Final report from the PBPL funded project: Understanding para-professional learning Caring practice: negotiating the intentional use of self Chris Kubiak May, 2010 Chris Kubiak Faculty of Health and Social Care The Open University Walton Hall Milton Keynes MK7 6AA United Kingdom c.d.kubiak@open.ac.uk 1 PBPL paper 53 Final report from the PBPL funded project Understanding paraprofessional learning Chris Kubiak 2010 Abstract Those designing practice-based educational experiences need an understanding of the dynamics of practice in order respond to the learning needs of practitioners. To this end, this report explores the way in which English paraprofessionals in health and social care incorporate ‘use of self’ in the collective construction of caring practice within their workplaces and through education. This construction of caring practice is framed as a learning process that involves the negotiation between personal agency and social agency. 14 practitioners were interviewed and 6 were observed. It was found that practitioners attempted to fashion caring practice as a personal encounter involving a distinctive relationship, understanding and approach to clients. However, practice as personal and idiosyncratic had to be performed within an organisational context that typically involved co-configured practice. This negotiation of the use of self involved conflict, the identification of personal affordances and affirmation through education. Implications for educators include the facilitation of reflection, reflexivity, visibilisation of self and the creation of personalised learning experiences. 2 PBPL paper 53 Final report from the PBPL funded project Understanding paraprofessional learning Chris Kubiak 2010 Introduction Those designing practice-based learning experiences need an understanding of the dynamics of practice in order respond to the needs of practitioners. To this end, this report explores the way in which English paraprofessionals in health and social care incorporate ‘use of self’ in the collective construction of caring practice within their workplaces and through education. This construction of practice is framed as a learning process that involves the negotiation between personal agency and social agency. Implications for managers and educators are discussed. In recent years, understanding the development of paraprofessionals has become increasingly important. In England, paraprofessional workers (for example, health care assistants or care workers) who work under the direction of registered staff to provide much of the frontline and one-to-one care have long been one of the enduring features of the workforce but often overlooked in research. However, recently a focus on the development of their practice has emerged as one of the main planks in government policy (Cameron and Boddy, 2006, Department of Health, 2006a, Department of Health, 2006b). This concern with practice development has had a number of drivers. Higher standards of care have been required through government policy and implemented through various standards and service frameworks. Even so, concerns about the quality of care provided by some practitioners remain. For example, Storey (2007) writing about health care assistants argues that workers are practically ‘brought in off the streets’ with no experience and employed providing hands-on care for vulnerable people. However, what exactly is required of paraprofessionals? Paraprofessionals are a diverse group making any single statement of required role and skills elusive or impossible to make. However, they are all expected to provide caring practice which itself raises questions about the very nature of caring practice and the associated capabilities of practitioners. Mol (2008) explores a range of interpretations of care. Theologians cast care as a selfless activity inspired through love and charity. Anthropologists have described care as a gift, but one which must be paid back in some way. Sociologists have considered the care and devotion one may have at work as a poor fit with the formality of the employment contract. Caring practice may consist of evoking emotions within others and adherence to appropriate display rules (de Jonge et al., 2008). It has a strong moral dimension incorporating personal virtues and responsibilities (Duncan et al., 2003). Thus, caring practice involves a giving of oneself in formal settings for reward. It includes emotional and moral practices. In this report, I have adopted Tronto’s (1993) conceptualisation of caring as it offers breadth of definition that incorporates many of the elements above. Care is a structured process involving: Caring about - awareness that care is needed Taking care - taking responsibility for those needs Care-giving – concrete actions to meet needs Care-receiving – the caree responds to the care-giving possibly with change or improvement 3 PBPL paper 53 Final report from the PBPL funded project Understanding paraprofessional learning Chris Kubiak 2010 Within this definition, care involves openness to the needs of others, a moral sense of responsibility and the competence to provide an effective intervention of some kind. Care also includes a mutual responsiveness with the carees exposing their vulnerabilities and the provider answering these expressions. What Tronto (1993) offers is a view of care that incorporates the technical and physical aspects of the work as well as softer skills such as the empathy, insight and communication skills to enable the practitioner to engage in the clients’ lives. As such, care work can be seen as a complex and demanding activity. Thus, in the English sector in general (Cameron and Boddy, 