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Reflective Practice

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Reflective diaries in medical practice

a

Jason Raw ; David Brigden ; Romesh Gupta

a
Lancashire Teaching Hospitals NHS Trust, Chorley and South Ribble District
General Hospital. Chorley. UK
b
University of Liverpool/NHSE. Liverpool. UK
To cite this Article: Raw, Jason, Brigden, David and Gupta, Romesh , 'Reflective
diaries in medical practice', Reflective Practice, 6:1, 165 - 169
To link to this article: DOI: 10.1080/1462394042000328697
URL: http://dx.doi.org/10.1080/1462394042000328697

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Downloaded By: [University of Dundee] At: 13:33 25 May 2007

Reflective Practice
Vol. 6, No. 1, February 2005, pp. 165169

THOUGHTPIECE

Reflective diaries in medical practice

Jason Rawa*, David Brigdenb and Romesh Guptaa
aLancashire

Teaching Hospitals NHS Trust, Chorley and South Ribble District General
Hospital, Chorley, UK; bUniversity of Liverpool/NHSE, Liverpool, UK
0Chorley
JasonRaw,
00000February
&Francis
South
Registrar
2005
Ribble
General HospitalLancashire Teaching HospitalsNHS Trust, Preston RdPR7 1PPChorleyLanesjasonraw@msn.com
Reflective
10.1080/1462394042000328697
CREP6111.sgm
1462-3943
Taylor
2005
61Thoughtpiece
&
and
Practice
(print)/1470-1103
Francis
Ltd
Ltd District
(online)

Increasingly, we as health professionals are being asked to practise reflective learning.

The process of reflection is seen as essential to improving working practices, making
sense of difficult situations and utilising positive experiences. Everybody reflects from
time to time; we mull over the days events and reminisce about incidents that have
left an indelible memory with us. Do we use the process of reflection to our full
advantage? Do we all have a subconscious or conscious process for maximising it and
ensuring we do reflect in a timely manner rather than when it is too late to do anything
about it? As well as using reflection to help with analysing how a protocol may be
developed for management of a particular condition, or for planning an audit, it is
most useful when clinicians try to use their day-to-day experiences to shape and
evolve their practices. By doing so they avoid the mistakes of old, or reinforce positive
outcomes; this in turn benefits their working lives and the lives of their patients, the
team they work in, the hospital as a whole including the Trust and PCT.
There are several steps to systematic and useful reflective learning, which are
outlined below, followed by some examples of true reflective learning from the
authors experience. There are three stages of reflective practice and learning:

The first stage is triggered by an awareness of unsettling feelings and uncomfortable

thoughts about an event or events. Realising that there are questions to ask yourself,
such as, is this the right management? Is the patient satisfied? Can I do better?
The second stage involves a critical analysis of the situation and an examination of
feelings and knowledge, or thinking on your feet, or reflection in action, whereby
an immediate change is made based on critical thinking, to improve the result. This
process entails association, integration, validation and appropriateness (Atkins &
Murphy, 1993). It may involve reassessment of a management plan, checking that
preparation is correct, ensuring that possible problems are predicted and plans are
in place.

ISSN 1462-3943 (print)/ISSN 1470-1103 (online)/05/0101655

2005 Taylor & Francis Group Ltd
DOI: 10.1080/1462394042000328697

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166 Thoughtpiece

The third stage involves the development of a new perspective on the situation.
This means firmly deciding to implement change in practice as a result of the
earlier stages, for the benefit of similar future situations. This stage can be aided by
making a conscious decision to use reflective learning regularly and often, and can
be facilitated by the use of a Reflective Diary, in which events that have shaped
your practice can be recorded and ensure that the reflective process did not go to
waste. Reflective diaries can provide the user with an invaluable resource for the
teaching and education of junior staff so as to ensure everyone benefits from your
experiences. Recording these reflective episodes should lead to targeted learning
using research evidence to further reinforce the learning points, turning the anecdotal story of a difficult case into one the listeners learn from appropriately and
take into their own practices.

