Academic and creative writing techniques as an aid to professional development 17 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b Setting the landscape for a study of academic and creative writing techniques as an aid to professional development of healthcare professionals Penny Grubb1 Summary: The purpose of this work is to set the landscape for a study to be carried out in several stages addressing the question: Will creative writing techniques allow healthcare professionals to capture the emotional journeys they experience in a way that makes a significant difference to the effectiveness of such material as teaching and professional development aids? This paper addresses the basis for the study and the assumptions behind it, looking to map out parameters within which later studies can be carried out and a set of learning materials developed. The initial 2-year period has been used to test and enhance a staged workshop teaching model for Health Professional Studies students at levels 4, 5 and 6, using information from studies of creative writing teaching in healthcare plus work on writing techniques. The initial work suggests that creative writing techniques are better understood as a useful developmental tool when taught in the context of academic writing. The response from students has been positive. In this first stage, the work has been a qualitative, testing-the-waters approach from which to build a framework to launch a follow-on quantitative study. Keywords:creativewritingtechniques;academicwritingtechniques;nurse-patient relationship; emotionally-charged experience; teaching and learning 1.Lecturer,DeptofHealthTechnologyandPerioperativePractice,UniversityofHull Address for correspondence: Depart of Health Technology and Perioperative Practice,,FacultyofHealthandSocialCare,UniversityofHull,HU67R.P.A.Grubb@ hull.ac.uk Date of first (online) publications: Penny Grubb 18 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b Introduction Many of the critical and emotionally-charged situations met by patients and their families in a healthcare setting will be once-in-a-lifetime experiences for them. They will look to healthcare professionals, often nurses, for support at these moments. It is an accepted part of a nurse’s role to provide emotional support. Nurses are given training in various ‘soft’ skills as well as the technical skills required to offer appropriate standards of care. But although providing support during critical and high-stress events becomes part of a nurse’s role there will be occasions when nurses meet such situations in circumstances where they are, or feel they are, unable to provide the necessary support. The once-in-a-lifetime nature of such situations for the patients mean there is little leeway for training ‘on the job’ and little scope to retrieve a situation that has not been appropriately handled. This work has looked at some of the reasons why nurses find themselves in situations where they lack the means to provide adequate emotional support; why it is important both for nurses as healthcare professionals and for patients that appropriate support is provided; and where issues around training and education for health professionals might be addressed. It is hypothesized that healthcare professionals should be able to use practice scenarios to learn how to react to emotionally-charged events in much the same way that physical simulators are used to train students in clinical skills. It is taken as a given that the curriculum for nurses and healthcare professionals is crowded and tightly resourced. There is no leeway for huge investment in extra training in soft skills, nor leeway to reduce time in education and training in other areas. The initial part of this project has been to introduce tasks that allow the students to appreciate and understand the benefits and importance of the written word: aiming to facilitate deeper understanding of all the topics to which they are introduced, more critical assessment of works they read and assignments they write, and to build on this to introduce the concepts and techniques of creative writing as a means of recording and experiencing an emotional journey at second hand with sufficient authenticity to inform a real situation. Academic and creative writing techniques as an aid to professional development 19 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b Background The need to support patients through emotionally-charged and traumatic events Health care professionals, especially nurses, routinely deal with patients and their families in emotionally-charged and traumatic situations. The expanding role of the nurse, for example, in general practice (Goodwin, 2011) added to the increasing number of patient consultations (HippisleyCox, 2009) mean that the number of such situations is increasing. In hospital clinics and home care situations also, the nurse will often be the key health professional, for example, in helping to provide support on receipt of a terminal diagnosis, during end of life care, in the aftermath of serious injury and also in supporting families. The events through which nurses are expected to provide support will often be once-in-a-lifetime events for the patients and families concerned. It is recognized that the relationship between the nurse and patient is central to a patient’s wellbeing and ultimate chance of recovery (Stavropoulou, 2012; McMahan 1991) but the nature of many traumatic incidents means there can be no guarantee of being able either to predict or to prepare for them. The ideal situation would be for an experienced nurse who has already built up a relationship with the patient and family to