The Reflective Practitioner - Scotland Deanery
thereflectivepractitionerGuidance for doctorsand medical students
thereflectivepractitionerguidance fordoctors andmedical studentsContents3. Foreword4. Being a reflective practitioner Why being a reflective practitioner is important Approaches to reflectionA toolkit to support reflectionWhat? So what? Now what?6. Demonstrating reflection Documenting reflective thinkingMedical studentsDoctors in trainingAll other doctors engaging in revalidation and appraisal Anonymising details in reflections Documenting reflections is not the same as reporting serious incidents Being open and honest with patients10. Disclosure of reflective notes Disclosing records to the courts Reflective notes and GMC fitness to practise concerns12. References and further reading
ForewordMedicine is a lifelong journey, immensely rich, scientifically complex and constantly developing.It is characterised by positive, fulfilling experiences and feedback, but also involves uncertaintyand the emotional intensity of supporting colleagues and patients. Reflecting on theseexperiences is vital to personal wellbeing and development, and to improving the quality ofpatient care. Experiences, good and bad, have learning for the individuals involved and for thewider system.This short guide supports medical students, doctors in training and doctors engaging inrevalidation on how to reflect as part of their practice. It has been developed jointly by theAcademy of Medical Royal Colleges, the UK Conference of Postgraduate Medical Deans(COPMeD), the General Medical Council (GMC), and the Medical Schools Council.Ten key points on being a reflective practitioner:1. Reflection is personal and there is no one way to reflect. A variety of tools are available tosupport structured thinking that help to focus on the quality of reflections.2. Having time to reflect on both positive and negative experiences – and being supported toreflect – is important for individual wellbeing and development.3. Group reflection often leads to ideas or actions that can improve patient care.4. The healthcare team should have opportunities to reflect and discuss openly and honestlywhat has happened when things go wrong.5. A reflective note does not need to capture full details of an experience. It should capturelearning outcomes and future plans.6. Reflection should not substitute or override other processes that are necessary to record,escalate or discuss significant events and serious incidents.7. When keeping a note, the information should be anonymised as far as possible.8 The GMC does not ask a doctor to provide their reflective notes in order to investigate aconcern about them. They can choose to offer them as evidence of insight intotheir practice.9. Reflective notes can currently be required by a court. They should focus on thelearning rather than a full discussion of the case or situation. Factual details shouldbe recorded elsewhere.10. Tutors, supervisors, appraisers and employers should support time and space for individualand group reflection.3
Being areflectivepractitionerThe Academy of Medical Royal Colleges and COPMeD define reflective practice as‘the process whereby an individual thinks analytically about anythingrelating to their professional practice with the intention of gaininginsight and using the lessons learned to maintain good practice or makeimprovements where possible’.1Why being a reflectivepractitioner is importantApproachesto reflectionReflection empowers medical studentsand doctors to:There are no hard and fast rules on how toreflect – it is personal. Both positive and negativeexperiences can generate meaningful reflections.The approach taken to reflective practice may beinfluenced by the nature and scope of individualpractice, and personal style of learning. 2, 3 demonstrate insight by identifyingactions to help learning, development orimprovement of practice, developing greaterinsight and self-awareness i dentify opportunities to improve quality andpatient safety in organisations.There is a strong public interest in medicalstudents and doctors being able to reflect inan open and honest way.Thinking should be structured to capture, analyseand learn from the experience. A range of differentexperiences can be reflected on, including clinicalevents or interactions, complaints or complimentsand feedback, reading a research article, attendinga meeting, having a conversation with a colleagueor patient, team debriefs, or exploring a feeling oremotional reaction.Teams and groups improve patient care andservice delivery when they are given opportunitiesto explore and reflect on their work together. 4These interactions often lead to ideas or actionsthat improve care across organisations. Groupreflection activities should be encouraged byemployers and training providers as they providemechanisms to identify complex issues and effectchange across systems.Time should be made available, both for selfreflection, and to reflect in groups. Supervisorsand appraisers also need time to facilitatereflection.4
A toolkit to support reflectionThe Academy of Medical Royal Colleges and COPMeD’s Reflective practice toolkit describes theprinciples for effective reflective practice and includes a number of templates and examples.5This should be considered alongside this guidance.What? So what? Now what?There are many approaches to reflection. The What? So what? Now what? framework is oneexample of a simple way to structure reflections, whether it be of a single event or of a period oftime. 6, 7 It could include personal experience, interaction or observation of others andformal/informal learning events.Key elements in this framework that might be helpful to consider: What? focuses onthoughts at the time ofan experience. It exploresthought processes when aparticular action or decisionwas taken and how thosemay have impacted onactions and feelings. So what? involvesconsidering the significanceof what happened as wellas the values and feelingsat the time of and promptedby the experience, and whythese may influence futurelearning or actions.eg ’What was I thinking whenI took the actions or made thedecision that I did’eg ‘How did I feel at the timeof and after the experience,why was it important?’WHAT Now what? looks atthe processes andopportunities that canhelp learning from theexperience and identifyingfuture actions, reflectionon those actions, and howto use these to developfurther.eg ’What can I learn from ordo differently next time’SO WHAT(thinking)(feeling)NOW WHAT(doing)5
