Microsoft Word - Analyticalessaywebsite.doc

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EXAMPLE ESSAYS FOR

Critical Thinking and Writing for Nursing Students

Bob Price and Anne Harrington

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CONTENTS:

Example analytical essay - page 1

Example reflective essay - page 11

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EXAMPLE ANALYTICAL ESSAY

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ThisexampleofananalyticalessayispresentedinassociationwithPrice,BandHarrington,A(2010)

CriticalThinkingandWritingforNursingStudents,Exeter,LearningMatters.Readersare

introducedtotheprocessofcriticalandreflectivethinkingandthetranslationoftheseinto

courseworkthatwillhelpthemto

achievebettergradesinnursingcourses.Stewart,Raymet,Fatima

andGinaarefourstudentswhosharetheirlearningjourneythroughoutthechaptersofthebook.In

thisessayontheevaluationofdifferentsortsofevidence,Stewartdemonstrateshiswritingskills

neartheendofhiscourse.Stewartwassetthe

taskofevaluatingdifferentsortsofevidencewithin

nursingandmakingacaseregardinghowthenursemightproceed.Attheendoftheessayweoffer

notesthatexplainthecriticalthinkingandwritingfeaturesofStewart’swork.

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N.B.Remember,copyingessayssuchasthis,submittingthemasa

wholeorinpartforassessment

purposes,withoutattributingthesourceofthematerial,mayleaveyouopentothechargeof

plagiarism.Significantsanctionsmayfollowfornurseswhodothis,includingreferraltotheNursing

andMidwiferyCouncil.

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Evaluatingevidenceinnursing

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Forreasonsofpatientsafetyandtheimprovementsinthequalityofhealthcare,nursesareurged

tobasetheirpracticeonevidence(Barker,2009).Evidencetoomaybearguedasabasisfor

arrangingthemostcosteffectivecare,usinglimitedresourcestobesteffect.Idefineevidence

hereasconsistingofthatinformationthatthenursecanpointtoasauthoritative,beingmore

thansimpleopinionorpredilectiontopracticeinaparticularway.Inpractice,theavailabilityof

evidencemaybelimited,someevidencemaycontradictotherevidenceandthenursemust

thereforemakejudgementsaboutwhatisfound(Jolley,2009).Itisnecessarytonotethat

differentsortsofevidencemaybeusedtodifferentpurpose.Forexample,evidenceof how

patientsexperienceillnesscantellthenurseabouthowpatientsfeelandwhatmattersmostto

them.Itcannotguidethenurseonwhatsortsofcarearemosteffective.Statisticalevidence,

especiallythatoriginatingfromrobustexperiments,mighthelpthenursetodeterminewhat 

causesaparticulareffectandtodecidewhethertoarrangecaredifferently.Notallevidenceis

thesamethen,someismorepowerfulthanothers,andafitbetweenevidenceandpractice

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needstobedetermined(Brotchieetal,2010).

InthispaperIfirstreviewthedifferenttypesofevidencethatmaybeavailabletothenurse.I

thenusetheworkofProctorandRosen(2004)tohighlightpossiblefitsbetweenevidenceand

effortstoimprovepractice.Thethirdpartofthispapersummarisespointsabouthowbestto

judgethedifferentevidenceavailable—thecriteriatobeusedwilldiffer,dependentonthe

evidenceconsidered.Iarguethecasethatthenurseevaluatesevidencewellwhereheorshe

understandsthenatureoftheevidence,establisheswherethatevidencemightservewelland

makeswisejudgementsontheauthority,completenessandcoherenceoftheevidenceavailable.

Typesofevidence

Whilstevidencecanbeclassifiedindifferentways,Isuggestherethatitisusefultomake

distinctionsbetweenresearchandexperientialevidenceinthefirstinstanceandthenwithin

researchevidencetonotethattherearedifferentresearchdesignsthataffectthenatureof

evidencepresented.Itmayseemcontentioustothinkofexperienceasaformofevidence,butin

practiceitisfrequentlycalleduponasjustthat(e.g.Finlay,2009;Beametal,2010).Atits

weakest,groupsofnursesdevelopaworkingimpressionofhowpatientscope,howcareis

deliveredandwhatconsequencesemergeifnursingisdeliveredinparticularways.Inmy

experience,nursesmightrefertothisaspracticewisdom,acollectiveknowhowthatseemsto

workwellwithgivengroupsofpatients.Suchevidenceprovidesatbestafirstimpression,and

overviewofissues.Itisenhanced wherethenurseplansreflectionandobservationmore

carefully,withreferencetoparticularquestionsandfocusingperhapsoncasestudiesthatallow

matterstobemappedanddiscussed(Leach,2007).Itincreasesstature,asevidence,tothe

degreethatinformationisgatheredinadisciplinedandorganisedway,andwithastatedpurpose

inmind.Thatexperientialevidenceisimportantinhealthcareisimportantisillustrated bythe

analysisofcasestudiesincareandespeciallythoseassociatedwithriskmanagement(e.g.

Stewart,2010).Nursesandothersmayanalysecasesinsomedepthtoestablishwhatwent

wrong,whatwasmissedormisinterpreted,allwiththeaimofavoidingmistakesandofimproving

performanceinthefuture.

Themorefamiliarformofevidencethatmostcolleaguesrefertowhendiscussingevidence‐based

practiceisthatwhichemergesfromresearch(Barker,2009).Researchproducesevidence

preciselybecauseofthedisciplinedwayinwhichenquiriesarearrangedandtheeffortsmadeto

gatherdatathatattendtotheaims,questionsorhypothesesoftheresearchproject.Designsare

influentialhere.Researchthathasbeendesignedwithinthepositivisttraditionworksassiduously

toremovetheriskofresearcherbiasandtogathersufficientdataoftherighttypetomakeclaims

aboutapopulationofpeople.Thereisanemphasisuponimpartialenquiry,withtheresearcher

arrangingchecksbyotherssuchascriticalreviewerstoensurethatassumptionsarenot

prematurelymadeaboutwhatisfound(Grix,2004).

Otherresearchisconductedwithinthenaturalisticorinterpretivetradition(e.g.phenomenology,

groundedtheory,someformsofethnography)andheretheworkproceedsdifferently.The

researcherarguesthatitismoreimportanttoconductworkthatisauthentictohealthcare,than

toconductastudythathasexcludingallpossibleformsofbias(Silverman,2004).Thegoalofsuch

researchisoftentohelpothersportraytheirexperienceofhealth,illnessorcareandtohelp

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nursesunderstandwhatpatientsandothersmightneedorhopefor(Brotchieetal,2010).The

researchermightsuggestthatitisimpossibletocompletelydisassociatethemselvesfrom

perspectivesorviewsthatcouldshapethelineofenquiry.Athirdresearchdesignmaybe

describedascriticaltheory(Swartz,1997).Theresearcherstartswithacknowledgedgoalsto

correctinequalitiesinhealthorcareandtomakeacaseforthedisadvantaged.Feministresearch

forexampleacknowledgesthattheresearcherwillnotstanddispassionatelyasidewhen

deliberatingonwhatneedstobediscoveredorhowevidencemightsupportacaseforchange.

Sometimesnaturalisticandcriticaltheoryresearchisgroupedtogetheras‘qualitativeresearch’

becausetheyoftenproducequalitativedataandincontrasttothequantitativedatathat

sometimesemergesfrompositivistresearch(GreenandThorogood,2009).

