A Correlational Study on Reflective Capacity and Ethical Engagement in Adult Learners of Health Professions

Abstract

Because professional ethical engagement is essential to the delivery of high-quality healthcare services, health professions education programs must have effective instructional practices to train future healthcare providers of various disciplines to practice ethically. As research has found reflection to be an effective instructional practice for educating adult learners and teaching professional ethics, promoting health professions students’ tendency to reflect by boosting their reflective capacity may be helpful. Therefore, the study sought to examine the relationships between reflective capacity and professional ethical engagement to offer quantitative evidence for the significance of reflection in professional ethical engagement among health professions students. Correlational analyses revealed a strong, positive relationship between reflective capacity and professional ethical engagement in health professions students. Reflective capacity, specifically reflection-on-action and self-appraisal, could predict professional ethical engagement in health professions students. These findings provided insights into the reflective capacity and professional ethical engagement in health professions students. However, further research on the relationship between reflective capacity and professional ethical engagement in adult learners of health professions is needed.

Keywords

Reflection reflective capacity ethics adult learners health professions education

“Regardless of healthcare discipline, professional ethics in health care serve as a foundation in providing high-quality health care to all patients.”

Importance of Ethics in Health Care

Ethics is a series of principles that guides one’s behavior in terms of right and wrong (Or et al., 2021; Plante & McCreadie, 2019). As such, professional ethics in health care, also known as healthcare ethics, refer to a set of principles that steers healthcare professionals in making decisions pertaining to healthcare practices. Despite the variety of ethical theories and standards for different healthcare disciplines, healthcare ethics generally entail four principles, including autonomy, beneficence, nonmaleficence, and justice (Beauchamp, 2007). For instance, the Nursing Code of Ethics describes nurses’ ethical duty to treat patients with respect, commit to patients’ welfare, and promote justice at both individual and collective levels (American Nurses Association [ANA], 2015). The American Association for Respiratory Care’s (2015) Statement of Ethics and Professional Conduct outlines the importance of respecting patients’ choices, using scientific practices to treat patients, providing care without discrimination, and practicing only within the scope of competence. The American Occupational Therapy Association’s [AOTA] (2020) Code of Ethics is another example in which Beauchamp’s (2007) four ethical principles are reflected in its standards, including “altruism, equality, freedom, justice, dignity, truth, and prudence” (p. 2).

Regardless of healthcare discipline, professional ethics in health care serve as a foundation in providing high-quality health care to all patients (Mashayekhi et al., 2021). An absence of professional ethics may lead healthcare professionals to discount ethical issues in day-to-day clinical care and make unjust clinical decisions that harm patients (Chen et al., 2021). Furthermore, a deficiency in vigilance of professional ethics in healthcare professionals weakens patients’ trust and confidence in their clinical care, which may be detrimental to patient health outcomes (Mashayekhi et al., 2021). To facilitate whole-person care, it is imperative for all healthcare professionals to engage in ethical issues related to healthcare practices (Hindmarch et al., 2015). For example, healthcare professionals must respectfully respond to the unique needs of patients from different cultural backgrounds (Carrese et al., 2015). They must also respect the autonomous choices of patients, even when they do not agree with these choices. There is also a need to safeguard patients’ confidentiality and privacy while balancing consideration for concerned loved ones of patients during difficult times.

Teaching Professional Ethics in Health Professions Education

Because professional ethics are an essential component to healthcare delivery, professional ethical engagement is crucial during health professions education. Health professions education is the stage when learners are confronted with different ethical problems in health care for the first time (Andersson et al., 2022). Having greater ethical engagement helps health professions students navigate ethical challenges and lowers distress associated with these challenges. In addition, technical proficiency along with ethical conduct influences the quality of patient care (Dehghani, 2019). The abundant interpersonal interactions with peers and teachers during health professions education bring opportunities for role modeling, mentorship, and collaboration, which foster professional ethics development in students (Dehghani, 2019). Hence, it is necessary for health professions education to support the development of professional ethical engagement in health professions students, as it empowers students to become more interested in how ethical issues or dilemmas influence patient care and more committed to caring for patients (Andersson et al., 2022).

