During the final term of my Diagnostic Radiography degree, I attended clinical placement for a total of 11 weeks to gain experience and practice my imaging techniques in various imaging departments. The placement module provided me with a learning experience in a hospital environment and helped to broaden my clinical skills in a variety of clinical environments. I was formally assessed by a member of the clinical staff on 2 different imaging procedures, a mobile chest x-ray and a CT head scan, as part of the degree evaluation process. I kept a reflective diary from the first day of my placement to help me record my feelings and thoughts on the examinations I was asked to perform, the varying patients I examined, the outcomes of these examinations and any problems or achievements I felt important in my time there. The most significant reflection, however, was in respect to my clinical staged assessments. I will be using this diary as a means to help me reflect on my experiences on this placement and on how I have developed both professionally and personally.
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What is reflection and why does reflection help me in my learning? Reflection is a process of gradual self-awareness, critical appraisal of the social world and how it transforms your thinking. Johns and Freshwater (2005) state that “reflection is an active process that will enable me and other health care professionals to gain a deeper understanding of any experience with patients”. One definition that is appropriate for student radiographers is “Reflection in the context of learning is a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations (Boud et al, 1985). The use of a reflective journal during my final placement helped me with my reflective development as it would have been difficult for me to remember all the numerous thoughts and feelings I experienced over an 11 week period. Kennison (2002) sees the reflective clinical journal as a method in which a learner may write about clinical learning experiences and reflect on them. He considers this as a beneficial tool of reflection which not only improves the learner’s writing skills but also essentially helps to “reflect on their practice, explore reactions, discover relationships and connect new meanings to past experiences”. On the other hand Newell (1992) states that any reflective practice is reliant on memory and interpretation of events – selective memory is a particular problem especially following a negative event. I can relate to this as I did find that a balance was required when recalling certain events, I was inclined to remember more negative situations than positive ones, these negative feelings and thoughts of particular events stayed with me longer and had a bigger impact on me.
If I am to approach this account of my clinical placement reflectively I must choose an appropriate model of reflection. Johns (2002) found that there are several models have been developed to guide the process of reflection. The first model I will use to aid my analysis and to explore my feelings is the Gibbs (1988) reflective cycle. This model has 6 stopping points which are – Description, Feelings, Evaluation, Analysis, Conclusion and Action Plan. I feel this cycle allows analysis to make sense of the experience, it takes into account a sequence of feelings and emotions which play a part in a particular event and leads you to a conclusion where you can reflect upon the experience and what steps you would take if the situation happened again. This model can also be used through different levels of reflection from novice to advanced. The second model I am employing is Boud et al (1985). This model helps reflect before, during and after an action and will be ideal to explore my feelings and experiences through the whole of my placement. Boud et al (1985) identify reflection as “a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations”. This reflective model is therefore appropriate for radiographers and other health professionals to adopt in critical reflection exercises. Boud et al, (1985) & Schon, (1995) state that the development of the abilities to be reflective and critically reflective in practice can be perfected through active, repeated, guided practice.
Model of reflection (Boud et al 1985 from Johns 1995)
Stage 1: Return to experience
Describe the experience, recollect what happened
Notice what happened/ how you felt/ what you did
Stage 2: Attend to feelings
Acknowledge negative feelings but don’t let them form a barrier
Work with positive outcomes
Stage 3: Re-evaluate the experience
Connect ideas and feelings of the experience to those you had on reflection
Consider options and choices
Stage 4: Learning
How do I feel about this experience?
Could I have dealt with it better?
What have I learnt from this experience?
Starting at the beginning of the Gibbs (1988) cycle and Boud et al (1985) framework, I am asked to describe the two different clinical staged assessments that I completed and my recollection of thoughts and feelings before, during and after the process.
My timetable actually dictated that I would perform my mobile chest x-ray assessment first. This was due to me spending the majority of my first few weeks on placement in the General Department where I would be performing this type of procedure regularly on ward patients. I thought it best to be assessed during the third week after I had performed the examination many times and would be feeling confident. At the start of the second week of my placement I felt confident that I would be ready for this assessment in week 3 and was looking forward to my 2 timetabled days in the Accident and Emergency (A&E) Department prior to working in the General Department again. On the first morning in A&E the radiographer in charge asked if I had any staged assessments to be evaluated on, I advised her that I had a mobile chest x-ray to do but I was happy to do this in the General Department the next week once I had gained more practice. Unexpectedly, the radiographer suggested that she would assess me that morning and that I should carry out the examination on the next patient that required a chest x-ray in resuscitation.
