'Look well into thyself; there is a source of strength which will always spring up if thou will always look.' – attributed to Marcus Aurelius.
I have recently been reading and enjoying stoic philosophy. The quote above is attributed to Marcus Aurelius, found readily online and supposedly from his book Meditations. When I looked through my copy and tried to find the passage it is from though, I was unable to find it. Whether the quote is Marcus Aurelius or not it caused me think about reflective practice in my clinical placement. Consequently, I dived into my notebooks and revisited scribbled notations about how I’d ‘messed up a knee’ or ‘over rotated the wrist’. A lot of these notes are underlined several times and at the start of my placement quite negative in their nature. As I flipped through the notebooks they became more positive, focusing on improvements I’d made or helpful tips that radiographers had shared; ‘ankles away, like anchors away for lateral’ or ‘consultant thanked us at the end of surgery – buzzing’ or ‘happy with chests now, rad said could do assessment – hug bucky for older patients ’. My formal reflections in my record handbook though are more a record of what I did in each modality. They aren’t reflective at all it turns out. Or any reflection that is present is superficial at best. As a former teacher who is well used to a reflective cycle in practice and having completed a module where the main assessment was a reflective essay this gave me pause to stop and consider reflection in more detail as I thought I had been reflecting effectively where in actual fact I’ve mostly just been keeping a diary.
Reflection should be part of our toolkit as practitioners, the SoR code of conduct (2013) states that individuals should become reflective practitioners as part of their development. In fact, there is literature suggesting embracing reflective practice has been shown to improve competence in healthcare students (McLeod et al, 2020) and allow qualified practitioners to keep up with changing fields (Mantzourani et al, 2019). It has also been shown to help maintain professional competence throughout a professional’s career (McIntyre, Lathlean and Esteves, 2019). All this suggests reflection is something that will help me improve so I should strive to do better with it.
Unfortunately, it has been suggested that forcing reflection on individuals will just lead to them producing a ‘desired’ reflection for an assignment, which negates the point and lessens its impact (Hobbs, 2007). A way through this is to have reflective practice gradually introduced over time, to students or practitioners, allowing their confidence and skill at reflection to be nurtured (Kelsey and Hayes, 2015 and Hobbs, 2007). This will require a successful modelling of reflection by experienced individuals for those learning to gain the most from it (Fletcher, 1997). I know in my own course; reflection was the subject of one of our first assignments and as said weekly reflections on our placement are a part of our documentation for clinical practice. Also as said, I failed to really use reflection in a meaningful way during my clinical practice. However, as a first year I have time to embed regular reflection in my working life and really thread it through my thought process when I consider my performance. In other words, I can start small and gradually work on my reflective skills during my course. Checking with mentors and lecturers to ensure that I am using reflective models correctly and self-assessing what I am getting out of the process.
I have mentioned my assignment a few times already, in researching that I came across something with regard reflection that I hadn’t previously considered. That being its potential to help with dealing with the anxiety felt around placement.
You see there is an increase in both the rates and the severity of mental health disorders in university students, and this is specifically higher in healthcare students (Macauley et al, 2018). This is probably because healthcare professionals experience higher levels of stress than those in non-medical environments (Newdrow, Steckler and Hardman, 2013). The reason for these stresses is most likely due to witnessing the tragedy, suffering and distress of people first-hand which is something students are exposed to early in studies and training (Taylor, 2019). This is supported by the fact students feel highest stress levels due to clinical practice (Wang, Lee and Espin, 2019). A lot of the stress felt or mentioned above is potentially ‘state anxiety’ (Cassady and Johnson, 2002) which is the same kind of feeling that one might get around a test or assignment. This contrasts with ‘generalised anxiety disorder’ which is a long-term condition where the anxiety felt is not linked to specific situations (Tyrer and Baldwin, 2006). This means that some people who feel anxious about a particular scenario (going on clinical placement) might be feeling anxious more generally rather than just because of that scenario. This is a serious problem as anxiety is shown to affect working memory, causing issues with cognition, memory and processing capacity (Al-Ghareeb, McKenna and Cooper, 2019) and there is evidence of strong links between anxiety and other conditions such as burnout and depression (Nedrow et al, 2020).
Reflective practice is a metacognitive exercise designed to allow individuals to address gaps in knowledge, skills and even reshape attitudes (Kanofsky, 2020) yet it is even more powerful than that. Guided reflection has been shown to help reduce anxiety in students (Sharif et al, 2013) and reflection can be used to allow individuals to look beyond just the good and bad for their practice and focus more on improving their patient centred care (Joyce-McCoach and Smith, 2016). This can lead to a higher level of self-esteem in an individual and towards self-actualization which is the path for realization of potential in Maslow’s hierarchy of need (Sharma, Chaturvedi, N., 2020). As a result, this ability to reflect accurately while balancing the emotions that might bring about is very important. A deep study into reflection in nursing practice listed empathy and self-awareness as two of their eleven essential ingredients for successful reflection (Clarke. 2014). This means that by developing a good, strong reflective process a student or practitioner can not only improve their patient centred care by improving their empathy, technical abilities, and knowledge. They can also improve their own feeling of self-esteem and confidence by being able to see their improvements and experience individual growth. This has to be seen as a positive impact on a student’s anxiety towards placement.
There are many models of reflection Kolb’s (1984), Gibbs (1988) and Rolfe et al (2001) are some of the main ones. Most dealing in similar themes of ‘experience’ then ‘what happened’ and finally ‘what will you do’. The Rolfe model mentioned previously is one of the simpler versions of this with its ‘What?’, ‘So What?’ and ‘What Next?’ questions whereas Gibbs’ model of reflection is a bit more detailed and includes focusing on the emotions felt at the time. This I feel gives an important extra layer to the reflection when applied to a healthcare environment (for the reasons listed above). Gibbs is the model I used in my assignment and the one I aim to use more going forward.
However, reflection is a very personal process. It does not need to be done all the time nor do you only have to follow one model (or any) of reflection. What is important though is that you engage with reflection voluntarily and wholeheartedly as Kelsey and Hayes (2015) suggested that there is possibility that forcing practitioners to reflect using a model could cause them to reject the notion of reflection totally, which is not what we want to happen at all.
In short, learning to reflect on your practice effectively can help you to be a better radiographer by focusing on how you can best help patients. This is done not by thinking about what you did wrong, but how you might improve on what you previously did in a constant non-judgemental self-improvement cycle. In turn this can make you feel like your role within patient’s healthcare pathway is done to the best of your abilities which can improve how you feel and help reduce the stress and anxiety around placement.
Personally, I’m willing to invest in reflective practice in order to be less anxious and more confident about my placement. I want to develop reflection as a tool so that I can gain the most from my practice and become the best I can be. Whether the quote at the start of this article is truly his words or not I’d like to think Marcus Aurelius would be pleased at that thought.
Chris Gibson is a first year diagnostic radiography student at Canterbury Christ Church University and a member of the SoR Student Forum.
References
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