Reflective writing in undergraduate medical education: A qualitative review from the field of psychiatry

Abstract The aim of this study was to identify the types of reflective writing produced by a cohort of medical students undertaking a clinical psychiatry module as part of their undergraduate medical programme at a University in the Republic of Ireland. A random sample of 80 reflective essays were selected for review. These assignments were evaluated using a comprehensive content analysis process with a pre-determined reflective writing coding instrument and coding protocol. Dialogic reflection was the most common type of reflective writing identified, with 56.3% (n = 45) of the summative assignments categorised as such. Twenty five percent (n = 20) of the assignments were classified as descriptive reflection, while 18.8% (n = 15) of the assignments demonstrated critical reflection. Overall, the findings of the study indicate that this innovative programme was successful in fostering and developing reflective writing in medical students to quite an advanced level. The paper concludes with specific recommendations for facilitating reflective writing in professional and higher education.


Abstract:
The aim of this study was to identify the types of reflective writing produced by a cohort of medical students undertaking a clinical psychiatry module as part of their undergraduate medical programme at a University in the Republic of Ireland. A random sample of 80 reflective essays were selected for review. These assignments were evaluated using a comprehensive content analysis process with a pre-determined reflective writing coding instrument and coding protocol. Dialogic reflection was the most common type of reflective writing identified, with 56.3% (n = 45) of the summative assignments categorised as such. Twenty five percent (n = 20) of the assignments were classified as descriptive reflection, while 18.8% (n = 15) of the assignments demonstrated critical reflection. Overall, the findings of the study indicate that this innovative programme was successful in fostering and developing reflective writing in medical students to quite an advanced level. The paper concludes with specific recommendations for facilitating reflective writing in professional and higher education.

Subjects: Education Studies; Higher Education; Medicine
Ann Donohoe

ABOUT THE AUTHOR
The research team has a broad range of expertise in health professions education and a particular interest in exploring how healthcare students can be supported to engage in reflective practice. The team has conducted research studies which have examined reflection in a diverse range of educational contexts including medical education, higher education and nursing and midwifery. The research reported in this paper focuses on a clinical psychiatry module, where undergraduate medical students were facilitated to engage in reflective writing. The study is designed to develop empirical and practical knowledge, that will assist both educators and students to engage in effective reflective activity. The study also demonstrates the research teams wider commitment, to advancing the reflective practice agenda in healthcare education and practice.

PUBLIC INTEREST STATEMENT
Reflective practice is considered an integral part of contemporary medical education programmes. While this educational approach has garnered considerable attention in the literature, evidence-informed guidance as to how reflection can be facilitated in practice, is less evident. This paper reports on a study that utilised an interactive e-learning resource, to introduce reflective practice to a group of undergraduate medical students, as part of their psychiatry training. The students learned the principles of reflection, explored how this related to their experiences in practice, and then completed a reflective essay. Their assignments were evaluated by the research team to identify the types of reflective writing that the students produced. Overall, the findings of the study showed that this programme was successful in fostering and developing reflective writing. Specific recommendations for facilitating reflective writing in medical and health professions education are discussed.

Introduction
Reflection is proclaimed as a means to help physicians deal with medicine's inherent complexity, yet there is little agreement on the nature of reflection or how it should be taught and practiced (Schei et al., 2019). While the importance of reflective thinking is emphasised by prominent scholars such as Dewey and Schön, a consensual definition of the term remains elusive (Nguyen et al., 2014). Dewey (1933) defined reflection as the "[a]ctive, persistent, and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends" (p9). Dewey's approach provided a basis for the concept of "reflective practice" which Schön explored in his influential books, The Reflective Practitioner (Schön, 1983) and Educating the Reflective Practitioner (Schön, 1987). Since then, reflective practice has been integrated into professional preparatory programmes, continuing education programmes, and by the regulatory bodies of a wide range of health and social care professions (Kinsella, 2010). However, the evidence to support and inform these curricular interventions and innovations remains largely theoretical (Mann et al., 2009). Medicine has followed a similar trajectory. In recent years, professional medical organisations and accrediting bodies have called for the inclusion of reflection at all levels of medical education (Aronson, 2011). This has resulted in an increasing emphasis on the use of reflection in undergraduate, graduate and continuing professional development programmes (Aronson, 2011;Hargreaves, 2016;Sandars, 2009;Winkel et al., 2017). While the topic has generated significant research interest particularly in the last decade, there is no clear consensus as to what methods are effective for teaching reflection in medicine (Chaffey et al., 2012;Uygur et al., 2019). Despite this, reflective writing predominates at undergraduate level  and is viewed as an important strategy in medical education (Wald & Reis, 2010) and psychiatry (Bekas, 2013) .

