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Reflection—context and definition, reflection in practice, a typology for reflective practice in health promotion, barriers to reflection, conflict of interest statement.

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Reflection—a neglected art in health promotion

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Paul Fleming, Reflection—a neglected art in health promotion, Health Education Research , Volume 22, Issue 5, October 2007, Pages 658–664, https://doi.org/10.1093/her/cyl129

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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.

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.

… 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.

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.

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.

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.

A Typology for Reflective Practice in health promotion.

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:

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?

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?

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.

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.

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.

None declared.

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Teaching critical reflection in health professions education with transformative-vygotskian praxis

• Published: 08 March 2023
• Volume 28 , pages 1191–1204, ( 2023 )

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Reflective practice is a complex concept to adequately describe, communicate about and, ultimately, teach. Unrelieved tensions about the concept persist within the health professions education (HPE) literature owing to reflection’s diverse theoretical history. Tensions extend from the most basic, e.g., what is reflection and what are its contents, to the complex, e.g., how is reflection performed and whether it should be evaluated. Nonetheless, reflection is generally seen as vital to HPE, because it imparts crucial strategies and awareness to learners in their professional practices. In this article, we explore both conceptual and pedagogical dimensions of teaching for reflection. We address the concept of reflection, its application to practice, and how to remain faithful to transformative, critical pedagogy when teaching for it. We present (a) an analysis of two theories of education in HPE: Transformative Learning and Vygotskian Cultural Historical Theory. We (b) outline a pedagogical approach that applies Piotr Gal’perin’s SCOBA: schema for the complete orienting basis of an action. We then employ (a) and (b) to provide affordances for developing materials for educational interventions across HPE contexts.

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Dialogic Reflection: An Exploration of Its Embodied, Imaginative, and Reflexive Dynamic

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Acknowledgements

Christina Weese for the visual design of the conceptual SCOBA. Douglas Buller for the visual design of the procedural SCOBA. Lindsay Baker and Lindsay Herzog for informing and supporting the SCOBA design. Members of the Bridging Lab for their feedback during the conceptualization and design phases of the SCOBA.

Work for this article was funded by the Arrell Family Chair in Health Professions Teaching and the AMS Healthcare Foundation.

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Diaz, B.A., Rieker, J. & Ng, S. Teaching critical reflection in health professions education with transformative-vygotskian praxis. Adv in Health Sci Educ 28 , 1191–1204 (2023). https://doi.org/10.1007/s10459-023-10209-y

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Health, well-being and education: Building a sustainable future. The Moscow statement on Health Promoting Schools

Health Education

ISSN : 0965-4283

Article publication date: 18 March 2020

Issue publication date: 4 June 2020

The purpose of this paper is to introduce the official statement of the Fifth European Conference on Health-Promoting Schools.

Design/methodology/approach

The Fifth European Conference on Health-Promoting Schools was held on 20–22 November 2019 in Moscow, Russian Federation, with over 450 participants from 40 countries. A writing group was established to prepare a draft version of the statement before the conference. On the basis of an online and offline feedback process, the opinions of the participants were collected during the conference and included in the finalisation of the statement.

The final conference statement comprises six thematic categories (values and principles; environment, climate and health; schools as part of the wider community; non-communicable diseases (NCDs); evidence base; and digital media), with a total of 23 recommendations and calls for action.

Originality/value

The recommendations and calls for action reflect current challenges for Health Promoting Schools in Europe. They are addressed to all actors in governmental, non-governmental and other organisations at international, national and regional levels involved in health promotion in schools and are to be applied for the further development of the concept.

• Health Promoting Schools
• Social change
• Child and adolescent health
• School health promotion

Dadaczynski, K. , Jensen, B.B. , Viig, N.G. , Sormunen, M. , von Seelen, J. , Kuchma, V. and Vilaça, T. (2020), "Health, well-being and education: Building a sustainable future. The Moscow statement on Health Promoting Schools", Health Education , Vol. 120 No. 1, pp. 11-19. https://doi.org/10.1108/HE-12-2019-0058

Emerald Publishing Limited

Copyright © Kevin Dadaczynski, Bjarne Bruun Jensen, Nina Grieg Viig, Marjorita Sormunen, Jesper von Seelen, Vladislav Kuchma and Teresa Vilaça

Published in Health Education . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at: http://creativecommons.org/licences/by/4.0/legalcode

1. The Health Promoting Schools approach and its development

The Ottawa Charter, adopted in 1986, was a milestone in the development of a holistic and positive understanding of health that requires actions at different levels, from healthy public policy to the development of personal skills, using different strategies, such as enabling and advocacy approaches ( WHO, 1986 ). The charter can also be regarded as marking the birth of whole-school approaches to health that have been established in Europe and internationally under the term Health Promoting Schools ( Stewart Burgher et al. , 1999 ).

A Health Promoting Schools reflects a holistic approach that moves beyond individual behaviour change by also aiming at organisational change through strengthening the physical and social environment, including interpersonal relationships, school management, policy structures and teaching and learning conditions. This approach can be seen as the result of overcoming traditional health education at school, which aimed to influence students' knowledge, attitudes and behaviour ( Clift and Jensen, 2005 ). In accordance with a social-ecological perspective, health is considered to be the result of a complex interplay of individual, social, socio-economic and cultural factors ( Dahlgreen and Whitehead, 1991 ). Since the early 1990, actions on school health promotion have been coordinated in national networks and the European network on Health Promoting Schools as a WHO supported network. The current work on school health promotion on a European level is organised through the Schools for Health in Europe Network Foundation (SHE), with national representatives from 36 countries.

Values of the Health Promoting Schools approach

Health Promoting Schools ensure equal access for all to the full range of educational and health opportunities. This in the long term makes a significant impact in reducing inequalities in health and in improving the quality and availability of lifelong learning.

Sustainability

Health Promoting Schools acknowledge that health, education and development are closely linked. Schools act as places of academic learning. They support and develop a positive view of pupils' future role in society. Health Promoting Schools develop best when efforts and achievements are implemented in a systematic and continuous way. Desirable and sustainable health and educational outcomes occur mostly in the medium or long term.

Health Promoting Schools celebrate diversity and ensure that schools are communities of learning, where all feel trusted and respected. Good relationships among pupils, between pupils and school staff and between school, parents and the school community are important.

Empowerment

Health Promoting Schools enable children and young people, school staff and all members of the school community to be actively involved in setting health-related goals and in taking actions at school and community level to reach the goals.

Health Promoting Schools are based on democratic values and practise the exercising of rights and taking responsibility.

Pillars of the Health Promoting Schools approach

Whole-school approach to health

Taking a participatory and action-oriented approach to health education in the curriculum;

Taking into account the pupil's own concept of health and well-being;

Developing healthy school policies;

Developing the physical and social environment of the school;

Developing life competencies and health literacy;

Making effective links with home and the community; and

Making efficient use of health services.

Participation

A sense of ownership is fostered by pupils, staff and parents through participation and meaningful engagement, which is a prerequisite for the effectiveness of health-promoting activities in schools.

