European Journal of Dental Education ISSN 1396-5883
Using discussion groups as a strategy for postgraduate implant dentistry students to reflect S. Koole1, P. Fine2 and H. De Bruyn1,3 1 2 3
Department of Periodontology and Oral Implantology, Faculty of Medicine and Health Sciences, Dental School, Ghent University, Ghent, Belgium, Department of Continuing Professional Development, UCL Eastman Dental Institute, London, UK, € University, Malmo €, Sweden Department of Prosthodontics, Faculty of Odontology, School of Dentistry, Malmo
keywords postgraduate education; implant dentistry; reflection. Correspondence Dr. Sebastiaan Koole Department of Periodontology and Oral Implantology Faculty of Medicine and Health Sciences Ghent University Hospital De Pintelaan 185 – 1P8 9000 Ghent Belgium Tel: +32 9 3324017 Fax: +32 9 3321526 e-mail: [email protected] Accepted: 16 March 2015 doi: 10.1111/eje.12148
Abstract Introduction: More than undergraduates, postgraduate students have the day-to-day clinical experience to reflect upon. Nevertheless, reflection in postgraduate dental education is less well studied. Hence, the purpose was to investigate the attitude towards reflection and the content of reflections in postgraduate implant dentistry education in the UK and Belgium. Materials and Methods: To investigate the attitude towards reflection, a questionnaire was administered to the 10 postgraduates at UCL Eastman Dental Institute (EDI) and 6 postgraduates at Ghent University (UGent). Additionally, students were invited to attend two reflective sessions (60-90 minutes). The sessions’ audio recordings were transcribed and analysed using a thematic approach. Results: In total, 16 postgraduate implant dentistry students participated. Although the majority reported prior experience with reflection, there was variation in the provided definitions of reflection. EDI students agreed with reflection being beneficial for professional development/clinical reasoning and were positive about discussing clinical experiences in groups, but were divided about individual/group reflections. Their UGent counterparts were more indecisive (=neutral), but were positive about discussing clinical experiences. Thematic analysis identified recurring themes as individual learning process, learning and clinical experiences, attitude towards implant dentistry and course programme. EDI postgraduates’ reflections focussed on specific clinical situations, while UGent postgraduates’ reflections described general considerations. Conclusion: Although students/professionals often report to reflect, it is not clear whether/how they actually reflect, due to the all-purpose word reflection has become. A strategy, using group discussions along with supervision/guidance in how to reflect, demonstrated to expand clinical reasoning into reflections about postgraduate students’ clinical actions and professional growth.
Introduction Reflection is considered as a valuable attribute for professional growth in healthcare practitioners (1). It involves a metacognitive process characterised by the awareness of own experiences, critical analysis and purposeful outcome (2). Systematic reflection on experiences facilitates professionals to understand their own actions and reactions of others, to identify gaps in their ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 59–64
knowledge and skills and to direct their individual learning trajectory, enabling continuous improvement and maintaining high-quality standards of care (1, 3–5). Reflection, or looking in the mirror, was initially approached as an individual process of thought. At present, an alternative viewpoint has emerged, advocating that reflections also have to be shared (6). Beneficial to this approach is that by including other persons and their perspectives, a large and rich 59
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environment is created in which reflections can be developed. Paradoxically, it can be said that through others, a person learns about himself (7, 8). Furthermore, other individuals can actively facilitate the process of critical analysis by posing thought-provoking questions and stimulate the identification of individual learning goals (1, 2). In literature, multiple studies have reported about the use of reflection in undergraduate dental education. In portfolio learning, Koole et al. (9) demonstrated a relationship between reflection and the acquirement of competences in social dentistry and oral health promotion. Boyd (10) reported a growth in reflective thinking in undergraduate dental students during the first year of clinical training, using an approach of journal writing and semi-structured interviewing. On the introduction of reflective education, by means of written reflections in a portfolio and mentor group discussions, Bush and Bissel (11) described that students expressed a dislike of writing reflections, rather than reflecting itself. Moreover, they were positive about the group discussions and having a mentor. In their reflections, undergraduate students are limited to their experiences during (clinical) training or have to rely on presented situations in clinical cases (12). In contrast to this, postgraduate students are equipped with additional experience of treating patients on a daily basis, in a clinical practice and/ or during their clinically orientated postgraduate training programme. These experiences are perfect to reflect upon. Consequently, postgraduate students are ideally placed to reflect as experiences trigger reflections (2, 13). It is therefore striking that to our knowledge, reflection in postgraduate dental education has been less well investigated. The use of oral implants is increasing and offers a valuable treatment alternative for the replacement of missing teeth in full or partially edentulous patients. Implant dentistry is not considered as a specialty, but can be described as the totality of clinical activities related to dental implants (14). Postgraduate implant dentistry programmes in Europe range from 1 year half-time to multiple years of full-time education, in which postgraduate dental students and dental professionals are educated in implant therapy (15, 16). This study is purposed to describe a strategy of interaction to stimulate reflections in postgraduate implant dentistry students in the UK and Belgium, to analyse their attitude towards reflection and to investigate the content of their reflections. To structure this explorative study, two research questions (RQ) were adopted: RQ1: What attitude have postgraduate implant dentistry students in the UK and Belgium towards reflection? RQ2: What are the main themes of reflections by dental implant students in the UK and Belgium, during their postgraduate training?
