reflecting on reflective practice for professional education and development in health promotion

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http://hej.sagepub.com/ Health Education Journal http://hej.sagepub.com/content/62/2/173 The online version of this article can be found at: DOI: 10.1177/001789690306200210 2003 62: 173 Health Education Journal Mary Issitt development in health promotion Reflecting on reflective practice for professional education and Published by: http://www.sagepublications.com can be found at: Health Education Journal Additional services and information for http://hej.sagepub.com/cgi/alerts Email Alerts: http://hej.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: http://hej.sagepub.com/content/62/2/173.refs.html Citations: What is This? - Jan 1, 2003 Version of Record >> at UCSF LIBRARY & CKM on August 26, 2014 hej.sagepub.com Downloaded from at UCSF LIBRARY & CKM on August 26, 2014 hej.sagepub.com Downloaded from

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Page 1: Reflecting on reflective practice for professional education and development in health promotion

http://hej.sagepub.com/Health Education Journal

http://hej.sagepub.com/content/62/2/173The online version of this article can be found at:

 DOI: 10.1177/001789690306200210

2003 62: 173Health Education JournalMary Issitt

development in health promotionReflecting on reflective practice for professional education and

  

Published by:

http://www.sagepublications.com

can be found at:Health Education JournalAdditional services and information for    

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What is This? 

- Jan 1, 2003Version of Record >>

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ARTICLE

Reflecting on reflective practice forprofessional education and development inhealth promotion Mary Issitt1

1Senior Learning and Teaching Fellow and Programme Leader, Postgraduate Diploma/MA in Health Promoting Practice, Department of Humanities and Applied Social Studies,Manchester Metropolitan University.Correspondence to: Mary Issitt, Department of Humanities and Applied Social Studies,Manchester Metropolitan University, Crewe+Alsager Faculty, Hassall Road, Alsager,Cheshire UK ST7 2HL. [email protected]

AbstractThis paper reviews reflective practice and associated terms and suggestsan approach that can encompass the criticality required in professionaleducation and training in relation to current agendas for healthpromotion. Although reflective practice is an accessible notion and hasachieved great popularity as a means of synthesising thinking and doing,it is contested in terms of its conceptualisation and application. It is notneutral and value free, but affected by personal, political and professionalfactors that impact upon practitioners.

Examples are drawn from professional literature in teaching,nursing and social work that illustrate different levels of reflection, toshow that whilst there are considerable benefits there are dangers inassuming common understandings. A developing conceptualisation ofcritical reflective practice is proposed for health promotion which seeksto enable professionals to use reflection in their immediate situation, aspart of a wider social process that contributes to societal change andprofessional development.

Key words: reflective practice, criticality, health promotion, multidisciplinarity

Reflective practice has already had considerable impact in professional education anddevelopment in nursing, teaching and social work 1,2 yet its relationship with healthpromotion remains unexplored. Health promotion is an eclectic discipline whichpositively bristles with models and theories, encompassing notions of health as an ideal

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state, alongside pragmatic goals and targets for improvement and development. Ineducation for health promotion that is concerned with bridging the gap betweenunderstanding the nature of health and wellbeing and taking action to achieve positivechange, there are indications that reflective practice is an increasingly attractive concept.In 1997 National Occupational Standards for Professional Activity in Health Promotionand Care incorporated reflection within Key Role 1. This role was seen as underpinningall other standards for health promotion work and included the demonstration ofcompetence to ’reflect on and evaluate one’s own values, priorities, interests andeffectiveness’ (Key Role 1. 1. 1) and to ’synthesise new knowledge into the developmentof one’s own practice’ (Key Role 1.1.2 )3,4. Within professional training programmes forhealth promotion, reflection is being used to bridge the theory/practice divide, asexemplified by papers presented at a recent conference organised by this journal*. Thisarticle reviews retlective practice and associated terms, illustrating that it is a usefulconcept for health promotion that needs to be approached with criticality. Key aspectsof the current health promoting agenda are firstly considered in order to provide acontext for the ensuing discussion of reflection and its potential in professional educationfor health promoting practice.

