Critical Creativity: Melding, Exploding, Blending

Educational Action Research
Vol. 14, No. 2, June 2006, pp. 239266

ISSN 0965-0792 (print)/ISSN 1747-5074 (online)/06/02023928
2006 Educational Action Research
DOI: 10.1080/09650790600718118
Critical creativity: melding,
exploding, blending
Brendan McCormack
a
* and Angie Titchen
b
a
Institute for Nursing Research, University of Ulster/Royal Hospitals Trust, UK; Monash
University, Melbourne, Australia; School of Health, Community & Education Studies,
Northumbria University, UK;
b
Royal College of Nursing Institute, London, UK;
Knowledge Centre for Evidence-based Practice, Fontys University, Eindhoven, Netherlands
Taylor and Francis Ltd REAC_A_171779.sgm 10.1080/09650790600718118 Educational Action Research 0965-0792 (print)/1747-5074 (online) Original Article 2006 Taylor & Francis Ltd 14 2000000June 2006 BrendanMcCormack [email protected]
In this article, the authors expose, for critical review and public scrutiny, their challenge to the
critical paradigm as an adequate location for the transformational practice development and
research approaches that they are developing in healthcare. Whilst they accept the fundamental
assumptions of the critical paradigm, in their view it does not recognise the creativity required in
their approaches. Neither does it explicitly acknowledge that creativity often requires moral and
sacred dimensions as people push out the boundaries of the known within their own practices. In
particular, the authors expose these gaps within Fays eight critical theories for practice. Over the
last decade, the authors have addressed these gaps by combining the assumptions of the critical
paradigm with their experiences of using creative imagination and expression in their practice
development (PD) and action research work. Then through a critical review of their work, they
have created a new paradigmatic synthesis to add to the critical paradigm. They call this synthesis
critical creativity. In this article, the authors set out their reflexive journey that has led to the
articulation of critical creativity as a paradigmatic synthesis for action-oriented development and
research.
Keywords: Critical Creativity; Practice Development; Action Research; Reflexivity;
Critical Paradigm; Praxis
Introduction
Over recent years, we have been working at the margins of mainstream thinking in
healthcare development and research. The ultimate purpose of our work is to enable
*Corresponding author. Nursing Development Centre, 3rd Floor, Bostock House, Royal
Hospitals Trust, Grosvenor Road, Belfast BT12 6PA, UK. Email: Brendan.mccormack@royalhos-
pitals.n-i.nhs.uk
240 B. McCormack and A. Titchen
individuals, teams, organisations and communities to deliver and to co-construct new
knowledge about person-centred, evidence-based healthcare, and to move towards
human flourishing for all involved in the endeavour. We have experimented, in our
practice development (PD) and action research, with ideas and theories from fields
of practice such as creative arts therapy, arts facilitation in healthcare and diverse
spiritual traditions that are concerned with creativity and the use of creative imagination
and expression to promote human flourishing (for example, Higgs & Titchen, 2001;
Seizing the Fire, 2001; Coats et al., 2004). Practice development is becoming estab-
lished in nursing as a recognised field of practice. It is concerned with creating trans-
formational cultures of effectiveness, for the purposes of delivering person-centred,
evidence-based healthcare. It uses systematic approaches and skilled facilitation to
develop practitioners, teams, practices, workplaces, organisations and communities.
In this work, we have questioned whether the critical paradigm provides sufficient epis-
temological and ontological support for such work and have found it wanting.
In this article we set out the dimensions of our inquiry thus far. We explore philo-
sophical assumptions underpinning the dominant discourse of PD as it currently
exists. We present the processes we have used in our inquiry in order to challenge
these dominant assumptions and a particular outcome emerging from that work, i.e.
a theoretical framework of critical creativity situated within the critical paradigm.
The framework could be used to underpin any kind of PD or research (including
action research). It is derived from our critique of Fays (1987) eight practice theories
of being critical, in which we conclude that the creative nature of the work in which
we are engaged is missed within these theories. The critical approach as elaborated
by Fay does not sufficiently explain or direct attention to the issue of how a critical
theory can be translated into actual practice. Even sub-theory 10 of Fays model (a
plan of action that indicates how people are to carry out a social transformation)
leaves the impression that the movement from the level of theory to the level of prac-
tice is nothing more than the application of an abstract theory. But this is mistaken:
practical activity involves skills, sensitivities and capacities that require a practical
wisdom that involves far more than knowing the contents of a theory. Practical activ-
ity is a form of praxis in which practitioners learn how to pick out salient features of
their environment, develop perspicacious responses to these features, and adjust and
adapt themselves to the particularities of a given situation. Of course, praxis can be
informed by a theory, but genuine praxis requires that practitioners go well beyond
learning this theory in order to be effective practitioners. In particular, in trying to act
as a critical theory would recommend, practitioners need to employ a kind of creative
activity whereby they render themselves able to perform in particular situations. Prac-
tising this creative activity will give to practitioners a professional artistry without
which their interventions in the practical world would be clumsy or routine or
unresponsive. What is needed to augment Fays critical model, then, is a praxis
spiral that focuses attention on the important creative work in which practitioners
must engage if they are to be effective.
1
Therefore, we propose the augmentation of Fays theory of transformative action
by proposing a significant alteration and elaboration of sub-theory 10 by particularly
Critical creativity 241
focusing on ways in which practice can be transformed through a critically creative
engagement with practice. We name this addition, creativity, and set it out in the
context of holistic engagement that is at the heart of critical social science.
Critical creativity centres on the basic concepts of praxis and human flourishing,
the former a concept associated with the critical paradigm and meaning thoughtful,
intentional action. Within critical creativity, the concept of praxis is extended to
include action that is also creative. Praxis is thus achieved through creative thinking,
thinking about thinking (metacognition) and critique blended with creative imagina-
tion and expression. This blending occurs through professional artistry (Titchen,
2000b; Titchen & Higgs, 2001). This new understanding of praxis is the means
through which human flourishing is brought about, and further understood. Human
flourishing (as we understand it) focuses on maximising the potential for individuals
to achieve their potential for growth and development. We will discuss this concept
in more depth later in this article. Within critical creativity, it is intended that human
flourishing should be the outcome, not only for those for whom the development or
research is intended, but also for those who carry out the work. Thus human flour-
ishing is seen as both end and means of development and research. In this last respect,
critical creativity bears similarities to the ideas of a few qualitative researchers, such
as Reason (1993) and Lincoln and Denzin (2000).
In relation to Fays critical theories it is beyond the scope of this article to address
each dimension of the theory in detailthis is the focus of ongoing and future
inquiries. However, in presenting our work at this stage of its development, we hope
to raise the issue of creativity in readers consciousnesses and open up our inquiry
for public scrutiny, contestation and debate. Whilst our ultimate intention is to
engage in meaningful dialogue with others who are interested in facilitating transfor-
mative practice, we are well aware that this article cannot achieve this purpose in
itself. In particular, we are conscious of the need for greater articulation of the prac-
tical application of the principles set out in this article. Table 1 (see pp. 245248)
provides a summary of examples that we have been working with in our practice
development work. These and other examples will be analysed in greater depth in
our ongoing publications. The framework presented here offers new theoretical
understandings of the ways in which practitioners, activists, practice developers,
educators and researchers can transform themselves, individuals, teams/groups,
organisations, communities, cultures and practices and, if desired, generate theory.
