Reflective Practice in Physical Therapy: A Scoping Review

Abstract

Background

Many practitioners experience complex, uncertain, and unique clinical practice situations that can be navigated with reflection. Little is known about the theoretical and pragmatic perspectives of reflection in physical therapy.

Purpose

The purpose of this paper was to examine the literature on reflection in physical therapy and identify gaps in the literature.

Data Source

The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, EMBASE, Scopus, and PsycINFO were used to identify articles.

Study Selection

Studies were selected to describe: (1) theoretical concepts related to reflection, (2) examples of reflection, and (3) the use of reflection in clinical or educational contexts.

Data Extraction

Authors, year of publication, country of origin, publication type or source, methodology, conceptual approach (including terminology used, definition of terminology used), and practical approach (including theoretical underpinning, context of reflection/reflective practice, and target group) guided the data extraction.

Data Synthesis

A total of 46 articles were reviewed spanning from 1992 to 2017, which included research studies, field articles, editorials, and a review article. Theoretical underpinnings of reflection were based on the thoughts of Donald Schön. Written approaches to reflection were most common, and reflection was used to inform education, clinical practice, and professional growth.

Limitations

As with any review paper, there is a certain level of interpretation required when collating and interpreting data.

Conclusions

Reflection in physical therapy could be advanced by a thorough conceptualization of reflective practice, a broader and deeper pool of research to inform optimal implementation of reflection across the career span from learners to experts, and a clear definition and linkage of reflection to epistemologies of physical therapy practice.

Donald Schön has conceptualized a reflective practitioner as someone who uses reflection as a means of learning from experiences to advance one's expertise, but also as a means to navigate through the murky, indeterminate grounds of complex problems that arise in professional practice.¹ Schön is a seminal theorist on reflection and coined the term reflective practice. Although there have been other theorists on reflection, Schön will be used as the foundation for the discussion of reflection in professional practice. Schön identifies a crisis in confidence in the professions and attributes it to a growing skepticism about professional effectiveness and professional knowledge.² He discusses how many practitioners experience clinical practice situations that are complex, uncertain, unique, and generally do not fall within the skills and techniques learned through traditional expertise.² Schön and other theorists suggest that although technical rationality is the leading epistemology of practice, technical rationality does not necessarily help a practitioner navigate the murky grounds of complex clinical cases.² It is through reflection that we can begin to acknowledge the practical knowledge gained through professional practice.

Reflection has emerged as a reoccurring theme in many allied health professions in the last several decades.³ Specifically, reflection and reflective practices have been used in nursing,^4,5 occupational therapy,^6,7 and speech language pathology,⁸ among other fields. In physical therapy, reflection has been used improve patient care, better support clinical supervision,⁹ improve collaboration,¹⁰ and advance clinical reasoning.¹¹ However, little is known about how reflection and reflective practice are being adopted in the discipline of physical therapy. Scoping review methodology is appropriate to define the state of the literature in a given field and how a complex topic, like reflection, has been operationalized in the literature. It can be useful to understand how reflective practice has been applied within the profession and to a course and identify gaps that might be addressed to move the field forward.

The purpose of this paper was to identify and describe the nature of current literature on reflection and reflective practices in physical therapy and potential gaps in the research literature.

Methods

This scoping review used the framework proposed by Arksey and O'Malley (2005), with consideration given to suggestions from Levac, Colquhoun, and O'Brien (2010) to guide the methodology. Scoping reviews offer a comprehensive overview of the literature. Scoping reviews broadly identify published evidence and concepts supporting a research area.^12,13 A scoping review was selected for this study as a means of gaining an overview of the scholarly literature available on reflection and reflective practice in the field of physical therapy. Because no systematic reviews have been completed on this topic, this scoping review can provide an overview of key concepts underpinning this area, the main sources of scholarship, and the types of evidence that are available.¹²

Data Sources and Searches

Relevant peer-reviewed articles were identified in a search of several online databases: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, EMBASE, Scopus, and PsycINFO. These databases were purposefully selected for their broad inclusion of allied health care disciplines, including physical therapy. To ensure all relevant studies were captured, manual reference list checks and citation tracking of included studies using Google Scholar were performed. The search terms used to identify relevant studies were [reflection] OR [“reflective practices”] AND [“physical therapy”] OR [physiotherapy]. No restrictions were placed on the date of the study search to ensure inclusion of the full breadth of the literature.

Study Selection

To capture the breadth of the topic area, articles were included if they addressed physical therapy and any of the following: (1) theoretical concepts related to reflection (including key words of reflection or reflective practice), (2) examples of reflective practices or processes, or (3) the use of reflection or reflective practices in clinical or educational contexts. Exclusion criteria were (1) non-English texts, (2) no available full-text article, or (3) did not address physical therapy. See Figure 1 for the PRISMA chart for selection of articles.

