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  • Reflection for health care workers

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    Reflection, and reflective practice, is increasingly being encouraged to help health care workers (HCW) learn and become more effective practitioners. There is a large body of material to assist HCWs, and how to find your way through all this can be daunting. This brief course has therefore been prepared to help both, trainees and established HCWs, understand the basics and start their journey of reflection; unusually the course has been developed not from a theoretical perspective but from the lived experience of a practitioner – it is case study-based. 

    The course starts with some background and then describes the key elements of reflection. To access resources you may find interesting - click on the blue resources hyperlink which will take you to the resources and links to relevant papers.   

    One caution - only undertake this course if you want to, since unless you are motivated enough it is of no use.

    Towards the end you will see that you can gain a Certificate of Completion - you can download this yourself if you feel that you have gained enough from the course to warrant this. We encourage you to make notes as you go along as this is a good way to be sure that you can understand the information presented and the lessons to learn from it. This can then become part of your personal development plan. Also, there are two exercises for you to practise your learning. 

    The course was developed by Rajan Madhok, Former Chair of the Peoples-uni Trustees.

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    This work is licensed under a Creative Commons Attribution 4.0 International License.

  • Reflective practice

    Background

    "The unexamined life is not worth living” said Socrates, and as society and healthcare in the 21st century becomes more complex we should heed his saying;  the need to step back, review what we are doing and plan for the future is more necessary than ever.

    To begin with, here is a personal example from the author’s own professional life - this compendium  was produced a few years ago, and as I explain in it my practice started after I moved from orthopaedic surgery into public health when I realised that I needed to improve my critical thinking and communication skills and started writing; it was not until much later that I realised that what I was doing was reflection. The term reflective practice was not much in use then and indeed even now. I sort of fell into it, but once I got the ‘bug’ I kept going and tackled increasingly complex subjects. I had discovered that writing made me think and make sense of what I had observed or done, and most importantly how I could improve. As you will notice I had approached the subject back to front. Until very recently I had very limited knowledge of the theory of reflective practice and I basically did what I felt like! I did not know ‘Reflection on Action’ from ‘Reflection in Action’ (more on this later). See this website for details of my work: https://www.ramareflections.com/

    Before you proceed further, here is an exercise. 

    Exercise No. 1

    Write a paper

    1. describing your current thinking about, and your practice of, reflection – what do you understand by it and how do you practise it

    2. why you want to learn more about it – what is your motivation

    3. what do you think will be challenges and how will you overcome them – to basically create a plan”

    Once you have done this, save this paper for yourself and use it for Exercise No 2 later.

    The basis of reflection

    “The only constant in life is change” goes the old cliche but it is actually true and indeed 21st century is going to see more and frequent changes. This applies to all aspects of life including healthcare as science and technology advance and as societies change. What this means is that HCWs need to constantly update themselves and review their practice in the context of changes in their professional and political, economic and social environment. Just following the old model of education and learning is not going to suffice and HCWs need to invest in life-long and adult-learning. See the table below for a comparison of the Pedagogy (‘old/traditional’) and Andragogy (new/modern) ways of learning. It is not, however, an either/or decision and more of a balance, though at the practitioner level andragogical approaches are more useful.

    Source: https://www.educatorstechnology.com/2013/05/awesome-chart-on-pedagogy-vs-andragogy.html licensed under Attribution-NonCommercial-NoDerivs CC VY-NC-ND

    What is reflection

    Reflection is ‘‘a generic term for those intellectual and effective activities in which individuals engage to explore their experiences in order to lead to a new understanding and appreciation’’ (Mann, Gordon and MacLeod), and critical reflection is the process of analysing, questioning, and reframing an experience in order to make an assessment of it for the purposes of learning (reflective learning) and/or to improve practice (reflective practice) (Aronson). NOTE: neither of the papers are available through open publishing, so the links are to the abstracts only.

