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Physiotherapy 94 (2008) 63–70

Reflection in an intermediate care team

Lynette Sutton a,∗, Jayne Dalley b

a Intermediate Care Services, Coventry Teaching Primary Care Trust, Stretton Avenue, Willenhall, Coventry CV3 3AH, UKb Department of Physiotherapy and Dietetics, Faculty of Health and Life Sciences, Coventry University, Coventry, UK

bstract

bjectives Reflection has been cited as an effective method of providing evidence of professional development, learning and continuedompetence. Reflection in teams is thought to develop trust within the team and greater understanding of other team members’ roles andesponsibilities. The aim of this qualitative study was to describe the experiences and perceptions of reflection by members of an intermediateare team.esign Phenomenological design, consisting of individual semi-structured audiotaped interviews. The interviews were transcribed and read

o gain understanding. Themes were identified and grouped into categories.articipants Ten members of a multidisciplinary intermediate care team were interviewed.indings Team reflection had not been developed formally in the intermediate care team, although many of the prerequisites for team

eflection were present. Team members primarily used dialogical reflection in clinical practice as a problem-solving tool. Written reflectionas limited, with its use being dependent on the skills, level of training and postqualification support of the participants.

onclusion A formal structure and managerial support is necessary to facilitate team reflection. Additional postgraduate support is required

o enable team members to utilise written reflection effectively. Further research to investigate reflection in health and social care teams isarranted.2007 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

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eywords: Reflection; Intermediate care; Continuous professional developm

ackground and context

Public interest in standards of care delivered by theational Health Service (NHS) increased during the 1990s,

ntensified by several high-profile medical cases reportedxtensively in the media [1,2]. The protection of clients andhe public became the focal point of the Clinical Governancetrategy and Modernisation Agenda [3–5]. In addition, leg-

slation [6] placed a statutory duty on all NHS trusts andodies to address quality issues and standards, and concur-ently increased the accountability of individuals to maintainafe, effective and competent practice through knowledge andkills development. The duty to maintain competence to prac-ice has also been incorporated within the rules and standards

f all professional bodies [7–9]. It has long been recognisedhat failure to update professional knowledge and skills leadso a decline in competence, with the level of this obsoles-

∗ Corresponding author. Tel.: +44 2476 786765; fax: +44 2476 305397.E-mail address: lynette.sutton@coventrypct.nhs.uk (L. Sutton).

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031-9406/$ – see front matter © 2007 Chartered Society of Physiotherapy. Publisoi:10.1016/j.physio.2007.04.008

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ence being proportional to the time since qualification [10].he maintenance of this knowledge and skill base means

hat issues of competence are linked inextricably to clinicalovernance and continuous professional development (CPD).rom July 2006, the Health Professions Council required allllied health professions to undertake CPD in order to main-ain registration [11]; this requirement of formal monitorings already applicable to nurses [12].

This study was conducted within an intermediate careeam; a multidisciplinary team with staff employed fromealth and social services. Intermediate care developed as aesult of the National Beds Inquiry Report [13], and becamembodied in several policy documents [5,14]. In essence,hree domains were identified as key to the development ofntermediate care: facilitating hospital discharges; prevent-ng avoidable admission to hospital; and early admission to

ong-term care. The efficient functioning of intermediate careervices essentially involves co-operative working across thenterface of social, primary and secondary care [14], wherenowledge and information is shared, and roles and responsi-

hed by Elsevier Ltd. All rights reserved.

