Writing and rhetoric, Conditions and diagnosis in recreation and Inclusive recreation and Psychopathology

 

 Parts 1 and 2  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

 Parts 3 and 4  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

 Parts 5 and 6  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

 Parts 7 and 8  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

 Parts 9 and 10  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

APA format

1) Minimum 29 pages  (No word count per page)-   Follow the 3 x 3 rule: minimum of three paragraphs per page 

You must strictly comply with the number of paragraphs requested per page.  

The number of words in each paragraph should be similar

Part 1: minimum 3 pages (70 hours)

Part 2: minimum 3 pages (70 hours)

Part 3: minimum 2 pages (70 hours)

Part 4: minimum 2 pages (70 hours)

Part 5: minimum 2 pages (44 hours)

Part 6: minimum 2 pages (44 hours)

Part 7: minimum 2 pages (44 hours)

Part 8: minimum 2 pages (44 hours)

Part 9: minimum 1 page (92 hours)

Part 10: minimum 1 page (92 hours)

Part 11: minimum 3 pages (92 hours)

Part 12: minimum 3 pages (92 hours)

Extra Part 13: minimum 3 pages (70 hours)

Submit 1 document per part

2)¨******APA norms

        The number of words in each paragraph should be similar

        Must be written in the third person

         All paragraphs must be narrative and cited in the text- each paragraph

         The writing must be coherent, using connectors or conjunctive to extend, add information, or contrast information. 

         Bulleted responses are not accepted

         Don’t write in the first person 

  Do not use subtitles or titles      

         Don’t copy and paste the questions.

         Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph

Submit 1 document per part

3)****************************** It will be verified by Turnitin (Identify the percentage of exact match of writing with any other resource on the internet and academic sources, including universities and data banks) 

********************************It will be verified by SafeAssign (Identify the percentage of similarity of writing with any other resource on the internet and academic sources, including universities and data banks)

4) Minimum 3 references (APA format) per part not older than 5 years  (Journals, books) (No websites)

Extra PArt 13:  Minimum 4references (APA format) per part not older than 5 years  (Journals, books) (No websites) 

All references must be consistent with the topic-purpose-focus of the parts. Different references are not allowed 

5) Identify your answer with the numbers, according to the question. Start your answer on the same line, not the next

 

Example:

Q 1. Nursing is XXXXX

Q 2. Health is XXXX

Q3. Research is…………………………………………………. (a) The relationship between……… (b) EBI has to

6) You must name the files according to the part you are answering: 

Example:
Part 1  
Part 2

__________________________________________________________________________________

 Parts 1 and 2  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 
 Parts 3 and 4  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

Part 1: Writing and rhetoric (Write in the first person)

 After reading “Reflection Writing and the Revision Process: What Were You Thinking?” (Check the file attached) 

Giles explains the ways in which her understanding of reflective writing shifted as a result of having “to write those darned process notes” (193).

1. Describe her original approach to reflective writing also, (One paragraph)

a. Describe the specific ways in which her perspective and actions changed.

According to the section of the reading titled “How It Works,” 

2. What are 2 specific benefits of engaging in reflective writing? also, (One paragraph)

a. How can reflection help us become stronger and more effective writers and communicators?

Consider which of the benefits from your response to question 2 connects the most to you and your experiences as a writer. 

3. Explain which one(s) you feel like you’ve experienced in your own writing journey or which one(s) you feel like you could benefit the most from and why.(One paragraph)

On page 200, Giles writes, “My students often resist writing about their composing processes, but it’s good for them to see and analyze how they did what they did, and it also helps me know what they were thinking when they made composing decisions.” She then goes on to explain the specific ways in which reflective writing can help not only the student, but also the instructor. According to Giles

4. What are at least 3 specific ways in which reflective writing can help the instructor more effectively respond to and understand student writing? (One paragraph)

5. Is this recognition that reflective writing can help the instructor more effectively respond to their students a new idea for you, or is this an idea you had previously considered/experienced? (One paragraph)

a. Explain

On page 202, Giles writes, “Teachers don’t want you to say certain things, we want you to think in certain ways.” 

6. How do you understand what she means here also (One paragraph)

 a. What are some specific ways that reflective writing can help us to get into the productive “habit of thinking reflectively?” (202)

Think about your own experiences with reflective writing. These might be experiences you’ve had in school on an assignment, writing in a personal journal/diary, at your job, or somewhere else. 

7. Describe one specific experience you’ve had with reflective writing (One paragraph)

Make at least one specific connection to something Giles writes in this article. Here, you might respond to one of the following questions:

8. Do your personal experiences with reflective writing agree with something Giles says?  (One paragraph)

a. If so, what is the agreement?

9. Do your personal experiences with reflective writing contradict something Giles says?  (One paragraph)

a. If so, what is the contradiction?

Part 2: Writing and rhetoric (Write in the first person)

 After reading “Reflection Writing and the Revision Process: What Were You Thinking?” (Check the file attached) 
Giles explains the ways in which her understanding of reflective writing shifted as a result of having “to write those darned process notes” (193).
1. Describe her original approach to reflective writing also, (One paragraph)
a. Describe the specific ways in which her perspective and actions changed.
According to the section of the reading titled “How It Works,” 
2. What are 2 specific benefits of engaging in reflective writing? also, (One paragraph)
a. How can reflection help us become stronger and more effective writers and communicators?
Consider which of the benefits from your response to question 2 connects the most to you and your experiences as a writer. 
3. Explain which one(s) you feel like you’ve experienced in your own writing journey or which one(s) you feel like you could benefit the most from and why.(One paragraph)
On page 200, Giles writes, “My students often resist writing about their composing processes, but it’s good for them to see and analyze how they did what they did, and it also helps me know what they were thinking when they made composing decisions.” She then goes on to explain the specific ways in which reflective writing can help not only the student, but also the instructor. According to Giles
4. What are at least 3 specific ways in which reflective writing can help the instructor more effectively respond to and understand student writing? (One paragraph)
5. Is this recognition that reflective writing can help the instructor more effectively respond to their students a new idea for you, or is this an idea you had previously considered/experienced? (One paragraph)
a. Explain

On page 202, Giles writes, “Teachers don’t want you to say certain things, we want you to think in certain ways.” 
6. How do you understand what she means here also (One paragraph)
 a. What are some specific ways that reflective writing can help us to get into the productive “habit of thinking reflectively?” (202)

Think about your own experiences with reflective writing. These might be experiences you’ve had in school on an assignment, writing in a personal journal/diary, at your job, or somewhere else. 
7. Describe one specific experience you’ve had with reflective writing (One paragraph)
Make at least one specific connection to something Giles writes in this article. Here, you might respond to one of the following questions:
8. Do your personal experiences with reflective writing agree with something Giles says?  (One paragraph)
a. If so, what is the agreement?
9. Do your personal experiences with reflective writing contradict something Giles says?  (One paragraph)
a. If so, what is the contradiction?
 Parts 3 and 4  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

Part 3: Writing and rhetoric

Audience: Your classmates. 

Purpose: Explain to your classmates what you have learned about information literacy and about researching rhetorically and responsibly in the 21st.

 Genre: Assume that your audience has read/viewed all of the course information we’ve covered together until this point in the semester. 