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Materials and methods To investigate the reflections of postgraduate dental implant students within a broad perspective, two institutions with a similar educational programme in the UK and Belgium were included. It was felt that postgraduate courses in implant dentistry were appropriate for this study as they were self-contained courses and were aimed at postgraduate students who 60
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were interested in furthering their knowledge and skills. Furthermore, they were willing to be investigated. UCL Eastman Dental Institute (EDI) offers a 3 year parttime curriculum. The programme is built around six core modules (Table 1) and is focussed on patient selection, diagnosis, treatment planning, implant surgery, restorative aspects of implant dentistry, patient care and practice management. Ghent University (UGent) has a 2 year part-time modular programme, containing 6 modules (Table 1). Taught topics include evidence-based implant dentistry, indications and contra indications, implant configurations/connections, anatomy and osseointegration, basic surgery, treatment planning, temporary and definitive restorations, coordination of multidisciplinary treatment and guided surgery techniques. Both EDI and UGent provide theoretical, preclinical and clinical education, including interactive lectures, seminars, hands-on training, live surgery and supervised clinical treatment. At EDI as well as UGent, the programme leads to a postgraduate diploma. In response to the research questions, a collaborative study was performed including two cohorts of students both in the clinical phase of their training. A questionnaire was developed to identify the characteristics of each cohort and attitude towards reflection. The questionnaire requested information on (i) age, (ii) experience as a dental professional, (iii) past experience of reflective education either as undergraduates or postgraduates, and (iv) attitude towards reflection. Items i-iii were open-ended questions. Item iv contained four statements that had to be scored on a three-point scale (disagree–neutral– agree). All items were reviewed on ambiguity of questions by experts on reflection and implant dentistry in both institutes. All postgraduate students in the participating study programmes were asked to complete the questionnaire. In the second phase of the study, students were invited to participate in two reflective sessions (60–90 min), facilitated by an expert on reflective learning (PF and SK). During the session a semi-structured format was used, agreed on by the researchers at both institutes (Table 2). This format included open-ended questions starting from clinical experiences and facilitating reflection, characterised by the awareness of experiences, critical analysis and a purposeful outcome (2). Prior verbal consent for audio records of reflective sessions was sort and granted by all participants. Afterwards the audio tapes were transcribed and analysed using a thematic approach. The thematic approach to qualitative data analysis develops three stages: characterise, cutting and coding (17). Characterise is very much up to the researcher to decide what data are important to record. Cutting is the process whereby the researcher cuts data into meaningful segments. Segments can be a word, a sentence, a paragraph or a whole text. Coding being the process by which the researcher has begun to notice behaviours, strategies, states of mind, meanings, patterns, relationships, interactions and/or consequences.
Results In total, 16 postgraduate students took part in the reflective sessions (EDI n = 10, UGent n = 6), representing a participation rate of 100% and 75%, respectively. The average age of the students at EDI was 33 years (range 27–51) and at UGent ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 59–64
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TABLE 1. Overview of both modular postgraduate implant dentistry programmes at UCL Eastman Dental Institute (UK) and Ghent University (Belgium) UCL Eastman Dental Institute Implant Dentistry Postgraduate Diploma
Ghent University Postgraduate Studies in Oral Implantology
Implant Science 1 Anatomy, local diseases that will affect implant treatment, basic componentry and implant design, wound healing, implant materials, surgical implant treatment and principles, pharmacology, and laboratory stages in preparation for implant placement (e.g. wax ups, stents) Implant Planning Patient assessment, special tests/imaging and their interpretation, diagnosis, treatment planning and specifics of implant planning
Introduction Evidence-based dentistry; statistics; literature search, osseointegration, implants (configuration, connection and surface); anatomical structures
Implant Science 2 Applied dental materials (e.g. abutment and restorative materials), screw mechanics, implant restorative procedures, restorative laboratory procedures, maintenance, guided surgery/computer aided planning, augmentation procedures, complications and their management Implant Practical Case assessment, laboratory stages, hands-on phantom head implant placement and restorative procedures Implant Clinical 1 and Implant Clinical 2 Patient selection and planning, lab procedures, implant surgery, prosthetics, maintenance, case discussion and documentation of cases with photos and video
26 years (range 25–30). The students at EDI were more experienced than their counterparts at UGent, with an average professional experience of 12 years (range 4–28) and 2 years (range 1–5), respectively. When asked about previous experience of reflective learning, 60% (n = 6) of the graduates at EDI reported previous experience of reflective learning either as undergraduates or postgraduates. The reflection took place both as a planned event in conjunction with a taught programme or as a result of the realisation that a treatment had been unsatisfactory. In the latter case, reflection was undertaken as a strategy to identify the reasons for the outcome and how to improve clinical actions in the future. At UGent, 67% (n = 4) of the students reported experience with reflection but none of them in a structured format as part of an educational programme. As dental professionals, they all reported to use reflection as a method to improve practice on an individual basis (n = 3) and/or with colleagues (n = 2). Although the majority of participants reported to reflect, only EDI students had a structural background, while prior experience with reflection in UGent students could be characterised as non-educational, unstructured and predominantly associated with clinical aspects. Participants’ attitude towards reflection was investigated by asking the participant to describe their definition of reflection and to respond to four statements about reflection and professional development, clinical reasoning and group aspects. Each participant provided a different definition. Although similarities could be identified, variance in focus was obvious. ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 59–64
Therapy planning and patient selection (Contra-) indications; aesthetics, radiological screening, presurgical planning and surgical templates; extraction management; restoration, endodontic treatment, extraction or implant; treatment of periodontal patients Surgical procedures Basic principles; incision and suturing; diagnostics; medication, sterile and aseptic aspects; immediate/delayed placement; single; full arch (fixed and removable)
Prosthetic procedures Impression techniques; single; full arch; cement or screw retained; platform switching; occlusion and articulation; dental laboratory Maintenance and advanced implant procedures Post-operative care and oral hygiene; smoking; peri-implantitis; risk patients; immediate placement and loading; hard tissue augmentation; sinus grafting; soft tissue augmentation Clinical training Supervised diagnostics, planning and placement of implants
Reported definitions of reflection at EDI included looking back at what had been previously achieved particularly in the clinical setting, considering the value of studying and how to improve a clinical procedure, particularly if that procedure had fallen short of the expectations of the clinician. This type of reflection was seen as a positive approach to learning and a desire to improve as a result of analysis of one’s strengths and weaknesses. Participants at UGent defined reflection as a sort of feedback in which positives and negatives are discussed, allowing to question your work and yourself, to be honest with yourself and to learn from mistakes and to use personal experience and experiences by others to deepen and expand knowledge about dentistry. The responses to the statements in the questionnaire are presented in Table 3. Students at EDI identified reflection as beneficial for professional development and clinical reasoning. A majority of postgraduates at UGent answered neutral. Students at both institutes welcomed the possibility to discuss clinical experiences in group. Nevertheless, whether reflections should be individual or in group, the answers did not provide a clear view. Postgraduates at EDI responded almost evenly between the answer options, and at UGent, all reactions were neutral. Thematic analysis resulted in six main themes in reflections by the participants at EDI, individual learning process, experience (learning), time, familiarity with materials and equipment, new techniques and concerns and importance. At UGent, four main themes could be identified including individual learning process, experience (clinical situation), attitudes towards implant dentistry and course programme. The main themes 61
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TABLE 2. Semi-structured format used to facilitate postgraduate students’ reflections during the group sessions, based on questions related to the process of reflection
undertone and described more general considerations without a direct link towards a specific clinical experience.
