Reflective learning: Definitions and teaching methods

Learning as understanding experience and informing subsequent judgment

Reflective learning involves looking back on experiences to examine what was learned and which assumptions and emotions influenced judgment. In medical education, it serves purposes from acquiring clinical knowledge to building relationships with patients and forming a professional identity. Reflection occurs through writing after an event, while preparing for or acting in a situation, and in conversations with peers or supervisors. Teaching reflection involves explaining the purpose of the activity, establishing relationships and allocating time to review experiences, and deciding which materials to use to understand the process and its outcomes.

Reflection as a metacognitive process and guided learning

AMEE Guide No. 44 reviews definitions of reflection, approaches to it, and strategies for teaching and assessing it in undergraduate, postgraduate, and continuing medical education (Sandars, 2009). Reflection is a metacognitive process through which learners develop an understanding of themselves and the situation before, during, and after an event and apply that understanding to subsequent experiences. The guide categorizes approaches to reflection into ‘reflection for learning’, ‘reflection for the therapeutic relationship’, and ‘reflection for professional practice’. ‘Reflection for learning’ integrates experience into existing knowledge. ‘Reflection for the therapeutic relationship’ explores the beliefs, values, and emotional responses of clinicians and patients. ‘Reflection for professional practice’ involves making judgments in complex and uncertain situations. Discussions of the re-evaluation of experience and emotion, reflection-in-action, and reflection-on-action support this classification (Boud et al., 1985; Schön, 1983). Reflection encompasses knowledge and skills as well as the values and beliefs underlying empathy and care, described as the therapeutic self.

Educational strategies are organized around self-regulated learning goals, ‘will’ as motivation, and ‘skill’ as the ability to monitor strategies. Mindfulness, recording experiences immediately after an event, feedback from others, and critical incident analysis can be used throughout the stages of noticing, processing experience, and behavior change. Single-loop learning involves consulting a textbook when treatment decisions are uncertain. Double-loop learning examines the reasons for that uncertainty, prompting a review of learning methods that have relied on chance. Triple-loop learning extends this inquiry to the systems of power and control that influence behavior. Discomfort or anxiety signals the need for reflection, though strong emotions can also make it difficult to discuss the experience. The guide emphasizes reflection guided by tutors and mentors who provide support and ask non-judgmental questions. It proposes group supervision and peer co-supervision that account for workload.

A limited literature review focused on undergraduate medical education identified 21 articles, with one study comparing approaches and four studies reporting positive outcomes on objective indicators. The indicators in the four studies were reflection skills, diagnostic thinking, professional identity, medical humanities aptitude scores, and final examination grades in obstetrics and gynecology. A systematic review of health professions education also emphasizes the context and support conditions for reflection (Mann et al., 2009). The assessment tools presented include a framework with four categories—dedicated reflection, emotional exploration, objective reporting, and distracted reporting—and a classification with six levels from grade A to grade F. Assessing deeper reflection may expose personal vulnerability. Access rights, record confidentiality, and relationships with learners matter when facilitators also serve as evaluators. Group creative activities or digital storytelling are proposed alongside writing.

Reflection operating across five stages of adult learning

AMEE Guide No. 83 reviews adult learning theories to explain how learning occurs as learners become medical professionals and proposes an integrated model applicable to curricula and individual learning (Taylor & Hamdy, 2013). The theories are organized into six categories, focusing on how new knowledge is constructed from existing knowledge: instrumental learning theories, humanistic theories, transformative learning theories, social learning theories, motivational models, and reflective models. Experience and learner participation are key resources in andragogy, considered alongside collaborative learning and the social context in which learners exercise self-directedness (Knowles, 1973; Merriam, 2001). Related discussions examine adult learners’ self-directedness and self-assessment in relation to educational support (Norman, 1999). The discussion of motivation addresses autonomy, competence, and relatedness in self-determination theory, as well as ‘expectancy of success × value of success’ in expectancy-value theory. Transformative learning explains how learners examine existing premises through a disorienting dilemma and critical reflection within personal, professional, and social contexts.

The integrated model organizes learning into five stages—dissonance, refinement, organization, feedback, and consolidation—with reflection extending from goal setting to review of the learning process. In the dissonance stage, learners recognize gaps in existing knowledge and determine learning outcomes. In the refinement stage, they seek possible explanations and solutions and develop concepts from new information through tasks, research, reflection, and discussion. In the organization stage, they structure information into schemas through reflection-in-action, formulating and testing hypotheses. In the most crucial feedback stage, learners articulate new knowledge verbally and test it against peers’ and teachers’ understanding. They modify or reinforce schemas. In the consolidation stage, reflection-on-action confirms how much their knowledge has expanded and what they have learned from the learning process.

