7. Evidence-Informed Practice and Learning Through Critical Reflection

Across the recent past, efforts to improve quality, reliability, and service-user outcome and experiences, have promoted the move away from practices based on tradition and rituals, towards the implementation of best available evidence in guiding interventions (Kumah et al. 2019). Health and social care professionals are expected to apply the best available evidence to inform their clinical decision‐making, roles, and responsibilities (Kelly et al. 2015; Andre et al. 2016; Kumah et al. 2022). The many advantages to the service user, professional, organisation, and health and social care systems of the use of best available evidence have been espoused. These include improved outcomes for service users and increased transparency, enhanced cooperation between professionals, greater job practitioner satisfaction, and improved system efficiency (Tickle-Degnen & Bedell 2003; Nevo & Slonim-Nevo 2011; Kelly et al. 2015).

Two main concepts have been associated with the application of evidence into healthcare practice: evidence‐based practice and evidence‐informed practice. Evidence-based practice (EBP) is well-established in health and social care and regarded as the norm or gold standard for the delivery of effective healthcare (Kumah et al. 2022). The universally accepted definition of evidence‐based practice (EBP), adapted from the definition of evidence‐based medicine, is “the conscientious, explicit and judicious use of the best evidence in making decisions about the care of the individual patient” (Sackett et al. 1996). In recent times, the concept of evidence-informed practice is increasingly being adopted instead of evidence-based practice (Kumah et al. 2022). Evidence-informed practice (EIP) has been described as the “assimilation of personal judgement and research evidence regarding the efficiency of interventions” (McSherry et al. 2002). It is an approach to care that involves combining research evidence regarding the efficacy of interventions with the professional’s experience and judgement and the client’s preferences and values, while demonstrating cognisance of the context of the situation (Nevo & Slonim-Nevo 2011).

Best evidence, from an EBP perspective, is categorized in a hierarchy of quality (Evans 2003). Systematic reviews or meta-analyses are considered to be the gold standard in EBP. Randomized controlled trials are thought to provide strong evidence and are rated as second-level evidence. Evidence, believed to hold less value in EBP, include surveys and all forms of qualitative research. In this regard, EBP has been criticized for privileging statistical and meta-analytical techniques over qualitative research and interpretive, discursive, or narrative approaches to knowledge, which can simplify and distort complex situations (Morrell & Learmonth 2015). The term evidence-informed practice (EIP) grew out of a need for a more inclusive understanding of evidence (Davis et al. 2000). This has been contested as the debate about what constitutes best evidence for EBP has become more sophisticated over time and additional forms of evidence in informing the delivery of healthcare have gained recognition (Rycroft-Malone 2008). Acknowledging that EBP traditionally based clinical decision making on empirically supported treatments, protocol adherence, and standardisation, the American Psychological Association (2006) consider the application of EIP to be more comprehensive, describing the process as a synthesis of empirically supported treatments with client characteristics, culture, and preferences. Both EBP and EIP aspire to incorporate evidence to improve quality of care and the terms are often used interchangeably in the literature (Gambrill 2007).

Reflection is described as “a metacognitive process including connecting with feelings that occur before, during and after situations with a purpose of developing greater awareness and understanding of self, other, and situation, so that future encounters with the situation including ways of being, relating, and doing are informed from previous encounters” (Wald 2015). Critical reflection contributes to conceptual understanding of health-and-social-care-related issues and has the power to transform experiences into meaningful learning. To reflect critically involves more than pausing, thinking back over events, problem solving, and planning future practice based on what is already known and how issues are typically managed. Additionally, it demands critically appraising the content, process, and premise underlying the experience to make better sense of what has happened and reach a better understanding of the experience. Reflection has scope to give meaning to experience, turn experience into practice, link past and present experiences, and prepare us for future practice. 

How Critical Reflection Works

Reflection, in helping to improve self-awareness and encourage critical thinking (Ghanizadeh 2017) may improve our ability to learn (Mann et al. 2009). By linking concrete real-world experiences to professional knowledge, it can help make sense of practice situations.

Theorists (e.g., Brookfield; Schön; Kolb; Gibb; Mezirow) have each emphasized aspects of the reflection process they consider important and developed methods of reflecting that encourage analysis of experiences to enhance learning. For instance, Schön (1991) emphasizes Reflection-in-Action and Reflection-on Action. Reflection-in-action encourages practitioners to think about what is happening during the interaction or event—thoughts, feelings, decisions, actions, consequences, and meaning. Reflection-on-action encourages practitioners to consider the events at a later time, allowing time to process experiences, feelings, and actions while taking into account new information and an opportunity to link the experience of theory and knowledge.

