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paragraphs
The example assignment paragraphs presented in this guide relate to work discussed
Critical Thinking and Writing for Nursing Students, 3rd ed. London SAGE. The guide
there are four levels of reflective reasoning, extending from the least sophisticated
summarise those levels in the following table (see Table 3.2, Chapter 3 for a more
detailed breakdown).
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
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
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?
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
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
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
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
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
nurse should seek to improve her rapport building skill and so this reflection sounds
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
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
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
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 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
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
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
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
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
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.
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
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.
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
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
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
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
unprofessional and, at the very least, absolutist. You have not imagined how the
Here are three paragraphs of writing about others, but can you spot that which is
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
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
Example C: I had a more junior student with me to watch the wound cleaning
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
remember that even the descriptive passages can convey your attitude towards care
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.
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
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
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
Illustrating learning
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
expressed, and there may be caveats to note, but deduce you must if you are to
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
together insights and thought afresh about matters, perhaps more profoundly still
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
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
cancer seems more normal when you’re 80 lass, but it still confirms something, it still
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
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
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
The second paragraph shares a deduction, that the body has meaning through a sense
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.
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.