1. Amanda Deaves Clinical Tutor
Reflective Practice
Amanda Deaves
Clinical Tutor

2. Objectives To increase knowledge of reflective practice
To review models of reflection
To understand the role of critical reflection on clinical placement
To understand the role of reflection within physiotherapy practice
To prepare for assignment ?

3. Last year we defined reflection and discussed how we might use this method of thinking back over actions and considering how we might improve the experience
Dictionary definition: careful or long consideration or thought
It is not just reflection that we wish to consider but reflective practice and critical reflection

4. Definitions
‘A process of reviewing an experience of practice in order to describe, analyses, evaluate and so inform learning about practice’ (Reid 1993 in Schutz 2007)
‘A process of internally examining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self and results in a changed conceptual perspective’ (Boyd and Fayles 1983 in Schutz 2007)
Useful to agree a common perspective
A way of learning about and as a way of changing practice
Emphasis the process of review and analysis and a personal experience

5. Why Reflect? Hallmark of professional practice
To improve complex decision-making and clinical reasoning skills
To achieve experiential learning
Critical to the learning process
Central to the process of self-appraisal
CSP expectation that physiotherapists should be reflective practitioners
There are many reasons to improve our reflective practice skills and it is essential that as health care providers we embrace the concepts of evidence-based practice and clinical effectiveness. We need to be continuously reviewing our practice in a critical and analytical manner. Reflective practice is part of this process, it is the link between competence to practice and life-long learning. The CSP have produced many documents that stress the importance of this process and guidance on how to present our CPD.
By using reflection we are using our clinical experiences as the starting point for our learning, we can understand them differently and start to take action as well

6. CSP
The Chartered Society of Physiotherapy expects its qualified members, student members and associate members to maintain and develop their skills, knowledge and competence in order to practise safely and effectively through continuing professional development (CPD). There is a strong link between evaluation, learning and the enhancement of patient care and quality of service. (Policy Statement CPD Sept 2007)
CPD should be seen as a systematic, ongoing structured process of maintaining, developing and enhancing skills, knowledge and competence both professionally and personally in order to improve performance at work.
Reflective practice is one of the ways to achieve affective CPD

7. Reflective practice ‘bridges’ the gap between pure theory and direct practice by providing a strategy that helps to develop deeper understanding and learning.
Consolidate learning
Highlight gaps / areas which need further consideration / learning / understanding

8. Developing Expertise
Novice – follows rules – performance often halted and mediocre
Expert – knowledge is a by-product of experience and reflection, ability to unpick a complex (new) situation and find effective interventions, able to ‘go beyond’ rules, confident in own expertise
Reflection is key in novice to expert journey (Poulter 2004)
It is the desire to understand, to question and to challenge that helps us become an’expert’

9. Gap analysis
Learning plan
Learning activities
Review & evaluation
Competencies
We learn by doing and analysing what has happened and taking action from a different perspective
Kolb’s experiential learning cycle has formed the basis for many models of reflective practice. We talked about Kolbs learning cycle in Yr 1 and we now need to apply this to practice
You need to have the experience, observe, consider the information, consider the connections, ideas and theories, plan for next time and then have the experience again. This is the cycle described by Kolb
The idea is to use the reflection to give a deeper understanding of what has happened and then develop our own theories and ideas on the experience and then this will inform further actions.
To apply to clinical practice, we have the learning activities, we need to review and evaluate that experience, identify the gaps in our learning, formulate the learning plan and then move on to the new learning opportunity.

10. Gibb’s Reflective Cycle (1988)
Description of the event
Feelings
Action plan
Conclusion
Evaluation
This is a staged process model
An extension of kolbs cycle
Description – what happened
Feelings – what are you thinking and feeling
Evaluation – what was good and bad about the experience
Analysis – what sense can you make of the situation
Conclusion – what else could you have done
Action plan – if it arose again what would you do
This has a sense of past – present and future
This model focuses on learning from the incident and focuses of the individuals actions
Analysis

11. The Task Choose one of your examples from your observation week
Think back and expand your thoughts and reflective skills by completing the proforma
What are you initial reactions to the above situation?
what could be the context of this situation
What are your feelings here
What other perspectives might there be that should be considered

12. Describe a recent experience in your professional life
Context
What happened?
Who was involved?
What was the context for the event?
Why is the event important to you?
What did you do..
Thoughts / feelings
What happened
How did you respond to the event?
And why?
Analysis
What were you thinking at the time? (during/after)
What was most demanding / rewarding
What went well…
What helped?
And what could have been better?
Evaluation good / bad
What hindered?
What assumptions, beliefs, values, intuitions underpinned the response/reaction?
Continued next slide

13. What would you now do differently, faced with a similar situation?
Conclusion
What else could be done
Alternative actions or approaches
What is the significance of what happened?
What else do I need to consider to understand better what happened and why?
What sense can I make of the event/situation?
Describe what you have learnt from this experience?
In what ways was the sequence of events connected?
How did it influence or change: me, my learning, my practice?
What action would I take in a similar situation?
What do you need to learn?
How might you learn this?

