Reflective practice and writing

Reflective practice and writing Professor Jennifer Cleland and Dr Sarah Ross

Reflection We all learn from experience and from thinking back over our experiences. When done in formal ways to identify areas for learning this process is known as reflection. ‘Harry stared at the stone basin. The contents had returned to their original, silvery white state, swirling and rippling beneath his gaze. “What is it?” Harry asked shakily. “This? It is called a Pensieve,” said Dumbledore. “I sometimes find, and I am sure you know the feeling, that I simply have too many thoughts and memories crammed into my mind.” “Err,” said Harry who couldn’t truthfully say that he had ever felt anything of the sort. “At these times” said Dumbledore, indicating the stone basin, “I use the Pensieve. One simply siphons the excess thoughts from one’s mind, pours them into a basin, and examines them at one’s leisure. It becomes easier to spot patterns and links, you understand, when they are in this form.”’ (Rowling 2000) Reflective learning is a process of examining experiences with the intention of learning or gaining new insights to improve practice. Rather like Dumbledore’s pensieve, reflection is a method of standing back from our own thoughts and feelings about an experience and studying them. Gibbs puts it well: ‘It is not sufficient simply to have an experience in order to learn. Without reflecting upon this experience it may quickly be forgotten, or its learning potential lost. It is from the feelings and thoughts emerging from this reflection that generalisations or concepts can be generated. And it is generalisations that allow new situations to be tackled effectively.’ (Gibbs 1988) Another useful quote: ‘It will usually involve the sorting out of bits of knowledge, ideas, feelings, and awareness of how you are behaving and so on. It could be seen as a melting pot into which you put a number of thoughts, feelings, other forms of awareness, and perhaps new information. In the process of sorting it out in your head, and representing the sorting out on paper, you may either recognize that you have learnt something new or that you need to reflect some more’ (Moon 2004)

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Two other writers have been influential in defining reflection. Kolb discusses a learning cycle represented as follows:

Kolb suggests that learning can start at any one of the four points, but often it starts with carrying out an action. The action is then reflected upon, which forms new ideas and solutions, which are then tested out in further similar experiences. Schon describes two types of reflection; reflection-in-action, where the individual is thinking through aspects of a problem whilst in the situation, and reflection-on-action which occurs afterwards. Both these activities are needed for development and learning from situations. For example, during a difficult consultation with a patient, you may be reflecting in action by trying to work out how you can improve your communication to get particular information across. Afterwards, when you think back over the consultation and how you might do better next time, you are reflecting on action. Both models are discussed further in one of the early Community Course lectures.

Why use reflective learning? Reflection is an activity that everyone undertakes to some degree. Reflective learning is about making this process explicit and in doing so, maximising learning and providing evidence of reflection. Reflective learning has become more widely used for a number of reasons, but one important factor is that this type of learning promotes “deep” learning, i.e. the kind of learning where the material is understood in a personal context and builds on previous knowledge. Reflection also promotes personal development and growth and can help a student to integrate knowledge, skills, attitudes, and values. The General Medical Council specifically require that medical students should be able to reflect on practice and be self-critical. Accordingly, many post graduate training programmes now use reflective learning portfolios. It is expected that doctors will be “reflective practitioners”, a term which includes being self-aware, recognising limitations and identifying areas for improvement and undertaking continued professional development (CPD).

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What is reflective writing?

Reflective writing is evidence of reflective thinking. In an academic context, reflective thinking usually involves:  Looking back at something (often an event, i.e. something that happened, but it could also be an idea or object).  Analysing the event or idea (thinking in depth and from different perspectives, and trying to explain, often with reference to a model or theory from your subject).  Thinking carefully about what the event or idea means for you and your ongoing progress as a learner and/or practising professional. Reflective writing is thus more personal than other kinds of academic writing. We all think reflectively in everyday life, of course, but perhaps not to the same depth as that expected in good reflective writing at university level. While reflection is useful as an exercise, reflective writing adds an extra dimension. By documenting reflection, we can have a useful record of those thoughts which can be revisited, but the act of writing encourages a further level of depth. Jenny Moon lists a range of purposes for reflective writing which include:          

