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Reflection and Questions

Developing Self-Awareness and Critical Thinking for Continuous Improvement in Practice

Margaret M. Plack, PT, DPT, EdD and Maryanne Driscoll, PhD

CHAPTER OBJECTIVES

After reading this chapter, the reader will be prepared to:

• Recognize the value of reflection in clinical practice and professional development.
  
• Describe reflective practice, including the elements underlying the reflective process.
  
• Link reflective practice to critical thinking and clinical decision making.
  
• Apply the elements of reflection to enhance critical thinking in practice.
  
• Describe strategies for developing and asking effective reflective questions.
  
• Develop effective questions to facilitate critical thinking and reflective practice.
  
• Use the questioning process as a basis for creative problem solving.

As we learned in the previous chapter, Dewey³ believed that our experiences are the basis for learning. However, he also thought that experience is not enough; it is what we do with our experiences that allows us to learn from them. In this chapter, we explore the concepts of reflection and critical thinking as means of making sense of and learning from our experiences.

Bernard et al⁴ describes reflection as “a cognitive process in which new information and experiences are integrated into existing knowledge structures and mental models, resulting in meaningful learning.” The reflective process enables us to search for connections to prior learning and past experiences so that we can make sense of our current experiences in the context of what we do and do not know. The reflective process helps us continually build new neuronal connections by linking to prior learning. As mentioned earlier, connecting to prior knowledge also helps us learn and retain information. The more we can link new knowledge or new experiences to what we already know, the more sense it makes and the easier it is to learn and retain.

Conscious reflection and critical thinking facilitate deeper learning (ie, learning beyond simple rote memorization).

To move beyond role memorization requires us to use the upper levels of Bloom’s Taxonomy (analysis, synthesis, and evaluation) rather than simply relying on knowledge, comprehension, and application.⁵ Through reflection, we can begin to view and analyze our own situations from multiple perspectives. The reflective process provides us the opportunity to reframe problems, question our assumptions, and analyze and evaluate our experiences.^1,3,6–12 It is also through this process that we can connect our personal experiences, preferences, and beliefs to the experiences of others, including our patients, in the clinical decision-making process.¹³

Reflection has been widely used in higher education to facilitate deeper learning, and, more recently, researchers have studied the reflective process and its importance in educating physicians, nurses, physical therapists, and other health care providers.^14–27 In physical therapy specifically, reflection has been considered the hallmark of professional practice, the basis for expert practice,^28,29 the key to critical thinking,^11,30,31 and the link to the development of self-regulated, self-directed, and lifelong learning.^32–35 Reflection provides one with an opportunity to actively manipulate information, encode it further, and transform it into learning that lasts (ie, enhances memory pathways).^{11,13,30,31,36,37} It allows us to retrieve information we already learned (ie, access prior knowledge), elaborate on that knowledge (ie, make additional links), and generate new ideas based on the connections made.³⁶ Reflection has also been linked to the development of therapeutic relationships, improved patient care and teamwork, decreased medical errors and stress, and mindful practice.^{34,35,38–40}

In this chapter, we explore the reflective process, including what it is, why it is important, and how to facilitate it. We describe how reflection is the basis for critical thinking, self-monitoring, the development of therapeutic relationships, and lifelong learning, which are all critical to the development of effective clinical decision making and expertise in practice. Finally, we provide you with some strategies to facilitate the process in yourself, your patients, your learners, and others.

Thinking is something that comes naturally to all of us; however, thinking and reflecting are not synonymous. So what is reflection? The term reflection has many definitions.4,43,44 Boyd and Fales⁴⁵ describe it as an internal process we use to help refine our understanding of an experience, which may lead to changes in our perspectives. It is both the cognitive and affective behaviors that we engage in to gain new insights into, and a deeper understanding of, our own experiences.⁷ Reflection is our ability to monitor our thinking and to recognize what might be influencing our decision making. Why am I thinking what I am thinking? What am I missing? Am I making an assumption here? Are my emotions influencing my decision making? In discussing perceptions and assumptions in Chapter 1, we noted how we all perceive things from our own lens, we all make assumptions, and our assumptions often influence how we think and act. We do not see the world objectively; rather, we see it as we believe it to be, based on our own perceptions.^38,46 The reflective process is what enables us to monitor our own thinking to determine what is truly influencing how we think and how we act. Reflection is an analytical process and is future-oriented; it enables us to continually improve what we think, how we think, and how we perform.⁴⁷ Reflection requires us to think critically to accomplish the following: (1) to clarify our own thinking, (2) question our own assumptions, and (3) consider other viewpoints and perspectives.⁴⁸

REFLECTION: WHY IS IT IMPORTANT IN CLINICAL PRACTICE?