be on hand to provide the appropriate support at the time of the traumatic incident. However, there is some evidence that the length of time of a patient’s relationship with a health professional is not the key factor in building empathy between them. Studies in a clinical psychology context (Caskey, 1984) are borne out by the student accounts that are recorded from Yale University’s creative writing programme for nurses (Griswold, 2011) which suggest that an empathetic and supportive relationship can be built very quickly. Other than the time factor, problems might arise because a nurse is new either to a role or a clinical location; sickness or staff shortages might leave a nurse without adequate support at the critical moment. In areas such as A&E or critical care nursing the nurse’s first meeting with a patient and family might be at the height of the traumatic incident for which they are expected to provide appropriate support. Due to the unpredictable nature of some events, a traumatic or emotionally-charged situation might occur unexpectedly in the presence of a nurse who has had no relevant prior training. This could be down to various factors: a junior nurse might not have covered a particular element Penny Grubb 20 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b in their training to date; the relevant training for a particular situation might not have been mandatory or indeed considered relevant. Even with the relevant training, it is impossible to cover all possibilities for emotionallycharged situations where different people will react very differently and need different types and levels of support. The fact of the once-in-a-lifetime nature of certain situations for patients and families make it all the more important that the support provided is appropriate and relevant on every occasion, leaving little leeway for ‘training on the job’ for the professionals concerned. Resource problems for teaching ‘soft’ skills Historically, there has been more emphasis in education and training on technical skills than skills around caring and empathy. Indeed it is hard to argue that time should be taken from the teaching of technical skills when these are clearly vital to patient well-being. Pressures on nurses’ time are recognized as obstacles even for their becoming proficient in the technical and specialist clinical skills they are expected to learn (Jenner, 1998). Yet soft skills can be vital in patient welfare and recovery. Jenner goes as far as to conclude that ‘educationalists who do not facilitate the learning of these skills are failing nurses and patients’. In the face of scarce and often diminishing resources for training, there is sometimes a choice between teaching the technical skills required to support physical needs and the emotional skills required to give emotional support. To take a single example where the technical know-how and skills required are substantial, but where psychological factors play a significant role: extended care facilities and home care can now include mechanical ventilation. This means that the critical care nurses require knowledge of the process. However, in standard texts on the subject there is such a wealth of detail to cover on the physiological and technical aspects that issues of patient trauma have to take a back seat. Clearly it cannot be argued that the technical detail should be skimped as this would put patients’ lives at risk. One such text (Hess, 2002) notes that, ‘The need for mechanical ventilation is a very terrifying experience’ (p.123), but this is necessarily a small section of a much larger text. In all the technicalities and detail of the process itself it is hard to find time to concentrate on the psychological effect on the patient. A key aim will be to wean the patient from mechanical Academic and creative writing techniques as an aid to professional development 21 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b ventilation at the appropriate time, but even where all the physical signs point to a successful weaning, the patient’s own emotional trauma can cause it to fail. Indeed the primary reason for failure to wean a patient from mechanical ventilation is that the process itself stresses the patient to exhaustion (Hess, 2002 p.130). The nurse supporting the process needs to be technically knowledgeable or the patient will be at risk. And yet an empathy with the emotions that the patient experiences has the potential to significantly increase the success rate for weaning. The question is how, in a crowded curriculum and busy working environment to teach the levels of empathy required to support patients and their families through the wide range of emotionally challenging events that can occur. This study aims to put down the groundwork to explore a possible solution to this based on the techniques of creative writing. The right emotional response can lessen trauma It has long been recognized that the nurse’s response to a patient’s emotional trauma can have a profound effect on the patient and his/her family (Stavropoulou, 2012; McMahan 1991). Without prior experience or relevant training and preparation, the nurse is reliant on an intuitive reaction which may not be helpful or supportive, being based on the feelings of discomfort and helplessness that witnessing such events can engender. Nurses will develop their own bank of experience to call upon when a challenging incident occurs. But there will always be a first time that such a situation is encountered and it is in the nature of such events that they cannot be organized to happen in the presence of an experienced colleague. The first time a nurse is expected to support a patient / family through a specific trauma might be the only time that this particular patient needs this type and level of support, but at this one time their need is great. It is incumbent upon nurse educators to equip nurses with the skills to deal appropriately with such events whether they are meeting them for the first or the nth time. It is not just the patient and family who are let down if inadequate support is provided. The exposure to trauma can also have a detrimental effect on the nurses who have to deal with it (Lam, 1999; Akbayrak 2005). The nurse who provides appropriate and relevant support is less likely to be burdened also with feelings of guilt and inadequacy. Penny Grubb 22 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b Training and support is available to nurses in, for example, counselling skills, mentoring and supervisory functions. However, there is little focused specifically on teaching nurses to react appropriately in emotional terms to traumatic and emotionally-charged situations which by their nature will present differently for different patients and their families. The use of structured, tried and tested techniques such as reflective practice and counselling techniques cannot always adequately prepare for these situations. A nurse who can empathize and form a genuine emotional connection with a patient and their family at moments of crisis or stress will provide more appropriate support and is less likely to suffer vicarious trauma; that is,. the appropriate emotional connection will be of benefit to all (Kutaka, 2002). Experiencing genuine emotion second-hand The requirement is for educational tools that allow nurses to meet emotionally-charged situations during their training and development in such a way that they experience the genuine emotions of the events and that they can feel and explore their own reactions at a remove from the real situation. This requires more than traditional academic teaching and literature because what is often lost from the written account is the totality of the emotional journey. The experienced professional who pays attention to their own continuing development learns and grows through each experience, not only through reflection but also through having experienced an emotional journey. The theories and details of techniques can be taught and learnt, but the emotional journey is often unique to the situation and the people involved. Despite its uniqueness, each such journey adds to the professional’s store of experience and serves to inform them the next time. It is posited that if such events could be recorded in a way that allowed others to experience the emotional journey and actual emotions, this would be a valuable teaching tool. Nurses learn and pass on their experiences to others in practice by being shown what to do and by showing others; and by recording what they do and by studying what others have recorded. The vital role of practice cannot be overemphasized and yet a nurse in his or her career will meet and need to know about many more situations than they can possibly be explicitly taught ‘in the field’. Recorded experiences are of great importance because a far wider range can be studied and learnt. The means by which such Academic and creative writing techniques as an aid to professional development 23 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b experiences are recorded is key to their usefulness as educational tools. The peer-reviewed academic paper with facts, results and conclusions is the foundation for reliable texts and teaching materials, the engine that pushes the discipline forward. Yet the nature of the academic paper is a reflection-on-action, a ‘with hindsight’ view. For some of the events and episodes a nurse will encounter, valuable experience comes from living through the roller-coaster and uncertainties of the events as they unfold. It is not the purpose of an academic paper to provide that experience. However, it is the exact purpose of many creative writing techniques (Grubb, 2012; Swain 1982). The use of creative writing techniques in healthcare Simulators have been used in medical training for many years to teach physical skills. Simulators vary from low-tech devices to teach techniques such as venipuncture to highly sophisticated systems where computerized models mimic the reality of patients and their physiological responses. Emotional skills are also important and it is believed could be taught in a comparable way. Creative writing techniques are already recognized as valuable in healthcare education (Warren, 2010; Philpott, 2012; Irvin 1996; Young 1996). In some places, use is made of first-person accounts written using these techniques such as the Yale University creative writing awards for nurses (Griswold, 2011; Maier, 2011). If the appropriate set of techniques can be developed and shown to be effective, it is posited that it will be possible to build a bank of ‘experience’ for health professionals to draw on; experience that is real enough to provide a foundation to support them when they meet situations with real patients. The long established techniques of creative writers - novelists, playwrights and so on – are designed deliberately to draw people into the heart of a scenario so that they experience the emotional journey themselves. Particular techniques are used to draw readers into stories such that the readers feel as though they are going through the experience described on the page: from straightforward tension-building techniques (Grubb, 2012) to conceptual scenarios using text worlds theory (Werth, 1999 pp.7-16). The emotions experienced are powerful and real to the extent that