Health Education Research Advance Access originally published online on October 27, 2006
Health Education Research 2007 22(5):658-664; doi:10.1093/her/cyl129
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Reflection—a neglected art in health promotion
Faculty of Life and Health Sciences, University of Ulster, Jordanstown, Newtownabbey BT37 0QB, UK
Correspondence to: P. Fleming. E-mail: p.fleming{at}ulster.ac.uk
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Abstract |
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 Top Abstract Reflection--context and...Reflection in practiceA Typology for Reflective...Barriers to reflectionConclusionConflict of interest statementReferences |
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Evaluation and quality assurance have, over time, become the bedrock of health promotion practice in ensuring effectiveness and efficiency of programme planning and delivery. There has been less emphasis, however, on formal recognition of the contribution of the personal characteristics and perspectives of those who plan and deliver programmes and to the more subtle underlying effects of prevailing societal and professional norms. This paper seeks to highlight the neglect of formal reflection as a key professional skill in professional health promotion practice. It outlines key theories underpinning the development of the concepts of reflection and reflective practice. The role of reflection in critical health education as it contributes to critical consciousness raising is highlighted through its contribution to the empowerment of change agents in a societal change context. A conceptual typology of reflective practice is described which provides a flexible structure with which professionals can reflect on the role of self, the context and the process of health promotion programme planning. Its use is illustrated from the author's published work in health promotion which is related to prevention of workplace violence.
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Reflection—context and definition |
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TopAbstractReflection--context and...Reflection in practiceA Typology for Reflective...Barriers to reflectionConclusionConflict of interest statementReferences |
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Professionals in health promotion focus on its effectiveness and efficiency [1] and acceptability [2–4]. Increasingly, concepts such as empowerment of individuals, communities or larger populations [5] are taken into account when assessing the quality and outcomes of health promotion programmes. It could be argued, however, that evaluation has been less useful in enabling individuals and teams working in health promotion to examine their own unique contribution to practice. Further, they are not always encouraged to examine the internal and external influences on programme planning and delivery agendas. It is this admixture of internal factors such as attitudes, skills, experience, team dynamics and external factors such as policy, professional and societal influences which can influence health promotion practice. To reflect on these influences, freedom from managerial, political and other constraints is important. Reflection should normally sit outside formal programme/project reporting mechanisms and be within the realm of personal/professional development. This paper therefore seeks to define reflection in the context of a brief overview of underpinning theory and to illustrate its practical application through the introduction of a typology of reflective practice in health promotion.
Reflection can be practised by individuals and teams in health promotion and is transformational in nature. It is defined here as the ability to gain understanding by reflecting on specific issues in practice through critically contextualizing, observing and analysing to generate new knowledge and insights which can enhance practice [6–8]. Current nomenclature employed in reflection can lack clarity of thinking and therefore elicits both positive and negative responses [9]; it is becoming less cohesive over time [10–12]. Commenting on reflection, Moon [13] observes that:
... the literature contains many interpretations of the word and, immersed within this chaotic catalogue of meanings, it can be difficult to recall that there are common-sense meanings of reflection as well ... (p. 3).
The benefits of reflection and the development of the reflective professional [14] have become a feature of professional practice in the contemporary contexts of academia [15, 16], health professions [17–21] and education [22, 23]. Reflection in these contexts, however, tends to be largely focused on the practice of individual professionals at specific points in time and/or on specific elements of practice. It could be argued that those who challenge and question current epistemological and ideological issues in current health promotion practice [1, 24] are engaging in a critique which is, in fact, reflection at the macro level. The concepts of reflection on the context of practice and team-focused reflection at the meso and micro levels have, however, been less well-documented in the health professions. The approach which focuses on individual practice is, however, less appropriate for health promotion which more often involves uni- and multi-disciplinary, multi-sectoral teams in multi-phasic interventions [25]. The capacity for teams to reflect is vital as programme delivery is often longer term, population focused and policy-led in a more acute manner.