School quality

Health Promoting Schools support better teaching and learning processes. Healthy pupils learn better, and healthy staff work better and have greater job satisfaction. The school's main task is to maximise educational outcomes. Health Promoting Schools support schools in achieving their educational and social goals.

School health promotion in Europe is informed by existing and emerging research and evidence focused on effective approaches and practice in school health promotion, both on health topics (such as mental health, eating and substance use) and on the whole-school approach.

Schools and communities

Health Promoting Schools engage with the wider community. They endorse collaboration between the school and the community and are active agents in strengthening social capital and health literacy.

Since the establishment of the European network of Health Promoting Schools, four European conferences on Health Promoting Schools have been organised. The resolution of the first conference, held in Thessaloniki, Greece, in 1997, stated that every child and young person in Europe had the right to be educated in a Health Promoting Schools and urged governments in all European countries to adopt the Health Promoting Schools approach ( ENHPS, 1997 ). The Egmont Agenda was published in 2002 as a result of the Second European Conference on Health Promoting Schools in The Netherlands and emphasised conditions, programming and evaluation as being essential to developing and sustaining Health Promoting Schools ( ENHPS, 2002 ).

Seven years later, the Third European Conference on Health Promoting Schools was held in Vilnius, Lithuania ( SHE Network, 2009 ). The conference and its resolution marked an important milestone in the development of the Health Promoting Schools approach by highlighting that education and health have shared interests and complement each other. Based on this, joint actions beyond sectoral responsibilities were urged.

The Fourth European Conference was held in Odense, Denmark, in 2013 and resulted in The Odense Statement, which recognised the core values and pillars of school health promotion as a strong contributor to the aims and objectives of the WHO policy framework for health and well-being in Europe, Health 2020 and the EU2020 strategy for inclusive and sustainable growth ( SHE Network, 2013 ).

2. Recent societal challenges

Since the establishment of the Health Promoting School approach in the late 1980s, the world has seen constant societal change, with progressively faster dynamics during recent years. The changes have not only altered substantially the conditions in which people grow up and live, but have also affected behaviours in relation to health, social cohabitation, learning and working. Wars and violence, often rooted in cultural and religious differences or political and economic crisis, and climate change alter significantly the environmental and societal determinants of health ( Mucci et al. , 2016 ; Watts et al. , 2019 ).

Often, it is countries that already are experiencing political and socio-economic instability that feel the effects most ( Reibling et al. , 2017 ). An increase in international migration, commonly in perilous circumstances for migrants and refugees ( Silove et al. , 2017 ), is the consequence, raising social tensions and challenges in many countries, some of which are undergoing political developments characterised by protectionism and isolationism that can partly be seen as a countermovement to the idea, values and principles of Europe ( Harteveld et al. , 2018 ).

In many cases, uncertainty has replaced political, economic, social and individual stability, raising concern and anxiety about the future in young people and adults. This has led to an unprecedented social (grassroots) movement of participation, primarily driven by young people who are demanding social, political, ecological and economic change ( O'Brien, Selboe and Hayward, 2018 ).

These developments should not be seen as being separate from school health promotion, the aim of which is to support young people to develop healthy and self-determined lifestyles and enable them to co-create their social, physical and ecological environments and the determinants of health positively and sustainably ( Clift and Jensen, 2005 ; Simovska and McNamara, 2015 ). As the conditions for growing up and living together change, the question arises of how schools, as places for health-related teaching, learning and development, need to adapt.

Where does the Health Promoting School approach stand today, more than 30 years after the Ottawa Charter on health promotion? Can the Health Promoting School, with its holistic orientation, deliver on its promise of addressing health inequalities and improving children's and young people's health, well-being and academic achievement? To what extent can school health promotion be implemented systematically in schools and be linked to local communities?

These and more questions were raised and discussed during the Fifth European Conference on Health Promoting School, culminating in recommendations for the future development of the Health Promoting School approach.

3. The Fifth European Conference on Health Promoting Schools

The Fifth European Conference on Health Promoting Schools was held on 20–22 November 2019 in Moscow, Russian Federation, with over 450 participants from 40 countries.

A range of topics was addressed through more than 160 contributions and nine keynote presentations focusing on conceptual aspects of the Health Promoting School approach, implementation and dissemination and current social change processes, such as digitisation and heterogeneity.

Holistic approaches to school-based health promotion and health education (such as organizational change and environmental approaches to school health promotion and strategies to promote individual and organizational health literacy in schools);

Implementation and dissemination of school-based health promotion and health education (facilitators and barriers to implementing interventions in school-based health promotion and professional development and capacity-building of, for example, teachers, non-teaching school staff, school health services, parents and external professionals);

Networking and intersectoral collaboration in school-based health promotion and health education (schools as part of the wider community, and multisectoral partnerships at local, national and international levels);

Innovative approaches to dealing with heterogeneity, inclusion and special needs (pupils' and teachers' health in inclusive schooling, school-based health promotion and education for refugees, students with special needs and innovative approaches to school-based health services); and

Digital media and information and communications technology (ICT) in school health promotion and health education (practical approaches to ICT use in school-based health promotion and digital devices and media as a target for interventions and a means to promote health and well-being).

4. Recommendations for action

Be based on democratic processes and foster equal access, active involvement and participation;

Take into account the needs and background of all young people regardless of their gender, geographical, cultural and social background or religious beliefs: in that sense, a Health Promoting School can be seen as an inclusive school that celebrates heterogeneity and diversity as an enriching dimension for mutual learning, respect and acceptance;

Reflect a whole-school approach addressing different target groups and combining classroom activities with development of school policies, the physical, social and cultural environment of the school and the necessary capacities needed: we welcome new and established concepts and approaches within school-based health promotion, such as health literacy, salutogenesis, action competence and life skills, which should complement each other and be integrated in the holistic framework of the Health Promoting School approach; and

Be systematically linked with educational goals and school quality as part of a so-called add-in approach: based on rich evidence, a Health Promoting School can be regarded as a school that not only promotes and maintains health, but also strives for successful learning for pupils and working conditions for teaching and non-teaching staff, and involves parents and families in the school's daily life.

Urge all stakeholders in health and climate/sustainability education to work together systematically to support young people to grow up and live healthily and sustainably;

Urge all stakeholders to support and empower young people to raise their voice and make a lasting contribution to shaping a healthy and sustainable future for themselves and their fellow human beings;

Call for actions to link planetary health and the Health Promoting School approach more explicitly by, for instance, integrating the impact of human action on the environment and its health consequences into school curricula and everyday life; and

Call for realignment of health-promotion research agendas to address environmental challenges in, with and through schools.

All actors to move from a single-setting approach to an integrated multi-setting approach that systematically links actions at school level with actions in the local community: these actions should not be implemented in isolation, but in a coordinated fashion to create synergies and avoid discontinuities;

Intersectoral collaboration among different actors and professions, such as teachers, school health services and social and youth-care services: this requires professional development, and that existing local networks and their leadership capacities be strengthened to align sectoral policies and enable the development of a common vision and language; and

All actors to strengthen links with existing national and regional cooperation mechanisms, such as Health Promoting School networks and healthy city or healthy region networks, by pursuing joint objectives and actions.

