=Paper=
{{Paper
|id=Vol-1103/paper3
|storemode=property
|title=Support for collaborative reflection in healthcare: Comparing two workplaces
|pdfUrl=https://ceur-ws.org/Vol-1103/paper3.pdf
|volume=Vol-1103
|dblpUrl=https://dblp.org/rec/conf/ectel/PrillaD13
}}
==Support for collaborative reflection in healthcare: Comparing two workplaces==
https://ceur-ws.org/Vol-1103/paper3.pdf
Support for Collaborative Reflection in Healthcare:
Comparing two Workplaces
Michael Prilla, Martin Degeling
1
Ruhr-University of Bochum, Institute for Applied Work Science
{michael.prilla, martin.degeling}@ruhr-uni-bochum.de
Abstract. Reflection is a frequent and integral part of daily work, and often it is done
by multiple actors in meetings or during joint work. Its support, however, has mainly
been investigated with respect to educational settings or individual reflection processes.
This paper describes a framework for the support of collaborative reflection at work
and a study on its implementation at two workplaces in healthcare. Results of the study
show which means of supporting collaborative reflection can be beneficial in practice
and that we need to understand this support as a socio-technical task.
1 Introduction: Collaborative Reflection at Work
Reflection is a frequent and integral part of daily work (Boud 1985; Kolb and Fry 1975).
Typical examples are thinking about whether certain decisions were right and groups consid-
ering whether their cooperation is effective. Reflection processes contain three steps: Going
back to experiences, re-evaluating them and drawing conclusions for future work from this
(Prilla et al. 2012a). While this has been investigated for individuals reflecting, collaborative
reflection is done by a group of people sharing their experiences and jointly developing
changes for future work from that (Daudelin 1996; Dyke 2006). The result of such collabora-
tive processes can be relevant for individual work, but also on group and organisational lev-
els. By this, collaborative reflection complements education and vocational training at work
with a process of bottom-up understanding and evaluating work and helps people to learn
from experiences in a self-directed, collective manner (Daudelin 1996; Hoyrup 2004). How-
ever, there are hardly any insights on the design of tools for collaborative reflection.
This papers aims to bridge the resulting gap and describes a study in which support for
collaborative reflection was trialled in two healthcare workplaces. From this, the paper
shows how collaborative reflection can be supported, that we have to understand this support
as a socio-technical task and that there is a need for further work on exploring such support.
In what follows, we describe existing work and insights into collaborative reflection as
well as the “Talk Reflection App” as a means to support such reflection (section 2). After
that, we present the study conducted in the healthcare workplaces (section 3), its results (sec-
tion 4) and a discussion on conclusions to take from our work, including impacts on the de-
sign of collaborative reflection tools (section 5).
41
Support for collaborative reflection in healthcare: comparing two workplaces
2 Computer Supported Collaborative Reflection
2.1 A Framework for Supporting Collaborative Reflection
Tools for the support of reflection have been discussed mainly in educational settings or with
respect to individual reflection. Authors have proposed journals or portfolios or series of
pictures to help users to reconstruct and reflect experiences (Fleck and Fitzpatrick 2009;
Scott 2010). With the exception of support for specific situations such as post-mortem pro-
ject reflection meetings (Kerth 2001) and generic tools such as shared whiteboards (Lin et al.
1999) there is hardly any support for collaborative reflection available.
Differences between individual and collaborative reflection can foremost be seen in sup-
port for communication among participants and sustaining results – to reflect together, par-
ticipants need to exchange experiences, different individual perspectives and understandings
need to be discussed and solutions need to be agreed on. To operationalize the respective
steps of collaborative reflection and the corresponding needs, we created a cyclic blueprint
for collaborative reflection tools based on insights from earlier user studies on collaborative
reflection (Prilla et al., 2012a; Fig. 1).
Fig. 1. Cyclic blueprint of collaborative reflection, based on (Prilla et al. 2012a).
