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312  |  wileyonlinelibrary.com/journal/medu Medical Education. 2020;54:312–319.© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education

1  | INTRODUC TION

The social roles of health professionals, such as advocate, collabo- rator and communicator, matter to patient care. Without effective enactment of these roles, patients can feel unheard, and experience

practitioner conflict or excess burden in navigating systems or advo- cating for quality and compassionate care.1-3 Hence, health profes- sions education (HPE) needs research into what these roles look like in practice, how clinicians come to learn them, and how we might go about teaching or fostering their development.

Received: 14 June 2019  |  Revised: 11 September 2019  |  Accepted: 31 October 2019

DOI: 10.1111/medu.14032

R E S E A R C H P A P E R

Critically reflective practice and its sources: A qualitative exploration

Stella L. Ng1,2  | Maria Mylopoulos2  | Emilia Kangasjarvi1 | Victoria A. Boyd2,3  | Sabrina Teles4 | Angela Orsino5 | Lorelei Lingard6 | Shanon Phelan7

1Centre for Faculty Development, St Michael's Hospital, Toronto, Ontario, Canada 2Wilson Centre for Research in Education, University of Toronto, Toronto, Ontario, Canada 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada 4The Department of Recreation and Leisure Studies, University of Waterloo, Waterloo, Ontario, Canada 5Developmental Paediatrics, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada 6Department of Medicine and Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada 7Faculty of Rehabilitation Medicine, Occupational Therapy, University of Alberta, Edmonton, Alberta, Canada

Correspondence Stella L. Ng, Centre for Faculty Development, St Michael's Hospital, Toronto, Ontario M5B1W8, Canada. Email: [email protected]

Funding information This study was funded by a Canadian Institutes of Health Research (CIHR) Open Operating Grant and the Arrell Family Chair in Health Professions Teaching.

Abstract Context: Critical reflection may improve health professionals’ performance of the so- cial roles of care (eg collaboration) in indeterminate zones of practice that are ambig- uous, unique, unstable or value- conflicted. Research must explore critical reflection in practice and how it is developed. In this study, we explored what critical reflection consisted of in a context known for indeterminacy, and to what sources participants attributed their critically reflective insights and approaches. Methods: The study context was the interface between health care and educa- tion for children with chronic conditions or disabilities necessitating health- related recommendations and supports (eg accommodations or equipment) at school. We conducted a secondary analysis of 42 interview transcripts from an institutional eth- nographic study involving health professionals, school- based educators and parents of children with chronic conditions or disabilities. We coded all transcripts for in- stances of critical reflection, moments that seemed to lack but could benefit from critical reflection, and participant- attributed sources of critically reflective insights. Results: Critically reflective practice involved getting to know the other, valuing and leveraging different forms and sources of knowledge, identifying and communicat- ing workarounds (ie strategies to circumvent imperfect systems), seeing inequities, and advocating as collaborators, not adversaries. Participants invariably attributed critically reflective insights to personal experiences such as former careers or close personal relationships. Conclusions: This study shows that personal experiences and connections inspire critically reflective views, and that being critically reflective is not a binary trait pos- sessed (or not) by individuals. It is learnable through personally meaningful experi- ences. Health professions education could aim to preserve philosophical space for personal experience as a source of learning and integrate evidence- informed ap- proaches to foster critically reflective practice.

     |  313NG et al.

Indeterminate zones of practice are those that are value- conflicted, ambiguous, unstable or unique.4 These zones demand that health professionals shift from a focus on medical expertise towards humanistic and social foci of care. For example, this need for a shift has been found in practice contexts such as those of delivering bad news in neonatology5 and providing compassionate care in chronic pain.1 Another such practice area is school- based health care, in which health professionals work with schools to help children with disabilities or chronic conditions participate as mean- ingfully as possible.6 Decades of research show that these efforts often fail to achieve their intentions.6-8 In one study, health profes- sionals espoused health advocacy as a core role in their practice at the school–health interface but usually performed it ‘by proxy.'3 They wrote letters or reports as advocacy tools to be relayed by parents to schools, which unintentionally contributed to conflict between and burdened parents and educators, rather than enabling support and participation for the child.3 Yet sometimes health pro- fessionals found ways to overcome systemic constraints in order to support families and engage positively with schools.2 Although not named as such by participants themselves, these more productive approaches to this practice area represented the concept of criti- cally reflective practice, thereby sparking the current study.