Statement of problem
There is a significant lack of clarity as to the strategies that are effective in facilitating the development of reflective capacity. While reflective writing is viewed as an important educational approach, little is known about how students can be supported to write reflectively. Consequently, there is a need to investigate how undergraduate medical students can be facilitated to engage in reflective writing. There is also a need to understand the types of reflective writing that is produced, particularly while on clinical placement.

Significance of the study
This study seeks to contribute to the relatively limited body of knowledge concerning the facilitation of reflective practice in undergraduate medical education. It details how reflective practice was introduced to a cohort of undergraduate medical students as part of a clinical psychiatry module. It is one of the few studies to provide a comprehensive overview as to how reflective writing can be supported using an e-learning resource. The study also offers a relatively unique insight into the process of facilitating and examining reflective writing in undergraduate medical education.

Reflective writing in medical education
In medicine, reflective writing supports the examination of complex, ethically ambiguous, troubling, or inspiring situations while developing critical thinking skills and emotional awareness (Walling et al., 2013). It is also considered to foster reflective capacity (Wald & Reis, 2010); empathy (Chen et al., 2014) and resilience (Wald et al., 2016). However Charon, a recognised authority on narrative medicine, describes the field of reflective writing as being at a productive yet perilous stage (Charon & Hermann, 2012;p. 2). Productivity is evidenced by an ever-evolving knowledge base and a robust academic discourse supported by research from a wide range of countries including the United States of America, the United Kingdom, the Republic of Ireland, Qatar and China. Literature examining the application of reflective writing in areas as diverse as clerkship (Stuart et al., 2020), family medicine (Bradner et al., 2015), skills development (Braun et al., 2013;Chen et al., 2014;Misra-Hebert et al., 2012) professional identity formation (Wald et al., 2015) assessment rubrics (Cheng & Chan, 2019;Coulehan & Granek, 2012;Wald et al., 2012), portfolios (Kassab et al., 2020) and blogs (Bracken et al., 2021;Fischer et al., 2011) is also indicative of the pervasive nature of reflective writing in medicine.
Yet the perilous position to which Charon and Hermann (2012) refer, is also evident in the academic discourse. The ongoing development of reflective checklists, portfolios and other writing/assessment tools may be indicative of a reductionist mindset, incongruent with the philosophy of reflective practice (Grierson et al., 2020;Ng et al., 2015). Furthermore, a false sense of security can be generated by an over reliance on an instrumental approach, where many interpretations of reflection do limited justice to the theoretical underpinnings of true reflective thought (De la Croix & Veen, 2018). This has led to calls for the medical field to broaden its conceptualisation and deepen its understanding of what reflection is, from which philosophical contexts it derives, and what its purpose can be within the context of medical education and research (Ng et al., 2015). Nonetheless, reflective writing is an important aspect of medical education (Shapiro et al., 2006) as it has the potential to challenge the way we think, while providing the learner with an opportunity to review an approach, consider the meaning involved, or just express and process his/her emotions (Braun et al., 2013).

