Enhancing Professionality Through Reflectivity in Social and Health Care 3031288009, 9783031288005

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Walter Lorenz Zuzana Havrdová   Editors

Enhancing Professionality Through Reflectivity in Social and Health Care

Enhancing Professionality Through Reflectivity in Social and Health Care

Walter Lorenz  •  Zuzana Havrdová Editors

Enhancing Professionality Through Reflectivity in Social and Health Care Reviewed by Prof. Silvia Fargion

Editors Walter Lorenz Faculty of Humanities Charles University Prague, Czech Republic

Zuzana Havrdová Faculty of Humanities Charles University Prague, Czech Republic

ISBN 978-3-031-28800-5    ISBN 978-3-031-28801-2 (eBook) https://doi.org/10.1007/978-3-031-28801-2 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

Preface

The motivation for writing this book arose in the context of our extensive experience in post-graduate courses at Charles University, Prague, in giving the professional ability to reflect a central role in preparing students for supervisory and management roles in social and health services. Since we always were able to select highly experienced professionals from these areas for our course programme, we noticed the presence of a distinct level of reflectivity among them, particularly in those students who had the experience of guided supervision that had equipped them with a good level of self-awareness and a critical approach to prevailing forms and standards of practice. This concern corresponded to the growing emphasis given in the literature to reflectivity in professional practice, particularly in publications on nursing training. We recognised that the acknowledgement that higher professional status, and with that greater professional autonomy in decision-making, is intricately related to the reflective abilities expected of professionals in general, which allows them to rise above the following of regulations and prescriptions. At the same time, this proliferation of references to reflectivity or reflexivity was accompanied by ambiguities and great imprecision in the use of these terms. Many attempts at defining them more clearly and consistently had not found wider acceptance. In many ways, it had become “fashionable” to make frequent references to reflecting when dealing with aspects of professional practice but that only increased the impression of the terms reflexivity or reflectivity functioning as a kind of black box that was held in high esteem but which nobody dared to open and examine more deeply for fear of ruining its mythical aura. These observations spurred us to undertake our own thorough examination of the origins and wider implications of the terms and particularly of the variety of elements that make up the “reflecting complex” and, building on that, the constituent factors from which effective learning programmes could be constructed. This required us, first of all, to put the terms into wider contexts, which was fairly obvious given how closely the gesture and in many ways the necessity of constantly reflecting is associated with life under conditions of modernity and how immediately intellectual activities are identified with reflective activities in modernity so that they can constitute the “autonomous self”. It then emerged that this project of v

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modernity itself is fraught with doubts of whether it could achieve its emancipatory objective, and this led us to examine and value the organisational and indeed the political settings that could secure positive outcomes of acts of reflecting, both for the individuals concerned and for society overall. The attention to framing conditions in turn had to be matched by a brief exploration of neuro-psychological research, which is producing important insights into the complexity of unconscious and conscious processes and their interplay in constituting reflective acts of any kind. Against this background, we sought to test the extent and forms of the presence of these conceptual elements of the reflectivity/reflexivity complex in the general population of the Czech Republic with the help of recently established psychological tests, as a baseline against which we could then identify facets of the complex among our student population and then also among professionals, social workers, nurses and managers in social and health services. This took place in the form of a research project for which funding was granted by the Czech national research funding agency GAČR 19-07730S, which provided us with the resources to undertake the differentiated research in a series of phases described in this volume. Our overall aim with this volume is to make a contribution not only to be the better understanding of what factors and processes are involved in professional reflecting, but also above all to use the insights for the purposeful stimulation and enhancement of reflecting in professional and educational settings in the areas of health and social services. We do not, however, propose our findings in the form of a singular model or a guidebook for enhancing reflective practice in the areas concerned because one of the central findings of our research was that reflectivity is always very context-specific and that for a particular approach and objective of reflectivity to “work” requires the setting up of a specific organisational context which very much depends on socio-political, organisational and indeed personal circumstance in which this process takes place. Nevertheless, we ended up with a series of reference points and criteria that need to be addressed in any developmental process, be it enhancing reflexivity at the workplace or in a training process or formal programme that aims at improving reflective professional practice and can be presented in a clear conceptual form. These reference points arise at the personal level where trainers and learners need to be prepared to confront their personal make-up of concepts and indeed prejudices with which they “make sense” of their environment, but they require a correspondence at the organisational level where academic “learning regimes” and managerial practices and attitudes have been identified as being highly influential. An educational programme cannot simply assume that beneficial conditions for learning and practising reflectivity are “given” and therefore concentrate on the didactics per se. It needs to attend explicitly to underlying power issues, which are part of every learning and helping relationship, by way of exposing and addressing them. Including these aspects into a learning programme concerning reflectivity thereby brings to bear the underlying transformative potential of the reflective act which questions taken-for-granted realities and assumptions from a plurality of perspectives and seeks to promote a dialogical, democratic pathway towards settling divergent viewpoints for commonly negotiated and motivating purposes. But it can only

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realise this potential when such an educational programme is being constructed with specific reference to the prevailing organisational and political circumstances as well as to where individual learners find themselves personally. In light of the often-confusing diversity of normative positions that characterise contemporary societies, the fostering of reflective abilities exceeds a mere professional mandate. Our hope is that professionals in the critical service areas of health and social support, whose central importance was not in the least demonstrated during the global COVID-19 pandemic, can apply their reflective abilities both concretely in arriving at accountable practice decisions and symbolically as a contribution to the peaceful settlement of divergences that threaten to divide societies ever more deeply. Prague, Czech Republic January  2023

Walter Lorenz Zuzana Havrdová

Acknowledgements

This publication is the outcome of the project “Reflexivity in social workers and nurses”, funded by the Czech Science Foundation GAČR, reg. nr. 19-07730S, realised at Charles University, Faculty of Humanities. We cordially thank all students, managers, social workers and nurses who participated in the four research studies and shared their expertise and experience presented in this volume.

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Contents

 1 Introduction:  Reflectivity in Philosophical, Sociological, Psychological and Pedagogical Contexts�����������������������������������������������    1 Zuzana Havrdová and Walter Lorenz  2 The  Significance of Reflectivity in Professional Social and Health Care in Relation to Changing Socio-Political Contexts ����������   17 Walter Lorenz  3 Promoting  Reflective Learning Styles Among Social Work and Nursing Students: A Review������������������������������������������������������������   39 Monika Čajko Eibicht and Walter Lorenz  4 Supervision  at the Workplace as a Unique Space for Reflection��������   61 Martin Hajný and Zuzana Havrdová  5 Gender  Aspects of Reflectivity in the Social and Healthcare Field: Forms of Feminization of the Caring Profession as Frames for Reflexivity������������������������������������������������������������������������   83 Monika Bosá  6 R  eflective Approaches to Professionalisation Through Legislation, Structures and Cultures: Example from Czech Social and Health Services����������������������������������������������������������������������  107 Matěj Lejsal and Jiří Krejčí  7 Researching  Reflectivity by Scales ��������������������������������������������������������  129 Iva Šolcová, Filip Děchtěrenko, and Zuzana Havrdová  8 The  Interaction Between Institutional Cultures and Individual Dispositions to Self-Reflection: A Hierarchical Analysis����������������������  147 Zuzana Havrdová

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 9 Levels  of Reflectivity: Conditions and Strategies for Supporting Reflectivity in Healthcare and Social Care Services: Qualitative Research��������������������������������������������������������������������������������  175 Zuzana Havrdová and Walter Lorenz 10 Towards  an Integrated Approach to Fostering Reflectivity in Social and Health Professions������������������������������������������������������������  201 Walter Lorenz Bibliography ����������������������������������������������������������������������������������������������������  213 Index������������������������������������������������������������������������������������������������������������������  235

About the Editors

Walter Lorenz  PhD, is a recognized expert on professional social work education. German by birth, he trained as a social worker at LSE and practiced in East London before teaching social work in Ireland, Italy and other European countries. As president of the European Centre for Community Education, he steered the first Erasmus Thematic Network for the Social Professions in the 1990s which helped to develop country-specific curricula in various European countries, oriented towards the creation of autonomous professionals. Together with Hans-Uwe Otto, he was co-founder of the International Summer Academy TISSA and launched the European Journal of Social Work and later the online journal Social Work and Society. Since retiring from the Free University of Bozen, Italy, he holds a visiting appointment at Charles University Prague. His research and development specialties are didactic forms of professional courses that enhance students’ reflective abilities, integrating knowledge, experience and personality with sound social policy analysis. Zuzana  Havrdová  CSc, is a clinical psychologist, trained psychotherapist and clinical supervisor who practices individual, group and team supervision in social work and uses her extensive experience in guiding supervision training. In the last 20  years, she has been the Lecturer and Programme Leader of the master’s programme in Management and Supervision in Social and Health organisations at the Faculty of Humanities, Charles University, and Board Leader and Supervisor of the PhD programme in Social Work, both of which were founded by her. She is part of the group of experts who have been building up social work in the Czech Republic after 1989, giving particular attention to the aspects of practice and social work methods (e.g., developing competences and minimum standards in social work practice) in collaboration with other schools of social work. She has extensive experience in developing study courses and curricula for master’s and PhD levels in social work and social and health care and was also a leader and member of EU

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international higher education programme. She has co-edited and co-authored international books and papers in partnership with scholars from different European countries (Finland, Scotland, Portugal). Her research and educational focus is on external supervision in helping professions, which is based on collaborative reflection and knowledge of good practice.

Contributors

Monika Bosá  Faculty of Humanities, Charles University, Prague, Czech Republic Filip  Děchtěrenko  Faculty of Humanities, Charles University, Prague, Czech Republic Institute of Psychology, Czech Academy of Sciences, Brno, Czech Republic Monika Čajko Eibicht  Faculty of Humanities, Charles University, Prague, Czech Republic Martin Hajný  Faculty of Humanities, Charles University, Prague, Czech Republic Zuzana  Havrdová  Faculty of Humanities, Charles University, Prague, Czech Republic Jiří Krejčí  Faculty of Humanities, Charles University, Prague, Czech Republic Matěj Lejsal  Faculty of Humanities, Charles University, Prague, Czech Republic Walter Lorenz  Faculty of Humanities, Charles University, Prague, Czech Republic Iva Šolcová  Faculty of Humanities, Charles University, Prague, Czech Republic Institute of Psychology, Czech Academy of Sciences, Brno, Czech Republic

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Chapter 1

Introduction: Reflectivity in Philosophical, Sociological, Psychological and Pedagogical Contexts Zuzana Havrdová and Walter Lorenz

Introduction The guiding focus of the contributions in this volume is the phenomenon of reflection in the realm of professional activities of social workers and nurses. Given the wide range of meanings that are being attributed to the term reflection, reflectivity, and reflexion in the literature, we want to clarify in this chapter our understanding of these concepts from a philosophical, sociological, psychological, neurobiological and pedagogical perspective so as to construct from these reference points some core parameters of our understanding of the concept cluster and its potential for practice. In this chapter, we will use reflexivity as a broader term, including reflectivity as its intentional part and giving space for various semi-intentional or not-­intentional modes of reflectivity/reflexivity. We map out the tensions and polarities inherent in the concepts and in the practice of reflectivity to draw attention to the value implications that need to be taken into consideration in reflective practice. The contributors to this volume use the structure of the first six chapters to explore and deepen our framework of understanding of the multi-layered concept of reflection. The next three chapters offer our own research findings which we interpret on the basis of this framework. In the last chapter, we reformulate the framework and make suggestions for educational approaches to enhance reflectivity by applying key insights that emerged in previous chapters. The layers of understanding which we will explore in the first six chapters are as follows:

Z. Havrdová (*) · W. Lorenz Faculty of Humanities, Charles University, Prague, Czech Republic e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Lorenz, Z. Havrdová (eds.), Enhancing Professionality Through Reflectivity in Social and Health Care, https://doi.org/10.1007/978-3-031-28801-2_1

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–– The structural layer of society  – how the professional practice of reflectivity interacts with specific structural conditions. –– The educational layer in social and health care professions – what approaches support individual and group professional reflectivity and what resources can educators and managers use to draw inspiration for enhancing reflectivity/ reflexivity. –– The organisational layer – what cultural and communicational patterns of interaction enable professional reflective processes at individual and team levels. Here, we present lessons learned through many years of nurturing reflectivity in helping professions through supervision. –– The gender layer – this asks whether it is possible and appropriate to identify and promote gender-specific aspects of (self-)reflectivity. –– The specific national (Czech) layer – the culture- and nation-specific factors for reflection that frame personal services in the Czech Republic. –– The personal layer  – what facets do the individual dispositions for reflection show in view of authors who operationalise the concept of reflection by means of psychological measuring scales. In the last three chapters, we present and discuss the results of our research studies, in which three sets of questions were addressed. The first concerns the way reflection is being understood and practised by social workers and nurses: Do they consider reflection as something particularly significant for their professionality? Do these two groups of professionals differ in how they look at reflection? Do they show preferences for certain facets or types of reflection? Do they differ in personal dispositions and use of reflection from the general population? The second set of questions concerns the status and nature of reflection in social and health care organisations: Do attitudes towards and uses of reflectivity in organisations have significant consequences for organisational and professional processes and the well-­ being of their employees? The third set of questions addresses the educational and organisational resources and methods commonly used and asks whether they enhance or hinder the development and use of reflection in social workers and nurses. Four consecutive studies conducted since 2019 on the Czech population will be presented in Chaps. 7, 8, and 9 to add a further layer of understanding to these questions: • Study A – qualitative research through in-depth interviews focused on how social workers and nurses reflect, how education influenced their reflectivity and what conditions of and support for reflectivity did they receive at their work place (Havrdová et al., 2022). • Study B – validation of personal reflectivity scales SRIS and PHLMS (Havrdová et al., 2020). Those scales measure various aspects of personal reflectivity. • Study C – realisation of the survey in the social and health care sector on predictive factors of reflexivity at the workplaces.

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• Study D – qualitative research through focus groups with managers in social and health organisations, which focused on the possible ways of how to shape reflexivity at the workplace. In view of the wide variety of interpretations of the meaning and purpose of reflection, we maintain that the rich diversity of views, conceptual delineations and empirical research findings provides ample resources for gaining a gradual hermeneutic grasp of its use across various discourses. Concepts like self, consciousness, mind, social interaction or communication are similarly multifaceted and multi-­ layered and also lead to widely differing interpretations. While there are many cross-disciplinary references and exchanges in the shaping of various concepts of reflection, we found it useful to distinguish four epistemological frameworks in which the various notions of reflection were captured and developed: –– Our brief review of philosophical references to the concept aim to show that it has indeed ancient origins in various philosophical traditions and can in a certain way be considered as the essence of philosophising per se and as a means of gaining insight into the world and one’s self. –– The sociological perspectives relate to the observation that modern societies are characterised by the dissolving of traditional structures, which had given members of society definite forms and contents of meaning. This necessitated an ever-­ increasing involvement of citizens in the creation of meaning and hence of reflective efforts which are to some extent liberating and to another confusing and anxiety-inducing (Beck, 1994). –– In this modern context, reflectivity consequently became an important object of psychological studies, given the challenges faced by all citizens and particularly by professional experts in confronting new and constantly changing situations in human interaction. Psychology asks, to what extent people are equipped to orient their thinking and acting purposefully under such fluid conditions, both in terms of their external coping and in relation to the constitution of their Self? In many ways, recent neurobiological insights help to answer questions which the previous dimensions had to leave unanswered, particularly regarding the neurophysiological distinction between pre-conscious and conscious neurological processes in relation to reflecting. Nevertheless, even from this perspective, the aspect of intentionality, which is crucial for the psychological understanding of reflectivity, has become blurred. This connects again with fundamental philosophical questions concerning the existence of a “free will”. Our ultimate goal is the application of the various epistemological insights for pedagogical frameworks and approaches that identify and enhance specific reflective abilities in the context of professional training and supervision in social work and nursing. We do not consider such insights a professional prerogative but seek to extend the pedagogical principles also to learning processes from which everybody can benefit in the sense of life-long learning.

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Philosophical References to Reflectivity Throughout history, reflection has always been looked upon with esteem, as something unequivocally positive. Teilhard de Chardin (1956) understands the crossing of the “threshold of reflection” as an elementary evolutionary step that distinguishes humans from other animals. For him, reflection is the ability of our consciousness to turn on itself. The origins of philosophy, both in Western and Eastern traditions, can be directly related to the systematic use of reflecting abilities applied to the modes of thinking themselves. Wang and King (2006) identify the central role of reflecting in the thought of Confucius. For him to reflect deeply means a “digging and drilling” that leads to an awareness of the self not as a mental construct but as an experienced reality involving the whole person. Thus, he characterises knowledge as the “learning of the body and mind,” which is the way of developing and asserting one’s personhood. The Western philosophical tradition since the Greek period, according to Arendt (1978), is characterised by a dynamic exchange between the self at an experiential and at a reflexive or conceptual level with the aim of reaching the latter “higher” level. Plato gave methodological expression to the reflective gesture in his dialogues in which Socrates demonstrates the mind’s ability to question the world, including the self, dialectically and dialogically as a means of gaining higher levels of knowledge. For Plato, this was not simply a philosophical device but a way of affirming the quasi divine faculties in humans, a view then taken by Aristotle in a slightly different direction. His theory of perception postulates that the precondition for perceiving oneself is the ability to perceive the outside world so that self-consciousness and hence reflectivity arises out of cognitive abilities (Smith, 2020), a thought actualised in modern neurobiology (see below). The philosophical issue of how to achieve self-consciousness was taken up as relevant for Christian theology early on in its systematic development, for instance by Augustine with his statement that the mind “gains the knowledge of [itself] through itself” (Augustine, 2002, “On the Trinity” 9.3). He applies this form of reflectivity emblematically to his own biography in his “Confessions” that became a reference point for introspection as a theological topic but also anticipate the later emphasis on reflex as “mirroring”. In the further development of Western philosophy, the problem of how thinking (cogitare) can turn on itself, therefore the ability to reflect, becomes constitutive of a person’s self. This finds its classical expression in Descartes’ statement “cogito ergo sum”. It must however not be forgotten that this was written against this philosopher’s existential anxiety over the uncertainty of all perception, which drove him to combine in other formulations “cogito” with “dubito”. In terms of reflectivity, Descartes distinguishes awareness (conscientia) of something from a second-­ order awareness which is the awareness that one is aware. This implies a potential distinction of two versions of reflectivity (although Descartes hesitates to call the first level type awareness reflection (see Jorgensen, 2020)), which will later become significant for the contemporary debate on two levels of reflectivity, an “automatic” and a “conscious” form. Following on from Descartes, in modern consciousness

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doubting as critical reflectivity continued to have both a despairing side, when it leads to the realisation that nothing is beyond doubt, and a reassuring side that the mere act of doubting confirms one’s existence (Newman, 2015). Descartes’ version of self-consciousness sets in motion the search for the constitution of the modern Self as a continuous project which he, being still rooted in religious faith, approached with a confidence that subsequently eroded (Tauber, 2010). Reflectivity plays a central role later in Kant’s epistemology. He operates with a fundamental distinction between logical and transcendental reflection whereby the first concerns purely the ability to apply logic to any kind of representations in the mind, be they a priori or empirical. The innovative impulse from Kant’s treatment of reflectivity stems from the latter. With the attribute “transcendental”, Kant aims at the mind’s fundamental faculty to bring together sensory impressions with reason (or experience and concepts; Tauber, 2010) to arrive at “reflective judgements” that can stand up to the mind’s scrutiny (Balanovskiy, 2018). Transcendental reflectivity is the basis of all conscious activities because “all conscious representation must be reflexive” (Kraus, 2020, p. 94) and at the same time expresses the relation of what has been apperceived to the thinking subject who synthesises these phenomena with reference to a priori categories so that the result can “mean something” to that person. The unity to which this representation of reality relates is in turn constitutive of the identity of the reflecting subject. “To apprehend this reality, a subject is required” (Tauber, 2010, p. 149). Although Kant’s considerations are oriented predominantly to establishing the “logic” behind reflecting, the reference to “giving meaning in reflection” was to become very significant in the “linguistic turn” of philosophy and is also a guiding principle of our present understanding of dialogical reflectivity. Hegel with his prevalent interest in applying philosophical stringency to the study of history and society adds an important social dimension to Kant’s notion of reflexivity as self-consciousness in that he proposes that meaning derives primarily from the recognition (Anerkennung) of other self-conscious subjects as self-­ conscious subjects (Ng, 2020). It is out of these processes of mutual recognition that in Hegel’s Phenomenology (Chap. 3), his concept of objective spirit (Geist) emerges to provide “the social matrix within which individual self-consciousnesses can exist as such” (Redding, 2020). Here reflectivity reaches a political dimension. The break with rationalism, foundational to the Kantian understanding of reflectivity, comes philosophically with Nietzsche who embraced the multiplicity of perspectives that constitutes knowing: “There is only perspective seeing, only a perspective ‘knowing’… the more eyes, different eyes, we can use to observe one thing, the more complete … our objectivity” (Nietzsche, 1967, p.  119, cited in Tauber, 2010, p. 162). In terms of intentionality and hence the mode of reflecting, Nietzsche, instead of grounding it in rationality like Kant or striving for a rational Ego that can govern desires (as argued later by Freud), resorts to the imperative of human biology in the form of the will to power. This will, he claims, is innate to all persons as a positive force but gets largely suppressed by social and religious conventions. In the Nietzscheans tradition, self-awareness and hence reflection assumes a positive stance towards submerged layers of consciousness as it asserts the non-­ divisibility of mind and body.

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The transition from pre-reflective intuitions, or pre-reflective self-consciousness, to reflective higher-order judgements became a central theme in phenomenological philosophy in the tradition of Husserl whose work is devoted to a clearer understanding of intentionality. The intentional structure of consciousness depends on the reflective analysis of various forms and levels of experience through which intentionality or meaning can be attributed to the actions that make up experience. Reflecting at this level liberates humans from being preoccupied with the “real existence” of the objective world (Moran, 2005). In this phenomenological tradition, Sartre expanded the role of reflecting to a key existential activity that, as a constant making of choices, grounds both the self and the freedom of the choosing self, even though he postulated that self-consciousness is “pre-reflective”. Overall, his philosophical treatment of reflectivity brought the “bodily” dimensions of consciousness back into the philosophical debate (Wider, 1997) which today has gained great actuality. In certain contrast, the Frankfurt School emphasised again the role of rationality in the Kantian tradition. Members like Horkheimer and Adorno established their version of “critical reflection” as not just an intellectual but as a practical political act that is, however, always conscious of the oppressive potential of rationality as a technocratic tool. Habermas went on to link reflectivity very explicitly to the human ability to communicate, seeing reflectivity ideal-typically realised in “public discourses” where consensus over normative issues is at stake (Habermas, 1984). This position lay the ground for what in our texts will be termed “dialogical” or “democratic reflectivity”.

Sociological Perspectives on Reflectivity Sociology as perhaps the most characteristic discipline as a product of modernity deals with the factors and processes that constitute the social fabric of society. And since modern societies emerged from a process which Giddens (1991) terms “disembedding” from traditional bonds and structures, they are increasingly founded on the will of citizens to determine their own terms of reference for the kind of society they want to live in and ultimately for the kind of individual they choose to be. This transformation from what Durkheim (1984) called “mechanical” to “organic” solidarity required the ever more comprehensive formation and activation of reflective abilities as the mental precondition for these constant personal choices. Modern social conditions caused a dynamic interplay about a dynamic interplay between what sociologists call “agency” and “structure” because, although the latter is represented by and works its influence through binding and external and, in many ways, material conditions, these can never totally determine the individual behaviour of people. It could be said that sociology in all its versions has hence been concerned with the relations between agency and structure. Reflectivity from a sociological point of view mirrors this interplay between agency and structure.

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In sociology, the work of G. H. Mead (1934) became very influential through highlighting this link from the perspective of social psychology and indeed of philosophy by taking up Kant’s notion of the transcendental self. He sees reflexiveness as “the turning back of experience of the individual upon himself” and states that “it is by means of reflexiveness that the whole social process is brought into the experience of the individuals involved in it” (Mead, 1994, cited in Aboulafia, 2022). From this, he derives the dual functional constitution of the self as “me”, meaning the self that forms in relationship to a generalised “other”, and as the “I” that can take position towards the social role ascriptions and constitutes a sense of freedom and initiative. The awareness of this interdependence rests in turn again on a function of the “me”: “The action with reference to the others calls out responses in the individual himself  – there is then another ‘me’ criticizing, approving, and suggesting, and consciously planning, i.e., the reflective self” (Mead, 1934, cited in Aboulafia, 2022). Parsons elaborates on the effects that the increasing structural differentiation of modern societies has on the formation of the “self”. It “produces increasing pluralization of the role-involvements of the typical individual. This means both an often-­ bewildering range of possible choices and complex cross-pressures once commitments have been made” (Parsons, 1968, p. 11). This renders reflectivity an essential tool for one’s social orientation in society. Reflectivity in the work of Habermas follows the notion of “critical reflexivity” which is central to the Frankfurt School (see above) but places it in the context of his theory of communication. Reflectivity for him is linguistically constituted: “because of the reflexive character of natural languages, speaking about what has been spoken, direct or indirect mention of speech components belongs to the normal process of reaching an understanding” (Habermas, 1979, p. 18). The reflective form of communicative action for him has a central social and political function as an interactive means of establishing valid truth claims (Habermas, 1984). When ordinary speech is raised to the reflexive level of “discourse”, it means “that processes of argumentation and dialogue in which the claims implicit in the speech act are tested for their rational justifiability as true, correct or authentic” (Bohman & Rehg, 2017). Enabling and enhancing reflectivity is the ontological foundation of communication through language which thereby assumes a political function in democracies since they rely ideal-typically on open public discourses for their legitimation. Reflective processes at interpersonal and political level ensure for Habermas the connection between structure and agency. Giddens approaches the relationship between structure and agency differently, thereby also giving reflectivity a different role. His view of modernity, which has been taken up very forcefully by Archer (2012), is that it has made reflectivity a necessity, both for individuals and for society: “The self, like the broader institutional contexts in which it exists, has to be remade reflexively” (Giddens, 1991, p.  3). Rather than merely promoting critical reflecting as an emancipatory task, Giddens recognises that this modern self can also become paralysed by an overload of options between which it has to constantly choose. He therefore acknowledges the stabilising function of routines in everyday contexts so that reflectivity comes into play mostly only in unexpected situations. “The need for reflexivity is contextually

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bound and is mobilized when discontinuities arise amidst practice and the pre-­ conscious platforms that shape the habitus” (Akram & Hogan, 2015, p. 618). This dual aspect of reflectivity, which already was noticeable in philosophical developments, now features in sociological debates following on from Bourdieu’s introduction of the term “habitus” as distinct from “habit” (Bourdieu & Wacquant, 1992, p. 22). While the latter implies acting habitually, and hence without any reflective examination of reasons or intentions, habitus in a sense is both the product and the producer of reflectivity. In relation to the sociological concern with agency and structure, operating with a comprehensive notion of reflectivity that constitutes habitus means for Bourdieu: “The habitus is both structured – through a subject's active, practical engagement with the social world over time – and structuring – the practices generated on the basis of these dispositions contribute to the ongoing production of the social world” (Farrugia & Woodman, 2015, p. 630). This means that members of societies are socialised into reflecting in certain patterns that express their agency but also their being bounded by, and in turn contributing to, structural social inequalities. Creativity, one of the hallmarks of reflectivity, for Bourdieu is not based on cognitive rationality but represents “spontaneity without consciousness or will” (Bourdieu, 1990, p. 56), however always within the limits of the respective habitus. Following on from Giddens and Bourdieu, the observation that the modern self has undergone radical changes that manifest themselves as a heightened emphasis on reflectivity has become an important debate in recent sociology, particularly with regard to its reliance on rationality as against its embeddedness in culture and social context (Adams, 2003). The post-modern delusion with rationality opened the way to a more holistic way of conceptualising reflecting in sociology which in a way takes in a much wider range of psychological considerations. Archer states for instance, “Our ultimate concerns are sounding-boards, affecting our (internal) responses to anything we encounter, according to it resonating harmoniously or discordantly with what we care about most” (Archer, 2012, p. 22). Accordingly, for her the resulting life projects, which increasingly require “relational reflexivity”, result in either stagnation within existing structures (“morphostasis”) or “morphogenesis” as their transformation (Archer, 2012). Her empirical analysis of the way young people cope with this “reflexive imperative” suggests four categorises: the “communicative reflexives”, a group in decline, “who seek the intergenerational replication of their familial relationships” (Archer, 2012, p. 125) and hence find it difficult to fit into the “morphogenic social order” that has arisen; the “autonomous reflexives”, who by contrast seek change and pursue their interests competitively according to opportunities, thereby promoting a new social order; the “meta-­ reflexives”, who deal with and contribute to change by way of seeking “critical detachment” and living by ethical and political principles even when this means loneliness and does not bring them personal advantage; and finally, the also growing category of “fractured reflexives”, who according to Archer represent young people whose reflective abilities are either under-developed or who get paralysed by the abundance of “situational opportunities”, a logic characterising the new social order of contemporary societies. This sociological analysis provides a differentiated view of the actual social importance of reflectivity for the realisation of agency under conditions of

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accelerating social change in as much as it underlines the importance of reflective abilities reaching a “meta-level” in order to help individuals to engage creatively and constructively with social structures that have become disengaged from “habits”. Archer’s limited empirical findings give rise to the hope that a growing number of young people, albeit those with a sufficiently stable family background, are capable of achieving this and could therefore rise to the immense global challenges facing politics like global justice and equality, peace and social integration, and this in conjunction with ecological stability. Golob and Makarovič (2022) in their empirical study confirm the importance of meta-reflectivity in the efforts by individual members of late-modern society to steer this morphogenesis in the direction of responsibility and state: “Through their reflexive deliberations, they are able to engage in actions and behavioral practices that contribute to the transformation of the initial socio-cultural conditions” (Golob & Makarovic, 2022, p.  2). It leaves open, however, how this meta-level of reflectivity relates to the habitual or unconscious predispositions for acting which retain their basic influence under changed social conditions or which play even a greater role, given the considerable efforts that need to be invested in higher levels of reflectivity in the face of an incremental growth of life-choices to be made. One way or the other, reflectivity remains a central sociological topic in recognition of its vital importance for how well individuals can cope with social change and how societies as a whole can ward off dangers of disruption through lawlessness, war or ecological threats. Fostering competence in reflecting emerges from these analyses as a comprehensive societal concern.

Reflectivity in Light of Newer Neuroscientific Research Newer neuroscientific research supports the crucial significance of primordial body experiences for building the sense of identity/self, actualising and adapting its meaning (Schacter et al., 2007). They can modify choice, perception and interpretation of the selected “cues” a person receives from the environment (Felin & Koenderink, 2022). This research leads to a more holistic concept of reflectivity/ reflexivity that transcends the often difficult distinction between body-mind, intentional-­unintentional or aware-unaware processes. This neuroscientific research helps to distinguish various levels of reflectivity from a physiological perspective. In this sense, the work of Lieberman et al. (2002) sheds new light on the otherwise confusing duality between the terms reflectivity and reflexivity. This group of scientists elaborate on the “dual-process model of automatic and controlled social cognition” (Lieberman et al., 2002, p. 200) which had become well established in cognitive social psychology. They distinguish between two neurocognitive systems, the X-system (which stands for the X in reflexive) and the C-system (for the C in reflective). According to these authors, the two systems are instantiated in different parts of the brain, carrying out different kinds of “inferential operations”, and are associated with different mental experiences but working together build a coherent and constantly interacting whole. The

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X system “corresponds roughly to an automatic social cognition system” and to the neural regions associated predominantly (but not solely) with the lower brain structures, such as the amygdala and basal ganglia (Lieberman, 2007a, p.  261). The C-system corresponds to “a controlled social cognition system”, and the main (but far from only) region associated with the C-system is the lateral prefrontal cortex (LPFC) (Lieberman, 2007a, p.  261). Findings suggest that while the “X-system processes may be linked to our ongoing experience of the world, colouring the semantic and affective aspects of the stream of consciousness, the C-system, and LPFC in particular, appears to be linked to our experience of responding to the world and our own impulses with our freely exerted “will” (Lieberman, 2007b, p. 9). This research evidences the importance of taking “embodied” rather than purely rational or logical aspects into account when building up a comprehensive and differentiated understanding of processes of reflecting. It attributes a certain reflective value to, for instance, the understanding of empathy and thereby goes beyond the “theory of mind” approach by distinguishing between “(a) an emotional and experiential response that approximates that of the target and (b) an awareness and identification of this emotion as referring to the target’s experience” (Lieberman, 2007a, p. 264). The detailed analysis of self-focused reflecting processes, which include reflecting on past experiences, current position of self in relation to others and future intentions, confirms those composite features at the neurological level which had been proposed in the context of modern philosophy and sociology, namely that these self-concepts are a product of inner dialogues in which social norms as well as individual position-taking feature interactively at an automatic, a pre-conscious and a conscious level. This means that self-knowledge is made up of automatically accessible and deliberately accessed representations (Klein et al., 1992) that closely interact with each other. In terms of influences that might alter reflective processes of both kinds, there is some evidence emerging that “under processing conditions that favor automatic processing, X-system structures tend to be more active than C-system structures, whereas during conditions that favour controlled processing, C-system structures tend to be more active than X-system structures” (Lieberman, 2007b, p. 17). In terms of the educational opportunities of enhancing reflectivity as the more conscious shaping of X-systems through supported C-systems, it might be encouraging to note “that the C-system is largely evolved to override the X-system when the habits and impulses of the X-system are contextually inappropriate” (Lieberman, 2007b, p. 17). Nevertheless, the X-system is constantly and simultaneously being influenced by contextual conditions along pathways that evade the conscious control of the C-system. Apparently, this brought evolutionary advantages in as much as potentially threatening situations and hence stress of that kind need to be processed by the brain quicker than those less threatening and yet urgent conditions that require the advantage (but also the luxury) of conscious deliberation. However, whether modern circumstances that produce stress are of the same kind as those more “primordial” ones for which the neurological structures, evidenced in these studies, evolved (Esch & Stefano, 2010) is an open question. It therefore raises

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further issues for how best to prepare professionals for stressful work demands (McEwen, 1998), issues that, for instance, methods of professional supervision can address (see Chap. 7). In addition, it can be illuminating to look at this conceptual development through the distinctions used by Nehyba (2015). His typology of reflection is based on so-­ called attributes of reflection, which according to the author characterise the nature of reflection in analyses of various discourses. Attributes are understood as an essential property ascribed to the phenomenon of reflection within a certain discursive perspective. Nehyba (2015) names several attributes which include, for example, content of reflection (inner/outer, thoughts/feelings, self/others etc.), form (inner speech, dialog, written diaries, etc.), or processual polarities like conscious-­ unconscious, thinking-acting, intentional-unintentional, learning-maturation, social perspective (individual, group) or time perspective (actual-continual, past-future). The nature of these attributes in different patterns may constitute various meanings of the concept. The attributes are often complementary to each other. In this optic, the conceptual development of reflection in the history of science moves from rationally based reflecting self (I think therefore I am) to a complex hierarchical process of reflectivity which encompasses multi-layered, both autonomous and intentional modes of operating brain circuits (Evans & Stanovich, 2013, Lieberman, 2007b), semantic and neuronal networks of symbols. The meaning of the situation is formed on a continuum of the attributes: conscious-unconscious, intentional-unintentional, thought-action, internal-external, semantic-experienced-­ bodily. Questions provoking reflection draw attention to certain contents of consciousness and activate the corresponding neuronal networks. With the help of pure language, a new connection occurs, which is in fact the reconsolidation of previous ones, and a new shape of the network is thereby constructed (Lawley & Tompkins, 2000).

Reflection in Education and Social Work/Nursing The philosophical interpretations of the notion of reflecting had a direct influence on pedagogical approaches in the fields of education, social work and lately also nursing. Authors like James (1884), Dewey (1933) and later Kolb (1984) and Schön (1983) defined reflection as a process of conscious and deliberate processing of one’s own various sources of knowledge and derived from this ability pedagogical methods to deliberately work with them. Already in the work of the first pragmatists, particularly James and Dewey, knowing was being related to what is not pure rationalistic volitional effort, allowing thereby also for something to “happen” through living and doing things reflectively. For them, this type of reflectivity was facilitated by confrontations with reality and interaction with others. The concept of experience has consequently followed a similar route as the concept of reflection to take an important place in educational processes: Beside thinking, conceptualisation, planning and testing (Kolb, 1984), the notion of “experience” included later also feelings and behaviour (Boud et  al., 1985), tacit and intuitive knowledge

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(Schön, 1983) and interaction with a “situation” (Iedema, 2011), all these became the subject of reflection. Thanks to this development, a gradual distinction between reflection and purely rational thinking could be made. The work of Schön and the Kolbs had considerable impact on the way social work education paid attention to reflectivity, given that practice experience had always played an important role in the academic and professional development of that discipline, as will be outlined in Chap. 2. However, many renowned authors in social work, education or psychotherapy till now understand reflection of experience as an intentional thinking process (D’Cruz et al., 2005). Ferguson (2018) and Fook (1999), in the broader tradition of the enlightenment and its emphasis on “critique”, see in reflection a kind of cognitive activity like analysing, planning, interpreting or evaluating. The influence of “technical” rationality has been identified even in Donald Schön’s illuminating concept of reflective practice and the reflective practitioner (1983) which he bases on tacit knowledge. This shows how difficult it is to shift the understanding of reflection away from a rationalistic to a more holistic view even when speaking of “reflection through action or as action” (Clegg, 2000). Bleakley’s (1999) characterisation of reflection as action then necessitates both an awareness of the self and environment by way of involving also the body which emphasises the importance of now including neuroscience considerations. This is evident also from developments in nursing education where reflectivity has assumed growing significance. The educational approaches which this volume seeks to promote for social work and nursing education and which will be presented in subsequent chapters aim therefore at implementing a multi-layered and multidisciplinary understanding of reflectivity that connects personal psychological processes with the wider organisational and indeed socio-political context in which they take place.

Conclusion: How We Understand Reflection As stated initially and as illustrated by the references to philosophical, sociological and psychological insights on this conceptual complex, in this volume, we will use reflexivity as a broader term that includes reflectivity as its intentional part. In our view, working with this continuum gives space for considering also various semi-­ intentional or not-intentional modes of reflectivity/reflexivity when focusing on their role in professional training and practice. The importance attributed to the human ability to reflect in philosophy and its ever more prevalent role in modern societies from a sociological point of view has been underlined by neuroscientific research that identifies it as a specific, continuous metacognitional activity of the brain. Its psychological function is to monitor and coordinate the neuronal processess from a specific “point of view” of the individual Self. This process in turn helps to confirm a stable sense of identity and allows to construct a situation-specific meaning-gestalt from cues selected both from inside the mind’s repertoire and from outside stimuli. Another way to express

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it is that reflecting is a basic inborn ability that helps to frame and give meaning to everything that one engages in. The nature of cues and their processing is shaped by inborn brain structures (patterns), action and action context, semantic representations and situations where learning and social interactions occur. The nature of cues selected for the resulting actual gestalt is not limited to one modality (memory, perception, thinking, intuition, emotions, body sensations), but it can include various channels of transmission. Data between some channels may be directly integrated into a resulting meaning, since a common semantic network is already developed between the channels in the form of, for example, verbal representations or other representations through symbols. Other channels may not be related to a common semantic network, for example primordial body awareness. Therefore, some cues may not be immediately available for reflectivity as the conciouss construction of meaning. Therefore, different approaches have developed to overcome such limits. For example, in the processes of meditation training or in methods of mindfulness (Farb et al., 2007), subjects are guided not to jump on the usually available “cues” they have been using so far (as streams of thoughts, stereotypes or prejudices) but to postpone their inner reactions and to open themselves up to other cues/modalities in order to reflectively include a wider range of cues in their gestalt-formation. The universal purpose of reflection is to construct such gestalt-meanings from the position of the reflecting subject, which lead the person to a more viable handling of various situations. It can now be seen that this takes place informally on the personal level of physical and mental existence, as well as on the more formal level of a small group or organisation. It has also become institutionalised at various levels in society, for instance in the form of democratic processes, and can be regarded as characterising humanity as a whole through collective cultural manifestations of the symbolic representations of basic human experiences. When we attribute a central role to reflective abilities in the practice of social and health care professionals, this has to do with their competence repertoire being constantly challenged by new situations for which standardised and habitual responses might not be appropriate and in which actions that come spontaneously to mind might not be appropriate or sufficient. The context of these professional activities is changing very rapidly, as demonstrated by the Covid-19 pandemic and this calls for reflectivity being given even more attention on professional courses. It has to be remembered, however, that reflectivity as a professional commitment relates to and builds upon challenges now continuously faced by everybody in as much as our habitual ways of coping with everyday problems comes up against limitations that challenge us to perceive a problem from new angles and hence provokes reflection. What will be the gestalt (meaning, framework of understanding, vision) that will lead to a more viable version of coping is the subject of endless smaller or greater struggles that again take place on different levels of human existence.

