Write a reflective account critically appraising action taken by you during an intervention with a service user on placement. Consider how your intervention meets the principles and values set out in the NHS Constitution, and other legislation and policies guiding your service user intervention as appropriate to your service setting.
Introduction
Historically, reflection has been considered “an active” and “careful consideration” of knowledge (Dewey, 1933). Reid (1993) develops this definition, adding the need for analysis and evaluation of an experience to “inform learning” for future practice. More recent literature explains the necessity for reflective practice in identifying issues and making change in healthcare (Taylor, 2010, Jasper, 2013).
Whilst it is human nature to look back on events, it is another task to critically reflect and evaluate our own performance in everyday life. Therefore, reflective practice involves individuals, teams, and services working within healthcare, to actively participate in consideration of their professional practice.
Reflection allows practitioners to identify professional development needs, their individual strengths as well as the needs of the service to improve practice and therefore delivery of care (Health and Care Professions Council, 2013).
Inertia is a common occurrence within healthcare and the temptation to ignore the possibility of improvement through change can often mean that services do not work as efficiently as they could. However, reflection challenges habits and routines that all professionals fall into, and provides opportunities for positive change (Taylor, 2010). It is important to note that there are challenges and criticisms of reflective practice.
Increasing caseloads and limited time are factors in preventing professionals from engaging in consistent reflective practice (Thompson & Thompson, 2008). Available opportunities to provide written reflection is another barrier that can prevent practitioners from producing evidence of reflective practice within their field.
This reflective account aims to demonstrate critical analysis and evaluation of an intervention carried out by myself during practice placement, using a Kolb’s experiential learning cycle (McLeod, 2017) to form my account. My appraisal includes consideration of the principles and values of the NHS Constitution (Department of Health [DoH], 2015) as well as legislation and policy that influences professional practice.
Model
Throughout my occupational therapy (OT) studies, I have used several reflective models including Gibb’s reflective cycle (Gibbs, 1988) and Schon’s reflection in- action/on-action (Schon, 1991). The majority of learning completed on placement is experiential, and therefore Kolb’s experiential learning cycle appeared appropriate to use in this reflective account.
For my learning on this placement, utilising Kolb’s experiential learning cycle enabled me to identify strengths within my developing skills, but also highlighted areas of improvement that needed addressing. Kolb’s experiential learning cycle is derived from Kolb’s experiential learning style theory. According to Kolb, effective learning occurs when a full cycle of the four stages is completed.
Figure 1: Kolb’s experiential learning theory (McLeod, 2017).
Kolb’s theory has been well utilised in education and professional development (Moon, 2008, Jasper et al, 2013). Within the OT profession however, there is much more limited literature surrounding the use and success of reflection in practice; this could potentially be linked to the profession’s perceived lack of identity (Turner, 2015). If OT practitioners are not providing evidence of reflection within their profession, it will be a challenge for other professionals to understand the importance of OT in the multidisciplinary team (MDT). However, engaging in reflective practice is an essential skill required of healthcare professionals (Forest, 2008, Mann, 2009), which allows us to enhance our continued professional development as well as form evidence of development within practice. It is on reflection that I consider that the use of Gibb’s reflective model could have provided me with an account more relevant to my profession. From my experience and relevant literature, I understand that Gibb’s is used much more frequently in reflections specific to OT. Nevertheless, my chosen reflective model allowed me to complete an account that will enable my own development within the occupational therapy profession and it can be said that reflection is commonly understood by professionals regardless of the model used (Boniface, 2002).
Intervention:
Context
The service setting of this placement was an acute stroke ward within a public hospital, providing treatment and rehabilitation to patients recovering from a stroke. The therapy team included three OT’s, three physiotherapist’s (PT) and two therapy assistants.
