cover

Reflective Practice

Key Themes in Health and Social Care series

Nick J. Fox, The Body

Reflective Practice

JANET HARGREAVES AND LOUISE PAGE

Copyright © Janet Hargreaves and Louise Page 2013
The right of Janet Hargreaves and Louise Page to be identified as Authors of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
First published in 2013 by Polity Press
Polity Press
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Polity Press
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ISBN: 978-0-7456-5694-6
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Contents

Figures
Tables
Boxes
Acknowledgements
Introduction
  1.  Reflection in context: what this book is all about
  2.  The context of reflective practice: choosing an approach that works for you
  3.  The Reflective Timeline
  4.  Writing reflection for assessment: the individual voice
  5.  Reflecting together: the collective voice
  6.  Expressing reflection in other ways
  7.  Reflective practice is ethical practice
  8.  Asking difficult questions – exploring reflection in challenging situations
  9.  Is reflection always a good thing? Arguments and evidence
10.  Conclusion: embedding reflection – looking forward
References
Index

Figures

1.1  The cliff top and the swamp (adapted from Schön, 1991).
2.1  The top ten picture.
3.1  An inter-professional circle.
3.2  First thoughts.
3.3  Reflection in the moment.
4.1  Gibbs’ reflective cycle (Gibbs, 1988).
4.2  So what are you thinking?
5.1  Group reflection.
6.1  A Knickerbocker Glory.
7.1  The four arenas of accountability (Dimond, 2008).
8.1  Factors affecting whistle blowing (adapted from Miceli & Near, 2002).
9.1  Flow diagram of a learning experience using constructive alignment (after Biggs, 2006).

Tables

1.1  Skill acquisition from novice to expert (Dreyfus & Dreyfus, 2009).
2.1  Learning styles (adapted from Fleming, 2001; Honey & Mumford, 1992).
2.2  The top ten quick-view list.
4.1  The essay timeline.
5.1  Group reflection checklist.
7.1  Case studies: issues and actions.

Boxes

4.1  Golden rules for reflective writing.
8.1  Margaret Haywood.

Acknowledgements

Writing this book together has been a great journey, uniting our different experiences and ideas. It has been helped by encouragement and critique from family and friends, in particular Richard Hargreaves, who has patiently drafted and re-drafted the original diagrams and made, photographed and helped to eat the Knickerbocker Glory.

Introduction

This book is written for students and qualified professionals who want to extend their knowledge, skills and understanding of reflective practice. This book does not seek to focus on any one discipline, because reflection is shared by all professional groups. It is written by Janet, an academic with nursing qualifications, and Louise, a professional writer with academic support experience. We both use reflection in our teaching and everyday life. We are sure that reflective practice can have a positive and confidence-boosting role in all aspects of professional learning and will illustrate this through the stories in the book.

Looking at the literature, every health and social care discipline has a motivation for using reflection. Development of life-long learning is highlighted for medical students (Barley, 2012) as the vast knowledge base required for practice cannot all be learned and remembered, but this sentiment is true of all professions as research and legislation leads to rapid change: all of us need the ability to find things out for ourselves and learn from our experience. Understanding how to learn is explored in most detail in the literature from teacher education, and so we draw on this regularly throughout the book. The development of empathy and self-awareness also features in many justifications for the teaching of reflective practice, for example in health care (Bulman & Schutz, 2008), social work (Brookfield, 2009) medicine and dentistry (Brett-MacLean, Cave, Yiu, Kelner & Ross, 2010; Brown, 2010).

In different ways, the literature suggests that reflection and reflective practice help professionals to develop and critique their own practice. By deliberately choosing literature that comes from as many professional viewpoints from health and social care as we could find, as well as teacher education, we hope to show the universality of the concepts involved. What became clear to us was that each profession values reflection and reflective practice in different ways. For many of the texts written about medicine and dentistry, reflection was promoted as a necessary tool for helping with complex decision making and with the tension between the clinical and the personal. For teachers it seems to be more cerebral; a process that helps teachers to learn to learn, and thus to help others. For health and social work, intuitive and self-reflective behaviour is already assumed so there is more focus on deeper personal reflection and critical reflection, looking at the socio-political aspects of practice. This difference seemed helpful and enlightening to us, reflecting perhaps the discourses identified by Mantzoukas & Watkinson who say: ‘In the process of learning a discipline, individuals have to be able to differentiate themselves from others while remaining part of a social context’ (Mantzoukas & Watkinson, 2008, p. 130).