Despite the significance of professional ethics education, the methodology of teaching ethics remains widely varied (Hindmarch et al., 2015). Often, ethics is not taught as a separate course for health professions students. It is integrated into several didactic courses throughout the health professions education curriculum. Professional healthcare ethics is also usually taught in a lecture format (Subedi et al., 2022). Health professions students have reported finding unsystematic ethics curricula challenging (Monteverde, 2014). Some have reported having little confidence to perform high-quality, ethical patient care (Dehghani, 2019). They have also reported experiencing distress as a result (Monteverde, 2014). An absence of professional ethical engagement may lead to unintentional, unethical practices in health professions students (Mashayekhi et al., 2021). Hence, there is a need to improve ethics teaching in the healthcare curriculum to enhance students’ ethical engagement (Mashayekhi et al., 2021).

Teaching Healthcare Ethics Through Reflection in Adult Education

It has been suggested that a way to effectively teach health professions students ethics in health professions education is through reflection (Branch & George, 2017; Priddis & Rogers, 2018; Schön, 1987). Reflection is the “active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends” (Dewey, 1933, p. 9). Additionally, there is a relationship between reflection and action (Dewey, 1933). As such, reflection is an intentional process of examining existing beliefs and using such examination to inform decisions on course of actions.

Students in health professions education programs are typically considered adult learners because they are at least 18 years of age, considered matured within their cultural context, and developing a competency with emphasis in becoming actively participating members of a community through practical experiences (Owusu-Agyeman, 2019). Reflection is valuable to the learning of adult learners (Glowacki-Dudka & Barnett, 2007; Jordi, 2011; Mezirow, 1990; Rutherford-Hemming, 2012). This is especially the case for adult learners of health professions because reflection enables them to have greater awareness of the interactions between them and patients in the healthcare setting (Brookfield, 1998, 2018).

Adult learners tend to be motivated to learn (Alejandro, 2001). They are driven by a variety of extrinsic and intrinsic factors such as financial benefits, promotion opportunity, a love of learning, and a desire to improve themselves to benefit the lives of others. With a high level of motivation, health professions students as adult learners are more likely to be involved with the learning materials and clinical training actively to make meaning of their experiences (Glowacki-Dudka & Barnett, 2007). This makes health professions students well positioned for reflection. When they practice reflection, they revisit past experiences and attend to these experiences at not only an intellectual level but also an emotional level (Rutherford-Hemming, 2012). They then use the prompted emotions to reassess the experiences and make decisions about future actions. Through reflection with focus on healthcare ethics, adult learners of health professions develop professional ethical engagement from their experiences by evaluating their beliefs and reshaping their actions (Branch & George, 2017; Schön, 1987).

Studies have been conducted to explore the role of reflection in professional ethics development in adult learners of health professions. For instance, Stark et al. (2006) found that guided reflection facilitated the growth of professional ethics in medical students through qualitative analysis. Upon reflection, medical students reported improved awareness about patients’ dignity, limits of competence, and health inequity related to race, as well as increased desire to deepen knowledge about medical ethics. Moreover, Kyle (2008) investigated the effectiveness of anonymized reflection on teaching ethics related to caring for dying patients in health professions students. Qualitative findings revealed an increase in all participating health professions students’ knowledge of professional ethics following the reflection on the ethics training module (Kyle, 2008). Approximately 41% of the students reported the same at a follow-up inquiry 5–6 weeks after the study, suggesting that reflection may help to sustain the development of professional ethics.

Recent studies conducted with working adults in health services yielded similar results. Nurses who participated in group reflection obtained higher scores in knowledge, attitude, and practice related to nursing ethical codes, compared with before they participated in group reflection (Momennasab et al., 2021). These results indicate that reflection may aid not only the intellectual engagement in professional ethical issues but also practical engagement in professional ethical issues. Qualitative results from another study showed that healthcare professionals found reflection to be helpful to enhancing awareness about ethical issues, respect for perspectives of patients and colleagues, as well as personal growth (Söderhamn; 2015). These research findings illustrate the significance of reflection in professional ethics development in health professions students (Kyle, 2008; Momennasab et al., 2021; Söderhamn, 2015; Stark et al., 2006). They suggest that consistent reflection may be beneficial to professional ethical engagement in health professions students.