To record experience To facilitate learning from experience To support understanding and the representation of that understanding To develop critical thinking or the development of a questioning attitude To encourage metacognition (understanding of how we learn) To increase active involvement in, and ownership of, learning To increase ability in reflection and thinking To enhance problem solving skills For reasons of personal development and self empowerment To support planning and progress in research or a project

She also describes four levels of writing, which are increasingly reflective: (see appendix 1 for examples) Descriptive writing  Account is descriptive and contains little reflection.  Ideas are linked by the sequence of the account/story rather than by any meaning.  There may be references to emotional reactions, but they are not explored and not related to behaviour.  There is little attempt to focus on particular issues.  Most points are made with similar weight. Descriptive account with some reflection  The basic account is descriptive however, the account is more than just a story.  It is focused on the event as if there are questions to be asked and answered.  Points where reflection could occur are signalled.  There is recognition of the benefits of further exploration, but it does not go very far. Dialogic reflection  There is description but it is focused with particular aspects accentuated for reflective comment.  The material is being “mulled around”.

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   

There is evidence of external ideas or information and where this occurs, the material is subjected to reflection. The account shows some analysis, particularly exploring motives or reasons for behaviour. Where relevant, there is willingness to be self-critical. There may be recognition that things might look different from other perspectives, and that views can change with time or the emotional state.

Critical Reflection  Description now only serves the process of reflection, covering the issues for reflection and noting their context.  There is clear evidence of standing back from an event, “mulling over” and internal dialogue.  There is recognition that the frame of reference from which an event is viewed can change.  There is critical awareness of one’s own thought processes.  The view and motives of others are taken into account.  There is recognition that prior experience and thoughts can interact to produce current behaviour.  Points for learning are noted.  There is recognition that the personal frame of reference can change according to the emotional state in which it is written, the acquisition of new information, the review of ideas and the effect of time passing.

Reflective thinking can be followed by or accompanied by reflective writing. Reflective writing is not only a record of reflective thinking but also provides “space” for thinking, helps to order thoughts, encourages deep learning, and promotes understanding of how we, as individuals, learn. Reflective thinking – especially if done in discussion with others – can be very ‘free’ and unstructured and still be very useful. Even reflective writing can be unstructured, for example when it is done in a personal diary. In assignments that require reflective writing, however, tutors normally expect to see carefully-structured writing. Basically, reflective writing can be broken down into three parts: description, interpretation and outcome. Different words and phrases are useful at each of these three parts of the reflective writing process. The following includes a few suggestions for appropriate language to use in reflective writing, presented within the simple model of description, interpretation and outcome. Using any of these words and phrases will not in itself make you a good reflective writer, of course! 1. Description (keep this bit short!) What happened? What is being examined? We are not suggesting specific vocabulary for any descriptive elements of your reflective writing, because the range of possible events, ideas or objects on which you might be required to reflect is so great. Do remember, though, that if describing an idea, for example a theory or model, it is usually best to use the present tense e.g. ‘Social interdependence theory recognises…’ (not ‘recognised’). Events, of course, are nearly always described using the past tense.

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2. Interpretation What is most important / interesting / useful / relevant about the object, event or idea? How can it be explained e.g. with theory? How is it similar to and different from others?

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3. Outcome What have I learned from this? What does this mean for my future?

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This is just one way of structuring reflective writing. It is in essence no different from Moon’s four levels. Try to bear in mind the following four key points: • Reflection is an exploration and an explanation of events – not just a description of them. • Genuinely reflective writing often involves ‘revealing’ anxieties, errors and weaknesses, as well as strengths and successes. This is fine (in fact it’s often essential!), as long as you show some understanding of possible causes, and explain how you plan to improve. • It is normally necessary to select just the most significant parts of the event or idea on which you’re reflecting. (The next page has some suggestions on how to do this in your writing.) If you try to ‘tell the whole story’ you’re likely to use up your words on description rather than interpretation. • It is often useful to ‘reflect forward’ to the future as well as ‘reflecting back’ on the past. Read through the reflective writing examples in Appendix One and consider how each gets the balance between description, interpretation and reflection, and outcomes right, or not as the case may be.