A resource-oriented intervention approach (as described in the SHE values and pillars) be taken to tackle NCDs rather than a traditional top-down and disease-oriented approach, which normally dominates interventions related to risk factors;

Young people be viewed as part of the solution and not only as part of the problem of NCDs – we need to work with young people as powerful agents of healthy change and not as victims and recipients of risk factors;

A school environment that promotes healthy practices in areas like healthy eating, physical activity, social and emotional well-being and good hygiene be created; and

Commercial determinants are addressed by empowering young people to become critical and responsible citizens who are able to understand and critically reflect on media advertising and market mechanisms through, for instance, consumer education.

Call for evaluation approaches that reflect the complexity of the Health Promoting School by, for example, applying mixed-methods designs and considering graded health and educational outcomes;

Demand that the available scientific evidence be reviewed and evaluated using existing tools and be translated into recommendations for practical action;

Urge that a one-sided focus on outcomes research be augmented by focusing also on implementation to identify the conditions under which interventions can be effective, systematically linking both research perspectives; and

Call for systematic and strong partnerships between researchers and practitioners who develop and implement innovative interventions in school health promotion and those who conduct empirical surveys on child and adolescent health (such as the Health Behaviour in School-aged Children (HBSC) study) and the health of teaching and non-teaching staff. By sharing available social-epidemiological data, previously untried evaluation potential can be exploited.

Call on all actors in school health promotion to use the possibilities of digital media in the context of research, development, implementation and exchange of innovative interventions and good practice;

Urge all actors to use digital media as a supplement to, and not as a substitute for, non-digital (face-to-face) school health-promotion actions;

Call on all actors to ensure that the use of digital media does not lead to a step back to individual and behavioural prevention, but rather is used at organisational level to, for instance, build capacity, communicate with partners outside the school and promote low-threshold participation in change processes within the school; and

Call for actions to empower individuals and whole-school systems to deal effectively with health information complexity, including its critical assessment, selection and use and to take responsibility for providing suitable and reliable health information.

The Health Promoting School approach

Buijs , G.J. ( 2009 ), “ Better schools through health: networking for health promoting schools in Europe ”, European Journal of Education , Vol. 44 No. 4 , pp. 507 - 520 .

Clift , S. and Jensen , B.B. ( 2005 ), The Health Promoting School: International Advances in Theory, Evaluation and Practice , Danish University of Education Press , Copenhagen .

Dahlgren , G. and Whitehead , M. ( 1981 ), Policies and Strategies to Promote Social Equality in Health , Institute of Future Studies , Stockholm .

European Network of Health Promoting Schools (ENHPS) ( 2002 ), The Egmond Agenda. A New Tool to Help Establish and Develop Health Promotion in Schools and Related Sectors across Europe , available at: https://tinyurl.com/y2py8wzr ( accessed 19 November 2019 ).

European Network of Health Promoting Schools (ENHPS) ( 1997 ), “ Conference resolution ”, available at: https://tinyurl.com/wcunrec ( accessed 19 November 2019 ).

Harteveld , E. , Schaper , J. , De Lange , S.L. and Van Der Brug , W. ( 2018 ), “ Blaming Brussels? the impact of (news about) the refugee crisis on attitudes towards the EU and national politics ”, JCMS: Journal of Common Market Studies , Vol. 56 No. 1 , pp. 157 - 177 .

Mucci , N. , Giorgi , G. , Roncaioli , M. , Perez , J.F. and Arcangeli , G. ( 2016 ), “ The correlation between stress and economic crisis: a systematic review ”, Neuropsychiatric Disease and Treatment , Vol. 12 , pp. 983 - 993 .

O'Brien , K. , Selboe , E. and Hayward , B. ( 2018 ), “ Exploring youth activism on climate change: dutiful, disruptive, and dangerous dissent ”, Ecology and Society , Vol. 23 No. 3 , p. 42 .

Reibling , N. , Beckfield , J. , Huijts , T. , Schmidt-Catran , A. , Thomson , K.H. and Wendt , C. ( 2017 ), “ Depressed during the depression: has the economic crisis affected mental health inequalities in Europe? findings from the European social survey (2014) special module on the determinants of health ”, The European Journal of Public Health , Vol. 27 Suppl 1 , pp. 47 - 54 .

Schools for Health in Europe (SHE) Network ( 2013 ), “ The Odense Statement. Our ABC for equity, education and health ”, available at: https://tinyurl.com/rk8rh5e ( accessed 19 November 2019 ).

Schools for Health in Europe (SHE) Network ( 2009 ), “ Better schools through health: the Third European Conference on Health Promoting Schools. Vilnius resolution ”, available at: https://tinyurl.com/qskr692 ( accessed 19 November 2019 ).

Silove , D. , Ventevogel , P. and Rees , S. ( 2017 ), “ The contemporary refugee crisis: an overview of mental health challenges ”, World Psychiatry , Vol. 16 No. 2 , pp. 130 - 139 .

Simovska , V. and McNamara , P. (Eds) ( 2015 ), Schools for Health and Sustainability , Springer , Dordrecht .

Stewart Burgher , M. , Barnekow , V. and Rivett , D. ( 1999 ), The European Network of Health Promoting Schools. The Alliance of Education and Health , WHO Regional Office for Europe , Copenhagen .

Watts , N. , Amann , M. , Arnell , N. , Ayeb-Karlsson , S. , Belesova , K. , Boykoff , M. , … and Chambers , J. ( 2019 ), “ The 2019 report of the Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate ”, The Lancet , Vol. 394 No. 10211 , pp. 1836 - 1878 .

WHO ( 2016 ), Declaration: Partnerships for the Health and Well-Being of Our Young and Future Generations. Working Together for Better Health and Well-Being: Promoting Intersectoral and Interagency Action for Health and Well-Being in the WHO European Region , WHO Regional Office for Europe , Copenhagen .

WHO ( 1986 ), “ Ottawa Charter for Health Promotion ”, available at: https://tinyurl.com/mohfbn6 ( accessed 19 November 2019 ).

Acknowledgements

This publication has received funding under an operating grant from the European Union's Health Programme.

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• Open access
• Published: 21 May 2024

Health profession education hackathons: a scoping review of current trends and best practices

• Azadeh Rooholamini   ORCID: orcid.org/0000-0002-9638-7953 1 &
• Mahla Salajegheh   ORCID: orcid.org/0000-0003-0651-3467 1  

BMC Medical Education volume  24 , Article number:  554 ( 2024 ) Cite this article

Metrics details

While the concept of hacking in education has gained traction in recent years, there is still much uncertainty surrounding this approach. As such, this scoping review seeks to provide a detailed overview of the existing literature on hacking in health profession education and to explore what we know (and do not know) about this emerging trend.

This was a scoping review study using specific keywords conducted on 8 databases (PubMed, Embase, Scopus, Web of Science, ERIC, PsycINFO, Education Source, CINAHL) with no time limitation. To find additional relevant studies, we conducted a forward and backward searching strategy by checking the reference lists and citations of the included articles. Studies reporting the concept and application of hacking in education and those articles published in English were included. Titles, abstracts, and full texts were screened and the data were extracted by 2 authors.

