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Reflection in professional practice and education


Reflection in professional practice and education

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									                                                                                                       Training • PROFESSIONAL PRACTICE

Reflection in professional
practice and education

Kathryn Robertson, MBBS, MEd, FRACGP, is Senior Lecturer, Department of General Practice, University of
Melbourne, and a general practitioner, Watsonia, Victoria.

   Reflection is a crucial process in the transforming of experience into knowledge, skills and attitudes. As
   such it is at the core of both learning and continually evolving professional practice. This article draws
   on literature from adult learning and medical education fields to present a theoretical framework for
   reflection and practical techniques for its application in general practice. It is directed toward the training
   of medical students and registrars on clinical rotations, but also for the established general practitioner.

   ‘... all genuine education comes about               So what exactly is meant by reflection?                   Although considering reflection
through experience, [although this] does not        Hillkirk et al8 defined reflection as ‘a conscious       as occurring in stages can suggest a
mean that all experiences are genuinely or          and intentional examination of the behaviour,            linear process, the phases are actually
equally educative’.1                                ideas and feelings generated by a learning               integrated. 4 In fact, reflection does not
                                John Dewey          experience with the purpose of increasing the            only occur after experience, but can

                                                    experience’s usefulness to the learner’.                 commence with anticipation and planning
       hile experience forms the basis of                                                                    for the experience, continue throughout the
deep learning, a balance is needed between
                                                    The process of reflection                                experience, and follow the experience. It is
learning by experience and learning from            Reflection is often triggered by a mismatch              both a looking forward and a looking back.
experience. The former involves ‘learning by        in existing knowledge, skills or attitudes               Unconscious reflection does occur naturally,
doing’, while the latter refers to the process of   and their application to current experience.             but tends to be unfocussed and unsystematic.
thinking and reflecting on events.2 Learning by     This causes what Schön, in his book The                  It is only when we can bring these processes
doing can be a slow process without reflection      reflective practitioner, calls an ‘experience of         into consciousness that we can evaluate
and an inaccurate process if mistakes are           surprise’.9,10                                           them and make active decisions based
uncritically repeated. 3 ‘Learning from                 The second phase involves a constructive,            on them.1,5,11
experience’ through reflection contributes to       critical analysis of the experience, including
human adaptability. Lessons learned in one          a n ex a m i n a t i o n o f k n ow l e d g e a n d
                                                                                                             Reflection in planning
context can be adapted for another.                 feelings.1,5,11–13                                       Reflection in the planning stage may include
    Reflection forms the essential bridge               The third phase involves the development             the practitioner anticipating what might be
between practice and theory.2 The teaching of       of new perspectives on the situation, or                 required of them, and what resources they
theory, for example in lectures or textbooks,       the individual’s relationship to the situation,          might be called upon to provide. It may
deals with generalisations and idealised            or even the restructuring of an underlying               incorporate rehearsal. Prior reflection may
models. Reflection on the ‘real world’ where        schemat a. Schön referred to this as                     reveal gaps in knowledge and abilities that
these theories apply enables the practitioner       ‘reframing’.9 Mezirow suggested that this                will need to be addressed.5,7 An example
to integrate new knowledge and experience           process could either occur through a sudden              would be the medical practitioner reviewing
within the existing cognitive frameworks and        ‘blinding flash’ of insight, or more slowly              the content of their doctor’s bag by
skills.2,4–7                                        through a series of step wise transitions.4,11           anticipating possible uses, ensuring they have

                                                                                       Reprinted from Australian Family Physician Vol. 34, No. 9, September 2005 4 781
Professional practice: Reflection in professional practice and education