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ilities of team members are defined clearly [15]. A climate ofo-operative working in intermediate care is thought to pro-ide a foundation for the development of reflective practice16].

eflection

This study focused on one element of CPD, that ofeflection, which has been clearly linked in the literatureo experiential learning [17–19]. Kolb’s model of experi-

ental learning [20] has provided healthcare professionalsith a framework that they can utilise for their reflection.olb’s cycle consists of four stages: exposure to a concrete

xperience, which initiates reflective observation; abstractoncepts and generalisations are formed from these obser-ations, which are then tested by active experimentation.ther frameworks facilitating reflection [21–23] have similar

lements for the reflective process. Reflection is a com-lex and multifaceted concept to define, with terminologyreflection, reflective practice, thinking and cognition) usednterchangeably and inconsistently [24]. However, reflections considered to be ‘activities in which individuals engage toxplore their experiences in order to lead to new understand-ng and appreciations’ [24]. The lack of clarity surroundingerminology has impacted on professionals’ understandingnd utilisation of reflection in practice [25,26]. It remainsnclear how clinicians undertake reflection on a day-to-dayasis [27], although it appears to be a spontaneous activityithout formal structure or support [28]. It is also not knownhether reflection is utilised primarily as a problem-solving

ool or as a mechanism leading to deeper learning [29].

ialogical reflection

Different modes of reflection can offer different opportu-ities and challenges to professional development. Whilstrofessionals frequently internalise reflective processes,any do discuss complex or intricate cases with colleagues

27]. Internalisation of reflection can prove problematic at anndividual level, and the opportunity to talk to another per-on is a coping mechanism whereby a new perspective cane gained [23,30]. This dialogical strategy or conversation isn opportunity to review the experience and discuss ideas,ften in an informal, superficial or unplanned way [24,25].ialogical reflection most frequently occurs some time after

he event [27].

ritten reflection

Reflective writing is now viewed as the main strategy forhe promotion of reflection in practice. It is most commonly

inked to writing within a portfolio or journal [27]. Writ-en reflection is particularly valuable in organising thoughtrocesses to clarify the experience [31]. Solidification oflinical reasoning processes on to paper can be challeng-

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rapy 94 (2008) 63–70

ng and daunting, particularly for professionals who qualifiedrior to the teaching of reflective practice in undergrad-ate courses [32]. Undergraduate students find reflectiveriting a worthwhile, valuable activity, albeit time consum-

ng [24]. However, in contrast, little is known about thettitudes of postgraduate professionals towards written reflec-ion. Many authors [24,28,33] agree that clinicians haveifficulty in finding the time during busy work schedules toomplete written reflection. Written reflection is often per-eived as low priority, particularly in under resourced areas34].

In practice, reflective writing can be rapid fire in recordingr descriptive in nature [26], when it simply records what wasearnt in a concise manner, and details proposed alterations toractice. Whilst advantageous in the time taken to complete,his type of recording probably equates more to Moon’s [29]dea of surface learning, although a distinction could be madeetween the process of reflection (which might be deep) andhe recording of it (which might be quick). Changes in prac-ice associated with deeper learning only occur when ideasnd knowledge are assimilated and implemented into prac-ice and subjected to further episodes of reflection [23,35]. Its unclear to what extent professionals return to reflect uponrevious learning or undertake more detailed recording ofeflective episodes.

eam reflection

Much has been written on effective team working [36],nd whilst the literature purports that reflection is beneficialor team development, little is known about the actual pro-esses supporting team reflection. The main benefits of teameflection are considered to be improved communication,nformation sharing, greater clarity of roles and responsi-ilities of individual team members, and the developmentf trust and support mechanisms [15,24,37]. Furthermore,eflection at team level can lead to greater creativity thanbserved by lone working, widen the scope of learning andnhance critical thinking, particularly in individuals lackingeflective skills [19,24,31,38].

The effective implementation of team reflection is depen-ent on team composition and stage of development, whichetermines whether the environment is conducive to everyember expressing opinions. A lack of ground rules, trust

r ignorance of each other’s roles and responsibilities canistort team dynamics, which develops barriers to fur-her team reflection [24]. Team reflection can be difficultor some, who actively avoid engaging or participating inhe process [29], ultimately affecting team performance36].

