의과대학 3학년에서 성찰능력 교육을 위한 두 가지 방법 비교(Med Educ, 2012)

의과대학 3학년에서 성찰능력 교육을 위한 두 가지 방법 비교(Med Educ, 2012)

A comparison of two methods of teaching reflective ability in Year 3 medical students

Louise Aronson,1 Brian Niehaus,2Laura Hill-Sakurai,3 Cindy Lai4 & Patricia S. O’Sullivan5

INTRODUCTION

1990 년대 후반에, 인정 기관들은 medical practice를 향상시키기 위해 의학 교육에서의 성찰의 중요성을 인식 해왔다 .1-4 이에 대한 대응으로 교육자들은 과목, 임상실습, 전공의교육, 재인증, CME에 성찰 활동을 추가해왔다.5-8

Since the late 1990s, accrediting bodies have recognised the importance of reflection in medical education to improve medical practice .1–4 In response, educators have added reflective activities into courses, clerkships, residencies, recertification and continuing education.5–8 

성찰에 관한 중요한 문헌에도 불구하고 다양한 용어와 반영의 정의가 남아있다. 유사한 프로세스가 성찰적 학습, 12 성찰 실천, 13 비판적 성찰, 14 mindfulness, critical incident review 등으로 다양하게 묘사됩니다. 정의가 어떻든 이론가들은 성찰이 주로 인지적 또는 메타인지적 과정이며, 자기와 상황 모두에 대한 examination을 요구하고, 그 목표는 학습과 개인적, 전문직업적 효과성 향상이라는 것이라고 동의한다 .12-14,17,18

Despite a significant literature on reflection there remain a diversity of terminologies and definitions of reflection. Similar processes are variably described as reflective learning,12 reflective practice,13 critical reflection,14 mindfulness15 and critical incident review,16 among others. Theorists agree, however, that reflection is principally a cognitive or metacognitive process, that it requires engaged examination of both self and situation, and that its goals are learning and improved future personal and professional effectiveness.12–14,17,18

성찰을 위한 용어를 생각해 보면, 아마도 성찰을 가르치는 데 널리 받아 들여지는 접근법이 존재하지 않는다는 것은 놀라운 일이 아닙니다. 의학 교육에서의 교육 및 학습 반영에 관한 대부분의 연구는 세 가지 유형 중 하나에 속합니다.

• (i) 교과 과정 및 학습자의 경험에서 주제를 확인하기위한 학습자 성찰의 질적 분석 19-21

• (ii) 학습자의 성찰기술을 측정하는 척도 개발 및 테스트, 22-24 및

• (iii) 학습자의 성찰이 학습 및 수행에 미치는 영향 평가 .4,25,26

지금껏 여러 가지 유형의 성찰 exercise가 묘사되었고, 다양한 교수법을 제안하지만, 교수법 그 자체를 평가하지는 않습니다.

Given the assorted terminologies for reflection, perhaps it is not surprising that there exists no widely accepted approach to teaching reflection. The majority of studies on teaching and learning reflection in medical education fall into one of three types: 

(i) qualitative analyses of learner reflections to identify themes in the curriculum and the learners’ experience;19–21 

(ii) development and testing of scales to measure learners’ reflective skills,22–24 and 

(iii) assessment of the impact of learner reflection on learning and performance.4,25,26 

Such studies describe many different types of reflective exercises, which suggest various pedagogical approaches, but they do not evaluate the teaching method per se.

많은 연구가 성찰 연습활동exercise의 개발과 평가에 대해 설명하지만, 성찰을 어떻게 가르쳐야하는지에 대한 더 큰 문제를 다룬 것은 비교적 적다.

Numerous articles describe the development and evaluation of reflection exercises, but relatively few address the larger issue of how reflection should be taught.

많은 자료들이 의과대학생들의 낮은 성찰 능력을 보여줌에도, 최선의 교수법에 대한 자료가 부족한 상황에서 성찰 기술을 가르치는 구조화 된 접근법의 개선을 다루어야한다.

In the face of mounting data showing low levels of reflective ability in medical trainees,23,31,32 but improvements with structured approaches to teaching reflective skill,33,34 the paucity of data on best teaching practices needs to be addressed.

방법

METHODS

연구 설계

Study design

This study follows the framework of a randomised controlled trial (Fig. 1). After receiving definitions of reflection and critical reflection, third year medical students were sorted into small groups for delivery of their standard curriculum and exposed to one, both or neither of two methods of teaching reflection, guidelines and feedback.