DemonstratingreflectionSometimes medicalstudents anddoctors may wantto discuss orwrite down theirreflections, or maybe required to aspart of theireducation, trainingand development.6
Documenting reflective thinkingReflecting helps an individual to challenge assumptionsand consider opportunities for improvement.Developing the capacity to reflect should focus on thereflective process and how to use it productively ratherthan on a specific number or type of reflective notes.Engagement in reflection can be demonstrated in differentways, depending on career stage.Medical studentsDoctors in trainingA medical student, by the time they graduate,must be able to:Doctors in training, as part of their genericprofessional capabilities, must demonstrate‘an ability to learn from and reflect on yourprofessional practice and clinical outcomes’.10This is part of the revalidation requirementsfor doctors in training. ‘explain and demonstrate the importanceof engagement with revalidation, includingmaintaining a professional developmentportfolio which includes evidence ofreflection’ 8 ‘develop a range of coping strategies, suchas reflection’ to demonstrate awareness ofthe importance of their personal physicaland mental wellbeing. 9This skill is often developed by writingstructured reflections, commonly withconstructive feedback. These are used aspart of the evidence that certain curricularoutcomes have been met.Each medical school will have more detailedguidance explaining how the outcomes can bemet for their own curriculum.The opportunity to reflect in practical andclinical settings is also beneficial.Doctors in training should discuss theexperiences they are planning to reflect on,or have already reflected on, with their clinicaland educational supervisors. Discussionassists with the learning aspect of thereflective process to make it more meaningful.It also helps to demonstrate engagementin reflective thinking as an educational andprofessional tool.Doctors in training should include insightsgained and any changes made to practice intheir learning portfolio. Supervisors shouldconfirm in the learning portfolio that theexperience has been discussed, and agreeappropriate learning outcomes and whatactions are planned.Sharing original, non-anonymised informationwith supervisors is important, but factualdetails should not be recorded in thelearning portfolio.7
Doctors in training (continued)The Gold Guide (guidance for postgraduate specialty training in the UK) suggests thateducational supervisors should assist in developing the skills of self-reflection and self-appraisalthat will be needed throughout a professional career.11Self-reflective learning logs may be reviewed as part of the Annual Review of CompetenceProgression (ARCP) process.12 These should not contain the full details of experiences or events– the focus should be on learning outcomes and action plans.All other doctors engaging in revalidation and appraisalRevalidation requires all licensed doctors to participate in regular appraisals that considerinformation drawn from their whole practice. The GMC’s Guidance on supporting informationfor appraisal and revalidation explains that reflection is a core requirement for revalidation.It describes how to reflect on learning and development as part of the annual whole practiceappraisal.13 Doctors in training will demonstrate this by meeting the requirements fortheir ARCP.Responsible Officers will normally take account of discussions and reflections consideredat annual appraisals or with a doctor’s supervisors, when they come to consider theirrecommendation about the doctor’s revalidation.A doctor should discuss the experiences they have reflected on with their appraiser, andmaintain a note of these discussions. The doctor may be asked to record these in an onlineappraisal or learning portfolio system approved by their organisation. These notes should focuson the learning identified and any planned actions arising from their reflections. Factual detailsshould not be recorded in appraisal or learning portfolios.Appraisals should also be used to reflect on the most important things learned or changed overthe past year.Responsible Officers and education providers should consider what support is necessary forsupervisors and appraisers to help them develop skills in evaluating the quality of reflection.8
Anonymising details in reflectionsAnonymised information will usually besufficient for all purposes other than the directcare of the patient, so should be usedwherever possible in reflection.The Information Commissioner’s Officeconsiders data to be anonymised if it doesnot itself identify any individual, and if it isunlikely to allow any individual to be identifiedthrough its combination with other data.Simply removing the patient’s name, age,address or other personal identifiers is unlikelyto be enough to anonymise informationto this standard. 14 The GMC guidanceConfidentiality: good practice in handlingpatient information supports how to do this.The GMC guidance Confidentiality: disclosinginformation for education and trainingpurposes gives advice to doctors onanonymising and managing personal data intraining records, including when it can’t beanonymised. 15 The same principles apply toreflective notes.Documenting reflections is not the sameas reporting serious incidentsReflecting on the learning resulting from a significant event or serious incident is an importantpart of continuous improvement and a requirement of medical education and revalidation.Reflection cannot, however, substitute or override other processes that are necessary todiscuss, record and escalate significant events and serious incidents. See the GMC’s Guidanceon supporting information for appraisal and revalidation for details about reflecting onsignificant events. 