Journal of Public Health | Vol. 35, No. 2, pp. 308 –312 | doi:10.

1093/pubmed/fds083 | Advance Access Publication 17 October 2012

Reflection as part of continuous professional development

for public health professionals: a literature review
Nishamali Jayatilleke1, Anne Mackie1,2
1
UK National Screening Committee, London, UK
2
Faculty of Public Health, London, UK
Address correspondence to Nishamali Jayatilleke, E-mail: nj201@doctors.org.uk

A B S T R AC T

Background For many years, reflection has been considered good practice in medical education. In public health (PH), while no formal training
or teaching of reflection takes place, it is expected as part of continuous professional development. This paper aims to identify reflective
models useful for PH and to review published literature on the role of reflection in PH. The paper also aims to investigate the reported
contribution, if any, of reflection by PH workers as part of their professional practice.

Methods A review of the literature was carried out in order to identify reflective experience, either directly related to PH or in health
education. Free text searches were conducted for English language papers on electronic bibliographic databases in September 2011.
Thirteen papers met the inclusion criteria and were reviewed.

Results There is limited but growing evidence to suggest reflection improves practice in disciplines allied to PH. No specific models are
currently recommended or widely used in PH.

Conclusions Health education literature has reflective models which could be applied to PH practice.

Keywords education, employment and skills, models

Background well as cognitive. In practice, the cognitive aspects are most

easily measured through assessments or performance, while
The practice of public health (PH) is a science as well as an
the emotional and social aspects may be less easily captured.
art.1 PH professionals may work across all or some of its
Frameworks of reflection could support the development of
main domains—health improvement, health protection and
both these dimensions.5 Further to this, if learning is con-
health services. The Faculty of Public Health provides direc-
sidered to take place in the form of a cycle, as shown in
tion and guidance to enable the development of profes-
Fig. 1, the role of reflection becomes apparent.
sionals and establish competencies that specify behaviour,
The cycle of learning comprises four elements—a con-
skills and attitudes. The Faculty encourages professionals to
crete experience, an observation and reflection, formation of
reflect as part of essential practice.2 Many different disci-
abstract concepts and testing in new situations.6 The circular
plines contribute to the PH workforce, but all are expected
model does not mean each stage should be equally weighted
to keep themselves up to date through continuing profes-
in time and emphasis.7 Kolb and Fry, in their theory, argue
sional development (CPD). However, the mere experience
that the cycle can begin at any of those points. However, in
of carrying out some developmental activity may not be suf-
ficient to enable future improvements and thus many
medical specialities encourage their practitioners to reflect
on their experiences.3 Nishamali Jayatilleke, Specialty Registrar in Public Health
Reflection can contribute to learning.4 Illeris4 describes Anne Mackie, Director of UK National Screening Committee & CPD Director of
learning to consist of emotional and social dimensions as Faculty of Public Health

308 # The Author 2012, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved

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 R E F L E CT I O N FO R P U B L IC H E A LTH P RO F E S S I O NA L S 309

Concrete experience

Testing in new situation Reflective observation

Abstract conceptualization

Fig. 1 Four stages of Kolb’s learning cycle6.