Whatseemssignificantinthisoverviewofdifferentresearchdesigns,isthatthereisno

universallyagreedgoalofresearch,noristheevidenceproducedallofonesort.Researchers

adoptdifferentrolesdependingonthedesignofresearchused.Inpositivistresearchtheroleof

theresearcheristypicallydescribedasdispassionateandtheyproceedtogatherinformation

fromoutsidetheexperienceofothers(itisdescribedas‘etic’).Innaturalisticandcriticaltheory

researchtheresearcheroftenapproachestheirsubjectmuchmoreclosely,int imately,for

exampleobservingandinterviewingasaparticipantinthesituationexplored(itisdescribedas

‘emic’)(Brotchieetal,2010).Togatherauthenticdatatheresearcherpermitsthemselvesto

becomeinvolvedinproceedings,tousetheirownexperienceaspartoftheprocessof

interpretingwhathasbee nwitnessed.Thesedistinctionsareimportantifthenurseisnottouse

researchevidenceinappropriately,assomethingthatwasneverintendedbytheresearcher,

makingclaimsthatareunsupportable.Theevaluatingnurseneedstounderstandtheresearch

designaswellastheresearchevidenceonoffer.

Evidenceandpracticefit

Itistemptingtoarguethatonesortofevidence(positivist)issuperiortoallothersandthatitis

uponthatwhichnursingshouldbebased.Thisisattractivewherenurseswishtohighlightnursing

asascienceandwhereprecisionisakeyconsiderationincare.Itisextremelyattractivewhere

thenursehastomanageriskanddefendactions,especiallyiflitigationisaconsideration.Nursing

thoughdrawsuponmanydifferentsortsofevidenceandthisisinlargepartbecausethenurse

workswithotherstomakesenseofhealthandillness(AveyardandSharp,2009).Ifthenurse

helpsthepatienttodecidewhatchronicillnessmeanstothem,andtodevisecopingstrategies

thatseemmanageable,theyareworkingtohelpothersmanageuncertainty.Therecanbeno

singlegoldstandardsolution,becausepatients’circumstancesandneedsaredifferentandvery

individual.Itfollowsthenthatresearchwhichattendstothisprocess,ofmakingsenseofwhat

hashappenedandwhatmighthelpnowisalsovaluable.Suchresearchismorespeculativein

nature,moretentativeasregardswhatcanbeprovenorclaimed.Nursingthenmayrequireboth

‘hard’and‘soft’evidence,thefirstconcernedwithwhatworks,whatissafeandbeneficialand

thesecondassociatedwithprocess,howitfeelsorwhatitmeanstorecoverorrehabilitatefor

example.

ProctorandRosen(2004)describeastepwiseprocessforfindingandevaluatingresearchthat

mightcontributetoevidence‐basedpractice(seeTable1).Importantly,thepurposeofthe

evaluationneedstobeunderstoodfirst.Whatoutcomesisthenursemostinterestedin?Itis

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necessarytoreviewthatresearchwhichfitsclearlywiththeidentifiednursingneed,andfor

ProctorandRosen(2004)thisislargelyaboutdemonstratingtangibleimprovementsincare

(outcomes).InStep2thenurseselectsfromtheevidencereviewedthebestfittingintervention,

thatwhichachievesthedesirableoutcome.InStep3thenursesupplementsormodifiesthe

intervention,drawingupontheirexperienceandknowledge.Thisthirdstepcanseem

contentious,butitisimportantwhereresearchwasconductedindifferentcontextstothe

practiceconsidered,orwheretheresearchevidenceavailableisincompleteorperhaps

contradictory.InStep4thenursemonitorsandevaluatesthechangedpractice,tomakesurethat

thedesirableoutcomeissustained.

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Table1:Developingevidence‐basedpracticeguidelinesandanursingillustration(adaptedfrom

ProctorandRosen,2004)

Step Illustration

Step1:Locateevidence‐basedinterventions

relevanttotheoutcomesofinterest.

Thenurseisinterestedinhelpingpatientsto

managetheirasthmabetter.Three

interventionsarelocatedwithintheresearch

literature,oneassociatedwithgroupteaching,

anotherwiththeuseofvideotraininganda

thirdlinkedtocoaching.

Step2:Selectthebestfittinginterventionin

viewofclientproblems,situationand

outcomes.

Thenurseselectstheinterventionthat

producestherequiredoutcome(patient

independence)andwhichalsoisaffordableand

realisablegiventhetimeandexpertise

available.Inthisexampleitmightbegroup

teaching.

Step3:Supplement/modifythebest

intervention,usingnurseexperienceand

knowledgesothatitfitswithpracticecontext.

Groupteachingiscosteffectivebutdemanding

ontheskillsofthenurse,sotomakethiswork

moreeasily,ateacherguidancepackis

produced,onethatwillleadtoconsistentand

wellorganisedteachingsessions.

Step4:Monitorandev aluatethe e f fectiveness

oftheoutcome.

Overthenextyearthenursemonitorspatients’

levelsofselfcareandtheincidenceof

readmissionstohospitalforasthmacrises.

Expressedconfidenceandlowerincidenceof

hospitalreadmissionareseenasindictorsof

bettercoping.



InTable1itispossibletoimaginepositivistresearchbeingusedinassociationwithStep2(thesort

ofresearchthatfocusesuponcauseandeffectrelationships),whilstnaturalisticandpossiblycritical

theoryresearchmighthaveaparttoplayinStep3.Forinstance,therewouldbeacasetoconsider

researchrelatingtopatientexperience(ofasthmaeducation)alongsidethatwhichsuggestedthe

bestwaytoproceedifindependentlivingwasthegoal.Theroleofexperientialevidenceismuch

lessclearintheProctorandRosen(2004)approachandforsomecolleaguesitmightbeseentonot

havearoleatall.Nevertheless,experienceofparticularpatients,theirneedsandlevelof

confidence,theskillsofstaff(inthisinstanceaspatienteducators)couldandperhapsshouldfactor

indeterminingwhichinterventionisused.Coachingforexamplerequiresconsiderableskillsand

longtermcommitment,somethingthatmightseemlessfeasiblehere.

 5

Judgingevidence

Asdifferentevidenceisfound,thereisaneedforthenursetojudgeitsmerits(AveyardandSharp,

2009).Justhowtheevidenceisjudgedisassociatedwiththedesignoftheresearch,orinthecaseof

experience,theprocessbywhichitwasgathered,collatedanddiscussed.Inpositivistresearch

judgementfocusesupontheauthorityofthedesignandthisisjudgedusingthreequestions.First,

wastheresearchethical—canwereasonablydrawuponthisevidence?Second,whetherthe

researchwasreliable—ifthestudywasdoneagain,wouldwebelikelytoobtainthesameorvery

similarresults?Third,whethertheresearchwasvalid—diditasktherightquestions,attendtothe

correctstudypopulationandsecureaviablesample?Inshor t,didtheresearchmethodshelpthe

researchersecureenoughoftherelevantinformationtomeettheaimsofthestudy,toanswerthe

questionsorpermitthereviewofhypothesesstated?Whereinformationofthiskindismissingfrom

theresearchreport,orthedesignarrangementsseemambiguous,doubtsareraisedaboutthe

validityand/orthereliabilityoffindings.

Differentjudgementcriteriaareusedwithregardtonaturalisticresearchandtheseareusually

associatedwiththeauthenticityofdataobtained(Brotchieetal,2010).Thereviewersearchestosee

iftheresearcherhasleftanaudittrail ofhowtheresultswerearrivedatandhowfieldworkordata

analysisdecisionsweremade.Theresearchismeanttotellastoryaboutthereasoningofthe

researcher,sothatthenursecanestimatewhether(intheirexperience)theresultsreportedare

likelytoberepresentativeofwhatresearchsubjectsmightreport.Judgementinthisresearch

involvesagreateramountofwhatIterm‘freestyle’reasoning.Thenurseasks,dotheseresults

seemlikely,importantandcentralgivenwhathasbeenwrittenandwhatIknowwithinmyown

nursingwork?

Judgingcriticaltheoryresearchseemsrathermoredifficult.Itentailsestablishingwhetherthe

researcherhashonestlyandfullystatedtheirpremisesaboutthesubjectconcerned,the

assumptionsthattheystartwithastheyconductresearch(Brotchieetal,2010).Itinvolves

evaluatingwhethertheresearcherhasbeenclearaboutthecriticalfilter,thepremisesthathave

beenusedtoselectdataforcollectionanditsinterpretationafterwards.

