Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students: A Scoping Study

Abstract

Reflexivity involves the ability to understand how one's social locations and experiences of advantage or disadvantage have shaped the way one understands the world. The capacity for reflexivity is crucial because it informs clinical decisions, which can lead to improvements in service delivery and patient outcomes. In this article, we present a scoping study that explored educational strategies designed to enhance reflexivity among clinicians and/or health profession students. We reviewed articles and grey literature that address the question: What is known about strategies for enhancing reflexivity among clinicians and students in health professional training programs? We searched multiple databases using keywords including: reflexivity, reflective, allied health professionals, pedagogy, learning, and education. The search strategy was iterative and involved three reviews. Each abstract was independently reviewed by two team members. Sixty-eight texts met the inclusion criteria. There was great diversity among the educational strategies and among health professions. Commonalities across strategies were identified related to reflective writing, experiential learning, classroom-based activities, continuing education, and online learning. We also summarize the 19 texts that evaluated educational strategies to enhance reflexivity. Further research and education is urgently needed for more equitable and socially-just health care.

URN: http://nbn-resolving.de/urn:nbn:de:0114-fqs1603140

Full text

Educational Strategies to Enhance Reflexivity Among Clinicians and
Health Professional Students: A Scoping Study
Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent
Oliver & Stephanie A. Nixon
Abstract: Reflexivity involves the ability to understand how one's social locations and experiences
of advantage or disadvantage have shaped the way one understands the world. The capacity for
reflexivity is crucial because it informs clinical decisions, which can lead to improvements in service
delivery and patient outcomes. In this article, we present a scoping study that explored educational
strategies designed to enhance reflexivity among clinicians and/or health profession students. We
reviewed articles and grey literature that address the question: What is known about strategies for
enhancing reflexivity among clinicians and students in health professional training programs? We
searched multiple databases using keywords including: reflexivity, reflective, allied health
professionals, pedagogy, learning, and education. The search strategy was iterative and involved
three reviews. Each abstract was independently reviewed by two team members. Sixty-eight texts
met the inclusion criteria. There was great diversity among the educational strategies and among
health professions. Commonalities across strategies were identified related to reflective writing,
experiential learning, classroom-based activities, continuing education, and online learning. We
also summarize the 19 texts that evaluated educational strategies to enhance reflexivity. Further
research and education is urgently needed for more equitable and socially-just health care.
Table of Contents
1. Introduction
2. Methods
2.1 Stage 1: Identifying the research question
2.2 Stage 2: Identifying relevant literature
2.3 Stage 3: Study selection
2.4 Stage 4: Charting the data
2.5 Stage 5: Collating, summarizing and reporting the results
3. Results
3.1 Characteristics of included texts
3.2 Strategies for enhancing reflexivity among clinician and health profession students
3.3 Studies evaluating educational strategies to enhance reflexivity
4. Discussion
4.1 About strategies to enhance reflexivity
4.2 Limitations
5. Conclusion
References
Authors
Citation
This work is licensed under a Creative Commons Attribution 4.0 International License.
Forum Qualitative Sozialforschung / Forum: Qualitative Social Research (ISSN 1438-5627)
Volume 17, No. 3, Art. 14
September 2016
Key words:
reflexivity; health
professional
education;
practicing health
professionals;
scoping study

FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
1. Introduction
Critical reflection is a topic of longstanding interest in the health professions, yet
its meaning can be unclear (MANN, GORDON & MacLEOD, 2009; MÉNARD &
RATNAPALAN, 2013; TAYLOR, 2004). Nina DOHN (2011, pp.671-672) explains
that the term reflection carries "multiple meanings, ranging from the 'act of
thinking' to 'critical assessment of presuppositions,' and from 'contemplation' to
'acting with awareness.'" In this article, we focus on one aspect of critical
reflection that we term reflexivity. Our definition of reflexivity aligns with DOHN's
"critical assessment of presuppositions" and similar understandings in qualitative
research (MRUCK & BREUER, 2003). Specifically, we are concerned with the
ability to understand how one's own social locations and experiences of
advantage or disadvantage have shaped the way one understands the world and
produces knowledge (LAM, WONG & LEUNG, 2007; OTERHOLM, 2009; SMITH,
2011). [1]
While reflexivity is widely embraced as an essential skill in qualitative research
(DENZIN & LINCOLN, 2011; MRUCK & BREUER, 2003; SHAW & ARMIN, 2011),
its role within clinical practice is not as commonly accepted. The capacity for
reflexivity is crucial for health care providers because it informs clinical decisions,
which can improve service delivery and patient experiences of care (SMITH,
2011). Ching Man LAM et al. frame this approach to reflexivity as a process of
thinking critically about the basis of our own knowledge claims, becoming "more
than benign introspection" (2007, p.95). Furthermore, insight about one's relation
to structures of privilege and oppression are crucial for enabling clinicians to
understand and address health inequities (BROWN, 2012; D'CRUZ,
GILLINGHAM & MELENDEZ, 2007). This framing of reflexivity aligns with Donald
SCHÖN's "reflection-in-action" (1983, p.ix), which involves critically analyzing the
construction of professional practice. This approach requires analysis of the
power relations and hegemonic assumptions guiding one's actions as an opening
for imagining and enacting equity-promoting care (MANN et al., 2009). Our team
comprises a group of 11 interdisciplinary health researchers, clinicians, students
and community advocates, who work in the fields of global health and HIV, in
cross-cultural, resource-poor and resource-rich settings. All are involved in the
training of future health professionals. Furthermore, all co-authors have
reflexively engaged with the influence of their own positions of privilege and
oppression in shaping how they see the world. Challenges and successes related