Twenty-two articles were included. The findings are organized into two main categories, including (a) a Description of the interventions and expected outcomes and (b) Aspects of hacking in health profession education.

Hacking in health profession education refers to a positive application that has not been explored before as discovering creative and innovative solutions to enhance teaching and learning. This includes implementing new instructional methods, fostering collaboration, and critical thinking to utilize unconventional approaches.

Peer Review reports

Introduction

Health professions education is a vital component of healthcare systems to provide students with the knowledge, skills, and attitudes necessary to provide high-quality care to patients [ 1 ]. However, with the advent of innovative technologies and changing global dynamics, there is a growing need to incorporate new educational methods to prepare medical science students for the future [ 2 ].

Although traditional methods can be effective for certain learning objectives and in specific contexts and may create a stable and predictable learning environment, beneficial for introducing foundational concepts, memorization, and repetition, however, they may not fully address the diverse needs and preferences of today’s learners [ 3 ]. Some of their limitations may be limited engagement, passive learning, lack of personalization, and limited creativity and critical thinking [ 4 ].

As Du et al. (2022) revealed the traditional teaching model fails to capture the complex needs of today’s students who require practical and collaborative learning experiences. Students nowadays crave interactive learning methods that enable them to apply theoretical knowledge in real-world situations [ 5 ].

To achieve innovation in health professions education, engaging students and helping them learn, educators should use diverse and new educational methods [ 6 ]. Leary et al. (2022) described how schools of nursing can integrate innovation into their mission and expressed that education officials must think strategically about the knowledge and skills the next generation of students will need to learn, to build an infrastructure that supports innovation in education, research, and practice, and provide meaningful collaboration with other disciplines to solve challenging problems. Such efforts should be structured and built on a deliberate plan and include curricular innovations, and experiential learning in the classroom, as well as in practice and research [ 7 ].

The incorporation of technology in education is another aspect that cannot be ignored. Technology has revolutionized the way we communicate and learn, providing opportunities for students to access information and resources beyond the traditional education setting. According to the advancement of technology in education, hacking in education is an important concept in this field [ 8 ].

Hack has become an increasingly popular term in recent years, with its roots in the world of computer programming and technology [ 9 ]. However, the term “hack” is not limited solely to the realm of computers and technology. It can also refer to a creative approach to problem-solving, a willingness to challenge established norms, and a desire to find new and innovative ways to accomplish tasks [ 10 ]. At its core, hacking involves exploring and manipulating technology systems to gain a deeper understanding of how they work. This process of experimentation and discovery can be applied to many different fields, including education [ 11 ].

In education, the concept of “hack” has become popular as educators seek innovative ways to engage students and improve learning outcomes. As Wizel (2019) described “hack in education” involves applying hacker mentality and techniques, such as using technology creatively and challenging traditional structures, to promote innovation within the educational system [ 12 ]. These hacking techniques encompass various strategies like gamification, hackathons, creating new tools and resources for education, use of multimedia presentations, online forums, and educational apps for project-based learning [ 9 ]. Butt et al. (2020) demonstrated the effectiveness of hack in education in promoting cross-disciplinary learning in medical education [ 13 ]. However, concerns exist about the negative connotations and ethical implications of hacking in education, with some educators hesitant to embrace these techniques in their classrooms [ 7 , 14 ].

However, while the concept of hack in education has gained traction in recent years, there is still a great deal of uncertainty surrounding its implementation and efficacy. As such, this scoping review seeks to provide a comprehensive overview of the existing literature on hacking in health profession education (HPE), to explore what we know (and do not know) about this emerging trend. To answer this research question, this study provided a comprehensive review of the literature related to hacking in HPE. Specifically, it explored the various ways in which educators are using hack techniques to improve learning outcomes, increase student engagement, and promote creativity in the classroom.

Methods and materials

This scoping review was performed based on the Arksey and O’Malley Framework [ 15 ] and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to answer some questions about the hacking approach in health professions education [ 16 ].

Search strategies

The research question was “What are the aspects of hacking in education?“. We used the PCC framework which is commonly used in scoping reviews to develop the research question [ 17 ]. In such a way the Population assumed as learners, the Concept supposed as aspects of hacking in education, and the Context is considered to be the health profession education.

A systematic literature search was conducted on June 2023, using the following terms and their combinations: hack OR hacking OR hackathon AND education, professional OR “medical education” OR “medical training” OR “nursing education” OR “dental education” OR “pharmacy education” OR “health professions education” OR “health professional education” OR “higher education” OR “healthcare education” OR “health care education” OR “students, health occupations” OR “medical student” OR “nursing student” OR “dental student” OR “pharmacy student” OR “schools, health occupations” OR “medical school” OR “nursing school” OR “dental school” OR “pharmacy school”) in 8 databases (PubMed, Embase, Scopus, Web of Science, ERIC, PsycINFO, Education Source, CINAHL) with no time limitation. (A copy of the search strategy is included in Appendix 1 ). To find additional relevant studies, we conducted a forward and backward searching strategy by checking the reference lists and citations of the included articles.

Inclusion and exclusion criteria

Original research reporting the different aspects of hacking in health professions education and published in English was included. We excluded commentaries, editorials, opinion pieces, perspectives, reviews, calls for change, needs assessments, and other studies in which no real interventions had been employed.

Study identification

After removing the duplicates, each study potentially meeting the inclusion criteria was independently screened by 2 authors (A.R. and M.S.). Then, the full texts of relevant papers were assessed independently by the 2 authors for relevance and inclusion. Disagreements at either step were resolved when needed until a consensus was reached.

Quality assessment of the studies

We used the BEME checklist [ 18 ], consisting of 11 indicators, to assess the quality of studies. Each indicator was rated as “met,” “unmet,” or “unclear.” To be deemed of high quality, articles should meet at least 7 indicators. The quality of the full text of potentially relevant studies was assessed by 2 authors (A.R. and M.S.). Disagreements were resolved through discussion. No study was removed based on the results of the quality assessment.

Data extraction and synthesis

To extract the data from the studies, a data extraction form was designed based on the results of the entered studies. A narrative synthesis was applied as a method for comparing, contrasting, synthesizing, and interpreting the results of the selected papers. All outcomes relevant to the review question were reported. The two authors reviewed and coded each included study using the data extraction form independently.

A total of 645 titles were found, with a further four titles identified through the hand-searching of reference lists of all reviewed articles. After removing the duplicate references, 422 references remained. After title screening, 250 studies were considered for abstract screening, and 172 studies were excluded. After the abstract screening, 73 studies were considered for full-text screening, and 177 studies were excluded due to reasons such as:1. being irrelevant, 2. loss of data, and 3. language limitation. 22 studies were included in the final analysis. The 2020 PRISMA diagram for the included studies is shown in Fig.  1 . The quality was evaluated as “high” in 12 studies, “moderate” in 7 studies, and “low” in 3 studies.

