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Reflection on practice: consultation skills.

In January 2019, the Department of Health and Social Care (DHSC) published the highly anticipated NHS Long Term Plan ( NHS, 2019 ). While the publication of a White Paper is not typically celebrated, some of the key paradigms outlined in the Plan signal a move away from a traditional view of health being ‘what's the matter with someone’ to a more personalised approach that embraces a philosophy based on ‘what matters to someone’. Against the backdrop of the increasing number of children, young people and adults living with at least one long-term condition, the change from the pathogenic to the salutogenic model heralds a very different approach to care based on the comprehensive model of personalised care ( NHS England, 2018 ) which highlighted the significance of the ‘person’ and not just the ‘patient’. This article will outline this model and focus on social prescribing as integral to successful operationalisation of the personalised approach.

The NHS Long Term Plan

Personalised care promotes the health professional to consider the ‘person’ as opposed to the ‘patient’ ( NHS England, 2018 ). In doing so, the person's needs are placed central to decision-making, facilitating patient choice and control over their care.

The NHS Long Term Plan ( NHS, 2019 ) promoted a paradigm that actively encourages the shift from pathogenic to salutogenic approaches through its comprehensive personalised care model. Salutogenesis focuses on factors that promote and support health and wellbeing rather than factors that cause disease. It is estimated that up to 2.5 million people will benefit from the model by 2024 and that personalised care will become ‘business as usual’ ( NHS, 2019 ). Re-orienting healthcare with the underpinning theory of salutogenesis is not a new concept ( World Health Organization (WHO), 1986 ; Lindström and Eriksson, 2005 ); however, its resurgence provides opportunities to alleviate the challenges and demands of general practice nursing in the 21st Century ( The Queen's Nursing Institute, 2015 ).

Delivering universal personalised care using the comprehensive personalised care model will involve the implementation of trained ‘social prescribing’ link workers, personal health budgets, and the coproduction of personalised care and support plans to help individuals experiencing long-term conditions; 75 000 clinicians and professionals will be needed to provide support for personalised care in their practice ( NHS England, 2019 ). Underpinning this approach are six core principles:

  • Shared decision-making
  • Personalised care and support planning
  • Enabling choice
  • Social prescribing and community-based support
  • Supported self-management
  • Personal health budgets and integrated personal budgets across the NHS and the wider healthcare system ( NHS, 2019 ).

These are all necessary ingredients for a universal personalised care model. Key to the success is the social prescribing systems and processes that will help professionals and individuals navigate the many non-medical, community health assets available to support the personalised approach to wellbeing. All communities have local health assets which can include the skills, knowledge, motivation of individual community members, existing friendships and neighbourliness, formal or informal voluntary groups and associations, physical, environmental and economic resources available in the community, as well as assets brought by external agencies ( Public Health England (PHE), 2015a ).

Social prescribing

One of the key components to enabling personalised care is social prescribing. This is a form of community referral that enables frontline staff to refer a person for non-medical, non-clinical support. It involves using assets in the community to support a person through a wellbeing conversation, predicated on what matters to the person rather than what is the matter with them. Understanding a person's perspective of a ‘community’ (place, geography, interest or identity) is an integral part of valuing people as active participants in the planning and management of their own health and wellbeing ( PHE, 2015a ). This strengths-based approach focuses more on the individual's assets rather than their deficits, and embraces a personalised approach to care. Putting this into operation this has led to a Government pledge for 1000 trained social prescribing link workers to work with primary care networks (PCNs) and the voluntary community and social enterprise (VCSE) sector to create pathways for people into social prescribing interventions. Essentially, this approach considers the wider determinants of health by placing an emphasis on wellbeing rather than on health alone. Social prescribing uses non-medical, asset-based, salutogenic approaches to promote a personalised paradigm that places the person at the centre of decision-making.

Social prescribing models

Anchored in primary care, social prescribing is considered a pathway to participation in the family of community-centred approaches for health and wellbeing ( PHE, 2015a ). Although social prescribing is influenced by national agenda, the way in which it has been implemented across the UK can differ significantly. Kimberlee (2015) identified four different types of social prescribing models:

  • Social prescribing signposting, a frontline practitioner can send someone to an organisation, such as a knitting group, for social conversation
  • Social prescribing light, sending at-risk or vulnerable population groups to specific social prescribing programmes
  • Social prescribing medium, there is a conversation between an individual and a dedicated social prescribing practitioner to understand what matters to the person and determine an appropriate referral, for example someone who may be overweight maybe referred to a walking group
  • Holistic social prescribing, actively promotes personalised care using the ‘wellbeing’ conversation as integral to empowering personal choice.

There are a number of non-medical services available ranging from art workshops to nature-based interventions

The wellbeing conversation is led by a link worker, who may have up to eight meetings to determine what matters to the individual, after which, the person is referred to a non-medical service to support them. The holistic approach is predicated on multi-professional, cross-agency communication and collaboration; integration is therefore considered to be the fabric of the model, enabling the person to have a choice over their care.

The need for a different approach

There are a number of non-medical services and interventions available across the UK. These range from Arts on Prescription (a series of art workshops for people experiencing depression, anxiety and other mental health conditions), to nature-based interventions, such as allotment or gardening groups. Evidence suggests that nature-based activities such as gardening or walking outdoors can improve our wellbeing ( Annersted and Währborg, 2011 ). Interestingly, joining a gardening group can help reduce social isolation for older people ( Howarth et al, 2016 ) and those with mental health problems ( Wood et al, 2015 ). It is estimated that being socially isolated can have significant detrimental effect on health and social isolation is known to cause early death ( Holt-Lunstad et al, 2010 ). Equally, mental health is now a major global burden ( WHO, 2019 ) and is the main cause of ill-health ( GBD 2016 Disease and Injury Incidence and Prevalence Collaborators, 2017 ). Social prescribing can provide a non-medical solution to supporting people across a range of age groups with diverse needs to regain control of their wellbeing and help tackle future and existing long-term conditions.

Public health and wider agenda

To ensure that the comprehensive model of personalised care becomes ‘business as usual’, the ten-point action plan for general practice nursing ( NHS England, 2017 ) recognises that practice nurses need access to educational programmes to develop skills to support case-finding and promoting self-care for all people with long-term conditions.

To deliver the radical upgrade still needed in prevention ( NHS, 2019 ), a new online learning platform called All Our Health has been developed with GPNs in mind to help embed and extend prevention, health protection and promotion of wellbeing and resilience into everyday practice ( PHE, 2015b ; NHS England, 2017 ; Health Education England (HEE), 2019 ).

PHE (2013) re-emphasised its vision that public health practice becomes every nurse's responsibility at an individual, community and population level vision more than 5 years ago. The All Our Health framework for personalised care and population health ( PHE, 2015b ) identified seven evidence-based approaches that all health professionals, including nurses, could adopt to ensure that public health is embedded into practice:

  • Improving the wider determinants of health
  • Health improvement
  • Health protection
  • Supporting health, wellbeing and independence
  • Life-course approaches to improving health and wellbeing
  • Place-based services of care.

Social prescribing provides numerous aspects of this framework of evidence that aims to help all health professionals, including practice nurses, to use their skills and relationships to maximise their impact on avoidable illness, health protection and the promotion of wellbeing and resilience ( PHE, 2018 ).

An all-age, whole-population approach to social prescribing

The comprehensive personalised care model sets out how social prescribing is a universal population intervention that can be used in primary care to support people to stay well and build community resilience ( NHS England, 2018 ). This suggests that health improvement efforts such as Making Every Contact Count (MECC) could routinely include non-medical solutions such as social prescribing to address MECC's five core elements: stopping smoking, reducing alcohol use, maintaining a healthy weight and diet, and promoting mental health and wellbeing ( PHE and HEE, 2018 ).

The estimated 30% of a general practice population living with long-term physical and mental health conditions will benefit from targeted support to build knowledge, skills and confidence to live well with their health condition(s) and self-manage. A further 5% of the practice population living with complex needs will benefit most from specialist interventions that empower people, including the use of personal health budgets. NHS England (2018) is clear that people living with long-term physical and mental health conditions will benefit from targeted interventions plus universal interventions, and that those with complex needs will benefit from specialist interventions plus targeted and universal interventions, thus suggesting that social prescribing offers an effective intervention for the whole population.

The comprehensive personalised care agenda provides nurses with an opportunity to revisit the significance of salutogenesis and the call to action for every nurse to maximise their impact on the public's health – in practice, education and research. Keeping abreast of the social prescribing movement in communities and working in collaboration with link workers will help the practice nurse community to empower patients and not just regain control of their health – but also invigorate and promote their wellbeing.

