보건의료인 교육에서 성찰과 성찰적 실천: systematic review (Adv in Health Sci Educ, 2009)

보건의료인 교육에서 성찰과 성찰적 실천: systematic review (Adv in Health Sci Educ, 2009)

Reflection and reflective practice in health professions education: a systematic review

Karen Mann Æ Jill Gordon Æ Anna MacLeod

Introduction

성찰적 실천reflective practice의 근거를 제시하는 것이 의료인에게 공식적인 요건이 되고 잇으며, 면허와 재인증 절차의 부분이 되고 있다.

Formal requirements for practitioners to provide evidence of reflective practice are becoming part of licensing and revalidation processes (Catto 2005; College of Family Physicians of Canada 2007; General Medical Council 2005).

첫째, 자신의 경험으로부터 효과적으로 배우는 것이 평생 진료practice에 필요한 역량을 개발하고 유지하는데 중요하다. 대부분의 성찰에 대한 모델은 학습요구를 발견하게끔 해주는 경험과 실천에 대한 비판적 성찰을 포함한다.

First, to learn effectively from one’s experience is critical in developing and main- taining competence across a practice lifetime. Most models of reflection include critical reflection on experience and practice that would enable identification of learning needs (Scho¨n 1983; Boud et al. 1985).

 

둘째, 전문직으로서의 정체성이 개발되어가면서 전문직 문화의 맥락에서 스스로의 개인적 신념, 태도, 가치에 대해서 이해할 필요가 많아진다. 성찰은 이들의 통합에 있어서 명시적explicit 접근법이다.

Secondly, as one’s professional identity is developed, there are aspects of learning that require understanding of one’s personal beliefs, attitudes and values, in the context of those of the professional culture; reflection offers an explicit approach to their integration (Epstein 1999).

 

셋째, 통합된 지식을 쌓는 것은 기존의 이해를 위한 능동적 접근이며, 기존 지식과의 연결 과정이다.

Thirdly, building integrated knowledge bases requires an active approach to learning that leads to understanding and linking new to existing knowledge.

 

마지막으로, 자기-인식 하는 능력이 있는 전문직이 이러한 능력을 가지고 있다고 할 수 있으며, 이는 곧 자기-모니터와 자기-조절을 할 수 있는 전문직을 말한다.

Finally, taken together, these capabilities may underlie the develop- ment of a professional who is self-aware, and therefore able to engage in self-monitoring and self-regulation (Bandura 1986).

 

Boud는 '성찰적 실천의 emergence'는 학생이 한 과목을 배우는 동안 프로페셔널하고 행동하고 사고하는 것이 학습에 중요한 부분이라는 필요성을 인정하는 변화의 한 부분이라고 주장하였으며, 학생이 practice를 하기에 앞서서 이론을 먼저 배워야 한다고 주장하지 않았다.

Boud (1999) has asserted that the emergence of reflective practice is part of a change that acknowledges the need for students to act and to think professionally as an integral part of learning throughout courses of study, rather than insisting that students must learn the theory before they can engage in practice.

(성찰에 관한) 교육과정 인터벤션 혹은 혁신을 지지하는 근거들은 대체로 이론에 머물고 있으며, 무엇이 효과가 있는지 불분명하다.

The evidence to support and inform these curricular interventions and innovations remains largely theoretical and it is unclear which approaches may have efficacy or impact (Andrews 2005).

 

 

성찰의 정의

Reflection defined

1933년 Dewey는 성찰을 다음과 같이 정의했다.

As early as 1933, Dewey defined reflection as

‘‘active, persistent and careful consid- eration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusion to which it tends’’ (p. 9).

 

이러한 점에서 성찰은 '비판적 사고'와 유사하다. Moon은 성찰을 다음과 같이 묘사했다.

In this sense, reflection shares similarities with our understanding of critical thinking. Moon (1999) describes reflection as

‘‘a form of mental processing with a purpose and/or anticipated outcome that is applied to relatively complex or unstructured ideas for which there is not an obvious solution’’ (p. 23).

Boud 등은 성찰을 이렇게 정의했다.

Boud et al. (1985) define reflection as

‘‘a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to a new understanding and appreciation’’ (p. 19).

 

이 세 가지 정의 모두 목적을 가지고 지식과 경험에 대하여 비판적으로 분석하는 것을 강조하며, 이를 통해 더 깊은 의미와 이해를 찾는 것이다. Boud의 정의는 보다 명시적으로 개인의 경험을 성찰의 대상으로 초점을 두고 있으며, 성찰에서 감정emotion의 역할을 보다 명시적으로 언급하고 있다.

