�

� �

�

Becoming a Reflective Practitioner

�

� �

�

To my wife, Otter, my constant inspiration

�

� �

�

Becoming a ReflectivePractitioner

Fifth Edition

Edited by

Christopher JohnsVisiting Professor at Christ Church Canterbury and University of Bedfordshire

�

� �

�

This edition first published 2017

© 2017 John Wiley and Sons Ltd.

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 aspermitted by law. Advice on how to obtain permission to reuse material from this title is available athttp://www.wiley.com/go/permissions.

The right of Christopher Johns to be identified as the editor of this work has been asserted in accordancewith law.

Registered OfficesJohn Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USAJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial Office9600 Garsington Road, Oxford, OX4 2DQ, UK

For details of our global editorial offices, customer services, and more information about Wiley products visitus at www.wiley.com.

Wiley also publishes its books in a variety of electronic formats and by print-on-demand. Some content thatappears in standard print versions of this book may not be available in other formats.

Limit of Liability/Disclaimer of Warranty

The contents of this work are intended to further general scientific research, understanding, and discussion onlyand are not intended and should not be relied upon as recommending or promoting scientific method,diagnosis, or treatment by physicians for any particular patient. The publisher and the authors make norepresentations or warranties with respect to the accuracy and completeness of the contents of this work andspecifically disclaim all warranties, including without limitation any implied warranties of fitness for aparticular purpose. In view of ongoing research, equipment modifications, changes in governmentalregulations, and the constant flow of information relating to the use of medicines, equipment, and devices, thereader is urged to review and evaluate the information provided in the package insert or instructions for eachmedicine, equipment, or device for, among other things, any changes in the instructions or indication of usageand for added warnings and precautions. Readers should consult with a specialist where appropriate. The factthat an organization or website is referred to in this work as a citation and/or potential source of furtherinformation does not mean that the author or the publisher endorses the information the organization orwebsite may provide or recommendations it may make. Further, readers should be aware that websites listed inthis work may have changed or disappeared between when this works was written and when it is read. Nowarranty may be created or extended by any promotional statements for this work. Neither the publisher northe author shall be liable for any damages arising herefrom.

Library of Congress Cataloging-in-Publication Data

Names: Johns, Christopher, editor. | Preceded by (work): Johns, Christopher.Becoming a reflective practitioner.

Title: Becoming a reflective practitioner / edited by Christopher Johns.Description: Fifth edition. | Hoboken, NJ : John Wiley & Sons Inc., 2017. |Preceded by Becoming a reflective practitioner / Christopher Johns ; withcontributions from Sally Burnie ... [et al.]. 4th ed. 2013. | Includesbibliographical references and index.

Identifiers: LCCN 2016059300 (print) | LCCN 2016059908 (ebook) | ISBN9781119193920 (paperback) | ISBN 9781119193937 (Adobe PDF) | ISBN9781119193944 (ePub)

Subjects: | MESH: Philosophy, Nursing | Models, Nursing | ThinkingClassification: LCC RT84.5 (print) | LCC RT84.5 (ebook) | NLM WY 86 | DDC610.73–dc23

LC record available at https://lccn.loc.gov/2016059300

Cover Design: WileyCover image: © Matt Anderson Photography/Gettyimages

Set in 10/12pt, SabonLTStd by SPi Global, Chennai, India.

10 9 8 7 6 5 4 3 2 1

�

� �

�

Contents

Notes on Contributors xiiiPreface xviiAbout the Companion Website xxiii

1 Imagining Reflective Practice 1Christopher JohnsReflective Practice 2Reflexivity 6A Brief View of Reflective Theories 8Prerequisites of Reflection 11The Significance of Reflective Practices for Professional Practice 12The six Dialogical Movements 16Summary 17References 18

2 Writing Self 21Christopher JohnsBringing the Mind Home 21Writing Self: The First Dialogical Movement 22Writing Rather than Telling 25Tapping the Tacit 29Opening the Reflective Space through the Humanities 30The Value and Therapeutic Benefit of Writing 30Summary 32Endnotes 33References 33

3 Engaging the Reflective Spiral: The Second Dialogical Movement 35Christopher JohnsModels of Reflection 36The Model for Structured Reflection [MSR] 36Preparatory and Descriptive Phases 38Was I Effective in Terms of Consequences for Others and Myself? 40What Factors Influenced my Response? 40How Was I Feeling/poise 41How Were Others Feeling? 43Conforming to Normal Practice 43How Does this Situation Connect with Previous Experiences? 43Values and Attitude 44

�

� �

�

vi Contents

The Ethical Demand 44Deeper Psyche Factors 45Ethics – Doing What was Right 45The Ethical Map Trail 46Stress and Anxiety 49The Need to be in Control 52Knowledge to Act in a Particular Way? 53Anticipatory Reflection 53What Would be the Consequences of Alternative Actions for the Patient,Others and Myself? 55

What Factors Might Stop me from Responding Differently? 55‘How Do I Now Feel About the Situation’? 56Summary 56Endnotes 56References 56

4 Framing Insights 59Christopher JohnsSingle Lines 59Framing Insights 60Carper’s Fundamental Ways of Knowing 61The Being Available Template 64Summary 67Endnotes 67References 67

