"We're all learning together”: Educator perspectives on medical student reflective practice

"We're all learning together”: Educator perspectives on medical student reflective practice | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article "We're all learning together”: Educator perspectives on medical student reflective practice Hannah Woodall, Brendan Carrigan, Linda Furness, Robert Heffernan, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3357325/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Reflective learning skills are important in the development of medical students. Through reflection, students learn about self and medicine and the integration of theoretical knowledge into real life work. However, reflection requires time, willingness, and skills on the part of the student. This study explored the factors perceived by educators to influence reflective learning amongst medical students undertaking a rural longitudinal integrated clerkship (LIC) in southeast Queensland. Methods: Within the described LIC program, medical students receive teaching and support from both medical and nursing educators. Two qualitative focus groups were conducted with eleven educators from a medical (6 participants) and nursing (5 participants) background. Transcripts were analysed using Braun and Clark’s approach to thematic analysis. Results: Three major themes were identified as contributing to student reflective learning. Fostering a culture of reflection within the organisation was seen as important for supporting and setting expectations for reflection. Undertaking the reflective learning journey together recognised the importance of students and educators learning collaboratively. Finally, looking through “the student lens” allowed educators to recognise the wider contextual factors impacting on student reflection. Recognition of these factors allows educators to tailor reflective teaching to the student. Discussion Reflective learning is a critical skill for medical students and their educators. This study identified that reflection can be supported through the development of a supportive organisational culture, through encouraging educators and students to learn together, and through recognising the student perspective. reflective practice medical students rural medical education Figures Figure 1 Introduction Reflective practice is central to navigating what has been described as the “transformative learning journey” of medical students (Greenhill et al., 2017 ). Reflection is “a metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters”(Sandars, 2009 , p. 685). Reflective learning plays an important role in the education of medical students, especially in the early years of clinical training. During this time students learn how to translate theory into practice and integrate knowledge about ethics, communication, professionalism, and culture into real-life (Malau-Aduli et al., 2020 ). Through the reflective process, students learn about themselves as well as medicine, with the aim of integrating lessons in a manner that improves future practice. This integration is achieved by encouraging students to actively look back on experiences and examine their own skills, beliefs, or assumptions. In so doing, the students begins to make sense of a situation and learn lessons to apply next time (Chambers et al., 2011 ; Fernandez et al., 2015 ; Gillingham et al., 2020 ). The skill of reflection is central to transformative learning within medical education (Greenhill et al., 2017 ). Transformative learning theory is based on a constructivist paradigm, which “holds that the way learners interpret and reinterpret their sense experience is, central to making meaning and hence learning”(Mezirow, 1994 ). The theory describes how students experience “disorienting dilemma/s”, which cause them to move through a process of evaluating and assessing their knowledge, beliefs and attitudes, through which they are prompted to examine their perspectives and worldviews (Mezirow, 1994 ) (Christie et al., 2015 ). The experience of being a medical student automatically places the learner in challenging situations which can give rise to these disorienting dilemmas. These may result from the experience of cognitive dissonance, “the uncomfortable tension we experience when we hold….inconsistent beliefs, or when our behaviour is inconsistent with our beliefs” which can arise at many points in the medical student journey (Klein & McColl, 2019 ). The purpose of reflection is to begin to recognise these situations as learning experiences, which will develop the learner for future practice. Reflective skills are key to this process. Many universities have instituted some form of reflective learning for students, in recognition of the need for students to develop these skills. Evidence suggests that students benefit from the opportunity to address and reflect on real issues, rather than hypothetical ones (Lutz et al., 2013 ). Reflective skills allow students to reframe challenging situations as learning opportunities and allow the processing of experiences within a safe space; consequently reducing student stress (Lutz et al., 2013 ). Students also report improvements in patient care after reflective activities due to improved communication and understanding of the patient as a person (Lutz et al., 2013 ). However, although reflection is triggered by an experience of uncertainty or cognitive dissonance, it is not an automatic or passive process. Rather, it requires students to have the time, willingness, and skills to reflect and process their experiences (Chaffey et al., 2012 ; Chambers et al., 2011 ). Current practice in reflective learning within medical education has been criticised due to its reliance on formulaic, mostly written reflection which tend to lead to contrived, inauthentic reflections and, in the words of one research team, risks creating a “reflective zombie” (de la Croix & Veen, 2018 ). Such activities focus on assessment, rather than on supporting the student to reflect and participate in transformative learning (Gathu, 2022 ). Evidence is building towards supporting diverse reflective methods to enable learners to identify their own personal systems for engaging in reflection.(MacAskill et al., 2023 ). It is critical that reflective learning skills are taught well and supported if we are to strive for transformative learning amongst medical students. This study therefore aimed to explore the factors perceived by educators to influence the development of reflective learning skills amongst medical students in a rural longitudinal integrated clerkship. Methods Setting: This study explored reflective learning in a four-year postgraduate medical degree program in Australia. Ethical approval for the study was obtained from the Griffith University Human Research Ethics Committee (GU 2021/376). Medical students in this program have the opportunity to participate in a longitudinal integrated clerkship (LIC), the “Longlook” Program, for one or both of their clinical years (years three and four). Longlook is unique in that it is delivered in partnership with a non-for profit organisation, Rural Medical Education Australia. Medical students in the Longlook program participate in a longitudinal integrated clerkship (LIC) for one or both of their clinical years (years three and four). Student LIC placements last for 1–2 years and are based in rural locations where they meet learning goals across multiple disciplines within a longitudinal placement rather than through isolated blocks, affording students’ continuity of relationships with both supervising clinicians and patients over this time (The Consortium of Longitudinal Integrated Clerkships, 2020 ). Medical students are taught and supported by educators from both a medical and nursing background within this program. Approximately 50 students participate in this program each year at one of eight rural clinical training sites. Students in the rural program follow a curriculum which includes the completion of two forms of reflective assessment. The first is a written reflection on the student’s topic of choice, completed by all students in both third and fourth year. The second is a series of case presentations which are expected to incorporate reflection on the care provided as well as consideration of ethical, legal, professionalism or other non-biomedical aspects of the case. Students complete twenty-four of these case presentations in Year 3, and six in Year 4. Research Team: The research team has broad experience across medical education and clinical practice. HW is an academic GP who works in research within the not for profit which facilitates the Longlook program described within this paper. KB, BC and RH are clinicians and medical educators who have been and continue to be actively involved in the development and implementation of the LIC model within which this study was conducted. KB is Director of Education and Training at the not-for-profit through which this LIC program is facilitated, with BC and RH leading the 3rd and 4th year student programs. LF is an occupational therapist with expertise in the field of education and reflective learning within the allied health context. JP is an experienced researcher who works for the not for profit facilitating this program. Participants: Participants were recruited from both nursing and medical educator staff at all eight rural sites within this program. Participants included six educators with a medical background, and five with a nursing background. All participants are involved in the training of medical students through the Longlook program and are co-located with students in hospital sites spread over southeast Queensland. Longlook medical educators are rural generalists; “general practitioners who provide primary care services, emergency medicine and have training in additional skills like obstetrics, anaesthetics or mental health services” (Australian Government Department of Health and Aged Care, 2021 ). Longlook clinical nurse educators in the program have advanced training to work in rural generalist hospitals and support education delivery within the LIC. Both nursing and medical educators attend hub training sessions with the students at a central location on monthly intervals throughout the academic year in addition to providing teaching and learning support to medical students at their respective local sites. Project design: To ensure methodological congruence and fore front the experiences and voices of the research participants, a constructivist case study research paradigm was used in this study. Constructivist perspectives reflected the desire to explore the participants constructions of their lived experiences as an educator (Shannon-Baker, 2023 ). The case study approach was able to understand and describe the specific experiences of educators within the setting of a rural LIC program by purposively selecting educators within the program (Hall et