Considering on the Bigger Picture of Public Health: Student Reflections on University Mission

Introduction

University faculty have the opportunity to promote both character and career development through structured activities and instructor-led discussions in classroom environments (Bharuthram, 2018; Ryan, 2013). Amitai Etzioni (1998) thoughtfully said, “If educators are silent on moral issues, that means only that the other voices will have exclusive call on children’s minds.” This article explores the role reflection can play in public health education and provides a contextual example of the application of critical reflection in higher education. Additionally, this article outlines a best practice for applying reflection-based activity to critical professional and personal development. Reflection promotes internalizing information and prompts innovative thinking (Alsina, Ayllón, & Colomer, 2019; Bharuthram, 2018; Ryan, 2013). However, there remains debate on the extent to which reflection should be taught and facilitated by course instructors in higher education. Consideration of current research and the current implementation of reflection as a learning strategy has prompted this best practice article.

In instructor-led reflection, students are encouraged to participate in reflection activities which provide them with the opportunity to consistently reflect on their progression in both their personal and professional development. Reflections are most often structured with prompted, introspective reflection and narrative written responses by students. Discussion is then encouraged in team settings; followed by an instructor-led question and answer discussion. This best practice article describes the use of reflection activities in connection with university mission.

To offer context, implementation of this this critical, university-mission-based student reflection occurred at a private, religious university. Brigham Young University (BYU) in Provo, Utah (USA), founded and supported by The Church of Jesus Christ of Latter-Day Saints (LDS), is recognized for its commitment to both religious and academic rigor. The university has established a mission which is to, “. . . assist individuals in their quest for perfection and eternal life. That assistance should provide period of intensive learning in a stimulating setting where commitment to excellence is expected and the full realization of human potential is pursued” (BYU Board of Trustees, 1981). In order to fulfill this mission, the university has outlined four aims in which it strives to fulfill this mission through the development of “. . . [student’s] faith, intellect, and character” (BYU Board of Trustees, 1981). These aims include providing an environment that is (1) Spiritually Strengthening, (2) Intellectually Enlarging, (3) Character Building, and (4) Leads to Lifelong Learning and Service (BYU Board of Trustees, 1981).

Background

As students engage in higher education opportunities, it is imperative that they are provided an exploratory environment which promotes growth and learning (Alsina et al., 2019; Bharuthram, 2018). Not only are students expected to master career specific content they are also expected to gain the skills and competencies necessary to promote productive collaboration (including ethical leadership). As they become professionals who are “self-aware [and] compassionate, they are better able to provide culturally safe care” in any setting they will work (Herzog, 2017). Herzog stresses that this responsibility is in the hands of higher educationalists as they have the opportunity to create a community environment and safe place for exploration. This safe space, “a protected time to think,” allows for structured and directed exploration promoting both the students’ personal and professional development (Coward, 2018). Dallavis supports this belief by encouraging educators to “take advantage of cultural patterns and webs of relationship” that students naturally contribute due to their personal life exposure. He describes this asset as “cultural capital” and iterates that educators in any setting have the opportunity to either promote or discourage this cultural and religious involvement in education (Dallavis, 2011).

Engaged dialog and critical reflection are considered to be two important and connected parts of personal development and exploration (Boys, 1999; Kennison, 2012). Ribchester (2016) highlights the important role of higher education in establishing ethical leaders and workers. He finds that reflection prepares students to “negotiate increasingly complex professional, civic and personal futures” and emphasizes that exploratory learning encourages the development of responsible students and future leaders. Furthermore, the role of higher education is to produce and inspire community involvement and development (Willimon, 1997). That same higher education has a responsibility to encourage the ethical and personal character development of its students (Willimon, 1997). Dialog and reflection provide students with an opportunity to consider life orientation, sense enlightenment, and find a voice for their opinions and perspectives (Boys, 1999). Reflection is currently used in professions such as nursing (Coward, 2018; Kennison, 2012), education (Glowacki-Dudka & Barnett, 2007), marketing (Catterall, Maclaran, & Stevens, 2002), and with MPH (masters of public health) cohorts (Roe, Mamary, Perales, & Demers, 2015); however, limitations of implementation often include time, planning, and/or direction for such activities (Kennison, 2012). These limitations have caused educators to assess the specific strategy of reflection as they continue to fine-tune the impact of ethical development in higher education (Alsina et al., 2019; Bharuthram, 2018; Willimon, 1997). Reflection is considered most effective when students are familiar with the topic being discussed and are given an opportunity to think carefully about the topic (Boys, 1999; Coward, 2018).

