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38 OPINION
Shrina Nathwani and Katy Martin
DOI: 10.1308/rcsfdj.2021.9
A dentist’s guide to reflection:
a framework for use in clinical practice
by Shrina Nathwani and Katy Martin
How can reflection benefit
dentists and their patients?
Authors: Shrina Nathwani*, Consultant in
Oral Surgery, Surrey and Sussex Healthcare
NHS Trust, UK; and Katy Martin,
Registrar in Oral Surgery, Birmingham
Community Healthcare NHS Trust, UK
*Corresponding author:
E: shrina.nathwani1@nhs.net
Keywords: Reflection in dentistry, reflection
in dental practice, reflective practice,
continuing professional development
FACULTY DENTAL JOURNAL January 2021 • Volume 12 • Issue 1OPINION 39
Reflection is an integral component of education, with and Chevannes advising against the total reliance on
increased emphasis on the use of reflective practice in reflection in training as beginners will require a degree
developing the dental care professional. While reflective of nurturing and direction from their supervisors.6
practice is a key feature in both undergraduate and
postgraduate dental training, the skill of knowing how The controversies surrounding the case of Dr Bawa-Garba
and when to reflect is not easily developed. raised several questions around the use of reflective mate-
rial in legal cases relating to medical negligence. Although
Reflective practice facilitates learner development in the GMC has since confirmed that personal reflections
two ways: 1) by encouraging learning of new knowledge, can only be shared on a voluntary basis as evidence to
and 2) through exploration of existing processes and demonstrate insight, there is a tangible loss of trust across
information. In dentistry, there is a natural gravitation the healthcare profession.7 The Williams review on gross
towards the development of technical and clinical aspects negligence manslaughter in healthcare also stated that
of healthcare delivery. With increasing time pressures and ‘reflective notes are far more likely to be used in sup-
service demands, the development of reflective capacity port of an individual rather than against them’ but the
and professional insight is at risk of being neglected.1 residual fall out from the Bawa-Garba trial has inevitably
caused reservation in how healthcare professionals choose
While the need for reflective practice is becoming to reflect.3 A survey carried out by the British Medical
increasingly prevalent across all healthcare sectors, Association determined that 81% of junior doctors had
learners are often assumed to have the necessary skills altered their reflective style following the Bawa-Garba legal
to reflect, without actually having the appropriate time case8 and this remains a challenge when reflective practice
or framework to do so effectively. Given that reflecting is such an integral part of training.
from professional experiences has been suggested to be
more beneficial in developing personal and professional Reflection, self-assessment and metacognition are
skills than learning through formal teaching, perhaps an all key components required to develop professional
emphasis should be made on how to reflect in dentistry, insight; ‘to have insight into one’s performance and
rather than simply stipulating that it is a requirement.2 practice, to recognise personal strengths, weaknesses
and deficiencies […] is universally accepted as one of
Reflective practice in dentistry the primary requirements of a competent practitioner
Reflective practice is an intrinsic part of healthcare pro- within the health professions’.9 It would therefore seem
vision and training, and it has become synonymous with prudent to suggest that reflection and development of
continuing professional development (CPD). The use of personal and professional insight are symbiotic, and one
reflection ‘leads to personal insight, improved practice simply cannot exist without the other.
and greater professionalism’,3 all of which are key at-
tributes to developing a safe and holistic practitioner. Why reflect?
