323J Contemp Med Sci | Vol. 7, No. 6, November-December 2021: 323–329 Review Explaining the Concept of Learning Based on Reflection in Clinical Education: Scoping Review Soleiman Ahmady1,2, Zahra Ayazi3*, Masomeh Kalantarion3, Nasrin Khajeali4 1Head of Department of Medical Education, Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 2Research Affiliated Faculty at Department of LIME, Karolinska Institute, Sweden. 3Department of Medical Education, Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 4Department of Medical Education, Jundishapur University of Medical Sciences, Ahvaz, Iran. *Correspondence to: Zahra Ayazi (E-mail: ayazi_z56@yahoo.com) Abstract Objective: This study was conducted with the aim of theoretically explaining the concept of reflection in medical science education in texts and identifying the dimensions and characteristics of education based on reflection and their application in clinical nursing education and existing models in 2021. Methods: This scoping review was conducted in five phases following the method developed by Denyer and Tranfield. The scope of the review was limited to Reflection and Reflective in nursing education. Using the keywords in combination and separately, they were searched in databases of ERIC/ www.iranmedex.com/ www.magiran.com/ www.irandoc.ac.ir/ www.sid.ir/ www.medlib.ir/ All Sciences/ Web of Science/Search Engines Google/Google scholar/Scopus/Ovid/ERIC/Wiley/PubMed and Science Direct from1970s to 2021. Results: Based on inclusion and exclusion criteria, 24 articles and documents were selected. During the theoretical explanation of the concepts and components of reflection in clinical nursing education, the model is abstracted. In this model: The Clinical education triangle has 3 main components in its three angles: patient, teacher, or tutor, and student. It is necessary that the sides of this triangle including teaching-learning, teaching-caring, and caring-learning to be formed in the best way and to serve the student and the patient. Conclusion: The results of this study emphasize the practical and constructive nature of knowledge in learning based on reflection and its special position so that by eliminating the gap between theory and practice in nursing education, one can see the excellence of the operational part of education and promotion of the level of health of the society by providing an appropriate performance of the nursing staff. Keywords: Reflection, clinical education, scoping review, nursing, theoretical model ISSN 2413-0516 Introduction “Reflection in the field of learning” is a general term for mental and emotional activities in which people engage to discover their experiences which leads to a new understanding. Learning based on reflection is the process of exploring and discovering the subject matter that has been considered through experience, where the individual generates and clari- fies the meaning by himself, and the conceptual view of the individual is modified. Learning based on reflection requires learners to review their previous interpretations of knowledge and, as a group, create a new common sense of position and commitment to action based on this new learning.1 Therefore, reflection is addressed with terms like Reflective training, Reflective Teaching, Reflective learners, Reflective skills, or Reflection. Approaches used to promote learning based on reflection include action research, case write-ups, microteaching, and supervised practicals.2,3 Nursing is a professional knowledge that is dependent on practice along with science. In a way that in many studies, it is known as practice-oriented professional. In the field of testing science and nursing, art is in the domain of clinical, so in addi- tion to learning knowledge, a nursing student needs to learn skills. Clinical education is undoubtedly the most important and fundamental part of the nursing education program.7,8 It is close to half of the undergraduate education and therefore clinical education is referred to as the heart of nursing education.9 The value of clinical education is accepted by all; And all experts in the field of nursing education believe that the development of scientific and professional nursing educa- tion is impossible without improving clinical education. In this regard, many nursing schools consider the evaluation of clinical education as the main pillar of educational planning.10 It is important for “both the nurse and the patient” to per- form along with a reflective approach in nursing practices. In holistic caregiving, nurses in the task of taking care of man- kind, should