  • Salutogenesis is an asset-based approach to supporting an individual's wellbeing
  • There is a need for practice nurses to be aware of and work with social prescribing link workers to enable them to form part of the social prescribing pathway and support them
  • Practice nurses may already be familiar with the concept of community referral; the wider personalised care agenda has refreshed the language used and social prescribing offers an opportunity to rebalance practice through salutogenic principles
  • All Our Health is a call to action for every nurse to maximise their impact on the public's health – in practice, education and research

Annersted M, Währborg P. Nature-assisted therapy: systematic review of controlled and observational studies. Scand J Public Health. 2011;39(4):371–88. https://doi. org/10.1177/1403494810396400 Dumbreck S, Flynn A, Nairn M et al. Drug-disease and drug-drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines. BMJ. 2015;350:949. https://doi.org/10.1136/bmj.h949 Health Education England. All Our Health – e-Learning for healthcare. 2019. https://www.e-lfh.org.uk/programmes/allour-health/ (accessed 13 May 2019) Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS Med. 2010;7(7):e1000316. https://doi.org/10.1371/journal. pmed.1000316 Howarth ML, McQuarrie C, Withnell N, Smith E. The influence of therapeutic horticulture on social integration. J Public Ment Health. 2016;15(3):136–40. https://doi. org/10.1108/JPMH-12-2015-0050 GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1211–59. https://doi.org/10.1016/ S0140-6736(17)32154-2 Kimberlee R. What is Social Prescribing? Advances in Social Sciences Research Journal. 2015;2(1):102–10. https://doi. org/10.14738/assrj.21.808 Lindström B, Eriksson M. Salutogenesis. J Epidemiol Community Health. 2005;59(6):440–42. http://dx.doi. org/10.1136/jech.2005.034777 NHS. NHS Long Term Plan. 2019. https://www.longtermplan. nhs.uk/publication/nhs-long-term-plan/ (accessed 6 June 2019) 340 Practice Nursing 2019, Vol 30, No 7 © 2019 MA Healthcare Ltd Social prescribing.indd 340 28/06/2019 10:10 Downloaded from magonlinelibrary.com by 213.123.122.025 on February 14, 2020. PRESCRIBING PRESCRIBING PROFESSIONAL NHS England. General practice – developing confidence, capability and capacity. 2017. https://www.england.nhs.uk/ publication/general-practice-developing-confidence-capabilityand-capacity/ (accessed 6 June 2019) NHS England. Comprehensive model of personalised care. 2018. https://www.england.nhs.uk/ publication/ comprehensive-model-of-personalised-care/ (accessed 6 June 2019) NHS England. Universal personalised care: implementing the comprehensive model. 2019. https://www.england.nhs.uk/ publication/universal-personalised-care-implementing-thecomprehensive-model/ (accessed 6 June 2019) Public Health England. Nursing and midwifery contribution to public health: improving health and wellbeing. 2013. https://assets.publishing.service.gov. uk/government/uploads/" class="redactor-linkify-object"> https://assets.publishing.service.gov. uk/governmen... system/uploads/attachment_data/file/210100/NMR_final.pdf (accessed 6 June 2019) Public Health England. Health and wellbeing: a guide to community centred approaches to health and wellbeing: full report. 2015a. https://www.gov.uk/government/ publications/" class="redactor-linkify-object"> https://www.gov.uk/government/ publications/ health-and-wellbeing-a-guide-to-community-centredapproaches (accessed 6 June 2019) Public Health England. All Our Health: personalised care and population health. 2015b. https://www.gov.uk/government/ collections/all-our-health-personalised-care-and-populationhealth (accessed 6 June 2019) Public Health England. Health matters: community-centred approaches to health and wellbeing. 2018. https://www. gov.uk/government/publications/health-matters-health-andwellbeing-community-centred-approaches/health-matterscommunity-centred-approaches-for-health-and-wellbeing (accessed 6 June 2019) Public Health England, Health Education England. Making every contact count (MECC): quality marker checklist for training resources. 2018. https://assets.publishing.service.gov. uk/government/uploads/system/uploads/attachment_data/ file/769489/MECC_Training_quality_marker_checklist_ updates.pdf (accessed 6 June 2019) The Queen’s Nursing Institute. General practice nursing in the 21st century: a time for opportunity. 2015. https://www. qni.org.uk/wp-content/uploads/2016/09/gpn_c21_report.pdf (accessed 6 June 2019) Wood CJ, Pretty J, Griffin M. A case-control study of the health and well-being benefits of allotment gardening. J Public Health. 2015;38(3):e336–44. https://doi.org/10.1093/ pubmed/fdv146 World Health Organization. The Ottawa charter for health promotion. 1986. https://www.who.int/healthpromotion/ conferences/previous/ottawa/en/ (accessed 6 June 2019) World Health Organization. Mental health. 2019. https://www. who.int/mental_health/en/ (accessed 6 June 2019)

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  • v.25(2); 2007

“A memorable consultation”: Writing reflective accounts articulates students’ learning in general practice

Kristian svenberg.

1 Department of Community Medicine and Public Health/Primary Health Care, The Sahlgrenska Academy at Göteborg University, Sweden

Mats Wahlqvist

Bengt mattsson.

To explore and analyse students’ learning experiences of a memorable consultation during a final-year attachment in general practice.

After a two-week primary care attachment in the undergraduate curriculum, students were invited to write a reflective account of a memorable consultation.

A total of 52 reflective accounts were read and processed according to qualitative content analysis. Credibility of the analysis was validated by two co-authors reading the descriptions separately and trustworthiness was tested at local seminars.

Three main themes emerged. In “The person beyond symptoms” the students recognize the individual properties of a consultation. “Facing complexity” mirrors awareness of changing tracks in problem-solving and strategies of handling unclear conditions. “In search of a professional role” reflects the interest in role modelling and the relation to the supervisor.

Involving students in writing reflective accounts appears to stimulate them to articulate practice experiences of the consultation.

Reflection on experiences in practice is recommended as a learning method in medical students’ ambulatory clinical education. Students’ written reflective accounts of a memorable consultation in primary care were analysed qualitatively.

  • Main themes of students’ learning experiences were “The person beyond symptoms”, “Facing complexity”, and “In search of a professional role”.
  • Involving students in writing reflective accounts of consultations appears to stimulate them to articulate learning experiences.

Situated at the heart of medicine, the consultation is a very complex phenomenon. In the patient–doctor encounter, biological, psychological, and social aspects of medicine are integrated. Considering the central position of the consultation, how can medical educators facilitate students’ learning of consultation skills in a practice setting? This question has been addressed in several reports and reviews during the last few decades [1–7] . An experiential method of learning communication and consultation skills is nowadays implemented in most curricula. However, concerns have been expressed regarding the risk of superficial learning due to a too narrow approach of skills training [8] .

In 1997, reflection on learning experiences was recommended in undergraduate ambulatory clinical education by Smith & Irby [9] . Main references for these recommendations are Kolb's and Schön's contributions to experiential learning theory in which reflection plays a central role [10] , [11] . One definition of reflection is proposed as follows: “Reflection is an important, human activity in which people recapture their experience, think about it, mull it over and evaluate it” [12] . Different ways have been practised to encourage students to reflect on clinical practice by writing reflective accounts. In “portfolio learning”, which is a broad concept of learning tasks, the students could be asked to answer specific questions. The answers could constitute a framework of personal diaries aimed at enhancing the students’ reflective thinking [13] . In some curricula, students were asked to convey their feelings in the form of poetry, hence expressing difficult questions raised after seeing patients [14] . Reflective writing might help the students to articulate qualities of experiences not covered by traditional medical vocabulary. In primary care where patients are seen in an early and unorganized state of illness it could accordingly be appropriate to stimulate students to express personal reactions.

Students’ attachments in general practice

In the Göteborg medical curriculum comprising 11 terms, a general practice attachment is arranged during the 10th term. Students are supervised by an experienced GP and see patients of their own. The purpose of this training is to expose students to patients and problems in primary care, in order to learn from personal experiences and to start to grasp the essentials of general practice. Before the 10th term, the students spend most of their time in hospitals, mainly in university clinics. Less than one year after the general practice attachment, most students start their internship (“allmäntjänstgöring”) implying gradually independent clinical work and high personal responsibility.

In 2001–2002, students were asked to recall and share a memorable consultation experienced during the PHC (Primary Health Care Centre) attachment in a small-group setting. Supervisors then heard many noteworthy and unexpected stories. Patients’ assorted symptom presentations and attitudes to their complaints were often highlighted in students’ oral reports. In addition, the students had captured new medical skills and various working manners of the GPs. We wanted to develop these presentations more systematically.

The study aimed at exploring and analysing students’ learning experiences of a memorable consultation during a final-year general practice attachment.