Reflective Capacity

Reflective capacity may facilitate consistent reflection in adult learners of health professions. Reflective capacity is “the ability, desire, and tendency of students to engage in reflective thought during their academic studies and clinical practices” (Rogers et al., 2019, p. 1). It is conceptualized by four components, including reflection-in-action (i.e., reflect during the experience), reflection-on-action (i.e., reflect after the experience), reflective with others (i.e., reflect together with other people), and self-appraisal (i.e., evaluate one’s own capabilities; Priddis & Rogers, 2018). Adult learners of health professions who possess higher degrees of reflective capacity are more likely to engage in reflection consistently regarding their clinical training and the influence of their work on their patients. Reflective capacity is a skill that can be nurtured and grown (Priddis & Rogers, 2018). Hence, it may be helpful to tend to adult learners’ reflective capacity in health professions education (Rogers et al., 2019).

Purpose of the Study

Given the importance of professional ethics in health care and teaching ethics in healthcare education, there is a need for effective instructional practices to support health professions students to develop ethical knowledge and engagement (Monteverde, 2014). Since reflection is an effective practice to educate adult learners and develop professional ethical engagement in health professions students, it may be helpful to support these students to reflect consistently by promoting reflective capacity. Despite some qualitative research on the topic, the research on reflection and reflective capacity in health professions students is limited (Priddis & Rogers, 2018). Therefore, the purpose of this study is to examine the relationships between reflective capacity and professional ethical engagement in adult learners of health professions to provide quantitative evidence about the significance of reflection and reflective capacity in healthcare ethics development. Based on this purpose, the following two research questions emerged.

Research Question 1

Is there a statistically significant relationship between reflective capacity and professional ethical engagement in adult learners of health professions?

Research Question 2

Do components of reflective capacity (reflection-in-action, reflection-on-action, reflective with others, and self-appraisal) predict professional ethical engagement in adult learners of health professions?

Research Methods

Sampling and Recruitment

We used G*Power Version 3.1.9.7 to compute an a priori analysis to determine the minimum sample size needed (Faul et al., 2009; Kang, 2021). For Research Question 1, results showed that the required sample size to attain 80% power for detecting a medium effect at a significance level of α = .05 with two tails was N = 84 for Pearson correlation. As for Research Question 2, results showed that the required sample size to attain 80% power for detecting a medium effect at a significance level of α = .05 with two tails was N = 85 for linear multiple regression. Based on these results, our minimum sample size needed to ensure sufficient power was 85 participants.

With IRB approval, we administered an online questionnaire to adult learners at a college focused on health professions education in Midwest United States, including those in nursing, sonography, radiology, respiratory care, occupational therapy, and physician assistant programs. Nursing, sonography, radiology, and respiratory care programs were undergraduate programs, whereas occupational therapy and physician assistant programs were graduate programs. To assess the relationships between reflective capacity and professional ethical engagement in adult learners of health professions, we employed convenience sampling to include only adult learners with clinical training, as they had had professional experience in health care as part of the clinical training of their education. Therefore, they would be able to provide information on their professional ethical engagement related to the practice of health care. Approximately 250 students qualified for the study and received a research invitation email with a link to the online questionnaire, which contained items that measured one’s reflective capacity and ethical engagement.

Instruments

We used the 16-item reflective capacity subscale from the Reflective Practice Questionnaire (RPQ; Priddis & Rogers, 2018) and the 10-item Santa Clara Ethics Scale (SCES; Plante & McCreadie, 2019). The reflective capacity subscale measures reflective capacity with the average score of all its 16 items (Rogers et al., 2019). Each item is rated with a Likert scale of 1–6. The reflective capacity subscale is valid and reliable, supported by a single factor solution from the factor analysis of the subscale, suggesting that the multiple items included in the reflective capacity subscale can be reduced to and accounted for one construct, reflective capacity (Rogers et al., 2019). It also has a Cronbach’s alpha of .84, indicating good reliability (Rogers et al., 2019). The RPQ and its reflective capacity subscale is suited for this study because it is designed to focus on interactions with consumers such as clients or patients in different professional contexts (Priddis & Rogers, 2018; Rogers et al., 2019).

