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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
BECOMING A REFLECTIVE PRACTITIONER
In the newly revised sixth edition of Becoming a Reflective Practitioner, expert researcher and nurse Christopher Johns delivers a rich and incisive resource on reflective practice in healthcare that offers readers a diverse and expansive range of contributions. It explores the value of using models of reflection, with a focus on John’s own model of structured reflection, to inform and enhance the practice of professional nursing.
This book is an essential guide for everyone using reflection in everyday clinical practice or required to demonstrate reflection for professional registration. Students will acquire new insights into how they interact with their colleagues and their environment, and how those things shape their own behaviours, both positively and negatively. Readers will learn to “look in” on their thoughts and emotions and “look out” at the situations they experience to inform how they understand the circumstances they find themselves in.
Readers will also benefit from:
- Thorough introductions to reflective practice, writing the Self and engaging in the reflective spiral
- Comprehensive explorations of how to frame and deepen insights, weave and perform narratives
- Practical discussions of how to move towards more poetic form of expression and reflecting through art and storyboard
- In-depth examinations of the reflective curriculum, touch and the environment and reflective teaching as ethical practice
Perfect for nurses in clinical practice, conducting research or developing their practice, the latest edition of Becoming a Reflective Practitioner is also an indispensable resource for mentors and clinical supervisors, post-registration nursing and healthcare students and other healthcare practitioners.
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Table of Contents
Cover
Title Page
Copyright Page
Preface
Chapters
Part 1
Part 2
References
CHAPTER 1: Envisaging Reflective Practice
Professional Artistry
Reflection
A Brief View of Reflective Theories
Boyd and Fales (1983)
Boud et al. (1985)
Gibbs (1988)
Mezirow (1981)
Balancing the Winds
Spectrum of Reflective Practices
Reflection‐on‐experience
Reflection‐in‐action
The Internal Supervisor
Reflection‐within‐the‐moment
Christopher Johns Conception of Reflective Practice
Creative Tension
Vision
Mandy Reflects on Having a Vision for Practice
Barriers
Tradition
Authority and Power
Embodiment
Empowerment
Finding Voice
The Silent Voice
The Received Voice
The Subjective Voice
The Procedural Voice
The Constructed Voice
Transformation and Reflexivity
An Encouraging Note
Summary
References
CHAPTER 2: The Six Dialogical Movements
The Hermeneutic Spiral
Dialogue
Six Rules of Dialogue
Developing the Reflective Attitude
Commitment
Curiosity
Intelligence
Bringing the Mind Home
References
CHAPTER 3: Writing Self; the First Dialogical Movement
Keeping a Reflective Journal
Journal Entry 1
Journal Entry 2
Triggers
Tapping the Tacit
Being Creative
The Value and Therapeutic Benefit of Writing
Summary
References
CHAPTER 4: Engaging the Reflective Spiral
The Model for Structured Reflection
The Reflective Cues
What is Significant to Reflect On?
Why Did I Respond as I Did?
Did I Respond in Tune With My Vision?
Did I Respond Effectively in Terms of Consequences?
Did My Feelings and Attitudes Influence Me?
Did Past Experiences Influence Me?
Did I Respond Ethically for the Best?
Autonomy
Benevolence and Non‐malevolence
Utilitarianism
Confidentiality
The Ethical Demand (Justice, Equality, and Cultural Safety)
Different Perspectives
Ethical Mapping
Anticipatory Reflection
Am I Able to Respond as Envisaged?
Am I Skilful and Knowledgeable Enough to Respond Differently?
Do I Have the Right Attitude?
Am I Powerful Enough to Respond Differently?
Am I Poised Enough to Respond Differently?
How Do I Now Feel About the Situation?
Summary
References
CHAPTER 5: Framing Insights
Introduction
Single Lines
Framing Insights
Carper’s Fundamental Ways of Knowing (1978)
The Framing Perspectives
Philosophical Framing
Aesthetic Framing
Ethical Framing
Reality Perspective Framing
Role Framing
Theoretical Framing
Reflexive Framing
Parallel Process Framing
Developmental Framing
Being Available Template
Summary
References
CHAPTER 6: Deepening Insights:
Third Dialogical Movement
Theoretical Mapping
Guiding Reflection: The Fourth Dialogical Movement
Why Guidance is Beneficial
Co‐creation of Insights
Revealing Woozles
Planting Seeds
Dialogue
Guidance Attitude
Balance of Challenge and Support
The Challenge/Support Grid
Journal Entry 1
Journal Entry 2
Finding Voice (revisited)
Facing the Reality Wall
Picking Up Issues
Opening Up the Guidance Space
Inputting and Exploring Theory
Finding Your Own Way
Journal Entry 3
Journal Entry – Realising Our Power
Parallel Process Framing
Role Play
Game Playing
Contracting
What Issues Need to be Contracted?
Summary
References
CHAPTER 7: Weaving and Performing Narrative:
Introduction
Weaving
‘Life Begins at 40’ Introduction
Life Begins at 40
Deepening Insight
Trigger
Transitional Moments
Show or Tell?
Narrative Form
Giving Voice to Others
Coherence
Summary
References
CHAPTER 8: Applying the MSR
Bringing the Mind Home
Writing Self
What is Significant to Reflect On?
Why Did I Respond as I Did?
Did I Respond Effectively in Terms of Consequences?
Did My Feelings Influence Me?
Did Past Experiences Influence Me?
Did I Respond Ethically for the Best?
Did I Respond in Tune with My Vision?
Given a Similar Situation, How Could I Respond More Effectively, for the Best and in Tune with My Vision?
What Would Be the Consequences of Alternative Actions for the Patient, Others and Myself?
Am I Able to Respond as Envisaged?
Am I Skilful and Knowledgeable Enough to Respond Differently?
Am I Powerful Enough to Respond Differently?
Do I Have the Right Attitude?
Am I Poised Enough to Respond Differently?
What Tentative Insights Do I Draw?
How Has Extant Theory/Ideas Inform and Deepen My Insights? (Dialogical Level 3)
How has Guidance Deepen My Insights? [Dialogical Movement 4]
What Insights Do I Draw from This Experience?