Using a series of examples and templates, we will guide you through reflective practice in a variety of situations. Our emphasis is on practicalities. We recognize that the majority of people in health and social care disciplines are ‘hands on’ and kinaesthetic learners. Sharing stories is a powerful tool for learning. Using stories and drawing on academic literature, we have collected ideas, exercises and theoretical situations to develop skills for the learning, understanding and recording of reflective practice. We feel that reflective practice is strongly linked to ethics and professional judgement, so these feature throughout the book, not as add-ons, but embedded in everyday reflection.

In chapters 1, 2 and 3, we introduce you to reflection and reflective practice, including background, models and a time-line for development.

Chapters 4, 5 and 6 look at three different ‘how to’ aspects: Introduction writing reflection, particularly where you might need to write for an academic assessment; reflecting in groups; and reflecting in other ways, such as through walking, and using the environment around you.

Chapters 7 and 8 take reflection in different directions. Chapter 7 looks at situations where an individual professional may be in trouble, and the ways in which reflection can help to avoid, and recover from, personal difficulties. Chapter 8 looks at the awkward, dangerous questions that reflection can lead to, and how you might manage these in practice.

Chapter 9 offers some of the cases against and barriers to reflection: the arguments that it is ‘just thinking’, makes no difference to practice and cannot be assessed are reviewed and suggestions made.

Finally, we conclude by bringing together the themes of the book and our personal reflection on writing it.

CHAPTER ONE

Reflection in context: what this book is all about

Chapter Summary

Reflection is promoted for effective development in every professional code and educational course that you will come across in your career. This chapter will set the scene for the book; locating reflective practice within the recent historical development of professional education. Through studying this chapter and engaging in the exercises, you will be able to:

•  discuss the place of reflective practice in professional education
•  identify the significance of storytelling to understanding practice
•  make connections between your personal beliefs, your practice and major ethical theories
•  reflect on the application of reflective skills to your own professional practice and development.

Introduction

What does it mean to reflect, or to be a ‘reflective practitioner’? Is it innate, a personal way of being or learning style? Alternatively, is it something you can learn, develop and improve?

In this book, we are going to help you to discover what reflective practice is, to develop your reflective abilities, to express your reflection in ways that other people can understand and to successfully demonstrate your reflection when used for assessment. Throughout this book, we do not have any particular profession in mind. Louise is not qualified in any health or social care profession; she has worked with and supported health and social care students, and writes plays about health and illness. Janet is a nurse by background; she works in higher education in a multi-professional setting. We draw on literature from health, medicine, social work, dentistry and education, in fact from any discipline that we think adds to understanding and offers useful ideas. Naturally, we draw on our own experience but we use stories and illustrations from many professional viewpoints, in order to demonstrate that reflection crosses inter-professional language and practice.

In order to start on this journey, we want to offer three areas for consideration:

(1)  A short history of reflective practice, where it came from and why it has become so important.
(2)  The use of stories – storytelling is a powerful medium for reflection. It offers a structure in which to narrate actual events, but also the freedom to explore safely thoughts and feelings that may be taboo. We will frequently use stories in this book and will help you to develop your own skills of narration.
(3)  Ethical practice – questions about what is the right way to behave are rarely far from view when we engage in reflection. There is no single way to decide on the most ethical course of action and frequently no perfect answers. Here we will explain ethical theories and suggest one framework we think is particularly suitable for thinking about ethics as you reflect on your practice.

A short history of reflective practice

The industrial revolution is probably as good a starting place for this as any. In the nineteenth century, the mechanization Reflection in context of just about everything from transport to food production changed the way people all over the world worked and lived their lives. Central to this revolution was the application of scientific methods – if you can observe and measure, then you can predict and control. The effects of this scientific explosion were not just concerned with factories or industry; the philosophy behind them infiltrated every aspect of human life. In medicine, health and social care, the human condition was investigated, dissected, measured and categorized.