to nurturing our own reflexivity as educators, clinicians and advocates led to our
interest in this inquiry. Specifically, the team coalesced around a shared interest
in better understanding how to develop reflexivity among health care providers in
order to be able to provide competent and ethical care for diverse patients in a
myriad of settings. Early exploration of the topic revealed a lack of coherent
literature on this topic, which led to our decision to conduct a scoping study as an
initial step to map out what is known in this field. [2]
Reflexivity is a skill that requires teaching and ongoing learning throughout
clinicians' careers. Yet education to nurture reflexivity is either absent or
underdeveloped within many clinical training and professional development
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
settings (KAI, BRIDGEWATER & SPENCER, 2001; MANN et al., 2009; SCHIFF
& RIETH, 2012). The result is a potential competency gap among health care
providers who may have strong technical training but little understanding of
reflexivity and its essential role in patient care. Furthermore, the evidence base
for how to nurture reflexivity among health professionals is a work in progress. In
their systematic review of 29 studies of reflective practice in the health
professions, Karen MANN et al. (2009, p.596) note that activities to promote
reflection (including and beyond reflexivity) are being incorporated into
undergraduate, postgraduate and continuing education across a variety of health
professions despite there being "surprisingly little [evidence] to guide educators in
their work to understand and develop reflective ability in their learners." The
literature base is even less developed in terms of educational strategies that
develop reflexivity related to one's social locations. As Elizabeth SMITH (2011,
p.212) explains, little is known about the "difficulties, practicalities and methods"
related to nurturing reflexivity or the "issues of teaching the theory and practice of
critical reflections in academic contexts." [3]
Our research seeks to advance the field by focusing on educational strategies
designed to nurture reflexivity within the health professions. Specifically, in this
article we present a scoping study that explored what is known about educational
strategies for enhancing reflexivity among clinicians and/or students in health
professional training programs. Below, in Section 2 we describe the iterative
process of our scoping study, in Section 3 we present salient characteristics of
the studies identified by the search and, finally, in Section 4 we discuss
implications for future education and research. [4]
2. Methods
We conducted a scoping study following the framework introduced by Hilary
ARKSEY and Lisa O'MALLEY (2005) and advanced by Danielle LEVAC, Heather
COLQUHOUN and Kelly K. O'BRIEN (2010). The intent of scoping studies is to
conduct a literature review and consultation phase that may be used to: 1.
examine the extent, range and nature of research activity, 2. determine the value
of undertaking a full systematic review, 3. summarize and disseminate research
findings, or 4. identify research gaps in the existing literature (ARKSEY &
O'MALLEY, 2005). We felt a scoping study was the most appropriate
methodological design to map out the literature in this field as it allows for a
rigorous examination of expansive topics and allows for the inclusion of many
study designs. [5]
2.1 Stage 1: Identifying the research question
We focused on the question: What is known about educational strategies for
enhancing reflexivity among clinicians and students in health professional training
programs? We understood "educational strategy" to include any activity that
promotes knowledge, including traditional in-class curricula and non-traditional
methods of learning outside a classroom. [6]
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
2.2 Stage 2: Identifying relevant literature
We sought published academic articles and grey literature that addressed topics
related to reflexivity and educational strategies. We engaged a health sciences
librarian to assist in developing search terms and a search strategy and to both
identify and search the most relevant databases. The health sciences librarian
identified the following databases: CINAHL, EMBASE, ERIC, IPA, PubMed,
OTSeeker and PEDro. We searched these databases, and not large
multidisciplinary databases, as we were specifically interested in the health and
education literature and were advised these databases covered the literature. Our
search was limited to texts published in English available as of January 1, 2013.
Search terms included "reflexivity OR reflexive OR critical reflection OR self
reflection OR reflective" and "allied health personnel OR clinicians OR physicians
OR nurses OR doctors OR pharmacists OR students OR health professionals."
Texts identified by our search strategy were imported into the data organization
software, RefWorks. [7]
2.3 Stage 3: Study selection
All authors were involved in the review process. Criteria for inclusion were
iteratively revised three times, such that three reviews of relevant literature were
completed (see Figure 1). The first two reviews were conducted to broadly
identify literature pertaining to reflexivity and education, and the third review was
conducted to specifically identify literature pertaining to educational strategies to
enhance reflexivity training in health professional training. In the first review, two
team members independently read the title and abstract for each text to
determine inclusion. The inclusion criterion was that texts addressed reflexivity in
relation to health care providers or students whereby "reflexivity" included any of
the following:
1. the ability to critically reflect on one's own social locations or belief systems in
relation to larger social norms and/or,
2. recognition of how one's social locations, privileges, advantages,
disadvantages or positions of dominance may shape the way one sees and
understands the world and/or,
3. the concept of critical reflection. [8]
After the first review, we narrowed our definition of reflexivity to remove the third
criterion and, therefore, to exclude texts that only addressed critical reflection on
clinical issues without attention to one's social locations. In the second review,
two reviewers independently assessed each of the previously identified texts
using these revised inclusion criteria. When the conceptualization of reflexivity
remained ambiguous in the abstract, full texts were reviewed. A third two-person
review was then conducted to identify texts that presented an educational
strategy for enhancing reflexivity. Members of the study team met between each
review to ensure that inclusion criteria were interpreted and applied consistently.
