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


Reflection and Questions

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

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


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.


Having experiences does not necessarily mean that you have learned from them.


Without an ability to reflect…practitioners are forced into haphazard, reactive patterns of behavior when faced with professional dilemmas.

—Brown and Gillis2


Have you ever known someone who does not seem to learn from his or her experiences? Someone who seems to make the same mistake over and over again? Why do you think that might be?

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.1,3,612 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.1427 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.3235 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.34,35,3840

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.


In Table 2-1,41,42 select 2 of the core values on the left hand side of the table and think about how they might link to some of the essential affective behaviors noted on the right side of the table. For example:

  • In what ways do the core values of care and compassion influence how you interact on an interpersonal level with your patients?
  • In what ways might the core values of excellence and integrity influence how you self-assess?

Compare and Contrast

  • How was your response to the questions above different from the responses you provide to basic factual questions?
  • How was your approach to answering the questions above different from completing multiple-choice examination questions?



  • Facilitates deeper learning and more critical thinking.
  • Provides us the opportunity to view our own experiences from multiple perspectives.
  • Has been linked to the development of therapeutic relationships, improved patient care and team work, decreased medical errors and stress, and mindful practice.
  • Requires us to self-monitor and continually self-assess.
  • Enables us to reframe problems, question our own assumptions, and analyze our own experiences.
  • Is the hallmark of professional and expert practice?


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


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.5052 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.



  • Facilitates self-assessment

    • Self-assessment facilitates lifelong learning

  • Facilitates critical thinking
  • Informs the clinical decision-making process
  • Is integral to the development of expertise



Figure 2-1. The expert practitioner: reflective, mindful, and self-monitoring.


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


When the telephone rings, you automatically answer it and say “hello,” as does the person on the other end of the phone. That is the typical “phone script” with which we are all very familiar. Have you ever received one of those annoying automated phone calls? How does it not fit the pattern of a typical phone call? How quickly do you know that it is automated? What triggers you to recognize the difference? How does this sudden recognition change your actions? What do you do when you recognize that it is not a typical call? Do you respond with the typical “hello”? How long does it take you to hang up the phone? Have you ever hung up the phone only to realize that it actually was not an automated call? What caused you to recognize your error?

  • Are there other times in life when you seem to function on “auto-pilot”?
  • Are there other times in life when you do not function on “auto-pilot”?
  • What is the difference? How do you know to switch?

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 al58,60 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.



Reflection-in-action: Occurs while the individual is in the midst of an activity “The problems that came up made us feel stressed…we didn’t anticipate [them] and did not have any alternative plan…not knowing the disease process and side effects…made us feel anxious…[it] was a wake up call because it made me realize that lack of knowledge of a disease process adds to an already difficult situation for both my patient and myself. It was a very uncomfortable situation.”
Reflection-on-action: Occurs after the individual has completed the action/encounter “This week helped me to get over the difficulty…when someone challenged an idea I had I’d back down and lose confidence. I[’d] feel angry…that they were trying to get me. But this week I realized that…people challenging my thoughts, allowed me to look at things from all angles. I learned so much by standing my ground and pursuing a difference in opinion. The challenge…helped me…see things from different perspectives…[I] realized that I can be misunderstood at times…I want to improve this because…I must be able to communicate properly. It is vital to the patients’ safety.”
Reflection-for-action: Occurs when the individual begins to anticipate situations before being faced with them, and/or begins to plan for the future to improve the present situation/outcome “I realize now that my frustration made me raise my voice and made other people feel something against me…I don’t think I acted like a professional. Next time, I would talk to my professors about how I felt…and how I thought…we needed more time to reflect on our own…[I learned that] taking things to a professional level with my teachers at this point and asking my classmates instead of interrupting them could have helped me to overcome this challenge.”

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.12,23,6165 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.


