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'It is only when practitioners understand themselves and the conditions of their practice that they can begin to realistically see how they might respond differently.' (Johns 2009 P16)

The concept of reflection in learning is not new. It can be traced back as far as Aristotle's discussions of 'practical judgement and moral action' in his Ethics (Grundy 1982 cited in Boud. D et al P11).

In 1933, Dewy stated that there were two kinds of 'experiential process' leading to learning. The first process was 'trail and error which was limited by the specificity of the problem which was solved and the scope of the trial and error explorations' and the second was that 'reflective activity involved the perception of relationships and connections between the parts of the experience.'(Boud. D et al 2005 P12). He explained reflection as a learning loop, continually feeding back and forth between the experience and the relationship being inferred. (Boud. D et al 2005).

In 1980, reflective practice was introduced and seen as three core components: 'Things that happen to a person, the reflective process that learning has occurred and the action that was taken from this new perspective' (Jasper 2003 p2)

In more recent times, Kolb (1984) developed an 'experimental learning cycle' which has been suggested to be the most effective way of learning from our experiences by linking theory to practice (Jasper 2003):

When looking at the reflective process, Schon (1983) identified two types of reflection: 'reflection on action' and 'reflection in action'. Reflection in action is reflecting while doing, which occurs subconsciously, intuitively and unconsciously (jasper 2003 p6). Reflecting on action involves thinking about action after it has occurred. (Jasper 2003 p6)

Many people have defined reflection and In 2009, Johns defined reflection as

'Learning through our everyday experiences towards realising ones vision of desirable practice as a lived reality. It is a critical and reflexive process of self-inquiry and transformation of being and becoming the practitioner you desire to be'.

Furthermore, Boud. D et al (2005 p18) suggested that 'reflection is a form of response of the learner to experience'. Where experience involves the response of a person to a situation or event e.g. feelings, thoughts, actions and concludes at the time or immediately thereafter. The situation or event could be a course or an unplanned occurrence in daily life. It could be provoked by something external or an internal experience, evolving from discomfort. (Boud. D et al 2005).

There are many positive uses to reflecting on practice. Johns (2009 p15) suggests that the positive uses of reflection 'encourages the expression, acceptance and understanding of feelings. Negative feelings can be worked through and their energy's converted into positive energy for taking future action based on understanding of the situation and appropriate ways of responding'. Furthermore he proposes that 'reflection is empowering, enabling the practitioner to act on insights towards realising desirable practice. If practitioners truly wish to realise their caring ideals then they have no choice but to become political in working towards establishing the conditions of practice where that is possible.' (Johns 2009 p17)

Reflection can identify learning needs, and new learning opportunities. It can find ways in which we learn best, differently and new courses of action toward an event. Reflection can help problem solve aiding personal and professional development and provides an escape from routine practice. Reflection allows us to be aware of the consequences of our actions, demonstrate our competences to others and achievements to ourselves. Reflection allows us to build theory from observations, help make decisions or resolve uncertainty and empower or liberate ourselves as individuals (Jasper 2009).

However, reflective practice has been criticised for its lack of definition, modes of implementation and its unproven benefit (Mackintosh 1998 cited in Johns 2009 p22). Platzer et al (2000, cited in Johns 2009 p22) noted that students may be resistant to reflection revealing self, a point highlighted by Cotton (2001 cited in Johns 2009 p22) that reflection becomes a type of surveillance, assessment and control.

Reflection can be used in order to aid Occupational Therapy (O.T) principles and values, continuous professional development, ethical , legal and professional views/codes of conducts/standards of pracrtice. Maintaining professionalism has been suggested as a 'core process competent, essential to O.T practice' (Bosseers. A et al 1999 p116), as have lifelong learning, professional development and service quality and governance (Professional Standards for O.T practice 2007). Therefore reflection can be an important part in maintaining knowledgeable skills as part of professional practice.

