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What I Learned in Communication Class: a Reflection

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Published: Mar 18, 2021

Words: 632 | Page: 1 | 4 min read

Works Cited

  • Peterson, C. M., & Ray, M. N. (2019). Communication Skills for Success: Student Workbook. McGraw-Hill Education.
  • Beebe, S. A., Beebe, S. J., & Ivy, D. K. (2018). Communication: Principles for a Lifetime. Pearson.
  • Sole, K. (2017). Making Connections: Understanding Interpersonal Communication. Oxford University Press.
  • DeVito, J. A. (2016). The Interpersonal Communication Book. Pearson.
  • Guerrero, L. K., Anderson, P. A., & Afifi, W. A. (2019). Nonverbal Communication in Close Relationships. Routledge.
  • Floyd, K. (2019). Interpersonal Communication: The Whole Story. McGraw-Hill Education.
  • Pearson, J. C., & Nelson, P. L. (2017). An Introduction to Human Communication: Understanding and Sharing. Oxford University Press.
  • O'Hair, D., Wiemann, M., Mullin, D. I., & Teven, J. (2017). Real Communication. Bedford/St. Martin's.
  • Miller, K. (2019). Organizational Communication: Approaches and Processes. Cengage Learning.
  • Guffey, M. E., Loewy, D., & Almonte, R. (2019). Business Communication: Process and Product. Cengage Learning.

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reflective essay about communication

Critical Reflection

A Critical Reflection (also called a reflective essay) is a process of identifying, questioning, and assessing our deeply-held assumptions – about our knowledge, the way we perceive events and issues, our beliefs, feelings, and actions. When you reflect critically, you use course material (lectures, readings, discussions, etc.) to examine our biases, compare theories with current actions, search for causes and triggers, and identify problems at their core. Critical reflection is not a reading assignment, a summary of an activity, or an emotional outlet. Rather, the goal is to change your thinking about a subject, and thus change your behaviour.

How to Critically Reflect

Writing a critical reflection happens in two phases.

  • Analyze: In the first phase, analyze the issue and your role by asking critical questions. Use free writing as a way to develop good ideas. Don’t worry about organized paragraphs or good grammar at this stage.
  • Articulate: In the second phase, use your analysis to develop a clear argument about what you learned. Organize your ideas so they are clear for your reader.

First phase: Analyze

A popular method for analyzing is the three stage model,

What? So What? Now what?

In the  What?  stage, describe the issue, including your role, observations, and reactions. The what? stage helps you make initial observations about what you feel and think. At this point, there’s no need to look at your course notes or readings.

Use the questions below to guide your writing during this stage.

  • What happened?
  • What did you do?
  • What did you expect?
  • What was different?
  • What was your reaction?
  • What did you learn?

In the second  So What? stage, try to understand on a deeper level why the issue is significant or relevant. Use information from your first stage, your course materials (readings, lectures, discussions) -- as well as previous experience and knowledge to help you think through the issue from a variety of perspectives.

Tip:   Since you’ll be using more course resources in this step, review your readings and course notes before you begin writing.

Below are three perspectives you can consider:

  • Academic perspective : How did the experience enhance your understanding of a concept/theory/skill? Did the experience confirm your understanding or challenge it? Did you identify strengths or gaps in your knowledge?
  • Personal perspective: Why does the experience matter? What are the consequences? Were your previous expectations/assumptions confirmed or refuted? What surprised you and why?
  • Systems perspective: What were the sources of power and who benefited/who was harmed? What changes would you suggest? How does this experience help you understand the organization or system?

In the third Now what? stage, explore how the experience will shape your future thinking and behaviour.

Use the following questions to guide your thinking and writing:

  • What are you going to do as a result of your experiences?
  • What will you do differently?
  • How will you apply what you learned?

Second phase: Articulate

After completing the analysis stage, you probably have a lot of writing, but it is not yet organized into a coherent story. You need to build an organized and clear argument about what you learned and how you changed. To do so, develop a thesis statement , make an outline , write , and revise.

Develop a thesis statement

Develop a clear argument to help your reader understand what you learned. This argument should pull together different themes from your analysis into a main idea. You can see an example of a thesis statement in the sample reflection essay at the end of this resource.

Make an outline

Once you have a clear thesis statement for your essay, build an outline. Below is a straightforward method to organize your essay.

Write and revise

Time to get writing! Work from your outline and give yourself enough time for a first draft and revisions.

Sample Critical Reflection

Below are sample annotated paragraphs from one student’s critical reflection for a course on society and privilege.

The University of Edinburgh home

  • Schools & departments

Reflection Toolkit

Reflective essays

Guidance and information on using reflective essays.

The reflective essay is one of the most common reflective assignments and is very frequently used for both formative and especially summative assessments. Reflective essays are about presenting reflections to an audience in a systematic and formal way.