Figure 1.

Modified PRISMA chart of article selection and process of conducting a scoping review on reflective practice in physical therapists. The 5 stages depicted on the left side of the figure represent the stages outlined by Arksey and O'Malley for conducting a scoping review (2005, 9. 22 and Stage 5 results on p. 27).

Charting Extraction

A data extraction form was created. The following categories were used to organize the data: authors, year of publication, country of origin, publication type or source, methodology, conceptual approach including terminology used, definition of terminology used, and practical approach including theoretical underpinning, context of reflection/reflective practice, and target group.

Data Synthesis and Analysis

After charting the data, the data were first collated according to the years of publication, countries of origin, sources or types of publication, and methodological approaches used. Frequency within these categories was identified to gain an understanding of the dominant areas of research in terms of intervention, research method, and geographical location. This process informed a broad, descriptive overview of the types of literature that address reflection and reflective practices in physical therapy.

Next, a more in-depth analysis of the literature was conducted to gain insight into the content represented in the review. Thematic content analysis of the articles was the first step in ordering and understanding these data.¹⁴ Terms and emergent themes were observed for patterns, and meaningful data were clustered to enhance data comparison and interpretation. It was necessary to return to the identified articles, re-read, and further extract data to ensure a comprehensive recording of content and themes. These data were charted. The process of thematically reviewing the articles led to a conceptual map of approaches to reflection and reflective practices within the profession of physical therapy and provided context and target populations.

Five themes emerged through the analysis of reflection and reflective practices in physical therapy: (1) identification of terminology used, (2) the methods used to facilitate reflection or reflective practice, (3) the theories and models that informed conceptions of reflection and reflective practices, (4) the purpose for engaging in reflection or reflective practice, and (5) identification of the targeted population.

Role of the Funding Source

The authors received no specific funding for this work.

Results

Distribution of Publications by Year and Country of Origin

The articles analyzed were published between the years 1992 and 2017. Eight of the years had 1 publication, 6 of the years had 2 publications, and the years 2000, 2005, 2006, 2008, 2010, 2011, and 2012 had 3 or more publications within the year (Fig. 2).

Figure 2.

Distribution of publications by year.

The majority of papers were written by scholars in the United States (n = 15), United Kingdom (n = 8), Canada (n = 8), and Australia (n = 6). Three articles were published from scholars in Sweden, and scholars in Norway, Scotland, and United Arab Emirates published 2 articles. Scholars in each of the following countries published 1 article: Belgium, Brazil, Finland, Malaysia, and Portugal (Fig. 3). Three^15–17 of the 46 articles reviewed represented an international collaboration (United Arab Emirates and Canada, and Australia and Canada).

Figure 3.

Distribution of publications by country of origin.

Distribution by Type of Publication

The majority of the reviewed articles were research studies (n = 37). Additionally, there were 5 clinical or field articles,^11,18–21 1 editorial,²² 1 opinion article,²³ 1 program evaluation,²⁴ and 1 review article.²⁵ No theoretical articles were published related to reflection in physical therapy.

Distribution by Type of Methodology

Of the 46 articles retrieved, 31 involved qualitative research approaches, 2 adopted a quantitative approach,^26,27 5 used mixed methods approaches,^9,17,28–30 and 1 was a systematic review.²⁵ The qualitative research methods adopted in the articles were qualitative content analysis (n = 9), case report (n = 3), interviews (n = 1), focus groups (n = 1), phenomenological research (n = 1), grounded theory (n = 3), ethnographic research (n = 1), a reflective paper (n = 1), and a retrospective content analysis (n = 1). Several studies employed multiple methodologies as a means of triangulation (n = 8). The quantitative studies used a test-retest methodology. The mixed methods articles combined interviews and questionnaires (n = 3), content analysis, and questionnaires (n = 2).

Conceptual Approaches: Identification of Terminology Used

Ten different terms related to reflection and reflective practices were identified. Many of the papers used multiple terms to address reflection and reflective practices (41%). The term “reflection” was most commonly used (n = 19, 41%), followed by “reflective practice” (n = 12, 26%). Reflective thinking (n = 6) and critical reflection (n = 11) were also commonly used. Less commonly used terms were self-reflection (n = 4), reflective journal (n = 3), dialogical reflection, reflection-on-practice, reflection-in-action, reflective activity, reflective capacity, reflective process, reflective skills, reflective framework, embedding reflection, collaborative reflection, and reflective writing, which were all terms that appeared to be used in only 1 article.

