Clinical Reflection


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


Introduction

Originating from Donald Schön's work, reflective practice is recognised as a key component of healthcare. Clinical reflection enables professionals to navigate complex situations and develop best practices, which is why many professional bodies now advocate its use for quality service delivery.

With growing pressures for service development, clinical reflection is considered an essential skill for all healthcare professionals. In physiotherapy, it enhances patient care, clinical supervision, collaboration, and clinical reasoning, whilst meeting regulatory Continuing Professional Development (CPD) requirements in some countries. When implemented properly, reflective practice enhances clinical skills.

What is Professional Reflection / Reflective Practice?

"Reflective practice is 'a process of reviewing an experience of practice in order to describe, analyse, evaluate and so inform learning about practice". It involves systematically examining experiences, actions, and responses to learn from both successes and mistakes.

In healthcare, clinical reflection requires critical thinking skills to identify existing knowledge, integrate new information, and develop better understanding for future practice. Reflective practice goes beyond simply thinking about your work. It involves deliberately examining challenging or unclear situations to identify learning opportunities, helping practitioners continuously improve their skills.

Watch this video on reflective practice to find out more:

Key Reflective Frameworks

Various frameworks exist for structuring reflection. There is no right or wrong method of reflection. Effective reflection should be useful, honest, and involve objective, critical thinking. Below are descriptions of some of the most common reflective frameworks and models.

Levels of Reflection - Hatton and Smith (1995)

This widely used framework, developed by Hatton and Smith (1995), identifies four hierarchical levels that help practitioners develop sophisticated reflective skills.

Levels of Reflection

1. Descriptive (Technical) Writing

This involves factual reporting without analysis or reflection. Simply document what occurred without personal interpretation or consideration of alternatives. Example: "Patient presented with knee pain. Range of motion measured at 90 degrees flexion. Applied manual therapy for 15 minutes. Provided exercise sheet."

2. Descriptive Reflection

It includes basic description including personal judgements and feelings, with limited consideration of alternatives. Begin to include personal judgements and feelings about the experience. Example: "The patient seemed anxious about their knee pain. I felt confident using manual therapy as it had worked well in previous cases. The treatment went smoothly and I believe it helped."

3. Dialogic Reflection

Questioning decisions and seeking evidence from research or guidelines. Considering alternative approaches, evidence from research or professional guidelines and examining personal biases. What could have done differently? Example: "Why did I choose manual therapy? Research suggests exercise therapy may be equally effective for knee osteoarthritis. How did my previous positive experiences bias my decision? What alternative approaches might have been appropriate?"

4. Critical Reflection

Challenging fundamental beliefs and assumptions. Examining how social, cultural, and political factors influence decisions, questioning power relationships, biases affect their clinical reasoning and exploring systemic influences on care. Example: "How do healthcare inequalities affect this patient's access to treatment? What assumptions about compliance am I making based on their background? How does the power dynamic in our therapeutic relationship influence treatment decisions?"

Schön's reflection-in-action/on-action

Schön's Model

Schön distinguishes two forms of reflection: reflection-on-action (analysing practice after the event) and reflection-in-action (reflecting whilst carrying out the activity).

Reflection-on-action - typically used by novice practitioners, this involves thinking about what happened, examining beliefs and biases, and considering how to change outcomes next time. This process transforms experience into knowledge.

Reflection-in-action - used by expert practitioners, this involves 'on the spot research' whilst practice is happening, requiring conscious attention and acting as your own supervisor.

Example: A physiotherapist treating a patient with back pain notices mid-session that their usual approach isn't working (reflection-in-action). They immediately adjust their technique based on the patient's responses. Later that evening, they think through the entire session, considering why their initial approach failed and what they learned for future similar cases (reflection-on-action).

Kolb's Experiential Learning Cycle

Kolb's model describes learning through a four-stage process that connects experience, reflection, conceptualisation, and testing to improve future practice. We move through experience, reflection, conceptualisation, and testing, turning each loop into better action next time. This continuous cycle helps healthcare practitioners translate experiences into better clinical outcomes.

Kolb's four stages

Kolb's Experiential Learning Cycle

1. Concrete Experience

• Having direct experiences in clinical practice.
• Example: A physiotherapist treats a patient with chronic lower back pain using manual therapy techniques, but the patient reports no improvement after three sessions.

2. Reflective Observation

• Stepping back to think about what happened and observe different perspectives.
• Example: The physiotherapist steps back and thinks: "The manual therapy isn't working as expected. I notice the patient seems tense during treatment and mentions work stress. Maybe I'm focusing too much on the physical aspects."

