Bortons Reflective Model Essay Link


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]

By: Kelly Dundon

When I thought about my experience and methods of using reflective practice, I wondered how I would ever be able to articulate and make sense of the complex, critical, and sometimes deep and painful thoughts that underpin my practice in front line child protection. Eventually I came to the realization that we all do a certain amount of reflective and critical practice on many differing levels. We can easily find time to reflect before, during, and after events, from the superficial to extensive and through our personal to professional lives.    Reflection allows us to plan, articulate, evaluate, exact change, and perhaps more importantly, learn in the complex issues that we face daily. As part of our working with often disordered and dysfunctional children and families, with reflection, we are able to positively work toward best outcomes and in the best interests of the children with whom we work.

    The importance of thinking reflectively, that is to break down and closely analyze the processes that occur in decision making, in child protection, I believe is an essential part of our role. Doing so helps us to develop a sense of what has been achieved, what is likely to be achieved, and what could be done better, the importance of which has long been evaluated by many writers, including Schon (1983), Johns (1996, 2000), and more recently Rolfe (2001) and Fook (2002). As students, child protection practitioners, and later in our careers as practice teachers, leaders, and in helping to shape policy, we are able with the methods of reflective practice to conclude, inform, and broaden our practice knowledge.

    I began to understand the importance of utilizing the tools that were available to me long before I knew what it was actually called. In 1998, I grappled with being a broke student and 21-year-old single mother of two. I juggled diaper changing and textbooks and felt overwhelmed with the demands that were either placed upon me, or that I had placed upon myself. I needed a way to make sense of it all, so I began to write a few lines every night about my placement, theories and methods, thoughts, fears, and achievements. This helped me to really focus on what the issues were. Not being a natural academic, I found this very useful. About a month later in a seminar, I learned that I had been documenting my learning experience and that this was an essential tool for every student. I have now kept eight years of practice diaries—all strictly confidential, of course, but boy, you should read the contents! Some are highly emotional and not very productive excerpts. Others are productive and insightful. It is pleasing to see one’s sense of self develop over time.

    I look at how I, and others around me, have grown in competence and thoughtfulness through this process. I can clearly see that at the end of each time we really think about what we are doing, there is what I call an “awakening”—the sudden realization that we are on the right or wrong track, that we can do this very difficult job. I see the clarity, harmony, and satisfaction. When I feel this way, it is almost as if I have lifted above the situation. I am able to see below and think laterally about the potential impacts of my actions, before, during, and after an event. I add that a major part of working in child protection is the responsibility placed upon us as practitioners and team leaders to make good decisions. We can, with reflection, be able to accurately describe in progress notes and through assessments what has led us to our decisions and critically analyze our practice without feeling the burden of blame.

A Model for Reflection

    Borton’s Developmental Model for Reflective Practice, developed as early as 1970, is of great interest to me. The framework works in a sequential and cyclical order and is very easy to follow and recommended for first-time reflective practice. Borton’s (1970) model looks at three levels of reflection—What? So what? and Now what?

    He starts with a descriptive level of reflection, which he calls the “what.” An example is: What is the issue/problem? What was my role? What was mine and others’ response to the actions taken? Then we move to “So what?” This concentrates on the theory and knowledge building level of reflection: So, what does this tell or teach me about my service user, about myself, about the model of care that I am providing? So, what did I base my actions on and what was going through my mind as I acted upon them? So, what could I have done differently? So, what is my new understanding of this situation? “Now what” looks at what we can now do to break the cycle and to improve the situation in the future. The broader issues now need to be examined if this action is now to be successful. Once we have done all this, we can look at the end of this cycle by asking ourselves: Now what might be the consequences of this action?

    When opening one’s mind to using a model such as Borton’s, and particularly with practitioners who are new to reflection, I find that a very simple exercise is to concentrate on something like what happened at breakfast this morning and to really start to pick apart the events—why certain things occurred and others didn’t, and so forth.

Other Models

    I also see great value in drawing or mapping situations that are complex and in need of a good sorting out. In one of my previous positions, we used a visual mapping technique in looking at one particular child whose needs were complex. The map was huge. It covered a wall. Everyone really got into drawing and describing different ideas over the course of about a week. This type of free association whet many an appetite and allowed us to think creatively and outside of the boxes that we can often get stuck in when working in child protection.

