Influences and Outcomes: A Systematised Review of Reflective Teaching Strategies in Student Healthcare Placements


  • Michael Dunne Work Integrated Learning, Faculty of Health Sciences, University of Sydney; Westmead Hospital, New South Wales, Australia; Health Education and Training Institute (HETI);
  • Gillian Nisbet University of Sydney
  • Merrolee Penman University of Sydney
  • Lindy McAllister University of Sydney



Outcome Assessment (Health Care), Students, Workplace, Reflection


The development of reflection in tertiary students benefits from facilitation. Educators commonly facilitate the development of affective, cognitive, and meta-cognitive skills associated with reflection. Reflective teaching strategies, that is, guiding comments or questions used within an activity to stimulate cognitive processes, are strategies used by educators to facilitate reflection. This systematised review focuses on the approaches used to measure influences and outcomes of the teaching of reflection in order to enhance educators’ understanding of recent evidence for use in the placement setting. The review explores what outcome measures are used in current research, and how the evidence incorporates contextual factors such as time, safety, mentorship, supervision, and emotional and intellectual support to develop reflection in students. Systematised searching of CINAHL®, ProQuest, ERIC, OvidSP, Scopus®, and Web of Science™ databases for the period 2005 to 2015 identified 26 studies, from a pool of 6968 that met the inclusion criteria. Results indicate that a range of reflective teaching strategies are being used by allied and oral health, nursing, and the medical professions that assist movement towards critical reflection. No direct connection between this movement and the presence of contextual factors was established. Review outcomes are limited by the variable quality of the included studies and the lack of high quality tools for measurement of teaching effect on the development of reflection. We recommend that future studies into the use of reflective teaching strategies continue to incorporate contextual factors in combination with valid and reliable measurement practices in the workplace.

Author Biography

Michael Dunne, Work Integrated Learning, Faculty of Health Sciences, University of Sydney; Westmead Hospital, New South Wales, Australia; Health Education and Training Institute (HETI);

Senior Speech Pathologist;

Senior Program Officer


Andersen, N. B., O’Neill, L., Gormsen, L. K., Hvidberg, L., and Morcke, A. M. (2014) 'A validation study of the psychometric properties of the Groningen Reflection Ability Scale'. BMC Medical Education 14 (1), 214. doi: 10.1186/1472-6920-14-214

Aronson, L., Niehaus, B., DeVries, C. D., Siegel, J. R., and O'Sullivan, P. S. (2010) 'Do writing and storytelling skill influence assessment of reflective ability in medical students' written reflections? Academic Medicine 85 (10), S29–S32. doi:10.1097/ACM.0b013e3181ed3aa7

Aronson, L., Niehaus, B., Hill‐Sakurai, L., Lai, C., and O’Sullivan, P. S. (2012) 'A comparison of two methods of teaching reflective ability in Year 3 medical students'. Medical Education 46 (8), 807–814. doi: 10.1111/j.1365-2923.2012.04299.x

Aronson, L., Niehaus, B., Lindow, J., Robertson, P. A., and O'Sullivan, P. S. (2011) 'Development and pilot testing of a reflective learning guide for medical education'. Medical Teacher 33 (10), e515–e521. doi: 10.3109/0142159x.2011.599894

Asselin, M. E. (2011) 'Using reflection strategies to link course knowledge to clinical practice: The RN-to-BSN student experience'. Journal of Nursing Education 50 (3), 125–133. doi:10.3928/01484834-20101230-08

Aukes, L. C., Geertsma, J., Cohen-Schotanus, J., Zwierstra, R. P., and Slaets, J. P. (2007) 'The development of a scale to measure personal reflection in medical practice and education'. Medical Teacher 29 (2-3), 177–182. doi:10.1080/01421590701299272

Beylefeld, A. A., Nena, K. D., and Prinsloo, E. A. (2005) 'Influence of community experiences on first-year medical students’ reflective writing'. Medical Teacher 27 (2), 150–154. doi:org/10.1080/01421590400029590

Bloom, B. S. (ed.) (1956) Taxonomy of Educational Objectives: The Classification of Educational Goals. Handbook I: Cognitive Domain. New York: David McKay Company

Bolton, G. (2010) Reflective Practice: Writing and Professional Development (3rd edn.). London: Sage

Boud, D., Keogh, R., and Walker, D. (1985) Reflection: Turning Experience into Learning Abingdon, UK: Routledge

Canniford, L. J. and Fox-Young, S. (2015) 'Learning and assessing competence in reflective practice: Student evaluation of the relative value of aspects of an integrated, interactive reflective practice syllabus'. Collegian 22 (3), 291–297. doi:org/10.1016/j.colegn.2014.04.003