Health promotion - some key issues for reflectionEmphasis on standards and outcomes has enhanced the significance of practice as astarting point for professional education and development in health promotion. Butone of the first questions to be addressed is who is the health promoter, the agent throughwhom health development and improvement takes place in relation to overarchingvalues and ideals? Whilst health promotion may now be located as a specialism withinthe new public health it is also implicit in the work of other health professionals.Moreover, it may be included in allied human service occupations such as youth work,teaching and social work. Indeed, current policy proclaims health as everyone’s businessand a multiplicity of partnerships is required, not just between professionals, but’individuals, communities and government&dquo; in order to tackle social and economicinequalities. The policy shift in health and social care is away from expert-led provisiontowards

... a pooling of expertise, experience and rcsources f roln social support networksof service LlSel’s, fallJlhes and COllllllunities with iliosejl-otti health and social careorganisations. It requires a profound Cllltural change. A sociallllodel of disabilit~;

. racial and Cllltural diversity and social inclusion are all based on civil rights and

rellloving barriers and discrilllinatiod,:

*This conference entitled ’Postgraduate Training in Health Promotion’ was held at theUniversity of Manchester on 28th January 2003. Two of the papers by Deborah Ritchieand Helen Smart5 on the proposed Scottish Masters in the Principles and Practice ofPublic Health, and John Davies6 on the European Masters in Health Promotion,outlined programmes which feature reflective practice as a necessary component.

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This cultural shift involves re-evaluating and sharing practice, whilst ’continuouslyadapting to reflect the lessons learned from experience’9, building on common valuesand perspectives for the promotion of health and wellbeing and related professionaleducation and development. Equity has been an enduring concern for health promotion,and a well-established literature testifies to the debate aroused by the tackling ofinequalities in health and wellbeinglo,’ i,i’-,’3. In social care, the implementation of thesocial model in the above quote from Statham, has long been a desirable objective ofanti-oppressive practice. This was reinforced by the findings of the The Stephen LawrenceInquÍ1y, which alerted all public bodies to the dire consequences of institutional racism,and its affects on all levels of activity&dquo;. Anti-oppressive practice is not only about workersdeveloping sensitivity in their own approach, it also recognises and challengesinstitutionalised oppression that causes’group deprivation and exclusion...powerimbalances embedded within social relations’’~. Professional qualification in social workin Britain requires both understanding of inequalities and the demonstration of anti-oppressive practice directly through the individual social worker’s role and actions.National Occupational Standards for Professional Activity in Health Promotion andCare incorporated this into Key Role’0’, underpinning all activity. Professional educationand training programmes for health promotion also see practice to tackle inequalitiesas a central concern. However, as Statham argues, ’the goal is not sameness, but theskills to cope with differences in perspectives and values, and hence about options andacceptable risks’ .

Thus health promoters, whatever their professional location, will need educationand training to enable them to evaluate the possibilities and limitations of their ownvalues and actions in relation to the‘macro’ political context in which they are operating,and the challenges they face personally and professionally in tackling health inequities.Figure 1 seeks to capture the dynamic between the dimensions of practice,which impactupon learning for health promotion. Could reflective practice facilitate the understandingof, and prepare for engagement with this dynamic, and the translation of principles forequity and social inclusion into action? .

FIGURE 1 Tackling inequalities in health: dimensions of practice

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In order to make sense of the personal, professional and political demands theyface, health promoters may need to reflect upon the extent to which ’top down’ and’bottom-up’ policy and practice agendas are compatible’~. Reflection will involveexploring similarities, differences and shared understandings of values and action fordeveloping and improving health. Whilst reflective practice may be a desirable sloganto signify a re-orientation of professional education to address these challenges, itsapplication can be problematic. There are many different interpretations and uses forreflection, but these do not inevitably lead to the criticality and sensitivity required tolearn how to tackle action against social exclusion and inequalities that are unfair andunjust, which are central to agendas to promote health and wellbeing. The relationshipof reflection to professional education and development is now considered in order toidentify the possibilities and problems for health promotion.