Material and methods

In 2003 the students (n = 60) on two courses were asked to select a memorable consultation and write down their learning experiences and reflections. The task was voluntary and the students were notified that the purpose of the reflective descriptions was to explore in more depth their experiences of a memorable consultation. Students were also informed that their texts would not be assessed by marks and grades. It was stressed that participation was voluntary and the students could omit the names on the sheets if they wanted. The GP–patient encounter could deal with any kind of problem, purely medical as well as mainly human. The students’ own choice was entirely decisive. The task was to answer three questions: What happened to the patient before the consultation? What happened when meeting the patient at the PHC ? What did I learn from the consultation ?

The accounts were maximized to two pages, collected on a follow-up day and processed according to qualitative content analysis [15] , [16] . The whole data material comprised 78 pages of text, which was analysed accordingly:

  • The first author, KS, read the reports three times. The core content of each account was identified and units of meaning were grouped to get a view of the entire material.
  • The accounts were read by KS again and BM to get an overview of the material and the initial analysis made by KS was discussed at three meetings.
  • In a couple of sessions the units of meaning were condensed and coded into preliminary categories.
  • The categories were grouped and condensed into themes.
  • The third researcher (MW) read all accounts independently.
  • Categories and themes were discussed in new sessions and re-evaluated in order to confirm the findings.

Perspectives used in interpretation of data were a learner-centred model of education and Ian McWhinney's model of a theory for family medicine [17] , [18] .

A total of 54 students (90%, 31 female and 23 male, mean age 27 years) submitted their accounts. Two accounts deviated from the others by not answering the three questions in the task and by lacking reflection. These accounts were omitted from the analysis.

A framework of the content analysis of students’ reflective descriptions is depicted in Table I .

A framework of content analysis of students’ reflective accounts: General practice course, 10th term, medical curriculum, Göteborg university.

Themes and categories supporting themes are presented below. In order to illustrate and clarify the analysis, additional examples of quotations from students’ texts are given in italics.

Theme: The person beyond symptoms

Underpinning this theme were the categories “What's behind the patient's story?” and “Importance of consultation skills?”

Category: What's behind the patient's story?

Many accounts dealt with the patient's personal conditions relevant to the visit and frequently the person behind the symptom emerges. Fear of cancer, family and social problems were sometimes, noted the students, expressed as physical complaints. The students experienced that presenting symptoms like back pain, headache, or a common cold could be an “admission ticket” to the PHC. In the subsequent encounter the focus was narrowed and another realm of interest appeared: So much seems to be hidden behind the problem that brings the patient to the PHC.

Importance of consultation skills

The students elicited the importance of good consultation skills and the significance of listening to the patient's story: If you try and give yourself and the patient some time to be quiet together you can learn more than by just asking a lot of questions .

Facing complexity

Categories supporting this theme were “Changing tracks” and “Dealing with uncertainty”.

Changing tracks

The students noted in their stories that you have to improve your ability to wait and see and reassess your preliminary judgement. You need not, and cannot, immediately transfer the problems into diagnostic terms: It was an impressive chain of events and consultations that, finally, led to the underlying diagnosis.

Dealing with uncertainty

These statements tell of the uncertainty that a future doctor has to learn to live with and the implication of this insecurity in clinical work: I don't understand his symptoms but I do not think it is anything urgent.

In search of a professional role

The theme was established by the categories “Personal style in the consultation” and “Supervisor scrutinized”.

Personal style in the consultation

Consultations revealing that theory and practice do not always fit have a high instructive value. The importance of finding a personal style of one's own – and that it takes some time – was emphasized: …  the most important thing is to find yourself as a doctor …  and another student: My discreetness must not prevent me from putting a question that the patient might find embarrassing  … .

Supervisor scrutinized

The supervisor, an experienced GP, had a key position and in some cases the student described the supervisor as an object of identification. You imitate and praise some of the GP's behaviour whereas other manners were less striven for: When summarizing the patient's story to my supervisor, he sat with his back to the patient, looking at the computer.

Comments on methods

After informing the students about the motive of the study, the procedure was carried out smoothly. The number of participants was high (90%). The non-responding six students did not vary from the others regarding sex and age. In addition, the two courses examined did not differ from adjacent student groups in respect of course design. Two accounts were removed from the analysis. They lacked answers to the three questions originally put and were more in line with a short hospital record. For different reasons, these two students had obvious difficulties with reflection. We refrain from speculation as to why this was the case.

Limitations of our research method concern credibility. Credibility was increased by thoroughly conveying the analysis and perspectives used in interpretation of data [15] , [16] . During 2001–2003, two other GP academics participated in a group presentation by the students at an oral session on “a memorable consultation”. Altogether, these GPs have listened to more than 50 students and a preliminary version of our results has been presented to them. Our analysis matches well their experiences of the students’ oral reports and this increases the trustworthiness of the study.

Comments on results

The theme “ The person beyond the symptoms” tells us how the students are confronted by the psychosocial perspective and the “first contact function” of general practice. Patients often see the GP in a zone of transition between society and healthcare. Similar findings are reported from students’ attachments in primary care and community medicine [19] , [20] . In addition, this theme is quite close to McWhinney's description of a patient-centred approach: “to enter the patient's world, to see the illness through the patient's eyes … ” [21] .

The theme “ Facing complexity” indicates that the students have identified a certain predicament in almost every form of medical work. It mirrors the fact that many students have acquired an awareness of the complexities doctors see in clinical practice. Reality is seldom close to the textbooks so recently shut and dealing with clinical uncertainty is definitely experienced during the PHC attachments [22] , [23] .

“In search of a professional role” raises questions concerning the students’ relation to their supervisor. In our study the students were on the threshold of clinical work with individual responsibilities. At this stage, the supervisor is important as a role model. Committed supervisors were reported as pivotal to learning in studies of students’ views of attachments in primary care [24] , [25] . Indeed, the teacher–learner relationship is reported to have a considerable impact on the quality of teaching and learning [26] . Moreover, learning clinical and professional skills in the clinical context is vital in a socialization process of gradually entering into a “community of practitioners” [27] . A few students expressed criticism concerning their supervisor. An explanation for this could be the student's position as an observer, “sitting in” with the GP without responsibility for the patient.

One may question whether the written reflective accounts really mirror the students’ genuine learning experiences. There might be a risk of bias from students’ pragmatic opportunism in order to pass the course – described as a “chameleon phenomenon” [28] . However, students’ reflections were voluntary and not assessed by marks and grades. We think these circumstances have lessened the risk of opportunistic writing and strengthen the validity of the data.

To interpret and understand physical signs and signals is taken for granted as a learning objective in medical education. Symptoms have a grammar of their own, often with a medical key signature. This order, in many cases, is a prerequisite for a correct diagnosis and treatment. But it has to be developed and completed. An active search for the patient's thoughts and feelings regarding his/her current complaints is needed to grasp and understand the complex symptoms of many patients. This view is often expressed in the students’ accounts.

Implications

Patient encounters in ambulatory practice represent a rich and authentic source of learning experiences. In our exploration of students’ reflective accounts, the complexity of the clinical encounter, containing both medical and psychosocial problems, is elicited. Consequently, what is particularly learned and remembered by the students after spending some weeks at a PHC carries the distinctive character of the essentials of general practice [18] , [29] .

In conclusion, involving students to write and reflect on a memorable consultation appears to stimulate them to articulate learning experiences and key features of general practice. It could also be a useful tool for supervisors in order to better understand students’ perspective and learning process during general practice attachments [9] , [30] , [31] .

Acknowledgements

The authors would like to thank the participating students who made this study possible.

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09 December 2017

Publication Status:

10.12968/npre.2017.15.12.600

Library of Congress:

Dewey decimal classification:.

610.73 Nursing

Edinburgh Napier Funded

McLeish, L., & Snowden, A. (2017). Reflection on practice: Consultation skills. Nurse Prescribing , 15(12) , 600-604. https://doi.org/10.12968/npre.2017.15.12.600

reflection on practice consultation skills 1

Prof Austyn Snowden 

Professor School of Health and Social Care

 0131 455 2965

  [email protected]

   

Consultation; reflection; guidelines; pain; pain ladder; antibiotics; melatonin

Monthly Views:

Reflection on practice: consultation skills file is currently unavailable , please contact [email protected] to request a copy, downloadable citations.

Essay on Reflection on Clinical Skills

As a nurse professional I must be full equipped with appropriate skills to offer the right services to my clients. As such, in my clinical practice I applied the blood pressure diagnosis skill. In the exercise I carried out a systematic process involving, wrapping a cuff, pressing the stethoscope, inflating the cuff, listening to the stethoscope and taking measurements. My approach is affirmed by the existing literature, which offers key insights about the process. Consequently, my practice was highly influenced by professional values outlined in local policies and the NMC.In this regard, the report is a reflection of how I applied the blood pressure diagnosis skill in my clinical practice and how the experience impacted my nursing practice.