    Having spoken to many workers involved in child protection, I have found that we all have different ways and levels in which we reflect. Some use a log, mapping techniques, and supervision or verbal accounts and discussions within teams to thrash out the problems to get differing opinions and ideas. You may ask a colleague to play devil’s advocate and question your beliefs, values, and attitudes about, say, drug affected parenting. We can, with this level of discussion, learn a great deal from each other and ourselves. We can closely examine and reflect upon our fears, discriminations, power relations, values, and beliefs. We can also examine the ripple effects of these issues for our service users and the wider community setting.

Why Reflect?

    I can think of many different reasons to keep reflecting upon what we do. First, we are in the business of protecting children. We need to be clear that we do protect children and ourselves when we are in the field. A little bit of thought and planning now may be of huge benefit later. Something that I have found is that reflection seems to create a certain clarity and sense of safety around this business we are in. The log I use is a very safe way of offloading and debriefing myself, as well as discussions with colleagues and managers. It enables me to avoid stress and vicarious trauma. It helps me to move forward from anger and frustration at service users, colleagues, departments, policy, and red tape toward a certain inner peace! It helps me to understand why I feel this way, why it needs to be this way, and how what I do could potentially change this situation positively, I guess from negative energy to positive energy or something like that. By doing this we can go a long way toward keeping well at work, which affects our service delivery and ultimately the way in which we do our business with children.

    The constant weight of workload pressure and prioritization is often of concern to us as child protection workers. It is easy to get caught in the overwhelming feeling of drowning in paperwork, children with high needs, and balancing risk like a trapeze artist. When we feel this way, to sit quietly in a park for five minutes and briefly run through the priorities, we can look at how we can work smarter, perhaps delegate tasks to families, therefore empowering them and including them in planning for children. In the wider spectrum, we can look at how we can establish a work-life balance, while still getting through all tasks and complying. A balance is possible with some thought, care, and of course, departmental policy, which positively supports work-life balance and understands its importance in terms of overall success and health of its work force and work practices.

    Second, instead of finding ourselves bogged down with constraints, if we are serious about our roles as corporate parents, we can truly focus on the children we serve and what would be in the best interests for that child, even if what we think would be the best solution is not possible. We have thought through the “what ifs.” We can evidence this through formal and ad-hoc supervision and case notes. When an adult seeks information on his childhood file, if he can clearly see the efforts that were made to keep him within his family or the reflective practice and decision-making that led to his removal, this may be part of his healing process, and we have helped to identify to him what the department is, why we do what we do, our mistakes, and how we have learned and developed over time, a transparency about child protection.

    We can encourage others to utilize reflection by offering consultation papers, questionnaires, and service user groups to empower our staff groups, children, and families. The benefits of reflection in terms of collaborative practice with other agencies and wider communities opens many doors to our understanding of roles and responsibilities, and it can be critical in removing boundaries and stopping us from blaming others. We must seek to empower others around us to take personal responsibility for reflection, for speaking up and letting people know what we think and why through this process.

    Another part of reflection is being able to use the criticism we face and utilize it—that is, turn the situation on its head, and learn something positive from it. Instead of being defensive and subjective, we can learn and move forward. I acknowledge, through my own experience, that this healing process may take time, especially if we are particularly wounded by a scathing remark or insult in our work practices, but it is possible.

    We are also able to establish boundaries when working with children, something that is often assumed that we can automatically do, although it does take experience, time, and skill. When a worker does over-identify with a client, this can be a negative experience for the provider and user. If we find the ability, through reflection, to step back and look at the bigger picture, we are able to work more effectively with a service user.

    In conclusion, the importance of critical and reflective practice is difficult to measure and often under-estimated, yet it is crucial to our professional and personal development. More important, I feel that reflection helps and prepares us to be accountable and responsible for the very difficult decisions and challenges we often face in child protection and allows us to make good choices and have better outcomes for children.

Kelly Dundon, her husband Martin, and their four children immigrated to Australia in 2005 from England. Kelly has six years of front-line child protection experience and is now a team leader in a statutory organization. Kelly spends her spare time with her family and writing about the ups and downs of child protection.

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