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Working with Alice: a reflection.

Reflective practice has become established within educational programmes and in clinical supervision. Yet what does it mean to be a reflective practitioner? This paper seeks to give some meaning to this concept by drawing on a story I wrote in my reflective journal one evening. My reflection on this event draws out key issues of practice and reflection that enable me to gain insight and apply to future practice within a reflexive learning spiral.

Attitude of Health Personnel↗

Nurses' perceptions of the value of written reflection.

Reflective writing is increasingly becoming a feature of professional practice as nurses seek to provide evidence of their continuing development and competence. This study reports the process and findings of a study using grounded theory to explore how nurses are using and developing writing techniques as a tool for facilitating and supporting their development in practice. Two focus group interviews were conducted with 12 experienced nurses completing a professional course which involved reflective writing as the assessment component over a calendar year. These interviews generated the broad base of concepts and categories which direct the later stages of a grounded theory study. These preliminary categories suggest that firstly, the skills of reflective writing need to be learnt rather than being assumed as a natural capacity; secondly, that this leads to the acceptance of writing as a learning strategy in its own right; thirdly, reflective writing is considered to be a tool which helps the practitioner to develop analytical and critical abilities; finally, the nurses identified their own personal, as well as professional growth as being facilitated by reflective writing. Lincoln and Guba's (1985) criteria for establishing rigour in qualitative studies, and Strauss and Corbin's (1990) criteria for judging a grounded theory study are used as benchmarks throughout the paper.

Attitude of Health Personnel↗

Reflective education for professional practice: discovering knowledge from experience.

To continually develop as a discipline, a profession needs to generate a knowledge base that can evolve from education and practice. Midwifery reflective practitioners have the potential to develop clinical expertise directed towards achieving desirable, safe and effective practice. Midwives are 'with woman', providing the family with supportive and helpful relationships as they share the deep and profound experiences of childbirth. To become skilled helpers students need to develop reflective skills and valid midwifery knowledge grounded in their personal experiences and practice. Midwife educators and practitioners can assist students and enhance their learning by expanding the scope of practice, encouraging self-assessment and the development of reflective and professional skills. This paper explores journal writing as a learning strategy for the development of reflective skills within midwifery and explores its value for midwifery education. It also examines, through the use of critical social theory and adult learning principles, how midwives can assist and thus enhance students learning through the development of professional and reflective skills for midwifery practice.

Adult↗

[Value of reflecting disposable insulation (Thermodrape) in preventing perioperative hypothermia].

OBJECTIVE: The aim of the study was to evaluate the value of reflecting disposable insulation for the prevention of perioperative hypothermia. METHODS: After approval by the local ethics committee 36 patients undergoing long lasting urological intraabdominal surgery were studied. Anaesthesia was performed using etomidate, fentanyl, midazolam, pancuronium and succinylcholine. Patients were randomly assigned to 4 groups. These groups were treated as follows: Gr. 1: Infusion warmer (Hotline HL-90 with System L-70, Level 1 Technologies Inc., Marshfield, USA) and standard O.R. draping with two layers of cotton drapes. Gr. 2: Infusion warmer and reflecting disposable insulation (Thermadrape, O.R. Concepts Inc., Roanoke, USA) covering the legs, upper body, arms and head. Gr. 3: Infusion warmer and convective air warming with upper body blanket (WarmTouch, Mallinckrodt Medical, Hennef/Sieg, Germany). Gr. 4: Infusion warmer, convective air warming and reflecting disposable insulation. RESULTS: After 2 hours of surgery patients of groups 1 and 2 became hypothermic with core temperatures of 35.1 and 35.6 degrees C respectively. No relevant difference could be found between the two groups. The combination of an infusion warmer and convective air warming was an effective method to prevent hypothermia in groups 3 and 4. After 2 hours of surgery these patients had core temperatures of 36.6 and 36.4 degrees C respectively. Reflecting disposable insulation did not improve the effect of convective air warming. CONCLUSION: Reflecting disposable insulation was insufficient in the investigated operative setting.

