Health Promotion International Advance Access originally published online on November 1, 2004
Health Promotion International 2004 19(4):419-427; doi:10.1093/heapro/dah403
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HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 4 © Oxford University Press 2004; All rights reserved.
How can critical incidents be used to describe health promotion in the Finnish European Network of Health Promoting Schools?
1University of Kuopio, Department of Nursing Science, Finland and 2The Finnish Centre of Health Promotion, Finland
Address for correspondence: Hannele Turunen, University of Kuopio, Department of Nursing Science, POB 1627, 70211 Kuopio, Finland E-mail: hannele.turunen{at}uku.fi
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONINTERPRETATION OF CRITICAL...AIMS OF THE STUDYDATA COLLECTION, ETHICAL...RESULTSDISCUSSIONREFERENCES |
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The purpose of this study was to elicit critical incidents that illustrate the reality in which health promotion processes take place in the Finnish European Network of Health Promoting Schools (ENHPS). In this study, critical incidents were used as a data collection method. The data were collected by asking representatives (n = 30) of the schools to describe in writing both positive and negative critical incidents related to health promotion in their school community. Altogether 48 critical incidents were analysed using qualitative content analysis. The results show that collaboration in a network of participants from inside and outside the school community to plan and implement a special school health day was the most commonly described positive critical incident. In addition, the organizational culture of the schools seemed to improve in a positive way. The reorganization of resources for health promotion resulted in positive progress, whereas a lack of resources had a frustrating and negative effect. The most commonly described negative critical incident was a failure to discourage smoking by pupils.
Key words: critical incident; health promotion; school community
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONINTERPRETATION OF CRITICAL...AIMS OF THE STUDYDATA COLLECTION, ETHICAL...RESULTSDISCUSSIONREFERENCES |
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The European Network of Health Promoting Schools (ENHPS) has introduced the concept of ‘health-promoting school’ across Europe, and most European countries have joined the network since it was launched in 1992. An evaluation carried out in 15 EU member states showed that the ENHPS concept has successfully motivated the compilation of comprehensive health plans in schools (Barnekow Rasmussen and Rivett, 2000
). Similar positive results related to the development of healthy school projects have emerged in other contexts, too [e.g. (McBride et al., 1999; Moon et al., 1999); see also (Lister-Sharp et al., 1999; McNeely et al., 2002)]. Still, further evaluation and research are needed about the concept of health-promoting school and the factors that enhance or inhibit health promotion in school settings [e.g. (St Leger and Nutbeam, 2000; St Leger, 2001; Lynagh et al., 2002)].
Active participation and collaboration in the development of health-promoting schools is one of the main principles, but it may also be a demanding process in which "the shared aspects often get lost" (Rowling and Jeffreys, 2000). Teachers may primarily focus on pedagogical issues, whereas health professionals focus on health issues. At the personal level, it is a question of the members' motivation to participate in joint negotiations in an unpredictable project in complex and dynamic situations. St Leger emphasizes that the concept of health-promoting school "will only then be successful if teachers can understand, interpret and shape it to meet the needs of their school community" [(St Leger, 1998), p. 234]. At the organizational level, it is a question of the resources to be allocated to health promotion (Tossavainen et al., 1996; McBride et al., 1999; Green and Tones, 2000; McBride, 2000) and should be facilitated by management support, staff commitment, staff's concern for pupils' health and pupils' awareness of health (St Leger, 1998; Moon et al., 1999). The barriers to achieving the goal of health-promoting school have been recognized as inadequate preparation in teacher education and in-service education concerning health issues, a lack of time and resources and poor facilities (St Leger, 1998; St Leger, 2001; Moon et al., 1999; Apostolidou and Fontana, 2003).
Finland joined the Network in 1993 (Tossavainen et al., 1996). Several authors have pointed out the need for methodological pluralism in research on health promotion [e.g. (Nutbeam, 1999; Coombes, 2000; Green, 2000; South and Tilford, 2000)] and health-promoting schools [e.g. (Moon, 2000; Rowling and Jeffreys, 2000; Parson and Stears, 2002)] because of the complex nature of health promotion. The purpose of this paper is to report the results of a qualitative study, in which representatives of the Finnish ENHPS, mostly teachers, described critical incidents of health promotion in the school community based on their experiences.
