or mixed-method designs) that discussed the influence or
effectiveness of reflection teaching methods
From December 2023 to March 2024, three databases were searched: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Educational Resources Information Center (ERIC). Eight duplicated articles were removed (see Table 2 ). One article was retracted by the journal due to systematic manipulation of the publication process and was subsequently removed from the screening process. Five articles were not accessible, leaving 1929 articles for title and abstract screening. 93 articles were further assessed for eligibility with the full-text reading.
Database | Search terms | No. of articles found |
---|---|---|
PubMed | | 1255 |
| 337 | |
| 1143 | |
CINAHL Plus | (reflection or reflective or reflective practice) AND (medical students or nursing students or healthcare professional students) AND (university or college or higher education) | 1126 |
(reflection or reflective or reflective practice) AND (medical students or nursing students or healthcare professional students) AND (university or college or higher education) Limiters - Publication Year: 2014–2024; English Language Expanders - Apply equivalent subjects Search modes - Boolean/Phrase | 588 | |
ERIC | (reflection or reflective or reflective practice) AND (medical students or nursing students or healthcare professional students) AND (university or college or higher education) Limiters - Published Date: 20140101-20241231 Expanders - Apply equivalent subjects Narrow by Language: - english Search modes - Boolean/Phrase | 212 |
(reflection or reflective or reflective practice) AND (medical students or nursing students or healthcare professional students) AND (university or college or higher education) | 393 |
The Inclusion and exclusion criteria were applied and 76 articles were excluded:
Six articles also were manually searched from the reference lists; five articles were excluded and one was included for the final analysis 2 . Together, the final numbers of the included articles were eighteen (see Figure 1 ) 21 .
Data from the included articles were extracted into Microsoft Excel. The extraction process was iterative and the focus of the extracted data was revised to ensure that they were relevant to the aims of the review. The final data extraction file included:
Title, Author’s name, Year, Country, Type of study, Aims, Teaching methods employed, Data collected/generated, Data analysis techniques, Underlying theory/pedagogy, Participants, How the teaching methods influence reflection, Themes and Limitations of the study.
Narratives were used to describe the findings. The author read and reread the included articles to see the patterns, similarities and differences within them. The focus related to the aims of the review. Given that there were diverse types of study from several countries within different groups of students, the underlying theory and pedagogical approach was examined to conceptually capture the findings in a more meaningful way. The included articles were not critically appraised since this review did not intend to determine the quality of each article and intended to explore a broad range of existing practices.
The included 18 articles were published from 2014 to 2024. There was a well-distributed geographical distribution of the included studies. The majority of the included articles (5) were conducted in the United States 5 , 22 – 25 , followed by the UK (3) 26 – 28 . Two articles were conducted in Australia 10 , 29 . One article each originated from The Netherlands 30 , New Zealand 15 , Norway 31 , Singapore 32 , Spain 33 , South Korea 34 , Taiwan 35 and Thailand 2 .
Eight articles had qualitative study designs. Six articles had quantitative designs and four had the mixed-method designs. The HCPs students in these articles were also diverse. Almost all of the articles predominantly focused on students from one field which were medical students (8), nursing students (8) and healthcare assistants (1). Only one study focused on the first-year students from various fields 35 , indicating a universal interest of reflection from the educator’s standpoint from various disciplines.
The most frequently used underlying theory employed in these articles was Constructivism (4) followed by social constructionism (2), Sociocultural learning theory (1), Social cognitive theory (1) and Sociocritical paradigm (1). Kolb’s experiential learning theory were mentioned in two articles. Seven articles did not explicitly mention their underlying learning theory utilised; two were implied to utilise positivism research paradigm and five were implied to base on constructivism (see Extended data 1).
This section respectively discusses the findings and relates them back to the aims of this review.
Based on the included articles, the teaching of reflection could be categorised as a spectrum, ranging from:
The structured format of reflection approach usually involves any teaching with reflective templates or reflective models that students could use to enhance and demonstrate their reflection. The reflective models used were Gibb’s reflective model 2 and Bain’s reflective framework 10 . Often, structured tools such as a reflective journaling 34 , or post-activities debrief were offered to students to facilitate on how they could express their reflection. In such instances, reflection was often not the main focus of the activities but students could demonstrate their increased capacity to reflect as well. This mainly occurred in high fidelity simulations with debriefing 5 , 10 , 32 which suggested multiple benefits of the learning activities.
