Introduction

Reflection is a process that is acknowledged as being fundamental to skilled clinical practice for healthcare professionals. However, the value and application of reflection is widely debated. In some instances, reflection is just seen as the completion of a portfolio submitted at the end of a period of learning; however, it is argued here that reflection should be much more – an attitude or approach that enhances professional development and practice. This chapter aims to introduce physiotherapy students and physiotherapists to the concept of reflective practice, including definitions of reflection and the rationale for reflection in practice. It then highlights the key processes and important principles involved in reflection. It concludes by discussing ways to reflect, including tools and models that can be used to explain and encourage reflection.

This chapter is built around Salford physiotherapy graduates’ views on reflection and becoming reflective practitioners in the real world. Consequently, the emphasis of this chapter is on how to successfully start to analyse practice. Ideally reflective practice should involve an emotive, as well as technical element; however, the consideration of ‘feelings and emotions’ is also frequently cited by physiotherapy graduates as a barrier to initial engagement.

This chapter aims to engage physiotherapists who are new to these concepts by giving them a toolkit to begin, and develop, as reflective practitioners. Becoming a reflective practitioner is an essential life skill for all physiotherapists. Skills of reflexivity – being able to think about and critically analyse experiences and understand their meaning – is important in becoming more proficient in practice. Reflecting on day-to-day experiences helps professionals to ‘think through’ decisions that have been made with respect to say a particular patient case or work scenario. This is essential in new or novel situations – which for the student practitioner will be most of day-to-day practice to begin with.

Defining reflection

There are numerous definitions of reflection, a selection are provided below.

Reflection is a form of mental processing – like a form of thinking – that we use to fulfil a purpose or to achieve some anticipated outcome. It is applied to relatively complicated or unstructured ideas for which there is not an obvious solution and is largely based on the further processing of knowledge, understanding and possibly emotions that we already possess (Moon 1999).

It is clear from the numerous definitions of reflection that people develop personal and individual views of what reflection is; this is influenced by factors such as disciplinary background. The differences in terms used, interpretation and perspective can result in confusion; however, there are clear commonalities and overlap within the work of different authors on the subject. In its simplest form, reflective practice is a process of thinking about and analysing an experience or set of actions. In this case, it would relate to a work scenario or situation. There are many tools that can help processes of reflection, such as keeping reflective logs or diaries, which will be discussed later in the chapter; this is common practice with many other disciplines, such as nursing and sports coaching (Knowles and Telfer 2009).

Knowles and Telfer (2009: 24) make it clear that reflective practice is not just a process of thinking where you literally ‘go round in circles’, but a cognitive process which encompasses ‘deliberate exploration of thoughts, feelings and evaluations focused on practitioner skills and outcomes. The outcome of reflection is not always preparation for change, or action based, but perhaps confirmation/rejection of a theory or practice skill option’. This description gives the process of reflection a feeling of trajectory where the individual undertaking the reflection ends up in a different place from where they started, whether through new understanding of practice, new knowledge or both. This process of moving forward is crucial in gaining a better understanding of effective practice. Understanding what is not working well in a service, process or any practice situation is just as important as identifying positive practice – it highlights what needs to change.

For further reading on the topic of reflection and reflective practice see Ghaye (2005), Moon (1999) and Schon (1983).

Clinical reasoning and evidence-based practice

A common characteristic of students, and even new graduates, is that they may display knowledge but cannot always apply it in practice. In other words, they struggle with what is known as clinical reasoning.

As it can be seen it is therefore obviously not something that can come from absorbing.

In order to develop clinical reasoning, novice practitioners first need to acquire a large amount of biomedical knowledge. It is then often assumed that once acquired, and simply with repeated practice, they will then be able to make appropriate links between different aspects of that knowledge. This is usually not the case; hence the difficulties seen in application.

As Higgs and Jones (2008) state, clinical reasoning relies on the integration of three key processes in order to be successful (Figure 5.1).

This last component, meta-cognition, is considered the integrative link between the other two areas. Reflecting on practice takes place within the meta-cognitive domain.