Reflective component
Discussion
Awareness of experiences/ educational context
Analysis of experiences/ educational context
Outcome
Question Please describe what happened during your clinical practice in implant dentistry. Were there any critical incidents? How do you feel about your clinical activities, satisfied/ not satisfied, why? What did you want to learn and why? What feedback did you received in the past period? Did you agree? Considering your clinical activities, what could you have done to have a better outcome? Do you feel you have sufficient knowledge – skills to perform implant dentistry, if yes what are key features, if not what do you still need? If you have seen your peers and/or supervisors perform implant dentistry, what features are really good (would you like to copy) or the opposite. Please describe and provide arguments. What do you think are the characteristics of a good implant professional? What specific items to you want to learn in the upcoming period and why do you want to learn them? Do you have a plan to achieve these learning goals? Considering your clinical activities – What are you proud of? Still needs improvement? About what (clinical) aspects do you wish feedback in the upcoming period and why?
TABLE 3. Participants’ reactions (frequency) to the items in the questionnaire about attitude towards reflection. Results are displayed for participants at UCL Eastman Dental Institute (EDI) and Ghent University (UGent). Not all participants answered all items Item
Institute
Disagree
Neutral
Agree
Reflection is necessary for professional development Reflection is beneficial to clinical reasoning Discussing clinical experiences in groups is a welcome aspect of the course I would prefer to reflect as an individual
EDI UGent
1 0
0 3
8 2
EDI UGent EDI UGent
0 0 0 0
1 3 1 0
9 1 8 5
EDI UGent
3 0
2 5
4 0
and quotes derived from the reflective group sessions in both institutes are depicted in Table 4. In general, the reflections at EDI could be characterised as clinically orientated, focussed on detailed technical features/situations and problem-related aspects. Opposed to these practical-orientated reflections at EDI were more vision-related reflections at UGent. These reflections had a philosophic 62
In reaction to the minimal literature on reflection in postgraduate dental education, the present study was conducted to investigate the attitude and the content of reflections amongst postgraduate implant dentistry students. Results demonstrated that the majority of participants reported to reflect upon experiences. Nevertheless, with various interpretations, the term has become an all-purpose word, with an unclear meaning. The attitude towards reflection differed between both student groups. EDI postgraduates acknowledged the benefit to reflect for professional development and clinical reasoning and were positive about discussing clinical experiences in group, but were divided about individual or group reflections. UGent students answered more neutral, but were also positive about clinical experience group discussions. Furthermore, reflections in the EDI group were more practical orientated, while the UGent reflections had a more philosophical undertone. Thematic analysis, however, identified the individual learning process, learning and clinical experiences, vision on implant dentistry and the course programme as recurring topics. The attitude towards reflection found in the present study is in line with the literature, which identifies divergence in definition as an important barrier to improve the understandings about reflection (2, 18, 19). As a result, most dental professionals will report that they do reflect. The question that is raised, however, is what they actually do and how they do it. Some professionals will engage themselves in a process of solely clinical reasoning without any link to personal development, while others believe reflection is an automatic and unconscious activity. To overcome this problem, professionals need to be educated, providing handles to engage in efficient reflection. Ideally, this strategy starts in undergraduate education, teaching students about the process of reflection and how to reflect (20). This should include learning to take a step aside and to create an overview of one’s own actions and practice, learning to critically question experiences and learning to use the outcome of reflections to improve (2). While students progress through the continuum of education, gradually a shift of focus should take place from the process of reflection towards the content and its impact for the reflecting individual. The present study group sessions were used as a format to facilitate reflection in postgraduate students. Departing from their clinical experiences, participants were eager to explore, analyse and discuss their inner thoughts and feelings. Nevertheless, in general, there was a distinct focus on reflections. Reflections in the EDI group were directed towards specific and detailed clinical situations. Reflections in de UGent group, although starting from experiences, ended in more general comments. In literature, outcomes of reflections have been described as single loop and double loop learning, arisen from Argyris and Sch€ on’s theory of action (21). Single loop learning is focussed on alternative actions to obtain a certain result (instrumental problem-solving). Double loop learning tries to understand the mechanism behind the actions and solutions. The overhand in clinical experience and previous encounters with reflective education may have caused ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 59–64
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TABLE 4. Main themes and quotes from postgraduate implant dentistry students at UCL Eastman Dental Institute and Ghent University during two reflective group sessions UCL Eastman Dental Institute
Ghent University
Individual learning process Gains confidence as the programme developed A better view on the individual’s limitations Need for mentoring during clinical training Reflective sessions to enhance clinical reasoning and to heighten discussions on clinical experience
Individual learning process I feel I need between 50 and 200 cases to acquire sufficient experience Step by step without skipping one Not being afraid is not smart I rate myself between 2 and 5 on a scale of 10 Important to identify difficult cases to avoid being a cowboy Experience is key! Feedback is paramount A starting practitioner checks everything five times Experience (clinical situation) Supervision is crucial Be aware of anatomical variance Stress (yourself – patients) Additional training required for difficult cases The problem of dropping an implant Pain is criterion patient satisfaction Aggressive patients? Correct position of implant ‘Safe’ educational institute vs private practice Mental preparation patients gum incision/drilling Easy cases: single, non-aesthetic, enough bone, healthy critical patient Reason for implants is important for treatment planning Attitudes towards implant dentistry No 100% success guarantee Surprised by complexity of implant dentistry Patients that refuse to pay the bill Peri-implantitis remains a difficult topic Finance is important aspect Aesthetics is hard to predict Still today implant dentistry has limitations Course programme Reason to start programme: to identify indications for implant therapy, treatment of simple cases, a first step towards difficult cases 2 year programme is too short to acquire the experience to treat patients without supervision Hard to find suitable cases in my private practice Preclinical training (to feel on a model) is important New situation when performing treatment in educational clinic (chairs, material, logistics, . . .)