참가자와 연구세팅

Participants and setting

The study population consisted of the entire third year class at UCSF during the 2009–2010 academic year, a total of 163 students. At our institution, third year students participate in three mandatory ‘intersessions’, which are week-long units of classroom time that occur after the first, third and sixth (final) clerkships in months 2, 6 and 12, respectively, of the third year. During each intersession, which includes coursework on health policy, medical ethics, basic sciences, clinical decision making and professional development, students are required to write a critical reflection on professionalism in response to a prompt related to that week’s curricular focus (transition to clerkships, good and bad professionalism, medical mistakes). In prior years, students received only a prompt for the reflection exercise. The critical reflections were de-identified for the purposes of this study, and all learners received feedback on at least the content of their reflections.

Procedures

All students were given definitions of reflection and critical reflection (

• 성찰: 무언가를 돌아보고, 고려하는 것
  reflection – looking back at something, considering it; 

• 비판적 성찰: 경험을 분석하고, 재고하고, 질문하는 프로세스로서, 학습을 위해 성찰되는 것에 대한 평가를 내리는 것
  critical reflection – the process of analysing, reconsidering and questioning experiences and of making an assessment of what is being reflected upon for the purposes of learning

and a specific prompt for each critical reflection assignment. 

Students who were assigned to also receive guidelines were given structured reflective learning guidelines called LEaP (Learning from your Experiences as aProfessional).33,35 These three-page, literature-derived guidelines 

• first provide guidance on strategies for more effective critical reflection, 

• next take learners through a four-step process of structured questions modelled on the clinical SOAP (Subjective, Objective, Assessment, Plan) note, and 

• finally provide answers to a set of frequently asked questions about the purpose and methods of critical reflection.

Two faculty members previously trained as raters,36 with an inter-rater reliability (intraclass correlation coefficient [ICC]) of 0.91, between them scored all reflections using a previously validated rubric31 for scoring reflective ability. According to this rubric,37 scores were given in increments of 0.5 on a scale of 0–6, where 

• 0 = ‘failure to address assignment’ and 

• 6 = ‘analyses experience and feedback, identifies lessons learned, crafts a plan for the future, and cites a means of determining the plan’s success’.

The blinded reflections were read and each student was given feedback on the content of each reflection by one of four study faculty (the two raters and two others)using an agreed-upon protocol that 

• acknowledged the learner’s experience and feelings, 

• listed the learner’s major concerns or themes, and 

• provided comments or questions to challenge assumptions and beliefs and provoke further learning. 

Half of the students in each arm also received feedback on their reflective skills from two study faculty. The consensus protocol for the reflective skill feedback began with the phrase: 성찰은 직관적인 것이 아니며, 훈련과 연습이 필요하다‘Reflection is not intuitive; it requires training and practice.’ Next, faculty 

• noted which of the components of critical reflection had been performed well, 

• suggested how the reflection might have been improved, and 

• tried to offer a specific example of how the next component of the LEaP guidelines might have been applied.

자료분석

Data analysis

We calculated descriptive statistics of means and standard deviations for the reflection scores. We conducted a repeated-measures analysis of variance with two between-groups factors (LEaP versus nonLEaP, and Feedback group–Content versus Feedback group–Content + Process) and one within-subjects factor (Time). The dependent variable measured on each of the two occasions was a reflective ability score obtained from two written reflections.

결과

RESULTS

두 경우 모두 성찰능력은 변화가 없었음. 3-way와 2-way interaction모두 통계적 유의성 없었음. 

• 가이드라인을 사용하는 것이 퍼포먼스에 영향을 줄 것이라는 가설은 유의함: 성찰의 정의만 제공할 때보다 가이드라인을 사용한 경우 성찰점수가 더 높음.

• 피드백을 받으면 내용과 성찰능력에 영향을 줄 것이다는 가설은 유의함: 피드백 내용과 성찰능력 모두에 대해서 피드백 받은 경우 피드백 내용에 대해서만 받은 경우보다 더 성찰점수 높음

 Regardless of study arm, reflective ability did not change across the two occasions. Similarly, the three-way interaction (guideline · feed-back · occasion) and the two-way interactions (guide-line · occasion, feedback · occasion, guideline · feedback) were non-significant (Table 2). 

• Our hypothesis that the use of guidelines would affect performance was significant; reflection scores were better for learners who used the guidelines than for learners who received only the definitions of reflection. 

• Our hypothesis that the receipt of feedback would have an effect on both content and reflective ability was supported; students who received feedback on content and reflective ability achieved higher scores than those who received feedback only on content (Table 2).

