The paramedic role is becoming increasingly complicated and varied, necessitating paramedics to be highly-skilled and knowledgeable evidence-based practitioners. High-quality education and subsequent continued professional development (CPD) are essential.
Reflection encompasses a key part of this CPD (Health and Care Professions Council (HCPC), 2012; 2014). The process of reflection, when involving the collection of evidence and data from multiple sources, is said to promote deep reflection and self-assessment, which in turn produces a more accurate and valid evidence base from which skill and knowledge development and improvement can take place (Boyd and Fales, 1983). In order for reflection and reflective practice to develop and thrive, the environment should provide certain factors. These include intellectual and emotional support, and an organisational climate that promotes respect, mentoring access, time for group discussion and reflection, as well as freedom to express opinions (Devenny and Duffy, 2014). For reflection to be entrenched in the learner's mind, mentors and facilitators need to provide quality teaching and learning opportunities, support, clinical leadership behaviours and a positive work culture (Walker et al, 2013).
When exploring concepts of learning and development within a clinical environment, it is therefore important that socialisation theory is considered. Professional socialisation is fundamental when considering the process of transforming a beginner into a professional (Dimitridou et al, 2013). The beginner integrates into the new environment and adopts the values and norms of behaviour. The person who wishes to integrate into the environment begins to adopt stereotypes and ideologies held by members of the profession they wish to integrate into (Brennan and McSherry, 2007).
Review of the literature
Searching the key words ‘reflection AND paramedics’ yielded very few results, which focused mainly on ‘how to’ guidance on reflection. The literature search was therefore widened to encompass other healthcare professions.
Boud et al (1985) state that reflection enables students to handle everyday clinical situations competently. Critical reflection allows the examination of implicit assumptions that have the potential to limit professional practice (Fook, 2002). Reflection offers students the opportunity to make sense of their experiences in clinical practice, recognise any learning that has taken place and build a foundation for further experience and learning (Boud, 2011). It is apparent in the research that students, particularly novice students, find reflection challenging and can struggle to see its benefits (Parish and Crookes, 2014).
How reflection is taught and threaded through the curriculum is vitally important to encouraging participation in reflection, but also to enabling understanding. Fernandez-Pena et al (2016) concluded that when questioned, students often reported confusion over reflection and had the perception that it was a difficult concept to engage with. However, it appears through studies such as Smith and Jack (2005) that when a clearer understanding is developed and there is regular engagement with reflection, this leads to improved clinical competency, and increased self-awareness.
In a study with nursing students and nursing staff, Clarke (2014) found that the harnessing of a climate of safety, which cultivates honest reflection, is essential to engaging students with reflective conversations. Clarke (2014) also highlighted that reflection needs to be encouraged and present in both the clinical practice environment and the educational institution for it to have maximum impact. The results section is a little unclear in its presentation; however, there are valid points for any healthcare programme aiming to teach and encourage reflection.
Reflection is complex in nature and requires the students to possess self-awareness, analysis and critical-thinking skills (Braine, 2009). Those students who find reflection difficult will need high levels of support in order to become reflective practitioners (Halton et al, 2007). The way reflection is taught and encouraged is therefore vitally important in any profession. Roche and Coote (2008) investigated students' perceptions pre- and post-reflective module delivery, and the module was seen to have a significant impact on the perceptions of reflection.
Reflection is part of experiential learning. It facilitates learning in and on action (Jasper, 2003). Reflection, within this experiential cycle, allows a practitioner to develop theoretical knowledge gained from an experience, thus contributing to their overall development as a practitioner (Rolfe et al, 2001). In her study with psychiatric nursing students, O'Donovan (2006) identified that mentor support and mentor encouragement of reflection were seen as being essential. Students experienced mentor involvement ranging from minimal to enthusiastic; this appeared to have profound effects on the student and their engagement with reflection. As well as disengaged mentors or non-motivational lecturers, time constraints were another major limiting factor (O'Donovan, 2006).
