Education for Health

REVIEW ARTICLE
Year
: 2012  |  Volume : 25  |  Issue : 3  |  Page : 198--203

Facilitating Students' Reflective Practice in a Medical Course: Literature Review


Lisa Jane Chaffey1, Evelyne Johanna Janet de Leeuw2, Gerard Anthony Finnigan3,  
1 Occupational Therapist, Casual Research, School of Medicine, Deakin University, Australia
2 Chair and Professor, Community Health Systems & Policy, School of Medicine, Deakin University, Australia
3 Senior Lecturer Community Health School of Medicine, Deakin University, Australia

Correspondence Address:
Lisa Jane Chaffey
School of Medicine, Geelong Waurn Ponds Campus, Deakin University, Victoria
Australia

Abstract

Introduction : Reflection and reflective practice is of increasing importance in medical education curricula. The aim of this review is to summarise the literature published around facilitating reflection in a medical course, and to answer the question : W0 hat is the current evidence regarding learning and development moments across the medical curriculum in developing students«SQ» reflective practice? Methods : A review of the literature was undertaken using defined databases and the search terms «SQ»medical students«SQ», «SQ»medical education«SQ», «SQ»reflection«SQ», «SQ»reflect*«SQ» and «SQ»medicine«SQ». The search was limited to peer-reviewed published material in English and between the years 2001 and 2011, and included research, reviews and opinion pieces. Results : Thirty-six relevant articles were found, identifying enhancing factors and barriers to effectively teaching reflective practice within medical curricula, relating to: The breadth of the meaning of reflection; facilitating reflection by medical educators; using written or web-based portfolios to facilitate reflection; and assessing the reflective work of students. Discussion : A variety of reflective purposes was found in this literature review. Evidence indicates that, if students are unclear as to the purpose of reflection and do not see educators modelling reflective behaviours, they are likely to undervalue this important skill regardless of the associated learning and development opportunities embedded in the curriculum.



How to cite this article:
Chaffey LJ, de Leeuw EJ, Finnigan GA. Facilitating Students' Reflective Practice in a Medical Course: Literature Review.Educ Health 2012;25:198-203


How to cite this URL:
Chaffey LJ, de Leeuw EJ, Finnigan GA. Facilitating Students' Reflective Practice in a Medical Course: Literature Review. Educ Health [serial online] 2012 [cited 2020 Apr 7 ];25:198-203
Available from: http://www.educationforhealth.net/text.asp?2012/25/3/198/109787


Full Text

 Introduction



Reflection in medicine has been described as the action of thinking critically and consciously about one's practice, [1] so as to reduce the risk of non-conscious habitual practice, which can lead to compromised patient care and safety. Reflective capacity is seen as an essential characteristic of competent professional practice, [2],[3] and important in the development of professional behaviours. [4],[5],[6],[7],[8],[9],[10] Reflection is an ongoing skill, particularly useful when faced with situations requiring flexible adaptation [11] or that have no obvious solution. [12]

Boenink [13] suggested that reflection requires the conscious integration of different perspectives and views into practice, which Sandars [14] asserted results in a broader understanding of experiences and the self, informing future actions. This application for medical curricula is even further clarified by Ewen, [15] who emphasised the importance of questioning the truth and knowledge of both oneself and others by students learning about themselves. In his investigation of low levels of Indigenous representation in Australian medical schools, Ewen outlined the role of this form of questioning in challenging non-indigenous dominance, and as a vehicle of self-care. Reflection is now a core part of medical curricula, but there are still questions as to the efficacy of its teaching methods. [16] This review summarises the literature regarding the facilitation of reflection in a medical course, and aims to answer the question:

What is the current evidence regarding learning and development moments across the medical curriculum in developing students' reflective practice?

