Introduction

Reflective practice is like a pool of blue, inviting water. The pool has a shallow end where the bottom is visible and a deep end where the blue is deep and the bottom unknown. ¹

I open this chapter by referring to the words of Christopher Johns, a well-known devotee of reflection from the nursing world because it is my perception that the pool provides an apt metaphor for discussing the status of reflection in the contemporary practice of dietitians. Having recently interviewed several highly experienced practising dietitians in the UK, my impression is that they are floating tentatively at the shallow end with an unfounded lack of confidence in venturing into deeper water to claim to be reflective practitioners, notwithstanding overwhelming evidence to the contrary.

Discussions with practitioners have highlighted that the perceived inadequacy of reflective skills can be attributed to lack of formal teaching about reflection and little or no experience of it, which is in agreement with other research findings. ² This inadequacy is exacerbated by the sense that undergraduate students, for whom practitioners are frequently responsible on placement, are perceived to be better equipped to engage in reflection which is promoted in undergraduate curricula. The current UK Health Profession Council’s (HPC) Standards of Proficiency for Dietitians explicitly highlight the requirement to understand the value of reflection for clinical practice and the need to record the outcome of such reflection. ³ While this stipulation aligns with continuing professional development (CPD) requirements, it necessitates the acquisition of additional skills in written reflection, which practitioners can find challenging. These factors appear to conspire to create uncertainty and ambivalence about reflection and its potential benefits for practitioners.

Perhaps the most powerful driver encouraging the uptake of some form of reflective dialogue within teams and departments is the necessity to demonstrate competence through CPD. ⁴ This requirement is not confined to dietitians, but includes other health professions and extends worldwide. The Dietitians Association of Australia Accredited Practising Dietitian programme is a self-regulatory strategy, which actively promotes reflective practice as a means of ensuring high-quality practice and service delivery. ⁵ Dietetic colleagues in the USA and Canada are already familiar with and have embraced the necessity to submit a professional development portfolio based on a reflective learning cycle for recertification every five years. From 2010 dietitians renewing their registration in the UK will be chosen at random and asked to produce a profile of evidence, taken from a professional CPD portfolio and stemming from work-based learning, underpinned at least partially by reflective practice.

Dietitians keen to learn more about reflection are confronted with a dearth of literature in dietetics, previously highlighted. ² Fade provides a useful account of models and structures used to support the development of reflection within the dietetics curriculum. However, she emphasises the challenge faced by the profession to develop its own research-based literature. A limited literature around the experiences of completing the professional development portfolio in the USA and Canada informs this account. However, given that the research base currently remains inadequate I draw on research and conceptual thinking across a wide range of professions to suggest ways in which practising dietitians might engage in reflection. My aim is to clarify what is meant by reflection, to explore the potential value of reflection for dietitians and the profession and its juxtaposition with evidence-based practice (EBP), as well as discussing a variety of approaches to facilitating reflection in practice. I hope to persuade colleagues that establishing a departmental or unit framework for reflection is achievable, useful and sustainable in the context of contemporary healthcare.

Some definitions

Reflection is a specialized form of thinking that requires technical mastery of a subject plus active analysis of the purposes and consequences of decision-making. ⁶

It seems to be worth briefly exploring what we mean by the terms reflection and reflective practice, which tend to be used interchangeably. Conceptions vary and both terms have been defined from a range of perspectives. For instance, Johns’ definition of reflective practice as ‘the practitioner’s ability to access, make sense of and learn through work experience, to achieve more desirable, effective and satisfying work’, emphasises the focus on self, as well as its developmental potential. ⁷ Boud et al.’s definition focuses pragmatically on the process by which ‘people recapture their experience, think about it, mull it over and evaluate it’ in a relatively straightforward and unproblematic way. ⁸ However, Mezirow’s notion of reflection as ‘seeing through habitual ways of interpreting everyday experience’ suggests greater complexity and a necessity to venture beyond the shallows to transcend this basic appraisal. ⁹ The purpose of reflection is ultimately to come to new understanding and appreciation, opening the way for transformational learning that ‘changes the way people see themselves and their world’. ¹⁰ However, this capacity for reflection to act as a catalyst for change might operate at a range of levels, whether it leads to a new way of doing something, the clarification of an issue, the development of a skill or the resolution of a problem. ¹¹

One might ask whether reflection is different to analysis. My response is to suggest that they are synonymous but belong to different paradigms or ways of viewing the world. Analysis refers to a cognitive or behavioural process where the person undertaking the analysis adopts a position of objectivity an separateness in an attempt to establish ‘truth’ claims. Alternatively, reflection involves affective as well as cognitive and behavioural domains, and therefore acknowledges subjectivity. The person is actively involved in developing understanding of self and others in a particular context, which is consistent with a professional artistry view of the world. As individuals and professionals, we all differ in how we view the world. However, health professionals tend to be driven down a scientific route, which influences their approach to their work not least because they have been persuaded by the discourse of evidence-based practice.