As students use reflection to better understand their own personal development, they continue to see the implications in understanding and navigating their professional futures. Coward (2018) argues that understanding personal identity, purpose, and the impact of actions on others “are related to and transferable from self to professional self.” Through his study of nursing education, he finds that placing a focus on personal development increased productivity and satisfaction in educational and work settings (Coward, 2018). Additionally, higher education has the potential to play a critical role in “nurturing lifelong learning and critical citizenry” and presenting the inclusion of reflection as a learning strategy greatly influences performance in education and future workplace settings (Bharuthram, 2018). Providing students with the skills needed to understand and process the stressors they will encounter throughout their careers is a necessary role of higher education (Maselko, Hughes, & Cheney, 2011; van den Heuvel, Au, Berstein, Ford-Jones, & Martimianakis, 2014). By encouraging and providing resources for these quiet reflections, observations, and conversations, higher education promotes critical analysis of sources and promotes a more culturally competent and responsive workforce (Dallavis, 2011; Willimon, 1997). During reflection and subsequent conversation, students learn how to create and maintain bonds of concern, trust, respect, and appreciation (Boys, 1999). These attributes help students develop skills in networking, or partnership, leading them to success in the workplace (Boys, 1999).

Religion is often considered a social determinant of health, acting as a protective factor against many causes of mortality (Harvard Public Health, 2016; Idler, Blevins, Kiser, & Hogue, 2017; Li, Stampfer, Williams, & VanderWeele, 2016; VanderWeele, Balboni, & Koh, 2017). Nonetheless, religion as a social determinant of health remains poorly understood (Presser & Chaves, 2007). For example, in a 2017 longitudinal study, those who considered religion to be “very important” were often experiencing a functional disability or morbidity outcome (Idler et al., 2017). The connection between religion and health prompts the need for competency training of health care providers. Because of the role of religion in understanding health, this training should be focused on religious health benefits and sensitivity to patients’ religious beliefs and practices (Idler et al., 2017). For a student attending a private religious university, understanding the role of religion in their own lives and in the lives of the others can act as a lens to understand the health outcomes of the populations they are serving (Maselko et al., 2011). Connections can be made to other existing social determinants of health and expand a health practitioner’s ability to utilize the positive effects of religion (Maselko et al., 2011). A suggested reason for religion as an important facet to higher level education is to help students more carefully consider their faith, and the faith of others, thus resulting in a vital source of social capital (Cavadini, 2013).

Development of Best Practice: The “Reflection Activity”

Public health has long had theological principles embedded in its history. Clergy were often relied on to aid the poor and needy worldwide, and they were in some cases first responders in epidemic situations (Cavadini, 2013). In fact, John Snow, the father of modern epidemiology, like many of his time had a religious upbringing, practicing reading, writing, mathematics, and scripture study at school (Frerichs, 2018). Foundational to the mission of public health is the concept of improving one’s condition, self, and possible future (Institute of Medicine [US] Committee for the Study of the Future of Public Health, 1988). Some see the reflection of these words in their faith or vice versa. The concept of faith, or rather the actions one’s faith drives a person to do. The public health connection to enabling individuals to enact faith and improve their health is not new. Paul Farmer and Father Gutierrez discuss these very concepts in In the Company of the Poor, describing the concept of accompaniment, walking “with,” not ahead or behind, others in their real-life struggles (Griffin & Block, 2013). Likewise, Albert Schweitzer (1961), humanitarian and Nobel Peace Prize recipient, described the empowerment his faith gave him to do seek the welfare of “so many people . . . struggling with sorrow and suffering.” It is with this backdrop, the Reflection Activity was considered.

In order to meet the four aims of a BYU Education, a blended, interconnected activity was developed, such that students could visualize, critically reflect on “bigger picture,” and develop links between all four areas. In our case, those connections are about faith, public health, building character, and developing lifelong learning and service. The concept of reflecting has its roots in critical reflection which is often attributed to Dewey (though he may have been opposed to adding “faith” to the method). “[Reflection is] active, persistent, and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it . . .” (Dewey, 1933). This activity essentially provides students with the chance to go beyond a monologue-style reflection and consider how a class teaching, experience, assignment, and so on, will shape their thinking and actions. These in-depth, critical reflection activities have shown to be important for applied learning pedagogy (e.g., experiential learning or service learning) and have a positive effect on student engagement and learning (Ash & Clayton, 2009). Therefore, what we called the Reflection Activity was born.

Description of Best Practice for the Reflection Activity

The Reflection Activity consists of three parts, each taking about 5 minutes: material, written reflections, and sharing. The duration of each part is adjustable but the parts are sequential. Students are given some form of content that has ranged from reading text passages to watching video. At the same time, a few prompting questions are written on the board. The questions are shared prior to students reading or watching the material. Both content and prompting questions are posted in the course’s learning management system daily schedule. At times, readings are too long for some students to be completed in 5 minutes, so a timer is used to indicate it is time to move to the next step of the Reflection Activity. Select sections can be identified within other materials, such as paragraphs or passages within larger texts, in order to direct students to important areas of the reading, for example, “I want you to focus on the two paragraphs starting with He went . . .”

