Clinical Reflection


Original Editor - Michelle Lee Top Contributors - Michelle Lee, Ewa Jaraczewska, Tarina van der Stockt, Tony Lowe, Kim Jackson, Jess Bell, Wanda van Niekerk, Olajumoke Ogunleye and Stacy Schiurring


Introduction

Originating from the work of Donald Schön the concept of reflective practice is recognised as a key component of a health professional's practice. It enables clinicians from many disciplines to develop and maintain professional best practices. In healthcare, this practice is termed "clinical reflection". With the ever-growing pressures for service development and self progression, clinical reflection is now considered an essential skill that should be put into practice regularly by every health care professional. In physiotherapy, the use of reflection has been adopted to enhance patient care, clinical supervision, collaboration, and clinical reasoning. When done properly, reflective practice can enhance your skills as a healthcare worker.

What is Reflection / Reflective Practice?

Health workers often experience complex clinical practice situations, that can be navigated through reflection. Because of this, reflection and reflective practice are advocated by many professional bodies to promote high-quality service delivery. But what are 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.' 
• 'Conscious and systematic approach to thinking about experiences with the aim of learning and changing behaviours.'

A clinical reflection is a tool that enables the individual to learn from their experiences and actions and is applicable in the health care setting and through the day to day life. It enables the individual to learn from mistakes and their poor choices to acknowledge when things have gone well so the process can be repeated. To clinically reflect and utilise this skill in the health care setting some practice is needed, as it requires critical thinking. Using critical reflection tool helps the therapist to figure out what is known already. Adding the new information that was gained, resulting in better understanding, knowledge and a new meaning.

By 'consciously looking and thinking about experiences, actions, emotions, feelings and responses' you can interpret them so that you can learn thus becoming more critical about your views of the practice and the world.

Watch this video on reflective learning to find out more.

The Reflective Journey

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. This is why the educational institutions are incorporating critical reflection into their programmes to establish these competencies early in the individual's professional career. However, these skills need to be practised to be developed. 

It is uncommon that the health care professional students will start their reflective development journeys by being given the task of keeping a reflective journal or diary of their day on clinical placements. This journal involves answering multiple thought-provoking questions to facilitate and direct the reflection. These questions are: 

• What happened?
• Why did you choose that method?
• Is there any research to support your decisions?
• What went well?
• What could have gone better?
• What are the action points for implementation next time? 

It is encouraged that reflections are initially in writing as it helps to cement their different stages. Once the skill develops, health care professionals can reflect internally throughout the day and only reflect formally (in writing) 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. It aims for trainee doctors, but any health care professional can benefit from the principles presented.

Methods of Reflection

There are many configurations of formal reflection, including various reflective practice questionnaires and scales. 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 complete
• involve thinking which is objective, critical and deep.

Schön distinguishes two forms of reflection: reflection-on-action and reflection-in-action. You reflect on the action when you are analysing your practice after the event. The information gained is then turned into knowledge. Reflecting in action means to reflect while you are carrying out the activity. Here is a detailed characterisation of each of the reflections.

Reflection-on-action

• Done by novice practitioners.
• After the event, thinking about 'beliefs, expectations and biases'.
• Thinking about what happened, actions that were performed and what could change the outcome next time.
• This reflection changes experience to knowledge.

Reflection-in-action

• 'Reflecting on practice while it is happening'.
• Done by expert practitioners
• 'On the spot research' - while the practitioner gains new understanding of the situation the situation is changed.
• It requires "conscious attention to the task".
• The practitioner acts as their own supervisor and questions their own actions (meta-reflection on the reflection).

There are several frameworks offered for structuring reflection. See this PowerPoint presentation for different examples.

Below are descriptions of some of the most common reflective frameworks and models. To find the best model for you, you should practise with several different frameworks and choose the one you feel is the most effective for your particular situation. Reflection is a very personal activity, as is your framework choice to ensure that you are getting the most from it.

Gibbs Reflective Cycle (1988)

Gibbs Reflective Cycle model provides a structure for learning from experiences. It is cyclical and leads through 6 stages: description, feelings, evaluation, analysis, conclusion, and action plan. Using this model to reflect on clinical cases and on the causes of adverse events increases critical thinking skills in nurses, studies have found.

Description

The section in the reflective cycle is describing the event that is being reflected upon. It should provide short and precise 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 concluded from answering the following questions

• How did you react 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 is an evidence for the event you are reflecting on, it can be included 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.
• Deside what went well, and what has not gone so well.
• Link your experience to what the literature is reporting.

Conclusion

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

• Would you do the same again?
• What would you change?
• What could you do to stop the same things from happening in future?
• How can you make sure the same thing happens again to ensure the same positive outcome?

Action Plan

This section is about what you are going to do next. It describes how you are 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) 

John's model is structured and contains set of questions that are being asked to direct the reflector through the process. Some users found this model a little restrictive .

The questions are grouped in five categories: description, reflection, influencing factors, evaluation and learning.

1. Description
   • Phenomenon - -describe the here and now experience.
   • Causal - what essential factors contributed to this experience?
   • Context – what are the significant background factors to this experience?
   • Clarifying – what are the key processes (for reflection) in this experience?
2. Reflection
   • What was I trying to achieve?
   • Why did I intervene as I did?
   • What were the consequences of my actions for
     • myself?
     • the patient/family?
     • the people I work with?
   • How did I feel about this experience when it was happening?
   • How did the patient feel about it?
   • How do I know how the patient felt about it?
3. Influencing factors
   • What internal factors influenced my decision making?
   • What external factors influenced my decision making?
   • What sources of knowledge did/should have influenced my decision making?
4. Evaluation
   • What choices did I have?
   • What would be the consequences of these choices?
5. Learning
   • How do I feel now about this experience?
   • How have I made sense of this experience in light of past experiences and future practice?
   • How has this experience changed my ways of knowing
     • empiric?
     • aesthetics?
     • ethics?
     • personal?

Borton's/Driscoll's Development Framework (1970)

Borton's three questions (What? So what? Now what?) were mapped on to an experiential learning cycle by John Driscoll to form a simple framework for supporting reflection. This framework is a popular option used by many health care professionals and advocated by professional bodies. 

Example of Borton's questions used to reflect on experience :

What?

These questions prompt the reflector to describe what has happened.

• What were the roles of the people involved?
• What was my role?
• What were the problems?
• What happened? 
• What did I do?
  

So What?

This is the analysis of the reflection.

• What was the outcome?
• What did you learn?
• What was important?

What Now?

This section focuses on what will you do next and what does your learning experience mean for future practice.

• What do you need to do now?
• What were the consequences?
• How do you resolve the situation / improve the outcome?
• How will what have you learnt from this experience change your future practice?                                         

Conclusion

You have learnt about 3 of the main learning frameworks / reflective structures to use in clinical practise. It is important to understand that reflection is a skill that is developed through repeated practice. When selecting a model to use it is essential to choose different structures and frameworks for different situations depending on which suit you and a particular context best. Day to day reflections (e.g. for CPD events) may be better suited to Borton's framework, whereas for an academic piece of work or a significant incident at work, a more detailed framework such as Gibbs may be more appropriate. It is also important to review relevant literature, analyse your own experience, explore anecdotal evidence and include this within your reflections to develop an evidence- based practice approach in your reflective practice. 

Resources

• https://www.physiospot.com/physiopedia/a-conversation-about-reflection-with-dr-patricia-miller/
• Enhancing skills of critical reflection to evidence learning in professional practise, by C. Paterson and J. Chapman
• Clinical reflection - a conversation with John Driscoll