The blueprint shows how collaborative reflection is tightly coupled to phases of individual
reflection and that these phases constantly switch, e.g. if a topic is discussed in a group, then
reflected by individuals with respect to own experiences and later on again reflected within a
group. Such reflection needs a sustainable documentation of experiences to share them with
others and to sustain all relevant aspects – usually, after a certain time details may be forgot-
ten and emotions may fade, which affects the reflection processes afterwards. Moreover,
reflection should end up in sustainable and shareable results if it is to lead to changes in work
– otherwise, only the group reflecting knows about proposed changes ad their origin (Prilla et
al. 2012b). A central requirement for al steps is support for articulation of experiences, ideas,
42
Support for collaborative reflection in healthcare: comparing two workplaces
solution proposal and results and to be able to share these articulations. Table 1 summarizes
the resulting requirements (cf. Prilla et al. 2012a).
Table 1. Requirements for the support of articulation in collaborative reflection.
Articulation Requirement
Experiences Documenting experiences for later use
Individual Reflection Documenting and sharing insights (e.g., in comments)
Collaborative Reflection Sharing similar experiences and ideas for solutions (e.g., in
comments)
Results Documentation and sharing of results
2.2 Supporting Collaborative Reflection of Conversations: The TalkReflection App
The „Talk Reflection App“ (Fig. 2) was developed to support the phases of the collaborative
reflection blueprint shown in Fig. 1 and to implement the requirements documented in Table
1. The app supports reflection on conversations with patients in hospitals, residents in care
homes, relatives of patients and third parties such as social workers, as our studies in
healthcare workplaces revealed that this is a relevant and reflection intensive topic (see Prilla
et al. 2012a). Therefore the app supports articulation to explicate experiences from conversa-
tions as described in Table 1. It also supports sharing these documentations and the articula-
tion of outcomes from collaborative reflection. The usage of the app is explained in the fol-
lowing scenario.
Fig. 2. The Talk Reflection App. Left: Overview of accessible, articulated experiences (documenta-
tions); Right: Form for documenting a conversation.
The caregiver Anna has had a difficult conversation with relatives of a resident in the care
home she is working hat. Afterwards she documents (articulates) the content and topic of the
conversation together with her feelings during the conversation in the app. She describes her
insecurity when telling the son of an older lady that the lady’s medical conditions are getting
worse dramatically, and she might die soon. She uses the content fields to describe this and
43
Support for collaborative reflection in healthcare: comparing two workplaces
the self-assessment sliders below it to document her feelings about the situations (see Fig. 2,
right).
Her colleague Bernd notices that Anna has shared her note with him (Fig. 2, left). When
he reads it, he remembers a similar situation he has been in and comments on Anna’s docu-
mentation, suggesting to refocus the conversation on the relative and to offer him support –
in other words, he reflects on his own experience and makes a suggestions for coping with a
comparable situation in the future. Since the topic is of interest for the rest of the ward, too,
Anna’s case is also discussed in a meeting with all caregivers of the ward and together they
discuss strategies how to support and teach new caregivers in similar situations. They agree
on three things to include in this process and document this outcome of their collaborative
reflection in the Talk Reflection App, connecting it to the cases it is related to. They shared it
with all colleagues on the ward in order to enable them to reconstruct the suggested solution
based on the cases linked to it.
3 Supporting Collaborative Reflection with the Talk Reflection App: A Study at
two Workplaces
The Talk Reflection App was trialled for four weeks in a German hospital specialized in care
for neurological diseases (case 1) and for five weeks in a British care home for people suffer-
ing from dementia (case 2).
In case 1, reflection was focused on conversations between physicians and relatives of pa-
tients, as physicians felt they needed to systematically use experiences from such conversa-
tions to learn how to act professionally if the conversations get emotionally stressful. They
stated that their prior education had not covered this topic and that they would be willing to
form a group helping each other in it by using the Talk Reflection App. The study was con-
ducted with five participants, including inexperienced assistant physicians, who had just
started work at the hospital and more experienced senior physicians (see Table 2).