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References Aboulafia, M. (2022). George Herbert Mead. In E. N. Zalta (Ed.), The Stanford encyclopedia of philosophy (Summer 2022 Edition). https://plato.stanford.edu/archives/sum2022/entries/mead/ Adams, M. (2003). The reflexive self and culture: A critique. British Journal of Sociology, 54(2), 221–238. https://doi.org/10.1080/0007131032000080212 Akram, S., & Hogan, A. (2015). On reflexivity and the conduct of the self in everyday life. The British Journal of Sociology, 66, 605–625. https://doi.org/10.1111/1468-­4446.12150 Archer, M. (2012). The reflexive imperative in late modernity. Cambridge University Press. Arendt, H. (1978). The life of the mind. Vol I: Thinking. Harcourt Brace Jovanovich. Augustine. (2002). On the trinity: Books 8–15 (G.  B. Matthews, Ed., S.  McKenna, Trans.). Cambridge University Press, Balanovskiy, V. (2018). What is Kant’s Transcendental Reflection? In Proceedings of the XXIII World congress of philosophy. Vol. 75, “Theories of knowledge and epistemology”, pp. 17–27. https://doi.org/10.5840/wcp232018751730 Beck, U. (1994). The reinvention of politics: Towards a theory of reflexive modernisation. In U. Beck, A. Giddens, & S. Lash (Eds.), Reflexive modernization (pp. 1–55). Polity Press. Bleakley, A. (1999). From reflective practice to holistic reflexivity. Studies in Higher Education, 24, 315–330. Bohman, J., & Rehg, W. (2017). Jürgen Habermas. In E. N. Zalta (Ed.), The Stanford encyclopedia of philosophy (Fall 2017 Edition). https://plato.stanford.edu/archives/fall2017/entries/ habermas/ Boud, D., Keogh, R., & Walker, D. (1985). Promoting reflection in learning: A model. Reflection: Turning reflection into learning. Routledge. Bourdieu, P. (1990). The logic of practice. Polity. Bourdieu, P., & Wacquant, L. J. D. (1992). An invitation to reflexive sociology. Polity Press. Clegg, S. (2000). Knowing through reflective practice in higher education. Educational Action Research, 8(3), 451–469. https://doi.org/10.1080/09650790000200128 D’Cruz, H., Gillingham, P., & Melendez, S. (2005). Reflexivity, its meanings and relevance for social work: A critical review of the literature. British Journal of Social Work, 37(1), 73–90. https://doi.org/10.1093/bjsw/bcl001 de Chardin, T. P. (1956). Le phénomène humain. Les Éditions du Seuil. Dewey, J. (1933). How we think. Prometheus Books. (Original work published 1910). Durkheim, E. (1984). The division of labour in society. Macmillan. Esch, T., & Stefano, G. B. (2010). Endogenous reward mechanisms and their importance in stress reduction, exercise and the brain. Archives of Medical Science, 6(3), 447–455. https://doi. org/10.5114/aoms.2010.14269 Evans, J. S. B. T., & Stanovich, K. E. (2013). Dual-process theories of higher cognition: Advancing the debate. Perspectives in Psychological Science, 8, 223–241. Farb, N.  A. S., Segal, Z.  V., Mayberg, H., Bean, J., McKeon, D., Fatima, Z., & Anderson, A. K. (2007). Attending to the present: Mindfulness meditation reveals distinct neural modes of self-reference. Social Cognitive and Affective Neuroscience, 2(4), 313–322. https://doi. org/10.1093/scan/nsm030 Farrugia, D., & Woodman, D. (2015). Ultimate concerns in late modernity: Archer, Bourdieu and reflexivity. British Journal of Sociology, 66(4), 626–644. https://doi. org/10.1111/1468-­4446.12147 Felin, T., & Koenderink, J. (2022). A Generative View of Rationality and Growing Awareness. Frontiers in Psychology, 13. https://doi.org/https://doi.org/10.3389/fpsyg.2022.807261 Ferguson, H. (2018). How social workers reflect in action and when and why they don’t: The possibilities and limits to reflective practice in social work. Social Work Education, 37(4), 415–427. https://doi.org/10.1080/02615479.2017.1413083 Fook, J. (1999). Reflexivity as method. Annual Review of Health Social Science, 9(1), 11–20. https://doi.org/10.5172/hesr.1999.9.1.11

1  Introduction: Reflectivity in Philosophical, Sociological, Psychological…

15

Giddens, A. (1991). Modernity and self-identity. Self and society in the late modern age. Polity Press. Golob, T., & Makarovič, M. (2022). Meta-reflexivity as a way toward responsible and sustainable behavior. Sustainability (Switzerland), 14(9). https://doi.org/10.3390/su14095192 Habermas, J. (1979). Communication and the evolution of society. Polity. Habermas, J. (1984). The theory of communicative action (Vols. 1 and 2). Beacon Press. Havrdová, Z., Šolcová, I., & Děchtěrenko, F. (2020). Dotazník sebereflexe (SRIS) a Filadelfská škála všímavosti (PHLMS): psychometrické charakteristiky českých verzí [Self Reflection and Insight Scale (SRIS), and Philadelphia Mindfulness Scale (PHLMS): Psychometric properties of the Czech versions]. Československá psychologie, 64, 535–549. Havrdová, Z., Růžička, M., & Lorenz, W. (2022). Between practical and dialogic reflection in social workers and general nurses. Sociální práce/Sociálna práca, 5, 92–106. Iedema, R. (2011). Creating safety by strengthening clinicians’ capacity for reflexivity. BMJ Quality and Safety, 20(Suppl. 1), i83–i86. James, W. (1884). What is an emotion? Mind, IX(34), 188–205. https://doi.org/10.1093/mind/ os-­IX.34.188 Jorgensen, L.  M. (2020). Seventeenth-century theories of consciousness. In E.  N. Zalta (Ed.), The Stanford encyclopedia of philosophy (Spring 2020 Edition). https://plato.stanford.edu/ archives/spr2020/entries/consciousness-­17th/. Accessed 15 Sept 2022. Klein, S. B., Loftus, J., Trafton, J. G., & Fuhrman, R. W. (1992). Use of exemplars and abstractions in trait judgments: A model of trait knowledge about the self and others. Journal of Personality and Social Psychology, 63, 739–753. Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Prentice Hall. Kraus, K. T. (2020). Kant on self-knowledge and self-formation: The nature of inner experience. Cambridge University Press. Lawley, J., & Tompkins, P. (2000). Metaphors in mind: Transformation through symbolic modelling. Crown House Publishing. Lieberman, M. D. (2007a). Social cognitive neuroscience: A review of core processes. Annual Review of Psychology, 58(1), 259–289. https://doi.org/10.1146/annurev.psych.58.110405.085654 Lieberman, M.  D. (2007b). The X- and C-systems: The neural basis of automatic and controlled social cognition. In E.  Harmon-Jones & P.  Winkielman (Eds.), Social neuroscience: Integrating biological and psychological explanations of social behavior (pp. 290–315). The Guilford Press. Extract: http://www.scn.ucla.edu/pdf/X&C%20(in%20press).pdf. Accessed 20 Oct 2022. Lieberman, M. D., Gaunt, R., Gilbert, D. T., & Trope, Y. (2002). Reflection and reflexion: A social cognitive neuroscience approach to attributional inference. Advances in Experimental Social Psychology, 34, 199–249. McEwen, B. S. (1998). Protective and damaging effects of stress mediators. New England Journal of Medicine, 338(3), 171–179. Mead, G. (1934). Mind, self, and society. University of Chicago Press. Moran, D. (2005). Edmund Husserl: Founder of phenomenology. Polity Press. Nehyba, J. (2015). Reflexe mezi diskursy: Hledání atributů reflexe pro pedagogickou vědu. Dizertační práce [Reflection between discourses: The search for attributes of reflection for educational science]. Dissertation. Masarykova University. Newman, L. (2015). Cogito Ergo Sum. In L.  Nolan (Ed.), The Cambridge Descartes Lexicon (pp. 128–135). Cambridge University Press. https://doi.org/10.1017/CBO9780511894695.056 Ng, K. (2020). Hegel’s concept of life: Self-consciousness, freedom, logic. Oxford University Press. Parsons, T. (1968). The position of identity in the general theory of action. In C.  Gordon & K.  J. Gergen (Eds.), The self in social interaction (Classic and contemporary perspectives) (Vol. 1, pp. 11–23). Wiley.

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Redding, P. (2020). Georg Wilhelm Friedrich Hegel. In E. N. Zalta (Ed.), The Stanford encyclopedia of philosophy (Winter 2020 Edition). https://plato.stanford.edu/archives/win2020/entries/ hegel/. Accessed 25 Sept 2022. Schacter, D.  L., Addis, D.  R., & Buckner, R.  L. (2007). Remembering the past to imagine the future: The prospective brain. Nature Reviews Neuroscience, 8(9), 657–661. https://doi. org/10.1038/nrn2213 Schön, D. (1983). The reflective practitioner: How professionals think in action. Basic Books. Smith, J. (2020). Self-consciousness. In E.  N. Zalta (Ed.), The Stanford encyclopedia of philosophy (Summer 2020 Edition). https://plato.stanford.edu/archives/sum2020/entries/self-­ consciousness/. Accessed 24 Sept 2022. Tauber, A. I. (2010). The odd triangle: Kant, Nietzsche, and Freud. In A. I. Tauber (Ed.), Freud, the reluctant philosopher (pp. 146–173). Princeton University Press. Wang, & King. (2006). Understanding Mezirow’s theory of reflectivity from Confucian perspectives: A model and perspective. Radical Pedagogy, 8(1), 1–17. Wider, K. (1997). The bodily nature of consciousness: Sartre and contemporary philosophy of mind. Cornell University Press.

Chapter 2

The Significance of Reflectivity in Professional Social and Health Care in Relation to Changing Socio-Political Contexts Walter Lorenz

As has been demonstrated in Chap. 1 of this volume, the notion of reflectivity has assumed a growing significance in modern societies. Reference was made to the connections between philosophical, sociological and psychological approaches to the concept which account not only for its pervasiveness but also for its multiple meanings. This chapter looks more specifically at the relationship between academic and professional interpretations and uses of reflectivity on one side and the sociopolitical framework conditions under which it is being practised on the other. The awareness of the possible impact of organisational and political interests in a particular version of reflectivity concerning the way it is being understood and practised has considerable implications for the teaching and further development of this competence, which will be the subject of subsequent chapters. The example of how and in what form reflectivity plays a role in the academic and practice context of the two professions of social work and nursing, which was the subject of the research project underpinning this volume, can provide particular insights into the differential impact of structural framework conditions at various stages of the establishment of both professions (Čajko, Lorenz, & Havrdová, 2021). This in turn can provide reference points for current and future developments in other professional contexts in which more and more emphasis is also being placed on reflectivity as a professional attribute.

W. Lorenz (*) Faculty of Humanities, Charles University, Prague, Czech Republic e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Lorenz, Z. Havrdová (eds.), Enhancing Professionality Through Reflectivity in Social and Health Care, https://doi.org/10.1007/978-3-031-28801-2_2

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Reflectivity, Science and Professional Epistemology Comparing the history of professionalisation in two related human service fields, social work and nursing, through the lens of the role that reflectivity assumed in the process of gaining professional recognition and autonomy in the respective ambits against the background of general developments in modern universities, offers interesting insights into the process of practice-relevant knowledge creation. Both professional areas have grown out of practice experience without the initial backing by an equivalent academic discipline so that reflectivity in these cases assumed a dual purpose. Firstly, it constituted the process of “filtering” and extracting knowledge from practice experiences through their intellectual evaluation in what could be described as a deductive effort so that single incidents and “cases” could yield generalisable insights. Secondly, in a kind of inductive process, reflecting was turned into a specific practice competence that formed a continuous part of the professional skills repertoire. While medicine is certainly a profession that also arose from the direct practical involvement with illnesses and the systematic accumulation and scrutiny of observations, it has always had the backing at university level for the processing of this information, and this form of academic legitimation in turn served as a mark of distinction against non-academic (and largely non-conventional) forms of medical practice (Bynum, 1994). In the case of a younger profession, that of psychology, the academic connection and the resulting professional status and power was also associated with its location in the university and partly built on the growing dominance of positivist models of knowledge in the sciences. This accounted in some countries for the shift from being part of a philosophical to a natural science faculty. But its connections to philosophy also helped to address the inevitability of subjectivity when humans research human behaviour and hence philosophical notions of reflexivity were of considerable use in this discipline (Danziger, 1990). Measured by core demands of modernity, those of rationality, objectivity and universality, natural sciences could claim a certain position of superiority in academia over and against disciplines in the so-called humanities, which could not aspire to adhering to the same “modern” criteria on account of the inevitable elements of subjectivity involved in “making sense” of documents and artefacts of literature, history or aesthetics. In the humanities, the observing scientist cannot be divorced from the observed “objects” as easily as in the natural sciences, and this challenge was frequently met with references to the importance of reflectivity in human sciences, particularly in psychology and sociology. Here, reflecting broadly means evaluating positively the subjective aspects of research because they convey meaning, whereas in the natural sciences, reflecting signifies more the objective sifting of evidence arising from observations. This means that despite all the exchanges between natural science and arts and humanities subjects that have developed in universities, the two traditions still represent distinct approaches to the processing of knowledge. This indicates that already the respective disciplinary context in which training is located at the university level had considerable influence over the meaning and use of reflecting as a key academic learning and

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knowledge-­creation tool and in connection with that over the status of a discipline in academia and more generally in society. The most fundamental element of the cognitive act of reflecting, the foundation of all scientific research, consists in the ability to weigh up the validity of different kinds of information concerning a specific phenomenon according to systematic procedures in order to arrive at an interpretation (Whitaker & Atkinson, 2021). These can be said on the natural science side to aim at the elimination of aspects of subjectivity on the part of the observer or analyst as they might carry the risk of “contaminating” the quality of emerging knowledge and the subsequent effectiveness of its application. On the side of the humanities, subjectivity has to be deliberately factored-in because only subjects can be carriers and participants of meaning. Human contexts are suffused in meaning and hence in normative values which have to be taken into consideration reflectively in order to arrive not only at the right conclusion but at a socially and ethically justifiable line of action. Reflecting in the humanities can be described as a hermeneutic process that contextualises knowledge and at the same time individualises it so that it applies to unique persons and situations and yet transcends this uniqueness by being processed in language (Alvesson & Sköldberg, 2009). Nevertheless, as Kuhn’s (1970) analysis of paradigm shifts points out, reflectivity is also a driving force of reaching new levels of understanding in the natural sciences. As an ongoing process of checking empirical data against existing explanatory theory frameworks, it can lead to the questioning of the entire prevailing theory paradigm in a discipline and thereby trigger periodic revisions of the most fundamental premises. However, the central criterion across the paradigm shifts remains the effectiveness with which new theories grasp phenomena and make them universally applicable. This always associates this kind of scientific reflectivity with criteria of efficiency and instrumental purpose.

Reflexivity and Modernity The attitude of reflectivity developed its significance for modern social and political processes out of the enlightenment movement. This was summarised by Kant’s famous definition of enlightenment as “man’s emergence from his self-incurred immaturity (Unmündigkeit)” (Kant & Wood, 1996, p. 11), which he linked to the so-called sapere aude, which is an exhortation to dare to know and hence to use rational faculties as the essence of reflecting (Kant, 1992). It brings into play a rational approach to self-knowledge in the form of an inner experience (Kraus, 2020) and expresses the confidence that “‘rationality’ describes the human capacity for a reflexive mastering of practice problems” (Honneth, 1987, p. 696). This emancipatory project manifested itself subsequently at the academic level in the form of the development of modern science subjects independent of religious and other ideological influences, at social and economic levels in the change from mechanical to organic forms of solidarity and the growing division of labour (Durkheim, 1960) and at the political level with the drive towards democratic forms of the legitimation

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of political power (Goodin, 2003). At all these levels, it spells an increase of autonomy of the individual on account of the use of reflective deliberations and at the same time an increase in responsibility for the consequences of one’s actions. The ideal notions of modern democracy, irrespective of the great variety of political implementations of democratic principles, build on the individual’s ability and willingness to exercise rational choices as a means of legitimating the power of governments in representative decision-making (Schumpeter, 2011). The link to rational faculties, and hence to Kantian notions of reflective abilities, is demonstrated by the fact that the right to vote in elections was only gradually expanded from privileged male property owners to all adult males and finally to women in the acceptance of the principle of universal suffrage (Sowerwine, 1982) and today still contains restrictions for younger people who are presumed not to be capable of making such deliberative choices. But in contrast to the kind of (highly selective but continuous) form of Athenian democracy, modern politics largely depend on a process of delegating ongoing decision-making to elected representatives and hence to an elite who, through party systems, shape and condense the options for the electorate in the form of programmes and visions. Constant political voting and participation would lead to ungovernable conditions and is regulated in periodic referenda even in the Swiss case of direct democracy. Parliamentary democracy, as it gradually developed in the course of the nineteenth century beginning with Western countries, automatically sets up an institutional tension with regard to the growing insistence on the rights – and capacities – of individual citizens to reflect on and act upon their interests which the mere act of voting does not satisfy or even denies in as much as a majority consensus is counted as “the general will” of “the people” (Rosanvallon, 2011a). The tension becomes visible in relation to two developments parallel to the establishment of political democracy in forms of “direct participation” that are not dependent on numeric majorities. On the one hand, the economic system of capitalism created the market as an instrument in which the (presumed) rational reflective choices of individuals as sellers and buyers of goods and services can be directly negotiated (Coleman & Fararo, 1992). This sets up its own type of reflective logic where the consequences of one’s actions become mostly immediately visible or at least calculable which means that it favours purposeful-rational forms of reflexivity and action in Weber’s sense. On the other hand, the phenomenon of civil society assumes a specific significance in the overall political process by giving voice and some organisational structure to interests and groupings, outside the parliamentary structures but as their influential context, through creating the “public sphere” (Habermas, 1989). These political developments leave it open whether democracy remains an incomplete and fragile project because of the insufficient reflective capacities of the mass electorate (Dewey, 1927) or whether democratic rituals become geared towards actively dampening or even eliminating such reflective competences in the general population, especially once the development of mass media set in as a factor in political elections (Phillips, 2000). In any case, this uncertainty calls for processes and structures of legitimation of political power and of power in society in general. This weakness in the formal processes of democracy puts the spotlight on

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the supportive reflexive elements of democracy and their corrective contribution to making governmental power legitimate. As Rosanvallon argued, the voting act itself is insufficient for that, and legitimacy for democratic systems, since the American and the French revolutions, was increasingly being provided from additional societal sources in the form of third parties and institutions. Such examples are independent watch-dog and service institutions that ideally epitomise impartiality in their monitoring of the correctness and impartiality not only of political but also of public administrative processes. Most evidently, however, the institution of constitutional courts assumes this function through their presumed independence from the political system and provides “legitimacy of reflexivity” (Rosanvallon, 2011b, p. 118). This author’s conclusion of his analysis of the creation of reflexive public legitimation processes is: “Without reflexivity, no subject can take form, and no history can be sketched” (Rosanvallon, 2011a, p. 134). The general historical growth of expert systems and their particular contribution to modern societies in terms of building trust and legitimacy has to be seen in the context of the development of modern democratic structures. They can be broadly categorised into private-commercial and public non-profit organisations. The former receive their legitimation largely through direct interactions with service users or customers who, at least in the abstract sense, make their individual decisions whether to use them or not and under what kind of conditions. The latter do not or cannot, ideal-typically, rely on this mechanism because they are not being financed and hence influenced by direct transfers from service users. Instead, their legitimation, and in turn their legitimating function for the overall political system, relates to the notion of accountability, and this in a dual sense. As public institutions, they are accountable to the political organs which give them their financial and legal structure and define their broad function. As such, they are legitimated through the democratic process itself which, in a broad sense, relates back to the reflective capacities of the voting citizens and their choices in elections. But they also function as a kind of third-party institutions which in turn contribute to and strengthen the legitimacy of the political system by being directly accountable to the users and even more so to independent ethical standards. The normative profile of public institutions and its perception among citizens is an important indicator of the trust they can have in political institutions and processes. These considerations have particular relevance for the role professions take on in modern societies. For them, an additional axis of accountability comes into play, independent of whether they operate in the private commercial or the public sphere, namely, one that relates accountability to the independence of their professional knowledge which at that time was growing rapidly owing to the expansion of scientific research. It becomes the hallmark of professionalism that members of these groupings, which often organise themselves in “chambers”, distinguish their acting by a high degree of autonomy from external regulation and constraints, even when in most cases they owe their institutional existence to governmental initiatives (Burns, 2019). This self-referentiality can only be perceived as legitimate if it is based on a corresponding attitude and competence of reflectivity members of professions apply in relation to the scientific sources of their knowledge, the forms in

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which qualifications are accredited, the regulatory context which defines them, ethical standards of conduct and the perception of the service in the eyes of the users. Modern professions in that sense operationalise rationality in the tradition of Kant but resist conforming to Weberian bureaucracies (Porter, 2020), and this on account of their aiming to realise the element of rational reflectivity contained in that Kantian rationality project. Of course, in actual practice, additional factors like the fact that early professionals were predominantly men and belonged to a distinct privileged class served to “insulate” them from the necessity to render the aspect and practice of reflectivity fully transparent. This put professions early on under suspicion of being self-referential and elitist instead of truly reflective, especially since this organisational form could also command high levels of income. But the expectation of independence applies first and foremost to the legal profession and the institution of constitutional courts through which “reflexivity thus becomes an exercise in lucidity and a reminder of reality” for the whole of society (Rosanvallon, 2011a, p. 143). In the judicial process, the deliberative element of reflectivity is “institutionalised”, and the “deliberative” functioning of courts, in which opposing views are being critically and controversially debated, can serve as a paradigm for the “internal” deliberative dimensions that are constitutive of professional reflectivity and plays also a role when individuals personally engage in reflecting. So far a highly idealised version was presented of democracy, of civil society institutions and hence also of professional organisations in modernity when in fact each of these contexts contains fundamental tensions and contradictions. These can predominantly be related to the fact that as reflectivity came to assume an ever more central function in all those contexts, the rational dimensions of this human faculty by no means determined the process of reflecting. The modern gesture of reflecting itself did not contribute to an overall increase in certainty in arriving at effective and legitimate decisions and hence at greater trust in science, expert systems, public institutions and political processes but on the contrary became also a source of uncertainty and a growing awareness of risk which impacted on the self-confidence particularly of social workers (Parton, 1998). This manifested itself strongly in the latter part of the twentieth century in what has been described as a crisis of modernity and in the phenomenon of “risk society” (Beck, 1992), but the tensions erupted periodically well before in the form of scientific paradigm shifts as well as in political revolutions and system changes. To sum these up in terms of the understanding of different aspects of reflecting and their practical application in personal, professional and political decision-­ making, the historical overview reveals fundamental tensions that concern the preconditions for reflecting abilities. Here, firstly, the question is whether these lie in the “transcendental” a priory faculties of every human mind to use reasoned rationality or whether these faculties need to be developed through education or socialisation so as to become competent and responsible guides for action. Secondly, there is the question whether reflectivity is primarily a cognitive-rational phenomenon or whether irrational, affective and habitual dispositions do not play a greater and perhaps decisive role in reflecting and have to be treated as legitimate and constructive

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rather than obstructive to rational considerations. Thirdly, the tension concerns the contents of what needs to be reflected upon and whether these can be generated or selected by individuals themselves or whether they are of necessity socially, culturally or politically “pre-structured” as concrete categories of choices whose contents individuals have always already internalised as “pre-judgements”. And finally, there is the tension over the purpose of reflectivity and whether this is defined more by concrete demonstrable outcomes, achievements or products of reflecting or by the meaning that people engaged in reflecting derive for themselves from the process without them necessarily having a visible effect. In view of these considerations, it is not surprising that the notion of reflexivity came to carry such a wide variety of meanings.

 he Role of Reflecting in the Development of Educational T Programmes in Social Work Raising these questions calls for the examination of the concept under various disciplinary perspectives, as is the purpose of various chapters of this volume. The concern here is to relate the epistemological ambiguities of the concept to specific organisational and political contexts as they concern the social and health professions. The conditions outlined under which modern societies evolved and with them modern professions form the background against which also professional developments in social work and nursing took place. The fact that both were for a long time only regarded as “semi-professions” gives important additional insights into the role of reflectivity in relation to academic status and professional autonomy. Looking at the historical development of systematic and later academic training in social work, this began with pioneers who were largely volunteers engaged in civil society organisations such as philanthropic and charitable organisations. They recognised that the rapidly growing negative social effects of industrialisation, urbanisation and secularisation in the nineteenth and early twentieth centuries could not be addressed effectively with sweeping policy measures of a punitive or a supportive kind, as had been the governmental responses in the early period of industrialisation, without creating secondary adverse conditions: The punitive intentions behind the establishment of prisons or work houses negated or at least relativised their benefits for society and delegitimised the system when they affected persons who “did not deserve” to be punished in that manner, and likewise welfare assistance measures that helped persons who did not “deserve them” on account of their irresponsible or devious behaviour failed in their “educational” objective (Lorenz, 2006). Realising this required training in more nuanced decision-making for volunteers in preparation for the matching of the person’s character and circumstances to available institutional responses. It involved considerations “case by case” that could not be cast in rules and regulations but were based on the careful analysis of cases from which “lessons” for future decisions could be derived (Payne, 2005).

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The archives of such voluntary organisations contain an abundance of such case descriptions, and their study aimed at sharpening both the observational and the reflective competences of members of these organisations (see Bosanquet, 1914). In this way, volunteers gradually developed into professionals in a process that had personal emancipatory implications for mainly women who trained and service implications in as much as interventions became less punitive (Waaldijk, 2011). Training programmes became ever more elaborate and combined this way of reflecting on individual cases with acquiring relevant general knowledge of hygiene, economics and law. These study programmes undoubtedly benefitted from the advance of related academic disciplines such as psychology, sociology or economics, but the key characteristic of the emerging profession of social work was always the synthetic and comprehensive approach to such discipline-specific knowledge which would allow practitioners to recognise the situation of individual persons in need in the context of their history, their social relationships and their material and political conditions. It was thereby acknowledged, as exemplified in the work of one of the first authors on professional social work Mary Richmond (Agnew, 2004), that the actual medium through which effective assistance can be given is not primarily the “superior” knowledge of the trained “expert” but whether knowledge had a beneficial effect depended additionally on the personal relationship through which knowledge could be brought to bear and to interact with the knowledge and life experience of the “recipient”. This means that, even where the term and the “technique” of reflectivity were not openly referred to in these early study programmes for social workers, they required attention to modes of reflectivity on at least three different levels: at the level of knowledge acquisition where information from academic sources needs to be processed against the background of the learner’s own history and experience in order to have relevance; at the level of learning how to apply this knowledge through the “diagnostic” interactive analysis of the needs of the respective service users, which always concerned a higher-grade complexity of interrelated factors than, for instance, medical diagnosis was directed at; and at the level of devising forms of intervention through personal relationships whose acceptance and suitability had to be constantly monitored and in a professional role distinct from both that of “officials” like civil servants and of the informal role of personal friends. This meant that practitioners had to be constantly aware within what kind of boundaries the helping relationship was developing and make appropriate adjustments. The complexity of these reflective processes in social work was given recognition in the form of the early and widespread use of supervision in professional practice (Gould & Baldwin, 2006). At the theoretical level, social work as case work received a strong undergirding from the psychoanalytic movement. This provided the emergent profession with a theoretical framework within which the elements of a professional helping relationship, the only “tool” with which to assist and to achieve change in people’s lives, could be analysed systematically. It allowed for reactions on the part of service users to be understood, as was claimed, from a scientific point of view. This proved a crucial point in training to professional level in view of the fact that untrained

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volunteers mostly made use of moral judgements when clients showed resistance to their “good advice” and acted “irrationally” in response to assistance given (Goldstein, 1984). Reflecting as a professional tool helped in these situations in two regards: Psychoanalytic theories in the elaboration by Anna Freud (1936) enabled a deeper level of understanding of such behaviour by recognising it as a defence mechanism that constitutes a pattern in a person’s ego history. By promoting reflective insight into this pattern in a client, professional social workers, just like therapists, can attempt to induce changes in these patterns and therefore increase the capacity of the ego to gain more conscious control over their behaviour and to cope with challenging situations in a manner that works not simply as an impulse (Strean, 1979). At the same time, reflective skills aid social worker to pay attention to the way their relationship with service users also follows certain patterns, a phenomenon known as transference, so that they can monitor the course and effect of their professional relationship. From this description, it becomes clear that both aspects bear the hallmarks of reflecting as the bringing-to-consciousness of underlying inclinations with the aim of strengthening a person’s ego (Elliott, 2002; Parad, 1958). Reflecting in that sense incorporates two dimensions that sometimes separated in later developments into what became known as ego psychology in the 1930s, a strand that focused more on unconscious processes and therefore on reflecting as introspection, and one that emphasises the cognitive dimension of reflecting as gaining more conscious control over actions (Goldstein, 1984). The division arose from different institutional frameworks in which the practice developed. Psychiatry, particularly in the private practice sector, deepened the first trend, whereas social work with the emphasis on getting clients to show tangible change in behaviour picked up more on the latter. The trend towards identifying social problems through the study of individual behaviour, particularly of children and young people, was induced by the increasing use of psychological test methods around the beginning of the twentieth century and became a part of the belief in the power of science as a motor of progress. The “Progressive Movement” of psychology sought structural reforms but put the emphasis on individual freedom as the fulfilment of human capacity, a principle which resonated with the liberal politics dominant in the UK and particularly in the USA that diverted attention away from structural issues in relation, for instance, to poverty and delinquency (Stromquist, 2006). The need for social workers to be trained was recognised most in the psychiatric field which became a model of methodical social work training, and this helped to ground the professional status of social workers but narrowed the understanding of reflecting to a cognitive diagnostic skill focused on the psycho-social understanding of abnormal behaviour from which behaviour-changing interventions could be derived (Woods & Hollis, 2000). Despite the nominal inclusion of wider social context factors in diagnosis, the psychodynamic method, as it became known, induced social workers to focus on individual or on family behaviour as the primary point of change when social problems occur. Clinical forms of social work subsequently were regarded as having a higher professional status. In the USA and in the UK, these developments were supported by the parallel growth of the “Child Guidance Movement” (Smuts et al.,

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2006), which fitted with the ideological principles of liberalism. These emphasise the freedom and responsibility of individuals as against reliance on state support which should only be a last resort (Stromquist, 2006). They were strongly represented in these countries throughout the 1920s and early 1930s and were reinforced by the opposition to the socialist approach to solving social problems at the material and collective level which had become a central plank of policies in the Soviet Union after the 1917 revolution. Only the devastating social effects of the Great Depression, particularly in the USA, when unemployment and poverty could no longer be attributed to failings in individual behaviour, forced the government of F.D. Roosevelt to initiate public work projects and increase state social support in the form of the “New Deal” (Venn, 1998). However, the “Child Guidance Movement” in the USA and the UK, which provided the main employment base for trained professional social workers, partly in psychiatric clinics but partly also in community centres, comprised also another dimension of reflectivity which was influenced by the settlement movement. Hull House, the seminal settlement at Chicago, was a fulcrum of progressive ideas and practices that aimed at social reform rather than the charitable helping of individuals. The pioneer and feminist campaigner Jane Addams, who was later awarded the Nobel Peace Prize, pursued a vision of social transformation towards peace and justice that involved particularly those at risk of being excluded and discriminated. At Hull House, she collaborated with John Dewey and together they developed their ideas of pragmatism, his on democratic forms of education and hers on socialising democracy (Seigfried, 1999). Dewey’s philosophy on his part inspired forms of education that encourage children to develop their potential by learning to reflect on concrete experiences (Dewey, 2021), whereas Addams took this approach into the wider political arena and underlined the role of reflecting in directing democracy towards social goals: Being involved in democratic processes furthers reflective abilities and the application of these abilities in turn strengthens democracy (Addams, 1902).

Reflectivity in the Social Pedagogical Tradition What the settlement movement in the UK and the USA represented in terms of an approach to social problems that had a strong community dimension and involved experiential learning had its equivalent in Germany in the form of the social pedagogy approach. Germany had become a country with a corporatist approach to welfare on account of Bismarck’s welfare legislation that embodied the principle of subsidiarity in which institutions of civil society like the family, the churches or associations are treated as the prime sources of social support, with state organisations only playing a secondary supporting role (Lorenz, 2006). This places the emphasis on strengthening people’s sense and ability to belong to a community and to feel responsible to actively contribute to its life and activities. While this ultimately conservative concept is geared towards preserving traditional civil society

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organs, it also implies that members are responsible for adapting these to the changing conditions of modernity which requires them to engage in communal deliberative processes. Subsidiarity was also a central part of Catholic welfare doctrine since Pope Leo XIII’s encyclical Rerum Novarum of 1891 which took position against socialism and its prioritising of collectivism as well as against liberalism with its over-emphasis on individual responsibilities by promoting “small units” in which people can become active and show responsibility and care for each other in a personalised way (Stjernø, 2005). Both socio-political models contain an implicit model of reflectivity on the part of individual actors that has a strong normative orientation towards benefiting the community rather than the individual. This orientation is also at the core of the theoretical models of social pedagogy that developed there already during the late nineteenth century. One of its pioneers, the German neo-Kantian philosopher Paul Natorp, was critical of the notion of education turning learners into passive recipients of knowledge which dominated nineteenth-century schooling. He elaborated instead on the critical and “poetic” faculties of the human mind (Natorp, 1974). This means that learners “are given the freedom to assess themselves and especially their performance in reflective judgements, to search for an as yet undetermined universal, to pursue their own Bildung by broadening the concept of humanity, as Wilhelm von Humboldt proposed” (Ruhloff, 2004, p. 385/6). This element of “Bildung” (formation), in contrast to “top-down” education, can be found as the motivating force in the social movements like the feminist or the workers’ movement that sprang up in that formative period in opposition to the official punitive treatment which promotors of these movements received, in as much as participation in the initiatives for them became a learning process from experience. Social pedagogy approaches treat “community education” that takes place in settlements (Köngeter & Schröer, 2013) and also in workers’ and adult education contexts, as opportunities of gaining autonomy not only as a “self” but as a member of a community that seeks to transform existing restrictive and oppressive structures of society. This principle became constitutive of community work seen as collective self-development (Eriksson, 2011). This model of social pedagogy influenced the policy approach to welfare that developed in Germany during the Weimar Republic in the 1920s. It conceptualises social relational competences as lifelong learning processes which are the subject not just of educational programmes in schools but feature especially in out-of-­ school youth projects, community initiatives, adult education schemes and many self-help and self-improvement movements (Frampton, 2022). Social pedagogy in its politically critical tradition is not operating primarily at the points of crisis but along a continuum of potential crisis situations as they evolve over the life cycle of every person and therefore has a predominantly preventive orientation. It contains a strong implicit element of critical reflectivity, inspired by Natorp’s philosophical neo-Platonism (Kim, 2007), since it proposes that people of all ages can learn from experience when guided in a critical way, either by facilitators or by fellow community members, to examine alternative perspectives and to draw conclusions from that in a creative and socially constructive way.

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Academically, social pedagogy’s status was strengthened by its links to general pedagogy which, owing to its relation to hermeneutic philosophy, had an established position at universities. What is more, its theoretical models were not dominated by positivist natural science paradigms as had been those of social work with their affiliation with sociology and psychology in the Anglo-Saxon tradition and could therefore develop a less “instrumental” understanding of reflecting. This means that in the specific historical and political context in which reflectivity in social pedagogy took shape, reflecting capacities were seen as having a social basis and the potential to bring about change not primarily in individuals but in social and lastly also in political relations (Lorenz, 2008). This idea later on found the best-­ known expression in the work and writing of Paulo Freire, whose “pedagogy of the oppressed” is based on and aims at “conscientisation” (Freire, 1970) and who had a considerable influence on the politicisation of social and community work approaches in the 1970s. Freire explicitly relates his notion of consciousness to the phenomenological approach to awareness by Husserl and writes: “As women and men, simultaneously reflecting on themselves and on the world, increase the scope of their perception, they begin to direct their observations towards previously inconspicuous phenomena” (Freire, 1970, p. 82). However, there are quite contrary political aspects of the social pedagogical project to be considered. The emphasis on autonomy from traditional bonds and an alternative communal lifestyle, which characterised particularly the German youth movement in the first decades of the twentieth century, became susceptible to social nationalist ideologies which monopolised the forms in which young people and other community movements, oriented on encounters with nature or enthusiastic about sports, sought to express their creativity. Instead of strengthening the reflective abilities contained in the democratic pedagogical projects in the tradition of Dewey and Natorp, Nazi and also Bolshevik ideology aimed at eliminating reflectivity at the individual level and at institutionalising it at the level of the party (Schnurr, 1994). Reflecting as a response by the individual was manipulated to become automatic “reflexes” that ideally were to mirror the united “will of the folk” according to the Nazi motto, “you are nothing, your folk is everything”. Reflectivity in terms of professional autonomy in Nazi Germany was systematically eliminated from the work of social workers, and public as well as non-­ governmental welfare institutions were brought under the sway of nationalist and racist social policies that excluded, stigmatised, imprisoned and killed those deemed “unworthy”. Where social workers resisted or practised outside these norms they did so at extreme personal risk (Sünker & Otto, 1997). Many influential social workers who had pioneered the profession’s development internationally, like Alice Salomon, had to flee Germany, and some like Gisela Konopka developed social pedagogy models in US exile in the form of social group work, which after the end of World War II influenced the new start of social work in Germany and other European countries (Lorenz, 2006).

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Post-war Democratic Reconstruction and Social Work Eliminating these ideological interferences with the scientific and professional status of social work was the prime objective of “democratic reconstruction programmes” in Western Europe after the defeat of Nazism and Fascism. Social work education became henceforth an important issue even at the level of the United Nations through its expected contribution to social integration on democratic principles (Kendall, 1960). The educational model that dominated these initiatives of promoting academic social work courses focused on giving them a “conventional” scientific orientation. This meant that social workers learned to understand society and human behaviour according to “universal principles” which should ensure “neutrality” and an unprejudiced attitude with which they were to meet clients irrespective of their cultural, ethnic or class background. Reflectivity on these courses was largely limited to the ability of finding the right methods approach to the specific kind of social problem, and the lingering influence of psycho-social concepts did not take reflecting to a more politically critical level but focused on emotional aspects in professional relationships (Goldstein, 1984). This professional direction was not only oriented towards the attitudes prevalent in other professions in the immediate post-war period which commanded high status and authority in society. It also fitted with the emerging “welfare state consensus” that prevailed in industrial Western countries which, despite the variations of “welfare regimes” (Esping-Andersen, 1990), converged on the aspiration that inequality and social problems in general could be resolved by effective public social policy measures that ensured a balance between the interests of a capitalist economy and the concern for a “decent standard of living” and could therefore “harmonise” war- and class-riven societies around a given notion of normality (Kessl, 2009). The Cold War competition with the East was an important factor in these developments because Communist regimes could claim that welfare and equality were their prime policy aims and that the state had taken decisive steps to take care of the social needs of its citizens. In view of this, the West could not afford to neglect social needs but related their satisfaction with the attention to personal liberty which the East in turn undervalued (Lorenz, 2020). The confrontation between both political frameworks has implications for the topic of reflectivity because it could be said that while the communist state system sought to obviate (and often downright suppress) the need of individuals to reflect, since the party took control and made decisions on behalf of the citizen, the democratic systems represented a version of individualised reflectivity within a collective institutional framework. Citizens in public debates and in their voting behaviour were required to demonstrate reflective abilities when deciding which party presented the best arguments so that parliament could become the ultimate institutional seat of deliberative processes. However, the welfare consensus that Western politics sought to bring about failed in its objective on two accounts. On the economic side, the assumption that welfare spending could be financed from taxes did not materialise on account of growing

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unemployment which triggered the “fiscal crisis of the welfare state” (O’Connor, 1973). On the societal side, social movements that emerged after 1968 challenged the neglect of aspects of individuality and diversity expressed in these seemingly neutral and technical social policies. Black and minority civil rights movements, feminist movements, empowerment and self-help initiatives including disability and survivor groups all focused on the need to recognise their specific identities combined with demands for self-determination. They considered the formal democratic structures and the corresponding prevailing bureaucratic orientation of welfare and health services to be unresponsive to their specific needs and demanded direct participation in public decision-making processes. They thereby exposed the limited use of reflectivity in training and practice in social work particularly as this was centred on how best to transmit expert knowledge to clients within the parameters of welfare organisations (Otto & Dewe, 2012). And in constituting themselves as social movements, they evidenced the effects of a critical understanding of reflecting. “A social movement recognizes itself through a reflexive understanding of its relation to the context or environment in which it develops, including an awareness of the opportunities and constraints it faces in a given field of action” states Flesher Fominaya (2010, p. 395) with reference to Melucci’s (1995) work on social movements. This brought the issue of the reflective legitimation of democracy once more to the fore. This, as stated above, cannot rest alone on the voting system but requires parallel processes and institutions. In this perspective, social movements expressed the need to re-invigorate the reflective function of civil society in general. As Gusfield writes, “social movements have a reflexive character. They are something members of a society reflect on, think about and are aware of” (Gusfield, 1994, p. 69). In the course of this, they also challenged the elitism and power concentration of bureaucracy and of seemingly independent institutions like the traditional professions. They exposed the lack of democratic accountability of institutions like the police and professions like medicine under their claim for autonomy and thereby brought the issue of reflectivity into the public arena as both a personal and a political issue.

