The Effect of Reflective Activities on Reflective Thinking Ability in an Undergraduate Pharmacy Curriculum

INTRODUCTION

Reflective thinking and learning capacity is regarded as an essential attribute in the health professions to link theory with application and to address the challenges that arise in clinical practice.^2-8 However, evidence to support the integration of these skills and curricular innovations in health education remains largely theoretical.² Furthermore, evidence of integration of reflective practice teaching and learning modules into curriculum is scant.

Reflective practice is an umbrella term used to describe the professional strategy to constantly improve one’s practice.⁵ It is a cognitive process of understanding and evaluating the meaning of an experience within the context of one’s previous experience, previous and existing knowledge, firmly held beliefs, and assumptions.^9,10 Through reflective practice, professionals continue to critique their skills, performance, outcomes, and behavior. It can be argued that constant critiquing of practice, upgrading skills and performance, and/or changing behavior, allows for better informed decisions and clinical judgments,¹¹ thus enabling improvement for future practice.^5,6,12,13

Integrating reflective practices into health education settings can enhance self-reflection⁶ and fundamental reflective thinking ability.¹⁴ Integrating reflective learning activities may also assist with bridging pharmaceutical theory to the complexities of pharmacy practice.^5,13 Furthermore, enhancing reflective thinking and reflective learning improves lifelong learning skills¹⁵ such as critical thinking,^16,17 problem solving,^18-20 clinical reasoning and decision making,^11,16 communication skills,^21,22 self-directed learning, and professional development.^7,10,23-32 Subsequently, enhanced reflective thinking skills may better prepare students for the challenges that may arise in future clinical practice.

Moreover, adopting reflective learning and thinking skills may enhance deep learning and develop metacognitive ability.²¹ Enhancing metacognitive ability of pharmacy students can assist with improving the application of theory to resolve issues they may encounter in future clinical practice.^21,33,34 Therefore, incorporating these fundamental skills into pharmacy curriculum may be a sound teaching methodology.

Several scholars posit that structured reflective guides or prompts are a useful tool to enhance reflective processes^6,35 and promote the strategies for continuous professional development,³¹ better clinical decisions and improvement of clinical practice.^6,11,36,37 Some researchers believe that the art of reflection is a skill that can be taught without any prerequisites of knowledge in this area as long as the learning environment is conducive for reflective activities.^10,38 Integrating learning and teaching modules into an undergraduate pharmacy curriculum to enhance such a fundamental skill has the potential to assist the pharmacy student to become prepared for the real world of pharmacy practice.

Several tools enhance reflective capacity. For example, reflective writing as a tool to enhance reflective capacity is at the forefront of the published literature.³⁹ Reflective writing tools such as statements,^40,41 essays,^42,43 diaries,^44,45 logbooks,⁴⁶ portfolios^47-54 and journals^55-59 have been used to enhance the reflective thinking process. Extended from these are the more technologically oriented online versions such as e-portfolios,^60-68 e-journals, and blogs.^17,69-71 Such tools enhance professional continuing education to allow a continuous critiquing of skills in practice.^15,72 Furthermore, reflective exchange blogs (REB) have been considered for effective exchange of reflective dialogue between multidisciplinary health team members.⁵ To assess the depth and level of reflection, tone can draw from the theories and ideas of early researchers and leaders in the field of reflective practice: Dewey,⁷³ Polanyi,⁷⁴ Kolb,⁷⁵ Schon,^3,4 Boud,⁷⁶ Mezirow^77,78 and Moon.⁸ We wrote a timeline of the key educators of reflection as a guide to understanding the development of reflective practice since the 1900s.⁵

Integration of reflective activities into an undergraduate pharmacy curriculum included a suite of reflective tasks, the primary one consisting of media and written tools: video podcasts (to enhance self and peer reflection) and a written task in the form of a reflective statement. Videos are an effective tool in health professions education to enhance communication skills and self and/or peer reflection.^79-83 Video podcasts may be a useful way for students to improve their counseling and clinical competency skills by reflecting on their own counseling shortcomings, as well as their strengths and those of a peer. Moreover, addressing their inner thoughts about and challenges from the whole task (including the video task) through reflective writing allows students to develop strategies to overcome barriers and concerns to improve future tasks.^22,84 The objective of this study was to determine the effectiveness of integrating reflective practice activities into a second-year undergraduate pharmacy curriculum and to evaluate its impact on reflective thinking ability.

