Dr Honor Merriman discusses the revalidation process for doctors and nurses, and offers tips on making effective reflective notes

merriman honor

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Read this article to learn more about:

  • why reflection is an important part of the revalidation process
  • how to write notes on reflections
  • why a healthcare practitioner should consider their own health as part of the appraisal.

 

Revalidation is a process that all doctors are required to follow in order to demonstrate they are up to date and fit to practise, and can therefore hold a licence to practise medicine.1 In March 2016, the General Medical Council (GMC) updated the requirements for revalidation, resulting in an increased emphasis on reflection.

In April 2016, the Nursing and Midwifery Council (NMC) introduced revalidation for nurses, which all nurses and midwives need to follow to maintain registration with their relevant council.2 The NMC has set up a website to help guide nurses through the process.

Revalidation for doctors and nurses requires annual appraisal and the appraiser’s review of the individual’s portfolio is an important part of this process.

Reflection

Guidance from NHS England Responsible Officers, sent to all GPs in November 2016 by Dr Maurice Conlon, states:3 ’Your annual appraisal should be a rewarding professional event. Preparing for it should take you away from your patients for as little time as possible. … Your appraiser is primarily interested in your ability to reflect with insight on your practice. Honest reflection on a small number of well-chosen items, in which you demonstrate your learning and actions to improve patient care, is preferable to bland reflection on many.’

Reflection for doctors

There are six types of supporting information that doctors are expected to provide and discuss at an appraisal at least once in each 5-year cycle; these are:4

  • continuing professional development (CPD)
  • quality improvement activity
  • significant events
  • feedback from colleagues
  • feedback from patients
  • review of complaints and compliments.

Reflections on the different types of information, and how this has led to a change in practice, forms a significant part of the appraisal discussion. The GMC clearly states that reflection is an important part of the revalidation process:1

  • ’Reflection drives change in performance and is the key to effective CPD. Good Medical Practice requires you to reflect regularly on your standards of medical practice
  • You must reflect on all aspects of your professional work. This should be informed by discussion with others and by specific evidence, such as data from audit, complaints and compliments, significant events, information about service improvements, results of workplace-based assessments, and feedback from patients and colleagues.
  • You must also reflect on what you have learnt from your CPD activities and record whether your CPD has had any impact (or is expected to have any impact) on your performance and practice. This will help you assess whether your learning is adding value to the care of your patients and improving the services in which you work.
  • Reflection must be integral to your [personal development plan] PDP and appraisal and job planning discussions.’

Reflection for nurses

Similarly, the Royal College of Nursing (RCN) advises the following:5

  • ’… you are required to record a minimum of five written reflections on your continuing professional development (CPD) activity and/or feedback and/or a practice related event over the 3 years prior to revalidation.
  • Reflection helps us to think about, plan and deliver high quality and safe care to our patients/clients.’

Writing down your reflections

Finding time to capture reflections can seem to compete with the needs of patients in a busy healthcare environment. Following a template can help save time by providing focus and clarity when recording reflective notes.

Why write it when you could just think it?

The first step in making sense of an experience (for example, an educational activity or feedback from patients) is to write it down. Reflecting on an experience in this way provides an opportunity to change what we think or what we do in future practice. For healthcare professionals, there might be implications for how we manage patients. Unless the process is formalised on paper (or electronically) we may not make changes to clinical practice, and chances for improvement may be missed.

Use a template to guide your written reflections

The NMC has produced a form that can be adapted for use by all healthcare professionals to record reflective notes. The form includes the following questions:6

  • ’What was the nature of the CPD activity and/or practice-related feedback and/or event or experience in your practice?
  • What did you learn from the CPD activity and/or feedback and/or event or experience in your practice?
  • How did you change or improve your practice as a result?
  • How is this relevant to the Code [for nurses and midwives]? Select one or more themes:
    • prioritise people
    • practise effectively
    • preserve safety
    • promote professionalism and trust.’

Another example of a reflective account is provided by the GMC, on the theme Better care for older people (see Box 1, below).7 This example includes more information than most doctors might want to write down, but would be appropriate detail for a significant project. It illustrates the principle of making fewer overall reflective notes, but those that are chosen are more detailed.

Box 1: General Medical Council reflections record: promoting professionalism—better care for older people7

1. State the name of the Better care of older people theme you have chosen to look at, and explain why you want to learn about this.

  • Sample answer: I have chosen to look at Families and Carers. This is because I deal with lots of older patients and their relatives and want to understand how to keep them better informed and work out how they can best look after their relative at home.

2. Reflect on areas of practice relating to this theme that you’ll aim to develop in future. Note the actions you will take towards achieving these—be sure to make these realistic. The focus should be on changes to your practice that will improve patient care.

  • Sample answer: I’m going to arrange a short survey of the carers of my older patients with dementia, to understand what challenges they face. I’ll use the outcomes to develop support for them in the areas they need it most.

