Borton Reflective Essay Examples

I get a lot of views on my website as a result of people typing into search engines “OT reflection example”. I don’t blame these intrepid Googlers, it means that I am not alone in struggling to get the knack of reflections. This usually leads to a certain amount of grumbling about why we have to do them. Sound familiar?

 

So, why do we have to reflect?

Reflection is essential in getting healthcare students to make links between theory and practice (Jasper, 2013), this in turn helps us to develop our clinical reasoning (Rigby et al.,2012). It’s not just important while we are students. Oh no, it’s not over when you graduate, as British Association of Occupational Therapists (2007) informs us that reflective practice is vital to our continuing professional development (CPD). CPD is really important to keep our skills and knowledge up to date to be able to practice safely, legally and effectively (College of Occupational Therapists [COT], 2010; Health and Care Professions Council [HCPC], 2012a). Using models of reflective thinking make sure our reflections are meaningful to our CPD (Armitage et al., 2012).

Using models of reflection

Models of reflective thinking are the structures that we use to help us think reflectively. There are lots of different models out there for you to mull over. These models vary in how much hand-holding they give you and how much description and critical analysis are needed. The common ones that healthcare students use are; Gibbs, Johns and Borton. You should choose your reflective model based on what you want to achieve and how deep you want to go with your reflection (Jasper, 2006). Although to be honest, I tend to use Gibbs as I am more familiar with it but I have also started using Borton for quick, on the spot reflections.

I am going to give you an example of a reflection that I have done. I’ve chosen Gibbs’ (1988) model. My reflection is to help me understand my behaviour in a critical incident; I felt that I made the right decision but was unsure why. Gibbs’ model is useful examining a completed rather than an ongoing issue as it proposes action (Jasper, 2013). If the incident was ongoing, Borton’s (1970) model may have more use as it makes action happen, rather than just suggesting action (Jasper, 2013).

OK, so from now on I’m going to use more academic language for my reflection, as I think reflections should be written more formally for university. I hope it is helpful and doesn’t make you switch off!

Description

On placement a resident disclosed to my placement buddy and I that he was walking and transferring on his own, against advice. This behaviour resulted in several falls in his room. He had not raised this with the staff; not wanting them to be concerned. The following morning, we informed the client that we had discussed his falls with the care manager. We advised him to await carers for transfers until we could assist him doing this safely.

Thoughts/feelings

I felt uneasy that the client did not want us to tell anyone that he had fallen: my intuition was that we needed to inform a manager. I was concerned that he might injure himself. I felt uncomfortable that I had acted against his wishes and without his knowledge which is contrary to professional standards that advise relationships with service users should be based on trust (HCPC, 2012b).

Evaluation

I was pleased that a safety risk had been identified as a potential intervention. It was important to the resident to be independent with his self-care. I realised that night that we should have told the client that we intended to discuss his falls with staff so the following morning we informed him.

Analysis

Professional practice involves abiding by the codes of conduct, ethics, and standards of a professional body (Jasper, 2006). In the case of occupational therapists this is the HCPC and COT.  Professional behaviour requires complying with legislation and government policies (Jasper, 2006). This behaviour ensures that the therapist acts safely, legally, and in accordance with the values of the profession (COT, 2010).

The incident was an ethical dilemma: resulting from conflicting ethical principles (Alsop & Ryan, 1996). The ethical dilemma was that of autonomy and confidentiality versus beneficence (Beauchamp & Childress, 2009). Autonomy and confidentiality directed us to respect the wishes and privacy of the client by not telling staff of his falls, yet beneficence required us to safeguard the client from harm by doing the opposite. Ethical reasoning can be used to analyse a dilemma and determine the right action (Boyt & Schell, 2008) by evaluating the likely consequences (Beauchamp & Childress, 2006). The likely consequence of informing staff would be that the client would be safeguarded from further harm at the cost of a loss of trust. Conversely not telling would maintain trust but expose the client to potential harm.