DESIGN

In 2014, a novel design for a learning and teaching module along with a pioneering strategy were introduced into the second-year undergraduate pharmacy curriculum for the course Pharmacy Practice. The goal of integrating the new tutorial modules and self-directed reflective learning activities—along with a new strategy, the Reflective Ability Clinical Assessment (RACA)—was to enhance the reflective thinking and learning capacity of pharmacy students.

Reflective activities integrated into the undergraduate pharmacy curriculum included a self-directed online learning activity (involving multiple-choice questions) to enhance understanding of the concept and purpose of reflective learning (Appendix 1) and a reflective thought guide (Appendix 2) for use with the clinical modules, to ascertain the outcome measures of the clinical cases. Following the introduction of these activities, the RACA took place, which included three main components: scenario writing of possible nonprescription events, reflective video podcasts (Figure 2), and a reflective statement (Appendix 3).

A quasi-experimental cross-over intervention-control design with repeated measures was employed to enhance the robustness of the research method (Figure 1). One of the advantages of using a cross-over design is the capacity to determine whether any improvement in reflective thinking ability is a result of student maturation.

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Figure 1.

Consort diagram: Cross-over design with repeated measures

Reflective ability and change in students’ reflective thinking ability was evaluated using a previously validated tool that employed a 5-point Likert-type response scale.¹ This tool was adapted by the researchers so that it was applicable to pharmacy students. The word “pharmacy” was added prior to the words “course” and “lecturer,” so that the tool was applicable to pharmacy students. Reflective ability was assessed at baseline (prior to integration of the reflective activities) and after integration of reflective activities.¹

All students participated in the reflective activities as part of the new curriculum material; however, approximately half the cohort commenced these activities first, followed by the remaining cohort. Students were asked to voluntarily complete the pre/postreflective thinking questionnaires (RTQ).¹ The cross-over design was carefully considered so that students were not disadvantaged. The cohort was divided into 10 tutorial groups. Five of the 10 tutorial groups (groups 1,2,3,7, and 8), labeled Intervention Group A, initially participated in the reflective activities, The remaining five tutorial groups (groups 4,5,6,9 and 10), labeled Control Group B, participated in regular curriculum activities.

As this study involved a number of teaching staff, tutorial groups were allocated into the the intervention or control group based on the staff teaching days. For example, one educator facilitated tutorial groups 1, 2, and 3, and these groups were placed into Intervention Group A. Another educator facilitated groups 7 and 8, and the students from these groups were also placed into Intervention Group A. Students from tutorial groups 4,5,6,9, and 10 were all placed into Control Group B as the third educator facilitated groups 4,5 and 6, and the fourth educator facilitated groups 9 and 10.

Students took tutorials at different stages throughout the semester and additional times were allocated for students to go online and complete the self-directed learning task (Appendix 1). Dates were also set for students to submit assessment tasks (RACA). All students were assured that they would eventually participate in all tutorials and would be given the same number of days to submit their assessment (RACA) tasks. Teaching staff were also informed of this process.

Once Intervention Group A completed their reflective activities and the assessment tasks, (which took 25 days), Intervention Group B (previously Control Group B) commenced the reflective tasks while Group A continued with the regular curriculum. Both groups were administered the RTQ prior to Control Group B commencing the intervention (Figure 1).

Prior to the reflective activities and modules, students were invited to go online and complete a self-directed learning activity as part of their pretutorial work. The purpose of this activity was to brief the students on the main concepts of reflection. This activity consisted of a series of multiple-choice questions relating to reflective practices (Appendix 1). In addition to this online activity and prior to commencing reflective tutorial modules, students in the intervention groups were asked to access evidence-based research articles on reflective practices used in pharmacy education.^5,13,19,27 The purpose of this exercise was to enhance the understanding of the main concepts and importance of reflective practice.