Schön describes the following 3 types of reflection, all of which are essential to quality clinical practice:

  1. Reflection-in-action
  2. Reflection-on-action
  3. Reflection-for-action

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.15,21,22,6671 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


The following is a quote from a reflective essay written by a student after having worked with his first patient as a physical therapy student. He was initially uncomfortable with the emotions displayed by his patient, as described in the following passage:

“When he [our patient] remembered his friends in the war, he became teary-eyed. My first reaction was ‘Oh my gosh, what do we do now?’ in my head, but at the same time, I put my hand on his shoulder to let him know that it was okay. He had his arms in the air; when I put my hand on his shoulder, they dropped to the side and he sighed a deep breath out. It was like a double nonverbal communication. It was beautiful.”

The following is a quote from a reflective essay written by a student after working on a project with a group of students from his class:

“From this challenge I learned that I am not always going to have everything my way and…maybe if I listened closer and asked questions [of] my classmates…[perhaps] I will get that interest in them and the enthusiasm I need. I think the only way that we all can grow is if we work together. I know now that if I listen, I will learn from my classmates and my teachers and will be more challenged than I am now.”

Reflective Questions

  1. Which of Schön’s reflective elements do you recognize in each of these quotes?
  2. What do you think that each of the students learned from this experience?
  3. What do you think that each of the students will do differently the next time they are faced with a similar situation?

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.


  • Reflection is much more than just stopping to think and solving problems based on what you already know.
  • Reflection is much more than just exploring your thoughts or feelings.
  • Reflection requires you to continually question your experiences, what you know, and how you know it.

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.


Students are working together in groups on a particular case study. At the end of the day, one of the students goes home and reflects. She writes the following in her journal:

“There was an instance when a group member’s frustration was hindering the progress of the entire group. Some people felt hurt or left out, even though they did not verbalize it. After going home, I was disappointed that I did not even attempt to offer a solution or acknowledge the problem. I did not stand up for what I thought was right. In the end, I realized that it’s much easier to believe in an idea than to do something about that idea.”

Reflective Questions

  1. What do you think was going on in this scenario?
  2. Whose perspectives did the student take into consideration?
  3. How might you have approached this situation differently?
  4. What assumptions did this student make about the situation?
  5. Why do you think she did not say anything at the time?

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


The following are quotes from reflective essays written by students after having worked with their first patients as physical therapy students:

  1. “Working with a real patient is very different from working and practicing on my fellow classmates…Many times in class we were not only given a problem…but a solution to go with it. It prevented me from going through the valuable thought process of, ‘What intervention should I choose?’ ‘Why am I choosing this intervention?’ Instead, I allowed the thinking to be done for me and then understand, afterwards why, what, etc?”
  2. “What I found most helpful in this course is that you should never judge a book by its cover. You should approach each patient with an open mind. Before I met Mr. B, my judgment [was] that he was going to be a difficult [patient] because of what I read in his past medical history (PMH). After a few moments, I realized there was a great deal of life, history, and joy in him. I saw that personality and thought, ‘How could I have missed that?’ I feel it was from reading his PMH and judging him by it without ever meeting him. I was close-minded.”

Reflective Questions

  1. Which of Mezirow’s reflective elements do you recognize in each of the quotes?
  2. What assumptions might have each of these students held before working with these patients?
  3. What do you think each of the students learned from this experience?
  4. What do you think the instructor reading these quotes might have learned?
  5. What do you think each of the students will do differently the next time they are faced with a similar situation?