1. Describe four specific observations related to information literacy and/or researching rhetorically and responsibly in the 21st century (One paragraph)

2. How has what you learned in Researching Rhetorically shaped impacted your ideas about information literacy and researching rhetorically and responsibly in the 21st century according to your topic ( Deaths caused by school shootings clearly show the need to develop programs to improve students’ mental health. ) (Two paragraphs)

3. Discuss the importance of fact-checking sources.(Two paragraphs)

a. Explain one of the sources you fact-checked 

4. What information or insight you gained about your research topic due to this fact-checking process? (One paragraph)

Part 4: Writing and rhetoric

Audience: Your classmates. 
Purpose: Explain to your classmates what you have learned about information literacy and about researching rhetorically and responsibly in the 21st.
 Genre: Assume that your audience has read/viewed all of the course information we’ve covered together until this point in the semester. 
1. Describe four specific observations related to information literacy and/or researching rhetorically and responsibly in the 21st century (One paragraph)

2. How has what you learned in Researching Rhetorically shaped impacted your ideas about information literacy and researching rhetorically and responsibly in the 21st century according to your topic (Recognizing sex work would allow women in this industry to unionize and access benefits that workers in other industries have.) (Two paragraphs)

3. Discuss the importance of fact-checking sources.(Two paragraphs)
a. Explain one of the sources you fact-checked 
4. What information or insight you gained about your research topic due to this fact-checking process? (One paragraph)
 Parts 5 and 6  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

Part 5: Conditions and diagnosis in recreation

Check:

 

1. Describe your experience. (did you enjoy it? Did you find it relaxing? What would you change about it?) also, (Two paragraphs)

a. Would you recommend it to anyone or ever use it in a therapeutic context? (One paragraph)

Suppose you find OR write a script for a pain management meditation or guided imagery session, and lead at least one person (or group of people) through the full script (should be a minimum of 15 minutes long). 

2. Describe your experience being the facilitator and the reaction/experience of the people who participated. (Two paragraphs)

a. What your process was for choosing the script.  

  3.  If you had to choose an album to play in the background during a pain management session with a client (One paragraph)

a. What album would you choose and why?   

Part 6: Conditions and diagnosis in recreation

Check: 

1. Describe your experience. (did you enjoy it? Did you find it relaxing? What would you change about it?) also, (Two paragraphs)
a. Would you recommend it to anyone or ever use it in a therapeutic context? (One paragraph)
Suppose you find OR write a script for a pain management meditation or guided imagery session, and lead at least one person (or group of people) through the full script (should be a minimum of 15 minutes long). 
2. Describe your experience being the facilitator and the reaction/experience of the people who participated. (Two paragraphs)
a. What your process was for choosing the script.  
  3.  If you had to choose an album to play in the background during a pain management session with a client (One paragraph)
a. What album would you choose and why?   

 Parts 7 and 8, have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

Part 7: Inclusive recreation

Check:

Check:

https://www.nytimes.com/interactive/2020/us/disability-ADA-30-anniversary.html?campaign_id=9&emc=edit_nn_20200724&instance_id=20585&nl=the-morning&regi_id=126942757&segment_id=34251&te=1&user_id=c15461edca860849af3878373d1eadd5

1. Who are current influential individuals making an impact for individuals with disabilities? 

a. And what are they doing?

2. How do human rights, disability rights, and civil rights relate to each other locally, nationally (in our country) and internationally (across the globe)?

3. In the podcast, Judy mentions the IDEA and 504. 

a. What are these and who do they apply to?

4. What did you find most interesting from listening to the Podcast?

5. According to File 7 and 8

a.  What did you find interesting? 

b. What shocked you? 

Part 8: Inclusive recreation

Check:

Check:
https://www.nytimes.com/interactive/2020/us/disability-ADA-30-anniversary.html?campaign_id=9&emc=edit_nn_20200724&instance_id=20585&nl=the-morning&regi_id=126942757&segment_id=34251&te=1&user_id=c15461edca860849af3878373d1eadd5
1. Who are current influential individuals making an impact for individuals with disabilities? 
a. And what are they doing?
2. How do human rights, disability rights, and civil rights relate to each other locally, nationally (in our country) and internationally (across the globe)?
3. In the podcast, Judy mentions the IDEA and 504. 
a. What are these and who do they apply to?
4. What did you find most interesting from listening to the Podcast?
5. According to File 7 and 8
a.  What did you find interesting? 
b. What shocked you? 
 Parts 9 and 10  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

Part 9: Inclusive recreation

Topic: Implement Universal Design; Videos: Disability Rights

1. Have you ever given thought to any of those environmental designs? for disabled people?  

2. Describes the ways ISA should be properly displayed. 

Search guideline provisions for playgrounds including ground-level play components, elevated play components, accessible routes, transfer systems, ground systems, and self-contained play structures.  I am curious

3. Do you think these guidelines are too extreme?  Or too lenient?  

Part 10: Inclusive recreation

Topic: Implement Universal Design; Videos: Disability Rights

1. Have you ever given thought to any of those environmental designs? for disabled people?  
2. Describes the ways ISA should be properly displayed. 
Search guideline provisions for playgrounds including ground-level play components, elevated play components, accessible routes, transfer systems, ground systems, and self-contained play structures.  I am curious
3. Do you think these guidelines are too extreme?  Or too lenient?  

Part 11:  Psychopathology 

Topic Schizophrenia Spectrum and Other Psychotic Disorders

Disorder: Schizotypal (Personality) Disorder

According to DSM-5 primarily:

1. Explain what is Schizophrenia Spectrum and Other Psychotic Disorders (One paragraph)

2. Briefly explains the subcategories (Tree paragraphs: One paragraph for a and b; One paragraph for c and d; One paragraph for e and f)

a. Schizotypal (Personality) Disorder

b. Delusional Disorder

c. Brief Psychotic Disorder

d. Schizophreniform Disorder

e. Schizophrenia

f. Schizoaffective Disorder

3. For the disorder, explain ( Four paragraphs: One paragraph for a and b; One paragraph for c and d; One paragraph for e and f;  One paragraph for g and h)

a. Diagnostic Features

b. Age-related factors

c. Symptoms

d. Describes rule-out three differential diagnoses

e. Risk factors

f. Prognostic Factors

g. Prevalence

h. Management

4. Reflection (One paragraph)

Part 12:  Psychopathology 

Topic: Trauma- and Stressor-Related Disorders

Disorder: Posttraumatic Stress Disorder

According to DSM-5 primarily:

1. Explain what is Schizophrenia Spectrum and Other Psychotic Disorders (One paragraph)
2. Briefly explains the subcategories (Tree paragraphs: One paragraph for a and b; One paragraph for c and d; One paragraph for e and f)

a. Posttraumatic Stress Disorder

b. Reactive Attachment Disorder

c. Disinhibited Social Engagement Disorder

d. Acute Stress Disorder

e. Adjustment Disorders

f. Other Specified Trauma- and Stressor-Related Disorder

3. For the disorder, explain ( Four paragraphs: One paragraph for a and b; One paragraph for c and d; One paragraph for e and f;  One paragraph for g and h)
a. Diagnostic Features
b. Age-related factors
c. Symptoms
d. Describes rule-out three differential diagnoses
e. Risk factors
f. Prognostic Factors
g. Prevalence
h. Management
4. Reflection (One paragraph)

Extra Part 12:  Professional Dynamics 

Check the File extra part

Review the recommendations of The National Academy of Medicine 2021 report

1. Explain why health equity is significant in this report (One paragraph)

2. Define social determinants of health (One paragraph)

3. Discuss one of the determinants and (One paragraph)

a. Explain how this impacts health equity.(One paragraph)

4. Describe the role nurses have in improving health equity and impacting social needs. (Two paragraphs)

5. Discuss the significance of self-care to decrease nursing burnout. (Two paragraphs)

6. What self-care and evidence-based strategies are available for nurses to maintain personal and spiritual health? (One paragraph)

Reflective Writing and the Revision Process:
What Were You Thinking?
by

Sandra L. Giles

This essay is a chapter in Writing Spaces: Readings on Writing,
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Library of Congress Cataloging-in-Publication Data
Writing spaces : readings on writing. Volume 1 / edited by Charles Lowe
and Pavel Zemliansky.
p. cm.
Includes bibliographical references and index.
ISBN 978-1-60235-184-4 (pbk. : alk. paper) — ISBN 978-1-60235-185-1
(adobe ebook)
1. College readers. 2. English language–Rhetoric. I. Lowe, Charles,
1965- II. Zemliansky, Pavel.
PE1417.W735 2010
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191

Reflective Writing and the Revision
Process: What Were You Thinking?

