Reflection MSc HPE DR(1) PDF

Reflection QHPE 601 Evidence-based Teaching and Learning Learning Objectives By the end of this session, the learner will be able to… Describe theoretical approaches to reflection (Rolfe’s, Gibb’s, Schon’s) Differentiate between descriptive and reflective writing Discuss the importance of do...

Reflection QHPE 601 Evidence-based Teaching and Learning Learning Objectives By the end of this session, the learner will be able to… Describe theoretical approaches to reflection (Rolfe’s, Gibb’s, Schon’s) Differentiate between descriptive and reflective writing Discuss the importance of documenting transformative or confirmatory learning via reflection Employ the theoretical approaches to reflection in your own reflection Evaluate examples of reflection using a provided rubric 2 What is Reflection? ‘…purposeful deliberate revisiting of an experience to explore and extract the learning offered by the experience’ Thoughtful deliberation Understanding roots and processes Making sense of things Learning from experience Helping you plan for the future Davis and Ponnamperuma, 2009 3 What is Reflection? (Cont.1) ….. The process of analyzing, questioning and reframing an experience in order to make an assessment of it for the purpose of learning (reflective learning) and/or to improve practice (reflective practice) ‘It is not sufficient to have an experience in order to learn. Without reflecting on this experience it may quickly be forgotten, or its learning potential lost’. (Gibbs, 1988) 4 Reflective writing video Reflective Writing Source: https://www.youtube.com/watch?v=QoI67VeE3ds 5 3 Models of Reflection Schon’s reflection in-action and on-action Gibb’s reflective cycle Rolfe’s framework for reflective practice 6 Schon's Reflective Practitioner Reflection in action This occurs during an experience/task Time limited to only during the experience/task The cognitive load of the experience must be lower in order to reflect during an experience/task Reflection on action This occurs AFTER an experience (e.g. you made a treatment decisions and are now thinking if it was the correct choice) No time limitations – you can take as long as you wish to reflect 7 Reflection prompts before, during and after a learning process. (Schon, 1983) During an experience… Before an experience… After an experience… (thinking on our feet) What are your insights immediately What do you think might What’s happening now, as you after, and/or later when you have happen? make rapid decisions? more emotional distance from the event? What might be the challenges? Is it working out as I expected? In retrospect how did it go wrong? What do I need to know or order Am I dealing with the challenges What did I particularly value and to be best prepared for these well? why? experiences? Is there anything I should to do, In there anything I would do say or think to make the differently before or during a similar experience more successful? event? What am I learning from this? What have I learnt? 8 Video for Schon's Schon's Reflective Practice Source: https://www.youtube.com/watch?v=Tzjz-l8L1lc 9 Gibbs reflective cycle 10 Video for Gibbs Gibbs' Reflective Cycle Explained Source: https://www.youtube.com/watch?v=-gbczr0lRf4 11 Gibbs’ Reflective Cycle Describe in detail the event you are reflecting on. Include e.g. what was the context of the event; Describe the event what happened; what was your part in this; what parts others play; what was the result. At this stage try to recall and explore the things that were going on inside your head. Include e.g. Feelings how did it make you feel; how did others make you feel; what do you think about it now. Try to evaluate or make a judgement about what has happened. Consider what was good about Evaluation the experience and what was bad about the experience or didn’t go so well Break the event into parts so they can be explored separately. Include e.g. what went well; what Analysis did others do well; what went wrong in what way did you or others contribute to this You have explored the issue from different angles to base your judgement. The purpose of Conclusion reflection is to learn from an experience. So what have you learnt from this experience? Think forward into encountering the event again and to plan what you would do – would you act Action Plan differently or would you be likely to do the same? What goals can I set for the future? 12 Rolfe’s Framework for Reflective Practice What? So What? Now What? … was my role in the situation? … does this tell me/teach me/imply/mean … do I need to do in order to make things about me/my class/others/our better/stop being stuck/improve my … what actions did I take? relationship/my teaching/resolve the situation/feel patient’s care/the model of care I am better/get on better/etc., etc.? … was the response of others? using/my attitudes/my patient’s attitudes? … broader issues need to be considered if … were the consequences for myself? My … was going through my mind as I acted? this action is to be successful? student? Others? … did I base my actions on? … might be the consequences of this … feelings did it invoke? action? … other knowledge can I bring to the … was good/bad about the experience? situation? … could/should I have done to make it better? … is my new understanding of the situation? 