The continual progression and dynamic nature of health care provision, increasing consumer demands and the requirements of clinical governance in the modern NHS, have dictated the need for the adaptation of systems of care which are resource efficient and cost effective (Department of Health (DH), 1998). Furthermore, the knowledge and skills required of health care professionals have evolved and it is paramount that future practitioners are ‘fit for practice’ at the point of registration (Health Professionals Council (HPC), 2007).
These changes are reflected in the provision of prehospital care (DH, 2001) with greater responsibility being afforded to the ambulance service for mobile health provision (DH, 2005). These changes have necessitated the development of the role of the paramedic to provide evidence based emergency care (College of Paramedics (CoP), 2008).
Consequently, there has been a shift in the training and education of technicians and paramedics from the customary methods instigated by the Institute of Health Care Development, towards an academic pathway in association with higher education institutes (HEIs). This is supported by the CoP Paramedic Curriculum Guidance and Competence Framework (2008), the HPC Standards of Proficiency (2007) and Standards of Education and Training (2009), and the Quality Assurance Agency (QAA) Benchmarking Statements (2004). As a result, greater emphasis has been placed upon the need for paramedics to demonstrate clinical effectiveness through the use of critical reflection and evidence–based practice (EBP).
Paramedics must then be able to demonstrate their knowledge, understanding and fitness to practice by evaluating and developing their professional practice based on the best available evidence. To meet these objectives, they must develop the skills to critically analyze what they are doing. This involves asking questions about their practice to determine the most appropriate actions which should be taken and to present an argument to support this using appropriate research based resources. This will provide an evidence base from which they can decide what actions they should take in the future and how their practice could be improved.
Background
Reflective practice has been highlighted as a key component of evidence-based healthcare (Craig and Smyth, 2002). It is suggested that these two elements function synergistically to improve clinical effectiveness; the former serving as a tool to appraise aspects of patient care, and the latter a method of supporting the treatment and management of healthcare needs with scientific evidence (Muir Gray, 1997).
Reflection in and on action are dominant models used by nurse practitioners to demonstrate their clinical effectiveness through evaluation and development of their professional practice, which is based on the best available evidence; a skill which can enhance life-long learning and demonstrate competence to practice (Adams, 1999). As a result, reflective writing has become established as a key component of reflective practice in health care education and academic assessment (Palmer, 1994).
However, it has been documented that the nursing profession continues to be faced with the dilemma of how to get evidence into practice (Lockett, 1997). This is supported by Funk et al (1991 and 1995), Carroll et al (1997) and Miller et al (1994), whose studies demonstrate a consensus that the main contributory factors include a lack of knowledge about how to access, read and translate research into practice.
Furthermore, several authors have reported student difficulty in applying critical thinking and analysis in theory and practice and have formulated models to support the development of this skill (Case, 1994; Dobrzykowski, 1994; Kataoka-Yahiro et al. 1994; Price, 2004).
These findings were reflected by a group of the author's personal nursing students, who expressed difficulty in combining the skills of critical analysis and EBP in their academically assessed reflections on practice using the Gibbs reflective cycle (1988). Evaluation of group discussions identified the need to develop a guide for the students to:
In response to student requests, a set of guidelines were developed. These were underpinned by Brunner's constructive theory of learning (1997) through which learners construct new ideas or concepts in a spiral manner, providing meaning to experiences and allowing the individual to construct hypotheses and make decisions. This was augmented by adaptation of the Lenburg competency outcomes and performance assessment (COPA) model (2002), the Sackett et al patient, intervention, comparison, outcome (PICO) model (2000) and the Gibbs' reflective cycle (1988).
Student and tutor evaluations revealed that the students had found the instructions easy to follow. They were able to plan their work effectively and had developed an insight into the types of questions they could ask about their practice. They had also begun to retrieve and use appropriate evidence and develop their skills of critical analysis. As a result, they received higher marks for their academically reflections on practice.
Furthermore, the students reported that they had applied these skills to their essays, case studies and in reflective discussions with their mentors in practice, giving them more confidence to link theory with practice. As a result, this guide is used across a range of health care programmes and continues to be positively evaluated by students. The guide has been adapted to support paramedic students and is outlined below.
How to plan and write an evidence based critical reflection using the Gibbs' reflective cycle (1988)—a guide for paramedic students
This guide has been designed to help you to write evidence-based critical reflection on your practice based on the Gibbs reflective cycle (1988), which will help you to demonstrate your fitness to practise. It is divided into four stages which will guide you and give examples of how to identify a focus for discussion, to conduct a respectively focused literature search, to critically analyze your practice using an evidence based argument and how to systematically plan your work.