‘How Do I Now Feel About the Situation’?
References
CHAPTER 9: ‘Reflections on Not Giving a Therapy’:
Reflections on Not Giving a Therapy
Alfie Boundary
Naomi
Dora Franke
Mrs Wells
Belinda
George Keeler
Frank Seymour
Bernard Barker
Rita Pike
Summary
References
CHAPTER 10: The Sixth Dialogical Movement:
Narrative Performance
Introduction to the Performance Narrative ‘Passing People By’
Activity
References
CHAPTER 11: Performance Narrativeas Play:
Introduction to Musical Chairs
1
Performing Musical Chairs
Audience Response
References
CHAPTER 12: ‘People are Not Numbers to Crunch’:
Introduction
People are Not Numbers to Crunch
People are Not Numbers to Crunch
References
CHAPTER 13: Narrative Art and Storyboard
Narrative Art Workshops
Storyboard
‘People are Not Numbers to Crunch’ Storyboard
References
CHAPTER 14: The Reflective Curriculum
Radical Shift
Journal Entry 1
Roots
Format of the Reflective Curriculum
Professional Identity
Clinical Practice
Clinical Skills
Theory
Responsibility for Learning
Clinical Credibility
Potential Constraints to the Reflective Curriculum
Summary
References
CHAPTER 15: Grading Reflective Assignments
Journal Entry
Reflection on Touch and the Environment
Environment
Commentary
Activity
References
CHAPTER 16: Guiding First Year NursingStudents
Introduction
Guiding Reflection with First Year Nursing Students
Michelle’s Experience
Lucy’s Reflection
Summary
References
CHAPTER 17: Guiding Third Year Nursing Students
Introduction
Karen’s Experience
Next Session
Next Session
Summary
References
CHAPTER 18: Guiding Trudy
Session 1
Session 2
Session 3
Session 4
Session 5
Session 6
Skill Box
Summary
References
CHAPTER 19: Becoming a Leader: A Little Voice in a Big Arena
Introduction
A Little Voice in a Big Arena
Drawing Insight
Commentary
References
CHAPTER 20: The Learning Organization Exemplified by the Burford NDU Model
The Learning Organisation
Vision
Personal Mastery
Mental Models
Team Learning
Systems Thinking
Leadership
Reflective Journal Entry
The Burford Nursing Development Unit (NDU): Caring in Practice Model
Vision for Clinical Practice
The Three Cornerstones of a Valid Vision
The Nature of Caring
The Internal Environment of Practice
Social Utility
A System of Working with Patients in Tune with the Hospital’s Person‐centred Vision
The Nine
Reflective
Cues
Applying the Reflective Cues
What Meaning Does This Health Event Have for the Person?
How is This Person Feeling?
How Do I Feel About This Person?
How has This Event Affected Their Usual Life Pattern and Roles?
How Can I Help This Person?
What is Important for This Person to Make Their Stay in the Hospice Comfortable?
What Support Does This Person Have in Life?
How Does This Person View the Future?
A System to Ensure Effective Communication
Narrative Notes
Bedside Handover
De‐briefing
Summary
References
CHAPTER 21: A System to Enable Practitioners to Live and Ensure Quality
Clinical Audit
It Works Like This
Standards of Care
Triggers for Standards
What is a Standard of Care?
Confidentiality
Constructing a Standard of Care Concerned with Communication with Relatives
Relatives Feel Informed and Involved in Care
The Value of Standards of Care
NOTES
References
CHAPTER 22: A System to Enable Practitioners to Develop Personal Mastery Towards Realising Their Vision of Practice
Bumping Heads
Susan Writes
3
Commentary
Contracting – The Bottom Line
Variables of Clinical Supervision/Guided Reflection
Who Should the Guide/Supervisor Be?
Peer Guidance
Voluntary or Mandatory
Group versus Individual Supervision
Single or Multi‐professional
Summary
References
CHAPTER 23: Awakenings: Guided Reflection as ‘Reality Shock’
Prologue
The First Assignment
The Second Assignment
My Third Assignment
Commentary
References
CHAPTER 24: Holding Creative Tension
In the Beginning
Was I not a Philistine!
My Leadership Despair
Five Smooth Stones
Psalm of Victory
Four Years On, What is the Condition of My Harp?
Detecting the Sheep from the Wolves
Wolf: Abandon Your Wicked Ways
Taking Off My Armour
The Future
References
CHAPTER 25: The Complexity of Teaching
Narrative: PGCE Science at the Beginning of the Academic Year
Transforming
The New Story
Teacher Education
Reflections on the Introductory PGCE Science Workshops
Understanding the Classroom Environment
Narrative: Work with Student Teachers, at the Beginning of the Academic Year
Undergraduate Workshop on Water
Reflection
Summary
References
CHAPTER 26: Guiding Nursing Students’ Reflection on a Simulated Patient Experience
Preparatory Phase‐bring the Mind Home
Reflective Phase
Anticipatory Phase
Insight Phase
References
APPENDIX 1: Guided Reflection Evaluation Tool
Introduction
Guided Reflection Evaluation Tool
APPENDIX 2
Index
End User License Agreement
List of Tables
Chapter 1
TABLE 1.1 Barriers to Rational Change (Fay 1987)
Chapter 2
TABLE 2.1 The Six Dialogical Movements of Reflective Learning Within the Hermeneu...
Chapter 3
TABLE 3.1 Value of Constructing Story
Chapter 4
TABLE 4.1 Model for Structured Reflection (18th Edition)
TABLE 4.2 Model for Clinical Judgment
TABLE 4.3 The Becoming Assertive Action Ladder
8
Chapter 5
TABLE 5.1 The Being Available Template
Chapter 14
TABLE 14.1 MSc Leadership in Healthcare Programme
Chapter 15
TABLE 15.1 Assignment Criteria for Reflective Narratives.
a
Chapter 16
TABLE 16.1 Six Factor Intervention Analysis (Heron 1975)
Chapter 19
TABLE 19.1 Front Foot Thinking
Chapter 20
TABLE 20.1 Burford Vision for Clinical Practice (4th edition).
