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Using Reflection to Teach
Professionalism
Karen V. Mann, BN, MSc, PhD
Professor Emeritus, Dalhousie University
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Objectives
 Describe
approaches to defining professionalism
 Describe
approaches to understanding reflection
 Identify
and discuss methods to teach
professionalism using reflection
 Discuss
approaches to assessing professionalism
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What is professionalism?
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What is professionalism?
 Competence
and mastery of appropriate
knowledge skills and attitudes
 Capability
to adapt to change, generate new
knowledge, and continue to improve
 Self-awareness
and self-regulation
+Different Paradigms for Understanding
Professionalism
Positivist
(objective,
definable)
Individual
Interpersonal
Societal/Institutional
•Characteristic/trait
•Behaviour/cognitive
process
• Generalizable across
contexts
•Stable
•In interactions
•In interactions
generalizable across
cultural contexts
Subjectivist - Subjectively constructed
constructivist within individuals arising
from cultural contexts
•Interpersonally
constructed:
•Socially constructed
•not
generalizable
across contexts
Adapted from Hodges et al. (2011) p 356
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Reflection : a definition
 ‘reflection
is a meaning-making process that
moves learners from one experience into the next,
each time with a deeper understanding of its
relationships with and connections to other
experiences and ideas. It is the thread that makes
continuity of learning possible.’
(Dewey as cited in Wear et al, 2012)
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Approaches to reflection
Knowing-in-action
Reflection-on-action
Experimentation
Surprise
Reflection-in-action
(Schön, 1987)
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Approaches to reflection
Behaviour
Ideas
Feelings
Returning to
experience
• Utilizing positive
feelings
• Removing obstructing
feelings
Re-evaluating
experience
Experience(s)
Reflective processes
New
perspectives on
experience
Change in
behaviour
Readiness for
application
Commitment to
action
Outcomes
The reflection process in context
(Boud, Keogh & Walker, 1985)
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Approaches to reflection
Concrete experience
Testing implications
of concepts in new
situations
Observations
and
reflections
Formation of abstract
concepts and generalizations
(Kolb, 1984)
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Approaches to Reflection
•Right/wrong answers
•Pre-reflective thinking
•Recognize uncertainties
•Quasi-reflective thinking
•Defensible conclusions
about complex problems
•Reflective thinking
Optimal level of
functioning
King and Kitchener (1994)
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Characteristics: What models of
reflection share
A
return to experience
 Reflection
and reframing
 Lessons-
capacity to inform future practice
 Iterative
process
 Levels
of reflection
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The elements of reflection
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Reflection on experience involves elaborating on or
interrogating the experience.
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Reflection has a purpose: to ‘work out’ an issue or felt
difficulty.
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Reflection involves complicated mental processing of
issues for which there is no obvious solution.
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Reflection provokes transformative thinking, leading to
transformative action.
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Reflection is a social rather than a solitary act.
Wear et al, 2012)
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What would be our goals in using
reflection as a teaching strategy?
+ What would be our goals in using
reflection as a teaching strategy?
To help the learner to:
 Articulate
their own reasoning, including tacit
understandings
 Construct
and make meaning of experience- to
develop new knowledge
 Understand
the broader context of their practice
 Connect
theory and practice- move outside their
comfort zone
 Monitor
their developing professionalism and
professional identity-to develop agency
 Increase
self-awareness
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Reflection in Professional
Development
 Experiential
learning as part of becoming a
physician
 Reflection
 Offers
transforms the experience into learning
opportunity for ‘deep learning’
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Sources of Stimuli for Reflection
 Formal learning
experiences
 Personal experiences
 Interactions with
patients
 Learning gains and
needs
 Seminal events
 Personal beliefs and
values
 Interactions with
colleagues
 Observations
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Sources of Stimuli for Reflection
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Overall impressions
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What went well
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What they were thinking
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Any new goals that emerged
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Any assumptions or biases
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What they were feeling
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What others were feeling
(Westberg & Jason, 2001)
+ How Can Reflection Help Learners in
Understanding Professionalism?
 What
choice did the learner make?
 What
did the learner do?
 Why
did the learner choose that action?
 How
did they justify their actions?
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Reflection on Professional Dilemmas
A
reflective approach to the self-assessment of
professionalism
 Reflection
may require a socially interactive process
 Emphasizes
both behaviours and internal and
external context
Bernabeo et al.,
2013
+ The Role of Reflection on Lapses in
Professionalism
 Focusing
on action
 Illuminate
professional and non-professional
behaviour
 Helps
 Can
to reveal the broader context
reveal competing values
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What is the Teacher’s Role?
Modeling Reflection
 Ask
reflective questions
 Reflect
on events with students
 Create
a safe environment
 Provide
debrief opportunities
(Sutkin et al., 2008; Weissmann et al., 2006)
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What vehicles for reflection?
 Informal
,impromptu approaches
 Structured
approaches
 Individual
approaches
 Collective
approaches
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Portfolios as a Vehicle for
Reflection
A
file of achievements vs. a tool for reflection
 Identification
 Details
of learning needs
of learning experiences
 Demonstration
 Formative
value
of what has been learned
and summative assessment – teaching
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Sample Portfolio Items for Medical
Education
•Professionalism goals
•Learning plan
•Standardized and real patient evaluations
•Videotape segments
•Self-evaluation forms
•Peer feedback
•Reflective exercises
•Formative faculty feedback from small
groups or mentoring
•Faculty evaluation forms
p. 216, of Stern (2006)
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Elements of Successful Portfolio
Programs
 Self-reflection
from evaluated portfolios
 Promote
a supportive climate for learning and
feedback
 Advance
development of self-assessment and
mentoring skills
 Chart
progress over time: observation and
interactive goal-setting
 Support
learning development
p. 222, of Stern (2006)
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Methods to Assess Professionalism
 Portfolios
 Direct
observation
 Multisource
feedback
 Self-assessment
 Critical
and feedback
incidents
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Factors that Enhance Reflection
 At
the level of:
 Institution
 Teaching
environment
 Individual
 What
does this mean for teaching?
Factors that Promote or Hinder
Reflective Practice as Teachers
 Personal
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factors
 Contextual
factors
 Environment
 Culture
 Other
Pressures
 Colleagues
 Administrative
Support
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Challenges of Teaching Reflection
in the Professional Context
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Barriers and enablers
 Free
expression of opinion
 Perceived
 Prior
usefulness of the activity
experience
 Organizational
 Time
climate
for reflection
 Non-reflective
professionalism
Boud and
Walker, 2002
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+ Review Recommendations from
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Systematic Review
 Use
reflection as a learning strategy and ensure
that you are a guide for learners to this process
 Model
reflection for the learners
 Include
learners in your own reflective practice
 Provide
feedback on both the content and process
of the learners own reflective practice
 Provide
an environment that encourages reflective
practice
(Mann, Gordon & MacLeod, 2009)
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Tips for Implementing a Program
 Define
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reflection for the learner
Decide on goals for reflective practice.
 Choose
the right method to teach reflection
 Decide
whether you will use a structure or
unstructured approach to prompt reflection
Aronson (2011)
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Tips for Implementing a Program
 Make
a plan for dealing with concerns
 Follow
up with the learner
 Create
a learning environment that fosters
reflection
Aronson (2011)
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Tips for Implementing a Program
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Teach learners how to reflect before asking
them to do it
 Provide
 Make
feedback and follow-up
reflection part of a larger curriculum
 Reflect
on your own teaching of reflection
Aronson (2011)
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Preparing and Supporting Faculty
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Faculty can benefit from experiencing reflection as well,
both in personal growth and in developing skills in
promoting learners’ reflection.
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Longitudinal faculty development, where groups can
reflect on their own practices, as well as learn new skills,
in a safe, trusting environment, lead to changes in
teaching
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Opportunity to reflect on teaching practices can lead to
sustained change in teaching approaches. (Mann, in
press)
The Iceberg of Professional
Practice
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Fish & Coles, 1998
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Summary
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Professionalism is more than a set of behaviors.
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Learners construct their identity throughout their
education.
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Reflecting on experience can provide learners a means
to integrate learning and to construct an understanding
of their own professionalism.
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To be effective, reflection must be more than superficial
or ritualistic.
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Feedback and guidance on reflection, and modeling
reflection are important roles for Faculty.
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References
Aronson, L. (2011). Twelve tips for teaching reflection at all levels of medical
education. Medical Teacher, 33 (p. 200-205)
Bernabeo, E.C., Holmboe, E.S., Ross, K., Chesluk, B., Ginsburg, S. (2013). The
utility of Vignettes to stimulate reflection and professionalism: Theory
and Practice. Adv in Health Sci Edu, 18: 463-484
Boud D, Keogh R, Walker D. Reflection: turning experience into learning. Kogan
Page London, 1985 (eds).
Boud D. and Walker D. (2002). Promoting reflection in professional courses: the
challenge of context. In R. Harrison , F. Reeve, A. Hanson and J. Clarke.
(eds.) Supporting Lifelong Learning. Vol. 1. Perspectives on learning.
London UK: Rutledge Farmer. (pp. 91-110)
Coles, C. (2002). Developing Professional Judgment. J. Cont. Educ. Health Prof.
22, 3-10.
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References
Ginsburg, S. & Lingard, L. (2006). Using reflection and Rhetoric to
Understand Professional Behaviours. In Stern, DT. (ed) (2006).
Measuring Medical Professionalism. New York, NY. Oxford University
Press (pp. 195-212).
Fryer-Edwards, K., Pinsky, L.E., Bobins., L. (2006). The Use of Portfolios to
Assess Professionalism. In Stern, DT. (ed) (2006). Measuring Medical
Professionalism. New York, NY. Oxford University Press (pp. 213-233).
Hodges et al. (2011). Assessment and Professionalism: Recommendations
from Ottawa 2010 Conference. Medical Teacher, 33: 354-363.
King, P.M. (1994). Developing Reflective Judgment. San Francisco: JosseyBass.
Mann KV, Gordon JJ, MacLeod AM. Reflection and Reflective Practice in
Health Professions Education: A Systematic Review of the literature in
the Health Professions. Advances in Health Sciences Education.
2009;14:595-621
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References
Mann K. ( 2013 In press) Faculty development for reflection and
role-modeling. In Steinert Y. Faculty development for the
Health Professions. Springer In press
Moon J. (1999). Reflection in Learning and Professional
Development. London UK: Kogan Page
Murdock-Eaton D, Sandars J. (2013) Reflection: moving from
mandatory ritual to meaningful professional development.
Archives of Disease in Childhood.doi:10.1136/archdischild2-13-303948
Schön D. (1987) Educating the Reflective Practitioner: toward a
new design for teaching and learning in the professions.
Jossey-Bass, San Francisco, CA
Wear D, Zarconi J, Garden R, Jones T. (2012) Reflection in/and
writing: Pedagogy and Practice in medical Education.
Academic Medicine 87:603-609