EXAMPLE ESSAYS FOR

Critical Thinking and Writing for Nursing Students

Bob Price and Anne Harrington

CONTENTS: Example analytical essay - page 1 Example reflective essay - page 11

EXAMPLE ANALYTICAL ESSAY

ThisexampleofananalyticalessayispresentedinassociationwithPrice,BandHarrington,A(2010) CriticalThinkingandWritingforNursingStudents,Exeter,LearningMatters.Readersare introducedtotheprocessofcriticalandreflectivethinkingandthetranslationoftheseinto courseworkthatwillhelpthemtoachievebettergradesinnursingcourses.Stewart,Raymet,Fatima andGinaarefourstudentswhosharetheirlearningjourneythroughoutthechaptersofthebook.In thisessayontheevaluationofdifferentsortsofevidence,Stewartdemonstrateshiswritingskills neartheendofhiscourse.Stewartwassetthetaskofevaluatingdifferentsortsofevidencewithin nursingandmakingacaseregardinghowthenursemightproceed.Attheendoftheessayweoffer notesthatexplainthecriticalthinkingandwritingfeaturesofStewartswork. N.B.Remember,copyingessayssuchasthis,submittingthemasawholeorinpartforassessment purposes,withoutattributingthesourceofthematerial,mayleaveyouopentothechargeof plagiarism.Significantsanctionsmayfollowfornurseswhodothis,includingreferraltotheNursing andMidwiferyCouncil.

Evaluatingevidenceinnursing

Forreasonsofpatientsafetyandtheimprovementsinthequalityofhealthcare,nursesareurged tobasetheirpracticeonevidence(Barker,2009).Evidencetoomaybearguedasabasisfor arrangingthemostcosteffectivecare,usinglimitedresourcestobesteffect.Idefineevidence hereasconsistingofthatinformationthatthenursecanpointtoasauthoritative,beingmore thansimpleopinionorpredilectiontopracticeinaparticularway.Inpractice,theavailabilityof evidencemaybelimited,someevidencemaycontradictotherevidenceandthenursemust thereforemakejudgementsaboutwhatisfound(Jolley,2009).Itisnecessarytonotethat differentsortsofevidencemaybeusedtodifferentpurpose.Forexample,evidenceofhow patientsexperienceillnesscantellthenurseabouthowpatientsfeelandwhatmattersmostto them.Itcannotguidethenurseonwhatsortsofcarearemosteffective.Statisticalevidence, especiallythatoriginatingfromrobustexperiments,mighthelpthenursetodeterminewhat causesaparticulareffectandtodecidewhethertoarrangecaredifferently.Notallevidenceis thesamethen,someismorepowerfulthanothers,andafitbetweenevidenceandpractice 1

needstobedetermined(Brotchieetal,2010). InthispaperIfirstreviewthedifferenttypesofevidencethatmaybeavailabletothenurse.I thenusetheworkofProctorandRosen(2004)tohighlightpossiblefitsbetweenevidenceand effortstoimprovepractice.Thethirdpartofthispapersummarisespointsabouthowbestto judgethedifferentevidenceavailablethecriteriatobeusedwilldiffer,dependentonthe evidenceconsidered.Iarguethecasethatthenurseevaluatesevidencewellwhereheorshe understandsthenatureoftheevidence,establisheswherethatevidencemightservewelland makeswisejudgementsontheauthority,completenessandcoherenceoftheevidenceavailable.

Typesofevidence
Whilstevidencecanbeclassifiedindifferentways,Isuggestherethatitisusefultomake distinctionsbetweenresearchandexperientialevidenceinthefirstinstanceandthenwithin researchevidencetonotethattherearedifferentresearchdesignsthataffectthenatureof evidencepresented.Itmayseemcontentioustothinkofexperienceasaformofevidence,butin practiceitisfrequentlycalleduponasjustthat(e.g.Finlay,2009;Beametal,2010).Atits weakest,groupsofnursesdevelopaworkingimpressionofhowpatientscope,howcareis deliveredandwhatconsequencesemergeifnursingisdeliveredinparticularways.Inmy experience,nursesmightrefertothisaspracticewisdom,acollectiveknowhowthatseemsto workwellwithgivengroupsofpatients.Suchevidenceprovidesatbestafirstimpression,and overviewofissues.Itisenhancedwherethenurseplansreflectionandobservationmore carefully,withreferencetoparticularquestionsandfocusingperhapsoncasestudiesthatallow matterstobemappedanddiscussed(Leach,2007).Itincreasesstature,asevidence,tothe degreethatinformationisgatheredinadisciplinedandorganisedway,andwithastatedpurpose inmind.Thatexperientialevidenceisimportantinhealthcareisimportantisillustratedbythe analysisofcasestudiesincareandespeciallythoseassociatedwithriskmanagement(e.g. Stewart,2010).Nursesandothersmayanalysecasesinsomedepthtoestablishwhatwent wrong,whatwasmissedormisinterpreted,allwiththeaimofavoidingmistakesandofimproving performanceinthefuture. Themorefamiliarformofevidencethatmostcolleaguesrefertowhendiscussingevidencebased practiceisthatwhichemergesfromresearch(Barker,2009).Researchproducesevidence preciselybecauseofthedisciplinedwayinwhichenquiriesarearrangedandtheeffortsmadeto gatherdatathatattendtotheaims,questionsorhypothesesoftheresearchproject.Designsare influentialhere.Researchthathasbeendesignedwithinthepositivisttraditionworksassiduously toremovetheriskofresearcherbiasandtogathersufficientdataoftherighttypetomakeclaims aboutapopulationofpeople.Thereisanemphasisuponimpartialenquiry,withtheresearcher arrangingchecksbyotherssuchascriticalreviewerstoensurethatassumptionsarenot prematurelymadeaboutwhatisfound(Grix,2004). Otherresearchisconductedwithinthenaturalisticorinterpretivetradition(e.g.phenomenology, groundedtheory,someformsofethnography)andheretheworkproceedsdifferently.The researcherarguesthatitismoreimportanttoconductworkthatisauthentictohealthcare,than toconductastudythathasexcludingallpossibleformsofbias(Silverman,2004).Thegoalofsuch researchisoftentohelpothersportraytheirexperienceofhealth,illnessorcareandtohelp

nursesunderstandwhatpatientsandothersmightneedorhopefor(Brotchieetal,2010).The researchermightsuggestthatitisimpossibletocompletelydisassociatethemselvesfrom perspectivesorviewsthatcouldshapethelineofenquiry.Athirdresearchdesignmaybe describedascriticaltheory(Swartz,1997).Theresearcherstartswithacknowledgedgoalsto correctinequalitiesinhealthorcareandtomakeacaseforthedisadvantaged.Feministresearch forexampleacknowledgesthattheresearcherwillnotstanddispassionatelyasidewhen deliberatingonwhatneedstobediscoveredorhowevidencemightsupportacaseforchange. Sometimesnaturalisticandcriticaltheoryresearchisgroupedtogetherasqualitativeresearch becausetheyoftenproducequalitativedataandincontrasttothequantitativedatathat sometimesemergesfrompositivistresearch(GreenandThorogood,2009). Whatseemssignificantinthisoverviewofdifferentresearchdesigns,isthatthereisno universallyagreedgoalofresearch,noristheevidenceproducedallofonesort.Researchers adoptdifferentrolesdependingonthedesignofresearchused.Inpositivistresearchtheroleof theresearcheristypicallydescribedasdispassionateandtheyproceedtogatherinformation fromoutsidetheexperienceofothers(itisdescribedasetic).Innaturalisticandcriticaltheory researchtheresearcheroftenapproachestheirsubjectmuchmoreclosely,intimately,for exampleobservingandinterviewingasaparticipantinthesituationexplored(itisdescribedas emic)(Brotchieetal,2010).Togatherauthenticdatatheresearcherpermitsthemselvesto becomeinvolvedinproceedings,tousetheirownexperienceaspartoftheprocessof interpretingwhathasbeenwitnessed.Thesedistinctionsareimportantifthenurseisnottouse researchevidenceinappropriately,assomethingthatwasneverintendedbytheresearcher, makingclaimsthatareunsupportable.Theevaluatingnurseneedstounderstandtheresearch designaswellastheresearchevidenceonoffer.

