Professional reflection

Schon’s (1983; 1987) work on reflection started with a consideration of how professionals such as doctors and lawyers solved problems. In principle, Schon argued that one way

professionals solved problems was by applying scientific knowledge in a rigorous and logical manner, which he called technical rationality. This model of technical rationality was

comparable to Kolb’s converger (1984), who used theory to help solve problems. It can also be equated to the principle of evidence based medicine (Sackett et al., 1996) where the doctor bases their patient care on evidence.

Schon also viewed that professionals functioned in more complex ways than just the application of knowledge and logic. He understood that many of the day-to-day problems, with which patients present to doctors, did not fit into the simple logical model of technical rationality. Furthermore, doctors could not always explain the how or why of many of the decisions and judgements they made everyday. Many of their decisions were tacit. It was his attempt to understand what underpinned these tacit decisions, which led him to describe the importance of reflection. He divided reflection into two categories, reflection-in-action, and reflection-on-action.

He suggested that a feature of being a professional was an ability to modify actions in ‘real time’, while a situation was ongoing. Professionals were able to reflect during the action and used this immediate reflection to modify their action. He called this reflection-in-action. The analogy he used was that of a jazz musician who is able to improvise at the same time as playing. An example from anaesthesia might be the ability to adjust the depth of anaesthesia to the changing condition of the patient and the requirements of the surgeon as an operation proceeds.

He also identified a separate process of reflection, which took place after the action or the event, which he called reflection-on-action. This reflection-on-action equated to the reflection suggested by Kolb. Schon’s ideas and suggestions have had a major influence on how many people view professionals, how they work and what they do.

Others have expanded Schon’s ideas on the difference between in and on action. Eraut (1995; 2004) revisited Schon’s work and queried the difference between in and on. He suggested that the difference was not as simple as Schon implied and continued by illustrating that Schon’s examples of the differences were not necessarily conclusive. Nevertheless, he acknowledged that Schon has had a large influence on thinking about professionals.

Eraut (1995) also suggested that Schon’s ideas could be reframed by changing the prepositions in and on. He considered the element of time scale should be explicitly

acknowledged. The idea of the ‘in’ action was that it was an on-the-spot reflection. However, the more deliberate longer-term type of reflection affected future actions but that this might be over several time spans. There could be the ‘immediate’ reflection after the action or a

reflection that took place much later. He suggested expansion of the process by thinking in the three dimensions of context, focus, and purpose. The context related to both the immediate and the wider aspects of the action. The focus of reflection related to the group to which the action referred. The purpose related to the use of the reflection in improving both current and ongoing actions.

Others too have developed the work of Schon. Bengtsson (1995) suggested that Schon could be expanded and developed into four categories, reflection as self-reflection, reflection as thinking, reflection as self-understanding and the distancing function of self-reflection. Van Mannen (1995), again looking at and acknowledging the importance of Schon, emphasised that it should be accepted or acknowledged that there is a difference between practical knowledge and reflective practice when applied to pedagogy.

This illustrates that when using the word reflection we need to be mindful of its variable interpretation.

2.2.7 Summary

Learning is a complex process. Doctors spend their professional lives learning and can be considered experts in the field of learning. In order to make their learning more effective, an understanding of the underlying process is a good starting point. Some studies, which measured Kolb’s learning styles (Kolb, 1984), suggest there are preponderances of certain learning styles in different specialties of medicine. However, the preponderances do not exceed 50% indicating that at least half have different styles.

A training programme that addressed the learning needs of less than half of the audience or learners would exclude the remainder. Teachers, who understand both their own and their learners’ learning style preferences, will be well equipped to select experiences appropriate for their individual learners The experiences should be selected on the preference and need of the learner rather than the teacher. However, in the workplace the teacher does not have the same degree of control over the experiences as in the classroom. This unpredictability of experiences is particularly evident in the OR because of the variability in the patient requirements.

The number of experiences that an individual has each day may be overwhelming. An

important early first task of a teacher is to help the learner identify the relevant experiences. In addition, Kolb would argue that the teacher should try to match the experience to the learning style of the learner, concrete or abstract. This would be followed by the teacher facilitating the learner’s reflection or action on the experience to enable the learner to utilise their learning strengthens. However, whichever is their preferred style, on occasions, it will be necessary for them to adopt a different style. Perhaps it is this ability to adapt that makes the best learners. Rather than hunting for learners with a particular style to teach, perhaps teachers should enable learners to be adaptive.

In relation to this, teachers may need to teach their learners how to learn and to become self- directed learners, an aspect emphasised by the GMC (1999) in their publication ‘The Doctor as Teacher’. The next section addresses this role of the doctor as a teacher.