The O.T Codes of Ethics states that 'O.T's shall be responsible for maintaining evidence of their continuing professional development '(College of Occupational Therapists Code of Ethics and Professional Conduct 2005, 5.3) therefore, this can be done through reflection. New learning and containing professional development depend on how' skilfully you can reflect on your and others practice, to gain new insights, see new relationships, make new discoveries and make explicit the new learning that occurs. (Aslop 2000 p114). Any new knowledge gained from experience will be stored for future reference as and when similar situation arises. (Aslop 2000 p115)

In the following reflective account, I am going to use Johns model of reflective structure (appendix one) mixed with Gibbs reflective cycle (appendix two) and will be reflecting on action. I feel both are extremely valuable models and help to express different ideas/feelings in different ways at different points of my reflective account. Other models I could have used are Goodman's levels of reflection (1984), Bortons development framework (1970) and Fish et al strands of reflection.

I choose Gibbs reflective cycle as it has characteristics of all other strategies/ frameworks for reflection that have been developed. It has been developed from Kolb's ideas and the ERA cycle. However Gibbs cycle stops at the stage of action so not providing a way to close the cycle or move to reflective practice in terms of taking action (Jasper 2003). This is because Gibbs framework had its foundations from an education context as opposed to a practice one.

Therefore I decided to mix Gibbs cycle with John's model of structured reflection, to combine theoretical reflection and practice environment. Johns is helpful in having cue questions. It provides personal awareness of 'ourselves, our knowledge and actions' .It asks 'what you could do rather than what you will do'. (Jasper 2003 p98).

The following narrative describes a critical incident that had a significant effect on me which made me stop and think and raised questions. This incident was the role of Occupational Therapist's (O.T's) within social care and the impact of this upon a service user's journey. The role of O.T and Social worker have been combined within social care producing the title 'Self Directed Support

Practitioners' (SDS practitioners)

Mr.B was a 60 year old man, who lived in a bungalow on his own, with no adaptations or carers. He was admitted to hospital due to a fall whilst using the toilet. He had been released from hospital about 2 months ago and still having problems with self-care, cooking and general mobility. An S.D.S practitioner and myself carried out a home visit on Mr.B. We received a referral from the hospital regarding Mr.B's health and ability to perform activities of daily living (ADL's). We carried out an assessment on Mr.B and upon assessment; Mr.B used the sink to aid standing from toilet which seemed to be coming off of the wall. His mobility was generally good but had difficulties raising and lowing himself in and out of the bath and rising legs over the lip of the bath. He had slight problems in the kitchen due to mild arthritis when opening of cans and jars, lifting heavy equipment and gripping cutlery.

When we assessed Mr.B, I was unsure and slightly confused how to assess in an S.D.S way. I was thinking about my O.T values and beliefs and how I could involve these within the assessment. This would involve me assessing in a way that promotes independence, empowering him and motivating him as well as using occupation as a theraputic tool. I was unsure about how to implement social work values as they seemed to clash with my own, for example care packages. Overall I was trying to achieve independence for Mr.B with the least amount of equipment.

When we actually started the assessment I was thinking how I could make Mr.B as independent as possible, using equipment to aid this if necessary and therefore empowering him. On the other hand, I had to consider social work values and beliefs. This made me feel extremely confused and concerned that I was not providing the best service for Mr.B when carrying out the assessment and going against my ethics of do good, do no harm, autonomy and justice. When assessing Mr.B he managed to lift his legs over the side of the bath, when using a bath board and hand rail to grip and hd good sitting balance. His transfers off of the toilet needed support so we offered a toilet frame to aid this. The S.D.S practitioner suggested meals on wheels to overcome the problems Mr.B had in the kitchen. When suggested, the equipment and care packages to Mr.B he mentioned that he wanted a 'wet room' and 'why could he not have one as his friends had one fitted not that long ago' This made me think about funding and O.T's values and beliefs, which in turn made me feel unhappy as Mr.B could not have something he wanted, although this would go against my O.T values.

The outcome of the event was not very good. Mr.B refused equipment and care packages and became angry. That made me feel sad as I wanted to help Mr.B with his activities of daily living, to live an independent life. Looking back at the event, I feel maybe I could have convinced Mr.B more to accept the equipment and care packages suggested. Although the care packages conflicted with my O.T values, I can see a place for these with extremely impaired individuals. I would have suggested adapting equipment within the kitchen, such as grips for cultury, automatic tin openers, a kettle tipper and a perching stool.

