Implementing Reflective Writing at a Newly Established Health Science Academy of Nepal: Exploring a Novel Practice,Overcoming Obstacles and Recommendations

Abstract

Establishing new institutions for health professions provides the opportunity to implement innovative approaches catering to the current health needs and also allows to address the inadequacies of well-established institutions. Grabbing this opportunity, we initiated the implementation of reflective practices at Madan Bhandari Academy of Health Sciences, a new provincial university in Nepal. Though literature shows that reflection is a helpful tool to reflect on choices, experiences, and failures and obtain knowledge for the students, the adoption of reflective writing in health professions education in Nepal is limited. Therefore, we looked into the practices from other countries to adopt them in our settings and integrated them into our curriculum. But, we came across many impediments during the process—particularly those related to limited resources. We found innovative solutions like using technology and peer mentoring to overcome these challenges and integrated these practices to initiate reflective writing at the institution. The introspective “talking to oneself” has been a valuable strategy for implementing the reflective practices at our institution. Based on our experiences, we highly recommend educators in Nepal or similar settings embrace team-based writing practices that are contextually appropriate. But, we also recognize the benefits of team-based reflective writing that considers the cultural context. We hope this review will inspire educators, particularly those who lack the resources to initiate such practices at their institution. Our firsthand experience is detailed in this perspective article.

Introduction

Transforming education is the fundamental means by which we can develop society. Thus, the health professions education of Nepal is urging for an overhaul to drive positive changes in healthcare today. As our health professions curriculums have failed to extrapolate the evidence related to the latest pedagogical techniques generated from the developed setting and effectively utilize them in our context, integrating newer practices into learners’ activities could develop a health workforce that meets the global standards in medicine. ¹ There is plenty of evidence that reflective writing is one of the approaches to developing health professions guided by strong ethical principles and capable of adapting to the demands of present-day healthcare. We believe that writing a reflective journal is an impactful way for health professions students to reflect on their choices and arduous experiences, eventually making them more aware of the areas they have failed and learned from. In reflective practice, we both project and review. A dialectical conversation frequently occurs between projections and reviews to determine what we know, what we have learned, and what we might understand. ² An analysis of what should have happened (theory) and what happened (practice) in a situation provides practical insight to students that they don't find in a standard essay.

Experiential learning is at the core of professional development and reflection is considered a core skill of professional competence. It is through reflection and consideration of one's experiences that one learns from them, which is a critical component of experiential learning. Facilitated or guided reflection is generally more effective than a single person's endeavor. ³ According to Schön, ³ critical self-awareness and cognitive reorganization of knowledge are characteristic of experts. Consequently, medical students may find reflection difficult and struggle with creating meaning from it. Using guiding, open questions to facilitate a student's reflective process can lead the student to an objective and specific analysis of their performance and feedback. ⁴ Hence, during the curriculum development process, we took inspiration from relevant literature to incorporate reflective writing practices into the learning experience of Madan Bhandari Academy of Health Sciences. Hence, this perspective paper draws on our experiences of implementing the novel practice of reflecting writing at our institution and highlights the obstacles we encountered. This work can be taken as a reference for educators at other institutions who wish to start similar practices.

Reflective writing

While the use of reflective practice in academic contexts is well established, it is also important to emphasize that reflective writing is complicated and demands high persuasive skills. Therefore, it is difficult for students to master reflective practices without explicit and scientific instruction. ⁵ Evidence suggests that reflective capacity enhances professionalism in general and interpersonal skills, empathy, and teamwork in particular. A systematic review and meta-synthesis of qualitative studies by Artioli et al ⁶ provides evidence of positive experiences of reflective writing. Regrettably, the study did not have any studies conducted in Nepal. The study reviewed the experiences of students and in-service involved in reflective writing. The article excludes studies in which participants used reflective writing together with other learning tools, as well as personal experiences that did not involve solely reflective writing. The findings suggested that reflective writing engenders reflective thinking and reflexivity that contributes to professional growth, skill development, and building empathy for others and oneself. Similarly, in a systematic review of interventions by Winkel et al ⁷ involving reflection in graduate medical education, the authors found that reflection enhances empathy, increases comfort in learning in complex situations, and increases engagement.