Generally, all good academic practice for assignments applies when posing reflective essays.

Typical reflective essay questions

Reflective essays tend to deal with a reflective prompt that the essay needs to address. This also often means that the essay will have to draw on a range of experiences and theories to fully and satisfactorily answer the question.

The questions/prompts should not be too vague, for example ‘reflect on your learning’, but should define an area or an aspect relevant to your learning outcomes. This is most easily ensured with thorough guidelines, highlighting elements expected in the essay.

Questions could be something like (not exhaustive):

  • reflect on learning in the course with regards to [choose an aspect]
  • reflect on personal development across an experience with regards to certain skills
  • reflect on development towards subject benchmarks statements and the extent to which these are achieved
  • reflect on the progression towards the course’s defined learning outcomes or the school’s or the University’s Graduate Attributes
  • reflect on some theory relevant to the course. (Remember that for this to be a reflective essay and not an academic/critical essay, the student must use that theory to explain/inform their own experiences, and use their own experiences to criticise and put the theory into context – that is, how theory and experience inform one another.)

Typical structure and language

Reflective essays will often require theoretical literature, but this is not always essential.  Reflective essays can be built around a single individual experience, but will often draw on a series of individual experiences – or one long experience, for example an internship, that is broken into individual experiences.

The typical language and structure is formal – for thorough descriptions on this, see ‘Academic reflections: tips, language and structure’ in the Reflectors’ Toolkit, which can be valuable to highlight to students.

Academic reflections: tips, language and structure (within the Reflectors’ Toolkit)

Length and assignment weight if assessed

There is no one length that a reflective essay must take. As with all written assignments, the main consideration is that the length is appropriate for evidencing learning, answering the question and meeting the criteria.

Similarly, there is no clear answer for what percentage of the overall mark is attached to the assignment. However, the choice should mirror the required workload for the reflector to complete it, how that fits into your initiative, and the amount of preparation the reflector has had.

For instance, if the student has received formative feedback on multiple pieces of work, a larger proportion of the course mark may be appropriate, compared to if the student had not had a chance to practice. It is important to keep in mind that many students will not have had many chances to practice reflective essays before university.

Back to ‘Components of reflective tasks’

Sample details

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  • Nursing home


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Reflective on communication

Reflective on communication

I am a health care assistant (HCA) on an elderly care surgical ward and we nurse many different patients who have had elective surgery and corrective surgery after a trauma. I have a lot of contact with patients who suffer with dementia, ongoing confusion due to urinary tract infections and can often display challenging and aggressive behavior.

I have found on a daily basis that patients become can frustrated when they cannot communicate what they want, and I was sure that with my strong accent I would come across as harsh. This left me feeling worried and sometimes inadequate because it is in my job and personal nature to want to help those in my care. As part of my Personal Assessment Document (PAD) my mentor and I decided that I would I would push myself to speak with patients more and see how they reacted to me. I would read the patient’s purple “This is me” folder to try and engage them on a more personal level.

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With this reflective account I will be discussing an experience that I had on my ward and how through reflection I have managed to gain more confidence in my ability to talk to my patients and convey my compassion in the way I communicate with the patients in my care.

I will use the reflective framework devised by Atkin and Murphy (1994) to construct this account. It is the right model of reflection for me to look back and learn from my experiences.

Personally, being a good student and health carer does not just come with reflection in the mind but also reflective practice which, according to the nursing standard “enables a student to develop their skills, increase their knowledge and deal with emotionally challenging situations” (RCN 2012). Reflection is something that should be engaged with on an everyday basis and from very early on in your health care career. It enables you to carry on caring about the patients you treat and how to improve yourself personally and professionally.

I enjoy both the personal rewards and the challenges that go hand in hand with working with patients with dementia. I find that on the drive home I tend re-evaluate everything in my life and be grateful for the now. A patient whom will go by the pseudonym of “Polly” to maintain her confidentiality (The NMC Code of professional Conduct, 2004) was admitted to the ward with a fracture to the neck of her femur. I was advised that the patient was very confused, and would spit at staff and be both physically and verbally aggressive when approached but would constantly cry out that she needed help. She was in the early to middle stages of Alzheimer’s disease and had come from a care home for those suffering with dementia. Alzheimer’s disease is characterised “by the loss of short term memory, deterioration in both behaviour and intellectual performance and slowness of thought” (Dictionary of Nursing 1998).

In handover that morning I found that I would be working with her that day, and as she was post operative I would need to wash her and try to mobilise her to sit out in her chair so that the physiotherapists could help her to walk again and get her on the pathway to being discharged back to her care home. I found that I was nervous in approaching this patient as I did not want to upset her or get hurt. Personally I would always wake patients like Polly who require the attention of more than one member of staff last as it is better to leave the patient to sleep so that they are well rested. That, and from handover I had learned that Polly had experienced a rather active night.