Judgingexperientialevidenceisdifficult.Whilstreflectiveframeworksfocusontheanalysisof

experience,mostoftheseoperatetootherpurposes,typicallythedevelopmentofthenurses’

thinkingskills(JohnsandFreshwater,2005).Theyarenotyetusedtoimprovethequalityof

healthcareexperiencereporting,asasofterformofevidence.Questionsthatmightbeusedto

distinguishmoreconvincingexperientialevidencethoughinclude:

 Havequestionsbeenusedtofocusthereflectionsundertaken?

 Havethereflectionsbeenrecordedsoonaftertheexperienceiscomplete?

 Havethereflectionsbeendiscussedbyagroupofpractitionersworkinginthesame

 area(e.g.apracticereviewgroup?)

 Haveeffortsbeenmadetorefineorimprovethereflectiveactivity,sothat information

isbetterunderstood?

 6

Conductingreflectionintheseways,asacollectiveandcriticalactivityaddsdisciplinetotheprocess

andenablesthereviewertoweighthepointsbeingmadeasaresultofthereflectionsundertaken.

Evaluationproblems

Whatbringstheabovethingstogether,anunderstandingofthedifferenttypesofevidence,a

processforrelatingevidencetoachosenpracticeandthejudgingofthequalityofevidence;is

systematicevaluation.ProctorandRosen(2004)demonstratesuchasystematicapproach,although

inthisessayIsuggestthattheevaluationmightconsidermorethantheauthorsoriginallyintended.I

proposethatitcouldbeusedtodescribehowresearchandexperientialevidencecouldbe

combined.Thenurseascertainswhatworksandthenconsiderstheprocessofworkingtowardsa

newpractice—thatwhichisrealisable.

Whatisburiedherearethedifficultdecisionswhenevidenceispatchyandcontradictory.Notonly

mighttherenotbeenoughresearchevidence,buttheevidencefromexperiencemightbe

inconclusiveaswell.Thenurseisleftwithapartialpictureofnursingcare,whatmighthelppatients,

howpatientsexperiencethatcareandwhatwouldenablethenursetoproceeddifferently.Under

theseconditionsitmaybeimpossibletoevaluatetheevidence,atleastbeyondnotingthatitis

incomplete,contradictoryorincoherent.Thenthenursehastoproceedwithnewinvestigations,

eithermoreresearchorreflection,sothatthevolumeandqualityofevidenceincrease.Inthe

meantime,nursingcarecontinuesbasedupontraditionorwhatmightbeconsidered‘common

sense’solutions(i.e.thosethatthenursebelieveswillhelpbutforwhichthereisnoproofof

success).

Conclusions

Thisessayhasdescribedthedifferentcomponentsofworkasanurseevaluatesevidence.Itsuggests

thatthenursehastohaveagoodappreciationofthedifferenttypesofevidenceandwhatisoffered

there.Failingtoappreciatethatcouldleadtothenursedistortingtheevidence,usingittopurposeit

cannotsupport.Clarityisneededtoothoughasregardswhatpurposetheevidencereviewhasto

serve.Whatdowereallywanttodoorknowhere?Beforethenursecanconcludewhatthe

evidenceoffers,heorshemustevaluatethemeritofindividualevidence—somethingeasiertodo

withregardtoresearchwheretherearelongerestablishedcriteriabywhichtomeasurethequality

ofwork.Insomeinstancesthenursemusthonestlyconcedethatthereisinsufficientclearor

coherentevidencetorecommendaparticularwayforward.

Thecasestatedatthestartofthispaperdoeshoweverseemsupported.Consideringeachofthe

abovethings,thenurseevaluatesevidenceinamoremethodicalwayandusingrelevantquestions

tojudgewhathasbeenfound.Itispossibleforgroupsofnursestowor ktogethertoevaluateto

clearerpurpose,insteadoftheadhocwaythatindividualnursesmighthavedoneinthepast.

Withoutanunderstandingofeachoftheabove,nurseswouldnothaveidentifiedconsistentwaysto

engageinevidenceevaluation—somethingthatisimportantifnursingistodevelopareputationfor

evidence‐basedpractice.



 7

References

Aveyard,HandSharp,P(2009)Abeginner’sguidetoevidencebasedpracticeinhealthandsocial

care,MiltonKeynes,OpenUniversityPress/McGrawHill

Barker,J(2009)Evidence‐basedpracticefornurses,London,Sage

Beam,R.,O’Brien,Randneal,M(2010)Reflectivepracticeenhancespublichealthnurse

implementationofnurse‐familypartnership,PublicHealthNursing,27(2),131‐139.

Brotchie,J,Clark,L.,Draper,J.,Price,BandSmith,P(2010)Designinghealthcareresearch(K824

StudyGuide)MiltonKeynes,TheOpenUniversity

Finlay,I(2009)Developingatemplatetoplanpalliativecareservices:theWelshexperience,Journal

ofPainandSymptomManagement,38(1),81‐6.

Green,JandThorogood,N(2009)Qualitativemethodsforhealthresearch,2

ed,London,Sage

Grix,J(2004)Thefoundationsofresearch,Basingstoke,PalgraveMacMillan

Johns,CandFreshwater,D(eds)(2005)Transformingnursingthroughreflectivepractice,2

ed.

Oxford,Blackwell

Jolley,J(2009)Introducingresearchevidence‐basedpracticefornurses,Harlow,Pearson

Educational.

Leach,M(2007)Revisitingtheevaluationofclinicalpractice,InternationalJournalofNursing

Practice,13(2),70‐74

Proctor,EandRosen,A(2004)‘Concisestandardsfordevelopingevidence‐basedpracticeguidelines’

inRoberts,AandYeager,K(eds)Evidence‐basedpracticemanual:researchandoutcomemeasures

forhealthandhumanscience,Oxford,OxfordUniversityPress193‐199.

Silverman,D(2004)Qualitativeresearch;theory,methodandpractice,2

ed.LondonSage.

Stewart,D(2010)Diagnosisandmanagementofanadultpatientwithanatrialseptaldefect,Nurse

Practitioner,35(2),8‐11.

Swartz,O(1997)Conductingsociallyresponsibleresearch:criticaltheory,neopragmatismand

rhetoricalenquiry,ThousandOaksCalifornia,Sage.



 8

Ournotes

Youmightbestruckuponfirstreadingjusthowpolishedthisessayisandwonderwhetheryoucould

producesomethingquitesoconvincing.Beforeyoujudgesuchthings,rememberthata)Stewarthas

receivedparticularteachingonevidence‐basedpracticeandb)thatheiswritingattheendofhis



course.Hiswork,ashewouldconcede,wasnotalwayssowelldeveloped!Seebeyondthepolish

thenandconsiderthestructureofthisessay.Lookbeyondwhetheryouagreewithhispoints,for

exampleaboutwhatdoesordoesn’tconstituteevidence,todeterminehowhebroughtinformation

togetherto

createthefinalimpressionofthiswork.

Theintroduction

Theintroductionconsistsoftwoparagraphs,thefirstofwhichisdesignedtocapturethereader's

interestandestablishwhatheiswritingabout,andthesecondofwhichisusedtosignposthowthe

restofthepaperissetoutandthecasethatheismaking.Stewartcaptures

ourinterestbylinking

hispapertotheimportanceplacedonevidence‐basedpracticeinnursingtoday.Thisisnota

whimsicalorpassinginterest—nursesneedtoknowaboutit!Inthesecondparagraphhesetsout

hiscasebrieflyandclearly.Inanalyticalessays,especiallyasinthisinstance

whentheyevaluate

whatisinvolvedinparticularnursingwork,statingthecaseisveryhelpfulindeed.Itindicatestothe

readerthattheauthorknowswhereheisgoing,whatheistryingtodemonstrateinthepaper.Itis

almostasthoughwearechallengedbythecase.Do

Iagreewiththis?DoIthinkthatthesethings

wouldleadto bett erevaluationofevidence?Asaresultwereadthepapermoreattentively.