Evidenceandpracticefit
Itistemptingtoarguethatonesortofevidence(positivist)issuperiortoallothersandthatitis uponthatwhichnursingshouldbebased.Thisisattractivewherenurseswishtohighlightnursing asascienceandwhereprecisionisakeyconsiderationincare.Itisextremelyattractivewhere thenursehastomanageriskanddefendactions,especiallyiflitigationisaconsideration.Nursing thoughdrawsuponmanydifferentsortsofevidenceandthisisinlargepartbecausethenurse workswithotherstomakesenseofhealthandillness(AveyardandSharp,2009).Ifthenurse helpsthepatienttodecidewhatchronicillnessmeanstothem,andtodevisecopingstrategies thatseemmanageable,theyareworkingtohelpothersmanageuncertainty.Therecanbeno singlegoldstandardsolution,becausepatientscircumstancesandneedsaredifferentandvery individual.Itfollowsthenthatresearchwhichattendstothisprocess,ofmakingsenseofwhat hashappenedandwhatmighthelpnowisalsovaluable.Suchresearchismorespeculativein nature,moretentativeasregardswhatcanbeprovenorclaimed.Nursingthenmayrequireboth hardandsoftevidence,thefirstconcernedwithwhatworks,whatissafeandbeneficialand thesecondassociatedwithprocess,howitfeelsorwhatitmeanstorecoverorrehabilitatefor example. ProctorandRosen(2004)describeastepwiseprocessforfindingandevaluatingresearchthat mightcontributetoevidencebasedpractice(seeTable1).Importantly,thepurposeofthe evaluationneedstobeunderstoodfirst.Whatoutcomesisthenursemostinterestedin?Itis 3

necessarytoreviewthatresearchwhichfitsclearlywiththeidentifiednursingneed,andfor ProctorandRosen(2004)thisislargelyaboutdemonstratingtangibleimprovementsincare (outcomes).InStep2thenurseselectsfromtheevidencereviewedthebestfittingintervention, thatwhichachievesthedesirableoutcome.InStep3thenursesupplementsormodifiesthe intervention,drawingupontheirexperienceandknowledge.Thisthirdstepcanseem contentious,butitisimportantwhereresearchwasconductedindifferentcontextstothe practiceconsidered,orwheretheresearchevidenceavailableisincompleteorperhaps contradictory.InStep4thenursemonitorsandevaluatesthechangedpractice,tomakesurethat thedesirableoutcomeissustained.

Table1:Developingevidencebasedpracticeguidelinesandanursingillustration(adaptedfrom ProctorandRosen,2004) Step Illustration Step1:Locateevidencebasedinterventions Thenurseisinterestedinhelpingpatientsto relevanttotheoutcomesofinterest. managetheirasthmabetter.Three interventionsarelocatedwithintheresearch literature,oneassociatedwithgroupteaching, anotherwiththeuseofvideotraininganda thirdlinkedtocoaching. Step2:Selectthebestfittinginterventionin Thenurseselectstheinterventionthat viewofclientproblems,situationand producestherequiredoutcome(patient outcomes. independence)andwhichalsoisaffordableand realisablegiventhetimeandexpertise available.Inthisexampleitmightbegroup teaching. Step3:Supplement/modifythebest Groupteachingiscosteffectivebutdemanding intervention,usingnurseexperienceand ontheskillsofthenurse,sotomakethiswork knowledgesothatitfitswithpracticecontext. moreeasily,ateacherguidancepackis produced,onethatwillleadtoconsistentand wellorganisedteachingsessions. Step4:Monitorandevaluatetheeffectiveness Overthenextyearthenursemonitorspatients oftheoutcome. levelsofselfcareandtheincidenceof readmissionstohospitalforasthmacrises. Expressedconfidenceandlowerincidenceof hospitalreadmissionareseenasindictorsof bettercoping.

InTable1itispossibletoimaginepositivistresearchbeingusedinassociationwithStep2(thesort ofresearchthatfocusesuponcauseandeffectrelationships),whilstnaturalisticandpossiblycritical theoryresearchmighthaveaparttoplayinStep3.Forinstance,therewouldbeacasetoconsider researchrelatingtopatientexperience(ofasthmaeducation)alongsidethatwhichsuggestedthe bestwaytoproceedifindependentlivingwasthegoal.Theroleofexperientialevidenceismuch lessclearintheProctorandRosen(2004)approachandforsomecolleaguesitmightbeseentonot havearoleatall.Nevertheless,experienceofparticularpatients,theirneedsandlevelof confidence,theskillsofstaff(inthisinstanceaspatienteducators)couldandperhapsshouldfactor indeterminingwhichinterventionisused.Coachingforexamplerequiresconsiderableskillsand longtermcommitment,somethingthatmightseemlessfeasiblehere. 4

Judgingevidence
Asdifferentevidenceisfound,thereisaneedforthenursetojudgeitsmerits(AveyardandSharp, 2009).Justhowtheevidenceisjudgedisassociatedwiththedesignoftheresearch,orinthecaseof experience,theprocessbywhichitwasgathered,collatedanddiscussed.Inpositivistresearch judgementfocusesupontheauthorityofthedesignandthisisjudgedusingthreequestions.First, wastheresearchethicalcanwereasonablydrawuponthisevidence?Second,whetherthe researchwasreliableifthestudywasdoneagain,wouldwebelikelytoobtainthesameorvery similarresults?Third,whethertheresearchwasvaliddiditasktherightquestions,attendtothe correctstudypopulationandsecureaviablesample?Inshort,didtheresearchmethodshelpthe researchersecureenoughoftherelevantinformationtomeettheaimsofthestudy,toanswerthe questionsorpermitthereviewofhypothesesstated?Whereinformationofthiskindismissingfrom theresearchreport,orthedesignarrangementsseemambiguous,doubtsareraisedaboutthe validityand/orthereliabilityoffindings. Differentjudgementcriteriaareusedwithregardtonaturalisticresearchandtheseareusually associatedwiththeauthenticityofdataobtained(Brotchieetal,2010).Thereviewersearchestosee iftheresearcherhasleftanaudittrailofhowtheresultswerearrivedatandhowfieldworkordata analysisdecisionsweremade.Theresearchismeanttotellastoryaboutthereasoningofthe researcher,sothatthenursecanestimatewhether(intheirexperience)theresultsreportedare likelytoberepresentativeofwhatresearchsubjectsmightreport.Judgementinthisresearch involvesagreateramountofwhatItermfreestylereasoning.Thenurseasks,dotheseresults seemlikely,importantandcentralgivenwhathasbeenwrittenandwhatIknowwithinmyown nursingwork? Judgingcriticaltheoryresearchseemsrathermoredifficult.Itentailsestablishingwhetherthe researcherhashonestlyandfullystatedtheirpremisesaboutthesubjectconcerned,the assumptionsthattheystartwithastheyconductresearch(Brotchieetal,2010).Itinvolves evaluatingwhethertheresearcherhasbeenclearaboutthecriticalfilter,thepremisesthathave beenusedtoselectdataforcollectionanditsinterpretationafterwards. Judgingexperientialevidenceisdifficult.Whilstreflectiveframeworksfocusontheanalysisof experience,mostoftheseoperatetootherpurposes,typicallythedevelopmentofthenurses thinkingskills(JohnsandFreshwater,2005).Theyarenotyetusedtoimprovethequalityof healthcareexperiencereporting,asasofterformofevidence.Questionsthatmightbeusedto distinguishmoreconvincingexperientialevidencethoughinclude: Havequestionsbeenusedtofocusthereflectionsundertaken? Havethereflectionsbeenrecordedsoonaftertheexperienceiscomplete? Havethereflectionsbeendiscussedbyagroupofpractitionersworkinginthesame area(e.g.apracticereviewgroup?) information

Haveeffortsbeenmadetorefineorimprovethereflectiveactivity,sothat isbetterunderstood?

