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Fostering Fellow/Resident Professional Reasoning and

Interprofessional Practice Through Clinical Narratives

Bobbi Greiner, OTD, OTR/L

Jennifer Furze, PT, DPT, PCS

Anna Domina, OTD, OTR/L

June 28, 2019

Learning Objectives

1.Describe the use of clinical narratives as a teaching strategy of facilitate clinical reasoning and as an assessment tool to evaluate reasoning.

2.Justify the use of the clinical narrative as a teaching tool to integrate clinical reasoning into interprofessional clinical practice.

3.Discuss strategies for implementation and assessment of clinical narratives in residency and fellowship programs or professional curricula.

The PresentersJennifer Furze, PT, DPT, PCS• Associate Professor/ Vice chair

• Pediatric PT Residency Coordinator

Bobbi Greiner, OTD, OTR/L, BCP• Assistant Professor

• Pediatric OT Fellowship Coordinator

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OT Fellowship & PT Residency Programs at Creighton

• OT Fellowship Programs– Gerontology

– Neurology

– Pediatric

• PT Residency Programs– Geriatric

– Neurology

– Orthopedic

– Pediatric

– Women's Health

• A process to facilitate reflection on experiences in the clinical setting

• “See the Mentee’s thinking”

• Clinical cases provide the first order of experience and clinical narratives allow for the 2nd order of experience as the resident re-collects the information about the case, re-experiences the case, and re-reflects upon the experience. It is a process of learning from the experience.

What is a Clinical Narrative?

We do not learn from experience.

We learn from reflecting on experience.

John Dewey

Learning Through Reflection

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OT & PT Educational Continuum & Clinical Narratives

• Reflection on Action –reflection occurs after you have completed your action

• Reflection in Action – deciding in the moment based on your reflection

• Reflection for Action –planning/reflecting for future event and what may occur

Critical Reflection

Development of Clinical Reasoning (Furze et al, 2015)

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Gibbs Reflective

Cycle

Description

Feelings

Evaluation

Analysis

Conclusions

Action

Gibbs Reflective Cycle

• Detailed description of the scenario

• What happened?

• When and where did this happen?

• What did I do?

• What did other people do?

• What was the outcome?

Gibbs Reflective

Cycle

Description

Feelings

Evaluation

Analysis

Conclusions

Action

What: Paige was a 22-year-old college student majoring in elementary education and had endured chronic low back painWhen: For the last 10 years, since she was in a car accident in middle school.What did I do? At this point in the examination I am thinking to myself, how am I going to work with and help this patient who is so clearly frustrated and in so much pain that she can barely go throughout her day? I had never worked with anyone with this severe of chronic low back pain and high fear of movement before. I am sitting there listening to her in the subjective examination, trying to figure out where I can even start, and deep down I am freaking out about how to comfort Paige while also trying to continue with my objective examination and start with therapeutic interventions.

PT Resident

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Gibbs Reflective

Cycle

Description

Feelings

Evaluation

Analysis

Conclusions

Action

Gibbs Reflective Cycle

• Thoughts, feelings, and emotions related to the event

• What was I thinking and how did I feel before, during, and after the event?

• What do I think other people thought and felt before, during, and after the event?

Feelings I had: I could see the disappointment on the student’s face, and I felt it as well. We may have boxes of AFOs available, but if we cannot get her ankle remotely close to neutral, they will likely not be of any service and could cause more harm than good related to skin integrity. I felt conflicted; I wanted us to be able to help Esteffany so badly.

PT Resident

Feelings I had: While administering this intervention I was nervous. I wanted this session to be of benefit to the patient and for him to be satisfied at the end of it. I also wanted to feel more confident in my skills by planning the intervention and then adjusting it if needed as the session went on. I think the patient felt challenged and maybe a little nervous too.

OT Level I Student

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Gibbs Reflective Cycle

• Reflect on the pros and cons of the experience

• What went well?

• What did not go well?

• What did I and others do to contribute to the situation?

Gibbs Reflective

Cycle

Description

Feelings

Evaluation

Analysis

Conclusions

Action

Evaluation: As I have reflected, there was so much I gained from this evaluation in terms of clinical reasoning and reflection. The most challenging part of this evaluation, however was the constant oral seeking behaviors and the visual aspect as it so significantly impacted function. When working with adults or even older children it can be so easy to obtain information regarding vision. However, when working with someone who does not verbally communicate and is constantly moving and bouncing between activities, it can be difficult to discern one component from another. It required significant thought and creativity to work through especially as this child has difficulty processing and modulating other sensory systems. There are multifactorial pieces to this puzzle, however, seeing positive results with a treatment in the initial evaluation directly related to the caregiver’s goals was incredible. As I formulated goals to address in this plan of care, I frequently thought about how an insurance company or someone reimbursing services might interpret the function of this child and the potential for gains.