All three definitions emphasize pur- poseful critical analysis of knowledge and experience, in order to achieve deeper meaning and understanding. Boud’s definition more explicitly focuses on one’s personal experience as the object of reflection, and is more explicit about the role of emotion in reflection.

Schon은 성찰적 실천가reflective practitioner라는 개념을 도입하였고, 이를 학습을 위하여 경험을 재방문revisit하는 도구로서, 그리고 불분면하고 복잡한 전문직의 문제의 프레이밍을 위한 도구로서 성찰을 사용하는 사람이라고 했다. '의미meaning'은 전문직 담화의 커뮤니티community of professional discourse에서 구성되는 것이며, 학습자들로 하여금 그들의 경험의 직관적 측면에 대해서 비판적 통제를 성취하고 유지할 수 있게 하는 것이다.

Scho¨n(1983) introduced the concept of the ‘‘reflective practitioner’’ as one who uses reflection as a tool for revisiting experience both to learn from it and for the framing of murky, complex problems of professional practice. Meaning is constructed within a community of professional discourse, encouraging learners to achieve and maintain critical control over the more intuitive aspects of their experience.

성찰과 성찰적 실천에 대한 모델

Models of reflection and reflective practice

성찰적 실천에 대한 대부분의 모델은 성찰을 니즈를 인식하거나 일상적 실천이 파괴disruption될 때 성찰이 활성화된다고 말한다. 이것은 복잡하거나 일상적이지 않은non-routine 상황에서 일어나기 마련있데, "어떻게 해야할지 앎‘‘knowing-in-action’’" 혹은 습관적 행동이 문제를 프레이밍하거나 해결하는데 부적절할 때 일어나게 된다. 이들의 공통된 전제는 경험으로 돌아와서 그것을 살펴보는 것, 의도적으로 (지금) 배운 것이 미래에 (비슷한) 상황의 가이드가 되도록 하는 것, 그리고 그것을 자신의 기존 지식에 포함시키는 것 이다.

Most models of reflective practice depict reflection as activated by the awareness of a need or disruption in usual practice. This tends to happen in complex or non-routine situations where the individual’s ‘‘knowing-in-action’’ (Scho¨n 1983), and/or habitual action are inadequate to frame or resolve the problem. Their common premise is that of returning to an experience to examine it, deliberately intending that what is learned may be a guide in future situations, and incorporating it into one’s existing knowledge.

성찰 모델에는 두 개의 주요한 차원이 있다.

There are two major dimensions to the models of reflection we reviewed, as follows:

반복적 차원iterative dimension. 경험에 의해 성찰의 프로세스가 시작되고trigger, 새로운 이해를 만들어내며, 미래의 경험에 따라 다르게 행동하려는 잠재력 혹은 의향으로 이어지는 것.

a: as an iterative dimension, within which the process of reflection is triggered by experience, which then produces a new understanding, and the potential or intention to act differently in response to future experience. Among the models that conceptualize reflection as an iterative process are Boud, Keogh and Walker (1985) and Scho¨n (1983).

수직적 차원vertical dimension. 성찰에 다양한 층위를 포함시키는 것. 표면적 층위는 기술적이고 덜 분석적이며, 깊은 층위는 분석적이고 비판적 통합이다. 깊은 층위는 도달하기 어렵고, 덜 흔하게 관찰된다.

b: a vertical dimension, which includes different levels of reflection on experience. Generally the surface levels are more descriptive and less analytical than the deeper levels of analysis and critical synthesis. The deeper levels appear more difficult to reach, and are less frequently demonstrated. The models which focus on the depth and quality of reflective thinking include Dewey (1933), Hatton and Smith (1995), Mezirow (1991) and Moon (1999).

 

 

방법

Method

선택 과정

Selection process

리뷰 과정

Review procedure

• Do practicing health professionals engage in reflective practice?
• What is the nature of students’ reflective thinking?
• Can reflective thinking be assessed?
• Can reflective thinking be developed?
• What contextual influences hinder or enable the development of reflection and reflective capability?
• What are the potential positive or negative effects of promoting reflection?

결과

Results

의사/간호사 등은 성찰적 실천을 하는가?

Do practicing health professionals engage in reflective practice?

