Burton's cycle of three questions comprises the questions: These are questions which the reflector can answer during the reflective process. Boud describes three main components to consider—experience, reflection and outcome. The experience can be a behaviour, ideas or feelings.
The reflection will include returning to the experience, attend to feelings that it brought about and a re-evaluation of the experience. The outcome will look at new perspectives, changes to behaviour and an application of learning into practice. The Gibbs' reflective cycle encourages a clear description of the situation, analysis of feelings, evaluation of the experience and an analysis to make sense of the experience.
This would be followed by conclusions where other options are considered and reflection upon experience to examine what one would do if the situation arose again. The evaluation component describes what was good and not so good about the experience. The analysis should identify what sense can be made of the situation and the conclusion details of what else could have been done.
The process of reflection is ended with an action plan for what could be done if the situation arose again. Atkins and Murphy 5 through their model suggest that for reflection to have a real effect it needs to be followed by an action commitment.
The authors describe a cycle of awareness, description, analysis, evaluation and learning. The reflective process begins with the awareness of uncomfortable feelings and thoughts from the action or new experience followed by a description of the situation including thoughts and feelings. This would need to include salient events and key features identified by the reflector.
The reflector would need to analyse feelings and knowledge relevant to the situation—identifying knowledge, challenging assumptions, imagining and exploring alternatives. The reflection process would also need to include evaluation and consolidating learning. Evaluate the relevance of knowledge through asking questions includes the following: These steps would be followed by identifying any learning which has occurred. After-action review is a de-brief process in practice originally developed by the US army which aims to identify how to improve, maintain strengths and focus on performance of specific objectives.
The de-brief manual provides guidance for individuals and group reviews. What was supposed to happen? Why were they different? What did we I learn? There is no published evidence of the use of particular models of reflection in PH practice.
The general medical education literature contains various approaches to reflection. The evidence base to suggest learner's self-reflection skills can be improved through formal training is still lacking. There are a variety of theories on reflection in the education literature. The implication this brings to individual PH practitioners is to consider when and how they will reflect as part of their continuous learning cycle.
In addition, whether the act of reflection should be done alone or as part of a team or both will need to be established. As a discipline that has focused less on reflection in the past it is possible to draw on theories and models already existent and in use within medicine. There are a range of ways to reflect which include methods like journal writing, discussions and use of technology such as blogs. Ultimately, the aim of reflection would be to improve practice and learn from relevant experiences.
It is obvious that this comes from being an analytical reflector and moving beyond pure description. As some of the literature suggests, it is useful to recognise emotional influence and challenge one's ideas. In broader learning terms, it is also useful to consider the relevance of prior experience. Reflection enhances personal development by leading to self-awareness.
Often action takes place across multi-sectoral teams and involves multi-phased interventions. Programme delivery is often longer term, should be population focused and policy led.
The learner involvement is a key fundamental principle of adult education. PH CPD and the reflection that forms part of it can be viewed in light of adult education as individuals need to take ownership and engage in setting their learning agenda. There needs to be opportunity to reflect as individuals as well as in teams in an acute manner while carrying out the longer term projects.
Reflection can be used as a tool to facilitate professionals to assess beliefs, values and approaches to practice. Adult learners are more likely to believe and instil ideas that they help create.
The environment can provide many structured activities that generate the ideas, concepts or techniques if an active decision to do so is taken. The practitioner could then experience surprise, puzzlement or confusion associated with the situation. Reflecting on the phenomena that is being experienced and prior understanding which have implicated, the resulting behaviour will lead the learner to new understanding. In the health promotion literature, reflection on external and internal factors is recommended.
These factors, however, could be equally applied to other domains of PH as they will include policy, professional and societal influences examples of external factors and attitudes, skills, experiences and team dynamics examples of internal factors. The practice of self-reflection in academic achievement has been captured in disciplines that contribute to PH.
A positive impact was noted through reflective journal writing over only scientific report writing for those studying biology. In studies of mathematics students, while reflection was not necessary for high grades of achievements, it supported better conceptualization of meanings of the technical definitions. This is already considered important within health promotion.
Educational concepts and the impact of reflection are not easily measurable. One can argue that this approach of reflecting on an issue is too straight forward and, in practice, difficult issues may take months to reflect on. Doing so quickly might lead to a paper exercise. Explicit frameworks may not be suitable for some situations.
Frameworks vary in their focus of contexts. However, they are aimed to be critical analyses of knowledge and experience to deepen understanding. Time, motivation, initial expertise and lack of peer support are recognized barriers to reflection.
To add to this are organizational contexts and team dynamics—frequent problems faced by PH professionals. With the aim of providing a broad overview of reflective approaches relevant to PH professionals, this work provides a selection and not a complete comprehensive collection of medical education literature.
There are very few articles relating the use of reflection to current PH practice and furthermore on the strengths and weaknesses of different models that could be applied. This review article outlines some of the most applicable and outlines their merits and otherwise. Individuals working in PH may consider some of the approaches described here alongside their current professional development activities either as individual learners or as part of learning within teams.
At present, the strength and extent of the evidence base for the educational effects of reflection in a PH setting is limited. However, there is evidence of an improving trend in the quality of reported studies. In recognition of the time commitment involved, the benefits to the profession must be apparent.
In addition, the opportunity cost of other learning and developmental activity forgone needs to be considered. Further work is needed to strengthen the evidence base for reflection, particularly, where possible, comparative studies which observe changes in knowledge and abilities directly. Given its merits, while the quantitative evidence base is limited, what are the implications for practice? Given PH's stated desire to base practice upon evidence there is urgent need to formally assess the effectiveness of reflection in the improvement of PH practice.
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