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
When reviewers did not agree on inclusion or exclusion of a text, the text was
reviewed and consensus was reached by three members of the research team. [9]
2.4 Stage 4: Charting the data
Relevant data from each of the included references were extracted by members
of the research team and recorded in a Microsoft Excel spreadsheet. Data
captured included population studied, country of study, year of publication, study
objectives, article type, methodology, educational strategies used, methods of
evaluating reflexivity-enhancing strategy, outcomes measured, authors' findings,
and authors' conclusion. [10]
2.5 Stage 5: Collating, summarizing and reporting the results
Using a modified conventional content analysis approach (HSIEH & SHANNON,
2005), we grouped the identified educational strategies into categories to address
the research question. We then descriptively synthesized the subset of texts that
empirically evaluated strategies for enhancing reflexivity. [11]
3. Results
Our initial search of the literature identified 2,543 texts, of which 1,570 met
inclusion criteria. Once the definition of reflexivity was revised, the second review
identified 157 texts that met inclusion criteria. The third review identified 68 texts
that discussed at least one educational strategy for enhancing reflexivity (Figure 1).
Figure 1: The iterative study selection process (modified PRISMA 2009 flow diagram,
(MOHER, LIBERATI, TETZLAFF & ALTMAN, 2009, p.267) [12]
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
3.1 Characteristics of included texts
Below we present the scoping study results in three parts. First, we describe the
characteristics of the 68 included texts. Second, we present findings about the
strategies for enhancing reflexivity among clinicians and health profession
students. Finally, we describe characteristics of the subset of 19 texts that
included empirical evaluations of strategies to enhance reflexivity. [13]
Sixty-eight texts presented educational strategies for enhancing reflexivity among
clinicians and/or health professional students (Table 1).
Author Educational Strategies
ABEDINI, GRUPPEN,
KOLARS & KUMAGAI
One-week international service learning trip for American
medical students in Cuba, Dominican Republic, Guatemala,
Jamaica or Peru
ADAMSHICK & AUGUST-
BRADY
International cultural immersion experience for American
nursing students in Honduras
ANDREWS et al. Narrative pedagogy in nursing education
ARND-CADDIGAN,
AVERETT & POZZUTO
Reflective judgment and ill-structured problem activities with
social work students
ASH et al. A self-directed learning resource for practicing nurses on
cultural safety, nursing care for Indigenous People with
cancer, with video vignettes and reflective exercises
BALLON & SKINNER Educational reflection techniques in addiction psychiatry
training, including reflection discussions and reflective
journaling
BANKS, CLIFTON,
PURDY & CRAWSHAW
Critical reflection on clinical supervision as "a confessional
act"
BARRETT A curriculum to promote culturally integrated behaviors
among allied health students
BENDER Integrating cultural competency into physiotherapy (PT)
training curricula
BHOGAL & BRUNGER Strategies for cross-cultural communication and critical
reflection in the context of prenatal genetic counseling for
family physicians
BINDING, MORCK &
MOULES
Reflective writing to "see the other" in student nurses
BOLTON Reflective expressive writing for healthcare providers
BOROVOY & HINE A critical approach to cultural competence for American
health care professionals regarding diabetes care for elderly
Russian Jewish emigres
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
Author Educational Strategies
BRANCH & ANDERSON Storytelling as a means of reflective thinking and writing
among student nurses
BROWNE et al. Cultural safety in a social justice curriculum for nursing
practice
BRUNGER & DUKE 1st year medical curriculum to integrate critical self-
reflections, including "reflexive" activities, written and video
case studies and journals
DASGUPTA & CHARON Reflective writing of personal illness narratives for medical
students
DELANY & WATKIN Six-week, 3 hour/week critical reflection program for PT
students to reflect on critical incidents during first clinical
placements
EPSTEIN Mindfulness and mindful practice in medicine
FOSTER Cultural humility through a north-south collaboration
between nurses in the United States and Dominican
Republic
GLAZE Pre-entry and advanced reflective practice learning modules
in nursing
GLEN Education for dialogue and dialogic relationships
GREENWOOD, WRIGHT
& NIELSEN
Cultural safety and reflexivity education related to child and
family health nursing
GROBLER, VAN
SCHALKWYK &
WAGNER
Curriculum to develop reflective practitioners in a South
African orthotics/prosthetics training program
GUPTA Interdisciplinary service learning course to enhance civic
engagement
HALABI, MAJALI,
CARLSSON & BERGBOM
An international nursing exchange in Sweden and Jordan
guided by FREIRE's theory of dialogical action
HAYWARD &
CHARRETTE
A 2-semester capstone course to integrate culturally
competent care, including an international service-learning
(ISL) experience for American physical therapy students in
Ecuador, cultural awareness activities and reflective
journaling
HEATH Models of guided reflection in nursing
HOPPES, HAMILTON &
ROBINSON
Autoethnography in occupational therapy student training
HUMPHREY A 3-stage model of critical reflection used with social work
students
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
Author Educational Strategies
IEDEMA Critical reflection on video of real-time everyday clinical
practice and patients' stories
ISSITT A model of critical reflective practice for health promotion
JENSEN & PASCHAL Strategies to develop habits of mind, critical self-reflection
and virtuous practice among PT students
JOHNSTON A human behavior social work diversity course to teach
students to "think outside the box," including book analyses,
creative expression and a comfort zone experience
KARBAN & SMITH Embedded critical reflection in an integrated strategy for
interprofessional learning
KAYLOR A course for allied health students on values, using
reflexiveness as the course's structural principle
KIM A 3-phase critical reflective inquiry model for student and
practicing nurses
KOSKINEN et al. Reflective writing using "critical incident technique" in a
