As paramedic practice develops cognitive skills such as reflection and reflective writing are becoming as important as traditional psychomotor skills such as cannulation. This development is not unique to our profession. The ubiquitous nature of reflection within healthcare education is due to the fact that learning is fostered through the acknowledgment of the links between theoretical and practical knowledge, emotion and action (Bulman, 2004). There are many ways in which reflection can be used to aid learning. Action learning is a form of reflective learning which occurs with the aid of a group and aims to achieve workable solutions to real problems (McGill and Beaty, 2001).
How action learning works
Although a form of group work, the focus of action learning is the individual. The individual brings a real-life problem to the group known as the ‘set’ and receives the full attention of the set as they present their problem. Through a process of insightful questioning the individual is helped to reflect not only on the problem itself but also on previous patterns of behaviour in order that they may move towards a new understanding of the problem and, ultimately, of themselves. This new understanding then shapes their planned future actions which may solve not only the immediate problem but also determines how future challenges and opportunities are approached (McGill and Beaty, 2001). Reflective practice involves critical analysis of situations which includes activities such as identifying existing knowledge and assumptions, exploring feelings and alternative courses of action (Brookfield, 1987). The action learning process can help an individual with any or all of these activities which therefore makes it a valuable tool to develop reflective practice.
The roots of action learning lie in the field of management development. Revans (2011) stated that the passing down of the traditional knowledge of an organisation will ill-prepare staff for future development. Instead, action learning is advocated as an educational solution. It is proposed as a necessary tool to enable organisations to adapt in a rapidly changing environment (Ibid). With this in mind, action learning ought to be ubiquitous in the NHS in the current political climate. In fact its potential lays largely untapped. Action learning has been successfully employed in educational programmes and professional spheres (McGill and Beaty, 2001) and may be suitable for CPD of all grades of clinical staff (Rivas and Murray, 2010).
Examples of use
Action learning has been employed in the development of non-clinical NHS staff such as those managing projects (Booth et al. 2003). Often such staff are employed on short-term contracts with little time built in for training and development and so action learning offers an opportunity for learning for and from a project whilst it is ongoing. Booth et al (2003) described an action learning project which shared some of the characteristics describe by McGill and Beaty (2001) such as regular meetings (every four to six weeks) lasting for a set time period (2–21/2 hours) with a fixed lifespan (one year). However, these sets differed in the content. Meetings were based on a topic with pre-prepared materials supplied by a facilitator. Action learning, in its pure form, involves the discussion of real life problems chosen, defined and described by individual set members (McGill and Beaty, 2001). Use of scenarios or case studies provided by a facilitator is a poor substitute since they contain no element of risk. A real problem brings a real possibility of failure which heightens motivation to success and therein acts as a drive to learning (Revans, 2011).
Bell et al (2007) described the experience of an interdisciplinary group using a more traditional form of action learning. Meetings followed a similar structure on each occasion (see Table 1)
Each presentation was followed initially with clarifying questions and then with reflective questioning. Such questions should enable the presenter to explore the problem in greater depth, from a different perspective and/or explore themselves and their behavioural or personality traits. These are what Revans (2011) terms ‘insightful questions’ and are posed in order to reveal to the presenter that of which they were previously unaware. As is common in new action learning sets Bell et al's (2007) set initially needed careful monitoring in order to avoid slipping from questioning to advising. Set members found that as a result of taking part in the set their problem solving skills developed. They were better able to break down problems, consider the evidence base and generate multiple solutions as a result of the action learning experience (Bell et al, 2007).