Content reflection: Occurs when the individual attempts to explore the problem to better understand it “I learned that…the sit to stand transfer has many domains. We discussed…strength, biomechanics, flexibility, endurance and the affective domain…Initially, I viewed Mrs. E’s sit-to-stand transfer basically as a strength issue. As my group analyzed Mrs. E’s sit to stand technique, I revised my opinion of her problem and realized that her problem may lie in all of the domains.”
Process reflection: Occurs when the individual begins to explore the strategies and/or processes involved in an experience or problem-solving situation; the more skillful reflector might begin to explore other possible strategies “I spent time meeting [with] my group prior to meeting the [patient] and there we shared our ideas…I had a flow chart that I wrote out the night before, which we could have followed. When it was time to meet…the [patient], none of us used the flow chart…we adapted to diff[erent] situations.”
Premise reflection: Occurs when the individual recognizes and begins to explore or critique his or her own assumptions, values, beliefs, and biases; the more skillful reflector may begin to seek multiple perspectives and alternative explanations “In the beginning, I felt like I was getting the easier patient. What a silly assumption…The lesson gained was far more valuable. I realized that the reason I felt this…was because I don’t feel confident in my skills…I realize…patients can be equally challenging and yet equally rewarding. There is no such thing as an easy or difficult patient…How I choose to percieve[sic] the situation is what ultimately counts.”

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 down58,60 and move from System 1 to System 2 thinking57,59 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.


Figure 2-2. Reflection: many definitions, one common process.

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.

Using an adaptation of Bloom’s Taxonomy as a framework for reflection can help you to identify the problem or determine the source of difficulty and then identify strategies to achieve a better outcome. For example, a therapist is working with a young child and has provided her caregiver with a list of activities/exercises that she should be doing with the child throughout the day to improve the child’s motor abilities. When the caregiver and child return for a follow-up session, the therapist inquiries about the home activities that she suggested. The caregiver indicated that she did not do any of the exercises that the therapist had asked her to perform. It would not be uncommon in this scenario for some therapists to get annoyed, assume the caregiver does not want to do the home exercise program (HEP), and give up on providing any additional activities for her to do at home. However, to truly understand what is preventing the caregiver from adhering to the HEP, it is important for the therapist to fully analyze what is going on in this situation before drawing any conclusions. The therapist might analyze the situation by asking questions using the adapted Bloom’s framework. For example, the therapist might start by gathering some facts (Level I) such as, “What is getting in the caregiver’s way of doing the HEP?” “What other responsibilities does she have at home?” “Does she have any additional supports, perhaps someone else who can do the HEP with the youngster?” “Does she understand the purpose of the HEP?” The therapist can move into more analysis and application questions such as, “In what ways does the mom feel most confident and least confident in performing the exercises?” “Are the exercises that you asked her to do with the child very different from what she has done in the past?” “Is she having difficulty adapting the activity to her home environment?” Finally, she may ask some evaluative or Level III questions such as, “Does the mom believe the HEP will help?” “Has the mother been able to see any differences in the child when the HEP is not performed?” Taking time to analyze the situation from multiple perspectives may help the therapist reframe her approach, enabling her to work with the caregiver to problem solve different strategies to meet the needs of the child within the constraints of her current situation. Rather than annoyance and frustration, reflection may have resulted in a shift in perspective for the therapist, which may make her interactions much more productive. This analytic process—collecting information, analyzing that information, and then evaluating what you know—will enable you to make more informed clinical decisions.


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 Mezirow31,51 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.


A student returns from clinic and is debriefing with her director of clinical education (DCE). The student shares her frustration by telling the DCE that she has a terrible clinical instructor (CI). When the DCE asks her to elaborate, the student says that the CI’s examinations are always very short and that she neglects to perform a number of special tests. When probed, the student indicates that the treatment sessions seem to go okay and that the patients are generally satisfied.

Reflective Questions

  1. In describing this scenario, what type of reflection was the DCE facilitating in the student?
  2. What other factors might the student consider in judging the performance of her CI (content reflection)?
  3. What assumptions might the student have made about her CI (premise reflection)?
  4. What strategies might the student consider in checking her assumptions about the CI (process reflection)?
  5. How might the student approach this situation differently in the future (reflection-for-action)?
  6. We know that expert therapists make many rapid unspoken decisions when working with patients. How might the student better understand the decisions made (process reflection)?
  7. What might the CI do to make her thinking process more transparent for the student (process reflection)?

May 30, 2017 | Posted by in NURSING | Comments Off on Reflection and Questions: Developing Self-Awareness and Critical Thinking for Continuous Improvement in Practice

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