Assessment of reflection Assessment drives learning so reflective practice teaching and learning needs to be assessed. Evidence also indicates that people need to learn to write reflectively – practice, with feedback, makes perfect! Formative assessment means the assessment constitutes a learning experience in its own right, a way of enhancing knowledge as well as for developing research, communication, intellectual and organisational skills. Formative assessment is usually not formally graded as its purpose is for feedback from your Community Course tutor. Feedback is an important element of learning. It helps you to identify strengths and weaknesses in order to improve performance. Feedback on your reflective writing aims to encourage self-reflection, raise self-awareness and help you plan for future learning and practice. A lack of feedback may lead inexperienced learners to rely on self-assessment, which has been shown to be inaccurate in many instances.

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Appendix 1 Reflective Writing Examples

These are examples of the 4 models of writing described by Moon. The first piece of writing is not reflective, and merely a description of the event. The following pieces are increasingly reflective. Account 1 – Descriptive Writing Early January. I had had a bad night. Our 17-year-old had gone out clubbing with her friends and phoned at 1.00 a.m. unable to find a taxi – would one of us come and get her. I didn’t argue – just got up and went. It was hard getting up in the morning and it was a particularly long list of the worried well, with coughs and colds and ‘flu’ being used to hide their family discords and boredoms with work. I’m cynical – OK. I was getting towards the end when the door opened on Marissa. She came in – hunched shoulders, grey-faced as usual – and clutching her bag in that peculiar way. She is 30, but always manages to look twice her age. Our practice is well aware of Marissa and her aches and pains. I welcomed Marissa in. She had a wrenched shoulder this time and she said that it had happened when she was lifting a bed in her mother’s house. Unusual. She was more of the tummy-ache and headache brigade. I had a quick look and prescribed painkillers. I typed the prescription and looked up, expecting the relieved look, but it was not there and she asked me if the painkillers would really take away the pain. I was a bit perplexed and I asked her why she had been moving furniture. She started to tell me how she had decided to move back to live with her mother. In my tired state at this end of the morning, I prompted questions about her family relationships and she seemed to open up. I felt I was doing the right thing. I thought that just letting her talk for a few moments was probably helpful to her. Marissa had been born long after the other children and felt as if she had been seen as a nuisance, particularly by her mother. But now she could not cope alone and was moving back in with this cold mother. I had got her talking and I brightened, thinking I was doing a good job. I wondered why I had not let this talk flow before. We ran out of time, and I asked her to come back to talk more. I was thinking that we might be able to get on top of these recurrent visits to the surgery. I did actually feel better after seeing her. My attitude to my ‘success’ with her changed the next week. Marissa did come back – but not to me. She chose to come back when Geoff, the senior partner, was on. She was still complaining about the shoulder and she told Geoff that I had obviously thought that her shoulder was to do with her family – but it was not and she needed more than painkillers. Looking at the shoulder, Geoff agreed with her and referred her for physiotherapy. This little incident has perturbed me a bit. It stirred up my professional pride. I had thought I was doing a good job. 497 words Account 2 – Descriptive Reflective Writing There was a recent event that made me think a bit about the way I see patients and the manner in which I work with them. I’d had a disrupted sleep. It was difficult to feel on top of the job and to cap it, it was also early January. Lots of patients with the after-effects of Christmas – the colds, the ‘flu’s’ and those who do not want to go back to work. All this makes me irritable when the lists of genuinely ill patients are almost too long to manage. I am not sure how much the generally bad start had to do with the event – how much has my own state to do with how I function? So it was the end of this particularly long morning when Marissa walked in. Marissa is a regular with minor aches and pain. Sometimes there is just not time for these patients – but how do we solve