Conductingreflectionintheseways,asacollectiveandcriticalactivityaddsdisciplinetotheprocess andenablesthereviewertoweighthepointsbeingmadeasaresultofthereflectionsundertaken.

Evaluationproblems
Whatbringstheabovethingstogether,anunderstandingofthedifferenttypesofevidence,a processforrelatingevidencetoachosenpracticeandthejudgingofthequalityofevidence;is systematicevaluation.ProctorandRosen(2004)demonstratesuchasystematicapproach,although inthisessayIsuggestthattheevaluationmightconsidermorethantheauthorsoriginallyintended.I proposethatitcouldbeusedtodescribehowresearchandexperientialevidencecouldbe combined.Thenurseascertainswhatworksandthenconsiderstheprocessofworkingtowardsa newpracticethatwhichisrealisable. Whatisburiedherearethedifficultdecisionswhenevidenceispatchyandcontradictory.Notonly mighttherenotbeenoughresearchevidence,buttheevidencefromexperiencemightbe inconclusiveaswell.Thenurseisleftwithapartialpictureofnursingcare,whatmighthelppatients, howpatientsexperiencethatcareandwhatwouldenablethenursetoproceeddifferently.Under theseconditionsitmaybeimpossibletoevaluatetheevidence,atleastbeyondnotingthatitis incomplete,contradictoryorincoherent.Thenthenursehastoproceedwithnewinvestigations, eithermoreresearchorreflection,sothatthevolumeandqualityofevidenceincrease.Inthe meantime,nursingcarecontinuesbasedupontraditionorwhatmightbeconsideredcommon sensesolutions(i.e.thosethatthenursebelieveswillhelpbutforwhichthereisnoproofof success).

Conclusions
Thisessayhasdescribedthedifferentcomponentsofworkasanurseevaluatesevidence.Itsuggests thatthenursehastohaveagoodappreciationofthedifferenttypesofevidenceandwhatisoffered there.Failingtoappreciatethatcouldleadtothenursedistortingtheevidence,usingittopurposeit cannotsupport.Clarityisneededtoothoughasregardswhatpurposetheevidencereviewhasto serve.Whatdowereallywanttodoorknowhere?Beforethenursecanconcludewhatthe evidenceoffers,heorshemustevaluatethemeritofindividualevidencesomethingeasiertodo withregardtoresearchwheretherearelongerestablishedcriteriabywhichtomeasurethequality ofwork.Insomeinstancesthenursemusthonestlyconcedethatthereisinsufficientclearor coherentevidencetorecommendaparticularwayforward. Thecasestatedatthestartofthispaperdoeshoweverseemsupported.Consideringeachofthe abovethings,thenurseevaluatesevidenceinamoremethodicalwayandusingrelevantquestions tojudgewhathasbeenfound.Itispossibleforgroupsofnursestoworktogethertoevaluateto clearerpurpose,insteadoftheadhocwaythatindividualnursesmighthavedoneinthepast. Withoutanunderstandingofeachoftheabove,nurseswouldnothaveidentifiedconsistentwaysto engageinevidenceevaluationsomethingthatisimportantifnursingistodevelopareputationfor evidencebasedpractice.

References
Aveyard,HandSharp,P(2009)Abeginnersguidetoevidencebasedpracticeinhealthandsocial care,MiltonKeynes,OpenUniversityPress/McGrawHill Barker,J(2009)Evidencebasedpracticefornurses,London,Sage Beam,R.,OBrien,Randneal,M(2010)Reflectivepracticeenhancespublichealthnurse implementationofnursefamilypartnership,PublicHealthNursing,27(2),131139. Brotchie,J,Clark,L.,Draper,J.,Price,BandSmith,P(2010)Designinghealthcareresearch(K824 StudyGuide)MiltonKeynes,TheOpenUniversity Finlay,I(2009)Developingatemplatetoplanpalliativecareservices:theWelshexperience,Journal ofPainandSymptomManagement,38(1),816. Green,JandThorogood,N(2009)Qualitativemethodsforhealthresearch,2nded,London,Sage Grix,J(2004)Thefoundationsofresearch,Basingstoke,PalgraveMacMillan Johns,CandFreshwater,D(eds)(2005)Transformingnursingthroughreflectivepractice,2nded. Oxford,Blackwell Jolley,J(2009)Introducingresearchevidencebasedpracticefornurses,Harlow,Pearson Educational. Leach,M(2007)Revisitingtheevaluationofclinicalpractice,InternationalJournalofNursing Practice,13(2),7074 Proctor,EandRosen,A(2004)Concisestandardsfordevelopingevidencebasedpracticeguidelines inRoberts,AandYeager,K(eds)Evidencebasedpracticemanual:researchandoutcomemeasures forhealthandhumanscience,Oxford,OxfordUniversityPress193199. Silverman,D(2004)Qualitativeresearch;theory,methodandpractice,2nded.LondonSage. Stewart,D(2010)Diagnosisandmanagementofanadultpatientwithanatrialseptaldefect,Nurse Practitioner,35(2),811. Swartz,O(1997)Conductingsociallyresponsibleresearch:criticaltheory,neopragmatismand rhetoricalenquiry,ThousandOaksCalifornia,Sage.

Ournotes
Youmightbestruckuponfirstreadingjusthowpolishedthisessayisandwonderwhetheryoucould producesomethingquitesoconvincing.Beforeyoujudgesuchthings,rememberthata)Stewarthas receivedparticularteachingonevidencebasedpracticeandb)thatheiswritingattheendofhis course.Hiswork,ashewouldconcede,wasnotalwayssowelldeveloped!Seebeyondthepolish thenandconsiderthestructureofthisessay.Lookbeyondwhetheryouagreewithhispoints,for exampleaboutwhatdoesordoesntconstituteevidence,todeterminehowhebroughtinformation togethertocreatethefinalimpressionofthiswork.

Theintroduction
Theintroductionconsistsoftwoparagraphs,thefirstofwhichisdesignedtocapturethereader's interestandestablishwhatheiswritingabout,andthesecondofwhichisusedtosignposthowthe restofthepaperissetoutandthecasethatheismaking.Stewartcapturesourinterestbylinking hispapertotheimportanceplacedonevidencebasedpracticeinnursingtoday.Thisisnota whimsicalorpassinginterestnursesneedtoknowaboutit!Inthesecondparagraphhesetsout hiscasebrieflyandclearly.Inanalyticalessays,especiallyasinthisinstancewhentheyevaluate whatisinvolvedinparticularnursingwork,statingthecaseisveryhelpfulindeed.Itindicatestothe readerthattheauthorknowswhereheisgoing,whatheistryingtodemonstrateinthepaper.Itis almostasthoughwearechallengedbythecase.DoIagreewiththis?DoIthinkthatthesethings wouldleadtobetterevaluationofevidence?Asaresultwereadthepapermoreattentively. ThisisquiteasophisticatedsubjectsothereareanumberoftermsthatStewartneedstouse.He neededtodecidewhichhewouldassumethatthereaderunderstoodandwhichwouldneedtobe defined.Inthisexamplehedefinesevidenceasheusesitinthiscontext.Youcouldconsiderthatit mightstrengthenapaperifyouusedapublisheddefinitionofatermsuchasthis.Inthisinstance though,asheismakinghisownpointaboutwhatconstitutesevidence,somethingmorethansome othersmightinclude,hesetsouthisowndefinition.Whilstitisrighttodrawthereadersattention toreferencesources,andtobuildthesetogetherinsupportofyourowncase,itisstillnecessaryfor youtohaveadoptedapositionofyourown.Simplyreportingeveryoneelsescase,theirarguments, willnotusuallybeenoughtosecurethebestpossiblemarks.Thisisakeypointinlearningtothink critically.

