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Reflective Practice: International and

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Learning from reflective practice and

metacognition an anaesthetists
perspective
Mark Barley

Department of Anaesthetics , Queens Medical Centre ,

Nottingham , NG72UH, UK
Published online: 14 Feb 2012.

To cite this article: Mark Barley (2012) Learning from reflective practice and metacognition an
anaesthetists perspective, Reflective Practice: International and Multidisciplinary Perspectives,
13:2, 271-280, DOI: 10.1080/14623943.2012.657792
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Reective Practice
Vol. 13, No. 2, April 2012, 271280

Learning from reective practice and metacognition an

anaesthetists perspective

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Mark Barley*
Department of Anaesthetics, Queens Medical Centre, Nottingham, NG72UH, UK
(Received 5 April 2011; nal version received 9 December 2011)
Within medicine, the concept of reection is becoming a fashionable component
of lifelong learning and revalidation. It remains poorly practised and misunderstood with scant guidance available on the benets, methodology or founding
principles. Using the intrinsically unsafe state of anaesthesia as a clinical example, the stages of reection are discussed in context. Components of metacognition (thinking about thinking) are also clinically contextualised. Barriers to
reection and metacognitive practice are discussed, emphasising the need for
medical regulators to deliver clarity on the processes they propose clinicians to
use to reect. Opportunities to promote reective practice from clinicians existing working patterns are proposed.
Keywords: reective practice; metacognition; anaesthesia; lifelong learning;
continuing medical education

Introduction
Medicine is becoming increasingly complex; societal expectations increase, medical
technology advances and the mass of medical knowledge doubles every ve years,
of which 85% is obsolescent within 15 years (Ryan, 2010, citing Robinson, 1993).
Medical practitioners face a knowledge dilemma; doctors are no longer able to
confront and absorb this tsunami of information but must become procient in
assessing, interpreting, applying and communicating knowledge from their discipline through a habit of lifelong learning and curiosity (Ryan, 2010). Despite ever
increasing technological and knowledge resources, medical error is still prevalent.
Vincent, Neale, and Woloshynowych (2001) estimated that 10% of hospital admissions in the UK are associated with an adverse incident; a gure comparable to that
announced in the landmark publication from the Institute of Medicine, To err is
human: building a safer healthcare system (Kohn, Corrigan, & Donaldson, 2000),
which estimated 98,000 deaths following adverse incidents occurred annually in the
USA. Moving healthcare towards the error-rates of high reliability industries such
as aviation, nuclear power and rail transport is a noble goal, requiring cultural
change in healthcare delivery with a focus on measuring and consistently improving
the quality of care.
At the forefront of advances in patient safety is anaesthesia, a profession that
has strived to reduce mortality from 1:5000 to 1:200,000 over the past two decades
*Email: mark_barley@mac.com
ISSN 1462-3943 print/ISSN 1470-1103 online
2012 Taylor & Francis
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(Hallinan, 2005). However, the state of anaesthesia is intrinsically unsafe (Davis &
Aitkenhead, 2001); the multiple steps required to achieve this vulnerable condition
expose the patient to potentially signicant morbidity and mortality. Unique to
anaesthesia are problems encountered during advanced airway management the
unique core skill of the anaesthetist (i.e. intubation). Data from the National
Health Service Litigation Authority from 1995 to 2010 reveal 90 claims from complications of airway management, with specic intubation difculties noted in 33%,
of which 63% resulted in death or hypoxic brain injury (McLeod & Yentis, 2011),
with a mean settlement cost of 650,000. Although rare, such injuries are devastating to the patient, their families and the second victim the anaesthetist and theatre team.
This risk has been recognised by the Royal College of Anaesthetists (RCoA),
and the curriculum (RCoA 2010, p. B-38) reects the need to acquire the necessary
knowledge and practical skills to mitigate these risks. Following Flexners (1910)
seminal report on the state of American undergraduate medical education, applied
basic science has become the keystone of medical education and the pre-eminently
valued basis of medical practice (Mann, 2011); however, such science is frequently
learnt away from the context in which it will ultimately be applied. Postgraduate
professional practice implies an obligation that the knowledge base established
during the formative years is maintained and upgraded (Bridgley Young, Littlejohns & McEwan, 1997). This assumes that all clinicians can match scientic
knowledge to a broad range of clinical situations, but as Bridgley et al. (1997)
noted, specialist academic knowledge only becomes professional knowledge when
it is applied practically in particular clinical contexts.
The requirement for knowledge is but one facet of a medical professionals
journey to expertise indeed intelligence alone is not enough to meet the practical
skills, attitudes and behaviours demanded by a holistic health service. Using examples from anaesthetic practise, the application of reective practice and metacognition to lifelong learning will be explored.
Reective practice
Reective practice has become a buzz word in medical curricula. Tomorrows doctors (21, p. 26, GMC, 2009) specically states that practitioners must continually
and systematically reect on practice and, wherever necessary, translate that reection into action. Mann (2011) acknowledges that reection and reective practice
are complex concepts, and although the critical analysis of experience is an important learning tool, this is a shift away from Flexners (1910) original pedagogy.
The concept of reection borrows from three well-established epistemologies:
positivism, interpretive theory and critical theory (Kaufmann & Mann, 2010; Schn,
1983). The positivistic view of science (the only source of knowledge), describes
the acquisition of theoretical knowledge as an academic pursuit, which is unrelated
to practice. Untestable propositions are felt to be emotive utterance or nonsense; it
is the predicative value of knowledge which has practical use. Reection proposes
that theory and practice are intertwined and modify each other. One can accept that
theoretical knowledge becomes interwoven with clinical practice; clinicians revise,
test and modify their knowledge based on experience; the interpretive model suggests such knowledge is interpreted with respect to the clinicians previous experiences and the current clinical context. Thus theory guides action and

