5. Awareness of and need for reflective practice
CHAPTER OBJECTIVES
• Recognise the importance of reflection for effective communication
• Demonstrate understanding of the importance of reflection for the health professions
• State the difference between reflective and reflexive practice
• Understand the significance of the result of reflection – changes in thoughts and actions
• List their own barriers (defenses) to experiencing and resolving negative emotions
• Reflect about their own functioning and thus their abilities when communicating.
Effective communication requires an understanding of how an individual affects others and how others affect the individual (Higgs et al 2005). It requires awareness of the ‘self’ and the effects of personality and communication styles upon interactions. Effective communication requires an understanding of how elements of the self, the ‘other’ and the environment influence the outcomes of interactions. Reflection promotes this understanding.
Reflection is the process through which experience, knowledge and theory are used to guide and inform thoughts, action and practice (Thompson 2002). Reflection ultimately facilitates the transformation of the individual and thus transforms the thoughts and actions of that individual to achieve positive outcomes in practice (Brown & Ryan 2003). Reflection achieves the necessary awareness of those factors that contribute to the self-maintenance essential for health professionals. It also contributes to their effectiveness when communicating. These reasons make reflective practice important for health professionals.
The ‘what’ of reflection: A definition
Reflection provides connection with and awareness of unconscious emotional processing (Pritchard 2005). Please note that reflection in this context is not synonymous with meditation. Reflection occurs when individuals examine their attitudes and reactions to an interactive experience. It reveals causes of negative emotional responses, which facilitates understanding of these reactions. It allows resolution of these causes and, ultimately, changes in thought and thus behaviour in preparation for more positive responses in similar future interactions. The process of reflection usually makes some parts of an interaction clearer and may allow the fading or removal of other parts (see Figure 5.1).
Boud & Walker (1991) suggest that reflection is the basis of knowledge. Reflection for the health professional is certainly the basis of self-knowledge. Payne (2006) describes reflection as being the bridge between theory and practice. Reflection can certainly form the theoretical basis of effective communication, because effective communication is not possible without reflection. Some view reflection as the process of revisiting experiences in order to understand them. When reflection results in changes in behaviour over time to manage similar situations with greater satisfaction, this is known as reflective practice (Gustafson & Fagerberg 2004, Stein-Parbury 2006). Others see reflection as a consideration of the way in which the self affects and is affected by particular events; this is known as reflexivity (Finlay & Gough 2003). Perhaps the best health professionals are both reflective and reflexive.
Reflection for a health professional consists of thoughtful and often critical consideration of events and reactions occurring during previous interactions or times of decision-making (Harms 2007). Such reflection promotes understanding of the thoughts, attitudes and associated reactions that occurred during those interactions or while making those decisions. It facilitates clearer understanding of the causes of the negative reactions that can occur during interactions. Reflection highlights areas needing conscious attention and further exploration, and can result in acceptance and resolution of the causes of negative reactions. Resolution facilitates behavioural change and thus positive outcomes during future interactions. Note that reflection here is not about ‘reflecting back’ the perceptions of the feelings of the ‘other’.
For health professionals, reflection is about careful, deliberate and critical consideration of events that take place during communicative interactions. It does not provide a formula for thoughts or behaviours, or a ‘one-answer-fits-all’ solution, but it does provide insight and understanding upon which to base behaviour during future interactions (Thompson 2002).
The result of reflection: Achieving self-awareness
Reflection is the primary method of achieving self-awareness. Reflection reveals the reality of the unique nature of each individual and promotes understanding of self and others (Miller 2003). Reflection has the potential to create a new awareness of self. It provides direction for constructive use of that knowledge to establish the truth about the self and related events (Plack 2006). This truth allows the individual to institute different methods of relating, reacting and being (Backus & Chapian 2000). This reflection promotes change in actions and reactions.
REFLECTION
• How have the comments of others about your abilities affected your performance in particular activities? Think about the positive or negative comments of a parent, teacher, friend, acquaintance or fellow worker.
• Does it enhance or erode your motivation and performance when someone does or does not believe in your abilities despite the reality of the situation?
• How important are the opinions of others to you?
