Reflective Practice, Professionalism and Acupuncture Education

Introduction: The Challenge of Reflective Practice

Some years ago, at an accreditation visit to an acupuncture institution, a group of managers, lecturers, acupuncturists and educationalists were sitting round a table discussing reflective practice. More specifically, the visitors from the British Acupuncture Accreditation Board were putting the case for introducing reflective practice into the curriculum of the degree level course that was being accredited.

One young acupuncturist, who was also a parttime lecturer at the institution, looked bemused and exasperated throughout the discussion. He became especially agitated at the proposal that lecturers in the institution might choose to model the same approach to reflective practice that they would be requiring from students, for example by keeping their own log or diary of good and bad professional experiences and by being prepared to share them openly with colleagues, or even with students. Eventually he could stay quiet no longer, and expostulated: 'What is the big deal about reflective practice? Surely it's just plain common sense. All teachers and all acupuncturists go home at the end of the day and reflect on what's happened, what went well and what went badly. If things have gone wrong, then they try to put them right next time. But everyone does it in their own fashion. It's noone else's business. How can something that's so personal be taught in a formal way, when it's so subjective and there's nothing objective to assess. We should be concentrating on teaching students the theories and the scientific knowledge they will need. Reflective practice is simply not measurable enough to be a major part of the curriculum'. He happened to be an acupuncturist, but these comments could just as easily have been spoken by a young teacher, nurse or doctor in a similar position. The thinking may be misguided in terms of the type of reflective practice to be discussed in this article, but it is neither uncommon nor unintelligent; indeed in its appeal to objectivity and to measurable outcomes it is in tune with contemporary western culture, as manifest in current health and education policies and in mainstream scientific research. Most people have been brought up absorbing a similarly objective way of thinking about knowledge and the way it is acquired. Skolimowski (1994) calls this upbringing the 'yoga of objectivity', meaning the stringent mental exercises practised from when pupils go to high school – the purpose of which is to ensure that the mind becomes detached, analytical and unemotional as it confronts reality, knowledge and nature. Yet the simplistic assumptions made by this welleducated practitioner about professional practice, and about learning to become a professional practitioner, are going to be challenged in this article. To take reflective practice, with all its imponderables and its subjectivity, more seriously than this young man did is partly an assertion of the most effective method to educate and develop proficient, thoughtful and ethicallyaware practitioners; but it is also about asserting a distinctive and currently unconventional perspective on life and on knowledge. Although reflective practice has been adopted as an educational approach in a number of mainstream professions over the years, it would seem to have a special affinity with the emerging profession of traditional acupuncture. Like acupuncture, reflective practice encourages people to look at everyday experience in an unfamiliar way. Both insist on the uniqueness of particular situations and the importance of context. Each shares a suspicion of 'offthepeg' prescriptions and universal solutions to life's problems. In these ways they act as a necessary counterweight to the current dominance in the western world of a narrow scientific and objectivist approach to life 2 and to knowledge. The acupuncture traditions have much to offer the western world in the 21st century, because they never lost sight of the mindbody connection and the interconnectedness of all things on earth. Reflective thinkers also tend to become aware of such links, simply by going into complex human realities in great depth. Whenever practitioners get below the surface in this way, it is hard for them not to recognise the holistic nature both of themselves – their 'self' – and of their clients, patients or students. Reflective practice may have an affinity with today's counterculture, but its roots are in an educational philosophy – John Dewey's 'learning through experience' – that could, and perhaps should, have become entirely conventional and mainstream during the twentieth century. Unfortunately, Dewey's personcentred ideas lost out in the struggle for educational supremacy, first to the academic purists – 'learning through great books' – who did not like his emphasis on 'vocational' education, and later to the industrial trainers or instrumentalists whose 'learning through outcomes' approach still prevails today. Donald Schon's pioneering work in the 1970s and 80s built on Dewey's ideas and also on the insights of the early action researchers. Schon (1983, 1987) gave reflective practice its name, its form and its place at the heart of professional education. His many eminent followers in the past three decades have included Della Fish (1998), who is well known in the acupuncture world as an advocate and teacher of reflective practice. It is by now well established that focussed reflection of a deep, personal kind can help practitioners in all fields of health care to become better and more professional in their work. The best become individual 'practitionerresearchers' continually looking for ways to improve their practice. Through reflection on their experience, many health professionals have also come to appreciate the limitations of the technicalrational, orthodox scientific approach to complex care situations and to acknowledge that it is in the very nature of the human condition for unknowns and uncertainties to lie at the heart of much practice. This suggests that to become truly professional will always mean something over and