성찰적 실천과 관련된 두 가지: 진료practice 기간이 늘어나면 성찰적 실천이 감소한다. 의료행위의 과학적 기반이 강요되지 않는 곳에서 성찰적 실천이 감소한다.

Mamede and Schmidt (2004, 2005): Two correlates of reflective practice emerged (Mamede and Schmidt 2005); reflective practice appeared to decrease with increased years in practice, and in practice settings where the scientific basis of clinical practice was not reinforced.

성찰적 실천의 구조는 다섯 가지 요인으로 되어 있다.

Mamede and Schmidt (2004) found that reflective practice in medicine in their study had a five-factor structure:

• 의도적 귀납: 친숙하지 못한 문제에 대해서 시간을 가지고 성찰해봄
  deliberate induction, which involves the physician taking time to reflect upon an unfamiliar problem;
• 의도적 연역: 여러 가능한 가설로부터 논리적으로 결과를 연역해보는 것
  deliberate deduction, which occurs when a physician logically deduces the consequences of a number of possible hypotheses;
• 검증: 발견된 문제에 대한 예측을 평가하는 것
  testing, which involves evaluating predictions against the problem being explored;
• 성찰에 대한 열린 태도: 친숙하지 못한 상황에 닥쳤을 때 건설적 활동에 참여하는 것
  openness to reflection, occurring when a physician is willing to engage in such constructive activity when faced with an unfamiliar situation; and,
• 메타-추론: 스스로의 사고과정에 대한 비판적 사고
  meta-reasoning, which means that a phy- sician is able to think critically about his or her own thinking processes.

 

이 다섯 가지 요인은 순차적으로 이뤄지는 것은 아니며, 각 요인이 unique dimension이다.

This five-factor model is not a step-by step process; rather, each factor is a unique dimension, overlapping and occurring during and following an event.

"habits of action"이라는 두 가지 distinct한 접근법을 제안했다.

Klemola and Norros (1997, 2001) suggested two distinct approaches to practice, or ‘‘habits of action’’:

• 세계는 예측불가능하다는 신념에 기반한 '해석 지향적 접근'
  the ‘‘interpretive orientation’’ guided by a belief in an unpredictable world, and
• 세계는 예측가능하다는 신념에 기반한 '반응 지향적 접근'
  the ‘‘reactive orientation,’’ guided by a belief in a predictable world.

 

해석지향적 접근이 성찰과 비판적 능력에 기여하며, 반응지향적, 객관주의적 접근은 이의 발달을 저해한다.

The authors suggested that the interpretive orientation contributed to the development of reflective and critical capabilities, but the reactive or objectivistic orien- tation hindered their development.

성찰의 세 phase

Two studies of reflection in clinical teaching in medicine were found (Pinsky and Irby 1997; Pinsky et al. 1998). They identified three phases of reflection:

• 예측적 성찰: 과거 경험을 가지고 교육활동을 계획하는 것
  anticipatory reflection, which used past experience for planning teaching activities;
• 행동 중 성찰: 교육하는 동안에 유연성을 유지하는 것
  reflection-in-action, which involved maintaining flexibility during teaching; and,
• 행동 후 성찰: 경험에 대해서 심사숙고하여 분석하는 것
  reflection-on-action, which involved thoughtful analysis of the experience.

간호사들 역시 의사와 마찬가지로 예측적 성찰 혹은 예비-성찰pre-reflection이 중요하다고 하였다. 행동 중- 행동 후- 성찰도 모두 언급하였다. 성찰에 있어서 지도guidance와 감독supervision이 핵심이었다.

Two studies are reported of reflection in practicing nurses (Gustafsson and Fagerberg 2004; Teekman 2000). Similar to the physician studies, nurses described an anticipatory or pre-reflection, occurring before an activity, as central to their practice. They also described reflection both ‘‘in’’ their practice and ‘‘on’’ it. They reported guidance and supervision as key to reflection.

감독supervision이 성찰에 핵심 요인이었다. 세 가지 위계적 수준을 발견함.

Teekman (2000) studied ten registered nurses, Supervision was a key factor. Teekman identified three hierarchical levels of reflection:

• thinking-for-action (what to do here and now);
• thinking-for-evaluation (integrating multiple view- points); and,
• thinking-for-critical-inquiry.

이 연구들을 보면...

• 성찰은 예측 단계를 포함하며, 이 단계에서는 과거의 경험을 가지고 계획을 세운다.
• 성찰은 적절한 supervision이 있을 때 더 잘 일어난다.
• 성찰은 기존의 지식knowledge-in-action이 적합하지 않는 새롭거나 도전적인 상황에서 일어난다.

