Reflection In Occupational Therapy Practice

I have always struggled with reflection, initially I didnt see the point of going over and over events that had happened, I was confident that the action I had taken at the time was right for the moment, but if I felt that it wasnt I would acknowledge that and improve next time, obviously this process is going on in my head, (according to Schon this is Reflection in action), and improves with experience over time, I can understand how reflecting can help with thought and behavioural processes, and also provides evidence so others can see the outcomes of my actions. It seems to me that reflection is used to teach people skills that they may not have, some people are good with people and some are not, I do not think that is something that can be taught. You either have it or you don’t.

Initially I was quite apprehensive with my choice of placement – community mental health – having worked, with adults with mental health problems, in the past, I was basing my past experience on what I would experience at the placement; and my past experiences had not always been positive, so I was maybe a little anxious to start with. What I found was totally different to my preconceptions, I had never experienced group work before, and was interested with the impact this would have on the service users and also what the Occupational Therapy (OT) role was. The therapists were there to facilitate, and support the group processes, initially I queried that the OT’s were more counsellors than OT’s, and many had chosen to gain a counselling qualification to aid their role. Then again If everything is about occupation and has meaning to someone, then to enable an individual with low self esteem, or mild depression to engage with their fellow peers could be part of the OT role, especially if it enables them to participate in work, leisure and self care. My critical incident is taken from one experience in a creative group, half way through my placement.

Reflective practice is not a new concept – Boud, Keogh and Walker (1985) stated 20 years ago that it features the individual and their experiences, leading to a new conceptual perspective or understanding. They included the element of learning, as well as involvement of the self, to define reflective practice:

“Reflection is a forum of response of the learner to experience” (Boud et al. 1985)

Johns and Freshwater (1998) also described the value of reflective practice as a means of learning. There is no doubt that “reflection” is a complex concept that has defied consensus on definition although some commonalities exist. It involves the self and is triggered by questioning of actions, values and beliefs. An understanding of the purpose of reflective practice and its components can be gained by considering some of the definitions provided in literature. A few useful definitions include the following:

…“Reflection is a process of reviewing an experience of practice in order to describe, analyse, evaluate and so inform learning about practice” (Reid, 1993)

…“Reflective practice is something more than thoughtful practice. It is that form of practice that seeks to problematise many situations of professional performance so that they can become potential learning situations and so the practitioners can continue to learn, grow and develop in and through practice” (Jarvis, 1992).

To maximise learning through critical reflection we need to locate ourselves within the experience and explore available theory, knowledge and experience to understand the experience in different ways. Thus Boyd & Fales (1983) claim that critical reflection:

…“is the core difference between whether a person repeats the same experience several times becoming highly proficient at ones behaviour, or learns from experience in such a way that he or she is cognitively or affectively changed”.

Critical reflection is viewed as transformational learning which according to Baumgartner (2001) can happen either gradually or from a sudden or critical incident and alter the way people see themselves and their world.

According to Kolb (1984) reflecting is an essential element of learning. He developed the cycle of experiential learning which has formed the basis of many models for reflective practice in the past two decades. Kolb draws attention to the fact that, when we want to learn from something that has already happened to us, we need to recall our observations of the event and then reflect on those observations in some way. Once we have these ideas in our heads, Kolb suggests that we frame some action as a result and that this possible course of action is seen as our ‘learning’. This will then inform any action that we take as a result of the experience. Kolb (1984) advocated that experiential learning was a cyclical process, emphasising that there was no end to learning but just another cycle. The crux of experiential learning is that the learner in not a passive recipient of education, but actively explores and tests their environment.

Schon (1983) suggests that we can engage in reflection in one of two ways; either by ‘reflecting on action’, after the experience, or by ‘reflecting in action’, during the experience. When reflecting-on-action, the first step in the process is the description of the incident. Much attention has been given to the value of recording events and experiences in written form, particularly through the use of reflective diaries and journals (Zubbrizarreta 1999 and Tryssenaar 1995). The exercise of diary writing promotes both the qualities required for reflection, i.e. Open-mindedness and motivation and also the skills i.e. self-awareness; description and observation; critical analysis and problem-solving; and synthesis and evaluation (Richardson & Maltby, 1995).

www.practicebasedlearning.org

Pre-requisites for effective reflective practice include honesty and openness. Gillings (2000) states that a commitment to self-enquiry and a readiness to change practice are important if the individual is to get the most out of the process. Many authors identify self-awareness as essential to the reflective process. This implies that the individual needs to be well informed of their own character, including beliefs and values. Many models of reflective practice also include self awareness and questioning of beliefs, values and attitudes. The last stage of many models of reflection relates to a willingness to change practice, where new conceptual perspectives are reached in order to inform practice. If the learner is not willing to change practice they will not gain the potential benefits from the process in terms of practice development, advances will not be made and professional practice will not evolve.