Model
The service did not routinely use a model to structure their assessments and interventions. Efficient practitioners may not require a model to structure their interventions due to their experience within the setting and therefore the use of a model could be unnecessary and time-consuming (Carswell et al, 2004). However, there is strong evidence to suggest that using a model adheres to evidence-based practice and provides well-informed interventions (Turpin & Iwama, 2011). My previous use of the Canadian Model of Occupational Performance (CMOP) enabled me to structure my practice more efficiently. As a student, my confidence in following the OT process in this setting was limited due to inexperience and therefore the use of a model was beneficial in formulating assessment findings and producing intervention plans in line with the theory behind the model.
Figure 2: The Canadian Model of Occupational Performance. (Polatajko, H.J., Townsend, E.A. & Craik, J. 2007).
Outcome measure
Although there was no formal outcome measure used in this setting, the occupational therapy team strived to use the Modified Rankin Scale (mRS) as an informal measure within the acute stroke setting. The mRS is a tool used to determine disability following a neurological event. It assesses disability on pre-admission, admission and discharge. It is worth noting that the mRS is open to bias (MDCalc, 2018) and therefore the reliability of this as an outcome measurement should be considered.
Concrete Experience
The essence of my intervention was implementing safe manual handling (MH) practice for a particular patient and their family. For data protection reasons, this account does not make reference to the real names or information of individuals included (College of Occupational Therapists, 2015, Health and Care Professions Council, 2013). In keeping with the NHS’s commitment to the rights of patient confidentially (DoH, 2015), the pseudonym John Smith will be used throughout this account.
John Smith was admitted to the stroke ward with a dense right-sided stroke resulting in aphasia, paralysis in the right upper and lower limb and impaired cognition. The Royal College of Physicians [RCP], (2016) produced guidelines which state the importance of timely OT assessment in the recovery for patients following a stroke. In keeping with these guidelines, the initial OT assessment was carried out within the twenty-four to forty-eight-hour timeframe from when John was admitted to the stroke ward. Through initial assessment, John was deemed to have good sitting balance and an appropriate method of transfer was identified. To transfer, John would require two members of staff using a piece of equipment called a steady. The moving and handling of patients is a regular occurrence in health and social care and if this is not done in a safe way, patients and employees are at risk of harm (Health and Safety Executive, 2018). Therefore, establishing a safe means of transfer was essential for this patient. It was also identified that becoming as mobile as possible was the most important thing to John and his family. Furthermore, through this initial assessment, one of the goals formulated was to improve John’s mobility to enable him to use the toilet with the assistance of his family. Literature emphasises that goal setting is an essential and core skill of healthcare professionals working in inpatient rehabilitation services (Holliday et al, 2007, Dudeck et al, 2011). My intervention was in keeping with this. John’s family were very keen to get him home and willing to provide support for him on discharge. To facilitate this, my intervention included educating John’s wife on using the piece of equipment with another member of staff. Education can be a large part of the OT role in many settings (Taylor, 2008, Hoffman, 2009). On review, it was identified that John’s wife wasn’t competent to use the necessary MH skills in a safe manner to transfer her husband from the bed to commode chair. The risk of injury to both John and his wife was the primary concern that needed to be addressed.
In the first instance, a PT and I spoke to the wife to explain safe MH procedures and the risk of using unsafe methods. Unfortunately, the wife continued to use unsafe methods. My next action was to include a member of the MH team as well as a senior member of the OT team from the hospital to further discuss with John’s wife the implications of moving her husband in an unsafe way. Jointly, it was decided to formally assess the wife’s ability to carry out MH to enable her to assist her husband’s transfers. My last independent attempt at solving this issue was to sit down to discuss John’s wife’s’ emotions, providing her an opportunity to speak about how she was dealing with her husband’s stroke and provide advice to cope. This intervention coupled with the collaborative work around safe MH achieved the outcome of John being safely transferred with the assistance of his wife. The first value set out by the NHS Constitution (DoH, 2015) involves working together to achieve quality care for individuals. Working together with John’s wife was difficult, however, it was the team’s ability to work collaboratively which allowed for the successful outcome of the intervention. Cameron, Lart, Bostock, and Coomber (2014) describe the need for effective communication between healthcare professionals and service users. This provides evidence of the influence that this had on collaboration between myself, members of the MDT as well as John and his wife.
