The Reflective Practitioner 2024 SD MUB PDF

The Reflective Practitioner BMF MED1 Prof. Denis Harkin MB MD FRCSI Dr Sally Doherty FEBVS Dept Psychology Consultant Vascular Surgeon Chair of Medical Professionalism, Academic lead in Bahrain...

The Reflective Practitioner BMF MED1 Prof. Denis Harkin MB MD FRCSI Dr Sally Doherty FEBVS Dept Psychology Consultant Vascular Surgeon Chair of Medical Professionalism, Academic lead in Bahrain RCSI for Professionalism Learning Objectives By the end of the lecture, learners will be able to: 1. Define Reflective Practice 2. Describe Reflective Practice Theory and Gibb’s Reflective Cycle 3. Understand the role of Reflection in Continuous Professional Development 4. Discuss the application of Reflection to learning from Clinical Scenarios Reflective Practice insights A cognitive process that helps us to gain and rethink our practice, learn from our experiences and help us to cope with similar situations in future. Rolfe, G., Freshwater, D. and Jasper, M. (2001). Critical reflection in nursing and the helping professions: a user’s guide. Basingstoke: Palgrave Macmillan.  “Don’t just say you have read books. Show that through them you have learned to think better, to be a more discriminating and reflective person.” – Epictetus  Ars Longa, Vita Brevis “Life is short, and art is long,… …the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also make the patients, the attendants, and externals cooperate.” - Hippocrates of Kos Adams, Francis (1891), The Genuine Works of Hippocrates, New York: William Wood and Company. To Err is Human In USA 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from MVA, breast cancer, or AIDS. Indeed, more people die annually from medication errors than from workplace injuries. To Err Is Human asserts that the problem is not bad people in health care - it is that good people are working in bad systems that need to be made safer. However, individual professionals’ “dangerous, reckless or impaired” behaviour can sometimes harm patients. “To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.” - Sir Liam Donaldson (2004) Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000. PMID: 25077248. Reflective Practice: IMC Code of Professional Conduct and Ethics Performance (Pillar) The behaviours and processes that provide the foundation for good care. Reflective Practice Developing insight into professional practice is important to improve standards of care. Reflective practice includes: Formal Reviews through audit and outcome data. Informal Reflection on how personal values may affect communication with patients, colleagues or others, and ultimately the care provided to patients. https://medicalcouncil.ie/news-and-publications/reports/guide-to-professional-conduct-and-ethics-8th-edition-2016-.pdf Accessed 13 August 2020 Learning Culture & Safety: IMC Culture of patient safety Medical treatment involves some degree of risk. We should strive to minimise risk and learn from harm. “You should promote a culture of patient safety” Adverse events result in unintended outcomes for patients as a result of clinical interventions or omissions, or the systems or processes used in managing patient care. “If you are involved in an adverse event, you should report it, learn from it and take part in any review of the incident”. https://medicalcouncil.ie/news-and-publications/reports/guide-to-professional-conduct-and-ethics-8th-edition-2016-.pdf Accessed 13 August 2020 Reflective Practice: AoMRC Reflective Practice “The process whereby an individual thinks analytically about anything relating to their professional practice with the intention of gaining insight and using the lessons learned to maintain good practice or make improvements where possible” Situation may be observed, or directly involved, or part of formal learning. Reflection happens with both positive and negative events, either to reinforce behaviour or to change it. Reflection on Experience should be part of a doctor’s everyday practice. http://www.aomrc.org.uk/wp-content/uploads/2018/08/Reflective_Practice_Toolkit_AoMRC_CoPMED_0818.pdf Reflective Practice: GMC, AoMRC & CoPMED Doctors must feel able to have honest and open discussions about clinical events and should be confident that engaging in reflection provides them: Improved opportunities to learn Evidence of a professional approach to self-development Changes leading to improvement of patient care where appropriate Reflection should not be a detailed description, nor an attribution of blame, but should focus on feedback and descriptions of the increased understanding gained which has led to an affirmation of, or change of, practice. http://www.aomrc.org.uk/wp-content/uploads/2018/08/Reflective_Practice_Toolkit_AoMRC_CoPMED_0818.pdf Royal College of Surgeons in Ireland Definition Medical Professionalism: “Values, behaviours and attitudes that promote professional relationships, public trust and patient safety” On the next slides we can consider additional information on the respective sub-headings of Medical Professionalism.  