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Upon reflection: five mirrors of evidence‐based practice

2010; Wiley; Volume: 27; Issue: 3 Linguagem: Inglês

10.1111/j.1471-1842.2010.00902.x

1471-1842

Andrew Booth,

Innovations in Medical Education

The Medical Library Association (MLA) landmark research policy statement, The Research Imperative,'challenges the association and its members to build a culture of reflective practice in which the profession's evidence base is routinely used'.1 Neatly sidestepping the devil in the detail of that singular word 'routinely' we nevertheless encounter a major hurdle in the concept of 'a culture of reflective practice'. In her comprehensive systematic review of the role of reflection within our profession, Grant (2007) states that: 'It could be reasoned that reflection can improve professional practice by facilitating understanding through self discovery, and for this understanding to enable individuals to manage and bring about change more effectively'.2 She concludes that such a state is yet to be achieved; not least because of the absence of meaningful evaluation of whether reflection within our profession is actually effective. Incidentally, the choice of 'build a culture of reflective practice' in the MLA statement, perhaps unwittingly conveys a sense that artifice and industry will be required, particularly in contrast to more natural, organic expressions such as 'foster' or 'stimulate'. If reflective practice is not currently 'doing what comes naturally' for our profession, is there any likelihood that such a situation will change in the foreseeable future? In her review Grant highlights the distinction made by Schön between Reflection In Action (typified as 'What is happening?') and Reflection On Action (commonly characterised as 'What happened?'). She illustrates the former as when, during a training session, you 'become aware, and act upon, the need to rearrange the layout of the room so that all participants can watch a demonstration'.2 In contrast, the latter is when, after a team meeting, you consider your response to a comment or criticism, by reflecting on 'how this made you feel, what you have learnt from that experience, and how you might respond in the future'.2 It is noticeable that the catalyst for both episodes of reflection is your personal action as a participant or affected party. Clearly such reflection is closely related to the fifth stage of the evidence-based practice process, namely Assess. This involves reflecting on changes to practice that have been initiated and considering implications for your personal growth (Am I different?) and for the team or organisation (Have we made a difference?).3 However, reflective practice has much wider implications for evidence-based practice. As Todd (2003) observes: 'Evidence based practice is about best practice and reflective practice, where the process of planning, action, feedback and reflection contributes to the cyclic process of purposeful decision making and action, and renewal and development'.4 The catalyst for initiating such a cycle may indeed be research, as the chosen focus of evidence-based practice. However, equally it may be the comments of a colleague, feedback from a user or your own observations when walking the 'library floor'. For this and related reasons, I have previously stated that: 'the long term future of evidence based information practice…lies not in a single minded focus on research derived evidence but in a more encompassing approach that embodies reflective practice'.5 Recently renewed exposure, via one of my PhD students, to the so-called 'Stages of Change Model'6 has given me cause to reflect more deeply on the relationship between evidence-based practice and reflective practice, making me consider that reflection is not simply linked to our own Actions as individuals or members of a team. Vicariously, through the recorded experience of others, we can broaden and maximise our opportunities for reflection. The advantage of such 'freeze dried experience' is that we learn not only from our own doing but equally from the actions of others. Furthermore, the value of such reflection need not be confined to a single stage of change, i.e. Action, but can be harnessed at any point in the change cycle. For those unfamiliar with the 'Stages of Change Model', it typically relates to health education or health promotion where a healthcare provider is trying to initiate some helpful life change for a client's benefit. It is argued that the client needs to progress through sequential stages of Pre-Contemplation, Contemplation, Preparation, Action and Maintenance in order for a change (e.g. giving up smoking or taking up exercise) to be successful. A brief characterisation of the Stages of Change model is provided in Fig. 1 and Table 1. Stages of change model Reflective practice is, fundamentally, reflection in the context of practice7 and therefore should be able to take place at any point during the various stages of change. I was interested to discover that, to Reflection In Action and Reflection On Action, some commentators add Reflection Before