The purpose of this study was to examine and explorendividual professional’s experiences of reflection. Specif-

cally, it explored the perceptions and experiences ofhe written, dialogical and team forms of reflectiony individual practitioners within an intermediate careeam.

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ims of the study

The aims of this study were:

to explore the experiences and perceptions of reflection bymembers of an intermediate care team;to develop some understanding of the utilisation of reflec-tion in clinical practice; andto gain insight into how reflection can be integrated furtherinto practice at individual and team level.

esearch approach

A phenomenological approach was used for this research.he common denominator between the schools of phe-omenology is that the description of the experience revealsacts about the ways in which man experiences the world, asell as revealing facts about the world [39]. Furthermore,im and Wright [40] suggested that phenomenology is aeneral qualitative approach rather than a distinct methodol-gy per se. Generally, a phenomenological approach exploreshe meanings, attitudes or feelings of individuals to describethe lived experience’ [41]. This study was designed to gainome insight into professionals’ views and perceptions ofeflection.

ethod

Data were collected by audiotape recording of semi-tructured one-to-one interviews. This is recognised as thereferred method for phenomenological approaches [41,42].he interview schedule was designed to address the focus of

he research question. The literature in this field was reviewednd the different methods of reflection being reported wereoted. Professional guidelines from the Chartered Societyf Physiotherapy [43] were included in this review. Per-onal observations of the practices and difficulties of staffttempting reflection guided the selection of relevant mate-ial. In addition, discussions with academics in the fieldf professional development consolidated the developingdeas. Two typical questions are: ‘What do you understandy the term “reflection”’? and ‘What experiences have youad of reflecting by discussing clinical situations with col-eagues’? The interview schedule was standardised acrossach interview, and consisted of 16 topic headings. Theudicial use of open-ended questions, prompts and probesllowed a degree of flexibility. Three initial interviewsere completed to check the interview schedule; the data

rom these interviews were included in the findings of thetudy, as amendments did not alter the design significantly

44].

Interviews took between 40 min and 1 h to complete. Fol-owing each interview, the data were transcribed accuratelysing a transcription scheme. All participants received a

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rapy 94 (2008) 63–70 65

opy of their transcription prior to analysis, allowing themo confirm or correct the description given in the interview,hereby providing an accurate picture of what that individualctually meant to express [45]. Common meanings were iden-ified by reading and re-reading the transcripts. Themes weredentified and the themes were organised into categories. Aample of the transcripts was reviewed by another researcheror verification of the emerging themes. Re-occurrences andelationships were explored, and exceptions and extremes tohe general pattern were included, broadening the explana-ion and verifying the findings [41,45]. The trustworthinessf the analysis could have been improved by obtainingurther feedback from the participants during the analysistage.

articipants

All members of one intermediate care team were invitedo participate in the study (n = 20). Ten members of the teamave informed consent to be included in this study. For-uitously, these participants included a representative fromach of the professional groups, and a range of experienceollowing qualification.

nclusion criteria

Professional groups, nurse practitioners, social workers,hysiotherapists, occupational therapists, and speech and lan-uage therapists were included in this study.

xclusion criteria

Administrative staff were excluded from this study.

indings

Findings included the participants’ perceptions of reflec-ion and the practices of reflection within the team.hemes arising from their perceptions were those of annderstanding of what reflection is, how they practicedt, and how it contributed to their development. Withegard to reflective practice within the team, participantseported individual reflection and dialogical reflection buto formal team reflection. The themes that emerged wereutcomes, triggers and limiting factors. Fig. 1 provides aummary.

erceptions of reflection

The participants generally described reflection as a retro-

pective activity, looking back on experiences in the recentnd not-so-recent past. This retrospection was strongly asso-iated with a thinking activity where events were recalledrom memory. Little reference was made to reflection in the

66 L. Sutton, J. Dalley / Physiotherapy 94 (2008) 63–70

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resent, although one participant did allude to this. A typicalesponse was:

Thinking about what you’ve done and thinking over whatou’ve done and how could you possibly do it better orhether you’ve done it to the best of your ability.’ (Participant)

Whilst one participant perceived reflection as an inherentnd natural function undertaken throughout life, others hado consciously stop and think about their use of reflectionn day-to-day practice. For some, the research process itselfrovided the catalyst for this examination:

Everybody does it and you know what you’re asking me Inow but I haven’t really thought of it before, hadn’t reallyhought that’s what we do.’ (Participant 1)

This is in accordance with the view that reflection ismplicit in daily life [17,23]. It appeared from the responseshat the terms ‘reflection’ and ‘thinking’ were used inter-hangeably, mirroring the lack of clarity of terminology inhe literature [24,25]. Thinking came across as core to thearticipants’ understanding of reflection, consistent with theoncept that reflection was strongly correlated with think-ng at an intellectual level [17,29,46]. Whilst the participantslearly made a link between reflection and thinking, the levelf metacognition and active monitoring of thought during theeflective process was uncertain. Reflection, in this instance,s perhaps more akin to ‘thinking on their feet’ as proposed bylouder [27], where decisions are made rapidly during prac-

ice by using accelerated decision making or problem solvingt an intuitive level [26]. The description suggests that, forhem, reflection is a simple mental activity leading to surface

earning [29].

However, most of the participants stated that they wouldiscuss and explore problems after the event, utilising ana-ytical or evaluation skills:

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Analysing what you did, what could have been improved byt, what did you learn by it.’ (Participant 7)

The responses linked the ability to problem solve withhinking and reflection, which are known to form the basisf clinical reasoning in practice [47]. The Cognitive Con-inuum Theory [48] proposes that analysis and intuitionre different modes of thinking at opposite ends of a con-inuum. The balance between analysis and intuition variesccording to the situation, task and knowledge base. Itould be surmised that the participants were using differ-nt modes of thinking; i.e. proportionally more intuitivekills during practice and more analytical skills when lookingack.

Most participants stated that reflection was central to theirearning, a method of identifying gaps in their knowledgease and a means of demonstrating career progression:

It makes you develop, that’s the whole thing about it. If youo it properly, then it changes you as a person, it changes yourractice, it makes you a better practitioner.’ (Participant 8)

One participant referred to the process by which knowl-dge is continually updated and enhanced:

When you reflect in the past, you bring it back to the present,ou are able to add your new knowledge from the present andake it forwards.’ (Participant 9)

Knowledge is developed through practice and when con-ciously combined with existing theoretical knowledge, newnowledge is generated [49]. However, none of the partic-pants stated that they would return to previous episodes ofeflection, and therefore did not appear to demonstrate deeperearning associated with the cyclical nature of reflection [20].

eflection was viewed as a method of preventing professionalbsolescence and maintaining competence to practice. Thiss consistent with the literature and views of professionalodies [28,33,43]. The participants demonstrated an inher-

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nt commitment to continued learning at a professional andersonal level, with the belief that reflection is key to therocess [16,29].

eflection within the team

The most frequent experience of reflection was as anndividual, followed by individuals reflecting with otherndividuals from the same team. Reflection by the wholeeam, or formal reflection within the team, was not expe-ienced. At team level, the participants perceived reflections unstructured, and primarily as a forum for communica-ion, information exchange and knowledge sharing. Whilsteflection within the team was in its infancy, many of thearticipants perceived that reflection would have a positiveffect on team development and were enthusiastic about itsotential. However, one participant did state that a commonnderstanding of reflection would be essential to this pro-ess. The stage of team development could be measuredrom the replies and was indicative of interprofessional work-ng, where the team had developed a clear understanding ofther members’ roles and responsibilities and were respectfulf other members’ opinions [15]. The most common expe-ience of reflective activity across the team was dialogicaleflection. The participants expressed that dialogical reflec-ion was used frequently and inherently in day-to-day practices one-to-one conversations or in small groups:

There’s always ongoing dialogue reflecting back to what’sappened previously, how you did, who was involved andopefully best way forward.’ (Participant 4)

It was undertaken without formal structure with littlendication of preferred professional group. The participantserceived dialogical reflection as an extremely valuable tool,articularly to discuss problems and issues and to procureifferent perspectives of a clinical situation. However, onearticipant did perceive dialogical reflection in a negative waynd potentially ineffectual in attaining consensus opinion:

Everybody has an opinion as to what would have been rightn that circumstance and sometimes you can actually comeway feeling that you have not gained anything, that you’veot more things to reflect on, still not having gained anythingositive or beneficial out of it.’ (Participant 3)

The effectiveness of dialogical reflection appeared to benfluenced by the size of the group and impeded by annstructured process [15,22]. Dialogical reflection was apontaneous activity generally undertaken without formaltructures; these findings were consistent with the litera-ure [28]. However, dialogical reflection was clearly valuedy the majority of the team members and utilised in clin-cal practice at a level not previously recognised [27].

ialogical reflection was also important as a means of

onfirming actions and benchmarking practice, an oppor-unity to review experience critically and discuss ideas23,25,50].

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rapy 94 (2008) 63–70 67

Written reflection was used inconsistently by the teamembers. Only two of the participants reported regular, indi-

idual use of written reflection, the content of which appearedo be more descriptive in nature [26] and associated with theormal aspects of employment (e.g. personal developmentlanning). Whilst some were uncertain about the purpose ofritten reflection, one participant was extremely clear about

he benefits of written reflection, particularly in relation toolidifying thoughts on to paper:

If you’re writing things down, it helps you to clarify yourhoughts. I think just thinking about something, it can alleem a bit woolly. If you jot things down, it actually helpso clarify what you feel about what you’ve done and whereou’re going to be moving with that, whether it’s somethingou don’t want to touch on again.’ (Participant 6)

One subject was particularly unusual in discussing whenhey would use different depths of written reflection:

If you were having a piece of in-service training, then maye it is adequate to jot something briefly, highlighting someits that you need to go and find out about, and somethinghat was a bit more personal to you or you were involvedith emotions and things like that, then may be you needed

o write more down.’ (Participant 10)

Two participants indicated that the frequency of writteneflection often declined with experience, as knowledge andkills develop.

The replies highlighted some of the practical difficultiesssociated with implementing and using written reflectionn practice [24–26]. Descriptive written reflection recordsearning outcomes and details proposals for alterations toractice in a concise manner, which equate more to Moon’sdea of surface learning [29]. Deeper learning is confirmedhen these ideas and knowledge are assimilated and imple-ented in practice, and crucially subjected to further episodes

f reflection [23,35]. In addition, Mezirow [51] suggestedhat experience is only transformed into new learning fol-owing exposure to significant events. Significant events orbig issues’ (Participant 8) may become less frequent as pat-erns grow and knowledge is constructed through experientialearning. Therefore, in this way, the use of written reflection

ay become more selective with experience:

You do need to reflect just as much when you’re older buterhaps the things that a younger professional would reflectn, you’d be skilled at.’ (Participant 2)

utcomes of reflection

The participants agreed that reflection in some format isundamental to clinical practice and impacted positively on

he care, management and treatment of their clients. Reflec-ive outcomes are continually developed, changed and builtpon by experience or with interaction with colleagues [20],nd practice is modified as a consequence of problem solving.