Adult↗

[Tendinitis of the long head of biceps tendon associated with lesions of the "biceps reflection pulley"].

UNLABELLED: In some patients with persistent pain around the Long Head of Biceps Tendon (LHB), lesions of the "biceps reflection pulley", associated with biceps tendinitis, can be found. The aim of this study is to describe the anatomy of the reflection pulley and the arthroscopic appearance of the pulley lesion. Therapeutic options will be discussed. METHOD: The results of a former histo-anatomic study done by the authors in 13 cadaver shoulders are compared with the intra-operative findings in patients with persistent tendinitis of the LHB together with a lesion of the reflection pulley and signs of LHB instability. Intra-operative findings from patients with either posttraumatic anterior instability or calcific tendinitis served as control. RESULTS: The superior glenohumeral ligament (SGHL) together with the coraco-humeral ligament (CHL) and fibers from the subscapularis and supraspinatus tendons form a stabilizing reflection pulley for the LHB in the rotator cuff interval. Arthroscopy shows an association between a lesion of this pulley and persistent LHB-tendinitis. Pulley lesions can occur as isolated ligamentous pathology or together with a partial detachment of rotator cuff tendons. CONCLUSION: In patients with therapy-resistant pain around the LHB, lesions of the reflection pulley need to be excluded beside more common causes of biceps problems. Arthroscopy is a reliable tool to assess these lesions. Therapy should address the definite pathology.

Adult↗

Twelve tips for promoting significant event analysis to enhance reflection in undergraduate medical students.

The facilitation of reflection and development of reflective abilities are increasingly considered to be an important component of professional development (Eraut, 1994). It is known that students find the process of reflection difficult and that it does not come naturally to all, requiring a safe trusting environment in which students can develop with staff support (Woodward, 1998). The structured and deliberate review of significant events has been advocated as a useful way to encourage reflection (Brookfield, 1990). These tips are based on recent research, which revealed that students' difficulties with significant event analysis arise from a range of unforeseen emotional reactions or conflicts. We pass on our tips for minimizing these conflicts and enhancing the reflective and creative aspects of significant event analysis.

Creativity↗

Facilitating reflection in an undergraduate medical curriculum.

A reflective practitioner is one of the desired outcomes of medical education. This paper describes the introduction of a reflective assignment in the first year of a medical curriculum. Students completed written reflective assignments for which individual and group feedback was provided. Tutors reflected on their roles throughout the development and implementation of this new assignment. The majority of students completed the assignments and while some students became highly involved in the task others worked at a surface level. Tutors found the process time consuming and less enjoyable than working directly with students who need to be supported in the development of skills necessary for reflective practice.

Australia↗

Utilizing theatrical tools in consultation training. A way to facilitate students' reflection on action?

The aim was to give the individual student a group-based opportunity to reflect on possible consultation strategies as the consultation was evolving. An actress acted as patient in the consultation training for a group of 30 students. The consultation was stopped at each critical incidence, and time-out given to allow the students to reflect on possible continuation strategies, and then to carry out one of them. The project was evaluated adopting a pragmatic version of the reflective practitioner research strategy as developed by Taylor. The evaluation was based on tutor and actress's field notes, students' written free text evaluation and students' evaluation through two focus groups. The qualitative analysis resulted in the three categories: the fiction created, temporality manipulated, and students' learning through reflection. Implications for students' learning process are discussed. We conclude that our way of creating fiction and manipulating temporality in the consultation training was paralleled by most students' report on substantial learning feed-forward abilities from reflection on action.

Education, Medical↗

A library based fitting method for visual reflectance spectroscopy of human skin.