13 Video for Rolfe's Framework Reflecting on a Personal Experience Using the “What, So What, Now What” Model Source: https://www.youtube.com/watch?v=_mQ_zDUX9nE 14 Why is there an emphasis to develop reflective learning in higher education? Can improve professionalism and clinical reasoning. Reflective practice can contribute to continuous practice improvement and better management of complex health systems and patients (Mann et. al 2007, Sanders 2009) So that graduates acquire the habit of reflection as a means of continuing to learn and grow in their professions. Reflective learning can lead to : personal growth, professional growth and meaningful change. 15 Common errors in reflective writing 1. Planning: You should be thinking about possible subjects and opportunities to reflect on before and during your rotations, not only after them 2. Writing style: Avoid writing too informally; don’t ignore academic style Original text Alternative text In my opinion, if there are too many ‘buts’ in my The reservations I currently feel about practicing in choosing to practice clinical pharmacy then I must clinical pharmacy suggest that I am not yet ready to not be ready for it, so it’s better for me to do carry on commit to this decision. So at this stage I plan to as a staff pharmacist. work as a staff pharmacist. 16 Common errors in reflective writing (Cont. 1) 3. Too little or too much detail: You need to describe the experience adequately. However, its not enough to describe the experience in great detail; you must ANALYZE and EVALUATE the events and thinking process. 4. Being judgmental: Try to describe events accurately and honestly, but avoid moralizing about people’s behavior. Original text Alternative text I was shocked when the doctor showed me the I was surprised when the doctor showed me the patient’s file without seeking consent. His disregard patient’s file without seeking consent. It made me for the rules regarding patient consent cause me to realize that discrepancies can exist between what is lose respect for him and to question his ethical taught on course and the way in which medicine is standards. practice in reality. From my own perspective, as a future clinical pharmacist, I would seek to maintain high ethical standards, and to encourage that among staff under my supervision. 17 Common errors in reflective writing (Cont. 2) 4. Being judgmental: (contd) Original text Alternative text During the second week of my clinical study, I met a During the second week of my clinical study. I met a patient who needed an X-ray for her knee and hip patient who needed an X-ray for her knee and hop joint. She was overweight and not very aware of my joint. This was made more difficult because she was role as a pharmacist- she treated me more like a significantly overweight and not very aware of my technician than a future clinical pharmacist. Even role as a pharmacist. She appeared distracted and worse, she was not cooperative, kept murmuring had difficulty coping with her level of pain, and shouted out about her pain throughout the sometimes shouting out. In terms of the X-ray procedure. Furthermore, the patient didn’t listen to procedure, the patient was uncooperative- she did out instructions and wouldn’t stay still after not follow out instructions and would not stay still positioning. after positioning. This made it very difficult to produce an adequate X-ray. 18 Common errors in reflective writing (Cont. 3) 4. Being judgmental: (contd) It could be useful to analyze this incident further Original text Alternative text During the second week of my clinical study, I met a What surprised me most about this incident was the patient who needed an X-ray for her knee and hip attitude of the patient to the health professionals. In joint. She was overweight and not very aware of my my culture, most people treat HCPs with great role as a pharmacist- she treated me more like a respect, and acknowledge their authority. I realized technician than a future clinical pharmacist. Even that in the XXXX context, compliance from the worse, she was not cooperative, kept murmuring patient cannot be assumed. The HCP has to gain and shouted out about her pain throughout the the trust and cooperation of the patient and this may procedure. Furthermore, the patient didn’t listen to not always be easy. In this case, I found that talking out instructions and wouldn’t stay still after quietly to the patient and explaining each positioning. requirement in detail reassured her, and ultimately led to a greater level of cooperation. However, this made the consultation much longer than it otherwise would have been. 19 Self reflection v. Self criticism Go beyond simply admitting a weakness or mistake or failure Describe how you felt, what you learnt from the experience, and how it will inform your behavior in the future. Use the reflection to raise new questions or speculate about