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INTERPRETATION OF CRITICAL INCIDENTS IN HEALTH PROMOTION IN SCHOOLS |
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TOPSUMMARYINTRODUCTIONINTERPRETATION OF CRITICAL...AIMS OF THE STUDYDATA COLLECTION, ETHICAL...RESULTSDISCUSSIONREFERENCES |
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The term "critical incident" may have different meanings, depending on the situation and context where it is used. Originally, "critical incidents" referred to certain events or situations that marked significant turning points or changes in the life of a person or an organization or in some social phenomenon [e.g. war; see (Flanagan, 1954
)]. In the school community, "critical incident" may also refer to traumatic incidents, such as violence or suicide, and a plan to manage these incidents by the members of the school community (Rowling and Holland, 2000).
Additionally, critical incidents have been used as an experiential teaching and learning method with the purpose of helping pupils to understand and control their educational experiences by reflecting on them [e.g. (Brookfield, 1990; Smith and Russell, 1991)]. Tripp emphasizes that incidents happen but critical incidents are created, which means that, to be critical, an incident needs to be considered significant (Tripp, 1993). Therefore, in the context of teaching and learning health promotion, most critical incidents, e.g. pupils' smoking in the school environment, are not at all dramatic, but they may be events in the school's everyday routines and learning culture. Consequently, incidents are more typical than critical, but they are made critical through analysis. This means that everyday events related to health promotion are discussed and reflected on openly, and solutions and best practises are developed to foster health promotion in the school community, e.g. by outlining a written non-smoking policy and an action plan for its implementation (Tossavainen et al., 2004).
The use of critical incidents as a teaching and learning method in health promotion comprises two phases. First, the phenomenon is recognized (e.g. pupils' smoking), which produces a description of what happened. By writing down the incident, the teacher is able to reflect upon his/her experiences and to share the incident with other teachers, school health professionals, pupils, parents and other community members. A written description is important because it encourages a deeper and more objective analysis compared with spontaneously recalling past thoughts and events (Tripp, 1993; Woods, 1993). At the second phase, the original, authentic event is viewed in a wider context, to find out the more general meaning of the incident (Wodlinger, 1990; Tripp, 1993). At this phase, critical incidents are shared and experiences compared. According to Tripp, such comparisons are, however, often too limited and unsystematic in schools (Tripp, 1993). Therefore, in health promotion, it is important also to compare one's experiences with the results of published health research findings and health policies related to the critical incident in the question. This enables reflective learning from experience (Woods, 1993; Preskill, 1997; Tossavainen et al., 1998). The use of critical incidents can empower teachers to transform health promotion in the school community for themselves by themselves [cf. (Tripp, 1993)].
Furthermore, the critical incident technique is a qualitative method that has been assumed to be appropriate for investigating the process of health promotion in the school community, because critical incidents are concrete and detailed descriptions of reality based on the community members' experiences (Parson and Stears, 2002). Critical incidents allow members of the school community to recount their experiences of whether a health promotion intervention has met and satisfied the identified needs for health promotion [cf. (Macdonald and Davies, 1998)]. Tripp mentions two reasons for the use of critical incidents in the school community (Tripp, 1993). The first reason is the development of professional knowledge, and the second reason is that teachers can use critical incidents in action processes to identify problems and to change their teaching and learning practices. Additionally, Kain used the critical incident technique as a data collection method in examining the conditions that promoted and hindered teachers' interdisciplinary collaboration (Kain, 1997). The critical incident technique effectively identified team behaviours and school conditions that facilitated collaboration. But he noticed that, although the critical incident technique as a data collection method had its strengths, it also had some limitations. The interviewed participants gave very general answers instead of concrete and detailed descriptions. Therefore, in order to reveal the whole "picture" of teacher collaboration, supplementary fieldwork research would be needed. Thus, in building an academic knowledge base of health promotion research, methodological pluralism has been emphasized [e.g. (South and Tilford, 2000)]. Qualitative critical incidental reports of experiences have been considered a suitable technique for collecting contextual data about the health promotion process [e.g. (Parsons and Stears, 2002)]. Nevertheless, a search of the current databases (including Chinal, Ebsco, PubMed) showed that there are no studies available where the critical incident technique would have been used in health promotion research in the school community.
