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Using Reflection to Teach Professionalism

Karen V. Mann, BN, MSc, PhD Professor Emeritus, Dalhousie University

+Objectives

Describe approaches to defining professionalism

Describe approaches to understanding reflection

Identify and discuss methods to teach professionalism using reflection

Discuss approaches to assessing professionalism

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+What is professionalism?

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+What is professionalism?

Competence and mastery of appropriate knowledge skills and attitudes

Capability to adapt to change, generate new knowledge, and continue to improve

Self-awareness and self-regulation

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+Different Paradigms for Understanding Professionalism

Individual Interpersonal Societal/Institutional

Positivist (objective,definable)

•Characteristic/trait•Behaviour/cognitive process• Generalizable across contexts•Stable

•In interactions •In interactions

Subjectivist - constructivist

Subjectively constructed within individuals arising from cultural contexts

•Interpersonally constructed: •not generalizable across contexts

•Socially constructed

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generalizable across cultural contexts

Adapted from Hodges et al. (2011) p 356

+Reflection : a definition

‘reflection is a meaning-making process that moves learners from one experience into the next, each time with a deeper understanding of its relationships with and connections to other experiences and ideas. It is the thread that makes continuity of learning possible.’

(Dewey as cited in Wear et al, 2012)

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+Approaches to reflection

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Knowing-in-action

Surprise

Reflection-in-actionExperimentation

Reflection-on-action

(Schön, 1987)

+Approaches to reflection

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Behaviour

Ideas

Feelings

Returning to experience• Utilizing positive feelings

• Removing obstructing feelings

Re-evaluating experience

Newperspectives on

experience

Change in behaviour

Readiness for application

Commitment to action

Experience(s) Reflective processes Outcomes

(Boud, Keogh & Walker, 1985)

The reflection process in context

+Approaches to reflection

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Concrete experience

Formation of abstractconcepts and generalizations

Testing implications

of concepts in new situations

Observations and

reflections

(Kolb, 1984)

+Approaches to Reflection

•Right/wrong answers

•Recognize uncertainties

•Defensible conclusions about complex problems

•Pre-reflective thinking

•Quasi-reflective thinking

•Reflective thinking

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Optimal level of functioning

King and Kitchener (1994)

+Characteristics: What models of reflection share

A return to experience

Reflection and reframing

Lessons- capacity to inform future practice

Iterative process

Levels of reflection

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+The elements of reflection

Reflection on experience involves elaborating on or interrogating the experience.

Reflection has a purpose: to ‘work out’ an issue or felt difficulty.

Reflection involves complicated mental processing of issues for which there is no obvious solution.

Reflection provokes transformative thinking, leading to transformative action.

Reflection is a social rather than a solitary act.

Wear et al, 2012)

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+What would be our goals in using reflection as a teaching strategy?

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+ What would be our goals in using reflection as a teaching strategy?

To help the learner to:

Articulate their own reasoning, including tacit understandings

Construct and make meaning of experience- to develop new knowledge

Understand the broader context of their practice

Connect theory and practice- move outside their comfort zone

Monitor their developing professionalism and professional identity-to develop agency

Increase self-awareness

In telling stories, learners are constructing their professional identity

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+Reflection in Professional Development

Experiential learning as part of becoming a physician

Reflection transforms the experience into learning

Offers opportunity for ‘deep learning’

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+Sources of Stimuli for Reflection

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Formal learning experiences

Personal experiencesInteractions with

patientsLearning gains and

needs

Seminal eventsPersonal beliefs and

valuesInteractions with

colleaguesObservations

+Sources of Stimuli for Reflection

Overall impressions

What went well

What they were thinking

Any new goals that emerged

Any assumptions or biases

What they were feeling

What others were feeling

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(Westberg & Jason, 2001)

+How Can Reflection Help Learners in Understanding Professionalism?

What choice did the learner make?

What did the learner do?

Why did the learner choose that action?

How did they justify their actions?

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+Reflection on Professional Dilemmas

A reflective approach to the self-assessment of professionalism

Reflection may require a socially interactive process

Emphasizes both behaviours and internal and external context

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Bernabeo et al., 2013

+The Role of Reflection on Lapses in Professionalism

Focusing on action

Illuminate professional and non-professional behaviour

Helps to reveal the broader context

Can reveal competing values

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+What is the Teacher’s Role? Modeling Reflection

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Ask reflective questions

Reflect on events with students

Create a safe environment

Provide debrief opportunities

(Sutkin et al., 2008; Weissmann et al., 2006)

+What vehicles for reflection?

Informal ,impromptu approaches

Structured approaches

Individual approaches

Collective approaches

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+Portfolios as a Vehicle for Reflection

A file of achievements vs. a tool for reflection

Identification of learning needs

Details of learning experiences

Demonstration of what has been learned

Formative and summative assessment – teaching value

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+Sample Portfolio Items for Medical Education

•Professionalism goals

•Learning plan

•Standardized and real patient

evaluations

•Videotape segments

•Self-evaluation forms

•Peer feedback

•Reflective exercises

•Formative faculty feedback from

small groups or mentoring

•Faculty evaluation forms

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p. 216, of Stern (2006)

+Elements of Successful Portfolio Programs

Self-reflection from evaluated portfolios

Promote a supportive climate for learning and feedback

Advance development of self-assessment and mentoring skills

Chart progress over time: observation and interactive goal-setting

Support learning development

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p. 222, of Stern (2006)

+Methods to Assess Professionalism

Portfolios

Direct observation

Multisource feedback

Self-assessment and feedback

Critical incidents

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+Factors that Enhance Reflection

At the level of:

Institution

Teaching environment

Individual

What does this mean for teaching?