This approach, whilst perceived as useful, was paradoxically seen by students as rigid. Students from several articles expressed a dislike of this approach since it was perceived as inauthentic and repetitious 15 , 22 , 30 . Pedagogically, students could even become a reflective zombie 36 ; that is, they might emulate the reflective process but did not actually reflect thus making it more challenging to ascertain the authenticity of their reflection 1 .
Alternatively, the semi-structured format of reflection provides more flexibility to students to express their thoughts but still offers scaffolding of their reflection. This approach includes Balint student support group 28 , Schwartz round 27 , video recording of students’ performance 31 and AI generative arts 25 , problem-based learning group discussions 22 , virtual classrooms 23 and concept mapping 30 and in-verse reflection workshops 29 .
The teaching methods under this approach tend to include group learning experience, utilise social constructionism and offer several methods for students to express their reflections e.g., either verbally or in writing. The process almost always includes an extensive preparation for the students before during and after the sessions and is mainly dependent on facilitator’s skill to lead the sessions. For instance, Reed et al. (2023) piloted a novel approach to integrate the use of generative AI to facilitate nursing students’ reflection. The learning process included students, who are also the coauthors of the article, creating AI prompts to create photos that were related to nursing. They were subsequently encouraged to write and reflect on the photos and subsequently joined a small group discussion.
As the description attest, the process is rather laborious and comprised of several preparations, making this approach relatively time and resource extensive. This limitation is similar to what Gleeson et al. (2020) acknowledged. That is, they agreed with the usefulness of the medical Schwartz round to enhance students’ capacity to reflect yet found it financially and logistically challenging to facilitate the sessions thus may not be applicable to scale within their institution or beyond.
Finally, the flexible and creative format of reflection almost always relates to art-based pedagogy. This approach leverages the use of art forms to empower students to creatively express their reflections without any constraints. The studies included an offer to use various creative outlets namely poetry, visual arts, narrative prose, photography, sculpture, music, needlework 15 . Or, one alternative approach over the formal reflection form of writing was offered such as poetry 26 or narrative writing 24 , 33 , 35 . Still, despite the creativity freedom within this approach that empower student’ agency, some expressed concern over their learning process since they found it harder to express themselves or could not fully relate its relevance to a more ‘formal’ reflective assessment which tends to be dominated by a written format 15 , 26 . This was compounded from the educators’ standpoint; that is, it is impossible – and even inappropriate – to assess the quality of students’ reflection with this approach due to their subjectivity. As such, the flexible and creative format may be suitable for learning activities that do not involve any assessment.
All of the included articles reported that students had either an improved understanding of reflection or improved reflective capacity. This claim was usually asserted by validated instruments to demonstrate students’ improved capacity to reflect before and after the class such as the Groningen Reflection Ability Scale (GRAS) 22 , 23 , 32 , or the Reflective Thinking Level 34 . Zhang et al. (2020) conducted a study to assess 63 third year nursing students GRAS post-class and one week after the class after their high-fidelity simulations with the use of video-assisted debrief. Results showed that participants had significantly improved their debriefing reflective abilities (p<0.01) after the video-assisted debrief intervention from the median of 84 to 87 pre- and post-class; this trend is also similar to other included studies, indicating the usefulness of the teaching methods employed.
For qualitative or mix-method studies, students’ textual outputs or interview transcripts were often used to support the claim that they have a better understanding of reflection. McBain et al. (2015) offered 14 fourth year medical students to freely choose their medium to reflect which could be either a traditional reflective essay or more creative options such as poetry, visual arts, or sculpture; their textual commentaries that accompany their works were used for the analysis. Participants universally expressed that creative outputs were more effective for them to express emotion or ideas that are difficult to articulate. This is particularly important since these students were doing a clinical rotation in a palliative care department which may be rather emotionally demanding, indicating that it might be useful to have certain tools to ease the cognitive load of participants when they were reflecting 24 , 31 , 33 . Students also stated that the arts created were helpful since they could reflect in a different way that was not as repetitious or perceived as just another reflective essays 15 . Still, most of the studies tend to capture participants’ self-perceived of enhanced reflection. Or it could come from educators’ perception that these students had a better capacity to reflect which might be challenging to verify.
