Reflective Learning: Making a Difference â Andrew Grant
I was sufficiently interested in its possible applications to make reflective learning in undergraduate medical students the subject of my PhD. Studying the subject in depth taught me that reflection can enhance medical students' learning in a variety of ways.
My early work was largely focussed on reflection as a way of learning from experience. I used a number of techniques to help students to reflect on learning encounters and to identify the learning needs that were revealed. I have used templates based on the Kolb cycle (Kolb, 1984) as well as facilitated reflective learning groups (Grant, 2013) to support this form of learning. What I discovered through my research in this area is that reflective learning helps learners to better integrate learning and to be more self-directed. When students are addressing learning needs that they have identified for themselves, their motivation is intrinsic. What reflection particularly offers medical students is a way of constantly modifying and adding to their body of knowledge, with the result that they are able not just to reproduce what they know but to apply it in future situations, which might be different from the context in which they first learned it. Medical students are faced with a wide, varied and interconnected body of knowledge that they have to master. Reflection offers them a potent tool, which allows them to take control of this process and to become much more aware of their body of knowledge at any one time: where its strengths lie and where the gaps are.
Further study of reflective learning showed me that the use of reflection as a way of managing what you know and what you need to know is just one facet of reflective learning, albeit an important one. As well as acquiring a body of knowledge that they can apply appropriately in multiple clinical contexts, medical students also have to undergo a degree of professional development. Through reflection on clinical encounters they can examine their own values and recognize the qualities that they will need to develop in order to think, speak, act and behave like doctors.
As reflection becomes a core learning activity for medical students and practising doctors at all stages of their careers, it forms an essential part of an increasing number of core learning activities. Of particular note is the way reflection is embedded in aspects of selection and forms part of professionalism. For example, as part of selection processes at undergraduate and for speciality training, applicants are typically asked to how they would approach a situation with a number of conflicting demands and explain and reflect on their choices. They may also be asked to reflect on significant events or ethical dilemmas they have faced, and discuss what they have learned from the process and how this would affect their future practice. Reflection is a key aspect of professionalism, but also in terms of how a lack of reflection and self-insight often underpins unprofessional behaviours. The General Medical Council (GMC) notes that âthe sort of misconduct, whether criminal or not, which indicates a lack of integrity on the part of the doctor, an unwillingness to practise ethically or responsibly or a serious lack of insight into obvious problems of poor practice will bring a doctor's registration into questionâ (GMC, 2014). Such behaviours (from students and practitioners) can lead to investigation by their medical school/university or the regulator. As part of the investigation or fitness to practise (FTP) process, they may be asked to give an account of the events and through reflection to demonstrate that they are able to show insight into their actions and the possible consequences. For example, the Doctors' Defence Service UK advises doctors who are required to attend a GMC FTP hearing to provide evidence of personal insight to support their case: âa doctor should write out their reflections, giving careful thought to what they want to say, with a view to submitting their writings to the FTP panel. The exercise will also assist the doctor in presenting their case when they give oral evidenceâ (Doctors' Defence Service UK 2016). Whilst these examples are at the extreme end of the spectrum in terms of why reflection is important, they highlight its importance in maintaining professionalism throughout one's career, which is founded on self-insight, reflection and learning.
Start Early, Make it Routine â Judy McKimm
Working with doctors in training on postgraduate leadership programmes for over 10 years has caused me to think about the effectiveness of the training in purposeful reflection that occurs at undergraduate level and beyond. As with many masters' programmes, being able to reflect on and for action and think critically, and to link this meaningfully to practice, are key learning outcomes and âtransferable skillsâ. A few things come to mind when I think about how we embed reflection and critical thinking into the programme. The first is how little prepared (and often resistant) most of the students are to engage in formal reflective activities. Whilst they are more than happy to reflect on, in and for action through small group and whole class activities, when it comes to writing, especially writing for summative assessments, it becomes more challenging. Most students and doctors in training have not done purposeful reflection to any great extent, other than perhaps writing reflective accounts that do not get feedback or, whilst they have to be completed, are not marked summatively. So, one thought is that perhaps we need to educate teachers better on the different ways in which reflection can be embedded into a programme from the start, the ways in which reflection can be assessed (formally and informally, formatively and summatively) and how to overcome resistance in learners. Kurt Lewin says âthere's nothing as practical as a good theoryâ (Lewin, 1946), and I would paraphrase this to say âthere's nothing as practical as good reflectionâ. Fiona talks more below about some of the challenges, but my students would say (see some quotes in later chapters as well as this one) that the benefits far outweigh the challenges in terms of developing them as truly reflective practitioners.
So what do we do in the leadership programmes to help develop reflection as a routine learning and practice activity? First, we openly discuss the students' experiences of reflection (positive and negative) and set this in the context of the programme and its requirements. We know that âassessment drives learningâ, and, because every written assignment has a reflective component included, this becomes a key motivation factor. We spend half a day with the students (out of eight contact days) on reflective practice and its importance for leadership development. This includes the theoretical background, some frameworks and models, the importance of triangulating experiences and observations with the leadership literature and what âgoodâ and âpoorâ reflections look like, and, most importantly, students have time to practise and receive constructive feedback from tutors and peers on both oral and written reflective activities. Whilst we teach leadership âtheoryâ, our main aim is something much broader than this, encapsulated in a written reflection from a student:
I expected to gain knowledge, which would be directive to say, in this situation we do that, and in this situation we do this. But instead, it has given me a way of thinking, to tie any theory in with practice (K, C7).
Such a way of thinking has reflection at its heart. Throughout the course, we take a reflective approach to teaching, through questioning our own and others' practice; encouraging challenge and facilitating âfierce conversationsâ; enabling students to learn more about themselves (their strengths and areas for development), and equipping students with different tools and techniques to âthink differentlyâ, critically and from different perspectives, such as de Bono's âthinking hatsâ, (de Bono, 1885) âwhat if?â questions and âempathy mappingâ. A range of reflective and critical thinking assessments include: a âsignificant event analysisâ, their âleadership journeyâ reflective narrative, critical review of a leadership article, critique of effective and failing leadership, reflection on the way they managed their quality improvement project and critical reflection on themselves as âchange leadersâ. The culmination of these activities is shown in the quote below from one of the students at the end of the first year of the clinical leadership programme:
I think that the biggest development has been in deciphering what type of leader I am. I thought I knew, I thought I was aware of my strengths and weaknesses and had a good understanding of the traits and behaviours necessary to lead a team successfully. But what I have learnt is that I have become more self-aware, more able to appreciate the differences between the re...