With the move towards more structured career pathways for non-medical healthcare professionals in the NHS (Department of Health, 2012) there is a need for supportive mechanisms. Action learning may offer the opportunity of such support for clinicians moving into new roles particularly when these roles are community based, providing little opportunity for peer interaction. Board and Symons (2007) described the benefits of using this approach to support the development of community matrons in Dorset and Somerset. Moving from a role in which they were competent to a new role in which they were novice left the matrons feeling vulnerable. This is common for those moving from expert to novice (Benner, 1984). The action learning group provided a safe environment where members felt able to acknowledge and share these feelings and begin to grow and develop (Board and Symons, 2007). As a result their confidence grew which, in turn, impacted on their team and the service (Ibid). Although used for the support of novice advanced practitioners in this case action learning may be appropriate in supporting all levels of novice practitioner. Preceptorship periods may benefit greatly from the application of action learning groups.
Action learning can support a move from mere competency, where issues are clear and straightforward solutions can be employed, towards capability where problems are often ill-defined and solutions multifarious (Edmonstone and Mackenzie, 2005). Professional knowledge is developed as the practitioner begins to question their practice. Action learning provides an excellent vehicle for this reflection. With the requirement of registering bodies to provide records of continuing professional development (CPD) it would be advantageous for the practitioner to record their reflection originating from the action learning set. Although having its basis in Kolb's (1984) learning cycle, McGill and Beaty (2001) do not specify any preferred reflective model to help document the action learning experience. Use of a model would aid set members in construction of a structured presentation of the learning taken from the action learning experience.
‘Action learning may offer the opportunity of such support for clinicians moving into new roles particularly when these roles are community based’
Where this experience differs from a standard reflective piece is in the unique contribution of the set members. Revans (2011) refers to their questions as insightful questions. Since each question is designed to offer, or direct, the set member to some useful insight it would be valuable to record them. Construction of a reflective piece is usually confined to one or two key issues. Any more than this risks only a surface consideration of issues. However, it is useful to think about why a particular issue is selected to reflect on. Usually there is an emotional component to this selection, either the negative feelings arising from a poor clinical interaction or more positive feelings associated with a well-managed incident (Greenwood, 1993). Such feelings are usually the trigger for selecting a particular clinical incident on which to reflect. Reflective models such as Gibb's (1984) reflective cycle require elucidation of the feelings inspired by the incident. However, in the case of the action learning experience the selection of the insightful question that guide the presenter's thinking may be due to factors other than emotion. Also, when reflecting on a clinical experience the owner of that experience will already have selected their focus whereas the presenter at an action learning set does not know which direction their thought process will move until they have had the opportunity to hear all of the group questions.
Although the choice of focus may tell the presenter something about their self-perceived weakness or area for development, exploration of the questions that were not selected may be even more revealing. Perhaps these questions addressed areas of perceive strength or topics that seemed less important to the presenter. But, more interestingly, perhaps these were areas that the presenter did not feel comfortable to tackle. Some questions are difficult questions requiring a great deal of personal investment to answer. It is possible that what may not seem important at the time may become a recurring theme in future and therefore demand exploration at a later date. For these reasons it would be useful to record all of the insightful questions and a justification for selecting key issues to explore over others.In terms of CPD this record would provide the presenter with the opportunity to revisit incidents in order to explore them with a different focus.
‘…what may not seem important at the time may become a recurring theme in future and therefore demand exploration at a later date.
Presentation of the SQIFED model
The format of action learning demands a new model of reflective writing. The SQIFED model presented here offers a unique and novel approach which allows the author not only to present their initial learning from the action learning experience but also ‘leaves the door open’ to revisit some of those group insights in the future.The SQIFED model comprises ‘scenario’, ‘question to the group’, ‘insightful questions’, ‘focus’, ‘evaluation’ and ‘development’. Each shall be considered in turn.