always consider mankind with a holistic nature and provide care considering all his dimensions; and in this area, perform their caregiving actions with the least mistakes. Therefore, it is necessary to reflect on the desired action while performing specific measures or to reflect after performing them, so that the distance between theory and practice is reduced and the necessary points are learned from specific experiences.11 The importance of a reflective approach for a nurse is because one can avoid making mistakes or substitute the right things. So it can help to increase the development of his abilities; in a way that when performing reflection, nurses become able to provide their care with better understanding and more competent knowledge and have motivation in changing and improving the quality of holistic care.11 Since clinical education and the need to reduce and eliminate the gap between theoretical and clinical education in nursing edu- cation have a special position, so it seems that the use of models such as reflection, is effective in this regard. Therefore, this study was conducted with the aim of theoretically 4,5,6 (Submitted: 02 September 2021 – Revised version received: 21 September 2021 – Accepted: 11 October 2021 – Published online: 26 December 2021) 324 J Contemp Med Sci | Vol. 7, No. 6, November-December 2021: 323–329 Explaining the Concept of Learning Based on Reflection in Clinical Education: Scoping Review Review S. Ahmady et al. explaining the concept of reflection in medical science educa- tion in texts and identifying the dimensions and characteris- tics of education based on reflection and their application in clinical nursing education and existing models in 2021. Materials and Methods The concept of reflection, despite its relatively broad applica- tion, does not have clear definitions and there is some degree of ambiguity and lack of transparency around its characteris- tics. Therefore, in order to distinguish this concept in medical education from similar concepts and also because of lack of the provision of a specific model of reflection in the clinical education of nursing in the world and Iran, we decided to use the method of “Arksey & O’Malley Scoping review”,12 with a general overview, so that while clarifying the concept of reflec- tion and examining the existing models, a comprehensive model of their integration is provided. Scoping review is used to quickly provide a concept map, main sources, and key evidence of research background and can be used as an independent background review project in cases that are both a broad field of study and are not been com- prehensively studied in the past.13 The research methodology is defined by Denyer and Tranfield based on five steps of structuring the research, deter- mining the scope of the study, selecting and reviewing articles, data analysis, and conclusions.14 In the first step, research questions were determined as: “What are the concepts and components of reflection in med- ical education, especially clinical education?” Then, in the second step, to answer the questions of the previous step, the following different electronic databases were used systematically: ERIC/ www.iranmedex.com/ www.magiran.com/ www. irandoc.ac.ir/ www.sid.ir/ www.medlib.ir/ All Sciences/ Web of Science/ Search Engines Google/ Google scholar/ Scopus/ Ovid/ ERIC/ Wiley/ PubMed and Science Direct. Given that there was no other equivalent for the word Reflection in the Mesh Dictionary, the following keywords were used to search for a wide range of articles: “Reflection, Reflective Learning, Reflective training, Reflective Teaching, Reflective thinking, Reflective Practice” OR “levels of reflectivity, Reflective Learning model, Reflective Practice in nursing.” The above keywords were searched in English and Farsi during the 1970s (the introduction of the term Reflection and Reflective in education by Burton) till 2021 in the mentioned databases. In order to select the main studies in the third step: inclu- sion and exclusion criteria were modified and adjusted based on the research question and scoping review objectives during the searches and study of documents during an interactive process. Articles that are published in English or Farsi and in a scientific-research journal (approved) and the term Reflection or Performance-based on Reflection is in the title or abstract and their full text is available were included in the study. Criteria for excluding sources from the study were: lack of access to the full text of the article, scientific-promotional arti- cles, letter to the