reflection literature review

Schools & departments

Reflection literature

This section contains a review of literature on reflection and a list of helpful literature to explore the area further.

The Reflection Toolkit is intended to be used and to be easy to navigate. Therefore, we have tried to streamline it by removing large theoretical discussions and constant references to literature. However, these are important so from here you can access information on the historical development of the concept of reflection, the evidence behind whether it actually works, the literature used in developing the Reflection Toolkit and references to other relevant literature and materials.

Literature review

Below is a PDF that contains a review of literature on reflection. The review explores the development of the theoretical concept of reflection, deals with associated challenges, and highlights the empirical evidence behind the benefits of reflection. It also explains how we chose the definition of reflection that is used across the Reflection Toolkit.

Reflection bibliography

The page below contains the literature that contributed to the development of the Reflection Toolkit and other relevant literature in the area. The literature is divided into broad topics to make it easy to find relevant content and to see how literature has informed the Reflection Toolkit.

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Knowledge Base

Methodology

How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

Search for relevant literature
Evaluate sources
Identify themes, debates, and gaps
Outline the structure
Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

Quick Run-through
Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

Demonstrate your familiarity with the topic and its scholarly context
Develop a theoretical framework and methodology for your research
Position your work in relation to other researchers and theorists
Show how your research addresses a gap or contributes to a debate
Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
Body image, self-perception, self-esteem, mental health
Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

Your university’s library catalogue
Google Scholar
Project Muse (humanities and social sciences)
Medline (life sciences and biomedicine)
EconLit (economics)
Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

What question or problem is the author addressing?
What are the key concepts and how are they defined?
What are the key theories, models, and methods?
Does the research use established frameworks or take an innovative approach?
What are the results and conclusions of the study?
How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

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To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
Themes: what questions or concepts recur across the literature?
Debates, conflicts and contradictions: where do sources disagree?
Pivotal publications: are there any influential theories or studies that changed the direction of the field?
Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

Most research has focused on young women.
There is an increasing interest in the visual aspects of social media.
But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

Look at what results have emerged in qualitative versus quantitative research
Discuss how the topic has been approached by empirical versus theoretical scholarship
Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
Critically evaluate: mention the strengths and weaknesses of your sources
Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

Sampling methods
Simple random sampling
Stratified sampling
Cluster sampling
Likert scales
Reproducibility

Statistics

Null hypothesis
Statistical power
Probability distribution
Effect size
Poisson distribution

Research bias

Optimism bias
Cognitive bias
Implicit bias
Hawthorne effect
Anchoring bias
Explicit bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

To familiarize yourself with the current state of knowledge on your topic
To ensure that you’re not just repeating what others have already done
To identify gaps in knowledge and unresolved problems that your research can address
To develop your theoretical framework and methodology
To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other academic texts , with an introduction , a main body, and a conclusion .

An annotated bibliography is a list of source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a paper .

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Reflection: a review of the literature

Affiliation.

1 School of Health Care Studies, Oxford Brookes University, England.
PMID: 8376656
DOI: 10.1046/j.1365-2648.1993.18081188.x

This paper is a review of the literature on reflection. The purpose was to unravel and make sense of the complex literature, and to identify the skills required to engage in reflection. An analysis of the literature revealed that differences between authors' accounts of reflective processes are largely those of terminology, detail and the extent to which these processes are arranged in a hierarchy. Key stages of reflection are identified and represented by a model. Skills required to engage in reflection were found to be implicit in the literature and these are identified. Methodological issues related to empirical literature are discussed. It is suggested that reflection is an important learning tool in professional education and that the skills required for reflection need to be developed in professional courses.

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Literature review.

What is a Literature Review?
What is Its Purpose?
1. Select a Topic
2. Set the Topic in Context
3. Types of Information Sources
4. Use Information Sources
5. Get the Information
6. Organize / Manage the Information
7. Position the Literature Review
8. Write the Literature Review

A literature review is a comprehensive summary of previous research on a topic. The literature review surveys scholarly articles, books, and other sources relevant to a particular area of research. The review should enumerate, describe, summarize, objectively evaluate and clarify this previous research. It should give a theoretical base for the research and help you (the author) determine the nature of your research. The literature review acknowledges the work of previous researchers, and in so doing, assures the reader that your work has been well conceived. It is assumed that by mentioning a previous work in the field of study, that the author has read, evaluated, and assimiliated that work into the work at hand.

A literature review creates a "landscape" for the reader, giving her or him a full understanding of the developments in the field. This landscape informs the reader that the author has indeed assimilated all (or the vast majority of) previous, significant works in the field into her or his research.

"In writing the literature review, the purpose is to convey to the reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. The literature review must be defined by a guiding concept (eg. your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries.( http://www.writing.utoronto.ca/advice/specific-types-of-writing/literature-review )

What is a Literature Review? How to Write It (with Examples)

A literature review is a critical analysis and synthesis of existing research on a particular topic. It provides an overview of the current state of knowledge, identifies gaps, and highlights key findings in the literature. 1 The purpose of a literature review is to situate your own research within the context of existing scholarship, demonstrating your understanding of the topic and showing how your work contributes to the ongoing conversation in the field. Learning how to write a literature review is a critical tool for successful research. Your ability to summarize and synthesize prior research pertaining to a certain topic demonstrates your grasp on the topic of study, and assists in the learning process.

What is the purpose of literature review?
a. Habitat Loss and Species Extinction:
b. Range Shifts and Phenological Changes:
c. Ocean Acidification and Coral Reefs:
d. Adaptive Strategies and Conservation Efforts:

How to write a good literature review

Choose a Topic and Define the Research Question:
Decide on the Scope of Your Review:
Select Databases for Searches:
Conduct Searches and Keep Track:
Review the Literature:
Organize and Write Your Literature Review:
How to write a literature review faster with Paperpal?
Frequently asked questions

What is a literature review?

A well-conducted literature review demonstrates the researcher’s familiarity with the existing literature, establishes the context for their own research, and contributes to scholarly conversations on the topic. One of the purposes of a literature review is also to help researchers avoid duplicating previous work and ensure that their research is informed by and builds upon the existing body of knowledge.

What is the purpose of literature review?

A literature review serves several important purposes within academic and research contexts. Here are some key objectives and functions of a literature review: 2

1. Contextualizing the Research Problem: The literature review provides a background and context for the research problem under investigation. It helps to situate the study within the existing body of knowledge.

2. Identifying Gaps in Knowledge: By identifying gaps, contradictions, or areas requiring further research, the researcher can shape the research question and justify the significance of the study. This is crucial for ensuring that the new research contributes something novel to the field.

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3. Understanding Theoretical and Conceptual Frameworks: Literature reviews help researchers gain an understanding of the theoretical and conceptual frameworks used in previous studies. This aids in the development of a theoretical framework for the current research.

4. Providing Methodological Insights: Another purpose of literature reviews is that it allows researchers to learn about the methodologies employed in previous studies. This can help in choosing appropriate research methods for the current study and avoiding pitfalls that others may have encountered.

5. Establishing Credibility: A well-conducted literature review demonstrates the researcher’s familiarity with existing scholarship, establishing their credibility and expertise in the field. It also helps in building a solid foundation for the new research.

6. Informing Hypotheses or Research Questions: The literature review guides the formulation of hypotheses or research questions by highlighting relevant findings and areas of uncertainty in existing literature.

Literature review example

Let’s delve deeper with a literature review example: Let’s say your literature review is about the impact of climate change on biodiversity. You might format your literature review into sections such as the effects of climate change on habitat loss and species extinction, phenological changes, and marine biodiversity. Each section would then summarize and analyze relevant studies in those areas, highlighting key findings and identifying gaps in the research. The review would conclude by emphasizing the need for further research on specific aspects of the relationship between climate change and biodiversity. The following literature review template provides a glimpse into the recommended literature review structure and content, demonstrating how research findings are organized around specific themes within a broader topic.

Literature Review on Climate Change Impacts on Biodiversity:

Climate change is a global phenomenon with far-reaching consequences, including significant impacts on biodiversity. This literature review synthesizes key findings from various studies:

a. Habitat Loss and Species Extinction:

Climate change-induced alterations in temperature and precipitation patterns contribute to habitat loss, affecting numerous species (Thomas et al., 2004). The review discusses how these changes increase the risk of extinction, particularly for species with specific habitat requirements.

b. Range Shifts and Phenological Changes:

Observations of range shifts and changes in the timing of biological events (phenology) are documented in response to changing climatic conditions (Parmesan & Yohe, 2003). These shifts affect ecosystems and may lead to mismatches between species and their resources.

c. Ocean Acidification and Coral Reefs:

The review explores the impact of climate change on marine biodiversity, emphasizing ocean acidification’s threat to coral reefs (Hoegh-Guldberg et al., 2007). Changes in pH levels negatively affect coral calcification, disrupting the delicate balance of marine ecosystems.

d. Adaptive Strategies and Conservation Efforts:

Recognizing the urgency of the situation, the literature review discusses various adaptive strategies adopted by species and conservation efforts aimed at mitigating the impacts of climate change on biodiversity (Hannah et al., 2007). It emphasizes the importance of interdisciplinary approaches for effective conservation planning.

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Writing a literature review involves summarizing and synthesizing existing research on a particular topic. A good literature review format should include the following elements.

Introduction: The introduction sets the stage for your literature review, providing context and introducing the main focus of your review.

Opening Statement: Begin with a general statement about the broader topic and its significance in the field.
Scope and Purpose: Clearly define the scope of your literature review. Explain the specific research question or objective you aim to address.
Organizational Framework: Briefly outline the structure of your literature review, indicating how you will categorize and discuss the existing research.
Significance of the Study: Highlight why your literature review is important and how it contributes to the understanding of the chosen topic.
Thesis Statement: Conclude the introduction with a concise thesis statement that outlines the main argument or perspective you will develop in the body of the literature review.