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that? I welcomed Marissa. She was pale and hunched as usual. She told me that she had a wrenched shoulder from when she had been moving a bed in her mother’s house. I had a quick look: I had probably diagnosed a simple muscular sprain even before I examined her shoulder. I made out prescription for painkillers. When I looked up, she was still looking at me and asked if the painkillers would really take the pain away. I was surprised at her question – and clearly should have taken more note of it. Instead, I launched into a little bit of conversation, hoping to shift on to the next patient quite quickly. I asked her why she had been moving furniture and she started to tell me how she could not cope alone any longer and had decided to move back in with her mother who did not seem to care for her. As she talked, I thought that she seemed to brighten up and I felt that I must be on a helpful track. We ran out of time and she agreed to come back the following week to discuss it all further. I was hoping that we might be able to sort something out that would prevent the recurrent visits. I felt better in myself after the session. Marissa did come back, but to see Geoff, the senior partner. She said to Geoff that I had been asking her all sorts of questions about her family and that what she wanted was help for her shoulder. She said that the painkillers were no good – and she had known that at the time I had prescribed them – hence, I suppose, the comment that she had made. Geoff had another look at her shoulder and was not happy about it. He referred her for physiotherapy. And then he told me all about the session with her and I felt very responsible for my mistake. I did not say anything to Geoff about how I had been feeling that morning. It felt relevant, but perhaps I should be superhuman. When I look back on this incident, I can see that there are things that I can learn from it. There are all sorts of intersecting issues and feelings tangled up in there. 537 words Account 3 – Dialogic Reflection A particular incident in the surgery has bothered me. It concerns Marissa, a 30-year-old woman who visits the surgery regularly for minor complaints (abdominal discomfort/headaches). She presented with a wrenched pain that was incurred when she was moving a bed in her mother’s house. I diagnosed a muscular strain and prescribed painkillers. I suppose that I assumed that because it was Marissa, it was likely to be similar to her usual visits and that she may need little more than a placebo. She came back to the senior partner, Geoff, a few days later saying that I had not taken her shoulder seriously enough. He examined her and referred her for physiotherapy, as I can now see as appropriate management. The event stirred up a lot of other things. The context was important. It was a January morning with the surgery full of worried well with ‘flu’s’ and the post-Christmas traumas. I came in tired and irritable because of disrupted sleep. Marissa came in and I did look at her shoulder – but I know that I had already made a judgement about it before I examined her. This was Marissa, looking, as usual, pale and hunched – and I saw any symptom as an expression of her state and nothing else. My look at the shoulder seemed an irrelevant act as I judged it then. I think about the many discussion of how easy it is to get misled by preconceptions and there was I doing just that. I can see that I should have taken the shoulder more seriously. Marissa, herself, asked if the painkillers were all she needed. What would it have taken for Marissa to have said to me that I was on the wrong track that day, and to have brought my attention back to her shoulder? I wonder if she knew that I was feeling ‘off’ that day. I suppose I did respond to Marissa’s persisting discontent by launching into questions about her family situation – in particular her relationship with her mother and why she was going back to live there – things that later Marissa said were irrelevant. When I stand back now and think of the event like a film, I can see how I was wrong-footed when Marissa questioned the initial prescription and did not seem any happier as a result of getting it. I just grabbed at the story she had given me. When she seemed willing to talk more about her family, I turned it to my favour – seeing myself as ‘obviously’ being helpful. That day, I think I needed to feel successful. If I am utterly cynical, I would say that I used Marissa’s situation to alter my mood. But then again, I suppose, that in turn might have helped the patients whom I saw after her that day.

