Journal of Public Health | Vol. 35, No. 2, pp. 308 –312 | doi:10.1093/pubmed/fds083 | Advance Access Publication 17 October 2012
Reflection as part of continuous professional development
for public health professionals: a literature review
Nishamali Jayatilleke1, Anne Mackie1,2
1
UK National Screening Committee, London, UK
Faculty of Public Health, London, UK
Address correspondence to Nishamali Jayatilleke, E-mail: [email protected]
2
A B S T R AC T
Background For many years, reflection has been considered good practice in medical education. In public health (PH), while no formal training
or teaching of reflection takes place, it is expected as part of continuous professional development. This paper aims to identify reflective
models useful for PH and to review published literature on the role of reflection in PH. The paper also aims to investigate the reported
contribution, if any, of reflection by PH workers as part of their professional practice.
Methods A review of the literature was carried out in order to identify reflective experience, either directly related to PH or in health
education. Free text searches were conducted for English language papers on electronic bibliographic databases in September 2011.
Thirteen papers met the inclusion criteria and were reviewed.
Results There is limited but growing evidence to suggest reflection improves practice in disciplines allied to PH. No specific models are
currently recommended or widely used in PH.
Conclusions Health education literature has reflective models which could be applied to PH practice.
Keywords education, employment and skills, models
Background
The practice of public health (PH) is a science as well as an
art.1 PH professionals may work across all or some of its
main domains—health improvement, health protection and
health services. The Faculty of Public Health provides direction and guidance to enable the development of professionals and establish competencies that specify behaviour,
skills and attitudes. The Faculty encourages professionals to
reflect as part of essential practice.2 Many different disciplines contribute to the PH workforce, but all are expected
to keep themselves up to date through continuing professional development (CPD). However, the mere experience
of carrying out some developmental activity may not be sufficient to enable future improvements and thus many
medical specialities encourage their practitioners to reflect
on their experiences.3
Reflection can contribute to learning.4 Illeris4 describes
learning to consist of emotional and social dimensions as
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well as cognitive. In practice, the cognitive aspects are most
easily measured through assessments or performance, while
the emotional and social aspects may be less easily captured.
Frameworks of reflection could support the development of
both these dimensions.5 Further to this, if learning is considered to take place in the form of a cycle, as shown in
Fig. 1, the role of reflection becomes apparent.
The cycle of learning comprises four elements—a concrete experience, an observation and reflection, formation of
abstract concepts and testing in new situations.6 The circular
model does not mean each stage should be equally weighted
in time and emphasis.7 Kolb and Fry, in their theory, argue
that the cycle can begin at any of those points. However, in
Nishamali Jayatilleke, Specialty Registrar in Public Health
Anne Mackie, Director of UK National Screening Committee & CPD Director of
Faculty of Public Health
# The Author 2012, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved
R E F L E CT I O N FO R P U B L IC H E A LTH P RO F E S S I O NA L S
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Concrete experience
Testing in new situation
Reflective observation
Abstract conceptualization
Fig. 1 Four stages of Kolb’s learning cycle6.
its simplified form, the learning cycle will begin by carrying
out a task, the person would reflect on that experience and
apply the learning in a new situation. In order to apply experience to the new situation, the ability to generalize through
identifying principles and their connections to actions over a
range of circumstances is required. Throughout the process,
learners rate themselves which is an important element for
adult learners8 and could be considered relevant for continuous professional development. In his work, Donald
Schon9 concludes that the possible objects for reflection can
be as varied as the situations faced and the systems in which
they occur. Reflection can be understood as the ‘ability to
gain understanding of specific issues in practice through critically contextualizing, observing and analysing to generate
new knowledge and insights which can enhance practice’.10
This may mean the individual might reflect on the feeling
for a situation which has led to adoption of a particular
course of action, the way in which the problem has been
framed and/or the role this has created for the individual in
the wider institution as a result.9 It can be seen as the
process of reasoned thought which enables a critical assessment of both self as a professional and as an agent of
change.10 This latter is of particular relevance to PH professionals in their roles of influencing decision-making.
However, as a speciality on the whole, PH has focused
heavily on quantitative measures for evaluation. The
purpose of this paper is to describe the development of a
framework for learning to reflection for individuals as well
as for teams and to identify approaches to guide continuous
professional development. This paper describes how this
could be implemented and used in everyday work to enable
professional development.
Method
Literature search strategy
A literature search was undertaken using CINAHL, Medline
and OvidSP electronic databases in September 2011. The
search terms used were evidence-based practice, research
evidence, medical education, qualitative research, reflective
practice, reflection and evidence. Other sources included
handpicking of books on evidence-based practice, reflection
and research. Full texts of potentially relevant articles were
obtained. Papers were identified for inclusion in the review
by examination of full text articles. Data relating to characteristics of the population, intervention, outcome measures,
study design and outcomes were collected.
Inclusion criteria
Papers written in English only were included. Articles pertaining to reflection in or on practice in PH or related disciplines were included. Documents published between 1970
and 2011 were included. Peer- and non-peer-reviewed publications were considered.