5 Deepening Insights (The Third And Fourth Dialogical Movements) 69Christopher JohnsThird Dialogical Movement 69Finding Voice 70Guiding Reflection: The Fourth Dialogical Movement 71Guidance 74Co-creation of Insights 74Dialogue 75The Reality Wall 77Power 78Finding Your Own Way 79The Guidance Process 79Inputting Theory 80Balance of Challenge and Support 80Six Category Intervention Analysis 81Energy Work 83Pulling Free 84Contracting 84The Learning Environment 85A Quiet Eddy 85Summary 91Endnotes 92References 92

�

� �

�

Contents vii

6 Weaving and Performing Narrative: The Fifth and Sixth Dialogical Movements 95Christopher JohnsIntroduction 95Passing People By 95Methodology and Plot 101Narrative Form 102Creativity 103Empathic Poems 103Coherence 105The Sixth Dialogical Movement 107Performance Narrative 108Curriculum Potential 110Summary 110Endnotes 110References 111

7 Moving Towards a More Poetic Form of Expression 113Christopher JohnsIntroduction 113Veronica 113Linda 115Summary 118Endnote 118References 118

8 Reflection Through Art and Storyboard 119Otter Rose-Johns and Christopher Johns‘Tuning’ Exercises 121Storyboard 122Summary 124Endnotes 125References 126

9 The Reflective Curriculum 127Christopher JohnsIntroduction 127Journal Entry 128Imagine 129One Month Later 137Art and Performance Workshops 137Journal Entry 2 138Journal Entry 3 138Journal Entry 4 139Journal Entry 5 140Journal Entry 6 140Journal Entry 7 141Summary 141Endnotes 141References 142

�

� �

�

viii Contents

10 A Teaching Dilemma Journal Entry 145Christopher JohnsThe Actual Session 147Three Months Later 148Summary 148Endnote 149References 149

11 Life Begins at 40 151Christopher JohnsIntroduction 151Deepening Insight 159Grading 160Summary 161Endnotes 161References 161

12 Reflection on Touch and the Environment 163Christopher Johns and Jill JarvisIntroduction 163Touch 163Environment 166Commentary 169Summary 169Endnote 170References 170

13 ‘Opening My Mind’: The Ripples of Story 173Margaret GrahamIntroduction 173Illustration of Learning 173Sharing the Story 174Reflection 177Ripples Continue 179Rippling Outwards 181Endnotes 181References 181

14 Guiding First-year Nursing Students in Guided Reflection 183Christopher JohnsIntroduction 183Michelle’s Experience 183Lucy’s Reflection 188Summary 191Endnotes 191References 191

�

� �

�

Contents ix

15 Guiding Third-Year Nursing Students in Guided Reflection 193Christopher JohnsIntroduction 193Karen 193Next Session 196Practice Supervision 199Next Session 199Summary 203Endnotes 203

16 A Tale of Two Teachers 205Christopher JohnsIntroduction 205Endnotes 212

17 Teaching Teachers about Teaching 213Adenike AkinbodeNarrative: PGCE Science at the Beginning of the Academic Year 1 213Teacher Education 216Narrative: Work with Student Teachers, Beginning of Autumn term 218Narrative: PGCE Science at the Beginning of the Academic Year 2 218Chaos Theory 219Narrative: PGCE Science at the Beginning of the Academic Year 3 220Endnotes 222References 222

18 Reflective Teaching as Ethical Practice 223Adenike AkinbodeExcruciatingly Busy 224Reflection 226The Session on Water 227Reflection 228Managing Behaviour 230Reflection 231Summary 231Endnote 231References 232

19 A Reflective Framework for Clinical Practice 233Christopher JohnsThe Burford NDU Model: Caring in Practice 233Vision 234The Internal Environment of Practice 238A System to Ensure the Vision is Realised Within Each Clinical Moment 238Narrative Notes 245A Reflective System to Live Quality 248

�

� �

�

x Contents

A System to Ensure Staff are Enabled to Realise the Vision as a Lived Reality 250Organisational Culture 252Summary 255Endnotes 255References 256

20 The Standards Group 259Christopher JohnsStandards of Care 259Standards Group 262Triggers for Standards 263Confidentiality 265The Value of Standards of Care 267Endnote 268References 268

21 Trudy 269Christopher JohnsSession 1 269Session 2 270Session 3 272Session 4 273Session 5 274Session 6 275Summary 277Endnotes 277

22 Reflective Leadership 279Gerald RemyIn the Beginning 279Five Smooth Stones 283Four Years On: What is the Condition of My Harp? 285Distinguishing the Sheep from the Wolves 286The Future 288References 289

23 ‘People are not Numbers to Crunch’ 291Christopher JohnsIntroduction 291The Story of Three Blind Mice and the Movie Star 292Endnotes 298

24 Smoking Kills 301Christopher Johns and Otter Rose-JohnsSome thoughts on narrative performance 301Smoking kills 301Context 302Part 1 303Part 2 303

