Developing personally, using reflective practice in supervision: The evidence base for reflective pr

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Developing personally, using reflective practice
in supervision The evidence base for
reflective practiceGundi Kiemle, University of
Liverpool

• What is RP?
• What is the evidence base for RP?
• Why is RP important?

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Evidence Base for Reflective Practice

• Do healthcare practitioners (including clinical
  psychologists) actually participate in reflective
  approaches?
• What is the link between their reflective
  activities and changes in practice?
• And So what? - How does reflective practice
  link to improved patient outcomes?

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Reflective Practice

• Reflection
• a means by which practitioners develop a
  greater level of self-awareness about the nature
  and impact of their performance (Osterman
  Kottkamp, 1993)
• ..a process whereby we reflect in order to learn
  something, or we learn as a result of reflecting
  (Moon, 2004)

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Reflective Learning

• Boud, Keogh Walker (1985)
• Model to promote reflective learning reflective
  process is between the initial experience and the
  outcome
• Returning to the experience (what happened?)
• Attending to feelings (so what?)
• Re evaluating the experience (what next?)

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Reflective Practice

• a mode that integrates thought and action with
  reflection. It involves thinking about and
  critically analysing ones action with the goal
  of improving ones professional practice (Imel,
  1992)
• a tool for revealing discrepancies between
  espoused theories (what we say we do) and
  theories-in-use (what we actually do) (Imel,
  1992)

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Why is Reflective Practice important?

• RP in the healthcare professions
• pre-and post-qualification nursing training
  (Clarke, James, Kelly, 1996 Andrews, Gidman,
  Humphreys, 1998 Williams Lowes, 2002
  Ruth-Sahd, 2003) ,
• midwifery (Yearley, 2003),
• occupational therapy (Murray, McKay, Thompson,
  Donald, 2000 Khanna, 2004),
• social work (Taylor, 2006 Yip, 2006),
• physiotherapy (Plack, 2004 White, 2004 Clouder
  Sellars, 2004),
• radiography (Castle, 1996 Williams, 1998),
• podiatry (Young, 2004),
• dietetics (Fade, 2004),
• pharmacy (Tomlin, Costello, Kostrzweski,
  Dhillon, 2006 Rees, 2004),
• dentistry (Simpson Freeman, 2004), and
• medicine (Brigley, Young, Littlejohn, McEwen,
  1997 Richards, 1998 du Boulay, 2000 Sandars,
  2006 Launer, 2006)

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Why is Reflective Practice important?

• Ruth-Sahd (2003) Critical analysis of RP
• 20 articles, 12 dissertations and 6 books
  published between 1992-2002.
• Inclusion criteria
• Reflective practice having been defined according
  to key theorists in the field, evidence of a
  clearly defined methodology, and emphasis on
  reflective practice in an educational setting.
• Reflective practice was described in a range of
  settings such as higher education, nursing,
  social work, education, and management and
  leadership training. Most of the studies assessed
  reflective practice from the students or
  practitioners perspective.

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Why is Reflective Practice important?

• Ruth-Sahd (2003) Critical analysis of RP
• Positive outcomes notes from the literature
• helping students to develop their clinical
  knowledge and skills,
• integration of theoretical concepts to practice,
• increased learning from experience,
• improvement in practice by enabling greater
  self-awareness,
• enhanced critical thinking and the ability to
  make judgements in complex and uncertain
  situations,
• acceptance of professional responsibility and
  continuous professional growth,
• improved self-worth through learning,
• empowerment of practitioners, and
• increased social and political emancipation. 

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Evidence Base for Reflective Practice

• Difficulties with
• Definition - what counts as RP?
• Measurement - how do we measure RP in action?
• Evidence base for what? Relation to what outcome?
• Few robust, empirical studies largely
  descriptive, practice-based accounts, or models/
  frameworks, or guidance policy

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Reflective Teaching

• Lowe Kerr (1998)
• Comparison of reflective v. conventional teaching
  methods in nursing students
• No difference in results between the 2 groups,
  but
• Unsuitable teaching material
• Unsuitable outcome measure
• Sample size insufficiently powered
• Randomisation not specified

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Reflective Practice in Nursing Practice

• Nursing Midwifery Council (2004)
• Post-registration practice all nurses must
  engage in reflection and provide written evidence
  within a personal professional profile
  (reflective accounts).
• Andrews, Gidman Humphreys (1998)
• Reflection in nursing generally unplanned and
  occasional, rather than systematic part of
  practice.
• Lack of empirical evidence to suggest that
  engaging in reflection changes practice or brings
  specific benefits re improved patient outcomes.