Exclusion criteria
Articles that included reflection as by-product rather than
the main focus were excluded. Non-English language publications were excluded.
Results
Electronic searches yielded over 100 citations. Further citations were obtained by hand searching of reference lists.
More than 20 full articles were retrieved and assessed
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against the set inclusion criteria. Of the five papers included
in this review, none were from PH, two from nursing and
two from other allied health professions or other education
literature. One further model was included from non-health
background.
The search did not find evidence that particular frameworks were in regular use in current PH practice. The
search identified educational concepts from the literature
which could be applied to PH. Several approaches to reflection were found. While none of these were linked directly to
PH practice, their use in medicine was referenced. The literature discussed here were selected on relevance and
focused on the synthesis on framework, service-based learning and mentorship.
Burton’s approach11 was to use the core questions
focused on reflection on action but with the ability to be
applied in and before action. Burton’s cycle of three questions comprises the questions: What? So what? Now what?
These are questions which the reflector can answer during
the reflective process.
Boud et al.12 defines reflection in the learning context and
focuses on the personal experience as the object of reflection—as the intellect and affects lead to new understandings
and appreciations. 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 (1988) 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.13 In
essence, Gibbs describes a cycle of description, feelings,
evaluation, analysis, conclusion and action plan. The description is questioning what happened followed by the feelings
brought about through the questions—‘what were you
thinking and feeling?’. 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 Murphy5 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:
‘Does it help to explain and/or solve problems’? ‘How
complete was the use of knowledge’? 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.14 The review would
answer the following four questions: What was supposed to
happen? What actually happened? Why were they different?
What did we (I) learn?
Discussion
Main findings
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.15 There is also a range of aspects
to be considered, for example, individual perspective, team
dynamics and societal impacts. 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
R E F L E CT I O N FO R P U B L IC H E A LTH P RO F E S S I O NA L S
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.16 If the focus of reflection is improvement in
patient care, it helps to expand and develop clinical knowledge and skills.17 – 19 The process slows down activity providing time to process material of learning and link to
previous ideas.20 It should also enable more ownership of
the learning taking place.20 Reflection has been reckoned to
promote optimum effectiveness and efficiency in an ever
evolving and complex health-care system through practitioners auditing their own practice.21,22 ‘Reflection reminds
qualified practitioners that there is no end point to learning
about their everyday practice’.18
Where it exists, the practice of reflection has tended to
focus on individual professionals at specific points in time
and/or on specific elements of practice.10 This, however,
can form only a part of the experience as many PH actions
involve many disciplines. 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.23 Therefore, the mere act of reflecting supports the
androgogical model as adults need to be able to establish
the purpose of the activity undertaken and identify how to
cope effectively with real-life situations.24
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.25 These factors determine how individuals personally and the policies/programmes which they deliver, act
as agents of change, contributing to empowerment. 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.9
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
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as they will include policy, professional and societal influences (examples of external factors) and attitudes, skills,
experiences and team dynamics (examples of internal
factors).26
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.27 This was evidenced through greater awareness of
cognitive strategies and conceptions of learning when learners constructed more complex and related knowledge
when learning from text. 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.28 Practice, shaped
through reflection can develop professionals, organizations
and society. This is already considered important within
health promotion.25
Educational concepts and the impact of reflection are not
easily measurable.29 Therefore, its merits may be overlooked.
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.10 However, a structure to guide the process of reflection on the content and the process of learning would
be deemed useful.30
Limitations
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.
What does this report add?
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.
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Conclusions
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. ‘Higher quality’ papers identify
improvements in knowledge and understanding, increased
self-awareness and engagement in reflection and improved
opportunities through specialist training and continuous
professional development.
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.
Acknowledgements
11 Burton AJ. Reflection: nursing’s practice and education panacea?
J Adv Educ 2000;31(5):1009 – 17.
12 Boud D, Keough R, Walker D. Reflection: Turning Experience into
Learning. London: Kogan Page, 1998.
13 Gibbs G. Learning by Doing: A Guide to Teaching and Learning Methods.
Oxford: Further Education Unit, Oxford Polytechnic, 1988.
14 Department of the Army. Washington, DC, 1993. http://www.au.
af.mil/au/awc/awcgate/army/tc_25-20/tc25-20.pdf (March 2012,
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15 Chretien K, Goldman E, Faselis C. The reflective writing class blog:
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16 Cotton AH. Private thoughts in public spheres: issues in reflection
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17 Graham IW. Reflective practice and its role in mental health nurses’
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18 Driscoll J, Teh B. The potential of reflective practice to develop
individual orthopaedic nurse practitioners and their practice.
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19 Paget T. Reflective practice and clinical outcomes: practitioners’
views on how reflective practice has influenced their clinical practice. J Clin Nurs 2001;10:204– 14.
We would like to thank Joanne Harcombe for her helpful
comments on the draft manuscript.
20 Moon J. PDP Working Paper 4: reflection in higher education learning. Learning and Teaching Support Network Generic Centre, 2002.
http://www.ltsn.ac.uk/genericcentre/projects/pdp/working-papers
(March 2012, date last accessed).
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