The title of this book is Reflective Practice, the length of it and the fact that it has been published implies that reflective practice is ‘a good thing’. But we are sure that, on your journey through the book, you have had thoughts that reflective practice is not always the right practice at the right time. Your own experience may have shown you times when reflection did, or did not, help, or when you were frustrated by having to ‘do’ reflection that felt false or contrived. Our experience shows us that reflection can help individual professionals to develop, to manage crises and to improve the care that they give to others. However, reflection and reflective practice have little in the way of evidence of efficacy, or research-based validity, and, as we have discussed in chapter 8, there are times when it can lead to conflict and anxiety. Through studying this chapter and engaging in the exercises, you will be able to:
• critically review the case for, or against, reflection
• review some of the literature that explores the nature of reflective practice
• debate the issues raised when reflection is assessed
Are some people naturally more reflective than others? We have all said at some time: ‘I wish I’d thought’ or ‘Why didn’t you think?’ These are expressions that we only use when something has gone wrong in some way. When some chance action has gone spectacularly well, we do not usually question it critically. Indeed, had the person stopped to think things through, the cat might not have been rescued or the football match won: too much reflection and thinking about things that could go wrong may stop us doing anything at all. We have all witnessed people who spend so long deciding what to do that in the end they do nothing.
Usually, when we do think before acting, we use our previous experience and our calculation of what could go well, or go wrong. How much we are willing to risk depends on how high the stakes are. A 20 per cent chance of winning a raffle may not seem good, but a 1 in 5 chance of an operation saving our lives may look like very good odds indeed.
In chapter 1, we introduced reflective practice as a technique that was developed as a counter to the ‘technical rationality’ of scientific methods of decision making, education and practice development in professions. However, its practical, ‘messy’ orientation makes it harder to research and less verifiable; the very reason for saying it’s good makes it difficult to defend. Furthermore, embedding it into professional education has required assessment, usually through written accounts. How authentic are these? Do they truly ‘test’ how reflective the writer is or just how well they can ‘play the game’ and reproduce text in a reflective style? In this chapter, we want to focus down onto the three most difficult issues that we have come across in writing this book.
Can reflection be taught, or is it simply more natural to some than others?
Does reflective practice improve practice? Is there any evidence to support this?
What are the issues with assessing reflective practice?
Can reflection be taught?
Schön’s argument, introduced in chapter 1, is that professional learning has come to rely upon ‘technical rationality’. The educational process he challenges – of starting with rules and theory and moving on to practice later (Schön, 1991) – suggests that the basic rules of a task need to be taught and learnt prior to mastery and intuitive working. The reversal of this process in reflective practice – stating that the practice of a profession is where learning should start, with application and theory following from this – locates reflection in doing and being a professional, rather than thinking and reading. Edwards and Thomas strongly argue against reflection being taught: ‘reflective practice cannot be a rubric of prescriptive skills to be taught. In fact, to view it in this way reverts to the very technisist assumptions reflective practice was meant to exile’ (Edwards & Thomas, 2010, p. 404).
However, if reflective practice is something that we desire, and even require, from professionals, can we assume that they will automatically understand and be able to do it? Other authors (such as Russell, 2005) disagree, stating that it should and ought to be taught: how can we ask students to be reflective, tell them it is important and ask them to get better at it, if we cannot teach it? Some of his concern comes from reports he has heard from students that they make up stories for assessment, which suggests that teaching reflection needs to be seen in connection to assessing it, an area we discuss later in this chapter. He argues that students need to be given clear structure, and to be assessed, in order to frame and develop written reflection. Whilst he refers to teaching, what he describes may be closer to ‘facilitated learning’ (Bolton, 2012). This issue may be one of semantics, or the philosophical matter of the role of ‘teacher’ and ‘learner’ in an educational setting.
Although research evidence is limited, a literature review (Mann et al., 2009) sifted through hundreds of published papers to identify twenty-nine empirical studies exploring reflection in medical and nursing education. They judged these to be well designed and thorough, but mainly exploratory and qualitative in nature. Just four of the studies aimed to test whether reflection had been taught – these conclude that the studies did show a difference in students’ reflective ability over time. However, the designs tended to rely on the assumption that the assessment of student learning is a measure of their increased reflective ability.