PRISMA flow diagram for included studies

The review findings are organized into two main categories: (a) Description of the interventions and expected outcomes and (b) Aspects of hacking in health profession education.

Description of the interventions and expected outcomes

The description of the studies included the geographical context of the interventions, type, and number of participants, focus of the intervention, evaluation methodology, and outcomes. Table  1 displays a summary of these features.

Geographical context

Of the 22 papers reviewed, 11 studies (45.4%) took place in the United States of America [ 7 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ], two studies in Pakistan [ 13 , 29 ], one study performed in international locations [ 30 ], and the remainder being in the United Kingdom [ 31 ], Germany [ 32 ], Finland [ 33 ], Australia [ 34 ], Austria [ 35 ], Thailand [ 36 ], Africa [ 37 ], and Canada [ 38 ].

Type and number of participants

Hacking in HPE interventions covered a wide range and multiple audiences. The majority of interventions targeted students (17 studies, 77.2%) [ 7 , 13 , 20 , 21 , 23 , 24 , 25 , 26 , 27 , 29 , 30 , 31 , 32 , 33 , 36 , 37 , 38 ]. Their field of education was reported differently including medicine, nursing, engineering, design, business, kinesiology, and computer sciences. Also, they were undergraduates, postgraduates, residents, and post-docs. Ten interventions (45.4%) were designed for physicians [ 13 , 19 , 21 , 24 , 25 , 26 , 28 , 29 , 33 , 35 ]. Their field of practice was reported diverse including psychology, radiology, surgery, and in some cases not specified. Eight (36.3%) studies focused on staff which included healthcare staff, employees of the university, nurses, care experts, and public health specialists [ 13 , 22 , 26 , 28 , 29 , 30 , 32 , 35 ]. Interestingly, nine of the hacking in HPE interventions (40.9%) welcomed specialists from other fields outside of health sciences and medicine [ 13 , 19 , 22 , 25 , 26 , 28 , 29 , 33 , 35 ]. Their field of practice was very diverse including engineers, theologians, artists, entrepreneurs, designers, informaticists, IT professionals, business professionals, industry members, data scientists, and user interface designers. The next group of participants was faculty with 5 studies (22.7%) [ 7 , 23 , 32 , 34 , 36 ]. An intervention (4.5%) targeted the researchers [ 27 ]. The number of participants in the interventions ranged from 12 to 396. Three studies did not specify the number of their participants.

The focus of the intervention

The half of interventions aimed to improve HPE (12 studies, 54.5%) [ 7 , 13 , 21 , 23 , 24 , 26 , 28 , 30 , 31 , 32 , 34 , 38 ], with a secondary emphasis on enhancing clinical or health care [ 19 , 22 , 25 , 29 , 33 , 35 , 36 , 37 ]. Two studies highlighted the improvement in entrepreneurship skills of health professions [ 19 , 20 ]. One study aimed to improve the research skills of health professionals [ 27 ].

Evaluation methodology

Methods to evaluate hacking in HPE interventions included end-of-program questionnaires, pre-and post-test measures to assess attitudinal or cognitive change, self-assessment of post-training performance, project-based assessment through expert judgment and feedback, interviews with participants, and direct observations of behavior.

Hacking in HPE interventions has resulted in positive outcomes for participants. Five studies found high levels of satisfaction for participants with the intervention [ 21 , 31 , 32 , 33 , 37 ]. Some studies evaluated learning, which included changes in attitudes, knowledge, and skills. In most studies, participants demonstrated a gain in knowledge regarding awareness of education’s strengths and problems, in the desire to improve education by enhancement of awareness for technological possibilities [ 7 , 13 , 19 , 21 , 23 , 30 , 32 , 33 , 34 , 35 , 38 ]. Some studies found improving participant familiarity with healthcare innovation [ 19 , 22 , 24 , 25 , 26 , 33 , 36 , 37 ]. Some participants reported a positive change in attitudes towards HPE as a result of their involvement in hacking interventions. They cited a greater awareness of personal strengths and limitations, increased motivation, more confidence, and a notable appreciation of the benefits of professional development [ 20 , 21 , 29 , 34 ]. Some studies also demonstrated behavioral change. In one study, changes were noted in developing a successful proof-of-concept of a radiology training module with elements of gamification, enhancement engagement, and learning outcomes in radiology training [ 28 ]. In a study, participants reported building relationships when working with other members which may be students, faculty, or healthcare professionals [ 7 ]. Five studies found a high impact on participant perceptions and attitudes toward interdisciplinary collaboration [ 22 , 26 , 27 , 36 , 38 ].

Aspects of hacking in health profession education

The special insights of hacking in HPE included the adaptations considered in the interventions, the challenges of interventions, the suggestions for future interventions, and Lessons learned.

Adaptations

The adaptations are considered to improve the efficacy of hacking in HPE interventions. We found that 21 interventions were described as hackathons. Out of this number, some were only hackathons, and some others had benefited from hackathons besides other implications of hacking in education. Therefore, most of the details in this part of the findings are presented with a focus on hackathons. The hackathon concept has been limited to the industry and has not been existing much in education [ 39 , 40 ]. In the context of healthcare, hackathons are events exposing healthcare professionals to innovative methodologies while working with interdisciplinary teams to co-create solutions to the problems they see in their practice [ 19 , 22 , 24 , 25 , 30 , 41 , 42 ].

Some hackathons used various technologies for internal and external interactions during the hackathon including Zoom, Gmail, WhatsApp, Google Meet, etc [ 37 ]. . . Almost all hackathons were planned and performed in the following steps including team formation, team working around the challenges, finding innovative solutions collaboratively, presenting the solutions and being evaluating based on some criteria including whether they work, are good ideas with a suitable problem/solution fit, how a well-designed experience and execution, etc. For example, in the hackathon conducted by Pathanasethpong et al. (2017), the judging criteria included innovativeness, feasibility, and value of the projects [ 36 ]. Also, they managed the cultural differences between the participants through strong support of leadership, commitment, flexibility, respect for culture, and willingness to understand each other’s needs [ 36 ].

Despite valuable adaptations, several challenges were reported. The hackathons faced some challenges such as limited internet connectivity, time limitations, limited study sample, power supply, associated costs, lack of diversity among participants, start-up culture, and lack of organizational support [ 13 , 19 , 25 , 28 , 30 , 34 , 37 ]. Some interventions reported the duration of the hackathon was deemed too short to develop comprehensive solutions [ 37 ]. One study identified that encouraging experienced physicians and other healthcare experts to participate in healthcare hackathons is an important challenge [ 26 ].

Suggestions for the future

Future hackathons should provide internet support for participants and judges, invite investors and philanthropists to provide seed funding for winning teams, and enable equal engagement of all participants to foster interdisciplinary collaboration [ 37 ]. Subsequent hackathons have to evaluate the effect of implementation or durability of the new knowledge in practice [ 19 , 28 ]. Wang et al. (2018) performed a hackathon to bring together interdisciplinary teams of students and professionals to collaborate, brainstorm, and build solutions to unmet clinical needs. They suggested that future healthcare hackathon organizers a balanced distribution of participants and mentors, publicize the event to diverse clinical specialties, provide monetary prizes and investor networking opportunities for post-hackathon development, and establish a formal vetting process for submitted needs that incorporates faculty review and well-defined evaluation criteria [ 22 ]. Most interventions had an overreliance on self-assessments to assess their effectiveness. To move forward, we should consider the use of novel assessment methods [ 30 ].