Re-Validation
Starting early in your careers by designing and utilising a Reflective Diary will help
guide your career progress very successfully, providing you with confidence to face
your mistakes and learn from them and to be aware of positive experiences you have
or hear about. Lifelong learning is an important aspect of a career in medicine, with
the need to keep up to date with current research and developments foremost. This
includes improving our communication skills, our ability to empathise with patients
and educating our colleagues as much as our self, not just clinical skills improvement.
With revalidation part of professional appraisal and development, the use of a reflective
diary and a systematic approach to reflection will greatly aid the revalidation process
and help the building of a portfolio of experiences and evidence for active learning.
The following are examples adapted from a medical practitioners reflective diary:

A very ill elderly lady with severe COPD and respiratory failure is taken to high
dependency for non-invasive ventilation. The family were asked to wait in the waiting room. Over one hour passes with the doctors and nurses unable to get her
settled and tolerate the mask and oxygen. Due to the severity of her COPD and
her poor functional ability normally is not considered a suitable candidate for intubation and ventilation on the intensive care unit. Suddenly she cardiovascularly
collapses and dies. One of the doctors and a nurse go to inform the family. They
get an unexpectedly hostile reaction, the family are very angry with the staff, having
waited for over one hour to see their relative, then get told she had died. The
familys reaction greatly upsets the doctor and nurse who feel they had tried hard
to save her.
On reflection the doctor and nurse decide that in future they will make sure relatives will be able to be with their family member as early as possible even if their
relative is very sick and needs a great deal of medical attention. They realise that if
the family of a very sick patient can be with their loved one at those times, it is
better for all concerned, rather than in a room not knowing what is happening. The
nurse brings up the episode in a staff meeting, with the doctor present, and uses

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Thoughtpiece 167

her experience to encourage other staff to involve relatives as early as possible when
patients become very unwell. Even if the unwell patient is requiring a great deal of
attention, the family can be at the bedside holding their hand while the staff work,
this may be all the family want. The doctor decides to look into the problem and
finds out that research has shown that relatives present at the bedside during
cardiac arrest situations appear to cope better with the grieving process and this
should probably apply in episodes of life threatening illness also (Robinson et al.,
1998).
Despite being taught how to break bad news, when a doctor goes to tell a grandson
that his granddad has died in the A&E resus room, he finds the conversation goes
badly wrong. As he enters the relatives room the doctor is quickly asked what
happened. Without hesitating the doctor proceeds to describe the events of the
cardiac arrest resuscitation attempt. Feeling that the grandson understands what
he has been told, he finally asks, Do you have any questions youd like to ask?
Straight away the grandson replies, Yeah, how is he? The doctor, taken aback
has to state clearly his grandfather has died and leaves knowing he handled it badly
and he has possibly made things worse for the grandson. He reflects on it over time
and resolves to be clearer and not beat about the bush when breaking bad news in
the future as the worried relative is usually not ready for a great deal of detail and
may fail to fully comprehend the intended message. He talks to colleagues about
his experience and finds some have had similar problems; they all agree that relatives need to be given clear messages without ambiguity. The doctor finds a journal
article, entitled Breaking bad news to patients (Mueller, 2002), to help reinforce
his learning and he distributes it to his colleagues.
A man with metastatic terminal lung cancer comes to hospital with a clinical pneumonia. He has had several infections recently and is aware of his condition and
prognosis. His family called the ambulance and want him admitted and treated.
This is straightforward for the doctor attending to arrange. The patient tells him
however that he is dying and he wants to go home to die. His wife cant look after
him without help however, and his family are not yet prepared for him to die.
Instead of persuading the patient to stay at least over night for intravenous antibiotics, which may get him better, the doctor spends a long time talking to the
patients family about his prognosis and the patients wishes. He also manages to
organise emergency home palliative nursing care. Four hours later the patient goes
home from A&E. The doctor leaves the hospital wondering if it was all worth the
hassle. The doctor bumps into the patients son later in the week as he is in the
hospital to obtain his fathers death certificate. He tells the doctor that his father
died peacefully at home with his family around him and that they are very grateful
to the doctor for helping them with that. The doctor realises that as well as the
patient getting his wishes, even if it meant extra work, he is heartened to know he
made a small difference to that patient and his family. It seems to him that most
terminal patients would probably prefer to spend their last days at home with their
family if it were possible, as this person did, than in a hospital environment having
tests and getting treatment that may not benefit them. He finds out that there is

