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Reflective writing and critical incidents

Reflection on practice is an important aspect of your ongoing professional learning. In your course, this may take the form of a critical incident report. However, the focus is less on the event or incident or experience in itself – what is important is your reaction to it, and how it has informed your thinking and your learning.

Assessment tends to focus on how successfully you have demonstrated a capacity to analyse and reflect on events in order to learn from them. Also relevant to assessment is how much you are able to relate your current theoretical learning (for example, about the doctor-patient relationship, or about what constitutes effective communication) to a real life situation.

This section explains what is meant by reflective writing and the term "critical incident", and helps you explore the reflective learning process.

You will also find a format for the critical incident report, a sample piece of student writing, criteria for assessment and suggestions to help avoid some common errors in reflective writing.

The section on characteristics of reflective writing covers language features like:

tenses
speculative and hypothetical writing
the language of self-reflection vs criticism.

Reflective writing

What is reflective writing?

What is the role of reflection in the learning process?

Conditions for reflection

The action-reflection model

Characteristics of reflective writing

This section covers the language features of reflective writing.

Tenses

Reflective writing often requires movement between past and present tenses, depending on whether you are recounting the actual events or making a more general comment (for example, on the doctor-patient relationship, or on an aspect of your current course).

Generally, when recounting a particular experience or incident, past tense is used.

Example 1

As part of my placement at a small rural hospital in north-west Victoria, I worked closely with the nursing staff. I was impressed by the rapport they had with their patients – while performing their duties professionally they often joked with the patients, and in that way maintained a relaxed and pleasant atmosphere on the ward. I noticed that the nurses had more regular contact with patients than the doctors, and consequently seemed to develop a closer relationship.

Example 2

When two of the patients became agitated I did not know what to do. I asked them to return to their beds, but they simply ignored me. I did not know what the correct procedure was in this situation.

When making a general comment, or relating an incident to current practice or to a particular theoretical perspective, present tense is normally used.

Example 3

It seems that the roles of nurses and doctors are quite different, and that doctors need to acknowledge the importance of the nurse-patient relationship.

Example 4

Clearly making new staff aware of the procedures and rules is important when they join a new workplace or institution.

Tip

It's always good to stop and reflect on what you have written. Have your views been affected by your personal or professional experiences? Think about your use of tenses. Check that you have written your reflections in a non-judgemental way.

Speculative and hypothetical writing

In reflective writing you may be asked to speculate about the future, or about a hypothetical situation. For example, you may be asked to comment on whether you would like to practice in a rural area in your future career.

Notice in the example below the movement between past and present tenses, and the use of 'would' when speculating about the future.

Example 5

Although my rural placement was a very positive experience, I would not like to work in the country when I first graduate. There are several reasons for this. Firstly, being a country doctor is more challenging – you do not have the support networks available in the city, so you have to cope with many different situations. Also, you have less privacy. In the country I would have to behave as the local doctor all the time, 24 hours a day. There would not be an opportunity to just be myself and not worry about what people think. Living in the country I would be far away from my family, and might feel lonely for that reason. Finally, I would have to focus on general practice, whereas my interest lies in more specialized areas of medicine.

Example 6

As soon as I started there, I could see that having a good working relationship with the nurses would make my job much easier, and would possibly result in better health care for patients.

Self reflection v self criticism

Some writers become confused between self-reflection and self-criticism. You need to go beyond simply admitting a weakness or mistake or failure – what is important is not only what you did, but how you felt, what you have learnt from that experience, and how it will inform your behaviour in the future.

Addressing course issues and topics

Try not to confine your writing to the event and your feelings. If possible, use it to raise new questions or to speculate about possible causes and solutions. Remember where possible to link your reflections to theoretical aspects of your course. For example:

Addressing course issues and topics – comparison

Original text	Alternative text
When the doctor raised his voice to the patient I felt embarrassed. It reminded me to maintain an appropriate communication style with patients when I am a doctor.	When the doctor raised his voice to the patient I felt embarrassed and the patient appeared to feel humiliated. Clearly this behaviour by the doctor was not appropriate, even though the doctor was obviously frustrated at the patient's apparent inability to understand the instructions. While it is the responsibility of every doctor to behave respectfully with patients, on this occasion an excessive workload and the lack of availability of an interpreter no doubt contributed to the doctor's behaviour. It reminded me that structural factors within the health care system, such as staffing and budgets, can impact on the quality of attention delivered to patients.

Original text

Alternative text

When the doctor raised his voice to the patient I felt embarrassed. It reminded me to maintain an appropriate communication style with patients when I am a doctor.

When the doctor raised his voice to the patient I felt embarrassed and the patient appeared to feel humiliated. Clearly this behaviour by the doctor was not appropriate, even though the doctor was obviously frustrated at the patient's apparent inability to understand the instructions. While it is the responsibility of every doctor to behave respectfully with patients, on this occasion an excessive workload and the lack of availability of an interpreter no doubt contributed to the doctor's behaviour. It reminded me that structural factors within the health care system, such as staffing and budgets, can impact on the quality of attention delivered to patients.

