Examination of the truth
It isn’t enough to think ‘I did that OK’; professionals need to give the process of reflection authority and value
[ Words: Will Peakin ]
Earlier this year, the General Dental Council and eight other healthcare regulators published a joint statement on the importance and benefits of being a reflective practitioner. The organisations’ chief executives signed a joint statement which outlined the processes and advantages of good reflective practice for individuals and teams.
Reflection is the process whereby healthcare professionals assess their professional experiences – both positive and where improvements may be needed – recording and documenting insight to aid their learning and identify opportunities to improve. Reflective practice allows an individual to continually improve the quality of care they provide and gives multi-disciplinary teams the opportunity to reflect and discuss openly and honestly.
The statement made clear that teams should be encouraged to make time for reflection, as a way of aiding development, improving wellbeing and deepening professional commitment. Chief executives of nine regulators – the General Chiropractic Council, General Dental Council, General Medical Council, General Optical Council, General Osteopathic Council, General Pharmaceutical Council, Health and Care Professions Council, the Nursing and Midwifery Council and the Pharmaceutical Society of Northern Ireland – have all signed the statement.
“Reflection plays an important role in healthcare,” said Ian Brack, Chief Executive and Registrar of the GDC. “It brings significant benefits to patients by fostering improvements in practices and assures the public that professionals are learning from the challenges they encounter – and seeking to improve.
“Our recent research on CPD highlighted the importance of multi-professional teams coming together regularly to reflect when things go wrong and when things go right, and this is one of the things that we are going to be seeking views about when we consult on the future of lifelong learning for dental professionals in the early part of this summer” [See Meaningful milestone, p26]
The joint statement by the regulators reinforces the view that reflection is a key element of development. It also makes clear that patient confidentiality is vital, and that registrants will never be asked to provide their personal reflective notes to investigate a concern about them. Guidance is given on how to get the most out of reflective practice, including having a systematic and structured approach with proactive and willing participants. It makes clear that any experience, positive or negative and however small – perhaps a conversation with a colleague – can generate meaningful insight and learning. Multi-disciplinary and professional team reflection is viewed as an excellent way to develop ideas and improve practice.
How can reflection help dental professionals?
As well as reinforcing how reflection can help dental professionals to gain insight into their whole practice, the statement highlights the direct impact it can have on improving services and patient care. It endorses the value of dental teams reflecting as a group and in multi-professional settings, to help develop ideas that can bring about positive change in practice. As part of this, it makes it clear that employers should encourage their teams to make time for reflection as a way of aiding development, improving wellbeing and deepening professional commitment.
Reflection is now common practice among dental professionals and will help to foster improvements in your dental practice and services. It can demonstrate how patient feedback and complaints are listened to, and acted upon, in the dental practice setting, as well as assure patients that the dental team is continuously learning. It encourages professionals to “remember to reflect on things that go well, alongside things that don’t go to plan”.
Jessica Rothnie, a policy manager at the GDC, who was involved in the roll-out of the Enhanced CPD scheme and in the formulation of the statement on reflective practice, acknowledged that there was a need for more guidance around what reflective practice should cover and what form it should take.
“Professionals need more guidance and help on how they reflect and how they do it effectively,” said Jessica. “Absolutely, I think there is a gap there and part of the CPD consultation is building up more information around the concept.”
As part of that process Janet Hayes-Hall, the GDC’s Clinical Dental Adviser, is publishing a series of blogs over the summer. “As the recent publication of the joint statement attests, health regulators now consider that reflection is an essential aspect of clinical practice,” said Janet. “For dental professionals, it might feel as though ‘reflection’ has worked its way into our lexicon in recent years as a relatively new concept.”
But, she added, reflective practice has a long history. John Dewey, a philosopher and educator addressed this issue as far back as the late 1890s. He described reflection as “active, persistent, and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it, and the further conclusions to which it tends”. While there have been many interpretations and variations in the wording since, Janet believes that his first considerations remain the core to reflective practice.
She points to the academic author and editor Gillie Bolton who observed: “I have come to realise …. that reflection is not a cosy process of quiet contemplation, it is an active, dynamic, often threatening process which demands total involvement of self and a commitment to action. In reflective practice there can be nowhere to hide.”
Janet Hayes-Hall’s interpretation is that reflection is expected to support deep, rather than strategic or superficial learning. This means that the reflective process should help professionals to remember and embed new practice, learning or behaviours into their clinical or practice repertoire.
“However, in my experience with many dental professionals, reflection is often considered to be a ‘cosy’ process such as thinking that a procedure went well, or ‘those crowns looked great’. I have also found that dental professionals are unclear as to what they ‘should’ be doing to reflect effectively. For example, when I have asked a dentist for a piece of reflective writing I have been presented with a formal essay or cut and paste items from a textbook or journal document. But, while it’s good to see there is genuine enthusiasm for the subject matter, I am often disappointed that real learning hasn’t been demonstrated. Ultimately, the reflective process has been missed.
“Perhaps this is because when asked to reflect in a more formal sense, dental professionals get stuck. I suspect a huge number of dental professionals actually ‘reflect in action’ on a regular basis, a phrase first introduced by Schon in 1991. In other words, we think on the go: we may determine that we will use a different product next time because the one we are using hasn’t produced the appropriate colour, fit or shade, or we will use a different technique because of something learnt on a course. These actions or thoughts may be reflective in nature, but is this what reflection is really all about?
“Looking back on Dewey’s definition, he states that reflection is the ‘active persistent and careful examination of the truth and the facts that surround it’. I think that ‘active’ is the key word here. Active means we should engage with the process, that we need to do something. It isn’t really enough to just think ‘Oh that went well’ or ‘I did that ok’. We need to do something more to give that process of reflection some authority and value.”
What the literature says about reflective practice
CPD and reflective practice are interrelated: reflection can enhance the benefit of CPD, and reflective approaches to practice can be promoted by CPD. Reflective practice is prominent within the most current CPD schemes and revalidation processes (UK solicitors, UK engineers, UK pharmacists, Ontario pharmacists and others).
Key points are:
- It is argued that the ability to reflect is not inherent and practitioners may need to be educated on how to reflect. This ability increases over time and with practice.
- The impact of reflection-on-practice is enhanced when it is undertaken willingly and shared with colleagues. Peer learning, group learning, mentoring and appraisal enhance the professional’s ability to reflect on their practice.
- Portfolios can be used to record learning experiences and promote reflection. Portfolio-based learning is used, for example, with UK doctors and Ontario pharmacists. Questions remain as to whether current CPD systems really foster reflective practitioners. The portfolios and other reflective exercises included within the CPD schemes have to be real opportunities for practice improvement and not just a ‘box to tick’ exercise within the CPD scheme.
Source: A Review of the Literature on Continuing Professional Development (CPD)
Executive Summary (commissioned by the GDC) January 2019.
Joint statement: https://www.gdc-uk.org/professionals/cpd/reflective-practice
Other useful links