This assumption is supported in other studies, for example an experimental design with three groups attempting a written reflective assignment: a control group with no additional support, a group with ‘critical incident prompts’, and a final group with an additional flow diagram to aid structure (Lai & Calandra, 2010). They found that the two structured groups wrote better assignments, with more evidence of ‘higher level’ reflection. We would like to argue that studies claiming to show that reflection has been taught by measuring reflective writing may be oversimplifications. An alternative explanation for the assessment results is that students learn to demonstrate what is valued by the person doing the marking, rather than becoming more reflective.
A further study with medical and dental students (Brett-MacLean et al., 2010) claims that developing narrative reflective practice did help students to ‘story’ their own devel-opment and empathetic understanding of the people they were caring for, but, as with other studies, they fall short of suggesting that this, of itself, shows that reflective practice can be taught.
So can it? We recognize reflection and reflective practice in ourselves and others and often note an absence of reflection, which suggests that it has been learnt, but how and when that learning takes place, and the role of formal teaching and learning, are much less clear. What seems obvious to us is that it is not learned in a classroom, and is not learned just from reading about it. Things that seem to be important are:
• spending time thinking, returning to events and actions in order to appraise their meaning
• engaging in group or one-to-one dialogue
• recording reflections in some way – written or otherwise
• feeling safe to explore without being judged
Perhaps most importantly, these acts are undertaken in parallel with being a particular person, a combination of professional and personal identities. These are framed, or motivated, by a moral agency akin to professional wisdom (Banks & Gallagher, 2009) and values-based practice (Thornton, 2008).
Does reflective practice improve practice?
It is clear from the research undertaken to identify how reflection is taught, and the experiences of trying to assess its existence and quality, that not everyone finds reflective practice easy, and many respondents in research and opinions in published papers challenge its worth. So why do it? Is there any evidence to support the role of reflection in improving practice? And if there is not, what is its purpose?
A number of papers report findings that claim a link between reflection and practice improvement. Mamede and colleagues argue for a relationship between being able to reflect critically on practice and the reduction in diagnostic errors (Mamede, Schmidt & Rikers, 2007). They identify that, whilst some errors may be unavoidable – for example, unpredictable factors or systems failures – many errors are cognitive. Their work is supported by later authors: firstly, Barley (2012), who accepts the theoretical position that managing complex cases is aided by reflection, but acknowledges there is yet to be robust research evidence to confirm this; secondly, Wald and Reis (2010), who reprise some of the arguments about how to assess through focusing on how to measure reflection from reflective writing. Both papers acknowledge that possible links between reflection and diagnostic reasoning cannot be assumed to be measured through reflective writing, and that formal assessment can lead to formulaic answers.
Similarly to Benner’s ‘expert’ nurse (Benner, 1984), experienced doctors in Mamede’s later work use pattern recognition and heuristics to fast-track decision making, thus creating bias that may miss important signposts to alternative decisions (Mamede, Schmidt & Penaforte, 2008). They identify a number of elements that are involved in reflection, concerning questioning, testing, exploring and being open to criticality and learning. Although empirical testing showed no statistically significant improvement in decision making, they did note that reflective skills were significant when dealing with more complex situations, echoing Schön’s theoretical position on the ‘messy swampland’ of professional practice, introduced in chapter 1 (Schön, 1991).
Other authors note positive connections between reflection and practice improvement: Balla et al. (2009) and Graber (2009), looking at decision making for family doctors and clinicians; McCracken and Marsh (2008), focusing on evidence-based practice related to social work; and, looking at expertise in nursing, MacLeod (1996), who identifies that defining features of the experienced ward sisters in her research were reflection and openness to learning. By contrast, practitioners who were not judged to be experts by their peers lacked the critical awareness associated with reflective practice (Benner et al., 2009).