trans-Atlantic exchange program for Canadian and
European rural community nursing students
KOWAL & PARADIES A workshop to facilitate critical reflection among public
health practitioners on how race and culture construct
Indigenous ill-health
LAM et al. Reflective logs of autobiographical stories by social work
students during fieldwork placement
LARSON & ALLEN Conscientization for Canadian social work students during
an intense experiential course in Mexico, involving a
reflective final paper
LATTANZI & PECHAK Curricular strategies to prepare American PT students for
diverse, global practice in Niger, Tanzania and Ecuador,
including ISL and video conferencing
LAWLER Reflective essays about community-based service learning
projects for adult nursing students
LIE, SHAPIRO, COHN &
NAJM
Written reflection and reflective discussions in family
medicine clerkships
MACDONALD,
CARNEVALE & RAZACK
Cultural training workshop for pediatric residents, with
activities to make familiar strange and vice versa
MALTBY & ABRAMS Reflective journals during international immersion
experiences for American student nurses in Bangladesh
McALLISTER Critical education through reflective practice and dialectical
critique in nursing
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
Author Educational Strategies
MILLER Journal writing reflecting on gerontology rotation for nurses
MKANDAWIRE-VALHMU
& DOERING
A community health study abroad program in Malawi for
American nursing students using a postcolonial feminism
framework, and involving experiential learning and reflective
journaling
MURRAY-GARCIA,
HARRELL, GARCIA, GIZZI &
SIMMS-MACKEY
Using racial identity theory to inform self-reflection in
multicultural education, using the example of medical
students in the United States
NAIRN, CHAMBERS,
THOMPSON, McGARRY
& CHAMBERS
Applies MEZIROW's principles of reflexivity within the
broader perspective of BOURDIEU's habitus to inform
critical reflection in nursing education
NEWCOMB, CAGLE &
WALKER
Guided discussions and written reflections on readings from
two fictional texts, "The House on Mango Street" by
CISNEROS (1988) and "The Bluest Eye" by MORRISON
(1970), among nursing students in the United States
NIXON et al. A liberation pedagogical model to facilitate education about
diversity among family therapy students in the United States
OTERHOLM An online course for social work students in Norway
reflecting on field placement critical incidents through online
chat, a virtual forum, and reflection papers
PARKER & MYRICK Clinical scenarios using human patient simulation to
promote transformative learning events in undergraduate
nursing education in Canada
PHILLIPS, FAWNS &
HAYES
Using positioning theory and "professional conversations" to
support transformative learning within midwifery curricula
SANTALUCIA &
JOHNSON
Transformational learning activities for occupational therapy
(OT) students, including journaling, reflective discussions,
storytelling, an "aha moment" exercise
SCHUESSLER, WILDER
& BIRD
Reflective journaling about community clinical experiences
SHAW & ARMIN Critical approaches to cultural competence training for
health care providers
SMITH A model of forms, domains and indicators of critical
reflection for healthcare higher education
SPERSTAD Guided critical reflection based on a nursing cultural
immersion experience for American students with a
Mexican-American community
TILBURT Worldview consciousness training for health disparities
education
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
Author Educational Strategies
WALTON Education session for nursing students about Native
American patients receiving dialysis using a sacred circle
model
WEAR, ZARCONI,
GARDEN & JONES
Reflection and reflective writing within medical curricula
within a "pedagogy of discomfort"
WELLARD & BETHUNE Reflective journal writing in nursing education
WEPA Reflective diaries on action research among cultural safety
educations in New Zealand
WHITEFORD Narratives to reflect on experience of working with patients
of different cultures during occupational therapy training
WILLIAMS Cultural safety guidelines and reflective questions for public
health practitioners working with Indigenous People
Table 1: Educational strategies reported for enhancing reflexivity (n=68 texts) [14]
Of the 68 texts, 65 were peer-reviewed articles (96%), 2 were dissertations (3%)
and 1 was a grey literature report (1%). The 65 peer-reviewed articles were
published in 47 different journals. Overall, authors of the 68 texts discussed
strategies for enhancing reflexivity in a variety of health professions (Figure 2).
The disciplines most commonly targeted by educational strategies to enhance
reflexivity were nursing (38%), followed by medicine (16%), social work (9%) and
PT (7%). Authors of 10 texts described strategies that targeted multiple health
disciplines.
Figure 2: Types of health disciplines targeted by educational strategy (students, clinicians
and/or faculty) (n=68 texts) [15]
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
Although we did not limit our search strategy by date, all but one of the 68 texts
were published after 1996, with the majority published after 2008 (Figure 3).
Figure 3: Number of texts published by year [16]
The first authors of included texts were from 10 different countries, and most
commonly from the United States (50%), United Kingdom (15%), Australia (13%)
and Canada (12%). All first authors were from high-income countries with the
exception of two articles first authored by scholars in Jordan and South Africa,
which are considered upper-middle income countries (WORLD BANK, 2015). [17]
3.2 Strategies for enhancing reflexivity among clinician and health
profession students
Of the educational strategies to enhance reflexivity in the 68 included texts, no
strategy was described more than once (see Table 1). However, there were
common characteristics identified among subsets of the educational strategies. In
Tables 2a-f we present results related to six common characteristics that may be
relevant to health professions educators: reflective writing, experiential learning,
classroom-based activities, continuing education strategies, online strategies, and
strategies that invoked the theories of Paulo FREIRE and/or Jack MEZIROW. [18]
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
Reflective writing was a component in the educational strategies of 25 texts.
