2. The use of reflection in medical education: AMEE Guide No. 44 JOHN SANDARS The University of Leeds, UK 1

3. Twelve tips for teaching reflection at all levels of medical education LOUISE ARONSON University of California, USA 2

4. 3 LearningProfessionalism Clinical reasoning

5. But how?? 4

6. Reflection in the education context A process in which thoughts are ‘turned back’ so that they can be interpreted or analyzed. Outcome: increased understanding or awareness which can be used in future when faced with a similar event. 5

7. Definitions Reflection (Dewey 1938): ‘an active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusion to which it tends’. Reflection (Boud et al. 1985): ‘a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to a new understanding and appreciation’. Reflection (Moon 2004): ‘a form of mental processing with a purpose and/or anticipated outcome that is applied to relatively complex or unstructured ideas for which there is no obvious solution’. 6

8. Critical reflection Process of analyzing, questioning, and reframing an experience in order to make an assessment of it for the purposes of learning (reflective learning) and/or to improve practice (reflective practice). 7

9. A medical mistake A superficial, educationally ineffective reflection: Description of the events or a description accompanied by reasons such as the team/clinic was busy and other people failed in their responsibilities. 8

10. A medical mistake A more useful and deeper reflection : - How and why decisions were made - Underlying beliefs and values of individuals and institutions - Assumptions about roles, abilities and responsibilities - Similar past experiences - Contributing hospital circumstances and policies - Frank discussion with team members - Explicit notation of lessons learned and creation of a specific, timely, and measurable plan for personal or system change to avoid future similar errors 9

11. “Reflective learning” goals Meaningful learning Practice improvement Help learners integrate (1) new learning with existing knowledge; (2) affective with cognitive experience; and (3) past with present or present with future practice 10

12. Reflection process 11

13. Reflection is a metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters. 12

14. Metacognition ‘thinking about thinking’ effective reflection 13

15. Reflection before, during and after Reflection before an action Approaching situations with a particular learning goal Greater personal growth and learning 14

16. Future action Reflection is a process with a definite purpose Making sense of a situation will not improve practice unless these insights can change future responses to situations. 15

17. Approaches to Reflection in medical education 16

18. 1.Reflection for learning Experiential learning Experience must be interpreted and integrated into existing knowledge structures to become new or expanded knowledge. 17

19. Experiential learning cycle 18

20. 2. Reflection to develop a therapeutic relationship with patients Recognition and understanding of the personal belief and value systems of the clinician or patient. Differences between these systems can produce a strong emotional reaction in the clinician, which in turn can influence their decision making and subsequent actions. 19

21. 3. Reflection to develop professional practice Integration of knowledge and skills 20

22. Self-regulated learning and reflection Self-regulated learners use metacognitive processes to select, monitor and evaluate their approach to a task. Reflection can be considered as a self- regulated learning activity. 21

23. Guided reflection Support of another person: a peer group member, a supervisor or mentor to facilitate reflection. 22

24. Ethical aspects of reflection Confidentiality Who has access to the reflection and for what purpose? 23

25. The educational impact of reflection Reflection is associated with a deeper approach to learning that allows new learning to be integrated with existing knowledge and skills. 24

26. Educational strategies to develop reflection a)Motivation for reflection reflection for personal growth and professional development. 25

27. Clear goalsInternal factorsExternal factors 26

28. Goal setting Initially provide information about the nature and outcomes of reflection, including its importance for professional practice and lifelong learning. 27

29. Internal factors Self-efficacy and ease of the task Motivation can be increased by encouragement and by gradually increasing the reflective tasks, such as beginning with only noticing and then introducing the complete reflective process. 28

30. External factors Educational environment within which reflection is expected to occur Assessment drives learning Assessed portfolio for personal and professional reflective learning 29

31. b) Metacognitive skills for reflection Altered action Processing Noticing 30

32. 1. Noticing Recognition of when your existing mental models and personal theories are being challenged by the experience of an event. Before, during or after Without an initial awareness no reflection can occur. 31

33. Noticing can be developed by using several techniques (i) Self monitoring Increased awareness by constant self- monitoring of thoughts and emotions. Mindfulness has its roots in Eastern philosophical-religious traditions. 32

34. Becoming mindful requires deliberate and non-judgemental attention to the immediate thoughts and emotions: regular self-recording (by the use of written or audio diaries and logs). Record should be made as soon as possible after the event. 33