The SCES measures ethical engagement with the sum score of all 10 items (Plante & McCreadie, 2019). The items pertain to one’s interest and engagement in ethical values including integrity, competence, and respect and concerns for others. Each item is rated with a Likert scale of 1–4. The SCES is a valid and reliable measure, with ethical engagement explaining 42% variability in all 10 items of the scale and a Cronbach’s alpha of greater than .83, indicating good reliability (Plante & McCreadie, 2019). It is designed to be brief and generic, which can measure ethical engagement in various settings, including the educational setting (Plante & McCreadie, 2019). To ensure participants were considering their professional ethical engagement, we inserted a statement to instruct participants to consider their ethical engagement related to their clinical training prior to presenting the items that measured ethical engagement.

Data Analysis

To clean the data, we used mean substitution to treat missing data for datasets that had fewer than three missing values. As a result, we included all the datasets collected. Then, we performed statistical analyses using SPSS Version 28. In addition to descriptive statistics, we computed Pearson correlation with bootstrapping to address Research Question 1 and Linear Multiple Regression with bootstrapping to address Research Question 2. Normality checking of the data was not performed due to the use of bootstrapping, which created simulated samples to generate an approximately normal distribution of the dataset (Hesterberg, 2015).

Results

Descriptive Statistics

One hundred and 25 students participated in the study. Among the participants, 10.4% identified as male and 89.6% identified as female. In addition, 72% identified as White or Caucasian, 12% identified as Asian American or Asian, 9.6% identified as Black of African American, 4% identified as Hispanic or Latino, 1.6% identified as biracial or multiracial, .8% identified as Native Hawaiian or Other Pacific Islander. The participants were from various health professions education programs including nursing (39.2%), sonography (20.8%), physician assistant (20%), occupational therapy (9.6%), radiology studies (5.6%), and respiratory care (4.8%). They had been in clinical training of different lengths, including 1–3 weeks (48%), 1–6 months (12.8%), 7–12 months (8%), 13–18 months (23.2%), 19–24 months (3.2%), 25–30 months (3.2%), 31–36 months (.8%), and 37 or more than 37 months (.8%). The information about the participants’ demographics is summarized in Table 1. Finally, descriptive analyses provided information about the participants’ reflective capacity (M = 4.389, SD = .719; with the maximum score of the RPQ reflective capacity subscale being 6) and professional ethical engagement (M = 35.28, SD = 3.607; with the maximum score of the SCES subscale being 40), as presented in Table 2.

Table 1.

Participants’ Demographics.

	Frequency	Percent
Gender
Male	13	10.4
Female	112	89.6
Race/ethnicity
Asian American or Asian	15	12.0
Biracial or multiracial	2	1.6
Black or African American	12	9.6
Hispanic or Latino	5	4.0
Native Hawaiian or other Pacific Islander	1	.8
White	90	72.0
Program
Nursing	49	39.2
Occupational therapy^a	12	9.6
Physician assistant^a	25	20.0
Radiology studies	7	5.6
Respiratory care	6	4.8
Sonography	26	20.8
Months of clinical training
Less than 1 month	60	48.0
1–6 months	16	12.8
7–12 months	10	8.0
13–18 months	29	23.2
19–24 months	4	3.2
25–30 months	4	3.2
31–36 months	1	.8
37 or 37+ months	1	.8

^aIndicates graduate program.

Table 2.

Descriptive Statistics.

	N	Minimum	Maximum	Mean	Std. Deviation	Skewness	Std. Error
Ethical engagement	125	27	40	35.28	3.607	−.306	.217
Reflective capacity	125	3	6	4.389	.719	.119	.217

Inferential Statistics

The 16-item reflective capacity scale from the Reflective Practice Questionnaire (RPQ) and the Santa Clara Ethics Scale (SCES) were employed to measure the constructs of interest. The 16 items from the RPQ to measure reflective capacity had a high level of internal consistency, as shown by a Cronbach’s alpha of .905, so did its four subscales such as reflective-in-action (α = .717), reflection-on-action (α = .865), reflective with others (α = .717), and self-appraisal (α = .826). A Cronbach’s alpha of .843 also demonstrated a high level of internal consistency in the SCES.