To measure the manual blood pressure, I used the sphygmomanometer and the stethoscope. First, I welcomed the patient, informed her about my intentions. I also informed the consent and asked her if she had any concern or preferences. I confirmed that the cuff was of the right size for the patient arms circumference. Since the patient was in a seated position, I ensured that her arm was flexed and her elbow was at the same level as the heart.I waited for four minutes for the patient to rest before initiating the measurement process. I then wrapped the patient’s upper arm, one inch above the antecubital fossa, with the cuff and located the brachial artery. Then using one hand, I positioned the stethoscope so that it was over the brachial artery. I then rapidly inflated the cuff of size 16 by 36 cm to 180mmHg, which is within the range of a normal person’s systolic pressure and released air at a moderate rate of 3mm/sec. I recorded the reading on the sphygmomanometer as the systolic pressure when I heard the first knocking sound with the stethoscope. On further deflation, I listened to the heartbeat stop at some point and recorded the reading as diastolic pressure180/120. After waiting for a few minutes, I took the second measurement using an automatic sphygmomanometer. I wrapped the cuff around the patients left arm, turned on the power and recorded the reading as180/114 to affirm my earlier readings. I then pressed the exhaust button to release the air from the cuff and repeated the measurement after 2 minutes using a sphygmomanometer to improve my accuracy. Since the blood pressure was high, I referred the patient for further analysis and management.

Before taking blood pressure measurements, The British and Irish Hypertension Society recommends that a patient should be allowed to rest quietly and comfortably for a period of between 3-5 minutes (Williams et al., 2018). Typically, the rest period reduces anxiety and allows significant drop in blood pressure of up to 75% within the first 10 minutes (Levy et al., 2016). However, some studies suggest that five minutes resting time is not enough and recommend periods of up to 25 minutes (Mahe et al., 2017). Such findings question whether the examination of blood pressure can be effectively made during routine outpatient visits. Waiting for 25 minutes may not be feasible especially in situations where there are limited resources and a high number of patients hence explaining why I allowed a rest of between 3-5 minutes.

According to NMC guidelines, a carer is required to select a diagnosis tool that accurately detects what is being diagnosed (NMC, 2018). My tool of choice for measurement of blood pressure was the sphygmomanometer. Based on robust evidence, a sphygmomanometer is regarded as a standard device for measuring blood pressure (Seongll et al., 2018). I performed the second measurementusing electronic digital sphygmomanometer. Studies show that electronic digital sphygmomanometer significantly increases precision by reducing statistical errors (Padwal & Ringrose, 2018).The British and Irish Hypertension Society recommends a bladder length and cuff width of approximately 80% and 46% respectively of the patient’s arm circumference to reduce errors (Muntner et al., 2019). Since my patient had an arm circumference of between 35 and 44 cm, I used an appropriate cuff size of 16 by 36 cm.

Hypertension is a modifiable cardiovascular risk factor hence correct diagnosis and management depend on accurate measurements (Stergiou et al., 2018). Taking measurements both arms was important in improving the accuracy of the diagnosis(Keisuke et al., 2018).Also, I placed the patient’s elbow at the same level as the heart. According to Medicines and Healthcare Product Regulatory Agency, putting the arm below or above the heart level can lead to underestimation or overestimation of blood pressure (Medicines and Healthcare products Regulatory Agency, n.d.).According to a study conducted by Levy et al. (2016), body posture is also important when determining a persons blood pressure. If I had left the arm unsupported, the muscles might have contracted to increase diastolic blood pressure (Lai et al., 2018).

A healthcare professional should act professionally and in the best interest of the patient (NMC, 2018).When using the sphygmomanometer, I ensured that I wrapped the patient’s upper arm, one inch above the antecubital fossa, with the cuff and then using one hand, I positioned the stethoscope so that it is over the brachial artery. Studies show that placing the stethoscope over the brachial artery is the surest way to measure blood pressure (Smith, 2015).

Moreover, several studies have recommended taking more than one blood pressure reading at intervals especially when high blood pressure or low blood pressure is detected during the first reading(Shahbabu et al., 2016; Kario et al., 2018). However, for effectiveness, the successive readings should be in intervals of between 1-3 minutes and the average of the intervals used to represent the patients’ blood pressure, thus informing my approach (Levy et al., 2016). Equally, I had to use the automated sphygmomanometer to improve the accuracy of the diagnostic process by calculating weighted averages (Seongll et al., 2018). Notably, hypertension and hypotension, which refers to high and low blood pressure can lead to severe complications in patients such as stroke and dizziness. Therefore, hypertension quality metrics that rely on single clinic measurements have a high potential of misclassifying a large proportion of patients (Padwal & Ringrose, 2018). Using a different measurement method is also vital in determining the validity and reliability of measurement instruments (Muntner et al., 2019). The main aim of using the automatic aneroid device was to provide a confirmatory test.

According to NMC standards, healthcare professionals should promote not only non-judgemental care but also be sensitive to patient needs to avoid assumptions, disrespect and poor diagnosis (NMC, 2018).Indulging and conversing with the patient ensured that I support compassionate care. Since the patients’ blood pressure was high, I flagged her case as of top priority. To ensure that I act in the best interest of the patient, I showed her consent while at the same time valuing her right to confidentiality and privacy.

On reflection, I realised that my capability to set a conducive environment for communication with the patient highlighted my ability to deal more efficiently with the situation. I could have faced challenges if I had lacked empathy and compassion (RCN, 2018). My feeling is that by promoting effective communication and being able to relate well to the patient, I significantly improved the accuracy of the diagnosis by proper preparation of the patient for the procedure. Studies show that the ability to connect with patients is essential which explains why the patient felt comfortable under my care (Delaney, 2017). I also discovered that there is a difference in accuracy between manual and automatic blood pressure measurement tools with the automatic one being superior in reliability and validity. Hence in the future, I will use the automatic sphygmomanometer in specific occasions where need arises to improve patient care outcomes.

Nevertheless, carrying out several confirmatory tests is also essential in enhancing the overall effectiveness of the diagnosis process (Delaney, 2017). I felt a range of both negative and positive emotions during the consultation, the patients’ blood pressure was very high,and that disturbed me. In similar situations, I will continue to provide quick referrals and lifestyle education whenever necessary. Generally, the experience helped me understand that I need to research and attend more training opportunities regarding management advocacy on high blood pressure. Also, with more experience and training, I will gain more skills in managing various emotional issues that come with providing care.

Overall, the report offers a reflection on blood pressure by examiningthe process involved in creating a conductive environment for the patient and then taking a measurement using both manual and automatic sphygmomanometer.Taking measures on both arms using multiple diagnoses was important in improving the accuracy of the outcome, considering the fact that patient care is paramount. Other considerations included the positioning of the patient, professionalism and following NMC standards. On reflection, I understood that my positive relationship with the patient, empathy, and compassion contributed significantly to an accurate diagnosis. The experience helped me understand that I am competent, but I also need to attend more training opportunities regarding management of high blood pressure.

Delaney, L. (2017). Patient-centered care as an approach to improving health care in Australia.  College, 25 , pp. 119–123.

Kario, K., Stergiou, S., McManus, R., Ohkubo, T. et al. (2018). Home blood pressure monitoring in the 21st century. The Journal of Clinical Hypertension, 20(7) , https://doi.org/10.1111/jch.13284.

Keisuke, N. K. (2018). Ambulatory blood pressure variability increases over a 19-year follow-up in a clinic on a solitary island.  Blood Pressure Monitoring. 23(6) , pp. 283-287.

Lai, M., Zhou, W., Wang, WY., Wan, TX., Peng, Q., Su, H. (2018). A lower blood pressure threshold to define hypertension: the effect on prevalence, control rate, and a constituent ratio of systolic and diastolic hypertension.  Blood Press Monit. , doi: 10.1097/MBP.0000000000000361.

Levy, J., Geber, L., Wu, X., Mann, S. (2016). Nonadherence to Recommended Guidelines for Blood Pressure Measurement. The Journal of Clinical Hypertension, (18)11 , pp. 1157-1161.

Mahe, G. C. (2017). A minimal resting time of 25 min is needed before measuring stabilized blood pressure in subjects addressed for vascular investigations — s cientific reports, 7(1) , 12893.

Medicines and Healthcare products Regulatory Agency. (n.d.). Retrieved from https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency

Muntner, P., Shimbo, D., Carey, R. M., Charleston, J. B., Gaillard, T., Misra, S., …& Urbina, E. M. (2019). Measurement of blood pressure in humans: a scientific statement from the American Heart Association.  Hypertension ,  73 (5), e35-e66.