people can be manipulated to feel genuine grief at the simulated death Penny Grubb 24 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b of a cartoon animal: cinema-goers cry real tears at the death of Bambi’s mother, or terror and anticipation: readers and viewers experience the symptoms of fear as Clarice Starling in the Silence of the Lambs (Harris, 1999) creeps through a pitch-black cellar with a serial killer on her heels. The creative writing and cinematic techniques bring out genuine emotion in the reader or viewer. Having a way of recording events that serves to immerse the reader in an experience to the point they actively feel the emotions experienced by those who were there, gives them an informed base from which to build when faced with the real situation. If they have been virtually through the emotional journey and seen both instinctive but inadequate reactions as well as effective and appropriate actions, it is posited that they are more likely to react appropriately if faced with such a situation themselves. The current project The project is at an early stage, currently building a base for the teaching and use of creative writing techniques in the curriculum of nursing and health professional studies students. The first stage has been to develop a series of workshops around the techniques of active reading, critical academic writing and creative writing, to integrate these into study skills and critical enquiry modules and to judge their reception and effects upon the students. Later stages propose to look in more detail first at simple techniques such as (Grubb, 2012), the cliff-hanger (p.35), cinematic devices (pp.40-41) and use of archetypes to build tension (p.44), and later at more complex theories such as foregrounding (Leech, 2007, ch 1) and mock reality (Leech, 2007, ch 4) and discourse worlds, text worlds and sub-worlds (Werth, 1999, pp.68-93). The aim will then be to measure their effectiveness within the educational context both in allowing students to experience firsthand emotions at secondhand and to teach the students specific techniques to record their own experiences for their own or others’ later use. Students at levels 4, 5 and 6, approximately 200 in all, have been introduced to the concepts described below. These have been taught in the context of Study Skills (levels 4, 5 and 6) and Critical Enquiry (level 6) modules. The overarching aim of this early part of the work has been to introduce the students to the hypothesis that there is real value in these concepts for their own educational and professional development. At this Academic and creative writing techniques as an aid to professional development 25 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b stage there have been no mandatory assignments associated with these concepts. Instead there have been classroom workshop tasks. The teaching model has been built in three stages. Firstly, the students are shown how to recognize when their understanding of the written word is too shallow, and are given techniques to address this. Secondly, they are introduced to the underlying concepts of academic writing and shown how to recognize the merits of a substantive piece and how to judge their own work by the same standards. Thirdly, they are asked to consider certain creative writing techniques which are chosen as ostensibly at odds with the requirements for academic writing. The students are encouraged to discuss why such techniques are inappropriate in an academic piece and then to develop the discussion to look at areas where key elements of professional experience are better expressed using creative than academic writing techniques. Active reading The students have been introduced to paraphrasing as a means of understanding. Starting with simple paraphrasing and moving on to a more structured version following the example of Paul and Elder (Paul, 2003) where they have to provide real-life examples as well as metaphor or analogy to explain what they have read. The examples used in the workshop tasks vary from simple sentences such as: Don’t sweat the small stuff, to more complex quotes from politicians and philosophers, such as ‘Whoever wishes to keep a secret, must hide from us that he possesses one’ (Goethe, 1829). The exercises are designed to demonstrate some key differences: between deep and shallow understanding; between read-many-times rote learning and read-once-andretain reading; between explaining what has been said and expressing an opinion about it. Critical academic writing The students have already been taught the basics such as structure and referencing in other classes. The task for this project concentrates on the generic aspects of academic writing (Paul, 2007) based upon the tenets of critical thinking as laid down by the Centre for Critical Thinking (Paul, Penny Grubb 26 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b 2008) showing how good academic writing will have a set of elements to it: a clear purpose, a key question and so on. The students are asked to identify the elements in examples of academic writing. They are also asked to distinguish between the points of view expressed. Following from this, they then distinguish their own point of view and identify whether or not it accords exactly with one of the points of view expressed in the literature, if it is an amalgam of several or if they have their own views. They look also at how different points of view are supported and justified. The students are given a set of questions to apply both to articles they use in their research and also to their own draft assignments. Questions include: The key point in this article is…? The conclusions