Brookfield’s reflective theory (Brookfield 1995) requires the identification of significant events within an interaction or experience: it encourages practitioners to think about what happened in the event; feelings, thoughts, and actions during the event; what happened after the event; and the learning from that event. Brookfield also recommends accessing different perspectives and questioning assumptions. Gibbs (1988) highlights the importance of identifying other possible behaviour or action choices. Kolb (1984) proposed the experiential learning cycle, which emphasizes the role of reflection in learning. In this model, learning begins with an event (concrete experience) which the individual reflects upon (reflective observation). The reflection leads to the formation of new ideas (abstract conceptualisation) which can then be applied in the future resulting in new experiences (active experimentation). Knowledge gained from reflection does not arrive in a logical and structured fashion but instead requires an active participatory element (Eaton 2016).

Reflection and Professional Identity

Reflection and Interprofessional Collaboration

• Use meaningful clinical situations and rely on IPECP theory and evidence (theory to practice).
• Engage a well-trained facilitator during group discussions or two facilitators with complementary expertise (IPECP and critical thinking), where possible.
• Support the reflective approach using a rigorous and explicit process based on precise criteria. To achieve critical reflection, planning and explicit training in critical thinking are key.

Reflective Writing

Thinking reflectively usually involves looking back at something, analysing an idea, experience, or event, and thinking carefully about its meaning. Committing this reflection to paper involves an exploration and an explanation of events, not just a description of them. Reflective writing is not a straightforward description of an event to convey information or support simple decision-making, but a critical practice with a consequent utility to improve health and social care. Reflective writing requires the professional to see and understand what is happening above and below the surface. Situations must be analysed critically to uncover assumptions, biases, motives, and understand others’ perspectives, taking time to consider how thoughts and feelings interact to influence behaviour. Adopting this approach facilitates the professional to learn more about themselves, the situation, their practice, and others.

Application of Reflective Writing in Practice

To ensure reflections are critical and not merely descriptive, the professional might consider applying the guidance in this list:

• Use description only to serve the process of reflection.
• Show awareness of one’s thoughts, values, attitudes, assumptions—ask oneself questions about the event.
• Identify the impact of emotion but don’t be emotive.
• Make connections between behaviours, emotions, ideas.
• Recognize possible change.
• Show evidence of valuable learning.
• Identify the implications of this learning on practice.

Further prompts that can be used to structure reflective writing, to help ensure reflection goes beyond description and demonstrates critical thinking, are outlined in Table 7.3.

Critical Reflection in Refugee Health

• The impact of power and privilege of a majority/dominant culture (likely the health/social care professional’s) on the professional’s behaviours—are they collaborative or autocratic—and on the behaviours of the refugee/asylum seeker—are they confused, quiet, subservient, angry?
• How the spaces, regulations and routines of where the refugee/asylum seeker lives might impact behaviours and mood during interactions.
• How the refugee is experiencing difference; think about their norms and how their current situation differs from these.
• How they are experiencing: autonomy, adjustment, assimilation, identification, inclusion, community.

Working in a multi-disciplinary team, professionals need to think critically about how they work with their colleagues and how well they function as a team. When being critical across disciplines, the wellbeing of the refugee remains the central focus. Colleagues’ behaviour should be considered in the context of their disciplinary background, experience, professional bias, and expertise. It is important to appreciate the different perspective they bring to any situation so that mutual understanding of the problem can be found. Future interactions should be planned on the basis of what is learned from critical reflection on collaboration.

The environment beyond that of the immediate setting in which an event took place can impact the behaviours and activities within the micro level setting. Cognizance of and reflection on wider contexts in which services operate can assist more meaningful problem solving and future planning. Potential factors to consider at these levels are displayed in Figure 7.2.

Below there is a suggested activity to practice critical reflective writing related to interactions with a service user who has refugee experience.

This chapter has outlined two important practices that health and social care professionals can implement to ensure quality in their practice and to improve the services that they deliver. Through critical reflection on their experiences of working with people with refugee experience, professionals can become aware of areas that work well, in addition to those where further development is needed. Taking an evidence-informed approach enables the individual service user’s unique experiences, conditions, goals, and preferences to be taken into account when delivering and planning care. Integrating these approaches into their practice can help to ensure that health and social care professionals are able to strive to deliver optimal care for people with refugee experience.