Identify a specific aspect of practice for discussion
In order to write a critical reflection, which is restricted by a word limit, you will need to focus specifically on an experience in a particular area of practice. Lenburg (2002) proposed that health care practitioners can promote the quality of their own practice by engaging in critical self-reflection, where they thoughtfully analyze their skills and limitations under each core competency category in her competency outcomes and performance assessment model (COPA).
This has been adapted to provide examples of six specific aspects of paramedic practice which you could focus upon.
Assessment
Demonstrate how you assessed a patient. What strategy did you use? For example, you may have used a pain assessment scoring tool, a full systematic assessment using the ALERT (ABCDE) tool or a strategy based on a JRCALC protocol/guideline.
Management
Show how you managed a patient. What care, treatments or support strategies did you use? For example, you may have maintained your patient's airway using a chin lift/jaw thrust, or given a diabetic patient in a hypoglycaemic state an IM injection of Glucagon.
Communication
Demonstrate your use of communication skills. This might encompass verbal/non verbal or written skills. For example, you might discuss how you used your skills to reassure a patient, how you recorded the care and treatment given to a patient or how you conducted a patient handover to a member of A&E staff.
Human caring relationships
Discuss how you maintained a human caring relationship with another. For example, you may have shown empathy, compassion or sensitivity towards a patient or the parents of a critically ill child or shown your respect for the religious beliefs of a patient/carer.
Teaching
Show how you used your teaching or mentorship skills. For example, you might discuss how you planned, delivered, facilitated or evaluated a teaching strategy to educate or train a patient or a colleague, or the strategies you used to mentor a colleague or student.
Leadership
Demonstrate how you applied the skills of leadership to your practice. For example, you might discuss the strategies you used to motivate a member of staff or how you delegated tasks to a team of colleagues to coordinate triage.
To enhance your work further, it is important to demonstrate how your practice was influenced from a wider political perspective. For example, you might discuss how your practice complied with current policies, procedures, CoP and or JRCALC guidelines, the HPC Code of Conduct, law and ethics or clinical governance/national service frameworks.
An example of identifying a specific aspect of practice for discussion
It is difficult to cover all these competencies in one piece of work when you first start, so it is a good idea to initially focus on one or two.For example, if you want to write a reflection on how you cared for a diabetic patient in a hypoglycaemic coma. Your focus on this occasion might be how you assessed the patient's blood glucose level using a blood glucose monitor and the procedure that you followed. As you are discussing your use of an assessment tool to ensure that your patient is managed effectively, you are focusing on competency 1.
You may wish to take the discussion further and reflect on how you also managed your patient by giving an IM injection of Glucagon, therefore including competency 2 in your work.
As you become more experienced in your writing skills, you could expand your discussion to include the difficulties you might have encountered when communicating with your patient to gain patient consent and this would then cover competency 3. Ultimately, you will be able to cover all the competencies which are applicable to your particular experience in one piece of work, which will help you to demonstrate the degree to which you were able to care for your patient in a holistic manner.
Finding the evidence
It is difficult to analyze what you are doing in practice if you have no knowledge or understanding of the subject area or evidence of current recommendations. While much information can be gained from books and web sites, published research, available online from university and hospital libraries can provide the most up–to–date evidence of best practice. It can take hours to conduct a literature search, as an online search often produces an abundance of article and research titles which are irrelevant. However, a focused search, which is based on a question about your practice is more likely to produce appropriate literature and your time will be better spent.
The patient, intended outcome, paramedic intervention (PIP) chart in Table 1 is based on the Sackett et al's patient, intervention, comparison, outcome (PICO) chart (2000). This was adapted to help you ask questions about a specific area of paramedic practice and to identify the relevant search terms to help you conduct a focused literature review.
| PIP | Search Terms |
|---|---|
| Patient | |
| Intended outcome | |
| Paramedic action |
Having identified an appropriate scenario and the focus you wish to discuss and analyze, you should then formulate a question you wish to answer, which could take one of two forms. Your question might involve asking if your practice on this occasion was correct or you may want to compare two possible interventions used in paramedic practice to determine which one was the most appropriate.
Examples of the type of questions that could be asked
Was my action correct?
Mrs Green, a 45–year–old lady had suffered an epileptic fit and her convulsions had ceased. She was in a semi-conscious state and her breathing was compromised by a partially blocked airway due to a build up of saliva in her oropharynx. You used a yankeur sucker to clear her airway.
You should therefore ask the question ‘was the use of a yankeur sucker an appropriate method to clear a patient's airway which was compromised by saliva? (By answering this question you could demonstrate your ability to meet the management competency).
