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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
Define 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)
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): 31-37
Charon R. JAMA 2001; 286(15): 1897-1902
Greenhalgh T and Hurwitz B. BMJ 1999; 318: 48-50
Improve Patient Care
• 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
Price B. Making better use of older people’s narratives.
Nursing Older People 2011; 23(6):31-37
Oral History Narratives
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
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): 628-639
Butler RN. JAGS 1974; 22(12): 529-535
Young @ Heart
You’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): 1897-1902
Charon R. Ann Intern Med. 2001;134:83-87
C.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): 21-5
Chochinov 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):289-300
2Heliker D. J Gerontol Nurs. 2009;35(6):43-9
3Heliker D. J Psychosoc Nurs Ment Health Serv. 2007;45(7):20-3
4Heliker D. Issues in Mental Health Nursing. 1999; 20:513–525
5Graneheim 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?