ThisisquiteasophisticatedsubjectsothereareanumberoftermsthatStewartneedstouse.He

neededtodecidewhichhe

wouldassumethatthereaderunderstoodandwhichwouldneedtobe

defined.Inthisexamplehedefinesevidenceasheusesitinthiscontext.Youcouldconsiderthatit

mightstrengthenapaperifyouusedapublisheddefinitionofatermsuchasthis.Inthisinstance

though,

asheismakinghisownpointaboutwhatconstitutesevidence,somethingmorethansome

othersmightinclude,hesetsouthisowndefinition.Whilstitisrighttodrawthereaders’attention

toreferencesources,andtobuildthesetogetherinsupportofyourowncase,itisstill

necessaryfor

youtohaveadoptedapositionofyourown.Simplyreportingeveryoneelse’scase,theirarguments,

willnotusuallybeenoughtosecurethebestpossiblemarks.Thisisakey pointinlearningtothink

critically.

Typesofevidence

ThecraftingoftheparagraphsinthissectiontookStewartsometime.Eachhadtosummariseatype

ofevidenceclearlyandsuccinctlyandinsuchawaythatthereaderunderstoodwhathebelieved.

Thereisagreatdealofcompressionofinformationhere,hesummarisesagreatdealand

thereisa

realriskthathecouldoversimplifyormisrepresentpointsifheincludestoomuch.Hegoesstraight

intoanargumentthatexperience,whenobservedandreflecteduponadequately,canconstitutea

typeofevidence.Thisisperhapscontentious,butbymakingthisargumentfirst,heensuresthat

he

setsoutarobustposition.‘Iamwritingaboutthisfirst,becausethisiswhatIbelieve.IfIwrote

aboutitlastinthissection,itmightseemlikeanafterthought’.Noticehowheusesexamplesfrom

practicetoreinforcehisclaimregardingthecredentialsofexperientialevidence.Audit,

riskanalysis

work,reviewsofcasesthathavegonewrong,allhighlighttheimportanceofexperiencetopractice.

 9

Later,Stewartwillarguethattoimprovethecredentialsofsuchevidence,reflectionwillneedtobe

moresystematicandcollective.

Paragraphdisciplineisimportantwhenyoutrytoconveyagreatdealofinformationinasmall

volumeofwords.Makesurethateachparagraphisaboutaclear

subject(inthiscase,thedifferent

typesofevidence)andthatwithinthoseparagraphsyouavoidexcessivelylongsentences.Try

readingaloudthesentence—ifyoufindyourselfpausingforbreath,itmayalreadybetoolong.

Thelastparagraphinthissectionisespeciallyimportant.HereStewartshowshisreasoning

asthe

essayproceeds.Hemakessomejudgementsaboutresearchevidenceasaformandnotesthatitis

veryvaried.Itreallywouldbetoosimpletodescribeitasonething,somethingtobecontrasted

againstexperientialevidence.Itismanythings,andthenurseneedstounderstandeach

ifthe

evidenceistobereviewedwell.

Evidenceandpracticefit

First,wemaketwostylisticpoints.NoticehowStewartisusingsub‐headingstohelpthereader

navigatehisessay.Historically,sub‐headingswerenotusedwidelywithinacademicessays,butwe

suggestthattheyarevaluable.Ifyouwerewritingfornursingjournals,youwouldalsousesub‐

headingsto

guidethereader.Second,noticetheuseofthetable.Stewartusesthistoconvey

informationquicklyandclearlyandcombinesthatprovidedbysomeotherauthors(leftcolumn)

withpointsofhisown(rightcolumn).ThesourceofinformationisattributedandStewartbegins

hereanillustration(asthma)that

willhelphimtoexplainimportantpoints.Stewartshouldadd

referencestothethreeapproachestoasthmaeducation,astheywouldnormallycomefrom

publishedwork.HereStewartisusingideasasanillustration,itisanexampleonlyofwhatmightbe

found.Byandlarge,assessorswillpreferthat

studentsdrawuponactualexamplesfromthe

literature,demonstratingthestudent’sworkwithinthelibrary.Imaginativeandpertinentthough

Stewart’sworkis,itonlyshowswhatmightbepossible,thestrongercasedrawsonthatalready

arguedordemonstratedelsewhere.

Ifthelastsectionwasmadeofparagraphargumentsabout

whatcountedasevidence,thissection

setsouttoarguethataprocesscanhelpexplainhowevidenceandpracticerequirementscanbe

matched.HeusesProctorandRosen’s(2004)frameworktoshowthisworkinaction.Atthispointit

wouldbeeasytowriteextensivelyabouttheframework,where

itcamefrom,whodesignedit,but

todosowouldbeadistraction.Frameworksofthiskindareheuristic,thatis,theyserveapurpose,

andrightnowthisistoshowhowdifferenttypesofevidencecouldserveastatedpurpose.Ourown

viewofthisisthat

Stewartmanagesthisratherwell,withthepossibleexceptionofhislastpoints

aboutdrawingexperientialevidenceintotheprocess.Stewartisboldhere,hesuggeststhat

experientialevidencehasaroletoplay,butperhapsthisisnotapointfullysubstantiateduntillater,

whenhedescribeswhatisrequired

tomaketheevidencemorerobust.

Judgingevidence

Thisisanothersectionwhereinformationhasbeencompressed.Wholetextbookshavebeen

writtenonhowtoevaluateresearch!Nonetheless,ifStewartistosupportthecasethatthisworkis

butapartofevidenceevaluation,heneedstoconveytheessentialinformationquicklyandclearly.

Largerdebatesandexplanations,

forinstanceaboutthedifferentsortsofvalidity,cannotfindspace

 10

hereandwewouldsupporthisselectionofpoints.Validity,reliability,authent icityandaudittrailare

importantconsiderationsinjudgingresearch.Hadwewishedtoaskforfurtherelaborationonanyof

them,itwouldbeimportanttoalsosuggestwhatelsehemighthaveomittedinthisessayto

make

roomforthis.

Noticehoweachgroupofjudgementsisassigneditsownparagraph—thisaddstotheoverall

impressionofadisciplinedessay.Attheend,inthefinalparagraphheusesbulletpointsto

introducehisownrecommendedcriteriaforjudgingexperientialevidence.Thisisanotherboldstep,

onethatdemonstratesthatStewartisreasoningconfidently.Irrespectiveofwhetherreadersagree

hisstancehere,weth inkthattheseareindeedthingswhichwouldmakereflectionmore

systematic—moredisciplinedinwaysthatwemightexpectifevidencewastoresult.

Evaluationproblems

ItwasatthisjuncturethatStewartrealisedsomethingwasmissing.Hisoriginalessayplanhadnot

includedthissection!Whenhewasplanningtheessay,hethoughtthatiftheabovethree

componentsofevidenceevaluationwerearguedthathewouldhaveaconvincingaccountof what

evidenceevaluationentailed.

Theproblemisthatevidenceisrarelythatcomplete,coherentorneat.

Sotheadditionofthissectionnicelyhighlightsthentheneedtostopandpausesometimesandto

considerwhetherwhatyouhavewrittenisadequate.Stewartneededtoaddsomethingmore,and

hadsomewordspaceto

dothis.That'something'wasaboutwhathappenedifthecomponentparts

oftheevaluationwerenotenough,iftheydidnotsuggestabestwayforward.

Thisisquiteashortsection,andperhapsyoufeelthatStewartdidnotquiteclinchthepoint?Itis

notmerelythecase

thatsometimesthatevidencedoesnotcometogetherwell,orthatitis

incompleteorcontradictory, itisthattheworkingwithuntidy,incompleteandsometimesconfusing

evidenceisfrequentlya challengeforth enurse.Thesuccessfulevaluatorofevidenceconfrontsthis

confidentlyandispreparedtoargue'wedon’t

haveenoughev idenceheretoproceed'.Decision

makingatthispointpossiblydistinguishesthemorefromthelesssuccessfulevidenceevaluators!It

perhapsrequiresgreatintegritytomakethisdecision,whenthepressurebuildstochangepractice

insomeway.