Reflection is a process through which the individual considers and learns from positive and negative experiences. The individual considers the meaning of their experiences and why the experiences have that particular meaning (Andrews 2000, Roberts 2002). This consideration facilitates understanding of the inadequacy, fear or vulnerability of the inner-self that manipulates and directs thoughts and responses during interactive events (Ben-Arye et al 2007). These inadequacies and fears often cause negative and regrettable events during interactions. Reflection is the process that facilitates understanding of the action required to overcome the inadequacies, fears or vulnerabilities that manipulate the reactions of individuals when communicating.
Particular individuals react differently to reflecting, and factors such as personality, age and gender affect interest in and commitment to reflection. Because reflection promotes informed and controlled thought and thus action, practising reflection has potential benefit for all health professionals regardless of personality, age or gender.
REFLECTION
• Do you usually ‘reflect’ about interactive events?
• Do you replay positive interactions or simply savour the emotions associated with those interactions?
• Do you replay unpleasant and uncomfortable interactions?
• Think of interactions you have had in which there were negative feelings.
– In situations where you cause the reason for bad feelings, what do you usually do after the interaction? Do you regret your actions? Do you replay the interaction while thinking of different ways to react next time? Do you feel guilty? Do you think the other person deserved the bad feelings? Do you try to think of how you can redeem the situation and/or relationship? Do you feel OK about admitting you were inappropriate and apologising? Do you simply forget it and move on? Can you describe your typical reaction if it is none of the above? Does your reaction depend on the closeness of the relationship? Why do you think this is so? Should the closeness of a relationship be relevant when practising as a health professional?
– Consider each reaction listed above.
▪ Which are unproductive? How can you avoid these reactions?
▪ Which are productive and an investment for future interactions? How can you ensure such productive reactions in the future?
– In situations where another person provides the reason for discomfort, how do you usually react after the interaction? Do you feel hurt and continue ‘licking your wounds’ for some time? Do you think about it often and avoid seeing the other person if you can do so? Do you minimise interacting with them if you have to see them? Do you find it difficult to understand how anyone could treat you that way? Do you feel angry and resentful towards the person? Do you try to understand their behaviour and thus forgive them? Do you talk about their behaviour to other friends to try to discourage others from relating to that person? Do you reflect upon why you feel hurt, explore the reasons and resolve them? Do you place ‘walls’ around your emotions so you never feel hurt in an interaction? Do you think the reaction of the other person tells you more about them than it does about you and therefore understand that you do not need to feel hurt (i.e. do you have control of your emotional ‘button’)? Do you think life is too short and move on?
– Consider each reaction listed above.
▪ Which are unproductive? How can you avoid these reactions?
▪ Which are productive and an investment for future interactions? How can you ensure such productive reactions in the future?
The ‘why’ of reflection: Reasons for reflecting
Reflection is an important means of learning about attitudes, experiences and self (Mohan et al 2004, O’Toole 2007, Plack 2006). It provides information that promotes improved performance when communicating with others, allowing health professionals to repeat actions and reactions that achieve positive outcomes and to change them when they have a negative effect. Reflection provides health professionals with awareness about their individual abilities (Jack & Smith 2007, Kinsella 2001) and also highlights abilities and skills that are lacking. Thus, through reflection health professionals can focus on improving those skills that will increase their emotional control and therefore facilitate family/person-centred practice.
REFLECTIVE ACTIVITY
• List at least five things you know you perform well.
• List five things in which you would like to improve your performance.
• Ask someone who knows you well to make a similar list.
• Ask this person Do you know how I will react to your list? Was their expectation of your reaction correct?
• Compare both lists. Are they similar? Consider the other person’s list and explore why you might agree or disagree with their list.
Reflection allows health professionals to understand the ‘chaos’ sometimes evident during interactions (Purtilo & Haddad 2002, Stein-Parbury 2006). It indicates that individuals are responsible for their own reactions and emotions, whether the individual is the health professional or the person seeking assistance. Reflection reveals that no-one can actually make another person feel particular emotions or make them react in a particular way. It indicates that feelings and emotional responses come from within the individual and usually originate from previous life experiences. Reflection releases the health professional to understand that they are not the cause of emotional responses in others and that the other person is not the cause of the emotional responses of the health professional. It provides the understanding that individuals behave and respond in particular ways because of underlying, usually internal causes. This realisation encourages the tolerance and understanding that promotes unconditional positive regard of individuals regardless of the situation (Purtilo & Haddad 2002, Rogers 1967).
