This research aimed, in its first phase, to adapt the GRAS for Turkish postgraduate medical education. In the second phase, the adapted scale was used to examine the correlation between reflection skills and various variables of FM residents in Turkey.
4.1 Scale adaptation
In the first phase, the adapted GRAS-TR-pg scale was administered face-to-face to 230 students receiving specialized training at X University Faculty of Medicine.
Through the data obtained, CFA was employed to assess the construct validity of the original scale, consisting of 23 items and three factors. It was determined that the 20-item, three-factor model achieved an acceptable level of fit after removing only three items from the third dimension. The final GRAS-TR-pg scale consists of 10 items in the first factor, six items in the second factor, and, differing from the original, four items in the third factor. In contrast to our study, Şenol et al. concluded that a two-factor structure ("Self Reflection" and "Reflective Communication") is more suitable for Turkish culture [15]. A Danish adaptation study was found that none of the factors adequately explained the variance, particularly the reversed items which performed poorly in the instrument. Consequently, neither the one-factor nor the three-factor structure could be confirmed. Therefore, the researchers recommended postponing the use of GRAS-DK for effect measurements and group comparisons until further review and validation studies are conducted [21].
In Şenol et al's study, the GRAS-TR adapted for undergraduate medical education was validated with 19 items and a two-factor structure by excluding items 7 and 18 from the first factor, item 8 from the second factor, and item 21 from the third factor [15]. In our study, after removing items 3, 4, and 17 from the third sub-factor, a 20-item scale was validated with a three-factor structure, similar to the original scale. It is evident that both the excluded items and the confirmed structures significantly differ in the undergraduate and postgraduate Turkish adaptation studies. This result indicates that the scales function differently in various groups, highlighting the importance of adapting GRAS-TR-pg.
After removing three items, Cronbach's alpha and McDonald's omega coefficients were computed to evaluate the reliability. The reliability values obtained for the entire scale and its factors were deemed satisfactory. In Şenol et al.'s study, Cronbach's alpha coefficient was also considered adequate [15]. In the Danish adaptation study, the Cronbach's alpha was found to be 0.87 [21].
The analyses conducted have yielded sufficient evidence for both validity and reliability of the scale. In essence, the results indicate that the scale, in its final form with three factors and a total of 20 items, can effectively assess the reflective skills of postgraduate medical students and serve as a valid and reliable tool.
4.2 Evaluation of FM residents' reflective abilities
Although Mamede's study found higher reflection skills among those in Public Health, Pediatrics, and Internal Medicine [3], we selected participants from FM residents in the second phase of our study because FM distinguishes itself by offering continuous primary healthcare regardless of age, gender, or disease differentiation [9].
Researches indicate a positive correlation between reflection and physician competence [5]. Reflective practices during FM residency enable learners to derive insights from their experiences through retrospective thinking [12]. Teaching reflection to FM residents and integrating it into clinical training promotes lifelong learning [10].
Mamede's study demonstrated that primary care physicians also working in hospitals scored higher in reflective practice [3]. In Turkey, specialization education is provided in two main institutions: Education and Research Hospitals (ERH) and University Hospitals (UH) [22]. ERH serve a larger and more diverse patient population, offering specialty students greater experience. However, the higher workload can challenge students' focus on their educational requirements. Additionally, there may be fewer and less experienced instructors. Thus, our study examined whether participants' reflection scores varied depending on their educational institution. In 2023, during data collection, FM specialization training was available in 31 ERH and 61 UH. We assessed the reflection skills of 336 FM residents from 22 institutions, including eight ERH and 14 UH. However, we found no statistically significant difference in scores, both in sub-factors and the total score.
Mamede's study reveals a negative correlation between reflective practice and both age and total duration of medical practice. This suggests that as experience grows, engagement in reflective practice tends to decline [3]. As our study concentrates on postgraduate education involving FM residents, we examined the correlation between reflective skills and the duration of specialization education instead of participants' professional experience period. However, we found no statistically significant difference in scores based on seniority, both in sub-factors and the total score.
In our study, we also found no statistically significant difference in scores based on gender, both in sub-factors and the total score.
Reflection is essential in medical education. A study indicated that increased reflective capacity greatly influences critical thinking. Environments fostering reflection aid in enhancing reflective capacity and developing critical thinking skills [23]. Another study involving FM residents showed that engaging in reflective activities led to a deeper comprehension of concepts through discussions with mentors and peers. These activities were found to foster the creation of new concepts and their practical implementation, thus promoting professional growth [12]. In another study evaluating the effect of integrating reflective case-based activities into the FM Residency Program curriculum on residents' perceptions, it was noted that most residents not only enjoyed and found these sessions beneficial but also reported improvements in patient care and increased interest in their medical specialty [11]. Another study assessing how reflection impacts the perception of clinical rotation objectives and the achievement of curriculum goals for obstetrics and gynecology residents revealed that these sessions may enhance awareness of rotation goals and increase the likelihood of successfully achieving them [24].
Reflection significantly impacts all stages of medical education. In a study conducted in Denmark, it was found that undergraduate medical students who participated in an elective course with the most comprehensive abstract learning outcomes achieved significantly higher scores compared to students in other elective courses [21].
Our research introduced a Turkish-adapted reflection scale for postgraduate medical education, examining its psychometric properties. The original Dutch scale has been adapted to various languages and cultures, facilitating cross-cultural comparisons. Additionally, our study data informed the assessment of the necessity for instilling reflective skills in postgraduate education. Moreover, there might be a requirement for developing reflection scale studies for use in postgraduate education across other specialties.
2.1 Strengths and limitations
In the first phase of the study, while the face-to-face administration of the scale enabled the inclusion of residents from various disciplines, the limitation of data collection to a single institution is acknowledged. Additionally, in the second phase, the nationwide distribution of the form online was limited to a select number of institutions. Furthermore, self-reporting by participants may impact the objectivity of the collected data.