al., 2008 ). In accordance with the constructivist approach, semi-structured focus groups were developed to capture the experiences and subjective opinions of research participants. Two focus groups were conducted with a total of eleven educators (six medical, five nursing). Medical and nursing educator focus groups were held independently to manage group dynamics and appreciate important differences between the two groups. The potential for power differentials between medical and nursing educators was recognised, and consequently, the groups were siloed to ensure that the perspectives of both groups could be explored. The focus group with medical educators was conducted by HW, who has a medical background but is not one of the medical educators. The clinical nurse educator focus group was conducted by a clinical educator with a nursing background. Focus groups lasted approximately one hour and were conducted in person during student teaching days. The focus groups explored educator views on reflective learning activities for students, an evaluation of current reflective methods and how reflective learning could be improved. Focus group data recordings were transcribed and uploaded to NVivo™ for coding. Aligning with the qualitative approach to data generation and in keeping with the constructivist paradigm underpinning the research design, Braun and Clarke’s 6-step approach to thematic analysis was adopted to generate codes and themes inductively from the transcribed data (Braun & Clarke, 2006 ). Initially, two researchers worked independently on this process before coming together to define each theme and decide on the most significant themes applying the principals of thematic analysis in a non-linear and iterative way. Results Importance of Reflection Educators agreed on the importance of reflection as a skill for medical students. Identified benefits of reflection included: preparing students for future career requirements and allowing them to reflect on their own practice as a means to both learn from it and process challenging situations. It was also identified that reflection is an important skill for educators. “reflective practice is important….. And it's increasingly acknowledged as important, and the medical board is starting to push this now” Medical Educator (ME) 2 “reflection is a very important skill, that if they can learn as a student and keep applying when they’re clinicians, will help them to continue to develop in a multifaceted way.” ME5 “it’s also good for the educators, too, because if you’re getting the feedback from the students, you can then tailor your education” Nursing Educator (NE) 6 How to foster reflective learning Three key themes were identified related to fostering reflective learning in medical students. These can be visualised as three concentric circles (Fig. 1 ). The outer circle represents the importance of fostering an organisational culture supportive of reflection. Within this sits the relational aspect of reflection, representing educators and students undertaking the reflective journey together. In the centre lies the student lens, in recognition of the many individual factors influencing a student’s ability to reflect. Fostering a culture of reflection Organisational culture dictates what is defined as reflection and how reflective activities are valued and performed within the organisation (Mannion & Davies, 2018 ; Sheehan & Wilkinson, 2022 ; Sparrow, 2016 ). A major aspect of this is the modelling of reflective behaviour within the organisation. The example set by medical educators was identified as particularly important in modelling reflective behaviour to medical students. “I wonder if the groaning about, and negativity to reflective practice is in the hidden curriculum in that as a profession, we groan and have a negative attitude to reflective practice.” ME2 Modelling also influences the focus of student reflections, in particular the deficit model commonly noted in student reflective exercises. “We use terms like debriefing, we go to M&Ms ( morbidity and mortality meetings) ... We're doing it because it was a challenging situation, not because it went beautifully.” ME1 Development of reflective culture was seen to be complicated by the fact that frequently, reflective activities were not recognised or labelled as such. In some cases, this was seen as a deliberate decision. “I hear lots of philosophical conversations coming from my colleagues with medical students... I've never heard any of them termed as reflection.” ME3 “You asked if we use the word reflection, and I think we all try and shy away from it” ME5 Organisational culture is also influenced by the presence or lack of clear expectations for reflective activities, especially within the medical school curriculum. “We could probably do a better job of actually setting that standard with orientation...We want you to go and look at the case and then say, “Yes, this is what happened in the case, but this is what I what I think we could improve or what went well, and this is what I'm going to incorporate into my practice going forward.” ME2 Another factor is the time allowed within the medical school program for reflective activities, both for educators and students. “Since I think a common perception amongst the third years is that they have a lot to do... the corner to cut is, you know, that reflective bit. ” ME3 “When you've only got like two hours to get through six people, you may not be able to sort of expand on some of those reflections, as interesting as they might be to discuss as a group.” NE1 The LIC model and rural setting of this program was seen as having a positive influence on reflection. Students were perceived to have more exposure to issues that are likely to prompt reflection and have more informal opportunities for reflection through the communal accommodation arrangements in these settings. “I wonder within the rural context whether our students are naturally doing it at night when they go home and talk to each other a little bit anyway” ME 6 “By the end of the year…we've prompted them to have a think about how this case will be different between rural and metro. And I think that that's really important even if they never go back and be a rural doctor.” NE5 Undertaking the reflective journey together The next layer reflects the value of students and educators learning together. This was identified to occur on a peer-to-peer basis as well as with the educator team. “One thing I try and do with the students is every week we catch up and I ask them all the question, “What was the most interesting thing you saw this week?”....I always try and do one as well to model firstly that I'm still learning. ...we're all learning together.” ME5 It was recognised that different disciplines within the educator team may have more skills in this area that should be utilised. “Perhaps the nurse educators are better positioned to talk to them about reflective practice …Because perhaps the medical educators don't do it well, either.” NE5 However, this learning relationship requires trust and vulnerability from both sides. “Because they're (students) so used to being such high performers, being in a position where you're not performing so well definitely puts them in a vulnerable position...” NE1 “I think that depends on trust. That's probably the key thing. And the relationship that exists, so it wouldn't be a natural thing at the start of a year to do it with an educator.” ME3 Upskilling educators was felt to be vital given the importance of the student-educator relationship to the reflective experience and the wide variety in reflective experience and skill amongst educators. “Maybe …some professional development for the medical educators as well, just to see how comfortable they are with it.“ NE5 “Often I think that myself and my colleagues don't recognize that that is the process that we're undertaking with the student there and then. Or with each other” ME3 Looking through the student lens Finally, student specific factors must be considered when teaching reflective practice. One of the challenges associated with reflective practice is that students and educators have varying levels of skill and comfort with reflective practice. “You’re teaching for some people, something that they're doing already and then for others, … you are actually trying to teach, you know, an unnatural kind of process.” ME3 “I did nursing a number of years ago, and I remember doing reflective practice at uni. We did reflections on everything.” NE 4 The students’ level of clinical experience also played a role in shaping their ability to reflect. “At the beginning, the reflection was just, this is all new and different. And now the reflection is more about what was done well and how they contributed and how they could do better or could do things differently.” ME1 “By the end of it, they've learnt so much that the reflective practice is actually more where they're thinking...They're now more thinking about reflecting on their practice and how they're going to be a better doctor.” NE2 Student perceptions of reflection is also influenced by whether these activities are formally assessed or not. “Reflection or reflective learning can be done both formally and informally” NE5 “I do worry that in assessment that people will just write the minimum of what they have to do because they don’t see it as a priority.” ME6 “I wonder if it should be separate to assessment. In that the assessment, there's a power differential there... knowing that you're either going to pass or fail at the end… reflective practice isn't about other people assessing you, it's about you assessing yourself so that you can self-improve going forward” ME2 Discussion This study explored the factors perceived by educators within a rural medical program to influence reflective learning amongst medical students undertaking a longitudinal integrated clerkship. Many of these factors have implications for reflective learning within medical education more broadly. Dissonance A key finding in this study was the dissonance between the recognition of the importance of reflection to both students and educators, and the tendency to avoid using the term reflection, or, as one participant labelled it, the “groaning” about reflection. The finding of this dissonance reflects a significant barrier to reflective learning and highlights a conflict between the reported value of reflection (as recognised by all participants) and the interest in participating in reflective activities. This dissonance between perceived value and interest in reflection has been described elsewhere in the literature amongst both students and educators (Gathu, 2022 ; McLean et al., 2022 ) Cultural shifts are needed to address this dissonance, otherwise it represents a significant barrier to the effectiveness of future interventions in this area. Influencing Culture Organisational culture can be described as “the shared ways of thinking, feeling and