Chirema, K. D. (2007) 'The use of reflective journals in the promotion of reflection and learning in post-registration nursing students'. Nurse Education Today 27 (3), 192–202. doi:org/10.1016/j.nedt.2006.04.007

Chretien, K., Goldman, E., and Faselis, C. (2008) 'The reflective writing class blog: Using technology to promote reflection and professional development'. Journal of General Internal Medicine 23 (12), 2066–2070. doi: org/10.1007/s11606-008-0796-5

Donovan, M. O. (2007) 'Implementing reflection: Insights from pre-registration mental health students'. Nurse Education Today 27 (6), 610–616. doi:org/10.1016/j.nedt.2006.09.001

Driessen, E., Tartwijk, J. v., and Dornan, T. (2008) 'The self critical doctor: Helping students become more reflective'. BMJ (CR)-print 336 (7648), 827. doi:org/10.1136/

Dye, D., Scott, K. W., Ostrom, L., Devine, N., and Leight, J. (2011) 'The effect of specific feedback on critical reflection of physical therapy students during internships'. Journal of Adult Education 40 (2), 9–18.

Epstein, R. M. (1999) 'Mindful practice'. JAMA 282 (9), 833–839. doi:org/10.1001/jama.282.9.833

Findlay, N., Dempsey, S. E., and Warren-Forward, H. M. (2011) 'Development and validation of reflective inventories: assisting radiation therapists with reflective practice'. Journal of Radiotherapy in Practice 10 (1), 3–12. doi: org/10.1017/S1460396910000142

Goleman, D., Boyatzis, R., and McKee, A. (2001) 'Primal leadership: The Hidden driver of great performance'. Harvard Business Review 79 (11), 42–51.

Gordon, J. (2003) 'Assessing students' personal and professional development using portfolios and interviews'. Medical Education 37 (4), 335–340. doi:org/10.1046/j.1365-2923.2003.01475.x

Grant, M. J. and Booth, A. (2009) 'A typology of reviews: An analysis of 14 review types and associated methodologies'. Health Information and Libraries Journal 26 (2), 91–108. doi:org/10.1111/j.1471-1842.2009.00848.x

Harrison, P. A. and Fopma-Loy, J. L. (2010) 'Reflective journal prompts: A vehicle for stimulating emotional competence in nursing'. Journal of Nursing Education 49 (11), 644–652. doi:10.3928/01484834-20100730-07

Health Education and Training Institute (HETI) (n.d.) Allied health professionals in NSW health [online]. Retrieved from [30 June 2016]

Hill, A. E., Davidson, B. J., and Theodoros, D. G. (2012) 'Reflections on clinical learning in novice speech–language therapy students'. International Journal of Language & Communication Disorders 47 (4), 413–426. doi: 10.1111/j.1460-6984.2012.00154.x

Huberman, A. M. and Miles, M. B. (eds.) (2002) The Qualitative Researcher's Companion. Thousand Oaks, CA: Sage

Hulsman, R. L., Harmsen, A. B., and Fabriek, M. (2009) 'Reflective teaching of medical communication skills with DiViDU: Assessing the level of student reflection on recorded consultations with simulated patients'. Patient Education and Counseling 74 (2), 142–149. doi: org/10.1016/j.pec.2008.10.009

Ip, W. Y., Lui, M. H., Chien, W. T., Lee, I. F., Lam, L. W., and Lee, D. (2012) 'Promoting self-reflection in clinical practice among Chinese nursing undergraduates in Hong Kong'. Contemporary Nurse 41 (2), 253–262. doi: 10.5172/conu.2012.41.2.253

Jensen, S. K. and Joy, C. (2005) 'Exploring a model to evaluate levels of reflection in baccalaureate nursing students' journals'. Journal of Nursing Education 44 (3), 139–142

Kim, H. S. (1999) 'Critical reflective inquiry for knowledge development in nursing practice'. Journal of Advanced Nursing 29 (5), 1205–1212. doi:10.1046/j.1365-2648.1999.01005.x

Kleinheksel, A. J. (2014) 'Transformative learning through virtual patient simulations: Predicting critical student reflections'. Clinical Simulation in Nursing 10 (6), e301–e308. doi:10.1016/j.ecns.2014.02.001

Kuiper, R., Murdock, N., and Grant, N. (2010) 'Thinking strategies of baccalaureate nursing students prompted by self-regulated learning strategies'. Journal of Nursing Education 49 (8), 429–436. doi:10.3928/01484834-20100430-01