Scenario
‘Scenario’ replaces ‘description’ which typically appears in reflective framework (Gibbs, 1984; Johns, 1997). This is because the word ‘description’ invites a lengthy recreation of events. Many reflective frameworks encourage a rich and detailed revisiting of events (Gibbs, 1984; Johns, 1995) or at least a ‘description of events’ which implies detail (Smith and Russell, 1991; Burrows, 1995). When writing a description of events an author should aim to provide a:
‘…clear, accurate and comprehensive account of a situation.’ Atkins (2004)
In recording an action learning experience it is possible to be clear and accurate without the need to be comprehensive. Critical analysis would normally come from an individual writing a reflective piece reflecting on their experience alone or with a mentor. In this case it is useful to have a full description to refer back to in order to identify key points on which to reflect. Within the context of action learning the presenter may have taken around ten minutes to verbalise a situation which is bound to capture both necessary and extraneous detail. The group then identify the key points which will be evident in the insightful questions that are asked. All that is necessary for the presenter to record in their write-up is a brief scenario. The word ‘scenario’ suggests a brief outline of the key factors that the reader needs to know in order to tackle a situation.
Question to the group
A question to the group is asked by the presenter in order to indicate what it is that seems to be the main issue with which they need help. Many of the insightful questions asked by the group may not touch on the same theme as the presenter's question but it is useful to record the original question since it allows the presenter to compare and contrast their perception of the situation with that of the set.
Questions from the group
Insightful questions
Insightful questions are those posed by the various set members and recorded at the time by a member wiling to act as scribe. These questions are extremely valuable to the presenter as it is these that enable them to see the situation through fresh eyes. As Edmonstone and Mackenzie (2005) point out action learning offers support of our views or accurate feedback from respected others. The insightful question may offer either of these.
Recording all of these questions in the reflection allows the author to revisit different aspects of the case in future.
Focus
The purpose of this section is twofold. It should firstly enable the presenter to explore their motivation for their own learning. The focus section allows the presenter to consider the questions they posed to the action learning set and insightful questions which may lead them to frame a new understanding of the situation and why that situation had particular meaning for them.
The purpose of recording all of the questions asked is in order that the focus is justified. It is often that which makes us feel uncomfortable or surprised that prompts reflection (Greenwood, 1993). However, this may mean that we miss the opportunity to analyse why we feel comfortable about other aspects of an experience. For example in a clinical encounter we may seek to analyse that which made us most uncomfortable, for example an unsuccessful handover, while overlooking the successful interaction with the patient. Recording all of the questions may afford us the opportunity to go back and revisit some of these other features of an experience. So the second purpose is to justify why other issues were not explored on this occasion.
Exploration
Exploration of the issues identified in the focus involves consulting the literature in order that theory and practice may be integrated. It is more than mere application of theory to the problem. It involves synthesising theory and practice to arrive at new understanding. Exploration may involve processes such as analysis, interpretation and synthesis. Freshwater and Avis (2004) offer a theory by which individuals may integrate these processes with existing experience in order to reach a new understanding.
Analysis is the breaking down of experience or evidence into constituent parts in order to simplify and contextualise each within the individual's personal theories. Interpretation is a process of generalising these small units into broader knowledge and experience (Freshwater and Avis, 2004). Synthesis may occur when these processes are contextualised within the values, beliefs and personal theories of the individual. Exploration is led by the presenter; although insightful questions are offered by the group it is ultimately the individual who chooses to respond (or not) to these questions.
Their interpretation of the questions as well as the process of finding answers is determined by how the individual constructs their personal theories and how they consider others’ responses to these theories.
Development points
Development points may be presented as bullet pointed summaries of action to be tested. These may be revelations about the self, heightened awareness of which may allow them to be applied to future practice. They may be summaries of new learning about patient care that may be acted on in future. Or they may be statements of intent regarding personal or professional development.
These development points may be revisited and expanded as the actions are applied in practice.
The process may be cyclical as the group's questions may need to be revisited at the point or linear if a real life solution to a problem is achieved. Authors may wish to cycle back to the development points as they are addressed or may wish to revisit the insightful questions to begin a new reflective process. In this way one action learning experience may provide a basis for many reflections. It is easy to see how this may enable a CPD portfolio to become interwoven as each insightful question links to a different case.
An example of the model in use is presented below. By using the SQIFED model to record action learning experiences set members may be able to organise and record their thoughts in a clear and consistent manner. This will aid their own development as well as provide a record for their continuous professional development portfolio.