Last year
(2013) as my thank you for the BAPIO Award for “Outstanding contribution to the
health services in the NHS and abroad” I had put together the compendium of my
reflective writings over the last 25 years in the NHS (download here www.leadershipforhealth.com)
It contains my writings on various aspects of health services (not my research
publications) and range from a one pager to very substantial documents like the
Milroy Lecture. Now it was not until much later, years after I started writing,
that I realised that what I was doing was reflection – the term reflective
practice was not much in use then and indeed even now. I sort of fell into it,
mainly as a way of improving my writing skills which were (are) essential for
public health practice, and once I got the ‘bug’ I kept going and tackled
increasingly complex subjects including my observations on medical leadership
and about my time as the GMC Council member. I had discovered that writing made
me think and make sense of what I had observed or done and most importantly how
I could improve.
The
publication of the compendium has provided further impetus and I now want to
find out more about reflective practice. I realised that I had approached the
subject back to front. Until very recently I had very limited knowledge of the
theory of reflective practice and I basically did what I felt like! I did not
know ‘Reflection on Action’ from ‘Reflection in Action’.
The
definition that I find useful now is from Boud et al who define reflection as
‘‘a generic term for those intellectual and affective activities in which
individuals engage to explore their experiences in order to lead to a new
understanding and appreciation’’ (p. 19). Schon introduced the concept of the
‘‘reflective practitioner’’ as one who uses reflection as a tool for revisiting
experience both to learn from it and for the framing of murky, complex problems
of professional practice. (from 1)
Simply put, critical reflection
is the process of analysing, questioning, and reframing an experience in order
to make an assessment of it for the purposes of learning (reflective learning)
and/or to improve practice (reflective practice). (2)
Now, you must wonder why I am
being so self-indulgent, and what does it mean for clinicians.
In this regard, this analysis
probably sums it up
“If we take the example of a
medical mistake, a superficial, educationally ineffective reflection will
consist of a description of the events or a description accompanied by reasons
such as the team/clinic was busy and other people failed in their responsibilities.
A more useful and deeper reflection would include consideration of how and why
decisions were made, underlying beliefs and values of both individuals and
institutions, assumptions about roles, abilities and responsibilities, personal
behavioural triggers, and similar past experiences (‘‘when pressed for time, I
. . . ’’), contributing hospital/clinic circumstances and policies, other
perspectives on the events (frank discussion with team members, consultation of
the literature or other people who might provide alternative insights and
interpretations), explicit notation of lessons learned and creation of a
specific, timely, and measurable plan for personal and/or system change to
avoid future similar errors. Effective reflection, then, requires time, effort
and a willingness to question actions, underlying beliefs and values and to
solicit different viewpoints. This ‘‘triple loop’’ approach moves beyond merely
seeking an alternate plan for future similar experiences (single loop) or
identifying reasons for the outcome (double loop) to also questioning
underlying conceptual frameworks
and systems of power.” (2)
In essence,
reflection is the basis of patient safety and is about learning from mistakes
and putting things right. It is a bit like the “5 Whys’ approach to
investigating incidents whereby one keeps asking why at each stage of
questioning until you understand the root cause.
Now, look at
your, and others, practice- how far up this triple loop scale are you? When you
make notes after CPD are you being critical/reflective enough? Is revalidation
in danger of becoming a tick box exercise? Are we really doing enough for
patient safety – do we know the root causes in our settings and are we
addressing them, and why not? Are we ‘learners’ and able to constantly innovate
and improve?
These are
some fundamental questions facing us as doctors. We have to provide the
leadership in these challenging times in the NHS, and central to being a leader
is insight, self-awareness and ability to reflect and learn. In any case, the
future of medicine is self- and life-long learning, and without a good
grounding in reflection it will be difficult to cope with increasingly
demanding jobs.
So what
could/should we do – can we do something together? Do you think we need more
reflective practice in the NHS? Can you help me in my journey? Can
I help you? Shall we form a group – virtual or real – to develop this further?
I will be
very interested to hear from you- contact me at rajan.madhok@btinternet.com
RAJAN MADHOK
16 JULY 2014
1) Mann K, Jill AE, Macleod A. Reflection
and reflective practice in health professions education: a systematic review.
Adv in Health Sci Educ (2009) 14:595–621
2) Aronson, L.
Twelve tips for teaching reflection at all levels of medical education. Medical
Teacher 2011; 33: 200–205
