Can learning from workplace feedback be enhanced by reflective writing? A realist evaluation in UK undergraduate medical education.

Introduction: Doctors and medical students in the UK are currently required to provide evidence of learning by reflective writing on (among other things) feedback from colleagues. Although the theoretical value of reflecting-on-action is clear, research is still needed to know how to realise the potential of written reflection in medical education. This study arose out of efforts to improve medical student engagement with a reflective writing exercise. We used realist methodology to explain the disinclination of the majority to do written reflection on workplace feedback, and the benefits to the minority.Method: Realist evaluation is a suitable approach to researching complex interventions which have worked for some and not for others. Focus groups were held over a three-year period with year 3 and 4 students. Focus group transcripts were coded for context-mechanism-outcome configurations (the realist approach to analysing data) explaining students' choice not to write a reflection, to write a 'tick-box' reflection or to write for learning. A sub-set of eight students' reflections were also analysed to ascertain evidence of learning through reflection.Results and discussion: 27 students participated in 4 focus groups. Three summary theories emerged showing the importance of context. Firstly, written reflection is effortful and benefits those who invest in it for intrinsic reasons in situations when they need to think more deeply about a learning event. Secondly, following a reflective feedback discussion writing a reflection may add little because the learning has already taken place. Thirdly, external motivation tends to result in writing a 'tick-box' reflection.