While we discuss what reflective writing is, it is also equally important to understand what it is not:

Mere imparting information, directions, or argument;

Simple description, yet it may include certain descriptive features;

A straightforward judgment, such as whether something is right or wrong;

Simple problems such as directions to the nearest mall;

A summary of the lecture materials;

A typical college essay ⁷ ;

Reflective writing in Nepalese curriculums

Nepal's history of medical education dates back to the 1950s. Still, much work remains to integrate reflective practice in curricula across the continuum of medical education in the country. ⁸ Even though two universities offer medical programs (including 19 medical colleges) and all seven provincial health sciences universities are fully capable of designing their curriculum, the absence of reflective practices in their existing curriculums is overtly visible. In Nepal, the Medical Education Commission (MEC) is the main body that overlooks medical education. It serves as its national regulating and implementation authority. A prominent role of MEC in this field is to shape its standards and practices. In addition, it facilitates the sharing of best practices between medical educators. ⁹ Likewise, the Association of Health Professions Educators of Nepal is a non-profit, non-political, and non-governmental organization advocates and supports innovations in health professions education. ¹⁰ Despite these efforts and resources, Nepal still lacks a standardized curriculum that facilitates reflective practice. However, Patan Academy of Health Sciences, a non-profit autonomous health professions education institution in Nepal, promotes reflective writing as a part of its community-based learning and education (CBLE) initiative. The objective of CBLE is to provide students with exposure to healthcare facilities in rural Nepal to improve the retention of doctors in rural Nepal. There are still many more unexplored areas of reflective writing in our medical education curriculum that could be ideal for a contextually relevant curriculum design. ⁸ Naidu et al ¹¹ in their enthralling perspective argue against the applicability of Western philosophy to global health professions education. The author suggests that the generally accepted structure of reflective writing is based on introspection-thinking about one's thinking that might undermine local beliefs, values, and perspectives. The author critically examined the reflective practices and recalled when the author's trainees disregarded contextually relevant patients’ information and sought solutions in Western texts. The authors also made a compelling argument regarding the sustainability of reflective practices, highlighting their resource-consuming nature. This is a relatable issue as health professionals in our context face significant pressure on effectively treating diseases, which makes it difficult for them to prioritize reflective practices. Furthermore, a lack of alignment between cultural context and educational practices may bring disharmony among the professionals. Hence, it is critical to probe into the underpinnings of culture-oriented philosophy because misalignment with societal necessities and aspirations may lead to wasted resources.

Reflective writing at Madan Bhandari academy of health sciences

MBAHS offers three undergraduate programs in health sciences—Bachelor of Public Health, Bachelor of Pharmacy, and Bachelor of Science in Medical Laboratory Technology. In their first and second semesters, students learn applied integrated basic sciences (analogous to the 2-year basic science of medical students). ¹² As promoting the humanistic theory of learning remains the guiding principle of MBAHS, the courses developed were meticulously aligned with the learning philosophy and the institution's mission. Similarly, the course contents, instructional methodologies, and assessments were also intentionally matched with the institution's strategic values. Furthermore, to enrich the student's learning experience and help them acclimate to the institutional culture of MBAHS, we implemented reflective practices from the outset of their time at MBAHS. ¹³ To kickstart this initiative, we introduced reflective writings in the foundation course. The foundation course is a 2-week long non-credited course designed to support student's transition to the academic and social expectations of the institution. The students were asked to write and submit a reflective piece of each day. The submission of reflective journals was a prerequisite to advance to the core courses. We introduced reflective practices in the formative years rather than the final years based on findings by Quintero et al. The paper highlights the need to incorporate medical humanities in the pre-clinical years of their medical training as it would aid in developing a more comprehensive understanding of the role of health professions beyond the confines of knowledge alone. ¹⁴

On the first day of the foundation course, we shared guidance with the students on how to write reflective journals. We simplified the writing process by breaking down the process into three manageable steps: descriptive, interpretive, and applicative sections.

Descriptive writing (What?): This section describes the events in detail and facts. Here, students exhibit assimilation of new knowledge.

Interpretive writing (So what?): In this section, students demonstrate their ability to recognize and attend to their feelings about that particular event. Students interpret the event and evaluate its impact on them. Additionally, they connect this newfound knowledge with their prior knowledge. Students display the practical aspect of the learning to a broader perspective of professional and personal lives.