  the necessary equipment and medications,                     and from as many perspectives as possible.           assistance in trying to extract the maximum
  and reviewing their application skills.                      This requires that the practitioner is not only      benefit from the experience. Debriefing is best
                                                               aware of the situation, but can define it in         left unfinished or open ended, so that further
  Knowing-in-action                                            an explicit, nonjudgmental way, and usually          ongoing reflection is encouraged. 3,11,12,14,20
  Schön described the concept of ‘knowing-                     includes identifying the similarities and            The GP supervisor is ideally placed to fulfil
  in-action’.9 This type of knowledge does not                 differences with previous experiences. Thus,         this facilitating role by guiding the registrar
  involve a series of conscious steps in the                   reflection-on-action may involve making              or medical student through the processes
  decision making process. The knowledge                       connections with internal prior knowledge, or        of reflection. Supervisors also present a
  is inherent in the action, may be context                    external sources of information, to mediate          powerful role model of a reflective approach
  specific and includes recognitions,                          action or aid deliberation.3,11,14,18,19             to professional practice.
  judgments and skills. The interaction with
  the situation call forth this tacit knowledge
                                                               Techniques for reflection                            The use of a group
  within the individual which is not consciously               Ideally, conscious, purposeful reflection            One of the most valuable resources of
  articulated.9,13–15 This knowing-in-action is the            should be an integral part of professional           an educational program is the group
  process so impressive to medical students                    practice, not an ‘add-on’ or self indulgent          of participants themselves. 13 Through
  sitting in on a consultation. They often                     luxury. There are some specific techniques to        interaction, they can ‘leap frog’ their
  comment on how the doctor ‘just knew’ the                    aid reflection, either initially, or as an ongoing   learning, each contributing to the others’
  right question to ask.                                       routine (Table 1).                                   progress. They can provide support,
                                                                                                                    acknowledgement, challenge, identify ‘blind
  Reflection-in-action                                         Allocating time                                      spots’ and offer alternative perspectives,
  Professionals do not only perform by                         Rather than adding to the busy and                   knowledge or skills. To be effective, group
  knowing-in-action, they clearly think about                  demanding day of the typical general                 environments need to be safe, respectful,
  what they are doing. Schön calls this                        practitioner, taking reflective time can             tolerate diversity and allow free participation,
  ‘reflection-in-action’ and drew an analogy                   involve reframing the time that is already           so that the learning needs of all group
  with jazz musicians improvising together.                    available. For example, writing up the notes         members are attended to.21,22 Fully functional
  They make on-the-spot adjustments as they                    or finalising the paperwork when the patient         groups assist their participants to develop a
  listen to and make sense of the music that                   has left the room is often a time when               range of professional behaviours, including
  they play. The adjustments are based on                      doctors will reflect on the consultation, and        self awareness.22,23
  ‘a feeling of where the music is going’, a                   perhaps take the opportunity to stand back
  theoretical framework and a repertoire of                    from the immediate concerns to consider
                                                                                                                    The telling of anecdotes
  musical figures based on experience, not                     the broader context for the patient, the             Although the use of anecdotes is
  mere trial and error.9,14,15                                 doctor, the practice or wider community.             dismissed in most academic and
      Reflection-in-action may involve a process               Often at this time, the underlying issues            professional communities, it can be a
  of pattern recognition – and be triggered                    crystalise and become more apparent.                 means of reflection that involves the use
  by a recognition that ‘something doesn’t                         Taking a short time at the end of the day        of selection, organisation and interpretation
  seem right’. 9,16,17 It is usually a subliminal              to review the session overall – acknowledging        of experience. Its subjectivity, which is the
  process, like knowing-in-action, of which                    the successes, identifying any lingering             basis for its dismissal, actually reveals the
  the practitioner is only partially, or not at all            concerns and exploring solutions – can be            key dilemmas and lessons of the experience
  aware. If it can be expressed, for example for               a liberating and energising process, when            for the individual.24
  the benefit of a student, the tacit knowledge                compared with carrying the niggling worries
  becomes explicit and available.4,14,17                       and doubts which otherwise tend to build up
                                                                                                                    Focus on the routine
      This process matches the hypothetico                     day-by-day.                                          There is a natural tendency to reflect on
  deductive model of clinical problem solving                                                                       memorable events, either good or bad, and
  which is a tacit process made explicit.
                                                               Debriefing                                           to ignore the larger part of experience that
                                                               Debriefing is not counselling or therapy, nor is     may offer many useful learning opportunities.
  Reflection-on-action                                         it simply ‘having a chat’. As with other forms       We tend to select critical incidents that are,
  Most simply, reflection-on-action occurs after               of reflection it is purposeful and benefits from     by their nature, extraordinary, and thus less
  the activity rather than during it. It most                  an underlying structure. It requires a facilitator   relevant to our usual lives. An alternative
  often commences with reconstructing the                      whose role encompasses providing a stimulus          would be to deliberately select a more
  experience with particular regard to context,                to reflection, support in the process, and           routine event to consider.24