Occupational therapists are autonomous practitioners (HCPC, 2012b) able to make informed decisions that they are able to justify. These decisions involve assessing risks and devising ways to deal with them. Part of this risk management involves an awareness of relevant legislation (COT, 2010).  Occupational therapists have a legal duty of care to act in a way that ensures that no injury occur to a client in their care (COT, 2010; Health and Safety at Work Act 1974). We had a duty of care to tell staff of the high fall risk brought about by the client’s action.  Occupational therapists also have a legal duty to safeguard confidential information about clients (HCPC, 2012b). Information can be disclosed if the client consents, there is a legal justification or to prevent serious harm to the client or another person (COT 2010; HCPC, 2012a; Public Interest Disclosure Act [PIDA] 1998).  We were justified in breaking confidentiality because we were concerned about harm however we should have attempted to gain consent before disclosure (HCPC, 2012c).

Fundamental to occupational therapy is the commitment to client-centred practice (COT, 2010). Client- centred methods recognise the importance of individual autonomy (Creek, 2003; Rodger, 2013). Professional codes instruct a respect for client autonomy if they have mental capacity (COT, 2010; HCPC, 2012a, 2012b).  We knew the client had capacity as he was able to understand, evaluate, retain the information, and consent to our help (Mental Capacity Act 2005). Providing psychosocial support to clients is important to a holistic approach (McKenna, 2010). Advanced communication skills such as active listening, and open questioning could have been used to explore concerns, and explain the importance of telling staff (McKenna, 2010).

Professional behaviour involves knowing the limits of the therapist’s scope of practice: the knowledge and experience needed to practice safely and legally, (HCPC, 2012b).  Care is seldom provided alone; sharing information within the team is good practice and often essential for effective care (HCPC, 2012c). As students it was outside of our practice to keep the client safe at all times and even it was not, sharing information within the team represented best practice.

Conclusion

Although it was the right decision to discuss the client with staff it was undertaken it in the wrong manner. I should have explored disclosure with the client and explained why it would be in his interests. I could have tried to gain consent and prevented the ethical dilemma. It is important to be familiar with current legislation, professional guidelines and policies to be able to make autonomous, informed decisions that I am able to justify. If I had this knowledge I could have reflected in the moment rather than after the moment.

Action Plan

Personal development

Maintaining confidentiality, I use my occupational therapy blog to reflect on my professional experience. I will employ different models of reflection to enable me to select the model that best fits the situation. In practice placement 6 (PP6) and when qualified I will use counselling skills to explore worries that a client may have about disclosing information. I will try to gain client consent.

Professional development

When qualified I will keep up to date with professional issues and by becoming a member of COT, reading the British Journal of Occupational Therapy. I will keep up to date with relevant HCPC policies and guidance by reading the HCPC ‘In Focus’ newsletter. I will access the Department of Health website for current policy and guidelines and regularly maintain CPD by participating in activities suggested by HCPC (2012d). I will document these activities in my CPD portfolio for ongoing registration.

For PP6 I will discuss with my educator the policies most pertinent to the setting to ensure familiarity.  I will be aware for the potential of ethical dilemmas and consider likely consequences of action. I will reflect in supervision on my clinical reasoning skills.

References:

Alsop, A., & Ryan, S. (1996). Making the most of fieldwork education: a practical approach. London: Chapman & Hall.

Armitage, A., Evershed, J., Hayes, D., Hudson, A., Kent, J., Lawes, S.,…Renwick, M. (2012). Teaching and Learning in lifelong learning (4th ed.).  Maidenhead: Open University Press.

Beauchamp, T.L., & Childress, J.F. (2009). Principles of biomedical ethics (6th ed.). Oxford: Oxford University Press.

Borton, T. (1970). Reach, Teach and Touch. London: Mc Graw Hill.

Boyt Schell, B.A., & Schell, J. (2008). Clinical and professional reasoning in occupational therapy. Baltimore: Lippincott Williams and Wilkins.

British Association of Occupational Therapists.(2007). Recording CPD: transforming practice through reflection. Retrieved from http://ilod.cot.org.uk/files/cpdtools/recording_cpd_transforming_prac_1.pdf

College of Occupational Therapists.(2010).  Code of ethics and professional conduct. London: College of Occupational Therapists.

Creek, J. (2003). Occupational therapy defined as a complex intervention. London: College of Occupational Therapists.

