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 enquiryExample 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 correctlyExample 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?