Sandra L. Giles

“Reflection” and “reflective writing” are umbrella terms that refer
to any activity that asks you to think about your own thinking.* As
composition scholars Kathleen Blake Yancey and Jane Bowman Smith
explain, reflection records a “student’s process of thinking about what
she or he is doing while in the process of that doing” (170). In a writ-
ing class, you may be asked to think about your writing processes in
general or in relation to a particular essay, to think about your inten-
tions regarding rhetorical elements such as audience and purpose, or
to think about your choices regarding development strategies such as
comparison-contrast, exemplification, or definition. You may be asked
to describe your decisions regarding language features such as word
choice, sentence rhythm, and so on. You may be asked to evaluate or
assess your piece of writing or your development as a writer in general.
Your instructor may also ask you to perform these kinds of activities
at various points in your process of working on a project, or at the end
of the semester.

A Writer’s Experience
The first time I had to perform reflective writing myself was in the
summer of 2002. And it did feel like a performance, at first. I was a

* This work is licensed under the Creative Commons Attribution-
Noncommercial-No Derivative Works 3.0 United States License and is sub-
ject to the Writing Spaces Terms of Use. To view a copy of this license,
visit http://creativecommons.org/licenses/by-nc-nd/3.0/us/ or send a letter to
Creative Commons, 171 Second Street, Suite 300, San Francisco, California,
94105, USA. To view the Writing Spaces Terms of Use, visit http://writing-
spaces.org/terms-of-use.

Sandra L. Giles192

doctoral student in Wendy Bishop’s Life Writing class at Florida State
University, and it was the first class I had ever taken where we English
majors actually practiced what we preached; which is to say, we ac-
tually put ourselves through the various elements of process writing.
Bishop led us through invention exercises, revision exercises, language
activities, and yes, reflective writings. For each essay, we had to write
what she called a “process note” in which we explained our processes
of working on the essay, as well as our thought processes in developing
the ideas. We also discussed what we might want to do with (or to)
the essay in the future, beyond the class. At the end of the semester,
we composed a self-evaluative cover letter for our portfolio in which
we discussed each of our essays from the semester and recorded our
learning and insights about writing and about the genre of nonfiction.

My first process note for the class was a misguided attempt at good-
student-gives-the-teacher-what-she-wants. Our assignment had been
to attend an event in town and write about it. I had seen an email an-
nouncement about a medium visiting from England who would per-
form a “reading” at the Unity Church in town. So I went and took
notes. And wrote two consecutive drafts. After peer workshop, a third.
And then I had to write the process note, the likes of which I had never
done before. It felt awkward, senseless. Worse than writing a scholar-
ship application or some other mundane writing task. Like a waste of
time, and like it wasn’t real writing at all. But it was required.

So, hoop-jumper that I was, I wrote the following: “This will even-
tually be part of a longer piece that will explore the Foundation for
Spiritual Knowledge in Tallahassee, Florida, which is a group of local
people in training to be mediums and spirituals healers. These two
goals are intertwined.” Yeah, right. Nice and fancy. Did I really intend
to write a book-length study on those folks? I thought my professor
would like the idea, though, so I put it in my note. Plus, my peer re-
viewers had asked for a longer, deeper piece. That statement would
show I was being responsive to their feedback, even though I didn’t
agree with it. The peer reviewers had also wanted me to put myself
into the essay more, to do more with first-person point of view rather
than just writing a reporter-style observation piece. I still disagree with
them, but what I should have done in the original process note was go
into why: my own search for spirituality and belief could not be han-
dled in a brief essay. I wanted the piece to be about the medium herself,
and mediumship in general, and the public’s reaction, and why a group

Reflective Writing and the Revision Process 193

of snarky teenagers thought they could be disruptive the whole time
and come off as superior. I did a better job later—more honest and
thoughtful and revealing about my intentions for the piece—in the
self-evaluation for the portfolio. That’s because, as the semester pro-
gressed and I continued to have to write those darned process notes,
I dropped the attitude. In a conference about my writing, Bishop re-
sponded to my note by asking questions focused entirely on helping
me refine my intentions for the piece, and I realized my task wasn’t
to please or try to dazzle her. I stopped worrying about how awkward
the reflection was, stopped worrying about how to please the teacher,
and started actually reflecting and thinking. New habits and ways of
thinking formed. And unexpectedly, all the hard decisions about revis-
ing for the next draft began to come more easily.

And something else clicked, too. Two and a half years previously, I
had been teaching composition at a small two-year college. Composi-
tion scholar Peggy O’Neill taught a workshop for us English teachers
on an assignment she called the “Letter to the Reader.” That was my
introduction to reflective writing as a teacher, though I hadn’t done
any of it myself at that point. I thought, “Okay, the composition schol-
ars say we should get our students to do this.” So I did, but it did not
work very well with my students at the time. Here’s why: I didn’t come
to understand what it could do for a writer, or how it would do it, until
I had been through it myself.

After Bishop’s class, I became a convert. I began studying reflection,
officially called metacognition, and began developing ways of using it
in writing classes of all kinds, from composition to creative nonfiction
to fiction writing. It works. Reflection helps you to develop your in-
tentions (purpose), figure out your relation to your audience, uncover
possible problems with your individual writing processes, set goals for
revision, make decisions about language and style, and the list goes on.
In a nutshell, it helps you develop more insight into and control over
composing and revising processes. And according to scholars such as
Chris M. Anson, developing this control is a feature that distinguishes
stronger from weaker writers and active from passive learners (69–73).

My Letter to the Reader Assignment

Over recent years, I’ve developed my own version of the Letter to the
Reader, based on O’Neill’s workshop and Bishop’s class assignments.

Sandra L. Giles194

For each essay, during a revising workshop, my students first draft
their letters to the reader and then later, polish them to be turned
in with the final draft. Letters are composed based on the following
instructions:

This will be a sort of cover letter for your essay. It should
be on a separate sheet of paper, typed, stapled to the top
of the final draft. Date the letter and address it to “Dear
Reader.” Then do the following in nicely developed, fat
paragraphs:

1. Tell the reader what you intend for the essay to do for its
readers. Describe its purpose(s) and the effect(s) you want
it to have on the readers. Say who you think the readers
are.

• Describe your process of working on the essay. How did
you narrow the assigned topic? What kind of planning did
you do? What steps did you go through, what changes did
you make along the way, what decisions did you face, and
how did you make the decisions?

• How did comments from your peers, in peer workshop,
help you? How did any class activities on style, editing,
etc., help you?

2. Remember to sign the letter. After you’ve drafted it, think
about whether your letter and essay match up. Does the
essay really do what your letter promises? If not, then use
the draft of your letter as a revising tool to make a few
more adjustments to your essay. Then, when the essay is
polished and ready to hand in, polish the letter as well
and hand them in together.

Following is a sample letter that shows how the act of answering
these prompts can help you uncover issues in your essays that need
to be addressed in further revision. This letter is a mock-up based on
problems I’ve seen over the years. We discuss it thoroughly in my writ-
ing classes:

Reflective Writing and the Revision Process 195

Dear Reader,

This essay is about how I feel about the changes in the
financial aid rules. I talk about how they say you’re
not eligible even if your parents aren’t supporting
you anymore. I also talk a little bit about the HOPE
scholarship. But my real purpose is to show how the
high cost of books makes it impossible to afford col-
lege if you can’t get on financial aid. My readers will
be all college students. As a result, it should make
students want to make a change. My main strategy
in this essay is to describe how the rules have affected
me personally.

I chose this topic because this whole situation has re-
ally bugged me. I did freewriting to get my feelings
out on paper, but I don’t think that was effective be-
cause it seemed jumbled and didn’t flow. So I started
over with an outline and went on from there. I’m still
not sure how to start the introduction off because I
want to hook the reader’s interest but I don’t know
how to do that. I try to include many different argu-
ments to appeal to different types of students to make
the whole argument seem worthwhile on many levels.

I did not include comments from students because I
want everyone to think for themselves and form their
own opinion. That’s my main strategy. I don’t want
the paper to be too long and bore the reader. I was
told in peer workshop to include information from
other students at other colleges with these same fi-
nancial aid problems. But I didn’t do that because I
don’t know anybody at another school. I didn’t want
to include any false information.

