Make reflection part of your daily practice

When the editor of Clinical Pharmacist asked me [Katy Morris] to write an article on reflective practice, I set about to find some colleagues who could offer personal insights into the topic. Aamer Safdar, Barry Jubraj, Sue Jones and I all have backgrounds in education and training, and a passion to support others in their professional development. This article summarises an informal discussion we had about reflective practice. The questions I pose in the article are collated from common questions that pharmacists and pharmacy technicians have asked me during my research for this article. We do not profess to have all the answers but we hope that this article helps you to think about how you can use reflection in your daily practice.

Katy: I’ve found that some pharmacists and pharmacy technicians struggle with the term “reflective practice” and what it means. How would you describe it Aamer?

Aamer: Well, for me, reflective practice is all about thinking about and learning from what you have done, or from experiences you have had. It really is nothing more than that; we do it all the time without always recognising that we are. Think about something that you have done at work that didn’t go quite as planned. I bet you went home and thought about it in terms of what happened, why things didn’t go to plan and what you might have done differently if you had had more time to think.

Katy: I see what you mean — reflective practice is a way of learning from your direct experiences, rather than from the experiences of others. I have heardsome people call it “experiential learning”.

Katy: When I asked colleagues about how they approach their work it became clear a lot of people do not reflect on their day. Some people are happy to close the door on the day and not think any further about it.What advice can you offer them?

Aamer: I understand what you mean and often I try to do the same. But I also believe that reflective practice offers me the opportunity to sit back and think about what I could have done better or, perhaps more importantly, pat myself on the back and congratulate myself on a job well done. I often think about, or more correctly, reflect on things when I have a quiet moment —which is often in the bathroom!

Katy: For me, reflective practice is a state of mind, a way of thinking and about self awareness. But I also think action is as important as reflection. What is your view?

Aamer: It is about asking yourself questions to increase self awareness. I believe that we have to know ourselves before we can instigate a change in our behaviour. I’ve mentioned that reflective practice involves thinking about what you have done, but I agree it also has to include action. For example, if an activity in work went well then we may choose to do it in the same way again next time. In another situation we may identify that we would like to see a change in our behaviour for the future. It is sometimes helpful to use a set of questions as a prompt for your reflections (see Box 1).

Katy: What benefits do you think you get from reflective practice?

Aamer: I believe reflective practice has helped me to get where I am today. My job is all about looking after learners; and I have discovered a lot about the different types of learner I have encountered by reflecting on some of the problems I faced in my interactions with them. I can now deal with similar situations without stressing out — I have been there before.

Sue: Aamer raises some good points. In the context of my work I am always looking to improve my ability to help learners to become self-sufficient. Reflecting on my techniques, and what has been successful or less successful, has allowed me to develop my own “toolkit” of techniques to support learners.

Barry: Reflective practice offers me confidence when I’ve done something well, and I can use that experience and reflection in other situations. That experience and reflection can also be used when I am advising or helping colleagues.

Katy: Many people say that they do not have the time to reflect. Should they tackle it at work or at home?

Aamer: There are two types of reflection, which were described by Donald Schön in 1973: one is “reflecting in practice” and the other is “reflecting on practice”. Reflecting in practice is what we do at the time of the event; we are basically using our previous experiences to inform our future actions but are doing this intuitively and “in the moment”. Reflecting on practice is what we do when we think about things after the event.

Katy: So how can readers adapt their mindset to aid reflection? Any top tips?

Sue: As scientists the problem we have is that we just want to have the answer and move on. In order to reflect effectively and incorporate this into your practice I suggest that you start to think of reflective practice as looking at yourself in a mirror. Some days you look in the mirror and spend a bit more time straightening your hair, etc. Other days you think that you look great and smile. Try to imagine your day as a mirror. What would your day say back to you? [See Box 2 for more tips.]

Katy: Some colleagues have asked me if reflective practice has to be written down? Can someone just mentally reflect and still be a reflective practitioner?

Aamer: You do not necessarily need to write anything down to be a reflective practitioner, but you will probably lose the essence of what you reflected on if you do not have a record of it. I only record the events that I think might be useful in the future. These are the big issues that really influence my practice and make me change what I would do. Keeping a record helps me to remember the situation. I even use these thoughts to teach my students so that they can learn from my experience and reflections.

Katy: When is it appropriate to perform reflective practice?