Body: The body of the literature review is where you provide a comprehensive analysis of existing literature, grouping studies based on themes, methodologies, or other relevant criteria.

Organize by Theme or Concept: Group studies that share common themes, concepts, or methodologies. Discuss each theme or concept in detail, summarizing key findings and identifying gaps or areas of disagreement.
Critical Analysis: Evaluate the strengths and weaknesses of each study. Discuss the methodologies used, the quality of evidence, and the overall contribution of each work to the understanding of the topic.
Synthesis of Findings: Synthesize the information from different studies to highlight trends, patterns, or areas of consensus in the literature.
Identification of Gaps: Discuss any gaps or limitations in the existing research and explain how your review contributes to filling these gaps.
Transition between Sections: Provide smooth transitions between different themes or concepts to maintain the flow of your literature review.

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Conclusion: The conclusion of your literature review should summarize the main findings, highlight the contributions of the review, and suggest avenues for future research.

Summary of Key Findings: Recap the main findings from the literature and restate how they contribute to your research question or objective.
Contributions to the Field: Discuss the overall contribution of your literature review to the existing knowledge in the field.
Implications and Applications: Explore the practical implications of the findings and suggest how they might impact future research or practice.
Recommendations for Future Research: Identify areas that require further investigation and propose potential directions for future research in the field.
Final Thoughts: Conclude with a final reflection on the importance of your literature review and its relevance to the broader academic community.

Conducting a literature review

Conducting a literature review is an essential step in research that involves reviewing and analyzing existing literature on a specific topic. It’s important to know how to do a literature review effectively, so here are the steps to follow: 1

Choose a Topic and Define the Research Question:

Select a topic that is relevant to your field of study.
Clearly define your research question or objective. Determine what specific aspect of the topic do you want to explore?

Decide on the Scope of Your Review:

Determine the timeframe for your literature review. Are you focusing on recent developments, or do you want a historical overview?
Consider the geographical scope. Is your review global, or are you focusing on a specific region?
Define the inclusion and exclusion criteria. What types of sources will you include? Are there specific types of studies or publications you will exclude?

Select Databases for Searches:

Identify relevant databases for your field. Examples include PubMed, IEEE Xplore, Scopus, Web of Science, and Google Scholar.
Consider searching in library catalogs, institutional repositories, and specialized databases related to your topic.

Conduct Searches and Keep Track:

Develop a systematic search strategy using keywords, Boolean operators (AND, OR, NOT), and other search techniques.
Record and document your search strategy for transparency and replicability.
Keep track of the articles, including publication details, abstracts, and links. Use citation management tools like EndNote, Zotero, or Mendeley to organize your references.

Review the Literature:

Evaluate the relevance and quality of each source. Consider the methodology, sample size, and results of studies.
Organize the literature by themes or key concepts. Identify patterns, trends, and gaps in the existing research.
Summarize key findings and arguments from each source. Compare and contrast different perspectives.
Identify areas where there is a consensus in the literature and where there are conflicting opinions.
Provide critical analysis and synthesis of the literature. What are the strengths and weaknesses of existing research?

Organize and Write Your Literature Review:

Literature review outline should be based on themes, chronological order, or methodological approaches.
Write a clear and coherent narrative that synthesizes the information gathered.
Use proper citations for each source and ensure consistency in your citation style (APA, MLA, Chicago, etc.).
Conclude your literature review by summarizing key findings, identifying gaps, and suggesting areas for future research.

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Frequently asked questions

A literature review is a critical and comprehensive analysis of existing literature (published and unpublished works) on a specific topic or research question and provides a synthesis of the current state of knowledge in a particular field. A well-conducted literature review is crucial for researchers to build upon existing knowledge, avoid duplication of efforts, and contribute to the advancement of their field. It also helps researchers situate their work within a broader context and facilitates the development of a sound theoretical and conceptual framework for their studies.

Literature review is a crucial component of research writing, providing a solid background for a research paper’s investigation. The aim is to keep professionals up to date by providing an understanding of ongoing developments within a specific field, including research methods, and experimental techniques used in that field, and present that knowledge in the form of a written report. Also, the depth and breadth of the literature review emphasizes the credibility of the scholar in his or her field.

Before writing a literature review, it’s essential to undertake several preparatory steps to ensure that your review is well-researched, organized, and focused. This includes choosing a topic of general interest to you and doing exploratory research on that topic, writing an annotated bibliography, and noting major points, especially those that relate to the position you have taken on the topic.

Literature reviews and academic research papers are essential components of scholarly work but serve different purposes within the academic realm. 3 A literature review aims to provide a foundation for understanding the current state of research on a particular topic, identify gaps or controversies, and lay the groundwork for future research. Therefore, it draws heavily from existing academic sources, including books, journal articles, and other scholarly publications. In contrast, an academic research paper aims to present new knowledge, contribute to the academic discourse, and advance the understanding of a specific research question. Therefore, it involves a mix of existing literature (in the introduction and literature review sections) and original data or findings obtained through research methods.

Literature reviews are essential components of academic and research papers, and various strategies can be employed to conduct them effectively. If you want to know how to write a literature review for a research paper, here are four common approaches that are often used by researchers. Chronological Review: This strategy involves organizing the literature based on the chronological order of publication. It helps to trace the development of a topic over time, showing how ideas, theories, and research have evolved. Thematic Review: Thematic reviews focus on identifying and analyzing themes or topics that cut across different studies. Instead of organizing the literature chronologically, it is grouped by key themes or concepts, allowing for a comprehensive exploration of various aspects of the topic. Methodological Review: This strategy involves organizing the literature based on the research methods employed in different studies. It helps to highlight the strengths and weaknesses of various methodologies and allows the reader to evaluate the reliability and validity of the research findings. Theoretical Review: A theoretical review examines the literature based on the theoretical frameworks used in different studies. This approach helps to identify the key theories that have been applied to the topic and assess their contributions to the understanding of the subject. It’s important to note that these strategies are not mutually exclusive, and a literature review may combine elements of more than one approach. The choice of strategy depends on the research question, the nature of the literature available, and the goals of the review. Additionally, other strategies, such as integrative reviews or systematic reviews, may be employed depending on the specific requirements of the research.

The literature review format can vary depending on the specific publication guidelines. However, there are some common elements and structures that are often followed. Here is a general guideline for the format of a literature review: Introduction: Provide an overview of the topic. Define the scope and purpose of the literature review. State the research question or objective. Body: Organize the literature by themes, concepts, or chronology. Critically analyze and evaluate each source. Discuss the strengths and weaknesses of the studies. Highlight any methodological limitations or biases. Identify patterns, connections, or contradictions in the existing research. Conclusion: Summarize the key points discussed in the literature review. Highlight the research gap. Address the research question or objective stated in the introduction. Highlight the contributions of the review and suggest directions for future research.

Both annotated bibliographies and literature reviews involve the examination of scholarly sources. While annotated bibliographies focus on individual sources with brief annotations, literature reviews provide a more in-depth, integrated, and comprehensive analysis of existing literature on a specific topic. The key differences are as follows:

	Annotated Bibliography	Literature Review
Purpose	List of citations of books, articles, and other sources with a brief description (annotation) of each source.	Comprehensive and critical analysis of existing literature on a specific topic.
Focus	Summary and evaluation of each source, including its relevance, methodology, and key findings.	Provides an overview of the current state of knowledge on a particular subject and identifies gaps, trends, and patterns in existing literature.
Structure	Each citation is followed by a concise paragraph (annotation) that describes the source’s content, methodology, and its contribution to the topic.	The literature review is organized thematically or chronologically and involves a synthesis of the findings from different sources to build a narrative or argument.
Length	Typically 100-200 words	Length of literature review ranges from a few pages to several chapters
Independence	Each source is treated separately, with less emphasis on synthesizing the information across sources.	The writer synthesizes information from multiple sources to present a cohesive overview of the topic.

References

Denney, A. S., & Tewksbury, R. (2013). How to write a literature review.  Journal of criminal justice education ,  24 (2), 218-234.
Pan, M. L. (2016).  Preparing literature reviews: Qualitative and quantitative approaches . Taylor & Francis.
Cantero, C. (2019). How to write a literature review.  San José State University Writing Center .

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Home — Essay Samples — Education — Research — Reflection in Literature Review: An Essential Component of Scholarly Research

Reflection in Literature Review: an Essential Component of Scholarly Research

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Published: Jun 13, 2024

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Introduction, the role of reflection in synthesizing information, critical evaluation of sources through reflection, articulating relevance to current research.

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On Self-Reflection, Stories, and and What Mirrors Really Tell Us

“the narrative of your present is crafted by the past.”.

I can recall the moment I realized the girl staring back at me in the mirror was already past, that the reality reflected in the glass was of a time already gone.

As a child I retreated to the restroom to read when I should have been getting ready for bed, the room full of echoes: the steady faucet drip, the gentle ring of bubble bath around the tub, my parents murmuring from the living room. Climbing to the sink, I would seek myself in the mirror above the counter.

One evening when I was five or six, my reflection became a question. I knew it was me, but the longer I stared, the more fully my image became a stranger.

The odd feeling that I existed both in and out of that reflection was unsettling, for neither was fully real. She was girl and ghost, and the contradiction of duality weighed heavy in my stomach as I began to float. I could not tell where or when or even if I began.

Holding my face close to the mirror, I studied the image closely, so convinced it could not be me at the same time I knew it to be true, that I scarcely noticed that my breath fogged the glass, barely heard my mother from the other room calling me back.