Further papers in progress will articulate the particular details of the theoretical
framework as it unfolds and its practical application through a framework for trans-
formative practice development.
Beginning our journey of discovery
Alone on the edge
Melding, exploding, blending
Critical creativity
(Haiku created by Brendan McCormack and Angie Titchen, 2003)
If we think of the critical paradigm as a flowing river, then critical questioning is like
the turbulence that small feeder streams create when their waters confront the main
flow of the river. At this confluence, the waters eddy and spiral to blend with those
of the mainstream and thus form a new synthesis (melding). This new mix of waters
flows alongside the mainstream and may eventually blend with it. One example of
this melding is The International Colloquium on Theory Development in PD.
This colloquium is a cooperative inquiry (Heron & Reason, 2001) of practice devel-
opers, practitioner researchers and educators from healthcare who share and
critique work dedicated to deepening our understandings of practice development
through critically creative practice, learning and research. The key output from the
work of the colloquium is the publication of a series of practice development theo-
retical and methodological papers. As members of this colloquium the two of us
have created such turbulence and blending through our deconstruction (exploding)
of the critical paradigm, as an underpinning for our PD and research work, and have
begun to construct a new synthesis within the critical paradigm to support it (blend-
ing). In the work of the international PD colloquium, we have used critical dialogue,
contestation and debate in combination with the use of creative imagination, artistic
expression and thematic analysis to develop a theoretical framework of critical
creativity.
This synthesis we have called critical creativity. Our inquiry processes are
informed by our experiences of engaging in emancipatory action research as
described by Grundy (1982) and Carr and Kemmis (1986) with nurses and other
healthcare workers, wherein barriers to improvements in healthcare practice are over-
come (see for example Binnie & Titchen, 1999). These barriers are both internal, that
is, within ourselves, and external in relation to the contexts and cultures in which
improvements are sought. Such experiences have broadened and deepened our
understanding of the philosophical, theoretical and methodological perspectives in
action research and enabled this work to happen. As our inquiry develops, we are
locating our action research within the critical creativity paradigm, in a yes and rela-
tionship to emancipatory action research to encompass the inherent and broader
notions of transformation within critical creativity.
Philosophical and theoretical critique
Practice development is a well-established movement in United Kingdom healthcare
and is increasingly becoming an international movement. Over the past 10 years
significant conceptual, theoretical and methodological advances have been made in
the development of frameworks to guide PD activities. Of most significance has been
our increased understanding of key concepts underpinning PD work irrespective of
the methodological perspective being adopted. For example, workplace culture
(Manley, 2004), person-centredness (Titchen, 2000b; Dewing, 2004; McCormack,
2004; Nolan et al., 2004), practice context (McCormack et al., 2002), evidence
(Rycroft-Malone et al., 2003), values (Manley, 2001; Wilson, 2005; Wilson et al.,
2005) and approaches to action learning for sustainable practice (Hockley et al.,
2004). A number of researchers have explored the meaning of PD through concep-
tual analysis (Unsworth, 2000; Garbett & McCormack, 2002, 2004), action inquiry
(Manley, 1997a; Binnie & Titchen, 1999; Clarke & Wilcockson, 2001; Gerrish,
2001; Clarke et al., 2004) and evaluation (Tolson, 1999; McCormack et al., 2004;
Wilson & McCormack, 2006).
In a concept analysis of PD, Garbett and McCormack (2004) articulated the inter-
connected and synergistic relationships between the development of knowledge and
skills, enablement strategies, facilitation and systematic, rigorous and continuous
processes of emancipatory change in order to achieve the ultimate purpose of
evidence-based person-centred care. Manley and McCormack (2004) articulate
these elements of PD in a model called emancipatory PD, drawing on previous theo-
retical developments in action research (Grundy, 1982). The similarities between
emancipatory PD (EPD) and emancipatory action research (EAR) are recognised
and acknowledged, in that both are concerned with overcoming obstacles and with
generating new understandings about context, culture and how to overcome barriers
within them. However, whilst both EPD and EAR are concerned with generating
knowledge that is particular to, and helpful in, the specific situation, in EAR only,
work is done by the action researchers to offer findings to others that are potentially
transferable to other settings. Whilst this distinction is evident in much EPD activity,
an increasing PD literature is emerging that also articulates transferable principles for
action (Manley, 1997a, b; Binnie & Titchen, 1999; Manley & McCormack, 2004;
Wilson et al., 2005). Emancipatory PD explicitly uses critical social scientific
concepts on the basis that the emphasis on the development of individual practitio-
ners, cultures and contexts within which they work will result in sustainable change.
Critical social science is derived from critical theory. Critical theory may be distin-
guished from other forms of theory in its explicit intent towards emancipation. With
its roots in a Western European Marxist tradition, the aim of emancipation is to
liberate human beings from the circumstances that enslave them (Horkheimer,
1982, p. 244). Thus critical theory goes beyond practical theory in the sense that it
does not just set out to explain and understand social contexts but instead aims to free
people from circumstances of domination and oppression. Emancipation arises from
critique undertaken by individuals or groups concerned with exposing contradictions
in the rationality or justice of social actions. Such theories can result from practical
interest (understanding and clarification), but they do not in themselves result in
action (in the context of PD, action is concerned with changing practice) (Carr &
Kemmis, 1986). Critical social science is concerned with the kind of action that arises
from raised awareness or increased understanding that leads to a desire by individuals
or groups to redress contradictions, oppressions or domination, rather than action
resulting from power or coercion. PD from a critical social science perspective,
therefore, is concerned with challenging and reframing established practices, as well
as opening up and showing tensions in language use. These processes encourage
productive dissension rather than taking surface consensus as a point for departure
(Garbett, 2005). The intention is to contribute to emancipationto encourage new
ways of thinking and acting.
In the context of PD, the work of Brian Fay has been used most often in the artic-
ulation of a critical social science perspective underpinning emancipatory PD (Fay,
1987). Through inductive retrospective analysis of PD activities, we have begun to
make explicit the links between Fays theories of critical social science and the meth-
odological perspectives of emancipatory PD (Table 1).
Fay undertook a critique of critical social science and concluded that the epistemo-
logical underpinnings of critical social science are valid (i.e. that a rigorous scientific
theory can be at the same time politically engaged through practical and critical
intent), but that its ontological basis was limited. Fay argued that these limitations
arose because of epistemological limits (to the capacity of individuals to achieve self-
actualisation), therapeutic limits (to the extent by which systems of domination can
be overcome by action arising from rational reflection), ethical limits (the emancipa-
tion of one group can oppress another) and power limits (constraints on human
power that restrict the ability of humans to be self-determining and therefore auton-
omous). As a result, Fay suggests that any social scientific theory that tries to be scien-
tific, critical, practical and non-idealistic all at once must consist of a complex of
theories which are systematically related to one another. Fay therefore suggested that
a comprehensive critical social scientific theory is necessarily comprised of a complex
of eight theories and 20 sub-theories (Table 2).
