Abstract
Background
Reviewing experiences and recognizing the impact of personal and professional views and emotions upon conduct shapes a physician’s professional and personal development, molding their professional identity formation (PIF). Poor appreciation on the role of reflection, shortages in trained tutors and inadequate ‘protected time’ for reflections in packed medical curricula has hindered its integration into medical education. Group reflection could be a viable alternative to individual reflections; however, this nascent practice requires further study.
Methods
A Systematic Evidence Based Approach guided Systematic Scoping Review (SSR in SEBA) was adopted to guide and structure a review of group reflections in medical education. Independent searches of articles published between 1st January 2000 and 30th June 2022 in bibliographic and grey literature databases were carried out. Included articles were analysed separately using thematic and content analysis, and combined into categories and themes. The themes/categories created were compared with the tabulated summaries of included articles to create domains that framed the synthesis of the discussion.
Results
1141 abstracts were reviewed, 193 full-text articles were appraised and 66 articles were included and the domains identified were theories; indications; types; structure; and benefits and challenges of group reflections.
Conclusions
Scaffolded by current approaches to individual reflections and theories and inculcated with nuanced adaptations from other medical practices, this SSR in SEBA suggests that structured group reflections may fill current gaps in training. However, design and assessment of the evidence-based structuring of group reflections proposed here must be the focus of future study.
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Discover the latest articles, news and stories from top researchers in related subjects.Introduction
Reflection allows physicians the opportunity to reflect on their actions, recognize how their thoughts, feelings and emotions affect decision-making processes, clinical reasoning, and professionalism [1,2,3,4,5,6], from which these insights are then integrated into the evolving values, beliefs, and principles (henceforth belief system) that shape the professional development of physicians [7,8,9,10,11]. The critical role reflection plays in the professional identity formation (henceforth PIF) of physicians [12,13,14,15,16,17] merits further investigation into its different applications in medical education.
One such example of its application, are group or collaborative reflections, which sees reflections shared amongst two or more participants moderated by a facilitator or supervisor, infused with personal and cultural ‘frames of reference’, emotional insights and personal interpretations and consolidated by shared meaning-making [18,19,20,21,22,23,24,25,26]. The social nature and interaction in clinical education increase the need to improve upon current reflective practices in medical education [27], which are often challenged by the lack of protective time, limited access to trained support in the packed curriculum of healthcare professionals [19, 23,24,25, 28,29,30].
Therefore, a review is proposed to provide a consistent understanding on practices in group reflections, and effective guidelines on the design, structuring, assessment and oversight of group reflective practice in medical education. This review aims to answer the questions of “What is known about group reflections in medical education?” and “How are group reflections structured, assessed and supported in medical education?”.
Methods
Krishna’s Systematic Evidence-Based Approach (SEBA) was adopted to guide this systematic scoping review (SSR) (henceforth SSR in SEBA) [31, 32] to identify available data, key characteristics, and knowledge gaps in current concepts of group reflections in regnant medical education literature (Fig. 1). The SSR in SEBA’s constructivist approach [33,34,35,36,37,38,39,40] and relativist lens [41,42,43,44,45] acknowledges reflective practice as a sociocultural construct influenced by the physician or medical student’s narratives, contextual considerations, clinical insights and the program culture and environment.
The SEBA process
Stage 1 of SEBA: systematic approach
Identifying the research question
The primary and secondary research questions were determined to be “What is known about group reflections in medical education?”, and “How are group reflections structured, assessed and supported in medical education?”. These questions were designed around the PICOs (Population, Intervention, Comparison, Outcome, study design) (Table 1).
Searching
Members of the research team carried out independent searches from bibliographic databases such as Pubmed, EMbase, Psychinfo, CINAHL, ERIC, ASSIA, Scopus, and Google Scholar, as well as grey literature databases Open Grey, GreyLit, and ProQuest using variations of the term “group reflections”, “group debrief”, and “Collaborative reflections” (Table 2).