Type of Reflective Writing Strategy References
Journal/diary BALLON & SKINNER, 2008; BRUNGER &
DUKE, 2012; HALABI et al., 2011;
HAYWARD & CHARRETTE, 2012;
MALTBY & ABRAMS, 2009; MILLER,
2011; MKANDAWIRE-DOERING &
DOERING, 2012; SANTALUCIA &
JOHNSON, 2010; SCHUESSLER et al.,
2012; WELLARD & BETHUNE, 1996;
WEPA, 2003
Autoethnography HOPPES et al., 2007
Autobiographical stories LAM et al., 2007
Personal illness narrative DASGUPTA & CHARON, 2004
Personal storytelling BRANCH & ANDERSON, 1999
Critical Incidents KOSKINEN et al., 2009; OTERHOLM,
2009
Reflecting on fiction/nonfiction NEWCOMB et al., 2006, JOHNSTON,
2009
Reflective essays BINDING et al., 2010; HOPPES et al.,
2007; LAWLER, 2008, LARSON & ALLEN,
2006; LIE et al., 2010
Other reflective writing BOLTON, 2008; WEAR et al., 2012
Table 2a: Strategies involving forms of reflective writing [19]
Another common mechanism (n=14) for promoting enhancement of reflexivity
was experiential learning whereby learners developed insights through
participation in health-related activities in a real-world setting.
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
Experiential Learning References
Local community-based experiential
learning
GUPTA, 2006; LAWLER, 2008;
SCHUESSLER et al., 2012; SPERSTAD,
2010
ISL/exchange experience ABEDINI et al., 2012; ADAMSHICK &
AUGUST-BRADY, 2012; FOSTER, 2009;
HALABI et al., 2011; HAYWARD &
CHARRETTE, 2012; KOSKINEN et al.,
2009; LARSON & ALLEN, 2006; LATTANZI
& PECHAK, 2012; MALTBY & ABRAMS,
2009; MKANDAWIRE-VALHMU &
DOERING, 2012
Table 2b: Strategies involving experiential learning [20]
Twelve texts described educational strategies that were conducted in a classroom
setting for health profession students. The specific classroom-based activities
were diverse with no patterns of activities across texts. Furthermore, authors
commonly described more than one activity as part of a multi-faceted approach to
enhancing reflexivity.
Health Professional Students Involved
in Classroom-Based Activities
References
Nursing students BRANCH & ANDERSON, 1999;
NEWCOMB et al., 2006; PARKER &
MYRICK, 2010; WALTON, 2011
Medical students BALLON & SKINNER, 2008; BRUNGER &
DUKE, 2012; MACDONALD et al., 2007
PT students HAYWARD & CHARRETTE, 2012;
JENSEN & PASHAL, 2000
Social work students ARND-CADDIGAN et al., 2010;
JOHNSTON, 2009
OT students SANTALUCIA & JOHNSON, 2010
Table 2c: Strategies involving classroom-based activities [21]
14 texts described strategies to educate practicing health care providers: five
texts for nurses, three for physicians, three for health promotion or public health
practitioners, and texts for health care providers in general. Three of these texts
focused on critical reflection and cultural safety to enhance care with Indigenous
Peoples in particular.
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
Health Professionals Involved in
Continuing Education
References
Nurses ASH et al., 2010; GREENWOOD et al.,
2006; HALABI et al., 2011; HEATH, 1998;
KIM, 1999
Physicians BHOGAL & BRUNGER, 2010; EPSTEIN,
1999; MACDONALD et al., 2007
Health Promotion/Public Health ISSITT, 2003; KOWAL & PARADIES,
2005; WILLIAMS, 1999
General Health Care Professionals BOROVOY & HINE, 2008; IEDEMA, 2011;
SHAW & ARMIN, 2011
Table 2d: Continuing education strategies for practicing health care providers [22]
Six of the texts included online components in their strategies to enhance
reflexivity.
Online Strategies References
Posting reflective questions HAYWARD & CHARRETTE, 2012
Facilitating communication in out-of-country
placements
KOSKINEN et al., 2009; LATTANZI &
PECHAK, 2012
Delivering reflexivity-enhancing curricula OTERHOLM, 2009; SANTALUCIA &
JOHNSON, 2010; SHAW & ARMIN, 2011
Table 2e: Online educational strategies [23]
Of the texts that explicitly based their strategies on educational theory, FREIRE
(n=12) and MEZIROW (n=15) were referenced most often for their work related
to pedagogies of adult learning and education.
Approaches Based on FREIRE and
MEZIROW
References
Authors who evoked FREIRE and/or
MEZIROW's theories as part of literature
review on developing reflexive skills
ABEDINI et al., 2012; BANKS et al., 2013;
ISSITT, 2003; KIM, 1999; McALLISTER,
2005; SMITH, 2011
Authors who referenced MEZIROW's
theory of transformative learning
ADAMSHICK & AUGUST-BRADY, 2012;
GLAZE, 2002; KARBAN & SMITH, 2009;
PARKER & MYRICK, 2010; SANTALUCIA
& JOHNSON, 2010; TILBURT, 2010
Authors who referenced MEZIROW's
model of reflection
BINDING et al., 2010; ISSITT, 2003;
NAIRN et al., 2012; SMITH, 2011; WEAR
et al., 2012
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
Approaches Based on FREIRE and
MEZIROW
References
Authors who referenced FREIRE's
development of critical consciousness
KARBAN & SMITH, 2009
Authors who referenced FREIRE's
pedagogy of adult education
BROWNE et al., 2009; HALABI et al., 2011;
LARSON & ALLEN, 2006
Table 2f: Approaches based in the pedagogy of FREIRE and MEZIROW [24]
3.3 Studies evaluating educational strategies to enhance reflexivity
Of the 68 texts that described educational strategies, 19 presented empirical
evaluations of educational strategies designed to enhance reflexivity among
clinicians and clinical students (Table 3). Below we summarize characteristics of
these studies.