These exploratory studies reveal some aspects, functions and uses of reflective practice.

• Reflection appears to include an anticipatory phase, where past experience informs plan- ning;
• it is encouraged by appropriate supervision;
• it appears to occur most often in novel or challenging situations, where the professional’s knowledge-in-action is not adequate to the situation.

 

의사와 간호사 모두 성찰을 통해서 의료행위에 필요한 정보를 습득하며, 그러나 한 개인에 있어서, 혹은 여러 개인 간 일원화된unitary 현상은 아니다.

The findings of these few studies suggest that physicians and nurses use reflection to inform practice, but that it is not a unitary phenomenon either within or across individuals.

 

학생들의 성찰적 사고의 특성은 무엇인가?

What is the nature of students’ reflective thinking?

네 단계를 찾음

Niemi (1997): Based on content analysis, they described four levels:

• 헌신적 성찰
  committed reflection(n = 14), meaning an analytical consideration of the experiences and observations made inthe health care centre;
• 정서적 탐구
  emotional exploration (n = 27), an exploration characterized by self-consciousness, emotional expressions and embarrassment;
• 객관적 보고
  objective reporting(n = 27), an exploration focused on objective events, clinical facts and performance; and,
• 보고 회피
  scant or avoidant reporting (n = 23) meaning reporting which is scant, empty, avoidant ordiffuse. 

포트폴리오와 관련하여 세 카테고리 도출

Pearson and Heywood (2004): Three categories emerged in relation to the portfolio:

• 성찰자
  reflectors, those who recorded data in the portfolio, reflected on that information and/or discussed it;
• 기록자
  recorders, those who used the portfolio to record data; and,
• 비-사용자
  non-users, those who did not record data in the portfolio.

Wong et al. (1995): 

 

• 비성찰자는 묘사적이고, 비-분석적이었음.
• 성찰자는 경험을 묘사하고 기존 경험과 연결지었으며, 새로운 학습 기회를 개발하였다.
• 비판적 성찰자는 가정을 검증validate하고 종종 관점을 전환하였음transformations of perspectives

 

• Non-reflectors were descriptive and non-analytic;
• reflectors described and related experi- ence, and developed new learning opportunities;
• critical reflectors validated assumptions and sometimes transformations of perspectives occurred.

학생들은 일정한 경험이 쌓인 뒤에야 성찰적으로 사고하는 능력과 자신감이 개발된다고 생각함.

Hallett (1997): Students believed that confidence and the ability able to think reflectively about their practice developed only after some practice experience.

16문항 설문을 통하여 Mezirow의 네 가지 구인을 평가하였음

Kember et al. (2000) used a 16-item questionnaire to measure reflective thinking instudents, assessing four constructs as described by Mezirow (1991):

• 습관적 행동 habitual action;
• 이해 understanding;
• 성찰 reflection; and,
• 비판적 성찰 critical reflection.

 

습관적 행동은 자동적으로, 거의 의식하지 않고도 일어나는 것. 나머지는 점차 성찰적 사고의 깊이가 깊어지는 것

Habitual action represents action that is automatic or with little conscious thought;

the remaining constructs represent increasing depth of reflective thinking.

의료진과 마찬가지로, 학생들도 성찰에 대한 서로 다른 지향, 그리고 다양한 성찰적 사고의 층위를 보여주었다. 깊은 층위는 도달하기 어렵다. 성숙한 전문직에 대해서 관찰한 결과가 학생에게도 적용되는 듯 보였으며, 그러나 학생은 의료진과 동일한 실제 상황authentic setting에서의 성찰적 실천의 기회가 없다.

As with practitioners, students demonstrated different orientations to reflection and different levels of reflective thinking; similarly, the deeper reflective levels appeared most difficult to achieve. The observations made about mature professionals seem to apply equally to students, despite the fact that students do not have the same opportunities for reflective practice in authentic settings.

성찰적 사고가 평가될 수 있는가?

Can reflective thinking be assessed?

Sobral (2001): Students (n = 196) completed the 14-item Reflection-in-Learning Scale(RLS) along with the CVI and the Approaches to Study Inventory (ASI) (Richardson1990). The RLS is a self-report questionnaire. Each item is appraised via a seven-pointresponse scale ranging from ‘never’ = 1 to ‘always’ = 7. 

