Guidance on Reflective Writing

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). 

 

Reflective Practice

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:

1. Experiences that happen to a person
2. Reflective process that enables a person to learn from their experience
3. 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:

 

 

                                                       OBSERVATION                

 

ACTION                                                                                                                      REFLECTION           

 

 

                                     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? 

 

Your knowledge:

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)

                                                                                                          Description

                                                                                                        (What happened)

                        

                          

 

Action Plan                                                                                                                                                                                                                  Feelings

(If it arose again what                                                                                                                                                                                              (what were you

would you do?)                                                                                                                                                                                                      thinking and feeling?)

 

 

 

Conclusion                                                                                                                                                                                                                    Evaluation

(What else could you                                                                                                                                                                                      (What was good and bad about

Have done?)                                                                                                                                                                                                      the experience?)

                                                                                                      

                                                                                                      Description

                                                                                (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:

1. What?
2. So what?
3. 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?   Cue questions: Description of the experience Phenomenon - describe the here and now experience Causal - what essential factors contributed to this experience? Context - what are the significant background factors to this experience? Clarifying - what are the key processes (for reflection) in this experience?   Reflection What was I trying to achieve? Why did I intervene as I did? What were the consequences of my actions for: Myself? The patient/family The people I work with? How did I feel about this experience when it was happening? How did the patient feel about it? How do I know how the patient felt about it?   Influencing factors What internal factors influenced my decision making? What external factors influenced my decision making? What sources of knowledge did/should have influenced my decision making?   Could I have dealt with the situation better? What choices did I have? What would be the consequences of these choices?   Learning How do I feel now about this experience? How have I made sense of this experience in light of past experiences and future practice? How has this experience changed my ways of knowing Empirics Aesthetics Ethics Personal

 

Compiled by Maria Hayfron-Benjamin

Lecturer in Medical Education,

Barts and the London School of Medicine and Dentistry

m.j.hayfron-benjamin@qmul.ac.uk

 

References

 

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 students’ writing on a structured worksheet.  Medical Education, 36, 575-585