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On: 25 May 2007
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Reflective Practice
Reflective Practice
Vol. 6, No. 1, February 2005, pp. 165169
THOUGHTPIECE
Teaching Hospitals NHS Trust, Chorley and South Ribble District General
Hospital, Chorley, UK; bUniversity of Liverpool/NHSE, Liverpool, UK
0Chorley
JasonRaw,
00000February
&Francis
South
Registrar
2005
Ribble
General HospitalLancashire Teaching HospitalsNHS Trust, Preston RdPR7 1PPChorleyLanesjasonraw@msn.com
Reflective
10.1080/1462394042000328697
CREP6111.sgm
1462-3943
Taylor
2005
61Thoughtpiece
&
and
Practice
(print)/1470-1103
Francis
Ltd
Ltd District
(online)
166 Thoughtpiece
The third stage involves the development of a new perspective on the situation.
This means firmly deciding to implement change in practice as a result of the
earlier stages, for the benefit of similar future situations. This stage can be aided by
making a conscious decision to use reflective learning regularly and often, and can
be facilitated by the use of a Reflective Diary, in which events that have shaped
your practice can be recorded and ensure that the reflective process did not go to
waste. Reflective diaries can provide the user with an invaluable resource for the
teaching and education of junior staff so as to ensure everyone benefits from your
experiences. Recording these reflective episodes should lead to targeted learning
using research evidence to further reinforce the learning points, turning the anecdotal story of a difficult case into one the listeners learn from appropriately and
take into their own practices.
Re-Validation
Starting early in your careers by designing and utilising a Reflective Diary will help
guide your career progress very successfully, providing you with confidence to face
your mistakes and learn from them and to be aware of positive experiences you have
or hear about. Lifelong learning is an important aspect of a career in medicine, with
the need to keep up to date with current research and developments foremost. This
includes improving our communication skills, our ability to empathise with patients
and educating our colleagues as much as our self, not just clinical skills improvement.
With revalidation part of professional appraisal and development, the use of a reflective
diary and a systematic approach to reflection will greatly aid the revalidation process
and help the building of a portfolio of experiences and evidence for active learning.
The following are examples adapted from a medical practitioners reflective diary:
A very ill elderly lady with severe COPD and respiratory failure is taken to high
dependency for non-invasive ventilation. The family were asked to wait in the waiting room. Over one hour passes with the doctors and nurses unable to get her
settled and tolerate the mask and oxygen. Due to the severity of her COPD and
her poor functional ability normally is not considered a suitable candidate for intubation and ventilation on the intensive care unit. Suddenly she cardiovascularly
collapses and dies. One of the doctors and a nurse go to inform the family. They
get an unexpectedly hostile reaction, the family are very angry with the staff, having
waited for over one hour to see their relative, then get told she had died. The
familys reaction greatly upsets the doctor and nurse who feel they had tried hard
to save her.
On reflection the doctor and nurse decide that in future they will make sure relatives will be able to be with their family member as early as possible even if their
relative is very sick and needs a great deal of medical attention. They realise that if
the family of a very sick patient can be with their loved one at those times, it is
better for all concerned, rather than in a room not knowing what is happening. The
nurse brings up the episode in a staff meeting, with the doctor present, and uses
Thoughtpiece 167
her experience to encourage other staff to involve relatives as early as possible when
patients become very unwell. Even if the unwell patient is requiring a great deal of
attention, the family can be at the bedside holding their hand while the staff work,
this may be all the family want. The doctor decides to look into the problem and
finds out that research has shown that relatives present at the bedside during
cardiac arrest situations appear to cope better with the grieving process and this
should probably apply in episodes of life threatening illness also (Robinson et al.,
1998).
Despite being taught how to break bad news, when a doctor goes to tell a grandson
that his granddad has died in the A&E resus room, he finds the conversation goes
badly wrong. As he enters the relatives room the doctor is quickly asked what
happened. Without hesitating the doctor proceeds to describe the events of the
cardiac arrest resuscitation attempt. Feeling that the grandson understands what
he has been told, he finally asks, Do you have any questions youd like to ask?