Applicative (Now what?): In this section, students are encouraged to consider how this experience will influence their future. They identify the areas of deficiencies and develop a plan to address them.

Students were encouraged to write the reflective journal clearly emphasizing the relevance of their learning outcomes, interrelatedness, and self-assessment. They were instructed to cite their sources as well. This simplified and understandable approach helped students articulate their thought processes and link them to their personal experiences, enabling them to draw meaningful insights and recognize areas for self-improvement. To guide the students on what is expected of the reflective journal and also standardize the evaluation we adopted the rubric developed by the University of Alberta Health Sciences Council. ¹⁵

Reflective writing in professional development course

The curriculum of MBAHS incorporates the humanistic theory of learning by providing two credited professional development courses, one credit in the first semester and another in the second semester. This vertical integration of professional development is essential for improved retention of professionalism among students. ⁶ The inclusive professional development course covers varying themes such as professionalism, empathy, ethics, medical humanities, communication, and art, which spans over 16 units. The course has the learning outcome of acquainting students with cultural competence and professionalism for optimum patient care. During the first semester, students are required to submit nine reflective journals related to professionalism, ethics, autonomy, attitude, medical humanities, communication skills, respect for learning, and empathy. The objective of this practice is to understand how the students learn, perceive, analyze, and apply the content of the course in their own professional lives. Reflective journal writings from students were collected to understand their perspectives and reactions to myriad events that occurred in their lives, like an argument with someone or the process of learning something new. Reflective journals were assessed based on the rubrics, with a weightage of 20% towards the final grade. These reflective writings serve as aids in the diagnostic process of the learning process of the students, which can contribute to the development of better teaching practices as well.

Role of facilitators

Facilitators play a vital role in the process of reflection by providing support and guidance to the students. Faculty members who served as facilitators in professional development courses collaborated to create a list of students’ assignments. This practice aimed towards maximizing the effects of reflective writing. Before the start of the session, our facilitators decided to provide the direction and framework to the students by identifying key themes to explore. In addition, facilitators presented students with insightful questions to motivate them to delve into self-reflection. Facilitators offered feedback to students on their reflective writings to refine their ideas and enhance clarity. They employed Socrates’ methods to evaluate their assumptions in the context of reflections. Facilitators can collaborate with the students to establish a safe and secure environment for dialogue regarding reflective writing without fear of judgment. In this dialogue session, facilitators can help students find significance in their reflections and identify avenues for self-improvement, which plays a significant role in the context of parent-faculty member interactions. We employed a similar strategy. Discussing the students’ reflections with parents fostered our confidence to continue this practice and also garnered support from parents to promote the student's growth. ¹⁶

Overcoming the challenges in implementation

The reflective writings received from students in the foundation course contained mostly the descriptive portion that lacked interpretive and applicative portions and their personal experiences. However, the later reflective writings, especially those in the audio-visual class on “The Death of Mr Lazarescu” in the professional development course, included more personal experiences along with thorough interpretive and applicative components. This change could be due to an increase in mutual understanding and rapport between the students and facilitators in the later sessions. ¹⁷

As a highly subjective concept, reflective writing is challenging for both teachers and students to define clearly. This lack of clarity may lead teachers to loosely define the process or sometimes even misdirect the learners. They might fail to adequately explain the value or goal of activities centered on encouraging reflective practice. Undergraduates may wonder whether it will be of value, not understanding where self-awareness fits into their learning process. Novices may find the process challenging and see reflective writing simply as an unnecessary add-on to their existing curricula. Moreover, they may adopt a lackadaisical attitude toward such new learning practices if they hesitate to have their reflections read and assessed by others. Hvidt et al presented qualitative evidence of medical students’ perception and attitude towards courses addressing soft skills such as medical humanities. Notably, students expressed that core courses in biomedical sciences were of greater importance, while soft-skill subjects were observed as mere distractions. The author argues that students develop a dichotomous perspective on hard and soft courses in their professional identity formation. In their perspective, the medical curriculum is predominantly centered on biomedical sciences, further reinforced during their undergraduate years. The author posits the poor institutionalization of the inclusion of medical humanities in medical education, where medical humanities are often relegated as extraneous to core academic programs. ¹⁸