its simplified form, the learning cycle will begin by carrying Method
out a task, the person would reflect on that experience and
Literature search strategy
apply the learning in a new situation. In order to apply ex-
perience to the new situation, the ability to generalize through A literature search was undertaken using CINAHL, Medline
identifying principles and their connections to actions over a and OvidSP electronic databases in September 2011. The
range of circumstances is required. Throughout the process, search terms used were evidence-based practice, research
learners rate themselves which is an important element for evidence, medical education, qualitative research, reflective
adult learners8 and could be considered relevant for con- practice, reflection and evidence. Other sources included
tinuous professional development. In his work, Donald handpicking of books on evidence-based practice, reflection
Schon9 concludes that the possible objects for reflection can and research. Full texts of potentially relevant articles were
be as varied as the situations faced and the systems in which obtained. Papers were identified for inclusion in the review
they occur. Reflection can be understood as the ‘ability to by examination of full text articles. Data relating to charac-
gain understanding of specific issues in practice through crit- teristics of the population, intervention, outcome measures,
ically contextualizing, observing and analysing to generate study design and outcomes were collected.
new knowledge and insights which can enhance practice’.10
This may mean the individual might reflect on the feeling Inclusion criteria
for a situation which has led to adoption of a particular Papers written in English only were included. Articles per-
course of action, the way in which the problem has been taining to reflection in or on practice in PH or related disci-
framed and/or the role this has created for the individual in plines were included. Documents published between 1970
the wider institution as a result.9 It can be seen as the and 2011 were included. Peer- and non-peer-reviewed publi-
process of reasoned thought which enables a critical assess- cations were considered.
ment of both self as a professional and as an agent of
change.10 This latter is of particular relevance to PH profes- Exclusion criteria
sionals in their roles of influencing decision-making. Articles that included reflection as by-product rather than
However, as a speciality on the whole, PH has focused the main focus were excluded. Non-English language publi-
heavily on quantitative measures for evaluation. The cations were excluded.
purpose of this paper is to describe the development of a
framework for learning to reflection for individuals as well
Results
as for teams and to identify approaches to guide continuous
professional development. This paper describes how this Electronic searches yielded over 100 citations. Further cita-
could be implemented and used in everyday work to enable tions were obtained by hand searching of reference lists.
professional development. More than 20 full articles were retrieved and assessed

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 310 J O U RN A L O F P U B L I C H E A LTH

against the set inclusion criteria. Of the five papers included awareness, description, analysis, evaluation and learning. The
in this review, none were from PH, two from nursing and reflective process begins with the awareness of uncomfort-
two from other allied health professions or other education able feelings and thoughts from the action or new experi-
literature. One further model was included from non-health ence followed by a description of the situation including
background. thoughts and feelings. This would need to include salient
The search did not find evidence that particular frame- events and key features identified by the reflector. The re-
works were in regular use in current PH practice. The flector would need to analyse feelings and knowledge rele-
search identified educational concepts from the literature vant to the situation—identifying knowledge, challenging
which could be applied to PH. Several approaches to reflec- assumptions, imagining and exploring alternatives.
tion were found. While none of these were linked directly to The reflection process would also need to include evalu-
PH practice, their use in medicine was referenced. The lit- ation and consolidating learning. Evaluate the relevance of
erature discussed here were selected on relevance and knowledge through asking questions includes the following:
focused on the synthesis on framework, service-based learn- ‘Does it help to explain and/or solve problems’? ‘How
ing and mentorship. complete was the use of knowledge’? These steps would be
Burton’s approach11 was to use the core questions followed by identifying any learning which has occurred.
focused on reflection on action but with the ability to be After-action review is a de-brief process in practice origin-
applied in and before action. Burton’s cycle of three ques- ally developed by the US army which aims to identify how
tions comprises the questions: What? So what? Now what? to improve, maintain strengths and focus on performance
These are questions which the reflector can answer during of specific objectives. The de-brief manual provides guid-
the reflective process. ance for individuals and group reviews.14 The review would
Boud et al.12 defines reflection in the learning context and answer the following four questions: What was supposed to
focuses on the personal experience as the object of reflec- happen? What actually happened? Why were they different?
tion—as the intellect and affects lead to new understandings What did we (I) learn?
and appreciations. Boud describes three main components
to consider—experience, reflection and outcome. The ex-
perience can be a behaviour, ideas or feelings. The reflection
Discussion
will include returning to the experience, attend to feelings
that it brought about and a re-evaluation of the experience. Main findings
The outcome will look at new perspectives, changes to be- There is no published evidence of the use of particular
haviour and an application of learning into practice. models of reflection in PH practice. The general medical
The Gibbs’ reflective cycle (1988) encourages a clear de- education literature contains various approaches to reflection.
scription of the situation, analysis of feelings, evaluation of The evidence base to suggest learner’s self-reflection skills
the experience and an analysis to make sense of the experi- can be improved through formal training is still lacking.
ence. This would be followed by conclusions where other There are a variety of theories on reflection in the educa-
options are considered and reflection upon experience to tion literature. The implication this brings to individual PH
examine what one would do if the situation arose again.13 In practitioners is to consider when and how they will reflect as
essence, Gibbs describes a cycle of description, feelings, part of their continuous learning cycle. In addition, whether
evaluation, analysis, conclusion and action plan. The descrip- the act of reflection should be done alone or as part of a
tion is questioning what happened followed by the feelings team or both will need to be established. As a discipline
brought about through the questions—‘what were you that has focused less on reflection in the past it is possible
thinking and feeling?’. The evaluation component describes to draw on theories and models already existent and in use
what was good and not so good about the experience. The within medicine. There are a range of ways to reflect which
analysis should identify what sense can be made of the situ- include methods like journal writing, discussions and use of
ation and the conclusion details of what else could have technology such as blogs.15 There is also a range of aspects
been done. The process of reflection is ended with an to be considered, for example, individual perspective, team
action plan for what could be done if the situation arose dynamics and societal impacts. Ultimately, the aim of reflec-
again. tion would be to improve practice and learn from relevant
Atkins and Murphy5 through their model suggest that for experiences. It is obvious that this comes from being an
reflection to have a real effect it needs to be followed by an analytical reflector and moving beyond pure description.
action commitment. The authors describe a cycle of As some of the literature suggests, it is useful to recognise

