Students may engage in different types of reflection during case-based discussion board activities. These types may be grouped into several main themes, and each theme may have corresponding subthemes. The present study identified 4 main themes (ie, content, contextual, dialogic, and personal). The groups’ working processes showed 9 types of collaboration functions for creating a sense of community in an online environment.
Types of reflection have been theorized in many ways. The literature contains various models directed to promoting reflective thinking and practice. On the basis of experiential learning theory, Hutchinson and Allen
9 developed the Reflection Integration Model to enhance reflective learning among students. This model comprises 4 components: preexperience, experience, reflection, and integration. Schön
10,11 recognized the substantial contribution of critical reflection in the development of professional knowledge and clinical expertise and identified 3 stages of reflection: conscious reflection, criticism, and action. Boud et al
12 presented a 4-stage model of reflection: analyze, interpret information, prepare an evaluation report, and prepare an action plan. Moon
13,14 approached reflection as a form of mental processing and described 5 stages of learning (noticing, making sense, making meaning, working with meaning, and transformative learning), which move from surface learning to deep learning. Moon
13,14 argued that reflection occurs in the transformative learning stage, facilitating deeper learning. The commonalties of these models
9-14 seem to indicate that reflection is executed either in a hierarchy of stages and levels or in a linear way.
The model examined in the present study may be interpreted as having both a vertical and iterative loop structure (
Figure). The vertical nature was evident when data analysis detected multiple levels of reflection types. Some discussions started at a superficial level and then moved to deeper levels that incorporated critical analysis and synthesis. The reflection process itself characterized the iterative dimension, which was activated through problem solving (ie, case-based scenarios) or experience toward gaining new insights.
The current model has multilayered reflection phases. Students may begin with 1 type of reflection and then lead to another. Thus, each type revisits or reveals new meanings or creates a new concept or way of thinking. The variability in reflection types and students’ reflection processes mirror Mezirow’s notion of transformative learning.
15,16 The ultimate goal of the current reflection model is the transformation of the gained knowledge, skills, and behaviors into action in the medical practice setting.
Implementing reflective practices to discussion-based collaborative learning in training medical students seems to provide substantial pedagogical value. Using an online curriculum that emphasizes collaborative learning techniques has great potential to develop students’ higher-level thinking and reflective skills as well as to develop responsibility for each other’s learning. Case-based discussion board activities were further found to:
With no identifiable change in the nature of student responses as they progressed from 1 case challenge to the next, the impact of this tool in creating a reflective mindset among students remains unclear. We need to understand how a reflection tool can be used by students and how evidence of reflection during this type of online education can be captured. It seems that the tool created for the present study enhanced students’ metacognitive processes through their self-disclosure statements and offered a framework to interpret how group collaboration created content knowledge, how group members offered deeper insights about the content, and how students regulated their own cognition and group learning skills. Goos et al
17 described 2 types of self-oriented statements: (1) self-disclosure statements, which clarify, elaborate, evaluate, and justify one’s own thinking, and (2) feedback requests, which invite a peer to critique one’s own thinking.
Learning community building was very strong in the present study as evidenced by consistency in the use of dialogic reflection. Case-based group discussion activities seemed to increase group interaction, with higher critical thinking skills, intragroup support to each other’s learning, group synergy, student engagement, and collective efforts to complete assignments. An effective learning community is that in which all students collaborate to exchange ideas, extract relevant questions from the cases, and reflect on multidimensional case analysis for meaningful learning.
18,19 Further, effective learning occurs through social interaction and negotiation.
20 The case-based project assignments were an effective way to form a foundation for both individualized reflection as well as collaborative learning. By its nature, therefore, collaborative learning promotes skills in communication and professionalism, which are core competencies of osteopathic medicine.
The present study did have some inherent limitations. One limitation was that the data are heavily qualitative, with limited quantitative data for further triangulation. The available quantitative data are provided to demonstrate the overall consistency of participation by the students in all aspects of the online module. The use of 2 coders and 2 methods of qualitative data analysis (manual coding and automated coding) was an effort to minimize bias in interpreting and categorizing student comments. Whereas the final sample size was small (N=17), we drew compelling insight into the reflective activities of the students. Demographic breakdown was not considered in the final analysis of responses. Last, the temporal relationship of student comments and those of faculty facilitators was treated as irrelevant in developing the conclusions drawn.