to it in an inquisitive and professional way. Some students write quite naively about insight. For example: ‘I had never realised before how much more difficult daily living could be for older patients.’ Whilst this does constitute a revelation, a new understanding, it starts from a low base. The reader might well ask, as a nurse: Are you really so unaware physical difficulties may accumulate as people age? What are you really sharing here? Insight needs to relate to your stage of training, what could reasonably be expected for you to know or understand this far. Here are some passages of writing that share insights, but which of these seems the best expressed? Which helps the reader understand the significance of what the nurse observed?

Example paragraphs: demonstrating insight

Example A: Caring for the twins on the paediatric ward made me think again about mothers and how they love their children. If one child gets sick then you hurt. But if two get sick and they’re twins, then maybe the hurt is ten fold. There’s so much more investment there.

Example B: Mr Jones sat down with me after receiving the news that his tumour had returned and he smiled. He went back over his life, to when he was a young man, much my age and he said, ‘back then we were bullet proof. No one got ill, no one died after injuries, we could smoke and drink and do as we please. We lived in different bodies you see, young bodies, bodies like yours lass if you like.’ As I listened, it struck me. I would not always feel this way about my body; I would not always be able to trust it as I do now. There would come a day when my body was weaker, more suspect and I would worry about it more. This was the context in which you might get news about cancer recurring. This was what you would have to take into account as you thought about the significance of that fact. Cancer wasn’t affecting your perfect body; it arose again in a vulnerable body.

Example C: There was a lot to think about watching Mr Dale cleaning up his stoma. There was the way that he prepared all the kit and looked around. He seemed ashamed about what he needed to do. There was the fact that his fingers were arthritic and it wasn’t so easy to manage the wipes and then the fitting of the stoma bag. There were things to think about the way he had to wash his hands and about how long it all took.

Paragraph A is a very weak example of insight sharing for a couple of reasons. First the paragraph is short and it is quite difficult to demonstrate real insight in just a couple of sentences. You usually need to substantiate your insight by sharing rather more. But it is weak too because the insights display some assumptions. We might ask why is loving twin children ten fold more painful than loving one. What is the nature of this investment when twins become sick? The author in this passage hasn’t really explained the insight, what the emotional investment is. Building the paragraph some more would lift it as an example of reflective writing. At the moment it hints as issues and concerns, it is transitional (see Table 1); there is little that is being clearly deduced here.

Paragraph B is the best piece of insight writing in this box. It is powerful because the issues raised are existential ones, what is it like to live in a body that is no longer trustworthy. The nurse writing this piece was stopped short, thinking about whether she really understood what it was like to receive bad news about cancer. If the body is frail, if it faulty in some way, the meaning of the news of tumour recurrence becomes different. Mr Jones (wittingly or unwittingly) has confronted her with some thoughts about the nurse’s ability to understand a patient at such a time. The nurse’s thoughts here are profound, she starts to muse about what it might feel like for Mr Jones. Using the analogy of youth and vigour, he has prompted her to question what she can assume for her own future.

In paragraph C the nurse catalogues a lot, about what the patient is doing. But they never quite clinch what the insight is! That might be something about how consciously toilet has to be managed. It might be about how time consuming and difficult it is. But the observations made just hint at these things and they leave the reader to sum up what the author may be deducing from this episode. Imagine if the author had then written, ‘I have paused now to think. When I toilet it is managed almost unconsciously. I don’t worry about a smell, or an accident that could occur, I don’t have to carry a bag on the front of my body… toilet happens below and behind me.’

Respecting others

It is critical that you convey respect for patients, relatives and colleagues when writing reflectively. If you don’t, your writing is likely to be judged unethical, unprofessional and, at the very least, absolutist. You have not imagined how the episode discussed could seem to other parties involved.

Here are three paragraphs of writing about others, but can you spot that which is problematic within them?