Critical reflection may serve as an underlying capability to inform the social roles of care. Critical reflection adds a layer to reflection, which is the active, persistent and careful consider- ation of knowledge claims.9 Through a critical reflection lens, this consideration process questions individual and societal assump- tions, disrupts unhelpful power relations, and strives for social change.10-13 Reflective practice is a way of practising in indetermi- nacy that involves drawing upon personal and experiential knowl- edge in addition to scientific knowledge to solve messy problems in practice. It can also occur through a critical lens, resulting in critically reflective practice.10-13

Given these theoretical assertions, the health professional roles of advocate, collaborator, communicator and professional, and goals such as compassionate care or systems- based prac- tice,1-3,14-17 may benefit from critical reflection as a basic under- lying capability or critically reflective practice as an approach for practice in indeterminacy. Related research supports this asser- tion; for example, clinicians who became hospitalised developed lenses consistent with critical reflection and this, in turn, engen- dered more compassionate orientations towards care.18 In this study, we wanted to explore what critical reflection or critically reflective practice consisted of in the school- based health care context, and to what knowledge sources participants attributed their views and practice approaches. The literature contains many usages of terms relating to reflection, critical reflection and critical reflexivity. We chose to use just one term for simplicity; to clarify, we are referring to both critical reflection and reflexivity when we say ‘critical reflection.' For the purposes of this study, we focus only on critical reflection. For a summary of the history and sub- tle differences between these related concepts, see papers by Ng et al19 and others.12,13,20

2  | METHODS

The study context was the interface between health care and edu- cation for children with chronic conditions or disabilities that ne- cessitate the provision of supports at school (eg anxiety disorder, cerebral palsy, attention deficit hyperactivity disorder, hearing loss). We acquired research ethics board approval from our university, local academic health sciences centre, and four participating school boards to conduct interviews and observations, and document col- lection for a larger institutional ethnographic study.6 These sites and local privately and publicly funded clinics were included in our study. For the purposes of this paper, we conducted a focused, secondary analysis of 42 interview transcripts involving health professionals, school- based educators and parents of children with chronic condi- tions or disabilities.

2.1 | Secondary data source

Following the tradition of institutional ethnography,21,22 the loosely structured interviews focused on encouraging participants to articulate the work they did at the clinic-school interface in rela- tion to supporting children with disabilities.23,24 Participants were explicitly probed about how they learned to practise in this con- text and how certain views or approaches described during their interviews were derived. Although the original institutional eth- nography study included observation and document data, these were not included in the secondary analysis presented in this cur- rent paper.

Interviewed informants included a total of 40 people: health pro- fessionals from traditional health care settings such as hospitals and clinics (n = 17); health professionals embedded in school- based set- tings (n = 4); education professionals (n = 6); parents of children with disabilities (n = 10), and parent advocates/mentors (ie parents who had similar prior experiences and now worked formally to support other parents) (n = 3). Three participants were interviewed twice (as is common in institutional ethnography) and one interview session had two participants (two parents together); thus we had a total of 42 transcripts. The health professionals represented the following practice areas: health care administration; audiology; nursing; occu- pational therapy; physiotherapy; psychology; speech and language pathology, and social work. The physician disciplines included de- velopmental paediatrics, neurology, paediatric cardiology and pae- diatric psychiatry. Interviews were conducted during 2011-2014 by three researchers.