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 R E F L E CT I O N FO R P U B L IC H E A LTH P RO F E S S I O NA L S 311

emotional influence and challenge one’s ideas. In broader as they will include policy, professional and societal influ-
learning terms, it is also useful to consider the relevance of ences (examples of external factors) and attitudes, skills,
prior experience. experiences and team dynamics (examples of internal
Reflection enhances personal development by leading to factors).26
self-awareness.16 If the focus of reflection is improvement in The practice of self-reflection in academic achievement
patient care, it helps to expand and develop clinical knowl- has been captured in disciplines that contribute to PH. A
edge and skills.17 – 19 The process slows down activity pro- positive impact was noted through reflective journal writing
viding time to process material of learning and link to over only scientific report writing for those studying
previous ideas.20 It should also enable more ownership of biology.27 This was evidenced through greater awareness of
the learning taking place.20 Reflection has been reckoned to cognitive strategies and conceptions of learning when lear-
promote optimum effectiveness and efficiency in an ever ners constructed more complex and related knowledge
evolving and complex health-care system through practi- when learning from text. In studies of mathematics students,
tioners auditing their own practice.21,22 ‘Reflection reminds while reflection was not necessary for high grades of
qualified practitioners that there is no end point to learning achievements, it supported better conceptualization of
about their everyday practice’.18 meanings of the technical definitions.28 Practice, shaped
Where it exists, the practice of reflection has tended to through reflection can develop professionals, organizations
focus on individual professionals at specific points in time and society. This is already considered important within
and/or on specific elements of practice.10 This, however, health promotion.25
can form only a part of the experience as many PH actions Educational concepts and the impact of reflection are not
involve many disciplines. Often action takes place across easily measurable.29 Therefore, its merits may be overlooked.
multi-sectoral teams and involves multi-phased interven- One can argue that this approach of reflecting on an issue is
tions. Programme delivery is often longer term, should be too straight forward and, in practice, difficult issues may
population focused and policy led. take months to reflect on. Doing so quickly might lead to a
The learner involvement is a key fundamental principle of paper exercise. Explicit frameworks may not be suitable for
adult education. PH CPD and the reflection that forms part some situations. Frameworks vary in their focus of contexts.
of it can be viewed in light of adult education as individuals However, they are aimed to be critical analyses of knowledge
need to take ownership and engage in setting their learning and experience to deepen understanding. Time, motivation,
agenda.23 Therefore, the mere act of reflecting supports the initial expertise and lack of peer support are recognized bar-
androgogical model as adults need to be able to establish riers to reflection. To add to this are organizational contexts
the purpose of the activity undertaken and identify how to and team dynamics—frequent problems faced by PH pro-
cope effectively with real-life situations.24 fessionals.10 However, a structure to guide the process of re-
There needs to be opportunity to reflect as individuals as flection on the content and the process of learning would
well as in teams in an acute manner while carrying out the be deemed useful.30
longer term projects. Reflection can be used as a tool to fa-
cilitate professionals to assess beliefs, values and approaches
Limitations
to practice.25 These factors determine how individuals per-
With the aim of providing a broad overview of reflective
sonally and the policies/programmes which they deliver, act
approaches relevant to PH professionals, this work provides
as agents of change, contributing to empowerment. Adult
a selection and not a complete comprehensive collection of
learners are more likely to believe and instil ideas that they
medical education literature.
help create. The environment can provide many structured
activities that generate the ideas, concepts or techniques if
an active decision to do so is taken. The practitioner could What does this report add?
then experience surprise, puzzlement or confusion asso- There are very few articles relating the use of reflection to
ciated with the situation. Reflecting on the phenomena that current PH practice and furthermore on the strengths and
is being experienced and prior understanding which have weaknesses of different models that could be applied. This
implicated, the resulting behaviour will lead the learner to review article outlines some of the most applicable and out-
new understanding.9 lines their merits and otherwise. Individuals working in PH
In the health promotion literature, reflection on external may consider some of the approaches described here along-
and internal factors is recommended. These factors, side their current professional development activities either
however, could be equally applied to other domains of PH as individual learners or as part of learning within teams.