    What does reflection entail

    In essence, reflection is about making sense of our actions in order to improve further, and one would have thought that we would all be practising this. However, that is not the case - reflective practice is still in its infancy and is also in danger of becoming a ‘tick box’ exercise.

    Here is what good reflection would look like:

    “If we take the example of a medical mistake, a superficial, educationally ineffective reflection will consist of a description of the events or a description accompanied by reasons such as the team/clinic was busy and other people failed in their responsibilities.

    “A more useful and deeper reflection would include consideration of:

    • how and why decisions were made,

    • underlying beliefs and values of both individuals and institutions,

    • assumptions about roles, abilities and responsibilities,

    • personal behavioural triggers, and similar past experiences (‘‘when pressed for time, I . . . ’’),

    • contributing hospital/clinic circumstances and policies,

    • other perspectives on the events (frank discussion with team members, consultation of the literature or other people who might provide alternative insights and interpretations),

    • explicit notation of lessons learned and;

    • creation of a specific, timely, and measurable plan for personal and/or system change to avoid future similar errors.

    “Effective reflection, then, requires time, effort and a willingness to question actions, underlying beliefs and values and to solicit different viewpoints. This ‘‘triple loop’’ approach moves beyond merely seeking an alternate plan for future similar experiences (single loop) or identifying reasons for the outcome (double loop) to also questioning underlying conceptual frameworks and systems of power.” (Aronson).

    You could use the same approach to any health care issue: smoking, alcohol or infectious diseases, or care of the elderly, or patient safety, for example and so the topic is relevant to all HCWs in all settings. The following diagram (from UK Faculty of Public Health) is a good summary. 



    From: Reflective notes, UK Faculty of Public Health FPH Tips on Writing Effective Reflective Notes

    How to practice reflection

    But how does one acquire the necessary skills and become a reflective practitioner, especially as we are all busy and have too many demands on our times? At this stage we should also point out, in case you have not already noticed, many different terms are used when talking about reflection, such as:

    • reflective learning

    • reflective practice (or reflection in education or research)

    • reflective thinking and

    • reflective writing

    and whilst it may be useful to look at these various aspects in details, for now they are part of the continuum whereby one learns and puts learning into practice and uses thinking and writing to achieve this. Indeed, as one acquires the basic knowledge and skills and starts practising reflection, it moves from being a retrospective (Reflection on Action) to a real-time (Reflection in Action). You may want to see Reflective practice in health - from La Trobe University to learn more about some of these issues. 

    In addition, here are two resources from the Monash University Library; have a look at this first: Reflective writing and critical incidents  which offers a simpler way to start your reflective practice: 

    • Description – What happened?

    • Analysis – Why did it happen? What were you feeling? What theories might help explain what happened? Are there other perspectives that challenge your views?

    • Outcomes or Action – What did you learn? What would you do differently next time?


    Getting started

    To begin with it is important to recognise that not everybody is as reflective, and that reflection is an active choice to pause, examine, and analyse and that it requires dedicated time and use of different techniques/methods- some alone, others with help from mentors/peers.

    To do reflection one needs to start with the objectives – the piece of work that you are going to reflect on and whether the objectives of that work were clear, and also the objective for reflection – to assess what more to learn and how to use the results of reflection in practice. Overall you need to develop your own approach to how you would do this, what techniques to use and how much to do alone or with peers/mentor. As an example, one can use new technologies/apps like mindmap to aid this process.

    For those of you who are already more advanced, and also following the saying that the best way to learn is to teach, you may want to see this table of the twelve tips from Aronson on how to teach reflection - whilst it is about medical education, the scheme and ideas are relevant to all HCWs. 