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AIMS OF THE STUDY |
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TOPSUMMARYINTRODUCTIONINTERPRETATION OF CRITICAL...AIMS OF THE STUDYDATA COLLECTION, ETHICAL...RESULTSDISCUSSIONREFERENCES |
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The aim of this study was to describe critical incidents that took place in school communities during a health promotion programme as identified by teachers and school nurses. The objective of this study was as follows: to describe events that enhanced and inhibited health promotion in the school community.
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DATA COLLECTION, ETHICAL QUESTIONS AND DATA ANALYSIS |
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TOPSUMMARYINTRODUCTIONINTERPRETATION OF CRITICAL...AIMS OF THE STUDYDATA COLLECTION, ETHICAL...RESULTSDISCUSSIONREFERENCES |
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This was a descriptive study, in which data were collected from representatives (n = 30), mostly teachers and some school nurses, of the Finnish ENHPS schools who participated in a national meeting in November 1998. The participants were asked to describe in writing two critical incidents: one that had enhanced and another that had inhibited pupils' and the whole school community's health. The written introduction given to the participants was as follows:
Please recall an event related to the health promotion that has happened in your school community during the time that your school has belonged to the European Network of Health Promoting Schools. Describe an event that has enhanced positively and another event that has inhibited negatively health at your school. Describe what happened, who were involved (do not mention names), and why the incident was significant from the point of view of health promotion in your school community.It was also made clear in the introduction that all the data would be considered anonymous and confidential.
Altogether 48 (f = 48) critical incidents were described. Twenty-seven (f = 27) were positive and 21 (f = 21) negative. The data were analysed using inductive content analysis. First, the critical incidents were read through carefully in order to understand their contents. Thereafter, they were categorized and labelled (Waltz et al., 1991).
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RESULTS |
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TOPSUMMARYINTRODUCTIONINTERPRETATION OF CRITICAL...AIMS OF THE STUDYDATA COLLECTION, ETHICAL...RESULTSDISCUSSIONREFERENCES |
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Table 1 shows the positive and negative critical incidents related to health promotion in the Finnish ENHPS schools.
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Enhancing critical incidents related to health promotion in the school community
The informants most commonly regarded a special school health day as a positive event. The school health day was typically organized by a network of representatives of several fields to highlight health promotion in the school community. On a special school health day, health-promoting topics, such as non-smoking, non-drug-use and sexuality, were taught and learnt in a new way. Special attention was given to the planning and implementation of health education in collaboration with teachers, pupils, parents, school nurses and representatives of the municipal and parish youth work organizations as well as other comprehensive schools or nursing colleges. The planning process for the special school health day lasted for several weeks, being thus a real collaborative planning process. The planning of this special day included several meetings of representatives of all participants to work out objectives, concrete contents and a timetable for the day. This promoted the participants' networking and commitment to the health-promoting process for a longer period compared with just making an ad hoc agreement for a single outside visitor. Moreover, the process helped to disseminate the ideas of health promotion to other schools, too.
Teachers and pupils met in new roles. Everybody was involved in an active process and had many positive experiences, which can be shared later on.A number of teachers saw the outcomes of their health promotion activities as "critical incidents" when reflecting on their involvement in the ENHPS project. Teachers' involvement had improved the social learning environment, and positive changes had taken place in the school atmosphere. Replacement of teacher-centred teaching and learning methods by collaborative ones and implementing parents' evenings in a new collaborative way further improved the atmosphere in the school community. One teacher described her experiences of successfully handling a bullying situation. The atmosphere in the classroom improved markedly after she recognized the victim and talked to him, his three bullying classmates and the parents, because her pupils started to cooperate with each other.