Please click here for Table 3: Characteristics of studies that evaluated educational
strategies designed to enhance reflexivity (n=19) [25]
3.3.1 Study design
Thirteen of the 19 studies exclusively used qualitative approaches to evaluate
reflexivity; the remaining six studies reported using both quantitative and
qualitative study designs. Data in the qualitative studies were generated from
interviews, focus groups and/or written reflective texts. Several quantitative
assessment tools were used in the mixed methods studies: the "Transcultural
Nursing Immersion Experience Questionnaire" (SPERSTAD, 2010), SHRAW's
"Personal Epistemology Scale" (ARND-CADDIGAN et al., 2010), the
"Professionalism in Physical Therapy Core Values Survey" (HAYWARD &
CHARRETTE, 2012) and the "Cross Cultural Adaptability Inventory" (ibid.). [26]
3.3.2 Participant characteristics
Participants were graduate and/or undergraduate clinical students in all 19
studies, with the addition of clinical instructors in one text (ANDREWS et al.,
2001). Students were most commonly in nursing programs (n=9), with four
studies involving social work students, three studies involving medical trainees,
two studies with PT students, and one study with health science students. Study
sample sizes ranged from 7 to 188 participants, with most studies involving less
than 50 participants (number of participants was not stated in two studies). [27]
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
3.3.3 Characteristics of educational strategies being evaluated
Educational strategies varied across studies. While similar educational strategies
were used in several studies (e.g., reflective writing), in no case was an identical
strategy used in multiple studies. In most studies, multiple educational activities
were used in combination. Similarly, there was little consistency in the concepts
or constructs studied across the evaluations as indicators for enhanced reflexivity
(e.g., cultural competence, cultural awareness, meanings attributed to a cultural
learning experience, development of personal epistemology, attitudes, and
conscientization). The length of time of the educational strategies varied greatly,
with the shortest intervention lasting one hour (WALTON, 2011) and the longest
lasting two years (HAYWARD & CHARRETTE, 2012). Most strategies (n=16)
lasted from one week to four months. In all 19 studies, authors reported positive
effects of their interventions on the development of some aspect of reflexivity
among learners (see Table 2a-f). [28]
4. Discussion
To our knowledge, this is the first study to comprehensively and systematically
scope the peer-reviewed and grey literature regarding educational strategies
used for enhancing reflexivity among clinicians and students in clinical health
professional training programs. Given the widely-accepted role of political, social,
historical and economic determinants in shaping health (CSDH, 2008), reflexivity
about one's positions of privilege and oppression becomes a vital tool for
improving patient care (KINSELLA & WHITEFORD, 2009; LAM et al., 2007;
SCHIFF & RIETH, 2012; SMITH, 2011). By presenting a snapshot of the
literature on strategies for enhancing reflexivity, this scoping study offers a
foundation for advancing education in this important area by describing what is
known and not known about reflexivity in health professional curricula. In
particular, this study offers educators and education researchers a description of
diverse strategies for enhancing reflexivity among health professionals. This
article presents a comprehensive depiction of strategies, as presented in the
literature at this point in time, upon which educators can build and mature the
field. [29]
4.1 About strategies to enhance reflexivity
A striking finding was the lack of consistency across educational strategies for
enhancing reflexivity. Not a single strategy was employed in a consistent way
across more than one of the 38 texts. Even texts that engaged common
approaches (e.g., immersive experiences, reflective writing) used these
approaches differently. This finding affirms that the field is under development,
with a diverse array of strategies for nurturing reflexivity amongst students and
clinicians that can be tailored to the fit the learners and learning context.
However, this lack of consistency also makes it difficult to compare across
interventions, signaling a direction for future research. Creativity and
thoughtfulness appear to be at the core of many approaches, which offers a
welcoming environment to educators new to this field. Unfortunately, this scoping
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
study also found that there is little evidence to guide educators in nurturing
reflexivity among students or clinicians; less than one-third of the included studies
involved empirical inquiries related to the educational strategies. Future research
is crucial for exploring processes related to the development of reflexivity,
particularly from research approaches deriving from interpretivism that enable
understanding of meaning-making, and critical theory that take into account the
broader sociopolitical forces that influence the educational process. [30]
We also note the wide range of disciplines reflected in the included texts,
demonstrating the relevance of reflexivity across the health professions and the
opportunity for interprofessional education related to reflexivity (KUPER &
WHITEHEAD, 2012). This insight is particularly relevant given the relationship
between reflexivity and the non-expert competencies that underpin licensure
requirements for many health professions (KUPER & D'EON, 2011), such as
CanMEDS, which is a national educational framework that describes desired
medical and non-medical competencies for students attending Canadian medical
schools (CanMEDS, 2014) or the parallel framework for physical therapists
(NATIONAL PHYSIOTHERAPY ADVISORY GROUP, 2009). While the included
texts involved multiple disciplines, we note that 38% targeted a nursing audience.
