reflection

Norwich City are the tractor boys! Lets reflect on this are all their fans farmers?

Why now again Ever since the ‘reflective practioner’ was released in 1983 it has become ‘a thing’ in education As latin suggests little pieces of you are bent back on themselves and aligned on a service for convenient viewing But sometimes it seems like arbitary testing or busy work what is the evidence for it?

overview What is it and why? Task looking over elements of reflection? Back to why? Theories of reflection Hindrances Observations Insight & feedback Theory of knowledge Feelings Venturing into the narrative and complexity

What is it and why important? Important as process which people ‘think with a purpose’ ie. thinking about experience, mull it over and evaluate it with the purpose of improving their understanding and future behaviour

Why do we need it? Increase knowledge and apply it Widen professional boundaries Benchmark our performance against peers Develop as adaptive experts Generate questions that will inform service improvement and research agendas

Task – re introducing to reflection elements Think about last clinical encounter which resulted in a significant piece of learning. Write the story of the encounter with beginning, middle and end Then refer to these elements

Elements element Does what you have written show that? Demonstrated by: observing Being alert and noticing what is obvious and less obvious about the situation Observations, questions, looking for unfamiliar Self-awareness Aware of what you think but also what you sense or feel about the experience and are willing to take responsibility Use of I Self-regulation You recognise when experiences and behaviour are outside what the profession would consider as being competent Level of competencies Internal conversation You have made sense of your thoughts and feelings Use of feeling words, your reactions to your observations Openness Honest about your performance in relation to what might be expected by the profession Seeking feedback against standards Learning You have clarified what you need to learn and why you need to take this on Statements of learning and impact on performance, plan for review

Intellectuals!

Analysis of event Best done using a method that appeals to you and which you do consistently Examples: ‘kipling’ method Mind mapping

Back to why? Simple answer because is required by GMC as regulator for good medical practice More meaningful answer starts with medicine being knowledge based Knowledge is applied with skill & artistry The traditional education formula of knowledge, skills and attitudes now wrapped up in competency model Where ability to demonstrate performance is test of fitness to practice So modern medicine can be looked as service profession where ability to perform (rather than just ‘knowing’)

Add in professionalism KNOWING one’s limitations RELATE openly with patients, colleagues and oneself BENCHMARK personal practice DISCARD obsolete DEVELOP new competencies APPLY personal and professional critical review Because of public and professional accountability this is why we have portfolios ‘regular service record’

Background theory of reflection Traced back to Plato Kolbs learning and problem solving circles in relation to individual’s preferred learning style and process of learning to solve problems Honey and mumford developed learning style inventory indentifying your preferred style as activist, reflector, theorist or pragmatist (www.peterhoney.com)

Hindrances to reflective practice? What stands between the need or desire and actual practice apart from internal preferences? Examples for feedback GPs Time Service pressure Personal fear External control Not seeing reason for it Defensive attitude Major element is the value clinicians place on the process of reflection

political

observations Several people who observe a single event will record it differently – some of this if through thinking and some through sensing important to understand how we as individuals affect the final picture colouring it with our personal values and attitudes Building up the picture need to use all our available senses and these determine our reactions and therefore feelings:

Feminine, culinary & tough

intrapersonal ‘insight’ in relation to personal performance is important. Difficult to find clear definition but has origins in psychological theories (hobson, mears) insight is dependent on ability of individual to have internal conversation. Can be cool, objective and journalistic. To have impact individual needs to articulate feelings. These shape our beliefs and attitudes and in turn our behaviours (fishbein) Acknowledging the discomfort of a particular encounter can help manage in present and potential in future (eg do not label a patient analyse you feelings and belief set)

Reacting to feedback In practice the ability to handle feedback about personal performance is a marker of insight Recall the last time you received feedback on your performance. How do you react?

Which set of words most accurately describe reaction? Defensive Head in sand Mildly anxious Take it or leave it With open arms

Examine these Indiffence (answer 4) hides potential blockers and needs serious reflection not professional Mild anxiety is more effective for learning (yerkes-dodson curve) This is normal arousal response to challenge also called ‘learning at the edge’ Head in sand is defense mechanism to avoid challenge used to hope that bad things will pass. Can be due to poor experiences in past or repeating behaviour patterns seen in respective role models. Need to ask self why?

Continued reactions Extreme defensive lack of personal ownership and for actions taken. Often occurs as a result of teaching by humiliation Need to create secure safe environment to improve self esteem (maslow theory of human motivation) Welcoming feedback is this a devise to deflect the more challenging elements?

A question for everyone Do you know what to do with the feedback being given to you? Can you own it, internalise it and learn from it?

Super Human

Theories of knowledge Data, information, knowledge, wisdom theory (DIKW) Starts with data or facts as raw element Fashioned into information Indivduals take information and transform into knowledge Knowledge is then synthesised and analysed through experience into wisdom

DIKW Reflection here is part of processing Incorporate good practice Because knowledge is part of our individuality this process involves our feelings Humanities has helped us reveal the complexity of the whole. Reflexivity has much to do with to do with humanistic as scientific traditions

What is all this feelings about? Feelings are facts as much as your height and weight but unlike these your feelings have a major impact on your ability to hold a fluent functional internal conversation Internal conversation is the skill that will enable you to have develop insight and deep learning This way you develop beliefs & attitudes that determine actions and thus performance

Reflection and professional boundaries Schon developed model of reflective practice In essence it is a practioner working in a zone of mastery and being sensitive to the unusual The ‘surprise’ or where the data does not fit the pattern Feeling this and responding enables practitioner to learn from experience and build expertise (zone of mastery) Model fits with the ‘adaptive expert’

Professional expertise Various models and theories have been proposed One model sits well with reflective practice is that of ROUTINE and ADAPTIVE EXPERTISE Routine is practiced when practitioner performs well within guidelines and protocols Adaptive performs well within guidelines but can use imagination and experience to solve problems that do not conform to orthodoxy or are new This development requires reflective practice and professional alertness (Mylopoulos 2009 med educ 43)

Reflective analysis and recording Might employ kiplings 6 honest serving men (r kipling the elephants child) some examples: What could I have done better? What did I do well? How do I feel? Why do I feel this way? What is the feeling telling me? What words can I use to describe the feeling? Who should I speak to? What are the boundaries of my competencies? How can I develop these? How will I put them into practice? How will I know I am developing?

Who, where, how, what, why, when Venturing into narrative based medicine Rather than journalistic At any one time the reflective process is a complex one Complexicity theory incorporates where the system starts to be come unstable ‘the edge of chaos’ the place where things happen In medicine it is the point where learning can be maximal – learning on the edge

conclusion Very nature of reflective practice makes it quantification challenging There have been systematic reviews but there needs to be creative and disciplined application of a range of study designs and methods to understand this element of practice So far it is largely theoretical

Knowledge

feelings

Lack of insight