Clinical Judgement and Patients Preferences overlooked components of EBP Education? How Might Reflection Help?

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1 Clinical Judgement and Patients Preferences overlooked components of EBP Education? How Might Reflection Help? Dr Chris Bulman Faculty of Health and Life Sciences Oxford Brookes University

2 Evidence Based Practice Sackett et al ( ) have defined EBP for medicine as: the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

3 Connected with improving quality of care Critiquing, synthesising and applying research to practice. Clinical expertise - emphasises the importance of clinical know how and judgement to the process of EBP. Individual preferences and choices of patients

4 External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into the clinical decision. Sackett et al. ( )

5 How do we develop clinical judgement and ability to be responsive and sensitive to patients? Need ways to help students develop their clinical judgement and responses to individual patients, as well as their ability to understand and use empirical evidence. Repertoire of practice building up and valuing Motivation to learn through experience Ability to work with uncertainty, complexity, conflict and lack of evidence Drawing on knowledge in different forms Critical Thinking and Reflection useful especially in dialogue because this makes it more critical

6 Most daily nursing decisions are made using a variety of knowledge (Mantzoukas 2007) There are many different approaches to knowledge generation (Kitson 2002) Research (RCTs but also nonexperimental) Policy/protocols/guidelines Experiential Personal Patients/Stakeholders Practical Aesthetic Ethical/Moral

7 REFLECTION Reflection involves reviewing experience from practice so that it can be described, analysed and evaluated. We can then use this to inform and change future practice (Bulman 2013) Reflection also involves sharing one s practice with others; this takes courage and open-mindedness and means that we need to be willing to take on board and act on constructive criticism (Dewey 1933) Simply put - Reflection is a process of making sense of experience in order to move on and do better as a practitioner. (Bulman et al 2012)

8 THE REFLECTIVE PROCESS A period of thinking (reflection) to examine often complex experiences or situations. This allows us to make sense of an experience, perhaps to liken the experience to other similar experiences and to place it in context. Faced with complex decisions, thinking it through (reflecting) allows us to separate out the various influencing factors and to come to a reasoned decision or course of action Clarke and Graham (1996:26)

9 Gibbs Reflective Cycle (1998) updated in Bulman and Schutz (2013) Description- What Happened? Final Evaluation and Action Plan What would you do differently? What were your Feelings and how did you react? Conclusion What have you learnt from reflecting on this experience? Critical Analysis What sense did you make of the experience? Initial Evaluation of the experience What was good and bad about it?

10 There has to be an attempt on the part of students seriously to come to know the world and to understand the self as a constituent of that world; there has to be a propensity to form an evaluation of both the world and the self; and there has to be a willingness to engage in the world so as to effect changes that are not purely instrumental. When all three exemplifications of the critical spirit are together thought, action and self - we are in the presence of critical persons. Barnett (1997:87)

11 We should encourage students to: Critically think about their practice Learn from their experiences Make sense of their experiences Come to understand the effects of their practice

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13 The personal- practical knowledge acquired through reflective learning that mediates healthcare delivery and that cannot be pinned down completely in protocols and procedures needs to be captured and developed. Hyde (2009:119)

14 A professional encounter with service users in health and social care settings is a unique situation which requires the professional to draw upon a vast range of knowledge and experience. The uniqueness of each encounter may be compared with the infinite varieties of patterns seen in a microscope view of snowflakes. McCarthy et al. ( )

15 Models for Good Practice? Finding ways to: Develop students self-knowledge and self assessment activities Develop competency in using research evidence to inform practice Encourage students to think critically about EBP and ALL its components Model critical thinking and reflective skills Develop ways to promote dialogue fostering analysis of clinical situations and decision making

16 REFERENCES Barnett, R. (1997). Higher Education: A Critical Business. The Society for Research into Higher Education and Open University Press. Buckingham. Bulman, C. and Schutz, S. (2013) Reflective Practice in Nursing (5 th Ed.) Wiley-Blackwell: Oxford Bulman, C. (2013) An Introduction to reflection. In: Bulman, C. and Schutz, S. (2013) Bulman, C., Lathlean, J. and Gobbi, M. (2012) The concept of reflection in nursing: Qualitative findings on student and teacher perspectives, Nurse Education Today 32 (2012), pp. e8-e13 Brookfield, S. D Developing Critical Thinkers. Challenging Adults to Explore Alternative Ways of Thinking. Jossey Bass, San Francisco. Clarke, D.J. and Graham, M. (1996) Reflective practice, the use of reflective diaries by experienced registered nurses. Nursing Review. 15, Autumn, (1): Dewey, J How We Think: A restatement of the relation of reflective thinking to the educative process. DC Heath and Company, Massachusetts. Freshwater, D. and Stickley, T. (2004). The heart of the art: emotional intelligence in nurse education. Nursing Inquiry 11(2):

17 Hyde, A. (2013) Thoughtpiece: Reflective endeavours and evidence-based practice: directions in health sciences theory and practice. Reflective Practice: International and Multidisciplinary Perspectives. 10:1, Kitson, A. (2002) Recognising relationships: reflections on evidence based practice. Nursing Inquiry. 9(3): Mantzoukas, S. (2007) A review of evidence-based practice, nursing research and reflection: levelling the hierarchy. Journal of Clinical Nursing. doi: /j x Mantzoukas, S. and Watkinson, S. (2008). Re-describing reflective practice and evidence based practice discourses. International Journal of Nursing Practice. Apr 14 (2): McCarthy, J. and Rose, P. (2010) Values- Based Health and Social Care: Beyond Evidence Based Practice. Sage Publications: London. Sackett, D.L, Rosenberg, W.M.C., Muir Gray, J.A., Brian Haynes, R. and Scott Richardson, W. (1996) Evidence based medicine: what it is and what it isn't. British Medical Journal. Vol. 312, 13 th Jan: Tanner, C.A. (2009) The case for cases: a pedagogy for developing habits of thought. Editorial. Journal of Nursing Education. 48 (6),