A variety of definitions related to reflection, reflective practice, or other terms used to represent reflection, with most articles drawing definitions from Schön (Tab. 1).

Table 1.

Conceptual Approaches to Reflection and Reflective Practices

Reference	Year of Publication	Definition
Atkinson and Nixon-Cave38(p419)	2011	“An awareness or analysis of one's own learning or thinking processes."
Bohomol et al24	2016	Not clear
Barredo52	2005	Not clear
Caeiro et al31(p573)	2014	Although a clear definition of reflection was not provided, instructions in the study provided a working definition. Students were encouraged to reflect on inconsistencies between their professional identity, their reasoning approach, and their clinical actions and were invited to challenge and expand on their existing perspectives.
Cambier23	1997	Critical reflection was used in the context of thinking about which methods are used and what value is placed on statistical significance to determine best practice.
Clouder10(p517)	2000	Adapted from Johns73(p23): “Practitioners’ ability to access, make sense of, and learn through work experience to achieve more desirable, effective, and satisfying work.” Reflection is described as a process occurring before and after education programs.
Clouder18(p212)	2000	Adapted from Schön2(p56): “equates critical practice with reflection-in-action, which focuses ‘interactively on the outcomes of action, the action itself, and the intuitive knowing implicit in the action.’”
Clouder and Sellars9(p263)	2004	Adapted from Boud et al74(p19): “Reflection in the context of learning is a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciation.”
Cole and Wessel46(p164)	2008	Adapted from Brookfield75: “Educators reflect on their practice through four lenses: autobiography, learner's eyes, colleagues’ experiences and theoretical literature.”
Constantinou and Kuys28(p49)	2013	Reflective practice was defined to involve “critical thinking with the ability to self-monitor, be self-directive and professionally autonomous.”
Cross32	1993	The reflective practitioner was defined as a “professional activity which values the development of open capacities and aptitudes alongside the simple acquisition of closed terminal competencies and which looks for evidence of quality through such methods as narrative inquiry and action research.”
Cross45(pp375,376)	1997	Although not providing a direct definition of reflection, this author defined continuing professional development (CPD) as: “a systematic educational process entered into by professional practitioners to maintain, enhance and broaden their professional competence” and through CPD themes of organisation, reflection, thinking and accountability emerge. Reflective thinking was defined as: “Reflective thinking is able to inform the other two by having within it the potential for a variety of interrelated functions.”
Donaghy and Morss33(p83)	2007	“Reflective thinking is generally espoused as central to developing one's own complex understandings, such as insight into personal theories about practice, or reviewing clinical experiences and challenging existing practice.”
Donaghy and Morss11	2000	Gathering evidence of reflection to allow knowledge that is normally tacit to become more explicit and available for critical appraisal.
Dunfee et al42(p61)	2008	“Reflective learning [is] a process that requires critical analysis of a situation and the facts presented before drawing conclusions.”
Dunn and Musolino26(p128)	2011	Reflection was defined on the basis of the concepts of Dewey76 as “a systematic, rigorous, disciplined way of thinking that needs to happen in interaction with others … moving the learner from one experience to another, with a deeper understanding of relationships within connections, other experiences, and ideas.”
Dye et al27(p9)	2011	From Donaghy and Morss11: “The higher order intellectual and affective activities in which physiotherapists engage to critically analyze and evaluate their experiences in order to lead to new understandings and appreciation of the way they think and operate in the clinical setting.”
Dyment and O'Connell17	2010	Not clear
Edgar et al34(p147)	2013	“Intentional and skilled activity in which a person analyzes and describes his or her thoughts, actions, feelings, and behaviours and makes judgments about their effectiveness.”
Edwards et al44(p313)	2004	“Clinical Reasoning refers to the thinking and decision-making processes that are used in Clinical Practice. Higgs and Jones have defined clinical reasoning as a process in which the therapist, interacting with the patient and others … helps patients structure meaning, goals, and health management strategies based on clinical data, patient choices, and professional judgement and knowledge.”
Fougner and Kordahl53(p16)	2012	Although not defining reflection specifically, the authors suggested that art (a form of reflective practice) can be used “as a pedagogical tool to develop knowledge about and foster understanding of the importance of observational skills in physiotherapy clinical practice.”
Gibson et al22	2010	Critical theoretical reflection is a tradition in the social sciences of explicitly examining ideas and concepts that are dominant, given, or taken for granted in social institutions and practices, in order to reflect on how “things could be otherwise.”
Gummesson and Nordmark35(p87)	2012	Reflective thinking was defined as “the process of interaction with other physical therapists, [the] need to use clinical reasoning, also regarded as collaborative reasoning, including individual reflections.”
Jensen et al47(p29)	2000	Reflection was used in the context of clinical reasoning; however, neither term was defined. A rationale provided for the project gives some insight into the authors’ operationalized definition: “We know very little about how experts practice in physical therapy, that is, what knowledge they hold, how they engage in clinical reasoning and decision making, and what beliefs and related behaviours they exhibit during their work with patients and families.”
Jensen and Saylor5(p345)	1994	The reflective learning process was defined as the connection between thought and action, theory and practice, the academy and the everyday world.
