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Learning through reflective practice: a professionalapproach to effective continuing professionaldevelopment among healthcare professionalsMark Cole aa Chartered Society of Physiotherapy , London, United KingdomPublished online: 19 Dec 2006.

To cite this article: Mark Cole (2000) Learning through reflective practice: a professional approach to effective continuingprofessional development among healthcare professionals, Research in Post-Compulsory Education, 5:1, 23-38, DOI:10.1080/13596740000200067

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Research in Post-Compulsory Education, Volume 5, Number 1, 2000

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Learning through Reflective Practice: a professional approach to effective continuing professional development among healthcare professionals

MARK COLEMARK COLEMARK COLEMARK COLE Chartered Society of Physiotherapy, London, United Kingdom

ABSTRACT Continuing Professional Development (CPD) should aim to develop the individual practitioner, their profession (through architectonics and the dissemination of ‘best practice’), and (as a consequence of the above) the delivery of the service itself. However, many CPD schemes are ‘input-led’, relying on the mechanistic and bureaucratic recording of study days and courses; little or no mind is paid to the outcomes of that activity. This is particularly the case in healthcare, where the formal idea of CPD is relatively new. This article argues for an approach to CPD that is learning focused, accenting the vital importance of experiential learning through reflective practice. It suggests ways in which a learning culture for practice development in the human services can be developed.

Introduction

The requirement for individuals to undertake some form of continuing professional development (CPD) is now seen as integral to the development of the professions. It is seen as contributing to the rigour and integrity that defines professional activity. To a large extent, the luxury of relative autonomy that has traditionally been enjoyed by professions in society is being eroded by a balancing pressure to ensure their accountability in action. Nowhere is this more true than in healthcare.

In the recent flurry of policy documents produced in relation to the development of the National Health Service (NHS), the Government made clear

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the importance that it attached to CPD. In the NHS White Paper, Government committed itself to working with healthcare professions to agree principles to underpin CPD, and to identify the respective roles in this area for agencies such as the professional bodies, individual practitioners, and the state (Department of Health, 1997, p. 46).

In a later publication, the Government spells out the connection that it sees between CPD and quality of care: ‘Health professionals in all healthcare settings need the support of lifelong learning through CPD programmes. Individual health professionals and NHS employers should value CPD as an integral part of quality improvement’ (Department of Health, 1998, p. 42).

However, one of the key debates around CPD and its relationship to continuous improvements in quality relates to causality: Does engagement in a traditional, formal learning opportunity necessarily lead to improvements in professional practice? The point is often made that a great deal of learning takes place outside of formal educational structures and programmes, while it is possible to participate in education without necessarily learning what was intended by the programme.

Moreover, it is arguable that continuing development is an integral part of professional activity in and of itself. There is a traditional and false dichotomy in professional development of theory and practice, with the clear view that the former precedes the latter. Increasingly, however, it is being suggested that the relationship is less unidirectional and more circular: professional practice, whilst guided by the existing corpus of professional knowledge, actually begets theory. And this generation of theory is best undertaken in a practical rather than a research or academic setting.

This article is sympathetic to that view, seeking to show that professional action actually distinguishes itself from other activity by its reflective qualities in practice and the way in which that practice is both contemporaneously and subsequently interpreted. In this sense, the Government’s attempts to impose external controls on professional activity through CPD misses the point: CPD is not something external to professional activity; it is an integral and essential part of that action.

The Application of CPD

CPD is increasingly seen as central to professional activity for three reasons: it is integral to the development of professional status, forming a vital part of any ‘profession-building’; it is a key way in which individual professionals can develop both their specialisms and (in many cases linked to that) their careers; and it is seen as a central means by which quality of professional service can be maintained, thereby reassuring its recipients and (if different) the purchasers of those services. This section looks briefly at each of these in turn.

The need to be seen to be continuously ‘profession-building’, securing the social position and status of the profession, is taken to be particularly important in the current climate of constant and rapid development. Madden & Mitchell

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make reference to a ‘competency gap’, where the growth in knowledge and the speed of technological change, plus the obsolescence of existing knowledge, means that the qualifying programme of professional education can no longer be seen as a career-long statement of professional competence (Madden & Mitchell, 1993, p. 63).

