DOI: 10.1111/tog.

12625 2020;22:75–82
The Obstetrician & Gynaecologist
Tips and techniques
http://onlinetog.org

Articles in the Tips and techniques

Clinical reflective practice section are personal views from
experts in their field on how to
undertake procedures in obstetrics
and gynaecology.
Ruth Roberts MBBS PhD MRCOG, Bid Kumar MBBS DGO MD Dip NBE FRCOG
PGCert Med Education PGCert Clin Risk Management*

Consultant Obstetrician and Gynaecologist, Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, Wrexham LL13 7TD, UK
*Correspondence: Bid Kumar. Email: bidyut.kumar@wales.nhs.uk

Accepted on 4 April 2019. Published online 14 December 2019.

Please cite this paper as: Roberts R, Kumar B. Clinical reflective practice. The Obstetrician & Gynaecologist 2020;22:75–82. https://doi.org/10.1111/tog.12625

through reflective practice can be challenging for many of us.

Introduction
This article reviews the literature that underpins the practice
Reflective practice is an established component of medical and aims to provide practical advice to facilitate the process.
education and clinical development. It is accepted that the
process of critically reflecting on a clinical experience
enhances knowledge and understanding, and facilitates History of reflective practice
learning.1 Experiences, good and bad, provide learning
Most modern-day philosophies on reflective writing are
opportunities for the individuals involved and for the wider
based on the US psychologist and philosopher John Dewey’s
system. While intuitively one might accept that reflective
assertion that ‘we learn by doing and realising what came of
practice will benefit the patient, to date there is little clinical
what we did’.6 However, Dewey’s reflective thought is only
evidence to support this notion.2 However, reflective practice
triggered by challenging or uncertain circumstances and the
is a compulsory part of medical training and is seen as
need for their resolution. According to Dewey’s theoretical
integral to a clinician’s continued professional development.3
description of reflective thinking:7
Reflection is a type of self-regulated learning. Self-regulated
 a problem arises out of present experience;
learning can be broken into three essential components:
 suggestions for a solution come to mind;
 Cognition: the mental process involved in knowing,
 relevant data are observed;
understanding and learning.
 a hypothesis is formed, acted on and tested.
 Metacognition: often defined as ‘learning to learn’.
 Motivation: a willingness to engage our metacognitive and Donald Sch€ on contextualises this for the professional and
cognitive skills. describes how reflection may be used to manage complex
problems: ‘Competent practitioners usually know more than
Metacognition and self-regulation approaches (sometimes
they can put into words. To meet the challenges of their
known as ‘learning to learn’) aim to improve learning by
work, they rely less on formulas learned in graduate school
encouraging individuals to think about their own learning
than on the kind of improvisation learned in practice.’8
more explicitly so as to take increased responsibility for
Sch€on described two terms:8
their own achievement. Metacognition involves con-
1. Reflection-in-action: thought processes that occur and
sciously planning, monitoring and evaluating one’s
influence actions taken contemporaneously during
own learning.4
an event.
The word ‘reflection’ has its roots in the Latin word
2. Reflection-on-action: a process that occurs after the event
reflectere, meaning ‘to bend back’. In medical education,
and can potentially enhance the effects of reflection-
reflection can be difficult to define. Over the past century,
in-action.
medical educators have put forward various definitions and
descriptions of reflection. In essence, it is the process of He also suggests that there are two types of knowledge:8
learning through the critical analysis of one’s actions. As De 1. Technical rationality: evidence or research-based
Cossart and Fish surmise,5 ‘there is far more to a clinical theoretical knowledge.
event than is visible on its surface’. 2. Professional artistry: knowing in action, which could be
As clinicians, every day we instinctively reflect on our clinical inferred to be a consequence of ‘reflection-in-action’ and
encounters. However, illustrating this intuitive process ‘reflection-on-action’.

