Collaborative Reflection Under the Microscope: Using Conversation Analysis to Study the Transition From Case Presentation to Discussion in GP Residents' Experience Sharing Sessions

Critical reflection in team-based practice: A narrative review

INTRODUCTION

Research on critical reflection (a process of recognising and challenging assumptions that frame health care practice) has demonstrated strong potential for making health care more collaborative and equitable, yet its enactment within team-based health care remains underexplored. We conducted a narrative review to advance understanding of how critical reflection develops, occurs in and impacts team-based practice and care.

METHODS

We searched three databases (Medline, CINAHL and Scopus) for articles related to the concepts of critical reflection and/or critically reflective practice in the context of team-based health care and examined how teams engage with those theoretical concepts, to inform ideas for a new approach to support critically reflective practice.

FINDINGS

The search identified 974 citations of which nine articles showed elements of critical reflection in team-based practice. However, since only one of the nine included articles explicitly used the term 'critical reflection' in their research, critical reflection as a theoretical concept was found to be largely missing from the current team-based health care literature. Instead, aspects of critical reflection were evident in terms of challenging power hierarchies and questioning practice assumptions through dialogue, with a goal of collaborative practice. This sharing of knowledge and skills allowed teams to push boundaries and innovate together in practice. The included articles also emphasised the importance of creating a purposeful environment for open dialogue and practice change to occur.

CONCLUSION

To support equitable care through collaborative practices, we suggest dialogue as and for critical reflection should be explicitly developed and researched within team-based health care.

The writer's voice repertoire: Exploring how health researchers accomplish a distinctive 'voice' in their writing

INTRODUCTION

Much published research writing is dull and dry at best, impenetrable and off-putting at worst. This state of affairs both frustrates readers and impedes research uptake. Scientific conventions of objectivity and neutrality contribute to the problem, implying that 'good' research writing should have no discernible authorial 'voice'. Yet some research writers have a distinctive voice in their work that may contribute to their scholarly influence. In this study, we explore this notion of voice, examining what strong research writers aim for with their voice and what strategies they use.

METHODS

Using a combination of purposive, snowball and theoretical sampling, we recruited 21 scholars working in health professions education or adjacent health research fields, representing varied career stages, research paradigms and geographical locations. We interviewed participants about their approaches to writing and asked each to provide one to three illustrative publications. Iterative data collection and analysis followed constructivist grounded theory principles. We analysed interview transcripts thematically and examined publications for evidence of the writers' described approaches.

RESULTS

Participants shared goals of a voice that was clear and logical, and that engaged readers and held their attention. They accomplished these goals using approaches both conventional and unconventional. Conventional approaches included attention to coherence through signposting, symmetry and metacommentary. Unconventional approaches included using language that was evocative (metaphor, imagery), provocative (pointed critique), plainspoken ('non-academic' phrasing), playful (including humour) and lyrical (attending to cadence and sound). Unconventional elements were more prominent in non-standard genres (e.g. commentaries), but also appeared in empiric papers.

DISCUSSION

What readers interpret as 'voice' reflects strategic use of a repertoire of writing techniques. Conventional techniques, used expertly, can make for compelling reading, but strong writers also draw on unconventional strategies. A broadened writing repertoire might assist health professions education research writers in effectively communicating their work.

How does guided group reflection work to support professional identity formation in postgraduate medical education: A scoping review

PURPOSE

In postgraduate medical education, guided group reflection is often applied to support professional identity formation. However, little is known about how guided group reflection is shaped and how it works. Our scoping review synthesizes existing evidence about various approaches for guided group reflection, their aims, components and potential working mechanisms.

METHODS

We conducted a scoping review using JBI (Joanna Briggs Institute) guidelines for conducting scoping reviews. We searched PubMed, PsycINFO, EMBASE and ERIC databases for all research articles published in English or Dutch in an iterative team approach. The articles were extracted and summarized quantitatively and qualitatively.

RESULTS

We included 71 papers (45 primary research papers and 26 non-empirical papers including program descriptions, theoretical concepts and personal experiences). We identified a diversity of approaches for guided group reflection (e.g. Balint groups, supervised collaborative reflection and exchange of experiences), applied in a variety of didactic formats and aims. We distilled potential working mechanisms relating to engagement in reflection, group learning and the supervisor's role.

CONCLUSIONS

There are significant knowledge gaps about the aims and underlying mechanisms of guided group reflection. Future systematic research on these topics is needed to understand the effectiveness of educational methods, that can help facilitate learning conditions to best shape professional identity formation (PIF) in educational curricula.

