A framework and toolkit of interventions to enhance reflective learning among health-care professionals: the PEARL mixed-methods study
Authors: Bion Julian , Brookes Olivia , Brown Celia , Tarrant Carolyn , Archer Julian , Buckley Duncan , Buckley Lisa-Marie , Clement Ian , Evison Felicity , Smith Fang Gao , Gibbins Chris , Hayton Emma-Jo , Jones Jennifer , Lilford Richard , Mullhi Randeep , Packer Greg , Perkins Gavin D , Shelton Jonathan , Snelson Catherine , Sullivan Paul , Vlaev Ivo , Wolstenholme Daniel , Wright Stephen ,   the PEARL collaboration
Published: August 2020

Background
Although most health care is high quality, many patients and members of staff can recall episodes of a lack of empathy, respect or effective communication from health-care staff. In extreme form, this contributes to high-profile organisational failures. Reflective learning is a universally promoted technique for stimulating insight, constructive self-appraisal and empathy; however, its efficacy tends to be assumed rather than proven. The Patient Experience And Reflective Learning (PEARL) project has used patient and staff experience to co-design a novel reflective learning framework that is based on theories of behaviour and learning.

Objective
To create a toolkit to help health-care staff obtain meaningful feedback to stimulate effective reflective learning that will promote optimal patient-, family- and colleague-focused behaviours.

Design
A 3-year developmental mixed-methods study with four interlinked workstreams and 12 facilitated co-design meetings. The Capability, Opportunity, Motivation – Behaviour framework was used to describe factors influencing the behaviour of reflection.

Setting
This took place at five acute medical units and three intensive care units in three urban acute hospital trusts in England.

Participants
Patients and relatives, medical and nursing staff, managers and researchers took part.

Data sources
Two anonymous surveys, one for patients and one for staff, were developed from existing UK-validated instruments, administered locally and analysed centrally. Ethnographers undertook interviews and observed clinical care and reflective learning activities in the workplace, as well as in the co-design meetings, and fed back their observations in plenary workshops.

Main outcome measures
Preliminary instruments were rated by participants for effectiveness and feasibility to derive a final set of tools. These are presented in an attractively designed toolbox with multiple sections, including the theoretical background of reflection, mini guides for obtaining meaningful feedback and for reflecting effectively, guides for reflecting ‘in-action’ during daily activities, and a set of resources.

Results
Local project teams (physicians, nurses, patients, relatives and managers) chaired by a non-executive director found the quarterly reports of feedback from the patient and staff surveys insightful and impactful. Patient satisfaction with care was higher for intensive care units than for acute medical units, which reflects contextual differences, but in both settings quality of communication was the main driver of satisfaction. Ethnographers identified many additional forms of experiential feedback. Those that generated an emotional response were particularly effective as a stimulus for reflection. These sources of data were used to supplement individual participant experiences in the nine local co-design meetings and four workshops to identify barriers to and facilitators of effective reflection, focusing on capability, opportunity and motivation. A logic model was developed combining the Capability, Opportunity, Motivation – Behaviour framework for reflection and theories of learning to link patient and staff experience to changes in downstream behaviours. Participants proposed practical tools and activities to enhance reflection ‘in-action’ and ‘on-action’. These tools were developed iteratively by the local and central project teams.

Limitations
Paper-based surveys were burdensome to administer and analyse.

Conclusions
Patients and health-care staff collaborated to produce a novel reflective learning toolkit.

Future work
The toolkit requires evaluating in a cluster randomised controlled trial.

Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 32. See the NIHR Journals Library website for further project information.