Reflection as a learning strategy for the training of nurses in clinical practice setting: a scoping review

The objective of this review is to identify and map the tools and approaches used for reflection as a learning strategy for nurses and nursing students in clinical settings.

Several types of reflection interventions exist to develop nurses' reflective competencies in clinical practice. This scoping review mapped the available literature on the use of reflection in the education of nurses and nursing students in clinical settings. Three questions guided the review: i) What tools and approaches for reflection have been reported? ii) What levels of reflection have been identified (low/descriptive, middle/application, or high/evaluative)? iii) What outcomes of reflection have been reported?

Studies investigated nursing students or nurses working in clinical settings involved in patient care, and described reflective interventions and definitions of reflection, descriptions of the contents reflected on, measurement instruments, and outcomes of interventions.

MEDLINE (PubMed), Emcare (Ovid), MEDLINE (Ovid), ERIC (ProQuest), CINAHL (Ovid), and Web of Science databases were searched for full-text studies published in English, Danish, Swedish, or Norwegian. Studies from any country and published from 2007 to September 2020 were eligible for inclusion. The review followed the JBI methodology for scoping reviews and was based on an a priori protocol. Two independent reviewers assessed studies against the inclusion criteria and extracted data. Inclusion for review was determined according to the pre-determined eligibility criteria and consensus between researchers. Data were extracted using a standardized data extraction table and results were summarized narratively with accompanying tables.

Seventeen articles were included; nine quantitative studies and eight qualitative studies. Findings are presented separately due to varying study designs and outcomes. Most studies used physical tools and reflective dialogues in clinical settings. Some tools included specific questions for participants to reflect on, while others included open questions or no questions. Reflective approaches included lectures, workshops, or reflection with supervisors or peers in clinical settings. None of the 17 studies included the same combination of tools and approaches. Measurement of reflection was varied across articles, and there was a lack of standardization in how reflection outcomes were classified.

Interventions, tools, approaches, and the measurement of nurses' reflection in clinical settings are highly varied, and none of the included studies had the same combination of elements. The studies indicate that reflection skills are achieved potentially according to the tools and approaches used, and the foci for reflection. There is little agreement among the research community on how best to assess the measurement and quality of reflection. It is recommended that future studies are explicit on the classification of low-, middle-, and high-level reflection according to standardized criteria.