Clinical Reflection

 Introduction

Clinical reflection is a skill which is now developed from university level, with the ever growing pressures for service development and self progression this is now an essential skill that should be put into practice regularly by every health care professional. 

So this page is going to run through:

• What is refection and why we use it
• The reflective journey 
• Different methods of reflection

What is Reflection / Reflective Practice?

Reflection and reflective practice is advocated by many professional bodies to promote high quality service delivery, but what is reflection and reflective practice? Here are some definitions: 

• "Reflection is a process of reviewing an experience of practice in order to describe, analyse, evaluate and so inform learning about practice"

• “Reflective practice is something more than thoughtful practice. It is that form of practice that seeks to problematise many situations of professional performance so that they can become potential learning situations and so the practitioners can continue to learn, grow and' 'develop in and through practice” 

• "a window through which the practitioner can view and focus self within the context of his/her own lived experience in ways that enable him/her to confront, understand and work towards resolving the contradictions within his/her practice between what is desirable and actual practice” 

Clinical reflection is a tool which enables the individual to learn from their experiences and actions, this is not only applicable in the health care setting but through day to day life. It enables the individual to learn from mistakes and poor choices they take and acknowledge when things have gone well so this can be repeated; but to clinically reflect and utilise this skill in the health care setting needs some practice, as this requires critical thinking. 

Watch this video on reflective learning to find out more.

The Reflective Journey

It has been acknowledged that critical reflection in clinical practice is essential for clinical effectiveness and continuing professional development. There is evidence to suggest that critical reflection is difficult without expert guidance, therefore educational institutions are now incorporating this into their programmes to establish this skills early in the individuals professional career. Reflection and critical analysis is a skill which needs to be practised in order to be develop. 

Quite often student health care professionals will start of their reflective development journeys by being given the task of keeping a reflective journal or diary of their day on clinical placements. This journal will involve certain thought provoking questions to facilitate and direct the reflection such as: 

• What happened
• Why did you chose that method
• Is there any research to support your decisions
• What went well
• What could have gone better
• Action points for implementation next time

It is encouraged that reflections are initially written; this will help to cement the different stages of reflection, but once this skill is fine tuned health care professionals do this regularly (internally) throughout the day. They then may only reflect formally (written) upon an event or activity that was particularly significant for them.

Watch this small lecture from the London deanery on reflection and learning in the workplace. This is aimed at trainee doctors but the principles can be translated into any health care profession.

Methods of Reflection

There are many forms of formal reflection, all differing slightly. There is no right or wrong method of reflection as long as it is:

• A record which is useful to you
•  A cue to memory
• Honestly written
• Enjoyable to you in its production

Here are some of the different structures that can be used. To find the best structure to use is to practice with a few and choose the one which you feel is most effective for you, as reflection in clinical practice is about your learning. 

Gibbs Reflective Cycle (1988)

Gibbs reflective cycle is a formal structure which can be used for academic pieces of work but also in clinical practice which can be used to evidence continuing professional development. 

Description

The section in the reflective cycle is describing the event that is being reflected upon. Is only needs to be short and precise to give background information on the event.

Feelings

This section focuses on thoughts and feelings at the time of the event and after. 

Evaluation 

The evaluation is reflecting upon the experience, such as;

• How you reacted to the situation,
• How did you react after,
• How did other people react
  
• If it was a problem solving situation - was the issue resolved. 

If there are pieces of evidence for the event you are reflecting upon you can include these here.

Analysis 

This section is where you can really demonstrate your reflection on the experience. Pick out points that you think have hindered or enhanced the experience. What went well, and what has not gone so well. Similarly to the evaluation section where references may have been incorporated, the analysis section is where you can link your experience to what the literature is reporting. This is where you will improve your grades if this is an academic piece of work, but also useful for using as a piece of evidence in a CPD.

Conclusion

This section is about summarising the outcome of the event being reflected upon.

• Would you do the same again
  
• What would you change
• Identify what you could do to stop the same things from happening in future
• or how can you make sure the same happens again to ensure the same positive outcome

Action Plan

This section is essential to any reflection, this is about what you are going to do next. How are you going to implement the changes you have identified to achieve the desired outcome next time, be it performance improvement or maintaining the standard achieved. 

John's Model for Structured Reflection (2000) 

Description	Describe the experience Background to the experience Key factors / process that are going to be reflected upon
Reflection	What was the aim of the event Why did you do what you did What were the results / consequences of your actions - to yourself and others What were your thoughts / feelings at the time  How did others feel about the actions you took and how do you know this
Influencing Factors	Internal factors affecting actions External factors affecting actions Literature / sources of knowledge affecting actions
Evaluation	How could you have improved the situation What other options were available What would have been the result of those other options
Learning	What are your thoughts and feelings about the experience now How has this experience affected your knowledge Are there any learning points for future experiences