2.2 | Data analysis

Data analysis was informed by the concepts of critical reflection and critically reflective practice as described in the introduc- tion. As mentioned in our introduction, critical reflection builds upon reflection so that reflective practice is encompassed within

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critically reflective practice. Based on these operating definitions, two research associates (EK and ST) coded all transcripts for in- stances of critical reflection, as well as for moments that seemed to lack but could benefit from critical reflection. The first author (SLN) checked the coding for consistency between the coders as well as with the theoretical framework. After coding transcripts for all critically reflective insights and work processes described, the research associates then reanalysed the transcripts to identify related, attributed sources of these insights (eg ‘I see it this way be- cause ...'). Next, EK re- reviewed all transcripts to look for any other instances of critical reflection or any additional sources of knowl- edge that related to critically reflective insights, but found none. Finally, engaging in a process informed by Charmaz's approach to focused and theoretical coding,25 the first author (SLN) organised statements that had been identified as critically reflective into the thematic categories of findings presented below, which were informed by, and expand upon, extant theoretical knowledge of critical reflection and critically reflective practice. Enacting and ensuring researcher reflexivity involved reflexive conversations during team meetings from planning to the final write- up, closely informed by published guides for ethical research involving chil- dren and for qualitative research more broadly.26-30

3  | RESULTS

Being critically reflective or not was not a binary state for individual clinicians. Instead, participants who shared critically reflective in- sights also demonstrated missed opportunities for such insights. In the context of school- based health care, critically reflective practice manifested as five related and overlapping thematic categories of views and approaches to practice: (i) getting to know the other; (ii) valuing different forms and sources of knowledge; (iii) identifying and communicating systems workarounds; (iv) seeing inequities, and (v) advocating as collaborators, not adversaries. We elaborate these categories below and conclude with a sixth category of findings: (vi) deriving critically reflective insights.

3.1 | Getting to know ‘the other’

Participants described successful collaboration attempts with schools as hinging upon a genuine and concerted effort to get to know the ‘other’, meaning the other system, or another person and how they were situated within a system. By contrast, in moments demonstrating a lack of critically reflective insight, participants of- fered assumptions and guesses about the other's constraints, needs and intentions; some participants specifically described the other system as a ‘black box.'

However, many also made critically reflective statements demonstrating a desire to know what was in that black box when acknowledging that people working in another context or system may face unique systemic constraints, and are likely to have useful

perspectives or specific needs. Appreciating this unique position mattered when interacting with or communicating with the other:

I think it would be actually quite helpful to just under- stand what's going on inside that black box. Who am I communicating with, even. And it would be useful to understand what information they really require, what is going to make their decision making easier. And, I guess, to get some feedback that says, thanks, but actually, we need to know this and not what you have told us. (John, paediatrician)

Along with a desire to get to know the other, there was often a de- sire to learn from the other, as demonstrated in John's statement. John referred to desiring feedback from schools about what may be more or less useful in reports used to communicate about and advocate for patients.

3.2 | Valuing different forms and sources of knowledge

Many participants privileged medical and physician knowledge over parent, educator or health disciplines knowledge. Sometimes this privileging was a result of the uncritical acceptance of tradi- tional norms and hierarchies, as when physicians expressed frustra- tion that their recommendation was not taken as the truth, or as an order. At other times the privileging was critically reflective: it was intentional and strategic, using physician knowledge and power as currency when also questioning its inherent power. For example, some health professionals (eg occupational therapists) described calling upon the power of physician knowledge to back up their own recommendations. Similarly, parents used the written word of physicians to try to trump the constraints of the school boards.

Critically reflective practice also resisted the traditional hier- archy of professions and knowledge and held different sources of knowledge in tension. For example, appreciating and valuing the knowledge of school- based professionals tended to lead to pos- itive, collaborative interactions with these professionals. Instead of engaging the traditional hierarchy, critically reflective moments sometimes demonstrated humility and deference to the experiential knowledge of others, parents and professionals alike:

So a lot of it is trying to get past that balance of power to show that parents are experts and they do have value, and that they should be considered as equals in the plan- ning process. (Josephine, parent advocate)

However, our participants sometimes used the language of role distinction rather than that of knowledge distinction. For example, one physician, Steven, described his deference to schools and in- house professionals as a matter of what his role was, as opposed to valuing others’ knowledge. He recognised the limits of his jurisdiction and

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trusted the school to take over at the edges of his own scope. This trust was not always apparent, and perhaps not always appropriate, as it was precisely in the interface points between clinic and school that the system's limitations could result in problems. In these moments, system workarounds were often enacted.