The diffuse reflectance spectrum of human skin in the visible region (400-800 nm) contains information on the concentrations of chromophores such as melanin and haemoglobin. This information may be extracted by fitting the reflectance spectrum with an optical diffusion based analytical expression applied to a layered skin model. With the use of the analytical expression, it is assumed that light transport is dominated by scattering. For port wine stain (PWS) and highly pigmented human skin, however, this assumption may not be valid resulting in a potentially large error in visual reflectance spectroscopy (VRS). Monte Carlo based techniques can overcome this problem but are currently too computationally intensive to be combined with previously used fitting procedures. The fitting procedure presented herein is based on a library search which enables the use of accurate reflectance spectra based on forward Monte Carlo simulations or diffusion theory. This allows for accurate VRS to characterize chromophore concentrations in PWS and highly pigmented human skin. The method is demonstrated using both simulated and measured reflectance spectra. An additional advantage of the method is that the fitting procedure is very fast.

Algorithms↗

Modelling and validation of spectral reflectance for the colon.

The spectral reflectance of the colon is known to be affected by malignant and pre-malignant changes in the tissue. As part of long-term research on the derivation of diagnostically important parameters characterizing colon histology, we have investigated the effects of the normal histological variability on the remitted spectra. This paper presents a detailed optical model of the normal colon comprising mucosa, submucosa and the smooth muscle layer. Each layer is characterized by five variable histological parameters: the volume fraction of blood, the haemoglobin saturation, the size of the scattering particles, including collagen, the volume fraction of the scattering particles and the layer thickness, and three optical parameters: the anisotropy factor, the refractive index of the medium and the refractive index of the scattering particles. The paper specifies the parameter ranges corresponding to normal colon tissue, including some previously unpublished ones. Diffuse reflectance spectra were modelled using the Monte Carlo method. Validation of the model-generated spectra against measured spectra demonstrated that good correspondence was achieved between the two. The analysis of the effect of the individual histological parameters on the behaviour of the spectra has shown that the spectral variability originates mainly from changes in the mucosa. However, the submucosa and the muscle layer must be included in the model as they have a significant constant effect on the spectral reflectance above 600 nm. The nature of variations in the spectra also suggests that it may be possible to carry out model inversion and to recover parameters characterizing the colon from multi-spectral images. A preliminary study, in which the mucosal blood and collagen parameters were modified to reflect histopathological changes associated with colon cancer, has shown that the spectra predicted by our model resemble measured spectral reflectance of adenocarcinomas. This suggests that an extended model, which incorporates parameters corresponding to an abnormal colon, may be effective for differentiation between normal and cancerous tissues.

Algorithms↗

Reflection of CO2 laser radiation from typical surfaces encountered in hospital environments.

Measurements of the reflectivity of CO2 laser radiation (10.6 micron) from typical clinical surfaces are reported. The results obtained confirm that stray reflections from these surfaces could be a potential hazard to both patient and hospital staff. Some conducting surfaces, for example, reflect up to 95% of the radiation incident upon them and even dielectrics reflect over 50% in some cases. The results reported are for linearly polarised light only. Strong evidence is shown that the deposition of certain thin coatings dramatically reduces the percentage of 10.6 micron radiation reflected.

Carbon Dioxide↗

Chronic coffee consumption has a detrimental effect on aortic stiffness and wave reflections.

BACKGROUND: The effect of coffee consumption on the cardiovascular system is still an unresolved issue. Aortic stiffness and wave reflections are important prognosticators of cardiovascular disease risk. We have shown that caffeine acutely increases aortic stiffness and wave reflections. OBJECTIVE: The objective was to investigate the effect of chronic coffee consumption on aortic stiffness and wave reflections. DESIGN: This was a cross-sectional study of 228 healthy subjects: 141 men (x +/- SD: 41 +/- 8 y old) and 87 women (41 +/- 9 y old). Aortic stiffness was evaluated with carotid-femoral pulse wave velocity (PWV). Wave reflections were evaluated with augmentation index (AIx) and augmented pressure (AP) of the aortic pressure waveform with the use of high-fidelity pulse wave analysis. Coffee consumption was ascertained over 1 y with a food-frequency questionnaire. RESULTS: A linear relation between coffee consumption and PWV, AIx, and AP was observed (P for trend < 0.05). Compared with the nonconsumption group, PWV was on average 13% higher, AIx was 2-fold higher, and AP was 2.4-fold higher (P < 0.01 for all) in the high-consumption group (>450 mL/d). The findings remained significant after control for confounders such as age, sex, smoking habits, body mass index, total and LDL cholesterol, triacylglycerols, blood glucose, mean blood pressure, and heart rate. The linear relation (P for trend < 0.05) observed between coffee consumption and arterial pressures was largely explained when the covariates were entered in the model. CONCLUSIONS: Chronic coffee consumption exerts a detrimental effect on aortic stiffness and wave reflections, which may increase the risk of cardiovascular disease.