TABLE 20.2 The Burford NDU Reflective Cues.
Chapter 22
TABLE 22.1 Advantages and Disadvantages of the Line Managed Guidance within the ...
List of Illustrations
Chapter 1
FIGURE 1.1 Typology of reflective practices.
Chapter 4
FIGURE 4.1 Ethical mapping (adapted from Johns 1999).
FIGURE 4.2 The feeling fluffy–feeling drained scale.
Chapter 5
FIGURE 5.1 Carper’s fundamental pattern of knowing in nursing (1978) (Johns ...
FIGURE 5.2 Framing perspectives.
Chapter 6
FIGURE 6.1 The intent‐emphasis scale (Johns 2001).
FIGURE 6.2 Challenge‐support axis.
Chapter 7
FIGURE 7.1 People in the treatment room.
Chapter 13
FIGURE 13.1 Thumb print impact.
FIGURE 13.2 Nurse Bully and the timid sheep storyboard
(from pages 261–268,
...
Chapter 14
FIGURE 14.1 The basic structure of the reflective curriculum.
Chapter 16
FIGURE 16.1 Michelle’s application of ‘Ethical mapping’.
Chapter 17
FIGURE 17.1 Mapping the Thomas and Kilmann conflict mode instrument (1974)....
FIGURE 17.2 The becoming assertive action ladder.
FIGURE 17.3 Leadership power typology French and Raven (1968).
FIGURE 17.4 Feeling drained, feeling fluffy scale applied to Karen’s experie...
Chapter 20
FIGURE 20.1 The six disciplines of the Learning Organisation.
FIGURE 20.2 The three cornerstones of a valid vision.
FIGURE 20.3 The Burford NDU: caring in practice model.
FIGURE 20.4a Tuning in and flowing with the patient’s wavelength.
FIGURE 20.4b Forcing the patient’s wavelength to ‘fit‐in’.
Chapter 21
FIGURE 21.1 Model for reflective inquiry.
Guide
Cover Page
Title Page
Copyright Page
Preface
Table of Contents
Begin Reading
APPENDIX 1 Guided Reflection Evaluation Tool
APPENDIX 2
Index
Wiley End User License Agreement
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Becoming a Reflective Practitioner
Sixth Edition
Edited by
Christopher Johns
This edition first published 2022© 2022 John Wiley & Sons, Ltd
Edition HistoryWiley‐Blackwell (5e, 2017)
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, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
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Library of Congress Cataloging‐in‐Publication Data
Names: Johns, Christopher, editor.Title: Becoming a reflective practitioner / edited by Christopher Johns.Description: Sixth edition. | Hoboken, NJ : Wiley, 2022. | Includes bibliographical references and index.Identifiers: LCCN 2021047893 (print) | LCCN 2021047894 (ebook) | ISBN 9781119764748 (paperback) | ISBN 9781119764755 (Adobe PDF) | ISBN 9781119764762 (epub)Subjects: MESH: Philosophy, Nursing | Nurse Practitioners | Models, Nursing | ThinkingClassification: LCC RT82.8 (print) | LCC RT82.8 (ebook) | NLM WY 86 | DDC 610.7306/92–dc23LC record available at https://lccn.loc.gov/2021047893LC ebook record available at https://lccn.loc.gov/2021047894
Cover Design: WileyCover Image: © agsandrew/Shutterstock
PREFACE
Reflective practice matters. It matters because it opens a gateway for practitioners’ to learn and grow towards realising their potential and their visions of practice as a lived reality. A reflective practitioner is someone who lives reflection naturally within everyday practice. It is a mindful way to practice whereby the practitioner pays attention within the unfolding experience, mindful of responding most appropriately in tune with their vision. It is a process of self‐realisation. Rolling Thunder describes this as ‘seeking and knowing one’s own identity’ [Boyd 1974:7].
Reflective practitioners learn through reflection on experience. In this way, the practitioner gains insights that inform future experiences within a reflexively spiral of being and becoming. I assume that the practitioner’s practice matters to them and that values and vision are important. Hence realising one’s vision of practice as a lived reality must be the aim of every practitioner who takes themselves seriously. Recipients of service deserve nothing less.
The emphasis of this book is on becoming a reflective practitioner. Becoming is a journey. No matter the practitioner’s level of experience or status. It commences with the first reflection on experience. In the uncertainty and uniqueness of everyday practice, practitioners face situations that often feel chaotic. As Salzberg notes (2002:76)
No matter how much we want it to otherwise. The truth is that we are not in control of the unfolding of our experience. We can affect and influence and impact what happens, but we can’t wake up in the morning and decide what we will encounter and feel and be confronted by during the day.
The experience becomes less chaotic as the practitioner becomes more able to ride with chaos rather than be thrown by it. Such learning isn’t complex or difficult. Yet it does take commitment and discipline to learn in this way.
The spin‐offs are great. We become more effective, more purposeful, more motivated and satisfied, more in control of ourselves and our practice. Our lives become richer with meaning, purpose and expertise. We become more satisfied and committed. For these reasons, reflection has become a normal learning approach within the professional curriculum and, as such, demands serious consideration.
I wrote against a background of social unrest following the death of George Floyd in May 2020, and the resurgence of Black Lives Matter into the social consciousness as a consequence. His death is a wake‐up call for all people to be critically reflective of their own attitudes to ethnic minority peoples, most notably health care practitioners who espouse person‐centred nursing. Hence reflective practice matters as the key to enable practitioners towards cultural safety to become aware, examine, understand and shift their attitudes to ensure peoples of all races feel culturally safe. Becoming culturally safe that must be a key aspect of person‐centred practice. It is a massive challenge given the deeply embodied racism that most white people would deny and yet is reflected subconsciously in most aspects of daily life. Why is it that black people are ten times more likely to be stopped and searched than white people? [BBC News 8th July 2020].