Evaluating faculty members’ and students’ attitudes and perceptions toward reflective writing is beyond the purview of this study. However, the budgetary constraints were one of the most challenging obstacles we had to overcome. When designing the course on foundation and professional development, we couldn't invite and ensure the participation of external experts. Hence, we concede that there exists significant room for improvement and we are proactively exploring opportunities to improve the course and its contents. However, there were several steps we followed to promote reflective writing at our institution despite the limited resources we had:

Most of our faculty members don't have any prior training in health professions education. Hence, convincing them to start such a practice was a grueling project. Additionally, we could not organize a workshop on reflective practices for the facilitators who took an interest in facilitating the foundation and professional development courses due to budgetary limitations. Hence, we organized dialogue sessions with them. We used the opportunity to provide them with compelling evidence and information regarding reflective writing. These dialogs clarified the importance, relevance, and potential benefits of reflective writing. Drawing from our experiences, we assert that effective training of faculty members is imperative for the successful implementation of this novel practice and is critical for maintaining assessment validity. We are therefore actively seeking support for their training and professional development. ¹¹

We encouraged peer mentoring among faculty members to support the necessary skills for facilitating reflective writing. The faculty members learned from each other and guided each other as needed.

Google Classroom, an open learning management system, was used to manage the reflective writing process. The facilitators assigned reflective journal tasks to the students via Google Classroom and they upload their work on the platform. Submitted journals were assessed by the facilitators who then provided each student with personalized feedback. This paperless technology allowed us to streamline the management of assignments and significantly minimize the administrative burden associated with handwritten submissions. Fisher et al, in their study, made comparisons of two cohorts: web-based reflections and traditional essay-style reflections. The comparison was made in terms of content, insightfulness of reflection, and student preferences. They did not observe any significant differences in any of the variables between the two groups. However, an administrative hassle with the management of paper was significantly reduced by web-based reflections. The research further highlighted that with the expansion of electronic media, the perception that blogging is structured and formal was instilled. Furthermore, there was an increased frequency of reflective pieces in cohorts utilizing web-based reflections. ¹⁹ Given the constraints of resources at our institution, open platforms such as Google Classroom provided us with an enormous advantage. However, institutions with well-established infrastructure can opt for web-based reflection by blogging. ²⁰ Web-based reflections could be more viable options because students can revisit and edit their reflections. ¹⁶ We plan to implement web-based blogging via WordPress, which is a good alternative for resource-limited institutions. Other alternatives are online note-sharing applications such as Evernote or One Note. These applications are also convenient for managing reflective journals as faculty members can provide real-time reviews of the entries. Similar to web-based blogging, such platforms provide longitudinal records of reflective journals. ²¹

There were no barriers to receiving reflective journals from students. Conversely, they were zealous about this novel approach and were excited to share their work. As a means of encouraging students to write reflective journals, we mostly focused on providing comments on their content. Later, we planned to emphasize grammatical errors at higher levels.

The session that utilized audio-visual aid by screening the movie “The Death of Lazarescu” had a profound impact on the quality of reflective writings submitted by the students. Therefore, based on our limited experience, utilizing audio-visual aid can be an effective and enriching pedagogical strategy to improve reflective practices.^22,23

We incorporated reflective journals with assessment elements to motivate students and institutionalize the reflective practices. The findings from Grant et al concluded that unless reflective writing is enforced by the curriculum or assessment, the students are less interested in writing reflective journals. ²² But, genuine reflections might be limited by assessment based on grades. Students may write the reflection to get better grades rather than gauze deep into their insights. ²³ We have attempted to manage these mixed blessings of assessments by dedicating 20% of the grades for professional development courses to be dependent on them. In non-credited foundation courses, reflective journals are compulsory for advancement to core courses but are not subject to grading.

