reflective essay on quality improvement

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How to get started in quality improvement

Linked opinion.

The benefits of QI are numerous and the challenges worth overcoming

Read the full collection

• Related content
• Peer review
• Bryan Jones , improvement fellow 1 ,
• Emma Vaux , consultant nephrologist 2 ,
• Anna Olsson-Brown , research fellow 3
• 1 The Health Foundation, London, UK
• 2 Royal Berkshire NHS Foundation Trust. Reading, UK
• 3 Department of Molecular and Clinical Pharmacology, The Institute of Translational Medicine, University of Liverpool, Liverpool, UK
• Correspondence to B Jones bryan.jones{at}health.org.uk

What you need to know

Participation in quality improvement can help clinicians and trainees improve care together and develop important professional skills

Effective quality improvement relies on collaborative working with colleagues and patients and the use of a structured method

Enthusiasm, perseverance, good project management skills, and a willingness to explain your project to others and seek their support are key skills

Quality improvement ( box 1 ) is a core component of many undergraduate and postgraduate curriculums. 1 2 3 4 5 Numerous healthcare organisations, 6 professional regulators, 7 and policy makers 8 recognise the benefits of training clinicians in quality improvement.

Defining quality improvement 1

Quality improvement aims to make a difference to patients by improving safety, effectiveness, and experience of care by:

Using understanding of our complex healthcare environment

Applying a systematic approach

Designing, testing, and implementing changes using real time measurement for improvement

Engaging in quality improvement enables clinicians to acquire, assimilate, and apply important professional capabilities 7 such as managing complexity and training in human factors. 1 For clinical trainees, it is a chance to improve care 9 ; develop leadership, presentation, and time management skills to help their career development 10 ; and build relationships with colleagues in organisations that they have recently joined. 11 For more experienced clinicians, it is an opportunity to address longstanding concerns about the way in which care processes and systems are delivered, and to strengthen their leadership for improvement skills. 12

The benefits to patients, clinicians, and healthcare providers of engaging in quality improvement are considerable, but there are many challenges involved in designing, delivering, and sustaining an improvement intervention. These range from persuading colleagues that there is a problem that needs to be tackled, through to keeping them engaged once the intervention is up and running as other clinical priorities compete for their attention. 13 You are also likely to have competing priorities and will need support to make time for quality improvement. The organisational culture, such as the extent to which clinicians are able to question existing practice and try new ideas, 14 15 16 also has an important bearing on the success of the intervention.

This article describes the skills, knowledge, and support needed to get started in quality improvement and deliver effective interventions.

What skills do you need?

Enthusiasm, optimism, curiosity, and perseverance are critical in getting started and then in helping you to deal with the challenges you will inevitably face on your improvement journey.

Relational skills are also vital. At its best quality improvement is a team activity. The ability to collaborate with different people, including patients, is vital for a project to be successful. 17 18 You need to be willing to reach out to groups of people that you may not have worked with before, and to value their ideas. 19 No one person has the skills or knowledge to come up with the solution to a problem on their own.

Learning how systems work and how to manage complexity is another core skill. 20 An ability to translate quality improvement approaches and methods into practice ( box 2 ), coupled with good project and time management skills, will help you design and implement a robust project plan. 27

Quality improvement approaches

Healthcare organisations use a range of improvement methods, 21 22 such as the Model for Improvement , where changes are tested in small cycles that involve planning, doing, studying, and acting (PDSA), 23 and Lean , which focuses on continually improving processes by removing waste, duplication, and non-value adding steps. 24 To be effective, such methods need to be applied consistently and rigorously, with due regard to the context. 25 In using PDSA cycles, for example, it is vital that teams build in sufficient time for planning and reflection, and do not focus primarily on the “doing.” 26

Equally important is an understanding of the measurement for improvement model, which involves the gradual refinement of your intervention based on repeated tests of change. The aim is to discover how to make your intervention work in your setting, rather than to prove it works, so useful data, not perfect data, are needed. 28 29 Some experience of data collection and analysis methods (including statistical analysis tools such as run charts and statistical process control) is useful, but these will develop with increasing experience. 30 31

Most importantly, you need to enjoy the experience. It is rare that a clinician can institute real, tangible change, but with quality improvement this is a real possibility, which is both empowering and satisfying. Finally, don’t worry about what you don’t know. You will learn by doing. Many skills needed to implement successful quality improvement will be developed as you go; this is a fundamental feature of quality improvement.

How do you get started?

The first step is to recruit your improvement team. Start with colleagues and patients, 32 but also try to bring in people from other professions, including non-clinical staff. You need a blend of skills and perspectives in your team. Find a colleague experienced in quality improvement who is willing to mentor or supervise you.

Next, identify a problem collaboratively with your team. Use data to help with this (eg, clinical audits, registries of data on patients’ experiences and outcomes, and learning from incidents and complaints) ( box 3 ). Take time to understand what might be causing the problem. There are different techniques to help you (process mapping, five whys, appreciative inquiry). 35 36 37 Think about the contextual factors that are contributing to the problem (eg, the structure, culture, politics, capabilities and resources of your organisation).

Clinical audit and quality improvement

Quality improvement is an umbrella term under which many approaches sit, clinical audit being one. 33 Clinical audit is commonly used by trainees to assess clinical effectiveness. Confusion of audit as both a term for assurance and improvement has perhaps limited its potential, with many audits ending at the data collection stage and failing to lead to improvement interventions. Learning from big datasets such as the National Clinical Audits in the UK is beginning to shift the focus to a quality improvement approach that focuses on identifying and understanding unwanted variation in the local context; developing and testing possible solutions, and moving from one-off change to multiple cycles of change. 34

Next, develop your aim using the SMART framework: Specific (S), Measurable (M), Achievable (A), Realistic (R), and Timely (T). 38 This allows you to assess the scale of the intervention and to pare it down if your original idea is too ambitious. Aligning your improvement aim with the priorities of the organisation where you work will help you to get management and executive support. 39

Having done this, map those stakeholders who might be affected by your intervention and work out which ones you need to approach, and how to sell it to them. 40 Take the time to talk to them. It will be appreciated and increases the likelihood of buy in, without which your quality improvement project is likely to fail irrespective of how good your idea is. You need to be clear in your own mind about the reasons you think it is important. Developing an “elevator pitch” based on your aims is a useful technique to persuade others, 38 remembering different people are hooked in for different reasons.

The intervention will not be perfect first time. Expect a series of iterative changes in response to false starts and obstacles. Measuring the impact of your intervention will enable you to refine it. 28 Time invested in all these aspects will improve your chances of success.

Right from the start, think about how improvement will be embedded. Attention to sustainability will mean that when you move to your next job your improvement efforts, and those of others, and the impact you have collectively achieved will not be lost. 41 42

What support is needed?

You need support from both your organisation and experienced colleagues to translate your skills into practice. Here are some steps you can take to help you make the most of your skills:

Find the mentor or supervisor who will help identify and support opportunities for you. Signposting and introduction to those in an organisation who will help influence (and may hinder) your quality improvement project is invaluable

Use planning and reporting tools to help manage your project, such as those in NHS Improvement’s project management framework 27

Identify if your local quality improvement or clinical audit team may be a source of support and useful development resource for you rather than just a place to register a project. Most want to support you.

Determine how you might access (or develop your own) local peer to peer support networks, coaching, and wider improvement networks (eg, NHS networks; Q network 43 44 )

Use quality improvement e-learning platforms such as those provided by Health Education England or NHS Education for Scotland to build your knowledge 45 46

Learn through feedback and assessment of your project (eg, via the QIPAT tool 47 or a multi-source feedback tool. 48 49

Quality improvement approaches are still relatively new in the education of healthcare professionals. Quality improvement can give clinicians a more productive, empowering, and educational experience. Quality improvement projects allow clinicians, working within a team, to identify an issue and implement interventions that can result in true improvements in quality. Projects can be undertaken in fields that interest clinicians and give them transferable skills in communication, leadership, project management, team working, and clinical governance. Done well, quality improvement is a highly beneficial, positive process which enables clinicians to deliver true change for the benefit of themselves, their organisations, and their patients.

