Making Reflection Happen

Do you work alone, or work in a team, or do you work in an organisation?
Does it matter?

Making reflection happen is something the registration (regulation) bodies (Councils) are concerned with. A publication was produced in 2019 making everyone aware. There are few checks and balances as to whether you do reflect on your clinical work unless you are tested. It is only at this point that you are made aware of any deficiencies.

Having a profile or evidence of your activity can do much to mitigate deficiencies but making reflection happen is down to you. Certainly, this article has no intention of looking at this aspect of practice but regulatory bodies have lists of clinicians reported for activities other than formal practice. It is the arena of clinical reflection that we need to concentrate on. So significant is the subject of reflection that I have written a series of articles for professional registered colleagues covering aspects of podiatric medicine and surgery. I have called these Reflective Podiatric Practice. Click on the blue to see the articles covered. A newsfeed is also provided by sign-up to keep abreast of new issues.

In 2020 I published my first reflective series book called Selling Foot Health as Podiatry. This is not about business itself but about reflecting upon how we should communicate.


What do we reflect upon?

But what are you or we, as a profession, trying to reflect on? Again the truth comes down to being up to date If we all know what the processes and protocols are this makes striving for those true reflective goals.

The Independent Sector

Often we are caught out when we breach a protocol, and this is mostly for good reasons. In the hands of poor managers this can be disasterous, but in  the hands of caring managers this can be positive. So, where does the balance lie? When you are on your own, as a sole trader, the difficulties become accentuated. It becomes your word again others unless everything is documented. The lack of a team around you can become a disadvantage because you need someone to verify that you are up to date.

At one time I had a modest paediatric practice in the independent sector but keeping up to date and finding a place to work that supported paediatric care became more difficult. As numbers of children who sought treatment dropped, the cost of providing this service became untenable. We set up a small but effective unit to deal with ingrown toe nails within the NHS where a colleague of mine provided general anaesthetic. I had to chose to service adult foot problems over children. 

Presently children can still be managed in most podiatry services as outpatients together with local anaesthetic provision.The corollary to this action means paediatric care has started to become scantily covered in healthcare. This may not extend to feet alone.

The National Health Service

The NHS generally is better geared to support reflection because it has internal courses that have to be attended. Computerised monitoring of staff takes place and flags light up when someone’s attendance has dropped. Most of these internal courses benefit the organisation. This can affect risk, liability and insurance. The list will cover; lifting methods, basic life support, fire safety and evacuation, as protecting people’s rights (equality, diversity, GDPR), child safe guarding and infection control to mention the key ones.

Working with children has become an all time problem because of ‘safeguarding’ and the need to ensure good chaparone support. Safeguarding is a title all of its own now and bestows responsibility on all those treating patients. Clinicians are now charged with spotting child abuse and NHS training has increased in this field. For many, it is no longer viable to manage children because of the legislative expectations imposed. The cost of having trained paediatric nurses impacts on many treatments, especially invasive techniques.


Continuous Professional Development

Continuous professional development (CPD) forms the largest component of your evidence to establish evidence that you are up to date. It may come down own to your own personal budget and time. You can invest your time and money usually by going to annual conferences. But do these always meet your need? Everything is a gamble and clinicians can get away with the barest minimum. No one says that each national conference provides all your needs and some have to invest elsewhere. Let’s face it, today we have to prioritise but being professional means we have a duty to stay up to date.


Download the reflective podiatric practice article Sept. 2019 Bristow on CPD here. This article covers the history of podiatric CPD dating back to the 1950’s


What does CPD mean to you?

armi1961/Shutterstock

CME’s used to be the currency now ascribed as CPD. CME’s were in fact the same thing (click here for CME) but had different outer clothing. Proof of attendance was evidence.  The regulatory bodies provide a wide latitude in how to reflect upon your educational profile. The golden nugget gained from attending a lecture or talk is perhaps as important as the certificate you walk away with. The golden nugget is a piece of information that you can translate into direct value and use back in practice. This may be a method of approaching a patient, it may be an idea that helps you overcome a problem you keep experiencing. A solution is truly golden as it saves frustration, and possibly prevents wasted money, and may make your patient much happier to provide a simplistic approach. A golden nugget includes going on a skills course that allows you to take away a new technique.

 

What does CPD mean to others?

Formal CPD becomes tied up with the departmental needs under the NHS. Innovation is not always fostered within the NHS.  Personal drive is required to develop innovation and this extends to research.  Clinical research is very different from the seventies and eighties, and curtailed often by rigorous ethical boards which stifle personal ideas unless they come with a heavy pedigree. The NHS does not see research as part of routine CPD unless enmeshed within a degree course. A three year Master’s degree is every part of CPD because it consists of massive learning, new skills, innovation and reflection in leaps and bounds. 