The use of collaborative teaching and learning methods has had a positive effect on the class atmosphere, as it has reduced bullying and made the class well-balanced. Now nobody tries to bully, and one may freely be oneself because we have got to know each other better.One positive critical incident described a new strategy used in the school community to systematically analyse health promotion by organizing a weekly meeting for teachers, pupils and school health professionals to discuss the progress of the ENHPS project.
Teachers have a meeting every Wednesday from 2 p.m. to 4 p.m. to discuss different issues. Teachers, pupils and parents were interviewed, and the issues that emerged in these interviews are collaboratively reflected on. We have plans to include pupils in these meetings.Getting more teaching staff and starting a sports project for the staff was also reported as positive critical incidents. A more pleasant dining-hall environment was also a positive event in the schools.
Inhibiting critical incidents related to health promotion in the school community
The representatives of the schools most commonly experienced pupils' smoking as a negative critical incident. During the schools' participation in the ENHPS network, pupils' smoking had either remained at the same level or even increased. One school had implemented a non-smoking project that initially successfully reduced pupils' smoking. However, the project did not have a long-term impact, and as soon as the project was over, pupils' smoking began to increase. One incident described a teacher's perception of signs of pupils' possible use of drugs. Some negative critical incidents described the disturbing behaviour of some pupils in the neighbourhood of the school and at a school disco.
For quite a long time, teachers have been worried about pupils' smoking during breaks. The law against smoking provided teachers with a weapon, and we decided to start a new battle against smoking. We started a very goal-oriented battle, including a smoke-free competition, a special school day focusing on smoking, including measurement of carbon monoxide, and obeying the law prohibiting smoking in the school grounds. The process went well, and positive development emerged rapidly. However, the "key persons" lost interest, and maybe it was also believed that the positive progress would continue by itself. But no, we are back to square one.Teachers felt that the high number of pupils per class as well as the lack of resources for teachers' continuing education and even salaries made it difficult to advance health promotion. Moreover, a lack of success in attempts to develop well-being in the school community in the form of guided activities during breaks and the school nurse's decreasing opportunities to work in the school community were described as negative critical events. An event concerning a lack of discussion with pupils about a teacher's serious mental illness that developed gradually caused great confusion in the whole school community. Dismal physical school environment was described in one critical incident as significantly inhibiting the success of health promotion in the school community.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONINTERPRETATION OF CRITICAL...AIMS OF THE STUDYDATA COLLECTION, ETHICAL...RESULTSDISCUSSIONREFERENCES |
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The health-promoting school concept demands teachers to operate in several areas in addition to class-based curriculum implementation, e.g. developing appropriate school health policies, enhancing the social environment and linking with relevant community agencies (St Leger, 1998
). The health-promoting school approach presumes that learning to teach health issues requires time and practice, but also supported experiences of both successful and unsuccessful activities.
The results of this critical incident study suggest that, during the three-year period that the schools had been participating in the ENHPS programme, significant advance in line with the goals of the programme had been made in the schools. However, teachers also described unsuccessful events related to health promotion in the school community during that time. The most commonly described positive event related to health promotion in the schools was "a special school health day", which had been planned and implemented collaboratively by the members of the school community (teachers, pupils, parents, school nurses) and outside representatives (municipal youth workers, parish workers and other comprehensive schools and nursing colleges). The reason for this kind of collaborative planning and implementation of a health promotion action being mentioned frequently can be approached from five perspectives: (1) situated learning, (2) socially shared cognition, (3) joint activity, (4) zone of proximal development and (5) culture, context and cognition (Vygotsky, 1981; Samaras and Gismondi, 1998).