Reflectivity in Nursing Education At this historical juncture where public social relations were changing profoundly, it is worth looking at the specific route that professionalisation took in the case of nursing. It had arisen around the same period as social work in the latter part of the nineteenth century when women like British Florence Nightingale and Jamaican Mary Seacole (Morris, 2022), who both served in the Crimean War, established key principles of nursing care along modern medical and ethical lines. Nightingale opened the first School of Nursing in London in 1860 with an emphasis not only on hygiene rules and patient empathy but also on personal character building. In an address to nurses, she states: “No training is of any use, unless

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one can learn (1) to feel, and (2) to think out things for oneself” (Nightingale, 1914, https://www.gutenberg.org/files/49732/49732-­h/49732-­h.htm). However, this ethos amounted to a subservient attitude towards the medical profession and kept nursing at a “para-professional” level in terms of autonomy in decision-making. It prevailed until the 1970s when in several countries this mainly female profession gained entry into universities and with that to becoming a discipline in its own right, a decisive turn towards professional autonomy together with changes in the organisational structure of hospitals (Hall, 1970; Freshwater et al., 2008). In this context, growing attention was given to the aspect of reflecting as a tool for learning and for professional practice (Clarke et al., 1996). In this development, one can recognise the confluence of two, in other contexts often oppositional, trends: reflectivity as a means of achieving and strengthening professional autonomy focused more on the intellectual examination of different sources and contents of knowledge, while reflectivity as a means of asserting the personalisation of learning in terms of the importance of the learner’s identity represented clearly a strand of contemporary feminism, especially in the case of nursing. In view of this dualism, the notion of reflectivity in nursing education and practice remained not uncontested, partly on account of the ambiguity contained in the term itself, partly because reflectivity could also be incorporated into the emergent trend towards technical effectiveness in all public services, as discussed below. As Johns remarked: “In a world dominated by a technological approach to education and health care, the reflective practice is at risk of being perceived and understood as merely another educational technology” (Johns, 2000, p. vii).

 eflectivity, New Public Management R and the Commodification of Public Services The backlash against autonomy and identity movements in the new millennium made extensive use of one of the institutions, i.e. the market, that provided an alternative to the reflexive legitimation of democracy which since the origins of modern nation states had formed in parallel with the political voting legitimation. This concerns the use of the reflexive function implicit in free market exchanges between suppliers and consumers. The economic and political ideology of neoliberalism, which gained ground in the Reagan and Thatcher era, shifted the emphasis from legitimation through political to legitimation through market-economic processes by privatising large parts of public services and dismantling welfare structures (Pierson, 1994) so that citizens were forced to “plan ahead” individually and independently by weighing up options of how to solve their problems and thereby to become “activated”, without consideration of the resources this would be required for such independence (Lorenz, 2017). These principles transformed the approach to welfare policies fundamentally (Esping-Andersen, 1996) and gained global diffusion after the ending of communist regimes post- 1989, a revolution that could

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also be described as an assertion by civil society movements of their right to reclaim reflective competences from the monopoly of the authoritarian state. The advent of neoliberalism in post-communist countries however threatened to narrow the scope of reflective choice-making here also to the economic sector and therefore demonstrated once more the ambiguity of the project of modern democratic reflectivity that can lead to a “disenchantment of politics” (Davies, 2014). Social and health service professionals in this constellation of political and civil developments faced an acute dilemma over their professional mandate. The demand for greater immediate responsiveness to the needs and demands of service users on the one hand came from those civil society groups themselves and on the other hand was generated by managerial demands for greater consumer orientation in the interest of delivering “personalised services” in the application of “New Public Management” principles (Hyslop, 2018). This caused in both fields a shift in epistemological orientation from operating within clearly delineated theoretical “school boundaries” towards pragmatic “what works best” approaches. The new practice framework operated under the heading of “evidence-based practice” (Ziegler, 2020), and this again had an impact on the way reflectivity was interpreted in a professional context. It privileged the more instrumental form to “achieve best results”. Accountability and quality in services generally came to be counted in quantitative terms (Banks, 2011) in correspondence with the advance of “regulatory welfare” principles (Benish & Levi-Faur, 2020), with the added effect of increasing defensiveness and fear of making mistakes among professionals, which in turn carries the risk of cutting them off from potentially learning from mistakes (Sicora, 2017). A way forward for practitioners and educators in social work critical of these developments, and to a lesser extent also in medical education (Foreshew & Al-Jawad, 2022), took the form of elaborating on the implications of participative approaches to research, knowledge creation and methodology that arose from self-­ help movements and their critique of professional self-centredness. It promised a fuller understanding of what counts as “knowledge” generally beyond the dichotomy of subjectivity and objectivity by using the heuristic potential of inter-­ subjectivity (Butler et al., 2007). To some extent, the emphasis on participative approaches coincided with the trend towards subjectivity that occurred intellectually in the context of the formation of late or post-modern societies with their radicalised tendency to “de-centre”, pluralise and thereby radically relativise existing normative positions (Ziman et al., 2005). But this fundamental critique of “scientific certainty” on account of its power implications left professionals in the caring field with a profound dilemma concerning how to demonstrate accountability (Mantzoukas & Jasper, 2004). It seems attractive from an abstract ethical point of view to respect the dignity of service users by approaching decisions concerning their welfare and health through democratic shared deliberations, but in the end, professionals have to take responsibility for the consequences of such decisions. This brings the political and practical focus back on the issue of what kind of professional reflecting can fully take account of these dilemmas and on the demands they place on professionals without paralysing them with the lurking danger of

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“hyper-reflexivity” (Rose, 1979) or forcing them to adopt positivist-technological perspectives on human behaviour which, as history has shown in authoritarian regimes, can have a de-humanising effect (Ioakimidis & Trimikliniotis, 2020). This concern has been taken up in proposals for professional accountability to be demonstrated in the form of “reflexive professionalism” (Kessl, 2009) and “democratic professionalism” (Dzur, 2004). These approaches imply the recognition of the profound transformation processes that are taking place in social relations at all levels and the plurality of perspectives on lifestyles and the entire structuring of society which does not allow professionals to take recourse to fixed institutional certainties and notions of normality. At the same time, the reflective engagement in these processes does not amount to resignation in the face of this seeming relativity but on the contrary to a stronger engagement in democratic interactions by acknowledging that all human relations are ultimately “agonistic” (Mouffe, 1999). This means that reflecting, precisely because it has of necessity a political dimension, takes into consideration the implications of power in personal, professional and political relationships by acknowledging the social constitution of one’s self as a person and as a professional and exposes these to dialogical scrutiny in which supervision also then plays a more comprehensive role (Jones, 2004). This way of reflecting does not “neutralise” the aspect of the power invested in professional roles but seeks to arrive at a point of legitimation at which relationships can reach a degree of certainty, reliability and continuity. Practising “expertise” carries with it responsibilities and is based on having “good enough reasons” which have to be made explicit and opened to criticism, but considering different options cannot end in total relativity and “indifference”. Applying these criteria is required not just in professional helping relationships, which can only work if they result in an increase in trust, but the concern reaches beyond that horizon and aims at modelling wider social relations and social structures on such trust-building processes. This is the current challenge for entire societies which in view of the Covid pandemic, the environmental crisis and the international wars that have erupted are in danger of becoming ever more deeply divided and fragmented, and the “helping professions” can make a crucial contribution to the reconstruction of democratic relationships that incorporate trust.

References Addams, J. (1902). Democracy and social ethics. Macmillan. Agnew, E.  N. (2004). From charity to social work: Mary E.  Richmond and the creation of an American profession. University of Illinois Press. Alvesson, M., & Sköldberg, K. (2009). Reflexive methodology: New vistas for qualitative research (2nd ed.). Sage. Banks, S. (2011). Ethics in an age of austerity: Social work and the evolving new public management. Journal of Social Intervention: Theory and Practice, 20(2), 5–23. https://doi. org/10.18352/jsi.260 Beck, U. (1992). Risk society: Towards a new modernity. Sage.

34

W. Lorenz

Benish, A., & Levi-Faur, D. (2020). The expansion of regulation in welfare governance. Annals of the American Academy of Political and Social Science, 691(1), 17–29. https://doi. org/10.1177/0002716220949230 Bosanquet, H.  D. (1914). Social work in London, 1869 to 1912: A history of the Charity Organisation Society. E. P. Dutton & Co. Burns, E. A. (2019). Theorising professions: A sociological introduction. Springer. Butler, A., Ford, D., & Tregaskis, C. (2007). Who do we think we are?: Self and reflexivity in social work practice. Qualitative Social Work, 6(3), 281–299. https://doi. org/10.1177/1473325007080402 Bynum, W. F. (1994). Science and the practice of medicine in the nineteenth century. Cambridge University Press. Čajko Eibicht, M., Lorenz, W., & Havrdová, Z. (2021). Enhancing reflectivity in social, care and health professionals  – Identifying students’ abilities and needs. European Journal of Social Work, 1–13. https://doi.org/10.1080/13691457.2021.2016644 Clarke, B., James, C., & Kelly, J. (1996). Reflective practice: Reviewing the issues and refocusing the debate. International Journal of Nursing Studies, 1996(33), 171–180. Coleman, J. S., & Fararo, T. J. (Eds.). (1992). Rational choice theory. Advocacy and critique. Sage. Danziger, K. (1990). Constructing the subject. Historical origins of psychological research. Cambridge University Press. Davies, W. (2014). The disenchantment of politics: Neoliberalism, sovereignty and economics. In W. Davies (Ed.), The limits of neoliberalism: Authority, sovereignty and the logic of competition (pp. 1–34). SAGE. https://doi.org/10.4135/9781473906075.n1 Dewey, J. (1916/2021). Democracy and education. Duke Classics. Retrieved November 10 2022 from https://api.overdrive.com/v1/collections/v1L1BzlEAAA28/products/03e71ca9-­f02a-­4 21b-­902c-­38aafa6dd587 Dewey, J. (1927). The public and its problems. Swallow Press. Durkheim, É. ([1893] 1960). The division of labour in society. (G. Simpton, Trans.). Free Press. Dzur, A. W. (2004). Democratic professionalism: Sharing authority in civic life. The Good Society, 13(1), 6–14. https://doi.org/10.1353/gso.2004.0026 Elliott, A. (2002). Subject to ourselves: Social theory, psychoanalysis and postmodernity. Paradigm. Eriksson, L. (2011). Community development and social pedagogy: Traditions for understanding mobilization for collective self-development. Community Development Journal, 46(4), 403–420. https://doi.org/10.1093/cdj/bsq008 Esping-Andersen, G. (1990). The three worlds of welfare capitalism. Polity Press. Esping-Andersen, G. (Ed.). (1996). Welfare states in transition. Sage. Flesher Fominaya, C. (2010). Collective identity in social movements: Central concepts and debates. Sociology Compass, 4(6), 393–404. https://doi.org/10.1111/j.1751-­9020.2010.00287.x Foreshew, A., & Al-Jawad, M. (2022). An intersectional participatory action research approach to explore and address class elitism in medical education. Medical Education. https://doi. org/10.1111/medu.14857 Frampton, M. (2022). German social pedagogy and social work: The academic discourses mapping a changing historical relationship. International Journal of Social Pedagogy, 11(1). https://doi. org/10.14324/111.444.ijsp.2022.v11.x.004 Freire, P. (1970). Pedagogy of the oppressed. Continuum. Freshwater, D., Taylor, B. J., & Sherwood, G. (2008). International textbook of reflective practice in nursing. Blackwell. Freud, A. (1936). The ego and the mechanisms of defense. International Universities Press. Goldstein, E. G. (1984). Ego psychology and social work practice. Free Press, Collier Macmillan. Goodin, R. E. (2003, November 1). The autonomy of preferences. In Reflective democracy (Online ed.). Oxford Academic. https://doi.org/10.1093/0199256179.003.0002. Accessed 26 Oct 2022. Gould, N., & Baldwin, M. (2006). Social work, critical reflection and the learning organisation. Ashgate.

2  The Significance of Reflectivity in Professional Social and Health Care in Relation…

35

Gusfield, J. R. (1994). The reflexivity of social movements: Collective behavior and mass society theory revisited. In J. R. Gusfield, E. Laraña, & H. Johnston (Eds.), New social movements: From ideology to identity (pp. 58–78). Temple University Press. Habermas, J. (1989). The structural transformation of the public sphere: An inquiry into a category of bourgeois society. MIT Press. Hall, O. (1970). Social change, specialization, and science: Where does nursing stand? In M. Q. Innis (Ed.), Nursing education in a changing society (pp. 3–15). University of Toronto Press. Honneth, A. (1987). Enlightenment and rationality. The Journal of Philosophy, 84(11), 692–699. Hyslop, I. (2018). Neoliberalism and social work identity. European Journal of Social Work, 21(1). https://doi.org/10.1080/13691457.2016.1255927 Ioakimidis, V., & Trimikliniotis, N. (2020). Making sense of social work’s troubled past: Professional identity, collective memory and the quest for historical justice. The British Journal of Social Work, 50(6), 1890–1908. https://doi.org/10.1093/bjsw/bcaa040 Johns, C. (2000). Becoming a reflective practitioner. A reflective and holistic approach to clinical nursing, practice development and clinical supervision. Blackwell. Jones, M. (2004). Supervision, learning and transformative practices. In N. Gould & M. Baldwin (Eds.), Social work, critical reflection and the learning organisation (pp. 11–22). Ashgate. Kant, I. (1992, orig. 1785). Groundwork for the metaphysics of morals. (J. W. Ellington, Trans.) (Akademie Ausgabe Vol. 4). Hackett Publ. Kant, I., & Wood, A. (1996). An answer to the question: What is enlightenment? (1784). In M. Gregor (Ed.), Practical philosophy (The Cambridge edition of the works of Immanuel Kant) (pp. 11–22). Cambridge University Press. https://doi.org/10.1017/CBO9780511813306.005 Kendall, K.  A. (1960). Social work training around the world. Social Service Review, 34(2), 203–213. https://doi.org/10.1086/640838 Kessl, F. (2009). Critical reflexivity, social work, and the emerging European post-welfare states. European Journal of Social Work, 12(3), 305–317. https://doi.org/10.1080/13691450902930746 Kim, A. (2007). Recollecting the soul: Natorp’s construction of a platonic ‘psychology’. Internationale Zeitschrift für Philosophie, 10(1), 159–174. Köngeter, S., & Schröer, W. (2013). Variations of social pedagogy  – Explorations of the transnational settlement movement. Education Policy Analysis Archives, 21(42), 42. https://doi. org/10.14507/epaa.v21n42.2013 Kraus, K. T. (2020). Kant on self-knowledge and self-formation: The nature of inner experience. Cambridge University Press. Kuhn, T. S. (1970). The structure of scientific revolutions. University of Chicago Press. Lorenz, W. (2006). Perspectives on European social work – From the birth of the nation state to the impact of globalisation. Barbara Budrich Publishers. Lorenz, W. (2008). Paradigms and politics: Understanding methods paradigms in a historical context. The case of social pedagogy. British Journal of Social Work, 38(4), 625–644. Lorenz, W. (2017). European policy developments and their impact on social work European policy developments and their impact on social work. European Journal of Social Work, 20(1), 17–28. https://doi.org/10.1080/13691457.2016.1185707 Lorenz, W. (2020). 1989 as a key moment in the development of international dimensions of social work. In W. Lorenz, Z. Havrdová, & O. Matoušek (Eds.), European social work after 1989: East-west exchanges between universal principles and cultural sensitivity (pp. 1–15). Springer. Mantzoukas, S., & Jasper, M.  A. (2004). Reflective practice and daily ward reality: A covert power game. Issues in Clinical Nursing, 13(8), 925–933. https://doi. org/10.1111/j.1365-­2702.2004.01008.x Melucci, A. (1995). The process of collective identity. In H. Johnston & B. Klandermans (Eds.), Social movements and culture (p. 41–63). University of Minnesota Press. Morris, G. (2022). Mother Seacole: How Mary Seacole’s dedication to healing shaped nursing. Nurse Journal. https://nursejournal.org/articles/how-­mary-­seacoles-­dedication-­to-­healing-­ shaped-­nursing/. Accessed 22 Oct 2022

36

W. Lorenz

Mouffe, C. (1999). Deliberative democracy or agonistic pluralism? Social Research, 66(3), 745–758. Natorp, P. (1974). Sozialpädagogik 1899. Ferdinand Schöningh. Nightingale, F. (1914). Florence Nightingale to her nurses. A selection from Miss Nightingale’s addresses to probationers and nurses of the Nightingale School at St. Thomas’s Hospital. Macmillan. https://www.gutenberg.org/files/49732/49732-­h/49732-­h.htm O’Connor, J. (1973). The fiscal crisis of the state. St Martin’s Press. Otto, H. U., & Dewe, B. (2012). Reflexive Sozialpädagogik: Grundstrukturen eines neuen Typs dienstleistungsorientierten Professionshandelns. In W. Thole (Ed.), Grundriss Soziale Arbeit: Ein einführendes Handbuch (pp. 197–217). VS Verlag. Parad, H. J. (Ed.). (1958). Ego psychology and dynamic casework. Family Service Association of America. Parton, N. (1998). Risk, advanced liberalism and child welfare: The need to rediscover uncertainty and ambiguity. British Journal of Social Work, 28(1), 5–27. https://doi.org/10.1093/oxfordjournals.bjsw.a011317 Payne, M. (2005). The origins of social work: Continuity and change (2nd ed.). Palgrave Macmillan. Phillips, L. (2000). Risk, reflexivity and democracy. Nordicom Review, 21(2), 115–136. https://doi. org/10.1515/nor-­2017-­0389 Pierson, P. (1994). Dismantling the welfare state? Reagan, Thatcher, and the politics of retrenchment. Cambridge University Press. Porter, T. (2020). Revenge of the humdrum: Bureaucracy as profession and as a site of science. Journal for the History of Knowledge, 1(1). https://doi.org/10.5334/jhk.20 Rosanvallon, P. (2011a). Democratic legitimacy: Impartiality, reflexivity, proximity. Princeton University Press. Rosanvallon, P. (2011b). The metamorphoses of democratic legitimacy: Impartiality, reflexivity, proximity. Constellations, 18(2), 114–123. https://doi.org/10.1111/j.1467-­8675.2011.00631.x Rose, H. (1979). Hyper-reflexivity — A new danger for the counter-movements. In H. Nowotny & H. Rose (Eds.), Counter-movements in the sciences (Sociology of the sciences a yearbook) (Vol. 3). Springer. https://doi.org/10.1007/978-­94-­009-­9421-­8_13 Ruhloff, J. (2004). Problematising critique in pedagogy. Journal of Philosophy of Education, 38, 379–393. https://doi-­org.libproxy.unibz.it/10.1111/j.0309-­8249.2004.00392.x Schnurr, S. (1994). Sozialpädagogen im Nationalsozialismus. Eine Fallstudie zur sozialpädagogischen Bewegung im Übergang zum NS-Staat. Beltz-Juventa. Schumpeter, J. (2011). Capitalism, socialism, and democracy (2nd ed.). Martino. Seigfried, C. H. (1999). Socializing democracy: Jane Addams and John Dewey. Philosophy of the Social Sciences, 29(2), 207–230. https://doi.org/10.1177/004839319902900203 Sicora, A. (2017). Reflective practice, risk and mistakes in social work. Journal of Social Work Practice, 31(4). https://doi.org/10.1080/02650533.2017.1394823 Smuts, A. B., Smuts, R. W., Smuts, R. M., Smuts, B. B., & Chase-Lansdale, P. L. (2006). Science in the service of children, 1893–1935. Yale University Press. Sowerwine, C. (1982). Sisters or citizens?: Women and socialism in France since 1876. Cambridge University Press. Stjernø, S. (2005). Religion: Solidarity in Catholicism and Protestantism. In S.  Stjernø (Ed.), Solidarity in Europe: The history of an idea (pp. 60–90). Cambridge University Press. https:// doi.org/10.1017/CBO9780511490378.004 Strean, H. S. (1979). Psychoanalytic theory and social work practice. Free Press. Stromquist, S. (2006). Reinventing the people: The progressive movement, the class problem, and the origins of modern liberalism. University of Illinois Press. Sünker, H., & Otto, H.-U. (Eds.). (1997). Education and fascism. Taylor & Francis. Venn, F. (1998). The new deal. Edinburgh University Press. Waaldijk, B. (2011). Social work between oppression and emancipation: Histories of discomfort and inspiration in Europe. Social Work & Society, 9. Online publication http://www.socwork. net/sws/article/view/272. Accessed 23 Oct 2022

2  The Significance of Reflectivity in Professional Social and Health Care in Relation…

37

Whitaker, E.  M., & Atkinson, P. (2021). Varieties of reflexivity. In E.  M. Whitaker & P. Atkinson (Eds.), Reflexivity in social research (pp. 1–16). Palgrave Macmillan. https://doi. org/10.1007/978-­3-­030-­84095-­2_1 Woods, M. E., & Hollis, F. (2000). Casework: A psychosocial therapy (5th ed.). McGraw-Hill. Ziegler, H. (2020). Social work and the challenge of evidence based practice. In F. Kessl, W. Lorenz, H.-U. Otto, & S. White (Eds.), European social work – A compendium (pp. 229–272). Barbara Budrich. Ziman, J., Flynn, M., Brekke, J. S., Soydan, H., Steinmetz, G., Chae, O. B., Shaw, I., Lunt, N., Funtowicz, S., Ravetz, R., Nowotny, H., Schram, S. F., Flyvbjerg, B., Landman, T., Studies, I., Ioannidis, J. P. A., Kaiser, M., Di Iorio, F., Funtowicz, S., et al. (2005). Science for the post-­ normal age. Social Work Research, 29(2), 73–86. https://doi.org/10.1093/swr/29.2.73

Chapter 3

Promoting Reflective Learning Styles Among Social Work and Nursing Students: A Review Monika Čajko Eibicht and Walter Lorenz

Introduction Imparting and enhancing reflective abilities has become an important aspect of higher education across a range of disciplines but particularly in human science and human service contexts. The considerations of this chapter seek to present concepts and instruments that facilitate the learning of reflection. These concepts are compiled and analysed from a wide literature review and reflect also experiences in teaching reflectivity on a professional programme on social management and supervision, offered at the Master’s level at the Faculty of Humanities of Charles University, Prague. We have taken the terminological ambiguities that characterise the literature on reflection and the often-inconsistent use of terms like reflectivity, reflexivity, critical reflection and reflexiveness as an invitation to treat this skills area as necessitating the bringing together of different agendas and perspectives derived from psychological, social, pedagogical and political considerations. These cannot be neatly assembled into a unified educational model, but each area contains important messages and poses questions that need to be addressed in the educational process. The distinctions suggested in Chap. 1, based on the neurological findings of Lieberman et al. (2002) that point towards the “X-system” (denoting reflexivity) being a precondition for the development of the “C-system” (referring to reflectivity), not only guide our terminology but also underline the specific focus of this chapter which is to distinguish the role of the professional academic educator from that of a supervisor, a counsellor, a psychotherapist or a line manager. We therefore understand M. Č. Eibicht Katedra aplikovaných sociálních věd FHS UK, Faculty of Humanities, Charles University, Prague, Czech Republic W. Lorenz (*) Faculty of Humanities, Charles University, Prague, Czech Republic e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Lorenz, Z. Havrdová (eds.), Enhancing Professionality Through Reflectivity in Social and Health Care, https://doi.org/10.1007/978-3-031-28801-2_3

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“reflectivity” as the purposeful intellectual inspection of personal and professional experience in the light of scientifically established evidence, theoretical perspectives and intervention goals and hence the main focus of learning approaches. The reflective educational process aims at giving experiences a deeper meaning and interventions purposefully chosen and critically examined objectives. This approach does not deny the importance of processes associated with the notion of “reflexivity” as an ongoing, largely unconscious or automatic mental activity with which, at a neurological level, the brain seems to continuously sift impressions and phenomena to create orientation and meaning as the basis for decisions and actions (Bargh, 1996), but takes these into consideration without however deliberately focusing on them. Our objective in this chapter is to demonstrate how an effective educational programme on professional human service courses can pay attention to and integrate the various dimensions that constitute and promote the phenomenon of reflectivity, ranging from psychological to structural-contextual and didactic considerations, as reference points for an educational programme. Watts (2019) describes the objective of reflective capacities in social work training as follows: “The use of social worker reflexivity is thus aimed at problem-solving, building understanding from, and about, practice situations, the use of self, and for improving and learning from practice” (Watts, 2019, 17). This objective can also be applied to nursing education.

Reflectivity as an Educational Concern The concept of reflection as self-consciousness played an important role early on in pragmatic psychology through the work of William James on subjectivity (Taylor, 1996). Here, reflection features as the distinct human “awareness of awareness” and, in a different form, establishes a basis in psychoanalytic practice as the therapeutic method that raises unconscious material to conscious awareness through “insight” (Aron, 2000). In the educational field, inspired by similar psychological and philosophical developments, parallel considerations were launched primarily through the work of John Dewey (1933). He maintained that by systematically linking experiences and ideas, reflecting becomes a “meaning-creating process essential to all forms of practice-related learning” (in Čajko Eibicht et al., 2021, p. 2). In the educational context, perhaps the most influential author was Schön (1983), who proposed distinguishing between two phases of reflection, reflection-in-action and reflection-on-action. Kolb (1984) further upgraded the role of practice experience in academic training programmes with the concept of “experiential learning” by linking it to a four-stage reflective learning model, which considerably impacted a range of human service disciplines. In higher-level social work education, reflectivity has been established more or less since its origins in the context of the emphasis on supervision as an essential tool for developing the required professional practice competences (Mo et  al., 2021). Reflecting involved the guided examination of experience with and reaction to problem situations in practice and was already mentioned in early textbooks such as Mary Richmond’s Social Diagnosis (1917). The concept was given a more

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specific political orientation in the wake of the influence of critical theory in the 1970s through the specification of “critical reflection”. According to its proponents, this attribute was necessary to extend the range of reflective deliberations beyond psychological to political issues of power, particularly as a defence against using professional power to oppress service users (Askeland & Fook, 2009). This attention to structural issues in promoting reflectivity on professional training courses has recently been returning to more psychological processes as a result of service agencies demanding courses that teach “evidence-based practice” approaches (Kessl, 2009), a trend discussed in Chap. 2 of this volume. Overall, the educational orientation in nursing has been strongly determined by being so closely interconnected with the medical profession, where traditionally the biomedical model prevailed, and its dominance over other groups of healthcare workers. Nevertheless, some reference to reflecting as a learning tool can already be traced back to Florence Nightingale (1820–1910), a British nurse, healthcare reformer and statistician (Lim & Shi, 2013). According to these authors, Nightingale’s Notes on Nursing, published in 1860, show “one of the finest examples of masterful reflection on the art of nursing and perhaps the first official reference for quality professional nursing—long before best practices became the standard” (p.  1). These principles have inspired other nursing scholars such as Peplau, Orem, Henderson and King to question the dominance of the biomedical approach and thereby promote a more autonomous nursing profession (Fawcett, 2001; Špirudová, 2015). In North America, many nursing curricula emerging during the 1970s were influenced by these scholars and their theories which grounded a patient-centred approach and greater professional autonomy (Simpson & Abbot, 2010). In the 1980s, this movement spread to Australia, Europe and Asia as more and more countries began transferring nursing education to colleges and universities (Freshwater et  al., 2008). The advance of nursing at the academic level and as a discipline in its own right underpinned autonomous decision-making in health care instead of “obedience” to decisions made by medical doctors (e.g. Boychuk Duchscher, 1999; Gillings, 2000; Kim, 1999). The broad outlines of these developments in social work and nursing can be observed internationally, although with varying degrees of educational impact (see Norrie, Hammond, D’Avray, Collington, & Fook, 2012).

 ontextual Conditions for Adopting Reflectivity C in Education Programmes Reflection oriented towards acting professionally and accountably implies the possibility that it may reveal mistakes, failures and shortcomings in attitudes and actions. In practice and in education, this carries a considerable risk of being assessed as “inadequate” with potential study or career consequences. Yet identifying and confronting mistakes and shortcomings is an essential precondition for achieving accountable practice (Reason, 1990; Sicora, 2019). This means that the

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development of reflective abilities is directly related to processes of trust-building, and this in a cyclical manner (Healy, 2017): It requires initial trustworthy conditions that enable reflectivity to take shape, but the exercise of reflection in the context of direct relationships with teachers, fellow students or team members, supervisors or line managers, in turn, can, if carried out in a non-threatening way, become itself an element of trust-building. Overall, for reflectivity to be present and to develop requires an ambience of emotional safety (see Chaps. 6, 8 and 9), which in turn is constituted by a combination of procedural and personal factors that ensure, for instance, confidentiality and respect for the dignity of each person (Egan et al., 2017). Even for “solitary” reflection to occur, certain structural conditions need to prevail, such as a protected space free from intrusive external influences and a specifically marked time in which other tasks and commitments can be kept at bay (Knott & Scragg, 2016). This applies even more so when reflectivity is to be given explicit attention in education and practice and when administrative regulations and frameworks about time and space allocation and use come into play. In this regard, Knott and Scragg (2016) maintain that it should be in the interest of administrators to enhance the employees’ learning capacity and thus organise time and space for reflection. While this is obvious at the workplace, in the educational context, the stress exercised on students to “achieve” can result in constraints on their willingness to engage in reflecting (Willingham, 2009). Where there exists little motivation on the learner’s side, formal requirements that measure reflectivity are counter-­ productive, as Maclean (2022) points out: “When you see reflection as a chore or something that ‘has to be done,’ then there is a problem. Reflection is about so much – learning, improving practice, self-care…we can learn to enjoy it!” (08:00). Where reflection for learning purposes is promoted, it mostly takes a dialogical form. It means that the student’s partner or guide in reflecting carries out a particular role, either informally as a fellow student or formally as a tutor (leaving aside the role of counsellors who make a remedial or therapeutic contribution to academic life). Formal roles of teachers imply standardised and sanctioned functions that carry authority and power over the learner, an aspect which needs to be addressed openly, critically and reflectively to lend that authority legitimacy and thereby build trust in the person and in the process (Egan et al., 2017). In an educational course context, the effectiveness of teaching reflectivity in such relationships is also related to the authenticity with which educators practise and represent reflection (Di Gursansky et al., 2010). The competence of teaching reflective practice skills cannot be assumed to be automatically present in social work and nurse educators since this requires specific conditions for it to develop. Braine (2009) points out that reflection is “a process that takes time and experience” (p.  268), and it is not an easy skill to develop. Similarly, Russell (2006) warns that “[f]ostering reflective practice requires far more than telling people to reflect and then simply hoping for the best” and suggests that reflective practice “can and should be taught—explicitly, directly, thoughtfully and patiently” (p. 203) with the aid of approaches we discuss below. In our experience, educators who were encouraged to reflect during their professional training had developed the basic skills of teaching reflective practices and continued to

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engage in reflection regularly. They were also open to using various methods to promote reflectivity in their students, whereas teachers who were not previously guided to reflect faced difficulty engaging themselves and their students in reflection and were themselves more dependent on guidance. In line with the dialogical form of reflection, Ryan and Ryan (2013) argue that “reflection cannot be taught as a discrete skill but, rather, that it must relate to the discursive context, and strategies must therefore be chosen carefully for their applicability to that context” (p.  247). In other words, to be effective and productive, reflection should always have a clear purpose in terms of its place in an educational setting and learning outcomes that enable students to make decisions deliberatively in full awareness of the complexity they have to cope with. When considering practical didactic instruments that have been proven to impart and enhance reflective abilities in social work and nursing students, a distinction is nevertheless appropriate between promoting reflective skills as an aid to acquiring academic knowledge more actively, particularly in practice-related subjects, and focusing specifically on reflection as a “competence repertoire” in preparation for professional practice, although both are obviously related to each other and are grounded in the same principles. As far as the former is concerned, all academic teaching based on research implies elements of what must be called critical reflection, building on the Kantian understanding of “critique” as the hallmark of rational, unbiased examinations of evidence and propositions. Ever since Plato developed the Socratic dialogue, a technique based on disputing contrasting positions as the path to truth, philosophy and then modern science proceeded by weighing up alternatives according to ultimately reflective procedures (see Chap. 1). Learning to question taken-for-granted assumptions is a central objective of academic didactics and implies elements of what Mezirow (1990) terms “perspective transformations”. Since social work and nursing education deal predominantly with practice issues that are embedded in popular assumptions about health and welfare, this kind of critical reflection is vital for knowledge acquisition in these professions because it helps to induce in students a reflective distance to these “popular” notions, for instance, about the causes of poverty or the limitations of the autonomy of people with disability (White et al., 2006). Their professional perspectives use scientific knowledge derived from empirical research as reliable reference points for the engagement with un-reflected assumptions, e.g. about immigration or delinquency, particularly since they are now being spread through social media. Reflection, understood as transformative learning, enables students to relate their knowledge-acquiring tasks in the academic context to an “external reality” of the world of practice and of people’s everyday concerns (Béres & Fook, 2020). This process is ultimately not external because students are always already part of it with their background, experience and life-world assumptions (Segev & Nadan, 2016). This constitutes the specific pedagogical effect of reflection as it points out different perspectives that can be taken on hypothetical case examples. It involves students holistically in the learning process and in a manner that has been described as a “pedagogy of discomfort” (Boler, 1999), which is fundamentally challenging their values, assumptions, stereotypes and outlook on life (Nadan & Stark, 2017).

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The attention to reflectivity as a practice skill in professional social work and nursing builds on these holistic educational principles and concepts that question taken-for-granted assumptions and introduce students to using multi-perspectivity in a way that engages with the views of other professionals and of service users and patients themselves. It gives students particular tools for reflective practice according to models discussed in the next section.

 earning Strategies Promoting Reflection and Enhancing L Student Engagement Techniques themselves are insufficient to stimulate reflectivity as they require an overall educational context to define their wider use and purpose. Research shows that more profound, permanent and meaningful levels of education can be achieved by actively engaging the learner in the process of acquiring knowledge and skills (Aji & Khan, 2019; Schunk & Mullen, 2012). Similarly, Illeris (2017) maintains that “all learning contains two different processes, both of which must be active before we can learn anything” (p. 21). The first process comprises the interaction between individuals and their environment; the second is the acquisition of skills of psychological processing occurring during the interaction, including content and incentive elements. The content element regards what is learned, and the incentive element concerns the mental energy needed to carry out a learning process and includes motivation and emotions. Another essential factor in learning is one’s prior knowledge (Illeris, 2017). Concerning the learning process, among the widely used theories in professional education is the experiential learning theory which represents a “dynamic view of learning based on a learning cycle driven by the resolution of the dual dialectics of action/reflection and experience/abstraction” (Passarelli & Kolb, 2011, p.  4). For example, Colomer et  al. (2020) reported a study showing that implementing the experiential learning approach improved higher education students’ knowledge and skill acquisition across disciplines and increased their readiness for future engagement in the subject when the experiential learning method was used. Landy et al. (2016) gathered from a comprehensive literature review that experiential learning (along with reflective writing) was among the most common strategies used to enhance reflectivity and gain insight among health and social work students. It has also been used to encourage students “to apply their theoretical knowledge in a practical way within the learning environment” (Hill, 2017, p. 936). In terms of the experiential learning approach, Kolb’s experiential learning cycle is the most widely utilised and recognised experiential learning model. It comprises four phases that allow the learner to get experience from concrete activities, reflect on the experience, transfer the experience into conceptualised knowledge and guide them to apply the abstract knowledge to active experimentation (Kolb & Kolb, 2009). The authors based their theory on the work of James, Dewey, Lewin, Rogers

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and Freire. They define experiential learning as “the process whereby knowledge is created through the transformation of experience. Knowledge results from the combination of grasping and transforming experience” (Kolb & Kolb, 2009, p.  298). Although the model is illustrated as a cycle, the authors describe it as: [a] spiral where the learner ‘touches all the bases’—experiencing, reflecting, thinking, and acting – in a recursive process that is responsive to the learning situation and what is being learned. Immediate or concrete experiences are the basis for observations and reflections. These reflections are assimilated and distilled into abstract concepts from which new implications for action can be drawn. These implications can be actively tested and serve as guides in creating new experiences. (see Fig. 3.1, Kolb & Kolb, 2009, p. 298)

In their research, the Kolbs have also focused on assessing individual learning styles and proposed nine basic learning styles that describe the unique ways in which individuals navigate through the learning cycle: (1) experiencing, (2) reflecting, (3) thinking, (4) acting, (5) diverging, (6) assimilating, (7) converging, (8) accommodating and (9) balancing style. These are partly genetic and partly learnt through socialisation and life experiences. Depending on which learning style a person prefers, they resolve the conflicts between being concrete and abstract and between being active and reflective (Kolb & Kolb, 2009). In other words, the learning profile can provide a picture of the individual’s strong sides and accommodate the teaching structure accordingly. An individual profile or learning style emerges by measuring these orientations through special tests. Apart from the personal benefits, assessing learning styles can also benefit educators. Research shows that people often share a specific learning style in studying certain education programmes and choosing particular occupations. For example, students enrolled in psychology, political science and

Fig. 3.1  The experiential learning cycle in Kolb and Kolb (2009, p. 299)

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history often have an assimilative learning style; engineering students often share a convergent learning style, etc. (Illeris, 2017). Kolb’s work on learning styles has also been criticised as it has been regarded as another example of his “mastery in putting everything in its place in his system and thereby quite firmly limiting and systematising human diversity” (Illeris, 2017, p. 175). However, other scholars have devoted their attention to this aspect. Felder (2020) defines learning styles as “common patterns of individuals’ preferences for certain approaches to instruction and personal attributes associated with each pattern” (p. 3). At the same time, the author warns that they are not “pairs of strict either-or categories, invariant, and reliable guides to what learners are strong and weak at” (p. 3). He maintains that “Kolb’s central idea is not to teach each student according to his or her style preferences but rather to teach around the cycle, sequentially addressing the preferences of students with different styles” (Felder, 2020, p. 10). Knowing about various learning styles can help educators to implement multiple teaching methods to engage their students according to their dispositions (Norrie et al., 2012). An indication that more profound and more engaged learning has occurred is when the acquired knowledge can be transferred to another context. In this regard, experiential learning is seen as a very appropriate and widely used tool in nursing and social work professional education and continuing professional development (Hill, 2017; Cheung & Delavega, 2014) as it transforms the student from a passive to an active lifelong learner (Lyons, 2010). Fry et al. (2009) view experiential learning as a continuous process that implies that “understanding is not a fixed or unchangeable element of thought and that experiences can contribute to its forming and reforming” (p. 15). It encompasses many teaching and learning activity types, including work-based learning, action learning or reflective practice, using case studies, role play and games. Drahanská (2020) describes three steps of experiential learning: (1) purpose, “what are the learning outcomes of the activity?”; (2) programme, selecting suitable activity (games, role-playing, challenges); and (3) reflection, “a royal discipline, the icing on the cake, the finishing touch” (p. 22). As Drahanská argues, without reflection, the intended purpose of learning outcomes and the implementation of the learning activity will have no effect. In other words, reflection helps to make sense of experiences and to arrive at new insights and has the potential to promote a transformational change. Hill (2017) provides a practical example of using experiential learning as a tool in nursing education. The purpose of the activity was to teach practical skills required for physical examination. Students worked in pairs and explored knowledge of human anatomy and organ placement. Among the activities was drawing human organs with fabric pens in their correct size and anatomical position onto white T-shirts while their partner was wearing the T-shirt. This teaching strategy aimed to provide a safe environment to practice and improve assessment and clinical reasoning skills. By learning in this fashion, the students could explore and share knowledge with their peers in a safe, non-clinical environment that allowed reflection and facilitated learning. It also sparked discussions in the group regarding the past experiences of patients. All students passed the evaluation and the final exam

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on the first attempt, which proved that experiential learning was a successful teaching method for the described project. According to the student evaluation, experiential learning enabled and motivated them to learn productively. Seventy per cent of the students felt that their learning was enhanced by the safe environment that allowed them to make mistakes.

Models of Reflection The objective of teaching reflection as a professional core competence can be promoted along two related pathways, which Maclean (2020), based on her long social work practice experience, termed “the process models” and “the component models”. The process models can only be used to reflect on past situations or experiences. They are linear, guiding a reflector through the defined, consecutive steps towards the reflective analysis of an experience. For these qualities, they are often the first choice in higher education programmes as they provide more structure and are better suited for inexperienced learners (Maclean, 2016). The component models are more flexible and demand more experience on the part of the reflector. Instead of providing a step-by-step approach, they offer certain domains or components on which the reflector can focus during reflection. They can be used for anticipated situations and reflecting on the moment of an experience or later on a past event (Maclean, 2020).

The Process Model An example of a commonly used process model is the Gibbs model (1988), which focuses on the reflective analysis of an event from practice to stimulate a progressive learning process. The process begins by asking “what happened”, to prompt the reflector to consider a past event. It continues by asking “what were you feeling”, “what went well”, “what didn’t go well”, “what have you learned” and “what would you do differently”. The Gibbs (1988) model of reflection is frequently used in the higher professional training of social workers and nurses. It enables students to look back on a specific instance, offering the following series of tasks to be completed: (1) a description of what occurred, (2) an assessment of one’s reactions and feelings, (3) an analysis of the event to make sense of it, (4) a conclusion to what was learned and (5) an action plan (what will be done differently). The steps are intended to aid the reflector in thinking through many facets of a pre-existing scenario or incident and must be followed chronologically. The Gibbs model was constructed for nurses as part of an experiential learning programme to facilitate discussions or “debriefings” that followed an experience (Gibbs, 1988, p. 49). It is frequently employed to reflect on a singular experience. Although it is widely used, it has drawn criticism for leading to descriptive instead of reflective writing in some people (Maclean, 2016).

