Developing personally, using reflective practice in supervision: The evidence base for reflective practice Gundi Kiemle, University of Liverpool •What is RP? •What is the evidence base for RP? •Why is RP important? Evidence Base for Reflective Practice 1. Do healthcare practitioners (including clinical psychologists) actually participate in reflective approaches? 2. What is the link between their reflective activities and changes in practice? 3. And “So what…?” - How does reflective practice link to improved patient outcomes? Reflective Practice Reflection “…a means by which practitioners develop a greater level of self-awareness about the nature and impact of their performance” (Osterman & Kottkamp, 1993) “..a process whereby we reflect in order to learn something, or we learn as a result of reflecting” (Moon, 2004) Reflective Learning Boud, Keogh & Walker (1985): Model to promote reflective learning – reflective process is between the initial experience and the outcome: • Returning to the experience (“what happened?”) • Attending to feelings (“so what?”) • Re –evaluating the experience (“what next?”) Reflective Practice “…a mode that integrates thought and action with reflection. It involves thinking about and critically analysing one’s action with the goal of improving one’s professional practice” (Imel, 1992) “…a tool for revealing discrepancies between espoused theories (what we say we do) and theories-in-use (what we actually do)” (Imel, 1992) Why is Reflective Practice important? RP in the healthcare professions: • pre-and post-qualification nursing training (Clarke, James, & Kelly, 1996; Andrews, Gidman, & Humphreys, 1998; Williams & Lowes, 2002; Ruth- Sahd, 2003) , • midwifery (Yearley, 2003), • occupational therapy (Murray, McKay, Thompson, & Donald, 2000; Khanna, 2004), • social work (Taylor, 2006; Yip, 2006), • physiotherapy (Plack, 2004; White, 2004; Clouder & Sellars, 2004), • radiography (Castle, 1996; Williams, 1998), • podiatry (Young, 2004), • dietetics (Fade, 2004), • pharmacy (Tomlin, Costello, Kostrzweski, & Dhillon, 2006; Rees, 2004), • dentistry (Simpson & Freeman, 2004), and • medicine (Brigley, Young, Littlejohn, & McEwen, 1997; Richards, 1998; du Boulay, 2000; Sandars, 2006; Launer, 2006) Why is Reflective Practice important? Ruth-Sahd (2003): Critical analysis of RP 20 articles, 12 dissertations and 6 books published between 1992-2002. Inclusion criteria: Reflective practice having been defined according to key theorists in the field, evidence of a clearly defined methodology, and emphasis on reflective practice in an educational setting. Reflective practice was described in a range of settings such as higher education, nursing, social work, education, and management and leadership training. Most of the studies assessed reflective practice from the students’ or practitioners’ perspective. Why is Reflective Practice important? Ruth-Sahd (2003): Critical analysis of RP Positive outcomes notes from the literature • helping students to develop their clinical knowledge and skills, • integration of theoretical concepts to practice, • increased learning from experience, • improvement in practice by enabling greater self-awareness, • enhanced critical thinking and the ability to make judgements in complex and uncertain situations, • acceptance of professional responsibility and continuous professional growth, • improved self-worth through learning, • empowerment of practitioners, and • increased social and political emancipation. Evidence Base for Reflective Practice Difficulties with: 1. Definition - what counts as RP? 2. Measurement - how do we measure RP in action? 3. Evidence base for what? Relation to what outcome? 4. Few robust, empirical studies – largely descriptive, practice-based accounts, or models/ frameworks, or guidance & policy Reflective Teaching Lowe & Kerr (1998): Comparison of reflective v. conventional teaching methods in nursing students No difference in results between the 2 groups, but: • Unsuitable teaching material • Unsuitable outcome measure • Sample size insufficiently powered • Randomisation not specified Reflective Practice in Nursing Practice Nursing & Midwifery Council (2004): Post-registration practice: all nurses must engage in reflection and provide written evidence within a personal professional profile (reflective accounts). Andrews, Gidman & Humphreys (1998): Reflection in nursing generally unplanned and occasional, rather than systematic part of practice. Lack of empirical evidence to suggest that engaging in reflection changes practice or brings specific benefits re improved patient outcomes. Reflective Practice in Nursing Practice Andrews, Gidman & Humphreys (1998): Potential obstacles to RP and evaluation include reflecting on one’s own, lack of supervisor, lack of reflective skills in practitioner and supervisor, lack of effective external