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understanding (Kaufman & Mann, 2010). Critical theory and reection share the
observation that theory is related to practice by a process of critical thought and
self-examination; as experts we can break-free from concrete patterns of thought,
reformulating our practice and the way in which future problems and challenges are
viewed. The context in which our knowledge is applied, the outcome and our emotional response all reframe the dry theory; knowledge becomes something that lives,
breaths and evolves.
Schn (1983) has made a signicant contribution to understanding of reective
practice (Ghaye & Lillyman, 2000). However; Dewey (1933, p. 6) dened reective
thought 50 years previously thus:
Active, persistent, and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it
tends.

Schn based his works on the study of professions (i.e. engineering, medicine,
music). He described practitioners of science-based professions (such as doctors)
confronting a problem as engaging in a very limited kind of on-the-spot inquiry,
inattentive to phenomena not tting their intuitive thoughts. He proposed that the
reective practitioner, thinking have I selected the right diagnosis from my range
of differentials or have I selected the right problem-solving technique [treatment]
from my stock of known techniques? would notice the problem not tting recognised patterns and engage in deep thinking to diagnose and treat.
Schn observed that mapping the signs of the present situation onto known
problems and solutions can become extraordinarily complex (Schn, 1983, p. 169).
However, with new, unique or messy problems, this mapping does not occur, and
the process becomes more artistic constructing a manageable problem from the
situation and self-monitoring by reection. Work on expert performance suggests
that the concept of reective practice is a primary mechanism of expertise acquisition (Mamade & Schmidt, 2004).
Schn (1983) proposed four components of reective practice: Reection before
Action; Knowing in Action; Reection in Action; and Reection on Action. These
will be discussed as applied to anaesthesia, with advanced airway management as a
clinical scenario.
Reection before Action (RbA)
A key part of airway management is planning clinical examination may suggest
that intubation may be difcult, but bedside tests lack positive predictive value,
generating a signicant number of false positives (Yentis, 2002). This does not
detract from their value, as be prepared is the anaesthetists motto. However, clinical decision making under cognitive load is plagued by cognitive biases; the infrequency of impossible intubation and our subconscious awareness of the fallibility of
bedside tests leave us exposed to familiarity heuristics where we erroneously predict
future states based on prior experience (it will be alright, it always is) and with
increasing clinical experience and chronological age we recall relatively more positive than negative events (Mather & Carstensen, 2005).
Prior to inducing anaesthesia, there is much for the anaesthetist to take into
account:

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Am I the best person for this patient; is my fatigue, mood or skill below par?
What are the benets and risks to the patient of my chosen techniques?
What equipment do I need to give myself the best chance of success rst
time?
What do I expect to see with the laryngoscope?
How will I know when I am out of my depth?
Who should I call if I need help?
For the novice these questions are conscious thoughts, for the expert practitioner
these are tacit, but there is awareness of cues indicating a deviation from prior
experience. Such pre-reection is critical in medicine as it prepares our thoughts
and forms our plan for when an unexpected circumstance arises (Ong, 2011).
Indeed, many anaesthetists will have mentally rehearsed plans for serious situations,
and guidelines aiding decision making are widely circulated.
The cognitive mechanisms used by experts to respond to surprises in management plans are described by Schn as Knowing in Action and Reection in Action.
Knowing in Action (KiA)
The way a professional thinks on his feet and responds subconsciously to variations
in practice is particularly important in time-critical situations. Klein (1999, p. 24)
describes this naturalistic thought process as recognition-primed decision making.
Gladwell (2005, p.14) summarised the need for this process succinctly: there are
moments, particularly in times of stress, when haste does not make waste, when
our snap judgments and rst impressions can offer a much better means of making
sense of the world. Intuitive thinking is an instantaneous process fast, automatic
and subconscious; it is a hard-wired survival instinct vital for emergency situations, from evading a sabre-toothed tiger to medical emergencies. Despite the value
in KiA, as it is a rapid, subconscious emotional decision, it is subject to bias and
errors which can lead to incorrect decisions.
Within our clinical situation, KiA may be as simple as noting a difcult laryngoscopic view and executing pre-learned strategies to improve it application of cricoid
pressure, an alternative laryngoscope blade or use of a bougie. These are all
expected rapid responses requiring minimal cognitive outlay for the expert, but conscious thought and decision making for the novice, which increases cognitive load
and stress.
Reection in Action (RiA)
Whilst intuitive KiA produces rapid reex decision making in response to a variation in normality, RiA occurs in response to a surprise or to the unexpected when one
recognises that the situation is unique. Schn (1983) described three components:
reframing and reworking the problem from different perspectives;
establishing where the problem ts into existing knowledge and experience;
understanding the implications of the problem, the solution and their consequences.
These observation and critical reasoning skills are a greater cognitive load than the
easy KiA reexes. When confronted with a clinical surprise (for example, an

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unanticipated difcult intubation) one must rapidly decision-make and problemsolve in parallel. Because of the higher cognitive awareness of these processes they
are less likely to be biased by emotion and subjectivity. Piaget (1952, cited by
Ryan, 2010) concluded that that the highest order of intelligence included the ability
to anticipate and reect on ones own behaviour.
Returning to our clinical situation, RiA occurs as our anaesthetist recognises that
despite reex quick xes (KiA) he is unable to obtain a satisfactory laryngoscopic
view. This is an unexpected difcult intubation (incidence 14%; Klock & Benumof, 2007). He recognises that help is required, and invokes the planning created
at the RbA stage. He also reframes the problem; intubation is difcult so attention
must focus on oxygenation. The implications of failing to oxygenate are well understood, and although this problem is new to this anaesthetist, active cognition and
reection have prevented xation on intubation and the exclusion of oxygenation
and a potential harm event.
Reection on Action (RoA)
This occurs after the event, and is what most clinicians think of by reection. There
is a delay between the index event and the reection, which involved a careful examination of the experience, action, interactions and emotions. The details are recalled
and analysed to give fresh insight into perceived individual and team performance,
and can be a stimulus to prompt new knowledge or reinforce what is known.
It is not just clinical problems that can benet from reection; ethical problems,
communication issues, complaints and interpersonal relationships can all be examined reection on action explores our emotional intelligence (our ability to consider our own, and others thoughts, feelings and values). Some individuals nd
such empathy easy, but others may be less intuitive. The emotional substrate this
form of reection exposes makes it the richest, yet the riskiest form of reection for
the practitioner. RoA is a component of revalidation for anaesthetists (RCoA, 2010)
which is more a retrospective narrative than true reection with an emotional component; however, a move away from just tick-box technical assessments may give a
deeper understanding of a practitioners insight into their knowledge and practice.
However, RoA is not without critics; the value of medical morbidity and mortality
(M&M) meetings has been criticised, as they do not seem to prevent future errors
by examining and assigning blame for events in the past. Supercial excuses like I
was tired or the patient was uncooperative really do not explore our own inconvenient truths about our personal deciencies (I did not assess the airway, I have
never had a problem before so I assumed it would be okay).
For our anaesthetist, reection may be informal during a quiet moment, written
as a piece for a learning portfolio or mentored with a trusted colleague. It is a challenge to reframe existing knowledge in the light of new events and identify areas
for personal and professional development.
In this form, experience modies pre-existing knowledge directly; insights and
learning from one experience may be incorporated into future knowing in action.
Metacognition
Schn described how a professional responds to surprises with KiA and RiA,
while Quirk (2006) referred to them as intuition and metacognition. Metacognition
is described as the experiences and knowledge we have about our own thought