�

� �

�

Contents xi

Part 3 304Part 4 307Part 5 308Part 6 308Part 7 Max’s song 309Part 8 310Part 9 311Part 10 312Denouement 313Part 11 314Endnotes 314

25 Anthea: An Inquiry into Dignity 317Christopher Johns and Otter Rose-JohnsIntroduction 317Cast 318Part 1 318Summary 330Endnotes 330

Appendices 333Index 341

�

� �

�

�

� �

�

Notes on Contributors

Christopher Johns

Formerly Professor of Nursing at University of Bedfordshire, where I continue tosupervise PhD students using reflexive narrative. I am also Visiting Professor at ChristChurch Canterbury. My academic work is focused on developing reflective practicefrom clinical, educational and research perspectives reflected in many journal, book andchapter publications, conference presentations and performances. I have convened theInternational Reflective Practice Conferences since 1993. In 2011 I convened the firstReflective Practice Gathering as a more congruent approach to reflective conferencingthrough dialogue. Becoming a reflective practitioner was first published in 2000. Mylatest book isMindful leadership published by Palgrave in 2015. My other books are: TheBurford NDU Model: caring in Practice (1994); Being mindful, easing suffering (2004);Transforming nursing through reflective practice, second edition with Dawn Freshwater(2005); Engaging reflection in practice: a narrative approach (2006); The good, the wise,and the right clinical nursing practice, with Charlotte Delmar (2008); Guided reflection:a narrative approach for advancing practice, second edition, 2010.

I live in Cornwall with my wife, Otter, and Jerry, our Labrador Retriever. We offerbespoke workshops and consultancy for those interested in developing reflective practiceand leadership from any perspective.

c.johns198@btinternet.com

Otter Rose-Johns

My background is in nursing, community and hospice, the latter developing an art roomfor patients to use for expression. My interests are reflective and mindful practice andusing art as a means of discovery, teaching and learning. I have exhibited and performedwidely including in Sweden, the United States and Japan. I have recently finished ayear-long mentoring course at the Newlyn School Of Art, Cornwall and I have beenworking with another 14 artists in a group called Drawing Down The Feminine, atravelling show, next due to exhibit in Plymouth. I work with mixed media and intuition,and my work includes wrapping, scratching, covering and scraping. I peel back the layers,almost like getting rid of the ego to find the core of the art and enhance meaning to thepiece on which I am working.

�

� �

�

xiv Notes on Contributors

Margaret Graham

I am a qualified nurse and lecturer at the Department of Nursing and MidwiferyEducation and Health Sciences, Faculty University of Limerick, Ireland. I lead andcoordinate reflective practice within undergraduate programmes. Exploring how wecreate dialogical learning spaces with students through reflection, fostering transferablelearning to practice is central to my work. I have been a member of a community ofinquiry with Professor Chris Johns as Guide in constructing my doctoral thesis. Insightsgained through my journey of self-inquiry and transformation, sustain my commitmentto the potential of developing practice through reflexive narrative methodologies.

Adenike Akinbode

I am currently working in a university school of Education. My first career was teachingin primary schools and a secondary school after completing my PGCE. Reflective practicehas been a research interest for some years. I conducted research for my masters degreeinto supporting student teachers’ reflective practice development. I then went on toself-inquiry through reflective practice for my doctoral research.

Gerald Remy

I am a 53-year-old Afro-Briton who was raised with six siblings in a deprivedneighbourhood in southeast London. I grew up with Catholic teachings in a blackghetto environment of crime and violence. I was educated by the code of the streets; theschool curriculum lacked cultural competence, so I was inspired by black antisocial leadersin my neighbourhood. My father was hard-working, honest and charismatic. My motherwas a strict disciplinarian, but she was my main motivator. As a youth, optimism wasstifled because the power of the ghetto gripped and rendered me powerless to achieve. Onbecoming an adult I was almost lost to every tender feeling until I metmywife and, with ourfive children, life began to have meaning and purpose. I was energised by a spiritual callingand underwent a transformation to the amazement of my friends and family, turning toChristianity. This prompted me towards self-improvement and I re-educated myself touniversity degree level in the sciences. Fortunately, I was able to evade the stereotype ofblack delinquency and became a medical professional in the NHS and am now I am nowa respectable State Registered Dietitian in my twentieth year of dietetics. I moved fromLondon to Buckinghamshire in 2004 and became a manager and therapy lead, responsiblefor a large team of medical professionals in a large public organization, and completed amaster’s degree in leadership with distinction. The masters gave me insight into the worldof reflective practice, which has influenced me ever since and impacted on my team, whonow see reflective enquiry as a meaningful requirement for great quality care.

�

� �

�

Notes on Contributors xv

Jill Jarvis

Jill worked as a hospice staff nurse at the time of writing her story as part of her BScNursing Studies.

Clare Coward

Clare worked as a psychiatric staff nurse at the time of writing her story as part of her BScNursing Studies.

�

� �

�

�

� �

�

Preface

There are no facts, only interpretations.Friedrich Nietzsche1.