The emotions I have gone through was anxious, excitement, inquisitive during the start of the event followed by sadness toward the end.

To evaluate, the good thing about the experience was the enormous opportunities for continuous professional development as the role of O.T continues to grow. I also feel my understanding of O.T and clinical reasoning skills have developed.

I feel that the role of an S.D.S practitioner causes confusion, loss of role identity and crossing over of professional boundaries.

Although I feel not a lot went well, I believe my contribution and O.T knowledge aided the situation. I put this across very well, sticking to O.T values and beliefs. The S.D.S. practitioner that I was with managed to balance out the professions very well but I feel provided a care package where adapted equipment would have been enough. This may have happened due to little knowledge of O.T and herself coming form a social work background.

I know realise that there was not much I could have done to alter the situation anyway and perhaps a more in-depth knowledge of social work may have helped.

I am now more prepared for the role of an S.D.S. practitioner. If carried out again I would definitely gain more insight into the values and beliefs of social workers and be more vocal about my O.T ones. I would have tried to encourage the Mr.B to take the equipment and explained more as to why this was important.

To conclude, I have learnt that theory; professional and personal values and beliefs, ethics and legal issues often influence practice. I have learnt the importance of reflecting in order to develop myself professionally and personally. My needs in order to develop my professional practice at this stage of my career are huge. I mainly need to develop my knowledge, communication skills, professional skills and clinically reasoning skills. I have also learnt the role in which I play within a team and according to Belbins team roles, I am a monitor-evaluator mixed with team worker. This means I see all the options and judge accurately, working co-operatively in sensitively and diplomatically. (www.teambuilding.co.uk/belbin-team-role.html)

Looking back over the situation, I had to look in-depth at the codes of ethics. It states that O.T's can only provided services in which they have been taught to do so (5.1). The code of ethics also state in section 5.3 that O.T's shall recognise the need for multi-professional collaboration but not undertake work that is deemed to be outside the scope of O.T. (College of Occupational Therapists Code of Ethics and Professional Conduct 2005). When offering equipment and services the most significant rights to health and social care are for example the National Health Service Act (1977), Mental Health Act (1983), NHS and Community Care Act (1990) (Dimond 2004 p51)

I also had to think about professional negligence as litigation is increasing due to expectations of clients in relation to health care growth and the publicity about awards of compensation raises hopes of vast settlements.(Dimond 2004 p97)

The white paper on the NHS made changes in the scope of professional practice so that the traditional boundaries between different professions were removed. This presents challenges (diamond P112) no team liability (every professional is accountable for their own actions and cannot blame the team for negligence which has lead to harm), no defence of inexperience (the patient is entitled to the reasonable standard of care whoever provides the treatment), determination of competence (carried out by competent colleagues or external assessors), refusal to undertake activities outside scope of competence (no O.T should undertake activities which are outside the scope of her professional practice)

Occupational therapy as a new profession is facing new challenges from the introduction of the HPC and the council for regulation of healthcare profession. Greater integration of health and social care provision is taken place and the college of occupational therapists is preparing for these changes by seeking to refocus the organisations of the work of the o.t by its strategic document from 'interface to integration'. (Dimond 2004 P397). The role of a S.D.S practitioner is extremely difficult. O.T's felt they were taking on responsibilities of social workers and not the other way around. There were huge issues with professional boundaries and both professions disagreed with the SDS roles and were angry about the change causing conflicts between professionals and within professions.

Boud et al (2005b p11) suggested that In the case of reflecting on learning, firstly only 'learners themselves can learn and only they can reflect on their own experiences'. They suggest that teachers assist, but only have admittance to individual's thoughts and feelings by what individuals decide to reveal about themselves. Therefore the learner is in total control.

