Medical education has traditionally focussed on the assimilation of vast amounts of knowledge and on clinical apprenticeship as the hallmark of good training, and has undervalued reflection in learning. Today, however, medical and dental education needs to prepare students for lifelong learning. It must foster professionals who take a deep approach to learning and equip students to determine their own learning needs, set their own learning goals and monitor the occurrence of continuing progress. To achieve this, a more reflective approach is called for (Pee et al, 2000).
It is important that students develop a habit of assessing their own learning needs, developing strategies to meet them and reflecting on their own learning and personal development.
Reflection - the conscious weighing and integrating of views from different perspectives - is a necessary prerequisite for the development of a balanced professional identity. Acquiring knowledge and practical skills alone are not enough to become a medical professional. Reflecting on education and clinical experiences in medical practice, including one's own behaviour, becomes crucial (Boenink et al, 2004).
Introduced as a concept for many professions in the 1980s
Means that we learn by thinking about things that have happened to us and seeing them in a different way.
There are three components:
- Experiences that happen to a person
- Reflective process that enables a person to learn from their experience
- Action resulting from the new perspective taken as a result of the reflection
Reflection as a learning activity comes from educational theory, Kolb (1984) describes a cycle of stages that are gone though in learning from experience:
CONCEPT DEVELOPMENT and THEORISING
Levels of Reflection
Goodman (1984) describes three levels of reflection:
Level 1: Reflection to reach given objectives criteria for reflection are limited to technocratic issues of efficiency, effectiveness and accountability i.e. students gives an account of an incident and demonstrates some learning
Level 2: Reflection on the relationship between principles and practice there is an assessment of the implications and consequences of actions and beliefs as well as the underlying rationale for practice i.e. students begin to link theory to practice and to extrapolate their experiences to other similar situations
Level 3: Reflection which besides the above incorporates ethical and political concerns issues of justice and emancipation enter the deliberations over the value of professional goals and practice and the practitioner makes links between the setting of everyday practice and broader social structure and forces e.g. health economics and resources.
Frameworks for Reflection
There are many frameworks that can be used to encourage and support reflection; the choice of framework depends on the students skills and experience and may change as students become more expert in their reflections. A range of frameworks and tools follow:
Helping students to reflect:
Consider what you did on your placement visit today - did anything that happened during the day surprise you? Has anything that happened during the day contradicted or challenged your ideas or expectations? Have your views changed? For example:
If you met a patient:
How did the patient's life experiences differ from your own?
Did you feel able to empathise with the patient?
If you were shadowing a health care professional:
Did anything about the person's role surprise you? Do you think the roles of all members of the MDT are valued? How do you feel about team working with other professionals?
Have you identified gaps in your knowledge or skills? How might you go about addressing these?
Or you might like to use one of the following frameworks to reflect on your experience:
A Learning Experience (Pee et al, 2002)
Briefly describe what happened.
- Describe your feelings at the time this happened.
- Why do you consider this experience to be worthy of reflection?
- What strengths in your clinical practice did this experience demonstrate?
- What learning needs did this experience reveal to you?
Gibbs Reflective cycle (1988)
Action Plan Feelings
(If it arose again what (what were you
would you do?) thinking and feeling?)
(What else could you (What was good and bad about
Have done?) the experience?)
(What sense can you make of the situation?)
Borton's Developmental Framework (1970)
This is a simple model that is suitable for novice practitioners, at its simplest its three steps can be summarised as:
- So what?
- Now what?
i.e. the What questions such as: What happened?, What was I doing? Serve to identify the experience and describe it in detail.
The So what? Questions include questions like: So what do I need to know in order to understand this situation? So what does this tell me about me? About my relationship with the patient? With the other members of the team? I.e. the student breaks down the situation and tries to make sense of it by analysing and evaluating in order to draw conclusions.
The Now what? Questions e.g. Now what do I need to do to make things better? Now what might be the consequences of this action? At this stage the student plans intervention and action according to personal theory devised.
Johns Model of Structured reflection (1994)
Core questions: What information do I need to access in order to learn through this experience?
Compiled by Maria Hayfron-Benjamin
Lecturer in Medical Education,
Barts and the London School of Medicine and Dentistry
Boenink AD, Oderwald AK, deJonge P, vanTilburg W and Smal JA (2004) Assessing student reflection in Medical Practice. Medical Education, 38, 368-377.
Borton, T. (1970) Reach, Touch and Teach. London: Hutchinson
Gibbs, G. (1988) Learning by Doing. Oxford Polytechnic, Oxford
Goodman, J. (1984) Reflection and teacher education: a case study and theoretical analysis. Interchanges, 15, 9-26
Jasper, M. (2003) Beginning Reflective Practice. Nelson Thornes, Cheltenham.
Johns, C. (2000) Becoming a Reflective Practitioner. Blackwell Science, Oxford.
Palmer, A., Burns, S. and Bulman, C. (1994) Reflective Practice in Nursing. Blackwell, Oxford.
Pee B, Woodman T, Fry H, and Davenport E. (2000) Practice-based learning: views on the development of a reflective learning tool. Medical Education, 34, 754-761.
Pee B, Woodman T, Fry H and Davenport E. (2002) Appraising and assessing reflection in studentsâ€™ writing on a structured worksheet. Medical Education, 36, 575-585