Thanks,

(signature)

Notice how the letter shows us, as readers of the letter, some prob-
lems in the essay without actually having to read the essay. From this

Sandra L. Giles196

(imaginary) student’s point of view, the act of drafting this letter should
show her the problems, too. In her first sentence, she announces her
overall topic. Next she identifies a particular problem: the way “they”
define whether an applicant is dependent on or independent of par-
ents. So far, pretty good, except her use of the vague pronoun “they”
makes me hope she hasn’t been that vague in the essay itself. Part of
taking on a topic is learning enough about it to be specific. Specific is
effective; vague is not. Her next comment about the HOPE scholar-
ship makes me wonder if she’s narrowed her topic enough. When she
said “financial aid,” I assumed federal, but HOPE is particular to the
state of Georgia and has its own set of very particular rules, set by its
own committee in Atlanta. Can she effectively cover both federal fi-
nancial aid, such as the Pell Grant for example, as well as HOPE, in
the same essay, when the rules governing them are different? Maybe.
We’ll see. I wish the letter would address more specifically how she
sorts that out in the essay. Then she says that her “real purpose” is to
talk about the cost of books. Is that really her main purpose? Either
she doesn’t have a good handle on what she wants her essay to do or
she’s just throwing language around to sound good in the letter. Not
good, either way.

When she says she wants the readers to be all college students, she
has identified her target audience, which is good. Then this: “As a re-
sult, it should make students want to make a change.” Now, doesn’t
that sound more in line with a statement of purpose? Here the writer
makes clear, for the first time, that she wants to write a persuasive
piece on the topic. But then she says that her “main strategy” is to
discuss only her own personal experience. That’s not a strong enough
strategy, by itself, to be persuasive.

In the second section, where she discusses process, she seems to
have gotten discouraged when she thought that freewriting hadn’t
worked because it resulted in something “jumbled.” But she missed
the point that freewriting works to generate ideas, which often won’t
come out nicely organized. It’s completely fine, and normal, to use
freewriting to generate ideas and then organize them with perhaps an
outline as a second step. As a teacher, when I read comments like this
in a letter, I write a note to the student explaining that “jumbled” is
normal, perfectly fine, and nothing to worry about. I’m glad when I
read that sort of comment so I can reassure the student. If not for the

Reflective Writing and the Revision Process 197

letter, I probably wouldn’t have known of her unfounded concern. It
creates a teaching moment.

Our imaginary student then says, “I’m still not sure how to start
the introduction off because I want to hook the reader’s interest but
don’t know how to do that.” This statement shows that she’s think-
ing along the right lines—of capturing the reader’s interest. But she
hasn’t quite figured out how to do that in this essay, probably because
she doesn’t have a clear handle on her purpose. I’d advise her to ad-
dress that problem and to better develop her overall strategy, and then
she would be in a better position to make a plan for the introduction.
Again, a teaching moment. When she concludes the second paragraph
of the letter saying that she wants to include “many different argu-
ments” for “different types of students,” it seems even more evident
that she’s not clear on purpose or strategy; therefore, she’s just written
a vague sentence she probably thought sounded good for the letter.

She begins her third paragraph with further proof of the problems.
If her piece is to be persuasive, then she should not want readers to
“think for themselves and form their own opinion.” She most certain-
ly should have included comments from other students, as her peer
responders advised. It wouldn’t be difficult to interview some fellow
students at her own school. And as for finding out what students at
other schools think about the issue, a quick search on the Internet
would turn up newspaper or newsletter articles, as well as blogs and
other relevant sources. Just because the official assignment may not
have been to write a “research” paper doesn’t mean you can’t research.
Some of your best material will come that way. And in this particular
type of paper, your personal experience by itself, without support, will
not likely persuade the reader. Now, I do appreciate when she says she
doesn’t want to include any “false information.” A lot of students come
to college with the idea that in English class, if you don’t know any in-
formation to use, then you can just make it up so it sounds good. But
that’s not ethical, and it’s not persuasive, and just a few minutes on the
Internet will solve the problem.

This student, having drafted the above letter, should go back and
analyze. Do the essay and letter match up? Does the essay do what
the letter promises? And here, does the letter uncover lack of clear
thinking about purpose and strategy? Yes, it does, so she should now
go back and address these issues in her essay. Without having done
this type of reflective exercise, she likely would have thought her essay

Sandra L. Giles198

was just fine, and she would have been unpleasantly surprised to get
the grade back with my (the teacher’s) extensive commentary and cri-
tique. She never would have predicted what I would say because she
wouldn’t have had a process for thinking through these issues—and
might not have known how to begin thinking this way. Drafting the
letter should help her develop more insight into and control over the
revising process so she can make more effective decisions as she revises.

How It Works

Intentions—a sense of audience and purpose and of what the writer
wants the essay to do—are essential to a good piece of communicative
writing. Anson makes the point that when an instructor asks a student
to verbalize his or her intentions, it is much more likely that the student
will have intentions (qtd. in Yancey and Smith 174). We saw this pro-
cess in mid-struggle with our imaginary student’s work (above), and
we’ll see it handled more effectively in real student examples (below).
As many composition scholars explain, reflective and self-assessing ac-
tivities help writers set goals for their writing. For instance, Rebecca
Moore Howard states that “writers who can assess their own prose can
successfully revise that prose” (36). This position is further illustrated
by Xiaoguang Cheng and Margaret S. Steffenson, who conducted
and then reported a study clearly demonstrating a direct positive ef-
fect of reflection on student revising processes in “Metadiscourse: A
Technique for Improving Student Writing.” Yancey and Smith argue
that self-assessment and reflection are essential to the learning process
because they are a “method for assigning both responsibility and au-
thority to a learner” (170). Students then become independent learners
who can take what they learn about writing into the future beyond a
particular class rather than remaining dependent on teachers or peer
evaluators (171). Anson echoes this idea, saying that reflection helps a
writer grow beyond simply succeeding in a particular writing project:
“Once they begin thinking about writing productively, they stand a
much better chance of developing expertise and working more success-
fully in future writing situations” (73).

Reflective Writing and the Revision Process 199

Examples from Real Students

Let’s see some examples from actual students now, although for the
sake of space we’ll look at excerpts. The first few illustrate how reflec-
tive writing helps you develop your intentions. For an assignment to
write a profile essay, Joshua Dawson described his purpose and audi-
ence: “This essay is about my grandmother and how she overcame
the hardships of life. [. . .] The purpose of this essay is to show how a
woman can be tough and can take anything life throws at her. I hope
the essay reaches students who have a single parent and those who
don’t know what a single parent goes through.” Joshua showed a clear
idea of what he wanted his essay to do. For a cultural differences paper,
Haley Moore wrote about her mission trip to Peru: “I tried to show
how, in America, we have everything from clean water to freedom of
religion and other parts of the world do not. Also, I would like for my
essay to inspire people to give donations or help in any way they can
for the countries that live in poverty.” Haley’s final draft actually did
not address the issue of donations and focused instead on the impor-
tance of mission work, a good revision decision that kept the essay
more focused.

In a Composition II class, Chelsie Mathis wrote an argumentative
essay on a set of controversial photos published in newspapers in the
1970s which showed a woman falling to her death during a fire escape
collapse. Chelsie said,

The main purpose of this essay is to argue whether
the [newspaper] editors used correct judgment when
deciding to publish such photos. The effect that
I want my paper to have on the readers is to really
make people think about others’ feelings and to make
people realize that poor judgment can have a big ef-
fect. [ . . . ] I intend for my readers to possibly be high
school students going into the field of journalism or
photojournalism.

Chelsie demonstrated clear thinking about purpose and about who
she wanted her essay to influence. Another Comp II student, Daniel
White, wrote, “This essay is a cognitive approach of how I feel You-
Tube is helping our society achieve its dreams and desires of becom-
ing stars.” I had no idea what he meant by “cognitive approach,” but I

Sandra L. Giles200

knew he was taking a psychology class at the same time. I appreciated
that he was trying to integrate his learning from that class into ours,
trying to learn to use that vocabulary. I was sure that with more prac-
tice, he would get the hang of it. I didn’t know whether he was getting
much writing practice at all in psychology, so I was happy to let him
practice it in my class. His reflection showed learning in process.