Created in 1970 by American psychologist Gordon Gallup Jr., the mirror test is designed to determine whether an animal is capable of self-recognition. The test is simple—animals are anesthetized and marked with a spot of red paint or a sticker on a part of their body they can’t normally see. When they wake, they are placed in front of a mirror. If the animal investigates the new mark, they are considered capable of self-awareness.

Most animals fail the test. Only humans, a few apes, a single Asiatic elephant, dolphins, orcas, the Eurasian magpie, and cleaner wrasse fish have passed—and scientists disagree on the majority of these successes. Most animals simply gaze in the mirror.

Humans don’t pass the test until they are toddlers, and this often occurs after extensive coaxing where the toddlers learn to mirror the adults around them. Recently, rhesus monkeys and small fish have learned to pass the test, indicating that they are latently aware of the self, or, at the very least, capable of learning new cognitive skills.

For many years, it was assumed that animals who passed the test were capable of reflecting on their being and identity, and, by extension, potentially understanding that other animals have distinct selves and minds. But this is assumption, abstraction based on what we observe when watching animals watch themselves.

In 2011, photographer James Geddes captured the image of an eagle standing on frozen ice, staring down at its reflection. The photo seems quintessentially American—the symbol of freedom pensive at its likeness, a national self-reflection captured a few years after Obama took office and began to write a narrative of hope and the country responded by beginning to unravel.

The eagle’s reflection is crisp and sharp, the bird craning its neck forward to peer closer. It is easy to read the image as one of contemplation: the eagle considering its place in a changing world, assessing the apparent stability of ground even as the water rushes underneath.

The world is always leaving.

I realized this young. My body was a vehicle, time a stretch of road. There was no choice but to move forward, try to stay in the careful lines to avoid a collision. If I did stray, the car would rumble, the road designed to keep me in, to startle me back in position if I tried to leave or simply drifted unaware.

From my position in the passenger seat, I witnessed how the reality of the road in front of me could become a memory fading behind. We were always heading to the future, even if the destination was a museum that celebrated the past: polished silver cups or obsidian knives glinting under the lights, my gape-mouthed reflection in the glass. The beach was full of waves retreating forward and back, and I tried to capture that blurring sense of time on my tiny camera, though mostly I strained my eye to find the mirror inside. I tried to capture my kitten growing bigger each day, the way the window reflected sunlight on my lap, rainbows through the air, my own face looking in a mirror so I could see both versions of myself at once.

Objects in mirror are closer than they appear , read the rear-view mirror. I did not understand, for perceptions of depth and time have always made me dizzy. I like the unreality of compressing time, past and present not so different, or looking down from a tall building, stomach drooping into my temple.

Caution , my parents explained. It meant that when you’ve left something behind it can sneak up on you, that you are never as far ahead of something as you believe. That the narrative of your present is crafted by the past.

Invented in 1903, the two-way mirror is not a mirror of binaries, of doubles. The mirror is actually referred to as a one-way , the name a trick, much like the device.

A mirror is made by applying a thick layer of reflective material to the back of a sheet of glass in order to make it opaque. When we gaze into the mirror, the layer of silvering reflects our image back at us. In a one-way mirror, however, the silvering is applied by half, so that the glass is not opaque, but translucent, ethereal. Half the light striking the glass passes through it, the other half reflects.

This mirror is often used to mislead, to interrogate. Those gazing at the mirror from a brightly-lit room see themselves reflected, while those on the other side in a room dimly-lit are obscured. The mirror is deception, a play of light and shadow, expectation and ego.

Turn the lighting up on both sides and the reflection disappears, the mirror simply glass, images free to float between the veil.

At the start of 2020, I have not looked into a mirror for over four years. I do not know when my childhood fascination with the self—the certainty of its mutability—shifted into grief. I only know that at some point I grew wary of the reflection, not my likeness but my living.

The last time I can recall looking into the mirror without dread was when the world was on the cusp of dismantling. There was a new president, a new climate, a new decade approaching, time gone fast and slow all at once. Trump took office as I reluctantly claimed a new job and thus a new home, neither of which I wanted, though I knew I was lucky.

In my early twenties I’d watched eagerly as California faded from the rear-view mirror, a new home in Nebraska on the horizon, but nearly a decade later as Nebraska faded from sight and Massachusetts came into focus, I felt only disappointment. The life, the home, the country were nothing like I’d expected, nothing I’d written for myself.

Within days of arriving, I caught sight of my face in the mirror, saw my mouth pinched into a straight line like the horizon behind me, eyes glazed like a museum specimen frozen in the past. The image was a ghost of who I had been before, and for months I stood before her, tried to fake-smile at the me in the mirror the way I did with people at work, though there was no one I wanted to smile at, or at strangers in the street, though Massachusetts seemed full of resentments bitter as the cold and I missed the quiet comfort of Nebraska and the golden beaches of my California youth.

Soon I was haunting my own life, caught in the present while longing for the past. I was nostalgic for my father’s classic rock buzzing through the radio while we dipped low into a backroad, or peeling the skin of a California acorn to reveal the mealy flesh beneath. I missed the way the ocean wind made me forget precision, hair whipping in my mouth, nose running, and the way the summer heat pooled in the parts of my body I would otherwise forget, mingling with the smell of sunscreen and BBQ.

I wanted the messy freedom of my girlhood, where time stretched long into the afternoon and abandoned walls were for bouncing balls against, rocks for gathering heavy in your pocket and flinging from high vistas or across a still lake. I missed the promise of a few years past, sipping wine with friends late into the night, knowing I might never see them again, which was what made our stories more compelling long after the candles had spilled their wax across the table to pool like amorphous phantoms.

I was nostalgic for the environment of my childhood too, the country a place that grew more fractured. I didn’t recognize the images of my country just as I didn’t recognize the images of myself. The television showed children in cages and women crying for their lost families, soldiers on the Capitol steps and Nazi flags. The news reported storms ravaging the coastlines, leaving countries in the dark, washing away cities, tornadoes snaking through the South, hurricanes hovering over the East, the West Coast black and burning each year. Online, friends and family argued over two seemingly-different worlds, each inhabiting their own side of the mirror, unable or unwilling to turn on the light to see the other. It was as though the image of the world and those within it had been smashed, the country’s reflection reduced to jagged shards.

What was reality and what was perception melted before me, politicians reporting everything was fine just as I reported the same to those who asked how I was doing, though I could no longer look in the mirror without weeping or seizing up in panic. Once, I caught sight of myself in a restaurant mirror and lost my appetite, so sad I was for that lonely, lost woman.

It was unsettling to see the images of my reality reflected back at me—a country that seemed to be, like the climate itself, on the verge of extinction, each home I’d known under attack, fires threatening to burn my childhood California to rubble, tornadoes winding themselves like a noose around Nebraska, snow threatening to bury Massachusetts, leaving us as dark and dead as I felt most days. The forward momentum of my childhood proved incorrect—I’d driven forward, but now there was nowhere else to go, only ocean at this other end of the continent. And the danger in the rearview mirror was much closer than it appeared. So I simply stopped looking.

To be clear, I didn’t disdain my appearance as much as mourn for the woman trapped as if behind glass in a place and position she never wanted to claim. Though I loved my childhood in the golden light of small-town California, from my vantage point many miles and years away, I realized it had written a narrative of sameness on me—one that defined my gender, sexuality, and speaking in a way that sought to silence.

Though I loved my husband, our marriage after nearly a decade seemed stifling and prescriptive and felt, the longer I was in the role of wife, like it was closing in all around. Though I loved my work, I took a job I did not particularly want because there are few in my field and we are told to be grateful, and after I arrived, the photo filters were removed one by one until all that remained was the grainy image of my new reality. I’d sought movement for many years, thrilled by the images whirring out the window, my face reflected over them in the glass, but I realized now it was the other way around, that my image was the one upon which the world had been superimposed.

The longer time went on, the more blurred and faint the image of myself, my home, my country seemed. Everything felt lost, disappeared by a power beyond our control. It pained me to see what I had become without my permission so I simply stopped looking at myself at all, stopped taking photos so as not to mark this passage of time.

I spent so much time longing for the past that at a certain point I felt nearly dead, as though I were a ghost haunting my own life. Nostalgia and haunting are not so very different, after all—we are only nostalgic for things that are gone, we are only haunted by the things we once loved.

I used to read beside my reflection, my child body curled up with a book on the bathroom counter. Mirrors seemed to be everywhere—the bathroom, the car, the vanity in my bedroom, the walls of ballet class where we were told to be strong but also small enough to disappear. They were in the glint of a knife and the windows of buildings where I saw myself pulled forward by the hand, my feet moving by duty rather than desire. The city skylines of every place I visited were lined with mirrors as if to reflect the world back onto itself, but the older I got, the more I saw confusion, the way a mirror faced against a mirror created reflections to infinity, no sense of logic or place. The way a bird flew into a window believing it sky.

I read books about ghosts because, like time or gravity or the certainty that my body would remember to breathe or beat, it filled me with wonder and a bit of fright. I read the one where a boy finds a mirror in the attic that can make him invisible. He likes disappearing and makes a little game of it, the way I liked to look at myself in the mirror to be both image and abstraction. Eventually the boy disappears for too long, struggling to find his way home. I thought about how one day my angry grandfather was alive and then he was dead and my grandmother seemed like she could finally breathe.

I thought about how my friend down the road with the best climbing trees moved away and then her trees were forbidden even though I knew all the footholds and how to reach one hand around the branch to the knot at the back, hoisting myself up and into the pine, sap glistening across my thighs as I looked across the riverbed to my house on the other side, the river disappearing, the bed full of cracks where the water vanished, birds pecking at the dry ground.