Reflective Practice Developing insight into Compassion professional practice is important to Communicat Self Care improve standards of care. ion Reflective practice includes formal reviews through audit and outcome data. It also includes informal reflection on how personal values may affect Cultural Integrity communication with patients, Sensitivity Honesty colleagues or others, and ultimately the care provided to patients. Patient Continuous Centred Improvement Evidence Service Continuous Quality Improvement Based Advocacy Practice (CQI) in Health Care is a structured organizational process that involves physicians and other personnel in planning and implementing ongoing proactive Reflective improvements in processes of Practice care to provide quality health care outcomes. Continuous Altruism You should improve systems, or raise concerns with an appropriate Improveme person, nt Working in Ethical if you believe that administration Partnership Practice or other systems are impeding good patient care. Reflective Practice Theory  Know Thyself Maxims from the Temple of Apollo at Delphi The Delphic Maxims. 147 Ancient Rules for a Happy Life. https://warblerpress.com/wp-content/uploads/2020/02/Delphic-Maxims-cover-half-663x1024.jpg https://whc.unesco.org/en/list/393/gallery/ What is Reflection Reflection allows the reflector’s learning and knowledge to benefit from conscious thought. Two main conceptions: Reflection on Experience – using experiences as a foundation for learning and updating personal understanding of existing theories; Reflection as Metacognition – particularly focusing on a problem, conception, or an idea. Knowledge is a continual development and is shaped by its relationship with experience or conscious critical thought. Moon, J.A. (2004a). A handbook of reflective and experiential learning: theory and practice. London: Routledge Falmer. Schön, D. (1983). The reflective practitioner: how professionals think in action. New York: Basic What is not Reflection Writing a diary? Gazing at the clouds? Reflective Thought (Dewey) John Dewey (1993) He defines reflective thought as an: “active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and further conclusion to which it tends” Thinking about a problematic situation that needs to be resolved: “the function of reflective thought is, therefore, to transform a situation in which there is experienced obscurity, doubt, conflict, disturbance of some sort, into a situation that is clear, coherent, settled, harmonious” By adopting reflective thought the individual “converts action that is merely appetitive, blind and impulsive into intelligent action”. Dewey, J. (1933). How we think: a restatement of the relation of reflective thinking to the educative process. New York: D.C. Heath and Company. Reflection: Active Learning and Consolidation Piaget (1971) Constructivist Learning Theory Reflection forces students to engage with content matter and contextualise it with their own experience, which is why it can allow for better engagement and retention. Marton & Saljo (1976) “Deep Learning” Students who engage more deeply with material will learn and retain principle ideas better compared to those who adopt a surface learning of simply trying to uncritically remember anything or everything. Transforming “surface learning” into “deep learning”. Piaget, J. (1971). Psychology and epistemology: towards a theory of knowledge. New York: Grossman Marton, F. and Saljo R., (1976). On qualitative differences in learning. 1: Outcome and process. British Journal of Educational Psychology (46), 4-11. Reflection: Definition Cognition, can be defined as “the mental acquisition of knowledge through thought, experience, and the senses”. Reflection, is a cognitive process that helps us to gain insights into the “big picture” and rethink our practice, learn from their experiences and help us to cope with similar situations in the future. Self-Reflective Practice is a “meta-cognitive” ability, meaning that it involves thinking about and reflecting on one’s own mental processes. Oxford English Dictionary (2020). Reflection: on Experience In adult education the benefit of learning from experience, rather than passively through knowledge transfer, is established. Donald Schön (1983) highlighting the importance of experience as a tool for updating professional theories and through reflection using them to improve practice. Kolb (1984) formalised the modern conception of experiential learning: Allowing the student to reflect on their experience is essential for the student to extract meaningful elements and incorporate them into a personal knowledgebase. Without this time to purposefully debrief the experience, the learning is likely not to become conscious or lasting for the student. Schön, D. (1983). The reflective practitioner: how professionals think in action. New York: Basic Books Kolb, D.A. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice- Hall Reflection: Metacognition Metacognition: awareness and understanding of one's own thought processes Jack Mezirow (1991) Transformational Learning Theory Mezirow suggests that reflection is useful to understand the content and premise of the problem as well as the problem-solving process itself. This is obtained by stepping back and looking at one’s thinking process – reflection therefore becomes “thinking about thinking” and how to do so effectively. Loughran (1996) highlights problem solving by reflection and learning from experience, to: “untangle a problem, or make more sense of a puzzling situation; reflection involves working toward a better understanding of the problem and ways of solving it” Mezirow, J. (1991). Transformative dimensions of adult learning. San Francisco, CA: Jossey-Bass. Loughran, J.J. (1996). Developing reflective practice: learning about teaching and learning through modelling. London: The Falmer Press. Reflection: Critical Thought (Moon) Moon (2004) highlights six different areas where reflection can be helpful: 1. critically reviewing our own behaviour, the behaviour of others, or the product of our behaviour (for instance, a piece of work); 2. building general theories from observing, or being involved in, practical situations; 3. making decisions or resolving uncertainty; 4. considering the process of our own learning, in other words engaging in ‘thinking about thinking’ or metacognition; 5. engaging in personal or self-development; and 6. empowering or emancipating ourselves as individuals or within our social group. Moon, J.A. (2004a). A handbook of reflective and experiential learning: theory and practice. London: Routledge Falmer. Reflecting on Experience Reflective Models can help with structure, guidance and questions. Gibbs’ “Reflective Cycle” (1988) Driscoll’s or Rolfe’s Reflective Practice Model “What? So what? Now what?” Kolb’s learning Cycle (1984) Schon’s Reflective Practitioner (1991) Bassot’s “The Integrated Reflective Cycle” Greenaway’s “The Active Reviewing Cycle” of “four F’s” Reflection and Professional Development The Task of Medical Education “To shape the novice into the effective practitioner of medicine, to give him (her/they) the best available knowledge and skills, and to provide him (her) with a professional identity so that he (she/they) comes to think, act and feel like a – Amending Millar’s Pyramid, Creuss (2016) physician.” Merton RK. Some preliminaries to a sociology of medical education. In: Merton RK, Reader LG, Kendall PL, eds. The Student Physician: Introductory Studies in the Sociology of Medical Education. Cambridge, Mass: Harvard University Press; 1957:3–79. Cruess RL, Cruess SR, Steinert Y, eds. Teaching Medical Professionalism. Cambridge, UK: Cambridge University Press; 2009. Amending Miller’s Pyramid to Include Professionalism Identity Formation, Cruess R & Cruess – Merton S in Ed Cruess RL, Creus SR, (1957) Steinert Y. Teaching & Creuss Medical (2009) Professionalism. Cambridge University Press (2009) 2016. Principles of Adult Learning Andragogy “the art and science of helping Concrete adults learn” Experience Independent Variety Motivations and Expectations Active Different Learning Styles Experimentati Reflective Observation on Changes in Attitudes as well as Skills Kolb’s The Experiential Learning Learn through Experience Cycle “Learning by Doing” Incentives come from within Abstract Conceptualiza Feedback is usually more important tion Kolb DA, Fry R. TowArds an applied theory of experiential learning. In Cooper, CL, ed. Theories of Group Processes. London, UK: John Wiley; 1975:33-58. Creus RL, Cruess S,R, Steinert Y, eds. Teaching Medical Professionalism. New York, NY: Cambridge University Press; 2009. Life Long Learning Life Long Learning Definition: “all Learning Activity undertaken through life, with the aim of improving knowledge, skills and competences within personal, civic, social and/or employment-related perspective” Learning throughout all stages of life General, vocational and personal skills involved Formal system of education and informal activities Communication from the Commission: Making a European Area of Lifelong Learning a Reality. Nov. 2002. http://Europa.eu.int/comm/education/ Clinical Learning Environment: Definition Clinical Learning Environment: The Macy Foundation (2018) defined the learning environment as: “…social interactions, organizational cultures and structures, and physical and virtual spaces that surround and shape participants’ experiences, perceptions, and learning.” For Healthcare Professionals: Learning in a clinical context is foundational Healthcare systems rely on learners for service An effective and supportive CLE thus is important to the quality and safety of patient care, to the health and well-being of the medical workforce, and to trainee learning and socialization into the profession. Josiah M. Jr. Foundation. 2018. Improving environments for learning in the health professions. Recommendations from the Macy Foundation Conference. New York: Josiah Macy Jr. Foundation.. Jonas Nordquist, Jena Hall, Kelly Caverzagie, Linda Snell, Ming-Ka Chan, Brent Thoma, Saleem Razack & Ingrid Philibert (2019) The clinical learning environment, Medical Teacher, 41:4, 366-372 Reflection for Self-awareness Strengths and weaknesses Increasing self-awareness of strengths and weaknesses to increase effectiveness. Asking yourself targeted questions Direct: What are my strengths? What are my weaknesses? Indirect: What have I been complemented upon? What do I frequently need help with? Analysing experiences Something went well (strengths)? Something went poorly (weakness)? Asking Others Critical Friend, Mentor, Multi-Source Feedback (MSF), 360-degree Appraisal Reflection: on