Jensen et al40(p712)	1992	Adapted from Schön's77 definition of knowledge-in-action, which was described as ‘the knowledge that is embedded in the skilled action of the professional. The challenge for researchers is to “get inside the heads” of practitioners in order to see the world as they see it and understand the manner in which professionals think about, construct and solve clinical problems.’
Jensen30(p2)	2003	Adapted from Dewey78: “The object and reward of learning is continued capacity for growth and that students develop skills and habits of mind that will enhance their creativity and problem solving abilities with respect to the issues they are likely to meet. The tools of ethics include developing habits of thought for reflection on complex, changing situations that are part of everyday practice. Facilitating reflective habits of the mind is a necessary, but difficult challenge in a professional education environment.”
Jensen and Richert41(p79)	2005	From Dewey78 (1916): “The object and reward of learning is continued capacity for growth and that students develop skills and habits of mind that will enhance their creativity and problem-solving abilities with respect to the issues they are likely to meet.”
Kordahl and Fougner48(p206)	2017	Although reflection was not clearly defined, the authors suggested that “evidence-based medicine is the integration of best research evidence with clinical expertise and with patient values … assimilating the philosophy of science into clinical practice provides clinicians with greater insight into the logic that underlies decision-making reasoning and facilitates better approaches in practice.”
Kurunsaari et al50	2015	Not clear
Ladyshewsky and Gardner54(p241)	2008	Reflective practice was not clearly defined, but professional development was suggested to occur by spending “time in novel clinical activities and reflect upon these in order to develop a robust clinical knowledge base.”
Larin et al15	2005	“Reflection is the process where individuals think about and evaluate their experience in order to come to new understandings and appreciations … a process of thinking about experiences … [leading] to a change in perspective or understanding.”
Mann et al25	2009	Adapted from Schön79: The reflective practitioner was defined: “as one who uses reflection as a tool for revisiting experience both to learn from it and for the framing of murky, complex problems of professional practice. Similarly, reflective learning involves the processing of experience in a variety of ways. Learners explore their understanding of their actions and experience, and the impact of these on themselves and others. Meaning is constructed within a community of professional discourse, encouraging learners to achieve and maintain critical control over the more intuitive aspects of their experience.”
Morris and Stew51(p421)	2007	“Three levels of reflection exist. The first most superficial level allows the learner to recall an event while the second enables learners to consider what happened during that event. The third or micro level of reflection encourages learners to make links with prior knowledge, to identify new learning and to make changes to future practice.”
Musolino and Mostrom19(p55)	2005	“Examination of the justification for one's belief, primarily to guide action and to reassess the efficacy of the strategies and procedures used in problem solving.”
Paterson and Chapman21(p3)	2013	From Boud74: Reflection is “consciously looking and thinking about experiences, actions, emotions, feelings, and responses then interpreting them in order to learn from them.”
Plack et al36(p200)	2005	A literature review was conducted to define reflection. One example definition from Schön80 stated that “clinicians, when faced with problems, are often forced to stop, think, and problem solve on the spot … reflective practitioners revisit their experiences through reflection on action, which occurs after action when practitioners attempt to view problems from alternative perspectives.”
Ramli et al56	2012	Not clear
Wainwright et al39	2010	Definition from Schön: Active engagement in intellectual processes, exploration of problems or experiences, and a subsequent changed perspective or new insights.
Walker20(p216)	2006	“A process regarding thinking about and exploring an issue of concern, which is triggered by an experience.”
Ward and Gracey29(pe32)	2006	Adapted from Schön81: “Reflective practice has been espoused as facilitating theory and practice and producing critical thinkers and ‘doers.’”
Wickford and Rosberg55(p285)	2012	Critical theory, inspired by Habermas and cited from Mezirow,82 suggests that “the transformation of our meaning perspectives or frames of reference, [enable] us to broaden our understanding and perspective, to expand what and how we learn.”
Wickford43(p41)	2014	Reflection is viewed as “a cognitive and affective process or activity that (1) requires active engagement on the part of the individual; (2) is triggered by an unusual or perplexing situation or experience; (3) involves examining one's own responses, beliefs, and premises in light of the situation at hand; and (4) results in integration of the new understanding into one's experience.”
Williams and Wessel37	2004	Students record learning events and their reactions to them and reflect on the impact of those events and how they might affect their future, behavior, or learning. Reflection refers to the intellectual and affective activities used by individuals to explore their experiences and come to new understandings and appreciations.
Williams et al57(p5)	2002	Reflection is the “process where individuals think about and evaluate their experience in order to come to new understandings and appreciations.”
Wright and Lundy49(p73e)	2012	“Reflection is the method that intentionally bridges service activities with course content. Through structured reflective communication with others, students make connections between their professional curriculum and real world experiences. It is this critical reflection that allows students to create new meaning from experiences.”

