John Dewey, David Kolb, Donald Schön

Terry Borton, Kevin Eva, Graham Gibbs, Karen Mann, Glenn Regher

Jeffrey felt he had prepared well for the case after receiving prehospital notification from paramedics.  He had run through possible interventions with his attending, readied his equipment at the bedside, and positioned himself at the head of the stretcher prior to patient arrival.  The patient had been a young gentleman with a gunshot wound to the thorax, presenting with hypotension.  Unfortunately however, the trauma room became chaotic the moment the patient arrived.  Multiple providers were shouting orders, even before the paramedics could provide a history or the patient had been transferred onto the ED stretcher.  The ED pharmacist acted on the first order he received for opiate analgesia, but he did not hear the other requests for antibiotics.  The charting nurse shouted multiple times for the blood pressure value, clearly unable to hear the response that Jeffrey provided.  The EM and surgical staff argued for a short spell whether the patient needed to be emergently intubated.  Once the decision was made in favor of intubation, Jeffrey was given approximately 60 seconds to attempt the procedure, only to be bumped out of place by an anesthesiologist. “The trauma room is no place to learn a procedure for the first time!” stated the trauma attending.  The surgeons had no idea that Jeffrey had, in fact, performed a number intubations in the past.  After the patient was stabilized, the ED staff began to wheel the patient to the radiology suite for advanced imaging, only to have the senior surgical resident scream “I told you he’s too unstable for CT, we’re taking him to the OR!  Are you deaf?”

Jeffrey was asked to stay around after the case, as the charting nurse was unable to hear any elements of Jeffrey’s primary and secondary survey.  The senior nurse in the trauma room (who had been practicing at Obama MC for 25 years) told Jeffrey “you need to do a better job keeping control of the room.”  Jeffrey was so demoralized he was unsure if he could complete the rest of his shift.

Reflection or ‘reflective practice’ is a theory of knowledge acquisition predicated on the belief that learning occurs through deliberate and comprehensive thinking about a schema or activity, both during and after the performance of that activity.¹  Most descriptions of reflective practice postulate that a learner considers and ‘reflects’ on a need or a problem when s/he encounters a new practice or unexpected difficulty with a familiar practice.²  Reflective practice supports a constructivist epistemology of knowledge (i.e. theory of learning that suggests that new knowledge is integrated and interpreted based on past experience and learning), as the learner often has predisposed attitudes and knowledge that directly influences that individuals’ experience (i.e. intepretation) with a learning opportunity.³  Finally, some models of reflective practice stress that reflection may occur both during and after an activity – a medical student who was lazy in his studies and scored poorly on Step I of the USMLE, learns from the experience and develops a strategy to complete 5 practice questions every evening in preparation for the Step II exam.

Reflective practice is fundamentally an iterative process with thoughts that drive action during an activity and the consideration of the elements of the activity after the fact, informing future performance of the activity.²  These inter- and post-performance cognitive process yield learning and knowledge.

The theory of reflection as a fundamental skill for learning first arose from the writings of John Dewey, who defined reflection as “active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusive to which it tends.”²  In his book “Reach, touch and teach”, Terry Borton built upon Dewey’s thesis when he described a simple iterative cycle of learning, coining a phrase that is familiar to many, “What, So what, and Now what?”⁴  In this model, the ‘what’ is the new activity or experience, the ‘so what’ is the rational, cognitive examination of the experience that just occurred, and the ‘now what’ is the manner by which the learner incorporates the results of their cognitive analysis into future action.⁴

Donald Schön became a thought leader in reflective practice when he described a knowledge cycle predicated on education and expertise that occurs both consciously and subconsciously during activity.  Consistent with other theorists in the field, Schön’s description is learner-centric; it is through the step-wise progression of thoughts and impressions that a learner develops knowledge, regardless of the teacher.   Schön posited that the approach an individual employs when addressing a particular problem arises from both the learning that occurred during the performance of that action, as well as the processing of problems, solutions and outcomes after the fact⁵.  Schön described a reflective loop, wherein the individual knowledgeably performs an action (knowing-in-action), but may encounter a stimulus outside of their expertise, a ‘surprise.’ A skilled individual may be able to improvise or ‘think on their feet” to attend to the problem directly, perhaps through experimentation.  After the new experience, the individual may engage in reflection-on-action, a post-hoc analysis of actions, reactions and consequences.  This latter reflection reinforces knowledge and provides mastery or expertise.⁶

A contemporary of Schön, David Kolb described a cyclical theory of experiential learning.  Kolb states that an adult learner may have or participate in a “concrete experience.” After this, the individual engages in “reflective observation”, reviewing the concrete experience.  Next, the learner engages in “abstract conceptualization”, where the reflection gives rise to new ideas or schemata or modification of a previous concept.  Finally, the learner will employ “active experimentation”, applying the new ideas to the world around them, utilizing the new approach in the subsequent concrete experience.⁷

Graham Gibbs built upon previous theories and described his own ‘reflective cycle’ to describe growth and development in the learner.⁸  His highly intuitive model of the learning cycle provides the learner with cue questions based on integral concepts to be examined after a new activity, in order to help an individual work through the elements of learning and knowledge development.  The steps of Gibbs’ cycle include; description (objective review of events without editorial), feelings (how the events made the learner feel), evaluation (what did or did not go well with the event, the place for subjective judgements), analysis (global impression of the events within the context of other knowledge and experience), conclusion (how best to frame the events, evaluating what could been done, or avoided), and finally the action plan (what to do in analogous situations in the future to improve circumstances and outcomes).⁸

Recent publications have tried to align reflective practice and experiential learning, where the similar concepts are related and overlap.  As quoted in Jennifer Moon’s book, “transforming experiential and tacit knowledge into principled explicit knowledge about teaching requires intentional reflection for the purpose of making sense of and learning from experience, for the purpose of improvement….reflection requires linking existing knowledge to an analysis of the relationship between current experience and future action…reflection aids in the reflective processes themselves, thereby building and expanding knowledge.”⁹

The implementation of reflective practice has recently gained favor in medical education.  In her systematic review on the practice of reflection in the education of healthcare professionals, Karen Mann identified multiple studies to suggest that reflective practice is a key practice for health professionals.²  Reflection appears to be a useful approach for learners to make sense of complicated situations, as frequently occurs in the realm of patient care.  The process appears to be stimulated by complex scenarios, though variably utilized, depending on the individual.²   Reflection can be a skill that is developed over time and put to use in various contexts.  Multiple studies demonstrate that healthcare professionals use processes that resemble  ‘reflection in action’ and ‘reflection on action’ during patient care.²  Mann argues that reflection may be most useful when viewed as a learning strategy to “ assist learners to connect and integrate new learning to existing knowledge and skills.”²  Reflection may not be an explicit learning tool among novices.  However it can be modeled by experienced practitioners and taught to junior learners as a means to assess their state of knowledge, to identify strengths and weaknesses, and to improve the learning environment in subsequent iterations.²

Reflective practice has been used with medical students,^2,5 nursing professionals,¹⁰  and pharmacy professionals.¹¹   In one study, Gibb’s reflective cycle was used to optimize learning in a simulation curriculum.⁸  In the classroom, reflective writing is a practice that has shown to be of benefit to medical students and residents seeking to cultivate empathy, resilience and wellness.

1. Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ Theory Pract. 2009;14(4):595-621. doi:10.1007/s10459-007-9090-2

This systematic review introduces a number of historical theories about the concept and utility of reflective practice.  It makes manifest the inherent iterative process of reflection, comparing and contrasting different theories from different thought leaders within the field.  Most significantly, this review highlights references in the medical and medical education literature that apply reflective practice to healthcare education.

2. Eikeland Husebø S, Nestel D. Theory for Simulation Reflective Practice and Its Role in Simulation. Clin Simul Nurs. 2015;11(8):368-375. doi:10.1016/j.ecns.2015.04.005.

Husebø et. al. provide a clear, concise review of reflective practice and relevant key theories.  The authors examine multiple conceptions of reflection, using Gibbs’ reflective cycle to translate the different steps of reflection to learning via simulation.

The learner-centric nature of this reflective practice necessitates an engaged learner.  As this practice may be novel to some learners, appropriate instruction and framing is critical to its success.  It is important that learners see this as not “just another assignment”, but as an integral component to their ongoing growth.

Eva and Regehr suggest that cognitive, sociobiological and social factors limit an individual’s insight into their own performance and abilities.  This impairs the accurate summative self-assessment required of reflection.  As the authors state, “personal, unguided reflections on practice simply do not provide the information sufficient to guide performance improvements.”¹²  In essence, reflection requires pedagogical oversight and feedback from an expert or mentor, a process Eva and Regehr term ‘self-directed assessment seeking.’¹²