 Methods



The literature search was undertaken using the online databases of CINAHL and Medline. Keyword searching was conducted using MeSH headings, Boolean operators, and the terms, 'medical students', 'medical education', 'reflection', 'reflect*' and 'medicine'. The search was limited to peer-reviewed published material in English and between the years 2001 and 2011 to maintain currency of practice. The primary search yielded 129 references of eligible papers, including research papers, reviews, formal reviews and opinion pieces. Abstracts were read by the first author, and only articles pertaining to facilitating or teaching reflection in undergraduate or postgraduate medical courses were included. The first author read and classed all included articles, categorising them into construct sub-categories. At several stages in this process all authors reviewed the validity and legitimacy of the classifications. This led to the sub-headings and analysis presented below.

 Results



Thirty-six relevant articles were found. These articles were classified by methodology (see [Table 1]. Relevant references identified). As can be seen in [Table 1], this review included many opinion pieces, reviews and descriptions of methods of facilitating reflection, but little in regards to primary data in the area. Qualitative methodology was the main research output, providing largely descriptive data of the facilitation of reflection. The quantitative research was also largely descriptive, with survey methodology being the most popular in the articles found. This review found only two case-control studies comparing facilitation methods of reflection.{Table 1}

The literature presented enhancing factors and barriers to effectively teaching reflective practice within medical curricula, related to:

The breadth of the meaning of reflection;Facilitating reflection by medical educators;Using written or web-based portfolios to facilitate reflection; andAssessing the reflective work of students.

Each will be explored in turn.

The breadth of the meaning of reflection

The term 'reflection' is widely mentioned within medical education literature, but the purposes and goals described indicate a breadth of purposes of reflection. [14] Mann et al.[10] concluded from their systematic review of reflective practice in the health professions that the nature of reflection makes it difficult to quantify. From this current review, we determined that the breadth of reflection covers the purposes of reflecting to improve judgements, to personally develop and, and to contextualise practice, and are explained in [Table 2].{Table 2}

Reflection to improve judgement centres on improving students' clinical skills, problem solving, [11] flexible thinking, lifelong learning and the development of expertise. [1],[10],[14],[17] Reflection for this purpose usually has a problem focus, involves critical thinking, and is commonly indicated by hypothesis testing.

Reflection to personally develop is essential in client-centred practice, as doctors need to consider they own values and assumptions, and those of the patient, while making clinical decisions. [18] From reviewing the literature, Sandars [14] asserted that the knowledge of one's values and beliefs is important for a doctor to develop therapeutic relationships with patients, as understanding oneself enables empathy and caring. Aukes et al.[11] reviewed literature in preparation for creating an assessment tool for reflection, and noted that personal reflection has often been overlooked in medical education. They suggested that this has occurred as personal development and has been seen as outside the domain of the problem-solving culture of medical practice, and thus, outside the domain of medical education.

Reflection to contextualise practice helps students integrate theory with their own experience. Several authors have hypothesised that this aspect of reflection is essential in developing a sound medical practice, [5] with a lack of reflective ability resulting in poor self-awareness, and thus poor medical practice. [19] Howe et al.[8] found, from their study of the development of professionalism, that reflecting on practice and developing self-awareness are important mechanisms of resilience in the face of a demanding profession.

Although this breadth of reflective practice makes it an essential skill in medical practice, this very strength can also be a barrier in teaching facilitating reflective practice as there is often ambiguity of the educator's goals in regard to the use of a particular reflective task. [20],[21] Aukes et al.[11] noted that purposes of a reflective tasks were rarely articulated, and students were often unaware of the perspective, reflective purpose or role, they were expected to take. Sanders [14] concluded from a literature review of reflection in medical education that, for students to reflect effectively, they required clarity in determining the appropriate purpose of a reflective task.

Facilitation reflection by medical educators

Reflection is often provoked by uncertainty or unease resulting from an experience. [13],[22] According to Albanese, [22] in addition to this uncertainty or unease, a student requires knowledge of how to reflect, and time and motivation for reflection to occur. Supporting this opinion, Carr and Carmody [23] found in their qualitative study that some students could attain an acceptable level of reflection independently. However, reflection was greatly enhanced through medical educators' facilitation.