Before waking Polly I had read her personal “This is me” purple file to find out if she had any preferred names, and how she liked to be spoken too. This is me was devised by the Alzheimer’s society and “is intended to provide professionals with information about the person with dementia as an individual. This will enhance the care and support given while the person is in an unfamiliar environment“(Alzheimer‘s society 2011). With this information I could help maintain a similar routine for Polly and I would not confuse her by overloading her with too many questions and instructions.

I woke Polly up gently, and sat myself down in the chair by her bed so that I was not standing over her. I spent almost thirty minutes with Polly getting her up and ready, the patient did not get upset or frustrated with me, and she was able to do most of the washing and dressing herself with help from me. Once this was completed I handed over to physiotherapists that they too should take this approach with Polly.

I spent twelve days in total with Polly. In this time she was aggressive with me, and she would spit at me when I approached her. Yet, once I used her preferred name and tailored my approach to what she needed from me, I found that Polly was a pleasant and wonderful lady, who could be the complete opposite to the patient that was first handed over to me that first morning.

Morris and Morris state that the symptoms of dementia are experienced by each person in “their own unique way” (2010) and this is reinforced by the publication of the “this is me” leaflet. It enables staff to really look at each individual patient and assess what their needs are. In reflection, if I had not read this leaflet and just gone ahead and woke Polly up as I do each patient, the events of the day could have taken a very different path. I found that by talking to Polly as requested in her leaflet that she reacted in a calmer manner and did not get as anxious or frustrated as quickly as my colleagues had prepared me to think.

Reflecting over my first day with Polly, I do not remember struggling to say my words more clearly than what I normally would have done. Polly was not deaf, nor was she a child and I kept it in my mind that this patient was still a scared lady who had broken a big part of her body and was in a large amount of pain. Furthermore, she might not be able to communicate this fact as clearly as someone without dementia. Hobson states that, the HCA will need to “learn to adapt how they attempt to understand what the person is saying to them” and that this can only be achieved by “entering the same world as the person with dementia” (2012, P337). At times Polly would pretend to cry like a child and repeat the words “Oh Mummy, mum, mum. Oh Mummy” but not be able to give an answer when questioned what was wrong and how could we help her. Taking this into consideration, Polly might not be actually asking for her Mum but actually trying to communicate a much deeper need.

My understanding of how patients with dementia communicate lead me to point to Polly’s hip and ask her if she felt pain there when she moved, to which she replied yes she did. In reflection I found this was a much better approach rather than just asking if Polly wanted any pain relief. Elkins has stated that asking the patient with dementia a direct question is almost a waste of time, as the patient does not have the information to give you. Instead it is more beneficial for the patient’s sense of self worth to ask them a question with an optional answer of “yes” or “no”. It could also be said that a statement rather than a question is better because it leaves the patient feeling more in control (2011). From this experience, I suggested to the nurses that when doing their drug round that they should lower themselves down to Polly’s eye level and ask her if her hip hurt her, rather than standing at the end of her bed or beside her asking if she wanted any pain relief. This suggestion meant that Polly had more regular pain relief, and as a team we knew when she was in pain. Furthermore, this information could be added to her file and become part of Polly’s future care pathway. Elkins raised the very same argument that “once an effective communication bridge had been achieved, the individual is much more like to remain calm and anxiety free” This would show that dialogue between patient and healthcare professional had been greatly improved and would continue to do so in the future (2011).

In reflection, I have found that I was so focused on the need to be understood through my use of English that at times I under-estimated the importance of non-verbal communication. Now, having taken a step back I see that I am almost in the same boat as the patient suffering with dementia, we are both just “an individual attempting to communicate” (Hobson, 2012) and as a HCA the method of employing “feelings and emotions” should become more “significant than the spoken word” (Hobson, 2012).

Although my confidence in speaking to patients is always growing, I am more appreciative of how much more effective my body language, and the tone of my voice can be when communicating with a patient with dementia. Yes, looking after these patients can be a challenge but getting past the dementia and working in ways that compliment the patient’s mindset will be of more benefit to the patient. By spending some time reading each patient’s information leaflet I am able to help maintain a patient’s well being and create a more anxiety free environment for our patients.

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reflective essay about communication

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  • Published: 16 November 2023

Grading reflective essays: the construct validity and reliability of a newly developed Tool- GRE-9

  • Nisrine N. Makarem 1 ,
  • Diana V. Rahme 1 ,
  • Dayana Brome 2 &
  • Bassem R Saab 1  

BMC Medical Education volume  23 , Article number:  870 ( 2023 ) Cite this article

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Metrics details

The main objective of this study is to assess the construct validity and reliability of the Grading Reflective Essays-9 (GRE-9).