Reflective writing in undergraduate psychiatry education
Psychiatry is a medical specialty in which reflective practice is considered to be of particular value (Bekas, 2013;O'Loughlin et al., 2012;Omer & McCarthy, 2010).Academic knowledge on its' own is often insufficient to facilitate the holistic treatment of patients with mental health problems. Psychosocial dimensions such as culture, ethnicity and stigma are but some of the factors that contribute to the complexity of patient management. Certainty is often challenged by this complexity and is compounded by the patient and carer perspectives and their access to varied information. The reflective psychiatrist will question their own implicit knowledge, engage in a dialogue with colleagues and patients, validate their theories and assumptions and present them to open scrutiny (Bekas, 2013) . Reflection can assist psychiatrists to coexist harmoniously with this multi-voiced world and challenge assumptions about their knowledge and the ways they think and act (Bekas, 2013). Therefore consultant psychiatrists and educators with responsibility for training and competence assurance, have a pivotal role to play in promoting reflective practice (O'Loughlin et al., 2012).
Like medical education, there is a lack of consensus regarding the most effective methods to teach reflection in psychiatry. Furthermore, the literature exploring reflective writing in undergraduate psychiatry is quite varied in terms of purpose and focus. Studies which examine the role of reflective writing in undergraduate psychiatry education can generally be divided into two categories: those that use reflective writing as a mechanism to understand students views of their psychiatry experience/education and those studies that seek to examine how reflective writing can be facilitated in undergraduate psychiatry education.
In terms of studies that use reflective writing to gain insight and understanding, Brenner (2011) conducted a qualitative study which sought to examine medical students views of psychiatry. 100 reflection papers written by medical students in their psychiatry clerkship were analysed. The most common themes identified related to social issues in psychiatry, the reality of mental illness, the role of trauma, difficulties forming alliances with patients, the efficacy of interventions, the power of empathic connection, and students' personal identifications. Brenner (2011) concluded that reflection exercises can be used to foster students' awareness of their pre-existing attitudes toward mental illness and the evolution of their views during training. Educators can also use reflection exercises to better understand their students' concerns and to also target curriculum content toward specific issues (Brenner, 2011). Similarly, O'Brien and Mudunkotuwe (2012) examined 100 reflective assignments that were completed by medical students as part of their psychiatry attachment. The aim of this study was to gain a better understanding of the student's psychiatry experience. Six primary themes were identified: stigma, social and cultural aspects of psychiatry, fear of mental illness in the students themselves, fear of conducting the interview and criticism of the care the patient received. O'Brien and Mudunkotuwe (2012) noted that utilising reflective practice assignments in this way provided valuable feedback not only for the learner, but also for the educators and the medical school. Schatte et al. (2015) conducted a study which examined medical students' reflections on their psychiatry clerkship. 100 reflective journals were analysed using grounded theory. The most common themes identified related to a recognition that the psychiatric patient does not exist in a vacuum; an acknowledgement of one's respect for the struggle of patients with mental illness; an expressed or demonstrated empathy for patients and a reduced scepticism of the biological basis of mental illness and efficacy of treatments. Schatte et al. (2015) concluded that reflective exercises, in association with quality mentorship and feedback, can be used to facilitate change and refine assumptions among medical students, as well as promoting critical self-assessment and personal growth.
In a more recent study Stuart et al. (2020) examined the reflective writing of senior medical students across a co-ordinated reflection education programme in General Practice, Paediatrics and Psychiatry clerkships. 135 reflection assignments were qualitatively analysed. Common themes across the three clerkships related to students' emotional struggles in developing a professional identity while the sense of perceived risk was specifically identified by students on psychiatry clerkship. Stuart et al. (2020) identified the need for the utilisation of evidence-based pedagogies, such as interactive reflective writing, as a mechanism to support the emotional development and professional identity formation of medical students.
In terms of studies that explore how reflective writing can be facilitated, Whitmore et al. (2019) examined a pilot reflective writing program which was delivered during a four-week psychiatry clerkship. Students were provided with weekly writing prompts, and their reflective writing assignments were assessed using the Reflection Evaluation for Learners' Enhanced Competencies Tool (the REFLECT rubric) as devised by Wald et al. (2012). The findings illustrated how medical students who participated in this reflective writing course, demonstrated a significant increase in their reflective writing scores. This study also suggested that a relatively short, four-week reflective writing program, can enhance reflective capacity in medical students as part of a psychiatry clerkship. Watts et al. (2011) and Watts (2013) utilised online learning activities to foster reflective writing among medical students on psychiatry placement. Participation was measured by counting the number of online posts and a sample of students were interviewed on their motivation for engaging with the online resource. The results demonstrated a close relationship between the number of posts and high grades in both the essay and the reflective component of the essay (Watts, 2013). Watts (2013) concluded that the use of online learning resources can facilitate students to develop their reflective writing skills.
The literature, while relatively limited, is therefore consistent in articulating the benefits of reflective writing in psychiatry clerkships (Brenner, 2011;O'Brien & Mudunkotuwe, 2012;Stuart et al., 2020). However practical evidenced based exemplars as to how reflective writing can be fostered and developed specifically within undergraduate psychiatry are more difficult to locate. The literature therefore indicates that while the "why" of reflective writing is understood and viewed as valuable, the "how" of reflective writing requires further empirical exploration, particularly within the context of undergraduate medical and professional education.
It is against this background that the current study was designed. We sought to demonstrate how some of these educational challenges could be addressed in a practical and meaningful manner. This study provides an account of an educational approach that was used to introduce reflective practice to medical students undertaking a clinical psychiatry module, as part of their undergraduate medical programme at a University in the Republic of Ireland. Further, we sought to determine the predominant reflective writing style evident in each submitted student assignment.