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I need to think, too, about Geoff’s role in this and about my relationships with him and the rest of the team. I am the most junior and I tend to look up to them. I suppose I want to impress them. I could talk this one over with Steve, one of the other partners, he might see it differently. 528 words Account 4 – Critical Reflection I write about an incident that continues to disturb me. I have gone over it several times and my perspectives seem to change on it – so I talked it over with Steve (one of the other partners) to see how he saw it. The incident concerns Marissa, a 30-year-old woman who visits the surgery frequently with various aches and pains (mostly tummy aches and headaches). The symptoms have never been serious, through she never looks well, nor does she seem happy. On this visit she presented with a wrenched shoulder which she said resulted from moving a bed. I did a brief examination and prescribed painkillers. There still seemed to be something bothering her so I engaged her in conversation about her family relationships (this arose from the circumstances of moving the bed). I thought she was responding well and we might be getting somewhere. Time ran out and I invited her to continue the conversation next week. She agreed to come back – but came back to see Geoff, the senior partner, still complaining about the shoulder. He gave her a more detailed examination and referred her for physiotherapy. He told me that she said that I thought that her family was the problem when it really was her shoulder. I can see now that the shoulder was a problem and I misconstrued the situation, engaging in the talk about her family. This was a multiple mistake. I missed the shoulder problem itself when I examined it, but I also missed the cues that Marissa gave me when she was not happy with the prescription. But I was tired and out of sorts – not as sharp as I need to be when I am with patients. I am human, but I am a professional human and professionalism dictates that I should function well. I then headed off on the wrong track – getting into the discussion that I assumed was relevant about her family. I think of a consultation with our local GP when I was 14. I did not agree with his diagnosis about my foot – he just said I should come back in four weeks if it was not better. I did not say anything then, though I knew in myself that it needed treatment. I ended up in plaster for six weeks. There is a power thing there. Looking at it from Marissa’s point of view, she may have known that I was on the wrong track, but someone like Marissa would not question a doctor’s judgement at the time. How often were principles like this drummed into us at medical school – and yet it seems so easy to forget them. There is something more there too, though – this is what Steve suggested. That day, maybe I needed to feel helpful even more than usual – so I was looking for cures from Marissa that suggested that she was pleased with me. I had to make do with the cue that suggested that she was no longer unhappy and I suppose I made up the rest – thinking that the conversation about her family must be helpful. Maybe I can be more self-critical when I am in a better mood and less tired. Maybe I need less and can give more then. 542 words

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Medical student example The following is a piece written by a local medical student. Some analysis of where it sits in Moon’s framework follows the account. ‘Last week I went to take a history from a patient for the first time. It was my first day on the infection unit and we arrived to quickly be informed that we should go to take a history and come back to present it. I hadn’t been expecting to be thrown so quickly into the deep end, having only briefly read through the history taking sheet a couple of nights before and I realised that I couldn’t remember any of the headings. Luckily we had to work in pairs. I was so relieved that I had someone to help me, and one of the doctors took pity on us looking lost and bewildered and gave us the “cheat sheet”, a clerking sheet with all the areas we should ask about. The first challenge was finding our patient. We got there eventually. After a bit of stalling by taking another squirt of alcohol rub and a bit of negotiation of who was to go first, we nervously went and introduced ourselves. I don’t know what it was that made the situation so scary. I suppose I’m not the most outgoing person, but I would usually quite happily meet new people. Maybe it’s because I’m now in the role of a medical student, I guess that carries with it all the expectations of how we should behave. Thinking about it, it was a completely new environment as well. I’ve never been on a ward except for occasional visits when people I know have been admitted. Here I was, on a ward, as a medical student about to make an attempt at the most important activity you have as a doctor. “History taking is 90% of the diagnosis” they told us, well that’s the theory. Our patient was a lovely old woman, who had been admitted with a chest infection. Despite her being not in the slightest bit threatening or unwilling to speak to us, I was incredibly nervous. I think the nerves came from knowing that I wasn’t prepared enough to know what questions to ask. It’s not like speaking in a normal conversation, you’re in charge and if you can’t think of something to ask the “conversation” quickly dies. My partner also had problems, although from my perspective I was the much more flustered of the two of us. I think we both did well, as much as I’m sure (hope) it won’t be the best history I ever take, we did manage to find out something about her condition. Presenting them was pretty painless, although it had looked to be another scary prospect. The doctor who took us made it more of a tutorial, we only had to present a few sentences each. He helpfully pointed out all the things we hadn’t asked that we should have as well, guess that’s a fairly clear area for improvement. I think the same setup will happen this Thursday. I’m still not looking forward to it, but I think with time it will become less daunting. I will be studying the “cheat sheet” on Wednesday night for sure. As much as it might be a good challenge, I hope that I don’t have to go on my own for now at least. 540 words Analysis of Medical Student Example This fits the ‘descriptive reflective writing’ category. It is an account of a single incident, with mainly description, however it does include self-questioning and thoughts on learning points. Emotion is considered, but not in enough detail to see how it affected the situation and behaviour. There are points at where there are opportunities for further reflection. When writing, this would be a good start. It often takes more than one draft to produce reflective writing. The process of writing itself helps to sort thoughts and rewriting can allow for themes to be drawn out. In order for this example to be more reflective, several things could be done. Firstly, the writer should try to stand back further from the incident and consider it from different viewpoints. What was the patient likely to be thinking? What would the other student have been thinking? Secondly, the writer could consider how their anxiety affected their behaviour and how this could be changed to improve their performance. It might also be valuable to compare this situation to other anxiety-provoking situations in the past and to consider more deeply why she is afraid. Thirdly, the purpose of the exercise should be kept in mind – learning. What has been learned from this incident and reflecting on it? What are the lessons for next Thursday?