2006) policy emphasises care work as a skilled practice. Service users are no longer framed as passive recipients of care but active citizens with the right to determine what needs are met and how. Care is framed as a holistic activity. So for example, the discrete tasks of caring (e.g. washing or feeding) are not merely instrumental tasks to be delegated to the unskilled. They are part of developing and deepening the relationship with the client and creating opportunities for supporting that person’s development and autonomy (Moss et al., 2006). As such care work requires skilled, knowledgeable and reflective practitioners. However, this conclusion leads to questions about the way in which caring practice is supported and developed in the settings in which it is provided. Developing caring practice How then does the practitioner learn to provide caring practice? In recent years analyses of learning have stressed the role of context, communities of practice or activity systems in shaping and developing practice. In effect, the physical and social context determines practice and what is known (Barab et al., 2002, Sfard, 1998). Billett (2008) argues that the requirements for performance at work are projected by the workplace practices, norms and discourses of the workplace. For example, Goodrich and Cornwell (2008), taking up the issue of compassionate practice in formal settings, suggest that the provision of good care does not simply happen through individual efforts alone, but is connected to the way teams and organisations operate. Is learning to care then a matter of the practitioners’ context ensuring practice proceeds in a particular fashion? After all, workplaces expend considerable effort ensuring the reproduction of ‘the way things are done around here’. Supervision, shadowing, mentoring, induction, training and team meetings not to mention peer pressure are all ways of ensuring the continuity and coherence of practice across practitioners. However, Holloway (2006) is particularly critical of this type of socially situated analysis. She argues that the capacity to care is not simply a matter of social structure but also rests on personal qualities. These personal qualities are overlooked if learning is analysed from a perspective where the practitioner is presented as subsumed in the social and their development facilitated by socio-cultural conditions any sense of the individual with differing as well as similar values, histories and practices is erased (Hodkinson et al., 2004a). After all, people do not enter workplaces as tabula rasa. Many people have had prior experience of providing care for family or friends. It is a taken for granted aspect of many lives (Barnes, 2006). Many paraprofessional workers may be employed because of their experience of 4 PBPL paper 53 Final report from the PBPL funded project Understanding paraprofessional learning Chris Kubiak 2010 providing non formal care. Surely practitioners bring much skill and ability with them when they enter the workplace? In health and social care, any analysis that looks only to work context to understand how learning and practice proceeds is problematic as compassionate and personal care rests upon the practitioner bringing something personal and individual to the encounter. Therefore any analysis of the development of effective care must attend to the characteristics of the individual. Reference to the related field of counselling offers a useful analysis. Wosket (1999) writing about counselling practice argues that the practitioners’ use of the self is crucial to the effectiveness of the process. That is, the way in which practitioners apply themselves, make their personhood present and extend aspects of their personality in order to influence the client are crucial to the effectiveness of the intervention. Edwards and Bess (1998) argue that effective therapeutic practice requires the formation of relationships which serve as a context for change. In such relationships, the practitioner does not simply offer skills and knowledge but themselves as a person – their values, their empathy and their genuineness. In other words, there is no such thing as an impersonal worker-client relationship – effective and caring practice is personal – and the practitioner mines his and her personal qualities in the service of caring practice. This concern with the ‘use of self’ and Tronto’s conception of care involving mutual expression draws attention to the place of individual contributions in practice. Writing more generally, Billett (2008) has taken up this question arguing that understanding participation at work is to understand the intersections between the shaping of collective workplace practices and the individuals’ own evolving development as they engage in work. In other words, the individual and the social are interdependent. It is the nature of this interdependence between the collective processes of social structuring and the need for individual expression and agency that demands further investigation for those interested in practice-based learning. Individuals operating within this interdependence are actively constructing caring practice in a way that draws from the social shaping of their context and their own disposition. Understanding the nature of this dynamic is important for educators supporting practice-based learning. After all, they too work the interface between enabling practitioners to become competent within the collective demands of the workplace and profession – in other words, get with the way things are done in the workplace. At the same time, educators have a strong allegiance to the individual student who is pursuing an individually meaningful learning and work experience. This tension between personal and social agency in workplace practice will be explored in this report to illuminate the dynamics of practice construction. This report discusses the way in which paraprofessionals negotiate caring practice in relation to health and social care practice and education. Method This report is built around a subset of data from a project focused on understanding paraprofessional learning through practice. 