The feasibility of an electronic reflective practice exercise among physiotherapy students

Abstract

Background: Reflective practice is a skill that serves as a model for continuous learning. Like any skill, reflective practice can be improved and health professional curricula should include opportunities to develop these skills. The clinical component of health professional curriculum is a natural component where reflective practice skills can be developed. Electronic means will help students and faculty stay in contact during clinical internships.

Aims: The purpose of this study was to evaluate the feasibility of an electronic reflective practice exercise during a clinical internship and explore the potential trends on students’ reflective practice skills and self-directed learning readiness.

Methods: We used a prospective pre-post intervention design in a cohort of physiotherapy students to examine feasibility and explore trends. Faculty also rated the depth of reflection papers. In addition, students completed a reflective practice exercise questionnaire and the self-directed learning readiness scale (SDLRS) was completed pre- and post-internship.

Results: All 84 students completed the reflective practice questionnaire. Sixty-six students consented to complete the questionnaire and 17 consented to complete the SDLRS pre- and post-internship. It took an average of 7 min for faculty to review each student's reflection and there were no significant electronic difficulties encountered. Initial reflection papers were rated at a descriptive (23%), descriptive-analytical (28%) or analytical level (33%). Eighty-six percent of students rated faculty feedback as helpful and 92% rated peer feedback as helpful. Almost all students (97%) students reported that they followed through on some or all of the items on their reflective practice learning plans. The SDLRS significantly improved with the exercise (mean difference 6.8 ± 9.9; p < 0.05).

Conclusions: This electronic reflective practice exercise during the physiotherapy students’ clinical internship was feasible and demonstrated trends to positively impact the learners’ skills and self-directed learning readiness.

Introduction

Health care reform and funding-related issues lead to an ever changing environment for practising health care professionals (Canadian Institute of Health Information 2000). Continuous learning and dealing with change is an expectation of each health care professional. Therefore, one of the goals of health care professional curricula is to facilitate development of future health care professionals who will display reflective practice, as demonstrated by their ability to assess their performance, identify their practice gaps, as well as a plan to minimize the gaps and commit to the plan.

The skill of reflective practice is well described by Schön (1983) and provides a model for continuous learning (Figure 1). Individuals practice in a comfortable ‘Zone of Mastery’. Occasionally, more frequently in new practitioners, individuals are faced with a ‘surprise’ that challenges their ‘zone of mastery’ providing the opportunity for the individual to ‘reflect in action’ where they consider the situation and make decisions during the moment and/or ‘reflect on action’ where they consider the situation at a later time. Individuals then incorporate their thoughts and theory, ‘artistry’, and the outcome of this reflective process into their ‘zone of mastery’. This cycle occurs again and again for each practitioner and contributes to their continuous learning and development of expertise. The reflection ‘on’ and ‘in’ action stages are a unique opportunity for practitioners to self-direct their learning. Often during this stage, the practitioner identifies areas of strength, areas for improvement and an action plan. The artistry stage pulls their reflection and action plan together. Thus, reflective practice has the ability to greatly impact the learners’ self-directed learning.

Figure 1. Schön's model of reflective practice.

Table

Practice points

Faculty should seek input from students on how to best incorporate the reflective practice component within the curriculum. Restricting comments by faculty to the reflective practice process and not the content was appreciated by the student and potentially minimized the students’ anxieties. Electronic means is an efficient and feasible way to complete the reflective practice exercise. Providing a structure for the reflection papers is helpful to the students as they start to develop their skill. Peer discussion is beneficial to the students and could potentially replace faculty feedback after the first stage.

Reflective practice, like any skill, can be improved with training (Ker 2003), although the implications for practice and development of the healthcare professional have not yet been adequately documented. Health care professional curricula should allow for opportunities for students to develop these skills during their program. However, a recent survey of physiotherapy Professional Practice Coordinators within universities offering undergraduate courses in the United Kingdom found that, while reflection was considered a method that did improve and facilitate the integration of theory and practice, there was no one consistent method of facilitation or assessment within the curricula in the United Kingdom (Ward & Gracey 2006).

