Clinical reflective practice

A group-based, situative approach

to promote personal professional development

A qualitative developmental evaluation

Structure of the presentation

Background

Aim of the study

Setting

Method

Results

Discussion

Future research

Background

Communication skills are mainly taught in an additive

manner in the

• preclinical phase and in general techniques

Even with proper preparation in communication skills,

there is a decline in patient-centeredness, moral

judgement and empathy in medical students*

Especially when entering clinical phase or residency

* Neumann M et al 2011: Empathy decline and its reasons: A systematic review of studies with medical students and residentsKatrien Bombeke et al 2010: Help, I’m losing patient-centredness! Experiences of medical students and their teachers

Aim:

Aim of the intervention:

Is a group-based situated clinical reflective practice

(CRP) helpful in preventing this decline in this

vulnerable phase?

Aim of the developmental qualitative evaluation:

To learn about the students‘ perspectives on

• how they experience their educational

situation

• whether CRP helps

• and if so, how and where it helps.

Setting

Clinical education ward

• German system: 6th year - 3 4months rotations

• Internal medicine, 3-5 students

• In groups, acting interns, individualized increase in

number of patients

Clinical reflective practice

• 1 session every two weeks for 1 ½ hours, 5-6 total

Kolb A, Kolb D (2005). Learning Styles and Learning Spaces: Enhancing Experiential Learning in Higher Education .Academy of Management Learning & Education, 2:193–212

Kolb‘s learning cycle

Intervention:

Process sequence – Core sessions

Stop and perceive

Brief sharing of observations and selection of situation

Sharing of the situation of the day

Collection of impressions of the group

Naming and framing of most important issues

Individual possible solutions and their possible consequences

Method I

Use of „developmental evaluation“ in the

initial test phase as it allows for

„conceptualizing, designing and testing new

approaches in a long-term, on-going process of

continuous improvement, adaptation and

intentional change”*

*Patton, MQ (2010). Developmental Evaluation: Applying Complexity Concepts to Enhance Innovation and Use . Guilford Press

Method II

In 2011 11 in depth interviews with students using

open-ended questions were conducted

Findings were analysed using thematic content analysis

seeking to categorise explicit and implicit experiences

of participants

The content of the data was coded, compared and

categorized

Possible relationships between emerging themes were

analysed

Method III:

The questions of the evaluation covered the

following areas:

how did students experience their

clinical situation?

which factors were important to them

within the CRP-process?

which short term

and longterm effects were described?

Reality: „Breakers“, „Vortex“

Results: Ward experience

*

Motivation:Intention to helpOpenness

Medical:• Application of general medical knowledge onto individual cases, work management• Help through clinical supervisor• Effort to fit in• Attention outside

Psychosocial:• Overwhelming complexity • „constant nonverbal communication thunderstorm“• Effort to meet expectations• Higher impact• Insecure, left alone• Protection - Withdrawal („crept through it like a mole“)

Results: Process of reflection

Which elements were stated as essential regarding CRP?

„Rock in the midst of breakers“

• Step back, adequate distance

• Sorting of „situational emotional mess“

• Zoom, slow-motion

Change in view-direction

Help for self-help

Developing individual solutions

Suitability for daily use

Group

Support, multiperspectivity, mirroring

Results: Short term effects

… on the student: - „ go upright again“

Stress-reduction („little mental pot“)

positive change in perception of pitfalls,

comprehensability of self and other, experience of

meaning, options to act, capacity to provide

feedback, tolerance for ambiguity and complexity,

openness… on the patient: - „more open again“

… on team-work: - „we laughed again“

improved ability for conflict management, willingness to help, feedback culture

Results: Long term effects

„… to realize that looking quietly back on a situation, in which you

felt terribly uneasy and reflecting then on what you could have

done to prevent such an uneasy situation, … opens up many more

options for the next ten situations“.

„…I developped a higher sensibility, an internal warning system,

which whenever I have an encounter with a difficult patient starts

blinking in my head and tells me to step back from my primary

feelings, from quick judgment … and therefore developped a

higher inner flexibility and openness towards my patients…“

Results: CRP process

Active experimentation

Problem definitionIndividual PlansTrial action

Distanced empathyPersonal aspectsMultiperspectivity

Emotional Reg:Suppression or

Learning experience

Group-perspective

Delegation

Perception of misfits

Discussion:

Medical students and residents in the present study

describe substantial benefit from this CRP format

short term and

in the long run regarding

• the handling of psychosocial and clinical complex

situations

• professional communication and

• personal development

Future research and limitations

Qualitative findings cannot be generalized

Subjectively reported “effect” needs further scientific

substantiation

Experiential learning as a major factor for professional

development – barely taught in medical education

The experience of successful learning through reflective

practice could have high impact on patient satisfaction

and outcome and professional development.

Questions for discussion

Your reflection?

Contact

Gabriele Lutz, neurologist and specialist in psychosomatic medicine

Witten/Herdecke University, Faculty of Health, School of Medicine,

Integrated Curriculum for Anthroposophic Medicine, Germany

Email: Gabriele.Lutz@gmx.net

Thank you very much for your attention!

| 03/ 09/ 2008 | The qualitative short surveyPage 21

University Hospital Evaluation setting

Clinical Education Wardfor Integrative Medicine

•group of final (6th) year stud. cover 1 – 5 pts and are primary caregivers for the pts• internal medicine ward• close clinical supervision

Witten/Herdecke

Faculty of Health,

Germany

• only private medical

school in Germany

• very practice-oriented

•Strong emphasis on

“fundamental studies”

Gemeinschaftskrankenhaus

Herdecke,

University’s academic hospital

• specialized in Integrative Medicine

Organizational background