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An introduction to reflective practice for paramedics

An introduction to reflective practice for paramedics

Reflective practice is an important tool in practice-based professional learning settings where individuals learning from their own professional experiences, rather than from formal teaching or knowledge transfer. It is an important process in continuous professional competency and development. Reflection is nothing to be scared of – we all reflect every day in different forms and about different things.

Learning to be a reflective practitioner includes not only acquiring knowledge and skills, but also the ability to establish a link between theory and practice, providing a rationale for actions. Reflective practice is the link between theory and practice and a powerful means of using theory to inform practice thus promoting evidence based practice (Tsingos et al., 2014). It can be used by both students and qualified paramedics to reflect on their strengths, weaknesses and areas for development.

Reflective practice has many definitions

  • A process of learning and developing through examining our own practice, opening our practice to scrutiny by others, and studying texts from the wider sphere. It is a focusing closer and closer. (Bolton, 2010)
  • An approach to learning and practice development which is patient-centred and which acknowledges the untidiness and confusion of the practice environment (Burns & Bulman 2000).
  • An active process that enables health care professionals gain a deeper understanding of their experiences (Conway, 1996)
  • Reflection is being mindful of self, either within or after experience, as if a window through which the practitioner can view and focus self within the context of a particular experience, in order to confront, understand and move toward resolving contradiction between one’s vision and actual practice (Johns, 2004)

Reflective practice remains a relatively unknown concept in paramedic practice compared to other healthcare professions such as nursing, where it has been embraced as an essential foundation of professional practice and continuous development.

Paramedic associations and regulatory bodies worldwide suggest that all paramedics maintain a personal CPC portfolio, and a reflective journal or diary is an essential part of this portfolio.

How many of us discuss calls and patient outcomes with other practitioners back at base or in the ambulance (aka a call “post-mortem”)?

Hands up!

Quite a few? As I thought – so reflection on practice is not a new concept to Paramedics, but the formal application of it as part of professional development may be.

Putting these reflections down on paper and in a logical, structured manner is what proves difficult to many practitioners. The Gibbs Reflective Cycle is commonly used in nursing, and we also recommend this as an introductory process to paramedics and prehospital care providers, as it allows for a logical pathway for constructing reflective diary entries.

Reflective journals should not be seen as a laborious task required for CPC, and rather for an opportunity to critically reflect upon and develop one’s practice, as well as developing one’s critical thinking skills (Brookfield, 1987). Students in other health disciplines such as medicine, nursing, pharmacy and allied health professionals find reflective journals a useful tool in the reflective process (Constantinou & Kuys, 2013; Koh et al., 2014; Asselin & Fain, 2013)

Gibbs Reflective Cycle

Gibbs reflective cycle is seen as one of the easiest to follow and implement, and is therefore a good starting point for those beginning with reflective practice. Once you are comfortable with the reflective process, you may decide to use another reflective cycle such as those by Kolbs, Johns, Brookfield, Rolfe or Ganshirt. Remember, reflection is a personal activity, and one model will not fill all – feel free to adapt cycles or processes to suit your individual needs. Sometimes, writing down the reflection is helpful in giving structure to your thoughts (Price, 2004).

Once you are comfortable with reflective practice, you will begin to focus on the evaluation, analysis and planning phases in more detail. Your reflections will become more insightful, probing and detailed as opposed to a generalised narrative description commonly seen when beginning reflective diaries. Some authors refer to achievement of this level as critical reflection.

Gibbs (1988)

Description

A description of the call or incident, with relevant details. Remember to maintain patient confidentiality. Don’t make any judgement yet or try to draw conclusions; simply describe the events and the key players. Set the scene! It might be useful to ask yourself the following questions

  • What happened?
  • When did it happen?
  • Where were you?
  • Who was involved?
  • What were you doing?
  • What role did you play?
  • What roles did others play?
  • What was the result?

Feelings

Don’t move on to analysing these yet, simply describe them.

  • How were you feeling at the beginning?
  • What were you thinking at the time?
  • How did the event make you feel?
  • What did the words or actions of others make you think?
  • How did this make you feel?
  • How did you feel about the final outcome?
  • What is the most important emotion or feeling you have about the incident?
  • Why is this the most important feeling?

Evaluation

  • What was good about the event?
  • What was bad?
  • What was easy?
  • What was difficult?
  • What went well?
  • What did you do well?
  • What did others do well?
  • Did you expect a different outcome? If so, why?
  • What went wrong, or not as expected? Why?
  • How did you contribute?

Analysis

  • What can you apply to this situation from your previous knowledge, studies or research?
  • What recent evidence is in the literature surrounding this situation, if any?
  • Which theories or bodies of knowledge are relevant to the situation – and in what ways?
  • What broader issues arise from this event?
  • What sense can you make of the situation?
  • What was really going on?
  • Were other people’s experiences similar or different in important ways?
  • What is the impact of different perspectives eg. personal / patients / colleagues’ perspectives?