Lessons learned

Based on the findings of hackathons, they have developed efficient solutions to different problems related to public health and medical education. Some of these solutions included developing novel computer algorithms, designing and building model imaging devices, designing more approachable online patient user websites, developing initial prototypes, developing or optimizing data analysis tools, and creating a mobile app to optimize hospital logistics [ 25 , 26 , 27 , 36 ]. Staziaki et al. (2022) performed an intervention to develop a radiology curriculum. Their strategies were creating new tools and resources, gamification, and conducting a hackathon with colleagues from five different countries. They revealed a radiology training module that utilized gamification elements, including experience points and a leaderboard, for annotation of chest radiographs of patients with tuberculosis [ 28 ].

Most hackathons provide an opportunity for medical health professionals to inter-professional and inter-university collaboration and use technology to produce innovative solutions to public health and medical education [ 7 , 23 , 26 , 30 , 37 , 38 ]. For example, one study discussed that hackathons allowed industry experts and mentors to connect with students [ 37 ]. In the study by Mosene et al. (2023), results offer an insight into the possibilities of hackathons as a teaching/learning event for educational development and thus can be used for large-scale-assessments and qualitative interviews for motivational aspects to participate in hackathons, development of social skills and impact on job orientation [ 32 ].

The participants’ willingness to continue working on the projects after the hackathons was also reported in some papers [ 13 , 29 , 33 ]. One study highlights the potential of hackathons to address unmet workforce needs and the preference of female surgeons for small-group discussions and workshops [ 24 ]. Craddock et al. (2016) discussed that their intervention provided a unique opportunity for junior researchers and those from developing economies who have limited opportunities to interact with peers and senior scientists outside their home institution [ 27 ].

Dameff et al. (2019) developed and evaluated a novel high-fidelity simulation-based cybersecurity training program for healthcare providers. They found significant improvements in the knowledge and confidence of participants related to clinical cybersecurity after completing the simulation exercise. They also reported high levels of satisfaction with the training program [ 21 ].

This scoping review provided a detailed overview of the existing literature on hacking in health profession education and explored what we know (and do not know) about this emerging trend. Our results emphasized the increasing pattern of utilizing hacking in HPE for enhancing teaching and learning, problem-solving, and product generation. Our findings revealed that elements of hacking in HPE can include; innovation, creativity, critical thinking, and collaboration. Innovation is a critical element of hacking in education that holds different meanings for different disciplines. Those involved in HPE consider innovation to create new tools and resources [ 7 , 28 ], hackathons [ 13 , 19 , 20 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ], gamification [ 28 ], and simulation-based training [ 21 ].

This study by introducing a different perspective or a new application of hacking that has not been explored before allows for a broader understanding of hacking and its potential positive applications in HPE. Although it does mention “hacking,” it does not refer to the malicious or illegal activities often associated with the term [ 43 , 44 ]. The results of this study indicate incorporating hacking into HPE aimed at improving education and enhancing clinical or healthcare had positive outcomes in learning, attitudes, knowledge, and skills. Embracing hacking in HPE revolutionizes traditional teaching methods, promotes interdisciplinary collaboration, leverages cutting-edge technologies, and cultivates a culture of lifelong learning, ultimately enhancing clinical outcomes and the healthcare system as a whole [ 13 , 20 , 21 , 22 , 26 , 27 , 28 , 30 , 31 , 32 , 33 , 34 , 36 , 37 , 38 ].

This study reveals that hackathons are more prominent in the United States of America (USA) education system compared to other countries due to the culture of innovation and entrepreneurship [ 7 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ]. It is important to note that while hackathons are more prominent in the USA, they are also gaining popularity in other countries [ 13 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ]. This mindset directly contributes to designing effective interventions and driving innovation across different countries and regions around the world. In comparison to other educational interventions, in hacking within education studies, the geographical context, the focus of the intervention, and outcomes can play a significant role in shaping the educational intervention. The relationship between them can be explained through Socio-cultural theory which emphasizes the influence of social interactions and cultural factors in learning and development [ 45 ]. According to this theory, factors such as cultural values, societal norms, availability of technological resources, access to educational opportunities, and collaboration with local communities all play a role in shaping the outcomes of hacking in education. In light of the findings, creating a positive impact on education through “hacking” as innovation requires adaptations and overcoming challenges. Adaptations could involve modifying traditional teaching methods, incorporating new technologies into the learning process, or adopting new pedagogical approaches, such as project-based learning or blended learning [ 40 ]. Adapting education through hacking means finding innovative solutions to improve teaching methods, student engagement, and overall learning outcomes [ 46 ]. Challenges refer to the obstacles or barriers that educators, leaders, or organizations may face when trying to implement innovative changes in education could be related to resistance to change, lack of resources or funding, bureaucratic hurdles, or simply the complexities of navigating a rapidly changing educational landscape [ 47 ]. Therefore, driving positive change requires leading with creativity, perseverance, and collaboration [ 48 ]. In this way, different leadership and management approaches and models can help to create change. For example, studies show that Kotter’s 8-Step Change theory can be considered a guide for educators to lead innovation in education through hacking [ 49 ].

With a clear definition of innovation, the next is to consider how to systematize and embed a culture of innovation within the educational organization. An important component of this strategy is tying innovation to professional, school, and university priorities. Innovation is a human-centered endeavor and requires key stakeholders’ engagement to identify challenges and opportunities. Our findings emphasized that while meeting with multiple stakeholders is critical, developing other champions of an innovation focus is essential. Consider resources available in developing internal and external advisory members, local entrepreneurs, or leaders in innovation roles. Other strategies can be used to guide the design and development of innovation programs including co-design sessions, focus groups, and the use of external consultants.

Faculty members are the main actors of change and the most effective source of creativity in education. They have a significant role to play in driving change in education by preparing the ground for creativity, adapting to new changes, and stimulating change within the classroom. They can create a positive and innovative learning environment that benefits both students and the entire organization [ 50 , 51 ].

For many faculty members, innovation will be a new area of inquiry. Hence, based on our findings we recommend to the planners and organizers of faculty development programs to design and implement some programs about innovation in the teaching and learning process considering these three key elements: building knowledge, acquiring skills in applying rigorous innovation methodologies to identifying and solving problems, and generating opportunities to participate in innovation activities can way to develop an interest in innovation and elevate it as a school goal and priority [ 51 , 52 ].