A competent reflective practitioner continuously reflects
Guidance released by the General Dental Council (GDC) on experience and is capable of doing this in action to
discusses the requirement to include an element of benefit future actions.10 In medical education, reflective
reflection in a CPD record.4 The enhanced CPD scheme practice is rapidly becoming a competence in its own
devised by the GDC necessitates reflection following CPD right; it enhances personal responsibility for learning and
activities, acknowledging the importance of reflection in supports professional development.11 Trainees are ‘encour-
assuring patients that the dental professional is continu- aged to learn from the experience of existing and novel
ously learning. It also aids in shaping and constructing an situations, drawing on, interpreting and integrating the
individual’s personal development plan (PDP). A PDP is information these present in order to support the develop-
compulsory for all dental practitioners, and can provide ment of new behaviours’.12 Reflection can aid development
a structured and supported process for individuals to of self-directed learning, enhance motivation, transform
reflect on their own learning, performance and achieve- practice in a meaningful way and ultimately, improve the
ments.5 A PDP should be continuously reviewed and quality of care practitioners are able to deliver.13
adapted following the experiences of the clinical learner,
and personalised to facilitate personal, educational There are numerous models available to facilitate
and professional development. Interestingly, there is no reflection but the themes are similar across all models:
reflective template for practitioners to use, with the GDC what happened, why does this matter and what are the
acknowledging the individualistic nature of reflection.4 next steps?13 It is important for an individual to be able
to develop a sense of the problem at hand, elaborate
Dental training places a large emphasis on reflective a conclusion and be able to apply that conclusion to
practice in professional development through the use practice, before repeating the process. This process can
of workplace-based assessments. When amalgamated be applicable to the learning of new things or the devel-
with supervisor feedback, reflective comments allow the opment of existing knowledge and processes. One could
learner to reflect more deeply and analytically. The com- argue that when developing a clinical skill, a learner is
bination of extrinsic feedback with learner reflection unable to transition from ‘unconsciously unskilled’ to
stands as a powerful teaching aid, encouraging learners ‘unconsciously skilled’ without demonstrating reflective
to take control of their own learning requirements and capacity and insight. It is important to recognise that re-
appropriately highlight further training needs. This is flective practice is not simply about self-indulgence but
particularly important for junior trainees, with Fowler instead about attempting to perceive how things are.6
FACULTY DENTAL JOURNAL January 2021 • Volume 12 • Issue 140 OPINION
Shrina Nathwani and Katy Martin
When to reflect safety. Outcomes of such events can often result in
In healthcare, there is often a reliance on quantitative system changes as well as individual adaptations to
measures to identify quality of care and formulate practice, to prevent things from going wrong in future.
what is best practice. This usually involves adherence However, it is important that reflective processes are
to evidence-based practice, policies and procedures, not just focused on negative events but also on positive
of which the outcomes are usually measurable against experiences so that these can be replicated in future
current standards. Reflective practice can also help practice and develop the confidence of the team.
guide best practice, identifying new areas for research,
encouraging the development of new evidence and When reviewing an event, either alone or in a group,
audit of existing practice.14 The benefits and barriers to the reflector determines what happened, their
reflective practice are summarised in Table 1. thoughts and feelings, experiences of others and most
importantly, considers ‘why?’.6 In a dental team, the
Reflective practice is not just an individual process, and consolidation of experiences from multiple perspec-
it can be effectively utilised to improve team perfor- tives can help us understand the links between what
mance, patient safety and overall healthcare experience. we do now (our current practice) and how we might
This can range from reflection following the manage- improve (our development of practice).15 These
ment of an individual patient, personal performance, collaborative reflective activities are reliant on good
patient experience, communication and professionalism communication and rapport in the team, without fear
to collaborative reflection following a learning activity of retribution.
or significant event. The importance of individual and
organisational reflective practice is outlined in Figure 1. Regular team meetings can promote collaborative
reflection by supporting and questioning learning, and
The investigation of a serious incident can facilitate can encourage interprofessional feedback from other
both individual and team reflection, allow application members of the team. Reflection in a team can also
of lessons learnt to future care and improve patient enhance both personal and collective responsibility
for professional development, and facilitate learning
Table 1 Benefits of and barriers to reflection6,13 and analysis of outcome as well as influencing clini-
........................................................................................................................... cal practice. The change in attitude, knowledge and
skills can influence our behaviour, and can encour-
Benefits Barriers age experiential learning on both an individual and
Collaborate personal and Inexperience of individual team platform.16
professional experience
Reflecting can promote greater wholeness of experience
Promote communication Lack of time to the practitioner while also encouraging strategies
within team to bring things out into the open in a safe and confi-
Replicate positive events in Lack of motivation dential environment.6 One could argue that without
future the use of reflective practice, the individualistic nature
Allow changes for safer Fear of retribution of providing dental care is lost and we instead simply
practice become technicians carrying out technical skills with no
development of insight or room to improve care.
