A whole systems approach to developing reflective practice across healthcare organisations, writes Natius Oelofsen
The cost of healthcare in industrialised countries is set to rise in the next few decades due primarily to the increasing cost of new medical technologies and drugs. Here in the UK there is also an acknowledgement that an increasingly older population will present further cost challenges to the health economy − especially with regards to the projected increase in the incidence of conditions such as dementia.
‘Health and social care systems under intense financial pressure need to make concerted efforts to ensure they do not lose the human touch’
The health system is bracing itself for these future cost increases, centred as they are around advances in medical science and technology on the one hand, and increasing demands for services on the other.
In such a climate, it is easy to target cost savings at those less tangible aspects of healthcare provision that depend on human interaction. For example, fewer nurses on busy wards have more to do and less time available to engage with patients. Staff in mental health services are asked to increase the number of patient contacts they register and steered towards using specific, highly manualised treatments at the expense of supportive contact with patients. Data collection and outcome measurement consume increasing proportions of clinicians’ non-clinical work time.
Due to budget constraints, funding for continuing professional development is becoming increasingly scarce. Overall, the various pressures on the clinical workforce and the performance frameworks that provider organisations and commissioners apply to healthcare appear more suited to a factory production line than the intensely human endeavour that lies at the heart of all healthcare: people healing people.
I believe that health and social care systems under intense financial pressure need to make concerted efforts to ensure that they do not lose the human touch. The risk of consecutive cutbacks and reorganisations for health care providers is that efficient systems will emerge that do not take account of the people in them − both those who deliver the care and those who receive it.
This process starts with acknowledging that the nature of the work in frontline services involve people and the way we treat people in the systems we set up matter very much. Professor Phil Stokoe, clinical director of the adult department at the prestigious Tavistock and Portman Foundation trust, writes about this as follows: “In industry, for example, it does not matter how the workforce treat the raw material on the way to producing a dustbin. In our work it matters very much indeed how we treat our ‘raw material’, because we are working with people.”
The corollary to this is, of course, that the way in which we treat our staff matter very much too. In an online discussion forum on the Nursing Times website, which followed the publication of a paper I wrote on reflective practice for frontline nurses, one anonymous participant wrote: “During most of our very hectic days we had to work on automatic pilot which is what good training and expert skills is all about and essential in emergencies. However, with more time to reflect and even time which we very often did not have available to us to look up new information as required and also time to reflect on alternative courses of action would greatly enhance care. Often we had to take the quickest and best know option only to reflect later at report or in our own free time off the ward. On late shifts this often caused restless nights when we thought over what else could have been done and whether we could have done things better.”
‘At both an individual and organisational level, the impact of reflective practice should be a process of continual questioning of assumptions’
Good quality care takes time and involves investing in staff development and providing staff teams with opportunities to take time out of their caring or treatment roles to reflect on and improve their practice.
Reflective practice, by its nature, is a process of sense making leading to action. Elsewhere, I have proposed a model of effective reflection and how this could be implemented on an individual or small group basis for professionals at all levels of seniority across the health and social care field.
Here are some prerequisites for effective reflective practice in organisations:
Reflection should be part of the organisation’s culture
For reflective practice to make a difference, healthcare organisations need to instil a culture of reflection within their staff. Reflective managers are likely to make better decisions, reflective practitioners to deliver better, more humane care. The need for staff groups who work with vulnerable and complex people to engage in effective reflective practice is being recognised more widely as illustrated by a recent report on good practice for developing psychologically informed approaches to working with people who are homeless.
Reflective practices should take place at all levels of the hierarchy
A culture of reflective practice means that reflective practices should be prevalent in teams at all levels of the hierarchy, rather than being seen as solely an individual endeavour. This will ensure that a thoughtful, reflective approach to service delivery is valued for its contribution to good thinking, good decision making, and excellence in quality of care throughout the organisation.
At both an individual and organisational level, the impact of reflective practice should be a process of continual questioning of assumptions and accepted ways of doing things, leading to transformation and improvement on an ongoing basis, the epitome of the “learning organisation”.
Opportunities for reflection should be created outside governance and supervision processes
For clinicians and other practitioners, it is important to access reflective space that is free from the constraints imposed by the governance functions inherent in supervision − in other words, a culture of reflection outside of case or management supervision is important.