OT Fellow

Evaluation: My experience with this client was motivating for me as a student to continue learning and growing so I can one day help severe cases like these. It showed me the importance of clinical reasoning and being able to address activities and occupations that were feasible for him to complete again or the steps needed to get there. This experience was positive overall because I got to engage with the client during the process and practice on my client interaction and fine tune my clinical reasoning and problem solving.

OT Level I Student

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Gibbs Reflective Cycle

• Provide rationale for the outcome of the experience

• Why did the situation go well?

• Why did the situation go poorly?

• What could have been done to avoid the negative consequences?

Gibbs Reflective

Cycle

Description

Feelings

Evaluation

Analysis

Conclusions

Action

Analysis: As I discussed this evaluation with my mentor afterwards, I liked how he gave the analogy of “if we’re trying to connect the dots and come to a concluding picture, we can get confused if we have too many dots.” In this case, where I was flustered and overwhelmed, I started adding too many dots and lost the connection, ending up with a fuzzy and inconclusive picture. Language barriers can be tough, and I do think it will continue to take practice utilizing interpreters to break down those barriers. As I reflect, I have found areas I struggled and areas I succeeded. I felt I struggled establishing an effective communication bridge but was still successful in obtaining important information that allowed me to provide a treatment that was effective.

PT Resident

Gibbs Reflective Cycle

• Brainstorm alternative actions or responses– How could this have been a

more positive experience for everyone involved?

• Identify gaps in knowledge and skills– What skills do I need to

develop so that I can better handle this type of situation in the future?

Gibbs Reflective

Cycle

Description

Feelings

Evaluation

Analysis

Conclusions

Action

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Gibbs Reflective Cycle

• Develop a plan

• Seek resources to fill the identified knowledge and skill gaps

• If the situation arose again, what would I do?

Gibbs Reflective

Cycle

Description

Feelings

Evaluation

Analysis

Conclusions

Action

Future: I learned many valuable lessons throughout this care. I learned the importance and necessity of deep, thorough evaluation. If I would have stopped Betty’s cognition evaluation after the Kettle Test, there would have been no objective evidence for any sort of deficit. I learned the importance for advocating for your client to receive the best possible care available to them. This may involve spending extra time each day, outside of patient care, to ensure quality care. I learned how important therapeutic rapport is with your client’s. Lastly, I learned that treating the whole person, in a client-centered way, provides the most room for positive recovery. Through this small interaction of requesting speech orders for a client, I gained far more in my clinical reasoning skills than I would have bargained for.

OT Fellow

Mentee Preparation

Mentor Review

Face-to-face Discussion

Phases of the Clinical Narrative

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Identify a patient or client

Whom to choose?

Mentee felt like he/she made a difference

Memorable interaction that enhanced learning

Situation where there was a breakdown, error, or moral dilemma

Clinical interaction that challenged clinical or ethical decision making

Mentee Preparation

Reflection on the experience

Gibbs Reflective Cycle

Personal perceptions and feelings

Positive and negative consequences

Future actions (Gibbs, 1988)

Reflection on the greater context

Patient, spouse, or caregiver’s perspective

Facility or payer source perspective (Plack et al, 2005)

Mentee Preparation

Write the narrative

Use 1st person

Tell the story

Thoughts, feelings, and emotions

Avoid editing until after the first draft

Review and add missing details

Mentee Preparation

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Read the narrative

Review the Gibbs Reflective Cycle and the Clinical Narrative guidelines

Have a copy of the grading rubric or guidelines for reference

Note questions that come to mind while reading the narrative

Mentor Review

Expectations of the Mentee

Present the Narrative

Expand on Details

Seek support and advice

Respond to mentor’s comments and feedback

Face-To-Face Discussion

Face-To-Face Discussion

Expectations of the Mentor

Active listening without interruption

Ask follow up questions

Provide comments

Offer advice

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• Interprofessional and Intraprofessional grading by the coordinators and mentors

• Peer-to-peer grading by the residents and fellows

• Brings a new and unique interprofessional perspective

Grading the Clinical Narrative

Premise• What is the narrative about?• Does the Mentee identify clinical practice, clinical reasoning, and

ethical issues?

• What is the narrative about?• Does the Mentee identify clinical practice, clinical reasoning, and

ethical issues?

