Clinical Reflection


Original Editor - Michelle Lee Top Contributors - Michelle Lee, Tarina van der Stockt, Tony Lowe, Jess Bell and Kim Jackson

Introduction[edit | edit source]

Originating from the work of Donald Schon[1] the concept of reflective practice is recognised as a key component of a health professional's practice.[2] It enables clinicians from many disciplines to develop and maintain professional best practice. In healthcare, this practice is termed "clinical reflection" and is a skill-set that is commonly developed from university level. 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.[3] In physiotherapy, the use of reflection has been adopted to enhance patient care, clinical supervision, collaboration, and clinical reasoning.[4] If done properly, reflective practice can enhance your skills as a healthcare worker.[5]

So this page is going to run through:

Thinking picture.png
  • What is reflection and why do we use it?
  • The reflective journey 
  • Different methods of reflection

What is Reflection / Reflective Practice?[edit | edit source]

Health workers often experience complex clinical practice situations, that can be navigated through reflection.[4] 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" [6]
  • “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” [7]
  • "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” [8]
  • "conscious and systematic approach to thinking about experiences with the aim of learning and changing behaviours."[9]

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. [10] It helps the therapist to figure out what is known already and then add the new information that was gained, resulting in better understanding, knowledge and a new meaning.[9]

By "consiously looking and thinking about experiences, actions, emotions, feelings and responses" we can interpret them so that we can learn thus you become more critical about your views of practice and the world.[9]

Watch this video on reflective learning to find out more.

The Reflective Journey[edit | edit source]

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 individual's professional career. Reflection and critical analysis is a skill which needs to be practised in order to be developed. [11][12]

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 choose that method
  • Is there any research to support your decisions
  • What went well
  • What could have gone better
  • Action points for implementation next time [13]

It is encouraged that reflections are initially written; this will help to cement the different stages of reflection, but once this skill is developed health care professionals can 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.[14]

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[edit | edit source]

There are many forms of formal reflection, all differing slightly, including numerous reflective practice questionnaires and scales.[15] 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

Reflection-on-action [9]

  • 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 [9]

  • "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 many different frameworks offered for structuring reflection. Here is a powerpoint presentation that runs through a number of examples.

Below are descriptions of some of the most common reflective frameworks and models that can be used. In order to find the best model for you, it is recommended that you practise with several different frameworks and choose the model or models which you feel are most effective for you in particular situations. Reflection is a very personal activity and so this choice should also be personal to ensure the greatest benefit to you. 

Gibbs Reflective Cycle (1988)[edit | edit source]

Gibbs reflective cycle is a formal structure that can be used for academic pieces of work, as well as in clinical practice. These reflections can also be used to evidence continuing professional development.[16] A study from 2018 has found that using the Gibbs cycle to reflect on clinical cases, increases critical thinking skills in nurses.[17]

Steph Gib Model.jpg
Description
[edit | edit source]

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[edit | edit source]

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

Evaluation [edit | edit source]

The evaluation is reflecting upon the experience, such as;

  • How did 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 is evidence for the event you are reflecting on, you can include it here.

Analysis [edit | edit source]

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? Like 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 it as a piece of evidence in a portfolio for continued education purposes.

Conclusion[edit | edit source]

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 thing happens again to ensure the same positive outcome?

Action Plan[edit | edit source]

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) [edit | edit source]

John's Structured Reflective model is exactly that. It is a set of questions that are asked to direct the reflector through the process. This may be attractive to some people, but potentially could be a little restrictive for others.[18]

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?
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?
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?
Evaluation
  • What choices did I have?
  • What would be the consequences of these choices?
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[edit | edit source]

Borton's three Whats questions[19] were mapped on to an experiential learning cycle by John Driscoll[20] to form a simple a framework for supporting reflection. This framework is easy to remember and implement, and is therefore a popular option used by many health care professionals and advocated by professional bodies. 

There are only 3 steps in this framework: [21]

Bortons 1970.jpg
What?
[edit | edit source]

These questions prompt the reflector to describe what has happened by: 

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

So What?[edit | edit source]

This is the analysis of the reflection.:

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

What Now?[edit | edit source]

This is one of the most important sections of a reflection. This section focuses on what will you do next /  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?                                         [22]

Conclusion[edit | edit source]

Now you have learnt about 3 of the main learning frameworks / reflective structures to use in clinical practice. 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, as discussed previously, to try different structures and frameworks for different situations to learn which suit you and a particular context best. Day to day reflections (e.g. for CPD events) may be better suited to the 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 as well as your own experience and anecdotal evidence and include this within your reflections to develop an evidence based practice approach in your reflective practice. 

