Developing Reflexivity in Students: an essential component for clinical reasoning and decision making

1. Developing Reflexivity in Students: an essential component for clinical reasoning and decision making Dr Marie Donaghy Head of School of Health Sciences

2. Defining reflexivity • looking closely at one’s self in relation to actions thoughts and behaviours in relation to particular activities / situations and considering the outcome of these actions. • Donaghy (2003)

4. Rationale • Reflective practice has been linked to: • clinical decision making • competence to practice • critical self-appraisal and life long learning

5. Defining reflection in the context of Physiotherapy • “…….activities in which physiotherapists engage to critically analyse and evaluate their experiences in order to lead to new understandings of the way they think and operate in the clinical setting”. • Donaghy and Morss (2000)

6. Purpose • A framework was specifically developed to facilitate and assess reflective practice by physiotherapy students in the clinical context. • The aim of the study was to evaluate the framework

7. Stages of the Framework • Select and describe one patient case in writing - reviewing the process of data analysis and problem identification • Engage in an on-placement structured taped dialogue with a tutor • Write up 1500 word report

8. Study participants • 43 third year physiotherapy students who give informed consent participated in 5 focus groups.

10. Methodology • Post modern qualitative approach • Over a three year period 35%-45% of the student cohort participated in focus groups to explore students’ experience of using the reflective framework

11. Analysis • One hour discussions recorded and transcribed verbatim • Students were numbered to anonymise but allow tracking • Numbered responses were recorded during the interview by an independent observer

12. Analysis • Data were analysed by scrutinising scripts identifying emergent themes and sub themes. • Excel was used to record themes, individual responses and transcript location.

13. Results • Two key categories related to process and outcome emerged from the thematic analysis. • Process related themes focused on strengths and weaknesses and issues in using the framework

14. Strengths of using the framework • Students reported that using the framework gave them insight into their own behaviour thoughts and feelings .

15. ‘‘I also wrote about what I was feeling, my personal feelings about ‘Oh no, I should have got her lying differently’ …..or I should have asked her about that’ 2:4(D)

16. It facilitated self-critique ‘………..it is making you question yourself what you have done and when you come across a similar sort of situation you know that there are a number of options, you don’t just go automatically for the first easy option.’ 5:7(2)

17. It enabled them to recognise their own and others expectations ‘it made me realise that the expectations that I was putting on myself were not realistic I wanted to be much better than I was at that stage’ 4:4 (2)

18. Prompter questions • The prompter questions helped students concentrate on -

19. Assumptions ‘I think it makes you realise that you make assumptions about people, you look at the records,before going to see them and you have this little image of what you are going to see and quite often you are surprised, not just by the type of person but how they look…….. 5:1(7)

20. Habits ‘I noticed that if I hadn’t looked back and seen why I had made those decisions, I would have just continued with those bad habits…. 4:2 (7)

21. Performance ‘I think when you do have a difficult patient you can get bogged down with it and think oh, I did that terribly, but when you are reflecting back you actually find bits that you have done well and bits not so well.’ 5:5 (2)

22. Taped dialogue • The taped dialogue which encourages analysis of actions, reactions, thoughts and decisions was said to be most effective in developing clinical reasoning skills. • The tape serves as ‘evidence’ for further reflection

23. I felt after the taped interview that this was the real reflective process I got a lot of feedback through that.’ 2:7(3) ‘

24. ‘…….actually talking just allowed me to think.’ 3:6(T)

25. Written Report • Some students found that writing of the final report was helpful in identifying an action plan for improving practice.

26. ‘I found actually writing it down cleared everything up. The interview did help but when it come to the crunch, I found it easier to identify areas that could be improved upon next time from reading it.’ 5:8(2)

27. Weaknesses of using the Framework • Some students felt that the focus on one patient was too narrow this linked to a desire to focus on a problematic case.

28. ‘It needs to be complicated enough for you to have problems with it.’ 3:11(K)

29. Most students felt that there was variation in tutors expectations. ‘So although they have got the same guidelines, I think all the lecturers have a slightly different view of how they want the assignment done. 3:3(E)

30. ‘I think different tutors are marking in different ways.’ 2:4(L)

31. Writing in the first person • Students found it difficult to write in the first person, for several reasons:

32. Writing in this form of syntax was awkward for some ‘………….we have always just written scientific type essays….. so to suddenly change and use all different types of adjectives to describe how you are feeling, was difficult …’ 4:9(5)

33. ….for others it made them feel uncomfortable. ‘…it is not very comfortable. It is difficult to write things down that you know people are going to read but that is what it is about.’ 5:6(7)

34. Issues of Assessment • Students taking part in the focus groups recognised the tensions created by assessment. Their opinions about the impact of the assessment are represented by these statements:

35. ‘…you wouldn’t go into it in as much depth if it wasn’t part of your coursework.’ 1:24(H)

36. ‘If it wasn’t going to be assessed you wouldn’t have thought so much about what you were writing.’ 4:10(5)

37. ‘…I needed those two assignments to make me start thinking like that.’ 3:16(T)

38. Fabrication in assessment Students freely discussed the issue of fabricating or embellishing the narrative written in the final report.

39. ‘I think about writing what I think will get me a good mark, basically I think they want to see me writing about this particular thought process, so I am going to write it regardless if it was my thought process or not.’ 2:6(P)

40. Several students admitted embellishing their accounts ‘I know I tended to exaggerate a bit. I made it sound like I had made a mess of a situation when in fact it wasn’t too bad. You knew you had to write, if you could be seen to be looking at the situation and learning from it… 3:8(H)

41. Conclusions • The framework is a useful tool to facilitate and assess personal reflection • It encourages students to be self-critical and to learn from experience • Assessment is an important component although fabrication and variance in tutor expectation is an issue

43. Recommendations • Reflective exercises, including writing in the first person, are introduced in year 1 • Appropriate training is undertaken by staff • Students are facilitated to use reflection to evaluate routine tasks not just complex issues and critical incidents