My students often resist writing about their composing processes,
but it’s good for them to see and analyze how they did what they did,
and it also helps me know what they were thinking when they made
composing decisions. Josh Autry, in regards to his essay on scuba div-
ing in the Florida Keys at the wreck of the Spiegel Grove, said, “Map-
ping was my preferred method of outlining. It helped me organize my
thoughts, go into detail, and pick the topics that I thought would be
the most interesting to the readers.” He also noted, “I choose [sic] to
write a paragraph about everything that can happen to a diver that is
not prepared but after reviewing it I was afraid that it would scare an
interested diver away. I chose to take that paragraph out and put a few
warnings in the conclusion so the aspiring diver would not be clue-
less.” This was a good decision that did improve the final draft. His
earlier draft had gotten derailed by a long discussion of the dangers of
scuba diving in general. But he came to this realization and decided
to correct it without my help—except that I had led the class through
reflective revising activities. D’Amber Walker wrote, “At first my or-
ganization was off because I didn’t know if I should start off with a
personal experience which included telling a story or start with a sta-
tistic.” Apparently, a former teacher had told her not to include per-
sonal experiences in her essays. I reminded her that in our workshop
on introductions, we had discussed how a personal story can be a very
effective hook to grab the reader’s attention. So once again, a teach-
ing moment. When Jonathan Kelly said, “I probably could have given
more depth to this paper by interviewing a peer or something but I
really felt unsure of how to go about doing so,” I was able to scold him
gently. If he really didn’t know how to ask fellow students their opin-
ions, all he had to do was ask me. But his statement shows an accurate
assessment of how the paper could have been better. When Nigel El-
lington titled his essay “If Everything Was Easy, Nothing Would Be
Worth Anything,” he explained, “I like this [title] because it’s catchy
and doesn’t give too much away and it hooks you.” He integrated what
he learned in a workshop on titles. Doing this one little bit of reflec-

Reflective Writing and the Revision Process 201

tive thinking cemented that learning and gave him a chance to use it
in his actual paper.

How It Helps Me (the Instructor) Help You

Writing teachers often play two roles in relation to their students. I am
my students’ instructor, but I am also a fellow writer. As a writer, I have
learned that revision can be overwhelming. It’s tempting just to fiddle
with words and commas if I don’t know what else to do. Reflection is
a mechanism, a set of procedures, to help me step back from a draft
to gain enough distance to ask myself, “Is this really what I want the
essay (or story or poem or article) to do? Is this really what I want it to
say? Is this the best way to get it to say that?” To revise is to re-vision or
re-see, to re-think these issues, but you have to create a critical distance
to be able to imagine your piece done another way. Reflection helps
you create that distance. It also helps your instructor better guide your
work and respond to it.

The semester after my experience in Bishop’s Life Writing Class, I
took a Fiction Writing Workshop taught by Mark Winegardner, au-
thor of The Godfather Returns and The Godfather’s Revenge, as well as
numerous other novels and short stories. Winegardner had us create
what he called the “process memo.” As he indicated in an interview,
he uses the memo mainly as a tool to help the workshop instructor
know how to respond to the writer’s story. If a writer indicates in the
memo that he knows something is still a problem with the story, then
the instructor can curtail lengthy discussion of that issue’s existence
during the workshop and instead prompt peers to provide suggestions.
The instructor can give some pointed advice, or possibly reassurance,
based on the writer’s concerns that, without being psychic, the in-
structor would not otherwise have known about. Composition scholar
Jeffrey Sommers notes that reflective pieces show teachers what your
intentions for your writing actually are, which lets us respond to your
writing accurately, rather than responding to what we think your in-
tentions might be (“Enlisting” 101–2). He also points out that we can
know how to reduce your anxiety about your writing appropriately
(“Behind” 77). Thus, without a reflective memo, your teacher might
pass right over the very issue you have been worried about.

Sandra L. Giles202

The Habit of Self-Reflective Writing

One of the most important functions of reflective writing in the long
run is to establish in you, the writer, a habit of self-reflective thinking.
The first few reflective pieces you write may feel awkward and silly
and possibly painful. You might play the teacher-pleasing game. But
that’s really not what we want (see Smith 129). Teachers don’t want
you to say certain things, we want you to think in certain ways. Once
you get the hang of it and start to see the benefits in your writing,
you’ll notice that you’ve formed a habit of thinking reflectively almost
invisibly. And not only will it help you in writing classes, but in any
future writing projects for biology class, say, or even further in the
future, in writing that you may do on the job, such as incident reports
or annual reports for a business. You’ll become a better writer. You’ll
become a better thinker. You’ll become a better learner. And learning
is what you’ll be doing for the rest of your life. I recently painted my
kitchen. It was a painful experience. I had a four-day weekend and
thought I could clean, prep, and paint the kitchen, breakfast nook,
and hallway to the garage in just four days, not to mention painting
the trim and doors white. I pushed myself to the limit of endurance.
And when I finished the wall color (not even touching the trim), I
didn’t like it. The experience was devastating. A very similar thing had
happened three years before when I painted my home office a color I
now call “baby poop.” My home office is still “baby poop” because I
got so frustrated I just gave up. Now, the kitchen was even worse. It
was such a light green it looked like liver failure and didn’t go with the
tile on the floor. Plus, it showed brush marks and other flaws. What
the heck?

But unlike three years ago, when I had given up, I decided to apply
reflective practices to the situation. I decided to see it as time for revi-
sion-type thinking. Why had I wanted green to begin with? (Because
I didn’t want blue in a kitchen. I’ve really been craving that hot dark
lime color that’s popular now. So yes, I still want it to be green.) Why
hadn’t I chosen a darker green? (Because I have the darker, hotter color
into the room with accessories. The lighter green has a more neutral
effect that I shouldn’t get sick of after six months. Perhaps I’ll get used
to it, especially when I get around to painting the trim white.) What
caused the brush strokes? (I asked an expert. Two factors: using satin
finish rather than eggshell, and using a cheap paintbrush for cut-in-

Reflective Writing and the Revision Process 203

areas.) How can they be fixed? (Most of the brush strokes are just in
the cut-in areas and so they can be redone quickly with a better quality
brush. That is, if I decide to keep this light green color.) Is the fact that
the trim is still cream-colored rather than white part of the problem?
(Oh, yes. Fix that first and the other problems might diminish.) What
can I learn about timing for my next paint project? (That the cleaning
and prep work take much longer than you think, and that you will
need two coats, plus drying time. And so what if you didn’t finish it
in four days? Relax! Allow more time next time.) Am I really worried
about what my mother will say? (No, because I’m the one who has to
look at it every day.) So the solution? Step one is to paint the trim first
and then re-evaluate. Using a method of reflection to think back over
my “draft” gives me a method for proceeding with “revision.” At the
risk of sounding like a pop song, when you stop to think it through,
you’ll know what to do.

Revision isn’t just in writing. These methods can be applied any
time you are working on a project—of any kind—or have to make de-
cisions about something. Establishing the habit of reflective thinking
will have far-reaching benefits in your education, your career, and your
life. It’s an essential key to success for the life-long learner.

Discussion

1. Define what metacognitive or reflective writing is. What are
some of the prompts or “topics” for reflective writing?

2. Have you ever been asked to do this type of writing? If so,
briefly discuss your experience.

3. Why does reflective writing help a student learn and develop as
a better writer? How does it work?

4. Draft a Letter to the Reader for an essay you are working on
right now. Analyze the letter to see what strengths or problems
it uncovers regarding your essay.

Works Cited

Anson, Chris M. “Talking About Writing: A Classroom-Based Study of Stu-
dents’ Reflections on Their Drafts.” Smith and Yancey 59–74.

Sandra L. Giles204

Bishop, Wendy. “Life Writing.” English Department. Florida State Univer-
sity, Tallahassee, FL. Summer 2002. Lecture.

Cheng, Xiaoguang, and Margaret S. Steffenson. “Metadiscourse: A Tech-
nique for Improving Student Writing.” Research in the Teaching of English
30.2 (1996): 149–81. Print.