Conclusion

  • How could you have made the situation better?
  • How could others have made the situation better?
  • What could you have done differently?
  • What have you learned from this event?

Action Plan

  • What do you think overall about this situation?
  • What conclusions can you draw? How do you justify these?
  • With hindsight, would you do something differently next time and why?
  • How can you use the lessons learned from this event in future?
  • Can you apply these learnings to other events?
  • What has this taught you about professional practice? about yourself?
  • How will you use this experience to further improve your practice in the future?

Kolb’s learning/reflective cycle

Kolb’s learning/reflection cycle is a reflection of the learning styles that Kolb defines (Kolb & Fry, 1975). It consists of 4 stages – planning, doing, reflecting and linking. The key elements of the cycle are:

  1. Plan/Test – here the learner’s interest is captured, and the learning subject or material is established and learning objectives are identified.
  2. Do/Experience – the student constructs knowledge on the subject by exploring through active learning methods such as questioning, observation and interacting.
  3. Reflect – learners provide their explanation of the material that was covered.
  4. Link/Conceptualise – applying the knowledge gained to various different situations and problems.

Kolb & Fry (1975)

Practitioners using Kolb’s cycle self analyse if learning objectives were met – this starts the cycle again at the plan phase. The cycle can however begin at any stage. The learner reviews the learning content, plans study and learning objectives. The learner then studies the material, reflects on what they have learned, and see if they can apply it practically to a number of exercises and problems. If not, then they must reevaluate and start the cycle again. This can also occurred based on a discontinuity – the learner may discover something they do not know, and therefore the cycle begins at the reflection phase. (Boyatzis, 2002)

Ok…I’ve reflected! What next?

Reflection should be a never-ending process. Done regularly, reflective practice will enable you to pay attention to the details of your clinical practice, and your ability to bridge the gap between theory and practice. Bearing this in mind, you will be able to anticipate upcoming situations as being new learning experiences, and in doing so, become a more informed, safer and more skillful practitioner.

Further reading

A practical approach to promote reflective practice within nursing

Becoming a reflective practitioner

Johns, C., Freshwater, D. (2005) (eds.) Transforming Nursing Through Reflective Practice. (2nd Ed.) Oxford, Blackwell Science.

References

Asselin ME1, Fain JA. Effect of reflective practice education on self-reflection, insight, and reflective thinking among experienced nurses: a pilot study. J Nurses Prof Dev. 2013 May-Jun;29(3):111-9. PMID: 23703269.

Bolton, G (2010) Reflective Practice, Writing and Professional Development (3rd edition), California, SAGE publications.

Boyatzis, R.E. (2002). Unleashing the power of self-directed learning; in R. Sims (ed.) Changing the Way We Manage Change: The Consultants Speak. New York, Quorum Books

Brookfield, S. (1987). Developing Critical Thinkers: Challenging Adults To Explore Alternative Ways of Thinking and Acting. Milton Keynes, Open University Press.

Burns, S., Bulman, C. (2000). Reflective Practice in Nursing: The Growth of the Professional Practitioner. (2nd Ed.). Oxford, Blackwell Science.

Constantinou M1, Kuys SS. Physiotherapy students find guided journals useful to develop reflective thinking and practice during their first clinical placement: a qualitative study. Physiotherapy. 2013 Mar;99(1):49-55. PMID: 23219653.

Conway, J. (1996) Nursing Expertise and Advanced Practice.  London, Quay Books.

Gibbs, G., (1988). Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Further Educational Unit, Oxford Polytechnic.

Johns, C. (2004) Becoming a Reflective Practitioner, 2nd edn. Oxford, Blackwell Science.

Koh YH1, Wong ML, Lee JJ. Medical students’ reflective writing about a task-based learning experience on public health communication. Med Teach. 2014 Feb;36(2):121-9. PMID: 24350800.

Kolb, D. A. and Fry, R. (1975). Toward an applied theory of experiential learning; in C. Cooper (ed.) Theories of Group Process. London, Wiley.

Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ Theory Pract. 2009 Oct;14(4):595-621. PMID: 18034364.

Price A. Encouraging reflection and critical thinking in practice. Nurs Stand. 2004 Aug 4-10;18(47):46-52, quiz 53-4. PMID: 15357553.

Tsingos C1, Bosnic-Anticevich S2, Smith L1. Reflective practice and its implications for pharmacy education. Am J Pharm Educ. 2014 Feb 12;78(1):18. PMID: 24558286.

This article was originally published online at http://prehospitalresearch.eu/?p=1550

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