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 312 J O U RN A L O F P U B L I C H E A LTH

Conclusions 11 Burton AJ. Reflection: nursing’s practice and education panacea?

J Adv Educ 2000;31(5):1009 – 17.
At present, the strength and extent of the evidence base for 12 Boud D, Keough R, Walker D. Reflection: Turning Experience into
the educational effects of reflection in a PH setting is limited. Learning. London: Kogan Page, 1998.
However, there is evidence of an improving trend in the 13 Gibbs G. Learning by Doing: A Guide to Teaching and Learning Methods.
quality of reported studies. ‘Higher quality’ papers identify Oxford: Further Education Unit, Oxford Polytechnic, 1988.
improvements in knowledge and understanding, increased 14 Department of the Army. Washington, DC, 1993. http://www.au.
self-awareness and engagement in reflection and improved af.mil/au/awc/awcgate/army/tc_25-20/tc25-20.pdf (March 2012,
opportunities through specialist training and continuous date last accessed).
professional development. 15 Chretien K, Goldman E, Faselis C. The reflective writing class blog:
In recognition of the time commitment involved, the benefits using technology to promote reflection and professional develop-
ment. J Gen Intern Med 2008;23(12):2066– 70.
to the profession must be apparent. In addition, the opportunity
16 Cotton AH. Private thoughts in public spheres: issues in reflection
cost of other learning and developmental activity forgone needs
and reflective practices in nursing. J Adv Nurs 2001;36(4):512– 9.
to be considered. Further work is needed to strengthen the evi-
17 Graham IW. Reflective practice and its role in mental health nurses’
dence base for reflection, particularly, where possible, comparative
practice development: a year-long study. J Psychiatr Mental Health
studies which observe changes in knowledge and abilities directly. Nurs 2000;7:109– 17.
Given its merits, while the quantitative evidence base is 18 Driscoll J, Teh B. The potential of reflective practice to develop
limited, what are the implications for practice? Given PH’s individual orthopaedic nurse practitioners and their practice.
stated desire to base practice upon evidence there is urgent J Orthopaedic Nurs 2001;5:95– 103.
need to formally assess the effectiveness of reflection in the 19 Paget T. Reflective practice and clinical outcomes: practitioners’
improvement of PH practice. views on how reflective practice has influenced their clinical prac-
tice. J Clin Nurs 2001;10:204– 14.
Acknowledgements 20 Moon J. PDP Working Paper 4: reflection in higher education learn-
ing. Learning and Teaching Support Network Generic Centre, 2002.
We would like to thank Joanne Harcombe for her helpful http://www.ltsn.ac.uk/genericcentre/projects/pdp/working-papers
comments on the draft manuscript. (March 2012, date last accessed).
21 Degazon CE, Lunney M. Clinical journal: a tool to foster critical think-
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1 Winslow CA. The untilled fields of public health. Science reflection in trainee teachers. Qual Higher Educ 2000;6(3):245 – 57.
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Herewith a summary of the Jayatilleke, N. et al. (2013) paper: Establish the
process of becoming a reflective practitioner: Jayatilleke, N. and Mackie, A.,
2013. Reflection as part of continuous professional development for public
health professionals: a literature review. Journal of Public Health, 35(2),
pp.308-312.

• Reflection has been considered good practice in medical education however in the public
health sector (PH), there is no formal training or teaching of reflection yet it is expected as
part of continuous professional development.

• This paper aims to identify reflective models useful for PH.

