Shaun Cavanagh, John Masson & Kathryn McDowell CITATION Cavanagh, S.; Masson, J.; McDowell, K. (2011) Reflective practice groups in learning disability services. Cumbria Partnership Journal of Research Practice and Learning, 1(1), 25-29.
Practice development: Using a innovative approach to transforming occupational therapy services within a memory clinic, has prompted discussions within the team regarding assessments and the ability of services to measure engagement and wellbeing. A team leader of a community mental health team reported an increase in the level of identification of occupational need within the team since the start of this project. The way forward Ultimately the aim for this project is for occupational therapists throughout the Trust to be improving health outcomes for people who use our services. This practice development process provides the opportunity, and the means, for occupational therapists throughout the Trust to use their skills to develop clinically credible and evidencebased measures for improving services. Eventually, through this process, occupational therapists within our Trust will be contributing to the generation of theory and research and developing tools and interventions for practice. To get to this stage the practice development programme needs to support practitioners through distinct phases. The next stage for this project will be focusing on embedding the routine use of MOHO assessments to inform the development of patient-focussed interventions. Although the practice development project was launched less than a year ago the level of engagement and energy put into it by occupational therapists has been impressive. Like other health professionals throughout the Trust occupational therapists have a large contribution to make towards providing excellent patient care. This project has begun to provide occupational therapists with the support, training, networks and, crucially, trust to start to re-examine and change practice and services. As a method for meeting the specific professional training needs of occupational therapy, this approach is an efficient use of resources. There is no need for additional external training, and the practice development structure is designed to create a flexible workforce with skills that can be easily transferred within, and even between, service lines. The scholarship of practice model offers a template that could be used in future for other professional groups and/or service areas in the Trust, and could be explored as a channel for integrating staff groups in future. References College of Occupational Therapists (2006). Recovering ordinary lives: The strategy for occupational therapy in mental health services 2007-2017, a vision for the next ten years. London: COT. Darzi, A. (2008). High quality care for all: NHS next stage review final report. London: Department of Health. Department of Health (2010). Liberating the NHS: Legislative framework and next steps. London: DoH. Duncan, E. (Ed.) (2009). Skills for practice in Occupational Therapy. London: Churchill Livingstone. Duncan, E. A. S., & Moody K. J. (2003). Integrated care pathways in mental health settings: An occupational therapy perspective. British Journal of Occupational Therapy, 66, 473-478. Forsyth, K., Summerfield-Mann, L. & Kielhofner, G. (2005). Scholarship of practice: Making occupation-focussed, theorydriven and evidence-based practice a reality. British Journal of Occupational Therapy, 68, 260-268. Melton, J., Forsyth, K., & Freeth, D. S. (2009). Using theory in practice. In E. Duncan (Ed.), Skills for practice in occupational therapy (pp 9-23). London: Churchill Livingstone. Parkinson, S., Chester, A., Cratchley, S. & Rowbottom, J. (2008). Application of the Model of Human Occupation Screening Tool (MOHOST) in an acute psychiatric setting. Occupational Therapy in Healthcare, 22, 63-76. REFLECTIVE PRACTICE/CASE STUDIES Reflective practice groups in learning disability services Shaun Cavanagh, John Masson & Kathryn McDowell Abstract This paper gives an overview of reflective practice and describes the processes and evaluation of reflective practice groups that were established in the Cumbria Learning Disability services. The paper reflects upon the processes that made these groups successful and how they could be improved in the future. Keywords reflective practice; learning disabilities; group facilitation The Cumbria Partnership Journal of Research, Practice and Learning 1(1) 25
Reflective practice For professional development, Reflective Practice is different from clinical and managerial supervision, support groups or psychotherapy. Donald Schön defined Reflective Practice as, the capacity to reflect on action so as to engage in a process of continuous learning (Schön, 1983). Alternatively, Moon defined reflective practice as: A set of abilities and skills, to indicate the taking of a critical stance, an orientation to problem solving or a state of mind (Moon, 1999). In his book, The Reflective Practitioner Schön (1983) shows how a wide range of professionals from architects to engineers to psychotherapists can and do make use of reflecting in and on practice to develop their professional skills. In so doing, he helps the professional analyse their intuition or gut feeling, when coming up with solutions. Others have developed models of Reflective Practice. For example, consider Gibbs Reflective Cycle (1988) in Figure 1. Gibbs takes an evaluative approach that considers the individual s thoughts and emotions in response to a problem situation, before considering alternative options and making plans for dealing with similar situations in the future. Another way of considering the importance and difference of reflective practice is presented by Carper (1978), which was developed by Johns (1995; figure 2), who considered reflexivity as a different type of knowing, that is responding to the situation in terms of a tacit way of knowing, made conscious by reflection on past experience This is considered different to responding to a situation in terms of right or wrong (ethical knowing); grasping, interpreting, envisaging, what is to be achieved, and intentionally responding to the unfolding moment