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168 Thoughtpiece

research evidence to back this up (Wilkinson et al., 2003), including a YouGov

survey in early 2004 that stated that 64% of people would choose to die at home if
they could. He sets about educating the A&E staff to try to broach this subject with
patients if they feel it may be appropriate.
An elderly gentleman is admitted to hospital as an emergency after being found
unconscious at home. A senior house officer who is on-call that day sees him. The
patient has a history of cardiovascular disease and clinically he is completely unresponsive, including no response to painful stimuli. He is given a diagnosis of brainstem stroke and due to his frailty and poor prognosis a brain scan is not organised,
his family are informed of the diagnosis and that he should not be for cardiopulmonary resuscitation in the event of a cardio respiratory arrest. The family agree
and he is placed on a ward to be kept comfortable.
Twenty-four hours later the patient begins to wake up. Forty-eight hours later the
patient is awake and interacting with staff on the ward. Whilst on the ward he
confesses to a Dietician that he took an overdose of tablets to end his life prior to being
admitted. The ward consultant is informed and he finds out from the family that the
patient has been depressed for some time and had talked about taking his own life.
After the patient is discharged from hospital the consultant reflects on this
patients admission. He wonders how the wrong diagnosis had been made and how
the senior house officer who saw him didnt consider an overdose as a possibility.
In the future he will make an effort to consider overdose in such patients. Time
goes by and the senior house officer who saw the patient has left the hospital and
the consultant feels he should have done more at the time of the patients admission to bring this to the attention of the doctor in question. He decides in future
that it would be in the best interests of the doctors to have feedback so they can
learn from their errors, and he resolves to inform the doctors if such a situation
arises in the future. If junior doctors are spoken to in a relaxed and nonjudgemental atmosphere they are more likely to appreciate any feedback and take
on board the lessons learned. As junior doctors working hours have been reduced
and working practices have changed, they often no longer have responsibility for
the ongoing care of patients they admit once they go to a ward and without appropriate feedback they may now be losing out on important training and education
opportunities. The consultant decides a monthly meeting to address junior doctor
feedback may be a good way of helping to solve this problem.
A junior doctor working within the medical department at a hospital finds his regular on-call commitment difficult to cope with. He worries about the upcoming oncall shifts and what might come into the hospital needing him to deal with it. To
deal with these worries he finds that he tends to hide away when on-call, staying in
the doctors mess and waiting until he is paged, hoping he wont be. He knows that
even then he cant relax and let the time pass, he constantly feels on edge as if the
next emergency call is coming at any minute. He notices the on-call shift drags on
and on as if never-ending before he can go home again. He is unaware that he has
a reputation amongst the nursing staff for never being around, for being difficult to
deal with and the staff do not have confidence in him as a doctor.

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Thoughtpiece 169
He is getting increasingly stressed and begins to reflect on his career. He decides
he is sure he wants to do medicine but finds the on-calls unbearable. He feels the
time dragging and the apprehension of what might be about to happen is the worst
problem. After a time he realises that if he didnt wait to be called and instead went
to the admissions units and casualty and got involved in what was going on the time
may go faster. He tries this out and finds he enjoys being involved and the ward
atmosphere. He stops wondering when and what his next call will be because he is
too busy to think about it. He enjoys working with the staff and they appreciate him
being around. His confidence rises and the time no longer drags through the day.
He even begins to look forward to his on-call shifts. He uses this experience in the
future to educate junior doctors about getting the most from their working lives
and how to better cope with stress.
In conclusion, reflective learning is rapidly becoming accepted practice and is a vital part
of lifelong learning as health care professionals. The use of a diary for recording reflective learning experiences is invaluable for professional development and maximising
career potential; it is not all about reading medical journals and attending conferences.
Notes on contributors
Jason Raw is a Specialist Registrar in Geriatrics and General Medicine, North West
Region, UK.
David Brigden is Regional Advisor for Postgraduate Medical and Dental Education
in Mersey Deanery (University of Liverpool/NHSE). He is also an Honorary
Senior Lecturer in the School of Postgraduate Medicine and Health Science at
University of Central Lancashire; Honorary Senior Fellow in Education at
University College Chester; Professor of Health Sciences Education at University College Chester and Professor of Professional Development in the Faculty
of Health Sciences at the University of Cape Town, South Africa.
Romesh Gupta is Consultant Physician with Special Interest in Elderly Medicine/
Stroke Medicine, Chorley and South Ribble District General Hospital, UK. He
is also Professor of Ethnicity and Health with an interest in Education and
Training, Bolton Institute, Lancashire, UK.
References
Atkins, S., & Murphy, K. (2003) Reflection: a review of the literature, Journal of Advanced Nursing,
18, 118119.
Mueller P. (2002) Breaking bad news to patients, Postgraduate Medicine, 112(3), 1516.
Robinson, S. M., Mackenzie-Ross, S., Cambell-Hewson, G. L., Egleston, C. V. & Prevost, A. T.
(1998) Psychological effect of witnessed resuscitation on bereaved relatives, The Lancet,
352(August), 614617.
Wilkinson, S., Fellowes, D., Goodman, M., Low, J. & Harvey, F. (2003) District Nurses
perception of a home based nursing service for dying patients: a national survey of reasons for
referral and non-referral, European Journal of Cancer, supplement 1(5), S: 376.