Experience (learning) Had to repeat impression four times Learned a lot about healing abutments It was a good learning curve I would check the depth of the margin in future I have learnt a couple of things that I should have known Useful to learn how to deal with problems We know what to look for now Need feedback on everything To have all the correct components Time Better preparation before appointment Took quite a while to get impression correct Familiarity with materials and equipment How does the torque wrench work? The prosthetic screwdriver has a hole in the handle for floss, which is good Nobel equipment does not need a locating jig, unlike Ankylos, which has no anti-rotational slots There are two sizes of screws in fixture head New techniques Protecting the screw head with cotton wool Replace healing collar whilst working on adjacent teeth Modifying tooth anatomy on provisionals Use of jig to locate abutment Need to improve impression technique Special tray is a lot easier than stock tray Use of composite in impression technique Only thin layer of cement needed Concerns and importance Inflamed gingivae and oral hygiene need to improve Importance of occlusion Can never have too much experience Struggled to get large tray into mouth Teeth need to be dry for impression
the reflections in the EDI group to be more instrumental. The lesser experienced UGent students may have discussed lesser experiences in their sessions, but more in-depth and in a more general approach. Secondly, the reflective sessions at EDI and UGent were guided by two different supervisors. Although the same semi-structured format was used, it may have been possible that they influenced the reflections by the additional questions they posed during the sessions. The development of competence in implant dentistry was an issue in both student groups, as expected. Supervision and ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 59–64
feedback were identified as key factors in this process. Efficient supervision was characterised by Subramanian et al. (22) to include mentoring, visual demonstrations, ongoing support, availability and approachability of staff. This suggests the need for faculty staff not only to be competent in clinical aspects, but also to develop didactic skills and even the skills to facilitate student reflections and reflective practice (23). Schaub-de Jong et al. (24) identified teachers’ competencies for facilitating reflective learning as supporting self-insight, creating a safe environment and encouraging self-regulation. Open questions 63
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are an important tool for a supervisor to facilitate reflection, stimulating students to create a broad awareness, critically analyse experiences and to consider alternative actions (23). Furthermore, feedback can also facilitate reflection, especially when the received feedback is inconsistent with the student’s self-perceptions. Alternatively, it has also been suggested that reflection has a pivotal role in the acceptance of feedback and its integration in clinical practice (25). To create an efficient learning environment, a supervisor should be able to stimulate reflections and provide feedback. Not every supervisor may be suitable for this job or at least require training. In addition to guidance across the postgraduate curriculum, both groups of postgraduate students reported a need for longterm supervision beyond the confines of the course and the possibility of ongoing mentoring. Dentistry and implant dentistry in particular seem to demand a level of continued support by teaching staff and the possibility of regular alumni meetings which would allow the cohorts to come together, discuss current issues, exchange experiences and receive up-to-date information. Perhaps mentors should be prepared to go to individual practices and assist with complex cases. Interestingly, reflections were also about knowing your limitations. Implant dentistry is not considered as a speciality (26). Consequently, dental professionals with various educational backgrounds are allowed to practice implant therapy. Within this context, it is important that practitioners know what they can do and even more important what they cannot do, to establish a safe clinical environment. As one postgraduate student mentioned: ‘It is important to identify difficult cases to avoid being a cowboy!’. Clearly with relatively small numbers in this study, results should be interpreted with restraint and cannot be generalised automatically. Nevertheless, this collaborative study involved two postgraduate student groups in different countries, each with its own specific context concerning organisation of education and dental care. Even with these differences, results demonstrated remarkable parallels between the groups and the reflections provide an fascinating insight in the considerations of postgraduate implant dentistry students. Future research should focus on the methods to educate/ facilitate reflection in postgraduate dental education. Furthermore, it would be interesting to investigate how a strategy of systematic reflections about (clinical) experiences impact learning and practice in dentistry. In conclusion, although students/professionals often report to reflect, it is not clear whether/how they actually reflect, due to the all-purpose word reflection has become. A strategy, using group discussions along with supervision/guidance in how to reflect, demonstrated to expand clinical reasoning into reflections about postgraduate students’ clinical actions and professional growth.
References 1 Plack MM, Greenberg L. The reflective practitioner: reaching for excellence in practice. Pediatrics 2005: 116: 1546–1552. 2 Koole S, Dornan T, Aper L, et al. Factors confounding the assessment of reflection: a critical review. BMC Med Educ 2011: 11: 104.