• Reflection can contribute to learning where learning is described to consist of emotional and
social dimensions as well as cognitive.

• Kolb’s cycle of learning comprises four elements—a concrete experience, an observation and
reflection, formation of abstract concepts and testing in new situations. The circular model
does not mean each stage should be equally weighted in time and emphasis and it should be
noted that the cycle can begin at any of those points:

• Practically, the learning cycle will begin by carrying out a task, the person would reflect on
that experience and apply the learning in a new situation.

• Reflection can be understood as the ‘ability to gain understanding of specific issues in practice
through critically contextualizing, observing and analysing to generate new knowledge and
insights which can enhance practice’.

• However, as a speciality on the whole, PH has focused heavily on quantitative measures for
evaluation.
MAIN FINDINGS

• There is no published evidence of the use of particular models of reflection in PH practice,

however, various approaches are used. Learner’s self-reflection skills can be improved
through formal training is still lacking.

• Consideration needs to be given the “when” and “how” reflection by the PH practitioner
needs to take place as well as whether it should take place alone, as a team, or a combination
of the two.

• There are a range of ways to reflect which include methods like journal writing, discussions
and use of technology such as blogs.

• Ultimately, the aim of reflection would be to improve practice and learn from relevant
experiences.

• Reflection enhances personal development by leading to self-awareness. If the focus of

reflection is improvement in patient care, it helps to expand and develop clinical knowledge
and skills.

• Reflection has been reckoned to promote optimum effectiveness and efficiency in an ever
evolving and complex health-care system through practitioners auditing their own practice.

• ‘Reflection reminds qualified practitioners that there is no end point to learning about their
everyday practice’.
CPD reflective narratives
The personal stories in this document show how reflective practice has
helped these doctors with their development.

Why reflect?
There’s growing evidence from research that reflective practice improves the way
people perform in their jobs. This is particularly important for medical practitioners
to maintain and improve their standard of practice.

Reflective narratives
The GMC and the Academy of Medical Royal Colleges are jointly collecting a series of
anonymised reflective narratives, examples of how some doctors have reflected on
their practice.

These narratives are not intended to be used as templates about reflection for
appraisal. They are instead designed to help doctors with the thought process for
reflection, which is an important part of their professional development and
appraisals.

In this document

Paediatrics - better communication in emergencies

Dr A is a consultant in paediatrics, working in the emergency department of a
teaching hospital. He reflects on the need for better communication in emergency
situations.

General practice - self-motivation to continue clinical work

Dr D is a general practitioner reflecting on the self-motivation she needed to
continue in clinical practice as a locum.

Public health medicine - developing effective and fair funding policies

Dr C is a consultant in public health medicine. Here he reflects on developing
effective and fair policies with CCGs for funding.

Public health medicine - giving an effective TV interview

Dr B is a consultant in public health medicine. Here she reflects on how to give an
effective TV interview.
Paediatrics - better communication in emergencies
Dr A is a consultant in paediatrics, working in the emergency department of a
teaching hospital. Here he reflects on the need for better communication in
emergency situations.

What's the issue you reflected on?

Tell us about an incident/situation/feeling that gave you cause for

reflection

A 4 year old child with established epilepsy came to A&E following a prolonged
seizure and was admitted to the paediatric ICU following a respiratory arrest. I was
the consultant on call that weekend and arrived in A&E about mid-way between the
child’s arrival in A&E and their respiratory arrest.

What made you stop and think?

It became apparent later that they had received 4 doses of benzodiazepines prior to
a loading dose of intravenous phenytoin, the latter of which quickly stopped their
seizure. It also transpired that one of these benzodiazepine doses had been doubled
in error. In the melee of the situation neither I, nor anybody else, had fully
appreciated how many doses of benzodiazepine they had already received until after
their respiratory arrest.

It was later agreed that the likely cause of their respiratory arrest was secondary to
the number of doses of benzodiazepine they had received across a number of
settings: at home from the family, in the ambulance from paramedics, in A&E from
casualty doctors and nurses and again in A&E from attending paediatricians.

They needed a short period of intubation and ventilation but fortunately made a full
recovery.

There are many ways to reflect - how did you do it?

I discussed this with colleagues in A&E and in my paediatric unit.

I reviewed the literature on the management of status epilepticus independently.