Imagine. Otter visits her father in intensive care following a triple heart bypass. A staffnurse is attempting to put some TED compression stockings on his legs. The nurse doesnot introduce herself. Otter, who is a trained community nurse, anxiously asks ‘What areyou doing?’ ‘All patients have them,’ the nurse responds. ‘That’s not how to put them on,’Otter says, ‘Here let me show you. But wait, Dad’s legs are so swollen and he has arterialdisease. I don’t think he should have them anyway.’ Leaving the nurse, Otter approachesa doctor who confirms Dad should not have the TED stockings applied. Later a wardsister when challenged says ‘All staff are taught to apply TED stockings.’

You can draw your own conclusion about this experience but clearly a case of poorprofessional artistry. Facts aren’t enough. Every situation requires interpretation.

Healthcare professions are practice disciplines in changing times. As such, professionaleducation must be primarily concerned with enabling practitioners to develop professionalartistry – that knowing necessary to practice. In the uncertain world of practice suchknowing is largely intuitive, informed as appropriate by theory or technical rationality.Indeed, theory has always to be applied to inform the particular situation within anorganisational context with its own particular mores and resources. Professional practiceis a string of experiences, with each experience as a potential learning opportunity.Reflection on experiences is the gateway to developing professional artistry. Such learningultimately leads to mindful practice and the development of wisdom.

However, education and clinical practice are dominated by a technical rationalapproach that seeks certainty, predication and control. Hence, as Schon (1983) hasilluminated, a tension exists between technical rationality and professional artistry. Whilstreflective practice within curriculum has become normal, it is usually accommodatedfrom a technical rational perspective, thus limiting its learning impact. This book exploresthis tension and advocates that professional artistry must be the focus of professionalhealthcare education through a truly reflective approach.

In her introduction to the exhibition catalogue ‘Drawing down the feminine’ KateWalters writes – ‘this world which seems to me to focus on the surface of things. So Ibecame more alert and looked about myself’.

These words resonate in relation to education: this educationwhich seems tome to focuson the surface of things. No depth. This surface is grounded in the technical and rationalthat fails to value or nurture the intuitive. Take nursing as an example. It is fundamentallyconcerned with the relationship between nurse and patient. Nothing about this relation-ship can be assumed to be certain or predictable. Everything is an interpretation dependingon context. As such the practitioner’s response to the patient is largely intuitive gleanedthrough understanding the patient’s experience and needs and informed as appropriate by

�

� �

�

xviii Preface

the technical, that is unless the patient is viewed as an object to do things to. Then thepatient is no more than of technical interest. Disembodied. Education must radically shiftto ways of learning and knowing that value and nurture the intuitive rather than skid alongthe technical surface of things. We need to create opportunity to learn through experienceto reveal the very depth of professional artistry. This is the way of reflective practice. Andyet, if we are not alert, reflective practice too can skid along the surface of things.

Like previous editions, this fifth edition has been extensively scrutinised, revised anddeveloped:

• I have moved to an edited book with guest authors to give wider perspectives onreflective practice;

• I focus more on the idea of guiding reflection and in doing so acknowledging that skilledguidance is a necessary for effective reflective learning;

• Linked to the previous point I give greater emphasis to the idea of the ‘reflectivecurriculum’ and utilising performance narrative as a curriculum approach;

• I introduce skill boxes through the book to guide and engage readers in reflection andaction making the book a more engaging and practical text.

The book is constructed in 25 chapters. Chapter 1 opens the dialogue with a broad gazeat the nature of reflective practice. Reflective practice is at risk of being a cliché with itsmultiple interpretations that raise the question, what exactly is reflective practice? Ofcourse this concern reflects a technical rationale to know it. If known, it can be appliedwith prediction and control. Everyone knows what we are talking about. However, thisperspective misses the point that reflective practice is fundamentally an ontological questto know self rather than an epistemological quest to know something, which, whilstimportant, is a secondary issue.

I have always viewed reflective practice as practical rather than theoretical, assomething learned through doing. Indeed, this is true for my own description of reflectivepractice through the six dialogical movements.

In Chapters 2–6 I develop the artistry of reflective practice through six dialogicalmovements, commencing with bringing the mind home and writing self. The idea ofbringing the mind home is to learn to pay attention to experience. Paying attention is alsoa highly significant clinical skill. It is simply learned using the breath.

Writing self is the raw data of experience and sets up the reflective encounter using theModel for Structured Reflection [MSR]. I have revised the MSR, now in its 17th edition,to better appreciate the essence of reflective practice. From global feedback, I get theimpression that many people think that simply using the MSR is reflective practice. Worsethey view a model of reflection as a prescription. It isn’t! It is a heuristic, a means toan end towards gaining insight. I urge readers to dwell with the MSR, to feel the depthof the cues rather than view it superficially and skid along the surface of reflection. Ifapproached superficially, reflection looses its vitality. It can become a chore and wasteof time. It must be taken seriously. In Chapter 5 I explore dialogue between insights andan informing literature. This is the value of technical rationality: to inform rather thancontrol knowing. No theory is accepted on face value but is always critiqued for its valueto inform. I also explore the art of guiding reflection, arguing that guidance is imperativefor learning through reflection. In Chapter 6 I explore the expression of insights in areflexive narrative form. Insights are the manifestation of learning and yet they are noteasy to articulate, given that much knowing in practice is tacit. Insights often emergeover time, recognised reflexively within subsequent experiences. Perhaps it is easier to ask

�

� �

�

Preface xix

someone what was significant about an experience rather than what insights were gainedfrom it. Significance points the finger at insights.