The book is also set against an environmental background of climate change as a result of the way the planet has been exploited for economic growth. In response to the environmental crisis, there must be a radical shift in consciousness towards living in harmony with the planet resulting in healthier lives. Failure to do so will simply be extinction. Evidence is all about us. Take, for example, Covid 19. As such, practitioners, no matter what discipline, but perhaps especially health and social care practitioners, should reflect on their practice set against this background of creating healthier lives for themselves and for those they work with and care for. It is the bigger picture. It is our individual and collective responsibility to practice in harmony with the planet. It is a tough ask given the world we live in but, as Rolling Thunder (1974:7) notes –
mankind’s strength and ultimate survival depend not upon an ability to manipulate and control, but upon an ability to harmonize with nature as an integral part of the system of life.
My approach to ‘Becoming a Reflective Practitioner’ ever since the first edition published in 2000, is to create a reflective text to engage and dialogue with its readers. As such, I use many stories and dialogue to illuminate ideas and give examples of reflective writing. This approach illustrates the reflective process and what the writer seeks to realise in their practice. Hence, the text is also a text on realising person‐centred practice.
My inquiry into the nature of reflective practise commenced in 1989, resulting in an understanding of guided reflection (Johns 1998) that has been continuously reflected on for its rigor, coherence and utility as presented throughout this book.
The book is designed to guide both student and registered practitioners at any level of professional learning, along with their guides, teachers, and managers, to become reflective practitioners, not just clinical practitioners but also educators, managers, and most significantly, leaders able to enable others to grow and fulfil their potential. Although the book’s background is healthcare, it is a resource for all professionals who aspire to offer a service to people.
Health care, no matter what discipline, is fundamentally concerned with the relationship between the practitioner and the person receiving health care to meet the person’s health needs, whatever they may be. Nothing about this relationship can be assumed to be certain or predictable. Everything is an interpretation depending on context. As such, the practitioner’s response to the patient is perceptive, seeking to understand the patient’s experience and needs to inform an appropriate and effective response. This is the essence of person‐centred health care that is unless the patient is viewed as an object to do things to. Then the patient is no more than of technical interest. Disembodied. Education and practice must radically shift to ways of learning and knowing that nurture person‐centred health care rather than skid along the technical surface of things. We need to create opportunity to learn through experience to reveal the very depth of professional artistry. This is the way of reflective practice. And yet, if we are not alert, reflective practice too can skid along the surface of things. Most importantly, approach the book with a sense of play and curiosity to see where it takes you. Most of all, reflective practice is about YOU and nothing can be more interesting.
Like previous editions, this sixth edition has been extensively revised and reorganised to comprehensively guide students, practitioners, managers, and their guides across disciplines no matter their level of experience to learn through reflection on experience to become a reflective practitioner. I have looked back through previous editions and associated books (Johns 2002, Johns 2010, Johns and Freshwater 2005), reading and reflecting again on these published narratives resulting from my guidance of practitioners within the guided reflection. Some narratives are republished because they tell such vital stories of becoming a reflective practitioner. New guest authors give wider perspectives on reflective practice, including contributions from international authors.
Chapters
The book is organised in two parts. Part 1 is written by myself with the exception of Chapters 12 and 13 jointly written with Otter Rose. Part 2 is written by contributors who offer the reader wider perspectives on reflection and reflective practice.
Part 1
In Chapter 1, I envisage reflection. Reflective practice is at risk of being a cliché with its multiple interpretations that begs the question ‘what exactly is reflection and reflective practice’? How can we know it and apply it certain of its validity?’ If known, it can be applied with prediction and control, so everyone knows what it is. However, things are not that simple. Reflective practice will always be interpreted in different ways according to the interpreter’s perception and intentions. I give a brief overview of reflective theories that I have dialogued with over time and which, to a varying extent, have influenced my own conception of reflective practice. In describing reflection, I view learning as a movement through understanding, empowerment and transformation. At each level, insights can be gleaned.
I explore vision as fundamental to reflection. Vision sets out what the practitioner is striving towards. Vision sets up creative tension, the dynamic learning moment within reflection between vision and an understanding of our current reality. In understanding this tension, the practitioner can work towards resolving it so the vision can be more realised. Barriers that constrain are identified and worked towards overcoming. Without vision, reflection has no real meaning except perhaps as a superficial problem‐solving tool. As such, reflection is always an exploration of values that constitute vision and the assumptions and attitudes that support realising the vision as a lived reality.
In Chapter 2, I set out the Six dialogical movements that structure the reflective learning process that is systematically explored through succeeding chapters. I set out the reflective attitude comprised of a number of attributes the practitioner needs to cultivate to engage reflection to gain maximum benefit. One of these attributes is developing bringing the mind home. Bringing the mind home helps to prepare the practitioner to be fully present within‐the‐moment, whether in clinical practice or reflecting on experience.
In Chapter 3, I explore the first dialogical movement concerned with paying attention to a particular experience with the intention to write or portray a description of that experience. This expression is the raw data reflection. Paying attention immediately cuts across the taken for granted nature of much of experience and habitual practice. Over time, through paying attention, the practitioner becomes increasingly self‐aware, leading to mindfulness where nothing is taken for granted and the whole span of practice is an inquiry. I advocate keeping a reflective journal to write descriptions that becomes an ongoing and unfolding reflective record of experience.
In Chapter 4, I explore reflection using the Model for Structured Reflection [MSR]. The MSR has been significantly revised from previous editions and is easy to apply. From feedback, I get the impression that many people think that simply using the MSR is reflective practice. Worse, they view a model of reflection as a prescription. It isn’t! It is a heuristic, a means to an end towards gaining insight. I urge readers to dwell with the MSR, to feel the depth of the cues rather than view it superficially and skid along the surface of reflection. If so, reflection loses its vitality.
In Chapter 5, I explore insight. Insights are the learning accrued through reflection. They are described as embodied learning because they change the person in some way so that they now view and respond to the world differently, however slight. They are not necessarily easy to identify because of their embodied nature. Insights are initially tentative and held loosely. They are most often acknowledged reflexively through subsequent experiences.