3.3 | Identifying and communicating systems workarounds

The workaround is a common strategy used to achieve goals within and despite imperfect processes and systems. However, the criti- cally reflective way of engaging workarounds in this study seemed to add a unique step to a typical workaround. This step was the explicit and purposeful communication of the underlying rationale to others involved. For example, a parent reflected on a conversation in which a clinician clearly communicated and reframed a workaround as a strategy to help make the otherwise disappointing diagnostic labels of her child more palatable:

‘I know that you don't want the labels, but what we do is we take it off the shelf, we get funding and resources, and then we put it back on the shelf. So it doesn't define him, but it helps us to resource him, because otherwise we can't.’ […]. So, [the clinician] said, ‘…and then we put it back, and the shelf is high, and we don't use it every day, we just take it down again, we blow the dust off, and we'll use it when we need it.’ So, for me, that reframed it, a lot, because that makes sense, then I'm okay with it. (Ivonne, parent)

Of note, workarounds were more common in our dataset than were explicit efforts to change the imperfect system necessitating the workaround.

3.4 | Seeing inequities

Some participants identified underlying reasons for gaps in the sys- tem that led to inequitable access to services. For example, several participants mentioned inequities that could result for newcomers to Canada or English- language learners. However, most did not nec- essarily act upon these inequities; rather, they became more aware of them and began to imagine systems change.

This finding was consistent across professional and parent par- ticipants. Interestingly, parents, who were quite focused upon their efforts to advocate for their own child's needs, often knew of an- other parent who made them critically reflective about access and equity:

So, I think about Aiden and then I think about the families that I work with as a social worker. I work a lot with new- comers because I speak Spanish as well and […] I know

how it can be if that's not your language. I just think that just on behalf of the families that I know and work with that [it] is just not okay. It's not okay. I can't sit back be- cause I don't like it for Aiden and then it does make me angry thinking about it for other kids. (Heidi, parent and social worker)

A few participants did enact change—beyond workarounds—when possible. For example, Ursula, a private practice- based health profes- sional, saw systems challenges related to equity and created a specific role of ‘parent advocate’ in her clinical team in order to support parents facing these challenges:

I've seen where people don't speak English as a first language and they get bumped around; I find that un- acceptable. So anyhow, that's why we've brought on the [parent] advocate, is to deal with the bigger system is- sues. (Ursula, health professional)

3.5 | Advocating as collaborators, not adversaries

Clinicians often talked about the written report or letters to schools as their primary tool for advocacy, but these reports or letters, as our broader institutional ethnographic study found, would often be the impetus for years of conflict between parents and schools:

A doctor will write something [in a letter] like this child needs an educational assistant. Well, that may be true, and that may be something that's really going to help this child, but there is a process that's involved in the school system to go about getting that. It can be challenging for a family if they go in with a piece of paper and hand that over to a school board saying this is what the doctor said. There's a different route that is required to go down that road and get those resources in place and I think that's where those two different languages don't always mesh. (Karin, parent advocate)

However, those clinicians who advocated through a criti- cally reflective lens positioned themselves alongside parents and school personnel; all were members of the same team working for the child:

Not only do I communicate with other health care pro- fessionals through the consultation letters but I'm com- municating with the school and […] advocating. (Anna, physician)

Those with a critically reflective ‘advocating with’31 rather than ‘advocating at’ mentality crafted their reports differently, carefully choosing their wording to avoid the issuing of directives and instead

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316  |     NG et al.

issuing invitations for collaboration. Yet even when advocating along- side others, advocacy tended to remain at a micro- level and often took the form of workarounds, communication through written reports, and the identifying of a need for change as opposed to taking larger, macro- level action (eg trying to change a problematic practice protocol).