Typesofevidence
ThecraftingoftheparagraphsinthissectiontookStewartsometime.Eachhadtosummariseatype ofevidenceclearlyandsuccinctlyandinsuchawaythatthereaderunderstoodwhathebelieved. Thereisagreatdealofcompressionofinformationhere,hesummarisesagreatdealandthereisa realriskthathecouldoversimplifyormisrepresentpointsifheincludestoomuch.Hegoesstraight intoanargumentthatexperience,whenobservedandreflecteduponadequately,canconstitutea typeofevidence.Thisisperhapscontentious,butbymakingthisargumentfirst,heensuresthathe setsoutarobustposition.Iamwritingaboutthisfirst,becausethisiswhatIbelieve.IfIwrote aboutitlastinthissection,itmightseemlikeanafterthought.Noticehowheusesexamplesfrom practicetoreinforcehisclaimregardingthecredentialsofexperientialevidence.Audit,riskanalysis work,reviewsofcasesthathavegonewrong,allhighlighttheimportanceofexperiencetopractice.

Later,Stewartwillarguethattoimprovethecredentialsofsuchevidence,reflectionwillneedtobe moresystematicandcollective. Paragraphdisciplineisimportantwhenyoutrytoconveyagreatdealofinformationinasmall volumeofwords.Makesurethateachparagraphisaboutaclearsubject(inthiscase,thedifferent typesofevidence)andthatwithinthoseparagraphsyouavoidexcessivelylongsentences.Try readingaloudthesentenceifyoufindyourselfpausingforbreath,itmayalreadybetoolong. Thelastparagraphinthissectionisespeciallyimportant.HereStewartshowshisreasoningasthe essayproceeds.Hemakessomejudgementsaboutresearchevidenceasaformandnotesthatitis veryvaried.Itreallywouldbetoosimpletodescribeitasonething,somethingtobecontrasted againstexperientialevidence.Itismanythings,andthenurseneedstounderstandeachifthe evidenceistobereviewedwell.

Evidenceandpracticefit
First,wemaketwostylisticpoints.NoticehowStewartisusingsubheadingstohelpthereader navigatehisessay.Historically,subheadingswerenotusedwidelywithinacademicessays,butwe suggestthattheyarevaluable.Ifyouwerewritingfornursingjournals,youwouldalsousesub headingstoguidethereader.Second,noticetheuseofthetable.Stewartusesthistoconvey informationquicklyandclearlyandcombinesthatprovidedbysomeotherauthors(leftcolumn) withpointsofhisown(rightcolumn).ThesourceofinformationisattributedandStewartbegins hereanillustration(asthma)thatwillhelphimtoexplainimportantpoints.Stewartshouldadd referencestothethreeapproachestoasthmaeducation,astheywouldnormallycomefrom publishedwork.HereStewartisusingideasasanillustration,itisanexampleonlyofwhatmightbe found.Byandlarge,assessorswillpreferthatstudentsdrawuponactualexamplesfromthe literature,demonstratingthestudentsworkwithinthelibrary.Imaginativeandpertinentthough Stewartsworkis,itonlyshowswhatmightbepossible,thestrongercasedrawsonthatalready arguedordemonstratedelsewhere. Ifthelastsectionwasmadeofparagraphargumentsaboutwhatcountedasevidence,thissection setsouttoarguethataprocesscanhelpexplainhowevidenceandpracticerequirementscanbe matched.HeusesProctorandRosens(2004)frameworktoshowthisworkinaction.Atthispointit wouldbeeasytowriteextensivelyabouttheframework,whereitcamefrom,whodesignedit,but todosowouldbeadistraction.Frameworksofthiskindareheuristic,thatis,theyserveapurpose, andrightnowthisistoshowhowdifferenttypesofevidencecouldserveastatedpurpose.Ourown viewofthisisthatStewartmanagesthisratherwell,withthepossibleexceptionofhislastpoints aboutdrawingexperientialevidenceintotheprocess.Stewartisboldhere,hesuggeststhat experientialevidencehasaroletoplay,butperhapsthisisnotapointfullysubstantiateduntillater, whenhedescribeswhatisrequiredtomaketheevidencemorerobust.

Judgingevidence
Thisisanothersectionwhereinformationhasbeencompressed.Wholetextbookshavebeen writtenonhowtoevaluateresearch!Nonetheless,ifStewartistosupportthecasethatthisworkis butapartofevidenceevaluation,heneedstoconveytheessentialinformationquicklyandclearly. Largerdebatesandexplanations,forinstanceaboutthedifferentsortsofvalidity,cannotfindspace 9

hereandwewouldsupporthisselectionofpoints.Validity,reliability,authenticityandaudittrailare importantconsiderationsinjudgingresearch.Hadwewishedtoaskforfurtherelaborationonanyof them,itwouldbeimportanttoalsosuggestwhatelsehemighthaveomittedinthisessaytomake roomforthis. Noticehoweachgroupofjudgementsisassigneditsownparagraphthisaddstotheoverall impressionofadisciplinedessay.Attheend,inthefinalparagraphheusesbulletpointsto introducehisownrecommendedcriteriaforjudgingexperientialevidence.Thisisanotherboldstep, onethatdemonstratesthatStewartisreasoningconfidently.Irrespectiveofwhetherreadersagree hisstancehere,wethinkthattheseareindeedthingswhichwouldmakereflectionmore systematicmoredisciplinedinwaysthatwemightexpectifevidencewastoresult.

Evaluationproblems
ItwasatthisjuncturethatStewartrealisedsomethingwasmissing.Hisoriginalessayplanhadnot includedthissection!Whenhewasplanningtheessay,hethoughtthatiftheabovethree componentsofevidenceevaluationwerearguedthathewouldhaveaconvincingaccountofwhat evidenceevaluationentailed.Theproblemisthatevidenceisrarelythatcomplete,coherentorneat. Sotheadditionofthissectionnicelyhighlightsthentheneedtostopandpausesometimesandto considerwhetherwhatyouhavewrittenisadequate.Stewartneededtoaddsomethingmore,and hadsomewordspacetodothis.That'something'wasaboutwhathappenedifthecomponentparts oftheevaluationwerenotenough,iftheydidnotsuggestabestwayforward. Thisisquiteashortsection,andperhapsyoufeelthatStewartdidnotquiteclinchthepoint?Itis notmerelythecasethatsometimesthatevidencedoesnotcometogetherwell,orthatitis incompleteorcontradictory, itisthattheworkingwithuntidy,incompleteandsometimesconfusing evidenceisfrequentlyachallengeforthenurse.Thesuccessfulevaluatorofevidenceconfrontsthis confidentlyandispreparedtoargue'wedonthaveenoughevidenceheretoproceed'.Decision makingatthispointpossiblydistinguishesthemorefromthelesssuccessfulevidenceevaluators!It perhapsrequiresgreatintegritytomakethisdecision,whenthepressurebuildstochangepractice insomeway.