I thought about how every spring the eucalyptus groves where the monarchs wintered were emptied and the flutter of gold vanished and though this was the way it should be, it was hard not to wonder if the butterflies would ever return. And I thought about how the historic mission in my town had stood for centuries but then it rained too much and the wall around the graveyard—the one my parents said kept the spirits in—collapsed and what would keep them in now or would they wander lonely through the town, confused why it seemed familiar though everything was different?

There is a delay between seeing and perceiving. It takes our brains a moment to process what we are looking at, so the image of my girlhood I saw in the mirror was from the past. At the mirror, I was both there and then. I was present and past, living and memory, girl and ghost. The longer I thought about time, how fast it goes—the first reflection I saw in the mirror long gone just as the one I was currently seeing was suspect, a version of myself I could no longer get back—the more I felt the sad sweet swell of nostalgia. I was only five, then six, then eight and ten, twenty and thirty, but already I was longing for and missing what was right in front of me.

One of my favorite books told the story of a young girl named Jane who visits her family in New England one summer and becomes intrigued by a garden reflecting ball. She spends long hours gazing at the reflection in the mirrors, the way they refract reality, until she begins, like me when I look in the mirror for too long, to see things that aren’t real.

Then, one day, Jane sees the ghost of a wicked girl named Emily. She does not know where one girl ends and the other begins, what is present and what is past. The adults around her say it’s make-believe like my parents say when they pull me away from the mirror to play in the real world. Jane and Emily merge into one.

I read the book time and again for a fright, stopping to stare at my reflection like a moon in the darkness of my bedroom window or in the skylight high in the bathroom ceiling, my pale face looking up as if from the end of a long tunnel.

It is myth that a mirror inverts your image. You do not reflect in reverse. Instead, the left of your face is imposed on the left of the mirror, the right over the right. It is merely illusion—another trick of perception—that you exist altered. This is why photos and videos of ourselves seem so unnatural. We are more used to existing in the lag time between reflection and perception.

To view an accurate image, you must position two mirrors together at ninety degrees, stand at the split, straddle the images on either side. You must exist in multiples, view yourself from where the many selves join.

A true mirror is one that projects your image as others see you. Wave your right hand and the three-dimensional image will wave as if from the left. Lean to one side and see yourself lean away. The image is lifelike in a way that a traditional mirror is not and the experience disrupts our understanding of reflection, at once more human and intimate than our many years brushing our teeth or hair at the abstraction in front of us.

Some are startled, shaken, some shamed they have understood themselves incorrectly. And some weep at the rare chance to witness the self in as it truly exists in time and space.

Now, in my mid-thirties, I am trying to see myself as I exist rather than as I reflect. I am searching for the place where the two mirrors come together to reveal the truth.

The image of the woman and the world I have been avoiding is both reflection and abstraction, the images not quite accurate, but ones I have been mourning these past few years. I have been so distracted by perceived loss that I’ve missed things disappearing right before me, even my own sense of wonder.

I no longer want to hang a Victorian veil over the mirror as though I am dead, as though the looking glass might trap my soul, prevent me from moving on. I want to go back to that girl in the mirror, watching, searching, enthralled by the many versions of the self.

When I stare in the mirror now, as I am (re)learning to do, as our reliance on video chats requires these months and years we isolate, the woman before seems a stranger and a support. I marvel at the way memory and nostalgia compress time so that I am here and then, in mirror and memory, the me of now and also of a split second ago and also all those years ago when I first stared in the mirror, headband pushing hair from my face, teeth starting to jut through the gums, that slow smile of recognition.

Reflection is both the mirrored image and careful rumination. I’ve been avoiding the image because I’ve been avoiding the thinking—about the homes I’ve made and the ways they do not fit, about the country changing underfoot. But these images I’ve avoided are not true reflections, and each is already gone. The only thing to do is remember there is no mirror test to convince your restless animal self that existence is precious, to convince you to step away from the reflection and into reality.

This doesn’t mean we forget history or stop aching for it, mourning it if we must, but rather that living requires we keep some distance between our past and present, we keep our many selves in sight in the rearview mirror, as we determine which path to take and where to deviate.

The first images of Earth were captured in the 1940s, a 35mm camera snapping a shot each second from a rocket, the photos falling back to land in a steel canister. What was reflected was revolutionary—horizon curve backdropped by space—but scientists worried over whether or not to release the images.

Earth surrounded by the vast dark of space, they feared, would counter people’s self-perceptions. They thought people would feel insignificant, alone, fearful. They thought people might see human life as futile when faced with the vast isolation of space.

These first images fell to Earth from the future, but revealed a world already in the past. It is difficult to look at these photos without the complexity of time tugging comprehension in multiple directions. This image of the world is foreign and familiar, comfort and chaos. Astronauts tasked with leaving in order to move humankind forward to the edge of the galaxy, to live where the darkness was so deep there was no light to reflect, were compelled to turn back, nostalgic for what they’d abandoned.

__________________________________

Excerpted from Halfway from Home by Sarah Fawn Montgomery, available via Split/Lip Press.

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J Caring Sci
v.12(3); 2023 Sep
PMC10663437

Relationship between Nurses Reflection, Self-efficacy and Work Engagement: A Multicenter Study

Associated data.

The datasets are available from the corresponding author on reasonable request.

Introduction:

Reflection is considered an essential element in nurses’ practice with different positive outcomes, we decided to determine the level of nurses’ reflection and then assess the relationship between nurses’ reflection with their self-efficacy and work engagement.

In this cross-sectional study, a total of 240 nurses were selected from seven educational hospitals affiliated with Tabriz University of medical sciences (Iran). The stratified random sampling method was used to select the participants from hospitals. Data were collected through three questionnaires including Groningen Reflection Ability Scale (GRAS), Sherer’s General Self-Efficacy Scale (SGSES), and Utrecht Work Engagement Scale (UWES). Data were analyzed using SPSS version 13.

According to the results, the mean (SD) score of nurses’ reflection was calculated as 86.51 (8.17) out of 115. The mean (SD) score of nurses’ self-efficacy was 60.89 (11.11) out of 85. Moreover, the mean (SD) total score of nurses’ work engagement in a possible range of 0 to 6 was 3.39 (1.36). There was a positive and significant relationship between the total reflection score with work engagement and self-efficacy scores.

Conclusion:

According to the results, nurses working in different units showed different scores of reflection. Moreover, the results of the present study showed that nurses’ reflection is associated with nurses’ work engagement and self-efficacy. Therefore, nurse managers and nurse educators should improve nurses’ skills in reflection and they should support the reflective practice in clinical settings.

Introduction

Nurses significantly affect the effectiveness of the health care system and play an important role in health promotion, disease prevention, and promoting a healthier lifestyle for society. 1 , 2 In the current healthcare context which is changing rapidly, professional nurses should improve their skills for providing high quality care. 3 , 4 The main characteristics of nurses that help to optimize nursing care and inter-professional development are; self-motivation, preference for workplace learning, relevance to practice, positive workplace culture, self-efficacy, and strong enabling leadership. 5 - 7 Reflection is one of the important nursing skills that has been emphasized in recent years which influences clinical performance and professional behaviors. 8 , 9

Reflection is the accurate identification of a clinical situation or an experience that includes the analysis of feelings, thoughts, actions and personal behaviors. It requires cognitive activities such as description, critical analysis, evaluation, and planning. As an active and dynamic process, reflection is also a way to learn from clinical situations or experiences. 10 In other words, reflection is a process in which thoughts are returned so that they can be interpreted or analyzed. Hence, the understanding from reflection can be used in similar situations in the future. 11 Reflection has been introduced as a learning and evaluation method in many nursing programs worldwide. 9

There are three main types of reflection including reflection for action, reflection in action, and reflection on action. Reflection for action involves thinking about what you want to achieve and understanding the method by which you will achieve that goal with the help of previous experiences. Reflection in action is related to a person’s behavior while performing a task and allows him/her to modify or change what he is doing. The focus of this type of reflection is on gaining a new perspective. Reflection on action includes a retrospective look at the action procedure and the analysis of the collected data in terms of knowledge, new learning, and professional development. 12 Reflection is considered as an essential factor for the development of independent, critical-thinking, and providing high quality nursing care. 13 , 14 In recent years, there has been a main focus on developing reflective practice in the current complex context of clinical settings. 15 According to the literature review, reflection plays a more prominent role in medical education and professional development. 9 , 16 Improving nurses’ skills on reflection could significantly increase nurses’ empowerment and professionalism, improves the quality of nursing care and nurse-patient communication skills. 17 - 19

One of the other important concepts in the nursing profession, which may be influenced by nurses’ reflection, is the concept of nurses’ self-efficacy. 20 Bandura defines self-efficacy as a person’s belief, expectations, and judgment of his/her ability to perform tasks successfully. 21 In other words, self-efficacy shows the feeling of self-confidence and is related to the motivation level. 22 The level of self-efficacy varies among different people, and factors such as age, gender, 23 occupation, 24 social support, 25 living environment, 26 and level of education affect self-efficacy. 23 People with high self-efficacy have a high level of flexibility 27 , 28 and have a greater ability to control difficult situations. 27 , 29 The importance of self-efficacy is very high, especially in the nursing profession where nurses always face unexpected situations. 29

Another variable that may be affected by reflection is nurses’ work engagement. With increasing demands and limited resources for healthcare services, more attention has been recently paid to nurses’ work engagement and related factors. 30 Work engagement is a positive and satisfactory state of mind, 31 - 33 which is characterized by vigor, dedication, and absorption. 33 Work engagement has a positive relationship with health, 34 happiness, 35 job satisfaction, 36 personal initiative, 37 active learning, 36 and career achievement. 38 Moreover, employees with a high level of work engagement often experience positive feelings that lead to greater productivity. 39

Although there have been studies on reflection in nursing education, the review of the literature shows that this issue has less been investigated in nurses working in the clinical environment. Since reflection is considered an essential element in nurses’ practice with different positive outcomes, we decided to determine the level of nurses’ reflection and then assess the relationship between nurses’ reflection with their self-efficacy and work engagement.