Kuusela, H. and Pallab, P. (2000) 'A comparison of concurrent and retrospective verbal protocol analysis'. The American Journal of Psychology 113 (3), 387–404

Lasater, K. (2007) 'Clinical judgment development: Using simulation to create an assessment rubric'. Journal of Nursing Education 46 (11) [online]

Lasater, K. and Nielsen, A. (2009) 'Reflective journaling for clinical judgment development and evaluation'. Journal of Nursing Education 48 (1), 40–44. doi:10.3928/01484834-20090101-06

Law, M., Stewart, D., Letts, L., Pollock, N., Bosch, J., and Westmorland, M. (1998) Guidelines for Critical Review of Qualitative Studies. [unpublished manuscript] Ontario, Canada: McMaster University Occupational Therapy Evidence-Based Practice Research Group

Learman, L. A., Autry, A. M. and O’Sullivan, P. (2008) 'Reliability and validity of reflection exercises for obstetrics and gynecology residents'. American Journal of Obstetrics & Gynecology 198 (4), 461. e1¬461. e10. doi:10.1016/j.ajog.2007.12.021

Lethbridge, K., Andrusyszyn, M.-A., Iwasiw, C., Laschinger, H. K., and Fernando, R. (2013) 'Assessing the psychometric properties of Kember and Leung’s Reflection Questionnaire'. Assessment & Evaluation in Higher Education 38 (3), 303–325. doi:10.1080/02602938.2011.630977

Levine, R. B., Kern, D. E., and Wright, S. M. (2008) 'The impact of prompted narrative writing during internship on reflective practice: A qualitative study'. Advances in Health Sciences Education 13 (5), 723–733. doi: 10.1007/s10459-007-9079-x

Lie, D., Shapiro, J., Cohn, F., and Najm, W. (2010) 'Reflective practice enriches clerkship students’ cross-cultural experiences'. Journal of General Internal Medicine 25 (2), 119–125. doi:10.1007/s11606-009-1205-4

Lillyman, S., Gutteridge, R. and Berridge, P. (2011) 'Using a storyboarding technique in the classroom to address end of life experiences in practice and engage student nurses in deeper reflection'. Nurse Education in Practice 11 (3), 179–185. doi:10.1016/j.nepr.2010.08.006

Makoul, G., Zick, A. B., Aakhus, M., Neely, K. J., and Roemer, P. E. (2010) 'Using an online forum to encourage reflection about difficult conversations in medicine'. Patient Education and Counseling 79 (1), 83–86. doi:10.1016/j.pec.2009.07.027

Mamede, S. and Schmidt, H. G. (2004) 'The structure of reflective practice in medicine'. Medical Education 38 (12), 1302–1308. doi: 10.1111/j.1365-2929.2004.01917.x

Mamede, S., van Gog, T., van den Berge, K., Rikers, R. M., van Saase, J. L., van Guldener, C., and Schmidt, H. G. (2010) 'Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents'. JAMA 304 (11), 1198–1203. doi: org/10.1001/jama.2010.1276

Mann, K., Gordon, J., and MacLeod, A. (2009) 'Reflection and reflective practice in health professions education: A systematic review'. Advances in Health Sciences Education 14 (4), 595–621. doi: 10.1007/s10459-007-9090-2

Mezirow, J. (1981) A critical theory of adult learning and education. Adult Education Quarterly 32 (1), 3–24. doi: 10.1177/074171368103200101

Mezirow, J. (1990) 'How critical reflection triggers transformative learning'. In Fostering Critical Reflection in Adulthood: A Guide to Transformative and Emancipatory Learning ed. by Mezirow, J. and Associates. San Francisco: Jossey-Bass, 1–20.

Mezirow, J. (1991) Transformative Dimensions of Adult Learning. San Francisco: Jossey-Bass.

Miles, M. B. and Huberman, A. M. (1994) Qualitative data analysis: An expanded sourcebook 2nd edn. Thousand Oaks: Sage

Moustakas, C. (1994) Phenomenological Research Methods. Thousand Oaks, CA: Sage

O’Sullivan, P., Aronson, L., Chittenden, E., Niehaus, B., and Learman, L. (2010) 'Reflective ability rubric and user guide'. MedEdPORTAL Publications. 2010;6:8133. [online]

Paget, T. (2001) 'Reflective practice and clinical outcomes: Practitioners’ views on how reflective practice has influenced their clinical practice'. Journal of Clinical Nursing 10 (2), 204–214. doi: 10.1111/j.1365-2702.2001.00482.x

