professional development in healthcare essay

Research article
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Published: 14 April 2021

Lifelong learning and nurses’ continuing professional development, a metasynthesis of the literature

Mandlenkosi Mlambo 1 , 2 ,
Charlotte Silén 2 &
Cormac McGrath 2 , 3

BMC Nursing volume 20 , Article number: 62 ( 2021 ) Cite this article

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Continuing professional development (CPD) is central to nurses’ lifelong learning and constitutes a vital aspect for keeping nurses’ knowledge and skills up-to-date. While we know about the need for nurses’ continuing professional development, less is known about how nurses experience and perceive continuing professional development. A metasynthesis of how nurses experience and view continuing professional development may provide a basis for planning future continuing professional development interventions more effectively and take advantage of examples from different contexts. The aim of this paper is to conduct such a metasynthesis, investigating the qualitative research on nurses’ experiences of continuing professional development.

A metasynthesis of the qualitative literature was conducted. A total of 25 articles fulfilled the inclusion criteria and were reviewed.

We determined five overarching themes, Organisational culture shapes the conditions, Supportive environment as a prerequisite, Attitudes and motivation reflect nurse’s professional values, Nurses’ perceptions of barriers and Perceived impact on practice as a core value. This metasynthesis highlights that nurses value continuing professional development and believe that it is fundamental to professionalism and lifelong learning. Moreover CPD is identified as important in improving patient care standards.

Conclusions

Based on the metasynthesis, we argue that access to continuing professional development could be made more attainable, realistic and relevant. Expediently, organizations should adequately fund and make continuing professional development accessible. In turn, nurses should continue to actively engage in continuing professional development to maintain high standards of nursing care through competent practice. This paper highlights the perceived benefits and challenges of continuing professional development that nurses face and offers advice and understanding in relation to continuing professional development. We believe that this metasynthesis contributes with insights and suggestions that would be valuable for nurses and policy makers and others who are involved in nurse education and continuing professional development.

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Introduction

Health care professionals need to update their skills regularly and continuing education, or continued professional development (CPD) enables the renewal and updating of skills in health care settings. While we know about the need for CPD, less is known about how nurses experience and perceive CPD, and currently, there is no comprehensive global picture of how nurses view and experience CPD. A metasynthesis of the qualitative literature on nurses’ experiences of CPD may provide a basis for planning future CPD interventions more effectively and take advantage of examples from different contexts. This paper is organised in the following way; first we present the notion of CPD, we then use the United Kingdom, (UK) as a setting to offer an overview of the different mechanisms that exist in one specific health care setting, which may impact engagement with CPD. We acknowledge that similar mechanisms may exist in other health care settings and countries too, and identify the UK context, merely as a way to frame the paper. Subsequently, we conduct a metasynthesis of the qualitative literature addressing the topic of how CPD is experienced by nurses.

Continued professional development

This section aims to unpack the notion of CPD, which exists in different forms and is driven, in part, by top-down requirements, but also, bottom-up, from the needs of practitioners. Continuing professional development (CPD) programmes are central to nurses’ lifelong learning and are a vital aspect for keeping nurses’ knowledge and skills up-to-date. The requirement for nurses to participate in CPD differs between European countries and elsewhere in the world and can be mandatory or voluntary [ 1 , 2 ]. For example, CPD is mandatory in the U. K, Belgium, Spain, Australia and in some states in the United States of America, [ 2 , 3 , 4 ]. In these countries, nurses engage in CPD because it is a mandatory condition by nurse regulators for remaining registered to practice. However, in Sweden, Netherlands and Ireland nurses participate in CPD of their own volition [ 1 , 3 , 4 , 5 ]. Table 1 provides an overview of some of the European countries which provide mandatory and non-mandatory CPD.

In jurisdictions where CPD is mandatory, nurses engage in continuing education by participating in professional development that is relevant to their areas of practice. Mandatory CPD, refers to “… the process of ongoing education and development of healthcare professionals, from initial qualifying education and for the duration of professional life, in order to maintain competence to practice and increase professional proficiency and expertise” ([ 6 ], p.1). CPD can sometimes refer to a learning framework and activities of professional development which contribute to the continual professional effectiveness and competence [ 7 ]. Broadly, CPD is related to continuing education, and continual learning, both formal and informal, which results in the acquisition of knowledge and skills transfer by the practising nurse with the aim of maintaining licensure and competent practice [ 8 ]. Learners can utilise a mixed style approach to learning depending on the circumstances and context of the learning environment [ 9 , 10 , 11 ]. To succeed in providing comprehensive care for their patients, nurses need to utilise the best evidence available to them [ 12 , 13 , 14 ]. This requires different modes of learning and ways of knowledge acquisition and construction. To achieve this, nurses can engage in different approaches of acquiring knowledge through CPD, through formal learning, courses or workshops as well as workplace informal learning, through self-reflection, appraising literature for best evidence through journal clubs and giving feedback to each other [ 5 , 7 , 15 ]. Informal learning is often volitional and is largely initiated and controlled by individual nurses with the intention to develop their knowledge and skills [ 16 , 17 , 18 ]. Due to its unstructured and, at times, unintentional manner, such learning is often acquired during interactions with colleagues and patients [ 19 ]. One of the advantages of on-site learning, both formal and informal is that learners can utilise expertise which are already available on the ward [ 5 , 15 ]. On-site learning occurs often at the discretion and the willingness of managers to facilitate by providing time and space for learning to occur within the clinical areas. Even so, the fact remains that informal on-site learning is not an event but a continuous process, which draws from daily professional experiences. Lack of CPD trained nurses and ward needs, coupled with poor staffing levels, are cited as main barriers to informal workplace learning [ 5 , 15 ]. Evidence from CPD literature indicates that many nurses prefer informal work-based methods of learning, noting that most meaningful learning occurs through interactions with their colleagues [ 20 ]. From a study by Clarke [ 21 ], it was noted that nurses found informal learning methods such as supervision, attending team meetings/briefings, mentoring and observations to be important. Ultimately, whichever delivery method is used for CPD, continuous professional development extends the practitioner’s professional ability beyond pre-registration training, qualification and induction, thereby potentially enhancing the practitioner’s practice.

Continued professional development: the UK example

This next section aims to illustrate the different mechanisms that arise in one specific health care setting when implementing CPD on a national scale. We recognise that other mechanisms will exist in other contexts, and in places where CPD is not a formal requirement.

Today, nurses in the U.K. are required to engage in continuous learning in order to maintain competence as a means of keeping their licensure with their professional body, the Nursing & Midwifery Council (NMC) [ 22 ]. Since the 1980s, UK nurses and other allied health care professionals such as physiotherapists and occupational therapists have been required to engage in continuous professional development [ 23 ]. A justification for CPD has been the need to maintain professional registration to practice. For registered nurses in the UK, the requirement to engage in CPD came to the fore of continuing education in 1995. It was introduced by the then licensing body, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) as post registration education and practice (PREP) [ 24 ]. Further to that, the Agenda for Change Reforms in 2003 introduced a system for linking pay and career progression to competency called the National Health Service Knowledge and Skills Framework [ 25 ]. The framework is linked to the individual nurse’s ability to demonstrate that they possess the necessary knowledge and skills to get promoted and be remunerated accordingly [ 25 ]. In the UK, further reforms to CPD were introduced in 2012 through the introduction of the Health Education England (HEE) in England [ 27 ]. Its mandate was to equip the NHS (National Health Service) workforce, including nurses with appropriate knowledge and skills to deliver high standard care to patients. The HEE’s role was to support workforce development by providing funding largely for nurses’ CPD. In 2016, PREP was replaced with revalidation, which still requires nurses to attend 35 h of CPD every 3 years [ 24 , 26 ]. Revalidation is the process through with nurses and midwives continue as registrants with the Nursing and Midwifery Council (NMC) [ 25 ]. However, comprehensive HEE budget cuts have had a negative effect on nurse CPD initiatives [ 27 ]. CPD funding in UK was cut from 205 million pounds in 2015–16 to 83 million in 2017–18 [ 28 , 29 ]. Consequently, nurses have struggled to fulfil revalidation requirements due to some authorities freezing access and refusing to give nurses time to attend CPD activities [ 27 ].

This previous section offers an insight into different push-pull mechanisms, in the UK alone. Statutory requirements are underpinned by the need for nurses to maintain and develop the knowledge and skills to meet the expected competence standards of practice in response to expanding nursing roles and global trends. Our experience suggests that local governing bodies may enforce similar measures in contexts where CPD measure are not formalised. Nurses may find themselves caught between a patchwork of statutory requirements and a need to develop their skills and knowledge. Consequently, while we know about the need for nurses’ continuing professional development, less is known about how nurses experience and perceive continuing professional development. Therefore we propose that a metasynthesis of the qualitative literature could be a part of forming such a comprehensive view and use the following three questions to examine the literature What is the reported value of CPD for nurses’ lifelong learning and its impact on nursing knowledge?, What are the conditions necessary for CPD?, and, What are the challenges faced by nurses when engaging in CPD?

In this study, a metasynthesis was used to investigate the qualitative literature [ 30 , 31 ]. Metasynthesis is a form of systematic review method used to review qualitative studies in order to develop theory, to explore and understand phenomena or generate new knowledge, thereby creating meaning from that knowledge [ 32 , 33 , 34 , 35 , 36 ]. In this review, we present a metasynthesis based on the interpretation of qualitative results from topically related qualitative reports. In doing so we strive towards theoretical development, which according to Zimmer refers to the synthesis of findings into a product that is ‘thickly descriptive, and comprehensive’ and thus more complete than any of the constituent studies alone ( [ 30 ] p.313).

The results from metasynthesis studies may be used to underpin and inform healthcare policy, nursing practice and patient care. Furthermore, such information can be utilised by health care professionals involved in nursing education to inform planning and designing of training and educational programs. A number of steps are taken when conducting a metasynthesis [ 36 ] and involve;

a) bringing together a multidisciplinary team, in our case the team of three people includes two skilled medical education professional researchers with extensive experience in qualitative studies, including systematic reviews, moreover these two authors have more than 40 years of comprehensive experience of CPD in health care settings, two of the team are registered nurses and afford the team key insights into the context of nursing CPD, the team is spread across three institutions in two countries, finally, the team consisted of a search engine expert,

b) defining inclusive but manageable research questions, see the questions above;

c) conducting the systematic search, in our case this was conducted by the search engine expert, see Table 2 for the search criteria,

d) quality assessment of the studies, this was done using the CASP (Critical Appraisal Skills Programme) criteria, weighting three levels (not met, partially met, totally met) where assessment was done by all three authors see Table 4 , e) extracting data from the studies, see Table 3 ,

e) data analysis, which is explained in more detail below, and.

f) expressing the details of the synthesis which is done in the findings sections below.

Search strategy

A comprehensive systematic search of literature was subsequently conducted on Medline (OVID), PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science (Clarivate) and ERIC (ProQuest). The literature search was conducted by a librarian. The literature search was conducted in December 2019 and was limited to articles published in English from 2010 to 2019. Inclusion and exclusion criteria for the literature search were established and are presented below in Table 2 . The inclusion criteria comprise of articles from empirical studies (using qualitative methods), discussing nurse continuing learning and education, professional development, lifelong learning, CPD, motivation and barriers.

Data analysis

A total of 1675 records were identified, and following de-duplication, 1395 articles remained. All 1395 articles were screened. Articles had to address nurses’ CPD and continuing education, using qualitative oriented methods. After the first screening 72 articles remained. These articles were divided into three batches and were divided among the researchers. Each author read one batch to further identify if the articles were to be included. For each batch, a second author read the articles, meaning all articles were read by at least two authors. Any remaining ambiguities were discussed and resolved among the team. Figure 1 is a summary of the literature search and screening and Table 3 presents an overview of each study with its citation, location, cohort size and data collection method. 25 articles were identified for the final metasynthesis. All authors read the final 25 articles. Quality assessment using CASP criteria as outlined by Lachal et al., [ 36 ] is reported in Table 4 . In the quality assessment we assess the following components; Was there a clear statement of the aims of the research?, Is a qualitative methodology appropriate?, Was the research design appropriate to address the aims of the research?, Was the recruitment strategy appropriate to the aims of the research?, Were the data collected in a way that addressed the research issue?, Has the relationship between researcher and participants been adequately considered and reported?, Have ethical issues been taken into consideration?, Is there a clear statement of findings? We also introduce the question of whether the texts are available in Open Access form or not. We introduce this question, as we believe the outcomes on research on nurses’ perceptions and experiences of CPD is potentially important for their practice, and access via Open Access channels could act as a quality dimension. However, without access to the data and the process of interpretation we choose not to assess; How valuable is the research?, Was the data analysis sufficiently rigorous?

Overview of the steps in the literature screening

For the final analysis enabling the synthesis of the studies in this metasynthesis the articles were read carefully, findings related to the research questions; What is the reported value of CPD for nurses’ lifelong learning and its impact on nursing knowledge?, what are the conditions necessary for CPD? And what are the challenges faced by nurses when engaging in CPD?, were identified. In the next step of the analysis, study findings were examined using constant comparative analysis. The findings and conceptual categories were coded, compared, and sorted, focusing on conditions, strategies, and consequences. Finally, the synthesis, the interpretation of the findings, were described as themes, and these were revised several times until a coherent whole was formed [ 30 , 36 , 37 , 38 ] Before the final description of the synthesized themes, all the three authors discussed the content of the themes until consensus concerning credibility was reached.

From the metasynthesis we present five overarching themes, Organisational culture shapes the conditions, Supportive environment as a prerequisite, Attitudes and motivation reflect nurse’s professional values, Nurses’ perceptions of barriers and Perceived impact on practice as a core value. Each theme is further explained below with references to the relevant literature.

Organisational culture shapes the conditions

Organisational culture played an important role towards the professional development of staff. Organisational commitment and support to personal and professional development of its staff was seen as an indication that staff were valued [ 5 , 15 ] Moreover, CPD initiatives contributed to attracting and retaining staff [ 39 ]. Additionally, a culture that was flexible and adaptable to change was perceived by some participants to be favourable towards CPD [ 40 , 41 , 42 ]. Flexibility extends to matters such as CPD availability, and also location, but related also to creating opportunities in the work schedule for the nurses to participate [ 43 ]. Other organisational factors such as funding for CPD programs, staff access of CPD learning, role of management in staff CPD, manageable nursing workloads, the design & delivery of CPD activities, communication and collaboration between CPD providers and management are specifically organisational factors seen as crucial to effective staff development [ 44 , 45 ]. Developing a strategy for CPD was also acknowledged as a key element of organisational culture as a way of enabling participation [ 46 ]. In a similar fashion, it was argued that the organisation needs to be focussed on incremental, but constant development of practices, and here CPD was seen to play a key role [ 47 ]. This sentiment was expressed elsewhere too, but from a re-skilling, or keeping up-to-date perspective, where the organisation is seen to have great importance [ 48 , 49 ]. The value of partnerships and shared understanding between managers and nurses as key enabling factors was identified in several studies [ 46 , 50 ]. In a related fashion, Jantzen argues that organisations should actively avoid fragmentation of CPD initiatives [ 51 ]. As more CPD training is digitised IT/ICT (information communication technology) skills were seen as key to successful CPD implementation [ 46 , 52 ]. It was acknowledged that the transformation to online learning does not only affect nurses, it involves change for the whole department [ 52 ].

