Reflective Practice - Re-connecting with a lost art might ignite a revolution in training

Excerpt: Service users and carers are likely to benefit most when they are served by a workforce that is motivated and enthusiastic about its work, that recognizes and works to its strengths, that feels supported, and is able to reflect on practice as an on-going function of its own development. Within this picture training as a function has an important role to play, but can easily become a wasted resource if it is poorly focused and lacks clarity of purpose. Furthermore, service users and carers possess invaluable experiences and skills that can contribute to the development of the workforce. So, why does it so often feel like reflective practice and genuine involvement are lofty ideals belonging to a parallel universe?

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'Practice Development' in Mental Health

The article was below was written by me in 2001, which is a long time in mental health (it's quite a long time full stop!) But I am include it here as it was an important piece for me at the time and remains pertinent today, I think.

The Need

The education and training of the mental health workforce needs to change in order to keep pace with how modern mental health services need to be delivered. The Workforce Action Team has produced a Capable Practitioner report, which outlines a framework of capabilities that broadly encompass the knowledge, skills and attitudes required by the workforce of mental health practitioners. Many organisations have commissioned the growing range of flexible post-graduate education courses, which seek to target and customise training to meet local need. These have achieved a limited success at credentialing practitioners, through successful attendance levels and completion of set assignments. However, transferring the dissemination of information (the evidence) into routine clinical practice remains the next challenge.

Practice Development has now become an essential challenge to the workforce, of linking the research-based evidence of clinical theory with the practice-based evidence of clinical reality. Training initiatives should no longer stand-alone, they need to be the initial stage of a fuller package of education and support. The aim of developing high quality services will be achieved by going beyond just delivering the message, to close modelling and supervision of its implementation within the available resources and creativity of the personnel in local services.

The on-going credibility of the trainers will be sustained by closer contact with the point of service delivery, and the publishing of ideas and evidence from routine clinical practice, not just artificially resourced research programmes. Credibility for local and national services requires a move on from the theoretical frameworks of a Capable Practitioner, to the practical realisation of Creative Capability (David Juriansz). The individual practitioner, team and wider network of support are clearer about effective ideas, and in the effectiveness of how they function.

The Idea

‘Practice Development’ is an outcome-driven process supporting the implementation of recognised good practice into the routine daily functioning of individual practitioners and teams. Its overall aim is the improved quality of care and support offered to service users. Specific goals include:

• Identifying and translating the ideas from ‘evidence-based practice’ (messages through training programmes) into the realities of ‘practice-based evidence’ (realities of routine clinical practice).
• Recognising and supporting elements of existing good practice.
• Raising individual and collective standards of practice, through managing, modelling and supporting the implementation of changes in practice.
• Examining individual and collective attitudes underpinning the philosophy of care, specifically the implementation of real service user involvement.
• Promoting an understanding of the links between, and co-ordination of, the different components of comprehensive mental health services.

Training is an essential component for supporting effective contemporary mental health practice, but its focus on dissemination of messages only partly achieves the aim of changing practice. Even the very well evaluated training workshops offer no clear guide as to how the ideas, thoughts and discussions will be subsequently incorporated into changes in practice beyond the workshop setting. Informing service managers of the ideas, and reviewing practice in the workshop setting, are further methods of promoting good practice, to a limited degree; but offer no further evidence of how the people attending the event are likely to bring about real change. Portfolios of evidence to support developments in individual practice provide a better snapshot, but are often only a picture of one person’s chosen examples of what they wish to divulge; rarely offering a guide to the practice across a team.

It is the philosophy of ‘Practice Based Evidence’ that truly effective changes to clinical practice, in line with the messages from the research, can only be achieved through the sharper focus offered by a presence alongside practitioners and teams in their daily routines. This requires much the same approach as would be expected in the work with individual service users:

• Engaging a trusting relationship with practitioners and teams.
• Establishing a baseline of current knowledge, skills and attitudes.
• Reflecting existing strengths and good practice.
• Suggesting, modelling and supporting ideas for change.
• Monitoring and measuring changes.

The Practicalities

'Practice Development' requires a flexible responsive approach to the needs identified in a particular individual and team. Like most innovations, a certain amount of the challenge in the process is about working it out as you go along. Standardisation is necessary to implement the perceived wisdom of good practice from national and international research studies, but too much negates the reality of the local circumstances and constraints in which people have to operate. The trick is not to lose the important elements of the messages about effective practice in the balance of evidence and practice.

The challenges for successful implementation require the manager of the process to perform many of the following functions (not an exhaustive list):

• Being a regular presence, working alongside people, as time and consistency are essential elements in the change process.
• Supporting all functions of the team and all team members, managerial and clinical (supporting the team leader, not taking over), and providing a trusting impartial conscience and inquisitor within the team.
• Chairing meetings, to propose changes through constructive discussion e.g. implementing a strengths approach within a broadly problems-orientated culture.
• Shadowing and co-working a range of planned and unplanned interventions (assuming the roles of guide and mentor, as required); what are the aims of a specific contact? What if it doesn't go to plan? What contingency plans do you have in place? What have you learned after the event?
• Encouraging active personal reflection through a process of in vivo supervision.
• Reviewing the administrative process of care e.g. note-keeping and other forms of required documentation.
• Reviewing existing policies and procedures e.g. Care Programme Approach and risk management, defined client groups and caseload management.
• Identifying and working with resistance.
• Providing copies of relevant educational materials e.g. articles, references, clinical tools.
• Providing in vivo training that responds to the immediate needs of the individuals or teams in a client-centred way, rather than planning a series of training workshops to fulfil a pre-determined programme in a service-centred way.
• Promoting service user involvement and evaluation, as well as Practice Development Manager reports of progress and evaluation.

Steve Morgan
Practice Based Evidence
October 2001.