possible causes and solutions. Where possible link your reflections to theoretical aspects. Original text Alternative text When the doctor raised his voice When the doctor raised his voice to the patient I felt embarrassed and to the patient, I felt the patient appeared to feel humiliated. Clearly, this behavior by the embarrassed. It reminded me to doctor was not appropriate, even though the doctor was obviously maintain an appropriate frustrated at the patient’s apparent inability to understand the communication style with instructions. While it is the responsibility of every doctor to behave patients when I am a doctor. respectfully with patients, on this occasion an excessive workload and the lack of availability of an interpreter no doubt contributed to the doctor’s behavior. It reminded me that structural factors within the health system, such as staffing and budgets, can impact on the quality of attention delivered to patients. 20 Achieving Critical Reflection Stems from Mezirow’s transformative and confirmatory learning Within reflection, it moves beyond descriptive writing and requires to writer to evaluate their assumptions, values, beliefs, and biases that led to the particular action that is being reflected upon 21 Evaluating Reflection There are a plethora of tools available to evaluate reflections each with their own strengths and shortcomings We will use the Reflection Evaluation for Learner’s Enhanced Competencies Tool (REFLECT) rubric throughout this course and program Wald HS, Borkan JM, Taylor JS, Anthony D, Reis SP. Fostering and Evaluating Reflective Capacity in Medical Education: Developing the REFLECT Rubric for Assessing Reflective Writing. Acad Med 2012; 87: 41-50. 22 The REFLECT Reflection Evaluation For Learners' Enhanced Competency Tool: Rubric 23 Reflection Assessment #1 “Clinical Question Development” online session was presented by Dr. Daniel on Monday, August 17, 2020. This session aims to meet the SC2.1 AFPC competency, which is to teach the PharmD students to develop focused clinical questions (FCQ) related to needs for information, recommendations, and decisions in practice. The session started by introducing some basic concepts such as the types of the clinical questions, followed by presenting a heart failure patient case and ask the students to use their previous learned techniques to develop and search for the created clinical questions in order for them to manage the patient case. Ending with home assignment to answer any of the developed FCQs. An example of the FCQ that I developed and searched about was: In adult patients who have HFrEF, does furosemide compared to Torsemide is associated with more reduction in hospitalization and mortality rate? This paper aims to reflect on the process of developing and searching the assignment FCQ and its impact on the patient care process. 24 Reflection Assessment #1 (Cont. 1) During the developing the FCQ, my expectations and thoughts toward this process meet what was done. For instance, knowing the PICO formatting technique for generating and searching for the FCQ, made me confident in approaching the patient case, as its easier to answer any unconfident, unclear or a controversial clinical question, by using the same taught strategies used during the session. However, it seems that missing some of the patient’s background information (e.g. lab results) affect the patient case management and made the clinical pharmacist unconfident when generating the appropriate FCQ and in searching for the appropriate articles. This was very interesting assignment, as this activity increase our confidence on our ability to approach any patient case, by using the appropriate technique in generating and searching for any patient related clinical question, weather it is related the diagnosis or therapy of any medical condition. 25 Reflection Assessment #1 (Cont. 2) The process of generating and searching about the FQC went very well, as using the keywords, with limiting the search to the highest level of evidence made it easier to find the articles needed to answer the FCQ. However, it seems that using only one database will reduce the trust of finding the all published articles in this field, which might affect the conclusion reliability. Also, being unable to access the full articles, limit the ability of the student to evaluate and assess the selected papers, and thus drawing a conclusion becomes unreliable. Thus, using the Qatar National Library to access the full text of these articles, is an option to ensure the recommendation accuracy. 