changed, through joint reflection, to community based, flexible services for the individuals living with dementia and their caregivers.
Reflection Is Not Only an Individual Act
Reflection requires knowledge, skills, and an attitude to be open to changing professional practice. For several decades there has been access to models of reflection, practical tools, and questions that prompt reflection that focuses on the individual level with inconsistency in how these tools are used. There are also growing ranges of tools available for quality improvement within health and social care that encourage an element of reflection although this is not always explicit in the structure. The Plan, Do, Study, Act (PDSA) cycle (Taylor et al. 2014) has reflection within the study phase and this is used widely in healthcare improvement (see Chapter 5). As reflection is key to all health and social care practitioners’ standards for practice, it is essential to view reflection as integrated within ‘daily’ practice rather than being perceived as an exercise only completed in pre- or post-graduate education or as an extra task only completed to pass any professional standards as a tick box exercise. It is also important to consider reflection as being beyond an activity only undertaken individually in isolation, but as core to the supervision process. Reflection is valuable when undertaken with peers, in teams, and with colleagues from a mixture of professional grades and backgrounds. The ultimate aim would be to also consider reflection inclusive of service users to truly bring together the core tenets of EBP. This will refine clinical reasoning and can add to the evidence base through informing future practice.
Reflective Models, Settings, and Tools
Being reflexive is essential for the advancement of professional practice. As is ever apparent with key national and international events, health and social care practitioners are having to demonstrate that they are capable of applying competencies and EBP in ever changing, complex, and often unfamiliar contexts. Individuals need to feel empowered to reflect on and question their own practice and the clinical reasoning of others, so that critical problem solving can lead to positive change for the wider community.
There are a wide range of models and tools available to practitioners to promote reflection. From the early work by Schön (1987) that highlighted both reflection in action and on action, based on the reflection of designers, an array of models have evolved for application in health and social care. Reflection-in-action occurs in the moment, whereas reflection-on-action occurs after the event and evaluates the situation through a staged process. The challenge is seeking practical strategies that push you further with your reflection to becoming reflexive, as well as being helpful to generate positive change within your profession and work context.
The HCPC, which is the professional regulator in the United Kingdom, give clear expectations of threshold standards regarding reflection that are in place to protect the public. All health and social care professionals are expected to reflect on and review their practice, although there are subtle differences between professions in terms of how this is expected to occur. This brings us on to valuing a range of approaches to reflection, whether this is an individual act or something undertaken with others. Core to each of the HCPC professional standards for proficiency is the need to ‘record the outcome of such reflection’ as outlined in Standard 11.1 for occupational therapists (HCPC 2018) highlighting that reflection, and documenting it, is essential to maintain professional registration within the United Kingdom.
There are a multitude of methods and settings where reflection can occur and these are outlined below.
Case conferences – although there is a need to shift from viewing these as meeting to only discuss a client, to actively considering how things can be delivered differently through interprofessional collaboration, debriefing, and simulation. This is supported by the HCPC through valuing multidisciplinary team reviews in standards of proficiency for example with dieticians (HCPC 2013a), paramedics (HCPC 2014), and chiropodists/podiatrists (HCPC 2013b).
Supervision – 1:1, with a peer, and within and across professions.
Debriefing – there are a range of techniques used as a means of facilitated, guided reflection as part of a debrief process. This can involve formal, structured techniques or more ad-hoc debriefing with peers, or facilitators, in pairs or groups.
Stakeholder meetings – these meetings are often strategic events to bring people together to discuss and commit to particular projects or developments (as in case study 1). This can be a great opportunity for reflection from multiple perspectives and may take a problem solving or appreciative inquiry (exploring strengths) focus.
Individual methods – reflective questions, diaries, reflective models (see case study 2), engaging in post-graduate study (case study 3), and as technology evolves, using mobile apps.
Schwartz rounds – The principles of Schwartz rounds are discussed in Chapter 2 (Care and Self-Care).
Models of Reflection
To deepen the engagement in a reflective cycle and become more reflexive, models can assist through providing a structure and prompts. The preference for a particular model of reflection is often based on previous experience, exposure to a particular model, personal preference, learning style, professional bias, or the time prioritised to engage with reflection. Reflective models stem from the work of Kolb in the 1980s on the experiential learning cycle with four stages of reflection crucial for learning to occur (Kolb 1984). Models of reflection have evolved to some degree over time and they differ in complexity. The models by Gibbs (1988) and Johns (1995) are popular within the health and social care professions as they involve responding to key questions within a linear or cyclical method. Some practitioners prefer the models by Boud and Walker (1990) as they have more stages or strands to revisit and potentially promote a more reflexive approach. More recently, Jasper (2013) developed a framework, ERA (Experience, Reflection, Action) which encourages building understanding from experience through reflection to move forward into action. When reviewing methods to promote reflection it is important to trial and critique a variety of techniques individually and with others to maximise your potential to be a reflective practitioner.
Case Study 2 – Individual Reflection (Model of Reflection): Realisation that Not as Evidence Based in Practice as First Thought
Working as an Allied Healthcare Professional in a community rehabilitation team, Nick identified that there were some inconsistencies in how complexity of healthcare needs was being defined when prioritising referrals. On reflection, Nick considered that this might be due to different professional viewpoints on how complexity of need is assessed and a range of practice experience across team members. Reviewing evidence was used as a way to improve the triage process to ensure that clients received the appropriate care and access to services. The process involved defining what complexity was in relation to context, reviewing government policy/guidance, and identifying triage tools to implement in practice. To facilitate this process Nick utilised a change management tool and also used a model of reflection, both were valuable in keeping this project on track and adding depth to learning from the process. Nick felt that sometimes undertaking a specific project, while providing useful outcomes for practice, can also highlight that as practitioners we are not as evidence-based as first thought.
Case Study 3 – Individual Method of Reflection (Post-Graduate Study): Didn’t Find What Was Expected but Found More
An occupational therapist sought to change the delivery format of fatigue management for clients with neurological conditions
