Reflective practice: when things go wrong whose business is it?

Reflective practice forms a critical part of all members’ continuing professional development (CPD) and both the Health and Care Professions Council (HCPC) and the CSP expect registrants and members to reflect on their practice. 

Analysing and evaluating our actions and decisions underpins a continuous cycle of improvement, ultimately leading to better quality patient care. Meaningful reflective practice relies on honesty and openness. 

But how honest should you be? Are there situations when your reflections could be used as ‘evidence’ against you, for example when a patient has come to serious harm? 

#IAmBawaGarba

The reporting of Dr Bawa-Garba vs the General Medical Council case (2017/18) caused widespread concern for many healthcare professionals. It was widely reported that her personal reflective statements, both verbally and in her e-portfolio, made after the death of a six-year-old boy in her care, had been used as evidence in the subsequent criminal gross negligence manslaughter trial. Much of this reporting was inaccurate but it did raise questions about the potential use of personal reflections and the impact this may have on the willingness of professionals to engage with open discussions when things go wrong.

Can my personal reflections be requested by the HCPC?

Prompted by the Bawa-Garba case, the HCPC released a joint statement with other healthcare regulators (supported by the CSP), re-affirming the key role of reflective practice in CPD and expectations that registrants continue with the practice. The HCPC gave reassurance that ‘we will not ask those who are on our registers to provide their personal written reflections in order to investigate a concern about them. Registrants can choose to offer them as evidence of insight into their practice.’ (HCPC guidance on the benefits of becoming a reflective practitioner)

What about in a criminal context?

Theoretically, a criminal court could order the disclosure of reflective material, but it is the view of the CSP that this is highly unlikely. It is important that this notional possibility does not stop members from fully engaging in honest and transparent reflective practice to aid learning.

Should I just put the bare minimum in my reflections then?

Reflections can be as detailed as you choose but should not just be a tick-box exercise. Remember they are not intended to be full case discussions or a list of events. They should be a synthesis of the insight and learning gained from experiences, focusing on personal and service development as a result.

However, physiotherapists do have a regulatory duty to fully engage with investigations. The HCPC is clear that all registrants must be ‘open and honest when things have gone wrong with the care, treatment or services that they provide’ (Standard eight, Standards of Conduct, Performance and Ethics). In addition, all members working for most health and social care organisations in England and Scotland have a statutory (legal) duty of candour (similar legislation is due this year in Wales and is under review in Northern Ireland). This means that legally, organisations must tell patients where the care or treatment has caused significant harm or has the potential to result in significant harm in the future. 

Can managers ask to see my reflective material?

The HCPC recognises the value of multidisciplinary reflective practice, therefore team reflections may well involve managers and other staff members. Requesting the completion of a reflective account to conclude an investigation into a complaint or incident is also common practice. This is different to your ongoing personal reflective accounts. The purpose of this request should always be made clear at the start of the process and you should be informed who will have access to your reflective material. 

Ensuring patient confidentiality

While reflections do not constitute part of an individual’s medical record, if you do not fully anonymise your reflections, depending on the content, it could be classed as personal data and be subject to GDPR regulation.  A patient could therefore make a Subject Access Request (SAR, the process through which patients get their personal data from organisations). The Information Commissioners Office (ICO) provides further advice about what constitutes personal data.

Remember that a combination of information can result in patients being inadvertently identifiable. Avoid gender, specific age and diagnosis if rare disease. If using e-portfolios, you may wish to record your reflections at a different time to the events.

Finally, the tendency for us all is to focus on using reflective exercises when things go wrong, but it is equally important to remember to use reflection to learn from success. Whatever you are reflecting on the CSP provides examples of how to get the best out of reflections each month via the Frontline CPD series. 

References

• HCPC guidance on CPD 
• CSP encourages members to engage with ‘reflective practice’
• HCPC standards of conduct, performance and ethics 
• Information Commissioners Office (ICO) – What is personal data?

• Helen Harte and Abigail Henderson are CSP professional advisers