14 participants working in learning disability, mental health services and health visiting were involved in the study. 6 workers were observed in practice. For example, working with clients or attending meetings. Those in the mental health and health visiting services participated in 5 PBPL paper 53 Final report from the PBPL funded project Understanding paraprofessional learning Chris Kubiak 2010 interviews only. Twelve participant were interviewed four times over 6 months. 1 was only interviewed twice and another was only interviewed 3 times. The first interview consisted of a biographical interview and an exploration of their role and setting. The second two interviews carried out at monthly intervals explored critical incidents in their practice as well as follow up questions drawn from the previous interviews. The fourth interview combined the discussion of a participant profile prepared out of the data and a further critical incident interview. This profile interview was not simply respondent validation. It was a final stage in data collection and the first step in analysis in which the participant discussed at a deeper level some of the themes in their development and practice and contributed to an interpretation of the data. Thematic analysis was carried out on these profile documents to write this report. Findings Use of self in practice Practitioners attempted to fashion caring practice as a personal encounter involving a distinctive relationship, understanding and approach to clients. Caring practice was concerned with ensuring client choice, facilitating personal development and supporting participation in the activities of daily life. Relationship work was an essential part of this process, necessary for the negotiations, support and understanding that facilitated client development. Certainly, the relationship ‘chemistry’ was different for different clients. Some were enjoyed or regarded as favourites, others feared or considered exhausting. Practitioners emphasised striving for a personal relationship with clients, valuing rapport and being seen as more than just another worker who is, for example, missed when absent or asked for over other workers. These sorts of relationships were seen as a context for change and support, unavailable to other practitioners. For example, a team dealing with an unresponsive client tapped into this rapport: “He was sectioned and they rang up and said ‘is there anybody in the team that’s got a good rapport with him that can come and persuade him to get in the ambulance before we call the police’, so I was asked to go then …” (PB) Working out of person-centred values, regular contact with clients was emphasised as the basis for insight into their unique circumstances and needs. Practitioners strived to remain open to how each client presented to them personally rather than working from preconceptions or generalisations based on diagnostic labels, client notes or behaviour with other practitioners. Client notes and staff meetings did inform practice but practitioners favoured improvisation in the moment - “floating things into the equation” (PU), trying things out and observing reactions to understand what works. As such, practitioners emphasised their understanding as personal and distinctive, a kind of ‘frontline authority’ with a different value to the theorised and detached knowledge of the academically trained practitioner. Idiographic understandings supported tailored responses. While responding to seizures, feeding or providing medication, for example, involved well defined and routinised skills or strategies, much work melded the practitioners’ personal style to the client’s individual needs. Practitioners emphasised ‘being me’, doing what comes 6 PBPL paper 53 Final report from the PBPL funded project Understanding paraprofessional learning Chris Kubiak 2010 naturally or working out of instinct, exploiting their personal characteristics – their enthusiasm or their humour, for example in their work with clients: “… when I came to this job I stated in my interview the only thing I can bring is me. I don’t have any qualifications in any kind of social care.” ‘Going through the motions’ (acting in a depersonalised, unresponsive fashioned) was criticised in others. ‘Truly caring’ for others, suppressing some aspects of their personality or feelings and emphasising others was part of practice. Practice was not detached from the practitioners’ sense of self or being in the world but intertwined with it. In its ideal state, workers tried to connect care work to personal interests and history (for example, the exercise enthusiast worked the gym sessions) creating authentically human encounters based on shared enthusiasms. Similarly, past and present experience influenced the practitioners’ approach and sense of competence – the ex-teacher worked from educational principles, ex social work assistant focuses on social care needs or the Mother caringly supporting personal growth. Negotiation between personal agency and social agency This data suggests that caring practice involves the intentional use of self to build relationships, understand clients and provide personalised interventions. However, practice