Developing reflective writing among trainees

This is something I wrote to encourage trainers to use reflection with their trainees, and to guide them to encourage trainees to use a structured approach to reflection in completing their portfolios

Reflective practice is an essential component of the Portfolio for all trainees today. The ISCP requires it as do other forms of training and education both at undergraduate and postgraduate level. However, very few syllabuses or training programmes define exactly what it is; fewer still give any advice on how to do it – or for supervisors and trainers, how to teach it. This paper will give trainees a greater understanding of how to approach their reflective practice, and trainers a framework for encouraging and developing the practice among their juniors.

What is it?
“Reflection is vital for learning from clinical experiences” (Driessen et al, BMJ 2008 336)
To many people "experience" means "making the same mistakes with increasing confidence over an impressive number of years" (O’Donnell, 1997). The “impressive number of years” that surgeons spent in training previously has now gone and in the era of EWTD and ISCP, trainees cannot afford to make the same mistake twice. One way of addressing this is to encourage and develop the use of reflection in all trainee doctors.

Defining reflection
When we say that trainees need to be more reflective, what we mean is that they need to let future behaviour be guided by systematic and critical analysis of past actions and beliefs and the assumptions that underlie them. (Dewey, 1933)

Why use it?
All doctors in the UK are now required to make reflection a critical foundation of their lifelong learning (GMC 2000). Research evidence from nursing, (Jarvis in Nurse Educ 1992) and teaching (Korthagen et al, 2001) suggests that reflection can help students learn from their experiences.

How do we do it?
“Students do not generally adopt reflective learning habits spontaneously, so teachers must help them” (Driessen et al, BMJ 2008 336)
Most trainees do not really know how to reflect effectively on their practice. They may be aware that something has not gone particularly well; for Dewey, reflection was stimulated by an event that aroused a state of doubt, perplexity and uncertainty that often leads to the individual searching for the possible explanations or solutions. (Dewey, 1933) Trainees are less keen to reflect on practice that has gone well, although it is useful for them to do this from time to time to ensure they understand why it went well in order to replicate the good practice. Most of us want to improve the poor practice and this is where much of reflection is centred.
Supervisors and trainers need to stimulate students to assess and analyse their actions and devise alternative actions. To do this they need to provide a safe learning environment, give honest feedback and ask the right questions. The skill of the trainer is to listen well and ask open questions

Approaches to stimulating reflection in trainees
1. After conducting an assessment tool (mini CEX, CbD, DOP, PBA)
- Ask the trainee what they felt their strengths were in that activity.
- Add your own view of the strengths
- Ask the trainee where they think they could develop
- Ensure you shape the area(s) for development to make them meaningful and not too many
- Finally ensure that there are agreed actions for the trainee to follow up in order to learn from and then demonstrate development in this area.

Example:
After a Mini CEX in clinic, you and your trainee identify together the strengths of professionalism and appearance, rapport with a patient and organisation of encounter. In need of development was the history taking. You discuss the areas of weakness here and agree that he will shadow you in clinic next week, recording your history taking approach. He will then teach this to the F1s the following week and do a follow up mini CEX the week following that.
This is the most helpful way you can encourage reflection in a trainee especially early in their specialty training career. Encourage them to document their development too, with evidence in this case of the records he makes of your history taking, and the evaluations he receives from the F1 teaching the following week. When he has received his next mini CEX form he can put all of these pieces of evidence together to show that he has learned from this period of time.

2. LISA model for reflecting
- List - basic elements of practice, situation, problem
- Identify - assumptions, beliefs, feelings, rules, motives etc underlying practice and your approach to it
- See - with other practice? Possible alternatives? Comparative merits
similarities and drawbacks?
- Act - plan and then implement a new approach.
LISA is the framework used in the TAIP manual and provides a basic approach to Reflecting on practice from which to begin a reflective conversation with a trainee. In a simpler, but similar manner to Dewey’s 5 stage approach (Dewey 1933) LISA looks at the facts of the event or problem, the assumptions or beliefs or feelings that resulted from it and may stop the learner from accessing further learning or activity, the cognitive progress made from the reflection – looking at thought processes and other comparable practice and the patterns between them, before finally deciding upon an alternative action plan to implement. Like most reflective practice this is influenced by Schon (1987).