This finding suggests that the development of reflexivity may have more traction
in nursing and that other disciplines may learn from the work in this field. Finally,
it is noteworthy that the first author of every text was from either a high-income or
upper-high income country, which may reflect a limitation of the study in that we
only included English texts. This finding could also reflect that teaching about
reflexivity may occur more often in countries with greater economic privilege,
supported by the finding that many experiential learning strategies occurred in
resource-poor contexts. However, structures of privilege and oppression exist in
all education and health environments and, thus, strategies to develop awareness
of one's relation to these structures are important in all settings. [31]
Another key finding in this scoping study was the lack of conceptual clarity within
the literature regarding the term "reflexivity." The range of meanings presented
challenges for our search strategy, which required an iterative fine-tuning of our
inclusion and exclusion criteria. Additionally, reflexivity and reflection are often
conflated, which is exacerbated by the fact that certain reflection activities may be
used to enhance reflexivity. Furthermore, lack of consensus on a single
conceptualization of reflexivity means there is not a coherent body of literature on
reflexivity to guide health professions educators. This is a complex topic made
even more difficult for newcomers to grasp because of the diversity of ways that
reflexivity can be understood. This lack of conceptual consistency also presents
challenges for discussions within and across disciplines. We focused on the
version of reflexivity that involves personal introspection related to one's own
social locations, and the implications for equity and justice. This is not a
requirement of other versions of reflexivity in the literature, which refers instead to
critical reflection on certain aspects of practice (e.g., one's clinical reasoning) but
not on oneself. Our framing and its concern with privilege and oppression may
account for the one-third of included texts that explicitly invoked the justice-
oriented theories of MEZIROW or FREIRE (DASGUPTA et al., 2006). Overall,
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FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
there is great capacity-building potential among educators about these various
understandings and how they are relevant to the clinical process. The majority of
texts included in this scoping study were published in the last 10 years. A
direction for future research is the archeology of the concept of "reflexivity" and
the multiple ways it has been understood in different health disciplines and in
relation to non-health fields including qualitative research methodology (see
MRUCK & BREUER, 2003). Looking forward, deepened consensus on the
elements that constitute reflexivity within the clinical care context may help bridge
and advance efforts across health professions. [32]
4.2 Limitations
We did not seek to critically analyze the evidence on strategies for enhancing
reflexivity nor to synthesize their results; this work was beyond the scope of this
study but is an area for future research. Likewise, future research could unpack
the ways in which various strategies for enhancing reflexivity relate to different
components of reflexivity, such as which educational strategies best address
attention to institutional power structures or ontological differences. A key
limitation is that the literature search was conducted to the end of 2012. The
trend in increasing publications on this topic in recent years suggests that
additional research may have been published since 2013, which should be
included in a future review. Another limitation is our definition of "reflexivity,"
given its multiple meanings and, further, that the understanding of reflexivity for
this paper is also known by other terms. As such, it was difficult to ensure
sufficient breadth of search terms to capture all relevant texts. For example,
"transformative education" shares conceptual terrain with our definition of
reflexivity yet fell outside the scope we set for our search. This is a limitation of
this study, but also a challenge for the field in general given such diversity in
language and conceptualizations related to reflexivity. ARKSEY and O'MALLEY
(2005; see also LEVAC et al., 2010) suggest a consultation phase as an optional
sixth step in their scoping methodology. A future consultation with key informants
regarding reflexivity and curriculum development could provide insight on this
point and contribute to building a common language for enhancing reflexivity
amongst health professionals. [33]
5. Conclusion
The results of this scoping study are hopeful given that we found far-ranging
evidence of educators inviting learners to question the status quo. This study
identified 68 examples of strategies to help learners recognize their own
experiences of privilege and oppression, so that they are better able to act on
those understandings to change dominant systems. While evidence of the impact
of these educational strategies is limited, this scoping study offers educators a
menu of options for building capacity in reflexivity in various contexts (e.g., online,
classroom-based), using diverse approaches (e.g., reflective writing, experiential
learning) to a variety of audiences (e.g., students and clinicians across health
disciplines). Further education scholarship is required to advance this concept not
only within clinical training but also as a means for dismantling the institutional
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A Scoping Study
structures that create and reinforce health inequities. Reflexivity can be a new
and daunting topic for health professions educators, but is crucial for developing
clinicians who can deliver effective, socially-just and equitable care. [34]
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Authors
Rachel LANDY, MA, is a PhD candidate in the
Faculty of Medicine, Memorial University of
Newfoundland. Her research focuses on the
development of decolonizing, arts-based HIV and
sexual health education for Indigenous youth in
Canada.
Contact:
Rachel Landy
Division of Community Health and Humanities
Faculty of Medicine, Memorial University of
Newfoundland
Health Sciences Centre, 300 Prince Philip
Drive
St. John's, NL Canada, A1B 3V6
E-mail: rlandy@mun.ca
Cathy CAMERON, MHSc, is the coordinator,
International Centre for Disability and
Rehabilitation in Canada. She conducts research
and evaluation projects related to HIV,
rehabilitation and disability.
Contact:
Cathy Cameron
International Centre for Disability and
Rehabilitation
160-500 University Avenue
Toronto, ON, Canada, M5G 1V7
Tel: +1-647-460-3871
E-mail: cathy.cameron@rogers.com
FQS http://www.qualitative-research.net/

FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
Anson AU, MSc in social research methodology, is
a researcher in the Department of Social Policy,
London School of Economics, UK. His research
focuses on social determinants of health,
sociological methodology, and politics.
