Impact of reflective writing skill on emotional quotient

Abstract

Background

The skill of reflective writing and emotional drivers of behavior is enhanced by boosting the awareness of one's feelings and emotions. Individuals having characteristic activity of reflection have more emotional quotient (EQ). EQ has more significance than intelligence quotient in personal and professional life. This study is conducted to analyze the impact of reflective writing skills on components of EQ among first-year MBBS students and to find out the impact of reflective writing between components of EQ and different levels of reflective writing skills among first-year MBBS students.

Methods

An observational-analytical study was carried out for EQ self-assessment and reflections of first-year MBBS students. A paired t-test was used to check the difference between different segments of EQ. Analysis of reflections was done by modifying the REFLECT rubric method.

Results

There was a significant difference in the motivation component between pre and post-test (p-value = 0.013), whereas no significant difference was observed in other components, viz. self-awareness, empathy, self-control, self-confidence, and social competency. The average total scores among EQ domains compared were more at the level of reflection than habitual and introspection levels.

Conclusion

Along with intelligence quotient, EQ is critical for students' overall development. The average total scores of EQ were higher among the students who had a higher level of reflection. Developing reflective writing skills had an impact on the motivation component of the EQ of the students within a short duration.

Introduction

Reflective writing is a logical approach which helps an individual express any actual or imaginary view or situation by way of thinking, recalling, or explaining it in his/her own way.¹ To become a good doctor, a clinician needs to establish and maintain a good doctor–patient relationship other than through the use of his/her knowledge and skills. Mere knowledge and skills of the medical syllabus cannot make good physicians. As quoted by William Osler, “The good physician treats the disease; the great physician treats the patient who has the disease.” The physician is responsible not only for the physical health of the patient but also for providing psychological support, which in turn depends on his emotional quotient (EQ).² Communication with the patient and their caregivers, empathy, and care toward the patient are major attributes of treatment. Emotional intelligence plays an important role in interpersonal relationships, handling difficult issues and also makes it possible to work in collaboration to treat the patient.³ Emotional intelligence can be defined as the ability to identify, express, understand, manage, and use emotions sensibly.^4,5 Emotional intelligence is measured as an EQ.⁶ A person's EQ determines the development of his attitudes and communication skills.² EQ comprises many subdomains.⁶ Six components used in the present study are self-awareness, empathy, social competency, motivation, self-control, and self-confidence.⁷ Individuals having the characteristic activity of reflective writing have better EQ.

Reflection has been defined by Moon as a set of abilities and skills, to indicate the taking of a critical stance, an orientation to problem-solving, or a state of mind.⁸ Adult learning mainly depends on understanding and evaluating our experiences for better achievement. Reflective writing has been shown to improve problem-solving attitudes by providing a better understanding of oneself, primarily what one already knows (individual), and identifying what one needs to know for a more advanced understanding of the subject (contextual), making sense of new information and feedback from his/her own experience (relational), guiding learning choices (developmental), and managing others.^9,10 Specific approaches for reflective writing with an aligned objective like learning, development of therapeutic relationships, or development of professional practices can improve reflective writing skills.^11,12 Regular reflective writing benefits medical graduates or professionals.¹³

First-year MBBS students usually are at a malleable age making it possible to incorporate reflective writing skills in them at very early professional years. Assessing and enhancing EQ along with knowledge and skills is required for medical graduates to achieve better competence. Evaluating reflective writing skills and their impact on EQ in first-year MBBS students are required. The present study was conducted to analyze the impact of reflective writing skills on the components of EQ among first-year MBBS students and to associate the levels of reflective writing skills with the average scores of components of EQ among first-year MBBS students.

Materials and Methods

The study was a prospective observational analytical type of study conducted at a tertiary care hospital.

The inclusion criteria was all first year MBBS students who were willing to participate and the exclusion criteria was those students who were not willing to take part in the study or who did not return the reflections and feedback within the stipulated time.

Tools used

• •Semi-structured questionnaire for demographic profile (prepared, prevalidated, and then administered) and prevalidated EQ self-assessment checklist by Sterrett.
• •The EQ self-assessment checklist by Sterrett consists of six components, namely self-awareness, empathy, self-control, motivation, self-confidence, and social competency, with 30 statements (5 statements per component).
• •The scoring was done by a total of each score marked on a 5-point Likert scale from 1 as virtually never to 5 as virtually always.