Medical educators' facilitation was found to be useful for reflection in one-on-one meetings with students and in small group tutorials. [9],[24] According to results of a study by Schaub-de Jong et al., [9] educators who wished to encourage reflection needed to model reflective practice by making their experiences more explicit, investigating emotions and stimulating interaction among students. Albanese [22] suggested that medical faculty staff should be trained to articulate their reflections to enhance modelling to students.

Using written or web-based portfolios to facilitate reflection

Portfolio-based learning is a common method of encouraging students' reflections. [8],[25] Portfolios require students to think critically and structure their thoughts about personal and clinical experiences. [8] Fish and de Cossart [7] supported the use of writing in reflection, as they suggested that learning occurs through the process of writing, not evidenced by it. They also suggested that the writing process and content needs to be revisited and refined to allow for an increasingly greater depth of knowledge. [7]

Portfolios are highly valued by educators, [26] however, explorations of students' views indicated a range of opinions as to their value. Davis et al. [27] reported on UK medical students' feedback, indicating that students perceived portfolios to assist in their ability to reflect. Also in the UK, Rees and Sheard [26] surveyed 178 second-year medical students regarding their views about a reflective portfolio assessment, using the reflective portfolio questionnaire (RPQ). They found a significant relationship between the RPQ scores and students' rating of their reflection skills, students' confidence in building another portfolio, and students' marks for their portfolio assessment. This suggests that students with more positive views about portfolios were more likely to rate their reflection skills as good, be more confident in building a portfolio and receive better marks for their portfolio.

Driessen et al. [25] interviewed portfolio mentors of undergraduate medical students in The Netherlands regarding conditions for reflection via portfolios. Participants determined that the following four conditions needed to be met to encourage reflection: coaching; portfolio structure and guidelines; experience and materials; and summative assessment. The mentors' role of coaching involved showing students what questions to ask themselves when reflecting, helping students to identify their own learning needs and motivating students to reflect, often by explaining the value of reflection. Portfolio structure and guidelines needed to clearly explain to students what was expected. Participants reported that a more open structure was useful once students had learnt to reflect, and too much structure may be an obstacle for students with good reflective skills. The importance of a variety of interesting reflective subjects was articulated by participants in the theme experiences and material. Finally, the theme of summative assessment described some difficulty in providing the right amount of focus on assessment. The participants indicated that portfolios needed to be part of an assessment in order for them to be taken seriously by the students, but the assessment criteria needed to be sufficiently flexible to allow for individual reflective styles.

Sargeant et al. [28] conducted focus groups to explore medical students' perceptions of self-assessment, with students reporting a range of views on the use of portfolios. Some students reported portfolios had little benefit. Many suggested they were, at best, a record of performance over time. For a smaller number, the use of portfolios stimulated reflection about specific incidents and progress, and the act of writing stimulated a deeper level of reflection. The authors reported that the level of importance that students placed on portfolios was diminished if supervisors did not understand the value of this reflective tool.

Traditionally, reflective tasks have been paper based. Recently, web-based methods and social media have been adopted to facilitate reflective skills. Cook [29] asserted that there has been little study of the efficacy of these methods. Fischer et al. [30] compared content, depth of reflection and student preference for web-based versus traditional essay-style reflections in two medical schools in the USA. Ninety-five students were quasi-randomly assigned to one of two study groups, where one group wrote a traditional reflective essay and attended a small-group discussion, while the other group posted two writings in a group blog and commented on a peer's post. The writings were coded for theme, and level of reflection, with the authors finding no difference between groups for either variable.

Student opinion of e-portfolios was sought by Pink et al., [31] who developed an e-portfolio system for final year medical students at the University of Cardiff. They reported that 87% of respondents agreed that e-portfolios improved their engagement in reflective learning. Teaching staff opinion has been sought by Bashook et al., [32] who surveyed eight teaching staff from the University of Illinois, and qualitatively coded their responses. Participants reported that students' responses of reflective questions via e-portfolios gave them greater insight than other methods of reflection into students' thinking and reflective ability.