Materials and Methods

Inclusion criteria included having at least a bachelor’s degree in nursing and working as a clinical nurse. Incomplete questionnaires (where more than 10% of the questionnaires were incomplete) were not analyzed.

Data were collected through demographics (such as participants’ age, gender, marital status, work experience, and work unit) and three main questionnaires including Groningen Reflection Ability Scale (GRAS), Sherer’s General Self-Efficacy Scale (SGSES) and Utrecht Work Engagement Scale (UWES).

GRAS was used to measure nurses’ reflection ability. The scale was developed in 2007 by Aukes et al. 40 This scale consists of 23 items with three subscales including self-reflection (10 questions), empathic reflection (6 questions), and reflective communication (7 questions). Each item is scored based on a five-point Likert scale ranging from 1 to 5 (1=completely disagree and 5=completely agree). Therefore, the possible score range was 23 and 115. Items 14, 17, 18, 22, and 23 were scored in reverse. The validity and reliability of this tool have been evaluated by Rostami et al and a Cronbach’s alpha value was reported as 0.73. 41 In the present study, the content validity of the Persian version of GRAS was evaluated. For this purpose, after being translated and re-translated by an English expert, the questionnaire was given to ten faculty members of the Faculty of Nursing and Midwifery so that they provided their comments about the content of this tool. After collecting their comments and making necessary changes, the questionnaire was given to 30 nurses and the reliability of this questionnaire was obtained 0.77 using Cronbach’s alpha.

To measure the nurses’ work engagement, UWES was used. The 21-item UWES was developed at Utrecht University by Schaufeli et al 42 and Schaufeli et al 43 introduced the short form of this scale that included 9 items as follows: Vigor (3 items), dedication (3 items), and absorption (3 items). They used a large amount of international data and showed that UWES-9 has acceptable psychometric properties so that its Cronbach’s alpha was obtained>0.80 in 10 different countries. Each item is scored based on a seven-point Likert scale, ranging from 0 to 6 (0=Never and 6=Always). Psychometric properties of the Iranian version of UWES-9 were assessed by Hajloo 44 and Cronbach’s alpha coefficient was reported as 0.79. In the present study, the internal consistency of this tool using Cronbach’s alpha was obtained at 0.71.

SGSES was used to measure nurses’ self-efficacy. SGSES was developed by Sherer et al 45 and consists of 17 items. Each item is scored based on a five-point Likert scale.

The total SGSES scores range from 17 to 85. The higher scores indicate higher self-efficacy. Scores 17-28, 29-57, and 58-85 indicate low, moderate, and high self-efficacy, respectively. The psychometric properties of this questionnaire was assessed by Barati Bakhtiari 46 and the reliability coefficient and Cronbach’s alpha were reported as 0.76 and 0.79, respectively. The internal consistency of the SGSES tool was obtained at 0.89 using Cronbach’s alpha coefficient in the present study.

The researcher invited eligible nurses to participate in the study. In this regard, the research objectives were explained to all participants, and if they wished to participate in the study, they were asked to read and sign the written consent form. Then, the above-mentioned questionnaires were given to the participants one by one and they were asked to read and complete them carefully. The questionnaires were filled out anonymously and the participants’ information was kept completely confidential.

Data analysis was carried out using SPSS version 13. Descriptive statistics including mean (SD) were used to measure the value of each variable. After ensuring the normality of the data distribution, Pearson’s correlation test was used to determine the relationship between the variables. P value < 0.05 was considered as the level of significance in all tests.

A total of 240 clinical nurses—with a mean (SD) age of 33.41(7.36) years—participated in the present study. The majority of participants (81.7%) were women. Moreover, 67.9% of the research subjects were married and most of them (91.7%) had a bachelor’s degree in nursing. In terms of working shit, 80% of the nurses had rotating shifts ( Table 1 ).


Age (y)	33.41(7.36)
Gender
Female		196 (81.7)
Male		44 (18.3)
Marital status
Single		75(31.3)
Married		163 (67.9)
Divorced		2(0.8)
Degree
Baccalaureate		220(91.7)
Master in nursing		20(8.3)
Work experience in nursing (y)	9.24(6.64)
Work experience in the current unit (y)	6.65(5.82)
Main working time
Fixed shift		40 (20)
Rotation shift		200 (80)
Work unit
Emergency		23 (9.6)
Medical		105 (43.7)
Surgical		27 (11.3)
Critical care		85 (35.4)

According to the results, the mean (SD) score of nurses’ reflection was calculated as 86.51 (8.17) out of 115. Moreover, the results showed that the self-reflection, empathic reflection, and reflective communication scores were 40.13(4.44), 22.46(2.64), and 23.93(3.94), respectively ( Table 2 ). The results showed no statistically significant difference in the mean reflection scores in terms of gender, marital status, level of education, type of shift and type of work, as well as years of work experience, age, number of nurses per shift and nurse-to-patient ratio ( P > 0.05). However, a statistically significant difference was observed between the reflection scores of nurses working in the emergency department (ED) and those working other departments, so that the mean reflection score of ED nurses was relatively higher than nurses working in other departments ( P <0.05).


GRAS	Self-reflection	10-50	40.13 (4.44)	24	50
	Empathic reflection	6-30	22.46 (2.64)	12	29
	Reflective communication	7-35	23.93 (3.94)	11	34
	Total score	23-115	86.51 (8.17)	62	108
SGSES	Total score	17-85	60.89 11.11)	29	84
UWES	Vigor	0-18	3.23 1.61)	0	6
	Dedication	0-18	3.10 1.40)	0	6
	Absorption	0-18	3.07 1.37)	0	6
	Total score	0-54	3.39 1.36)	0	13

GRAS, Groningen Reflection Ability Scale; SGSES, Sherer's General Self-Efficacy Scale; UWES, Utrecht Work Engagement Scale.

The results showed that the mean (SD) score of nurses’ self-efficacy was 60.89 (11.11) out of 85 ( Table 2 ). The results showed no statistically significant difference in the mean score of self-efficacy in terms of nurses’ gender, marital status, level of education, type of shift and type of work, as well as number of nurses in each shift and nurse-to-patient ratio. However, the mean score of self-efficacy among nurses working in ED was higher than nurses working in the internal, surgical and ICU wards. There was also a statistically significant correlation between the mean score of self-efficacy with age and years of work experience.

The results showed that the mean (SD) total score of nurses’ work engagement was 3.39 (1.36). The mean score of each domain is shown in Table 2 . According to the results, the highest and the lowest scores are related to the vigor and absorption domains, respectively. The analysis showed no statistically significant difference in the mean work engagement scores in terms of gender, type of shift, marital status, level of education, hospital wards, and type of work.

The analysis of data by Pearson correlation coefficient showed a positive and significant relationship between the total reflection score and a total score of work engagement (r=0.28, P <0.001). Moreover, there was a positive relationship between the total reflection score with a total score of self-efficacy (r=0.48, P <0.001). Also, a total score of nurses’ work engagement showed a positive correlation with total score of self-efficacy (r=0.25, P <0.001) ( Table 3 ). More details of correlations between the subscales of the questioners are shown in Table 3 .

1.Self-Reflection

2.Empathic reflection

0.47***

3.Reflective communication

0.19**

0.30***

4.Total reflection index

0.79***

0.73***

0.69***

5. Vigor

0.15*

0.12

0.07

0.15*

6. Dedication

0.29***

0.30***

0.13

0.31***

0.39***

7. Absorption

0.13*

0.19**

0.13

0.19**

0.27***

0.50***

8.Total work engagement score

0.24***

0.26***

0.14*

0.28***

0.75***

0.81***

0.74***

9.Total self-efficacy score

0.30***

0.24***

0.45***

0.48***

0.17**

0.27***

0.13*

0.25***

* P <0.05; ** P <0.01; *** P lt;0.001.

The aim of this study was to determine the relationship between reflection with self-efficacy and the work engagement of nurses working in selected educational hospitals.

The possible score range on GRAS was 23-115, so a higher score in this questionnaire indicated a higher reflection score. The mean reflection score in the present study indicated a relatively high level of reflection in nurses.

Reflection is considered an important part of nursing education and practice and plays an important role in facilitating the learning of clinical nurses. 47 It also improves the quality of care given by nurses. 48 The results of a study by Akbari et al 49 showed that reflection is a multidimensional concept and may be related to different psychological and behavioral characteristics. Reflection encourages people to search and discover solutions for difficult situations. By using reflection, nurses will gain new experiences and insights from clinical and educational settings. Therefore, they feel ownership of the acquired knowledge. It can be stated that reflection significantly improves the knowledge and expertise of nurses in clinical situations. Similarly, Shahrokhi et al 50 showed that reflection can improve the clinical decision-making of nurses.

Pai et al measured the reflection score in nursing students using the self-reflection and insight scale (SRIS), which was obtained 75.81 out of a possible score range of 20-100. They also showed that students who had a higher reflection score had higher nursing qualifications. 51 In a recent study, Chen et al. measured the reflection score of Chinese nurses as 73.60 using the SRIS. 8 In another study conducted on nursing students by Cheng et al 52 results showed that the reflection score was 70.33 using SRIS.