The reflective tutorial modules followed the completion of the self-directed learning activities. The reflective tutorial modules consisted of a series of real hospital and community clinical cases for students to discuss during tutorial times. These modules encouraged students to “think outside the box,” by asking students to consider other aspects that might relate to alternative outcomes of a critical incident. For example, students were asked to consider a person’s biases, assumptions, firmly held beliefs, as well as their medication and clinical backgrounds. Students were provided with a reflective thought guide to assist them with final clinical decision making (Appendix 2). This guide was derived by an adaptation of similar guides used to enhance clinical decision making in nursing ^36,85,86 and medical education.¹¹

During the first day of the reflective modules, students were allocated an nonprescription condition and were asked to research the condition and the type of advice or products recommended for the condition. This formed the basis for their assessment tasks incorporated into the RACA. The purpose of the (RACA) was four fold: (1) to enhance self-directed learning activities, (2) to enhance counseling skills, (3) to encourage both self and peer reflection on a task, and (4) to provide valuable counseling practice for the summative end-of-semester oral assessment.

Part of enhancing the skills of reflective practice is to learn from experience.¹³ For students to prepare a possible nonprescription scenario, they were asked, as part of the reflective module, to voluntarily participate in a self-directed learning activity: an informal chat/interview with a practicing pharmacist (from either a hospital or community based clinical setting), which required the student to ask the practicing pharmacist about a nonprescription experience he or she had previously dealt with. A guide of possible questions to ask the practicing pharmacist was provided to the students (Appendix 4).

This activity took place during the weeks between reflective module tutorials. Students had a general discussion about the complexities of clinical pharmacy practice during the following week’s tutorial (without disclosing pharmacist name or pharmacy details). Presented scenarios and challenges of pharmacy practice were discussed during the tutorial. Tutors were provided with a discussion guide to facilitate this exchange of information. This guide was based on the prompt reflective questions provided to the students for this activity (Appendix 4).

The scenario writing task was initiated to enhance research skills utilizing evidence-based medical guides. Each student was asked to research an allocated nonprescription condition and related signs, symptoms, advice, products, and when to refer to a physician. Example conditions included: heartburn, sunburn, impetigo, travelers’ diarrhea, worms, chicken pox, scabies, ticks, or head lice. These conditions differed from the conditions introduced in prior tutorial modules or lectures. This gave every student the best opportunity to have a new condition to research. Students were then asked to develop a possible scenario involving this condition, write about it, utilize the video podcasts to counsel a student in the role of the patient (maximum of 5 minutes for counseling), providing appropriate advice, counseling points, products, required referrals, and ensuring patient understanding. This exercise was followed by a reflective statement (Appendix 3).

The video podcasts were introduced as a means to reflect on counseling and clinical competency skills and as a practice for the upcoming oral examinations. Students were allocated into groups of two or three, and each student was asked to prepare one case using the allocated nonprescription condition and focus on communication and clinical competency skills. A maximum of a five minutes was allowed for the consultation video. Any form of technology was allowed (eg, iPhones, iPads, computers, tablets) to record the podcast. Provisions were made for students who did not have access to technology and were allowed to borrow devices from the faculty (school). Each student had to play the role of pharmacist, counsel, and write reflectively about the task itself. All students were then asked to swap partners and become the patient (thus enabling more communication practice) and encouraged to review and reflect on their partner’s counseling and clinical competency skills on the video podcasts (Figure 2). This exercise allowed for both self- and peer reflection. There was no limit placed on the podcasts recorded prior to uploading to Blackboard Learning Management System.

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Figure 2.

A model for using vedio podcasts to enhance reflective capacity (self- and peer reflection) of pharmacy students.

The reflective statement was an introspective writing task, which allowed students to open up and reflect on their skills, shortcomings, and challenges with the whole task (researching, scenario writing, producing a counseling video, and writing a reflective statement). Students were asked to consider challenges to their previously held beliefs and assumptions, and document strategies employed to overcome challenges, either through a change of behavior or through acknowledgment of updating their skills. The purpose of the reflective statement was to enhance self-reflection on the task so that students could then review and reflect on how they could improve their skills for future tasks (Appendix 3).

Approval for the study was granted by the University of Sydney Human Research Ethics Committee, the Teaching and Learning Committee, and the second-year course coordinator of the unit (course) of study in the Faculty of Pharmacy, University of Sydney.