In Chapter 6, I explore the third dialogical movement between the practitioner’s tentative insights and informing literature whereby relevant information from whatever source is accessed, critiqued, juxtaposed with insights and assimilated into personal knowing. I show how theory can be explored as theoretical mapping enabling practitioners to position themselves within the theory and plot movement towards a more desirable position.
The second part of this chapter is devoted to the fourth dialogical movement, the dialogue between the practitioner with a guide and peers. Guidance opens a learning space where the practitioner can share their experiences and insights, inviting the guide to offer their own perspectives. As a result of this dialogue, new insights emerge, deepened, and co‐created. Guidance radically shifts the relationship between student and teacher and, as such, has profound implications for curriculum as explored in later chapters.
In Chapter 7, I explore the fifth dialogical movement as weaving insights into threads and patterns represented in reflexive narrative form. The word ‘narrative’ has seeped into everyday speak. I wonder, have we moved beyond the technical rational to value experience and anecdote reflected in this seepage? Or is narrative simply a word to reflect ‘the story’ or ‘vision’. Whatever, it does suggest a valuing of context and subjectivity; that people are not machines. People are human and that experience is human and unique. And that no matter the difficulty, learning through reflection is dynamic. Narrative is creative. The practitioner has a license to construct narrative in ways that best express their reflexive learning and journey, for example, through poetry, art, metaphor and images. It cannot be prescribed even though academic institutions will nevertheless impose criteria about how it should be expressed.
In Chapter 8, I apply the model for structured reflection to my description of being with Peggy one morning at the Day Hospice. I apply the MSR in a systematic way to illustrate my use and understanding of each cue and as an exemplar to readers.
In Chapter 9, I set out my narrative of ‘patients I do not give a therapy to’ written as a series of prose poems about different patients who share the fact I did not give them a physical therapy, challenging myself about my role and the concept of therapy.
In Chapter 10, I explore the sixth dialogical movement as the dialogue between the text and its audience. In doing so, I emphasise that the text is more than simply an account of the practitioner’s journey. It offers an audience a focus for their own reflection and learning. The practitioner invites the audience to dialogue with an intent to stir the audience to draw and act on their own insights. With this idea in mind, the practitioner writes in a way to engage the audience and open this reflective space. Audience can be readers or listeners through performing the narrative.
In Chapter 11, I explore the idea of performing narrative to an audience in contrast with an audience reading a narrative. I give an example of how one practitioner converted her written assignment into a play ‘Musical chairs’ that was performed at a reflective practise conference.
In Chapter 12, I set out the performance narrative ‘people are not numbers to crunch’. It was written from my perspective as a partner to witness Otter’s experience of undergoing an angiogram. It exposes issues which reflect an unsatisfactory level of care, notably that nursing staff do not introduce themselves and treat Otter as if she is an object and myself as an outsider beyond their gaze. The performance is set against a CQC report of care at this particular hospital. Otter’s graphic storyboard of this experience can be accessed on the Wiley Blackwell website.
In Chapter 13, I explore with Otter how art and storyboard offer as a particular visual approach to reflection and narrative that may offer an alternative to language approaches and hence may benefit visual reflectors. Breaking narrative into visual scenes, like poetry, aids the revelation of insights. Poetry and art are expressive forms that open up the neglected right brain moving away from rational thought to nurture imagination, perception and ultimately intuition. We use Otter’s storyboard of bullying in the workplace. We know from experience that many practitioners will relate to this because bullying is endemic within the workplace. Storyboard’s visual storyboard is easy to relate to, opening a clearing for practitioners to explore their own experience of being bullied and how such pernicious behaviour can be confronted.
In Chapter 14, I contemplate the reflective curriculum. It is fascinating to look back at the previous editions to see this chapter’s reflexive development. It is the most vital chapter because health discipline curriculum is entrenched in a technical rational modus where reflection is viewed as just another teaching technique. If this is the case, then much of the benefit of reflective practice is lost. The reflective curriculum views professional artistry and identity as its education aim, and reflective practice as its primary approach, re‐orientating theory to inform this process. In other words, it turns the traditional relationship between practice and theory on its head. Easier said than done. I imagine how two teachers with differing teaching approaches explore teaching nursing students about stroke. John takes a theory‐driven approach typical of a dominant technical rational approach. Jane takes a reflective approach that embraces performance and with it, cross‐discipline teaching. At Bedfordshire, I involved drama and dance teachers as co‐supervisors for reflexive narrative doctoral students. Their involvement opened up the performance potential as a profound learning space. Performance engages and empowers people. It is an embodied learning that is necessary for practice disciplines where the body has to learn rather than the mind simply think.
Developing post‐registration reflective curriculum is illustrated through two courses; one as part of a ‘top‐up’ degree and one as a total masters degree in leadership.
Much of the reflective practice taught in Universities is by people who are not reflective. As a consequence, they adopt technical rational approaches to teaching reflection that are inadequate. The whole book is itself a treatise on the need to create reflective learning environments if we are to practice reflective practice critically rather than as a superficial problem‐solving exercise. Of course, it has value even at that level if it enables practitioners to pause and reflect on what they are doing in terms of best practice. But much of what we do and the way we think about what we do is culturally prescribed, And so, the reflective teacher, like the reflective practitioner, must pierce this cultural veil to understand and shift the norms that govern teaching of teachers if the value of reflective practice to develop professional artistry is greater than a technical rational approach to do reflection.
In Chapter 15, I explore how reflective academic writing can be meaningfully graded from a professional artistry perspective in contrast with a technical rational perspective. I argue that the focus of all reflective examination should primarily focus on the insights the practitioner draws from reflection, not on the reflective process itself. I use Jill’s reflective assignment on touch and the environment to invite readers to grade and reflect on how they graded.
Chapters 16 and 17 are illuminations of guiding nursing students in dedicated guided reflection sessions. The two situations: ‘Michelle finding a woman upset about her breast biopsy’ and ‘Hank’s complaint’ are real situations shared in guided reflection. As you might expect, guiding the first year group is more directed, whilst guiding the third year group is more open. The chapters illuminate the use of theoretical mapping, the way can be fed into the dialogue between guides and students.