Quality improvement in action: three doctors and a medical student talk about the challenges and practicalities of quality improvement

This box contains four interviews by Laura Nunez-Mulder with people who have experience in quality improvement.

Alex Thompson, medical student at the University of Cambridge, is in the early stages of his first quality improvement project

We are aiming to improve identification and early diagnosis of aortic dissections in our hospital. Our supervising consultant suspects that the threshold for organising computed tomography angiography for a suspected aortic dissection is too high, so to start with, my student colleague and I are finding out what proportion of CT angiograms result in a diagnosis of aortic dissection.

I fit the project around my studies by working on it in small chunks here and there. You have to be very self motivated to see a project through to the end.

Anna Olsson-Brown, research fellow at the University of Liverpool, engaged in quality improvement in her F1 year, and has since supported junior doctors to do the same. This extract is adapted from her BMJ Opinion piece ( https://blogs.bmj.com/bmj/ )

Working in the emergency department after my F1 job in oncology, I noticed that the guidelines on neutropenic sepsis antibiotics were relatively unknown and even less frequently implemented. A colleague and I devised a neutropenic sepsis pathway for oncology patients in the emergency department including an alert label for blood tests. The pathway ran for six months and there was some initial improvement, but the benefit was not sustained after we left the department.

As an ST3, I mentored a junior doctor whose quality improvement project led to the introduction of a syringe driver prescription sticker that continues to be used to this day.

My top tips for those supporting trainees in quality improvement:

Make sure the project is sufficiently narrow to enable timely delivery

Ensure regular evaluation to assess impact

Support trainees to implement sustainable pathways that do not require their ongoing input.

Amar Puttanna, consultant in diabetes and endocrinology at Good Hope Hospital, describes a project he carried out as a chief registrar of the Royal College of Physicians

The project of which I am proudest is a referral service we launched to review medication for patients with diabetes and dementia. We worked with practitioners on the older adult care ward, the acute medical unit, the frailty service, and the IT teams, and we promoted the project in newsletters at the trust and the Royal College of Physicians.

The success of the project depended on continuous promotion to raise awareness of the service because junior doctors move on frequently. Activity in our project reduced after I left the trust, though it is still ongoing and won a Quality in Care Award in November 2018.

Though this project was a success, not everything works. But even the projects that fail contain valuable lessons.

Mark Taubert, consultant in palliative medicine and honorary senior lecturer for Cardiff University School of Medicine, launched the TalkCPR project

Speaking to people with expertise in quality improvement helped me to narrow my focus to one question: “Can videos be used to inform both staff and patients/carers about cardiopulmonary resuscitation and its risks in palliative illness?” With my team I created and evaluated TalkCPR, an online resource that has gone on to win awards (talkcpr.wales).

The most challenging aspect was figuring out which tools might get the right information from any data I collected. I enrolled on a Silver Improving Quality Together course and joined the Welsh Bevan Commission, where I learned useful techniques such as multiple PDSA (plan, do, study, act) cycles, driver diagrams, and fishbone diagrams.

Education into practice

In designing your next quality improvement project:

What will you do to ensure that you understand the problem you are trying to solve?

How will you involve your colleagues and patients in your project and gain the support of managers and senior staff?

What steps will you take right from the start to ensure that any improvements made are sustained?

How patients were involved in the creation of this article

The authors have drawn on their experience both in partnering with patients in the design and delivery of multiple quality improvement activities and in participating in the Academy of Medical Royal Colleges Training for Better Outcomes Task and Finish Group 1 in which patients were involved at every step. Patients were not directly involved in writing this article.

Sources and selection material

Evidence for this article was based on references drawn from authors’ academic experience in this area, guidance from organisations involved in supporting quality improvement work in practice such as NHS Improvement, The Health Foundation, and the Institute for Healthcare Improvement, and authors’ experience of working to support clinical trainees to undertake quality improvement.

Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies.

The authors declare the following other interests: none.

Further details of The BMJ policy on financial interests is here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests

Contributors: BJ produced the initial outline after discussions with EV and AOB. AO-B produced a first complete draft, which EV reworked and expanded. BJ then edited and finalised the text, which was approved by EV and AO-B. The revisions in the resubmitted version were drafted by BJ and edited and approved by EV and AO-B. BJ is responsible for the overall content as guarantor.

Provenance and peer review: This article is part of a series commissioned by The BMJ based on ideas generated by a joint editorial group with members from the Health Foundation and The BMJ, including a patient/carer. The BMJ retained full editorial control over external peer review, editing, and publication. Open access fees and The BMJ’s quality improvement editor post are funded by the Health Foundation.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/ .

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• ↵ The Health Foundation. Involving junior doctors in quality improvement: evidence scan. September 2011. https://www.health.org.uk/publication/involving-junior-doctors-quality-improvement
• ↵ Zarkali A, Acquaah F, Donaghy G, et al. Trainees leading quality improvement. A trainee doctor’s perspective on incorporating quality improvement in postgraduate medical training. Faculty of Medical Leadership and Management. March 2016. https://www.fmlm.ac.uk/sites/default/files/content/resources/attachments/FMLM%20TSG%20Think%20Tank%20Trainees%20leading%20quality%20improvement.pdf
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• ↵ Bohmer R. The instrumental value of medical leadership: Engaging doctors in improving services. The King’s Fund. 2012. https://www.kingsfund.org.uk/sites/default/files/instrumental-value-medical-leadership-richard-bohmer-leadership-review2012-paper.pdf
• ↵ Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature. BMJ Qual Saf 2012;1e9. doi: 10.1136/bmjqs-2011-000760 OpenUrl Abstract / FREE Full Text
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• ↵ Institute for Healthcare Improvement (IHI). IHI resources: How to improve. IHI. 2018 http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
• ↵ Lean Enterprise Institute. What is lean? Lean Enterprise Institute. 2018. https://www.lean.org/WhatsLean/
• ↵ Bate P, Robert G, Fulop N, Øvretveit J, Dixon-Woods M. Perspectives on context. A selection of essays considering the role of context in successful quality improvement. The Health Foundation. 2014. https://www.health.org.uk/sites/health/files/PerspectivesOnContext_fullversion.pdf
• ↵ Improvement NHS. (NHSI) Quality, Service Improvement and Redesign Tools. Project management an overview. September 2017. https://improvement.nhs.uk/resources/project-management-overview/
• ↵ Clarke J, Davidge M, James L. The how-to guide for measurement for improvement. NHS Institute for Innovation and Improvement 2009. https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/How-to-Guide-for-Measurement-for-Improvement.pdf
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• ↵ Improvement NHS. (NHSI) Quality, Service Improvement and Redesign Tools: conventional process mapping. January 2018. https://improvement.nhs.uk/resources/process-mapping-conventional-model/
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• Scottish Social Services Council (SSSC) Appreciative Inquiry Resource Pack
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4. Reflection as a quality improvement tool

At its simplest level, we can use reflection to assess clinical outcomes – either as an individual or as a group (for example, during clinical rounds).

We often only reflect on the cases where something went wrong or we had an unexpected outcome. However, any decision can benefit from reflection ( Koshy et al ., 2017 ) – whether it is implementation of a well-researched new treatment, diagnostic or biosecurity protocol or simply reflection on a series of cases that were managed in a particular way in order to better understand how that management might be improved.  If we don’t reflect on what we are doing, our practices may remain stagnant and become rapidly outdated.

