A behind the Scenes Look at Reflective Practice In My Patellofemoral Pain Practice: An Open and Honest Account.

Introduction.

Reflective practice is often banded around with many reminded of student journals they were made to write. In this blog I explain how I use it in my practice and how the literature on this topic helps to inform us.

Experience

‘I pay attention to my ‘experience’ because I constantly strive to become a more effective practitioner and realise my vision of practice.’ (Johns, 2004). Is paying attention to the ‘experience’ enough? As a researcher and clinician I would hate to stop either component. For me there is a richness that comes from my clinical practice but this vast experience I now have of PFP, is devalued without reflection.

Throughout the last decade I have had a note pad which has now evolved into the notes section on my phone to jot down things to look up, give further thought to or even research myself. My crepitus work came out of my reflections on many patients talking about their crepitus.

Questioning

It is good to question and challenge yourself, and ask why did that patient not respond to treatment, why did a patient report an unusual symptom, why, why why…On those occasions where someone is looking to me as an expert in the field and they aren’t responding to treatment it’s imperative I ask why. This is not to beat myself up but learn from each and every patient through my questioning reflection.

Stages of Reflection

Kolb’s experiential learning cycle, (1984) reminds us of the stages of reflection. However, this doesn’t have to be a laboured process involving writing. This for me often occurs during practice so it is reflection in action as described by Schon (1983). So, for example, if I am about to ask a patient to do a single leg squat but I note their fear at the pain from getting out of a chair then I might reflect and in a second decide not to use a single leg squat.

Peer Support-Critical Friendships

‘All professionals are concerned with knowing and realizing desirable and effective practice, yet work in conditions where for one reason or another such realization is often difficult.’ (Johns, 2009). Peer support really can help with this. I am really fortunate that I work in a team that is passionate and friendly. When I’m stuck with a patient I will look to colleagues to reflect on the patient with them. Sometimes just verbalising in itself helps, and two brains knocked together is always better than one. As I have become more experienced I’ve been more comfortable to do this, accepting that we all have head scratchers! Critical friends to reflect with are valuable.

Feelings

Gibbs, (1998) work reminds us that we have feelings and this can impact on our interactions. These may be brought in to the consultation from home, eg anger, frustration about something, or induced by something in the consultation. For example, a spate of patients not progressing well will take the edge off my confidence that may subtly alter my communication style. To reflect on this and be self-aware is important to for me to add to the rich understanding of my practice.

Feedback

Patients’ give both formal, (e.g. questionnaires), and informal feedback. I have learnt so much off patients over the years especially ways in which they have innovatively found to do exercises at home. Apart from the patient who put his pedometer on his sausage dogs collar these will often be top tips that I ‘bank’ and pass on to future patients, leading to a richer experience for everyone. To listen well and reflect on patient’s experiences greatly aids this process.

Problematic Experience

We’ve all had them. Those consultations we’d rather forget about. But actually these are such useful sources of learning from reflection. Osterman and Kottkamp, (2004) refer to this as problem identification. As opposed to Kolb’s reflection they talk about analysis, so really breaking down the components of a negative experience. It is useful not to simply think of what didn’t go well and what you do differently next time, but reflect on the underlying assumptions that led you to act in a certain way. Just dealing with patients with PFP I need to be really careful with this. My inevitable strong pattern recognition with this patient group can lead to the wrong assumptions and reflecting on this helps guard against it!

Re-visiting a Reflection.

Ultimately we reflect and conceptualise with the information we have at any one moment in time. However when I reflect on a patient after a 6-month gap I am looking to see how my reflections have evolved due to six months of extra experience and reading. I often ask my course delegates to reflect on a patient in the light of my course and hope that their reflections will have evolved.

Beliefs

It is very easy to look for evidence to support a pre-existing belief. This can make us feel sure of our stance and avoid the discomfort of change. Argyris’s ladder of inference, (1982) neatly shows us how we easily select data to reinforce an assumption. This is something to be aware of when reading literature. The plethora of literature means that even the articles we select to read and their take-home messages may in itself be reinforcing assumptions. I try and make myself reflect on what literature I am choosing and why to ensure I keep evolving in my PFP practice and teaching.

Personal Mastery

‘People with a high level of personal mastery are acutely aware of their ignorance, their incompetence and their growth areas.’ (Senge, 2006). This really is very annoying at times as the more you know the more you realize you don’t know! However, it is also hugely exciting to be in a profession where I can learn, learn, learn, even if the ‘to read’ list gets a bit overwhelming at times.

To conclude

I feel hugely privileged to be in a career that is so rewarding and stimulating. When I reflect on my days as a student with faradism, slings and de Lorme boots I can see what a journey I’ve been on. Reflection has, and continues to be a vital part of that journey.

‘Reflective practice is the antidote to complacency, habit and blindness.’ (Johns, 2004)

Top Tips for ensuring you have a Reflective Practice:

1. Keep a log or pop things on your phone to look up, give further thought to.
2. Regularly make time to talk to a ‘critical friend’ and reflect on tricky cases or problematical scenarios.
3. Ask yourself why you have chosen to read the papers you have.
4. Try and be self-aware of your own beliefs and feelings.

References:

Argyris C (1982) Reasoning learning and action: Individual Organizational, San Francisco: Jossy-Bass

Gibbs G. (1998) Learning by Doing: a Guide to teaching and learning methods, Oxford: Further Education Unit, Oxford Polytechnic.

Johns C. (2004) Becoming a Reflective Practitioner, 2nd Ed, Oxford: Blackwell Publishing.

Johns C. (2009) Becoming a REflective Practitioner, 3rd Edition, Chichester: Wiley-Blackwell

Kolb D. (1984) Experiential Learning: experience as the source of learning and development, New Jersey: Prentice Hall

Ostermann KF, Kottkamp RB (2004) Reflective Practice for Educators,2nd edition, London: Kogan Page

Schon D. (1983) `the reflective practitioner, New York: Basic Books.

Senge P (2006) The fifth discipine, 2nd edition, London: Random House Business