EBP has been defined as the means by which the scientific credentials of health are re-established, ¹² and the movement has grown within the health professions internationally, ¹³ despite criticism that the only evidence for EBP is reliance on the very same introspection and intuition for which reflection is condemned. ¹⁴ In fact, reflective practice complements the EBP discourse by providing a means of addressing the ‘messiness’ of the real world of health and social care practice. It has become widely accepted as the means by which the self of the practitioner, the context of the lived experience and humanistic aspects of practice are made explicit. EBP supports development of propositional knowledge whereas reflective practice acknowledges the importance of personal knowledge. The two discourses, although presented as oppositional, are highly congruent. Johns argues that to value personal knowledge ‘challenges the view of the practitioner as a largely uncritical receiver and user of knowledge produced by others’, challenging the dominance of EBP in favour of a more balanced view that values both approaches. ⁷

Plath acknowledges critical analysis as integral to the effective use of research evidence in social work practice, emphasising the need for practitioners to become less rigid in their interpretation of what counts as evidence. ¹³ This echoes messages conveyed by colleagues in dietetics, ^15,¹⁶ advocating reflection on the biases created by personal values and assumptions in order to evolve from practising in ‘black and white’ to being comfortable practising ‘in grey’. ¹⁶ Personal knowledge and that produced by others complement rather than oppose one another and need to be valued in their own right. ¹² Developing Plath’s suggestion I argue that they can be assimilated through the notion of criticality or critical reflection. Criticality is the ‘willingness to challenge, recreate and re-imagine in a manner that is searching, persistent and resolute’. ¹⁷ The consideration of evidence as one resource to be judged alongside other ways of knowing in practice, provides a healthy compromise and an essential means of confronting, understanding and resolving what Johns refers to as ‘the contradictions between what is desirable and actual practice’. ¹⁸ Brookfield highlights that in order to become critically reflective it is necessary to be able to identify and challenge assumptions, to challenge the importance of context and to imagine and explore alternatives, which he believes leads to ‘reflective scepticism’. ¹⁹

The value of reflection in advancing practice

Brookfield suggests that non-reflexive learning, lacking a critical element, often takes place in action contexts that are easily equated with healthcare practice. ²⁰ Conjure up an image of the practice setting and the practitioner, coping with increasing service demands and the consequences of poor staffing levels, trying to deal with heavy patient workloads, as expeditiously as possible. The suggestion that the ability to engage in critical reflection is a matter of social determination certainly seems to ring true here. Submission ‘without resistance to rules of debate, argument assessment, and decision-making processes that the dominant culture favors [ sic]’ feels all too familiar in the type of context described. ²⁰ Whether the all too common organisational context is the cause of a lack of reflection in dietitians’ day-to-day practice, ² or it is attributed to professional cultural beliefs about what counts as valuable knowledge, it seems that dietitians need to be alert to the potential for critical reflection to advance practice.

Such advancement of practice can occur on several fronts. First, critical reflection provides a means of improving practice through the development of personal knowledge, professional expertise and competence. In other words, there is potential for professional and individual growth. Recognising this potential allows practitioners to identify their own learning needs and to take increased responsibility for their own learning. ²¹ Furthermore, critical reflection encourages us to scrutinise our own implicit, unexamined assumptions, which might limit or undermine intended or espoused practice. ²² By reflecting and deconstructing our own interpretations of a situation we may be able to challenge internal barriers in our thinking that preclude other possible conceptualisations or options. ²³ For example, a dietitian asked to see a new cancer patient might decide that nutrition support is the best treatment for the patient. Finding that s/he is more concerned with quality rather than length of life and being cared for at home might mean a compromise, which could prove challenging in terms of what is clinically appropriate. Space for reflection allows greater depth of thinking about the psychosocial perspectives of care and tensions with evidence-based clinical decision-making. In broader terms the case potentially raises issues of human rights and healthcare ethics and at an individual level it might provoke thoughts about personal and professional values and beliefs. This example illustrates the interaction between different areas of work interest served by reflection. ⁴ Namely it is the overlap between instrumental/evaluative interests (getting the job done), personal growth and development (searching for greater understanding) and ethical interest (confronting moral or ethical dilemmas and being empowered to take action).

Secondly, advancement of practice will occur if assumptions on which practice is based are questioned. This is of particular importance in organisational contexts not necessarily conducive to critical practice, namely, the contexts in which most dietitians work. Morley suggests that critical reflection ‘forces us to reflect on how we subjectively position ourselves within certain contexts and discourses’. ²³ For example, within the health- and social care context, the medical model with attendant hierarchical structures and working relationships based on traditional power differentials forms the dominant discourse with which there seems to be an imperative to identify. Practitioners quickly learn to find their level in the hierarchy and sink into habitual practice, failing to question whether things could be bettered when it might be argued that it is their professional responsibility to challenge structural barriers of this nature. Part of advancing practice might be to make the invisible, such as alternative approaches, visible and valued. ⁷ Current changes in the healthcare practice offers more opportunities than ever before for dietitians and other health professionals to re-imagine systems and practices to exploit new ways of working. Guided reflection offers a means of negotiating new roles and new identities.

Approaches to facilitating reflection

Johns is adamant that reflective practice always needs to be guided in some way. ⁷ His rationale is that lone reflection can be difficult because practitioners tend to focus narrowly on disturbing experiences, and find it difficult to know what to reflect upon and what factors need to be attended to. He maintains that without some guidance much of ‘normal’ practice is not rendered problematic and hence does not become the focus for reflection, limiting potential for increased understanding and learning. I have argued elsewhere that lone reflection serves to maintain the status quo rather than promoting change, so is less effective and desirable than reflection that includes some form of dialogue. ²⁴

There are a number of approaches for facilitating reflection in practice that are discussed at present. However, reflection is essentially individualistic; therefore finding the optimal means of structuring it probably comes down to individual preferences regarding models and strategies. Griffin highlights the need to take into account a number of assumptions when selecting facilitation methods. ²⁵ For instance, she stresses that reflection is developmental in nature, that writing is a critical lever for learning and that dialogue can help externalise thinking by ‘enrich[ing] internal conversations’. ²⁶

Given insufficient space to discuss the wide range of models and frameworks that might help to structure reflection, a reading list is provided at the end of the chapter. Popular models tend to incorporate similar stages of awareness, description, evaluation, new awareness, learning and action. ²¹ Research suggests that simple practical guidance works best. ²⁷ However, Jones warns against the repeated use of guides, which can become ritualistic, leading to superficial learning. ²⁸

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