Developing reflective writing skills - part one

In the first of two articles on how to write a reflective account, a typical reflective entry is used to explain the theory and practice of reflective writing. By Dr Prashini Naidoo

It is important to reflect as soon as possible after the event (Photo: iStock)
It is important to reflect as soon as possible after the event (Photo: iStock)

What is reflective writing?

There are many definitions of reflection. A common thread within all definitions is the idea of purposeful or careful thinking about an experience, to learn from it and to move forward.  The act of writing seems to be a more powerful and structured way of exploring thoughts and feelings than merely thinking.

Writing helps us to analyse in greater depth and to compare our experience with theory. The linkage of experience to academic theory gives it credibility. At the end of the exercise we also have a record of how we made sense of the professional experience and how we distilled the experience into wisdom.

Structured reflection – narrative, learning, change

When we first start to write reflectively, a structured framework is helpful as a prompt to cover the key points, namely narration or description; feelings; evaluation of what was good or bad about the experience; analysis of what was happening; conclusions; and ideas of what we will do differently next time.

The narrative

Start with a story of what happened: set the scene and summarise the action. This bit is easy, but needs to be succinct. Describe your emotional response to the plot if this is pertinent to the story.

Unlike most pieces of academic writing, a reflective account is written in the first person and in the past tense.

For example, a trainee writes:
I consulted in routine clinic today with a 29-year-old unmarried lady whose partner was told by a GP last week that he had penile warts and was advised to tell his partner to 'get checked out'. I was a bit confused by the advice to be 'checked out'; I felt the patient expected some sort of action from me.

The learning

Think about what was learnt from the experience. This is hard work as it involves weighing up what was good and bad about the experience; exploring why you responded in the way that you did; and analysing what happened.

Analysis may involve a comparison of what was actually done against what we should do. What we should do may be taken from books or guidelines or it may be advice from other colleagues with greater or different experience. The product of this analysis should be a deeper understanding of how we practise and act as we do.

The trainee writes:
Having discussed patient-centred consulting in a COT last week, I explored, using open questions, the patient’s agenda. She believed that she did not have genital warts and so could not have infected her partner (her idea).

She was concerned about having warts on her cervix (her concern). She expected me to perform an examination of the cervix and reassure her about her fertility (her expectation).

I performed a vaginal and speculum examination. I was happy with my examination technique. The patient commented that unlike the smear test she had, this examination was not too bad. I told her that I did not see any genital warts. The patient was happy.

I think that by being professional, non-judgemental and competent in my examination, she felt reassured.

However, after she left I remembered that different strains of HPV are responsible for genital and cervical infection, so I used an online resource to learn further. I read that up to 30% of patients with genital warts could be co-infected with another STI. Should I have advised about or screened for chlamydia?

Here, three learning points are commented on.

  1. The trainee has used patient-centred consulting techniques and weighed up that they had the desired effect.
  2. The trainee received a compliment for her examination technique and so gained confidence in her skills.
  3. Outside ideas from online guidance were used to make sense of the accuracy of her advice. On checking, she discovered that perhaps what the partner’s GP may have meant by 'being checked out' was a screen for STIs rather than a visual examination for genital warts. Checking the online guidance made the trainee realise that she should have considered other STIs.

Change

After coming to an understanding of the experience and hopefully developing some insight into our behaviour, we may comment on what we will do differently in the future. This is the section in which trainers are most interested.

Sadly it seems that most trainees are too tired or embarrassed or shy at this point to write very much at all. If this were an examination paper, I would award a third of the total mark to this section.

This is the learner’s opportunity to sum up the case. In the above example, the take home message was that she was confused by the patient’s request to be checked out, perhaps because the patient herself did not know what her partner’s GP meant by this.

In her desire to meet the perceived patient expectations, the trainee undertook a vaginal examination. Had she considered 'red flags', the consultation may have evolved differently.

This case was summed up with:
If I encounter this again, I will consider the medical conditions it is important not to miss. This is an important part of a GP’s job. I will share my thoughts with the patient and her expectations may alter.

The trainee demonstrated that she has compiled a new view of what happened and has come to a deeper understanding of safe patient-centred consulting.

What can we learn from this?

The reflective account above has some important attributes:

  • Even though the trainee wrote in the first person, she tried to be as objective as possible.
  • There is an impression from the writing that this experience happened recently. It is important to reflect as soon as possible after the event, to recall as accurately as possible what happened and what was felt.
  • The trainee wrote openly and honestly about her anxieties. However, by candidly exploring this experience, she demonstrated how she came to a deeper understanding of 'red flags' and her ability to influence patients' expectations in future consultations. She has used reflection to develop her skills.

Dr Naidoo is a GP trainer in Oxford

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Resources

  • Bolton G. Write to learn: reflective practice writing; InnovAiT 2009; 2(12): 752-4.  

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