Amanda Deaves Clinical Tutor Reflective Practice Amanda Deaves Clinical Tutor

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 ?

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

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

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

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

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

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’

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.

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

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

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

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?

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

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.

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

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

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.

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

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

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.

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

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’

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

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

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

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