Reflection can be considered to be a process of reasoned thought which enables a critical assessment of both ‘self’ as professional and ‘practice’ as an agent of change through realignments in power. This introduces immediate synergies with existing conceptual debates in areas such as critical health education, which has been described as ‘... creating social and political change in the interests of promoting public health’ [1] (p. 213). The theory base of critical health education, critical theory [26, 27], has its emphasis on challenging oppressive social structures. Refection can therefore be used as a tool to facilitate professionals to assess beliefs, values and approaches to practice. These determine how they personally, and the policies/programmes which they deliver, act as agents of change, contributing to empowerment [28].
The terms ‘critical reflection’, ‘reflective practice’ and ‘reflection’ can be taken, by some, to exist synonymously [29, 21]. Moon [13], however, sees reflection as a concept which is the basis for reflective practice—once we know what we are trying to do, we can then develop ways of doing it. The concept of critical reflection is, at its core, a form of experiential learning [30]. Dewey [31, 32] was concerned primarily with the process of reflection, which was seen to rely on ‘five aspects of reflective thought’, namely, suggestions, intellectualizations, the hypothesis, reasoning and testing the hypothesis in action.
Habermas [28] used reflection to develop particular forms of knowledge which he described as ‘Knowledge Constitutive Interests’. Thus ‘technical or instrumental constitutive interests’ are derived from the empirical/analytical sciences and seek to understand and control our environment, objectifying the world and understanding it in scientific terms. ‘Knowledge constitutive interests in historic hermeneutic disciplines’, located primarily in the humanities and social sciences, seek to understand human behaviour and forms of communication through the interpretation and integration of ideas. Finally, ‘emancipatory interests’ see the emancipation of social groups through development of knowledge from critical or evaluative modes of thought—understanding self, the human condition and self in the human context. The aim here is to produce a transformation in the self, personal, social or world situations. Synergies are evident here with the principle of empowerment, key to defining health promotion activity [33–35].
Schön's views of reflection [14, 36, 37] are based on technical rationality where theory is perceived from two key perspectives. Espoused theory arises from formal professional constructs and is the ‘official’ theory which informs professional practice. Theories in use, on the other hand, are generated from day-to-day professional life and circumstances and reflect the ‘real life’ of the professional. The dissonance between espoused theory and theory in use can produce a sense of ‘crisis’ for professionals—PRAXIS—theory as opposed to practice. It is this state of praxis which can lead to two different forms of reflection, reflection-in-action and reflection-on-action. The former, controversially, reflects the ‘ability to think on one's feet’ [38]—the debate continues as to whether this is reflection of simple problem solving. The latter is the ability to consider the process and outcomes of a specific element of practice. Both these forms of reflection require ‘artistry’ which denotes both coping with difficult situations when ignorant of theory and also the generation of a professionally defensible position.
Finally, Van Manen [39, 40] defines reflection as a means of mental action which distances the person from events in order that they may be viewed in a more objective manner. He identifies four levels of reflection, these being
- Level 1—thinking and acting on an everyday basis,
- Level 2—specific reflection in incidents and events,
- Level 3—development of understanding through interpretation,
- Level 4—reflection on reflection itself to gain understanding of knowledge and its nature to lead to emancipation.
- Level 2—specific reflection in incidents and events,
In the context of these levels, Van Manen talks about thought processes which indicate a reflective mind-set, mindfulness, ongoing awareness and thoughtfulness.
In the midst of a plethora of theory, however, the core skills of critical reflection have still to be agreed [41, 42], highlighting the need for good empirical studies using identified models of reflection [43] and enacted through a developed sensitivity (sentiency) [44]. This is particularly relevant in the discipline of health promotion where little has been published on the process or results of critically reflective studies.
