Reflection: Principles and Practices for Healthcare Professionals 2nd Edition

Title page

Reflection: Principles and practices for healthcare professionals

Second edition

by Tony Ghaye and Sue Lillyman

Publisher information

Quay Books Division, MA Healthcare Ltd, St Jude’s Church, Dulwich Road, London SE24 0PB

© MA Healthcare Limited 2010

2014 digital version by Andrews UK Limited

www.andrewsuk.com

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission from the publishers.

Note

Health care practice and knowledge are constantly changing and developing as new research and treatments, changes in procedures, drugs and equipment become available.

The author and publishers have, as far as is possible, taken care to confirm that the information complies with the latest standards of practice and legislation.

Contributors

Tony Ghaye Cert Ed, BEd (Hons), MA (Educ) PhD

Director, Reflective Learning, UK

I am currently the founder and Director of a not-for-profit, social enterprise called, Reflective Learning-UK (www.reflectivepractices.co.uk). We work around the world striving to improve lives and livelihoods through strengths-based approaches to enhancing well-being, quality of life and positive engagement. I have worked at eight universities in different countries and am a professor in Educare (the education of those in the helping and caring professions). I have a background in social, organisational and positive psychology, education and healthcare. Much of what I do is as a strengths-based, organisational strategist, across sectors, disciplines, with multi-national companies through to grassroots community-based organisations. I have reported to Government departments in the UK and Australia and presented numerous keynote lectures at international conferences. I have written 20 academic texts on enhancing performance through reflective learning and published 107 refereed papers and book chapters to various audiences. I am the founder and Editor-in-Chief of the peer reviewed journal, Reflective Practice - International and Multi-disciplinary Perspectives (Routledge Taylor & Francis). My research and development interests are in high performance, teamwork, organisational well-being and positive engagement through reflective practices.

Sue Lillyman MA, BSc (Nursing), RGN, RM, DPSN, PGCE (FAHE)

Senior Lecturer, University of Worcester

As a registered general nurse and midwife I had experience in various areas, including intensive care, gynaecology, care of the elderly, and rehabilitation and acute medicine prior to entering nurse education in 1989. I held posts as senior lecturer at the University of Central England and Faculty Head of Quality Assurance before taking three years out to do voluntary work in Peru with street children and medical clinics in the shanty towns of Lima and in remote communities on the Amazon River. On returning to the UK I took up a post at Birmingham City University as route director for the post-graduate certificate in case management of patients with long-term conditions and module leader for older adult pre-registration nursing. I am currently working at the University of Worcester. Specialist areas of interest include improvement of patient care through reflective practice, care of the elderly and those with long-term conditions and care of vulnerable adults. My research and publications are related to care of older adults, nursing people with long-term conditions and using reflection to enhance care and quality of life.

Acknowledgements

We would like to acknowledge all our colleagues, in many places and cultures, who have engaged in positive conversations with us about the power and potency of learning through reflection. We would particularly like to show our deep appreciation to Simona Marchi, Francesco Consoli, Ruggiera Sarcina, Massimo Tomassini, Elisa Cavicchiolo, Bruna Lucattini, Debora Giannini, Emma Ciceri, Antonella Barile, Galina Markova, Hari Alexandrov, Antoaneta Mateeva, Furio Bednarz, Shiphrah Mutungi, Tunji Olaopa, Funmi Amobi, Anita Melander-Wikman, Ulrika Bergmark, Catrine Kostenius, Karen Deeny, Sarah Lee, Dan Shaw, Gavin Chesterfield, Maureen Sydney, Dave Collins, Andrew Jeffrey, Vince Russel and Philip Chambers.

About the series

The series is comprised of five books, entitled:

Reflection: Principles and practices for healthcare professionals

Effective Clinical Supervision: The role of reflection (2nd edition)

Empowerment Through Reflection: The narratives of healthcare professionals

Caring Moments: The discourse of reflective practice

The Reflective Mentor

The books are about and for the improvement of healthcare practice and policy development. We have tried to write them in such a way that a variety of healthcare professionals might find them readable, enjoyable and useful. Reflection, after all, is a generic quality that makes healthcare professionals the kind of people they are! We do, however, admit to a bias in that we have included quite a lot of nursing material. This is not to devalue or marginalise the work of any other kind of healthcare professional; it merely reflects some of our own interests, limitations and frailties. It also reflects those we have largely worked with and those who have been willing to share their work with us. Although we have not been able to illuminate all the books with examples from the perspective of every healthcare group, we hope we have been able to offer each one some ideas, inspiration and hope so that, through reflection, practice may become more knowable, manageable and satisfying.

