Introduction

There is general agreement that reflective practice is an essential skill for dental professionals, but are we really reflecting and gaining the potential benefits, or just ruminating and putting our wellbeing at risk? This article will highlight the difference between reflection and rumination and look into how we can ensure that our reflective practice is beneficial, not only to our patients, but also to our own learning and mental health.

Reflection

The General Dental Council (GDC), in their joint statement with the other healthcare regulators, define reflection as ‘the thought process where individuals consider their experiences to gain insights about their whole practice'.1 Ideally, these insights not only highlight personal strengths and areas of success, but also encourage the practitioner to become aware of areas for development. This process, known as reflective practice, involves thinking about our experiences and subsequently acquiring new knowledge and understanding in order to facilitate ongoing professional development.2

The benefits of reflective practice are widely recognised and have been summarised by Nathwani and Martin.3 They include promotion of critical thinking and deeper understanding, improved collaboration, enhanced quality outcomes, improved staff and patient relationships, and decreased burnout. As such, the GDC expects all dental schools and postgraduate training providers to ‘support the development of a reflective, professional registrant', especially as reflective practice is thought to be essential in developing professional identity.4 It is also expected that all registered dental professionals undertake reflective practice as part of their ongoing enhanced continuing professional development. However, true reflective practice is not easy to undertake, and in order to truly gain benefit, training is usually required. Dental students are now commonly taught how to use reflective models, such as Rolfe et al. 5 or Gibbs,6 but many current practitioners may not be familiar with these, and most untrained written reflection tends to be descriptive rather than being useful by enhancing insight and self-awareness.

Many barriers to reflection have been highlighted, including logistical matters, such as lack of time or the absence of a known reflective model. Other more personal reasons relate to a lack of trust in the purpose or use of the reflection, perfectionism, fear of retribution, or a reluctance to admit mistakes. Unfortunately, perceived barriers have likely increased following the Dr Bawa-Garba medico-legal trial, and consequently the Health Education England guidance for dental foundation trainees on reflection states ‘it is essential that in all your reflections...that you do not describe events as mistakes or accidents'.7

In order to reflect effectively, the dental professional needs to feel in a position to confront the experiences, good or bad, and address both the experiential learning gained and process the emotional response to the situation. They need to be able to identify successes and have insight as to the cause of the success, but also admit failure and address the negative emotions that consequently emerge. If this is not addressed, true reflection cannot occur, and the practitioner will tend towards rumination.

Rumination

Rumination can be defined as ‘repetitively thinking about the causes, consequences and symptoms of one's negative affect'8 or alternatively, ‘an emotion-focused coping response whereby individuals try to get more insight into their dysphoric mood following an event by repeatedly thinking about the event, without employing active problem-solving techniques'.9 Rumination is a type of thinking that focuses on the past and the negative aspects of the experience and is associated with guilt, shame and blaming oneself for what happened. As a result, rumination can lead to increased stress, anxiety and insomnia and is a known risk factor for depression and even suicidal ideation. It also results in impaired decision-making, avoidance behaviour and, consequently, does not facilitate learning or professional growth.

We can all think of a clinical case where the outcome was not as intended and how it played on our minds for days on end. Were we reflecting on the situation as to what we could learn from it and producing action plans for the future, or were we ruminating over and over with the guilty feeling of failure, and convincing ourselves that the next thing would be a letter from a solicitor or the GDC? Did we turn to a trusted colleague to discuss the case and our emotional response to it, or did we internalise our feelings of shame and anxiety? If this rumination is allowed to persist and is not identified and managed, it can lead to the unhelpful behaviours noted above. As dental treatment without a diagnosis is unlikely to remedy pain, the tendency of telling clinicians to become more resilient without identifying the cause of the problem is not going to improve wellbeing within the profession.

Rumination can occur in all aspects of our lives. However, as reflective practice is particularly encouraged during dental training, this can unfortunately exacerbate the ruminating tendencies in dental students and trainees. Failure is part of learning but how this failure is managed can have a significant effect on the individual. For example, if a student exposes a pulp of a tooth by accident, how is this dealt with? Do the processes which are required for patient safety (for example, completing a Datix form) ensure appropriate individual reflection occurs? Currently, wherever a blame culture exists, it is not easy to admit mistakes and therefore rumination is more likely.

Factors predisposing to rumination

People who tend to have a low self-image or low self-esteem, who are already suffering from anxiety and stress, or have a tendency to focus on the negative aspects of a situation, are more prone to rumination.10 Due to evolutionary factors, humans have a tendency for a negative bias as it is more important for survival to avoid a potentially harmful situation than seek out a potentially beneficial one.11Negative information has a stronger influence on our behaviour, motivation and decision-making than positive information and, therefore, we tend to act on this first. In addition, this negativity bias has been shown to be stronger in women than men.11 Consequently, if these negative tendencies become the predominant way of thinking, they predispose the individual to rumination. It has also been suggested that high job strain (defined as high demand, low control at work) is positively associated with rumination,12 and that the environment in which the reflection occurs can affect the outcome.