Improve staff and patient ‘Tick box exercise’
relationships How to reflect
Opportunity to improve and Insecurity and self-esteem of Learners have varying preferred learning methods and
explore new ways to tackle individual reflective processes are no different. Reflection is a
problems personal process and there is simply no right or wrong
way to reflect appropriately. Written reflections can
Promote critical thinking, and Desire to be perfect be creative or analytical, with learners encouraged to
develop insight into how we focus on the learning rather than a full discussion of
think and act an anonymised patient encounter. Learners should be
Reduce risk of burnout Absence of insight encouraged to engage in reflective practice, of both
positive and negative situations, as a crucial part of
Introduce/build on new ideas Seen to be used solely for
personal and professional development, and ultimately,
and question learning serious incidents/negative
to promote safer and more effective patient care.
experience
Develop deeper Seen to be narcissistic/ The Conference of Postgraduate Medical Deans
understanding of self-indulgent discusses the importance of reflections being not just
experiences, actions and a regurgitation of an experience but instead encourag-
impact on others ing learning and development of a future action plan.17
Improve competence and Managing expectations (both Essentially, written reflection should not substitute
identify areas to improve personal and wider) other processes required to record and escalate serious
incidents. In a busy clinical environment, learners
Contribute to quality Absence of reflective model and their supervisors are often faced with challenges
improvement specific to dentistry of clinical and time pressures, which can affect the
FACULTY DENTAL JOURNAL January 2021 • Volume 12 • Issue 1OPINION 41
ability to engage in an effective reflective process. It Figure 1 An overview of reflective practice
is important that learners maintain courage, curios- ......................................................................................................................................................................
ity, determination and commitment to the reflective
process in order to take responsibility for actions, and
encourage the development of professional insight
and identity.6
It is vital that a reflective model in dentistry can be Organisation and teams
applicable to both practical and theoretical skills. The • Reflection on quality of systems
aim of a framework (Figure 2) is to encourage critical • Lessons learnt and changes made
thinking, personal, professional and collaborative de-
velopment, and to support provision of evidence-based,
safe, patient centred care.
Planning: reflection before action Safer systems Safer culture
This stage encourages an inquisitive approach to the
event. It develops the curious practitioner inviting
questions before an event has even taken place, which Optimise
allows critical review as well as collaboration of previ- patient care
ous experiences. When applied to a practical skill, the Individual healthcare
learner reviews the available evidence and how this can professionals
be applied to a clinical environment. This stage can Leadership and education Safer • Reflection on quality
enable communication with peers, consolidation of professionals of their work
experiences and identification of a practical solution to • Lessons learnt and
a clinical endeavour. changes made
Implementation: reflection in action
Reflection in action combines both an experiential
and emotional perspective, and supports a continuous
implementation and cognitive feedback loop. This
allows consolidation of feedback from patients, peers
and other team members to develop an emotional Discussion
response to an event. This stage aids enhancement of Reflective practice has been shown to improve the
self-awareness, allows progress of an experience and process of andragogy as well as outcomes for patients. A
encourages learners to make sense of construct. framework to guide the dental practitioner can support
and promote both individual and collaborative learning.