However, in our critique of Fays work as the epistemological foundation for PD,
we identified a number of limitations. Action-oriented models of research and devel-
opment (including participatory action research and emancipatory PD) reject inter-
pretive methods because of the naive assumption that having an understanding of a
situation leads to action. Habermas (1972) articulates such approaches as knowledge
that is focused on practical interest, i.e. knowledge that is concerned with under-
standing and clarifying how others see their worlds. Practical interest generates prac-
tical understanding which can inform and guide practical judgement. It is concerned
with the medium of language and the hermeneutic or interpretive sciences such as
phenomenology. Although greater understanding of patients and users experiences
may be achieved this does not necessarily result in a change in the way nurses (for
example) practise. It is the action component that is addressed by critical social
science, i.e. emancipatory interest. Critical social science argues that achieving under-
standing is necessary in order to identify possibilities for action, but it is only through
the processes of taking action and the learning that results that true enlightenment
(i.e. freedom from previous forces of domination that hinder effective action) can be
achieved.
Dunne (1993) argues that despite the intention of emancipatory interest it is
impossible to make previous understandings or ways of being disappear. Thus it is
argued that no matter how hard we try to bring about a perspective transformation,
prior understandings cannot be made to disappear because human beings are not that
rational. Individual pieces of our lives cannot be picked off and subjected to change.
These limits to rationality are further reinforced by too much weight being placed on
the clarity, and rationality potential, of language and human interaction (Alvesson &
Deetz, 2000). Habermas suggests that reaching consensus and stable understanding
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are the exception in everyday life and that a more realistic picture is that of a diffuse,
fragile, continuously revised and only momentarily successful communication
(1972, p. 100), where people feel their way from one occasional consensus to the
next. When agreement about change does occur it cannot be verified by rational
processes of verification, but instead, agreement can only be reached by the replace-
ment of barriers with motivating reasons for change. However, no change occurs in
isolation and thus constraining factors (such as organisational hierarchies, power
Table 2. The theories and sub-theories of critical social science (adapted from Fay, 1987)
Theory Sub-theory
1. False consciousness 1. Demonstrates the ways in which the self-understandings of a group
of people are false or incoherent or both.
2. Explains how the members of this group came to have these self-
misunderstandings and how they are maintained.
3. Contrasts them with an alternative self-understanding, showing
how this understanding is superior.
2. Crisis 4. Spells out what a crisis is.
5. Indicates why the particular crisis exists.
6. Provides a historical account of the development of this crisis in
terms of structures and processes.
3. Education 7. Offers an account of the conditions necessary and sufficient for
enlightenment to happen.
8. Shows how these conditions are satisfied in a given context.
4. Transformative
action
9. Isolates those aspects of a society that must be altered if the
dissatisfaction of a groups members is to be lessened.
10. Details a plan of action indicating how people who are to carry out
social transformation are to do this.
5. The body 11. Develops an explicit account of the nature and role of inherited
dispositions and the ways in which knowledge is embodied.
12. Points out how embodied knowledge is created without reaching
consciousness.
13. Spells out the limits which inherited dispositions and embodied
knowledge place on transformative action.
6. Tradition 14. Identifies which parts of a particular tradition are, at any given time,
changeable.
15. Identifies which parts of a particular tradition are, at any given time,
not changeable or worthy of change.
7. Power
2
16. Develops an account of the conditions and use of power in a
particular situation.
17. Explicitly recognises the limits and effectiveness of critical theory in
certain situations of power.
8. Reflexivity 18. Explains ones own historical tradition and makes explicit ones
own biases and prejudices in particular contexts.
19. Does not pretend that any one change is able to capture the essence
of emancipation.
20. Offers an account of the ways in which any change is contextual and
incomplete.
relationships with managers or national policies) which are often outside the power
of the individual to change, act as limitations to emancipation.
The limits of consensus in the making of rational judgements when deciding on the
choice of methods to effect change in a given context are largely reified in reports of
emancipatory change (Gore, 1992; Orner, 1992). Rather than focus on consensus,
Fay argues for the centrality of reflection in emancipatory processes. He suggests that
reflection is important not as a means of learning about theory but as a means of
learning about oneself in terms of the theory. Fays theory of the body is central to
being reflective, i.e. understanding how we inherit ways of being and the limits
imposed by these inherited dispositions on our freedom. Dunne (1993) argues that
our life-world is not freely available for thematic reflection and van Manen (2002)
argues that to make such an assumption denies the existence of and access to our pre-
consciousness. Critiques of critical social science argue that little consideration is
given to problematising mechanisms of empowerment such as critical reflection
(Manias & Street, 2000). This critique is evident in the PD literature, where reflective
learning strategies are actively encouraged but few critiques of the effectiveness of the
models used (such as action learning) are evident.
To overcome many of these limitations of critical social science, Fay argues that all
eight theories (Table 2) need to be kept in balance in order to achieve emancipation
because our world is marked by continual tension in human life between illumination
and activity on the one hand, and concealment and dependency on the other
(p. 215). He suggests that it is a mistake to focus on one side of the tension at the
exclusion of the other and that by integrating the eight theories into the critical social
science project, a balance can be achieved:
A proper critical social theory is one which possesses a stereoscopic vision which recog-
nizes every situation as one of both gain and loss, of change and stasis, of possibility and
limit. The amended scheme [eight theories] is meant to incorporate this dual vision.
(p. 215)
However, the methodological complexity in operationalising eight theories and 20
sub-theories in any one project is not addressed and thus, whilst Fay clearly articu-
lates a comprehensive theory of critical social science, little consideration of method-
ological approaches is proffered. Given the tensions that exist between ad hoc and
systematic development activities, the complexity of PD roles and the lack of prepa-
ration for practice developers (Garbett & McCormack, 2001), then the expectation
of holding these theories and sub-theories in balance would appear to be unrealistic.
Thus far, despite the claims for critical social science as the underpinning framework
for emancipatory PD (e.g. Manley & McCormack, 2004), there is no evidence, in the
literature, of Fays theoretical framework being used explicitly to frame PD projects.
This critique of critical social science led us to question its sufficiency as a compre-
hensive theory for PD that adequately captures and informs the creativity required in
operationalising PD methodologies. Increasingly, the importance of creativity in
development activities is explicitly recognised (Angus, 2001; Philipp, 2002; Titchen,
2004). The use of creative imagination and expression has recently been explored in
health and social care PD, education, evaluation and research (e.g. Payne, 1993;
Cotter et al., 2001; Spouse, 2000; Titchen & Higgs, 2001; Seizing the Fire, 2002;
Simons & McCormack, 2002; Coats et al., 2004; Manley et al., 2004).
The development of a new paradigmatic synthesiscritical creativity
Three phases of development were undertaken.
3
In Phase 1 we undertook artwork
(collage and painting) expressing how we experienced PD. Through these processes
we articulated our embodied knowing as practice developers exploring questions of
What is it like being a practice developer?, What does it feel like to be a practice
developer?, How do we articulate ways of knowing in our emancipatory activities?,
What models and frameworks help or hinder our intentions as practice developers?
