SAFILT Additional Concepts to Strengthen Facilitation: Developing Skills for Reflection

Increasingly there is an expectation that learners and professionals develop the skills to be able to reflect on practice. Reflection can be defined in a number of ways, but essentially it is a process whereby learning takes place through a critical analysis of an experience. Facilitating a debrief can support not only an immediate form of reflection to take place, but can also give delegates the skill of reflection for life-long learning.

Clinical knowledge and know-how are clearly of paramount importance to Doctors.
However, they also need to be able to practise more iterative skills and examine the ways in which care can be influenced by their actions, behaviours and attitudes as examples.

Good reflective practice should enable a critically constructive appraisal of performance which supports positive change where necessary

Introduction

The concept of reflection as a professional development tool has at times been overlooked by the health care professions. In clinical simulation scenarios and the debriefs which follow, it is a crucial ingredient to a successful outcome.

Reflection is more than a description of what occurred in an event, and is certainly not a form of navel gazing. When applied critically reflection provides new personal insights and discoveries that were previously inaccessible. While it may be considered subjective as a form of evidence or fact, reflection is a powerful learning process.

Facilitation and debriefing of clinical scenarios for doctors may have a clinical focus, depending on their needs and stages of development. Yet while it may need to be directive in some ways, it can also open up possibilities for non- technical learning in others. Being able to support this process of opening up topics for discussion and critical review is an important skill of debriefing.

Reflection

Boud, Keogh, and Walker (1996) believe that experience by itself is not the key to learning. The question then is; what turns experience into learning, and how can this be re-contextualised into new experiences? Often, as Boud et al (1996) point out, as educators we make assumptions that reflection is occurring effectively for all, and as such we skim over it. But as Duley (1981) suggests; ‘The skill of experiential learning in which people tend to be the most deficient is reflection’ (p.611. cited in Boud et al, 1996). More often than not we criticize those that appear to be non-reflective, but the question needs to be asked as to whether as educators we are giving people the best opportunity to develop their reflective skills.

And why exactly is it important to reflect anyway? The seminal work of Donald Schӧn (1983) primarily focused on the ways in which professionals think in action. He observed how the model for preparation for professional life was one which supplied technical knowledge relevant to the practice of that discipline, but which failed to provide the capacity to work through the complexity associated with that professional activity. Arguably, while medicine has traditionally focused on what can be done to people, it has struggled with the complexity of working with people. The terms of thinking in action and on action (while in doing something and after it has been done) developed by Schӧn have come to have recent significance in professional education. Schӧn’s central argument is that whilst professionals are able to deal with the specifics of their discipline, they are ill equipped to manage the human interactional relationships between that discipline and its impact on social life.

As a result of this work, the concept of critical reflection in adult learning has begun to permeate into professional education.

Transformative Learning – a form of reflection

Jack Mezirow (1990) began exploring the idea of transformative learning. Presuppositions based on technical professional knowledge suggest that things will just happen as planned because the knowledge suggests it. But we know of course that this is not always the case. It then becomes important, as Mezirow (1990) indicates, to enter into an act of transformation whereby what we believe we know becomes reformulated as understanding the meaning of an experience.

‘Perspective transformation is the process of becoming critically aware of how and why our pre-suppositions have come to constrain the way we perceive, understand, and feel about our world; of reformulating these assumptions to permit a more inclusive, discriminative, permeable, and integrative perspective; and of making decisions or otherwise acting on these new understandings. More inclusive, discriminating, permeable and integrative perspectives that adults choose if they can because they are motivated to better understand the meaning of their experience’ (Mezirow, 1990:14)

The Link Between Reflection and Debriefing

How you create a climate for reflection in debriefing depends on how you set out your strategy for the simulation scenario and what you hope to achieve educationally.  The concept of educational alignment is important here. Essentially this breaks down your strategy into three areas: Learning aims, Learning Tasks, and Learning Outcomes.  You can then gear up and manipulate your scenario to ensure that these three areas are achieved. In order to create an environment for reflection you need to be clear on your strategy to focus on either the grey areas of clinical activity and uncertainty of diagnosis or outcome, or the inter-relational activities occurring between individuals in the scenario. These phenomena can also be synthesized, so careful observation is needed to draw these points out as ‘teachable’ and reflective moments.

ACCESS VIDEO FILE SKILLS_FOR_REFLECTION_1 NOW USING THE BUTTON AT THE TOP RIGHT OF THIS WEBPAGE

This is the first of two sequences in which Ian picks up on a particular word as a teachable moment.  This has resonance with the technique of clean language (see tools and resources).  He notes the terms and returns to it later in the debrief.

ACCESS VIDEO FILE SKILLS_FOR_REFLECTION_2 NOW USING THE BUTTON AT THE TOP RIGHT OF THIS WEBPAGE

By picking up on the term, in this clip, Ian is able to explore the use of language and its possible interpretations.

The questions asked to facilitate reflection are central to the core activity of debriefing. Debriefing in a clinical sense generally centres around three stages: Description, Analysis, and Application. From a reflective position, these stages can be redefined as:

What happened?

How did the participants feel?

What does it mean? (Boud et al, 1996)

In the case of clinical simulation, these stages can be broadened out to the observers of the scenario – the other delegates participating in the simulated activities. This can lead to a reflective dialogue that opens up a much greater and more interactive form of learning. A collaborative dialogue is inclusive of what individuals perceive and understand out of which wider possibilities of understanding for others can unfold. The issue is the way in which others can be brought into the discussion and contribute to it as a dialogue rather than a debate. As Johns (2004:5) notes; ‘Fundamental to dialogue is to listen’ - though it is important that the dialogue does not lapse into a debate or power relationship whereby one person emerges as the winner. The facilitator needs to be able to encourage listening rather than hearing and be able to paraphrase what is said and repeat back for accuracy of understanding prior to opening it up to the rest of the group.

Equalising the relationship

Reflective dialogue can be equalized by moving away from a construct of monitoring and supervision and of judgement of performance. It therefore becomes a process of learning and self assessment of effectiveness rather than being a method of surveillance. In effect, this means ‘letting go’ (Johns and McCormack 2002) of traditional hierarchies and outcome orientated activities and moving towards entering into the learning experience. The facilitator needs to find a balance between managing the group and the outcomes required with considering themselves a learner in the process, where they too will discover new things.

Click here to go to the next section

References:

Boud D. Keogh R. Walker D. (1996) Reflection: Turning Experience into Learning. Kogan Page, London

Duley. J.S (1981) Field Experience Education. In Chickering A.W. (Ed) The Modern American College. Jossey Bass. San Francisco

Johns C. McCormack B. (2002) Unfolding the Conditions Where the Transformative Potential of Guided Reflection (Clinical Supervision) Might Flourish or Flounder. In Johns C. Freshwater D.  Transforming Nursing Through Reflective Practice. Blackwell Science. Oxford