A great deal of good has come from these developments. In medicine, the discovery of bacteria and viruses has transformed our understanding of disease (Le Fanu, 1999). Psychological research has led to greater understanding of how the human mind works, revolutionizing the care of people who are mentally ill (Rodham, 2010), and theories from sociology have given us ways of explaining and predicting human behaviour (Cohen & Kennedy, 2007).

However, the downside to this focus on science was that, by the twentieth century, its dominance was such that knowledge gained from scientific methods seemed more important than any other sort of knowledge. Many people challenged this view, but it was Donald Schön’s seminal work, published originally in 1983 and 1987, that challenged the scientific method in professional education (Schön, 1991): reflective practice was born.

Schön’s argument goes like this:

The cliff top and the swamp

Imagine you are with a group of people who are on a journey (see figure 1.1). You come to a cliff top and can see a range of possible destinations in the distance. You need to decide on the correct destination and best route to get there. The various paths below you are clear to see; you can trace each one, plan ahead, decide on a direction and continue on your way.

Another group of people are also trying to reach their destination, but they are starting from the bottom of the cliff, where the ground is swampy. They cannot see clearly ahead and the destination is out of sight, so they do not know which may be the best path to take. They use trial and error, learning from their mistakes and picking up new information as they pick their way carefully through the swamp.

image

Figure 1.1 The cliff top and the swamp (adapted from Schön, 1991)

For Schön, the scientific approach available to the cliff-top people, which he calls ‘technical rationality’, is fine where problems have definition and clarity, outcomes are predictable and all the people involved have shared goals. However, he claims that problems in professional life are rarely this simple. We are often uncertain about what the problems might be, have limited research to guide us, and disagree about what the best course of action is. In these situations, the skills developed by the swamp people are much more effective. This – the ‘artistry’ of professional practice – is the skill-set Schön sought to teach, develop and constantly improve through reflective practice.

A reversal of priorities

Schön looked around him and started to analyse the way in which professionals were educated. He noticed a hierarchy in highly regarded professions where the most attention and Reflection in context value were given to theory, followed by application of knowledge, and finally by skills and everyday practice. For example, a barrister or attorney studied the theory of law for several years before having the opportunity to practise, and medical students studied anatomy and physiology long before they met their first patient. As professions with an apprentice basis, such as allied health and social work, nursing and midwifery, aspired to greater professional status, they too began to adopt these principles. Much has changed in professional education in the last few decades, the privileging of theoretical learning over practice learning is no longer as common and most professional courses include at least some development of the skills and artistry of the profession right from the start. It may therefore seem that the trend has been reversed.

Or has it?

Despite these changes, professions remain very guarded and defend the ‘knowledge’ that they see as central to their unique practice. Think about the last place you worked, or attended for a placement. Who earned the most money, had the most power or gained the most respect as a professional person? It is much more likely that this person also had the longest period of education and the most academic qualifications.

Evidence-based or research-based practice still privileges quantitative rather than qualitative methods of enquiry. Projects that use scientific methods, for example predicting the probability of a cause-and-effect relationship, or the effectiveness of a new policy, treatment or drug, are more likely to gain funding.

So, whilst there has been a great deal of change, there remains ambivalence about the place of the artistry or craft basis of professional behaviour.

Deconstructing reflective practice

Schön went on to try to identify the successful activities undertaken by the swamp people that helped them to think well professionally. It is probably easiest to illustrate these using two examples.