In a study in Sweden, Gabrielsson et al 53 found no statistical relationship between men and women in terms of mean reflection scores of participants, as well as in terms of age and years of work experience. This result was consistent with our findings.

One of the other important concepts in the nursing profession, which may be influenced by nurses’ reflection, is the concept of nurses’ self-efficacy. 20

The mean self-efficacy score was calculated 60.89 using SGSES, which indicates the high self-efficacy. This result is consistent with a study done by Bahreini Brujeni and Alavi. 54 They reported that the mean self-efficacy scores among nurses was 58.03. However, Norouzinia et al 55 reported a moderate self-efficacy of nurses. They also showed a positive and significant relationship between self-efficacy with the quality of life of nurses. Van Dyk et al 56 showed a positive and significant relationship between self-efficacy of nursing managers with years of their work experience, which is consistent with the current study.

Leontiou et al 57 showed that the mean (SD) of nurses’ self-efficacy score was 33.33 (0.38), and the mean self-efficacy scores were not statistically significant in different hospitals. There was also no statistically significant difference between self-efficacy with gender and level of education, but there was a statistically significant relationship between the mean self-efficacy score with age and years of work experience, which is consistent with the present study. However, Hu et al 58 found no statistically significant difference in the mean self-efficacy scores of nurses with years of work experience and hospital wards, which is inconsistent with the present study.

Self-efficacy theory is based on the assumption that people’s beliefs about their abilities and talents have positive effects on their actions and form the basis of people’s activities. If a person believes that he/she cannot achieve the expected results or believes that he/she cannot prevent unacceptable behaviors, he/she will have lower motivation to do that work and will not be able to do it. 59 Nurses’ self-efficacy increases the quality of patient care. The literature review shows a positive and significant relationship between self-efficacy and work performance, and the assessment of self-efficacy is a suitable guide for predicting nurse’s clinical practice. 60 Individuals with high self-efficacy can overcome problems more easily because of their higher problem-solving ability. When problems and difficult conditions arise, they focus on their abilities to solve the problem and look for a new solution. 61

Another concept that may be influenced by nurses’ reflection is work engagement. Work engagement is an individual’s commitment to the organization or employer. 62 Work engagement has a positive effect on the performance of employees and the organization. Job satisfaction, organizational commitment, and work performance are among the variables that are positively affected by work engagement. 63 Work engagement shows the feeling of vigor and identification in work activities. 64

In the present study, the mean (SD) of the work engagement score was 3.39 ( 1.36) using UWES–9. In a study in China, Zhu et al 65 showed that the mean of nurses’ work engagement score was 3.83 (1.08), which is higher than the same score in the present study. Vander et al also reported that the mean of work engagement score was 5.62 (1.12), which is at a high level. 66 Results of a study in Europe showed that the level of work engagement differed in different countries and cultures. 67 In a study in Spain by Giménez-Espert et al the mean score of nurses’ work engagement was lower than the present study. 68

The results of a review study show that general characteristics such as nurses’ age, gender, level of education, work-related characteristics such as workplace stressors or co-worker support, and individual characteristics such as coping strategies and personality could influence on nurses’ work engagement. 33 However, our findings showed no relationship between nurses’ age, gender and level of education with their work engagement. Wan et al showed a positive relationship between work environment and work conditions with nurses’ work engagement. 30 Remegio et al found that work engagement was higher in nursing leaders who had higher education and experience. 62

The results of the present study showed a positive and significant relationship between nurses’ reflection with work engagement and self-efficacy. It means that when the reflection scores is increased the mean score of nurses’ self-efficacy and work engagement is increased too. In a study in the state of Arizona, Lawrence found a positive and significant relationship between reflection and work engagement of nurses working in the intensive care units. 69 Sundgren et al 70 showed higher self-efficacy and quality of life scores among Australian nurses with higher reflection score.

Galutira 4 argue that reflection brings positive consequences such as personal development, professional development, and better quality of care. Moreover, reflection helps nurses improve job satisfaction. 71 Momennasab et al 72 reported that group reflection can improve the knowledge, attitude and practice of nurses regarding ethical codes. More recently, Pangh et al 19 showed that reflection not only had a positive effect on nurses’ verbal, non-verbal and general communication skills, but also helped them to improve the patients’ safety. In other words, reflection enables nurses to support patients more effectively at every stage of the disease and play a more prominent role in promoting their health status despite the limited resources and heavy workload.

The results showed that nurses working in different units have different scores of reflection. Moreover, there was a positive significant relationship between nurses’ reflection, work engagement and self-efficacy. This study highlighted the importance of reflection in providing nursing care. Therefore, nurse managers, health care policy makers, and nurse educators should improve nurses’ skills in reflection. Moreover, they should support the cultivation of reflective practice in clinical settings. Further studies are needed to explore the impact of reflective practice on nurses’ turnover and the quality of care perceived by patients.

Acknowledgments

This research is related to the MSc thesis project of first author in the Tabriz University of Medical Sciences. We thank all nurses who participated in this study. Moreover, we thank the managers of studied hospitals who helped us for data collection.

COI-statement

There are no conflicts of interest.

Data Availability Statement

Ethical approval.

This study was approved by the ethics committee of Tabriz University of Medical Sciences (Ethical code: IR.TBZMED.REC.1400.1125). Written informed consent was obtained from all participants.

Research Highlights

What is the current knowledge.

Reflection is considered as a vital component of the curriculum and practice in health care.
Reflection is an important component in every nurse’s practice and is embedded in the Nursing and Midwifery Council’s code of conduct.

What is new here?

The results showed that nurses working in different units showed a different level of reflection.
The results of the present study showed that nurses’ reflection associated with their work engagement and self-efficacy.

Funding Statement

Tabriz University of Medical Sciences provided the financial support

Reflection In Literature Review

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Dermoscopic characteristics of Merkel cell carcinoma

Dimitra Koumaki ORCID: orcid.org/0000-0001-7074-2374 1 ,
Georgios Evangelou ORCID: orcid.org/0000-0003-4468-446X 1 ,
Alexander C. Katoulis ORCID: orcid.org/0000-0001-8189-7486 2 ,
Zoe Apalla 3 ,
Aimilios Lallas 4 ,
Marios Papadakis ORCID: orcid.org/0000-0002-9020-874X 5 ,
Stamatios Gregoriou ORCID: orcid.org/0000-0002-7585-1032 6 ,
Elizabeth Lazaridou ORCID: orcid.org/0000-0002-4072-3591 3 &
Konstantinos Krasagakis ORCID: orcid.org/0000-0003-2197-2530 1

BMC Cancer volume 24 , Article number: 785 ( 2024 ) Cite this article

Metrics details

Merkel cell carcinoma (MCC) is a rare, aggressive, cutaneous tumour with high mortality and frequently delayed diagnosis. Clinically, it often manifests as a rapidly growing erythematous to purple nodule usually located on the lower extremities or face and scalp of elderly patients. There is limited available data on the dermoscopic findings of MCC, and there are no specific features that can be used to definitively diagnose MCC.

Aim of the study

Here, we aimed to summarize existing published literature on dermatoscopic and reflectance confocal microscopy (RCM) features of MCC.

Materials and methods

To find relevant studies, we searched the PubMed and Scopus databases from inception to April 12, 2023. Our goal was to identify all pertinent research that had been written in English. The following search strategy was employed: (“ dermoscopy” OR “ dermatoscopy” OR “ videodermoscopy” OR “ videodermatoscopy” OR “ reflectance confocal microscopy”) AND “ Merkel cell carcinoma”. Two dermatologists, DK and GE, evaluated the titles and abstracts separately for eligibility. For inclusion, only works written in English were taken into account.

In total 16 articles were retrieved (68 cases). The main dermoscopic findings of MCC are a polymorphous vascular pattern including linear irregular, arborizing, glomerular, and dotted vessels on a milky red background, with shiny or non-shiny white areas. Pigmentation was lacking in all cases. The RCM images showed a thin and disarranged epidermis, and small hypo-reflective cells that resembled lymphocytes arranged in solid aggregates outlined by fibrous tissue in the dermis. Additionally, there were larger polymorphic hyper-reflective cells that likely represented highly proliferative cells.

Dermoscopic findings of MCC may play a valuable role in evaluating MCC, aiding in the early detection and differentiation from other skin lesions. Further prospective case-control studies are needed to validate these results.

Peer Review reports

Introduction

Merkel cell carcinoma (MCC) is a rare but aggressive type of skin cancer that typically affects older individuals with fair skin. It usually presents as a rapidly growing, firm nodule that may be flesh-colored or bluish-red in appearance, often found in sun-exposed areas of the body (Fig. 1 ) [ 1 ]. Recent studies from various countries have reported an increasing incidence of MCC over the past few decades [ 2 , 3 , 4 , 5 ]. Based on early histologic and ultrastructural studies, it is believed that MCC originates from Merkel cells, which are found in the basal layer of the epidermis and hair follicles and are associated with sensory neuritis in the dermal papillae, the skin mechanoreceptors [ 6 ]. However, this hypothesis is controversial, and an alternative hypothesis suggests that these tumors may originate from immature multipotent stem cells that acquire neuroendocrine features during malignancy transformation (Fig. 2 ). UV radiation exposure may be particularly relevant in the pathogenesis of the virus-negative subtype of MCC, as evidenced by a lower prevalence of MCPyV-positive tumours in areas with sun damage [ 6 ].