Overall, these findings demonstrate that the hackathon effectively met its objectives in the case of HPE by promoting interdisciplinary collaboration, building relationships, facilitating learning, developing innovation, knowledge acquisition, practical problem-solving skills, cross-disciplinary tools for teaching and learning, and inquiry-based learning. In addition, findings reveal the positive outcomes of hackathons in HPE including increasing confidence levels as innovators, enhancing awareness of technological possibilities for future healthcare givers, improved familiarity with healthcare innovation and teaching entrepreneurship, improving engagement, and learning outcomes in training, high participant satisfaction, and increased motivation with the program. Also, Hackathon in HPE emphasizes the role of multidisciplinary teams and technology in solving medical education problems and encourages disciplinary collaborations to improve data collection and analysis [ 7 , 13 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ]. A potential gap of knowledge in this study is the lack of research on the long-term impact and sustainability of hacking in HPE. While the study highlights the positive outcomes of incorporating hacking into education, it does not delve into the long-term effects or address the potential challenges in maintaining and sustaining these innovative practices. Additionally, there is limited mention of the assessment methods used to measure the effectiveness of hacking in education, which could be an area for further investigation.

Some limitations of this study are including, this comprehensive study includes a straightforward research question, a predefined search strategy, and inclusion and exclusion criteria for studies that summarize all relevant studies, allowing for a detailed understanding of the available evidence. This had some limitations when it came to collecting eligible articles. Since this review extracted only published research, there are educational interventions that are reported at conferences but have not yet been published in the literature. The moderate quality of full-text studies is indeed a limitation of this study. Future research should consider including higher-quality full-text studies to enhance the robustness of the findings.

Although we searched for articles using general keywords, these were limited to hackathon keywords. Further research is needed to conduct hackathons in HPE to drive sustained innovation and crowd-source solutions. First, research should investigate how to enhance faculty and student engagement and retention to foster hackathons in HPE. Second, a multidisciplinary study is crucial to strike a balance between embracing innovation and evaluating its impact to ensure its successful integration into the education system. Third, future research could focus on exploring the long-term impact, sustainability, and assessment methods of incorporating hackathons in HPE.

Hacking in the health profession educational context refers to the positive applications in teaching and learning that have not been explored before. Embracing hacking requires adaptations, overcoming challenges, and driving change through creativity, perseverance, and collaboration. The goal of hacking in health profession education is to create a more dynamic, adaptable, and effective educational system that meets the needs of all learners and prepares them for success in the rapidly evolving 21st-century economy.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

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This study was conducted with the financial support of the Vice-Chancellor for Research and Technology of Kerman University of Medical Sciences (project number: 402000210).The role of the funding body was to provide support for data collection and analysis.

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AR and MS formulated the research idea, extracted data, and performed the analysis of the data, wrote the manuscript, and edited the draft of the paper. All authors approved the final manuscript.

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Correspondence to Mahla Salajegheh .

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Rooholamini, A., Salajegheh, M. Health profession education hackathons: a scoping review of current trends and best practices. BMC Med Educ 24 , 554 (2024). https://doi.org/10.1186/s12909-024-05519-7

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Reflective practice in health care and how to reflect effectively

Kiron koshy.

a Brighton and Sussex University Hospital

Christopher Limb

b Western Sussex University Hospitals, Worthing

Buket Gundogan

c UCL Medical School, University College London, London

Katharine Whitehurst

d Royal Devon and Exeter Hospital, UK

Daniyal J. Jafree

Reflective practice is a paper requirement of your career progression in health care. However, if done properly, it can greatly improve your skills as a health care provider. This article provides some structure to reflective practice to allow a health care provider to engage more with reflective practice and get more out of the experience.

Introduction

Reflective practice is something most people first formally encounter at university. This may be reflecting on a patient case, or an elective, or other experience. However, what you may not have considered is that you have been subconsciously reflecting your whole life: thinking about and learning from past experiences to avoid things that did not work and to repeat things that did. For example after tasting a food you do not like, you remember that experience, think about it, and when you next see that same food you know to avoid it. In medicine it is one of the best approaches to convert theoretical knowledge into practice.

As you progress through medical school and into foundation years as a doctor it becomes even more common. It is now expected to provide evidence of your reflections through your training on the ePortfolio and then throughout the rest of your professional life in revalidation. Hence, it is a good idea to get it right from the beginning.

First and foremost the biggest mistake you can make when reflecting is to treat it as a tick box exercise and a waste of time. With a bit of thought reflections can be a very useful tool in learning. Would you remember a generic case from a book? Would hanging all of those facts on a patient you have met make it more memorable? It allows you to recognize your own strengths and weakness, and use this to guide on-going learning. By reflection you will develop your skills in self-directed learning, improve motivation, and improve the quality of care you are able to provide.

What to reflect on

This can be anything.

Most reflections are on things that go wrong. These situations stay in one’s head and force us to begin to think about whether they could have done anything differently. For example:

• Postoperative complications
• Missed diagnosis
• A dissatisfied patient
• Failed procedure

However, reflecting on things that went well can often be more rewarding and be just as useful. It can build confidence and help you to repeat it again on another occasion. For example:

• A well-managed cardiac arrest
• An interesting seminar or conference
• A patient thank you letter
• A difficult but well performed procedure

Stages of reflecting

There are numerous models for reflections, but it is important to understand why you are asking each question and how that will help you to reflect 1 . This an integration of many concepts but the broad process is similar in all models: what happened, why does this matter and what are the next steps? 2

What, where, and who—the situation

Think about the situation in detail: What happened exactly and in what order, where were you at the time and who else was involved? What part did you have to play? What was the final outcome?

How did it make you feel—your emotional state

What was running through your head and how did you feel about it? Be honest with yourself: were you afraid, confused, angry or scared? If you can understand how you were feeling at the time it will help you put together why things happened as they did, and help you to recognize similar situations in the future.

Why did it happen—making sense of the situation

Now you have thought about the situation in greater detail, and probably recognized things that would have otherwise gone unnoticed, think about why things happened as they did. How did the situation, yourself, and others interact at the time. Did the situation go well or was there room for improvement?

Could you have done anything differently—critical review and development of insight

With the help of hindsight how would you have managed the situation differently? Think about what factors you could have influenced: is there anything you could have tried that may have improved the situation, or is there anything you did that was particularly important in the situation? It is easy to remember the things that you did not do and it is often the things that you did well that are forgotten.

What will you do differently in the future—how will this change your practice

This is arguably the most important stage in reflecting. You need to pull together everything you have thought of before to learn, change your own practice, and improve 3 . Do not only think about what you would do differently in that specific situation, but think whether you have thought of any transferable knowledge or skills you can utilize elsewhere. For example: if you reflect on a postprocedural complication do not only think of how you would manage this again but also how you would prevent it happening if you performed the procedure yourself! If you are a part of a well-led cardiac arrest do not think only of what you would do next to help, but also how you would lead an arrest in the future, or even how you would lead a team in any other situation!

Re-enforcement—what happens when you put this into practice

Test your reflections: When comparable situations happen again, do things change as you would expect them to? This is a chance to repeat the reflective cycle to refine and develop your understanding.

How to make the best use of reflective practice

As mentioned previously most people see reflective practice as a tick box exercise, but it does not have to be.

Over the next day take note of any interesting situations that arise. Later in the day try mentally reflecting, following this framework, and if you think any will be particularly useful to you write them down. If you try this for a week you will begin to see similar situations arising and how your reflective practice is positively affecting you.