DISCUSSION

우리는 (아무런 교육 없이 작성된 성찰문보다) 가이드라인과 피드백을 제공할 경우 의대생의 written reflection에 대한 성찰 점수가 향성될 것이며, 가이드라인과 피드백이 함께 제공된 것이 둘 중 하나만 제공된 것보다 도움이 될 것이라고 가설을 세웠다. 어느 쪽이든. 우리는 (내용에 관한 피드백에 더하여) 비판적 성찰 가이드라인과 성찰 프로세스에 대한 피드백이 제공된 경우 모두 퍼포먼스를 성능을 향상 시켰지만, 가이드라인과과 피드백 간 상호 작용은 없었음을 발견했습니다.

We hypothesised that two teaching methods involving the provision of, respectively, guidelines and feedback, would improve reflection scores on medical students’ written reflections compared with those on reflections written without any teaching of reflection, and that guidelines and feedback together would be more helpful than either alone. We found that critical reflection guidelines and feedback on the reflective process in addition to feedback on content each improved performance, but there was no interaction between guidelines and feedback.

우리의 결과는 임상실습에서처럼, 가이드라인이 성찰 능력을 향상 시킨다는 것을 암시합니다. 효과 크기는 적당했습니다.

Our results suggest that in reflection, as in clinical practice, guidelines improve performance. The effect size was moderate.

구조화 된 개입이 없는 상태에서 학습자의 성찰 능력을 평가한 문헌에 따르면, 가이드라인이 없는 성찰 활동은 학습자의 성찰 능력을 개발하는 데 거의 도움이되지 않는다고 주장한다.

Moreover, the literature assessing learner reflective ability without such structured interventions argues that reflective activities which do not include guidance do little to develop reflective capacity in learners.

Scho¨n18과 Mezirow14는 성찰 학습에서 멘토십과 피드백의 중요성에 대한 이론적 주장을한다. 이 논문은 그들이 주장하는 긍정적인 결과를 입증하려고 시도합니다. 전반적으로, 특히 성찰에서 피드백의 이점을 보여주는 문헌을 바탕으로, 우리는 피드백이 학습자의 성찰 기술을 향상시키는 데 있어서 가이드라인만큼 효과적일 것으로 예상했다. 가이드 라인과 피드백 모두의 효과가 통계적으로 유의 했음에도 불구하고, 효과 크기는 상당히 달랐습니다. 피드백의 효과 크기는 매우 작았다. 또한, Scho¨n18과 Mezirow가 권고한 [학습자의 가정에 도전하는] 내용 피드백의 영향은 (가이드라인의 사용과는 달리) 그 효과가 유의하지 않은 것으로 나타났습니다.

Scho¨n18 and Mezirow14 make theoretical arguments for the importance of mentorship and feedback in reflective learning. Although their arguments are sound, this paper attempts to demonstrate the positive outcomes for which they argue. Based on the literature showing the benefits of feedback in learning generally and in reflection specifically,3,40,41 we expected that feedback would be at least as effective as guidelines in improving learners’ reflective skill. Although the effects of both guidelines and feedback were statistically significant, their effect sizes were quite different. Feedback had a very small effect size. Further, we found that the impact of content feedback, which challenged learners’ assumptions as recommended by Scho¨n18 and Mezirow,14 did not reach significance, whereas the use of guidelines did.

이상적으로 모든 trainee는 연습에 들어가기 전까지 거의 완벽한 성찰 점수를 얻을 수 있습니다. LEaP 그룹의 학생들이 더 깊고 효과적인 수준의 성찰을 보여주었지만, 평균 점수는 이상적인 수준에 미치지 못했다(3.81/6). 따라서 피드백과 가이드라인을 사용하여 이러한 실습을 통해 기술을 향상시킬 수는 있지만, 어떻게 그들의 professional life에 의미있는 학습기술을 개발하고 유지할지에 대해서는 더 많은 작업이 필요합니다.

Ideally, all trainees would achieve near perfect reflection scores by the time they enter practice. Although students in the LEaP groups more often achieved deeper and more effective levels of reflection, their average scores still fell short of those indicating optimal reflection (3.81 out of 6). Thus, although we can improve skill with these exercises using feedback and guidelines, it would appear that more work is required to determine how to develop and sustain in our learners skills that could be meaningful to their professional lives.

우리의 경험에 비추어 볼 때, 우리는 교육자들에게 다음을 권유한다.

• (i) 성찰은 의과 대학의 시작부터 배워야한다. 그것은 복잡한 기술이며, 시간과 연습이 필요하다.