This study took place in a major tertiary academic medical center in Beirut, Lebanon. 104 reflective essays written by years 1–3 residents in the department of Family Medicine at the American University of Beirut Medical Center (AUBMC) were graded by 2 trained raters who independently scored the essays using GRE-9. GRE-9 scores were then correlated with scores on communication skills OSCE stations and in-training examinations to investigate, respectively, convergent and divergent validity. One of the 2 raters scored the essays twice one month apart to assess the reliability of the GRE-9 using intra rater reliability and internal consistency.

There was a weak, non-significant correlation between GRE-9 score and In training examination (ITE) score ( r  = − .213, p  = .395). There was a moderate, non-significant correlation between GRE-9 scores and the Objective structured clinical examination ( OSCE) communication station scores ( r  = − .412 p  = .162). The correlation coefficient between trails 1 and 2 was significant ( r  = .832, p  = .000). Intra class correlation coefficient (ICC) analysis demonstrated almost perfect intra-rater agreement (0.819; 95% CI: 0.741–0.875) of the test ratings over time.


GRE-9, is a short, concise, easy-to-use reliable grading tool for reflective essays that has demonstrated moderate to substantial intra-rater reliability and evidence of divergent validity. The study found non-significant correlations between reflective writing scores OSCE communication scores demonstrating a lack of relationship between reflective writing and this measure of performance.

Peer Review reports

Reflective writing is a well-accepted tool within medical education that supports the growth of reflective capacity among medical students [ 1 ].With its consideration as an essential aspect of lifelong self-directed learning, reflective writing has become a crucial element integrated into a competence-based curriculum of the medical program [ 2 ]. The idea of reflective practice was primarily established by Schon in 1987, and it was characterized by three stages: awareness of thoughts and feelings, critical analysis of a condition, and development of a new viewpoint of the situation [ 3 ]. Reflection is also conceptualized as a process for change [ 4 ] and it is considered a fundamental aspect of enhanced learning [ 5 ] as it provides the opportunity for ‘reflection-on-action’ [ 6 ] and the demonstration of critical reflection by individuals. It follows that reflection allows the development and integration of new knowledge into practice leading to the core experience of greater professional competence [ 7 ] as it leads to improvements in empathy, communication, collaboration and professionalism [ 1 ]. A growing body of research has also highlighted the relationship between reflective capacity and the enhancement of physician competence [ 8 , 9 ].

Realizing the beneficial consequences of reflection [ 10 ], medical educators have sought to explore a variety of methods for fostering and assessing reflection in learners, ranging from one-to-one mentoring [ 11 ] to guided discussions [ 12 ], digital approaches like video cases [ 13 ] and written methods like reflective portfolios, journal and essay writings [ 11 , 14 ]. Reflective writing was reported to be one of the most extensively and widely used forms of reflective teaching in medical education [ 15 , 16 ]. Reflective capacity within these reflective writing exercises can be assessed through various qualitative and quantitative tools [ 17 ]. Despite the presence of diverse methods, there is still a lack of best practices [ 17 ].With the proliferation of reflective writing in promoting and assessing reflection [ 18 ], the need for a valid, reliable evaluative tool that can be effectively applied to assess students’ levels of reflection was strongly called for [ 19 ].

Given that reflection is hard to measure and assess directly [ 14 ], it becomes imperative to develop simpler tools that are short, concise, include well-defined descriptors, and are easily accessible for analysis and interpretation with high level of objectivity. Since students’ approaches to learning might be affected by the type of assessment strategy used [ 20 , 21 ], unreliable and invalid assessment strategies can lead to unfair results. Hence, designing a reliable and a valid assessment tool is needed.

Consequently, to serve in filling this research gap and in an effort to improve the reflective essays grading process at the American University of Beirut Medical Center (AUBMC), a new scale called the Grading Reflective Essays- 9 (GRE-9) was developed by faculty members at the Department of Family Medicine. The developed GRE-9 was found to be a reliable, concise and simple grading tool that has demonstrated moderate to substantial inter-rater reliability enabling raters to objectively grade reflective essays and provide informed feedback to residents and students [ 22 ].