The word ‘narrative’ has seeped into everyday speak. I wonder, does this seepageindicate that we have moved beyond the technical rational to value experience andanecdote? Or is narrative simply a word that means ‘the story’ or ‘vision’. Whatever, itdoes suggest a valuing of context and subjectivity; that people are not machines. Peopleare human and their experience is human and unique. And that no matter the difficulty,learning through reflection is dynamic. Narrative is creative and cannot be prescribed,even though academic institutions will nevertheless impose criteria about how it shouldbe expressed.

In Chapter 7, I advocate a poetic approach, not simply for its aesthetic value andexpressive pleasure but as a way of opening up language to reveal and communicateinsights. In Chapter 8 Otter and I explore storyboard as a visual approach to reflectionand narrative that may offer an alternative to language approaches and hence may benefitvisual reflectors. Like poetry, breaking narrative into visual scenes aids the revelation ofinsights. Poetry and art are expressive forms that open up the neglected right brain, movingaway from rational thought to nurture imagination, perception and ultimately intuition.

In Chapter 9, I contemplate the reflective curriculum. It is fascinating to look back atthe two immediately preceding editions to see this chapter’s reflexive development. It is themost vital chapter because the health discipline curriculum is so entrenched in a technicalrational modus that reflection is viewed as just another technical rational approach. If so,its real value is lost. The reflective curriculum views professional artistry and identity asits education aim, and reflective practice as its primary approach, re-orienting theory toinform this process. In other words, it turns the traditional relationship between practiceand theory on its head. Easier said than done.

In Chapter 10, I give an example of my reflective thinking in preparing for a teachingsession on reflective practice. It shows the problem of falling between two stools, ofwanting to be in control of a session and yet wanting it to be open and dialogical.

In Chapter 11, I offer an example of reflective writing and explore how reflectiveacademic writing can be meaningfully graded from a professional artistry perspective incontrast to a technical rational perspective.

Chapter 12 offers a further example of reflective writing for readers faced with settingand writing reflective assignments. Students must feel free to express themselves ratherthan have stringent criteria imposed on the way they write. The imposition is resented,resisted, and its value diminished.

In Chapter 13, Margaret Graham reflects on using story in her teacher teachingand its learning significance through evaluating student response. Teaching becomesalive through relevant story because students can easily relate to it through their ownexperiences, especially in addressing difficult topics such as family abuse where stories areoften hidden through fear and shame.

Chapters 14 and 15 open a dialogical space to contemplate guiding nursing students.The two situations – Michelle finding a woman upset about her breast biopsy andHank’s complaint – are real situations that were shared with me in clinical supervision(Johns 2013). I have transposed these situations into how they could be explored withinfirst-year and third-year student guided reflection groups. As you would expect, thefirst-year group is more directed whilst the third-year group is more open, reflecting thecurriculum agenda and experience of the student both in reflective learning and the topicsbeing explored.

�

� �

�

xx Preface

In Chapter 17, I imagine how two teachers with differing teaching methods educatenursing students about stroke. John takes a theory-driven line typical of the dominanttechnical rational approach. Jane takes a reflective approach that embraces performanceand with it, cross-discipline teaching. At Bedfordshire I involved drama and danceteachers as co-supervisors for reflexive narrative doctoral students. Their involvementopened up the performance potential as a profound learning space. Performance engagesand empowers people. It is an embodied learning that is necessary for practice disciplineswhere the body has to learn rather than the mind simply think.

Much reflective practice teaching in universities is carried out by people who are notreflective. As a consequence they apply inappropriate technical rational approaches to theteaching of reflection. This whole book is itself a treatise on the need to create reflectivelearning environments if we are to practise reflective practice critically rather than asa superficial problem-solving technique. Of course, it has value even at that level if itenables 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.So, if the value of reflective practice to develop professional artistry is to be more thana technical rational approach to the doing of reflection, the reflective teacher, like thereflective practitioner, must lift this cultural veil to understand and shift the norms thatgovern teaching of teachers.

In Chapter 17, Adenike, herself a teacher of teachers, relates the classroom to chaostheory – that nothing is certain or predictable despite previous experience, and that orderevolves around meaning. In other words, order is inherent and unfolds. This means theteacher does not have to worry about ‘controlling’ the classroom. Indeed the more she triesto control the classroom the more difficulty she will have with control. It is the same withthe clinical health environment: order manifests itself around meaning. Hence, the attemptto control the healthcare environment is counter-productive. Things work just fine or evenbetter when left to unfold naturally around meaning such as the intention to care.