  782 3Reprinted from Australian Family Physician Vol. 34, No. 9, September 2005
                                                                                            Professional practice: Reflection in professional practice and education

                                                                                                                 9.    Schön DA. The reflective practitioner. How profes-
 Table 1. Setting up a reflective session with a registrar                                                             sionals think in action. Harper Collins, 1983.
                                                                                                                 10.   Schön DA. Educating the reflective practitioner.
                                                                                                                       Oxford: Jossey-Bass Publishers, 1987.
 This is not a step-by-step guide, but an indication of the types of approaches that can
                                                                                                                 11.   Boud D, Keogh R, Walker D, editors. Promoting
 encourage reflection.                                                                                                 reflection in learning: a model, in reflection: turning
 • An effective teaching relationship is founded on mutual trust, respect and                                          experience into learning. New York: Nichols
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 • Establish a mutually convenient, dedicated, uninterrupted time and place                                      12.   Pearson M, Smith D. Debriefing in Experience-
                                                                                                                       Based Learning, in Reflection: Turning Experience
 • Negotiate an area for consideration – this may be general or specific; this begins the                              into Learning. Boud D, Keogh R, Walker D, editors.
    reflective process in the planning stage. You might ask the registrar if there are any                             Nichols Publishing Company: New York 1985.
    areas they would like to focus on. This does not necessarily mean the areas they                             13.   Henderson E, Berlin A, Freeman G, Fuller J. Twelve
    are finding difficult – it can be valuable to spend teaching time on identifying the                               tips for promoting significant event analysis to
    characteristics of areas the registrar enjoys or is curious about                                                  enhance reflection in undergraduate medical stu-
 • Negotiate how first hand information will be gathered. This might involve reviewing                                 dents. Med Teach 2002;24:121–4.
                                                                                                                 14.   Hewson MG. Reflection in Clinical Teaching: an
    one or more consultations either directly or pre-recorded. It might involve reviewing
                                                                                                                       Analysis of Reflection-on-Action and its Implications
    case records or referrals, depending on the area under consideration                                               for Staffing Residents. Med Teach 1991;13:227–31.
 • Begin by asking the registrar to describe what occurred at both intellectual and                              15.   Korthagen FA. Two Modes of Reflection. Teaching
    emotional levels. Use communication skills such as probing, clarification and active                               and Teacher Education 1993;9:317–26.
    listening to understand the experience as deeply as possible. Explore underlying                             16.   Saylor CR. Reflection and Professional Education:
    interpretations, assumptions, beliefs and expectations. In helping you to reach this                               Art, Science and Competency. Nurse Educ
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                                                                                                                 17.   Shapiro J, Talbot Y. Applying the Concept of
 • Together review the same situation from as many different perspectives as possible                                  the Reflective Practitioner to Understanding
   or helpful. For example, how might the patient have been feeling, what might they                                   and Teaching Family Medicine. Fam Med
   have understood by the end of the consultation? How might the patient explain their                                 1991;23:450–6.
   illness to their family? What are the possible effects on the family? Are there broader                       18.   Burnard P. Using Video as Reflective Tool in
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                                                                                                                       Education Clift RT, Houston WR, Pugach MC,
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                                                                                                                       editors. Teachers College Press: New York London
   of a number of different, equally valid approaches
 • Move from reflecting on a specific event to identifying general concepts. Explore if                          20.   Taylor CA, Dunn TG, Lipsky MS. Extent to which
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                                                                                                                 21.   Pololi L, Clay MC, Lipkin M Jr, Hewson M, Kaplan
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Conflict of interest: none declared.                   tion into staff development programs. Journal of
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                                                                                              Reprinted from Australian Family Physician Vol. 34, No. 9, September 2005 4 783

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