NMC. (2018).  Professional standards . Retrieved 2018, from Nursing and Midwifery Council: https://www.nmc.org.uk/standards/code/read-the-code-online/#second

Padwal, R., & Ringrose, J. (2018). How to ensure personalized accuracy in home blood pressure devices: Should we play it by ear?  The Journal of Clinical Hypertension .

RCN. (2018).  Royal College of Nursing . Retrieved 2018, from Principles of Nursing Practice: https://www.rcn.org.uk/professional-development/principles-of-nursing-practice

Seong, C. K. (2018). Comparison of the accuracy and errors of blood pressure measured by two types of non-mercury sphygmomanometers in an epidemiological survey.  Medicine, 97(25) , e10851: doi: 10.1097/MD.0000000000010851.

Shahbabu, B. Dasgupta, A., Sarkar, K., Sahoo, SK. (2016). Which is More Accurate in Measuring the Blood Pressure? A Digital or an Aneroid Sphygmomanometer.  J Clin Diagn Res 10(3) , doi: 10.7860/JCDR/2016/14351.7458.

Smith, L. (2015). New AHA Recommendations for Blood Pressure Measurement.  Am Fam Physician, 72(7) , 1391-1398.

Stergiou, G., Roland, A., Martin, M. et al. (2018). Improving the accuracy of blood pressure measurement: the influence of the European Society of Hypertension International Protocol (ESH-IP) for the validation of blood pressure measuring devices and future perspectives. Journal of Hypertension, 36(3) , pp 479–487: doi: 10.1097/HJH.0000000000001635.

Williams, B., Mancia, G., Spiering, W., AgabitiRosei, E., Azizi, M., Burnier, M., …&Kahan, T. (2018). 2018 ESC/ESH Guidelines for the management of arterial hypertension.  European Heart Journal ,  39 (33), 3021-3104.

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Clarity, feedback, and reflective practice are key, finds Abi Rimmer

“Communication failures can lead to complaints”

— Emily Shepherd, medical adviser, Medical and Dental Defence Union of Scotland (MDDUS)

“Effective communication is a key part of the doctor-patient relationship and has a direct impact on patient safety. At MDDUS we have dealt with many examples of patient complaints as a result of communication failures. Many of these could have been avoided by taking some simple steps.

“One common scenario we encounter is when a doctor issues unclear instructions. Doctors have a duty to discuss their patient’s condition and treatment options in a way that’s easily understandable—this lets the patient make informed decisions. Use clear, simple, and consistent language and avoid complex explanations or jargon.

“Many complaints can be prevented by listening to the patient’s worries and adopting an open and constructive approach. It is important to avoid acting defensively and instead show empathy and foster an atmosphere that encourages questions. The GMC’s Good Medical Practice guidance states that doctors must “give patients the information they want or need in a way they can understand.

“Ask for feedback to gauge how you’re doing”

— Sarah Coope, GP and communication skills trainer and coach

“Firstly, what feedback have you had about your communication skills? It could be formal or informal, from patients or colleagues. Reflect on the feedback and clarify the impression you would like to be making. For example, if you’ve been told you seem rushed and disinterested, then set your intention as being more empathetic and calm.

“Secondly, “observe” yourself during interactions with others to gain insight into what you are doing. Notice the other person’s verbal and non-verbal responses to what you’re saying and doing—do they appear to feel understood, reassured, and respected by you? If not, what, specifically, are you doing or not doing that is getting in the way?

“Thirdly, decide what you are going to do differently, one step at a time. For example, to be more empathetic and a better listener, start by allowing the other person to fully finish what they are saying without interrupting and show that you have heard by recapping what they’ve told you and reflecting back any emotion that you pick up on.

“Finally, ask for feedback to gauge how you’re doing and keep practising until the new skills become automatic.

“Reflective practice is required to improve communication skills”

— Angela Rowlands, senior lecturer in clinical communication, Queen Mary University of London

“Extensive reflective practice is required to develop clinical skills, 1 and improving communication skills is no different. Evidence shows that doctors who attend workshops to improve their skills and then have the opportunity to get feedback about how they communicate in real consultations will learn the most. 2

“Learning to communicate effectively means making the most of every interaction. Simulated patients are often used in communication skills training, giving students and clinicians the chance to immerse themselves within a protected and controlled environment. 3 Although their use has been criticised for the occasional lack of authenticity, simulated patients can give valuable practice opportunities and feedback. 4 5

“Annie Cushing, Vivien Cook, and I have written about a project aimed at supporting students in communicating with patients in clinical settings during their undergraduate years. 6 Students learnt about communication within the consultation process and got immediate, focused, one-to-one feedback. Moreover, they were able to maximise the feedback by immediately applying it to further consultations.

“Doctors can continue their learning over time by self and peer assessment, and attending further courses or workshops.”

  • ↵ Ericsson KA, Krampe RT, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev 1993 ; 100 : 363 - 406 doi:10.1037/0033-295X.100.3.363 . OpenUrl CrossRef Web of Science
  • ↵ Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002 ; 325 : 697 - 700 . doi:10.1136/bmj.325.7366.697   pmid:12351365 . OpenUrl FREE Full Text
  • ↵ Nestel D, Morrison T, Pritchard S. Simulated patient methodology. In: Nestel D, Bearman M, eds. Simulated patient methodology: theory, evidence and practice. John Wiley & Sons, 2014 : 1 - 30 .
  • ↵ Nestel D, Kneebone R. Perspective: authentic patient perspectives in simulations for procedural and surgical skills. Acad Med 2010 ; 85 : 889 - 93 . doi:10.1097/ACM.0b013e3181d749ac   pmid:20520046 . OpenUrl PubMed
  • ↵ Nestel D, Tierney T. Role-play for medical students learning about communication: guidelines for maximising benefits. BMC Med Educ 2007 ; 7 : 3 . doi:10.1186/1472-6920-7-3   pmid:17335561 . OpenUrl CrossRef PubMed
  • ↵ Rowlands A, Cushing A, Cook V. Meeting the students on their own territory. International Journal of Practice based . Learn Health Soc Care 2013 1 : 93 - 7 . OpenUrl

reflective essay on consultation skills

Reflective account example: a community pharmacist reflects on his communication skills

Reflective account

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As the General Pharmaceutical Council’s (GPhC’s) revalidation deadline (31 October 2019) approaches, many pharmacists will be recording their learning and considering how to complete their reflective account.

The following example reflective account is intended to act as a guide to better enable you to complete your own learning record for submission to the myGPhC site. You should not replicate or copy and paste this material, rather create your own entry based on your experience. You should reflect on your own practice and consider how your patients or service users have benefited from your learning.

In your first year of completing a reflective account, you need to reflect on one or more of the following standards:

  • Standard 3 – pharmacy professionals must communicate effectively;
  • Standard 6 – pharmacy professionals must behave professionally;
  • Standard 9 – pharmacy professionals must demonstrate leadership.

The following example is based on standard 3.

Improving my communication technique

What’s your area of work/ who are your service users?

Provide us with a reflective account of how you met one or more of the standards for pharmacy professionals. Give a real example(s) taken from your practice to illustrate how you meet the standards we have selected.

I am a community pharmacist manager working in a small pharmacy chain based in Scotland. I work alongside a pharmacy technician, two dispensers and several pharmacy counter assistants.

My service users vary, but are generally made up of patients, parents/carers, pharmacy staff members and other healthcare professionals (e.g. those from nearby general practices).

It is necessary as a community pharmacist to communicate effectively on a daily basis, whether this is with patients, staff or other healthcare professionals. However, after several years of practice, I realised I had not considered the effectiveness of my communication skills.

When considering the third standard ‘Pharmacy professionals must communicate effectively’, I thought about how I could improve my communication to ensure I am delivering person-centred care. I was conscious that communication encompasses not simply the words I use, but also body language and tone of voice. I wanted to ensure that I was being as effective as possible and where I could make improvements for my patients.

To better understand my current communication style, I asked a pharmacy colleague to observe me while I spoke to a patient about a minor ailment and make notes based on what she thought went well and what did not go well. Prior to the patient consultation I informed the patient that a colleague would be observing, but that the consultation would continue as normal and no details of the patient were going to be recorded. The patient was happy to continue with the consultation with an observer.

After the consultation my colleague collected her thoughts and made a list of points. We discussed these and I was able to find aspects of my professional practice that required improvement, such as consciously changing my body language and trying to ask fewer closed questions. In order to do this, I practiced body positioning in front of the mirror and created a list of open questions that would aid me in future consultations. I shared my learning with the team and encouraged them to let me know if they observed further communication issues.

