Abstract
This article describes the use of reflection, and particularly reflective models, to harness the concept of hindsight as a way of deepening insight and learning from experience to minimize serious complaints.
References
Cambridge dictionaries. http://dictionary.cambridge.org/dictionary/english/hindsight (Accessed 14.4.16)
Watson SJ. Before I Go to Sleep.London: Transworld Publishers; 2012
Doyle AC. The Case-Book of Sherlock Holmes.London: John Murray; 1927
Onuoha IE. Overcoming the Challenges of Life. AuthorHouse. 2011;
Johns C. Becoming a Reflective Practitioner.Chichester: Wiley-Blackwell; 2009
ibbs G. Learning by Doing: A Guide to Teaching and Learning Methods.Oxford: Oxford Polytechnic, Further Education Unit; 1988
Borton T. Reach, Touch and Teach.London: McGraw-Hill; 1970
Driscoll J. Practising Clinical Supervision.London: Bailliere Tindall; 2000
Love your complaints – hindsight is a great thing
From Volume 44, Issue 9, October 2017 | Pages 892-897
Article
Complaints happen; as dental professionals we cannot hope to meet every patient's expectations all the time. We cannot be 100% successful in all we do. Many patients appreciate that. Regardless of whether patients are sympathetic to dental professionals being less than super human, complaints happen. Often what is done immediately after something has not gone to plan is crucial in determining if a complaint will be the result or not. Moreover, if there is a complaint, will it be a serious complaint? Giving a complaint top priority as soon as it is made can be vital in preventing the complaint becoming serious. This also enhances the chances of resolving the underlying issues locally and successfully.
To set the scene it is worth remembering the following:
This article is about hindsight; what it is and how it can be used specifically to minimize serious complaints. Tools that help to make the most of hindsight will also be included. The article makes an assumption that readers are aware of the issues that underpin complaints and the factors that can cause dissatisfaction and thereby the escalation into a serious complaint involving a third party organization.
When thinking about hindsight and how it can be used to reduce serious complaints and maximize feedback from patients, what is really meant is using hindsight to give individuals the insight to learn from mistakes. Where there is insight into how a mistake happened, steps can be taken to reduce the chances of the same mistake happening again. When those steps are embedded into everyday practice, improvements have truly been made to the way a practitioner works. An effective method of using hindsight to create insight, embed change and improve is reflection. When thinking about reflection what is really meant is learning from experience.
Hindsight
It would be so much better if complaints could be prevented from happening, certainly the serious ones. If it can be harnessed, hindsight can be a great help in achieving that.
The Cambridge dictionaries online1 gives this definition of hindsight as:
‘The ability to understand an event or situation only after it has happened’:
‘With (the benefit/wisdom of) hindsight, I should have taken the job’.
‘In hindsight, it would have been better to wait’.
Here are a few quotes about hindsight that the author particularly likes:
‘It's so difficult, isn't it? To see what's going on when you're in the absolute middle of something? It's only with hindsight we can see things for what they are’.
‘It is easy to be wise after the event’.
‘To fulfill your vision, you must have hindsight, insight and foresight’.
These are all great quotes from fiction, written by thoughtful, reflective authors. They have in common the use of hindsight to become wiser (gain insight) and to use that acquired wisdom in the future, to develop foresight.
Using hindsight to develop foresight, via insight
To have hindsight is basically to be wise after the event. Hindsight is worth developing because using hindsight can help to develop insight and insight aids foresight. Foresight is the opposite of hindsight in that the individual tries to foresee the future. This is not mystical, it's about recognizing patterns of behaviour that produce a particular result. Where the result was poor or unwanted, postively using the experience will reduce those patterns occurring again and replace them with patterns that give a better result. Of course, vice versa also applies. It is important to recognize patterns of good or productive behaviour so that they can be repeated. Hindsight might not help in preventing a particular event from occurring for the first time, Let's call that the index event. However, it can help prevent or reduce the severity of another similar outcome from occurring in the future. In this way, developing hindsight radar is well worth doing. How can an individual begin to develop his/her radar? Time travel? A sixth sense? Becoming a seer? Those might all be good, if only they were possible. A well tried, tested and possible way to use and develop hindsight into foresight is reflection. There are many ways to reflect and lots of tools and methods are available to gain the maximum benefit from reflection. Reflection is predicated on learning from experience, any experience. Often the experience is one's own, but it doesn't have to be. It can be the experience of others. Young children learn from the experience of their parents who guide and pass on their knowledge and experience. At school, college or university students learn from the experience of teachers, lecturers and tutors. At the same time individuals learn from their own experiences and actions and also from friends and peers around them. Our own learning from experience or reflection is generally intuitive and rarely structured. This means that the benefits from reflection are rarely maximized and often superficial. Using models to reflect can help to structure reflection and deepen usefulness.