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My first instinct was to put this off and decline, as in my mind I had planned to be assessed on a ward patient the following week. I also felt panicked as I did not have much practice using the mobile x-ray machine in the resuscitation area at this point and the surprise of the request took away some of my confidence. This was a test of my mental strength and as a future health care worker I would have to get used to making quick decisions and rising to challenges on a daily basis. My response was to agree, which surprised myself, I accepted that I was going to be assessed that day. I did not have my assessment sheet and criteria to hand but I managed to find another student who had the information and photocopied it. The morning passed very quickly and I was worried every time a request card was passed through to the viewing area from the A&E staff as I thought it would my turn to carry out my assessment. When the request eventually arrived it was to image a 64 year old male that had breathing problems and a history of Chronic Obstructive Pulmonary Disorder (COPD), he was sitting upright on a trolley in the resuscitation area of Accident & Emergency. A chest x-ray was required and so I checked the request card and the patient’s history on the hospital information system (HIS) system to check for any previous history and corresponding images, I washed my hands, collected a cassette and proceeded to take the mobile unit into the required area. The radiographer accompanied me and asked the patient for his consent and his co-operation to have a student perform the x-ray, the patient agreed. She then observed the whole procedure to evaluate my performance.
The chest x-ray procedure was carried out routinely as an erect, antero-posterior view, the patient was very co-operative and aware of the situation around him which made it easier for him to understand and carry out the breathing instructions I was giving him. The resulting image showed prominence of hilar vasculature and was an acceptable diagnostic image. I received an excellent assessment mark from the radiographer and although I was relieved that it was over I still felt pleased with myself that I had carried out the mobile x-ray to a high level. I am thankful however that I kept my reflective diary on this occasion as everything happened so quickly and not to the plan that I anticipated that I benefit from reading my emotional conflicts that I experienced at a later date. This feeling is reinforced by Schön (1987) who argued that reflection is not a simple process and that practitioners need coaching and require the use of reflective diaries as tools for dealing with practice problems.
The second assessment on the other hand was not as stressful as the above experience and I feel I coped with the anticipation of this assessment better. I was timetabled for a week in the CT Department and so I knew that I would definitely be assessed then on a CT head scan. After discussion with the radiographer in charge it was agreed that we would wait until the Friday to be assessed to ensure that I had plenty practice in carrying out CT head examinations. On the day of the assessment I decided to be assessed on the first patient to attend for a CT head examination. I did not feel as nervous as the first assessment as the arrangements had been made at the start of the week and I knew when I was being assessed. I was also confident in my ability to use the CT scanner and my positioning skills. The first patient to arrive for a CT head scan was a 69 year old female who presented with a history of persistent headaches and dizziness. On checking her identification I found that the lady was hard of hearing and I had to make sure to explain the procedure slowly, clearly and slightly louder than usual. I instantly became concerned that the patient would not hear the instructions given immediately prior to the examination, e.g. that she should remain very still and not move her head which is very important in achieving a clear and diagnostic head scan. This was a scenario that again I had not predicted. Radiographers, medical students, and nurses alike are constantly faced with unique and ambiguous problems in the clinical setting, where they are required to stop, think, and problem solve in the middle of activities or procedures they are carrying out and is a challenging part of the job.
I proceeded to explain to the patient prior to positioning her in the CT scanner what the examination would entail as she would be lying in a supine position with her head resting on a head support which would further obscure her hearing. She acknowledged my instructions and I felt happy to continue with the examination. The patient was positioned head first into the scanner no intravenous contrast was necessary and the patient raised on the table so the lasers were at the level of the orbitomeatal line. I then carried out the appropriate CT head protocol on the computer system, the scout was carried out to make sure the patient was in the correct position and the x-ray beam was set at an angle along the base of the skull to prevent unnecessary radiation of the patients orbits, the slice thickness was selected between 5mm and 10 mm and the CT examination was started. Everything went smoothly and the patient was not found to have any significant pathology showing on the scan. The radiographer in charge was pleased with my technique and anatomy knowledge and gave me a good mark for my assessment.