Example paragraphs: writing respectfully

Example A: When Mrs Gore’s daughter came in to visit, she said that her mother worried about the hysterectomy and wondered what might best reassure. I recalled that Mrs Gore had signed her operation consent form and spent half an hour discussing surgery with the surgeon and myself. So I suggested to the daughter that Mrs Gore talk to Mrs Evans in the bed on her left as she was recovering well from her surgery now. Positive experience of others recovering was an encouraging thing.

Example B: I paused beside the bed and explained to Mr Dean that I was going to teach him about using a syringe pump. There were real advantages in using a device such as this as it delivered a more measured and constant supply of insulin and there were many fewer chances then that his blood sugar glucose levels would fluctuate as widely as before. I showed the pump to Mr Dean and went through the steps for setting the pump up. I explained what checks would be made at a later date on whether he was managing the pump successfully.

Example C: I had a more junior student with me to watch the wound cleaning procedure. I remembered that in a demonstration you need to break the procedure down into steps and to give a rationale for what you are doing at each stage. So we gathered the equipment and I asked the patient if he minded whether student nurse Perkins join us to watch. He said that he didn’t mind the student watching. When I took the old dressing off I was surprised to see a significant amount of puss had built up in the cavity and I explained to the nurse that I now suspected that there was a tract down to a deeper pocket of infection. There was a real risk that, unless this was explored and if necessary drained, the patient might develop septicaemia and that would be much harder to treat.

Most reflective practice essays include passages of descriptive writing that sum up the activities underway. These can simply seem to be narrative bridging pieces that connect elements of reflective analysis together. But it remains important to remember that even the descriptive passages can convey your attitude towards care situations. It is necessary to write with discretion, remembering what you commit to as part of a code of professional conduct.

Paragraph A confides a breech of confidentiality. The author has admitted to telling a visitor (Mrs Gore’s daughter) something about the treatment and the recovery of a neighbouring patient. Whilst it might be a very good thing for a recovering patient to share their positive experiences, this can only be done with their informed consent and it should not be conveyed to a third party such as a visitor, unless of course the neighbouring patient is content for the information to be shared. You might fall into this trap as part of short hand writing, trying to convey action quickly in your limited word space. If you did in fact proceed this way, sharing information inappropriately, then you will need to pause and evaluate why it was unprofessional.

What is problematic in paragraph B is that teaching is conveyed simply as information sharing, there is no obvious sense that the nurse has consulted with the patient as regards whether he is ready and no apparent effort made to ask if he has questions. Confusing information giving with teaching is a common problem. In your reflective writing however, in your learning, there are deeper things to consider. What did the patient seem to understand? What worried him about the pump? The goal is always to convey an empathetic interest in his experience of care.

In paragraph C the nurse correctly asks the permission of the patient to have the junior student join the procedure. But concern arises as the nurse thinks aloud about what is discovered beneath the dressing. At issue here, is choosing the right form of words that might teach the student, but also have due regard for patient anxiety and discomfort. Some explanations are best handled away from the bedside. Clinical discoveries such as this can pose traps, but in reflective writing after the event, there is opportunity to reflect on the difficulty and show that you understood the conundrum that arose.

Illustrating learning

We come last to illustrating learning, which determines whether a piece of reflective writing constitutes deeper thought and higher levels of reflection across paragraphs. The examiner gains insights into your reasoning as the reflection advances through paragraph on paragraph. To illustrate that you have learned through the reflective process you will need to audit trail your reasoning as you proceed (show the workings out) and you will have to be prepared to deduce things from the observations that you have made. To be sure, those deductions will sometimes need to be cautiously expressed, and there may be caveats to note, but deduce you must if you are to demonstrate contextual or independent reflective reasoning (see Table 1).

Your learning illustration is likely to be positioned in the second half of your assignment. It is going to appear (dependent on the reflective model you use) in the ‘so what?’ part of your assignment answer. Learning is signalled clearly by change in your thinking, a shifting or a broadening of your perspective. You have added together insights and thought afresh about matters, perhaps more profoundly still about your attitudes, values and beliefs.

In this final boxed illustration we offer a passage of text within which such change, a revisiting of perspective is illustrated. Please read the text, decide what change you think the author might be making and then take a look at our last set of notes.