Secondly, reflection is a 'purposeful activity directed toward a goal and lastly the reflective process where both feelings and thoughts are interconnected and interactive. Negative feelings, can form major barriers toward learning'. Positive feelings and emotions can improve the learning process, keeping the learner on the task and providing a stimulus for new learning.' (Boud et al 2005b p11)

Appendix One

The model of structured reflection (msr 1991) p51

Enable practitioners to access the depth and breath of reflection necessary for learning through experience.:

§ Bring the mind home - a preparatory cue to put the person in the best position to reflect. Helps to shift the balance of seeing reflection as a cognitive activity to a more meditative activity. P52

§ Focus on a description of an experience that seems significant in some way

§ What issues are significant to pay attention to - issues that perhaps are moved by a feeling or thought p54

§ How do I interpret the way people were feeling and why they felt that way - illness and admission to hospital create significant anxiety for people p55. understanding how others are feeling strengthens my empathic inquiry, my ability to know and connect with the experience of the other person.

§ How was I feeling and what made me feel that way - did it contradict my values and beliefs. Reflection is most often triggered by negative or uncomfortable feelings (boyd & Fales 1983) it seems natural to focus on negative experiences because theses situations present themselves to consciousness p56. some question which could help are why I feel this way, do I often feel this way in similar situations, could I have not been this way. Another approach is to simply write a story around the feeling p57. Reflection is about coming to know 'who I am' so I can better use my self for therapeutic work p58. Through reflection we become aware of our fear and see the way it constrains our practice. As we reflect we begin to work through the fear. However the deeper we go the more defended we are likely to become. One reason why reflection needs to be expertly guided is to explore these depths within a secure relationship.P58

§ What was I trying to achieve and did I respond effectively (aesthetic)- reflect on my responses and actions within the experience and whether my responses were effective in meeting my intended outcomes. E.g. how I appreciated the situation, how I made clinical decisions, my skilful response, my reflection on consequences.p59. Model of reflective inquiry helps to review the way I appreciated the situation, made clinical judgements, responded skilfully and considered if I was effective in meeting the patient's health needs. I then think about the influence of the ethical, empirical and person ways of knowing on my performance 'what is significant about this experience'.p60. I can then contemplate how I might respond more effectively given the situation again, did we act for the best, do we know what the best is, what needs to change so we can act for the best p61

Model of reflective inquiry (Johns 2006 p61)

§ What were the consequences of my actions on the patient, others and myself - involves contemplating the consequences of actions for others and yourself. It is deceptively deep.p61

§ What factors influence the way I was/am feeling, thinking and responding to this direction (personal) - gateway to knowing self - what makes me tick, what factors pull my strings? To change ourselves we have to access, appreciate and then shift our mental models. This can feel scary as it leads the person deep within themselves, unearthing and revealing influences that stem from social and cultural practices or past experiences that have left a trace. p62

Influences grid (adapted from Johns 2004a:24) p 62

To change who I am requires awareness and understanding of these influences so I can begin to let go of them and learn new patterns of being more congruent with desirable practice. This cue explores boundaries with therapy and highlights the vital need for self-development in human-human encounter work that espouses the intention to work with people from spiritual, psychological and emotional frames of reference.

§ What knowledge did or might have informed me (empirical) - guides the practitioner to identify and access relevant theory or research, critique it for its value to inform the particular experience, and assimilate it within personal knowing to inform future practice, enabling the practitioner to develop praxis (informed moral practice). Allows practitioners to respond meaningfully to the evidence-based practice agenda.p63

§ To what extent did I act for the best and in tune with my values (ethical) - all action is ethical. Every story is a moral story concerning the practitioners intention to act for the good. This cue has two inter-related issues: firstly, an ethical reflection on the 'best', and secondly, a review of my values and beliefs that constitute desirable practice. Often ethical principles contradict each other. As such, 'acting for the best' always needs to be interpreted within each moment (copper 1991, parker1990) p64

This may create difficulties within the team if practitioners have different values and personal agendas or demand compliance with authority.