Contact:
Anson Au
Department of Methodology
Columbia House
London School of Economics
Houghton Street, London WC2A 2AE, UK
Tel: +44-78-214-32016
E-mail: a.c.au@lse.ac.uk
Debra CAMERON, PhD, is an assistant professor
in the Department of Occupational Science and
Occupational Therapy and Rehabilitation Sciences
Institute, University of Toronto She is education
lead for the International Centre for Disability and
Rehabilitation and her research focuses on
cognitive intervention approaches, global health
and educational scholarship.
Contact:
Debra Cameron
Department of Occupational Science and
Occupational Therapy
University of Toronto
160-500 University Avenue
Toronto, ON, Canada, M5G 1V7
Tel: +1-416-946-8568
E-mail: Deb.Cameron@utoronto.ca
Kelly K. O'BRIEN, PhD is an assistant professor in
the Department of Physical Therapy,
Rehabilitation Sciences Institute (RSI), and
Institute of Health Policy, Management and
Evaluation (IHPME) at the University of Toronto in
Canada. Kelly holds a New Investigator Award
from the Canadian Institutes of Health Research
(CIHR). Her area of research is focused on HIV,
disability and rehabilitation. Kelly is also a
founding member of the Canada-UK-Ireland HIV
and Rehabilitation Research Collaborative
(CUIHRRC) which is a collaborative of
researchers, clinicians and community members
interested in HIV and rehabilitation research.
Contact:
Kelly K. O'Brien
Department of Physical Therapy
University of Toronto
160-500 University Avenue
Toronto, ON, Canada, M5G 1V7
Tel: +1-416-978-0565
E-mail: kelly.obrien@utoronto.ca
Katherine ROBRIGADO, MPH, is a monitoring and
evaluation specialist with the Department of
Education, Culture and Employment at the
Government of the Northwest Territories, Canada.
Her work focuses on the systematic development
and implementation of a common monitoring,
evaluation, and accountability framework for
departmental programs.
Contact:
Katherine Robrigado
Government of Northwest Territories
PO Box 1320
Yellowknife, NT, Canada, X1A 2L7
Tel: +1-867-767-9349 ext. 71093
E-mail: Kathy.Robrigado@alum.utoronto.ca
Larry BAXTER is a person living with HIV whose
research interests include HIV and aging; HIV
rehabilitation and food security. He is retired from
the non-profit sector and living in Halifax, Nova
Scotia.
Contact:
Larry Baxter
3544 Acadia Street
Halifax NS, Canada, B3K 3P2
E-mail: Larrynbaxter@gmail.com
FQS http://www.qualitative-research.net/

FQS 17(3), Art. 14, Rachel Landy, Cathy Cameron, Anson Au, Debra Cameron, Kelly K. O'Brien,
Katherine Robrigado, Larry Baxter, Lynn Cockburn, Shawna O'Hearn, Brent Oliver & Stephanie A. Nixon:
Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students:
A Scoping Study
Lynn COCKBURN, PhD, is an assistant professor
in the Department of Occupational Science and
Occupational Therapy at the University of Toronto
in Canada. Lynn's practice and research
addresses professional education, community
development and disability inclusive development,
and social and occupational justice with a focus on
Canada and Cameroon.
Contact:
Lynn Cockburn
Department of Occupational Science &
Occupational Therapy
University of Toronto
160-500 University Avenue
Toronto, ON, Canada, M5G 1V7
Tel: +1-416-978-8541
E-mail: l.cockburn@utoronto.ca
Shawna O'Hearn is the director for Global Health
at Dalhousie University. Her research focuses on
community engagement, health equity and
incorporating social accountability principles into
education, health and post-secondary institutions.
Contact:
Shawna O'Hearn
Dalhousie University
5849 University Avenue
Clinical Research Centre, C-241
PO Box 15000
Halifax, NS, Canada, B3H 4R2
Tel: +1-902-494-1965
E-mail: Shawna.ohearn@dal.ca
Brent OLIVER, PhD, is an assistant professor in
the Department of Child Studies and Social Work
at Mount Royal University, Canada. Brent's
research focuses on HIV, sexual and gender
diversity, and the scholarship of teaching and
learning.
Contact:
Brent Oliver
Mount Royal University
4825 Mount Royal Gate SW
Calgary, Alberta, Canada
Tel: +1-403-440-6443
E-mail: boliver@mtroyal.ca
Stephanie NIXON, PhD, is an associate professor
in the Department of Physical Therapy,
Rehabilitation Sciences Institute and Dalla Lana
School of Public Health at the University of
Toronto in Canada. She is also the director of the
International Centre for Disability and
Rehabilitation. Stephanie's research focuses on
HIV, rehabilitation disability and equity.
Contact:
Stephanie Nixon
Department of Physical Therapy
University of Toronto
160-500 University Avenue
Toronto, ON, Canada, M5G 1V7
Tel: +1-416-946-3232
E-mail: stephanie.nixon@utoronto.ca
Citation
Landy, Rachel; Cameron, Cathy; Au, Anson; Cameron, Debra; O'Brien, Kelly K.; Robrigado,
Katherine; Baxter, Larry; Cockburn, Lynn; O'Hearn, Shawna; Oliver, Brent & Nixon, Stephanie A.
(2016). Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional
Students: A Scoping Study [34 paragraphs]. Forum Qualitative Sozialforschung / Forum: Qualitative
Social Research, 17(3), Art. 14,
http://nbn-resolving.de/urn:nbn:de:0114-fqs1603140.
FQS http://www.qualitative-research.net/