Reflection in medical education

1. In the name of God Reflection in medical education M. Hassani

3. So how is reflective practice learned?

4. Objectives • Provide an overview of the concept &its role in learning and self-direction • Provide practical advice for the effective implementation • Assessment of reflection in undergraduate, postgraduate and continuing medical education

5. Word ‘reflection’ • Latin origins: ‘to bend’ or ‘to turn back’ • From physics to education

6. Reflection in one sentence Reflection is a metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future actions can be informed by this understanding. The use of reflection in medical education: AMEE Guide No. 44. Sandars J et al. Med Teach. (2009)

7. Reflection A metacognitive process A metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future actions can be informed by this understanding. • Thinking about thinking’ • A self-regulatory process that selects, monitors and evaluates a cognitive process • A process that can be controlled

8. Reflection Before, during and after situations A metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future actions can be informed by this understanding. • Before an experience • (anticipatory reflection) • During an experience • (reflection-in- action) • Following experience • (reflection-on- action) (Westberg and Jason, 2001)

9. Reflection Understanding of both the self and the situation Paying deliberate, analytical attention to: One’s own actions in relation to intentions From an external observer’s perspective A metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future actions can be informed by this understanding.

10. Reflection Future actions can be informed by this understanding A metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future actions can be informed by this understanding. Making sense of a situation will not improve practice unless these insights can change future responses to situations.

11. Simple Example of Reflection

12. What might you reflect upon in day to day life? • I’m always late for work • That was a awful holiday • I’ve had a very productive weekend • I keep running out of money before the end of the month • I failed my exam

13. What to Reflect Upon • Personal experiences • Personal beliefs and values • Interactions with patients • Interactions with colleagues • Learning gains and needs • Observations • What went well • What they were thinking • Any new goals that emerged • Any assumptions or biases • What others were feeling (Westberg and Jason, 2001)

14. What they Reflect Upon! • A patient death • Some students wrote about problems with preceptors, the limits of medicine, and other difficult topics. • Noticing the contrast in a preceptor's negative attitude in treating a suicide survivor ("voluntarily" ill) with attitude in caring for an older, dying patient

15. What they Reflect Upon! • Sometimes, students’ experience evoked unexpected thoughts and questions about medical practice. • Students questioned themselves when suddenly faced with difficult ethical situations • Feeling ethically challenged in the face of a dying patient who refuses care (Westberg and Jason, 2001)

16. The main approaches to reflection in medical education • Reflection for learning • Reflection to develop a therapeutic relationship • Reflection to develop professional practice

17. Reflectionin medical education Reflection for learning What happened Reflection for learning Reflection to develop a therapeutic relationship Reflection to develop professional practice Analysis Planning future actions Make generalizations Kolb's experiential learning cycle (1984)

18. Reflectionin medical education Reflection for learning Reflection for learning Reflection to develop a therapeutic relationship Reflection to develop professional practice Simplified Kolb’s learning cycle

19. Reflectionin medical Education Reflection to develop a therapeutic relationship Reflection for learning Reflection to develop a therapeutic relationship Reflection to develop professional practice • A ‘good’ clinician: • Appropriate knowledge and skills • Establish and maintain a therapeutic relationship with patients and their carers • Effective reasoning is a mainly subconscious process with modulation of logical information processing by emotions (personal belief and value systems)

20. Reflectionin medical Education Reflection to develop professional practice Reflective Practice “Critical thinking inAction on Action” (Neil Thompson 2009) Masters of your own lifelong learning Reflective Practice Capacity - Blood Supply of Professionalism Reflection for learning Reflection to develop a therapeutic relationship Reflection to develop professional practice

21. Effective reflective practitioner vs Ineffective practitioner (Schon (1983)) • The Effective reflective practitioner is able to recognise and explore confusing or unique (positiveor negative) events that occur during practice • The Ineffectivepractitioner is confined to repetitive and routine practice, neglecting opportunities to think about what he/she is doing

22. So how is reflective practice learned?

23. Educational strategies to develop reflection: self-regulated learning model • Motivation for reflection • Metacognitive skills for reflection • Noticing • Processing • Future action • Reflective storytelling and writing • Personal development plans and portfolios

24. Self-regulated learning model Motivation for reflection Motivation for reflection Metacognitive skills for reflection Noticing Processing Future action Reflective storytelling and writing Personal development plans and portfolios • Recognizing importance of Reflection • Clear goals: • Internal factors: • Self-efficacy • Perceived ease of the task • External factors: • Assessment (assessed portfolio for personal and professional reflective learning)

25. Self-regulated learning model Metacognitive skills for reflection Motivation for reflection Metacognitive skills for reflection Noticing Processing Altered future action Reflective storytelling and writing Personal development plans and portfolios • Developing metacognitive skills to monitor and evaluate the key aspects of reflection: • Noticing • Processing • Altered Future action

26. Self-regulated learning model Noticing • The recognition of when our existing mental models and personal theories are being challenged by the experience of a particular event or situation. Motivation for reflection Metacognitive skills for reflection Noticing Processing Future action Reflective storytelling and writing Personal development plans and portfolios

27. Self-regulated learning model Noticing • Techniques for noticing: • Self monitoring: • Participating in mindful practice • ‘Thought catching’ approach (hindsight bias) • Feedback from others: • Sarcastic comment • Non-verbal behavior • Critical incidents and significant event analysis • ‘Moments of surprise’ Motivation for reflection Metacognitive skills for reflection Noticing Processing Future action Reflective storytelling and writing Personal development plans and portfolios