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Fig. 3.2  The ALACT model and the nine boxes, with questions that help with step 2 of the reflection (Korthagen & Nuijten, 2022)

Another example of a process model is Korthagen’s ALACT model for reflection (Fig.  3.2), named after the initial letters of the five steps: (1) action (experience, event), (2) looking back on the experience, (3) awareness of essential aspects, (4) creating alternative methods of action and making a choice and (5) trial (Korthagen & Nuijten, 2022). It is comparable to the Gibbs model in that it also guides the reflector to inspect a pre-existing event in five steps that need to be chronologically followed. However, Korthagen and Nuijten (2022) warn that although it may look easy, most people “subconsciously follow routine patterns in their own way of reflecting”, mainly focusing on step 3 and neglecting steps 2 and 4 (p. 5). According to the authors, this can be avoided by consciously paying attention to each step, recognising there is a difference between “action-oriented reflection (‘What should I do’) and meaning-oriented reflection (‘What exactly is going on and why?’)” (Korthagen & Nuijten, 2022, p. 23). The second type of reflection leads to deeper insight and improves long-term learning. Effective meaning-oriented reflection demands careful completion of the five steps as well as understanding that our behaviour is driven by our “thinking, feeling and wanting (needs and desires)” (Korthagen & Nuijten, 2022, p. 26). The same needs to be considered in the other actors involved in the reflected situation, such as students, service users or clients. To explain the concept, the authors use the iceberg model where doing (our actions and behaviour) is the only visible, above-water part of the iceberg, while thinking, feeling and wanting, the main driving forces of our behaviour, are hidden below the water surface. To uncover the hidden elements of our behaviour, which are invisible to others and made visible to us only through conscious awareness, Korthagen offers nine concretising questions (see Fig. 3.2). Question 0 regards the context of the experience and encompasses social justice and cultural differences, as the norms and values continually shape the reflections we acquired during our upbringing and in the society we inhabit (Korthagen & Nuijten, 2022). Teachers, social workers and nurses need to become aware through the (critical) reflection of their possibly biased beliefs and behaviours to be able to teach, relate and help their clients.

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The Component Model While process models can best be used to reflect on a situation that has already occurred, the component models can be applied at any stage of reflection concerning practice, including the reflective planning of an intervention yet to commence. It examines the practitioner’s “skills repertoire” from different perspectives and levels and encourages educators to consider specific levels of depth or issue contexts as they become relevant at various stages of practice. The onion model developed by Korthagen (2004) is an illustration of a component model that offers the following six layers, each characterised by a specific kind of questions: (1) environment (What do I encounter? What am I dealing with?), (2) behaviour (What do I do?), (3) competencies (What can I do?), (4) beliefs (What do I believe in the situation?), (5) identity (Who am I in my work/as a professional?) and (6) mission (What inspires me? What is my ideal?) (see Fig. 3.3, Korthagen & Nuijten, 2022). These layers and enquiries stimulate and guide reflection. They can be applied in any order on all four stages of reflection (Edwards, 2017), including reflection before, during, after and beyond action. As Korthagen and Nuijten (2022) propose, reflection can occur on both surface and deeper levels, the latter they refer to as “core reflection” (p.  88). The onion model’s premise is that the inner layers determine how an individual functions on the outer layers and vice versa. For example, reflection on the innermost level can produce enquiries such as why the person decided to become a nurse or social worker or what they see as their calling in the world. Maclean (2016) contends that social workers like this model because it takes a “person-in-environment” perspective to the practice. However, the author encourages the reflectors to go deeper by

Fig. 3.3  The onion model (Korthagen & Nuijten, 2022)

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adding the socio-political context of power and inequalities to the environment layer, as no explicit reference guide towards exploring these elements of critical reflection is foreseen in the onion model (Maclean, 2016, p.  12). Nevertheless, Korthagen and Nuijten (2022) maintain that “reflection with the aid of the onion model can help people to become aware of beliefs underlying their behaviour” (p. 98). The authors specifically state that “[c]ritical reflection about the onion levels enhances awareness of biased ways of thinking about race, gender, religion, social classes, etc.; therefore, it is an important instrument for counteracting inequality and discrimination, and for enhancing social justice” (p. 108). In other words, from the authors’ perspective, the elements of critical reflection are present at each level of the model as each component encourages reflectors to go beyond the surface to discover the sources of their behaviours and actions. Another example of a component model is the head, heart and hands model (Fig. 3.4), which is commonly used in social pedagogy (Maclean, 2016). According to Ingram (2013), the model works by combining “the active goal-oriented aspects of emotional intelligence with potentially unconscious or repressed emotions such as anger to produce a piece of practice that reflects the management and use of

Fig. 3.4  The head, heart and hands model (Singleton, 2015)

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emotions” (p.  10). The author illustrates the process by providing a practical example of an interview he conducted with a criminal justice social worker as part of a broader study of emotions and practice that illustrates the active awareness, management and use of emotions in practice. The worker provided an account of the internal ethical struggle he experiences when working with sex offenders who do not take responsibility for their offences. He acknowledged his feelings of rage and the possibility of misusing his position of authority as a result. Adopting a strategy that recognises the service user from a holistic perspective, considering the service user’s defensiveness as being based on past and present experiences with social work interventions, alleviated this tension for him. This resulted in actively managing his emotions and motivated his decision to draw on his understanding of motivational interviewing and role modelling to engage with the service user constructively. The employee was guided by the model, which led him to deconstruct the emotional triggers in a way that manages them and funnels them into an active part of his practice. The case also stresses the value of supervision in giving him room to grow in his knowledge and mastery of handling and deconstructing emotional triggers as an integral part of his profession. Figure 3.5 provides further context for this approach as it combines potentially unconscious or suppressed emotions, such as anger, with active goal-oriented elements of emotional intelligence and creates “a piece of practice that represents the management and use of emotions” (Ingram, 2013, p. 10). Understanding models of reflection and exploring them from various professional backgrounds can stimulate the ability to see situations from multiple perspectives. Models can also help students, educators and professionals when reflecting individually, as they provide a framework to guide their thinking in a self-aware and self-critical direction. For example, when a social worker or nurse is unsure how to intervene, examining the problem using different models might provide various solutions and possibilities. Furthermore, models of reflection can aid in organising reflective writing or catalyse brainstorming before writing. Finally, understanding the specific objective of different stages of reflection is crucial because it guides in deciding which model to use for which purpose. Some models “give a process for reflective practice and are therefore more suited to reflecting after an event (reflection on action)”, and others “point to the issues/areas to be reflected on” (Maclean,

Fig. 3.5  Head, heart and hands practice (Ingram, 2013)

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2016, p. 13). Additionally, since different practitioners may be personally attracted to different models, no particular model must be imposed on them. In this regard, it can be helpful to be familiar with several models and aware of the relationship between them and the stages of reflection because it can provide the practitioner with more alternatives. It can also make reflecting more appealing and creative, which are necessary conditions for a systematic practice of reflection. As Korthagen and Nuijten (2022) put it, “systematic reflection leads to awareness of the essence of the situation and can help with finding a suitable approach” (p. 5).

Application of Reflective Models Reflectivity is primarily a mental activity that can take place and usually does take place even without the aid of didactic tools. However, our attention will be drawn to a few means that have been found conducive to stimulating and direction reflecting in a training context and where various models can be applied to guide one’s reflection. In promoting reflectivity, particular value is attributed to the pedagogical approaches that focus on the transition from thinking to writing. This transition familiarises learners with the benefits of reflecting, preventing them from considering the “mental exercises” too abstract and ephemeral. These techniques include reflective journals (diaries), autobiographical stories (on paper or electronically), critical incident reports, seminar presentations (essays) and professional portfolios (Fragkos, 2016). There is widespread agreement in the literature that keeping a journal can assist students in developing reflective skills and habits (Di Gursansky et al., 2010). It has also been reported that journal writing enhances self-awareness, interpersonal understanding, critical analysis, cognitive learning and clinical reasoning skills (Lyons, 2010). Furthermore, it is “one way of maintaining memories through which to think about practice actions and consider the knowledge that is being used” (Coward, 2011, p. 886). However, some suggest that journaling must be related to a specified purpose to have this effect and hence requires “a structured format, clear instructions and ongoing feedback” to maintain students’ engagement (Dye, 2005 in Taylor-Haslip, 2010, p. 69). Opposing views warn that if the format for writing is too restricting and students are marked according to how well they use a “recognised” model of reflection, the assignments might lose the impact of reflective learning (Coward, 2011, p. 883). In this regard, Cottrell (2017) acknowledges that writing a reflective journal can be very challenging for students. The author asserts that it is vital that students understand the personal benefits of keeping a journal and are well supported by their teachers and not assessed on the literary quality of their writing. It is also essential to consider that students improve their writing skills gradually. Initially, their writing is frequently descriptive, and more structured guidance is needed for students to adopt a more analytical style. Over time and with constructive feedback and growth

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of trust with their teachers, they develop their own style and become capable of a deeper level of reflection (Knott & Scragg, 2016). Portfolios are other commonly used tools to promote reflection. In the early phases of professional training, they were used to bring academic and field-based learning together in a summative assessment format (Lyons, 2010). However, in recent years, their use has come to serve a more developmental and formative process. In portfolios, students are encouraged to “deconstruct practice work on an ongoing basis and, in the process, to excavate their underpinning beliefs, values, knowledge and skills, and their influence on decision-making processes” (Lyons, 2010, p. 179). As with journal writing, for students to engage in portfolio writing might be difficult and requires mentoring from academic tutors and safe boundaries regarding the implications of the technique for assessment purposes. As revealed in the research, the main effects of using portfolios are improved student knowledge and understanding, their ability to learn independently and greater self-awareness and engagement in reflection (Fragkos, 2016). There are also benefits for educators. Research shows that in reading portfolios, they can feel “extremely privileged to witness the learning and development of students …, participating with students in the construction of their identities as future social workers [or nurses]” (Lyons, 2010, p. 179).

Multimedia Approaches With technological advancements and increasing interest in multimedia activities, it has been suggested that students might benefit from writing their journals and portfolios in digital format as they are more used to these media and can incorporate visual and acoustic records. Koole et al. (2011) propose that supporting students to reflect with the creative use of multimedia could “increase their commitment to reflect and stimulate even more efficient reflection” (p. 6). These authors also point out that although the ability to semantically describe reflections is essential to effective reflection, other skills are required to translate reflection into writing. There is often a decline in motivation brought on by a mismatch between a student’s preferred learning style, which might depart from the prerogative of the written medium, and a standardised written evaluation approach. Additionally, there are specific considerations in terms of the assessment criteria which can no longer be based on traditional academic concepts of “right or wrong” but rather on the students’ ability to give an account of their own learning and development in a variety of formats, which might make it easier to include “mistakes” and dilemmas they encounter (Lyons, 2010, p. 186). Overall, including considerations of critical reflectivity on professional courses in preparation for practice realities in which digital recording and communication will play an increasing role (Winman, 2020) might add an essential element to the development of “digital literacy” from a position of ethics and rights (Allen & Light, 2015).

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Critical Incident Recording Analysing a critical incident from practice is another effective method used to enhance reflectivity in social work and nursing students. It was first used by Flanagan (1954), who identified turning points in military strategy through the eyes of war veterans. In presenting a critical incident, writers recount an event that they feel has a significant impact on their practice. It can be a lesson learned, a meaningful moment or a powerful experience, something the actor saw that had a profound impact. Critical incident reporting is encouraged in undergraduate education and is standard practice in many forms of postgraduate training and continuing professional development (Branch, 2005). The method is beneficial for investigating underlying presumptions and facilitates transformative learning by providing access to experiences that encourage personal growth (Mezirow, 1990). Critical incidents can challenge or critique pre-existing patterns of thoughts and behaviour. However, such an incident may also embrace current thinking and practice by providing evidence of its worth or emphasising some aspects of good practice that have previously gone unnoticed and can be shared with others (McKinnon, 2016). The author maintains that viewing critical incidents as positive experiences is particularly important for learners in the nursing setting as “nursing has historically existed in a very self-critical, even denigrating environment in which weaknesses are often highlighted over strengths” (McKinnon, 2016, p.  53). In social work education, critical incidents have been used to examine hegemonic assumptions and power relationships and “help the students reflect on disparities between their espoused values or theories and their actual practice” (Oterholm, 2009, p. 363). The method has also been helpful as a pedagogical tool to help students to explore sensitive ethnic and cultural issues with service users from contrasting cultures and to describe and analyse the complexity of the processes of interaction with the service users (Green Lister & Crisp, 2007).

Critical Friendship Reflection is best facilitated in learning situations that are not dominated by demands for assessment and hence by the power differential between learner and educator. The notion of a “critical friend” helps to suspend these implications even when assessment criteria may have to be fulfilled at the end of the learning process. The notion of friendship underlines the constructive relationship aspect inherent in reflecting and, more specifically through the implied support, makes “mistakes” and their analysis more accessible to the learner. Providing “critical friendship” is therefore a further method of encouraging reflection and active learning through a role that is different from that of a teacher or a superior. It should be reminded here that, as mentioned in relation to critical reflection, the word critique should not be seen in contradiction to a supportive

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relationship. On the contrary, critique is integral to quality development (Costa & Kallick, 1993). Critical friends are more explicitly prepared to highlight the positive aspects of their friend’s work and shortcomings than their peers. Therefore, as pointed out by Costa and Kallick (1993), the critique given by a friend is supportive, positive and uplifting in its most profound meaning. In order to be beneficial, comments by others require an understanding of the general context and the situation being evaluated, and the framework relationship needs to be participative, collaborative and mutually informing (Gibbs & Angelides, 2008). The concept of critical friendship can be used to promote a reflective dialogue between students, professionals and teachers. Concerning the latter, it has been noted that in nursing and social work professional education, educators often teach without teacher-specific training (Dahlgren et al., 2006). Critical friendship can be a way to advance their teaching skills as it involves a mutual learning situation. For example, Fuentealba and Russell (2020) report that their critical friendship approach has resulted in the enhancement of teaching practices: “Each helped the other with analysis and justification of the changes in practice, so that reframing inspired repracticing” (p. 9). These results are supported in other studies of critical friendship and identify the concept as “a powerful instrument to stimulate elicitation of professional knowledge – even in experienced teachers” (Dahlgren et al., 2006, p. 77).

Conclusions Teaching and supporting reflective skills in a learning and practice context require considerations from several perspectives. The complexity of situations confronted by practitioners in the social and nursing professions makes high demands on training courses to affect knowledge transmission and knowledge transformation (Kalantzis & Cope, 2008; Leonardo, 2004). Students learn how to continuously adapt their skills to changing demands and base  them on newly accumulating knowledge so that they can see themselves as active change agents and not mere executors of regulations and prescriptions or followers of routines (Mezirow, 2006). As Chap. 1 pointed out, recent neuro-psychological research established that effective reflecting must consider ongoing reflexive processes through which the brain maintains stability and continuity of mental orientation. At this level, individuals habitually give meaning to their past perceptions and actions based on past processed experiences. Reflecting as a conscious and intentional brain function operates at a level of awareness through which some of those categories and their associated meaning can be accessed and turned into deliberate intentions (Peper et al., 2019). Linearity or circularity then become more explicit pedagogical considerations when choosing one of the models proposed in the literature. As mentioned, the process models promote a more linear, progressive and systematic reflective treatment of specific experiences (e.g. Gibbs, 1988). They are therefore more suited for enhancing reflectivity in inexperienced practitioners. In contrast, the component

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models (e.g. Korthagen, 2004) focus on nested layers of mindfulness and intentionality, leaving the choice of pace and depth to the reflector. For specific training contexts, various instruments and techniques were suggested above which can trigger reflective processes on the occasion of a concrete structured exercise such as writing. These tools were found useful because they focus on the transition from continuous reflexivity to focused reflecting which is more evident and accessible when initiated by putting one’s mind to writing than by “merely thinking or talking” since writing requires greater attention to a consequential structure. While reflectivity can obviously be learned individually, this volume concerns primarily formal learning situations in which the intention is to develop these skills interactively. In this context, it has to be stressed that it is not the technique or the model per se which accounts for effective reflecting to develop. Instead, these need to be “embedded” in interactive relationships of a particular kind and with roles that have distinct contours. Dialogical reflection can only be enacted in learning contexts when peers informally provide mutual stimulation and support. However, defining the supportive role requires more experienced educators’ facilitation. As noted, facilitators, supervisors and peers can also adopt the position of a “critical friend” through which feedback becomes separated from the function of assessment through a constructive, non-threatening understanding of the notion of “critique”. Where assessment and formal qualifications enter the process, they are not automatically inimical to the relaxed exploration of diverse reflecting styles. Much hinges on the treatment of “mistakes”, which can be made thematic in relation to reflectivity in either a motivating or a demotivating manner. It is therefore suggested that as much attention needs to be given to contextual conditions that make up different learning agendas as to the actual interactive processes and the contents of reflecting. Time allocation in terms of regulations to pass exams or to deliver work within specified parameters, as well as physical and architectural settings, can all be facilitating or inhibiting factors. Ultimately, the appropriate correspondence between these levels and the authenticity with which objectives and limitations are negotiated are constitutive of trust (Egan et al., 2017). Being oriented towards trusting relationships is as important in formal learning situations as in the context of service agencies where the element of “psychological safety” has been found to be constitutive of constructive organisational cultures (Baer & Frese, 2003; Widmer et al., 2009). The constitutive factors for such cultures include confidentiality and recognition of the dignity and individuality of each person, a professional colleague or a service user. And the level of emotional safety influences the function and direction of reflectivity that can be practised and developed under these conditions. Overall, it emerges from research in professional learning and practice contexts that developments occur most readily when reflection is treated as a goal-oriented activity where everyone understands its purpose (Norrie et al., 2012). An opposing practice would be treating reflection as an end in itself or a preliminary exercise (van Beveren et al., 2018). Given the widespread use of often superficial references to reflection in professional training curricula and guide books, authors warn against

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indiscriminate use of the concept that is either divorced from questions of values and ethics or implies a hidden agenda of increasing pressure for efficiency in agencies (Biesta, 2011). It is essential that nursing and social work students become aware of the power implications of their expert knowledge and learn to continuously monitor the effects this has on their effectiveness and their relationship with service users. Practising reflection remains one of the foundations and hallmarks of professional practice. It can only be acquired and maintained through systematic educational programmes designed to develop and enhance this competence. But in view of the controversies surrounding the notion of autonomy in current organisational and political debates, approaches to training reflectivity have to include ethical and political considerations so that they can amount to a comprehensive understanding of “critical reflectivity” in the interest of linking reflectivity solidly to accountability.

References Aji, C. A., & Khan, M. J. (2019). The impact of active learning on students’ academic performance. Open Journal of Social Sciences, 7(3), 204–211. https://doi.org/10.4236/jss.2019.73017 Allen, D., & Light, J. S. (Eds.). (2015). From voice to influence: Understanding digital citizenship in a digital age. The University of Chicago Press. Aron, L. (2000). Self-reflexivity and the therapeutic action of psychoanalysis. Psychoanalytic Psychology, 17(4), 667–689. https://doi.org/10.1037/0736-­9735.17.4.667 Askeland, G. A., & Fook, J. (2009). Critical reflection in social work. European Journal of Social Work, 12(3), 287–292. https://doi.org/10.1080/13691450903100851 Baer, M., & Frese, M. (2003). Innovation is not enough: Climates for initiative and psychological safety, process innovations and firm performance. Journal of Organizational Behavior, 24, 45–68. Bargh, J. A. (1996). Principles of automaticity. In E. T. Higgins & A. Kruglanski (Eds.), Social psychology: Handbook of basic principles (pp. 169–183). Guilford Press. Béres, L., & Fook, J. (2020). Learning critical reflection. Experiences of the transformative learning process. Routledge. Biesta, G. (2011). Philosophy, exposure, and children: How to resist the instrumentalisation of philosophy in education. Journal of Philosophy of Education, 45, 305–319. Boler, M. (1999). Feeling power: Emotions and education. Routledge. Boychuk Duchscher, E.  J. (1999). Catching the wave: Understanding the concept of critical thinking. Journal of Advanced Nursing, 29(3), 577–583. https://doi. org/10.1046/j.1365-­2648.1999.00925.x Braine, M. E. (2009). Exploring new nurse teachers’ perception and understanding of reflection: An exploratory study. Nurse Education in Practice, 9(4), 262–270. https://doi.org/10.1016/j. nepr.2008.08.008 Branch, W. T. (2005). Use of critical incident reports in medical education. Journal of General Internal Medicine, 20(11), 1063–1067. https://doi.org/10.1111/j.1525-­1497.2005.00231.x Čajko Eibicht, M., Lorenz, W., & Havrdová, Z. (2021). Enhancing reflectivity in social, care and health professionals  – Identifying students’ abilities and needs. European Journal of Social Work, 25(4), 1–13. https://doi.org/10.1080/13691457.2021.2016644 Cheung, M., & Delavega, E. (2014). Five-way experiential learning model for social work education. Social Work Education, 33(8), 1070–1087. https://doi.org/10.1080/02615479.2014.92553 8

58

M. Č. Eibicht and W. Lorenz

Colomer, J., Serra, T., Cañabate, D., & Bubnys, R. (2020). Reflective learning in higher education: Active methodologies for transformative practices. Sustainability, 12(9), 3827. https:// doi.org/10.3390/su12093827 Costa, A. & Kallick, B. (1993) Through the lens of a critical friend. Educational Leadership, 51(2), 49–51. Cottrell, S. (2017). Critical thinking skills: Effective analysis, argument and reflection (3rd ed., pp. 1–309). Red Globe Press. Coward, M. (2011). Does the use of reflective models restrict critical thinking and therefore learning in nurse education? What have we done? Nurse Education Today, 31(8), 883–886. https:// doi.org/10.1016/j.nedt.2011.01.012 Dahlgren, L. O., Eriksson, B. E., Gyllenhammar, H., Korkeila, M., Saaf-Rothoff, A., Wernerson, A., & Seeberger, A. (2006). To be and to have a critical friend in medical teaching. Medical Education, 40(1), 72–78. https://doi.org/10.1111/j.1365-­2929.2005.02349.x Dewey, J. (1933). How we think. Prometheus Books. (Original work published 1910). Di Gursansky, D., Quinn, D., & Le Sueur, E. (2010). Authenticity in reflection: Building reflective skills for social work. Social Work Education, 29(7), 778–791. https://doi. org/10.1080/02615471003650062 Drahanská, P. (2020). Učení prožitkem. Jak postavit vaše výchovné a vzdělávací programy na prožitku. Gymnasion. Edwards, S. (2017). Reflecting differently. New dimensions: Reflection-before-action and reflection-­beyond-action. International Practice Development Journal, 7(1), 1–14. https://doi. org/10.19043/ipdj.71.002 Egan, R., Maidment, J., & Connolly, M. (2017). Trust, power and safety in the social work supervisory relationship: Results from Australian research. Journal of Social Work Practice, 31(3), 307–321. https://doi.org/10.1080/02650533.2016.1261279 Fawcett, J. (2001). The nurse theorists: 21st-century updates—Dorothea E. Orem. Nursing Science Quarterly, 14(1), 34–38. https://doi.org/10.1177/08943180122108021 Felder, M.  R. (2020). Opinion: Uses, misuses, and validity of learning styles. Advances in Engineering Education, 8(1), 1–14. [PDF] asee.org Flanagan, J. C. (1954). The critical incident technique. Psychological Bulletin, 51(4), 327–358. https://doi.org/10.1037/h0061470 Fragkos, K. C. (2016). Reflective practice in healthcare education: An umbrella review. Education Sciences, 6(27). https://doi.org/10.3390/educsci6030027 Freshwater, D., Taylor, B. J., & Sherwood, G. (2008). International textbook of reflective practice in nursing. Blackwell Publishing. ISNB: 978-1-4051-6051-3 (Pbk). Fry, H., Ketteridge, S., & Marshall, S. (2009). A handbook for teaching and learning in higher education: Enhancing academic practice (3rd ed.). Routledge. Fuentealba, R., & Russell, T. (2020). Telling is not teaching, listening is not learning: New teacher education practices from a critical friendship. In C. Edge, A. Cameron-Standerford, & B. Bergh (Eds.), Textiles and tapestries. EdTech Books. Retrieved from https://edtechbooks. org/textiles_tapestries_self_study/chapter_24 Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Further Educational Unit, Oxford Polytechnic. Gibbs, P., & Angelides, P. (2008). Understanding friendship between critical friends. Improving Schools, 11(3), 213–225. https://doi.org/10.1177/1365480208097002 Gillings, B. (2000). Clinical supervision and reflective practice. In S. Burns & C. Bulman (Eds.), Reflective practice in nursing: The growth of the professional practitioner (pp.  106–121). Blackwell Science. Green Lister, P., & Crisp, B. (2007). Critical incident analyses: A practice learning tool for students and practitioners. Practice, 19(1), 47–60. https://doi.org/10.1080/09503150701220507 Healy, K. (2017). Becoming a trustworthy profession: Doing better than doing good. Australian Social Work, 70(1), 7–16. https://doi.org/10.1080/0312407X.2014.973550 Hill, B. (2017). Research into experiential learning in nurse education. British Journal of Nursing, 26(16), 932–938. https://doi.org/10.12968/bjon.2017.26.16.932

3  Promoting Reflective Learning Styles Among Social Work and Nursing Students…

59

Illeris, K. (2017). How we learn. Learning and non-learning in school and beyond. Routledge. ISBN 9781138689817. Ingram, R. (2013, March). Emotions, social work practice and supervision: An uneasy alliance? Journal of Social Work Practice, 27(1), 5–19. https://doi.org/10.1080/02650533.2012.745842 Kalantzis, M., & Cope, B. (2008). Language education and multiliteracies. Introduction: Initial development of the ‘multiliteracies’ concept. In S. May & N. H. Hornberger (Eds.), Language policy and political issues in education (Encyclopedia of language and education) (Vol. 1, 2nd ed., pp. 195–211). Cham. Kessl, F. (2009). Critical reflexivity, social work, and the emerging European post-welfare states. European Journal of Social Work, 12(3), 305–317. https://doi.org/10.1080/13691450902930746 Kim, H. S. (1999). Critical reflective inquiry for knowledge development in nursing practice. Journal of Advanced Nursing, 29(5), 1205–1212. https://doi.org/10.1046/j.1365-­2648.1999.01005.x Knott, C., & Scragg, T. (2016). Reflective practice in social work. Sage. Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Prentice Hall. Kolb, A.  Y., & Kolb, D.  A. (2009). The learning way. Simulation & Gaming, 40(3), 297–327. https://doi.org/10.1177/1046878108325713 Koole, S., Dornan, T., Aper, L., Scherpbier, A., Valcke, M., Cohen-Schotanus, J., & Derese, A. (2011). Factors confounding the assessment of reflection: A critical review. BMC Medical Education, 11(104) http://www.biomedcentral.com/1472-­6920/11/104 Korthagen, F.  A. J. (2004). In search of the essence of a good teacher: Towards a more holistic approach in teacher education. Teaching and Teacher Education, 20(1), 77–97. https://doi. org/10.1016/j.tate.2003.10.002 Korthagen, F., & Nuijten, E. (2022). The power of reflection in teacher education and professional development: Strategies for in-depth teacher learning. Routledge. ISBN 978-1-03-211770-6. Landy, R., Cameron, C., Au, A., Cameron, D., O’Brien, K.  K., Robrigado, K., Baxter, L., Cockburn, L., O’Hearn, S., Oliver, B., & Nixon, S.  A. (2016). Educational strategies to enhance reflexivity among clinicians and health professional students: A scoping study. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research, 17(3), 1–24. http://eprints. lse.ac.uk/68328 Leonardo, Z. (2004). Critical social theory and transformative knowledge: The functions of criticism in quality education. Educational Researcher, 33(6), 11–18. https://doi.org/10.310 2/0013189X033006011 Lieberman, M. D., Gaunt, R., Gilbert, D., & Trope, Y. (2002). Reflection and reflexion: A social cognitive neuroscience approach to attributional inference. Advances in Experimental Social Psychology, 34, 199–249. https://doi.org/10.1016/S0065-­2601(02)80006-­5 Lim, F.  A., & Shi, T. (2013). Florence nightingale: A pioneer of self-reflection. Nursing, 1–3. https://doi.org/10.1097/01.NURSE.0000428713.27120.d2 Lyons, N. (Ed.). (2010). Handbook of reflection and reflective inquiry. Mapping a way of knowing for professional reflective inquiry. Springer. https://doi.org/10.1007/978-­0-­387-­85744-­2 Maclean, S. (2016). Reflective practice cards. Prompt cards for social workers (1st ed.). Kirwin Maclean Associates. ISBN: 978-1-903575-99-4. Maclean, S. (2020). Reflective practice: Component models of reflection. [Webinar]. April 22, 2020. https://www.youtube.com/watch?v=_1w4AyRNFDU&list=PL-­VvBcDnqAcXuRVZW AHW0BmTOhGFoU3sw&index=7 Maclean, S. (2022). Back to basics. Student Connect Webinar 87. [Webinar]. Siobhan Maclean. https://www.youtube.com/watch?v=BHDKtMzYgIw&t=174s McKinnon, J. (2016). Reflection for nursing life. Routledge. Mezirow, J. (1990). Fostering critical reflection in adulthood: A guide to transformative and emancipatory learning. Jossey-Bass. Mezirow, J. (2006). An overview of transformative learning. In P. Sutherland & J. Crowther (Eds.), Lifelong learning (pp. 24–38). : Routledge. Mo, K. Y., O’Donoghue, K., Wong, P. Y., & Tsui, M. (2021). The historical development of knowledge in social work supervision: Finding new directions from the past. International Social Work, 64(2), 187–200. https://doi.org/10.1177/0020872819884995

60

M. Č. Eibicht and W. Lorenz

Nadan, Y., & Stark, M. (2017). The pedagogy of discomfort: Enhancing reflectivity on stereotypes and bias. The British Journal of Social Work, 47(3), 683–700. https://doi.org/10.1093/ bjsw/bcw023 Norrie, C., Hammond, J., D’Avray, L., Collington, V., & Fook, J. (2012). Doing it differently? A review of literature on teaching reflective practice across health and social care professions. Reflective Practice, 1(4), 565–578. https://doi.org/10.1080/14623943.2012.670628 Oterholm, I. (2009). Online critical reflection in social work education. European Journal of Social Work, 12(3), 363–375. https://doi.org/10.1080/13691450902930738 Passarelli, A. M., & Kolb, D. A. (2011). Student learning abroad sterling (M. Vande Berg, M. Page, & K. Lou, Eds.). Stylus Publishing Peper, E., Harvey, R., & Lin, I.-M. (2019). Mindfulness training has elements common to other techniques. Biofeedback, 47(3), 50–57. https://doi.org/10.5298/1081-­5937-­47.3.02 Reason, J. T. (1990). Human error. Cambridge University Press. Richmond, M. (1917). Social diagnosis. Russell Sage. Russell, T. (2006). Can reflective practice be taught? Reflective Practice, 6(2), 199–204. https:// doi.org/10.1080/14623940500105833 Ryan, M., & Ryan, M. (2013). Theorising a model for teaching and assessing reflective learning in higher education. Higher Education Research & Development, 32(2), 244–257. https://doi. org/10.1080/07294360.2012.661704 Schön, D. (1983). The reflective practitioner: How professionals think in action. Basic Books. Schunk, D. H., & Mullen, C. A. (2012). Self-efficacy as an engaged learner. In S. J. Christenson, A. L. Reschly, & C. Wylie (Eds.), Handbook of research on student engagement (pp. 219–235). Springer. https://doi.org/10.1007/978-­1-­4614-­2018-­7_10 Segev, E., & Nadan, Y. (2016). Facing reality: Context-oriented reflection in social work education. British Journal of Social Work, 46(2), 427–443. https://doi.org/10.1093/bjsw/bcu138 Sicora, A. (2019). Reflective practice and learning from mistakes in social work student placement. Social Work Education, 38(1), 63–74. https://doi.org/10.1080/02615479.2018.1508567 Simpson, S., & Abbot, K. (2010). Traditions and transitions. History of the nursing program at Thompson Rivers university, 1973–2003. Gauvin Press. Singleton, J. (2015). Head, heart and hands model for transformative learning: Place as context for changing sustainability values. Journal of Sustainability Education, 9. http://www.jsedimensions.org/wordpress/wp-­content/uploads/2015/03/PDF-­Singleton-­JSE-­March-­2015-­Love-­ Issue.pdf Špirudová, L. (2015). Doprovázení v ošetřovatelství I: pomáhající profese, doprovázení a systém podpor pro pacienty (1st ed.). Grada Publishing. Taylor, E. (1996). William James on consciousness beyond the margin. Princeton University Press. Taylor-Haslip, V. (2010). Guided reflective journals depict a correlation to the academic success of nursing students. Teaching and Learning in Nursing, 5(2), 68–72. https://doi.org/10.1016/j. teln.2010.01.002 Van Beveren, L., Roets, G., Buysse, A., & Rutten, K. (2018). We all reflect, but why? A systematic review of the purposes of reflection in higher education in social and behavioral sciences. Educational Research Review, 24, 1–9. https://doi.org/10.1016/j.edurev.2018.01.002 Watts, L. (2019). Reflective practice, reflexivity, and critical reflection in social work education in Australia. Australian Social Work, 72(1), 8–20. https://doi.org/10.108 0/0312407X.2018.1521856 White, S., Fook, J., & Gardner, F. (2006). Critical reflection in health and social care. Open University Press. Widmer, P. S., Schippers, M. C., & West, M. A. (2009). Recent developments in reflexivity research: A review. Psychology of Everyday Activity, 2(2), 8–20. http://eprints.lancs.ac.uk/53195/ Willingham, D. T. (2009). Why Don’t students like school? Jossey-Bass. Winman, T. (2020). The role of social pedagogy in a digitalized society. The Educational Review, USA, 4, 81–92.

Chapter 4

Supervision at the Workplace as a Unique Space for Reflection Martin Hajný and Zuzana Havrdová

Introduction In this chapter, we propose to view workplace supervision as a unique nurtured space for shared reflection in professional social and health services, a practice which has been evolving for more than 120 years. Part of the definition of supervision is that it focuses on specific opportunities to align work attitudes, practices and relationships with the realisation of professional values and goals in a work situation through shared reflection. Supervision has evolved in the course of the professional development for instance of social work. As Kadushin and Harkness (2014), Tsui (2005) or Levicka et al. (2021) point out, since the early twentieth century, the prevailing conception of supervision has been the controlling, guiding or later ‘counselling’ process between a supervisor and a supervisee, with the focal point being clients and the improvement of their situation (Harkness & Poerkner, 1989). The supervisor was seen as a powerful authority, an expert on solutions of problems (Petes, 1967; Wilson & Ryland, 1949). Later, there was a shift in focus from the client to the worker; however, the authority of the supervisor continued, as he taught, controlled and even treated the supervisee. Further development replaced this kind of unequal relationship by a more equal working alliance (Watkins, 2005) in which collaborative reflection has been more and more pronounced. New institutions emerged gradually since the 1990s manifesting the influence of context on supervision (e.g. as the seven-eyed model of supervision, Hawkins & Shohet, 2004). The earlier understanding of a supervisor-supervisee-client triangle relationship has been replaced by a supervisor-supervisee-client-organisation quadrangle relationship (Havrdova et al., 2011). This has brought to higher attention the M. Hajný · Z. Havrdová (*) Faculty of Humanities, Charles University, Prague, Czech Republic e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Lorenz, Z. Havrdová (eds.), Enhancing Professionality Through Reflectivity in Social and Health Care, https://doi.org/10.1007/978-3-031-28801-2_4

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relation between supervision, supporting workers in their professionality and management, which has the power to manage the quality of care. Supervision has been related to management sometimes as being part of it as a form of so-called internal supervision, and sometimes as being separated from it, in the form of external supervision or supervision of private practice. Our position as authors has been shaped by the middle-European understanding of supervision in its external form, where the supervisor is an independent expert from outside the organisation, who has been educated as the helping professional in the context of the values of the person-centred helping professions, expressed as patient-centred care (e.g. Liberati et al., 2015; Berwick, 2009; Institute of Medicine, 2001). He/she works based on a contract negotiated with the employer and the participants in workplace supervision, usually in teams, but sometimes also individually or in groups. We acknowledge the important role of supervision in the development of the organisation by supporting the quality of care provided by participants in supervision. From that position, we also interpret the relation of supervision and management as an important mutually respecting partnership, based on a transparent supervision contract. As was suggested, supervision can be provided in many forms, internal and external, individual, group and team, administrative or supportive and others (see, e.g. Hawkins & Shohet, 2004). We will focus here on the type of supervision referred to as reflective supervision [1] (e.g. Hewson & Carroll, 2016; Rankine, 2017), where reflection is seen as the core task of mutual cooperation between a supervisor and supervisee. Therefore, we set out to empirically explore specific attitudes, values, conditions and other aspects of supervision, which serve this objective. Supervision in many countries has in the last 30  years established itself as a stand-alone profession (see reference at www.ANSE.eu), with clearly defined methodological, ethical and professional requirements, taught by a specially trained and certified supervisor. Those requirements together with specific know-how elements, which are repeatedly passed to new supervisors by the certified training, make up the developing corpus of complex conditions which in our view are enabling deep professional reflection. In the following, we want to outline these elements and describe the conditions which contribute to reflective supervision with the vision that some of those elements might be used at the workplace even outside of the supervision framework. This does not mean we recommend neglecting the precious supervision framework, which has its special role and has been so successfully developing for a long time, but the intention is to enlarge various opportunities for reflection as reflective supervision cannot be always available. Supervision is a complex and highly culturally situated process. Owing to its diversity, it cannot be reduced to some few core fields and principles; however, we believe there are some learning points on enhancing reflection that can be derived from the field of reflective supervision, to complement the different views on reflectivity discussed in this volume.

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To pick up those learning points from the complex process, we have taken the view of a supervisor who is supposed to introduce supervision into social or health service organisation. To get oriented, he must first look for the purpose and negotiate if supervision is what the organisation needs. Then he must try to find out if the organisational culture is favourable for reflexive supervision. Last, he needs to establish specific conditions and introduce specific processes relevant for concrete form of supervision and concrete participants. This view helped to identify six interrelated areas in the supervision field describing relevant needs, organisational culture and specific conditions and processes in supervision enhancing professional reflection. The identified areas can be seen as the added value of supervision for enhancing reflection. They are specific purposes which supervision can serve in the organisation, the organisational leadership and culture, the person and role of the supervisor, the structure and overall setting of supervision, the nature of relations in supervision and the different processes, methods and skills which support and activate reflection. Before going into details of these areas, we need to address the risks of supervision and reflexivity. Like in any effective method of working with people, codes of ethics provided by national or international counselling associations or associations for supervision circumscribe how this type of supervision is conducted and what are the limits for the supervisor to avoid abuse. Effective methods of reflection should not be divorced from their value base in social work and psychotherapy where they originated, which concerns the well-being and dignity of people (Brashears, 1995). In addition, the purpose for which participants are invited and guided to reflect should always be clearly agreed and consented to by the participants, specifying in advance who is allowed to have access to the results and under what conditions, and negotiating  further issues of confidentiality. This corresponds to the purpose of reflection, which must always be negotiated, and hidden ethical challenges must be addressed (see Chaps. 1, 2, and 3). This renders the seemingly simple topic of reflection a complex dynamic process. The risk of misuse for so-called managerialist purposes as a kind of surveillance through supervision is currently prominently discussed in the literature (e.g. Tsui, 2004; Wilkins et  al., 2017; Rankine & Beddoe, 2020). [1] The concept is itself a result of the long development of supervision and slowly has been occurring since 2016, sometimes replacing also the concept of clinical supervision. We understand its meaning as the Australian Nursing and Midwifery Federation (ANMF) clarified it in its position statement: https:// anmj.org.au/what-­is-­clinical-­reflective-­supervision/. [2] External supervision is led by an external supervisor, which means he is not employed in the organisation, but he is either freelance or sometimes he is employed elsewhere. He is responsible for both the management and the supervisee on the basis of negotiated contract (Havrdova et al., 2008).