Leung et al. (2003): Students from all years of study in a health science faculty (n = 402) completed the Revised Study Process Questionnaire (Biggs et al. 2001), and the Reflection Questionnaire (Kember et al. 2000). The authors found that the surface learning approach was correlated with habitual action (r = 0.65), while deep learning approaches were correlated with understanding (r = 0.33), reflection (r = 0.49), and critical reflection (r = 0.50).

Mamede and Schmidt (2004) developed an instrument to understand the nature of reflection in medical practice.

Wong et al. (1995) attempted to develop and test coding systems for written reflective journals, based on the models of reflective thinking of Boud et al. (1985) and Mezirow (1991). Boud et al. (1985) categorized six stages of increasing depth of reflection:

• attention to feelings,
• association,
• integration,
• relationship-seeking,
• validation,
• appropriation and outcome.

 

The journals were also categorized using Mezirow’s categories into non- reflectors, reflectors and critical reflectors.

Kember et al. (2000) developed a four scale 16-item questionnaire to measure reflective thinking, based principally on Mezirow,

성찰은 평가할 수 있으며, 서로 다른 층위의 성찰이 구분될 수 있다. 이론적으로 일관된 방향으로 다른 척도와도 상관관계를 보인다. 학생은 실제 상황에 대한 성찰의 기회가 없기에, 일부 질문들이 타당한 지표인지에 대한 의문이 남음.

From the studies reviewed, it appears that reflection can be assessed and different levels of reflection discerned. Further, the studies demonstrate that measures of reflection cor- relate with other measures in theoretically consistent ways. Students do not have the same opportunities as professionals do for reflective practice in authentic settings and therefore some questions remain regarding whether what is being measured (e.g. text) is a valid indicator of reflective activity, when one considers the influences of context and culture.

성찰적 사고가 개발될 수 있는가?

Can reflective thinking be developed?

일렉티브 기간동안의 성찰적 사고의 개발

Sobral (2000) studied the development of reflective thinking based on activities designed to foster reflection during an elective experience.

성찰적 사고의 향상. reflection-in-learning은 다음과 관련됨 (자기조절학습에 대해 스스로 인식하는 역량, 학습경험의 유의미한 정도)

Eighty-one percent of participating students had increased scores for reflection in learning compared with 45% in the comparison group; also, the level of reflection-in-learning was significantly associated with

• self-perceived competence for self- regulated learning (r = -.60; p = 0.001), and with the
• meaningfulness of the learning experience (r = 0.38; p = 0.001).

reflection-in-learning이 높을수록 GPA도 높음. 자기-보고식 진단역량 점수와도 상관관계

Further, those with higher reflection in learning skills had higher GPAs. Higher scores were associated with higher scores on self-reported diagnostic competence (r = 0.34; p = 0.001).

포트폴리오를 준비하는 것이 성찰적 사고의 포럼과 자극이 되며, 변화의 플랫폼이 된다.

Beecher et al. (1997): The authors concluded that the process of port- folio preparation provided a forum and stimulus for reflective thinking, as well as a platform for change.

일정한 인터벤션을 통해서 성찰적 사고는 개발될 수 있다. 성찰적 사고의 발달은 학습과 전문직 개발의 다른 측면과도 연결되는 것으로 보임. 주로 관찰적, 분석적 연구방법 사용. 그러나 대조군 있는 연구가 별로 없어서 전이가능성이 불확실. 또한 성찰은 자동적spontaneous으로 일어나지 않았으며, 교육 맥락에 따라 의도적deliberate 자극을 받음.

The findings of these few studies suggest that reflective thinking may develop in association with certain interventions. It also appears that the development of reflective thinking is related to other aspects of learning and professional development. The methods employed were usually observational and analytical, and appropriate to the questions asked. However, only one of these studies had a comparison group, so the transferability of the interventions and results across contexts is unclear. In addition, reflection was not spontaneous, but was deliberately stimulated by the educational context. Although it seems likely that events occurring naturally in an authentic professional context would stimulate a similar response, this has not been demonstrated.

성찰과 성찰적 능력의 개발을 장려하거나 방해하는 맥락적 영향은?

What contextual influences hinder or enable the development of reflection and reflective capability?

성찰을 위해서 더 많은 노력을 할수록 더 긍정적인 학습경험과 연결되며, 학습에 대한 성찰은 자기조절학습에 대한 준비, (학습)경험의 유의미함과 관련된다.

Sobral (2000): He suggests that a greater effort at reflection is associated with a more positive learning experience, and that reflection in learning is related to readiness for self- regulated learning, and to the meaningfulness of the experience.