A potential opportunity to encourage reflective practice skill development is during the clinical components of the health care professional curriculum. Specifically in the field of physiotherapy, Donaghy and Morss (2000) discuss a framework linking systematic critical enquiry, problem solving and clinical reasoning to facilitate reflective practice. Similarly, Perkins (1996) explored benefits and potential problems of using personal journals to promote reflective practice in physiotherapy. Clouder (2000) recommended strategies to facilitate dialogical reflection rather than focusing soley on written reflection for undergraduate physiotherapy students. White (2004) reviewed the use of reflective practice in the physiotherapy curriculum and suggested that the implementation and assessment of the portfolio be one approach for reflective practice. Given this literature on reflective practice in physiotherapy, we developed, a reflective practice exercise during physiotherapy students’ clinical internship. Since students are off-campus for their clinical internships, we used electronic methods to communicate between faculty and students. Therefore, the purpose of this study was to evaluate the feasibility of this electronic reflective practice exercise during a clinical internship. A secondary objective was to explore the trends on students’ reflective practice skills and self-directed learning readiness.

Methods

We conducted a prospective pre-post intervention study. Ethics approval was obtained for this study from the University of Toronto Research Ethics Board.

Participants

The participants in this research study were 84 first-year students admitted in September 2006 to the Masters of Science Physical Therapy (MScPT) degree program at the University of Toronto. Students who did not complete their reflections or who did not provide consent were excluded from the study.

Recruitment

The Masters of Science Physical Therapy curriculum at the University of Toronto includes 28 weeks of full-time clinical practice. The first clinical internship, which is 3 weeks in duration, occurs 6 months into the program and provided an opportunity for the students to apply their reflective practice skills. Eligible students were recruited by a faculty member (DB) who did not have any current responsibility for teaching or grading their current academic course, nor any expectation of grading this cohort in the future. The students were informed of the nature of the research study verbally and in written format prior to their 3-week clinical internship and asked to participate in the research study. Students were not reimbursed, remunerated or provided with other compensation for participation in this study.

The reflective practice component

Prior to the internship

Prior to the start of their clinical internship, students were instructed on the theory of reflective practice, including an orientation to Al-Shehri's level of reflections in a 2-hour session. The reflective practice assignment was explained at that time. This assignment is a core curriculum requirement for all first-year students, and consists of three reflection papers during their first 3-week clinical internship. Though there were suggested topics for the reflections for each week (an experience transferring a patient; an experience interviewing a patient; an experience with another health care professional), students were encouraged to reflect on any salient topic. The guiding (Table 1) were used to facilitate the reflection and were adapted from the College of Physiotherapists of Ontario Professional Portfolio Guide (March 2004). The College of Physiotherapists of Ontario is the provincial licensing/registration body for physiotherapists in Ontario. The Professional Portfolio Guide was developed as a tool for registered (licensed) physiotherapists for the competency reflection and integration component of the Quality Management Program. The authors chose to base the reflective practice assignment questions on the College's Professional Portfolio Guide with the intent of preparing the students for the portfolio they would have to complete once registered (licensed) to practice.

Table 1.  Guiding questions for reflection assignment

1. Describe the event, issue, or situation.

2. What went well?

3. What were the difficulties encountered?

4. What gaps in your educational knowledge and skill have you identified?

5. How are you going to minimize the gaps? (i.e. a learning plan)

6. What additional resources do you need to improve this?

7. What will you do differently next time?

Notes: Questions were adapted from the College of Physical Therapists of Ontario Professional Portfolio Guide (March 2004). The College of Physiotherapists of Ontario is the provincial licensing/registration body for physical therapists in Ontario. The Professional Portfolio Guide was developed as a tool for Registered physical therapists to demonstrate ongoing competency.

To facilitate the reflection process and assignment, reflection examples were provided to the students on the course website and were discussed during the initial instruction session. These four examples were obtained from a colleague from another discipline who used reflective practice in her teaching. The four examples varied from a descriptive level to an evaluative level of reflection.

Clinical faculty supervising the students were orientated to the reflective practice component of the curriculum and the reflective practice assignment during the pre-internship meeting prior to the start of the internship.

During internship

Students were required to submit one reflection per week during the 3-week internship as part of their curriculum requirement. The clinical facilities were also asked to provide the student with one half day per week of protected time during the internship for students to complete, review, discuss and act on their reflections.

The reflections were reviewed using the process summarized in Table 2. The reviewer provided feedback with the goal of improving the reflective process. Students did not receive a grade on their reflections; however, completion of their three reflections was a component of their pass/fail grade for the clinical internship component of their curriculum. Students constructed their reflections in their word processing programs and saved them in a self-designated folder. The reflections were then submitted to the Director of Clinical Education faculty (Brenda Mori, BM) via email (which was the most convenient method for faculty and students) instead of the digital drop box on the course website. Faculty (BM) reviewed these first reflections and replied back to the students via email within 3 days, inserting her comments regarding the reflective practice process in block letters.