reached are…? The assumptions underlying the author’s reasoning are…? If the author’s view is accepted, the implications are…? and so on. An understanding of the basic concepts leads to discussions of what is recorded in a piece of academic writing and why the structure and form is appropriate. The assignments for the modules are focused on academic pieces exploring particular healthcare areas. There is no specific assignment on the generic aspects taught, but the students are encouraged to use the techniques in their own academic writing. Creative writing At the third stage, the students are introduced to some specific concepts of creative writing. This is done by building on the work on academic writing techniques and highlighting the differences. For example contrasting two opening paragraphs, one from an academic paper: This paper examines the effects of comments and identifier names on program comprehension. (Takang, 1996) and one from a novel: The words changed on the long drive north. Annie’s determination did not (Grubb 2010) Another example used is the academic abstract which gives a clear Academic and creative writing techniques as an aid to professional development 27 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b outline of the work, the results and outcomes, which is contrasted with a creative piece whose raison d’être is to mislead the reader to the end of the piece and then spring a surprise outcome. The students discuss the idea of swapping the techniques; what would it mean if an academic paper deliberately misled the reader? What would be the effect of an academic abstract at the start of a twist-in-the-tale short story? Having reinforced the reasons behind academic and creative writing and their different purposes and audiences, the discussion is led towards particular types of events, the emotionally-charged events that nurses will meet as part of their professional lives. The students are asked to think about the positions they take in people’s lives; how they can become one of the most important figures in someone’s life at a moment when all the traditional trappings of power and influence count for nothing. Discussion moves onto the recording of such events and explores the following idea: that academic papers record quantitatively or qualitatively after the event, when the outcomes are known; that academic papers look back and draw lessons for the future; that academic papers might mention issues of misdiagnosis, atypical symptoms, equipment breakdown, staff shortages and so on, but in a way that explains the effects from the viewpoints of analysis and hindsight. Whilst emphasizing the importance of academic recording in this way, the discussion is then steered to what has been lost in terms of the minute-by-minute experience of the emotionally-charged event. The students are read a number of creative pieces that give firsthand accounts of the emotional journeys both from a nurse and a family member point of view. Discussion then centers on how the real emotions are captured: for example, fear, helplessness, anger, and the effects of writing these accounts in this way. As yet, the creative writing element does not carry a mandatory assessment, nor is it explicitly used in the general assignments for the modules. However, students are encouraged to keep short journals to record difficult events in practice. They already use structured reflection to go back over difficult incidents and are now being encouraged to think about creative writing techniques and where they might be appropriate in recording their experiences. Penny Grubb 28 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b Results Active reading tasks In the early sessions, especially at level 4, the students struggled with the active reading tasks. The set of tasks was amended to start the process with easier tasks and gradually increase the complexity. A device that proved useful once the students were confident in tackling the paraphrasing tasks was to give fairly minimal example answers and allow the students to volunteer alternatives and amendments. This demonstrated firstly that there was no single right answer and secondly that they could provide answers that were ‘better’ than the example answer. This gave confidence, at times to the whole class, to volunteer more information and to participate in the discussions. All the students were receptive to the usefulness of active reading techniques, noting that the techniques would allow them a more in-depth understanding of the academic texts they needed to read. They responded with enthusiasm to the initial simple exercises. As the examples became harder and more complex, they were drawn into discussing different versions of both simple and structured paraphrasing. When examples were introduced that gave controversial views, the students started to include their own opinions within the paraphrasing. Critical writing tasks The students were particularly responsive to discussions about the generic elements of academic writing, on several occasions asking for further references to allow them to go into the topic in more depth. Examples of the concepts explored in discussion are levels of understanding. The students develop the concepts used in the active reading tasks to see how an inability to be able to paraphrase indicates a lack of clear understanding. Leading from this they develop and appreciate the idea that if a real world example cannot be provided, it indicates a lack of understanding at a practical level; and similarly that if an analogy cannot be provided, there is a lack of depth to understanding as the concepts cannot be more widely applied. They clearly