Using videos in a smartphone app logbook to aid obstetricians and gynaecologists with reflection following critical events

Abstract

Introduction

Reflection is essential for continuous professional development. Many opportunities to reflect during training in obstetrics and gynaecology are not utilised. A Smartphone App (Healthcare Supervision Logbook), allows doctors training in obstetrics and gynaecology to view videos to aid reflection. The App incorporates a comprehensive logbook of practical skills. A self-facilitated reflective process, prompted by offering the viewing of a video when logging an event such as a shoulder dystocia, has been integrated into the logbook. The objective of this study was to evaluate how this function aids reflection.

Methods

Forty doctors training in obstetrics and gynaecology undertook a shoulder dystocia drill as part of a mock examination. After completing the drill, participants scored their performance on a proforma, before watching a video of simulated standard management for shoulder dystocia on a Smartphone. Participants then re-scored themselves before completing a survey. This assessed their agreement with three statements on a five-point Likert scale.

Results

50% of participants marked themselves lower after watching the video. 100% agreed or strongly agreed that watching the video helped them reflect on the shoulder dystocia drill. 80% agreed or strongly agreed that they would feel more prepared to deal with shoulder dystocia as a result of using the video to reflect. 93% agreed or strongly agreed that they would be willing to use a Smartphone App with videos to aid reflection following critical events. Student’s t test showed that viewing the standardised video clip on the App resulted in a significant down-marking (P<0.0005).

Conclusions

Many emergency scenarios in obstetrics and gynaecology unfold quickly and are rapidly resolved, doctors-in-training need to use opportunities for self-directed reflection. Using the video self-reflection function integrated into Healthcare Supervision Logbook Smartphone App could help to prompt this process, which could be utilised in other specialities and disciplines.

Introduction

Reflection is recognised as an important skill for continuous professional development in obstetrics and gynaecology as well as in other medical specialities. The General Medical Council in the UK states in its core guidance, Good Medical Practice, that all doctors should regularly reflect on their standards of practice and the care they provide.¹ Evidence of personal reflection is now also a requirement for revalidation of doctors in the UK. The Royal College of Obstetricians and Gynaecologists (RCOG) states that by reflecting on clinical situations and performance, professional values and patient and team interactions, that doctors in obstetrics and gynaecology can help develop their clinical skills, understanding, self-awareness and professionalism.² The RCOG suggests that any clinical or professional experience in which a doctor has been directly involved can form the basis for reflection. This can include a difficult or challenging situation (eg, with a poor outcome or involving difficult relationships with colleagues) or a positive and rewarding experience (e.g. a good result following effective team working).

A logbook function on a Smartphone App (Healthcare Supervision Logbook), used to facilitate reflection among trainees and consultants in obstetrics and gynaecology has been in use since January 2015 at Sheffield Teaching Hospitals, UK. Healthcare Supervision Logbook is a Smartphone App developed in the obstetrics and gynaecology department at Sheffield Teaching Hospitals.³ It has a number of functions and comes in both trainee and supervisor versions. Trainees in obstetrics and gynaecology use Healthcare Supervision Logbook to provide day-to-day feedback in their training after every session (clinic, theatre, on-call etc.) that they attend. Consultant supervisors use Healthcare Supervision Logbook to provide feedback on a trainee’s performance after each session.

The App also has an advanced logbook of practical procedures in obstetrics and gynaecology, comprising all of the procedures and events which are anticipated to occur within the obstetrics and gynaecology department at Sheffield Teaching Hospitals (figure 1). This is identical on both trainee and supervisor versions of Healthcare Supervision Logbook. This logbook function prompts the user to record the level of supervision they had for a procedure (if they are a trainee) or if they were supervising a trainee or not (if they are a supervisor). Users can also record details of any complications and a comment if desired. Each logbook entry recorded also provides the user with an option to record a reflective entry about the event they are logging. The content of the App is fully modifiable via a content management system and can be changed simply and easily. The content management system has a function which allows a link to a video to be inserted into each logbook skill.

Figure 1.

shows a screenshot of the logbook function in Healthcare Supervision Logbook Smartphone App.

When logging certain critical events, such as involvement in shoulder dystocia or post partum haemorrhage, there is a prompt for the user to view a video to aid their reflective processes (figure 2). There is also a link to a short guide on how to use the video to reflect in an effective way. Therefore a self-facilitative reflective process, prompted by offering the use of a video when logging involvement in a critical event, has been integrated into the Healthcare Supervision Logbook Smartphone App. This novel function is anticipated to be a helpful solution to facilitate reflective processes in this busy work place environment.

Figure 2.

shows an extended screenshot of the logbook reflection function within Healthcare Supervision Logbook Smartphone App, in this case for a shoulder dystocia.

Methods

To evaluate this function of Healthcare Supervision Logbook, 40 obstetrics and gynaecology trainees in Yorkshire, UK took part in a study. All participants undertook a shoulder dystocia drill as part of a formal objective structured clinical exam (OSCE). Fourteen were in year two of training (ST2) undertaking a locally organised OSCE before going up to year three (ST3- the first year as a registrar). The other 26 participants were in years ST4-ST5 undertaking a formally organised practice OSCE for the MRCOG exam. All participants had yet to become members of the RCOG. The project was registered as a service evaluation at Sheffield Teaching Hospitals.