‘Effective reflection in organisations tends to be possible when the process is formalised and facilitated’
One of the fundamental reasons for this is that, in reality, the discourse in supervision has an inherent power imbalance between supervisee and supervisor. Clinical decisions made in supervision is also permeated by the practical realities of organisational constraints, making it more difficult for either the supervisor or the supervisee to question the assumptions that are made in clinical practice or the prevailing discourse about services and service users within their team or their organisation.
Reflective space, if it is intended to lead to service improvement, need to be located outside of governance and scrutiny functions. Effective reflection has at its core a healthy curiosity and questioning stance in relation to accepted practices and underlying assumptions. These questions lead to practitioners taking a closer look at themselves, their organisation, and their practices, which in turn leads to transformation: learning that increases insight and generates fresh approaches and initiatives that can change practice for the better.
Reflective work needs facilitation within a context of systems thinking
Effective reflection in organisations tends to be possible when the process is formalised and facilitated in some way, perhaps through facilitated group work. The process should also contain feedback loops so that the outcomes of reflective sessions can be considered for further action within broader systems where relevant.
The reflective capacity of participating staff need to be developed
Finally, in my experience, effective reflection requires that participants have an appropriate vocabulary that would enable them to engage in the sense making process. For practitioners in health and social care settings, this extends beyond formal professional knowledge to practitioners developing an awareness of the human or psychological dynamics of service delivery (not routinely covered in clinical training programmes) as well as an experiential understanding of their own psychological processes and the impact of their work on them as people.
Implementing reflective practice across large healthcare organisations
But how might you implement such a reflective approach in large, modern healthcare organisations where time is precious and budgets tight?From my experience and drawing on the examples cited in Helen Keats and colleagues’ report Psychologically informed services for homeless people. Good practice guide, the first step is to devise a strategy that encompasses a range of locally relevant solutions.
Qualified clinicians, especially those members of staff who deliver services to particularly complex service users, might benefit from externally facilitated reflective groups in addition to their clinical supervision. Other clinical teams might benefit from internally facilitated reflective work, for example, through attending monthly reflective groups that are run by trained facilitators with who they do not have direct reporting relationships.
‘The potential benefits are immense: better decision making, better and more humane care, increased staff wellbeing’
Managers and unqualified clinical assistants are two groups that could particularly benefit from targeted opportunities for reflective practice, because both of these groups are so often neglected by way of opportunities for professional development and access to training. Once again, a range of options exist to address the needs for reflective practice among these staff groups.
I have worked with a number of non-clinically qualified staff across a range of health and social care settings, facilitating monthly reflective groups for up to 15 participants at a time. Training impact evaluations with their managers indicated that the groups served to help practitioners become more confident, practice more thoughtfully and reflectively - as evidenced by the ways in which they made better use of their case supervision, and found the group support from colleagues and the input from the facilitator useful in managing stress.
Managers have found similar externally facilitated groups beneficial, but found that quarterly meetings with the facilitator was adequate to meet their needs. To the extent that reflective sessions can improve thinking and decision making alongside benefits in addressing stress and burnout, it is my hypothesis that boards and senior executive teams who engage in reflective work themselves, can expect similar benefits with massive consequential gains for their organisations. In large organisations, facilitators at all levels can be trained and supported to run such reflective groups, which would enable reflective practice to percolate through entire organisations in cost effective ways.
Bringing people back into the centre of healthcare delivery
In an increasingly competitive healthcare environment, there is a temptation to take shortcuts to realise savings targets. Driving down costs through reduced investment in staff development might lead to short term gains, but discounting the intensely human nature of the work in health care will invariably come back to haunt (and hurt) those organisations that do not value their staff.
Creating opportunities for staff to develop through facilitating reflective practice at all levels in the organisation is one way in which people can be brought back into the centre of healthcare delivery. The potential benefits are immense: better decision making, better and more humane care, increased staff wellbeing and engagement, and, perhaps also, fewer incidents and complaints.
Although these claims cannot yet be substantiated by robust quantitative evidence, some encouraging data is emerging on the benefits of fostering reflective work among staff teams. Anecdotal evidence from a variety of organisations that did choose to invest in their staff this way also lead me to believe that some of these goals are achievable for a very modest additional investment.
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Dr Natius Oelofsen is a clinical psychologist, consultant, director at Reflective Learning International and author of Developing reflective practice: a guide for students and practioners of health and social care