as personal and idiosyncratic had to be performed within an organisational context that typically involved co-configured practice. That is, teams attempted to build a common understanding, agreement on shared goals and in part, consistent approaches to each client. Formal and informal discussions, problem solving, care plans, supervision and service goals were often concerned with the consistency and continuity of established practice. Yet, effective caring practice is personal, involving the ‘use of self’ within collective practices and as such, involves a negotiation between personal agency and social agency. Conflict While building a shared understanding was a typical team process, practitioners also deviated in their understanding, values and interests. Thus, co-creating practice involved working with ‘rough drafts of contract’ – provisional understandings rather than objective maps of a fixed and agreed reality (Rommetveit 1979). The construction of practice therefore becomes a contested practice given voice not only in group discussions about practice but while in practice itself: “ …he [client with learning disability] asked me to come and open the sachet – so I said to him you’re more than capable of opening a sachet – and I could see the other staff member getting up from here – I knew they were going to go across to take over - and I said leave it for a second – now what I thought was strange – I’m trying to control, if that’s the right word, another support worker from interfering …” (PU) Practitioners present their negotiations as a balancing act between direct conflict and avoiding damage to positive team relationships. Power plays a part: “Sometimes I forget myself that I’m, there is a hierarchy and that I am an access worker; I forget that because I’ve always worked in … that I forget that I actually am not in a position where I can actually engage so openly in a clinical discussion.” 7 PBPL paper 53 Final report from the PBPL funded project Understanding paraprofessional learning Chris Kubiak 2010 Managers will be lobbied or positional authority used to pull rank. More subtle power sources may also used. Frontline authority (extensive personal experience with the client) and the capital of long term experience may be asserted but did not bring the same certainty that the registered practitioner’s veto power holds. Teams sometimes broke into factions divided along ‘old school’ or ‘new school’ approaches, social care or medicalised orientations, friendships and cliques or registered and non-registered workers. Factions provided a locus for discussion to get an angle on practice, moral support or ‘back-up’ in disputes. They may also operate through subversion by, for example, dealing with an overly negative colleague by asserting to clients and colleagues behind his back that “We don’t listen to [colleague], you know.” Affordances for the use of self Practitioners and managers also negotiated affordances for the use of self within the constraints of the role or the team’s skill mix. Negotiations may be focused on finding tasks that better match practitioner skills, interests and ambitions. Others seek to carve out a particular niche: “How am I - me and my personality – not just as another body - how am I going to fit in here – and am I going to be able to offer something different?” (PG Workers may also seek the sense of competence and confidence arising out of continuity with past skills, knowledge and interests. Others have ambitions to develop themselves further. Losing these continuities or growth opportunities can be demoralizing: “I’m beginning to feel that most of the skills that I have is not being utilised, and I’m beginning to lose those skills and because I have that fear of losing those skills I’m always going on. I think I find myself going on about wanting to do this and this, because I have those expertise, and sometimes I just think - am I in the right place?” (PC) Workers also lobby managers to visibilise their capabilities to create, or move to, a better fitting role. Recognising the value of use of self to caring relationships, managers may fold the service around the practitioner’s personal characteristics by, for example, giving the gardening groups to the gardener or matching them with clients they have a rapport with. Such discussions are also an important part of supervision: “… every time we had a supervision I’d just sort of say the ones that I liked doing. I suppose that’s how I’ve come to do the ones that I like really, cos they’ve tried to keep me with the ones that obviously I’ll be . . . if I’m enjoying them I’ll be putting more in and therefore so serviceusers are getting more out.” (PG) However, such affordances for the use of self may have an ambivalent place in the organisation. Accommodating client-practitioner rapport may be balanced against ambivalence about ‘dependant’ relationships inappropriate in a professional service relying on an interchangeable workforce. Practitioners new to a workplace seeking continuities with a past role may encounter resistance from colleagues: “… other staff will say you know, like I’m an arselicker because I’m doing more than I should be doing …” (PJ) 8 PBPL paper 53 Final report from the PBPL funded project Understanding paraprofessional learning Chris Kubiak 2010 Education Participants suggest that education plays a part in the use of self. Practitioners described the way that training and education consolidated understanding and built personal confidence. Vocational qualifications provided space to have skills assessed, discussed and certified. The worker may have an approach all their own but the award affirms that practice is