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Area 1: Purpose and Topics of Supervision What specific purposes can supervision serve in an organisation? This can be best illustrated by examples of topics for reflection which the supervisee typically brings to supervision. Generally, the topics for reflection can be work attitudes and practices, as well as relationships within the team and the organisation, and their settings that help to fulfil professional values and goals. If this is successful, participants in supervision will experience a shift or even a change that legitimises for them the time and effort devoted to the supervision process. Questions what people bring as topics must be related to how they do it, and why they do it, as we explain below. The specification of a clear topic and purpose of its selection is important in supervision as both become the focus of shared reflection and intensive elaboration during supervision. The topic is related to a particular aspect of experience and can be quite broad, but still concrete, for example, ‘to look what happened between me and the client as soon as he came today’ or ‘my mixed feelings around this particular decision’. Presenting a specified topic contributes to a supervision session becoming more effective (Koob, 2003). Each topic can be selected for different purposes, and the purpose mirrors the unique motivation of the supervisee which is highly situational and can change even within one supervision session. For example, the purpose ‘to look what happened between me and the client as soon as he came today’ can be motivated by insecure feelings of the supervisee concerning her relationship with the client which need to be ventilated and reflected, or it can be motivated by the need to check by the supervisee if her following intervention was relevant to the needs of the client. The purpose will guide the supervision process, which will go on differently depending on the topic and the purpose. The concrete topic must be selected by the employee, not the employer or supervisor. The active role of supervisees has been advanced by the adult learning theories developed by Schön (1983) and Kolb (1984) which represent also an advance in democratic participation. Research findings on organisational factors and the job environment having a positive influence on personal engagement confirm this trend (Kahn, 1990). Providing space for participation and acknowledging the dignity of each employee contribute to readiness to learn and work commitment. Specifying a topic is often not so easy since the topic selected is usually a part of a complex situation with various experientially contradictory and partly hidden aspects (e.g. Bond & Holland, 2011). When participants start to engage in supervision, they slowly learn how to become actively engaged in ‘discovering’ their actual topics in their professional practice and how to raise and express it, thereby making it accessible for reflection in supervision. The characteristics of a fruitful topic are that it is concrete and situated in time and relationships; it should be related to a real and not virtual work situation. It is normally of great actuality and contains challenging elements for supervisees, bound to the purpose behind the choice, so that they are strongly motivated to focus their reflection on it and even to shift their perspective despite difficult emotions which might be raised in relation to the topic. The shift implies that a learning process has been triggered leading towards

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fulfilling the unique individual purpose behind the chosen topic. This can be a solution in the form of an inner or outer change which the supervisee had been looking for, in terms of, for instance, finding another approach, a new possibility how to proceed, a change in attitude, abandoning an inefficient strategy, freeing oneself from burdening feelings or finding courage to persevere. What topics generally occur in supervision? Knowing there is still little knowledge regarding international and interdisciplinary supervision (Goodyear et  al., 2016), still we can find similar topics of supervision across different countries and cultures. While each topic may be unique to the concrete persons and situations which require reflection, many experiences, especially personal experiences, bear similarities across different countries (Goodyear et  al., 2016). According to O’Donoghue et al. (2018), the similarity not only is related to the understanding of supervision as a relational and reflective process helping to improve job performance but also concerns the subjects raised in supervision, which concern direct practice matters of supervisees and their professional development. They usually deal with some kind of uncertainty, complexity or emotional burden, which require a kind of visualisation, the gradual uncovering of subtle shades of hidden meanings or the identification of sources of tension. If such topics are given time and space for reflection, supervision can make the hidden cues visible, and this is necessary for arriving at rational professional decisions best fitting to the high complexity of the life situations. Organised reflection particularly in the team counts also as a useful means to reach consensual decision and preventing making the one-sided or catathymically coloured decision. Topics that are normally not regarded as suitable for supervision are, for example, purely personal problems unrelated directly to the work under review. These would be more suitable for psychotherapy or counselling. Topics which are not related to one’s own competence, for example, behaviour or attitudes of another person which one cannot influence, topics which require more instruction or knowledge than reflection and topics which require simply following established routines or strictly standardised activities, are also not considered suitable for reflective supervision. Generally, however, the specific assessment of whether the topic offered constitutes a relevant subject for reflection in supervision is always the result of exploration and clarification of the purpose between the supervisor and the worker or team, as is the search for the perspective from which it is necessary and possible to grasp it. Such negotiations are part of building the working alliance between the supervisor and the supervisee. In the following, we will present some examples from the range of topics that social work and also nursing practitioners come up with effectively in supervision. Three broad categories of relevant topics in supervision are: 1. Case Study The most common subject of reflection is direct work with clients. For example, the worker wants to help a client who repeatedly fails to achieve change in the form of, for instance, a relapse to drug use or eating disorders, loss of impotant personal

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documents and aggressive behaviour. Such themes usually have several nodal points – understanding the client’s own dynamics, one’s own feelings and way of thinking, developing a common relationship, the nature of communication with a service user, one’s own role and links to theoretical or methodological assumptions. 2. Team relationships and roles The topics of working relationships and team roles occur both in individual and in team supervision, or in supervision of team leaders, for example, relationships between colleagues and miscommunication, lack of consensus on priorities and progress and unresolved personal conflicts that complicate internal collaboration and work with clients. These kinds of topics are welcomed by both social workers and nurses and are worth raising especially in multidisciplinary teams. 3. Value assumptions and cultural habits Reflection on value assumptions and cultural habits is one of the most challenging topics in supervision. This can be an aspect of both previous points, especially in multidisciplinary or multicultural teams. Professional values are strongly linked to personal values, and challenging these can evoke a range of emotions as this may imply interference with the integrity of the adult (Rabušic, 2001). Overall, it can be observed that identifying and negotiating suitable topics and purposes forms part of the competences of all participants in supervision. Where external supervision is planned according to regular time schedules, employees can sometimes feel the need for supervision earlier and cannot wait till the next supervision session. This calls for more variable opportunities for reflection at the workplace.

Area 2: Organisational Culture and Leadership Many supervisors reported that although they did not ‘care about the organisation’ in the supervision process, they were getting into a conflict with their supervisees. Without often realising it, they struggled over supervisees’ individual rights, counselling values versus fiscal values, roles in working with clients that clashed with other roles required by the organisation, etc. (Carroll & Holloway, 1999). These experiences have led to the need for recognition of the importance of the organisational context to the course of supervision and a more consistent concern for it. There may be a cultural clash between the culture of supervision and the culture of the organisation. Carefully considering aspects of organisational culture and leadership styles that enable reflective supervision can avoid that obstacles against this practice build up in organisations. Despite the fact that we focus here on external supervision where the supervisor is not part of the organisation, all the processes that take place in supervision are interconnected with the context of the organisation. According to Schein, shared social experiences emerge in every organisation (and in each team), creating shared beliefs about how to deal with dilemmas

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(Schein, 2004). Such beliefs are passed on to newcomers who then try to adapt to them and mostly identify with them. Supervisors take into consideration that the culture prevailing in a respective organisation has an impact on the way supervision could be practised. Proctor (2008) points out that managers of organisations who often do not have a clear understanding of professional supervision have a negative influence on supervision when they expect it to function as some form of control and direction over their employees (see also Hughes & Pengelly, 1997). Team leaders need to be committed to ideas of supportive supervision through reflection and actively support and participate from an interest in their own development so that supervision arrangements can augment professional development (Gormley & Nieuwerburgh, 2014). Thus, a committed and positive attitude of the manager towards reflective supervision is a central condition that encourages the establishment of supervision at the workplace. Supervision as a profession has its own culture and this can be better or worse compatible with the workplace culture. Hawkins and Shohet (2004) described the learning and developmental organisational culture as most suitable for supervision. This is characterised by a high degree of congruence between the goals of the organisation and the goals of the workers, and also by the fact that the goals affect daily work activities (Hawkins & Shohet, 2004, pp. 202–203). Davys and Beddoe (2010) proposes a resilient culture as optimal for organisational development, in which supervision has its place. Resilient culture according to Davies and Beddoe (ibid, p. 75) includes work-life balance and empowerment, collaborative decision-making and space for reflection. In such an organisational culture, greater participation of workers and lower management interference in what is happening within the organisation can be expected. Another aspect mentioned by Davies and Beddoe (ibid) is giving space for supervision and participation that includes the recognition of the emotional demands of work and ongoing feedback to workers. We think that resilient culture involves traits which are mirroring the culture of reflective supervision; therefore, those two cultures should very well accept each other. Important elements of an organisational culture compatible with supervision are the interest in learning and hope for the possibility of change, which includes providing opportunities for informal conversations among colleagues and other professionals through which informal learning at the workplace can take place (Eraut, 2007). Team or group supervision supports this through the sharing of everyday stories and situations in the workplace and responds to the agenda that workers themselves bring and want to share with others. Carroll (2004) emphasises that because emotions in organisations are frequently not acknowledged, there is a need to make them accessible and integrate them through supervision; otherwise, they can become uncontrollable. Defensive strategies lead to high control over one’s own thoughts and hinder their communication. Selective communication allows to solve concrete or practical tasks but does not lead to deeper reflection. The atmosphere of fear within an organisation or team therefore requires a very sophisticated approach that allows for something in the sense of a corrective emotional experience – in the safe environment of supervision. Smith (2000, p. 24) draws on his research on fear in supervision. He argues that

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‘participants did not want clever or “helpful” interpretations of what they were feeling and why. They wanted to be allowed to rediscover their sense of self in the company of another’. In fact, openness itself can pose a potential risk – a sense of threat, a fear of failure and a threat to existing relationships. Sharing work experience, which may involve mistakes, insecurities and fears, is not a given, especially in the case of group or team supervision in the workplace, moreover in the presence of a supervisor. Reflecting together on a work issue or problem is therefore more challenging and threatening than, for example, finding a ‘solution’. The influence that emotions and relationships in an organisation have on supervision is described by Hajny (2008, pp. 94–96). Already when entering an organisation, a supervisor may encounter expressions that make his or her job difficult and affect how he or she feels about the organisation. These include passive attitudes, silence, denial or downplaying of problems and constant joking. In the author’s opinion, these manifestations can be the background of the characteristics of a director or manager – for example, if it is a personality that is very strongly personally connected to the whole organisation, or if it is a manager who is obviously dominant or, on the contrary, excessively helpful, sacrificial and rescuing. Workers then covertly resist, boycott the initiative and do things their own way. Emotionally, according to the author, such supervision can be accompanied by boredom coupled with tension. At other times, the supervisor may clash with such a supervisor and is pushed into a subordinate or loyal role. If, on the other hand, the supervisor is weak and does not take on the role, the supervisor may fall into the trap of taking on the role of shadow supervisor. Aligning the culture of the organisation with the values and methods of working in supervision is one of the great challenges to ensuring adequate safety for deep and open reflection. This must be considered from the moment supervisors begin to negotiate their supervision contract. In an organisation where workers are not experienced in reflection and learning culture, where there is a strong tension and mistrust between workers and management, where every wrong performance is considered as a sanctionable offence and where management is strongly hierarchical, workers cannot be expected to come up with suggestions on what is going wrong, what should be improved and what they themselves do not know or have doubts about. In such organisations, all change depends on orders from the top, and the potential for change from below is completely blocked unless management starts to deliberately and consciously support and exploit this potential. If the leadership of such an organisation decides to introduce reflexive supervision, it is a great opportunity to get new and often unexpected resources and suggestions from below. However, it will be a challenging and vulnerable process with many risks. The values and attitudes of individuals in the organisation, especially founders and members of the leadership team, are cited as important for changing organisational cultures and should be therefore involved in negotiating the rules of supervision where possible.

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To summarise, a purely outcome-oriented, controlling and hierarchical organisational culture through top-down leadership negates the purpose of professional reflection in the social and healthcare fields and can become an obstacle to the implementation and fruitful practice of supervision at the workplace. On the contrary, participative forms of leadership that support resilient organisational culture including creative and risk-taking psychological safety in teams can support and enhance reflective supervision.

Area 3: Supervisor’s Role and Activities The third area is related to the person and role of the supervisor. We look at how he/ she can enhance or hinder reflection and why there are special requirements for training and ethical behaviour on the part of the supervisor. Care for building adequate psychological safety for reflection enabling risk and creativity is one of the key tasks of the supervisor. We propose that in the quadrilateral relationship between supervisor, supervisee, client and context, supervisors play an important role by constantly negotiating and balancing out the dynamic tensions in the interactions between these four poles through their behaviour, inviting the other actors to participate and moving the supervision process towards the contractually agreed goal. The main tools for shaping an appropriate space for reflection in supervision are the initial and ongoing negotiation of the contract with the actors involved and the subsequent behaviour of the supervisor. Together with the appropriate setting and transparent management of the supervision process in its different phases (see below), these tools contribute to making the space for reflection safe and predictable while encouraging openness and risk-taking based on appropriate relational attachment among participants. The relation between appropriate attachment and risk-­ taking has been clarified by Bowlby (1969).

Contracting as a Process Contract in supervision defines the field in which joint work is to take place and is thus the first prerequisite for mutual participation in a predictable space for reflection. Initial contracts include the subject(s) of supervision, the overall setting of supervision (see below), who will be involved in supervision, when, for what purpose and under what conditions. It is useful for the reflection process when the role and objectives of supervision in the organisation, and their meaning for the different actors, are transparent and when the organisation’s leaders are actively involved in defining it. This reduces the ever-present risk that the culture of the organisation will later aversely react to supervision, treating it with distrust, questioning its purpose or outright rejecting it.

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In order to ensure active participation in supervision, it is important that during the negotiation process, everybody’s expectations of supervision and what they are willing to put into the process are clarified and thereby cooperation is initiated. This concerns not only time and finances but also values and motivation that are important for supervision, like the willingness to cooperate for a quality and relational-­ based service, openness to explore different possibilities, resilience in overcoming obstacles and safe space ensuring confidentiality. Information given in a supervision meeting is not shared with staff who are not participating in the supervision unless otherwise agreed. For example, the supervisor may provide to the management a brief summary of the issues discussed in the supervision sessions without stating who solved what. However, such a report is available to the participants beforehand, so that they have control over what information reaches the organisation and they have the possibility to influence it. Similarly, clients should be informed that their therapists or social workers are participating in a supervision session in which information about their case is handled in a safe manner. This all should be clarified in the contracting phase. The supervisor leads the negotiation and is responsible for making a qualified estimate whether supervision makes sense in the set-up and circumstances at the workplace that have become apparent during the negotiation. If an agreement is reached, and supervision initiated, negotiations continue as an ongoing process of clarifying what each actor wants to reach and motivating everyone to reflect with a fair degree of openness. Contracting is therefore not limited to initial agreements. It is a key process that permeates all the supervisor’s interventions, starting with selection of topics and exploring the purpose and resulting approach how to handle the topic.

The Supervisor as a Person Supervisors contribute to reflection by their uniqueness, curiosity and authenticity. Showing interest in what happened in each situation – why and how the supervisee approached – can re-activate the reflective thinking of the worker. Giving occasional explanations, alternating with diverse questions, expands the field in which colleagues reflect on their work. The supervisors also use all sorts of subtle appreciation for what the worker does, how he or she thinks about the topic and how he or she engages in reflection. The supervisor’s behaviour, empathy and approach to others in the form of co-­ creating open and respectful relationships are important parts of the supervisor’s equipment. It can be surprisingly effective when supervisors offer their own approach as a role model. For example, if the supervisor communicates authentically and openly with a clear intention to meet the needs of the supervisee, this will contribute to a better working alliance (Knox et al., 2011). If supervisors express their own sense of safety in this way, it can reduce supervisees’ fears of risk-taking. However, balancing one’s own authenticity with other roles and responsibilities of

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the supervisor requires maturity and a sufficient degree of self-reflection. Supervisors must be able to gauge when and how to withdraw from managing the process and create enough space for supervisees to develop reflection at their own pace or elaborate on their actual emotions. When strong emotions emerge in the team, the experienced supervisor becomes their ‘container’, letting them wash over and guiding the team through emotional storms to solid ground. All this places high demands on the person of the supervisor in terms of a mature handling of emotions and challenging situations in the team. This is one of the reasons why most training programs in the Czech Republic require long-term self-­ experience training before entering supervision training. A supervisor who has not the same professional experience as the supervisee brings different variables to the process than one who has a very similar professional history, training and experience. Homogeneous peer experience undoubtedly has great benefits in many ways – it allows for quicker insight and can be a good means of identification for novice workers. However, in terms of the degree of reflective supervision, a supervisor from a different discipline, with a different specialism, can be an asset. Based on their study, Davys and Beddoe (2008) describe the benefits of supervision in which a supervisor with a different profession is present and/or the supervision group is heterogeneous. For example, it prevents stereotyping in professional jargon and broadens the range of coping strategies and thinking, and the need to go beyond the ‘obvious’ leads to necessary perspective and deepened reflection.

Area 4: Structure and Setting for Supporting Reflection This section concerns the structure and overall setting in which supervision takes place – what is its importance and how does it contribute to the process of reflection. Higher safety for reflection is the result of creating a predictable negotiated environment. International research has confirmed that supervision that is structured and progresses in stages from preparation to activation, planning and working to completion is the favoured supervisee orientation and satisfaction (O’Donoghue et al., 2018). If the participants understand the structure and stages of supervision, it gives them safety to focus on the negotiated topic and to reflect more freely and in more depth than is usual in daily situations. Structure in the context of supervision can be understood in several senses. More generally, it is a principle that defines the context and framework of supervision. Basically, it is a transparent set of rules that are agreed in advance and that best suit the agreed objectives of supervision. This concerns mainly an undisturbed space, stipulating the type of supervision,1 participants and conditions, the length and frequency of meetings and how information and outputs from supervision are

 Internal or external supervision; individual, group or team supervision; professional or student supervision; etc. (see, e.g. Hawkins & Shohet, 2004). 1

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handled to assure confidentiality, so that insights from supervision can be constructively used in organisational learning. In a narrower sense, structure is a particular method or technique of supervision that facilitates reflection on a given topic. ‘By structure, we mean a clearly delineated technique for making the topic present or exposed in the group so that reflection is facilitated as much as possible’ (Havrdova et al., 2008). This can include a variety of methods of making the situation present, for example, a simple narrative of what the worker did with the client, the process, the interaction and the worker’s own thinking and experiencing. The supervisor facilitates the narrative with questions and ideas or directs the team’s attention in a particular direction. This actually leads to a restructuring and the emergence of new ways of grasping the topic. Noticing new interconnections is easier in a predictable space. The place, time and manner of supervision is established as a relatively stable setting to be adhered to. The individual supervision meetings have regular shape. For example, the supervisor asks at the beginning for a brief description of how the group members are feeling today, what important things have happened in the organisation in the interim and how the case from the last supervision has developed. She encourages everyone to offer a brief description of what they would like to focus on. Individual cases or topics have an allotted time. In addition to this explicit structure, the supervisor continually recaps, summarises and articulates the understanding achieved so far and encourages disclosure and engagement of group or team members. This creates a sense of dynamic order that is understandable and meaningful. One of the items to be considered in defining specific supervision settings is the composition of the group of participants as this can enhance or hinder reflection. Davys and Beddoe (2008) in their study confirmed the assumption that the effectiveness of supervision is enhanced by a professionally heterogeneous composition of the group. Their separation into sub-teams, for instance, of nurses, social workers, nursing assistants and doctors, impoverishes supervision in the diversity of perspectives. An important aspect of the supervision structure is if the supervisor is external or internal, as this influences his position as an authority. External supervision can be a safer alternative to internal supervision, as the supervisor is not part of the power structure of the organisation. The external supervisor is bound by an agreement with the organisation but is not an employee – he is significantly less bound in the system of power. It is likely that the external supervision format allows for greater openness on the part of supervisees and a more flexible and supportive attitude on the part of the supervisor. This may be based more on the supervision situation and the agreed contract than on the norms, procedures and methodology of the organisation. Overall, she has a different set of information about the worker. External supervision, supported additionally by the use of a different physical space for supervision outside the institution, is more suitable for sharing frustrations, more personal associations related to work and insecurities. Equally there is better opportunity to reflect and ‘not know’ and to search, to look ‘afresh’, to experiment with unusual strategies. From their study, O’Donoghue et  al. (2018, p.  84) conclude that ‘The respondents described [supervision] as the place where they connected with their

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supervisor, profession, peer and group; shared their frustrations and successes; could be challenged; and could learn and develop’. Beddoe (2012) points out that external supervision carries certain risks for a split between the supervisee and the management of the organisation. This should be carefully addressed in the contract which should include the forms of communication of information with management, the methods of evaluation of the supervision outcomes and explicitly also the role of management in working with the outcomes of supervision as well as ensuring the safety for workers. The advantage then is the consensus that supervision should contribute to the development or cultivation of reflection in the organisation as a whole. The multifaceted contract that treats responsibilities and mutual communication is also emphasised by Davys (Davys & Beddoe, 2010) – particularly in relation to the risk of unhealthy triangulation on the part of the supervisor, whether with management versus staff or vice versa. In an organisation where there is a strong tension between the culture of the organisation and the culture of supervision, and where the multi-party contract does not promote collaboration and a good flow of information, there is a risk that the gains of reflection will not be used to bring about change in the organisation. There may even then be a concern that supervision blocks such change (Bradley et al., 2010). It is very important that the supervisor and the management of the organisation avoid this and instead take full advantage of all the opportunities for systematic reflection that happens at multiple levels through supervision. Theoretical and practical training of the supervisor can equip him/her in the question of how supervision can contribute not only to the support and development of individual workers or teams but also to the development of reflection of the whole organisation (O’Donoghue, 2010). In our experience, a consistently negotiated contract can diminish the risk of an abusive approach to reflection or lack of necessary safe and productive cooperation between the supervisor and the management. A multi-party contract that spells out responsibilities and the form of mutual communication is also emphasised by Davys and Beddoe (2010). For carrying out those sensitive tasks competently and responsibly, the supervisor needs theoretical and practical training, so that supervision can support not only the development of individual workers or teams but also the development of reflection in the whole organisation (O’Donoghue (2010)). According to our experience, it is very useful if the managers also receive training on how to use reflexive supervision in their organisation and how to negotiate an effective contract with the supervisor (Evaluation of KRS, 2018). Reflection is enhanced by setting up predictable structures and clear rules and settings enabling focused and individualised deeper level reflection in a heterogenous group. For the effective use of reflection at the workplace, Beddoe (2012) proposes a broader spectrum of various forms of reflection instead of just the polarisation between external and internal supervision. At one end is internal managerial supervision, which focuses on tasks and processes. At the other end is external individual supervision, which will be worker-focused and based mainly on the narrative

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that the worker brings. The key, as Tsui et al. (2017) also point out, is to seek optimal forms of organisational learning by promoting reflexivity at different levels of the organisation.

Area 5: Relations in Supervision The nature of relations in supervision involves relations between the supervisor and the participants of supervision, among the participants themselves and to the management. There are two important aspects: (1) safe supervisory relationship as an important condition for reflection and (2) reflection of relationships among participants and supervisor which is facilitating the relations and becoming an instrument for learning about parallel processes and other issues.2 Research in the field of supervision confirms the importance of the quality of the supervisory relationship for successful supervision. Although the nature of these relationships has been changing greatly over time, its attributed importance is still very high (e.g. Bordin, 1983; Johnson & Stewart, 2008; Watkins & Scaturo, 2013). A good supervisory relationship necessarily involves a sense of safety and trust. This is maintained by constant, conscious and partly unconscious exploration of the possibilities of openness in the interaction. In a Canadian study (Wong-Wylie, 2008), the authors arrived at a list of factors that enable good reflective practice: a relationship based on trust was at the top of the list. A positive experience of the supervisory relationship was also found to contribute to the internalisation of the supervisory process (Geller et al., 2010). Consequently, for example, Watkins and Scaturo (2013) made building this alliance a central task of their learning model. Conversely, the poor state of the supervisory relationship has been shown to be associated with negative development and outcomes (Worthen & McNeill, 1996), primarily associated with trainee shame (Hahn, 2001) and the non-disclosure of important information (Ladany et al., 2016). The psychological safety for reflection associated with trust and willingness to open up and share threatening content with another in supervision is based primarily on the relationships. In individual supervision, it is the relationship between the supervisor and the supervisee. In group and team supervision, this is compounded by the dynamics of the relationship between the participants and their relationship to the group or team as a whole. All of this is embedded in a complex matrix of organisational context, interrelationships with the organisation’s leadership, other teams, clients and the supervisor. The understanding of the supervisory relationship has undergone a long and colourful evolution. Even contemporary conceptions of the optimal supervisory relationship are related to the different experiences and therapeutic models to which  By parallel processes are meant according to Searles (1955) processes working currently in the relationship between the patient and therapist, which occur in a similar way between the worker and supervisor and can be thus reflected in supervision. 2

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particular supervisors have gravitated and the field of supervision. For example, supervision of the therapeutic process will require the  parallel elaboration of the therapeutic relationship in supervision depending on the relevant theoretical approach used, while in social work, the focus will be on a working alliance similar as between the social worker and his client. Concepts and theories of the supervisory relationship have been at the beginning significantly influenced by psychoanalysis and psychotherapy. It is important to note that supervision has long evolved in the pairing of supervisor and supervisee, with the agency between the two gradually gaining attention and becoming a significant and in-depth topic of elaboration and exploration in many forms of psychotherapy and counselling. The supervisor was an authoritative teacher who urged the supervisee to follow him or her in the sense of ‘do what I say’. Change began to occur in the early 1950s as Fleming and Benedek (1964) came out of the established concept of the therapeutic alliance and argued for a learning alliance (Fleming & Benedek, 1966). Thus, the educational function of supervision began to emerge clearly while absorbing a number of parallel developments in adult education. Supervision thus was understood as much more ‘supervisor-centred’, focusing on the candidate’s learning process in supervision. As a result, the relationship emphasised collaborative, goal-focused and task-focused cooperation. From the 1970s onwards (e.g. Frijling-Schreuder, 1970), this approach began to be applied in the practice of training institutes and was developed by other authors. Mutual and collaborative relationship gave space for reflection of the phenomena of relationship in therapy and even in the supervisory relationship itself. Another step that influenced the concept of the supervisory relationship was the concept of supervisory working alliance. Bordin (1983, p. 36) identified three components of the supervisory relationship: ‘The bond between supervisor and supervisee, their mutual understandings and agreements about the goals of supervision, and their mutual understandings and agreements about the tasks to be executed in the service of goal attainment’. All of these levels of the relationship are related to trust and security. The shared understanding of what is to happen in supervision and with what goal represents the conscious, rational part of the relationship. A still vaguely definable but significant aspect of the supervisory relationship called ‘bond’ was described by Bordin (1983, p. 36) as follows: ‘The supervisor and supervisee bond was considered to involve their shared ‘feelings of liking, caring, and trusting’. He emphasises here the importance of natural distortions and ruptures in each relationship, which, if repaired and managed, deepen this important personal dimension of the relationship. Systemic therapy initially did not pay much attention to this topic. The biological metaphors of Bateson and the constructivist ideas of Maturana had difficulty finding an adequate language to describe the emotional and personal dimensions of the therapeutic relationship. When second-order theories emerged, the therapist-family relationship also came to the fore (Flaskas, 1993). Systemic theory was inspired by Donald Winnicott’s concept of ‘holding environment’ and ‘good enough’ mothering in the 1990s (Harari, 1996; Winnicott, 1971). The metaphor of environment was consistent with a systemic relational focus. The second way of conceptualising the

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therapeutic relationship in a systemic context is called ‘engagement’ (Flaskas, 1993). Good enough engagement is ‘good enough’ if the therapist and family find a ‘fit’ between them. This then corresponds to an understanding of relational agency in supervision quite often in social work as well. Another perspective on the ‘binding’ aspect of good supervisory relationships, which is important not only for the supervisee but also for the supervisor, is presented by Scaife (2001, p. 63): ‘ongoing supervisory relationship is the creation and maintenance of safety for all the parties involved in the helping experience’. Systemic theories are of particular relevance for the understanding of the internal interaction of participants in a group and their external relationship to specific contexts so that all these processes can be reflected in supervision. In practice, it is important that supervisees can participate in the choice of their supervisor, and the supervisor choses also if to accept the supervision with these partners, so that the developed working alliance is ‘good enough’ for the topics and purposes of the supervision. Free choice of the supervisor based on the consensus in the group or team and also evaluation of the supervisory process by all partners in supervision can be a good prevention for severe incompatibilities which might hinder the ability to open collaborative reflection.

Area 6: Processes that Support and Activate Reflection A precondition for supervision to take place is an interest by workers in delivering good practice in their profession and at least an elementary hope that this can be improved upon. Without this minimum condition, the supervisor cannot work with supervisees. Furthermore, at least a basic level of trust on the part of the supervisee towards the supervisor is necessary. It ensures that communication shows a certain amount of openness and inner truthfulness with a focus on real practice and on what can change, even if the messages received are sometimes not very pleasant or positive. Truthful communication (i.e. one that the worker stands behind internally) constitutes the beginning of accepting responsibility for developing a common dialogue (Havrdova et  al., 2008). A willingness to continue the learning is also essential. Finally, Watkins (2017, p. 144) includes reflectivity and psychological mindedness3 among universally shared prerequisites of supervision, which he argues form the ‘bedrock that makes the work of supervision possible’. Deliberative and collaborative reflection does not usually arise by itself – it must be prepared and organised. The whole process of preparing the conditions for reflection, reflection itself and giving meaning to the reflected situation or event in a group or team takes place within an experiential or action learning mode. Part of  Psychological mindedness is a psychological term which expresses an individual ability or disposition to be interested in one’s feelings and understanding of it, as well as of feelings of others and motivation to understand the meaning and motivation of one’s thoughts, feeling and behaviour. Some authors include also a capacity for change (Tryon, 2014). 3

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this framework usually follows the stages of a joint setting of goals with tasks and possible assignments, the actual work on the assignment and the evaluation of the process through feedback (Hajny, 2008). The supervisor needs to find out from the supervisee what he or she wants to do, or what he or she wants to achieve or learn, with a sufficient degree of openness. When finding out what the upcoming supervision will involve, the supervisor finds out both the ‘topic’ (case, problem, question, dilemma, etc.) and what the person needs help with or wants to achieve and what he/she wants to focus on in the first place. This way of formulating the ‘order’ is consistent with the style of using questions in systemic therapy (Tomm, 1985). In the phase of work on the previously negotiated assignment (see area 1), the supervisor usually chooses a method or technique that corresponds well to the topic. The actual reflection usually happens through some form of visualisation and reflection focusing on different aspects of the disclosed situation (emotions, attitudes of the participants, their positions and communication) in which a new meaning-gestalt of the situation, a new connection or a different perspective emerge. Often, it shows up in a non-linear way – that is, not in logically progressing steps of a solution algorithm, but shows up as a shape, and sometimes an image. Thus, if adequate safety is established, the supervisor uses a number of tools to encourage and allow reflection to develop. For example, if the assignment is ‘to look what happened between me and the client as soon as he came today’ because the supervisee is confused about his feelings in relation to the client, the supervisor can suggest the supervisees’ narration about the cooperation with the client. Other times, reflection is facilitated by another form of externalisation, such as using a flipchart, to fix some points in the supervision process, and to create a graph of relationships in the organisations, or some creative method to explore different feelings, the process of Balint group, sculpting in a drama therapy approach, drawing, graphic representation or modelling. Through externalisation, other participants in the supervision group and, of course, supervisors themselves can participate in the reflection and even action involved in the method used. Continually checking that all actions and reflections help the supervisee to move towards the agreed-upon goal provides a greater sense of assurance, a verification that the supervisee is not getting lost in the multitude of suggestions and reflections. During the whole process of elaboration of ‘the order’, the supervisor continues to explore the views, needs and state of mind of the supervisee, negotiates possible pathways, clarifies expectations and promotes engagement in specific activities and co-responsibility for them. Within these explicit structures, an interactive process can develop that is highly individualised in what Holloway (2016) calls ‘tailoring to fit’. The supervisor sensitively guides, supports and summarises specific reflections within the immediate development of the participants’ experience, encourages the supervisee and values each step forwards. In case they both get stuck in the process, supervisors might reveal their own dilemma, thus ‘inviting’ the supervisee or the whole group to discuss the different options. This widens the field, invites active collaboration of ideas and engages activity and co-responsibility of participants.

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A supervised team engaged in such an interaction may experience short-term unease caused by the need to express themselves openly, not relying on ‘guidance’. But this moment of non-safety paradoxically brings a deeper reflection, a ‘sense of co-ownership’ of the process – and thus a greater sense of security and trust. At each stage of supervision, it is important to re-induce reflexivity. To do this, it helps, for example, if the supervisee takes a pause just listening, while other members of the group reflect on ‘for him’. In the team, the supervision process is similar. The supervisor might invite team members at the beginning to briefly share how they are currently doing or how the team is doing. This leads to self-reflection, drawing attention to personal mood and state of mind. Instead of ‘what do we need to solve’, it opens up the question ‘what is going on inside me’. At other times, the supervisor invites reflection on the current state of teamwork, but does not leave the floor open for intellectual debate which might hinder deeper reflection and prompt instead, for example, for everyone to choose a metaphor for the team. These subtle interventions interrupt and suspend thinking and experiencing by providing space and fertile ground for reflection. Each supervision session introduces something new into the standard flow of team operations. The undisturbed environment, the suspension of normal activities and the unusual format (often sitting in a circle) all interrupt or change the normal flow of thinking and communication of the team members. The shared experience is subjected to different perspectives, creating ‘a zone of safe uncertainty’ (Watkins, 2015, p. 146). This can again lead to stopping and problematising particular aspects of the team behaviour or interpretation, turning attention to other alternatives of how to approach the matter, sometimes even asking about possible consequences or rules that may apply to the problematised situation. Opening up to new perspectives and possibilities is safer for the supervisees’ self-esteem and autonomy and keeps the participants engaged in the process, as opposed to confrontation with mistakes which may lead to disruptive polarisations.

Conclusion Providing supervision in social and health services has developed into a specialised professional activity that requires structured training in the various facets that make up effective supervision. This systematic approach to supervision is particularly geared to enhance reflectivity in supervisees. To achieve this, professional supervision must be situated and practised in the context of conditions and criteria discussed above. Organising and providing supervision to standards established by professional associations also makes a valuable contribution to the well-being of staff and contributes to the development of psychological safety in organisations, particularly where different professional cultures meet and interact. Reflection in the framework of reflective supervision is enhanced by specially trained supervisors whose behaviour, empathy and approach to participants can interactively create open, respectful and participative collaboration for growth in

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quality practice. The purpose and added value of reflective supervision is perceived in handling complex, often rather unclear, issues around clients’ and workers’ relationships and situations. These have at times hidden or not fully perceived aspects. Topics for supervision are broadly related to direct care, team relationships or values and cultural assumptions. Such topics should be ‘ripe’ to be handled and presented and negotiated by the employee (or the team) who is motivated and decides to make a shift in perspective. This is a difficult and risky step that requires psychological safety in a predictable contractually negotiated environment for creative risk-taking and shared reflection. Such an environment can be built if leaders in organisations support reflection and if the organisational culture can respect the culture of reflective supervision. Reflection is enhanced also by specific methods or techniques which provide a good fit with the presented job experience. Clear structure, rules and settings enable focused and individualised deep reflection that can be enriched by a heterogenous group. For effective use of reflection at the workplace, a broader continuum of various forms of reflection is recommended. Reflective supervision has a special role particularly in cases where a trained supervisor is able to contain and maturely handle difficult emotions and challenging topics for reflection. All explained conditions together ensure that reflexive supervision achieves its essential objectives of facilitating relational and accountable provision of care based on complex shared reflection of different aspects of the client’s social and health situation and the service context.

References Beddoe, L. (2012). External supervision in social work: Power, space, risk, and the search for safety. Australian Social Work, 65(2), 197–213. https://doi.org/10.1080/0312407X.2011.591187 Berwick, D.  M. (2009, July–August). What ‘patient-centered’ should mean: Confessions of an extremist. Health Affairs (Millwood), 28(4), w555–W565. https://doi.org/10.1377/ hlthaff.28.4.w555. Epub 2009 May 19. Bond, M., & Holland, S. (2011). Skills of clinical supervision for nurses. Open University Press. Bordin, E. S. (1983). Supervision in counselling: II. Contemporary models of supervision: A working alliance-based model of supervision. The Counseling Psychologist, 11, 35–42. Bowlby, J. (1969). Attachment. Attachment and loss: Vol. 1. Loss. Basic Books. Bradley, L. J., et al. (2010). Counselor supervision. Routledge. Brashears, F. (1995, September). Supervision as social work practice: A reconceptualization. Social Work, 40(5), 692–699. Carroll,M. & Holloway,E. (1999). Counselling supervision in context. (Eds.) London, Sage Publications. Carroll, M. (2004). Supervize v organizacích a supervize pro organizace. In M.  Carroll & M. Tholstrupová (Eds.), Integrativní přístupy k supervizi (pp. 67–86). Triton. Davys, A., & Beddoe, L. (2008). Interprofessional learning for supervision: ‘Taking the blinkers off’. Learning in Health and Social Care, 8(1), 58–69. Davys, A., & Beddoe, L. (2010). Best practice in supervision: A guide for the helping professions. London: Jessica Kingsley.

80

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Eraut, M. (2007, September). Learning from other people in the workplace. Oxford Review of Education, 33(4), 403–422. Evaluation of KRS. (2018). https://krs.fhs.cuni.cz/KRS-­10-­version1-­abskrs2018_zprava_ finale.pdf Flaskas, C. (1993). On the project of using psychoanalytic ideas in systemic therapy: A discussion paper. Australian and New Zealand Journal of Family Therapy, 14, 9–15. Fleming, J., & Benedek, T.  F. (1964). Supervision. A method of teaching psychoanalysis. Psychoanalytic Quarterly, 33, 71–96. Fleming, J., & Benedek, T. F. (1966). Psychoanalytic supervision. Grune & Stratton. Frijling-Schreuder, E. C. M. (1970). On individual supervision. International Journal of Psycho-­ Analysis, 51, 363–370. Geller, J.  D., Farber, B.  A., & Schaffer, C.  E. (2010). Representations of the supervisory dialogue and the development of psychotherapists. Psychotherapy: Theory, Research, Practice, Training, 47(2), 211–220. Goodyear, R., et al. (2016). A global portrait of counselling psychologists’ characteristics, perspectives, and professional behaviors. Counselling Psychology Quarterly, 29(2), 115–138. https://doi.org/10.1080/09515070.2015.1128396 Gormley, H., & Nieuwerburgh, C. (2014). Developing coaching cultures: A review of the literature. Coaching: An International Journal of Theory, Research and Practice, 7(2), 90–101. Hahn, W.  K. (2001). The experience of shame in psychotherapy supervision. Psychotherapy: Theory, Research, Practice, Training, 38(3), 272–282. Hajný, M. (2008). Týmová supervise. In Z. Havrdová, M. Hajný, et al. (Eds.), Praktická supervize. Průvodce supervizí pro začínající supervizory, manažery a příjemce supervize (pp. 93–116). Galén. Harari, E. (1996). Empathy and the therapeutic relationship in systemic-oriented therapies: A historical and clinical overview. In C. Flaskas & A. Perlesz (Eds.), The therapeutic relationship in systemic therapy. London: Karnac Books. Harkness, D., & Poerkner, J. (1989). Research and social work supervision: A conceptual review. Social Work, 34(2), 115–118. Havrdová, Z., Hajný, M., et  al. (2008). Praktická supervize. Průvodce supervizí pro začínající supervizory, manažery a příjemce supervize (pp. 39–58). Galén. Havrdova, et al. (2011). Organizační kultura v sociálních službách jako předmět výzkumu. FHS. Hawkins, P., & Shohet, R. (2004). Supervize v pomáhajících profesích. Portál. Hewson, D., & Carroll, M. (2016). Reflective practice in supervision (309 p). International Kindle Paperwhite. Holloway, E. L. (2016). Supervision essentials for a systems approach to supervision. American Psychological Association. Hughes, L., & Pengelly, P. (1997). Staff supervision in a turbulent environment: Managing process and task in front-line services. Jessica Kingsley Publishers. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Report. National Academies Press (US). ISBN-10: 0-309-07280-8. https://www.ncbi. nlm.nih.gov/books/NBK222274/ Johnson, E.  A., & Stewart, D.  W. (2008). Perceived competence in supervisory roles: A social cognitive analysis. Training and Education in Professional Psychology, 2(4), 229–236. Kadushin, A., & Harkness, D. (2014). Supervision in social work. Columbia University Press. Kahn, W.  A. (1990). Psychological conditions of personal engagement and disengagement at work. Academy of Management Journal, 33, 692–724. https://doi.org/10.5465/256287 Knox, S., Edwards, L. M., Hess, S. A., & Hill, C. E. (2011). Supervisor self-disclosure: Supervisees’ experiences and perspectives. Psychotherapy, 48(4), 336–341. Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Prentice Hall. Koob, J. (2003). The effects of solution-focused supervision on the perceived self-efficacy of therapists in training. The Clinical Supervisor, 21, 161–183. https://doi.org/10.1300/J001v21n02_11

4  Supervision at the Workplace as a Unique Space for Reflection

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Ladany, N., Friedlander, M. L., & Nelson, M. L. (2016). Supervision essentials for the critical events in psychotherapy supervision model. American Psychological Association. Levická, J., Vaska, J., & Vrťová, J. (2021). Historical roots of supervision in social work framed by the Anglo-American tradition. Sociální práce/Sociálna práca, 21(4), 53–69. Liberati, E., Moja, L., Galuppo, L., Ripamonit, S., & Scaratti, G. (2015, May). Exploring the practice of patient centered care: The role of ethnography and reflexivity. Social Science & Medicine, 133, 45–52. O’Donoghue, K. (2010). Towards the construction of social work supervision in Aotearoa New Zealand: A study of the perspectives of social work practitioners and supervisors. PhD thesis, Massey University, Palmerston North. O’Donoghue, K., et al. (2018). Constructing an evidence-informed social work supervision model. European Journal of Social Work, 21(3), 348–358. Petes, D. E. (1967). Supervision in social work. A method of student training and staff development. George Allen & Unwin. Proctor, B. (2008). Group supervision: A guide to creative practice. Sage. Rabušic, L. (2001). Úvodem. Sociální studia, 6, 9–16. Rankine, M. (2017). Making the connections: A practice model for reflective supervision. Aotearoa New Zealand Social Work, 29(3), 66. https://doi.org/10.11157/anzswj-­vol29iss3id377 Rankine, M., & Beddoe, L. (2020). The space to think critically: How supervision can support sustainable practice in social service organisations. In M. Rankine, L. Beddoe, M. O’Brien, & C.  H. Fouche (Eds.), Contemporary practices in social work supervision (pp.  100–112). Routledge. Scaife, J. (2001). Supervision in the mental health professions. Contributions from F.  Inskipp, B. Proctor, J. Scaife, S. Walsh. Taylor & Francis. Schein, E. H. (2004). Organizational culture and leadership (3rd ed.). Jossey Bass. Schon, D. (1983). The reflective practitioner: How professionals think in action. Basic Books. Searles, H.  F. (1955). The informational value of the supervisor’s emotional experiences. Psychiatry: Journal for the Study of Interpersonal Process, 18, 135–146. Smith, M. (2000). Supervision of tear in social work: A re-evaluation of reassurance. Journal of Social Work Practice, 14(1), 17–26. Tomm, K.  M. (1985). Circular interviewing: A multifaceted clinical tool. In D.  Campbell & R. Draper (Eds.), Applications of systemic family therapy: The Milan approach (pp. 33–45). Academic Press. Tryon, W. (2014). Cognitive neuroscience and psychotherapy. Academic Press. Tsui, M. S. (2004). Gone with the wind: The impacts of managerialism on human services march 2004. British Journal of Social Work, 34(3), 437–442. Tsui, M. S. (2005). Social work supervision. Context and concepts. Sage. Tsui, M. S., O’Donoghue, K., Boddy, J., & Pak, C. (2017). From supervision to organisational learning: A typology to integrate supervision, mentorship, consultation and coaching. The British Journal of Social Work, 47(8), 2406–2420. Watkins, C. E., Jr. (2005). Toward an integrative, learning-based model of psychotherapy supervision: Supervisory alliance, educational interventions, and supervisee learning/relearning June 2013. Journal of Psychotherapy Integration, 23(1), 75–95. Watkins, C. E., Jr. (2015). The learning alliance in psychoanalytic supervision: A fifty-year retrospective and prospective. Psychoanalytic Psychology, 32(3), 451–481. Watkins, C. E., Jr. (2017). Convergence in psychotherapy supervision: A common factors, common processes, common practices perspective. Journal of Psychotherapy Integration, 27(2), 140–152. Watkins, C. E., Jr., & Scaturo, D. J. (2013). Toward an integrative, learning-based model of psychotherapy supervision: Supervisory alliance, educational interventions, and supervisee learning/relearning. Journal of Psychotherapy Integration, 23(1), 75–95. Wilkins, D., Forrester, D., & Grant, L. (2017). What happens in child and family social work supervision? Child & Family Social Work, 22, 942–951.