Extracting and charting
Titles and abstracts were independently reviewed by the research team to identify relevant articles that met the inclusion criteria. Full-text articles were independently reviewed, with each reviewer producing their own final list of included articles. Sandelowski and Barroso [46]’s approach to ‘negotiated consensual validation’ was used to achieve consensus on the final list of articles to be included.
Stage 2 of SEBA: split approach
The ‘Split Approach’ [34, 46,47,48,49,50] was employed to enhance the reliability of the data analyses, which saw the research team split into three groups to independently analyse the included articles.
The first team summarised and tabulated the included full-text articles in keeping with recommendations drawn from Wong et al. [51]’s RAMESES publication standards: meta-narrative reviews and Popay et al. [41]’s “Guidance on the conduct of narrative synthesis in systematic reviews”. Concurrently, the second team analysed the included articles using Braun and Clarke [52]’s approach to thematic analysis whilst the third team of researchers drew categories from Lim et al. [5]’s review entitled “A systematic scoping review of reflective writing in medical education” in their employ of Hsieh and Shannon [53]’s approach to directed content analysis.
Stage 3 of SEBA: jigsaw perspective
Overlaps between categories and themes allowed their combination to create a bigger piece of the puzzle referred to as themes/categories.
Stage 4 of SEBA: funnelling process
Through the Funnelling Process, themes/categories were compared with the tabulated summaries to determine the consistency of the domains created, forming the basis of the discussion.
Stage 5: analysis of evidence-based and non-data driven literature
The themes from data-driven or research-based peer-reviewed data were compared to those drawn from grey literature and found to be the same and thus unlikely to have influenced the analysis.
Stage 6: synthesis of scoping review in SEBA
The Best Evidence Medical Education (BEME) Collaboration Guide and the Structured approach to the Reporting In healthcare education of Evidence Synthesis (STORIES) were used to guide the discussion.
Results
A total of 1141 abstracts were reviewed, 193 full-text articles were appraised, and 66 articles were included and analysed. The PRISMA flow diagram may be found in Fig. 2.
PRISMA flowchart
The participant population and the country of origin are shown in Table 3.
The domains identified were (1) Theories and models, (2) Indications for group reflections, (3) Types of group reflections, (4) Structure of group reflections programs, and (5) Benefits and challenges. Here we consider the data in their entirety and include nurses, allied health professionals, medical students and physicians under the umbrella term ‘clinician’.
Domain 1: theories and models
Current accounts of group reflections are framed by the traditional concepts and theories employed in individual reflections and reflective writing. These concepts and theories focus on the critique and group discussion of a specific experience and the lessons drawn from this process. However, current concepts also recognise the influence of the clinician’s narratives, clinical insights, belief systems, contextual and environmental considerations as well as their willingness and readiness to share their insights and emotions on the impact on their thinking and practice (Table 4).
Many theories follow the process of allowing participants to share their reactions to the experience, followed by a deconstruction of the experience through the process of inquiry and discussion [104]. While Kolb’s Learning Cycle served as a baseline for many models for reflection [104, 114], some studies use a combination of models.
Domain 2: indications for group reflections
Current indications for the employ of group reflections centre on enhancing holistic and collaborative learning [18, 54]. Other indications for group reflections include as a means of determining the nature of the ‘takeaway’ from a specific learning interaction and boosting engagement [19, 20, 99, 117] (Table 5).
Group reflections served a valuable means of accessing the hidden curriculum through facilitating discussions and self-reflection, providing insight into unspoken norms and values which influence clinical reasoning [54]. The synthesis of different perspectives in group reflections also encouraged participants to integrate these diverse viewpoints into their individual understandings of medical practice [61]. As a community of practice, group reflections played an important role in increasing the social belonging of participants through the safe space provided for open dialogue and sharing experiences [106, 116, 118]. This contributes significantly into the development of cohesive learning communities through the co-construction of a shared understanding of relevant concepts and strategies in the clinical context [28, 84, 114, 115, 119, 120].
Domain 3: types of group reflections
Three distinct methods of group reflections emerged from the data: dialogues, debriefings and focus groups (Table 6).