2
What did you do?
I flagged this as a “near miss” incident in our hospital safety system.

I reviewed the latest literature on the management of convulsive status epilepticus. I

ran an update on the status epilepticus protocol for the junior staff in my own
paediatric department and A&E, emphasising the correct doses, pathways of
medication use and the importance of a timeline.

I asked my nurse colleagues to review the “emergency care protocol” for all children
with epilepsy on emergency buccal midazolam so that it was clear how many doses
of benzodiazepine their child could have. Families were asked to give a copy of this
protocol to the ambulance crew should this be necessary.

We reviewed the communication pathway, how information is gathered on

medication and recorded in an acute paediatric “resus” setting.

Tell us what you took away or learned from this experience?

I could have made more stringent enquiries about the number of doses and quantity
of doses of benzodiazepine he had already received when I arrived in A&E myself.

This emphasised the importance of team work in this acute setting.

It also emphasised the importance of good communication between parents,

ambulance staff, A&E clinicians and paediatricians in an acute, high pressure
situation.

How did it change your thinking or practice?

I also took away the importance of good communication. Asking the right questions
in the “heat of the moment”. Ensuring my team knows about the appropriate
management of status epilepticus.

What have been the effects of your changes?

Has it improved your practice and outcomes?

Over the next 6 months, we will audit the number of doses of benzodiazepines a
child receives from community through to hospital should a child be admitted with a
prolonged epileptic seizure.

3
I will consider running some simulation exercises with my colleagues to test how
well our status epilepticus protocol works in our hospital. This will test knowledge of
the team within my unit - and also be a learning exercise for myself.

Top tips

What top tips would you give to doctors in your specialty about how to get
the most from reflection or thinking constructively about a particular
problem?

 Put aside time to reflect. Record it as something you need to address and
remember to complete your reflective notes when this is finished.
 Discuss the situation with your colleagues.
 Look at the literature and any clinical guidance to further inform you. Reflect
on how your team functions in addressing a problem.
 Act on what you have learned.
 Communicate what you have learned with your colleagues.

4
General practice - self-motivation to continue
clinical work
Dr D is a general practitioner. Here she reflects on the self-motivation she needed to
continue in clinical practice as a locum.

What's the issue you reflected on?

Tell us about an incident/situation/feeling that gave you cause for

reflection

Since leaving my partnership, I have not been as diligent in getting locums as I

intended. There always seems to be something high priority in my educational and
management roles that makes me put off getting my CV out to practices and locum
sessions booked in.

I am worried that if I don’t get back into primary care clinical practice soon, I will
start to lose confidence.

What made you stop and think?

I suddenly realised that three months had gone by without me doing a locum in
clinical work (part of that was Christmas).

There are many ways to reflect - how did you do it?

This was an internal area of disquiet, but what brought it up to conscious awareness
was that I went on a mentoring course where I chose to raise this issue to discuss in
a “mini-mentoring” session with another delegate. We looked at practical strategies
to get over the barrier caused by moving into a new way of working - like working
out what to charge and where to send my CV.

It only took 30 minutes but it was a really important and thought provoking
discussion. I had not realised how much I was inhibited by having to set a price on
my time and ask for money.

5
What did you do?

Tell us what you took away or learned from this experience?

I have realised how helpful it is to talk through things that seem difficult to get on
with. I liked being introduced to some ideas about how to deal with procrastination -
such as breaking the task down into bite sized chunks, and giving myself mini-
rewards for achieving each stage.

How did it change your thinking or practice?

I have stopped allowing my fears about being a locum from stopping me any longer
and I have started to take on locums in a variety of GP practices.

I have professionalised my locum work with a clear standard “service level

agreement” with each practice.

I have joined the National Association of Sessional GPs.

What have been the effects of your changes?

Has it improved your practice and outcomes?

By getting back into clinical work, my confidence has been restored. I am getting
more experiential learning to target my CPD, although I do have some learning
needs that are entirely about this career change - such as learning new computer IT
systems that we did not use in my practice.

Has it affected others?

I have shared my learning about how to deal with procrastination with some of my
friends and colleagues and shared my findings on setting myself up as a locum GP
with other new locums in my position (former partners with well-established links
into one particular practice and team).

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Top tips

What top tips would you give to doctors in your specialty about how to get
the most from reflection or thinking constructively about a particular
problem?