Assessing reflective writing
This investigation was predicated on the need to identify the types of reflective writing in a sample of reflective essays. It was therefore necessary to source a reliable framework that could facilitate this process. Consequently, frameworks devised by Mezirow (1981), Goodman (1984), Van Manen (1977), and Hatton and Smith (1995) were considered. Mezirow (1981) original framework, developed from his collaborative research with mature university students, consists of seven hierarchical levels of reflection. The first four levels (1-4) of reflectivity are characteristic of what he refers to as consciousness, and the last three (5-7) levels are characteristic of critical consciousness. Later, Mezirow (1990) developed his framework further by identifying three categories of reflection: thoughtful action, reflective action, and critical reflection. Mezirow argues for a progression towards critical reflection, which involves awareness and critique of the reasons why an individual performs an action or arrives at a particular insight. Goodman (1984) theoretical framework, based on grounded theory research with student teachers, identifies three hierarchical levels of reflection: reflection to reach given objectives; reflection on the relationship between theory and practice; and reflection that incorporates ethical and political concerns. Van Manen (1977) framework for reflection also consists of three hierarchical levels: (1) the technical level, where the application of knowledge is supposed to serve a given purpose; (2) the theoretical or practical level, where it is realised that any choice requires a process of analysing and clarifying individual and cultural experiences, meanings, perceptions, assumptions, and prejudgments, and (3) the critical level, where the practical addresses itself, reflectively, to question the worth of knowledge and the nature of social conditions. The approaches outlined by Mezirow (1981), Goodman (1984), andVan Manen (1977) appear to encapsulate a more hierarchical approach to reflection where practitioners are encouraged to progress to the highest level of reflection, making links between the setting of everyday practice and broader social structures and forces. This contrasts somewhat with the work of Hatton and Smith (1995) and their classification of reflective writing which is commonly cited in the education literature. Their framework consists of a set of criteria that are specifically designed to facilitate the identification of different types of reflective writing and was generated from the findings of a comprehensive study that examined the reflective writings of pre-service teachers at the University of Sydney in Australia. Hatton and Smith (1995) framework consists of four distinct types of writing: i.e., descriptive (technical) writing, descriptive reflection, dialogic reflection, and critical reflection. In this framework the categories of writing are viewed as part of a developmental process as opposed to hierarchical one.
While the frameworks by Mezirow (1981), Goodman (1984), and Van Manen (1977) provide valuable criteria for the assessment of reflective writing, Hatton and Smith's (1995) classification appeared more suited for use in this study for a variety of reasons. Firstly, in Hatton and Smith's (1995) framework, descriptive writing (technical writing) is viewed as a useful starting point for reflectors who can then be encouraged to move from descriptive writing to understand and use other forms of reflective writing. In recognising that reflective writing is developmental in nature and that each type of writing is of value, Hatton and Smith's (1995) approach rejects the more hierarchical nature of other frameworks. This is consistent with how reflective writing was presented to the medical students during their undergraduate psychiatry placement. Furthermore, it is also reflective of the aim of the reflective essay i.e., to develop medical students' ability to apply technical, descriptive, dialogic, and/or critical reflection to their clinical experiences during their undergraduate psychiatry rotation. Therefore, the decision to utilise Hatton and Smith's (1995) framework in this study was largely influenced by the developmental nature of reflective writing and its value in incrementally developing students' knowledge and understanding. An overview of Hatton and Smith's (1995) reflective writing framework together with a definition of each type of reflective writing is presented in Table 1.

Methods
Qualitative content analysis was used to identify the types of reflective writing that were evident in a sample of reflective essays.

Research context
All undergraduate medical students are required to complete a six-week module in psychiatry as part of their final clinical year. The students in this study had access to an interactive e-learning resource which introduced the concept of reflection and elaborated on different types of reflective writing. The students also participated in an online blog which was specifically designed to facilitate reflective writing. Contributions to the blog were graded and the course tutor provided feedback. Students were then required to choose from a selection of predetermined essay titles and submit a 1,500-word summative reflective essay.

Sample
A total of 217 undergraduate final year medical student essays were available, of which a random sample of 80 essays were selected for inclusion in the study.

Data analysis
The content analysis procedure was primarily governed by the application of a specific coding instrument and a corresponding coding protocol. The Reflective Writing Coding Instrument (RWCI) was developed by (Donohoe, 2012) from the work of Hatton and Smith (1995). It was originally devised to facilitate researchers to ascertain the type of reflective writing produced by students using online discussion forums. Consequently, the coding instrument required a series of modifications so that it could be reliably used to analyse reflective assignments. The RWCI was accompanied by a pre-determined three-stage coding protocol. The development of the coding protocol was influenced by negotiated coding, as described by Garrison et al. (2006). In negotiated coding, researchers code relevant transcripts independently and then actively discuss their respective codes with the aim of arriving at a final agreed version in which most, if not all, coded transcripts are brought into alignment (Garrison et al., 2006). While negotiated coding was originally devised for use with computer transcripts, the approach lends itself to different types of content analysis, Reflective, not only a description of events but some attempt to provide reason justification for events or actions but in a reportive or descriptive way.
3 Dialogic Reflection Demonstrates a "stepping back" from the events/actions leading to a different level of mulling about,discourse with self and exploring the experience, events, and actions using qualities of judgements and possible alternatives for explaining and hypothesising.