Supportive environment as a prerequisite

An environment that supports learning was seen as a necessary prerequisite for CPD. Conditions had to include, flexible off-duty patterns to allow time for staff to study, availability of workplace learning, workloads were not excessive and CPD was fully funded or a shared responsibility between employer and staff [ 46 , 52 ]. Other indicators of a supportive environment included staff access to different CPD activities relevant to their career goals, while at the same time meeting organisational goals and where staff felt free to study openly and not secretively [ 15 , 41 ]. Moreover, the development of local and contextual CPD was seen as something that supported and made participation possible [ 43 , 53 , 54 ]. Participants indicated that nurses required financial support and practical support in the form of adequate time to participate in CPD activities and suitable staff cover when colleagues were away attending CPD activities [ 47 ]. Jantzen et al. [ 51 ] suggest there are three catalysts in a supportive environment; mentors, workplace camaraderie and a highly functional workplace team. Moral support or encouragement was identified in more than one study, where it was articulated that learners want to know there is an appreciation for the time and dedication needed to engage in CPD [ 44 , 46 , 50 ]. The value of learning from other health professionals other than nurses, in the day-to-day work was highlighted for professional development [ 54 ]. Similarly, the sense of a supportive environment with a strong team spirit is communicated elsewhere [ 39 ]. Explicit support is noted in several studies; support for novice nurses [ 39 ] but also the importance of explicit managerial support [ 55 ]. Conversely, in one study, respondents noted that there was less support for experienced or late career nurses [ 56 ].

Attitudes and motivation reflect nurse’s professional values

The value and importance of CPD was discussed in many of the studies. In some, CPD was perceived to be key in defining nurse professionalism [ 6 , 15 , 40 , 47 , 49 ]. Engaging in CPD was also viewed by new nurse graduates as an important element of their individual professionalisation in nursing [ 6 , 15 , 40 ]. In addition, CPD was perceived to be important for enhancing and up or re-skilling, keeping knowledge and skills up-to-date, considering that nursing practice has become more evidence based [ 6 , 43 , 46 , 51 , 54 , 56 ]. Furthermore, nurses stated that CPD was important for maintaining licensure, and felt that the responsibility for enrolling and participating in CPD activities was with the individual nurse, not with the employing organisations [ 53 ]. On the other hand, participants felt more motivated to learn if they could easily access CPD programs, if they felt supported and if there were a variety of CPD activities on offer. Here, bedside and informal learning was emphasized as important [ 57 ]. Similarly, contextualising learning and placing it in close proximity to practice was seen to enhance motivation and engagement [ 42 ]. CPD was also viewed as a way to start networking with other peers [ 44 ]. In one study, a competency framework was introduced, here participants felt that such a framework could help them reflect on their own practice and, as it provides a systematic approach to assessing a patient, look at their own strengths and weaknesses [ 58 ]. Such competency frameworks help to harness scarce training more effectively and encourage individuals to take more responsibility for their own development [ 58 ].

Participants’ attitudes towards CPD funding were mixed, with some stating that funding for CPD was the employer’s responsibility, while others felt that the individual practitioner was responsible or that the burden ought to be shared between the organisation and the nurse [ 5 , 15 , 40 ].

Nurses’ perceptions of barriers

Poor staffing levels, heavy workloads, lack of funding, lack of study time and anti-intellectualism were some of the perceived barriers to CPD brought out by this review. Participants in the studies reviewed felt that a lack of organisational support, especially from their managers, was an indication that the organisation did not take professional development of its staff seriously [ 46 ]. Some respondents reasoned that an anti-academic culture and lack of relevant CPD programs was further indication of this [ 5 , 15 , 40 ]. Seeing a connection to patient care was identified as a strong driver and nurses identified that CPD initiatives would be filtered out unless there was such a clear connection to patient care [ 43 , 51 ].

Additionally, some studies indicated that as role models, managers had to show interest in their own CPD, in order to motivate other nurses. In other words, the manager’s knowledge of CPD activities was reflected by their attitude towards work-based study, acceptance of staff who studied openly, the way the manager prioritised funding support and managed staff shift schedules to allow study release time [ 5 , 39 , 54 , 56 ]. Fatigue was identified as a major barrier. For example in Jho et al. [ 53 ], in a context of mandated CPD, respondents felt tired due to the heavy nursing workload in conjunction with CPD. Lack of strategy, and financial initiatives in terms of money, or time off to study was also acknowledged as a barrier [ 5 , 39 , 54 , 56 ]. Lack of transparent career trajectories were also acknowledged as an area of concern [ 44 ].

Other barriers, or de-motivating factors were identified; difficulties in attending CPD and keeping a life-work balance [ 48 ]. Barriers included: formal CPD courses away from the clinical areas were perceived to lack in authenticity [ 47 , 49 ] and a mis-match in expectations and outputs, where nurses viewed themselves as agents of change, but where the organisation was unable to offer means to capitalise on this perception and desire to bring about change [ 50 , 59 ]. As much as competency frameworks were viewed positively in offering a sense of direction, a divergent view was that they were limiting or created set boundaries that participants experienced as limited, for example, if used as prescriptive, hindering nurses to define their own learning needs [ 58 ]. Lack of IT competence was also perceived as a barrier [ 52 ] with more CPD being conducted online.

Perceived impact on practice as a core value

The impact of CPD on nursing practice was perceived as important and valuable in different ways. The impact could be both direct and indirect depending on the organisational culture [ 41 , 45 ]. This mixed perception could be due to the complex nature of health care organisations which can make knowledge sharing difficult [ 45 ] and that some CPD learning was done secretly, results of which were difficult to evaluate [ 41 ]. In the case where a competency framework was studied, participants felt that using the competency framework helped them organise their work and their thought processes [ 58 ]. A common sentiment was that CPD would benefit health care organisation through the provision and enhancement of practitioners’ knowledge and skills [ 46 ]. Sentiments articulating expectations of an impact of CPD could also be seen elsewhere too [ 52 , 55 , 56 , 60 ]. Moreover, CPD is expected to rely on better communication between managers and nurses as a way of informing each other about needs and means of fulfilling those needs [ 48 ]. Direct impact was realised through improved interprofessional collaboration and the idea that new methods could be directly translated into practice [ 47 ]. Others however, raised concerns that CPD programmes or courses may not translate into new practices [ 50 ]. This sentiment was echoed elsewhere too, where a need to situate CPD in close proximity of patients was seen as important for CPD to impact practice [ 49 ] While indirect impact happened through dissemination of knowledge and skills from CPD learning to other nurses at ward level, arguments were put forward that there will be no difference to practice unless organisational processes support and evaluate its effect on practice [ 46 ]. Participants reported that their professional confidence was enhanced, they felt they could challenge medical decisions and the status quo [ 41 ]. Furthermore, participants felt that CPD enhanced their professional knowledge and skills for better patient care through improved care standards, how they communicated and collaborated with other professionals. Participants also believed that learning increased their chances for career progression and reduced work-related anxiety because of enhanced knowledge [ 40 , 41 ].

The aim of this paper is to conduct a metasynthesis investigating the qualitative research on nurses’ experiences of continued professional development. As a result, this metasynthesis revealed a number of overarching themes, which synthesize the findings of previous qualitative oriented research during the period 2010–2019. 2010 was chosen to include the last 10 years of CPD research. The themes are; Organisational culture shapes the conditions, Supportive environment as a prerequisite, Attitudes and motivation reflect nurse’s professional values, Nurses’ perceptions of barriers and Perceived impact on practice as a core value. The themes put focus on important issues that were recurrently put forward by the nurses in the studies reviewed. However, the themes are not isolated from each other, rather, the content of the themes is interrelated. Some of the themes mainly mirror an overarching perspective at the organisational level of health care, while other themes describe the nurses’ experiences and needs on a personal level. The following discussion explores the above themes in relation to the three questions posed earlier; what is the reported value of CPD for nurses’ lifelong learning and its impact on nursing knowledge? What are the conditions necessary for CPD? What are the challenges faced by nurses when engaging in CPD? While we acknowledge that the questions and themes overlap, we have endeavoured to frame the discussion around the three research questions individually.

What is the reported value of CPD for nurses’ lifelong learning and its impact on nursing knowledge?

Nurses reported that CPD raises professional standards through competencies gained, thereby increasing professional performance with positive benefits for patients, organisations and individual nurses [ 40 ]. These outcomes were seen most prominently in the themes Attitudes and motivation reflect nurse’s professional values, and Perceived impact on practice as a core value. Closely aligned to CPD are the nurses’ clinical effectiveness and competence. Maintaining both requires nurses to keep their practice up-to-date highlighting the importance of CPD for nurses. The knowledge and skills gained by nurses through CPD advances the professional status of nursing, which was an idea that was prevalent in some of the studies in this review [ 15 , 40 , 47 , 50 ], but is also illustrated elsewhere in the literature [ 8 , 21 ]. Nurses acknowledged that expectations of professional accountability meant that standards of practice ought to be kept high in order to pass public scrutiny [ 15 , 40 ]. Furthermore, skills acquired through CPD, such as the ability to conduct systematic peer-reviews [ 45 ] and appraise literature for best evidence, provide nurses with essential professional competencies, embeds values such as caring behaviours, influences beliefs and attitudes which in turn shape nurses’ professional conduct [ 61 ]. As such CPD is seen as a tool for nurses to update their skills, and in doing so deliver safe and high-quality health care. As revealed in this review, nurses were willing to fully fund or part-fund their CPD as long as CPD programs were captivating, easily accessible, there was fair allocation of study time and their efforts towards CPD were recognised. The latter implies that nurses want time and space to transfer their CPD learning into practice and for their CPD to be recorded [ 5 , 45 ]. The belief is that, consequently, patient care will improve with positive impact from organisational change [ 15 , 45 ]. However, it is clear that the organisation is key in making CPD work for nurses. The issues brought up in the theme organisational culture shapes the conditions is thus very important in stimulating nurses to engage in CPD. The nurses’ attitudes and motivation to engage in CPD also depends on a supportive environment and engagement may in turn influence the organisational culture.

What are the conditions necessary for CPD?

A disconnect could be seen in relation to the conditions for CPD, where access to CPD training came to the fore as problematic in some of the studies. Nurses had to travel long distances to attend courses [ 15 , 62 , 63 ]. To avoid these challenges, nurses settle for CPD as long as it fulfils mandatory requirements for registration [ 53 ]. If intentions of CPD are to provide a basis for the continual updating of skills, then authentic learning as an expected outcome is seen as a prerequisite for nurses to engage in CPD, whether it occurs at the bedside, at a training facility or through an IT mediated interaction. This calls for accessible CPD, improved design and delivery methods for all nurses [ 52 ]. Nurses’ experiences described in the themes Organisational culture shapes the conditions, Supportive environment as a prerequisite, show that structural and moral support are both important. Structural support in the form of availability, time to engage in CPD, as well as clear expected outcomes [ 46 , 49 ], but also moral support in the form of an understanding management and environment, and also peers and leaders who themselves also prioritise CPD [ 58 ]. Organisational support and commitment towards CPD should mean allocation of study time, support of nurses who study privately, by creating space for knowledge and skills integration and managing poor cultural practices that hinder open study. Funding is seen as a key factor across many of the studies, both in terms of enabling nurses to participate, but also as a way of acknowledging nurses who engage in CPD. Further studies may need to look more closely at how nurses perceive different aspects of funding. For nurses’ lifelong learning to endure, CPD programs need to be more accessible and kept interesting by making them more relevant to nurses’ practice contexts. Here the importance of the organisation for creating a CPD conducive environment is emphasized [ 46 , 51 , 52 ]. As role models, managers need to lead by example and engage in CPD themselves, but also demonstrate explicit support. They also need to influence policy to create environments conducive to CPD. If funding situations do not improve, work-based CPD learning could be one of the alternative ways of CPD delivery for nurses. To promote CPD engagement and cost reduction, eLearning approaches could be utilised for education and training. However, poor IT skills among nurses, but also within organisations continues to be a potential weakness [ 52 ]. A challenge remains here in enabling nurses to get recognition from informal on-site learning [ 16 , 17 , 18 ], where elements of meta-cognitive reflection can be used to acknowledge nurses’ continued professional development.

What are the challenges faced by nurses when engaging in CPD?

In some of the literature reviewed, participants lamented their current conditions for CPD, and identified clear barriers and challenges in the form of concerns related to lack of funding for CPD, staffing levels, time allocation for study, lack of organisational support because of negative cultural practices, CPD design & delivery and limited choice of CPD activities. This is articulated within the themes: Organisational culture shapes the conditions, Supportive environment as a prerequisite, Nurses’ perceptions of barriers [ 2 , 11 , 34 , 41 ] . However, studies did not explore the views of nurses on recruitment and retention and its impact on accessing a variety of CPD activities. Evidence from this review indicates that modernising healthcare and simultaneously cutting CPD funding for nurses could lead to a limited number of nurses attaining the skills and competences needed for the modernisation process. In view of the understaffing that is reported elsewhere [ 5 , 15 ], we identify a cause for concern. These perceived barriers may undermine nurses’ professional development [ 23 , 59 ]. Moreover, the findings presented here revealed that nurses face a number of challenges in relation to their CPD participation. The challenges include limited CPD activities to choose from, poor CPD delivery methods, negative organisational culture practices such as anti-intellectualism and lack of support. As a result, nurses were less motivated to participate in CPD training [ 57 ].

It is clear from the review, that IT concerns are becoming more and more prominent, given that more CPD programmes are being offered through digital platforms [ 47 ]. This is a concern for both the individual nurses, but also their organisations. On concerns regarding CPD delivery methods, nurses indicated that they preferred different styles. With these concerns comes the view that learners learn in different ways depending on the context and subject of study [ 61 , 62 ]. This supports the notion that individuals have different learning preferences [ 61 ], where some adult learners learn better in a structured and teacher guided context, while others prefer self-direction.

Limitations

The search was conducted by an experienced search engine expert. Even so, we may still have been unsuccessful in finding all the relevant articles. The study was focussed on qualitative studies, which means that studies using predominantly quantitative or mixed methods were not included, but could hold important insights. In the introduction to the study we used the UK as an example for how CPD might be regulated. However, we have conducted a comprehensive search of the literature and our analysis was not conducted with a UK-centric perspective. While each study needs to be understood in terms of local rules and regulations, the similarities in the findings are striking.