Table 2. Overview of study participants and tools used to gather data
Participants Data from studies
Case 1 5 physicians (2 experienced, 3 less expe- Questionnaires
(Hospital) rienced) (Pre/Post), interviews,
Case 2 5 caregivers (3 to 20 years of experi- observations (meet-
(Care home) ence), (1 manager) ings), log files
In case 2, the caregivers wanted to reflect on conversations and interactions with others relat-
ed to such conversations, including encounters with residents, their relatives and third parties
such as social workers. Care for people suffering from dementia is especially demanding for
caregivers, as these people might (re)act strangely or even become aggressive. Being able to
talk to them, their relatives and third parties in a professional way not only diminishes the
personal stress level resulting from that, but also improves the reputation of a care home. The
study was conducted with five caregivers, who used the Talk Reflection App to learn about
44
Support for collaborative reflection in healthcare: comparing two workplaces
these situations, and the manager, who wanted to be informed about it, but did not actively
use the app.
In both cases, the app was introduced to the five participants in a common workshop in
order to enable them to work with it in a self-directed manner. Before the workshop, they
were asked to fill out a short (pre-) questionnaire (10 items) to create a baseline on their cur-
rent reflection practice and need for learning about the respective topics. In the middle of the
trial period and at its end, we conducted reflection workshops with the participants, in which
they were asked to skim through experiences documented in the app and choose some for
reflection in the workshop. During the meetings a researcher was present to observe and
document reflection among the participants and to get feedback on the app.
Table 3. Meetings during the trial periods in both cases.
Time Meeting and Tools for data gathering
Observation
Begin of trial period Introduction and training, pre-questionnaire
Middle of trial period Initial reflection meeting on cases in the app
End of trial period Final reflection meeting, post-questionnaire, short
interviews
At the end of the trial period, in addition to the final reflection meeting the participants were
asked to fill out a post-questionnaire (30 items), which included the same items used to cre-
ate the baseline and an additional set of items on aspects such as acceptance, value and im-
pact of using the app, which were aligned to the levels of evaluation on the model of Kirk-
patrick (1975) – typical questions can be found in section 4. Moreover, the participants were
interviewed briefly on their experiences in using the app. Table 3 summarizes the course of
the studies and the tools used for gathering data. This data was complemented by the log data
captured throughout the usage of the app.
4 Results
In both cases, the participants used the Talk Reflection App for the documentation of critical
conversations and (in case 2) interactions in order to reflection on them later. In case 1, for
example, an assistant physician documented a conversation with relatives, which she per-
ceived to be very demanding (see Table 4). She created a comment to document this percep-
tion. In a later meeting with the other participants, she used this documentation as a memory
aid to present this case to her colleagues in a very detailed manner. This caused immediate
reactions by her colleagues and in the resulting reflection session of this case, colleagues
reported similar cases and proposed different ideas how to better deal with such situations. In
the end, they agreed that in these situations, inexperienced physicians should always ask a
senior physicians to join until they were confident to deal with such situations alone.
In case 2, caregivers reflected about the death of a resident, who has been admitted to
hospital against her advice to the relatives and social workers. One of the caregivers had
documented the interaction with the relatives that led to the admittance (see Table 4), and
45
Support for collaborative reflection in healthcare: comparing two workplaces
afterwards used this documentation to reflect on this it with her colleagues and the home
manager. Some senior staff members reported on similar situations in the past and that a
conversation how to deal with the emotional affection directly after the situation had helped
them to overcome their grief. Although some had stated initially that such situations can
happen in a care home and that the group should not take any particular measures, after the
reflection session they agreed that there would be a possibility to have such group conversa-
tions after very demanding situations in the future, which would be led by the manager.
Table 4. Sample Documentation, Comments and Outcomes of using the Talk Reflection App in both
cases.