We are able to more quickly make sense of novel and complex situations, identify gaps in our knowledge, and act to fill those gaps through the reflective process. In addition, reflection enhances our self-awareness and our awareness of others, which is central to the development of therapeutic relationships; good therapeutic relationships can lead to better patient satisfaction and improved outcomes. Finally, reflection promotes lifelong learning through ongoing self-monitoring and self-assessment, both of which are skills that are essential to continuous improvement in practice.^34,49

Reflection is critical in physical therapy, as evidence-based practice and client-centered care require us to analyze best evidence while considering our own values and assumptions as well as the values, beliefs, and goals of each patient. The reflective process requires us to slow down and take time to consider the situation from the view of our patients, their families, and other stakeholders, such as the doctor or insurance provider. It facilitates critical thinking by engaging each of us in recognizing our assumptions and how those assumptions might impact our therapeutic relationships and the clinical decisions we make. Reflection also helps us, as learners and clinicians, develop a questioning attitude and the skills needed to continually assess our own knowledge and recognize the gaps in our knowledge and understanding, which is essential to quality care—particularly given our rapidly changing global health care environment.²³

Initially, Schön¹¹ analyzed the curricula of a number of professional programs and stated that many of these programs favored what he called technical rationalism over problem solving and professional development. That is, the focus was on attainment of knowledge and skills, almost to the exclusion of the development of professionalism and critical thinking skills. Times have changed and so has the emphasis on reflective practice! This has significant implications for physical therapists. In physical therapy, expert practitioners use their own intuition and personal thoughts and feelings to inform the gathering, analysis, and interpretation of clinical data. Through the reflective process, they continually elicit multiple perspectives and seek alternative solutions as they question their personal assumptions, which ultimately better informs their clinical decision-making efforts.^50–52 Reflection is integral to the development of expertise and, as such, it is important that students and novice clinicians be given opportunities to both develop and practice the skills of reflective practice, along with the technical knowledge and skills needed to develop clinical expertise.

In addition to enhancing our clinical decision-making skills, reflection is the key to self-assessment and self-monitoring, which are critical to professional development and lifelong learning. It is through the reflective process that we begin to hone our self-assessment skills.23,42,53 Self-critique is what allows us to recognize the limits of our own knowledge; it is only once we recognize our own limitations that we begin to seek new knowledge and skills. It is this ongoing critique that leads to continuous improvement in practice and encourages lifelong learning. The process of self-monitoring also enables us to be mindful practitioners. Epstein³⁸ describes a mindful practitioner as one who “attends, in a nonjudgmental way, to his or her own physical and mental processes during ordinary everyday tasks to act with clarity and insight.” Reflection and mindful practice enable us to recognize how our emotions and biases may be influencing our thoughts and actions. For example, if you are upset with your patient because he or she did not follow your instructions and reinjured him- or herself, you may interact differently than if you were empathetic instead.³⁴ Through this metacognitive or self-monitoring process we can begin to recognize our own “blind spots” or areas of deficiency in our thinking and decision making that we might not have otherwise recognized.³⁸

Finally, through the reflective and critical-thinking processes described by Schön, Mezirow, and Brookfield,^{9,11,30,31,51,54,55} we can begin to recognize our own values, beliefs, attitudes, and assumptions, and how they might differ from those of our colleagues, patients, and families. Integrating the perspective of the practitioner and the patient in the clinical decision-making process ultimately enhances patient adherence and outcomes. Reflection, underlying mindful practice, is what enables us to recognize our own beliefs, attitudes, and assumptions. Of equal importance, reflection and mindful practice enable us to recognize and consider our patients’ beliefs, values, and assumptions, making for a more effective therapeutic relationship. Figure 2-1⁴¹ depicts the essence of an expert practitioner; reflective, mindful, and self-monitoring while engaged in patient care.