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Factors that Promote or Hinder Reflective Practice as Teachers Personal factors

Contextual factors

Environment

Culture

Other Pressures

Colleagues

Administrative Support

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Boud and Walker, 2002

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Challenges of Teaching Reflection in the Professional

Context

Barriers and enablers

Free expression of opinion

Perceived usefulness of the activity

Prior experience

Organizational climate

Time for reflection

Non-reflective professionalism

+ Review Recommendations from Systematic Review

Use reflection as a learning strategy and ensure that you are a guide for learners to this process

Model reflection for the learners

Include learners in your own reflective practice

Provide feedback on both the content and process of the learners own reflective practice

Provide an environment that encourages reflective practice

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(Mann, Gordon & MacLeod, 2009)

+Tips for Implementing a Program Define reflection for the learner

Decide on goals for reflective practice.

Choose the right method to teach reflection

Decide whether you will use a structure or unstructured approach to prompt reflection

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Aronson (2011)

+Tips for Implementing a Program

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Make a plan for dealing with concerns

Follow up with the learner

Create a learning environment that fosters reflection

Aronson (2011)

+Tips for Implementing a Program Teach learners how to reflect before

asking them to do it

Provide feedback and follow-up

Make reflection part of a larger curriculum

Reflect on your own teaching of reflection

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Aronson (2011)

+Preparing and Supporting Faculty

Faculty can benefit from experiencing reflection as well, both in personal growth and in developing skills in promoting learners’ reflection.

Longitudinal faculty development, where groups can reflect on their own practices, as well as learn new skills, in a safe, trusting environment, lead to changes in teaching

Opportunity to reflect on teaching practices can lead to sustained change in teaching approaches. (Mann, in press)

36The Iceberg of ProfessionalPractice

Fish & Coles, 1998

+Summary

Professionalism is more than a set of behaviors.

Learners construct their identity throughout their education.

Reflecting on experience can provide learners a means to integrate learning and to construct an understanding of their own professionalism.

To be effective, reflection must be more than superficial or ritualistic.

Feedback and guidance on reflection, and modeling reflection are important roles for Faculty.

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+References

Aronson, L. (2011). Twelve tips for teaching reflection at all levels of medical education. Medical Teacher, 33 (p. 200-205)

Bernabeo, E.C., Holmboe, E.S., Ross, K., Chesluk, B., Ginsburg, S. (2013). The utility of Vignettes to stimulate reflection and professionalism: Theory and Practice. Adv in Health Sci Edu, 18: 463-484

Boud D, Keogh R, Walker D. Reflection: turning experience into learning. Kogan Page London, 1985 (eds).

Boud D. and Walker D. (2002). Promoting reflection in professional courses: the challenge of context. In R. Harrison , F. Reeve, A. Hanson and J. Clarke. (eds.) Supporting Lifelong Learning. Vol. 1. Perspectives on learning. London UK: Rutledge Farmer. (pp. 91-110)

Coles, C. (2002). Developing Professional Judgment. J. Cont. Educ. Health Prof. 22, 3-10.

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+References

Ginsburg, S. & Lingard, L. (2006). Using reflection and Rhetoric to Understand Professional Behaviours. In Stern, DT. (ed) (2006). Measuring Medical Professionalism. New York, NY. Oxford University Press (pp. 195-212).

Fryer-Edwards, K., Pinsky, L.E., Bobins., L. (2006). The Use of Portfolios to Assess Professionalism. In Stern, DT. (ed) (2006). Measuring Medical Professionalism. New York, NY. Oxford University Press (pp. 213-233).

Hodges et al. (2011). Assessment and Professionalism: Recommendations from Ottawa 2010 Conference. Medical Teacher, 33: 354-363.

King, P.M. (1994). Developing Reflective Judgment. San Francisco: Jossey-Bass.

Mann KV, Gordon JJ, MacLeod AM. Reflection and Reflective Practice in Health Professions Education: A Systematic Review of the literature in the Health Professions. Advances in Health Sciences Education. 2009;14:595-621

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+References

Mann K. ( 2013 In press) Faculty development for reflection and role-modeling. In Steinert Y. Faculty development for the Health Professions. Springer In press

Moon J. (1999). Reflection in Learning and Professional Development. London UK: Kogan Page

Murdock-Eaton D, Sandars J. (2013) Reflection: moving from mandatory ritual to meaningful professional development. Archives of Disease in Childhood.doi:10.1136/archdischild-2-13-303948

Schön D. (1987) Educating the Reflective Practitioner: toward a new design for teaching and learning in the professions. Jossey-Bass, San Francisco, CA

Wear D, Zarconi J, Garden R, Jones T. (2012) Reflection in/and writing: Pedagogy and Practice in medical Education. Academic Medicine 87:603-609

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