Reflective Practice in Healthcare Homepage
Reflection, and reflective practice, is increasingly being encouraged to help healthcare workers (HCW) learn and become more effective practitioners. There is a large body of material to assist HCWs - A Google search on 26 June 2020 with key words “reflective practice” and “healthcare workers” generated over 34 million links! How to find your way through all of this can be daunting. This Open Online Course has therefore been prepared to help both trainees and established HCWs understand the basics and start their journey of reflection.
The course is designed to help you:
Identify some background and describe the key elements of reflection.
This course is an Open Online Course (OOC) and the course was developed by Rajan Madhok, Chair of the Peoples-uni Trustees. It has been adopted from Peoples-uni and was further developed by NextGenU.org (NGU).
Unusually, the course has been developed not from a theoretical perspective, but from the lived experience of a practitioner. In essence, it is a case study-based course. The course starts with some background and then, describes the key elements of reflection. To access resources we think you will find interesting, click on the blue resources hyperlink. This will direct you to resources and links to relevant papers. There are two exercises for you to practice your learning. These are for your personal use but if you want, you can share them through the BLOG.
Approximate time for completion of this course is 2 hours at an average reading rate of 144 words/minute.
Engaging with this course
- To register for this course, complete the registration form. Begin the course with “Reflective Practice”.
- There are practice exercises that you will need to complete successfully to gain an understanding of the topic.
Requirements to obtain the certificate
You may browse this course for free to learn for your personal enrichment. There are no requirements.
To obtain a certificate, a learner must successfully complete:
- All reading requirements
- All exercise completed successfully
- The self and course evaluation forms
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"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 – see this compendium which contains my reflective writings over 25 years in the NHS. As I explain in the compendium it 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). NOTE: it is not expected that you fully read the compendium unless interested but to scan it to get an idea, and perhaps later on return to it.
One caution - only undertake this course if you want to, since unless you are motivated enough it is of no use.
Before you proceed further, here is an exercise.
Exercise No. 1
Write a paper
describing your current thinking about, and your practice of, reflection – what do you understand by it and how do you practise it
why you want to learn more about it – what is your motivation
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 and to create a log-book whereby you visit what you have written every year and write a yearly report – you will be amazed at a) how time flies and b) what joy you will get when you look back after 25 (land hopefully Longer) years.
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 public health and social care issues: smoking, alcohol or infectious diseases, or care of the elderly, 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
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 practice (or reflection in education or research)
reflective thinking and
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: the first of these Reflective writing and critical incidents includes this structure, which is a simpler way to start and can enable one to go deeper and start exploring the Triple Loop mentioned above:
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?
The second one is the following video:
Created by the Monash University Library
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
Decide on learning goals for the reflective exercise
Choose an appropriate instructional method for the reflection
Decide whether you will use a structured or unstructured approach and create a prompt
Make a plan for dealing with ethical and emotional concerns
Create a mechanism to follow up on learners’ plan
Create a conducive learning environment
Teach learners about reflection before asking them to do it
Provide feedback and follow-up
Assess the reflection
Make this exercise part of a larger curriculum to encourage reflection
Reflect on the process of teaching reflection
Depending on your professional background, you may wish to see these three resources focused on Nursing and Midwifery, Doctors, and Public Health Professionals - these are from the UK and you may wish to look out for similar ones from your own settings and also your own professional bodies.
Nursing and Midwifey Council (UK) : Joint statement by UK regulators https://www.nmc.org.uk/globalassets/sitedocuments/other-publications/benefits-of-becoming-a-reflective-practitioner---joint-statement-2019.pdf
General Medical Council (UK). The reflective practitioner https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/reflective-practice
Faculty of Public Health (UK). Reflective notes. https://www.fph.org.uk/professional-development/cpd/reflective-notes/
Once you have gone through the above you can create your own approach to reflective practice- noting that although it is becoming a requirement for some professions, to get best value from your time investment you need to make it a regular habit, not a task, and something to be enjoyed! 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?
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, and to demonstrate this, I recently wrote a supplement to the compendium referred to above – and this time in verse; you can find it here. The anthology is focused on life lessons, based on my learning, and this 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 60s); they will have repeated career changes with learning interspersed with periods of work and constant reflection can and will make all the difference in achieving a good work:life balance and ensuring that one becomes professionally successful and personally happy. .
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 and now deserve the certificate.
Exercise No. 3
Select a topic related to substance use. You may focus on a specific substance (alcohol, tobacco, opioids etc.) or you may consider substance use in general. Without doing any research, briefly share your thoughts on the topic (100-200 words).
Be sure to include the following points:
1. What are some significant risk factors that lead to substance use?
2. What approaches can be used to effectively treat, prevent, or control substance use in a population?
Now, research the two questions above and reflect on your initial preconceptions.
Be sure to include the following points:
1. Identify any views that have changed after conducting research
2. Explain the role of reflectivity in updating your view on the topic.
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! So, do consider sending in your work. You may want to leave your personal e-mail (if comfortable) in case the course leader needs to contact you.
If you want to upload your note, please do so in the Blog section of the course: Add an entry about this course. You will see that you are offered the choice of publishing to the group, in which case you can receive feedback. If you chose private upload to yourself, others cannot see the post, but you will be able to see it by clicking on your profile which you see at the top of the page.
Course and Self Evaluation & CertificateIn this section, you can provide feedback about this course to help us make NextGenU.org better. Once evaluations are completed, you will be able to download your Certificate of Completion.