The metasynthesis indicates that differences exist between the nurses’ CPD needs and expectations and organisations’ approaches to nurses’ professional development. The review lays bare a disconnect between the rhetoric of identifying CPD as a way to enhance nurses’ skills, and the reality of CPD interventions, where nurses do not feel support within their organisations or from their immediate supervisors. The review also revealed that CPD is an important element of nursing practice and nurses’ lifelong learning. Furthermore, it suggests that nurses are motivated to take part in CPD to enhance their knowledge, improve skills and keep up- to -date with recent evidence. While evidence from this review indicates that nurses believe that CPD has a positive impact on patient care, there is lack of contemporary research to qualify this claim and there is limited evidence from this review to support this assumption. However, evidence from the review suggests and confirms, that the greatest barriers for CPD in nursing are a lack of funding and time to participate in CPD activities, which are clearly related to organisation structure. It is difficult to envisage how such conditions could be conducive for nurse CPD to flourish. Such perceived barriers undermine nurses’ efforts to keep knowledge and skills up-to-date and provide better patient care while meeting the ever-changing needs and expectations of their patients. This is further exacerbated by negative organisational cultural practices and lack of knowledge on how to facilitate, design and deliver CPD for their staff. We conclude that policy makers and relevant stakeholders need to put in place strategies to support nurse CPD in long term and in doing so tear down the barriers of CPD.

Availability of data and materials

The data in the study is comprised of previous research articles. A full list of articles is included in the Table 3 .

Abbreviations

Continued Professional Development

United Kingdom Central Council for Nursing, Midwifery and Health Visiting

Post registration education and practice

Nursing & Midwifery Council

Health Education England

National Health Service

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We would like to thank Gun Brit Knutssön, at Karolinska Institutet’s University Library, Stockholm, Sweden for the systematic search.

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Mlambo, M., Silén, C. & McGrath, C. Lifelong learning and nurses’ continuing professional development, a metasynthesis of the literature. BMC Nurs 20 , 62 (2021). https://doi.org/10.1186/s12912-021-00579-2

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professional development in healthcare essay

Professional Development for Nurses Essay

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Introduction

Academic experiences, professional development plan.

The Nursing profession is rewarding, challenging, and fascinating since it involves solving intricate problems and interacting with people. My most exciting moment was in college where I learnt about professional development and interpersonal growth. Routine interactions with my class mates and fundamental nursing courses have shaped my reasoning and creative thinking skills. As learned in one of my classes, professional ethics has shaped my perception of nursing practices and values. Reading materials like the “Joint Statement on Academic Progression for Nursing Students and Graduates” and “Professional Development for Nurses” have helped me gain insights into the nursing profession and solve problems at personal and group levels (Bodine, 2019). Furthermore, my learning experiences have bolstered my professional development plan. Pursuing advanced certification and understanding the various lead patient initiatives will advance my career growth.

The experiences gained in and outside class have shaped my interpersonal thinking, and I aim to improve my service quality at work. During my first year, I was introduced to nursing ethics and values essential for quality service delivery. I was motivated by an article on professional values and career choice among nursing students (Alkaya et al., 2018). The article sheds light on human dignity, autonomy in decision-making, privacy, and professional competency. Upon reading the article, I started exercising the values personally and made them part of routine practices.

Furthermore, interacting with the nursing stakeholders was worth my time since I learned much about the different nursing associations fundamental for my career development. The information sessions organized by the college and partner organizations were fascinating and provided networking platforms. My academic experiences involved learning and applying my knowledge in real-life situations and networking with different professions. I created my career development plan that would allow me gain more knowledge and become a competent nurse.

Pursue Advanced Certifications

College education can be insufficient in promoting an influential nursing profession. Therefore, advanced nursing certifications help one gain knowledge not taught in class. Furthermore, the certifications play a significant role in explaining concepts that nursing students fail to understand in classes (Beebee et al., 2018). I intend to pursue certifications in informatics and psychiatry to expand my knowledge in the two study areas. The accreditation in informatics will shape my technological skills, while the certification in psychiatry will facilitate enough information on mental health issues medication. The certificates will also add to my career portfolio, opening the door for advanced opportunities.

Lead Patient Safety Initiative

Nursing education emphasizes patient safety practices and conducive working environment creation. Most of the readings I came across at college discussed the various patient safety initiatives. Due to technological advancements, the nurses should be conversant with multiple mechanisms adopted to enhance patient safety. For instance, the Smart Intravenous Pumps and Barcode Medication Administration help administer the correct dosage (Bodine, 2019). I intend to understand the different patient safety initiatives that enhance my relationship with patients. Pursuing certifications, involvement in the nursing associations, and in-depth research will help me understand the industries.

The nursing profession has involved fascinating experiences and insights from the reading materials. Professional ethics is significant since it enhances interpersonal growth and nursing values. The nursing associations are persuaded by unity as manifested through my interactions during different occasions organized by the university. The knowledge gained in class has convinced me to research on diverse topics and participate in various nursing students’ associations. Furthermore, I have developed a career progression path that involves pursuing advanced certifications and understanding lead patient initiatives. In my view, nursing is the most fascinating and demanding profession.

Alkaya, S. A., Yaman, Ş., & Simones, J. (2018). Professional values and career choice of nursing students. Nursing Ethics , 25 (2), 243-252.

Beebe, L. H., Roman, M., Raynor, H., Thompson, D., & Ray, S. (2018). Transforming health care through interprofessional graduate education. Perspectives in psychiatric care , 54 (1), 19-24.

Bodine, J. L. (2019). Preparing nurse leaders in nursing professional development: Association for Nursing Professional Development Leadership Academy. Journal for nurses in professional development , 35 (6), 351-353.

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Reflective essay of personal and professional development

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Reflection as part of continuous professional development for public health professionals: a literature review

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Nishamali Jayatilleke, Anne Mackie, Reflection as part of continuous professional development for public health professionals: a literature review, Journal of Public Health , Volume 35, Issue 2, June 2013, Pages 308–312, https://doi.org/10.1093/pubmed/fds083

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For many years, reflection has been considered good practice in medical education. In public health (PH), while no formal training or teaching of reflection takes place, it is expected as part of continuous professional development. This paper aims to identify reflective models useful for PH and to review published literature on the role of reflection in PH. The paper also aims to investigate the reported contribution, if any, of reflection by PH workers as part of their professional practice.

A review of the literature was carried out in order to identify reflective experience, either directly related to PH or in health education. Free text searches were conducted for English language papers on electronic bibliographic databases in September 2011. Thirteen papers met the inclusion criteria and were reviewed.

There is limited but growing evidence to suggest reflection improves practice in disciplines allied to PH. No specific models are currently recommended or widely used in PH.

Health education literature has reflective models which could be applied to PH practice.

The practice of public health (PH) is a science as well as an art. 1 PH professionals may work across all or some of its main domains—health improvement, health protection and health services. The Faculty of Public Health provides direction and guidance to enable the development of professionals and establish competencies that specify behaviour, skills and attitudes. The Faculty encourages professionals to reflect as part of essential practice. 2 Many different disciplines contribute to the PH workforce, but all are expected to keep themselves up to date through continuing professional development (CPD). However, the mere experience of carrying out some developmental activity may not be sufficient to enable future improvements and thus many medical specialities encourage their practitioners to reflect on their experiences. 3

Reflection can contribute to learning. 4 Illeris 4 describes learning to consist of emotional and social dimensions as well as cognitive. In practice, the cognitive aspects are most easily measured through assessments or performance, while the emotional and social aspects may be less easily captured. Frameworks of reflection could support the development of both these dimensions. 5 Further to this, if learning is considered to take place in the form of a cycle, as shown in Fig. 1 , the role of reflection becomes apparent.

Four stages of Kolb's learning cycle 6 .

The cycle of learning comprises four elements—a concrete experience, an observation and reflection, formation of abstract concepts and testing in new situations. 6 The circular model does not mean each stage should be equally weighted in time and emphasis. 7 Kolb and Fry, in their theory, argue that the cycle can begin at any of those points. However, in its simplified form, the learning cycle will begin by carrying out a task, the person would reflect on that experience and apply the learning in a new situation. In order to apply experience to the new situation, the ability to generalize through identifying principles and their connections to actions over a range of circumstances is required. Throughout the process, learners rate themselves which is an important element for adult learners 8 and could be considered relevant for continuous professional development. In his work, Donald Schon 9 concludes that the possible objects for reflection can be as varied as the situations faced and the systems in which they occur. Reflection can be understood as the ‘ability to gain understanding of specific issues in practice through critically contextualizing, observing and analysing to generate new knowledge and insights which can enhance practice’. 10 This may mean the individual might reflect on the feeling for a situation which has led to adoption of a particular course of action, the way in which the problem has been framed and/or the role this has created for the individual in the wider institution as a result. 9 It can be seen as the process of reasoned thought which enables a critical assessment of both self as a professional and as an agent of change. 10 This latter is of particular relevance to PH professionals in their roles of influencing decision-making.

However, as a speciality on the whole, PH has focused heavily on quantitative measures for evaluation. The purpose of this paper is to describe the development of a framework for learning to reflection for individuals as well as for teams and to identify approaches to guide continuous professional development. This paper describes how this could be implemented and used in everyday work to enable professional development.

Literature search strategy

A literature search was undertaken using CINAHL, Medline and OvidSP electronic databases in September 2011. The search terms used were evidence-based practice, research evidence, medical education, qualitative research, reflective practice, reflection and evidence. Other sources included handpicking of books on evidence-based practice, reflection and research. Full texts of potentially relevant articles were obtained. Papers were identified for inclusion in the review by examination of full text articles. Data relating to characteristics of the population, intervention, outcome measures, study design and outcomes were collected.

Inclusion criteria

Papers written in English only were included. Articles pertaining to reflection in or on practice in PH or related disciplines were included. Documents published between 1970 and 2011 were included. Peer- and non-peer-reviewed publications were considered.

Exclusion criteria

Articles that included reflection as by-product rather than the main focus were excluded. Non-English language publications were excluded.

Electronic searches yielded over 100 citations. Further citations were obtained by hand searching of reference lists. More than 20 full articles were retrieved and assessed against the set inclusion criteria. Of the five papers included in this review, none were from PH, two from nursing and two from other allied health professions or other education literature. One further model was included from non-health background.

The search did not find evidence that particular frameworks were in regular use in current PH practice. The search identified educational concepts from the literature which could be applied to PH. Several approaches to reflection were found. While none of these were linked directly to PH practice, their use in medicine was referenced. The literature discussed here were selected on relevance and focused on the synthesis on framework, service-based learning and mentorship.

Burton's approach 11 was to use the core questions focused on reflection on action but with the ability to be applied in and before action. Burton's cycle of three questions comprises the questions: What? So what? Now what? These are questions which the reflector can answer during the reflective process.

Boud et al . 12 defines reflection in the learning context and focuses on the personal experience as the object of reflection—as the intellect and affects lead to new understandings and appreciations. Boud describes three main components to consider—experience, reflection and outcome. The experience can be a behaviour, ideas or feelings. The reflection will include returning to the experience, attend to feelings that it brought about and a re-evaluation of the experience. The outcome will look at new perspectives, changes to behaviour and an application of learning into practice.

The Gibbs' reflective cycle (1988) encourages a clear description of the situation, analysis of feelings, evaluation of the experience and an analysis to make sense of the experience. This would be followed by conclusions where other options are considered and reflection upon experience to examine what one would do if the situation arose again. 13 In essence, Gibbs describes a cycle of description, feelings, evaluation, analysis, conclusion and action plan. The description is questioning what happened followed by the feelings brought about through the questions—‘what were you thinking and feeling?’. The evaluation component describes what was good and not so good about the experience. The analysis should identify what sense can be made of the situation and the conclusion details of what else could have been done. The process of reflection is ended with an action plan for what could be done if the situation arose again.

Atkins and Murphy 5 through their model suggest that for reflection to have a real effect it needs to be followed by an action commitment. The authors describe a cycle of awareness, description, analysis, evaluation and learning. The reflective process begins with the awareness of uncomfortable feelings and thoughts from the action or new experience followed by a description of the situation including thoughts and feelings. This would need to include salient events and key features identified by the reflector. The reflector would need to analyse feelings and knowledge relevant to the situation—identifying knowledge, challenging assumptions, imagining and exploring alternatives.

The reflection process would also need to include evaluation and consolidating learning. Evaluate the relevance of knowledge through asking questions includes the following: ‘Does it help to explain and/or solve problems’? ‘How complete was the use of knowledge’? These steps would be followed by identifying any learning which has occurred.

After-action review is a de-brief process in practice originally developed by the US army which aims to identify how to improve, maintain strengths and focus on performance of specific objectives. The de-brief manual provides guidance for individuals and group reviews. 14 The review would answer the following four questions: What was supposed to happen? What actually happened? Why were they different? What did we (I) learn?

Main findings

There is no published evidence of the use of particular models of reflection in PH practice. The general medical education literature contains various approaches to reflection.

The evidence base to suggest learner's self-reflection skills can be improved through formal training is still lacking.

There are a variety of theories on reflection in the education literature. The implication this brings to individual PH practitioners is to consider when and how they will reflect as part of their continuous learning cycle. In addition, whether the act of reflection should be done alone or as part of a team or both will need to be established. As a discipline that has focused less on reflection in the past it is possible to draw on theories and models already existent and in use within medicine. There are a range of ways to reflect which include methods like journal writing, discussions and use of technology such as blogs. 15 There is also a range of aspects to be considered, for example, individual perspective, team dynamics and societal impacts. Ultimately, the aim of reflection would be to improve practice and learn from relevant experiences. It is obvious that this comes from being an analytical reflector and moving beyond pure description. As some of the literature suggests, it is useful to recognise emotional influence and challenge one's ideas. In broader learning terms, it is also useful to consider the relevance of prior experience.

Reflection enhances personal development by leading to self-awareness. 16 If the focus of reflection is improvement in patient care, it helps to expand and develop clinical knowledge and skills. 17–19 The process slows down activity providing time to process material of learning and link to previous ideas. 20 It should also enable more ownership of the learning taking place. 20 Reflection has been reckoned to promote optimum effectiveness and efficiency in an ever evolving and complex health-care system through practitioners auditing their own practice. 21 , 22 ‘Reflection reminds qualified practitioners that there is no end point to learning about their everyday practice’. 18

Where it exists, the practice of reflection has tended to focus on individual professionals at specific points in time and/or on specific elements of practice. 10 This, however, can form only a part of the experience as many PH actions involve many disciplines. Often action takes place across multi-sectoral teams and involves multi-phased interventions. Programme delivery is often longer term, should be population focused and policy led.