saw the relevance to their professional development in improving the quality of their own work. They also reacted positively Academic and creative writing techniques as an aid to professional development 29 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b when shown the similarities between the techniques of critical writing and active reading usually reaching the conclusion on their own that these were techniques they could use to analyze and assess their own writing. Creative writing tasks Reactions to the introduction of creative writing techniques into the mix were more positive than expected. There was a concern that these techniques would be seen as irrelevant. In the earlier workshops this element was greeted with a degree of puzzlement, but the relevance was appreciated when explained. In the later workshops, after the structure had been honed, it was often the students themselves who volunteered opinions of how and where creative writing had a place in their professional lives. In the level 6 classes in particular, the students were quick to see the links between creative writing techniques and the need for health professionals to cope with emotionally-charged scenarios, volunteering ideas themselves and giving positive feedback on the usefulness and relevance of the sessions. Group working Initially, the intention was that the students should work on their own for the first set of exercises before moving on to groupwork. However, in the larger classes, it was necessary to move to group work almost immediately and this proved so successful in encouraging participation and discussion that group work became the norm for all tasks. Analysis and enhancement of the workshops The students were observed during the workshops and asked questions to judge their opinions of the relevance of the different stages. The ease or difficulty with which they did the exercises was noted. Levels of participation in the specific exercises and the discussions were also noted. There were no formal questionnaires on the students’ opinions of the sessions but they were free to comment on the formal feedback for the modules. All such comments were positive. Lack of formal assessment was deliberate as the intention at this stage Penny Grubb 30 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b was to hone the structure and process so that the elements of the workshop flowed naturally and could be understood as to both content and relevance. Conclusions Better standards of written work have been apparent from the time that the Study Skills and Critical Enquiry modules have been in the curriculum. There has been as yet no attempt to measure standards against the explicit inclusion of the work described in this paper. General observations A significant factor has been lack of space in a crowded curriculum. The aim therefore has been to design tightly focused workshops from which the students can learn skills and understand the advantages of applying these to their continuing development. This lack of time means that the work develops slowly and is not yet sufficiently advanced to look at specific techniques and draw firm conclusions as to their efficacy. Issues have arisen, as recorded earlier, over group or individual working. At this stage the workshops have simply been run in the way that maximizes participation without any attempt at in-depth analysis of the group dynamic. The range of teaching single- or mixed-level groups has been a factor of the lack of room in the curriculum and not a deliberate strategy. The effects of this have been interesting anecdotally, but although observed and recorded, no attempt has yet been made to analyze this aspect specifically. Student participation and feedback It is important to ensure that everyone is engaged in the group discussions and understands what is being talked about. Students who ‘get lost’ at the active reading stage find it hard to cope with the concepts and later discussions. It is important that all students are drawn in actively at the early simple stage of the active reading phase, so they have confidence to join in when the examples get more complex. Academic and creative writing techniques as an aid to professional development 31 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b One block to participation was concern of giving a ‘wrong’ answer, but once the idea was accepted that there were many right answers and that most answers were at least partly right, levels of participation increased. Providing only minimal example answers to some of the early exercises proved to be a useful boost to overall participation as it gave the students confidence in their ability to do the tasks when they produced an answer that was ‘better’ than the example answer. Student feedback has been overwhelmingly positive. One dyslexic student commented on the ‘practical information regarding academic writing, critical reading, and writing that were a revelation to me’, and added ‘I really wish I had [had these concepts] pointed out to me … at the beginning of my [career]’. Final workshop structure Some basic conclusions have been drawn about the nature of the workshops and how to structure them to be more effective. Making explicit links between the three stages was the most important as it showed how they built up and retained relevance to the world of the health care professional. The gradual building up of complexity and introduction of the concepts of understanding, explaining and giving opinions led the students to initiate discussions on the differences between these concepts and where and why each one was appropriate. For example, students inserted their own opinions when