In the series we argue that reflection has the potential to transform both who we are and what we are able to do for and with others in our healthcare worlds. Above all else, we have tried to avoid turning reflection into something that might just be seen as anecdotal and ‘soft’, or like a slavish following of cycles or spirals. We do not wish to convey learning through reflection as though it were akin to ‘painting with numbers’. In other words, simply procedural. It is also about deep things like values and feelings. We attempt to steer clear of valuing reflection in its own right, so to speak. We attempt to avoid it being seen as self-indulgent navel-gazing-as only about feeling better after reflecting on problems where, perhaps, we judged ourselves harshly and as failing in some way. In this second edition we offer the reader a more strengths-based approach to reflective practice. We hope the series points to the content of reflection being important, as well as reflective processes being challenging and sometimes painful. Skilful facilitation, high quality mentoring and the necessity for good support networks is important here. The bottom line is that we believe that reflection on practice can generate really useful knowledge that can help us to make better, wiser and more justified decisions about quality, safety and efficiency.

This actionable knowledge is derived from the context in which the healthcare professional is working. This is made up of an understanding of the self as a practitioner and lifelong learner, an understanding of the context of the patient/client relationship and the whole context in which care is given. It is knowledge derived from, and based on, professional practice (Durgahee, 1997).

All the books in the series tackle what we might call ‘the knowledge question’. It is perhaps the most fundamental one of all, as we use knowledge every time we make a practice-related move. There is knowledge which guides what we do and which helps us to improve our work. There is other people’s knowledge, and knowledge about and for practice which we develop for ourselves, in collaboration with others. The role of reflection is significant with regard to the latter. Without knowledge of different kinds we cannot claim to be competent. The series makes an important statement about the kinds of knowledge which we generate through reflection. In brief, it is knowledge which:

is about and for the improvement of self, the team and the context of healthcare

is without apology but not solely practical in kind

is ‘local’ and related closely to the actual clinical work context of the practitioner

is generated and owned by practitioners themselves

is often built up collaboratively and openly and not just individually and privately

can be used to question existing practice and therefore to aid the development of a ‘critical’ stance towards healthcare

is useful or ‘good enough’ to enable us to make more sense of our thoughts and actions

contributes to the development of an enquiring posture which is an important element in being able to claim that we are lifelong learners

and, above all, is appreciative.

(Ghaye et al 2008)

In this second edition we devote a new chapter to the nature and usefulness of this kind of knowledge.

We have tried to emphasise that learning through reflection supports acting with care and integrity and acting safely. Of course, not all learning is fun. Everything we learn is not sweet-smelling and rosy-red. However, certain kinds of reflection, if undertaken in a properly supportive and yet extending manner, may serve to energise individuals and clinical teams, open up new possibilities for action and may, over time, lead to improvements in what we do.

Currently many healthcare professionals are being swamped with policies and guidelines for a National Health Service which delivers more cost-efficient, safer and even higher quality care to patients. This is an NHS with clear national standards for services and for treatments, with high quality healthcare delivered locally through clinical governance, self-regulation and a commitment by practitioners to lifelong, and more recently, to work-based learning. The health service in the UK is responding to the Darzi report (DoH 2008) A High Quality Workforce, NHS next stage review which emphasizes a quality-focused, patient-centred, clinically-driven, flexible workforce that values people. However, good intentions simply are not sufficient in practice any more and many professional bodies, including the Health Profession Council, place importance on continuing professional development that reflects the Darzi report. Intentions have to be properly and sensitively implemented, reviewed and possibly refocused over time. So how can this be done? What is clear to us is that a service that does not value learning from reflection-on-practice, and a Government that does not have this at the very heart of its policies, runs the risk of being accused of oversimplifying the process of developing a modern and dependable health service. It also runs the risk of misunderstanding, devaluing and distorting the capacity and commitment of healthcare professionals to deliver its wishes.