Reflection, education and professional developmentReflection has long been seen as a key feature of adult learning, which when made aconscious process enables people to apply theory to, and derive it from experience,with the potential for transforming understanding. Mezirow’s identifies levels ofreflection which differentially impact on the learner and their learning sphere. Theseare content reflection, process reflection and premise reflection. Thus adults learn bylooking at what we are doing (content) and how we are doing it (process). Throughasking why (premise) we can go beyond intellectual understanding to transform broaderperspectives and values and gain insights into ’the very structure of cultural andpsychological assumptions which has limited or distorted one’s understanding of selfand relationships’. Mezirow links this deeper level of learning or perspectivetransformation with Freire’s 19 process of ‘conscientisation’ and Habermas’ emancipatoryaction (see also Carr and Kemmis20), both of which propose that learning can radicallychange adults’ understandings and material situations. To do this a particular learningprocess is required that accredits and enhances experience rather than relying on inputsfrom experts. For Freire’9 this involved acknowledging the expertise of the people hewas sent to teach, engaging in a dialogue with them to establish how his skills andresources could be applied in a learning partnership. This process of accreditation wastransformative for the learners, as they defined and acted upon their learning needs ina way that could make a difference to their immediate situation rather than having acurriculum imposed from outside their culture.

Reflection has been translated into particular models and approaches inprofessional work. ‘Reflective observation’ as one of the key stages of Kolb’s 21 learningcycle, is often used in professional training, along with ‘concrete experience’, ’activeexperimentation’ and ’abstract conceptualisation’, to extend and reinforce learning .For Ixer22 it has become’a critical element in the enhancement of&dquo;knowing-for-doing&dquo;’(p514) in professions such as nursing, social work and education. As well as promotingpractical problem-solving it can ’release dormant creative capacities, transporting

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everyday ideas into a new sphere’&dquo;- (p516), leading to the perspective transformationMezirow describes. Thus it would seem that reflection potentially can lead to thecreativity, new ways of thinking and skill development that multidisciplinarypartnerships to promote health and wellbeing and professional training require.

The link between different levels of reflection and learning has had considerableattention in teacher education. Reflection can operate at the simple level of improvingtechnical performance being concerned with questions such as - have thepredetermined goals of the lesson plan been achieved? A second level is broader andaddresses the influence of context on teaching and learning, and consideration ofcompeting educational goals. A third level, which accords with Mezirow’s notion ofperspective transformation, sees education as a form of critical inquiry, with teachersinterrogating their practice in relation to its contribution to a just and humane society.At this level reflection is a social practice, not merely an individual activity23,24. Thusfor Adler

, The area of the probletyzatic moves beyond... the immediate situation into anawareness of ethical and political possibilities. It involves learning to makedecisions about teaching and learning based upon perceived ethical and politicalconsequences attd an awareness of alternatives. The pedagogy utilized to promotecritical enquir y must be designed to encourage students to question, analyze andconsider alternatives within an ethical, and political frame¡yorkl7,

Reflection at this level can, therefore, help us transform our knowledge,understanding and impact in our professional world. For education and training inhealth promotion it promises to make connections between personal, professional andpolitical dimensions of practice to tackle inequalities in health - yet reflection is not anunproblematic activity.

Reflection has dangers as well as advantages~ In spite of the benefits of different levels of reflective learning, reflection does not

necessarily lead to setting ’ourselves free from hidebound patterns of thought andaction’21. It can be superficial and self-congratulatory preventing us from changingand dealing with the world, confirming rather than challenging practice. After all weonly have to think of Narcissus for whom reflection became so self-absorbing that hewas rooted to the side of a pool in which his own beauty was mirrored. There is also adanger of solitary reflection being an infinite regress 26 as we become sucked into avortex of reflecting on reflection that becomes entirely theoretical without unlockingthe capacity for creative action. For Bleakley 27 an ‘excess of consciousness’ may cut usoff and anaesthetise us, making us less rather than more tolerant and prepared tocounteract disadvantage. Sometimes, reflection turned inward on the self can lead tothe internalisation of erstwhile external rules that run counter to emancipation,operating as a form of ’self-surveillance’21. Thus it may impede the capacity to turncriticality into agency to resist oppressive regimes of truth.