The evidence suggests that when taught well and encouraged in both the academic setting and clinical placement environment, reflection can have significant positive implications for students' learning. There appears to be significant barriers to reflection in clinical practice and educational environments, which need to be addressed in order to nurture and encourage reflection.
Method
An interpretist qualitative research design was chosen for the study. Qualitative research strives to gather inductive information on the lived experiences of the people immersed in a particular phenomenon, generating theory or thinking around the phenomenon (Flick, 2014). This work does not intend to generalise its results to the paramedic profession; instead, it aims to generate ideas on the perceptions of reflection.
Purposive sampling was used in order to select the participants. The participants were required to be student paramedics who were at the end of their academic course. All of their marks had been awarded, external examiner processes had taken place and marks agreed, so they were only awaiting academic board process. This was essential to ensure the ethical soundness of the work and paramount that the students didn't feel pressured into participating or worried about open honest conversation affecting their grades.
A detailed participant information sheet was given and students had the right to withdraw from the study. The selected participants were comfortable talking in a group which was essential, as focus groups were chosen as the method of data collection. Nine participants in total were spread across two focus groups. Four participants were male and five were female. There was a mix of age and experience in the group. As advised commonly in the literature, with the participants' permission, the focus groups were audio-recorded, with transcription and data analysis occurring after the interviews (Gerrish and Lacey, 2010). The wellbeing of the participants was of primary concern during the research study.
Thematic analysis was chosen as the most suitable data analysis tool. Braun and Clarke (2006) state that thematic analysis suits methodologies that are without a defined theory or epistemology. Owing to this theoretical freedom, thematic analysis provides a flexible and useful research tool which can provide rich and detailed data (Braun and Clarke, 2006).
All data were stored and destroyed in line with the Data Protection Act 1998. An application for ethical approval form was submitted, as well as a research proposal document, disclosing details of the research piece. Ethical approval was granted by the University of Worcester's ethical approval board.
For the original submission, the full transcripts were disclosed, along with a rationale for emergent themes. Sampling and data analysis methods were described in detail, as well as focus group questions and transcripts, thematic analysis process and documents. It was decided during the peer review process however that it is beyond the scope of this article to provide this level of information.
Results
The transcripts were initially broken down into sentences and phrases that matched the grouped codes. The transcripts were then grouped together according to grouped codes which created more generic subjects. These were placed together in a different document in order to begin the thematic analysis of the data as recommended by Aurini et al (2016). The researcher had experience of clinical practice as a paramedic student, a mentor and an educator. Data analysis therefore had to be reflexive. Nine themes in total emerged from the data. These were: group or individual reflection; useful reflection; novice to expert; dealing with feelings; targets times; hierarchy; new versus old and negative triggers; assessment and reflection; and no time or support.
Individual or group reflection
There was a very clear differentiation between group reflection and more formal individual reflection, and most group members highlighted them as two separate processes. Group reflection appeared to be more consistently encouraged in clinical practice:
‘I think that [group reflection] is more important, if you are working as part of a team you would all reflect on something’.
‘I think it can be individual, but I also think it can be done in a group, like a more informal thing, I think on your own is more academic and uses more of the evidence’
Useful reflection
All of the participants found reflection to be useful and felt that it helped to improve their practice. Most of the participants envisaged using it once they were qualified:
‘I think it has definitely made me a better clinician. By reflecting on what I didn't do well or [when] I was happy with what I was doing, I have been able to look at my practice and make improvements, and I have become a better clinician because of it’.
Novice to expert
The participants discussed their reflective ability improving as they moved through the course. They developed their reflective skills and were therefore able to do more with their reflections, making them more useful and more evidence-based:
‘The way I reflect has changed loads since I started this course, like at the start you are focused on the little things that you did wrong and how you could change that, to like now when I reflect I am looking at like medically or clinically how could you improve upon that patient's care… I think it gets bigger and broader. At the start you know you might be thinking, “oh no I didn't put the ECG dots on right”… now it's bigger, you reflect on bigger things, the whole thing really’.