The use of art enabled us to explore pre-conscious understandings and the placing of
these in the context of worldviews that guide our practice (such as critical social
theory, interpretive science). We used collage to map our individual and collective
journeys as researchers in the world of PD and to articulate key PD concepts such as
culture, context, evidence and reflection. In this work we tested our presuppositions
and espoused values in order to shed light on what Dunne (1993) describes as the
shadow side of emancipatory action (i.e. presuppositions). However, recognising
Fays (1987) challenge of embodiment and the need to understand how we inherit
roles and ways of being through the lived body, we recognised the need to go beyond
the interpretation of our artistic expression through words. This work led to Phase 2
of our methodological developmentembodiment of the attributes and processes.
We did this through the use of movement and dance in order to feel them. Having
danced with these attributes we interpreted our movements through paintings and,
through critical conversation, facilitated each other to articulate the key concepts
embedded in our embodied artwork. The critical conversations were tape-recorded.
Figures 13 present embodied artworks developed by Brendan, Angie and Maeve
with the key words/phrases highlighted that are representative of the concepts embed-
ded in the paintings.
Figure 1. Maeves painting Figure 2. Brendans painting Figure 3. Angies painting
Finally, in Phase 3, we listened to the tape-recordings of our critical conversations
and identified common words and phrases that articulated the key concepts embed-
ded in each of our embodied artworks. We generated lists of keywords and dialogued
meanings until metaphors representative of our collective meanings emerged.
Metaphors that were common across each of our paintings were:
spiralling through turbulence;
circles of connections;
creative effectiveness;
movement in the stillness;
embodied knowing;
energising forces;
openness to all ways of being;
flowing with turbulence.
We discussed each of these metaphors and derived a shared understanding of the
meanings embedded in each metaphor (Table 3). This dialogue led us to consider the
conceptual basis of critical creativity as a paradigm that synthesises other ways of
knowing within the critical paradigm.
Critical creativity as a paradigmatic synthesis for emancipatory practice
development and action research
The limitations of the interpretive and critical paradigms for providing philosophical,
theoretical and methodological justifications for emancipatory PD and action
research have been set out. Our work requires a new set of assumptions to underpin
our discovery that the use of creative imagination and expression enables people to go
beyond the limits that critique critical thinking and that being systematic can place on
potential visions and on the actions to achieve them. Titchen (in preparation) lays out
the current assumptions of creative inquiry that is undertaken through body senses,
emotions, spirituality, creative imagination and artistic expression influenced, for
example, by Gibran (1926), Merleau-Ponty (1962), Jung (1979), Eisner (1985),
Arrien (1993), Allen (1995), Osho International Foundation (1995), Goleman
Figure 1. Maeves painting
(1996), ODonohue (1997), McNiff (1998), Zohar and Marshall (2000), Seizing the
Fire (2002) and Simons and McCormack (2002). In that analysis, creative inquiry,
within the interpretive paradigm, is seen as located in the philosophical stance of
idealism and/or hermeneutics/existentialism/aesthetics and/or a range of spiritual
traditions and artistic ways of knowing. These philosophical assumptions shape and
colour emancipatory practice development and action research by influencing strate-
gies for change, the nature of action, the simultaneous creation of new understand-
ings and insights and how they are then used to inform subsequent action. So, what
is missing from this melding of idealism, existentialism, aesthetics, spirituality and
realism in existing notions of creative inquiry is the explicit notion of human flourish-
ing, both inner and outer, not only as an end to the project, but also as the means and
all that this entails. Whilst we know that a few researchers, such as Reason (1993) and
Denzin and Lincoln (2000), are working with, and promoting, the potential of such
human flourishing, we are unaware of any thorough paradigmatic, theoretical and
methodological exploration into achieving this potential in development and
research.
Whilst there is recognition within the interpretive and critical paradigms of the
use of creative imagination and expression as means of gathering, analysing and
Figure 2. Brendans painting
interpreting data and presenting findings, their intentional use for the above
purposes has not been justified philosophically, theoretically or methodologically.
Whilst critical creativity thus draws from the assumptions of the interpretive and
critical paradigms, we have identified assumptions that seem to be unique.
Philosophical assumptions
There are four philosophical assumptions that make critical creativity distinctive:
There is a creative connection and blending of assumptions, if assumptions across different
development and research paradigms are combined within a project. In order to answer
development, research and evaluation questions, most projects require the blending
of assumptions from different paradigms. The use of the creative arts enables a
pragmatic approach to the blending of differing worldviews with an attention to
embodied meanings, i.e. how it feels and is experienced, rather than getting caught
up in the detail of words the way that cognitive approaches often do (our phases of
development described earlier is just such an example!). A cognitive approach focuses
on acquiring a deep understanding of the assumptions of different paradigms in order
Figure 3. Angies painting
to justify the choice and blending of assumptions, philosophically and methodologi-
cally, because, for purposes of rigour, there must be coherence or epistemological and
ontological authenticity within a project or study. Whilst this cognitive understanding
is a vital part of professional artistry in development and research, it is acquired
through an often-prolonged scholarly and experiential engagement with epistemolog-
ical and ontological authenticity. However, this may not be feasible for busy health-
care practitioners and people who use health services who, without development or
research backgrounds, are involved in the design and carrying out of PD evaluation
Table 3. Embodied artwork keywords
Metaphor Metaphorical Meaning
Spiralling
through
turbulence
Practice development work creates turbulence in a given context through which
the practice developer needs to journey in a way that is authentic and consistent
with the shared values and beliefs of co-participants and that results in human
flourishing.
Circles of
connection
The methodology of practice development rejects linear models of personal and
professional growth. Through the creation of circles of connection, co-
construction of a shared reality is achieved which leads into a spiralling awareness
and understanding that has no beginning and no end. Such meanings are evident
in many ancient traditions such as the Celtic knot.
Creative
effectiveness
Creative effectiveness recognises the creativity embedded in all professional
practice and that to enable transformation, creative approaches to the facilitation
of increased understanding of effectiveness is required. Through blending,
improvisation, synchronicity, attunement and balance of professional artistry,
particularised creative approaches are made possible.
Movement in
the stillness
Not all PD work requires overt activity in order for movement to occur. The
stillness of reflection, contemplation and emptying the mind creates a movement
that enables future meaningful, ethical action and understanding to occur.
Embodied
knowing
Effective facilitation in practice development requires the embodiment of the
practice culture, i.e. a connection with the environment through an
internalisation of its culture(s) or the culture is enacted and seen through a
persons body/being in the world. Such knowing is usually difficult to put into
words and a facilitator helps others to recognise and articulate their own and
others embodied knowing.
Energising
forces
Transformation occurs through moments of crisis that trigger a need for change.
This crisis creates an energy for growth and flourishing or for the synthesis of
opposing or distinct forces, ideas, knowledges or understandings to create
something new. Creative expression at moments of crisis generates energy from
a new ability to express feelings, experiences, spirituality, ethical concerns,
embodied and tacit ways of knowing.
Openness to all
ways of being
Facilitators of practice development need to be open to and appreciative of
different worldviews.