Reflection and unstructured EBVM is simple and easy to incorporate into everyday practice, but it is important to try to still follow the EBVM cycle . Reflection without support of the literature or without a clear question can lead to a vague outcome. Referring to the literature as part of your reflection allows you to utilise the entire EBVM cycle:  Asking the correct question,  Acquiring  and Appraising the evidence,  Applying that information and then finally Assessing if the application was appropriate. Reflecting about how you navigated the five stages of the EBVM cycle also offers a simple way of assessing your own performance as an EBVM practitioner.

While it may require some additional planning and time management compared to personal reflection, team-based reflection can be a very useful quality improvement tool ( Shaw et al . , 2012 ) .

Example Scenario

Postoperative physiotherapy.

During monthly clinical rounds in a busy small animal practice, Sam reported that his last case of cranial cruciate ligament (CCL) rupture had re-presented with rupture of the CCL in the contralateral limb three months after surgery.

On presentation, Sam had noticed that the dog was not using the limb he had initially operated on fully, and suspected poor return to function of the operated limb had been a contributing factor. The owner was upset because when she had anterior cruciate ligament surgery herself, she had received an intensive programme of physiotherapy postoperatively, and wondered if the lack of physiotherapy could have been a factor in her dog’s new CCL injury.

One of Sam’s colleagues, Nicky, could recall similar cases in the practice and remembered reading a paper about early intensive physiotherapy used postoperatively after CCL surgery in dogs. Sam and Nicky worked together in an informal EBVM cycle of reflection, asking the question ‘In dogs with CCL injury, does postoperative physiotherapy compared to our traditionally prescribed controlled exercise programme improve function in the operated limb?’.

They identified a small number of papers that supported this approach, and although the evidence was not based on large multicentre trials in dogs, they felt there was sufficient evidence to apply physiotherapy as part of the postoperative management plan.

Together they found a local animal-qualified physiotherapist and implemented a new practice guideline for referral of all CCL cases for postoperative physiotherapy, starting with Sam’s patient following its second surgery.

The head nurse was involved with keeping a record of the cases of contralateral limb CCL rupture, as well as documenting client feedback on the physiotherapy, all of which were scheduled to be reviewed in a meeting in 12 months’ time.

Key points:

• This example shows a simple use of EBVM to address a problem following reflection on a case (although it could equally have been used pro-actively before a problem arose).
• A question was asked, information was acquired and appraised (albeit relatively informally), and the veterinarians applied the information in developing a new management guideline for dogs with CCL injury.
• In order to ensure that this new management protocol is actually doing what the veterinarians hope it will do, it is essential that they also implement a system to assess the response against clear outcome measures. In this case the outcomes are:
• the number of cases presenting for contralateral limb CCL injury.
• client feedback on the postoperative management guideline.
• A realistic time frame was set in order to ensure the guideline could be appropriately evaluated.

Organizing Your Social Sciences Research Assignments

• Annotated Bibliography
• Analyzing a Scholarly Journal Article
• Group Presentations
• Dealing with Nervousness
• Using Visual Aids
• Grading Someone Else's Paper
• Types of Structured Group Activities
• Group Project Survival Skills
• Leading a Class Discussion
• Multiple Book Review Essay
• Reviewing Collected Works
• Writing a Case Analysis Paper
• Writing a Case Study
• About Informed Consent
• Writing Field Notes
• Writing a Policy Memo
• Writing a Reflective Paper
• Writing a Research Proposal
• Generative AI and Writing
• Acknowledgments

Reflective writing is a process of identifying, questioning, and critically evaluating course-based learning opportunities, integrated with your own observations, experiences, impressions, beliefs, assumptions, or biases, and which describes how this process stimulated new or creative understanding about the content of the course.

A reflective paper describes and explains in an introspective, first person narrative, your reactions and feelings about either a specific element of the class [e.g., a required reading; a film shown in class] or more generally how you experienced learning throughout the course. Reflective writing assignments can be in the form of a single paper, essays, portfolios, journals, diaries, or blogs. In some cases, your professor may include a reflective writing assignment as a way to obtain student feedback that helps improve the course, either in the moment or for when the class is taught again.

How to Write a Reflection Paper . Academic Skills, Trent University; Writing a Reflection Paper . Writing Center, Lewis University; Critical Reflection . Writing and Communication Centre, University of Waterloo; Tsingos-Lucas et al. "Using Reflective Writing as a Predictor of Academic Success in Different Assessment Formats." American Journal of Pharmaceutical Education 81 (2017): Article 8.

Benefits of Reflective Writing Assignments

As the term implies, a reflective paper involves looking inward at oneself in contemplating and bringing meaning to the relationship between course content and the acquisition of new knowledge . Educational research [Bolton, 2010; Ryan, 2011; Tsingos-Lucas et al., 2017] demonstrates that assigning reflective writing tasks enhances learning because it challenges students to confront their own assumptions, biases, and belief systems around what is being taught in class and, in so doing, stimulate student’s decisions, actions, attitudes, and understanding about themselves as learners and in relation to having mastery over their learning. Reflection assignments are also an opportunity to write in a first person narrative about elements of the course, such as the required readings, separate from the exegetic and analytical prose of academic research papers.

Reflection writing often serves multiple purposes simultaneously. In no particular order, here are some of reasons why professors assign reflection papers:

• Enhances learning from previous knowledge and experience in order to improve future decision-making and reasoning in practice . Reflective writing in the applied social sciences enhances decision-making skills and academic performance in ways that can inform professional practice. The act of reflective writing creates self-awareness and understanding of others. This is particularly important in clinical and service-oriented professional settings.
• Allows students to make sense of classroom content and overall learning experiences in relation to oneself, others, and the conditions that shaped the content and classroom experiences . Reflective writing places you within the course content in ways that can deepen your understanding of the material. Because reflective thinking can help reveal hidden biases, it can help you critically interrogate moments when you do not like or agree with discussions, readings, or other aspects of the course.
• Increases awareness of one’s cognitive abilities and the evidence for these attributes . Reflective writing can break down personal doubts about yourself as a learner and highlight specific abilities that may have been hidden or suppressed due to prior assumptions about the strength of your academic abilities [e.g., reading comprehension; problem-solving skills]. Reflective writing, therefore, can have a positive affective [i.e., emotional] impact on your sense of self-worth.
• Applying theoretical knowledge and frameworks to real experiences . Reflective writing can help build a bridge of relevancy between theoretical knowledge and the real world. In so doing, this form of writing can lead to a better understanding of underlying theories and their analytical properties applied to professional practice.
• Reveals shortcomings that the reader will identify . Evidence suggests that reflective writing can uncover your own shortcomings as a learner, thereby, creating opportunities to anticipate the responses of your professor may have about the quality of your coursework. This can be particularly productive if the reflective paper is written before final submission of an assignment.
• Helps students identify their tacit [a.k.a., implicit] knowledge and possible gaps in that knowledge . Tacit knowledge refers to ways of knowing rooted in lived experience, insight, and intuition rather than formal, codified, categorical, or explicit knowledge. In so doing, reflective writing can stimulate students to question their beliefs about a research problem or an element of the course content beyond positivist modes of understanding and representation.
• Encourages students to actively monitor their learning processes over a period of time . On-going reflective writing in journals or blogs, for example, can help you maintain or adapt learning strategies in other contexts. The regular, purposeful act of reflection can facilitate continuous deep thinking about the course content as it evolves and changes throughout the term. This, in turn, can increase your overall confidence as a learner.
• Relates a student’s personal experience to a wider perspective . Reflection papers can help you see the big picture associated with the content of a course by forcing you to think about the connections between scholarly content and your lived experiences outside of school. It can provide a macro-level understanding of one’s own experiences in relation to the specifics of what is being taught.
• If reflective writing is shared, students can exchange stories about their learning experiences, thereby, creating an opportunity to reevaluate their original assumptions or perspectives . In most cases, reflective writing is only viewed by your professor in order to ensure candid feedback from students. However, occasionally, reflective writing is shared and openly discussed in class. During these discussions, new or different perspectives and alternative approaches to solving problems can be generated that would otherwise be hidden. Sharing student's reflections can also reveal collective patterns of thought and emotions about a particular element of the course.