Dealing with feelings
Some of the participants highlighted that reflection could be used to deal with feelings if they had experienced an upsetting case and felt they needed to talk it through. They felt however that this was more suited to the group style reflection:
‘I think when something has really upset you, you need that other person. You need to talk to people’.
New versus old
There was a distinct sense in both of the focus groups that there were two kinds of clinicians, and that they had a very different way of thinking about a variety of things including reflection:
‘The people who are newly qualified do a bit more I think, people who have done the mentor course definitely, people like CTMs [clinical team mentors] do, they talk about reflection more… Paramedics who have come through University, they do definitely’.
‘Some of the senior paramedics don't talk about it at all’.
Negative triggers
It appeared that negative triggers seemed to be the most common prompt for reflection. Things like difficult cases, feelings or inadequacy, or a mentor or nurse suggesting something that they themselves had not thought of, commonly prompted reflection. The students did not appear to reflect to consolidate or confirm good practice:
‘Bad jobs, jobs where you didn't get the outcome you thought you were going to get’.
‘Jobs that take you out of your comfort zone, or the ones that you really didn't have a clue, or felt that you didn't have a clue, what you were doing’.
Assessment and reflection
The participants' perceptions and viewpoints of reflection appeared to be affected by their educational experience; in particular, an assessment they had been given in year one of their studies:
‘Our first real experience of structured reflection, I found it really hard to understand how to write it, how to understand it, how to follow the tool that we had, and I think because of that, I got it in my head that I couldn't do it and I didn't like doing it, and it gave me a negative image’.
No time or support
There was a seeming lack of support in clinical practice and a general lack of time to engage with activities like reflection. There was also a sense that they would have no one to go to once they had qualified, and there would be no equivalent to the lecturer support they had experienced:
‘You are here to work if you want to do that type of thing then you do it at home, tough, there is not time. And I think it is unreasonable, of course you expect to do some, but you have families and lives and you are less likely to do it in your own time’.
Intended use in the future
All of the students were confident that they would use reflection in their future practice and it was identified as one of the ways they could keep up to date:
‘I think for the whole 2 years we have been on a reflective cycle really. I intend to act not differently really once I qualify. Every time you go to a job whether it is something you have seen before, as you walk in the door you are reflecting’.
‘I will 100% use it, not only because I have to for my registration, but to be the best I can be’.
‘I think it will give me new ideas on how to do things, and if I hadn't reflected then I wouldn't have come up with them you know’.
Discussion
The purpose of the present study was to learn about nearly qualified student paramedics' perceptions of reflection and their intended use of reflection post qualification. All of the participants shared the viewpoint that reflection was necessary and a useful tool for improvements in their own practice; some even saw a broader value in terms of potential improvements in paramedic practice in general.
The participants definitely saw group and individual reflection as two different concepts. In the commonly used group reflection, the theoretical evidence base appeared to be missing. In more formal reflection, when re-evaluating the experience, there will be an engagement with a theory base that may not be seen in informal reflection (Boud et al, 1996).
In an empirical study testing the perceptions of reflection of mental health nurses, Clarke (2014) noted that a safe climate, which cultivated honesty in reflection and review, was important and would encourage reflective practice. This needed to be embraced by clinical leaders and mentors in clinical practice. The experiences of the participants in the current study suggests that this reflective conversation or the harnessing of honest reflection is patchy at best and is very dependent on the mentor or mentors the student works more regularly with. This particularly appears to be the case when considering formal theory-based reflection. There does not appear to be an overly negative view of reflection in clinical practice, but rather an absence of it in many areas. This absence is worrying as it does not encourage either reflective conversations or theory-based reflection.