Procedure

This study was conducted in the years 2018–2019. Institutional Ethics Committee permission was obtained before commencing the study. Written informed consent was taken and confidentiality of the participants was maintained throughout the study. After the administration of a semi-structured demographic profile, students were sensitized to reflective writing skills and were informed to write a total of four reflections in any language comfortable to them over six months. Out of four, the first two were video clips on the doctor–patient relationship and the role of the doctor in society, and the latter two were on real incidents faced by them in their lives, viz., teaching–learning methods and terminal examination. After evaluation of each reflection, individual feedback and/or focus group discussion were conducted. At the beginning (before the first reflection) and end of reflections (after the fourth reflection), the EQ self-assessment checklist by Sterrett was administered.

Analysis

Qualitative and quantitative analysis was done

• •The qualitative method for the analysis of the level of reflection used was the REFLECT RUBRIC method. As students were not aware of reflective writing, no concept level was added as per local need where general opinion was given in reflection. Hence, the Modified Reflect Rubric with five levels, viz., no concept, habitual, introspection, reflection, and critical reflection, was considered. Two assessors assessed the reflections separately and where there was a difference of opinion for evaluation, it was discussed by them and unanimously decided on the level of the reflection.
• •The quantitative methods used for analysis were the chi-square test of independence, average scores for each factor of EQ concerning its total EQ score, and the paired t-test. A chi-square test of independence was performed to examine the relationship between gender and the EQ score of participants. Average scores for each factor of EQ concerning its total EQ score were measured before the first reflection and at the end of the fourth reflection. The association between the level of reflection and the EQ score was analyzed. A paired t-test was applied to check the difference in EQ score at the beginning and fourth reflection among all levels of reflection.

Results

Due to the non-availability of all responses (all four reflections were not present) from 13 students, analysis was done for 47 students. It seems that 57% (27 students) were showing habitual reflection, whereas 34% (16 students) were showing no concept of reflective writing skills at the beginning of writing reflection. By comparing average EQ scores based on scores at the beginning and the end of the fourth written reflection of all 47 students, all domains of EQ showed more average scores at the level of reflection than habitual and introspection factors (Table 1, Table 2). None of the students had reflected at the level of critical reflection. The EQ score showed considerable growth, with an increase in the level of reflection. In Table 3, by applying paired t-tests for different components of EQ, it was found that there was a significant difference (p-value 0.013 0.05) in the motivation component between pre- and post-test. Hence, the motivation component showed a significant difference in before and after writing reflections. On a chi-square test of independence (Table 4), it was observed that the EQ score of participants did not differ by gender. This relationship was not significant; X2 (2, n = 47) = 0.1534, p = .9261 > 0.05.

Table 1.

EQ score before the first written reflection.

Reflection level before the first written reflection	Average EQ score
	Self-awareness	Empathy	Self confidence	Motivation	Self-control	Social competency
No Concept (16)	18.3	19.9	17.7	18.7	18.3	17.8
Habitual (27)	17.6	19.3	18.3	18.8	17.1	16.2
Introspection (03)	16	18.3	17.7	18.3	17.3	16.3
Reflection (01)	22	21	8	19	21	21

Table 2.

EQ score at the end of the fourth written reflection.

Reflection level at the end of the fourth written reflection	Average EQ Score
	Self-awareness	Empathy	Self confidence	Motivation	Self-control	Social competency
No Concept (00)	0	0	0	0	0	0
Habitual (15)	17.0	17.3	16.9	16.8	16.3	14.4
Introspection (27)	18.3	20.0	17.4	17.9	17.4	16.6
Reflection (5)	19.2	18.8	19.4	18.6	19.6	19.6

Table 3.

Difference in EQ segment pre and post test scores.

Paired t test	Self awareness	Empathy	Self confidence	Motivation	Self control	Social competency
Test statistic value	−0.312	0.875	1.211	2.598	0.759	1.194
p value	0.756	0.386	0.232	a0.013	0.452	0.238

^aDenotes significant p-value.

Table 4.

Association between gender and average EQ score.

Reflection level at the end of the fourth written reflection	Association between gender and EQ score
	Male	Female	Test statistic	P value
Habitual	7	8	0.153	0.926
Introspection	11	16
Reflection	2	3
TOTAL	20	27

