Reflection: tick box exercise or learning for all?

What is reflection?

Reflection has many different definitions, but all describe a process of seeking an understanding of self or situations to inform future action.3 Mann and colleagues, for example, describe three objectives and benefits of reflection: to learn from experience; to integrate personal beliefs into the context of professional culture; and to link new and existing knowledge.2

Reflection and reflective thinking have become accepted tools to enhance deeper learning, particularly clinical reasoning and professionalism. Paradoxically, however, there is little evidence on either the best way to “do” reflection or on its long term effect on clinical practice.

Invariably, busy clinicians have competing demands on their time, which can prevent or diminish reflection. Doctors are told to include in their portfolios reflections on clinical practice or critical incidents, but the objectives and benefits of reflection are often not made explicit, and so reflections are not assessed constructively or are dealt with too fleetingly.

Many medical schools offer specific education and training to support reflective practice. Within postgraduate training, however, those who read through reflections during supervisions or continuing professional development activities are often not confident in reflective practice because they qualified before such training in medical schools was introduced.

In short, the reason for reflective practice is often not made explicit; we do not know how to do it; and we are not supported in the activity.

A positive experience

Our team developed a new intercalated BSc for undergraduate medical students to improve the profile of paediatrics and child health. As part of the degree, students compile a reflective diary during their specialist ward attachments. They are given training and a guide for reflective practice, but they should not have any clinical preconceptions, because most of them have never been on the ward before.

Our guide is based on the principles of “critical reflection” as outlined by Hatton and Smith,4 who proposed that the components of good critical reflections were:

• Linking past, present, and future experience

• Integrating cognitive and emotional experience

• Considering the experience from multiple perspectives

• Reframing the experience

• Stating the lessons learnt, and

• Planning for future learning or behaviour.

Many of the reflections made by our undergraduate students challenge medical practice and identify clear areas for improvement; as teachers, we too have learnt from their “fresh” perspective. Students reflected on many expected areas but also on topics to which we have become immune or have not considered for many years.

Thought provoking examples have been the ethics of numerous medical students being dragged over to patients “just for their signs”; the correct way to run a ward round, with critical differences across specialties; how medical jargon may marginalise patients and their families; parents’ rights to withhold diagnosis from Gillick competent children (http://cinaps.co.uk/Gillick_Competent.html); and the key attributes of a medical leader. Some may consider such observations naive, but we believe that this type of reassessment of accepted practices reveals an inherent value of reflection: done properly it can lead to learning for reflectors and their assessors.

How can we improve the process for all?

On the basis of our experience and Aronson’s recommendations5 we suggest that the following points can improve the effect of reflection for all those involved in reflective practice, across all levels of training:

• Make the objectives of reflection clear—Give a succinct definition of reflection and the reasons why we should all be undertaking reflection.

• Teach learners about reflection—Develop a structure for the reflective practice by using the critical reflection checklist above or something similar.

• Make it easier to record reflections—Encourage electronic logging, which is known to increase the frequency of reflection.5

• Discuss the reflections with someone—A reflection shared is an idea redoubled. An educational supervisor is an ideal person to share your reflections with, but he or she should be trained in reflection.

• Make reflective practice and debriefing central to your clinical activities.

• Discuss cases with your colleagues whenever you can—Even discussing cases over a coffee “counts” as reflection if some of Hatton and Smith’s principles are followed.4

Finally, as one student wrote, “If I had to choose what I felt to be the most important thing that I have taken from these experiences, it would be to remind myself, no matter how I feel, to think about how the patient is feeling. To never forget that off-hand comments made when tired or stressed have the potential to upset people to such an extent that they remember them for years.”

We could all do with remembering that.