Consequently, professionals need to be seen to be constantly developing themselves and (as a result) the profession as a whole in order that clients can be confident of the maintenance of professional ability in such an environment. In fact, this has always been a key aspect of professionalisation. For example, physiotherapists are governed by a set of rules of conduct, the first of which requires them to practice only in areas in which ‘… they have established and maintained their ability to work safely and competently’ (Chartered Society of Physiotherapy, 1996, p. 5).

CPD has also been extremely important to professionals in terms of their individual career development. For instance, if a healthcare professional wishes to move into an area of specialist practice, they have traditionally been expected to undertake a formal programme of education in order to demonstrate competence. This effect has been amplified as professions such as nursing and physiotherapy have moved to graduate status, with schools of healthcare studies now absorbed into the university sector.

Lastly, but of increasing importance at this time, is the perceived link between the quality of professional service and CPD. It is argued, particularly in a healthcare setting, that the safety of clients can only truly be maintained if professionals are committed to constantly updating their knowledge and practice.

In an analysis of nursing staff undertaking post-qualification education, Rogers highlighted an anxiety about professional competence when she noted that:

Issues of confidence, support, awareness of the need for recognition in a chosen speciality, the need to fill the ‘gaps’ left by basic training were all reasons for taking a post-basic clinical course. It is salutary to remember that fewer than 10% of qualified nurses complete one or more of these particular courses. [Certificated post-qualification short courses – M.C.] The needs expressed by respondents cannot be confined to course members. (Rogers, 1987, p. 79)

Since the time of that study, many healthcare professions have assumed graduate status, and CPD is now seen not merely as an optional ‘add-on’ but as a central part of being a professional. Nevertheless, it surely underscores the importance of professionals ensuring that their development continues well past the completion of qualifying education in order that clients might be reassured as to the quality of the service they are receiving.

A second aspect of the issue of CPD and quality relates to what might broadly be described as the ‘New Consumerism’ in society, a phenomenon that is beginning to manifest itself particularly strongly in the NHS. For example,

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the New Labour government has put clinical effectiveness at the centre of its NHS reforms: it is also currently building the concept of ‘competence’ into its review of the statutes governing healthcare professions.

Moreover, it is increasingly the case that consumers of professional services themselves are far more willing to express their precise needs in this regard. Partly, this can be ascribed to the fact that, by and large, clients are a good deal better informed about issues, particularly in relation to healthcare, and are therefore more confident in making their wishes known.

CPD in Practice

One of the key writers on the topic of professional activity has stated that it has traditionally been largely governed by a ‘technical rationality’ that ‘… holds that practitioners are instrumental problem solvers who select technical means best suited to particular purposes’ (Schön, 1990, p. 3).

Writing about the teaching profession, this point is expanded upon by Elliott, who suggests that the rationalist view of professional activity,

... [E]mphasises the image of the teacher as a rational-autonomous professional. Underpinning this image is the basic principle of rationalism; namely, that good practice transcends the biased and prejudiced practical cultures of everyday living when it is derived from a theoretical understanding of educational values and principles. (Elliott, 1993, p. 16)

In such a view, of course, CPD is entirely voluntary, as any prescription in this regard would weaken the fundamental premise of the autonomous professional. This is an indication of one of the major tensions in regard to professional self-reliance and external compulsory requirements that CPD be undertaken, namely that in the traditional model the individual professional is de facto the ultimate judge of their own need for updating, upskilling or development.

There are additionally a number of problematics in regard to the current conception of CPD. First, there is the question of whether CPD should assume an input- or outcome-based approach. The former simply formally acknowledges that the individual has undertaken some sort of prescribed CPD activity, while the latter urges that practitioners analyse their learning needs, identify (or create) a suitable learning opportunity, and assess whether their learning needs were satisfied by that activity. The latter is also strongly oriented towards experiential, rather than classroom, learning.