14. The reflective process involves both feelings and cognition which are closely interrelated and interactive.
Emotions are very important to the reflective process.
These feelings may be positive or negative.
They cue the individual to respond at the initial stage of the reflective process and there are intensive personal feelings at the end of the reflective process
Emotions can spur us on to action to remedy a situation or avoid repetition. Emotions are closely related to values and without recognition of our own values, we cannot begin to reflect on out practice because we need to evaluate what has happened against those values
The cognitive activities include making inferences, discriminating and associating relationships, and validating assumptions

15. Five quick tips to start reflection
Initial write as if you are talking to a confident – imagine their probing questions?
Talk – share your reflections with peers
Use a model to frame your reflections
Go beyond describing – follow up with the question – so what?
Write quickly / naturally at first then add layers, answer questions, develop themes
Imagine an audience for your musings. It’s hard to write without an audience. Write like you are talking to someone that you trust and connect with, and to extend your thoughts imagine their probing questions when you hit natural pauses.
Talk, don’t just write. Use voice memos on your phone to capture thoughts in the moment and then write them down when back at base. Some of the most reflective thoughts happen in the car – catch them! This model is effective with adults and children alike.
Use a model … a blank page can be daunting, use a reflective model to provide a writing frame for your reflections. Gibbs is my favourite but there are others too …
Go beyond describing what happened in an event or situation. Always follow up with the question, so what? (so what …. For me, for my students, for my colleagues, for my CPD needs, for my confidence, for my progression , for my efficiency, for my well-being?*).
Write quickly, naturally and without concern for prose. This is a first layer of reflection. Then a) develop the text and tidy it up and b) add comments or text boxes to annotate and add further observations on your initial thoughts. Comments or annotations can add major depth compared to a first attempt – ‘when I wrote this, I was thinking …. And I thought this because … but now I have discussed it with my colleague/friend and have revised my original understanding’ or ‘ I can see the choices I made here were limited by ….’. Adding layers to a reflection in this way can be very productive and can help us to question how we see things in the moment.

16. Critical Thinking
Achieved by recognizing and analyzing multiple perspectives and is essential to problem solving
Meta-cognition
Systematic critical enquiry will lead to a better understanding of practice
Questioning and challenging existing beliefs, values, customs and rituals
Part of reflection is critical thinking or reflecting critically.
Critical thinking is the ability to evaluate and assess information to make judgements on clinical practice, it will incorporate evidence based medicine
Metacognition is a higher order thinking process. It is the active monitoring of one’s own cognitive activities . It is the checking of the outcome of an attempt to solve the problem, planning the next action, monitoring the effectiveness and testing, revisiting, evaluating one’s strategies for learning.
By thinking critically we can develop advanced clinical knowledge and clinical reasoning skills
Critical analysis involves the examination of knowledge of the situation, which may include aesthetics, personal, moral and empirical knowledge. This allows examination of existing knowledge and the generation of new knowledge. It will consist of association, integration, validation and appropriation.
Synthesis and evaluation are crucial to the development of a new perspective.
The highest level is critical reflection and this necessitates a change to deep seated and often unconscious beliefs leading to new belief structures
Critical reflection will involve perspective transformation, this will take time to achieve.
To explain or expand knowledge is important

17. Reflection needs to included the bigger picture
This includes personal and professional aspects and the ethical and political issues that are a feature of modern day health care

18. Goodman’s levels of reflection
There are several frameworks which can be used to facilitate the process of reflection and reflective writing. One of the simplest was developed by Goodman (1984) who suggested that there are 3 levels of reflection that a practitioner can achieve.
Lets review the reflections in line with Goodmans reflection.

19. Level 1
Reflection to reach given objectives. These usually relate to efficiency, effectiveness and accountability of own actions.
Mainly descriptive in nature
Identify key features
Recording of basic facts
Indication of some awareness of what has happened
Some learning indicated

20. Level 2 Reflection on the relationship between principles and practice
This involves assessment of the consequences of actions and beliefs as well as the underlying rational for practice
Shows awareness of personal and professional values
Identifies the reasoning and evidence base of actions taken
It will trigger the need to know more and search out more information

21. Level 3
Reflection which incorporates level 1 & 2 plus ethical and political dimensions
Looks at the immediate event, it’s implications for practice and then broader social structures and forces.
It acknowledges the wider influences of ethical and political decisions with regard to care delivery and practice.

22. Goodman’s Example
Work through the example and add bullet points to indicate how the example could be expanded to achieve Level 2 and then Level 3 reflection

23. Facilitation of Reflection
Identifying ‘critical incident’
Awareness of feelings / attributes / strengths / weaknesses
Awareness of own learning
Making connections with prior knowledge / experience
Recognition of / planning of next stage
a critical incident is an event that stands out in your mind and contributes directly to developing as a practitioner. what have you learnt today?
What did you do new today?
One of your experiences you have had +ve or -ve
Vocalise your thoughts to your educator, show them your reflective logs’

24. Tools to help reflection
SWOT analysis
SWOB analysis
Johari’s window
Reflective log
Pebble pad CSP eJournal

25. PHTY 223 Assignment
Reflect on one key learning incidents which occurred during the placement
Word limit: 1,000 words
Different topics you may wish to consider for your reflection
You must demonstrate evidence of your own Personal Development
Guidelines for reflective writing
See assignment sheet, handbook
Use all the various tools to help with reflection

26. Summarise - Reflection is……
Applied to any activities / situations
Beyond the descriptive
Intellectual: analytical, draws in evidence and literature
Personal: about your experience
May include feelings
May include wider perspectives
Intended to enhance learning and performance

27. References
Jasper M (2003) Beginning Reflective Practice, Nelson Thornes
Kember et al (2001) Reflective Teaching & learning in the Health Professions, Blackwell Science
Plack M, Santasier A (2004) Reflective Practice: A Model for Facilitating Critical Thinking Skills within an Integrative Case Study Classroom Experience, Journal of Physical Therapy Education, 18,1,4-12
Poulter (2004) Time to Reflect. Nursing Standard, 18, 21
Schutz S (2007) Reflection and Reflective Practice, Community Practitioner, 80,9,26-29