Special thanks to Nabil Sultan, MD, FRCPC, M.Ed., for developing this resource.
Commonplace experiences in today’s medical education such as a trainee who has a nurse submit a complaint against her, or another who is criticized by their staff physician can often become demoralizing or even traumatic experiences where little growth occurs. Reflection is a tool that can allow these and other types of experiences to be real catalysts to personal development. Reflective practice is the process of exploring, analyzing and learning from one’s experience in practice, in light of a particular context, in order to lead to new understanding, awareness and appreciation. Reflection facilitates the integration of new learning to existing knowledge. It is a process which uses critical analysis of one’s knowledge and experience to understand learning gaps in order to develop and maintain competence over a lifetime.
Reflection allows learners to explore their own beliefs and values and how they relate or contrast with the socializing culture around them, a process critical to identity formation. A self-conscious trainee, for example, who catches themself lying to their attending during rounds about a patient encounter goes beyond the experience of guilt and disappointment and digs deeper to understand what lead to those circumstances and what is it about their approach, values, personality or knowledge and skills gaps predisposed to such an encounter. They would also assess the values and culture of their workplace that created the context of the experience.
The ‘reflective practitioner’, a term introduced by Schon1 in 1983, describes the professional who utilizes reflection to explore work-based experience as a learning opportunity and to better understand the complex problems of professional practice. Learners can better understand the effects of their actions and experiences on themselves and others, co-constructing meaning in communities of practice.
Many models of reflection have been described. Most of these models share in common the activation of reflection occurring as a result of an awareness of a need or disruption in practice. The reflection allows for learning to occur from those experiences such that it can inform future situations and be integrated into existing knowledge and understanding.
Mann et al2 describes two major dimensions to the various models of reflection (see Table 1). The first is an iterative dimension where experience leads to new awareness which then leads to change in future behavior in response to future experiences. Models that describe this iterative process include Boud, Keogh, Walker and Schon. The second is a vertical dimension described by models such as Dewey, Hatton and Smith, Mezirow and Moon, which describes various depths of reflection on experience increasing in analysis and critical synthesis.2
| Table 1 Models of reflection and reflective practice describing (a) an iterative process; (b) vertical dimensions |
|
|---|---|
| Author | Process of reflection (Iterative) |
| (a) An iterative process Schön (1983, 1987) | 1. Knowing-in-action, 2. Surprise, 3. Reflection-in-action, 4. Experimentation, 5. Reflection-on-action |
| Boud et al. (1985) | 1. Returning to experience, 2. Attending to feelings, 3. Reevaluation of experience, 4. Outcome/Resolution |
| Author | Levels of reflection (Vertical) |
| (b) Vertical dimensions | |
| Dewey (1933) | 1. Content and process reflection, 2. Premise reflection/critical reflection |
| Mezirow (1991) | 1. Habitual action, 2. Thoughtful action/Understanding, 3. Reflection, 4. Critical reflection |
| Boud et al. (1985) | 1. Association, 2. Integration, 3. Validation 4. Appropriation |
| Hatton and Smith (1995) | 1. Description, 2. Descriptive reflection, 3. Dialogic reflection, 4. Critical reflection |
| Moon (1999) | 1. Noticing, 2. Making sense, 3. Making meaning, 4. Working with meaning, 5. Transformative learning |
| Table 1. Adapted from Mann et al2 | |
Boud et al’s3 approach to reflection integrates both iterative and vertical dimensions (Figure 1). The model highlights the emotional nature of learning from experience, allowing the learner to reflect and re-evaluate the experience. The model invites the learner to form new perspectives on the experience and develop a readiness for application of these perspectives in future experience. Trainees are able to learn and utilize this model in reflecting on their daily experiences in clinical practice.3
Figure 1: Reflection Cycle by David Boud.3
In the vertical dimension of reflection, the dishonest resident exemplified earlier may begin with considering their guilt and disappointment and reflect that these emotions are emanating from their own betrayal of deeply held values such as honesty and integrity. They would return to the experience and assess the situational pressures they experienced including, perhaps a difficult and condescending senior resident on the team, and maybe an experience they witnessed when another resident was openly chastised in front of the group the week before. They would reflect on their emotional burnout that led to the serious omission in their patient-encounter which led to their embarrassment and urge to cover up the mistake.
In the iterative dimension of reflection, they would consider their own values and their own standard of behavior in light of their experience and commit to a different pattern of behavior in the future. They would reflect on how they can exercise courage in speaking out in defense of others who are chastised cruelly. They would consider recommitting to healthy life-habits such as exercise or the connection with friends and family to address their chronic stress that led to some of their shortcomings. They would prepare themselves mentally to react and respond differently when a similar encounter occurs.