Finlay, L. (2008). Reflecting on ‘reflective practice’. Retrieved from http://www.open.ac.uk/cetl-workspace/cetlcontent/documents/4bf2b48887459.pdf

Gibbs, G .(1988). Learning by doing: a guide to teaching and learning methods. Oxford: Further Education Unit, Oxford Polytechnic.

Health and Care Professions Council. (2012a), Standards of conduct, performance and ethics. Retrieved from http://www.hpc-uk.org/assets/documents/10003B6EStandardsofconduct,performanceandethics.pdf

Health and Care Professions Council.(2012b). Standards of proficiency occupational therapists. Retrieved from http://www.hpc-uk.org/assets/documents/10000512Standards_of_Proficiency_Occupational_Therapists.pdf

Health and Care Professions Council. (2012c). Guidance on confidentiality. Retrieved from http://www.hpc-uk.org/assets/documents/100023F1GuidanceonconfidentialityFINAL.pdf

Health and Care Professions Council. (2012d). Continuing professional development and your registration. Retrieved from http://www.hpc-uk.org/assets/documents/10001314CPD_and_your_registration.pdf

Health and Safety at Work Act 1974

Jasper, M. (2003). Beginning Reflective Practice (Foundations in Nursing and Health Care). Cheltenham: Nelson Thomas Ltd. Jasper, M. (2006). Vital notes for nurses: professional development, reflection and decision making. Oxford: Blackwell publishing.

Jasper, M. (2013). Beginning reflective practice (2nd ed.). Australia: Cengage Learning

Johns, C. (2009). Becoming a reflective practitioner (3rd ed.). Chichester:Wiley-Blackwell.

McKenna, J. (2010).Psychosocial support. In M. Curtin, M. Molineux & J.  Supyk-Mellson (Eds.), Occupational therapy and physical dysfunction: enabling occupation (6th ed.)(pp.190-212). Edinburgh: Churchill Livingstone.

Mental Capacity Act 2005

Public Interest Disclosure Act 1998

Rigby, L., Wilson, I., Baker, J., Walton, T., Price, O., Dunne, K., & Keeley, P. (2012). The development and evaluation of a ‘blended’ enquiry based learning model for mental health nursing students: “making your experience count”. Nurse Education Today (32), 303-308. doi: 10.1016/j.nedt.2011.02.009

Rodger, S., & Keen, D. (2013). Child and family centred service provision. In S. Rodger (Ed.), Occupation centred practice with children: a practical guide for occupational therapists. Retrieved from http://books.google.co.uk

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Posted in OT student advice | Tagged Borton, Gibbs, Johns, OT, placement, reflection, reflective models | |


Original Editor - Michelle Lee Top Contributors - Michelle Lee, Tony Lowe and Tarina van der Stockt

Introduction

Originating from the work of Donald Schon[1] the concept of reflective practice is recognised as a key component of developing and maintaining professional best practice in many disciplines. This practice in the healthcare context is termed clinical reflection and is a set of skills commonly developed from university level. With the ever growing pressures for service development and self progression this is now an essential skill that should be put into practice regularly by every health care professional. [2]

So this page is going to run through:
  • What is reflection and why we use it
  • The reflective journey 
  • Different methods of reflection

What is Reflection / Reflective Practice?

Reflection and reflective practice is advocated by many professional bodies to promote high quality service delivery, but what is reflection and reflective practice? Here are some definitions: 

  • "Reflection is a process of reviewing an experience of practice in order to describe, analyse, evaluate and so inform learning about practice" [3]
  • “Reflective practice is something more than thoughtful practice. It is that form of practice that seeks to problematise many situations of professional performance so that they can become potential learning situations and so the practitioners can continue to learn, grow and' 'develop in and through practice” [4]
  • "a window through which the practitioner can view and focus self within the context of his/her own lived experience in ways that enable him/her to confront, understand and work towards resolving the contradictions within his/her practice between what is desirable and actual practice” [5]

Clinical reflection is a tool which enables the individual to learn from their experiences and actions, this is not only applicable in the health care setting but through day to day life. It enables the individual to learn from mistakes and poor choices they take and acknowledge when things have gone well so this can be repeated; but to clinically reflect and utilise this skill in the health care setting needs some practice, as this requires critical thinking. [6]

Watch this video on reflective learning to find out more.