ª 2019 Royal College of Obstetricians and Gynaecologists 75

 Clinical reflective practice

An individual’s approach to reflective practice may be
influenced by the nature and scope of individual experience
and their personal style of learning.
Models of reflection
Reflection is personal, often confidential, and there are
numerous ways to reflect. Two major dimensions to the
models of reflection are described by Mann:2
1. Iterative dimension: here, reflection is triggered by
experience, which then produces a new understanding,
and the potential or intention to act differently in response
to future experiences.
2. Vertical dimension: this includes different levels of
reflection on experience. Generally, the surface levels are
descriptive and less analytical than the deeper levels of
analysis and critical synthesis. The deeper levels
appear more difficult to reach, hence are less
frequently demonstrated.
While clinical reflective practice might seem an abstract
concept with an ill-defined process, doubtful endpoints and
uncertain benefits, several authors have described
frameworks for reflection based on Dewey’s original
model. One of the most common methods used by
clinicians is that offered by Gibbs.9 Gibbs’ reflective
framework prompts us to consider what happened and
how we felt at the time of the event, what the good and bad
points were in the experience of that incident and what
additional or alternative actions could have been taken. A
plan of action is then formulated for similar future
encounters (Figure 1).
Kolb puts forward an alternative framework,10 in which he
maintains that learning ‘is the process whereby knowledge is
created through the transformation of experience’. Kolb’s
cycle of experiential learning (Figure 2) implies that effective
learning occurs when a person progresses through a four-
stage cycle.10
Kolb views learning as an integrated process with each
stage being mutually supportive of, and feeding into, the
next. It is possible to enter the cycle at any stage and follow it
through its logical sequence. However, effective learning only
occurs when a learner can execute all four stages of the
model. Therefore, no one stage of the cycle is effective as a
learning procedure on its own.10

Description
(what happened)

Feelings
Action plan (what were you
(if the event arose again, thinking and feeling
what would you do?) at the time
of the event?)

Evaluation
Conclusion
(what was good
(what else could you
and bad about
have done?)
the experience?)

Analysis
(what sense can you
make of the situation?)

Figure 1. Gibbs's reflective framework.9

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 Roberts and Kumar

Fish and de Cossart’s model describes elements of clinical  appreciation of the significance of context;
practice that should be considered by the practitioner during  personal qualities;
any episode of clinical reflection.11 These elements include:  professional values;
 knowledge;
 technical processes and procedures undertaken;
 clinical thinking that the practitioner engages in;
Concrete experience
(doing or having  the ability to formulate sound professional judgement and
an experience) engage in wise practice;
 the ability to establish a sound therapeutic relationship
with the patient (holistic medical practice);
 the ability to work reflectively in socially and clinically
complex settings and further deepen a holistic vision of
Active experimentation Reflective observation clinical practice.
(planning or trying out (reviewing or reflecting
what you have learnt) on the experience) Numerous templates based on the models of reflection
described have been developed to facilitate the process of
clinical reflection. The template shown in Box 1 provides an
example that may be of use to the reader and has been
adapted from one provided by the Academy of Medical Royal
Abstract
Colleges.12 This template has similarities with the one
conceptualisation
(concluding/learning
available on the Royal College of Obstetricians and
from the experience) Gynaecologists’ website.13

Figure 2. Kolb's cycle of experiential learning.10

Box 1. Template for written reflection, adapted from the Academy of Medical Royal Colleges12

Title and description of activity or event

 Date(s) of activity or event(s)
 Category in which the activity belongs
 General information about your practice
 Review of your practice – for example, quality improvement, significant events, etc.
 Feedback on your practice – for example, patient/carer/colleague feedback, complaints and compliments

What have you learned?

 Describe how this activity contributed to the development of your knowledge, skills or professional behaviours.
 Consider linking this to one or more of the General Medical Council’s Good Medical Practice domains to demonstrate compliance with their
principles and values:
○ Knowledge, skills and performance
○ Safety and quality
○ Communication, partnership and teamwork
○ Maintaining trust

How has this influenced your practice?

 How have your knowledge, skills and professional behaviour changed?
 Have you identified any skills and knowledge gaps relating to your professional practice?
 What changes to your professional behaviour were identified as desirable?
 How will this activity or event lead to improvements in patient care or safety?
 How will your current practice change as a result?
 What aspects of your current practice were reinforced?
 What changes in your team/department/organisation’s working were identified as necessary?

Looking forward, what are your next steps?

 Outline any further learning or development needs identified (individual and team/organisation, as applicable).
 If further learning and development needs have been identified, how do you intend to address these?
○ Set SMART objectives for these (specific, measurable, achievable, relevant and time-bound).
 If changes in professional practice (individual or team/department) have been identified as necessary, how do you intend to address these?

ª 2019 Royal College of Obstetricians and Gynaecologists 77

 Clinical reflective practice

Table 1. Skills of reflective supervision, as described by Rolfe and Freshwater14

Skill Description

Listening and responding Be able to use questions within the learner's professional context to stimulate reflection.

Be able to respond skillfully with clarification, summarising, reflecting and accepting.

Reflexive Be self-aware and flexible in approach.

Be able to examine one's own prejudices, values, preconceptions and ideas, and assess the impact that these have on the
learner or trainee.

Observing Recognise and acknowledge progress.

Observe strengths and weaknesses and any recurrent patterns in clinical practice.

Identify areas for development.