Common errors in reflective writing

1. Planning

You should be thinking about possible subjects and opportunities for reflective writing before and during your placements, not only after them.

2. Writing style

Writing too informally: just because it is based on your experience does not mean you can ignore academic style.

Example

Original text	Alternative text
In my opinion, if there are too many 'buts' in my choosing to practice in a rural area then I must not be ready for it, so it's better for me to stay put in the city.	The reservations I currently feel about practising in a rural setting suggest that I am not yet ready for such a move. So at this stage I plan to work in the city on graduation.

3. Too little or too much detail

You need to describe the experience adequately – the reader needs to be given enough detail to understand the context in which the experience occurred. However, it is not enough just to describe the experience in great detail: you also need to analyse and evaluate the events and the thinking processes involved. You should aim to consider deeper levels of meaning, exploring moral, ethical, social and/or professional issues.

Take time to organise and structure your writing. Try to focus on what was most significant about the experience, and relate it to aspects of your course and future career. Be careful that your writing does not seem to simply drift without direction or focus.

4. Being judgemental

Try to describe events accurately and honestly, but avoid moralising about people's behaviour.

Example

	Original text	Alternative text
1.	I was shocked when the doctor showed me the patient's file without seeking consent. His disregard for the rules regarding patient consent caused me to lose respect for him and to question his ethical standards.	I was surprised when the doctor showed me the patient's file without seeking consent. It made me realise that discrepancies can exist between what is taught on course and the way in which medicine is practised in reality. From my own perspective, as a future doctor I would seek to maintain high ethical standards, and to encourage that among staff under my supervision.
2.	During the second week of my clinical study, I met a patient who needed an x-ray for her knee and hip joint. She was overweight and not very aware of my role as radiographer – she treated me more like a technician than a future practitioner. Even worse, she was not cooperative, kept murmuring and shouted out about her pain throughout the procedure. Furthermore, this patient didn't listen to our instructions and wouldn't stay still after positioning.	During the second week of my clinical study, I met a patient who needed an x-ray for her knee and hip joint. This was made more difficult because she was significantly over-weight and not very aware of my role as radiographer. She appeared distracted and had difficulty coping with her level of pain, sometimes shouting out. In terms of the x-ray procedure the patient was uncooperative – she did not follow our instructions and would not stay still after positioning. This made it very difficult to produce an adequate x-ray. *It could be useful to analyse this incident further – for example:* What surprised me most about this incident was the attitude of the patient to the health professionals. In my culture most people treat health professionals with great respect, and acknowledge their authority; they are even sometimes intimidated by them. I realised that in the Australian context compliance from the patient cannot be assumed. The doctor has to gain the trust and cooperation of the patient, and this may not always be easy. In this case I found that talking quietly to the patient and explaining each requirement in detail reassured her, and ultimately led to a greater level of cooperation. However, this made the consultation much longer than it otherwise would have been.

Critical incidents

What is a critical incident?

Critical incident analysis

Format for the critical incident report

Sample critical incident report

The writing style required in producing a critical incident report is different from that of an academic essay; however, it is still important to present ideas in a systematic and organised way, and to use appropriate language. The sample below uses sub-headings consistent with the assignment requirements to explicitly organise the report. It is simply written, and avoids use of jargon or colloquial language.

Click the icons next to each paragraph to show comments. Click again to hide the comment.

Legend:

Good Problem Comment Question

Context of the incident

This report will outline a critical incident which occurred in Week 9, Semester 2 in my clinical tutorial. The incident was initiated by my tutor, who announced that she would provide individual feedback to students on their performance in clinical tutorial discussions. She also stated that she would be producing written comments on each student's behaviour, attitude and contribution in tutorials to be incorporated into student portfolios for Semester 2.

Details of the incident

At the end of my clinical tutorial my tutor arranged for us to meet briefly in order for her to discuss her feedback with me. She stated that over the semester she had noticed that I very rarely spoke in the tutorials and did not appear to engage with the other students.Lecturer's comment 1:
Note the use of reported speech to describe the conversations between those involved in the incident.