Flowing with
turbulence
Whilst it is recognised that high challenge with high support is a key mechanism
for perspective transformation and emancipatory action, the conscious use of
turbulence is key to empathising with and facilitating particular developmental
journeys. Working with turbulence requires the use of emotional and spiritual
intelligences.
or research. We have found that the use of creative arts media can help such people
to grasp the blended assumptions of critical creativity and to live them together in
their work (see for example Table 1, Exemplar 3).
The use of creative expression to create synergy between cognitive and artistic approaches to
critique. This synergy is symbolised in the development processes we used to develop
the theory of critical creativity. The approach utilised a movement between creative
expression, critical dialogue and contestation in order to develop and understand key
concepts. Each stage combined cognitive with artistic critique, creating a synergy
through a reiterative, reciprocal dialogue between words and art forms.
Transformational development and research is person centred. Whilst the moral intent of
the critical paradigm (i.e. the achievement of social justice, democracy and equity) is
accepted in critical creativity, the moral intent of attaining human flourishing for all
involved requires further philosophical underpinning. We have found through expe-
rience that being person centred is key to human flourishing as ends and means in
development and research (e.g. Binnie & Titchen, 1999; McCormack, 2001; McCor-
mack & Titchen, 2001; Manley et al., 2004). Being person centred is linked to beliefs
and values about the intrinsic moral good of personhood and to a universal moral
principle that extends beyond politics, religion, wealth, privilege, cognition or ratio-
nality. McCormack (2004) described four dimensions of person-centred nursing
Being in relation; Being in a social world; Being in Place and Being with self. These
four dimensions of being in a therapeutic relationship locate person-centredness
within the philosophical framework of humanistic existentialism with its concern
about the value of being human, of existence and of the quality of that existence.
Three main characteristics, therefore, in this respect shape critical creativity: (1) the
uniqueness of the human individual; (2) a concern with the meaning and purpose of
human life; and (3) the individuals freedom to choose.
Emancipatory PD and research facilitators in this tradition are, therefore,
concerned with facilitating human potential and growth of the whole person. This
means finding out what peoples whole being needs are, from their own perspectives.
By seeking an understanding of peoples perspectives about their own experiences,
facilitators can help them to focus on their unique experiential journeys of learning,
critique, creativity and transformation. Within critical creativity, therefore, there is a
blending of the moral intent of the critical paradigm, with its focus on improvement
and transformation within the social world, with the moral intent of attaining
improvement and transformation of the individual life-worlds of persons (see for
example Table 1, Exemplar 4).
The three philosophical assumptions above are blended with spiritual intelligence. If emanci-
patory development and research is ultimately concerned with human flourishing in
its myriads of ways, then it is likely to involve the human spirit. Whilst recognising
that human flourishing may be understood and conceptualised in a variety of ways,
for us, the work of Lincoln and Denzin (2000) proved to be a useful starting point in
understanding human flourishing and is consistent with our current understandings:
We may be entering an age of greater spirituality within research efforts. The emphasis
on inquiry that reflects ecological values, on inquiry that respects communal forms of
living that are not Western, on inquiry involving intense reflexivity regarding how our
inquiries are shaped by our own historical and gendered locations, and on inquiry into
human flourishing as Heron and Reason (1997) call it, may yet reintegrate the sacred
with the secular in ways that promote freedom and self-determination We may be in a
period of exploring the ways in which we can both be and promote others being, as
whole human beings. (Lincoln & Denzin, 2000, p. 185)
Critical creativity is underpinned by an honouring of all forms of spirituality and
recognition that particular spiritual beliefs may imbue and shape knowing, doing,
being and becoming within a project. It is likely that people will hold a variety of spir-
itual beliefs, but that commonalities can be found. Within critical creativity, the two
commonalities of significance are spiritual intelligence and helping relationships
imbued with moderated love.
Spiritual intelligence refers to what human beings do with their deepest-held
spiritual beliefs and values, whatever the doctrine, wisdom or tradition. According to
Zohar and Marshall (2000), and Titchen and Higgs (2001), spiritual intelligence
enables people to address and solve problems of meaning and value and place their
actions, lives and pathways in wider, richer meaning-giving contexts. It gives human
beings their moral sense and allows them to discriminate, to aspire, to dream and to
uplift and energise themselves. Spiritual intelligence lets people work with the bound-
aries and shape and transform the situation. They call upon it when they are creative
and in moving into the unknown. They use their deep, intuitive sense of meaning and
value to guide them when they are at the boundary of order and chaos, that is, at the
very edge of their comfort zones. The idea of a moderated love within professional
relationships was first described by Campbell (1984). Since then, the importance of
such love in person-centred nursing (e.g. Bradshaw, 1996; Ersser, 1997; Binnie &
Titchen, 1999) and person-centred facilitation (e.g. Titchen, 2000a; Henderson,
2004) has been expressed, particularly through the process of graceful care. In our
experience, enabling the human flourishing of others requires a generosity of heart,
mind, body and spirit.
Theoretical assumptions
Four theoretical assumptions, located within the previous philosophical assumptions,
underpin critical creativity.
Conscious to unconscious blending of assumptions. Critique of assumptions begins
consciously through individual and group processes in order to link new ideas with
what people already know and also to blend different worldviews (epistemological
concerns). This work begins as a conscious blending process, but as people begin to
genuinely live the assumptions in their practices, there may be a move from conscious
to unconscious blending. In other words, the blending becomes embodied and part
of human being in the world (ontological concern). This theoretical assumption
builds on research into how nurses transform knowledge within their practice (e.g.
Benner, 1984; MacLeod, 1994; Titchen, 2000b; McCormack, 2002).
Connecting worldviews. As demonstrated above, in the context of different spiritual
traditions, the connecting of different worldviews can occur cognitively if commonal-
ities are found and distinctions honoured and acknowledged. Although this way of
connecting worldviews can occur in any paradigm, within critical creativity it can also
happen by seeking the archetypal wisdom between traditions or, in Jungian terms,
the collective unconscious.
Human flourishing is an intentional means as well as the ultimate end. This principle
makes explicit the integrated process and outcome intent of critical creativity. Human
flourishing is both a means and an end of transformative PD and research.
Human becoming. This assumption sees human becoming as the development of
mind, heart, body and spirit through approaches to learning and facilitation that draw
upon a variety of perspectives and traditions.
Methodological assumptions
Critical creativity assumes a critically creative approach to reflective action as the
key methodological approach. Professional artistry provides the synergy and power
to blend the philosophical and theoretical assumptions and convert them into
action in transformative development and research. Professional artistry is a blend-
ing of personal qualities (e.g. bodily, emotional and spiritual intelligences, passion,
courage, connoisseurship), practice skills (e.g. critical appreciation, metacognitive
skills), creative imagination processes (e.g. emptying the mind, going with the
unexpected or bizarre without knowing where it is going), creative and practice
wisdom with authentic use of self (Titchen & Higgs, 2001). This blend is used to
mediate science in professional practice, i.e. particularising propositional knowledge
to make it useful to the particular situation and people. Blending and particularisa-
tion seem to involve artistic processes, such as appreciation, attunement, harmoni-
sation, synthesis, being able to see the whole and the parts of some aspect of
professional practice or experience and moving between them and getting the
balance and form right.
