Wong described reflection on action to take place at various levels, ranging from the superficial level to the critical reflective analysis level. Boyd and Fales described reflection on action to focus more on self-development in terms of knowledge and values. They then explained their premise by stating that an individual doesn’t necessarily see more through reflection, but views issues from different perspectives. Reflection on previous experiences is a necessary skill because a student can utilize it to develop greater insight as a medical practitioner. The method of past reflection involves the evaluation of previous choices and views, which is exemplified in Gibbs’ five step reflective cycle (1988). This series of steps investigates the individual’s thought processes and how they can be altered to improve judgement and understanding in clinical practice. Kolb (1984) stated that through the reflection or ‘relearning’ of experiences a practitioner can gain an increased level of understanding and proficiency in that particular area.
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Self-reflection additionally refines personal views and behaviour by contemplating “values and attitudes. In medical trainees, values and attitudes are heavily influenced by a process of socialization resulting from a group or cultural dynamic” (Branch, 2005). Understanding and empathising with a patient can vary according to differing cultural backgrounds and the socio-economic class, so continual interaction and reflection can help prepare an undergraduate medical student for the confronting world which follows graduation. Branch (2005) continues to explain that reflection in the form of writing, aids in the progression and augmentation of emotional experiences involving life and death. To have past thoughts and views recorded in text is important in defining personal development throughout the undergraduate period and into professional life. Undergraduate medical students and medical practitioners are placed in very emotionally and physically demanding situations such as critical care and lengthy surgery. Reflective writing helps as a form of stress control and expressing one’s self and allows the release of some of the mental burdens.
Reassessing personal ability to identify strengths and weaknesses, and use them for personal improvement, is a key benefit of the self-reflective process. Epstein and Hundert (2002) found that after determining the exact strengths and weaknesses, a learning plan could be implemented to enhance learning and maximise efficiency. With the abundance of knowledge to be acquired in the undergraduate medical course, any approach to studying which is beneficial to the student must be considered and integrated in the study plan.
Reflecting in the present
Greenwood (1993) defined reflection in action as process in which people use their experience and judgement to analyse what they are doing whilst they are doing it. To step back and critically examine one’s responses to what is happening can provide a student with a much wider and clearer view of the situation. The consequent decision making process can be better considered and much more impersonal, allowing the undergraduate student to make more refined judgements in medical practice. It involves reflection before and during action, a process which can be applied by the student in a wide range of situations during the undergraduate period and throughout a future career in medicine.
Eva and Regehr (2005) highlighted the point that “reflection in practice is a substantially more important mechanism for ensuring safe and effective performance”. As reflection in action is required for continued professional development and general safety, the process of reflection gives the student a heightened mental awareness of the context of action. When faced with difficult ethical and administrative decisions relating to medication or surgery, a slight falter in mental awareness at the wrong time can cause disastrous results for the student/professional practitioner and the patient. Maintenance of the student’s mental health is also an important part of reflection in action, as compounding stresses can lead to physical exhaustion and mental instability. Beonink (2004) pointed out the correlation between student fatigue and reflective ability when he conducted his study of 195 fourth year medical students.
Practical importance of reflection
Reflection can be used to analyse educational or emotional experiences and process them in such a way that a medical student can effectively learn from that experience. Branch and Paranjape (2002) stated that if reflection is undertaken by an undergraduate student, then it can promote growth “morally, personally, psychologically, and emotionally as well as cognitively”. Psychological development in the student influences both values and attitudes towards many controversial medical issues such as cloning, stem cell research, tissue transplantation and surrogate motherhood. For example, the reflective process can assist the undergraduate student’s understanding and ability to remain unbiased when a patient insists on refusing a treatment because of personal or religious commitments. The approach towards learning is also assisted through the cognitive development of the student.
A study conducted by Mamede and Schmidt (2005) highlighted the current pattern within health professionals in which the use of reflective practice decreased with years of medical practice. Possible explanations for this may be the more experienced health professionals using reflection solely on new or complex problems. An individual gains more experience by encountering familiar problems regularly, but when the reasoning and mindset becomes too automatic and habitual, a momentary lapse of judgement could lead to a disastrous situation. Regular use of reflective practice increases awareness for patient centred care.
But it should also be noted that
Teamwork is a fundamental part of modern medicine and reflective practice plays an important role within the foundations of teamwork. Branch (2005) suggests that reflection within a team does not only benefit the individual but the entire group. The team as a whole can improve in efficiency, communication, provide support for one another and help define team direction in terms of patient care. Reflective group work is also involved in the discussion and feedback from mentors and staff. As they have more experience than an undergraduate student, experienced practitioners can share stories and anecdotes which are valuable to the inexperienced undergraduate students. Group reflection is also relevant beyond the undergraduate medical course because of the network of teams which function together in all health professions.
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The evolving definition of ‘reflective practice’, and its increasing significance, are changing the way in which undergraduates and health professionals are required to approach and learn about medical practice. Kanthan and Senger (2011) found that “reflective practice is becoming mandatory in many of the licensing and re-validation processes â€¦ Therefore, it is imperative that early and repetitive practice to acquire competency in this skill is explicitly included in the curriculum in the early years of undergraduate medical education.” Personal portfolio writing and other reflective tasks have become a necessity for undergraduate students in medical schools and centres across the world, in the hope that an era of reflective health practitioners can be created.
Potential disadvantages of reflection
For some personalities, reflective practice can also have negative consequences. Bound and Walker (1998) noted that reflection on action is a very thought driven process and may sometimes be confusing if an undergraduate student reflects without learning from the experience or reflects without the correct thought processes. Internal conflict can also result because of clashing personal values and beliefs. Students may lose sight of the true aim of reflective practice and its benefits. It becomes a mindless and boring encumbrance in which students use a progressive checklist to overcome reflection as an obstacle, rather than addressing the significant personal concerns and questions. Time is a constraining factor in the education of an undergraduate medical student, and the various areas which require reflection are relatively time consuming. If reflection is not used effectively or within the correct context in action and on action, then it is unnecessarily consuming valuable time which could be better spent on studying or for patient care.
Reflective practice involves and brings together many aspects of the undergraduate medical course and beyond in future professional life. The research quoted above indicates that, when used correctly, reflective practice gives an undergraduate student the tools required to become a skilled reflective medical practitioner. The possible disadvantages of reflection seem insignificant when compared to the bigger picture of all the positive effects. In summation, reflective practice is an important attribute because it allows an undergraduate medical student to make better informed decisions, learn from his/her own mistakes and from the previous experience of others, and maintain good physical and mental health.
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