Articulation Hospital (Case 1) Care home (Case 2)
Talk / “[Patient’s] therapy finished. „The resident passed away suddenly,
Interaction Again relapse, palliative ther- had been here long, was liked by all
apy. Prepared [relatives] for staff. Was ill in the morning and her
begin of home care, asked to guardian admitted her to hospital, Un-
seek professional support for fortunately she passed away [there].
care. Talk was very difficult, This was very distressing to the staff as
parts were not received or they felt it would have been more dig-
blocked out.” nified for the client to be in familiar
surrounding.“
Comment “[Relative] conveys the feel- - (verbal statements)
ing it is our fault. (…) Hears
for the first time that [patient]
is going to die”
Outcome “Problem: Conversation held „After discussing with the homes man-
alone. It should be known that ager about the staff being upset, it was
a senior physician can be decided that staff who were most af-
asked for support” fected get together and discuss
thoughts and feelings.“
The examples shown in Table 4 illustrate that besides documenting experiences and making
them accessible later, using the Talk Reflection App also had an impact on the reflection of
each individual: In the articulation work (cf. Suchman 1996) of documenting their experi-
ences, the participants had also documented insights from reflection. In case 1, the physician
mentioned that she perceived that the relative had blocked out certain information given to
her, and in case 2, the caregiver (verbally, not in the app) stated that the grief of staff was
mainly caused by the manager, relatives and social workers not listening to their advice. This
shows how documenting the cases already triggered reflection.
Looking at the usage of the app in both cases (see Table 5), we can see that is was pre-
dominately used for the documentation of cases. Given that a critical situation does not ap-
pear every day, we consider the creation of 7 documentations in 121 days (case 1) and 18
1
Due to technical problems, there is only solid data for the last 12 days of the trial period, although the
participants stated to have used the app before as well. In addition, some physicians created docu-
46
Support for collaborative reflection in healthcare: comparing two workplaces
documentations in 33 days (case 2) to be sufficient for an initial test, in which in both cases
the users needed some time to adopt the application and integrate it into their work tasks. All
documented experiences were shared with all other participants in both cases.
Despite the sufficient amount of documentations, other features such as commenting and
creating outcomes were used below our expectations (see Table 5): Compared to the amount
of documentations, the number of outcomes (three in case 1, two in case 2) and the number
of comments (nine in case 1 and 14 in case 2) are not sufficient and, especially in the case of
comments, cannot lead to fruitful exchange of experience as it is necessary collaborative
reflection. In addition, some of the created outcomes in the app are a result of reminding the
participants during reflection meetings to also write down their outcomes.
Table 5. Number of Documents, Outcomes and Comments created in the Talk Reflection App in both
cases.
Type of articulation Case 1 Case 2
Documentation of critical conversations / interactions 7 18
Documentation of outcomes from reflection 3 2
Comments on (own / others’) documentations 9 (4/5) 14 (11/3)
Despite the numbers shown in Table 5, an analysis of statements and feedback given by the
participants of both studies during the meetings and in the final interviews shows that they
perceived using the app to be valuable for exchanging experiences, reflection on them in the
group and deriving outcomes for future work. In meetings, we could observe participants
vividly discussing during reflection how certain situations needed to be understood or could
be tackled better in the future. In interviews, participants could easily describe comments
they had made verbally on others’ documents and also some agreements the participants had
come up with to solve certain issues expressed in the documentation. The participants report-
ed that all of these articulations and communications had happened outside the app in face to
face interactions as they happen daily in hospitals and care homes when people meet each
other during work, in meetings or between shifts. These casual interactions were perceived to
cause less effort and led to features such as commenting being used less. This effect could
also be seen in meetings, in which participants used documented experiences from the app to
describe a certain situation to their colleagues and to reflect on it verbally afterwards.
Data from the questionnaires used in the study underpins that there was value from using
the Talk Reflection App in both cases, as it indicates that participants perceived it to have a
positive impact on constructively thinking about conversations (that is, individual reflecting
on them) and discussing conversations with colleagues (part of collaboratively reflecting
them, see Fig. 3). The data also indicates a light effect on the perception of how situations
reflected on could be improved during the trials, which was slightly stronger for case 2. Giv-
en that the trials only lasted four and five weeks, this goes beyond our expectations as we
had expected changes in behaviour to take longer than this period to be implemented. How-
ever, long-term evaluations need to approve this finding.
mentations offline and wanted to save them to the app, although they had no connection to the Inter-
net. This resulted in lost cases.