ELEMENTS OF REFLECTION

Schön’s⁹ work is often cited in the reflective practice literature. He describes 2 types of reflection: reflection-in-action and reflection-on-action. We, as learners, teachers, and therapists, are often faced with unique and ambiguous problems in the clinical setting during which we are forced to stop, think, and problem solve in the midst of what we are doing. For example, you may walk into a patient’s room in an acute care setting with a plan to work on ambulation. As you begin to transfer the patient from sit to stand, he or she complains of feeling faint. You immediately change your plans to accommodate a very different situation than you had anticipated. At the very moment when you recognize that something was not right, you begin to reflect and question what was going on in that situation and how you would need to quickly adapt. Schön⁹ calls this reflection-in-action. In clinical practice, reflection-in-action requires us to function on the following 2 levels simultaneously:

1. Attending to the task of interacting with the patient.
   
2. Continually self-monitoring, questioning, observing, assessing, and adjusting our thoughts and actions throughout the session.²³

Based on the previous example, in addition to monitoring your outcomes throughout the session, you want to be sure that you are continually interacting with your patient to ensure that trust, confidence, care, and compassion are maintained. Simultaneously, you are continually assessing outcomes and making decisions about any changes you might need to make given the dynamic situation in play. It is truly a complex interaction! While some of this is done on a relatively subconscious level, the more we can focus on the decisions we make and how and why we make them, the more we can learn from our everyday experiences. The more we are able to focus on being in the moment with our patients without being distracted by the world around us, the better able we are to reflect-in-action and optimize outcomes.56

Literature suggests that expert clinicians routinely use the reflective process.⁵⁰ In practice, the more patients we see with the same type of health condition, the more quickly we are able to recognize that condition with the use of fewer and fewer tests and measures. We begin to see clusters and patterns of symptoms and can quickly begin to put the pieces together for an effective treatment. We develop mental models or scripts of how we anticipate the session will progress.⁴⁷ In the case of health conditions, these are referred to as illness scripts. Poole et al⁴⁷ define scripts as those “files we store in memory that tell us how events should unfold.” They then provide an example, such as when the telephone rings, and you answer it and say “hello.” That is a typical script; that is how you expect the phone-ringing event to unfold. With experience, we begin to recognize patterns and similarities in presentations, and that is how we develop our “illness scripts.” Schön refers to this as knowing-in-action.¹¹ This anticipation becomes somewhat intuitive, automatic, and nonanalytic. However, when something does not go as anticipated (ie, a script violation) or somehow contradicts your own belief system (ie, self-schema), it is the reflective process, your ability to reflect-in-action, that enables you to transition to a more effortful analytic process and quickly change what you are doing to achieve a more successful outcome.^47,57,58

In his book Thinking Fast and Slow, Kahneman⁵⁷ describes a dual processing model that incorporates fast and slow thinking, or System 1 and System 2 thinking. System 1, or fast thinking, is when we rely on our knowing-in-action, our mental models, and scripts. It relies on our brain’s ability to see clusters and patterns and to put the puzzle pieces together quickly. If all is going well, we do not have to overanalyze or overthink; it is as if we are on autopilot, our fast thinking is sufficient. On the other hand, when something does not fit our mental model or script, if something does not go as anticipated (for better or for worse) our System 1 (fast) thinking cannot process this information sufficiently and it triggers our System 2, or slow thinking, or the reflective process. However, we must be ready to quickly “notice” when something is not going as planned and that requires continual self-monitoring. It is this inability to quickly notice and begin the analytical reflective process that often leads to errors.⁵⁹ This is what Moulton et al^58,60 call slowing down to think expertly. Often, particularly in the clinical setting, the challenge is knowing when to “slow down” so your thinking can be more effective in preventing errors.^40,59 In addition, as expert clinicians, beyond monitoring what is working and what is not working, we continually strive to do the best for our patients. So, while we may function habitually at times, especially in the fast-paced clinical environment, it is critical that we continually slow down and shift into System 2 thinking to make sure that we are providing optimal care for each individual patient. Again, this is where the habit of continual self-monitoring becomes critical.

Beyond reflecting in the moment, expert clinicians stop to reflect on what they did after each patient interaction, and ask themselves what worked, what did not work, and why? Again, in the earlier example, once you have quickly adapted, modified, and completed your session, as a reflective practitioner you would take a moment to think about what happened and what signs you may have missed in bringing the patient to standing too quickly. Schön refers to this as reflection-on-action.^9,11 Conscious use of the reflective process is essential to developing expertise.⁵⁰

There is one more component of this reflective process that is very important and often missed. Once you have taken the time to think about what happened, the logical next step would be to think about how you might do things differently the next time and perhaps anticipate potential problems before they even arise. Building on the work of Schön,¹¹ Killion and Todnem⁸ describe this process as reflection-for-action. Experts take this proactive stance; they apply what they learned from experience and use it to plan ahead in anticipation of similar situations in the future.60 It is by consciously taking this next step that we enhance our future practice and patient care.

