So, why do we have to reflect?
Reflection is essential in getting healthcare students to make links between theory and practice (Jasper, 2013), this in turn helps us to develop our clinical reasoning (Rigby et al.,2012). It’s not just important while we are students. Oh no, it’s not over when you graduate, as British Association of Occupational Therapists (2007) informs us that reflective practice is vital to our continuing professional development (CPD). CPD is really important to keep our skills and knowledge up to date to be able to practice safely, legally and effectively (College of Occupational Therapists [COT], 2010; Health and Care Professions Council [HCPC], 2012a). Using models of reflective thinking make sure our reflections are meaningful to our CPD (Armitage et al., 2012).
Using models of reflection
Models of reflective thinking are the structures that we use to help us think reflectively. There are lots of different models out there for you to mull over. These models vary in how much hand-holding they give you and how much description and critical analysis are needed. The common ones that healthcare students use are; Gibbs, Johns and Borton. You should choose your reflective model based on what you want to achieve and how deep you want to go with your reflection (Jasper, 2006). Although to be honest, I tend to use Gibbs as I am more familiar with it but I have also started using Borton for quick, on the spot reflections.
I am going to give you an example of a reflection that I have done. I’ve chosen Gibbs’ (1988) model. My reflection is to help me understand my behaviour in a critical incident; I felt that I made the right decision but was unsure why. Gibbs’ model is useful examining a completed rather than an ongoing issue as it proposes action (Jasper, 2013). If the incident was ongoing, Borton’s (1970) model may have more use as it makes action happen, rather than just suggesting action (Jasper, 2013).
On placement a resident disclosed to my placement buddy and I that he was walking and transferring on his own, against advice. This behaviour resulted in several falls in his room. He had not raised this with the staff; not wanting them to be concerned. The following morning, we informed the client that we had discussed his falls with the care manager. We advised him to await carers for transfers until we could assist him doing this safely.
I felt uneasy that the client did not want us to tell anyone that he had fallen: my intuition was that we needed to inform a manager. I was concerned that he might injure himself. I felt uncomfortable that I had acted against his wishes and without his knowledge which is contrary to professional standards that advise relationships with service users should be based on trust (HCPC, 2012b).
I was pleased that a safety risk had been identified as a potential intervention. It was important to the resident to be independent with his self-care. I realised that night that we should have told the client that we intended to discuss his falls with staff so the following morning we informed him.
Professional practice involves abiding by the codes of conduct, ethics, and standards of a professional body (Jasper, 2006). In the case of occupational therapists this is the HCPC and COT. Professional behaviour requires complying with legislation and government policies (Jasper, 2006). This behaviour ensures that the therapist acts safely, legally, and in accordance with the values of the profession (COT, 2010).
The incident was an ethical dilemma: resulting from conflicting ethical principles (Alsop & Ryan, 1996). The ethical dilemma was that of autonomy and confidentiality versus beneficence (Beauchamp & Childress, 2009). Autonomy and confidentiality directed us to respect the wishes and privacy of the client by not telling staff of his falls, yet beneficence required us to safeguard the client from harm by doing the opposite. Ethical reasoning can be used to analyse a dilemma and determine the right action (Boyt & Schell, 2008) by evaluating the likely consequences (Beauchamp & Childress, 2006). The likely consequence of informing staff would be that the client would be safeguarded from further harm at the cost of a loss of trust. Conversely not telling would maintain trust but expose the client to potential harm.
Occupational therapists are autonomous practitioners (HCPC, 2012b) able to make informed decisions that they are able to justify. These decisions involve assessing risks and devising ways to deal with them. Part of this risk management involves an awareness of relevant legislation (COT, 2010). Occupational therapists have a legal duty of care to act in a way that ensures that no injury occur to a client in their care (COT, 2010; Health and Safety at Work Act 1974). We had a duty of care to tell staff of the high fall risk brought about by the client’s action. Occupational therapists also have a legal duty to safeguard confidential information about clients (HCPC, 2012b). Information can be disclosed if the client consents, there is a legal justification or to prevent serious harm to the client or another person (COT 2010; HCPC, 2012a; Public Interest Disclosure Act [PIDA] 1998). We were justified in breaking confidentiality because we were concerned about harm however we should have attempted to gain consent before disclosure (HCPC, 2012c).