Critical Reflection
Demonstrates an awareness that actions and events are not only located in, and explicable by, reference to multiple perspectives but are located in, and influenced by multiple historical, and socio-political contexts.
such as the type presented in this paper. It facilitates coding scheme refinement, and controls for simple errors thereby increasing reliability. An overview of the Reflective Writing Negotiated Coding Protocol is presented in Table 2.

Procedure
The complete set of reflective essays was firstly de-identified by a researcher who was not involved in the data analysis process. Three coders were then allocated to the coding process (AD, GO'N & AG). In Stage 1, AD and GO'N independently assigned a type of reflective writing to each reflective essay e.g., descriptive (technical) writing, descriptive reflection, dialogic reflection, or critical reflection. In Stage 2, both AD and GO'N together reviewed the results of stage 1 of the coding process. The assignments where the coders were not in agreement were identified. Each of these assignments were then discussed in detail, with each coder providing reasons and justifications for their respective decisions. The aim of this process was to negotiate an agreed code (i.e., type of writing) for all essays. If agreement could not be reached in stage 2, there was a provision whereby the essays would be transferred to Stage 3, where a senior researcher (AG) could provide the final adjudication. However, agreement was reached on all essays in stage 2. Hence the stage 3 process was not required.

Findings
Three of the four types of reflective writing were identified. Dialogic reflection was the most common type of reflective writing, with 56% (n = 45) of the assignments demonstrating this.
Descriptive reflection which was evident in 25% (n = 20) of the assignments. Nineteen percent (n = 15) of the assignments demonstrated Critical reflection. No assignment was classified as having a predominant Descriptive (technical) writing style. An overview of the types of reflective writing identified is presented in Table 3. A more detailed account of the specific elements associated with each type of reflective writing is provided in the following sections. • A code is presented for each transcript.
• Each coder signs the coding results for Stage 1.
• Each coder retains 2 copies of the results from each coder (1 hard copy and 1 electronic copy)

Stage 2 Negotiated Coding
• The transcripts where coders are not in agreement are identified.
• The coders attempt to reach agreement on each transcript.
• Where agreement cannot be reached, those transcripts are transferred to Stage 3.
• The coders co-sign the coding results for Stage 2.
• Each coder retains 2 copies of the final results from the 2 nd Stage.(1 hard copy and 1 electronic copy)

Stage 3 Expert Coding
• The expert provides the final adjudication for any transcript that is outstanding from Stage 2.
• The expert signs the coding results for Stage 3.
• Each coder retains 2 copies of the final results from the Stage 3.(1 hard copy and 1 electronic copy)

Descriptive reflection
Twenty five percent (n = 20) of the assignments analysed demonstrated descriptive reflection. In this category there was evidence that the student had attempted to provide some reasons or justifications for the events or actions that were being discussed. However, this reasoning was invariably presented in a descriptive manner. For example, one student when discussing the implications of family secrecy surrounding suicide stated that:

'One can imagine that keeping secrets of this magnitude can put a great deal of stress on family members'
In this instance the writer did not attempt to explore the issue from an empirical or critical perspective and remained firmly in the realm of their personal judgment. Furthermore, while assignments in this category demonstrated some evidence of an exploration of the self or the students' own views or thoughts, the use of the term "I" was invariably applied in a superficial manner. For example, a student when writing about the challenges of patients being seen by different psychiatrists noted that:

'Although I agree strongly that it would be preferable for patients to only ever see one doctor, I cannot see how this can be put into practice especially for those who attend a registrar, a figure who changes every few months'
Here again the student did not seek to explore how the service could be improved or how similar processes are operationalised perhaps more successfully, in other healthcare systems or environments. Thus overall, assignments that were categorised as being indicative of descriptive reflection were primarily based upon personal judgements with a limited exploration of possible alternative actions or approaches. While empirical literature was cited within the text, invariably it was not used to develop or substantiate the writer's thoughts or opinions. This resulted in a relatively limited critical engagement with the literature.