In a study of expert clinicians, Jensen et al50 note that the use of the reflective process was a key factor that set expert clinicians apart from their peers. Expert clinicians routinely self-monitor, engaging in reflection, and continually searching for new strategies to improve their approaches to patient care. Reflection is integral to competent and professional practice, and it is a skill that can and must be learned and practiced by novice clinicians in both the academic and clinical settings.^{12,23,61–65} While we may frequently stop to think about how a particular session has gone, we do not always consciously analyze the situation sufficiently to enhance our own practice, nor do we routinely take it to the next level to determine how what we learned from the experience might improve how we practice next time. Understanding the complexity of the process and practicing the components and elements of reflective thinking will increase the likelihood that you will become a reflective practitioner and skillful clinician.

We have completed a number of research studies, written a number of articles, and conducted numerous workshops on reflection with physical therapy students, clinicians, educators, medical students, residents, physicians, and other health care providers.^{15,21,22,66–71} Through this process we have developed a number of frameworks to help new learners begin to recognize and apply the different elements of the reflective process. Recognizing each of the elements of reflection can prompt us to more fully analyze our experiences and become more conscious of the decisions we make and the factors that have influenced those decisions. By engaging in this process, we can begin to move toward more expert practice.

These frameworks are based on the works of numerous reflective theorists, the most commonly cited of which are Schön⁹ and Mezirow.³¹ Table 2-2 provides a definition of the reflective elements described by Schön⁹ and Killion and Todnem.⁸ To help you put these elements into context, we have provided some quotes from student reflections to illustrate each of the elements in Table 2-2.^8,9,11,21,66

People often suggest that reflection is just something we do naturally. We have started a number of workshops by asking people whether they believe that they reflect. Most people say, “of course I do, I think all the time, doesn’t everyone?” Sure, people stop to think about what they are doing and to solve whatever problems they are facing. However, Mezirow31 believes that being a reflective practitioner requires much more than just stopping to think, solving problems based on what we already know, or daydreaming about the future. Reflection is much more than just exploring our thoughts or feelings. According to Mezirow,³¹ to be a reflective practitioner, it is important to continually question our experiences, what we know, and how we know it. Stopping to question what just happened can help us to further analyze and make sense of our experiences and learn from them.

Mezirow’s³¹ work provides a different perspective, adds another dimension to the reflective process, and offers us another framework from which to explore the reflective process.

The questions raised in the critical thinking clinical scenario above are reflective questions; yet they go beyond Schön’s9 concepts of in-action, on-action, and for-action. They require us to analyze the situation from different perspectives. Mezirow³¹ contends that reflection is a higher order, conscious thought process. He offers the following 3 additional elements to the reflective process: content reflection, process reflection, and premise reflection. He suggests that taking time to analyze a situation using these 3 elements of reflection may help clarify our understanding of, and assumptions about, our current situation. Behaviors may result that reflect changes in underlying values, attitudes, and beliefs, which are critical to becoming professionals. The questions posed in the previous scenario are based on Mezirow’s reflective framework.

Content reflection involves the analysis of the problem or situation from the perspectives of all of those involved.³¹ This is common in patient-centered practice where we are required to routinely consider the perspectives of patients, caregivers, families, nurses, third-party payers, and all of those involved in patient care. By exploring the perspectives of all individuals involved, we can begin to determine what factors may be influencing the situation and from there, be better prepared to develop the most appropriate and effective plan of care for that particular patient. Content reflection can help us to better understand the personal, environmental, social, and contextual factors that might influence a patient’s beliefs and abilities to engage in therapy and in following through with an established home program.

Only after we have analyzed the situation from all perspectives can we effectively begin to determine how we might approach the situation or what strategies we might choose in addressing the problem. The more we know about our patient’s situation, the more equipped we are to help our patient develop effective strategies. Mezirow terms this process reflection. As practitioners, we use process reflection when analyzing a situation to determine the problem-solving strategies we will choose, determine the efficacy of the strategies chosen, and perhaps explore what other strategies might be available. Process reflection also requires us to continually monitor how we are making our own decisions.

Finally, premise reflection is the most difficult and complex of Mezirow’s reflective constructs because it requires us to question and analyze our own assumptions or the assumptions underlying the problems with which we are faced.³¹ As you learned in Chapter 1, assumptions are taken-for-granted beliefs, often accepted without thinking, and, as a result, they are difficult to recognize, especially personal assumptions. How often have you made assumptions about individuals based on their disability, culture, race, size, or socioeconomic status? We all make assumptions, but as health care providers it is particularly important that we do not act on those assumptions or allow those assumptions to influence how we act or make decisions without first confirming what we know. Premise reflection enables us to recognize those assumptions and question them before making judgments or decisions based on our unconscious and unquestioned notions.