Since the items of the GRE-9 scale were conceptually and thematically based on solid theoretical underpinnings and match with the four reflective levels of the REFLECT tool [ 19 ] as well as with the three essential aspects of personal reflection in the context of medical practice and education of the GRAS [ 2 ], the content validity of the scale was assumed and appeared to be satisfactory as it was grounded in reflection literature. Although GRE-9 was found to be reliable and demonstrated content validity, the construct validity of the instrument was not determined due to the small sample size. As such, investigating the validity of an instrument is of vital importance given that clear robust validity is crucial for an effective instrument [ 23 ]. Construct validity is a significant objective of validity as it mainly focuses on whether the obtained score of the instrument provides a useful and effective purpose when used in research practice [ 24 ]. A common method used in examining the construct validity of an instrument is investigating its relation to other variables. In the case of GRE-9, we tested its correlation with written examination scores and communication skills scores [ 25 ]; exploring the divergent and convergent validity of GRE-9. Research has shown that the development of reflective capacity incorporates intrinsic skills such as communication, clinical reasoning and professionalism [ 8 , 26 , 27 ]; thus, it is contended that scores in reflective writing will correlate with residents’ scores in measures of intrinsic skills specifically communication skills as generated by stations of objective structured clinical examination ( OSCE) that particularly assess communication skills, but not with their scores in knowledge based examinations. Therefore, evidence of a significant correlation between OSCE score in stations that assess communication skills and reflective writing scores would be taken as evidence of convergent validity, while lack of a significant correlation with multiple-choice question on in-training examination scores that assess medical knowledge would be taken as evidence of divergent validity [ 28 ]. In an effort to additionally investigate the reliability of the GRE-9, intra rater reliability and internal consistency were also explored.


Overview of study design, sample and procedures.

As part of a routine formative assessment activity, Family Medicine residents in years 1–3 training in a four-year program at the AUBMC are asked to write 1–2 reflective essays per year based on incidences from their medical practice demonstrating their ability to reflect on their learning experience. The reflective essays are not prompted and residents are asked to reflect on any incident that touched them during their practice. This provides a broader scope for reflection and bypasses the restriction on their ability to reflect when given prompts [ 29 ]. Over the academic years 2016–2020, a total number of 60 family medicine residents at AUBMC in their first to third year of residency participated in reflective writings yielding 104 reflective essays. This sample size was sufficient given that a minimum number of 40 assessment observations were required to test Cronbach’s alpha when different from 0.50 at a significance level of p < .05 and power of 0.80 [ 30 ].The sample size calculation for intra-rater reliability is computed based on the criterion value of 0.8 and the obtainment of 80% power at 5% significance level by using Power Analysis and formula for minimum sample size (n) and yielding the requirement of 70 ratings per rater [ 31 ], thus rendering the study’s sample sufficient.

Family Medicine residents sit for an annual in-training exam (ITE) conducted by the American Board of Family Medicine. This exam is in the form of multiple choice questions and aims to test the residents’ comprehensive biomedical knowledge. Residents also sit for a yearly OSCE exam that consists of 13 stations one of which assesses their communication skills.

The three types of data (OSCE score, ITE score, and GRE9 score) for each resident in years 1 to 3 across academic years 2016 to 2020 were matched to give a complete dataset, and then anonymized by using participant codes. This process was carried out by an honest broker at the department of Family Medicine. Each reflective essay was graded by two trained raters versed in the field of medical teaching, curriculum development, as well as reflective writing assessment using the GRE-9 rubric, who independently scored the reflective essays. Before starting the grading process, training sessions on the GRE-9 were conducted which included a review of the elements of the GRE-9 followed by a group discussion on how the tool should be applied. The two raters then conducted three meetings to discuss their grading of 10 randomly selected reflections, which were excluded from the study, as a way of increasing consistency across raters’ scores.

Following the training, the two raters assessed the 104 essays. To determine the final ‘reflection’ score for a given essay, the average score across the two raters was used. The average score for each participant across his/her writing samples throughout the years assessed was calculated as a final score. One of the 2 raters also rated the reflective essays another time one month after the first rating.

Ethical considerations

Before starting the research project, approval was sought from the Institutional Review Board (IRB) at the AUBMC. An email was sent to all residents involved informing them about the study and asking for their consent to include their reflective essays. Lack of reply to the email was considered as consent to include their anonymized reflective essays in the study. Only the reflective writings of the residents with complete ITE and OSCE data and who have consented for their anonymous data to be used in the validation analysis for the GRE-9 were utilized. Participation did not impact residents’ evaluations, which were completed before the analysis began.

Research Design

This study aimed to assess the different sources of evidence that support the construct validity of the study instrument. The sources of validity evidence for GRE-9 were based on investigating the relation of GRE-9 scores to other variables by testing convergent and divergent validity. Reliability of the scale was also investigated through internal-consistency and intra-rater reliability.


Grading reflective essays − 9 (gre-9).

The GRE-9 obtained a moderate to substantial inter-rater reliability based on the Intra class correlation coefficient (ICC) krippendorff’s alpha (ICC of 0.78). The standardization of the scoring for the GRE-9 includes the following: the first 2 items of the scale, which are descriptive, are given a maximum grade of 1 whereas the rest, which are analytical, are given a maximum grade of 2. The maximum score is 16. The items are followed by a guide that clarifies each point with the aim of facilitating and standardizing the grading process. The GRE-9 consists of 9 items (Appendix).