Some articles provided working definitions based on the context of the study. One study, although not providing an explicit definition of reflection, stated that students were encouraged to reflect on inconsistencies between their professional identity, their reasoning approach, and their clinical actions and were invited to challenge and expand on their existing perspectives.^31(p573)

Conceptual Approaches: Theoretical Frameworks That Informed Reflection and Reflective Practices

Of the articles that discussed a theoretical underpinning to their protocol (n = 32, 76%), it seemed there were 2 major categories: articles drawing on important theorists of reflective practices, and articles that drew on a theoretical discipline.

Of the 32 articles that identified a theoretical underpinning, many of them included ideas from Schön (n = 13, 41%).^{5,10,18,25,26,28,32–40} Six articles drew on ideas from Schön, in addition to other theorists in reflective practice such as Dewey,^10,19,33 Habermas,¹⁸ Boud,^25,36 Mezirow,^25,36 and Robertson.¹⁸ Three articles used the theoretical underpinnings of Dewey,^11,30,41 Boyd,²⁰ Jarvis,⁴² and Boud.¹⁷

Several articles used frameworks to conceptualize reflection and reflective practices. Two articles^27,43 drew on the thoughts of Donaghy and Morss^11,33 to advance a reflective framework. Interestingly, Donaghy and Morss used the theoretical underpinnings of seminal thinkers in reflection: Dewey and Schön. Each of the following frameworks was cited as guiding reflective practice: the International Classification of Functioning,³⁸ Schulman's Table of Learning,⁴¹ van Manen's Levels of Reflexivity,¹⁹ Kolb's Cycle of Experiential Learning,²¹ Gibb's Reflective Cycle,²¹ and Schön's model of Reflective Practice.³⁹ Edwards, in 2004, developed a descriptive framework to aid in clinical reasoning strategies.⁴⁴ Jensen, in 1992, also developed a conceptual framework to aid in understanding the physical therapist practice environment.⁴⁰

The purpose of using a framework was identified to help practitioners ask themselves questions to improve their reflective practice,¹⁹ help develop skills of critical reflection,²¹ and improve clinical decision-making.³⁹

Five articles used theoretical disciplines as the theoretical underpinning, including pedagogical;²⁴ phenomenology, hermeneutics, and ideography;³¹ social constructionist;⁹ personal construct theory;⁴⁵ and critical theoretical reflection.²²

Practical Approaches: Context of Reflection

The literature review identified 3 key contexts for engaging in reflection: education of students and practitioners, learning in clinical practice, and professional growth. Some of the articles identified 2 of these categories as reasons for engaging in reflection or reflective practices.

Educational practices were identified as the reason for engaging in reflective practices in 18 of the 46 articles reviewed.^{17,19,20,25,28–30,34,41–43,46–52} Educational context for reflection was most commonly used with physical therapist students and novice practitioners. Many of the studies used reflective practices to teach students or novice practitioners to think about their clinical placement or to consciously understand the value of their learning.^{17,20,24–28,30–33,35,36,41,45,46,48–51,53–55} Specifically, in Cole and Wessel, reflection was used to understand physical therapist students’ perceptions of their learning during their first clinical experience,⁴⁶ and Kurunsaari et al wanted insight into the skills physical therapist students gained in their first year of physical therapist school.⁵⁰ In some articles, however, reflection was used with proficient-expert practitioners to foster better understanding of how effective their communication was with their students.^{19,22,23,29,43,45,52} In one study, proficient-expert practitioners used reflective practices to determine the value of a course or project as a means of changing curriculum to better serve physical therapist students.²⁹