The learner involvement is a key fundamental principle of adult education. PH CPD and the reflection that forms part of it can be viewed in light of adult education as individuals need to take ownership and engage in setting their learning agenda. 23 Therefore, the mere act of reflecting supports the androgogical model as adults need to be able to establish the purpose of the activity undertaken and identify how to cope effectively with real-life situations. 24

There needs to be opportunity to reflect as individuals as well as in teams in an acute manner while carrying out the longer term projects. Reflection can be used as a tool to facilitate professionals to assess beliefs, values and approaches to practice. 25 These factors determine how individuals personally and the policies/programmes which they deliver, act as agents of change, contributing to empowerment. Adult learners are more likely to believe and instil ideas that they help create. The environment can provide many structured activities that generate the ideas, concepts or techniques if an active decision to do so is taken. The practitioner could then experience surprise, puzzlement or confusion associated with the situation. Reflecting on the phenomena that is being experienced and prior understanding which have implicated, the resulting behaviour will lead the learner to new understanding. 9

In the health promotion literature, reflection on external and internal factors is recommended. These factors, however, could be equally applied to other domains of PH as they will include policy, professional and societal influences (examples of external factors) and attitudes, skills, experiences and team dynamics (examples of internal factors). 26

The practice of self-reflection in academic achievement has been captured in disciplines that contribute to PH. A positive impact was noted through reflective journal writing over only scientific report writing for those studying biology. 27 This was evidenced through greater awareness of cognitive strategies and conceptions of learning when learners constructed more complex and related knowledge when learning from text. In studies of mathematics students, while reflection was not necessary for high grades of achievements, it supported better conceptualization of meanings of the technical definitions. 28 Practice, shaped through reflection can develop professionals, organizations and society. This is already considered important within health promotion. 25

Educational concepts and the impact of reflection are not easily measurable. 29 Therefore, its merits may be overlooked. One can argue that this approach of reflecting on an issue is too straight forward and, in practice, difficult issues may take months to reflect on. Doing so quickly might lead to a paper exercise. Explicit frameworks may not be suitable for some situations. Frameworks vary in their focus of contexts. However, they are aimed to be critical analyses of knowledge and experience to deepen understanding. Time, motivation, initial expertise and lack of peer support are recognized barriers to reflection. To add to this are organizational contexts and team dynamics—frequent problems faced by PH professionals. 10 However, a structure to guide the process of reflection on the content and the process of learning would be deemed useful. 30

Limitations

With the aim of providing a broad overview of reflective approaches relevant to PH professionals, this work provides a selection and not a complete comprehensive collection of medical education literature.

What does this report add?

There are very few articles relating the use of reflection to current PH practice and furthermore on the strengths and weaknesses of different models that could be applied. This review article outlines some of the most applicable and outlines their merits and otherwise. Individuals working in PH may consider some of the approaches described here alongside their current professional development activities either as individual learners or as part of learning within teams.

At present, the strength and extent of the evidence base for the educational effects of reflection in a PH setting is limited.

However, there is evidence of an improving trend in the quality of reported studies. ‘Higher quality’ papers identify improvements in knowledge and understanding, increased self-awareness and engagement in reflection and improved opportunities through specialist training and continuous professional development.

In recognition of the time commitment involved, the benefits to the profession must be apparent. In addition, the opportunity cost of other learning and developmental activity forgone needs to be considered. Further work is needed to strengthen the evidence base for reflection, particularly, where possible, comparative studies which observe changes in knowledge and abilities directly.

Given its merits, while the quantitative evidence base is limited, what are the implications for practice? Given PH's stated desire to base practice upon evidence there is urgent need to formally assess the effectiveness of reflection in the improvement of PH practice.

We would like to thank Joanne Harcombe for her helpful comments on the draft manuscript.

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Month:	Total Views:
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December 2016	45
January 2017	155
February 2017	306
March 2017	315
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September 2017	162
October 2017	375
November 2017	542
December 2017	3,596
January 2018	3,695
February 2018	2,893
March 2018	4,113
April 2018	6,124
May 2018	6,749
June 2018	4,475
July 2018	3,727
August 2018	4,805
September 2018	4,171
October 2018	5,277
November 2018	6,860
December 2018	5,454
January 2019	5,179
February 2019	4,963
March 2019	6,521
April 2019	7,564
May 2019	7,750
June 2019	5,457
July 2019	4,482
August 2019	4,909
September 2019	4,247
October 2019	4,845
November 2019	4,177
December 2019	3,437
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February 2020	2,898
March 2020	2,971
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May 2020	2,243
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July 2020	1,603
August 2020	1,518
September 2020	1,658
October 2020	2,042
November 2020	2,346
December 2020	2,254
January 2021	2,718
February 2021	2,100
March 2021	3,634
April 2021	3,593
May 2021	4,133
June 2021	2,396
July 2021	1,671
August 2021	1,759
September 2021	1,731
October 2021	2,225
November 2021	2,323
December 2021	2,057
January 2022	2,583
February 2022	1,834
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November 2022	1,176
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March 2023	1,222
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January 2024	1,020
February 2024	807
March 2024	1,069
April 2024	1,167
May 2024	1,166
June 2024	563
July 2024	464
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Home — Essay Samples — Nursing & Health — Nursing — Professionalism in Nursing

Professionalism in Nursing

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Why is Professional Development Important?

Learn the role of professional development in advancing your career.

Lian Parsons

Professional development is an important aspect of continuing your career growth and striving to reach your goals.

This blog post will explain what professional development is, its benefits to both employers and their employees, and how to seek different opportunities out to reach your full potential.

What is Professional Development?

Professional development is gaining new skills through continuing education and career training after entering the workforce. It can include taking classes or workshops, attending professional or industry conferences, or earning a certificate to expand your knowledge in your chosen field.

Some companies offer in-house opportunities for professional development, such as training sessions or mentoring programs, but many professional development programs are done independently.

Professional development is important because it has the potential to open opportunities for career advancement, such as promotions. It can assist you in honing existing skills and in learning new ones.

It can also help you stand out in a pool of applicants; showing that you have completed professional development programs or additional industry certifications on your resume can go a long way in showing your expertise in your field.

Employees who show initiative in independent learning can signal to employers that you are open to new experiences and are enthusiastic about continuing to grow.

Benefits of Professional Development for Employers

Professional development can be instrumental in growing a stronger team.

Employers who encourage their employees to seek out professional development opportunities are in turn encouraging higher productivity and job satisfaction.

Higher Retention Rates

According to a Business News Daily article, businesses should offer professional development opportunities to their employees to improve potential turnover.

Professional development can help to bolster employees’ confidence in their work. Greater confidence can, in turn, translate into higher overall job satisfaction, employee performance, productivity, and overall morale.

Investing in professional development training programs also shows employees that their company is invested in their success and interested in cultivating their advancement.

Attract Better Talent

It can be challenging to find — and retain — talented employees. Offering professional development opportunities can help employers fill open positions by attracting and retaining skilled employees.

According to talent management platform Clear Company, 74 percent of employees say that a lack of professional development opportunities are preventing them from reaching their full potential. Additionally, 94 percent of employees would stay longer at a company if it invested in staff development.

Employers offering these benefits are more likely to attract potential employees who are interested in striving for excellence and pursuing advancement.

Investing in professional development for employees can grow an existing team’s skills and entice new talent to join with the incentive of a clear learning and development plan.

Help Employees Stay Up to Date With Industry Trends to Keep Skills Sharp

Industry trends move rapidly, and it’s important for companies to keep pace with the times. Ongoing professional development can prevent potential stagnation by maintaining — and improving — employee skills.

Look for programs that will help you stay up to date, such as those for agile leadership for hybrid work, or for innovation strategy .

Employees engaged in professional development are also more likely to stay engaged in their work and to be enthusiastic about pursuing their goals.

Get started on your professional development journey today.

Benefits of Professional Development for Employees

From gaining confidence in your abilities to building potential for advancement, professional development offers employees many benefits for not only your career, but your personal goals as well.

Learn new skills

Through professional development, you may hone both hard and soft skills in your work. Hard skills pertain to job-specific knowledge you can obtain through formal training or education. Soft skills are personal competencies, such as effective communication or the skills that contribute to emotional intelligence .

Developing both types of skills is important to reaching your professional goals — and even some of your personal ones.

Boost Confidence and Credibility

Adding additional skills or certification from a professional development program to your resume is one way to boost your confidence in your skills and show your credibility to employers.

Professional development opportunities can expose both new and experienced professionals to new ideas and expertise. Seeking out these opportunities shows ambition and the space to practice those new competencies.

Develop Leadership Skills

A confident employee is also likely an enthusiastic employee. If you take the step to grow and develop your skills, the incentive to seek out additional opportunities can continue to expand along with it.

If you are an employee who wants to advance your career but isn’t sure how to do so, professional development can encourage you to put your hand up for leadership opportunities you may not have sought out otherwise.

This blog post offers helpful tips on how to choose a leadership development program.

Build Your Network

Professional development can provide many opportunities for networking. Workshops, conferences, classes, and webinars are all spaces in which professionals can meet new people within their industry and make new connections.

These connections can lead to new opportunities, mentorship, and support which may provide the next stepping stone in your career.

Advance in your career

A well-qualified employee attracts employer attention. Employees who are invested in professional development display commitment to their work and an interest in continuing to improve.

Professional development can also boost your earning potential by increasing your value through obtaining credentials, certifications, and designations.

Where to Take Professional Development Courses

There are a broad range of professional development opportunities.

Harvard Division of Continuing Education’s Professional & Executive Development offers dozens of courses spanning multiple industries. Your employer may even help you pay for these opportunities if you effectively show their worth.

There are both in-person and online options available, so choose what works best for your goals and lifestyle.

Seek out programs, workshops, seminars, mentorship programs, and more within your industry. Investing in yourself is just the first step.

Take the next step to advance your career. Find the program that’s right for you.

Browse all Professional & Executive Development programs.

About the Author

Lian Parsons is a Boston-based writer and journalist. She is currently a digital content producer at Harvard’s Division of Continuing Education. Her bylines can be found at the Harvard Gazette, Boston Art Review, Radcliffe Magazine, Experience Magazine, and iPondr.

Strategic Leadership

Senior level managers must tackle complex problems using creative problem-solving and a portfolio of skills and styles. Here’s a look at how being a strategic leader can move an organization—and your career—forward.

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The Division of Continuing Education (DCE) at Harvard University is dedicated to bringing rigorous academics and innovative teaching capabilities to those seeking to improve their lives through education. We make Harvard education accessible to lifelong learners from high school to retirement.

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Celtic Leadership Institute

The Healthcare Professional We Deserve

During COVID-19, healthcare workers and emergency responders reached a new level of acclaim in the public eye. As the pandemic wore on, doctors and nurses were seen performing selfless acts daily – putting themselves in harm’s way to help others. The refrain was “not all heroes wear capes,” yet one group of health professionals has been consistently compared to the Caped Crusader.

Respiratory therapists specialize in assessment, treatment, and care of patients with breathing disorders. They work with patients taking their first breath, premature infants in the NICU, and with adult patients taking their final breath. In certain corners of the internet, they’re often called the “Batman of Healthcare,” because they get the signal, show up with their gadgets, save the day, then disappear, and no one knows their name.

Despite their crucial role on the healthcare team, the profession is often less recognized compared to other more high-profile positions, such as nursing. Although less understood by the public, they are in high demand, with job growth much faster than average.

Carlow has three tracks for students to become respiratory therapists and start working in the field quickly.

The new two-year Associate of Science track trains students to become Registered Respiratory Therapists (RRT) and work in all aspects of the profession, such as hospitals, clinics, diagnostic labs, pulmonary rehabilitation, and homecare.
The three-year Bachelor of Science track prepares respiratory therapists to move into leadership, management, education, or research roles. Unique in this field, this program offers an accelerated track which allows students to begin their careers fast.
The fully online RRT to BS Degree program is designed to provide working respiratory therapists the ability to advance their degree.

Like most Carlow students , graduates of the Respiratory Therapy program tend to find employment immediately after graduation, either locally, nationally, or as a traveling respiratory therapist. Many enjoy the fast-paced, dynamic nature of the job, while finding gratification in diversity, collaborative teamwork, and helping patients breathe easier.

We can only hope for a Grey’s Anatomy character to emerge and raise awareness of this vital profession. Until then, respiratory therapists will continue to stand in the shadows, working tirelessly while finding fulfillment in the impact of their work.

Open access
Published: 20 August 2024

Impact of a game-based interprofessional education program on medical students’ perceptions: a text network analysis using essays

Young Gyu Kwon 1 ,
Myeong Namgung 2 ,
Song Hee Park 3 ,
Mi Kyung Kim 3 , 4 ,
Sun Jung Myung 5 ,
Eun Kyung Eo 6 &
Chan Woong Kim 1 , 2

BMC Medical Education volume 24 , Article number: 898 ( 2024 ) Cite this article

130 Accesses

Metrics details

The increasing complexity of the healthcare environment and the necessity of multidisciplinary teamwork have highlighted the importance of interprofessional education (IPE). IPE aims to enhance the quality of patient care through collaborative education involving various healthcare professionals, such as doctors, nurses, and pharmacists. This study sought to analyze how game-based IPE activities influence students’ perceptions and reflective thinking. It also aimed to identify the shifts in perception and effectiveness caused by this educational approach.

The study is based on a game-based IPE program conducted at University A, involving medical and nursing students in structured learning and team-based activities. Data were collected using essays written by the students after they had participated in IPE activities. Text network analysis was conducted by extracting key terms, performing centrality analysis, and visualizing topic modeling to identify changes in students’ perceptions and reflective thinking.

Keywords such as “patient,” “thought,” “group,” “doctor,” “nurse,” and “communication” played a crucial role in the network, indicating that students prioritized enhancing their communication and problem-solving skills within the educational environment. The topic modeling results identified three main topics, each demonstrating the positive influence of game-based collaborative activities, interprofessional perspectives, and interdisciplinary educational experiences on students. Topic 3 (interdisciplinary educational experience) acted as a significant mediator connecting Topic 1 (game-based collaborative activity experience) and Topic 2 (interprofessional perspectives).

This study demonstrates that game-based IPE activities are an effective educational approach for enhancing students’ team building skills, particularly communication and interprofessional perspectives. Based on these findings, future IPE programs should focus on creating collaborative learning environments, strengthening communication skills, and promoting interdisciplinary education. The findings provide essential insights for educational designers and medical educators to enhance the effectiveness of IPE programs. Future research should assess the long-term impacts of game-based IPE on clinical practice, patient outcomes, and participants’ professional development.