16 Factual details should not be recorded in reflective discussions butelsewhere, in accordance with each organisation’s relevant policies.Where there are concerns or questions about the content of reflection, the advice of asupervisor or appraiser should be sought as to whether the information is appropriate.The purpose of the reflection is to indicate learning and, where appropriate, future plans.The Academy of Medical Royal Colleges’ Guidance for entering information on e-Portfoliosrecommends that doctors involved in a serious incident should ‘set out the narrative onpaper immediately so that the events are recorded while still fresh in your mind, but formallydocumented reflection is probably better done after some consideration.17Being open and honest with patientsAll doctors have a professional duty to be openand honest with patients and those close tothem where something goes wrong.See the guidance Openness and honestywhen things go wrong: the professional dutyof candour. 18 Medical students are expectedto follow similar advice in Achieving goodmedical practice. 19All members of the healthcare team shouldhave opportunities to reflect on and discusswhat has happened openly and honestlywhen things go wrong in a supportive andconfidential setting. This is different to anindividual’s personal reflections about,and learning from, the incident and whatactions they plan to take , but representsa vital aspect of systematic andorganisational development.9
Disclosure ofreflective notesIt should be rare for areflective note to containfactual details thathave not been recordedelsewhere, or alreadydiscussed with thepatient and/or their family.Reflective notes shouldfocus on the learning, nota full discussion of thecase or situation.10
Disclosing recordsto the courtsReflective notes and GMCfitness to practise concernsRecorded reflections, such as in learningportfolios or for revalidation or continuingprofessional development purposes, are notsubject to legal privilege. Disclosure of thesedocuments might be requested by a court ifthey are considered relevant.The GMC does not ask a doctor to providetheir reflective notes in order to investigatea concern about them. The GMC’s focusin a fitness to practise investigation is onfacts and evidence relating to a seriousallegation. Following a significant event ora serious incident, factual details shouldnot be recorded in reflective discussionsbut elsewhere, in accordance with eachorganisation’s relevant policies.The GMC guidance Confidentiality: goodpractice in handling patient informationsays that information must be disclosed if it isrequired by statute, or if ordered to do so by ajudge or presiding officer of a court.20The guidance explains that, if disclosure ofconfidential patient information is required bylaw, ‘you should: satisfy yourself that personalinformation is needed, and the disclosure isrequired by law only disclose information relevant tothe request, and only in the way required bythe law.’ 21Evidence of insight and remediation mayreduce the need for the GMC to take action.It plays an important role in how the GMCassesses whether a doctor’s fitness to practiseis impaired. Doctors are invited to provideevidence of insight and remediation as part oftheir defence, but whether they do this andthe form it takes is for the doctor to decide.The GMC advises doctors to get legal advicebefore sending any documentary evidence.Where a disclosure request is received, theowner of the learning portfolio or otherreflective note should seek advice from theiremployer, legal adviser, medical defenceorganisation or professional association.11
References andfurther reading1. Academy of Medical Royal Colleges/COPMeD. Reflective practice toolkit, CJ15414-AcademyReflectivePractice-Main-v3.pdf2. Peter Honey and Alan Mumford. The Manual of Learning Styles. 3rd Edn,Peter Honey publications, 1992.3. David Kolb. Experiential Learning: Experience as the Source of Learning and Development.Prentice-Hall, 1984.4. Nina Dutta, Lewis Peake, Jude Tweedie and Andrew Goddard. Improving teams in healthcareResource 4: Team development. Royal College of Physicians, 2017.5. Academy of Medical Royal Colleges/COPMeD. Reflective practice toolkit, CJ15414-AcademyReflectivePractice-Main-v3.pdf6. Terry Borton. Reach, touch and teach. Hutchinson, 1970.Adapted by Colin Melville 20187. Andrew Grant, Judy McKimm and Fiona Murphy. Developing reflective practice: A guide formedical students, doctors and teachers. Wiley Blackwell, 2017.8. General Medical Council. Outcomes for graduates (para 2t), aduates9. General Medical Council. Outcomes for graduates (para 3c), aduates10. General Medical Council. Generic professional capabilities framework, ional-capabilities-framework11. COPMeD. A Reference Guide for Postgraduate Specialty Training in the UK (Gold guide)(para 4.24iii), 2018www.copmed.org.uk/images/docs/gold guide 7th edition/The Gold Guide 7thEdition January 2018.pdf12. COPMeD. A Reference Guide for Postgraduate Specialty Training in the UK (Gold guide)(para 4.39x), 2018www.copmed.org.uk/images/docs/gold guide 7th edition/The Gold Guide 7thEdition January 2018.pdf12
13. General Medical Council. Guidance on supporting information for appraisaland revalidation, ng-principles14. General Medical Council. Confidentiality: good practice in handling patientinformation, 2017 (para patient-information-for-secondary-purposes15. General Medical Council. Confidentiality: disclosing information for education andtraining purposes, 2017 (para ation-andtraining-purposes16. General Medical Council. Guidance on supporting information for appraisal andrevalidation, 7. Academy of Medical Royal Colleges. Guidance for entering information on orts-guidance/academy-guidance-e-portfolios/18. General Medical Council. Openness and honesty when things go wrong: the professionalduty of candour, things-go-wrong19. General Medical Council. Achieving good medical practice (paras 16-19), e20. General Medical Council. Confidentiality: good practice in handling patient information,2017 (para personal-information-a-framework21. General Medical Council. Confidentiality: good practice in hand
Documenting reflective thinking Reflecting helps an individual to challenge assumptions and consider opportunities for improvement. Developing the capacity to reflect should focus on the reflective process and how to use it productively rather than on a specific number or type of reflective notes.
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