In the following piece, Rob discusses the importance of reflective practice and considers how it has helped him in his career as a paramedic.
What is reflection?
Reflective practice allows us to learn from experience and is a valuable tool to dig out elements of our practice requiring attention which may otherwise be overlooked.
It can help make the difference between garnering twenty years of experience, or one year of experience repeated twenty times .
Let’s have a quick look at a couple of types of reflective practice: reflection-in-action and reflection-on-action.
Reflection-in-action is a conscious and subconscious recollection of past experiences and skills, which are utilized at an appropriate time. Essentially it is drawing upon knowledge we already have to aid decision making when there is little time for active reflection. This can be enhanced by reflection-on-action, which takes place after an event, and is a useful tool for expanding our reflective foundation. It can be something as simple as talking about it with a colleague, but to gain the most benefit we can capture our insights and reflect critically in writing .
Getting it down on paper
Writing a reflective piece seems like a fairly simple task; we just write about how we felt and what we learned from an incident, right?
Yes and no.
When we are required to write a reflection as an academic piece of work, it is important to make sure that we are showing insight and reflection in addition to producing an engaging written assignment. It is not enough to simply describe the incident and include some clinical evidence, as is commonly presented by those new to reflective or academic writing. This is unlikely to expose any revelations, and it is through unpacking the incident that we begin to understand our roles to a more meaningful level and “construct new appreciations of practice realities” .
We must be clear about the feelings and thoughts we experienced at the time and be critical in our assessment of our performance. There is little point in dressing things up; yes, it is important to recognise what went well, but it’s vital that our opportunities for improvement are highlighted too .
A good reflection will describe the event and then evaluate and analyse, before setting out a plan to make use of what has been identified. Which brings us onto reflective models.
There are several models used to facilitate written reflection. We’ll look at two of the most widely used in healthcare: Gibbs  and Borton .
This is separated into five sections:
Description – a purely descriptive account of the event upon which you have chosen to reflect. No thoughts, feelings or analysis need to be included here.
Feelings – this is where you describe how you felt throughout the incident. Try not to fall into the trap of simply describing what you thought; ensure you include whether you were nervous, confident, scared, etc. You can also include how you think others involved were feeling, and what your feelings are when looking back with hindsight.
Evaluation – an honest and objective look at what went well and what did not. How did your contribution affect this? Do not get caught up in reasons why just yet, simply outline the good and bad.
Analysis – this is where you delve into the reasons why, and you make sense of what you have identified in the feelings and evaluation sections. This is where the bulk of your academic literature can be included to support your understanding.
Conclusion – here, as the heading illustrates very clearly, you should summarise your learning from the chosen incident. Include how the insights you have gained from this reflection could have impacted upon the outcome, and think about what else you could have done.
Action Plan – write about how you will act next time a similar situation occurs, and directly link this to the evaluation and analysis you have created. For example, if you highlighted that your ECG interpretation was poor and extra time was needed to contact further support, you could include here that you intend to carry out CPD to remedy this for the benefit of future patients.
This model is comprised of three sections:
What? – Describe the events upon which you are reflecting. Consider what happened, what your role was and how you interacted with others involved, how you reacted and why you have chosen to reflect on this incident. Try not to get caught up in trying to make sense of anything in this section.
So What? – Analyse the event and unpick the meaning of the experience as a whole. How did you feel at the time, and how do you feel about it now with hindsight and reflection-on-action as your allies? What impact did your actions and interactions have on the process and outcome, both positive and negative (consider factors such as the tasks you carried out, contribution to planning and leadership, how you communicated with the rest of the team)? Did you debrief the incident and if so, what feedback was gained from your colleagues? You can use supporting literature in this section to enhance your analysis.
Now What? – How will you alter your practice, if at all, following this incident and your reflection upon it? What do you feel could have improved the outcome, and how will you ensure that this will be implemented in future?
Here’s an example of a time that I used reflection to positively influence change in practice as a newly qualified paramedic: Working as part of an ambulance crew I attended a traumatic cardiac arrest on a motorway for a van vs motorbike collision. We arrived on scene first, and it didn’t go well, with delays initiating the HOT  approach (a protocol for effective management of traumatic cardiac arrest) caused by a variety of human and environmental factors. My composure all but dissolved, and this impacted my scene management.
Thankfully, a specialist critical care paramedic arrived to salvage things after five minutes (that felt like an hour), and once he provided some calm direction, the process became more efficient and all appropriate steps were taken. Unfortunately, the resuscitation efforts were not successful. We debriefed afterwards, and there was lots of assurance about how everyone did well under difficult circumstances. I accepted this at the time, but I knew that this did not address the issues with my own performance.
Reflecting on it several days later, it was tempting to take comfort in excuses: the HOT protocol was very new at this time and it was a big shift away from years of prehospital trauma practice; it was the first time I had attended a traumatic cardiac arrest; the scene was chaotic; the patient had such massive injuries and no decent protective gear – the outcome was inevitable, and so on. However, I wasn’t learning anything from this, and it gave me no assurance that next time would be better. So, I wrote a reflection using the approach outlined above, recognising that I had failed to manage myself effectively and this had a direct impact on the provision of care. Part of the action plan was to engage in further CPD in both the HOT protocol and managing human factors. I took the time to have a candid discussion with the critical care paramedic who was with me at the incident, read around the subjects and take part in simulations with colleagues.
Several months later I was allocated to a similar call: pedestrian vs lorry on the motorway. We received very little time to prepare, once again coming across the incident in traffic. The main difference this time around, which was evident from the outset, was that my confidence was much greater. The HOT process was initiated straight away, and I had a far clearer vision about what I wanted to achieve and how I would achieve it. As such we were able to implement the plan far more effectively.
Had I not reflected properly on the previous incident, there is every chance that I would have made the same mistakes and become submerged in the negative mindset which had hindered me before. Reflection, and the subsequent actions, had directly impacted my ability to perform in a high-pressure environment.
Below, Dr Brian Goldman further emphasises the point that all of us make mistakes – it is inevitable – but we should recognise it, reflect and engage in learning. Burying our collective heads in the sand does nobody any favours in the long run:
Reflect on everything to improve your practice! It doesn’t always have to be written down, it’s just as possible to reflect in your thoughts – but a structured approach remains important to organise and make sense of it. There is a plethora of articles and books available on the value of reflection, and this short blog is merely an introduction to a massive topic that goes way beyond healthcare applications and into the realm of centuries of philosophical contemplation.
“Reflection is continuous with practice, and our
practice can go worse or better according to the
value of our reflections. A system of thought is
something we live in…and if our intellectual
house is cramped and confined, we need
to know what better structures are available.” 
 Beaty L (1997). Developing your teaching through reflective practice. London: SEDA.
 Schon D (1983). The reflective practitioner: how professionals think in action. Aldershot: Ashgate.
 McDrury J & Alterio M (2002). Learning through storytelling in higher education: Using reflection and experience to improve learning. London: Kogan Page.
 Brockbank A & McGill I (2007). Facilitating reflective learning in higher education. Buckingham: Society for Research into Higher Education and Open University Press.
 Gibbs G (1988). Learning by doing: A guide to teaching and learning methods. London: Further Education Unit.
 Borton T (1970) Reach, Touch and Teach. London: Hutchinson.
 Brown A (2018) ‘Traumatic cardiac arrest: what’s HOT and what’s not’, Journal of Paramedic Practice. [Online].
 Blackburn S (1999). Think. Oxford. Oxford University Press.