I have heard “reflective practice” mentioned a few times, in the years I have been talking with physicians, medical educators, and public health professionals.
Dr. Tasha Wyatt, of the Educational Innovation Institute at the Medical College of Georgia, explained to me:
“Physicians are trained–very much so–to gather data, to make decisions. And reflective practice is a way to slow down that process.”
If I could say one thing about the term “reflective practice” in my experience as an educator…it would not be a nice thing to say.
A bad reputation
Reflective practice is certainly a term that gets thrown around. It elicits groans.
Let me be clear: I am a reflective practitioner. Critical reflection is the engine of my practice. I have spent most of my time in higher education trying to rescue “reflective practice” from its own reputation in my students’ imaginations.
That’s not to say this reputation is undeserved. From where I stand, there are some punitive, reductive, top-down things going on under the guise of “reflective practice.”
And I’m hearing similar statements from the health sector.
A broad spectrum
Reflective practice is a broad spectrum that covers many different understandings of and approaches to reflection (and practice).
This has advantages and disadvantages. Flexibility is essential in an approach that generally is an alternative to practices that are more didactic or directive.
There seems to be support of reflection as a skill. Health professionals all require critical-thinking and problem-solving skills, and reflective practice has been used to support these. Reflection is used to increase metacognition. It is sometimes invoked as a way to connect theory to practice, or to enhance communication. Professionals reflect in classes, in continuing education, or in communities of practice; alone, in dyads, or in small groups.
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Yet this literature review points out the variation in what reflective practice means, and how it is facilitated and assessed, in medical education. This literature review finds similar results in pharmacy education, pointing out the conflicting interpretations and applications of the term ‘reflective practice.’ I highly recommend both these literature reviews for references on reflective practice in health professions.
Both also cite Donald Schön, whose highly-influential books The Reflective Practitioner and Educating the Reflective Practitioner describe and analyze reflection-in-action across multiple professions and professional contexts.
In Educating the Reflective Practitioner, Schön explains why:
[T]he problems of real-world practice do not present themselves to practitioners as well-formed structures. Indeed, they tend not to present themselves as problems at all but as messy, indeterminate situations. Often, situations are problematic in several ways at once. These indeterminate zones of practice—uncertainty, uniqueness, and value conflict—escape the canons of technical rationality. It is just these indeterminate zones of practice, however, that practitioners and critical observers of the professions have come to see with increasing clarity over the past two decades as central to professional practice. (p. 4)
What I want to share here is a key tool in reflective practice: questioning or problem-posing as a way to begin to investigate and address the “problems of real-world practice.”
“Problems of real-world practice”
If I hear ‘what could you have done differently?’ posed as a ‘reflective practice’ question one more time, I’ll scream.
So instead, I’m going to give you twelve prompts that you can ask yourself when you wish to engage in some critical reflection.
These questions are designed to get at your taken-for-granted beliefs and actions. They encourage you to problematize structures, processes, and practices (as these authors do), accepting current arrangements not as given or natural but as politically and historically situated (as these authors point out).
These questions are aimed at those times when you are educating—a patient, or a student. But they can have broader applicability. Overall, they are designed to encourage you to take a critical view of the customary practices and conventional arrangements in your practice context.
After each, there always is a follow-up question: what implications does this have for your practice? In other words, why might this matter to you and your work with patients?
Which patients tend to draw your attention? Why do you think this is? Which patients tend to escape your notice? Why do you think this is?
Are there patients you find it difficult to get along with, or relate to, or reach? How do you feel about this?
What information or knowledge are you assuming patients have when they meet with you? Where would they have acquired this knowledge or information? How have you responded when they do not appear to have this knowledge or information?
What’s presenting a challenge to you recently when it comes to patient education, that you did not think would present a challenge?
Did anything a patient did or said surprise you today? What was it? Why was it surprising to you? How can you let patients surprise you more often? Have you surprised yourself lately? How?
What’s going on around you that piques your curiosity this week? That you’d like to give more time and attention to, if you could?
When you meet with a patient, how are you talking to this person? What do you tend to think of people in this social group? How might your conversational dynamics be based on biases and stereotypes?
If you broke down the time you spent this week on different tasks and put it on a chart or graph, what would it look like? To what extent does this match your idea of a successful or productive use of your time?
What have you done this week that you were proud of, no matter how simple it might sound?
Are there times you are unsure of what you are communicating to a patient or colleague? How do you deal with this?
If you could wave a magic wand and give yourself the insights, knowledge, dispositions or skills you need in order to succeed this week, what would you give yourself?
What clever hacks, little-known tricks, or productivity boosts have you discovered lately? What might these be telling you about yourself, or your context?
Again, the important question at the end of each set is always: what implications does this have for your practice?
“Is reflection safe?”
Reflection is an important process for any profession. Yet, at the same time, health care providers are held to such high expectations that reflection can seem risky, as recent events in the UK illustrate.
“Is reflection safe?” Dr. Wyatt wondered aloud, as we were talking. “If so, under what conditions? If not, under what conditions?”
Of course, no one can eliminate the stress and messiness of practice. Reflection, when critically oriented, is designed to press into–and not deny–the stress and messiness of practice. It is an irreplaceable, powerful tool that invites professionals to imagine other possible practices, roles, and relationships.
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