임상환경의 시간 압박이 성찰의 장애요인이 된다. 복잡한 문제가 성찰적 사고를 촉진하며, 특히 진료의 과학적 토대를 지속적으로 염두에 두었을continuously revisited 때 더 그러하다. 또한 경험이 늘어날수록 한 사람이 가진 knowing in action이 대부분의 임상상황을 프레이밍하고 풀어나가기 충분해질 것으로 추측함.

Mamede and Schmidt (2005) found two correlates of reflective practice: reflection appeared to decrease with increasing years in practice, and was lower in practice settings where reflective thinking was not reinforced. The authors noted that time pressure in a busy clinical environment can act as a barrier to reflection. They suggested that complex problems stimulate reflective thinking, especially if the scientific basis of clinical practice is continuously revisited. They also speculated that, as experience increases, one’s ‘‘knowing in action’’ may be sufficient to frame and address most clinical situations.

지지적 트레이너, 명확한 목표, 충분한 시간이 있을 때 포트폴리오 활용이 강화됨

Pearson and Heywood (2004) found that portfolio use was enhanced with a supportive trainer, clear objectives, and sufficient time.

성찰적 학습을 촉진하는데 포트폴리오가 핵심 요인은 아닐 수 있음. '멘토링 관계mentoring relationship'가 포트폴리오 그 자체포다 성찰을 자극하고 가이드하는데 더 중요할 수 있음. 간호사에 대한 두 연구에서 supervision이 성찰의 핵심 요인으로 밝혀진 바 있음.

Portfolios may not be the key factor in promoting reflective learning; the mentoring relationship, which can be expressed in a number of different ways, may be more important than the portfolio itself in stimulating and guiding reflection. Two studies of practicing nurses (Teekman 2000; Gustafsson and Fagerberg 2004) identified supervision as a key factor promoting reflection in practice.

병동의 위계적 조직, 특히 의료진의 권위가 성찰을 비정상적abnormal 인 것으로 보여지게 함. 그 결과 성찰은 간호사 개인의 시간과 공간으로 국한됨. 이는 성찰적 실천에 있어서 IPE가 당면한 문제를 강조함.

Mantzoukas and Jasper (2004): It appeared that the organizational hierarchy of the ward, specifically the authority of the medical staff, portrayed reflection as an abnormal method of practice and knowledge development. As a result, reflection became confined to nurses’ personal time and space. The study underscored some of the challenges that face inter-professional education in relation to reflective practice.

 

간호의 복잡성과 비판적 이론화critical theorizing에 대한 학습자의 변화에 기여하는 요인

Francis et al. (1998): The study explored the change in learners’ appreciation of the complexity of nursing and consideration of critical theorizing. Several factors contributed to change:

• prior experience of journal writing,
• viewing reflection as including reflection-on-action as well as in-action,
• having prior models of reflection (e.g. everyday reflection),
• expectation of nursing as a complex practice involving both science and communication, and
• having comfort in trying things out in the group session.

 

journal writing의 경험이 없는 경우 성찰이 in action 에만 일어났고, 성찰에 대한 사전 모델이 없었음.

Those who reported no change had had no previous experience of journal writing, viewed reflection as occurring only in action, and had no prior models for reflection. They viewed personal and professional thinking as separate, lacked comfort in the group setting, and were focused on individual evaluation.

성찰과 성찰적 실천을 가능하게 해주는 가장 중요한 요인은..

Across all of the diverse settings and methods, it appears that the most influential elements in enabling the development of reflection and reflective practice are

• a supportive environment, both intellectually and emotionally;
• an authentic context;
• accommodation for individual differences in learning style;
• mentoring;
• group discussion;
• support; and,
• free expression of opinions.

 

Additional enabling factors include

• perceptions of relevance,
• positive prior experience,
• organizational climate, including respect between professionals, and
• time for reflection.

성찰 촉진의 긍정적/부정적 효과는?

What are the potential positive and negative effects of promoting reflection?

deeper learning 촉진, 학습경험에 대한 긍정적 태도

Sobral (2000) suggests that the ability to form associations and integrate information may result in deeper learning, facilitating students having a more positive learning experience.

교사-학습자의 관계 개선, 교육의 퀄리티 향상

Reflective practice may also improve relationships among teachers and learners and teaching quality.

적절한 타이밍과 감독supervision support가 있을 때 효과적

Hallett’s (1997) study suggests that the benefits of reflection may rely on appropriate timing of the intervention as well as supervisor support.