correct. Even so, colleagues with university-based training may disregard the value of vocational qualifications despite the practitioners’ reports of a deepened understanding and enhanced competence. Similarly, some practitioners aspired to train for registered professional groups. Financial motivations were part of this aspiration but vocational drives overshadowed these. Without qualifications, practitioners felt they would be less influential and autonomous. Therefore their understanding or approach to their clients was less likely to be accepted. “See this is where the qualification comes in. If I am a qualified social worker, yeah? I’ve had colleagues say ‘Oh, you can be listened to’; I don’t believe that. If I’m qualified and I have my degree and I have my qualification, that is where that I feel that I have the authority to make a difference. I’d have authority to fight this person’s corner because I would have all the skills and the values that I’m supposed to meet in terms of; I’m supposed to use in terms of meeting that client’s needs; I’ll be able to use those things within that authority to get what I want to get for the client.” This autonomy was not simply a pursuit for power but framed as a fuller expression of their vocation – a desire to make a positive difference in a client’s life and do it their way. In contrast, academic study can make feelings of personal displacement more manageable. For example, one participant with a social care orientation (traditionally low status) working in a medically oriented team felt that her social work studies affirmed the validity of her approach ameliorating her sense of displacement. She explained that the underpinning knowledge and evidence accessed through study gave her the power to take the initiative on practice and to assert her perspective. In addition, hoping to enter professional training, this worker negotiated with her line manager to build up a relevant portfolio of experiences, some of which did not fit her current role. Framing these activities as aligned with organisational goals was not always successful. However, linking them to her studies provided a validation that convinced her manager who widened her opportunities for activities that fitted not just her ambitions but her orientation as a whole. Similarly, observations and interviews with two experienced practitioners who had not only made the role their own but had developed considerable authority reveal a similar effect. Financial support and unambiguous encouragement from management to enter university was read as an affirmation of their approach to practice – they were practically working as nurses and this was now formally recognised. In contrast, aspirations that are not supported are read as a demoralising rejection of what the practitioner has to offer. However, enactment of these affordances was reliant on a 9 PBPL paper 53 Final report from the PBPL funded project Understanding paraprofessional learning Chris Kubiak 2010 particular sense of self – fears of moving away from frontline work, lack of confidence in abilities to cope with study or divergent aspirations led practitioners to reject opportunities. Discussion Caring for others is one is one of the characteristic behaviours of our species (Tronto, 1993). Parents care for children and friends help each other out. We strive to develop relationships that are special in their intimacy and understanding. We use our skills, knowledge and personal qualities to provide care. Such activities have meaning for us and relate to our identity and values. When the people in this study entered the workplace and went ‘professional’, they did not leave these aspects of self behind. They drew on pre-existing skills and knowledge (gardening, cooking, teaching, or nursing, for example) and extended their personality and values into the practice. Such qualities are exploited to advance the aims of the caring relationship - not simply in terms of relationship building or intervening in a personal and authentic fashion but also to build insight into the client and their needs. This process of using oneself in practice has been referred to elsewhere as ‘presencing’ (Kwaitek et al., 2005). The use of self raises the question concerning the way in which organisations and individuals manage the negotiation between personal and social agency. As the study suggests, engaging in the practices of a workplace is a negotiated and contested process, not simply a matter of being shaped by social agency. This report has also highlighted the tensions with positive team relationships associated with practitioners attempting to negotiate a way of working that is personally congruent. The factional relationships and the assertion of shared interests and values that coexist with disagreement underline the need practitioners have to belong and affiliate. After all, collegial relations are a necessary part of care work. This dynamic only highlights the negotiated relationship between the self and the collective. At the same time, as Hodkinson et. al., (2004a) argue, power differentials and workplace equalities are important to attend to. Learning is a contested practice and shaped by power relations (Billett, 2002). Certainly, paraprofessionals are low-paid, predominantly female and at the bottom of the work hierarchy. For some workers, their authority appears fixed by positional authority. However as suggested by the authoritative roles served by practitioners, power is something negotiated and not set. The negotiation of the use of self also relates to reflection. The study described the way that the practitioners’ insights into their clients was filtered through