Conclusions

Conclusionshavetworoles.Thefirstistosummarisewhathasalreadygonebefore—somethingthat

Stewartdoesinthefirstparagraph.Thesecondistodemonstratetheauthor’sdeductionsabout

whathasgonebefore.Inthisinstancethatisthatthecasehesetoutatthestartoftheessay

is

supported.Stewartarguesthatsuccessfulevaluationisfoundeduponamixtureofthingsandthe

moresystematicallytheseareconducted,thebetter.Hisessaywouldbeevenstrongerifhehad

arguedthattheprocesswastransparenttootherswholistenedtothecaseforchangemade

afterwards.



 11

EXAMPLE REFLECTIVE ESSAY

ThisexampleofareflectiveessayispresentedinassociationwithPrice,BandHarrington,A(2010)

CriticalThinkingandWritingforNursingStudents,Exeter,LearningMatters.Readersare

introducedtotheprocessofcriticalandreflectivethinkingandthetranslationoftheseinto

courseworkthatwillhelpthemtoachieve

bettergradesinnursingcourses.Stewart,Raymet,Fatima

andGinaarefourstudentswhosharetheirlearningjourneythroughoutthechaptersofthebook.In

thisessayontheassessmentofpain,Raymetdemonstratesherreflectivewritingskillsnear theend

ofhercourse.Raymethadbythisstagewritten

severalreflectivepracticeessaysandgainedgood

marks.Thistimethoughsh ewasencouragedtodeepenherreflections,speculatingselectivelyon

howtheaccountofpainexperiencedbyapatient(MrsDrew)mighthelphertoworkmorecreatively

withpatientperceptionsandreportedneeds.



N.B.Remember,copyingessayssuch

asthis,submittingthemasawholeorinpartforassessment

purposes,withoutattributingthesourceofthematerial,mayleaveyouopentothechargeof

plagiarism.Significantsanctionsmayfollowfornurseswhodothis,includingreferraltotheNursing

andMidwiferyCouncil.



AssessingMrsDrew’sPain

McCafferyandPasero(1999)statethatpainiswhatthepatientsaysitis.Ifweacceptthatpoint,

thennursesneedtoexplorethepatient’sperceptionsofpain,aswellastheirreportofexperiences.

Thetwoarenotquitethesame.Patientsmayreporttheirpaininavarietyofways,dependenton

thenatureandtheintensityofpainandthecontextinwhichitisfelt(e.g.whethertheyareever

distractedfromthepain).Theirperceptionofpainisalittlemorethoughanditincludesthe

meaningthatthepainhasforthem.Itincludesexplanationofwhythepainisthereinthefirstplace,

whatitindicatesabouttheirbodyandwhatitcouldsuggestmighthappeninthefuture(getting

better,gettingworse).Thenurseassessestheaccountofpainsharedbythepatient,andthismaybe

givenintheformofastory.Thisishowitbegan,thisishowitfelt,thisiswhatthatmeanttomeand

thisiswhatIdidaboutit(Mishleretal.2006)

InthisessayIexploretheassessmentofpainasconductedwithone60yearoldpatientwhomIwill

callMrsDrew.Whilsttheessaydescribesanassessmentofpainwithasinglepatient,Itrytoshare

toosomeideasandquestionsthatthisprovokeswithinmeaboutpainassessmentmoregenerally.

MrsDrewmademethinkaboutotherpatients,futureassessmentsandwhatIhadtodoasanurse

tohelppatients.TohelpstructurethisessayIusetheframeworkdescribedbyGibbs(1988).Whilst

theepisodeconcernedrelatesastageinMrsDrew’sillnesswhenshechallengedhertreatment

protocol,italsoincludessomeofthememoriesandthoughtsthatthispatientreferstoregarding

herearlierillnessandpastwaysofcopingwithpain.Inparticular,itpromptedmetoquestionto

whatextentIasanurseshouldrecommendanalgesia,drawingonwhatIhadbeentaughtaboutthe

effectivecontrolofpain.Ihadlearnedthatitwasbettertocontrolratherthantochasepain(e.g.

MannandCarr,2006;Forbes,2007).

MrsDrewwasdiagnosedwithlungcancerayearearlierandhadinitiallyhadherillnesstreatedby

chemotherapy.Thishadhelpedhertoachievearemissionthatlastedfornearlytenmonths(Huntet

al,2009describetheprognosisofthisdisease).Thecancerhadret urnedthoughandspreadtoher

 12

spineanditwasherethatsheexperiencedmostofherpain.Itwasatthisstagethatthedoctors

explainedthathercarewouldnowbedirectedtowardshercomfortratherthanacure—towhich

shehadreplied,‘youmeanpalliativecare’.MrsDrewwassupportedathomebyherhusbandNeil

andvisitedonaregularbasisbycommunitybasednursestowhomIwasattachedaspartofmy

studentnursetraining.Shewasprescribedoralmorphineandcoulddecidewithinstatedlimitshow

manytabletsshecouldtakeinanyone24hourperiod.

Thesituation

IhadvisitedMrsDrewonseveraloccasionsovertheperiodofamonthwhenthecommunitynurse

andIwereconfrontedbyatearfulpatientwhoannouncedthatshedidnotwishtotaketheoral

opiatesquiteasoftenaswewererecommending.Asshespokesheheldherhusband’shandtightly,

lookingacrosstohimasshedescribedherexperiencesandfeelingsaboutthematter.Yes,therehad

beensomebadnightswhenthepainhadwokenherandshehadtositupandwatchtelevisionto

tryanddistractherself.Yes,sometimesthepainmadeherfeelnauseous,butshewasalarmedat

howfrequentlyshewastakingthe‘paintablets’andhowthismadeherfeelaboutherself.However

wellmeantthemedicationwas,itdidn’tfeeldignifiedtobesoreliantondrugs,orquitesosleepy

andunresponsiveforsuchahighpercentageoftheday.Whilsttheanalgesiawasworkingwellwhen

shetookthetablets,thequalityoflifewasn’twhatshewanted.

ThecommunitynurselistenedpatientlytoMrsDrewandthen explainedthatitwasnormaltohave

panicmomentsaboutsuchmedication.Morphinehadareputation,onethatpeopleassociated

withmisuseofdrugs,ratherthantheirtherapeuticuse.Usedonaregularbasis,thedrugwouldn’t

causeaddictionanditwouldprovideagreatdealofreassurancetoMrDrewaswell.Thecommunity

nursestatedthatshewasquitesurethatherespectedhiswife’sneedtosleepwhenshewishedand

tobuildtherhythmofthedayaroundherneeds.

AtthispointMrsDrewshookherhusband’shand,andsaid,‘tellher…tellherwhatwe’vetalked

about!’MrDrewthenexplainedthathiswifewasusedtodealingwithpain,shehadsuffered

recurrentpaininherneckandshoulderafteraroadtrafficaccidentsomeyearsbefore.Thepainhad

sometimesbeensevere,buthehadmassagedhershouldersandusedheatpacksthatshefound

soothing.Theyhaddecidedthattheywishedtousethistechniquenow,keepingthemorphinefor

absoluteemergencies,whenshewaslosingsleepandcouldn’teatasaresultofthediscomfort.

Thecommunitynurseassuredthemthattheywereinchargeoftheanalgesiaandwouldbeallowed

tomaketheirowndecisions.Shestartedtomakenotesthough,andannouncedthatshewas

makingareferraltothecancerpainclinic,somethingthatwouldhelpthemtotakestockofthe

situation.Therewasverygoodreasontosupposethatthismightbeaproblemassociatedwith

choosingtherightdosageofthemorphine,ratherthanusingsupplementalpainreliefmeasures.

MrsDrewrespondedsharply,‘You’renotlisteningtomethoughJane(thecommunitynurse’s

name—apseudonymisusedhere),Iwanttouseheatpacksinsteadofmorphine,atleast duringthe

day.Iwanttobemorealivewithmyhusband.’ThecommunitynurseassuredMrsDrewthatshe

hadheardwhatshehadsaidandrespectedherpointofview.Therewouldthoughbenothinglost

byusingtheclinictogainafurthercheckonthismatter.Withthatsheexcusedus,explainingthat

wehadafurtherappointmentthatmorningandweleft,havingcheckedthatMrsDrewhada

sufficientsupplyofherdifferentmedicines.