'You are not alone.' An exploratory study on open-topic, guided collaborative reflection sessions during the General Practice placement

BACKGROUND

To support professional development of medical students faced with challenges of the clinical phase, collaborative reflection sessions (CRSs) are used to share and reflect on workplace experiences. Facilitation of CRSs seems essential to optimise learning and to provide important skills for lifelong learning as a professional. However, little is known about which workplace experiences students share in CRSs without advance guidance on specific topics, and how reflecting on these experiences contributes to students' professional development. Therefore, we explored which workplace experiences students shared, what they learned from reflection on these experiences, and how they perceived the value of CRSs.

METHODS

We conducted an exploratory study among medical students (N = 99) during their General Practice placement. Students were invited to openly share workplace experiences, without pre-imposed instruction. A thematic analysis was performed on shared experiences and student learning gains. Students' perceptions of CRSs were analysed using descriptive statistics.

RESULTS

All 99 students volunteered to fill out the questionnaire. We found four themes relating to students' shared experiences: interactions with patients, complex patient care, diagnostic or therapeutic considerations, and dealing with collegial issues. Regarding students' learning gains, we found 6 themes: learning from others or learning from sharing with others, learning about learning, communication skills, self-regulation, determination of position within the healthcare team, and importance of good documentation. Students indicated that they learned from reflection on their own and peer's workplace experiences. Students valued the CRSs as a safe environment in which to share workplace experiences and helpful for their professional development.

CONCLUSIONS

In the challenging General Practice placement, open-topic, guided CRSs provide a helpful and valued learning environment relevant to professional development and offer opportunities for vicarious learning among peers. CRSs may also be a valuable tool to incorporate into other placements.

When and how teachers intervene in group discussions on experiences from practice in postgraduate medical education: an interactional analysis

Medical educators constantly make decisions on when and how to intervene. Current literature provides general suggestions about types of teacher interventions. Our study aims to specify that knowledge by describing in detail the actions teachers do when intervening, the interactional consequences of those actions, and how these relate to teacher roles in group discussions. We collected all first teacher interventions (n = 142) in 41 videorecorded group discussions on experiences from practice at the Dutch postgraduate training for General Practice. We analyzed the interventions using Conversation Analysis. First, we described the timing, manner, actions, and interactional consequences of each intervention. Next, we inductively categorized actions into types of actions. Finally, we analyzed the distribution of these types of actions over the group discussion phases (telling, exploration, discussion, conclusion). First teacher interventions were done at observably critical moments. Actions done by these interventions could be categorized as moderating, expert, and evaluating actions. Moderating actions, commonly done during the telling and exploration phase, are least directive. Expert and evaluator actions, more common in the discussion phase, are normative and thus more directive. The placement and form of the actions done by teachers, as well as their accounts for doing those, may hint at a teacher orientation to intervene as late as possible. Since the interventions are occasioned by prior interaction and responded to in different ways by residents, they are a collaborative interactional accomplishment. Our detailed description of how, when and with what effect teachers intervene provides authentic material for teacher training.

Strategies to encourage participation in debrief sessions with nursing students for whom English is an additional language: A qualitative study

BACKGROUND

End-of-day debriefs are reported to offer students opportunities to reflect and consolidate learning. However, there is little evidence about how clinical facilitators encourage student participation that leads to refection and learning, particularly in debrief sessions with linguistically diverse students.

AIM

This research investigated how the pedagogic practices of clinical facilitators enabled or constrained student participation during debrief.

DESIGN

This study used an ethnographic approach combined with linguistic analysis of audio recordings of debrief in two metropolitan hospitals in Australia.

RESULTS

The study found that several key factors contributed to student participation during debrief. Factors included: establishing a space that offered visual and aural privacy; using strategies that encouraged student talk; and adopting roles of expert teacher, facilitator, clinical expert, and therapeutic agent.

CONCLUSION

Conducting debrief in appropriate settings and adopting strategies and roles that encourage student talk can lead to opportunities for students to reflect on their day, and for facilitators to make judgements about students' knowledge.

IMPACT

Facilitators can enable student participation by using spaces that offer physical and aural privacy for debrief, focusing on knowledge within students' scope of practice, and using communication strategies that encourage talk.

General practice residents’ perspectives on their professional identity formation: a qualitative study

Objectives

To move beyond professionalism as a measurable competency, medical educators have highlighted the importance of forming a professional identity, in which learners come to ‘think, act, and feel like physicians’. This socialisation process is known as professional identity formation (PIF). Few empirical studies on PIF in residency have been undertaken. None of these studies focused on PIF during the full length of GP training as well as the interplay of concurrent socialising factors. Understanding the socialisation process involved in the development of a resident’s professional identity and the roles of influencing factors and their change over time could add to a more purposeful approach to PIF. Therefore, we aimed to investigate the process of PIF during the full length of General Practice (GP) training and which factors residents perceive as influential.