understandings derived from their history and particular values. Personal style was also helpful in relationship formation and past orientations shaped present activities. Kwaitek et. al., (2005) problematises these ideas arguing that underlying values and assumptions may lead practitioners to intervene in an unhelpful or inappropriate fashion. For example, if the experience of Mothering prepares one for care work, could this also bring with it inappropriately paternalistic attitudes? Kwaitek et. al., (2005) advocate the need to focus on the ‘therapeutic self’ – a process of evaluating the way that personal characteristics and values impact on the client. They describe a course which includes extensive self awareness and reflection coupled with an understanding of person-centred practice and the appropriate use of ‘presencing’. They focus on practitioners striving to know themselves within the context of the work environment and how internal factors and external factors shape behaviour. 10 PBPL paper 53 Final report from the PBPL funded project Understanding paraprofessional learning Chris Kubiak 2010 Courses like this highlight the negotiated nature of use of self. I also suggest that reflection needs to expand beyond its framing as a meta-cognitive activity rather like a study skill to encompass the wider process of reflexivity. By reflexivity, I am referring to self authoring and identity work, an idea with links to Wenger’s (1998) work on learning as intertwined with identity. Issues of who am I, what do I want to be, how do I want to be in this place, what do I feel comfortable doing and ready to develop further are all questions for such reflexive work. Returning to the interpenetration of personal and social agency, it may also be fruitful for reflection and supervision to consider such matters not only in relation to the individual but also in terms of organisational affordances to accommodate the use of self. Reflexive organisations foster reflective practitioners. Literature can stress the destabilizing properties of formal learning – challenging existing beliefs and perceptions, for example. This study appears to underline the role education plays in affirming use of self. However, the effectiveness of one size fits all approaches may be limited. While much attention needs to be given to organisational drives for learning and the collective needs of the workforce, individual disposition and structural factors (that is workplace conditions) will operate in an integrated fashion to generate widely divergent conditions for learning and determine the success of the endeavour (Hodkinson et al., 2004b). For example, individual disposition leads to quite different responses to educational opportunity. Affordances for the use of self are no small matter. Sennett (1998) argues that practitioners do not strive to be just another pair of labouring hands but desire to develop careers, professional identities and meaningful vocation. Individuals want to develop a narrative of identity and life history. As suggested by these studies, the organisation of work processes requires attention to use of self. Certainly, workplaces attended to ensuring that workers had a place in the organisation that responded to personhood. Indeed, there seemed to be an acknowledgement that to do otherwise would be to jeopardize effective practice and in particular, the authentic human encounters and mutual rewards that constitute positive relationships in health and social care. Conclusion While the use of self has been highlighted in this report, much writing elsewhere stresses assimilation into the norms of the community of practice, professional socialization and the performance of professional roles. For example, anecdotally practitioners report ‘donning the uniform, assuming the role and walking out on the stage and into practice’. While such dynamics play a part in the construction of practice, this report suggests that it is also relevant to explore how the self – values, unique understandings and experiences, capabilities – can be intentionally and appropriately used in practice. As suggested by this study, the use of self may be contested, involve negotiation and will be related to education. To conclude, I wish to draw attention to five implications for educationalists: 1 Practice-based learning courses could give as much attention to the use of self as central to caring practice. The view that use of self plays a part in the construction of caring encounters could be stressed. 11 PBPL paper 53 Final report from the PBPL funded project Understanding paraprofessional learning Chris Kubiak 2010 2 3 4 5 Use of self may lead to inappropriate behaviour or responses. Refection upon how one presents in practice and the likely impacts on others, seeking out relevant ‘data’ through observation or discussion should be facilitated. A focus on self awareness within the particular context of the practice setting and with clients would be of value. Reflexivity focused on understanding how one wants to be or would like to become should also be promoted. While career aspirations will be part of this activity, work concerning the kind of identity the student has and wishes to have in practice could be considered. Courses may facilitate the visibilisation of personal qualities and aspirations in order to affirm and facilitate the negotiation of the use of self with managers and supervisors in practice. Issues may include the students’ particular aspirations for their career and within their current practice, the type of role they feel matched to or areas where they feel at odds with their colleagues. 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