Afterward, students are reminded of the prompting questions and given time to “reflect and write.” We use our learning management system as a place for students to write their reflections. In essence, we created a discussion forum where only the student and instructor were invited, thus making it a private place for students to post their reflections. Students who do not have a smartphone, tablet, or computer available during the Reflection Activity are invited to handwrite their reflection and submitted it at the end of class. These handwritten reflections were uploaded to that student’s reflection discussion thread.

Next, students share what they saw as the highlight(s) from the material in answering the prompting questions. Student work is organized using team-based learning (Michaelsen, Knight, & Fink, 2002), so the structure is already in place. They are generally given 2 to 3 minutes to share as a team and 1 to 2 minutes to share with the large class. Instructor comments are generally shared last, to point out their insights from the material and answers to the questions. Students are assessed in two ways: participation points for their daily written reflections and a few open-ended questions on midterm exams.

Reflection Activity Examples

Data and data-informed decision making was the topic of one session. For the Reflection Activity, students watch a 4-minute video titled, “Discovering Truth” (Mormon Channel, 2018). The video tells a story of several villagers who find an elephant and each of the villagers can only feel a small portion of the elephant but not the whole thing. It goes on to explain how each villager had misinterpreted what the elephant was because it only saw a small portion of it. For example, one villager felt the elephant’s trunk and believed it was a snake and another felt its rough skin and thought it was a brick wall. Students were given the reflections prompts: In what ways do we seek to discover truth personally, professionally, and spiritually? and How does the video relate to us personally and professionally?

On another day where bias was discussed, students read Matthew 7:1 to 5 from the New Testament (LDS.org, 2018). In the story, Jesus shares a story where one character having a beam, or plank, criticizes and tries to remove a mote, or small speck, from another’s eye. In essence, the story demonstrates that we ought not to be judgmental of others. In fact, Jesus says in these verses that we often find minor faults in others when we ourselves have significant faults that bias our judgement. The prompt for the written reflection was What do we “see”? and How does this affect our personal and professional work?

A third example was shared on a day where we discussed professional development and future goals. BYU president, Kevin Worthen (2015), gave a commencement address titled, “Who You Are and The Things You Do.” The address describes how sometimes our jobs and job titles can come to define our identities. It further discusses how our educational and career pursuits are important, but they do not necessarily define us as human beings. On this day, students were asked the following: What insights can you gain in making career-oriented decisions? and How does (or doesn’t) this change the way you see your educational training?

Application at Other Universities

We recognize the application of this faith-based Reflection Activity will not work at many universities. Here, we will share a few ways this can be reworked to fit other needs. First, one could organize a set of materials around their college or university mission. Many colleges and universities have mission statements, supporting values and aims related to public service, seeking knowledge, improving humanity, and developing character among its students. Readings and critical reflections could be organized around these topics. A side benefit from this reflection structure is it could help students better understand the mission of their university. Second, there are many logistical changes that could be undertaken. Parts of the Reflection Activity could be completed by students before or in class. For example, students could complete their materials reading/watching and written reflection before class, saving the discussion for class time. Likewise, the entire Reflection Activity could be implemented entirely online in the case of online or hybrid-style classes.

Discussion

The Reflection Activity has been implemented at a private, religious university; however, principles can be adapted for critical reflection in connection to one’s unique university mission. Our experience with the Reflection Activity has supported the previous reflection and religious introspection research. The activities used in these public health courses have aimed to promote ethical leadership and personal and professional development in a safe environment facilitated by the professor. Providing students with time for study and reflection encourages students to expand their thinking and internalize public health ideology and practice. Implementation of these practices fosters successful and culturally competent health care professionals and promotes the university aim of engaging in “lifelong learning and service” (BYU Board of Trustees, 1981).

Additionally, reflection as a pedagogical tool has allowed for increased consideration of religion being a social determinant of health. While some reflection activities are not religious in nature, the use of religious material has encouraged students to view their own religiosity and the religious beliefs of others when considering cultural competency and intervention planning to improve health and well-being of communities. This introspection encourages reflection and contemplation that promotes not only the consideration of religion but the consideration of communities’ holistic culture in determining health.

As previously mentioned, reflection is an effective and powerful tool to help future health professionals develop personally and professionally. On an institutional level, BYU remains dedicated to providing an environment for students to receive a quality education with four emphasized areas of development. The reflection activity utilized in BYU classrooms is aimed to bridge theology with public health principles, but this can be modified to the needs of the class and university. For example, public health principles can be connected to civic leadership principles or different areas of study. The methodology of the reflection activity implemented at BYU can be implemented at universities that are nonreligious, or even other departments within a university that are not related to health. The main principle of the reflection activity is to provide students with an opportunity to make connections to guiding ethical principles that can help shape their personal development and achievement in the workforce. Reflection is a pedagogical tool that may be seldom used and rarely analyzed to pinpoint specific benefits, including specific elements that could improve its efficacy. Future discussion and implementation of this teaching tool would provide needed information to effectively implement within public health higher education culture.