• (ii) 피드백은 성찰 내용뿐만 아니라 성찰 기술에 대해서도 제공되어야 하며, 성찰하는 문화를 수립하고, 학습자에게 성찰의 중요성을 알리고, 그것을 배울 수 있도록 피드백을 제공해야한다.

• (iii) 이미 교육과정이 꽉 차 있음을 고려하면, 역량 마일스톤의 평가와 같은 다른 커리큘럼 목표를 달성하는 동안 성찰 기술을 학습하는 것이 가장 좋을 수도 있지만, 그것이 어떤 맥락에서든 교육하였든, 성찰 기술을 build하는데 명확한 주의를 기울여야 한다.

• (iv) 성찰을 교육하는 과정에서 challenge가 발생하므로, (성찰이 자기 모니터링과 평생 학습의 기초가되는 중요한 기술이라면) 그것을 어떻게 효과적이고 비용 효과적인 방법으로 성찰을 교육할 수 것인가를 알아내는 것은 필수적이다.

Based on our experience, we feel comfortable recommending the following to educators: 

(i) reflection should be taught fromthe start of medical school as it is a complex skill that takes time and practice to master; 

(ii) feedback should be provided not only on content and to improve reflective skills, but to establish a culture of reflection, signal its importance to learners, and enable recipients to learn from it; 

(iii) given the already full curriculum, it might be best to build reflective skill while accomplishing another curricular goal, such as the assessment of competency milestones, but explicit attention should be given to building reflective skill in whatever context it is taught, and 

(iv) as teaching reflection poses challenges, figuring out how to do it in an effective, costeffective way is essential if indeed it is one important skill underlying self-monitoring and lifelong learning.

33 Aronson L, Niehaus B, Lindow J, Robertson P, O’Sullivan P. Development and pilot testing of a reflective learning guide for medical education. Med Teach 2011;33 (10):e515–21.

35 Aronson L, Niehaus B, Kruidering-Hall M, O’Sullivan P. The UCSF LEaP: a guide for reflective learning in medical education. MedEdPORTAL. 2012. http:// www.mededportal.org/publication/9073. [Accessed 30 May 2012.]

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Med Educ. 2012 Aug;46(8):807-14. doi: 10.1111/j.1365-2923.2012.04299.x.

A comparison of two methods of teaching reflective ability in Year 3 medical students.

Aronson L1, Niehaus B, Hill-Sakurai L, Lai C, O'Sullivan PS.

Author information

1

Division of Geriatrics, School of Medicine, University of California San Francisco (UCSF), San Francisco, California 94118, USA. louise.aronson@ucsf.edu

Abstract

CONTEXT:

Little is known about best practices for teaching and learning reflection. We hypothesised that reflective ability scores on written reflections would be higher in students using critical reflection guidelines, or receiving feedback on reflective skill in addition to reflection content, or both, compared with those in students who received only a definition of reflection or feedback on reflection content alone.

METHODS:

Using a 2 (guidelines) × 2 (feedback) × 2 (time) design, we randomly assigned half of our sample of 149 Year 3 medical studentsto receive critical reflection guidelines and the other half to receive only a definition of critical reflection. We then randomly divided both groups in half again so that one half of each group received feedback on both the content and reflective ability in their reflections, and the other received content feedback alone. The learners' performance was measured on the first and third written reflections of the academic year using a previously validated scoring rubric. We calculated descriptive statistics for the reflection scores and conducted a repeated-measures analysis of variance with two between-groups factors, guidelines and feedback, and one within-group factor, occasion, using the measure of reflective ability as the dependent variable.

RESULTS:

We failed to find a significant interaction between guidelines and feedback (F = 0.51, d.f. = 1, 145, p = 0.48). However, the provision of critical reflection guidelines improved reflective ability compared with the provision of a definition of critical reflection only (F = 147.1, d.f. = 1, 145, p < 0.001). Feedback also improved reflective ability, but only when it covered reflective skill in addition to content (F = 6.5, d.f. = 1, 145, p = 0.012).

CONCLUSIONS:

We found that the provision of critical reflection guidelines improved performance and that feedback on both content and reflective ability also improved performance. Our study demonstrates that teaching learners the characteristics of deeper, more effective reflection and helping them to acquire the skills they need to reflect well improves their reflective ability as measured by performance on reflective exercises.

© Blackwell Publishing Ltd 2012.

PMID:

 

22803758

 

DOI:

 

10.1111/j.1365-2923.2012.04299.x