Ethical mapping (johns 1998b) p 65

§ How does this situation connect with previous experiences (personal)

* Looking forward cues

§ How might I reframe the situation and respond more effectively given this situation again (reflexivity) -it is the fuelling of inquiry and opening to other possibilities in the quest for effectiveness and professional responsibility p72

§ What would be the consequences of alternative actions for the patient, others and myself - helps weigh up judgements (developing practical wisdom) rather than leaping to quick assumptions p73

§ What factors may constrain me responding in new ways - weighing up possibilities and considering the consequences of each also the influence grid p73

§ How do I now feel about this experience - draws attention to my feelings e.g. frustrated, angry or positive ones p73

§ Am I more able to support myself and others better as a consequence - am I supported well enough within my clinical practice p73

§ What insights have I gained - as I become more experienced at reflection, I internalise the cues and find myself not using them so formally, more as a check list, especially the influences grid and ethical mapping. P75

§ Am I more able to realise desirable practice (framing perspectives) - insights are inchoate, tentative. They impact on future practice and in doing so are transformed in response. There are at least six sources of responsibility: being responsible to: p77

1. the patient and family, to help them meet their health needs and support them through the medical response

2. self, to act with integrity according to beliefs and values and to ensure self-effectiveness

3. society, to fulfil and enhance societal expectations

4. the profession, to justify actions within the guidelines of the code of conducts

5. peers, to work in collaboration and mutually supportive ways to ensure patients and families receive congruent, consistent and effective care

Appendix Two

Gibbs reflective cycle was developed from Kolb's experimental learning cycle:

Appendix Three

Another model I have chosen to follow for my reflections is that of Boud (1994). Boud states that we undergo three stages of reflection before we commit to actions or outcomes. These stages are: -

o Stage One - Returning to the experience.

Replaying the experience in the mind to observe the event as it happened and to notice what occurred.

o Stage Two - Attending to feelings.

Whilst emotions and feelings can be a significant source of learning they can also become a barrier (Boud, 1996). For this reason we need to either work with our emotional responses, find ways to set them aside or retain and enhance them should they be positive. If our feelings form barriers it is important that we recognise this and remove them as only then can learning proceed (Boud, 1996).

o Stage Three - Re-evaluating experience.

This evaluation stage may consist of four aspects which can enhance reflection and its outcome. These are association, integration, validation and appropriation. These stages help us relate the new experience to what we already know, seek relationships amongst the information and authenticate the resulting ideas and feelings (Boud, 1996).

References

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College of Occupational Therapy (2005) College of Occupational Therapists Code of Ethics and Professional Conduct. London, College of Occupational Therapists

Diamond. B (2004) Legal Aspects of Occupational Therapy (2nd Ed), Great Britian, Blackwell Publishing

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Boud. D, Keogh. R & Walker. D (2005) Promoting Reflection in Learning: a Model Cited in Boud. D, Keogh. R & Walker. D Reflection: Turning Experience into Learning, London & New York, RoutledgeFalmer

Boud. D, Keogh. R & Walker. D (2005b) What is reflection in Learning? Cited in Boud. D, Keogh. R & Walker. D Reflection: Turning Experience into Learning, London & New York, RoutledgeFalmer

The nine Belbin Team Roles (2009) retrieved 25.1.10 http://www.teambuilding.co.uk/belbin-team-role.html

Alsop. A (2004) Continuing Professional Development - A Guide for Therapists, Oxford, Blackwell Publishing

Butler & Creek (2008) Ethics. In Creek J, Occupational Therapy & Mental Health (4th Ed) Edinburgh, Churchill Livingstone

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Creek, J (2003) Occupational Therapy defined as a complex intervention London, College of Occupational Therapist.

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Foster, M (2002) Skills for practice. In Turner. A, Foster. M & Johnson.S.E Occupational Therapy & Physical Dysfunction (5th Ed) Edinburgh, Churchill Livingstone

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McClure, P (2004) Reflection on practice, Retrieved 07.10.09 from: http://www.practicebasedlearning.org/resources/materials/docs/reflectiononpractice.pdf

Reeves S, Zwarenstein M, Goldman J, Barr H, Freeth D, Hammick M & Koppe I (2008) Interprofessional education: Effects on Professional practice and health care outcomes. Cochrane Database of systematic Reviews issue 1. Retrieved 11.10.09 from: http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002213/pdf_fs.html

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