they were first asked to paraphrase a controversial statement. However, in the discussion of these paraphrases, it was often the students themselves who highlighted the inappropriateness of giving an opinion when the task was to explain someone else’s words. This happened more often than expected and future work will build on this to encourage more student participation. The use of some controversial texts during the active reading workshops was a useful lead into the area of critical writing. It was not unanticipated that the students would muddle the concepts of explanation, understanding and voicing opinions but the speed was unexpected with which they drew out these differences for themselves and initiated debate. This was especially noticeable in classes where level 4, 5 and 6 students were taught together. The major change to the workshop structure over the course of the project was to make the links more explicit between the three stages so that the tasks flowed better from one to the next. This worked well and will be Penny Grubb 32 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b the structure used as the foundation for taking the work to the next stage of devoting more time to specific creative writing techniques and getting the students both to record their own experiences and to react to experiences of others recorded using these techniques. References Akbayrak, N., Oflaz, F,. Aslan, O., Ozcan, C.T., Tastan, S., and Çiçek, H.S. (2005) Post-traumatic stress disorder symptoms among military health professionals in Turkey. Military Medicine, 170, 2, 125-9 Caskey, N.H., Barker, C., and Elliott, R. (1984) Dual perspectives: Clients’ and therapists’ perceptions of therapist responses. British Journal Of Clinical Psychology, 23, 4, 281-290 Goethe, J.W. von (1829) Wilhem Meister’s Journeyman Years, or The Renunciant. Stuttgart: Cotta’sche Buchhandlung Goodwin, N. Dixon, A. Poole, T. Raleigh, V. (2011) Improving the Quality of Care in General Practice. London: King’s Fund Griswold Special Home Care Creative Writing Awards for nurses (2011) (before 2011 known as the Yale University creative writing awards). Critical Care Nurse Online Publishes Yale University Creative Writing Awards 2011, AACN Bold Voices, 3, 8, 20 Grubb, P. (2010) The Doll Makers. London: Robert Hale Grubb, P. and Reah, D. (2012) The Writers’ Toolkit: A handbook for writers of commercial fiction. Hull: Fantastic Books Harris, T. (1989) The Silence of the Lambs. London: Heinneman Hess, D.R. and Kacmarek, RM. (2002) Physiological Effects of Mechanical Ventilation. Essentials of mechanical ventilation. New York: McGraw Hill Hippisley-Cox, J. and Vinogradova, Y. (2009) Final Report to the NHS Information Centre and Department of Health Trends in Consultation Rates in General Practice 1995/1996 to 2008/2009: Analysis of the QResearch® database. London: The NHS Information Centre Irvin, S. (1996) Creative teaching strategies ... a story-telling and personification approach ... creative writing and presentation, Journal of Continuing Education in Nursing, 27, 3, 108-114 Jenner, E. (1998) A case study analysis of nurses’ roles, education and training needs associated with patient-focused care. Journal Of Advanced Nursing, 27, 5, 1087-1095 Academic and creative writing techniques as an aid to professional development 33 J. of Practice Teaching & Learning 12(1), pp.xx-xx. DOI: 10.1921/4102120101. © w&b Kutaka, G (2002) The Essential Structure of the Lived Experience of Connection Between Nurse and Patient. Doctoral dissertation. University of Hawaii at Manoa Lam, LT. Ross, FI. Cass, DT. Quine, S. Lazarus, R. (1999) The impact of work related trauma on the psychological health of nursing staff: A cross sectional study. Australian Journal of Advanced Nursing, 16, 3, 14-20 Leech, G. and Short, M. (2007) Style in Fiction: A linguistic introduction to English fictional prose. London: Pearson Education Maier, S. (2011) The emotional challenges faced by sexual assault nurse examiners: ‘ER nursing is stressful on a good day without rape victims’, Journal Of Forensic Nursing, 7, 4, 161-172 McMahan, R, Pearson, A. (1991) Contemporary perspectives in nursing intimacy. Journal of advanced nursing, 35, 2, 188-196 Paul, R. and Elder, L. (2003) The Thinker’s Guide to the Art of Close Reading. Tomales, CA: Foundation for Critical Thinking Press Paul, R. and Elder, L. (2007) How to Write a Paragraph: The art of substantive writing. Tomales, CA: Foundation for Critical Thinking Press Paul, R. and Elder, L. (2008) The Miniature Guide to Critical Thinking Concepts and Tools, Tomales, CA: Foundation for Critical Thinking Press Philpott, S.L. and Clabough, J. (2012) Using ‘brags and whines’ as a creative writing technique. Science Scope, 35, 5, 74-77 Stavropoulou, A., Kaba, E., Obamwonyi, V.A., Adeosun, I., Rovithis, M., and Zidianakis, Z. (2012) Defining nursing intimacy: Nurses’ perceptions of intimacy. Health Science Journal, 6, 3, 479-95 Swain D. (1982) Techniques of the Selling Writer. Norman, OK: University of Oklahoma Press Takang, A., Grubb, P., and Macredie, R. (1996) The effects of comments and identifier names on program comprehensibility: An experimental investigation. Journal of Programming Languages, 4, 3, 143-167 Warren, J., Morgan, M.M., Morris, L.B., and Morris, T.M. (2010) Breathing words slowly: Creative writing and counselor self-care—the writing workout. Journal of Creativity in Mental Health, 5, 2, 109-124 Werth, P. (1999) Textworlds: Representing conceptual worlds in discourse. New York: Pearson Young, S. (1996) Uncovering Common Meanings: Expository writing, creative writing, and nursing students [e-book]. Louisville , KY: University of Louisville