Dialogic reflection
This type of reflective writing demonstrates what Hatton and Smith (1995) (p. 48) term as "a stepping back from the events/actions, leading to a discourse with self". Evidence suggests that the experience, events, and actions are explored using qualities of judgment and alternative actions have been considered (Hatton & Smith, 1995). Dialogic reflection (56%, N = 45) was the most prevalent type of reflective writing identified in the study sample. In this group, there was evidence that students had "stepped back" from the issues under consideration and had This approach contrasts sharply with that which is evident in descriptive reflection. In dialogic reflection, the writer demonstrates that they have based their opinions and/or thoughts on some objective source (e.g., the empirical literature) as opposed to a personal judgment or belief. As such, this represents a more evolved engagement with the self, where students can recognise the interplay between themselves as individuals and the self as an emerging healthcare professional.
Another key indicator of dialogic reflection is the ability to consider possible alternative courses of action or approaches and an ability to recognise inconsistencies. However again, the emphasis is on considering such alternatives and inconsistencies with reference to an objective source as opposed to personal judgments or beliefs. For example, one student while citing a Cochrane review in the context of exploring the challenges associated with treating depression in primary care noted that:

' . . . there is strong evidence for the use of psychotherapy such as cognitive behavioural therapy (Arroll et al 2009) . . . however in this setting the use of anti-depressants alone is easier due to resource constraints'
Here the student suggests that while CBT can play a role in treating depression, particularly in a primary care setting, the process of prescribing antidepressants may be in fact more pragmatic due to limited resources. Again, this demonstrates that the student has the capacity to identify alternative courses of action while simultaneously acknowledging inconsistencies and conflicts in care.
Overall, the students whose assignments showed dialogic reflection, demonstrated an ability to "step back" and consider issues from an objective standpoint as opposed to a personal one. These students also had the ability to recognise that an alternative course of action was possible, while also acknowledging the existence of inconsistencies and/or competing forces in case management. Overall, these assignments demonstrated a critical engagement with the literature which went beyond mere substantiation. Most importantly however, these students were able to clearly demonstrate how the literature had informed their thoughts, knowledge and opinions as they continued to develop as healthcare professionals.

Critical reflection
Nineteen percent (n = 15) of the assignments were classified as demonstrating critical reflection. Students in this category shared many of the characteristics of dialogic reflectors; the critical reflectors demonstrated the ability to step back from the discussion and consider issues from an objective stance. They were also able to communicate a more evolved sense of self that went beyond mere personal judgment or belief and used literature to effectively elucidate an opinion, knowledge base or view. Again, similar to dialogic reflectors, critical reflectors demonstrated the ability to consider alternative courses of action and inconsistencies. However, the defining feature of critical reflection is the ability to recognise that actions, alternative actions and inconsistencies are located in, and influenced by, multiple contexts such as historical, social, economic and political paradigms. Students in this category demonstrated the ability to recognize and discuss the multiple contexts that surround and influence mental health and wellbeing. For example, a student writing about the role of psychiatrists in suicide prevention noted that: 'There are several challenges to the potential influence a psychiatrist may have on preventing suicide. These include cultural attitudes such as stigma . . .

.political allocation of resources, socioeconomic factors including social change and the influence of the financial crisis on suicide rates'
In this assignment the writer goes on to discuss the medical, cultural, social, political and economic factors that influence suicide prevention. Relevant literature is used to substantiate the account. Similarly, another student who was focusing on the importance of mental health noted the following: 'The WHO has described diagnostic overshadowing as part of a hidden human rights emergency that encompasses a decreased standard of care for those with mental illness. In light of the gross impact that mental illness has both globally and individually, the stigma that is associated with it needs to be eradicated; in addition to instituting change in resource allocation and access to effective treatment' Here the writer demonstrates an awareness of the multiple contexts that are associated with mental illness. They challenge clinical practice and social norms in terms of stigma at both an individual and a societal level. They also demonstrate awareness that change is closely aligned with the appropriate allocation of fiscal resources, while also recognising that access to effective care is pivotal. Again, relevant literature is used to substantiate the account.

