Adapting the Girandole framework for cross-disciplinary social justice reflection in health professions education

1 Introduction

Equality, diversity and inclusion (EDI) have become central priorities within health professions education, reflecting the need to prepare graduates who can deliver equitable, culturally responsive, and socially just care. Despite increasing emphasis on inclusive curricula and learning environments, challenges relating to belonging, representation, differential attainment, power dynamics, and hidden curricula persist across healthcare disciplines. Addressing these issues requires approaches that move beyond policy compliance and support critical reflection on how equity and social justice are experienced in educational and clinical contexts.

This paper emerged from a collaboration between academics from Nursing, Pharmacy, and Biomedical Sciences at the University of Birmingham who identified shared concerns relating to EDI. Building on the Girandole Framework (1), originally developed within nursing education as an EDI-focused reflective tool, we explore its adaptation for use across health professions education. This paper describes the Girandole cross-disciplinary adaptation and ongoing refinement, highlighting its potential to support meaningful reflection on social justice across healthcare curricula and informing future research, student co-production, and EDI-focused educational initiatives.

1.1 Social justice, EDI and the need for cross-disciplinary reflection

Healthcare professionals work within increasingly diverse societies and must be able to provide equitable, person-centred care to patients from a wide range of cultural, social and ethnic backgrounds. Consequently, health professions education has a responsibility not only to promote EDI, but also to prepare students to recognise and respond to the structural inequalities that contribute to health disparities (2).

Across the United Kingdom, EDI is firmly embedded within the expectations of professional regulators. Standards issued by the Nursing and Midwifery Council (NMC), General Pharmaceutical Council (GPhC) and General Medical Council (3, 4) emphasise inclusive learning environments, the reduction of discrimination, and the promotion of fairness throughout education and professional practice (4–6). However, despite these commitments, inequities continue to be reported across healthcare education and the wider workforce. Differential attainment, ethnicity-related awarding gaps, experiences of discrimination, and unequal opportunities for progression remain persistent concerns across several health professions (7, 8).

This mismatch between institutional aspirations and lived experience suggests that embedding EDI within healthcare education requires more than policy statements or isolated teaching sessions. Rather than being presented as a discrete curricular topic, EDI should provide a lens through which all aspects of healthcare education and practice are critically examined. A social justice approach therefore encourages students and educators to engage with broader questions of power, representation, belonging, privilege and structural inequality, while recognising the influence of the hidden curriculum. These often shape professional identity, learners' sense of belonging and understandings of inclusive practice as powerfully as formal teaching. Addressing these issues requires structured reflective approaches that help learners critically examine these interconnected dimensions of educational and professional life.

Although healthcare disciplines differ in their professional contexts, they share many of the same social justice challenges. Consequently, there is value in adopting reflective approaches that provide an adaptable language for examining these issues across disciplinary boundaries. Such approaches can support dialogue between educators and students while encouraging critical engagement with the social, cultural and structural factors that shape healthcare.

Reflective approaches can provide tools for examining inclusion across disciplinary boundaries, facilitating dialogue and supporting critical exploration of strengths and gaps within curricula. Reflection is a cornerstone of professional development in health professions education, but meaningful engagement with social justice requires structured frameworks that help learners examine power dynamics, organisational culture, professional values, representation, and lived experience. Without such scaffolding, educators may struggle to translate EDI ambitions into practice, while students may lack the tools to recognise and challenge inequity. The need, therefore, is not simply for more EDI content but for practical pedagogical approaches that support critical engagement with the social, cultural, and structural factors shaping healthcare education and practice. It is within this context that the current project explores the adaptation of the Girandole Framework as a cross-disciplinary reflective tool for social justice learning.

1.2 Existing reflective EDI frameworks

Higher education institutions in the UK operate within a well-established EDI landscape shaped by legislation, institutional strategies, and national accreditation schemes such as Athena SWAN and the Race Equality Charter (9). These initiatives have played an important role in promoting organisational accountability and addressing inequalities relating to gender, race, disability, and other protected characteristics. Alongside these structural approaches, universities have increasingly adopted concepts such as intersectionality, decolonisation of the curriculum, and inclusive educational practices to address more complex and interconnected forms of inequality.