Example 1: a child learning a skill

ActivityAnalysis
A sunny day in the park; a young child is poised at the top of a sloping grassy bank about to cycle down it without trainer wheels for the first time. The adult observing from a distance sees much theory is evident. Forces of gravity, mass, kinetic energy and velocity act on the child and the bike’s frame as s/he shakily proceeds down the hill. The focus is on staying upright but the presence of ‘theory in use’ is all around.Theory in use
Despite being young, s/he already brings a wealth of knowledge to the problem. S/he knows how to coordinate limbs and eyes to progress forward, and to shift body weight from left to right to avoid falling. S/he has also already mastered the art of steering using the handlebars whilst riding with trainer wheels. The child will probably not be able to articulate an understanding of gravity but knowledge of its effect is evident from observed behaviour. This ‘knowledge in use’ is added to and refined every time s/he gets onto the bike.Knowledge in use
The child is absolutely focused on the task in hand – in the moment, s/he concentrates, appraises how well s/he is doing, adjusts balance, speed and steering.Reflection in action
Arriving shakily at the bottom of the hill, the child thinks back over the event – powerful feelings of pride at staying upright and relief at not being too badly hurt – a few cuts and grazes but nothing worse! S/he thinks about what was good and how to improve – the adults give praise, ask questions about feelings and give feedback on performance – this greatly enhances the child’s ability to ‘reflect on action’.Reflection on action
Many cycle rides later, we see this young person riding through town. Mastery of the bike is evident as we watch a skilfully, smoothly executed turn at speed: observing traffic, wind speed, road conditions, pot holes and pedestrians, our cyclist rides the bike with ease. This thoughtful, engaged, conf dent cycling is an example of ‘reflective practice’ – learning continues with every journey taken and the skill is evident in the performance.Reflective practice!

The years roll on –

Example 2: the child is now the adult

ActivityAnalysis
Our young person is now an adult, engaged in a professional conversation. Theories of communication are evident in body language, eye contact and verbal and non-verbal communication techniques.Theory in use
The person in conversation is showing anger – raised voice, wide gestures, aggressive stance. Our professional sits back a little, uses open body language, active listening and questions to understand and dissipate the angry response – knowledge in action is evident from the behaviour displayed.Knowledge in use
S/he may look relaxed but inside his/her mind is racing: ‘How am I doing?’ ‘What should I say next?’ ‘What questions will get the best reaction?’ ‘What has worked before?’ S/he engages in a constant internal narrative, appraising feelings and combining theoretical understanding and experience; reflecting in the moment helps to navigate through a potentially difficult situation.Reflection in action
Reflecting back on the encounter, our professional analyses his/her skills and the outcomes of the conversation. S/he is excited and pleased to have managed a difficult situation well, but by narrating the event to a supervisor more can be learned. The supervisor asks probing questions offering challenges and alternative views.Reflection on action
This professional is a reflective practitioner – engaged, open to learning and self-aware, each professional encounter helping to learn and improve on performance.Reflective practice!
image

EXERCISE

Think back to the last time you were working in your professional role. It may have been the first time you had met a person and you were assessing their needs, or you were with a person you know well and have a regular professional appointment with, or maybe a teaching or management issue that you were dealing with. Jot down your thoughts on the questions below:

image  Theory – what theoretical ideas underpin the episode you are thinking about?
image  Knowledge – what knowledge was evident in your behaviour?
image  Reflection in action – think back to what you did and said, how you felt, what was going through your mind at the time; how did you decide how to act in a particular way, what to say, or not to say?
image  Reflection on action – looking back now, how do you feel about the episode? Did it go as well as it could have, what went well and why – can you use this learning again? What were you less pleased with, and what would you change if you could?
image  Stop at this point and look again at what you have written. If you have the opportunity to do so, ask a friend or colleague if they will listen to your story and ask you questions about it. Does what you have written surprise you? Does the telling of the story, either to yourself by writing it down or verbally to another, reveal anything to you that you could not see before? Be honest – are there things you have omitted or embellished? Why?

Reflection and professional education

So far so good – but how often do you actually do this in your everyday practice? When practice becomes familiar, it is easy to drop into a routine where we no longer have this heightened awareness. Just like the cyclist earlier, we fall into automatic routines, so it may only be when something unexpected or worrying occurs that we are jolted back into thinking more Reflection in context critically. Supporters of reflective practice say that developing reflective skills can harness the learning in everyday practice as well as in critical moments, aiding personal development and improving skills.

image

TIME FOR REFLECTION

Did you find this exercise easy or difficult? In chapter 2, we will introduce you to ways of structuring your reflection, using a number of models.