After completing the shoulder dystocia drill station in the OSCE participants rotated to a rest station. At this rest station participants scored their performance on a proforma adapted from a recognised obstetric drill course before watching a video of gold standard management of shoulder dystocia on a Smartphone. Participants were then asked to re-score themselves before completing a three question survey. This assessed their agreement with three statements using a five point Likert scale. The three statements were ‘The video helped me to reflect on the shoulder dystocia drill’, ‘I will feel more prepared to deal with shoulder dystocia as a result of using the video to reflect on my performance’ and ‘I would be willing to use a Smartphone App with videos of critical events to aid reflection’. Participants were made aware that this station was not part of the exam, would be anonymous and that they could score the questions as openly and honestly as they wished.

Student’s t test was used to compare the pre-video viewing self-assessment scores and the post-video self-assessment scores to assess if there were statistically significant changes in score. Binomial logistic regression analysis was used to assess the effects of pre-video viewing score, the answers to the three feedback questions using the questionnaire instrument and the trainee’s training grade (ST2, ST4 or ST5) on the likelihood that the trainees down-marked their performance after viewing the video.

Results

The number of participants who marked themselves lower on the profroma was 52.5%. Of these participants, 71% marked themselves lower by one mark, 14% by two marks and 5% lower by three marks. There was no different between the ST2 group and the ST4/5 group regarding likelihood to mark themselves lower.

As regards agreement with the three statements on a five point Likert scale: 100% of participants agreed or strongly agreed that watching the video helped them reflect on the shoulder dystocia drill, 80% agreed or strongly agreed that they would feel more prepared to deal with shoulder dystocia as a result of using the video to reflect on their performance and 93% agreed or strongly agreed that they would be willing to use a Smartphone App with videos to aid reflection following critical events. A full summary of the results can be seen in table 1.

Table 1.

Agreement with the survey statements, which the participants were asked to score on a five-point scale after viewing the video and completing the reflective exercise

Statement	Summary of responses
The video helped me reflect on the shoulder dystocia drill	Strongly disagree: 0% Disagree: 0% Neither agree nor disagree: 0% Agree: 47.5% Strongly Agree: 52.5%
I will feel more prepared to deal with shoulder dystocia as a result of using the video to reflect on my performance	Strongly disagree: 0% Disagree: 2.5% Neither agree nor disagree: 17.5% Agree: 42.5% Strongly Agree: 37.5%
I would be willing to use a Smartphone App with videos of critical events to aid my reflection	Strongly disagree: 0% Disagree: 0% Neither agree nor disagree: 7.5% Agree: 42.5% Strongly Agree: 50%

Student’s t test (paired-t test) was used to compare the pre-video score and the post-video score and showed that viewing the standardised video clip resulted in a significant down-marking from 11.73±1.585 to 11.06±1.819 with a decrease of 0.662±0.763 (t (40)=5.496, P<0.0005).

A binomial logistic regression model was used to assess (1) the effects of pre-video viewing score, (2) the answers to the three questions on the questionnaire instrument and (3) the participant’s training grade on the likelihood that the trainees down-marked their performance after viewing the video. The logistic regression model was not statistically significant (χ2 (9)=14.783, P=0.097). None of the factors examined were significant predictors for down-marking: answer recorded for question one (χ2 (1)=0.269, P=0.604), answer recorded for question two (χ2 (3)=1.830, P=0.608), answer recorded for question three (χ2 (2)=3.143, P=0.208), specialty training grade (χ2 (2)=0.464, P=0.793) or pre-video viewing score (χ2 (1)=1.649, P=0.199).

Discussion

Each obstetrics and gynaecology trainee in the UK is required to complete eight reflective logs each year during their training. This number has increased from four to six to eight over the last 3 years, recognising the value of reflection for the development of life-long learning and good medical practice. Trainees in obstetrics and gynaecology in the UK are also required to record a reflective entry in their portfolios if they are involved in a serious incident or a complaint. Likewise, reflection is becoming an increasingly important part of annual appraisal and revalidation for consultants in the UK.

In learning theory reflection integrates skills, knowledge, values and attitudes allowing assimilation and reordering of concepts, skills, knowledge and values into pre-existing knowledge structures within the learner’s cognitive framework.⁴ Using reflection is said to lead to growth of the individual morally, personally psychologically and emotionally.⁴ This is the difference between feedback and reflection. Feedback promotes technical efficiency whereas reflection allows the professional to know the larger context of their work and use this knowledge for lifelong learning.⁵

There are multiple definitions of what reflection actually is and what it involves. Three elements of reflection have been defined: (1) Awareness of self and the situation (monitoring); (2) Critical analysis and understanding of both self and the situation (evaluation); (3) Development of new perspectives to inform future actions (planning).⁶ Similarly, Hatton and Smith propose that the components of good critical reflection are linking past, present and future experience; integrating cognitive and emotional experience; considering the experience from multiple perspectives; reframing the experience; stating the lessons learnt and planning for future learning or behaviour.⁷ The viewpoint that learning results from transmission of knowledge is moving towards a viewpoint that ‘actively constructed’ knowledge underpins self-regulated lifelong learning.⁸ Central to this is reflection, which is an essential component of awareness and active control over the cognitive processes we use as life-long learners.⁶

