A GUIDE TOREFLECTIVE PRACTICE
Introduction
One important component of your Phase 2 portfolio will be evidence of
reflective practice. Professionals need to develop and practice their reflective skills throughout their careers. You began to practice and record these skills in your Phase 1 portfolio and you are encouraged to continue to do this in Phase2, particularly now that you are in regular contact with patients and health care professionals.
We want reflective practice to be a genuinely useful exercise that helps you to develop real insights; not just a paper exercise that has to be done. With this in mind, we have introduced an element of choice: you can either commit to verbal reflective practice in a supported group setting or written reflective practice with personalised feedback. Different people prefer different methods of reflection and this choice of activity allows you to develop your reflective practice in a way that helps you to learn from it. You will find that whichever method you choose to undertake, most insights/reflections when committed to paper or discussed in a group begin to develop more personal meaning and allow us to learn from our experiences in a way that is helpful to patients as well as to ourselves.
What is Reflective Practice?
You will be reflecting everyday on your actions and inactions and those of the people around you; this is how adults learn. We would also like you to develop these skills further by undertaking activities of more critical reflection; by
‘stepping back’ from events and actions and exploring your personal role or interpretations. This increases the learning potential of these experiences and allows you to recognise events and actions from multiple perspectives (Hatton & Smith1995).
The Elements of Reflective Practice in Phase 2 to be Recorded in Your Portfolio
1. The standard patient clerking format (see below) alerts you to the need to incorporate aspects of insightful or reflective practice in every clerking. You should keep all your patient clerkings in a supporting documents box file.
2. During the year you will be expected to undertake one of the following reflective practice activities:
a. 2 extended pieces of reflective writing that will be submitted to a reflective practice tutor who will give you feedback on your developing reflective writing skills.
OR
b. Take part regularly in a Balint group, either as your Year 3 Student Selected Component (SSC) activity or in addition to it.
OR
c. Take part in the Student Psychotherapy Scheme including supervision
1. Clerking Format
1. The patient’s problems (PC) 2. Clinical history (HPC)
3. Physical Examination (OE) 4. Summary
5. Differential diagnosis (∆∆) 6. Problem list
7. Investigations (Ix) 8. Management (Rx)
9. Reflection/insight on an aspect of the clerking. Select one of the scenarios suggested in appendix 1or choose your own example. Write a few lines or short paragraph as an integral part of the clerking and/or presentation.
10. Follow up notes and discharge planning
Below are some suggestions of areas you might like to explore for the
reflections/insight component of patient clerkings. You need only select one of the bullet points here or one area of your own:
• What is really happening with regard this patient? • What was interesting or worrying?
• What can you conclude generally about the situation this patient is in? • What did the patient say and think about their illness? (if appropriate) • What were the patient’s ideas, concerns and expectations?
• What did the staff say and think? (if appropriate)
• What has been done well with regard this patient’s care? • What should be done differently next time?
• What did you learn about yourself? • Can you identify future learning needs?
2. Extended Reflective Practice
During module 1 and module 3 you will submit electronically two pieces of reflective writing. We would expect the stimulus for the reflection to be an action (or inaction) by you or by others, a patient related encounter or a growing
realisation that you are developing during the course, but it can be anything relevant to you as a developing health professional. The expected word count will be between 500 and 1,000 words. This will be submitted to your reflective practice tutor who will give you individual feedback on your developing reflective writing skills. The tutor will also indicate whether the item is suitable for
submission into your portfolio or needs further work. OR
You will join one of the Balint groups. These are supported student discussion groups that allow the time and space to discuss the doctor, the patient, and his illness and the experiences and emotions that arise as part of medical practice. You will need to attend regularly throughout the year and provide evidence in your portfolio in the form of either a certificate of regular attendance or a
satisfactory completion of SSC form (if you have chosen to do this as your SSC for Year 3).
How to Get Started with Reflective Practice
You will need to decide during your first module which method you will use to develop your reflective practice skills. You will be contacted electronically by the year 3 administration team early in your first module. You must reply to this alert so that you can either be allocated to a group or a writing tutor.
Satisfactory engagement with reflective practice is your responsibility: don’t leave the attendance at a Balint Group or the completion of written work too late – satisfactory completion of a portfolio is required coursework and needed for satisfactory completion of year 3 and thus progression into year 4.
Important information
If you choose to join a Balint Group you may register for this as your SSC choice for the year or you may be involved in your own time and choose another SSC. Please note many Balint groups happen after hours and regular attendance is necessary. Please do not commit to this as your chosen method of reflective practice is you cannot manage a regular after hours commitment. If you chose to submit written work please note that we treat plagiarism very seriously indeed. UCL has now signed up to use a sophisticated detection system (Turn-It-In) to scan work for evidence of plagiarism. This system gives access to billions of sources worldwide, including websites and journals, as well as work previously submitted to by other students in the medical school, UCL and other universities.
A MODEL FACILITATING STRUCTERED REFLECTION
The following approach can be used to enhance discussions around significant event analysis
DESCRIPTION: Describe this in more detail What exactly happened? What did you do?