Schön, along with many other theorists, continued to develop their ideas, which have been progressively adopted and embedded into professional education and development through the late twentieth and early twenty-first centuries. People researching professional behaviour also began making theoretical links between being reflective and expert practice. The work of Patricia Benner (Benner, 1984; Benner, Chesla & Tanner, 2009) has been particularly influential, not just within nursing – the subject of her research – but across professional education generally. In her original (1984) research, Benner used Critical Incident Technique to gain insights into the everyday practice of nurses. From this, she developed a model of skill acquisition that uses the work of Dreyfus and Dreyfus, who contribute a chapter in her later work (Dreyfus & Dreyfus, 2009). This suggests that, through a combination of education and practice, practitioners progress from novice, where theoretical knowledge is used under supervision, to expert in five stages, which, like the swampy lowlands in Schön, require experience and artistry for success (see table 1.1).

Many texts make links between gaining such professional expertise and reflective practice. For example, McCracken and Marsh (2008) show the importance of critical reflective thought to applying expertise to evidence-based practice in social work, whilst Bulman and Schutz (2008) identify the development and importance of reflection in nursing. There are also an increasing number of papers making links between reflection and decision making for medicine – see, for example, Balla, Heneghan, Glasziou, Thompson and Balla (2009) and Graber (2009). All suggest that using the seemingly ‘soft’ skills of reflection can enhance professional practice in many settings.

Table 1.1 Skill acquisition from novice to expert (Dreyfus & Dreyfus, 2009)
NoviceThe learner is inexperienced. At this stage the learner gains theoretical knowledge and learns rules – such as following instructions or a recipe for action. The cyclist in the example above demonstrates basic rules of handling the bike, and road safety. The professional would have learned about the rules of verbal and non-verbal communication.
Advanced beginnerThe learner now practises these skills and begins to recognize patterns, and the various aspects of the skill. They may still fall back on ‘how to’ rules and make frequent mistakes, and can be frustrated by uncertainty and complexity. The cyclist may cope in a straight line but not round corners; the communicator may be gaining good speaking skills but be unable to watch for non-verbal cues at the same time.
CompetentThis is the stage when the learner has embedded, or learned, the rules and begins to reach out. In real practice, simply following a set of rules is rarely sufficient. Soon you are in the position of having to decide which rule to follow first, or which is most appropriate. Usually you are dealing with more than one situation at a time, so, like the cyclist, just being able to ride the bike is not enough. The learner uses experience, trial and error, success and failure, leading to greater skill and understanding.
ProficientWith greater experience our learner is now more able to make decisions intuitively and perform with skill and ease. Seeing beyond the immediate issues, and being able to draw on wide practice and knowledge, the communicator will recognize distress or anger and start to use skills to address and manage this, before things get out of hand.
ExpertThe expert knows what needs to be achieved, and how to do this in a range of complex and uncertain settings. They no longer ride a bike, they just ride – bike and human in harmony. Similarly, communication is no longer a set of learned rules, but is a complex embedded interaction. Experts can, of course, make mistakes, but they are generally able to perform smoothly and with confidence.

Although the basis of this assumption – that reflection is always a ‘good thing’ – can be challenged (see chapter 9), for now we will use this as the starting point for exploration. Our reason for this is that, in the wake of the assertion that it is a good thing, regulated medical, health and social care professions began to see reflection and reflective practice as a hallmark of good professional behaviour. They now require it to be embedded into education courses, requirements for continued registration / licence to practise, and Continuing Professional Development. Like it or not, reflective practice is here to stay.

Storytelling

Storytelling is something that all people do – we use stories to explain, construct and understand our lives. Even if you are very new to your chosen profession, you will already have found that there is a strong oral tradition in health and social care professions whereby colleagues often tell stories (‘my worst day’, ‘my most embarrassing moment’). It is not surprising then that reflective practice often revolves around storytelling. In this book we have already used several stories – Schön uses ‘the cliff top and the swamp’ (see figure 1.1) to make sense of how professionals need to think if they are to be successful, and you have thought of stories from your own life or professional practice to do the exercises.

