Becoming Reflexive Practitioners

For those of us involved in creating this resource, the words “haunting” and “reflexive practice” are two sides of the same coin. Reflection is a state of mind, an evolving component of professional practice and growth and a way of continuing ongoing learning (Bolton, 2010). Reflective practice is the conscious effort to pause and think through events in practice and develop insights into why something happened or didn’t happen, to understand our own blind spots in relation to others. There is critical value and indeed—necessity—in the use of reflexivity for everyone who works in the applied health sciences. Reflexivity is engaging in strategies, like those presented in this workshop, that assist us to reflect and to question our own attitudes, prejudices and hidden implicit biases.

Reflection permits a purposeful act of thinking through an experience or health related encounter at a deeper level and is essential if one is to understand the layered meanings of the situation and to grow wiser from it.  “Reflective learning is the process of internally examining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self and results in a changed conceptual perspective” (Boyd & Fales, 1983, p.113). Reflective practice in and of itself should haunt us. It should haunt us, because we are in significant positions of power over the people that we serve as health professionals. And haunt us-because it requires us to go deep inside ourselves in ways that sometimes challenge the worldview we hold that is familiar and comforting to us. It makes us ask hard questions: “Could I be racist?” “How could I have caused harm when I didn’t mean to?” And “Aren’t I a good person?”  These are “haunting questions” and they are a catalyst to reflective practice.

Reflective practice is a deliberate way of critically unpacking a situation or experience to learn from, creating new awareness and knowledge or skill development, to improve or further develop professional competency and provide compassionate, ethical and humane practice (CNO, 2015; DunnGalvin, Cooper, Shorten, & Blum, 2019; Taplay, O’Keefe-McCarthy, & Tyrer et al., 2021). Typically, it may be carried out individually, in a peer-to-peer dyad or within a group reflection. Reflective practice allows health care professionals the opportunity to reflect on their practice and to evaluate strengths and weaknesses, identify areas for improvement: to constantly re-evaluate the care they provided to another (Taplay et al., 2021). Within medicine and nursing over the decades, reflective practice has been understood to augment student self-directed learning and motivation, promote integration of theoretical concepts to practice (Davies, 1995), enhance experiential learning (Atkins & Murphy, 1993), improve self awareness and facilitate greater quality care, individualized treatment and more accurate diagnoses (Bonde, 1998; Brookfield, 2000; Clouder, 2000; Coombs, 2001). Alternatively, without ongoing reflective practice that challenges our thinking, reasoning, assumptions and judgements can translate into missed or inappropriate diagnosis and treatment decisions and disparate and or privilege levels of care. Health care professionals need to be intentional to use reflective practice and participate in reflexive exercises and activities.

Seeking out effective learning strategies such as providing this applied theatre dialogic educational encounter in class is a direct example of engaging in reflexive practice. Reflexivity helps us find ways to question our own preconceived notions, ideas, values and thought processes. It enables us to examine our own biases, assumptions and habitual actions and reactions to situations and helps us to understand the complexity of our role(s) in relation to others (Bolton, 2010). Reflexivity allows us to examine, for example, how we— seemingly unknowingly—help create professional hierarchies or social or professional structures and systems that promote privilege, exert power or normalize exclusion or marginalization of some individuals or social groups over others. These actions are often different from what we espouse or what we believe our values stand for (Cunliffe, 2009). By engaging in reflexive activities and practices, we can then unlearn in order to learn and to relearn a more ethical and intentional way of providing care.

Helping Our Students to become Reflexive Practitioners, with Dr. Sheila O’Keefe-McCarthy, RN BScN MN PhD CNCC(C) 

Written Transcript of Video

Hello, my name is Dr. Sheila O’Keefe-McCarthy, I am an Associate Professor at Brock University in the Department of Nursing. I have been privileged to be able to work in clinical practice in the various areas of GI medicine, neurology, hematology, cardiology, in the intensive care and the emergency wards. I have always been very privileged to work with individuals on their health, illness, wellness and death trajectories. I am delighted to speak with you a little bit to identify how important it is for us as health care professionals-how to use our ability to think reflexively to uncover, perhaps our implicit biases.

For those of us involved in creating this resource for you, the words “haunting” and “reflexive practice” go together, they are kind of two sides of the same coin. Reflection as you well know, is a state of mind, an evolving component of professional practice that allows us to grow in an ongoing continual way. Reflection permits that purposeful act of thinking through an experience that might have impacted the care that we gave, thinking about the care we gave and the health-related encounter at a deeper level. It allows us to understand that meaning, the rich layered nuances that perhaps we were blind to. Reflective learning is the process of internally examining and exploring an issue of concern, triggered by our clinical experience (Boyd & Fales, 1983). This practice reality is in and of itself-should haunt us. I say Haunt us, because we are in a significant position of power over some one. And haunt us because it requires us to go deep, deep inside ourselves in ways that sometimes challenges our worldview or what we hold as familiar or comfortable to us. It challenges us, it makes us ask those hard questions: Could I be racist? And to say things like “But I didn’t mean any harm” or “But I’m a good person.” These are the kinds of questions as health care providers and people that engage in the health sciences, these are “haunting questions” and they are the actual impetus, a catalyst in doing reflexive care.

For me over the years, a foundational core attribute that guides the health care encounters that I engage in, is the word “care.” When I think of care, I think health care cannot really happen without care. What does it mean to care for someone, or to provide care to someone… more importantly, are we able to provide unbiased care? As health care professionals our actions, inactions and thoughts (both conscious and unconscious) impact the care that we give and the care that we withhold. We know that from research and clinical practice that research has documented and demonstrates unrecognized and uncontested or unchallenged implicit biased encounters that have been in health care result in health inequities and disparities. Entrenched Implicit Bias encounters, they create poorer health related quality of life for individuals, worse diabetic, chronic care and disease and pain care management related care. Less colorectal, breast cancer and in my area of research cardiovascular screening. The ways in which we think as health care professionals really does impact the care that is received by others. This is important to think about.

We are guests, as I have said, in the individual’s life. Our invitation comes with that person seeking health care for a health-related symptom, issue or problem. In order to provide care for another, one needs to understand the meaning within that human experience and how (or not) our implicit biases may have shaped and or impacted that encounter. We achieve this knowing by incorporating reflective practice and reflexive activities within our professional work.

So hopefully by seeking out effective learning strategies such incorporating an applied theatre dialogic educational experience allows you to operationalize or use reflective practice in a very focused way. This use of reflexivity, is a strategy to help us question our own preconceived notions, ideas, values, thought processes, biases and assumptions that we have not examined thoroughly. It will help us to understand then, the complexity of of our role within the relationship to others and how we impact care.

Some last thoughts, to be reflexive means that we actively, it is courageous work to engage in confronting what disturbs us. Reflexivity allows us to examine, for example, how we – seemingly, unknowingly, help create professional hierarchies or social or professional structures and systems that promote privilege, exert power or normalize exclusion or marginalization of certain kinds of individuals (different from what we espouse or think we believe that our values stand for). Something to think about. In being reflective and engaging in reflexive activities we can unlearn to relearn a better way of being ethical health care professionals. Thank you very much.