In-training examination (ITE)

During their first to third residency years at the department of family medicine, residents complete an annual ITE from the American Board of Family Medicine. This consists of 200 multiple-choice questions assessing their medical knowledge. The purpose of the ITE is to provide an assessment of the residents’ progress in acquiring the medical knowledge needed to become a family physician. The ITE is scored using statistical analyses whereby there is no passing score, since the purpose of this examination is to assess the resident’s progress over the years of their residency training. Performance reports provide identified areas that the resident needs to improve and can be used to develop an individual educational plan in coordination with the residency program. Each resident is given a scaled scored that is compared to the national mean score. Because the ITE scores are contended to reflect knowledge-based performance, a low correlation is expected to emerge between the GRE-9 score and ITE score; thus, confirming evidence of divergent validity.

Objective structured clinical examination (OSCE)

Family Medicine residents complete an annual OSCE examination consisting of 13 stations of which one station assesses their communication skills. A clinical faculty member scores each resident on each OSCE station and evaluates his/her performance using a station-specific checklist that assesses dimensions of performance specific to that station as well as factors such as organization of the encounter and accord with the patient. A final score is given per station per resident. The total (weighted) score calculated for the single station that specifically evaluates performance on a communication challenge was extracted for each resident throughout years 2016 to 2020. A significant correlation is expected to emerge between scores on communication skills OSCE stations and reflective writing scores; thus, confirming evidence of convergent validity.

Data Analysis

Data was analyzed using the Statistical Package for the Social Sciences (SPSS 22.0). As a definitive measure of criterion-related validity, convergent and divergent validity were investigated by using Pearson correlations coefficients (moderate = 0.3–0.7; strong 0.7–1.0). In order to determine the intra-rater reliability of the ratings, the correlation coefficients between the two grading of the same rater (R1) for the same reflective essays were also computed by using Pearson Correlation Analysis. The intra-rater reliability was also assessed using the ICC with a 95% confident intervals based on a mean-rating ( k  = 2), absolute-agreement, 2-way mixed-effects model. GRE-9 was also examined for its internal consistency using Cronbach’s alpha (α). The Spearman–Brown prophecy formula was used to determine the number of raters necessary to achieve inter-sample reliability of at least 0.90. For all inferential analyses, a p-value of ≤ 0.05 established statistical significance.

Divergent and convergent validity

The association between the students’ reflective scores and each of the ITE and OSCE scores was investigated to assess the GRE-9 criterion-related validity. Results yielded a weak, non-significant correlation between GRE-9 score and ITE score ( r  = − .213, p  = .395). The absence of a significant association between the two variables confirmed evidence of divergent validity. When assessing the reflective GRE-9 scores for convergent validity, results demonstrated the emergence of a moderate, non-significant correlation between GRE-9 scores and OSCE communication station scores ( r  = − .412 p  = .162. This indicated that GRE-9’s convergent validity was not supported.

Intra-rater reliability and internal consistency

Intra-rater reliability.

Intra-rater reliability was determined for GRE-9 by examining the consistency of rater 1 reflection assessment at time 1 (first assessment) and at time 2 (second assessment in a one month interval). The correlation coefficient between trails 1 and 2 was significant ( r  = .832, p  = .000). Given that the correlation coefficient was above 0.70 which refers to a sufficiently high correlation and relatively high consistency [ 32 ]; thus, indicated a strong intra-rater reliability. In order to determine the number of raters needed to achieve an almost perfect agreement (0.90-1) across the two raters, the Spearman–Brown prophecy formula was calculated and results indicated that 2 raters are enough to score 104 reflective writing samples to achieve an inter-rater reliability of at least 0.90.

Intra-rater reliability for GRE-9 was also examined using Intraclass correlation coefficients measures of agreement. Given that ICC values between 0.81 and 1.00 represent almost perfect agreement and thus high reliability according to Landis and Koch [ 33 ],

ICC analysis demonstrated almost perfect intra-rater agreement (0.819; 95% CI: 0.741–0.875) of the test ratings over time.

Internal consistency

Internal consistency for GRE-9 scale was assessed through an overall Cronbach’s alpha calculated for the first and second rater assessments. Given that Cronbach’s alpha of 0.70 was considered as an adequate consistency, 0.80 was considered good, and > 0.9 was considered highly consistent [ 34 ], thus, producing a low to moderate reliability (α = 0.518). Given that the length of the scale influences the value of alpha which gets reduced for short length scales, a Cronbach alpha between 0.5 and 0.7 is regarded as acceptable for such scales [ 35 ]. Table  1 presents the pattern of correlations across all measures.