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Wilson, G., & Ryland, G. (1949). Social group work practice. Houghton Mifflin. Winnicott, D. (1971). Playing and reality. Tavistock. Wong-Wylie, G. (2008). Barriers and facilitators of reflective practice in counsellor. Canadian Journal of Counselling and Psychotherapy, 41(2). Worthen, V., & McNeill, B. W. (1996). A phenomenological investigation of “good” supervision events. Journal of Counseling Psychology, 43(1), 25–34.

Chapter 5

Gender Aspects of Reflectivity in the Social and Healthcare Field: Forms of Feminization of the Caring Profession as Frames for Reflexivity Monika Bosá

Several chapters of this monograph deal in detail with the need for and importance of reflection in the helping professions. From a gender point of view, it is also possible to rely on the feminist definition of reflection, which refers to the consideration of the gender positionality of the reflecting person, but also to the gender aspects of the situation and contexts in which the reflection is carried out. The reflection of power is also an integral part of it. According to Ackerly (2008, p.  28), feminist reflection is attentive to: (1) power in all of its visible and invisible forms, (2) boundaries and their potentials for exclusion, marginalization, and incomplete or superficial inclusion, (3) relationships of power and obligation (between people in different parts of the global economy, between men and women, parents and children, researchers and research subject, reader and audience), and (4) the role for self-reflexive humility and maintaining attentiveness to these concerns.

The purpose of this chapter is to use gender optics to look at reflection, its forms and use in social services and healthcare. As a starting point, I chose the fact that both social services and healthcare are among the feminized fields of the labour market, and social workers and nurses who represent these fields in our research are the professions with the highest degree of feminization. I am interested in whether/how this fact shapes the forms of reflection and the ways of its use in helping practice. I will try to show that the nature of the feminization of these professional fields is not the same and may bring different expectations for the need for reflection.

M. Bosá (*) Faculty of Humanities, Charles University, Prague, Czech Republic e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Lorenz, Z. Havrdová (eds.), Enhancing Professionality Through Reflectivity in Social and Health Care, https://doi.org/10.1007/978-3-031-28801-2_5

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I rely on the results of the secondary analysis of in-depth interviews with social workers and nurses. I used transcripts of interviews conducted by Michael Ružička with 17 women – social workers, social and healthcare workers and nurses, which were carried out in Study A1. The guidance for interviews included areas of participants’ personal perceptions of the meaning of reflection, their use of reflection in their work and perceived impact of professional training and work context on their experience, understanding and use of reflection. For the secondary analysis, I chose a method of qualitative content (thematic) analysis (Schreier, 2012) with the optics of the ethics of care. To triangulate the findings, I used the comments on the transcripts created by Monika Čajko Eibich (unpublished material). With support in the feminist concept of ethics of care, I will try to identify the nature of care in health and social services. I will try to show how a different perception of care does/doesn’t enable the use of reflection and identifies the space for its use. And finally, using the features of a caring organization, I will consider the possibility of how an organization can support reflection in the practice of care.

Gender as an Analytical Tool Gender lenses offer an understanding of some of the mechanisms of social practice. Social services and healthcare are fields of social practice created and implemented in the context of existing social structures, within which the gender structures of the division of labour and the division of power represent one of the important components. Although the concept of gender was originally used as an argument for the possibility (and necessity) of social change and as a counterargument against the “nature” of women’s social position, its broader analytical potential gradually became apparent. Gender is not just what is often simplistically referred to as “cultural sex”, nor is it an undifferentiated “stock of characteristics of masculinity and femininity”. It is a theoretical concept that makes it possible to investigate, analyse and interpret various phenomena of social reality and social relations (especially relations of inequality). Thus, the concept of gender does not only apply to individuals (regardless of their biological sex). It affects wider social phenomena, the entire social reality and all its areas (relationships between individuals, groups, institutions, and organizations, but also language, social symbols, etc.). A consistent use of the concept of gender must therefore primarily include social relations and structures of society.

 Research project GAČR P407 no. 19-07730S entitled Self-reflection in the social workers and nurses. Partial results of the project have already been published, and Chap. 9 of this book deals with it in more detail. 1

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Sandra Harding (1986) identifies three interrelated “levels of gender” that should be the subject of a critical examination. She identifies them as processes by which gender is present and reproduced in the social structure. The first level at which gender can be identified is the gender identity that individuals within a “gendered” society create for themselves, accept and cope with. Harding (1986) refers to this level as the individual level of gender. The second level of gender is represented by the gender structure of human activities, which refers to the assignment of gender characteristics to the entire areas of human activity and institutions. Regardless of whether certain activities are performed by men or women, the individuals who perform them are judged based on the gendering of such activity. Thus, entire sectors, professions and institutions are perceived as feminine or masculine. Due to the hierarchical relationship between “masculine” and “feminine”, even these activities carry an evaluation that is associated with masculinity and femininity. The gender segregation of occupations can be a significant example, where professions that are perceived as feminine have a lower social and economic evaluation. Both women and men who perform them either bear the negative consequences of the “femininity” of the given activity or profession or, on the contrary, benefit from the advantages that result from “masculine” professions. The gender division of labour is thus represented on the one hand by often unpaid “female” activities, and on the other hand by powerful, influential and economically profitable “male” activities. In the case of the gender structure of human activities, we talk about the institutional level of gender. At this level, gender roles and gender norms play a significant role. Regarding the possibilities of enforcing gender equality at this level, compensatory measures in the form of positive support action can have a certain positive impact. The third level of gender is referred to by Harding (1986) as gender symbolism. She refers to attributing the connotations of masculinity and femininity to phenomena that have nothing to do with men and women. Gender symbolism is present in the language itself and in the way it is used – language is “gendered”. The essential fact is that the attribution of a “male” or “female” connotation carries with it an evaluative, hierarchizing position and creates the impression of a general dichotomous structure of society. It is the symbolic level of gender – language and specifically gender stereotypes as an organizational control mechanism presented in language. Gender and gender power asymmetry are also constructed through metaphors, phrasal verbs and images (“to man up”, “sissy”, etc.) At this level of gender, it is possible to think primarily about gender stereotypes, which to a significant extent “maintain” the gender status quo. Identifying the symbolic level of gender is also the most complicated because gender stereotypes operate unconsciously. Because they are present in the language itself, which we use to express or describe phenomena, we are not aware of their manifestations. They operate mainly on an emotional level. At the same time, it is necessary to emphasize that the symbolic level fundamentally affects the other levels of gender – the division of both labour and identity. Real gender equality cannot be achieved without eliminating gender stereotypes.

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Like Sandra Harding (1986), Raewyn Connell (2009) points out that gender does not only concern individuals but manifests itself in the entire social structure. Connell identifies four core dimensions that are strongly gender conditioned. Like Harding, she presents the individual dimension (represented by identity); the production and institutions dimension (family, school, labour market, division of labour, etc.), which is comparable to the structural level of gender in Harding; and the symbolic dimension of gender (language, culture, values, etc.). However, she also adds a fourth dimension, which she considers to be specific  – a separate emotional dimension, which is mainly represented by social relationships. She defines it partly from the individual level, and to a lesser extent also from the structural level, as perceived by Harding. Both Harding and Connell draw attention to the fact that gender primarily expresses a power relationship; however, power is not a property of individuals, but a fundamental aspect of social life, including all social relations (Connell, 2009). Power, the area of relationships and emotions defined by Connell and the area of institutions, also designated by Harding as the structural level of gender, represent the key dimensions of gender for gender analysis in this chapter. Gender optics encourages a critical analysis of social institutions, social relations, social problems and individual social events. Joan Wallach Scott (2006) draws attention to two elements of the genus that allow such an analysis. Due to the structural level of gender as identified by Harding (1986), Scott (2006) also points out that any gender analysis must include the concept of politics and must refer to social institutions and organizations. The concept of politics can be identified as the form and structure of power relations. The second factor of the analysis of gender as a constitutive part of social relations, subjective identity, also corresponds to the individual level of gender characterized by Harding. As Scott (2006) points out, real women and men do not always fit within their own society or within our analytical categories. For this reason, it is essential for me to look at the structural area of gender as it is present in a feminized environment where nurses and social workers perform their work. For the purpose of reflexivity analysis in the context of social services and healthcare, it is possible to look at what role plays the fact that both sectors represent feminized professions. Therefore, it means analysing the institutional (structural) level of gender. In this chapter, I offer an interpretive framework of gender analysis based on the feminist concept of gender defined by Harding, as I presented above, and the feminist concept of ethics of care for understanding the forms of reflection and self-­ reflection as it is present in social services and healthcare.

 ocial Services and Healthcare and the Nature S of Their Feminization Feminized professions are generally seen as an extreme manifestation of the gender segregation of the labour market and are perceived as a barrier to gender equality. For the purposes of analysis, I will try to examine the characteristics of a feminized

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profession, as they apply in the social service sectors represented by social workers and the health sector represented by nurses. We speak of gender segregation (of labour market) if one group of activities (professions) is performed more (or almost exclusively) by men, while another is predominantly (exclusively) performed by women. In 2020, a total of 2,901,200 men and up to 9,300,200 women were employed in the field of healthcare in the EU (EIGE, 2022). In social services in the EU in 2018, women represented 82% of employees (Turlan, 2019). In our conditions, segregation and, above all, feminization are defined quantitatively, a field where the representation of women exceeding 60% is considered to be feminized (Tokárová, 2006). When trying to explain gender segregation, we come across several theories. They mainly focus on two questions: Why do women prefer certain professions? (demand); Why do employers prefer men or women for certain occupations? (supply). These questions are also related to the gender difference in the career progression of women and men – the difference in the career paths of women and men, as well as the predominance of men in management positions. A more complex explanation is offered by feminist theories using the concept of gender. The unequal position of women and men in the labour market is a consequence of persistent gender stereotypes. One of the key stereotypical concepts is the division of labour and its consequences, which are manifested in the persistent dichotomy of the public and private spheres (Kiczková, 1997; Slater, 1998). It seems to enclose women and men in separate spheres. Women are “destined” to take care of the family, and in a wider context, any other caring activities, stereotypically perceived primarily as an area of emotional experience and relationships with others, while men are “sent” from the area of home, emotionality, care and custody to the “outside”, to the public sphere. Although the boundaries between the public and private spheres are currently shifting, the activities identified with them remain socially and economically valued asymmetrically. Activities related to raising children, caring for children and the elderly, babysitting services, cleaning, etc. are socially and economically valued very low, which is also confirmed by the current hierarchical relationship between the public and private spheres. Anker (1998), Anker et al. (2003) identify several types of gender stereotypes, distinguishing them into positive, negative and others. Positive stereotypes are those that open certain professions to women. These include the ones that derive from the image of women as “naturally” caring and providing care – nursing – which apply mainly to jobs requiring this qualification, such as nurses and social workers; another stereotypical expectation from women is their assumed ability and experience in skills associated with housework, and it mainly applies to jobs such as cleaners, cooks, waitresses and the like; an example of this group of stereotypes are also ideas connecting women with better fine motor skills resulting from smaller hands, such as seamstresses, knitters and typists; stereotypically, women are also expected to be more honest; therefore, women are considered suitable for the professions of accountant and cashier; the stereotypical idea of women as representatives of the “beautiful sex” creates space for receptionists, hostesses, etc.

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Negative stereotypes, on the other hand, close some professions to women. They derive from the following stereotypical characteristics of femininity: from the idea of women as submissive beings with a reluctance to direct others; from the idea of women as physically weaker; from the perception of women as less technically skilled; with minor prerequisites in mathematics and natural sciences; with the expected lower willingness of women to travel; or face dangerous situations. Anker (1998), Anker et al. (2003) also mention a group of so-called other stereotypes, which primarily serve as a rationalization of the negative consequences of gender segregation on the labour market (lower salary, lower prestige, precariousness of work). As Barošová (2006) states, these general characteristics qualify women for many low-paid jobs; they do not require special skills and they are of a routine nature (repetitive activities). “Other” stereotypes correspond to positive and negative stereotypes, but they say less about the prerequisites for work and more about the willingness to accept a disadvantaged position, or the ability to tolerate it better. Such stereotypical ideas are mainly related to the stereotypical concept of a man as a breadwinner and a woman as a housekeeper. In the first group of “other” stereotypes, there are expectations that women are more willing to work according to a certain order, are more malleable and less likely to comply (adaptability) with work demands (character of work) and working conditions, are less likely to join unions and have greater willingness to accept monotonous (repetitive) work. These expectations stem from the idea of a submissive woman as primarily family oriented. The second group of other stereotypes are those that result from the idea of the presence of a male breadwinner on whose shoulders lies the main burden of the family’s economic security. It is mainly about the idea that women have a lower need for income and are willing to work even for a lower wage. Apart from the fact that certain professions, sectors or trades are dominated by women or men, gender segregation has several negative consequences (mainly for women). Women are underrepresented in better-paid jobs, in company management and generally in power positions.2 It is a well-known fact that feminized professions are characterized by a reduced supply of financial resources and a decrease in social prestige (Smetáčková, 2005). An inverse relationship applies – the greater the representation of women in jobs (professions), the lower the salary and prestige (Kimmel, 2008; Cviková & Filadelfiová, 2008)  If we talk about gender segregation, it is necessary to realize that segregation occurs both on the horizontal (different types of work, tasks or entire sectors performed by men and women) and on the vertical level (different positions represented by women and men in the organizational hierarchy). It is vertical segregation that results in unequal remuneration and unequal prestige for women and men even in the same professional fields. Here, too, the result of gender-stereotyped expectations is manifested, which are linked to ideas about men as performance-oriented, able to handle power and women as providing support, performing “small jobs”, or “ready to sacrifice for others” (in our case, working even almost for free and without recognition). This phenomenon is also manifested in social work as a profession, but also in social work situated in an academic environment (simplified: the higher the position, the greater the probability of meeting men even in a significantly feminized sector). 2

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Adriana Jesenková (2009) mentions similar characteristics, while in addition to lower average wages, limited opportunities for career growth or further education, she mainly focuses on characteristics associated with the decline in the value and importance of work in feminized industries and professions and the subsequent decline in the social status of those employed in the given profession, as well as a decline in the social prestige of the whole profession.

 he Shape of the Feminization of Social Services T and Healthcare in Relation to the Nature of Care Through the Lens of Gender Analysis Social services and healthcare fulfil both the quantitative and qualitative characteristics of feminization. However, the nature of work in both environments (and within them) differs. To understand how the nature of the work and the nature of the environment (the culture of the organization) affect the use of (self-)reflection, I will take a deeper look at the nature of feminization in these environments. For our research, healthcare is represented by the profession of a nurse and social services by the profession of a social worker. How are they similar and how are they different? Both professions are identified by caring activities. They differ in the nature of the work and the context of the work. While social workers working in the environment of social services, although while in contact with other professions they are mostly not in a hierarchical relationship with them, professional hierarchy is strictly present in the field of healthcare: But of course , if you serve with a doctor with whom you have something in common or perhaps understand or know that you can say something to him you can like this but if it’s already someone more above , so of course you won’t share all feelings with them, but if something upsets you , you don’t agree with something, that’s what you do through the nurse manager, who will solve it with the doctor manager. (Nurse, Cardio Intensive Care) About the fact that there is little communication between one another. ... and when someone has something to say, so the one who is above can give them the brush-off, that’s right. And it’s coming from competence maybe, yeah. (Nurse, Cardio Intensive Care)

The social health worker also identified the presence of hierarchy in the healthcare environment: That boss is the doctor and everyone who is lower, like does everything to adapt to him or I don’t know how I would like to have it said. (Social Health Worker, Hospital).

This is confirmed by other nurses: Well, the doctor treats the patient, and the nurse takes care of him. And at the same time, she implements the doctor’s treatment. ... Like a doctor and a nurse, they should be in cooperation. But of course, anyway, I think that it always must be a little bit that the doctor has a say, because he gives the treatment to the patient. So, it’s like he’s the Kapo there. (Nurse, Cardio Ambulance)

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In the healthcare environment, in addition to the sign of a feminized profession oriented towards caring activities (in line with social services), the idea of a feminized profession as performed by persons willing to submit and adapt also plays a role. The second area I want to focus on is the nature of work. The point is that while there is room for negotiation and explanation in social services, there is no such a room in the medical environment, especially in emergency departments. Orientation towards routine activities or strict adherence to effective procedures prevails: I think you can’t get it [way of working] changed because can happen that you have a patient with a heart attack and you will not improvise, but [it is necessary] follow the procedure. There for sure no, well. ... When they are already stable, you can. That space is there, but not in that one acute phase. (Nurse, Cardio Intensive Care)

The specifics are also the intensity and sudden nature of the work, which limits the possibility of mutual sharing: And certainly, at coronary unit, as it is like intensive care medicine, ... that it really is a lot of bumpy work, so some shifts were so exhausting that a person would spend twelve hours not sitting down, didn’t even have time just to go for lunch, to the toilet and the like, but sometimes there was again the space that simply perhaps for half an hour nothing happened. You had your job like done, so you’ve made yourself coffee and it just happened to chat. (Nurse, Cardio Ambulance)

So, the question arises, in which way it is possible to use reflection in this context. The answer is that it is possible mainly in situations “after the activity”. In this context, Havrdová et al. (2022) distinguish practical and dialogical reflection as borderline forms of reflection in the statements of our informants. Between these poles, there is room for other “degrees” or “depths” of using reflection. However, it seems that what differentiates the use of reflection is not primarily the profession, but the way in which the care service is delivered. Therefore, I would like to formulate the hypothesis that while social workers and nurses represent feminized professions (both in accordance with their quantitative and qualitative definitions), regarding the expected performance of care, the field of social services and the field of healthcare cannot be identified so unambiguously in this way. Mainly the field of healthcare is characterized by rather stereotypical signs of masculinity – ability to act, performance, decisiveness and hierarchical structure. In the context of stereotypical distinctions between “male” and “female” professions, or areas of the labour market, I would like to state that social work as a “female” profession is carried out in an environment close to “feminine” characteristics, while nurses perform their “female” profession in the context of a “masculine” environment. I stress that the adjectives male/female in this context refer to stereotypical expectations that arise in a gendered society. I do not perceive them in an essentialist way but rather as models that serve to understand the gender context and mechanisms of gendered social practice, where certain types of action and attitudes are expected from participants. If we think about “feminine” and “masculine” professions or professional fields in this context, in accordance with the structural level of

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gender as defined by Harding (1986), we can better understand the opportunities and limitations that such professions/fields bring. If we think of reflexivity, it is possible to expect that “female” professions, stereotypically tied to relationships, emotions and care, open more possibilities than a “male” environment, tied to performance, individuality and rationality. Similarly, in the context of gendered professions and areas of the labour market, the nature of care, which is realized in such different environments, is perceived differently.

Care as a Relational and Reflective Practice Feminist ethics of care has been developing since the 1980s in response to Carol Gilligan’s work (1986). There, Gilligan tried to present two ways of ethical decision-­ making depending on gender socialization and gender-stereotyped concepts of masculinity and femininity. She thus defined, on the one hand, the ethics of justice, where ethical decision-making is realized in the context of principles derived from firmly defined norms of virtues and values, and the ethics of care, where ethical decision-making is realized contextually, in relationships and through relationships. The ethics of care thus redefines care as a general value and practice through relations of interdependence. Caring is no longer seen only as a female activity, but as a general democratic practice. The feminist concept of ethics of care has since its beginnings developed into several variations represented by authors from various scientific fields (political sciences, philosophy, nursing, social care, ethics, etc.) So, what is the nature of care? What type of practice is it? The ethics of care perceives care as a fundamental human activity. Tronto (1993, 2013) emphasizes that the starting point for every decision and action must be a relationship with others (mutual dependence). It is a shift from ethics as theory to ethics as practice, with an emphasis on the elements (or steps) of care defined by Joan Tronto (1993, 2013). Collins (2015), who clearly emphasizes the situatedness and relationality of care, agrees with this. The definition of care as formulated by Tronto (1993, p. 103) is as follows: On the most general level, ... caring should be viewed as a specific activity that includes everything we do to maintain, continue, and repair our ‘world’ so we can live in it as well as possible. That world includes our bodies. Ourselves, and our environment, all of which we seek to interweave in a complex, life-sustaining web. (Tronto, 2010, p. 160) All human beings must be engaged in the activities, both as receivers of care and, in most cases, also as caregivers. (Tronto, 1993, p. 142)

Joan Tronto (1993, 2013) identifies them as follows: The first step is recognizing the need for care (caring about). It is the realization that someone (an individual or a group) needs care. However, recognizing the need for care may not automatically lead to the implementation of specific care activities.

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The second step is accepting responsibility for care (caring for). It is the situation that is a response to a recognized need for care. At this stage, someone must take responsibility for the need to be met. It is a state when we realize that we are the ones who can fulfil the need for care. Only in the third step can the direct activity of care-giving occur. Tronto states that under care-giving, she perceives mainly direct care – specific activities (work) that are performed in contact with those to whom care is provided 3 (1993, p. 103). The fourth step is care-receiving. If the care was provided, it is appropriate to expect a response or reaction to the care. This step within care provides a picture of whether the care that was provided adequately met the care needs. In this way, care providers become care receivers themselves. Care-receiving disrupts the notion of a one-way care process. In 2013 in her work Caring Democracy, Tronto added a fifth phase to care: caring with). It is about being aware of other actors of care and perceiving of care also as a commitment to justice, equality and freedom for all (Tronto 1993, pp. 106–108, 2013, pp. 22–23). For individual steps of care, Tronto also defines basic ethical elements (virtues): Attentiveness is essential for recognizing the need for care (caring about). It is also perceived as a necessary condition for a person as a social being. It is a prerequisite for any social interaction. Responsibility for care as the second element of care is directly conditioned by the virtue of responsibility. Responsibility is generally seen as the ability to fulfil an obligation. Unlike duty, it has a more sociological and anthropological character – it is anchored in cultural practice rather than in formal rules. The cultural conditionality of responsibility also indicates the diverse ways in which it is perceived and expressed by persons, depending on gender, age, but also ethnicity or religious affiliation. In particular, the gender conditionality of responsibility is perceived as significant in the context of ethics of care. Competence (mainly) in the context of care-giving does not mean only knowledge and skills, or even just a professional definition, but also significantly concerns issues related to professional ethics. In connection with the fourth stage of care, it is also necessary to consider the virtue that is associated with care receivers and which Tronto identifies as responsiveness with their ability and willingness to respond to care and provide an answer about its adequacy. However, it is a two-way process – at this stage, direct and active interaction is necessary on both sides, on the part of the recipient and the care provider. For good mutual care, the presence of values such as plurality, communication, trust and respect, which Tronto perceives as part of solidarity, is essential (compare: Tronto 1993, pp. 127–136, 2013, pp. 34–35).  Tronto uses a situation when we provide money to ensure care that is performed by someone else, as an example that is not the provision of care. She identifies such a situation rather as caring for (taking responsibility for care). 3

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 he Nature of Care in Healthcare and Social Services T Through the Lens of a Feminist Ethic of Care Social workers and nurses who shared their experience and perception of reflexivity with us in their statements identify reflection in the context of all stages of care. However, the differences are in how they consider their own self-reflection and shared reflection in the context of the environment and the nature of the work where it takes place/should take place. What Havrdová et al. (2022) refer to as practical reflectivity refers mainly to the first two levels of care according to Tronto and is as if “automated” in the context of acute healthcare. As the authors state, it is  a “spontaneously ongoing process of intrapsychic mediation between perceived stimuli of external situation, formulas of specialized tacit skills that actors were aware of in the phase of acquisition but it became unaware, learned knowledge of ‘what you have to pay attention to’, up-to-­ date suggestions and instructions from others members team, especially from the doctor who decides and determines the next procedure”. The recognition of care and the readiness to provide care, but also partly the provision of care, are obvious in relation to patients. However, even at this level, other relationships and actors who could be the subject of reflection are present: ... Or was perhaps stressful when the ambulance brought for resuscitation someone up to us, straight to the ICU. And there was resuscitation ... That was the most stressful because _ you do everything terribly quickly ... (so that) the person was saved. At the same time, the doctor must assess whether the person perhaps will go to the catheterization room, if it’s a heart attack, it’s not a heart attack... or it’s pulmonary embolism ...? You must act in quick succession. And at the same time when it was hospitalization already during resuscitation, so you don’t care if with that person´s name is Karel or Ivan .... (Nurse, Intensive Care)

The automatic division of labour is based more on the division of professional competences and expected performances, which must be implemented immediately – space for the doctor’s decision, the nurse’s own activity and preparedness for the unexpected. One would expect that attention can be paid to the action through reflection “after the action”. However, as it turns out, in the healthcare environment, this type of activity is rather present in the form of abreactive reflection or corrective reflection. However, it primarily concerns performance, less the reflection on relationships, the nature of cooperation and emotions at minimal level (if at all). However, the nurses themselves perceive space for reflection in other areas, such as communication, cooperation, relationships and emotions. However, they do not perceive a similar need from doctors: Which bothers me even about those doctors, that there simply is such a thing as there are many various performances, so with that person they just like don’t talk much, yeah. That it is like that terribly fast, yes, a lot of things then, of course is transmitted to us. ... Well, so it’s like they put on us a lot of responsibility [to communicate with patients] those doctors. (Nurse, Cardio Intensive Care)

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In her statement elsewhere, the same nurse draws attention to a significant difference, which, in my opinion, characterizes the different nature of care and reflection in the environment of healthcare and social services: That it is like that them being just doctors. Like they are not interested, or it seems to us that they are not interested as much as the person, but rather simply that really performances matter. And that the part of human there seems to be neglected a lot, well. But on one hand, a person sometimes seems to understand that simply there are a lot of performances, but I don’t know, well. Simply there should be five, ten minutes I think, or we think. Yes, those people are scared, afraid and so, well. (Nurse, Cardio Intensive Care)

I believe that performance orientation is the “masculine” element in feminized healthcare, and relationship orientation is the “feminine” element in social services. Although nurses and social workers or social healthcare workers perceive relationships (and communication) as equally or comparably valuable as professional performance, they are not evaluated equally in the healthcare environment. Perhaps it could be expressed more explicitly in another way: while in healthcare relationships (and communication and emotionality present in them) are a supplement or background to professional performance, in social services they are part of it – the ability to create relationships and maintain them through communication and emotions are among professional competences. Of course, this is echoed also in what is worth of (suitable for) reflection. It seems that the space for reflecting of care in all its stages is only possible where care is perceived as relational, not only taking place in relationships but also requiring and creating relationships. This is, in my opinion, the key difference to the “traditional” perception of care as a linear activity, one-way service realized in a hierarchical relationship between the care giver and the care receiver. In this context, there is only room for reflecting on the correctness of the performance, its effectiveness and possible correction of care steps. In the context of a feminized profession, where care is perceived as “natural”, requiring no special procedures, knowledge, skills and competences for its quality, it can give the impression that it is actually always “the same”: When you’ve been doing it for so long, it’s... it’s basically always the same, you just have to know what to pay attention to. (Nurse, Intensive Care)

If we perceive care in relational terms, there is always a context of care, which is created by a network of relationships (care). It also seems from the statements of our informants that this space is identified based on the extent to which relationships are perceived as part of care, not just its “background”. The nature of care in the healthcare space is thus more performance-oriented (saving health and life) through the control of “correct” care procedures, while the social service environment is more amenable to relationship-oriented care, realized through “negotiation” of care procedures. However, this division cannot be perceived completely unambiguously  – the dividing line between types of care does not exactly follow the line between healthcare and social services, but rather the line between acuteness and risks of care in relation to patients/clients.

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For example, we can perceive palliative care at the border between healthcare and social services as open to relationship-oriented care, and on the contrary, some services provided by SLP 4 as closer to performance-oriented care. This distinction is even more complicated if we consistently think of care as a relational practice. Even in the context of acute healthcare, this is realized in the context of relationships – among colleagues, among professions and among patients/ their loved ones and professionals. Caring for these relationships is an essential part of good care (even good care directed at performance). Even the nurses themselves are aware of this: Interpersonal relationships for sure. Just like if I have a problem with someone, it’s certainly good to say: “Look, you’re annoying because ...” But it doesn’t happen very often, those folks can’t do it. Or they are afraid. But they are afraid rather in relation to those superior ones ... Or why don’t they tell the doctor that they are not right? When he’s not right, I’m still the one I can’t be allowed to afford it. Right now, he can afford it. That is why he should afford it. Because he is not right, and she must stand up for herself. (Nurse, Intensive Care)

The need for shared reflection is essential for cultivating relationships: But then it would be good to sit down after an acute situation and say: “Hey, here it was good, this we must do otherwise next time, me, I am, if I shouted, I’m sorry.” But there is not completely space for that because the care for those patients while acute continues, ... But I have to say that it happens, that the doctor who serves comes and says: “Hey, thank you, it was good,” or: “We have to upgrade here.” And ---, and it’s very pleasing. (Nurse, Intensive Care)

From a gender point of view, one can also consider whether nurses who are professionally prepared and socialized for performance-oriented care, but at the same time, as women, are socialized more for care realized through relationships and for relationships, do not face a fundamental contradiction in the performance of their work (mainly in hospitals). This contradiction creates yet another space for shared reflection. However, according to the statements of our informants, they are left to deal with it in isolation and personally: And that the component of the human there seems to be neglected a lot, well. But on the one hand, a person sometimes seems to understand that simply there are a lot of performances, but I don’t know, well. (Nurse, Cardio Intensive Care)

As mentioned above, care means caring not only for patients but also for colleagues. Our participant reflects this aspect of care and transfers it into practice: Um (agreeing). When you work together in acute medicine, where those conditions are, you perceive certain situations, and then, when it is possible, within the possibilities, you (make it easier for colleagues), in those situations which are taken badly. They know it. But it can be done, of course, only if you trust yourself, if you share that information because when you know there are situations, which do not do him ok, then you feel free to send (another one) yes. (Nurse, Intensive Care)

 Social and legal protection of children (SLP).

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A specific feature in (acute) healthcare is the absence of a conscious work with emotions as a source of information, or even a tool for effective (co)operation. One of the nurses expressed it undeniably when asked: “It is possible to share – or talk about your really inner feelings like emotions perhaps?” She replied quickly: “Something such as this doesn’t work here. Yeah”. (Nurse, Intensive Care).

A prerequisite for shared reflection is a safe environment based on trust. In their statements, our participants also mentioned this significantly: Absolutely no sharing, absolutely no trust in the team, the team grouped into three, four pairs, threes. There was just no communication at all. It worked in such a way that the team simply ... when one, one entered the office of the other one, so it got silent. And here, there was such a dark atmosphere, fearful. I don’t know there it just was ... There was just missing simply, there was missing an open negotiation towards everyone equally. There like unfortunately in my opinion this... That manager simply resorted to such like ... Somewhere she whispered certain information ahead and there was no ..., there was simply no discussion simply with everyone equally. And that team, by the way couldn’t have a feeling of trust. Never. It simply could not function well. (Social Worker, SLP) Like my subjective feeling is that we have enough trust at the SLP department meetings, and we even open the topics here that maybe then we don’t want to go on. But it is my subjective feeling if, if that’s just this way, you would have to ask the department girls and that... Like I think that yes, that on that, on that, on that first level at that SLP, we have trust in that team and open things that we just don’t want to go on then. And that, that they stay here. (Social Worker, SLP)

I defined the border between different types of feminized environments in relation to the nature of care (its urgency, precision of performance), rather than through the professional orientation (healthcare/social services). At the same time, I believe that the building material from which the border is “built” is the perception of relationships (either as essential or as necessary, but not primary). What is usually the content of reflection expressed by participants in the research relates to the practice environment and also depends on what is considered essential for care in the given environment. Whether it was about reflection, how it is perceived by nurses and social workers, about its sharing, about the organization of work or the nature of the organization, the topic of relationships appeared in all the statements, either explicitly in direct formulations, or implicitly, as another context of what was said. Its importance was emphasized by social workers and nurses repeatedly and in different contexts: I think that we really can solve also, also relational things. I can simply also confront unpleasant situations when needed, but then in some way I will finish and treat it. But I, I don’t know when I am drawn into the collective, whether I’m the right person to tell you objectively, how it is here. (Social Worker, SLP) Like if I were with that sister in this clinic, with whom indeed like one works closely, to get along, so I would probably leave that job. Like, I could not simply work with someone, with whom one does not have completely like a good relationship. (Nurse, Cardio Ambulance) And to continue working with those people, because it’s hard work as in any service, so it’s still work with people and it’s very demanding. And if the team works and there are good

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relationships, which I think it is also a lot important because as soon as the team doesn’t work, so then it reflects on that worker and then also on that service. So, I think it’s good that when the team communicates and solves different issues together. (Social Worker, Community Centre)

While nurses (mainly in hospitals and clinics) were aware of the importance of relationships, but often did not consciously work with them, social workers had the opportunity to share this, for them, fundamental topic, also during supervision: As those relationships at the workplace go, for example, that’s usually what we solve at the supervision that we think that these are things which we need, so that there was someone out there and helped, helped us with that so we did not get in cycle. (Social Worker, Community Centre)

Good relationships were perceived by our informants as those based on trust. This is another moment that the ethics of care also emphasizes. In the context of caring and caring relationships, trust is a condition of responsiveness and reciprocity. Also, according to Anette Baier (1994), to trust is also to let the others think and act so that they protected and developed something the trustee cares about. Trust towards colleagues and relationships of trust were perceived not only by social workers but also by nurses as a condition for shared reflection, although they rather formulated their thoughts by saying that lack of trust is an obstacle to sharing: Well, there I would dare to say nothing simply. There, the current management does not have any trust among employees. So, I think this is a big difference, those micro teams versus leadership. This I think is a general problem to most organizations, I would dare to claim. (Social Health Worker, Hospital) It certainly isn’t t like an environment full of trust that a person would completely open there. It should probably be like that, someone will do it, but I don’t think everyone seems to do it and wants to do it, to like open like to everyone. (Nurse, Cardio Ambulance)

The presence or absence of trust was perceived mainly by nurses as a coincidence rather than as a deliberate effort and activity, and they similarly formulated the possibility and impossibility of sharing: Yes, I say it depends on, well, who you are in shift with and to whom one trusts and how one trusts them, so yes. It is not a lot of them, but they are, they are, well. (Nurse, Cardio Intensive Care)

Quite differently, the presence of trust was perceived by social workers, and especially social and social health workers in palliative care, as an active “setting” and the result of the efforts of the team/organization: Well, because it is probably in that team, let’s say set from the beginning such like openness. It’s for me perhaps like quite safe environment and here like there is the trust. (Social Health Worker, Palliative Care)

Nurses describe relationships of trust with support by the term friendship: I don’t know. I guess it just depends on with whom the person is working there... we served in threes usually, sometimes the group was more as if, like a person is as if friends with them, so maybe one as if confided, ... but with someone I would not share. It just depends really after that on some more friendly relationships than just a colleague. (Nurse, Cardio Ambulance)

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The concept of friendship is presented by the work of several theorists, but above all by Barnes as a relationship of a specific nature of care: “Friendship can be a source note only of practical care and support, but also of ethical development that contributes to our capacity to respect the preferences and commitments of others” (Barnes, 2012, p. 88). Possibility and willingness to share emotions and to reflect on working with them together are also a manifestation of trust: I think that in this kind of work it would be impossible to survive without sharing. And I, myself, I couldn’t imagine how I would it here like ... that I would bear it within myself and then what? Then I would probably crash somewhere like a volcano. You can’t do that in this job. Maybe somewhere, I don’t know, somewhere maybe for example, where the cases aren’t developing or where you have it just like definitive that this is how it is given. I don’t know. (Social Worker, SLP)

As mentioned in the first part of the chapter, the level of emotions is perceived by Connell (2009) as a specific feature of the gender structure and as one of the manifestations of the division of labour. Emotional work (of care) as a part of power (and gender) relations is thus a relevant area of critical reflection and gender analysis examining its nature in various caring professions. In accordance with how care (realized in and through relationships) is perceived as a natural skill in a woman’s profession on the one hand, or as a social and professional practice realized in relationships with others, is perception of the need for formalized reflection also either marginal, left to the interest or activity of helping professionals “if they need it” (mainly in the health sector), or there is the space created for it as a full-fledged part of care practice (in social work and in multidisciplinary teams). The need for reflection, as well as its implementation, is present in the statements of all our informants, regardless of their profession or performance environment. Where their statements differ is the degree of previous training for reflection, where more often, social workers or medical social workers than nurses have completed some type of education where either reflection would be used, or the education would be directly focused on reflection. Another difference is that social workers have access to a formalized space for reflection in the form of targeted meetings, or their parts, or interviews and supervisions. Their statements also differ about the fact that although they consider shared reflection as a tool for improving their work, relationships with colleagues, or working with their own emotions and the emotions of patients/clients as necessary, they do not perceive its provision as something that results from the organization’s obligations. Rather, they perceive it as a matter of their own initiative, or the interest of the collective or department. The dividing line runs between performance-oriented care through the control of “correct” procedures, where care is perceived as a one-way activity from the care provider to the recipient, and relationship-oriented care through the negotiation of procedures, where care is perceived as a process of active partners working together to implement it (see Table 5.1). It is about the extent to which relationships have a place in its implementation.

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Table 5.1  Performance-oriented care vs. relationship-oriented care Category Care process

Stereotypical care Performance-oriented care Linear and one-way (from active care giver to passive care receiver)

Actors of care Primarily an active provider and a passive recipient; other participants (other professionals, close to the patient/client, other patients/clients) do not participate directly in the care; they can help or hinder it, but they have no influence on its form

Relationships Hierarchical, diverted from professional of care competences with strictly separated activities; relationships are professional, and their quality and effectiveness depend on expertise and performance Trust Based on faith in the competence of the actors, their professionalism and skills, implemented in the context of individual responsibility and autonomy Working with Focused primarily on their control, emotions suppression and management so that they are not an obstacle to the performance of care, or that they are used to effectively support the receiver of care Reflection

Focused mainly on reflection on the adequacy and effectiveness of care procedures – “correctness” (practical reflection); reflecting on one’s own procedures and the procedures of others “after the action” aimed at improving the practice of care (corrective reflection); implemented formally as an assessment, otherwise mostly informally, as ventilation (abreactive reflection)

Relational care Relationship-oriented care Negotiated and implemented by active actors who co-participate in the care Active participants identifying and negotiating the need for care, the process of care and the form of care; other participants (other experts, close to the patient/client, other patients/clients) are full actors of care with various proportions of their own participation in its nature and form Non-hierarchical, variable in time and context, negotiated; their nature is professional and emotional, and their quality and effectiveness depend on the depth of cooperation Based on the awareness of interdependence, shared care, shared responsibility and relational autonomy Focused primarily on their recognition, effective use as a source of information and a care tool; focused on their cultivation as a full-fledged part of care relationships Focused on the process of care in a network of relationships and contexts (thoughtful reflection); conscious and deliberate practice as part of caring for “good care” realized in and through caring relationships (dialogic reflection). It has the character of critical reflection

It seems that the more there is room for its relationality in the context of care, the more room (and need) there is for reflection. Thus, the mentioned two models of care represent a kind of edge of the spectrum of forms of care, as it is realized in different environments of helping practice – from paternalistic practice perceiving care as a naturally feminine activity that does not need to be specifically cultivated through care relationships, but only through education containing familiarization with the right procedures and leading to their adoption up to relational care as an expression of democratic practice based on cooperation and mutual care realized

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through care relationships based on trust, which is an expression of interdependence as a positive value. If we look at reflexivity through a gender lens at its structural level, we cannot avoid one more aspect that affects the reflexivity used in professional practice. It is a gender division of labour not only in the public sphere but also in the private sphere, in the family. The traditional perception of women as the main performers of unpaid work (care) in the family and as responsible for the atmosphere in the family 5 also affects their self-realization in the professional field. In addition to the higher demands on time and energy that women face, experiencing the situation in the family and household significantly affects their perception and performance (including reflection and sharing) at work. Our informants confirm this in their statements: Well, maybe by something a person is tired just like in general by the household or simply the care at home. Yeah, like I don’t get much more strength for it in that job somehow to solve a lot. (Nurse, Cardio Intensive Care) That taking that step and opening it requires some energy, some strength for me from inside, simply to go out on a limb. Sometimes a person does not have it, just when totally full of something. (Social Worker, Hospice) Well, I don’t know, so I guess I have to be comfortable at home, yes, to feel comfy at work as well, to not take it to work. (Nurse, Cardio Intensive Care)

In the context of social services and social work, personal matters were also perceived as a relevant area for sharing and reflection: If I had some problems in my private and it reflected somehow in my work and it came up for supervision, so I have the option to take advantage of individual [supervision]. ... The one that the organization pays for. (Social Worker, Community Centre)

Unfortunately, the area of private life, as well as emotions, is more of a space for suppression than reflection, a sign of the hierarchical structures of the healthcare system, especially in hospitals and predominantly in the field of acute care. As indicated above, the ethics of care perceives the need to redefine care as a democratic practice and considers its realization possible only through caring relationships based on trust that can be cultivated by caring institutions and organizations.

 aring Organization as a Space for Reflection and Reflection C as a Condition of Caring Organization The absence of reflexivity and responsiveness is part of what Tronto (2010) identifies as bad practice of care: Firstly, it is the very definition of the cause of the need for care, due to certain unfortunate or other unfavourable circumstances in the life  In the Czech and Slovak languages, for the dyad breadwinner – housekeeper the designation head of the family – protector of the fireplace, referring not only to activities but also to relationships is also used. 5

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of the client. This prejudice stems from the individualistic definition of autonomy as self-sufficiency and independence, thus excluding the need for care. As it has been defined above, interdependence is not an obstacle to autonomy, but a natural part of it. This prejudice can result in the exclusion of many clients from care because they do not face difficult circumstances. Another feature of bad care is, according to Tronto, if the definition of client needs in the institution (including social work) is perceived as obvious. Here, a significant role is played by prejudices that may be based on the general use of expertise or the “expert position” of an assisting professional, where they consider their experience and knowledge to be sufficient to assess and define the needs of specific clients independently (without need to double check with client). In close connection with the risk of using “expert position” as a sort of prejudice, Tronto regards as another feature of bad care the practice where care receivers are excluded from decision-making because on account of their lacking expertise. Bad care, according to Tronto, becomes a commodity rather than a process. Care is something the client “gets”; it’s the result, the product or the service they get. It is not perceived as part of the interaction with the client and other performers, or as an interaction itself. Understanding care as a commodity is also associated with the following symptom of poor care that Tronto understands as a narrowing of care just to provide it instead of understanding the care as a whole process, with allocation of responsibilities (both to providers and to receivers but also to others, including administration, policy, etc.). Bad care is also where the organizational requirements of the providers are perceived as barriers rather than as support for care. In the case of good care, the organization of care is an integral part of it, not an “external” structure or even a complication. As the last feature of bad, undemocratic care are, according to Tronto, situations when care is provided depending on social background, ethnicity, race, gender, etc. In this case, it is often a manifestation of direct or indirect discrimination of receivers (but this may also apply to the discrimination of some workers). Understanding care as relational and as democratic practice is possible (and desirable) to practise in caring institutions that perceive care as a process rather than a commodity, and which at the same time meets the criteria of democracy. Caring institution as defined by Tronto (2010) must meet the condition of three “Ps”: power and politics, particularity and plurality and purpose of care. P1: Power and Politics of Care/Institution This means to have a clear picture of power in care relationships, and hence recognizing and understanding that caring has a political dimension at every level. This is manifest in relations between providers and receivers and management and staff, in institution – state or institution – and the public relations, but also between the individual components and members of the institution. These power relations have to be discussed and negotiated on a continuous basis, corresponding to the context of the particular situation.