Concept development: reflection on action Reflection is most effective when interactively shared,
Concept development facilitates deconstruction of an whether with a team or a suitable mentor. It is a process,
event, encouraging the learner to analyse what he or and one that can be learnt. Thus far, models have
she has gained through the implementation phase. This remained in the realms of the educational literature, leav-
stage questions both the process and the outcome, and ing clinicians to tackle the process of reflection in this
supports analytical thinking for learners to establish modern era independently and often without adequate
whether they achieved their goals. Although concept training or experience.
development encourages learners to review the conse-
quences of their actions, it is important that the focus Dentistry consists of experiential learning, and the work
is on the entire process and not just the outcomes of of Kolb16 and Schön18 should therefore not be dismissed.
an event. Performed during the task, reflection in action facili-
tates active thinking and experimentation with regard
Action: reflection for action to reasoning and purpose. Reflection on action encour-
The reflection for action phase helps learners to adopt ages learners to consider the activity and how it has
a transformative perspective, questioning their actions progressed the learning or resulted in an unexpected
and encouraging development of an action plan for fu- outcome, allowing for improvement.
ture events. This stage urges learners to adopt a deeply
inquisitive and analytical approach, taking ownership The accomplished clinician will often consider the
of their own learning and development (either inde- activity before it is even performed, planning for
pendently or with a supervisor/team). Reflection for the activity by collating previous experiences, often
action can act as a supportive framework for the entire subconsciously. Many will benefit from a debrief
dental team to review a situation, collaborate, provide after the activity and will be able to link experiential
feedback and determine how future interventions can learning in this way to enhance their development
be managed effectively. for the future such as engagement with a course. This
approach encourages a transformational perspec-
Figure 3 outlines the application of this model to a tive by promoting development of self-esteem, self-
clinical situation. awareness, self-motivation and self-affirmation while
FACULTY DENTAL JOURNAL January 2021 • Volume 12 • Issue 142 OPINION
Shrina Nathwani and Katy Martin
also supporting flexibility, application of learning and Reflection has, however, been shown to lead to a culture
learning from failure. of openness, empathy and compassionate care. As dental
professionals continue to face and deal with society
Dental clinicians need to apply critical thought to what (and the need to be socially responsible), reflection also
they do so they can integrate their skills, knowledge, provides an outlet and an opportunity for mindfulness.
attitudes and understanding. They need reflection to ex-
pand their knowledge, and to assess their own progress Ultimately, the coordination of care and promotion of
by identifying strengths and weaknesses, growing their patient safety highlights the regulatory onus of reflection
strengths and remedying their weaknesses. This takes in dental education. Reflective learning can transform
self-assessment. Equally, reflection is necessary to assess ‘textbook outcomes’ to ‘gold standard’ dental care.20
treatment outcomes, be prepared for and amend unex- Consequently, there needs to be understanding among
pected outcomes, and work in an oral healthcare team. the dental community of the value of reflection in
competence-based education and that it will improve the
The combination of experience and reflection are crucial quality of patient care. It is easy to become goal focused
aspects of developing both practical and professional and be unmotivated, resulting in difficulty with the
practices in healthcare delivery. The GDC emphasises reflective process and therefore bypassing it. There is
this as it expects all dental schools and training providers value in undertaking reflection early in a dental career so
to ‘support the development of a reflective, professional that like the clinician, it can grow and develop with time.
registrant’19 but it would be unwise to presume that den-
tal registrants are competent in reflective practice. Simi- Just as there is focus on the learner, for those in a posi-
larly, enhanced CPD demands reflection following an tion as dental educator, the process of reflection has
activity, adapting a quantitative approach to a qualitative its constraints: the subjective nature of reflection, time
one, formalising the significance for lifelong learning. restrictions on providing the scaffolding opportunities and
thereafter, the facilitation of reflection itself. It requires
It underpins professional activity and behaviours, justify- careful planning and implementation, with requirements
ing the decisions and actions undertaken by clinicians. of learning outcomes, instructional methods, prompts,
It also enables communication with patients to ensure feedback and follow-up plans. Dental educators need to
formulation of appropriate decision making in complex provide consistency in learning the art of reflection across
treatment plans as well as with colleagues to share both the curriculum and with all trainees, teaching it as a vital
good and bad experiences to reduce stress and isolation. skill that develops the learner in a conducive environment.