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Stark, Stronach and Cooke’9 highlight further dangers when reflection byindividuals, and in teams, is presented as a panacea for difficulties in the workplacecaused by organisational turbulence ‘where rapid changes in context render inflexibleand hierarchical organisations vulnerable’. This turbulence, with its other causes, isoften characterised as a gap between professionals’theory and their practice, and theseauthors are sceptical of the invocation of reflection as a ‘smoothing mechanism’. Theyacknowledge its contribution to education and practice, but argue that focusing onindividual reflection can sometimes be a no-cost diversionary strategy away fromconflict and turbulence which may be caused by ’a real gap [ ... ] between resources andneeds’. They see this as ’deflective’ practice. Their own research shows that many whoadvocate reflection may not be skilled in its facilitation nor have the time or resourcesto support it. Thus the positive activities associated with reflection such as action-research, and the generation of theory from practice&dquo;’, may in fact be resisted by healthprofessionals who are having to cope with the pressures of working in the NHS.

Thus there are potential limitations and tensions in using reflection in learningand development processes. Boud and Walker 31 make a strong case for the incorporationof reflective learning in professional education programmes but they have concernsthat echo those of Stark et al as ’the guise and rhetoric of reflection’ can be used to maskpoor educational practice. Problems arise when reflection becomes a ritualised formof recipe-following, yet without structure and direction it can be inconclusive. Educatorshave both to manage this tension and recognise that reflection cannot be easilycontained. Whilst it can be a liberating and creative process it may also lead to disclosureand trauma that is outside the competence of the learning facilitator.

This has further implications when reflection is linked with assessment,

particularly in relation to the ethical use of power by the assessor. Some learners/practitioners may be wary about engaging in honest reflection as this could make themvulnerable in a situation in which they feel their competence is beingjudged 12 Assessorsneed to be open to different forms of reflection being undertaken and sensitive to culturaland other differences amongst those engaged in reflective processes. The discourse onreflection may be dominated by white academics and practitioners, but it can be aconscious part of everyday practice in some cultures. It can be likened to the act of‘reasoning’ which may take place among Jamaican people

when you check out the position you are coming from, think about the positionother people are comingfrom, does it lzold water... if not, why not, and that startswithin your family and your friends... it’s a whole that informs and influencesthe position that you take 33

Boud’s and Walker’s work reinforces the importance of attention to all levels ofreflection, importantly with reference to the context, noting that it is difficult to promotereflection in situations that may be oppressive in terms of gender, race disability andother forms of difference. However, they remain optimistic and suggest ways of settingup supportive local contexts.

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Graham’s34 research details how through sustained, systematic reflectioncommunity psychiatric nurses (CPNs) with patients of Alzheimer’s Disease were ableto understand their relationships to clients and carers and their relative roles. For Pietronicritical reflection enables practitioners ’to maximise the capacity for critical thought,and produces a sense of professional freedom and a connection with rather than adistance from clients’35. Reflection helped the CPNs to negotiate and renegotiate theirprofessional role. This led to a perceived lessening of the distance between themselvesand other actors within the care partnership whom Statham identifies as needing towork together.

Graham’s account shows how reflection on their own feelings made the CPNsmore sensitive and person-centred (for the client and the practitioner) guarding againsthome visits becoming routinised. Whilst the concern for anti-oppressive practice is notmade explicit in the way that emerges from Boud’s and Walker’s principles for thecontexts for reflection, Graham does show how reflection enabled the CPNs to link the

personal, professional and political dimensions of their work. Through reflection theyrealised that they were valued by their clients and their carers, and gained a sense oftheir own personal power as service providers, which led to confidence in questioningorganisational practices. Through reflection, sanctioned by but occurring outside thework setting, they began to understand when and how they were acting ascommunicators of, and sometimes apologists for trust policy, how this made them feeland what they could do about it.

Even though there are sceptics the discussion so far indicates that reflection canbe a significant aid to learning and professional development, leading to critical thoughtand action - but is this enough? What this might mean for health promotion will beconsidered later in the paper when an approach to reflection is discussed that addressesthe anti-oppressive concerns of Boud and Walker within the dynamic between thepersonal, professional and political aspects of practice. However, the practice of reflectionis not necessarily the same as reflective practice, which requires reflection to be linkedto action informed by the reflective process undertaken, and knowledge gained frombeyond the immediate situation.

