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Monday, 09 March 2020 21:58

Physiotherapist as a reflective practitioner

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Reflective Practice is defined as ‘the process whereby an individual thinks analytically about anything relating to their professional practice with the intention of gaining insight and using the lessons learned to maintain good practice or make improvements where possible' (Academy of Royal Medical Colleges, 2008). As scientific professionals, it aims to make physiotherapists more aware of our own professional knowledge and action by ‘challenging assumptions of everyday practice and critically evaluating practitioners’ own responses to practice situations’. 

Why is reflection important for physiotherapists?


In simple terms, reflective practice is a process of self-analytical thought process whereby we review and evaluate our lessons either individually or in groups to identify areas of learning and self-development. So there are two key elements of reflective practice:

1. Analysis of our own self as practitioners - Our knowledge, our skills, our goals, what we want to achieve and how we are going to get there. These are related to our personal development planning. We have to regularly reflect upon and review our progress towards our long term goals. 

2. Our clinical reasoning skills: When we are fresh out of physiotherapy school and inexperienced, we use the hypothetico-deductive model of clinical reasoning. But over a period of time, we can start to develop pattern recognition or experiential reasoning. This comes only through reflection and learning.  

3. Improvement of patient interaction: As a healthcare professional, it is vital for us to ensure that the care we are giving to the patients is in their best interest. This means that the interaction we have with our patients has to be effective, whether it is our verbal subjective assessment (which is an art form itself) or objective tests we use, we can always learn from our experiences of dealing with the patients to ensure we can serve our next patients better. 

4. Providing effective therapy: A reflective practitioner physiotherapist will be able to analyse the outcomes of interventions provided, the impact the intervention had and the progress a patient made towards their goals. Thus, through the process of reflection and learning, they will be able to utilise the most effective interventions whilst discontinuing the use of non-effective physiotherapy interventions. 

5. Reflection as a precursor for innovation: When we review our actions, we can often think of how things could be done differently more creatively, imaginatively and resourcefully, and be ready to adapt to new ways and methods of thinking, thus helping in innovation of our practice. 

6. Reflection as a risk management approach: Whilst risk management strategies are generally based on forward planning and risk identification, reflection is a very important tool for risk management. Reviewing, analyzing and learning from adverse events is an important aspect of risk management. 

5. Requirement as a part of registration: Some regulatory bodies (e.g. Health and Care Professions Council) stipulate demonstration of reflection as a part of the information required for continued registration through revalidation, continuing professional development or continuing education requirements.

For this to be a meaningful process, individuals need to examine their previous beliefs about their practice. These beliefs are often firmly held, and individuals needs to learn to accept that things can be done differently or better. By continuously evaluating previously held beliefs and assumptions learning occurs and practice develops.


How to undertake reflection?

Reflection can be undertaken as an individual or group activity. For this to be a meaningful process, individuals need to examine their previous beliefs about their practice. These beliefs are often firmly held, and individuals needs to learn to accept that things can be done differently or better. By continuously evaluating previously held beliefs and assumptions learning occurs and practice develops.

There are no hard and fast rules on how to reflect – it is personal. Both positive and negative experiences can generate meaningful reflections. The approach taken to reflective practice may be influenced by the nature and scope of individual practice, and personal style of learning. Thinking should be structured to capture, analyse and learn from the experience. A range of different experiences can be reflected on, including clinical events or interactions, complaints or compliments and feedback, reading a research article, attending a meeting, having a conversation with a colleague or patient, team debriefs, or exploring a feeling or emotional reaction.

HCPC's guidance on undertaking reflection considers " Any experience, including a conversation with a colleague, a significant clinical or professional event, or a period of time can generate meaningful reflections, insights and learning." 

A systematic and structured approach that aims to draw out learning outcomes has a greater impact. There are many good models of reflective practice and methods that can be used to drive reflection. Some of the common models of reflection include:

1. Gibbs Model of Reflection - In 1988, the American sociologist and psychologist Graham Gibbs published his Reflective Cycle model in his book ‘Learning by Doing‘. Gibbs Reflective Cycle encourages people to think systematically about the experiences they had during a specific situation, event or activity. Using a circle, reflection on those experiences can be structured in phases. This often makes people think about an experience, activity or event in more detail, making them aware of their own actions and better able to adjust and change their behaviour. By looking at both negative and positive impacts of the event, people can learn from it. 

Gibbs Model has six steps to complete the process of reflection.

a. Description which involves simply a description of the event, activity or experience. It is simply an enumeration of the event without assigning any blame or drawing any conclusions. 

b. Feelings - this step involves describing your feelings at that time in a non-judgemental way. 

c. Evaluation  - in this step, the reflecting physiotherapist  is encouraged to analyse the event and their feelings objectively thinking about WHAT were the positive and negative aspects of their experience. 

d. Analysis - Building upon the evaluation, the analysis step aims to assess WHY it was a positive or negative experience. This should form the bulk of your reflection process. 

e. Conclusion - This step involves summarising the experience and focus on learning and outcome. What have you learnt? What will you do differently?

f. Action Plan - Finally, what specific actions can you now take to build on your knowledge or skills? Consider formal or informal training, people or resources you would need to learn from this experience. 

I have written about the Gibbs Model of Reflection along with practical examples of its use in my own practice here. 

2. Johns Model of Reflection - Johns model is based on five cue questions which enable a reflective practitioner physiotherapist to break down your experience and reflect on the process and outcomes. Similar to Gibbs Model, the first step is description of event, activity or experience. The second question to be answered is what was I trying to achieve and what are the consequences? Then the physiotherapist has to consider the external or internal influencing factors and whether we could have done it differently. Finally it encourages the physiotherapist to consider what will change because of this experience. As such it is quite similar to Gibbs Model of reflection. 

3. Driscoll Model of Reflection - Driscoll used a simpler version of reflective process using the questions - What, So What and Now What? In this process, What provides the description of the event which can be the whole event or focus on certain aspect of event. So What is the phase of reflection which focuses on the impact of the event and its outcome. Whilst the final aspect is Now What which highlights use of reflection to consider change in practice or consideration of further activities which will follow from the learning and reflection. 

Of the three models discussed above, Gibbs Model is the most extensively used and discussed in physiotherapy literature. 

Some other thoughts on reflection include:

“Reflective practice is something more than thoughtful practice. It is that form of practice which seeks to problematise many situations of professional performance so that they can become potential learning situations and so the practitioners can continue to learn, grow and develop in and through their practice” Jarvis P. (1992) 

Reflection in action means to think about or reflect while you are carrying out the activity. It is typical when something is going wrong or you are nervous about something new or out of the ordinary and you cannot help yourself thinking about it, but practitioners rarely formalise the process. Reflection on action, however, means thinking about the practice undertaken after the event and turning that information into knowledge.

Whilst reflection can help us in our professional development as a physiotherapist, maintaining a reflective diary can also be a useful self-development and personal growth tool in all aspects of life. A reflective journal (aka a reflective diary) is the perfect place to jot down some of life's biggest thoughts. In a reflective journal, you can write about a positive or negative event that you experienced, what it means or meant to you, and what you may have learned from that experience. A well-written journal can be an important tool. As with any tool, to get the most benefits, you need practice. This could mean forcing yourself to write, at first, but after a while, it will become like second nature. Write down your entry as soon as possible after the event. This way, the details will still be fresh in your mind, which will help later in your analysis. 

Summary: Reflection is a structured process of evaluating any event, activity or action to consider its impact and outcome. Reflective practitioner continues to grow through consideration of What happened, So What was the outcome (good or bad) and Now What - taking the learning from the present event to ensure positive outcomes for future. 






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