Table 2.  Submission and action for student reflections

	What was submitted	Submitted to?	Action
Reflection 1	Reflection paper	Faculty (BM)	Feedback from DCE
Reflection 2	Reflection paper	Student Peer	Receive feedback from peer
Reflection 3	Learning plan	Faculty (BM)	Sent back to students before next clinical internship

To encourage the dialogical reflection professional socialization as recommended by Clouder (2000), the second reflection was reviewed by a student peer completing their clinical internship at the same facility. Protected time was scheduled for the students to discuss their reflections and suggest additional resources or assist with carrying through the learning plans. During the peer review, students were encouraged to apply the theory and content presented to them during the initial in-class component on reflective practice.

The third reflection was to be self-reviewed and the learning plan (response to question #4 and 5, Table 1) was submitted to faculty (BM). This learning plan was then resent to the students 8 weeks later as they were preparing for their next clinical internship as a way to remind them to complete their identified learning plan.

Data collection and analysis

Feasibility data

Feasibility was measured by the number of students who completed their reflections; the number of reminders required from the DCE before all reflections were submitted; the time required by the DCE to review, provide feedback and respond to each reflection submitted; and technical difficulties with the course website and email (included in the survey above). Frequency statistics were used to analyse the feasibility data.

Quality of reflection papers

All submitted reflection papers were included in the analysis of the quality of the reflection paper. The quality of the reflection was determined by the faculty reviewer (BM) using the scale by Al-Shehri (1995) described in Table 3. In addition, intermediate categories, ‘descriptive-analytical’ and ‘analytical-evaluative’ categories were added by the researchers to allow for more flexibility in determining the quality of the reflection paper.

Table 3.  Quality of reflection papers

Rating	Quality parameters/criteria
Descriptive	□ Simple description of the event
Analytical	□ Description of the event
	□ Some insight into potential improvements to the situation
	□ Does not demonstrate how the event fits in the bigger picture
Evaluative	□ Description of the event
	□ Deep insight into improvements to the situation
	□ Demonstrates how the event fits in the bigger picture

Reflective practice exercise survey

Students were asked to consent to complete a hard copy questionnaire regarding the feasibility and perceived utility of the reflective practice assignment to enhance self assessment and reflection. The questionnaire used close-ended questions on: (1) availability of protected time during their internship to write their own reflections and review their peer's reflections; (2) usefulness of feedback regarding the reflective practice process that they received; (3) their comfort in providing feedback to their peer; (4) confidence with the reflective practice process; (5) success with executing their learning plans; (6) general satisfaction questions; and (7) technical difficulties with accessing the website and submitting the reflection papers. Frequency analysis was performed on the results.

Self-directed learning readiness scale

The self-directed learning readiness scale (SDLRS) is a standardized measure to assess an individual's perceived self-directed learning readiness (McCune et al. 1990). A modification of the scale developed by Guglielmino (1978), it is a self-administered questionnaire comprised of 58 statements each to be rated according to the specified scale. The tool has been shown to be reliable, valid and responsive (Merriam & Caffarella 1999; Delahaye & Choy 2000). The SDLRS was used to determine if completing the reflections changed the students’ self-directed learning readiness. This data was collected from consenting students pre- and post-internships. The completed tool was confidentially assigned a unique identifier by the research assistant, allowing the investigators to track any changes in the scores following the internship. A paired t-test was used to analyse the results from the SDLRS.

Results

Sample

All 84 students completed the reflective practice exercise. All students had a previous Bachelors degree and 76% of the students were female. Students could be assigned to any area of practice for this 3-week basic skills application internship. General medicine was the most common area of practice, followed by inpatient orthopaedics, and inpatient acute cardiorespiratory care. Four students were in a paediatric area of practice. Sixty-six students consented to complete the survey and 17 students consented to complete the SDLRS both before and after the internship. All students completed the reflection papers, which were part of the MScPT core curriculum and all the papers were analysed for this study.

Feasibility data

Eighty-two students submitted their reflections by the deadline and two students required one email reminder. Email proved to be an efficient method for sending and receiving the reflection papers as no papers were lost. It took an average of 7 min (range 2 : 22–12 : 00 minutes) for the faculty (BM) to review and provide feedback to each student's reflection. While there were no significant electronic difficulties reported by the faculty, eight students reported difficulty logging on to the course website having to enter their password twice before being allowed access.