Conclusions
Conclusionshavetworoles.Thefirstistosummarisewhathasalreadygonebeforesomethingthat Stewartdoesinthefirstparagraph.Thesecondistodemonstratetheauthorsdeductionsabout whathasgonebefore.Inthisinstancethatisthatthecasehesetoutatthestartoftheessayis supported.Stewartarguesthatsuccessfulevaluationisfoundeduponamixtureofthingsandthe moresystematicallytheseareconducted,thebetter.Hisessaywouldbeevenstrongerifhehad arguedthattheprocesswastransparenttootherswholistenedtothecaseforchangemade afterwards.

10

EXAMPLE REFLECTIVE ESSAY

ThisexampleofareflectiveessayispresentedinassociationwithPrice,BandHarrington,A(2010) CriticalThinkingandWritingforNursingStudents,Exeter,LearningMatters.Readersare introducedtotheprocessofcriticalandreflectivethinkingandthetranslationoftheseinto courseworkthatwillhelpthemtoachievebettergradesinnursingcourses.Stewart,Raymet,Fatima andGinaarefourstudentswhosharetheirlearningjourneythroughoutthechaptersofthebook.In thisessayontheassessmentofpain,Raymetdemonstratesherreflectivewritingskillsneartheend ofhercourse.Raymethadbythisstagewrittenseveralreflectivepracticeessaysandgainedgood marks.Thistimethoughshewasencouragedtodeepenherreflections,speculatingselectivelyon howtheaccountofpainexperiencedbyapatient(MrsDrew)mighthelphertoworkmorecreatively withpatientperceptionsandreportedneeds. N.B.Remember,copyingessayssuchasthis,submittingthemasawholeorinpartforassessment purposes,withoutattributingthesourceofthematerial,mayleaveyouopentothechargeof plagiarism.Significantsanctionsmayfollowfornurseswhodothis,includingreferraltotheNursing andMidwiferyCouncil.

AssessingMrsDrewsPain
McCafferyandPasero(1999)statethatpainiswhatthepatientsaysitis.Ifweacceptthatpoint, thennursesneedtoexplorethepatientsperceptionsofpain,aswellastheirreportofexperiences. Thetwoarenotquitethesame.Patientsmayreporttheirpaininavarietyofways,dependenton thenatureandtheintensityofpainandthecontextinwhichitisfelt(e.g.whethertheyareever distractedfromthepain).Theirperceptionofpainisalittlemorethoughanditincludesthe meaningthatthepainhasforthem.Itincludesexplanationofwhythepainisthereinthefirstplace, whatitindicatesabouttheirbodyandwhatitcouldsuggestmighthappeninthefuture(getting better,gettingworse).Thenurseassessestheaccountofpainsharedbythepatient,andthismaybe givenintheformofastory.Thisishowitbegan,thisishowitfelt,thisiswhatthatmeanttomeand thisiswhatIdidaboutit(Mishleretal.2006) InthisessayIexploretheassessmentofpainasconductedwithone60yearoldpatientwhomIwill callMrsDrew.Whilsttheessaydescribesanassessmentofpainwithasinglepatient,Itrytoshare toosomeideasandquestionsthatthisprovokeswithinmeaboutpainassessmentmoregenerally. MrsDrewmademethinkaboutotherpatients,futureassessmentsandwhatIhadtodoasanurse tohelppatients.TohelpstructurethisessayIusetheframeworkdescribedbyGibbs(1988).Whilst theepisodeconcernedrelatesastageinMrsDrewsillnesswhenshechallengedhertreatment protocol,italsoincludessomeofthememoriesandthoughtsthatthispatientreferstoregarding herearlierillnessandpastwaysofcopingwithpain.Inparticular,itpromptedmetoquestionto whatextentIasanurseshouldrecommendanalgesia,drawingonwhatIhadbeentaughtaboutthe effectivecontrolofpain.Ihadlearnedthatitwasbettertocontrolratherthantochasepain(e.g. MannandCarr,2006;Forbes,2007). MrsDrewwasdiagnosedwithlungcancerayearearlierandhadinitiallyhadherillnesstreatedby chemotherapy.Thishadhelpedhertoachievearemissionthatlastedfornearlytenmonths(Huntet al,2009describetheprognosisofthisdisease).Thecancerhadreturnedthoughandspreadtoher 11

spineanditwasherethatsheexperiencedmostofherpain.Itwasatthisstagethatthedoctors explainedthathercarewouldnowbedirectedtowardshercomfortratherthanacuretowhich shehadreplied,youmeanpalliativecare.MrsDrewwassupportedathomebyherhusbandNeil andvisitedonaregularbasisbycommunitybasednursestowhomIwasattachedaspartofmy studentnursetraining.Shewasprescribedoralmorphineandcoulddecidewithinstatedlimitshow manytabletsshecouldtakeinanyone24hourperiod.

Thesituation
IhadvisitedMrsDrewonseveraloccasionsovertheperiodofamonthwhenthecommunitynurse andIwereconfrontedbyatearfulpatientwhoannouncedthatshedidnotwishtotaketheoral opiatesquiteasoftenaswewererecommending.Asshespokesheheldherhusbandshandtightly, lookingacrosstohimasshedescribedherexperiencesandfeelingsaboutthematter.Yes,therehad beensomebadnightswhenthepainhadwokenherandshehadtositupandwatchtelevisionto tryanddistractherself.Yes,sometimesthepainmadeherfeelnauseous,butshewasalarmedat howfrequentlyshewastakingthepaintabletsandhowthismadeherfeelaboutherself.However wellmeantthemedicationwas,itdidntfeeldignifiedtobesoreliantondrugs,orquitesosleepy andunresponsiveforsuchahighpercentageoftheday.Whilsttheanalgesiawasworkingwellwhen shetookthetablets,thequalityoflifewasntwhatshewanted. ThecommunitynurselistenedpatientlytoMrsDrewandthenexplainedthatitwasnormaltohave panicmomentsaboutsuchmedication.Morphinehadareputation,onethatpeopleassociated withmisuseofdrugs,ratherthantheirtherapeuticuse.Usedonaregularbasis,thedrugwouldnt causeaddictionanditwouldprovideagreatdealofreassurancetoMrDrewaswell.Thecommunity nursestatedthatshewasquitesurethatherespectedhiswifesneedtosleepwhenshewishedand tobuildtherhythmofthedayaroundherneeds. AtthispointMrsDrewshookherhusbandshand,andsaid,tellhertellherwhatwevetalked about!MrDrewthenexplainedthathiswifewasusedtodealingwithpain,shehadsuffered recurrentpaininherneckandshoulderafteraroadtrafficaccidentsomeyearsbefore.Thepainhad sometimesbeensevere,buthehadmassagedhershouldersandusedheatpacksthatshefound soothing.Theyhaddecidedthattheywishedtousethistechniquenow,keepingthemorphinefor absoluteemergencies,whenshewaslosingsleepandcouldnteatasaresultofthediscomfort. Thecommunitynurseassuredthemthattheywereinchargeoftheanalgesiaandwouldbeallowed tomaketheirowndecisions.Shestartedtomakenotesthough,andannouncedthatshewas makingareferraltothecancerpainclinic,somethingthatwouldhelpthemtotakestockofthe situation.Therewasverygoodreasontosupposethatthismightbeaproblemassociatedwith choosingtherightdosageofthemorphine,ratherthanusingsupplementalpainreliefmeasures. MrsDrewrespondedsharply,YourenotlisteningtomethoughJane(thecommunitynurses nameapseudonymisusedhere),Iwanttouseheatpacksinsteadofmorphine,atleastduringthe day.Iwanttobemorealivewithmyhusband.ThecommunitynurseassuredMrsDrewthatshe hadheardwhatshehadsaidandrespectedherpointofview.Therewouldthoughbenothinglost byusingtheclinictogainafurthercheckonthismatter.Withthatsheexcusedus,explainingthat wehadafurtherappointmentthatmorningandweleft,havingcheckedthatMrsDrewhada sufficientsupplyofherdifferentmedicines.