Peer Review reports

With rapid changes in the healthcare environment and the advancement of systems, effective collaboration among various healthcare professionals is crucial to meet patients’ high expectations [ 1 ]. This underscores the growing importance of interprofessional education (IPE), which aims to develop the ability to collaborate efficiently as multidisciplinary teams [ 2 , 3 ]. IPE involves students from two or more healthcare professions learning about, from, and with each other through collaborative education. The primary objective of IPE is to assist healthcare professionals, including doctors, pharmacists, and nurses, in developing the competence to collaborate more effectively in multidisciplinary teams to enhance patient care [ 4 ]. Its history began in the early twentieth century and has evolved to include numerous healthcare professionals such as nurses, pharmacists, and dentists [ 5 ]. The World Health Organization (WHO) reported that IPE provides highly collaborative teamwork experiences that improve job satisfaction and enhance access to and safety in patient care [ 6 ]. Recent studies have also shown that IPE is pivotal not only in promoting professional autonomy, understanding of professional roles, teamwork, and collaboration, but also in providing essential knowledge and skills for improving healthcare services [ 7 , 8 , 9 , 10 , 11 , 12 , 13 ].

One innovative approach to enhancing IPE involves game-based learning, which integrates educational content with interactive gaming elements to create engaging and effective learning experiences. Game-based learning has been shown to enhance students’ motivation, participation, and retention of knowledge by providing a dynamic and immersive learning environment [ 14 , 15 , 16 ]. In the context of IPE, these activities can simulate real-life clinical scenarios that require collaboration, communication, and problem-solving among diverse healthcare professionals [ 17 ]. This method allows students to practice and develop these critical skills in a safe and controlled setting, thereby preparing them for actual clinical practice [ 18 ].

Previous IPE studies involving students primarily used surveys, interviews, and participant observations to assess changes in students’ knowledge acquisition, collaboration, teamwork skills, and attitudes [ 19 , 20 , 21 , 22 , 23 ]. While these approaches have provided valuable information for evaluating the effectiveness of IPE programs, they have limitations in terms of exploring students’ direct expressions and deep thinking. Recent research has started exploring game-based learning in IPE, emphasizing its potential to enhance collaboration, communication, and problem-solving skills among healthcare students [ 24 , 25 ]. Game-based learning activities, such as serious games and simulations, offer engaging experiences that promote interprofessional collaboration and reflective thinking [ 17 ]. However, there is still a scarcity of research on students’ personal experiences, changing perceptions, and in-depth understanding of interprofessional collaboration through game-based learning. Addressing this gap can provide better relevance and context to the study of IPE.

Medical education literature has highlighted the importance of various educational strategies in enhancing reflective thinking skills [ 26 , 27 ]. Dewey defines reflective thinking as conscious thought in the problem-solving process, which can be considered as the active utilization of knowledge gained through experience [ 28 ]. Narrative materials, such as essays, are useful tools for gaining an in-depth understanding of students’ experiences and perceptions. Thus, analyzing reflective thinking through essays can help students better understand their learning experiences and improve their problem-solving abilities through effective collaboration across different disciplines [ 29 , 30 ].

This study aimed to analyze students’ perceptions of collaboration by examining essays they wrote after participating in game-based IPE activities, thereby providing evidence for the effectiveness of such education. The results of this study are expected to serve as foundational data to help design and implement more effective collaborative learning strategies for IPE programs.

Course design

The IPE program at a South Korean university targeted fifth-year medical and fourth-year nursing students to prepare them for clinical training. The course was divided into two phases: a six-day shadowing period and a four-day IPE activity period.

During the shadowing period, students observed various healthcare professionals in different clinical settings, including emergency rooms (ERs), ambulatory care, critical care, and outpatient environments. This phase emphasized understanding interprofessional roles and the importance of collaborative practice skills.

In the subsequent IPE activity period, students were grouped into teams of five or six, consisting of both medical and nursing students, to engage in team building exercises. These activities aimed to promote students’ collaboration, communication skills, mutual understanding in clinical settings. The activities during this phase were meticulously designed to develop essential soft skills through structured game-based exercises. These included the Marshmallow Challenge, which aimed to enhance understanding of team building dynamics; the Puzzle Game, which focused on defining roles and fostering teamwork to achieve a common objective; and the Message Game, which underscored the importance of clear and effective communication. Additional activities, such as the Drawing Shapes Game and the Drawing the Story Game, were designed to improve skills in accurate verbal description and to enhance understanding of the SBAR (Situation, Background, Assessment, Recommendation) communication protocol, respectively. Finally, the Board Game was specifically developed to reinforce systems thinking and to illustrate the need for interdisciplinary collaboration in addressing complex issues in a hospital. Table 1 outlines the key activities included in this period.

This study aimed to analyze essays written by students after participating in the IPE activities to assess their reflections and learning outcomes.

Research procedure

The fundamental premise of text network analysis is to extract keywords representing the core content from the literature [ 31 ]. This study focused on understanding students’ thoughts and perceptions by analyzing their essays. The research process comprised (1) data collection, (2) keyword selection and data processing, (3) core keyword extraction and network construction, (4) network connectivity and centrality analysis, and (5) topic modeling. This approach facilitated a nuanced understanding of the conceptual relationships within the text, yielding deeper insights into students’ reflective thinking and experiences with interprofessional collaboration, thereby aligning with the objectives of this study.

Data collection

Data were collected in 2021 after the IPE program. Of the 82 medical students who participated in the program, 77 voluntarily submitted essays, representing a 93.9% response rate from the entire cohort enrolled in the IPE program. The essays were collected after the completion of the entire program, capturing students’ reflections and feelings about the course. These essays were not intended for assessment or evaluation purposes but were written freely by students to express their thoughts and experiences regarding the program. The primary aim was to gather qualitative insights into how students perceived and internalized the IPE activities, which aligns with the study’s objective to understand the impact of game-based learning on developing interprofessional collaboration, communication, and team building skills. We focused on medical students’ essays to explore their specific perspectives and experiences within the IPE program, as these students often play crucial roles in multidisciplinary teams. Therefore, understanding their views can provide valuable insights for improving IPE programs and enhancing interprofessional collaboration in clinical practice [ 32 ].

Keyword selection and data pre-processing

The student essays were collected using MS Office Excel. Pre-processing involved an initial review using Excel’s Spell Check, followed by manual corrections to fix typographical errors. Morphological analysis was performed using Netminer 4.5.1.c (CYRAM), which automatically removed pronouns and adverbs, leaving only nouns. To extract the words, 25 designated words, 40 synonyms, and 321 excluded words were pre-registered. Designated words are terms that convey specific meanings when grouped [ 33 ]. In this study, terms such as “interprofessional education” and “Friday Night at the ER” were classified as such. Synonyms, a group of words that have similar meanings, were processed as a single term that can represent the common meaning of those words [ 34 ]. For instance, “Friday night ER,” “FNER,” and “Friday night in the ER” were extracted as “Friday Night at ER.” Words considered irrelevant to the current research focus or general words that did not contribute to meaningful analysis were excluded (e.g., “and,” “or,” “front,” “inside,” “during”). Three professors specializing in emergency medicine and one medical educator handled word extraction and refinement, and the final selection was reviewed by the entire research team.

The data analysis utilized was qualitative content analysis, focusing on both the identification and contextual usage of keywords. This approach involved the descriptive counting of keywords as well as an in-depth analysis of their usage within the essays. This rigorous process ensured that the keywords selected were relevant to the study’s focus on IPE and collaboration, providing both quantitative and qualitative insights into the students’ reflections and experiences.

Extraction of core keywords and network construction

Core keyword extraction was based on the term frequency-inverse document frequency (TF-IDF) method. The frequency of word occurrences is expressed as “term frequency (TF),” which indicates how often a word appears within a document [ 35 ]. By contrast, “inverse document frequency (IDF)” is calculated using the logarithmic value of the inverse of document frequency [ 36 ]. The TF-IDF value is computed by multiplying TF by IDF. A high value indicates that a word is important in a specific document but rarely appears in others [ 37 ]. This method allows the assessment of the importance of words in documents. For network analysis, the 2-mode word-document network was converted into a 1-mode word-word network. The co-occurrence frequency was set to occur at least twice, and the word proximity (window size) was set to two, following previous studies on text network analysis [ 38 ].

Network connectivity and centrality analysis

Network size and density, as well as the average degree and distance at the node level, were identified to understand the overall characteristics of the network. Network size denotes the total number of nodes (keywords). Density measures the ratio of actual connections to possible connections, indicating network cohesion. The average degree reflects the average number of connections per node, while the average distance shows the typical number of steps between nodes, revealing the network’s connectivity and compactness [ 35 , 38 ]. Centrality analysis included degree, betweenness, and eigenvector centrality, whereas closeness centrality was excluded due to poor performance in lengthy texts [ 39 ]. Degree centrality measures how well a node is connected within a network, helping to identify keywords that play a central role in the network [ 40 ]. Betweenness centrality measures how frequently a node appears on the shortest path between other nodes, indicating how well it acts as an intermediary between two nodes [ 41 ]. Eigenvector centrality assesses the influence of a node by considering the importance of its neighboring nodes beyond the degree of connection [ 42 ]. This study extracted the top 30 words for each degree, betweenness, and eigenvector centrality. Finally, a spring map was used to visualize the keywords and their connection structures in the network.

Text network analysis was chosen because it provides a detailed understanding of relationships between concepts, unlike traditional methods that focus on theme frequency. It visualizes keyword interactions, highlighting central themes and their connections, offering insights into students’ reflections on IPE and their thought patterns.

Topic modeling

Latent Dirichlet allocation (LDA) is a statistical text-processing technique that clusters keywords based on their probabilities and distributions to infer topics [ 43 ]. In this study, keywords extracted from essays were compiled into a matrix for LDA. To determine the optimal number of topics, combinations of α = 0.01–0.03, β = 0.01–0.03, topic model = 3–8, and 1,000 iterations were tested. The optimal model was selected based on the coherence score (c_v), with the highest coherence score ensuring the validity and reliability of the inferred topics [ 44 , 45 , 46 ].

Key keywords

Table 2 presents the keywords derived from analyzing medical students’ essays selected through the TF and TF-IDF analyses. In the TF analysis, “thought” appeared most frequently (365 times), followed by “group” 359 times, “class” 322 times, and “game” 278 times. The top 20 keywords in TF-IDF included “patient,” “game,” “group,” and “person.” Keywords that appeared in both TF and TF-IDF analyses included “nursing school,” “nurse,” “game,” “hospital,” “person,” “mutual,” “communication,” “time,” “group,” “important,” “progress,” “puzzle,” “patient,” and “activity.” Comparing the keywords between TF and TF-IDF, new terms that emerged in TF-IDF included “IPE,” “room,” and “clinical practice.”

Text network analysis

Network structure

In this study, a network was constructed based on a co-occurrence frequency of at least two words with word proximity (window size) set to two words. The resulting network comprised 1,218 nodes and 627 links. The network density was 0.012, with an average degree and distance of 3.919 and 3.447, respectively.

Centrality analysis

Table 3 lists the top 30 keywords according to degree, betweenness, and eigenvector centralities, providing insight into the overall network characteristics. The top three keywords across all three centrality analyses included “patient,” “thought,” “group,” “doctor,” “nurse,” and “communication.” The ranking and composition of the keywords were similar in both degree and betweenness centrality analyses. In the eigenvector results, “doctor,” “nurse,” and “communication” were ranked highest. When comparing the top 30 keywords from eigenvector centrality with those from degree and betweenness centrality, new terms such as “future,” “society,” and “need” emerged. These findings are presented in Fig. 1 , which illustrates the spring network map of centrality.

Spring network map of centrality. a Degree centrality. b Betweenness centrality. c Eigenvector centrality

Topic modeling: selection of the number of topics

To determine the optimal number of topics, 54 combinations of options were tested, including α = 0.01–0.03, β = 0.01–0.03, topic models = 3–8, and 1,000 iterations. Three topics were identified.

In the topic modeling process, after reviewing the keywords and contents of the assigned original documents, the research team convened and named each topic to reflect the trend of the subject matter, as shown in Fig. 2 . Following prior research, the final topic model was visualized using a topic-keyword map displaying the top eight to thirteen words [ 44 ]. Topic 1, accounting for 17% of the total topics, includes keywords such as “group,” “game,” “puzzle,” “delivery,” and “activity.” This reflects the inclusion of group-based, game-centric activities in the IPE classes; hence, it was named “game-based collaborative activity experience.” Topic 2 comprises 23% of the topics centered around the thoughts of doctors and nurses about patients in clinical settings, with keywords including “doctor,” “thought,” “patient,” “hospital,” and “nurse.” It was thus named “interprofessional perspectives.” Topic 3, with the largest share at 60%, incorporates keywords such as “class,” “nursing school,” “thought,” “activity,” and “student.” It primarily addresses class activities involving nursing students, thus the term “interdisciplinary educational experience.” Visually examining the entire network of topic modeling indicates that Topic 1, “game-based collaborative activity experience,” and Topic 3, “interdisciplinary educational experience,” are connected through the keywords “person” and “activity.” Topic 2, “Interprofessional Perspectives,” and Topic 3, are linked by “thought” and “class.” In the network, Topic 3 plays a vital role in connecting Topics 1 and 2, as illustrated in Fig. 2 .

Semantic keywords of topic modeling

This study is the first attempt to demonstrate the educational impact of game-based IPE activities on fostering an interprofessional perspective, communication skills, and team building skills among healthcare professionals through a text network analysis of student essays. This distinguishes this study from previous studies. This approach can help students develop collaborative skills, thereby effectively addressing various challenges in clinical settings. The primary findings and implications of this study are as follows:

First, the keywords with the highest degree of centrality were “patient,” “thought,” and “group.” High-degree-centrality keywords play a central role in the entire network, suggesting that the overall program should be designed around these keywords. The keywords with high betweenness centrality were also “patient,” “thought,” and “group.” These keywords act as necessary connectors within the network, indicating that they are crucial for establishing communication channels between different professions and ensuring a smooth flow of information in medical education. Keywords with high eigenvector centrality included “doctor,” “nurse,” and “communication.” The prominence of keywords such as “doctor,” “nurse,” and “communication” in centrality measures signifies their strong connections to other important terms in the network. This highlights the pivotal role of doctors and nurses in collaborative practices and underscores the importance of communication skills in IPE programs. The central positioning of these keywords within the network emphasizes the need to prioritize interprofessional roles and communication competencies to enhance collaborative practices in clinical settings. These results align with previous findings emphasizing the importance of education in promoting effective collaboration and communication among healthcare professionals [ 47 ]. The centralities thus provide quantitative evidence supporting the critical roles and interactions that are essential for successful IPE.

