Reflective practice: Its place in health system leadership training
In April this year, colleagues from low- and middle-income countries in Africa and Asia drew together under the banner of RESYST (a research network aimed at enhancing resilience in health systems) and CHEPSAA, to share ideas and experiences about training for health system leaders and managers. The meeting participants agreed that 'reflective practice' should be a core component of all health system leadership training programmes. They devoted much thought and discussion to the questions of what reflective practice is, how teaching programmes are incorporating the concept and delivering such teaching, and why it should have a place in health system leadership training offerings. This blog provides a few simple ideas to kickstart thinking about reflective practice and its place in health system leadership training.
What is reflective practice?
While there are many definitions of reflective practice, Donald Schön explains it simply as 'the ability to reflect on one's actions so as to engage in a process of continuous learning'. It is both about reflecting on one’s actions (before or after they take place) and reflecting-in-action.
Some distinguish between reflective practice (as the process) and reflexivity or being reflexive (as the outcome or the behaviour of being self-aware of one’s being and one’s behaviour towards others). Regardless of definition, it is a process of continuous learning and continuous self-awareness of your being, thoughts, assumptions, and behaviours in relation to others.
Ann L. Cunliffe speaks to this distinction and uses the term of being ‘critically reflexive’. While her article is not the easiest of reads, it is well worth the effort. As described in the April meeting by Professor Irene Agyepong of Ghana:
|'My understanding is that in one way or the other we all exhibit reflexive behaviour. The issue is becoming a bit more insightful and critical about our reflexive behaviours. Using reflection (or reflective practice) can help us to be critical about our social interactional and behavioural reflexes in a leadership and management setting. It could be in reaction to colleagues, in decision-making, in implementation etc. Reflection enables us to thoughtfully examine; critical reflexivity enables us to apply the thoughtful examining to our sometimes sub-conscious behaviour, including social interactional and behavioural knee-jerk type reactions, assumptions etc.'|
Why reflective practice?
Leadership is at its core a relational construct, as leaders work with and through multiple teams and have to build and navigate multiple relationships. It is therefore essential for leaders to understand who they are, how they think about and act in the worlds within which they work, as well as to have insight into how they think of and behave towards others. In the language of leadership competencies, these are social competencies - reflective practice cultivates the social competencies of leaders.
But what is the relevance of these social competencies? How do they relate to other dimensions of leadership competencies? Shouldn’t we just worry about “getting the job done”?
To think about these questions we can use the framework in the diagram below, which is derived from the integrated competency model of Le Deist and Winterton (2005). This framework underpins the leadership competency framework that three partner universities have developed for the Western Cape Provincial Department of Health in South Africa.
- The Head or Cognitive refers to the analytic and strategic competencies that leaders need to fulfil their roles;
- The Hands or Functional refers to technical tasks such as service delivery co-ordination and financial management;
- The Heart or Social refers to the understanding of self and self in relation to others; and
- The wHole body or Meta refers to a culmination of all of these competencies that enables leaders to operate in complexity and uncertainty and still survive and thrive.
Reflective practice in leadership training programmes is therefore aimed at improving understanding of the self, as well as the behaviours and relationships of the self in relation to others. In speaks directly to the 'software' of a health system - values, beliefs, and behaviours – and is in fact central to the make-up of a leader and to tasks such as supporting and coaching others, working collaboratively with and through others, and building organisational purpose.
How does one build reflective practice into a health system leadership course?
For me, the first necessity is that course convenors/facilitators should themselves embrace and exhibit reflexivity in how they conduct themselves in the class, the way that they relate to the students and the values and behaviours they demonstrate and promote in the class.
Secondly, reflexivity should be encouraged throughout all facets of the curriculum to flex the social competency muscle, alongside other elements such as critical thinking, which flexes the cognitive muscle.
Having said this, courses should have dedicated spaces where students are provided with reflective practice theory and engaged in practical exercises of how to improve reflexivity.
In the OTFP we draw heavily on the Thinking Environment approach as promoted by Nancy Kline. While there are other approaches to teaching reflective practice, the Thinking Environment provides many useful applications to, among other things, considering one’s own behaviour, learning to listen well (which encourages others to think openly and freely), and learning to run meetings in a positive way that emphasises equality of participation.
We run two dedicated reflective practice sessions in each of our four residential blocks. Out of 29 contact days, our participants are exposed to dedicated reflective practice sessions equivalent to 7 days - almost a quarter of contact time. In addition, the principles and practices of reflective practice are infused throughout in how we run our sessions, structure team work and promote interaction. Some of our practical techniques include:
We also set specific assessment tasks to promote regular structured weekly reflections in the inter-modular periods. Whilst we do not grade these reflections on the substance of what is often very deeply personal reflections, students do receive a grade for completing the requirements of the assessment and for their depth of reflection. However, it is important to note that reflection does not have to be so formal and structured to be useful. One manager we work with does it while taking a walk. Personally, I often do it whilst waiting in traffic - a perfect time, without interruptions from others.
In conclusion, reflective practice is central to the competencies of health system leaders. It can improve their decisions, but also impacts positively on their relationships with the people they work with. This, in turn, will positively influence the functioning of the health system which is, after all, a system of interconnected people.
To learn more about reflective practice and theory, please visit the website of one of our reflective practitioner collaborators. It generously offers access to many useful theories and materials, including videos, for those interested in reflective practice.
Maylene Shung King (RESYST member and convenor of the OTFP)