47
Support for collaborative reflection in healthcare: comparing two workplaces
5
4,0 4,0 4,0 4,0 3,8
4 3,5
3
2 Case 1
1
Case 2
The app has helped to The app has helped to The app has helped to
constructively think about discuss conversations with improve conversations
conversations afterwards. colleagues. with residents, relatives or
others.
Fig. 3. Perceived value of using the Talk Reflection App in both cases, n=5 for both cases.
The participants were also asked to clarify which factors had influenced their reflection prac-
tice. Answers to this show that being aware of reflection as an important topic and organisa-
tionally anchoring it in regular meetings was perceived at least to be as important as using
the app (see Fig. 4). For case 1, the answers even indicate that the participants perceived the
app to be less valuable for reflection that the other factors. These surprising results can be
attributed to the fact that the studies lasted for only four and five weeks and that in this short
period time, the effect of the intervention to more systematically reflect superseded the posi-
tive effect caused by the app. This might have been amplified by the time to adopt the app in
each of the cases as reported above. On the other hand it shows that the sheer process of
introducing the app acted as a reification of reflection, increasing awareness for it – this pro-
vides a good basis for long-term success of the app.
In the past weeks it helped me in thinking about conversations with
relatives and residents...
5 4,2
3,6 3,8 3,6 3,6
4 3,4
3
Case 1
2
Case 2
1
The app has helped to The app has helped to The app has helped to
constructively think about discuss conversations with improve conversations with
conversations afterwards. colleagues. residents, relatives or others.
Fig. 4. Factors impacting the reflection practice of participants in both trials.
Although our observations and insights cannot be generalized, as the data from the trials
was collected with low participants numbers, they point to the value potentially created by
tools such as the Talk Reflection App that support the collaborative reflection blueprint
48
Support for collaborative reflection in healthcare: comparing two workplaces
shown in Fig. 1. Further work will have to show whether these positive pointers also show in
other cases with more users and a longer period of usage.
5 Discussion: Reflection as a Socio-Technical Task
Results of the study show different perceived value and adoption of articulation support for
conversation and interaction experiences, comments and outcomes as described in the
framework in section 2.1: While the documentation of experiences and the possibilities to
share them with others was used quite frequently, the discussion of experiences and creation
of outcomes was observed to take place outside the app (but, sometimes, by using it to refer
to its content). This is also indicated by the questionnaire about reflection support (Fig. 4).
The results thus suggest that, with regard to support collaborative reflection, the Talk Reflec-
tion app was mostly used as a tool to prepare (by documenting and sharing cases), to medi-
ate (initial reflection within the documentations) and to trigger (discussion within the group)
reflection. To support communication and articulation about experiences and the documenta-
tion of outcomes from reflection, further work needs to be done. From these findings, we
derived a classification of reflection support as primary and secondary effects happening in
technical and social processes (Table 6).
Table 6. Primary and secondary support of collaborative reflection steps. Insights derived from the
studies and separated by technical (T) and social (S) parts of socio-technical support.
Purpose of Primary Support Secondary Support
Articulation
Documentation of expe- Documentation in app (T) Verbal explanation (S)
riences
Individual reflection Reflective parts in documentation (S and T)
Collaborative Direct communication (S) Comments in app (T)
reflection
Sustaining outcomes Direct Communication (S) Documented results (T)
Our observations indicate that supporting collaborative reflection is a socio-technical design
task: In both cases positive effects on the reflection process where the result of a combina-
tion of social processes with technological components. This explicitly includes that tech-
nical support for reflection needs to be complemented by establishing organizational pro-
cesses.