    Twelve Tips for teaching reflections at all levels of medical education

    Tip 1

    Define reflection
    Tip 2

    Decide on learning goals for the reflective exercise
    Tip 3

    Choose an appropriate instructional method for the reflection
    Tip 4

    Decide whether you will use a structured or unstructured approach and create a prompt
    Tip 5

    Make a plan for dealing with ethical and emotional concerns
    Tip 6

    Create a mechanism to follow up on learners’ plan
    Tip 7

    Create a conducive learning environment
    Tip 8

    Teach learners about reflection before asking them to do it
    Tip 9

    Provide feedback and follow-up
    Tip 10

    Assess the reflection
    Tip 11

    Make this exercise part of a larger curriculum to encourage reflection
    Tip 12

    Reflect on the process of teaching reflection

    Ultimately however you will need to create your own approach to reflective practice to get best value from your time investment, and for this you need to make it a regular habit not a task, and something to be enjoyed! I use writing to document my learning but you may choose other ways like drawing/paintings, and I use walking in nature and gardening to do my reflection and again you may have other activities which enable you to go inside yourself and reflect. In any case by this stage you should have a better idea  of how far up the Triple Loop (mentioned above) you are: when you make reflection notes after a CPD activity are you critical/reflective enough, did you understand the 'root causes' - what worked and what did not, what have you actually learnt and how will you build it into your practice? Over time reflection becomes 'automatic' - I call it my background operating system, always there helping me learn and improve; hard though it seems it does not delay or stop you from getting on with work and life, and it is not a chore- rather it can be enjoyable. One other caution, reflection is for personal use mainly and not for 'showing off'; the only judge of whether it works is you! 

    Conclusion

    This has been a brief introduction to the subject of reflection, and hopefully will stimulate you to learn more and practise it regularly.

    We started with a quote from Socrates, and here is another one and this time from Rumi – a 14th century poet/mystic (Sufi): “Do you pay regular visits to yourself? Start now.”

    Reflection is not just for professional practice but also for personal development, after all you want to have some balance between work and play and overall have a successful and happy life. Getting there takes time and so earlier the better, and all this starts with creating the mind-set – what you think becomes your actions, actions become habits and habits define your character. So start by creating the reflective thought processes in your mind: What am I doing? Why am I doing it? Is this good- and for whom? Can I do it better? and make this a way of living.

    How and what you reflect on will change with the stage of your life, if you go through Rama Reflections  you can how my practice changed. For example, I wrote an anthology which focused on life lessons, based on my learning, and not just about healthcare matters. I feel that this sort of reflection is all the more relevant for the younger generations who are likely to have different careers to the ones enjoyed by the older generations (like me in late 60s); they will have repeated career changes with learning interspersed with periods of work, and will need constant reflection to enable them to achieve a good work: life balance and be professionally successful and personally happy.

    Now for those who have some time (over an hour) and are interested to know more about the value of reflection - in terms of some lessons learnt, and on how to do it- the basics of reflective practice, you may want to see this video which was made for young clinical professionals but has wider relevance  - 

    ;

    To finish off here is the second exercise

    Exercise No. 2

    “Revisit the paper you wrote in Exercise 1 and add another section on what you have learnt and your plans for how to build reflection into your life: both professional and personal?”

    In the plan you should also include further reading especially articles written by your professional bodies and more relevant to your context.

    If you have got this far, then congratulations on having done both the above exercises which is basically you doing what Reflection is about! You can now build on it- here is an example of the type of personal journal you can create to ensure you have an ongoing record of your practice.

  • Gain a certificate

    We hope that you wrote the two exercises as well as you could have. Unlike most certificates which require some sort of 'test' and assessment, we do not feel such an approach is relevant to a subject like reflection. You can be your own examiner here and decide whether you have done enough and if you have then congratulations and go ahead and download the certificate by clicking on the link below.

  • One final thing

    Finally, although what you have done is personal to you, it can be important to share and learn from others. So if you feel able to - it is entirely voluntary - then you can upload your work with a short note about you, your motivations for posting it and if you want any specific feedback from others.  Do not be discouraged if you do not hear back - but also note that these feedback loops only work when everyone participates, and so do consider sending in your work.

    If you want to upload your blog, go to the Blog Menu on the side panel or via Add an entry about this course. You will see that you can publish your blog privately, or so that others can see.