Paraprofessionals and caring practice: negotiating between social

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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
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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.
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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
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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
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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
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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
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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.”
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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)
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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
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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.
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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.
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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. Self assessment of
personal skills may help students articulate what they have to offer and facilitate
the negotiation of the use of self.
One size fits all education does not take into account the role of personal
disposition in education. While discussions of learning preferences are often
considered in educational design, the place of disposition is less common.
Educationalists should explore the possibility of more personalized experiences
that resonate with personal orientations and concerns. For example, negotiated
study, individual projects or more choice of topics.
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