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While no one would deny that the nature of CET has changed in the current cycle there still appear to be mixed feelings about how worthwhile and effective the changes will be. The biggest change is in the requirement for the inclusion of peer reviewed training and for evidence of interactive training and reflection. For many practitioners the inclusion of reflective episodes as part of this training can be daunting. Reflective practice has a proven track record in professions such as nursing and teaching and has proved to be a worthwhile and useful tool.1
The changes to the CET requirements have resulted in it becoming more aligned with the practice of continuing professional development than it was in previous cycles. It now recognises and values the fact that practitioners will have different areas of interest that they wish to pursue as well as acknowledging the need to meet the basic requirements to be a safe and competent practitioner. This change of structure requires practitioners to recognise their strengths and weaknesses and to engage with the education process. The change of emphasis has put the focus for directing the process squarely with the individual and the focus on ‘me’ can be uncomfortable. However, by recognising the strengths of this approach and embracing the process it is possible to reap considerable rewards.
Reflective log
One of the most noticeable differences is the requirement to engage in peer reviewed and interactive training and to provide a reflective log of the experience. Reflection is a normal everyday occurrence that we all engage in to a greater or lesser extent. Whenever you think back to an event and wonder if it went well, or why it went badly, you are engaged in reflection. Reflective practice has been defined as the ‘process of making sense of events, situations and actions.’2
Informal reflection does not follow rules in the way that it processes and makes sense of events and the fact that the formal reflective process seems to be governed by rules and structure can be disconcerting and off-putting for many people.
The advantages of reflective practice are that it allows an objective view of situations, which highlights the strengths and weaknesses that you possess and then helps identify any training needs that you have. This understanding of why you behave in a certain way or choose to perform a particular action, coupled with an appreciation of how you feel about it allows you to develop your strengths and minimise your weaknesses.
The long-term advantages of reflective practice are that it improves professional judgement, increases awareness and utilisation of transferable skills and encourages a positive response to change.3
There are many perceived barriers to reflective practice and many busy practitioners are concerned with the time burden that it will impose. However, since reflective practice is merely a formalisation of something we all do naturally this should not be a problem. There is time to reflect for instance while commuting or in the gym and in the same way that discussions with colleagues during lunch or coffee breaks are a form of peer discussion, these discussions can also provide opportunities for reflection.
The fact that reflection is something that has been imposed as a necessary requirement can lead to a negative view of the process or the fear that the reflective report will be a tool that is used to criticise an individual’s practice or performance. It needs to be recognised that the reflective episodes are part of the learning cycle and provide evidence of the effectiveness of the learning episode rather than being something that is marked and critiqued and then used against you.
True reflection can be a brutally honest and soul-baring exercise, but the reflective episodes that are required as evidence of learning for CET are slightly different. There is an important distinction between written reflection and reflective practice. Written reflection is one of the tools of reflective practice but is not in itself reflective practice.
The goal of reflection is to encourage self-assessment of practice as a tool to facilitate learning and change and to enable the knowledge gained to be transferred to similar events in the future.
Model structure
There have been several models proposed to provide structure to reflection. The one most used in medical field is Gibbs’ model of reflection.3 This model is a cycle of reflection which is designed to encourage systematic thinking about an event (Table 1). It consists of the following six key areas to provide a framework for reflection:
? Description
? Feelings
? Evaluation
? Analysis
? Conclusion
? Action plan.
The most common method of reflection using this model is to keep a reflective journal. The journal records the different stages and allows you to return to and review the incidents recorded in the future. It demands an investment in time which can be seen as an unnecessary burden, yet can very quickly become a natural part of the working day.
The current CET structure does not require reflective journals to be submitted but asks for a short piece of reflective writing. The structure of a written reflective piece is different from a reflective journal. It consists of a short description of the events followed by an interpretation of those events and then discussion of the outcomes which forms the action plan for implementation of the learning.
The interpretation and the outcomes are the important aspects as it is here that we recognise what aspects of practice went well or went badly, what was meaningful or significant, how we felt or reacted and how it compared or differed to previous experiences.
To complete the full reflective cycle we need to move from reflecting on practice to reflecting in practice. That is, once we have described, identified and analysed a situation, we need to be able to apply those lessons in the ‘real world’. Reflecting on practice is stepping outside the situation as a curious observer of your action. It allows you to recognise situations or emotions and then act appropriately in the light of your new knowledge.
For instance, you may have experienced a situation with a patient that had an unfavourable outcome such as an argument in the practice. Reflecting on the incident allows you to understand the triggers that led to the flashpoint being reached. In a similar situation by reflecting in action you can recognise the trigger when it occurs and behave in a considered manner to avoid a disagreement. The reflective process can be thought of as a constant improvement process almost like an audit cycle and it may be that on this occasion there wasn’t a favourable outcome, but reflecting on the situation will allow you to identify what was better and where things became dysfunctional and allow the formulation of an alternative approach.
Reflection and reflective writing is not a stick to beat practitioners with, it is a framework for learning and is the mark of a true profession. It is a process that all practitioners should embrace for the good of their patients and for their own professional wellbeing. ?
References
1 Burns S, Bulman C. Reflective practice in nursing : the growth of the professional practitioner, Oxford, Blackwell Science 1999.
2 Oelofsen N. Using reflective practice in frontline nursing. Nurs Times, 2012; 108, 22-4.
3 Johns C. Becoming a reflective practitioner, Oxford, Blackwell 2004.
? Andrew Millington is an optometrist practising in Chepstow, Monmouthshire