Discussion

It is scientifically proven that in day-to-day life, the EQ is more significant compared to the intelligence quotient.^14,15 The EQ denotes the capability of the individual to manage and deal with the barriers in relationships with other people.¹⁶ It also helps to forecast an individual's professional and personal success.¹⁷ There are different components of EQ, viz. self-awareness, empathy, social competency, motivation, self-control, and self-confidence. These different components are considered to find out the impact of reflective writing skills on EQ. Self-awareness assists in recognizing behavioral and emotional features of the psychological framework.¹⁸ Empathy is the capacity to identify and realize how others are feeling and judge those feelings before reacting in social situations.¹⁹ Social competency consists of social, emotional, cognitive, and behavioral skills needed for successful social adaptation. Motivation is the ability to self-motivate with the goal of achieving inner or personal satisfaction. Self-control which is an aspect of inhibitory control is the ability to regulate one's emotions, thoughts, and behavior in the face of temptations and impulses. Self-confidence is one's ability to judge his own social and personal standing in relation to his environment and be able to derive satisfaction out of it.⁷

Behavioral scientist D. Goleman's EL theory implementation of the hypothetical supposition of EQ was well linked, which emphasizes that one's learning and overall life success are determined by emotional regulation, through self-awareness, social awareness, self-management, and relationship management.²⁰ He had mentioned, “The part of the brain which supports emotional and social intelligence is the last circuitry of the brain to become anatomically mature, and because of neuroplasticity, the brain shapes itself according to repeated experiences."²⁰ Reflective writing plays a role in neuroplasticity due to revisiting experience and analyzing it critically. It improves positive brain mapping, mainly by addressing all the components of the EQ. Training individuals for reflective thinking, learning, and writing skills can manage complexities better with ease and has a role in the growth of people.²¹

In the present study, most of the students were at no concept level before the first written reflection as they had not developed the reflective writing skills. After guiding those for six months with repeated exposure to reflections (four), all the students were sensitized to reflective writing skills and none of the students were at the no concept level after the fourth written reflection. All students developed the skills of reflective writing and had a higher level of reflection. In all written reflections, none of the students reached the level of critical reflection, which is the highest level of reflective writing skills. Critical reflection requires the development of critical analysis and a problem-solving attitude for higher grades, which takes a much longer time for its development.

In our study, we found that there was a significant difference in the motivation component of EQ when we compared different segments of EQ in pre- and post-test. The obtained result is in line with the findings of previous studies by Farrah and Faye et al.^22,23 The present findings might be due to the fact that motivation can improve self-directed learning by increasing resilience, creativity, persistence, performance, and well-being.²⁴ There was no significant change in other components of EQ, viz., empathy, self-control, self-confidence, self-awareness, and social competency in the present study. Though the other components of the EQ do not show statistically significant change, the total average scores of various components show higher scores with the increase in the level of reflection. Because the total number of reflections in each level of reflection is insufficient to compare, generalization of the result for the level of reflection with EQ may be difficult to correlate. A long-term study with an adequate sample size for each type of reflection is needed. Previous scientific information shows mixed opinions regarding the components of EQ and reflective writing. Siraj et al.²⁵ recorded no significant difference, while Misra-Hebart et al.²⁶ recorded a significant difference in self-awareness. Chen et al and Misra-Hebart et al.^13,26 found a significant difference in the empathy factor. Farrah²² recorded a significant difference in self-confidence. Guvenc et al.²¹ recorded a significant difference in self-control. Reflective writing is habitually used to build up the EQ.²⁶ It is an age-dependent socio-cognitive skill due to changes in neural activation.²⁷ This leads to slow attitudinal changes, which may be the reason for the small difference in EQ. Inadequate duration for the habituation of reflective writing may be the reason for no significant results in EQ. The long-term impact needs to be evaluated.

We also attempted to correlate the average EQ score with gender, and it was discovered that the gender of participants and their level of reflection status were not related. Sundararajan et al., Shanmugham, and Lawson et al. all found similar results in their studies.^3,28,29 This finding contradicts the previous research reported by Venkatappa et al. and Aithal et al.^6,30 stating that females had more EI than males.

The present study was conducted for a short time without considering the participants' personal life experiences and personality traits, which can be a major confounding factor for the development of EQ. Personality traits such as attention deficit hyperactivity disorders, attention deficit disorders, or bipolar personality disorders are known to have an impact on the development of problem-solving attitudes. However, further study needs more in-depth exploration in the future. Qualitative analysis by focus group discussion or in-depth interview can be compared with an EQ score and reflection level to reduce these biases.

It can be concluded that the present study shows significant differences in motivation compared to other components of EQ viz self-awareness, empathy, self-confidence, self-control, and social competency. Total EQ score among students with reflection level shows more average than habitual and introspection levels. An increase in the level of reflection improves the total score of EQ which is the need of every individual for personal and professional success. Hence practicing reflective writing with its analysis and appropriate feedback to the medical students should become an integral part of medical education for the holistic development of students as professionals.

Disclosure of competing interest

The authors have none to declare.