Adult↗

Effects of cultivar, fruit number and reflected photosynthetically active radiation on Fragaria x ananassa productivity and fruit ellagic acid and ascorbic acid concentrations.

BACKGROUND AND AIMS: A number of strawberry varieties were surveyed for their total ellagic acid concentration, and attempts were made to determine if ellagic acid and ascorbic acid concentrations of two strawberry cultivars could be increased by polythene reflective mulches. METHODS: After adjusting crop yields and cultivation using polythene mulches with two different PAR reflective capacities, field- and polytunnel-grown strawberries were analysed for ellagic acid and ascorbic acid concentrations by HPLC. Comparative measurements of yield and fruit quality were determined along with plant developmental changes. KEY RESULTS: Ellagic acid concentration varied widely with strawberry cultivar (60-341 microg g(-1) frozen weight), as did the ratio of conjugated ellagic acid : free ellagic acid. Also, there was significant year-to-year variation in total ellagic acid concentration with some cultivars. Mulches with different reflective capacities impacted on strawberry production; highly reflective mulches significantly increased growth and yield, the latter due to increases in fruit size and number. CONCLUSIONS: Highly reflective mulches significantly increased total concentrations of ellagic acid and ascorbic acid relative to control in fruit of different cultivars. The potential of agronomic practices to enhance the concentration and amounts of these important dietary bioactive compounds is discussed.

Ascorbic Acid↗

Multispectral fluorescence and reflectance imaging at the leaf level and its possible applications.

Images taken at different spectral bands are increasingly used for characterizing plants and their health status. In contrast to conventional point measurements, imaging detects the distribution and quantity of signals and thus improves the interpretation of fluorescence and reflectance signatures. In multispectral fluorescence and reflectance set-ups, images are separately acquired for the fluorescence in the blue, green, red, and far red, as well as for the reflectance in the green and in the near infrared regions. In addition, 'reference' colour images are taken with an RGB (red, green, blue) camera. Examples of imaging for the detection of photosynthetic activity, UV screening caused by UV-absorbing substances, fruit quality, leaf tissue structure, and disease symptoms are introduced. Subsequently, the different instrumentations used for multispectral fluorescence and reflectance imaging of leaves and fruits are discussed. Various types of irradiation and excitation light sources, detectors, and components for image acquisition and image processing are outlined. The acquired images (or image sequences) can be analysed either directly for each spectral range (wherein they were captured) or after calculating ratios of the different spectral bands. This analysis can be carried out for different regions of interest selected manually or (semi)-automatically. Fluorescence and reflectance imaging in different spectral bands represents a promising tool for non-destructive plant monitoring and a 'road' to a broad range of identification tasks.

Fluorescence↗

Dream self-reflectiveness as a learned cognitive skill.

This research was directed toward the contradiction sustained by cognitive dream psychology, which on the one hand regards dreaming as higher symbolic activity and, on the other, sees its organizational and functional characteristics as derivative and/or inferior to those of waking consciousness. Study 1 evaluates the degree of self-reflective meta-cognition in dreams from different sleep stages. Subjects were 24 college students selected such that half were self-reported high-frequency dream recallers and half were low-frequency recallers. Both groups were composed equally of men and women. Greater self-reflectiveness (SR) was found in REM dreams as compared with those from stages 2 and 4, which did not differ. High-frequency recallers showed more dream SR than did low-frequency recallers. Study 2 assessed the extent to which self-reflective and lucid dreaming can be learned as a cognitive skill by varying levels of intention and attention paid to dreaming. After 3 weeks of home dream collection, results showed that four experimental groups had greater dream SR than did a baseline group. The most effective treatment was the mnemonic, wherein attention patterning schemas learned in waking resulted in more self-reflective and lucid dreaming than did either baseline or attention-control conditions. These results provide evidence that dreaming is not single-minded but variable along a self-reflective process continuum, and suggest functional and organizational levels that are consistent with the conception of dreaming as higher order cognitive activity.