Feedback Reflection helps us make sense of feedback, and use it effectively. Sargeant et al. (2009) interviewed 28 different family physicians in a multisource feedback programme. In this case, reflection is used to conceptualise and re-evaluate practice. The authors saw that reflection was particularly useful to make sense of feedback that was inconsistent with the physicians’ self-belief. Reflection became a way for the physician to make sense of challenges to their taken-for-granted assumptions of how practice should be and how they need to act within it. Sargeant, J.M., Mann, K.V., Van der Vleuten, C.P., & Metsemakers, J.F. (2009). Reflection: a link between receiving and using assessment feedback. Advancement in Health Science Education, 14, 399-40 Reflection: Professional Development Reflection leads to higher self-awareness and make one more likely to effectively plan their professional and personal development. Cunningham & Moore (2017) particularly highlight how being taught reflection allows healthcare practitioners to effectively recognise development opportunities. Identifying suboptimal practice, the individual is well placed to think about what good practice looks like, and reflect on what excelling looks like, so they can start consciously move toward it. Cunningham, N., & Moore, K. (2014). Beyond the ‘swampy lowlands’: the welfare benefits of reflective practice through learning. Journal of Poverty and Social Justice, 22(3), 271-75. Reflection and Employability Employability “a set of achievements – skills, understandings and personal attributes – that makes graduates more likely to gain employment and be successful in their chosen occupations, which benefits themselves, the workforce, the community and the economy.” Reflect on what skills you have developed over the last week/month/year and how you will be able to evidence these skills with examples. Reflect to identify the skills that are required in the sector you want to end up in and start developing these by setting goals and objectives. Reflect on how you deal with challenges and how you can improve your approach and resilience. Reflect on the range of experiences you have and find ways to expand this range. Ensure you don’t neglect life-long learning. Yorke, M. (2004), Employability in higher education: what it is – what it is not, The Higher Education Academy/ESECT Learning Health System: Learning Cycle Learning health systems (LHS) are healthcare systems in which knowledge generation processes are embedded in daily practice to produce continual improvement in care. First proposed by the US Institute of Medicine (2006), built on ideas around evidence- based medicine and "practice-based evidence“. It has also been promoted by the NHS and AHRQ. LHS can be described as having four key elements: Organizational architecture that supports the formation of communities of patients, healthcare professionals and researchers who collaborate to produce and use "big data"; Large electronic health data sets, i.e. "big data"; Quality improvement at the point of care for each patient using new knowledge generated by research; Research done in routine healthcare settings. They are thus dependent on the use of electronic health records (EHRs) Olsen L, Aisner D, McGinnis JM (2007). The Learning Healthcare System: Workshop Summary. Institute of Medicine (US). National Academies Press (US). ISBN 978-0-309-10300-8. Agency for Healthcare Research and Quality (AHRQ) https://www.ahrq.gov/professionals/systems/learning-health-systems/index.html Quality Improvement and PDSA Cycle The Deming Wheel, or Deming Cycle, also know as PDCA (Plan, Do, Check, Act) Cycle was first introduced to Dr Deming by his mentor, Walter Shewhart of the famous Bell Laboratories in New York. It has evolved to become The PDSA Cycle (Plan-Do-Study-Act), a systematic process for gaining valuable learning and knowledge for continual improvement of a product, process, or service. Namely, Quality Improvement https://www.england.nhs.uk/improvement-hub/publication/first-steps-towards-quality-improvement-a-simple-guide- to-improving-services/ Reflections as Evidence: GMC Williams Review of Gross Negligence Manslaughter in Healthcare (2018) Professor Sir Norman Williams Review in the wake of the Dr Bawa Garba controversy considered wider concerns among healthcare professionals that simple errors could result in prosecution for gross negligence manslaughter, even if they happen in the context of broader organisation and system failings. It’s recommendations support a more just and learning culture in the healthcare system. It covers: the process for investigating gross negligence manslaughter reflective practice of healthcare professionals the regulation of healthcare professionals Sir Terence Stephenson (GMC Chair) advised doctors' reflections are: “so fundamental to their professionalism” that UK should consider providing legal protection. The Williams Review into Gros Negligence Manslaughter. https://www.gov.uk/government/publications/williams-review-into-gross-negligence- manslaughter-in-healthcare.The GMC will not ask for doctors’ reflective records for fitness to practise processes. https://www.gmc-uk.org/news/news-archive/doctors-reflections-should-be-legally-protected Reflective Practice Models (Gibb’s)  Sensing and Watching/ Feeling Reflecting Kolb’s Learning Cycle Concrete Reflective Experience Observation David Kolb (1984) Learning Cycle Promotes “learner centred pedagogy” and acknowledges Active Abstract that people learn in different ways. Experimentati on Conceptualisa tion Doing/Behaving Thinking It has been adapted to four Stages of Reflection: Concrete Experience, actually having an experience Reflective Observation, reflecting on the experience Abstract Conceptualisation, learning from the experience Active Experimentation, trying out what you have learnt Each stage has helpful questions (prompts), you don’t have to use them all, you can use your own. Kolb, D (1984). Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.  Feeling Gibbs’ Reflective Cycle Descripti Evaluatio on n Graham Gibbs (1988), gives structure to learning from (repeated) experiences. It covers six stages: Description of the experience Action Analysis Feelings and thoughts about the experience Plan Evaluation of the experience, both good and bad Conclusio Analysis to make sense of the situation n Conclusion about what you learned and what you could have done differently Action plan for how you would deal with similar situations in the future, or general changes you might find appropriate. Each stage has helpful questions (prompts), you don’t have to use them all, you can use your own. Gibbs Reflective Model, is widely used throughout the healthcare profession. Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford. Schon’s Reflective Practitioner Donald Schon’s The Reflective Practitioner (1991): Effective professional practice and human thought Reflectio The experience itself Thinking about it during the event Knowing in action n in Deciding how to act at the time Acting immediately Reflection-in-action Action Reflection-on-action Reflecting on something that has happened This model encourages practitioners to reflect whilst on the job. Reflectio Thinking about what you might do differently if it happened again n on New information gained and/or theoretical perspectives from Action study that inform the reflector’s experience are used to process feelings and actions Schon, D. (1991). The reflective practitioner: How professionals think in action. Aldershot: Ashgate Publishing Ltd.  So What What? So what? Now what? ? Driscoll (1994), proposed one of the simplest reflection frameworks. Also known as Rolfe’s Reflective Practice Model (2001). Now What What ? It is based on three simple questions: ? What? The experience of the situation So what? The implications of the situation Now what? The action plan Each stage has helpful questions (prompts), you don’t have to use them all, you can use your own. Borton. T. (1970). Reach Touch and Teach: Student Concerns and Process Education. McGraw-Hill, New York. Driscoll J. (1994). Reflective practice for practise. Senior Nurse, 13, 47 -50. Rolfe, G., Freshwater, D., Jasper, M. (2001). Critical reflection in nursing and the helping professions: a user’s guide. Basingstoke: Palgrave Macmillan.  Facts The four F’s of active reviewing Feelings Dr Roger Greenaway, an expert on training teachers and facilitators. Initial Model had three steps, namely: DO-REVIEW-PLAN Findings Greenaway’s The 4F’sModel (1995) steps are: Future Facts: An objective account of what happened Feelings: The emotional reactions to the situation Findings: The concrete learning that you can take away from the situation Future: Structuring your learning such that you can use it in the future Each stage has helpful questions (prompts), you don’t have to use them all, you can use your own. It is more widely used within teaching professions as opposed to healthcare. Greenaway, R. (1995). Powerful learning experiences in management learning and development: a study of the experiences of managers attending residential development training courses at the Brathay Hall Trust (1988-9), (Doctoral dissertation, University of Lancaster). https://reviewing.co.uk/learning-cycle/ Schwartz Rounds Schwartz Rounds, Reflecting on your practice and its emotional impact. The Point of Care Foundation describe Schwartz rounds as: "…A structured forum where all staff, clinical and non-clinical, come together regularly to discuss the emotional and social aspects of working in healthcare. The purpose of Rounds is encourage compassion in healthcare to understand the challenges and rewards that are intrinsic to providing care, not to solve problems or to focus on the clinical aspects of patient care. Evidence shows that staff who attend Rounds feel less stressed and isolated, with increased insight and appreciation for each other’s roles. They also help reduce hierarchies between staff and to focus attention on relational aspects of care. Lown, Beth A. MD; Manning, Colleen F. MA The Schwartz Center Rounds: Evaluation of an Interdisciplinary Approach to Enhancing Patient-Centered Communication, Teamwork, and Provider Support, Academic Medicine: June 2010 - Volume 85 - Issue 6 - p 1073-1081 doi: 10.1097/ACM.0b013e3181dbf741 https://www.theschwartzcenter.org/programs/schwartz-rounds/ Reflective Practice Building a reflective practice mindset typically involves: An ability and willingness