Reflection is also foundational to character and leadership development and is central to the process of turning experiences into learning, understanding and insight.4 Training learners and educators in reflective practice will support leadership development of both groups. Reflection plays a particularly important role in leadership development because character development, which is necessary for effective leadership, is highly dependent on effective reflective practice. Crossan et al5 provide the model below for character-reflection:
Figure 2: Character-Reflection Framework. Crossan et al5
The above character reflection framework is used to facilitate self-reflection over character-elements and values. Individuals learn to regularly reflect on multiple questions when they encounter ‘situational pressures’ in their work (or personal) environment that constitute a challenge to their character. As part of the character development process, learners are taught to exercise judgment in knowing which particular character-dimension is most relevant to a particular situation, and to then exercise that dimension in a balanced way, to achieve the Aristotelian ‘virtuous mean’. Each step in this process of character formation requires both iterative and vertical reflection.
The practice of critical reflection and reflexivity extends reflective practice described above to the practice of recognizing, exploring and questioning assumptions, beliefs, biases, stereotypes, power implications, as well as contextual, institutional, and systemic barriers influencing practice. One definition of reflexivity revolves around the idea of “recognizing one’s own position in the world both to better understand the limitations of one’s own knowing and to better appreciate the social realities of others”.6 This involves recognizing one’s position of privilege in society. This may include, but is not limited to one’s gender, education, socioeconomic status, profession, place of birth, family and social groups.
Engaging in critical reflection and reflexivity serves to broaden learners’ thinking about practice situations and themselves; to inspire a way of being that continually questions one’s underlying assumptions, one’s way of being, seeing and thinking. Mann et all proposes four basic tenets to critical literacy7:
Incorporating self-reflection into busy residency programs as a tool for leadership development is challenging both because of the lack of time and pressured environment, but also because of a lack of faculty experience, know-how and support for such endeavors, in addition to a lack of a culture that supports such activity. The guidance of experienced practitioners is critical to supporting trainee reflection and can help learners make sense of their experiences and draw connections to their growth as emerging leaders. Any educational intervention that incorporates reflection should therefore ideally engage faculty who are either comfortable and experienced in reflection or are willing to grow in that space and should ideally provide opportunities for learners to engage with such faculty.
Below is one example for how a postgraduate program could implement a resident self-reflection program with mentorship and feedback that takes into account a lack of faculty expertise in the area of reflection as well as a lack of a strong culture supporting reflection. The following example may be amended and adjusted to fit different needs and contexts:
Educators who are motivated to implement reflection-based learning in their programs struggle with the question of assessment. Given the personal and formative nature of reflection, determining appropriate and effective assessment and evaluation methods may be challenging. Also given that assessment of reflection is based on written or verbal language, learners who are not familiar with context-specific language expectations or non-native speakers may be reflecting appropriately but not describing it conventionally and/or effectively.
Some questions to consider when designing an assessment strategy for reflection:
Below are two available models for assessing reflection-based interventions that educators could use in designing their reflection-based educational intervention or program:
Hatton and Smith described four progressive levels of reflection, each with increased level indicating more/better reflective processes.
In using the above framing, educators assess to what level a particular piece of reflection reached and provide feedback and prompts to the learner to help them deepen their reflection and better connect it to the world around them.
Ash and Clayton describe a guided process for facilitating and assessing reflection. These researchers focus specifically on service learning, but their model could be applied to other types of learning experiences. In this model, students do the following:
Ash and Clayton recommend several ways instructors may use their framework to assess students’ reflection. One way is to use a rubric; they provide the top level of achievement for the critical thinking rubric they use for assessing articulated learning statements:
Level 4 (of 4) does most or all of the following:
| Element | Description |
|---|---|
| Mechanics | Consistently avoids typographical, spelling and grammatical errors |
| Connection to Experience | Makes clear the connection(s) between the experience and the dimension being discussed. |
| Accuracy | Makes statements of fact that are accurate and supported with evidence; for academic articulated learning statements, accurately identifies, describes, and applies appropriate academic principle(s). |
| Clarity | Consistently expands on and expresses ideas in alternative ways, provides examples/illustrations. |
| Relevance | Describes learning that is relevant to the articulated learning statement category and keeps the discussion specific to the learning being articulated. |
| Depth | Addresses the complexity of the problem; answers important question(s) that are raised; avoids over-simplifying when making connections. |
| Breadth | Gives meaningful consideration to alternative points of view and interpretations. |
| Logic | Demonstrates a line of reasoning that is logical, with conclusions or goals that follow clearly from it. |
| Significance | Draws conclusions, sets goals that address a (the) major issue(s) raised by the experience. |
| Table 2: adapted from Ash & Clayton8 | |
References