The colleague who conducted the initial observation has since observed my general consultation and communication skills and provided me with feedback indicating that I have addressed the issues discussed. This has experience has helped me ensure patients are getting the best possible experience from me during consultations.

Before creating your own reflective account, see ‘ Revalidation: how to complete your reflective account ’, which provides a step-by-step guide for pharmacists and pharmacy technicians writing and submitting this vital part of revalidation.

You may also find the following articles on effective communication useful:

  • ‘ Dispensing errors: where does responsibility lie? ’
  • ‘ A day caring for vulnerable people with learning disabilities ’
  • ‘ WhatsApp groups improve communication within pharmacy teams, finds study ’

How the Royal Pharmaceutical Society is supporting members with revalidation

A dedicated revalidation support hub, which also provides more information on the various support services offered is available on the Royal Pharmaceutical Society (RPS) website and includes:

  • RPS MyCPD app – An app supported by The Pharmaceutical Journal. Available for iOS devices via the App Store and Android devices via Google Play . For information on how to use the app, see  ‘ How to use the new ‘RPS MyCPD’ app for pharmacy revalidation ’.
  • Revalidation support service – Members can contact this service by phone (0333 733 2570 Monday to Friday 9:00 to 17:00) or email [email protected] .
  • Revalidation events – Information on the latest events can be found on the website.
  • MyCPD Portfolio – members can create a portfolio allowing you to make records of any CPD you have engaged with and retain these records throughout your career.

You may also be interested in

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Entrustable professional activities: a new approach to supervising trainee pharmacists on clinical placements

The privilege of becoming an rps fellow.

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Paul Rees: ‘Pharmacy First could be the saviour of general practice’

MEDLRN

  • Pharmacist Independent Prescriber Course
  • Minor Illnesses And Acute Conditions Course
  • Setting Up A Private Clinic

Non-medical prescribing reflection examples

  • Non-Medical Prescribing

reflective essay on consultation skills

Why do non-medical prescribers need to learn to become reflective practitioners?

During your non-medical prescribing course and clinical practice, nurse prescribers and pharmacist prescribers will be required to regularly reflect on their clinical practice to develop reflection and reflective practice skills.

Moreover, if you’re undertaking a non-medical prescribing course, you will be expected to submit as part of your coursework many reflective essays, i.e., a reflective account – so understanding what a reflection is and how to reflect is undoubtedly worth the investment.

Do medical prescribers need to reflect on their practice?

There is no one-size-fits-all answer to this question, as the need for reflection will vary depending on the individual and their clinical practice. However, medical prescribers should generally reflect on their practise to improve patient care and ensure they use evidence-based practices. Additionally, reflection can help medical prescribers identify areas where they need further education or training.

Do independent prescribers need to reflect on their practice?

Independent prescribers need to reflect on their practice to ensure that they prescribe safely and effectively. By reviewing their own practice, independent prescribers can identify areas where they may need to improve and make the necessary changes. This is important to protect patients’ safety and ensure that they are receiving the best possible care.

The above is relevant for all non-medical prescribing students, including; (1) future nurse prescribers, ; (2) allied healthcare professionals and (3) pharmacist prescribers wanting to undertake advanced practice training.

What is reflection?

reflective essay on consultation skills

Reflection is a mental process where people examine their experiences to better understand their whole profession. It allows individuals to enhance their work habits or the care they provide to patients regularly. It is an essential, continuous, and routine element of the job of healthcare and social service providers.

Teams comprised of professionals with different backgrounds, skill sets, and working experiences should be encouraged to reflect openly and honestly on what occurs when things go wrong. These practical reflective activities help develop resilience, enhance well-being, and increase professional devotion.

To be reflective during your prescribing practice, healthcare professionals must first be open to new ideas, explore them from various perspectives, be inquisitive – asking questions – and remain patient if the problem isn’t “simple.” (While this may suddenly leap out at you).

Your prescribing practice and reflective accounts need to make transparent to others and what you’re getting wrong or right. Therefore being honest with yourself is essential as a non-medical or independent prescriber.

Why do nurse prescribers, pharmacist prescribers and non-medical prescribing students need to reflect and write reflective accounts?

Reflection may help you learn a lot from your prescribing practice and prescribing decisions. There are several reasons to reflect. You can use it to:

  • Learn from the experience of independent prescribing
  • Improve your prescribing decision-making skills
  • Help you make decisions in the future
  • Identify continued professional development (CPD) needs

You can reflect on anything, but as a non-medical or independent prescriber, you should focus on your prescribing experiences. This will help you understand and develop your skills as a prescriber.

When thinking about your experiences, you should consider both the good and the bad. It’s important to reflect on what went well and what didn’t go so well. This will help you learn from your mistakes as well as your successes. Furthermore, it will ensure you identify gaps in your professional development needs.

There are many different ways to reflect. You can use written reflection, audio recordings, or even video. The important thing is that you’re taking the time to think about your experiences and what you can learn from them.

If you’re not sure how to get started, some helpful reflection templates and examples are below. You can also talk to us at MEDLRN for guidance on how to reflect on your independent prescribing experiences.

Remember, reflection is an integral part of being a successful non-medical prescriber. By reflecting on your experiences, you can improve your practice and make better decisions in the future.

Reflective practitioners and the benefits

The General Pharmaceutical Council, the General Chiropractic Council, the General Dental Council, the General Medical Council, the General Optical Council, the Health and Care Professions Council, the Nursing and Midwifery Council, and the Pharmaceutical Society of Northern Ireland’s top executives have signed a joint statement called Benefits of becoming a reflective practitioner.

https://www.pharmacyregulation.org/sites/default/files/document/benefits_of_becoming_a_reflective_practitioner_-_joint_statement_2019.pdf

This is what they say:

“We are committed to supporting our registrants in their professional development and we recognise the benefits of registrants engaging in reflective practice.

Reflective practitioners are more resilient, and adaptable and have a greater capacity to maintain their registration throughout their careers. They demonstrate professionalism by being able to reflect on their own values and behaviours, and how these might impact the people they care for.

Reflective practitioners are able to make well-informed decisions, using a range of strategies including critical thinking, problem-solving and lifelong learning. They can identify their own development needs and are committed to maintaining their registration by engaging in continuing professional development (CPD).

We would encourage all registrants to reflect on their practice and to use reflective tools and resources to support their professional development.

Reflective practice is a key part of being a healthcare professional. It helps us to learn from our experiences, both good and bad so that we can improve our practice and make better decisions in the future.

How to get started with reflective writing

Most people are unfamiliar with the concept of reflective writing. However, the following comments indicate a lack of clarity regarding reflective writing when it comes to courses and assessments: ‘I thought I wasn’t supposed to use “I” in my work.” ,,,,,,,,,, ‘I won’t say what I truly believe unless it is going to be evaluated.’

The following points will help you to understand what is meant by reflective writing and how it can be used to support your non-medical prescribing course:

  • Reflective writing is a way of exploring and analyzing your own thoughts and experiences.
  • It can help you learn from your own experiences and make better decisions in the future.
  • Reflective writing is different from other types of academic writing as it allows you to share your own thoughts and feelings on a subject.
  • When writing reflectively, you should use first-person pronouns (I, me, my) to share your own experiences.
  • You should also be honest about your thoughts and feelings, as this will help you learn from your experiences.
  • Reflective writing is usually informal in style and can be written in the first or third person.
  • It is important to remember that reflective writing is about your own thoughts and experiences, so you should use “I” when sharing your reflections.
  • When writing reflectively, it can be helpful to use a reflection template or guide. This will help you to structure your thoughts and ensure that you cover all the essential points.
  • Reflective writing is an integral part of the non-medical prescribing course, as it helps you learn from your experiences. By reflecting on your prescribing experiences, you can improve your practice and make better decisions in the future.

What is a reflective essay?

reflective essay on consultation skills

A reflective essay is a type of writing in which you (the author) interact with an audience (readers, listeners, viewers) to describe an experience and how that experience has changed you.

Reflective essays are usually written after a milestone. For example, a student may write a reflective essay at the end of a course of study or after completing an internship or other practical work.

The purpose of a reflective essay is to describe the experience and examine the meaning of the experience and how it has affected you as an individual.

Reflective essays are personal pieces of writing, so they should use first-person pronouns (I, me, my, we, us) and express your own thoughts and feelings about the experience.

Reflective essays can take many different forms. Standard formats include journals, letters to the editor, blogs, and photographic essays.

When writing a reflective essay, it is essential to use descriptive language. This will help the reader to understand your experience and how it has affected you.

It is also important to use concrete details and examples in your writing. This will make your essay more attractive and easier to read.

Finally, remember to proofread your essay before you submit it. This will help ensure that there are no errors or typos in your writing.