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his cyclical process is consistent with the views of Kolb [20],chon [18] and Dewey [17]. Whilst none of the participantsere able to provide concrete examples, one participant did

llude to some of the difficulties in demonstrating changes asconsequence of reflection in a multi-agency service:

You have to look at everyone on an individual basis. If youeflect on one client, you could say I’ll do that for the nextlient that could be very hard. I don’t think you could do that.f you get an outcome which is good for one it’s not alwaysoing to be the same for the next person.’ (Participant 7)

It appears that changes in practice are not always discern-ble since evaluation of care and management in intermediateare is on an individual client basis. Knowledge gained inhis process remains with the practitioner at a tacit level,nd is unlikely to pass into the public domain or inform thenowledge base of the professions [52]. This duplicates theack of empirical evidence in the literature [30]. The positiveiew of reflection expressed by the participants is particu-arly pertinent given the changes in professional regulationnd monitoring [11].

riggers

When the participants were questioned on what promptshem to instigate reflection, it was universally the more nega-ive aspects of practice or ‘the not going right bit’ (Participant):

I think more often than not when things go wrong, it’s veryommon to overlook the positives that’s going on and forget tocknowledge that it is happening. When something is wrongt has to be attended to.’ (Participant 9)

Triggers included doubts, uncertainties, emotions ornsatisfactory outcomes:

Sometimes it’s just you’ve almost made your mind up aboutomething and you just want that little second opinion. Youust want to run it by somebody, you kind of know but you’reot quite sure. So you run it by somebody and say I’ve donehis or I think I’ll do this and they can confirm it for you orive you another view.’ (Participant 8)

Issues have to be addressed promptly in situations wherelient care is affected adversely; actions that are unwarrantedn situations with a positive outcome. It is recognised in theiterature [53] that triggers for reflection frequently relate toegative outcomes, but it is also known that the continuedocus on adverse incidents can have a detrimental effect oneam cohesiveness and function [15]. Some of the participantsecognised this and stated that reflection should be a mecha-ism by which positive feedback can be given to the team.

imiting factors

Whilst acknowledging that reflection is considered goodractice, time was cited consistently as the most significant

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imiting factor, with recognition that priorities have to bealanced in the clinical environment:

I do think it’s very important but I think it does get kind ofhoved to the back of priorities because everyone’s so busyeeing clients and getting on with other stuff, it’s not reallyeen as a priority.’ (Participant 5)

This theme was developed further by Participant 6:

I think time for a start, allotted time. People being commit-ed to it. Everyone’s got to value it and feel it’s important.he managers have got to feel that it’s important, peopleave not got to feel uncomfortable if they take time out toeflect on practice.’

The participants clearly recognised that reflection doeslace additional demands on their time; views which are com-arable with previous findings [27,28]. Perceptions that directlient contact activities are given highest priority also corre-pond with recent research [34]. The level of reflective prac-ice has been shown to be directly affected by the prevailingulture of an organisation [46]; nevertheless, the responsesppeared to indicate a shift in opinion as the participants gen-rally expressed that reflection should be more formalised inractice and should be supported fully by the organisation.

One participant did state that a common understanding ofeflection would be essential in developing the team further:

I think to even acknowledge that you need to reflect is prob-bly one thing the team could do to assist it because if there’sembers of your team that think it’s valuable and like to

o it and there’s others that don’t know what it’s about thenhey’re not going to come together as a team in the first place.’Participant 10)

As discussed previously, reflection is a complex term toefine. In the absence of a consensus view, it is understand-ble that participants have a confusing picture of what isequired for effective reflection [23,25].

Generally, participants had received little support sinceualification to develop skills in written reflection. Participantstated that written reflection does require active develop-ent and support, and acknowledged that expression on paperas often difficult and challenging, as ‘it’s not something

hat comes naturally sometimes to people’. This participantppeared to be making a link between learning approachesnd one’s level of ability to write reflectively. It is not surpris-ng, therefore, that many of the participants felt ill equippedo implement and use written reflection [32].

imitations of the study

The reasons for the low response rate (50%) are unclear

ut may relate to time, interest level or willingness to discloseo the team leader. The views and perceptions of these non-esponders are unknown, and it is not clear whether the studyndings would have been affected as a result.