Action (What do we need to think about before we do this?).8 Indeed had this stage not been anticipated, I needed to contemplate inventing it! This stage, where we are starting to plan for an intended course of action, equates well to Preparation on the Stages of Change model. Here, a library manager will find it helpful to identify reports of implementation on how problems were encountered and (hopefully!) overcome. What of the preceding steps of Pre-Contemplation and Contemplation? Perhaps, these map best to the different types of evidence-based question, that is, Background and Foreground questions.9 A Background question occurs when someone is aware that something needs to be done, but is unable to identify the precise nature of the alternatives. This maps most closely to the latter stages of Pre-Contemplation (where you begin to reflect 'What am I going to do about X?'). A Foreground question similarly equates to Contemplation (where you reflect 'How am I going to do Y (in order to address X)?') and relates to choosing an appropriate course of Action. Once that choice is identified, we can then proceed to the Preparation phase. While the distinction between Pre-Contemplation and Contemplation is generally a useful one, when thinking purely in terms of the type of reflection required, these could merge within the concept of 'Reflection For Action'. You might start by identifying a range of available options, perhaps from an overview or a literature search and then proceed to a decision point, supported by a systematic review or by a comparative study. To the twin techniques of Reflection In Action, located within the Action segment, and Reflection On Action, located at the end of that same Action segment we can add one final point of reflection. This lies within the Maintenance stage and relates to ongoing evaluation (reflecting on 'Is this still worth doing?' and 'Is this still the best available course of action?'). This combination of an iterative and ongoing process of reflection and action seems most accurately conveyed by the variant 'Re: Action'. How might these five mirrors work in practice? Imagine that your institution is proposing the introduction of a new course.10 From a starting point of 'Not Thinking About It', Mirror One: Reflection For Action leads to recognition of a need for your library to provide some, as yet unspecified, support for the course (Pre-Contemplation). It then involves the identification and narrowing down of potential alternatives (Contemplation). These options may emerge from the literature, from fact-finding visits or some form of knowledge exchange with those in a similar situation. Having settled on your preferred alternative, Mirror Two: Reflection Before Action (Preparation) involves the instrumentalities of planning for the change to take place. This might be informed by the published experience of others or by anecdotal practice transmitted by word of mouth. While introducing the change (Action), you and your team use the tools of Mirror Three: Reflection In Action (diaries, reflective journals, blogs, etc.) to capture your experience thus allowing you to fine-tune as you go along. After the first running of the course, during those summer months that are never as quiet as they promise to be, you use an After Action Review (Mirror Four: Reflection On Action) to assess the success of the first year's provision and you make identified changes in response to this shared learning. Incidentally, this also provides you and your team with an opportunity to share your own 'freeze-dried experience' with national and international colleagues by contributing to the Using Evidence in Practice feature within Health Information & Libraries Journal! Finally, you initiate a regular and ongoing process of review, reflection and refinement (Mirror Five: Re: Action) to ensure that you keep-up-to-date with the wider environment, with newly emergent research and with the needs of your users. This brief feature proposes that, in addition to the widely accepted techniques of Reflection In Action and Reflection On Action, we can further benefit from reflection at other stages of the change cycle. It suggests that Reflection For Action provides a useful label for that preparatory evidence-based work that involves both Pre-Contemplation of a broad range of potential strategies or interventions and the subsequent narrowing down, and hence Contemplation, to specific alternatives for subsequent action. Recognising that some commentators have already identified the value of Reflection Before Action, this revised model aligns this particular stage with the need to identify evidence to facilitate implementation of our preferred course of action. Finally, a reflective practitioner will continue to make room for ongoing review (Re: Action), beyond the immediate evaluation frame of a change project, to ensure that both problem and solution remain aligned and to identify where new and emerging evidence may have a bearing on the preferred course of action. In such a way, evidence-based practice truly becomes integrated within the domain of the reflective practitioner.