Supporting critically conscious integrated care: A toolbox for the health professions

Health professions education has a growing obligation to develop practitioners who are conscious of health inequalities and the sociocultural dynamics of health care. This obligation is reflected in many of the competency and regulatory frameworks that drive current curricula. The central aim of integrated care is to improve patient experiences across health care settings by enhancing service coordination. Although addressing health inequalities is one of the core purposes of integrated care and its systems, educators have little guidance on how to effectively translate this into teaching activities. The reality of health care funding and constraints means that integrated care services may struggle to challenge health inequalities in a meaningful way. Patients from minoritised and marginalised backgrounds are more likely to fall through the cracks between health care services, experiencing fragmented care and negative effects on their physical and mental health due to poor integration. Further, scholars have continually drawn attention to two key issues: first, today’s graduates’ lack of awareness of social determinants of health and, second, the necessity for practitioners to take action in challenging the conditions that contribute to health inequalities. Although addressing health inequalities is one of the core purposes of integrated care and its systems, educators have little guidance on how to effectively translate this into teaching.


| INTRODUCTION
Health professions education has a growing obligation to develop practitioners who are conscious of health inequalities and the sociocultural dynamics of health care. [1][2][3] This obligation is reflected in many of the competency and regulatory frameworks that drive current curricula. [4][5][6] The central aim of integrated care is to improve patient experiences across health care settings by enhancing service coordination. 7 Although addressing health inequalities is one of the core purposes of integrated care and its systems, 8 educators have little guidance on how to effectively translate this into teaching activities. 9 The reality of health care funding and constraints means that integrated care services may struggle to challenge health inequalities in a meaningful way. Patients from minoritised and marginalised backgrounds are more likely to fall through the cracks between health care services, experiencing fragmented care and negative effects on their physical and mental health due to poor integration. 10,11 Further, scholars have continually drawn attention to two key issues: first, today's graduates' lack of awareness of social determinants of health and, second, the necessity for practitioners to take action in challenging the conditions that contribute to health inequalities. [12][13][14] Although addressing health inequalities is one of the core purposes of integrated care and its systems, educators have little guidance on how to effectively translate this into teaching.
One way in which clinical teachers can promote an integrated approach to patient care that is able to effectively challenge health inequalities is through adopting a critical approach to education. This involves fostering the development of critical consciousness amongst learners.

| WHAT IS CRITICAL CONSCIOUSNESS?
Critical consciousness is a concept that was developed by Brazilian philosopher, Paulo Freire, who advocated for critical pedagogy (an approach to teaching) as a way of empowering individuals to effect societal change through awareness and questioning of power and privilege. 15 Critical consciousness goes beyond traditional notions of cultural competence (focused on developing competencies and knowledge of particular patient groups) to concentrating on deeper levels of self-awareness and understanding of the social, cultural, historical and even emotional dynamics in health care. 16 For learners, deeper levels of awareness involve critical reflection on how power and privilege manifest within health care: both an awareness of one's own power as a health care professional and an external awareness of how minoritised patients hold little power within health care systems.
Critical consciousness also entails deep and sustained exploration of biases and values at the root of health inequalities and engaging in action to achieve societal change. 17 In the context of integrated care, a critically conscious approach involves questioning and critiquing the process of integrated care (i.e., the stages of the patient's journey and the practitioner's role in this) and the plurality of ways patients may interact and experience integrated care systems. It also requires sociocultural and political awareness of how wider systems within society influence patients' experiences and advocacy and action to challenge health care inequalities. Landreman et al. 18  Critical consciousness and its related approach to teaching, critical pedagogy (see Table 1 We describe how clinical teachers across the health professions might adopt a critical approach, supporting learners' development of critical consciousness to enhance integrated care. A core principle of critical consciousness involves 'self-reflective awareness' of how one's own power and privilege shapes clinical interactions and social structures.

| INVEST IN RELATIONAL APPROACHES TO HEALTH PROFESSIONS EDUCATION
Attaining critical consciousness requires learning that is transformative in nature. The shifting relationship between teachers and students, from teachers as fonts of knowledge to students as coinvestigators, whose voices are central to education is a key component to achieving transformative learning. Relational approaches involve developing curricula and implementing change through conversation and dialogue established through relationships (be that with patients, teachers, or peers etc.). Longitudinal Integrated Clerkships (LICs) are a model of clinical education that have been used within medical education 33 and pharmacy education 34 where students are placed in one location for an extended period, thereby allowing them to develop relationships with multiple stakeholders.
The shifting relationship between teachers and students, from teachers as fonts of knowledge to students as co-investigators, whose voices are central to education is a key component.
LICs have the potential on a broader scale to engender understanding of patients' journeys in a diversity of health care professions, as many models require students to journey with their patients across care settings. Following the patient's journey in this way not only fosters understanding of how health care systems interact (and issues with this interaction) but also creates possibilities for students to act T A B L E 1 Common practices of a critical pedagogy (adapted from Halman et al. 19 ).  35 is detailed in Figure 3.

| ENCOURAGE EXPLORATION OF PATIENTS' JOURNEYS AND STORIES
A critically conscious approach involves questioning the process of care or-in other words-the patient's journey. Though we may A critically conscious approach involves questioning the process of care or-in other words-the patient's journey.
Discussions on the journeys patients experience through care systems should start with considering the disparities that exist between journeys for patients with significant privilege, and those from minoritised backgrounds. Much of a patient's journey is determined before they even walk through the door of a general practice surgery or secondary care clinic. In some literature, these determining forces are referred to as 'social determinants of health'. SDH refer to the environmental conditions that influence peoples' health (e.g., socio-economic factors like income and education) and are one cause of the inequalities evident within patient care that integrated care systems are trying to address. Though SDH have such a significant influence on patient's journeys (for example, patient income may influence whether they can take time off work for an appointment or journey to an appointment in another care setting), discussion of SDH is relatively infrequent within discussions of integrated care. Naming and exploring SDH with students and exploring the wide-reaching impact of SDH on patients, particularly those from minoritised backgrounds and those living in underserved areas, might go some way to raising awareness of diverse experiences prior to engagement with and within integrated care systems. Figure 5 provides a few exercises that can be used to explore the patient's journey in relation to integrated care and approaches to support the exploration of the patient's story to help understand their experience.

| CREATE REFLECTIVE SPACES FOR SHARING EXPERIENCES
Critical to making sense of all the experiences above and channelling these experiences towards the development of critical consciousness is reflection. We are not advocating for more assessment of reflection Gooding et al. 46 See tip 9. Johnson et al. 47 Martinez et al. 48 See tips 3, 8 and 9.
F I G U R E 5 Exercises to support the exploration of the patient's journey and story.
SDH, spurring transformation as students are prompted to think differently about patient experiences and journeys. Opportunities for advocacy and social justice action can be discussed, and a relational approach to thinking about integrated care can be promoted.
Creating dialogic, reflective spaces for both educators and students to share their experiences of the social determinants of health, patients' journeys and advocacy can raise awareness of patient needs. (2) invest in relational approaches to health professions education; (3) encourage exploration of patients' journeys and stories; and (4) create reflective spaces for sharing experiences. Further examples of teaching exercises for each of these approaches are outlined in Table 2. Facilitating critical consciousness within ourselves and learners is only one small part of advancing integration and reducing health inequalities. Ultimately, part of our 'social justice action' or advocacy as health care professionals and educators must be challenging organisational leaders and politicians to prioritise health care funding, enhance collaboration and reform traditional models of education. Through action in both our individual practice as educators, and collectively as advocates for patients, we can move towards critical consciousness and improve health care experiences and outcomes for all patients.