Fostering learning in clinical practice was identified as a reason for physical therapists to engage in reflective practices in 16 of the 46 articles reviewed.^{9,10,15,18,20,21,23,28,31,37–40,42,44,52,56,57} Reflective practices were discussed in the context of encouraging clinicians to learn through work experiences, achieve more effective and satisfying work, and understand the value of experience in advancing clinical knowledge. Constantinou and Kuys²⁸ evaluated physiotherapy students’ guided journals to determine if the journals guided reflective thinking and practice and found that the reflective journals did facilitate reflection. An excerpt from the study highlighted the value of reflective journaling for a student, saying that the journals were a “good way to look at your professional practice to see how you have improved.”^28(p51)

Finally, professional growth was cited as a reason for physical therapists to engage in reflective practices (n = 19).^{5,11,16,17,19,22,25,30,32,33,35,36,43,45,47,53–55,58} Reflection was used to think back on previous cases, identify practices that were successful or unsuccessful, and encourage individual growth within the profession. Gummesson and Nordmark identified themes physical therapists commonly reflected on.³⁵ They found that the themes generally fell into 3 categories: effort-related reflections, which involved the therapist's time management, attitude, motivation, and concentration; goal-oriented reflections, which involved anxiety, test strategies, and selecting main ideas; and cognitive activities, which included information processing, self-testing, and study aids as themes involving reflection.³⁵ Some of the articles used reflection in continuing education so practitioners were required to think back on their practice over the year and assess how they might modify their practice in upcoming years.^{5,19,22,30,43,45,47}

It was of interest to determine whether reflective practice occurred over one time point, such as a discussion, or over time, such as journaling or a written blog. Some studies engaged in one time point of reflection,^{24,31,46,50,53} but most studies suggested reflection over time.^{16,26–28,30,32,33,35,36,41,42,45,48,49,54,55,59} Examples of reflection over time included participating in a questionnaire and reflecting on strategies for reflection, reflective journaling over a school semester, reflective assignments through a course, and blogging. One article sought to specifically evaluate how reflective practices changed over time.¹⁶

Practical Approaches: Outcomes of Reflective Practice

One study noted that written forms of reflection improved clinical reasoning,³¹ while another noted that it enhanced individual learning and aided in practicing empathy.³² However, although not disputing the value of written reflection, one article emphasized the importance of exploring other forms of reflection.¹⁰ Clouder¹⁸ advocates for dialogical reflection, which is a conversation between a novice and proficient-expert practitioner, as a way to improve professional socialization, enhance learning, and facilitate professional awareness.¹⁸

Practical Approaches: The Methods Used to Facilitate Reflection or Reflective Practice

Written reflections were the most commonly reported form of reflective approaches in the field of physical therapy. Written approaches included blogging,^34,49,54 journaling,^{15,17,20,22,27,28,32,36,37,52,56–58} written summaries,^31,35 field notes,^39,55 online discussion boards,⁴² and diaries.^10,55 Many of the aforementioned forms of reflection occurred over time, where participants engaged in several reflections. Several articles discussed other forms of self-reflection, which involved using videos,¹⁸ case reviews,^40,47 portfolios,⁵ narrative reflection,^30,41,43,50 and thinking about past situations,^21,23,44 which often happened at one point in time. One article discussed drawing as an artistic approach to reflection.⁵³ Self-directed reflection, specifically the use of written reflective approaches, was used with physical therapist students to reflect on clinical placements and their educational experience. Three articles discussed a reflective framework^19,43,55 and 7 articles discussed the use of several reflective practices (eg, writing and narrative reasoning): diary and simulated recall,¹⁸ written reflection, and peer-reviewed reflection.^{10,11,21,31,35,39}

Peer-supported approaches to reflection were also discussed. Dialogue,^9,18 peer review,³⁵ online discussion boards,⁴² questionnaires,²⁶ and guided reflection¹¹ were some peer-supported strategies. Novice practitioners were encouraged to gain insight from proficient and expert practitioners on strategies related to reflective practice, where expert practitioners provided feedback to novice practitioners. Small group discussions were encouraged to allow for practitioners of all skill levels to engage in reflective practices. In 5 of the articles, physical therapist students engaged in a reflective practice, which then informed expert practitioners and educators on their teaching and facilitated expert practitioner reflection.^{5,21,39,40,43,45}

Practical Approaches: The Identified Target Group

The target groups identified in the literature were undergraduate and graduate physical therapist students (n = 23), newly graduated physical therapist students (n = 7), physical therapist practitioners (n = 13), physical therapist supervisors (n = 1), physical therapist faculty (n = 1), and other health professionals (n = 1).