Within health professions education, reflective practice has long been recognised as a cornerstone of professional development. Frameworks such as Gibbs' Reflective Cycle (10), Schön's reflective practice model (11), Johns' Model of Structured Reflection (12), and Mezirow's transformative learning theory (13) are widely used to support students in examining their experiences, assumptions, and professional behaviours. Gibbs' cyclical stages, Schön's distinction between reflection-in- and reflection-on-action, and Johns' cue-based questioning across aesthetic, ethical and empirical ways of knowing each provide valuable structures for reflection, but none were specifically designed to explore issues of equity, diversity, inclusion, power, or structural inequality. Their cues prompt learners to examine what happened and how they responded, rather than whose voice was privileged or what structural conditions shaped the encounter.

In response to this limitation, EDI-specific approaches have increasingly emerged within healthcare education. Cultural competence has traditionally been the dominant framework, encouraging healthcare professionals to develop knowledge and skills for working with diverse populations. More recently, cultural humility has shifted the focus towards lifelong self-reflection, critical awareness of personal biases, and recognition of power differentials within healthcare encounters (14). Related concepts such as racial humility and cultural competency have further expanded these discussions by emphasising structural inequities and socially responsive practice (15).

Although EDI is increasingly embedded within higher education curricula and professional programmes, translating these commitments into practice remains challenging. Educators and students often lack tools to examine how power, inclusion, exclusion, hidden curricula, and organisational culture shape learning experiences. While reflective models focus on process and EDI frameworks often emphasise knowledge or organisational change, few combine these dimensions. The Girandole Framework addresses this gap by providing a structured lens for exploring social justice in health professions education.

2 The Girandole framework

The focus of this paper is the Girandole Framework¹ adaptation and early implementation within a new cross-disciplinary context. The Girandole's domains/vanes collectively shape the EDI culture in clinical learning environments (Figure 1).

The framework uses the metaphor of a spinning pinwheel to represent the dynamic and interdependent nature of these forces: depending on whether each vane operates as an enabler or a barrier, the Girandole can rotate in a positive or negative direction. Applied to real-world scenarios and vignettes, the framework prompts students, educators, and institutions to examine not only what happens in clinical and educational settings but how and why (Table 1).

Table 1. Structure of the Girandole framework.

The Girandole vanes are interconnected, and each scenario may demonstrate overlapping elements, as they can represent different layers or nuances of the same topic.

2.1 Strengths and distinctive features

Based on this early cross-disciplinary adaptation, the Girandole appears to offer several distinctive potential strengths. First, it is grounded in lived experience and developed collaboratively by an interdisciplinary, multicultural team drawing on their own professional and personal encounters with EDI challenges, adapting real stories from students' clinical placements accounts and giving it an authenticity that top-down policy frameworks often lack. Second, it moves beyond individual-level cultural competence approaches by incorporating structural and systemic dimensions making it one of the few EDI reflective tools in nursing education to engage with structural competency. Third, its visual simplicity and metaphorical clarity make it accessible and memorable for students and educators across different contexts, supporting its practical integration into case-based learning, mentoring, and institutional review. Fourth, the framework is explicitly dynamic by acknowledging that the direction and intensity of each domain can shift depending on context, and that EDI work is a continuous process rather than a one-off intervention. Finally, the Girandole was designed to be transferable beyond nursing to other health professions and educational settings, and adaptable with its vanes, capable of being modified to suit different institutional or professional contexts.

3 Cross-disciplinary and student-informed adaptation

3.1 Exploratory implementation

To inform the cross-disciplinary adaptation of the Girandole Framework, the framework was introduced during an exploratory EDI workshop involving healthcare professional students. The workshop formed part of an educational development activity intended to stimulate discussion around social justice and EDI concepts and to support ongoing refinement of the framework. It was not designed as an empirical research study, and no systematic data collection or formal qualitative analysis was undertaken Rather, this paper reports the team's experience of the workshop and the wider process of adapting the framework across disciplines.

The student discussions elicited during the workshop served as an exploratory implementation rather than a formal evaluation, providing insights into both the strengths of the framework and areas for refinement. The discussions highlighted much about the current state of EDI in health professions education as it did about the framework itself.

During the presentation, it became immediately apparent that four of the six Girandole vanes — Power, Culture, Personal Values and Professional Values — resonated strongly and spontaneously with the student group. Students engaged quickly and confidently with these concepts, readily offering examples drawn from their own clinical placement and educational experiences. Discussions around power dynamics on workplaces, the cultural dimensions of patient care, and the tension between personal beliefs and professional conduct emerged organically and with considerable depth. Students were not simply understanding these concepts abstractly; they were recognising them as descriptions of situations they had already lived.