Barry: I’m interested in how your question might make pharmacists feel — saying “perform reflective practice” almost makes it sound like it’s a mysterious technique with rights and wrongs in terms of how to do it. When I have facilitated others’ CPD, such notions can be a barrier. As Aamer said, in basic terms, reflection is just thinking about one’s experiences. Reflective practice encourages practitioners to think critically about how they do their work, and to be prepared to change in response to experience, consequences or feedback. So I think that my answer to your question is this: whenever you gain experience through doing your job — not just clinical but all aspects — or there is an outcome, like feedback or a clinical result. Reflective practice can simply mean taking the opportunity to think about what went well, what went not so well and what, if anything, you would do differently next time.

Sue: I agree. There is far too much effort made to make reflective practice seem complicated. The fear of doing things wrong can be a barrier to some people getting started. I think it’s important to allow your mind the freedom to think, with no barriers, in order to really benefit. Just think of my mirror metaphor above and it might seem easier for you. It really is not about developing your knowledge, we all know which books to read. It is about developing your skills, behaviours and attitudes to be a better practitioner in pharmacy.

Katy: Would it be helpful to develop set rules for reflective practice?

Sue: I think that question brings us to the tendency of the pharmacy profession to want a definitive list of rules and regulations. That way we can tick off the list and the job is done! In our training we are taught what is right and wrong, together with the consequences of making mistakes. Reflection is one of those areas where there are no rules and really no beginning or end. We are reflecting all of the time although sometimes more consciously than at others.

Katy: That’s a good point. As pharmacists and technicians we are often so black and white in our search for the “right answers”. Reflective practice offers us the opportunity to explore our practice in ways that may seem alien at first, but can be liberating if we embrace them.

Katy: What if reflection makes an individual feel that they are not doing their job well?

Barry: Good question! If you take the time to reflect on your experiences, it can evoke feelings, which might be good or bad; this partly depends on personality. The key is to look for outcomes in your work that are objective, because feelings are helpful but can be unreliable. A naturally pessimistic person may think that a training session with a junior colleague or a consultant ward round went badly, but you need to look at the objective outcomes or get feedback to weigh against your feelings. It’s important to make changes to your practice, where possible, based on objectivity, without completely putting your feelings to one side, since they can be a helpful guide. It’s about balance.

Sue: Barry is right. I will often ask practitioners to consider positive and negative elements of their work to enable a deeper engagement with reflective practice.

Katy: How can we help others to reflect?

Barry: First, should we be helping others to reflect? I think so, because if you are in a senior role, showing that you can reflect makes you a good role model for junior staff, and they are looking for role models. You can also support peers by being available to bounce ideas off, which is a great way of reflecting if you are striving to improve. It’s a shame that pharmacy doesn’t use an approach more like the nursing model of clinical supervision, since it works well in that culture. But a good way to start is being available to listen to someone tell you about a particular work experience and then asking them three simple questions:
What went well?
What didn’t go so well?
What you would do differently next time? Reflection on practice doesn’t have to be with a formally trained facilitator or in a scheduled appointment. Talking in the tearoom or on the bus home is fine too. The key is to make a start —it’s uncanny how quickly reflection can develop from there.

Sue: This perspective is interesting because I would suggest that senior practitioners were probably not taught how to reflect when they did their studies, so may struggle with the concept and need more support than their junior colleagues. Whoever the practitioner is, they should be encouraged to discuss their ability to reflect, as Barry suggests. People can work with their peers to participate in some peer review, for example, by asking someone else to be your “mirror”and help you to reflect on the things you can’t see. Another option is to ask a peer to review you using a tool called the “Johari window” this may help to reveal areas of practice that are “blind” or unknown to you.

Katy: Some pharmacists and pharmacy technicians believe that reflective practice is a waste of time. Why should they bother if they feel they are doing their job well already?

Sue: Many people may share the same view. I am sure that part of the reason is that we were never taught how to reflect or the purpose of reflection. When we make a mistake at work, such as a dispensing error, we have feelings of regret and fear, alongside a hope that the patient did not take any of the medicine. Once we find out that they did not, we breathe a sigh of relief. I feel that reflection has for too long been associated with negative feelings. What about patting yourself on the back for a job well done? Or reflecting about how something went smoothly then passing on your good practice to others. What about looking at your next career move or job role you would like to fulfil and working out, through reflection, how you might get there?

Katy: How do people know if they’ve fully reflected?

Sue: There is no simple way to know if you have “fully reflected”. Indeed, what does that mean? My suggestion to anyone reading this would be to just get stuck in to reflecting during and after practice, and take it from there!