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processes (Schwartz and Perfect, 2002, citing Flavell, 1979). The International
Association for Metacognition is more succinct: knowing about knowing.
There are a number of thought processes to metacognition:
Specialised Knowledge: a foundation of factual knowledge is required, as are
profession-appropriate psycho-motor skills and a commitment to learning.
Emotional Intelligence: also used in RoA, the ability to think about their own
and others feelings, emotions and values understanding the nature of people
as fellow cognitive creatures.
Perspective Taking: the ability to explore a problem from the patients perspective anticipating their needs and advocating on their behalf (Quirk,
2006).
Experiential Learning: the ability to learn from experience challenging prior
assumptions by asking questions and to recognise subtle patterns and visual
cues in complex situations whilst overcoming biases. Kolb and Kolb (2005,
citing Kolb, 1984), developing the work of others, produced a holistic model
of the experiential learning process. Their Experiential Learning Theory
dened learning as the process whereby knowledge is created through the
transformation of experience (Kolb & Kolb, 2005, p. 194).
Self-regulation: The ability to control ones thoughts and feelings in order to
think well we make more errors when tired or distracted. For the anaesthetist, eternal vigilance is the price of safety, and one needs strategies to counter
stress, fatigue, overwork, interruptions and distractions as well as having the
insight to recognise the impact these may have on performance.
Self-Awareness: being self-aware is an important life-skill; this can be promoted by setting aside time and space for reection, and practising attentiveness, curiosity and patience.
Both Schns description of reection, and metacognition appear to be valuable
strategies to reduce our biases, clarify our thoughts and optimise learning from new
experiences, putting into context our prior learning, but to what use? Although there
is widespread advocacy for these techniques, encouraged in both the undergraduate
and postgraduate curricula driven by the GMC and Royal Colleges, are there actually any proven benets to practice and patient safety or are these assumptions
based on hopes that humanistic doctors can do no wrong? Mamade and Schmidt
(2004) described this as a new professionalism, with a key factor being the ability
of physicians to critically reect on their own decisions.
Several studies have examined diagnostic accuracy with reective versus nonanalytical reasoning. Mamade, Schmidt, and Penaforte (2008) demonstrated a positive effect when reective practice was used in the diagnosis of complex, unusual
clinical cases but non-analytical reasoning was just as effective for routine clinical
cases. In a study of Brazilian internal medicine residents Mamade, Schmidt, Rikers,
Penaforte, and Coelho-Fildo (2007) demonstrated that complex cases triggered a
switch from automatic to reective reasoning; an extrapolation may be that
reection aids diagnostic accuracy. Despite these encouraging studies, there are no
randomised controlled trials demonstrating a patient outcome or mortality benet
from reective clinicians (hard evidence: Driessen, van Tartwijk, & Dornan,
2008). Despite this, there is evidence to support the notion that reection helps us
to learn from our experiences, identify our learning needs and stimulate learning

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which is focused on comprehension and understanding (Grant, Kinnersley, Metcalf,