T-tests were used to analyze if there were statistically significant mean differences in reflective capacity and professional ethical engagement between the participants from undergraduate programs (nursing, sonography, radiology, respiratory care) and graduate programs (occupational therapy, physician assistant studies). For reflective capacity, the participants from undergraduate programs had a score of 4.398 (SD = .731) while those from graduate programs had a mean of 4.365 (SD = .699), as presented in Table 3. There was not a statistically significant difference in reflective capacity between the participants from undergraduate programs and graduate programs, t (123) = .237, p = .803. For ethical engagement, the participants from undergraduate programs had a mean of 35.91 (SD = 3.516) while those from graduate programs had a mean of 33.78 (SD = 3.417), as presented in Table 3. There was a statistically significant difference in professional ethical engagement between the participants from undergraduate programs and graduate programs, with the participants from undergraduate programs having a higher level of professional ethical engagement than those from graduate program, M Diff = 2.125, 95% CI [.747, 3.478], t (123) = 3.111, p = .005. Statistics related to the t-tests are summarized in Tables 4 and 5.

Table 3.

Group Statistics.

Program			Statistic	Bootstrap^a
				Bias	Std. Error	95% Confidence Interval
				Bias	Std. Error	Lower	Upper
Reflection	Undergraduate	N	88
		Mean	4.398	−.004	.079	4.237	4.548
		Std. deviation	.731	−.006	.040	.650	.808
		Std. error mean	.078
	Graduate	N	37
		Mean	4.365	−.004	.119	4.136	4.602
		Std. deviation	.699	−.019	.075	.530	.825
		Std. error mean	.115
Ethical engagement	Undergraduate	N	88
		Mean	35.91	−.02	.38	35.16	36.64
		Std. deviation	3.516	−.021	.200	3.091	3.865
		Std. error mean	.375
	Graduate	N	37
		Mean	33.78	.00	.57	32.68	34.93
		Std. deviation	3.417	−.066	.316	2.740	3.948
		Std. error mean	.562

^aUnless otherwise noted, bootstrap results are based on 1000 bootstrap samples.

Table 4.

Independent Samples Test.

t-test for Equality of Means
	t	df
Reflective capacity	.237	123
Ethical engagement	3.111	123

Table 5.

Bootstrap for Independent Samples Test.

	Mean Difference	Bootstrap^a
		Bias	Std. Error	Sig. (2-Tailed)	95% Confidence Interval
		Bias	Std. Error	Sig. (2-Tailed)	Lower	Upper
Reflection	.034	.006	.140	.803	−.233	.306
Ethical engagement	2.125	−.039	.697	.005	.747	3.478

^aUnless otherwise noted, bootstrap results are based on 1000 bootstrap samples.

Inferential Statistics for the Research Questions

The results of Pearson correlation are presented in Table 6. We found a statistically significant relationship between reflective capacity and ethical engagement, with a large effect size (r = .509, p < .001; Cohen, 1988). This finding addresses Research Question 1, indicating the presence of a strong, positive correlation between reflective capacity and professional ethical engagement in adult learners of health professions at the Midwestern College.

Table 6.

Correlations.

				Ethical Engagement	Reflective Capacity
Ethical engagement	Pearson correlation			1	.509^a
	Sig. (2-tailed)				<.001
	N			125	125
	Bootstrapb	Bias		0	−.001
		Std. error		0	.067
		95% confidence interval	Lower	1	.370
		95% confidence interval	Upper	1	.639
Reflective capacity	Pearson correlation			.509^a	1
	Sig. (2-tailed)			<.001
	N			125	125
	Bootstrap^b	Bias		−.001	0
		Std. error		.067	0
		95% confidence interval	Lower	.370	1
		95% confidence interval	Upper	.639	1

^aCorrelation is significant at the .01 level (2-tailed).

^bUnless otherwise noted, bootstrap results are based on 1000 bootstrap samples.

The results of multiple linear regression are presented in Tables 7 –9. R² for the overall model was 30.8% with an adjusted R² of 28.5. This indicates that the combination of reflection-in-action, reflection-on-action, reflective with others, and self-appraisal explained 28.5% of the variability of ethical engagement. Furthermore, reflection-in-action, reflection-on-action, reflective with others, and self-appraisal together statistically significantly predicted professional ethical engagement in adult learners of health professions, F (4, 120) = 13.355, p < .001). Nonetheless, only reflection-on-action (p = .004) and self-appraisal (p = .002) added statistically significantly to the prediction. Reflection-in-action (p = .097) and reflective with others (p = .211) did not add statistically significantly to the prediction.

Table 7.

Model Summary.