The relevance of these keywords can be understood within the framework of the Interprofessional Education Collaborative (IPEC) Core Competencies, which emphasize patient-centered care, reflective thinking, and effective communication. The central keywords align with IPEC’s domains: values/ethics for interprofessional practice, roles/responsibilities, interprofessional communication, and teams/teamwork [ 4 , 48 ]. For instance, “patient” and “group” correspond to the emphasis on patient-centered care and teamwork, while “thought” and “communication” are essential for reflective practice and effective interprofessional communication. Integrating IPE into medical education strengthens transparent and efficient teamwork across different specialties, minimizes errors in clinical decision-making, and improves patient outcomes. Consequently, medical schools should develop curricula that provide students with ample opportunities to collaborate with team members from various specialties [ 49 ].

Second, the topic modeling analysis indicated that Topic 1 provides a collaborative experience through group-based gaming activities in an IPE course. This aligns with previous research, indicating that game-based learning can enhance participants’ socialization and communication skills. Thornton Bacon et al. [ 50 ] and Sanko et al. [ 51 ] reported that students who participated in the Friday Night at Emergency Room (FNER) game demonstrated a statistically significant increase in systems thinking scores. In addition, Fusco et al. [ 52 ] confirmed that gameplay positively affected students’ systematic thinking, effective collaboration, and socialization skills. This suggests that game-based learning is useful for developing collaborative problem-solving skills and can be effectively integrated into various educational designs of IPE programs. Topic 2 highlights the significant focus on the perspectives of healthcare professionals in clinical environments. According to Bridges et al. [ 53 ] and Prentice et al. [ 54 ], IPE provides opportunities to develop a better understanding of roles and improve communication among healthcare team members. In this process, improving knowledge about one’s own roles and responsibilities as well as those of other professions can enhance teamwork between professionals [ 55 ]. This finding suggests that IPE programs can improve the quality of healthcare delivery by fostering mutual respect and understanding among different healthcare professionals. Topic 3 primarily addressed class activities for nursing students and included interdisciplinary educational experiences. These results show that game-based IPE activities are an effective educational method for enhancing interprofessional perspectives and communication skills, going beyond traditional lectures that simply deliver knowledge to students.

Additionally, Bjerkvik and Hilli [ 56 ] stated that expressing thoughts through writing facilitates the understanding of personal experiences. This enables learners to explore their emotions and attitudes, ultimately leading them to deeper self-understanding and professional growth. Consequently, this study analyzed students’ reflective thinking through topic modeling and presented evidence that game-based IPE activities are crucial in promoting learners’ reflective thinking and professional growth.

This study has several limitations. First, a limited group of students from a specific university participated in this study, which may have restricted the generalizability of the findings. Additional research is required to verify the results of this study across multiple student groups from various backgrounds and environments. Second, the research methodology relied on text analysis of student essays, focusing only on students’ subjective experiences and perceptions. To address this limitation, we used a rigorous coding scheme, inter-rater reliability checks, and TF-IDF for keyword extraction. Our methodology included keyword selection, data pre-processing, network construction, and LDA-based topic modeling, optimized with the coherence score (c_v). These steps ensured that the data analysis was both robust and reliable. Additionally, incorporating multiple methods for data analysis allowed us to cross-verify the findings and enhance the overall rigor of the study. Future research should integrate a range of methods, including interviews and surveys, to achieve a more comprehensive evaluation. Third, the effects of IPE programs on students’ collaborative competencies in clinical practice and healthcare settings is limited. Future research should explore the long-term impacts of game-based IPE on clinical practice, patient outcomes, and students’ readiness for clinical environments. Additionally, tracking the career progression and professional development of participants will help assess the sustained benefits of these educational interventions.

Conclusions

This study is the first to explore changes in reflective thinking and perceptions among students who participated in IPE programs. This demonstrates the positive effects of IPE on professional healthcare students. Specifically, through the analysis of degree, betweenness, and eigenvector centrality, we identified keywords such as “patient,” “thought,” “group,” “doctor,” “nurse,” and “communication” as crucial to interprofessional perspectives and communication among healthcare professionals. Topic modeling further underscores the importance of game-based learning, interprofessional perspectives, and interdisciplinary educational experiences.

These findings emphasize the need for innovative teaching methods in medical education and reaffirm the importance of promoting effective inter-professional perspective, communication skills and team building skills. Medical schools should strive to improve the design and implementation of their IPE program by incorporating students’ experiences and reflective insights. This will ultimately improve the quality of medical education. This study can serve as valuable foundational data for future research. Future studies should investigate the long-term effects of game-based IPE on clinical practice and patient outcomes. Research should also explore the impact of game-based IPE on participants’ career progression and professional development to assess sustained benefits. Additionally, future research could examine how different game-based learning activities influence specific interprofessional competencies, such as teamwork, communication, and problem-solving skills, to identify the most effective approaches for IPE programs.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to ethical constraints but are available from the corresponding author on reasonable request.

Abbreviations

Interprofessional education

Friday night at emergency room

Latent Dirichlet allocation

Term frequency

Term frequency-inverse document frequency

Inverse document frequency

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The authors sincerely thank all those who have contributed to this work through their support, insights, and encouragement.

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Study conception and design: YK, MN, CK. Data collection: YK, MN, CK. Data analysis and interpretation: YK, MN, SM, EE, CK. Drafting of the article: YK, MN, SP, MK. Critical revision of the article: YK, MN, SP, SM, EE, CK.

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Kwon, Y.G., Namgung, M., Park, S.H. et al. Impact of a game-based interprofessional education program on medical students’ perceptions: a text network analysis using essays. BMC Med Educ 24 , 898 (2024). https://doi.org/10.1186/s12909-024-05893-2

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Health professionals and students’ experiences of reflective writing in learning: A qualitative meta-synthesis

Giovanna artioli.

1 Azienda USL-IRCCS di Reggio Emilia, Viale Umberto I, 50, 42123 Reggio Emilia, Italy

Laura Deiana

2 Medical and Surgical Department, University of Parma, Parma, Italy

Francesco De Vincenzo

3 European University of Rome, Rome, Italy

Margherita Raucci

Giovanna amaducci, maria chiara bassi, silvia di leo, mark hayter.

4 Faculty of Health Sciences, University of Hull, Hull, UK

Luca Ghirotto

Associated data.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Reflective writing provides an opportunity for health professionals and students to learn from their mistakes, successes, anxieties, and worries that otherwise would remain disjointed and worthless. This systematic review addresses the following question: “What are the experiences of health professionals and students in applying reflective writing during their education and training?”

We performed a systematic review and meta-synthesis of qualitative studies. Our search comprised six electronic databases: MedLine, Embase, Cinahl, PsycINFO, Eric, and Scopus. Our initial search produced 1237 titles, excluding duplicates that we removed. After title and abstract screening, 17 articles met the inclusion criteria. We identified descriptive themes and the conceptual elements explaining the health professionals’ and students’ experience using reflective writing during their academic and in-service training by performing a meta-synthesis.

We identified four main categories (and related sub-categories) through the meta-synthesis: reflection and reflexivity, accomplishing learning potential, building a philosophical and empathic approach, and identifying reflective writing feasibility. We placed the main categories into an interpretative model which explains the users’ experiences of reflective writing during their education and training. Reflective writing triggered reflection and reflexivity that allows, on the one hand, skills development, professional growth, and the ability to act on change; on the other hand, the acquisition of empathic attitudes and sensitivity towards one’s own and others’ emotions. Perceived barriers and impeding factors and facilitating ones, like timing and strategies for using reflective writing, were also identified.

Conclusions

The use of this learning methodology is crucial today because of the recognition of the increasing complexity of healthcare contexts requiring professionals to learn advanced skills beyond their clinical ones. Implementing reflective writing-based courses and training in university curricula and clinical contexts can benefit human and professional development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-021-02831-4.

Education of healthcare professionals supportstheir transformation into becoming competent professionals [ 1 ] and improves their reasoning skills in clinical situations. In this context, reflective writing (RW) is encouraged by both universities, and healthcare training providersencourage reflective writing (RW) since its utility in helping health students and professionals nurture reflection [ 2 ], which is considered a core element of professionalism. Furthermore, the ability to reflect on one’s performance is now seen to be a crucial skill for personal and professional development [ 3 ]. Writing about experiences to develop learning and growth through reflection is called ‘reflective writing’ (RW). RW involves the process of reconsidering an experience, which is then analyzed in its various components [ 4 , 5 ]. The act of transforming thoughts into words may create new ideas: the recollection of the experience to allow a deeper understanding of it, modifying its original perception, and creating new insights [ 6 ]. RWis the focused and recurrent inspection of thoughts, feelings, and events emerging from practice as applied to healthcare practice [ 7 ].

Reflection may be intended as a form of mental processing or thinking used by learners to fulfill a purpose or achieve some anticipated outcome [ 2 ]. This definition recalls Boud and colleagues’ view of reflection as a purposive activity directed towards goals [ 8 ]. For those authors, reflection involves a three-stage process, including recollection of the experience, attending to own feelings, and re-evaluating the experience. This process can be facilitated by reflective practices, among which RW is one of the main tools [ 9 ].

Between reflection-on-action (leading to adjustments to future learning and actions) and reflection-in-action (where adjustments are made at the moment) [ 10 ], RW can be situated in the former. It involves theprofessional’s reflections and analysis of experiences in clinical practice [ 11 , 12 ]. Mainly,RWinvolves the recurrent introspection ofone’s thoughts, feelings, and events within a particular context [ 13 ]. Several studies highlight how RWinfluencespromoting critical thinking [ 14 ], self-consciousness [ 15 ], and favors the development of personal skills [ 16 ], communication and empathy skills [ 4 , 17 ], and self-knowledge [ 3 ]. Thanks to the writing process, individuals may analyze all the components of their experience and learn something new, giving new meanings [ 5 ]. Indeed, putting down thoughts into words enables the individual to reprocess the experience, build and empower new insights, new learnings, and new ways to conceive reality [ 6 , 18 – 20 ].

Furthermore, RW provides an opportunity to give concrete meaning to one’s inner processes, mistakes, successes, anxieties, and worries that otherwise would remain disjointed and worthless [ 21 , 22 ]. The reflective approach of RW allows oneself to enter the story, becoming aware of our professional path, with both an educational and therapeutic effect [ 23 ].

Reflection as practically sustained by RW commonly overlaps with the process of reflexivity. As noted elsewhere [ 24 ], reflection and reflexivity originate from different philosophical traditionsbut have shared similarities and meanings. In the context of this article, we adopt two different working definitions of reflection and reflexivity. Firstly, we draw from the work of Alexander [ 25 ]: who explains reflection as the deliberation, pondering, or rumination over ideas, circumstances, or experiences yet to be enacted, as well as those presently unfolding or already passed [ 25 ]. Reflexivity at a meta-cognitive level relates to finding strategies to challenge and questionpersonal attitudes, thought processes, values, assumptions, prejudices, and habitual actions to understand the relationships’ underpinning structure with experiences and events [ 26 ]. In other words, reflexivity can be defined as “the self-conscious co-ordination of the observed with existing cognitive structures of meaning” [ 27 ].

Given those definitions,a philosophical framework for helping health trainees and professionals conduct an exercise that can be helpful to them, their practice, and – ultimately – their patients can be identified. There is a growing body of qualitative literature on this topic – which is valuable – but the nature of qualitative research is that it creates transferrable and more generalizableknowledge cumulatively. As such, bodies of qualitative knowledge must besummarized and amalgamated to provide a sound understanding of the issues – to inform practice and generate the future qualitative research agenda. To date, this has not been done for the qualitative work on reflective writing: a gap in the knowledge base our synthesis study intends to address by highlighting what connects students and professionals while using RW.

This systematic review addresses the following question: “What are the experiences of health professionals and students in applyingRWduring their education and training?”

This systematic review and meta-synthesis followed the 4-step procedure outlined by Sandelowski and Barroso [ 28 , 29 ], foreseeing a comprehensive search, appraising reports of qualitative studies, classification of studies, synthesis of the findings. Systematic review and meta-synthesis referto the process of scientific inquiry aimed at systematically reviewing and formally integrating the findings in reports of completed qualitative studies [ 29 ].

The article selection processwas summarized as a PRISMA flowchart [ 30 ]; the search strategy was based on PICo (Population, phenomenon of Interest, and Context),and the study results are reported in agreement with Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines [ 31 ].

Selection criteria

Inclusion criteria for the meta-synthesis were:

Primary qualitative studies published in peer-reviewed English journals.
With health professionals or health studentsas participants.
UsingRW in learning contexts (both pre-and in-service training).
Mixed methods where the qualitative part can be separated.
Articles should report the voice of participants (direct quotations).

Given the meta-synthesis indications, we excluded quantitative studies, non-primary research articles, meta-synthesis of qualitative studies, literature and systematic reviews, abstracts, unpublished reports, grey literature. In addition, we also excluded studies where participants were using RW in association with other learning tools and where the personal experience was not about using RW exclusively.

Data sources and searches

An experienced information specialist (MCB) performed the literature search on Medline, Embase, Cinahl, PsycInfo, Eric, and Scopus for research articles published from Jan 1st, 2008 to September 30th, 2019,to make sure we incorporated studies reflecting contemporary professional health care experience. Additional searchinginvolved reviewing the references or, and citations to, our included studies.

We filled an Excel file with all the titles and authors’ names. A filter for qualitative and mixed methods study was applied. Table 1 shows the general search strategy for all the databases based on PICo.

Search strategy for databases based on PICo

MedLine	EMBASE	CINAHL	PsycINFO	Scopus
Health Personnel”[Mesh] OR psychologist*	psychologist* OR health professional*	(MH“Health Personnel”) OR psychologist*	exp Health Personnel/ (psychologist* or health professional*)	(psychologist* OR health AND professional*)
Autobiography as Topic”[Mesh] OR “Writing”[Mesh] OR writing* OR autobiographical*	autobiograph*: ab,ti OR writing: ab,ti	(MH“Writing”) OR (MH“Autobiographies”) OR (autobiographic* OR writing)	exp Autobiography/exp. Creative Writing/	(writing OR autobiography OR autobiographic*)
Learning”[Mesh] OR “Education”[Mesh] OR “Thinking”[Mesh]	‘education’/exp./mj OR ‘thinking’/exp./mj	(MH“Thinking”) (MH“Learning”) OR (MH“Education”)	(MH“Thinking”) (MH“Learning”) OR (MH“Education”)	(training OR awareness OR critical AND thinking OR learning OR education)

* truncation

Four reviewers (GAr, MR, GAm, LD) independently screened titles and abstracts of all studies, then checked full-text articles based on the selection criteria. We also searched the reference lists of the full-text articles selected for additional potentially relevant studies. Any conflict was solved through discussion with three external reviewers (LG, MCB,SDL, and MH).