to reflect and learn Repeating reflection over a series of related experiences adds value Reviewing and reflecting on an extended period to identify patterns Setting and reflecting on goals and objectives Reflectio Reflectio Reflectio ERA model – Experience, Reflection, Action (Building from one n n n cycle to the next) Experien Experien Experien Action Action Action ce ce ce Reflective Assignments Writing Spectrum Presence Description of Conflict of disorienting dilemma Wald (2012) The RESPECT Rubric for assessing reflective writing. Attending to emotions Academic Reflections have a specific language and structure General Language Points Analysis and meaning making Be succinct; stick to word-count Attention to assignment (Optional) Use “I” and other personal nouns Almost always use the past tense Use subject-specific language and terminology (medical professionalism) Description, Thoughts and Feelings, Analysis/Interpret/Evaluating, Concluding and Planning Habitual Thoughtful Critical action (Non- action or Reflection reflection reflective) introspection Criterion/Level Wald, H.S., Borkan, J.M., Scott Taylor, J., Anthony, D., and Reis, S.P. (2012) Fostering and evaluating reflective capacity in medical education: Developing the REFLECT rubric for assessing reflective writing. Academic Medicine, 87(1), 41-50. Reflection Examples (Gibb’s and Rolfe’s) Gibb’s Reflective Cycle  Feeling Gibbs’ Reflective Cycle Descripti Evaluatio on n Description, here describe the situation in detail. Helpful questions: What happened? Action Analysis Plan When and where did it happen? Who was present? Conclusio What did you and the other people do? n What was the outcome of the situation? Why were you there? What did you want to happen? Each stage has helpful questions (prompts), you don’t have to use them all, you can use your own. Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.  Feeling Descripti Evaluatio on n Gibbs’ Reflective Cycle Action Analysis Plan Conclusio Description, here describe the situation in detail. n Conducting a health assessment on a patient who not only suffered with dementia but limited mobility as well as several other underlying health conditions. The patient was an elderly lady who had only recently been diagnosed with dementia though whose illness was quite advanced. As with some patients there is a delay in seeking out help given the stigma associated with dementia. The lady become aggravated during the assessment and vocal with myself – nothing physical but it was clear that the lady did not want to be here, though it was vital that we assessed her. Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.  Feeling Gibbs’ Reflective Cycle Descripti Evaluatio on n Feelings, feelings or thoughts you had during experience. Helpful questions: What were you feeling during the situation? Action Analysis Plan What were you feeling before and after the situation? What do you think other people were feeling about the situation? Conclusio What do you think other people feel about the situation now? n What were you thinking during the situation? What do you think about the situation now? Each stage has helpful questions (prompts), you don’t have to use them all, you can use your own. Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.  Feeling Descripti Evaluatio on n Gibbs’ Reflective Cycle Action Analysis Plan Conclusio Feelings, feelings or thoughts you had during experience. n Initially feeling confident given I had an understanding of the patient and their health background. However what I was ill prepared for was the behaviour of the patient who became agitated through the assessment and at sometimes could have been described as aggressive. Unfortunately this could happen with someone suffering with dementia given that the patient here was getting confused and aggressive as they were unsure of where they were. My mood changed. Under pressure to keep the patient calm my focus on the assessment waned and I felt the pressure getting to me which undermined my knowledge. I felt uncomfortable in this situation and I believed this showed in my body language, potentially coming off as me not caring for the patient, or me being ‘fed up’ of dealing with this patient. Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.  Feeling Gibbs’ Reflective Cycle Descripti Evaluatio on n Evaluation, evaluate what worked and what didn’t work. Helpful questions: Action Analysis Plan What was good and bad about the experience? What went well? Conclusio What didn’t go so well? n What did you and other people contribute to the situation (positively or negatively)? Each stage has helpful questions (prompts), you don’t have to use them all, you can use your own. Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.  Feeling Descripti Evaluatio on n Gibbs’ Reflective Cycle Action Analysis Plan Conclusio Evaluation, evaluate what worked and what didn’t work. n Good – I was knowledgeable and confident I could create a care plan for the patient. Bad – I allowed by feelings to cloud my mind and in turn impact on the quality of care I could provide at the time. While I was prepared to deal with the patient’s healthcare needs I was not fully prepared to deal with their behaviour during the assessment and given that I was unprepared for their attitude this did impact my own behaviour. Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.  Feeling Gibbs’ Reflective Cycle Descripti Evaluatio on n Analysis, chance to make sense of what happened (meaning). Helpful questions: Action Analysis Plan Why did things go well? Why didn’t it go well? Conclusio What sense can I make of the situation? n What knowledge – my own or others (for example academic literature) can help me understand the situation? Each stage has helpful questions (prompts), you don’t have to use them all, you can use your own. Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.  Feeling Descripti Evaluatio on n Gibbs’ Reflective Cycle Action Analysis Plan Conclusio Analysis, chance to make sense of what happened (meaning). n Empathy is a vital trait within medicine to build this patient – doctor relationship. The patient needs to feel re-assured that the healthcare team have their best interests at the forefront of any assessment and care plan, while also understanding their personal circumstances. It is a counterbalance between behaving in a way which showcases your authority and status as the healthcare provider while also being empathetic to create a personal, kind and friendly relationship with the patient. You want the patient to know that you have their best interests in mind Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.  Feeling Gibbs’ Reflective Cycle Descripti Evaluatio on n Conclusions, summarise learning and highlight positive changes. Helpful questions: Action Analysis Plan What did I learn from this situation? How could this have been a more positive situation for everyoneConclusio involved? What skills do I need to develop for me to handle a situation like this n better? What else could I have done? Each stage has helpful questions (prompts), you don’t have to use them all, you can use your own. Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.  Feeling Descripti Evaluatio on n Gibbs’ Reflective Cycle Action Analysis Plan Conclusio Conclusions, summarise learning and highlight positive changes. n From this experience I am more mindful of how my own behaviour and body language during an assessment or other interaction with a patient can directly influence their behaviour. I am now more aware how easily it is for a patient to sense my feelings from my body language, to how I speak. I need to be more empathetic in situations and also have more courage so that I am not impacted by the behaviour of the patient. I need to remain calm in these situations and maintain a professional manner. Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.  Feeling Gibbs’ Reflective Cycle Descripti Evaluatio on n Action Plan, what you would do differently in similar situation in future. Helpful questions: Action Analysis Plan If I had to do the same thing again, what would I do differently? How will I develop the required skills I need? Conclusio How can I make sure that I can act differently next time? n Each stage has helpful questions (prompts), you don’t have to use them all, you can use your own. Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.  Feeling Descripti Evaluatio on n Gibbs’ Reflective Cycle Action Analysis Plan Conclusio Action Plan, what you would do differently in similar situation in future. n In future I need to be more proactive at speaking with me colleagues and peers over their past experiences so that I can build a better understanding of what behaviour I could experience from dementia patients. Evidence has shown how the behaviour of two dementia patients can vary quite differently; one potentially being subdued while the other aggressive. I need to accept this and become more confident when it comes to dealing with the unexpected. I understand that I will become more confident over time with this as I am exposed to more situations, and as I get more advice from my peers on how they deal with it. Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford. What? So what? Now what?  So What What? So what? Now what? ? What? The experience of the situation. Helpful questions: What... Now... is the context? What What ?... is the problem/situation/difficulty/reason for being stuck/reason for success?... was I/we/others trying to achieve? ?... was the outcome of the situation?... was my role in the situation?... was the role of other people in the situation (if others were involved)?... feelings did the situation evoke in me? And in others (to the extent you know)?... were the consequences for me? And for others?... was good/bad about the experience? Each stage has helpful questions (prompts), you don’t have to use them all, you can use your own. Borton. T. (1970). Reach Touch and Teach: Student Concerns and Process Education. McGraw-Hill, New York. Driscoll J. (1994). Reflective practice for practise. Senior Nurse, 13, 47 -50. Rolfe, G., Freshwater, D., Jasper, M. (2001). Critical reflection in nursing and the helping professions: a user’s guide. Basingstoke: Palgrave Macmillan.  