Reflective practice enhances self-awareness and facilitates deeper understanding of complex problems without obvious solutions (1). There are several excellent reviews of reflection and its educational benefits, including improvement in competencies, clinical performance, and management of systems and patients (2–4). Reflective journaling, critical incident-analysis, and portfolio development are examples of reflective practice used for medical education (5–9).
Disciplines such as nursing and physical therapy recommend reflective practice throughout the life of the professional for continuous professional development, beyond the training phase (10, 11). However, to our knowledge, there is little written about the use of reflection for physician faculty development, outside of applications for professionalism.
Faculty development leaders are now advocating for faculty development activities situated specifically within the participants’ work environment and/or community of practice (12). In keeping with this recommendation to embed activities within the work environment, we suggest a novel application of reflection: structured, peer-facilitated reflection (PFR) as a faculty development strategy to help individuals solve “real-life” problems while also fostering a community of practice. Our suggested reflective practice occurs in the workplace context, where faculty participants are practicing experts with a shared knowledge domain. We describe a specific strategy to be used by groups of faculty colleagues, guidance on executing such a program at another institution, and a case example of our activities as an illustration. Our recommendations are based on the existing literature on reflection and our own experiences using this technique.
We developed our PFR method within a pre-existing group, the Clinician Teacher Junior Faculty Peer Mentoring Group at the University of Washington Medical Center, Department of Psychiatry and Behavioral Sciences, described elsewhere (13). In the course of discussing workplace challenges during peer mentoring meetings, members discovered that they shared similar clinical and administrative problems. This inspired interest in further scholarly examination of specific, shared problems. Sample topics included disruptive provider behavior, managing difficult countertransference with VIP patients, and giving feedback to difficult residents. At the same time, the group recognized that these problems were complex, included personal reactions, and were unlikely to be resolved by a simple review of existing literature or best practices. Thus, the group adopted PFR as a method for further exploration of the problems. Smaller, interest-driven subgroups were formed ad hoc to utilize PFR for specific problems. The number of meetings varied, depending on the topic and need for further exploration, and two-to-five meetings was a typical number. The meetings were held weekly for 1–2 hours, and group members engaged in individual work between meetings. The University of Washington Human Subjects Division determined that formal IRB was not required for this program.
Specific factors promote reflection: adequate time within an authentic and supportive environment, and the availability of either mentoring or group discussion (4). A safe atmosphere is created if discussions are kept confidential and explicitly not used for performance evaluation. A nonjudgmental, noncompetitive climate enables sharing of private reflections (4). We recommend discussion of confidentiality, logistics, and work expectations for group members before the start of the PFR process, during the first meeting. Furthermore, on the basis of our experience and a previous study of compulsory versus compelled participation in peer-mentoring activities, we recommend that participation be completely voluntary (14).
Complex problems without obvious solutions are suitable topics for peer-facilitated reflection. Problems that evoke strong reactions with potentially powerful influences on behaviors may work well for PFR.
By virtue of their shared work environment and career aims, several individual faculty members may face the same problem, albeit from slightly different angles.
We recommend structuring the activity by planning individual reflective writing assignments alternating with peer-facilitated discussions (2, 4). After identifying the topic, group members collaborate to develop a prompt for an independent reflective writing assignment, because prompts have been used to promote deeper level reflection in education (2). Using specific prompt questions may help participants to get started. Below are sample prompt questions, derived from the literature and our experience (2, 3):
Describe the situation.
Describe your thoughts, actions, and assumptions.
What emotions were you experiencing?
What past experiences have you had that relate to the current situation?
Are there things that you wish you had handled differently?
Writing should elicit candid reflection. The format may be individualized to maximize reflection and minimize discomfort with the writing process—stream-of-consciousness, vignettes, bullet-points, etc (2).
Peer-Facilitated Group Reflection
During the second meeting, individuals read all or part of their writing to the group. The objective is to harness the group to challenge pre-existing viewpoints through exposure to others’ perceptions of the problem. An individual working in isolation may try the same ineffective strategies repeatedly, unable to generate fresh ideas or understand deeper levels of the problem. Exploration of common problems in the context of divergent viewpoints provides the necessary element of challenge to habitual practices and assumptions. To be effective, the group needs to be supportive enough that individuals feel comfortable both revealing themselves as well as challenging each another. In describing reflective-practice groups for nursing students, Platzner and colleagues identified the same group-process elements that enabled critical thinking and change: peer support, encouragement to challenge one’s ideas, and exposure to contrasting viewpoints (11).
Sometimes, the first round of group reflection may yield a resolution. Often, the discussion reveals knowledge gaps or topics requiring further exploration. At the conclusion of this meeting, the group develops an action plan, which may include additional individual writing assignments or further study to better understand concepts that arise. Subsequent meetings are conducted in a similar fashion. Any writing assignments or results from further study are again reviewed in a peer-facilitated discussion session.