First, learning occurred in a situated activity and an authentic setting. Teachers seemed to gain experience as health-promoting teachers by participating and becoming accustomed to the modern action method, a special school health day, in health promotion. Situated learning may benefit teachers' understanding of health promotion planning, perspective taking, social negotiations and sense of ownership (Samaras and Gismondi, 1998). Secondly, learning, thinking and knowing arose through collaboration with others, and cognition was socially shared in social interaction. Teachers need experiences to integrate their reflections into practical health promotional matters and to talk about them, making adjustments and developing thoughts and views themselves as change agents (McMahon, 1997). Also, teachers feel themselves professionally responsible for health promotion when they are involved in a process of mutual activity to share and construct new knowledge and skills in partnership with health care professionals. Teacher development takes place most effectively in schools with a collaborative culture fostering pedagogic partnerships, which not only prevent professional isolation but also contribute to the enhancement of practice (Hopkins et al., 1998). Thirdly, furthermore, Vygotsky emphasizes that, in order for learning to become internalized, mediation must occur during actual problem-solving, joint activity and shared task definition with others, which did occur in the planning and implementation of the special school health day (Vygotsky, 1981).
Fourthly, learning will be enhanced through sensitive relationships that employ shared responsibility, gradations of free reign for experimentation, structured, content-specific and contingent feedback and reflective assessment. Additionally, the school culture and the social context have an impact on how and what teachers think about health issues, and what is their level of cognition about health promotion as individuals and as a school community [cf. (Samaras and Gismondi, 1998)].
The results of our study suggest, that teachers in the Finnish ENHPS have embraced, at least to some extent, a holistic whole-school approach to personal and community health promotion within a school setting by planning and implementing a special school health day. Sidebottom reported similar findings in his study focusing on the organization and delivery of health education and the involvement of outside agencies in health promotion at schools (Sidebottom, 1995). It emerged that it is important to carefully plan health promotion in collaboration with members of the school community and outside agencies, where both the school and the outside agency have a clear understanding of each other's views and a joint purpose. Also, McBride found that the planning time dedicated to health promotion activities serves to increase the comprehensiveness and quality of health-strategic planning by schools (McBride, 2000). However, St Leger noticed that teachers do not understand the meaning of local community partnerships in the health-promoting school framework (St Leger, 1998). Teachers appear to acknowledge the rhetoric, but see community partnerships more in terms of resource acquisition, such as visiting speakers and information kits than working collaboratively to improve the opportunities for pupils' health. Furthermore, according to Green and Tones (Green and Tones, 2000), the development of links with the community has received little attention in the ENHPS schools, for example, in England, and it is the most problematic area for progress.
Moreover, teachers in the Finnish ENHPS had adopted more collaborative teaching and learning methods. This is a important finding because the results of a baseline study of the Finnish ENHPS schools showed that, at the beginning of the project, teachers tended to use mostly teacher-centred teaching methods (Turunen et al., 1999). The shift towards collaborative teaching and learning methods helps to empower pupils to take real responsibility for their actions, which is also an important skill in making health-related choices generally in one's life (Jensen, 2000; Tossavainen et al., 2004). Also, the atmosphere in the classroom and, more widely, in the school community had developed into a more favourable direction. This is one of the objectives of the ENHPS programme, too. Nias et al. described collaborative staff as both happy and resilient and noted that their collaborative schools exhibited many of the characteristics of healthy organizations, including a capacity to adapt readily to change, although they also suggested that such schools were more responsive to internally generated than to externally imposed change (Nias et al., 1989). In addition to the mediating effect of the individuals involved, the organizational culture of the school will also affect teacher progress. Williams et al. found that the school culture may change from highly individualized through structurally collaborative to spontaneously collaborative (Williams et al., 2001). The objective of the ENHPS is to move from teacher- and classroom-centred towards pupil- and school community-centred practices, and on this continuum, the healthy school as a structure has represented a significant, potentially permanent positive change in the schools' organizational arrangements. The results of our study indicate that the Finnish ENHPS are at this level, possibly moving towards spontaneous collaboration.
It seems that, in some of the Finnish ENHPS schools, attention had also been given to reorganizing the teachers' timetable in such a way as to allow them to participate in a weekly joint meeting of the school community, where health promotion as well as other important issues are discussed collaboratively in a planned and systematic way. Moreover, the schools paid some attention to their staff's health promotion by employing assistant teaching staff and organizing sports activities for their staff. These are both significant issues with regard to fostering staff well-being in the school community, especially in view of the fact that many Finnish teachers are overburdened with work and even suffering from burn-out (Viinamäki, 1997). Obviously, teachers had been supported and encouraged by the school principal to facilitate their work. These are important findings because many studies show that a key or gateway person, who is responsible for the coordination of health promotion in the school community, needs a team to work with and organizational support in the school community (St Leger, 1998; McBride et al., 1999; Green and Tones, 2000).
