Evidence Base for Reflective Practice

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					Developing personally, using reflective practice in

    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

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


“…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

• 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
•   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
3. Evidence base for what? Relation to what
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
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
     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

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
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
 Reflective Practice and Supervision in Clinical
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
Milne and colleagues (various studies):
Clinical psychology and supervision – research focused
   on certain defined aspects of the supervision
   process, methodological rigour, and relation to
 Reflective Practice and Supervision in Clinical
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
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.

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!