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SCHŐN and REFLECTIVE PRACTICE Reflection-in-action is defined by Schön as the ability of professionals to ‘think what they are doing while they are doing it’. He regards this as a key skill. He asserts that the only way to manage the ‘indeterminate zones of (professional) practice’ is through the ability to think on your feet, and apply previous experience to new situations. This is essential work of the professional, and requires the capability of reflection-in-action. Schön was writing before the evidence based medicine revolution but, reading him again ‘post-EBM’, his words make a lot of sense to me, as I strive to be patient-centred, compassionate, evidence-based, and cost effective all at the same time! Schön also offers his thoughts on how this kind of professional is ‘produced’. He describes a number of key concepts, which are worth summarising: § The ‘Reflective Practicum’. This is his term for the educational setting, or environment: “A practicum is a setting designed for the task of learning a practice”. This is where students learn by doing, with the help of coaching. He tells us the practicum is ‘reflective’ in two senses: “it is intended to help students become proficient in a kind of reflection-in-action; and, when it works well, it involves a dialogue of coach and student that takes the form of reciprocal reflection-in-action.”
This comes from the work of Michael Polanyi3. He describes for example the remarkable way we are able to pick out a familiar face in a crowd. This does not require thinking about, or a systematic analysis of features. We cannot verbalise how this is done, and so the knowledge is ‘unspoken’ or ‘tacit’.
This is another of Schön’s concepts, and it derives from the idea of tacit knowledge. It refers to the kinds of knowledge we can only reveal in the way we carry out tasks and approach problems. “The knowing is in the action. It is revealed by the skilful execution of the performance – we are characteristically unable to make it verbally explicit.” This tacit knowledge is derived from research, and also from the practitioner’s own reflections and experience.
This is the kind of reflection that occurs whilst a problem is being addressed, in what Schon calls the ‘action-present’. It is a response to a surprise – where the expected outcome is outside of our knowing-in-action. The reflective process is at least to some degree conscious, but may not be verbalised. Reflection-in-action is about challenging our assumptions (because knowing-in-action forms the basis of assumption). It is about thinking again, in a new way, about a problem we have encountered.
This is reflection after the event. Consciously undertaken, and often documented.
This phrase was originally coined by Samuel Taylor Coleridge4 to describe the stance essential to an understanding of poetry. It describes the process of entering into an experience, without judgment, in order to learn from it. Schön uses the term in relation to the idea of learning by doing. One cannot will oneself to ‘believe’ until one understands. But understanding often will only arise from experience. So it is necessary first to allow the experience to happen.
This is listening and absorbing information, in a state of readiness to apply and experiment with the new information. An everyday example would be when we listen to directions on how to find an obscure address. This participation is important in the learning process – a learner needs to be already engaged in activity for further information to have meaning. This in turn is partly derived from Wittgenstein’s5 contention that the meaning of an operation can only be learned through its performance. Hence mechanical or imperfect performance of an activity prepares the learner for new information (feedback) on that activity, in order to develop understanding.
Schön speaks of a vertical dimension of analysis that can happen in the dialogue between learner and teacher. To move up a rung on the ladder involves reflecting on an activity. To move down a rung is to move from reflection to experimentation. This ladder has more than two rungs – it is also possible to reflect on the process of reflection. The importance of this concept is in its potential for helping out with ‘stuck’ situations in learning. Being able to move to another level may assist coach and learner to achieve together what Schön refers to as ‘convergence of meaning’. So what practical messages are there for us in 21st century health education? It is interesting to see how far these ideas have become integrated in the way we do things – have become part of our own tacit knowledge. To illustrate, here is a fictional vignette from a typical morning in a GP training practice:
A GP registrar finishes morning surgery, and has a couple of questions to ask the trainer at coffee time about a patient with a new presentation of hypothyroidism. How does the trainer respond? - Often not with a simple answer, but with a dialogue. The learner is encouraged to think back over the consultation and their previous knowledge and experience, and work their way to at least part of the answer for themselves. This demonstrates how the training practice can function as a reflective practicum. The registrar had never managed a patient with hypothyroidism before, but had to deal with the consultation anyway. Having done so, and having told the patient they would ring them back later in the day, the registrar is now in a prime state of operative attention. During the consultation, the registrar had to be able to consider in ‘real time’ what might be causing her patient’s weight gain and tiredness, and arrange appropriate investigations. Perhaps her first thought was that the patient was suffering with depression, but the picture wouldn’t quite fit. This is reflection-in-action. Later the same week, in the tutorial, the trainer refers back to this case. He encourages the registrar to reflect on how the consultation had gone, what her feelings had been that led her to question her initial diagnosis of depression. How had she felt about needing to find out more about the management of hypothyroidism? This reflection on action involves a step up the ladder of reflection, and a lot of learning can be developed which will have application in a much wider field than hypothyroidism. The registrar is learning to be a GP. References1. Schön D (1983) The reflective practitioner. Basic Books: New York 2. Schön D (1987) Educating the Reflective Practitioner. Jossey-Bass: San Francisco 3. Dewey, J (1974) John Dewey on Education: Selected Writings (R.D. Archambault, ed). University of Chicago Press:Chicago 4. Polanyi, M (1967) The tacit dimension. Doubleday: New York 5. Coleridge, ST (1983) Biographia Literaria (J Engell and WJ Bates, eds). Princeton University Press: Princeton NJ. (Originally published 1817) 6. Wittgenstein, L (1953) Philosophical Investigations (GEM Anscombe, translator). Macmillan: New York.
Mark Waters April 2005
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