So when Adenike writes – ‘I view the idea of teacher as “strange attractor” as a valuableway to understand what takes place in the classroom’ we can see its parallel - ‘I view theidea of nurse as “strange attractor” as a valuable way to understand what takes placein the clinical environment.’ Hence, the way the nurse teacher performs role models howthe nurse might perform. Reflection lifts this dynamic into mindfulness, hence processesbecome more significant than outcomes or, put another way, get the process right and theoutcomes naturally emerge. In Chapter 18 Adenike explores a range of issues that face heras a reflective teacher, notably emotional ethical issues. It is so easy to get caught up inthe classroom tension – mindfulness falls away and the teacher resorts to learned ways ofdealing with her anxiety. Hence the pivotal idea of poise as clinician or teacher and as ahallmark of mindful practice.

In Chapter 19, I turn my attention to creating the reflective clinical environment inwhich reflective practitioners can flourish. This is based on my work developing theBurford NDU Model of nursing: caring in practice. Experience, such as depicted in‘People are not Numbers to Crunch’ (Chapter 23), illuminates the mechanical approachto assessment based on set questions, an approach that is insensitive and unreflective.Applying a person-centred vision, practitioners need to tune into the person to identifyand focus on his or her health needs. Unequivocally, this must be the basis for care.Reflective systems of quality, staff development and communication are designed tosupport this focus against a background of leadership and learning culture.

In Chapter 20, I pick up the idea of a reflective quality system through developingstandards of care, imagining an actual standards group. Setting standards may be

�

� �

�

Preface xxi

time-consuming yet its value is immense, begging the question, how much effort shouldbe devoted to ensuring quality as something lived rather than having quality judgementimposed through systems such as CQC? Surely any professional should be activelyinvolved in ensuring quality of her performance? In Chapter 21 I examine the idea ofclinical supervision as both a quality and developmental process through my supervisionof Trudy over six sessions. In doing so I endeavour to portray its reflexive movement.

In Chapter 22, Gerald Remy reflects on his leadership. The need for strong leadershipis acknowledged with the NHS Forward Review2 at a time of radical change. However, itneeds to be the right type of leadership. Gerald was part of a learning community of tenaspiring healthcare leaders. I emphasise community for at least five reasons. Firstly, froma leadership perspective, creating community is fundamental requirement for any leader.Secondly, I believe that learning through community whereby others in a similar aspiringboat are available to each other through a period of time (in this case 28 months) enhanceslearning through reflection. Community creates the conditions for dialogue for a group oflearners aspiring to similar goals. This idea permeates many of the chapters in the bookand reinforces the need for guides to be themselves leaders and skilled at guiding others tolearn through reflection. Indeed this ability to guide learning in others is a prime qualityof leadership.

Thirdly, there is the question of whether learning can be sustained without guidance,especially in a hostile culture that puts constant pressure on the practitioner to conformto organizational norms that are previously learned ways of being. The ability to sustainlearning, against the grain so to speak, is reflected in the extent to which reflectionhas become inculcated within the practitioner’s community rather than being merelyan individual thing. Gerald suggests he has achieved that to some extent, although itremains precarious as he continues to holds creative tension. Of course, in terms ofthe efficacy of reflective learning, this issue of sustained learning at depth of is of vitalconcern; it underlines the necessity of, first, a clear understanding of the nature of reality(organizational norms that govern everyday ways of relating]) and, secondly, being ableto detach self from the anxiety of transgressing these norms. Living this tension is akin toplaying a subversive and dangerous game of survival where guidance is vital.

Fourthly, Gerald’s chapter opens up a dimension on expressing learning throughmetaphor. Gerald, like all NHS staff, has been socialised into the transactional culturethat governs healthcare organisations. Hence the idea of being a servant-leader or atransformational leader is immediately at odds with this culture. It raises the question‘How can one come to appreciate and separate self from this culture whilst beingimmersed within it, a culture where one’s every action has been socialised towards beingtransactional from either a subordinate or managerial perspective?’ Gerald used themetaphor of David and Goliath to see and work with this tension. If the tension is notaddressed then learning is limited, and yet one can see how difficult it is to unlearn learnedways 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. Tobecome a leader from a servant-leader or transformational perspective required Gerald tolook back at his upbringing in order to understand how his background influences who heis now and whom he seeks to become. He recognises the tension between a Goliath withinand a David within, and accepts the need to vanquish his Goliath through his David.Anybody learning through reflection will need to consider their background – perhapsusing the Influences Grid in Chapter 3, Table 3.4 (how does my background influence theway I respond within this particular situation/ experience?).

�

� �

�

xxii Preface

Chapters 23, 24 and 25 offer three performances. Performances are stylised narrativewritten to intentionally open a dialogical space towards social action. By focusing onunsatisfactory situations they intend to disturb an audience into action. ‘People arenot Numbers to Crunch’ is my reflection on accompanying Otter for an angiogram.Here, performance intends to expose the unsatisfactory behaviour of nurses who donot introduce themselves and treat Otter as if she is an object and myself as an outsiderbeyond their gaze. The performance is set against a CQC report of care at this particularhospital. Hence, I reflect not so much as a clinician but as a relative. ‘Smoking Kills’ wasinitially written as an educational performance for young people based around my care forthree men dying of lung cancer in a hospice. The performance has many themes that canbe adapted for different audiences. I developed the performance to focus on the way thattough men dying can problematise the hospice approach. Later I added the supervisionscenario to illustrate unsatisfactory guidance. ‘Anthea: An Inquiry into Dignity’ is basedon an experience shared by a staff nurse in guided reflection (personified as ‘Kate’ in theactual performance). I then developed the performance based on Anthea’s discharge homeraising controversial issues for audience to discuss. All these performances are powerfulteaching tools. They can involve students in their performances and give teachers andstudents pointers to constructing their own, as I suggested in Chapter 16.