The correlation coefficients computed, by using Pearson Product Moments Correlation, are presented below in Table 1.

This study demonstrates different sources of evidence to support the construct validity as well as the reliability of the GRE-9. This study is a follow-up to a prior study that was carried out by the same authors to examine the psychometrics of the GRE-9. As yielded in the primary study, content-related evidence was supported by the theory-informed construction of the study instrument since the GRE-9 rubric was based on a comprehensive analysis of relevant theoretical models of reflection as well as existing reflection assessment measures [ 36 ]. In addition to content validity, GRE-9 was found to be a reliable, concise and simple grading tool that has demonstrated moderate to substantial inter-rater reliability [ 22 ], yet the investigation of the construct validity was not determined due to the small sample size. As such, given that clear robust validity of an instrument is crucial [ 23 ], the present study aimed to further investigate the psychometrics of the GRE-9 by examining its construct validity, intra-rater reliability and internal consistency.

In accordance to examining the construct validity of the GRE-9, divergent and convergent validity were explored. Results yielded a weak, non-significant correlation between GRE-9 reflective score and ITE score; thus, confirming the evidence of divergent validity. When assessing for convergent validity, results demonstrated the emergence of a moderate, non-significant correlation between GRE-9 reflective scores and OSCE communication station scores; indicating that GRE-9’s convergent validity was not supported. Other studies in the literature that have also investigated the divergent and convergent validity of reflective tools through investigating the relationship between reflective writing scores and other measured of performance [ 1 , 28 , 37 ] have also yielded differential results related to construct validity. For instance, in a study aiming to investigate issues of reliability and validity in the quantitative assessment of reflective writing using an already establish reflective tool [REFLECT], results yielded a weak non-significant correlation between students’ REFLECT scores (averaged across four samples and four raters) and Year 2 MCQ examination scores which confirmed the divergent validity [ 1 ]. Study findings also yielded a weak non-significant correlation between REFLECT scores and OSCE measures; as such, failing to support the convergent validity of the scale [ 1 ]. Another similar study evaluating a newly developed scale [ 28 ] showed evidence of convergent validity for their scale. Specifically, correlations between scores in reflective portfolios and scores in both communication skills and PBL tutorials supported the evidence of convergent validity. Although, a small effect size correlation of the reflective scores in relation to written MCQ examination was obtained [ 28 ], divergent validity was not established. In another study that aimed to investigate the validity of the Reflective Practice Questionnaire (RPQ) in the Korean context to identify the level of reflection of medical students in clinical practice, the criterion validity test supported the convergent validity by yielding a positive correlation between most of the sub-factors of the Korean version of the RPQ (K-RPQ) with the Korean Self-reflection and Insight Scale (K-SRIS), which measures the attitude of daily insight, and “the Reflection-in-Learning Scale (RinLS),” which measures students’ reflective learning experiences in medical school and with “The Self-efficacy in Clinical Performance Scale (SECP)” which measures clinical performance self-efficacy [ 37 ]; in this study, divergent validity was not investigated.

The differential results related to convergent and discriminant validity in the aforementioned studies can be attributed to various factors such as content of the study instrument, levels of training of the raters, number of raters, as well as the sample size used [ 37 ]. In the present study, the emergence of a moderate, non-significant correlation between GRE-9 reflective scores and OSCE communication station scores and the disconfirmation of GRE-9’s convergent validity indicates that one or both of the variables failed to capture the intended construct well. In fact, while most theories of reflection encourage imaginative exploration of cognitive, affective, physical, and verbal experiences when making sense of ambiguous and uncertain situations, the development of a tool that breaks down reflection into discrete components restricts learners’ ability to be creative and encourages their propensity to tailor their writing to the objective of “scoring well” [ 38 ]. As such, further refinement of the reflection construct measured by GRE-9 is required in future studies. Furthermore, despite the statistical adequacy of the sample size, the non-significant correlation might also reflect the need of additional statistical power to detect a significant correlation among the variables [ 39 ].