The necessity of this integration is because of the fact that no situation will be like another: each clinical encounter will be unique. It is therefore important to consider all aspects of the experience in order to develop skills (cognitive and knowledge) for the next time. Failure to follow through these lines of inquiry will result in potential errors in the conclusions and plans drawn.

Applying the above concepts to a real world physiotherapy context, for example the painful shoulder

A client’s problem could be physical, psychosocial or a combination of these; it could be derived from a number of different origins and could be acute, chronic or an acute flare up of a chronic problem. The first time you are faced with this diagnosis the conclusions you draw might be ineffective or incorrect because of either a limitation in your knowledge base, problem-solving skills or limitations in your interaction with the patient for a variety of reasons. If you fail to reflect on the conclusions regarding a diagnosis and/or treatment plan then you are destined to make them again, even if they are not effectual. Likewise, if the conclusions you draw are correct you need to analyse how you came to them in order to perpetuate this with future patients. This is about understanding ‘what works well and why’.

It might, therefore, be assumed that the very first time you treat a condition your reasoning will be purely knowledge based. However, this is not the case as certain people will have previous experiences, have read different sources of material, and observed other clinicians. It is this individuality that also requires analysis and reflection after the experience so that it can be utilised and developed for the future.

Novice practitioners tend to use what is often known as hypothetico-deductive clinical reasoning (Jones et al. 2008). This is where hypotheses (initial impressions) are systematically tested out in order to reach a logical, diagnostic conclusion. This requires a significant cognitive demand, tends to focus primarily on physical impairments and may still result in the actual reason for presentation being elusive. By contrast, an expert is said to be someone who is perceived to be ‘capable of doing the right thing at the right time’ (Jensen et al. 2008: 123) – their method of clinical reasoning will be different in that it is based on pattern recognition (colloquially termed ‘patient mileage’) with not only large numbers of possible hypotheses considered but various other components of the individual patient and context taken into account. These include the patient motivations, reasoning based on the rapport and collaboration with the patient, envisioning the future and considering ethical implications (Jones et al. 2008). While seemingly more complex, this process actually requires less cognitive demand at the time of assessment.

The difference between the novice and the expert’s clinical reasoning skills is, in part, because of an increased depth of knowledge but also how that knowledge is manipulated. This cannot be achieved through repetitive practice, but rather practice-analysis (reflection) and the re-practice (Boshuizen and Schmidt 2008). In other words, if you do not learn from your experiences you will never develop expertise. Non-reflective clinicians will have a tendency to only look for, and over-emphasise, certain signs and symptoms, disregard others which do not concur with their preconceived ideas and form conclusions which do not consider the individual; in other words, they are not patient-centred. This can result in substandard care for that individual. This occurs most commonly when less experienced practitioners try and ‘mimic’ expert clinical reasoning without fully understanding the processes necessary to truly achieve expertise.

It is interesting to note, however, that to an expert, who has been reflective, routine clinical practice will actually be relatively non-reflective unless the situation is novel to them. In this instance, however, it should be remembered that their role and responsibilities will be such that they will have many other activities that they will need to reflect upon, such as leadership/team-management, service development and research, which may be deemed as higher practices.

There can be a perceived tension between the drive toward developing the scientifically researched evidence base for physiotherapy practice and the value of professional knowledge developed through experience. Much has been written previously on the processes of reflective practice as being part of a continual learning cycle (Ghaye 2005). Students are taught from an evidence base of ‘what works’, but the literature is often not complete or not relevant for the working context, so experiential learning ‘from practice’ and evaluation of that practice is required in order to understand what processes and interventions work best in order to develop clinical reasoning skills.

National and local guidelines/protocols that are based on the best available evidence at any time are designed to ensure consistent high quality care of patients. However, there can be a tendency, as a clinician, to simply follow that guidance without questioning. Firstly, in reality clinicians need to be critical of the evidence itself as it is of varying quality. This is why undergraduates are shown how to evaluate the quality of evidence and this skill requires continued practice once qualified to ensure the application of the most appropriate theory to practice. Secondly, consideration of the evidence/protocol/guideline needs to be taken in the context of individual practice (see below).

Example

Mental practice of upper limb movement following a stroke

In the Royal College of Physician’s national clinical guidelines for stroke (Intercollegiate Stroke Working Party 2008:76) ‘Patients should be taught and encouraged to use mental practice of an activity as an adjunct to conventional therapy, to improve arm function’.

As a clinician should you therefore assume that you should be using this with every patient you encounter who has had a stroke? This recommendation was based on a single paper and therefore this recommendation needs to be considered in the context of the quality/quantity and transferability of the evidence it was based on, for example sample size, the part of the population it was conducted on (generalisability), etc. and also your own knowledge, experience and skills, and, most importantly, your patient’s needs, goals and biopsychosocial abilities.

Additionally, as a clinician you need to be critical of current practice and may be working in a brand new or extended role (Figure 5.2). In this case, gaps in the literature base and/or your own experiences of implementing current practice may generate further questions for ongoing research. As Dugdill (2009:49) previously stated:

The advancement of a professional role requires that profession to be committed to the continual ‘development of thinking’ – both generating and testing new knowledge – in order to improve the delivery, and hence impact, of the role. Sometimes professional practice may involve trying new things, being innovative and challenging the boundaries of existing practice. This may be especially relevant when a client fails to respond to a tried-and-tested approach and the practitioner feels the need to try something different.

Therefore, reflective practice should be seen as a central process for both continuing professional development (CPD) and evidence-based approaches, both of which are fundamental to high quality professional practice. Without all these described processes being in play you will not be able to achieve your full potential as a physiotherapist remembering that ‘clinical reasoning and clinical practice expertise is a journey, an aspiration and a commitment to achieving the best practice that one can provide’ (Higgs and Jones 2008: 9).

For further reading on these topics please refer to Higgs et al. (2008).

Requirements for reflective practice

Becoming an effective reflective practitioner is now an expected requirement of all health professionals in order to drive continued improvement in practice and allow the interface between theory and practice to be constantly analysed by the professional.

In order to practice as a physiotherapist within the UK, practitioners must hold registration with the Health and Care Professions Council (HCPC). HCPC standards ensure that all health professionals must continue to develop their knowledge and skills in order to maintain registration. These standards (HCPC 2006) state that registrants must:

The HCPC states that physiotherapists must participate in ‘a wide range of learning activities through which health professionals maintain and develop throughout their career to ensure that they retain their capacity to practise safely, effectively and legally within their evolving scope of practice’ (AHP Project 2003: 9). The use of reflection is identified as one of the key activities, especially in learning from practice in the workplace. The recognition of learning requires a process of reflection and evaluation and it is this process that can prove difficult. Yet, reflecting on workplace practice after it has occurred is integral to workplace learning. It enables subconscious thought to be critically examined, evaluated and articulated. It also allows theories from formal programmes of study to be connected with and integrated into practice.

The physiotherapy graduates discussed how, as well as reflective practice being a mechanism to consider practice, collecting evidence of the process was often the only evidence of learning and achievements. It’s a way of ‘monitoring you along a timeline’ (Student 3) and ‘a way of fulfilling your portfolio requirements’ (Student 3).

Use of reflection as A form of assessment

Undergraduate and postgraduate physiotherapy programmes commonly use reflection as a component of assessment; this can be formal, summative assessment or more informal, formative assessment. Because the work is being produced for an external reader who will make a judgement about the ‘quality’ of that reflection and often give it a mark, the nature and content of the reflection will, inevitably, be altered. There is much debate within the literature regarding the effects of assessment on the development of honest and truthful reflection. A student, knowing the reflective essay or portfolio is to be assessed, will frame the written response to make them (and their practice/expertise) appear in a positive light; hence, the ‘messy reality’ and mistakes of practice may be lost from the reflective account. Some argue that reflection and assessment are incompatible (Hargreaves 2004); however, many practitioners will admit that without the external motivation that assessment provides, combined with the formal training and feedback received through the process, they would not have devoted the time and energy to developing the skill. Even the use of ‘I’ within academic writing can be seen as controversial in academic settings; traditional academic assignments require writing in the third person and discourage the expression of personal or unsubstantiated comment (Lindsay et al. 2010). The following quotes from physiotherapy students and graduates highlight the debate and motivations for undertaking assessed reflection:

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