Assessing the reflective work of students

Fish and de Cossart identified nine elements of practice that characterised the experience of working doctors in the UK, and they asserted, should be included in all post-graduate medical courses. [7] These elements included some related to the context of practice, the doctor's personal qualities and values as an influence in shaping practice, and professional judgement, all of which could be addressed by reflective practice. They suggested that there was no concrete way to formally assess the criteria of reflexivity, nor many of the criteria which rely on individual's values. However, the literature suggests that a challenge in facilitating reflection appears to be the fine balance between encouraging voluntary reflections and that of assessing reflective work as a means to ensure it is undertaken.

Grant et al. [33] studied the effects of voluntary involvement in reflective learning strategies on student learning. Around 10% of third year undergraduate students engaged in the voluntary program of fortnightly tutorials and ongoing learning journals. The students involved in the reflective learning perceived that they had an improved ability to integrate learning from various sources. The students who did not take part reported that the factual content of the course made reflective learning less useful. There was no difference in examination results between these two groups. The authors concluded that the students appeared unlikely to voluntarily engage in reflection if they did not think it was linked to the curriculum or assessment.

Albanese [22] noted that surviving a medical education was often a daunting process. Students were often task-focussed, with little time for reflection. Given that adequate time and motivation are required to instigate reflection, it is not surprising that voluntary reflection is unlikely to occur in the medical student population. [22],[33] However, the very nature of assessing a reflective task may decrease the effectiveness of the task. In Sargeant et al. [28] study of medical students' perception of self-assessment, students reported that formal assessment and external scrutiny of the portfolios diminished the personal reflexivity, and subsequent learning value of this method of reflection.

 Discussion



Several authors noted that reflection was an essential skill in medical practice, [2],[5],[7],[10],[14],[34] and advocated for training in reflective processes. [13],[22] Training in reflective practice can be significantly enhanced with the facilitation of skilled mentors, providing guidance and modelling of reflective behaviours, as found by Carr and Carmody. [23] Several studies and literature reviews report inconsistencies regarding the purpose of reflection, which was found to be a significant barrier to the facilitation of reflective practice. [11],[20],[21],[35] The implication for educators is that students need to be given clear guidelines as to the purpose for each individual reflective task.

Traditionally, paper-based methods of reflection have been popular with educators, [7],[8],[25] but recently, web-based methods have been adopted. Driessen et al. [36] found that the method of reflection appears to be less important than the guidelines provided, which should be structured initially, and become more fluid as students' reflective skills progress. Ideally, students should be able to revisit and edit the reflection, hence web-based methods may be suitable for this purpose.

Students need to have the designated time and motivation for reflective practice. A common method of increasing task motivation in the education setting is to include the task as an assessment piece. There was some debate in the literature about the efficacy of this method. Some authors found that students' quality of reflection would be diminished if undertaken for an assessment task, [28] whereas others reported that reflection simply would not happen if not attached to an assessable piece of work. [22],[33]

It is apparent from this review that the research surrounding the teaching and facilitation of reflection is generally weak. Although there are some descriptive data, there is very little empirical evidence of the efficacy of facilitation methods. Additionally, there is a lack of rigorous research investigating the impact of reflection on practice skills or patient outcomes. A major limitation of literature is the breadth of the construct of reflection. A more defined construct of reflection, with clear outcomes, could lead to the development of benchmarks useful in tracking student progress and as research outcome measures.

 Conclusions



Most authors cited in this review suggested that the emphasis on reflection is increasing in medical curricula. The construct of reflection was broad in the reviewed literature. This suggests that medical educators must be clear on the purpose of reflection, the intended outcome for the individual student and the process necessary to achieve these aims for students. Evidence indicated that, if students are unclear as to the purpose of reflection and do not see educators modelling reflective behaviours, they are likely to undervalue this skill regardless of the associated learning and development opportunities embedded in the curriculum.[40]

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