As an OT professional I am required to use clinical reasoning skills which enable me to make responsible therapeutic decisions; these decisions are based on professional judgements which are guided by individual morals and ethical values. (Sabonis-Chafee & Hussey 1998) My understanding of morals will be dependent upon my background, social environment, values and possibly religious beliefs, whilst ethics is:

‘…the study and philosophy of human contact…’

(Purtilo, cited in Sabonis-Chafee & Hussey 1998)

Every professional organisation has a code of ethical conduct and core values, these provide a guideline for making decisions and choices that can be regarded as proper (Creek 2003), and to assist professionals in practising the values and principles that promote and maintain high standards in OT. The main principles outlined in the code of ethics include; the ability to demonstrate concern for the well being of the client, cause no harm, respect the rights of all involved, maintain a high level of competency, to comply with laws and set policies, to be truthful and accurate and refrain from false claims.

An understanding of ethics gives me positive general guidance rather than defining limits to certain behaviours. Ethics influence every aspect of occupational therapy. Beginning in OT education when issues of plagiarism, library resources, and confidentiality begin, and then in the clinical environment from supervision, practice issues and client issues. (Duncan 2006)

In the last 20 years, reflection has gradually become more popular in care and healing professions. In many quarters, the reflective practitioner is seen as a crucial sign of the ideal practitioner. Not everyone agrees though, that truly professional or expert practitioners are or should be reflective practitioners. According to Dreyfus, real professionalism is characterised by the absence of reflection. Only novices and beginners need to think about what they are doing. Expert practitioners, in contrast, just do what needs to be done; they do it without thinking about it Practitioners, novices or experts, reflect when they consider what to do in somehow unusual situations, when they try to figure out how to handle a new and unexpected problem, when they have to choose between two nearly identical options.

Kinsella (2001), in advocating reflective practice for occupational therapists, emphasised the need for both reflection and action on that reflection (praxis). From this perspective, in order to learn from the reflective experience it is necessary to alter the normal way of responding. Argyris and Schön (1974) termed this ‘double-loop learning’. The act of paying attention to what would normally be routine may become part of a long process, with the stimulus being noticed again and again until further deliberate reflection is required. Schön (1983) noted that reflection-in-action was precipitated by a surprise, something not expected, interrupting the normal flow of experience. However, there are almost certainly ways in which a reflection is triggered other than this. An educational event may do this or a series of conversations with a colleague or an observation of a colleague’s practice (reflection-on-action).

Critical Incident:

Creative Group

K was attending a weekly creative group at the unit, it was 2 weeks before Christmas and we were making paper chains. K had a very limited attention span and could be quite disruptive, during quiet periods in the group she would whistle, sigh, hum, tap fingers or pencils on the table which we would ignore focusing instead on her creative project. The previous week K had referred to the OT as ‘Blondie’ which I thought was inappropriate and mentioned this to the OT, she said she had been aware but had chosen to ignore the incident and see what would happen this week.

I had chosen to use scissors with a crinkly edge and because of this, from then on K referred to me as Smart-Arse or as The Student, I didn’t feel she was trying to be nasty, I felt she thought she was making a joke. I informed her that my name was Julia – in case she had forgotten – and carried on with what I was doing. H the OT commented on her using the word smart a lot and wondered why that was. K replied that she was surrounded by smart people and hoped that some of it may rub off on her. We asked if she felt uncomfortable in the group and why she felt she wasn’t smart and she replied that was what she had been told all her life. K was definitely street smart, but possibly had mild learning difficulties. She then changed the subject and we spoke about her Xmas decorations, after that she called me Julia and the OT by her name.

Why did I choose to respond to K?

• Because I felt she was disrespecting group boundaries
• To get her to stop
• To be aware of respecting others in the group
• There may have been another reason for her hostility

What happened then?

• She stopped
• She chose to share personal experiences with the group about her life and her feelings.

How was the situation handled?

• I feel the situation was handled well, I did not get angry, I brought her attention to my name, and with the OT we made inquiry into her reasons for her behaviour, she did not get angry.

Any legal or professional issues?

• I had to maintain a professional manner throughout the situation, I may have been ‘The Student’ but there was an expectation, I may not have been in uniform but in that capacity I was a professional, so needed to be aware of attitudes, boundaries, and behaviour.

Johns’ model for structured reflection (1994) is more of a list of key questions to guide an analysis of a incident or general experience. Johns recognizes the benefits of sharing reflections which is an essential part of building a community of practice and the importance of the ‘situatedness’ of an incident as highlighted by the attention given to influencing factors and learning as involving considering actions to support others:

• Description: Drawing out of the key issues within an experience through a description of thoughts and feelings and contextual background of the experience
• Reflection: Examination of one’s motivations and the resulting actions, the consequences of actions for all stakeholders (including their possible emotional reactions).
• Influencing factors: Determining internal and external factors that influenced decisions and actions.Determine knowledge that did or should have influenced decisions and actions.
• Alternative strategies: Evaluation of one’s actions and consideration of other possible choices and their respective consequences.
• Learning: Situating the experience and feelings within past experience and future practice and in providing support to others and considering the impact the experience will have on reflection-in-action.