Premise reflection also occurs when we question why a particular problem exists. For example, when we stop to question why a particular patient is not entitled to certain medical treatment, why certain disparities exist in health care, or why we are required to treat 4 to 6 patients in 1 hour, we are using premise reflection. To recognize our own assumptions and biases and how they might impact our clinical decision-making process, and our role as patient advocate requires significant skill in premise reflection. Descriptions of Mezirow’s reflective elements and illustrative quotes from student reflections are presented in Table 2-3.^{21,31,51,66,72}

Atkins and Murphy44 performed a meta-analysis of the many definitions of reflection in the literature, and, as a result, they described 3 essential components to the reflective process (Figure 2-2). First is a trigger event. A trigger event is typically a personal awareness of a feeling and/or thought (ie, positive or negative); something out of the ordinary or a sense that something does not fit. Mezirow³¹ calls this noticing, and Poole et al⁴⁷ call this a script violation. This trigger causes us to slow down^58,60 and move from System 1 to System 2 thinking^57,59 to begin critically analyzing our own feelings and thoughts, why they exist, and how they relate to the experience itself or to some prior learning or past experience. This analytic process (ie, the reflective process) generally results either in the development of a new perspective or in the confirmation of the practitioner’s original perspective. This becomes the new starting point in our perception and thinking as we integrate what we have learned from this reflective process into our overall mental models or scripts, refining our mental models or scripts as we learn through our experiences.

The process described by Atkins and Murphy⁴⁴ is closely aligned with the third framework we have used in facilitating the reflective process, the previously mentioned Bloom’s Taxonomy. More than 50 years ago, Bloom⁷³ designed a method of classifying learning objectives along a hierarchy from simple to complex. To this day, Bloom’s Taxonomy is taught in almost any course related to teaching and learning. While the original taxonomy is still commonly used, a revised taxonomy was developed in 2001, which will be discussed further in Chapter 5. This hierarchy can be used as a framework to facilitate higher-order thinking through the reflective process. With slight modification, this hierarchy in the cognitive domain moves from the most basic knowledge and comprehension level (Level I), through the application and analysis level (Level II), to the highest levels of synthesis and evaluation (Level III). Oftentimes, learners gather all of the facts (Level I) and move directly to making decisions (Level III) based on those facts without pausing long enough to fully determine whether they have all the facts, analyzed those facts, or effectively applied them to the current situation. The reflective process helps to ensure that you take the time to fully analyze the facts before coming to a conclusion or decision. It requires that you use your higher-order processing skills (ie, application, analysis, synthesis) before drawing any conclusions.

Critical thinking has many different definitions; simply stated, however, it is described as “the use of cognitive skills or strategies that increase the probability of a desirable outcome.”48 As clinicians, our desired outcome is quality patient care. The globalization of our patient population, the increase in available evidence for care, and the evolving technology that continually brings the evidence to our fingertips require us to use reason to judge the credibility of the evidence and to continually examine and question our own assumptions in applying the evidence in patient care. Critical thinking enables us to make better clinical decisions and solve problems more effectively.⁴⁸

Critical thinking requires higher-order processing, which means using the higher levels of Bloom’s Taxonomy (analysis, synthesis, and evaluation) in our decision-making and problem-solving processes⁵ Brookfield³⁰ views reflection as a link to critical thinking and defines critical thinking as a direct outcome of the reflective elements of both Mezirow^31,51 and Schön.^9,11 He believes that we become critical thinkers by taking the time to revisit our experiences and process them from a number of different perspectives before drawing conclusions. Being a critical thinker requires us to have a healthy combination of skepticism (sufficient doubt to make us stop and question) and open-mindedness to enable us to recognize that alternative perspectives and explanations exist and that, at times, our assumptions are wrong.^30,48 Truly being a critical thinker requires not only higher-order processing skills, but also a mindset or critical spirit of continuous questioning.⁴⁸

Critical thinking is inherently a reflective and analytic process. It allows us to recognize, re-examine, and question the assumptions, beliefs, and values that underlie our decision-making processes when faced with new information. Critical thinking enables us, as clinicians, to solve problems, justify our own actions, and even anticipate potential outcomes. As critical thinkers, we use the analytic process of reflection to extract deeper meaning from our experiences, apply what we learn to new situations, and ultimately enhance our abilities as expert clinicians.

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