Quality of reflection papers

While initially the intention was to assess the quality of the reflections by the Al-Shehri criteria, the reviewer (BM) found only having three categories limiting in determining the quality of the reflections. Thus, additional categories, ‘descriptive-analytical’ and ‘analytical-evaluative’, were added. The majority of the students’ reflections were at a descriptive, descriptive-analytical or analytical level as presented in Figure 2.

Figure 2. Depth of first reflection.

Reflective practice exercise survey

Seventy-four percent of the students felt that the content on reflective practice during the session prior to the internship and the assignment instructions were clear. Ninety-nine percent of the students reported they were somewhat or extremely confident with the process of reflective practice when writing their third reflection. Eighty-nine percent of the students stated they were provided one half day of protected time for each week of their 3-week internship by the clinical facility. Students reported they took an average of 45–60 minutes to complete their reflection papers for the first and third reflection but required less time for their second reflection paper (Figure 3). Feedback on their first reflection paper from the DCE was somewhat helpful (70%) or extremely helpful (17%) and feedback from their peer was somewhat helpful (73%) or extremely helpful (20%) (Figure 4). Ninety-four percent of students reported they were somewhat or extremely comfortable in providing feedback to their peer regarding their reflection. Most importantly, 97% of students reported they followed through on some or all of the learning plans identified in their reflective practice paper. Over half (55%) reported that the exercise of completing the reflections facilitated their ability to direct their own learning and ultimately improve their practice.

Figure 3. Reported time to complete reflections.

Figure 4. Helpfulness of faculty and peer feedback.

Self-Directed Learning Readiness Scale

Seventeen students completed the SDLRS both pre- and post-internship. The SDLRS significantly improved over the internship from 218.2 to 224.6 (mean difference 6.8 + 9.9; p = 0.02).

Discussion

This is the first study to examine the feasibility of an electronic reflective practice exercise and explore potential trends on its impact on self-directed learning in physiotherapy. Using electronic communication methods during a clinical internship was feasible and yielded positive results.

Most of the reflective practice papers were at a descriptive or analytical level. Students chose to write about an experience transferring a patient, interviewing a patient, or an interaction with a health care professional. While most of the papers adequately described the experience, they did not provide an evaluative view of the experience beyond themselves to their profession. There was a lack of insight into how their experience fit within the bigger health care picture. This finding was expected given that this was the first opportunity for the students to practice their reflective practice skills. Furthermore, this internship was the first where students were exposed to full-time clinical work. While they had an understanding of theory and basic practical skills, the internship provided an opportunity to gain practical experience with health care teams, their role within the team and interactions with patients and clinical instructors. Even though the students were exposed to issues related to health care systems, funding and business resource management, they may not have had sufficient context at this stage to understand how their experience could relate to larger health care issues. It would be interesting to follow the students’ reflective practice skill in their final internship, close to graduation.

Students were provided with feedback to help them reflect at a deeper level when writing their future reflection papers. Faculty's comments on the first reflection paper identified Schön's reflective practice stages in their reflection paper (i.e. ‘this is reflection in action’, ‘this is your reflection on action’) as well as urged them to consider additional thoughts, i.e. ‘what are the implications of your decision’, ‘consider how this can be prevented in the future’. Comments were provided to progress the student's reflective practice skill and did not focus on the content of their reflection papers.

There is the question whether reflections should be read by anyone other than the author. If the student author knows that a reflection paper will be read by their faculty, they may choose to not disclose information or be tempted to write what would be expected of them. We tried to minimize the potential negative impact of faculty review through several methods in this study. First, we involved the students during the planning stage with discussion and the decision making process seeking their input whether faculty should review their reflections in the initial stages. They chose to have faculty review the papers as they felt this was a new experience and wanted the feedback. Second, we reinforced that the comments were only on the reflective practice process and not the content of the reflection paper. Faculty reviewing the paper did not make comments whether the student made the correct or incorrect decision. Most students were explicit in describing the difficult situations which they encountered in their reflection paper. Third, we minimized the faculty's role in reviewing the reflection papers, using peers as reviewers for the second submission and requesting that students only submit the learning plans for their third submission. It is interesting to note that most students submitted their entire third reflection paper rather than just the learning plan.