Second, there is the thorny problem of monitoring and measurement of CPD. An input-based model addresses this by simply recording course attendance, rather than trying to assess the outcomes of participation. Indeed, this is precisely the sort of structure that the nursing profession has opted for with its PREP system.

Requirements here are that ‘Every three years, each individual nurse, midwife or health visitor who wishes to maintain registration must: fill in a notification of practice form; complete five days of study activity; [and] maintain

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a personal professional profile’ (Wallace, 1999, p. 117). Although PREP makes clear that it is five days of study activity, rather than five study days, the focus is clearly very quantitative.

Measuring in an outcomes-based model is a good deal more difficult, and can be considerably more time-consuming for the individual professionals seeking to record their CPD. Indeed, it requires a very different approach on the part of participants to the question of learning, which in such a model is largely innovative and thereby departs from the traditional view of education, and the measurement and recording of that activity.

Lastly, there is the difficult question of the relationship between CPD and professional competence. As noted above, the Government’s expectation at this time is that healthcare professionals should be able to demonstrate competence in order that they be allowed to continue to practise. The moot point is how Government intends, first, to define and, second, to measure that competence.

Some writers have made a connection between structured competency frameworks, such as occupational standards, and professional competence. For example, it has recently been argued that:

There are many aspects of professional practice, its evaluation and its development, for which benchmarks in the form of occupational standards would be useful in setting and negotiating expectations: job descriptions, appraisals, personal development plans, the design of CPD activities, interprofessional collaboration, communication between individual professionals and their employers and between professional associations and the public. In some cases the standards would serve a normative function and in other cases, as a point of reference for comparisons in which modifications, additions and deletions would be explained and justified. (Eraut et al, 1998, p. 8)

The problem here is that such standards and competency frameworks do not lend themselves well to professional activity for a number of reasons. First, occupational standards are very much a mechanical measure and, as such, do not best fit the assessment of professional competence, which in practice involves individual and specialised judgements that relate specifically to each unique consultation.

Second, the rigidity of occupational standards in general hinder flexible application and, despite a general enthusiasm for them in the NHS, they are consequently not well suited to the dynamic environment of the modern healthcare sector. This is, in fact, very well demonstrated by a body of work entitled ‘Standards in Common’, an occupational standards framework developed for and by six of the Professions Allied to Medicine (PAMs) (Care Sector Consortium, 1997).

Third, in light of the above, it is also generally observable that occupational standards are very much process-focused, rather than patient-centred. Admittedly, the ‘Standards in Common’ were generic standards, looking primarily at general rather than clinical competence. However, it does mean that

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it is difficult to integrate occupational standards with professional standards, given their very different approaches.

Lastly, as with all such schedules of competency, the occupational standards are based on an attainment threshold. As such, they have a tendency towards stasis, insofar as their structure does not encourage continuous development.

Moving away from these practical considerations to a more philosophical level, there is the delicate point of how far it is acceptable for a politicised state and its agencies to interfere with and control bodies of people who enjoy a nominal autonomy in terms of their professional practice.

Beyond the question of acceptability, there is a more profound and far-reaching issue of whether it is actually more appropriate for professions, particularly in the area of healthcare, to be effectively ‘de-recognised’ and hence totally integrated into the healthcare workforce. In essence, is ‘professional status’ in the human services simply an archaic vestige, anachronistic in our post-modern age?

To return to the issue of CPD and competence, the obvious shorthand in this regard would be to suggest that undertaking some form of CPD is evidence of competence. However, this is patently false: completion of CPD activity in no way guarantees that the individual is competent. Moreover, it may well be the case that those who are competent will have developed their capability through methods other than accessing formal educational opportunities that come under the umbrella of CPD.

This is, in fact, a crucial point. Put simply, it is possible to argue that the very act of undertaking professional activity (as opposed to activity that is routinised and mechanistic) means that the individual is intrinsically competent. In effect, it can be inferred that the mere existence of a concept such as CPD, and an external requirement that professionals undertake CPD activity, suggests that those individuals are no longer working professionally. The following section explores this idea in more detail.