Bolton, Gillie. Reflective Practice: Writing and Professional Development . London: Sage, 2010; Chang, Bo. "Reflection in Learning." Online Learning 23 (2019), 95-110; Cavilla, Derek. "The Effects of Student Reflection on Academic Performance and Motivation." Sage Open 7 (July-September 2017): 1–13; Culbert, Patrick. “Better Teaching? You Can Write On It “ Liberal Education (February 2022); McCabe, Gavin and Tobias Thejll-Madsen. The Reflection Toolkit . University of Edinburgh; The Purpose of Reflection . Introductory Composition at Purdue University; Practice-based and Reflective Learning . Study Advice Study Guides, University of Reading; Ryan, Mary. "Improving Reflective Writing in Higher Education: A Social Semiotic Perspective." Teaching in Higher Education 16 (2011): 99-111; Tsingos-Lucas et al. "Using Reflective Writing as a Predictor of Academic Success in Different Assessment Formats." American Journal of Pharmaceutical Education 81 (2017): Article 8; What Benefits Might Reflective Writing Have for My Students? Writing Across the Curriculum Clearinghouse; Rykkje, Linda. "The Tacit Care Knowledge in Reflective Writing: A Practical Wisdom." International Practice Development Journal 7 (September 2017): Article 5; Using Reflective Writing to Deepen Student Learning . Center for Writing, University of Minnesota.

How to Approach Writing a Reflection Paper

Thinking About Reflective Thinking

Educational theorists have developed numerous models of reflective thinking that your professor may use to frame a reflective writing assignment. These models can help you systematically interpret your learning experiences, thereby ensuring that you ask the right questions and have a clear understanding of what should be covered. A model can also represent the overall structure of a reflective paper. Each model establishes a different approach to reflection and will require you to think about your writing differently. If you are unclear how to fit your writing within a particular reflective model, seek clarification from your professor. There are generally two types of reflective writing assignments, each approached in slightly different ways.

1.  Reflective Thinking about Course Readings

This type of reflective writing focuses on thoughtfully thinking about the course readings that underpin how most students acquire new knowledge and understanding about the subject of a course. Reflecting on course readings is often assigned in freshmen-level, interdisciplinary courses where the required readings examine topics viewed from multiple perspectives and, as such, provide different ways of analyzing a topic, issue, event, or phenomenon. The purpose of reflective thinking about course readings in the social and behavioral sciences is to elicit your opinions, beliefs, and feelings about the research and its significance. This type of writing can provide an opportunity to break down key assumptions you may have and, in so doing, reveal potential biases in how you interpret the scholarship.

If you are assigned to reflect on course readings, consider the following methods of analysis as prompts that can help you get started :

• Examine carefully the main introductory elements of the reading, including the purpose of the study, the theoretical framework being used to test assumptions, and the research questions being addressed. Think about what ideas stood out to you. Why did they? Were these ideas new to you or familiar in some way based on your own lived experiences or prior knowledge?
• Develop your ideas around the readings by asking yourself, what do I know about this topic? Where does my existing knowledge about this topic come from? What are the observations or experiences in my life that influence my understanding of the topic? Do I agree or disagree with the main arguments, recommended course of actions, or conclusions made by the author(s)? Why do I feel this way and what is the basis of these feelings?
• Make connections between the text and your own beliefs, opinions, or feelings by considering questions like, how do the readings reinforce my existing ideas or assumptions? How the readings challenge these ideas or assumptions? How does this text help me to better understand this topic or research in ways that motivate me to learn more about this area of study?

2.  Reflective Thinking about Course Experiences

This type of reflective writing asks you to critically reflect on locating yourself at the conceptual intersection of theory and practice. The purpose of experiential reflection is to evaluate theories or disciplinary-based analytical models based on your introspective assessment of the relationship between hypothetical thinking and practical reality; it offers a way to consider how your own knowledge and skills fit within professional practice. This type of writing also provides an opportunity to evaluate your decisions and actions, as well as how you managed your subsequent successes and failures, within a specific theoretical framework. As a result, abstract concepts can crystallize and become more relevant to you when considered within your own experiences. This can help you formulate plans for self-improvement as you learn.

If you are assigned to reflect on your experiences, consider the following questions as prompts to help you get started :

• Contextualize your reflection in relation to the overarching purpose of the course by asking yourself, what did you hope to learn from this course? What were the learning objectives for the course and how did I fit within each of them? How did these goals relate to the main themes or concepts of the course?
• Analyze how you experienced the course by asking yourself, what did I learn from this experience? What did I learn about myself? About working in this area of research and study? About how the course relates to my place in society? What assumptions about the course were supported or refuted?
• Think introspectively about the ways you experienced learning during the course by asking yourself, did your learning experiences align with the goals or concepts of the course? Why or why do you not feel this way? What was successful and why do you believe this? What would you do differently and why is this important? How will you prepare for a future experience in this area of study?

NOTE: If you are assigned to write a journal or other type of on-going reflection exercise, a helpful approach is to reflect on your reflections by re-reading what you have already written. In other words, review your previous entries as a way to contextualize your feelings, opinions, or beliefs regarding your overall learning experiences. Over time, this can also help reveal hidden patterns or themes related to how you processed your learning experiences. Consider concluding your reflective journal with a summary of how you felt about your learning experiences at critical junctures throughout the course, then use these to write about how you grew as a student learner and how the act of reflecting helped you gain new understanding about the subject of the course and its content.

ANOTHER NOTE: Regardless of whether you write a reflection paper or a journal, do not focus your writing on the past. The act of reflection is intended to think introspectively about previous learning experiences. However, reflective thinking should document the ways in which you progressed in obtaining new insights and understandings about your growth as a learner that can be carried forward in subsequent coursework or in future professional practice. Your writing should reflect a furtherance of increasing personal autonomy and confidence gained from understanding more about yourself as a learner.

Structure and Writing Style

There are no strict academic rules for writing a reflective paper. Reflective writing may be assigned in any class taught in the social and behavioral sciences and, therefore, requirements for the assignment can vary depending on disciplinary-based models of inquiry and learning. The organization of content can also depend on what your professor wants you to write about or based on the type of reflective model used to frame the writing assignment. Despite these possible variations, below is a basic approach to organizing and writing a good reflective paper, followed by a list of problems to avoid.

Pre-flection

In most cases, it's helpful to begin by thinking about your learning experiences and outline what you want to focus on before you begin to write the paper. This can help you organize your thoughts around what was most important to you and what experiences [good or bad] had the most impact on your learning. As described by the University of Waterloo Writing and Communication Centre, preparing to write a reflective paper involves a process of self-analysis that can help organize your thoughts around significant moments of in-class knowledge discovery.