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Appendix 2 Tips for effective reflective writing 

Reflection is best undertaken in small, regular chunks

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Be honest

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Remember why you are reflecting on a situation or topic

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Pick a single topic or incident to focus on, rather than a superficial sweep of a whole day

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Reflective writing requires practice

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You may need to write something and rewrite it a few times; this is a useful process in deepening reflection

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It can help to write in the first person and then to write the same information in the third person – this can help you to see other perspectives

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Discuss your ideas with others, this will help you to see other viewpoints

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Think about what you have learned, and what you should do next time

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Try to summarise the main themes and important points, perhaps referring back to other more detailed evidence

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Focus on the reflective learning points

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Remove personal information you do not wish to share

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Remove any personal details about other people. This is vital in ensuring you do not break data protection laws. In particular, you must not use patient names, addresses, dates of birth or hospital/CHI numbers.

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Appendix 3 Suggestions for getting started Hot writing One good way to start a writing session is to write whatever comes into your head for six minutes: “Write whatever is in your head, uncensored. Time yourself to write without stopping for about six minutes. Don’t stop to think or be critical about your writing, it will probably seem disconnected, rubbish even. Allow it to flow with no reference to spelling, grammar, proper form. Give yourself permission to write anything. You don’t even have to read it. Whatever you write it will be right: it’s yours, and anyway no-one else will read it.” (Bolton 2005) Other warm ups A range of exercises may help you to “warm up” and start writing. Here is a small selection from Bolton: Names Write anything about your name: memories, impressions, likes, hates, what people have said, your nicknames over the years – anything. Write a selection of names you might have preferred to your own. Read back to yourself.” Clothes Describe a favourite set of clothes in detail, including any features such as mends. Describe the buying of these clothes briefly. Describe one occasion when you have worn them. How do these clothes make you feel? Describe your least favourite clothing. When do you wear it and why? Why do you dislike them? Metaphors Respond to each of these, creating a list of phrases: If my work/study were an animal what animal would it be? If my work/study were a piece of furniture what would it be? If it were a season or weather what would it be? A food? A drink? A flower? A form of transport? And so on…

Although these exercises are unrelated to what you might write, they may be helpful to loosen your pen/keyboard and help to get started.

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Further reading Stephenson P, Brigden D. Reflective Medics. sBMJ 2008; 16: 156-157. Cottrell S. Skills for Success: The Personal Development Planning Handbook. 2003. Palgrave MacMillan: Hampshire. Martin Hampton. Reflective Writing: A Basic Introduction. University of Portsmouth.

References Gibbs G (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford. Kolb, D. A. (1984), Experiential Learning, Englewood Cliffs, Prentice Hall Moon, J.(2004) Reflection and Employability, LTSN http://www.heacademy.ac.uk/assets/York/documents/ourwork/tla/employability/id339 _reflection_and_employability.pdf Rowling, J.R. Harry Potter and the Goblet of Fire. London: Bloomsbury. Schön D A (1982) The reflective practitioner: how professionals think in action New York: Harper Collins.

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