How to Run Reflective Practice Groups

A Guide for Healthcare Professionals

Arabella Kurtz

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351112970
• Edition: 1
• Topic: Médecine
• Subtopic: Soins infirmiers

In How to Run Reflective Practice Groups: A Guide for Healthcare Professionals, Arabella Kurtz explores the use of reflective practice in the modern healthcare context.

Responding to the rapidly increasing demand for reflective practice groups in healthcare and drawing on her extensive experience as a facilitator and trainer, Kurtz presents a fully developed, eight-stage model: The Intersubjective Model of Reflective Practice Groups. The book offers a guide to the organisation, structure and delivery of group sessions, with useful suggestions for overcoming commonly-encountered problems and promoting empathic relationships with clients and colleagues.

Clearly and accessibly written, using full situational examples for each stage of the presented model, How to Run Reflective Practice Groups offers a comprehensive guide to facilitating reflective practice in healthcare.

1 Introduction

The world we live in is increasingly fast-paced, and it can often feel as if there is not enough time to think. We can all experience pressure to keep up with the speed of change and innovation, and can find ourselves becoming busier and busier without having much of a sense of why we are doing what we are doing. Digital technologies have brought many benefits; they have greatly increased the range and speed of our communications and have also raised expectations as to how quickly work can be done and answers can be found to our questions. Reflective practice provides a necessary corrective in the working environment to this fast, active and reactive aspect of our lives. It aims to help us with questions to which there is no easy or straightforward answer, and also to generate new questions in order to better frame our thinking about novel and complex situations.

This book is about the application of reflective practice in healthcare. Science and technology have a vital role to play in the delivery of healthcare services. However, clinical practice offers up many unique and ambiguous situations which require intuition, judgement and creativity if they are to be handled properly. When these situations are approached in an automatic way, relying too much on standard or pre-existing methods and procedures, they may at best be only superficially resolved and at worst important aspects may be missed and interventions go wrong. There is an art and a science to doing good clinical work.

Reflective practice was first coined as a phrase by the American town planner Donald Schon in his 1980s book The Reflective Practitioner and is in frequent usage nowadays in the education and healthcare fields (Schon, 1983). But it is not a recent idea, at least not in its essence. In many ways, reflective practice draws on ancient wisdom and common sense. The influence of the Socratic method, for example, lives on in its emphasis on exploring questions and areas of uncertainty, and on following up on hunches and moments of intuition. Reflective practice owes a debt to the focus in classical philosophy on asking better and more penetrating questions in order to establish a firm basis for critical inquiry. There is also Aesop’s (1998) traditional moral tale of ‘The tortoise and the hare’, which is for me a fable about the value of slowing down to think in a fast-paced world. In this tale, it is the slow, deliberate tortoise who gets to the finishing line ahead of the quick but foolhardy hare. The result of the race is an unexpected one, just as reflective practice often yields surprising results, in the sense that these results are not pre-set and therefore can rarely be anticipated. And to continue with animal metaphors: the often-invoked image of a headless chicken running around in circles vividly conveys how caught up we can get in a relentless round of activity if we do not take time to think, and how this can result in the loss of any real direction and purpose.

In modern healthcare organisations, reflective practice generally occurs in a group setting, and involves taking the time for staff to think about the serious, complex and emotionally charged work they do in caring for those in pain and distress. It requires resources to do it properly, and can seem like an unaffordable luxury when demand on clinical services is high and resources are stretched to the limit. But the cost of not doing so, certainly in the long-term, is immeasurably higher. It stands to reason that high levels of clinical activity without sufficient space to consider actions, process responses and draw on the support and encouragement of colleagues, will result in a sense of isolation amongst staff, burnout and poor or at least much less than optimal clinical practice. Indeed, research has shown us that healthcare staff are particularly at risk of burnout and compassion fatigue, and that these are associated with an increased risk of clinical errors, reduced capacity in staff for empathy and engagement with clients and higher rates of staff absence and turnover (Hall et al., 2016; Edwards et al., 2006). It has also been established that high-quality clinical supervision (and I would include reflective practice under this heading) is associated with increased staff well-being and job satisfaction, and reduced burnout (Hyrkas, 2005; Berg, Hansson & Hallberg, 1994). Furthermore, there is now a growing body of work which shows that high-quality clinical supervision is directly associated with positive clinical outcomes, particularly when the culture of the organisation is supportive of supervisory activity (Bambling et al., 2006; Bradshaw, Butterworth & Mairs, 2007; White & Winstanley, 2010).

What is reflective practice and what is reflective practice in a group?

Simply put, reflective practice is a form of in-depth thinking about work activity with the aim of developing as a practitioner. The concept of reflective practice has its origins in early twentieth-century phenomenological philosophy and the work of a diverse group of philosophers and psychologists including John Dewey, Kurt Lewin, Maurice Merleau-Ponty and William James. These figures had in common an interest in the nature of human thought and reasoning, and the view that a full engagement with experience – the messy, complex and surprising business of living as opposed to abstract ideas about living – is intrinsic to the learning process. John Dewey’s seminal work How We Think is concerned with understanding and defining critical thought (Dewey, 1910). This type of thought involves reflection on experience, a process whereby ideas about the world and how it works are tested and modified by as full and open engagement with lived experience as possible. His ideas are influential in pedagogy to this day and lie behind widely used reflective teaching models, such as Kolb’s experiential learning cycle and Gibbs’ stages of reflection (Kolb, 2015; Gibbs, 1988).

In The Reflective Practitioner, Schon made a case for the reintegration of intuition and reflexivity into professional practice, which he thought had been squeezed out by a narrow focus on technological expertise. He argued for the introduction of a form of creative and outside-the-box thinking about individual cases, which he called reflective practice, to counter the dominance of standardised, technological approaches (Schon, 1983). Schon described how reflection-on-action, meaning a kind of problem-solving based on close retrospective attention to the details of specific work experiences and the use of diverse thinking and creative methods to understand them, leads to reflection-in-action, and a new form of rigor in professional practice to complement scientific and technological approaches.

Since the 1990s in the United Kingdom, there has been a growing interest in the use of reflective practice in healthcare, especially amongst nurses and clinical psychologists. It has been recognised that the application of even the most up-to-date scientific evidence will only take us so far in the care and understanding of unique and complex human beings, and we need to have space to think creatively in order to apply our knowledge in a way which is relevant to the individual in context (Esterhuizen & Howatson-Jones, 2019; Stedmon & Dallos, 2009; Lavender, 2003). What happens in reflective practice groups in healthcare has been much influenced by other forms of group activity carried out in the health and social care settings, such as staff support, psychoanalytic work discussion groups, and group and systemic therapy. Healthcare staff in the UK are very used to working in groups and teams. The positive side to this is that staff are able to draw on a rich diversity of experiences and knowledge of a variety of theories and techniques. The negative side is that boundaries between reflective practice groups and other types of group can sometimes become unhelpfully blurred.

Construction of a model of group reflective practice has inevitably involved pinning my colours to the mast in terms of my understanding of what reflective practice is and what it is not. My definition is one that I have to some extent discovered, by which I mean that it emerged through a description of what I do, rather than as an abstract or ready-made concept. In my view, reflective practice in groups should have a clear focus on clinical practice and on developing thinking in the work situation. It should be wide-ranging in its means and methods, making use of the resources of the group – intellectual, imaginative and emotional – to open up perspectives and access new ways of thinking about clinical challenges and dilemmas. It is rooted in the lived experience of practitioners, who then work together, from the ground up, to build an understanding of what is going on. It has an emphasis on the human and relational aspects of the caring work we do, and on bringing intuitive and emotional understanding back into the healthcare frame. It also, in contrast to individual supervision of a reflective kind, aims to develop the capacity of the group to use peer support and create a more reflective working culture: an environment in which colleagues are better able to draw on each other for support and development of their thinking about clinical cases on a day-to-day basis.

The methods used by the group to open up thinking about practice may be diverse, but the overall focus should clearly be on helping members with the working task. That is, in my view reflective practice is decidedly not personal therapy. The main reasons colleagues have given over the years for negative experiences of reflective practice are a lack of clarity regarding its purpose, and feeling unsafe because of a perceived expectation of pressure for members to divulge personal information without a rationale for doing this – or, I should add, an ethical basis. One of the main activities of the facilitator of a reflective practice group is to communicate a strong sense of the purpose of the group, and the boundaries around the reflective task. As a qualification to this, I should add that moment-by-moment, or session-by-session, these boundaries are not always clear, particularly if the group is becoming more adventurous and explorative in its thinking. However, the facilitator will create a great deal of safety for group members if they remain grounded in their sense of the aim of reflective practice in the work context, allowing experimentation in thought and feeling but always bringing the group back to what this might mean for the development of practice.

Some words about the modern healthcare context

Those working in senior posts in clinical services receive increasing numbers of requests for staff to offer reflective practice groups to colleagues. These requests arrive in all shapes and sizes: they come from managers on behalf of staff on the ground, especially when levels of sickness and absence are high, and from staff who are overwhelmed by clinical demands and themselves recognise that they are in need of a thinking space; they come from staff in both mental and physical health services, and in the latter case, perhaps, particularly from those working in palliative care and with sick children; they come from staff who work closely together, sharing patients and common clinical dilemmas, and from those who are more isolated and want to access the help and support of a group of colleagues; and they come from those practicing in the community or in out-patient services, and from multidisciplinary or nursing teams in in-patient settings and secure services.

Why has the demand for reflective practice grown so much? On the positive side, the increase is largely the result of the development of emotional literacy and awareness of mental health issues in society as a whole. Admired and well-known figures are bravely opening up and talking to the media about their psychological difficulties and areas of vulnerability. And business academics and entrepreneurs are advocating a new style of collaborative leadership which aims to foster psychological safety and open communication (Edmondson & Verdin, 2018). Healthcare organisations generally still operate in a bureaucratic and a top-down way, but it is much more possible than before to talk with colleagues about the emotional impact of work and to share problems and vulnerabilities.

Despite these social developments, staff in many modern healthcare organisations are often overworked and highly stressed. Awareness of the need to focus on human relationships in our work environments may in one sense never have been greater. But when it comes to modern healthcare organisations, it has also perhaps partly come about as a reaction to the gross undervaluing of relational thinking that has characterised the introduction and consolidation of a somewhat old-fashioned, hard business model. The increase in requests for reflective practice comes, at least in part, as a corrective to the marketisation of healthcare, and in particular, the intense focus on cutting costs and meeting short-term budgetary targets at the expense of the longer-term needs of patients and staff. The demand for fewer and less qualified staff to meet higher levels of clinical need has drastically reduced resources and opportunities for practitioners to think about the specific needs of individual clients, and has set too little value on processing and recovery time for staff and on the use of the expertise and creative capacity in properly maintained peer relationships and clinical teams.

Healthcare staff feel, in practical, intellectual and emotional ways, under-resourced, and reflective practice is often invoked as a way to bridge the gap. The problem here, of course, is that if the overall environment is in general terms not sufficiently supportive, reflective practice will unintentionally be set up to fail. A group of staff may recognise the need for time and space to process and make sense of clinical issues, but the system they are working within may operate in a way that runs counter to the aims and methods of reflective practice, and this tension may be difficult to reconcile.

The intense modern disillusionment with professionals and professional expertise, and the lack of trust which characterises the relationship between the professional and wider society, have also influenced the way in which practitioners approach reflective practice. Schon described the cause of these as the idealisation of professionalism and the unrealistic set of hopes and beliefs invested in professional training and expertise in Western society since the time of the Enlightenment. As he saw it, the educated ruling classes and professionals – and the science and technology upon which their activities were supposed to be based – came to be revered in much the same way as God had been in pre-Enlightenment times. The great, long moment of disillusionment in America was during the closing stages of the Vietnam war and the Watergate scandal, both of which exposed dishonesty and corruption at the highest levels of government. But if we look back at the last fifty years or so in the United States and the United Kingdom, this now looks like only the first of many such low periods.

Schon understood this disillusionment and distrust as partly the result of the improbable expectations placed on individual professional practitioners for so long. The over-investment in professional expertise in the Western world has led inevitably to disappointment, and sometimes even an attitude of contemptuous disregard. Reflective practice is presented by Schon as a corrective to the unrealistic amount of hope and belief invested in standard and purely technological solutions to human problems. In contrast with what he calls Technical Rationality, recognition of the uniqueness, complexity and ambiguity of the situations that face staff working to innovate and solve human problems is at the core of reflective practice.

One of the results of this disillusionment with professionals in the healthcare context is the top-down and bureaucratic management of risk and, as a consequence, widespread and pervasive defensive practice. Healthcare practitioners can feel as if they are under close, and even hostile, scrutiny and need to look after their own professional survival as a matter of priority, and an atmosphere prevails in many services in which anything a professional is unsure or worried about is covered up, rather than looked at and thought about. What seems to be lacking in many healthcare organisations is the capacity in both attitudes and procedures to distinguish between genuinely poor clinical practice, which does, of course, need to be identified and remedied, and the more normal ups and downs of the real-life work experience of most competent practitioners.

What this means is that those of us setting up and running reflective practice groups are working, to some extent at least, against the grain of modern healthcare systems. We operate in a context in which there is a high degree of ambivalence towards reflective practice, about which staff as individuals may not consciously be aware. On the one hand, colleagues recognise how crucial reflective practice is for staff well-being and the delivery of high-quality clinical care, and for the prevention of mistakes; but its development is frequently not supported, at least in any practical sense, at the service and organisational level. It can even be regarded as a threat, and actively opposed in some quarters, while being enthusiastically sought out in others.

For this reason, the model I present in this book has a strong systemic component. It emphasises the need for facilitators to take account of characteristics in the external environment in deciding whether to set up a reflective practice group, and to develop and maintain a feedback loop with managers and senior staff to ensure that ongoing consideration is given to what is needed for a reflective practice group to run properly.

The Intersubjective Model of Reflective Practice Groups and key influences

There are a number of models of reflective learning available, all of which describe a progression from a retrospective description of experience to its evaluation or analysis to learning output (Stedmon & Dallos, 2009). Borton’...