- She stated that…
- She was concerned that…
- In her view… She was concerned that I appeared to lack confidence, and explained that being able to express opinions clearly and confidently was essential in my future career as a doctor. In her view the only way to develop confidence was to participate regularly. She asked me how I felt about this, and if there was a reason why I almost never spoke in class. I explained that in my culture students were not always encouraged to speak, and for that reason I did not find it easy. I also mentioned that I sometimes feel shy.Lecturer's comment 2:
Note the use of first person to describe the writer's reactions and feelings:

- I explained…
- I mentioned…
- I felt embarrassed…
- I was worried that…
- I realised that…

Thoughts, feelings and concerns

At the time of this incident, many emotions were running through me. I felt embarrassed that my lack of confidence was so obvious to her, and also concerned about what impact it might have on my results. I was worried that she would write negative comments about my behaviour and attitude, and that these comments would be available for other lecturers to read. At the same time, I realised that her concerns were justified – I had been aware of my lack of contribution throughout the semester, and had even avoided going to some tutorials because of those feelings. This was also an unfamiliar situation for me, as I had always done very well at school and achieved good marks, so I had never had to talk with a teacher in this way before. Although I understood that her intention was to help me to do better, I felt very uncomfortable and even ashamed to have to acknowledge my poor performance in this area. I felt guilty when I realized that in her opinion I had contributed so little to the class.

Demands

This incident was very demanding because it forced me to acknowledge an area where I have always lacked confidence. Even though I preferred to focus on other areas, I knew that my tutor would be noticing my behaviour in tutorials over the rest of the semester, and that her written comments would depend on my performance, so as a consequence I felt under pressure. I also felt anxious about confronting this issue and trying to develop the confidence I needed.

Impact on studies

Although this incident caused me discomfort and added pressure in the short term, I realise that it was a very significant event in my studies. As a result of the conversation with my tutor I was forced to reconsider my behaviour in tutorials and became more aware of how others viewed me. I had been used to think that I was 'invisible' in tutorials, but now I realised that not talking actually made me stand out more. Fortunately, the tutor gave me advice on how to gradually develop the confidence I needed, and I also sought help from some of my friends. I even organized to have some informal tutorials with friends to give me a chance to practice. Over the final weeks of the semester I managed to talk at least once in every clinical tutorial, either asking a question or making a comment. I have started trying to talk in other tutorials also, in other subjects. I have set myself the goal of talking at least once every tutorial.

This incident was therefore very important, because without it I would still be remaining silent in my tutorials, and would have received negative written comments from my clinical tutor in my portfolio. More importantly, it has helped me to acknowledge and work on an area for improvement which will be beneficial in all aspects of the course. Developing greater confidence at speaking in tutorials may lead to me being more confident in performing clinical examinations on patients. It may also lead to me feeling more in control and experiencing less nerves during my Objective Structured Clinical Examination (OSCE) assessments.Lecturer's comment 3:
Expression: it might be better to say 'less nervous' or 'have fewer nerves'.

Impact on career

My tutor was right in stating that a doctor must be able to express opinions clearly and confidently. Good communication skills are essential for doctors, and are important in nearly all aspects of medicine. I feel that I will be more confident in dealing with patients and more effective in taking a patient history, for example. Developing greater confidence in how I communicate can lead to patients having greater trust in me as their doctor. Improving my skills in this area will also make me more effective in discussing cases with colleagues, and in participating in teams when necessary.

This incident made me realise that I can talk confidently once I overcome my initial fears. It demonstrated to me that in order to make progress or create positive change you must first acknowledge that a problem exists. This is a lesson which may be useful in better understanding patient behaviour and attitudes. Often the first step to improving a situation, or dealing with a problem, is accepting that some change is necessary; and I may be more able to impart this information to patients having experienced this incident. Overall, this incident has had a positive impact on both my studies and the development of skills needed in my future career.

Criteria for assessment

Reflective writing is a vehicle which you use primarily to share your thinking and learning processes with your lecturers. The event or incident or experience in itself is not important – what is important is your reaction to it, and how it has informed your thinking and your learning. Assessment tends to focus on how successfully you have demonstrated a capacity to analyse and reflect on events in order to learn from them. Also relevant to assessment is how much you are able to relate your current theoretical learning (for example, about the doctor-patient relationship, or about what constitutes effective communication) to a real life situation.

Most importantly, you need to be genuine and honest in your reflections, as illustrated in the following quote from a lecturer:

The most important thing to get across to the students is that they be genuine in their reflections, and not write what they think I want to hear. For example, empty rhetoric like 'this incident has made me want to go and work with people in developing countries', 'since this incident I have decided to be the best doctor I can possibly be' or 'in future I will treat my patients holistically' does not score points.

References

Branch (Jr), W.T., & Paranjape, A., 2002, 'Feedback and reflection: Teaching methods for clinical settings', Academic Medicine, Vol. 77, No. 12/Dec, Pt 1, pp. 1185-1188.

Fook, J., & Cooper, L., cited in (2003) Bachelor of Social Work Fieldwork Manual, Dept. Social Work, School of Primary Health Care, Monash University.

King, T., 2002, Development of Student Skills in Reflective Writing, University of Portsmouth, UK, viewed 27 November, 2006, http://www.csd.uwa.edu.au/iced2002/publication/Terry_King.pdf.

Whipp, J., 2003, 'Scaffolding Critical Reflection in Online Discussions', Journal of Teacher Education, Vol. 54, No. 4, pp. 321-333.

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