There are several factors that faculty may consider to encourage reflective practice in novice health care professionals (Henderson et al. 2002). At this early stage in their health professional career, it is important to minimize the barriers to facilitate their development of this skill. Providing protected time for students to practice these skills in a fast paced clinical environment conveys the message to students that this component is valuable to their learning. In this study, most clinical internship sites were able to secure one half day a week of protected time for students to complete their reflection papers and discuss their reflections with their peers.

There was a trend for a shorter time to complete their second reflection paper, although this was not the case for the third paper. The second reflection paper was the only reflection that was not submitted to faculty but discussed with their peer. They may have instead invested the time discussing their reflection with their peer rather than writing a detailed account. The majority of students (53%) reported spending between 15–44 minutes discussing the reflections and 8% of the students reported spending more than 1 hour. The students also reported that they valued the feedback from their peers just as much as feedback from faculty. Students also reported that they were comfortable providing feedback to their peer. This finding suggests that the two-way discussion of the reflection was useful to their learning. In contrast, the faculty feedback was a one way electronic communication. The value of peer reflection discussion is reinforced in the literature (Clouder 2000; Henderson et al. 2002).

The value students placed on peer discussion of their reflections has important implications to faculty resources. Provided there is opportunity for peer discussion, faculty may not need to review every student's reflections. However, when students are developing these skills, it is important that an individual with expertise provides feedback. The instructions and feedback from faculty appear to have contributed to the students’ comfort in providing feedback to each other and confidence with the process of reflective practice while writing their third reflection.

One of the goals of initiating this reflective practice component of the curriculum was to provide students the opportunity to assess their performance, identify gaps and develop and execute the plan to minimize the gap. In the questionnaire, students reported that they followed through on some (70% of students) or all (27% of students) of their learning plan. This finding has substantial implications for their practice and contributes to Schön's Reflective Practice steps of ‘Artistry’ and adding new knowledge to the ‘Zone of Mastery’. Given that the questionnaires were anonymous with no impact on their grades, it is unlikely that students over-reported this follow through. Only 12% of the students felt that the reflections did not facilitate their ability to direct their learning and ultimately improve their practice.

Posting lecture notes, reflection examples and assignment directions on the course website was an efficient method of sharing the information with the students. Several students were unable to log on to the course website on their first attempt. Use of email for submission of the papers was effective and represented fewer steps than downloading and uploading to digital drop boxes on the course website. The only disadvantage of using email for submission of the assignment was the lack of guarantee that the student kept a record of their reflections. Keeping their reflections in an electronic portfolio would allow the students to track their reflective practice development and refer back to their learning plans. Finally, seeking student input regarding the submission process may have also been a contributing factor to the success in receiving almost all papers on time.

There are some limitations to note in this study. First, while 79% of the students consented to complete the Reflective Practice Exercise Survey, only 20% consented to complete the SDLRS. While the change in this measure was significant, it is difficult to conclude that the change was important and would change practice. The use of a control group with no reflective practice activities would allow for more definitive conclusions about the effectiveness of this approach. Our findings simply indicate a trend that is worth examining further. In addition, the questionnaire contained questions that included only three potential responses for some of the close ended questions, limiting the detail in the student responses. For the assessment of quality, the intermediate categories added by the researchers were not piloted. Lastly, only one faculty reviewed the reflection papers to assess the depth. The use of a second rater would ensure reliability in assessing the quality of the reflection papers.

Conclusion

This electronic reflective practice exercise for physiotherapy students during their first clinical internship was feasible and demonstrated some positive trends. Students valued peer feedback on their reflection papers as much as faculty feedback. Most students reported completing part or all of the learning plans identified in their reflection paper which has the potential to affect their practice.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article

Additional information

Notes on contributors

Brenda Mori

BRENDA MORI, BScPT, MSc, is the Director of Clinical Education and Community Affairs with the Department of Physical Therapy as well as the Assistant Director of the Education Scholars Program with the Centre for Faculty Development at St. Michael's and the Faculty of Medicine at the University of Toronto.

Helen P. Batty

HELEN BATTY, MD, CCFP, MEd, FCFP, is a Professor and Director of the Academic Fellowship and Graduate Studies Program with the Department of Family and Community Medicine at the University of Toronto.

Dina Brooks

DINA BROOKS, BScPT, MSc, PhD, is an Associate Professor with the Department of Physical Therapy at the University of Toronto. She was supported by the Canadian Institute of Health Research New Investigator Award and Canada Research Chair Award.