CPD as Practice

To open this section, we need to remind ourselves of the traditional view of professional activity. Schön has argued that:

According to the model of Technical Rationality – the view of professional knowledge which has most powerfully shaped both our thinking about the professions and the institutional relations of research, education, and practice – professional activity consists in instrumental problem solving made rigorous by the application of scientific theory and technique. (Schön, 1995, p. 21)

In trying to secure professional status, a number of disciplines have sought to incorporate the rigour of ‘scientific method’ into their functioning. This appropriation is less an acknowledgment of the innate usefulness of such an approach as a reflection of the value accorded to it by society. Indeed, in the

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context of healthcare, it can be argued that there has an almost exclusive focus on the science of those professions (mirroring medical discourse), and a serious neglect (at least until quite recently) of the artistry involved in their practice.

In fact, many writers in this area have pointed out the level of complexity that exists in regard to professional activity. For example, Schön argues that in regard to professional practice there is a ‘high ground’ of precise responses to manageable problems and a ‘low ground’ of the range of professional action that defies technical solution, relating to issues such as uncertainty, uniqueness and value conflict (Schön, 1990, p. 3).

This type of professional activity is often referred to informally as ‘black box’ issues. In essence, the argument runs that some intangible activity takes place in the head of the individual as they undertake professional activity that subtly imbues that action with a professional quality. The difficulty is demonstrating the nature of that ‘black box’ activity, and the way in which it distinguishes professional from any other occupational action. The argument has developed that it is ‘reflection’ that is the key activity that takes place in the seemingly impenetrable gloom of the mysterious ‘black box’.

There is a recognised philosophical basis for this argument, deriving from a range of schools of thought. A useful starting point is John Dewey, who makes plain that:

Reflection is not identical with the mere fact that one thing indicates, means, another thing. It commences when we begin to inquire into the reliability, the worth, of any particular indication; when we try to test its value and see what guarantee there is that the existing data really point to the idea that is suggested in such a way as to justify acceptance of the latter. (Dewey, 1933, p. 11)

Such a view clearly suggests that there is a difference in practice between merely doing something in a work context, and thinking in greater depth about whether there is sufficient support for the practitioner to judge that it is necessarily the right action. It could be argued that it provides an insight into what might distinguish professional from more mechanical activity.

Gilbert Ryle extends our understanding of reflection (and, by inference, professional thinking) by arguing that the division of thinking about and performing an action is actually a false dichtomy:

What distinguishes sensible from silly operations is not their parentage but their procedure, and this holds no less for intellectual than for practical performances. ‘Intelligent’ cannot be defined in terms of ‘intellectual’ or ‘knowing how’ in terms of ‘knowing that’; ‘think what I am doing’ does not connote ‘both thinking what to do and doing it’. When I do something intelligently, i.e., thinking what I am doing, I am doing one thing and not two. My performance has a special procedure or manner, not special antecedents. (Ryle, 1963, p. 32)

Providing a useful example to give substance to this view, Ryle argues that a boy who might be able to recite the rules of chess but is not able to play practically is not said to know how to play chess. However, a boy who can play

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in practice but is unable to recite the rules is said to be able to play. The ‘knowing’ is demonstrated in the effective ‘doing’ of an activity (Ryle, 1963, p. 41).

Schön has sought to apply this philosophical view directly to the issue of professional practice. In this schema, Ryle’s conflation of knowing/doing is referred to as ‘knowing in action’ (Schön, 1990, p. 25). But, argues Schön, the professional does not simply demonstrate ‘knowing in action’: they also show the important capacity to ‘reflect in action’.

In talking of ‘reflection in action’, Schön makes clear that it is a dynamic process of reviewing actions in the midst of their performance without necessarily interrupting those actions. The author makes evident that ‘When intuitive, spontaneous performance yields nothing more than the results expected for it, then we tend not to think about it. But when intuitive performance leads to surprises, pleasing and promising or unwanted, we may respond by reflecting-in-action’ (Schön, 1995, p. 56).