3. ALAC: (Driessen 2008)
Element of reflection - How to support reflective learning
- Action
Help trainees choose experiences that support and develop their learning
- Looking back
Separate performance from person (a mistake does not mean the person is a failure); be trustworthy and honest; acknowledge and make success explicit; provide feedback; encourage trainees to obtain information and evidence from various sources and put it into their portfolio
- Analysis
Focus on the trainee’s own role in the success or failure; encourage trainee to take the perspective of others; ask ‘why’ questions; ‘confronting’ questions; ‘generalising’ questions; point out inconsistencies in trainee’s analysis; help them generalise between experiences
- Creating alternative actions
Ask trainees to suggest options for change; encourage them to formulate plans and check these are in line with analysis; help them to focus on SMART objectives for learning

SMART: Make sure your actions are:
- Specific
- Measurable
- Achievable
- Relevant
- Timely

Advice for trainees in reflecting on their practice
The benefits of regular reflective writing
Reflective writing provides an opportunity for us to think critically about what we do and why. It provides
· a record of events and results and our reactions to them,
· data on which to base reflective discussion,
· opportunity for us to challenge ourselves and what we do and to look at doing it differently and better,
· impetus to take action that is informed and planned,
· an opportunity to view our clinical practice objectively and not see all problems as personal inadequacy,
· increased confidence through increased insight
· Basic documentation to support future entries in our portfolio and for job applications etc.
(http://www.clt.uts.edu.au/Scholarship/Reflective.journal.htm)

Peer reflection
Engaging in open and collaborative discussion about work with a peer is a process that can enable us to become more reflective doctors. You can use any of the models advocated above if you and your peer are reasonably confident and experienced in challenging one another in reviewing an event. If you are new to this you may wish to reflect with a supervisor first until you become more confident.

Using the LISA framework
A helpful way of understanding the process of reflection described by Stephen Brookfield (1995) describes the process of hunting out our assumptions and critically examining them. Ask yourself what are the assumptions behind your practice and then try to develop a contrary argument. You now have two sides of an argument to evaluate. This is engaging in personal critical reflection.

Keeping a journal
The journal is parallel to the field book or laboratory notes of the scientist. We not only record what happened or what was observed but in addition we can record a tentative hypothesis or the development of new understanding, we can use our writing to make a new sense of phenomena. Reflective writing has the potential to provide us with a systematic approach to our development as a reflective, critical and constructive learner. Our journal can provide an opportunity to make explicit our position on a range of issues of personal significance.

Your journal could be structured:-
· as a personal learning journey, tracking and documenting an evolving understanding of your clinical practice and learning
· a critical reflection on a clinical encounter you have witnessed between a colleague or your registrar or consultant supervisor

Ideas for getting started on reflective writing:
1. Use a checklist
· What is the current problem or issue? Describe the context
· What additional information would be useful?
· How is it related to other issues?
· Who or what could help?
· What are my assumptions? How can I test them?
· What can I do to create a change? Be as adventurous as you can
· What are the possible outcomes of these?
· What action will I take? Why?
· List the outcomes you hope to achieve.
· Reflection on the actual outcome What worked well?
· What could I do differently next time?

2. Focus on a critical incident that took place in your clinical practice.
· Describe the incident as objectively as possible.
· What were the assumptions that you were operating with?
· Is there another way to see this event?
· How would your patients explain this event?
· How do the two explanations compare?
· What could you do differently?

3.And from time to time...
· What has using this journal confirmed that I already know about my learning and how I affect that?
· What do I need to do to improve the quality of what I do?
· What might I do instead of what I do now?
· What innovation could I introduce?
· What professional development activities should I be seeking?

For more information on reflective practice see:
Ballantyne, R & Packer, J; (1995)Making Connections: Using Student Journals as a Teaching/Learning Aid, HERDSA ACT.
Boud, D; Keogh, R; & Walker, D, (1995) Reflection: Turning Experience into Learning, Kogan Page, London.
Brookfield S. (1995) On Becoming a Critically Reflective Teacher, Jossey Bass, San Francisco.
http://www.clt.uts.edu.au/Scholarship/Reflective.journal.htm
Dewey J. How we think: a restatement of the relation between reflective thinking to the education process. Boston: Heath, 1933Driessen E, van Tartwijk J, Dornan T The self critical doctor: helping students become more reflective. BMJ 2008 336:0
General medical Council. Revalidating doctors: ensuring standards, securing the future. London: GMC, 2000
Jarvis P. Reflective Practice and nursing. Nurse Educ 1992; 12; 174 – 81
Korthagen FAJ, Kessels J, Koster B, Lagerwerf B, Wubbels T. linking theory and Practice: the pedagogy of realistic teacher education. Mahwah, NY: Lawrence Erlbaum Associates, 2001
O’Donnell M. A sceptic’s medical dictionary. Oxford: Blackwell BMJ books, 1997
Schon, D; (1987) Educating the Reflective Practitioner; Jossey Bass, San Francisco.