REFLECTION
• When you have a negative emotional response to an interactive event, what is your usual reaction? Do you say or think They/It made me feel really bad? Is this your typical response?
• If so, have you ever explored the reasons why you respond in this manner in particular circumstances?
• Have you ever thought that negative emotions are your responsibility?
• Have you ever thought I make a choice about how I will feel during an interaction?
• Have you ever wondered about the other person and what caused them to relate in that particular way?
• Can you see the benefit of considering the above perspectives? That is, that
– Your attitudes and reactions are your responsibility and you may need to explore your reactions and resolve the causes.
– A negative interaction reveals more about the other person than it does about you and thus their reactions are not your responsibility.
• Reflect on the benefits of understanding that you are responsible for your own reactions to situations – that you cannot make anyone feel a particular emotion and nor can others make you feel emotions. You alone control your responses; you alone can choose how you will feel and react.
Reflection offers the individual an understanding of their primary need (see Ch 6), allowing them the opportunity to fulfil that need outside of their work environment. If health professionals seek fulfilment of their driving need within their professional life, not only will they experience disappointment but they will fail to provide family/person-centred practice. All individuals are responsible for their emotional responses and for how they fulfil their driving need.
Reflection provides understanding that the value of an individual does not come from what people think of that individual, the role the individual has in society, the car they drive or the clothes they wear. Individual value comes from within through understanding and respecting the self.
REFLECTION
• What do you feel gives you value?
• What do you feel gives other people value?
• From the perspective of a health professional, consider the benefits and limitations of believing that individual value comes from achievements or external factors (e.g. social status, colour, race, sporting skill or musical skill etc).
Reflection provides understanding that not only increases self-control, but also promotes self-honesty, self-awareness, self-acceptance and ultimately self-respect. If health professionals are able to practise these they will be more able to demonstrate awareness, honesty, acceptance and respect towards the vulnerable individuals seeking assistance (Purtilo & Haddad 2002). Demonstration of self-awareness promotes the overall goal of every health profession – family/person-centred practice.
REFLECTION
• How comfortable are you with considering your emotional responses? Do you find it easy or do you prefer to avoid experiencing emotions?
• Do you think that feeling emotions is a sign of weakness? If so, why?
• Do you think your emotional responses are never important? If so, why are the feelings of others more important than your feelings?
• Do you find that your emotions dominate your actions? If so, why is this?
• Do you think you really do not have emotional responses? If so, it is important to remember that everyone feels; why do you block yourself from feeling your emotions?
• Are the thoughts isolated through answering these questions true? For example, is it true that the feelings of others are more important than your feelings? Where do these thoughts originate?
Rudduck & Turner (2007) indicate that reflection is important when learning about previously unknown cultural contexts. It provides an understanding about the culture of the health professional compared with the previously unknown culture. This understanding can facilitate appropriate behaviour and communicative interactions to ensure effective communication with people from other cultures.
Health professionals who reflect are able to identify the reasons for their negative reactions during interactions and, as a result, resolve the causes of these reactions. They are able to improve their skills in managing emotional responses (of themselves and others) that control and negatively influence communication with the ‘other’. Such health professionals are able to use their skills of reflecting to observe and recognise emotions in those around them and thus validate and clarify these emotions and their possible causes.
The ‘how’ of reflection: Models of reflection
So how does one reflect? It is not difficult to consider some past interactions – the more pleasant ones usually do not pose questions, just happiness and pleasure. However, the uncomfortable ones often leave an individual wondering how and why. To remove any guilt associated with such interactions an individual will often wish to re-experience the events for an opportunity to react differently. Alternatively, individuals may feel hurt and resentment because of the actions or words of another during an uncomfortable interaction. The purpose of reflection is to provide information that empowers the health professional to react appropriately and thus i) avoid regret and guilt; or ii) understand, accept and forgive rather than feel hurt and resentment.
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