Howard, Rebecca Moore. “Applications and Assumptions of Student Self-
Assessment.” Smith and Yancey 35–58.

O’Neill, Peggy. “Reflection and Portfolio Workshop.” Humanities Division.
Abraham Baldwin Agricultural College, Tifton, GA. 25 January 2000.
Lecture, workshop.

Smith, Jane Bowman. “‘Know Your Knowledge’: Journals and Self-Assess-
ment.” Smith and Yancey 125–38.

Smith, Jane Bowman, and Kathleen Blake Yancey, eds. Self-Assessment and
Development in Writing: A Collaborative Inquiry. Cresskill, NJ: Hampton,
2000. Print.

Sommers, Jeffrey. “Behind the Paper: Using the Student-Teacher Memo.”
College Composition and Communication 39.1 (1988): 77–80. Print.

—. “Enlisting the Writer’s Participation in The Evaluation Process.” Journal
of Teaching Writing 4.1 (1985): 95–103. Print.

Winegardner, Mark. Personal interview. 3 February 2003.
Yancey, Kathleen Blake, and Jane Bowman Smith. “Reflections on Self-As-

sessment.” Smith and Yancey 169–76.

Millions of young people grew up knowing the landmark Americans With Disabilities Act as a birthright. They now demand its guarantees — and even more.

By Joseph Shapiro

Published July 17, 2020 Updated July 20, 2020 7 MIN READ

To hear more audio stories from publishers like The New York Times, download Audm for iPhone or Android.

To get to her job as the communications director of a legal office in Philadelphia, Imani Barbarin gets in her car — when the coronavirus pandemic doesn’t require working from home — and drives to a train station 20 minutes away.

There’s a station closer to her house, just a two-minute drive. But Ms. Barbarin, who has cerebral palsy, walks with crutches; the nearby station doesn’t have an elevator, and the steep steps are too hard to climb.

Ms. Barbarin was born four months before the landmark Americans With Disabilities Act became law in July 1990. She belongs to the A.D.A. generation — at least 20 million people with disabilities, according to the U.S. Census Bureau — that grew up knowing the transformative civil rights

law as a birthright. They expect the law to guarantee, not just promise, that they will get access to transportation, jobs, schools and other public places and to the same opportunities as anyone else.

Members of the A.D.A. generation are quicker than earlier ones to claim disability as a crucial part of identity — and with pride. The A.D.A., after all, erased some of the stigma. Now, it’s not just those with evident physical or sensory disabilities who say they are part of a disability civil

rights movement, but younger people and those with invisible disabilities, too. The A.D.A. generation is more likely to disclose a learning disability, a chronic condition such as lupus, or a psychiatric disability like bipolar disorder.

Ms. Barbarin, 30, finds daily reminders of how the A.D.A. makes her world easier: the fully accessible office buildings and restaurants, or simply the expectation that a woman with a disability will have the same chances to take part in everyday life.

There are also the markers that mock those raised expectations. The A.D.A. doesn’t require every old structure, like that train station, to be retrofitted for accessibility.

And then there was her job search. After graduate school, Ms. Barbarin sent out hundreds of applications and disclosed that she has a disability. She didn’t get one interview. She sent out more, without mentioning her disability, and did.

It’s “disheartening,” Ms. Barbarin said, for people of her generation, “who feel like the A.D.A. is the floor of what our rights should be. But we should be so much further along.”

Ariella Barker, who was born with spinal muscular atrophy, says people often assume that disability civil rights laws provide an advantage they do not. One of Ms. Barker’s classmates at the Kennedy School at Harvard told her that as a woman in a wheelchair she held the “golden ticket” to

a good job.

But high unemployment persists for people with disabilities, even after the A.D.A. banned discrimination in the workplace. Only 31 percent of working-age people with disabilities people held jobs last year, compared with 75 percent of those without disabilities, according to the U.S.

Department of Labor. When she graduated with a master’s degree in public administration this May, Ms. Barker, who already had a law degree, didn’t find the jobs she wanted and instead returned to an old one.

Since long before the A.D.A., there have been accepted roles for people with disabilities. They could be the objects of pity or of inspiration. They wanted neither.

Doron Dorfman, an associate professor of law at Syracuse University, argues that a new generation has grown up with an added unwelcome role — as objects of suspicion. The public knows little about the A.D.A. or the frequent discrimination faced by people with disabilities, Mr. Dorfman

says, and one result is what he calls “the fear of the disability con.”

People with disabilities constantly pay “a tax or price,” he said, “this idea of the disability con and always needing to prove they are actually disabled” and therefore worthy of protection.

Ms. Barker, who lost the ability to walk at 11, understands. When she was in law school, one day she was in the checkout line of an Atlanta clothing store, clutching a dress, a pair of pants and some tops. Another customer approached, explaining that she was curious about the young woman

in the wheelchair: “How do you have the money to buy all of that?” the woman asked. “Did you get injured and sue somebody?”

The A.D.A. generation grew up expecting its rights but also found resentment instead — propelling a need to keep pushing back. “There’s more of us who’ve grown up disabled and proud,” said Stephanie Woodward, 32, of Rochester, N.Y.

Ms. Woodward, who was born with spina bifida, was 7 or 8 when she first heard of the A.D.A. She had just started using a wheelchair at school, and a teacher complained that it was a safety hazard. The next day, her father went to demand an apology. Told that the principal was unavailable,

her father — an electrician and a “pull-yourself-up-by-your-bootstraps kind of guy” — raised the issue of his daughter’s rights and announced he was going to “find an A.D.A. lawyer.” That threat got results. Ms. Woodward recalls thinking: “What’s the A.D.A.? Like I really needed to know

because it got such a reaction.”

Today, Ms. Woodward is a disability rights lawyer and activist. A widely circulated photograph showed her getting arrested in a U.S. Senate office in June 2017, her hands zip-tied behind the back of her pink wheelchair. She was arrested with members of the disability group Adapt, protesting

a Republican bill to repeal the Affordable Care Act.

Disability Pride: The High Expectations of a New Generation

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the latest U.S. education news. Get it sent to your inbox.

[Image description: Protesters marching along a winding path, one of them carrying an American flag.] A
“Wheels of Justice” demonstration in Washington in 1990 by the group Adapt to support the Americans
With Disabilities Act. The Tom Olin Collection. Used by permission.

[Image description: George H.W. Bush sitting at a table signing the A.D.A. while a man in a wheelchair
looks on.] President Bush signed the Americans With Disabilities Act into law on July 26, 1990. It is one of
the country’s most comprehensive pieces of civil rights legislation. The Tom Olin Collection. Used by permission.

[Image description: A woman in a wheelchair with her
hands cuffed behind her.] Stephanie Woodward, a disability
rights lawyer and activist, was arrested in a U.S. Senate
office in June 2017. Colleen Flanagan

https://www.audm.com/?utm_source=nytmag&utm_medium=embed&utm_campaign=left_behind_draper

https://www.audm.com/?utm_source=nyt&utm_medium=embed&utm_campaign=disability_pride_shapiro

https://www.census.gov/content/dam/Census/library/publications/2018/demo/p70-152

https://www.dol.gov/odep/topics/DisabilityEmploymentStatistics.htm

https://www.vox.com/first-person/2017/6/27/15876442/healthcare-medicaid-cuts-disability-protests

Welcome to ADAPT

https://www.nytimes.com/

For people with disabilities, access to health care can have life or death consequences. They were among Obamacare’s biggest beneficiaries, especially its Medicaid expansion. The willingness of activists, especially younger ones, to get arrested and the impact they had in the fight for

Obamacare, bolstered their political power — at least with Democrats. Notably, Joseph R. Biden Jr., the presumptive Democratic nominee for president, now talks about expanding home care for the young and old with disabilities — a central issue to Ms. Woodward’s protests — as “just an

absolute, basic right.”

There’s a long history of successful disability rights protests. Judith Heumann, considered a founder of the movement, led a 26-day takeover in 1977 of a federal building in San Francisco and drove the Carter administration to enforce a law considered the precursor to the A.D.A.