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Reflection in practice |
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TopAbstractReflection--context and...Reflection in practiceA Typology for Reflective...Barriers to reflectionConclusionConflict of interest statementReferences |
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What, then, does that reflection look like in practice? Health promotion is, arguably, in the fortunate position of coming late to the concept of reflection and can therefore draw on the eclectic range of theories and models already extant in the literature to establish key principles. Individuals/teams can also develop their own models to best suit their circumstances. Van Manen's levels of reflective thought [39] would seem to provide a foundational framework for the focus of reflection. Thus Level 1 (thinking and acting on an everyday basis) can inform ongoing delivery at the client/community interface and maps, to some degree, onto Schön's concept of reflection-in-action [14]. This permits the boundaries between espoused theory and theories in use to be explored. Level 2 enables reflection on specific events and incidents in their entirety, linking to Schön's reflection-on-action [14], while Level 3, development of understanding and interpretation, permits an in-depth application of knowledge and theory to inform major innovation in practice or to give affirmation of existing good practice.
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A Typology for Reflective Practice in health promotion |
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TopAbstractReflection--context and...Reflection in practiceA Typology for Reflective...Barriers to reflectionConclusionConflict of interest statementReferences |
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To enable health promotion practitioners to engage in reflection in a planned and coherent manner, a Typology for Reflective Practice has been developed (see Fig. 1). It focuses on three domains of interest in health promotion practice, namely, the role of self (individuals and teams), the influence of the planning context (socio-economic and other environmental and political factors) and issues related to the process of planning/delivery of health promotion programmes. While these domains can be approached sequentially, it is equally possible to reflect on the domains in any order. Other domains of practice could be replaced or inserted to meet specific reflective needs.
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In order to permit the reflective practitioner to derive maximum benefit from the exercise, it is important that the most appropriate reflective questions are posed. The posing of such questions centring on issues such as values, models and theoretical and practice frameworks is not new in the health promotion literature [45, 46] but it has not, hitherto, been classified as reflection. The formulation of a tailored taxonomy of reflective questions enables in-depth thought and discussion to be undertaken and conclusions to be drawn. Sample questions which form a basis for a more detailed list of questions include:
Self:
- Have my/our attitudes/beliefs/values had an effect on perceptions of client populations and/or planning environments?
- Is my/our practice grounded in personally defensible approaches, which are grounded in an appropriately eclectic evidence base?
- How have I/we personally developed through involvement with this initiative?
Context:
- Does the policy environment (local, national, organizational) creates opportunities or constraints for enhancement of practice?
- Is the programme located and conducted within a defensible theoretical and ethical framework?
Process:
- Does the programme reflect best practice in relation to core principles of health promotion planning in relation to issues such as empowerment, advocacy and appropriate participation by the target population?
- Where were the major difficulties in the process and how could these be addressed?
- What are the implications of the outcomes for my/our future practice in this or other areas?
Questions posed for one domain may lead to questions being required in other domains as is indicated by the arrows connecting the domains. Essentially, each taxonomy is closely tailored to the needs of the reflective exercise being undertaken. The time line which underpins the typology indicates that these questions could also be rendered in the future or past tenses, depending on whether the reflection is at any point prior to, during or after the health promotion programme has been planned and implemented.
A practical example of the use of Typology can be drawn from the author's own experience. A needs assessment relating to workplace violence against employees in environmental health departments showed that workers of lower age, those in enforcement roles and working ‘out of hours’ were more likely to be victims of violence in the course of their work [47]. This led to the conclusion, through reflection-on-action [14], that there was a dearth of appropriate mechanisms to structure and implement effective health promotion interventions to address violence against workers. The results of this reflection were published as suggestions for strategy development in relation to workplace violence [48]. This reflection happened at the ‘post-implementation’ phase on the Typology's time line as it was triggered by the reporting of the project. As the purpose of the reflection was to interpret the findings of a needs assessment exercise, it was categorized as being at Van Manen's third reflective level—development of understanding through interpretation [39]. The taxonomy of reflective questions was configured and, due to the number and scope of the questions posed, exemplar questions have been selected for this paper from a wider taxonomy and outlined below to illustrate elements of the reflective process.
Reflecting on the role of ‘Self’ (the team)
- Were our assumptions about the nature and effects of violence in the workplace appropriate?