Transparency Be able to be open about one's own opinion, reflect openly and justify with reasoning.

Feedback Be able to recognise the learner's fears and anxieties, to provide positive feedback and to encourage the learner's
professional development.

Sensitivity to wider social Be able to recognise the possible influence of the supervisee's social background, belief, faith and values on the
context relationships of the supervisee and their interaction with the supervisor.

metacognitive process can be structured and formalised to

Box 2. Details of fictional clinical episode of a woman giving birth
The detailed case is included here as an example, but in practice, the
case notes will be available to the trainee and supervisor and this
detailed summary need not be included in the reflection.
A nulliparous woman at 38 weeks of gestation complained of reduced
fetal movements for the third time in 1 week. Her body mass index
was 36 kg/m2 and the estimated fetal weight was on the 95th centile.
A recent haemoglobin level was 95 g/l. She underwent induction of
labour (IOL) at 38 weeks and 3 days of gestation. In labour, fetal blood
sampling had to be performed twice because of a pathological
cardiotocogram (CTG). The result of both were normal. Twenty-
two hours after IOL, she had progressed to a cervical dilatation of 8 cm.
During the next 4 hours, there was no progress in labour and the fetal
head was in occipito-posterior position. The CTG had improved but
remained suspicious. A caesarean section was performed at 2:00AM by
an ST6 doctor. At caesarean section, the lower segment was found to
be distended and stretched. During delivery of baby, there was
extension of the caesarean section incision at one of the angles and
behind the urinary bladder. The consultant obstetrician was asked to
attend and the uterine defect was repaired. Estimated blood loss was
2 l. Umbilical cord pH was 6.98 (artery) and 7.04 (vein). Postoperative
maternal haemoglobin was 6 g/l. The woman was given 4 units of
blood. Haematuria persisted for 7 days. Urinary catheter was removed
on day 10 after caesarean section and the woman was discharged.
Types of reflection
Individual
This is a personal, internal, cognitive and confidential process
that may not necessarily be written down. This informal,
benefit our learning process and practice.
Group
Traditionally, within clinical practice, reflection is a solitary
process undertaken by individual practitioners. This could be
considered to be at odds with the clinical reality whereby
most practitioners work as part of a team. Group reflection
may be a more appropriate way of learning in some
situations – for example, following a critical incident on
the labour ward or in the operating theatre. Collective
discussion and reflection may lead to greater insight and
learning not only for an individual, but also for the team as
a whole.
The models or frameworks of reflection described above can
be implemented within a group. The group may consist of:
 team members sharing their reflections as equal partici-
pants;
 individuals with different roles within the group (for
example, a supervisor facilitating the reflective process of
the other group members).
Group reflection allows individuals to share their
interpretation of events. What one sees or experiences may
be very different from that of other team members.
Individual reflection may change as different perspectives
come to light, thereby facilitating the learning process.