 Build reflection into everyday practice. To get the most out of reflection, it
needs to be something that is part of normal practice. Talking this feeling of
disquiet through really helped me to work out why I was procrastinating, as it
is not usually like me. I don’t think it matters whether reflection takes place
alone or in a facilitated way but I do think that it is useful sometimes to take
a few minutes to write something down that captures and names the feeling
or problem or insight. A few good examples of reflective practice showing
how I think about what I am doing as a doctor will keep my appraiser and my
RO happy because they can see how I explore incidents that arise in my
practice and react to them by making appropriate changes. On the other
hand, I think it is essential not to waste time that could be spent with
patients, or the leisure time that is so important for recharging the batteries,
on a production line of documentation of reflection that becomes a burden or
a chore. My appraiser has been very helpful in pointing out where I have
been doing more than is needed, out of a misguided perfectionism.
 Use reflection to show how your practice is impacting on others. I am relieved
to see the new guidance from the GMC and the Royal Colleges on decreasing
the regulatory burden and increasing the emphasis on providing a few good
quality examples of reflective practice. I aim to reflect on the most important
things that I have learned every year and any significant changes that I have
made to my practice. That way I can show how my CPD, and my review of
my work and the feedback I get, has an impact on improving my patient care,
relationships with colleagues or my own resilience.

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Public health medicine - developing effective and
fair funding policies
Dr C is a consultant in public health medicine. Here he reflects on developing
effective and fair policies with CCGs for funding.

What's the issue you reflected on?

Tell us about an incident/situation/feeling that gave you cause for

reflection

I work in health care Public Health and support the local clinical commissioning
groups (CCGs) in their priority setting process including commissioning policy
development.

As a local health system we were updating the commissioning statement for

septorhinoplasty; especially under what circumstances it will be funded. Local ENT
consultants wanted further indications to be included so that septorhinoplasty could
be funded for these patients.

I found it was hard to define the boundary between clinical need (where there is
definite clinical benefit) and cosmetic intervention. The ENT consultants were trying
to do their best for their patients by including indications such as severe anosmia
and recurrent epistaxis.

As a Public Health consultant I need to consider the cost of performing these

interventions on patients who might gain marginal benefit. I did my best to work
with CCG GPs and the local ENT consultants to agree a consensus.

What made you stop and think?

I wondered what the appropriate approach to take was in finalising the funding
indications for septorhinoplasty. Should I be looking at the best available evidence?

I often find that the evidence is not available at the level I am looking for. It also
becomes hard to disagree with the local experts and I need to avoid giving an
impression that this is purely a cost cutting measure.

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There are many ways to reflect - how did you do it?
I went over the scenario many times and debated with myself what a rational person
will do. I also discussed this with one of my trainees to gauge their views.

I challenged myself to defend my course of action, and the indications that I was
intending to include/exclude. I thought about the possible reaction of the local ENT
consultants, the CCG GPs and the managers.

I thought through the impact the revised statement will have on the patients and the
resource implications for the local commissioning arm of the NHS.

What did you do?

Tell us what you took away or learned from this experience?

Evidence may not always be the answer in formulating commissioning policies as it

may not be available. Hence local consensus has to be reached working closely with
primary and secondary care clinicians.

When there is disagreement between the two it takes a lot of time and effort to
agree a common position. The purchaser provider split sometimes could hinder
clinical collaboration and cooperation and I need to work around this potential
barrier.

Taking the process through established mechanisms in the local health system at
times can be cumbersome and frustrating - plenty of time is needed.

How did it change your thinking or practice?

I will start a dialogue with the respective specialists and will involve the lead GP from
the CCG. However this may not always be possible due to time constraints. But I will
endeavour to adopt this approach.

Unless there is local buy in from secondary care specialists in commissioning policy
development, it is almost impossible to implement these locally.

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What have been the effects of your changes?

Has it improved your practice and outcomes?

This needs to be seen. I hope that the new approach will lead to better engagement
and commissioning policies that are agreeable to local clinicians.

Many commissioning policies are coming up for review and I will be adopting this
approach. A well-developed policy with local clinician engagement and approval will
benefit patients in the greatest need and avoid the opportunity cost of treating
patients who are unlikely to benefit from an invasive intervention.