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AswewalkedtothecarthecommunitynurseempathisedwithMrsDrewsplight,sayingthatifshe hadlungcancershewouldprobablygraspatstrawstoo.Shewouldreachoutforthingsthatseemed morenormal,andthenobserved,butthisisntnormalisit,thepainshehasisntnormal.Itsnot justawhiplashinjuryandoldage.

Feelings
Irememberthatduringthisepisodefeelingamixtureofconfusion,surprise,angerandimpotence. MrsDrewhadsurprisedmebythewayshehadspoken,usingwhatseemedtobeaplanned announcement.Theyhadwaitedforandperhapsrehearsedthismoment.Nothinginmyexperience todatehadpreparedmeforsuchanencounter,atleastinsuchcircumstances,whereweasnurses weresoobviouslyworkingtosupportthepatient.ItwasonlylaterthatIcalledtheepisodea confrontation.MrandMrsDrewhadconfrontedthecommunitynurseandIhadbeenthelargely silentwitnesstotheevent.AsthediscussionproceededIremembermakingsupportivenoises, remarkinghowusefulheatpackssometimeswereandglancingacrossatJane,whoseemedtobe signallingwithherexpressionthatIshouldleavethisdebatetoher.Iwastryingtoreadher reactionstotheDrewspointsandconcludedthatifIcouldntsupportherargumentstothepatient, thenIshouldremainsilent.TherewereissuesherethatIperhapshadntenoughexperiencetodeal with,atleast,whilstthinkingonmyfeet. Myinitialanger(withMrsDrewfornotacknowledgingallthatweweretryingtodo)quicklybecame displacedtowardsmycolleagueJane.DuringtheeventIcouldntexplainwhythatwas,but afterwards,whenImadenotes,Irealisedthatitwasbecausesheseemedtohavesettheagendain herownmindandtoberequiringthepatienttocomplywithconcernsofherown.Putrather crudely,Janeseemedtobesaying,listenIknowaboutthesethings,thisisaphase,ananxiety;you canworkthroughallthis.Ibelievedatthispointthatshehadmissedthesignificanceoftheevent, thewayinwhichtheDrewshadarrangedtheconversation.Forthem,thiswasnotaphaseatall, butaconsideredandveryimportantdecision,onethattheywantedthenursestoaccept (Freshwater,2002andEdwardsandElwyn,2009emphasizetheimportanceofnegotiatedcare planning). Myfeelingsofimpotencewereassociatedstronglywithmylackofclinicalexperience.Ihavemet thisbefore.NomatterhowmanyplacementsIdo,nomatterhowgoodthementoringIreceive,I keepmeetingsituationswhereIamunsureabouthowtorespondnext.Ifeelyounger,less knowledgeablethanIshouldbeatthisstageinmytraining.Iwanttoreassurepatients,tosupport colleaguesandtogivegoodadvice,butthereisnotenoughconfidencetodothat.IfIfeltunsettled anduncertainaboutJanesresponsetotheDrews,rightthenIcouldnteasilyexplainthat.I couldntofferasecondopinion,couldntsuggestanideathatmighthelpsupportthepatient.Tomy annoyanceIcouldntmanagethateitherasweleftthehouse.Janehadmadesomefairpoints,she clearlyseemedconcernedaboutthepatientsneeds,butperhapsshehadntspottedtheright needforMrsDrewtodetermineingreaterparthowshedealtwithherillness.

Experienceevaluated
Afterwards,thisshortepisodeprompteddoubtsanddebatesaboutseveralimportantaspectsof nursingforme.Settingasidetheetiquetteoflearninginclinicalpractice,notchallengingaqualified nurseinfrontofapatient,therewereproblemshereassociatedwithsupportingpatientdignity, 13

withmyassumptionsrelatingtoanalgesiaandpaincontrolstrategies,andIrealised,withmy assumptionsabouttypesofpainandwhohadtheexpertisetodefinethese. Dignityismorethansimplyusingtheappropriatetermsofaddress,protectingtheprivacyof patientsandattendingtotheirexpressedconcerns(Price,2004).Itisaboutclarifyingthewaysin whichtheyliveandaccommodateillnessortreatment.Itisaboutfindingoutwhatbenchmarksthey usetosaythatyes,Iamdoingwellhere,thismakesmefeelgoodaboutmyself.Uponreflection,I sensethatweonthisoccasionhadnotworkedhardenoughtodiscoverhowMrandMrsDrew definequalityoflife,orbeinginchargeoftheirsituation.Weweremoreconcernedwithproviding resources,sharingresearchortheoryaboutmedicationandquestioningthefamiliarmisconceptions associatedwithmorphine.Toputitsimply,weweremissingatrick,readingtheencounteras somethingthathadhappenedmanytimesbeforethereportofproblemsoranxieties,arequestfor help,ratherthanadecisionthatthepatientandhercarerhadalreadycometo.Readingsituations wellseemed,withthebenefitofhindsight,tobethefirstbasisfordignifiedcare.Whatishappening here,whatwillhelpthepatientmost?werequestionsthatweperhapsassumedthatwealready knewtheanswerto. IrealisedthatinmytrainingIhadalreadyacceptedtheargumentthatpatientswouldwishto remainpainfreecomewhatmayandthatthetacklingoffearsaboutprospectivepain,was somethingthatnursesengagedin.Iassumedthatbecausecancerpainrepresentedsuchamajor threat,becauseitwasgreaterandmoreallencompassing,thattherewaslittleornodoubtthatit shouldberemoved.Whatwassounsettling,andtooksomuchtimetoexamine,wasthatMrsDrew acknowledgedthepossibleseverityofmetastaticcancerpain,butthatshestillpreferredtorespond toitusingmeasuresthathadworkedforherwhiplashneckinjury.MrsDrewwaswillingtotradeoff apainfreestateforsomethingthatgaveheragreatersenseofcontrolandwhichperhapsenabled herhusbandtoexpresshissupportforherinaverytangibleway(preparingheatpacks,massaging herback,ratherthansimplygivingherthetablets).MrandMrsDrewquestionedallmyassumptions aboutbestanalgesiapractice,andseemedtowritealargequestionmarkonthetextbooksIhad readaboutchasingratherthancontrollingpaininpalliativecaresituations(MannandCarr,2006).

Reflections(learningopportunities)
TheepisodewithMrsDrewleftmeuncomfortablebecausemypastapproachtopainmanagement wastheoretical.I(andIbelieveJanetoo)regularlymadeuseofsciencetodecidewhatcouldbe doneasregardspainreliefandtoassumethatpatientswouldwishtoachieveallofthosebenefits. Thiswasntaboutlocalapplicationsofheatversusmorphine,MrsDrewcoulduseboth,itwasabout choiceandhowpatientsmadechoiceswhytheyreachedthedecisionsthattheydid.Itwasforme, aboutacceptingverypersonally,thatprovidingthatpatientsaregivenalltherelevantfacts,alerted totheoptions,thattheyreallyareabletomakechoicesthatworkforthem.TheveryfactthatMrs Drew'sillnesswasnowincurable,thatsheandherhusbandusuallytackledpaintogether,meant thathersolutiontothechallengewasdifferenttothosethatmanyotherpatientsarrivedat.Having dealtwiththispainforsometime,knowingthatitcouldandprobablywouldgetworse,meantthat shewasbetterequippedthanotherlessexperiencedpatientstomakeadecisionhere. Thistooknothingawayfromthebenefitsofsharingfurtherdiscussionwithpainclinicexperts.I thought,MrsDrewwillstandherground,shewillinsistondoingthingsherwayifherhusbandis