We hope that this guide has helped you and that reading our book will help some more. We wish you success in your studies!

An example of developmental reasoning that illustrates learning

Thinking about Mr Jones and the news that his cancer has recurred, something has shifted in my understanding of loss, grief and support. Mr Jones had reminded me that the body isn’t a constant, that that which was once resilient and strong when young, becomes vulnerable when you are older. He confronted me with the possibility that my body too could become diseased, that it would in some regard fail as the years went by. The reviewing of cancer recurrence then is referenced against these changing expectations of health and well being. As he put it to me subsequently: ‘Having cancer seems more normal when you’re 80 lass, but it still confirms something, it still tells you that you can’t go on forever.’

What seems important is that I don’t think of the body as something simply physiological and more or less functional. It is, and always will be, owned in some intimate way by the person who occupies that body. Individuals, Mr Jones and others, I too, develop attitudes towards our body. Yes, when the body wears a little, we may be more circumspect about its charms. We may laugh a little at it and remark on the aches and pains, the creaking and the crumbling. But we shouldn’t imagine that threat or damage to it is without distress, or loss and grief and this in a very individual way. The fact that something was excised from Mr Jones’ body and has recurred does not mean that tissue has been replaced, it means that something which was his has gone and something which is alien has taken its place. Yes cancer is more normal when you are old, but normal too is the attitude that it should be resisted, fought, and guarded against where possible.

Listening to Mr Jones I have been forced back on my thoughts about history taking. I have been forced to think afresh about what I really know about the patient’s experience of an ill body. To my discomfort I realised that I did not know so much. Yes, I knew about physical function and I knew about diagnosis and prognosis. I knew how a tumour might spread, and I knew what sorts of physical pain it could cause. But I did not know enough about the meaning of the body as it changes then. I did not know enough about how a patient reads his body when disease recurs. The only way that I can do this is to invite patients like Mr Jones to narrate their experiences more. I must set aside my concerns as to whether I can solve their problems, bring to bedside the solution, and simply accept that sometimes to nurse well is to witness what happens before me. This, I suspect Mr Jones will tell me, is no small thing. ‘No lass, it’s no small thing at all.’

There are three paragraphs in this passage. In the first of these the author reprises what has prompted her reflections. You met Mr Jones in a previous exercise in this handout. To help the reader appreciate how your thinking has changed, it is a good idea to remind them where your journey started from. The length and significance of that journey can only be appreciated if the reader understands where you started from and where you’ve got to. The paragraph already suggests significant thought. The body is not a constant, not a thing of health versus illness, but a thing of relative health beset with more or less threatening illness. The ambiguity of that is likely to distress a patient, something that the student hasn’t directly expressed, but which seems a developing theme in her writing.

The second paragraph shares a deduction, that the body has meaning through a sense of ownership. My body, this is where I live. This is what enables me to express myself. There is a good deal of literature on this and certainly references could be used here on embodiment, but nonetheless, the writing does suggest that the student is seeing the body afresh. The secondary point made is that an already damaged body might seem less threatened by recurring disease, but that we cannot know this for sure. It is necessary to understand how the patient interprets this new cancer assault.

The third paragraph carries the weightiest learning change points however. Notice how the student repeats the word ‘forced’. She conveys surprise, an unwillingness to change her thinking, but finally a compelling need to think again. There is a need to recognise her relative ignorance and to consider the ‘what next’ implications of this. If the only person who can tell her about such illness experience, to the body owned, is the patient, then she must give much greater attention to the narratives shared. The points about why this is not done already (not being sure we can do much with the information) seemed hurried to us. They are not fully developed points, but the conclusion being drawn remains powerful. To care is not always to solve something. To care may be to companion the patient in some way.

This passage represents a good audit trail of changing reasoning and at the end a quite powerful review of the nurse’s perspective. Few (we believe) would doubt that the nurse has taken something significant from this episode of care. The passage displays independent level reflective reasoning. The nurse is thinking outside her comfort zone and there is a significant chance now that she will reorder how she works with patients who face profound and distressing circumstances relating to the status of their bodies.

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