When reflecting on my own teaching and teaching strategies as a clinical tutor, by far my preferred reflective model is Gibbs' (1998). I like its ease of use and multifaceted approach to reflection. However, from a clinical practice point of view, I find that as Gibbs (as with many reflective models) doesn't necessarily demand that the reflecting clinician or student refer to literature and academia in order to compare their practice against empirical evidence, inexperienced reflecting persons may not do so. I have observed this tenancy particularly among those who have been trained vocationally rather than academically and so have not, in essence, been taught to reflect. Neglecting to refer to evidence when reflecting as clinical development activity appears to me to be a missed opportunity to embrace evidence-based practice and personal development.
As a paramedic, I value reflection highly as a way of building on my own development, and is a key tool for discovering information which you may previously have had little or no awareness of. However, this opportunity is reliant upon referral to contemporary evidence and literature. I wanted to build a model which directs the reflecting clinician to refer to literature to develop a deeper understanding of their actions, their patients and themselves. My aim was to guide clinicians into discovering what else is out there that could develop their own individual practice, and possibly practice on a wider scale. I chose a question-based format, as I thought this approach was unambiguous and direct, which would be particularly useful for those who are unfamiliar with the concept of reflection.
Why reflect?
The use of reflective models is well established as an essential element in the academic education of student paramedics, acting as a means of linking theory to experiences gained during placements. Reflection is the bridge of clarity that lies between the diverse and complex events witnessed in practice, and the literature that explains what we see and reinforces or corrects what we do. It is a tool with which developing practitioners can make sense of the world that they work in, but is also there to be utilised by experienced clinicians so that they may analyse critical incidents within their own practice against published knowledge and empirical evidence. The College of Paramedics identifies reflection as: ‘Essential items in a CPD portfolio,’ as it is a means by which clinicians can maintain currency in an ever changing world.
Johns (2000) summarises the benefits of becoming a reflective practitioner in practice:
A new model for paramedics
A variety of reflective models are available to guide the clinician in analysing their experiences, feelings and actions, including Gibbs (1988), Driscoll (1994) and Johns (2010). Models can be ‘appreciative’: a means of asserting the positive; ‘hierarchical’: guiding a progressively deeper knowledge; ‘questioning’: guiding the breaking down of a scenario with structured questions; or ‘iterative’: reflection on an experience produces new understandings with the potential to act differently in future. All these qualities in a reflective model are undoubtedly beneficial, and so, arguably should all be included in a fully incorporative reflective model, rather than being singularly identifiable characteristics of individual models. Including all these qualities was central in the design of this reflective model.
In acknowledgment of the importance of structured reflective models in promoting contemporary knowledge within our autonomous, hugely varied, and largely unsupervised profession, my aim was to build a reflective model specifically designed with the paramedic profession in mind, but which catered for novice as much as experienced reflectors. As reflective practice is often a skill which is taught in academic settings (Mann et al, 2009), there was a danger that those not familiar with the concept may find it difficult to engage with the formalised reflective process, which was considered in the models design, and the reason that the model is essentially a series of questions. It directs the examination of what happened to the patient, what the clinician did, and how they responded emotionally to the situation. They are then asked in each incidence to find reasons as to why all these things occurred, be it the evidence from literature or from peers/clinical supervisors. Finally, the clinician is asked to search for what is, in theory, the ‘ideal treatment’ for their patient, and consider how this may be applied to a similar patient in future, or even how practice may require development to better serve similar patients in future, thus promoting best practice.
What was found and what was done?
This model is designed to question every aspect of the incident or experience that is the subject of reflection. The individual should first choose a question coloured in black to answer, then answer the corresponding grey question, working through all of the pairs of questions within the model (see Figure 1). They could start on any of the outer questions, working inwards, but it is suggested that the individual starts at the top and works around clockwise. The questions may require a descriptive answer, or an answer based on the analysis of that descriptive information. Reflecting individuals must be encouraged to thoroughly analyse every aspect of their assessment and treatment against reliable information in order to gain an explicit understanding of the skills and tools in their armoury. This will encourage clinicians to feel far more prepared and confident to perform to a consistently high standard in similar future incidences, and to be adaptable and responsive to patients who present in unusual or complex ways.