The lack of training on reflective writing activities for the faculty members could impede the outcome of the writing activity. We understood that the development of reflective capacity among learners is complex and non-linear and may vary in pace and depth during this process. We addressed this issue by providing interested faculty members with learning resources and guidance to provide effective feedback. Regrettably, we could not conduct any research or take any action toward adopting a model for implementing scaffolding learning opportunities through reflective writing. However, recognizing that the students are non-native speakers, we made several developmental decisions to scaffold their learning. We provided feedback based on rubrics developed by the University of Alberta Health Sciences Council without focusing on English grammar. ¹⁵ As feedback plays a crucial role in strengthening the nexus between reflection and immersive learning, we have decided to revisit the scaffolding phases with the goals of gradually increasing students’ responsibility and decreasing faculty members’ involvement. The initial batches may serve as a facilitator in guiding their junior peers in the practice of reflective writing.

To effectively implement reflective practices, it is crucial to provide students with considerable opportunities to implement the insights gained from their reflections. Submitting a nearly perfect reflective journal alone does not suffice for the transformation process required to apply and achieve learning goals. In later years, when students are in field or hospital postings, we aim to assess students based on their portfolios. This method will help us evaluate how well students translate theoretical learning into practice in real-world settings. While convincing the hospital and field clinicians and staff to appreciate the value of reflective writing remains a huge challenge, the reflective writing skills that students acquire during college can disseminate knowledge about reflective writing to field and hospital clinicians and staff.

We acknowledge that we may have rushed into adopting reflecting writing activities without adequate preparation and support, which makes this task challenging and equally important. Moreover, we faced significant resistance in training our faculty members due to budgetary constraints, with only a meager $5000 allocated for developing the curriculum of each program. The transformation of a country relies on the advancement of human resources. ²⁴ Therefore, a significant budget allocation must be made for the training and capacity building of faculty members. Nevertheless, we preserved and toiled towards implementing a distinct curriculum in Nepal. Further, our goals were aligned with the strategic vision of the institution's humanistic learning. Hence, we aspire for our experience to reach the relevant authorities in planning and implementing newer pedagogical techniques involved in medical education in the country.

Recommendation for educators: guidance on reflective writing

Although we employed simplified reflective writing guidelines, we highly recommend educators follow more widely adopted the simple cyclical structure of Gibbs reflective cycle model as an easy framework for students to undertake reflective writing. ²⁵ We also recommend tailored adaptation to the reflective writing process to local settings by a thorough understanding of how reflective practices can occur in our context. To ensure culturally responsive adaptations, we should work to develop reflective practices in alignment with the collectivist culture of Nepal. Currently, most of the reflective practices are based on individualistic culture widely practiced in the West. ⁹ Furthermore, literature has highlighted the usefulness of team-based reflection in healthcare settings for quality improvement. The reflective writing practices we have adopted measure the progress of an individual in their learning activity (Individually based). Team-based reflective practices may prove beneficial for a collectivist culture such as ours. In making a collective approach, the team collaboratively interprets and analyzes constructing knowledge through discourse and dialogue. This process allows learners to break free from the singular perspective of an experience, as they engage in dialogic activities that expose them to alternate realities through others’ perspectives. We aspire to implement team-based reflective practices after problem-based learning sessions for students of all semesters and workplace-based learning for students from the final semester. Furthermore, we seek to explore learning opportunities that can incorporate team-based reflective practices. Bjerlöv et al have presented a framework on collective reflection through iterative processes as illustrated in Figure 1.^26,27

Figure 1.

Framework of work-based dialogue on reflective writing adapted from Bjerlöv et al. ²⁸ By the framework of team reflective writing in Figure 1, an individual differentiates different perspectives, which allows the person to decenter oneself and recognize diverse perspectives allowing an individual to resolve issues and generate a new perspective. Incorporating a broader context of immediate importance leads to a formulation of new knowledge and experience. Alteration in understanding may lead to resolution. ²⁸

Conclusion

As educators, we should realize the value of reflective writing and take steps to incorporate it into student's learning experiences. It is particularly valuable in newly established institutions that seek to establish themselves as innovative and forward-thinking. As reflective writing promotes critical thinking, self-awareness, and empathy, institutions can demonstrate their commitment to providing high-quality education that meets the needs of the twenty-first century by integrating reflective writing practices into their curricula. The start of such a curriculum involves many challenges, especially in traditional education settings like Nepal. One of the greatest challenges is resource allocation and resistance from old-school educators. Therefore, to ensure the successful integration of reflective writing into education, educators who are passionate about fostering reflective writing practices must be capable of advocating for resources and gaining support from stakeholders.