Quality appraisal

We used the Critical Appraisal Skills Programme (CASP): it provides ten simple guiding questions and examples to examine study validity, adequacy, and potential applicability of the results of qualitative studies. Guided by the work of Long and colleagues [ 32 ] and previously used in other meta-synthesis [ 33 ], we created 30 items from the 10 CASP questions on quality to ensure we could provide a detailed appraisal of the studies. FDV and LD independently assessed the quality of included studies with any conflicts solved by consulting a third reviewer (MCB and LG). Researchers scored primary studies weighingthe proposed items and ranking the quality of each included study [ 34 ] on high ( n > 20 items positively assessed), moderate (10 < n < 20), or low quality ( n < 10).

Analysis and synthesis

MCB created a data extraction table, GAr, GAm, and MRdescribed the included articles (Table 2 ). Quotations were extracted manually from the “results/findings” sections of the included studies by GAr, MCB, LDand inserted into adatabase. GAr, GAm, MR, and FDVperformed a thematic analysis of those sections, along with participants’ quotations. Then, they inductively derived sub-themes from the data, performing a first interpretative analysis of participants’ narratives (i.e., highlighting meanings participants interpreted about their experience). The sub-themes were compared and transferred across studies by adding the data into existing sub-themes or creating new sub-themes. Similar sub-themes were then grouped into themes, using taxonomic analysisto conceptually identify the sub-categories and the categories emerging from the participants’ narratives. This procedure allowed us to translate the themes identified from the original studies [ 28 ] into interpretative categories that could amalgamate and refine the experiences of health professionalsor health students on the use of RW [ 29 ]. The final categories are based on the consent of all the authors.

Summary of articles included in meta-synthesis (divided per groups: students and professionals)

Source and country	Purpose	Sampling	Previous training on RW	Type of professionals	Method	Data collection	CASP

Tsang et al. (2010) [ ] “Oral health students’ perceptions of clinical reflective learning-relevance to their development as evolving professionals” (Australia)	Student perceptions of clinical reflective learning and its relevance to their clinical and professional development.	17 students	Yes	Oral health professionals	Quantitative and qualitative analyses	Thematic analysis	14/30 Low to Moderate
Wald et al. (2010) [ ] “The loss of my elderly patient: interactive reflective writing to support medical students’ rites of passage” (United States of America)	Implement a narrative medicine curriculum innovation of students’ reflective writing.	25 students	Yes	Doctors	Qualitative study	Brown Educational Guide to the Analysis of Narrative (BEGAN)	18/30 Moderate
Garrison et al. (2011) [ ] “Qualitative analysis of medical student impressions of a narrative exercise in the third-year psychiatry clerkship” (United States of America)	Examine students’ written reactions to the narrative exercise, which drawing from narrative medicine and narrative therapy.	46 students	Yes	Doctors	Qualitative method	Thematic analysis	20/30 Moderate
Kuo et al. (2011) [ ] “Using clinical caring journaling: nursing student and instructor experiences” (Taiwan)	Explore the experiences and perceptions of student nurses using clinical care journaling.	880 students + 90 clinical instructors	Yes	Nurses	Descriptive qualitative research	Constant comparative method	18/30 Moderate
Bagnato et al. (2013) [ ] “The reflective journal: a tool for enhancing experience-based learning in nursing students in clinical practice” (Italy)	Understand the level of students’ reflections; The students’ experience.	33 students	Not described	Nurses	Qualitative data analysis	Mezirow’s qualitative method	13/30 Low to Moderate
Constantinou et al. (2013) [ ] “Physiotherapy students find guided journals useful to develop reflective thinking and practice during their first clinical placement: a qualitative study” (Australia)	Do physiotherapy students perceive that guided journals facilitate reflective thinking and practice?	90 students	Yes	Physiotherapists	Mixed methods study	Leximancer© V3.5 Software	15/30 Low to Moderate
Jonas-Dwyer et al. (2013) [ ] “First reflections: third-year dentistry students’ introduction to reflective practice” (Australia)	Introduce reflective practice to students; evaluate students’ self-perceived reflective skills before and after their reflective activities.	46 students	Yes	Dentists	Qualitative study	Wong et al.’s Schema	21/30 Moderate to High
Bowman et al. (2014) [ ] “Academic reflective writing: a study to examine its usefulness” (United Kingdom)	To explore students’ experiences of doing assessed academic reflective writing.	8 students	Not described	Nurses and midwives	Qualitative research methodology	Kitzinger and Barbour’s method	19/30 Moderate
Padykula (2016) “RN-BS students’ reports of their self-care and health-promotion practices in a holistic nursing course” (United States of America)	Explore the utility of reflective journal writing for enhancing RN-BS students’ self-care and health-promotion practices.	15 students	Not described	Nurses	Qualitative single case study	Creswell’s method	26/30 High
Binyamin (2018) [ ] “Growing from dilemmas: developing a professional identity through collaborative reflections on relational dilemmas” (Israel)	Illustrate how the pedagogical method of collaborative reflection can develop occupational therapists’ professional identity.	196 students	Yes	Occupational therapists	Qualitative research	Thematic analysis	16/30 Moderate
Hwang (2018) [ ] “Facilitating student learning with critical reflective journaling in psychiatric mental health nursing clinical education: a qualitative study” (Korea)	Explore types of events or issues that senior nursing students chose to reflect upon in their critical reflective journals during their 5-week psychiatric mental health nursing clinical practicum; assess students’ evaluations of critical reflective journaling.	59 students	Yes	Nurses	Qualitative study	Qualitative content analysis	16/30 Moderate
Persson et al. (2018) [ ] “Midwifery students’ experiences of learning through the use of written reflections – an interview study” (Sweden)	Examine how midwifery students experienced the writing of daily reflections on their practice.	19 students	Yes	Midwives	Interview study using an inductive method with descriptive design	Qualitative thematic content analysis.	23/30 Moderate to High

Levine et al. (2008) [ ] “The impact of prompted narrative writing during internship on reflective practice: a qualitative study” (United States of America)	Understand if prompted narrative writing led to increasing reflection by the study participants and what impact this had on participants’ attitudes and behaviors.	32 professionals	Not described	Internal medicine residents	Prospective qualitative study	Qualitative analysis	21/30 Moderate to High
Cashell (2010) [ ] “Radiation therapists’ perspective of the role of reflection in clinical practice” (Canada)	To explore radiation therapist’s understanding of the concept of reflection and how it was incorporated into their daily practice.	123 professionals	Yes	Radiation therapists	Mixed methods study	Thematic analysis	21/30 Moderate to High
Vachon et al. (2010) [ ] “Using reflective learning to improve the impact of continuing education in the context of work rehabilitation” (Canada)	Describe how occupational therapists used reflective learning to integrate research evidence into their clinical decision-making process and identify the factors that influenced the reflective learning process.	8 professionals	Yes	Occupational therapists	Collaborative research	The data analysis process was based on the methods proposed in Grounded Theory	25/30 High
Karkabi et al. (2014) [ ] “The use of abstract paintings and narratives to foster reflective capacity in medical educators: a multinational faculty development workshop” (Israel)	Foster reflective capacity using art and narrative.	23 professionals	Yes	Family medicine physicians	Qualitative assessment	Thematic analysis	16/30 Moderate
Caverly et al. (2018) [ ] “Qualitative evaluation of a narrative reflection program to help medical trainees recognize and avoid overuse” (United States of America)	To describe a writing program and to explore how participating influenced the thinking, attitudes, and behaviors.	20 professionals	Yes	Internal medicine residents	Qualitative research methodology	Thematic analysis	20/30 Moderate

Literature search and studies’ characteristics

A total of 1488 articles were retrieved. Duplicates ( n = 251) were removed. Then, articles ( n = 1237) were identified and reviewed by title and abstract. We excluded n = 1152 articles because they did not match the specified inclusion criteria, based on the title and abstract. Consequently, we assessed 85 full-text articles. Sixty-eight records did not meet the inclusion criteria. At the end of the selection process, 17 reportsof qualitative research were selected. Figure 1 illustrates the search process.

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PRISMA flow diagram

Table Table2 2 shows the characteristics of the included studies. Eleven studies involved healthcare students (58%, including nurses, midwives, physiotherapists, doctors, dentists, and oral health students), and six (32%, including doctors, occupational and radiation therapists) were referred to health professionals. In thirteen studies, participants were trained on RW before using it: this information could not be retrieved from the remaining articles.

Five articles reported studies conducted in the US, three in Australia, two in Canada, and two in Israel. The other studies were carried out in Italy, UK, Korea, Taiwan, and Sweden.

Critical appraisal results

We critically evaluatedall 17 studies to highlight the methodological strengthsand weaknesses of the selected studies. No article was removed on a quality assessment basis. Results of the quality appraisal are reported in Table Table2 2 .

Meta-synthesis findings

Through the meta-synthesis, we identified four main categories (and related sub-categories): (i) reflection and reflexivity; (ii) accomplishing learning potential; (iii) building a philosophical and empathic approach; (iv) identifying reflective writing feasibility (for the complete dataset, please refer to supplemental material , where we have listed a selection of meaningful quotations of categories and sub-categories).

Given such categories, we developed an interpretative meta-synthesis model (Fig. 2 ) to illustrate the commonalities of the experience of using RW according to both students and professionals: RWas a vehicle for discovering reflection and allowing users to enter personal reflexivity to fulfillone’s learning potential, alongside the building of a philosophical and empathic approach. In their experience, reflection and reflexivity generate different skills and competencies: reflection matures skills such as professional skills and the ability to activate change and innovation. Reflexivity allows students and professionals to reach higher levels of competencyconcerning inner development and empathy reaching. Finally, from our analysis, participants, while recognizing the value of RW, also defined factors that could encourage or limit its use. Differences among participants’ groups are also outlined.

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Meta-synthesis model: RW as experienced by health professionals and students

Reflection and reflexivity

Within this category, we collected the users’ narratives about the experience of applying RW and its disclosing capacity. By using RW, participants confronted themselves with both reflection and reflexivity. This category includes two sub-categories we named: discovering reflection and entering personal reflexivity.

Discovering reflection

The sub-category shows that experiencingRW deepened their reflection on experiences, practice, and profession. Thanks to RW, professionals, and students could explore previously unexplored topics and learn more about themselves.

“ Writing initiated me to think about my experiences … ” (professional) [ 46 ]. “ I think it’s good for physicians to reflect on what we’re doing ” (professional) [ 50 ]

“ Helped (me) reflect on positive aspects ” (student) [ 40 ]. “ I don’t usually think too much about what happens to me, but through critical reflective journaling, I was able to think carefully about things happening around me. This activity helped me to look into my mind ” (student) [ 44 ]

This sub-category explains transversal meanings coming from uniformly professionals and students.

Entering personal reflexivity

This sub-category includes data about RW enabling users’reflexivity. In this context, RW was considered training for reflexivity as it enabled participants to question themselves more often [ 48 ], reflect on their experiences [ 35 ], attitudes, actions [ 38 , 45 ], and also reconsider their actions and identify their strengths and weaknesses [ 40 , 44 ].

“ The questions in this study do make me stop and think about things – how I feel about what I’m doing in residency ”(professional) [ 46 ]. “ Helped me ID (identify) my strengths and weaknesses ” (student) [ 40 ] RW also helped eradicate the background noise that my mind does not yet know how to filter out [ 51 ] .

Interesting to note that this sub-category is more present in students’ narratives. While professionals referred to self-reflection practices (probably already acquired in other contexts), students often reported how RW helped them discover reflexivity.

Accomplishing learning potential

Our analysis showed how users RW used the technique to “Accomplish learning potential.”

According to the studies’ participants, RWcan enable a learning performancethat would be difficult to reach otherwise. In this context, participants addressed RW as a tool for“accomplishing learning potential.”Within this category, three sub-categories were highlighted: the improvement of skills, personal and professional growth, and assisting the change and development process.

Improvement of skills

Participants agreed that the development of skills and abilities through RWwas aimed at their clinical skills and –in relevant areas such as question asking – encouraged reflection and research [ 35 , 46 ]. Communication skills were also enhanced, as were their relationship with patients, family,colleagues, and friends [ 35 , 38 , 46 ].

Participants said:

“ Through reflective journal writing, my attitude towards learning has changed. I have been encouraged to be a proactive learner. (...) I have been able to identify necessary places for improvement and through research, question asking, goal-setting (...). I have improved my skills in relevant areas” (student) [ 35 ]. “I feel that it [participation in the study] has been a positive experience by motivating me to improve on my clinical, communication skills, and also my relationships with colleagues, patients, family, and friends ” (professional) [ 46 ]

Participants also reported that,in their experience, RWprovided an opportunity to assess and improve themselves and to enhance their self-confidence [ 38 , 40 ]. Cognitive skills, includinggaining more profoundknowledge and problem-solving, along withtime-management [ 35 , 40 , 46 , 49 ], were also enhanced: RW,therefore,represented a learning mode [ 45 ].

“ Without reflection, I absolutely believe these skills would be more unattainable for me ”(student) [ 35 ]

This sub-category applies more to students’ narratives. Health students mentioned the tools helping them most to develop their skills. Professionals focused principally on what RWcould improve (communication skills or organizational skills).

Personal and professional growth

Participantsidentifiedthat RWhad promoted personal [ 51 ] and professional growth [ 35 , 46 ]. RW meant for participants:an ameliorated attitude towards work [ 46 ]; a development path for one’s job potential [ 38 ]; an enhancement of their introspective knowledge [ 51 ]; an enrichment of their expressive capability [ 38 ];an improvement of their interpersonal relationships with patients and colleagues [ 50 ] and developed their use of critical and reflective thinking [ 38 ].

“ Reflecting introduces a new aspect to clinic that focuses on the individual’s learning experience ” (student) [ 35 ]. “I think that it does change the way that you think about the practice of medicine and your own personal tendencies and your interactions with your patients and colleagues. And I think it can be a really powerful driver of culture change ” (professional) [ 50 ]

This sub-category is more represented among students than professionals. Students are ‘surprised’ at how important RW was to their learning. Professionals still recognized how RW was an essential driver of change for their clinic activities.

Assisting the change and development process

We labeledthe third sub-category“assisting the change and development process.”The changeinvolvedintroducing modifications tothe way of working [ 48 ], assessing what needed to be changed to achieve a work-life balance [ 51 ], understanding elements that did not allow change, and how to act on them in the future, and also considering new and important issues [ 46 ], further information [ 51 ] and new ways of thinking. This sub-category equally explained the meaning given to RW by students and professionals.

“ I think writing answer to some of these questions has allowed me to reflect back on the year and think about specific important topics that I might not have thought about again.” (professional) [ 46 ]. (Reflective journaling encouraged) “Assessing and focusing on the changes that need to be done to achieve the balance in my life and being able to integrate that with my family and in my work as a nurse.” (Student 16/RJ2) [ 51 ]

However, thischange process could not be possible without witnessing change and becoming aware of it [ 38 , 46 ]. This allowedparticipants to ‘see one’slearning history and path of growth,‘have a picture of the problem, handle things differently, and broadening their vision of the problem [ 48 ].