To illustrate the use of the model, I'd like to give a brief outline of one of my own reflections on a call I had attended. The call was to a 2-year-old boy with life-threatening croup, which was around 25 minutes from both where I was when I got the call, and where the nearest emergency department was. There was a general practitioner (GP) on scene with the child's father. I chose to reflect upon this call, as I wanted a greater understanding of how croup was being treated in hospital, and how that compared to what paramedics were doing at the time. The following is a brief outline of my reflection: I first described the call I was reflecting upon—a floppy, pale 2-year-old with life-threatening croup symptoms and ineffective breathing, who was not interacting at all. His heart rate and breathing rate were the lower end of normal ranges for his age (though this presented in the context of a decompensating child), his oxygen saturations read 88%, he was mildly pyrexic, and his blood sugars were the lower end of normal range. I then went on to describe, using literature, what caused croup—typically viral induced laryngotracheitis. I then described what I had done—while gaining a history from the child's father (which initially included the croup typical seal bark cough, after which the child deteriorated), strip the child from the waist up to observe marked subcostal recession, auscultated to find poor air movement, removed the empty nebuliser mask that the GP had used to nebulise salbutamol, and replaced it with a non-rebreather on 15 litres per minute. I then got the bag valve mask ready to use, and started moving towards the children's hospital under emergency conditions. I had a student paramedic with me as my crewmate, but had passed her the ambulance keys as soon as I had laid eyes on the patient. On route, I phoned the hospital (once I had phone reception) for advice from the duty consultant on what else I could do. Once I had informed the doctor of my findings, I was advised to nebulise 5 mg/5 ml of 1 in 1 000 adrenaline. Before the nebuliser was finished, the child had markedly improved. His air movement was adequate with a mild wheeze, his recession had almost gone, he was alert and pink, and he was interacting with myself and his father, who had travelled with us. His clinical observations were all within normal limits five minutes after the nebuliser had finished. On arrival at hospital, I handed over a happy and much healthier child. I went on to research the pharmacokinetics of adrenaline on upper airways (both specific to croup, and for other swelling based obstructive upper respiratory tract complaints) to understand how adrenaline alleviated enough of the local tissue swelling to relieve airway compromise. Research also reiterated to me how short the half-life of adrenaline is, and so the need to get to definitive care regardless of whether the treatment itself was effective in the short term.
Feelings
The questions which enquire about feelings will require the individual to acknowledge their reaction to the incident, and develop an awareness of why they reacted in the way they did. This may be something that they can do on their own, can do through analysis using supportive literature or with the help of an experienced colleague or mentor. Indeed, this is likely to be the area of reflection which an experienced clinical supervisor or mentor may be able to provide the most help and insight of all the aspects of the model and of reflection in general. In the case of my croup patient, I documented my initial concern for this very unwell child—I had the bag valve mask out ready because I judged there to be a high chance of the patient becoming apnoeic. I was frustrated that I initially had no phone signal, and because I felt like I wasn't initially able to improve the child's situation. I felt encouraged by talking to the consultant on the phone, who was potentially providing me with a means of improving the child's situation, and was completely relieved when his sound advice resulted in my patient changing from being extremely unwell to being an alert, happy, slightly snotty child.
Once my jubilation had worn off a little, I came to the realisation that had I not been instructed by the consultant to administer nebulised adrenaline, there was a strong possibility that the child would have deteriorated further, possibly into a respiratory arrest which I would have struggled to reverse. I found discussing the case with my mentor peers hugely useful—I shared what I had learned, and was encouraged to instigate a change in accepted practice. This, coupled with the experience of reading literature to compare my emotional responses and thoughts to expected responses, proved cathartic and self-actuating.
‘Ideal’ treatment and best practice
The final two questions in the model asks what the ‘ideal’ treatment for the patient or situation they are reflecting upon is, and how this may be applied in future to develop our best practice. This question is there to encourage the person using the model to consider what would be the optimal treatment for the patient or patient group that they are reflecting upon. This may be within the current scope of a paramedic practice, but may be treatments or practices which would normally be done under the direction of another group of clinicians, such as doctors, nurses or physiotherapists. They may even be procedures or treatments that are currently being researched, that show promise of being used in the future. The key aim is that the individual is being encouraged to look at guidelines, research and other evidence to see what they could do for the benefit of the patient without considering any practical or theoretical constraints. The individual must then consider how what they have found could be adapted to future practice. This may be something that can be immediately initiated, requires further investigation, or presents as a possible area of clinical development to be pursued in order to instigate a wider change in general practice. The words ‘best practice’ (coloured red) represent the section in which the individual can sum up what they have learned from their reflection, and detail how they think they could deliver the best possible practice in future.
In the case of my reflection, I felt driven to research the applicability of paramedics having nebulised adrenaline for the treatment of croup within their guidelines. What I had initially done (high flow oxygen, and rapid transit to hospital) was at the time regarded as best practice for the treatment of life-threatening croup, but I had also discovered that the ideal practice was what I did under the direction of the consultant. I judged that there was a good case for paramedics doing this autonomously, so went on to research this practice, and with the support of a consultant paediatrician and my Trust's pharmaceutical advisor, I submitted a guideline proposal. The guideline was ultimately introduced to South Western Ambulance Service NHS Foundation Trust last year. In summary, I had identified what the ‘ideal treatment’ for this patient group was, and with a little help, had gone on to make this an accepted practice.
Conclusions
The purpose of this reflective model is that the clinician may develop a deeper understanding of pathophysiological processes related to illness and injury, rather than just acknowledging that they were present in their patient, being able to demonstrate a comprehension of how treatments work rather than just believing that they are likely to work, and attempting to make sense of our emotional responses to what we have seen and done. I feel it important to ask the reflecting practitioner to consider what may be the ‘ideal’ treatment for the patient they have attended, and do not suggest that this should be limited to the clinical spectrum illustrated in the clinician's professional guidelines. Although the treatment that clinicians provide may be directed by clinical guidelines and local operating procedures, this should not restrict the scope of knowledge that clinicians may aspire to gain. Indeed, an awareness of evidence-based treatments and practices that are performed by other groups of health professionals have the potential to improve and/or broaden the scope of paramedic practice, and so should be encouraged. Gubbins et al (2012) sum this up nicely by defining reflective practice as improving our effectiveness by helping us identify, develop and amplify what we do.