This question challenged the understanding of workplace violence on which the project was based. It became clear at the reporting stage that an adequate definition did not exist. We had assumed that a clear understanding of ‘categories’ of violence gave a basis for understanding the phenomenon. However, knowing the types of violence did not adequately define its effects or the roles of victim and perpetrator. Reflection on the literature and our results enabled us to propose a formal, inclusive definition of workplace violence [48] which provided a foundation for empowerment of at-risk workplace populations. In addition to generating a formal definition, the learning for the team in the ‘self’ domain was that assumptions regarding operational definitions should be more rigorously questioned and agreed at the outset of specific projects.
Reflecting on the context of planning
- Are there occasions when workers exacerbate stressful situations with clients, transforming those clients into perpetrators of violence and themselves into victims?
This question recognized that while violence can never be condoned, to understand the phenomenon, an objective knowledge of the antecedents and the ‘critical incident’ itself need to be understood; this should inform a coherent and defensible planning process. The issues of reporting, debriefing and aftercare were all seen as requiring a reflective element for the victim to identify how their future actions might need modification and what further support they would require.
Reflecting on the process of planning
- What are the implications of this needs assessment for developing planning models for intervention strategies in workplace violence prevention?
This led to the development of a sequential framework for health promotion planning which took account of needs assessment, policy formulation for prevention, incident management and reporting and post-incident support strategies. Other key factors such as timing, effective education and training for those involved in policy planning and implementation and good internal and external communications were also identified [48]. Reflection on process thus led to the formulation of an easily accessed, sequential planning framework based on realistic human and financial resource requirements. This framework could be disseminated through appropriately timed education and training, in this case for environmental health departments. This training, and ongoing partnership support from health promotion specialists, would be informed by a clear understanding of the nature, extent and effects of violence on workers.
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Barriers to reflection |
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TopAbstractReflection--context and...Reflection in practiceA Typology for Reflective...Barriers to reflectionConclusionConflict of interest statementReferences |
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Barriers to reflection for individuals involved in health promotion may, as in any emerging activity, be primarily motivation, time, initial expertize and lack of peer support. Reflection may bring about the desire for change and progress which may be difficult or impossible to realize in specific organizational contexts, leading to frustration and discontent. In the case of team reflection, there may be difficulty in agreeing the issues to which reflection should be applied and the content of a taxonomy of reflective questions; interpersonal relationships may also be an issue in teams where hierarchical structures or pre-existing tensions are predominant. Time allocation for reflection may require negotiation as may the use to which reflective outcomes are put. Teams may find the process difficult if there is a conflict between themselves and their organization in relation to political and/or professional perspectives of health promotion. This may in itself, however, be a rich field for reflection which could contribute to team building. In both individual and team contexts, the absence of a supportive management and organizational structure may prove problematical, but not impossible, for engaging in the reflective process.
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Conclusion |
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TopAbstractReflection--context and...Reflection in practiceA Typology for Reflective...Barriers to reflectionConclusionConflict of interest statementReferences |
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Reflective practice clearly has a role to play in the development of health promotion and can facilitate the individual or team to gain rich insights into themselves and their practice. The use of well-structured reflection can be used as a basis for critical consciousness raising [1, 27] and self-development—key foundations for practice. This use of reflection to promote critical consciousness raising through emancipatory activity [28] has the capacity for the development of empowering approaches such as health promoting settings e.g. workplaces. Practice, informed by reflection, can contribute to transformation in the personal, organizational, social or world situations. However, this must be seen in the context of a discipline which has led in the quest for effective evaluation as the lynchpin of good practice. Reflection does not replace, but enhances, the ability of the professional to engage in a range of coherent evaluation strategies. The capacity for structured, conscious reflective practice has yet to be fully realized and has the potential to inform the development of contemporary health promotion.
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Conflict of interest statement |
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TopAbstractReflection--context and...Reflection in practiceA Typology for Reflective...Barriers to reflectionConclusionConflict of interest statementReferences |
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None declared.
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References |
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TopAbstractReflection--context and...Reflection in practiceA Typology for Reflective...Barriers to reflectionConclusionConflict of interest statementReferences |
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Received on November 24, 2005; accepted on August 7, 2006
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