Model	R	R Square	Adjusted R Square	Std. Error of the Estimate	Durbin-Watson	Bootstrap^a
						Bias	Std. Error	95% Confidence Interval
						Bias	Std. Error	Lower	Upper
1	.555^a	0.308	0.285	3.050	1.867	−0.588	0.165	0.973	1.629

^aPredictors: (constant), self-appraisal, reflection-in-action, reflection-on-action, reflective with others.

^bDependent variable: ethical engagement.

^cUnless otherwise noted, bootstrap results are based on 1000 bootstrap samples.

Table 8.

ANOVAa.

Model		Sum of Squares	df	Mean Square	F	Sig
1	Regression	496.918	4	124.229	13.355	<.001^b
	Residual	1116.282	120	9.302
	Total	1613.200	124

^aDependent variable: ethical engagement.

^bPredictors: (constant), self-appraisal, reflection-in-action, reflection-on-action, reflective with others.

Table 9.

Coefficientsa.

Model	Unstandardized Coefficients		Standardized Coefficients		Bootstrap					Collinearity Statistics
	B	Std. Error	Beta		Bias	Std. Error	Sig. (2-Tailed)	95% Confidence Interval		Tolerance	VIF
	B	Std. Error	Beta	t	Bias	Std. Error	Sig. (2-Tailed)	Lower	Upper	Tolerance	VIF
Reflection-in-action	.596	.387	.135	1.541	.012	.349	.097	−.073	1.286	.748	1.337
Reflection-on-action	1.123	.36	.305	3.121	.019	.347	.004	.43	1.828	.605	1.653
Reflective with others	−.413	.38	−.113	−1.086	.002	.34	.211	−1.085	.311	.531	1.884
Self-appraisal	1.343	.437	.325	3.072	.001	.422	.002	.469	2.2	.514	1.944

^aDependent variable: ethical engagement.

^bUnless otherwise noted, bootstrap results are based on 1000 bootstrap samples.

Conclusion and Discussion

The results showed that reflective capacity was strongly, positively related to professional ethical engagement in adult learners of health professions at the Midwestern College. Those with more ability, desire, and tendency to engage in reflection are more likely to engage in ethical issues in the professional health setting, and vice versa. One’s capacity to reflect could also predict their ethical engagement. Specifically, one’s tendency to reflect after their experience and appraise their strengths and weaknesses plays a stronger role in the tendency to engage ethically. When adult learners of health professions reflect on their interactions with patients after the fact, they may be evaluating their delivery of healthcare services. Quality whole-person care fundamentally requires an interest in and the consideration of ethical issues (Hindmarch et al., 2015). In addition, reflection-on-action and self-appraisal are positively correlated with cognitive empathy (Horst et al., 2019). These factors may explain why adult learners of health professions with more reflective capacity are likely to be more ethically engaged in the clinical setting, as they are more focused on the experience of their patients during their reflection.

It is notable that the findings revealed adult learners from undergraduate health professions education programs to have a higher level of ethical engagement than adult learners from graduate health professions education programs. This may be related to the differences in undergraduate and graduate programs. Graduate programs mostly consist of subject matter courses, whereas undergraduate programs consist of general education courses such as humanities courses in addition to subject matter courses. Humanities courses are thought to develop humanistic and ethical competence in health professions students (Doukas et al., 2012), which may explain the higher level of ethical engagement in adult learners in undergraduate health profession programs. It is also interesting that the findings showed reflection-in-action and reflective with others to not have significant roles in the predictive model of reflective capacity for ethical engagement. These findings suggest that situational factors during an interaction may influence one’s ethical engagement and behavior in the situation (Aquino et al., 2009). Some examples of these factors may be time pressure and the ethical climate of the organization.

Overall, the results of the study align with the findings from the literature related to the use of reflection in adult education and professional ethical development. They also align with the research that supports the use of reflection as an instructional practice in healthcare education to cultivate professional healthcare ethics. Nonetheless, the existing research is primarily qualitative. The findings of this study offer quantitative evidence for the potential benefits of enhancing one’s reflective capacity to facilitate reflection and thus professional ethical engagement in adult learners of health professions.

