Document Type : Original Article


Department of Internal Medicine, Research Center of Gastroenterology, Isfahan University of Medical Sciences, Isfahan, Iran


CONTEXT: Reflection is a learnable process that enhances long‑life learning, clinical decision‑making,
and can foster empathy and professionalism. One of the methods for teaching reflection is “reflective
writing” that is conducted in “reflective practice.” Some tools have been developed to assess “reflective
capacity,” and The Reflection Evaluation for Learners’ Enhanced Competencies Tool (REFLECT)
is one of them.
AIMS: This study aimed to adapt the REFLECT rubric in Persian.
SETTINGS AND DESIGN: This quantitative study was conducted in a medical school with the
participation of medical interns through census sampling, and in three stages, including translation,
pilot study, and main study.
SUBJECTS AND METHODS: Persian translation was obtained by the “forward/backward translation”
method. We made some changes in the tool and used it in the pilot and main study to confirm validity
and reliability.
STATISTICAL ANALYSIS USED: Cronbach’s alpha coefficient, Pearson correlation, and Cohen’s
kappa were applied for statistical analysis. Data analysis was performed using SPSS23.
RESULTS: We inserted a numerical value of 1–4 at the reflection levels, and also removed Axis 2 and
an optional writing component. In the pilot study, face and content validity was confirmed involving
10 interns and five medical education specialists. Then, 67 interns participated in the main study,
and we measured the reliability of the tool by internal consistency through Cronbach’s alpha (0.83)
and test‑retest through correlation coefficient (0.89). The size of the agreement was measured to
determine the inter‑rater reliability by Cohen’s kappa (0.84).
CONCLUSIONS: The modified REFLECT version is a valid and reliable tool that can help us to
assess reflective capacity. The use of this tool is recommended for reflective practice in medicine.


1. Coulehan J, Granek IA. Commentary: “I hope i’ll continue to
grow”: Rubrics and reflective writing in medical education. Acad
Med 2012;87:8‑10.
2. Bolton G. Boundaries of humanities: Writing medical humanities.
Arts and Humanit High Educ 2008;7:131‑48.
3. Sandars J. The use of reflection in medical education: AMEE guide
no 44. Med Teach 2009;31:685‑95.
4. Santen SA, Hemphill RR. A window on professionalism in the
emergency department through medical student narratives. Ann
Emerg Med 2011;58:288‑94.
5. Tsingos C, Bosnic‑Anticevich S, Lonie JM, Smith L. A model for
assessing reflective practices in pharmacy education. Am J Pharm
Educ 2015;79:124.
6. Tsingos C, Bosnic‑Anticevich S, Smith L. Reflective practice
and its implications for pharmacy education. Am J Pharm Educ
7. Bryan CS, Babelay AM. Building character: A model for reflective
practice. Acad Med 2009;84:1283‑8.
8. Karkabi K, Wald HS, Cohen Castel O. The use of abstract paintings
and narratives to foster reflective capacity in medical educators:
A multinational faculty development workshop. Med Humanit
9. Epstein RM, Hundert EM. Defining and assessing professional
competence. J Am Med Assoc 2002;287:226‑35.
10. Wald HS, Borkan JM, TaylorJS, Anthony D, Reis SP. Fostering and
evaluating reflective capacity in medical education: Developing
the REFLECT rubric for assessing reflective writing. Acad Med
11. LevineRB, KernDE, Wright SM. The impact of prompted narrative
writing during internship on reflective practice: A qualitative
study. Adv Health Sci Educ Theory Pract 2008;13:723‑33.
12. Brady DW, Corbie‑Smith G, Branch WT. “What’s important
to you?” the use of narratives to promote self‑reflection and to
understand the experiences of medical residents. Ann Intern Med
13. Kumagai AK. A conceptual framework for the use of illness
narratives in medical education. Acad Med 2008;83:653‑8.
14. WangW. Students’ perceptions of rubric‑referenced peer feedback
on EFL writing: A longitudinal inquiry. Assess Writ 2014;19:80‑96.
15. Wald HS, Reis SP, Borkan JM. Reflection rubric development:
Evaluating medical students’ reflective writing. Med Educ
16. Wetmore AO, Boyd LD, Bowen DM, Pattillo RE. Reflective blogs
in clinical education to promote critical thinking in dental hygiene
students. J Dent Educ 2010;74:1337‑50.
17. O’Sullivan P, Aronson L, Chittenden E, Niehaus B, Learman L.
Reflective ability rubric and user guide. MedEdPORTAL. 2010;6:8133.https://‑8265.8133
18. McNeill H, Brown JM, Shaw NJ. First year specialist trainees’
engagement with reflective practice in the e‑portfolio. Adv Health
Sci Educ Theory Pract 2010;15:547‑58.
19. Kember D, McKay J, Sinclair K, WongFKY. A four‐category
scheme for coding and assessing the level of reflection in written
work. Assess Eval High Educ 2008;33:369‑79.
20. Devlin MJ, Mutnick A, Balmer D, Richards BF. Clerkship‑based
reflective writing: A rubric for feedback. Med Educ 2010;44:1143‑4.
21. Mezirow J. Transformative Dimensions of Adult Learning.
Jossey‑Bass, 350 Sansome Street, San Francisco, CA 94104‑1310;
22. Boud D, Keogh R, Walker D. Promoting reflection in learning:
A model. Boundaries of Adult Learn 1996;1:32‑56.
23. Chirema KD. The use of reflective journals in the promotion of
reflection and learning in post‑registration nursing students.
Nurse Educ Today 2007;27:192‑202.
24. Wong FK, Kember D, Chung LY, Yan L. Assessing the level
of student reflection from reflective journals. J Adv Nurs
25. Butani L, Blankenburg R, Long M. Stimulating reflective practice
among your learners. Pediatrics 2013;131:204‑6.
26. Tsingos‑Lucas C, Bosnic‑Anticevich S, Schneider CR, Smith L.
Using reflective writing as a predictor of academic success in
different assessment formats. Am J Pharm Educ 2017;81:8.
27. Kember D, Leung DY, Jones A, et al. Development of a
questionnaire to measure the level of reflective thinking. Assess
Eval High Educ 2000;25:381‑95.
28. Mann K, Gordon J, MacLeod A. Reflection and reflective practice
in health professions education: A systematic review. Adv Health
Sci Educ Theory Pract 2009;14:595‑621.
29. Hoffman LA, Shew RL, Vu TR, Brokaw JJ, FrankelRM. Is reflective
ability associated with professionalism lapses during medical
school? Acad Med 2016;91:853‑7.
30. TraceyMW, HutchinsonA, GrzebykTQ. Instructional designers as
reflective practitioners: developing professional identity through
reflection. Educ Technol Res Develop 2014;62:315‑34. Available
from:‑014‑9334‑9. [Accessed
4 Oct 2019.]
31. Patterson A, Sharek D, Hennessy M, Phillips M, Schofield S.
Medical humanities: A closer look at learning. Med Humanit
32. Huang CD, Liao KC, Chung FT, Tseng HM, Fang JT, Lii SC, et al.
Different perceptions of narrative medicine between Western and
Chinese medicine students. BMC Med Educ 2017;17:85.
33. Miller‑Kuhlmann R, O’Sullivan PS, Aronson L. Essential steps in
developing best practices to assess reflective skill: A comparison
of two rubrics. Med Teach 2016;38:75‑81.