Research with students, using digital equipment to log encounters that included cues to record related learning points, found a correlation between the logging of encounters and therapeutic relationships, and also between logging and interpretation skills, but not increasing factual knowledge (Thomas & Goldberg, 2007). Further evidence is offered by Glina and colleagues, who record the positive effect of group reflection on performance for a group providing hospital food services (Glina et al., 2011), and in research undertaken with nurse practitioners (Glaze, 2001, 2002), who identified (self-reported) positive responses to the effect of reflective practice.
So where does this leave us? Whilst much that is written about reflective practice is uncritically positive, there does seem to be a growing evidence base that supports the efficacy of such practice in:
• linking reflection with critical thinking skills and complex decision making
• supporting new people to learn and grow into their professional role, and experienced people to continue to learn and survive in complex and often stressful environments.
Many questions remain, not least of which are the relationships between personality and the tendency to be reflective, the role of culture and upbringing, and the extent to which innate learned behaviour and thinking can be directed, changed or improved through teaching or facilitated learning.
Finally, the results of empirical research are based on an assumption that we are able to identify what reflective practice is with sufficient clarity to measure it. This challenge is often mirrored by equally compelling issues regarding the assessment of reflection.
What are the issues with assessing reflective practice?
Since the turn of the century, a growing number of papers have appeared challenging the validity of assessing reflection and reflective practice. They suggest that we are not confident we know what we are trying to assess or why, or whether the assessment tasks set measure or test the things that are being looked for.
A talk by ‘looked-after’ children (children who are brought up by someone who is not a member of their birth family) left two students with very different responses.
One student was horrified and angry that there was such a category as ‘looked-after’ children. In the culture from which she came, children who had lost their parents would have been taken in by a relation, however distant, and the concept of looked-after children simply did not exist. Asked to reflect on her feelings after the talk, the student could only write about the shock of discovering that the society in which she was studying could think it appropriate to treat children in this way.
Another student who had been present at the same talk was deeply surprised that the children had said one of the things they disliked was being taken by social workers to discuss their cases at a local fast-food restaurant. This student thought that the children were being ungrateful and that they should see being taken to the restaurant as a treat. The student was unable, as a single parent, to afford family outings to the same restaurant and so thought the looked-after children ‘lucky’ to be given treats.
After reflection, the second student could recognize that the looked-after children did not like to be seen by their friends with their social workers. It was not the restaurant they were objecting to but the fact that others at their school might discover the truth about their family background. The student’s reflective journal was marked and passed.
The first student found it impossible to accept a culture that did not have strong kinship ties. The points she was making in her reflective journal were extremely valid but she was not able to debate her points within the structure required by the journal. Instead of an honest piece of reflection on herself and her response to the talk, she felt compelled to hand in a piece of work that was not honest to get the mark she required for the module.
 | TIME FOR REFLECTION |
This story will be familiar to anyone reading this book who has been involved with being assessed, or with assessing reflection. Both students’ reflections are valid and insightful. The facilitated learning has been effective as a trigger for greater understanding of the society in which they were learning to be professionals. Both have strong feelings that have led to reflection and learning. Should you judge them, and if so how? Is one ‘more’ reflective because they can articulate the process of learning to view the situation through the child’s eyes? Is the student whose cultural values are offended ‘less’ reflective because she struggles to contextualize this?
Educational models such as ‘constructive alignment’ (Biggs, 2006) view assessment as an important, integral part of learning as well as a measure of attainment. First, ‘learning outcomes’ articulate the lecturer’s aspirations for the changes in student knowledge, skills and attributes brought about by a particular course of study. This is then supported by a learning and teaching strategy that facilitates achievement of the outcomes. Assessment aligns with these processes to scaffold, measure and reward learning. Finally, feedback on student achievement and evaluation of the experience ‘feeds forward’ into ongoing student learning and curriculum development. The assertion that assessment is one equal component of this learning process is well established and accepted.
However, for all our belief that reflection is important to professional practice – that it can help to embed good practice, facilitate the recording of thinking processes, develop skills and improve practice and may help to move difficult situations forward – we acknowledge that the role of assessment in this may be flawed.
Figure 9.1 Flow diagram of a learning experience using constructive alignment (after Biggs 2006)
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