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As already indicated, the reflection of power and politics means consciously noticing power structures and the competences resulting from them or cultivating relations of care and the democratic practice of care within/across them. Understanding the interdependence of all components of power structures helps to cultivate relationships and, through them, the effective practice of care. A caring institution creates space at least for the reflection of power, ideally for the negotiation of power. Thus, reflection is necessarily always (even in the context of reflection on “correct” performance and procedure, in the context of relationships and sharing of emotions) critical reflection. The subject of working with power and reflection on power concerns also the area of division of power in the private life and family of professionals and clients of the organization. Power, and its negotiation and use, is part of the everyday practice of care and relationships of care. Power is never fixed, nor one-sided and one-­ way, but is always relevant (not only) for the realization of care and its organization. P2: Particularity and Plurality of Care/Institution In caring institutions, care is provided to ensure plurality and specificity/uniqueness of all participants. The caring institution considers the specificities of the individual components in the various areas, i.e. uniqueness in perception and definition of the needs of individuals, uniqueness in interactions and relationships (how individuals, by their own personality, character and other characteristics, enter into and implement relationships) and uniqueness in processes that can be expressed by the slogan of each differently, all with the same goal (i.e. having in mind that there is never only one correct way to work, but that everyone can give their own the best way of achieving an effective outcome within given terms of care conditions). It is necessary to remember that care is always contextual  – its conditions and forms change depending on specific actors, their specific situation and the specific outcome towards which they work. Even if the same procedure is necessary in some contexts, reflecting on the fact that everyone faces it in the context of different emotions, a different degree of mutual trust or a different level of cooperation, opens the space for reflecting on broader contexts of “usual” or prescribed procedures. The field of cooperative relations is frequently a space for reflection precisely in strictly defined practice procedures, such as in the field of acute healthcare. This element came out in our conversations mainly in the context of multidisciplinary cooperation. However, I believe that its place is also relevant in the environment of care carried out by only one profession. There is also room to do things “to the best of your own ability”. P3: Purpose of Care/Institution Each member of the institution is aware of the purpose to which they work, i.e. what is to be “at the end of the process”, as a desired result for all participants, for clients, members of the institution, the community and the profession. This inevitably means that both the process itself and the awareness of its purpose are always dynamic and discursive.

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A consistent understanding of the purpose of care in its meanings for all actors is central to good care practice. Reflecting on variations in the purpose of care helps this process. The characteristics of the caring institution based on the P3 condition and with regard to the dimensions of care as defined by Joan Tronto are never formulated as closed and definitive. The particular conditions and dimensions of care are extremely demanding especially for the (self-)reflection of its performers. In the context of the feminization of helping professions, the focus area for reflection is precisely the nature of care and the need for its defeminization – disrupting the idea of care as a “natural” activity for women and realizing its relationality. These steps open up not only the possibility, but also the necessity of using and cultivating reflexivity (not only) in the context of social services and healthcare. Reflexivity (in helping practice) can thus be focused not only on the quality of services in the context of relevant procedures, not only on cooperation in the sense of its effectiveness and not only on the organization in the sense of managing processes and services. Relevant areas for reflexivity are also the policy of the organization and the practice implemented in it, power relations not only in terms of hierarchy in the organization but also in terms of gender structures, the unique lived experience of female workers (both women and men) as caring professionals and clients and patients and their (gendered) social environment. As stated by Tronto (2010, p. 161), “Care is probably facing two dangers, namely those of paternalism, in which care givers assume that they know better than care receivers what those care receivers need, and parochialism”. The issue of power is perceived as essential in ethics of care. In the case of their neglect, there is a risk of inefficiency of work or even endangering receivers as well as their providers: All forms of caring, institutional as well as personal, require that attention be paid to purpose, power, and particularity. Identifying these three as the critical elements for assessing practices of care grows out of any understanding that to care is a relational practice. (Tronto, 2010, p. 161)

Examples of organizations using the mentioned elements emerged within our research particularly when they implement multidisciplinary cooperation. In our case, there were mainly examples from the palliative care environment, or community care. It seems that what is the central element supporting the caring character of organizations are the care relationships in the organization.

Conclusion The gender lens used for the secondary analysis of interviews with social workers and nurses in helping practice in the field of social services and healthcare focused on the structural level of gender, where we paid attention to the meaning that social workers and nurses representing feminized professions may offer as an explanation of the forms of reflection which they use in their work. We found that the nature of

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feminization in healthcare and social services is not the same. It turned out that while social work corresponds to both qualitative and quantitative definitions of feminization, healthcare as such combines two areas with nurses as a feminized profession nevertheless practising care in a hierarchical, performance-oriented healthcare environment. It is the nature of care, as perceived in both areas of helping practice, that determines what space is open in it for the cultivation of self-reflection and shared reflection. While in the healthcare sector, reflection focuses primarily on the performance of care (towards patients), or on the quality of relationships with colleagues, or in the form of self-reflection, it serves to process emotionally demanding situations. In the field of social work, there is more room for reflection focused on other aspects of care, on emotional experiences of more participants, on reflection of one’s own position in the network of relationships and power and on one’s own professional identity that of others. Under these conditions, critical reflection of alternative options, opinions, positions and explanations can take place. From the statements of informants in the research, it seems that it is not the nature of the work that primarily limits or encourages reflexivity, but rather the understanding of care, which is carried out in a specific environment of helping practice. Recognizing care as relational social practice automatically brings with it the need for reflection and emphasizes the necessity of preparation and cultivation of its use, as an inseparable part of care itself. We can summarize certain conditions which have to be met for reflexivity to be cultivated and used as a tool for development of good care on the basis statements of our informants: 1. Understanding care as relational. This means creating an organizational culture which appreciates and cultivates constructive relationships between management and employees, among employees themselves and also between workers and receivers of care. 2. Caring relationships based on trust to enable sharing. Caring organizations create a space for sharing timewise and materially and see trust as a precondition of democratic practice. This includes a culture of dialogue and transparency. 3. Democratic practice in relation to power. Power issues need to be addressed explicitly and negotiated as part of reflective processes, particularly in relation to gender issues and wider implications of justice at private and public level. 4. Reflexivity as a tool in care can be supported by specific education programmes both at undergraduate level and as an ongoing concern of management organizations.

References Ackerly, B. (2008). Feminist methodological reflection. In A.  Klitz & D.  Prakash (Eds.), Qualitative methods in international relations. A pluralist guide (pp.  28–42). https://doi. org/10.1057/9780230584129

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Anker, R. (1998). Gender and jobs: Sex segregation of occupations in the world. International Labour Office (Online). https://ilo.primo.exlibrisgroup.com/permalink/41ILO_INST/1jaulmn/ alma993223563402676. Accessed 4 Oct 2022. Anker, R., Melkas, H., & Korten, A. (2003). Gender-based occupational segregation in the 1990’s (Working paper). Focus Programme on Promoting the Declaration on Fundamental Principles and Rights at Work). International Labour Office (Online). https://www.ilo.org/wcmsp5/ groups/public/%2D%2D-­ed_norm/%2D%2D-­declaration/documents/publication/wcms_decl_ wp_18_en.pdf. Accessed 4 Oct 2022. Baier, A. (1994). Moral prejudices. Essays on ethics. Harvard University Press. Barnes, M. (2012). Care in everyday life. An ethic of care in practice. Policy Press. Barošová, M. (2006). Monitoring rodovej segregácie na trhu práce – analýza dopadov transformač ných zmien. Inštitút pre výskum práce a rodiny (Online). http://www.sspr.gov.sk/texty/File/vyskum/2006/Barosova/Monitoring_rod_segreg.pdf. Accessed 19 Nov 2022. Collins, S. (2015). The core of care ethics. Palgrave Macmillan. Connell, R. (2009). Gender in world perspective (2nd ed.). Policy Press. Cviková, J., & Filadelfiová, J. (2008). 2008. Rodový pohľad na školstvo. Aspekty kľúčových rizík. Aspekt. EIGE. (2022). Employment in human health activities by sex and age (from 2008 onwards) – 1000. Gender Statistics Database (Online). https://eige.europa.eu/gender-­statistics/dgs/indicator/ta_ wrklab_lab_employ_selected_healthcare__lfsa_egan22d_hlth. Accessed 7 Dec 2022. Gilligan, C. (1986). In a different voice. Psychological theory and women’s development. Harvard University Press. Harding, S. (1986). The science question in feminism. Cornell University Press. Havrdová, Z., Růžička, M., & Lorenz, W. (2022). Mezi praktickou a dialogickou reflexí u sociálních pracovníků a všeobecných sester. Sociální práce/sociálna práca, 22(5), 92–106. Jesenková, A. (2009). Etika Starostlivosti. Filozofická fakulta UPJŠ (Online). https://unibook.upjs. sk/img/cms/2016/filozoficka/etika-­starostlivosti-­jesenkova.pdf. Accessed 20 Oct 2022. Kiczková, Z. (1997). Vzájomný vzťah medzi verejnou a súkromnou sférou z pohľadu žien. Aspekt, 1(1). Kimmel, M. (2008). The gendered society (3rd ed.). Oxford University Press. Schreier, M. (2012). Qualitative content analysis in practice. Sage. Scott, J.  W. (2006). Rod: užitočná kategória historickej analýzy. In J.  Cviková, J.  Juráňová, & Ľ. Kobová (Eds.), Histórie žien: aspekty písania a čítania. Aspekt. Slater, D. (1998). Public/private. In C. Jenks (Ed.), Core sociological dichotomies. Sage. Smetáčková, I. (2005). Gender ve školství. In I. Smetáčková & K. Vlková (Eds.), Gender ve škole. Otevřená společnost. Tokárová, A. (2006). Feminizácia v školstve na Slovensku a jej sociálno-pedagogické súvislosti. In L. Macháček (Ed.), Gender-rodovosť v pedagogickom výskume a praxi (pp. 30–42). UCM. Tronto, J. C. (1993). Moral boundaries. A political argument for an ethic of care. Routledge. Tronto, J. C. (2010). Creating caring institutions: Politics, plurality, and purpose. Ethics and Social Welfare, 4(2). Tronto, J. C. (2013). Caring democracy. Markets, equality, and justice. New York University Press. Turlan, F. (2019). Social services workforce in Europe: State of play and challenges. Report. June 2019 (Online). http://socialemployers.eu/files/doc/Report%20-­%20Social%20Services%20 Workforce%20in%20Europe.pdf. Accessed 20 Nov 2022.

Chapter 6

Reflective Approaches to Professionalisation Through Legislation, Structures and Cultures: Example from Czech Social and Health Services Matěj Lejsal and Jiří Krejčí

The chapter introduces basic but specific quality standards that apply to professional social and health services in the Czech Republic with a view of how they take account of reflectivity. It will also offer references to quality systems used in Austria and the UK in that regard, because experiences with setting professional quality standards in these countries had influenced the development of social and health services in the Czech Republic after the revolution of 1989 when services were fundamentally re-organised. This will allow the identification of culture- and nation-­ specific factors that play always a role in the professionalisation of personal services. The comparison will focus on the role and position of social and health professionals within the system and the legislative regulation of their operation. Special attention will be given to “facilitators and barriers” regarding the use of reflectivity and supervision in practice. We will point out the connection between the continental legal system and Anglo-Saxon “common law” and the respective social policy context on the one hand and the formation of quality professional practice on the other hand in which reflectivity plays a part.

The Role of Reflexivity in Health and Social Care Reflectivity is not just a personal and professional concern that ensures accountable quality practice. As stated in previous chapters, it also requires particular organisational frameworks for systematic reflecting to take place, to be encouraged and to be used in a manner compatible with its professional and ethical purpose. This chapter M. Lejsal (*) · J. Krejčí Faculty of Humanities, Charles University, Prague, Czech Republic e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Lorenz, Z. Havrdová (eds.), Enhancing Professionality Through Reflectivity in Social and Health Care, https://doi.org/10.1007/978-3-031-28801-2_6

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describes examples of organisational developments in the Czech Republic that can be taken as instances where institutions created spaces and opportunities for professional reflecting. We first look at some of the principles and criteria that were used in the introduction of quality standards in social and health services in the Czech Republic. We then present the example of a recent reorganisation project within Czech general hospitals and analyse the effects which a national programme for the introduction of palliative care units into general hospitals had on organisational cultures in hospitals in terms of the psychological safety experienced by professional staff. Since the explicit recognition of the importance of reflecting in such demanding medical situations is one important element of palliative care approaches, conclusions can be drawn from these developments concerning institutional framework conditions under which reflectivity is more likely to develop. Social and health services were generally perceived in the Czech Republic as public services in their own right provided by the state. But after 1989, they were being provided and organised in a diversified way, on the basis of a legal entitlement or as expression of voluntary solidarity. Consequently, there are now mixed forms of service provision since some are entirely public, some are in the hands of private providers and some have a combined form of public/private financing. Their common feature is that in this kind of service sector, it is becoming apparent that it is not appropriate to apply commercial principles concerning relations between users and providers of these services since patients or clients cannot for themselves determine the value of the services they require and this sets limits to the commodification of public goods and services (Williams, 2002). In the majority of cases, the providers of these services are approached by people in a difficult life situation, for the solution of which they themselves lack the necessary material and technical resources, competences or knowledge. In their relationship with the service providers, they generally find themselves in a significantly weaker position in terms of their “bargaining power”. This means that this relationship in terms of the vulnerability of service users must be safeguarded by codes of ethics, international conventions and declarations and legal standards that govern the quality of the service (Banks, 2011). This also means that professionals operating these services are required to monitor the effects their “superiority” has for service users. Their legal responsibilities need to be related to the needs of service users in a reflexive way that goes beyond the mere application of regulations but has to have clear goals and achievable objectives. In this context of service provision, a number of instruments come into play in order to ensure that persons who urgently require assistance for their difficulty do not become dependent on representatives of service providers who are in a stronger position. A specific category of instruments in this regard that provide some security and protection are quality service standards (Lorenz et al., 2020). This is not achieved by the mere existence of such standards, but the effect depends on the way they are used and the degree to which they are treated as binding by all concerned. This is usually closely linked to the way they are developed, enforced and accepted.

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 tandardisation in Different Health and Social S Service Environments In the Czech Republic, as in many other European countries (European Commission, 2022), health and social services systems are differentiated in terms of legal regulation, public administration and financing systems. This separation also affects the system and application of quality standards of service. Due to their dynamic development in a relatively short period since 1989, it is possible to observe clear differences in the conception and development of quality standards for health and social services in the Czech Republic. Here, we will focus in more detail on standards that take the form of mandatory standards defined by legislation which gave significant impulses in the Czech Republic after 1989. This development was influenced by references to foreign experiences and examples particularly in the UK and in Austria and can be documented especially in the field of quality standards for residential social care services. The dynamic development of the field of long-term care and palliative care, which corresponds to the demographic development in the Czech Republic and in the whole of Europe, offers illustrative examples of the different meaning of the use of reflection in the practice of the helping professions in the field of health and social care. In order to gain a deeper understanding of the context and trends in development and to trace the different influences, it may be useful to understand the basic starting points for the development of “mandatory” standards in the Czech environment and to identify the more significant foreign factors that influenced the formation and format of quality standards. Among the foreign influences, the British influence prevailed at first through a Czech-British collaboration project, and in recent years, it is possible to trace a closer orientation of the Ministry of Labour and Social Affairs of the Czech Republic towards Austria in particular (Průša, 2016).

Approaches to Quality Standards The basic categorisation of approaches to quality standardisation offered by Kelly et al. (2022) in their review study is relevant for both the social and the health area. In terms of their function, standards can be defined in two main ways: 1. “Aspirational”, i.e. as a desirable level of service quality that all providers strive to achieve; this is the approach favoured by WHO. 2. “Minimal”, the minimum non-negotiable level, presenting regulatory or mandatory definitions of minimum quality standards. Standards of an aspirational nature aim at improving the quality of services and hence their continued development through an ongoing commitment by service organisations and their staff. Standards of a minimum (regulatory) nature represent the threshold of conditions above which it can be assumed that the service will be

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safe for the user. This approach frequently serves as a filter for allowing services entry into the respective sector. Another approach to the concept of quality standards distinguishes them according to their focus: (a) On meeting the prerequisites. (b) On process. (c) On the achievement of results. These dimensions of quality standards are of course interrelated. In order to achieve a result, effort and performance are required in relation to set goals. In social and health services, then, the focus of standardisation is on defining and monitoring the processes of service delivery or the experience and quality of life of individual service users which in turn requires a whole series of reflective processes and procedures within organisations that ensure that practice is being monitored internally as well as externally and standards are being adjusted to changing assessments of needs and priorities. This categorisation of approaches will serve to describe and characterise the main trends in the development of service quality standards and to point to cultural and structural difficulties in the application of standards in practice. We shall be examining developments in the Czech health and social services separately and then in comparison.

Standards in the Field of Health Services Fundamental changes in the system of health services in the Czech Republic took place in the early 1990s. During the years 1990–1995, key laws were approved that created the basic structure of the system of health services, their financing, and at the same time established a mandatory professional organisation, the Czech Medical Chamber.1 In principle, the Czech Medical Society of Jan Evangelista Purkyně,2 founded in 1924 as a voluntary membership association, continued to operate and define standards for medical practice. The regulation of the entire health sector was however in the hands of the Ministry of Health. The main changes affected the organisation of health services in terms of decentralisation and privatisation and correspondingly in the financing system through the introduction of mandatory health insurance. The basic approach to regulating standards in this sector was based on the control of financial resources through payment mechanisms tied to the  Act No. 220/1991 Coll. establishing the Czech Medical Chamber, the Czech Stomatological Chamber and the Czech Pharmaceutical Chamber; Act No. 551/1991 Coll. about the General Health Insurance Company of the Czech Republic; Government Resolution No. 247 of July 22, 1991, on the adoption of the National Health Recovery and Promotion Program; Act No. 86/1992 Coll. regulates caring for people’s health. 2  https://www.cls.cz/english-info 1

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definition of minimum standards of personnel. The provision of services specified qualifications and numbers of staff as well as material and technical security. This means that standards were defined as minimum prerequisites. The creation of other standards, especially standards focused on process, was delegated within the framework of this legislation to other entities – health service providers, mandatory and voluntary professional organisations, care payers and others. This orientation persists to this day in its essential outlines. These standards do not provide space for active reflection on the part of professionals engaged in the processes because it is based on a dichotomous assessment of “passed/failed”:3 To a certain extent, this principle poses a barrier to development and innovation, because rapidly changing conditions of need call for new formats and specialisations of services within the health services. This adjustment would require constant high-quality negotiations of issues arising by the relevant actors. An amendment to the Act on Health Services from 2011 (Act 372/2011) brought an essential element from the point of view of “standardisation” of services. It defined the standard of aspirational functions from the point of view of service quality with reference to the so-called “lege artis” principle often found in medical practice (Kraetschmer, 2014) and defined in Czech as “appropriate professional level”. This legal regulation defines the specific responsibility of a health professional who provides services according to standards generally regarded as being binding for professional practice. This opened the way for procedures in the field of health services becoming defined through dialogue between the key actors of the system. These are constituted by the main regulator and administrator of the system which is the Ministry of Health of the Czech Republic, but also by the funders of healthcare in the form of health insurance companies, the actual health service providers and professional associations. Similar principles that bring together key actors in defining standards can be found internationally, although the actors involved in individual countries may differ. For example, in the UK, it is the National Health Service that finances health services from public funds, whereas in Austria, they are health and social insurance companies. In practice, this produces non-binding quality standard levels, especially when expressed in the form of “recommended procedures”. The standards operating in this way are however in accordance with the “evidence-­ based” approach prevalent in medicine (but gradually also defining social service practice, Ziegler, 2020). Interventions and therapeutic procedures are thereby considered to be of accountable standards when their effectiveness has been demonstrated in empirical studies and are hence recognised by the professional community. Procedures are not legally binding; they provide support for the personal accountability of the healthcare professional when making decisions and as such carry weight. If complications occur during the provision of health services to a specific  Decree on minimum health personnel provision in care: Decree No. 99/2012 Coll.; Decree on requirements for minimum staffing of health services (https://www.zakonyprolidi.cz/cs/2012-99); MTZ health services: Decree No. 92/2012 Coll. Decree on requirements for minimum technical and physical equipment of medical facilities and home care contact workplaces (https://www. zakonyprolidi.cz/cs/2012-92) 3

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patient (damage to health, death, etc.), compliance with the “lege artis” principle is an important element in the assessment of culpability (Vojković, 2019). Although Czech legislation does not directly recognise the term lege artis, it represents a general reference to the duty of a health professional to follow the professionally correct procedure, i.e. the procedure according to the relevant professional duties, at the appropriate professional level and in accordance with the rules of the field. Undoubtedly, the quest for quality of health services in the Czech Republic was significantly influenced by the signing of international treaties, especially the European Council’s Convention on Human Rights and Biomedicine of 1999,4 the UN’s Convention on the Rights of Persons with Disabilities of 20065 and the United Nations Convention on the Rights of the Child of 1989.6 Although these conventions became part of the legal system of the Czech Republic and are thus binding for all service agencies seeking entry into the health services system, their practical application remains mainly at the level of non-binding recommendations, i.e. at the level of “aspirational standards”. In certain regard, this creates a wide space for a reflexive approach at the level of professional associations or specific organisations providing health services. However, whether this space will be actively and responsibly used is determined by a number of organisational factors, especially the policies and culture of the organisation, which are addressed in other chapters of this volume but also by the professional capacities to engage in these complex reflective processes which have become ever more demanding on staff.

Standards in the Field of Social Work and Social Services The dynamics of the development of quality standards in the Czech Republic in the field of social services and social work were different. Social services were fundamentally reconstituted in the early 1990s.7 There was a dynamic development of social service initiatives, and this development was fundamentally advanced by civil society organisations, almost “in spite of the system” (Lejsal & Havrdová, 2021) which brought innovative forms of practice inspired by foreign experiences. While until 1990 residential services in the Czech Republic were dominated by social care with a resistant culture of total institutions (Cháb et al., 2004), the newly emerging services were a response to an unsatisfactory situation and emphasised humanistic ideals and a person-centred approach and expressed the need for integrated, holistic  https://rm.coe.int/168007cf98  https://www.ohchr.org/en/instruments-mechanisms/instruments/convention-rights-personsdisabilities 6  https://www.unicef.org.uk/wp-content/uploads/2016/08/unicef-convention-rights-childuncrc.pdf 7  In 1990, the activity of the Society of Social Workers was resumed, in 1989 the first social work study programme was established, and subsequently in 1992 the first department of social work was established at the Faculty of Arts of Charles University, Prague (Matoušek & Havrdová, 2021). 4 5

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and personalised/individualised care. These principles and values represented a reflective ethos and thereby sought to influence the dialogue on the emerging law on social services and social work. This dialogue, which extended over a period of 15 years, resulted in the creation of the Act on Social Services in 2006, under which social work and social services are now jointly regulated in the Czech Republic. While the system of health services was regulated by a set of separate laws and delegated responsibilities to a larger number of entities, a comprehensive law was created for the social sector (Act 108/2006), which effectively established the profession of social worker and worker in social services, set up a financing system, defined the format of the provision of social services and explicitly empowered the Ministry of Labor to define quality standards for the provision of social services in implementing legislation in an appendix to Decree 505/2006 Coll. At the end of the 1990s, the Ministry of Labor and Social Affairs of the Czech Republic decided to carry out an extensive reform of social services, which was supported by established cooperation with the British Ministry for International Development, which provided the opportunity to use foreign experience and achieve compliance with the requirements for the regulation of social services and practices in EU countries. This cooperation, which took place in the years 2000–2003, was implemented in the form of a Czech-British project called “Support of the Ministry of Internal Affairs and Communications during the reform of social services”. The project facilitated the emergence of standards through a process of dialogue between a wide range of “bottom-up” actors. The project also implemented a series of so-­ called voluntary inspections that served to verify the applicability of the emerging standards. They worked with the principle of the active self-evaluation of organisations and took the form of a dialogue about the degree to which objectives were realised in practice. A set of 17 aspirational standards was created (MPSV, 2002), 15 of which were included in the legal text.8 They were built on basic quality principles and brought greater autonomy to service providers concerning their application. The standards were intended to stimulate the autonomous development of service quality, were of a universal nature and reflected key professional principles. In order for this approach to have effect, it assumed the active participation by professionals working in services in a process of communal reflecting. To a certain extent, this followed on from previous developments in the UK, especially in connection with the so-called Citizen’s Charter Initiative in the UK of 1991 (Schiavo, 2000), which was meant to “herald a revolution in public service” to make public service providers more responsive to the wishes of “customers” (https:// www.historyandpolicy.org/policy-­p apers/papers/the-­c itizens-­c harter-­t owards-­ consumer-­service-­in-­central-­government). Already during the preparation of the legislation, the basic aspirational nature of standards, together with the high degree of reflexivity required for their application, was the subject of many discussions.

 Two standards were dropped from the original 17  – one related to management and working conditions and the other related to the financing of the service. 8

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The risks were formulated by critics primarily with reference to their assessment and their enforceability in the context of the Czech law (Musil et al., 2003; Tomeš, 2014). In principle, the law established an “inspection” tool modelled on the UK. Its original form drew significant inspiration from the British environment (Care Standards Act, 2000). The aforementioned Citizen’s Charter in the UK, followed by the Care Standards Act, placed a strong emphasis on the “bottom-up” way of creating standards. They represent an aspirational concept aimed at enabling an organic development that takes into account reflection on the ongoing transformation of circumstances and context. The Charter declares a shift from “control of inputs” to “evaluation of results” and subsequent corrections at the level of inputs and processes. As part of the transfer of foreign experiences to the Czech context, the expected functions of the standards (aspirational and minimal) were mingled with other factors so that their focus became blurred, for instance, concerning the fulfilment of the necessary conditions, on the process and on the results. This culminated in inspections being given a practically unsolvable task, to connect the process of public control (primarily regulatory and sanctioning in nature) with the cultivation and development of services based on the professional, self-directed definition of good practice. The composition of the inspection teams of officials together with trained professionals corresponded to this potential dilemma. The roots of the problem over the implementation of quality standards can be found in the different ways these were conceptualised by the members of the inspection teams and the incompatibility of their goals, which were supposed to bring together public control over the fulfilment of minimum conditions with the development and supportive evaluation of results and processes (Jabůrková et al., 2007). All this was reinforced by the different legal systems between the country of inspiration (the UK where the principle of Common Law prevails) and the Czech Republic (which shares the Continental, constitutional approach to public law). While common law considers standards as aspirational goals that should be achieved and surpassed in an ongoing evolving process, public law perceives the standard as a necessary minimum corresponding to the rights and claims of users as laid down by constitutional principles (Schiavo, 2000). Gradually, first by practice and then by legal changes, the primary function of the standard as “minimum acceptable levels” was confirmed in the Czech case. However, it was not possible to solve the problem that persisted, namely, to clearly define the indicators of whether the given standard is satisfactorily fulfilled. These circumstances increase the likelihood of a formalistic approach to the application of quality standards in the Czech environment. The resulting explicit acceptance of the function of minimum standards increased the pressure to “objectify” the criteria and their identification.9 At the same time, the Czech regulator openly declared the need to seek inspiration in another cultural and legal environment, namely, in Austria (Průša, 2016). The Austrian approach to  Such efforts are mirrored, for example, in the methodological instructions for conducting inspections issued by the Ministry of Internal Affairs and Communications as a recommended procedure in 2008 and 2012. 9

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standards enshrined in law conforms to the public law perception of standards. Its function is to verify the minimum acceptable level of inputs. It focuses primarily on residential services and defines the requirements for the building and living conditions, the number and composition of staff in terms of professional qualifications and educational attainments. This approach places less emphasis on reflection, neither in the public administration context nor within the professions themselves. It implicitly assumes reflectivity to be a part of the skills repertoire of a helping professional in the delivery of services and strengthens the development of these competences through requirements in standards in the field of education (Leichsenring, 2009) but does not extend these abilities to reflective adjustments of quality standards. The consequences of such a trend of conceiving standards as minimal, aimed at meeting the necessary prerequisites and observing the described processes for social work and social services, can cause fear of making mistakes and lead to formalism at the neglect of innovation in a professional context that should maintain flexibility (Nordesjö, 2020).

Comparison From the description of the events of the last three decades, it is clear that the development in the social and health field in the Czech Republic has so far followed very different pathways. Fundamental structural changes in the health field, implemented at the beginning of the post-1989 transformation period, created solid reference points for the further development of quality standards in a way that appropriately combines their function and focus. The minimum standards are a tool for checking the fulfilment of the minimum acceptable level. Continuous development and innovation in quality are supported by a general reference to “lege artis” procedures, which promises to ensure the high probability of a desired outcome. This principle follows the example of natural sciences which tend to work with notions of linear causality which can be applied to test the results of interventions under predetermined conditions. At the same time, these principles have always concentrated a great deal of effort on diagnostics – the initial assessment of an individual’s condition or needs defined by “objective characteristics” of a largely quantitative nature (diagnostic hypothesis). Among other things, relevant in the context of the development of technology is the ambition of medical knowledge to define algorithms that will provide reliable guides for decision-making based on the variables identified. In the event that the desired outcome is not obtained, it is verified in health services whether the procedure was in accordance with the “lege artis” procedure. The principle of evidence-based medicine has now been widely established and gives the impression that treatments can be standardised according to scientific studies that prove their efficiency in a significant number of cases. A further development in medicine is that in the context of advances in technology, personalisation of medicine can be increasingly considered, in the sense of using individual

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characteristics as identified in diagnosis to select the appropriate personalised interventions (Stewart et al., 2013). This “personalisation” does not fundamentally change the “evidence-based” approach and confirms the a priori orientation towards criteria of rationality in setting quality standards and procedures so that it is the conformity with rational decisions that provides grounds for the legitimacy of an intervention (Park et al., 2018). In contrast, the development in the field of social work and social services shows significantly different dynamics. The active period of broad dialogue of the 1990s brought with it extensive innovations in practice that were not regulated by formal standards. They were largely based on mutual trust between professionals, their employers and service users and on the independent judgement of newly recruited professionals in the field as well as on inspiration from abroad. In the ensuing legal regulation of social services, it was not possible to capture and create space for such a concept of social work and social services. The aspirational function of standards of services and the performance of social work was displaced by the public law concept of a minimum standard. This concept reduces the space for reflexivity but at the same time encounters difficulties with the standardisation of processes and outputs in an environment whose task is to consistently respect the individuality of users, their environment and context. Moreover, in the field of social work in the Czech Republic, there is a lack of actors who would formulate standards of an aspirational nature and who would have sufficient weight and be widely accepted by the professional community and other actors, as is the case in the field of health, e.g. through professional associations. In social services, it has to be questioned whether such regulatory procedures can be applied because of the complex nature of social problems. Individualisation here can only be achieved through a process of direct interaction with the service user so that objectives become defined in an interactive and participative manner (Beresford, 2010). This principle places an extremely high demand on practically constant reflection in the work of the social worker, as it requires the ongoing evaluation whether the person requiring assistance has the necessary competence, opportunity or disposition to request a specific form of intervention and whether the requisite structural preconditions exist for this. At the same time, the work of the social worker necessitates the continuous reflection on appropriate personal and institutional boundaries. The absence of formalised “lege artis” procedures and the emphasis on autonomy (and individualisation/personalisation) in social services thus raise, on the one hand, high demands on the competence of the social worker and questions of moral responsibility, on the other hand; it provides for considerable freedom in the design of specific interventions. This difference characterises the potential for conflict in dealing with the same life situation of a person.

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Reflectivity and Approaches to Professional Responsibility The approach to the standardisation of the quality of health and social services is therefore influenced by significant differences in the definition of professional responsibilities of the professions concerned here, i.e. doctors, nurses and social workers. For medical professionals, the basic value is the preservation of human life. Health professionals are responsible for correctly assessing the individual’s situation and for choosing the “right” procedures with respect to the situation. When in doubt, the general principle of “saving a life” is available to them. This construction creates the conditions for a “defensive approach” which, from the individual’s point of view, appears attractive because it appears to satisfy the need for safety and security. However, studies confirm that “defensive medicine” increases the likelihood of conflict of interest between health professional and patient, because deviating from “established practices”, and following the expressed will of the patient, entails an increased personal risk for the health professional in the event of an undesirable development of the case (Ries & Jansen, 2021). This potential conflict is taken into account, among other things, in the part of the Convention on Biomedicine that emphasises patient autonomy. It defines a number of specific instruments (e.g. informed consent) that find expression in local legislation in order to promote greater patient autonomy. In view of the a priori unequal status (dependence on assistance, asymmetric information, etc.) and the potential conflicts arising from the combination of these principles, reflection can be thought of as a critically important part of the overall process of working to quality standards. Reflectivity assumes growing importance in decision-making by healthcare professionals acting in the interest of the client, respecting the interests of the healthcare facility and taking into consideration also the interests of a patient’s loved ones (Nelson, 2012).) Furthermore, competences and procedures based on reflectivity help to improve communication and have been recognised as essential for professional education (Kessl, 2009; Norris & Gimbr, 2013). From this perspective, standard-setting in health and social services becomes an issue of how to achieve accountable professional practice reflectively and by bringing together the attention to externally given quality criteria with that to the specific needs of service users. The following case study of the introduction of palliative care units into general hospitals in the Czech Republic illustrates the coming together of changes in organisational framework conditions with the creation of space for “institutionalised reflection” as promoted by health and social professionals themselves to point a way beyond the conflicts embedded in the contrasting institutional traditions.

 ilot Project for the Introduction of Palliative Care P in Hospitals in the Czech Republic Between 2017 and 2022, the Ministry of Health of the Czech Republic implemented the project “Supporting Palliative Care  – Increasing the Availability of Palliative Care Services in Acute and Post-Acute Care Hospitals”. The aim of the project was

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to obtain data on the benefits of palliative care in the general hospital setting. This involved supporting pilot palliative care consultant teams in the phase of the implementation of the programme and to standardise this version of palliative care. This resulted in the creation of methodologies for the introduction of palliative care into hospitals and the definition of quality indicators for standards of care. The indicator of success was that at least five of the original seven pilot teams would continue their activities after the end of the project (MoH, 2022). The existing palliative care teams provided care to more than 3000 patients and their families at an early stage of serious illnesses, with about half of the patients receiving care at the very end of life. The main focus of the consultant palliative teams was to identify the values and needs expressed by patients and their families and, following on from these findings, to formulate the goals of care and the appropriateness and intensity of therapy. The guiding palliative care principles were respect for the patients’ values and their dignity. This meant coordinating and finding a balance between the contributions of the different medical disciplines involved, providing follow-up care outside the hospital, supporting patients and their relatives in emotionally difficult situations and making recommendations for a coordinated and effective symptom management approach. At the time the project started, there were only three consultant palliative care teams and this widened to seven teams. The intention was to encourage the establishment of additional teams and to help the existing ones to anchor themselves firmly in the system of general hospital care. At the end of the project, there were already more than 25 consultant palliative teams established in the Czech Republic in hospital settings, including all the pilot teams. The original target number was therefore surpassed by a factor of 5 (MoH, 2022). The Institute of Health Information and Statistics of the Czech Republic conducted then an analysis of the effects of the implementation of the programme by comparing the palliative intervention group with a control group probabilistically balanced in baseline characteristics (sex, age, diagnosis, year of hospitalisation, time to expected death). Statistically significant differences were found in terms of several indicators. In the group of patients who were in contact with the palliative care team in hospitals, there was a decrease in the proportion of patients needing rehospitalisation, a decrease in the total number of days of hospitalisation and, conversely, an increase in the use of home care services (UZIS, 2022) Using the VOC10 questionnaire instrument (Pinto et al., 2019), it was also shown that patient satisfaction increased by 65% (MoH, 2022). The project evaluation report included information that the pilot project had succeeded in defining and validating a new version of health service: the hospital consultant palliative care team was distinguished by its terms of staffing, the nature and scope of the activities of the different professions that make up the team and their  VOC Views on care – patients or their family members answer questions such as “How would you rate your overall quality of life in the 3  days before you started seeing the palliative care team?” or “Thinking about how things are going for you today, how do you rate your overall quality of life today?”. 10

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way of formulating framework standards. They were able to verify that this form of specialised palliative care significantly improves the quality of life of patients and their relatives, increases their satisfaction with the care provided and contributes to a personalised approach to care planning. The project also developed a methodological guide for how to implement this health service in a hospital setting. The project was widely considered a great success by the professional community, and in the following text we will illustrate the impact of reflexivity on the process of implementation of palliative care into hospitals.

Reflection as an Element of Project Management Regular meetings of all consultant palliative care teams were implemented as part of the pilot project in such a way that allocating space for reflection and sharing of practice experiences between teams became part of the meeting agenda. For example, the initial three-day palliative team meeting in the project included 2 days dedicated to the sharing of experiences. During those 2 days, the emphasis was on giving the teams the opportunity of comparing and evaluating jointly their experiences of implementing this new service into a hospital setting in terms of team dynamics and personal reactions. In this context, it was important to refrain from exercising pressure on the teams to achieve pre-defined targets but to consider progress and obstacles from a variety of perspectives. This resulted in the setting up of a consultation system that could give a flexible organisational structure to this function of sharing ideas. The process of reflection in terms of evaluating experiences from different perspectives was also supported by the multi-professional composition of the team that managed the project at the level of the Ministry of Health and of the mentoring team of the project. This was composed of representatives of relevant medical specialists (palliative care physician, oncologist, paediatrician), as well as a psychologist, a nurse, a supervisor, a social worker, a university lecturer with specialisation in management subjects and a researcher (MoH, 2022). The regular meetings of the implementation and mentoring teams created a dedicated space where these multi-­ professional implementation and mentoring teams could jointly reflect on the progress of the project and respond to current challenges with proposals for action that had the backing of all representatives.

Reflection in Palliative Care Teams At the beginning of the project, it was noted that existing palliative teams already had a system in place for sharing information regularly. Each palliative team had set meetings as part of their care concept, and some teams held regular case seminars designed for sharing good practice and reflecting with collaborating colleagues from other departments in the hospital. Most had also started to use supervision

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formally (MoH, 2019). This practice became formalised as part of the guidance material produced by the project. For example, the folder “Methodology for the Implementation of a Palliative Care Programme in an Inpatient Health Care Facility” (Sláma et al., 2019), published at the beginning of the project, devoted a chapter to team dynamics and described this system of meetings, supervision and feedback-­ giving as an important part of palliative practice. The need for a space for open regular communication in meetings and supervision was also regulated as part of the standards for specialised palliative care in the hospital, which were developed as part of the project (MoH, 2022).

