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This guide outlines the In-Training Assessment Activity (ITA-act) on reflective practice for use in the assessment of pharmacy interns in Australia.
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Abbreviation |
Term |
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APC |
Australian Pharmacy Council |
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ITA-act |
In-Training Assessment Activity |
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ITP |
Intern Training Program |
This guide is to be used by pharmacist interns, preceptors, supervising pharmacists and Intern Training Program (ITP) providers.
This guide outlines the In-Training Assessment Activity (ITA-act) on reflective practice developed by the Australian Pharmacy Council (APC) for use in the assessment of pharmacy interns in Australia.
The ITA-act is intended to assist with the assessment of an intern’s achievement of one or more of the performance outcomes listed in the Performance Outcomes Framework 2020 which accompanied the 2020 Accreditation Standards for Pharmacy Programs in Australia.
Interns will use the templates, for completing a reflective statement following an incident, activity or event experienced in the workplace.
Preceptors and supervising pharmacists (collectively referred to as Supervisors) will review the intern’s reflective statement, provide feedback to the intern, and use the rubric to assess the level of reflection demonstrated by the intern.
Intern Training Program providers will incorporate the tool into the Intern Portfolio, which is the compiled record of the intern’s achievements during the intern year, and which is used as the basis for determining whether the intern has achieved many of the performance outcomes. ITP providers currently require the completion of reflective statements as part of the formal requirement of the ITP; this tool may be used to satisfy those requirements.
Familiarity with the following documents is recommended and they should be read in conjunction with this User Guide.
To promote learning from experience, learners need to make connections between the experience and the meaning that they derive from the experience. These connections can be created and reinforced through the process of reflection, a higher-order thinking process in which memories, thoughts, ideas, and emotions are associated with each other and new interpretations generated (Denton, 2011). Therefore, the learner is able to develop new insights and understandings which drive changes in beliefs, attitudes, and behaviours (Lucas et al, 2017).
Reflection and reflective practice are critical skills and characteristics of good health care professional practice and are considered central to making better informed decisions and clinical judgements, therefore leading to better patient outcomes (Lucas et al, 2017). At the point of general registration, intern pharmacists are expected to demonstrate competence in, and commitment to, “engaging in regular and systematic reflection to enhance professional learning and practice” (performance outcome 4.1, Performance Outcomes Framework).
There is no commonly agreed definition of reflection as an educational practice, however a number of elements are characteristic of the process. Denton (2011) suggests that two critical elements are time and thorough exploration: “reflection involves spending significant time on one topic in order to explore it thoroughly” (p. 840). This exploration is enhanced by metacognitive thinking, where learners explore their own thinking to become more self-aware (Lucas et al, 2017). Metacognitive thinking can, for example, allow learners to understand their strengths and weaknesses, consider the strategies they use, identify areas where change is necessary, and construct approaches to implement in the future.
Coulson and Harvey (2013) suggest that there are four phases in learning to engage in reflection: learning to reflect, reflection for action; reflection in action; and reflection on action. It is expected that interns will have been exposed to opportunities to engage in all four phases during their degree program, since the performance outcome at the end of the degree program requires graduates to demonstrate competency in undertaking structured reflection.
However, as Coulson and Harvey (2013) point out, engaging in reflection in professional practice once having left university requires interns to develop and apply different skills, most notably personal agency, as they learn to negotiate a context where there is less structure, guidance, and support. Agency is described as the ability to be proactive, self-organising, self-regulating and self-reflective. Coulson and Harvey (2013) conclude that “structuring opportunities for reflection before, during and after the experience will enable learners to navigate the inherent complexities of learning through experience” (p. 403).
Reflective language goes beyond a simple description of an event or incident. Reflective language uses words which express thoughts and emotions, and is written in the first person (I, me). It will often have a retrospective quality, as previous events are recalled and explored from the position of hindsight. It will show that an individual has made connections between different aspects or ideas, and/or that the individual has insight into what happened. It should almost always lead to an understanding of what could be improved in the future, and what is necessary to achieve this improvement.
The development of this tool is designed to provide a form of structure and guidance for interns and their preceptors and supervising pharmacists (supervisors) during and after experiences, as the interns learn from these experiences in the workplace. It thus primarily addresses reflection in action and reflection on action.
As described by Hickson (2011), “Reflection in action is the thought that we take whilst involved in a situation, during which we become aware of what we are thinking, feeling and doing, and reflection on action takes place sometime later, when we consider the events that took place, and recall what we were thinking, feeling and doing” (p. 831).
Simply stated, reflection is a process of thinking back on experiences; exploring them from the perspective of hindsight; trying to learn something as a result; and formulating a plan to change something in the future. When done effectively, it deepens and consolidates knowledge, skills, attitudes, and behaviours; enhances critical thinking and decision-making; and develops professional practice. Reflection promotes learning from experience and is a key skill of a health care professional.
Interns are faced with a very steep learning curve as they transition into the workplace, and reflection on their own experiences, and those of others around them, can accelerate their progress towards becoming capable and confident practitioners.