Reflective Observation
My ability to carry out the initial assessment independently was limited by my inexperience of working within the complex service setting. Therefore, I was supervised by my practice educator (PE) throughout the assessment. Whilst it was essential for her to be present to ensure that duty of care to John was adhered to (Social Care Institute of Excellence, 2012), I felt that her presence created a tense atmosphere for myself which may have impeded my confidence. I was able to use the therapy team’s written format for the initial OT assessment as a guide. Unfortunately, these factors meant that my delivery of the assessment was not natural and free-flowing. To improve my delivery of assessments within the acute setting, I observed other professionals carrying out assessments and gained constructive feedback from my PE and other members of the team which improved my confidence. Following my reflection of this intervention, I have since been able to complete competent assessments independently, which enabled me to become a more autonomous student practitioner whilst on placement. This is in keeping with the aims of the BSc Hons OT course that I am studying (the University of the West of England, 2018).
Adopting CMOP as an additional tool to assist my delivery of the intervention was beneficial, I believe. Utilising CMOP allowed me to focus on the occupation which in John’s case was toileting. Whilst the PT was solely focused on improving John’s trunk muscles to aid transfers, my focus was on the motivation behind engagement in rehabilitation. Being able to transfer with minimal assistance would allow John to be more independent and maintain his dignity (DoH, 2015). The mRS proved to be unhelpful as an outcome measure for my intervention alone as it did not provide evidence of the effect of my intervention solely. Therefore, adopting an outcome measure such as COPM (which would have worked alongside CMOP) could have demonstrated and provided evidence of the success of my intervention (Carswell et al, 2004).
On reflection, adhering to the RCP guidelines (2016) was challenging at times due to the increase in the number of stroke patients on the ward coupled with reduced staff numbers. This was managed through daily allocation between the therapy team and the employment of two additional members of staff. Another factor that prohibited patients from being seen with the given timeframe was the working hours of the therapy team. A patient admitted on Friday afternoon would not receive an initial assessment until at least Monday, therefore delaying the patient’s engagement in rehabilitation. Following this intervention, the therapy team has been preparing for the start of weekend working with the aim of improving the delay of assessments for newly admitted stroke patients and allow for continued therapy over a six-day working week. (RCP, 2016).
The importance of legislation such as the Mental Capacity Act (DoH, 2005) became more apparent on reflection. Through cognitive screening, it was identified that John had reduced cognition, however still had capacity to make own decisions. Had it been assessed that John did not have capacity to make his own decisions, it may have been appropriate for a formal capacity assessment to be completed by the suitable professional. If an individual does not have capacity, medical decisions will be made in their best interests (Social Care Institution of Excellence, 2017). Being aware of this will ensure I follow legislative procedure in future practice. Patients are expected to be fully involved in making decisions about their treatment, according to the NHS Constitution (DoH, 2015). On reflection, this was a strength of the intervention as all decisions made were done so jointly with John and his family.
Collaborative working has been a reoccurring theme throughout this account. Professionals being able to collaboratively work together in order to implement the intervention and problem-solve when issues arose, was paramount to the success of the intervention. Bassot (2013) explains the need for professionals to reflect on other disciplines that they work with. I feel that the within this service, the OT and PT work very closely together which empowers a mutual understanding of each profession. On the other hand, due to the close collaborative working with the PT, it was difficult at times to distinguish the skills and values that are unique to OT. Through independent study and formal discussions with my PE and other members of the team, I gained a concrete understanding of the individual contribution OT makes within the acute stroke setting. As in many other settings, the focus of occupation is central to OT practice and this was evident throughout this practice placement.