CPD is often seen as a list of evidential activity. CPD in turn can be used within a curriculum vitae (CV). We all need a CV (resume – USA). The CV details activity from basic training to courses, lectures given, papers and books written. We can now include blogs, vlogs, YouTube films, instructional in house courses as well as all the mandatory and desirable features associated with safe practice. Note keeping and safekeeping records are essential.


Clinical learning

www.pascom-10

Timeliness and information imperatives

A spreadsheet or database will allow you to keep a log of all your activity. The College of Podiatry, as an example, once offered Pebble Pad as a system for maintaining all your educational activity. This was withdrawn through lack of dedicated support despite showing that it had good value. Additionally a 360 appraisal system was also withdrawn mainly from the Faculty of Podiatric Surgery. Three-sixty was a concept of having other professionals and patients assess your preformance over all. With some 30 people reviewing a single clinician the method did have some stability. PASCOM-10 exists for all podiatrists and charts clinical activity. This has been in place for over 20 years but is used largely by podiatric surgeons because it is built into the education system. The new PODMO system only collects activity and does not offer any qualitative analysis. We can deduce that systems that have an integrated purpose for accreditation tend to be sustained, those that are wholly voluntary often fail.

What to record?

The list, and if you use a spreadsheet, should have dates, course activity names, organisations, indications of certificates, objectives with a dossier containing the evidence. Because the experience associated with CPD is so wide the professional organisations and regulatory bodies maintain a relaxed view. One can recall that it was expected that you should have read a journal within six months. Today with social media reports and hyperlinks most busy people find reading and clinical work not easy to fit it.

Staying up to date with reading is complex an requires a discipline (staying up to date). The legal view might appear woolly. This Bodlein article dates to 2016 and therefore has some useful background material. Reading a journal is not always essential, but the information covering a change in practice is vital to take note of. You may have six months perhaps legally to have read the article but if it is life changing then it is important to have taken on board the information as early as possible. If you have a website used for patients, this can be a useful place to make a comment if it relates to safety or standards.

Past examples of information 

Sometimes professional bodies are tasked with passing on information from government bodies such as NICE.

  • The dangers of exhaust waste from (nitrous oxide) cryosurgery were sent out in the eighties so we had to fit exhaust pipes.
  • Nail drills without dust exhalation became very topical because of allergies and respiratory disease from fungoids.
  • Phenol crystals became another target, but there are numerous cases where information of high importance had to be considered rather more quickly than just with publication. 

This article looks at CPD in developing countries as part of our interest in the subject. (CPD Healthworkers


 

We are now reminded that information is as likely to come from e-newsletters as it is from Journals and magazines, e-mails sent out as warning notices. Keeping your e-mail address current is important. While NHS e-mail addresses are fine for those working in the same sector, spam creates a problem which can divert important notices. 

How do we find information?

It is important to have at least one reliable journal source. We can scan contents quickly and identify material that we should prioritise. The responsibility falls to the organisation first who should have a good radar, but also members who should work with their professional body to feed information into the organisation.

Members are the eyes and ears of the organisation and cannot be divorced from their collective responsibility to police the health field. Research journals are slightly different, but nonetheless are important for disseminating new trends. The most important part of any organisation network is to translate pure research into simplistic language to guage the impact, importance or immediacy that information must be read, consumed and acted upon. I have called this the Primordial Cascade (Tollafield,D 2020).

The latest innvovations can be acquired by attending workshops. This forms an important way of establishing new skills.We now come back to reflection. 

How do you perceive your learning?

Is learning something to be regurgitated or something to be used in order to change direction?

We learn most when mistakes are drawn to our attention when something is not quite right. The trigger is the problem. How do we know something is wrong without a set of rules. Thinking outside the box is important and a whole subject can be dedicated to this area learning by mistakes.

In healthcare there is no rule that exists for every situation. Therefore we must take a model and adapt it. Sometimes this works, at other times it doesn’t work. It has taken us years to realise that the heel spur is not usually a source of heel pain.  The idea of removing a spur by surgery often resulted in needless pain and disability. Conservative care is always better than surgical care until something becomes so chronic. On the flip side thought, years of needless pain should be avoided when a resolution is at hand . 

Once we share information and overcome the fear of negative responses we can move forward. 

Consider the article How to go about clinical reflection

If you want to know more about reflective writing I have produced an audio article and a reflective written article which can be used as a resource. Reflection ‘Sorry I should have been clearer’ click here. Read or listen or both, the option is there.

Thank you for reading ‘Making Reflection Happen by David R Tollafield. 29 July 2019

Published by Busypencilcase Reflective Communications Est. 2015

Reviewed last July 2020