behaving in healthcare organisations”(Mannion & Davies, 2018 ). It may be better described in practice by the phrase “this is how we do things here”(Sheehan & Wilkinson, 2022 ). Those within the organisation, including educators and students, are frequently unaware of the nature of the surrounding culture or the impact that it has on their practice and education (Mannion & Davies, 2018 ; Sheehan & Wilkinson, 2022 ). After existing within a culture for some time, it is easy to presume that its core beliefs are widespread or even inevitable until alternatives are encountered (Sparrow, 2016 ). An additional complexity inherent in this setting is that educators sit within two cultures: the educational organisation and the health system in which they practice and supervise students. This can create a barrier where reflection is not valued in the time-limited clinical space and in a culture where “doing” is typically valued over reflection or learning (Ghaye, 2007 ; Mantzoukas & Jasper, 2004 ). Thus, it is important to first ensure that educators understand the organisational cultures in which they exist, as related to reflection. This initiates a circular process, whereby reflection on culture in turn influences culture by encouraging members to continually reflect and adapt their ways of working and thinking (James & Connolly, 2009 ). Development of a culture supportive of reflection thus contributes to transformative learning for both educators and students. Implications for Practice: Training Educators and Utilising Existing Skills Educator insights from the current study have highlighted areas where improvement is possible. While some areas, such as time constraints and a student’s natural tendency towards reflection, are very difficult to influence, there are other areas where relatively minor changes could influence culture and thus drive changes in student reflection. The first is the importance of training educators in the core concepts of reflective learning. Educator training has the potential to impact on all three themes identified through this study. Firstly, providing reflection training to educators demonstrates organisational culture by displaying that the skill of reflection is valued within the organisation. Secondly, the provision of reflection education also allows educators to better understand the purpose and process of reflection. Improving educator skills allows them to more effectively model reflective practice to the students placed with them and label reflection when it occurs, even informally. The modelling demonstrated by educators then provides a practical demonstration to students of the relevance and value of reflection in practice (Aronson, 2011 ). In this way, educators will be better placed to undertake the reflective journey with their students. Finally, reflective learning training for educators has the potential to help them to understand the student perspective, helping them to recognise the challenges their students are facing. An increased recognition of student challenges allows educators to address these challenges and assist students to move through them and learn from them. Another key outcome is the recognition of the need to utilise the skill of the diverse team of educators already involved within the Longlook program. The availability of educators from a multidisciplinary background within the program was recognised as an asset that can be utilised in teaching both students and other educators. The benefits of multidisciplinary education teams have been described elsewhere, particularly within simulation training.(Long et al., 2019 ; Stroud et al., 2017 ). However, this study demonstrates the benefit of multidisciplinary teaching teams in the teaching and modelling of reflective practice. The LIC Setting This study was conducted in the setting of a longitudinal integrated clerkship. Educators identified that the LIC model had a positive impact on reflection, given the longer term relationships with supervisors and peers, and the rural context where communal accommodation with peers is routine. This is supported by literature indicating benefits of the LIC model including: knowledge integration, relationship continuity, a holistic perspective on the patient and their experience and self awareness, all of which are required for reflection. (Bartlett et al., 2019 ; Carrigan et al., 2023 ; Gaufberg et al., 2014 ; Lam & Stickrath, 2021 ; Mylopoulos et al., 2020 ; Purea et al., 2022 ). This study did not have a comparator group within a more traditional block-mode setting but this may be a useful area for future enquiry. Members of the research team are involved within the LIC program described in this project, with three having senior roles in this program. This allows these individuals to bring an active interpretation to the results through their experience in this field. (Olmos-Vega et al., 2023 ). Within the context of this paper, the LIC program model was noted to be beneficial for reflection, given the long-term nature of the student-educator and student-student relationships, which was felt to enable the development of trust (despite the inherent power dynamics between educator and student). However, this reflects an important lesson for medical education more broadly regarding the challenges facing students in reflection. Further study is needed to explore how trust can be developed despite existing power differentials, particularly in the context of shorter term student-educator relationships. Future Research This study has demonstrated factors which influence student reflective learning within the context of a rural LIC. However, limitations of this study were that it considers only the perspective of educators. An extension of this study which will seek the student perspective for comparison is currently in progress. Given the importance of culture identified within this study, further studies exploring the perspective of senior staff and management would be of benefit in further exploring this area. Declarations Funding: The authors would like to acknowledge the funding received through the Rural Health Multidisciplinary Training (RHMT) program grant of the Australian Government that supported the salaries of HW, BC, LF, RH, JP and KB during the course of the study. . Acknowledgements: The writers acknowledge Dr Claire D Nicholls (University of Southern Queensland) for her assistance in reviewing the research methods section of this manuscript. Conflict of Interest: None Ethics: Ethical approval for this project was obtained from the Griffith University Human Research Ethics Committee (Reference 2021/376). References Aronson, L. (2011). Twelve tips for teaching reflection at all levels of medical education. Medical Teacher , 33 (3), 200-205. https://doi.org/10.3109/0142159X.2010.507714 Australian Government Department of Health and Aged Care. (2021, 14 December 2021). National Rural Generalist Pathway . Commonwealth of Australia. https://www.health.gov.au/initiatives-and-programs/national-rural-generalist-pathway Bartlett, M., Dowell, J., Graham, F., Knight, K., Law, S., Lockwood, P., . . . Watson, E. (2019). Dundee's Longitudinal Integrated Clerkship: drivers, implementation and early evaluation. Education for Primary Care , 30 (2), 72-79. https://doi.org/10.1080/14739879.2018.1564889 Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology , 3 , 77-101. https://doi.org/10.1191/1478088706qp063oa Carrigan, B., Bass, L., Pinidiyapathirage, J., Walters, S., Woodall, H., & Brumpton, K. (2023). Connectivity is the key to longer rural placement: Retaining students on rural longitudinal integrated clerkships. Medical Teacher , 1-7. https://doi.org/10.1080/0142159X.2023.2243025 Chaffey, L., de Leeuw, E. J., & Finnigan, G. (2012). Facilitating Students′ Reflective Practice in a Medical Course: Literature Review. Education for Health , 25 (3), 198-203. https://doi.org/http://dx.doi.org/10.4103/1357-6283.109787 Chambers, S., Brosnan, C., & Hassell, A. (2011). Introducing medical students to reflective practice. Education for primary care , 22 (2), 100-105. https://doi.org/10.1080/14739879.2011.11493975 Christie, M., Carey, M., Robertson, A., & Grainger, P. (2015). Putting transformative learning theory into practice. Australian journal of adult learning , 55 (1), 9-30. de la Croix, A., & Veen, M. (2018). The reflective zombie: Problematizing the conceptual framework of reflection in medical education. Perspectives on Medical Education , 7 (6), 394-400. https://doi.org/10.1007/s40037-018-0479-9 Fernandez, S. C., Chelliah, K. K., & Halim, L. (2015). A peek into oneself: reflective writing amongst undergraduate Medical Imaging students. Reflective practice , 16 (1), 109-122. https://doi.org/10.1080/14623943.2014.982524 Gathu, C. (2022). Facilitators and Barriers of Reflective Learning in Postgraduate Medical Education: A Narrative Review . Journal of Medical Education Curriculum Development, 3 (9) . DOI: 10.1177/23821205221096106 Gaufberg, E., Hirsh, D., Krupat, E., Ogur, B., Pelletier, S., Reiff, D., & Bor, D. (2014). Into the future: patient-centredness endures in longitudinal integrated clerkship graduates. Medical Education , 48 (6), 572-582. https://doi.org/10.1111/medu.12413 Ghaye, T. (2007). Building the Reflective Healthcare Organisation . John Wiley & Sons, Incorporated. http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=350980 Gillingham, K., Eggleton, K., & Goodyear-Smith, F. (2020). Is Reflective Learning Visible in Online Discussion Forums for Medical Students on General Practice Placements? A Qualitative Study. Teaching and Learning in Medicine , 32 (4), 434-441. https://doi.org/10.1080/10401334.2020.1730184 Greenhill, J., Richards, J. N., Mahoney, S., Campbell, N., & Walters, L. (2017). Transformative Learning in Medical Education: Context Matters, a South Australian Longitudinal Study. Journal of Transformative Education , 16 (1), 58-75. https://doi.org/10.1177/1541344617715710 Hall, S. L., Forrester, S., & Borsz, M. (2008). A Constructivist Case Study Examining the Leadership Development of Undergraduate Students in Campus Recreational Sports. Journal of College Student Development , 49 (2), 125-140. James, C., & Connolly, M. (2009). An analysis of the relationship between the organizational culture and the performance of staff work groups in schools and the development of an explanatory model. International Journal of Leadership in Education , 12 (4), 389-407. https://doi.org/10.1080/13603120902980804 Klein, J., & McColl, G. (2019). Cognitive dissonance: how self-protective distortions can undermine clinical judgement. Medical Education , 53 (12), 1178-1186. https://doi.org/10.1111/medu.13938 Lam, R., & Stickrath, C. (2021). It Takes a Village: Utilizing a Community-based Longitudinal Integrated Clerkship Model at a Regional Medical Campus to Provide the Core Emergency Medicine Clerkship Experience. AEM Education and Training , 5 (1), 5-11. https://doi.org/10.1002/aet2.10442 