above the acquisition of observable skills and competences. In making its pragmatic case for the virtues and benefits of reflective practice in acupuncture education, this article is also trying to throw light on that elusive 'something'. The Contested Nature of Professional Practice In any thoughtful exploration of professional practice there must be included important elements that cannot be reduced to observable or measurable skilled performance. The reason for this is simply that no two practice situations are ever completely identical; whereas a skill remains the same from one context to the next, a practice has to take each context into account. Frequently such contexts will be unpredictable, or met with for the first time. So the practitioner requires something more than skills and competence, important though they obviously are. Any practice will typically consist of a series of dialogues or interactions with individual human beings, who, like the practitioners themselves, will be bringing significant elements of biographical complexity and uniqueness to the engagement. To this uncertainty can be added an infinite variety of cultural, moral, historical and political factors that can shape the particular context in which a professional interaction or engagement takes place. Since all this inbuilt uncertainty and potential complexity is going to affect the performance of their skills, it would seem essential for practitioners who take their work seriously to be continuously reflective about it. 3 'What characterises reflective professional practice is commitment by the practitioner to the integration of moral, historical, political, social, psychological, economic and theoretical perspectives to make meaningful the complexity of the situation in which he or she is practising.' (Hopper in Penson and Fisher, 2002). But such a truism about the complexity of practice is far from current orthodoxy, which is better understood by unpacking the words of the exasperated acupuncturist and teacher quoted above. He had defined the words 'reflective' and 'practice' superficially in his own mind and come to the conclusion that reflective practice is nothing more than a mental review, or a rehearsal in the brain, of things that have happened during the working day. His background, experience and education led him to conceive of a professional practitioner as someone steeped in 'theories and scientific knowledge', engaged in objectively verifiable decisions leading to actions that are always either correct or incorrect. In his universe a 'right' answer must exist, even if the practitioner did not happen to find it on this particular occasion. Becoming a better practitioner in this technicalrational world view is a trial and error process of increasing competence by modifying behaviour over time: eventually one gets more and more things 'right', and fewer and fewer things 'wrong'. The process by which this increased professional competence or mastery is to be achieved (or not) is entirely subjective and should remain completely private, because it is of no business or concern to anyone else. All the important personal and emotional factors in this young man's personality, and in his life outside work, are seen by him (and others) as irrelevant to and separate from his 'day job' as practitioner or teacher of acupuncture. To tease out the young acupuncturist's words in this fashion should begin to undermine them, because it is immediately apparent that noone has ever actually lived or worked as an acupuncturist or as a teacher in such an individualistic cocoon. Nevertheless the technicalrational approach to reality and to knowledge that has engendered such misguided assumptions about professional practice is held by many people a lot older and more influential than this young lecturer. Ever since the 1980s, when politicians decided that public service professions needed to be made more accountable, an increasingly oversimple and reductionist version of professionalism has become the norm. For example, 'training for skills' has taken over all education policymaking and much education practice in recent years, in large part because 'education' is a complex concept and 'skills' are simpler to observe and to measure. Professionals in all public service professions over the last two or three decades have had to face a strong political attack on the longestablished idea of their professional autonomy and on the related idea that professional practitioners might possess some special expertise or distinctive 'artistry' that is of benefit to other people. Governments of both parties have suggested to the general public, implicitly and sometimes explicitly, that professionalism and professional autonomy are more likely to be selfserving than to be a force for the public good. Bernard Shaw's definition of professionalism as a 'conspiracy against the laity' has been promoted as a profoundly wise truth when it was never more than a glib wisecrack and at best a halftruth (Shaw, 1971). By way of contrast and for a fuller debate on whether the professions 'serve noble purposes' or not, see Freidson (1994). The attempts to simplify professional practice by redefining it as and reducing it to observable skills and measurable activities remain unceasing. In every field of health care and in every aspect of education an objective 'evidence base' is being sought, from which can be derived standards and prescriptions and specifications that are assumed to have universal validity. Since late 2004 a distinguished group of British acupuncturists has been meeting to challenge the application of such reductionism to traditional acupuncture practice; they are seeking to replace the overgeneralised 4 simplicities of National Occupational Standards (NOS) with a more useful and rigorous account of specific Professional Acupuncture Standards (PAS). Reflective practice at its best has always encouraged both novice and experienced practitioners to challenge reductionism and simpleminded approaches for themselves and in their own way. Objective knowledge and high levels of technical competence are clearly an essential part of effective practice; but