성찰에 필요한 시간과 관련한 우려, 구조적 접근법의 영향력에 대한 우려, 일시적 유행이라는 생각 등

Concerns were expressed about the time required and the limiting influence of a structured approach. Still others worried that reflection was a ‘fad.’ Similar to Strawson (2004), the authors questioned the extent to which, in reflecting, we can remember events as they actually were.

부정적 효과에는 학습자의 진정한 학습요구와 동떨어진 활동에 참여하게 요구하는 것에 대한 분노. "busy work"로 인식할 수 있음.

While no study in medicine directly addressed negative effects, some may be hypoth- esized from studies such as those of Pearson and Heywood (2004) and Dornan (2002). These might include resentment at being required to participate in activities that seem disconnected from the learner’s true learning needs or usual methods of learning and practice. Learners may perceive such activities as ‘‘busy work.’’

고찰

Discussion

현 연구 상황

Current state of the research

The research literature on the effectiveness of strategies to foster reflection and reflective practice is still early in development. We identified only 29 studies, the majority of which were observational in nature. Comparison groups were rarely included. At the time of ourreview, no randomized controlled studies were identified. 

초기 단계이므로, qualitative and explorative 접근법이 구인, 공통의 정의, 용어에 대한 일반적 이해를 높이는데 적절할 수 있다.

Because of the early stage of development in this area, qualitative and exploratory research approaches are appropriate to use to develop general understanding of the con- struct, common definitions and terminology.

연구마다 용어가 다양한 것은 한계점

One particular challenge of the review was the use of varied terminology across studies and fields. This hindered interpretation, comparison and synthesis of the data. Many studies did not identify the definition of reflection being used by the authors. Secondly, the terminology used to describe and classify reflective thinking drew on several fields, and so reflected different professional and disciplinary discourses.

결과 요약

Summary of our findings

성찰에 관한 여러 모델과의 관계

Relationship of the literature to the models

Knowing-in-action and surprise

복잡한 문제로부터 자극되는데, 진료경험기간이 늘수록 성찰 경향이 낮다는 것은, 복잡한 문제에 대한 'surprise'가 줄어들기 때문일 수 있다.

Scho¨n’s premise that reflection was stimulated in response to complex problems was supported by the studies of Mamede and Schmidt (2004, 2005). These studies also sup- ported the role of surprise in generating reflection, and it appears that surprise may occur in the form of a new or unrecognized, complex problem. The 2004 study showed a negative relationship between the tendency to reflect and years in practice. As reflection was reported as a strategy for dealing with complex problems, one explanation might be that the ‘‘surprise’’ of a complex problem occurs less often with increasing experience.

Reflection-in-action

'해석지향성'을 보이는 의사가 환자의 실시간 변화에 더 민감하게 반응

the physicians who demonstrated an ‘‘interpretive orientation’’ responded to minute-by-minute changes in their patients’ condition

교사들도 reflection-in-action을 함.

The Pinsky et al. (1997, 1998) studies also supported ‘‘reflection-in-action’’ among teachers in the course of their teaching.

그러나 학생에 대한 연구에서는 reflection-in-action을 찾기 쉽지 않다.

Notably, reflection-in-action was not explored or evident in studies of students, possibly because these studies were not reflecting on actual experience as it occurred.

Reflection-on-action

교사들에 의한 reflection-on-action이 드러남

Reflection-on-action was also described, particularly by teachers.

성찰의 여러 층위가 있음

Several studies demonstrated differences in the level of reflection achieved, supporting the models that suggest that levels of reflection, from the more superficial to critical reflective analyses, can be reliably discerned.

Boud는 성찰에 감정적emotinoal 측면을 포함시킴

Boud et al. (1985) explicitly include in their model the idea that reflection should include the emotional aspects of experience.

연구에 대한 함의

Implications for research

Does reflection enhance learning?

Does reflection improve self-understanding?

Is reflection most effective when shared?

What is the role of ‘‘reflection-in-action?’’

Does reflection enhance self-assessment?

Does reflection alter clinical behaviour?

Does reflection improve patient care?

Can reflective practice be taught and learned?

Are there negative effects of reflection?

교육에 대한 함의

Implications for educational practice

성찰은 학습전략으로 바라보는 관점에서 가장 유용하다. 이렇게 사용했을 때 학습자들이 새롭게 배운 것을 기존의 지식과 스킬에 연결/통합시키게 도울 수 이 있다. 성찰은 학습자들이 정서적affective측면을 학습에 명시적으로 통합시킬 수 있게 도와줌. 임상환경에서 이는 특히 도움이 될 것임.