EVALUATION AND ASSESSMENT

Although integration of the reflective activities into pharmacy education was a curriculum initiative, the research project involved pre/post administration of Kember’s Reflective Thinking Questionnaire (RTQ).¹ Reliability of this tool has been validated with Cronbach alpha scores for the four scales in an acceptable range (0.621 – 0.757)¹ with the psychometric properties of the questionnaire further validated by Lethbridge and colleagues.⁸⁷ Coding schemes and rubrics based on Kember’s scales from this questionnaire were developed and used to determine reflective thinking.⁶¹ The 16-item tool used a 5-point Likert-type scale that allowed quantitative measures to be collected. The basis of this questionnaire was drawn from Dewey’s⁷³ and Mezirow’s⁷⁸ theories of reflective thinking.⁸⁸

To evaluate the impact of integrating the reflective clinical modules into the curriculum, a cross-over intervention-control group design was employed. Repeated measures (at three different time points) were employed to contribute to the robustness of the research method and to enable the addition of another intervention group, thus increasing the sample size (Figure 1). We conducted a quantitative analysis of the reflective thinking questionnaire before (baseline) and after (25 days) reflective activities were integrated. Student responses were entered into SPSS, v20.0 (IBM Corp., Armonk, NY).⁸⁹ Each response required the student to circle a letter (A to E) for their choice to the relevant question on a 5-point Likert-type scale.

Each question on the RTQ related to one of four domains: (1) habitual action [doing something without much thought], (2) understanding [content and theory], (3) reflection [reviewing, questioning the way in which something is done, considering alternatives, reflecting on actions or experiences], or (4) critical reflection [looking beyond reflection, questioning your firmly held beliefs and assumptions, discovering shortcomings, changing behavior]. Neither habitual action nor understanding are considered reflective thinking. Although the concept of understanding can be considered reflective when a personal experience is drawn upon, the understanding of content or theory is not considered a reflective concept. As this study focused on the reflective and critical reflective ability, questions 3, 4,7,8,11,12,15, and 16 were collated and analyzed. Three measures were analyzed: (1) The cumulative scores from the reflective questions [3,7,11, and 15]; (2) the cumulative scores for the critical reflection questions [4,8,12, and 16], and (3) the combination of the cumulative scores from the reflection plus the critical reflection scores [3,7,11,15,4,8,12, and 16].¹

Two statistical procedures were conducted, an analysis of covariance (ANCOVA) and a repeated measures analysis of variance (ANOVA). To determine if there were significant differences (p<0.05 level) between the two groups (Intervention Group A vs Control Group B) in the reflective thinking ability of students after the intervention, the ANCOVA was employed. The ANCOVA provided a means for controlling pretest scores on the RTQ, thereby reducing systematic bias, as well as within-groups error in the analysis.⁹⁰ To determine if the outcome variable (posttest scores on the RTQ) had an effect, the covariate (pretest scores) on the dependent variable was controlled for during the analysis.

Levene’s tests were conducted (p>0.05), indicating that the homogeneity of variance assumptions were not violated. Three outcome variables were tested: (1) reflective thinking ability; (2) critical reflective thinking ability; and (3) cumulative scores of reflective thinking ability questions and critical reflective ability questions. As the RTQ contained questions relating to other domains such as understanding and habitual action, only the scores calculated from the questions regarding reflective processes were analyzed, as well as the cumulative scores from all the reflective-type questions (reflective thinking ability and critical reflective thinking ability) were measured as the third indicator of reflective thinking change. The results from the ANCOVA analyzes are recorded in Tables 1-3 of Appendix 5.

Results of the ANCOVA showed that Intervention Group A reported an improvement in reflective thinking ability compared to Control Group B [F (1, 211)=32.2, p<0.01; (Table 1)]. The partial Eta squared (=0.13) indicated 13% of the variance of reflective thinking ability could be explained by the group identity (Intervention Group). The observed power was 1.0 (computed using alpha=0.05). Observed power values over 0.08 indicated acceptable results.⁹¹

Intervention Group A reported an improvement in critical reflective thinking ability compared to Control Group B [F (1, 211)=20.5, p<0.01; (Table 2)]. The partial Eta squared, =0.088 indicated 9% of the variance of critical reflective thinking ability could be explained by the group identity (Intervention Group). The observed power was 0.99 of 1.00 (computed using alpha=0.05).