Participants' engagement with reflection improved as they developed clinically and gained experience in clinical practice. Knowledge and the notion of knowledge underpins deep reflection (Poom-Valickis, 2013). As experience was gained, this appeared to lend more value to the reflective process, and reflective work took on a broader more patient-care and evidence-based focus. When considering some of the reviewed literature, this may help explain some of the differences in perception, and perceived complexity of reflection between newer undergraduate students (Fernandez-Pena, 2016) and postgraduate students (Chirema, 2007).
Early use of formal reflection before this development, and without adequate support could therefore negatively affect the students' perceptions of reflection, and appears to have been the case with the participants in the present qualitative study. This could potentially instigate significant change in paramedic education as there is a need to understand the importance of timing of reflection within an educational programme. The students appear to need a sounder evidence base and clinical knowledge to gain any benefit from the reflective process. The nature of structured exercises or assessment tasks appeared to affect engagement and enjoyment significantly.
It appears from the results that the most common triggers for reflection were negative in nature. This is echoed in Gustafsson and Fagerberg's (2001) study, which found that the nurses questioned reflected more on poor nursing care situations. This finding is worrying as it relies on the students' own perception to identify a poor or negative trigger before a reflective process is initiated; this is particularly the case where the mentor isn't engaging them in the reflective process. Reflection needs to be more habitual than sporadic in nature in order to be as effective a practice improvement tool as possible, rather than being reliant on a negative trigger. Furthermore, always focusing on the negative could potentially affect the students' or paramedics' mental health, their perceptions of their role, their professional abilities and their attitudes towards work. It cannot be seen as helpful for any clinician to constantly review and relive only their negative experiences and this attitude and culture needs to be changed.
Following clinical, experiential and academic development, participants clearly felt more comfortable and confident with reflection than they did in their first year of study. This change in perception post teaching and post development in reflection appears to have been identified in the previous research. Roche and Coote (2008) reported a deeper understanding of reflection by students following a taught module on reflection. Laverty (2011) reported an improvement in attitude towards reflection and an understanding of its ability to bridge the gap between theory and practice. The participants were keen to continue being reflective as they moved into the newly qualified phase of their careers.
As Jasper (2003) states, reflection is part of experiential learning. The environment in which the learning takes place is fundamentally important. Boud and Walker (1998) state that when people group together in an organisation, the organisation influences the attitudes and behaviours of those within it. There appeared to be an absence of discussion about reflection, and possibly of its use, in more senior longer-serving clinicians. Participants felt they weren't encouraged or driven to use reflection when working with these clinicians. This was echoed by Turner (2015) who found that clinicians who had been vocationally trained did not tend to engage with the theory element of the reflective cycle.
Implications for paramedic education and practice
Reflection is a key part of paramedic development, and is a valuable learning tool that can help with the journey from novice to expert. However, it is not the case that reflection can simply be placed into a paramedic education curriculum with no thought or consideration to how it will be developed and how students will be supported. Reflection as an assessment technique appears to be challenging and possibly problematic; this needs to be considered as there may be an argument for not using it as an assessment tool at all.
Clinical practice has the potential to encourage and use reflective learning for and with the students they have in placement. Mentors are influential in this; close working and continuation of the encouragement of reflection needs to exist in order for there to be true parity between practice and education. Encouragement to partake in reflection should be given following good performance as well as negative events, in order to not only improve knowledge, but consolidate and enforce existing good practice.
Conclusion
This research has shown parity with similar research conducted in other healthcare fields. It has identified the need for further exploration on this subject and for a wider review of reflective practices in both educational settings and in clinical practice. When engaged with, it is apparent that reflection is a useful tool.
The students in the study used reflection in a group setting frequently, as well as individual reflection, which appeared to have more of an evidence base associated with it. Similar research with students would be beneficial; however, perhaps more importantly, research with qualified clinicians from a variety of qualification entry routes and time served would be recommended as these seem to be very influential factors on the students' behaviour and engagement with activities such as reflection, which shows parity with research on socialisation behaviours.