Fundamental to occupational therapy is the commitment to client-centred practice (COT, 2010). Client- centred methods recognise the importance of individual autonomy (Creek, 2003; Rodger, 2013). Professional codes instruct a respect for client autonomy if they have mental capacity (COT, 2010; HCPC, 2012a, 2012b). We knew the client had capacity as he was able to understand, evaluate, retain the information, and consent to our help (Mental Capacity Act 2005). Providing psychosocial support to clients is important to a holistic approach (McKenna, 2010). Advanced communication skills such as active listening, and open questioning could have been used to explore concerns, and explain the importance of telling staff (McKenna, 2010).
Professional behaviour involves knowing the limits of the therapist’s scope of practice: the knowledge and experience needed to practice safely and legally, (HCPC, 2012b). Care is seldom provided alone; sharing information within the team is good practice and often essential for effective care (HCPC, 2012c). As students it was outside of our practice to keep the client safe at all times and even it was not, sharing information within the team represented best practice.
Although it was the right decision to discuss the client with staff it was undertaken it in the wrong manner. I should have explored disclosure with the client and explained why it would be in his interests. I could have tried to gain consent and prevented the ethical dilemma. It is important to be familiar with current legislation, professional guidelines and policies to be able to make autonomous, informed decisions that I am able to justify. If I had this knowledge I could have reflected in the moment rather than after the moment.
When qualified I will keep up to date with professional issues and by becoming a member of COT, reading the British Journal of Occupational Therapy. I will keep up to date with relevant HCPC policies and guidance by reading the HCPC ‘In Focus’ newsletter. I will access the Department of Health website for current policy and guidelines and regularly maintain CPD by participating in activities suggested by HCPC (2012d). I will document these activities in my CPD portfolio for ongoing registration.
For PP6 I will discuss with my educator the policies most pertinent to the setting to ensure familiarity. I will be aware for the potential of ethical dilemmas and consider likely consequences of action. I will reflect in supervision on my clinical reasoning skills.
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Health and Care Professions Council. (2012a), Standards of conduct, performance and ethics. Retrieved from http://www.hpc-uk.org/assets/documents/10003B6EStandardsofconduct,performanceandethics.pdf
Health and Care Professions Council.(2012b). Standards of proficiency occupational therapists. Retrieved from http://www.hpc-uk.org/assets/documents/10000512Standards_of_Proficiency_Occupational_Therapists.pdf
Health and Care Professions Council. (2012c). Guidance on confidentiality. Retrieved from http://www.hpc-uk.org/assets/documents/100023F1GuidanceonconfidentialityFINAL.pdf
Health and Care Professions Council. (2012d). Continuing professional development and your registration. Retrieved from http://www.hpc-uk.org/assets/documents/10001314CPD_and_your_registration.pdf
Health and Safety at Work Act 1974
Jasper, M. (2003). Beginning Reflective Practice (Foundations in Nursing and Health Care). Cheltenham: Nelson Thomas Ltd. Jasper, M. (2006). Vital notes for nurses: professional development, reflection and decision making. Oxford: Blackwell publishing.
Jasper, M. (2013). Beginning reflective practice (2nd ed.). Australia: Cengage Learning
Johns, C. (2009). Becoming a reflective practitioner (3rd ed.). Chichester:Wiley-Blackwell.
McKenna, J. (2010).Psychosocial support. In M. Curtin, M. Molineux & J. Supyk-Mellson (Eds.), Occupational therapy and physical dysfunction: enabling occupation (6th ed.)(pp.190-212). Edinburgh: Churchill Livingstone.
Mental Capacity Act 2005
Public Interest Disclosure Act 1998
Rigby, L., Wilson, I., Baker, J., Walton, T., Price, O., Dunne, K., & Keeley, P. (2012). The development and evaluation of a ‘blended’ enquiry based learning model for mental health nursing students: “making your experience count”. Nurse Education Today (32), 303-308. doi: 10.1016/j.nedt.2011.02.009
Rodger, S., & Keen, D. (2013). Child and family centred service provision. In S. Rodger (Ed.), Occupation centred practice with children: a practical guide for occupational therapists. Retrieved from http://books.google.co.uk