NU678 Unit 6 Reflection Synthesis of Ten Log Entries Example

Ten Entries, Three Themes and One That Never Moved: A Reflection Synthesis of a Final Psychiatric Rotation, Read Through Schön's Reflection-on-Action and Reflection-in-Action

[Student Name]

Purdue University Global

NU678: PMHNP Diagnosis and Management Across the Lifespan Clinical III

Unit 6 Reflection Synthesis

[Instructor Name]

[Date]

The log entries are composite; quotations from them are bracketed placeholders, since the entries belong to the student.

Method

I reread all [ten] of my reflective log entries from the rotation in the order I wrote them, over two sittings. On the first reading I marked every decision point: any moment where I described choosing what to do, whether in the visit or afterward. There were [forty-one]. On the second reading I wrote a short label beside each mark, such as "waited for preceptor," "asked mother about sleep," or "ran out of time." I then grouped similar labels until three themes accounted for [thirty-four] of the forty-one marks. The remaining seven were scattered and did not form a pattern.

This is a simple version of the thematic analysis Braun and Clarke (2006) describe, in which a researcher codes the data, collects codes into candidate themes, and checks the themes back against the data. I did not use it as a research method, but its steps kept me from deciding in advance what I would find. I checked each theme against every entry, not only the ones I remembered.

Where the Themes Appear

The pattern across entries was clearest when I listed each theme with the entries in which it appeared.

1. Deferring to the preceptor: entries [1, 2, 3, 4 and 6].

2. Families in the room: entries [2, 3, 5, 7, 8 and 9].

3. Time pressure in short follow-up visits: every entry, 1 through 10.

The first theme stops appearing after entry six. The second appears throughout but changes character. The third appears in every entry and does not change.

Theme 1: Deferring to the Preceptor

It first appears in entry one, where I wrote about a patient with worsening anxiety: "[I knew what I would do but waited to hear what she thought first.]" In the first four entries I describe forming a plan and then holding it back until my preceptor spoke, and in two of those entries her plan was the same as mine. By entry six the pattern is weaker: I proposed a plan but prefaced it with an apology. By entry eight, I wrote: "[I told her my plan and why, and she changed one thing.]" In entries nine and ten, I describe proposing plans and defending them when questioned.

What this means for practice. Deferring was not humility so much as avoidance of being wrong in front of someone. The change came when my preceptor began asking for my plan before she offered hers, which shows how much the structure of supervision shapes a student's independence. In practice I will not have a preceptor to defer to, and the entries suggest I am ready to stand behind my own plans while still asking for review.

Theme 2: Families in the Room

In entry two I wrote about an adolescent's mother who answered every question for her son: "[I felt I was losing the visit to her.]" Early entries describe families as obstacles to the "real" interview. The change begins in entry five, when a daughter's comment about her father's drinking changed my plan. By entry eight, I wrote about asking a mother to describe her son's sleep in detail because she saw it and he did not: "[She knew things he could not tell me.]" In entry nine I describe deliberately planning time with the family and time alone with the patient.

What this means for practice. I began the rotation treating families as interference and ended it treating them as a second source of history, while still protecting time alone with the patient. That shift will matter in a clinic that sees all ages, where for children and older adults the family's account is often essential.

Theme 3: Time Pressure in Short Follow-Up Visits

Every entry mentions time. In entry one: "[Fifteen minutes was not enough to ask about side effects and mood.]" In entry ten: "[I ran over again and the next patient waited.]" I looked for change and found none. I tried starting with the most important question, I tried a pre-visit rating scale, and I tried writing the plan during the visit. Each helped a little in one entry and then disappeared from the next.

The honest finding of this synthesis is that one problem did not improve at all, and that the rotation gave me more practice at being short of time than at solving it.

What this means for practice. I have not yet found a way to fit a psychiatric follow-up into fifteen minutes without leaving something out. This is partly a system problem, since short follow-ups are set by the clinic, and partly a skill I have not learned: deciding in advance what a particular visit must cover and what can wait. I will ask experienced clinicians in my first job how they structure a short visit, and I will check a sample of my notes each month for what I consistently leave out.

Reflecting on Action and in Action

One well-known account distinguished reflection-on-action, thinking back over what happened after the event, from reflection-in-action, noticing and adjusting while the event is still happening (Schön, 1983). My early entries are almost entirely reflection on action. In entry two, for example, I described realizing after the visit that I should have asked the mother to step out. By entry eight, the entries describe changing course during the visit. I wrote: "[When she started to answer for him, I turned to him and asked what he thought, and she stopped.]"

That shift is the clearest sign of growth in the ten entries. It suggests that writing reflections after visits eventually changed what I noticed during them. A systematic review of reflection in health professions education found that the evidence supporting reflective exercises is largely theoretical, and that reflective capacity varies and may develop with guided practice and supportive environments (Mann et al., 2009). My entries are not evidence for any general claim, but they are consistent with that idea: the reflection became faster and moved into the visit.

Three Differences Between Entry One and Entry Ten

1. In entry one I waited for my preceptor's plan; in entry ten I proposed and defended my own.

2. In entry one I saw a parent's presence as interference; in entry ten I planned time with the family and time alone with the patient.

3. In entry one I realized my mistakes after the visit; in entry ten I sometimes caught them during it.

And one thing that did not change: in both entries, I ran out of time.

Limits of This Synthesis

The entries were written by me, about me, for a graded course, and they may present my decisions in a more favorable light than an observer would. I tried to reduce this by marking every decision point rather than only the ones I remembered, and by including the theme that shows no progress. A synthesis read by my preceptor, who saw many of these visits, would test the themes against a second view.

References

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa

Mann, K., Gordon, J., & MacLeod, A. (2009). Reflection and reflective practice in health professions education: A systematic review. Advances in Health Sciences Education, 14(4), 595-621. https://doi.org/10.1007/s10459-007-9090-2

Schön, D. A. (1983). The reflective practitioner: How professionals think in action. Basic Books.