Chapter 18 is a narrative of guiding of Trudy within the context of her clinical practice whilst also undergoing the Becoming a reflective and effective practitioner programme set out in Chapter 14. The narrative reveals how a particular experience is unfolds over six guided reflection sessions leading to profound insights. Of particular note is the richness of Trudy’s reflective description imbibed with MSR cues.
Chapter 19 reveals Sally’s narrative ‘a small voice in a big arena’ which was written as her conflict management assignment on the MSc Leadership in healthcare degree. It reflects how conflict is an everyday occurrence for many practitioners and hence a common focus for reflection. Her effort to respond to conflict from her vision of leadership heightens the conflict tension dramatically revealing the struggle to realize her vision of leadership as a lived reality within a transactional healthcare organization.
Chapter 20 sets out the Learning Organizations inspired by the work of Senge (1990) concerned with creating an environment in which reflective practitioners work collectively towards realising their vision of practice as a lived. This is exemplified through the Burford NDU Model of nursing: caring in practice. This model consists of four reflective systems set against the background of the Learning Organization. Two systems concerned with implementing the vision through reflective cues and communication are explored.
In Chapter 21, I set out ‘A system to live and ensure quality’ through developing clinical audit, standards of care, and group guided reflection that each foster reflection, personal mastery and team learning.
‘A system to enable practitioners to develop personal mastery towards realizing their vision of practice’ is the focus of Chapter 22. Within healthcare organizations guided reflection is usually termed clinical supervision that comes with a political agenda to essentially safeguard the public. Hence a tension exists between its regulatory and developmental intentions. Susan’s narrative, completed as an assignment on the MSc Leadership in Healthcare degree, gives focus on instigating clinical supervision as an element of leadership against the background of developing the Learning Organization.
Part 2
Awakenings [Chapter 23] reveals how arduous reflection can be for some practitioners, such as Aileen, in despair about her nursing predicament. As she quotes ‘There is much truth that learning through experience is arduous work’. For Aileen reflection was a rope to pull her out of her despair but her hands are slipping. The rope is hard to grasp. And what is it pulling her into?
In Chapter 24, Gerald Remy reflects on his leadership two years after completing the MSc Leadership in healthcare degree. Gerald, like Susan and Sally noted in earlier chapters, undertook the MSc Leadership in Healthcare degree. He was part of a learning community of 10 aspiring health care leaders. I emphasise community for a number of reasons. Firstly, from a leadership perspective, creating community is fundamental for any leader to create. Secondly, I believe that learning through community whereby others in a similar aspiring boat are available to each other through a period of time [in this case, 28 months] enhances learning through reflection. Community creates the condition for dialogue for a group of people learning towards similar goals. This idea permeates through many of the chapters in the book and reinforces the need for guides to be themselves leaders and skilled at guiding others to learn through reflection. Indeed this ability to guide learning in others is a prime quality of leadership.
Thirdly, is whether learning can be sustained without guidance, especially in a hostile culture that puts constant pressure on the practitioner to conform to organisational norms that are previously learnt ways of being. The ability to sustain learning, against the grain, so to speak, is reflected in the extent reflection has become inculcated within the practitioner’s community rather than an individual thing. Gerald suggests he has achieved that to some extent, although it remains precarious as he continues to hold creative tension. Of course, in terms of the efficacy of reflective learning, this issue of sustained learning at the depth of is of vital concern, that reinforced the necessity of first, a clear understanding the nature of reality [organisational norms that govern everyday ways of relating], and secondly, being able to detach self from the anxiety of transgressing these norms. Living this tension is akin to playing a subversive and dangerous game of survival where guidance is vital.
Gerald’s narrative gives a dimension on expressing learning through metaphor. Gerald, like all NHS staff have been socialised into the transactional culture that governs health care organisations. Hence the idea of being a servant‐leader or a transformational leader is immediately at odds with this culture. It begs the question – ‘how can one come to appreciate and separate self from this culture whilst being immersed within it where one’s every action has been socialised towards being transactional from either a subordinate or managerial perspective’. Gerald used the metaphor of David and Goliath to see and work with this tension. If the tension is not addressed then learning is limited and yet one can see how difficult it is to unlearn learnt ways of knowing [embodiment] to begin to respond differently and without coercive fear.
Fifthly, Gerald highlights the significance of one’s background in shaping the person. To become a leader from a servant‐leader or transformational perspective required Gerald to look back at his upbringing in order to understand how his background influences who he is now and who he seeks to become. He recognises the tension between a Goliath within and a David within and the need to vanquish his Goliath through his David. Anybody learning through reflection will need to consider their background‐ perhaps using the influences grid [How does my background influence the way I respond within this particular situation/experience?].
Chapter 25 offers a teacher of teachers’ perspective on reflective teaching. In particular it highlights how a ‘reflective mindset’ results in challenging previous ways of teaching that had been viewed as successful. The reflective teacher seeks to give responsibility to the students to find their own way with minimal guidance. Not easy to do when you think you know the best way, but it opens to door for the teacher to learn and be challenged through post‐exercise dialogue. Adenike also explores the culture of the classroom, highlighting the difficulty teachers face with issues such as control and emotions.
Chapter 26 offers a Canadian perspective on reflective teaching using the MSR and stimulating reflection through constructed narratives. Arlene lifts to the surface the dynamic nature of reflective teaching offering new perspectives on learning through reflection for both guides and students.
References
1. Boyd D (1994)
Rolling Thunder
. Delta, New York.
2. Johns, C (1998)
Becoming a Reflective Practitioner Through Guided Reflection
. PhD thesis, The Open University.
3. Johns C (2002)
Guided Reflection: Advancing Practice
Blackwell Publishing, Oxford.
4. Johns C (2010)
Guided Reflection~: A Narrative Approach to Advancing Professional Practice
. Wiley‐Blackwell, Oxford.
5. Johns C & Freshwater D (2005)
Transforming Nursing Through Reflective Practice [2nd edition]
Blackwell Publishing, Oxford;
6. Salzburg S (2002)
Faith: Trusting Your Own Deepest Experience
. Riverhead books, New York.