since they do not comprise the whole of a practising professional's repertoire, they should never constitute the entire curriculum of a professional qualification in the way that the technicalrational, lowest common denominator NOS approach is strongly suggesting. In situations characterised by uncertainty and complexity the practitioner needs, in addition to knowledge and technical skill, to develop good professional judgement. To establish, for example, whether an 'offtheshelf' prescription or 'expert' specification is actually going to be the most relevant or the best treatment in a given situation will always be a matter of individual judgement. The context is allimportant. Even when the particular treatment under question has been authorised as 'best practice' or labelled as 'clinically excellent' by fellow practitioners working in a governmentapproved agency, the confident (and reflective) practitioner may decide that there are good reasons to do something different in the particular situation presented by this particular client. Developing powers of judgement, and providing opportunities to rehearse safely the sorts of deliberation that precede good judgement, become therefore both the subject matter and the rationale of a reflective practice curriculum. It is not just the complexity of practice ignored by politicians, which professional practitioners have to take into account. It is also moral values. Any professional practice is as much a way of working and a 'tradition of conduct', with its own expectations and ethical values, as it is a field of objective knowledge and practical skills. It is through practical experience of the way of working, even more than through reading and listening, that novices or newcomers start to acquire a fuller understanding of the profession they are seeking to enter. Students arrive as outsiders and there are at least three key aspects of the 'tradition of conduct' that they must absorb before they can begin to feel like insiders. Each requires some intellectual effort but none can be entirely taught and learned in a library or a lectureroom, because a profession's 'tradition of conduct' will always be much more than any descriptive or propositional account of it. It has to be lived and felt. R.S. Peters, who was the opposite of a holistic philosopher in most respects, nevertheless talked about 'getting the grammar of the activity in your guts' (Peters, 1965). Becoming an insider in this sense is a complex process involving emotions, relationships and attitudes, not just knowledge and skills. It is a lifetransforming process, and the mystery that lies at the heart of such meaningful learning always needs to be honoured (Parrott, 1991), or at the very least acknowledged. The first aspect of a tradition that must be acquired by interested new recruits is historical and political awareness. Only by becoming aware of the stories of past growth and development, of old conflicts and current struggles, can a newcomer understand their chosen profession and its tradition of conduct from the inside. A second important requirement for the novitiate is an understanding of the moral values that guide the profession and the work of its practitioners. This is implied in the word 'conduct' which carries more moral weight than 'behaviour'. 'Conduct' implies the intention to perform ethically correct actions, not just to display technically correct competence. In particular, new professionals need to learn why particular ethical constraints, like the British Acupuncture Council's various Codes for instance, have been placed on practitioners and on their choice of action. In all professions 5 practitioners are constrained by the accepted norms handed down to the current generation: 'When we engage in the characteristic activities of a practice... we are disciplined by its standards as represented by our peers and our predecessors.' (Golby and Parrott, 1999). But no profession stays still. A profession is constantly in the process of modifying its norms and of developing (or rejecting) its accepted orthodoxies and present practices, in the light of what current individual practitioners are actually doing. So although practitioners can never ignore the tradition of conduct that they have inherited, they also need to recognise that through their practice they will also be making some contribution, however slight, to its ongoing development. This is especially true for those who are teaching the newcomers to a profession and who are therefore powerful role models whether they like this responsibility or not. Serious reflection on one's own practice as a teacher makes being a role model more of a conscious than an unconscious process. A third task for novitiates on their journey to becoming a fully fledged professional, and the most demanding for many of them, is the Socratic injunction: know thyself. To become an authentic insider they must find a way to locate themselves – their whole and unique self – within the profession and within its tradition of conduct. This entails becoming critically aware of one's self, including the past influences and present beliefs that provide one's strengths and one's weaknesses, so that one can consciously choose to become this particular kind of practitioner rather than that kind. To this end serious reflection is essential. Teaching and Learning Reflective Practice in Professional Degree Courses Reflective practice is often defined with a very strong emphasis on the third of the tasks above, the acquisition of self knowledge. For example, '(Reflective practice) is a means by which practitioners can develop a greater level of selfawareness about the nature and impact of their performance, an awareness that creates opportunities for professional growth and development'.. (Osterman and Kottkamp, 1993). These particular authors certainly did not mean to confine reflective practice to personal development or to ignore the significance of reflection on wider aspects of practice, but such narrow definitions can sometimes encourage a narrow behaviourist approach in which the allimportant contexts of practice are denied or ignored. It is however true