I was able to reflect on the core skills of OT and the generic skills shared by other professionals. A generic skill shared by all members of the MDT was safe MH; all professionals should have appropriate training and working knowledge of safe MH practice to ensure the provision of safe care to patients. Throughout my practice as an OT student, I have developed my own use of therapeutic self which is a core skill of OT (Taylor, 2008). I believe it was my ability to use this therapeutic use of self that enabled me to build a rapport with John and his family following the assessment and throughout the intervention. The ‘Reflective Practice Guide’ (Bassot, 2016) states the need for practitioners to become self-aware as arguably one of the most crucial skills for continued professional development. I believe developing my self-awareness will further improve my practice.
On reflection, having dealt with the wife and understanding her actions has provided me with an insight on how an illness can affect a whole family and this reinforced the significance of how considerate an OT must be to fulfil their job to the highest standards. Compassion is a crucial part of working within the NHS and is a key value embedded in the NHS Constitution (DoH, 2015). Feedback from members of the MDT as well as patient compliments has indicated that I am a compassionate practitioner. This is something I feel has been developed from my experience as a care assistant. As an occupational therapy student, I have harnessed compassion to implement change for individuals.
Abstract conceptualisation
As demonstrated throughout this account, using a reflective model throughout this account was beneficial. However, whilst reflecting upon my time on placement, I have contemplated how the use of an alternative model to Kolb’s experiential learning cycle could have further benefitted my learning and therefore my skill development. Using Schon’s reflection in action could have proved more appropriate in handling the situation at the time; I may have been able to solve the problem sooner if I had taken the time and consideration to reflect throughout the intervention. For example, had conversations with John’s wife taken place at the beginning of my intervention, it could have saved time and need for the input of other professionals. More so, using Gibb’s reflective model would have allowed me to create an action plan that clearly demonstrated how I aim to improve my practice and contributed to my continued professional development. In future, it may be useful to utilise this aspect of Gibb’s reflective model.
Throughout the placement, I identified personal goals that I aimed to achieve through engagement in the service setting. Among these was to improve upon my ability to clearly communicate my clinical reasoning with patients and members of the MDT team. Completion of my personal goals record from the practice placement demonstrated the achievement of this goal.
Figure 3: Personal goals record OTP3.
The Career Development Framework (RCOT, 2017) was produced by the Royal College of Occupational Therapists for everyone working within the OT profession across all settings. Individual practitioners can utilise this framework to identify their level of experience and plan further professional development needs. I have found the Career Development Framework to be personally useful in identifying the skills I possess in line with my OT studies and practice. Throughout my studies and practice, I will continue to use this framework to assess my competence as an OT student and inform professional development.
Finally, I considered that if this intervention was not successful, it may have been essential that I raise a safeguarding issue to protect John’s best interests. The 4th principle of the NHS Constitution (DoH, 2015) is about putting the person at the heart of their care. Throughout my intervention, John was put first by protecting his safety; through discussions with John’s wife to educate her on safe practice and involving her in planning and problem solving the issues. Should this dilemma arise in my future practice, I will be well equipped to handle the issue due to my experience from this intervention.
Active experimentation
Planning –
Following this intervention, I have considered what I need to do to improve my practice as an OT practitioner.
Figure 4: Planning for further professional development.
Trying out what I learnt –
Reflecting on this experience has allowed me to deliver safe MH advice to further patients and their families throughout this placement. It has given me a deeper appreciation for the importance of collaborative working as well as more awareness of the impact illness can have on a patient’s family and how communication can be an intervention alone in managing this.
I achieved my personal goals set for this placement (Figure 3). I communicated effectively with other members of the MDT throughout and will continue to employ my communication skills in future practice. I have continued to harness compassion and therapeutic use of self in interactions with patients which I feel has enabled me to provide holistic, person-centred care. I will proceed to critique my practice, developing my own self-awareness in order to identify further areas of improvement.
Conclusion
This reflective account has critically appraised an intervention carried out by myself during practice placement and has allowed me to consider how my actions adhered to the NHS Constitution and other relevant literature. In conclusion, it has enabled me to identify my skills as well as formulate a plan that will aid the development of my skillset during my ongoing training within the OT profession.