scrutiny for reflective activities and written evidence, reliance on self-evaluation. If reflection is not used systematically in clinical practice, then there is a danger that it becomes a tick-box exercise in order to fulfil mandatory registration requirements. Reflective Practice in Occupational Therapy Practice Lowe (2004): Examined theory –practice link: use of reflection in implementing CE learning into OT practice Used quantitative and qualitative measures Evidence for discriminant use of reflection: typically used when learning was complex (not during basic skills integration) Reflective Practice and Supervision Ellis, Ladany, Krengel & Schult (1996): Systematic review of 144 empirical studies of supervision 1981-1993: Much of the research surveyed was not methodologically rigorous Median effect size of .05 across studies does not allow for valid evaluation of effectiveness of clinical supervision Reflective Practice in Clinical Psychology Reflection and RP in pre-qualification training - Clinical Psychology Special Issue on Reflective Practice (2003) • Lavender (2003): 4 different processes involved in RP (based on Schon) • Gilmer & Marckus (2003): PPD components- survey of 17 clin. psych. courses • Stedmon, Mitchell, Johnstone & Staite (2003): RP model as an integral part of training, utilising a psychodynamically informed model of supervision Reflective Practice in Clinical Psychology (Pre-qualification training) Nokes (2005): importance of another person (mentor, supervisor) in order for RP to be effective; reflections on experience as a new trainee starting 1st placement. Powell & Howard (2006): facilitated RP groups of 8-9 trainees (B’ham) – benefits related to “reflection on self”, but less effect on behaviour change (e. greater self-care, seeking support). Reflective Practice and Supervision in Clinical Psychology Gabbay, Kiemle & Maguire (1999): Survey of 127 (40% of 321) qualified NW clinical psychologists’ supervision practice – most satisfying aspects concerned supportive elements, quality and availability of supervision to provide time and space to reflect. Sadler & Golding (2006): CPD survey of 174 (28 % response rate) NW clin psychs in 2004/05: 96.4% being supervised, 85.5% supervising others. ”Good/ regular supervision” 2nd most important for staying in current post and most important for professional competence. Reflective Practice and Supervision in Clinical Psychology Cushway & Knibbs (2004): Supervision workshop themes (33 trained clin psychs)– helpful aspects include giving space to reflect about clients, helping to explore CTF, linking clinical work to theory, s/v being reflective and integrative. Reflective Practice and Supervision in Clinical Psychology Milne and colleagues (various studies): Clinical psychology and supervision – research focused on certain defined aspects of the supervision process, methodological rigour, and relation to outcome. Reflective Practice and Supervision in Clinical Psychology Milne, Aylott, Dunkerley, Fitzpatrick & Wharton (2007): Best evidence synthesis of 24 rigorous and successful studies in which the training of the supervisor resulted in positive evaluations of the impact of supervision on the supervisees and clients. NB methods of supervision and performance monitoring emphasised – in contrast to communication, clinical reasoning, appropriate affective stance, and RP which were reported infrequently and insignificantly (RP mentioned in 8/48 studies). Reflective Practice and Supervisor Training in Clinical Psychology Green & Dye (2002): Supervisor training and RP – Delphi approach to ascertain consensus view of most important components of basic supervisor training programme – reflective stance implicit (e.g. ethical/ boundary/ safety issues). DROSS project 2004-2007: Core competencies and skills for supervisors, improving quality and consistency of supervisor training. Reflective Practice and CPD in clinical psychologists Kiemle (2008): Qualitative study exploring qualified clinical psychologists’ experience of RP and CPD, and links to their professional practice Difficulties with establishing the evidence base There is a lack of robust empirical evidence to assess practitioners’ use of RP, and the links between RP and changes in outcome. However: Whilst reflective theory and practice has not been adequately tested, neither has it been rejected. Rejection is not necessarily incapable of fulfilling the claims made for it – it is rather that the claims have not yet been empirically evidenced (Burton, 2000). In conclusion “Rather than sit on our hands bemoaning the absence of research findings to inform our CPD decisions, clinical psychologists need to make good use of the evidence that is available and contribute to expanding that knowledge base by conducting their own applied research” (Green, 2005) …Equally applies to Reflective Practice!