35. The self-monitoring techniques may feel artificial at the beginning but gradually it becomes a routine and subconscious process. 34

36. (ii) Feedback from others Individuals self-rate themselves higher and in a more positive light than when rated by others. Behaviour represents underlying beliefs Non-verbal behaviour (tone of voice or facial expression), is often a more powerful indicator of beliefs and can be readily observed by others. Feedback from colleagues and patients, supervisor or mentor : anonymously. 35

37. (iii) Critical incidents and significant event analysis. ‘Moments of surprise’ when an action unexpectedly happens valuable opportunity for reflection. 36

38. 2. Processing There are several techniques and these depend on the intention of reflection: 37

39. (i) Reflection for learning Do I have the information or skills to deal with this situation? Do I need to have further information or skills to deal with this situation, either now or in the future? What is the underlying reason why the identified issue was not resolved? 38

40. (ii) Reflection to develop a therapeutic relationship Communicative doctor-patient relationship through compassion and care. 39

41. What am I feeling and what are my emotions? Why do I feel like this? Are there other situations in my life or my encounters with others when I feel the same? Can I explain why I feel this way? What are the consequences of these emotions for me and for others? 40

42. 3. Future action Aim of reflection is to inform future actions so that they can be more purposive and deliberate. 41

43. Reflective storytelling and writing Information, opinions and emotions. Integral aspect of many stories is reflection on an experience with the development of new insights. Teller should notice and make sense of an experience. Therapeutic aspect: learner to release emotion, an essential part of the reflective process. 42

44. Assessment of reflection Judgment about the standard Formative assessment is an integral aspect of giving feedback and it also offers the identification of further learning needs. Summative assessment occurs after a period of study and this may be required for reflection. 43

45. Common problems encountered with reflection in medical education 44

46. 1.Low engagement in reflection Self-regulated learning : ‘goal’ ‘will’ (the motivation) ‘skill’ (the monitoring of strategies) 45

47. Internal factors Intrinsic interest in the activity Self-efficacy (a self-belief in being able to achieve the task) 46

48. External factors Support and encouragement by the organisation Role of facilitators Confidentiality 47

49. 2. Difficulties with the phases of reflection Noticing phase A reluctance to give feedback. 48

50. Processing phase Presence of strong emotions that the event has produced in the learner. Often the most important events, such as a missed diagnosis, that can stimulate reflection are also those that are associated with the most powerful emotions, such as anger or sadness. Recognise and release these emotions, they can block further reflection. 49

51. 3. Lack of integration of reflection in overall teaching and learning approach A process that is disconnected from the educational process. Reflection should become an integral part of each session and the overall curriculum. 50

52. Instructional methods for reflection In class or at home Oral or written There are no data for the superiority or inferiority of any approach Oral reflection is most suitable during a surprising or troubling experience Reflection-on-action: after the event. 51

53. Structured or Unstructured approach? Majority of learners produce reflections which are largely anecdotes devoid of learning. Structured approaches to help learners reflect in deeper and more educationally meaningful ways. 52

54. A structured prompt makes explicit the components of critical reflection: Discussion of processes and assumptions as well as actions and thoughts Consideration of the role of associated emotions and relevant past experiences Solicitation of feedback and review of relevant literature where appropriate Explicit notation of lessons learned Creation of a plan to improve future behavior and outcomes 53

55. Arguments against structured reflections Structure limits and distorts the very response the exercise is designed to elicit It risks encouraging mindless ‘‘recipe following’’ rather than insightful analysis. 54

56. Create a conducive learning environment Positive learning climate through the use of an authentic context and creation of a safe and supportive environment for reflection. Educators can increase authenticity by modeling reflection and encouraging other faculty to incorporate reflection into their practice and teaching. 55

57. Teach learners about reflection before asking them to do it Define reflection for your learners Provide them with evidence of the educational and practice-related benefits of reflection Outline the components of good critical reflections: (1) linking past, present, and future experience; (2) integrating cognitive and emotional experience; (3) considering the experience from multiple perspectives; (4) reframing; (5) stating the lessons learned; (6) planning for future learning or behavior. 56

58. Provide feedback and follow-up Feedback can be individual, group, faculty, or peer. Shared reflection is better than individual and self assessment is often inaccurate. In reflection, others often see things the reflector cannot see. 57

59. Make this exercise part of a larger curriculum to encourage reflection 58

60. Although the world is full of suffering… it is also full of overcoming it. Helen Keller 59