 13

AswewalkedtothecarthecommunitynurseempathisedwithMrsDrew’splight,sayingthatifshe

hadlungcancershewouldprobablygraspatstrawstoo.Shewouldreachoutforthingsthatseemed

morenormal,andthenobserved,‘butthisisn’tnormalisit,thepainshehasisn’tnormal.It’snot

justawhiplashinjuryandoldage.’

Feelings

Irememberthatduringthisepisodefeelingamixtureofconfusion,surprise,angerandimpotence.

MrsDrewhadsurprisedmebythewayshehadspoken,usingwhatseemedtobeaplanned

announcement.Theyhadwaitedforandperhapsrehearsedthis moment.Nothinginmyexperience

todatehadpreparedmeforsuchanencounter,atleastinsuchcircumstances,whereweasnurses

weresoobviouslyworkingtosupportthepatient.ItwasonlylaterthatIcalledtheepisodea

confrontation.MrandMrsDrewhadconfrontedthecommunitynurseandIhadbeenthelargely

silentwitnesstotheevent.AsthediscussionproceededIremembermakingsupportivenoises,

remarkinghowusefulheatpackssometimeswereandglancingacrossatJane,whoseemedtobe

signallingwithherexpressionthatIshouldleavethis debatetoher.Iwastryingtoreadher

reactionstotheDrew’spointsandconcludedthatifIcouldn’tsupportherargumentstothepatient,

thenIshouldremainsilent.TherewereissuesherethatIperhapshadn’tenoughexperiencetodeal

with,atleast,whilst‘thinkingonmyfeet’.

Myinitialanger(withMrsDrewfornotacknowledgingallthatweweretryingtodo)quicklybecame

displacedtowardsmycolleagueJane.DuringtheeventIcouldn’texplainwhythatwas,but

afterwards,whenImadenotes,Irealisedthatitwasbecausesheseemedtohavesettheagendain

herownmindandtoberequiringthepatienttocomplywithconcernsofherown.Putrather

crudely,Janeseemedtobesaying,listenIknowaboutthesethings,thisisaphase,ananxiety;you

canworkthroughallthis.Ibelievedatthispointthatshehadmissedthesignificanceoftheevent,

thewayinwhichtheDrew’shadarrangedtheconversation.Forthem,thiswasnotaphaseatall,

butaconsideredandveryimportantdecision,onethattheywantedthenursestoaccept

(Freshwater,2002andEdwardsandElwyn,2009emphasizetheimportanceofnegotiatedcare

planning).

Myfeelingsofimpotencewereassociatedstronglywithmylackofclinicalexperience.Ihavemet

thisbefore.NomatterhowmanyplacementsIdo,nomatterhowgoodthementoringIreceive,I

keepmeetingsituationswhereIamunsureabouthowtorespondnext.Ifeelyounger,less

knowledgeablethanIshouldbeatthisstageinmytraining.Iwanttoreassurepatients,tosupport

colleaguesandtogivegoodadvice,butthereisnotenoughconfidencetodothat.IfIfeltunsettled

anduncertainaboutJane’sresponsetotheDrew’s,rightthenIcouldn’teasilyexplainthat.I

couldn’tofferasecondopinion,couldn’tsuggestanideathatmighthelpsupportthepatient.Tomy

annoyanceIcouldn’tmanagethateitherasweleftthehouse.Janehadmadesomefairpoints,she

clearlyseemedconcernedaboutthepatient’sneeds,butperhapsshehadn’tspottedtheright

need—forMrsDrewtodetermineingreaterparthowshedealtwithherillness.

Experienceevaluated

Afterwards,this shortepisodeprompteddoubtsanddebatesaboutseveralimportantaspectsof

nursingforme.Settingasidetheetiquetteoflearninginclinicalpractice,notchallengingaqualified

nurseinfrontofapatient,therewereproblemshereassociatedwithsupportingpatientdignity,

 14

withmyassumptionsrelatingtoanalgesiaandpaincontrolstrategies,andIrealised,withmy

assumptionsabouttypesofpainandwhohadtheexpertisetodefinethese.

Dignityismorethansimplyusingtheappropriatetermsofaddress,protectingtheprivacyof

patientsandattendingtotheirexpressedconcerns(Price,2004).Itisaboutclarifyingthewaysin

whichtheyliveandaccommodateillnessortreatment.Itisaboutfindingoutwhatbenchmarksthey

usetosaythat‘yes,Iamdoingwellhere,thismakesmefeelgoodaboutmyself’.Uponreflection,I

sensethatweonthisoccasionhadnotworkedhardenoughtodiscoverhowMrandMrsDrew

definequalityoflife,orbeinginchargeoftheirsituation.Weweremoreconcernedwithproviding

resources,sharingresearchortheoryaboutmedicationandquestioningthefamiliarmisconceptions

associatedwithmorphine.Toputitsimply,wewere‘missingatrick’,readingtheencounteras

somethingthathadhappenedmanytimesbefore—thereportofproblemsoranxieties,arequestfor

help,ratherthanadecisionthatthepatientandhercarerhadalreadycometo.Readingsituations

wellseemed,withthebenefitofhindsight,tobethefirstbasisfordignifiedcare.‘Whatishappening

here,whatwillhelpthepatientmost?’werequestionsthatweperhapsassumedthatwealready

knewtheanswerto.

IrealisedthatinmytrainingIhadalreadyacceptedtheargumentthatpatientswouldwishto

remainpainfreecomewhatmayandthatthetacklingoffearsaboutprospectivepain,was

somethingthatnursesengagedin.Iassumedthatbecausecancerpainrepresentedsuchamajor

threat,becauseitwasgreaterandmoreallencompassing,thattherewaslittleornodoubtthatit

shouldberemoved.Whatwassounsettling,andtooksomuchtimetoexamine,wasthatMrsDrew

acknowledgedthepossibleseverityofmetastaticcancerpain,butthatshestillpreferredtorespond

toitusingmeasuresthathadworkedforherwhiplashneckinjury.MrsDrewwaswillingtotradeoff

apainfreestateforsomethingthatgaveheragreatersenseofcontrolandwhichperhapsenabled

herhusbandtoexpresshissupportforherinaverytangibleway(preparingheatpacks,massaging

herback,ratherthansimplygivingherthetablets).MrandMrsDrewquestionedallmyassumptions

aboutbestanalgesiapractice,andseemedtowritealargequestionmarkonthetextbooksIhad

readaboutchasingratherthancontrollingpaininpalliativecaresituations(MannandCarr,2006).

Reflections(learningopportunities)

TheepisodewithMrsDrewleftmeuncomfortablebecausemypastapproachtopainmanagement

wastheoretical.I(andIbelieveJanetoo)regularlymadeuseofsciencetodecidewhatcouldbe

doneasregardspainreliefandtoassumethatpatientswouldwishtoachieveallofthosebenefits.

Thiswasn’taboutlocalapplicationsofheatversusmorphine,MrsDrewcoulduseboth,itwasabout

choiceandhowpatientsmadechoices—whytheyreachedthedecisionsthattheydid.Itwasforme,

aboutacceptingverypersonally,thatprovidingthatpatientsaregivenalltherelevantfacts,alerted

totheoptions,thattheyreallyareabletomakechoicesthatworkforthem.TheveryfactthatMrs

Drew'sillnesswasnowincurable,thatsheandherhusbandusuallytackledpaintogether,meant

thathersolutiontothechallengewasdifferenttothosethatmanyotherpatientsarrivedat.Having

dealtwiththispainforsometime,knowingthatitcouldandprobablywouldgetworse,meantthat

shewasbetterequippedthanotherlessexperiencedpatientstomakeadecisionhere.