Dialogues promote new ways of understanding one’s self and their surroundings, focusing on subjective aspects and facilitating the sharing of perspectives between participants [23,24,25]. Debriefings are structured discussions which occur following specific events within medical education, serving as a method for reflection on action and identifying areas for improvement [62, 87, 89, 104, 109, 115, 121,122,123,124,125]. Focus groups are utilized for exploring and generating data on niche topics, providing a platform for participants to share insights and contribute to a deeper understanding of experiences [26, 28,29,30, 120].
Domain 4: structure of group reflections programs
A range of structures influencing the effectiveness of group reflective programs were uncovered, which encompassed various aspects such as the group size, frequency of meetings, modalities and assessment methods (Table 7).
Structured group reflection programs were predominantly organized with planning and specific guidelines, emphasizing key elements such as the preparation process, which often time entails pre-readings, communicating objectives [68], and establishing ground rules [104, 105]. Group sizes often varied between smaller groups, which allowed intimate and in-depth discussions [62, 126, 129,130,131]; and larger groups which allowed for a wider range of perspectives [21, 119, 132]. Frequency of these sessions varied between once-off sessions [130] to regular meetings [18, 132]. Group reflective programs utilized different modalities such as in-person meetings [21, 61, 126, 133] and online meetings [25, 128, 134] which are scaffolded by other activities reviewing video playback [104, 106].
With regards to the assessment of group reflective programs, the most common method used were feedback surveys [18, 86, 101, 105, 109, 116, 133, 134] and questionnaires [101, 116] to gather feedback and insight into the effects of the programs. Few articles mentioned the use of assessments such as evaluation of portfolios [18] or ungraded diary entries [99], or analysing interview transcripts relating to the group reflective program [61].
Domain 5: benefits and challenges
Group reflections have professional and personal benefits. On a personal basis, group reflections facilitate self-assessment and self-development, reduce anxiety [24, 119, 136], stress and burnout [18, 24, 81, 89, 137] and enhance compassion and empathy amongst participants [18, 119, 130, 132, 137].
At a professional level, group reflections strengthen shared mental models and a sense of community [61, 86, 100, 130, 135, 136], build ties with peers [138] and remove hierarchy [18, 24, 82]. A summary of these benefits is included in Table 8.
The challenges surrounding group reflections may be broadly categorised into structural and participant considerations. Structural considerations hinge on the presence of a formal and organised approach [89, 104, 124, 136, 138, 139, 153, 154]. Poor longitudinal support [62, 89, 109, 141, 151, 155, 156], and a lack of long term appraisals of the effects of this intervention [29, 118, 150] may hinder holistic development, impacting the skills, attitudes and well-being of participants. The lack of a formal structure compromises facilitator/tutor recruitment [55, 89, 123, 149, 157] and training [104, 109, 115, 123, 124, 138, 141, 154, 156, 158], and the provision of protected time [81, 84, 86, 89, 104, 109, 118, 153, 156, 159]. The lack of a formal program and an organised approach also compromise longitudinal oversight of participants and the program [28, 67, 110, 138, 140, 141, 154, 160] making it predisposed to resource limitations [153, 161] and unconducive practice environments [84, 109, 122, 124, 162].
Participant considerations include concerns over privacy [24, 89, 109, 158, 163], anonymity [162], and vulnerability [67, 109] within a group, as well as managing team dynamics [28, 29, 61, 67, 118, 127, 135, 150, 152, 164], negative emotions [21] and criticism [82, 122, 124, 165] within such settings. These concerns are heightened in mixed groups with participants from different specialities, backgrounds and settings [26], particularly when participants are unfamiliar with one another [22, 127]. Hierarchy and deference to elders may also inhibit sharing, interactions [22, 127], and the disclosure of views that may contradict others [139].
Iterative stage
As part of the iterative process of the SEBA methodology, members of the expert team shared their experiences with group reflections to help contextualise the data and inculcate practical considerations (Table 9).