that the focus of reflective practice will often be on the practitioner's own, unique self. The disciplines of reflective practice require people to become open to learning personal things about themselves – the kind of things that are often buried and that will never become apparent if the day's work activities are reviewed in a superficial or entirely cerebral manner. The way people approach their daily tasks as professional practitioners is always influenced by past experience in subtle fashions that they may not fully understand. Unless they are encouraged to take critical reflection seriously, most practitioners will be inclined to reinforce existing patterns of behaviour and to take for granted the routines of the day or of the particular institution they have come to know well. In school teaching there is the well known riposte to the middle aged teacher who is heard boasting about having had thirty years of experience in the classroom: 'No, Mr.Chips, you have had one year's 6 experience thirty times!' Or, as Della Fish used to say, 'it is possible to have a great deal of experience and no learning'. Each new student of acupuncture will start a course programme with their own understandings and beliefs that are deeply rooted in their individual biographies and experiences. New internal meanings are only arrived at slowly and often painfully, as values, assumptions and attitudes are challenged by new ideas or unanticipated experiences. Such personally meaningful incidents may slow down after the first few years of learning and of professional experience, but for the reflective practitioner they never stop altogether. As Socrates realised, to know oneself is a neverending task an aspiration rather than an achievable goal. Once the habit of reflection is acquired, it becomes an integral part of one's continuing professional development over a whole career. There will always be more to discover or to learn or to improve, about oneself or about one's performance – in work as in life itself. For the committed professional the two can never be entirely separated. The following excerpts happen to come from third year students on a university nursing course writing about their experiences of reflective practice, but they could just as easily have been written by third year acupuncture students on one of the degree courses fully accredited by the BAAB. Jane (a pseudonym) recalled that in her first year she had not really seen the point of reflective practice ' reflection is not something I have done naturally...the tutors told us it was something we should all do' She was told to keep a log/journal, but 'mine consisted of little more than a list of my placements'. For a long time she found it too challenging even to talk about her personal experiences more than superficially, although she learned a lot from listening to other peoples' accounts. Reflection was 'a skill I have had to work hard at developing'. Gradually she started to open up with one particular friend between the official tutorled group sessions and 'this made me look at my practice in more depth'. By the third year of her course she was writing: 'Reflection for me has become a way of learning through my practice and therefore refining my future practice...I have found that I do not reflect upon my practice in one set way...I have developed several personal and different methods...I have become better at reflecting on my practice and I can now use more formal methods, such as clinical supervision. I have experienced good and bad supervision and feel a growing awareness of what makes this good or bad for me. I am also starting to use my journal properly. Reflection helps me to look more deeply at my practice and learn much more about nursing and myself.' Jane's final two sentences imply that after two or three years the deeper process of reflection is just beginning for her. Her testimony also suggests how hard reflective practice, properly conceived, can be. Self knowledge is not easily acquired: it requires more than an intellectual understanding, it demands a strength of character and a level of honesty and selfawareness that few possess without having worked at it. In fact reflective practice can be usefully conceived as a continuous challenge to oneself and one's thinking. To understand where one has come from, to be able to articulate the values one holds dear and to become the kind of professional practitioner that one would wish to be, all seem to require such a subjective and deeply reflective approach to learning. Jane's reflective practice started properly when she began to talk deeply and mutually with a fellow student about their individual experiences on the wards. It was only later that she acquired the confidence to write similarly deep and personal 7 thoughts in her journal. Mary, who was on the same course, describes a different personal process in which writing reflectively was not such an issue or hurdle to be overcome. From the start she felt comfortable putting her thoughts on paper: 'I write about the positive and negative aspects... and try to consider if the situation could have been handled differently...She also had no problem being honest and critical about what she had observed on the ward. Mary's biggest worry was what people in authority were going to make of her critical writing: 'the personal reflections I wrote were passionate and critical of the patient's care. I was worried what my coach and tutor would say when they read it.' Mary was pleasantly surprised to find that in the event her tutors valued her honesty and were happy to discuss her concerns. But she also came to recognise that the more important aim of her reflections and of her journal was to be selfcritical and to improve her own practice, 'I am sure that this reflective writeup helped me to think about the care I will give to these patients in future.' One implication for tutors introducing reflective practice to students on a degree course is to be flexible. There is no single right way to teach or to learn it. Some students will prefer talking, others writing. There will be as many different ways of arriving at the goal of reflective practitioner