Levels of critical thinking in reflective writing

Until now, we have considered different critical thinking levels as they apply to theoretical knowledge. A different set of levels apply when undertaking reflective writing and you are asked to deduce things from experience. Kember et al (2008) and Weimer (2012) refer to four different levels of reflection (Figure 3).

Figure 3

Habitual action

In habitual action, which is the lowest level of reflection, the individual proceeds without conscious reconsideration of that which is assumed. Many things are treated as obvious, common sense or taken for granted and therefore not worthy of further discussion. The individual assumes that others think as they do and that their observations do not require further justification. This is considered to be obvious – the nurse anticipating that what they know is also understood by the patient.

Returning to the example of Gillian, a student might fail to reflect on what self-management of diabetes entails. If you think in this way about your practice, your writing may be described as ‘descriptive’. If you write this way about what should be done, what is right or best practice, your work may be considered ‘opinionated’.

Understanding

The second level of critical thinking in reflective writing is described as ‘understanding’. Experiences are related to theory, but in a naive way. The behaviour of a patient, such as Gillian, may exemplify a theory that you have read about. For example, Gillian’s management of her diabetes is explained by the Health Belief Model (Abraham et al 2000). You believe that the model sums up her behaviour, for example explaining what brings about failures in self-care. At the understanding level there is a greater awareness of experience and recognition of what is problematic or challenging. However, the explanations arrived at are unduly simplistic. Typically, experience is made to fit theory. This way of thinking is appealing. It seems much tidier than having to explore and explain the complexities of meaning that influence an illness and its management. In understanding, the student moves to a plausible explanation of what has been seen or heard, without pondering whether this seems entirely adequate.

Reflection

The third, higher level of reflective critical thinking in reflective writing is termed ‘reflection’. Deeper ways of reasoning on experience are only really apparent at this level (Kember et al 2008). Reflection in this usage means that you have embraced the experience as a place of negotiated meanings. Interest is taken in the way that the patient and others have ascribed meanings to what is happening.

So, to return to the example of Gillian, you might speculate about why Gillian’s self-management of diabetes has faltered, and what has intervened to make it more difficult for her to cope. You may speculate about motivation, confidence, and problems and stresses that the patient may have experienced. Now, the reference point for understanding experience is not solely a theory, but the ways in which a particular person makes sense of their circumstances. You engage in an examination of how the patient perceives things, which is an essential part of compassionate care.

Critical reflection

The most sophisticated level of reflective critical thinking is described as ‘critical reflection’. This is described as ‘perspective changing’ by Weimer (2012). Critical reflection demonstrates that you are openly confronting some of your values, attitudes and beliefs relating to a subject.

So, in the example of Gillian, you might write about your assumptions about the rational nature of human beings and their ability to learn about an illness and its management. Because you have been motivated by rational enquiry, a wish to manage events through your grasp of information, you have assumed that patients will think in the same way too. However, Gillian has confronted you with a conundrum. While she is intelligent, she does not want to cope in the prescribed way. She feels like a victim, fated to illness, and is unable to reason her way through the demands of the condition. You concede that you should think again about Gillian’s experiences and what type of help might be required.

Learning Points

1. Kember et al (2008) and Weimer (2012) refer to four different levels of reflection: habitual action, understanding, reflection and critical reflection. The lowest of these is ‘habitual action’.
2. One helpful way of identifying higher and lower levels of critical thinking is to examine excerpts of writing from past assignment answers and determine why the writing seems more or less analytical.
3. Negotiating care with reference to what seems best in the circumstances and with what the patient can most readily relate to often demonstrates nursing practice at its most individual and compassionate.
4. The most sophisticated level of reflective critical thinking is described as ‘critical reflection’.