Long, A. M. M. D. F., Lefebvre, C. M. M. D., Masneri, D. A. D. O., Mowery, N. T. M. D. F., Chang, M. C. M. D. F., Johnson, J. E. P., & Carter, J. E. M. D. F. (2019). The Golden Opportunity: Multidisciplinary Simulation Training Improves Trauma Team Efficiency. Journal of Surgical Education , 76 (4), 1116-1121. https://doi.org/10.1016/j.jsurg.2019.01.003 Lutz, G., Scheffer, C., Edelhaeuser, F., Tauschel, D., & Neumann, M. (2013). A reflective practice intervention for professional development, reduced stress and improved patient care—A qualitative developmental evaluation. Patient education and counseling , 92 (3), 337-345. https://doi.org/10.1016/j.pec.2013.03.020 MacAskill, W., Chua, W., Woodall, H., & Pinidiyapathirage, J. (2023). Beyond the Written Reflection: A Systematic Review and Qualitative Synthesis of Creative Approaches to Reflective Learning Amongst Medical Students. Perspectives on Medical Education , 12 , 361-371. https://doi.org/10.5334/pme.914 Malau-Aduli, B. S., Roche, P., Adu, M., Jones, K., Alele, F., & Drovandi, A. (2020). Perceptions and processes influencing the transition of medical students from pre-clinical to clinical training. BMC Medical Education , 20 (1), 279. https://doi.org/10.1186/s12909-020-02186-2 Mannion, R., & Davies, H. (2018). Understanding organisational culture for healthcare quality improvement. British Medical Journal , 363 , k4907. https://doi.org/10.1136/bmj.k4907 Mantzoukas, S., & Jasper, M. A. (2004). Reflective practice and daily ward reality: a covert power game. Journal of Clinical Nursing , 13 (8), 925-933. https://doi.org/10.1111/j.1365-2702.2004.01008.x McLean, D., Chiavaroli, N., Denniston, C., & Richardson, M. (2022). In-verse reflection: structured creative writing exercises to promote reflective learning in medical students. Journal of Medical Humanities , 43 (3), 493-504. https://doi.org/10.1007/s10912-022-09740-7 Mezirow. (1994). Understanding Transformation Theory. Adult Education Quarterly , 44 (4), 222-232. Mylopoulos, M., Kulasegaram, K., Weyman, K., Bernstein, S., & Martimianakis, M. A. (2020). Same but Different: Exploring Mechanisms of Learning in a Longitudinal Integrated Clerkship. Academic Medicine , 95 (3), 411-416. https://doi.org/10.1097/ACM.0000000000002960 Olmos-Vega, F. M., Stalmeijer, R. E., Varpio, L., & Kahlke, R. (2023). A practical guide to reflexivity in qualitative research: AMEE Guide No. 149. Medical Teacher , 45 (3), 241-251. https://doi.org/10.1080/0142159X.2022.2057287 Purea, P., Brumpton, K., Kumar, K., & Pinidiyapathirage, J. (2022). Exploring the learning environment afforded by an Aboriginal Community Controlled Health service in a rural longitudinal integrated clerkship. Education for Primary Care , 33 (4), 214-220. https://doi.org/10.1080/14739879.2022.2054371 Sandars, J. (2009). The use of reflection in medical education: AMEE Guide No. 44. Medical Teacher , 31 (8), 685-695. https://doi.org/10.1080/01421590903050374 Shannon-Baker, P. (2023). Philosophical underpinnings of mixed methods research in education. In R. J. Tierney, F. Rizvi, & K. Ercikan (Eds.), International Encyclopedia of Education (Fourth Edition) (pp. 380-389). Elsevier. https://doi.org/https://doi.org/10.1016/B978-0-12-818630-5.11037-1 Sheehan, D., & Wilkinson, T. J. (2022). Widening how we see the impact of culture on learning, practice and identity development in clinical environments. Medical Education , 56 (1), 110-116. https://doi.org/10.1111/medu.14630 Sparrow, J. (2016). Reflective Practice in Organizational Learning, Cultural Self-Understanding and Community Self-Strengthening. Infant Mental Health Journal , 37 (6), 605-616. https://doi.org/10.1002/imhj.21602 Stroud, J., Jenkins, K., Bhandary, S., & Papadimos, T. (2017). Putting the pieces together: The role of multidisciplinary simulation in medical education. International Journal of Academic Medicine , 3 (1), 104-109. https://doi.org/10.4103/IJAM.IJAM_44_17 The Consortium of Longitudinal Integrated Clerkships. (2020). CLIC – The Consortium of Longitudinal Integrated Clerkships . Retrieved 5th March from https://clicmeded.com/ Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3357325","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":233675648,"identity":"78bd9825-1ffa-40c5-a550-8cabdc6a80a7","order_by":0,"name":"Hannah Woodall","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYBACAzDJxiDDx97AwJBgI8fDIAEU4CFCCw8bzwGgljRjHh7itUgkABlpxgwEtZgz8Bg++FBmx8Mm+fzahwcJBjL20g2MD962McgbHMCuxbKBx9hwxrlkHjbpnOIZCQkGPDwyB5gN57YxGG7AocXgAO82ad42ZpCWZIbEH3+AfklgA4owMBLQUg902JlkBrAtEgnsv4Fa7AloOQz0PvthmBY2ZqCWRJxaDvN/BvrlODCQc5ghWm4kNkvOOSeRPBOXluNticAQq5bjZz/+mPFHgoE9+4zkgx/elNnY9uHQwsAMZ/EYQBmMDUBCAod6FMD+gBhVo2AUjIJRMAIBANQQTvfRw7wHAAAAAElFTkSuQmCC","orcid":"","institution":"Rural Medical Education Australia","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Hannah","middleName":"","lastName":"Woodall","suffix":""},{"id":233675649,"identity":"962b1995-cd58-4865-beeb-a299a6a2d543","order_by":1,"name":"Brendan Carrigan","email":"","orcid":"","institution":"Rural Medical Education Australia","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Brendan","middleName":"","lastName":"Carrigan","suffix":""},{"id":233675650,"identity":"3a02c0cc-5bc3-49ac-a6d0-26ab95978511","order_by":2,"name":"Linda Furness","email":"","orcid":"","institution":"Rural Medical Education Australia","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Linda","middleName":"","lastName":"Furness","suffix":""},{"id":233675651,"identity":"61c9f381-5e2e-462e-bdcc-a1888186f12d","order_by":3,"name":"Robert Heffernan","email":"","orcid":"","institution":"Rural Medical Education Australia","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Heffernan","suffix":""},{"id":233675652,"identity":"e17eb707-d011-4d4e-ad4d-0c2ca0374cea","order_by":4,"name":"Janani Pinidiyapathirage","email":"","orcid":"","institution":"Rural Medical Education Australia","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Janani","middleName":"","lastName":"Pinidiyapathirage","suffix":""},{"id":233675653,"identity":"84546735-6191-47e9-965c-5e26c0bc836d","order_by":5,"name":"Kay Brumpton","email":"","orcid":"","institution":"Griffith University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kay","middleName":"","lastName":"Brumpton","suffix":""}],"badges":[],"createdAt":"2023-09-15 05:29:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3357325/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3357325/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":43495901,"identity":"8b9b475b-7c76-4c2b-a503-a805af02c2bb","added_by":"auto","created_at":"2023-09-21 16:36:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":93933,"visible":true,"origin":"","legend":"\u003cp\u003eFactors impacting on student reflective learning in a rural medical program\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3357325/v1/211cea93c63a3b388ffd6817.png"},{"id":46820560,"identity":"415d6581-d2eb-4870-b4ff-d8a055207d27","added_by":"auto","created_at":"2023-11-21 04:22:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":365371,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3357325/v1/d62b136d-af82-44e2-9f40-85ae5a4ef3fd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\"We're all learning together”: Educator perspectives on medical student reflective practice","fulltext":[{"header":"Introduction","content":"\u003cp\u003eReflective practice is central to navigating what has been described as the \u0026ldquo;transformative learning journey\u0026rdquo; of medical students (Greenhill et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Reflection is \u0026ldquo;a metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters\u0026rdquo;(Sandars, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2009\u003c/span\u003e, p. 685). Reflective learning plays an important role in the education of medical students, especially in the early years of clinical training. During this time students learn how to translate theory into practice and integrate knowledge about ethics, communication, professionalism, and culture into real-life (Malau-Aduli et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Through the reflective process, students learn about themselves as well as medicine, with the aim of integrating lessons in a manner that improves future practice. This integration is achieved by encouraging students to actively look back on experiences and examine their own skills, beliefs, or assumptions. In so doing, the students begins to make sense of a situation and learn lessons to apply next time (Chambers et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Fernandez et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Gillingham et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe skill of reflection is central to transformative learning within medical education (Greenhill et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Transformative learning theory is based on a constructivist paradigm, which \u0026ldquo;holds that the way learners interpret and reinterpret their sense experience is, central to making meaning and hence learning\u0026rdquo;(Mezirow, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1994\u003c/span\u003e). The theory describes how students experience \u0026ldquo;disorienting dilemma/s\u0026rdquo;, which cause them to move through a process of evaluating and assessing their knowledge, beliefs and attitudes, through which they are prompted to examine their perspectives and worldviews (Mezirow, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1994\u003c/span\u003e) (Christie et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The experience of being a medical student automatically places the learner in challenging situations which can give rise to these disorienting dilemmas. These may result from the experience of cognitive dissonance, \u0026ldquo;the uncomfortable tension we experience when we hold\u0026hellip;.inconsistent beliefs, or when our behaviour is inconsistent with our beliefs\u0026rdquo; which can arise at many points in the medical student journey (Klein \u0026amp; McColl, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The purpose of reflection is to begin to recognise these situations as learning experiences, which will develop the learner for future practice. Reflective skills are key to this process.