The term reflection in physiotherapy is defined as “the higher order intellectual and affective activities in which physiotherapists engage to critically analyse and evaluate their experiences in order to lead to new understandings and appreciation of the way they think and operate in the clinical setting” (Donaghy & Morss pg. 6, 2000). Schön (1983) explains that uncertainties in clinical practice can be resolved through reflection, which enables personal experience and insight gained from that experience, to inform clinical reasoning. Shapiro, Kasman and Shafer (2006) explains that reflective writing may be one way of promoting professionalism, high ethical and moral standards for physicians in training. Thus, the aim of writing this piece is to reflect on my own growth within the past year as a physiotherapy final year student with respect to my clinical reasoning skills, and professional and ethical development.
This year being my final year of my undergraduate degree, there were five clinical placements which consisted of five or six weeks. I must admit that there were various challenges faced during this stressful year. I would like to highlight the main challenges as “themes” where some of them are also concepts that we were taught on in the Ethics module being; (1) professionalism, (2) ethics, (3) human rights and (4) clinical reasoning.
My first challenge/theme was based on professionalism at the first placement I was at, which was my first clinical experience for the year. I was at an ICU block which was the most intimidating block. To add to this experience professionalism was the highlight of this block because I made mistakes that being; I handed my professional conduct form to the clinician in the last week despite the fact that the physiotherapy department’s rules required it to be handed in during the second week, failing to communicate effectively with appropriate team members with regards to my patient being transferred within the hospital, and having to deal with a clinician who was strict and our personalities/opinions clashing most of the time. I can relate to what the study by Grace and Trede (2013) found as it is said that formal education in the classroom, in clinical placements and observed professional behaviours influences the development of a sense of professionalism. Professionalism is such a complex term, the concepts that I struggled to achieve was being punctual, responsible, communicating with staff and accepting others’ view and personalities. Looking at my first blog post the video and journal assisted my theoretical understanding and improvement of professionalism. From this block I tried to maintain my professionalism throughout the year with myself, my patients, fellow peers/students and the permanent staff. The observed professionalism of my clinician at the time has molded me to became an independent thinker, to reason with staff and the patients and this seemed have improved in the ICU setting and throughout the year.
The second most challenging highlight of the year was ethical challenges. I would say this was something I found challenging throughout the year but there were more ethical dilemmas that stood out for me during my second block (NMS/day hospital) and third block (general). At my NMS block there were situations where a patient would arrive late for their appointment or a patient would arrive for an appointment without the booking being notified by us. In addition students were left alone in the department without the clinician being there to “run the show”. This ultimately had a ripple effect on the queue of ±15 patients who had to be seen as it affected the time those patients waited in the queue to eventually be seen by a student physiotherapist, and the time we had with those patients during the assessment and treatment. In addition to this, patients who came late had their reason being because of crime in their area preventing them from using public transport early enough to leave the house. I was faced with the question in my mind “is it fair to treat this patient even though there are angry patients who have been waiting in a queue for hours to be seen?” What I eventually had to do in some situations was to listen to the patient’s reason for being late and make the patient aware that you understand their circumstances. Then I would kindly explain to them that because he/she was late we are under pressure with time and the patient needs to wait in the queue after those who waited for a long time. With the patients who showed up without an official appointment I decided to see them during sessions only if there was time to and/or based on how serious/acute their pain was.
Many occasions at my NMS block and sometimes at my general block there were patients whose condition was not progressing but I felt obligated to still treat them. These patients have been receiving physiotherapy for many years and to me it did not make sense why they have not been discharged. The treatment the patients were receiving were becoming a placebo effect. Being faced with this challenge I continued doing what was previously done for the patient even though this may have been the wrong this to do. Holm and Severinsson (2014) explained that ethical dilemmas is not an issue that should be dealt with individually but rather as a health care team when it comes to decision-making and reasoning. Thus, at the time it would have been acceptable for me to discuss with the necessary team members (doctor/physio/social worker) on the plan for a patient who is not benefiting from physiotherapy. This is something I hope to improve in over the years as a qualified physiotherapist; to be confident in what I know or in my opinion and share it with team members to try and make the best decision.
The third challenge I was faced with was in my last block where I was at placed at an interdisciplinary health care facility (IHCF) seeing neurologically disabled patients. Here the first thing I noticed was that there were hundreds of patients and there was only two qualified physiotherapists, two occupational therapists, one speech therapist, one dietitian and one social worker in the whole of the therapy team. There were assistants (also known as rehab care workers) but they were not qualified and were also understaff for the amount of patients who needed therapy. Firstly, my views on this was that the patients were not receiving the intensive “one on one” therapy they were promised to receive. Most of the time the patients were neglected especially with physiotherapy because we aim to return maximal function and independence. When I completed this block I felt that I had to lie to my patients and tell them that they will receive the same physiotherapy they were receiving from me, despite the fact that I knew it would not be the same after I leave. This was where I practically learned about human rights. In the class we were taught about human rights and in this situation the patients had the right to the health services they were told they would receive (HPCSA, 2008). They should be able to regain maximal function at this IHCF. Furthermore, I learned that ethics is quite crucial in situations like this as one is unable to maintain one’s professional and ethical stance and standard (Holm and Severinsson, 2014) because once I have left I would not know if my patients would progress- I had to learn to accept this.
It was found by Rowe (2012) that online social networks can be used to develop reflective practices among undergraduate physiotherapy students. During this year writing blog posts on the experiences/challenges I faced during clinical practice has assisted my clinical reasoning as it tested my own level of knowledge and exposed me to other students’ levels of knowledge and understanding of complex clinical situations. It was a bit challenging linking up ethics concepts that was taught in class to what was happening in clinical practice every day- the professionalism, ethics and morals, human rights etc. I do still battle with clinical reasoning with some patients at times but, I have valued the opportunities I get to do further research and to learn from others (sharing opinions and techniques). I feel that during this year I have grown in confidence and the passion I have to help others is enormous. When I watched the video about “the human connection to a patient” I was totally moved by it as it kind of sums up my experiences throughout the year with various patients and how I approach them. It reminds me of how important and influential my job is to the next person and that I will always strive to do my best as a physiotherapist.
Donaghy, M. E., & Morss, K. (2000). Guided reflection: A framework to facilitate and
assess reflective practice within the discipline of physiotherapy. Physiotherapy Theory and
Practice, 16(1), 3-14. doi:10.1080/095939800307566
Grace, S., & Trede, F. (2013). Developing professionalism in physiotherapy and dietetics
students in professional entry courses. Studies in Higher Education, 38(6), 793-806.
Holm, A. L., & Severinsson, E. (2014). Reflections on the ethical dilemmas involved in
promoting self-management. Nursing ethics, 21(4), 402-413.
HPCSA. (2008, May). National Patients’ Rights Charter. Retrieved September 16, 2016, fromhttp://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/conduct_ethics
Rowe, M. (2012). The use of assisted performance within an online social network to
develop reflective reasoning in undergraduate physiotherapy students. Medical
Teacher, 34(7), e469-e475. doi:10.3109/0142159x.2012.668634
Schön, DA (1983). The reflective practitioner. Temple Smith, London.
Shapiro, J., Kasman, D., & Shafer, A. (2006). Words and Wards: A Model of Reflective
Writing and Its Uses in Medical Education. Journal of Medical Humanities, 27(4), 231-244.