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3 Sch€ on DA. The reflective practitioner: how professionals think in action. New York: Basic Books, 1983. 4 Sch€ on DA. Educating the reflective practitioner. San Francisco: Jossey-Bass Inc., Publishers, 1987. 5 Boud D, Keogh R, Walker D. Reflection: turning experience into learning. London: Kogan Page, 1985. 6 Lockyer J, Gondocz ST, Thivierge RL. Knowledge translation: the role and place of practice reflection. J Contin Educ Health Prof 2004: 24: 50–56. 7 Eva KW, Regehr G. Self-assessment in the health professions: a reformulation and research agenda. Acad Med 2005: 80: S46–S54. 8 Sandars J. The use of reflection in medical education: AMEE Guide No. 44. Med Teach 2009: 31: 685–695. 9 Koole S, Vanobbergen J, De Visschere L, Aper L, Dornan T, Derese A. The influence of reflection on portfolio learning in undergraduate dental education. Eur J Dent Educ 2013: 17: e93–e99. 10 Boyd LD. Development of reflective judgement in the pre-doctoral dental clinical curriculum. Eur J Dent Educ 2008: 12: 149–158. 11 Bush H, Bissell V. The evaluation of an approach to reflective learning in the undergraduate dental curriculum. Eur J Dent Educ 2008: 12: 103–110. 12 Koole S, De Wever B, Aper L, Vervaeke S, Derese A, De Bruyn H. Using online periodontal case-based discussions to synchronize theoretical and clinical undergraduate dental education. Eur J Dent Educ 2012: 16: 52–58. 13 Korthagen FAJ, Kessels JPAM. Linking theory and practice: changing the pedagogy of teacher education. Educ Res. 1999: 28: 4–17. 14 Mattheos N, De Bruyn H, Hultin M, et al. Developing implant dentistry education in Europe: the continuum from undergraduate to postgraduate education and continuing professional development. Eur J Dent Educ 2014: 18(Suppl. 1): 3–10. 15 De Bruyn H, Koole S, Mattheos N, Lang K. A survey on undergraduate implant dentistry education in Europe. Eur J Dent Educ 2009: 13(Suppl. 1): 3–9. 16 Koole S, Vandeweghe S, Mattheos N, De Bruyn H. Implant dentistry education in Europe: 5 years after the Association for Dental Education in Europe consensus report. Eur J Dent Educ 2014: 18(Suppl. 1): 43–51. 17 Savin-Baden M, Howell-Major C. Qualitative research. The essential guide to theory and practice. 1st Ed. London and New York: Sage, 2013. 18 Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ 2009: 14: 595–621. 19 Aronson L. Twelve tips for teaching reflection at all levels of medical education. Med Teach 2011: 33: 200–205. 20 Bourner T. Assessing reflective learning. Educ Train 2003: 45: 267–272. 21 Greenwood J. The role of reflection in single and double loop learning. J Adv Nurs 1998: 27: 1048–1053. 22 Subramanian J, Anderson VR, Morgaine KC, Thomson WM. Effective and ineffective supervision in postgraduate dental education: a qualitative study. Eur J Dent Educ 2013: 17: e142–e150. 23 Driessen E, van Tartwijk J, Dornan T. The self critical doctor: helping students become more reflective. BMJ 2008: 336: 827–830. 24 Schaub-de Jong MA, Sch€ onrock-Adema J, Dekker H, Verkerk M, Cohen-Schotanus J. Development of a student rating scale to evaluate teachers’ competencies for facilitating reflective learning. Med Educ 2011: 45: 155–165. 25 Sargeant JM, Mann KV, van der Vleuten CP, Metsemakers JF. Reflection: a link between receiving and using assessment feedback. Adv Health Sci Educ 2009: 14: 399–410. 26 Mattheos N, Wismeijer D, Shapira L. Implant dentistry in postgraduate university education. Present conditions, potential, limitations and future trends. Eur J Dent Educ 2014: 18(Suppl. 1): 24–32.
ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 59–64
Using discussion groups as a strategy for postgraduate implant dentistry students to reflect S. Koole1, P. Fine2 and H. De Bruyn1,3 1 2 3
Department of Periodontology and Oral Implantology, Faculty of Medicine and Health Sciences, Dental School, Ghent University, Ghent, Belgium, Department of Continuing Professional Development, UCL Eastman Dental Institute, London, UK, € University, Malmo €, Sweden Department of Prosthodontics, Faculty of Odontology, School of Dentistry, Malmo
keywords postgraduate education; implant dentistry; reflection. Correspondence Dr. Sebastiaan Koole Department of Periodontology and Oral Implantology Faculty of Medicine and Health Sciences Ghent University Hospital De Pintelaan 185 – 1P8 9000 Ghent Belgium Tel: +32 9 3324017 Fax: +32 9 3321526 e-mail: [email protected] Accepted: 16 March 2015 doi: 10.1111/eje.12148
Abstract Introduction: More than undergraduates, postgraduate students have the day-to-day clinical experience to reflect upon. Nevertheless, reflection in postgraduate dental education is less well studied. Hence, the purpose was to investigate the attitude towards reflection and the content of reflections in postgraduate implant dentistry education in the UK and Belgium. Materials and Methods: To investigate the attitude towards reflection, a questionnaire was administered to the 10 postgraduates at UCL Eastman Dental Institute (EDI) and 6 postgraduates at Ghent University (UGent). Additionally, students were invited to attend two reflective sessions (60-90 minutes). The sessions’ audio recordings were transcribed and analysed using a thematic approach. Results: In total, 16 postgraduate implant dentistry students participated. Although the majority reported prior experience with reflection, there was variation in the provided definitions of reflection. EDI students agreed with reflection being beneficial for professional development/clinical reasoning and were positive about discussing clinical experiences in groups, but were divided about individual/group reflections. Their UGent counterparts were more indecisive (=neutral), but were positive about discussing clinical experiences. Thematic analysis identified recurring themes as individual learning process, learning and clinical experiences, attitude towards implant dentistry and course programme. EDI postgraduates’ reflections focussed on specific clinical situations, while UGent postgraduates’ reflections described general considerations. Conclusion: Although students/professionals often report to reflect, it is not clear whether/how they actually reflect, due to the all-purpose word reflection has become. A strategy, using group discussions along with supervision/guidance in how to reflect, demonstrated to expand clinical reasoning into reflections about postgraduate students’ clinical actions and professional growth.
Introduction Reflection is considered as a valuable attribute for professional growth in healthcare practitioners (1). It involves a metacognitive process characterised by the awareness of own experiences, critical analysis and purposeful outcome (2). Systematic reflection on experiences facilitates professionals to understand their own actions and reactions of others, to identify gaps in their ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 59–64
knowledge and skills and to direct their individual learning trajectory, enabling continuous improvement and maintaining high-quality standards of care (1, 3–5). Reflection, or looking in the mirror, was initially approached as an individual process of thought. At present, an alternative viewpoint has emerged, advocating that reflections also have to be shared (6). Beneficial to this approach is that by including other persons and their perspectives, a large and rich 59
Reflection in postgraduate implant dentistry
environment is created in which reflections can be developed. Paradoxically, it can be said that through others, a person learns about himself (7, 8). Furthermore, other individuals can actively facilitate the process of critical analysis by posing thought-provoking questions and stimulate the identification of individual learning goals (1, 2). In literature, multiple studies have reported about the use of reflection in undergraduate dental education. In portfolio learning, Koole et al. (9) demonstrated a relationship between reflection and the acquirement of competences in social dentistry and oral health promotion. Boyd (10) reported a growth in reflective thinking in undergraduate dental students during the first year of clinical training, using an approach of journal writing and semi-structured interviewing. On the introduction of reflective education, by means of written reflections in a portfolio and mentor group discussions, Bush and Bissel (11) described that students expressed a dislike of writing reflections, rather than reflecting itself. Moreover, they were positive about the group discussions and having a mentor. In their reflections, undergraduate students are limited to their experiences during (clinical) training or have to rely on presented situations in clinical cases (12). In contrast to this, postgraduate students are equipped with additional experience of treating patients on a daily basis, in a clinical practice and/ or during their clinically orientated postgraduate training programme. These experiences are perfect to reflect upon. Consequently, postgraduate students are ideally placed to reflect as experiences trigger reflections (2, 13). It is therefore striking that to our knowledge, reflection in postgraduate dental education has been less well investigated. The use of oral implants is increasing and offers a valuable treatment alternative for the replacement of missing teeth in full or partially edentulous patients. Implant dentistry is not considered as a specialty, but can be described as the totality of clinical activities related to dental implants (14). Postgraduate implant dentistry programmes in Europe range from 1 year half-time to multiple years of full-time education, in which postgraduate dental students and dental professionals are educated in implant therapy (15, 16). This study is purposed to describe a strategy of interaction to stimulate reflections in postgraduate implant dentistry students in the UK and Belgium, to analyse their attitude towards reflection and to investigate the content of their reflections. To structure this explorative study, two research questions (RQ) were adopted: RQ1: What attitude have postgraduate implant dentistry students in the UK and Belgium towards reflection? RQ2: What are the main themes of reflections by dental implant students in the UK and Belgium, during their postgraduate training?