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Table 2. Stages of clinical reflective practice following encounter with the practical example of the fictional case presented in Box 2
Stages of learning by learner
Considers prior knowledge and
personal experience, if any, in a
similar encounter (internal
experience)
Focuses attention on different aspects
of the clinical case and its complexity
(assimilation; this could be during
or after the action)
Draws comparison between ‘internal
experience’ and the new experience
(external experience; constructs
frames of reference)
Brings to bear the context of the case,
including the wider context of the
team (temporal relations)
ª 2019 Royal College of Obstetricians and Gynaecologists
Roberts and Kumar
Role of supervisor, facilitator or
Points for reflection (in first person) mediator
Am I confident about my knowledge about assessment of CTG Take into account what the learner
and the actions to be taken as a result? perceives to be his/her internal
experience so that the learner's
Am I happy undertaking caesarean sections in women with a objective and learning is appropriate.
high BMI and in the late first-stage of labour? How many times
have I performed this before? Do I have OSATS demonstrating
competence?
Was the woman allowed to remain in labour for too long before Simplify or provide a structure to the
caesarean section was performed, considering EFW is on the clinical encounter.
95th centile?
Was my technique of fetal blood sampling satisfactory? Why
were the cord blood results so different from the scalp blood
results?
I will need to discuss the CTG trace in our CTG meeting. Am I up-
to-date with my mandatory training for CTG?
Was my technique of delivering the fetal head correct for this
situation? Should I have asked for the fetal head to be pushed
up vaginally or should I have used a fetal pillow?
Does my assistant need any feedback about assisting during
caesarean section?
With a haemoglobin level of 95 g/l, I should have ensured that
blood was available if needed before starting the caesarean
section.
Was the WHO checklist followed satisfactorily or was everybody
in a rush because of the circumstances? Should we have
discussed the implication of high BMI, EFW and low
haemoglobin while going through the WHO checklist?
With a big baby, bulging lower uterine segment, occipito- Highlight variation between perceived
posterior position in a woman with a high BMI, this caesarean ‘internal experience’ and ‘external
section was different from any I have performed before. experience’.
With my supervisor, I need to explore other techniques for
delivering a baby in these circumstances.
I should have checked the colour of urine before closing the
abdomen; this would have alerted me to the haematuria and I
may have taken different actions intraoperatively, such as
ensuring the integrity of the urinary bladder by instillation of
methylene blue dye solution.
The suspicious CTG and lack of progress meant that I had to
proceed urgently and not wait for a consultant to arrive. The
cord pH supports my feelings.
On a previous occasion, such a low cord pH necessitated
prolonged neonatal support and the neonate suffered seizures.
I am at ST6 level and should be able to manage such cases on my Act as a resource for clarification of
own. the context and ensure appropriate
interpretation of the context.
79
 Clinical reflective practice
Table 2. (Continued)
Stages of learning by learner
Considers emotional factors,
professional values and human
values in managing a patient
As a result of the new experience,
considers exploring and searching for
existing evidence or literature about
the case
Assimilates the new knowledge and
change of cognitive structure leads
to accommodation (new
knowledge)
80
Role of supervisor, facilitator or
Points for reflection (in first person) mediator
If this happened during normal working hours with availability of
an in-house consultant obstetrician, would the outcome at
caesarean section have been different?
Usually, the anaesthetist would ask for cross-matched blood
before starting caesarean section in these circumstances.
My junior colleague is at ST2 level and is a trainee GP; this is his
first month in his first obstetrics placement.
Did the woman lose so much blood because of my technique, or
did the scrub team or assistant have a role in this?
To hasten the delivery, perhaps I should have asked for general
anaesthesia and not waited for spinal anaesthesia to be
administered. Could I have been more explicit regarding the
timeframe in which I wanted the baby to be delivered? This
does depend on the experience of the anaesthetist, but I should
also have considered the high BMI.
I should have asked for a category 1 caesarean section. I should
consider communication issues with the senior midwife, who
was the shift co-ordinator.
What was the educational value of this clinical episode for my
assistant, a GP ST2?
Decision to perform caesarean section was correct, but should it Signal to the learner the appropriate
have been done earlier than this, given the pathological CTG? emotional concepts and recall or
refresh the values that guide medical
At ST6 level, I should be able to manage such cases on my own. practice.
After another year I will be expected to take up a consultant job.
Debriefing for the woman and her relatives is important.
Will the baby have any long-term effects related to the low-cord
pH and hypoxia?
I must follow up with the neonatologist to find out what
happened.
Daily postoperative review was undertaken as I was worried
about undetected bladder injury. Should I have asked for
imaging tests of the urinary bladder?
I was relieved when haematuria subsided after 7 days but feel
that I removed the urinary catheter too soon after. What if there
was bladder injury and it did not heal properly.
Am I up-to-date with my mandatory CTG training? Guide the learner to the appropriate
resources – for example, an
I need to explore the literature and review outcomes of induction important publication.
of labour in large-for-gestational-age babies and delivery
methods that might have been less traumatic.
I could consider asking the consultant to attend when a difficult Act as a reflector of new ideas and
caesarean section is anticipated, but if there is fetal distress then direct the learner's process of
delay could be risky. accommodation in the appropriate
direction.
ª 2019 Royal College of Obstetricians and Gynaecologists
 Roberts and Kumar

Table 2. (Continued)

Role of supervisor, facilitator or

Stages of learning by learner Points for reflection (in first person) mediator

Mentally formulates an action plan or Help to define or provide structure to

a modified way of acting as a result the next learning objective. Consider
of the present encounter, which is to a timeframe for next session of
be implemented in the future reflective practice.

Considers whether a written record of Avoid using a patient's name or initials, date of birth or any
this process is necessary unique conditions or circumstances.

Try not to be judgmental of yourself and others, particularly

when your reactions and feelings are still raw.

Take advice from an experienced senior colleague when writing

reflections about cases that may be contentious or result in an
investigation.

Adapted from Moon (2004).16

BMI = body mass index; CTG = cardiotocography; EFW = estimated fetal weight; GP = general practice; OSATS = objective structured assessment
of technical skills; ST2 = Specialty Trainee (2nd year); ST6 = Specialty Trainee (6th year); WHO = World Health Organization.