\u003c/p\u003e \u003cp\u003eMany universities have instituted some form of reflective learning for students, in recognition of the need for students to develop these skills. Evidence suggests that students benefit from the opportunity to address and reflect on real issues, rather than hypothetical ones (Lutz et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Reflective skills allow students to reframe challenging situations as learning opportunities and allow the processing of experiences within a safe space; consequently reducing student stress (Lutz et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Students also report improvements in patient care after reflective activities due to improved communication and understanding of the patient as a person (Lutz et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). However, although reflection is triggered by an experience of uncertainty or cognitive dissonance, it is not an automatic or passive process. Rather, it requires students to have the time, willingness, and skills to reflect and process their experiences (Chaffey et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Chambers et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCurrent practice in reflective learning within medical education has been criticised due to its reliance on formulaic, mostly written reflection which tend to lead to contrived, inauthentic reflections and, in the words of one research team, risks creating a \u0026ldquo;reflective zombie\u0026rdquo; (de la Croix \u0026amp; Veen, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Such activities focus on assessment, rather than on supporting the student to reflect and participate in transformative learning (Gathu, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Evidence is building towards supporting diverse reflective methods to enable learners to identify their own personal systems for engaging in reflection.(MacAskill et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt is critical that reflective learning skills are taught well and supported if we are to strive for transformative learning amongst medical students. This study therefore aimed to explore the factors perceived by educators to influence the development of reflective learning skills amongst medical students in a rural longitudinal integrated clerkship.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting:\u003c/h2\u003e \u003cp\u003eThis study explored reflective learning in a four-year postgraduate medical degree program in Australia. Ethical approval for the study was obtained from the Griffith University Human Research Ethics Committee (GU 2021/376). Medical students in this program have the opportunity to participate in a longitudinal integrated clerkship (LIC), the \u0026ldquo;Longlook\u0026rdquo; Program, for one or both of their clinical years (years three and four). Longlook is unique in that it is delivered in partnership with a non-for profit organisation, Rural Medical Education Australia.\u003c/p\u003e \u003cp\u003eMedical students in the Longlook program participate in a longitudinal integrated clerkship (LIC) for one or both of their clinical years (years three and four). Student LIC placements last for 1\u0026ndash;2 years and are based in rural locations where they meet learning goals across multiple disciplines within a longitudinal placement rather than through isolated blocks, affording students\u0026rsquo; continuity of relationships with both supervising clinicians and patients over this time (The Consortium of Longitudinal Integrated Clerkships, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Medical students are taught and supported by educators from both a medical and nursing background within this program. Approximately 50 students participate in this program each year at one of eight rural clinical training sites.\u003c/p\u003e \u003cp\u003eStudents in the rural program follow a curriculum which includes the completion of two forms of reflective assessment. The first is a written reflection on the student\u0026rsquo;s topic of choice, completed by all students in both third and fourth year. The second is a series of case presentations which are expected to incorporate reflection on the care provided as well as consideration of ethical, legal, professionalism or other non-biomedical aspects of the case. Students complete twenty-four of these case presentations in Year 3, and six in Year 4.\u003c/p\u003e \u003cp\u003eResearch Team:\u003c/p\u003e \u003cp\u003eThe research team has broad experience across medical education and clinical practice. HW is an academic GP who works in research within the not for profit which facilitates the Longlook program described within this paper. KB, BC and RH are clinicians and medical educators who have been and continue to be actively involved in the development and implementation of the LIC model within which this study was conducted. KB is Director of Education and Training at the not-for-profit through which this LIC program is facilitated, with BC and RH leading the 3rd and 4th year student programs. LF is an occupational therapist with expertise in the field of education and reflective learning within the allied health context. JP is an experienced researcher who works for the not for profit facilitating this program.\u003c/p\u003e \u003cp\u003eParticipants:\u003c/p\u003e \u003cp\u003eParticipants were recruited from both nursing and medical educator staff at all eight rural sites within this program. Participants included six educators with a medical background, and five with a nursing background. All participants are involved in the training of medical students through the Longlook program and are co-located with students in hospital sites spread over southeast Queensland. Longlook medical educators are rural generalists; \u0026ldquo;general practitioners who provide primary care services, emergency medicine and have training in additional skills like obstetrics, anaesthetics or mental health services\u0026rdquo; (Australian Government Department of Health and Aged Care, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Longlook clinical nurse educators in the program have advanced training to work in rural generalist hospitals and support education delivery within the LIC. Both nursing and medical educators attend hub training sessions with the students at a central location on monthly intervals throughout the academic year in addition to providing teaching and learning support to medical students at their respective local sites.\u003c/p\u003e \u003cp\u003eProject design:\u003c/p\u003e \u003cp\u003eTo ensure methodological congruence and fore front the experiences and voices of the research participants, a constructivist case study research paradigm was used in this study. Constructivist perspectives reflected the desire to explore the participants constructions of their lived experiences as an educator (Shannon-Baker, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The case study approach was able to understand and describe the specific experiences of educators within the setting of a rural LIC program by purposively selecting educators within the program (Hall et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). In accordance with the constructivist approach, semi-structured focus groups were developed to capture the experiences and subjective opinions of research participants. Two focus groups were conducted with a total of eleven educators (six medical, five nursing).\u003c/p\u003e \u003cp\u003eMedical and nursing educator focus groups were held independently to manage group dynamics and appreciate important differences between the two groups. The potential for power differentials between medical and nursing educators was recognised, and consequently, the groups were siloed to ensure that the perspectives of both groups could be explored.\u003c/p\u003e \u003cp\u003eThe focus group with medical educators was conducted by HW, who has a medical background but is not one of the medical educators. The clinical nurse educator focus group was conducted by a clinical educator with a nursing background. Focus groups lasted approximately one hour and were conducted in person during student teaching days. The focus groups explored educator views on reflective learning activities for students, an evaluation of current reflective methods and how reflective learning could be improved.\u003c/p\u003e \u003cp\u003eFocus group data recordings were transcribed and uploaded to NVivo\u0026trade; for coding. Aligning with the qualitative approach to data generation and in keeping with the constructivist paradigm underpinning the research design, Braun and Clarke\u0026rsquo;s 6-step approach to thematic analysis was adopted to generate codes and themes inductively from the transcribed data (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Initially, two researchers worked independently on this process before coming together to define each theme and decide on the most significant themes applying the principals of thematic analysis in a non-linear and iterative way.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eImportance of Reflection\u003c/h2\u003e \u003cp\u003eEducators agreed on the importance of reflection as a skill for medical students. Identified benefits of reflection included: preparing students for future career requirements and allowing them to reflect on their own practice as a means to both learn from it and process challenging situations. It was also identified that reflection is an important skill for educators.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;reflective practice is important\u0026hellip;.. And it's increasingly acknowledged as important, and the medical board is starting to push this now\u0026rdquo;\u003c/em\u003e Medical Educator (ME) 2\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;reflection is a very important skill, that if they can learn as a student and keep applying when they\u0026rsquo;re clinicians, will help them to continue to develop in a multifaceted way.\u0026rdquo;\u003c/em\u003e ME5\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;it\u0026rsquo;s also good for the educators, too, because if you\u0026rsquo;re getting the feedback from the students, you can then tailor your education\u0026rdquo;\u003c/em\u003e Nursing Educator (NE) 6\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eHow to foster reflective learning\u003c/h2\u003e \u003cp\u003eThree key themes were identified related to fostering reflective learning in medical students. These can be visualised as three concentric circles (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The outer circle represents the importance of fostering an organisational culture supportive of reflection. Within this sits the relational aspect of reflection, representing educators and students undertaking the reflective journey together. In the centre lies the student lens, in recognition of the many individual factors influencing a student\u0026rsquo;s ability to reflect.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eFostering a culture of reflection\u003c/h2\u003e \u003cp\u003eOrganisational culture dictates what is defined as reflection and how reflective activities are valued and performed within the organisation (Mannion \u0026amp; Davies, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Sheehan \u0026amp; Wilkinson, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Sparrow, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). A major aspect of this is the modelling of reflective behaviour within the organisation. The example set by medical educators was identified as particularly important in modelling reflective behaviour to medical students.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I wonder if the groaning about, and negativity to reflective practice is in the hidden curriculum in that as a profession, we groan and have a negative attitude to reflective practice.\u0026rdquo;\u003c/em\u003e ME2\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eModelling also influences the focus of student reflections, in particular the deficit model commonly noted in student reflective exercises.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We use terms like debriefing, we go to M\u0026amp;Ms (\u003c/em\u003emorbidity and mortality meetings) ...\u003cem\u003eWe're doing it because it was a challenging situation, not because it went beautifully.\u0026rdquo;\u003c/em\u003e ME1\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDevelopment of reflective culture was seen to be complicated by the fact that frequently, reflective activities were not recognised or labelled as such. In some cases, this was seen as a deliberate decision.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I hear lots of philosophical conversations coming from my colleagues with medical students... I've never heard any of them termed as reflection.\u0026rdquo;\u003c/em\u003e ME3\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You asked if we use the word reflection, and I think we all try and shy away from it\u0026rdquo;\u003c/em\u003e ME5\u003c/p\u003e\u003cp\u003eOrganisational culture is also influenced by the presence or lack of clear expectations for reflective activities, especially within the medical school curriculum.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We could probably do a better job of actually setting that standard with orientation...We want you to go and look at the case and then say, \u0026ldquo;Yes, this is what happened in the case, but this is what I what I think we could improve or what went well, and this is what I'm going to incorporate into my practice going forward.\u0026rdquo;\u003c/em\u003e ME2\u003c/p\u003e\u003cp\u003eAnother factor is the time allowed within the medical school program for reflective activities, both for educators and students.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Since I think a common perception amongst the third years is that they have a lot to do... the corner to cut is, you know, that reflective bit.\u003c/em\u003e\u0026rdquo; ME3\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When you've only got like two hours to get through six people, you may not be able to sort of expand on some of those reflections, as interesting as they might be to discuss as a group.\u0026rdquo;\u003c/em\u003e NE1\u003c/p\u003e\u003cp\u003eThe LIC model and rural setting of this program was seen as having a positive influence on reflection. Students were perceived to have more exposure to issues that are likely to prompt reflection and have more informal opportunities for reflection through the communal accommodation arrangements in these settings.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I wonder within the rural context whether our students are naturally doing it at night when they go home and talk to each other a little bit anyway\u0026rdquo; ME\u003c/em\u003e6\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;By the end of the year\u0026hellip;we've prompted them to have a think about how this case will be different between rural and metro. And I think that that's really important even if they never go back and be a rural doctor.\u0026rdquo;\u003c/em\u003e NE5\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eUndertaking the reflective journey together\u003c/h2\u003e \u003cp\u003eThe next layer reflects the value of students and educators learning together. This was identified to occur on a peer-to-peer basis as well as with the educator team.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;One thing I try and do with the students is every week we catch up and I ask them all the question, \u0026ldquo;What was the most interesting thing you saw this week?\u0026rdquo;....I always try and do one as well to model firstly that I'm still learning. ...we're all learning together.\u0026rdquo;\u003c/em\u003e ME5\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIt was recognised that different disciplines within the educator team may have more skills in this area that should be utilised.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Perhaps the nurse educators are better positioned to talk to them about reflective practice \u0026hellip;Because perhaps the medical educators don't do it well, either.\u0026rdquo;\u003c/em\u003e NE5\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, this learning relationship requires trust and vulnerability from both sides.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Because they're\u003c/em\u003e (students) \u003cem\u003eso used to being such high performers, being in a position where you're not performing so well definitely puts them in a vulnerable position...\u0026rdquo;\u003c/em\u003e NE1\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think that depends on trust. That's probably the key thing. And the relationship that exists, so it wouldn't be a natural thing at the start of a year to do it with an educator.\u0026rdquo;\u003c/em\u003e ME3\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUpskilling educators was felt to be vital given the importance of the student-educator relationship to the reflective experience and the wide variety in reflective experience and skill amongst educators.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Maybe \u0026hellip;some professional development for the medical educators as well, just to see how comfortable they are with it.\u0026ldquo;\u003c/em\u003e NE5\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Often I think that myself and my colleagues don't recognize that that is the process that we're undertaking with the student there and then. Or with each other\u0026rdquo;\u003c/em\u003e ME3\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eLooking through the student lens\u003c/h2\u003e \u003cp\u003eFinally, student specific factors must be considered when teaching reflective practice. One of the challenges associated with reflective practice is that students and educators have varying levels of skill and comfort with reflective practice.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You\u0026rsquo;re teaching for some people, something that they're doing already and then for others, \u0026hellip; you are actually trying to teach, you know, an unnatural kind of process.\u0026rdquo;\u003c/em\u003e ME3\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I did nursing a number of years ago, and I remember doing reflective practice at uni. We did reflections on everything.\u0026rdquo; NE\u003c/em\u003e4\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe students\u0026rsquo; level of clinical experience also played a role in shaping their ability to reflect.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;At the beginning, the reflection was just, this is all new and different. And now the reflection is more about what was done well and how they contributed and how they could do better or could do things differently.\u0026rdquo;\u003c/em\u003e ME1\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;By the end of it, they've learnt so much that the reflective practice is actually more where they're thinking...They're now more thinking about reflecting on their practice and how they're going to be a better doctor.\u0026rdquo;\u003c/em\u003e NE2\u003c/p\u003e\u003cp\u003eStudent perceptions of reflection is also influenced by whether these activities are formally assessed or not.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Reflection or reflective learning can be done both formally and informally\u0026rdquo;\u003c/em\u003e NE5\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I do worry that in assessment that people will just write the minimum of what they have to do because they don\u0026rsquo;t see it as a priority.\u0026rdquo;\u003c/em\u003e ME6\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I wonder if it should be separate to assessment. In that the assessment, there's a power differential there... knowing that you're either going to pass or fail at the end\u0026hellip; reflective practice isn't about other people assessing you, it's about you assessing yourself so that you can self-improve going forward\u0026rdquo;\u003c/em\u003e ME2\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the factors perceived by educators within a rural medical program to influence reflective learning amongst medical students undertaking a longitudinal integrated clerkship. Many of these factors have implications for reflective learning within medical education more broadly.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDissonance\u003c/h2\u003e \u003cp\u003eA key finding in this study was the dissonance between the recognition of the importance of reflection to both students and educators, and the tendency to avoid using the term reflection, or, as one participant labelled it, the \u0026ldquo;groaning\u0026rdquo; about reflection. The finding of this dissonance reflects a significant barrier to reflective learning and highlights a conflict between the reported value of reflection (as recognised by all participants) and the interest in participating in reflective activities. This dissonance between perceived value and interest in reflection has been described elsewhere in the literature amongst both students and educators (Gathu, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; McLean et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) Cultural shifts are needed to address this dissonance, otherwise it represents a significant barrier to the effectiveness of future interventions in this area.