The relationship of reflection to reflective practiceThe most notable exponent of reflective practice is Donald Schon36 whose

conceptualisation has been widely quoted and applied. He emphasises the importanceof accrediting practitioners’ experience and challenges what he characterises as thedominant view of professional knowledge, based in positivist epistemology, whichseparates theory and research from the world of practice. He argues that this results in’technically rational’ formulae for working with people developed on the high groundof academia. Such formulae are often ill-equipped to deal with real life practical problemsin the swampy lowlands of practice. For Sch6n, the positivist paradigm whichemphasises the ’objective’ application of knowledge, leads to the practitioner’s stance

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being that of’spectator/manipulator’. The reflective practitioner recognises his or herinvolvement in a situation as inevitable. ’The sense he makes of it must include his own

contribution to it,31 , and therefore such detachment is an artificial construct.Reflective practice is ’conceived of as an interactive process through which

concepts and frameworks are’made to measure’ ’25, in order to face unique, uncertainconditions - ‘indeterminate zones of practice’ - for which there are no blueprints thatcan translate into straightforward solutions. Schon developed his thesis throughobservation of how practitioners in a variety of occupational contexts displayed’professional artistry’ in their work, improvising and using their creativity to handleuncertainty. This professional artistry is achieved through ‘retlection-in-action’,undertaken sensitively in ’an action-present - a stretch of time within which it is stillpossible to make a difference to the outcomes of an action’ . Schon claims that in’reflection in action’ he has discovered a new epistemology of professional practice. Heprovides protocols for working alongside a mentor who acts as a role model or coach.Sustained improvement of practice relies on ’reflection on action’, looking back,evaluating and learning from what we have done in order to develop the‘intelligence inaction’ when difficult, on-the-spot judgements have to be made.

Although reflective practice has become popular in a wide range of professions,Sch6n’s claim to have developed a new epistemology has been questioned. If learning isaccepted as ’a socialisation into particular practices’ then ’simply making explicit whatis implicit does not in itself transform the implicit area into a new epistemology.Also, as Adler notes, the emphasis in Sch6n’s epistemology of practice is on ’doing thejob effectively’, and, paradoxically, this is a technicist approach to problem solving withinthe paradigm that he attacks. She argues that in teaching, educating the retlectivepractitioner implies reform and has become a slogan for change around which educatorscan rally. However, ’that which is open to question is one’s technical practice, theimplementation of the curriculum, not the goals embedded in the curriculum, nor theschool structure itself’ 17. What seems to be missing in the way reflection is commonlyused is to go beyond the immediate into criticality of the context and the wider, moraland political issues that impact on practice. These issues often coalesce into’indeterminate zones’ which for Sch6n are endemic in professional work in any sphere.

Reflective practice and reflexivityAlthough Sch6n’s work has been foundational and reflective practice has become anembedded concept within the literature of professional education, there is a need to gobeyond the terrain of reflection that he demarcates in order to address the dynamicbetween the personal, professional and political dimensions of practice which areparticularly significant in health promotion and allied occupations. Dealing with theseindeterminate zones implies a criticality that Carr and Kemmis ascribe to Habermas’notion of ’critical social science’, in order to move beyond the ’structurally imposedrestraints of positivism’and the‘uncritical renderings of individuals’self understanding’

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of interpretivism20. It is for this reason that some authors apply the term reflexivity toilluminate the positioning of the worker in relation to the ethical and political dilemmasof human service.

Within critical social science the term reflexivity is not only applicable toprofessional practice, it is employed more broadly as an individual and social process.It is conceptualised as the capacity through which human beings accommodate to, andact to construct, their social world as they are confronted by and create changingrelationships and social structures. For Giddens38 the social sciences play an importantrole in retlexivity whereby ’most social activity and material relations with nature’ aresusceptible to ’chronic revision in the light of new information or knowledge. Suchinformation is not incidental to modern institutions, but constitutive of them’. However,Giddens sees reflexivity as an increasingly individualised activity in which peoplebecome obsessed with their own self trajectories, echoing the concerns raised byBleakley about the dangers of reflection. As with reflection, individual and socialdimensions become fragmented and disconnected.

However, for Taylor and White3‘~, in the sphere of health and welfare it is the notionof reflexivity which encompasses the possibility to interrogate our assumptions as bothprofessionals and human beings, in the way enjoined by Zeichner, Ixer and Mezirow,referred to earlier. Like Adlerl’, Taylor and White view reflective practice as a pragmaticactivity focusing on the technical competence of the individual. However for theseauthors, although reflexivity shares its origins with reflection in the same Latin verbrej1ectere) as a social phenomenon it links the personal, with the professional andpolitical. ’The &dquo;bending back&dquo; is not simply the individualized action of separatepractitioners ... it is the collective action of an academic discipline or occupationalgroup’39..

The problems of disentangling the semantics of reflection, reflective practice andreflexivity is illustrated by examples from research the author undertook in 1997-98,with women whose professional and voluntary activity covered a wide range of contextsin health, education and social care 33 . Their experience illustrated how the flexibility ofreflective practice meant that the concept could be invoked by those with competingideological positions. In some of their work settings it had become a superficial,mechanistic activity in which boxes were ticked in relation to outcomes achieved orcompetences demonstrated, reflecting new managerial imperatives. Respondentsexpressed dissatisfaction with this focus on task-centred reflection which acted as aform of self surveillance, falling into the danger of separating the practitioner, from theoverall context impacting on them. However, research participants had otherinterpretations and many were concerned not to be diverted from a reflective critiquewhich challenged the macrosocietal causation of problems whose solution lay inorganisational and political change.

These women used alternative systems through activities such as diary writingand networking to promote reflection at individual and group levels. Reflective practice

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had sometimes been learned elsewhere than the immediate work context throughinvolvement in activities such as feminist organising or nonmanagerial supervision,and for many there was necessarily a political edge. Thus reflection involved questioningtheir organisational context, critically evaluating and trying to change practice in relationto their professional, political and personal value-bases. The synthesis between reflectiveand anti-oppressive practice was central. One research participant described

reflective, anti-oppressive practice as a may of life, a state of being, it encompassesones ’ personal, social and professional practice. The long-term goal being thecreation of a more inclusive society;’-.

This summed up the feelings of a number of women who realised that whilst thiswas demanding and seemingly idealistic, constantly checking back with the value-base’32, helped link ideals and action, preventing practice from becoming reductionistand self-confirming. In order to maintain integrity, reflection often had to take placeoutside of the work setting, in order to put action into a wider professional/politicalperspective. In this way reflection in professional learning and development for humanservice becomes a critical, but also personally demanding activity. It is not neutral interms of class, race, gender and other forms of difference. It incorporates feministanalysis in which the bending back of reflexivity will inevitably be framed by experienceof such differences, which will affect the way we simultaneously react to and constructour social world40. This is qualified by our agency, our capacity to act autonomously,which includes the possibility of taking action, or choosing not to, within and againstsocial divisions, and recognises the limitations and possibilities of the structuring ofsuch divisions.

Reflective practice, professional education and healthpromotionHow do we sum up what we are looking for in relation to reflective practice forprofessional education, training and development in health promotion? In tacklinginequalities in health and wellbeing we are dealing with indeterminate zones of practice,which have been characterised by challenge and change from social movements. To beof use reflection has to go beyond simply looking at what practitioners are doing to linkwith social change. It will involve examining the synchronicity and tensions betweenpersonal, professional and political values and practice. In health promotion a widerange of technical competence is required, appropriate to a variety of professions andsettings. A critical interpretation of reflective practice can incorporate concerns toaccredit and extend technical competence whilst recognising that reflection is not aneutral activity. It will be framed in relation to social divisions and other contextualand political factors.

Figure 2 presents a conceptualisation of reflective practice that was informed, inpart through the research quoted above, but is in a continuous state of revision to meetvarying needs.

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FIGURE 2 Conceptualising critical reflective practice

Rather than offering a blueprint the aim of the visual summary presented inFigure 2 provides a stimulus to thought and questioning and, somewhat ambitiously, toindicate a multidimensional dynamic in two dimensions, as it seeks to show the interplayof personal, political and professional factors in relation to practice. The summary drawsupon some of Schon’s key ideas in relation to the uniqueness of professional work whichinvolves dealing with the value-base that can inform our approach to ’indeterminatezones of practice’. These are often contested concepts and situations faced by healthpromoters that are involved in determining and applying professional values. It retainsthe term reflective practice which the literature on professional education tends to use,even though other authors influenced by sociological theory prefer reflexivity to beapplied to health and welfare. Reflection, as interpreted in Figure 2 distinguishes betweenreflexivity as a social phenomenon applicable to all of us in our daily lives, and reflection

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which is the way reflexivity can be made a conscious part of learning and developmentfor human service. Critical reflective practice becomes a specialised term analogous tothe way ’active listening’ denotes how an everyday activity can be tuned and appliedskilfully in professional contexts4] .