3. Abstract Conceptualisation

• Making sense of the experience using prior knowledge and theories.
• Example: The physiotherapist connects this to their knowledge of biopsychosocial approaches and research showing that stress and psychosocial factors significantly impact chronic pain. They theorise that addressing lifestyle factors alongside manual therapy might be more effective.

4. Active Experimentation

• Testing new approaches in practice and applying lessons learned to future situations.
• Example: In the next session, the physiotherapist incorporates stress management techniques, discusses workplace ergonomics, and combines this with modified manual therapy. They plan to monitor how this integrated approach affects the patient's progress.

Gibbs Reflective Cycle

Gibbs' model provides a structured approach for learning from experiences through six systematic stages:

Gibbs' Reflective Cycle

1. Description

• What happened? Short description of the event.
• Example: Patient fell during transfer from bed to wheelchair.

2. Feelings

• What were you thinking and feeling at the time of the event and after?
• Example: Felt shocked and worried I'd made a mistake.

3. Evaluation 

• How did you react to the situation? How did other people react? Was the issue resolved?
• Example: I froze initially but helped quickly. Patient remained calm. No injury occurred. Afterwards I felt anxious.

4. Analysis 

• Why did things happen this way? What helped or hindered? Can you link your experience to what the literature reports?
• Example: Patient was more unsteady than expected, I rushed the transfer. What hindered: Time pressure and assumption of stability. What enhanced: Quick recovery response. Literature shows proper assessment protocols reduce transfer injuries by 40%.

5. Conclusion

• What have you learned? Would you do the same again? What would you change?
• Example: Always assess stability before transfers, even with familiar patients.

6. Action Plan

• How will you apply this learning? What will you do next and how will you implement change?
• Example: Use two-person transfers for unsteady patients, complete full assessment each time.

Johns' Model for Structured Reflection (2000)

Johns' model uses structured questions to guide systematic reflection, particularly valuable for leadership situations involving power dynamics and professional relationships. It helps practitioners reflect on both thoughts and feelings to identify relevant knowledge for practice.

The model examines five key areas before action planning:

Johns' Model of Structured Reflection

1. Description (What happened?)

• What happened objectively? What factors contributed?
• Example: I gave feedback about late documentation to a junior colleague in a busy area. They nodded, said little, and we ended quickly due to time pressures.

2. Aesthetics (The art of practice)

• What was I trying to achieve? How did the situation feel?
• Example: I wanted to protect patient safety and clinic flow. The space felt semi-private and rushed. My tone was firm and the interaction felt one-way rather than collaborative.

3. Personal (Self-awareness)

• How did I feel? What internal factors or personal knowledge and beliefs shaped my response/actions?
• Example: I felt pressure to meet targets and frustration about the late notes. I believe clarity is kind, but I equated clarity with speed instead of dialogue.

4. Ethics (Moral and professional obligations)

• What ethical principles and power dynamics were involved?
• Example: Timely documentation is an ethical obligation, but power differences can silence junior colleagues. Did I have consent to give feedback in this public space at this moment?

5. Empirics (Evidence and knowledge)

• What knowledge and evidence/policies informed my practice/response?
• Example: Our service has clear handover policies. Evidence supports specific, timely feedback and shows that psychological safety drives team learning. I used examples but didn't check for barriers.

Action Planning

• Develop a specific plan that addresses the insights from all five lenses.
• Example: Tomorrow I'll arrange a five-minute private conversation. I'll ask consent, show one example, invite discussion about barriers, and agree on one shared goal with regular check-ins.

Rolfe's Model of Reflection (2001)

Developed by Rolfe, Freshwater, and Jasper, this simple framework builds on Borton's original three key questions: What? So what? Now what? Unlike Driscoll's more detailed model, Rolfe's provides quick reflection suited for fast-paced healthcare environments.

Rolfe's Model of Reflection

1. What? (Description)

Describe the experience objectively: What happened? What was your and other's role? What influenced your actions? What feelings did this bring up for you? Example: During a team meeting, I noticed a junior colleague seemed hesitant to contribute, so I asked directly for their opinion. They shared a valuable suggestion we implemented.

2. So What? (Analysis)

Examine significance and implications: What assumptions were present? What does this reveal about the situation and your practice? Example: Power dynamics can inhibit junior staff. My direct approach worked, but I need to create inclusive environments from meeting start rather than relying on direct questioning.

3.Now What? (Action Planning)

Focus on specific future actions and barriers: What will you do differently? What knowledge or skills do you need? What might get in the way of this plan? What support do I need to help me with similar situations? Example: I'll start meetings by explicitly inviting all contributions and create ground rules encouraging different perspectives. I need mentorship on facilitating inclusive discussions.