A good example of this ‘reflection in action’ is the way in which we make constant, almost imperceptible adjustments as we undertake an action, such as sawing along a straight pencilled line on a piece of wood. The mental processes of following the line are buried deeply in the performance of the activity: moreover, we are constantly adjusting the performance on a continuous basis to ensure that we are following the line, altering the saw stroke to take into account the grain of the wood, and so on.

However, Schön extends the process a little further by suggesting that it is possible for performers of actions to not simply ‘reflect in action’ but also subsequently to ‘reflect on action’. Boud et al usefully explore this distinction in a review of the link between reflection and learning:

Why is it that conscious reflection [that is, reflection on action – M.C.] is necessary? Why can it not occur effectively at the unconscious level? It can and does occur, but these unconscious processes do not allow us to make active and aware decisions about our learning. It is only when we bring our ideas to our consciousness that we can evaluate them and begin to make choices about what we will and will not do. (Boud et al, 1985, p. 19)

This formulation clearly indicates the intrinsic and vital link between reflective practice and the sort of genuine learning that is likely to alter the learner’s perceptions and consequently engender (where appropriate) changes in behaviour. In fact, Schön has argued that:

When someone reflects-in-action, he [sic] becomes a researcher in the practice context. He is not dependent on the categories of established theory and technique, but constructs a new theory of the unique case ... he does not separate thinking from doing, ratiocinating his way to a decision which he must later convert to action. Because his experimenting is a kind of action, implementation is built into his inquiry. (Schön, 1995, p. 68)

Such an approach to reflection, and learning from reflection, will clearly tend to facilitate the development of continuing improvements in quality.

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Methodologically, this is sometimes referred to as Action Learning (McGill & Beaty, 1992), an approach that is cognate with the Action Research model that has become particularly popular in healthcare.

Reflection in and on action will encourage practitioners to interrogate critically the ‘common sense’ premises that underpin their day-to-day actions, and the justifications and nature of their particular work routines. All of which is vitally important in ensuring that the quality of institutional (and increasingly performance driven) healthcare provision, for example, remains constantly under review.

Indeed, the application of reflective practice to healthcare professions, particularly nursing, has been widely acknowledged. In particular, a number of studies have looked at how reflection can be integrated into the qualifying education that nursing students undertake (Wong et al, 1997). At least one study demonstrated that the learning around a chosen topic of a group of students using reflective methods was just as good as those taking a conventional approach (Lowe & Kerr, 1998).

In a practice setting, the experience of the West Dorset Nursing Development Unit indicates the true value of reflection as a means for staff to learn and develop in the healthcare environment. For example, it is reported that ‘The process of reflection helped the nurses shift their understanding of sickness away from the medical diagnosis and pathology to seeing patients as people facing stress, disease and pain – factors that had altered the patient’s perception of themselves and their lives’ (Graham et al, 1998).

Consequently, if CPD in healthcare is to have genuine usefulness in terms of both the development of staff and the continuous improvement in service quality, it needs to be concerned with encouraging a culture of reflective practice, developing easily navigable processes that assist with the formalisation of the activity, and creating tangible means for the systematic recording of that reflection.

Although such an approach generates its own difficulties, it will allow these professions to move away from the problematic input-based model. The latter is, with its short course orientation, seen to be a means of addressing a range of organisational constraints in terms of time and funding by providing a value-for-money learning package (Benn & Nicholas, 1996, p. 150).

However, through its economy, it is compelled to neglect the individual learning needs of all the participants. Moreover, it is invariably the case that such training interventions are employer-driven, defined by the employer’s perception of the learning needs of an entire workforce. Additionally, this model neglects the range of learning styles that individuals have, in favour of a blanket approach (Benn & Nicholas, 1996, p. 151). Ultimately, the quality of such interventions, in regard to their true ability to achieve genuine learning outcomes, is questionable.