Writing critically and reflectively during your non-medical prescribing course

Both critical and reflective may be used in a directive to ‘reflect critically’ on anything. The terms describe a writing trait in which the reader can discern that the text has been carefully considered.

To be critical, you must go beyond description and into the analysis. You evaluate ideas or methods (evaluate), apply them in your work (apply), and defend or refute them (defend). You also reflect on what you have read, thought, or experienced.

In both types of writing, the key features are similar: good, strong, and well-written essays. The major distinctions between critical and reflective writing are as follows:

1 You and your thoughts will be more apparent in your writings.

2 Your personal history – what you have done, thought about, read, and changed throughout your life – is a significant source of evidence in your writing.

3 You are more likely to use the present tense when writing reflectively.

The key features of critical and reflective writing:

Critical Writing 

  • More formal
  • Focuses on ideas and methods
  • Uses evidence from other sources
  • Tends to use the past tense

Reflective Writing 

  • Less formal
  • Focuses on you and your thoughts
  • Uses your personal history as evidence
  • Tends to use the present tense

Reflective writing for non-medical prescribing students and medical prescribers

reflective essay on consultation skills

Non-medical prescribing students and medical prescribers will be expected to:

  • Participate in or observe an incident (such as the care of a patient)
  • Discuss what went well and not so well about it
  • Examine their thoughts about it by linking to relevant theory/policy/science/guidance and to the experience of others in similar circumstances
  • Draw conclusions about what might be done differently next time and how this might improve patient care.

The use of frameworks to help non-medical prescribing students and medical prescribers write reflective essays or reflective accounts

A ‘framework’ is a method for structuring and analyzing an issue, scenario, or experience. It may help you extract the learning points from an event by taking a systematic approach:

  • What happened?
  • What was my role in it?
  • What went well and not so well?
  • What could I have done differently?
  • What did I learn from it?
  • How can I use what I learned in the future?

Reflective writing using the Gibbs Reflective Cycle

The Gibbs Reflective Cycle is a framework for reflection that helps you to think about your experiences and how they relate to your learning. The cycle is made up of six stages:

  • Description
  • Action Plan

These stages can be usefully applied to any reflective writing task.

An example of reflective writing using Gibbs reflective cycle

I recently observed an incident in which a patient was being discharged from the hospital. I was part of the team responsible for their care. I felt that the discharge process could have been better organized and that the patient could have been given more information about their condition and what to expect after leaving the hospital.

I evaluated the situation and identified some areas for improvement. I discussed my observations with the team, and we came up with a plan of action. I learned that it is important to be organized when discharge planning and to make sure that patients are given all the information they need to make a smooth transition from hospital to home. I will use this learning in future when discharge planning.

Example two of a reflective account using Gibbs reflective cycle

When I was first asked to do this reflective essay on weight loss, I was a little apprehensive. I wasn’t sure if I wanted to share my personal journey in this way or not. But after giving it some thought, I decided that it might be helpful for others who are either considering or currently trying to lose weight. So here goes…

I started my weight loss journey about 6 months ago. I had been feeling unhappy with my appearance for a while, and my health was also starting to suffer. I knew I needed to make a change, but I didn’t know where to start. Thankfully, a friend of mine recommended the Atkins Diet, and I decided to give it a try.

The first few weeks were tough. I had to make a lot of changes to my diet and lifestyle, and it was all very new to me. But I stuck with it, and after a few weeks, I started to see results. I felt better, both physically and mentally, and people were starting to notice the difference too.

Since then, I’ve lost a total of 30 pounds, and I’m still going strong. It hasn’t been easy, but it’s definitely been worth it. I’m now at a healthy weight, and I’m feeling the best I’ve ever felt.

The whole experience has taught me a lot about myself. I’ve learned that I’m capable of making big changes in my life, even when it’s hard. I’ve also learned that I’m stronger than I thought I was.

If you’re considering losing weight, or if you’re currently on a weight loss journey, then I encourage you to keep going. It’s not easy, but it’s so worth it. Trust me, I know from experience.

reflective essay on consultation skills

Gibbs’s Reflective Cycle (Gibbs, 1998) helps you to understand and practice your reflective skills. Use the template to reflect on a recent event in which you demonstrated a reflected ability to improve or demonstrate the need for further learning or development.

Description: what happened? 

I had undertaken a supervised consultation as part of the non-medical prescribing course in the presence of my designated medical practitioner(DMP) and university tutor. Mary (pseudonym) middle-aged woman with a previous diagnosis of hypertension, was invited to attend the OSCE, which involved taking a comprehensive medical history in order to undertake a clinical assessment of the patient. Mary was invited to attend the OSCE, and prior to the OSCE, she was informed of the particulars of the assessment, e.g. the presence of my university tutor and DMP etc.

 Mary was called to the consultation room, and verbal consent was gained. The consultation involved the following; undertaking a comprehensive history taking using the Cambridge and Calgary model, taking blood pressure, and an explanation of the pathology of hypertension and its management.

Upon completion of the consultation, I was informed by the DMP I had passed my assessment and feedback was given.

Feelings: what were you thinking and feeling?

As a pharmacist, this was the first time I had undertaken a structured consultation using the Cambridge and Calgary model. However, having been qualified for over 5 years, I was confident with my consultation skills, in particular, my communication skills and my knowledge of the pathophysiology and management of hypertension. In addition, I was comfortable and relaxed when taking Mary’s blood pressure as I have had considerable practice during my placement with taking blood pressure and felt confident when explaining the relevance of the readings as well as offering health advice. After the OSCE, I felt satisfied with the outcome and in agreement with the feedback of my DMP.

Evaluation: what was good and bad about the experience?

On evaluation, the event was good for a number of reasons. Firstly, Mary said she was satisfied with the advice and the explanation she was given regarding hypertension and the relevance of her blood pressure readings. In addition, feedback from my DMP included my good use of communication skills, especially eye contact and body language(NICE,2010). Furthermore, another positive of the consultation was that I was able to follow the Cambridge and Calgary model and address all the relevant assessment requirements. However, a negative of the consultation was that Mary had asked me to quantify how much of various fruits count towards your ‘5-a-day fruits requirements; however, I was a bit unsure and had to double-check the advice with my DMP even though it was correct. As such, I would have liked to have been more confident in providing that advice.

Analysis: what sense can you make of the situation?

Mary had asked me to explain to her what amount of different fruits count toward the ‘5-a-day’ requirement (NHS,2015), and I was unable to provide the answer confidently as mentioned above; this was the ‘part’ of the OSCE that did not go too well. A reason for this was that I had assumed certain health advice is ‘common knowledge and would not require much explanation. As such, It had never occurred that this was a gap in my knowledge. This negative aspect could have been avoided had I thought more deeply about the advice I offered and affirmed the understanding of patients. Conversely, a part of the consultation that did go well was that I was able to utilize the Cambridge and Calgary model to structure my consultations.

This was because I had undertaken considerable learning regarding structuring a consultation and practised the Cambridge and Calgary model on multiple occasions with my DMP and modified it slightly to address my needs. Furthermore, with regards to taking blood pressure, during my training with my DMP, I had reviewed best practice guidelines when undertaken taking blood pressure and asked for regular feedback, which ensured I was constantly improving my technique and skills.

Conclusion: what else could you have done?

As a result of the consultation, I have learned that I must confirm the understanding of the patient with regard to the health advice that is being given (Nursing Times, 2017) and ensure there is no confusion or misunderstandings. In addition, this experience (of undertaking a consultation) has highlighted the importance of ensuring there is structure to consultation and how I can use a model of consultation to suit the needs of the situation (Royal College Of General Practitioners Curriculum, 2010). Furthermore, I would have liked to have undertaken a level 3 clinical medication review (Brent CCG,2014) to determine adherence to the medication, as many hypertensives have poorly controlled blood pressure (heart Foundation,2016) with a lack of adherence to treatment cited as a major reason (Izzat,2009).

Action plan: if the situation arose again, what would you do?

In order to be better prepared to face a similar experience, I have decided I will continually practice using the Cambridge and Calgary model of consultation wherever possible and undertake self-appraisal (Royal College of General Practitioners,2013); in addition, in order to ensure I have adequate knowledge in health education, I will continue to undertake CPD and have decided to attend a training course within the next 4-8 weeks. Also, currently, I am trained to take blood pressure using an electronic machine but am not confident in measuring blood pressure manually, which would be useful if a patient had atrial fibrillation (NICE,2016). As such, I have decided to take further training under the supervision of my DMP to develop this clinical skill.