26 Reflection Assessment #1 (Cont. 3) Some limitations that the clinical pharmacist student can faced during the generation of the FCQ, is the incomplete patient clinical assessment (e.g. lab results). Also, the inability to access all of the clinical database, which will limit the ability to find all of the relevant articles, during the searching process, and thus reduce the ability to manage the patient case appropriately. In addition, comparing this assignment with the previous developed FCQs during the SPEP rotations, this was less efficient than the real life scenario, as we were provided with the full patient case information, and a complete access to the literature database, which approaching the patient case with making care plans was much easier. In conclusion, we achieved the aim of this session and assignment, which is to be able to generate and search for FQC in a timely manner that help in approaching the patient case and increase the ability to providing more care for the patients. As I gain knowledge of how to generate and search for the PICO question to approach any patient case. This session changes my perception toward using FQC in managing the patient case. However, to improve the next assignment, I will recommend including some detailed patient information with a full access to the literature. 27 Reflection Assessment #1 Answer Key Criterion Grade Comment I would recommend you to report more about reflection instead of description only (e.g. attempting to understand, analyzing the Writing Spectrum 2 event comprehensively, explore and critique your values, and beliefs) Evidence of full and deep presence is lacking. You have referred to yourself in very few sentences “my expectations and thoughts toward this process”, “as I gain knowledge”. Rather, you have referred to “the clinical pharmacist, student” through the Presence 2 whole reflection “made the clinical pharmacist unconfident”” limit the ability of the student to evaluate and assess”. I would recommend you in the next reflection to improve the sense of your full presence. You have stated the challenges identified with respect to developing a clinical question “that missing some of the patient’s background information” “using only one database will reduce..” However, it is not clear if these challenges are yours or you are referring to clinical pharmacist in general. Description of You have stated what went well during this experience. conflict or 2 You have stated “In addition, comparing this assignment with the previous developed FCQs during the SPEP rotations, this was disorienting dilemma less efficient than the real life scenario, as we were provided with the full patient case information...”. Based on this sentence, I assume you have faced some difficulties during this exercise, therefore, you could have stated them and state how did you deal with such situation. Your description is not clear enough. Your emotions to the described activity were not stated. I would recommend in your next reflection assignment to discuss your Attending to 1 feelings throughout the activity/experience e.g. your feelings at that time, the impact of your emotions, your thoughts about emotions others’ feelings. You have identified the challenges with respect to developing a clinical question and you have suggested approaches to solve them “using the Qatar National Library”. However, I would recommend if you could state what could have been done differently at that time especially that you didn’t Analysis and have all patient data. I can’t see your approach/suggestion in that situation. 2 meaning making You might wish to include how research/theories can help you in making sense of what happened (e.g. you have stated “where I struggle the most, searching through different databases is somehow challenging”, theories might help in explaining this difficulty). You have stated the skills you learned “process of generating and searching…” 28 Reflection Assessment #2 During my Structural Practical Experiences in Pharmacy (SPEP) rotation last year in Communicable Disease Center (CDC), I came upon a very challenging and exciting question during my infectious disease (ID) rotation. My preceptor used to get many calls on whether administration of dexamethasone for 4 days as an adjunctive treatment, compared to no treatment, can reduce the risk of mortality and disability in adults with bacterial meningitis. She asked me this clinical question and I replied honestly that I don’t have any clue what the answer would be. I remember when I told her that she didn't look down on me and she told me that many clinical pharmacists don’t know the answer. What made me more eager to search up the answer is her reply when she said "as a pharmacy student, you are in a learning process, you do not need to know everything but you need to know something about everything". At that time, her words boosted my enthusiasm to look up the answer and I was given 3 days to answer the clinical question and present it to the clinical pharmacists in the CDC department. 