Pill, & Houston, 2006).
If our curricula are to produce reective practitioners, how is this to occur? At
present, reective practice is perceived as a negative emotional process for the reflectee, focused on the minute dissection of action and thought following an adverse
clinical event. Blinded by hindsight this becomes a process of atonement rather than
learning. During departmental M&M meetings, clinicians deliver narrative descriptions of events and processes, which are scrutinised out of context by peers a
gladiatorial process. Our regulatory authorities diktat of compulsory reection as
part of a hectic revalidation process makes this an onerous process, perceived as the
uffy stuff we have to do for revalidation rather than a continuous process of
development of expertise. Time pressured senior clinicians typically have six hours
a week allocated for continuing medical education, audit, service evaluation and
development as well as their teaching and research interests; these are all activities
required by our regulatory authorities for revalidation, of which reection plays a
very small part.
We have a duty to highlight that critical analysis of experience is an important
learning tool, and this should happen from early in adult education. However, conscious reection is not a process that comes naturally for many people. Reective
skills can be taught and mentored a process which requires investment in staff and
time. Simulation-based medical education has acknowledged the principles of reection as a powerful learning modality; considerable care is taken to produce a safe
and supportive environment for adult learners prior to the learning event, where a
high-delity human simulator or an actor is used to emulate a realistic clinical situation, testing their diagnostic, practical and non-technical skills (communication,
decision making, teamwork). Following the event, a debrieng or after-action review
provides an opportunity for the participants to reect together, dissecting the events
and processes observed, offering critique or praise for aspects of the performance
and crucially generating strategies to counter difculties encountered. The goal is to
allow the participants to explain, analyse, synthesise information and emotional
states to improve performance in similar situations in the future (Rudolph, Simon,
Rivard, Dufresne, & Raemer, 2007). Anecdotally, this works well with a good group
dynamic and careful attention to creating the right learning environment; however,
small group simulation sessions are costly in both clinician time and infrastructure.
Reective diaries, narratives and portfolios can be used to encourage reection
cost-effectively, but they risk producing rather self-congratulatory and self-indulgent
pseudo-reection (Epstein, 2008) unless used as a stimulus for discussion with a
mentor or as part of a small group reective session. A busy medical curriculum
with teaching and learning as lectures, opportunistic bedside and operating theatre
teaching give little time for this to occur, as both under- and postgraduates perceive
the acquisition of clinical knowledge of paramount importance as this is a prerequisite of academic success. Are our undergraduates ready for an education enriched
by reection and experiential learning? Kolb and Kolb (2005) postulate that learning styles are inuenced by personality, education, career choice, current role and
tasks. Kolbs experiential learning theory development model chronicles three stages
from acquisition (birth to adolescence), specialisation (formal schooling to early
work) and integration (mid-career and later life) where there is increasing integration of reective observation and active experimentation. It may be that reection
needs to be practised in a different way at each stage.

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Nevertheless, an education that can integrate science, technology and reective

inquiry is needed (Ryan, 2010) if we are to have intelligent, fast thinking, driven,
ambitious problem-solving doctors who can also listen and communicate. Collectively we must emphasise the importance of reection, highlighting by example the
need to scrutinise our work practices and the dangers of rigid assumptions.
A reasonable, cost-effective approach is to integrate reection into existing
working patterns, learning from the failings of our M&M meetings where clinicians put up defences when reection yields insight, challenging their self-perception, competence and hierarchical position. As demonstrated in simulation-based
education, we must work to provide a safe learning environment with facilitation
and mentoring from a credible clinician with an interest in education, reection and
non-judgemental debrieng (Rudolph, Simon, Dufresne, & Raemer, 2006). It is
with the creation of this environment that reection can ourish, and a supportive
group can help individuals manage negative emotions. Similarly, team-based briefings and debriengs offer a valuable opportunity for small group reection, enhancing effectiveness and teamwork (TEA, 2011, Vashdi, Bamberger, Erez, & WeissMeilik, 2007) and perhaps modication of a team or organisations norms, policies
and objectives (Argyris & Schn, 1978).
Reective practice and metacognition can give us an awareness of our thought
processes; with this insight there is the possibility to reduce our subconscious
biases, make better decisions and engage in true constructivist experiential learning. However valuable we think reection is, concrete evidence is lacking, and
implementation of reective practice in postgraduate education seems to be a
token exercise, where it may be difcult to tell real reection from that produced to
tick a box at a revalidation exercise.
I see many parallels between reection, metacognition and experiential learning,
and personally feel these are useful topics for interested, insightful individuals. We
have a duty to emphasise that reection is a part of our routine clinical practice
with a potential to make us safer, more considered physicians.
The unexamined life is not worth living (Socrates)

Note on contributor
Dr Mark Barley is a Specialist Registrar in Anaesthetics and Clinical Fellow in Medical
Education and Simulation. His clinical interests are difcult airway management, emergency
surgery and major maxillofacial surgery. Non-clinical interests include improving Patient
Safety within emergency surgery and Human Factors in clinical practice. He is involved in
undergraduate and postgraduate medical education.

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