Design

A qualitative descriptive study employing focus group interviews.

Setting

Four GP training institutes across the Netherlands.

Participants

Ninety-two GP residents in their final training year participated in 12 focus group interviews.

Results

Study findings indicated that identity formation occurs primarily in the workplace, as residents move from doing to becoming and negotiate perceived norms. A tapestry of interrelated influencing factors—most prominently clinical experiences, clinical supervisors and self-assessments—changed over time and were felt to exert their influence predominantly in the workplace.

Conclusions

This study provides deeper empirical insights into PIF during GP residency. Doing the work of a GP exerted a pivotal influence on residents’ shift from doing as a GP to thinking, acting and feeling like a GP, that is, becoming a GP. Clinical supervisors are of utmost importance as role models and coaches in creating an environment that supports residents’ PIF. Implications for practice include faculty development initiatives to help supervisors be aware of how they can perform their various roles across different PIF stages.

Is reflection like soap? a critical narrative umbrella review of approaches to reflection in medical education research

Reflection is a complex concept in medical education research. No consensus exists on what reflection exactly entails; thus far, cross-comparing empirical findings has not resulted in definite evidence on how to foster reflection. The concept is as slippery as soap. This leaves the research field with the question, 'how can research approach the conceptual indeterminacy of reflection to produce knowledge?'. The authors conducted a critical narrative umbrella review of research on reflection in medical education. Forty-seven review studies on reflection research from 2000 onwards were reviewed. The authors used the foundational literature on reflection from Dewey and Schön as an analytical lens to identify and critically juxtapose common approaches in reflection research that tackle the conceptual complexity. Research on reflection must deal with the paradox that every conceptualization of reflection is either too sharp or too broad because it is entrenched in practice. The key to conceptualizing reflection lies in its use and purpose, which can be provided by in situ research of reflective practices.

Creative leaps in theory: the might of abduction

This paper argues that abductive reasoning has a central place in theorizing Health Professions Education. At the root of abduction lies a fundamental debate: How do we connect practice, which is always singular and unique, with theory, which describes the world in terms of rules, generalizations, and universals? While abduction was initially seen as the 'poor cousin' of deduction and induction, ultimately it has something important to tell us about the role of imagination and humility in theorizing Health Professions Education. It is that which makes theory possible, because it allows us to ask what might be the case and calls attention to the role of creative leaps in theory. Becoming aware of the abductive reasoning we already perform in our research allows us to take the role of imagination-something rarely associated with theory-seriously.

Shall We All Unmute? A Conversation Analysis of Participation in Online Reflection Sessions for General Practitioners in Training

The COVID-19 pandemic has induced many changes to education in many contexts. In this study, we describe how general practitioners in training (residents) accomplish participation in collaborative reflection sessions conducted on Zoom. In this online setting, taking part in interactions is understood to be crucial to the creation of educational value. To study forms of participation used on Zoom, we recorded three group reflection sessions and examined them with Conversation Analysis. We focused on how participation is shaped by and is contingent upon the affordances of the online environment. Our analyses show that participants explicitly orient to the interactional accomplishment of participation in frameworks that change in the various phases of case discussion. Participants establish new procedures to deal with both familiar and sometimes new problems of participation introduced by the online environment. We describe these procedures in detail to contribute to the understanding of the accomplishment of participation through situated practices such as embodied talk-in-interaction. The findings can serve training purposes in online education across both medical and non-medical curricula.

Using conversation analysis to explore feedback on resident performance

Feedback on clinical performance of residents is seen as a fundamental element in postgraduate medical education. Although literature on feedback in medical education is abundant, many supervisors struggle with providing this feedback and residents experience feedback as insufficiently constructive. With a detailed analysis of real-world feedback conversations, this study aims to contribute to the current literature by deepening the understanding of how feedback on residents' performance is provided, and to formulate recommendations for improvement of feedback practice. Eight evaluation meetings between program directors and residents were recorded in 2015-2016. These meetings were analyzed using conversation analysis. This is an ethno-methodological approach that uses a data-driven, iterative procedure to uncover interactional patterns that structure naturally occurring, spoken interaction. Feedback in our data took two forms: feedback as a unidirectional activity and feedback as a dialogic activity. The unidirectional feedback activities prevailed over the dialogic activities. The two different formats elicit different types of resident responses and have different implications for the progress of the interaction. Both feedback formats concerned positive as well as negative feedback and both were often mitigated by the participants. Unidirectional feedback and mitigating or downplaying feedback is at odds with the aim of feedback in medical education. Dialogic feedback avoids the pitfall of a program director-dominated conversation and gives residents the opportunity to take ownership of their strengths and weaknesses, which increases chances to change resident behavior. On the basis of linguistic analysis of our real-life data we suggest implications for feedback conversations.