as there are students in the group. A lot of first year students will find formal and selfcritical reflection hard to do, and it may take them a long time to find the courage and the method that suits them. Group sessions are important, because listening to others and reading their journals or portfolios may provide a breakthrough for the student who has difficulty in 'reseeing' their own experiences. Students may find it helpful to find out more from the literature of reflective practice itself, although too much immersion in the academic 'theory' behind reflective processes can sometimes be a way of avoiding the real task of using reflection to become a better practitioner. In this respect both a 'Narcissus' and a 'Hamlet' syndrome have been identified, whereby reflection is distorted and made an end in itself: a substitute for meaningful action rather than a helpful prompt towards it. One of the most effective ways to introduce reflective practice to students who are new to it, and possibly disturbed by the thought of it, is for the teacher himself to share his own experiences in a selfcritical way and for him to explore the ways in which his personal espoused theory has been built up over years of practice combined with years of reflection. This can be challenging for teachers with little previous experience of this type of reflective practice and so there are implications for the professional development of teachers themselves. For course managers there are also clear implications of the discussion above. Reflective practice is not effective when seen as the responsibility of one particular colleague teaching it as one module, or one module per year. All the key members of a course team need to be persuaded of the particular way of thinking that lies at the heart of the reflective practice philosophy. It works best in those degree programmes where practice and not theory is regarded as the central feature of the overall curriculum; these will be courses where students are encouraged to get out of the classroom as early and as frequently as possible in order to learn at first hand the nature of the profession they aspire to join, initially through observations and later through increasingly sophisticated handson experiences. Students as early as their first year should be encouraged to get below the surface of the practice situations that they have personally observed. 'Problematising' practice is an ugly phrase but a necessary activity. Throughout the process of reflective practice it is important to relate reflective practice to notions of criticality, researchmindedness and formal research. The key 8 term here is 'enquiry'. Reflecting deeply and systematically on one's own experience or practice is itself an enquiry. Indeed the whole curriculum of a degree level course in a practice like acupuncture can be seen as a process of enquiry over three or four years, in which students should be encouraged to take the lead role as critical and selfcritical enquirers. Enquiry is therefore the theme that connects the nervous beginner, who is perhaps hearing about the need to keep a reflective practice journal on day one of an acupuncture degree, with the confident dissertation writer she or he will have become at the end of year three or year four. There is also an obvious chain linking the selfcritical writer of a reflective journal with the critical reader of texts, the probing observer of other people's practice, the questioning student in group discussion, the supervisee admitting to uncertainty or mistaken diagnosis, the presenter to peers and teacher of complex clinical cases and, finally, the accomplished researcher writing an academic but heartfelt dissertation. All of these are forms of enquiry and all will have contributed to the safe, competent, thoughtful and deliberative practitioner who emerges at the end of the course able to make her or his distinctive professional contribution to British acupuncture's 'tradition of conduct'. Allen Parrott Ann Hopper April, 2005 Our thanks go to Rosemary Richardson and Fred Parrott who both commented valuably on an early draft of this article. We should also like to invite practitioners, teachers, or students of acupuncture to send in their reflective comments or critical responses to this piece. Particularly welcome would be accounts of reflective practice in action or case studies, even if their authors have come to different conclusions! Please address correspondence to: This email address is being protected from spambots. You need JavaScript enabled to view it. or This email address is being protected from spambots. You need JavaScript enabled to view it. References Bronowski, J. (1973) The Ascent of Man, London: BBC Publications Dewey, J. (1933) How We Think: A restatement of the relation of thinking to the educative process, Boston: Heath and Company Dewey, J. (1981, original edition 1916), Democracy and Education, New York: Macmillan Fish, D. and Coles, C. (1998) Developing Professional Judgement in Health Care, London: ButterworthHeinemann Freidson, E. (1994) Professionalism Reborn, Cambridge: Polity Press 9 Golby, M. and Parrott, A. (1999) Educational Research and Educational Practice, Exeter: Fairway Publications Hopper, A. (2002) "Reflective Practice in Palliative Care" in J. Penson, and R. Fisher (Eds), Palliative Care for People with Cancer (2 nd edition) London: Edward Arnold Ostermann, and Kottkamp (1993) Reflective Practice for Educators London: Sage Publications (Corwin Press) Parrott, A. (1991) SelfDirected Learning: Honouring the Mystery (Unpublished) PhD Thesis, University of Bath Peters, R.S. (1965) "Education as Initiation", in R.D. Archambault (Ed), Philosophical Analysis and Education, London: Routledge and Kegan Paul Schon, D. (1983) The Reflective Practitioner, Aldershot: Arena Schon, D. (1987) Educating the Reflective Practitioner, San Francisco; Jossey Bass Shaw, G.B. (1971 edition) Preface to "The Doctor's Dilemma", Collected Plays and their Prefaces, Volume 3, London: The Bodley Head Skolimowski H (1994) The Participatory Mind, Harmondsworth: Penguin Books (Arkana) 10

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