Resources[edit | edit source]

References[edit | edit source]

  1. Schön DA. The reflective practitioner: How professionals think in action. Basic books; 1983.
  2. McLeod GA, Vaughan B, Carey I, Shannon T, Winn E. Pre-professional reflective practice: Strategies, perspectives and experiences. International Journal of Osteopathic Medicine. 2020;35:50-6.
  3. McClure P. Reflection on Practice. http://cw.routledge.com/textbooks/9780415537902/data/learning/8_Reflection%20in%20Practice.pdf [accessed on 10 June 2016]
  4. 4.0 4.1 Ziebart C, MacDermid JC. Reflective Practice in Physical Therapy: A Scoping Review. Phys Ther. 2019;99(8):1056-68.
  5. Koshy K, Limb C, Gundogan B, Whitehurst K, Jafree DJ. Reflective practice in health care and how to reflect effectively. Int J Surg Oncol (N Y). 2017;2(6):e20.
  6. Reid B. But We’re Doing it Already! - Exploring afckLRResponse to the Concept of Reflective Practice in Order to Improve its Facilitation. Nurse Education Today 1993;13:305-309
  7. Jarvis P. Reflective Practice and Nursing. NursefckLREducation Today 1992;12:174-181
  8. Johns C. Becoming a reflective practitioner.fckLROxford: Blackwell Science, 2000
  9. 9.0 9.1 9.2 9.3 9.4 Paterson C, Chapman J. Enhancing skills of critical reflection to evidence learning in professional practice. Physical Therapy in Sport. 2013 Aug 1;14(3):133-8. Available from: https://members.physio-pedia.com/wp-content/uploads/2018/02/Enhancing2520skills2520of2520critical2520reflection2520for2520BURO.docx.pdf [Accessed Feb 2018]
  10. Patterson B. Developing and Maintaining Reflection in Clinical Journals. Nursing Today 1995;15:211-220
  11. McClure P. Reflection on Practice. http://cw.routledge.com/textbooks/9780415537902/data/learning/8_Reflection%20in%20Practice.pdf [accessed on 10 June 2016]
  12. Queen Mary University of London. Guidance on Reflective Writing. http://qmplus.qmul.ac.uk/mod/book/view.php?id=257889 [accessed 15 June 2016]
  13. McClure P. Reflection on Practice. http://cw.routledge.com/textbooks/9780415537902/data/learning/8_Reflection%20in%20Practice.pdf [accessed on 10 June 2016]
  14. Wessel J, Larin H. Blackwell Publishing Ltd Change in reflections of physiotherapy students over time in clinical placements. Learning in Health and Social Care 2006; 5(3):119–132
  15. Ooi Su, Fisher P, Coker S. A systematic review of reflective practice questionnaires and scales for healthcare professionals: a narrative synthesis, Reflective Practice. 2021;22:1:1-15.
  16. Queen Mary University of London. Guidance on Reflective Writing. http://qmplus.qmul.ac.uk/mod/book/view.php?id=257889 [accessed 15 June 2016]
  17. Ardian P, Hariyati RTS, Afifah E. Correlation between implementation case reflection discussion based on the Graham Gibbs Cycle and nurses' critical thinking skills. Enfermeria Clinica. 2019;29 Suppl 2:588-93.
  18. Queen Mary University of London. Guidance on Reflective Writing. http://qmplus.qmul.ac.uk/mod/book/view.php?id=257889 [accessed 15 June 2016]
  19. Borton, T. (1970) Reach, Touch and Teach. London:Hutchinson.
  20. Driscoll J. Reflective practice for practise. Senior Nurse. 1994;14(1):47.
  21. White S,Fook J, Gardner F. Critical Reflection in Health and Social Care. Maidenhead: Open University Press, 2006
  22. Queen Mary University of London. Guidance on Reflective Writing. http://qmplus.qmul.ac.uk/mod/book/view.php?id=257889 [accessed 15 June 2016]