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This study was conducted in one intermediate care team.he composition of other health and social care teams mayary in composition, and the transferability of the findingsay not be appropriate [54]. Certain principles, however,ay be applicable to other teams where team reflection is

oorly developed.

iscussion

Small groups within the team did discuss problems orssues as they arose, primarily as a means of reassurancend to confirm that actions were well judged and appropri-te. There was no evidence of formalised team reflection,nd the ad-hoc nature of these discussions brings into ques-ion whether events are examined thoroughly and in sufficientepth to enable the team to gain new insights into their actions20,55]. Furthermore, outcomes of reflection were not dis-ernable in the team. The ability to resolve difficult issues andemonstrate changes in clinical practice and service deliveryre important given the current changes in commissioningnd providing NHS services [56].

In addition, teams have to reach a common understandingf the purpose and mechanisms of reflection for implementa-ion to be successful. Trust in this team was demonstrated byo-operation between health and social care professionals inheir use of dialogical reflection. Whilst team members didemonstrate a clear understanding of each other’s roles andesponsibilities, it is evident that a more formal structure isequired to facilitate reflection at team level [29,35,51]. Man-gerial and organisational support is necessary to develophese systems actively within the team [46]. Issues of timeould be alleviated by developing agreements on protected

earning time within the service [43]. A more formal structureor reflection within the team could also assist team memberso establish links actively between reflection and resultanthanges in practice and service delivery. Mechanisms wouldeed to be established to disseminate and share best practicen health and social care, thereby informing the knowl-dge base of all professions working in intermediate care52].

Problem solving using dialogical reflection appears to behe main method within the team of critically analysing andvaluating practice. Whilst problems encountered in clinicalractice are discussed with colleagues, it is unclear whetherhe reflective outcomes of these discussions are revisited orecorded in a written format. It could be surmised that, inhese situations, the cycle of reflection is not completed orhat deeper learning is demonstrated. In addition, the viewhat reflection happens all the time is questionable given theack of metacognition or deliberate thinking cited within theeam [55]. However, the degree of dialogical reflection seen

ithin the team may explain this perception. It is difficult toetermine the underpinning processes of reflective activities,ut reflection in this team is suggestive of a mental activityt a problem-solving level [29].

rapy 94 (2008) 63–70 69

It is surprising that written reflection was used by so fewarticipants and appeared to be low in priority given thehanges in professional regulation. Many of the participantsualified prior to the introduction of reflective practice inndergraduate courses, and this may explain the limitedsage [32]. None of the participants mentioned reflectiverameworks [21,22], and it is not known whether the partici-ants were knowledgeable about them or had ever used themn practice. Furthermore, it emerged that participants werenclear about how to undertake written reflection or how tohoose an appropriate topic. The skill to write reflectivelyas generally underdeveloped due to the lack of training

nd support since qualification. The two participants whosed written reflection on a regular basis were unusualn having received assistance to integrate it into practice.dditional support and guidance would be warranted to

nable all professionals to gain a better understanding of theurpose and benefits of written reflection and the methodsnderpinning the process.

onclusion

The findings of this study demonstrate that dialogicaleflection is often utilised and valued in clinical practice.

hilst team members are positive about reflection, teameflection is unlikely to develop in the absence of a formaltructure. Protected time and managerial/organisational sup-ort are important in facilitating this development. Writteneflection is limited and descriptive in nature. It is evident thatupport and training opportunities need to be more readilyccessible for the team to develop these skills, which wouldquip them to demonstrate outcomes at an individual and ser-ice level. Further research to investigate reflection in healthnd social care teams is warranted.

cknowledgements

The authors wish to thank the members of the interme-iate care team for participating in this study, and the local&D department for support during the research.

Ethical approval: Local Research Ethics Committee,oventry University and the R&D Department of the trust

n which the study was conducted.

Conflicts of interest: LS was Team Leader for the physio-herapists at the time of the study.

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[2] Smith J. Independent public enquiry into the issues arising from the caseof Harold Frederick Shipman. The Shipman Inquiry: London, HMSO;2001.

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