The input-based model of CPD also carries within it a major paradox, identified by Aspland (1996) in his work on workplace enquiry. He argues, in critically reviewing the issue of bridging theory and practice, that ‘A major

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problem for course designers exists in the tension between structured course content – that conceptual knowledge and competence relating to the occupational function – and the process of systematic and rigorous enquiry and analysis necessary for the development of situational understanding’ (Aspland, 1996, p. 139). In contrast, reflection usefully conflates theory and practice.

The Question of Method

A major problem with reflective practice is its vagueness as a concept. To a large extent, the preceding section’s attempt to create a coherent whole from the work of a range of writers is an act of syncretism. Nevertheless, there is increasingly a consensual view developing as to precisely what reflective practice means. This is arising from the attempts that exist to apply the concept practically.

There are a number of key points that need to be made about the application of reflective practice. In a seminal review of the literature of the time, Atkins & Murphy acknowledged the theoretical variations that existed between writers on the topic, yet were still able to identify skills that the reflective practitioner requires: they are self-awareness, description, critical analysis, synthesis and evaluation (Atkins & Murphy, 1993).

There is also an observation that reflection should be geared towards double- rather than single loop learning. These concepts derive from the work of Argyris & Schön, who suggest that ‘In single-loop learning, we learn to maintain the field of constancy by learning to design actions that satisfy existing governing variables. In double-loop learning, we learn to change the field of constancy itself’ (Argyris & Schön, 1974, p. 19).

Applied to a nursing setting by Greenwood, these concepts become less abstract and more understandable:

... [S]ingle-loop learning has enormous limitations. Its focus on the means-end effectiveness of action could lead students to do the wrong things rightly (or correctly); this would be a sad irony indeed. What this clearly implies is that whenever reflective exercises are undertaken, irrespective of the expertise of the reflecting agents, some examination of the underpinning values and norms, and the social relationships/structures that render them meaningful, must be undertaken. What this also implies is that single-loop learning represents technical rationality’s colonization of reflective practice. (Greenwood, 1998)

Achieving such insight is never going to be easy, particularly where practice has become routinised and consequently reflection may merely occur at a superficial level. However, it has been noted that workplace ‘habitualisation’ has both a negative and a positive aspect: in the former regard, it results in routine and a ‘coping dominated practice’, while in the latter case it means that the practitioner has sufficient mastery to allow them to move on to seek new learning opportunities (Heath, 1998a).

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With regard to systematising one’s reflection, there is clearly great value in maintaining a practice journal. There are a number of ways of recording reflection (or material that might provide the basis for future reflection), and each reflecting agent is likely to develop a system that best suits their style and specific learning needs.

The use of such a tool is in no way unproblematic: issues of confidentiality surface; there is a tendency to focus solely on negative aspects of practice; completion of such a journal is time-consuming; issues of memory and recall are particularly difficult to negotiate; and the level of introspection involved appears to exclude multidisciplinarity (Mackintosh, 1998).

In light of the above, there is perceived to be great value in the sharing of reflection, through systems such as professional (often referred to in healthcare as clinical) supervision. It is seen to be a way in which to encourage the reflecting agent to take a totalised view of clinical activity, rather than simply become locked into specific events (Andrews, 1996). It also allows a regular and free exchange of experiences among a small group of peers.

One way in which these supervisory groups can approach reflective practice, aside from journal writing, synthesis and analysis, is through critical incident analysis. As Brookfield explains:

Critical incidents are brief descriptions written by learners of significant events in their lives ... As a means of probing learners’ assumptive worlds, the critical incident technique is rooted in the phenomenological research tradition and presumes that learners’ general assumptions are embedded in, and can be inferred from, their specific descriptions of particular events ... [T]he purpose is to enter another’s frame of reference so that the person’s structures of understanding and interpretive filters can be experienced and understood by the educator, or a peer, as closely as possible to the way they are experienced and understood by the learner. (Brookfield, 1990, pp. 179–180)

Clearly, there is a range of techniques around reflective practice, the practical application of which is serving to define the concept. Overall, however, the strength of the approach, as was noted elsewhere in this article, is its capacity to adapt flexibly to the learning needs and style of the individual.

