Preparing for Professional Practice in Health and Social Care. Группа авторов

Reflection and reflexivity are terms that are frequently used interchangeably although there are distinct differences. Reflection has been encouraged for several decades for practitioners within health and social care and is often defined as a process. It is viewed as fundamental to the professional development of health and social care practitioners and a core competency which has been essential during the COVID-19 pandemic (Walpola and Lucas 2021). Promoting and undertaking reflection ultimately seeks to ensure the quality of care provided for service users and should be undertaken by practitioners and managers (Stonehouse 2015). Reflexivity is a lesser understood term with roots in the philosophical underpinning of research. Self-reflexivity relates to exploring and highlighting your own values, particular biases, and preferences related to the research or topic area (Tracy 2010). As with researcher roles, health and social care practitioners can benefit from considering the influence of their own background and assumptions.

      Often referred to as deep reflection, reflexivity has a stronger focus on exploration of values, assumptions, and beliefs that inform the professional practice provided. Being reflexive is essential in order to become more self-aware and to question further our actions, and the evidence we use, to inform clinical decision-making. A reflexive process involves an individual looking back and reflecting on themselves in order to emerge or move towards desirable professional practice (Johns 2017). Also, as a reflexive practitioner, it will not only increase self-awareness but also assist in identifying where there may be differing values underpinning other professionals’ actions. Increasing awareness of this can assist with group reflection and explain where differing assumptions may inform clinical reasoning and different approaches to practice.

      Case Study 1 – Interprofessional Collaboration: Differing Assumptions Informing Ideas

When working with younger people with dementia, and their caregivers, an occupational therapist and a mental-health nurse reflected on how any service development should evolve. Both healthcare practitioners were passionate about providing a quality service and shared core values of respect, dignity, and compassion. Through reviewing the evidence base, of which there was little at this time, and speaking with the service users regarding their preferences, it became apparent that their own assumptions and clinical reasoning differed regarding the relevant type of setting for the service. Although both professionals were motivated to create a quality service, without taking time to engage with stakeholders and reflect on their own values and assumptions, the service developments could have gone in the wrong direction. An initial idea of an inpatient service changed, through joint reflection, to community based, flexible services for the individuals living with dementia and their caregivers.

      Reflection Is Not Only an Individual Act

Reflection requires knowledge, skills, and an attitude to be open to changing professional practice. For several decades there has been access to models of reflection, practical tools, and questions that prompt reflection that focuses on the individual level with inconsistency in how these tools are used. There are also growing ranges of tools available for quality improvement within health and social care that encourage an element of reflection although this is not always explicit in the structure. The Plan, Do, Study, Act (PDSA) cycle (Taylor et al. 2014) has reflection within the study phase and this is used widely in healthcare improvement (see Chapter 5). As reflection is key to all health and social care practitioners’ standards for practice, it is essential to view reflection as integrated within ‘daily’ practice rather than being perceived as an exercise only completed in pre- or post-graduate education or as an extra task only completed to pass any professional standards as a tick box exercise. It is also important to consider reflection as being beyond an activity only undertaken individually in isolation, but as core to the supervision process. Reflection is valuable when undertaken with peers, in teams, and with colleagues from a mixture of professional grades and backgrounds. The ultimate aim would be to also consider reflection inclusive of service users to truly bring together the core tenets of EBP. This will refine clinical reasoning and can add to the evidence base through informing future practice.

      Reflective Models, Settings, and Tools

      Being reflexive is essential for the advancement of professional practice. As is ever apparent with key national and international events, health and social care practitioners are having to demonstrate that they are capable of applying competencies and EBP in ever changing, complex, and often unfamiliar contexts. Individuals need to feel empowered to reflect on and question their own practice and the clinical reasoning of others, so that critical problem solving can lead to positive change for the wider community.

      There are a wide range of models and tools available to practitioners to promote reflection. From the early work by Schön (1987) that highlighted both reflection in action and on action, based on the reflection of designers, an array of models have evolved for application in health and social care. Reflection-in-action occurs in the moment, whereas reflection-on-action occurs after the event and evaluates the situation through a staged process. The challenge is seeking practical strategies that push you further with your reflection to becoming reflexive, as well as being helpful to generate positive change within your profession and work context.

The HCPC, which is the professional regulator in the United Kingdom, give clear expectations of threshold standards regarding reflection that are in place to protect the public. All health and social care professionals are expected to reflect on and review their practice, although there are subtle differences between professions in terms of how this is expected to occur. This brings us on to valuing a range of approaches to reflection, whether this is an individual act or something undertaken with others. Core to each of the HCPC professional standards for proficiency is the need to ‘record the outcome of such reflection’ as outlined in Standard 11.1 for occupational therapists (HCPC 2018) highlighting that reflection, and documenting it, is essential to maintain professional registration within the United Kingdom.

      There are a multitude of methods and settings where reflection can occur and these are outlined below.

      Case conferences – although there is a need to shift from viewing these as meeting to only discuss a client, to actively considering how things can be delivered differently through interprofessional collaboration, debriefing, and simulation. This is supported by the HCPC through valuing multidisciplinary team reviews in standards of proficiency for example with dieticians (HCPC 2013a), paramedics (HCPC 2014), and chiropodists/podiatrists (HCPC 2013b).

      Supervision – 1:1, with a peer, and within and across professions.

      Debriefing – there are a range of techniques used as a means of facilitated, guided reflection as part of a debrief process. This can involve formal, structured techniques or more ad-hoc debriefing with peers, or facilitators, in pairs or groups.

      Stakeholder meetings – these meetings are often strategic events to bring people together to discuss and commit to particular projects or developments (as in case study 1). This can be a great opportunity for reflection from multiple perspectives and may take a problem solving or appreciative inquiry (exploring strengths) focus.

      Individual methods – reflective questions, diaries, reflective models (see case study 2), engaging in post-graduate study (case study 3), and as technology evolves, using mobile apps.

      Schwartz rounds – The principles of Schwartz rounds are discussed in Chapter 2 (Care and Self-Care).

Models of Reflection

      To deepen the engagement in a reflective cycle and become more reflexive, models can assist through providing a structure and prompts. The preference for a particular model of reflection is often based on previous experience, exposure to a particular model, personal preference, learning style, professional bias, or the time prioritised to engage