Level of Reflection• Descriptive reflection focused on self• Dialogic reflection incorporating perspectives of others and

systems (Plack et al., 2005)

• Descriptive reflection focused on self• Dialogic reflection incorporating perspectives of others and

systems (Plack et al., 2005)

Gibbs Reflective Cycle • Does the narrative include six all components of the model?• Does the narrative include six all components of the model?

Grading Rubric

• Operational Definition- recognizes and begins to explore or critique his or her own assumptions, values, beliefs, and biases may seek multiple perspectives and alternate explanations

• O4/narr 4– “I immediately realized that this patient needs someone from the medical

team to step up and be an advocate for them as they kept getting passed along and lost in the shuffle.”

– “I will learn from this situation the importance of education and advocacy for patients that may not have a strong voice in their own care."

Case Example of Premise

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“I realized that there must be a reason why she was saying the things she was saying, and it was my job to figure out

why. So I did, I asked more questions. What would you like to be able to do? Why do you think you can’t do this? What

is stopping you from getting there? I felt like the clouds parted and she just let go.”

Case Example of Premise

Premise• What is the narrative about?• Does the Mentee identify clinical practice, clinical

reasoning, and ethical issues?

• What is the narrative about?• Does the Mentee identify clinical practice, clinical

reasoning, and ethical issues?

Level of Reflection

• Descriptive reflection focused on self• Dialogic reflection incorporating perspectives of others and

systems (Plack et al., 2005)

• Descriptive reflection focused on self• Dialogic reflection incorporating perspectives of others and

systems (Plack et al., 2005)

Gibbs Reflective Cycle

• Does the narrative include six all components of the model?

• Does the narrative include six all components of the model?

Grading Rubric

“It was a working relationship between father, son, and therapist. I worked hard for Craig and Chance, and they worked hard for me. Every goal was met and all parties

were happy in the end despite their concern early on in the process.”

Case Example of Level of Reflection

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"I learned the strength of parents and families. While I felt crushed and felt as if I was barely holding it together when

seeing Drew the last time, his mom was composed and made sure every person knew how thankful she was for them and

their impact on her son. Looking back at my time with Drew, I am still amazed at the strength of his family. I also learned the impact a life can have, no matter how brief, because I will carry

my lessons from Drew forward while interacting with other patients and families."

Case Example of Level of Reflection

Premise• What is the narrative about?• Does the Mentee identify clinical practice, clinical reasoning, and ethical

issues?

• What is the narrative about?• Does the Mentee identify clinical practice, clinical reasoning, and ethical

issues?

Level of Reflection• Descriptive reflection focused on self• Dialogic reflection incorporating perspectives of others and systems (Plack

et al., 2005)

• Descriptive reflection focused on self• Dialogic reflection incorporating perspectives of others and systems (Plack

et al., 2005)

Gibbs Reflective Cycle • Does the narrative include six all components of the model?• Does the narrative include six all components of the model?

Grading Rubric

The Clinical Narrative process• Provides an opportunity for targeted reflection on personal

and contextual perspectives• Helps the mentor better understand the resident or fellow’s

thought process and deepen the learning experience• Offers a systematic, tangible way for new and seasoned

mentors to facilitate advancement of clinical reasoning skills in the continuum of OT and PT education

• Provides an opportunity for interprofessional collaboration and reflection by considering others’ perspectives and expertise

Conclusion

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ReferencesCronin, A. & Graebe, G (2018). Clinical reasoning in occupational therapy.

Bethesda: AOTA Press.Furze JA, Greenfield BH, Barr JB, Gale JR, Geist K, Jensen

GM. Clinical Narratives in Residency Education: Exploration of the Learning Process. Physiotherapy Theory & Practice. 2018: (15);1-16.

Furze J, Kenyon L, Jensen G. Connecting Classroom, Clinic & Context: Clinical Reasoning Strategies for Clinical Instructors and Academic Faculty. Pediatric Physical Therapy. 2015;27(4):368-375.

Gibbs, G. (1988). The reflective cycle. Kitchen S (1999) An appraisal of methods of reflection and clinical supervision. Br J Theatre Nurs, 9(7), 313-7.

Greenfield BH, Jensen GM, Delany CM, Mostrom E, Knab M, Jampel A 2015 Power and promise of narrative for advancing physical therapist education and practice. Physical Therapy 95:924-933.

Greenfield B, Swisher LL 2013 The role of narrative in professional formation for students. In: Higgs J, Sheehan D, Currens JB, Letts W, Jensen GM, eds. Realising Exemplary PracticeBased Education, pp 163-170. Rotterdam: Sense publishers

Plack, M. M., Driscoll, M., Blissett, S., McKenna, R., & Plack, T. P. (2005). A method for assessing reflective journal writing. Journal of allied health, 34(4), 199-208.(4), 199-208.