Equally, dental educators must be trained and must model
Evidence demonstrating the true effect of reflection on the processes of reflective practice themselves.
learners and their development remains scarce. Reflec-
tion in dentistry is much behind other healthcare profes- Conclusions
sions such as nursing in that dentistry is more focused There continues to be a requirement for further
on development of practical procedures and techniques. research and development in the role of reflection in
Figure 2 Framework for reflection
............................................................................................................................................................................................................................................................
• Assessment and planning of • Continuous implementation and
intervention cognitive feedback loop
• What/How/When/Who • Support application to individual/
• Utilisation of evidence and team practice
previous experience • Awareness of limitations
• Incorporation of team and • Incorporate instantaneous
individual experiences feedback from patient and peers
• Why is this intervention of value...? Planning Implementation
Reflection Reflection in
before action action
• Learning and reconstruction of Action Concept • What have you gained through
intervention Reflection for development implementation?
• How can I adapt...? What other action Reflection on • Reflection on outcome and other
choices were available? action potential conclusions in relation to
• Application of learning evidence
• Incorporate feedback following • Consequences of actions
intervention • To what extent did I achieve...?
FACULTY DENTAL JOURNAL January 2021 • Volume 12 • Issue 1OPINION 43
Figure 3 Application of reflection framework to clinical event
............................................................................................................................................................................................................................................................
Reflection before action: Reflection before action:
• What is the procedure? • Extraction of UL6
• How will I carry this out? • Electively raise a mucoperiosteal flap, section roots and
• When will this take place? elevate separately
• What evidence is available? • Early morning as patient is taking apixaban
• If previously performed, how can I improve/ • Consider Scottish Dental Clinical Effectiveness
duplicate previous outcomes? Programme guidance
• How can I work with my team to deliver • Previous extractions were difficult due to patient anxiety
optimal patient outcomes? • Discuss with nursing team to ensure all equipment
• Why is this intervention of value? available
• Patient X is also nervous so will require additional
Reflection in action: support
• What is going well? • Patient X is in pain and UL6 is unrestorable
• Utilising feedback from both patient and team
• How can I support my team? Reflection in action:
• Do I need to stop? • Patient X is tolerating procedure well, nursing team is
• How does this look compared with previous providing excellent support and patient is happy
interventions? to continue
• Sectioning of roots has improved visualisation
Reflection on action: • Minimal bleeding noted
• What was the outcome?
• How can I improve the outcome and Reflection on action:
experience? • Successful extraction – patient X coped well and gave
• Was the experience for patient/team/ positive feedback to reception staff
myself optimal? • Sectioning could have been improved as palatal root was
• To what extent did I achieve what I set out difficult to elevate
to do? • Focus not just on outcome but also overall experience
• I was anxious about raising a flap and could have
Reflection for action: improved…
• Recount of intervention
• How did I feel? How did the patient feel? Reflection for action:
• Utilise feedback from other team members • I was anxious as I haven’t performed this procedure for
• How can I adapt? a while and was concerned about how patient X would
• Can I audit this process? cope with challenging treatment
• How can I apply this learning to • Nurse reported that patient X had coped well compared
similar situations? with previous visits
• Learn from failure/success – a success in one • Do I need to attend an oral surgery course to improve
situation may be failure in another my confidence?
dentistry, whether this be to consider the benefits or 10. Schön DA. The Reflective Practitioner. London: Temple Smith; 1983.
how to overcome barriers to its effective utilisation. 11. Ahmed M, Arora S, Carley S et al. Junior doctors’ reflections on
patient safety. Postgrad Med J 2012; 88: 125–129.
12. Foster-Turner J. Coaching and Mentoring in Health and Social Care.
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