Reflection generally follows a meaningful encounter or event. In obstetrics this is often an emergency situation such as the management of a shoulder dystocia, abnormal fetal heart rate pattern or post partum haemorrhage. For trainees in obstetrics and gynaecology, their management of such emergency events is often unseen by a supervisor- usually because the events unfold quickly and are usually rapidly resolved. Skilful facilitation of reflection by educational leaders begins with the recognition of opportunities for the trainee to reflect on a case or clinical scenario and providing them with the opportunity to reflect- usually through the use of open questions. Doctors who are no longer training are expected to self-facilitate their own reflection on critical events. However, many opportunities to reflect on events in obstetrics and gynaecology are lost. This may be because of a busy workload and a consequent lack of time to reflect⁹ or a lack of clear mechanisms to aid this reflective process. Some doctors may view reflection as a tick box exercise from which they derive little benefit.⁹ In addition, clinical teachers are often not skilled in facilitating reflection,^{4 9} which is another reason for a lack of uptake of these opportunities. Absolute pragmatism and concrete thinking have tended to prevail in medical discussions when trying to facilitate reflection and are potential barriers to good reflective processes- open questions and freedom to think laterally are important.⁴

Previously, electronic logging of activities has been shown to increase the frequency of reflection,¹⁰ therefore using a smartphone app logbook to prompt and facilitate reflection is a logical step in helping to facilitate this reflective process. Leaners reviewing videos of themselves participating in an emergency drill to aid their reflective processes is now a well-established technique and is used at several obstetrics emergency courses run in Yorkshire, UK. Likewise students watching videos of their peers engaged in a drill or interaction with a patient has been used to aid reflection in previous studies.^{6 11} Using a video to directly facilitate self-directed reflection is an extension of this process. The use of vignettes or short stories based on simulations of real events have also been used to stimulate the reflective process in previous studies.^{12 13}

The results of this small study were favourable with regard to using videos to facilitate self- directed reflection. The results showed that participants were statistically significantly more likely to be more critical of their own performance after watching a video of gold-standard management, with more than 50% marking themselves lower after viewing the video. The binomial logistic regression model did not find that training grade had a significant effect on likelihood of downmarking. Dual Coding theory helps us to understand why participants may have marked themselves lower. Plavio’s Dual Coding theory is that the human mind functions with two different types of mental representation (or ‘codes’). These are verbal representations and mental images. Dual coding theory suggests that the use of visualisation enhances learning and recall.¹⁴ This means that leaners remember images better than they do words. This theory has been demonstrated in studies showing that critical reflection scores were higher in groups using videos to reflect on a clinical scenario as opposed to a text.¹³ This helps us to understand why watching a video would aid the reflective process, as opposed to merely writing down a reflective piece from recall of the event alone.

By reviewing a video of gold standard practice, filmed specifically to fit with guidelines for how an emergency should be managed, the learner is able to use this as a prompt to monitor how they did in the scenario by comparing their performance to that in the video, helping them to understand both self and the situation and therefore plan and develop new perspectives to inform future actions when they are next involved in a similar scenario. This is supported by the results of this small study which showed that 100% agreed or strongly agreed that watching the video helped them reflect on the shoulder dystocia drill and 80% of participants agreeing or strongly agreeing that they would feel more prepared to deal with shoulder dystocia as a result of using the video to reflect on their performance.

As many emergency scenarios in obstetrics unfold quickly and are rapidly resolved, doctors training in the specialty need to learn to recognise opportunities for self-directed reflection. For trainees this is particularly important as they may not be facilitated well into processes of reflection by their clinical teachers who are absent from the situation. Using the Healthcare Supervision Logbook Smartphone App daily to record practical procedures and critical events will remind and prompt the learner, both trainee and consultant, to reflect; byproviding them with a video gold-standard practice for each critical event and asking them to watch it and reflect on their standards of practice and the care they provide. This Smartphone App provides the doctor with the ability to record a reflection using the same questions used in the RCOG’s ePortfolio for training and allows an accessible mechanism for recording reflection to be available on the user’s own personal Smartphone or tablet device. This study showed that 93% of participants agreed or strongly agreed that they would be willing to use a Smartphone App with videos to aid reflection following critical events, so it is hoped that uptake of this mechanism to aid reflection would be good; allowing more doctors the opportunity to record self-facilitated reflections of critical events in obstetrics.

While this study is small, and further evaluation of the use of the reflective functions in this Smartphone App are required, it is hoped that this function within Healthcare Supervision Logbook will help obstetricians, both junior and senior, to reflect more regularly and effectively. This tool could also be easily adapted for use in other specialties and disciplines to aid reflection. This type of tool could potentially be valuable in helping doctors-in-training and other healthcare professionals to provide an increasingly high standard of care as they develop on the path of life-long learning.