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Reflection in professional practice and education
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. firstname.lastname@example.org 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 W 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 acceptance, and values prior experience and knowledge Publishing Company, 1985. • 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. 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"Reflection in professional practice and education"