Implications for Health Professions and Adult Education

The findings of the study suggest that fostering reflective capacity and reflection may be helpful ways to enhance health professions adult learners’ engagement in ethical issues and considerations in healthcare settings. While additional confirmatory research is needed to extend the findings, this preliminary work suggests the value of integrating reflection activities into the health profession curriculum regularly. One technique is to use reflection guides such as the Reflective Practice Guide (RPG; Greenberger, 2020; Greenberger et al., 2022) and Critical Incident Questionnaire (CIQ; Brookfield, 1998). To begin with, the RPG is grounded in the seminal work of John Dewey (1933) and offers step-by-step guidelines on how one may engage in reflection related to practice-based problems. These steps include defining the purpose of the reflection, describing the problem and what is unknown about the problem, discussing working ideas on what may have led to the unknown about the problem, detailing the context and facts of the problem with a narrative, evaluating the working the ideas based on the literature, and deciding which working idea may be the most probably reason for the unknown of the problem.

Next is the CIQ, which also guides adult learners to reflect sequentially (Brookfield, 1998). Users of this reflection guide first identify when they are most engaged and least engaged. Then, they describe helpful or confusing actions others in the same learning environment have performed. Lastly, they pinpoint what they are surprised by the most from the learning environment. Structured reflection guides are useful because they bring problems from practical experiences to light and help adult learners make informed decisions (Brookfield, 2018). The current typical lecture format of teaching health care has limited opportunities for adult learners to transfer lecture-based ethics into practice-based ethics (Kim & Park, 2019). Structured reflection fosters intentional refinement of clinical practice, allowing for more reflective, ethical reasoning (Gonzalez et al., 2021). As structured reflection trains students to reflect systematically, not only could it support adult learners of health professions to reflect on ethical issues, but it could also cultivate adult learners’ reflective capacity (Brookfield, 1998; Dewey, 2020; Greenberger, 2020). However, structured reflection could be limiting and time consuming (Cengiz, 2020; Miller, 2020).

Adult learners’ documented reflection may also offer insights to instruction (Glowacki-Dudka & Barnett, 2007), as health professions educators may utilize the reflection provided by adult learners to inform curriculum development and implementation. Finally, the findings of the study indicate that the RPQ and SCES may be useful measures to investigate health professions learners’ reflective capacity and ethical engagement. Health professions educators may use these instruments to assess adult learners’ reflective capacity and professional ethical engagement in the professional healthcare setting. The instruments may serve as clinical training tools to identify health professions learners’ strengths and areas in need of intervention. Health professions educators and administrators may also use these instruments as program evaluation tools to identify whether programs and instructional activities are supporting health professions learners’ development of reflective capacity and ethical engagement.

Limitations and Research Recommendations

Despite the fruitful findings, this study has several limitations. To begin with, the study utilized a correlation design, which is exploratory in nature. It was unable to determine causal relationships between reflective capacity and professional ethical engagement in adult learners of health professions. Second, the study’s use of convenience sampling and relatively homogeneous sample limits the generalizability of the findings. Furthermore, the participants’ exposure to professional healthcare practice as part of their clinical training in their health profession education program varied, and the study did not account for these differences.

Therefore, future researchers may utilize more intensive study designs to establish causal relationships between reflective capacity and professional ethical engagement in adult learners of health professions. They may also utilize a probability sampling technique and a more heterogeneous sample to increase the generalizability of the findings. Moreover, future researchers may consider the length of clinical training of health professions students. It may be beneficial to investigate the relationship between reflective capacity and professional ethical engagement in adult learners of health professions who have had more clinical training. Finally, it is recommended that future researchers of health professions education and/or adult education study the effects of structured reflection using reflection guides, such as Greenberger’s (2020) Reflective Practice Guide and Brookfield’s (1998) Critical Incident Questionnaire, on reflective capacity and professional ethical engagement in adult learners of health professions.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Justina Or

Elizabeth Golba

Author Biographies

Justina Or, PhD is an educator and human services professional. She now teaches psychology and leadership at Kettering College. Her research interests include character strengths, ethics, reflective practice, and instructional practices related to diversity, equity, and inclusion.

Elizabeth Golba, EdD is an educator and a healthcare professional. She is now the Program Chair of Health Sciences and the Associate Director for the Division of Online Learning and Continuing Education at Kettering College. Her research interests include ethics, interdisciplinary healthcare learning, and improving student success with focus on diversity, equity, and inclusion.

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