• Using a thesis statement as a guide, note what experiences or course content stood out to you , then place these within the context of your observations, reactions, feelings, and opinions. This will help you develop a rough outline of key moments during the course that reflect your growth as a learner. To identify these moments, pose these questions to yourself: What happened? What was my reaction? What were my expectations and how were they different from what transpired? What did I learn?
• Critically think about your learning experiences and the course content . This will help you develop a deeper, more nuanced understanding about why these moments were significant or relevant to you. Use the ideas you formulated during the first stage of reflecting to help you think through these moments from both an academic and personal perspective. From an academic perspective, contemplate how the experience enhanced your understanding of a concept, theory, or skill. Ask yourself, did the experience confirm my previous understanding or challenge it in some way. As a result, did this highlight strengths or gaps in your current knowledge? From a personal perspective, think introspectively about why these experiences mattered, if previous expectations or assumptions were confirmed or refuted, and if this surprised, confused, or unnerved you in some way.
• Analyze how these experiences and your reactions to them will shape your future thinking and behavior . Reflection implies looking back, but the most important act of reflective writing is considering how beliefs, assumptions, opinions, and feelings were transformed in ways that better prepare you as a learner in the future. Note how this reflective analysis can lead to actions you will take as a result of your experiences, what you will do differently, and how you will apply what you learned in other courses or in professional practice.

Basic Structure and Writing Style

Reflective Background and Context

The first part of your reflection paper should briefly provide background and context in relation to the content or experiences that stood out to you. Highlight the settings, summarize the key readings, or narrate the experiences in relation to the course objectives. Provide background that sets the stage for your reflection. You do not need to go into great detail, but you should provide enough information for the reader to understand what sources of learning you are writing about [e.g., course readings, field experience, guest lecture, class discussions] and why they were important. This section should end with an explanatory thesis statement that expresses the central ideas of your paper and what you want the readers to know, believe, or understand after they finish reading your paper.

Reflective Interpretation

Drawing from your reflective analysis, this is where you can be personal, critical, and creative in expressing how you felt about the course content and learning experiences and how they influenced or altered your feelings, beliefs, assumptions, or biases about the subject of the course. This section is also where you explore the meaning of these experiences in the context of the course and how you gained an awareness of the connections between these moments and your own prior knowledge.

Guided by your thesis statement, a helpful approach is to interpret your learning throughout the course with a series of specific examples drawn from the course content and your learning experiences. These examples should be arranged in sequential order that illustrate your growth as a learner. Reflecting on each example can be done by: 1)  introducing a theme or moment that was meaningful to you, 2) describing your previous position about the learning moment and what you thought about it, 3) explaining how your perspective was challenged and/or changed and why, and 4) introspectively stating your current or new feelings, opinions, or beliefs about that experience in class.

It is important to include specific examples drawn from the course and placed within the context of your assumptions, thoughts, opinions, and feelings. A reflective narrative without specific examples does not provide an effective way for the reader to understand the relationship between the course content and how you grew as a learner.

Reflective Conclusions

The conclusion of your reflective paper should provide a summary of your thoughts, feelings, or opinions regarding what you learned about yourself as a result of taking the course. Here are several ways you can frame your conclusions based on the examples you interpreted and reflected on what they meant to you. Each example would need to be tied to the basic theme [thesis statement] of your reflective background section.

• Your reflective conclusions can be described in relation to any expectations you had before taking the class [e.g., “I expected the readings to not be relevant to my own experiences growing up in a rural community, but the research actually helped me see that the challenges of developing my identity as a child of immigrants was not that unusual...”].
• Your reflective conclusions can explain how what you learned about yourself will change your actions in the future [e.g., “During a discussion in class about the challenges of helping homeless people, I realized that many of these people hate living on the street but lack the ability to see a way out. This made me realize that I wanted to take more classes in psychology...”].
• Your reflective conclusions can describe major insights you experienced a critical junctures during the course and how these moments enhanced how you see yourself as a student learner [e.g., "The guest speaker from the Head Start program made me realize why I wanted to pursue a career in elementary education..."].
• Your reflective conclusions can reconfigure or reframe how you will approach professional practice and your understanding of your future career aspirations [e.g.,, "The course changed my perceptions about seeking a career in business finance because it made me realize I want to be more engaged in customer service..."]
• Your reflective conclusions can explore any learning you derived from the act of reflecting itself [e.g., “Reflecting on the course readings that described how minority students perceive campus activities helped me identify my own biases about the benefits of those activities in acclimating to campus life...”].

NOTE: The length of a reflective paper in the social sciences is usually less than a traditional research paper. However, don’t assume that writing a reflective paper is easier than writing a research paper. A well-conceived critical reflection paper often requires as much time and effort as a research paper because you must purposeful engage in thinking about your learning in ways that you may not be comfortable with or used to. This is particular true while preparing to write because reflective papers are not as structured as a traditional research paper and, therefore, you have to think deliberately about how you want to organize the paper and what elements of the course you want to reflect upon.

ANOTHER NOTE: Do not limit yourself to using only text in reflecting on your learning. If you believe it would be helpful, consider using creative modes of thought or expression such as, illustrations, photographs, or material objects that reflects an experience related to the subject of the course that was important to you [e.g., like a ticket stub to a renowned speaker on campus]. Whatever non-textual element you include, be sure to describe the object's relevance to your personal relationship to the course content.

Problems to Avoid

A reflective paper is not a “mind dump” . Reflective papers document your personal and emotional experiences and, therefore, they do not conform to rigid structures, or schema, to organize information. However, the paper should not be a disjointed, stream-of-consciousness narrative. Reflective papers are still academic pieces of writing that require organized thought, that use academic language and tone , and that apply intellectually-driven critical thinking to the course content and your learning experiences and their significance.

A reflective paper is not a research paper . If you are asked to reflect on a course reading, the reflection will obviously include some description of the research. However, the goal of reflective writing is not to present extraneous ideas to the reader or to "educate" them about the course. The goal is to share a story about your relationship with the learning objectives of the course. Therefore, unlike research papers, you are expected to write from a first person point of view which includes an introspective examination of your own opinions, feelings, and personal assumptions.

A reflection paper is not a book review . Descriptions of the course readings using your own words is not a reflective paper. Reflective writing should focus on how you understood the implications of and were challenged by the course in relation to your own lived experiences or personal assumptions, combined with explanations of how you grew as a student learner based on this internal dialogue. Remember that you are the central object of the paper, not the research materials.

A reflective paper is not an all-inclusive meditation. Do not try to cover everything. The scope of your paper should be well-defined and limited to your specific opinions, feelings, and beliefs about what you determine to be the most significant content of the course and in relation to the learning that took place. Reflections should be detailed enough to covey what you think is important, but your thoughts should be expressed concisely and coherently [as is true for any academic writing assignment].

Critical Reflection . Writing and Communication Centre, University of Waterloo; Critical Reflection: Journals, Opinions, & Reactions . University Writing Center, Texas A&M University; Connor-Greene, Patricia A. “Making Connections: Evaluating the Effectiveness of Journal Writing in Enhancing Student Learning.” Teaching of Psychology 27 (2000): 44-46; Good vs. Bad Reflection Papers , Franklin University; Dyment, Janet E. and Timothy S. O’Connell. "The Quality of Reflection in Student Journals: A Review of Limiting and Enabling Factors." Innovative Higher Education 35 (2010): 233-244: How to Write a Reflection Paper . Academic Skills, Trent University; Amelia TaraJane House. Reflection Paper . Cordia Harrington Center for Excellence, University of Arkansas; Ramlal, Alana, and Désirée S. Augustin. “Engaging Students in Reflective Writing: An Action Research Project.” Educational Action Research 28 (2020): 518-533; Writing a Reflection Paper . Writing Center, Lewis University; McGuire, Lisa, Kathy Lay, and Jon Peters. “Pedagogy of Reflective Writing in Professional Education.” Journal of the Scholarship of Teaching and Learning (2009): 93-107; Critical Reflection . Writing and Communication Centre, University of Waterloo; How Do I Write Reflectively? Academic Skills Toolkit, University of New South Wales Sydney; Reflective Writing . Skills@Library. University of Leeds; Walling, Anne, Johanna Shapiro, and Terry Ast. “What Makes a Good Reflective Paper?” Family Medicine 45 (2013): 7-12; Williams, Kate, Mary Woolliams, and Jane Spiro. Reflective Writing . 2nd edition. London: Red Globe Press, 2020; Yeh, Hui-Chin, Shih-hsien Yang, Jo Shan Fu, and Yen-Chen Shih. “Developing College Students’ Critical Thinking through Reflective Writing.” Higher Education Research and Development (2022): 1-16.