Figure 2 is currently employed with multidisciplinary professional groups ofstudents on the postgraduate Diploma/MA in Health Promoting Practice at ManchesterMetropolitan University to examine their technical knowledge, ability and values inrelation to personal, professional and political dimensions of health promotion.Reflection is systematically integrated into assignments, and teaching and learningstrategies, both face-to-face and at a distance. It reminds students of the location ofpersonal, professional practice within a wider political context. It can help accreditstrengths and also highlight areas for new learning and improvement. Differentdimensions of practice can be focused on separately or simultaneously, and the approachis constantly being reframed through ongoing dialogue in student groups.

The approach to critical reflective practice advocated above presents challengesfor course tutors, as the roles of learner and expert becomes diffused between studentsand lecturers. In implementing this approach lecturers have to demonstrate theirpreparedness to apply critical reflection to their own practice and be particularly opento learning and development through exchanges with their students42.

Reflective practice, health promotion and professionaleducation and trainingWhilst health promoters may seek clearly defined standards and outcomes within whichto frame and measure their action, they also need to be creative and visionary in orderto develop new ways of knowing and practising. This review of reflection and reflectivepractice shows that whilst there are inconsistencies there are many useful features thatcan be built upon to assist with managing tensions to provide a critical, retlexiveapproach in education and training. Unfortunately, we cannot take comfort from thecertainty of’there being any one meaning for reflective practice’43. Professionals maybe required, or voluntarily choose to engage in different interpretations of ’reflectivepractices’, and it is important to acknowledge that Sch6n’s work prepares us for this.Health promoters, as managers, educators, service planners, facilitators or providers,will have to understand and utilise different conceptualisations of reflection‘in’ and‘on’practice. For Bleakley 27, a strength is that’Schon’s view of reflection-in-action is of aneducation into tolerance of ambiguity’. This can be used in professional education and

*The author is currently engaged in researching good practice in managing distancelearning on postgraduate programmes within the Department of Humanities andApplied Social Studies in her capacity as Senior Learning and Teaching Fellow. Initialanalysis of findings from four cohorts of students representing different sectors ofhealth, welfare and education suggests that the approach to reflection in Figure 2 wasa key element in enabling them critically to evaluate and integrate health promotingpractice and theory.

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training to prepare ourselves for the complexities and challenges of the current policyand practice context in health promotion, without any false hopes that reflection canprovide a prescriptive approach to the indeterminate zones and uncertainties that maybe involved in this process.

Reflective learning can be derived from the critique of inequality developed inthe sphere of health, and the debates and action for anti-oppressive practice developedwithin social care, youth and community work, voluntary organisations and feministand other social movements. The creation of theory and practice relevant to multiagencyeducation for health and wellbeing will involve redefining existing professionalboundaries and training, with critical reflective learning linked to practice. For healthpromotion this may further fan the flame of existing uncertainties concerningprofessional identity and even though there are moves towards standardisation, theprocess of disaggregating occupational areas into competences is not withoutcontradiction’15. In light of the issues discussed in this article it is interesting to notethat whilst reflection and anti-oppressive practice were foundational to two key roles inNational Occupational Standards for Professional Activity in Health Promotion andCare, although they are mentioned, they appear not to have the same underpinningfunction in the National Standards for Specialist Practice in Public Health‘~~.

The critical conceptualisation of reflective practice presented in Figure 2acknowledges that reflective practice does not offer a straightforward way of dealingwith the dilemmas faced by health promotion, in managing the tension between thevision of overcoming inequalities in health and wellbeing and the route through whichthis is achieved. Critical reflection, which builds upon the spirit of openness and enquiryin Sch6i~s work helps us learn about and evaluate our own and others’ practice anddebate the key issues and identify ways forward. It is a demanding process and is notoffered as a ’retreat inside ourselves in order to find ways of surviving...adverseconditions>13, rather than seeking collective solutions. Learning about and implementingnew ways of improving health is central to health promotion. Reflective practice, when

approached systematically and with criticality, has the potential to enable practitionersfrom the wide variety of backgrounds for whom the improvement of health is a priorityto understand and act in relation to the personal, professional and political challengesthey face.

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