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A framework and toolkit of interventions to enhance reflective learning among health-care professionals: the PEARL mixed-methods study Julian Bion ,1* Olivia Brookes ,2 Celia Brown ,3 Carolyn Tarrant ,4 Julian Archer ,5 Duncan Buckley ,6 Lisa-Marie Buckley ,6 Ian Clement ,7 Felicity Evison ,8 Fang Gao Smith ,9 Chris Gibbins ,10 Emma-Jo Hayton ,11 Jennifer Jones ,4 Richard Lilford ,12 Randeep Mullhi ,13 Greg Packer ,13 Gavin D Perkins ,14 Jonathan Shelton ,7 Catherine Snelson ,11,13 Paul Sullivan ,15 Ivo Vlaev ,16 Daniel Wolstenholme ,17 Stephen Wright 7 and the PEARL collaboration† 1Department of Anaesthesia & Intensive Care Medicine, University of Birmingham, Birmingham, UK 2University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK 3Population Evidence and Technologies, University of Warwick, Coventry, UK 4Social Science Applied to Healthcare Improvement Research (SAPPHIRE) Group, Department of Health Sciences, University of Leicester, Leicester, UK 5Royal Australasian College of Surgeons, Melbourne, VIC, Australia 6Patient and Public Involvement Representative, Birmingham, UK 7Critical Care, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK 8Informatics Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK 9Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK 10Acute Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK 11Acute Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK 12Warwick Centre for Applied Health Research and Delivery, University of Warwick, Coventry, UK 13Critical Care, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK 14Critical Care Medicine, Warwick Medical School, Warwick Clinical Trials Unit, University of Warwick, Coventry, UK 15Acute Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK 16Behavioural Science Group, University of Warwick, Coventry, UK 17National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Yorkshire and Humber, Sheffield, UK *Corresponding author j.f.bion@bham.ac.uk †Members of the PEARL collaboration are listed in Appendix 1. 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 DOI: 10.3310/hsdr08320 Health Services and Delivery Research 2020 Vol. 8 No. 32 © Queen’s Printer and Controller of HMSO 2020. This work was produced by Bion et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. vii (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-, familyand 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. ABSTRACT NIHR Journals Library www.journalslibrary.nihr.ac.uk viii