However, two vanes — Hidden Curriculum and EDI Education and Awareness — did not achieve the same level of engagement. Students appeared uncertain, disengaged or simply unable to connect these concepts to their experience. The research team post presentation, reflected on this pattern revealed two distinct but related explanations. First, the language and framing used to introduce these vanes remained too abstract and academic — intelligible perhaps to an educator familiar with the literature but insufficiently grounded in the everyday realities of student educational and placement experiences. Second, and more strikingly, student's recollection of any formal EDI training prior to this session was missing and so lacked the critical engagement with these concepts. They were being asked to evaluate and reflect on aspects of EDI that although potentially encountered within the curriculum, had not been sufficiently not internalised or translated into their understanding of practice. an important question for health professions education: how effectively are existing approaches to EDI enabling students to develop the knowledge, language and critical awareness needed to recognise and interrogate issues of power, hidden curricula and structural inequity? The observation echoes wider concerns raised in the literature, where EDI has been described as inconsistently embedded in healthcare professions universities curricula, often remaining tokenistic or superficial rather than transformative (16, 17). These discussions prompted consideration of.

This reflection prompted a reconsideration of how these two vanes are introduced and supported in practice. Therefore, the interprofessional groups worked on two questions and reflected on what and how the Girandole next move can be pathed.

3.2 Engaging with the hidden curriculum

The hidden curriculum refers to what students learn in clinical placements and educational settings not through formal teaching, but through the unspoken norms, values, hierarchies and behaviours absorbed through observation and social pressure (18). In EDI terms, it represents the gap between what an institution formally states it values — in its policies, charter mark awards and mandatory training — and what is modelled and rewarded in daily practice (19). Students recognise the hidden curriculum most readily through their own lived experiences, once given the language to name it. It is present in the ward where no one explicitly prohibits a student from addressing the consultant directly, yet the social consequences make the unwritten rule unmistakable within days. It operates where certain patients — disproportionately from minority ethnic backgrounds or with mental health conditions — wait longer for care, yet this pattern is never discussed or challenged (20).

3.3 The paradox of evaluating what you have not been taught

The EDI Education and Awareness vane asks students to reflect on how meaningfully EDI has been embedded in their curriculum and clinical placement, and to identify gaps between stated institutional commitments and lived educational experience. This is among the most important reflective tasks the Girandole offers — and, as the presentation experience described above revealed, among the most challenging for students to engage with. The difficulty is structural rather than intellectual: it is extraordinarily difficult to evaluate the quality or completeness of an education you have not yet received. This paradox is not merely pedagogical — it is political. Before students can meaningfully apply this vane, they require a brief but substantive introduction to what EDI means in clinical and educational practice. In practice, EDI in a clinical setting might look like: a ward team that routinely considers cultural, religious and linguistic factors as part of care planning; a mentor who openly acknowledges and addresses a student's experience of microaggression; a debrief session that explicitly examines how a patient's ethnicity or disability status shaped the care they received. Its absence might look like: EDI training that is delivered once and never revisited in practice; a placement culture where discriminatory language is normalised or laughed off; a curriculum in which the perspectives, histories and experiences of marginalised groups are invisible; or a student who feels unable to raise a concern about unfair treatment for fear of jeopardising their placement assessment.

These aspects suggest that, even where EDI content is present, students may still struggle to translate theoretical knowledge into critical awareness of how power, representation, and inclusion operate within professional and educational settings. In this context, the Girandole may provide a useful reflective bridge between institutional EDI initiatives and students' lived learning experiences.

The central argument of the EDI Education and Awareness vane is that without meaningful, integrated EDI education — not a single mandatory online module, but sustained, reflective, practice-embedded learning — students will arrive in clinical and educational environments carrying unexamined biases they do not know they have, and without the tools to recognise or address them.

3.4 From reflection to application

These insights informed the next stage of framework development. Rather than viewing the difficulties encountered with the Hidden Curriculum and EDI Education and Awareness vanes as weaknesses, the project team treated them as opportunities to refine the framework and strengthen its pedagogical accessibility. The revised prompts illustrate how the Girandole could be operationalised beyond its original context. By translating its domains into practical reflective questions and context-specific examples, the framework has the potential to support teaching, learning and professional development across different health professions. These proposed applications require evaluation in authentic educational settings. Table 2 presents the adapted reflective prompts together with examples of how they might be applied across healthcare education contexts.

Table 2. Reflective prompts and examples to guide Girandole framework applications.

The revisions shown in Table 2 illustrate how student and educator feedback informed the evolution of the framework, transforming abstract domains into more accessible and actionable reflective prompts.

