Can learning from workplace feedback be enhanced by reflective writing? A realist evaluation in UK undergraduate medical education

Figures & data

Figure 1. Year 3 and 4 student usage of the ‘learning from feedback’ reflective add-on to their workplace assessment

Table 1. CMOcs with illustrative quotes

CMOc	Quotes
Explanations for students not using the reflective add-on
1. Poor past experience of reflective writing assignments (C) may put students off (M) using written reflection as a means of learning in future (O)	We had the big Longitudinal Patient reflection, and it might put some people off reflection. Like, I’m not very good at reflection at all, and my reflection is something that I need to improve on because it’s always just on the borderline. But sometimes you’re like, ‘oh no, not another reflection!’ I don’t want another one. FG2ID1n
2. Students who find writing difficult or have a preference for other methods of reflection (participant conditions) if given the option (C) may avoid writing (M) and not use the reflective add-on (O)	I am one of those people who sort of reflects and actually verbalises it having a chat with peers, as opposed to actually recording it. I tend to kind of talk things through with other people. We present a case and we reflect on what we have learnt from it. I find that actually far more beneficial than writing down a blurb about something. FG4ID1y
3. In a learning environment where there is email overload (C1) causing a tendency to skim-read messages (M1), if a learning activity is optional (C2) and there are competing priorities (C3) the extrinsic motivation (M2) to write is lacking so if there is weak internal motivation to write (M3) it gets neglected (O)	Then when I opened the email, and I was about to do it, and it said optional, and I was like, actually … …. FG3ID5y I mean I did see the reminder emails as well but I think it was a combination of the timing and then on top of all the other emails that you get and all the other things that you have reply to, it just gets lost … FG1ID8n
4. When a feedback discussion has taken place (C1), and was not about a significant event (C2) students may feel they had already reflected sufficiently (M) and writing would be superfluous (O)	I felt like it seemed like something that you’d do if it was a particularly memorable learning experience. Like if you’d had a consultation that had gone really badly or something particularly positive that had been drawn out in it, whereas a lot of the ones I’ve done it’s just been little minor tweaks, so I haven’t reflected on any of mine yet FG2ID3n
5. Delay in getting written feedback (C) caused declining ability to make mental connections (M) so no further useful reflection can be done (O) (even when verbal feedback had triggered memorable learning at the time)	I think it’s the fact that it didn’t inspire me to want to write a reflection …. if it had been closer to the event …. it would have been fresh in my mind and I would reflect on it better FG1ID1n
6. GP feedback which was not based on observation of the student (C1) or did not resonate with the student’s perception of the event (C2) may not be valued by the student (M1) and might therefore not trigger useful reflection either written or unwritten (O)	The feedback just wasn’t specific even though he was sat next to me. I felt like he’d switched off, didn’t really watch anything, and said takes good history, could examine, blah, blah, blah, you know. FG3ID3y
Explanations for students writing ‘tick-box’ reflections
7. Being reminded by the supervisor to write a reflection (C1) or knowing that there is a requirement to show some reflective writing in the e-portfolio (C2) triggers external motivation to write a reflection which is perceived as being for others (M1) and as a box-ticking exercise (M2) and may not be found to be very useful to learning (O)	So I think it depends on how keen the assessor is as well. So when my assessor was going through the (workplace) assessment with me, we talked through it and then she’d sort of type it up ….and then she would constantly remind me saying oh have you had a chance to reflect and she would say that at various points and I think that really helped because I thought actually I need to go and reflect so then I think after the second or third prompt, I said okay today is the day I’m gonna go and do my reflections [laugh] and I did it all in one go. FG1ID3y I think, on the whole, it’s done as a tick box exercise for me, because we used to have to submit reflections as assignments to be marked as opposed to a personal thing for our portfolio. I think that set it off as an assignment-based process as opposed to something that’s going to help you with your practice and your future development. And I think it needs like a shift of mindset. FG3ID3y
8. Writing for others to read (C) may arouse fear of reactions (M1) which may cause editing of what is written (O) to avoid awkwardness.	I would be scared to say something negative in the thought that, you know, someone else would see it or you know you’d get into trouble. FG1ID6n After I’d done my first one, the GP came and had a chat to me about it, about what I had written. It was a sort of moment of well, I don’t feel like I can be completely honest about the reflection. FG4ID3y
9. The topic of reflection being feedback from the GP supervisor rather than the student’s own choice of topic (C) may promote extrinsic motivation (M1) or little intrinsic motivation (M2) resulting in less useful reflection (O)	The fact that you reflect on feedback, is that not them pushing you towards a certain direction so it’s not promoting self-reflection as proper self-reflection FG3ID2y
Explanations for students getting added value from written reflection
10. Prior experience of benefit from reflective writing (O becoming C) encourages intrinsic motivation to do it again (M1) and may produce commitment to the habit (M2) so making students more likely to do it even when busy (O)	I don’t know why I was particularly organised that weekend but as soon as I got it, I’d done it so I think I derived a lot of value from that particular episode of reflection because the consultation that was assessed was very recent, as was my reflection so it was already like fresh in my mind FG1ID2y
11. The effortful cognitive processes (M) involved in a reflective writing exercise (C) can organise learning (O1) reinforce learning (O2) and add to learning (O3)	I thought it was a really good exercise because whatever I’d learnt the week before, I actually tried to implement that in the next following weeks and I think that it really, really did help me to sort of just focus on that particular consultation and particular things I need to include or things that I’ve missed out previously. FG1ID3y I think the value of the feedback and the reflection on the feedback is obviously highly variable, because you may get poor feedback or you may not be very good at reflecting, I think the value isn’t in the PDF you get at the end, it’s in the process you did to get there. FG2ID5y
12. Feeling the need to reflect deeply (M1) was a mechanism induced by situations which induced internal conflict (C) in reflective individuals (participant condition) which may result in writing (O) in an attempt to get resolution (M2)	Most of the time it’s when I’ve experienced a challenge that I’ve never experienced before or something’s been brought to my attention that I never considered before. And if it shifts my way of thinking or my ideas about something or how I approach things in the future or brings a learning even, that’s probably when I reflect. FG3ID4y
13. The tutor could trigger useful reflective writing (O) by their feedback conversations (C1) encouraging reflective thought and writing by triggering intrinsic motivation (M1) and by reading and commenting on the student’s reflections (C2) creating extrinsic motivation (M2)	I had two different experiences in third and fourth year. So in third year I didn’t do any of the reflections. I thought my feedback is very superficial. In fourth year, I thought it was very good. It was very detailed. It was very specific to me, even when she was giving me the feedback she put prompts and questions. So how do you think we could’ve done this better? How do you think you could handle this? So she did it very well, and so I had loads to reflect on and loads to talk on. FG3ID4y

Figure 2. Final programme theory