Peterkin, A., Roberts, M., Kavanagh, L., and Havey, T. (2012) 'Narrative means to professional ends: New strategies for teaching CanMEDS roles in Canadian medical schools'. Canadian Family Physician 58 (10), e563–e569

Plack, M. M., Dunfee, H., and Rindflesch, A. (2008) 'Virtual action learning sets: A model for facilitating reflection in the clinical setting'. Journal of Physical Therapy Education 22 (3), 33–42

Plack, M. M. and Greenberg, L. (2005) 'The reflective practitioner: Reaching for excellence in practice'. Pediatrics 116 (6), 1546–1552. doi: 10.1542/peds.2005-0209

Roche, A. and Coote, S. (2008) 'Focus group study of student physiotherapists’ perceptions of reflection'. Medical Education 42 (11), 1064–1070. doi:10.1111/j.1365-2923.2008.03178.x

Schön, D. A. (1987) Educating the Reflective Practitioner. San Francisco: Jossey-Bass

Sobral, D. T. (2005) 'Medical students’ mindset for reflective learning: A revalidation study of the reflection-in-learning scale'. Advances in Health Sciences Education 10 (4), 303–314. doi:10.1007/s10459-005-8239-0

Stark, P., Roberts, C., Newble, D., and Bax, N. (2006) 'Discovering professionalism through guided reflection'. Medical Teacher 28 (1), e25–e31. doi: 10.1080/01421590600568520

Stein, D. (2000) Teaching Critical Reflection. (Myths and Realities No. 7). Columbus, OH: ERIC Clearinghouse on Adult, Career, and Vocational Education. (ED445256). [online] Retrieved from

Teekman, B. (2000) 'Exploring reflective thinking in nursing practice' Journal of Advanced Nursing 31 (5), 1125–1135. doi:10.1046/j.1365-2648.2000.01424.x

Thomas, P. A. and Goldberg, H. (2007) 'Tracking reflective practice-based learning by medical students during an ambulatory clerkship'. Journal of General Internal Medicine 22 (11), 1583–1586. doi:10.1007/s11606-007-0315-0

Toy, E. C., Harms, K. P., Morris Jr, R. K., Simmons, J. R., Kaplan, A. L., and Ownby, A. R. (2009) 'The effect of monthly resident reflection on achieving rotation goals'. Teaching and Learning in Medicine 21 (1), 15–19. doi: 10.1080/10401330802384276

Tsang, A. K. (2012) 'Oral health students as reflective practitioners: Changing patterns of student clinical reflections over a period of 12 months'. Journal of Dental Hygiene, 86 (2), 120–129

Wald, H. S., Borkan, J. M., Taylor, J. S., Anthony, D., and Reis, S. P. (2012) 'Fostering and evaluating reflective capacity in medical education: Developing the REFLECT rubric for assessing reflective writing'. Academic Medicine 87 (1), 41–50. doi:10.1097/ACM.0b013e31823b55fa

Wald, H. S., Davis, S. W., Reis, S. P., Monroe, A. D., and Borkan, J. M. (2009) 'Reflecting on reflections: Enhancement of medical education curriculum with structured field notes and guided feedback'. Academic Medicine 84 (7), 830–837. doi:10.1097/ACM.0b013e3181a8592f

Walker, R., Cooke, M., Henderson, A., and Creedy, D. K. (2013) 'Using a critical reflection process to create an effective learning community in the workplace'. Nurse Education Today 33 (5), 504–511. doi:10.1016/j.nedt.2012.03.001

White, S., Fook, J., and Gardner, F. (2006) Critical Reflection in Health and Social Care. Maidenhead, UK: McGraw-Hill Education

Williams, R. M., Sundelin, G., Foster-Seargeant, E., and Norman, G. R. (2000) 'Assessing the reliability of grading reflective journal writing'. Journal of Physical Therapy Education 14 (2), 23–26

Wong, F. K., Kember, D., Chung, L. Y., and Yan, L. (1995) 'Assessing the level of student reflection from reflective journals'. Journal of Advanced Nursing 22 (1), 48–57. doi:10.1046/j.1365-2648.1995.22010048.x

Wright, L. and Lundy, M. (2012) 'Blogging as a tool to promote reflection among dietetic and physical therapy students during a multidisciplinary international service-learning experience'. Journal of Allied Health 41 (3), 73E–78E




How to Cite

Dunne, M., Nisbet, G., Penman, M., & McAllister, L. (2016). Influences and Outcomes: A Systematised Review of Reflective Teaching Strategies in Student Healthcare Placements. International Journal of Practice-Based Learning in Health and Social Care, 4(1), 55–77.

Most read articles by the same author(s)

1 2 3 > >>