Writing Tip

Focus on Reflecting, Not on Describing

Minimal time and effort should be spent describing the course content you are asked to reflect upon. The purpose of a reflection assignment is to introspectively contemplate your reactions to and feeling about an element of the course. D eflecting the focus away from your own feelings by concentrating on describing the course content can happen particularly if "talking about yourself" [i.e., reflecting] makes you uncomfortable or it is intimidating. However, the intent of reflective writing is to overcome these inhibitions so as to maximize the benefits of introspectively assessing your learning experiences. Keep in mind that, if it is relevant, your feelings of discomfort could be a part of how you critically reflect on any challenges you had during the course [e.g., you realize this discomfort inhibited your willingness to ask questions during class, it fed into your propensity to procrastinate, or it made it difficult participating in groups].

Writing a Reflection Paper . Writing Center, Lewis University; Reflection Paper . Cordia Harrington Center for Excellence, University of Arkansas.

Another Writing Tip

Helpful Videos about Reflective Writing

These two short videos succinctly describe how to approach a reflective writing assignment. They are produced by the Academic Skills department at the University of Melbourne and the Skills Team of the University of Hull, respectively.

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Quality improvement of guiding online-first field practice training through use of reflective essay and lesson study

H Susilo 1 and A K Sudrajat 1

Published under licence by IOP Publishing Ltd Journal of Physics: Conference Series , Volume 1760 , National Seminar of Physics Education 31 October 2020, Banjarmasin, South Kalimantan, Indonesia Citation H Susilo and A K Sudrajat 2021 J. Phys.: Conf. Ser. 1760 012054 DOI 10.1088/1742-6596/1760/1/012054

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1 Department of Biology, Faculty of Mathematics and Science,Universitas Negeri Malang Malang, Indonesia

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The purpose of this study is to describe the improvement of activities during the first field practice training conducted by online class through the use of Reflective Essay and Lesson Study. This action research is conducted on July 20-30, 2020, in the odd semester 2020/2021. The research subjects consisted of 6 biology students who perform peer-teaching practice. Students divided into two groups- each served as a lesson study team. Each student could practice teaching his friends twice through online teaching in the lesson study platform. Every day they write a reflective essay. The results showed that the use of Reflective Essay and Lesson Study could help the students improve lesson design preparation (media selection for apperception and leading activities, time, mastery of concepts). The students still having difficulties in implementing the training and measuring of 21st-century skills.

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Qualitative Analysis of Written Reflections during a Teaching Certificate Program

Ashley n. castleberry.

a University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas

Nalin Payakachat

Sarah ashby, amanda nolen.

b University of Arkansas at Little Rock

Martha Carle

c University of Arkansas for Medical Sciences Office of Educational Development, Little Rock, Arkansas

Kathryn K. Neill

Amy m. franks.

Objective. To evaluate the success of a teaching certificate program by qualitatively evaluating the content and extent of participants’ reflections.

Methods. Two investigators independently identified themes within midpoint and final reflection essays across six program years. Each essay was evaluated to determine the extent of reflection in prompted teaching-related topic areas (strengths, weaknesses, assessment, feedback).

Results. Twenty-eight themes were identified within 132 essays. Common themes encompassed content delivery, student assessment, personal successes, and challenges encountered. Deep reflection was exhibited, with 48% of essays achieving the highest level of critical reflection. Extent of reflection trended higher from midpoint to final essays, with significant increases in the strengths and feedback areas.

Conclusion. The teaching certificate program fostered critical reflection and self-reported positive behavior change in teaching, thus providing a high-quality professional development opportunity. Such programs should strongly consider emphasizing critical reflection through required reflective exercises at multiple points within program curricula.

INTRODUCTION

Reflection is an intentional, dynamic process that allows improvement in one’s actions, abilities, and knowledge by learning from past experiences. 1-4 While this process can be useful in almost all aspects of life, reflection in the workplace can be particularly beneficial. Successful professionals must be able to reflect on their experiences in order to find solutions to complex problems encountered on a daily basis. 1-2 Such reflection is not only necessary for pharmacists and other health care professionals to improve their practice, but also to further hone their expertise as educators. 5 Reflection should be used by pharmacists committed to professional growth as lifelong learners. 6

The practice of reflection during residency programs offers a valuable opportunity to observe and guide residents in this process at the beginning of their careers. Teaching certificate programs within pharmacy residency programs were founded on the idea that having specialized pharmacy knowledge does not necessarily equate with being an excellent teacher. 7 Teaching certificate programs give participants general pedagogical knowledge to combine with their existing content knowledge. Participants complete didactic and experiential teaching activities to develop such teaching skills. A critical component of the teaching certificate program at the University of Arkansas for Medical Sciences (UAMS) College of Pharmacy is the extensive reflection required throughout the year-long program. Because reflection is such an integral part of professional development, evaluation of the content and extent of participants’ reflections is imperative.

Research on the topic of reflection is extensive, but investigation of reflection on teaching by pharmacy faculty members or faculty members in training is not described in the literature. Additionally, methods to assess teaching certificate programs focus on surveys but lack the details offered by more in-depth analysis. Qualitative analysis of reflective essays could provide better understanding of program benefits and participant growth. Our mixed-methods evaluation is the first to examine thematic composition of reflections as well as the extent of reflection evidenced in the written essays of potential future pharmacy faculty members as they participate in teaching certificate programs.

This study was designed as a mixed methods thematic analysis of teaching certificate program participants’ reflective essays. A qualitative approach was chosen because this method allows deep analysis of the text not obtainable from survey-based research. A modified constant comparison method of analysis was employed, and categories and themes were constructed from open and axially coded data. 8 The coding scheme arose from the data as researchers explored them. Resulting themes were evaluated in comparison to the typology derived from teacher reflection theoretical framework. Qualitative methods were quantified to provide comparison of themes and level of reflection. The data evaluation provides a descriptive evaluation of the effectiveness of this teaching certificate program activity and its impact on teaching development.

The school’s teaching certificate program was originally developed in 2005 to enhance the teaching skills of pharmacy residents but quickly expanded to include preceptors because of an increased demand for preceptor development in teaching. The program, described in a previous manuscript, 9 facilitated development as an educator through the following experiences: formulating personal goals for development in teaching, tailoring teaching approaches to learning setting and audience, practicing effective assessment and feedback skills, receiving ongoing feedback from program faculty members, reflecting upon individual teaching experiences, developing a personal teaching philosophy, and documenting experiences through the development of a comprehensive teaching portfolio.

Over the course of the program (July to May), participants attended formal teaching seminars, self-selected teaching activities, and met with a faculty teaching mentor, who monitored their progression in the program. Participants also were required to write two reflective essays describing their teaching development. The midpoint reflection was submitted in December, and the final reflection was submitted in May of the program year. In these global reflections, participants were asked to discuss their teaching development and specifically include commentary on each of four topic areas: teaching-related strengths, teaching-related weaknesses, ability to effectively assess learners, and ability to provide effective learner feedback. Pharmacy residents and preceptors from across the state participated in all aspects of the program. All retrievable essays from participants who submitted written essays in December and May were analyzed. Participants were excluded if they did not complete the teaching certificate program by submitting December and May essays or if the data were not available.