Clearly, there was overlap between the categories of getting to know the other and valuing different knowledges. Subsequently, these categories inform the related categories of communicating about workarounds, identifying inequity and advocating as collab- orators, not adversaries. Together, the five overlapping categories animated critical reflection within our specific study context and led us to seek explanations for how these critically reflective views or actions came to be.

3.6 | Deriving critically reflective insights

Our interviews explicitly asked practitioners how they had come to view and approach their work in the ways they had described. When we looked to see how individuals had derived the experiences or in- sights that led to critically reflective practice, they invariably pointed to personal experiences and relationships. For example, Alyson, a re- habilitation practitioner, cited her close friends and colleagues who work in the education system:

So I've been around for a long, long time but that's the one setting I've never worked in is education. But I have enough friends and colleagues who work in education, and through years of conversations with them, I have a really good grasp of how the education system functions. But that took years and years to develop. (Alyson, health professional)

Kyle, a paediatrician, attributed his understanding of the educa- tion system to frequent conversations with his wife, a school teacher. Rebecca, a psychiatrist, reflected: ‘My sister is a principal so I am very sensitive to the other side of the coin.’ Susan, a physiotherapist, noted that she had learned from her teenage daughter's volunteer place- ment in a special needs classroom, and Wanda, a psychiatrist, had ac- tually worked as a school teacher in her previous career. Trish, now in a traditional clinical setting, had previously worked in a context that gave her more prolonged and meaningful engagement with schools:

In my previous life before I retired, I was working for a children's rehabilitation centre in the city and I had a lot of contact with schools and daycares because I did psy- chological assessments. I am a psychometrist by trade and there would be lots of times that information was shared with the schools or the daycare staff to start im- plementation of programmes or strategies that would make the time of the child in those particular educa- tional settings a little bit more successful. (Trish, health professional)

Across all of our professional participants, we found no instances of formal education as the source of critically reflective views or ap- proaches. The closest we could find was reported by one professional who had sought professional development outside her own field in re- sponse to her practice experiences.

Being critically reflective was not an all- or- nothing way of being and seeing; individuals who demonstrated instances of critical re- flection also exhibited missed opportunities for such. For example, Steven demonstrated many critically reflective insights in his inter- view. However, when asked about whether he ever modified his wording of written recommendations (for the child) in response to requests from schools, he stated very strongly (and uncritically) that it would be ‘grossly inappropriate’ for schools to make such a request of him and he assumed that schools would never ask him to do so anyway.

Overall, critically reflective views and approaches were tied to personal connections and experiences that had challenged assump- tions, provided insights into power relations, or motivations to cre- ate change.

4  | DISCUSSION

Reflective practice, critical reflection, and the related construct of critical reflexivity have been previously identified as capacities that may support difficult conversations5 and compassionate,18 humanis- tic32 and equitable care.33 Critical reflection has also been previously identified as learned through personal experience18 and in the work- place.33 Our study builds upon this literature, exploring what critical reflection looks like in another context for which it may be particu- larly crucial. In this study, we found that critical reflection involved getting to know the other, valuing and leveraging different forms and sources of knowledge, identifying and communicating workarounds, seeing inequities, and advocating as collaborators not adversaries. In this section, we discuss what this study offers to theories of critical reflection, and its implications for HPE.

Reflective practice and critically reflective practice tend to be most appropriate in indeterminate zones of practice.34 School- based health care is full of such moments; this practice area is not focused on diagnosis and treatment, but, rather, on collaborating with, com- municating across and navigating other systems, the culture and values of which may be quite different. Practitioners in this study needed to take time to get to know the other because each ‘other’ faced unique constraints and needs. Practitioners needed to employ their personal knowledge and knowledge from others to navigate complex systems. A critical lens seems vital as practitioners needed to overcome dominant power structures that may otherwise impede collaboration. Assumptions needed to be challenged in order to push past one's own views and knowledge (or lack thereof) of the school system as well as traditional professional structures. Additionally, enacting and communicating workarounds to mitigate the negative impacts of policies or protocols benefited from criticality. Depending on the situation, power relations were noted and explicitly used or

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disrupted as participants deliberately drew upon parents’ and oth- ers’ knowledge.