Adult↗

Differentiation among effects of nitrogen fertilization treatments on conifer seedlings by foliar reflectance: a comparison of methods.

Analysis of reflectance can be used to estimate foliar concentrations of photosynthetic pigments, thus providing information on the physiological status of green plants. We compared several methods of reflectance analysis for the capacity to differentiate among effects of fertilization treatments across different irradiances on seedlings of Engelmann spruce (Picea engelmanii Parry ex Engelm.). Seedlings were grown in two light treatments (0 and 60% shade) and three nitrogen (N) treatments (10, 25 and 100 mg N l-1) for one growing season, after which foliar reflectance of the needles was measured. Five indices were tested: R550 (% reflectance at 550 nm); red edge position; the ratio R698:R760; the structure independent pigment index (SIPI); and the photochemical reflectance index (PRI). Both the light and nutrient treatments significantly affected foliar chlorophyll a and b and carotenoid concentrations. Among the indices tested, R550, red edge position and R698:R760 ratio were related to chlorophyll concentration, and were significantly affected by both light and N treatments. Both SIPI and PRI were related to chlorophyll and carotenoid concentrations. Among these relationships, PRI was affected by both treatments, whereas SIPI was sensitive to N treatment but not to light treatment. All five indices were weakly but significantly correlated with growth as measured by dry weight.

Carotenoids↗

Feedback and reflection: teaching methods for clinical settings.

Feedback and reflection are two basic teaching methods used in clinical settings. In this article, the authors explore the distinctions between, and the potential impact of, feedback and reflection in clinical teaching. Feedback is the heart of medical education; different teaching encounters call for different types of feedback. Although most clinicians are familiar with the principles of giving feedback, many clinicians probably do not recognize the many opportunities presented to them for using feedback as a teaching tool. Reflection in medicine-the consideration of the larger context, the meaning, and the implications of an experience and action-allows the assimilation and reordering of concepts, skills, knowledge, and values into pre-existing knowledge structures. When used well, reflection will promote the growth of the individual. While feedback is not used often enough, reflection is probably used even less.

Clinical Medicine↗

Personal illness narratives: using reflective writing to teach empathy.

Reflective writing is one established method for teaching medical students empathetic interactions with patients. Most such exercises rely on students' reflecting upon clinical experiences. To effectively elicit, interpret, and translate the patient's story, however, a reflective practitioner must also be self-aware, personally and professionally. Race, gender, and other embodied sources of identity of practitioners and patients have been shown to influence the nature of clinical communication. Yet, although medical practice is dedicated to examining, diagnosing, and treating bodies, the relationship of physicians to their own physicality is vexed. Medical training creates a dichotomy whereby patients are identified by their bodies while physicians' bodies are secondary to physicians' minds. As a result, little opportunity is afforded to physicians to deal with personal illness experiences, be they their own or those of loved ones. This article describes a reflective writing exercise conducted in a second-year medical student humanities seminar. The "personal illness narrative" exercise created a medium for students to elicit, interpret, and translate their personal illness experiences while witnessing their colleagues' stories. Qualitative analysis of students' evaluation comments indicated that the exercise, although emotionally challenging, was well received and highly recommended for other students and residents. The reflective writing exercise may be incorporated into medical curricula aimed at increasing trainees' empathy. Affording students and residents an opportunity to describe and share their illness experiences may counteract the traditional distancing of physicians' minds from their bodies and lead to more empathic and self-aware practice.

Curriculum↗