EMOTIONS: What were you thinking/feeling at that point? OUTCOMES: What were the consequences for a) the patient
b) others c) yourself
EVALUATIONS: What were you trying to achieve? What was good/bad about it?
ANALYSIS: What internal factors were influencing you?
What knowledge/values did or should have informed you?
How did your actions match your beliefs/knowledge? What factors made you act in incongruent ways? CONCLUSIONS: How does this connect with previous experiences?
Could you have handled this better in a similar situation?
How do you now feel about this experience? Can you support yourself or others better as a consequence?
Faced with that experience again, what would you do?
Adapted by Anita Berlin July 2004
Possible Scenarios for Reflective Practice
About the patient
• A patient happy or unhappy with their treatment • How in control of a situation was the patient? • A question of confidentiality or consent • Was the patient at risk?
• Catheters, cannulae, nil by mouth, polypharmacy About you
• An aspect of the clerking that reveals gaps in yours or another health care professional’s knowledge skills or attitudes
• An area that caused you anxiety or enjoyment
• An aspect of care that leaves you surprised, puzzled or confused • Communicating with older or frail people
• Consultations involving more than one person (e.g. relative) • Length of consultation
• Difficulty obtaining the history or examination About the team
• Challenging an aspect of the diagnosis or management • A disagreement within the team about management
• Difference of opinion or dispute between yourself and a member of the team
• An observation that the team was under pressure Good Medical Practice
• times when you have seen Good Medical Practice
• times when you have seen practice that may be at odds with Good Medical Practice
Other examples (but you may, of course, choose your own examples) • An incident that made you proud of yourself or others
• Challenging a ‘self-evident’ clinical truth • Doing something for the first time
• Consultations involving more than one person (e.g. relative) • Length of consultation
• The most memorable event from that firm or module • A specific complaint
• Consent
• Sudden death or deterioration • Team working or lack of it
• An example of perceived good or bad teaching
• Valuing others in the MDT, the role of the doctor in the MDT and duty of care.
Good Medical Practice
The duties of a doctor registered with the General Medical Council Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must:
• Make the care of your patient your first concern
• Protect and promote the health of patients and the public
• Provide a good standard of practice and care
o Keep your professional knowledge and skills up to date
o Recognise and work within the limits of your competence
o Work with colleagues in the ways that best serve patients' interests
• Treat patients as individuals and respect their dignity
o Treat patients politely and considerately
o Respect patients' right to confidentiality
• Work in partnership with patients
o Listen to patients and respond to their concerns and preferences
o Give patients the information they want or need in a way they can understand
o Respect patients' right to reach decisions with you about their treatment and care
o Support patients in caring for themselves to improve and maintain their health
• Be honest and open and act with integrity
o Act without delay if you have good reason to believe that you or a colleague may
be putting patients at risk
o Never discriminate unfairly against patients or colleagues
o Never abuse your patients' trust in you or the public's trust in the profession.
You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.
1. ‘Structured Debriefing’ from ‘Learning by Doing’, Gibbs (1988), based on Kolb’s Experiential Learning Cycle
Description: What is the stimulant for reflection? (incident, event, theoretical idea) What are you going to reflect on?
Feelings: What were your reactions and feelings?
Evaluation: What was good and bad about the experience?
Make value judgements.
Analysis: What sense can you make of the situation? Bring in
ideas from outside the experience to help you. What was really going on?
Conclusions (general):
What can be concluded, in a general sense, from these experiences and the analyses you have undertaken?
Conclusions (specific):
What can be concluded about your own specific, unique, personal situation or ways of working?
Personal Action plans:
What are you going to do differently in this type of situation next time? What steps are you going to take on the basis of what you have learnt?
2. A framework that describes levels of reflection from Hatton and Smith (1995)
Descriptive writing: description of events or literature reports. No discussion beyond description. The writing is considered not to show evidence of reflection
Descriptive reflective: basically description, but some evidence of deeper consideration. No real evidence of the notion of alternative viewpoints in use.
Dialogic reflection: writing suggests ‘stepping back’ from events and actions - leads to different level of discourse. Sense of ‘mulling about’, exploration of personal role in events and actions. Consideration of the qualities of
judgements and possible alternative explanations. Reflection is analytical or integrative, linking factors and perspectives.
Critical reflection: in addition, shows evidence that the learner is aware that actions and events may be ‘located within and explicable by multiple
perspectives, but are located in and influenced by multiple and socio–political contexts’
References
Watton P, Collings J, and Moon J ‘Reflective Practice: a guide for students’, Exeter University (online) (April 2001), Available from:
http://www.ex.ac.uk/iwe2000/reflective.rtf (Accessed 18th August 2004)
http://www.gmc-uk.org/
guidance/good_medical_practice/duties_of_a_doctor.asp
Balint, M. (1964) The Doctor, his Patient and the Illness. 2nd edition. London: Pitman.
Students and Balint groups:
