What is reflective practice? The words reflective and practice are accessible and familiar.

Transcription

1 Introduction: What is reflective practice? The words reflective and practice are accessible and familiar. There have been many attempts to define reflective practice. In an article written by Clouder (2000,p.517) the definition of reflective practice is taken from Johns C (1995),where he mentioned that reflective practice is the practitioner s ability to access, make sense of and learn through work experience to achieve more desirable, effective and satisfying work. Wilkinson (1999) referring back to his own article on the same topic in 1996, preferred the definition of reflective practice taken from the Nursing Dictionary: Reflective practice is an active process whereby the professional can gain an understanding of how historical, social, cultural, cognitive and personal experiences have contributed to professional knowledge acquisition and practice. Wilkinson also mentioned that supervision can be used as one form of guidance in the process of reflective practice (1999,p. 36). Reflection as a way of thinking is not new. It is also describe as a tool or an instrument to promote the process of continuous development (Gustafsson and Fagerberg 2004,p. 272). We looked back at the article written by B. Clarke et al. (1996) where they refer to Dewey (1933) who first described reflection as the active, persistent and careful consideration of any belief or supposed form of knowledge (Clarke, James, and Kelly 1996,p.172). Donald Schon was one of the first writers to pay attention to the real difficulty of professional works. In one of his book, written in the year 1983, he recommended, practice across an array of professions had a numbers of characteristics in common. The problems professionals faces are messy, that is they are complex and there are no right or wrong answers, simply best and not so good. The knowledge on which professionals draw is broad, deep and multifaceted. For professionals the context in which they deploy their skills is important and significant. Professional practice cannot be understood in terms of skills alone. Professional knowledge is very difficult to articulate.

2 (Schon 1983). Practice is not a straightforward and rational application of theory. In fact, the knowledge of the practitioner is a substitute of inherent in the action. In practice, the practitioner does not intentionally depend on a series of simple decision-making steps. B. Clarke et al. (1996) suggested practice is based on past experiences interrelated with a particular situation, a process known as reflection-in-action (Clarke, James, and Kelly 1996, p.172). In the moment of practice, the professional practitioner possesses knowledge-in-action. Several articles perceive a gap between theory and practice in healthcare profession. Clarke et al. (1996) suggested that reflective practice may be the remedy for this. The scope of reflective practice is broad but has no specific boundaries. Many articles refer reflective practice as a personal development process and suggest that this affects occupational performance. A key function of reflective practice is the acquisition of knowledge and understanding (Wilkinson 1999). Two kinds of knowledge identified by Schon (1983) which are technical rationality and tacit knowledge. According to Schon, technical rationality is associated with empirical science while tacit knowledge is a way of knowing and understanding that which cannot be articulated, but which guides practice and is linked to experience and expertise (Wilkinson 1999, p.36). Again, by referring to Schon s perception of reflection, he identified two types of reflection; reflection-in-action and reflection-on-action (Milinkovic and Field 2005,p.176). Reflection-in-action is a way of thinking on one s feet simultaneously as practice occurs while reflection-on-action is a retrospective thinking about an experience (Wilkinson 1999,p. 38). Pattison et al. (2000) describe in details what reflection-in-action is and reflection-on action mean. Reflection-in-action is utilising issues such as past experiences, individual values, opinions and expectations on the spot. It has a clinical function in that the knowledge we have is questioned and our action may be reconstructed accordingly. Pattison et al. also stated that reflection-in-action could be classified as critically thinking on your feet.

3 On the other hand, reflection-on-action takes place after the event and needs to be guided so that thinking and practice can be move forward and this is what Ghaye and Lillyman (2000) think of what clinical supervision intends to do. In order for this reflection-on-action to be effective, they suggest a reflective conversation needs to occur. Why is reflection playing such a big role in heath sciences? Or in other words, what are the purposes of reflection? As Ghaye and Lillyman (2000) suggest, reflection has many purposes such as: Reflection act as a bridge from the unspecified knowledge to the considered action, and from the practice world to the process of theory generation. Reflection has enhances the quality of action as it allows individuals to talk about their practice and provide different methods of work which can be tried out. Reflection can increases individual and collective accountability. Reflection allows the practice to be challenged constructively and yet critically. (Pattison, Parsons, and Weatherhead 2000, p.77) Pattison et al. (2000) seen clinical supervision as a process which safeguards standards of patient care, and suggested as an advance health science practice through reflection. They suggested that the objectives of clinical supervision may be seen as follows: To provide support and guidance with issues related to the person an their professional practice. To maintain and improve standards of care in the clinical area. To enhance expertise. To encourage learning through reflection. To provide feedback on clinical practice. To improve communication between professionals. (Pattison, Parsons, and Weatherhead 2000, p.79) By reflecting on standards of practice and given that constructive feedback, practitioner s skills and professional values may well enhanced and clarified. This may then have a positive impact on practice (Ghaye and Lillyman 2000).

4 Reflective practices could be employed in order to discover what knowledge, skills and attitudes health sciences professionals employ, and to what extend they are applied. In nursing field particularly, reflection is often described as a structured means by which relevant practice knowledge may be identified, reviewed and made sense of either individually or in groups, just as in clinical supervision as well. Besides nursing, other health sciences professionals such as physiotherapy, occupational therapy, radiographer and even health sciences educators that involve with clinical supervision has adopted the notion of reflective practice as a desirable and necessary attribute of a competent practitioner. Atkins et al. (1993) highlighted the need for individuals to be open-minded and motivated when reflecting and outlined five main skills helpful for reflection. These are: Self-awareness honestly asking how the individual affected and was affected by a situation. Description the ability to recognise, recollect and describe situations as well as feelings and emotions. Critical analysis challenging assumptions, exploring alternatives and asking the relevance of knowledge in specific situations. Synthesis the mixture of new and previous knowledge in the move towards a new perspective. Evaluation making value judgements involving the use of criteria and standards. (Atkins and Murphy 1993) Nowadays, even the health sciences students are encouraged reflecting on their practice during their clinical placement. Reflection during clinical placement is fundamental if the students are going to learn from the experience. However, by just doing or demonstrates their skills, does not implying the students have understand or ensure their skills has been related to the basic theory that they may have learnt at university (Milinkovic and Field 2005). To encourage reflection while on placement, reflective clinical journal or some institutions call it reflective diary has been introduced in the education of health care. This is part of educational strategies within the clinical setting.

5 Clinical supervision through reflective practice: Clinical supervision in medical imaging profession is increasingly being seen as a necessary and essential part of the development of all radiographers and student radiographers, to assist them in coping with change effectively, efficiently and proficiently. Clinical supervision has the potential to assist radiographer and student radiographers specifically to develop and define theoretical knowledge based on their own practical experience. By actually demanding values, beliefs and assumptions, clinical supervision encourages radiographers and student radiographers to think about their practice in new and different ways and this promotes a deeper understanding about medical imaging field. Given that clinical supervision can be enhanced through reflective practices, it is necessary to provide some understanding of what reflective practice and also what purposes they serve. Reflection on practice is the central component of clinical supervision. Clinical supervision therefore embraces three types of action: Committed action where the participants have strong sense of commitment to learn through conversation or experience, and to enquire into practice. Intentional action where the participants seek to reflect systematically, critically and creatively on practice with the intention of improving thinking, practice and clinical area in some way. Informed action which stems from sustained reflective conversations that enable the participants to be clear about their own motives and professionals values and how both of these guide and shape clinical action (Ghaye 2000,p. 59). Clinical supervisor therefore play vital role in helping students to develop reflective skills. As power role models, one effective way in which they may achieved this desired outcome is by exposing their own reasoning processes and sharing their own experience and knowledge as they inform the decision making process during assessment and treatment session.

6 My initial thoughts about reflective practice: I was first introduced to the concept of reflective practice when I was a third year student radiographer completing my final placement in the medical imaging department. As a student, I always attached to different senior radiographers everyday according to which unit I will assigned to. However, I have my own mentor who supervised, reviewing and helping me with my final portfolio. We talked about her owned experience as a student radiographer before. She told me she used to keep a reflective journal, as part of her portfolio as well. She found it very useful and critically looked at what she was doing (reflection-on-action). This concept has provided her greater awareness and insight into her everyday work, not only during her student days but also after she works as a qualified radiographer. My first attempt to write my own reflective journal was very impromptu. I wrote down only incidents that caused me stress and concerned. The reflections were very much private dialogues with me. Even after I graduated and worked as a radiographer, I still keep my own reflective journal although I often went days or even weeks without actually putting pen to paper. However, at the end of the day, whenever I did reflect, I felt so relief and satisfied. By reflecting the incidents that I encounter everyday, it will explain the five W ives and one H usband concept which is Why, When, What, Who, Where and How does the incident happen. At the same time, reflection is a way to practice critical and lateral thinking. My initial thoughts about clinical supervision then : My journey as a clinical supervisor started back in 2003 after I joined University of Technology MARA, Malaysia as a young lecturer. I was then assigned to supervise a few groups of Diploma student during their clinical placement. I had a limited knowledge and experience in clinical supervision at that time because I was just finished my bachelor degree in Medical Imaging. It was a big challenge for me from the beginning. My vision of clinical supervision back then was based on my personal beliefs and reflected my own positive experiences. The staffs in the department

7 where I sent my students still had these perceptions that I was their former student as well. A lot of obstacle that I have to go through during my early years of involving in clinical supervision. It was very hard to gain their trust, built a new relationship with them, change their mind set and accept me of who I am at that time. Besides adjusting myself with my new career, I also learnt on how to assess my students. During my visit to the clinical place, I felt that there were something lack on how to assess student. I felt that the system needs a slight change on what and how to assess a student. We were not just assessing and critiquing on what the student produce, but in my opinion, the students also need to know why they get low marks or how they should improve their performance during clinical. Another problem that I encounter during my visit was, the way the preceptor evaluate my students. Sometimes the students gained such a high mark although some of them were not performed very well whenever I did my assessment. My final marks contradict with the preceptor given marks. From my observation, most of the preceptors were too busy to assess the students. Sometimes the preceptors just pass their responsibility to junior radiographer who has no experience and lack of knowledge on how to assess students. After such a disastrous start on the road to implementation, I felt that I required reassessing my roles as educator and facilitator in order to make the implementation of clinical supervision a success. Although I had not expected to change the situation overnight, I suggested to my program that we need to make some changes on student assessment system. Together with a few colleagues, we reviewed the system and implement a new system that we adapted from degree program in United Kingdom. We also introduced clinical portfolio and clinical journal to all students. Another step that we took to improve clinical supervision is organising Preceptor workshop once a year. The main objective of this workshop is how to improve the evaluating system and the clinical portfolio itself. We get a lot of positives and some negatives comments from our preceptor. All that were very useful to us by reflecting on what we have implemented in the clinical area so far. I can conclude below on how I feel, my initial thoughts of clinical supervision back then:

8 Confidence I was lack of confident in the beginning because I was lack of knowledge and experience makes me feel inadequate. I need understanding of the skills and processes involved to bridge the theory-practice gap. Sometimes I need someone to tell me I m doing all right. Competence I feel incompetent when I lack of confident in myself. When I involved in clinical supervision, I saw it as my great opportunity to discover my areas of uncertainty, where to start and how to go about improving my practice, also to increase my knowledge. Support I need support in dealing with my anxieties, concerns, demands of practice and other negative aspects of the job, so that I can stand up and go back out to face yet more demands on me. I see support and guidance from my colleagues as the centrality of clinical supervision. Practice practice is about me as an educator. How others see me, how I constantly try to improve myself, to provide the best education and share my knowledge with my students and the staffs in the clinical area. However, I was unable to reflect on my own practice back then, not sufficiently self-critical of practice to allow others to challenge me. Reflection with limited knowledge on reflection, I was unable to reflect constructively. I felt vulnerable and sometimes unwilling to let others to aid. Some of my reflection, likely to be overly self-critical without deconstructing the realities of a situation. Reflections also influence my decision-making process. Values - not capable to say with any clarity what my values are and how they affect my work with students, staffs in the clinical area and colleagues. Challenge to build a new relationship between the staff in the clinical area and myself was a big challenge for me. It was sceptical and sometimes it was very hard to gain trust from them. Also, back then, I was unable to see the relationship between challenge and accountability which relates reflection to the process of justification and validation in my decision making process. My perspective of clinical supervision now : Clinical supervision for me has been a positive experience so far; personal and career development that has increased my self-awareness and also improved my self-esteem. Critically

9 deconstructing incidents that has given me both joy and stress; asking myself why I did it the way I did; discovering alternative methods of working and shared all these thoughts with my colleagues, my students and the staffs in the clinical area, has better prepared me to interact with others. For me, the key to be success in clinical supervision is clearly by reflective practice. I believe that, if clinical supervision is to be effective and efficient, the students and the clinical staffs need to be self-directing and able to sustain their own reflection in order to build up a new level of awareness of themselves as people and of their work. This, I believe, will be a crucial aspect when training others to take on the role of clinical supervisor as well. As an educator in medical imaging field and involved directly with the clinical supervision, is a demanding as well as a joyful and satisfaction occupation. As for me, I frequently discuss and reflect on my own action in order to seek guidance and support from my senior colleagues. In my opinion as well, clinical supervision can offers more formal approach that acknowledges the heavy demands of radiographers, facilitates reflective practice and encourage a continuous striving improvement in the medical imaging field. I experienced so far, clinical supervision help me a lot to make sense of what I do and why I do it and so enables me constantly to push forward my professional boundaries. With my newfound knowledge of reflective practice, I feel now that I can challenge attitudes and question assumptions and show that using reflection the rewards far outweigh the discomfort. I can conclude below on how I feel after applying reflective practice in my clinical supervision experience now: Reflection I strongly believe reflective practice is the key to effective clinical supervisions. This must be self-directed yet shareable with my clinical supervisors which are my colleagues. I also believe that reflection develops a new level of awareness of myself as a person and my needs, gives me a vision on how to improve my work and allows me as an individual to learn and to grow. Being able to reflect constructively on my practice help me to deconstruct and reconstruct in a proactive way.

10 Values now I realise what my values are and understand the kind of professional I would like to become. I believe my values will affect the quality of supervision I will give. Support I believe that it is appropriate for professionals to seek advice from one another and to challenge practice, so can creating a culture of reflection on practice. I supposed there must be a formal structure in place within an organisation to support clinical supervision. This then ensures that boundaries are appropriately set and that supervisors or preceptor and supervisees or the students are clear about the nature of those boundaries. Besides, a framework that is approved by the organisation gives credibility to the notion of support for supervision within a busy operational area. Practice I am now more stronger in justification of my practice as a result of my questioning process and I am therefore able to rationalise clearly and accurately of what I am doing and why. Competence for me, there is no such thing as absolute competence but that a radiographer or clinical supervisor or student can be more or less competent depending upon their level of skills and experience. Influences my colleagues are my great influence and my personal clinical supervisor. I seek them out to help me grow and mature. Knowledge without my realisation, reflective practice does improved my knowledge in one way, and a better understanding on how to help others accept the concept of clinical supervision. Knowledge that I gained so far bridge the theory-practice gap that I initially experienced.

11 Conclusions: In working with our colleagues, we have found that some important areas for discussion and reflection in the clinical context which include: the analysis of critical incidents the review of workload a constructive critique of standards of care Supports of personal concerns. If reflection is to be of any use, the individual (or group) being supervised needs to be able to recount experiences honestly. A safe and supportive context needs to be created. For some, the asking and responding to key questions helps in re-telling and re-experiencing. Some of the questions suggested by Pattison et al. (2000) that might help in this process are: What did I/we do? Why did I/we do it like this? How has it come to be this way? How can I/we improve it? What serves to inhibit or foster this intention? Undertaking clinical supervision require a high degree of commitment from staff at all levels. Such commitment will be both practical and theoretical. Practically, in terms of the willingness to spend times and effort. Theoretically, there has to be a belief in the effectiveness and benefits of a supervisory system. All staff must be prepared to look critically at the quality of their own practice. Clinical supervision has the potential to be a powerful learning process. It is essential, therefore that it is used with sensitivity and understanding. Clear boundaries and safeguards are needed to protect both supervisors and supervisees. It is important that the extent and limitations of confidentiality are clarified and agreed. An understanding of what does and does not fall within the scope of clinical supervision must also be established. It would appear that promoting reflective practices through clinical supervision is the

12 way forward if we wish to have thoughtful, accountable and safe practitioners. With regards to reflective practice, some practitioners looked at it as a habit they employ naturally and in which they do not need guidance. A concept map is a very useful tool to illustrate our own personal thinking. It is a way of describing on paper, what it is that we are thinking. They reflect some big ideas or concepts and the links or relationships between them that we have in our minds. They are, then, mind maps that we can use to help us to reflect on things. One very beneficial concept map that created by Pattison et al. (2000), can be adapted here, showing some links between reflection, clinical supervision and related ideas. Aims to safeguard standard through critically analysing incidents Changing practice at the time Clinical supervision reflecting-on-action practice Values Theory Practice Values Theor y Reflection-in-action Changing our theory of practice Using clinical supervision with reflection to look both forwards and backwards in order to change practice and theory

13 The map showed some important messages. We can see the multiple and important roles of reflection are drawn in. The interactive relationship between practice and theory was seen highly significant. Theory is inseparable from practice. The cognitive processes of critical analysis raised so much discussion. This was a particularly valuable feature of the concept map, as much has been written in a lot of reflective practice literature review which leads to the clinical judgement and effective healthcare interventions (Ghaye and Lillyman 2000). Reflection-in-action and clinical supervision (reflection-on-action) both supported a single aim, that is to maintain and safeguard standards of patient care in clinical settings. Critical analysis of practice fuelled these reflections. Critical analysis also needed to be applied to our professional values, theory and practice. This was seen as essential in developing competence, safe practice and accountability. Wilkinson J summarised in his article written in 1999, the main issues that need to be considered when engaged in reflective practice: Complement technical rationality knowledge by using reflective practice to access tacit knowledge. Reflection does not occur simply by knowing about it. However, it depends on active strategies such as reflective writing in diaries or portfolios, and/or clinical supervision with or without the use of a model of reflection. Supervision by peers appears to be the most effective form of clinical supervision to facilitate reflection. Reflection can successfully occur before action, in action or on action. All experience should be considered as a potential precursor to reflection particularly habituated experiences. Reflective practitioners need to differentiate between that which is reflection and that which is recollection. Reflective practice should encompass critical analysis of personal self-awareness and the social context of health and health care.

14 Caution should be expressed about the ethical challenges of becoming a reflective practitioner in relation to enhancing self-evaluation and confidentiality. (Wilkinson 1999, p.39)

15 References: Atkins, C., and K. Murphy Reflection: a review of the literature. Advance Nursing 18: Clarke, B., C. James, and J. Kelly Reflective practice: reviewing the issues and refocusing the debate. Nursing Standard 33 (2): /08/07). Clouder, L Reflective Practice: Realising its potential. Physiotherapy 86 (10): (accessed 15/08/07). Ghaye, T The role of reflection in nurturing creative clinical conversations. In Effective Clinical Supervision - The Role of Reflection, ed. T. Ghaye and S. Lillyman, 126. Mark Allen Publishing Ltd. Ghaye, T., and S. Lillyman Reflection : principles and practice for healthcare professionals: Mark Allen Publishing Ltd. Gustafsson, C., and I. Fagerberg Reflection, the way to professional development? Journal of Clinical Nursing 13 (3): /08/07). Johns, C The value of reflective practice for nursing. Journal of Clinical Nursing 4: Milinkovic, D., and N. Field Demystifying the reflective clinical journal. Radiography 11: /08/07). Pattison, D., D. Parsons, and C. Weatherhead Connecting reflective practice with clinical supervision. In Effective Clinical Supervision - The Role Of Reflection, ed. T. Ghaye and S. Lillyman, 126. Mark Allen Publishing Ltd. Schon, D. A The Reflective Practitioner: How professionals think in action. New York: Basic Books. Wilkinson, J Implementing Reflective Practice. Nursing Standard: