The role of reflection in implementing learning from continuing education into practice

Original Research

The Role of Reflection in Implementing Learningfrom Continuing Education into Practice

MANDY LOWE, MSC, BSC; SUSAN RAPPOLT, PHD; SUSAN JAGLAL, PHD; GERALDINE MACDONALD, RN, BSCN,MED, EDD

Introduction: Although the use of reflection to facilitate learning and its application in practice has been widelyadvocated, there is little empirical research to establish whether or not health professionals use reflection tointegrate learning into clinical practice. Particularly troublesome is the lack of empirically based theory underlyingstrategies to promote reflection and understand factors that influence its use in translating learning into practice.Occupational therapists participated in this case study, in which reflection and implementation of learning from ashort course into practice were examined using a multimethod approach.

Methods: In phase one (n = 41), quantitative data were collected from a practice survey, the Self-Reflection andInsight Scale (SRIS) and Commitment to Change (CTC) statements. In phase two (n = 33), follow-up CTC datawere collected to quantify the extent of achievement of CTCs. Data from phases one and two were analyzeddescriptively to inform the selection of interview participants (n = 10) in phase three of data collection.

Results: Two models were generated. One model describes when reflection was used, and the second modelexplains factors influencing its use. Participants used reflection before, during, and after the course, and reflectionwas influenced by a range of factors associated with the course, practice context, and the individual.

Discussion: The theory and models depicting the use of reflection may guide educators’ use of reflective learningbefore, during, and after short courses.

Key Words: reflection, reflective practice, commitment to change, practice change, short course, occupationaltherapy, continuing professional development, knowledge translation

Introduction

Reflection has been defined as intentional mental process-ing, used primarily with complicated or uncertain situationsor ideas in order to fulfill a particular purpose in the presentor future.1 Of importance for educators, reflection is thought

to be significant in health professionals’ implementation oflearning from short continuing education ~CE! courses intopractice.2–4 However, there is little empirical evidence tosupport the use of reflection to enhance learning and prac-tice changes after short courses.5!As Lockyer ~2004!6 stated,“We have no good understanding of how reflection actuallyworks, whether everyone benefits from reflective work, andwhen it is most helpful in learning” ~p. 54!.

Although numerous theoretical contributions to the cur-rent understanding of reflection have been developed,6–12

there are several challenges to using these models when con-sidering how health professionals use reflection to imple-ment learning from short courses into practice. First, mostare based on student populations, student-teacher dyads, orlearning through practice rather than short course learning.Second, many models do not explicitly focus on the moredeliberate use of reflection in clinical reasoning rather thanin response to surprises or unexpected occurrences. Third,several models fail to address the influence of context onreflection. Given the lack of empirically derived theory forunderstanding reflection and its use in implementing learn-ing from short courses into practice, the intent of this studywas to examine whether or not health professionals use

Ms. Lowe: lecturer, Department of Occupational Science and OccupationalTherapy, University of Toronto, Interprofessional Education Leader, To-ronto Rehabilitation Institute, Toronto, Canada; Dr. Rappolt: associate pro-fessor, Graduate Department of Rehabilitation Science and Department ofOccupational Science and Occupational Therapy, University of Toronto,Canada; Dr. Jaglal: associate professor, Graduate Department of Rehabil-itation Science, University of Toronto, Canada; Dr. Macdonald: coordina-tor, Clinical Nursing Field, MN Program, Lawrence S. Bloomberg Facultyof Nursing, University of Toronto, Canada.

Correspondence: Mandy Lowe, lecturer, Department of OccupationalScience and Occupational Therapy, University of Toronto, Interprofes-sional Education Leader, Toronto Rehabilitation Institute, 550 Univer-sity Ave., Toronto, Ontario, Canada M5G 2A2; e-mail: [email protected].

© 2007 Wiley Periodicals, Inc. • Published online in Wiley InterScience~www.interscience.wiley.com!. DOI: 10.10020chp.117

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, 27(3):143–148, 2007

reflection in attempting to implement learning from a shortcourse into practice, and, if they do, when.

Methodology

A small sample of occupational therapists ~OTs! attendinga short CE course in Ontario served as a case study. Oc-cupational therapy is a self-regulating health profession inOntario, Canada. Although OTs frequently work within in-terprofessional teams, individual OTs are solely responsi-ble for their clinical decision making. OTs in this studyattended a 3-day CE course that addressed the assess-ment and treatment of visual perception deficits across arange of adult populations and included both didactic andhands-on workshop components.

To examine whether reflection was used in implementinglearning from a short course into practice, a multimethodapproach was used in which quantitative data addressingimplementation of learning and engagement in reflection werecollected in phases one and two to inform subsequent se-lection of interview participants.

Quantitative data collection for all participants occurredimmediately after the course and 2 to 3 months later. Inphase one of data collection, 41 participants in the class of63 consented to voluntary involvement in the study and com-pleted a practice survey, Self-Reflection and Insight Scale~SRIS!13 and Commitment to Change statements ~CTCs!14.The practice survey ~adapted from Rappolt and Tassone15!,gathered information about participants’ services, patients,and practices contexts. To measure self-assessed use of re-flection, a tool providing a reliable means of identifyingengagement in reflection was sought. The SRIS measuresself-assessed engagement in reflection ~SRIS-SR! and in-sight,13 but in this study, only SRIS-SR data were relevantto the research question. The SRIS-SR demonstratedadequate psychometric properties ~e.g., coefficient alpha of0.91! in studies establishing its validity and reliability withundergraduate students.13 For the SRIS-SR, respondents ratedtheir level of agreement with 12 statements on a 6-pointscale, ranging from “strongly disagree” to “strongly agree.” 13

CTCs14 were also completed after the course and have beenused to evaluate participants’ implementation of learning inpractice.16–18 In phase two, CTC follow-up data were gath-ered to ascertain the degree of follow-through with antici-pated practice changes 2 to 3 months after the course. Of the41 participants from phase one, 33 participants providedCTC follow-up data including number of CTCs set and theirachievement.

In phase three, interview participants who varied in theirimplementation of learning post course and their engage-ment in reflection were purposefully selected. Consistentlywith grounded theory methodology, 14 participants were cho-sen for interviewing to achieve maximal variation acrossself-assessed levels of reflection and CTC achievement. Tenparticipants consented to participate in individual in-depthinterviews ~refer to TABLE 1 for interview guide!, and tran-

scribed interview data were analyzed using the groundedtheory method.19 Line-by-line review and open coding oftranscripts were conducted using constant comparison, inwhich data from new interviews were reviewed, analyzed,and compared, and interviews were conducted until no newcodes were identified.19 Codes were then grouped into cat-egories of properties or conditions and relationships amongthese were explored through axial coding.20 Further inte-grative analysis of derived concepts ~the process of selectivecoding,20! led to the development of two models.

Results

Selection of Interview Participants

This article focuses on data gathered from the interview par-ticipants. Interview participants ~n � 10! ranged from 26 to49 years of age and had 3–25 years of experience; eightworked in either acute care or rehabilitation while the re-maining two worked across multiple populations. Three ofthe interview participants held master’s degrees, five heldbachelor’s degrees, and two possessed diplomas.

The 10 interview participants varied in their SRIS-SRscores and CTC achievement. Higher reflectors were clas-sified by SRIS-SR scores near the maximal score of 72 ~68–72! and lower reflectors had scores near the lowest end ofscores achieved ~26–52! in the samples. High CTC achieve-ment was indicated by progress made on every one of thetwo or three CTCs set per participant, and low CTC achieve-ment was indicated by progress made on only some or noneof the CTCs set. Of the four participants who had highSRIS-SR scores, three had low CTC achievement and onehad high CTC achievement ~two participants originally se-lected in this category did not consent!. Of the six partici-pants who had low SRIS-SR scores ~36–52!, four had highCTC achievement and two had low CTC achievement ~twoparticipants originally selected in this category did not con-sent to interviewing!. The 10 interview participants set atotal of 29 CTCs ~12 achieved, 9 partially achieved, and 8not achieved!.

TABLE 1. Key Questions From Interview Guide

What was the course like for you? What was the impact of this course onyou and your practice? Why?

Do you think that the course influenced your practice? If so, how? Why doyou think it influenced it in this way? What factors contributed to this?

Think about a time when you learned something from a course and itinfluenced your practice. Why do you think it influenced your practicethat way? What factors may have contributed?

Think about a time when you learned something from a course and it didnot influence your practice. Why do you think it did not influence yourpractice? What factors may have contributed to this lack of influence?

How would you describe the term reflection in relation to your thoughtsand your practice?

Learning to Practice: The Role of Reflection

144 JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—27(3), 2007DOI: 10.1002/chp

Reflection and CTC Follow-Through

In the entire sample of 33 participants, CTC achievementwas similar ~progress made on approximately 75% of allCTCs set! when comparing CTC achievement between par-ticipants with SRIS-SR scores above and below the 50thpercentile. Analysis of the interview data provided some in-sight into why both lower and higher reflectors reportedsimilar CTC achievement overall. Most ~3 of 4! of the higherreflectors stated that their use of CTCs mirrored their usualprocess for following through on their implementation oflearning into practice. In contrast, several ~3 of 6! of the lowreflectors indicated that CTCs facilitated follow-throughwith practice changes that they might not have otherwisemade. For example, when asked about the effect of makingCTCs, one of these lower reflectors stated, It forced me tocome back . . . and made me reflect. Interestingly, even inter-view participants who did not make any progress toward CTCsreported that they valued the CTCs and all interview partici-pants indicated that they would be open to future CTC use.

Factors Influencing Reflection

Interview participants identified individual, course, clinicalprocess, and practice context factors that influenced theirability to reflect ~FIGURE 1!. The participants’ level of mo-tivation and preparation for using reflection as well as theextent of their previous knowledge of the course topic werefactors described at the “individual” level. Participants dis-cussed “course” factors that affected their use of reflection,

including the difficulty of the content, as well as the pace,novelty, and volume of the material ~TABLE 2!.

Participants described factors associated with the pro-cesses of their clinical practices that affected implementa-tion of course learning in practice and stimulated reflection.Most frequently cited were their interactions with clients0patients, colleagues, and students, specifically indicating thatclients’0patients’ problems and students’ and peers’ ques-tions stimulated reflection. Factors within the “practice con-text” that participants identified as either hindering orfacilitating reflection included the availability of resources~time, staffing levels! and practice culture ~learning envi-ronments, openness to innovation, expectations, and man-agement support!. Supportive management was seen as keyto fostering a work environment that promoted reflection.Characteristics of managers who foster reflection were de-scribed by one participant as, openness and their willing-ness to try different things. . . . They’re not fixed in a certainway. They don’t say, “Oh, this is how it’s always beendone.”

Learning and Reflection

In discussing implementation of learning into practice gen-erally, interview participants described a difference in thequality of learning using reflection ~‘wider impact’ of learn-ing with reflection as depicted in FIGURE 1!. This differ-ence was highlighted by one participant who said of learningwithout using reflection, I think that I [can learn withoutreflection], but to what extent? I believe I won’t make a big

FIGURE 1. Factors that influence reflection and its effect on implementing learning from a CE course into practice. Reflection maybe affected by a variety of factors related to the individual, the CE course, the clinical process, and the practice context. Further,reflection may affect the impact of learning on clinical practice.

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change if I don’t see the relationship. Another participantdiscussed the wider impact of learning using reflection, ifyou don’t reflect you’re not going to get as much out ofthings you learn.

Roles of Reflection

Participants reported using reflection in a variety of poten-tial instances before, during, and after the course ~TABLE 3!,as depicted in the model, Roles of Reflection ~FIGURE 2!.For some, reflection played a role in evaluating both per-

sonal areas of strength and those in need of further devel-opment. Most participants reported some use of reflectionin response to problems or difficulties encountered in prac-tice, and some described using reflection to challenge roteaspects of their practices. In matching their learning needsagainst the course objectives and agenda, one participantstated, [You] ask yourself, “Is this what I want to learn?”. . .I used to downplay course objectives but they’re criticalbecause they [lay out] the framework, and . . . you can seehow the learning fits. Most participants reflected on therelevance of new information presented during the course

TABLE 2. Sample Participant Quotes Addressing the Relationship between Use of Reflection and Course Content

Reflection used with novel content If it’s something . . . a new area that I’m learning about, then I will be reflectingmore.

I do [reflect] most when there is a new learning component.

Reflection used with content that is complex or challenging Reflection for me happens when you sit down . . . and the answer is not alwaysjust that obvious. Sometimes you do have to sit down and think about it alittle bit.

I think if you learn things from a course that are very concrete, you may notneed to reflect. But if you need to do a lot to understand and apply and add toprevious knowledge, you need to do more (reflecting).

If it’s something that I’m not sure about and if I don’t understand, I reflect on itmore, how am I supposed to apply this? What am I supposed to do here?

Reflection less likely used if content is concrete, straightforward I think if you learn things from a course that are very concrete, things that youcan take away, that you don’t need to do a lot (of reflecting).

There would probably be some quite practical skills that you learn . . . you don’tneed to sit round and reflect on them.

TABLE 3. Sample Participant Quotes Addressing the Roles of Reflection

Reflect on practice Reflecting on what you do well and your strength: I don’t think it’s just looking at weaknesses andareas of learning; it’s looking at how you perform and work as a person.

Learning need identified I feel like I need more information on this. So I’m going to need to go and figure out how I’mgoing to change that.

Continuing education and learning need match [You] ask yourself, “Is this what I want to learn? . . . I used to downplay course objectives butthey’re critical because they [lay out] the framework, and . . . you can see how the learningfits.

During continuing education I definitely take information [during the course] and reflect on it . . . you don’t take everything asblack and white that way.

Not relevant That [course] was informative so I know a little bit more about that area, but I don’t think any ofit will really apply.

Subtle0no practice change Through reflection you can achieve reaffirmation of what you are doing. It doesn’t have to bechange; sometimes it’s also strengthening.

Recognize practice change needed You look at what you’re doing, what you just learned, and see if what you learned is going to beuseful in what you do . . . the different areas it could affect.

No practice change I needed to practice [an assessment learned in the course], but I did not have the time to actuallysit down and practice it.

Practice changed We were trying different things that I learned from the course and having problems because theseweren’t the patients I usually worked with. Certain interventions that I was trying to do had tobe more closely monitored than expected.

Just do it After some courses, they don’t sit and reflect on those skills; they just do it.



with respect to their past, present, or anticipated clinical ex-periences. If new information was perceived as relevant, itsmeaning and value were interpreted with respect to practice.However, new learning did not necessarily result in practicechange. In these cases, participants indicated that their re-flection on new learning provided enhanced levels of un-derstanding, confidence, and awareness or resulted in subtleshifts in clinical approaches. Although some participants iden-tified barriers to implementing their intended practice changesafter the course, their reflections on these barriers did notnecessarily lead to actions to eliminate these barriers. Ininstances when participants reported implementing practicechanges without reflection, they indicated that their imple-mentation of new learning was almost automatic. As oneparticipant stated, You put it into practice—you “just do it”.You don’t necessarily need to reflect. Finally, some partici-pants reported using reflection to monitor their practicechange, particularly when difficulties in implementationarose.

Discussion

The purpose of this study was to develop models and theoryregarding when practicing health professionals use reflec-tion in implementing learning from a short course into prac-tice. Reflection may play multiple roles in the ongoing processof implementing course learning into practice and is influ-enced by the individual learner, the course, clinical process,and practice context factors. A health professional who at-tends a short course seems more likely to use reflection if heor she values reflection and has the awareness, motivation,and ability to use reflection, and if factors associated withthe course itself promote reflection. The likelihood of theuse of reflection is further increased if the clinical processesand practice context are conducive to the use of reflection.

Health professionals use reflection to translate complex learn-ing into their practices, evaluate practice and learning needs,enhance understanding of new learning, and implement andmonitor practice changes.