Throughout the book I usually refer to practitioners rather than specific healthcarepractitioners. An exception is the particular focus on teaching nurses in Chapters 14–16.I generally use ‘her’ to represent people. I also use a different referencing format forperformance-related chapters.

Endnotes

1 Wicks, Robert, "Friedrich Nietzsche", The Stanford Encyclopedia of Philosophy (Fall 2016Edition), Edward N. Zalta (ed.), URL = http://plato.stanford.edu/archives/fall2016/entries/nietzsche/ .

2 https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

Reference

Schön D (1983) The reflective practitioner. Avebury, Aldershot.

�

� �

�

About the CompanionWebsite

This book is accompanied by a companion website:

www.wiley.com/go/johns/reflectivepractitioner

The website consists of:

Powerpoint images for chapters 24 and 25

�

� �

�

�

� �

�

Chapter 1

Imagining ReflectivePracticeChristopher Johns

Experience is a creative encounter

Hi, I’m beady eye. I’m called beady eye because I like to keep my eye on what’s going onthe quality of healthcare.

I was sitting in the train the other dayWhen a woman hobbles onFinds a seat to put her leg upShe says to her mate‘They just don’t care anymoreShe didn’t look properly at my footShe wasn’t interestedTold me it was probably a cornWasn’t listening to meTold her the pain was in me ’eelIn the end she said‘Your 10 minutes are upGot to see someone else.’Her mate rolls her eyes‘Bloody awful ain’t itChiropody on the NHS.’

Becoming a Reflective Practitioner, Fifth Edition. Edited by Christopher Johns.© 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.Companion Website: www.wiley.com/go/johns/reflectivepractitioner

�

� �

�

2 Becoming a Reflective Practitioner

Such experience reminds me of the fragile quality of health care. I wonder how the chi-ropodist would recall the event? Bet she isn’t a reflective practitioner!!

You’ll meet me again in some later chapters. Until then enjoy the book.O’Donohue (1997: 26) writes, ‘Everything that happens to you has the potential to

deepen you.’ This potential is actuated through reflection as a self-inquiry into experienceto find meaning, gain insight and prompt action that will deepen you.

Reflection enables you to understand yourself and, on that basis, to take leadership ofyour professional life. By leadership I mean the action towards realising your values orvision about your practice.

Recall a situation when you were last at work and ask yourself – ‘Did I respond in tunewith my values?’ which, of course, raises the question ‘What are my values?’ I assume asa healthcare practitioner you hold a set of values or a vision that is important in guidingyour individual and collective practice. Now, ask yourself – ‘Did I respond in the mosteffective way?’ Be open and curious about that. Did you choose to respond in that way orwas it your normal practice? How do you know if you were effective? Perhaps there aremore effective ways? Think about what factors influence your response. What interfereswith realising effective practice? As a consequence of this self-inquiry, you become moresensitive to your values and the notion of your effective practice. As such, you step alonga reflective road.

Reflective Practice

Reflective practice has become a normal requirement within professional curriculum and,as such, demands serious consideration. However, the words reflection and reflectivepractice are often used glibly in everyday discourse, as if reflection is simply a normal wayof thinking about something that has happened and which requires little skill or guidance.Smyth (1992: 285) writes:

Reflection can mean all things to all people… it is used as a kind of umbrella or canopyterm to signify something that is good or desirable… everybody has his or her own (usuallyundisclosed) interpretation of what reflection means, and this interpretation is used as the basisfor 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 aboutdefining reflection in an authoritative way and yet, on the other hand, practitioners doneed something to grasp, a conceptual grasp on reality.

Turning to the Compact Oxford English Dictionary 3rd edition (2005: 86), it defines‘reflect’ as:

throw back heat, light, sound without absorbing it[of a mirror or shiny surface] show an image ofrepresent in a realistic or appropriate waybring about a good or bad impression of someone or something [on]think deeply or carefully about

Interpreting this array of definitions, reflection can be viewed as a mirror to see images orimpressions of self in the context of a particular situation in a realistic way. It is an aware-ness of the understanding about the way the person thinks and feels about whatever he is

�

� �

�

Imagining Reflective Practice 3

experiencing. It is also judgemental, distinguishing between good and bad. If healthcare isconcerned with understanding and responding to the experiences of people who requirecare then it is first necessary for the practitioner to understand herself.

My description of reflection is always evolving –

Being mindful of self, either within or after experience, as if a mirror in which the practitionercan view and focus self within the context of a particular experience, in order to confront,understand, and become empowered to act towards resolving contradiction between one’svision of desirable practice and one’s actual practice to gain insight within a reflexive spiraltowards realising one’s vision of practice as a lived reality and developing professional identityand artistry.

Contradiction

The learning potential of reflective practice is the contradiction between one’s vision ofpractice and one’s actual practice as recalled. Contradiction is usually experienced as a‘disturbance’ that things are unsatisfactory in some way. However, because contradictionis so normal, it may not be noticed, or simply shrugged off. As such, much of experienceis unexamined.

To explore contradiction it is necessary for the practitioner to have a vision of herpractice. A vision gives purpose and direction to clinical practice. It is constructed from aset of values that are ideally constructed and shared with colleagues. In this way everyonepulls in the same direction. The practitioner must inquire into her vision. For example, ifthe vision states words such as ‘caring’, ‘holistic’ or ‘excellent’, then what do these wordsmean as something lived? Vision is thus a moveable feast.

Yet, It is one thing having a vision of practice it is another thing to realise it as somethinglived (Rawnsley 1990).

The practitioner must first seek to understand the nature of the contradiction. Onlywhen practitioners truly understand themselves and the conditions of their practice canthey begin to realistically change and respond differently. To understand, the reflectivepractitioner creeps ‘underneath his habitual explanations of his actions, outside hisregularized statements of his objectives’ (Pinar 1981: 177).

The practitioner must then act towards resolving the contradiction. If people wererational they would change their practice on the basis of evidence that supports the bestway of doing something. However, we do not live in a rational world. There are powerfulbarriers that limit the practitioner’s ability to respond differently even when they knowthere is a better way to respond. Fay (1987) identifies these barriers as tradition, authorityor force, and embodiment. These barriers govern the fabric of our social world. Theirinfluence lies thick within any experience. They are evident in patterns of talk that reflectdeeply embodied and embedded relationships that serve the status quo (Kopp 2000).Reflections are stories of resistance and possibility; chipping away at resistance andopening up possibility; confronting and shifting these barriers to become who we desireto be as health care practitioners.

Barriers to rational change (Fay 1987)

• Tradition: a pre-reflective state reflected in the assumptions and habitual practices that peoplehold about the way things should be.

• Force: the way normal relationships are constructed and maintained through the use ofpower/ force.

• Embodiment: the way people have been socialised to think, feel and respond to the world ina normative and pre-reflective way.

�

� �

�

4 Becoming a Reflective Practitioner

Fay (1987: 75) writes from a critical social science perspective,

The goal of a critical social science is not only to facilitate methodical self-reflection necessaryto produce rational clarity, but to dissolve those barriers which prevent people from living inaccordance with their genuine will. Put in another way, its aim is to help people not only tobe transparent to themselves but also to cease being mere objects in the world, passive victimsdominated by forces external to them.

In other words, reflection is concerned with empowerment. The language of a critical socialscience may be intimidating with its rhetoric of oppression and misery, yet it can be arguedthat nursing’s largely female workforce has been oppressed by patriarchal attitudes thatrenders it docile and politically passive, and thus limits its ability to fulfil its therapeuticpotential. If so, then realising desirable practice would require an overthrow of oppressivepolitical and cultural systems. The link between oppression and patriarchy is obvious,considering nursing as women’s work, and the suppression of women’s voices ‘knowingtheir place’ within the patriarchal order of things. Images of ‘behind the screens’ wherewomen conceal their work, themselves, and their significance (Lawler 1991) and imagesof emotional labour being no more than women’s natural work, therefore unskilled andunvalued within the heroic stance of medicine (James 1989), are powerful signs of thisoppression.

Maxine Greene (1988: 58) writes,

Concealment does not simply mean hiding; it means dissembling, presenting something as otherthan it is. To ‘unconceal’ is to create clearings, spaces in the midst of things where decisions canbe made. It is to break through the masked and the falsified, to reach toward what is alsohalf-hidden or concealed. When a woman, when any human being, tries to tell the truth andact on it, there is no predicting what will happen. The ‘not yet’ is always to a degree concealed.When one chooses to act on one’s freedom, there are no guarantees.

Reflection opens up a clearing where desirable practice and the barriers that constrain itsrealisation can be unconcealed and understood, where action can be planned to overcomethe barriers whatever their source, and where the practitioner is empowered to takenecessary action to resolve contradiction. No easy task, for these barriers are embodied,they structure practice and patterns of relating. Fear is a powerful deterrent to beingdifferent. It suppresses practitioners from speaking their truth. The commitment to thetruth is evident in Greene’s words. Yet how comfortable are people in their illusions oftruth? Is it better to conform than rock the boat? Is it better to sacrifice the ideal for aquiet life and the patronage of more powerful others? Better to keep your head downthan have it shot off above the parapet for daring to reveal the truth?

As such, reflection is always in context. Context is the background against whichexperience is positioned. ‘Context refers to the grand societal narratives, those clustersof beliefs and cultural norms that give shape and meaning to the human cultures withinwhich we live’ (Dawson (2015: 25). All too often, when people reflect, the backgroundis ignored or alluded to in a superficial way. Hence, reflection can help the loosening ofauthority. Dawson continues

Within this context, personal narratives of becoming, whatever the focus of that becoming, canbe viewed as ‘a loosening of the authority’ of the grand narratives of science and educationwhere the dominant construction of the learning self is the receptor of knowledge.