Quality of Space Team reflection of the kind described requires dedicated “space” in the sense of place and time meaning that the team needs to meet regularly, and these meetings should have adequate time allocated. At the same time, we propose that giving space alone is not enough for team reflection to take place, but that space requires to have a certain quality. This means, during meetings, which can take the form of supervision, it is important to monitor whether team members are open with each other or whether they develop a tendency of blaming themselves for mistakes or of creating opportunities for learning from them. Above all, quality criteria include that team members are accepted for having different opinions. This “quality of space” factor can be measured, for example, by the degree of team psychological safety which has been shown to be an important factor in team cohesion and effectiveness (Applebaum et al., 2020). Krejčí and Šafr (2022) in a Czech study on psychological safety and team reflexivity in medical contexts show the effect of psychological safety on reflexivity and the ability of teams becoming learning organisations. This study used Edmondson’s (1999) concept of psychological safety as a team quality which she defined as “team members’ shared belief that the team is safe to take interpersonal risks” (ibid, p. 350). Edmondson prepared a seven-item questionnaire to measure team psychological safety. The Edmondson scale has been subjected to extensive validation testing, which showed that the measure has strong predictive and construct validity and internal consistency (Newman et al., 2017). The quality of the space (as measured by psychological safety) can also affect the quality of team performance. Krejčí and Šafr (2022) confirmed this in a study conducted in a large Czech hospital setting that found that there was a positive relationship between psychological safety and engagement shown by staff. The authors suggest that a team that experiences higher levels of psychological safety is better able to adapt to arising challenges, leading to higher quality of work.

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 he Impact of the Multi-professional Nature of the Palliative T Care Team on Reflection During the course of the project, the pilot palliative teams were given the opportunity to reflect on their own set of organisational principles and values and to what extent they were different from those prevalent in other hospital teams since this could prove important in relation to the integration of palliative care teams. Cultural barriers have been identified as an important factor in the process of introducing palliative care into hospitals (e.g. Gibbs et al., 2015; Gardiner et al., 2011; Loučka & Kovaříková, 2018). Some of these factors can be found in the degree of hierarchical organisation. The prevailing hospital culture in the Czech Republic, but also in other countries (Bate, 2000), tends to be built on a clear subordination of para-­ medical to medical professions. Organisational approaches to palliative care propose flattening such hierarchical structures in the interest of patient-oriented care so that team members can relate to each other at eye level in recognition of the contribution that professionals from different specialties make to the overall team approach. Social workers, psychologists, pastors, physiotherapists and medical doctors from a variety of specialisations make up palliative teams and are not just being called upon for one-off consultations, as is the custom in the general Czech hospital setting (MoH, 2022). All these professions bring their own norms of behaviour and values and other cultural attributes that are either associated with their profession or with their previous work experience, to their palliative care teams. Although this is less likely for doctors and nurses, such experience may well have been collected outside the hospital setting, which accounts for the considerable diversity of professional experiences in palliative care teams. These can be treated as cultural differences and become a positive and creative factor when they are recognised and applied in an intercultural perspective of practice (Bennett, 2009).

 pace for Reflexivity and Palliative Care Standards: S International Comparison The international comparison which guided the monitoring project of Czech palliative care developments mentioned above collected standards of palliative care from continents and countries around the world, from Africa, Australia, Austria, Japan, Lebanon, Norway, Scotland, Slovakia and Wales, dealing with specialist palliative care that is being provided in hospitals (Loučka et al., 2019). These standards were analysed and compared to the standards defined in the Czech Republic at the beginning of the ministry project. When subjected to a further content analysis for the purposes of this chapter as to their references to the three concepts reflection, supervision and consultation, the following picture emerged concerning the prevalence of those terms as summarised in Fig. 6.1.

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Supervision

Reflection

Australia Africa

Czech Republic Norway

Lebanon Japan

Scotland

Slovakia Austria

Team meetings

Fig. 6.1  Content of the terms reflection, consultation and supervision in the standards of palliative care in hospitals

Of the ten standards, only the ones from Lebanon  (NCPCP, 2013) and Slovakia (MZSR, 2006) did not contain any references to the concepts. However, the Lebanese standards provide for a different kind of space for reflection, namely, in an institutional form of creating bioethics committees at centres of excellence to help resolve disagreements and support staff and families in making important decisions. To give some examples of the mode in which reflecting appears in the other standards: the authors of the African standards (APCA, 2011) prescribe that all staff at the operational level have regular supervision and support, and further that care providers are supported in self-awareness techniques and encouraged to become aware, through reflection, of the impact of working with death, dying and loss. The Australian standards (PCA, 2018) stress access to professional clinical supervision and formal and informal debriefing to meet the diverse needs of staff. The Welsh standards (NHS Wales, 2005) state that specialist palliative teams should have a set system of communication between team members and that the lead clinician is responsible for holding regular team meetings along those lines. In Scotland (Clinical Standards Board for Scotland, 2002), it is envisaged that regular multidisciplinary meetings take place involving all team members for open exchanges on events and impressions. Japanese standards (Sakashita et al., 2018) provide not only for regular team meetings but also for focused case conferences. Similarly, Norwegian standards  (Norwegian association for palliative medicine, 2004) stipulate that joint planning meetings are useful for the palliative team while also declaring that staff should regularly be offered guidance and supervision.

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These criteria entered also the standards for the provision of specialist palliative care in the form of a palliative care consultant team in acute and post-acute care hospitals in the Czech Republic (MZCR, 2022). They specify that palliative care teams should have a set system of multi-professional team collaboration consisting of daily joint debriefing by team members of the current condition of patients or weekly multidisciplinary team conferences. These are considered essential institutional arrangements for the purpose of creating a space for reflection. It is also regulated that members of palliative care teams must be allowed to attend a minimum of 1 hour of individual supervision per month and 2 hours of supervision for the whole team. In the Czech healthcare system, the emphasis on regular meetings and supervision is thereby being specifically pioneered in palliative medicine and is expected to have a positive impact on the psychological safety of staff. First indications (Krejčí & Šafr, 2022) are that members of palliative care teams show higher levels of psychological safety than other hospital staff and this is an indicator of the degree of openness to reflection achieved through these arrangements. From this, the authors concluded that reflection has become a standard part of palliative care in hospitals through the formalisation of regular supervision and team meetings.

 eneral Quality Indicators and the Attention to “Space G for Reflection” The complexity of palliative interventions requires corresponding quality indicators. From an international perspective, the National Consensus Project (NCP) for Quality Palliative Care (Ferrell et al., 2018) can be taken as typical, and it provides indicators for eight domains of palliative care: structure and process of care; care for physical symptoms; psychological and psychiatric aspects of care; social dimensions of care; spiritual, religious and existential dimensions of care; cultural aspect of care; care at the end of life; and ethical and legal aspects of care. It is noteworthy that while these standards concern the quality of care given to patients, there is no quality domain that concerns the well-being of the team itself, for instance, by defining the need for established meetings or supervision or other spaces for reflection. Similarly, Twaddle et al. (2007) who established 11 indicators to measure palliative care in hospitals in the USA did not include team-based qualitative indicators. An alternative set of indicators, PEACE (Hanson et  al., 2012), based on the NCP domains and expanded through the Measuring What Matters initiative (Dy et al., 2015), also left out references to the quality of team interactions. It was not until the European EUROPALL project (Woitha et al., 2012), which involved palliative care institutions from seven European countries and included a set of 110 process and structure indicators, that the domains of staff support and organisation of care were included. The specifically relevant indicators in this respect are team support, all team members to have an annual appraisal, all team members who professionally deal with loss to have access to a programme of care for the carers and satisfaction with working in the team to be assessed.

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Conclusion While there is considerable emphasis in palliative care on the emotional implications of the work, there still seems to be a tendency of quality standards to focus on the care given to patients and not enough on those addressing the needs of staff. The interdisciplinary working of palliative teams already institutionalises reflective processes in terms of reaching decisions deliberatively through giving voice to a variety of perspectives so that the interests of the patient can be clearly addressed. However, this orientation requires parallel attention to be given to reflective processes concerning the needs of staff working in this emotionally stressful environment. We can conclude from these observations that such reflective processes cannot be left to “private” initiatives by staff members but need to be given institutional “spaces” so that this support is available not just in times of crises but as a constitutive organisational element of all human care services. The interdisciplinary nature of palliative care crosses the boundaries of both approaches to quality standards, the legislative “top-down” and the aspirational “bottom-up” one. The focus on quality of life shapes the approach to patients and their loved ones. It fundamentally influences the work culture of caring professionals. Implementing a concept of service quality standards at the process (performance) level is not enough. The described story of the integration of palliative care into the hospital setting shows the need to extend the concept of standards to the achievement of the desired outcome (achievement), i.e. the highest possible quality of life for the patient, his/her loved ones and the caring professionals at the same time. Although palliative carers will follow all the standards, there will always remain an element of uncertainty associated with having only circumstantial evidence of the quality of the end of life. Honest reflection supported by supervision is both a tool for individuals and whole teams to deal with lived uncertainty and a way of avoiding mechanical or formalistic/formalistic practice. In this, the experience described can be a valuable inspiration for the long-term care field and other services at the health and social care frontier.

References Appelbaum, N.  P., Lockeman, K.  S., Orr, S., Huff, T.  A., Hogan, C.  J., Queen, B.  A., & Dow, A. W. (2020). Perceived influence of power distance, psychological safety, and team cohesion on team effectiveness. Journal of Interprofessional Care, 34(1), 20–26. https://doi.org/10.108 0/13561820.2019.1633290 Banks, S. (2011). Ethics in an age of austerity: Social work and the evolving new public management. Journal of Social Intervention: Theory and Practice, 20(2), 5–23. https://doi. org/10.18352/jsi.260 Bate, P. (2000). Changing the culture of a hospital: From hierarchy to networked community. Public Administration, 78(3), 485–512. https://doi.org/10.1111/1467-­9299.00215 Bennett, J.  M. (2009). Cultivating intercultural competence: A process perspective. In D. K. Deardorff (Ed.), The Sage handbook of intercultural competence (pp. 121–140). Sage.

6  Reflective Approaches to Professionalisation Through Legislation, Structures…

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Beresford, P. (2010). Public partnerships, governance and user involvement: A service user perspective. International Journal of Consumer Studies, 34(5), 495–502. https://doi. org/10.1111/j.1470-­6431.2010.00905.x Care Standards Act 2000,The United Kingdom of Great Britain and Northern Ireland; Available at: https://www.legislation.gov.uk/ukpga/2000/14/contents (Accessed: 23.5.2023) Cháb, M., Chábová, R., & Johnová, M. (2004). Svět bez ústavů [The institution-free world]. QUIP-­ Společnost pro změnu [QUIP – Association for Change]. Dy, S.  M., Kiley, K.  B., Ast, K., Lupu, D., Norton, S.  A., McMillan, S.  C., Herr, K., Rotella, J. D., & Casarett, D. J. (2015). Measuring what matters: Top-ranked quality indicators for hospice and palliative care from the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association. Journal of Pain and Symptom Management, 49(4), 773–781. https://doi.org/10.1016/j.jpainsymman.2015.01.012 Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350–383. https://doi.org/10.2307/2666999 European Commission. (2022). The MISSOC database. https://www.missoc.org/missoc-­database/ organisation/. Accessed 16.12.2022. Ferrell, B.  R., Twaddle, M.  L., Melnick, A., & Meier, D.  E. (2018). National consensus project clinical practice guidelines for quality palliative care guidelines, 4th edition. Journal of Palliative Medicine, 21(12), 1684–1689. https://doi.org/10.1089/jpm.2018.0431 Gardiner, C., Cobb, M., Gott, M., & Ingleton, C. (2011). Barriers to providing palliative care for older people in acute hospitals. Age and Ageing, 40(2), 233–238. https://doi.org/10.1093/ ageing/afq172 Gibbs, K. D., Jr., Mahon, M. M., Truss, M., & Eyring, K. (2015). An assessment of hospital-based palliative care in Maryland: Infrastructure, barriers, and opportunities. Journal of Pain Symptom Management, 49(6), 1102–1108. https://doi.org/10.1016/j.jpainsymman.2014.12.004 Hanson, L.  C., Rowe, C., Wessell, K., Caprio, A., Winzelberg, G., Beyea, A., & Bernard, S. A. (2012). Measuring palliative care quality for seriously ill hospitalized patients. Journal of Palliative Medicine, 15(7), 798–804. https://doi.org/10.1089/jpm.2011.0471 Jabůrková, M., Dohnalová, R., Jirků, L., Kudějová, T., Mátl, O., & Novák, P.. (2007). Od paragrafů k lidem: analýza situace v oblasti sociálních služeb po přijetí nového zákona o sociálních službách [From paragraphs to people: An analysis of the situation in the field of social services after the adoption of the new law on social services]. SKOK. Available on-line: http://poradna. nrzp.cz/docs/od-­paragrafu-­k-­lidem.pdf Kelly, Y., O’Rourke, N., Flynn, R., Hegarty, J., & O’Connor, L. (2022). Definitions of health and social care standards used internationally: A narrative review. The International Journal of Health Planning and Management. https://doi.org/10.1002/hpm.3573 Kessl, F. (2009). Critical reflexivity, social work, and the emerging European post-welfare states. European Journal of Social Work, 12, 305–317. https://doi.org/10.1080/13691450902930746 Kraetschmer, K. (2014). ‘Lege Artis’  – An outdated concept in modern medicine? European Journal of Health Law, 21(2), 119–122. Krejčí, J., & Šafr, J. (2022). Psychické bezpečí a reflexivita v týmu. In Havrdová et  al.(Eds.), Důstojnost, reflexe a participace v onfer zdravotních a sociálních služeb (pp. 58–71). FHS UK. Leichsenring, K. (2009). Developing and ensuring quality in LTC in Austria. European Centre for Social Welfare Policy and Research (INTERLINKS National Report), Vienna, available at http://interlinks.Euro.Centre.Org Lejsal, M., & Havrdová, Z. (2021). Nurturing opportunities to advance the European values in specific contexts  – Examples from The Czech Republic. In W.  Lorenz, Z.  Havrdová, & O. Matoušek (Eds.), European social work after 1989. East-West exchanges between universal principles and cultural sensitivity (pp. 33–49). Springer. Lorenz, W. A., Fargion, S., Nothdurfter, U., Nagy, A., Berger, E., Rainer, S., & Frei, S. (2020). Negotiating quality for social work: A participatory research project in South Tyrol. Research on Social Work Practice, 30(5), 505–514. https://doi.org/10.1177/1049731519897309

126

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Loučka, M., & Kovaříková, L. (2018). Rozvoj paliativní péče v nemocnicích. Centrum paliativní péče. Loučka M., Poláková K., & Vlčková K. (2019). Závěrečná zpráva ke klíčové aktivitě (Final report on key activity) č.1. MZČR: Praha. Matoušek, O., & Havrdová, Z. (2021). Beginning anew: Social work education in The Czech Republic after the velvet revolution. In W.  Lorenz, Z.  Havrdová, & O.  Matoušek (Eds.), European social work after 1989. East-West exchanges between universal principles and cultural sensitivity (pp. 17–31). Springer. Ministry of Health of the Czech Republic (MoH). (2019). Workshop for pilot teams. Ministry of Health of the Czech Republic. (MoH). (2022). Standardy poskytování specializované paliativní péče ve formě konziliárního týmu paliativní péče v nemocnicích akutní a následné péče v ČR. Věstník MZČR 2022/01. Ministry of Labour and Social Affairs CZ. (MoH). (2002). Standards for quality in social services. https://www.mpsv.cz/documents/625317/625935/standards.pdf/0be6636b-­c112-­6898-­51f4-­ e90618d19ba6. Accessed 28.12.2023. Musil, L., Hubíková, O., & Kubalčíková, K. (2003). Standardy kvality a kultura sociálních služeb: jaká napětí mezi politikou sociálních služeb a kulturou práce s klientem v pečovatelské službě mohou vznikat z hlediska kvality sociálních služeb?:(závěrečná zpráva z případové studie) [Quality standards and the culture of social services: what tensions between the policy of social services and the culture of working with the client in the care service can arise from the point of view of the quality of social services? (final case study report) ] Výzkumný ústav práce a sociálních věcí. [Research Institute of Labor and Social Affairs]. MZČR. (2022). Web projektu Podpora paliativní péče – zvýšení dostupnosti zdravotních služeb v oblasti paliativní péče v nemocnicích akutní a následné péče [Cit. 10. 11. 2022]. Dostupné z http://www.paliativa.cz. Nelson, S. (2012). The lost path to emancipatory practice: Towards a history of reflective practice in nursing. Nursing Philosophy, 13(3), 202–213. https://doi.org/10.1111/j.1466-­769X.2011.00535.x Newman, A., Donohue, R., & Eva, N. (2017). Psychological safety: A systematic review of the literature. Human Resource Management Review, 27(3), 521–535. https://doi.org/10.1016/j. hrmr.2017.01.001 Nordesjö, K. (2020). Framing standardization: Implementing a quality management system in relation to social work professionalism in the social services. Human Service Organizations: Management, Leadership & Governance, 44(3), 229–243. Norris, M., & Gimber, P. (2013). Developing nursing students’ metacognitive skills using social technology. Teaching and Learning in Nursing, 8(1), 17–21. https://doi.org/10.1016/j. teln.2012.09.003 Park, M., Giap, T.-T.-T., Lee, M., Jeong, H., Jeong, M., & Go, Y. (2018). Patient- and family-­ centered care interventions for improving the quality of health care: A review of systematic reviews. International Journal of Nursing Studies, 87, 69–83. https://doi.org/10.1016/j. ijnurstu.2018.07.006 Pinto, C., Firth, A. M., Groeneveld, E. I., Guo, P., Sykes, N., & Murtagh, F. E. (2019). Patients’ views on care and their association with outcomes in palliative care. Palliative Medicine, 33(4), 467–469. Průša, L. (2016). Aktuální trendy v rozvoji sociálních služeb v zemích EU av ČR ve světle očekávaných změn ve onferenc populace [Current trends in the development of social services in EU countries and the Czech Republic in the light of expected changes in the population structure] FÓRUM sociální politiky [FORUM of social policy] 2016 (6). Available online: https://www.vupsv.cz/wp-­content/uploads/2021/04/Prusa-­Ladislav-­Aktualni-­trendy-­v-­rozvoji-­ soc.-­sluzeb-­v-­zemich-­EU-­a-­v-­CR-­ve-­svetle-­ocekav.-­zmen-­ve-­strukture-­populace.-­FSP_c.6-­2016.pdf Ries, N.  M., & Jansen, J. (2021). Physicians’ views and experiences of defensive medicine: An international review of empirical research. Health Policy, 125(5), 634–642. https://doi. org/10.1016/j.healthpol.2021.02.005

6  Reflective Approaches to Professionalisation Through Legislation, Structures…

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Schiavo, L. L. (2000). Quality standards in the public sector: Differences between Italy and the UK in the citizen’s charter initiative. Public Administration, 78(3), 679–698. Sláma, O., Krejčí, J., & Ambrožová, J. (2019). Metodika implementace programu paliativní péče v lůžkovém zdravotnickém zařízení. MZČR. Stewart, M., Brown, J.  B., Weston, W., McWhinney, I.  R., McWilliam, C.  L., & Freeman, T. (2013). Patient-centered medicine: Transforming the clinical method. CRC Press. ISBN 978–1–909368-03-3. Tomeš, I. (2014). Sociální služby dnes a zítra [social services today and tomorrow]. Fórum sociální práce [Social Work Forum], 2014(1), 67–70. Twaddle, M.  L., Maxwell, T.  L., Cassel, J.  B., Liao, S., Coyne, P.  J., Usher, B.  M., Amin, A., & Cuny, J. (2007). Palliative care benchmarks from academic medical centers. Journal of Palliative Medicine, 10(1), 86–98. https://doi.org/10.1089/jpm.2006.0048. UZIS. 2022. Vojković, H. (2019). Differentiating medical malpractice from medical complications. Medicine, Law & Society, 12(1), 39–64. Williams, C.  C. (2002). A critical evaluation of the commodification thesis. The Sociological Review, 50(4), 525–542. https://doi.org/10.1111/1467-­954X.00397 Woitha, K., Van Beek, K., Ahmed, N., Hasselaar, J., Mollard, J. M., Colombet, I., Radbruch, L., Vissers, K., & Engels, Y. (2012). Development of a set of process and structure indicators for palliative care: The Europall project. BMC Health Services Research, 12, 381. https://doi.org/1 0.1186/1472-­6963-­12-­381 Ziegler, H. (2020). Social work and the challenge of evidence-based practice. In S. Kessl, F. Lorenz, W. Otto, & H.-U. White (Eds.), European social work - a compendium (pp. 229–272). Barbara Budrich.

List of National Quality Standard Sites APCA. (2011). Standards for providing quality palliative care across Africa. https://www.africanpalliativecare.org/images/stories/pdf/APCA_Standards.pdf Clinical Standards Board for Scotland. (2002). Clinical standards for specialist palliative care. Velká Británie. Japan: Sakashita, A., Kizawa, Y., Kato, M., Akizuki, N., Nakazawa, Y., Kaizu, M., Yano, K., Sato, T., & Tokoro, A. (2018). Development of a Standard for Hospital-Based Palliative Care Consultation Teams in Japan Using a Modified Delphi Method. Journal of Pain and Symptom Management, 56(5), 746–751.e5. https://doi.org/10.1016/j.jpainsymman.2018.08.013. Ministerstvo zdravotníctva Slovenskej republiky. (2006). Koncepcia zdravotnej starostlivosti v odbore paliatívna medicína vrátane hospicovej starostlivosti. Slovensko. Ministerstvo zdravotnictví České republiky. (2022). Standardy poskytování specializované paliativní péče ve formě konziliárního týmu paliativní péče v nemocnicích akutní a následné péče v ČR. Věstník MZČR 2022/1. National Committee for Pain Control and Palliative Care (NCPCPC). (2013). Practice standards for palliative care in Lebanon. Lebanon. National Health Service Wales. (2005). National Standards for specialist palliative care cancer services 2005. Velká Británie. Norwegian association for palliative medicine. (2004). Standard for palliative care. Norsko. Palliative Care Australia (PCA). (2018). National Palliative Care Standards. Austrálie.

Chapter 7

Researching Reflectivity by Scales Iva Šolcová, Filip Děchtěrenko, and Zuzana Havrdová

Introduction Since the 1990s, reflexive approaches to learning and self-reflection skills have been considered as central characteristics of professionalism (Schön, 1983), as keys to working with uncertainty and important determinants of an ability to make autonomous professional decisions and of ethical practice among social workers and nurses (D’Cruz et  al., 2007; Fook, 2002 etc.). However, critics (e.g. Ixer, 1999; Finlay, 2008; Coward, 2011) have argued that the emphasis on reflexivity is largely rhetorical, speculative and insufficiently grounded in empirical evidence. Against the background of this criticism, we have introduced the research on self-reflection in social workers and nurses as an attempt to specify empirically reflexive skills requirements and abilities and their meanings in the contexts of social and nursing care practice. The meaning of the term self-reflection and how the research team understands it in this book has been clarified in the first chapter. This chapter is the first of three methodological chapters. It introduces the first results from two phases of the quantitative part of the research. Its aim was the validation of relevant self-reflection measures in the Czech language and selection and eventually the (re)construction of scales. In the second phase, presented in Chap. 8, those scales were used to map differences among social workers and nurses and to explore reflexivity in the workplace. I. Šolcová (*) · F. Děchtěrenko Faculty of Humanities, Charles University, Prague, Czech Republic Institute of Psychology, Czech Academy of Sciences, Brno, Czech Republic e-mail: [email protected] Z. Havrdová Faculty of Humanities, Charles University, Prague, Czech Republic © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Lorenz, Z. Havrdová (eds.), Enhancing Professionality Through Reflectivity in Social and Health Care, https://doi.org/10.1007/978-3-031-28801-2_7

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To introduce the research process, we would like first to show the breadth of interest in the self-reflection topic and also the variety of facets self-reflection displays (e.g. state vs. trait; critical, empathetic, situative), and the richness of characteristics by which it can be described. Therefore, we will describe here several tools measuring self-reflection from which we selected two, SRIS and PHLMS, and validated them in the Czech Republic. In the last part of the chapter, we will present also other measures for individual, team and organisational factors which have been used in the next research phase.

Self-Reflection Measures In the following part, we introduce selected methods designed to measure reflection1. They were created on differing platforms, and they share a common effort to capture self-reflection and contribute to personal and/or professional growth. Some of them were developed to encourage self-reflection in (medical) students. The measures are listed according to the date of publication. The Rumination-Reflection Questionnaire (RRQ) was created 1999 by Trapnell and Campbell to measure ‘the extent to which participants are disposed to engage in repetitive thinking about their past (rumination) and to reflect on themselves out of epistemic curiosity, that is, out of a philosophical love of self-exploration (reflection)’ (Harrington & Loffredo, 2010, p. 45). According to the authors, rumination represents negative thinking about the past and especially chronic self-attention accompanying these thoughts. Reflection represents pleasurable self-examining, an intrinsic interest in self (Trapnell & Campbell, 1999, p. 292). An example of the rumination subscale item is ‘I often find myself re-evaluating something I’ve done’, and an example of the reflection subscale is ‘I love to meditate on the nature and meaning of things’. The RRQ consists of a 24-item five-point Likert-type scale (where 1 means ‘strongly agree’ and 5 means ‘strongly disagree’), where 12 items measure rumination and 12 items measure reflection. The final version of the inventory was tested with a sample of 1137 persons. Factor analysis confirmed the two-factor structure of the questionnaire, correlation between factors being r = 0.22. The authors report good reliability of the tool (Cronbach’s α values were 0.90 and 0.91, respectively). The authors also report a high, positive association between rumination and neuroticism (Five-Factor Inventory) and a high, positive association between reflection and openness to experience. The authors of the Reflective Thinking Scale (RTS) ‘experienced a need for methods to determine whether students were being prompted to reflect upon their practice in the courses under study’ (Kember et al., 2000, p. 382). The RTS is a 16-item five-point Likert-type scale (where A means ‘definitely agree’ and E ‘definitely

 A recent review of the self-reflection tools is also provided by Ooi et al. (2021).

1

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disagree’). The questionnaire comprises four subscales measuring four constructs: habitual action, understanding, reflection and critical reflection. Examples of items are as follows: ‘When I am working on some activities, I can do them without thinking about what I am doing’ (habitual action); ‘In this course, you have to continually think about the material you are being taught’ (understanding); ‘I like to think over what I have been doing and consider alternative ways of doing it’ (reflection); and ‘This course has challenged some of my firmly held ideas’ (critical reflection). The instrument was tested with a sample of 303 students from eight classes of a health science faculty. Confirmatory factor analysis showed a good fit to the proposed four-factor structure. The authors declare the reliability of the scale as acceptable (Cronbach’s α values range between 0.62 and 0.75 for four-item subscales). The questionnaire is public for scientific purposes. The Groningen Reflection Ability Scale (GRAS) was developed to encourage reflection by medical students (Aukes et al., 2007). According to authors, ‘the best medical practice today is seen as reflective practice’ (Aukes, 2008, p. 1). The instrument was used by its authors to measure the effect of experiential learning programme. The GRAS was created as a 23-item instrument in Dutch and uses a five-point Likert scale ranging from totally disagree (1) to totally agree (5). The questionnaire was developed as a one-dimensional scale, yielding one total score. The principal component analysis of the original instrument showed three factors. According to the authors, they are not to be interpreted as three subscales, rather should be seen as three aspects of the reflection dimension. These three aspects are self-reflection (‘I want to know why I do what I do’), empathetic reflection (‘I am aware of the possible emotional impact of information on others’) and reflective communication (‘I am open to discussion about my opinions’). Next to the original version, there was validated also a Danish version of the tool (Andersen et al., 2014). However, the authors were unable to replicate the structure of the original instrument or to come up with another satisfactory fit structure. The Reflective Functioning Questionnaire (RFQ) was created to provide ‘an easy to administer self-report measure of mentalizing’ (Fonagy et al., 2016, p. 1). The term mentalizing is used by the authors synonymously with the term reflective functioning, i.e. ‘the capacity to reflect on internal mental states, such as feelings, wishes, goals, and attitudes, with regard both to self and others’ (Fonagy et  al., 2016, p. 2). The RFQ is a 54-item seven-point Likert-type scale (where 1 means ‘strongly disagree’ and 7 means ‘strongly agree’). The authors proposed two subscales: certainty (RFQ_C, e.g. ‘It’s easy for me to figure out what someone else is thinking or feeling’) and uncertainty (RFQ_U, e.g. ‘People’s thoughts are a mystery to me’) about the mental states of self and others. The authors verified their instrument in three studies with different samples of patients and normal controls. Confirmatory factor analyses showed a good fit to the proposed two-factor structure. These two factors were relatively distinct, were invariant across clinical and non-clinical samples, had satisfactory internal consistency and test-retest stability and were largely unrelated to demographic features. The scales discriminated between patients and controls and showed good construct validity. To verify this, the authors used the measures of empathy, mindfulness and

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perspective-taking (Fonagy et al., 2016, pp. 1, 22). The instrument has been widely used and translated (into 15 languages)2. There is also the short (eight-item) version of the tool available. The Self-Awareness Outcomes Questionnaire (SAOQ, Sutton, 2016) is based on 83 items created by two expert focus groups representing two different approaches to self-awareness development. The resulting instrument is a 38-item five-point Likert-type scale from 1 (never) to 5 (almost always). According to the author’s proposal, it comprises four subscales, where three represent beneficial outcome of self-awareness and one represents negative outcome (costs): the reflective self-development subscale (RSD, ‘I am continuing to work on and develop myself’), the acceptance of self and others subscale (Acc, ‘I feel on the whole very comfortable with the way I am’), the proactive at work subscale (Pro, ‘I think about how my personality fits with my work role’) and the emotional costs of self-awareness (Costs, ‘I find making changes is difficult and scary’). The proposed structure was elaborated by means of factor analysis. The author verified her instrument in two studies. The data brought satisfactory results: the author reports the relatively high correlations between the RSD outcomes scale and the two measures of reflective self-awareness (RRQ-Reflection subscale and Self-Reflection and Insight Scale, SRIS-Self-Reflection subscale). According to the author, there is a conceptual difference between her scale and the RRQ and SRIS scales, as these were developed ‘as measures of trait self-awareness, while the SAOQ-RSD scale was developed from participants’ and experts’ reports of the effects of self-­ awareness, specifically the further development of reflective self-awareness’ (Sutton, 2016, p. 655). The reliabilities of the subscales (Cronbach’s alpha coefficient) range from 0.77 to 0.87. The Reflective Practice Questionnaire (RPQ) was developed by Australian psychologists Priddis and Rogers (2017). They aimed to create ‘a tool that could be applied across the broad range of contexts and professions where reflective supervision takes place’ (Priddis & Rogers, 2017, p.  92). The instrument comprises ten four-item scales reflective-in-action (RiA, ‘During interactions with clients, I consider how their personal thoughts and feelings are influencing the interaction’); reflective-on-action (RoA, ‘After interacting with clients, I wonder about my own experience of the interaction’); reflective with others (RO, ‘I gain new insights when reflecting with others about my work’); self-appraisal (SA, ‘I think about my strengths for working with clients’); desire for improvement (DfI, ‘I desire more knowledge to improve my ability to work with clients’); confidence, general (CG, ‘I have all the experience I require to effectively interact with clients’); confidence, communication (CC, ‘I feel confident sharing my formulations with clients’); uncertainty (Unc, ‘Sometimes I am unsure how to handle the needs of clients’); stress interacting with clients (SiC, ‘Sometimes I find interacting with clients to be stressful’); and job satisfaction (JS, ‘I enjoy my work’). RPQ utilises a six-item response scale ranging from 1 (‘not at all’) to 6 (‘extremely’). The reliability of the

 https://www.ucl.ac.uk/psychoanalysis/research/reflective-functioning-questionnaire-rfq

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scales (Cronbach’s alpha values) ranges between 0.91 and 0.82. The authors verified their instrument in two studies, first with the general Australian population (N=188) and then with a sample of mental health practitioners (N=45). The authors see the advantage of their tool in its potential for use in a wide variety of situations. According to them, the RPQ may be useful for research that ‘explores and examines different types of reflective supervision and also for comparing practitioners in workplaces where reflective practice is encouraged and supported, and in those where it is not. The RPQ has potential for use in longitudinal studies in mental health training programmes’ (Priddis & Rogers, 2017, p. 101). There exists also a Swedish version of the Reflective Capacity Scale (Gustafsson et al., 2020).

 elf-Reflection Tools Selected for Translation into Czech: S Psychometric Properties of the Czech Versions In the preparation phase of our study, we decided to adapt two measures to the Czech language for use in our research: The Philadelphia Mindfulness Scale (PHLMS; Cardaciotto et  al., 2008) is a 20-item questionnaire that contains two subscales, a psychological process of clear attention to ongoing internal processes, called awareness (ten items), and non-­ sticky, non-controlling acceptance (in the sense of absence of reflective assessment, ten items). The respondents should capture how often they noticed one of the mentioned situations during the last week. The instrument has a five-point range from 1, never, to 5, very often for the answers. A higher score indicates a higher level of awareness. An example of the item is as follows: ‘When I am startled, I notice what is going on inside my body’. For the acceptance scale, all questions are worded negatively, because otherwise it is difficult to capture the non-evaluative attitude that is primarily concerned. A higher score means less reflective judgment, i.e. a higher level of unconditional acceptance. An example of the item is as follows: ‘If there is something I don’t want to think about, I’ll try many things to get it out of my mind’. Factor analysis of the original tool led to a two-factor solution, and the factors were not correlated. Confirmatory factor analysis in a sub-study confirmed the structure with two uncorrelated factors. The reliability determined by Cronbach’s alpha coefficient was 0.75 and 0.81 for the awareness scale and 0.82 and 0.85 for the acceptance scale in different sub-studies in one study (Cardaciotto et al., 2008). The validity was verified in six consecutive studies, four of which were conducted on different samples, including a normative group of students and different groups of psychiatric patients. Convergent and discriminant validity were  verified using seven scales, including a different mindfulness scale and a rumination scale. The main reason for selecting this measure for our research has been its declared ability to capture two key constituents of mindfulness as separate and distinct constructs (Cardaciotto et al., 2008, p. 207).

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The Self-Reflection and Insight Scale (SRIS; Grant et al., 2002) was originally designed as a three-factor questionnaire with insight scale in terms of an inner understanding of what is happening in a person; engagement in self-reflection, in terms of the frequency with which one engages in self-reflection; and the need for self-reflection in terms of self-interest. However, testing the structure of the tool did not confirm the three-factor structure: the last two factors were merged into one labelled self-reflection. The resulting 20-item questionnaire thus contains two subscales, namely, self-reflection (SRIS-SR, 12 items, e.g. ‘I frequently examine my feelings’) and insight (SRIS-IN, eight items, e.g. ‘I usually have a very clear idea about why I’ve behaved in a certain way’). The respondent answers via a six-point scale from 1, ‘strongly disagree’, to 6, ‘strongly agree’. A higher score indicates a higher level of self-reflection. Principal component analysis showed two uncorrelated (r = −0.03 and −0.08 in different sub-studies) factors. The test-retest reliability after seven weeks was 0.77 for SRIS-SR and 0.78 for SRIS-IN. A comparison of the results of women and men did not show any statistically significant difference (Grant et al., 2002). Convergent and construct validity has been verified (Grant et  al., 2002; Lyke, 2009). The SRIS-SR correlated positively with anxiety and stress, but not with depression and alexithymia. The SRIS-IN was negatively correlated with depression, anxiety, stress and alexithymia, and positively correlated with cognitive flexibility and self-regulation. The psychometric validation of the Self-Reflection and Insight Scale was conducted in three studies with samples of undergraduate psychology students (N  =  260), (N  =  121), and (N  =  28; test-retest reliability). The main reason for selecting this measure for our research has been that (1) it includes reflection on emotions, cognitions and behaviour and (2) it focuses on reflection and insight as central to the self-regulatory process.

The Czech Versions of PHLMS and SRIS3 The Philadelphia Mindfulness Scale and the Self-Reflection and Insight Scale were translated into Czech by a professional translator. Based on alternative suggestions and discussions between the authors and the translator, the Czech translation was subsequently modified and passed on to another translator for back translation into English. It was sent to the authors of the original scales. After verifying inquiries, they approved the Czech version. The questionnaires were administered in February 2019 as part of a multi-client survey to a population sample (N = 1000) of the Czech Republic over the age of 18

3  For details concerning the analyses of both tools, we refer to Open Science Framework (https:// osf.io/2dcag/), and to our article (Havrdová et al., 2020).

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obtained by quota sampling. The quotas were gender, age, education, size of the municipality in which the respondent lives and region. The representativeness of the sample was also verified within individual regions. The survey was administered on a computer in the presence of the interviewer, who assisted in case of ambiguity or in case the interviewee wished the interviewer to operate the computer.

Confirmatory Analysis and Reliability The confirmatory analysis of the structure of the SRIS questionnaire (the two-factor model) showed poor fit with the data (χ2(169) = 2618, p < 0.001, SRMR = 0.14, RMSEA = 0.12, CFI = 0.73, TLI = 0.69). To secure the comparability of the SRIS results with other research results concerning the SRIS measure, we decided to reduce the number of items. The resulting 13-item questionnaire shows good fit of the two-factor model with data as well as high correlations with original factors. The reduced two-factor solution is stable and shows good fit with data even with different random subsamples. These new factors show a high correlation with the original factors formed by all issues (for SRIS-IN the correlation is 0.88 and for SRIS-SR the correlation is 0.97). The authors of the Korean and Chinese versions of the questionnaire also decided to reduce the number of items: four items were removed in the Korean version (Song & Kim, 2018), and eight items in the Chinese version (Chen et al., 2016). The reliability of SRIS showed high values on our sample (Cronbach’s α > 0.80, McDonald’s ωT > 0.80). The confirmatory factor analysis of the PHLMS structure brought satisfactory results as it proved the structure of the original inventory with two factors, awareness and acceptance. The reliability of the PHLMS showed high values (Cronbach’s α > 0.88, McDonald’s ωT > 0.88). However, the factors were significantly negatively correlated (r  =  −0.56), whereas in the original questionnaire, the correlation was negative, but low (0.1). Our finding was stable across the demographic subgroups, and so it is not a relation that could be attributed to some of them only. Similarly, a higher negative correlation, then calculated with the original tool, was found between the two factors of SRIS. In both cases, one of the scales is constructed/compiled from negatively formulated items. We assumed that we came across cultural differences in the semantic meaning of such negatively phrased scales. When we worked to construct the complex questionnaire for the next research phase, this was one of the reasons why we decided to use only some items on self-reflection facets from both scales (see Chap. 8).

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Correlation Analysis The scales of the validated tools, the scales of the ten-item Big Five Inventory and the scales of the Empathy Questionnaire entered into the correlation analysis. The ten-item Big Five Inventory (BFI-10; Hřebíčková et al., 2016) was created by shortening the BFI-44 scale. It represents each of the five dimensions of the Big Five with two items. The respondent has a five-point scale for answers from 1, strongly disagree, to 5, strongly agree. A higher score indicates a higher rate of the trait. The ten-item questionnaire predicts 57% variance of the full version of the BFI-44. An example item is as follows: ‘I see myself as someone who gets nervous easily’. We chose the questionnaire because of its low time and economic demands. The Empathy Questionnaire (DE-14; Tišanská & Kožený, 2012) is an original Czech tool designed to estimate the level of empathy. The authors conceive empathy as ‘a primarily cognitive attribute that includes an understanding of stimuli, experiences, orientation, concerns, and directions of others’ (p.  157). The respondent answers via a seven-point scale from 1, definitely not true, to 7, definitely true. A higher score indicates a higher empathy level. The 14-item questionnaire assumes three components of empathy, which are Receptivity4 (mostly items concerning of empathy for how other people feel), Respect (items aimed at respecting attitudes towards animals as living beings) and Openness (a domain consisting mostly of negatively scored items related to people, for example, ‘Dealing with seniors is especially challenging for me’. According to the authors, the structure of the questionnaire is invariant in terms of gender. The correlations are displayed in Table 7.1. With the exception of the correlation between SRIS-IN and SRIS-SR (r = −0.11), which corresponds to the original work of Grant et  al. (2002), most correlations are medium to large according to Cohen (1988). The correlations between the two validated tools indicate a positive relationship between the PHLMS awareness scale and the SRIS self-reflection scale, which is also in line with previous research (Cardaccioto et al., 2008; DaSilveira et al., 2015). The PHLMS acceptance scale is positively related to the SRIS insight scale, while the SRIS self-reflection and PHLMS acceptance scale correlate negatively (ibid). The correlation analysis also showed a correlation with the Empathy Questionnaire subscales for both instruments, namely, the PHLMS awareness and acceptance scale and the SRIS self-reflection scale with the receptivity scale, the relationship between the acceptance scale and the receptivity scale being negative. The insight scale of the SRIS questionnaire and the acceptance scale of the PHLMS correlate positively with the openness scale of the Empathy Questionnaire. There are negative correlations between neuroticism and the SRIS insight scale and the PHLMS acceptance scale and zero correlations with the PHLMS awareness scale and the SRIS self-reflection scale.

 Originally labelled Percipience by the authors.

4

DE-14 – respect

– −0.32*** 0.04 0.54*** −0.15*** −0.28*** 0.11***

0.43*** −0.43*** −0.24*** 0.31*** −0.35***

−0.31***

−0.11*** 0.55*** 0.33*** 0.05 0.56***

0.09**

0.06

– 0.23*** −0.17*** −0.12*** 0.50*** 0.51***

SRIS-SR

–

SRIS-IN

−0.56***

PHLMS – acceptance

−0.20***

– −0.14***

DE-14 – openness

0.05

–

DE-14 – receptivity

–

BFI-10 – neuroticism

PHLMS Philadelphia Mindfulness Scale, SRIS-IN Insight subscale of the Self-Reflection and Insight Scale, SRIS-SR Self-Reflection subscale of the Self-­ Reflection and Insight Scale, DE-14 Empathy Questionnaire, BFI-10 Big Five Inventory Note: For the SRIS questionnaire, the scales with a reduced number of items were used; *** p