Whilst professional artistry itself is not unique to critical creativity, its focus on a
critically, creative approach to reflective action is. This approach is concerned with:
Learning through intellectual, aesthetic and expressive creativity.
Releasing energy for creative practice through the use of creative arts media (Coats
et al., 2004) and intellectually creative thinking and problem solving.
Practising creatively as a practitioner, facilitator/educator, developer or researcher.
Methods
There are no differences in the actual methods for data gathering, analysis, interpre-
tation and presentation used within transformational development and research with
those utilised in the interpretive and critical paradigms. It is, of course, their intent
and the philosophical and theoretical assumptions above that differ. However,
research methods set within a critically creative methodological framework exist in a
dynamic state and in a constant state of movement. Roths (1990) 5 rhythms (flow-
ing, staccato, chaotic, lyrical and still) is a useful framework for understanding the
dynamic movement that takes place in methods in order to achieve the intent of trans-
formation.
Having articulated the assumptions underpinning critical creativity, we move now
to present a theoretical framework for transformational PD and action research
located in the critical paradigm.
Creativitya framework for transformative action
In our journey so far, we have critiqued critical social science in the context of trans-
formational PD and action research through philosophical, theoretical and method-
ological analysis. Fundamentally, we argue that whilst Fays eight theories of critical
social science provide an appropriate underpinning for transformational action, they
fail to capture the creativity that underpins much PD and action research work. We
therefore propose a significant elaboration and alteration of sub-theory 10 by focusing
on ways in which practice can be transformed through a critically creative engage-
ment with practice. We name this addition, creativity, and set it out in the context
of holistic engagement that is at the heart of critical social science. In the context of
Fays model, creativity blends and melds the 20 sub-theories and we define it as:
the blending and weaving of art forms and reflexivity (critical consciousness) located in the
critical paradigm. Blending and weaving occur through professional artistry in order to
achieve the ultimate outcome of human flourishing. Thus this theory has critical, moral
and sacred dimensions.
Figure 4 presents the theoretical framework for human flourishing within a critical
creativity worldview.
Figure 4. A theoretical framework for human flourishing located in the critical creativity dimension
The imagery (i.e. the spirals, movement in stillness at the centre, energising forces,
flowing with turbulence, etc.) represented in the framework was derived from the co-
construction through the creation of a sculpture with fellow inquirers and critical
dialogue. The co-construction followed the integration of creative and cognitive
processes as described earlier. Reflecting on the processes of construction further
enabled the philosophical, theoretical and methodological principles of critical
creativity to be articulated, affirmed and confirmed through embodiment, debate,
discussion and contestation.
The praxis spiral is the central spiral of the framework. It represents the journey
from wherever we are now towards human flourishing as the ends and means of trans-
formational development and action research. The journey is facilitated through the
processes of blending, connecting, energising, reflecting, practising, learning and
becoming.
The concept of praxis or practice wisdom/thoughtful doing with a moral intent has
been around for millennia (Aristotle created the term). Known as the practical
discourse in philosophy, it has been influenced, over time, by the dominant philo-
sophical thinking of the age. This means that different theories, values and beliefs
have influenced deliberative human action. Relevant here are the notions of emanci-
patory praxis and hermeneutic praxis. (The terms emancipatory and hermeneutic
refer to the intent and philosophical roots of particular kinds of praxis, that is, eman-
cipation from obstacles and understanding/transformation, respectively, as discussed
above.) Emancipatory praxis, for us, emerges from the philosophical underpinnings
of critical social science as critiqued above. Thus praxis and the praxiological
knowledge that accrues from it is about seeking to overcome the external and internal
barriers to achieving, in our case, human flourishing for all, through the delivery and
receipt of person-centred, evidence-based care. Hermeneutic praxis, on the other
Outcome:
Human
flourishing
8

2
1
4
5
6
7
Critical
practice
theories
3
Praxis spiral for
human flourishing
enabled by
professional
artistry
CRITICAL
CREATIVITY
Figure 4. A theoretical framework for human flourishing located in the critical creativity
dimension
hand, is concerned with reflexivity and transformation of understanding and thus
transformation of self, teams, organisations and communities. It emerges from the
philosophical tradition of hermeneutics.
As we are concerned with overcoming barriers and transformation, the praxis spiral
in our framework is influenced by a blending of emancipatory and hermeneutic
praxis, undertaken by transformational practice developers and action researchers.
We have highlighted in the figure the recurring processes that surfaced through our
use of creative arts media within the PD colloquium and previous scholarly inquiries.
Both the emancipatory and hermeneutic traditions use the spiral as imagery: the
recurring spirals of planning, action, observation, reflection, in relation to emanci-
patory praxis, and the spiral of reflexivity and increasing understanding, in relation to
hermeneutic praxis. In our cooperative inquiry, the spiral also keeps emerging as a
significant symbol of the practice ontology of transformational practice developers
and researchers (see Figures 13). It is for these reasons that we have chosen to repre-
sent praxis as a spiral. And because we engage in praxis when we are working with the
nine critical practice theories, we have also represented those theories as spirals. We
have placed praxis centrally because it is through this spiral that we tap our paradig-
matic foundation, that is, critical creativity, shown in Figure 4 as dynamic energy or
Catherine Wheel. This spiral then connects with the theory spirals at the centre of the
figure when we engage in praxis. Thus critical creativity flows throughout our frame-
work.
Professional artistry enabling the praxis spiral
Professional artistry is the meaningful expression of a uniquely individual view within
a shared tradition and involves the blending of practitioner qualities, practice skills
and creative imagination processes (Higgs et al., 2001). The blending of these quali-
ties, skills and processes is referred to as practice wisdom. But exactly what practice
wisdom is and how theory and practice become one are rarely articulated. This is
where we believe that the philosophical tradition of pragmatism has something to
offer to our blend of philosophical perspectives. Building on the ideas of pragmatist
and educationist John Dewey (1933), Donald Schn (1983), based on a scholarly
approach to his own and others practice, proposed that professional practice requires
professional artistry to mediate science within, and use generalisable, propositional
knowledge for, the particularity of professional practice. Within healthcare, Schns
ideas were elaborated and refined by Titchen and Higgs (2001) by combining previ-
ous hermeneutical nursing research (e.g. Benner, 1984; MacLeod, 1994; Titchen,
2000b) with their own scholarship (e.g. Higgs et al., 2001). They proposed that
professional artistry, as described above, encompasses practice wisdom. According to
Titchen and Higgs, the qualities, skills and processes of professional artistry and their
blending are built up through extensive introspective and critical reflection upon, and
review of, practice. This view supports our notion of reflecting, practising, learning
and becoming within the praxis spiral. Through a blend of cognitive and artistic
critique, transformational action researchers are able to turn the eight critical practice
theory spirals (Figure 4) into informed, transformed and transforming action with the
moral intent of social justice, equity and human flourishing for all stakeholders.
Professional artistry enables the continual reconstruction of theory in and on practice.
This is an area ripe for research to test and elaborate.