Discussion
The aim of this study was to determine the type of reflective writing produced by medical students during their psychiatry clinical module. A content analysis of a sample of reflective essays demonstrated that three of the four types of reflective writing were identified. The following discussion situates the analysis of these findings within the context of psychiatry education particularly at undergraduate level. The relevance of the study for general medical education and research is also considered.
The study provides some interesting insights into the role of reflective writing and reflection in psychiatry education and practice. The findings demonstrate that undergraduate medical students on psychiatry placement can be facilitated to engage in reflective writing. The reflective essays clearly show how students used this reflective activity to both explore the complexity of psychiatry practice while also challenging aspects of care. This supports Bekas (2013) contention that reflection provides a sound foundation for learning and practice in psychiatry. Furthermore, while O'Brien and Mudunkotuwe (2012) and Brenner (2011) analysed reflective essays to better understand the student psychiatry experience, this study extends the process further by using content analysis to identify types of reflective writing. This in turn indicates whether a student is processing their experiences at a technical, descriptive, dialog or critical level while also providing the educator with specific indicators as to when and how reflective writing should be supported. Overall, the findings from this study clearly support earlier research by Watts (2013) and Whitmore et al. (2019) which demonstrate that a dedicated reflective educational strategy must be integrated into the psychiatry practicum if it is to effectively support student reflection. The view expressed by Ryan (2011) that reflective writing is complex and difficult to master unless taught in an explicit and systematic way is also supported.
To our knowledge, no previous research used Hatton and Smith's (1995) categories of reflective writing to analyse medical students' reflective essays in undergraduate psychiatry. In this study content analysis revealed that three of the four types of reflective writing were evident: Dialogic reflection (56% n = 45), Descriptive reflection (25% n = 20) and Critical reflection (19% n = 15). Descriptive (technical) writing was not identified. These findings illuminate some interesting aspects of reflective writing particularly when viewed within the context of the reflective essay. Regarding descriptive (technical) writing, this type of writing is not reflective and consists of a description of events without reason or justification (Hatton & Smith, 1995). One of the defining features of technical reflection is its lack of regard for evidence (Nickerson, 1987) with the main criteria for evaluation being personal judgment (Hatton & Smith, 1995). In medical education, written assignments are designed to generate critical analysis and synthesis of up-to-date literature and evidence-based practice. Given the assessment criteria, it is reasonable to assume that a medical student would not submit an essay that was based purely on personal judgment and devoid of evidence. This may explain the lack of descriptive (technical) writing identified. A similar finding was noted by MacLellan (2004) in relation to reflective essay scripts written by postgraduate teacher-education students. However, technical reflection is considered by Hatton and Smith (1995) to be a first and very necessary level of reflection. Educators therefore may wish to considered utilising educational strategies that will surface technical writing (for example, free writing, brief narrative, group discussion) prior to the development and submission of a reflective essay or assignment.
Descriptive reflection accounted for 25% (n = 20) of the sample. This type of writing includes some attempt to provide justification for events or actions but generally in a descriptive way (Hatton & Smith, 1995). Descriptive reflection is more easily mastered than the more demanding forms of dialogical or critical reflection (Hatton & Smith, 1995). With descriptive reflection there is an awareness of the existence of evidence, but the evidence itself is not fully considered or analysed (MacLellan, 2004). Like technical reflection, descriptive reflection, is an important and necessary step in the reflective writing trajectory. Consequently, students at the descriptive level should be supported to review their writing and their approach to reading, critical analysis, synthesis and the integration of evidence-based knowledge.
Forty-five essays (56%) were at the more demanding level of dialogical reflection. This type of writing involves a stepping back from events and exploring the experience using qualities of judgment, while considering possible alternatives (Hatton & Smith, 1995). Dialogical Reflection suggests that understanding and evidence are interdependent (MacLellan, 2004). Essays at this level demonstrated an objective understanding of psychiatry practice where literature was used to support the discussion. Students displaying this type of writing were also able to identify alternative courses of action while recognising inconsistencies and/or competing forces in case management. Dialogical reflection is demanding (Hatton & Smith, 1995) as it is neither natural nor intuitive (MacLellan, 2004). The provision of additional strategies such as reflective coaching, mentoring etc. may therefore be required to support students at this level, and to progress to the next stage i.e., critical reflection.
Critical reflection accounted for fifteen essays (19%). Critical Reflection suggests that in coordinating understanding and evidence, the evidence must be appraised for its veracity (MacLellan, 2004). While critical reflectors share many characteristics with dialogic reflectors such as objectivity, criticality and an ability to recognise alternatives and inconsistencies in care, the defining feature of critical reflectors is their ability to identify that actions, alternative actions and inconsistencies are located in and influenced by multiple contexts (Hatton & Smith, 1995). Essays in this category demonstrate an understanding of these multiple contexts such as the historical, political, economic and social aspects of psychiatry while also outlining how care could be changed/ improved. The imperfect nature of what is in place and the need to strive for improvement is a feature of critical reflection (MacLellan, 2004). This approach was clearly evident in the reflective essays in the critical reflection category. As with dialogic reflection, the provision of additional support is required for students to develop and maintain this type of reflective writing.
Overall content analysis of the reflective essays reveals an interesting narrative in terms of types of reflective writing (technical, descriptive, dialogic and critical). However, it is valuable to conceptualise the process as a reflective trajectory where students are supported to progress their writing incrementally through structured and timely feedback. Examples in the literature of processes that include structured feedback to students on reflective writing are limited (Wald & Reis, 2010). Therefore, the approach used with these students is relevant as it supports the call for interactive reflective writing i.e., the use of timely faculty feedback to support learners' development of sophisticated reflection skills (Wald & Reis, 2010).
Another area of interest relates to the educational strategy that was used with this cohort of students. As part of their psychiatry module, the participants had access to an interactive e-learning resource, designed to support reflective activity. While it is not possible to draw direct inferences regarding the educational impact of the e-learning resource, it is interesting to consider some of its features. For example, the resource contained an online blog specifically designed to facilitate reflective writing. Bracken et al. (2021);Fischer et al. (2011) have demonstrated how online blogs can be used to support reflection. In addition, the students who participated in this study were required to post a blog entry relating to each type of reflective writing. This afforded students the opportunity to develop an understanding of reflective writing iteratively over the course of their psychiatry practicum. Another feature of the e-learning resource relates to the provision of online feedback. As part of the blog, a tutor provided individualised feedback to students on their reflective posts. Overall, the value of utilising an e-learning resource to facilitate reflection is an important aspect for consideration. The findings resonate with the view expressed by Sandars and Homer (2008) that students learning preferences indicate the importance of integrating group-based technological and multimedia projects. The potential for enhanced learning through online peer-to-peer feedback and the use of social media tools, particularly wikis, blogs, and podcasts (Boulos et al., 2006) to improve and add new collaborative dimensions to reflective learning should be considered.
The findings also contribute to our understanding of medical education research as it pertains to reflective and reflective writing. This study aligns with Ng et al. (2015) call for a more theoretical orientation to reflection in medical research and de la Croix and Veen's (2018) view that educators must avoid an overreliance on an instrumental approach to reflective practice. Demonstrating how content analysis and negotiated coding can be used to identify types of reflective writing in reflective essays, opens a new avenue of research and represents a move away from the instrumental approach that De la Croix and Veen (2018) caution against. Furthermore, this study demonstrates how utilising qualitative research can lead to new insights and perspectives. Again, this aligns with Malterud (2001) contention that medical research requires methodological diversity so that medical knowledge can continue to expand and develop.

Study limitations
The study was conducted with one cohort of students from a single institution. The study was also limited to students' experiences on one clinical module and was completed within a relatively short time frame. Consequently, local factors may have had some influence on the outcomes and the types of reflective writing identified. Furthermore, this was a qualitative study, therefore the generalisability of the findings is relatively limited. However, the study utilised an exploratory research approach and as such the findings provide a valuable insight into the types of reflective writing that undergraduate medical students produce while on psychiatry placement. The study also has significant relevance for educators who wish to facilitate reflective writing with undergraduate students in higher education.

Conclusion
Supporting students to engage in reflective writing is an important pedagogical endeavour. This study provides an account of an educational approach that introduced reflective writing to medical students undertaking a clinical psychiatry module. The findings were favourable as they demonstrated that this innovative programme was successful in fostering and developing reflective writing in medical students at quite an advanced level. Further research is required to examine the efficacy of this type of educational approach in the facilitation and development of reflective writing, and the broader concept of reflective practice in psychiatry curricula.
The study demonstrates the value of ascertaining the types of reflective writing produced by students. The findings offer an insight into how this information can be used by educators to better scaffold and support reflective writing. Reflective coaching, peer to peer support and interactive reflective writing, are just some of the areas worthy of further research particularly in undergraduate medical education where understanding the complex clinical demands of practice can be challenging for students.
The study also supports the need for the integration of more innovative teaching strategies including the use of web-based technologies, blogs, wikis, podcasts etc. that align more closely with students learning preferences and which can potentially foster the collaborative learning and social interaction required to develop reflective writing. Again, further research regarding the application of these tools and their impact on reflective learning is required.
Finally, there is a considerable lack of clear pedagogical evidence to guide the teaching and learning of reflection in professional education. However, the teaching and assessment of reflection is being introduced at undergraduate and graduate levels across a wide range of professional courses. While the integration of reflection into the relevant curricula is commendable, it is important to ensure that this does not occur within an empirical vacuum. It is therefore incumbent upon educationalists to conduct robust research investigations into the effective facilitation of reflective practice and reflective writing in professional and higher education.