That story is told in her recent memoir, “Being Heumann,” and in the new Netflix documentary “Crip Camp.: A Disability Revolution.” Ms. Heumann, who had polio as an infant, is now 72 and a mentor to the rising generation of leaders.

“The A.D.A. generation wants their lives to be benefited by the A.D.A.,” she said. “They also believe that the A.D.A. is not enough.”

The earlier generation modeled their movement after “the civil rights struggle of the ’60s and the women’s rights struggle of the ’70s,” said Maria Town, 33, who has cerebral palsy and is president and chief executive of the American Association of People with Disabilities. Members of the

A.D.A. generation, she said, “are informed by the marriage equality movement, the fight for the Affordable Care Act and are informed by the Black Lives Matter movement.”

One result is that they have an expanded view of disability justice, one that embraces other causes and other marginalized groups.

Keri Gray, 29, helped organize scores of people with disabilities at a June protest in front of the White House after the death of George Floyd, holding signs that read “Black Disabled Lives Matter.” For Ms. Gray, a diversity and inclusion consultant who lost a leg to childhood cancer, policing

is a disability issue, too. At least a third of those in American jails and prisons have disabilities, according to the Justice Department.

She argues that disability and racial justice issues encompass Covid-19, too. Black and Latino people have died from the coronavirus in disproportionate numbers, in part because of unequal access to health care and other causes of their greater prevalence of pre-existing conditions —

including disabilities like diabetes and chronic lung illness.

There are more young people with disabilities now than in the past, or, at least, more who are willing to accept the label. Today, almost one in four college students report having had a diagnosis of depression, according to the American College Health Association. That’s up from one in 10

college students in 2000.

“It’s a perfect storm,” said Mary T. Hoban, the association’s chief researcher. Students face an exceptionally stressful world, she says: the pressures of social media, fears of school shootings and, now, the pandemic’s many disruptions. Far more seek mental health services than used to be

the case, she says. One reason: The A.D.A. erased some of the stigma of mental health care issues by requiring schools to make accommodations — like private rooms for tests or liberalized permission to take a leave of absence.

Also true to their age group, members of the A.D.A. generation use social media to meet and organize. Ari Ne’eman was 18 when he started the Autistic Self Advocacy Network online in 2006 to challenge the prevailing narrative about autism, one that was driven by parents’ groups and

researchers. It largely saw autism as a tragedy and the answer as a cure.

For Mr. Ne’eman and other autistics, that ran counter to the proof of their lives, which were rich and fueled by the ambitions promised by the A.D.A. He and others wrote and organized to shatter the old images of autism. A recent academic study of newspaper content credited their work for

a dramatic shift to positive depictions of autistic life.

Mr. Ne’eman, now a visiting scholar at the Lurie Institute for Disability Policy at Brandeis University, said, “Finding the autistic community online was important to me because it sent the message that you don’t actually have to take, as written on stone tablets, everything that professionals

say about you as true.”

That freedom to think big is what most marks the A.D.A. generation. After Micah Fialka-Feldman helped move his sister into her college dorm, he decided he wanted the experience of dorm living, too. At the time, he was taking a two-hour bus ride to get to his nondegree program at a

college outside Detroit for students with intellectual disabilities and Down syndrome. When the university said he couldn’t live on campus, he used the A.D.A. to sue — and won in 2009.

Today, he works as a teaching assistant at Syracuse University’s school of education. He helps grade papers, reads students’ journals and talks to future educators about what it’s like to have an intellectual disability.

“I sometimes wonder if I’d been born at a different time, how much different my life would be,” said Mr. Fialka-Feldman, now 35.

But he says it’s hard to imagine a life without the expectations and rights made possible to his A.D.A. generation.

Joseph Shapiro is an investigative correspondent for NPR and the author of “No Pity: People with Disabilities Forging a New Civil Rights Movement.”

[Image description: Judy Heumann holding a microphone in her hand with other activists around her.] Ms.
Heumann, right, is considered a founder of the disability rights movement. She attended the January
premiere of the new Netflix documentary “Crip Camp: A Disability Revolution,” which tells her story. Also
pictured from left, Corbett O’Toole and Ann Cupolo Freeman. Matt Sayles/Invision for Netflix/AP Images

[Image description: A woman in yellow shorts and a black top speaking into a megaphone in the middle of a
protest.] Keri Gray, center, a diversity and inclusion consultant who lost a leg to childhood cancer, at a June
6 protest with the National Alliance of Multicultural Disabled Advocates in Washington. Jennifer White-

Johnson

[Image description: A pink button with orange lettering that reads “We’ve got the
power (ADA!)”] A disability awareness button. Millions of young people have grown
up under the A.D.A.’s protections. National Museum of American History

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https://www.tandfonline.com/doi/full/10.1080/09687599.2020.1751073

https://www.npr.org/people/2101159/joseph-shapiro

https://www.penguinrandomhouse.com/books/164946/no-pity-by-joseph-p-shapiro/

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Nursing Economic$

In May 2021, the National Academies of
Sciences, Engineering, and Medicine released
The Future of Nursing 2020-2030: Charting a

Path to Achieve Health Equity. This consensus study
from the Committee on the Future of Nursing, 2020-
2030, co-chaired by Mary Wakefield and David R.
Williams, builds on earlier work conducted by the
National Academy of Medicine and its predecessor,
the Institute of Medicine, to study the potential role
of nurses in advancing health and health care and
the action needed to realize this potential. The
Future of Nursing: Leading Change, Advancing
Health (Institute of Medicine, 2011) and 2016 report
assessing progress on the 2011 goals (National
Academies of Sciences Engineering and Medicine
[National Academies], 2016) focused on identifying
expanded roles for nurses and the actions needed to
build capacity for nurses to become engaged in and
prepare for those roles.

The new report asks, “to what end?” and targets
activities and roles for nurses in addressing equity in
health care and disparities in outcomes, care, and the
upstream sources of disparities. The focus on inequal-
ity and equity reflects the increasing attention the
National Academy of Medicine has given to health
equity and social determinants of health (SDOH), and
the Robert Wood Johnson Foundation’s agenda to
create a culture of health that provides everyone a
“fair and just opportunity for health and well-being,”
a plan that has equity at its center (National
Academies, 2021, p. 128).

The report embraces a shift from focusing on dis-
parities as circumstances requiring downstream reme-
diation to having causes that require upstream inter-
vention. It identifies inequities in housing, employ-

ment, education, and other precursors to health due
to systemic racism and discrimination. It flags
inequities associated with socioeconomic status, dis-
ability, poverty, limited access to health services, and
race, attributing all to systemic and structural causes,
not simply individual animus. The report embraces a
vision for health systems and healthcare providers to
move upstream, to consider how to intervene not just
with the patient who presents in the waiting room
and while they are in the office or facility, but outside
the traditional framework of healthcare delivery, both
to prevent illness and disease and treat patients with
full consideration of their circumstances.

Tapping Nurses’ Expertise and Experience

Much of the report identifies and discusses pro-
grams and activities that can be part of these inter-
ventions, both generically and with specific exam-
ples. The report notes nurses’ expertise in engaging
patients with chronic conditions, coordinating the
care of chronically ill patients between the site of
care and community and neighborhood resources,
leading teams to improve care of high-need, high-
cost patients, and working with communities to cre-
ate healthy living and work environments. It calls
for greater access for populations with complex
health and social needs by expanding multiple
sources of care and expanded roles of nurses in
these settings.

Among the areas for expansion are Federally
Qualified Health Centers, retail clinics (often staffed
primarily by nurse practitioners), home health and
home visiting care services, telehealth services, and
school-based health centers (National Academies,

Future of Nursing 2020-2030: Increasing the Focus of Nursing
and Health Care on Equity and Discrimination
Jack Needleman

The Future of Nursing 2020-2030 report responds to the heightened
recognition of systemic racism and discrimination based on ethnicity, gender,
and class; the impact of these systemic problems on health and access to
health services; and the need for the nursing profession to be deeply involved
in addressing these problems.