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strongtoo.Whatitdidhighlightthoughwastheimportanceoflisteningtopatients,hearinghow theyperceivepain,howtheynarratenotonlythepainbutwhattheydidaboutit.Inthisinstance thenarrationwasallaboutdignity,andcoping,andfindingwaystohelponeanotherandhowthis enablesustofeelinthefaceofsuchaterribleillness.So,intellingusaboutherpain,whatshedid aboutit,usingmorphinewhenitwasabsolutelyrequired,MrsDrewwasnotreportingher ignoranceofwhatcouldbeachievedifthemedicationwasuseddifferently,butwhatshepreferred todoasitenabledhertoachievedifferentgoals.MrsDrewsgoalswereaboutliveliness,alertness andstoicism,showingthatshecouldbearatleastameasureofpain. IwonderedwhyIhadntlistenedcarefullyenoughtosuchastory?Wasitbecauseoftimepressure, orperhapscomplacency,thatJaneandIfeltthatwealreadyknewwhataccountwouldbeshared? Didwethinkthatthepatientwouldaskforhelp,morehelp,asthepaincontinued?Ifso,thenour guesseshadpromptedustobehaveasexperts,andproblemsolvers,onthepatientsbehalf. Perhapshearingapatientnarrativeisaboutdiscoveringwhatsortofroletheywouldlikeyouto fulfil.Ifso,thenitmightbeadifficultrole.IthoughthardabouthowhardthiswasforJane.Shewas goingtobeaskedtowitnessMrsDrewsfuturepain,onethatwasnowlessperfectlycontrolled.She wasgoingtobeaskedtoreassure,tosuggestmeasuresthatmighthelp,withoutremindingthe patientthatshealreadyknewthatyoucouldntmanagepainthatway!WhenIthinkaboutitnow, thatisverystressfulforanurse.Itisaboutcaringandallowingpatientstomakechoicesthatwe personallymightnotmake.

Conclusions
Ihavedrawnthenthreeconclusionsfromtheabovereflection. First,thatbeingpatientcentredisnevereasyandrequiresreallisteningandinterpretationskills.My criticismofwhatJanechosetodo,totryanddissuadeMrsDrewfromacourseofaction, recommendingfurtherappraisalofthesituation,isaneasyonetomake.Nursesconfrontsituations suchasthisrelativelyunpreparedandreactasconsideratelyaspossible.Itiseasyinhindsightto recommendotherresponses,afurtherexplorationofwhatmotivatedMrsDrewspainmanagement preferences. Second,thatexperiencecanbeavaluableteacher,theequaloftextbooks.Ifnursesareinterestedin care,thenweshouldbeconcernedwiththesensethatpatientsmakeoftheirownillness,the treatmentorsupportthattheyreceive.Weneedtounderstandwhatpatientshavetoteachusand havetoacknowledgethatthismeansthatwewontalwaysseemincontrolourselves,expertand knowledgeable.Ourexpertisemightbeelsewhere,helpingpatientstoreachtheirowndecisions. Third,thatonewaytounderstandpatientperspectivesonillnessortreatment,onpainmanagement inthisexample,istohearhowtheytalkaboutthesituation.Howdotheydescribethepain,howdo theyrefertowhattheydidaboutit?Thewayinwhichthestoryisshared,howwecoped,howthis madeusfeel,isasimportantasthefactsrelated.Sometimesapatientneedstofeelstalwart,even heroicinthefaceofillness.

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Futurecare
Itwouldbefoolishandunprofessionaltorecommendtootherpatientsthattheymightnotwishto removepain,orthatovercomingpaindoesntalwaysmeanwedontcontinuetoexperienceit.For everyMrsDrewtheremaybemanyotherpatientswhowouldwelcomethecompleteremovalof pain,sothattheycandiecalmly,quietly,withtheirownversionofdignity.Butitdoesseemtome, thatitwillbeworththinkingaboutthediversityofpatientsandhowtheyprefertocopewhenI assesspainandhelpmanagethisprobleminthefuture.Iwontbeabletowalkawayfromthe responsibilityofdebatingwhetherIhaveexplainedallthatIcould,detailedthestrengthsand limitationsofdifferentwaysofcoping.Iwillneedtofindreflectiontimetoponderwhatpatients havesaidandifnecessarytogobackandsay,Ivebeenthinkingsomemoreaboutyourwordslast week..knowingthatthisdoesntmakemeanythelessprofessional.

References
Edwards,AandElwyn,G(2009)Shareddecisionmakinginhealthcare:achievingevidencebased patientchoice,2nded.Oxford,OxfordUniversityPress Forbes,K(2007)Opiodsincancerpain,Oxford,OxfordUniversityPress Freshwater,D(2002)Therapeuticnursing:improvingpatientcarethroughselfawareness,London, Sage. GibbsG(1988)Learningbydoing:aguidetoteachingandlearningmethods,Oxford,Oxford PolytechnicFurtherEducationunit Hunt,I.,Muers,MandTreasure,T(2009)ABCoflungcancer,Oxford,WileyBlackwell/BMJBooks Mann,EandCarr,E(2006)Painmanagement,Oxford,Blackwell McCaffery,MandPasero,C(1999)Pain:Clinicalmanual,Mosby,Philadelphia Mishler,E.,Rapport,FandWainwright,P(2006)Theselfinhealthandillness:patients,professionals andnarrativeidentity,Oxford,RadcliffePublishingLtd Price,B(2004)Demonstratingrespectforpatientdignity,NursingStandard,19(12),4551

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OurNotes
Thefollowingnotesofferpointsonthedesignofthisessaybutdonotconstituteamarkingofthe work.Thenotesaredesignedtohelpyouidentifykeyfeaturesofthework.

Characteristicsofreflectiveessaywriting
Raymetsworkischaracteristicofreflectivewritinginnursing,inparticular: Appropriateuseofthefirstpersonsingular(I).Thesearereflectionsofthenurseherself.To writeinthethirdperson(thenurse)couldbecomeconfusingandinauthentic. Useofareflectiveframework(itisnotbeyondpossibilitytouseaframeworkofyourown design,butthosetriedandtestedbeforehavemuchtocommendthem.Youarelikelyto covermaterialmoreevenlyandtodemonstrateadeeperanalysisusingthese). Explorationoffeelings,attitudesandvalues(theseareusedbynursestointerpretcare requirementsandtoplaninterventions). Descriptionofacasestudycareepisode(dispassionateandsuccinct). Limitedreferencetotheliterature(thefocushereisuponexperienceandthemeaningsthat mightbearrivedatthroughreflectionuponthesame.Referencestotheliteratureare importantbywayofillustrationoraspartofacomparisonoftheoryandpractice,butthe argumentswithintheessayarenotjustifiedbytheliterature.Theyarerecommendedtothe readerintermsofexperiencedescribedandwhattheysuggestasregardsthenurse's introspection). Patients/colleaguesrenderedanonymous(throughpseudonyms).

Introduction
Whilstmanyreflectivepracticeessaysgostraightintothedescriptionofthesituationwe recommendanintroductionthatsetsupthepurposeoftheessayandwhichhelpsthereaderto anticipatewhatwillappearbelow.Inreflectivewritingthisusuallyreferstoajourney,aprocessof enquiry.HereRaymetconveysthisveryclearlyandacknowledgessomethingofwhatshehas alreadyrealisedthroughtheprocessofnotemakingandessaydrafting.Inthiscase,thatisthat patientcentredcareandassessmentofpainareaboutnarratives,thewaysinwhichaccountsare sharedbythepatientaswellaswhatisreported.Werethisanessayabouttheory,Raymetmight stateacaseatthebeginningofheressay.Noticethesignpostingwithinthissection,Raymet explainshowshewilluseGibbs(1988)reflectiveframework.Thisisimportantasotherwisewe mightexpecttoseethesectionconclusionscomelastinthewrittenwork.