AI Tools in Clinical Reflection

AI tools can enhance reflective practice, like reflective partner, by providing structured prompts, alternative perspectives, and deeper exploration when expert guidance isn't immediately available.

How AI Can Support Your Reflection: AI offers structured questioning through reflective frameworks, suggests alternative viewpoints, provides a safe practice space for sensitive topics, and helps identify recurring patterns in your practice over time.

AI Reflection Prompt Template: You can use this template with AI tools such as the Physiopedia AI Assistant (PAI) to structure your clinical reflections:

"I want to reflect on a clinical situation using [specify framework: Gibb's/Johns'/Rolfe's/Kolb's]. The situation involved: [brief description]. Please guide me through each stage of this framework with specific questions tailored to my situation. Ask me one question at a time and wait for my response before moving to the next stage. After we complete the framework, help me identify key learning points and suggest how I might apply this learning in future practice."

Ethical Considerations: Always anonymise patient details when using AI tools. AI enhances but doesn't replace human guidance for complex situations. Use AI reflection as preparation for supervisor discussions rather than a complete substitute.

Selecting the Right Framework

Choose frameworks based on your context, available time, and situation complexity. Effective practitioners use different models for different purposes, so practice with several to find what works best for you.

For Quick Daily Reflections: Rolfe's "What? So What? Now What?" works well for brief reflections during busy days or routine CPD documentation.

For Significant Incidents or Complex Situations: Gibbs' comprehensive six-stage cycle suits deeper analysis of complex situations, formal reflections, or incidents requiring detailed documentation.

For Leadership and Ethical Dilemmas: Johns' model excels when power dynamics, relationships, or ethical considerations are central, focusing on personal awareness and ethics.

For Learning-Focused Reflection: Kolb's cycle effectively transforms experiences into broader learning for future application and skill development.

Consider Your Experience Level: Novice practitioners often benefit from structured frameworks like Gibbs, whilst experienced clinicians may prefer simpler models for routine reflection.

Match the Framework to Your Purpose: CPD evidence needs clear learning outcomes, personal development should resonate with your thinking style, and academic work requires sufficient analytical depth.

Getting Started with Reflective Practice

Beginning Your Reflective Journey: Many healthcare students start by keeping reflective journals during placements, answering key questions: What happened? Why did you choose that method? Is there research to support your decisions? What went well? What could improve? What are your action points?

Developing Your Skills: Initially, write reflections to develop your thinking through the different stages. As skills develop, you can reflect internally throughout the day and only write formal reflections for significant events.

Meeting Professional Requirements: Some professional bodies require reflective practice evidence for CPD. Regular reflection meets these requirements whilst demonstrating commitment to professional growth and patient safety.

Building Consistency: Start with brief, regular reflections using simple frameworks like Rolfe's model. Gradually incorporate detailed analysis for complex situations. Reflection develops through repeated practice.

The "Teach Back" Approach: Demonstrate understanding by explaining what you've learned to someone else (or even to yourself). This forces deeper processing, identifies knowledge gaps, and moves reflection from internal thought to external expression, revealing whether you truly understand concepts or just think you do. When you have to teach something, you naturally identify gaps in your understanding, organize the information coherently, and make connections you might have missed. Example: After a clinical training session, a physiotherapy student might explain back to their supervisor what they learned about a procedure. Or in a coaching context, you might summarize your insights from a difficult conversation to your mentor. The listener can then clarify any misunderstandings or confirm you've grasped the key points.

Reflection and Learning in the Workplace:

Watch this short 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.

Barriers and Enablers to Effective Reflection

Understanding what helps and hinders reflective practice enables healthcare professionals to create supportive conditions and address common obstacles.

Common Barriers: Time pressures from demanding workloads, lack of structured frameworks, unsupportive cultures, fear of vulnerability when acknowledging mistakes, insufficient motivation, and limited expert guidance.

Key Enablers: Protected time, supportive relationships, clear purpose, appropriate tools, learning cultures that normalise uncertainty, and formal recognition in professional development. Online reflection benefits from patient-focused learning, collaborative approaches, enhanced problem-solving creativity, progress tracking, and easy connection with colleagues for feedback.

Conclusion

Clinical reflection is a fundamental skill that transforms experience into learning and improves patient care. Whether you're documenting CPD requirements or examining complex ethical dilemmas, the frameworks and approaches outlined here provide structure for meaningful professional development.

Remember that effective reflection requires practice and often benefits from expert guidance or peer discussion. Start with the framework that feels most natural to your thinking style, experiment with different approaches for different situations, and always ground your reflections in evidence-based practice. Through consistent reflective practice, you'll develop enhanced clinical reasoning, better self-awareness, and ultimately provide higher quality care for your patients.