THE USE OF CRITICAL REFLECTION IN CLINICAL PRACTICE AND HEALTH PROFESSION EDUCATION

Milta Oyola Little, D.O. CMD

Saint Louis University

Disclosures

Dr. Milta Little has no relevant financial conflicts of interest to report.

Dr. Little will not be discussing any off-label or unapproved uses of any drugs/theraputics.

Objectives

• Describe the main forms of critical reflection

• Appreciate how critical reflection can be used to improve clinical practice and practitioner self-care  

• Implement critical reflection to evaluate the effectiveness of an educational intervention.  

Narrative Medicine

The practice of medicine that is empathic, reflective, professional and trustworthy.

- Charon R. JAMA 2001; 286(15): 1897-1902

As patient meets physician, a conversation ensues…

“A story – a state of affairs or a set of events – is recounted by the patient in his or her acts of narrating, resulting in a complicated narrative of illness told in words, gestures,

physical findings, and silences and burdened not only with the objective information about the illness but also with the

fears, hopes, and implications associated with it.”- Charon R. JAMA 2001; 286(15): 1897-1902

Narrative Types

• Critical Reflection

Critical reflection occurs when we analyze and challenge the validity of our presuppositions and assess the appropriateness of our knowledge, understanding, and beliefs given our present contexts (Mezirow, 1990)

Define Critical Reflection

CR combines learning objectives with experiential learning / application

Narrative Types

• Critical Reflection• Reminiscence

Exercise #1

The Tapestries Model

Close your eyes…

…and think.

Narrative Types

• Critical Reflection• Reminiscence• Life Review

Exercise #2

• You know yourself better than anyone else.• Think of the characteristics and values that define you as

a person.• Write down 4-6 words that tell important aspects of

yourself. • Share these with your neighbor.

• Congratulations! You have just participated in a simple form of Life Review!

Used with permission by Dr. Thomas Meuser, Associate Professor Gerontology, UMSL

Narrative Types

• Critical Reflection• Reminiscence• Life Review• Creative story-telling (TimeSlips, Poetry, Reader’s Theatre)

Why Study Narrative Medicine?• Improve patient care through illness scripts

“A scientifically competent [practitioner] alone cannot help a patient grapple with the loss of health or find meaning in suffering”

-- Rita Charon, MD, PhD, Columbia University

Price B. Nursing Older People 2011; 23(6): 31-37Charon R. JAMA 2001; 286(15): 1897-1902Greenhalgh T and Hurwitz B. BMJ 1999; 318: 48-50

• Listen to the illness narrative• Interpret what is most important or pressing to the person

• Reflect on personal narratives

• Build on past experiences to negotiate care

Improve Patient Care

Price B. Making better use of older people’s narratives. Nursing Older People 2011; 23(6):31-37

Allow the person to give his interpretation of his story.

•Myths of narratives• Must be “accurate” to be useful• Takes more time than a medical history• Is a one time interview• It must always be therapeutic

Oral History Narratives

Why Study Narrative Medicine?• Improve patient care through illness scripts• Tell the counter story to the dominant aging narrative

“I think that people sort of get in the mindset, ‘when you’re old, this is how it has to be.’ …But I’m not…I can do anything, just like as a younger person would in life…I can do anything.”

-- Keith, “Masters over 50s” bodybuilder

Phoenix C and Smith B. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences 2011; 66(5): 628-639Butler RN. JAGS 1974; 22(12): 529-535

Young @ HeartYou’re never too old to rock.

http://www.youngatheartchorus.com/index.php

Why Study Narrative Medicine?• Improve patient care through illness scripts• Tell the counter story to the dominant aging narrative• Self-improvement through reflection

“I began to write stories about patients who troubled or baffled me. The more I wrote about my patients and myself, the more confident I became that the act of narrative writing granted me access to knowledge—about the patient and about myself—that would otherwise have remained out of reach.”

-- Rita Charon, MD, PhD, Columbia University

Charon R. JAMA 2001; 286(15): 1897-1902Charon R. Ann Intern Med. 2001;134:83-87C.M. Bowe, L.Lahey, E.Armstrong, & R.Kegan, Medical Education 2003; 7:715-722

Why Study Narrative Medicine?• Improve patient care through illness scripts• Tell the counter story to the dominant aging narrative• Self-improvement through reflection• Therapy at end-of-life

Sorrell JM and Butler FR. J Psychosoc Nurs Ment Health Serv. 2009 ;47(11): 21-5Chochinov HM, Hack T, et al. J. Clin Onc 2005; 23:5520-25

Why Study Narrative Medicine?• Improve patient care through illness scripts• Tell the counter story to the dominant aging narrative• Self-improvement through reflection• Therapy at end-of-life• Educate the next generation on patient-centered

communication, empathy and care“Though difficult to measure objectively, teaching communication skills can help students develop definable communication competencies.”

-- Kay McFarland, MD, Distinguished Professor Emeritus of Medicine University of South Carolina

McFarland K, et al. Gerontol and Geriatrics Educ 2006; 27(1):81-94

Myths of narratives

• Must be “accurate” to be useful

• Takes more time than a medical history

• Is a one time interview

• It must always be therapeutic

Narratives in Long Term Care• Provider perspective and debriefing1

• Enhance provider-resident relationships2,4

• Restore reciprocity to residents3

• Define quality of care and individualize care plans4

• Uncover the meaning of illness and nursing home care from the residents’ perspective4,5

1Jakobsen R and Sorlie V. Nurse Ethics 2010;17(3):289-3002Heliker D. J Gerontol Nurs. 2009;35(6):43-93Heliker D. J Psychosoc Nurs Ment Health Serv. 2007;45(7):20-34Heliker D. Issues in Mental Health Nursing. 1999; 20:513–5255Graneheim UH and Jansson L. J Clin Nurs. 2006;15(11):1397-403

Why Do I Do Critical Reflection?

Get the students to really stop and think

What I Have Learned So Far• Unless I’m specific in my ask, I will get a wide variety of

responses that• Lack depth• Lack application to personal practice • Don’t tie back to patient care/patient safety• Describe the conversation or story without much discussion on

impact, barriers, solutions.

• Creating a culture of reflection does not mean one has to have multiple writing assignments

• Get regular feedback

Why Narrative Medicine - Review

• In the diagnostic encounter, narratives:• Form the patient illness script• Encourage empathy and promote understanding between clinician

and patient• Allow for the construction of meaning• May supply useful analytical clues and categories

• In the therapeutic process, narratives:• Encourage a holistic approach to management• Are intrinsically therapeutic or palliative• May suggest or precipitate additional therapeutic options

Greenhalgh T and Hurwitz B. BMJ 1999; 318: 48-50

Why Narrative Medicine - Review

• In the education of patients and health professionals, narratives:• Are often memorable• Are grounded in experience• Encourage reflection

• In research, narratives:• Help to set a patient centered agenda• May challenge received wisdom• May generate new hypotheses

Greenhalgh T and Hurwitz B. BMJ 1999; 318: 48-50

Young@Heart Story• Ms. Dora Morrow

Questions?