Notably, our findings did not align with a key component of crit- ical reflection: a focus upon social change. Although some aspects of advocacy in our findings leaned towards social change, overall advocacy was limited to seeing inequities, and working around them in particular situations rather than acting upon them more broadly. Whereas this may achieve advocacy goals for a particular child at a particular moment, it also risks perpetuating the overall status quo. This finding of limited macro- level or systems- level action echoes that in other literature, wherein a sense of limited agency or time has been identified as a barrier to greater action.35-37 Further study may be useful to identify instances in which clinicians engage in more macro- level social change. Further, the many theoretical definitions of critical reflection that include change- oriented, so- cial action10-13,38,39 may need to be examined relative to empirical studies. How social action relates to critical reflection and criti- cally reflective practice may perhaps require additional, nuanced examination.

In this study, critically reflective practice was not demonstrated as a fixed trait, but, rather, as a dynamic state arising out of per- sonal experiences and sources of knowledge. Critical reflection was not unique to professional practitioners; our dataset showed many instances of parents demonstrating critically reflective insights. Together, these findings highlight the role of personal experience in developing critically reflective ways of seeing. This makes sense given that critical and reflective pedagogies centre upon personal experience in education.40

4.1 | Implications for education: Making philosophical space for critical reflection

As critical reflection requires an acceptance of personal experi- ence as a source of knowledge, an epistemology of practice may be a prerequisite to its development.12 Health professions education can potentially diminish personal and experiential sources of learn- ing in its prioritisation of objectivity.1,15,41-43 If HPE wishes to foster critical reflection or reflective practice, it may need to ensure that admissions, curricula, assessments and faculty staff each commit to allowing philosophical space for personal and informal experience to influence one's learning and practice. This requires a view of educa- tion that not only focuses on the delivery of instruction and assess- ment for knowledge retention, transfer and skill development, but also acknowledges epistemological and identity- shaping forces that drive values, perspectives, and ways of seeing and being.44 Taking this view towards criticality would mean attending carefully to the values embedded in education before professional training even be- gins (ie during admissions45) and across the entire continuum of edu- cation and curriculum. For example, what messages are conveyed in admissions criteria? What types of learners and learning are deemed most valuable through these messages, and who and what, in the process, are overlooked or suppressed?45 This epistemology of

practice framing for a professional training programme, we suggest, would both liberate learners to include personal sources of knowing, and be a prerequisite to teaching for critical reflection.

4.2 | Implications for education: Purposeful integration with dominant teaching paradigms

In terms of teaching approaches, humanities education46-48 and critical pedagogy offer practical educational approaches that align with critical reflection.39,40,47,49 However, these approaches tend to be applied to curricula as addenda, which may limit their effectiveness and perceived value by learners and faculty mem- bers alike. Just as basic and clinical science should be taught with thoughtful integration, critical reflection should not be pre- sented as separate content knowledge (contributing to an over- filled curriculum50), but, rather, meaningfully integrated into the core learning experiences in the health professions curriculum. Perhaps integrating critical reflection with established construc- tivist and cognitivist approaches to education could enable more effective and cohesive integration rather than continuing to add it proximally as an elective or one- off event.

However, such efforts would need to be conducted with care- ful paradigmatic consideration. Critical reflection derives from paradigms that view education as a socialising and transformative force and speak of knowledge in embodied, philosophical and social terms.44 Meanwhile, cognitive constructivist paradigms commonly informing teaching and assessment approaches in HPE speak of knowledge in cognitivist terms.44 For example, current educational approaches to fostering medical expertise emphasise the conceptual knowledge development (knowing why) alongside the more tradi- tional emphasis on procedural fluency (knowing how).51 The argu- ment is that students require the fluency of knowing what to do in order to become efficient as they work through the many routine problems of practice, but that depth of understanding why allows them to shift beyond formulaic applications of knowledge in their practice when necessary. Being able to make this shift aligns with the shifts noted in our study (eg to employ and communicate work- arounds), as well as in extant studies of reflective practice.5 Thus, there could be potential for the teaching of critical reflection through the educational approaches used to foster knowing why and how.