Thistooknothingawayfromthebenefitsofsharingfurtherdiscussionwithpainclinicexperts.I

thought,MrsDrewwillstandherground,shewillinsistondoingthingsherwayifherhusbandis

 15

strongtoo.Whatitdidhighlightthoughwastheimportanceoflisteningtopatients,hearinghow

theyperceivepain,howtheynarratenotonlythepainbutwhattheydidaboutit.Inthisinstance

thenarrationwasallaboutdignity,andcoping,andfindingwaystohelponeanotherandhowthis

enablesustofeelinthefaceofsuchaterribleillness.So,intellingusaboutherpain,whatshedid

aboutit,usingmorphinewhenitwas‘absolutelyrequired’,MrsDrewwasnotreportingher

ignoranceof whatcouldbeachievedifthemedicationwasuseddifferently,butwhatshepreferred

todoasitenabledhertoachievedifferentgoals.MrsDrew’sgoalswereaboutliveliness,alertness

andstoicism,showingthatshecouldbearatleastameasureofpain.

IwonderedwhyIhadn’tlistenedcarefullyenoughtosuchastory?Wasitbecauseoftimepressure,

orperhapscomplacency,thatJaneandIfeltthatwealreadyknewwhataccountwouldbeshared?

Didwethinkthatthepatientwouldaskforhelp,morehelp,asthepaincontinued?Ifso,thenour

guesseshadpromptedustobehaveasexperts,andproblemsolvers,onthepatient’sbehalf.

Perhapshearingapatientnarrativeisaboutdiscoveringwhatsortofroletheywouldlikeyo uto

fulfil.Ifso,thenitmightbeadifficultrole.IthoughthardabouthowhardthiswasforJane.Shewas

goingtobeaskedtowitnessMrsDrew’sfuturepain,onethatwasnowlessperfectlycontrolled.She

wasgoingtobeaskedtoreassure,tosuggestmeasuresthatmighthelp,withoutremindingthe

patientthatshe‘alreadyknewthatyoucouldn’tmanagepainthatway!’WhenIthinkaboutitnow,

thatisverystressfulforanurse.Itisaboutcaringandallowingpatient’stomakechoicesthatwe

personallymightnotmake.

Conclusions

Ihavedrawnthenthreeconclusionsfromtheabovereflection.

First,thatbeingpatientcentredisnevereasyandrequiresreallisteningandinterpretationskills.My

criticismofwhatJanechosetodo,totryanddissuadeMrsDrewfromacourseofaction,

recommendingfurtherappraisalofthesituation,isaneasyonetomake.Nursesconfrontsituations

suchasthisrelativelyunpreparedandreactasconsideratelyaspossible.Itiseasyinhindsightto

recommendotherresponses,afurtherexplorationofwhatmotivatedMrsDrew’spainmanagement

preferences.

Second,thatexperiencecanbeavaluableteacher,theequaloftextbooks.Ifnursesareinterestedin

care,thenweshouldbeconcernedwiththesensethatpatientsmakeoftheirownillness,the

treatmentorsupportthattheyreceive.Weneedtounderstandwhatpatientshavetoteachusand

havetoacknowledgethatthismeansthatwewon’talwaysseemincontrolourselves,expertand

knowledgeable.Ourexpertisemightbeelsewhere,helpingpatientstoreachtheirowndecisions.

Third,thatonewaytounderstandpatientperspectivesonillnessortreatment,onpainmanagement

inthisexample,istohearhowtheytalkaboutthesituation.Howdotheydescribethepain,howdo

theyrefertowhattheydidaboutit?Thewayinwhich thestoryisshared,howwecoped,howthis

madeusfeel,isasimportantasthefactsrelated.Sometimesapatientneedstofeelstalwart,even

heroicinthefaceofillness.



 16

Futurecare

Itwouldbefoolishandunprofessionaltorecommen dto otherpatientsthattheymightnotwishto

removepain,orthatovercomingpaindoesn’talwaysmeanwedon’tcontinuetoexperienceit.For

everyMrsDrewtheremaybemanyotherpatientswhowouldwelcomethecompleteremovalof

pain,sothattheycandiecalmly,quietly,withtheirownversionofdignity.Butitdoesseemtome,

thatitwillbeworththinkingaboutthediversityofpatientsandhowtheyprefertocopewhenI

assesspainandhelpmanagethisprobleminthefuture.Iwon’tbeabletowalkawayfromthe

responsibilityofdebatingwhetherIhaveexplainedallthatIcould,detailedthestrengthsand

limitationsofdifferentwaysofcoping.Iwillneedtofindreflectiontimetoponderwhatpatients

havesaidandifnecessarytogobackandsay,‘I’vebeenthinkingsomemoreaboutyourwordslast

week..’knowingthatthisdoesn’tmakemeanythelessprofessional.



References

Edwards,AandElwyn,G(2009)Shareddecision‐makinginhealthcare:achievingevidence‐based

patientchoice,2

ed.Oxford,OxfordUniversityPress

Forbes,K(2007)Opiodsincancerpain,Oxford,OxfordUniversityPress

Freshwater,D(2002)Therapeuticnursing:improvingpatientcarethroughselfawareness,London,

Sage.

GibbsG(1988)Learningbydoing:aguidetoteachingandlearningmethods,Oxford,Oxford

PolytechnicFurtherEducationunit

Hunt,I.,Muers,MandTreasure,T(2009)ABCoflungcancer,Oxford,Wiley‐Blackwell/BMJBooks

Mann,EandCarr,E(2006)Painmanagement,Oxford,Blackwell

McCaffery,MandPasero,C(1999)Pain:Clinicalmanual,Mosby,Philadelphia

Mishler,E.,Rapport,FandWainwright,P (2006)Theselfinhealthandillness:patients,professionals

andnarrativeidentity,Oxford,RadcliffePublishingLtd

Price,B(2004)Demonstratingrespectforpatientdignity,NursingStandard,19(12),45‐51



 17

OurNotes

Thefollowingnotesofferpointsonthedesignofthisessaybutdonotconstituteamarkingofthe

work.Thenotesaredesignedtohelpyouidentifykeyfeaturesofthework.



Characteristicsofreflectiveessaywriting

Raymet’sworkischaracteristicofreflectivewritinginnursing,inparticular:

 Appropriateuseofthefirstpersonsingular(I).Thesearereflectionsofthenurseherself.To

writeinthethirdperson(thenurse)couldbecomeconfusingandinauthentic.

 Useofareflectiveframework(itisnotbeyondpossibility

touseaframeworkofyourown

design,butthosetriedandtestedbeforehavemuchtocommendthem.Youarelikelyto

covermaterialmoreevenlyandtodemonstrateadeeperanalysisusingthese).

 Explorationoffeelings,attitudesandvalues(theseareusedbynursestointerpretcare

requirementsandtoplaninterventions).

 Descriptionofacasestudycareepisode(dispassionateandsuccinct).

 Limitedreferencetotheliterature(thefocushereisuponexperienceandthemeaningsthat

mightbearrivedatthroughreflectionuponthesame.Referencestotheliteratureare

importantbywayofillustration

oraspartofacomparisonoftheoryandpractice,butthe

argumentswithintheessayarenotjustifiedbytheliterature.Theyarerecommendedtothe

readerintermsofexperiencedescribedandwhattheysuggestasregardsthenurse's

introspection).

 Patients/colleaguesrenderedanonymous(throughpseudonyms).



Introduction

Whilstmanyreflectivepracticeessaysgostraightintothedescriptionofthesituationwe

recommendanintroductionthatsetsupthepurposeoftheessayandwhichhelpsthereaderto

anticipatewhatwillappearbelow.Inreflectivewritingthisusuallyreferstoajourney,aprocessof

enquiry.HereRaymet

conveysthisveryclearlyandacknowledgessomethingofwhatshehas

alreadyrealisedthroughtheprocessofnotemakingandessaydrafting.Inthiscase,thatisthat

patientcentredcareandassessmentofpainareaboutnarratives,thewaysinwhichaccountsare

sharedbythepatientaswell

aswhatisreported.Werethisanessayabouttheory,Raymetmight

stateacaseatthebeginningofheressay.Noticethesignpostingwithinthissection,Raymet

explainshowshewilluseGibbs(1988)reflectiveframework.Thisisimportantasotherwisewe

mightexpecttoseethesection‘conclusions’come

lastinthewrittenwork.