So What ? What? So what? Now what? What Now What ? ? What? The experience of the situation. Excessive “On-call” and affect on performance. During my first month as Intern I was asked to cover several additional “on call” shifts covering general surgery, as they had too few trainees due to under- recruitment and absence. One day I had worked 8am-6pm and was asked by the Clinical Director (CD) at 3pm to cover the night shift, which I agreed to. The next day I was in Theatre with another consultant who was trying to teach me how to perform a wound closure, but performed poorly, barely able to suture, due to my exhaustion. Borton. T. (1970). Reach Touch and Teach: Student Concerns and Process Education. McGraw-Hill, New York. Driscoll J. (1994). Reflective practice for practise. Senior Nurse, 13, 47 -50. Rolfe, G., Freshwater, D., Jasper, M. (2001). Critical reflection in nursing and the helping professions: a user’s guide. Basingstoke: Palgrave Macmillan.  So What What? So what? Now what? ? So What? The implications of the situation. Helpful questions: So what... Now What practice/the... does this tell me/teach me/imply about the situation/my attitude/my What problem? ?... was going through my mind in the situation? ?... did I base my decisions/actions on?... other information/theories/models/literature can I use to help understand the situation?... could I have done differently to get a more desirable outcome?... is my new understanding of the situation?... does this experience tell me about the way I work? Each stage has helpful questions (prompts), you don’t have to use them all, you can use your own. Borton. T. (1970). Reach Touch and Teach: Student Concerns and Process Education. McGraw-Hill, New York. Driscoll J. (1994). Reflective practice for practise. Senior Nurse, 13, 47 -50. Rolfe, G., Freshwater, D., Jasper, M. (2001). Critical reflection in nursing and the helping professions: a user’s guide. Basingstoke: Palgrave Macmillan.  So What ? What? So what? Now what? What Now What ? ? So What? The implications of the situation. I knew what was happening was wrong and yet I took no steps to resolve the problem. I should not have allowed factors beyond my control (workforce planning and sickness) to impede my training, my clinical performance and potentially threaten patients safety. I should have alerted senior colleagues to the situation, especially once I started making mistakes. Borton. T. (1970). Reach Touch and Teach: Student Concerns and Process Education. McGraw-Hill, New York. Driscoll J. (1994). Reflective practice for practise. Senior Nurse, 13, 47 -50. Rolfe, G., Freshwater, D., Jasper, M. (2001). Critical reflection in nursing and the helping professions: a user’s guide. Basingstoke: Palgrave Macmillan.  So What What? So what? Now what? ? Now What? The action plan. Now What Helpful questions: Now what... What ?... do I need to do in the future to do better/fix a similar situation/stop being ? stuck?... might be the consequences of this new action?... considerations do I need about me/others/the situation to make sure this plan is successful?... do I need to do to ensure that I will follow my plan? Borton. T. (1970). Reach Touch and Teach: Student Concerns and Process Education. McGraw-Hill, New York. Driscoll J. (1994). Reflective practice for practise. Senior Nurse, 13, 47 -50. Rolfe, G., Freshwater, D., Jasper, M. (2001). Critical reflection in nursing and the helping professions: a user’s guide. Basingstoke: Palgrave Macmillan.  So What ? What? So what? Now what? What Now What ? ? Now What? The action plan. I have learned that I should look to identify situations where poor planning or excessive workload puts staff or patients at risk. With experience and confidence I have learned to speak out against these wrong working conditions. I am also aware of the need to support more vulnerable junior doctors and not ask them to overwork or put themselves or their patients in danger. Borton. T. (1970). Reach Touch and Teach: Student Concerns and Process Education. McGraw-Hill, New York. Driscoll J. (1994). Reflective practice for practise. Senior Nurse, 13, 47 -50. Rolfe, G., Freshwater, D., Jasper, M. (2001). Critical reflection in nursing and the helping professions: a user’s guide. Basingstoke: Palgrave Macmillan. Conclusions At the end of this talk you will: Discuss his/her reflection on a clinical scenario encountered Describe how after reflection he/she would act differently the next time they encounter a similar clinical scenario Identify the benefits of reflection including continuous improvement Describe what a Learning Health System is Discuss the benefits of a Learning Health System Thank You Bibliography 1. https://medicalcouncil.ie/news-and-publications/reports/guide-to-professional-conduct-and-ethics-8t h-edition-2016-.pdf 2. Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000. PMID: 25077248. 3. Dewey, J. (1933). How we think: a restatement of the relation of reflective thinking to the educative process. New York: D.C. Heath and Company. 4. Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford. 5. Rolfe, G., Freshwater, D., Jasper, M. (2001). Critical reflection in nursing and the helping professions: a user’s guide. Basingstoke: Palgrave Macmillan. Reflective Practice Toolkit – Academy of Medical Royal Colleges http://www.aomrc.org.uk/wp-content/uploads/2018/08/Reflective_Practice_Toolkit_AoMRC_CoPMED_08 18.pdf Reflective Practice Toolkit – University of Edinburgh