Preface

Friedrich Nietzsche1.

Imagine. Otter visits her father in intensive care following a triple heart bypass. A staff nurse is attempting to put some TED compression stockings on his legs. The nurse does not introduce herself. Otter, who is a trained community nurse, anxiously asks 'What are you 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 arterial disease. I don't think he should have them anyway.' Leaving the nurse, Otter approaches a doctor who confirms Dad should not have the TED stockings applied. Later a ward sister 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 poor professional artistry. Facts aren't enough. Every situation requires interpretation.

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

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

In her introduction to the exhibition catalogue 'Drawing down the feminine' Kate Walters writes - 'this world which seems to me to focus on the surface of things. So I became more alert and looked about myself'.

These words resonate in relation to education: this education which seems to me to focus on the surface of things. No depth. This surface is grounded in the technical and rational that fails to value or nurture the intuitive. Take nursing as an example. It is fundamentally concerned with the relationship between nurse and patient. 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 largely intuitive gleaned through understanding the patient's experience and needs and informed as appropriate by the technical, 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 must radically shift to ways of learning and knowing that value and nurture the intuitive 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.

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

• I have moved to an edited book with guest authors to give wider perspectives on reflective practice;
• I focus more on the idea of guiding reflection and in doing so acknowledging that skilled guidance is a necessary for effective reflective learning;
• Linked to the previous point I give greater emphasis to the idea of the 'reflective curriculum' and utilising performance narrative as a curriculum approach;
• I introduce skill boxes through the book to guide and engage readers in reflection and action making the book a more engaging and practical text.

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

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

In Chapters 2-6 I develop the artistry of reflective practice through six dialogical movements, commencing with bringing the mind home and writing self. The idea of bringing the mind home is to learn to pay attention to experience. Paying attention is also a 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 the Model 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 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 approached superficially, reflection looses its vitality. It can become a chore and waste of time. It must be taken seriously. In Chapter 5 I explore dialogue between insights and an informing literature. This is the value of technical rationality: to inform rather than control knowing. No theory is accepted on face value but is always critiqued for its value to inform. I also explore the art of guiding reflection, arguing that guidance is imperative for learning through reflection. In Chapter 6 I explore the expression of insights in a reflexive narrative form. Insights are the manifestation of learning and yet they are not easy to articulate, given that much knowing in practice is tacit. Insights often emerge over time, recognised reflexively within subsequent experiences. Perhaps it is easier to ask someone what was significant about an experience rather than what insights were gained from it. Significance points the finger at insights.

The word 'narrative' has seeped into everyday speak. I wonder, does this seepage indicate that we have moved beyond the technical rational to value experience and anecdote? Or is narrative simply a word that means 'the story' or 'vision'. Whatever, it does suggest a valuing of context and subjectivity; that people are not machines. People are 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 should be expressed.

In Chapter 7, I advocate a poetic approach, not simply for its aesthetic value and expressive pleasure but as a way of opening up language to reveal and communicate insights. In Chapter 8 Otter and I explore storyboard as a visual approach to reflection and narrative that may offer an alternative to language approaches and hence may benefit visual reflectors. Like poetry, breaking narrative into visual scenes 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.

In Chapter 9, I contemplate the reflective curriculum. It is fascinating to look back at the two immediately preceding editions to see this chapter's reflexive development. It is the most vital chapter because the health discipline curriculum is so entrenched in a technical rational 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 as its education aim, and reflective practice as its primary approach, re-orienting theory to inform this process. In other words, it turns the traditional relationship between practice and theory on its head. Easier said than done.

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

In Chapter 11, I offer an example of...