Using the PIP chart in Table 1, you can pinpoint the search terms which are most appropriate to find the answer your question. In this case you would enter the following search terms:
Which intervention was the most appropriate?
Mrs Green, a 45-year-old lady had an epileptic fit and her convulsions had ceased. She was in a semi-conscious state and her breathing was compromised by a partially blocked airway due to a build up of saliva in her oropharynx. You used a yankeur sucker to clear her airway but question if the use of an FG14 suction catheter might have been more effective.
You should therefore ask the question ‘was the use of a yankeur sucker or an FG14 suction catheter an appropriate method to clear a patient's airway which was compromised by saliva? (By answering this question you could also demonstrate your ability to meet the management competency).
In this case you would enter the following search terms into the PIP chart:
With both examples, you will need to enter the search terms under the PIP headings individually in your online search. If you then highlight them, then combine them and enter the search, you are more likely to find literature that will specifically answer your question.
Critically analyzing your practice and presenting an evidence based argument
Having read the literature and decided the action that was most appropriate to put into practice, you will need to present an argument that supports your findings. Any action taken under any circumstance will have either a positive or negative effect on the biophysical and or the psychosocial health of another, so discussing the consequences or effects of your actions or another's, on a person's health state, will provide a strong base to support your argument.
The adapted Gibbs' reflective cycle in Figure 1 shows a model which splits the evaluation and analysis sections of the cycle into a left or right sided pathway and provides an example of the questions you can answer to present an evidence-based argument. Both pathways provide examples of the questions you could ask about your practice and how you could present an argument.
Therefore, should you find evidence to support the fact that the actions taken in practice were correct, you would follow the left pathway. However, if you found evidence to the contrary, you would then follow the right pathway. Answering a set of these questions will help you to systematically present your argument in an evidence based critical manner, which will then allow you to make a conclusion to your findings and formulate an action plan for the future.
Planning your work through each stage of the adapted Gibbs' reflective model
Planning your work is an essential ingredient to success. It is therefore a good idea to work through the adapted Gibbs' reflective model as outlined below, drafting the points you are going to discuss under each stage before you start writing your reflection.
Stage 1 and 2
The model guides you to firstly identify an experience and then a focus. At this point, you should identify an experience you have had, then using the Lenburg COPA model (2002), decide the focus you wish to explore and discuss. If your critical reflection is going to be academically assessed, it is important to identify a focus which will meet the assessment criteria.
Stage 3 and 4
At this stage you need to plan how you are going to introduce the reader to your reflection, your patient and your experience. Use this stage to highlight the reflective model you are using and your rationale behind your choice. This should be followed by a brief description of the patient, their health state and the actions taken, making sure you make reference to how you have maintained patient confidentiality. Stage 4 also gives you the opportunity to highlight your self-awareness at the time. You should give a brief description of your thoughts and feelings and explain why the patient or experience was important to you.
Stage 5 and 6
Before attempting to plan your work at these stages, you will need to ask yourself if the appropriate actions were taken. Using the PIP model, conduct a literature search to find the evidence you need to answer to your question. Now, depending on the answer to your question, follow either the left or right side of the adapted Gibbs' model and draft an outline of how you are going to answer the questions, with specific points you want to raise and the references you are going to use to support your work.
Stage 7
Whichever side of the model you follow, the last stage requires you to provide a conclusion to your reflection and an action plan to support your future practice. It is at this point that you can describe what you have learned by reflecting on your experience and how you will apply your knowledge and experience to enhance and or change your practice in the future.
Please remember that while the term ‘critical’ often implies finding fault or expressing criticism, it also has a positive connotation in terms of enhancing or supporting an argument. It is therefore important to be open-minded when critically analysing or questioning practice because whether the conclusions you make are positive or negative, you will generate a new level of knowledge and understanding allowing you to develop your practice in a positive way.
Conclusion
The health care and educational literature present a range of individual models and guidelines, which provide instructions to either finding an evidence base, asking questions about practice or to critically analyze practice. However, these skills are interrelated and need to be combined by health care practitioners to ensure they demonstrate evidence based, effective and safe practice through critical reflection.
This guide has been tailormade for paramedics and technicians embarking on higher education, who find the task of combining the skills required to plan and write evidence based critical reflection somewhat daunting. The guide will not make you an instant expert as these skills take time and experience to develop.
However, it does provide you with the basic ingredients and a basic step by step recipe to follow as a starting point. As with all recipes, this can be adapted and made more elaborate as you become more experienced in the art of critical reflection.