• •
Materials and methods To investigate the reflections of postgraduate dental implant students within a broad perspective, two institutions with a similar educational programme in the UK and Belgium were included. It was felt that postgraduate courses in implant dentistry were appropriate for this study as they were self-contained courses and were aimed at postgraduate students who 60
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were interested in furthering their knowledge and skills. Furthermore, they were willing to be investigated. UCL Eastman Dental Institute (EDI) offers a 3 year parttime curriculum. The programme is built around six core modules (Table 1) and is focussed on patient selection, diagnosis, treatment planning, implant surgery, restorative aspects of implant dentistry, patient care and practice management. Ghent University (UGent) has a 2 year part-time modular programme, containing 6 modules (Table 1). Taught topics include evidence-based implant dentistry, indications and contra indications, implant configurations/connections, anatomy and osseointegration, basic surgery, treatment planning, temporary and definitive restorations, coordination of multidisciplinary treatment and guided surgery techniques. Both EDI and UGent provide theoretical, preclinical and clinical education, including interactive lectures, seminars, hands-on training, live surgery and supervised clinical treatment. At EDI as well as UGent, the programme leads to a postgraduate diploma. In response to the research questions, a collaborative study was performed including two cohorts of students both in the clinical phase of their training. A questionnaire was developed to identify the characteristics of each cohort and attitude towards reflection. The questionnaire requested information on (i) age, (ii) experience as a dental professional, (iii) past experience of reflective education either as undergraduates or postgraduates, and (iv) attitude towards reflection. Items i-iii were open-ended questions. Item iv contained four statements that had to be scored on a three-point scale (disagree–neutral– agree). All items were reviewed on ambiguity of questions by experts on reflection and implant dentistry in both institutes. All postgraduate students in the participating study programmes were asked to complete the questionnaire. In the second phase of the study, students were invited to participate in two reflective sessions (60–90 min), facilitated by an expert on reflective learning (PF and SK). During the session a semi-structured format was used, agreed on by the researchers at both institutes (Table 2). This format included open-ended questions starting from clinical experiences and facilitating reflection, characterised by the awareness of experiences, critical analysis and a purposeful outcome (2). Prior verbal consent for audio records of reflective sessions was sort and granted by all participants. Afterwards the audio tapes were transcribed and analysed using a thematic approach. The thematic approach to qualitative data analysis develops three stages: characterise, cutting and coding (17). Characterise is very much up to the researcher to decide what data are important to record. Cutting is the process whereby the researcher cuts data into meaningful segments. Segments can be a word, a sentence, a paragraph or a whole text. Coding being the process by which the researcher has begun to notice behaviours, strategies, states of mind, meanings, patterns, relationships, interactions and/or consequences.
Results In total, 16 postgraduate students took part in the reflective sessions (EDI n = 10, UGent n = 6), representing a participation rate of 100% and 75%, respectively. The average age of the students at EDI was 33 years (range 27–51) and at UGent ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 59–64
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TABLE 1. Overview of both modular postgraduate implant dentistry programmes at UCL Eastman Dental Institute (UK) and Ghent University (Belgium) UCL Eastman Dental Institute Implant Dentistry Postgraduate Diploma
Ghent University Postgraduate Studies in Oral Implantology
Implant Science 1 Anatomy, local diseases that will affect implant treatment, basic componentry and implant design, wound healing, implant materials, surgical implant treatment and principles, pharmacology, and laboratory stages in preparation for implant placement (e.g. wax ups, stents) Implant Planning Patient assessment, special tests/imaging and their interpretation, diagnosis, treatment planning and specifics of implant planning
Introduction Evidence-based dentistry; statistics; literature search, osseointegration, implants (configuration, connection and surface); anatomical structures
Implant Science 2 Applied dental materials (e.g. abutment and restorative materials), screw mechanics, implant restorative procedures, restorative laboratory procedures, maintenance, guided surgery/computer aided planning, augmentation procedures, complications and their management Implant Practical Case assessment, laboratory stages, hands-on phantom head implant placement and restorative procedures Implant Clinical 1 and Implant Clinical 2 Patient selection and planning, lab procedures, implant surgery, prosthetics, maintenance, case discussion and documentation of cases with photos and video
26 years (range 25–30). The students at EDI were more experienced than their counterparts at UGent, with an average professional experience of 12 years (range 4–28) and 2 years (range 1–5), respectively. When asked about previous experience of reflective learning, 60% (n = 6) of the graduates at EDI reported previous experience of reflective learning either as undergraduates or postgraduates. The reflection took place both as a planned event in conjunction with a taught programme or as a result of the realisation that a treatment had been unsatisfactory. In the latter case, reflection was undertaken as a strategy to identify the reasons for the outcome and how to improve clinical actions in the future. At UGent, 67% (n = 4) of the students reported experience with reflection but none of them in a structured format as part of an educational programme. As dental professionals, they all reported to use reflection as a method to improve practice on an individual basis (n = 3) and/or with colleagues (n = 2). Although the majority of participants reported to reflect, only EDI students had a structural background, while prior experience with reflection in UGent students could be characterised as non-educational, unstructured and predominantly associated with clinical aspects. Participants’ attitude towards reflection was investigated by asking the participant to describe their definition of reflection and to respond to four statements about reflection and professional development, clinical reasoning and group aspects. Each participant provided a different definition. Although similarities could be identified, variance in focus was obvious. ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 59–64
Therapy planning and patient selection (Contra-) indications; aesthetics, radiological screening, presurgical planning and surgical templates; extraction management; restoration, endodontic treatment, extraction or implant; treatment of periodontal patients Surgical procedures Basic principles; incision and suturing; diagnostics; medication, sterile and aseptic aspects; immediate/delayed placement; single; full arch (fixed and removable)
Prosthetic procedures Impression techniques; single; full arch; cement or screw retained; platform switching; occlusion and articulation; dental laboratory Maintenance and advanced implant procedures Post-operative care and oral hygiene; smoking; peri-implantitis; risk patients; immediate placement and loading; hard tissue augmentation; sinus grafting; soft tissue augmentation Clinical training Supervised diagnostics, planning and placement of implants