The Reflective Journey

It has been acknowledged that critical reflection in clinical practice is essential for clinical effectiveness and continuing professional development. There is evidence to suggest that critical reflection is difficult without expert guidance, therefore educational institutions are now incorporating this into their programmes to establish this skills early in the individual's professional career. Reflection and critical analysis is a skill which needs to be practised in order to be developed. [7][8]

Quite often student health care professionals will start of their reflective development journeys by being given the task of keeping a reflective journal or diary of their day on clinical placements. This journal will involve certain thought provoking questions to facilitate and direct the reflection such as: 

  • What happened
  • Why did you choose that method
  • Is there any research to support your decisions
  • What went well
  • What could have gone better
  • Action points for implementation next time [9]

It is encouraged that reflections are initially written; this will help to cement the different stages of reflection, but once this skill is developed health care professionals can do this regularly (internally) throughout the day. They then may only reflect formally (written) upon an event or activity that was particularly significant for them.[10]

Watch this small lecture from the London deanery on reflection and learning in the workplace. This is aimed at trainee doctors but the principles can be translated into any health care profession.

Methods of Reflection

There are many forms of formal reflection, all differing slightly. There is no right or wrong method of reflection as long as it is:

  • A record which is useful to you
  • A cue to memory
  • Honestly written
  • Enjoyable to complete
  • Involve thinking which is objective, critical and deep

There are many different frameworks offered for structuring reflection. Here is a powerpoint presentation that runs through a number of examples.

Below are descriptions of some of the most common reflective frameworks and models that can be used. A recommended approach to find the best model to use is to practice with several different frameworks and choose the model or models which you feel are most effective for you in particular situations. Reflection is a very personal activity and so this choice should also be personal to ensure the greatest benefit to you. 

Gibbs Reflective Cycle (1988)

Gibbs reflective cycle is a formal structure which can be used for academic pieces of work but also in clinical practice which can be used to evidence continuing professional development. [11]

Description

The section in the reflective cycle is describing the event that is being reflected upon. Is only needs to be short and precise to give background information on the event.

Feelings

This section focuses on thoughts and feelings at the time of the event and after. 

Evaluation 

The evaluation is reflecting upon the experience, such as;

  • How you reacted to the situation,
  • How did you react after,
  • How did other people react
  • If it was a problem solving situation - was the issue resolved. 

If there are pieces of evidence for the event you are reflecting upon you can include these here.

Analysis 

This section is where you can really demonstrate your reflection on the experience. Pick out points that you think have hindered or enhanced the experience. What went well, and what has not gone so well. Similarly to the evaluation section where references may have been incorporated, the analysis section is where you can link your experience to what the literature is reporting. This is where you will improve your grades if this is an academic piece of work, but also useful for using it as a piece of evidence in a portfolio for continued education purposes.

Conclusion

This section is about summarising the outcome of the event being reflected upon.

  • Would you do the same again
  • What would you change
  • Identify what you could do to stop the same things from happening in future
  • or how can you make sure the same happens again to ensure the same positive outcome

Action Plan

This section is essential to any reflection, this is about what you are going to do next. How are you going to implement the changes you have identified to achieve the desired outcome next time, be it performance improvement or maintaining the standard achieved. 

John's Model for Structured Reflection (2000) 

John's Structured Reflective model is exactly that. It is a set of questions that are asked to direct the reflector through the process. This may be attractive to some people, but potentially could be a little restrictive for others. [12]

Description

  • Phenomenon - -describe the here and now experience
  • Causal - what essential factors contributed to this experience?
  • Context – what are the significant background factors to this experience?
  • Clarifying – what are the key processes (for reflection) in this experience?
Reflection
  • What was I trying to achieve?
  • Why did I intervene as I did?
  • What were the consequences of my actions for:
  • Myself?
  • The patient/family
  • The people I work with?
  • How did I feel about this experience when it was happening?
  • How did the patient feel about it?
  • How do I know how the patient felt about it?
Influencing Factors 
  • What internal factors influenced my decision making?
  • What external factors influenced my decision making?
  • What sources of knowledge did/should have influenced my decision making?
Evaluation
  • What choices did I have?
  • What would be the consequences of these choices?
Learning
  • How do I feel now about this experience?
  • How have I made sense of this experience in light of past experiences and future practice?
  • How has this experience changed my ways of knowing
  • Empiric
  • Aesthetics
  • Ethics
  • Personal

Borton's/Driscoll's Development Framework

Borton's three Whats questions[13] were mapped on to an experiential learning cycle by John Driscoll[14] to form a simple a framework for supporting reflection. This framework is easy to remember and implement, and is therefore a popular option used by many health care professionals and advocated by professional bodies. 