editor, lecture, critique report, or articles not related to the field of medical education. In the initial search, several articles were found. In the first stage, after reviewing the titles of the articles (1414 items), a large number of sources were removed due to lack of the- matic relevance (1308 items), and 110 articles, books, and doc- uments were selected for further review. Then the summary of the articles was studied and those relevant to the concept of reflection in clinical education particularly nursing were chosen for full text studying. At this stage, 52 articles and doc- uments of which full texts were available were read. Finally, based on inclusion and exclusion criteria, 24 articles and doc- uments which had stated complete details regarding the desired concept, were selected as a base for scoping review and chosen for inclusion in the analysis (Figure 1). In the fourth step, after the final sources were selected, the definitions and frameworks provided in these sources were reviewed and the details of each of these definitions, frame- works, and models were embedded in the Excel software for better matching and comparison in the next stage.12 The purpose of collecting studies in the fifth step was to compile and summarize the results and provide a report. Analysis and combining of results is part of any review study, but the depth and type of analysis in this method was different from the systematic review because, in this type of study, the results of a scoping study are usually displayed in tabular form with some narrative interpretations by the researcher15 wherein this study, by matching different findings in relevant researches and relevant, a summary is given in Tables 1 and 2. Ethical Considerations The data were collected after obtaining the approval of the research proposal from the Ethics Committee of the Shahid Beheshti University of Medical Sciences (IR.SBMU.SME. REC.1400.014). Results Definitions and various components of reflection in the researched models and the consequences obtained in the models are summarized (Table 1); then the articles related to the relevant topics in the world are presented (Table 2); there- fore, ultimately we are able to present a conceptual model of Fig. 1 Selection process of studies to include in the scoping review. 325J Contemp Med Sci | Vol. 7, No. 6, November-December 2021: 323–329 S. Ahmady et al. Review Explaining the Concept of Learning Based on Reflection in Clinical Education: Scoping Review Ta bl e 1. D efi ni tio ns a nd co m po ne nt s o f a pp lie d re fle ct io n m od el s i n cl in ic al e du ca tio n Row M od el /D es ig ne r/ Ye ar M od el co m po ne nt s Describing the experience Feelings/Mental preparation Evaluation/ Combination Analysis Conclusion Action plan Self-awareness/ Self-assessment Detection/ Change negotiation Discovering new options Obtaining knowledge and skills by reflection Testing new behavioral method Substitution of the new method Self-confidence Enhancing professional behavior Inter professional role 1. G IB BS ’ M O D EL O F RE FL EC TI O N (G IB BS /s r1 98 8) 16 ,1 7 2. SM YT H ’S M O D EL O F RE FL EC TI O N (S M YT H - 19 89 )18 3. M EZ IR O W ’S R EF LE C TI VE M O D EL (M EZ IR O W - 20 02 )19 4. BO RT O N ’S M O D EL O F RE FL EC TI O N (B O RT O N /2 00 3) 20 ,2 1 5. A R EF LE C TI VE M O D EL F O R IN TE RP RO - FE SS IO N A L LE A RN IN G (Z ar ez ad eh et a l. - 2 00 9) 22 6. JO H N ’S R EF LE C TI VE F RA M EW O RK (J oh n - 2 00 9) 23 ,2 4 7. TH E CO RE M O D EL F O R CR IT IC A L RE FL EC TI O N C ot tr el l ( 20 10 )25 ,2 6 326 J Contemp Med Sci | Vol. 7, No. 6, November-December 2021: 323–329 Explaining the Concept of Learning Based on Reflection in Clinical Education: Scoping Review Review S. Ahmady et al. Ta bl e 2. R es ea rc h re la te d to le ar ni ng b as ed o n re fle ct io n in cl in ic al e du ca tio n (n ur si ng ) Au th or /Y ea r o f pu bl ic at io n Re se ar ch o bj ec tiv e Sa m pl e Re se ar ch m et ho d Ke y fin di ng s Pl at ze r, et a l. 20 00 D et er m in in g ba rr ie rs to re fle ct io n le ar ni ng A g ro up o f u nd er - gr ad ua te n ur se s Q ua lit at iv e re se ar ch Th e ex is tin g cu ltu re o r t he e nv iro nm en t w he re n ur se s w or k, is th e la rg es t b ar rie r t o re fle ct io n an d le ar ni ng th ro ug h ex pe rie nc e. 27 Ru th -S ah d 20 03 Cr iti ca l a na ly si s of re fle ct io n pe rf or m an ce w ith a pp lic at io n in n ur si ng N ur si ng s tu de nt s an d pr of es so rs Q ua lit at iv e re se ar ch Pe rf or m an ce b as ed o n re fle ct io n, b eg in s w ith b eg in ne r s