Resting place
In this article we have articulated an emerging paradigmatic synthesis of critical
creativity. We have proposed an elaboration and alteration of sub-theory 10 through
the theory of creativity as the blending of art forms and reflexivity, facilitated through
the blending and weaving that is evident in professional artistry in order to achieve the
outcome of human flourishing. We have outlined the background to this work includ-
ing our philosophical and methodological journeys with critical social science and the
creative arts that have enabled the articulation of critical creativity. Whilst recognising
the need to undertake further work clarifying the concepts underpinning the
proposed theory of creativity in Fays framework in order to make explicit the rela-
tionship between it and the other theories, this article provides a framework for those
interested in the integration of action-oriented methods of research and development
with the creative arts. Our challenge is to ensure that the theory of creativity possesses
what Fay describes as a stereoscopic vision for the integration of art forms with
reflexivity in order to enable human flourishing. Little work has been undertaken to
develop theoretical frameworks that integrate creative expression with systematic
approaches to research and development. The use of critical creativity as philosoph-
ical, theoretical and methodological bases enables traditional paradigms and research
methods to be challenged and explored. We propose here that the new theoretical
framework presented in this article underpins action research and offers direction for
action researchers who are interested in working with a creative methodology through
the integration of cognitive and artistic methods. The philosophical and theoretical
principles articulated here offer a basis for the co-construction of methodologies in
action research and PD. This journey of theoretical construction and methodological
development is far from over! We welcome further dialogue to assist us on our way.
Notes
1. We are grateful to Professor Brian Fay, who, through the process of peer review, provided us
with a form of words to help articulate the central message of our article when we were strug-
gling to do this in a way that captured the essence of our message. Professor Fays critique
enabled us to achieve a greater theoretical clarity in our work.
2. In Fays (1987) original work, he used the word force instead of power. For the purposes of
this article and our understanding of critical social science in the context of the development of
practice in health and social care contexts, we understand Fay to mean power when he uses
the word force.
3. The development processes were undertaken with some other members of the practice devel-
opment colloquium, namely: Maeve McGinley, Liz Henderson, Carolyn Kerr and Cathy
OConnell. We wish to acknowledge their contribution to the development of our understanding
of critical creativity and the articulation of key attributes and processes. We also wish to acknowl-
edge the critique offered by other members of the colloquium.
References
Allen, P. (1995) Art is a way of knowing: a guide to self-knowledge and spiritual fulfillment through
creativity (London, Shambhala).
Alvesson, M. & Deetz, S. (2000) Doing critical management research (London, Sage).
Angus, J. (2001) A review of evaluation in community-based art for health activity in the UK (Durham,
Centre for Arts and Humanities in Health and Medicine).
Arrien, A. (1993) The four-fold way (San Francisco, CA, Harper).
Benner, P. (1984) From novice to expert: excellence and power in clinical nursing practice (London,
Addison-Wesley).
Binnie, A. & Titchen, A. (1999) Freedom to practise: the development of patient-centred nursing
(Oxford, Butterworth Heinemann).
Bradshaw, A. (1996) Recovering the covenant tradition of patient-centred nursing, in: K. W. M.
Fulford, S. Ersser & T. Hope (Eds) Essential practice in patient-centred care (Oxford, Blackwell
Science), 2235.
Campbell, A. V. (1984) Moderated love (London, Society for Promoting Christian Knowledge).
Carr, W. & Kemmis, S. (1986) Becoming critical: education, knowledge and action research (London,
Falmer Press).
Clarke, C. & Wilcockson, J. (2001) Professional and organizational learning: analysing the
relationship with the development of practice, Journal of Advanced Nursing, 34(2), 264272.
Clarke, C., Reed, J., Wainwright, D., McClelland, S., Swallow, V., Harden, J., Walton, G. &
Walsh, A. (2004) The discipline of improvement: something old, something new?, Journal of
Nursing Management, 12(2), 8596.
Coats, E. (Ed.), Stephens, G., Titchen, A. et al. (2004) Creative arts and humanities in healthcare:
swallows to other continents (London, The Nuffield Trust).
Cotter, A., Fraser, F., Langford, S., Rose, L. & Ruddock, V. (2001) Getting everybody involved.
Report on a Magic Me action research project including people with dementia and those who work
with them (London, Magic Me).
Denzin, N. & Lincoln, Y. S. (Eds) (2000) Handbook of qualitative research (2nd edn) (London, Sage).
Dewey, J. (1933) How we think (Boston, MA, D. C. Heath).
Dewing, J. (2004) Concerns relating to the application of frameworks to promote person-centred-
ness in nursing with older people, International Journal of Older People Nursing, 13(3a), 3944.
Dunne, J. (1993) Back to the rough ground: phronesis and techne in modern philosophy and in Aristotle
(London, University of Notre Dame Press).
Ersser, S. J. (1997) Nursing as a therapeutic activity: an ethnography. Developments in Nursing and
Health Care 14 (Aldershot, Avebury).
Eisner, E. (1985) The art of educational evaluation: a personal view (London, Falmer Press).
Fay, B. (1987) Critical social science (Cambridge, Polity Press).
Garbett, R. (2005) Governmentality and practice change: using Foucault to critique practice develop-
ment. Unpublished doctoral thesis, University of Ulster.
Garbett, R. & McCormack, B. (2001) The experience of practice development: an exploratory
telephone interview study, Journal of Clinical Nursing, 10, 94102.
Garbett, R. & McCormack, B. (2002) A concept analysis of practice development, NT Research,
7(2), 87100.
Garbett, R. & McCormack, B. (2004) A concept analysis of practice development, in: B. McCor-
mack, K. Manley & R. Garbett, Practice development in nursing (Oxford, Blackwell), 1032.
Gerrish, K. (2001) A pluralistic evaluation of nursing/practice development units, Journal of Clinical
Nursing, 10(1), 109118.
Gibran, K. (1926) The prophet (London, Heinemann).
Goleman, D. (1996) Emotional intelligence: why it can matter more than IQ (London, Bloomsbury).
Gore, J. (1992) What we can do for you! What can we do for you?: struggling over empower-
ment in critical and feminist pedagogy, in: C. Luke & J. Gore (Eds) Feminisms and critical
pedagogy (New York, Routledge), 5473.
Grundy, S. (1982) Three modes of action research, Curriculum Perspectives, 2(3), 2334.
Habermas, J. (1972) Knowledge and human interests (J. J. Shapiro, Trans.) (London, Heinemann).
Henderson, E. (2004) Critical application of Johari Window in the development of clinical nurse special-
ists practice, utilising narrative inquiry. Unpublished Masters degree dissertation, University of
Ulster, Northern Ireland.
Heron, J. & Reason, P. (1997) A participatory inquiry paradigm, Qualitative Inquiry, 3, 274294.
Heron, J. & Reason, P. (2001) The practice of co-operative inquiry: research with rather than
on people, in: P. Reason & H. Bradbury (Eds) Handbook of action research (London, Sage).
Higgs, J. & Titchen, A. (Eds) (2001) Professional practice in health, education and the creative arts
(Oxford, Blackwell Science).
Higgs, J., Titchen, A. & Neville, V. (2001) Professional practice and knowledge, in: J. Higgs & A.
Titchen (Eds) Professional practice in health, education and the creative arts (Oxford, Blackwell
Science).
Horkheimer, M. (1982) Critical theory (New York, Seabury Press).