Intervention Group A reported an improvement in reflective thinking ability plus critical reflective thinking ability compared to Control Group B [F (1, 211)=36.5, p<0.01; (Appendix 5,⁹¹ Table 3)]. The =0.15, indicated 15% of the variance of the cumulative scores of reflective thinking and critical reflective thinking ability could be explained by the group identity (Intervention Group). The observed power was 1.000 (computed using alpha=0.05).

A repeated measures ANOVA was also conducted as an additional confirmatory analysis to determine the difference between the RTQ test scores (reflective thinking ability scores plus critical reflective thinking ability scores) from Control Group B /Intervention Group B at time 1 (M: baseline 28.2), time 2 (M: preintervention 27.7) and time 3 (M: postintervention 30.1). The repeated measures ANOVA with a Bonferroni paired comparison revealed a significant difference between test scores for time 3 and time 1 (p<0.01), time 3 and time 2 (after intervention, p<0.01), and a nonsignificant difference between tests scores from time 2 and time 1 (preintervention, p=0.26).

DISCUSSION

This study aimed to measure the impact of integrated reflective activities and assessment tasks on the reflective thinking ability of undergraduate pharmacy students in a Pharmacy Practice course. From a cohort of 264 students, 238 students (90% response rate) responded voluntarily to complete the pre/post-RTQs. This yielded 214 valid questionnaires. Both intervention groups (A and B) showed a significant improvement in reflective thinking ability postreflective activities and reflective assessment tasks, indicating that integrating reflective activities into pharmacy curriculum has a positive impact on a student’s reflective thinking capacity.

Repeated measures ANOVA on the Control Group B between the different RTQ scores at the different times indicated that for those students who were not involved with the reflective activities and assessment tasks during that time of the semester, there was no improvement in reflective thinking ability (from time 1 at baseline and time 2). It was not until the same students, who then became the second intervention group (B), participated in the reflective tasks, that their reflective thinking capacity improved significantly.

The limitations of this study were threefold: it involved only one course in a pharmacy curriculum; the study was of students from one pharmacy school; and a small number of teaching staff taught the reflective modules. Despite these limitations, the large sample size (n=264), positive response rate for the RTQs, and cross-over intervention-control design with repeated measures provided robustness to the study. Furthermore, the teaching staff all received training from the lead author and the small number of teacher participants ensured a greater consistency of teaching.

Implementation of structured and guided reflective activities in education for health professionals helps to develop reflective-thinking skills that improve clinical practice.^{9,11,36,37,39,92,93} Furthermore, research supports teaching and facilitating reflective practice in health professions education to develop students’ understanding of its application for clinical practice.⁹⁴ The results of our study provide evidence for the positive impact that integrating varied, structured reflective practice activities into the curriculum has on the reflective-thinking ability of students. Scaffolding such activities across a curriculum, however, poses challenges for both teacher and student. For example, developing reflective learning modules, grading, and organizing structured assessment tasks takes time, expertise, and resources. From the student’s perspective, learning and practicing reflective thinking may be a new way of constructing knowledge, thus presenting intellectual and, at times, emotional challenges. Nevertheless, the benefits include improving students’ clinical decision-making capabilities and potentially future pharmacy practice.

Further research is currently being undertaken to investigate student feedback and teacher participant perceptions of the integration of the reflective activities into curriculum and to explore the relationship between reflective learning and academic performance outcomes.

SUMMARY

This research focused on the impact of a new learning and teaching module and assessment task (RACA) integrated into an undergraduate pharmacy curriculum. These resources were designed to enhance pharmacy student understanding of reflective practice and improve reflective thinking skills. Student responses to the RTQ pretest and posttest showed an improvement in their reflective thinking ability. Thus, integrating reflective activities into curriculum enhanced reflective capacity. The strengths of this study were its large sample size and the cross-over intervention-control group design with repeated measures. As reflective thinking is a necessary attribute for health professionals and for enhancing skills in lifelong learning, further research into the impact of integrating reflective thinking modules into other courses should also be considered.