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Thesituation
Inreflectivewritingitisimportanttobeclearwhenyouarewritingaboutfactsandwhenyouare referringtoperspectivesandexperiences.Inthissectionthefocusisuponfactsandsothewritingis succinctanddescriptive,reportingthatwhichhappenedandwhichispertinenttotherestofthe paper.Raymetavoidssurmisingthemeaningofwhathashappened,forinstancethechangeinMrs Drewsprognosis.Welearnwhatthepatientandherhusbandsaid,gainasummaryofwhatthe communitynursesaidandarelefttoourselvesreflectonwhatthissignifiesaboutMrsDrew,about thepainassessmentandaboutthecarerelationshipinthiscontext.Ratherlikeapoliceofficer, reportinginformationfromaroadtrafficaccident,thefactsratherthaninterpretationsand speculationsaresharedhere. Towritethissectionitisnecessarytodecidewhatispertinentandwhatisnot.Youmightconsider thatweneededmoredetailaboutthemedicationused,howlongMrsDrewhadbeenprescribed opiates,thedosageandthepatternofuse.Itcouldbevaluabletolearnsomethingaboutpastpain assessmentsandtolearnwhetherthepatienthadkeptapaindiary.Nonetheless,thesectioniswell conceivedasitfocusespreciselyupontheissuesthatareupfordebate,thatis,whoshould determinehowbesttojudgepainandthenhowtomanageit.Itisthisrelationshipbetweencare philosophies,respectforthepatientaspartnerincaredecisions,andthenurse'seagernessto relievesufferingwhichisatissuehere. InapreviousdraftofsuchanessayRaymetmightnothaveachievedsuchaclearfocus.Draftingthe reflectiveessaycanitselfimprovereflection,promptingsecondandthirdthoughts.Ajudgementhas tobemadethenbetweenworkingandreworkingessaystoimproveclarityandtransformingthem intotheory,therebylosingsomeofthefreshnessofthefirstwork.WethinkthatRaymethasfound ahappybalancehere.

Feelings
InthissectionRaymetwritesaboutherfeelings.Shedoesnotsurmisewhatthoseofotherpeople mightbeandwereshetodoso,itwouldhavetobeclearthatsheisspeculating.Akeypartof reflectivewritingistoexplorehowourfeelingsmightfilterexperienceofcareepisodesandaffect perceptionsofwhathappened(asgood,bad,indifferent).Thiscanbeadifficultelementofwriting becauseyoumighthavetoownuptosomeuncomfortableemotions.Abalancehastobestruck betweenselfcritiqueandcompassion,recognisingwhysuchemotionscanarise.NoticehowRaymet identifiesthekeyfeelingsinthefirstparagraphhereandreviewseachinturnusingthefollowing paragraphs.Thisisaclearandmethodicalwaytoproceed.Wecanseenotonlywhatemotions occurredbuthowthefocusoftheseshifted.Thisdemonstratesacarefulconsiderationofemotions onherpart.Shedoesnotassumethatemotionsareright,justifiedorselfevident.Thereisno crusadehereregardinghowcareshouldbe.

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Experienceevaluated
Itispossibleforstudentstoconflatethenexttwoselectionsandtorepeatthemselves,butRaymet avoidsthathere,treatingthissectionasasummaryofwhattheepisodemeansandthenextsection asanindicationofwhatneedstobeexploredfurther,withregardtoassessmentanddialoguewith patients.Thissectionisverymuchreflectiononactionandaboutarrivingatameasuredjudgement ofhowtheepisodecanbecharacterized.ForRaymetitisaboutatensionbetweenphilosophy(care thatenablespatientstofeeldignified)andaboutmentalsetandtheory(thewaysinwhichnurses habituallyapproachcaresituationsandusetheorytoanticipatehowbesttoact).Itiscarethatwas lesssuccessfulthanitcouldbe.Shereviewstheissuesbriefly,butconveysinsightsintowhynurses behaveastheydo.Itsworthconsideringhere(andlater)whetheryouthinkthatRaymetshowsa dueregardforJanetheCommunityNurseandherpredicament.Doyouthinkthatshesimplyjudges Jane,orwhethersheshowsadueunderstandingofwhyhercolleaguemightbeoperatinginamore ritualorfamiliarway?NoticeRaymetsobservationthatweweremissingatrick.Thiscouldseem rathercolloquialwriting,butitdoesconveycrisplyhowRaymetsawthis,asalostopportunity.

Reflections(learningopportunities)
Thisispossiblythemostpowerfulsectionoftheessay,andonethatisconveyedverylucidly. Raymetreturnstothereflectionsometimelaterandbeginstoaskquestionsaboutwhysheandher colleaguefailedtoreadthecareepisodesuccessfully.Suchlaterstagethinkingisimportantif reflectivepracticeepisodesaretohelpthenurseidentifyusefulwaysofthinkingabouthealthcare, patternsofwhatitisimportanttoconsiderwhenmakingcaredecisions.Itisnotsimplythatthe nursesdidnotlistenlongenough,itwasthattheylistenedtothereportedfactsinthepatients account,butnothowtheaccountwasarranged.Raymethereisusingsometeachingweshared aboutpatientnarrativesandthepropensityofusalltotellstoriesabouteventsthatgivemeaningto whathappened.Forexample,wetellstoriesaboutatriptothedentist.Thesereportwhatwasdone (Ihadafilling)butmayalsoindicatesomethingaboutourbravery,thecostoftreatment,guiltabout eatingtoomanysweetsandmuchmore!Peopleusestoriestoconveythemeaningsofeventsto othersandtoelicitresponsesfromus,thelisteners.Inthisinstance,MrsDrewmighthavebeen lookingforapproval,supportandconsultationonherplantomanagepaindifferently.Instead,Jane treateditasareportoffalteringconfidenceinpainmanagementandsuggestedthatreinforcement mighthelp(thecancerpainclinic).

Conclusions
Raymetusesbulletpointshereandthesecanbeeffective,providingthattheyhelpyousummarise informationthathasbeeneitheraddressedelsewhereorwhichisincidentaltothemainarguments ofthepaper.Routineuseofbulletpointscanmakeyouressaylookalittletoonotational,souse themsparingly! Theconclusionsneedtosumuptheprecedingreflectionsandyourdeliberationsonthesame. Raymetachievesthathere,showingempathytowardshercommunitynursecolleague(thiswork 19

isnteasy),insightintopatientcentredcareandapossiblewayofthinkingaboutwhatpatientssay (narratives)thatmightassisthertoworkdifferentlyinthefuture.

Futurecare
ThisisquiteashortlastsectionfromRaymetandyoushouldavoidrunningoutofsteambyplanning yourworksothatanadequateproportionofwordsareallocatedthere.Itcanbedifficulttodecide whatnext,afteryouhavereachedconclusionsintheprevioussection.Hereitisnecessarytoavoid soundingtrite(Iwilllistentoandhearallpatientsnarrativesinthefutureandactaccordingly)and tobeclearaboutwhatcouldrepresentanextstep.Inthisinstancethatcouldbethingssuchas identifyingoneormorefuturecasestudieswhereyoutrytohearpatientaccountsmoreclearly, testingyourinterpretationwithothers.Itmightbetoreadmoreaboutpatientnarrativesandtheir role,sothatideascanbeevaluatedfurther.Raymetsfuturecareisappropriatelymeasuredin tone,butitlacksalittledetailaswell.

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