The purpose of the reflection tool is to provide interns with a structured means of learning through reflection on events, activities and incidents experienced or observed during the intern year. It is targeted towards reflection in action and reflection on action, as a means of mediating learning from experience. Interns will use the template to create a reflective statement following an event, activity or incident relating to their practice.
This tool is not intended for use with more general reflections on longitudinal development of skills, such as clinical decision-making, time management, professional judgement etc. While reflection on skills development is important, this tool has not been designed with this type of reflection in mind.
The tool comprises the following elements:
This tool facilitates the demonstration of achievement of Performance outcome 4.1 (refer below). It also can be used as evidence of achievement of other performance outcomes since it locates reflection in specific situations encountered in professional practice.
Performance outcome 4.1 specifically requires interns to be able to demonstrate that they “are competent in and committed to engaging in regular and systematic reflection to enhance professional learning and practice”..
The following describes how to write a reflective statement using the accompanying Intern Reflective Statement Template developed by the APC. Interns may already be familiar with the process of reflection prior to commencing their intern year. Where an intern is familiar and comfortable with an alternative structure and format for reflection and reflective writing (e.g., What? So what? Now what?), they are able to use that alternative structure if they so desire. It is preferable for interns to use a model with which they are familiar and comfortable, rather than expecting them to learn a new model for the purposes of the intern year.
Figure 1: Steps for completing the reflective statement template
The process starts with the occurrence of an incident/event/or activity in the workplace. Since the ultimate aim of reflection is to enhance learning and subsequent practice, interns and supervisors should remain alert for situations where this opportunity might arise. Routine tasks such as dispensing, compounding, counselling, contacting prescribers, providing primary care, or preparing dose administration aids may on occasion present opportunities for learning, as might scenarios involving the use of ethical or clinical decision-making, unusual patient requests or questions, and queries from other health professionals among others. In reality, there are many situations where reflection is able to consolidate learning, and the tool is therefore designed to encompass as many as possible of these situations.
As soon as practicable following the activity, event or incident, the intern should complete the details of the activity, event or incident and the feelings, thoughts and emotions experienced at the time. If time is limited, it is better to make some notes at the time, and then return to the report at a later time to put them into a more coherent and orderly account that is personally meaningful. Some interns may find it useful to carry a notebook in which to record their initial recall of the activity, event, or incident, together with their thoughts and feelings; alternatively, they may choose to record these thoughts on a device such as a mobile phone.
Section 1 is a short descriptive summary of the facts of the activity, event, or incident without reflection upon the meaning. Interns should simply describe what actually happened.
Section 2 is the start of the reflective process where interns should identify how the activity, event or incident made them think and feel. Some key questions that might form the basis for this aspect include:
Once the details of the activity, event or incident and the initial response have been recorded, the intern should spend some time thinking about Section 3 and putting together a response to the critical issues that were identified and what the intern has learned. Some key questions that might form the basis for this aspect could include:
Sections 4 and 5 are intended to prompt the intern to identify how learning from the experience will change future actions, and if any additional learning or practice is needed to help develop knowledge or skills.
This step encourages a full and frank discussion between the intern and supervisor, so this discussion should take place in a quiet area where neither person is likely to be distracted or interrupted. It may form part of the regular weekly meeting between the intern and preceptor if so desired.
There are two types of feedback which should be provided as part of the process of using this tool.
Firstly, the supervisor should provide feedback to the intern on how they handled the activity, event or incident, the learning that they gained, and the further actions that the intern has described. This feedback will usually focus on what has been written in sections 4 and 5 of the Interns reflective statement but could also cover sections 1 to 3. Supervisors may well have observed how the intern acted/reacted during and after the activity/event/incident, and may be able to provide comments that confirm, challenge, or correct what the intern remembers. They may also be able to reassure or affirm to the intern that the situation was one which they may handle differently in future with more experience.
Secondly, the supervisor should give feedback to the intern on the stage or level of the intern’s reflective skills as demonstrated in the reflective statement. The Assessment and Feedback form should be used as the basis for this feedback. The rubric should not simply be completed by the supervisor; it should also for the basis for discussion with the intern on how their reflective skills could be enhanced.
As part of the discussion, the supervisor and intern should jointly create a SMART development plan to enhance the intern’s reflective skills, where this is considered desirable. A SMART plan is characterised by being Specific, Measurable, Attainable, Relevant and Time-bound.
A Specific plan or goal considers what specifically needs to be accomplished – for example, the reflective statement needs to include evidence of changes in understanding and/or future actions.
A Measurable plan or goal is one which can be assessed or evaluated in a tangible way – for example, the next reflective statement will include at least one statement outlining a change in understanding, and at least one outlining a change in future action.
An Attainable plan or goal is one which is realistically achievable in the current circumstances and within a reasonable timeframe – for example, each successive reflective statement during the intern year will show some improvement.
A Relevant plan or goal is one which is important enough to pursue – for example, improving reflective skills will lead to more effective professional practice.