with skilful action (aesthetic knowing); responding based on empirical evidence and responding in personal ways that can include attitudes and prejudices (personal knowing). There are opportunities to reflect on practice with colleagues in various supervision situations and professional practice groups. However, something felt missing in these contexts and a question emerged, how can professionals access critical reflection opportunities to tap into a deeper level of thinking and gain positive learning from powerful felt experience? This article outlines how a small group of professionals within the Learning Disabilities service, applied their combined knowledge, skills and experience to reflect on clinical problems they brought to a Reflective Practice Group. Hopefully, this will encourage others to set up their own group. Figure 1: Gibbs Reflective Cycle (1988) 26 The Cumbria Partnership Journal of Research, Practice and Learning 1(1)
How the group was run In January 2005, following a presentation given to the service s Clinical Practice Group, it was decided that a Reflective Practice Group (RPG) be set up. The following list of guiding principles was developed with the aim of helping participants think about the type of material that could be discussed: Professionally focussed. The group will discuss professional (work) based issues. Personal issues are outside the scope of the group. Confidential. We will have a safe environment that gives us the freedom to express our feelings about the work that we do that effects us deeply, without the fear that it will be discussed elsewhere. Figure 2: Framing learning through reflection, Johns (1995) adaption of Carper s fundamental ways of knowing Silence. Sometimes we may not want to speak and we have the right to sit quietly. Respect. We will respect whatever people bring to the group for discussion as being important to them. Balance. Success is as worthy of discussion as a problem. Along with the difficulties we face, we may also want to discuss how we overcame a challenge in our work or how we nurture our enthusiasm. Growth. We want to enhance our working lives. We will strive to leave each group meeting feeling better! The group was to focus on professional issues, that may well have a personal impact, but not on personal issues that may have an impact on work. Although difficult to define, the group s aim was to use reflective practice to develop professional skills rather than being a place for personal psychotherapy. The guiding principles set out the limits of confidentiality and an atmosphere of respect, balance and growth. It may seem unusual, but group participants were allowed to sit in silence, to allow for those sessions that the individual may not have been comfortable to talk, a familiar experience for many of us! The group was open to everyone working in Learning Disabilities Services and included community nurses, administration staff, social workers, family support workers, physiotherapists, occupational therapists and psychologists. Meetings were held monthly, running for an hour around lunchtime and held in a quiet room with a large table and chairs. The eating of lunches gave a welcome, relaxed feel to the sessions. The group varied in size with some sessions having only four or five participants and others having over 15! To begin a session, each participant in turn, stated whether or not they had brought something to the group to reflect upon. When there was more than one topic to discuss the group agreed which to focus on and, when it was acceptable to the practitioner, it was sometimes agreed that their topic would be dealt with at the next session. The sessions were led by the group, but with some minimal facilitation, a role taken by members of the team who attended more regularly. The aim being to have the fullest possible reflective experience by drawing on the experiences of all the individuals and professions present, The Cumbria Partnership Journal of Research, Practice and Learning 1(1) 27
rather than privileging one or two members of the group. The group s reflections were wide ranging. As can be seen from the list below, topics included, amongst others, the sharing of experiences on training courses; times of professional challenge such as coping with complaints; or dealing with difficult working practices; ethical issues; understanding the concerns of the client group; and dealing with organisational change. Although the group had a tendency to reflect in a conversational manner, other methods were used. Sometimes therapy techniques were employed, for example appreciative interviewing and scaling questions from family therapy approaches. In other sessions, there was a creative use of artwork or objects that had special significance to the individual, perhaps encouraging the reflections to be out of the ordinary! Experiences that reminded us that the methods used and the flow of the sessions were limited by our imagination and our willingness to be challenged. Reflective practice group topics Inaugural session: principles and format; Discussion of the value of reflection; A clinical training experience; Disability and society; A found object used to reflect on the benefits of applying personal strengths to the workplace; The perception and place of a team in the Learning Disabilities Service; Advocacy for profoundly disabled people; Labelling and working within the tensions ; Agenda for Change and the Role of the Community Nurse; Supporting a family and a child with Autism Spectrum Disorder; Issues of confidentiality; Workload issues and appropriate service delivery; Coping with complaints; Managing time; Insights gained on a clinical training course; Skill-mix in care staff teams and the impact on the clinician; Learning from a complaint; Empowerment, families and children with a learning disability; A family therapy technique used to consider difficult relations between two clinicians; Experience of disempowerment with individual with a learning disability; and Challenging perceptions with the use of client artwork. Reflecting on the practice of group reflection An evaluation was undertaken to capture how the reflective groups were being experienced. The