  • Brent CCG ,2014. Medicines Optimisation:Clinical Medication Review [pdf]. Available at:<https://www.sps.nhs.uk/wp-content/uploads/2016/08/Brent-CCG-Medication-Review-Practice-Guide-2014.pdf> [Accessed 2nd April 2018].
  • Heart Foundation,2016.  Guideline for the diagnosis and management of hypertension in adults [pdf]. Available at:<https://www.heartfoundation.org.au/images/uploads/publications/PRO-167_Hypertension-guideline-2016_WEB.pdf> [Accessed 2 April 2018].
  • Izzat, L.,2009.  Antihypertensive concordance in elderly patients  [Online] Available at <https://www.gmjournal.co.uk/media/21571/gm2april2009p28.pdf> [Accessed on 28 February 2018]
  • National Institution for Health and Clinical Excellence, 2010.  Principles of Good Communication [pdf].Available at:<file:///C:/Users/ProScript%20Link/Downloads/supportsheet2_1.pdf> [Accessed 1 April 2018].
  • National health service, 2015.  Nhs Choices 5 A Day portion sizes . [Online] Available at:<https://www.nhs.uk/Livewell/5ADAY/Pages/Portionsizes.aspx> [Accessed 1st April 2018].
  • National Institute for Health and Care Excellence (2016).  The clinical management of primary hypertension in adults (NICE Guideline 127). [Online] Available at: https://www.nice.org.uk/guidance/cg127 [Accessed 25 February 2018]
  • Nursing Times, 2017.  Communication Skills 1: benefits of effective communication for patients [online]. Available at:<https://www.nursingtimes.net/clinical-archive/assessment-skills/communication-skills-1-benefits-of-effective-communication-for-patients/7022148.article> [Accessed 1 April 2018].
  • Royal College Of General Practitioners Curriculum, 2010.  The GP Consultation in Practice [pdf]. Available at:<https://www.gmc-
  • uk.org/2_01_The_GP_consultation_in_practice_May_2014.pdf_56884483.pdf> [Accessed 1st April 2018].
  • Royal College Of General Practitioners, 2013.  What are consultation models for? [pdf]/ Available at:<http://journals.sagepub.com/doi/pdf/10.1177/1755738013475436> [Accessed 2nd April 2018].

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Author:  Faheem Ahmed

Pharmacist Prescriber, 2x Award-Winning Pharmacist, Pharmacy and Clinic Owner, Founder of MEDLRN and loves sharing his experience with pharmacists.

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reflective essay on consultation skills

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reflective essay on consultation skills

Reflective essay clinical examination and procedural skills (primary care pathways)

  • Released: 06/2017
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reflective essay on consultation skills

This is an assessment that pharmacy professionals are required to complete as part of the Primary Care Pharmacy Education Pathway . You are only permitted to access and complete this assessment if you are participating in this learning pathway.  

Note for learners: essays will be marked within two weeks of the essay deadline and not within two weeks of submission Before you attempt this reflective essay assessment, you may find it useful to access the CPPE e-lecture on Reflection . This 30-minute learning programme looks at how we reflect and why this is a useful tool for pharmacy professionals. It will also allow you to develop your reflective skills and give practical tips on how to apply these to improve your practice.

This programme is not openly available, please see the details above.

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This is one of the essays that pharmacy professionals are required to complete as part of these learning pathways. Please note that your assessment will not be marked if you are not a part of the learning pathway.

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Prepare to pass

Please ensure that you familiarise yourself with the information in the assessment handbook and the CEPSAR book about the clinical examination and procedural skills assessment and reflective essay. The assessment handbook and CEPSAR book have all the information that you need to pass this essay.

Essay submission

The word count for this essay is between 800 and 1000 words.

Once you access the assessment and press the ‘submit’ button, you will see our terms and conditions for reflective essays. Once you click ‘begin’ you will see a page to enter your completed reflective essay. At this point you will not be able to exit the page and come back to the essay at a later date. We suggest you write your essay in a word document or other suitable file and then copy and paste your final submission into the assessment submission area once you have entered the assessment submission area. This allows more time for true reflection and ensures you have a personal copy as evidence of your continuing professional development.

You will need to access the relevant assessment to submit your essay. You can do this by searching for the topic using the search facility. The assessment is highlighted by the ‘A’ icon. Once you reach the webpage you can click on ‘Access’ to submit your essay.

Plagiarism and generative AI

Academic malpractice is any activity – intentional or otherwise – that includes plagiarism, collusion, fabrication or falsification of results, and is considered a serious offence. Plagiarism is presenting the ideas, work or words of other people or documents without proper, clear and unambiguous acknowledgement. It can also include a close paraphrase of written words. One way to prevent plagiarism is not to construct a piece of work by cutting and pasting or copying material written by someone else into something you are submitting as your own work. In recent years, the capabilities of generative artificial intelligence (AI) have rapidly evolved, with tools such as ChatGPT becoming widely available. Not using generative AI responsibly can be considered a form of plagiarism. As such, we ask that its use is openly and honestly declared. The University of Manchester Artificial Intelligence (AI) Teaching guidance states that “ presenting work created by Generative AI without suitable acknowledgement is plagiarism, and must be treated using the same principles and processes as plagiarism of a person ”. However, CPPE and The University of Manchester also recognise that, for some learners, tools such as generative AI can be beneficial in co-creating an essay from a series of their own concepts and ideas, where the individual may struggle with the task of long-form writing. When used appropriately, generative AI tools have the potential to enhance teaching and learning, and can support inclusivity and accessibility. This is considered to be a responsible use of generative AI.

We use reflective essays for a range of our learning programmes to encourage you to engage in reflective practice. The benefits of reflective practice are based on your personal learning and experience. Reflective practice can lead you to make positive changes for the benefit of people who use your services. Using a generative AI tool may help you in shaping and constructing your essay, but the personal elements that you need for your essay to pass cannot be generated by AI. If you use a generative AI tool, then you need to find a way to blend your personal experiences with the suggestions that the tool makes. If you use a generative AI tool to support you, you will need to complete a declaration as part of the essay submission process.

On submission, you may be asked to make a series of declarations. These will ask you to confirm you have followed good practice in constructing your essay and the work you are submitting is your own, original work. Additionally, you will need to declare whether you have chosen to use a generative AI tool to support you with this process.

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COMMENTS

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  9. PDF Reflection on practice: consultation skills

    Reflection on practice: consultation skills Abstract The aim of this case study is to illustrate how prescribing decisions can be enhanced through the use of systematic consultation, reflection on ...

  10. Reflection on practice: Consultation skills

    Reflection on practice: Consultation skills. The aim of this case study is to illustrate how prescribing decisions can be enhanced through the use of systematic consultation, reflection on practice and relevant information seeking. The enhanced Calgary-Cambridge model was used to structure the consultation. Reflection on practice was achieved ...

  11. Essay on Reflection on Clinical Skills

    Essay on Reflection on Clinical Skills. Published: 2021/11/18. Number of words: 1921. As a nurse professional I must be full equipped with appropriate skills to offer the right services to my clients. As such, in my clinical practice I applied the blood pressure diagnosis skill. In the exercise I carried out a systematic process involving ...

  12. Consultation Skills In Relation To Nurse Prescribing

    Many studies have looked at the influence of communication skills on prescribing and other factors related to the consultation. (Richards 1999) Many authorities (Butler et al 1998) advise that the prime skills associated with the prescribing process are: Adequate exploration of the patient's worries. Adequate provision of information to the ...

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    Provide us with a reflective account of how you met one or more of the standards for pharmacy professionals. Give a real example(s) taken from your practice to illustrate how you meet the standards we have selected. ... The colleague who conducted the initial observation has since observed my general consultation and communication skills and ...

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  17. Non-medical prescribing reflection examples

    Non-medical prescribing reflection examples. Gibbs's Reflective Cycle (Gibbs, 1998) helps you to understand and practice your reflective skills. Use the template to reflect on a recent event in which you demonstrated a reflected ability to improve or demonstrate the need for further learning or development.

  18. Module 5 assessments

    Use the following link to access the reflective essay Reflection on patient feedback. Direct observation of practice: consultation skills one. You will undertake two consultation skills assessments in your workplace. Your assessor will directly observe your practice and use the CPPE Medicines Related Consultation Assessment Tool (MR-CAT) form ...

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  20. Reflective essay clinical examination and procedural skills ...

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  21. Consultation Skills In Relation To Non Medical Prescribing Nursing Essay

    Consultation Skills In Relation To Non Medical Prescribing Nursing Essay. To illustrate this I will utilise the model of reflection adapted from (Boud, Keogh and Walker 1985) as to focus on influences on prescribing, psychology of prescribing working through the consultation, decision-making and therapy, and referral.

  22. How to Write a Reflective Essay

    2 Be mindful of length. Generally, five hundred to one thousand words is an appropriate length for a reflective essay. If it's a personal piece, it may be longer. You might be required to keep your essay within a general word count if it's an assignment or part of an application.

  23. A complete guide to writing a reflective essay

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