Findings from this review indicate that there are several approaches to enhance student’ capacity to reflect. This could be achieved either via a more structured approach which could be perceived as repetitious and inauthentic 15 , 30 . Or, students could be offered a semi-structured approach or even more creative and flexible form of reflection to empower their autonomy 24 , 26 .
Despite the various approaches to teach reflection, both the educators and students suggested that there is a need to balance between being directive and being flexible 28 , 30 . That is, for students who are relatively new to the concept e.g., those who are in the first year of their programme or have limited exposure to clinical experience, it might be more appropriate to have a structured guidance to scaffold their learning process 29 , 32 . Conversely, those who are in their later years or are more experienced reflective practitioners may find the structured reflective format repetitive or even restrictive to their reflection. Consequently, a more flexible and creative expression might be an alternative option for students to demonstrate their reflection.
To the author’s knowledge, this is the first review that has explored the way in which the concept of reflection is taught in higher education for HCPs students. The review demonstrates a comprehensive view of the teaching methods available that educators could consider and apply the most appropriate ones to their contexts. The review process was also thoroughly described hence making it transparent and replicable.
Still, this review poses few limitations:
First, despite the attempt to outline the screening process, this review was conducted by one person. As such, there might be certain articles that the author has overlooked. Second, the review only included articles that were published in English. This further perpetuating the dominant Western-centric scholarship, restricting the latest call for citational justice and may not be fully transferable to wider contexts 37 . Still, this review was conducted with a limited time and resource hence the author could not include more diverse scholarly outputs that were not in English.
Third, although this review did not intend to appraise the quality of the included articles, some articles indicated either poor study designs or superficial level of analysis that lack criticality. Also, almost all of the included studies except two were conducted with a relatively small sample size from a single institute thus makes it even more challenging to transfer the findings to other contexts.
This narrative review has identified several teaching methods that help facilitating HCPs students’ capacity to reflect. Even though findings are unable to recommend the most efficient way to teach reflection, it might be more appropriate to consider students’ learning needs and adjustments the teaching method accordingly. This could be achieved via a more relational approach to teaching that might begin with a structured format of reflection which gradually increases students’ autonomy to express their reflection throughout. Given that there is no one-size-fits-all to teaching due to different leaning contexts, the focus should be how educators could scaffold the students’ learning process to empower them to become a lifelong reflective practitioner.
[version 1; peer review: 2 approved]
The author(s) declared that no grants were involved in supporting this work.
Tanisha jowsey.
1 Bond University, Robina, Queensland, Australia
Hi there, thanks for undertaking this work, which I read with interest.
Here are recommendations to make this solid paper even better:
The title and introduction suggest your review is of the entire higher education field; we need clarity on the scope of your study throughout. I suggest you reword the title from higher education to 'undergraduate health professions students' and hone the focus of your introduction to match that focus.
methods suggest replacing this sentence: "Articles that were published during 2014–2024 within three databases, PubMed, CINAHL and ERIC were searched. 1929 articles were eligible for screening. 93 articles were further assessed for eligibility." I suggest this instead: "I searched three databases (PubMed, CINAHL and ERIC) for articles published between 2014–2024 using the following search terms and their derivatives: XXXX 1929 articles were eligible for title and abstract screening. 93 articles were further assessed (full text screening) for eligibility."
Methods is fine. I found it unusual and insightful that you've applied a narrative focus to the included studies but I didnt see a evidence of this unique method in the way the results are presented. Did I miss something?
Results - Ah yes, the reflective zombie - a constant frustration for teachers (!) I found Reed's approach to this - the Gen AI image reflection - a great example of one possible avenue to engage students and get them out of zombie mode.
The paragraph about "creative format of reflection almost always relates to art-based pedagogy" - I was surprised that creative outputs as evidence of reflection were deemed impossible to assess. There are whole schools of practice that do exactly that. For example, critical arts therapy. I myself published a book called Medicine Reflections (2017 1 ) where we showcased how creative elements in the reflective portfolios of our undergrad medical students were assessed. I would suggest that it can be done. The question of whether this is appropriate or not is another matter. Perhaps you could rework those last two sentences of the paragraph to split out whether you can assess from whether you should assess?
The remaining sections read well. Thanks.
Is the review written in accessible language?
Are all factual statements correct and adequately supported by citations?
Are the conclusions drawn appropriate in the context of the current research literature?
Is the topic of the review discussed comprehensively in the context of the current literature?
Reviewer Expertise:
I have used critical reflection in assessment in medicine for the past 12 years and currently supervise a doctoral student who is researching the role of critical reflection in paediatric surgery training. We have a published literature review in this space called 'Reflecting on insight and insights into reflection: a systematic review of insight and reflection in post graduate medical education.' I have also published a book called Medicine Reflections.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
1 Walailak University, Thai Buri, Nakhon Si Thammarat, Thailand
Well-written article. Your insights into this interesting topic are enlightening and comprehensively supported by citations. The use of easily understandable language makes the content accessible, and the conclusions drawn are appropriate in the context of the current research literature. The comprehensiveness and clarity of your article make it a valuable resource.
Some suggestions:
1. The title may be edited to reflect the specific issue on healthcare professional students/learners.
2. The methodology is well-written, constructed, and valid.
3. In the discussion section, the author may provide a subsection about further considerations or gaps in studies that need to be explored.
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JERUSALEM — Three hundred and thirty-two days after Hersh Goldberg-Polin danced in the courtyard next to his Jerusalem synagogue on the holiday of Simchat Torah, more than a thousand people gathered there in grief and prayer to mourn his murder by Hamas terrorists in Gaza.
During the Sunday night vigil, the courtyard railings were lined with oversized yellow ribbons to symbolize advocacy for the hostages, Hapoel Jerusalem soccer flags — the 23-year-old’s favorite team — and posters that read, “We love you, stay strong, survive,” a mantra coined by his mother, Rachel Goldberg-Polin.
Just hours earlier, one of the posters had been hanging over the balcony of the home of Shira Ben-Sasson, a leader of Hakhel, the Goldberg-Polins’ egalitarian congregation in the Baka neighborhood of Jerusalem.
“We were sure we would take it down when he came home,” Ben-Sasson said.
The community wanted to unite while respecting the Goldberg-Polins’ desire for privacy, she said, prompting them to organize the prayer gathering.
“But it’s like a Band-Aid or giving first aid, it’s what you do in an emergency. I don’t know how we go on after this,” she said.
A covered courtyard at the Hakhel congregation was filled with mourners the day after Hersh Goldberg-Polin, whose family are prominent members, was found to have been killed in Gaza. Hundreds of other people crowded outside the gates, Sept. 1, 2024. (Deborah Danan)
She added that the community, which has a large contingent of English-speaking immigrants, was not prepared for the High Holidays, which begin in about a month. She said, “Seeing his empty seat is hard.”
For Ben-Sasson, who wore a T-shirt bearing the Talmudic dictum “There is no greater mitzvah than the redeeming of captives,” the tragedy is especially painful because, she said, it could have been avoided with a ceasefire agreement that freed hostages.
“Hersh was alive 48 hours ago. We think a deal could have saved him. There is no military solution to this,” she said.
That feeling of bereavement, often mixed with betrayal, pervaded gatherings across Israel on Sunday, as the country struggled with the news that six hostages who may have been freed in an agreement were now dead as negotiations continue to stall. Speakers at protests in Tel Aviv blamed Israeli Prime Minister Benjamin Netanyahu, who himself apologized for not getting the hostages out alive but blamed Hamas for obstructing a deal. The country’s labor union, the Histadrut, has called a national strike on Monday to demand a deal.
A rare early September rain lashed parts of Israel on Sunday, leading to a widespread interpretation: God, too, was weeping.
Some at the Jerusalem gathering, including the relative of another former hostage, said Netanyahu had chosen defeating Hamas over freeing the captives.
Josef Avi Yair Engel’s grandson Ofir was released from Hamas captivity in November. He paid tribute to Hersh Goldberg-Polin, murdered in captivity, in Jerusalem, Sept. 1, 2024. (Deborah Danan)
Josef Avi Yair Engel, whose grandson Ofir, 18, was released from Hamas captivity in November during that month’s ceasefire deal, expressed shock over Hersh’s murder but said he was not surprised, given the wartime policies of Netanyahu’s government.
“We knew months ago this was going to happen. Bibi’s formula, to dismantle Hamas and return the hostages, wasn’t logical. It’s an either/or situation,” Engel said, referring to Netanyahu by his nickname. “He’s tearing the country apart. I’m afraid that in the coming months there won’t be a state at all.”
Engel said he felt a close bond with Hersh’s father Jon Polin, not only because of their joint activism in the hostage families’ tent outside the Prime Minister’s Residence, but also because of their shared identity as Jerusalemites.
“There aren’t many of us in the hostage circle,” he said. “We’re like family.”
Sarah Mann, who did not know the family personally, said the weekend’s tragedy reminded her of Oct. 7.
“This day has sparks of the seventh, which created numbness and an inability to talk. Just complete shock,” she said.
Mourners left notes at a gathering at Hersh Goldberg-Polin’s family synagogue in Jerusalem. Many of the messages used the Hebrew word for “sorry.” (Deborah Danan)
Part of the reason for that, Mann said, was Rachel, who she described as a “force of faith.” Goldberg-Polin’s mother emerged as the most prominent advocate for the hostages globally and became a symbol in her own right as she crisscrossed the world calling for her son’s freedom.
“Millions of people around the world held onto her. Once that was cut, people’s ability to hold onto faith was knocked out today. But even though this has shattered us, we need to keep holding onto God,” Mann said.
For Susi Döring Preston, the day called to mind was not Oct. 7 but Yom Kippur, and its communal solemnity.
She said she usually steers clear of similar war-related events because they are too overwhelming for her.
“Before I avoided stuff like this because I guess I still had hope. But now is the time to just give in to needing to be around people because you can’t hold your own self up any more,” she said, tears rolling down her face. “You need to feel the humanity and hang onto that.”
Like so many others, Döring Preston paid tribute to the Goldberg-Polins’ tireless activism. “They needed everyone else’s strength but we drew so much strength from them and their efforts, “she said. “You felt it could change the outcome. But war is more evil than good. I think that’s the crushing thing. You can do everything right, but the outcome is still devastating.”
Guy Gordon, with his daughter Maya, added a broken heart to the piece of tape he has worn daily to mark the number of days since the hostage crisis began, Sept. 1, 2024. (Deborah Danan)
Guy Gordon, a member of Hakhel who moved to Israel from Dublin, Ireland, in the mid-1990s, said the efforts towards ensuring Hersh’s safe return have been an anchor for the community during the war. The community knew him as the family described him in its announcement of his funeral on Tuesday, as “a child of light, love and peace” who enjoyed exploring the world and coming home to his family, including his parents and younger sisters, Leebie and Orly.
“It gave us something to hope for, and pray for and to demonstrate for,” he said. “We had no choice but to be unreasonably optimistic. Tragically it transpired that he survived until the very end.”
Gordon, like many others in the crowd, wore a piece of duct tape marked with the number of days since Oct. 7 — a gesture initiated by Goldberg-Polin’s mother. Unlike on previous days, though, his tape also featured a broken red heart beside the number.
Nadia Levene, a family friend, also reflected on the improbability of Hersh’s survival.
“He did exactly what his parents begged him to do. He was strong. He did survive. And look what happened,” Levene said.
She hailed Rachel Goldberg-Polin’s “unwavering strength and belief in God,” adding, “There were times I lost faith. I suppose I was angry with God. But she just kept inspiring us all to pray, pray, pray.”
Leah Silver of Jerusalem examined stickers showing Rachel Goldberg-Polin’s mantra for her son Hersh, who was murdered in captivity in Gaza, at a gathering after Hersh’s death, Sept. 1, 2024. (Deborah Danan)
Jerusalem resident Leah Silver rejected politicizing the hostages’ deaths.
“Everything turns political so quickly. I came here because I felt that before all the protests, we need to just mourn for a moment and to pray. And show respect for each other,” she said. “We’ve become confused about who the enemy is. It’s very sad.”
But not everyone at the gathering joined in to sing Israel’s national anthem at the closing of the prayer gathering.
“I’m sorry, I can’t sing ‘Hatikvah,'” Reza Green, a Baka resident who did not know the Goldberg-Polins personally, said. “I’m too angry. We shouldn’t be here.”
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