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Reflective Practice in Nursing Practice

• Andrews, Gidman Humphreys (1998)
• Potential obstacles to RP and evaluation include
  reflecting on ones own, lack of supervisor, lack
  of reflective skills in practitioner and
  supervisor, lack of effective external scrutiny
  for reflective activities and written evidence,
  reliance on self-evaluation.
• If reflection is not used systematically in
  clinical practice, then there is a danger that it
  becomes a tick-box exercise in order to fulfil
  mandatory registration requirements.

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Reflective Practice in Occupational Therapy
Practice

• Lowe (2004)
• Examined theory practice link use of reflection
  in implementing CE learning into OT practice
• Used quantitative and qualitative measures
• Evidence for discriminant use of reflection
  typically used when learning was complex (not
  during basic skills integration)

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Reflective Practice and Supervision

• Ellis, Ladany, Krengel Schult (1996)
• Systematic review of 144 empirical studies of
  supervision 1981-1993
• Much of the research surveyed was not
  methodologically rigorous
• Median effect size of .05 across studies does not
  allow for valid evaluation of effectiveness of
  clinical supervision

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Reflective Practice in Clinical Psychology

• Reflection and RP in pre-qualification training -
  Clinical Psychology Special Issue on Reflective
  Practice (2003)
• Lavender (2003) 4 different processes involved
  in RP (based on Schon)
• Gilmer Marckus (2003) PPD components- survey
  of 17 clin. psych. courses
• Stedmon, Mitchell, Johnstone Staite (2003) RP
  model as an integral part of training, utilising
  a psychodynamically informed model of supervision

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Reflective Practice in Clinical
Psychology(Pre-qualification training)

• Nokes (2005) importance of another person
  (mentor, supervisor) in order for RP to be
  effective reflections on experience as a new
  trainee starting 1st placement.
• Powell Howard (2006) facilitated RP groups of
  8-9 trainees (Bham) benefits related to
  reflection on self, but less effect on
  behaviour change (e. greater self-care, seeking
  support).

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Reflective Practice and Supervision in Clinical
Psychology

• Gabbay, Kiemle Maguire (1999)
• Survey of 127 (40 of 321) qualified NW clinical
  psychologists supervision practice most
  satisfying aspects concerned supportive elements,
  quality and availability of supervision to
  provide time and space to reflect.
• Sadler Golding (2006)
• CPD survey of 174 (28 response rate) NW clin
  psychs in 2004/05 96.4 being supervised, 85.5
  supervising others.
• Good/ regular supervision 2nd most important
  for staying in current post and most important
  for professional competence.

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Reflective Practice and Supervision in Clinical
Psychology

• Cushway Knibbs (2004)
• Supervision workshop themes (33 trained clin
  psychs) helpful aspects include giving space to
  reflect about clients, helping to explore CTF,
  linking clinical work to theory, s/v being
  reflective and integrative.

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Reflective Practice and Supervision in Clinical
Psychology

• Milne and colleagues (various studies)
• Clinical psychology and supervision research
  focused on certain defined aspects of the
  supervision process, methodological rigour, and
  relation to outcome.

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Reflective Practice and Supervision in Clinical
Psychology

• Milne, Aylott, Dunkerley, Fitzpatrick Wharton
  (2007)
• Best evidence synthesis of 24 rigorous and
  successful studies in which the training of the
  supervisor resulted in positive evaluations of
  the impact of supervision on the supervisees and
  clients.
• NB methods of supervision and performance
  monitoring emphasised in contrast to
  communication, clinical reasoning, appropriate
  affective stance, and RP which were reported
  infrequently and insignificantly (RP mentioned in
  8/48 studies).

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Reflective Practice and Supervisor Training in
Clinical Psychology

• Green Dye (2002)
• Supervisor training and RP Delphi approach to
  ascertain consensus view of most important
  components of basic supervisor training programme
  reflective stance implicit (e.g. ethical/
  boundary/ safety issues).
• DROSS project 2004-2007
• Core competencies and skills for supervisors,
  improving quality and consistency of supervisor
  training.

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Reflective Practice and CPD in clinical
psychologists

• Kiemle (2008)
• Qualitative study exploring qualified clinical
  psychologists experience of RP and CPD, and
  links to their professional practice

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Difficulties with establishing the evidence base

• There is a lack of robust empirical evidence to
  assess practitioners use of RP, and the links
  between RP and changes in outcome.
• However
• Whilst reflective theory and practice has not
  been adequately tested, neither has it been
  rejected. Rejection is not necessarily incapable
  of fulfilling the claims made for it it is
  rather that the claims have not yet been
  empirically evidenced (Burton, 2000).

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In conclusion

• Rather than sit on our hands bemoaning the
  absence of research findings to inform our CPD
  decisions, clinical psychologists need to make
  good use of the evidence that is available and
  contribute to expanding that knowledge base by
  conducting their own applied research (Green,
  2005)
• Equally applies to Reflective Practice!