Clinical presentation of Merkel cell carcinoma presenting as a violaceous nodule

Pathogenesis of Merkel cell carcinoma. Adapted with permission from Hernandez LE, et al. Dermatol Ther . 2022 Mar;35(3):e15292. doi: https://doi.org/10.1111/dth.15292

There is limited available data on the Dermoscopic reflectance confocal microscopy (RCM) findings of MCC, and there are no specific features that can be used to definitively diagnose MCC. In this study, we aimed to summarize existing published data on the dermoscopic and RCM features of MCC.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards were followed for conducting this systematic review with meta-analysis [ 7 ]. To find relevant studies, we searched the PubMed and Scopus databases from inception to April 12, 2023. Our goal was to identify all pertinent research that had been written in English. The following search strategy was employed: (“ dermoscopy” OR “ dermatoscopy” OR “ videodermoscopy” OR “ videodermatoscopy” OR “ reflectance confocal microscopy”) AND “ Merkel cell carcinoma”. Two dermatologists, DK and GE, evaluated the titles and abstracts separately for eligibility. For inclusion, only works written in English were taken into account.

All articles detailing the dermoscopic characteristics of MCC in one or more patients were considered. Reference lists of papers that were included were checked again for more publications that qualified. A consensus was reached in the event of a disagreement between the two researchers. The clinical, dermoscopic, RCM and histological data were collected from each relevant article after it had been fully retrieved. Based on the initial description provided by the authors of the included studies, the dermoscopic characteristics of MCC were initially evaluated.

In total 29 articles were retrieved of which 13 were irrelevant, therefore 16 articles were included in this study, in a total of 68 MCC cases (Fig. 3 ). The dermoscopic and RCM characteristics of MCC cases of our study are summarized in Table 1 [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. The most common dermatoscopic signs included the following (Fig. 4 ):

Flow diagram

Clinical and dermoscopic images of patients with Merkel cell carcinoma (MCC). Some dermoscopic characteristics are marked as follows: arrows: large vessels, arrowheads: shiny white areas, asterisk: non-shiny white areas. NPD: non-polarized dermoscopy, PD: polarized dermoscopy. Reproduced with permission from Jalilian C. et al. Br J Dermatol . 2013 Aug;169(2):294-7. doi: https://doi.org/10.1111/bjd.12376

Milky red areas

On dermoscopy, milky red areas were reported in 49/68 (72.05%) of published MCC cases. Milky red areas, also called pink-white structureless areas, and creamy red background or pink homogeneous areas, refer to structureless areas exhibiting pink to-white-red colour [ 24 , 25 , 26 ]. Although the occurrence of milky red areas in skin lesions is infrequent, their presence has been strongly linked to invasive melanoma. These areas/globules may help identify thicker amelanotic/ hypomelanotic melanomas (AHM), which often lack traditional melanoma features [ 27 , 28 , 29 ]. In AHM, milky read globules/areas were observed in 31% of thin melanomas (1 mm) and 93.3% of thick melanomas, in contrast to 17.3% and 9.1% of amelanotic/hypomelanotic benign melanocytic lesions and amelanotic/hypomelanotic non-melanocytic lesions, respectively, according to a study [ 30 , 31 ]. Vascular blush, also known as erythematous blush, pink veil, or milky red patches, is a red or pink area, corresponding to a more vascularized site of a lesion. Vascular blush can therefore be seen in a wide range of dermatologic entities, including dermatofibromas, vascular tumours such as pyogenic granulomas (PG), inflammatory lesions, melanoma, and nonmelanoma skin malignancies. Regarding melanocytic lesions, vascular blush can be seen in nevi, but it is more frequent and noticeable in melanoma [ 32 , 33 ].

Linear irregular vessels

Linear irregular vessels were noticed under dermoscopy in MCC cases with a frequency of 64/68 (94.11%) (Fig. 5 ). These vessels are red vascular structures that vary in size, shape, and distribution. The presence of irregular vessels is a strong indication of malignancy since they are commonly found in melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC). In a previous study, linear irregular vessels were identified in 33.3% of melanomas, with a positive predictive value (PPV) of 67.6% [ 30 ].

Schematic approach of dermoscopic characteristics of Merkel cell carcinoma (MCC) indicating multiple arborizing irregular, polymorphous vessels, shiny white, milky red areas as well as structureless areas Adapted with permission from Jalilian C. et al. Br J Dermatol. 2013 Aug;169(2):294-7. doi: https://doi.org/10.1111/bjd.12376

Arborizing vessels

The presence of arborizing vessels was reported in 51/68 (75%) of cases (Figs. 4 and 5 ). Arborizing vessels are vessels with large diameter, branching irregularly into fine capillaries. They are usually seen in BCC but they can also be present in furuncles, cysts, intradermal nevi, and other adnexal tumours. Bright-red, in focus, arborizing vessels have a PPV of 94% for BCC [ 34 , 35 , 36 ]. Arborizing vessels, when viewed under dermoscopy, are red linear vessels with a thick diameter (0.2 mm or more) that split into branches with progressively thinner diameters, resembling a tree-like pattern. In BCC these vessels are sharply focused due to their superficial location just below the epidermis and exhibit irregular branching into small diameter capillaries (10 μm). Traditionally, arborizing vessels were considered a reliable indicator of BCC, with a PPV of 94%, sensitivity of 96,1%, and specificity of 90.9%. However, a recent study from Korea found that only 54% of lesions displaying arborizing vessels (Avs) were confirmed as BCCs. The variation in PPV for BCC diagnosis using arborizing vessels can be attributed to the types of lesions included in the analysis. When only lesions in the differential diagnosis for BCC are considered, the PPV of arborizing vessels may be higher compared to when all lesions, regardless of differential diagnosis, are included. It is worth noting that adnexal tumours can sometimes exhibit similar features, including arborizing vessels, as BCCs [ 34 , 35 ].

Polymorphous vessels

Polymorphous vessels were seen in 27/68 (39.70%) of MCC cases (Figs. 4 and 5 ). Polymorphous vessels are a combination of two or more vessel morphologies, with the most common combination being dotted and serpentine vessels. Polymorphous vessels, corresponding to the neovascularization of a tumour, have been traditionally considered an indicator of melanoma. A study of lesions with vascular features on dermoscopy showed that only 20% of the lesions had a polymorphous pattern and their presence had a PPV of 52.6% for melanoma. Specifically, the combination of dotted and linear-irregular vessels was found in 18% of amelanotic/ hypomelanotic melanomas, but rarely in other nonmelanoma amelanotic/hypomelanotic lesions [ 36 , 37 ]. Polymorphous vessels may also be present in cutaneous metastases, and other tumours such as eccrine poromas [ 29 ].

Lacunes/vascular lakes

Lacunae were observed in 2/68% of MCC cases. Lacunae are clusters of numerous well-defined round or oval, reddish formations that are divided by septae, a white rim. They are comparable to dilated, thin-walled veins in the papillary dermis histologically. Vascular tumours, especially angiomas, are distinguished by lacunae. Black (violaceous, blue-black, or black) lacunae that are extremely distinctive to isolated angiokeratomas show partially or entirely thrombosed dermal arteries lying deeper in the dermis.

Ulceration was reported in 2/68 (2.94%) of MCC cases.

Structureless areas

Structureless areas were described in 13/68 (19.11%) MCC cases. Regions within a lesion that lack any discernible feature or structure are referred to as “structureless areas”. These areas should occupy at least 10% of the total surface of the lesion. Structureless areas can exhibit hypopigmentation, hyperpigmentation, or regular pigmentation [ 37 ].

Sharply focused vessels

Sharply-focused vessels were mentioned in 15/68 (22.05%) of MCC cases. Sharply focused vessels have been previously described in a case series of necrobiosis lipoidica (NL) [ 38 ].

White areas (Milky white background)

White areas or milky white backgrounds were noticed in 20/68 (29.41%) of cases.

Architectural disorder

Architectural disorder was reported in 9/68 (13.23%) of the cases.

Dotted vessels

Dotted vessels were seen in 25/68 (36.76%) of MCC cases. Dotted vessels are small red dots, ranging in diameter from 0.01 to 0.02 mm that histologically correspond to vessels with perpendicular orientation to the skin surface. Dotted vessels can be observed in inflamed, traumatized, or stasis skin, as well as in cutaneous tumours. The presence of dotted vessels is often indicative of melanocytic lesions, with a study showing that 90% of lesions with dotted vessels were melanocytic. In melanocytic tumours, dotted vessels have varying PPV for different types of melanoma, ranging from 38% for melanoma to 16% for dermal/congenital nevi, 21% for Clark nevi, and 16% for Spitz nevi. In benign nevi, dotted vessels correspond to vessels at the tips of dermal papillae and are often observed within the pigment network. In melanoma, dotted vessels, usually found in conjunction with other types of vessels, can be located anywhere within the lesion but are more concentrated toward the center. Studies have shown that dotted vessels are commonly seen in thinner melanomas (< 1 mm), compared to thicker ones (> 1 mm), particularly in amelanotic and hypomelanotic melanomas [ 39 , 40 , 41 ].

Large vessels

Large vessels were observed in 16 out of 68 cases (23.52%).

A collarette was shown only in one out of 68 cases (1.47%). A collarette refers to a thin rim of loosened keratin that overhangs the periphery of the skin lesion and is connected to the adjacent healthy skin. The external edge of the collarette is attached, whereas the internal edge is free. Collarette can be seen in eccrine poroma [ 28 ].

Scale was described in 14/68 (20.58%) cases.

Glomerular vessels

Glomerular vessels were noticed in 10/68 (14.70%) of cases. Glomerular vessels are coiled vessels mimicking the glomerular apparatus of the kidney. They can be seen in Bowenoid actinic keratosis, Bowen’s Disease (BD), SCC, and clear cell acanthoma. They have a 62% PPV for SCC [ 37 ].

