Have you stopped writing down your reflections?
Since the Bawa Garba legal case, there are many reports that medical and nursing staff fear recording their reflective work, in case it might be used against them. And yet surely we all still reflect? After a difficult shift, in the coffee room or at home?
How can we use reflection in a positive manner, to learn and to demonstrate learning as part of a learning portfolio, rather than merely ruminating on difficult events? How can we learn to trust this process again? Reflective practice has the potential to effect behaviour change and produce deep learning as the individual comes to better understand themselves and their decision making. The evidence suggests this should make us more effective healthcare professionals, aide practitioner well-being, and improve patient safety. Which is why the GMC, the NMC and the Academy of Medical Royal Colleges still want health professionals to demonstrate reflection in their learning portfolios, and yet new models and approaches towards written reflection have been slow to address the attendant fear that practitioners clearly have when recording their reflections. So we started looking for a new, more creative way to reflect on clinical encounters. We looked at literature.
‘Mr Hemingway says a lot of things I don’t understand,’ Matilda said to her. ‘Especially about men and women. But I loved it all the same.
The way he tells it I feel I am right there on the spot watching it all happen.’
‘A fine writer will always make you feel that,’ Mrs Phelps said. ‘And don’t worry about the bits you can’t understand. Sit back and allow the words to wash around you, like music.’
When reading poetry or prose, we can often be taken out of ourselves, transported to an event, or situation we have experienced in unexpected ways. Great literature has the power to disarm us, to get under our collective radars, to provoke thoughts and feelings that surprise. Taking this to the next level, by putting ourselves in another’s shoes, making an imaginative leap and reading and writing from the viewpoint of another, especially the patient: this can be a powerful learning tool.
“My name is Kathy H. I’m thirty one years old, and I’ve been a carer now for over eleven years. That sounds long enough, I know, but actually they want me to go on for another eight months, until the end of this year. That’ll make it almost exactly twelve years. Now I know my being a carer so long isn’t necessarily because they think I’m fantastic at what I do. There are some really good carers who’ve been told to stop after just two or three years…” If you want to read more, this extract is from the fantastic ‘Never Let me Go’ by Kazuo Ishiguro
In our workshops, we read texts such as this prose extract, with a multidisciplinary group. Reading aloud and then discussing together opens up discussion, starting with reflections on the piece and moving on to experiences in the groups’ clinical practice. It has been amazing to see the insights group members have shared and gained into their own practice and thought patterns and into those of others. Particularly we’ve seen the groups gain a deeper understanding of the similarities and differences between decision making as a doctor and a nurse.
After reading together, discussing in pairs and as a larger group, we then move on to facilitated writing exercises. Creative writing has the added advantage of protecting both patient and clinician anonymity through use of pseudonyms, and by filling in gaps in memory imaginatively we create richer pictures. Psychological safety in these workshops is especially important. The group has already established rapport through warm-ups, reading and discussion exercises. The facilitator needs to be skilled to support and lead participants in this process and to gain trust in the group.
We use a specially designed guided writing exercise to draw clinicians back to a clinical event, focusing on the sensory details they can remember, allowing participants to step outside and review the situation from a different angle. We would encourage everyone working in healthcare not to abandon reflective practice or writing about work. Take a creative slant, come along to one of our workshops! Writing is like a muscle: it must be used regularly in order to work effectively. The more you write, the easier it becomes.
Lucy cut her own hair
She had imagined a chic fringe
As she cut she enjoyed the beautiful sound of scissors on hair
High pitched scratch and snip
The cold steel against her forehead
My own mother cut my hair
Orange handled scissors
The regret came soon after
When will it grow back?
Can’t we put it back together?
We cannot go back to repair a mistake
Stick the hair back on
Reparations and regrowth take time
We can try to understand why?
Put the scissors out of reach
Explain the consequences
The glorious feeling of that moment
The cold steel
The beautiful sound
Strands of gold brushing past eyelids, tickling the nose
How haircuts are best left to experts
He walked in with a covered cage in one hand, white stick in the other.
Told her he had found out she was leaving,
presented a card with a handmade seal.
Indicated his chirruping gift with a lopsided grin. Said it was a special
something he wanted to show the doctor,
before she moved on to pastures new.
Leaning back in her chair she said OK and waited, for the big reveal.
Watched him, her breath held, as a sky-blue cloth
was lifted with a rustling flourish.
Like an impresario in a travelling circus he stood and bowed
as two budgies, one blush pink the other baby blue,
puffed themselves up and sang in her room.
Clapping she laughed and peered in: toys, mirrors, bells, whistles.
How he cooed and talked to them, his children,
tears of pride in his all-seeing, unseeing eyes.
He had educated her on many things, bird and human. Today,
how to tell the difference between boy and a girl budgies:
just look at the colour of their beaks!
Cage in hand, her leaving ceremony concluded, off he went,
white stick tapping. Impatient to introduce his feathered
friends, to the physios down the road.
Eleanor Holmes (pen name Eliot North) is a GP and a writer. She runs workshops on reflective practice. Beth Osmond is a Neonatal Consultant and Education Lead at UH Bristol.
Further readinghttps://www.dreleanorholmes.com/http://www.pulsetoday.co.uk/news/hot-topics/bawa-garba/over-half-of-gps-change-or-stop-reflections-following-bawa-garba-case/20036606.articleThe Reflective Practitioner: Academy of Medical Royal Colleges, https://www.aomrc.org.uk/wpcontent/uploads/2018/09/the_reflective_practioner_guidance_single_page.pdf