tu de nt s an d th e va lu e an d im po rt an ce o f re fle ct io n ca n be ta ug ht to b eg in ne rs . I n nu rs in g m ea su re s, re fle ct io n ne ed s to b e ex ec ut ed s o th at w e ca n pe rf or m m or e eff ec tiv e m ea su re s fo r p at ie nt s.2 8 Ri ch ar ds on 2 00 4 D et er m in in g th e st ra te gi es to le ar ne rs ’ le ar ni ng in c la ss e nv iro nm en t St ud en ts Q ua nt ita tiv e re se ar ch Th e us e of q ue st io nn ai re s ho ul d be c on si de re d in o rd er to fu lfi l t he ta sk s as a p re ci se re fle ct io n of co gn iti ve p ro ce ss in g of p eo pl e an d pe op le a ct d iff er en tly in re fle ct iv e le ar ni ng .29 G us ta fs so n, e t a l. 20 07 D et er m in in g th e eff ec t o f r efl ec tiv e pe rf or - m an ce in n ur si ng c ar e N ur se s in th e ar ea of c lin ic al c ar e Q ua lit at iv e re se ar ch Pe rf or m an ce b as ed o n re fle ct io n is a v al ua bl e to ol fo r n ur si ng c ar e an d in th is m et ho d, n ur se s fin d th e ab ili ty to p er fo rm h ol is tic n ur si ng c ar e an d ha ve lo gi ca l t hi nk in g an d ex pa nd th ei r k no w le dg e an d it’ s a w ay to in te gr at e th e ne w n ur si ng k no w le dg e w ith th e pr ev io us o ne in th e di re ct io n of ch an gi ng n ur si ng p er fo rm an ce .30 Ch on g 20 09 Ex pl ai ni ng n ur si ng s tu de nt s’ pe rc ep tio n of re fle ct iv e pe rf or m an ce N ur si ng s tu de nt s Q ua lit at iv e re se ar ch N ur si ng s tu de nt s ha ve a p os iti ve p er ce pt io n of re fle ct iv e pe rf or m an ce in c lin ic al n ur si ng w hi ch ra is es le ar ni ng a ct iv iti es a nd s el f- di re ct ed m ot iv at io n of s tu de nt s.3 1 M et tiä in en , e t a l. 20 13 D et er m in in g th e ap pl ic at io n of th e le ve ls of a w ar en es s an d th e le ve ls o f c rit ic al a w ar e- ne ss o f r efl ec tiv e le ar ni ng fo r a dj us te d us e N ur si ng s tu de nt s Q ua lit at iv e re se ar ch N ur si ng s tu de nt s in th ei r w or ki ng e nv iro nm en t c re at ed c on ce pt ua l s tr uc tu re s th ro ug h pe rc ep tio n an d th in ki ng , a nd re fle ct ed o n its th eo re tic al p er ce pt io ns a nd b ac kg ro un ds . I n th e le ve l o f c rit ic al kn ow le dg e, th e st ud en ts b ec am e aw ar e to w ar ds th ei r k no w le dg e an d le ar ne d to c rit ic iz e th is kn ow le dg e an d th ei r o w n as su m pt io ns .32 N ai ck er 2 01 3 Ex am in in g an d de sc rib in g th e ro le o f n ur s- in g tu to rs in fa ci lit at in g re fle ct iv e le ar ni ng in s tu de nt s N ur si ng tu to rs Q ua lit at iv e re se ar ch In p ra ct ic e, n ur si ng tu to rs , d id n’ t h av e m uc h su cc es s in te ac hi ng re fle ct io n. L ea rn in g ba se d on th is, is n ot c on si de re d as th e offi ci al a pp ro ac h in th ei r p ro gr am s, ho w ev er , t ut or s tr ie d to e xp lo it th es e m ea su re s in th ei r t ea ch in g ac tiv iti es .33 Ry an , e t a l. 20 13 Th eo riz in g a m od el fo r t ea ch in g an d ev al ua tin g of re fle ct iv e le ar ni ng in h ig he r ed uc at io n St ud en ts a nd pr of es so rs Q ua lit at iv e re se ar ch H ig he r e du ca tio n is a m ul ti- di m en si on al s pa ce w hi ch ju st ifi es th e ne ce ss ity o f p ay in g at te nt io n to a ll di ffe re nt d im en si on s of s tu de nt s’ le ar ni ng .34 M un cy 2 01 4 D et er m in in g th e ty pe o f l ea rn in g of st ud en ts w he n us in g an d ed iti ng th ei r d ai ly w rit in gs in b lo gs St ud en ts Q ua lit at iv e re se ar ch Bl og gi ng is a v al ua bl e to ol to le ar n re fle ct io n am on g st ud en ts .35 G aš ev ić , M irr ia hi & D aw so n 20 14 D et er m in in g an d an al yz in g th e eff ec ts o f us in g vi de o an d ed uc at io n fo r s up po rt in g le ar ni ng b as ed o n re fle ct io n in s tu de nt s St ud en ts Q ua lit at iv e re se ar ch Th e us e of v id eo a nd e du ca tio n im pr ov es re fle ct iv e le ar ni ng p ro ce ss es in s tu de nt s.3 6 U ga ld e 20 15 D et er m in in g th e re la tio ns hi p be tw ee n re fle ct iv e le ar ni ng , i nt er es ts a nd m ot iv at io ns in a ch ie vi ng s uc ce ss in s ta nd ar d re ad in g in in te rm ed ia te s ch oo ls St ud en ts o f in te rm ed ia te sc ho ol s (E ur op ea n st ud en ts ) Q ua lit at iv e re se ar ch M ot iv at io na l a ct iv iti es o f s tu de nt s le ad to a d iff er en ce in th ei r l ea rn in g an d fo r e ac h of th em , o ne or s om e le ar ni ng a ct iv ity w as c on si de re d as v al ua bl e. T he n ee d fo r p re pa rin g an d ex is te nc e of c le ar st an da rd s be tw ee n re fle ct iv e le ar ni ng a nd s tu de nt s’ su cc es s w as e vi