3. Next steps:

  • Record your next steps. For example, you may wish to discuss this with your clinical supervisor or another appropriate person.

4. Progress update: 3 months later

  • Looking back at your reflections and planned actions, what have you done to change your thinking or practice? Were there any obstacles? Any new reflections and actions to add?

5. Progress update: 6 months later

  • Looking back at your reflections and planned actions, what have you done to change your thinking or practice? Were there any obstacles? Any new reflections and actions to add?

6. Progress update: 12 months later

  • Looking back at your reflections and planned actions, what have you done to change your thinking or practice? Were there any obstacles? Any new reflections and actions to add?

General Medical Council. Reflections record: promoting professionalism—better care for older people. Manchester: GMC. www.gmc-uk.org/Reflections_record_BCOP.PDF_61844646.PDF

In my role as an appraiser, I regularly see accounts in the pre-appraisal paperwork that demonstrate many hours of study, but little or nothing in the way of a reflective account. The revalidation requirement will not have been met, and the loss to the individual is a gap in their own development. Using a simple template as a guide will help this process.

Reflect on your own health

Assessing and reflecting on your own health is an important aspect of the annual appraisal and the Health structured reflective template (see Box 2, below) can be a useful aid for initiating an open discussion.8 Where possible, reflections should be written in ‘SMART’ terms, (i.e. Specific, Measurable, Achievable, Realistic, Timely).

Healthcare practitioners are currently feeling the pressure of increasing workload so the development needs, and health status, of the individual can be overlooked all too easily. I have been meeting GPs for appraisal discussions for over 15 years and I have found that many do not consider their own health, despite spending many long hours looking after others. This is an important area that must not be overlooked.

Box 2: Health structured reflective template8

Name of doctor:            GMC No:            Date:

The following are health issues which commonly apply to doctors:

  • Are you registered with a GP?
  • Have you attended your GP in the past year?
  • Have you self-prescribed in the past year, or asked a colleague to prescribe?
  • Have you bypassed the normal NHS referral process in the past year?
  • Do you have a chronic illness?
  • Are you in pain?
  • Have you had a recent bereavement?
  • Are you experiencing stress at work or elsewhere?
  • What are your coping strategies for stress?
    • Do you actively self-care and consider work-life balance?
    • Do you have adequate holiday and study leave (and do you actually take this entitlement?)
    • What is your network of support at work and outside work? (Consider friends, colleagues, mentors, support groups)
  • Are you concerned that you may have a dependency on alcohol or drugs?
  • Are you involved in a complaint?
  • Are you sleep-deprived?

Select an issue, from this list or otherwise, in terms of your health affecting your ability to provide clinical care in the last year.

What is/are the issues?

How have I approached this in the past?

What could I do in the next year to improve things?

Final outcome after discussion at appraisal:

(Complete at appraisal considering how your approach will improve patient care.)

National Association of Primary Care Education. The Leicester 2007 conference statement on essential evidence for appraisal: health structured reflective template. Adapted from Whittet, S. Health and probity in appraisal: what do you ask? Available at: www.gpappraisals.uk/reflection.html

References

  1. General Medical Council. Continuing professional development: guidance for all doctors. Manchester: GMC, 2012. Available at: www.gmc-uk.org/Continuing_professional_development___guidance_for_all_doctors_0316.pdf_56438625.pdf
  2. Nursing and Midwifery Council website. Welcome to revalidationrevalidation.nmc.org.uk/welcome-to-revalidation (accessed 1 March 2017).
  3. NHS England. Simplifying appraisal preparation for general practitioners—a statement from the NHS England responsible officers. NHS England, 2016. www.gpappraisals.uk/uploads/4/5/8/5/4585426/simplifying_appraisal_preparation_nov_2016.pdf
  4. General Medical Council. Supporting information for appraisal and revalidation. Manchester: GMC, 2012. Available at: www.gmc-uk.org/static/documents/content/RT___Supporting_information_for_appraisal_and_revalidation___DC5485.pdf_55024594.pdf
  5. Royal College of Nursing website. Revalidation requirements: reflection and reflective discussionwww.rcn.org.uk/professional-development/revalidation/reflection-and-reflective-discussion (accessed 27 February 2017).
  6. Nursing and Midwifery Council. Reflective accounts form. Available at: revalidation.nmc.org.uk/download-resources/forms-and-templates (accessed 2 March).
  7. General Medical Council. Reflections record: promoting professionalism—better care for older people. Manchester: GMC. www.gmc-uk.org/Reflections_record_BCOP.PDF_61844646.PDF
  8. National Association of Primary Care Education. The Leicester 2007 conference statement on essential evidence for appraisal: health structured reflective template. Available at: www.gpappraisals.uk/reflection.html