 18

Thesituation

Inreflectivewritingitisimportanttobeclearwhenyouarewritingaboutfactsandwhenyou are

referringtoperspectivesandexperiences.Inthissectionthefocusisuponfactsandsothewritingis

succinctanddescriptive,reportingthatwhichhappenedandwhichispertinenttotherest

ofthe

paper.Raymetavoidssurmisingthemeaningofwhathashappened,forinstancethechangeinMrs

Drew’sprognosis.Welearnwhatthepatientandherhusbandsaid,gainasummaryofwhatthe

communitynursesaidandarelefttoourselvesreflectonwhatthissignifiesaboutMrs

Drew,about

thepainassessmentandaboutthecarerelationshipinthiscontext.Ratherlikeapoliceofficer,

reportinginformationfromaroadtrafficaccident,thefactsratherthaninterpretationsand

speculationsaresharedhere.

Towritethissectionitisnecessarytodecidewhatispertinentandwhatisnot.

Youmightconsider

thatweneededmore detailaboutthemedicationused,howlongMrsDrewhadbeenprescribed

opiates,thedosageandthepatternofuse.Itcouldbevaluabletolearnsomethingaboutpastpain

assessmentsandtolearnwhetherthepatienthadkeptapaindiary.Nonetheless,

thesectioniswell

conceivedasitfocusespreciselyupontheissuesthatareupfordebate,thatis,whoshould

determinehowbesttojudgepainandthenhowtomanageit.Itisthisrelationshipbetweencare

philosophies,respectforthepatientaspartnerincaredecisions,andthe

nurse'seagernessto

relievesufferingwhichisatissuehere.

InapreviousdraftofsuchanessayRaymetmightnothaveachievedsuchaclearfocus.Draftingthe

reflectiveessaycanitselfimprovereflection,promptingsecondandthirdthoughts.Ajudgementhas

tobemadethenbetweenworkingand

reworkingessaystoimproveclarityandtransformingthem

intotheory,therebylosingsomeofthefreshnessofthefirstwork.WethinkthatRaymethasfound

ahappybalancehere.



Feelings

InthissectionRaymetwritesaboutherfeelings.Shedoesnotsurmisewhatthoseofotherpeople

mightbeandwereshetodoso,itwouldhavetobeclearthatsheisspeculating.Akeypartof

reflectivewritingistoexplorehowourfeelingsmightfilterexperienceof

careepisodesandaffect

perceptionsofwhathappened(asgood,bad,indifferent).Thiscanbeadifficultelementofwriting

becauseyoumighthavetoownuptosomeuncomfortableemotions.Abalancehastobestruck

betweenselfcritiqueandcompassion,recognisingwhysuchemotionscanarise.Noticehow

Raymet

identifiesthekeyfeelingsinthefirstparagraphher eandreviewseachinturnusingthefollowing

paragraphs.Thisisaclearandmethodicalwaytoproceed.Wecanseenotonlywhatemotions

occurredbuthowthefocusoftheseshifted.Thisdemonstratesacarefulconsiderationofemotions

herpart.Shedoesnotassumethatemotionsareright,justifiedorselfevident.Thereisno

crusadehereregardinghowcareshouldbe.



 19

Experienceevaluated

Itispossibleforstudentstoconflatethenexttwoselectionsandtorepeatthemselves,butRaymet

avoidsthathere,treatingthissectionasasummaryofwhattheepisodemeansandthenextsection

asanindicationofwhatneedstobeexploredfurther,withregardtoassessmentanddialogue

with

patients.Thissectionisverymuchreflectiononactionandaboutarrivingatameasuredjudgement

ofhowtheepisodecanbecharacterized.ForRaymetitisaboutatensionbetweenphilosophy(care

thatenablespatientstofeeldignified)andaboutmentalsetandtheory(thewaysinwhich

nurses

habituallyapproachcaresituationsandusetheorytoanticipatehowbesttoact).Itiscarethatwas

lesssuccessfulthanitcouldbe.Shereviewstheissuesbriefly,butconveysinsightsintowhynurses

behaveastheydo.It’sworthconsideringhere(andlater)whetheryouthinkthatRaymet

showsa

dueregardforJanetheCommunityNurseandherpredicament.Doyouthinkthatshesimplyjudges

Jane,orwhethersheshowsadueunderstandingofwhyhercolleaguemightbeoperatinginamore

ritualorfamiliarway?NoticeRaymet’sobservationthat‘weweremissingatrick’.

Thiscouldseem

rathercolloquialwriting,butitdoesconveycrisplyhowRaymetsawthis,asalostopportunity.



Reflections(learningopportunities)

Thisispossiblythemostpowerfulsectionoftheessay,andonethatisconveyedverylucidly.

Raymetreturnstothereflectionsometimelaterandbeginstoaskquestionsaboutwhysheandher

colleaguefailedtoreadthecareepisodesuccessfully.Suchlaterstagethinkingisimportantif

reflective

practiceepisodesaretohelpthenurseidentifyusefulwaysofthinkingabouthealthcare,

patternsofwhatitisimportanttoconsiderwhenmakingcaredecisions.Itisnotsimplythatthe

nursesdidnotlistenlongenough,itwasthattheylistenedtothereportedfactsinthepatient’s

account,butnothowtheaccountwasarranged.Raymethereisusingsometeachingweshared

aboutpatientnarrativesandthepropensityofusalltotellstoriesabouteventsthatgivemeaningto

whathappened.Forexample,wetellstoriesaboutatriptothedentist.Thesereportwhatwas

done

(Ihadafilling)butmayalsoindicatesomethingaboutourbravery,thecostoftreatment,guiltabout

eatingtoomanysweetsandmuchmore!Peopleusestoriestoconveythemeaningsofeventsto

othersandtoelicitresponsesfromus,thelisteners.Inthisinstance,MrsDrew

mighthavebeen

lookingforapproval,supportandconsultationonherplantomanagepaindifferently.Instead,Jane

treateditasareportoffalteringconfidenceinpainmanagementandsuggestedthatreinforcement

mighthelp(thecancerpainclinic).



Conclusions

Raymetusesbulletpointshereandthesecanbeeffective,providingthattheyhelpyousummarise

informationthathasbeeneitheraddressedelsewhereorwhichisincidentaltothemainarguments

ofthepaper.Routineuseofbulletpointscanmakeyouressaylookalittletoonotational,souse

them

sparingly!

Theconclusionsneedtosumuptheprecedingreflectionsandyourdeliberationsonthesame.

Raymetachievesthathere,showingempathytowardshercommunitynursecolleague(thiswork

 20

isn’teasy),insightintopatientcentredcareandapossiblewayofthinkingaboutwhatpatientssay

(narratives)thatmightassisthertoworkdifferentlyinthefuture.



Futurecare

ThisisquiteashortlastsectionfromRaymetandyoushouldavoidrunningoutofsteambyplanning

yourworksothatanadequateproportionofwordsareallocatedthere.Itcanbedifficulttodecide

whatnext,afteryouhavereachedconclusionsintheprevioussection.Hereitis

necessarytoavoid

soundingtrite(‘Iwilllistentoandhearallpatients’narrativesinthefutureandactaccordingly’)and

tobeclearaboutwhatcouldrepresentanextstep.Inthisinstancethatcouldbethingssuchas

identifyingoneormorefuturecasestudieswhereyoutry

tohearpatientaccountsmoreclearly,

testingyourinterpretationwithothers.Itmightbetoreadmoreaboutpatientnarrativesandtheir

role,sothatideascanbeevaluatedfurther.Raymet’s‘futurecare’isappropr iatelymeasuredin

tone,butitlacksalittledetailaswell.