Reflection may be most useful when viewed as a learning strategy. Used in this way, it may assist learners to connect and integrate new learning to existing knowledge and skills. Reflection may also assist learners to explicitly integrate the affective aspects of their learning. This may be particularly beneficial in the clinical learning environment,

학습에 있어서 성찰의 역할은 학습자에게 명확하지 않을 수 있다. 또한 경험이 많은 의료진에게도 tacit process이다. 따라서 교사가 해야할 중요한 일은 자신의 교육에 성찰을 넣는model reflection것이다. 즉, 성찰활동을 명시적으로 만드는 것이다. 더 나아가서 학습자들이 여기에 기여하게끔 하여서 성찰이 개인적인 것일 뿐 아니라 협동적인 것임을 보여줄 수 있다. 협동적 성찰의 경험은 interprofessional team 참여를 대비하는 의미로 중요하다.

Reflection, and its role in learning, may not be obvious to learners; it may also be a tacit process in experienced practitioners. An important task for teachers may be to model reflection on their own practice; i.e., to make their own reflective activities explicit. Fur- ther, including learners and inviting their contribution may demonstrate that reflection can be a collaborative, as well as an individual, experience. Experience with collaborative reflection may be important as a preparation for participation in interprofessional teams,

특히 초기 단계에는 성찰 활동을 가이드해줄 구조가 필요하다. 성찰의 내용 뿐 아니라 프로세스에 대한 피드백이 필요하고 RIA와 ROA에 대한 피드백이 필요하다.

As with other skills, learners may need a structure to guide this activity, especially early in their learning. They may require feedback on both the content and the process of their reflection, both ‘‘reflection-in-action’’ and ‘‘reflection-on-action.’’

여러 문헌에서 지속적으로 guidance와 supervision이 성찰의 핵심이라고 제안하고 있다.

The literature suggested repeatedly that guidance and supervision are key to reflection and are factors that learners perceived to be beneficial to their learning. Therefore, as educators, we will want to ensure that when reflection is used as a learning strategy, the process is guided appropriately.

교수-학습 환경도 중요하다. 이 학습전략에 가치를 두지 않는 문화나 환경에서는 성찰이 활용되지 않을 것이다.

The environment for teaching and learning about reflection will be important. If the culture and environment do not value and legitimize this learning strategy, reflection may not be used, potential benefit may be lost, and negative reflective experiences may result.

성찰에 관련된 연구의 핵심 가정은 이것이 역량을 향상시킬 것이라는 기대이나, 이를 지지하는 근거는 아직 없다.

A key assumption underlying the literature on reflection is that it will enhance com- petence. As noted, to date there is no evidence to support or refute that assumption. Such a finding may suggest to some that attempts to teach reflection are fruitless, and should be abandoned.

그러나 기존 문헌을 보면 비록 방식은 다를지라도 전문직은 성찰을 한다.

The existing literature reveals that professionals reflect, albeit in different ways, and to different degrees. It also suggests that there may be improvements to learning and to learning from experience associated with reflection.

 

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Adv Health Sci Educ Theory Pract. 2009 Oct;14(4):595-621. Epub 2007 Nov 23.

Reflection and reflective practice in health professions education: a systematic review.

Mann K1, Gordon J, MacLeod A.

Author information

• 1Division of Medical Education, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada B3H4H7. karen.mann@dal.ca

Abstract

The importance of reflection and reflective practice are frequently noted in the literature; indeed, reflective capacity is regarded by many as an essential characteristic for professional competence. Educators assert that the emergence of reflective practice is part of a change that acknowledges the need for students to act and to think professionally as an integral part of learning throughout their courses of study, integrating theory and practice from the outset. Activities to promote reflection are now being incorporated into undergraduate, postgraduate and continuing medical education, and across a variety of health professions. The evidence to support and inform these curricular interventions and innovations remains largely theoretical. Further, the literature is dispersed across several fields, and it is unclear which approaches may have efficacy or impact. We, therefore, designed a literature review to evaluate the existing evidence about reflection and reflective practice and their utility in healthprofessional education. Our aim was to understand the key variables influencing this educational process, identify gaps in the evidence, and to explore any implications for educational practice and research.

PMID:

 

18034364

 

[PubMed - indexed for MEDLINE]