A Time-Bound plan or goal is one which has a defined end-point in time – for example, the next reflective statement will be completed within four weeks.
After discussion between intern and supervisor about the reflective statement, supervisors should assess and provide feedback on the intern’s demonstration of reflective practice, and facilitate the creation of a development plan to enhance the intern’s reflective skills where appropriate.
Sections 6 to 8 provide a structure for recording the process and outcomes of the feedback discussion. The primary purpose of reflection is to reinforce and consolidate the learning associated with an activity, event, or incident, and to consider how such an activity, event or incident might be handled or approached differently in future. Consequently, a critical component of the process involves follow-up.
Section 9 can be used to close the loop by outlining a subsequent event where the learning which arose from the initial reflection was put into practice.
Section 10 is available for any additional notes. It should be noted that the experiences which lead to reflection are likely to relate to other performance outcomes. Section 10 can be used for noting these outcomes and acting as a record of their demonstration. Two exemplars are also provided to illustrate how the template is designed to be used.
It should be noted that the template is designed to help to structure the reflective process. Where an intern is comfortable and confident with an alternative approach to reflection which is consistent with this template, this alternative approach may be used.
Purpose of the template
The template is provided for interns to record their reflections as a reflective statement. It is not intended to restrict or constrain intern reflections, but rather to provide a clear structure for the thinking that would normally be part of reflection and reflective writing.
Interns may already be familiar with the process of reflection prior to commencing their intern year. Where an intern is familiar and comfortable with an alternative structure and format for reflection and reflective writing (e.g., What? So What? Now what?), they are able to use that alternative structure if they so desire. It is probably preferable for interns to use a model with which they are familiar and comfortable, rather than expecting them to learn a new model for the purposes of the intern year. The reflection template and assessment/ feedback rubric can be used in a flexible way to accommodate alternative approaches.
Interns are encouraged to engage methodically and systematically with this process. Evidence suggests that the benefits of thorough reflection are usually worth the time and effort spent.
Format
The template is presented in a standardised form with 10 sections which are expected to be relevant in most situations where a reflective statement would be created. Interns are expected to fill out the template themselves, and to use it as the basis for a discussion with their supervisor. The first 5 sections would normally be completed before this discussion, and the remaining sections after discussion.
Who should use it?
The reflective statement forms the basis for learning from experience and should be used collaboratively by the intern and supervisor. The intern should complete the first half of the reflective statement, then discuss what they have written with the supervisor, before completing the second half of the statement.
When it should be used
The tool has been designed to be used flexibly, and to be applicable to a wide range of situations and activities.
It should be noted that reflection, self-assessment, and feedback comprise essential parts of the other workplace-based tools developed as part of the Intern Year suite. This reflection template is therefore designed to be used more generically, for experiences where other tools are not directly applicable. It is also capable of being used as the basis for reflection as part of any of the workplace-based assessment tools and its use is encouraged for this purpose.
Examples of situations when use of this reflective tool might be appropriate include events and activities which are unplanned or spontaneous, and/or incidents which occur during professional practice within the workplace.
There is no suggested number of reflections which should be completed during the intern year; the aim is that the tool can be used as a learning aid whenever a good learning opportunity arises.
Purpose of the form
The purpose of this form is for the supervisor to assess and provide feedback on the intern’s demonstration of reflective practice, and to facilitate the creation of a development plan to enhance the intern’s reflective skills where appropriate.
Format
The form includes an assessment rubric which the supervisor should use as he basis for identifying the intern’s current reflective skill level. For each section of the reflective statement, a descriptor is provided of the nature of writing including little or no reflective nature, for writing that includes incomplete reflection, and writing that is considered appropriately reflective.
The form also includes spaces for recording the important points discussed between the intern and supervisor, and for the creation of a SMART plan for developing the intern’s reflective skills further.
Who should use it?
The form should be jointly completed by intern and supervisor.
When it should be used
The form should be used during the discussion between intern and supervisor about the reflective statement. Generally speaking, the intern will have spent some time after the incident or event, preferably in a quiet place with time to complete the first five sections of the reflective statement in a thoughtful and thorough manner. The intern should then schedule a time with the supervisor for discussion, and the Assessment and feedback form will form part of the basis for this discussion. Following the discussion phase, the intern should complete sections 6-8 of the reflective statement, again in a quiet place with time to reflect on the discussion.
References
Coulson D. and Harvey M. (2013). Scaffolding student reflection for experience-based learning: a framework. Teaching in Higher Education. 18(4):401-413.
Denton D. (2011). Reflection and Learning: Characteristics, obstacles, and implications. Educational Philosophy and Theory. 43(8):838-852.
Hickson H. (2011). Critical reflection: reflecting on learning to be reflective. Reflective Practice. 12(6):829-839.
Lucas C., Bosnic-Anticevich S., Schneider C., Bartimote-Aufflick K., McEntee M and Smith L. (2017). Inter-rater reliability of a reflective rubric to assess pharmacy students’ reflective thinking. Currents in Pharmacy Teaching and Learning. 9:989-995.