Evidence for this assertion is emerging, but more research is needed. A guided discovery approach to support therapeutic in- terviewing skills development52 has begun to show the value of in- tegrating forms of knowledge beyond traditional basic and clinical science to support the development of conceptual knowledge.53 Whether it could also be used to integrate critically reflective ca- pacities is currently unknown. Further research is needed to un- derstand if and how constructivist and transformative approaches to education can be bridged, with the aim of fostering critically re- flective practice. Thoughtful integration with other paradigms and established education approaches, rather than engagement in ad- vocacy for one paradigm over another, may be a more productive

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way forward. Valuing and integrating different forms of knowledge, thoughtfully, would echo the findings of our study.

4.3 | Limitations

Primary rather than secondary data analysis would strengthen a study of how professionals engage in critically reflective practice and how they learn to do so. Research in other indeterminate con- texts could help to refine or challenge the assertions made in this study. Other definitions of critical reflection exist; although we pur- posefully chose our theoretical basis for this study, we acknowledge that many would consider Mezirow's work on the topic to be foun- dational.44 We argue that the strengths of this work in fact lie in the careful selection of our definition and our attention to its philo- sophical roots. This attention to paradigms allowed for careful and purposeful discussion of practical, pedagogical implications.44

5  | CONCLUSIONS

This study suggests that critical reflection and critically reflective practice offer useful theoretical framings for the social roles of health care practice that attend to humanistic, social and systems- based aspects of patient care. It also shows that critical reflection is not a static trait possessed (or not possessed) by an individual. Rather, it is achievable and learnable through personal experience. The implications for education are twofold. We suggest creating philosophical space for personal experience as a source of learn- ing in HPE, and the continued study of evidence- informed, aligned and integrated approaches to effectively foster critical reflection. Although it would seem to be an insurmountable problem, the HPE field could benefit from innovative research into whether and how teaching approaches can counter prevailing power relations. This continued research is important because the impacts of critically re- flective practice make it irresponsible to rely on the likelihood that people will pick up such lessons by chance.

ACKNOWLEDG EMENTS The authors acknowledge the contributions of the research partici- pants and staff at the study sites, who made this work possible. The authors also thank Christine Meston and Silke Dennhardt for their contributions to data collection and the larger Canadian Institutes of Health Research team for their contributions to the larger study from which the secondary data source derived.

CONFLIC TS OF INTERE S T None.

AUTHOR CONTRIBUTIONS SLN contributed to the study conception and design, data acquisition and analysis, and the drafting of the paper. MM, VAB and AO contrib- uted to data interpretation and the drafting of the paper. EK and ST

contributed to data analysis. LL and SP contributed to the study con- ception and design, and to data interpretation. All authors (SLN, MM, EK, VAB, ST, AO, LL and SP) contributed to the revision of the paper, approved the final manuscript for submission and have agreed to be accountable for all aspects of the work.

E THIC AL APPROVAL This study was approved by the research ethics boards of the University of Western Ontario, and the four participating schools.

ORCID Stella L. Ng https://orcid.org/0000-0003-1433-6851 Maria Mylopoulos https://orcid.org/0000-0003-0012-5375 Victoria A. Boyd https://orcid.org/0000-0003-3602-8964 Shanon Phelan https://orcid.org/0000-0003-2844-6250

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How to cite this article: Ng SL, Mylopoulos M, Kangasjarvi E, et al. Critically reflective practice and its sources: a qualitative exploration. Med Educ. 2020;54:312–319. https ://doi. org/10.1111/medu.14032

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