Of the 46 articles reviewed, 23 targeted novice-beginner practitioners, 3 articles targeted competent practitioners, and 6 articles targeted proficient-expert practitioners. Eleven articles addressed 2 or more of these stages. For the purposes of this analysis, novice-advanced beginner practitioners included students adhering to taught rules or following guidelines for action in need of supervision; competent practitioners were newly graduated practitioners with good working knowledge who are able to achieve most tasks using their own judgement; and proficient-expert practitioners were experienced practitioners with a deep and tacit understanding of practice.⁸

Discussion

This scoping review identified a small but informative body of literature, primarily qualitative research, that applied analysis of reflection to better understand physical therapist education and practice. The identified articles spanned the years 1993 to 2017, suggesting that reflection has been utilized in the profession for at least 20 years. The countries publishing on reflection within the profession were primarily from the United Kingdom, North America, and Australia, suggesting that reflection may be evidence of maturity in the profession or the publication densities a physical therapist scientists in those areas. Given the 20-year publication span, the number of papers published on this topic suggests that scholarship in this area is sparse. More literature on reflective practice is required. Specifically, exploring the conceptualization of reflection in physical therapists and the methods for fostering reflection skills should be explored in more depth. This review focused on the thoughts provided by Schön; however, other theorists can provide insight into implementing reflective practices in physical therapy, such has Dewey or Boud. The current literature review also identified frameworks for reflection (Donaghy and Morss), which could be utilized to further develop reflective practices in physical therapy. Future literature should explore reflection in proficient-expert practitioners, and the epistemologies of practice for physical therapists should be better understood. Given the lack of quantitative studies on reflection there is a substantial gap in evidence demonstrating the impact of reflection on either learner or patient outcomes. Studies that investigate changes in attitudes, practice behaviors, the effectiveness of clinical interactions, or patient satisfaction might provide quantitative evidence about the impact of reflection. Ultimately, more literature needs to be created in the field of reflection and reflective practice for physical therapists to explore additional modes of reflection and provide guidance on reflection in expert practitioners.

Although the results were interesting and provide insight into the use of reflection and reflective practices in physical therapy, the breadth of the literature is sparse. In fact, 46 articles published over the last 25 years suggest more literature is required to understand reflection in physical therapy. When observing the state of literature across other health professions, like speech language pathology⁸ and occupational therapy,^6,7 more literature is required to understand reflective practices in physical therapy.

Reflection and reflective practice in physical therapy were conceptualized through critical thinking, critical reflection, and reflective journaling most commonly. However, reflection can be much more complex than thinking back on a previous situation and evaluating how it went, and what the outcome of that situation was. Schön's ideas of reflection-in-action and reflection-on-action² were well represented in the literature identified in this scoping review. What was not well discussed in the current literature were the ideas that reflection is iterative and ongoing.⁶⁰ Despite many of the studies engaging in longitudinal reflection, it was not well discussed how the participants learned from previous reflections and how their reflections influenced their practice. None of the studies in this scoping review followed students through several years of education or post-education to assess that reflection was continuing. Further, the studies involving proficient-expert practitioners focused largely on evaluating their teaching methods, rather than facilitating personal reflection on their physical therapist practice. Reflective practices are ongoing and iterative; they should continue throughout a practitioner's career. Reflection tends to decrease with increasing years of practice,⁶¹ potentially due to proficient-expert practitioners having fewer feelings of navigating uncertainty and murky indeterminate grounds compared with novice practitioners. Understanding that reflective practices should occur throughout clinical practice regardless of clinical expertise should be emphasized. It may be that proficient-expert practitioners focus their reflective practices towards perspectives related to clinical biases, awareness of their feelings and attitudes related to clinical decision-making, or being more consciously aware of their clinical practice rather than development of knowledge or skill development, which may be the focus of novice practitioners. As well, learning from other proficient-expert practitioners and sharing personal experiences are some suggestions for continued engagement in reflection.⁶²

One strategy for improving long-term iterative reflection would be to draw on models of reflection. Theorists of reflective practices Boud and Schön focus on learning from experience or doing,¹ whereas Moon's model focuses on a conceptual understanding and meaning making.⁶³ Other researchers have identified models for reflective practice that focus on awareness of what is going on in the moment, and feelings influence behavior and professional identity.⁶⁴ One of the most important factors identified for clinical reasoning were the practitioners themselves.⁶⁵ Self-knowledge and self-awareness of how attitudes and beliefs influence practice are important to consider and identify. Perhaps a focus of reflective practice should be towards identifying clinical biases, which may be identified through personal expressions of reflection.