Critical thinking in assignments

Critical thinking taxonomies may seem clear. However, there is still the need to translate these different levels of critical thought into words. You have to find ways to demonstrate the relevant level of critical thinking in your text. It may seem tempting to populate your coursework with words that signal debate, introspection and the ability to consider different arguments, using words such as ‘arguably’ and ‘speculatively’. However, higher critical thinking levels are rarely demonstrated in words or short phrases. Where such phrases are used to excess, they suggest that you have not formulated a perspective of your own, but are only rehearsing the arguments of others. Passages of text, especially paragraphs, are the best ways to show critical thinking. Paragraphs allow you to present an argument, demonstrating how you focus on a topic, how you evaluate evidence from the literature or from experience, and how you rehearse ideas and establish a case. Linking a series of paragraphs together shows this analytical process.

One helpful way of identifying higher and lower levels of critical thinking is to examine excerpts of writing from past assignment answers and determine why the writing seems more or less analytical. This module includes two excerpts of writing in Box 2 and 3.

Box 2. Theory-related critical writing

The patient history taken at the outset of care forms one of the essential bases for successful patient education. The educator should understand the starting point from which the patient commences, as this indicates the amount of learning the patient must work through and something about whether they feel ready to proceed. It is important to understand what the patient already knows, and to appreciate exactly how they feel about their current state of knowledge. Both of these are important because the educator must help motivate the patient.

Patients may be more or less aware of what they don’t already know, and they may have doubts about their ability to learn. Elwyn et al (2014) explains that the motivation to learn stems from an apparent discomfort. The patient senses that their understanding and control (in this example, of self-management of diabetes) is incomplete. They may or may not want to rectify that at this stage.

Understanding exactly how the patient feels, right now, about the challenge of diabetes will help the nurse to determine whether the patient is ready to learn about self-management of diabetes or to conclude that psychological support must precede any teaching. It may be necessary to assure the patient that we understand their predicament, before we move to more practical teaching about what they can do about it.

Box 3. Reflective practice critical writing

‘Listening to Gillian’s tearful account of her struggles with managing her condition, I was struck by the profound frustration she expressed. She recounted how lapses in her injection regimen coincided with marital difficulties. Being diagnosed with diabetes, eating a restricted diet, injecting insulin and monitoring skin care didn’t happen in a vacuum, it happened in the context of a life, her life.

She recounted that she felt she should cope. After all, she was a school teacher and taught children about healthy eating, but well… she was human too.

Her revelations jolted me. I felt equipped to talk about a medical condition, but not a marriage. I appreciated suddenly that I was in the habit of compartmentalising health care. For me, health care occurred in a neat and separate place. I realised that illness, what it felt like to have a condition, meant blending the rational and the emotional. I couldn’t sensitively observe much about unhappy marriages, but neither could I exclude it from what I would try to do next, as I helped Gillian find a way forward.’

The excerpt of writing in Box 2 exhibits analysis. It does this by making an argument that preliminary assessment of the patient is important and explains why this is. If the patient is not assessed adequately, the nurse might proceed when the patient is not ready to learn about self-management. The teaching may be unsuccessful. Moreover, proceeding with teaching without making an assessment may mean that another option is missed.

The patient could be given psychological support, something that might sustain her control of diabetes in the longer term. The importance of assessment is outlined with reference to a theory of patient education and the importance of the motivation to learn. The relevant theory is alluded to briefly, but the excerpt as a whole succeeds as analysis. There is an appropriate emphasis on why assessment of the patient and their psychological state is so important and this is linked to two options later on, either to proceed with teaching or to concentrate on support.

Determining whether the excerpt in Box 2 is analytical does not rely on its inclusion of a reference from the literature. Instead, it is the selective application of information that persuades the reader that it is analytical. The student has made an argument about the importance of initial assessment and they have selected points to make in support of this. The extract exhibits a selective application of the theory, rather than reporting what that theory comprises. The basis of successful patient education is the understanding of readiness to learn and the patient’s motivation. This is the case that the student is developing.

To raise this answer to a higher level of critical thinking so that it is rated as evaluative, it would be important to include some caveats about opportunities to proceed in this logical manner of ‘patient assessment first, patient readiness to learn’. Pressures on bed occupancy, and the requirement to attend to other patients’ needs, might severely limit the nurse’s ability to delay patient education until this patient is ready. A compromise might have to be found, whereby support and teaching proceed side by side.