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInfluencing Culture\u003c/h2\u003e \u003cp\u003eOrganisational culture can be described as \u0026ldquo;the shared ways of thinking, feeling and behaving in healthcare organisations\u0026rdquo;(Mannion \u0026amp; Davies, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). It may be better described in practice by the phrase \u0026ldquo;this is how we do things here\u0026rdquo;(Sheehan \u0026amp; Wilkinson, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Those within the organisation, including educators and students, are frequently unaware of the nature of the surrounding culture or the impact that it has on their practice and education (Mannion \u0026amp; Davies, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Sheehan \u0026amp; Wilkinson, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). After existing within a culture for some time, it is easy to presume that its core beliefs are widespread or even inevitable until alternatives are encountered (Sparrow, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). An additional complexity inherent in this setting is that educators sit within two cultures: the educational organisation and the health system in which they practice and supervise students. This can create a barrier where reflection is not valued in the time-limited clinical space and in a culture where \u0026ldquo;doing\u0026rdquo; is typically valued over reflection or learning (Ghaye, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Mantzoukas \u0026amp; Jasper, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Thus, it is important to first ensure that educators understand the organisational cultures in which they exist, as related to reflection. This initiates a circular process, whereby reflection on culture in turn influences culture by encouraging members to continually reflect and adapt their ways of working and thinking (James \u0026amp; Connolly, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Development of a culture supportive of reflection thus contributes to transformative learning for both educators and students.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Practice: Training Educators and Utilising Existing Skills\u003c/h2\u003e \u003cp\u003eEducator insights from the current study have highlighted areas where improvement is possible. While some areas, such as time constraints and a student\u0026rsquo;s natural tendency towards reflection, are very difficult to influence, there are other areas where relatively minor changes could influence culture and thus drive changes in student reflection.\u003c/p\u003e \u003cp\u003eThe first is the importance of training educators in the core concepts of reflective learning. Educator training has the potential to impact on all three themes identified through this study. Firstly, providing reflection training to educators demonstrates organisational culture by displaying that the skill of reflection is valued within the organisation. Secondly, the provision of reflection education also allows educators to better understand the purpose and process of reflection. Improving educator skills allows them to more effectively model reflective practice to the students placed with them and label reflection when it occurs, even informally. The modelling demonstrated by educators then provides a practical demonstration to students of the relevance and value of reflection in practice (Aronson, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). In this way, educators will be better placed to undertake the reflective journey with their students. Finally, reflective learning training for educators has the potential to help them to understand the student perspective, helping them to recognise the challenges their students are facing. An increased recognition of student challenges allows educators to address these challenges and assist students to move through them and learn from them.\u003c/p\u003e \u003cp\u003eAnother key outcome is the recognition of the need to utilise the skill of the diverse team of educators already involved within the Longlook program. The availability of educators from a multidisciplinary background within the program was recognised as an asset that can be utilised in teaching both students and other educators. The benefits of multidisciplinary education teams have been described elsewhere, particularly within simulation training.(Long et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Stroud et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). However, this study demonstrates the benefit of multidisciplinary teaching teams in the teaching and modelling of reflective practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eThe LIC Setting\u003c/h2\u003e \u003cp\u003eThis study was conducted in the setting of a longitudinal integrated clerkship. Educators identified that the LIC model had a positive impact on reflection, given the longer term relationships with supervisors and peers, and the rural context where communal accommodation with peers is routine. This is supported by literature indicating benefits of the LIC model including: knowledge integration, relationship continuity, a holistic perspective on the patient and their experience and self awareness, all of which are required for reflection. (Bartlett et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Carrigan et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Gaufberg et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Lam \u0026amp; Stickrath, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Mylopoulos et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Purea et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This study did not have a comparator group within a more traditional block-mode setting but this may be a useful area for future enquiry. Members of the research team are involved within the LIC program described in this project, with three having senior roles in this program. This allows these individuals to bring an active interpretation to the results through their experience in this field. (Olmos-Vega et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eWithin the context of this paper, the LIC program model was noted to be beneficial for reflection, given the long-term nature of the student-educator and student-student relationships, which was felt to enable the development of trust (despite the inherent power dynamics between educator and student). However, this reflects an important lesson for medical education more broadly regarding the challenges facing students in reflection. Further study is needed to explore how trust can be developed despite existing power differentials, particularly in the context of shorter term student-educator relationships.\u003c/span\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFuture Research\u003c/h2\u003e \u003cp\u003eThis study has demonstrated factors which influence student reflective learning within the context of a rural LIC. However, limitations of this study were that it considers only the perspective of educators. An extension of this study which will seek the student perspective for comparison is currently in progress. Given the importance of culture identified within this study, further studies exploring the perspective of senior staff and management would be of benefit in further exploring this area.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003eThe authors would like to acknowledge the funding received through the Rural Health Multidisciplinary Training (RHMT) program grant of the Australian Government that supported the salaries of HW, BC, LF, RH, JP and KB during the course of the study. \u0026nbsp;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe writers acknowledge Dr Claire D Nicholls (University of Southern Queensland) for her assistance in reviewing the research methods section of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics:\u0026nbsp;\u003c/strong\u003eEthical approval for this project was obtained from the Griffith University Human Research Ethics Committee (Reference 2021/376).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAronson, L. (2011). Twelve tips for teaching reflection at all levels of medical education. \u003cem\u003eMedical Teacher\u003c/em\u003e,\u003cem\u003e 33\u003c/em\u003e(3), 200-205. https://doi.org/10.3109/0142159X.2010.507714 \u003c/li\u003e\n\u003cli\u003eAustralian Government Department of Health and Aged Care. (2021, 14 December 2021). \u003cem\u003eNational Rural Generalist Pathway\u003c/em\u003e. Commonwealth of Australia. https://www.health.gov.au/initiatives-and-programs/national-rural-generalist-pathway\u003c/li\u003e\n\u003cli\u003eBartlett, M., Dowell, J., Graham, F., Knight, K., Law, S., Lockwood, P., . . . Watson, E. (2019). Dundee\u0026apos;s Longitudinal Integrated Clerkship: drivers, implementation and early evaluation. \u003cem\u003eEducation for Primary Care\u003c/em\u003e,\u003cem\u003e 30\u003c/em\u003e(2), 72-79. https://doi.org/10.1080/14739879.2018.1564889 \u003c/li\u003e\n\u003cli\u003eBraun, V., \u0026amp; Clarke, V. (2006). Using thematic analysis in psychology. \u003cem\u003eQualitative Research in Psychology\u003c/em\u003e,\u003cem\u003e 3\u003c/em\u003e, 77-101. https://doi.org/10.1191/1478088706qp063oa \u003c/li\u003e\n\u003cli\u003eCarrigan, B., Bass, L., Pinidiyapathirage, J., Walters, S., Woodall, H., \u0026amp; Brumpton, K. (2023). Connectivity is the key to longer rural placement: Retaining students on rural longitudinal integrated clerkships. \u003cem\u003eMedical Teacher\u003c/em\u003e, 1-7. https://doi.org/10.1080/0142159X.2023.2243025 \u003c/li\u003e\n\u003cli\u003eChaffey, L., de Leeuw, E. J., \u0026amp; Finnigan, G. (2012). Facilitating Students\u0026prime; Reflective Practice in a Medical Course: Literature Review. \u003cem\u003eEducation for Health\u003c/em\u003e,\u003cem\u003e 25\u003c/em\u003e(3), 198-203. https://doi.org/http://dx.doi.org/10.4103/1357-6283.109787 \u003c/li\u003e\n\u003cli\u003eChambers, S., Brosnan, C., \u0026amp; Hassell, A. (2011). Introducing medical students to reflective practice. \u003cem\u003eEducation for primary care\u003c/em\u003e,\u003cem\u003e 22\u003c/em\u003e(2), 100-105. https://doi.org/10.1080/14739879.2011.11493975 \u003c/li\u003e\n\u003cli\u003eChristie, M., Carey, M., Robertson, A., \u0026amp; Grainger, P. (2015). Putting transformative learning theory into practice. \u003cem\u003eAustralian journal of adult learning\u003c/em\u003e,\u003cem\u003e 55\u003c/em\u003e(1), 9-30. \u003c/li\u003e\n\u003cli\u003ede la Croix, A., \u0026amp; Veen, M. (2018). The reflective zombie: Problematizing the conceptual framework of reflection in medical education. \u003cem\u003ePerspectives on Medical Education\u003c/em\u003e,\u003cem\u003e 7\u003c/em\u003e(6), 394-400. https://doi.org/10.1007/s40037-018-0479-9 \u003c/li\u003e\n\u003cli\u003eFernandez, S. C., Chelliah, K. K., \u0026amp; Halim, L. (2015). A peek into oneself: reflective writing amongst undergraduate Medical Imaging students. \u003cem\u003eReflective practice\u003c/em\u003e,\u003cem\u003e 16\u003c/em\u003e(1), 109-122. https://doi.org/10.1080/14623943.2014.982524 \u003c/li\u003e\n\u003cli\u003eGathu, C. (2022). Facilitators and Barriers of Reflective Learning in Postgraduate Medical Education: A Narrative Review\u003cem\u003e. Journal of Medical Education Curriculum Development, 3 (9)\u003c/em\u003e. DOI: 10.1177/23821205221096106\u003c/li\u003e\n\u003cli\u003eGaufberg, E., Hirsh, D., Krupat, E., Ogur, B., Pelletier, S., Reiff, D., \u0026amp; Bor, D. (2014). Into the future: patient-centredness endures in longitudinal integrated clerkship graduates. \u003cem\u003eMedical Education\u003c/em\u003e,\u003cem\u003e 48\u003c/em\u003e(6), 572-582. https://doi.org/10.1111/medu.12413 \u003c/li\u003e\n\u003cli\u003eGhaye, T. (2007). \u003cem\u003eBuilding the Reflective Healthcare Organisation\u003c/em\u003e. John Wiley \u0026amp; Sons, Incorporated. http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=350980 \u003c/li\u003e\n\u003cli\u003eGillingham, K., Eggleton, K., \u0026amp; Goodyear-Smith, F. (2020). Is Reflective Learning Visible in Online Discussion Forums for Medical Students on General Practice Placements? A Qualitative Study. \u003cem\u003eTeaching and Learning in Medicine\u003c/em\u003e,\u003cem\u003e 32\u003c/em\u003e(4), 434-441. https://doi.org/10.1080/10401334.2020.1730184 \u003c/li\u003e\n\u003cli\u003eGreenhill, J., Richards, J. N., Mahoney, S., Campbell, N., \u0026amp; Walters, L. (2017). Transformative Learning in Medical Education: Context Matters, a South Australian Longitudinal Study. \u003cem\u003eJournal of Transformative Education\u003c/em\u003e,\u003cem\u003e 16\u003c/em\u003e(1), 58-75. https://doi.org/10.1177/1541344617715710 \u003c/li\u003e\n\u003cli\u003eHall, S. L., Forrester, S., \u0026amp; Borsz, M. (2008). A Constructivist Case Study Examining the Leadership Development of Undergraduate Students in Campus Recreational Sports. \u003cem\u003eJournal of College Student Development\u003c/em\u003e,\u003cem\u003e 49\u003c/em\u003e(2), 125-140. \u003c/li\u003e\n\u003cli\u003eJames, C., \u0026amp; Connolly, M. (2009). An analysis of the relationship between the organizational culture and the performance of staff work groups in schools and the development of an explanatory model. \u003cem\u003eInternational Journal of Leadership in Education\u003c/em\u003e,\u003cem\u003e 12\u003c/em\u003e(4), 389-407. https://doi.org/10.1080/13603120902980804 \u003c/li\u003e\n\u003cli\u003eKlein, J., \u0026amp; McColl, G. (2019). Cognitive dissonance: how self-protective distortions can undermine clinical judgement. \u003cem\u003eMedical Education\u003c/em\u003e,\u003cem\u003e 53\u003c/em\u003e(12), 1178-1186. https://doi.org/10.1111/medu.13938 \u003c/li\u003e\n\u003cli\u003eLam, R., \u0026amp; Stickrath, C. (2021). It Takes a Village: Utilizing a Community-based Longitudinal Integrated Clerkship Model at a Regional Medical Campus to Provide the Core Emergency Medicine Clerkship Experience. \u003cem\u003eAEM Education and Training\u003c/em\u003e,\u003cem\u003e 5\u003c/em\u003e(1), 5-11. https://doi.org/10.1002/aet2.10442 \u003c/li\u003e\n\u003cli\u003eLong, A. M. M. D. F., Lefebvre, C. M. M. D., Masneri, D. A. D. O., Mowery, N. T. M. D. F., Chang, M. C. M. D. F., Johnson, J. E. P., \u0026amp; Carter, J. E. M. D. F. (2019). The Golden Opportunity: Multidisciplinary Simulation Training Improves Trauma Team Efficiency. \u003cem\u003eJournal of Surgical Education\u003c/em\u003e,\u003cem\u003e 76\u003c/em\u003e(4), 1116-1121. https://doi.org/10.1016/j.jsurg.2019.01.003 \u003c/li\u003e\n\u003cli\u003eLutz, G., Scheffer, C., Edelhaeuser, F., Tauschel, D., \u0026amp; Neumann, M. (2013). A reflective practice intervention for professional development, reduced stress and improved patient care\u0026mdash;A qualitative developmental evaluation. \u003cem\u003ePatient education and counseling\u003c/em\u003e,\u003cem\u003e 92\u003c/em\u003e(3), 337-345. https://doi.org/10.1016/j.pec.2013.03.020 \u003c/li\u003e\n\u003cli\u003eMacAskill, W., Chua, W., Woodall, H., \u0026amp; Pinidiyapathirage, J. (2023). Beyond the Written Reflection: A Systematic Review and Qualitative Synthesis of Creative Approaches to Reflective Learning Amongst Medical Students. \u003cem\u003ePerspectives on Medical Education\u003c/em\u003e,\u003cem\u003e 12\u003c/em\u003e, 361-371. https://doi.org/10.5334/pme.914 \u003c/li\u003e\n\u003cli\u003eMalau-Aduli, B. S., Roche, P., Adu, M., Jones, K., Alele, F., \u0026amp; Drovandi, A. (2020). Perceptions and processes influencing the transition of medical students from pre-clinical to clinical training. \u003cem\u003eBMC Medical Education\u003c/em\u003e,\u003cem\u003e 20\u003c/em\u003e(1), 279. https://doi.org/10.1186/s12909-020-02186-2 \u003c/li\u003e\n\u003cli\u003eMannion, R., \u0026amp; Davies, H. (2018). Understanding organisational culture for healthcare quality improvement. \u003cem\u003eBritish Medical Journal\u003c/em\u003e,\u003cem\u003e 363\u003c/em\u003e, k4907. https://doi.org/10.1136/bmj.k4907 \u003c/li\u003e\n\u003cli\u003eMantzoukas, S., \u0026amp; Jasper, M. A. (2004). Reflective practice and daily ward reality: a covert power game. \u003cem\u003eJournal of Clinical Nursing\u003c/em\u003e,\u003cem\u003e 13\u003c/em\u003e(8), 925-933. https://doi.org/10.1111/j.1365-2702.2004.01008.x \u003c/li\u003e\n\u003cli\u003eMcLean, D., Chiavaroli, N., Denniston, C., \u0026amp; Richardson, M. (2022). In-verse reflection: structured creative writing exercises to promote reflective learning in medical students. \u003cem\u003eJournal of Medical Humanities\u003c/em\u003e,\u003cem\u003e 43\u003c/em\u003e(3), 493-504. https://doi.org/10.1007/s10912-022-09740-7 \u003c/li\u003e\n\u003cli\u003eMezirow. (1994). Understanding Transformation Theory. \u003cem\u003eAdult Education Quarterly\u003c/em\u003e,\u003cem\u003e 44\u003c/em\u003e(4), 222-232. \u003c/li\u003e\n\u003cli\u003eMylopoulos, M., Kulasegaram, K., Weyman, K., Bernstein, S., \u0026amp; Martimianakis, M. A. (2020). Same but Different: Exploring Mechanisms of Learning in a Longitudinal Integrated Clerkship. \u003cem\u003eAcademic Medicine\u003c/em\u003e,\u003cem\u003e 95\u003c/em\u003e(3), 411-416. https://doi.org/10.1097/ACM.0000000000002960 \u003c/li\u003e\n\u003cli\u003eOlmos-Vega, F. M., Stalmeijer, R. E., Varpio, L., \u0026amp; Kahlke, R. (2023). A practical guide to reflexivity in qualitative research: AMEE Guide No. 149. \u003cem\u003eMedical Teacher\u003c/em\u003e,\u003cem\u003e 45\u003c/em\u003e(3), 241-251. https://doi.org/10.1080/0142159X.2022.2057287 \u003c/li\u003e\n\u003cli\u003ePurea, P., Brumpton, K., Kumar, K., \u0026amp; Pinidiyapathirage, J. (2022). Exploring the learning environment afforded by an Aboriginal Community Controlled Health service in a rural longitudinal integrated clerkship. \u003cem\u003eEducation for Primary Care\u003c/em\u003e,\u003cem\u003e 33\u003c/em\u003e(4), 214-220. https://doi.org/10.1080/14739879.2022.2054371 \u003c/li\u003e\n\u003cli\u003eSandars, J. (2009). The use of reflection in medical education: AMEE Guide No. 44. \u003cem\u003eMedical Teacher\u003c/em\u003e,\u003cem\u003e 31\u003c/em\u003e(8), 685-695. https://doi.org/10.1080/01421590903050374 \u003c/li\u003e\n\u003cli\u003eShannon-Baker, P. (2023). Philosophical underpinnings of mixed methods research in education. In R. J. Tierney, F. Rizvi, \u0026amp; K. Ercikan (Eds.), \u003cem\u003eInternational Encyclopedia of Education (Fourth Edition)\u003c/em\u003e (pp. 380-389). Elsevier. https://doi.org/https://doi.org/10.1016/B978-0-12-818630-5.11037-1 \u003c/li\u003e\n\u003cli\u003eSheehan, D., \u0026amp; Wilkinson, T. J. (2022). Widening how we see the impact of culture on learning, practice and identity development in clinical environments. \u003cem\u003eMedical Education\u003c/em\u003e,\u003cem\u003e 56\u003c/em\u003e(1), 110-116. https://doi.org/10.1111/medu.14630 \u003c/li\u003e\n\u003cli\u003eSparrow, J. (2016). Reflective Practice in Organizational Learning, Cultural Self-Understanding and Community Self-Strengthening. \u003cem\u003eInfant Mental Health Journal\u003c/em\u003e,\u003cem\u003e 37\u003c/em\u003e(6), 605-616. https://doi.org/10.1002/imhj.21602 \u003c/li\u003e\n\u003cli\u003eStroud, J., Jenkins, K., Bhandary, S., \u0026amp; Papadimos, T. (2017). Putting the pieces together: The role of multidisciplinary simulation in medical education. \u003cem\u003eInternational Journal of Academic Medicine\u003c/em\u003e,\u003cem\u003e 3\u003c/em\u003e(1), 104-109. https://doi.org/10.4103/IJAM.IJAM_44_17 \u003c/li\u003e\n\u003cli\u003eThe Consortium of Longitudinal Integrated Clerkships. (2020). \u003cem\u003eCLIC \u0026ndash; The Consortium of Longitudinal Integrated Clerkships\u003c/em\u003e. Retrieved 5th March from https://clicmeded.com/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"reflective practice, medical students, rural medical education","lastPublishedDoi":"10.21203/rs.3.rs-3357325/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3357325/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003eIntroduction\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eReflective learning skills are important in the development of medical students. \u0026nbsp;Through reflection, students learn about self and medicine and the integration of theoretical knowledge into real life work. \u0026nbsp;\u0026nbsp;However, reflection requires time, willingness, and skills on the part of the student. \u0026nbsp;\u0026nbsp;This study explored the factors perceived by educators to influence reflective learning amongst medical students undertaking a rural longitudinal integrated clerkship (LIC) in southeast Queensland.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMethods:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWithin the described LIC program, medical students receive teaching and support from both medical and nursing educators. Two qualitative focus groups were conducted with eleven educators from a medical (6 participants) and nursing (5 participants) background. \u0026nbsp;Transcripts were analysed using Braun and Clark’s approach to thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eResults:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThree major themes were identified as contributing to student reflective learning. Fostering a culture of reflection within the organisation was seen as important for supporting and setting expectations for reflection. Undertaking the reflective learning journey together recognised the importance of students and educators learning collaboratively. Finally, looking through “the student lens” allowed educators to recognise the wider contextual factors impacting on student reflection. \u0026nbsp;Recognition of these factors allows educators to tailor reflective teaching to the student.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDiscussion\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eReflective learning is a critical skill for medical students and their educators. This study identified that reflection can be supported through the development of a supportive organisational culture, through encouraging educators and students to learn together, and through recognising the student perspective.\u003c/p\u003e","manuscriptTitle":"\"We're all learning together”: Educator perspectives on medical student reflective practice","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-09-21 16:36:47","doi":"10.21203/rs.3.rs-3357325/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"847bcaf9-9de6-47bd-a9b3-dbbfc01921f6","owner":[],"postedDate":"September 21st, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-11-21T04:14:25+00:00","versionOfRecord":[],"versionCreatedAt":"2023-09-21 16:36:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3357325","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3357325","identity":"rs-3357325","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}