Although collaborative reflection was conducted successfully in direct communication be-
tween participants, there are also trade-offs to be considered: It is necessary to leave and
share traces of experience exchange and reflection outcomes for those that did not participate
in the reflection process personally. However, during the study participants needed to be
reminded to create comments in the app or to document an outcome. The sufficient number
of documentations also shows that this problem is not caused by the effort it takes to docu-
ment a difficult conversation. On the contrary, we conclude that users have to be triggered to
also use the app for other kinds of communication. “Prompting“ (e.g., Lin & Lehman 1999),
that remembers users of other content and features of a tool, may be helpful for that (e.g. by
49
Support for collaborative reflection in healthcare: comparing two workplaces
showing questions like “Have you been in a similar situation?”). This has to be analyzed in
future studies with the Talk Reflection app.
One limiting factor of the study is that the tests were conducted in participant groups
working closely together. Physicians in case 1 and caregivers in case 2 communicate regular-
ly as they mostly work on the same wards and floors. Therefore using the comments within
the app to exchange experiences may be less beneficial and more time-consuming for them
than just talking about it on the hallway during daily work. Future studies have to shed light
on the question whether groups that do not work together so closely (e.g. different wards of
the same care home or hospital) would use those functions more often.
6 Conclusion and Outlook
This paper describes a study about support for collaborative reflection at two healthcare
workplaces. For the study the “Talk Reflection App” was used that was developed based on
empirical results and a model of collaborative reflection. Analyzing the results of the study,
we suggest that this support has to be understood and implemented as a socio-technical sys-
tem rather than a development challenge. We found that in the studies the documentation and
sharing of situations to reflect about turned out to be a crucial preparation task and trigger for
reflection, while comments as part of collaborative reflection and development of outcomes
where observed to take place mostly in direct communication between participants.
Future studies have to show whether and how these later phases of collaborative reflection
can also be supported. Prompting mechanisms as described above and other concepts are
currently tested and evaluated.
References
Boud D (1985) Reflection: Turning experience into learning. Kogan Page, London
Daudelin MW (1996) Learning from experience through reflection. Organizational Dynamics 24:36–
48.
Dyke M (2006) The role of the “Other” in reflection, knowledge formation and action in a late moder-
nity. International Journal of Lifelong Education 25:105–123.
Fleck R, Fitzpatrick G (2009) Teachers’ and tutors’ social reflection around SenseCam images. Interna-
tional Journal of Human-Computer Studies 67:1024–1036.
Hoyrup S (2004) Reflection as a core process in organisational learning. Journal of Workplace Learn-
ing 16:442–454.
Kerth NL (2001) Project Retrospectives. Dorset House
Kirkpatrick DL (1975) Evaluating training programs. McGraw-Hill Education
Kolb DA, Fry R (1975) Towards an applied theory of experiential learning. In: Cooper C (ed) Theories
of Group Processes. John Wiley, London, pp 33–58
Lin X, Hmelo C, Kinzer CK, Secules TJ (1999) Designing technology to support reflection. Education-
al Technology Research and Development 47:43–62.
Lin X, Lehman JD (1999) Supporting learning of variable control in a computer-based biology envi-
50
Support for collaborative reflection in healthcare: comparing two workplaces
ronment: Effects of prompting college students to reflect on their own thinking. Journal of Research in
Science Teaching 36:837–858.
Prilla M, Degeling M, Herrmann T (2012a) Collaborative Reflection at Work: Supporting Informal
Learning at a Healthcare Workplace. Proceedings of the ACM International Conference on Supporting
Group Work (GROUP 2012). pp 55–64
Prilla M, Pammer V, Balzert S (2012b) The Push and Pull of Reflection in Workplace Learning: De-
signing to Support Transitions Between Individual, Collaborative and Organisational Learning. Pro-
ceedings of the Seventh European Conference on Technology Enhanced Learning. pp 278–291
Scott SG (2010) Enhancing Reflection Skills Through Learning Portfolios: An Empirical Test. Journal
of Management Education 34:430–457.
Suchman L (1996) Supporting articulation work. In: Kling R (ed) Computerization and Controversy:
Value Conflicts and Social Choices,. pp 407–423
51