What is a story? Stephen King says that stories have a plot and are in three parts (King, 2001, p. 187):

Narration: ‘this moves the story from a to b and so on to z’

Description: what happened when and how

Dialogue: the voices and words of the various characters.

These three devices draw the reader through the story. To illustrate this, here is a story from Janet’s experience of learning to nurse:

Janet’s First Nights

When she trained as a nurse in the 1970s in England you were apprenticed to a hospital, undertaking three-month periods of clinical work interspersed with month-long ‘blocks’ in nursing school. After eight weeks of basic theory, she went on her first ward, female surgical, and after about six weeks, did her first two-week period on night duty. They were taking emergencies one night and an elderly woman with acute abdominal pain was admitted. The doctor on duty asked for her to be starved, for an intravenous drip to be inserted, and for a naso-gastric tube to be passed, thus enabling her digestive system to be rested. Janet knew this procedure theoretically but had never actually seen one passed, let alone done one herself. The qualified nurse from an adjacent ward told her to set up her trolley, went through to check she had the right equipment and to observe that she safely passed the tube into her patient’s stomach – not her lung! The nurse stood in silence at the end of the bed and watched Janet: either the poor patient was remarkably compliant or she really felt too ill to resist, so the tube went in with no difficulty and Janet spent a while sitting with her as several litres of fluid drained from her stressed digestive system.

As King says, this story has a ‘plot’ and a beginning, middle and end; it then narrates what happened and introduces the four characters. It conforms to many types of story that we have seen repeated often in professional practice in that it is both a ‘my first placement’ story and a ‘rite of passage’ story. It is also what Plummer describes as an ‘epiphany’ – that is, a story that conveys a moment of realization or change (Plummer, 2001).

It attempts to convey what was an authentic experience at that time, including some of the feelings Janet remembers experiencing regarding the relationship between student nurse, doctor, patient and qualified nurse. It also contains some, but not all, of the characteristics of Schön’s reflective practice elements introduced earlier in this chapter in that theory in use and knowledge in action are evident. However, it gives the reader no insight into Janet’s thoughts or reflections; this was not something she discussed or thought about at the time.

It is an honest and faithful account but it is not verifiable as ‘true’. Knowing that stories are fiction helps to remind us that reflective accounts can never be exactly true of, or a perfect substitute for, the actual experience. Even factual accounts in newspapers and autobiographical writing are only proxy for the real thing and are subject to interpretation and challenge. We tell stories differently for different audiences. For example, you would relate your first date to a friend, a parent or your subsequent partner differently: the story may be the same, but the meaning you wish the listener to take from it will be different.

You may be wondering why storytelling matters. We believe that being aware that you are writing a story, and understanding how to do this well, will improve your ability to structure and share your reflections with others. In your reflective writing, you may be required to present something that is factual, such as that you were working on a certain day and that certain things happened, but the narration of this event will change depending on who you are telling it to, why, and how much time has elapsed since then.

The story of ‘Janet’s first nights’ is told decades after the event, and has been re-told periodically since. The pattern of night duty, the geography of the ward and the sketch of the events is a faithful account, but much of the detail is lost to time, memory and the re-telling of the story. At the time, Janet may well have recounted this as a positive example of her coping skills – she had what it took to be a ‘good’ nurse – resourceful, competent and successful: Look at me! I was left in charge on nights and passed my first naso-gastric tube! Now she tells it to illustrate how much has changed, particularly when faced with nostalgia for a lost ‘golden age’ of health care: Look at me! Left to manage a ward full of ill people with just a few months’ training! Finally, the story is re-told in this book.

You are not writing or reflecting to entertain or to make a living, but to convey your experience and the process of learning to yourself and third parties. Indeed, the very act of writing reflection may alter your perception (Bolton, 2010). You will not be judged on your creative abilities, but writing your story/ narrative with some confidence and clarity will help you to present your work well and to express your ideas clearly. Just as the ‘academic essay’ is a written form that can be learned, and improved, writing reflectively can be learned and improved too. In chapter 2, we will help you to construct your own reflective stories, and in chapter 4 to write for reflection.

Ethics