The Problem of CPD as Practice

Of course, this whole question of reflective practice is not without its detractors. Some of the practical objections that exist to the approach have been rehearsed in the above section on method. In her critical review of the technique, Mackintosh concluded that ‘... [T]he use of reflection as a learning strategy or tool for professional development is seriously flawed. Its terms, concepts and framework for implementation lack basic clarity. Where it has been attempted, within both education and clinical settings, its impact is unclear ...’ (Mackintosh, 1998).

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This view is countered by the growing volume of theoretical and research literature that makes a strong case for the use of reflective practice. In fact, it is possible to argue that objections to the approach have more to do with the way in which it radically departs from traditional ideas of professionalism (with the emphasis on technico-rational responses by discrete and autonomous professionals), and from the standard model of teaching and learning.

An additional concern about reflective practice is the way in which it can lead to a sense of powerlessness among professional staff. If one’s critical reflection on action raises issues that cannot be resolved within the extant discourse of practice and the environmental constraints that practitioners face, then disillusionment can follow.

However, Heath (1998b) notes that awareness in this regard can have a dual effect. Certainly, it can lead to a sense of demoralisation, but it can also act as a prompt to promote action. The critics’ focus on the former seems to lead inadvertently to an argument in favour of stasis: ‘That’s how it’s always been, there’s nothing that can be done to change it’.

The key here would seem to be that reflective practitioners need to be clear at the start of the formal process that there will be some things that fall within their control, and others that do not. The concentration on microcosmic changes that are achievable and realistic will have a cumulative effect on the macrocosmic picture of practice.

Perhaps of greatest concern is the question of the way in which reflective practice has been taken throughout this article to be a (if not the) defining characteristic of professional action. There is, after all, a strong argument in favour of all who are involved in ‘in-person service’ in healthcare to reflect on their practice, regardless of their occupational status.

It has been argued that there is an intrinsic link between reflective practice, learning and development, changes in behaviour, and consequently improvements in quality of service. Insofar as a great deal of the hands-on care that patients and clients now receive is from unqualified support staff, such as Healthcare Assistants, then surely they too should be encouraged to reflect in this systematic way?

The answer to this rhetorical question is resoundingly in the affirmative. But this means that an area for exploration, falling beyond the purview of this article, is the qualitative difference (if any) that exists between Schön’s concepts of knowing-in-action and reflecting-in- and reflecting-on-action (that is to say, the characteristics that distinguish professional activity) and the structured reflection that staff without a professional background might undertake.

From this, it might be possible to hypothesise that the ‘black box’ explanation of professionalism is a red herring, and the true distinction between professional and non-professional activity in a given context such as healthcare might simply be the individual’s opportunity to colonise a body of knowledge. These are manifestly issues that require a great deal more consideration, because they have wide-reaching implications for matters such as the human resource configurations and the resource implications of healthcare delivery.

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Finally, it must be acknowledged that reflective practice forms part of a far wider view of learning and development, namely the lifelong learning (LLL) agenda. In fact, LLL has seditious potential, insofar as it subtly undermines the current educational discourse. For example, it subverts the prevailing view of the relationship between teacher and learner, where the latter is utterly beholden to the former, who is imbued with authority on the basis of their supposed relationship to a defined body of knowledge.

Indeed, it might be argued that LLL, with its focus on personal and group development, undermines the traditional coupling of learning with the simple accretion of knowledge. It produces a model of social education that unhitches the learner from a rigid body of knowledge bounded by arbitrary social constructs, in favour of a view of learning that entails critical interpretation of experiential circumstance and action.

To what extent professions, which are, after all, discursively defined groups that rely for their status on those self-same bodies of knowledge, are able to accommodate a view of learning and development that is disaggregated from that body of knowledge is questionable.

Conclusion

Houle notes that ‘In every situation in which the professional works, complexities are present; otherwise trained talent would not be required’ (Houle, 1980, p. 45). This article has concerned itself with what it is that equips a professional to manage those complexities, and how those abilities can be continuously developed. A significant link has been strongly made between that development and the continuing improvements in quality of service that are so essential, particularly in relation to healthcare.

