Do photographs, older adults’ narratives and collaborative dialogue foster anticipatory reflection (“preflection”) in medical students?

Brand et al. BMC Medical Education (2016) 16:289 DOI 10.1186/s12909-016-0802-2 RESEARCH ARTICLE Open Access Do photographs, older adults’ narratives and collaborative dialogue foster anticipatory reflection (“preflection”) in medical students? Gabrielle Brand1* , Ashlee Osborne1, Mark Carroll1, Sandra E. Carr1 and Christopher Etherton-Beer1,2 Abstract Background: In changing higher education environments, medical educators are increasingly challenged to prepare new doctors to care for ageing populations. The Depth of Field: Exploring Ageing resource (DOF) uses photographs, reflective questioning prompts, older adults’ narratives and collaborative dialogue to foster anticipatory reflection or ‘preflection’ in medical students prior to their first geriatric medicine clinical placement. The aim of this research is to explore whether photographs, narratives and small group collaborative dialogue fosters reflective learning, enhances reflective capacity and has the potential to shift medical students’ attitudes towards caring for older adults. Methods: This study used a mixed method evaluation design, measuring attitudes using pre and post questionnaire responses and individual written reflections drawn from 128 second year medical students, exploring their perceptions toward older adults. Results: Quantitative and qualitative data indicated that the DOF session generated reflective learning that resulted in positive shifts in medical students’ perceptions towards older adults. The qualitative reflections were captured in four main themes: the opportunity provided to Envision working with older adults; the Tension created to challenge learners’ misinformed assumptions, and the work of Dismantling those assumptions, leading to Seeing older people as individuals. Conclusions: These findings highlight how visual and narrative methodologies can be used as an effective reflective learning tool to challenge medical students’ assumptions around ageing and how these may influence their care of older adults. Background How can we better prepare future doctors to care for ageing populations? Medical educators must be responsive to the changing demographics of population ageing, as older adults are one of the main health care consumer groups [1]. The need for medical students to become reflective learners and practitioners is of paramount importance [2–4], with an increasing focus on learning processes (as opposed to just gaining knowledge [5]). Reflective learning is integral in enhancing critical analysis * Correspondence: 1 Education Centre, the University of Western Australia, Faculty of Medicine, Dentistry & Health Sciences, M515, 35 Stirling Hwy, Crawley, WA 6009, USA Full list of author information is available at the end of the article of both experience and knowledge to ensure future health professionals are self-aware and engage in self-monitoring of their ongoing professional practice [6]. A recent study assessing the attitudes of medical students has found students to have moderately negative attitudes towards older adults, as well as little expressed desire to work with them [7]. Teal et al. [8] notes that reflective activities, such as writing, small group discussion, imagery exercises and perspective taking exercises, are used within medical education to surface stereotypical views and unconscious biases. In addition, socializing medical students with older adults in an intergenerational arts program [9] and narratives using doctor and patient stories, literature and film have also been successfully used © The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Brand et al. BMC Medical Education (2016) 16:289 to promote more patient or relationship focused care [10]. Photographs of older adults have also been used as an effective way to generate reflection amongst nursing students, encouraging them to anticipate their clinical placement in an aged care setting in more meaningful ways [11]. Reflective practitioners, [12] actively reflect during (reflection-in-action) and after (reflection-on-action) an event. Reflection-before-action, described as thinking through intentions before one proceeds [13] or anticipatory reflection [14], is also increasingly recognised as being important. This ‘preflection’ allows one to consider possible outcomes and anticipate experience before an event. Despite the educational importance of preflection, there is limited published literature on educational innovations and/or teaching tools and strategies that use preflection to address attitudes toward certain patient groups [8]. In particular, we found no research that explicitly evaluates preflection aiming to raise learners’ awareness and expose hidden stereotypes in an attempt to counteract disinterest in caring for older adults prior to geriatric medicine clinical practice; which will be the focus of this study. Page 2 of 9  Identify and examine their personal perceptions of older persons.  Express their views to their peers in a shared reflective learning journey.  Explore and reflect on their role as a health profession student working with older people. A short background on reflection and instructions on constructing a shared narrative through collaborative dialogue precede students (in groups of 3 or 4) being shown a series of five photographs accompanied by reflective questioning prompts. No prior context is given to the students. At the end of the session, students are shown a 3 min, audio-narrated film of the older adult featured in the photographs to challenge any unexplored assumption or (mis-) conceptions around ageing. This aims to surface any cognitive discrepancy between what the students thought they knew, and the older person’s actual narrative, creating the tension required for transformational learning [17] including shifts in perspectives, to occur. The session is concluded with a full-group facilitated guided discussion. Structure of reflective learning sessions Methods A mixed method evaluation design was applied to explore three research questions: 1. What are the perceptions of a group of 2nd year medical students towards caring for older adults prior to their first geriatric clinical placement? 2. How do photographs, narratives and small group collaborative dialogue (Depth of Field: Exploring Ageing ©) influence reflective learning in medical students? 3. What effect does this reflective learning techn (...truncated)