Jung, C. (1979) Word and image (Princeton, NJ, Princeton University Press).
Lincoln, Y. S. & Denzin, N. (2000) Paradigmatic controversies, contradictions, and emerging
confluences, in: N. Denzin & Y. S. Lincoln (Eds) Handbook of qualitative research (2nd edn)
(London, Sage), 163188.
McCormack, B. (2001) Negotiating partnerships with older peoplea person-centred approach (Basing-
stoke, Ashgate).
McCormack, B. (2002) In search of the bullexcellence through enquiry, The All Ireland Journal
of Nursing & Midwifery, 2(4), 3641.
McCormack, B. (2004) Person-centredness in gerontological nursing: an overview of the
literature, International Journal of Older People Nursing, 13(3a), 3138.
McCormack, B. & Titchen, A. (2001) Patient-centred practice: an emerging focus for nursing
expertise, in: J. Higgs & A. Titchen (Eds) Practice knowledge and expertise in the health
professions (Oxford, Butterworth-Heinemann).
McCormack, B., Kitson, A., Harvey, G., Rycroft-Malone, J., Titchen, A. & Seers, K. (2002)
Getting evidence into practice: the meaning of context, Journal of Advanced Nursing, 38(1),
94104.
McCormack, B., Manley, K. & Wilson, V. (2004) Evaluating practice developments, in: B.
McCormack, K. Manley & R. Garbett, Practice development in nursing (Oxford, Blackwell),
83117.
MacLeod, M. (1994) Its the little things that count: the hidden complexity of everyday clinical
nursing practice, Journal of Clinical Nursing, 3, 361368.
McNiff, S. (1998) Art-based research (London, Jessica Kingsley Publishers).
Manias, E. & Street, A. (2000) Possibilities for critical social theory and Foucaults work: a
toolbox approach, Nursing Inquiry, 7(1), 5060.
Manley, K. (1997a) A conceptual framework for advanced practice: an action research project
operationalizing an advanced practitioner/consultant nurse role, Journal of Clinical Nursing,
6(3), 179190.
Manley, K. (1997b) Editorial: Practice development: a growing and significant movement, Nurs
Crit Care, 2(1), 5.
Manley, K. (2001) Consultant nurse: concept, processes, outcomes (London, University of Manchester/
RCN Institute).
Manley, K. (2004) Transformational culture: a culture of effectiveness, in: B. McCormack, K.
Manley & R. Garbett, Practice development in nursing (Oxford, Blackwell), 5182.
Manley, K. & McCormack, B. (2004) Practice development: purpose, methodology, facilitation
and evaluation, in: B. McCormack, K. Manley & R. Garbett, Practice development in nursing
(Oxford, Blackwell), 3350.
Manley, K., Hardy, S., Titchen, A., Garbett, R. & McCormack, B. (2004) Changing patients
worlds through nursing practice expertise: a research report (London, Royal College of Nursing).
Merleau-Ponty, M. (1962) Phenomenology of perception (London, Routledge).
Nolan, M., Davies, S., Brown, J., Keady, J. & Nolan, J. (2004) Beyond person-centred care: a
new vision for gerontological nursing, International Journal of Older People Nursing, 13(3a),
4553.
ODonohue, J. (1997) Anam cara: spiritual wisdom from the Celtic world (London, Bantam Press).
Orner, M. (1992) Interrupting the calls for student voice in liberatory education: a feminist post-
structuralist perspective, in: C. Luke & J. Gore (Eds) Feminisms and critical pedagogy (New
York, Routledge), 7489.
Osho International Foundation (1995) Returning to the source: talks on Zen (Shaftesbury, Element
Books).
Payne, H. (1993) Handbook of inquiry in the arts therapies: one river many currents (London, Jessica
Kingsley).
Philipp, R. (Ed.) (2002) Arts, health and well-being: from the Windsor 1 Conference to a Nuffield
Forum for the Medical Humanities (London, The Nuffield Trust).
Reason, P. (1993) Sacred experience and sacred science, Journal of Management Inquiry, 2, 1027.
Roth, G. (1990) Maps to ecstasy: teachings of an urban shaman (San Rafael, CA, Mandala).
Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A. & McCormack, B. (2003) What
counts as evidence in evidence-based practice, Journal of Advanced Nursing, 47(1), 8190.
Schn, D. A. (1983) The reflective practitioner: how professionals think in action (London, Temple
Smith).
Seizing the Fire (2001) A collaborative inquiry into using creative arts in health & social care and
education, presentation at Enhancing Practice, 1st Annual Joint Conference, RCN Institute,
RCN Research Society, Collaborative Action Research Network and Foundation of Nursing
Studies, University of Keele.
Seizing the Fire (2002) Using the arts in research workphilosophical twists and methodological
turns, presentation at Enhancing Practice, 2nd Annual Joint Conference, RCN Institute, RCN
Research Society, Collaborative Action Research Network and Foundation of Nursing Stud-
ies, University of Keele.
Simons, H. & McCormack, B. (2002) Arts-based inquiry: the challenges for evaluation, paper
presented to Annual Conference, The Art of Evaluation, United Kingdom Evaluation Society
Conference, South Bank Centre, London.
Spouse, J. (2000) Talking pictures: investigating personal knowledge through illuminative art-
work, Nursing Times Research, 5(4), 253261.
Titchen, A. (2000a) Growing a new species of research and researchers: new directions for research in the
interpretive and critical paradigms using the creative arts. Centre for Professional Education
Advancement, University of Sydney.
Titchen, A. (2000b) Professional craft knowledge in patient-centred nursing and the facilitation of its
development. D.Phil., Linacre College Oxford (Tackley, Ashdale Press).
Titchen, A. (2004) Helping relationships for practice development: critical companionship, in: B.
McCormack, K. Manley & R. Garbett (Eds) Practice development in nursing (Oxford, Blackwell
Publishing), 148174.
Titchen, A. (in preparation) Qualitative research: philosophical starting points.
Titchen, A. & Higgs, J. (2001) Towards professional artistry and creativity in practice, in: J. Higgs
& A. Titchen (Eds) Professional practice in health, education and the creative arts (Oxford, Blackwell
Science), 273290.
Tolson, D. (1999) Practice innovation: a methodological maze, Journal of Advanced Nursing,
30(2), 381390.
Unsworth, J. (2000) Practice development: a concept analysis, Journal of Nursing Management, 6,
317322.
van Manen, M. (2002) Researching lived experience: human science for an action sensitive pedagogy
(London, The Althouse Press).
Wilson, V. (2005) Developing a vision for teamwork, Practice Development in Health Care, 4(1),
4048.
Wilson, V. & McCormack, B. (2006) Critical realism as emancipatory action: the case for realistic
evaluation in practice development, Nursing Philosophy, 7, 4557.
Wilson, V., McCormack, B. & Ives, G. (2005) Understanding the workplace culture of a special
care nursery, Journal of Advanced Nursing, 50(1), 2738.
Zohar, D. & Marshall, I. (2000) SQ: spiritual intelligence the ultimate intelligence (London,
Bloomsbury).

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Educational Action Research

Vol. 14, No. 2, June 2006, pp. 239266

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