Evaluation of family medicine residents’ reflection skills | BMC Medical Education

This research aimed, in its first phase, to adapt the GRAS for Turkish residents. In the second phase, the adapted scale was used to examine the reflection ability scores of FM residents in Turkey across gender, seniority, and institution type.

Scale adaptation

In the first phase, the adapted GRAS-TR-pg scale was administered face-to-face to 230 students receiving specialized training at X University Faculty of Medicine.

Through the data obtained, CFA was employed to assess the construct validity of the original scale, consisting of 23 items and three factors. It was determined that the 20-item, three-factor model achieved an acceptable level of fit after removing only three items from the third dimension. The final GRAS-TR-pg scale consists of 10 items in the first factor, six items in the second factor, and, differing from the original, four items in the third factor. In contrast to our study, Şenol et al.. concluded that a two-factor structure (“Self Reflection” and “Reflective Communication”) is more suitable for Turkish culture [15]. A Danish adaptation study was found that none of the factors adequately explained the variance, particularly the reversed items which performed poorly in the instrument. Consequently, neither the one-factor nor the three-factor structure could be confirmed. Therefore, the researchers recommended postponing the use of GRAS-DK for effect measurements and group comparisons until further review and validation studies are conducted [16].

In Şenol et al.‘s study, the GRAS-TR adapted for undergraduate medical education was validated with 19 items and a two-factor structure by excluding items 7 and 18 from the first factor, item 8 from the second factor, and item 21 from the third factor [15]. In our study, after removing items 3, 4, and 17 from the third sub-factor, a 20-item scale was validated with a three-factor structure, similar to the original scale. It is evident that both the excluded items and the confirmed structures significantly differ in the undergraduate and postgraduate Turkish adaptation studies. This result indicates that the scales function differently in various groups, highlighting the importance of adapting GRAS-TR-pg.

After removing three items, Cronbach’s alpha and McDonald’s omega coefficients were computed to evaluate the reliability. The reliability values obtained for the entire scale and its factors were deemed satisfactory. In Şenol et al..‘s study, Cronbach’s alpha coefficient was also considered adequate [15]. In the Danish adaptation study, the Cronbach’s alpha was found to be 0.87 [16].

The analyses conducted have yielded sufficient evidence for both validity and reliability of the measures obtained from the scale. In essence, the results indicate that the scale, in its final form with three factors and a total of 20 items, can effectively assess the reflective skills of residents and serve as a valid and reliable tool.

Evaluation of FM residents’ reflective abilities

Although Mamede’s study found higher reflection skills among those in Public Health, Pediatrics, and Internal Medicine [3], we selected participants from FM residents in the second phase of our study because FM distinguishes itself by offering continuous primary healthcare regardless of age, gender or disease differentiation [9].

Reflective practices during FM residency enable learners to derive insights from their experiences through retrospective thinking [12]. Teaching reflection to FM residents and integrating it into clinical training promotes lifelong learning [10].

Mamede’s study demonstrated that primary care physicians also working in hospitals scored higher in reflective practice [3]. In Turkey, specialization education is provided in two main institutions: Education and Research Hospitals (ERH) and University Hospitals (UH) [27]. ERH serve a larger and more diverse patient population, offering specialty students greater experience. However, the higher workload can challenge students’ focus on their educational requirements. Additionally, there may be fewer and less experienced instructors. Thus, our study examined whether participants’ reflection scores varied depending on their educational institution. In 2023, during data collection, FM specialization training was available in 31 ERH and 61 UH. We assessed the reflection skills of 336 FM residents from 22 institutions, including eight ERH and 14 UH. However, we found no statistically significant difference in scores, both in sub-factors and the total score.

Mamede’s study reveals a negative correlation between reflective practice and both age and total duration of medical practice. This suggests that as experience grows, engagement in reflective practice tends to decline [3]. As our study focuses on postgraduate education involving FM residents, we examined the effect of the duration of specialization education on reflective skills instead of participants’ professional experience period. However, we found no statistically significant difference in scores based on seniority, both in sub-factors and the total score.

In our study, we also found no statistically significant difference in scores based on gender, both in sub-factors and the total score.

Reflection and medical education

Reflection is essential in medical education. A study indicated that increased reflective capacity greatly influences critical thinking. Environments fostering reflection aid in enhancing reflective capacity and developing critical thinking skills [28]. Another study involving FM residents showed that engaging in reflective activities led to a deeper comprehension of concepts through discussions with mentors and peers. These activities were found to foster the creation of new concepts and their practical implementation, thus promoting professional growth [12]. In another study evaluating the effect of integrating reflective case-based activities into the FM Residency Program curriculum on residents’ perceptions, it was noted that most residents not only enjoyed and found these sessions beneficial but also reported improvements in patient care and increased interest in their medical specialty [11]. Another study assessing how reflection impacts the perception of clinical rotation objectives and the achievement of curriculum goals for obstetrics and gynecology residents revealed that these sessions may enhance awareness of rotation goals and increase the likelihood of successfully achieving them [29].

Reflection significantly impacts all stages of medical education. In a study conducted in Denmark, it was found that undergraduate medical students who participated in an elective course with the most comprehensive abstract learning outcomes achieved significantly higher scores compared to students in other elective courses [16].

Our research introduced a Turkish-adapted reflection scale for postgraduate medical education, examining its psychometric properties. Originally developed in the Netherlands, this scale has been adapted to various languages and cultures, facilitating cross-cultural comparisons. Additionally, data from our study emphasize the necessity of instilling reflective skills and conducting more comprehensive assessments of reflection within postgraduate education. Furthermore, there may be a need to develop reflection scale studies that can be used across other specialties in postgraduate education.

Strengths and limitations

Among the strengths of the study is the inclusion of participants from various disciplines in the first phase through the face-to-face administration of the scale, providing a broader perspective. However, the limitation of data collection being confined to a single institution is acknowledged. In the second phase, the inclusion of participants from different institutions at the national level increased the diversity of the data obtained. Nonetheless, the inability to reach all institutions may pose a limitation in terms of representation. Technical issues during the online form administration could have affected participation, thus limiting the generalizability of the results. Additionally, self-reported data from participants might impact the objectivity of the collected data. The online survey administration process may also influence participants’ motivation to engage.