Economic$ of Health Care and Nursing

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Nursing Economic$

2021). The report identifies school nurses and
school nursing as an area of front-line health care,
since school nurses help manage chronic conditions
and disabilities, address injuries and urgent needs,
and provide preventive care and assessments. The
report cites the need for improved care management
and transitional care. It recognizes care should be
customized in collaboration with patients and their
families to reflect each patient’s abilities, needs, and
preferences, citing research demonstrating the value
of person-centered care. And, as in the other areas,
the report highlights the role and experience of
nurses in providing this care.

Addressing Social Needs

The new Future of Nursing report explicitly dis-
cusses how social needs might be addressed in clini-
cal and community settings. It calls for increased
screening in clinical settings for social conditions,
impact of SDOH status, and individual and communi-
ty resources that can influence choice of interventions
and treatments. It urges more active engagement to
address these circumstances through community-
based interventions. In the discussion of community-
based interventions, the report calls for increases in
community and public health nursing and active
engagement of nurses and their expertise in interpro-
fessional, multisectoral collaborations. Two specific
examples of the latter interventions, the Camden Core
Model of the Camden Coalition and the American
Academy of Nurses’ Edge Runner initiative, are pre-
sented.

The Future of Nursing report also discusses the
importance of increased engagement of nurses in
policy and healthcare governance to increase nurse
involvement in effective interventions and to tap
nurse expertise in the design and implementation of
interventions. But the report is centered on expand-
ing interventions to improve equity. A core element
of this expansion is assuring these interventions can
be paid for and sustained outside of foundation and
philanthropic funding models. The issue of funding
is addressed in Chapter Six of the report and a com-
missioned paper by Needleman (2020). The pay-
ment issues discussed can be split into two related
but separate questions: What payment models sup-
port or facilitate increased health system and nurse
engagement in addressing equity and SDOH? What

payment models encourage or create incentives for
these interventions?

Payment Systems and Equity

The main form of payment for health services in
the United States remains fee-for-service (FFS). Under
FFS, revenue is generated through billing for specific
services by providers approved to deliver those serv-
ices. Concerning the equity agenda, there are multi-
ple weaknesses in relying upon payment to support
addressing inequity or SDOH. Payment is generally
limited to physicians and advanced practice registered
nurses (APRNs); billing for services by nurses, social
workers, and others for case management and social
interventions is minimal. (While some additional
billing codes have been created for case management
and related services, these services generally cannot
be provided by non-physicians/APRNs except when
delivered under standard procedures and protocols
and when the billing physician/APRN is physically on
site.) Billing for telehealth services may similarly be
restricted to physicians/APRNs, reducing the potential
for follow-up by other care team members. Many key
providers in the system, such as school nurses, are
not eligible for payment. Community-based outreach
and public health nurses may also not be able to bill
for services.

Another weakness of FFS is its incentive to
increase the volume of billable services provided.
Efforts to modify FFS created incentives to reduce
total costs per patient. These incentives may encour-
age providers to stint care, so they are often coupled
with additional incentives to deliver appropriate care.
This combination of incentives for cost containment
and improved quality form the core of value-based
payment, an essential modification of FFS.

The size of the incentives compared to the rev-
enue that can be realized from increasing FFS vol-
ume will determine whether the net motivation is to
reduce cost and improve care or continue to
increase volume. The measures in these systems
shape provider behavior. There are examples of pri-
mary care practices using registered nurses and
other case managers to reduce hospital readmissions
and other acute services. But the initiatives adopted
are often specific to which incentives can be earned,
such as reduced hospital readmissions or quality
measures tied to particular diseases.

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One program designed to create population-level
incentives within FFS is the Accountable Care
Organization (ACO) model created by the Centers for
Medicare & Medicaid. An Oregon ACO addressing
SDOH and health equity is highlighted. But ACOs
have weak incentives to promote such policies in
general. Entry into the program has not been ran-
dom. ACOs serving a higher proportion of racial and
ethnic minorities have had lower scores on quality
measures. Because the ACO accountability structure
is grafted onto the FFS payment system, internal
incentives through bonus sharing and coordination
can also limit the ability of ACO providers to address
the equity plan. The size of the bonuses themselves
is a constraint on the resources available outside of
the FFS system for program initiatives.

Capitation, per-patient payments, offers robust
support for provision of non-billable services or non-
billing staff to provide services that can reduce cost
or increase quality. Capitation provides the greatest
flexibility for health systems to design care processes
that reduce high-cost care since actions that fall out-
side of traditional billable services can be implement-
ed if they will lower costs or promote other organiza-
tional goals. Capitation also offers the greatest incen-
tives to avoid enrolling high-cost or high-risk patients
and stint care, subject only to discouraging healthier
patients from enrolling due to a poor reputation. This
outcome has led to risk adjustment in setting capita-
tion rates to reduce incentives to avoid high-cost
patients and value-based payment or incentive
approaches to encourage delivering high-cost care.
But capitation will address equity and disparities only
if it also lowers net costs.

Value-based payment systems, or systems with
incentives and rewards, base incentives and rewards
on specific measures. Measures define the expecta-
tions of care and determine the provider’s focus. If
the efforts focus narrowly on standard quality meas-
ures such as diabetes control or the patient care
experience, other considerations associated with
improved population health or reduced disparities in
care may not receive attention. None of the current
major initiatives encourage or create incentives for
interventions to improve equity and address social
determinants of care.

Near universal features of the bonuses or pay-
ments for high-quality care among the FFS or alterna-
tive payment systems are the comparison of quality

across providers and limited social-demographic
adjustment for risk factors, particularly community and
neighborhood effects. Missing in these systems are
adequate assessments of the social determinants of
poor health or access to health care, payment adjust-
ments to allow more intensive care to these popula-
tions, and reviews of performance or rewards based
on improvements over time in outcomes for socially
disadvantaged people or reducing disparities in care
and outcomes.

Given the quality metrics used to direct and
incentivize behavior, current alternative payment
methods are not well constructed to encourage
improving population health, equity, and disparities.
While there are actions that can address these issues,
some proven, some still being trialed, a payment sys-
tem that will support implementation of programs to
address disparities and equity should be developed
from the inside out, starting with the programs and
actions that will improve equity and reduce dispari-
ties, and then designing payment methods and incen-
tives that will encourage and support implementing
these programs and activities. Such programs should
recognize the vital role nurses play in implementing
actions to respond to incentives and assure payment
for engaging nurses and other non-physicians/APRNs
in this work.

The Future of Nursing report recognizes current
payment limitations and calls for including metrics on
equity and reducing disparities in payment systems. It
also highlights the importance of expanded funding
for school nurses and public health nurses and build-
ing payment and programmatic linkages between
health and social service providers.

Conclusion

Future of Nursing 2020-2030: Charting a Path to
Achieve Health Equity responds to the heightened
recognition of systemic racism and systemic discrim-
ination based on ethnicity, gender, and class. The
report recognizes the impact of these systemic prob-
lems on health and access to health services and the
need for the nursing profession to be deeply
involved in addressing these problems. These prob-
lems cannot be addressed without understanding
how the economics of care delivery influence
behavior. Payment must be changed to create strong
incentives and rewards for actions and activities that

July/August 2021 | Volume 39 Number 4 199

Nursing Economic$

address disparities and promote equity in health and
health care. $

Jack Needleman, PhD, FAAN
Fred W. and Pamela K. Wasserman Professor
Chair, Department of Health Policy and Management
UCLA Fielding School of Public Health
Los Angeles, CA
Nursing Economic$ Editorial Board Member

References
Institute of Medicine. (2011). The future of nursing: Leading change,

advancing health. The National Academies Press. https://doi.
org/doi:10.17226/12956

National Academies of Sciences, Engineering, and Medicine. (2016).
Assessing progress on the Institute of Medicine report the future
of nursing. The National Academies Press. https://doi.org/
doi:10.17226/21838

National Academies of Sciences, Engineering, and Medicine (National
Academies). (2021). The future of nursing 2020-2030: Charting a
path to achieve health equity. The National Academies Press.
https://doi.org/doi:10.17226/25982

Needleman, J. (2020). Paying for nursing care in fee-for-service and
value-based systems [White paper]. https://www.nap.edu/
resource/25982/Needleman%20Commissioned%20Paper

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