Consistently with other research,16 this study providessupport for the role of reflection in using CTCs. Althoughfollow-through on CTCs was similar for high and low re-flectors in the entire sample, the interview data suggesteduse of CTCs may have mirrored higher reflectors’ usual pro-cesses for following through on their implementation of learn-ing into practice. In contrast, some low reflectors reportedthat they were prompted to reflect and make practice changesby CTCs. Further, in this study, the more skill-based, con-crete nature of the course material may not have stimulatedreflection fully, thereby further minimizing differences inCTC achievement between higher and lower reflectors.

Interview participants described learning both with andwithout reflection ~FIGURE 1!. They reported that whenthey learned without reflection, their learning had less effecton their practices, as is consistent with Moon’s concept of“surface learning,” or learning that is retained only until theend of the course.3 In contrast, deeper learning occurs whenindividuals seek, “to understand meaning and make sense ofit in terms of what they know already” ~p. 6!.3 Several au-thors have argued that reflection is necessary for deeper learn-ing.1,5 Participants’ reports of their use of reflection wereconsistent with Moon’s “deeper learning,” 3 as suggested bytheir descriptions of the diverse effects of their learning ontheir practices.

Although interview participants in the current study val-ued the use of reflection, they expressed concerns regardingtheir abilities to use it in their practice because of barrierssuch as workload demands, similar to the findings of Pee,Woodman, Fry, and Davenport ~2000!.21 Findings from thisstudy also support a range of effects stemming from the useof reflection. While some have argued that particular prac-tice changes are the primary outcome of reflection,22,23 thefindings from this study and others24–26 suggest that reflec-tion may also be used to confirm knowing and change theway practitioners conceptualize their practice.

The results of this study have several implications foreducators and researchers. Educators may consider incor-porating its findings in current educational practices. Forexample, educators can integrate opportunities for reflectioninto courses by giving learners time to reflect on their pre-course learning priorities and facilitating learners’ consid-eration of the implications of learning on clinical processesand practice contexts. As this small study was exploratory innature, studies with larger sample sizes and other popula-tions of health professionals are needed to validate findings.Because interview participants indicated that factors asso-ciated with practice contexts influenced the use of reflectionin this study, future research should include participants froma wider range of practice environments. As the course ex-amined in this study addressed clinically applicable mate-rial, courses with more abstract content should be studied.

FIGURE 2. Roles of reflection in implementing learning from a CE courseinto practice. Reflection may play various roles as health professionalspractice, examine their needs, participate in courses, and implement learn-ing into practice.

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Objective measurement of practice changes, as well as self-reported practice changes, would also enhance the validityof the findings. Finally, as the use of the SRIS-SR was novelwith this population, its use with health professionals re-quires additional study.

Conclusion

Enhanced understanding of health professionals’ use of re-flection in implementing learning from short courses intopractice may assist educators in designing and implement-ing courses. Although reflection appeared to affect partici-pants’ abilities to make self-reported changes in practiceafter learning through a short course positively, other fac-tors, including elements of the practice context, clinicalprocesses, course factors, and aspects associated with theindividual, also influenced the use of reflection. Furtherstudy of these factors will inform the practices of educa-tors in the future.

Acknowledgments

Funding for this study was generously provided by Con-tinuing Education, Faculty of Medicine, University of To-ronto, and the Canadian Occupational Therapy Foundation.Mandy Lowe also received scholarships from the Universityof Toronto and the Toronto Rehabilitation Institute. Dr. Su-san Jaglal is the Toronto Rehabilitation Institute chair at theUniversity of Toronto. Thanks to Dr. Jocelyn Lockyer forreviewing earlier versions of this article and providingthoughtful comments and feedback.

References

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Lessons for Practice

• Reflection may lead to the implementationof learning from a short course into prac-tice, when (1) the individual has the aware-ness, motivation, and ability to use reflection;(2) factors associated with the course pro-mote reflection; and (3) the clinical pro-cesses and practice context are conduciveto the use of reflection.

• Reflection may play multiple roles duringthe process of implementing short courselearning into practice.

• Commitments to Change statements maypromote practice change using reflection.



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The role of reflection in implementing learning from continuing education into practice