There are only 3 steps in this framework: [15]

What?

These questions prompt the reflector to describe what has happened by: 

  • What were the roles of the people involved?
  • What was my role?
  • What were the problems
  • What happened 
  • What did I do?

So What?

This is the analysis of the reflection.:

  • What was the outcome?
  • What did you learn?
  • What was important?

What Now?

This is one of the most important sections of a reflection. This section focuses on what will you do next /  what does your learning experience mean for future practice?

  • What do you need to do now?
  • What were the consequences?
  • How do you resolve the situation / improve the outcome?
  • How will what have you learnt from this experience change your future practice?                                         [16]

Conclusion

Now you have learnt about 3 of the main learning frameworks / reflective structures to use in clinical practice. It is important to understand that reflection is a skill that is developed through repeated practice. When selecting a model to use it is essential, as discussed previously, to try different structures and frameworks for different situations to learn which suit you and a particular context best. Day to day reflections (e.g. for CPD events) may be better suited to the Borton's framework, whereas for an academic piece of work or a significant incident at work, a more detailed framework such as Gibbs may be more appropriate. It is also important to review relevant literature as well as your own experience and anecdotal evidence and include this within your reflections to develop an evidence based practice approach in your reflective practice. 

Resources

References

  1. ↑Schön DA. The reflective practitioner: How professionals think in action. Basic books; 1983.
  2. ↑McClure P. Reflection on Practice. http://cw.routledge.com/textbooks/9780415537902/data/learning/8_Reflection%20in%20Practice.pdf [accessed on 10 June 2016]
  3. ↑Reid B. But We’re Doing it Already! - Exploring afckLRResponse to the Concept of Reflective Practice in Order to Improve its Facilitation. Nurse Education Today 1993;13:305-309
  4. ↑Jarvis P. Reflective Practice and Nursing. NursefckLREducation Today 1992;12:174-181
  5. ↑Johns C. Becoming a reflective practitioner.fckLROxford: Blackwell Science, 2000
  6. ↑Patterson B. Developing and Maintaining Reflection in Clinical Journals. Nursing Today 1995;15:211-220
  7. ↑McClure P. Reflection on Practice. http://cw.routledge.com/textbooks/9780415537902/data/learning/8_Reflection%20in%20Practice.pdf [accessed on 10 June 2016]
  8. ↑Queen Mary University of London. Guidance on Reflective Writing. http://qmplus.qmul.ac.uk/mod/book/view.php?id=257889 [accessed 15 June 2016]
  9. ↑McClure P. Reflection on Practice. http://cw.routledge.com/textbooks/9780415537902/data/learning/8_Reflection%20in%20Practice.pdf [accessed on 10 June 2016]
  10. ↑Wessel J, Larin H. Blackwell Publishing Ltd Change in reflections of physiotherapy students over time in clinical placements. Learning in Health and Social Care 2006; 5(3):119–132
  11. ↑Queen Mary University of London. Guidance on Reflective Writing. http://qmplus.qmul.ac.uk/mod/book/view.php?id=257889 [accessed 15 June 2016]
  12. ↑Queen Mary University of London. Guidance on Reflective Writing. http://qmplus.qmul.ac.uk/mod/book/view.php?id=257889 [accessed 15 June 2016]
  13. ↑Borton, T. (1970) Reach, Touch and Teach. London:Hutchinson.
  14. ↑Driscoll J. Reflective practice for practise. Senior Nurse. 1994;14(1):47.
  15. ↑White S,Fook J, Gardner F. Critical Reflection in Health and Social Care. Maidenhead: Open University Press, 2006
  16. ↑Queen Mary University of London. Guidance on Reflective Writing. http://qmplus.qmul.ac.uk/mod/book/view.php?id=257889 [accessed 15 June 2016]

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