De-identified electronic copies of reflection essays were used to extract themes and the extent of reflection using the four prompted topic areas of strengths, weaknesses, assessment, and feedback. The 4-category coding scheme described by Kember et al 10 was adapted to determine the extent of reflection for each of the four prompted topic areas as well as the highest level obtained overall ( Table 1 ). A fifth level of “0” was added to be assigned when the participant did not discuss a topic area. Because the instructions for the reflective assignment served only as prompts for reflection, participants were not required to write about each area, and therefore could receive a score of “0.”

Five-Category Scheme for Assessing Extent of Reflection in Written Essays 10

Two investigators in the team independently identified the themes discussed in the essays along with the extent of reflection of each essay in the four topic areas using NVivo, v10 (QSR International Pty Ltd., Doncaster, Victoria, Australia). The primary coder used a sample of 10 essays to create initial categories of themes and shared this initial set of themes with the second coder. Coders independently analyzed essays for themes discussed and the extent of reflection obtained in each topic area. The coders met weekly to discuss the extent of reflection assigned to each essay and resolved any differences.

By using a constant comparative approach, coders agreed by consensus on every essay to achieve 100% inter-rater reliability. Additional reflective themes also were added based on coder agreement when a new topic was discussed that did not fit into one of the predetermined themes. A third investigator periodically reviewed the coding process and identified themes for verification to enhance agreement between coders. An electronic coding platform made it possible to efficiently code, analyze, and organize this large amount of data. Each essay, depending on length, took about 10-20 minutes to analyze.

Further patterns emerged from the data during qualitative analysis and were explored with additional detail using triangulation methods. Coder agreement on coding of themes was assessed using Cohen’s kappa. Data were analyzed to identify differences in the extent of reflection in the midpoint and final essays using Wilcoxon signed-rank test. These data were further analyzed to identify whether extent of reflection varied according to participant gender and experience (preceptor vs resident) using the Wilcoxon rank sum test with Stata/SE, v12.0 (StatCorp LP, College Station, TX). The thematic analysis was granted exempt status by the UAMS Institutional Review Board.

All available pairs of essays were evaluated from participants completing the teaching certificate program between 2006 and 2012. One hundred thirty-two essays were analyzed from 66 participants. Of the 66 participants, 53 (80%) were female, and 10 (15%) were preceptors.

The coders identified more than 11 000 references to 28 themes discussed within the 132 essays. Themes covered a broad range of professional development topic areas, including delivering educational content, interacting with students, evaluating success, and encountering challenges. A full list of identified themes is available from the authors. Agreement between the coders on themes discussed in each essay was high (kappa=0.74). Data saturation of the identified themes occurred early in the coding process, indicating that the list of themes was representative of the context of the essays.

Themes were tracked by the number of essays in which the theme was discussed (“mention”) as well as the total number of references to the theme in all essays (“weight”), as themes could be discussed multiple times within a single essay. Table 2 provides the 10 most common discussed themes and weight placed on theme according to total number of references to that theme. The same 10 themes ranked highly according to both mentions and weight, indicating the emphasis placed on these ideas by the participants was consistent between and within essays. (A detailed description of themes and results of analyses are available from the corresponding author.)

Ten Most Common Themes by Mention and Weight

High levels of reflection were exhibited in the participant essays, with 48% of essays achieving the level of critical reflection (level 4). Quotations from teaching certificate program participant essays specific to the area of assessment were extracted to illustrate the extent of reflection. An example of nonreflection (level 1) was: “Assessment questions are aimed at evaluating comprehension of stated objectives.” A statement that was consistent with understanding (level 2) was: “There are various characteristics that students display that allow assessment of their abilities.” Reflection was evident in the level 3 statement: “It is easier to see two students evaluate similar patients than it is to see students present two different cases and discern which is more proficient.” Critical reflection (level 4) was evidenced by the statement: “But then I realized that I didn’t know if I was being an effective teacher without an assessment of some type. So I have started incorporating pre- and post-lecture questions to see what the learner gained from the presentation.”

Figure 1 shows the levels of reflection obtained overall and in the four prompted topic areas of strengths, weaknesses, assessment, and feedback for midpoint and final essays. Mean levels of reflection achieved in combined midpoint and final essays in each topic area were 2.4, 2.9, 2.7, and 2.9, respectively, indicating the greatest extents of reflection in the weakness and feedback topic areas. Each topic area showed increases in the mean level of reflection between midpoint and final essays [strengths, 2.2 (1.1) vs 2.5 (1.1); weaknesses, 2.8 (1.0) vs 2.9 (1.0); assessment, 2.6 (1.0) vs 2.8 (0.9); and feedback, 2.4 (1.0) vs 3.0 (1.0)].

Level of Reflection 10 Achieved in Midpoint and Final Reflection Essays. Number of essays according to the highest level of reflection (Level 0=Absent; Level 1=Non-reflection; Level 2=Understanding; Level 3=Reflection; Level 4=Critical Reflection) attained in the four prompted topic areas for both midpoint and final essays (n=132).

The extent of reflection between midpoint and final essays significantly increased in the prompted topic areas of strengths ( p =0.03) and feedback ( p =0.0002). In the strengths topic area, 29 (43.9%) participants did not show change in the extent of reflection from midpoint to final reflections, but 25 (37.8%) showed deeper reflection, compared with only 12 (18.2%), who had decreased reflection scores. In the feedback topic area, 28 (42.4%) participants did not show change in the extent of reflection from midpoint to final reflections, but 30 (45.5%) showed deeper reflection, compared with only 8 (12.1%) who had decreased reflection scores. The highest level of reflection achieved seemed to be higher in the final essays [mean value 3.53 (0.53)] when compared with the midpoint essays [mean value 3.36 (0.57)], but this change did not reach significance ( p =0.055) despite increases in each individual topic area. There were no differences observed when comparing change in the extent of reflection at midpoint and final according to gender or preceptor/resident status.

Further patterns emerged from the data during qualitative analysis and were explored with additional detail using triangulation methods. Program participants often discussed others’ evaluation of their teaching activities, but focused primarily on receiving evaluations from students and faculty members (65% and 49% of essays, respectively). Just 24% of essays mentioned gaining evaluation by peers (despite a teaching certificate program requirement for obtaining a peer teaching evaluation), and only 4% commented on gaining feedback from patients on their teaching. In contrast to their discussion on receiving evaluations, only five (7.6%) participants discussed the process of evaluating others’ performance in teaching. Four of these regarded providing peer evaluations, and one participant commented on giving feedback to faculty members.

A frequent conclusion of the participants was that they did not have the opportunity to complete a specific type of teaching development activity. This theme was reported in 31 (23.5%) essays. As expected, just over 70% of these occurrences were found in midpoint essays, when participants had completed only the first half of the teaching certificate program. This theme often disappeared from the final essays. However, the perceived lack of opportunities to participate in formally grading students and writing test questions (n=4), serving as an experiential education preceptor for students (n=3), giving a formal presentation (n=1), and providing student feedback (n=1) remained in the nine final reflective essays.

Reflection is vital in the life of an educator. 11 Even more, reflection is the key to learning, which occurs when we create meaning from a past event and use this to shape future experiences. 4,12 While other disciplines such as education have been using reflective practices for some time, the health sciences professions have more recently adopted this concept in the training of future health care professionals. Medicine, nursing, and pharmacy are among the disciplines that are adapting these types of reflective processes in curricula to aid in learning as well as improve patient care. 13-21

The extent of medical residents' reflection has been explored 13-15 and showed that physicians' decision-making skills were improved in complex clinical cases if they were able to critically reflect on those experiences. 15 An evaluation of nursing students concluded that interview sessions (individual, paired, and group) on reflective practice were viewed as beneficial for the participating students and encouraged them to practice reflective thinking on their own. 17 Like many other professions over the past few decades, accreditation standards for pharmacy education require student reflection and subsequent assessment of these skills. 18-20

Additionally, the American Society of Health-System Pharmacists Required Competency Areas, Goals, and Objectives, for Postgraduate Year One Pharmacy Residencies address the need for residents to reflect on their personal performance and professional development. 21 Published works on reflection in pharmacy center on pharmacy students, but the literature suggests reflection is necessary in the day-to-day practice of a pharmacist as well. 22,23 However, little is known about the reflective abilities of pharmacy educators and how these skills affect teaching-related self-development.