Reported definitions of reflection at EDI included looking back at what had been previously achieved particularly in the clinical setting, considering the value of studying and how to improve a clinical procedure, particularly if that procedure had fallen short of the expectations of the clinician. This type of reflection was seen as a positive approach to learning and a desire to improve as a result of analysis of one’s strengths and weaknesses. Participants at UGent defined reflection as a sort of feedback in which positives and negatives are discussed, allowing to question your work and yourself, to be honest with yourself and to learn from mistakes and to use personal experience and experiences by others to deepen and expand knowledge about dentistry. The responses to the statements in the questionnaire are presented in Table 3. Students at EDI identified reflection as beneficial for professional development and clinical reasoning. A majority of postgraduates at UGent answered neutral. Students at both institutes welcomed the possibility to discuss clinical experiences in group. Nevertheless, whether reflections should be individual or in group, the answers did not provide a clear view. Postgraduates at EDI responded almost evenly between the answer options, and at UGent, all reactions were neutral. Thematic analysis resulted in six main themes in reflections by the participants at EDI, individual learning process, experience (learning), time, familiarity with materials and equipment, new techniques and concerns and importance. At UGent, four main themes could be identified including individual learning process, experience (clinical situation), attitudes towards implant dentistry and course programme. The main themes 61
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TABLE 2. Semi-structured format used to facilitate postgraduate students’ reflections during the group sessions, based on questions related to the process of reflection
undertone and described more general considerations without a direct link towards a specific clinical experience.
Reflective component
Discussion
Awareness of experiences/ educational context
Analysis of experiences/ educational context
Outcome
Question Please describe what happened during your clinical practice in implant dentistry. Were there any critical incidents? How do you feel about your clinical activities, satisfied/ not satisfied, why? What did you want to learn and why? What feedback did you received in the past period? Did you agree? Considering your clinical activities, what could you have done to have a better outcome? Do you feel you have sufficient knowledge – skills to perform implant dentistry, if yes what are key features, if not what do you still need? If you have seen your peers and/or supervisors perform implant dentistry, what features are really good (would you like to copy) or the opposite. Please describe and provide arguments. What do you think are the characteristics of a good implant professional? What specific items to you want to learn in the upcoming period and why do you want to learn them? Do you have a plan to achieve these learning goals? Considering your clinical activities – What are you proud of? Still needs improvement? About what (clinical) aspects do you wish feedback in the upcoming period and why?
TABLE 3. Participants’ reactions (frequency) to the items in the questionnaire about attitude towards reflection. Results are displayed for participants at UCL Eastman Dental Institute (EDI) and Ghent University (UGent). Not all participants answered all items Item
Institute
Disagree
Neutral
Agree
Reflection is necessary for professional development Reflection is beneficial to clinical reasoning Discussing clinical experiences in groups is a welcome aspect of the course I would prefer to reflect as an individual
EDI UGent
1 0
0 3
8 2
EDI UGent EDI UGent
0 0 0 0
1 3 1 0
9 1 8 5
EDI UGent
3 0
2 5
4 0
and quotes derived from the reflective group sessions in both institutes are depicted in Table 4. In general, the reflections at EDI could be characterised as clinically orientated, focussed on detailed technical features/situations and problem-related aspects. Opposed to these practical-orientated reflections at EDI were more vision-related reflections at UGent. These reflections had a philosophic 62
In reaction to the minimal literature on reflection in postgraduate dental education, the present study was conducted to investigate the attitude and the content of reflections amongst postgraduate implant dentistry students. Results demonstrated that the majority of participants reported to reflect upon experiences. Nevertheless, with various interpretations, the term has become an all-purpose word, with an unclear meaning. The attitude towards reflection differed between both student groups. EDI postgraduates acknowledged the benefit to reflect for professional development and clinical reasoning and were positive about discussing clinical experiences in group, but were divided about individual or group reflections. UGent students answered more neutral, but were also positive about clinical experience group discussions. Furthermore, reflections in the EDI group were more practical orientated, while the UGent reflections had a more philosophical undertone. Thematic analysis, however, identified the individual learning process, learning and clinical experiences, vision on implant dentistry and the course programme as recurring topics. The attitude towards reflection found in the present study is in line with the literature, which identifies divergence in definition as an important barrier to improve the understandings about reflection (2, 18, 19). As a result, most dental professionals will report that they do reflect. The question that is raised, however, is what they actually do and how they do it. Some professionals will engage themselves in a process of solely clinical reasoning without any link to personal development, while others believe reflection is an automatic and unconscious activity. To overcome this problem, professionals need to be educated, providing handles to engage in efficient reflection. Ideally, this strategy starts in undergraduate education, teaching students about the process of reflection and how to reflect (20). This should include learning to take a step aside and to create an overview of one’s own actions and practice, learning to critically question experiences and learning to use the outcome of reflections to improve (2). While students progress through the continuum of education, gradually a shift of focus should take place from the process of reflection towards the content and its impact for the reflecting individual. The present study group sessions were used as a format to facilitate reflection in postgraduate students. Departing from their clinical experiences, participants were eager to explore, analyse and discuss their inner thoughts and feelings. Nevertheless, in general, there was a distinct focus on reflections. Reflections in the EDI group were directed towards specific and detailed clinical situations. Reflections in de UGent group, although starting from experiences, ended in more general comments. In literature, outcomes of reflections have been described as single loop and double loop learning, arisen from Argyris and Sch€ on’s theory of action (21). Single loop learning is focussed on alternative actions to obtain a certain result (instrumental problem-solving). Double loop learning tries to understand the mechanism behind the actions and solutions. The overhand in clinical experience and previous encounters with reflective education may have caused ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 59–64