Building a philosophical and empathic approach

The “Reflection and reflexivity” category is closely aligned with the “Building a philosophical and empathic approach” category. Participants defined RW as a means for nurturing an intimate and profound level of learning, i.e., a philosophical and empathic approach towards real-life professional issues. The third category consists of three sub-categories: the ability to find benefits in negativity/adversity, assuming an empathetic attitude, and the awareness of things, experiences,emotions.

Finding benefits in negativity/adversity

According to participants, RWexerted a therapeutic effect by encouraging professionals and students to focus on the present (43)strictly. It seemed that RWeventually reduced their emotional stress [ 44 , 51 ]. Likewise,in the contextofnegative experiences [ 49 ], its practice acted as a catharsis [ 46 ] that could even allow them tolook back at those experiencesafresh – enabling a change in perspective [ 39 ].

“While writing the journal entry, I felt like I was unloading something from inside myself and being set free. This process made me feel better ” (student) [ 44 ]. “It is always good to pause to reflect on my experiences. The most cathartic question was a few months back when I got to describe my really bad experience.” (professional) [ 46 ] “Very therapeutic. I wrote on a bad experience, but at the end, we were laughing at it.” (professional) [ 49 ]

This specific approach allowed the practitioner/trainee to improve their self-care and focus on work objectives [ 51 ]:

“Self-reflection and reflective journaling promote self-understanding and is another part of self-care.” (Student 5/RJ3) [ 51 ]

Even if more emerging from students’ voices, professionals appeared genuinely amazed at how learning can be generated out of negativity.

Assuming an empathetic attitude

Study participants stressed the fact that RWhelped them develop empathetic attitudes. It seems that RWemphasized the importance of sensitivity and empathy by trying ‘to be in someone else’sshoes,’ especially that of patients or colleagues [ 36 , 37 , 44 ].

“How reflecting on patient encounters through field notes allowed her to “take a walk in someone else’s shoes ” (student) [ 36 ]. “It helps you see the humanity... ” (professional) [ 50 ]

This approach also applied in contexts outside of work and helped the practitioner take off his/her‘white coat’ and understand that before being a professional,he/shewas a person and a human being [ 36 , 37 , 46 , 50 ].

“ Which has made me more open to other’s ideas and thoughts ” (professional) [ 46 ]

As previously mentioned, according to the participants’ statements, awareness was the cornerstone to effective personal and professional growth [ 40 , 51 ].

This sub-category is equivalently present among the participants’ groups. Nonetheless, different meaningscould also be highlighted. Students appreciated RWby stressing its value of allowing them to enter deeply ‘into the other’ inner world (mainly patients). Professionals claimed they could recognize the profession’s human and relational aspects, whichcould also be helpful for their extra-professional relationships (family members, friends).

Awareness of things, experiences, emotions

Impartially balanced among professionals and students, awareness was cited in terms of ‘how things have affected me rather than simply continuing to work in a robotic manner’ [ 46 ], the awareness of who one was and who one has become thanks to the process of change [ 51 ]. This professional and relational awareness made it possible to think clearly about one’s practice and the health resources present in the context of belonging [ 50 ].

“Just being aware of what I know now and what I’ll know by the end of the semester … is a great way to learn who I am and what I can change about me for the better.” (Student 9/RJ1) [ 51 ]

The process of awareness that was facilitated by how their RW allowedthem to transform shapeless and straightforward ideasinto words and givethem a specific value and emotional charge [ 36 , 47 , 51 ]: it wasan authentic opportunity to turn emotions and feelings into something tangible –a journey of discovery and personal acceptance [ 43 ].

“ After two years or so, when you look back, it’s like, oh,that’s how I was feeling at the time, and right now, I feel differently. There is also this level of satisfaction. Like you have matured out of this thinking ” (professional) [ 47 ]

Identifying RW feasibility

The fourth category consists of three sub-categories: perceived barriers/impeding factors, facilitating factors, and when and how to use RW. Students and healthcare professionals who had the experience of practicing the RW in their work identified both limitations and facilitating factors and indications about when and how to use RW.

Perceived barriers/impeding factors

Some study participants (almost entirely students) identified several barriers to their activity. Some students could not see the benefits and thought RW was a waste of time [ 35 , 38 , 51 ]. However, others, who did see the potential benefits still felt that they lacked the time needed to devote to RW [ 42 ] or, sufficient mental space to report and describe a work situation, an excessive similarity of this activity to the regular working practice and, consequently, a lack ofmotivation to write [ 47 , 51 ]. In addition, some described the strainthey felt in writing down personal/professional experiences [ 47 ]. A lack of privacy was another problem, both for the concern about sharing the reflection and for the respect of confidentialityin writing itself [ 51 ]. Taken together,it appeared that some study participants did not recognizeRW as an effective means of help [ 39 , 50 ]. Althoughrealizing the potential of RW,others felt that their tutors did not provide noticeably clearexplanations of the aim of RW– which they would have found useful and motivating [ 45 ].

“ To be honest, not a great deal ( … ) it wasn’t really some revelation ” (professional) [ 50 ]. “ I got a hard time referring it [my experience] to citations … I could have sat and cried yesterday when I did my essay … when I actually read it [my essay] I thought, oh I don’t know what it means, myself ” (Female 2 - student) [ 42 ]

Facilitating factors

This sub-category was exclusively interpreted from students’ narratives. They valued the perspectives to use RWin their practice seeing it as a valuable tool to be applied throughout their career [ 35 , 45 ],with many students reporting that they would continue with this technique [ 38 ]. Studentssaw RW as a valuable means of staying focused on their own goals and needs [ 40 , 51 ]. They remarked that it helped them reduce stress, gain clarity in one’s life and practice [ 41 ], and spiritually connect with themselves [ 45 , 51 ]. Furthermore, RW enabled studentsto discover more information about their health and well-being, ‘it also helped me tie in ideas and beliefs from different sources and relate it to my own’ [ 51 ]. RWhelped maintain awareness and recall the medical being/human being dichotomy [ 37 ]. It remindedstudentsof the difference between studying literature and refining manual skills and the ability to learn from experience and mistakes [ 35 ].

“ During the interview, I felt an element of being more like a ‘normal person’ having a ‘normal conversation’ with another human being. This was a strange realization because it reminded me of the dichotomy that physicians may experience, being doctor versus human ” (student) [ 37 ]

When and how to use RW

Health professionals (a few) and many students finally mentioned the time considered most appropriate to use RW, underlining its usefulness primarilywas during hardship rather than daily practice [ 47 ].Moreover,RWshould not be forced onto someone in any given moment but instead left to individual choice based on one’s spirit of the moment [ 40 , 46 ].

“. .. like if you had a patient die; that would be the only time you might write it down ” (professional) [ 47 ]

Otherparticipantsconsidered instructions on RW to be too forceful and notapplicable to their own experience of reflection [ 40 ]. ‘Reflection wasn’t just signing on the line.’ It allowed constructive feedback for the trainee or the professional. Constructive feedback could be positive or negative, but it was a powerful tool for thinking and examining things [ 45 ].

In this meta-synthesis of qualitative studies, we have interpreted the experiences of health professionals and students who used RWduring their education and training. Given the number of studies included, RW users’ experience was predominately investigated in students. This result, although not surprising, raises the question of whether RW in professional training is being used. RW is not used in professional training as often as it is in the academic training of healthcare students.

As to this review’s aim, we could highlight continuities and differences from study participants’ narratives. Our findings offer a conceptualization of usingRW in health care settings. According to the experience of both students (from different disciplines) and health professionals, RW allows its exponents to discover and practice reflectionas a form of cognitive processing [ 2 ] and enablethem to develop a better understanding of their lived situation. We also interpreted that RW allows users to make a ‘reflexive journey’ that involves them practicing meta-cognitive skills to challengetheir attitudes, pre-assumptions, prejudices, and habitual actions [ 24 , 26 ]. This was particularly true for students: “entering personal reflexivity” appears to be newer for them than for the professionals who are likely to acquire reflexivity during academic training. Students seemed more focused on tools than RW-related results. This consideration makes us affirm that reflective capacity is in progress for them.

Challenging pre-assumptions and entering reflexivityenabledRWusers to realize how RW may develop their learning potential to improve skills and personal/professional growth. Skills to be enhanced are quoted mainly by students. Conversely, professionals could comprehend the final purpose of learning, achievable through RW, in terms of communication or organizational abilities. Professionals interpreted skills from RW as abilities to apply in the clinical activities to find new solutions to problems.

The category “Accomplishing learning potential”confirms what many authors highlight: putting thoughts into words not only permits a deeper understanding of events [ 6 ], enhances professionalism [ 52 ] but also improves personal [ 16 ], communication, and empathy skills [ 4 , 17 ]. In this context, RW fulfills its mandate by letting human sciences [ 53 ] and evidence-based health disciplines affect clinical practice. As noted [ 54 ], students and health professionals’RW training allowed integrating scientific knowledge with behavioral and sociological sciences to supporttheir learning [ 55 ].

Users understood that RWcould be a powerful means of developing empathy and developing their philosophy of care: this consideration is in line with a recent study from Ng and colleagues [ 24 ]. Additionally, some authors [ 4 , 17 ] stressed these empathetic skills and “humanistic”competencies as essential to care for patients effectively [ 56 ]. Professionals were amazed how negativity could generate learning through RW. On the other hand, by recognizingand writing experienced negative situations, students could free themselves from feelings impeding empathy.

By employing RW, users reported factors that could encourage or limit its use. These findings further illustrate that RW is not always a tool that is easy to use without adequate training [ 57 ]. Almost exclusively, students reported hindering factors (limited time, difficulty in writing and understanding assignments, privacy issues, feeling bored or forced). As to professionals, few describedRW as a very stressful activity. Although students could identify impeding factors, they also recognized many positive ones. For professionals, RW was not to be used every day but in ‘extreme’ situations, requiring reflection and reflexivity to be applied. In general, enhancing motivation to write reflectively [ 58 ] should be the first goal of any training to make the process acceptable and profitable for trainees. If this first stage is not accomplished, it will reduce RW’sapparent professional and personal effectiveness among health professionals and students substantially.

Strengths, limitations, and research relaunches

This review may enrich our knowledge about providing RW as an educative tool for health students and professionals. However, the findings must be applied,taking into account some limitations. We focused our attention only on recent, primary, peer-reviewed studies within the time and publication limits. Qualitative studies often are available as grey literature: considering it may result in a different interpretation of students’ and professionals’ experience in using RW. Therefore, our conceptualization should be read bearing in mind a publication bias and the need to expand the literature search to other sources. Besides limiting the risk of missing published qualitative studies, we reviewed the reference listsof included studies for additional items. Our meta-synthesis is coherent to the interpretation of the included studies’ findings.

At least two reviewers have conducted each step of this systematic review. We purposely did not exclude studies based on a quality assessment to maintain a robust qualitative study sample size and valuable insights.

During analysis, all possible interpretations were screened by authors, and an agreement was reached. Nonetheless, we did not cover all the possible ways to interpret the voices of students and professionals.

Since RW is not used in professional training as often as it is in the academic training of healthcare students, a research relaunch could be investigatingwhether and to what extent RW is being used in in-service training programs. Moreover, the studies included in this review were conducted within Western countries. Students’ and professionals’ perspectives from Africa and Asia are underrepresented within the qualitative literature about experiences of using RW. Therefore, geographicalgeneralizations from the present meta-synthesis should be avoided, and our paper reveals the necessity for RW research in other cultures and settings. Nonetheless, authors of primary studies have paid little attention to cultural and regionaldiversity. Therefore, we recommend furtherinvestigations exploring the differences between cultural backgrounds and howRW is recognized within training programs in different countries. Finally, additional qualitative and quantitative research is required to deepen our understanding of RW’s clinical and psycho-social outcomes in high complexity health practice contexts.

Our analysis confirms the crucial role of RW in fostering reasoning skills [ 59 ] and awareness in clinical situations. While its utility in helping health students and professionals to nurture reflection [ 2 ] has been widely theorized, this meta-synthesis provide empirical evidence to support and illustrate this theoretical viewpoint. Finally, we argue that RWis even more critical given the increasing complexity of modern healthcare, requiringprofessionals to develop advanced skills beyond their clinical ones.

Practical implications

Two important implications can be highlighted:

(i) students and professionals can recognize the potential of RW in learning advanced professional skills. ImplementingRW in academic training as well as continuing professional education is desirable.
(ii) Despite recognizing the effectiveness of RW in healthcare learning, students and professionals may face difficulties in writing reflectively. Trainers should acknowledge and address this.

Acknowledgments

We thank Dr. Silvia Tanzi for her insightful feedback about this work and Manuella Walker for assisting in the final editing of the paper.

Abbreviations

CASP	Critical appraisal skills programme
ENTREQ	Enhancing transparency in reporting the synthesis of qualitative research
PICo	Population, phenomena of interest and context
PRISMA	Preferred reporting items for systematic reviews and meta-analyses
RW	Reflective writing

Authors’ contributions

GArwas responsible for the original concept. MCB performed the literature search on databases. MCB, GAr, GAm, LD, MR were responsible of data curation. GAr, MR, GAm, and LD screened titles and abstracts of all studies. LG, MCB, SDL, and MH served as external auditors. FDV and LD assessed the quality of included studies. MCB and LG gave a third opinion in case of disagreement. GAr, GAm, MR, and FDV derived sub-categories from the data. GAr, LG, MH drafted the first version of the manuscript. FDV, LD composed tables, and figures. All authors read and approved the final manuscript.

Not applicable.

Availability of data and materials

Declarations.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Lifelong learning and nurses’ continuing professional development, a metasynthesis of the literature

Conclusions

Introduction

Continued professional development

Continued professional development: the UK example

Search strategy

Data analysis

Organisational culture shapes the conditions

Supportive environment as a prerequisite

Attitudes and motivation reflect nurse’s professional values

Nurses’ perceptions of barriers

Perceived impact on practice as a core value

What is the reported value of CPD for nurses’ lifelong learning and its impact on nursing knowledge?

What are the conditions necessary for CPD?

What are the challenges faced by nurses when engaging in CPD?

Limitations

Availability of data and materials

Abbreviations

Acknowledgements

Author information

Contributions

Corresponding author

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Competing interests

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Reflection as part of continuous professional development for public health professionals: a literature review

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Impact of a game-based interprofessional education program on medical students’ perceptions: a text network analysis using essays

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Extraction of core keywords and network construction

Network connectivity and centrality analysis

Topic modeling