The art of self-reflection

Self reflection is something of a buzz word in medical education.  Perhaps it’s a routine part of your practice, but if not, there is a strong body of evidence that if you commit yourself to it, self reflection can have positive effects on your practice.

Background

Self reflection has been defined as the act of deliberately reviewing thoughts, actions and emotions associated with a specific event, with the intent of understanding the reasons for the event and learning from them1.

Self reflection is generally accepted as an important component of adult learning1.   While the evidence of benefit is based on subjective outcomes in uncontrolled environments, the overall body of work strongly suggests reflection is effective (1,2).  It can help support feedback, reinforce theoretical learning, integrate theory with practice, and even improve job satisfaction (2). 

Some educators point out that simply reviewing an event does not make it a self-reflective exercise.   Rather, self reflection involves actively questioning the underlying reasons for actions, decisions and beliefs, for the purpose of self improvement2.  It is likely that the value of self-reflection is only as strong as the commitment of the individual to honest self assessment.   In fact, if used incorrectly, some educators believe it may even reinforce existing beliefs and actions (2).

True self reflection requires a commitment to have an honest and open discussion with yourself.

Self reflection is deliberately challenging, and therefore may often feel uncomfortable.  It requires an acceptance of the need to question existing knowledge, norms and assumptions (1).  In doing so however, it may unearth flawed logic, erroneous assumptions, harmful behaviours, knowledge gaps and process errors – all of which may potentially be avoided in the future by carefully documenting, analysing and planning.

Self reflection is a process usually applied to negative events, though it doesn't need to be (1).  While most reflection is done individually, there is evidence that sharing self-reflections with a mentor or coach can result in even better outcomes (4).

How do I start?

Okay, so you're interested? 

Here's a simple construct you can use to get going.

Based on the Gibbs' reflective cycle (3)

While many approaches have been published, one of the most popular is the Gibbs Cycle3, developed by Graham Gibbs in the 1980s.   The process is designed to first document the events in detail, before unpicking the reasons they occurred.  Based on this new understanding of the event, conclusions and actions can be developed to change the outcome of a similar event in the future.

To use the model, address each stage in sequence.  It may be useful to write down some of your thoughts to help order and process them.  There are no specific questions for each section, but to help you get started, we've included some examples in what follows.

Description

The first step in the model is to try to document the event in as much relevant detail as possible.   This provides a useful substrate for contemplation.  Ask questions such as:

  • What, when and where did the event happen?

  • Who was there?

  • What actions were taken?

  • What was the result?

It is important at this point not to make judgements or interpretations – this section is simply to document what happened.

Feelings

This may seem a little strange and unnecessary at first.  However, it might be useful to confront the emotions associated with an incident or scenario first.  Once this is out of the way, it can enable you to be more objective in your analysis of the events.

Questions like these can help :

  • How did the situation make you feel?

  • Did your feelings change during the event?  Are they different now?

  • How did others feel about the situation?

Again, at this point, try simply to document your feelings - you can analyse them in a later section.


Reflecting on the emotions you experienced can help you be more objective in your analysis

Evaluation

Now is the time to assess the incident, looking at positive and negative components.  

Ask questions like :

  • What was positive about the experience?

  • What didn’t go well?

  • What should have been done differently?

  • What was missed?

  • What could be changed to get produce a better outcome?

  • What factors contributed to the outcome?

Analysis

Now is the time to ask “why” questions.  Look for the reasons for the positive and negative elements outlined in the Evaluation phase.  Your aim should be to understand the reasons (the root causes) for the events unfolding as they did.

It is worth trying to dissect theory from practice here – why did something happen when it shouldn’t have?  Understanding why the real world operates differently from theory can be very informative.

Ask:

  • Why did this happen?

  • Why did something not happen when it should have?

  • Why did I feel the way I did?

One possible tool to use in this section is the “5 why’s technique” – the theory goes that if you ask "why" 5 times in a row, you’ll find root causes.  In practice, keep asking why until you can't go any further.  It's often interesting what you find.

For example :

Why did the patient become hypotensive?

Because there was no metaraminol available

Why was there no metaraminol available?

Because it wasn’t prepared before intubation

Why wasn’t it prepared?

Because the checklist wasn’t completed

Why wasn’t it completed?

Because no one knew where to find it

Why didn't they know?

Because it wasn't in the orientation manual

This process often leads to a range of opportunities for action

Conclusions

Summarise your analysis in terms of key reasons the event unfolded as it did, and make recommendations to address these reasons.

Use expressions such as “I learned…”, “Next time I will…” and “This happened because…”

Action Plan

Identify anything you can or should do prior to another event like this.  It might include undertaking a training course, doing some research or purchasing a piece of equipment.

Be specific and use SMART goals where possible:

  1. Specific

  2. Measurable

  3. Achievable

  4. Relevant

  5. Time based

This is often a good time to bring in an expert, a coach or someone you trust, to give another perspective.   They may see things differently or have additional strategies you haven’t thought of.

Summary

Self reflection is a useful tool to explore the underlying knowledge, attitudes and behaviours that lead to certain events.  When done properly, self reflection can be uncomfortable, but in doing so it opens up many opportunities to learn.

Why not give it a go?

References

  1. Mann, K., J. Gordon, and A. MacLeod, Reflection and reflective practice in health professions education: a systematic review. Advances in Health Sciences Education, 2009. 14(4): p. 595-621.

  2. The Reflectors Toolkit

  3. Gibbs, G. (1988). Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Oxford Further Education Unit

  4. Archer J et al.  The evidence and options for medical revalidation in the Australian context.  Accessed June30, 2021