Assignments in this teaching certificate program served as tools to facilitate and encourage reflective thinking in order to promote growth in teaching abilities, and participants achieved high levels of reflection when completing these assignments. Almost 50% of essays evidenced critical reflection by describing how change occurred in their practice of teaching (behavior change). This high level is rarely achieved by so many. 10 This could be because participants in this program were highly achievement-oriented as supported by their admission to and completion of pharmacy school as well as pursuit of residency training.

Additionally, preceptors in the program were seeking teaching development and voluntarily participated. The teaching certificate program also emphasized reflection throughout the program. In addition to the reflections reviewed in this evaluation, participants were asked to reflect immediately after each teaching activity; this practice of reflective thinking and writing may have facilitated deeper reflection in the more summative midpoint and final essays. Another factor that could have contributed to the high levels of reflection was the mentorship of program faculty members, who reviewed reflection drafts and further prompted participants to consider their experiences, personal characteristics, and teaching development goals.

When analyzing themes discussed by participants, it was evident that they considered the reflection prompts when writing their essays because strengths, weaknesses, assessment, and feedback all appeared often. A closer look at the references to these categories revealed that participants wrote most frequently about the areas of assessment and feedback. These areas stood out because they were the areas in which participants lacked confidence early in the teaching certificate program, but they were also the areas in which participants recognized the most growth at the conclusion of the program. Collectively, the extent of reflection significantly increased from the midpoint essays to the final essays in the feedback category.

There was no intervention on reflective writing between the midpoint and final essays, so the change evidenced by our evaluation seems to have occurred naturally. Participants gained more practice with these skills over the course of the program year, and they subsequently reflected more and explained their growth in this area. This finding of deeper reflection in the area of feedback validated the design of the UAMS teaching certificate program and its focus on self-reflection as a method of teaching skills development.

The area discussed by all participants in the final essays was their confidence and comfort in teaching. This linked nicely with the significant increase in the extent of reflection seen in the strengths category. Participants seemed to be more deeply aware of their strengths as the program progressed, and they discussed areas of perceived confidence in these essays. This is consistent with our previous findings that demonstrated increased self-perceived teaching abilities during the program. 9

Because the teaching certificate program provides the opportunity for gaining practical experience in teaching, confidence in these abilities is expected to grow. Gaining confidence can allow a deeper awareness of personal strengths. Growth was evidenced as experiences led to increased confidence, and prompted reflection on these experiences led to gains in self-perceived teaching abilities and strengths. Increased confidence through experiences was the aim of the teaching certificate program and explains why such programs are beneficial to participants, future employers, and academic institutions.

Participants most often solicited feedback from students and faculty members. Feedback from peers and patients were reported much less frequently. Because it is a teaching certificate program requirement for participants to receive feedback from faculty members, peers, and students, it is not surprising that these perspectives were discussed in the reflections. However, patient teaching also is encouraged by the program, and the perspective and feedback of patients should be valued. Although the number of participants soliciting feedback from patients was not collected in our evaluation, few discussed these perspectives in their reflections.

Twenty participants (30%) listed patient counseling as a teaching activity, but only three participants discussed receiving teaching evaluations from patients. This could be because this information was not solicited from participants and, therefore, they do not reflect on it specifically or because the participants perceived patient evaluations to be lower quality or less importance than those from faculty members or peers. Additionally, participants might have viewed the patient as a different type of learner than students and not seen the need for reflection on their evaluations. Curricular emphasis of patients as learners increased in later program years to encourage variation of feedback from learners. To foster the view of patients as learners, programs should consider requiring patient teaching activities along with assessment of patient learning and completion of teaching evaluations by patients.

It is also noteworthy that participants wrote more frequently about receiving feedback from students and faculty members and less frequently about feedback received from peers. This corresponds to the small number of participants who reported giving feedback to faculty members (n=1) and peers (n=4). Giving and receiving feedback from peers may be an area of discomfort for participants despite the teaching certificate program requirement to give and receive this type of feedback. Additionally, only one participant reflected on the program requirement to provide feedback to at least two faculty members after observing their teaching. Overall, reflection on giving feedback to peers and faculty members was lacking, and participants did not reflect on receiving feedback from all sources.

The extent to which feedback was sought is not known, so additional research is needed to clarify this finding. Many factors could contribute to this pattern, including the perceived need to obtain feedback from certain groups, the feasibility and convenience of sampling, the perceived relative importance of feedback from more experienced or more educated groups, or the comfort level of the participants to give feedback to and receive it from certain groups. Teaching certificate programs should consider increased emphasis on 360-degree evaluations of teaching and both giving and receiving feedback to help participants understand the necessity and value of feedback from others. If participants gain comfort in this activity, they could provide higher quality feedback to others and potentially could benefit more from the feedback they receive.

Participants were not prompted to write about opportunities they did not get to experience; therefore, it can be assumed that participants discussing this theme must have been expecting to participate in such activities. By identifying these patterns, program directors can get an idea of skills that some participants might want to gain from the program. As expected, more than 70% of the themes coded for no opportunity were expressed in the midpoint essays. Of the remaining nine items discussed in the final essays, grading students and writing test questions accounted for the most themes discussed. Our program has taken these comments into consideration, incorporating additional opportunities for examination item review sessions to give participants insight on how to develop and evaluate examination items.

Qualitative evaluation of participant reflections can provide feedback on teaching certificate program effectiveness. These reflections provide a detailed view of how participants develop teaching skills throughout the program and impart realizations of the effectiveness of the program. By using reflective essays as quality indicators, program directors can shape program content to better develop teachers. At the same time, the reflection itself can aid participants in the development of a well-informed, highly individualized written statement of teaching philosophy, another potential quality measure of the teaching certificate program. This research did not evaluate participants’ teaching philosophy statements. However, qualitative evaluations of these documents also could provide a proxy of the teaching certificate program’s effectiveness in increasing participants’ awareness of their own teaching style and ideals.

Although our qualitative evaluation was rigorous and followed the guidelines presented by Anderson, 24 care must be taken when generalizing the results to other programs. Our data represent the products of a single teaching certificate program and are specific to the participants and experiences of this program. The characteristics of the residents and preceptors completing the program are varied, but they may reflect these groups at other institutions.

The use of quantitative and qualitative measures to evaluate this teaching certificate program is a strength of the study, and additional analyses are needed to determine if participants’ reflective abilities remain constant over time and predict future teaching performance. Finally, because of the extensive nature of our evaluation and the volume of the qualitative data, the potential exists for coding errors and inconsistencies between coders. Several mechanisms were in place to limit these inaccuracies and preserve the integrity of the data.

Participation in the teaching certificate program appeared to increase confidence and enhance awareness of strengths through participant reflection. Pharmacy residents and preceptors frequently achieved the highest level of reflection (critical reflection) in global self-assessments of teaching experiences. Such deep reflection is indicative of professional development because teaching certificate program participants evidenced change not only in teaching attitudes, but also teaching behaviors, as discussed in written essays. Just as reflective exercises are emphasized for pharmacy students and residents, findings from this analysis suggest that teaching certificate programs should strongly consider emphasizing purposeful critical reflection through required reflective exercises at multiple points within the program curricula. Qualitative evaluation of participant reflections can provide quality indicators to assist program directors in shaping program content.