In our experience with group reflections, participants describe, discuss, and enrich a common or shared experience with personal, professional, practical, team, sociocultural and administrative insights, and perspectives. In many instances, the facilitator plays an active part in this process, acting as a source of clinical, professional, ethical, legal, and organisational knowledge that may be used to anchor the discussion. The facilitator also plays a key role in focusing the discussion, engaging all the participants and ensuring that the reflective process occurs within a safe environment that is conducive to the sharing of personal, private and emotional information [19, 20, 26, 28,29,30, 99, 117, 120]. A safe environment is one where participants see “one another as equal relational partners", and "question assumptions, power dynamics and structural inequities beyond medicine” [23,24,25].
Discussion
In addressing its primary research question on “what is known about group reflections in medical education?”, this SSR in SEBA reveals a growing role for group reflections in medical education, driven by growing reports of unprofessional conduct [166], poor communications [167] and inadequate mentoring support in medicine. This trend is exacerbated by a shortage of trained facilitators to support reflections, which has been further amplified by the challenges posed by the pandemic. Flourishing in its nurturing of PIF [168], interpersonal and professional skills, group reflections provide timely, personalised senior and peer support, integrates different perspectives and fosters cohesive working environments in medicine and the allied health specialities [31, 38, 169,170,171]. Yet the data suggests that the practice and effects of it vary, which is underlined by the presence of different forms of group reflections focused on varying depths of reflections guided by a mix of current theories of reflections.
Incorporating data from the review with practical experiences of group reflections (Table 9) demonstrate that group reflections can be shown to pivot on individual, group and environmental considerations.
Individual considerations
Given the scarcity of information on the individual aspects of group reflections within the current data, Krishna’s model of Reflective Writing (KmRW) from Lim et al. [5]’s review on the subject was adopted (Fig. 3). The KmRW was based on the same guiding theories and practice used in group reflective practice and provides evidence-based perspectives of the individual’s experiences with reflections, focusing on the clinician’s role in the reflective process, beginning with the clinician’s sensitivity to the presence of experiences and/or threats to belief systems [5, 172]. Rooted within the clinician’s self-concept of personhood, the belief system is shaped by and manifested in the sense of identity and in their feelings, attitudes, thoughts, decision making, and conduct. To preserve the current sense of self-identity, the clinician seeks to confront these threats to their self-concepts of personhood. This raises the notion as to their willingness to address these issues, their ability to judge and balance ramifications as a result of actions, omissions and partial actions that may arise within their personal, psychosocial, clinical, professional, research, academic, administrative, and situational context and their capability to adapt their belief system in response to the insights gained. The clinician’s ‘responsiveness’ highlights the individual’s capacity to attend and adapt their practice in light of the insights gained. The elements of the individual aspect of the reflective process are featured on the left aspect of Fig. 3.
Framework of group reflections
Group and environmental considerations
Our data coupled with expert experiences with group reflections (Table 8), spotlights the influence of group dynamics and the structure of the reflective process and its environment, setting and contextual factors. These facets shift attention from individual ‘judgement’, ‘willingness’, ‘balance’, ‘ability’ and ‘responsiveness’ to group-determined areas that include.
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the topic for discussion (this includes what, why and how the topic for reflection was identified),
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participation (this includes setting a basic level for participation, an expectation on conduct and interactions that influences group dynamics, and the sense of ‘safety’ the individual feels about sharing).
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willingness to reflect and share their reflections (aside from levels of participation, and establishing a safe environment for sharing, the group reflective process must motivate individual sharing and imbue the discussion with their narratives, experiences, and emotions).
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willingness and ability to analyze the experience.
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creating a ‘working hypothesis’.
Acknowledgement of these group, practice and structural considerations suggest a wider range of factors impacting group reflections than what is encompassed by the KmRW. Group reflections that confine discussions to a specific area of interest; establish parameters on the nature of interactions; knit together the various perspectives; and synthesize a cogent narrative of events replete with contextual, emotional, sociocultural and practical factors; underscore how organizing group reflective processes influences both experiences and results of the reflection. These features are delineated on the right side of Fig. 3.