de nt .37 Sa pe rs te in , e t a l. 20 15 Pr es en tin g a m od el o f r efl ec tiv e pe rf or - m an ce e du ca tio n w ith th e pr ep ar at io n an d im pl em en ta tio n of c ur ric ul um d ur in g th e 4 ye ar s of m ed ic al e du ca tio n in g ra du at e St ud en ts a nd p ro - fe ss or s of E dw ar d H eb er t S ch oo l o f M ed ic in e U SU Q ua lit at iv e re se ar ch Pr ac tic e ba se d on re fle ct io n lo ng itu di na lly in 3 s ta ge s of e du ca tio n an d by p ro vi di ng a s am pl e of re fle ct iv e w rit in g to s tu de nt s sh ow th at , b y re pl ac in g su ch a c ur ric ul um , h ow w e ca n ob se rv e its po te nt ia l b en efi ts s uc h as im pr ov ed in te r- pr of es si on e du ca tio n an d im pr ov ed s el f- aw ar en es s an d cl in ic al p er fo rm an ce .38 327J Contemp Med Sci | Vol. 7, No. 6, November-December 2021: 323–329 S. Ahmady et al. Review Explaining the Concept of Learning Based on Reflection in Clinical Education: Scoping Review reflection and learning based on it from the scoping review (Figure 2) with the use of the potential of this kind of learning for further application in clinical education specifically for nurses for the study objectives. Conceptual Model of Reflection and Learning Based on it from Scoping Review During the theoretical explanation of the concepts and com- ponents of reflection in medical education in the text and identifying the dimensions and characteristics of education based on reflection and their application in clinical nursing education, the model is schematically abstracted (Figure 2). In this model: the clinical education triangle has 3 main components in its three angles: patient, teacher, or tutor, and student. The purpose of these components in the clinic is to achieve patient health. In this way, it is necessary that the sides of this triangle including teaching-learning, teaching-caring, and caring-learning to be formed in the best way and to serve the student and the patient. In order for the student to learn better, in the clinic, ben- efiting from his experience, the teacher and patient enter a cycle that focuses on reflection in education and has 4 cyclic stages of Do/Review/plan/experience or practice. In the case of implementing these stages, the student enters the phase of thinking which, by thinking about experiences, manifests as Reflective thinking, Critical Reflective, or Reflective Learning. Teachers use different teaching methods and teaching strategies to teach better. In case of implementing the stages of Review/Do/Experience or practice, the student enters the phase of Doing/Experiencing and tries to take proper clinical measures for the patient by achieving Reflec- tive (professional) practice and it’s in this stage that along with self-monitoring, the teacher also gives feedback. The key point of this model is that a clinical student, including nursing, after the theory training process and reaching this point of clinical training, still has a gap between theory and practice, which with the help of professors, this gap must be repaired and compensated based on reflection so that a nursing student can better provide clinical services and bring the health system and patient closer to the lofty goal of recovery and promotion of health. Discussion As Freshwater addressed it in 2002, “being a good therapeutic staff and physician” requires appropriate knowledge and skills, but it also requires establishing and maintaining a therapeutic relationship between patients and their caregivers.39 This concept implies that a good relationship with the patient has a beneficial effect on the well-being and improve- ment of the patient. The importance of a therapeutic relation- ship has long been recognized in psychotherapy, but recent attention to patient-centered care suggests improvements in outcomes such as patient satisfaction and improved chronic patient care.40 An essential aspect of relationship therapy is recognizing and understanding the personal beliefs and value systems of the people involved, both physicians and patients. There may be differences between these systems and this can cause an acute emotional reaction in the physician which in turn may affect his next decisions and measures. Recent neurological research shows that effective reasoning is a largely uncon- scious process in which there is a modulation of the logical processing of information by emotions. For example, anger towards a patient may lead to a response that would be dif- ferent if it was empathy. Establishing a therapeutic relation- ship is an essential component of professional