Boud et al (1985) suggest that ‘In reflective practice, it is necessary to gain an appropriate balance between the analysis of knowledge and thoughts, and the analysis of feelings. It is also important to focus on positive feelings as well as trying to deal with negative feelings, in order for the process to be constructive.’ Bulman & Schutz. As I follow Gibbs (1988) cycle to explore my emotions and feelings I am aware that this step in Boud et al’s (1985) framework becomes appropriate. He advises to ‘acknowledge negative feelings but also to not let them develop a barrier. I did experience negative feelings, more so in the first staged assessment. This has been an emotion that has surfaced from the start of my training and continued until this point, although the fear factor has reduced significantly. I sometimes do let my nerves get the better of me but as I have come through this degree my worrying has lessened and my confidence has grown. Wondrack (2001) acknowledges that fear and feelings of guilt often accompany emotions which spring from a lack of confidence in how to resolve situations. On reflecting in past modules I have highlighted my nervousness and so I do not find it a barrier but a test of my determination now. With regards to my first staged assessment I was nervous and anxious as I was ‘put on the spot’ and not as fully prepared mentally as I would have liked. I think I coped as well as I did due to the fact that I have been learning how to adapt to changing circumstances since my first year placement. I know that I can deal with what is thrown at me now and ask questions if I am in any doubt of my actions. My general clinical placements have all required for me to think on my feet, in the case of the patient who was hard of hearing, the main problem was communication. Schön (1993, 1987 cited Moon 2001, p. 3) focuses on reflection in professional knowledge and its development. He identified two types of reflection which are ‘reflection in action’ and ‘reflection on action’. Schön proposes that these types of reflections are used in unique situations, where the practitioner is unable to apply ‘theories or techniques previously learnt through formal education’ (Moon 2001). It would therefore seem that ‘reflection in action’ and ‘reflection on action’ are highly beneficial to the healthcare environment as practitioners are working with individuals who are more often than not, text book examples. Reflection is a fundamental part of my radiography practice and future career, as all patients are unique this means that every time I image a patient I may have to approach it differently as I will need to consider the individual needs of the patient. The outcomes of both my staged assessments were very good and a positive result did come after my initial negative feelings.
Following both the reflective frameworks, I began to analyse what made me feel the way I did. As I considered the pros and cons as suggested by Gibbs (1988) I found that it was reasonable to feel the way I did and that it is all part of being a student. Every other student that I had spoken to felt nervous when both completing the staged assessments and facing new situations with patients. It was to be expected in the lead up to potentially becoming a radiographer. The cons were that I showed my weakness to the radiographer and maybe came across as less confident as I should have, the pros were that I used these feelings to push myself forward and it made me want to do my best to prove that I was capable of producing good diagnostic images.
Reflection is more than just thinking about something, it should be an active process, which should result in learning, changing behaviours, perspectives or practices (Boud et al, 1985). By reflecting I have certainly changed my perspectives and behaviours on clinical placement. I am a more positive student and person due to the challenging situations and people that I have encountered. Where I previously became flustered I now take a deep breath and think through the situation and take my time. I have the knowledge to back up my skills and vice versa now so it is my application of these tools that can move me forward. Gibbs (1988) cycle concludes by asking what could I have done differently, both staged assessments were not extreme cases and I was lucky to examine co-operative patients. I would not have done anything differently in the practical aspect. Experience will help me to become more confident in my own skills and capabilities and will help me in adapting to change quickly. This is where I prefer Boud et al’s (1985) framework as it encourages you to reflect on how you feel about the experience and what you have learned. Gibbs (1988) is slightly more negative and asks ‘what would you change and do differently’. I was unable to turn my nerves and emotions off and on but I could learn to control them and make them work for me.
From following both Boud et al (1985) and Gibbs (1988) models of reflection I have analysed the situation in detail in a logical order. These experiences have been immensely helpful in evaluating my emotional reactions and professional limitations in the clinical setting. Therefore, my diary has been an essential tool in my development. According to Maggs & Biley (2000) evaluating practice through reflection can bring advantages. The challenge is to recognize and use these advantages, together with the knowledge they generate.
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