There is clearly a range of drivers that are compelling healthcare professionals to take on board CPD. Regrettably, the general approach to the topic has been one that focuses primarily on input rather than outcome: it has taken a formal educational tack, rather than an experiential one.

This is especially disturbing insofar as this article has argued that professional activity is distinguished from other occupational behaviours by the centrality of reflection as a key component of practice. Consequently, this activity, and specifically the formal methods and techniques that serve to define it in practice, should be central to the idea of CPD.

Of course, such an approach is not without its detractors, and some of their points are well made. However, the shortcomings of reflective practice need to be explored in zones of action in which it operates, namely in practice. There is still much research to be done in this area.

Equally, the question of whether reflection is truly the defining characteristic of professional activity is moot, and requires far more exploration. This is not simply a matter of dry, philosophical debate. After all, healthcare is increasingly delivered by a workforce made up of both professional and

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unqualified support staff; the latter are more and more involved in the provision of the ‘in-person services’ that patients and clients receive.

The question, then, is what defines those two groups, both separately and in relation to each other. If we begin to encourage unqualified staff to reflect, are we actually equipping them with professional skills? If so, then they will patently be functioning at a professional level. Is professionalism defined merely by the individual’s relationship to the inseparable concatenation of a body of knowledge and its practical application? If so, should we expect support staff to perform procedures in a mechanical fashion rather than on the basis of knowledge-in-action? Indeed, are those staff actually knowing-in-action when they practice?

This is work for the future. The argument here is that CPD needs to be primarily concerned with encouraging healthcare practitioners to become reflective practitioners. Traditional education and training interventions have their merits, but they are also profoundly limited, insensitive to the needs of the individual, and of questionable effectiveness.

The philosopher Jurgen Habermas, whose work inderpins a great deal of thinking about reflection, talks about non-reflexive learning as taking place ‘… in action contexts in which implicitly raised theoretical and practical validity claims are naively taken for granted and accepted or rejected without discursive consideration’ (Habermas, 1976, p. 15). In contrast, reflective practice liberates the learner to analyse experience, interrogate it comprehensively and learn from it continuously; it is central to the development of the person, of the individual professional in practice, and of the professions themselves.

Correspondence

Mark Cole, Education Adviser, Chartered Society of Physiotherapy, 14 Bedford Row, London WC1R 4ED, United Kingdom (colem@csphysio.org.uk).

References

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Schön, D.A. (1990) Educating the Reflective Practitioner: towards a new design for teaching and learning in the professions. San Francisco: Jossey-Bass.

Schön, D.A. (1995) The Reflective Practitioner: how professionals think in action. Aldershot: Arena.

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Wong, F.K.Y, Wong, M. & Kan, E. (1997) An Action Research Study into the Development of Nurses as reflective Practitioners, Journal of Nursing Education, 36, pp. 476–481.

Other works consulted

Boud, D., Keogh, R. & Walker, D. (1985) What is Reflection in Learning?, in D. Boud et al (Eds) Reflection: turning experience into learning. London: Kogan Page.

Brook, V. & Champion, E. (n.d.) The Reflective Nurse Practitioner. Tiverton: Fair Way Publication.

Durgahee, T. (1998) Facilitating Reflection: from a sage on stage to a guide on the side, Nurse Education Today, 18, pp. 158–164.

Higgs, J. (1992) An Experiential Learning Approach to Developing Clinical Reasoning Skills, in J. Mulligan & C. Griffin (Eds) Empowerment through Experiential Learning: explorations of good practice. London: Kogan Page.

Kolb, D.A. (1984) Experiential Learning: experience as the source of learning & development. New Jersey: Prentice-Hall.

Mezirow, J. (1990) How Critical Reflection Triggers Transformative Learning, in J. Mezirow and Associates (Eds) Fostering Critical Reflection: a guide to transformative and emancipatory learning. San Francisco: Jossey-Bass.

Scanlan, J.M. & Chernomas, W.M. (1997) Developing the Reflective Teacher, Journal of Advanced Nursing, 25, pp. 1138–1143.

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