Remember: you do not always have to learn only from your own experience; learn from others’ mistakes as well. Reflect on situations that you have witnessed to work out why things happened as they did, and how this can influence you.

It can be useful to take these reflections for peer or senior review: others may be able to draw light on things you have not noticed. This can allow you to recognize points for improvement and work on them. This can also be a useful learning opportunity for the other involved!

An example to put this into practice

I was involved in a patient confrontation; the patient was unhappy with her hospital stay and wanted to be discharged home. Unfortunately she required a package of care and so could not be discharged. I explained this and she returned to her bed. I was happy I had explained everything to her and continued with my other jobs.

Who, what, and why

I was involved in a patient confrontation; an elderly patient was unhappy with hospital stay and wanted to be discharged home. She was under our general surgical team for a head injury and observation after a normal CT head. She had been seen on our ward round and told that she was medically fit for discharge but still awaiting social services: her house had been reviewed and deemed unsafe so she was waiting for banisters to be installed. The issue was raised with me by chance as I was doing other things on the ward. I explained this to her and although she remained annoyed I was able to make her understand what the delay was and she returned to her bedside. She did not seek further clarification that day.

How did it make you feel

At the time I felt rushed and frustrated. I had a lot of other work to be done and this was distracting from that. She had already been told she was waiting for social services in the morning. I understood why this was difficult for her but did not think I would be able to do anything to help.

Why did it happen

The morning ward round was quite rushed and so our explanation was limited to telling her we were waiting for social services. I can understand from her point of view this may have meant very little, and so my explanation of what exactly we were doing may have relieved some frustration. Having been waiting up to this point, it is no surprise she continued to be angry but may have been accepting of this plan.

Could you have done anything differently

I think my explanation was very good, and the patient seemed happy with this, although I did not give a rough idea of how long this would take. It may have been useful to have spoken to the sister in charge to ask for what progress had been made to feed back to the patient. Also I did not ask her whether she was happy with this explanation: I may have been able to satisfy her frustration further by answering a few more questions or even recognize any other issues at home that may need addressing before discharge. Although the information given in the ward round was correct, it was not understandable to the patient. If this had all been quickly clarified in the morning, the patient would have been happy throughout the day and not caused a problem later on.

What will you do differently in the future

I think that the route problem in this situation was our explanation on the morning ward round. Furthermore, I am not sure how long such issues take to be addressed. To avoid a similar situation in the future I will speak to the other health care professionals on the ward to get a round idea of how long occupational interventions such as this and other community interventions take to start. This means when future patients are medically fit I can spend a moment in the morning informing them of what needs to be done and how long it may take. Hopefully this will allow me to address patient concerns early to avoid them becoming an issue when it is too late.

Re-enforcement

I will reflect on how future situations similar to this develop, looking for an improvement in the quality of my patient care.

Following a structure helps to focus a reflection: I am sure you will agree the learning points are much clearer from a good reflection!

Conclusions

To summarize, the benefits of reflecting are clear: it may be difficult to do initially, but through practice you will develop your own skills and become a better learner. Many structures are available so choose one what works for you. Reflective practice is an important part of your career progression on paper, but if done well, can greatly improve your skills as a health care provider.

Conflict of interest statement

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 15 June 2017

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Russian Forces Close In on Ukrainian Town in Northeast

Vovchansk has been a prime target of Russia’s offensive in the northeast as it seeks to push back Ukrainian troops from the border.

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Reporting from Kyiv, Ukraine

Russian forces on Tuesday inched closer to the central part of Vovchansk, a town in Ukraine’s northeast that they have been attacking for the past 10 days as part of a new offensive in the region.

Roman Semenukha, the deputy head of the military administration in the northeastern Kharkiv region, said on television on Monday that Ukrainian forces had lost about 40 percent of the town, with Russian troops pushing from the north.

Open-source maps of the battlefield compiled by independent groups also show that Russia now controls the northern part of the town, which had a prewar population of 17,000.

Vovchansk, which lies just five miles from the Russian border, has been a prime target of Moscow’s new offensive. Both U.S. officials and President Vladimir V. Putin of Russia have said the offensive is part of an effort to establish a buffer zone.

The intention, analysts and military officials say, is to push Ukrainian forces away from the border , to prevent them from targeting Russian towns and cities with artillery.

“The Kremlin’s forces will try to make further advances in the weeks ahead, and try to carve out a buffer zone along the Ukrainian border,” Lloyd J. Austin III, the U.S. defense secretary, said on Monday during a meeting with Western allies of Ukraine.

Russian forces have also advanced to the west of Vovchansk, pushing about five miles into Ukrainian territory just north of Kharkiv, Ukraine’s second largest city. They now control more than 70 square miles of Ukrainian land in the area and have made their largest territorial gains since the end of 2022.

Ukrainian officials have said in recent days that the situation in the region has stabilized thanks to the urgent redeployment of Ukrainian units that have managed to slow the Russian advance.

But President Volodymyr Zelensky of Ukraine warned in an interview with the news agency Agence France-Presse that the assaults may be only the “first wave” in a wider offensive designed to stretch Kyiv’s already outnumbered and outgunned forces.

The Ukrainian Army has warned that Russia could open another front further north of Kharkiv, toward the city of Sumy. Officials have said that Russia is concentrating forces across the border and carrying out sabotage and reconnaissance raids in the area.

Gen. Kyrylo Budanov , the head of Ukraine’s military intelligence, told The New York Times last week that he expected Russian forces to make a hard push in the direction of Sumy after the culmination of their offensive in the Kharkiv region.

For now, Russian troops appear determined to capture Vovchansk. They have been pounding the town for days with powerful guided weapons known as glide bombs that can deliver hundreds of kilograms of explosives on impact, Ukrainian officials said.

After reaching the outskirts of the town in the first days of their offensive 10 days ago, Russian forces slowly pushed inside it, engaging in street fighting.

Oleh Syniehubov, the head of the Kharkiv regional military administration, said on Monday that the front line in Vovchansk now runs along the Vovcha river, which separates the northern part of the city from the rest of it. “Our soldiers are trying to take back house by house, street by street,” he said.

Russian forces have also conducted strikes on bridges across a river running further south, in what appears to be an attempt to disrupt Ukraine’s logistical lines in the area.

“Vovchansk is the largest settlement immediately on the border that would provide Russian forces a staging ground close to the Russian rear to prepare for and launch the second phase of the Russian offensive operation,” the Institute for the Study of War , a Washington-based think tank, said over the weekend.

Ukrainian authorities have been scrambling to evacuate under fire residents from the town.

“The situation in Ukraine has once more dramatically deteriorated with the massive Russian airstrikes on the civilian infrastructure and the brutal Russian offensive in the Kharkiv area,” the German foreign minister, Annalena Baerbock , said on Tuesday during a visit to Kyiv.

Constant Méheut reports on the war in Ukraine, including battlefield developments, attacks on civilian centers and how the war is affecting its people. More about Constant Méheut

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Ukraine has begun releasing prisoners to serve in its army , part of a wider effort to rebuild a military that has been depleted by more than two years of war and is strained by relentless Russian assaults.

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