However, several problems emerged in the schools, too. For instance, the classes had many pupils, teachers had difficulties obtaining funding for continuing education, and some municipalities even laid off teachers during the term to save labour costs. Moreover, the time available to school nurses to work in the school community was reduced. These findings describe the reality where school communities develop health promotion and pupils' health learning. Therefore, it is important to keep in mind what McBride et al. pointed out: the allocation of adequate school resources, time and personnel has a strong influence on the success of a programme, indicating the school's commitment to health promotion as part of its organizational practice (McBride et al., 1999). Moreover, Kain found, in his critical incident technique investigation concerning the conditions that encourage and discourage teacher collaboration, that time, training and organizational support are keys to collaboration (Kain, 1997). The schools that discouraged collaboration did not have structured support for it.
The issue that the schools found difficult was the effort to establish a smoke-free environment. This was shown by the fact that the most common negative event that the teachers described was pupils' smoking. The same crucial question also arose in the Wessex Healthy Schools Award (WHSA) intervention (Moon et al., 1999), where little improvement in the healthy smoke-free environment was achieved. The schools also found it difficult to work towards a smoke-free environment, despite the fact that schools should be smoke-free, and that the intervention had some decreasing impact on pupils' smoking. Many of the school health policies have been imposed on schools, e.g. non-smoking, and teachers appear to accept it and be prepared to monitor it. However, the various guidelines and frameworks as well as the tobacco law issued in Finland [e.g. Ministry of Social Affairs and Health, 2001; World Health Organization (WHO), 2002] presuppose schools to adopt and implement a non-smoking school policy that may be unrealistic in view of the expectations of what teachers and schools can and are prepared to do [cf. (St Leger, 1998)].
The informants were aware of the obligations imposed by the tobacco law on schools, and they accepted the responsibility by working actively according to them. Positive short-term results were seen, but the teachers did not have enough persistence to work in the long run when the key person got tired. The schools probably did not have a specific written action plan for a non-smoking policy at the school community level. Therefore, it seemed that the responsibility for working towards non-smoking or carrying out a non-smoking campaign was left to only some committed teachers. An earlier study by Moore et al. confirmed the correlation between a written non-smoking plan and pupils' smoking habits (Moore et al., 2001). Thus, a lack of success and a loss of interest in reducing smoking were felt to be negative critical events. It can be concluded that, although teachers accept the non-smoking policy imposed on them, they are discouraged by unsuccessful experiences and reluctant to initiate a policy without widespread community support. However, our results suggest that teachers cared about their pupils' health because they were willing to implement non-smoking interventions in their schools, even though the ownership of the project among the school staff was not clear.
This study describes distinct advances in health promotion in the Finnish ENHPS network. However, there are several developmental tasks remaining. These findings will be shared and reflected on with the participants in the Finnish ENHPS, in order to interpret them and to continue the dialogue, which has been started in this participatory action research process. This is the first and important level, but not enough to disseminate the healthy school idea more widely. In Finland, the second level was to utilize the ENHPS experiences at the national governmental level to amend the law on comprehensive school and the curriculum for health education during the past two years.
In our study, the use of critical incidents proved to be an appropriate method of collecting both positive and negative descriptions of the health promotion work that has been done in the Finnish ENHPS. They gave information about the situations where members of the school community act in reality and not with idealistic wishes or hopes of how things should be. Therefore, it is also important to clarify and describe failures (negative critical incidents) in health promotion, in order to find out the reasons for failure, whereas exploring the successful events that have taken place in the school community can bring out common features that are conducive to health promotion in the school community.
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ACKNOWLEDGEMENTS |
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The authors would like to thank all the teachers and school nurses who participated in this study and co-operators in the Finnish Centre of Health Promotion. This study was funded by the Finnish Ministry of Social Affairs and Health.
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