practice and a key characteristic of professionalism. Reflection directed by a supervisor or advisor is very beneficial for this approach because the beliefs and main and essential presumptions of the individual are identified and challenged. Reflection is impor- tant for establishing a therapeutic relationship, especially for postgraduate education and continuing medical education, but it is also used for general medical education, especially during the clinical period.40 Reflection is effective in developing professional practice. Therapeutic staff and physicians often have to respond to a wide range of conditions that are both complex and not well defined. This “disorder” of professional practice is at the heart of professional expertise.41 Experts are quick to make decisions that are appropriate to these complex situations, and they are able to create a set of mental models through an action-on-reflection process that mobilizes them quickly and can effectively resolve the situa- tion through action-in-reflection. Developing professional expertise requires nothing more than a set of knowledge and skills.42 The performance of an expert is a complex combination of knowledge and skills tailored to the unique situation he or she faces. Frequent confrontation with the complexities of professional life is an essential issue and directed reflection can maximize the opportunity to learn in this approach. Reflection is essential in developing professional acts for postgraduate education and continuous education. Although these three approaches have different outcomes, they all have an essential aspect. A conscious process to develop perception and create meaning from one situation to future measures done con- sciously is the essence of reflection. In this study, only one study compared different methods. This study was conducted to identify whether writing an important incident report, two-person interview, or a combi- nation of the two, is more effective in creating a reflection. The results of this study indicate that interview with a tutor is the most effective way to reflect on professionalism. During the experience of medical school, there is no longitudinal study and evidence of the benefits of reflection in long-term development, especially in subsequent clinical care. However, reflection in general medicine students has increased self- report measures about self-awareness, professional thinking skills, and skills needed for close examination of patients.43 Fig. 2 Conceptual model of reflection and learning based on it. 328 J Contemp Med Sci | Vol. 7, No. 6, November-December 2021: 323–329 Explaining the Concept of Learning Based on Reflection in Clinical Education: Scoping Review Review S. Ahmady et al. Four studies that reported positively targeted results in reflection were: Increased skill in reflection and diagnostic thinking (Sobral, 2000), professional identity (Niemi, 1997), medical-humanistic skills score (Wiecha et al. 2002), and final examination results for obstetrics (Lonka et al., 2001). As a result, students found that reflection was helpful, and the application of reflection led to improved self-report outcomes and objective learning and professional development.44-47 Grant et al. in 2006, by a study of first-year medical students, showed that instead of text-based reflection writing methods, students prefer to pursue group-based and creative reflective activities.48 It seems that the experience of the use of multi- media, voice, image, and video and creatively exploiting them for reflection, like digital storytelling, not only increases the students’ involvement but also increases the depth of their reflection.49 Individuals have a variety of preferred methods for presenting their thoughts and feelings, including painting, photography, and sculpture.50 Conclusion What emerges from the study of relevant research in the field of reflective learning indicates that the idea of this model entered the field of learning and education from Burton in 1970 and gradually became more apparent in clinical educa- tion. Of course, clinical education of students needs a lot of effort so that by reflection, one can expect the better perfor- mance of the students, especially the big group of nursing stu- dents. The results of reviewing various researches in parallel have confirmed the efficiency and positive effect of this type of learning in acquiring skills, student motivation, and the ability of collaborative learning and subsequently improving skills in clinical and working environments. 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