Comma vessels

Comma vessels were reported in 3/68 (4.41%) cases. Comma vessels which are vessels that are curved in a shape resembling a comma are typically blurry when viewed under dermoscopy due to their deeper location within the dermis. These vessels are commonly associated with dermal naevi, with studies showing that 66.3% of dermal/ congenital naevi exhibit this vascular pattern, and they have a PPV of 94% [ 36 , 37 ]. Additionally, in another study, the presence of organized comma vessels as the predominant vessel morphology is indicative that the lesion is not a melanoma, suggesting a benign naevus, commonly dermal or compound naevus.

Horseshoe-like structures

Horseshoe-like structures were described in 3/68 (4.41%) of cases.

Linear beaded vessels

Linear beaded vessels were seen in 9/68 (13.23%) of cases.

Pinkish structureless background

Pinkish structureless background was observed in 7/68 (10.29%) of cases.

Shiny white lines

Shiny white lines were reported in one case 6/68 (8.82%). These white streaks are oriented in parallel or sometimes perpendicular to each other. In dermoscopy, perpendicular white lines are short, separate white lines that are oriented parallel or perpendicular to each other and can only be seen under polarized light. They are also known by various names such as polarizing white lines, short white lines, shiny white lines, whiny white streaks, chrysalis, chrysalids, and crystalline structures. Polarized dermoscopy enables improved visualization of deep structures and reveals structures that are not visible with non-polarized dermoscopy, such as 4-dot clods (also known as rosettes) and shiny bright, linear, and white lines referred to as shiny white streaks (SWSs). SWSs can be found in both benign and malignant skin lesions, including melanoma, Spitz naevus, dysplastic naevus, intradermal naevus, BCC, dermatofibroma, scar tissue, and benign lichenoid keratosis. Previous studies have shown that SWSs are more prevalent in melanomas (ranging from 23.4 to 32.8%) compared to melanocytic naevi (ranging from 0.07 to 2.6%) and their visualization as thin, shiny, linear, white structures depends on the use of polarized dermoscopy. The presence of SWSs histologically corresponds to broad deep dermal fibroplasia. Cases with diffuse SWSs exhibited a significantly higher degree of deep fibroplasia than cases with focal SWSs [ 41 , 42 ].

Reflectance confocal microscopy (RCM) findings in MCC

RCM is a non-invasive technique that allows for high-resolution imaging that can provide detailed images of the cellular and structural features of the skin, including the epidermis, dermis, and other skin layers, as well as blood vessels and hair follicles [ 43 , 44 ].

In the case presented by Longo et al., which was a primary MCC, the use of reflectance confocal microscopy (RCM) showed that there were clusters of small cells that appeared darker compared to lymphocytes, and they were larger than normal cells. Some of these cells had irregularly shaped nuclei that filled up the entire cell (Table 2 ). These clusters were surrounded by fibrotic tissue. In live imaging, large blood vessels were observed near the tumour growth. Additionally, within these dark cells, some bright cells likely represented highly proliferative cells, which appeared more reflective in RCM [ 22 ].

Cinotti et al. described four patients who had four primary MCC lesions and one of them had six lesions of metastatic MCC located on the same limb. The RCM features observed in all cases by Cinotti et al., were very similar and confirmed the morphological aspects described in a previous study by Longo et al. The RCM images showed small hypo-reflective cells that resembled lymphocytes arranged in solid aggregates outlined by fibrous tissue in the dermis. Additionally, there were larger polymorphic hyper-reflective cells that likely represented highly proliferative cells. The epidermis appeared thin and disarranged due to the underlying tumours. Metastatic lesions exhibited the same RCM features. While these findings could also be seen in cases of amelanotic melanoma, MCC showed a less pronounced polymorphous appearance and a more evident fibrotic stroma between the cell aggregates, which supported the diagnosis of a non-melanocytic skin tumour. Notably, apart from the findings previously reported in the RCM case described earlier by Longo et al., Cinotti also noted the dissociation of cell aggregates in certain regions of MCC. While this dissociation has been suggested to be a potential artifact resulting from tissue processing and fixation, it should not be dismissed as such, as it was consistently observed in vivo in RCM images and was in perfect alignment with histopathology findings, similar to clefts around to BCC [ 23 ].

In a case of intraepidermal MCC described by Navarrette-Dechent et al., RCM assessment using VivaScope 3000, a device by Caliber Imaging and Diagnostics in Rochester, NY, USA, revealed the presence of dark pagetoid cells in the epidermis, as well as glandular nests at the dermo-epidermal junction that were separated by septae [ 21 ].

One of the characteristic, though non-pathognomonic, dermoscopic findings in MCC is the presence of polymorphous vessels, which are typically irregular or tortuous, and neoangiogenesis, crucial for tumor growth and invasion, may be associated with these dermoscopic structures in MCC [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ].

These vessels can appear as arborizing or linear with irregular shapes and sizes and are often distributed in a scattered or clustered pattern. Arborizing vessels, typically seen in BCC, are clearly defined with a distinct red color, indicating their superficial location. In contrast, the poorly focused and pink-colored vessels observed in MCC suggest a deeper vessel location. Histopathological findings support the notion that deep angiogenesis is associated with milky red areas in dermoscopy [ 24 , 25 , 26 ]. Well-defined large arborizing vessels may correspond to new vessels located closer to the surface, while blurry vessels may be located deeper. Linear-irregular vessels may indicate elongation of capillaries and tortuous horizontal vessels [ 8 , 9 , 10 , 11 , 12 ]. Milky-red areas or globules may also suggest deep tumoral angiogenesis, which could explain the presence of blurred white and pink structures. The disordered formation of new blood vessels, a characteristic feature of MCC, may account for the appearance of the rainbow pattern observed in such lesions. This pattern, typically seen in Kaposi sarcoma, could aid in diagnosing MCC [ 24 ].

One study demonstrated a link between the irregular linear vessels observed through dermoscopy and the presence of clustered dilated vessels at the tumor’s periphery upon histopathological examination [ 35 ]. These linear irregular vessels are indicative of small, structurally abnormal, and variably dense blood vessels, commonly seen in tumor angiogenesis. They often occur in areas where vessel dilation is prominent. Linear irregular vessels and milky red areas, although common in hypomelanotic and amelanotic melanoma, are less distinctive for MCC. Additionally, the clustering of dilated blood vessels in the middle dermis, along with increased vascular proliferation in the deeper dermis, can correspond to irregular vessels and milky red areas observed in dermoscopy. Another characteristic dermoscopic feature, known as glomerular vessels, is frequently seen in Bowen’s disease (BD) [ 25, 26]. The significance of shiny white chrysalis-like structures in MCC is not yet understood.

The differential diagnoses often considered alongside MCC include amelanotic melanoma, BCC, SCC, cutaneous B-cell lymphoma, and PG [14–16 ]. We observed that MCC typically lacks pigmented structures or a blue-grey veil, which helps distinguish it from hypomelanotic melanoma. Unlike well-differentiated SCCs, MCCs generally lack hyperkeratosis. The presence of a collarette is infrequent in MCCs, which is an important clue for distinguishing MCC from PG, which often exhibits milky red areas. Scale and hyperkeratosis, also present in BD and SCC, may suggest epidermotropism when found in MCC, as evidenced by a case of combined MCC/SCC [ 12 ].

RCM is a supplementary diagnostic technique that enables in-depth examination of the skin at a resolution close to that of histology. Reported RCM findings of MCC included small hypo-reflective cells forming solid aggregates in the presence of fibrotic stroma and prominent vasculature. These findings were similar to some melanoma subtypes (such as nevoid melanoma), but the monomorphous appearance favored a diagnosis of non-melanoma skin cancer, specifically not BCC [ 39, 40 ].

In conclusion, the dermoscopic findings of MCC are indicative of the rapid growth of this tumor. However, they are not specific to MCC, and therefore, their usefulness and value in diagnosis and management are unknown. All studies were descriptive and observational, without evaluation of diagnostic significance.

Data availability

The data that support the findings of this study are available upon reasonable request from the corresponding author, MP.

Abbreviations

Merkel cell carcinoma

Positive predictive value

Shiny white streaks

Basal cell carcinoma

Bowen’s Disease

Squamous cell carcinoma

Reflectance confocal microscopy

Pyogenic granuloma

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Dimitra Koumaki, Georgios Evangelou & Konstantinos Krasagakis

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Conceptualization, DK, AK, GE, MP, SG, KK and EL.; methodology, ZA, AL, SG, MP, KK and DK.; software, ZA, AL, SG, MP, DK; validation, DK, AK, GE, MP, and EL.; formal analysis, DK, AK, and SG; investigation, DK, AK, GE, MP, SG, and EL.; resources, DK, AK, and SG.; data curation DK, AK, GE, SG, MP, and EL, DK, AK, and SG.; writing—original draft preparation DK, AK, GE, SG, MP, KK and EL; writing—review and editing, ZA, AL, SG, MP, and DK.; visualization, ZA, AL, SG, MP, AK, KK, and EL; supervision, ZA, AL, SG, MP, AK, KK and EL.; project administration, DK, AK, KK, and EL; All authors have read and agreed to the published version of the manuscript.

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Koumaki, D., Evangelou, G., Katoulis, A.C. et al. Dermoscopic characteristics of Merkel cell carcinoma. BMC Cancer 24 , 785 (2024). https://doi.org/10.1186/s12885-024-12566-2

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Received : 14 May 2023

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Published : 01 July 2024

DOI : https://doi.org/10.1186/s12885-024-12566-2

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Reflectance confocal microscopy (RCM)
Merkel cell carcinoma (MCC)
Polyomavirus
Neuroendocrine carcinoma

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