The excerpt of writing in Box 3 operates at the critical reflection level. Here the student has stopped to reconsider their familiar way of thinking, about coping in a rational way. The student recognises that their familiar way of explaining coping is insufficient and that if they proceed in the usual way, they may seem insensitive to the patient. It is necessary to pause, reconsider and concede that we do not necessarily have all the knowledge that we require to establish rapport with a patient.

Writing in this reflective way takes bravery, since it means you must express self-doubt. This may seem a less comfortable thing to do when so much health care demands certainty, or at least an air of certainty, as nurses work with patients. Facing uncertainty is unsettling. In nursing, there is an urge to solve problems, assert and reassure. In subsequent paragraphs of this essay, this student could go on to explore the ways in which Gillian could be helped to take stock of her situation and to seek help from different agencies. It was not assumed, however, that the student could resolve all of the patient’s problems. Rather, she understood that it was her role to help Gillian cope in her own way.

What lifts the extract in Box 3 to a level of critical reflection is that the work centres on Gillian’s situation and her experience (that which might convey empathy), as well as on how it challenges the student to rethink what she does (that which attends to the student’s beliefs and abilities). It is the interplay of care need and the student’s examination of what Orem termed ‘care agency’ (McLaughlin Renpenning and Taylor 2003) that transforms this passage of writing into a critical reflection.

In my experience, students sometimes remark that this level of critical thinking through reflection seems ‘psychoanalytical’. They observe that it does not necessarily produce the correct answer, or a definitive course of action. The thinking does not reassure the student about the right course of action to take as they work through the reasoning process. However, critical reflection acknowledges the ambiguities of practice in situations where there is no perfect or infallible solution, only more sensitive ways of working. Negotiating care with reference to what seems best in the circumstances and with what the patient can most readily relate to often demonstrates nursing practice at its most individual and compassionate.

Learning Points

1. Passages of text, especially paragraphs, are the best ways to show critical thinking. Paragraphs allow you to present an argument, demonstrating how you focus on a topic, how you evaluate evidence from the literature or from experience, and how you rehearse ideas and establish a case.
2. Reflection level recognises that the familiar way of explaining coping is insufficient and that if they proceed in the usual way, they may seem insensitive to the patient. It is necessary to pause, reconsider and concede that we do not necessarily have all the knowledge that we require to establish rapport with a patient.
3. Critical reflection acknowledges the ambiguities of practice in situations where there is no perfect or infallible solution, only more sensitive ways of working.

Conclusions

• This module has demonstrated that there is value in re-examining our understanding of the word ‘critical’. In the clinical sense, this refers to precision and risk management.
• The social use of ‘critical’ as something negative can make it seem difficult to approach critical thinking in a more ruminative and speculative way.
• In academic settings critical thinking is undertaken differently, depending on whether you focus on theory or experience.
• In a theory-related context, you are engaged in defining concepts, summarising evidence and bringing these together to explain what is happening and what you might do.
• In a reflective practice context, you are operating within a world of meanings, understanding how others assign meaning to their experience and how you do the same.
• If you seek greater understanding of your assigned meanings as well as those of others, then you should be able to reflect on your practice more deeply and demonstrate more compassionate care.
• Taxonomies of critical thinking can be a useful resource for examining assignment questions and your own coursework. It is important to understand what the assignment asks (its focus) and what level of critical thinking is required.
• Different types and levels of critical thinking may be demonstrated through the different ways they are written.

Glossary

Critical thinking: a process of insightful thinking that uses multiple dimensions of cognition to develop conclusions, solutions and alternatives that are appropriate for the given situation.

Emotional intelligence: the capacity to be aware of, control and express one’s emotions, and to handle interpersonal relationships judiciously and empathetically.

Gestalt thinking: the study of perception and behaviour from the standpoint of an individual's response to organised wholes. Gestalt thinking emphasises uniformity of psychological and physiological events, and rejects analysis into separate events of stimulus, percept and response.

Manual dexterity: adroitness in using the hands.

Taxonomy: a system for classifying organisms according to their natural relationships, based on common factors such as embryology, structure or physiologic chemistry. The system has seven levels (taxa): kingdom, phylum, class, order, family, genus and species.

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