When training as a speech therapist (the title at that time), I loved my practice placements and when, in due course, I began my career, it was with youthful confidence and perhaps a little arrogance. I might not have been paying attention, but I don’t recall supervision or reflective practice featuring in my university lectures and it didn’t occur to me to ask at job interviews about supervision arrangements. I can still vividly recall moments in my first job when my initial confidence and arrogance were swept away; good job too, though I didn’t construe this so positively at the time. My good degree didn’t seem to have prepared me adequately for the uncertainties I encountered in practice and I concede, I felt a bit angry and let down. Some days I was the only speech therapist on site and while the wider multi-professional team were approachable and supportive, I often wondered whether I was missing obvious things and if another, more experienced speech therapist might do things differently. I had a good deal of knowledge, but it felt like I was winging it when it came to landing that knowledge in practice. When, I wondered, would I feel more certain and know how to be a speech therapist?
Thirty years on, with more knowledge, more know-how and more ideas about how to be in practice, the sense that sometimes, I’m winging it, remains familiar. In contrast to newly qualified me, I now know that practice uncertainty is inevitable, and that recognising uncertainty is a precursor for learning and for the maintenance of both professional and public safety. There’s nothing new in this. Rene Fox wrote in the 1950s about the need to ‘train for uncertainty’ in medical education and earlier still, Pragmatist John Dewey wrote about the relationship between uncertainty and learning. However, have justifiable contemporary policy responses to untoward events in health and social care made the relationship between uncertainty and risk so prominent that it has eclipsed the relationship between uncertainty and learning and, in turn, between learning, safety and the prevention of harm?
In my recent research about supervision with physiotherapists, occupational therapists and speech and language therapists, I was struck that both novice and experienced therapists often spoke freely about their practice uncertainties. In their accounts, l began to notice a cluster of recurring behaviours and characteristics which supported practitioners, not only to expect and recognise uncertainties, but to seek to address and resolve them; a sense that practice uncertainties provide a prompt for learning about practice knowledge, know-how and knowing how to be. In my research, I have characterised practitioners who display this cluster of behaviours and characteristics as ‘permeable practitioners’.
So, what are the helpful behaviours and characteristics displayed by permeable practitioners? The first is ‘Awareness’. Permeable practitioners combine self-awareness with awareness of and for others. Initially, I thought it was this awareness that was the key to resolving uncertainties but importantly, permeable practitioners do not keep their awareness of uncertainties to themselves and are instead willing to share them with others. Sometimes, ‘Awareness-Sharing’ will be enough to support the practitioner to resolve a concern but in other instances, the resolution of a practice uncertainty requires the practitioner to be both ‘Feedback-Seeking’ and ‘Open to Alternatives’. In essence, awareness-sharing is of limited value to the uncertain practitioner who is unwilling to hear feedback and consider alternative behaviours or courses of action. Furthermore, the permeable practitioner is discerning in appraising whether there is a good fit between the presenting uncertainty and the feedback or alternatives offered. So, a further important characteristic is to be ‘Critically Attuned’; weighing up the potential for the feedback or alternative to resolve a presenting concern. Even when feedback or an alternative seem promising, uncertainty will persist if the practitioner is ultimately unwilling to experiment with an alternative and possibly to change. This ‘learning disposition’, is the final and crucial permeable characteristic and differentiates permeable practitioners from the less permeable; those who ‘may be cognitively aware of a need to behave differently and yet remain determined not to do so in practice’, (Revans, 2011 p5).
It seems to me no accident, that provided there are conducive conditions such as trust, supervisee focus and so on, supervision is one place where permeable practitioners spoke about sharing and seeking to resolve uncertainty; a place to explore their knowledge, know-how and ways of being. So, whether a novice or a seasoned healthcare practitioner, be permeable and embrace supervision as a valuable opportunity for learning in the interests of both professional and public well-being and safety.
Dr Deborah Harding
Associate Professor, Director of Workforce Development, School of Allied Health Midwifery and Social Care, Faculty of Health, Social Care and Education, Kingston and St George’s University of London
Dewey J. (1938) Experience and Education. New York: Macmillan
Fox, R. (1957) Training for uncertainty. In Merton R. K., Reader G. and Kendall, P. L. Eds The Student Physician. Cambridge: Harvard University Press
Revans, R. (2011) ABC of Action Learning. Farnham: Gower