29 Reflection Assessment #2 (Cont. 1) Since I had my focused question already formulated by my preceptor, I started looking up the internet and brainstorming what I need to know about this disease. At first, I had to refresh up my mind by reading some background information about bacterial meningitis as a disease state. I even watched some animations on YouTube to explain the pathophysiology and treatment options as I recall information from videos faster than reading it in text. After brushing off the cobwebs, I looked up 4 databases (Pubmed, Cochrane, Embase, and SCOPUS) to allow for comprehensive search in the primary literature. The most crucial and troublesome part of the search was selecting appropriate keywords and search terms. I used Mesh terms, Boolean Operators, (dexamethasone, corticosteroids, bacterial meningitis, mortality OR death, disability) and filters to narrow down and refine the search results. Screening the results and excluding the articles based on titles and abstracts was time-consuming and very demanding. Finally, I was able to come up with two articles to answer the clinical question. The two articles had opposing conclusions so I had to look further and read a systematic review (SR) about my PICO question. Eventually, I was able to draw out a conclusion: Insufficient data to prove that corticosteroids cause a reduction in mortality but they cause lower rates of severe hearing loss and neurological sequelae. 30 Reflection Assessment #2 (Cont. 2) Frankly, going through a systematic review was a whole new level for me based on my critical analyzing skills. It has enriched my knowledge a lot and made me more confident about the answer instead of relying on two RCTs only. During university classes, I was never exposed to such detailed and precise clinical question. Moreover, I always looked up answers with my colleagues and we helped each other in the search process. But right now, it solely depends on you, no one to help or give you clues. It is just you and your laptop against the clinical question. One thing I feel that was missing during my presentation is the summary, I had overwhelming information and had to go through a SR to draw a conclusion. 31 Reflection Assessment #2 (Cont. 3) Next time, I would definitely conclude all the data and would print out a summary table. In addition, I felt that the clinical question was given to me easily and fully formulated which facilitated the search process. In the future, I would like to generate or re-frame a clinical question on my own since I will probably be in situations where I need to come up with my own focused questions for patients. if I had a clinical question again, I would also challenge myself to answer it in a shorter period of time instead of 3 days, during rotations clinical pharmacists don’t have that much time. This focused question made me aware of my knowledge gaps and made me learn how to pool a variety of resources to come up with an answer for a specific patient. Learning how to learn is very important. It’s this combination of understanding the clinical questions, searching for answers, and applying different strategies that led to the most rewarding learning experiences in my life. There is always something new to learn. 32 Reflection Assessment #2 Answer Key Criterion Grade Comment Overall there is good description to your writing and analyze the event but I would Writing Spectrum 3 like to have seen more comments around previous assumptions/values/beliefs or thought about the consequences of your perceived scholarly skills. good description of thoughts. I really get the sense of being ‘in your head’ during Presence 4 some of this time. I like how you have described the process and the story of answering this clinical Description of question. I like how you have also included the perception of your preceptor. It would conflict or 4 have been nice to finish off with your preceptors comments on answering your disorienting clinical question as you have some specific goals around how long it takes to answer dilemma a question and coming up research questions on your own. The wording of the text is clear and I do get a sense of your emotions during this time. I don’t get a full sense of your feelings and the processing. For example, you Attending to were excited at the start but note feeling overwhelmed by information and having to 3 emotions come to a conclusion based on perhaps opposing literature conclusions. To move to a 4, I would really like for you to be aware of these changes and address this in a couple of sentences. Analysis and Overall good and mostly clear. I would have liked to hear more about your process 3 with a specific plan or thoughts of a plan in place of how to meet your specified goals meaning making 33 References and Resources Models Schon, D. A. (1983). The Reflective Practitioner: How professionals think in action. Basic Books. Gibbs G. (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford. Rolfe, G., Freshwater, D., & Jasper, M. (2001) Critical reflection for nursing and the helping professions: A user’s guide, Palgrave Basingstoke. Reflect rubric Wal HS, Borkan JM, Taylor JS, Anothony D, Reis SP. Fostering and Evaluating Reflective Capacity in Medical Education: Developing the REFLECT Rubric for Assessing Reflective Wirting. Acad Med 2012; 87: 41-50. Smith, M. K. (2001, 2011). ‘Donald Schön: learning, reflection and change’, The encyclopedia of pedagogy and informal education. https://infed.org/mobi/donald-schon-learning-reflection- change/. Retrieved: June 2021. 34 Faculty Credits The following faculty are attributed to the slides and ideas of this session (in alphabetical order) Dr. Ahsan Sethi Dr. Daniel Rainkie Dr. Zacharia Nazar 35