By using John’s reflective model as a guide, I have been able to reflect on the incident and this has enabled me to evaluate the actions that I took during the incident, questioning whether my response was appropriate. It has also allowed me to think of other ways I could have dealt with the situation and the possible outcomes. The reflective strategy has helped me to learn from this experience and has given me an insight into how I might improve my own future practice. It has also shown me that, by continuing the reflective process by following reflective frameworks such as John’s in future incidents, I may improve the ways of dealing with situations, and acknowledging that I am actually learning something from every experience that I have.

Conclusion

Reflective practice has been identified as one of the key ways practitioners can learn from personal experience. In education it is recognised as an essential tool for students to enable them to make the links between theory and practice. It enables practitioners to develop knowledge and skills necessary for professional practitioners. Reflective practice can be summarised as experience-reflection-action (ERA) and seen as a cycle and having the following components:

• Things (experiences) that happen to a person
• The reflective process that enables the person to learn from those experiences
• The action that results from the new perspectives that are taken.

Reflective practice uses personal experience as a starting point for learning, by thinking about these experiences in a purposeful way the individual can understand them differently and take action as a result. The learning acquired using reflective practice differs from the theory which underpins practice, it is also different from the skills acquired from interacting with others because it involves thinking about things and actively making decisions, therefore reflective practice bridges the gap between pure theory and directed practice by providing a strategy that helps to develop understanding and learning.

The importance of reflection has been reinforced to me in writing up this critical incident, because I hadn’t realised how important maintaining boundaries were, and the showing of mutual respect. Continuing professional education is also accepted as having an important role in facilitating change in practice. It is argued here that reflection on practice is the means to ensure continuing development of both individuals and the profession in order to meet the challenge of change. Reflection may also be prompted by a challenge from another occupational therapist, a multidisciplinary team member or a student. Reflective diaries and written assignments are also useful ways of prompting application of theory to practice. In addition to applying theory to practice, literature searching, critiquing and reviewing, essential to postgraduate education, also stimulate reflection.

References:

Alsop, A. (2000/2004) Continuing Professional Development for therapists. U.K. Blackwell Science Available on-line at http://0www.netlibrary.com.serlib0.essex.ac.uk/Reader/

Baumgartner LM (2001) An update on transformational learning. New Directions for Adult and Continuing Education. No89:15-22. Jossey-Bass, San Francisco.

Boud D, Keogh R & Walker D (1985) Reflection: turning experience into learning. Kogan Page, London.

Boyd E & Fales A (1983) reflective learning: the key to learning from experience. Journal of Humanistic Psychology, 23 (2): 99-117

Clutterbuck, D. (1998) Learning Alliances: Tapping into Talent. Institute of Personnel and Development, London.

Creek, J. (2003) Occupational Therapy defined as a Complex Intervention London: College of Occupational Therapists. Available from: http://www.cot.co.uk/public/publications/skills/ot_definition/intro.php

(Accessed 13 Jan 2010)

Dimond, B.C. (2004) Legal Aspects of Occupational Therapy (2nd ed.) Oxford. Blackwell Science

Duncan, E. (2006) Foundations for Practice in Occupational Therapy (4th ed) Edinburgh: Churchill Livingstone.

Jasper, M. (2003) Beginning Reflective Practice Foundations in Nursing and Health Care. Cheltenham. Nelson Thornes Ltd

Johns C (2000) Becoming a reflective practitioner. Blackwell Science, Oxford.

Kolb DA (1984) experiential learning: Experience as the source of learning and development. Prentice Hall, New Jersey.

Mattingly, C and Fleming M (1994) Clinical Reasoning Forms of Therapeutic Practice Philadelphia. F.A. Davis

Moon J (1999) Reflection in Learning & Professional Development. Kogan Page, London.

Reid B (1993) ‘But we’re Doing it Already!’ Exploring a Response to the Concept of Reflective practice in Order to improve its Facilitation Nurse Education Today, 13: 305- 309.

Richardson G & Maltby H (1995) reflection on practice: enhancing student learning. Journal of advanced Nursing. 22:235-242.

Roberts, A E K (2002) Advancing Practice through Continuing Professional Education: the Case for Reflection British Journal of Occupational Therapy May 65(5)

Schon, D.A. (1995) The Reflective Practitioner: How Professionals Think in Action. New York. Basic Books

Sabonis-Chaffe B, Hussey S, M (1998) Introduction to Occupational Therapy 2nd edition, Mosby, USA

Tryssenaar J (1999) Interactive journals: an educational strategy to promote reflection. American Journal of Occupational Therapy 49 (7), 695-702.

Wackerhausen, s (2009) Collaboration, Professional Identity and Reflection across Boundaries. Journal of Physical Health 463 – 472

Zubrizarreta J (1999) Teaching portfolios: an effective strategy for faculty development in occupational therapy. American Journal of Occupational Therapy 53(1), 51-55.