Satisfying the basic human psychological needs with respect to autonomy and relatedness can contribute to a culture of psychological safety, which is important in decreasing the likelihood of rumination and facilitating reflection. Consideration should therefore be given to the environment in which reflection occurs, especially after a negative incident, and the support that is given to the practitioner. In addition, it has been noted that true reflection is difficult to undertake alone, and that by offering different perspectives and supportive challenges to a practitioner's way of thinking, an individual is helped to move through the reflective cycle, away from focusing on the negatives towards moving forward to learning and future action.13

The recent rise in mental illness in young adults has been well-documented and reasons for this are being sought.14One potential cause highlighted is the use of social media which, due to the constant comparisons and approval-seeking behaviours, reduces self-esteem and encourages perfectionism.15 However, with the relatively recent moves to online educational work-based assessments (WBAs) and portfolios within dentistry, the potential effects of these on trainees' wellbeing should also be considered. A recent study in the computing field has suggested that although personal informatic systems can facilitate self-reflection, the constant availability of self-tracking technologies may inadvertently lead to a focus on negative thoughts and emotions and consequently result in rumination.10 This rumination is thought to be most likely if attached to high-stakes goals which are tied to the individual's identity or self-worth, as in the case for a dental student or trainee. Therefore, as social media companies are currently expected to consider the effects of their platforms on consumers' mental health, it may be prudent for educational and training establishments within dentistry to consider the potentially negative effect of their online platforms on their trainees' behaviour. This may include the frequency of engagement, what time of the day or night it is being accessed, and whether engagement results in appropriate goal setting and action plans or is simply reinforcing performance-related anxiety.

Strategies to encourage reflective practice

In order to encourage reflective practice rather than rumination, there are a range of strategies that can help. These include:

  • Education in the benefits of reflection and identifying the difference between this and rumination

  • Establishing a culture of trust and empathy

  • Training in the use of appropriate reflection models

  • Training of mentors in facilitating reflection

  • Setting time for peer-/group-based reflection

  • Providing autonomy in how the reflection is undertaken

  • Designing appropriate online self-reflection portfolios/WBAs

  • Facilitating the practitioner's individual self-care measures.

Culture of trust

One of the key emotions that results in rumination is shame. Without effective support, involvement in an adverse incident can lead the practitioner to question their professional identity and believe that they are a ‘bad' clinician. Professor Brené Brown in her TED talk (2012) explains that ‘shame is an unspoken epidemic, the secret behind many forms of broken behaviour'. She goes on to say that when an individual feels shame, they feel alone and unworthy of connection. However, empathy is ‘the antidote to shame' and, together with courage and vulnerability, can help build resilience.16 Therefore, in order prevent rumination and build resilience in the healthcare setting, a culture of trust, openness and compassion is vital to not only promote growth and development within the staff, but also to identify where mistakes have been made and improve patient safety. Following the Bawa-Garba case mentioned above, trust of trainees in the reflective process was significantly harmed and this will take time to rebuild. However, every effort should be made to do so.

Training of mentors

As mentioned earlier, the quality of reflection is enhanced by having another person present.13 Therefore, in order to promote the learning and development of trainees, training of mentors is essential. Not only should mentors be familiar with the various models and methods of reflection, but training should also be given in how best to facilitate effective reflection and in applying coaching techniques to encourage a growth mindset and avoid rumination. In addition, mentors should be aware of those trainees most at risk of rumination, what social supportive environment they have available to them, and be aware of possible maladaptive behavioural habits shown by their trainees.

Peer-/group-based reflection

In addition to reflecting with a mentor, the benefits of peer- or group-based reflection have been recognised.13 These include gaining deeper insights and perspectives, challenging assumptions, or development of emotional intelligence, empathy, communication skills and self-regulation. These can become effective learning environments based on trust, where individual members can share best practices and learn from not only their own experiences, but those of others. An effective example of this within the healthcare setting is Schwartz Rounds.17 These are group forums that provide an opportunity for staff from all disciplines to come together and reflect on the emotional and social aspects of their work which are facilitated by trained staff. It provides a safe and confidential environment to enable a panel of three or four staff to relate a story about an experience that has had a significant impact on them. These Schwartz Rounds have now been implemented across the NHS (including in some dental schools). Studies have shown that attendance at such events facilitates reflection and is associated with an increased focus on compassion and appreciation of colleagues and a significant improvement in staff psychological wellbeing.17

Individual self-care measures

In addition to a supportive environment, individuals can help counteract rumination about previous events or mistakes by engaging in self-care measures.9 These may include:

  • Recognising that self-worth is not dependent on your successes or failures

  • Being kind to yourself and practising self-acceptance

  • Recognising that your failures make you human

  • Seeking feedback from trusted peers/mentors to gain another perspective and challenge assumptions

  • Engaging in mindfulness to counteract negative and ruminating thoughts

  • Seeking professional help if required.18

Conclusions

Reflection and rumination are very different sides of the same coin and we need to be acutely aware of how, and when, we are utilising them in our professional development. Reflection can help us learn from our experiences, improve our performance, cope with stress and avoid burnout. Alternatively, rumination can lead to negative emotions, decreased motivation and impaired decision-making, which can impact on patient care. Therefore, in order to reflect effectively, we each need to adopt a curious, constructive and compassionate mindset that is focused on learning from the past in order to improve the future for ourselves, our trainees and our patients. Discussion with a trained colleague or mentor can help ensure beneficial reflection rather than destructive rumination takes place.