Learning from hindsight – the reflective bubble
Experiential learning includes any kind of learning generated from experience. Many of the models that have been developed to aid reflection use a cycle, as a way of representing stages of the learning. Most models have two, three, four, or five stages. Experience-based learning is the process that links together education (formal training) to work (the practical implementation of education) with personal development. All of those three; experience-based learning, education and work underpin our personal development, however, it is experiential learning that really holds the key. It doesn't matter how many theories are read, how many lectures are attended, a person really begins to learn when he/she actually does something in a real situation. A dental student can learn about the theory of cavity design using phantom heads for practice, but it isn't until a cavity is cut on an actual patient that the learning begins. More than that, as more cavities are cut for more patients, the student begins to learn that one way doesn't suit every patient and he/she begins to modify technique from real life experience. That's the real power of experience-based learning.
Reflective practice – what is it?
Reflective practice is a way of taking stock of what has happened, making sense of the experience and taking the learning forward. In essence, it uses hindsight and converts it into foresight with insight as the catalyst. It's a structured process of notice and evaluation and it helps learning. The good news is that most people reflect, although not always consciously and not always as deeply as they could and should.
Reflection involves individuals in:
Let the learning begin
As an event is evaluated individuals begin to develop a new perspective on the event, thinking about why the event happened as it did, what contributed to the event and possible alternatives that were available. This is where learning from reflective practice occurs. The new perspective is developed from the critical analysis and the acknowledgement of how different ways of doing things can be adopted in the future. Once individuals have decided to change what they do, the change needs actually to occur and be repeated until it becomes regular practice. This is known as embedding. The changes made can be monitored in a number of ways, for example: audit; patient surveys; peer or team review.
In a nut shell
Reflective practice essentially means asking the following questions:
It's a style of learning from the individual's own experience.
To write reflectively it is important that people comment on their own perception of their learning and what they have achieved. Reflective writing is undertaken in the first person, a style that can feel uncomfortable and awkward when first attempted. Keep going, it does get easier with practice.
A simple tip when writing a reflection of an event is to do it as soon as possible after the event. The memory will be clearer and it will be easier to recall feelings and what was seen, heard and done.
Models of reflection
There is considerable academic literature about reflection and models. Here are a few that can be tried; not every model suits everyone. It can be helpful to try more than one to see which model is the most appropriate for the reflection being undertaken.
Johns' model5
Johns' model is simple, transferable to any situation and can be used in any organizational context. It was originally developed as an educational tool for general nurses. However, the professional group is irrevelant, the model is universal and, for that reason, it's an ideal model to begin with and start the habit of reflection. The steps will be described a little more.
1. Describe the experience
2. Reflect on the experience
3. Alternative actions
4. Learning and embedding
The model developed by Johns is useful as a guide for the analysis of a critical incident or for general reflection on experience.5 It can be especially helpful if undertaken with a buddy or mentor who can help the person to dig deep. The deeper the reflection, the greater the learning. In addition to the steps above, try looking in and looking out. By that is meant, first ‘look in on the situation’ – focus on yourself and pay attention to your thoughts and emotions as you remember and recall the experience. Then ‘look out of the situation’ – what you are trying to achieve, why you responded in the way you did, how others were feeling and whether you acted in the best way. Include factors such as, expectations from others, time factors, normal practice, anxiety levels of those involved.
Gibbs reflective cycle6
Gibbs reflective cycle is simple and flexible to use and it can be used by an individual as well as in pairs or teams. The model is a little different, in that it explicitly includes feelings and emotional intelligence as a finite step. It also specifically includes evaluation and action planning, both important steps to ensure changes are embedded into regular practice.
Borton7/Driscoll8
In 1970, Terry Borton suggested three simple questions:
John Driscoll developed those questions further when he mapped them into the stages of an experiential learning cycle, enhancing the three core questions with trigger questions:
Trigger questions for 1. What?