There appeared to be a lack of personal expression in reflection in the current literature, which may also encourage conceptualization of reflection. Art, poetry,⁶⁶ or other forms of self-expression may expose a new depth and understanding to the practitioner's practice.^67,68 Rather than fostering critical analysis to practice, it may be beneficial to allow the practitioner to first understand their practice, gain a deeper understanding of their self and identify the personal biases they bring to the practice, and then critically analyze and determine how they might change their practice. The college of physical therapists encourages reflection through thinking about what worked well and what did not by exploring, “Next time, I would do this instead.”⁶⁹ Reflection is conceptualized through a reflective cycle, describing how experience, reflection, and goal setting lead to learning activities and learning activities lead to implementing learning, evaluating and reflecting on the outcome, which in turn leads to further experience.⁶⁹ Future reflection studies might evaluate whether the reflective cycle or other expressions of reflection such as art or poetry might be more effective in helping a practitioner to gain an understanding of their practice.

The most common methods for fostering reflective practice identified in the articles were written forms of reflection; however, there may be value in exploring other strategies of reflection. For example, journaling, blogging, writing in a diary, or keeping field notes were common forms of written reflection. In fact, although journaling is commonly used as a means of “reflective practice,” a number of authors have advocated for other approaches to fostering reflection. For example, one article⁵³ in this review identified the value of art as a form of reflective practice. In this study, physical therapist students created a nude drawing as a way of communicating emotions and perspectives regarding the lived experience in clinical practice.⁵³ Art has been used as an expressive tool in other allied health professions as a means to foster reflection on ethical practice.⁶⁷ Seminal philosopher of education John Dewey wrote about the value of art as a means of learning from experience and seeing in new ways.²

We should also acknowledge epistemologies of practice knowledge, where reflection might be used to expose a practitioner's epistemologies of practice. Kinsella (2009) discusses several forms of professional knowledge and the epistemology of reflective practice. The epistemologies of practice within physical therapy were not well explored in the current set of articles. As discussed by Schön, practitioners, over time, develop a tacit and embodied knowledge.^1,2,70 Argyris and Schön⁷² describe tacit knowledge as a type of knowledge that we have but cannot state explicitly. Tacit knowledge, when explored, can provide insight into practitioner's assumptions about themselves, others, and the way they practice. A practitioner can make tacit knowledge explicit by examining their actions in practice and becoming aware of common assumptions and constructions that they place on reality.^71,72

Research Gaps and Future Directions

The following gaps in the research were identified in the current review of the literature:

1. The majority of research on reflection in physical therapy has been qualitative and thus has not provided quantitative evidence on the relative impact of reflection on groups or on specific attitudes, behaviors, or clinical outcomes. Quantitative studies might allow for prediction of who benefits from reflection, predictors of critical appraisal skills, or strategies to enhance reflection.

2. The majority of the articles retrieved in this literature review focused on novice practitioners. With trends to encourage reflective practice as a lifelong approach to practice, more studies are needed on reflection in competent and proficient-expert practitioners.

3. Little research has been conducted on the relative value of different methods of reflection. In most of the articles reviewed, written forms of reflection were adapted. Value could be gained by exploring other forms of reflective practice such as the use of art, small group discussions, or mentoring.

4. Little work has been done exploring the epistemologies of physical therapist practice, which could be advanced through reflective practices.

Strengths and Limitations

There are a few identifiable strengths and limitations to this paper. The paper is the first of its kind to our knowledge to identify the breadth of literature on reflective practice in the field of physical therapy. The paper has begun the process of mapping and analyzing the available literature on reflective practice in physical therapy, but also allows for identification of key gaps in the literature and future directions. Further, a rigorous methodological approach was applied, and results were compiled systematically to present a transparent review of the literature and to increase reliability of the findings. However, as with any review paper, there is a certain level of interpretation required when collating and interpreting data, which presents a potential limitation of this review.

Conclusion

In conclusion, this scoping review examined a total of 46 articles to map the current state of scholarship on reflection and reflective practice in the field of physical therapy. Although reflection in physical therapy is recognized as an important component of practice, the amount of scholarship in this area is relatively limited. Reflection in physical therapy could be advanced by a more thorough conceptualization of reflective practice, a broader and deeper pool of research to inform optimal implementation of reflection across the career span from learners to experts, and a clear definition and linkage of reflection to epistemologies of physical therapist practice.

Author Contributions and Acknowledgments

Concept/idea/research design: C. Ziebart, J.C. MacDermid

Writing: C. Ziebart, J.C. MacDermid

Data collection: C. Ziebart, J.C. MacDermid

Data analysis: C. Ziebart, J.C. MacDermid

Project management: C. Ziebart

We gratefully acknowledge Dr Elizabeth Anne Kinsella for her assistance and feedback on this review.

Funding

Dr MacDermid was supported by a Canadian Institutes of Health Research Chair in Gender, Work, and Health, and the Dr James Roth Chair in Musculoskeletal Measurement and Knowledge Translation.

Disclosures

The authors completed the ICJME Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.