Throughout the series we try to avoid both glorifying reflection and celebrating it uncritically. We have tried to describe its different forms and the many ways it can be facilitated. We have endeavoured to support, with evidence, the kinds of claims being made for reflection as the catalyst for enhancing clinical competency, safe and accountable practice, professional self-confidence, self-regulation and the collective improvement of more considered and appropriate healthcare.

In this second edition of Reflection: Principles and practices for healthcare professionals, we have included a chapter which introduces a new kind of reflection which we have called appreciative reflection. We have described, explained and justified it. Another new chapter is included for all health professionals and identifies the use and value of reflection in their practice, in line with continuing professional practice requirements. The book retains the 12 principles set out in the first edition. These serve to identify something of the ‘landscape of reflective practice’. Each one is illustrated and clearly positioned within the literature. This second edition acts as the introduction to the whole series and attempts to encourage the reader into the reflective mode. The 12 ‘principles of reflection’ described in it, and which are revisited and illustrated in the following four books in the series, are:

Reflective practice is about you and your work.

Reflective practice is about learning from experience.

Reflective practice is about valuing what we do and why we do it.

Reflective practice is about learning how to account positively for ourselves and our work.

Reflective practice does not separate practice and theory.

Reflective practice can help us make sense of our thoughts and actions.

Reflective practice generates locally owned knowledge.

The reflective conversation is at the heart of the process of reflecting-on-practice.

Reflection emphasises the links between values and actions.

Reflection can improve practice.

Reflective practitioners develop themselves and their work systematically and rigorously.

Reflection involves respecting and working with evidence.

The second book in the series, Effective Clinical Supervision: The role of reflection, explores the dynamic relationships between those involved in clinical supervision. This book was re-written as a second edition in 2007 to reflect the current trends and requirements of the NHS and included a chapter on action learning sets and what an appreciative relationship might mean and feel like in this context. Reflective practices and clinical supervision are contextualised in relation to the Clinical Governance and effective Human Resource Management agendas.

The third book, Empowerment Through Reflection: The narratives of healthcare professionals, explores the links between reflection and empowerment. It is a book in two parts: the first contains four reflective accounts written by practitioners; the second looks again at these and, in doing so, examines the notions of power and reality. The book questions the claim that ‘reflection is empowering’.

The fourth book, Caring Moments: The discourse of reflective practice, shows how reflective practices, of one kind or another, help us to make sense of those aspects or our work which we have called ‘caring moments’. It is essentially a book of powerful stories and an examination of the way reflection can help us to learn from them.

Finally, in the fifth book, The Reflective Mentor, we take a considered look at what being a reflective healthcare professional actually means in practice. We illuminate this by exploring the different roles and responsibilities of a mentor. We review the meaning of mentorship and its origins before discussing how mentoring impacts on practice and development. The important influence of emotional and social intelligence are explored in relation to the mentoring process.

We hope that this series portrays the holistic view (Bleakley, 1999) which we have of reflection. We do not celebrate it uncritically but we do feel it plays a fundamental role in effective and meaningful learning. Above all else, what we are saying is that reflective practice stands for a collection of intentions, processes and outcomes. It is also a contentious phrase; it means different things to different people. The one phrase holds together many views of the nature of reflection, how reflection might be facilitated and what impact it has, or might have, on healthcare practice and policy development. So, as you read through the series, please do not expect to find a neat and tidy definition of reflection, a recipe which makes you think: ‘this is the way it is done’, or a list of positive outcomes of reflection which you should not challenge, which are real, always well-supported with evidence and achievable by everyone who engages in reflection. Fundamentally, the series is about ‘learning’. Reflection, as we portray it here, has a concern for learning-learning from lived and experienced clinical practice. Johns (1999, p.297) expresses this notion of concern eloquently:

Concern can be likened to a fragile flower being blown by the winds of reality. Concern needs to be nourished, but also the winds of reality have to be understood, otherwise they may diminish concern in the need for personal survival.

When we portray reflection, we are not speaking about it as if it were a static, de-contextualised ‘thing’, but more as a set of inter-relationships and interactions involving conscious and intentional practitioners in technical, social, professional and political service acts-in-context. These acts involve changes-changes in our disposition towards what we do, how we live out our caring values in practice, and change in the contexts in which we work. All change, though, is not improvement. Reflection, however, is interested in achieving improvement. It may be a difficult, threatening, sometimes bewildering process.