CHAPTER 1Envisaging Reflective Practice
Christopher Johns
The woman’s comments suggest her care was unsatisfactory. You might accept her word that the chiropodist wasn’t listening to her and ponder the reason for that. Had the chiropodist’s practice become routine requiring little thought and engagement with the patient? The bottom line is that every professional, no matter what discipline, must take responsibility for ensuring the most effective and desirable practice. This requires practitioners not only to be reflective after the event but more significantly, to have the ability to reflect within the practice to ensure best practice. This is the stance of the reflective practitioner.
Sitting in the train the other day a woman hobbles on. Finds a seat to put her leg up. She says to her mate ‘They just don’t care anymore. She didn’t look properly at my foot. She wasn’t interested. Told me it was probably a corn. Wasn’t listening to me. Told her the pain was in me’ eel. In the end she said ‘Your 10 minutes are up got to see someone else’.
Her mate rolls her eyes ‘Bloody awful ain’t it, chiropody on the NHS’.
Professional Artistry
Before exploring the nature of reflection, it is necessary to consider the type of knowing it generates, what I term professional artistry stemming from Schön’s description as the ‘kinds of competence practitioners sometimes display in unique, uncertain, and conflicted situations of practice’ (Schön 1987, p. 22). Adding to Schön’s description ‘set against a background of realizing one’s vision’.
Every experience is unique. It cannot be determined. We may have many similar experiences that serve to inform our interpretation and response. There can be no prescriptive solutions. As such, practice is largely intuitive, drawing on our tacit knowing. By tacit, I mean knowing that is not easily articulated. We can only know our practice through reflection as something lived rather than as something theoretical. Take the example of caring. Frank (2002, p. 13) writes:
Caring is one of those activities that people know only when they are involved in it. From within, and only from within, caring makes sense. To try and explain care leads to the circularity expressed in statements such as ‘caring for this person requires doing this, and I do this because I care for this person’. Philosophy teaches that, for some activities, there is only practice.
It follows that if we accept Frank’s position, we can only know caring from within caring – the professional artistry perspective. Caring cannot be known as a technical or abstract thing. The practitioner knows self as caring only within the moment.
King and Appleton (1997) and Cioffi (1997) endorse the significance of intuition within decision making and action following their reviews of the literature and rhetoric on intuition. They note that reflection accesses, values, and develops intuitive processes.
Aristotle drew a distinction between practical wisdom and theoretical wisdom. Practical wisdom does not result in knowledge that is determinate and universal; indeed, it does not result in propositional knowledge at all but in discriminations and actions.
Technical rationality (or evidence‐based practice) has been claimed as necessary for nursing’s disciplinary knowledge base because it can be observed and verified (Kikuchi 1992). Historically, professions such as nursing have accepted the superiority of technical rationality over tacit or intuitive knowing (Schön 1983, 1987). Yet, a technical rational mentality is likely to lead to stereotyping, fitting the patient to the theory rather than using the theory to inform the situation. This mentality inevitably leads the practitioner to fit the person to the theory, thus reducing the patient/client to some object and the practitioner to the status of a technician carrying out a prescription irrespective of the person’s humanness.
In an educational and organisational culture dominated by a technical rational approach, the idea of writing spontaneous, subjective, and creative descriptions as a basis for reflection and gaining insight may seem to go against the grain. A technical rational approach gives dominance to theory and objective facts rather than subjective opinions and feelings. Indeed, feelings may be denigrated as unprofessional and stories as mere anecdotes with little learning potential. From this perspective, reflective practice is likely to be adapted to fit this dominant culture rather than see the potential for reflection to transform both educational and organisational culture.
Since the Briggs Report (DHSS 1972) emphasised that nursing should be a research‐based profession, nursing has endeavoured to respond to this challenge. However, the general understanding of what ‘research based’ means has followed an empirical pathway reflecting a dominant agenda to explain and predict practice. This agenda has been pursued by nurse academics seeking academic recognition that nursing is a valid science within university settings. Whilst abstract knowledge has an important role in informing practice, it certainly cannot predict and control, at least not without reducing the patient and nurses to the status of objects to be manipulated like pawns in a chess game. The consequence of this position in nursing has been the repression of other forms of knowing that has perpetuated the oppression of nurses of their clinical nursing knowledge (Street 1992). Has it improved in the past 20 years? I see no evidence to support that. We who plough the professional artistry field reap a poor reward in academic acclaim. Professional artistry is subjective and contextual, yet is often denigrated as a lesser form of knowing, even dismissed as ‘mere anecdote’ by those who inhabit the hard high ground of technical rationality. People get locked into a paradigmatic view of knowledge and become intolerant of other claims because such claims fail the technical rationality injunction as to what counts as truth.
It is unimaginable for any healthcare practitioner to face clinical practice with a technical rational mindset simply because each clinical moment is a unique human‐human encounter. Yet, unfortunately, the reality is otherwise. As a consequence, healthcare practitioners become technicians and patients objects.
Reflection
A good place to start is a quote from Wheatley and Kellner‐Rogers (1996, p. 69): ‘Life is playful and life plays with us. The future cannot be determined. It can only be experienced as it is occurring. Life doesn’t know what it will be until it notices what it has just become’. I like these words because they are playful. Reflection is playful and is the gateway to knowing life as it is occurring and knowing life as it has just become.
Reflection is a process of self‐inquiry towards self‐realisation, however, that might be expressed. It enables practitioners to learn reflexively through their everyday experiences. Experience is a rich learning opportunity when we pay critical attention to it. As O’Donohue (1997, p. 26) writes:
‘Everything that happens to you has the potential to deepen you’. This potential is actuated through reflection as a self‐inquiry into experience to find meaning, gain insight and prompt action that will deepen you.
Learning is expressed as insights. Insights are focused towards realising the practitioner’s vision of the desirable practice. Reflection moves the practitioner away from an uncritical, pre‐reflective state of being where aspects of the practice were not questioned but simply taken for granted (Cox et al. 1991).