These considerations draw attention to the secondary research question “How are group reflections structured, assessed and supported in medical education?”. Accrued data and expert opinions suggest that group reflections must build upon a consistent approach; agreed upon codes of practices, levels of participation, roles, and responsibilities; aligned expectations; effective facilitation and a nurturing environment [104, 105, 119]. The invitation to participate emphasizes privacy and includes information on the number of participants, the facilitator’s backgrounds, the setting, the duration of session, and how information will be shared [24, 89, 109, 158, 163]. The participants are also given access to personal debriefs, counselling and/or psychological support after the session [30, 67, 121, 133, 136, 138, 150, 152, 154, 157, 173, 174]. Groups should ideally comprise of participants with similar levels of experience or seniority, or individuals who are comfortable with sharing and discuss their views, experiences, insights and lessons learnt. The program should be facilitated by a trained and impartial facilitator who may be an expert in the field that can manage group dynamics, guide the synthesis of a cogent narrative, offer insights and personalised support should the need arise and debrief the participants individually if needed [21, 24, 28, 30, 89, 109, 121, 156, 162, 163, 175]. The session should be carried out in a ‘safe’ and appropriate setting that will be conducive to open sharing [29, 86, 109, 121,122,123, 134, 136, 143, 150, 154, 156, 176]. The session should be ring-fenced or be part of the ‘protected time’ for reflections during the training program [28, 30, 121,122,123, 137].
The assessment of group reflection programs is critical to understanding their impact on learners and evaluating their effectiveness. These assessment methods provide valuable feedback to educators and the continuous improvement of group reflection programs. The most common method of evaluation used in the included studies were feedback surveys and questionnaires which are valuable in gauging participant satisfaction and identifying the strengths and weaknesses of the program design. Other methods such as the written reflections, interviews and wellness scales were used in addition to these feedback methods to further explore participants’ experiences and insights that were gained through the reflective process. A future endeavour could be towards the development of a portfolio for medical learners to acknowledge the impact of these reflections on the well-being of participants, providing an avenue for feedback and improvement.
Limitations
Despite evaluation of the search process by the expert team, including only English language articles and excluding grey literature, the risk of failing to capture important articles is present. Concurrently, scrutinising publications in English skews the attention onto Western practice where distinct sociocultural, practice, education and healthcare considerations may limit the applicability of these findings in settings beyond the North American and European setting.
The purposeful selection of search terms and the employment of a wide range of databases broadened the approach to obtaining essential publications. However, the inclusion of a wide range of search terms and articles and the exclusion of non-healthcare settings may limit our analysis of the conceptualisation of the phenomenon.
Although thematic analysis was conducted by independent members of the team to improve the credibility and reliability of the data, inherent bias cannot be eliminated entirely. Perhaps most significantly is the conflation of terms and practices surrounding group reflections and debriefs.
Conclusions
Group reflections emphasize the need for targeted discussions, clear guidelines, and the incorporation of various perspectives to synthesize a comprehensive understanding of medical education. However, this review highlights the challenges in ensuring longitudinal support and appraisals, which are crucial in sustaining professional development. Aside from the need for further research into faculty training and structuring a consistent approach, future development of group reflections should focus on establishing robust frameworks for assessment, fostering ongoing support structures and integrating technological advancements to enhance the efficacy of reflective processes. A comprehensive approach considering both immediate and long-term impacts of group reflections is essential to cultivating well-rounded and empathetic healthcare professionals.
Data availability
All data generated or analysed during this review are included in this published article.
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Acknowledgements
The authors would like to dedicate this paper to the late Dr S Radha Krishna and A/Prof Cynthia Goh whose advice and ideas were integral to the success of the study, and to Thondy, Maia Olivia and Raja Kamarul whose lives continue to inspire us.
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Phua, G.L.G., Owyong, J.L.J., Leong, I.T.Y. et al. A systematic scoping review of group reflection in medical education. BMC Med Educ 24, 398 (2024). https://doi.org/10.1186/s12909-024-05203-w
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DOI: https://doi.org/10.1186/s12909-024-05203-w