Trigger questions for 2. So what?
Trigger questions for 3. Now what?
Driscoll's enhanced triggers to Borton's three core questions help to deepen the reflection as they guide the individual through description and understanding of what happened, followed by analysis and evaluation and finally to future application of the new knowledge.
All of the models above and many others can be of considerable help in reflecting on practice. However, you will only get out what you put in, so if you are superficial in your reflections then you will find your insights are superficial, hindsight wasted and foresight under developed. With any reflection you really have to push yourself to be critical (constructively) of the event you are reflecting upon.
Tools for reflection
A reflective learning log helps to review experiences, come to conclusions and plan how to do something differently. The experience chosen to log could be something that went particularly well, or not as well as hoped, or it could be something rather routine. When the experience is described it is best to concentrate on what happened, with no analysis at this stage, just as full a description as possible. The list made doesn't have to be practical and can be as long as necessary. It's likely to be a mixture of things known beforehand as well as new things learnt – new insights will occur as the description is reviewed. The action plan should include what will be done differently and when it will be done. The plan must be specific and timed. Each action must be explicit and not vague. When adding to the log it doesn't have to be all in one go; perhaps write the description of what was done whilst it's fresh in your mind, then come back to it a day or two later to record what was learnt and what you intend to do with that learning. The log must be completed, if not the person short changes him/herself. To ensure learning from experience actually happens, a review step should be included to see how the action plan has worked out and if processes can be improved upon even more.
Learning teams/practices/organizations
Groups and teams of dental professionals are well placed to learn from their everyday experiences of providing patient care. Groups can pool their experiences, the learning expands and everyone learns from each other as well as him/herself. Reflection undertaken with other people gains a supportive element that is not possible from individual reflection.
Learning teams have the following characteristics:
Teams that reflect together can produce powerful changes to practice and improvements for patient care. Reflection tends to be thought of as an individual activity and, of course, it is, but team reflection can open up learning that an individual struggles to find. Team reflection builds and improves trust between members of the team. Reflective teams are more in tune with each other. Ongoing reflection can pay real dividends in improving working practices and particularly in providing the best patient care possible.
Team reflection can have a number of benefits; whilst the primary aim is to reflect together on an event, complaint or incident, a byproduct can be that the team becomes stronger and more effective in other areas and that can only be helpful, particularly when working with patients. Teams that develop the honesty to reflect together find that it develops performance to a higher level. Common purpose is increased along with value and respect for individuals. Team reflection can help to bring together individual, team and business goals. Teams that use reflection and reflect together understand each other better. They have fewer misunderstandings and less conflict. Reflective teams are often more creative and find solutions to problems more quickly.
When using team reflection, it's often helpful to set some ground rules so that everyone feels encouraged to be open and candid. The sort of rules might be that everyone shows respect for all other opinions and all opinions have equal value. Team reflection works well for complaints as new dimensions can be explored beyond that of the individual who may be the object of the complaint.
When starting it can be helpful to use a structure, otherwise the discussion can turn into a general chit-chat or worse, a ‘soap box’ for one individual. Team reflection needs discipline, from everyone. Each member of the team takes his/her turn to recount the event or incident. The other members of the team then take turns to feedback on their recollection, analysing what their colleague has said, testing assumptions and asking questions as they emerge. In this way, the team can explore the same event from multiple viewpoints or perspectives. The discussion that develops is collective and shared. The team can decide whether or not they met their own performance criteria and together generate action plans to improve the group/team performance in the future. Team reflection is about the ‘we’ rather than the ‘I’. Actions may well be formulated for individuals of the team, but everyone shares accountability and responsibility for working together and playing their part in the success of the team in improving practice. To get started it can help to find a facilitator that can guide the team to reflect together. Once the team gets the hang of it and begins to see the benefits, they will be able to manage the reflection themselves. Questions that reflective teams can use to get the process rolling are: How did it go? How's it going? What can we do better? What got in our way? Why are we doing this? Why should we be doing this? Is this the right thing to do?
From problems to solutions
Focusing on problems, what caused them, who was responsible, who can be blamed and punished may not be the most productive way of trying to improve ourselves or our practice. Problems need to be recognized but, rather than concentrating on who was at fault, solution focused learning looks to the future. Teams that use solution-focused learning utilize reflection positively. It can be challenging to change the culture of a practice used to working in a problem-focused way, but it is worth it.