The reflective process may be continued in an iterative fashion until the problem is resolved or a plan to address the problem is developed, as suggested by Schon (15).
If the group is unable to come to a resolution, we suggest reevaluating problem-selection and process. It is possible that this method is not ideal for the particular problem identified or the particular group itself. The barriers may be environmental; participants may not “buy in” to the process or may not perceive the group as confidential and nonjudgmental. The group format may lack enough structure to enable reflection or lack sufficient freedom to generate ideas.
Within our varied roles at UW—professionalism educator, consultation–liaison psychiatrist, and hospital administrator—several of us (all psychiatrists) were struggling to effectively address disruptive physician behavior. Thus, disruptive physician behavior became a topic for PFR (16).
Meeting One: Problem-Identification and Individual Writing Assignments
Each peer agreed to write about his or her personal experience with disruptive behavior, focusing on emotional reactions and previous experiences that relate to the described situation. The educator wrote about teaching this topic to other physicians; the administrator wrote about provider-related patient complaints; and the consultation–liaison psychiatrist wrote about consultations in which provider behavior interfered with clinical care.
Meeting Two: PFR Discussion
During our discussion of disruptive behavior, similar interpersonal themes emerged in the reflections, even though each person’s role with disruptive providers was different. Defensiveness was a common theme and often proved a barrier to learning, resolution of a complaint, or functioning as a team. Although meaningful, this understanding was insufficient to develop strategies for improvement. Further review to better understand the etiology of the defensiveness and an additional individual reflective writing assignment about defusing defensiveness were assigned. Individuals were either assigned or volunteered to explore the identified knowledge-deficit via writing assignments and/or literature review. These were reviewed in a subsequent meeting.
Ultimately, the group recognized two problematic defensive reactions that prevented constructive discussion of disruptive behavior: 1) extreme anxiety and guilt about professional lapses; and 2) feeling persecuted and threatened by authority figures. On this basis, we were able to customize our approach to diffusing defensiveness. To address the educator’s need for help with a specific teaching task, the group reviewed adult-learning theory and designed educational strategies to engage audiences and promote behavioral change. We ultimately published, based on the results of the PFR process, an educational intervention for teaching physicians about disruptive behavior (16).
Other authors have noted that facilitation by supervisors or peers enhances individual reflection, and effective facilitation is a “skillful mix of support and challenge” (3). Peer-stimulated questioning of habitual practices and assumptions provides opportunity to look beyond individual experiences. Occurring in the workplace context, faculty participants are practicing experts with a shared knowledge-domain. By embedding this activity within a community of practice, peer relationships and shared knowledge support the further development of individual participants. Furthermore, the topics for reflection have immediate relevance for the participants as adult learners because they are drawn from their shared “real-life” challenges. Lastly, fruitful engagement in the peer-facilitated process may help to develop and reinforce both the community’s existence and growth. Faculty use of peer-facilitated reflection may have wider impact by cultivating a collaborative, collegial network. In a study of reflective learning among nursing students, group discussion of reflections caused, “a dramatic change . . . represented by students’ active participation in sharing thoughtful and meaningful feedback with each other,” yielding an increase in collaborative problem-solving efforts among group participants (7). Similarly, engagement in group reflection may increase collaboration among faculty members. Collaboration and communication between faculty members have been noted to enhance faculty vitality and productivity (17, 18). Furthermore, “unrelatedness,” moral distress, and lack of engagement have been associated with the desire to leave academic medicine because of dissatisfaction (19).
We started this technique with the goals of resolving problems and writing papers on specific topics. We did not intend to study this technique directly, and we have limited evaluation to assessing results. PFR was presented in workshop format at a national meeting (AAP, 2011) with positive reviews and uniformly favorable comments from participants. Although problem-resolution and the resulting publications were our original goals, ultimately, we also developed an enriching learning community, with increased opportunities for collaboration and productivity. Lave and Wenger describe a concept of “situated learning,” where practitioners learn through informal interactions, where knowledge-gaps are identified and solutions are developed by the social group (20).
Further study of structured reflection as a faculty development tactic is necessary (21). This may include evaluating both direct effects (i.e., resolution of a problem) and indirect effects, such as faculty vitality, morale, retention, and community functioning.
This is a portable technique that could be utilized in other institutions. Pros: low cost, morale-building, lifelong learning skills. Cons: safe environment required; the need to be voluntary; and the fact that group dynamics or competitiveness may impede its productivity.
PFR is a tool that can be used to grapple with complex problems. Faculty development can be enhanced by developing scholarly projects and also by developing a rich learning community with colleagues.