The words reflection and reflective practice are often used glibly in everyday discourse as if reflection is simply a normal way of thinking about something that has happened and which requires little skill or guidance. Smyth (1992, p. 285) writes:
Reflection can mean all things to all people … it is used as a kind of umbrella or canopy term to signify something that is good or desirable … everybody has his or her own (usually undisclosed) interpretation of what reflection means, and this interpretation is used as the basis for trumpeting the virtues of reflection in a way that makes it sound as virtuous as motherhood.
Smyth’s words are both salutary and provocative. They remind us to be careful about grasping reflection in any casual or authoritative way. The Compact Oxford English Dictionary 3e defines ‘reflect’ as:
throw back heat, light, sound without absorbing it,
(of a mirror or shiny surface) show an image of,
represent in a realistic or appropriate way,
bring about a good or bad impression of someone or something (on),
think deeply or carefully about.
Hence reflection can be viewed as a mirror to see images or impressions of self thrown back in the context of the particular situation. It is thinking deeply about the way the practitioner responded and reasons for that response in light of what they were trying to achieve. It is self‐judgmental – did I do good or bad? It is a wake up call because so much of practice is non‐reflective, merely a matter of habit and automatic response.
Next time you are at work, ask yourself some questions.
‘Why am I responding as I am?’
‘Am I being effective?’
‘Could I respond in different, perhaps more effective ways?’
‘Am I responding in tune with my vision of practice?’
Sensible questions the responsible practitioner should naturally ponder as they go about their practice and to reflect on later. These questions open the doorway to self‐inquiry. As a consequence, the practitioner becomes more sensitive to their practice. They step along the reflective road.
A Brief View of Reflective Theories
Imagine the practitioner’s cry – ‘tell me what reflection is so I can do it!’ However, it is not as simple as that. It is more complex than simply applying a technique, although on the surface, it might seem that a prescription is just what is required. Indeed, many practitioners and educators may misguidedly view it as such. If so, reflection becomes a task to be done rather than something meaningful and transformative.
When I first explored reflective theories, I discovered the work of Schön (1983, 1987), Boud et al. (1985), Boyd and Fales (1983), Gibbs (1988), and Mezirow (1981). It is not my intention to review these theories in any depth. The reader is directed to the primary sources to explore these theorists more deeply and explore more recent ideas.
All models of reflection should be viewed through a sceptical lens. Rather like the skilled craftsman, the practitioner will choose the tool that is most helpful. Models are not prescriptions for reflection. They must always be viewed as a heuristic, as a means to an end. In a technical rational society, reflective models are likely to be grasped as authoritative. The risk, from this perspective, is that practitioners will fit their experience to the model of reflection rather than use the model creatively to guide them to gain insight. It is easy to get wrapped up in the technology of reflection, especially in a learning culture dominated by technical rationality. It is a Western technological addiction (Rinpoche 1992).
Boyd and Fales (1983)
These authors write: ‘We define reflection as the process of creating and clarifying the meaning of experience (present or past) in terms of self (self in relation to self and self in relation to the world). The outcome of the process is changed conceptual perspective. The experience that is explored and examined to create meaning focuses around or embodies a concern of central importance to the self’. (p. 101)
From their research with counsellors, they extrapolate reflection through six components (p. 106):
A sense of inner discomfort.
Identification or clarification of the concern.
Openness to new information from internal and external sources, with ability to observe and take in from a variety of perspectives, and a setting aside of an immediate need for closure.
Resolution, expressed as ‘integration’, ‘coming together’, ‘acceptance of reality’, and ‘creative synthesis’.
Establishing a continuity of self with past, present, and future.
Deciding whether to act on the outcome of the reflective process.
In relation to stage 6, they note ‘the new insight or changed perspective is analyzed in terms of its operational feasibility involving the practitioner’s sense of rightness, values and potential acceptance by others’. (p. 112).
I generally agree that reflection is triggered by ‘inner discomfort’ for practitioners when first engaging reflection. However, as the practitioner becomes more mindful, then all experience, not just ‘inner discomfort’ becomes available for reflection. I equate the idea of changed conceptual perspective with insight (see Chapters 4 and 5).
Boud et al. (1985)
These authors posit reflection as moving through three key stages:
returning to experience
attending to feelings
utilising positive feelings
removing obstructing feelings
re‐evaluating experience
re‐examining experience in the light of the learner’s intent
associating new knowledge with that which is already possessed
integrating this new knowledge into the learner’s conceptual framework
appropriation of this knowledge into the learner’s repertoire of behaviour
Appropriation is akin to gaining insight; that the practitioner has changed through the reflective process, that when faced with a similar situation, they will respond differently. This differs from Boyd and Fales’s approach in that the practitioner makes a choice whether to respond differently in light of learning. Boyd and Fales (1983, p. 112) write: ‘The need to test one’s self‐changes [insights] against the mirror of others is an essential component of all growth’. These words emphasise that all individual learning must be set within its context.
Gibbs (1988)
Gibbs offers a practical reflective circle moving through six stages suggesting that each stage is important to inform the next stage ultimately resulting in an action plan for responding in future similar situations.
Description (of the situation).
Feelings (what were you thinking and feeling).
Evaluation (what was good and bad about the experience).
Analysis (what sense can you make of the situation).
Conclusion (what else could you have done).
Action plan (if it arose again what would you do).
Mezirow (1981)
Mezirow viewed reflection as a process leading to emancipatory action. He posited a depth of reflection through seven levels of reflectivity spanning from consciousness, the way we might think about something, to critical consciousness where we pay attention and scrutinise our thinking processes. Thinking is inherently problematic. Hence our thinking is a focus for reflection. Hence I need to think differently to perceive the situation differently, and in doing so, to unearth those assumptions that govern thinking. If reflection is viewed merely as problem solving, and we used the same thinking to solve the problem that caused the problem, then we wouldn’t get very far. Our solutions would quickly break down. Mezirow (1981, p. 6) conceptualised the outcome of reflection as perspective transformation:
