There are no facts, only interpretations.

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 reflective writing and explore how reflective academic writing can be meaningfully graded from a professional artistry perspective in contrast to a technical rational perspective.

Chapter 12 offers a further example of reflective writing for readers faced with setting and writing reflective assignments. Students must feel free to express themselves rather than 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 teaching and its learning significance through evaluating student response. Teaching becomes alive through relevant story because students can easily relate to it through their own experiences, especially in addressing difficult topics such as family abuse where stories are often 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 and Hank'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 within first-year and third-year student guided reflection groups. As you would expect, the first-year group is more directed whilst the third-year group is more open, reflecting the curriculum agenda and experience of the student both in reflective learning and the topics being explored.

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

Much reflective practice teaching in universities is carried out by people who are not reflective. As a consequence they apply inappropriate technical rational approaches to the teaching of reflection. This whole book is itself a treatise on the need to create reflective learning environments if we are to practise reflective practice critically rather than as a superficial problem-solving technique. Of course, it has value even at that level if it enables practitioners to pause and reflect on what they are doing in terms of best practice. But much of what we do and the way we think about what we do is culturally prescribed. So, if the value of reflective practice to develop professional artistry is to be more than a technical rational approach to the doing of reflection, the reflective teacher, like the reflective practitioner, must lift this cultural veil to understand and shift the norms that govern teaching of teachers.

In Chapter 17, Adenike, herself a teacher of teachers, relates the classroom to chaos theory – that nothing is certain or predictable despite previous experience, and that order evolves around meaning. In other words, order is inherent and unfolds. This means the teacher does not have to worry about ‘controlling’ the classroom. Indeed the more she tries to control the classroom the more difficulty she will have with control. It is the same with the clinical health environment: order manifests itself around meaning. Hence, the attempt to control the healthcare environment is counter-productive. Things work just fine or even better 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 valuable way to understand what takes place in the classroom’ we can see its parallel - ‘I view the idea of nurse as “strange attractor” as a valuable way to understand what takes place in the clinical environment.’ Hence, the way the nurse teacher performs role models how the nurse might perform. Reflection lifts this dynamic into mindfulness, hence processes become more significant than outcomes or, put another way, get the process right and the outcomes naturally emerge. In Chapter 18 Adenike explores a range of issues that face her as a reflective teacher, notably emotional ethical issues. It is so easy to get caught up in the classroom tension – mindfulness falls away and the teacher resorts to learned ways of dealing with her anxiety. Hence the pivotal idea of poise as clinician or teacher and as a hallmark of mindful practice.

In Chapter 19, I turn my attention to creating the reflective clinical environment in which reflective practitioners can flourish. This is based on my work developing the Burford NDU Model of nursing: caring in practice. Experience, such as depicted in ‘People are not Numbers to Crunch’ (Chapter 23), illuminates the mechanical approach to 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 identify and 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 to support this focus against a background of leadership and learning culture.

In Chapter 20, I pick up the idea of a reflective quality system through developing standards of care, imagining an actual standards group. Setting standards may be time-consuming yet its value is immense, begging the question, how much effort should be devoted to ensuring quality as something lived rather than having quality judgement imposed through systems such as CQC? Surely any professional should be actively involved in ensuring quality of her performance? In Chapter 21 I examine the idea of clinical supervision as both a quality and developmental process through my supervision of 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 leadership is acknowledged with the NHS Forward Review² at a time of radical change. However, it needs to be the right type of leadership. Gerald was part of a learning community of ten aspiring healthcare leaders. I emphasise community for at least five reasons. Firstly, from a leadership perspective, creating community is fundamental requirement for any leader. Secondly, I believe that learning through community whereby others in a similar aspiring boat are available to each other through a period of time (in this case 28 months) enhances learning through reflection. Community creates the conditions for dialogue for a group of learners aspiring to similar goals. This idea permeates many of the chapters in the book and reinforces the need for guides to be themselves leaders and skilled at guiding others to learn through reflection. Indeed this ability to guide learning in others is a prime quality of leadership.

Thirdly, 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 conform to organizational norms that are previously learned ways of being. The ability to sustain learning, against the grain so to speak, is reflected in the extent to which reflection has become inculcated within the practitioner's community rather than being merely an individual thing. Gerald suggests he has achieved that to some extent, although it remains precarious as he continues to holds creative tension. Of course, in terms of the efficacy of reflective learning, this issue of sustained learning at depth of is of vital concern; 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 able to detach self from the anxiety of transgressing these norms. Living this tension is akin to playing a subversive and dangerous game of survival where guidance is vital.

Fourthly, Gerald's chapter opens up a dimension on expressing learning through metaphor. Gerald, like all NHS staff, has been socialised into the transactional culture that governs healthcare organisations. Hence the idea of being a servant-leader or a transformational 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 being immersed within it, a culture where one’s every action has been socialised towards being transactional from either a subordinate or managerial perspective?' Gerald used the metaphor of David and Goliath to see and work with this tension. If the tension is not addressed then learning is limited, and yet one can see how difficult it is to unlearn learned ways of knowing (embodiment) to begin to respond differently and without coercive fear.

Fifthly, Gerald highlights the significance of one's background in shaping the person. To become a leader from a servant-leader or transformational perspective required Gerald to look back at his upbringing in order to understand how his background influences who he is now and whom he seeks to become. He recognises the tension between a Goliath within and a David within, and accepts the need to vanquish his Goliath through his David. Anybody learning through reflection will need to consider their background – perhaps using the Influences Grid in Chapter 3, Table 3.4 (how does my background influence the way I respond within this particular situation/ experience?).

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

Throughout the book I usually refer to practitioners rather than specific healthcare practitioners. 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 for performance-related chapters.