In an effort to additionally investigate the reliability of the GRE-9, intra rater reliability and internal consistency were also explored. Results yielded strong intra-rater reliability for GRE-9 ( r  = .832), indicating that a score above 0.70 refers to a considerably high and meaningful correlation [ 32 ] and relatively a high consistency [ 40 ]. A high intra-rater agreement was also recorded (0.819; 95% CI: 0.741–0.875); which further indicates that the rater assigned similar scores to the essays in both assessments when using the GRE-9 tool. When investigating the internal consistency for GRE-9 scale, results produced a low to moderate reliability (α = 0.518). This level of reliability can be attributed to several factors. Primarily, the length of the scale is reported to influence the value of alpha which gets reduced for short length scales; thus, yielding a Cronbach alpha between 0.5 and 0.7 as acceptable for such scales [ 35 ]. Numerous studies in the literature investigated the internal consistency of reflective tools used in a medical setting; results yielded diverse results from low to high internal consistencies. For instance, the reliability of 10 sub factors Reflective Practice Questionnaire (RPQ) in the Korean context was found to be satisfactory, ranging from 0.666 to 0.919 [ 37 ]. The Groningen Reflection Ability Scale (GRAS) was developed to measure the personal reflection ability of medical students; results yielded moderate to high Cronbach’s alphas of 0.83 and 0.74 for the scale [ 2 ]. In another study investigating the internal consistency of the REFLECT scale, similar results to the present study were obtained whereby the scale items yielded poor reliability across all criteria of the tool (0.529–0.621) [ 38 ]. The low reliability in terms of Cronbach’s alpha can be attributed to the notion that the good reliability statistics are not just observed to be the result of the function of the tool solely, but also as a result of the intersection between the assessors’ application of the tool and their comprehension of what it is designed to measure [ 38 ]. This type of consensus understanding building may have taken place as a result of the inclusion of the same raters throughout testing iterations or as a result of the research team providing raters with a set of progressively-refined instructions. Although efforts were made for the raters to be prepared for the rating procedure by allowing them to go through a pre-study rater training process, yet there is a proposed possibility that this could not have been enough to address any fundamental disparities between how the raters understood the tool’s constructions [ 38 ]. Our findings have implications for the number of raters needed to obtain inter-rater reliability of at least 0.90: our study concluded the need for two raters; this is similar to Wald and colleagues [ 19 ] who proposed the use of two or three raters based on their results.

It is worth noting that the very effort of quantifying reflective writing is in itself a challenge. Charon and Hermann have argued that this effort in itself can undermine the educational value of reflective writing. They suggest that the utility of reflective writing as a channel for learning is challenged once it undergoes formative assessment. They explain that reflective writing should be used to “attain the state of reflection” and rating or grading this process can be counterproductive. When reflective writings are graded, students and residents will write with the aim of performing well rather than to simply reflect, distorting the work of reflection itself [ 41 ].


The limitations of this proposed study are worth pointing to. Primarily, the design of the study was restricted to years 1–3 of residency in the family medicine department at AUBMC. In this case, participants cannot be assumed to be representative of a larger population outside the study context; thus, restricting the generalizability and the replication of the study findings in different years of study and in different educational settings. Also, given that residents from first to third year of residency participated in the reflective writings, there is a possibility that those in the third-year training were more exposed to experience as well as reflective thinking processes within the field; hence, allowing for the possibility of response bias to take place.

Despite the popular use of reflective essays as a tool to measure reflection, little quantitative evidence exists to support the psychometric properties of the available tools. In this study, we aimed to assess the psychometric properties of the GRE-9 as a step towards filling this research gap. Although the results did not confirm the convergent validity of GRE-9 and the scale had low internal consistency, results supported GRE-9 reliability and validity through divergent validity and high intra-rater agreement. Yet, prior to applying these findings to the evaluation of students in other medical schools, more research is required to confirm these findings and to assess additional measuring characteristics of the GRE-9. Factors, such as, content of the study instrument, levels of training of the raters, the number of raters, as well as the sample size used [ 28 ], could all be impacting the results related to the reliability and validity of the scale. An important notion is that reliability characteristics are contended to be relevant to the context in which a measurement tool is developed; as such, it becomes of paramount importance to replicate psychometric examination of such tools before applying them and using them in new educational medical context [ 38 ]. Therefore, it is important to further apply GRE-9 in different resident groups with a wider range of demographics in order to make sure that results are generalizable and to further clarify the meaning of reflection and the constructs related to this concept that is to be captured by GRE-9. Our study comes to support the notion that if medical educators are to use assessment tools to grade reflective writing, then future research should focus on the development of more reliable and valid instruments. Finally, when developing tools used to extract quantifiable data from conceptual frameworks once thought to be assessed only though qualitative methods, it is expected to be faced by conflicting results related to the scale’s reliability and validity.

Data Availability

The data is available upon reasonable request by contacting the corresponding author Dr. Diana Rahme, email [email protected].

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NM contributed to study design, grading the reflective essays, overseeing the study, and writing of the manuscript. DR contributed to study design, grading the reflective essays, and writing of the manuscript. DB did the data analysis and contributed to writing the results section. BS reviewed the final manuscript and gave his input.

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Makarem, N.N., Rahme, D.V., Brome, D. et al. Grading reflective essays: the construct validity and reliability of a newly developed Tool- GRE-9. BMC Med Educ 23 , 870 (2023). https://doi.org/10.1186/s12909-023-04845-6

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