following provides a sample of qualitative answers to one question regarding what changes might be made to the operation of the groups: I find some sessions more relevant than others but on reflection that might be just me! A more creative approach to discussion. Maybe sometimes splitting into pairs and groups and then returning to main group. I believe the reflective practice group could be more successful if it was more structured for example, reflective writing sessions, particular topics to reflect upon. I would like to see more people taking the opportunity to participate. It would be healthier for the service. Perhaps emphasis has been mostly on support and venting with less on challenge and bringing a more cutting edge perspective on practice linked to the knowledge base and socio-political context of practice. I wonder if more structure might benefit development of the group e.g., choosing topics to reflect on, or using different methods, e.g., reflecting on a passage from a book, different techniques within the group session. Reflecting on these responses, there is a sense that the groups were well received and used; but also that they tended to stay on safe ground in the way that reflection was undertaken, both in terms of techniques used and reflective parameters. The groups were used differently by individuals with some being more proactive in their public sharing than others. Yet regardless of whether contribution was through open reflection or primarily through attendance, there was a strong sense of solidarity and support across all regular participants. Perhaps the need for that sense of solidarity and support may have hindered a willingness within the groups to push the safety boundaries and incorporate more challenge into both the structure of how reflection was done and the content of the reflection. One incident springs to mind where some internal differences began to emerge in the course of reflective discourse but it felt that there was an implicit recognition that this could be uncomfortable and the conversation was truncated and stayed in the safe zone. However over the course of their existence, the groups did add an additional, deeper dimension to the culture of the teams. About two years ago it began to feel that there was a 28 The Cumbria Partnership Journal of Research, Practice and Learning 1(1)
going through the motions within the reflective practice groups. Consequently the groups ceased. Interestingly various team members, across professions, have recently asked to re-establish opportunities for reflective practice. At the time of writing it has just been agreed to do this commencing in the New Year. Affiliations Shaun Cavanagh, Senior Nurse, Learning Disability Challenging Behaviour Pathway, Cumbria Partnership NHS Foundation Trust John Masson, Consultant Clinical Psychologist, Learning Disability Service, Cumbria Partnership NHS Foundation Trust Kathryn McDowell, Clinical Psychologist, Learning Disability Service, Cumbria Partnership NHS Foundation Trust Contact information Shaun Cavanagh, shaun.cavanagh@cumbria.nhs.uk References Borton, T (1970). Reach, teach and touch. London: McGraw Hill. Carper, B (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Practice, 1, 13-23. Gibbs, G (1988). Learning by doing: A guide to teaching and learning methods. Oxford: Further Education Unit, Oxford Polytechnic. Johns C (1995). Framing learning through reflection within Carper s fundamental ways of knowing in nursing. Journal of Advanced Nursing, 22, 226-234. Moon, J. (1999). Reflection in learning and professional development: Theory & practice. London: Kogan Page. Schön D. (1983). The reflective practitioner. San Francisco: Jossey Bass. Schön D. (1987) Educating the reflective practitioner. Towards a new design for teaching and learning in the professions. San Francisco: Jossey Bass. Revisiting Melodic Intonation Therapy (MIT): A planned case study Lindsay King Abstract This paper describes the use of Melodic Intonation Therapy with aphasia. It is intended that the work introduced here will be written up for publication as a full case study in a speech and language professional journal. Keywords Melodic Intonation Therapy; case study; aphasia; speech and language therapy Introduction: What is Melodic Intonation Therapy? Melodic Intonation Therapy is a treatment used by Speech and Language Therapists that uses the musical elements of speech (melody and rhythm) to improve expressive language. It aims to capitalise on the preserved function (singing) and engage the language-capable regions in the undamaged right hemisphere (Norton, Zipse, Marchina & Schlaug, 2009). The original programme is designed to lead the nonfluent aphasic client from intoning (singing) simple 2-syllable words to speaking phrases over 5 syllables in length. There are 3 levels of treatment; elementary, intermediate and advanced. Each level consists of 20 high-probability words presented with a visual cue (picture). The syllables are intoned on 2 pitches; melodies are determined by the words natural prosody (rhythm). The stressed syllable is intoned with a higher pitch and the unstressed syllable is intoned with the lower pitch. For example, for the word water the syllable wa is intoned in a higher pitch and the syllable ter in a lower pitch, for the word television the syllables tel and e are intoned in a low pitch, the syllable vis in a high pitch and the syllable ion in a low pitch. The client and therapist sit across a table from each other. The therapist holds the client s left hand and taps the rhythm of the word with two fingers on the back of the clients hand at a rate of one syllable per second. The therapist and client start by introducing the target word with the visual cue. In unison they hum the word, as the therapist taps the rhythm on the client s left hand. This progresses to singing the target word in unison with tapping; gradually the therapist fades her voice. This stage is then followed by the therapist speaking with exaggerated prosody and tapping while the client listens. The client immediately repeats the word only assisted by the tapping. The Cumbria Partnership Journal of Research, Practice and Learning 1(1) 29