How to reflect - a guide for trainees and students

Developing reflective writing
A guide for doctors in training
©Hayley Allan 2009


Reflective practice is an essential component of the Portfolio for all trainees today. The ISCP ( Intercollegiate Surgical Curriculum Programme) 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. This paper will give trainees a greater understanding of how to approach their reflective practice, and some simple frameworks for structuring their writing.
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?
Most trainees do know how to reflect effectively on their practice, but they may not be aware that they are doing this. 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) We are less given to reflect on practice that has gone well, although it is useful for us to do this from time to time to ensure that we understand why it went well in order to replicate the good practice. However, most of us want to improve the poor practice and this is where much of reflection is centred.
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)
Where do we use it?
We need to be able to assess and analyse our actions and devise alternative actions. That is the essence of reflective practice in the workplace. To begin with it is helpful to have guidance and some structure given by more experienced colleagues. In the bust context of the clinical setting it is difficult to gain time to do this, but requesting that a trainer provide you with five minutes to run through an event, can be all that is needed to trigger the reflection you need.
1. Asking for feedback after conducting an assessment (mini CEX, CbD, DOP, PBA)
Ask the trainer what they felt your strengths were in that activity. Add your own view of the strengths and ask for comments
Ask the trainer where they think you could develop. Add your own view of areas for development
Ask them to focus on one or two key areas for follow up action and to give some suggestions for follow up activity to enhance learning
This approach to feedback is based on Pendleton’s rules. It is imperative that you draw up actions for development, and not merely talk about how to improve. Adding quality to your learning, practice and portfolio requires you to show progress as a result of learning on the job.
Example:
After a Mini CEX in clinic, you and your trainer 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 you will shadow him/her in clinic next week, recording his/her history taking approach. You 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 begin to develop reflection early in your training career. Make sure you document your development, with evidence in this case of the records you make of your trainer’s history taking, and the evaluations you receive from the F1 teaching the following week. When you next complete your Mini CEX form you can put all of these pieces of evidence together to show that you have learned from this period of time.
Try this model for structuring your reflections:
ALAC: (Driessen 2008)

Action - choose experiences that support and develop your learning (ie those from which you can learn)

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; seek feedback; obtain information and evidence from various sources and put it into your portfolio

Analysis - Focus on your own role in the success or failure; take the perspective of others; ask ‘why’ questions; ‘confronting’ questions; ‘generalising’ questions; look for inconsistencies in your analysis; generalise between experiences

Creating alternative actions - suggest options for change; formulate plans and check these are in line with analysis; focus on SMART objectives for learning

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

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.

Assumptions
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 recording your reflective writing, keep it simple.

HEADLINE: What you have learned from this event
EVENT: 1-3 sentences about the event itself with some idea of the area you targeted from reflection
LEARNED: now you can spend longer on this area, discussing what it was you learned from the event and expressing this in developmental but positive terms
ACTION: This is where you identify the actions resulting from the reflection. They may be short, medium or long term and you can revisit them after you have implemented them to comment on their efficacy once used in practice.
Remember to always follow up with a review of your amended practice after you have implemented your actions. This completes the cycle of learning initiated from the original piece of reflection.

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.