Straight away the grandson replies, Yeah, how is he? The doctor, taken aback
has to state clearly his grandfather has died and leaves knowing he handled it badly
and he has possibly made things worse for the grandson. He reflects on it over time
and resolves to be clearer and not beat about the bush when breaking bad news in
the future as the worried relative is usually not ready for a great deal of detail and
may fail to fully comprehend the intended message. He talks to colleagues about
his experience and finds some have had similar problems; they all agree that relatives need to be given clear messages without ambiguity. The doctor finds a journal
article, entitled Breaking bad news to patients (Mueller, 2002), to help reinforce
his learning and he distributes it to his colleagues.
A man with metastatic terminal lung cancer comes to hospital with a clinical pneumonia. He has had several infections recently and is aware of his condition and
prognosis. His family called the ambulance and want him admitted and treated.
This is straightforward for the doctor attending to arrange. The patient tells him
however that he is dying and he wants to go home to die. His wife cant look after
him without help however, and his family are not yet prepared for him to die.
Instead of persuading the patient to stay at least over night for intravenous antibiotics, which may get him better, the doctor spends a long time talking to the
patients family about his prognosis and the patients wishes. He also manages to
organise emergency home palliative nursing care. Four hours later the patient goes
home from A&E. The doctor leaves the hospital wondering if it was all worth the
hassle. The doctor bumps into the patients son later in the week as he is in the
hospital to obtain his fathers death certificate. He tells the doctor that his father
died peacefully at home with his family around him and that they are very grateful
to the doctor for helping them with that. The doctor realises that as well as the
patient getting his wishes, even if it meant extra work, he is heartened to know he
made a small difference to that patient and his family. It seems to him that most
terminal patients would probably prefer to spend their last days at home with their
family if it were possible, as this person did, than in a hospital environment having
tests and getting treatment that may not benefit them. He finds out that there is
168 Thoughtpiece
Thoughtpiece 169
He is getting increasingly stressed and begins to reflect on his career. He decides
he is sure he wants to do medicine but finds the on-calls unbearable. He feels the
time dragging and the apprehension of what might be about to happen is the worst
problem. After a time he realises that if he didnt wait to be called and instead went
to the admissions units and casualty and got involved in what was going on the time
may go faster. He tries this out and finds he enjoys being involved and the ward
atmosphere. He stops wondering when and what his next call will be because he is
too busy to think about it. He enjoys working with the staff and they appreciate him
being around. His confidence rises and the time no longer drags through the day.
He even begins to look forward to his on-call shifts. He uses this experience in the
future to educate junior doctors about getting the most from their working lives
and how to better cope with stress.
In conclusion, reflective learning is rapidly becoming accepted practice and is a vital part
of lifelong learning as health care professionals. The use of a diary for recording reflective learning experiences is invaluable for professional development and maximising
career potential; it is not all about reading medical journals and attending conferences.
Notes on contributors
Jason Raw is a Specialist Registrar in Geriatrics and General Medicine, North West
Region, UK.
David Brigden is Regional Advisor for Postgraduate Medical and Dental Education
in Mersey Deanery (University of Liverpool/NHSE). He is also an Honorary
Senior Lecturer in the School of Postgraduate Medicine and Health Science at
University of Central Lancashire; Honorary Senior Fellow in Education at
University College Chester; Professor of Health Sciences Education at University College Chester and Professor of Professional Development in the Faculty
of Health Sciences at the University of Cape Town, South Africa.
Romesh Gupta is Consultant Physician with Special Interest in Elderly Medicine/
Stroke Medicine, Chorley and South Ribble District General Hospital, UK. He
is also Professor of Ethnicity and Health with an interest in Education and
Training, Bolton Institute, Lancashire, UK.
References
Atkins, S., & Murphy, K. (2003) Reflection: a review of the literature, Journal of Advanced Nursing,
18, 118119.
Mueller P. (2002) Breaking bad news to patients, Postgraduate Medicine, 112(3), 1516.
Robinson, S. M., Mackenzie-Ross, S., Cambell-Hewson, G. L., Egleston, C. V. & Prevost, A. T.
(1998) Psychological effect of witnessed resuscitation on bereaved relatives, The Lancet,
352(August), 614617.
Wilkinson, S., Fellowes, D., Goodman, M., Low, J. & Harvey, F. (2003) District Nurses
perception of a home based nursing service for dying patients: a national survey of reasons for
referral and non-referral, European Journal of Cancer, supplement 1(5), S: 376.