28. Self-regulated learning model Processing • To develop an understanding of • both the self and the situation with several techniques depending on the intention of • reflection. • Reflection for learning • Reflection to develop a therapeutic relationship • Reflection to develop professional practice Motivation for reflection Metacognitive skills for reflection Noticing Processing Future action Reflective storytelling and writing Personal development plans and portfolios

29. Self-regulated learning model Future action The aim of reflection is to inform future actions which respect the context to which they are being applied; so that they can be more purposive and deliberate. Motivation for reflection Metacognitive skills for reflection Noticing Processing Future action Reflective storytelling and writing Personal development plans and portfolios

30. Models/Frameworks of Reflection • Gibbs (1988) reflective cycle • Guided reflection (John’s model of reflection) • The What? model of structured reflection by Driscoll

31. The reflective cycle (from Gibbs, 1988)

32. Gibbs reflective cycle Stage 1: Description of the event Description Feelings Evaluation Analysis Conclusion Action Plan • Where was I? • Who else was there? • Why was I there? • What was I doing? • What other people were doing? • What the context of the event was? • What happened? • What my part was? • What parts the other people played? • What the result was?

33. Gibbs reflective cycle Stage 2: Feelings Description Feelings Evaluation Analysis Conclusion Action Plan • How was I feeling at the beginning? • What was I thinking about at the time? • How it made me feel? • What did other people’s actions make me think / feel? • How did I feel about the outcomeof the event? • What do I think about it now?

34. Gibbs reflective cycle Stage 3: Evaluation Description Feelings Evaluation Analysis Conclusion Action Plan • What was good about the experience for me, the patient, others? • What was bad about the experience for me, the patient, for others?

35. Gibbs reflective cycle Stage 4: Analysis Description Feelings Evaluation Analysis Conclusion Action Plan • Breaking it down • What went well? • What did I do well / not so well? • What did others do well? • Did it go as expected? • Why / why not? • What theory / research helps me understand the experience? • What went wrong or did not turn out how it should have done? • Which way I, or others, contributed to this?

36. Gibbs reflective cycle Stage 5: Conclusion Description Feelings Evaluation Analysis Conclusion Action Plan • Could I have done anything differently? • What are the key things I have learned from this incident - about me, my performance, others and their performance? • Can this be evidence of achievement of placement outcomes / competencies?

37. Gibbs reflective cycle Stage 6: Action Plan Description Feelings Evaluation Analysis Conclusion Action Plan • What would I do in a similar situation in the future? • What aspects of my knowledge / skills could I develop? • How will I do this? • What goals can I set myself for the future? • What outcomes / competencies do I need to focus on now?

38. The reflective cycle (from Gibbs, 1988)

39. Guided reflection • Experiences resulting in challenge and change are usually associated with the presence of strong emotions • Consequences of these experiences • Role of facilitator

40. The What? model of structured reflection (Driscoll 2000) • A description of events (What?) • An analysis of events (So What?) • Proposed actions following events (NowWhat?)

41. Self-regulated learning model Reflective storytelling and writing Motivation for reflection Metacognitive skills for reflection Noticing Processing Future action Reflective storytelling and writing Personal development plans and portfolios • Add a different perspective or clarity to your initial thoughts • Allows the learner to release emotion • Evidence to include in your portfolio to help you achieve your placement outcomes

42. Self-regulated learning model Starting reflective writing • Have a pen and paper available at all times (’Putting your thoughts on paper) • Oral, written, using new media(audio recording, blogs, or digital storytelling) • Write down ideas as they come to you • Don’t worry about structure, order, spelling, grammar • Make sense later with the help of a more formalised structure Motivation for reflection Metacognitive skills for reflection Noticing Processing Future action Reflective storytelling and writing Personal development plans and portfolios

43. Self-regulated learning model Personal development plans and portfolios • To encourage and assess reflective learning: • Identification of learning needs: • “not having knowledge about the latest treatment for diabetes” • Developing a plan to meet the identified learning needs: • “attending a training course or reading an article” • Measurable learning outcomes which provide the evidence that the learning needs have been fulfilled Motivation for reflection Metacognitive skills for reflection Noticing Processing Future action Reflective storytelling and writing Personal development plans and portfolios

45. Ethical aspects of reflection • A safe overall environment • Inability to shut off thoughts and anxious attention to self • Confidentiality: when the assessor is also the facilitator

46. We Reflect; Because… • Improve critical thinking ability • Help ourselves to make more sense of difficult and complex practice • Enhance personal development by leading to self-awareness • “Remind us that there is no end point to learning about their everyday practice”

47. Top tips to be successful in Reflecting! • Experiment with different approaches until you find one that ‘fits’ • See it as an essential aspect to your practice rather than an ‘add on’. • Start small and work up to the big issues • Be willing to challenge your assumptions and practices

48. Top tips to be successful in Reflecting! • Be spontaneous – it is from the frank and honest self that important insights arise • Express yourself freely – you don’t need to observe the normal academic practices involved in writing • Remain open to ideas – early conclusions can inhibit further insights and solutions

49. Summary • When you reflect on a situation you do not simply see more, you see differently • Remember the purpose of reflection isto learn from an experience One small step…