Educators explore learners’ experiences, provide appropriate tasks and resources, and use an advance organiser during the organization stage. Institutions secure the time and resources required for these activities. This design is supported by subsequent guides that consider learning objectives and environments alongside teaching principles emphasizing the use of experience, a safe learning climate, and feedback (Kaufman, 2003; Mukhalalati & Taylor, 2019). An HRD perspective analyzes how interactions with peers and teachers, together with institutional support, contribute to individual knowledge construction. Related discussions examine the healthcare team and practice environment as units of learning (Bleakley, 2006).

Self-authorship and the educational relationships that form judgment criteria

AMEE Guide No. 98 introduces self-authorship as a framework supporting intellectual growth and personal development (Sandars & Jackson, 2015). Self-authorship is the capacity to develop internal criteria for constructing one’s beliefs, identity, and social relationships. Learners begin by following the explanations and expectations of external authorities. When those expectations conflict with their own experiences, they re-examine the grounds for their judgments. In the cognitive dimension, they understand the uncertainty and context of knowledge and compare the evidence supporting various explanations. In the intrapersonal dimension, they form an identity by aligning their own values with professional responsibilities. In the interpersonal dimension, they consider others’ perspectives and demands while maintaining their own stance. Self-authorship explains how judgments about knowledge, an understanding of one’s own values, and ways of relating to others develop together.

The Learning Partnerships Model follows principles that validate learners’ capacity to construct knowledge, situate learning in learners’ experiences, and construct meaning together. Educators begin with learners’ explanations, questioning the evidence and assumptions underlying their judgments and reviewing alternative interpretations together. Experiences that are difficult to explain through existing worldviews offer opportunities for learners to examine their own premises. Learners receive support to express confusion and reinterpret the experience. In reflective activities, learners first describe an event. They then examine which premises, emotions, and relationships influenced their judgment and how the event can be understood from different perspectives.

Educational research examines how choices are explained alongside the choices themselves. Even when learners behave identically in following a supervisor’s recommendation, their actions may involve different combinations of evidence-based judgment, acceptance of professional values, and expectations of gaining others’ approval. Interviews and reflective conversations provide material for exploring these differences across cognitive, intrapersonal, and interpersonal dimensions.

The value and burden of reflection constructed in the discourse of registrars

A qualitative study of GP registrars in the Netherlands explored how learners define and negotiate reflection through their experiences with formal reflective activities (Schaepkens et al., 2024). The training consists of four days of clinical practice and one university training day per week over three years. Registrars participate in weekly 90-minute experience exchanges involving 10–12 peers and two faculty members. They also participate in regular supervision, weekly meetings with their clinical supervisor, and portfolio development throughout the training period. The research team used discursive psychology to analyze 7 focus groups, each lasting 1 hour, conducted in 2021 with 71 registrars (44 first-year and 27 third-year). Five of the groups met online and two face-to-face. A moderator unaffiliated with the training program intervened minimally in participants’ conversations. Audio recordings were transcribed according to Jefferson guidelines, including phonological, prosodic, and temporal details. The analysis involved open coding using Atlas.ti, collecting reflection-related excerpts, and analyzing discursive and content features. It also included five data sessions involving a linguist, a GP professor, a registrar, and a medical professional.

Registrars affirmed the value of reflection while using ‘but’ to introduce burdens and complaints. The positive evaluations upheld the norm that reflection is valuable while creating room to criticize formal activities. Participants described how overlapping reflective activities led to cumulative fatigue, reduced the time available to review their own goals, and came to feel like additional tasks required by the university. Some participants who had understood reflection as report writing came to recognize everyday conversation as reflection after hearing peers’ stories. The meanings of reflection were grouped into four strands: a generally valuable activity, a naturally occurring activity versus report writing, externally added tasks and a straitjacket, and a performance demonstrating one’s competence. The discussion also addresses the concept of the ‘reflective zombie’ who performs expressions expected by evaluators (de la Croix & Veen, 2018).

Proposals to reduce reflective overload include reviewing the frequency and arrangement of activities and giving learners autonomy to choose methods that fit their needs. The discussion also addresses reflection literacy: explicitly teaching the purpose and various methods of reflection. A definition of reflection that encompasses thoughts, behaviors, and their underlying conceptual frameworks explains the learning process that reflection reports seek to capture (Nguyen et al., 2014). Discussions of the social conditions of practice and the uses of assessment also help explain registrars’ experiences with formal activities (Ng et al., 2015; Hodges, 2015). Because these findings derive from utterances constructed in focus groups within an institutionalized training environment, their interpretation depends on shared norms and the conditions of online and face-to-face interactions.

Reading notes

The review in AMEE Guide No. 44 did not include longitudinal studies following learners throughout their enrollment. Its results are interpreted in relation to the learning and developmental outcomes measured in each study. The registrar focus group study focused its analysis on the functions of utterances in interaction, without attempting to judge participants’ internal states. This distinction separates how learners explain the grounds for their judgments from how they negotiate the meaning of reflection in conversation. Research spanning HRD and medical education can analyze reflection records, feedback conversations, training schedules, and assessment criteria together to explore how individual learning processes connect with the conditions under which institutions operate.

References

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