Theory, a lost character? As presented in general practice education research papers

OBJECTIVES

The use of theory in research is reflected in its presence in research writing. Theory is often an ineffective presence in medical education research papers. To progress the effective use of theory in medical education, we need to understand how theory is presented in research papers. This study aims to elicit how theory is being written into general practice (GP) vocational education research papers in order to elucidate how theory might be more effectively used. This has relevance for the field of GP and for medical education more broadly.

METHODS

This is a scoping review of the presentation of theory in GP vocational education research published between 2013 and 2017. An interpretive approach is taken. We frame research papers as a form of narrative and draw on the theories of Aristotle's poetics and Campbell's monomyth. We seek parallels between the roles of theory in a research story and theories of characterisation.

RESULTS

A total of 23 papers were selected. Theories of 'reflective learning', 'communities of practice' and 'adult learning' were most used. Six tasks were assigned to theory: to align with a position; to identify a research problem; to serve as a vehicle for an idea; to provide a methodological tool; to interpret findings, and to represent an object of examination. The prominence of theory in the papers ranged from cameo to major roles. Depending on the way theory was used and the audience, theory had different impacts. There were parallels between the tasks assigned to theory and the roles of four of Campbell's archetypal characters. Campbell's typology offers guidance on how theory can be used in research paper 'stories'.

CONCLUSIONS

Theory can be meaningfully present in the story of a research paper if it is assigned a role in a deliberate way and this is articulated. Attention to the character development of theory and its positioning in the research story is important.

The reflective zombie: Problematizing the conceptual framework of reflection in medical education

Reflection is an ambiguous and profoundly complex human activity. We celebrate the developments in teaching and researching reflection in education, yet have identified flaws in the way reflection has been operationalized: medical education has translated the age-old concept into a teachable and measureable construct. We fear that in this process of operationalization, the philosophical underpinnings of reflection have been discarded. We illustrate this with a thought experiment about a 'reflective zombie': students who have been conditioned to follow prescribed thought steps rather than engaging in truly reflective behaviour. In research and assessment of reflection, measuring tools might be unable to distinguish reflective zombies from students who authentically reflect. We argue that the instrumental approach lies at the root of this problem as it limits the rich concept of reflection and illustrate our point by describing problems related to paradigm (we are looking at reflection in the wrong way), methods (we are using the wrong tools), and epistemics (can we even know what we want to know?). We offer three suggestions for implementing reflection into the curriculum and for research into reflection. First, acknowledge the diversity of reflection and let go of the 'checklist approach'. Second, embrace the personal nature of reflection by stimulating awareness of one's personal reflection styles as part of the reflective process. Third, shift the focus of research to the practice of reflection. We believe that a strong vision on reflection can lead to a balanced curriculum, setting students up for a lifelong learning as a reflective practitioner.

The swamplands of reflection: using conversation analysis to reveal the architecture of group reflection sessions

CONTEXT

Many medical schools include group reflection in their curriculum, and many researchers have considered both the concept and the outcomes of reflection. However, no research has been carried out on how 'reflective talk' is structured in the classroom. This paper describes how tutors and residents organise group reflection sessions in situ by describing an example of group reflection in medical education. Our aim is to provide an evidence base that can be used by medical educators to think about the way reflection should be included in their curriculum.

METHODS

We video-recorded 47 group reflection sessions of the general practice postgraduate training course at Erasmus University Medical School, Rotterdam. We used conversation analysis to unravel their overall structural organisation: the way participants organise and structure a conversation. Through micro-analysis of the moment-to-moment unfolding of group reflection, we distinguished the main building blocks that form the architecture of these sessions.

RESULTS

We found that participants consistently oriented towards the following activity types: significant event, reason for sharing, learning issue and learning uptake. There was variation in the order of the activity types, the amount of time spent on each of them, and how they were accomplished. By studying reflection in its messy social context, we found order, commonalities and patterns that were typical of the architecture of group reflection in this setting, even if no formal structure is prescribed.

CONCLUSIONS

In 'Exchange of Experience', the overall structural organisation consisted of activity types through which a case becomes shared, reflectable, learnable and valuable. There are essential discrepancies between cognitive reflection models and the reality of the classroom. Being conscious of this overall structural organisation can be a tool for tutors of these groups to help them navigate from one activity to another or to diagnose what is not working in the group discussion.