The revised prompts demonstrate how the Girandole can be operationalised as more than a conceptual framework. By translating its domains into practical reflective questions and context-specific examples, the framework becomes a flexible educational tool that can support teaching, learning, assessment, and professional development across multiple disciplines.

4 Potential applications across health professions education

The adapted Girandole framework has potential applications across health professions educationt (Table 3). Its six domains can support structured reflection withincontexts such as clinical and laboratory placements, professionalism teaching, portfolio-based learning and interprofessional education. These contexts are presented as illustrative possibilities rather than empirically evaluated applications. The framework may also offer educators a structured lens for curriculum review by prompting consideration of how power, hidden curricula, professional cultures and EDI are represented within formal and informal learning environments. Future implementation and evaluation will be required to establish its utility, acceptability and transferability across these settings.

Table 3. Illustrative potential applications of the Girandole framework across health professions education.

5 Discussion

The cross-disciplinary adaptation of the Girandole offers a structured approach to social justice reflection, helping to make visible power relationships, informal norms, and educational omissions.

The exploratory discussions here suggests that reflection cannot be separated from EDI literacy. Meaningful engagement with the Girandole requires learners to possess a baseline understanding of concepts such as equity, diversity, inclusion, and the hidden curriculum before they can critically recognise and interrogate what has been normalised, overlooked, or left untaught within their educational experiences. The workshop prompted reflection d that these concepts were not always immediately accessible to students, indicating a need for explicit educational scaffolding. Reflection alone cannot substitute for comprehensive EDI education; rather, it should complement and reinforce it. In this sense, the Girandole functions not only as a reflective tool but also as a diagnostic lens through which educators can examine the alignment between institutional EDI commitments and students' lived experiences.

Discussions of power, discrimination, and lived experiences can be emotionally challenging for both learners and educators. Reflective activities may surface experiences of bias, exclusion, or microaggressions that require sensitive facilitation and appropriate support. Educators therefore need the confidence and preparation to create psychologically safe learning environments and respond constructively to sensitive issues.

The Girandole should also be viewed as a complement to, rather than a replacement for, established reflective models such as Gibbs' Reflective Cycle and Johns' Model of Reflection. Its added value lies in explicitly foregrounding issues of equity, diversity, inclusion, and social justice that are often less visible within traditional reflective frameworks. Used alongside existing approaches, it can support a more socially informed form of reflection that considers broader structural influences on learning and professional development.

Finally, although the framework encourages critical inquiry and dialogue, it should not position learners or educators as solely responsible for addressing inequity. Many issues it seeks to illuminate are systemic in nature. Consequently, meaningful change requires organisational action, curriculum development, staff development, and sustained institutional commitment alongside individual reflection.

5.1 Future directions

The work reported here represents an early stage in the development of the Girandole as a cross-disciplinary reflective tool. Although the Girandole originated within nursing education, implementation discussions suggested that many of the issues represented by the framework transcend disciplinary boundaries. The examples identified relating not only to clinical nursing placements but also to pharmacy professionalism teaching, placement experiences, academic cultures, and biomedical science learning environments. This reinforces the potential value of a shared reflective language through which diverse health professions can engage.

The observations on the lack of EDI literacy across the students raise important questions for health professions education. How can EDI literacy be developed progressively throughout healthcare curricula? How can reflective approaches move beyond compliance-driven models towards deeper engagement with social justice? And how can institutions evaluate whether EDI teaching is genuinely transformative rather than tokenistic?

Future work will therefore focus on two interconnected areas: Rather than presenting a completed intervention, this paper represents an evolving programme of pedagogical scholarship aimed at strengthening the integration of EDI within health professions education. Further co-production and evaluation are required to establish its value across health professions curricula.

• Co-production with students and educators, empirical evaluation of the framework across multiple disciplines,
• Development of funded interdisciplinary projects examining the contribution of the Girandole to reflective practice, EDI literacy, belonging, and social justice learning.

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Footnotes

Edited by: Clare Puddifoot, Ulster University—Derry Londonderry Campus, United Kingdom

Reviewed by: Marina Gómez De Quero Córdoba, Universitat Rovira i Virgili, Spain

Footnotes

¹The Girandole Framework (De Luca et al., 2026) named after the French word for a spinning pinwheel was developed through an interdisciplinary framework lab at a UK university. The Girandole maps six interconnected domains: power, hidden curriculum, professional values, personal values, culture, and EDI education and awareness. These domains/vanes collectively shape the EDI culture in clinical learning environments.