Box 2 contains a fictional case involving a clinical episode

Supervision and feedback
Sch€on’s description of reflective learning also highlights the
role of a mentor.8 Clinical supervision has been described as a
process of facilitating reflection in a structured format.
Freshwater maintains that clinical supervision, when well
facilitated, can provide cues for reflection, allowing the
individual to identify their own ways of knowing.14 The skills
of reflective supervision as described by Rolfe and Freshwater
are summarised in Table 1.
While reflective practice is a mandatory component of
training and continued professional development, there are
recognised difficulties inherent to the reflective process:
 The obligation to provide a pre-determined ‘quota of
reflection’ may lead to disengagement and resentment.
 Questions have been raised about the process of assessing
and reviewing the reflections of individual clinicians. As
highlighted in a study by Sizer et al.,15 reflection may not
be an intuitive process for all doctors but a skill that needs
to be learnt, and while annual review of competence
progression panels comment on the poor standard of
reflective writing when challenged, they find it difficult to
explain why.
 In day-to-day practice, the educational supervisor is tasked
with several roles and may end up in the position of being
both a mentor facilitating the reflective process and the
one responsible for assessing the e-portfolio. Conflict may
arise when the facilitator is also the assessor.
For group and self-reflection, adequate time and scope
should be allowed. Individuals facilitating reflection also need
suitable training, opportunity and time.
of a woman giving birth. Table 2 shows a plan of the process
of reflective practice and the role of a supervisor or mediator,
based on this example.16
Ethical issues and confidentiality
In the wake of the recent case involving Dr Bawa-Garba,
concern has been raised in the medical profession about the
use of written reflective material as evidence in the court of
law. Despite reassurance from the Medical Protection Society
and the Queen’s Counsel that reflective notes were not part of
the evidence presented before the court, the profession
remains fearful that this case will impede open and honest
reflection, which in turn will prevent learning from mistakes
and errors. The General Medical Council (GMC) has
acknowledged the strength of feeling surrounding this case
in a recent publication.17 Important ethical considerations
regarding confidentiality include who has access to the written
reflection and for what purpose. Many educational
programmes and professional revalidation schemes insist on
individuals keeping a reflective diary and often the entries are
used for assessment. At the time of writing this article,
reflective notes can be required by a court of law. Therefore,
any such notes should focus on learning rather than a full
discussion of the case or situation. Factual details should be
recorded elsewhere. There remains a tension in these
circumstances, as assessment usually requires evidence of
‘deep’ reflection, but when documented, this type of reflection
may expose the vulnerability of the individual. Doctors in
training should include insights gained and any changes made

ª 2019 Royal College of Obstetricians and Gynaecologists 81

 Clinical reflective practice
to practice in their learning portfolio. Supervisors should
confirm in the learning portfolio that the experience has been
discussed, agree appropriate learning outcomes and plan
actions. Sharing original, non-anonymised information with
supervisors is important, but factual details should not be
recorded in the learning portfolio.
The GMC, however, highlights a clinician’s professional
duty of candour: ‘be open and honest with patients when
something goes wrong with their treatment or care that
causes, or has the potential to cause, harm or distress’.18 In
these situations, nothing should be recorded in the reflective
notes of which the patient, or those close to the patient, are
not already aware. As such, if a doctor faces a complaint and
they chose to share their reflections, being able to provide
evidence of their openness and insight will help them
demonstrate that they are fit to practise.3 The Academy of
Medical Royal Colleges has issued guidelines on how doctors
should record their written reflections.19
Conclusion
Writing a reflection will be off-putting to some, and may be
seen as the worst form of naval-gazing. However, reflective
practice is crucial for professional development, allowing
practitioners to learn from experiences and adverse events.
Reflection is believed to improve clinical competence and
subsequently patient care, with evidence showing that
adopting a reflective practice framework when making a
clinical diagnosis in complex or non-routine cases improves
diagnostic accuracy.1 Furthermore, it is a mandated
component of medical training and clinical and professional
development. Despite recent concerns around the possible
ramifications of reflection, if undertaken with openness and
honesty, it is a process that can only benefit both doctor
and patient.
Disclosure of interests
BK is an Associate Editor of The Obstetrician & Gynaecologist.
He was excluded from editorial discussions regarding the
paper and had no involvement in the decision to publish. RR
has no conflicts of interest.
Contribution to authorship
Both RR and BK searched the existing literature and
contributed equally to compiling the manuscript. Both
authors approved the final version.
82
Acknowledgements
Staff of the John Spalding Library at Wrexham Maelor
Hospital, BCUHB, North Wales, for their whole-hearted
support with the literature search and acquiring the
necessary references.
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ª 2019 Royal College of Obstetricians and Gynaecologists