Has it affected others?

Yes. The revised policy will make the intervention available to wider groups of
patients. Procedures will be offered to patients quicker as the clinicians are clear
what is being commissioned and which patients they can operate on.

This will also help if the local commissioning organisation decides to introduce prior
approval for procedures as the criteria is clearer and has the agreement of local
clinicians.

Top tips

What top tips would you give to doctors in your specialty about how to get
the most from reflection or thinking constructively about a particular
problem?

 If you feel something has gone particularly well then it is worthy of reflection
to identify actions, approach or areas to copy for future work.
 Similarly if something has gone badly this is certainly worthy of the
investment in time and effort to learn from it so that there is less of chance of
this happening again.
 Keep an open mind and try not to blame someone else or yourself for that
matter.
 The objective is to learn and improve on an ongoing basis.
 As far as possible write some brief reflective notes as soon as possible.
 Always use a selection of reflective notes during your appraisal and discuss
these with your appraiser.

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Public health medicine - giving an effective TV
interview
Dr B is a consultant in public health medicine. Here she reflects on how to give an
effective TV interview.

What's the issue you reflected on?

Tell us about an incident/situation/feeling that gave you cause for

reflection

I was asked to take part in a TV interview to support the public health campaign for
bowel cancer screening. A patient who had done the test and discovered invasive
cancer was part of the feature.

What made you stop and think?

Although I had had media training previously, this was the first time I was to
undertake a taped TV interview. It was going out to a range of audiences all at once
- I had to reflect on why it was important, and why others would want to listen and
take heed.

There are many ways to reflect - how did you do it?

Preparation for the interview is part of the reflective process - it helped me be very
clear about what I was to say, and the purpose behind it.

I anticipated likely questions and made sure I had the most up to date information
on bowel cancer. I also went through the process from the patient point of view by
using tips and resources compiled by my team.

I spoke to someone who had done the test, and to a patient whose screening test
had picked up an invasive tumour.

Following the interview, I had a feedback session with a colleague. This showed me
that I could have widened the scope of the message to tackling inequalities.

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What did you do?

Tell us what you took away or learned from this experience?

I sourced lots of information that I did not use. I found out that they were actually
looking for 20 second sound bites, with no straying off topic.

The interview stated that the process was straightforward, but I know this isn’t the
case for people with mobility problems or a disability. And people find it
embarrassing or unpleasant. There are also practical barriers like being unsure how
to take the sample and instructions being hard to read. On reflection, I could have
pointed out all these issues and how they can be overcome.

It was a good opportunity to talk about the subject openly on air.

How did it change your thinking or practice?

The media picked up our campaign because we had a great patient story to go with
it. They interviewed the patient first, then me (the public health expert). So, for
campaigns to raise awareness, press releases and quotes from experts are not
enough - a personal story has the impact.

Also, I developed a working relationship with the local health journalist through this
programme of awareness. And the patient and public get to see and hear the
messages in high visibility.

What have been the effects of your changes?

Has it improved your practice and outcomes?

I am cautious about media assignments now - I make sure I only accept ones I am
competent and knowledgeable about.

If it is a difficult news story with experts pitched against each other, I would need to
develop skill in handling challenging questions and making the points I needed to
make.

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Has it affected others?

I hope my reflections can remind others of the purpose of our media stories; about
how we would like to make a difference and reach people to raise awareness of
important issues.

Top tips

What top tips would you give to doctors in your specialty about how to get
the most from reflection or thinking constructively about a particular
problem?

 CPD is not something we do for the Faculty or to tick a box for the GMC. It is
the learning we document for ourselves.
 CPD is what we get out of the job in learning and experience; it is different
from the effort we put into our jobs as outlined in our work objectives.
 The four key questions that we reflect on for our CPD are a structured way of
experiential learning:
o Why did I choose this activity?
o What did I learn?
o How am I going to apply this learning in my work?
o What am I going to do in future to further develop this learning and/or
meet any gaps in my knowledge, skills or understanding?
 Go back to your reflective notes from a few years ago and you can track the
journey you have been on.
 A personal development plan is important to start you off on your cycle of
CPD - plan, reflect, review, plan again.
 Reflecting with a peer or buddy enables you to reflect more deeply as they
can question to help you find the answers for yourself.

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