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TABLE 4. Main themes and quotes from postgraduate implant dentistry students at UCL Eastman Dental Institute and Ghent University during two reflective group sessions UCL Eastman Dental Institute
Ghent University
Individual learning process Gains confidence as the programme developed A better view on the individual’s limitations Need for mentoring during clinical training Reflective sessions to enhance clinical reasoning and to heighten discussions on clinical experience
Individual learning process I feel I need between 50 and 200 cases to acquire sufficient experience Step by step without skipping one Not being afraid is not smart I rate myself between 2 and 5 on a scale of 10 Important to identify difficult cases to avoid being a cowboy Experience is key! Feedback is paramount A starting practitioner checks everything five times Experience (clinical situation) Supervision is crucial Be aware of anatomical variance Stress (yourself – patients) Additional training required for difficult cases The problem of dropping an implant Pain is criterion patient satisfaction Aggressive patients? Correct position of implant ‘Safe’ educational institute vs private practice Mental preparation patients gum incision/drilling Easy cases: single, non-aesthetic, enough bone, healthy critical patient Reason for implants is important for treatment planning Attitudes towards implant dentistry No 100% success guarantee Surprised by complexity of implant dentistry Patients that refuse to pay the bill Peri-implantitis remains a difficult topic Finance is important aspect Aesthetics is hard to predict Still today implant dentistry has limitations Course programme Reason to start programme: to identify indications for implant therapy, treatment of simple cases, a first step towards difficult cases 2 year programme is too short to acquire the experience to treat patients without supervision Hard to find suitable cases in my private practice Preclinical training (to feel on a model) is important New situation when performing treatment in educational clinic (chairs, material, logistics, . . .)
Experience (learning) Had to repeat impression four times Learned a lot about healing abutments It was a good learning curve I would check the depth of the margin in future I have learnt a couple of things that I should have known Useful to learn how to deal with problems We know what to look for now Need feedback on everything To have all the correct components Time Better preparation before appointment Took quite a while to get impression correct Familiarity with materials and equipment How does the torque wrench work? The prosthetic screwdriver has a hole in the handle for floss, which is good Nobel equipment does not need a locating jig, unlike Ankylos, which has no anti-rotational slots There are two sizes of screws in fixture head New techniques Protecting the screw head with cotton wool Replace healing collar whilst working on adjacent teeth Modifying tooth anatomy on provisionals Use of jig to locate abutment Need to improve impression technique Special tray is a lot easier than stock tray Use of composite in impression technique Only thin layer of cement needed Concerns and importance Inflamed gingivae and oral hygiene need to improve Importance of occlusion Can never have too much experience Struggled to get large tray into mouth Teeth need to be dry for impression
the reflections in the EDI group to be more instrumental. The lesser experienced UGent students may have discussed lesser experiences in their sessions, but more in-depth and in a more general approach. Secondly, the reflective sessions at EDI and UGent were guided by two different supervisors. Although the same semi-structured format was used, it may have been possible that they influenced the reflections by the additional questions they posed during the sessions. The development of competence in implant dentistry was an issue in both student groups, as expected. Supervision and ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 59–64
feedback were identified as key factors in this process. Efficient supervision was characterised by Subramanian et al. (22) to include mentoring, visual demonstrations, ongoing support, availability and approachability of staff. This suggests the need for faculty staff not only to be competent in clinical aspects, but also to develop didactic skills and even the skills to facilitate student reflections and reflective practice (23). Schaub-de Jong et al. (24) identified teachers’ competencies for facilitating reflective learning as supporting self-insight, creating a safe environment and encouraging self-regulation. Open questions 63
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are an important tool for a supervisor to facilitate reflection, stimulating students to create a broad awareness, critically analyse experiences and to consider alternative actions (23). Furthermore, feedback can also facilitate reflection, especially when the received feedback is inconsistent with the student’s self-perceptions. Alternatively, it has also been suggested that reflection has a pivotal role in the acceptance of feedback and its integration in clinical practice (25). To create an efficient learning environment, a supervisor should be able to stimulate reflections and provide feedback. Not every supervisor may be suitable for this job or at least require training. In addition to guidance across the postgraduate curriculum, both groups of postgraduate students reported a need for longterm supervision beyond the confines of the course and the possibility of ongoing mentoring. Dentistry and implant dentistry in particular seem to demand a level of continued support by teaching staff and the possibility of regular alumni meetings which would allow the cohorts to come together, discuss current issues, exchange experiences and receive up-to-date information. Perhaps mentors should be prepared to go to individual practices and assist with complex cases. Interestingly, reflections were also about knowing your limitations. Implant dentistry is not considered as a speciality (26). Consequently, dental professionals with various educational backgrounds are allowed to practice implant therapy. Within this context, it is important that practitioners know what they can do and even more important what they cannot do, to establish a safe clinical environment. As one postgraduate student mentioned: ‘It is important to identify difficult cases to avoid being a cowboy!’. Clearly with relatively small numbers in this study, results should be interpreted with restraint and cannot be generalised automatically. Nevertheless, this collaborative study involved two postgraduate student groups in different countries, each with its own specific context concerning organisation of education and dental care. Even with these differences, results demonstrated remarkable parallels between the groups and the reflections provide an fascinating insight in the considerations of postgraduate implant dentistry students. Future research should focus on the methods to educate/ facilitate reflection in postgraduate dental education. Furthermore, it would be interesting to investigate how a strategy of systematic reflections about (clinical) experiences impact learning and practice in dentistry. In conclusion, although students/professionals often report to reflect, it is not clear whether/how they actually reflect, due to the all-purpose word reflection has become. A strategy, using group discussions along with supervision/guidance in how to reflect, demonstrated to expand clinical reasoning into reflections about postgraduate students’ clinical actions and professional growth.
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